RESUMEN
BACKGROUND: Carotid atherosclerotic plaques are one of the causes of cerebral stroke. The risk is higher for the vulnerable plaques but there are no specific markers to identify them. The aim of our study was to identify vulnerable carotid plaques by the mean of atherosclerotic serological markers in patients undergoing carotid revascularization by endarterectomy (CEA) or stenting (CAS). METHODS: High sensitivity C-reactive protein (hsCRP) and vascular-endothelial-growth-factor (VEGF) levels were assessed preoperatively in patients undergoing carotid revascularization. Carotid plaques vulnerability were investigated in two different methods: the "biological vulnerability" with the histological evaluation of the plaques from CEA, scoring five parameters (microvessel density, fibrous-cap-thickness, calcification, inflammatory infiltrate and lipid core), and the "structural vulnerability" with the evaluation of the plaques debris detached during CAS and captured by the cerebral protection filter, in terms of percentage of filter pores occlusion (OP). Results were correlated using χ2, Fisher's, Mann-Whitney, Student's t-tests and regression analysis. RESULTS: The histological analysis was performed in 40 specimens, vulnerable plaques (30%) were correlated with higher hsCRP levels (>5mg/l; OR, 2.5; CI 95%, 1.1-5.5; P=0.01) and VEGF levels (VEGF>500 pg/l; OR 3.0, CI 95%, 1.1-7.7; P=0.01). All the filters (N.40) contained microscopic debris (mean OP 26.6%±9.9); higher hsCRP levels (>5mg/l) were correlated with greater than 25% OP (OR, 2.6; CI 95%, 1.2-5.7). An increase in the percentage of OP was also observed in patients with VEGF>500 pg/l (OR, 2.9; CI, 95% 1.3-6.3). CONCLUSIONS: This study suggests that serological determinants are useful in recognizing the structural and biological vulnerability of carotid plaques.
Asunto(s)
Proteína C-Reactiva/análisis , Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/sangre , Placa Aterosclerótica , Factor A de Crecimiento Endotelial Vascular/sangre , Anciano , Anciano de 80 o más Años , Angioplastia/instrumentación , Biomarcadores/sangre , Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/terapia , Distribución de Chi-Cuadrado , Endarterectomía Carotidea , Femenino , Humanos , Modelos Lineales , Masculino , Oportunidad Relativa , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Rotura Espontánea , Pruebas Serológicas , Stents , Resultado del Tratamiento , Regulación hacia ArribaRESUMEN
AIMS: The use of high-sensitivity cardiac Troponin T (hs-cTnT) assay might lead to overdiagnosis and overtreatment of Acute Coronary Syndromes (ACS). This study assessed the epidemiological, clinical and prognostic impact of introducing hs-cTnT in the everyday clinical practice of an Emergency Department. METHODS AND RESULTS: We compared all consecutive patients presenting with suspected ACS at the Emergency Department, for whom troponin levels were measured. In particular, we considered 597 patients presenting during March 2010, when standard cardiac Troponin T (cTnT) assay was used, and 629 patients presenting during March 2011, when hs-cTnT test was used. Patients with suspected ACS and troponin levels above the 99th percentile (Upper Reference Limit, URL) significantly increased when using an hs-cTnT assay (17.2% vs. 37.4%, p< 0.001). Accordingly, also the mean GRACE risk score increased (124.2 ± 37.2 vs. 136.7 ± 32.2; p< 0.001). However, the final diagnosis of Acute Myocardial Infarction (AMI) did not change significantly (8.7% vs. 6.8%, p=0.263) by using a rising and/or falling pattern of hs-cTnT (change ≥ 50% or ≥ 20% depending on baseline values). In addition, no significant differences were found between the two study groups with respect to in-hospital (2.7% vs. 1.9%, p=0.366) and 1-year mortality (9.8% vs. 7.6%, p=0.216). CONCLUSIONS: We did not observe overdiagnosis and overtreatment issues in presenters with suspected ACS managed by appropriate changes in hs-cTnT levels, despite the increase in the number of patients presenting with abnormal troponin levels. This occurred without a rise in short-term and mid-term mortality.
