Predictive Value of Perioperative Cytokine Levels on the Risk for In-Stent Restenosis in Acute Myocardial Infarction Patients.

To investigate the value of perioperative cytokine levels in predicting the risk for in-stent restenosis in patients with acute myocardial infarction. 452 patients with acute myocardial infarction admitted to our hospital between June 2018 and June 2020 were prospectively selected as subjects. All patients underwent percutaneous coronary intervention. The baseline data of the patients were collected. Venous blood was taken before, 24 hours, and 3 days after the operation to detect the levels of related cytokines. Follow-up was performed for 1 year. The patients were assigned to restenosis and nonrestenosis groups according to the presence and absence of restenosis. Multivariate logistic analysis was used to explore the influencing factors of the risk for in-stent restenosis in patients with acute myocardial infarction. By July 1, 2021, 449 cases had been followed up. Of them, 44 cases suffered from in-stent restenosis and 405 cases did not affect in-stent restenosis. The incidence of in-stent restenosis was 9.80%. Before, 24 hours, and 3 days after the operation, the lipoprotein-associated phospholipase A2 (Lp-PLA2) level was significantly higher in the restenosis group than that in the nonrestenosis group. At 3 days after the operation, the interleukin 6 (IL-6) level was significantly higher in the restenosis group than that in the nonrestenosis group (P < 0.05). Multivariate logistic analysis displayed that Lp-PLA2 level preoperatively (OR = 1.048, 95% CI 1.029-1.068), Lp-PLA2 level 24 hours postoperatively (OR = 1.013, 95% CI 1.007-1.019), Lp-PLA2 level 3 days postoperatively (OR = 1.032, 95% CI 1.015-1.048), and IL-6 level 3 days postoperatively (OR = 1.020, 95% CI 1.000-1.040) were risk factors for in-stent restenosis (all P < 0.05). IL-6 and Lp-PLA2 levels can predict the risk for in-stent restenosis in patients with acute myocardial infarction in the perioperative period.

1. Introduction

Percutaneous coronary intervention (PCI), one of the most basic and important methods and strategies for acute myocardial infarction currently [1], can remarkably improve the quality of life of acute myocardial infarction and decrease the occurrence of major adverse cardiovascular events [2]. Nevertheless, in-stent restenosis has become an important factor affecting the long-term prognosis of PCI and limiting its further development. In-stent restenosis refers to the stenosis of the stent lumen >50% after PCI, including the proximal 5 mm and distal 5 mm of the stent segment and adjacent vessel segments. In-stent restenosis can be divided into two stages: early and late stages. In the early stages, on the order of days or weeks, mechanical damage from the stent material and its polymer coating continues to irritate the arterial vessel wall. In-stent restenosis after PCI is a complicated process [3]. During the stent placement, friction between the guidewire and the vessel wall and hyperbaric balloon dilatation can break the plaque at the stenosis and destroy the integrity of vascular endothelial cells, which can induce intimal hyperplasia, vascular remodeling, and elastic retraction. Vascular endothelial injury is considered to be an initiating factor for restenosis after PCI [4]. Buszman et al. [5] analyzed the underlying mechanism of coronary artery restenosis in animal models and proved the causal relationship between vascular injury/inflammatory response and neointima formation in the stent. Highly severe vascular damage is associated with a stronger inflammatory response, a thicker neointima, a smaller lumen diameter, and a higher risk for restenosis.

Mechanistically, in-stent restenosis is a repair response after local vascular injury. Endothelial injury is the initiating factor of restenosis, which can promote local thrombosis, aggregation of platelets, chemokines, and adhesion molecules, and promote the occurrence of inflammation. Inflammatory cells and endothelial cells produce a large amount of cytokines and growth factors so that vascular smooth muscle proliferation and migration, resulting in restenosis [6]. The stimulation with proliferation-promoting factors such as endothelial progenitor cells and vascular endothelial cells can effectively suppress intimal hyperplasia and have a certain preventive effect on the occurrence of restenosis in the initial stage after balloon injury. In a rabbit AS model [7], it was found that the implantation of the stent at the target lesion caused the mechanical rupture of the plaque, the activated inflammasome in the plaque released inflammatory factors, persistent vascular inflammation, and accelerated AS lesions. The above findings reveal the relationship between PCI and stent restenosis as well as its mechanism, and provide new ideas and targets for anti-inflammatory treatment and prognosis improvement after PCI. However, due to this complexity, it is slightly insufficient to predict the risk of in-stent restenosis only before surgery. Thus, this study aimed to provide a theoretical basis for the risk of stent stenosis by analyzing the predictive value of perioperative cytokine levels on the risk of in-stent restenosis in patients with acute myocardial infarction after PCI.

