Visfatin and 25-Hydroxyvitamin D_(3) Levels Affect Coronary Collateral Circulation Development in Patients with Chronic Coronary Total Occlusion

Background:Coronary collateral circulation(CCC)plays a vital role in the myocardial blood supply,especially for ischemic myocardium.Evidence suggests that the visfatin and 25-hydroxyvitamin D_(3)[25(OH)D_(3)]levels are related to the degree and incidence of vascular stenosis associated with coronary artery disease;however,few studies have evaluated the effect of visfatin and 25(OH)D_(3) on CCC development in patients with chronic total occlusion(CTO).This study aimed to evaluate the relationship between the serum visfatin and 25(OH)D_(3) levels and CCC in patients with CTO.Methods:A total of 189 patients with CTO confirmed by coronary angiography were included.CCC was graded from 0 to 3 according to the Rentrop-Cohen classification.Patients with grade 0 or grade 1 collateral development were in-cluded in the poor CCC group(n=82),whereas patients with grade 2 or grade 3 collateral development were included in the good CCC group(n=107).The serum visfatin and 25(OH)D_(3) levels were measured by ELISA.Results:The visfatin level was significantly higher in the poor CCC group than in the good CCC group,and the 25(OH)D_(3) level was significantly lower in the poor CCC group than in the good CCC group(P=0.000).Correlation analysis showed that the Rentrop grade was negatively correlated with the visfatin level(r=−0.692,P=0.000)but positively correlated with the 25(OH)D_(3) level(r=0.635,P=0.000).Logistic regression analysis showed that the vis-fatin and 25(OH)D_(3) levels were independent risk factors for CCC(odds ratio 1.597,95%confidence interval 1.300-1.961,P=0.000 and odds ratio 0.566,95%confidence interval 0.444-0.722,P=0.000,respectively).The visfatin and 25(OH)D_(3) levels can effectively predict the CCC status.Conclusion:Serum visfatin and 25(OH)D_(3) levels are related to CCC development and are independent predictors of poor CCC.

Influence of preoperative coronary collateral circulation on in-hospital mortality in patients undergoing coronary artery bypass graft surgery with intra-aortic balloon pump support

Background Outcomes in patients requiring coronary artery bypass graft （CABG） surgery have been improved with devices such as the intra-aortic balloon pump （IABP）.Good coronary collateral circulation （CCC） has been shown to reduce mortality in patients with coronary artery disease （CAD）.We aimed to investigate whether poor preoperative CCC grade is a predictor of in-hospital mortality in CABG surgery requiring IABP support.Methods Fifty-five consecutive patients who were undergoing isolated first time on-pump CABG surgery with IABP support were enrolled into this study and CCC of those patients was evaluated.Results Twenty-seven patients had poor CCC and 28 patients had good CCC.In-hospital mortality rate in poor CCC group was significantly higher than good CCC group （14 （50％） vs.4 （13％）,P=0.013）.Preoperative hemoglobin level （OR：0.752; 95％ CI,0.571-0.991,P=0.043）,chronic obstructive pulmonary disease （OR：6.731; 95％ CI,1.159-39.085,P=0.034） and poor CCC grade （OR：5.750; 95％ CI,1.575-20.986,P=0.008） were associated with post-CABG in-hospital mortality.Poor CCC grade （OR：4.853; 95％ CI,1.124-20.952,P=0.034） and preoperative hemoglobin level （OR：0.624; 95％ CI,0.476-0.954,P=0.026） were independent predictors of in-hospital mortality after CABG.Conclusion Preoperative poor CCC and hemoglobin are predictors of in-hospital mortality after CABG with IABP support.

Characteristics of coronary microvascular lesions in autopsied elderly with hypertensive left ventricular hypertrophy

OBJECTIVE: To observe the characteristics of coronary microvascular lesions (CML) in the autopsied elderly cases with hypertensive left ventricular hypertrophy (LVH) and the difference of CML among the groups of essential hypertension (EHT), coronary heart disease (CHD) and diabetes (NIDDM) also with LVH. METHODS: A retrospective study was performed in 206 cases > or = 60 years old of EHT, CHD and NIDDM with LVH and 30 normal cases as control, out of 3195 consecutive autopsied cases from 1954 to 1996 in our hospital. Arterioles with diameters of 10 - 60 microm and capillaries in the muscular layer were shown by the methods of HE, Elastic fiber + VG staining and immunohistochemistry of CD31. Quantitative measurements on the arteriole density (AD), the ratio of arteriolar wall and cavity (RWC), capillary density (CD) and the area of endothelial cell (AEC) were performed with light microscope observation and image analysis by computer. According to the thickness of the left ventricle free wall, the severity of LVH was divided into four degrees from 0 to III. LVH of degree 0-III was observed in EHT group, while only LVH of degree I was found in CHD, EHT + CHD, and NIDDM groups. SAS system was used for statistical analysis. RESULTS: AD and RWC increased while CD and AEC decreased significantly with the progression of LVH in EHT groups (P

