A Collaborative Study to Establish the 2nd International Standard for Tissue Plasminogen Activator (t-PA)

An international collaborative study involving ten laboratories located in eight different countries was undertaken in order to replace the current International Standard (I.S.) for tissue plasminogen activator (t-PA). Two lyophilised candidate preparations of high purity were assessed in comparison with the current I.S. for t-PA using only a clot lysis assay. One preparation (coded 861670) was purified from a cultured melanoma cell supernatant and was about 98% single chain t-PA while the other preparation (coded 861624) was derived from Chinese hamster ovary (CHO) cells following DNA recombinant procedures and was 75% single chain t-PA.

Both candidate preparations of t-PA compared in quite a satisfactory manner with the current I.S. from the viewpoint of the biometrics of parallel line bioassays and both preparations were quite stable for long periods at low temperatures and stable from up to 1 month at temperatures of 20° and 38° C. Both fultil the criteria to serve as a satisfactory Znd International Standard for t-PA. The Fibrinolysis Subcommittee of the International Committee for Thrombosis and Haemostasis recommended the melanoma source t-PA (861670) as the next I.S. in order to maintain continuity with the 1st I.S. which was also a melanomatype preparation. The data from the ten laboratories indicated that each ampoule of the new proposed standard contains 850 international units of t-PA activity by the clot lysis assay. It is planned to present the results of this study to the Expert Committee on Biological Standardization of the World Health Organization at its next meeting and to request that the preparation of t-PA, coded 861670, be established as the 2ndlnternational Standard for t-PA.

The Establishment of a Standard for Plasminogen (Glu-Type)

Following an international collaborative study, a preparation of glutamic acid-(glu-)human plasminogen was established as a British Standard. This study compared the activity of the proposed standard following full activation to plasmin with the 2nd International Reference Preparation (IRP) for plasmin using both fibrinolytic and chromogenic assays. There was good agreement between the results of the two assay methods. The activity of the standard was 10 units per ampoule, these units being equivalent to those defined by the 2nd IRP for plasmin.

Standardization of Low Molecular Weight Heparins : A Collaborative Study

A collaborative study was carried out, in which eight laboratories each assayed eight low molecular weight (LMW) heparins against the International Standard (IS) for heparin. APTT assays and three types of anti-Xa method were used. The results of this study showed that:

1. LMW heparins cannot be validly assayed against the IS by APTT or anti-Xa methods.

2. Potencies of LMW heparins vs. the IS differed considerably between the four types of assay method used and also between different laboratories using the same type of method.

3. Adoption of a single LMW heparin standard would improve validity, improve inter-laboratory variation, and largely abolish the differences between the three types of anti-Xa method. However, since calibration of a LMW heparin standard against the IS would give potencies that differ widely by the different assay methods, a single assay method such as the anti-Xa amidolytic, plasma, would need to be chosen for this calibration.

A Collaborative Study Designed to Establish the 4th International Standard for Heparin

An international collaborative study, in which 22 laboratories participated, was carried out to establish a replacement for the International Standard for Heparin. A total of 248 assays were analyzed, including APTT, thrombin inhibition and anti-Xa assays, as well as pharmacopoeial assays. Overall, there was less than 5% difference in the mean potency estimates of the candidate preparations, by all assay methods. The freeze-dried preparation 82/502 demonstrated the closest parallelism by bioassay to the existing standard and was established by WHO as the 4th International Standard for Heparin, with an assigned unitage of 1780 i.u. per ampoule.

A Comparison of Heparin Potency Estimates Obtained by Activated Partial Thromboplastin Time and British Pharmacopoeial Assays

Heparin samples from five manufacturers were assayed by the revised British Pharmacopoeia (BP) heparin assay and the results compared with those obtained using the activated partial thromboplastin time (APTT) assay. The United States Pharmacopeia (USP) reference heparin preparation and the 4th International Standard (IS) for heparin were also assayed by the two methods relative to the 3rd IS. The results obtained by the revised BP assay were in close agreement with those obtained by the APTT assay for all the heparins that were tested. The assays revealed that there is at least a 10% discrepancy between the International Unit for heparin and the USP unit.

A Collaborative Study of a Proposed International Standard for Tissue Plasminogen Activator (t-PA)

An international collaborative study involving seven laboratories was undertaken to assess which of three lyophilised preparations might serve as an International Standard (I.S.) for tissue plasminogen activator (t-PA). Two of the preparations were isolates from human melanoma cell cultures while one was of pig heart origin. A clot lysis assay was used by all participants in the study.

