DETECTION OF RESTENSOSIS RISK IN PATIENTS RECEIVING A STENT
20170292965 · 2017-10-12
Inventors
Cpc classification
G01N33/86
PHYSICS
International classification
Abstract
Provided is a method of selecting a stent for implantation in the circulatory system of a human being. The method comprises obtaining a blood sample from a patient who requires implantation of a stent and testing said blood sample to determine a platelet coagulability level. The determined platelet coagulability level of said blood sample is compared with a threshold level of blood platelet coagulability. A determined platelet coagulability level above said threshold level indicates that a risk of restenosis is relatively high. If the determined platelet coagulability level is below said threshold level, a bare metal stent is selected. If the determined platelet coagulability level is at or above said threshold level, a drug-eluting stent is selected.
Claims
1. A method of selecting a stent for implantation in the circulatory system of a human being including the steps of: a) determining a threshold level of platelet hyper-coaguability (PHC) of blood, above which a risk of restenosis is relatively high; b) obtaining a blood sample from a patient who requires implantation of a stent; c) testing said blood sample for its PHC; d) comparing PHC of said blood sample with said threshold level; e) if said blood sample has a PHC below said threshold level, selecting a bare metal stent; and f) if said blood sample has a PHC at or above said threshold level, selecting a drug-eluting stent.
2. The method of claim 1, wherein said determining step includes the step of obtaining blood samples from a multiplicity of people, testing each sample for PHC and correlating said samples with data regarding onset of restenosis among said people to determine said threshold level.
3. The method of claim 1, wherein a marker of PHC measured comprises platelet-fibrin mediated clot strength (MA).
4. The method of claim 3, wherein said threshold level is MA=72.
5. The method of claim 3, wherein said testing step comprises: a) obtaining a viscoelastic monitor including a blood receiving cup; b) pouring blood into said cup; c) oscillating said cup with a pin suspended in said blood by a torsion wire; d) when clotting commences, said cup and pin become interconnected; e) measuring clot strength.
6. The method of claim 5, wherein said viscoelastic monitor includes automated analytical software.
7. The method of claim 6, wherein said software provides quantitative and qualitative measurements of initial fibrin formation, kinetics of clotting process, degree of platelet-fibrin mediated clot strength (MA), and dissolution.
8. The method of claim 5, wherein said oscillating step occurs over a distance of 4° 45′.
9. The method of claim 8, wherein said oscillating step occurs in 10 second cycles.
10. The method of claim 5, wherein said blood is mixed with a clot-promoting sub stance.
11. The method of claim 10, wherein said substance comprises kaolin.
12. The method of claim 3, wherein results from testing said samples are divided into quartiles sequentially numbered 1-4 from lowest to highest MA.
13. The method of claim 12, wherein patients having an MA in a 4.sup.th said quartile are implanted with a drug-eluting stent.
14. The method of claim 12, wherein patients having an MA in a 1.sup.st said quartile are implanted with a bare metal stent.
15. The method of claim 1, wherein a marker of PHC measured comprises speed of thrombin generation.
16. The method of claim 1, wherein a marker of PHC measured comprises platelet reactivity.
17. The method of claim 16, wherein said platelet reactivity is measured by an aggregometer.
18. The method of claim 16, wherein said platelet reactivity is measured by flow cytometry.
19. A method of selecting a stent for implantation in the circulatory system of a human being including the steps of: a) determining a threshold level of platelet-fibrin mediated clot strength (MA) of blood, above which a risk of restenosis is relatively high; b) obtaining a blood sample from a patient who requires implantation of a stent; c) testing said blood sample for its platelet-fibrin mediated clot strength, wherein said testing step comprises: i) obtaining a viscoelastic monitor including a blood receiving cup; ii) pouring blood into said cup; iii) oscillating said cup with a pin suspended in said blood by a torsion wire; iv) when clotting commences, said cup and pin become interconnected; v) measuring clot strength; vi) said viscoelastic monitor including automated analytical software; d) comparing clot strength of said blood sample with said threshold level; e) if said blood sample has a clot strength below said threshold level, selecting a bare metal stent; and f) if said blood sample has a clot strength at or above said threshold level, selecting a drug-eluting stent.