2. Data and Methods

2.1. Clinical Data

Inclusion criteria are as follows: (1) in accordance with the diagnostic criteria for acute myocardial infarction in the Guidelines for the Diagnosis and Treatment of Acute Myocardial Infarction [8], meeting two or more: ischemic chest pain >30 minutes cannot be relieved after rest or sublingual nitroglycerin administration; ECG shows that adjacent lead ST segment height >0.1 mv; abnormally elevated levels of myocardial necrosis markers such as serum high-sensitivity cardiac troponin I and serum creatine kinase isoenzyme; (2) meeting the indications for stent implantation; and (3) comprehensive clinical data. Exclusion criteria are as follows: (1) combined with heart diseases such as cardiogenic shock and severe ventricular arrhythmia; (2) a history of coronary artery bypass grafting; and (3) receiving the immunosuppressive drug in the past 3 months.

2.2. Research Plan

2.2.1. Research Ideas

This study was approved by the hospital ethics committee. All patients and their family members signed the written informed consent. The 452 patients with acute myocardial infarction admitted to our hospital from June 2018 to June 2020 were recruited for PCI and were followed up for 1 year to observe in-stent restenosis. Drug-eluting stents are all everolimus stents (Trade name: Xience Biosensor Company). The patients were divided into restenosis and nonrestenosis groups according to the presence and absence of restenosis. Based on previous reports and clinical practice, the baseline data of patients were collected, and the factors affecting the risk of in-stent restenosis in patients with acute myocardial infarction were explored and screened using logistic regression analysis.

2.2.2. Treatment Plan

In accordance with the Guidelines for Percutaneous Coronary Intervention (2016) [9], aspirin (Bayer Health Care Co., Ltd., approved by Chinese medicine J20130078) (≥75 mg/d) and clopidogrel (Sanofi Pharmaceutical Co., Ltd., China National Pharmaceutical approval no. J20180029) (300 mg for the first time, then 75 mg/d at least 9 months) were administrated before and after PCI, respectively. Simultaneously, 10000 UI of heparin was intravenously injected to maintain the activated clotting time before PCI. If necessary, balloon dilatation was performed before stent implantation. Standard drug treatment was given after stent implantation. After surgery, 4000 IU of low-molecular weight heparin was subcutaneously injected twice a day for 3–5 days, and 100 mg of aspirin and 75 mg of clopidogrel were orally administered daily for 1 year.

2.2.3. General Data Collection

Patient general information was collected, containing age; sex; course of condition; body mass index (BMI); smoking history (defined as smoking ≥5 cigarettes/d, for more than 1 year); combined diseases (hypertension: systolic pressure ≥140 mmHg and/or diastolic pressure ≥90 mmHg); diabetes: diabetes diagnosed in the past and/or multiple measurements of fasting blood glucose ≥7.8 mmol/L after admission, and 2-hour postprandial glucose ≥11.1 mmol/L; family history of acute myocardial infarction; and out-of-hospital medication.

2.2.4. Lesion Condition and Stent-Related Data Collection

Quantitative analysis of coronary angiography was used to interpret the target vessel. The diameter and length of the target vessel stent, the position of the stent, and the number of lesions were recorded during the operation.

2.2.5. Collection of Perioperative Cytokine Levels

Before, 24 hours, and 3 days after the operation, 4 mL of cubital venous blood was collected and placed in a tube with 2% EDTA-2Na for anticoagulation. The blood was centrifuged at 3000 r/min for 10 minutes and placed in a refrigerator for further use. An automatic biochemistry analyzer (model: Mindray BS-600) was utilized to detect plasma interleukin-6 (IL-6) (radioimmunoassay), C-reactive protein (CRP), serum lipoprotein-associated phospholipase A2 (Lp-PLA2), and tumor necrosis factor alpha (TNF-α) (immunoturbidimetry). The instrument was calibrated before testing and operated strictly in accordance with the reagent instructions.

2.3. Follow-Up and Evaluation of In-Stent Restenosis

Blood glucose, blood lipids, and uric acid were strictly controlled, and patients were instructed to quit smoking and restrict alcohol. After discharge, the patients were followed up once a month in the outpatient clinic for 1 year. The endpoint events were recorded. According to the Guidelines for Percutaneous Coronary Intervention (2016), in-stent restenosis is defined as compared with the lumen evaluated immediately after PCI, the PDS of the stent implantation segment was ≥50% at the 1-year follow-up.

