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Background The dual antiplatelet therapy (DAPT) duration is a matter of great interest among cardiologists. Because of the conflicting evidences and the necessity to balance the reduction in major cardiac events (MACE) occurrence and the risk of major bleedings after an acute coronary syndrome (ACS), there is a general consensus on prolonging DAPT on an individual basis. There is less consensus on which parameters are to be evaluated. Nowadays tests of platelet reactivity are not included in the decision-making. Few data are available on the prognostic value of aspirin response tests that are sensitive to other mediators of platelet adhesion and aggregation in vivo under flow conditions. Purpose To demonstrate the role of the Platelet Function Analyzer (PFA-100) Collagen/Epinephrine (CEPI) cartridge, which is very sensitive to von Willebrand factor (VWF) levels, an emerging vascular risk factor, in risk stratification in ACS patients undergoing percutaneous coronary intervention (PCI). Methods We measured platelet reactivity by PFA-100 CEPI cartridges in a prospective cohort of 928 patients admitted for ACS between January 2006 to December 2009 and urgently treated by PCI at day 6±1 after admission. All the patients were treated with aspirin and clopidogrel according to current standard of that time. Results High platelet reactivity (HPR) defined as PFA-100 values 190”). At a mean follow up of 5±1 years patients with HPR had a significant increase in cardiac death: 12.3% vs 2.6% (hazard ratio 6.05; 95% confidence interval: 3.34–10.95; p Conclusions Using a multivariable Cox-proportional hazard model, HPR was found to be an independent predictor of MACE. These results indicate that PFA-100 CEPI cartridge, which correlates well with VWF levels, may be a useful point-of-care test to stratify the cardiovascular risk after an ACS. This also underlines the additional value of this test in the decision-making about the correct extension of DAPT.

Background The CYP2C19*2 polymorphism is significantly associated with residual platelet reactivity (RPR) and maybe a major confounding factor in studies evaluating pharmacological interactions with clopidogrel. Objectives We sought to evaluate the influence of a proton pump inhibitor (PPI), pantoprazole, indicated as relatively less influent than other PPIs, on the antiplatelet effect of clopidogrel, considering a stratification of the population for the presence of cytochrome 2C19*2 polymorphism. Methods 105 patients with ST elevation myocardial infarction (STEMI), treated with percutaneous coronary angioplasty (PCI) and who received dual antiplatelet therapy, were randomized between pantoprazole (n=54) or ranitidine (n=51). RPR was evaluated by Platelet Function Analyzer-100 (PFA-100) with collagen-epinephrine (CEPI) and collagene-ADP (CADP) cartridges and by light transmitted aggregometry with 10μM adenosin diphosphate (ADP) and 1mM arachidonic acid (AA), on 5 (T0) and 30 (T1) days after PCI. Results Demographic, clinical and procedural data and the prevalence of CYP2C19*2 polymorphism were similar between the two groups. Not statistically differences were observed for CEPI-CT and for the maximal aggregation (MA) values with AA stimulus at both times. We observed a significant increase in MA values with ADP in PPI group at T0 (p=0.01) and T1 (p=0.03). At the multiple regression analysis PPI use remained significantly associated with ADP-MA both at T0 (p=0.05) and T1 (p=0.03). Conclusions This is the first documentation in a randomized trial, after correction for the bias of CYP2C19*2 polymorphism, that pantoprazole increases the ADP-MA in patients treated with dual antiplatelet therapy.

Background: In order to assess the reference intervals for B-type natriuretic hormone (BNP) in the first days of life, we measured peptide concentrations using the fully automated Access platform. Methods: Plasma BNP was measured in 188 apparently healthy newborns and infants throughout the first month of extra-uterine life, as well as in 245 healthy infants ranging from 1 month to 12 years of age. Results: BNP showed the highest concentrations in the first 2 days of life, with a progressive decline afterwards. Moreover, BNP values in the first week of life were significantly higher (p Conclusions: According to this data, our study indicates that at least two reference intervals should be used for newborns and infants. The first, with higher BNP values for neonates in the first week of extra-uterine life, and the other, with lower BNP values for infants aged 2 weeks to 12 years. Clin Chem Lab Med 2010;48:697–700.