20. The method of claim 19, wherein said step includes the step of obtaining blood samples from a multiplicity of people, testing each sample for platelet-fibrin mediated clot strength and correlating said samples with data regarding onset of restenosis among said people to determine said threshold level.
21. The method of claim 20, wherein said threshold level is MA=72.
22. The method of claim 19, wherein said software provides quantitative and qualitative measurements of initial fibrin formation, kinetics of clotting process, degree of platelet-fibrin mediated clot strength (MA), and dissolution.
23. The method of claim 19, wherein said oscillating step occurs over a distance of 4° 15′ and in 10 second cycles.
24. The method of claim 19, wherein said blood is mixed with a clot-promoting substance comprising kaolin.
Description
BRIEF DESCRIPTION OF THE DRAWINGS
[0022]
[0023]
[0024]
SPECIFIC DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0025] Platelets play a fundamental role in the genesis of stent restenosis by mediating inflammation and smooth muscle proliferation. Thrombi with high tensile strength may facilitate growth factor release to the adjacent vessel wall resulting in neointimal hyperplasia.
[0026] Applicant measured pretreatment ex vivo maximum thrombin-induced clot strength, time to fibrin formation, and the combined clotting index with thrombelastography (TEG) in 178 consecutive patients undergoing elective stenting of de novo (n=160) and restenotic lesions (n=18) and in 25 healthy controls. Patients were followed for 6 months for the development of symptomatic restenosis. Patients who developed restenosis (n=28) had greater maximum clot strength (71.0±5.0 vs. 66.1±7.0, p=0.0004), higher combined clotting indices (3.4±1.8 vs 2.1±2.3, p=0.005) and more rapid fibrin generation times (4.0±1.0 vs 4.8±1.7, p=0.03) than patients without restenosis and healthy controls (p<0.05 for all measurements). The relative risk of developing restenosis was 22.5 times greater for patients with clot strength in the highest quartile vs. the lowest quartile. Multivariate analysis demonstrated the independent predictive value of these laboratory measurements.
[0027] These results suggest that the prothrombotic state, measured by TEG and highlighted by increased clot strength, is independently predictive of the development of in-stent restenosis. High clot strength may serve as a new marker leading to patient-specific therapies targeting antiproliferative therapy for those at greatest risk.
[0028] Presently, platelet related periprocedural thrombotic and inflammatory processes that influence neointimal hyperplasia and angiogenesis are considered as important risk factors for restenosis. Despite these established mechanisms, there are few data in humans that examine the relation of ex vivo measurements of platelet reactivity to restenosis. Moreover, preexisting inflammatory and hypercogulable factors are also suggested as important factors influencing restenosis. Applicant has found that patients with high clot strength may be at greatest risk for restenosis since their thrombi may be most resistant to disruption by flowing blood. A robust clot would theoretically facilitate residence of platelets at the vessel wall and subsequent delivery of pro-restenotic factors. Moreover, patients with rapid thrombin generation would be expected to readily form thrombi.
[0029] The Investigational Review Board at Sinai Hospital of Baltimore approved a study resulting in development of the present invention. One hundred and seventy-eight consecutive patients who underwent successful elective coronary artery or saphenous vein graft stenting gave informed consent prior to the procedure and were prospectively followed post-discharge for the development of symptomatic restenosis. Inclusion criteria included patients over 18 years old. Exclusion criteria were a history of bleeding diathesis, acute myocardial infarction within 48 hours, elevated cardiac markers (above upper limits normal for the respective assay), cerebrovascular event within 3 months, chronic vessel occlusion or angiographically visible thrombus, illicit drug or alcohol abuse, prothrombin time greater than 1.5 times control, platelet count<100,000/mm.sup.3, hematocrit<30%, creatinine>4.0 mg/dl, and glycoprotein (GP) IIb/IIIa inhibitor use prior to the procedure.
[0030] Blood samples were obtained in the catheterization laboratory through an indwelling femoral vessel sheath and transferred to vacutainer collecting tubes (Becton—Dickinson, Rutherford, N.J.) containing 40 USP lithium heparin after discarding the first 2-3 ml of free flowing blood. Samples were obtained before GPIIb/IIIa inhibitors and heparin administration (baseline). Blood samples were also obtained at the time of the second procedure from patients who developed symptomatic restenosis.