2.4. Quality Control

By strictly implementing the inclusion and exclusion criteria and ensuring the authenticity of patient information, general patient data were collected and checked by a dedicated person. Parallel double data entry was conducted to ensure accurate data entry.

2.5. Statistical Processing

Epidate software was applied for data entry, and SPSS22.0 statistical software was employed for data analysis. Measurement data were subjected to a test of normality. Normally distributed data were represented as the mean ± SD. Two independent sample t-test was used for comparison between groups. Count data were expressed as ((n)%) or constituent ratio. The difference between groups was compared by the χ2 test. Collinearity diagnostics was performed for all variables and multivariate logistic regression analysis was performed for noncollinearity variables. A value of P < 0.05 was considered statistically significant.

3. Results

3.1. Follow-Up Results

By July 1, 2021, 449 cases were finally followed up, of which 44 cases had in-stent restenosis (restenosis group) and 405 cases did not experience in-stent restenosis (nonrestenosis group). The incidence of in-stent restenosis was 9.80%.

3.2. Comparison of Clinical Data

No significant difference was determined in sex, age, BMI, smoking history, family history of acute myocardial infarction, combined diseases, number of lesions, target vessel stent length, stent diameter, stent location, and out-of-hospital medication between the restenosis and nonrestenosis groups (P > 0.05), as shown in Table 1.

Table 1

Comparison of clinical data of patients (( ± s) (n, %)).

Clinical data	Restenosis group (n = 44)	Nonrestenosis group (n = 405)	t/χ 2	P value
Sex (n, %)			0.6921)	0.405
Male	25 (56.82)	256 (63.21)
Female	19 (43.18)	149 (36.79)
Age (year)	52.98 ± 8.26	51.61 ± 9.01	1.0352)	0.305
BMI (kg/m2)	22.88 ± 1.24	22.85 ± 1.37	0.1512)	0.881
Family history of acute myocardial infarction (n, %)	14 (31.82)	123 (30.37)	0.0391)	0.843
Smoking history (n, %)	25 (56.82)	186 (45.68)	1.9781)	0.160
Combined diseases (n, %)
Hypertension	11 (25.00)	105 (25.93)	0.0181)	0.894
Diabetes	12 (27.27)	103 (25.43)	0.0711)	0.791
Hyperlipidemia	20 (45.45)	144 (35.56)	1.6781)	0.196
Coronary intervention
Number of lesions (n, %)			1.5521)	0.213
Single vessel lesion	35 (79.55)	286 (70.62)
Double vessel/multi-vessel lesions	9 (20.45)	119 (29.38)
Target vessel stent length (mm)	18.24 ± 2.98	18.38 ± 3.01	0.2962)	0.769
Target vessel stent diameter (mm)	3.42 ± 0.53	3.32 ± 0.61	1.1702)	0.247
Target vessel stent location (n, %)			0.9231)	0.630
Anterior descending branch	26 (59.09)	214 (52.84)
Circumflex branch	13 (29.55)	125 (30.86)
Right coronary artery	5 (11.36)	66 (16.30)
Out-of-hospital medication (n, %)
β receptor blocker	35 (79.55)	286 (70.62)	1.5521)	0.213
ACEI/ARB	30 (68.18)	235 (58.02)	1.6931)	0.193
Dual antiplatelet therapy	34 (77.28)	268 (66.17)	2.2211)	0.136
Others	26 (59.09)	223 (55.06)	0.2611)	0.610

1) χ 2 test; 2)independent sample t-test.

3.3. Comparison of Cytokine Levels during the Perioperative Period

Before, 24 hours, and 3 days after the operation, the Lp-PLA2 level was significantly higher in the restenosis group than that in the nonrestenosis group. At 3 days after the operation, IL-6 level was significantly higher in the restenosis group than that in the nonrestenosis group (P < 0.05). There was no significant difference in TNF-α, CRP before, 24 hours, and 3 days after the operation, and IL-6 before and 24 hours after the operation between the restenosis and nonrestenosis groups (P > 0.05), as shown in Figures 1–3.

Figure 1

Levels of cytokines in the restenosis and nonrestenosis groups before surgery.

Figure 2

Levels of cytokines in the restenosis and nonrestenosis groups 24 hours after the operation.