The data suggested that both preparations of human cell origin were comparable, in that their log dose-response lines were parallel, while that of the porcine preparation was not. Accelerated degradation studies indicated that one melanoma extract (denoted 83/517) was more stable than the other and it was decided to recommend preparation 83/517 as the standard for t-PA. The International Committee for Thrombosis and Haemostasis (Stockholm 1983) has recommended the use of this material as a standard and it has been established by the Expert Committee on Biological Standardization of the World Health Organization as the International, Standard for tissue plasminogen activator, with an assigned potency of 1000 International Units per ampoule.

Bioavailability in Rats of Human Recombinant Tissue Plasminogen Activator After Subcutaneous and Intramuscular Injection

The bioavailability of human recombinant tissue plasminogen activator (rt-PA) in rats was measured after subcutaneous (s.c.) and intramuscular (i.m.) injection. Rt-PA was absorbed after both i.m. and s.c. injection, giving peak plasma concentrations within 30 min and 1 h, respectively, with detectable concentrations up to 6 h. These peak values of bioavailable t-PA were obtained in a functional fibrin plate assay of euglobulin precipitates and expressed as +88% and +243% (for s.c. and i.m. routes respectively) above basal rat fibrinolytic activity. Prior injection of rt-PA, s.c. or i.m., significantly reduced the weights of thrombi induced in the inferior vena cava after injection.

The Stability of Tissue Plasminogen Activator (t-PA)

Since tissue-type plasminogen activator (t-PA) derived from tissue culture and recombinant DNA procedures has been proposed for use in thrombolytic therapy in man, it is essential that the t-PA molecule should display reasonable stability in a lyophilised state to facilitate its usefulness. In this study, four laboratories compared the potencies of three preparations of t-PA following storage at 4°, 20°, 37° and 45° C, using each t-PA stored at -20° C as a reference (100% activity) in each case. A pig heart extract of t-PA was the most stable, losing no activity when stored for 30 days at 37° C, while two melanoma cell tissue culture extracts varied in their storage behaviour. One was quite stable at 37° C (losing about 3% of its activity) while the other lost about 16%. Thus both the pig heart t-PA and one t-PA from melanoma cell culture proved suitable for the further development of reference standards for t-PA activity.

Standardization of Factor VIII – IV. Establishment of the 3rd International Standard for Factor VIII: C Concentrate

An international collaborative study was carried out to establish a replacement for the current (2nd) international standard for Factor VIII: C, concentrate. Twenty-six laboratories took part, of which 17 performed one-stage assays, three performed two-stage assays and six used both methods. The proposed new standard, an intermediate purity concentrate, was assayed against the current standard, against a high-purity concentrate and against an International Reference Plasma, coded 80/511, previously calibrated against fresh normal plasma.

Assays of the proposed new standard against the current standard gave a mean potency of 3.89 iu/ampoule, with good agreement between laboratories and between one-stage and two- stage assays. There was also no difference between assay methods in the comparison of high-purity and intermediate purity concentrates. In the comparison of the proposed standard with the plasma reference preparation, the overall mean potency was 4.03 iu/ampoule, but there were substantial differences between laboratories, and the two-stage method gave significantly higher results than the one stage method. Of the technical variables in the one-stage method, only the activation time with one reagent appeared to have any influence on the results of this comparison of concentrate against plasma.

Accelerated degradation studies showed that the proposed standard is very stable. With the agreement of the participants, the material, in ampoules coded 80/556, has been established by the World Health Organization as the 3rd International Standard for Factor VIII :C, Concentrate, with an assigned potency of 3.9 iu/ampoule.

Standardization of β-Thromboglobulin and Platelet Factor 4: A Collaborative Study to Investigate the Sources and Extent of Variation in the Measurement of Platelet Specific Proteins

A collaborative study involving seven laboratories has been carried out to investigate the sources and extent of variation in the measurement by radioimmunoassay of β-thromboglobulin (β-TG) and platelet factor 4 (PF4). Three plasma samples, one purified β-TG sample and two purified PF4 samples were assayed against house standards for the respective antigens by each laboratory.

