Zusammenfassung
□ Hintegrund
Trotz zunehmender Etablierung der interventionellen Kardiologie stellt die Entwicklung einer Restenose nach PTCA ein bis dato ungelöstes Problem dar, welches in 30 bis 50% der Fälle auftritt. Das thrombozytäre Funktionssystem spielt in der Pathogenese der Restenose eine zentrale Rolle. Dipyridamol bewirkt durch Inhibition der thrombozytären Phosphodiesterase und Verhinderung des, Adenosinabbaues eine Thrombozytenaggregationshemmung.
□ Patienten und Methodik
In der vorliegenden Studie wurde erstmals untersucht, ob durch vorausgehende intrakoronare Applikation von Dipyridamol eine Reduktion der Inzidenz der angioraphischen und klinischen Restenose mit der Notwendigkeit einer erneuten Intervention resultiert. Hierzu wurde bei 763 Interventionen eine Randomisierung bezüglich konventioneller Therapie (Heparin 15 000 IE, Acetylsalicylsäure 500 mg i. v.) oder additiver intrakoronarer Applikation von Dipyridamol (0,5 mg/kg Körpergewicht) vorgenommen. Entsprechend der Randomisierung wurde bei 375 Interventionen (58 Interventionen bei Frauen, Alter 59,6±9,6 Jahre 57 Interventionen bei akutem Koronargefäßsyndrom) mittels Dipyridamol und bei 388 Dilatationen (61 Interventionen bei Frauen, Alter 60,5±8,7 Jahre; 47 Interventionen bei akutem Koronargefäßsyndrom) konservativ verfahren.
□ Ergebnis
Im Vergleich zu konventionell therapierten Patienten (Restenoserate 43,0%) zeigte sich nach Dipyridamol-Applikation eine Reduktion der angiographischen Restenoserate auf 36,8% sowie der klinischen Reinterventionsrate um 15,5%, wobei die statistische Signifikanz jeweils verfehlt wurde. Als ursächlich für diese tendenziell positive Beeinflussung ließ sich eine statistisch signifikant höhere verbliebene Lumenzunahme („net gain”) nach Dipyridamol bei Verlaufskoronarangiographie nachweisen.
□ Schlußfolgerung
Die Inzidenz der angiographischen und klinischen Restenose läßt sich durch Dipyridamol nicht signifikant beeinflussen, wobei sich allerdings ein Trend in Richtung eines günstigeren Langzeitverlaufs ergab.
Abstract
□ Background
Restenosis after PTCA remains a serious long-term complication of balloon angioplasty occurring in 30 to 50% of patients. Platelets play a crucial role in the pathogenesis of restenosis following PTCA. Dipyridamole has been shown to inhibit platelet aggregation in humans. Its action as an antithrombotic drug can be attributed to different mechanisms including inhibition of platelet phosphodiesterase and inhibition of the cellular uptake of adenosine.
□ Patients and Methods
The purpose of the following study was to investigate the effect of an intracoronary infusion of dipyridamole on the incidence of angiographic and clinical restenosis. In 763 balloon angioplasties patients were randomly allocated to receive either conventional pretreatment (heparin 15000 IE, aspirin 500 mg i. v.) or an additional intracoronary infusion of dipyridamole (0,5 mg/kg body weight). Conventional pretreatment was performed in 388 interventions (61 interventions in women, age 60.5±8.7 years; 47 interventions for acute coronary syndromes); in 375 interventions additional, intracoronary dipyridamole was infused (58 interventions in women, age = 59.6±9.6 years; 57 interventions for acute coronary syndromes).
□ Results
As compared to conventional pretreatment intracoronary dipyridamole application was associated with a reduction in angiographic restenosis from 43.0% to 36.8% and a reduction of target vessel revascularisation by 15.5% but failed to reach statistical significance. These results were due to an increase in net gain following dipyridamole application.
□ Conclusion
Intracoronary pretreatment with dipyridamole prior to PTCA fails to reduce the incidence of angiographic restenosis and target vessel revascularisation significantly. However, a moderate improvement of long-term follow-up can be achieved.
Literatur
The Benestent Study Group. A comparison of balloon-expandable stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489–95.
Casscells W. Migration of smooth muscle and endothelial cells — Critical events in restenosis. Circulation 1992;86:723–9.
Emmons PR, Harrison MJG, Honour AJ, et al. Effect of dipyridamole on human platelet behaviour. Lancet 1965;2:603–6.
The EPIC investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high risk coronary angioplasty. N Engl J Med 1994;330:956–61.
The EPIC investigators. Randomised trial of coronary intervention with antibody against platelet IIb/IIIa integrin for reduction of clinical restenosis: results at six months. Lancet 1994;343:881–6.