Asunto(s)
Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/epidemiología , Admisión del Paciente/estadística & datos numéricos , Troponina T/sangre , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/terapia , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
PURPOSE: To investigate serological predictors of risk for cerebral embolism after carotid artery stenting (CAS). METHODS: Twenty consecutive symptomatic and asymptomatic patients (13 men; mean age 74 years) with carotid artery stenosis undergoing standardized filter-protected CAS (Wallstent) were preoperatively evaluated to identify unstable plaque (duplex ultrasound), complicated aortic plaque (transesophageal echocardiography), and inflammatory status [high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA) serum levels]. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing the number, volume, and side (ipsilateral and non-ipsilateral) of preoperative and postoperative cerebral lesions detected on diffusion-weighted resonance magnetic imaging (DW-MRI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS. RESULTS: All CAS procedures were completed with no complications. All patients had a negative preoperative DW-MRI, but at least 1 asymptomatic cerebral lesion appeared on DW-MRI after the procedure in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 for men, p=0.03). Carotid plaque morphology, supra-aortic vessel anatomy, and procedure complexity did not correlate with number or volume of new cerebral lesions. Complicated aortic plaque was associated with a higher volume of non-ipsilateral cerebral lesions than uncomplicated plaque (235.0±259.3 vs. 63.6±63.2 mm(3), respectively; p=0.02). Hs-CRP ≥5 mg/L and SAA ≥10 mg/L were significantly associated with a higher number of new cerebral lesions [16.2±10.7 vs. 4.3±3.4 for hs-CRP <5 mg/L (p=0.02) and 14.8±10.3 vs. 2.8±3.4 for SAA <10 mg/L (p=0.006), respectively]. Hs-CRP ≥5 mg/L and SAA ≥10 mg/L also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis [37.0% (5.1%) vs. 26.9% (2.5%) for hs-CRP <5 mg/L, p=0.004; 35.9% (13.5%) vs. 22.2% (6.9%) for SAA <10 mg/L, p=0.02]. CONCLUSION: In addition to female gender and the presence of complicated aortic plaque, inflammatory status can be a predictor of cerebral embolism in CAS.
Asunto(s)
Angioplastia/efectos adversos , Angioplastia/instrumentación , Estenosis Carotídea/terapia , Mediadores de Inflamación/sangre , Embolia Intracraneal/etiología , Stents , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades Asintomáticas , Biomarcadores/sangre , Estenosis Carotídea/sangre , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/inmunología , Imagen de Difusión por Resonancia Magnética , Ecocardiografía Transesofágica , Dispositivos de Protección Embólica , Femenino , Humanos , Embolia Intracraneal/sangre , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/inmunología , Masculino , Microscopía Electrónica de Rastreo , Placa Aterosclerótica , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Factores de Riesgo , Factores Sexuales , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
BACKGROUND: The CD69 antigen is an indicator of early lymphocyte activation. GOALS: To evaluate the early activation of peripheral lymphocytes T, B, and NK in patients with acute pancreatitis in comparison with patients with acute abdomen of nonpancreatic origin. STUDY: Thirty patients with acute pancreatitis were studied; 20 of them had the mild form of the disease and 10 had the severe form. Thirty patients with nonpancreatic acute abdomen were used as controls. All patients were enrolled within 48 hours of the onset of pain. In all patients, leukocytes and total lymphocyte and lymphocyte subset counts (CD4+, CD8+, CD56+, CD19+, CD4+CD69+, CD8+CD69+, CD56+CD69+, CD19+CD69+) were determined upon hospital admission. RESULTS: The percentage of total lymphocytes was significantly lower in acute pancreatitis patients than in those with nonpancreatic acute abdomen (P = 0.014); patients with severe pancreatitis had a percentage of total lymphocytes significantly lower when compared with patients with mild pancreatitis (P < 0.001). The CD19+CD69+ count was significantly lower in patients with severe pancreatitis (24.6 +/- 14.6%) than in patients with mild pancreatitis (46.7 +/- 16.5%; = 0.006). The counts of the other lymphocyte subsets were not statistically different between patients with acute pancreatitis and those with nonpancreatic acute abdomen, as well as between patients with mild and severe acute pancreatitis. CONCLUSIONS: Patients with severe pancreatitis show impaired early activation of peripheral CD19+ cells.