The main source of variation of both β-TG and PF4 measurements was inter-assay (particularly for PF4). It was found that a significant component of this variation was due to the participants’ use of different preparations as house standards for β-TG and for PF4. This indicates that the first step in the standardization of β-TG and PF4 measurement should be the introduction of a reference for each.

Standardization of β-Thromboglobulin (β-TG) and Platelet Factor 4 (PF4): A Collaborative Study to Establish International Standards for β-TG and PF4

An international collaborative study was carried out to determine the suitability of freeze-dried preparations of β-TG and PF4 to serve as international standards, and to compare these materials with other purified preparations and with plasma samples. Although problems remain with the accurate measurement of these proteins, it has been demonstrated that common standards improve the precision of measurement by RIA and provide an essential foundation for future work into the effects of assay system differences.

The World Health Organization established in 1984 the purified preparation of β-TG (83/501) and the purified preparation of PF4 (83/505) as International Standards, with assigned potencies of 500 International Units per ampoule and 400 International Units per ampoule, respectively.

Enhanced Vascular Plasminogen Activator (t-PA) Release by Epinephrine in Aged Rats

Adrenergic stimulation induces an acute fibrinolytic response in the vascular wall and can play an important role in limiting thrombus growth. The incidence of thrombotic disease increases with age. As many adrenergic functions are affected by aging, the vascular response to adrenergic stimulation was studied in young (3 ± 1 months) and aged (18 ± 3 months) rats, using an experimental model of vascular perfusion. Five min epinephrine (EPI) infusion (0.15-25 μM) induced a dose-dependent increase in tissue-type plasminogen activator (t-PA) release and in perfusion pressure, in both young and aged rats. In the latter, however, the basal activity of t-PA was significantly higher than in young animals (0.22 ± 0.02 vs 0.13 ± 0.01 U/ml; means ± SE; p <0.01, n = 40) and EPI infusion induced a significantly higher increase in t-PA activity (0.78 ± 0.06 vs 0.47 ± 0.08 U/ml, p <0.01, for 6.25 μM EPI). The response was characterized by a delayed onset. In contrast, the increase in the perfusion pressure by EPI was significantly lower in aged that in young rats, its basal levels being normal.

To evaluate whether the increased vascular response of t-PA was peculiar for adrenergic stimulation, we infused platelet activating factor (PAF), an inducer of t-PA release, not related to catecholamines. PAF, during five-minute infusion induced a rapid and dose-dependent (100-1250 pM) increase in t-PA release, to the same extent in both young and aged rats.

In conclusion, basal t-PA secretion was increased in aged rats probably as a response of vascular endothelium to chronic stimulation. Moreover, the vascular fibrinolytic response to acute EPI stimulation was greater in aging. This response was specific for adrenoceptor stimulation and could represent an adaptative mechanism of adrenergic receptors, counteracting an increased thrombotic tendency.

An International Standard for Low Molecular Weight Heparin

An international collaborative study has been carried out with the aim of establishing an international standard for low molecular weight (LMW) heparin. Three preparations of LMW heparin were assayed against the International Standard for unfractionated heparin (UFH) by 25 laboratories in 13 countries, using nine different assay methods. The results confirmed previous findings of non-parallel assays, wide interlaboratory variability and differences between methods when LMW heparins are assayed against a UFH standard. Use of one of the LMW heparins as a standard for the other two gave parallel assays and much closer agreement between laboratories. The preparation in ampoules coded 85/600 was selected as likely to give the best agreement with the largest number of LMW heparins; potencies were assigned by taking the mean of all the anti-Xa assays, and the mean of the thrombin and APTT assays, to represent the two major groups of activities. Preparation 85/600 has been established by WHO as the 1st International Standard for LMW heparin, with potencies of 1,680 iu/ampoule by anti-Xa assays and 665 iu/ampoule by thrombin inhibition and APTT assays.