Insulin sensitivity and the diffuseness of coronary artery disease in humans

OBJECTIVE: To study the relationship between insulin sensitivity and diffuse coronary artery disease. METHODS: Ninety-two consecutive patients underwent coronary angiography were enrolled in the study. Relationships between the results of angiograms and both glucose tolerance and blood lipids were analyzed. RESULTS: The mean age of the 92 patients (70 males, 22 females) was 65.4 +/- 6.3 y. In the 78 patients diagnosed by angiography as coronary artery disease, diffuse lesion was more common in diabetic patients than in those without a diabetes history (12/13 vs 24/65, P = 0.00026). Fasting glucose [(6.06 +/- 2.43) x 10(-3) mol/L vs (4.80 +/- 1.47) x 10(-3) mol/L, P = 0.009], glucose levels at one hour [(12.37 +/- 4.38) x 10(-3) mol/L vs (9.10 +/- 3.97) x 10(-3) mol/L, P = 0.001], two hours [(11.12 +/- 5.64) x 10(-3) mol/L vs (7.49 +/- 4.29) x 10(-3) mol/L, P = 0.003] and three hours [(8.11 +/- 5.51) x 10(-3) mol/L vs (5.56 +/- 3.46) x 10(-3) mol/L, P = 0.020] after food were higher in patients with diffuse coronary disease than in those with non-diffuse coronary disease. Differences in the insulin sensitivity index (ISI) between the two groups was statistically significant (-4.36 +/- 0.52 vs -3.89 +/- 0.69, P = 0.003). The incidence of multiple-vessel disease in diabetic patients was higher than that in non-diabetic patients (12/13 vs 33/65, P = 0.00565). Glucose levels at two hours [(10.22 +/- 5.57) x 10(-3) mol/L vs (7.67 +/- 4.43) x 10(-3) mol/L, P = 0.034] and three hours [(7.90 +/- 5.47) x 10(-3) mol/L vs (5.22 +/- 2.79) x 10(-3) mol/L, P = 0.007] after food were higher in patients with multiple-vessel disease than in those with single-vessel disease. Impaired insulin sensitivity without a history of diabetes mellitus was commonly seen in patients with coronary artery disease. CONCLUSIONS: The diffuseness of coronary artery disease is associated with insulin sensitivity and blood glucose levels. Insulin resistance is a common phenomenon in non-diabetic patients.

A new echocardiographic system for assessment of epicardial and intramyocardial coronary flow in a swine model

OBJECTIVE: To visualize epicardial and intramyocardial coronary blood flow by using a noninvasive echocardiography system. METHODS: In five juvenile swines, coronary flow imaging was used to visualize the different segments of epicardial coronary and intramyocardial arteries. Pulsed-Doppler spectrums were recorded and analyzed. The left anterior descending artery (LAD) and intramyocardial coronary blood flow signals were recorded at baseline and during dipyridamole administration. RESULTS: Epicardial and intramyocardial coronary arteries could be visualized by coronary flow imaging. The systolic component of coronary flow in the right coronary artery (RCA) was greater than in the LAD. The intramyocardial blood flow was characterized by persistent retrograde blood flow velocity during systole. Vasodilation with dipyridamole produced exaggerated differences in the phasic pattern of coronary blood flow in epicardial and intramyocardial vessels. CONCLUSION: Color Doppler coronary flow imaging provides a noninvasive method to study the coronary blood flow.

Clinical and angiographic features associated with coronary collateralization in stable angina patients with chronic total occlusion

Objective： Coronary collateral circulation is an alternative source of blood supply to myocardium in the presence of advanced coronary artery disease. We sought to determine which clinical and angiographic variables are associated with collateral development in patients with stable angina and chronic total coronary occlusion. Methods： Demographic variables, biochemical measurements, and angiographic findings were collected from 478 patients with stable angina and chronic total coronary occlusion. The presence and extent of collaterals supplying the distal aspect of a total coronary occlusion from the contra-lateral vessel were graded from 0 to 3 according to the Rentrop scoring system. Results： Low （Rentrop score of 0 or 1） and high （Rentrop score of 2 or 3） coronary collateralizations were detected in 186 and 292 patients, respectively. Despite similar age, cigarette smoking, and medical treatment, patients with low collateralization were female in a higher proportion and less hypertensive, and had higher rates of type 2 diabetes and dyslipidemia than those with high coUateralization （for all comparisons, P〈0.05）. In addition, patients with low collateralization exhibited more single-vessel disease, less right coronary artery occlusion, more impaired renal function, and higher serum levels of high-sensitivity C-reactive protein （hsCRP） compared with those with high col- lateralization. Multivariate analysis revealed that age of 〉65 years, female gender, diabetes, no history of hypertension dyslipidemia, moderate to severe renal dysfunction, single-vessel disease, and elevated hsCRP levels were inde- pendently associated with low coronary collateralization. Conclusions： Coronary collateralization was reduced in almost 40% of stable angina patients with chronic total occlusion, which was related to clinical and angiographic factors. The impact of coronary collateralization on outcomes after revascularization needs further investigation.