Figure 3

Levels of cytokines in the restenosis and nonrestenosis groups at 3 days after the operation.

3.4. Multivariate Logistic Regression Analysis of the Risk for In-Stent Restenosis

Logistic regression analysis was performed using the occurrence of in-stent restenosis as the dependent variable (occurrence = 1, nonoccurrence = 0) and the abovementioned variables with statistical significance as independent variables. The variable selection was conducted by a stepwise method (α In = 0.05, α Out = 0.1). Multivariate logistic analysis exhibited that Lp-PLA2 level preoperatively (OR = 1.048, 95% CI 1.029–1.068), Lp-PLA2 level at 24 hours postoperatively (OR = 1.013, 95% CI 1.007–1.019), Lp-PLA2 level at 3 days postoperatively (OR = 1.032, 95% CI 1.015–1.048), and IL-6 level at 3 days postoperatively (OR = 1.020, 95% CI 1.000–1.040) were risk factors for in-stent restenosis (all P < 0.05), as shown in Table 2 and Figure 4.

Table 2

Multivariate logistic regression analysis of in-stent restenosis risk.

Relevant factors	β	SE	Wald	P value	OR	95% CI
						Lower limit	Upper limit
Lp-PLA2 level preoperatively	0.047	0.009	25.522	≤0.001	1.048	1.029	1.068
Lp-PLA2 level 24h postoperatively	0.013	0.003	16.761	≤0.001	1.013	1.007	1.019
Lp-PLA2 level 3d postoperatively	0.031	0.008	14.595	≤0.001	1.032	1.015	1.048
IL-6 level 3d postoperatively	0.020	0.01	3.932	0.047	1.020	1.000	1.040
Constant	−17.545	2.278	59.337

Figure 4

Forest plot of multivariate logistic regression analysis of the risk for in-stent restenosis.

4. Discussion

In-stent restenosis is a common risk in acute myocardial infarction patients undergoing PCI [10]. Because of the vulnerability of the artery after stent placement and the effect of endothelial regeneration, the stent site presents remarkable neointimal hyperplasia, which can lead to endothelial cell dysfunction, ectopic proliferation, and vascular smooth muscle cell migration as well as a series of inflammatory reactions. A Japanese study [11] concluded that the incidence of restenosis was 34.3% within 6–18 months of right coronary artery opening lesions. The incidence of restenosis was approximately 37.8% within 6 months after the implantation of the drug-eluting stent in CAD patients with DM [12]. The incidence of in-stent restenosis was lower in this study (9.80%) than that of the abovedescribed studies. This may be different from the follow-up time and the included subjects. Nevertheless, it cannot be ignored that the risk of restenosis is at a high level. Moreover, the study of valuable biomarkers for predicting restenosis is of great significance for optimizing the treatment plan for PCI in patients with acute myocardial infarction and improving the prognosis. Among them, perioperative cytokines exert a crucial effect on the development and progression of restenosis following surgery and are concerned.

In-stent restenosis involves a series of complex pathophysiological processes. Smooth muscle proliferation, inflammation, and extracellular matrix accumulation are the main pathological mechanisms of in-stent restenosis [13]. The stent placement can mechanically damage the blood vessel wall, cause tearing of the vascular intima, force the subintimal matrix to release local inflammatory factors, activate the endogenous and exogenous coagulation system, and cause the pathological reaction of early stenosis during interventional surgery. Subsequently, the damaged vascular endothelial cells and activated platelets continuously secrete various inflammatory factors to promote smooth muscle proliferation, migration, matrix synthesis, and deposition and ultimately cause intimal hyperplasia and vascular stenosis. This shows the importance of cytokines in the formation of restenosis after the intervention. CRP, IL-6, and TNF-α are involved in the occurrence and development of in-stent restenosis, and the increase in CRP can predict rapid angiographic progression of noncriminal lesions in non-ST-segment acute syndrome patients undergoing PCI [14]. Preoperatively circulating inflammatory cytokine TNF-α can be applied as a predictor of restenosis after PCI [15]. These previous results revealed the role of CRP and TNF-α levels in predicting the risk of in-stent restenosis. However, Jiang et al. [16] observed inflammatory factors at different time points during the perioperative period and found that serum hs-CRP and TNF-α increased 24 hours after coronary stent placement, but there was no obvious correlation with vascular restenosis within 6 months after surgery. This was also shown in this study, which may be caused by mechanical damage during stent placement, hypoxia, and the continuous extension of the stent to the vessel wall. Moreover, hs-CRP and TNF-α are nonspecific indicators of vascular inflammation and are affected by various factors such as potential or recent infections. At the IL-6 level, IL-6 concentration in the atherosclerotic wall is 200 times that in the serum. When the plaque is inflammatory or ruptured, the factor can be released into the blood. Guo et al. [17] evaluated the correlation of in-stent restenosis with IL-6 and serum hs-CRP levels at baseline and 24 hours postoperatively using multivariate logistic regression analysis and believed that IL-6 is a powerful independent predictor for the midterm outcome of femoral artery stent placement, indicating that its predictive value is better than CRP. In this study, IL-6 level was markedly higher in the restenosis group than that in the nonrestenosis group at 3 days postoperatively, and IL-6 is a risk factor for in-stent restenosis. This may be because IL-6 generation takes several hours, peaks at 24 hours, and then begins to decline. During vascular wall repair after stent implantation, IL-6 displays a nonlinear change; the peak period of traumatic inflammation has passed; the stable period of inflammatory response begins. At this time, the high IL-6 level indicates the continued existence of inflammation.

