An analysis of factors related to the development of in-stent restenosis after percutaneous coronary intervention.

To investigate the relationship between life style, medication adherence and the development of in-stent restenosis after percutaneous coronary intervention.A total of 230 patients with coronary heart disease were recruited and investigated with semi-quantitative food frequency questionnaire, international physical activity questionnaire, screening tool for psychological and Morisky questionnarie. Logistic regression was used for statistical analysis.Logistic regression analysis revealed that there was positive correlation between Morisky score (OR = 1.503), anger (OR = 1.135) and restenosis; and there was negative correlation between physical activity (OR = 0.346), folate intake (OR = 0.926), Vitamin C ingestion (OR = 0.881) and restenosis.The lifestyle and medication adherence of patients after percutaneous coronary intervention are predictors of restenosis, suggesting that it is necessary to strength intervention program to reduce restenosis.

Introduction

Percutaneous coronary intervention (PCI) is currently one of the main methods for the treatment of coronary heart disease, but there is still about 10% of the incidence of restenosis.[ Therefore, how to reduce restenosis has become the focus of interventional treatment. Previous studies[ have sought to determine the influencing factors of restenosis from clinical data, lesion types, and surgical procedures. However, the effects of lifestyle and medication adherence on restenosis have rarely been reported. The secondary prevention guideline for postoperative PCI[ pointed out that postoperative patients need to change the original unhealthy lifestyle from the aspects of diet, exercise, and emotion to maintain the patency of the coronary artery. However, the survey shows that the change of lifestyle after PCI is not optimistic.[ Therefore, this study aims to explore the impact of lifestyle and medication compliance on restenosis, which is of great significance.

Subjects and methods

Study population

Using a convenient sampling method, we selected coronary artery stenting at a tertiary hospital in Harbin from October 2016 to December 2017 and performed coronary angiography review within 6 to 18 months after surgery.

Inclusion criteria: First, the subject Conform to the American Heart Association diagnostic criteria for coronary artery disease. Second, Successful stent implantation for the first time which standard angiography shows a minimum stenosis diameter of less than 20% and distal coronary artery blood flow TIMI flow grade 3.Third, the re-examination of the angiography time was 6 to 18 months after the first stent implantation. Fourth, the case data is complete and voluntary.

Exclusion criteria: First, with severe systemic other systemic diseases. Then persons with a sense of language and language skills.

Finally, 68 patients were selected for restenosis and 162 were non-stenosis. According to the results of coronary angiography, they were divided into in-stent restenosis group[ (with or without stent within 5 mm and stent stenosis > 50% lumen defined as in-stent restenosis) and non-restenosis group.

Dietary assessment

Daily nutrional intakes were obtained from food frequency questionnaire, consists of a food list, the frequency of food intake, and the weight of each ingestion.[ It is used to collect the dietary status of the subjects in the past year. This questionnaire is based on the foods collected in the 2002 Survey of Nutrition and Health Status of Chinese Residents,[ and in combination with the dietary habits of the residents in the area, the types of foods that have been frequently consumed by residents have been screened out, and the reliability and validity have been measured. The test, CVI is 0.96, Cronbach's α coefficient is 0.853.[ According to “Chinese food composition table (2004)” to calculate the average daily intake of nutrients.[

Physical activity assessment

The measurement and evaluation of physical activity in this study was conducted in the Chinese version of the International Physical Activity Questionnaire. The questionnaire included seven questions concerning heavy physical activity, moderate physical activity, walking, and meditation,[ the reliability and efficiency of the questionnaire met the requirements.[ Referring to the recommendations of the International Physical Activity Questionnaire Expert Committee on Physical Activity and the General Health Activity Evaluation Standards developed in the Public Health Guideline,[ the levels of physical activity are categorized as follows:

Physically inactive

No moderate or severe physical activity during 1 week.

Physically active

In accordance with any of the following three items, it is determined that physical activity is active: 1 Severe physical activity not less than 3 days per week, not less than 20 minutes per day; 2 Weekly not Less than 5 days of moderate physical activity, not less than 30 minutes at a time; 3 Weekly, severe physical activity combined for not less than 5 days and total energy consumption of 600 METs/min. Third, physically vigorously active: A person who meets either of the following two criteria determines that physical activity is highly active: 1 Severe physical activity, at least 3 days per week, with an energy expenditure of 1500 METs/min; 2 The combination of moderate and severe physical activity each week accumulates no less than 7 days and the total total energy consumption reaches 3000 METs/min.

Physical activity questionnaire

The measurement and evaluation of physical activity in this study was conducted in the Chinese version of the International Physical Activity Questionnaire. The questionnaire included 7 questions concerning heavy physical activity, moderate physical activity, walking, and meditation. 4 In terms of aspects,[ the reliability and efficiency of the questionnaire met the requirements.[ Referring to the recommendations of the International Physical Activity Experts Committee and the General Health Activity Evaluation Standards developed in the Public Health Guideline,[ the physical activity levels are categorized as follows:

Physically inactive: There is no any week Moderate or heavy physical activity.