Clinical relevance of angiographic coronary collaterals during primary coronary intervention for acute ST-elevation myocardial infarction

Background Collaterals to occluded infarct-related coronary arteries （IRA） have been observed after the onset of acute ST-elevation myocardial infarction （STEMI）.We sought to investigate the impact of early coronary collateralization,as evidenced by angiography,on myocardial reperfusion and outcomes after primary percutaneous coronary intervention （PCI）.Methods Acute procedural results,ST-segment resolution （STR）,enzymatic infarct size,echocardiographic left ventricular function,and major adverse cardiac events （MACE） at 6-month follow-up were assessed in 389 patients with STEMI undergoing primary PCI for occluded IRA （TIMI flow grade 0 or 1） within 12 hours of symptom-onset.Angiographic coronary collateralization to the occluded IRA at first contrast injection was graded according to the Rentrop scoring system.Results Low （Rentrop score of 0 or 1） and high （Rentrop score of 2 or 3） coronary collateralization was detected in 329 and 60 patients,respectively.Patients with high collateralization more commonly had prior stable angina and right coronary artery occlusion,but less often had left anterior descending artery occlusion.At baseline,these patients presented with less extent of ST-segment elevation and lower serum levels of creatine kinase myocardial band （CK-MB） and cardiac troponin Ⅰ （cTnl）.Procedural success rate,STR,corrected TIMI flame count,and area under the curve of CK-MB and cTnl measurements after the procedure were similar between patients with high collateralization and those with low collateralization （for all comparisons P＞0.05）.There were no differences in left ventricular ejection fraction and rates of MACE at 6 months according to baseline angiographic collaterals to occluded IRA.Conclusions In patients with acute STEMI undergoing primary PCI within 12 hours of symptom-onset,coronary collateralization to the occluded IRA was influenced by clinical and angiographic features.Early recruitment of collaterals limits infarct size at baseline,but has no significant impact on myocardial reperfusion after the procedure and subsequent left ventricular function and clinical outcomes.

Long-Term Follow-Up of Chinese Herbal Medicines Combined with Conventional Treatment in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: A Multicenter Randomized Controlled Trial

Objective： To evaluate the prognosis effect of Chinese herbal medicines（CHMs） for benefiting qi and activating blood circulation adjunctive to conventional treatment in patients with acute coronary syndrome（ACS） after percutaneous coronary intervention（PCI）. Methods： A total of 702 patients with ACS who underwent PCI were enrolled and randomly assigned to receive conventional treatment plus CHMs for benefiting qi and activating blood circulation（treatment group, 351 cases） or conventional treatment alone（control group, 351 cases） for 6 months. Six months later, all patients received conventional treatment alone. Follow-ups were scheduled at 6th, 12 th, 18 th, 24 th month after enrollment in April 2008, and the final follow-up visit was during September 2011 and November 2011. The primary endpoint was the composite of cardiac death, nonfatal myocardial infarction or revascularization（PCI or coronary artery bypass grafting）; and the secondary endpoint was the composite of re-admission for ACS, congestive heart failure, nonfatal stroke or other thrombus events. Results： A total of 621（88.59%） patients completed 35.4±3.8 months follow-up, while 80（11.41%） patients withdrew from the trial（41 in the treatment group and 39 in the control group）. The incidence of primary endpoint was 5.7%（20 patients） in the treatment group versus 10.86%（38 patients） in the control group [relative risk（RR）： 0.53; 95% confidence interval（CI）： 0.30, 0.88; P=0.013; absolute risk reduction（ARR）： –0.052, 95% CI： –0.06, 0.01]. The incidence of secondary endpoint was 5.98%（21 patients） in the treatment group versus 10.28%（36 patients） in control group（RR： 0.58, 95% CI： 0.33, 0.97, P=0.037; ARR： –0.043, 95% CI： 0.06, 0.01）. Most of the primary and secondary endpoints were occurred in 18 months（84.50% in the treatment group versus 78.10% in the control group）. Conclusion： CHMs for benefiting qi and activating blood circulation adjunctive to conventional treatment improved clinical outcomes for patients with ACS after PCI in long-term follow-up.

Hypoxia,vascular smooth muscles and endothelium

Hypoxia,or the lack of oxygen,has multiple impacts on the vascular system.The major molecular sensors for hypoxia at the cellular level are hypoxia inducible factor and heme oxygenase.Hypoxia also acts on the vasculature directly conveying its damaging effects through disruption of the control of vascular tone,particularly in the coronary circulation,enhancement of inflammatory responses and activation of coagulation pathways.These effects could be particularly detrimental under pathological conditions such as obstructive sleep apnea and other breathing disorders.