[0031] The Thrombelastograph (TEG®) Hemostasis Analyzer with automated analytical software provides quantitative and qualitative measurements of the physical properties of a clot. Briefly, the TEG is a viscoelastic monitor that measures the degree of platelet-fibrin mediated clot strength as shown in
[0032] The R parameter is a measure of initial thrombin-generated fibrin formation and has been correlated with the velocity of thrombin generation. The coagulation index (CI) is a measure of overall coagulation that is calculated from the kinetics of clot development and formation in native or kaolin-activated whole blood. CI is derived from a computer calculated linear combination of R, K [the rate of thrombus formation], MA and the a-angle [a measure of the rapidity of fibrin generation and cross linking according to the following formula]:
(CI=−0.6516R−0.3772K+0.1224MA+0.0759α−7.7922).
Normal values for the CI lie between −3.0 and +3.0, which is equivalent to three standard deviations about the mean of zero. Positive values outside this range (CI>+3.0) indicate that the sample is hypercoagulable, whereas negative values outside this range (CI<−3.0) indicate that the sample is hypocoagulable.
[0033] Blood was analyzed according to the manufacturer's instructions. One mL of heparinized blood was transferred to a vial containing kaolin and mixed by inversion. Five hundred microliters of the activated blood was then transferred to a vial containing heparinase and mixed to neutralize the heparin.The neutralized blood (360 uL) was immediately added to a heparinase coated cup and assayed in the TEG analyzer according to the manufacturer's instructions to obtain the thrombin-induced clot. Once the sample assay is completed, automated analytical software generates the MA, R and CI values.
[0034] Patients were clinically followed by research staff for the development of recurrent angina defined as the occurrence of typical symptoms that warranted cardiac catheterization at the discretion of the treating cardiologist who was blinded to the study results of the given patient. Restenosis was defined as >50% luminal diameter stenosis in the stented segment by visual estimate. Stent thrombosis was defined by the sudden onset of coronary artery occlusion in a stented vessel resulting in hospitalization and judged by the treating interventionalist as due to thrombosis.
[0035] The linear logistic regression model was employed to fit the binary data (restenosis=1 and no-restenosis=0). This logistic regression model was fit using SAS procedure PROC LOGISTIC (Cary, N.C., USA). The model is given by:
Logit(p)=Log {p/(1−p)}=β.sub.0+β.sub.1.Math.X
where p=proportion of incidence of restenosis, and X is a predictor variable. The three variables (possible X) considered here are MA, LTA and R. β.sub.0 is constant or intercept (value of the dependent variable when X=0); β.sub.1 is the slope (increase in the value of p per unit increase in X).
[0036] The multiple linear logistic regression model was employed to fit binary data to compare the prevalence of demographic, angiographic and clotting variables in patients with restenosis and without restenosis. The logistic regression model was fit using SAS procedure PROC LOGISTIC. Odds ratios were calculated using SAS software, and ROC curves were generated using MedCalc Software (MedCalc Software, Broekstraat, Belgium). Based on the normal distribution of data the mean±SD is reported except as otherwise noted and p<0.05 was considered significant. Comparisons were made between the restenotic and non-restenotic groups by t-tests (Statistica software) for continuous variables and by Fischer's exact test for categorical data.
[0037] The results were as follows:
[0038] One hundred thirty-three patients received a loading dose of clopidogrel [300 mg (n=76), 600 mg (n=57)] in the catheterization laboratory immediately after successful stenting. Patients on a maintenance dose of clopidogrel at the time of admission (n =45) did not receive a loading dose. The GP IIb/IIIa inhibitor, eptifibatide was administered to 71 patients at the discretion of the treating physician. All patients treated with eptifibatide received unfractionated heparin according to the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) dosing regimen (60 U/kg) as a bolus. In all other patients, heparin was administered to achieve an activated clotting time of 300 seconds. Aspirin (325 mg) was administered on the day of the procedure and daily thereafter. The maintenance dose of clopidogrel was 75 mg daily.