As an inflammatory marker, lipoprotein-associated phospholipase A2 (Lp-PLA2) is often used to predict the occurrence, development, and prognosis of coronary heart disease. As a member of the phospholipase A2 (PLA2 superfamily), Lp-PLA2 can produce a variety of proinflammatory factors such as oxidized free fatty acids, and participate in the occurrence, development, and plaque rupture of atherosclerosis. Inhibiting the activity of Lp-PLA2 can effectively regulate the development of atherosclerosis [18-20]. A large number of studies have shown that Lp-PLA2, as a specific inflammatory marker, is an independent predictor of coronary heart disease as well as a predictor of coronary plaque instability and coronary stenosis and is associated with poor prognosis of cardiovascular disease [21]. High Lp-PLA2 level as an independent risk factor for coronary heart disease has been extensively recognized in clinical practice. A previous study [22] demonstrated that as the Lp-PLA2 level increases, the risk of coronary heart disease and stroke increases, especially in the elderly and asymptomatic people with atherosclerotic disease. A meta-analysis [23] has shown that Lp-PLA2 level is linearly and logarithmically related to coronary heart disease and vascular death. A cohort study [24] has suggested that Lp-PLA2 measured in the acute phase is associated with 1-year mortality, indicating that Lp-PLA2 may not be affected by acute inflammatory events, but is a specific indicator for vascular inflammation. A NOMAS study [25] continuously detected changes in Lp-PLA2 levels before and after myocardial infarction and demonstrated that unlike the rising trend of hs-CRP, Lp-PLA2 levels gradually declined (5% per year) from an average of 233 ng/ml before infarction to an average of 153.9 ng/ml after the acute phase. The present study also confirms that perioperative Lp-PLA2 level is a risk factor for in-stent restenosis, which may be associated with atherosclerotic plaque rupture, the main mechanism leading to acute thrombotic events, while Lp-PLA2 is a vital reason for increased plaque vulnerability. Furthermore, this study did not find that smoking, combined diseases, or postoperative drugs are associated with the risk for in-stent restenosis. This situation may be associated with the active control of the patient's blood glucose, blood lipids, and uric acid after PCI, strict smoking cessation and alcohol restriction, and the use of dual antiplatelet aggregation, lipid-lowering, and plaque-stabilizing drugs. It may also be associated with the relatively small sample size in this study.

5. Conclusion

To sum up, perioperative IL-6 and Lp-PLA2 levels play an important role in the process of in-stent restenosis and have certain predictive value for the risk of in-stent restenosis. At the same time, these results also confirm that dyslipidemia and inflammation do play an important role in the occurrence and development of coronary heart disease. Compared with the control of blood lipid indexes, there is no specific anti-inflammatory therapy in the field of coronary heart disease treatment. On the basis of traditional coronary heart disease treatment, improving the status of Hangzhou inflammatory therapy in the treatment of coronary heart disease may better control the progress of coronary atherosclerosis. It provides a theoretical basis for clinical anti-inflammatory treatment. The risk of in-stent restenosis is a complex process, involving a variety of factors, related to the different effects of different inflammatory factors at different time points. Due to the limited conditions, the time point of perioperative blood collection in this study is relatively small, which is still not enough to reflect the dynamic changes of perioperative cytokine levels. The follow-up time was relatively short. The predictive effect of perioperative cytokine levels on long-term restenosis needs to be further studied.