Physically active: Comply with any of the following 3 items and determine that physical activity is active: 1 Severe physical activity not less than 3 days per week, not less than 20 minutes per day; 2 not less per week The medium-strength physical activity in 5 days, each time not less than 30 minutes; 3 weekly, severe physical activity combined no less than 5 days, and the total energy consumption reached 600 METs/min.

Physically vigorously active: A person who meets either of the following two criteria determines that physical activity is highly active: 1 Severe physical activity, at least 3 days per week, with an energy expenditure of 1500 METs/min; 2 per Central and severe physical activity combined for not less than 7 days and the total total energy consumption reached 3000 METs/min.

Mental questionnaire screening questionnaire

A total of 5 items of this questionnaire were used to screen for psychosocial problems in depression, anxiety, stress, anger, and social support in patients with cardiovascular disease.[ The questionnaire was graded using a 10-point scale with a score range of 0–9. The thresholds for each item are 3, 4, 4, 3, and 6, respectively. That is, depression scores scored 0–2 in normal scores, 3–9 in depression scores, and anxiety scores in 0–3 scores in normal scores and 4–9 scores in anxiety scores; pressure scores 0–3 scored in normal scores and 4–9 scored in pressure scores. The anger entry 0–2 is divided into normal, 3–9 is divided into anger; the social support entry 0–5 is divided into low social support, 6–9 is normal.

The morisky self-reported adherence questionnaire

The Morisky self-reported adherence questionnaire was used to evaluate the patient's medication compliance after.[ The questionnaire included four items. Did you sometimes forget to take medication? Do you sometimes pay no attention to medication? When you feel better, stop taking medicine? Do you stop taking medicine when your symptoms are worse after taking medicine? Each question was answered with yes and no. “Yes” scored 1 point, and “No” scored 0 points. The higher the score, the worse the medication compliance.

Survey methods

Questionnaires are used as tools to collect data using the way the investigator asks patients to answer questions. A questionnaire survey was performed within 24 hours after the patient underwent coronary angiography examination. The patient's diet, exercise, psychosocial status and medication compliance were reviewed retrospectively. The results of the patient's angiography review were collected through the Cardiology Follow-Up Center database. The blood lipids and other biochemical indicators within 24 hours before surgery were analyzed before the investigation to explain the purpose and significance of the study and sign informed consent.

Statistical methods

SPSS 20.0 software was used for statistical analysis. Count data adoption rate or percentage, the 2 groups were compared using Chi-square test. Measured data with a non-normal distribution are described using the median (M) and the interquartile range (P25–P75), and the rank-sum test is used for comparison between groups. Multivariate analysis was performed using Logistic regression analysis to calculate the OR value. P < .05 was considered statistically significant.

Ethical considerations

Second Affiliated Hospital of Harbin Medical University ethics committee approved the study on the 24th June 2016, with code: 201606241. All participation was voluntary and participants were made aware of their right to withdraw from the study at any point without explanation. Participant anonymity was assured by the way the data was treated. There was not individual identification at the questionnaire. Participants were asked to provide written informed consent together with their answers to the questionnaire.

Results

Comparison of general demographic and clinical data between restenosis and non-restenosis

A total of 230 patients were investigated in this group, including 171 males and 59 females, aged 40 to 85 years, with an average age of 60.81 ± 9.90 years. There were 68 cases of restenosis group and 162 cases of non-restenosis group. The general data and clinical data of the two groups were compared and there was no significant difference (P > .05, see Table 1).

Table 1

Comparison of clinical data between restenotic and non-restenotic groups (n = 230).

Lifestyle comparison between restenotic and non-restenotic groups

Univariate analysis of the effects of smoking, body weight, physical activity, psychological status, and nutrient intake on restenosis in both groups was shown in Table 2.

Table 2

Single factor analysis of lifestyle of the two groups (n = 230).

Multi-factor regression analysis affecting restenosis

The univariate analysis showed statistically significant differences in physical activity, anger, vitamin A, folic acid, vitamin C, and alpha-TE as independent variables, and postoperative in-stent restenosis as a dependent variable for Logisitic stepwise regression analysis, restenosis and the relevant variables are given in Table 3. The results showed that restenosis after PCI was positively correlated with Morisky score and anger, and negatively correlated with physical activity, folic acid, and vitamin C intake. See Table 4 for details.

Table 3

Restenosis after percutaneous coronary intervention and assignment of related factors.

Table 4

Logistic analysis of influencing factors of restenosis (n=230).

