Comprehensive Assessment of Coronary Plaque Progression With Advanced Intravascular Imaging, Physiological Measures, and Wall Shear Stress: A Pilot Double-Blinded Randomized Controlled Clinical Trial of Nebivolol Versus Atenolol in Nonobstructive Coronary Artery Disease

Abstract

Background: We hypothesized that nebivolol, a β-blocker with nitric oxide-mediated activity, compared with atenolol, a β-blocker without such activity, would decrease oxidative stress and improve the effects of endothelial dysfunction and wall shear stress (WSS), thereby reducing atherosclerosis progression and vulnerability in patients with nonobstructive coronary artery disease.

Methods and results: In this pilot double-blinded randomized controlled trial, 24 patients treated for 1 year with nebivolol 10 mg versus atenolol 100 mg plus standard medical therapy underwent baseline and follow-up coronary angiography with assessments of inflammatory and oxidative stress biomarkers, microvascular function, endothelial function, and virtual histology intravascular ultrasound. WSS was calculated from computational fluid dynamics. Virtual histology intravascular ultrasound segments were assessed for vessel volumetrics and remodeling. There was a trend toward more low-WSS segments in the nebivolol cohort (P=0.06). Low-WSS regions were associated with greater plaque progression (P<0.0001) and constrictive remodeling (P=0.04); conversely, high-WSS segments demonstrated plaque regression and excessive expansive remodeling. Nebivolol patients had decreased lumen and vessel areas along with increased plaque area, resulting in more constrictive remodeling (P=0.002). There were no significant differences in biomarker levels, microvascular function, endothelial function, or number of thin-capped fibroatheromas per vessel. Importantly, after adjusting for β-blocker, low-WSS segments remained significantly associated with lumen loss and plaque progression.

Conclusion: Nebivolol, compared with atenolol, was associated with greater plaque progression and constrictive remodeling, likely driven by more low-WSS segments in the nebivolol arm. Both β-blockers had similar effects on oxidative stress, microvascular function, and endothelial function.

Clinical trial registration: URL: https://ichgcp.net/clinical-trials-registry/NCT01230892" title="See in ClinicalTrials.gov">NCT01230892.

Keywords: coronary flow; coronary microvascular function; endothelial function; intravascular ultrasound; wall shear stress.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1

Study flowchart.

Figure 2

Doppler velocity waveforms obtained from a patient undergoing endothelial and microvascular function assessment at baseline and 1‐year follow‐up. APV indicates average peak velocity; CFR, coronary flow reserve; IC, intracoronary; IV, intravenous.

Figure 3

A patient‐specific WSS profile of the left anterior descending coronary artery demonstrates areas of variable WSS magnitudes. WSS indicate wall shear stress.

Figure 4

Serial arterial remodeling by baseline WSS categories at 1 year follow up. P value is for comparison of frequency of 3 remodeling groups across 3 WSS categories. WSS indicate wall shear stress.

Figure 5

Distribution of baseline WSS by β‐blocker. P value is for comparison of the frequency of 3 WSS categories across 2 β‐blockers. WSS indicates wall shear stress.

Figure 6

Serial arterial remodeling by β‐blocker at 1‐year follow‐up. P value is for comparison of the frequency of 3 remodeling groups across 2 β‐blocker categories.