[0039] One hundred and sixty patients underwent stenting of de novo lesions and 18 patients underwent stenting of at least one restenotic lesion. Symptomatic restenosis developed in 12 patients over the 6 months of follow-up (10/160 initially treated with de novo lesions land 2/18 initially treated with at least one restenotic lesion). 4 patients developed a myocardial infarction in the distribution of the target vessel. Among the latter patients, 2 events were due to obstruction of the stented segment, and 2 patients had the frank occurrence of a subacute stent thrombosis (Tables 5, 6).
[0040] Healthy controls comprised 50% men at an age of 39±8 years and were free of cardiovascular risk factors and concomitant pharmacologic therapy. The clinical and angiographic demographics of patients with and without symptom driven restenosis are shown in Tables 1 and 2 and demonstrate equivalence between the groups except for a higher incidence of prior myocardial infarction in patients who developed restenosis.
Maximum Clot Strength, Rapidity of Fibrin Formation, and Clot Index Baseline Measurements
[0041] Patients undergoing stenting had markedly higher MA (67.0±6.0) and CI (2.3±2.0); and more rapid fibrin generation (4.7±1.5) than healthy controls (p<0.001 for all comparisons, Table 3). Patients undergoing treatment of restenotic lesions had higher baseline MA (69.9±3.0 vs. 67.0±6.0, p=.04) and CI (3.6±1.5 vs. 2.2±2.2, p=.005), and shorter R (3.7±1.2 vs. 4.8±1.6, p=0.009) than patients undergoing treatment of de novo lesions.
[0042] The mean normal value+2SD (72 mm) for MA (MA72) was evaluated to determine whether patients might be classified by restenosis risk based on having pre-treatment values above or below this high level of platelet-fibrin mediated clot strength (Table 4). Of the 12 patients who suffered restenosis, 8 had MA values above 72 mm (67%), compared with 30 of 150 patients (20%) who did not develop restenosis (p=0.0005). The odds ratio (OR) of symptomatic restenosis at 6 months post-PCI for patients with MA values greater than 72 mm was 10.9. Use of MA72 to differentiate risk of restenosis among post-PCI patients had a sensitivity of 67% and a specificity of 80% (
[0043] Overall, patients who developed restenosis had higher baseline maximum clot strength (75.5.±4.5 vs. 66.5±6.5, p=0.0001), more rapid fibrin generation (4.2±1.0 vs. 4.6±1.5, p=0.36), and a greater clot index (3.6±1.3 vs. 2.3±2.31 p=0.03) than patients who did not develop restenosis. Comparison of measurements with respect to the initial treatment of de novo vs. restenotic lesions demonstrates that high clot strength, rapid fibrin generation and a great clot index were associated with restenotic lesions. Similar findings occurred in the baseline analyses from the immediate study that demonstrated higher clot strength, more rapid fibrin generation and a greater clot index in those patients undergiong revascularization for stent restenosis as compared to treatment of a de nove lesion (Table 3).
[0044] The relative risk ratios for restenosis for each of the quartiles as compared to the first quartile based on the baseline measurements from both groups are shown in Table 4.
DISCUSSION
[0045] The current study demonstrates that: 1) The physical properties of ex vivo thrombi generated by thrombin in the blood of patients undergoing elective stenting differs dramatically from the thrombi generated in healthy controls. Patient thrombi have markedly greater maximum tensile strength and fibrin production occurs more rapidly, 2) The physical properties of ex vivo thrombi differs between patients undergoing treatment of de novo lesions versus patients undergoing treatment of restenotic lesions. Patients with restenotic lesions have greater thrombin-induced clot strength and produce fibrin more rapidly than patients undergoing treatment of de novo lesions, and 3) Baseline measurements of maximum thrombin-induced clot strength are highly predictive of restenosis; patients in the highest quartile have an approximate 23 fold risk of developing restenosis as compared to patients in the lowest quartile. Applicant's data demonstrates that these measurements are stable over the period of restenosis development.
[0046] The current study is the first to examine the predictive value of the physical properties (i.e. maximum tensile strength) of a patient's clot in determining restenosis. Moreover, it is the first study to assess the utility of thrombelastography measurements as markers for restenosis development in patients undergoing percutaneous coronary revascularization. Moreover, Applicant's data demonstrates the independent predictive value of the measurements irrespective of the clinical demographics that have been associated with restenosis.
