Inflammation and Arterial Injury

Question 1

What is the main concern with drug-eluting stents (DES) in relation to late stent thrombosis?

Answer 1

DES can elicit a chronic inflammatory response even after the drug has fully eluted

This reaction is generally localized and hypothesized to be associated with an increased risk of very late stent thrombosis.

Question 2

What is a significant difference between ticagrelor and clopidogrel?

Answer 2

Ticagrelor is a more potent platelet P2Y12 receptor antagonist than clopidogrel

In the PLATO trial, cardiovascular events were decreased with ticagrelor compared to clopidogrel among patients with ACS.

Question 3

What does the figure demonstrate regarding vasoconstriction with different stent types?

Answer 3

Significantly more proximal and distal vasoconstriction with PES and SES vs. BMS

This suggests a chronic inflammatory response to permanent polymer.

Question 4

What is the main outcome of the seminal meta-analysis of randomized controlled trials regarding CoCr EES?

Answer 4

Dramatically reduced rates of definite stent thrombosis at all time points compared to BMS

No other tested DES had lower definite stent thrombosis than BMS at 2-year follow-up.

Question 5

What role do polymers play in drug-eluting stents (DES)?

Answer 5

Polymers modulate the elution characteristics of the drug on DES

They do not have an independent positive effect on neoatherosclerosis or in-stent restenosis rates.

Question 6

What are the phases of the healing response after coronary stenting?

Answer 6

Phase I: de-endothelialization, Phase II: release of growth factors, Phase III: migration of smooth muscle cells and re-endothelialization

This process involves acute inflammatory cells and chronic inflammatory cells.

Question 7

How do Paclitaxel and Sirolimus affect neointimal hyperplasia?

Answer 7

They decrease the amount of neointimal hyperplasia compared to BMS

However, the underlying polymer has no favorable effect on the healing process.

Question 8

What are the factors that may increase inflammation and restenosis after stenting?

Answer 8

(a) certain polymers/drugs, (b) stent strut thickness, (c) medial injury or lipid core penetration

Deployment of stents in fibrous plaque can reduce inflammation.

Question 9

What adverse effects can high-dose Paclitaxel have?

Answer 9

Augmented inflammatory response compared to polymer alone

Adverse events related to chronic inflammation and delayed healing were noted with the QuaDS QP-2 stent.

Question 10

What is the primary systemic marker of inflammation studied in relation to PCI?

Answer 10

CRP (C-reactive protein)

The magnitude of pre-and post-PCI levels of CRP has been associated with adverse events after stenting.

Question 11

What has been observed regarding the rates of stent thrombosis in newer generation metallic DES?

Answer 11

Progressively decreasing rates of both early and late stent thrombosis compared to early-generation counterparts

This is attributed to thinner struts and better materials.

Question 12

True or False: Late acquired incomplete stent apposition is more common after BMS than DES.

Answer 12

False

Incomplete stent apposition is more common after DES.

Question 13

What cytokine is primarily responsible for stimulating CRP production?

Answer 13

IL-6

IL-6 is produced by macrophages and is the main hepatic stimulus for CRP production.

Question 14

Fill in the blank: The major cause of DES thrombosis is _______.

Answer 14

early cessation of DAPT

Rare hypersensitivity reactions can also occur post-implantation.

Question 15

What is the impact of statin therapy prior to PCI?

Answer 15

Statin therapy seems to have the most benefit among patients with the highest level of pre-PCI inflammation

Atorvastatin, clopidogrel, and abciximab may blunt the inflammatory response after PCI.

Question 16

What does flow-mediated dilation of the brachial artery reflect?

Answer 16

Systemic endothelial dysfunction

Abnormal endothelial function can be seen over 6 months after DES placement.

Question 17

What is the relationship between systemic cytokine rise and restenosis in the DES era?

Answer 17

No difference in systemic cytokine rise has been confirmed between DES and BMS

Local drug delivery likely suppresses inflammation and smooth muscle cell migration despite similar systemic responses.

Question 18

What occurs during cardiogenic shock according to newer evidence?

Answer 18

A systemic inflammatory response leading to nitric oxide synthase overproduction

This results in inappropriate vasodilation and refractory hypotension.

Question 19

What medications may blunt the inflammatory response after PCI?

Answer 19

Atorvastatin, clopidogrel, and abciximab

These medications may have a beneficial impact on PCI by reducing inflammation.

Question 20

What effect did abciximab have on CRP and IL-6 levels after PCI in the EPIC trial?

Answer 20

Blunted the rise of CRP and IL-6

This effect was observed in a subset of patients.

Question 21

How does clopidogrel affect patients with high CRP levels undergoing PCI?

Answer 21

Attenuates the increased risk associated with PCI

This suggests a protective role in high-risk patients.

Question 22

In which patients does statin therapy prior to PCI seem to have the most benefit?

Answer 22

Patients with the highest level of pre-PCI inflammation

This indicates that inflammation may influence the effectiveness of statins.

Question 23

Do systemic medications clearly impact long-term healing such as stent restenosis?

Answer 23

No

However, local applications of statin drugs may be promising for inflammation and smooth muscle cell migration.

Question 24

What factors have been proposed for increased stent thrombosis rates with bioresorbable scaffolds?

Answer 24

Thicker strut sizes, poorer radial strength, visualized intraluminal masses

These may represent early thrombi or late malapposed struts.

Question 25

What has been observed in follow-up studies from the ABSORB trials regarding bioabsorbable vascular scaffolds?

Answer 25

No residual struts seen at 5 years

Dilation improved but did not return completely to normal compared to adjacent undiseased segments.

Question 26

What did intravascular imaging reveal over areas of prior bioabsorbable vascular scaffolds?

Answer 26

Thick capped neointima

This finding indicates potential changes in the vascular structure post-implantation.

Question 27

What is the effect of GP IIb/IIIa inhibitors on platelet aggregation?

Answer 27

Decrease platelet aggregation and periprocedural myonecrosis

This is an important aspect of their function in PCI.

Question 28

What does the EPIC trial suggest about abciximab compared to heparin alone?

Answer 28

Decreased the rise of CRP and IL-6

This highlights its potential anti-inflammatory effects.

Question 29

What is the significance of the TARGET trial regarding tirofiban?

Answer 29

Inferiority of tirofiban compared to abciximab

This may relate to inadequate dosing and lack of anti-inflammatory effects.

Question 30

Have GP IIb/IIIa inhibitors been shown to prevent intimal hyperplasia and in-stent restenosis?

Answer 30

No

This raises questions about their long-term efficacy in preventing these conditions.