An increasing amount of evidence indicates that platelet reactivity, despite a standard anti-thrombotic therapy, is a potential risk factor for recurrent myocardial ischemia in patients with coronary artery disease. We now hypothesize that this condition, measured by collagen-epinephrine (CEPI) or collagen-ADP (CADP) closure times (CT) by Platelet Function Analyzer (PFA-100), may predict the recurrence of coronary events after percutaneous coronary intervention (PCI).CEPI and CADP-CT were measured 30+/-8 h after PCI in 175 consecutive patients admitted with a diagnosis of stable angina (n=94) or acute coronary syndromes (n=81) and prospectively followed up for a mean period of 6 months. We stratified the patients in accordance to both the CEPI-CT (or190 s), reflecting the intensity of cycloxygenase inhibition by aspirin and the distribution into quartiles for CADP-CT.CEPI-CT190 s as well as CADP-CT82 s were associated with a higher rate of clinical recurrence (hazard ratio 8.5, p0.001 and 22.9, p0.001, respectively). Multivariate analysis after adjustment for other risk factors confirmed that the lowest CADP-CT quartile significantly correlates with the risk of recurrent coronary events (hazard ratio 36.5, p0.01), as well as CEPI-CT190 s (hazard ratio 6.7, p=0.01).An enhanced platelet function after PCI when measured under high shear rates by PFA-100 is an independent predictor of a worst clinical outcome, even during a short term follow-up and may help in patients risk stratification.

Von Willebrand factor (VWF) is an emerging risk factor in acute coronary syndromes. Platelet Function Analyzer (PFA-100) with Collagen/Epinephrine (CEPI) is sensitive to functional alterations of VWF and also identifies patients with high on-treatment platelet reactivity (HPR). The objective of this study was to verify the effect of double dose (DD) of aspirin and clopidogrel on HPR detected by PFA-100 and its relation to VWF and to its regulatory metalloprotease ADAMTS-13. Between 2009 and 2011 we enrolled 116 consecutive patients with ST elevation myocardial infarction undergoing primary PCI with HPR at day 5 after PCI. Patients recruited were then randomized between a standard dose (SD,n=58) or DD of aspirin and clopidogrel (DD,n=58), maintained for 6 months follow-up. Blood samples for PFA-100, light transmittance aggregometry, and VWF/ADAMTS-13 analysis were collected after 5, 30, and 180 days (Times 0, 1, and 2). At Times 1 and 2 we observed a significantly higher CEPI closure times (CT) in DD as compared to SD (P<0.001). Delta of CEPI-CT(T1-T0)was significantly related to VWF (P<0.001) and inversely related to ADAMTS-13 (0.01). Responders had a significantly higher level of VWF atT0. Finally, in a multivariate model analysis, VWF and ADAMTS-13 in resulted significant predictors of CEPI-CT response (P=0.02). HRP detected by PFA-100 in acute myocardial infarction is reversible by DD of aspirin and clopidogrel; the response is predicted by basal levels of VWF and ADAMTS-13. PFA-100 may be a useful tool to risk stratification in acute coronary syndromes given its sensitivity to VWF.

OBJECTIVE: The risk of thrombocytopenia in patients undergoing aortic valve replacement (AVR) with the Freedom Solo (FS) bioprosthesis is controversial. The aim of our study was to evaluate the postoperative evolution of platelet count and function after AVR in patients undergoing isolated biological AVR with FS. METHODS: Between May 2005 and June 2010, 322 patients underwent isolated biological AVR. Of these, 116 patients received FS and were compared with 206 patients who received biological valves. Platelet count, mean platelet volume (MPV), and platelet distribution width (PDW) were evaluated at baseline (T0), first (T1), second (T2), and fifth (T3) postoperative days, respectively. RESULTS: Overall in-hospital mortality was 1.5% with no difference between the two groups. Thirty-seven (11.5%) patients developed thrombocytopenia. FS implantation was associated with a higher incidence of thrombocytopenia compared with the control group (24.1% vs 4.4%, p< 0.0001). Patients in the FS group showed a lower platelet count than the control group at T1 (99.4 ± 38 × 10 3 μl �1 vs 122.5 ± 41.6 × 10 3 μl �1 , p< 0.001), T2 (79.7 ± 36.3 × 10 3 μl �1 vs 122.5 ± 43.3 × 10 3 μl �1 , p< 0.001) and T3 (86.6 ± 57.4 × 10 3 μl �1 vs 158.4 ± 55.8 × 10 3 μl �1 , p< 0.001). Moreover, the FS group also had a higher MPV (11.6 ± 0.9 fl vs 11 ± 1 fl, p< 0.001) and higher PDW (15.1 ± 2.3 fl vs 13.9 ± 2.1 fl, p< 0.001) at T3. In a multivariable analysis, FS (p< 0.0001), body surface area (p< 0.0001), cardiopulmonary bypass time (p= 0.003), and lower preoperative platelet counts (p= 0.006) were independent predictors of thrombocytopenia. CONCLUSIONS: The FS valve might increase the risk of thrombocytopenia and platelet activation, in the absence of adverse clinical events. Prospective randomized studies on platelet function need to confirm our data.