Age- and sex-based ranges of platelet count and cause-specific mortality risk in an adult general population: prospective findings from the Moli-sani study

Platelet count varies by age, sex and ethnicity. However, previous studies have adopted standard ranges to identify subjects with thrombocytopenia or thrombocytosis. The aim of this study was to test the predictive role of age-sex-based cut-offs of platelet count proposed by an Italian collaborative study, towards the risk of cause-specific death. We conducted a prospective analysis on 21,563 adult subjects (mean age 55.6 ± 11.8) randomised from the general population of the Moli-sani study. Hazard ratios (HR) were calculated by multivariable Cox-proportional hazard models with 95% confidence intervals. Over a median follow-up of 8.2 years (interquartile range: 7.3 to 9.2 years; 175,972 person-years), we ascertained and validated 1,130 deaths, 415 of which are from cardiovascular disease, 439 from cancer and 276 from non-vascular/non-cancer causes. As opposed to the normal ranges defined by age and sex (extreme values from 122 to 405 x10⁹/L), lower platelet number (87.7% of values being higher than 100x10⁹/L) was associated with increased risk of total (HR = 1.92; 95%CI 1.38-2.67), cancer (HR = 1.77; 95%CI 1.03-3.05), and non-cardiovascular/non-cancer mortality (HR = 3.16; 95%CI 1.84-5.42) but was unrelated to cardiovascular mortality. Higher platelet count was not associated with any death risk. In conclusion, age-sex-based low platelet count, well above the traditional lower normal range of <100 x10⁹/L, is associated with increased total and specific mortality risk in a general population.

Health-related quality of life and risk of composite coronary heart disease and cerebrovascular events in the Moli-sani study cohort

Background To assess the association between health-related quality of life (HRQL) and a composite outcome including incident coronary heart disease (CHD) and cerebrovascular events in a large general population-based cohort. Design Prospective analysis on 17,102 men and women (mean age 53 ± 11) free from cardiovascular disease at time of enrolment in the Moli-sani cohort (2005-2010). Methods HRQL was assessed by the 36-Item Short Form Health Survey. Hazard ratios with 95% confidence intervals (95% CIs) were calculated using multivariable Cox-proportional hazard models. Results At the end of follow-up (median 4.2 years), 237 new events occurred (coronary heart disease n = 197, cerebrovascular disease n = 42). In a multivariable model adjusted for socioeconomic factors, chronic disease and health-related behaviours, both mental and physical HRQL were inversely associated with the risk of the composite outcome (hazard ratio = 0.57; 0.39-0.84 and hazard ratio = 0.62; 0.40-0.94, respectively; highest vs. lowest quartile). Further adjustment for C-reactive protein marginally modified the association with physical HRQL (hazard ratio = 0.67; 0.43-1.02). Similar findings were obtained when only CHD events were analysed (hazard ratio = 0.63; 0.41-0.96 for highest versus lowest mental HRQL) although results with physical HRQL were no longer significant (hazard ratio = 0.65; 0.40-1.04 for highest versus lowest quartile). Associations with incident cerebrovascular disease showed a trend toward protection (hazard ratio = 0.50; 0.22-1.17 and hazard ratio = 0.51; 0.22-1.23 for highest versus lowest tertile of mental and physical HRQL, respectively). Conclusions HRQL is an independent predictor of composite CHD/cerebrovascular outcomes in an adult population. The magnitude of the association was not affected either by socioeconomic factors, health conditions or health-related behaviours. Improvement of quality of life may be a major factor in targeting appropriate prevention strategies for cardiovascular health.

Experimental Arterial Thrombosis in Genetically or Diet Induced Hyperlipidemia in Rats

To investigate the relationship among lipids, coagulation and thrombosis in the absence of atherosclerosis, spontaneous or dietary-induced hyperlipidemic (FHL) rats were studied. FHL showed higher levels of coagulation factors VII, IX, X, VIII and XII and a shortening of the occlusion time (OT) of an artificial arterial prosthesis as compared with normolipidemic (FNL) animals. Damage of abdominal aorta of FHL was followed by increased fibrin deposition in the vascular intima as compared to FNL. After 5 months of cholesterol-rich diet FNL showed increased cholesterol, triglycerides and factor II, VII, IX, X, XII levels. A significant shortening of the OT and increased fibrin deposition was also observed. Two-month diet withdrawal restored the initial condition. Warfarin treatment, at a dose decreasing vitamin K-dependent factor to levels found in FNL, prolonged the OT and reduced fibrin deposition, without modifying F XII or changing lipid profile. An increase in the activated form of F VII was observed. In contrast, no difference was found in F VII clearance. High lipid levels favour the process of thrombus formation by increasing the activation of vitamin K-dependent coagulation factors. Low-dose warfarin treatment reverts the prothrombotic effect of hyper-lipidemia.