[0047] The current study strengthens the proposed central role of reactive platelets in the pathophysiology of restenosis. The maximum thrombin-induced clot strength measured by TEG is indicative of the tensile properties of the platelet-fibrin interaction. Applicant had hypothesized that robust clot formation may facilitate platelet residence at the vessel wall interface and thus enhance the transfer of growth factors, thus promoting intimal proliferation and restenosis. Platelet and fibrin deposition has been well described at the site of stent implantation. Platelet surface receptors facilitate attachment of leukocytes to the area of injury that further release growth factors. Moreover, in the current study, patients with the most rapid thrombin generation may be expected in vivo to generate activated platelets. Applicant's data supports the importance of the rapidity of thrombin generation and the responsiveness of platelets to thrombin as major factors in the development of restenosis.
[0048] It is well known that many patients experience excellent long-term clinical outcomes following treatment with non-drug eluting stents. In addition, there are pitfalls to the implantation of drug-eluting stents that include a requirement of prolonged dual antiplatelet therapy and concerns for late stent thrombosis. Prolonged therapy with clopidogrel adds significantly to cost and many patients are intolerant to treatment. Up to this date, there have been no validated markers that predict restenosis. The validation of a restenosis marker may assist in the decision making for a bare metal stent as compared to a drug-eluting stent. Applicant's data strongly suggests that patients in the lowest quartile for clot strength are at very low risk of developing restenosis whereas those in the highest quartile have extremely high risk. These quartiles may serve as cutpoints to be examined in prospective investigations of bare metal versus drug-eluting stents.
[0049] Applicant's results suggest that the prothrombotic state measured by TEG and highlighted by increased clot strength is independently predictive of the development of in-stent restenosis. High clot strength may serve as a new marker leading to patient-specific therapies targeting antiproliferative therapy for those at greatest risk.
[0050] As such, an invention has been disclosed in terms of preferred embodiments thereof which fulfill each and every one of the objects of the invention as set forth hereinabove, and provide a new and useful method for the detection of restenosis risk in patients receiving a stent by measuring the characteristics of blood clotting including the measurement of maximum thrombin-induced clot strength of great novelty and utility.
[0051] Of course, various changes, alterations and modifications in the teachings of the present invention may be contemplated by those skilled in the art without departing from the intended spirit and scope thereof.
[0052] As such, it is intended that the present invention only be limited by the terms of the appended claims.
TABLE-US-00001 TABLE 1 Patient Demographics No Restenosis Restenosis (n = 12) (n = 166) p-value Age (years) 66 ± 9 64 ± 12 NS Race (Caucasian) n, (%) 6(50) 121(73) .03 Gender (Male) n, (%) 4(33) 109(66) .007 BMI 30 ± 6 30 ± 7 NS Risk Factors/ Past medical Hx n, (%) Smoking 9(75) 86(52) .05 Family history of CAD 6(50) 91(55) NS Hypertension 6(50) 105(63) NS Hyperlipidemia 10(83) 126(76) NS Diabetes 5(42) 73(44) NS Prior Myocardial Infarction 7(58) 48(29) .009 CHF 3(25) 24(14) NS Prior CABG 4(33) 42(25) NS Prior PTCA 5(42) 44(27) NS Baseline Medications n, (%) Aspirin 12(100) 