Discussion

Coronary heart disease has now become a recognized lifestyle disease, and its occurrence, development and outcome are closely related to lifestyle factors.[ Lifestyle refers to a way of daily activities of the individual, including diet, exercise, mood, smoking, drinking and weight control.[ Studies have shown that lifestyle improvements can reduce blood pressure and blood lipids in patients with coronary heart disease, thereby reducing risk factors for coronary heart disease.[ However, previous studies have confirmed that the risk factors for restenosis after PCI are not completely the same as the risk factors for coronary heart disease.[ Therefore, it is of great significance to explore whether lifestyle can reduce the risk factors for restenosis.

The incidence of restenosis after PCI is high

In 1977, after the German doctor completed the first percutaneous coronary angioplasty to create a new era of interventional therapy, coronary intervention was widely promoted with minimal trauma, good efficacy, and rapid recovery. The incidence of restenosis after PCI is as high as 10% to 20%, which seriously affects the quality of life of patients and the long-term efficacy of PCI. In recent years, the popularity and application of drug-eluting stents have significantly reduced the incidence of intracoronary restenosis, but large-scale clinical trials at home and abroad have shown that the incidence of restenosis after drug-eluting stents remains 5%.[ Therefore, the problem of in-stent restenosis after PCI is receiving more and more attention. How to reduce the incidence of restenosis has become a problem in the field of coronary intervention.

High medication compliance reduces the incidence of restenosis after PCI

Medication adherence refers to the extent to which the patient performs the doctor's orders and is the performance of the patient's regular medication according to the doctor's orders.[ Evidence-based medicine has shown that patients undergoing PCI still need to take anti-platelet drugs, β-blockers and other drugs.[Table 4 shows that post-PCI compliance was significantly associated with restenosis, with an OR of 1.50. Previous studies have shown that poor adherence to medication is associated with negative events such as cardiovascular death and revascularization in patients with coronary heart disease.[ The results of this study further demonstrated that poor adherence to medication is a risk factor for restenosis. Previous investigations have shown that 60.92% of post-PCI patients cannot follow medications carefully.[ Therefore, nursing staff should improve compliance with medication and reduce the risk of restenosis through health education.

Anger can promote the occurrence of restenosis after PCI

Anger is one of the basic emotions of human beings, and it is the core of negative emotions. Many kinds of psychosomatic diseases can be traced back to long-term anger and indignation. Sirois et al found that negative emotions were one of the predictors of the frequency of angina attacks after PCI.[ Yoichi Chida's prospective cohort study of the period 1983–2006 revealed a significant correlation between anger and coronary heart disease events through a meta-analysis. This relationship is even more pronounced in people with coronary heart disease, suggesting that anger enhances coronary heart disease recurrence.[ At the same time, studies have also shown that anger can advance the progression of coronary atherosclerosis.[ This study shows that anger can promote the occurrence of in-stent restenosis. This may be due to the fact that anger individuals are more likely than ordinary people to smoke, drink, and have Due to poor eating habits,[ the mechanism of anger and restenosis still needs further study.

Folic acid and vitamin C intake can reduce the incidence of restenosis after PCI

Previous studies[ have evaluated the dietary quality of patients with coronary heart disease to qualitatively analyze the dietary structure of patients. In this study, a semi-quantitative food frequency questionnaire was used to quantitatively evaluate the dietary status of patients with coronary heart disease after PCI, and the relationship between dietary nutrients and restenosis was analyzed. The results showed that folic acid and vitamin C intake were protective factors for restenosis. Previous studies have shown that plasma homocysteine is a risk factor for coronary atherosclerosis, and folic acid is negatively correlated with homocysteine. Jorgensen et al[ showed that folic acid treatment can reduce the restenosis rate after stenting. The protective factors of vitamin C for restenosis may be related to the role of vitamin C in improving lipid metabolism and protecting the integrity of the vascular wall. Because fresh fruit is rich in folic acid and vitamin C, it is recommended that patients after PCI should increase the intake of fruits and vegetables.

Physical activity can reduce the incidence of restenosis after PCI

Table 4 shows that physical activity is a protective factor for restenosis with an OR of 0.34. Previous studies have shown that,[ lifestyle changes that increase physical activity can reduce the incidence of restenosis after PCI, with the rate of restenosis being 10.71% in the physical activity group and 43.75% in the control group. Zhang et al[ and other studies also showed that those who persist in physical activity have reduced their degree of vascular stenosis. This may be due to physical activity can promote the formation of collateral circulation, improve the function of endothelial cells, and then has a positive protective effect on stenosis.[

In summary, the compliance and lifestyle of patients after PCI can affect the occurrence of restenosis. The results of this study provide guidance for clinical staff to guide the lifestyle changes after PCI, and then reduce the incidence of restenosis from the perspective of behavior change.

Uncited reference

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Author contributions

Conceptualization: Gai Zhang.

Data curation: Yumei Chen.

Project administration: Gai Zhang, Shufang Li.

Resources: Shufang Li, Yumei Chen.

Supervision: Gai Zhang.

Writing – review & editing: Yumei Chen.