Mean platelet volume is associated with lower risk of overall and non-vascular mortality in a general population

Larger mean platelet volume (MPV) has been associated with adverse health outcomes in high-risk populations or patients with cardiovascular disease (CVD). We tested the association of MPV with mortality in a prospective cohort study including 17,402 subjects randomly recruited from an adult general population within the Moli-sani study (2005–2010). Two distinct subgroups (with or without CVD at baseline) were subsequently analysed. Hazard ratios (HR) were calculated using multivariable Cox-proportional hazard models. Over a median follow up of eight years (137,547 person-years), 925 all-cause deaths occurred (330 vascular, 351 cancer and 244 other deaths). In a multivariable model, the highest MPV quintile (mean MPV=10.0 fL), as compared to the lowest one, was associated with reduced risk of overall mortality (HR=0.79; 95 % confidence interval 0.64–0.98), cancer death (HR=0.70; 0.49–1.00) and death from other non- vascular/non cancer causes (HR=0.55; 0.36–0.84) but not with vascular mortality. The inverse association with overall death appeared even stronger in the subgroup without CVD at baseline (HR=0.64; 0.50–0.81). In contrast, within 920 subjects reporting a previous CVD event, larger MPV was associated with higher risk of total mortality (HR=1.69; 1.05–2.72; p for interaction=0.048) and with a trend of risk for other cause-specific deaths. In conclusion, larger MPV is associated with lower risk of overall and non-vascular death in subjects apparently free from CVD, but appears to be a predictive marker of death in patients with CVD history. The latter is a likely effect modifier of the association between MPV and death.

Postprandial cell inflammatory response to a standardised fatty meal in subjects at different degree of cardiovascular risk

A fatty meal may represent a challenge of in vivo acute inflammatory reaction. We evaluated the acute effects of a standardised fatty meal administration on leukocytes and platelets and on their interactions on 61 subjects at different degree of cardiovascular risk, without any clinical event. Before and 2 hours after a fatty meal, blood cells were counted and markers of leukocyte (intracellular myeloperoxidase [MPO] and Mac-1) and platelet (P-selectin and microparticles) activation and mixed platelet-leukocyte conjugates measured by flow-cytometry. After the fatty meal, both white blood cell and platelet count significantly increased, more markedly in subjects with lower cardiovascular risk score. Mac-1 expression too increased (from 32.2 ± 27.2% to 45.6 ± 29.0%, p=0.0016), while MPO decreased (from 83.1 ± 16.3% to 64.5 ± 23.1%, p<0.0001). A trend for increased platelet activation and interaction with leukocytes was also observed. Women were more markedly susceptible to fatty meal challenge, as compared to men, while age did not seem to affect any cell response to fatty meal. Waist-to-hip ratio and body mass index influenced polymorphonuclear cells (PMN) degranulation and platelet count increase, respectively. Cellular responses to the fatty meal, in particular PMN degranulation, were attenuated in subjects at higher degree of cardiovascular risk, who showed a basal mild inflammatory activation status. In conclusion, a fatty meal consumption may represent a model of acute inflammatory response and appears to be modulated by different demographic and cardiovascular risk degree. This model could be applied to study the effect of food-derived antioxidants or nutritional supplements, but its relevance remains to be demonstrated.

Moderate Alcohol Consumption Is Associated With Lower Risk for Heart Failure But Not Atrial Fibrillation

OBJECTIVES

The aim of this study was to assess the hypothesis that alcohol consumption is associated with onset of atrial fibrillation (AF) and/or heart failure (HF).

BACKGROUND

The connection between ethanol intake and AF or HF remains controversial.

METHODS

The study population was 22,824 AF- or HF-free subjects (48% men, age ≥35 years) randomly recruited from the general population included in the Moli-sani study, for whom complete data on HF, AF, and alcohol consumption were available. The cohort was followed up to December 31, 2015, for a median of 8.2 years (183,912 person-years). Incident cases were identified through linkage to the Molise regional archive of hospital discharges. Hazard ratios were calculated using Cox proportional hazard models and cubic spline regression.

RESULTS

A total of 943 incident cases of HF and 554 of AF were identified. In comparison with never drinkers, both former and occasional drinkers showed comparable risk for developing HF. Drinking alcohol in the range of 1 to 4 drinks/day was associated with a lower risk for HF, with a 22% maximum risk reduction at 20 g/day, independent of common confounders. In contrast, no association of alcohol consumption with onset of AF was observed. Very similar results were obtained after restriction of the analyses to regular or only wine drinkers or according to sex, age, social status, or adherence to the Mediterranean diet.