Growing evidence supports the role played by inflammation in atherosclerosis. Identifying sensitive biomarkers is useful in predicting accelerated atherosclerosis. We investigated prospectively the relationship between plasma levels of inflammatory biomarkers [osteopontin, C-reactive protein (CRP), interleukin-6 (IL-6)] and instent restenosis, and rapid coronary plaque progression in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).We studied 77 patients with CAD: 45 affected by unstable angina/non-ST elevation myocardial infarction [acute coronary syndrome (ACS)], and 32 by chronic coronary syndrome (CCS). Plasma osteopontin, IL-6, and CRP levels were measured before intervention in all patients; measurements were carried out on the basis of the following time course at 1,15, 30, 90, and 180 days follow-up in a subgroup of 39 consenting patients. Clinical and biohumoral data were correlated with baseline and 6-month PCI follow-up angiography.Osteopontin, IL-6, and CRP were higher in patients with ACS than in those with CCS (analysis of variance: P0.001, 0.05, and 0.05, respectively). Baseline osteopontin levels proved to be associated with rapid coronary plaque progression (P=0.005) and instent restenosis (P=0.05). The highest osteopontin levels were found in patients with CAD with both rapid plaque progression and instent restenosis (P=0.003). PCI increased inflammatory markers acutely, and osteopontin remained elevated in patients with ACS. Patients with ACS showed a higher percentage (74%) of rapid plaque progression than those with CCS (26%) (P0.05).The study prospectively shows the link between inflammatory status and accelerated atherosclerosis in patients with CAD undergoing PCI. The baseline and persistent rise of osteopontin is an expression of its contribution to the accelerated plaque progression, and therefore osteopontin may be a useful prognostic biomarker.

Background: Neutrophil-granulocyte and mononuclear-cell functional changes occur during cardiopulmonary bypass and cardiovascular surgery. In particular, leukocyte–platelet interaction, leading to generation of heterotypic coaggregates, represents an amplification mechanism of the local inflammatory response and tissue damage. Methods: Samples of 20 patients were drawn from venous coronary sinus before cardioplegic arrest and immediately after reperfusion, as well as from peripheral blood at 5 and 24 h postoperatively. The granulocyte and monocyte surface expression of CD162, CD15s, CD18, and CD11b were quantified by flow cytometry at the different times. Parallel variations of circulating leukocyte–platelet conjugates (percentages) and a derived (cell number-normalized) leukocyte–platelet adhesion index were measured using a combination of antibodies against CD45, CD14, and CD41a. The evaluation of platelet functional state was carried out using antibodies against CD62P (P-selectin) and PAC-1. Results: Monocyte and granulocyte cell number increased markedly in coronary blood at reperfusion and in peripheral blood postoperatively when compared with measurements done before cardioplegia. A very different course characterized the changes of the leukocyte–platelet adhesion index with respect to the variations of circulating leukocyte–platelet coaggregates (percentages). Leukocyte molecules expression showed no significant variations for CD15s on both the leukocyte subsets, while a significant up-modulation for CD162 was observed on monocytes at 24 h after extracorporeal circulation (P = 0.0002), and for CD11b on granulocytes at 5 h postoperatively (P = 0.033). A loss of CD162 expression was observed in coronary blood at reperfusion (P = 0.0038) on granulocytes, associated to a down-modulation of CD18 (P = 0.0033) and CD11b (P = 0.0184) in peripheral blood at 24 h postoperatively. No significant up-regulation of platelet activatory molecules expression was found at coronary reperfusion, as well as postoperatively in the peripheral blood, when compared with the before-cardioplegia derived data. Conclusions: The over time variations of a normalized leukocyte–platelet adhesion index seem to reflect the cumulative leukocyte–platelet functional interaction more accurately than the parallel measurements of cellular conjugates. The absence of platelet activation suggests that the leukocyte membrane modifications play a main role in controlling the formation and stability of heterotypic leukocyte–platelet coaggregates after cardiac surgery with extracorporeal circulation. © 2006 International Society for Analytical Cytology