Epstein SE, Speir E, Unger EF, et al. The basis of molecular strategies for treating coronary restenosis after angioplasty. J Am Coll Cardiol 1994;23:1278–88.
Fitzgerald GA. Drug therapy: Dipyridamole. N Engl J Med 1987;316:1247–57.
Foley DP, Melkert R, Umans VA, et al. on behalf of the CARPORT, MERCATOR, MARCATOR, PARK and BENESTENT trial groups. Differences in restenosis propensity of devices for transluminal, coronary intervention — A quantitative angiographic comparison of balloon angioplasty, directional atherectomy, stent implantation and excimer laser angioplasty. Eur Heart J 1995;16:1331–46.
Forrester JS, Fishbein M, Helfant R, et al. Paradigm for restenosis based on cell biology: clues for the development of new preventive therapies. J Am Coll Cardiol 1991;17:758–69.
Hamon M, Bauters C, Mc Fadden EP, et al. Restenosis after coronary angioplasty. Eur Heart J 1995;16:Suppl 1:33–48.
Heintzen MP, Heidland UE, Klimek, WJ, et al. Dipyridamol intrakoronar reduziert die Inzidenz des akuten Koronargefäßverschlusses bei der perkutanen transluminalen Koronarangioplastie — Eine prospektiv randomisierte Untersuchung. Z Kardiol 1997;86:961–7.
Heintzen MP, Motz W, Leschke M, et al. PTCA im Stadium des akuten Myokardinfarktes: Hospitalverlauf von 785 konsekutiven Patienten. Z Kardiol 1994;83:404–13.
Hermans WRM, Rensing BJ, Strauss BH, et al. Prevention of restenosis after percutaneous transluminal coronary angioplasty: The search for a “magic bullet”. Am Heart J 1991;122:171–87.
Hermans WRM, Foley DP, Rensing BJ, et al. Usefulness of quantitative and qualitative angiographic lesion morphology, and clinical characteristics in predicting major adverse cardiac events during and after native coronary balloon angioplasty. Am J Cardiol 1993;72:14–20.
Ip JH, Fuster V, Israel D, Badimon L, et al. The role of plastelets, thrombin and hyperplasia in restenosis after coronary angioplasty. J Am Coll Cardiol 1991;17:77B-88B.
Kübler W, Spieckermann PG, Bretschneider HJ. Influence of dipyridamole (Persantin) on myocardial adenosine metabolism. J Mol Cell Cardiol 1970;1:23.
Kübler W. Die Bindung des Koronardilatators Dipyridamol an die Plasmaeiweißkörper des, Menschen. Arch Kreisl-Forsch 1971;64:115.
Le Breton H, Plow EF, Topol EJ. Role of platelets in restenosis after percutaneous coronary revascularization. J Am Coll Cardiol 1996;28:1643–51.
Markovitz JH, Roubin GS, Parks JM, et al. Platelet activation and restenosis after coronary stenting — flow cytometric detection of wound-induced platelet activation. Coron Artery Dis 1996;7:657–65.
Mintz GS, Popma JL, Pichard AD, et al. Arterial remodeling after coronary angioplasty — A serial intravascular ultrasound study. Circulation 1996;94:35–43.
Moncada S, Korbut R. Dipyridamole and other phosphodiesterase inhibitors act as antithrombotic agents by potentiating endogenous prostacyclin. Lancet 1987;1:1286–9.
Schwartz L, Bourassa MA, Lesperance J. Aspirin and dipyridamole in the prevention of restenosis after PTCA. N Engl J Med 1988;318:1714–9.
Selzer RH. Precision and reproducibility of quantitative coronary angiography with application to controlled clinical trials: a sampling study. J Clin Invest 1989;83:520–6.
Serruys PW, Luijten HE, Beatt KJ, et al. Incidence of restenosis after successful coronary angioplasty: a time-related phenomenon. Circulation 1988;77:361–71.
Singh JP, Rothfuss KJ, Wiernicki TR, et al. Dipyridamole directly inhibits vascular smooth muscle cell proliferation in vitro and in vivo: Implications in the treatment of restenosis after angioplasty. J Am Coll Cardiol 1994;23:665–71.
Strauer BE. The significance of coronary reserve in clinical heart failure. J Am Coll Cardiol 1990;15:775–83.
The Stent Restenosis Study investigators A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994;331:496–501.
Topol EJ, Leya F, Pinkerton CA, et al. A comparison of directional atherectomy with coronary angioplasty in patients with coronary artery disease. N Engl J Med 1993;329:221–7.
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Heidland, U.E., Klimek, W.J., Michel, C.J. et al. Einfluß einer intrakoronaren Dipyridamol-Applikation auf die Inzidenz der Restenose nach PTCA. Med Klin 93, 579–584 (1998). https://doi.org/10.1007/BF03042672
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DOI: https://doi.org/10.1007/BF03042672