166(100) NS Clopidogrel 2(17) 43(26) NS Beta blockers 8(67) 147(89) .01 ACE Inhibitors 9(75) 117(70) NS Calcium blockers 2(17) 39(23) NS Lipid lowering agents 11(92) 142(86) NS 3A4 10(82) 91(55) NS Non 3A4 1(8) 51(31) NS Laboratory Data WBC (X1000/mm.sup.3) 7.8 ± 2.6 7.3 ± 2.2 NS Platelets (X1000/mm.sup.3) 263 ± 82 236 ± 69 NS Hematocrit (g/dl) 37.7 ± 5.5 40.0 ± 5.0 NS Hemoglobin (g/dl) 12.2 ± 2.3 13.4 ± 1.9 NS Creatinine (g/dl) 1.0 ± 0.3 1.1 ± 0.5 NS BMI = body mass index CABG = coronary artery bypass graft surgery CAD = coronary artery disease PTCA = percutaneous coronary angioplasty ACE = angiotensin converting enzyme WBC = white blood cells 3A4 = hepatic cytochrome 3A4
TABLE-US-00002 TABLE 2 Procedural Characteristics No Restenosis Restenosis (n = 12) (n = 166) p Value Ejection Fraction (%) 46 ± 12 50 ± 8 NS Number of vessels treated 1.3 ± .5 1.3 ± .6 NS Lesion Morphology Denovo n, (%) 10(83) 150(90) NS Lesion Location n, (%) LAD 4(34) 54(33) NS CX 1(8) 44(27) .07 RCA 7(58) 61(36) .06 SVG 0 7(4) NS Stent Types Drug eluting n, (%) 8(66) 116(70) NS Reference vessel diameter (mm) 3.1 ± 0.4 3.0 ± 0.4 NS Total lesion length (mm) 24 ± 13 19 ± 12 NS Pre-stenosis (%) 88 85 NS Post-stenosis (%) 5 4 NS CX = circumflex artery LAD = left anterior descending artery RCA = right coronary artery SVG = saphenous vein graft
TABLE-US-00003 TABLE 3 Clot Strength, Reaction Time, Coagulation Index in Healthy Controls and Patients with Baseline Denovo and Restenotic Lesions Patients with Baseline De novo Patients with Baseline Restenotic Lesions Lesions Restenosis Restenosis No (n = 10) No (n = 2) Restenosis At time Restenosis At time of Healthy (n = 150) of PCI (n = 16) PCI for Controls Baseline Baseline for Baseline Baseline recurrent (n = 25) Measurement Measurement restenosis Measurement Measurement restenosis Clot Strength (MA) 60.7 ± 5.1 66.2 ± 7.0* 75.0 ± 4.7** 77.4 ± 4.4 68.5 ± 3.1 76.5 ± 1.0.sup.ψ 76.6 ± 1.1 (mm) Reaction Time (R) 6.9 ± 1.2 4.8 ± 1.7* 4.8 ± 1.2 4.6 ± 1.5 4.0 ± 1.1 2.0 ± 0.5.sup.# 2.0 ± 0.5 (min) Coagulation Index (CI) −0.8 ± 1.8 2.1 ± 2.3* 3.1 ± 1.6 3.8 ± 1.4 3.2 ± 1.3 5.9 ± 0.4.sup.δ 6.0 ± 0.5 *p < 0.001 Healthy controls vs. patients with baseline de novo lesions who did not develop restenosis **p < 0.001 Patients with baseline de novo lesions who did not develop restenosis vs. who developed restenosis .sup.Ψp = 0.02 Patients with Baseline Restenotic Lesions who did not develop restenosis vs. who developed restenosis .sup.#p = 0.002 Patients with Baseline Restenotic Lesions who did not develop restenosis vs. who developed restenosis .sup.δp = 0.01 Patients with Baseline Restenotic Lesions who did not develop restenosis vs. who developed restenosis
TABLE-US-00004 TABLE 4 Relative Risk of Restenosis by Quartiles Relative Risk of Quartiles Restenosis Clot Strength (MA) 1.sup.st 1 2.sup.nd 2.5 3.sup.rd 5 4.sup.th 22.5 Reaction Time (R) 1.sup.st 1 2.sup.nd 3 3.sup.rd 4 4.sup.th 2 Coagulation Index (CI) 1.sup.st 1 2.sup.nd 3 3.sup.rd 3 4.sup.th 7
TABLE-US-00005 TABLE 5 Comparison of sensitivity and specificity of MA72 in predicting restenosis at 6 months post-PCI Odds Restenosis (n) No Restenosis (n) Total (n) Ratio MA > 72 mm 8 30 38 10.9 MA ≦ 72 mm 4 120 124 — Total 12 150 162 — Sensitivity (%) 67 — — — Specificity (%) 80 — — —
TABLE-US-00006 TABLE 6 Stepwise multiple logistic regression analysis Estimate SE p value OR 95% CI Intercept −2.25 1.87 .2305 — — Gender 2.11 0.85 .0129 8.26 1.57, 43.64 Prior PTCA −1.43 0.72 .0478 0.24 .06, .99 Prior MI −1.54 0.80 .0542 0.21 0.05, 1.03 MA72 2.39 0.79 .0025 10.88 2.31, 51.19 No additional effects met the .05 significance level for inclusion in the model