In animal models of conotruncal heart defects, an abnormal calcium sensitivity of the contractile apparatus and a depressed L-type calcium current have been described. Sarcoplasmic reticulum (SR) Ca(2+) ATPase (SERCA) is a membrane protein that catalyzes the ATP-dependent transport of Ca(2+) from the cytosol to the SR. The activity of SERCA is inhibited by phospholamban (PLN) and sarcolipin (SLN), and all these proteins participate in maintaining the normal intracellular calcium handling. Ryanodine receptors (RyRs) are the major SR calcium-release channels required for excitation-contraction coupling in skeletal and cardiac muscle. Our objective was to evaluate SERCA2a (i.e., the SERCA cardiac isoform), PLN, SLN, and RyR2 (i.e., the RyR isoform enriched in the heart) gene expression in myocardial tissue of patients affected by tetralogy of Fallot (TOF), a conotruncal heart defect. The gene expression of target genes was assessed semiquantitatively by RT-PCR using the calsequestrin (CASQ, a housekeeping gene) RNA as internal standard in the atrial myocardium of 23 pediatric patients undergoing surgical correction of TOF, in 10 age-matched patients with ventricular septal defect (VSD) and in 13 age-matched children with atrial septal defect (ASD). We observed a significantly lower expression of PLN and SLN in TOF patients, while there was no difference between the expression of SERCA2a and RyR2 in TOF and VSD. These data suggest a complex mechanism aimed to enhance the intracellular Ca(2+) reserve in children affected by tetralogy of Fallot.

BACKGROUND The determination of cardiac troponins is routinely used for rule in/out, risk stratification, and follow-up of patients with acute coronary artery syndrome. We evaluated the analytical and clinical performance of the advanced immunoassay for troponin I (cTnI) carried out on an AxSYM platform (Abbott Diagnostic Division) and compared these characteristics to those of the previous version of this assay and to cTnI on the Access 2 immunoassay system (Beckman Coulter, Inc.). METHODS We assayed plasma samples from healthy subjects (n=66) and cardiac patients (n=132) using AxSYM Plus system assays called the old (OLD AxSYM) and advanced TnI (ADV AxSYM) methods and using an Access system. RESULTS An improvement in analytical sensitivity (detection limit) was observed for the advanced cTnI AxSYM compared to the previous method (0.014 vs. 0.31 microg/L), while the cTnI value for the 10% CV (i.e., functional sensitivity) was 0.41 microg/L for the ADV and 1.9 microg/L for the OLD method. The kinetics of cTnI release was similar, as evaluated in 25 patients with typical acute myocardial infarction (AMI). A close linear relationship was found between the two methods on the AxSYM system (OLD cTnI=7.436+6.858 ADV cTnI; R=0.968, n=214) and with the Access system (OLD AxSYM=7.154+7.9 Access, R=0.876, n=158; ADV AxSYM=0.23+1.209 Access, R=0.927, n=160). However, wide bias was found between the OLD and ADV AxSYM methods (mean difference 118.4 microg/L, p

Many complex cardiac defects produce a functionally single ventricle, in which there is mixing of the systemic and pulmonary circulations. The output from the functionally single ventricle is divided between the two circulations: the proportion going to the systemic and pulmonary vascular beds being determined by the relative resistance to flows within the respective circulations.

Background Neutrophil and mononuclear cell functional changes represent a hallmark of inflammation during cardiopulmonary bypass and cardiovascular surgery. Knowledge of mechanisms underlying monocyte functional modulation in coronary blood may be useful to develop protective interventions that can limit ischemia/reperfusion injury. Methods Samples of 13 patients were drawn from venous coronary sinus before cardioplegic arrest and after reperfusion. The following parameters were studied: surface molecules expression (CD18, CD11b, CD44, CD162, CD15s, CD80, CD86, CD16, CD49d, CD29, CD25, HLA-DR, Toll-like receptor-4 [TLR-4], CXCR1, CCR2, CCR5, CX3CR1), oxidative burst response, monocyte-platelet conjugates (using antibodies against CD45, CD14, CD41a), and platelet activation (CD62P, PAC-1). Enzyme-linked immunosorbent assays were performed to measure levels of interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor-α (TNF-α). Results Coronary reperfusion down-modulated monocyte molecules expression, especially for CD18 (P = 0.048), CD44 (P = 0.0035), CD49d (P = 0.0029), CD29 (P = 0.032), HLA-DR (P < 0.0001), TLR-4 (P = 0.0109), CCR2 (P = 0.0184), CCR5 (P = 0.0396), and CX3CR1 (P < 0.0001). A marginal increase (P = 0.062) of a normalized adhesion index between monocytes and platelets was observed at reperfusion. No variations were detected for the monocyte oxidative burst and platelet activation. Increased levels of IL-6 (P = 0.013), TNF-α (P = 0.0272), and IL-10 (P = 0.0008) were measured after cardioplegia. Conclusions The lack of CD11b and CD25 variations and of the oxidative burst exclude monocyte activation at reperfusion. The high after-cardioplegia level of IL-10, the decreased expression of HLA-DR and TLR-4, and the absence of IL-1β and IL-8 suggest an IL-10–mediated functional depression of monocyte, including their adhesive and migratory capacities. The lack of an after-cardioplegia orientation toward IL-10 producing a “macrophage-like” CD14+/CD16+ phenotype might mean that myocardial infiltrating lymphocytes are the main source of IL-10. Moreover, the increased after-cardioplegia levels of IL-6 and TNF-α might be due to myocardial and endothelial activations. The increased adhesion index between monocyte and platelets, without receptor variations, suggests a monocyte membrane modification induced by extracorporeal circulation. © 2005 Wiley-Liss, Inc.

