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Residual Inflammatory Risk After PCI
Study Questions:
What is the prevalence of patients with persistent high levels of inflammation after percutaneous coronary intervention (PCI) and the clinical outcomes according to inflammatory response?
Methods:
The investigators conducted a retrospective cohort study assessing patients undergoing PCI between 2009 and 2016 with serial inflammatory status assessment from a large, prospective, and single-center PCI registry. They assessed inflammation status with at least two high-sensitivity C-reactive protein (hsCRP) measurements at baseline and follow-up with >4 weeks apart. High residual inflammatory risk (RIR) was defined as an hsCRP ≥2 mg/L. Patients were divided into four groups: persistent high RIR, increased RIR (first low-, then high hsCRP), attenuated RIR (first high-, then low hsCRP), or persistent low RIR. The primary endpoint was all-cause mortality at 1-year follow-up. Occurrence of myocardial infarction (MI) was assessed as a secondary outcome. Clinical outcomes were analyzed using the Kaplan–Meier method and compared using the log-rank test.
Results:
Seven thousand and twenty-six patients were identified with serial hsCRP measurements (30.8% of all PCI patients). Of these patients, 2,654 (38%) had persistent high RIR, 719 patients (10%) had increased RIR, 1,088 patients (15%) had attenuated RIR, and persistent low RIR was seen in 2,565 patients (37%). All-cause mortality at 1 year was 2.6% in patients with persistent high RIR, compared with 1.0% in increased RIR, 0.3% in attenuated RIR, and 0.7% in persistent low RIR patients (p < 0.01). MI at 1 year was observed in 7.5% of persistent high RIR, compared with 6.4% in increased RIR, 4.6% in attenuated RIR, and 4.3% in persistent low RIR (p < 0.01). In an adjusted model, including accounting for diabetes mellitus, acute coronary syndrome, and baseline low-density lipoprotein, results were sustained.
Conclusions:
The authors concluded that persistent high RIR is observed frequently in patients undergoing PCI with significantly higher all-cause mortality and MI rates observed in these patients at 1-year follow-up.
Perspective:
This study reports that persistent high RIR is observed frequently in patients undergoing PCI and is associated with higher 1-year all-cause death and MI. These data suggest that determining RIR in PCI patients may identify a high-risk population, but whether the use of anti-inflammatory medication in this population reduces recurrent cardiovascular events deserves additional investigation. Of note, the CIRT (Cardiovascular Inflammation Reduction Trial) trial (NCT01594333) assessing whether taking low-dose methotrexate reduces heart attacks, strokes, or death in people with type 2 diabetes or metabolic syndrome did not result in fewer cardiovascular events than placebo. Whether, other agents targeting the interleukin-1β innate immunity pathway can reduce cardiovascular events without increasing the risk of fatal infections needs further study.
Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, ACS and Cardiac Biomarkers, Lipid Metabolism, Interventions and ACS
Keywords: Acute Coronary Syndrome, C-Reactive Protein, Diabetes Mellitus, Type 2, Inflammation, Lipoproteins, LDL, Metabolic Syndrome, Methotrexate, Myocardial Infarction, Percutaneous Coronary Intervention, Primary Prevention, Risk, Stroke, Vascular Diseases
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