The non-thyroidal illness syndrome (NTIS) is considered a transient and completely reversible phenomenon, but it has been shown that it may last for several days postoperatively after coronary artery bypass grafting (CABG) surgery. This study was undertaken to assess thyroid function 6 months after uncomplicated CABG. The thyroid profile was evaluated in 40 consecutive patients undergoing CABG preoperatively, at 0, 12, 48, and 120 h postoperatively, and at 6-month follow-up. Triiodothyronine (T3), free T3 (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) were assayed using a microparticle enzyme immunoassay. T4 and total serum thyroid hormone-binding capacity (T-uptake) were measured on the same samples using a fluorescence polarization immunoassay. Patients with severe systemic illness and patients treated with amiodarone were excluded. All patients were euthyroid at admission. Mean age was 67.4+/-9.0 years. There were 31 (77.5%) men. Typical NTIS was observed in all patients, and the FT3 concentration was still reduced by postoperative day 5 (p

Background Cardiovascular surgery with cardiopulmonary bypass (CPB) induces systemic inflammation and postoperative complications depending on pro- and anti-inflammatory mechanisms. Activated polymorphonuclear cells and monocytes may be responsible for morbidity associated with CPB. Knowledge of the monocyte functional state in particular may help to develop protective interventions. Methods Samples were drawn from venous peripheral blood (basal condition, at 4 and 24 h after CPB) and coronary blood (before and after cardioplegic arrest) of 14 patients undergoing cardiac surgery. The following phenotypic and functional parameters of the monocyte population were studied by flow cytometry: surface molecules expression (CD18, CD11a, CD11b, CD14, CD15, CD45, HLA-DR, and Toll-like receptor [TLR]-4), myeloperoxidase (MPO) content, and intracellular cytokine production (tumor necrosis factor [TNF]-α, interleukin [IL]-1β, IL-6, and IL-8). Results Cardiac surgery with CPB induced down-modulation of surface molecules expression on peripheral monocytes, especially at 24 h after CPB, for CD18, CD11a, and CD11b (P < 0.003) and for the CD15 adhesive cluster (P = 0.0028) and HLA-DR (P < 0.001). At 4 h after CPB, downregulation was observed for CD14 (P = 0.004), CD45 (P = 0.014), and CD15 (P = 0.0056). A loss of MPO was detected in venous peripheral (at 24 h after CPB, P = 0.01) or coronary (at reperfusion, P < 0.02) blood. The CD15 cluster complex exhibited a down-modulation in coronary blood (at reperfusion, P = 0.0003). Spontaneous intracellular production of IL-1β, IL-6, and IL-8 decreased at 24 h after CPB (P < 0.05). Conclusions The down-modulation of integrins and adhesive receptor expression and the loss of MPO suggest a strong activation and shedding reaction of circulating monocyte after CPB, further exacerbated by contact with coronary ischemic vessels. The changes of differentiation antigens may reflect the appearance of a partially immature population immediately after CPB. The reduced proinflammatory cytokine production, observed at 24 h after CPB, suggests a functional polarization of circulating monocytes. © 2003 Wiley-Liss, Inc.

 to analyze the time trend of neuronal injury markers differentiated according to morphological composition of the carotid plaques, as important factor for prognostic stratification of carotid lesions. T h i s s u b t l e n e u r o l o g i c a l damage, o f ten be low the detection threshold of clininical neurological tests, can be early d e t e c t e d b y m e a s u r i n g peripheral serum markers of brain injury (S100beta protein and neuronal-specific enolase NSE).