CONCLUSIONS

Consumption of alcohol in moderation was associated with a lower incidence of HF but not with development of AF.

Frontal plane T-wave axis orientation predicts coronary events: Findings from the Moli-sani study

BACKGROUND AND AIMS

The orientation of the frontal plane T-wave axis (T axis) is a reliable measure of ventricular repolarisation. We investigated the association between T-axis and the risk of coronary heart disease (CHD), heart failure (HF), atrial fibrillation (AF), stroke and cardiovascular (CVD) mortality.

METHODS

A sample of 21,287 Moli-sani participants randomly recruited from the general adult (≥35 y) Italian population, free of CVD disease, were followed for a median of 4.4 years. T-axis was measured from a standard 12-lead resting ECG.

RESULTS

After adjusting for CVD risk factors, subjects with abnormal T-axis showed an increase in the risk of both CHD (Hazard Ratio (HR) = 2.65; 95% CI = 1.67-4.21), HF (HR = 2.56; 1.80-3.63), AF (HR = 2.48; 1.56-3.94) and CVD mortality (HR = 2.83; 1.50-5.32). The association with CHD and HF, but not with AF or CVD death, remained significant after further adjustment for ECG abnormalities. Subjects with abnormal T-axis showed higher levels of subclinical inflammation, hs-troponin I and hs-NT-proBNP (p < 0.001 for all). However, further adjustment for troponin I and/or NT-proBNP determined a reduction of HRs ranging from 12.1 to 24.0% for CHD, while additional adjustment for inflammation markers did not change any association.

CONCLUSIONS

An abnormal T-axis orientation is associated with an increased risk of both CHD and HF, independently of common CVD risk factors and other ECG abnormalities. This association was partially explained by increased hs-troponin I and hs-NT-proBNP levels.

Relative contribution of health-related behaviours and chronic diseases to the socioeconomic patterning of low-grade inflammation

OBJECTIVES

To test the association of low-grade inflammation with socioeconomic status (SES) and determine the relative contribution of prevalent chronic diseases and health-related behaviours in explaining such association.

METHODS

Cross-sectional analysis on 19,867 subjects (age ≥35, 48.1% men) recruited within the Moli-sani study from 2005 to 2010 (Italy). A score of low-grade inflammation, including platelet and leukocyte counts, the granulocyte-to-lymphocyte ratio, and C-reactive protein was applied. SES was measured by education, household income, and occupational social class.

RESULTS

Low SES was associated with elevated levels of low-grade inflammation. Health behaviours (including adiposity, smoking, physical activity, and Mediterranean diet adherence) explained 53.5, 53.9, and 84.9% of the association between social class, income, and education with low-grade inflammation, respectively. Adiposity and body mass index showed a prominent role, while prevalent chronic diseases and conditions only marginally attenuated SES inequalities in inflammation.

CONCLUSIONS

Low-grade inflammation was socioeconomically patterned in a large Mediterranean population. Potentially modifiable behavioural factors explained the greatest part of this association with a leading contribution of adiposity, body mass index, and physical activity.

A score of low-grade inflammation and risk of mortality: prospective findings from the Moli-sani study

Low-grade inflammation is associated with an increased risk of chronic degenerative disease, but its relationship with mortality is less well explored. We aimed at evaluating, at a large epidemiological level, the possible association of low-grade inflammation, as measured by a composite score, with overall mortality risk. We conducted a population-based prospective investigation on 20,337 adult subjects free from major hematological disease and acute inflammatory status, randomly recruited from the general population of the Moli-sani study. A low-grade inflammation score was obtained from the sum of 10-tiles of plasmatic (C-reactive protein) and cellular (leukocyte and platelet counts, granulocyte/lymphocyte ratio) biomarkers of low-grade inflammation; higher levels indicated increased low-grade inflammation. Hazard ratios were calculated using multivariable Cox proportional hazard models with 95% confidence intervals. At the end of follow-up (median 7.6 years), 837 all-cause deaths were recorded. As compared to subjects in the lowest quartile of the low-grade inflammation score, those in the highest category had a significantly increased risk in overall mortality (HR=1.44; 1.17-1.77), independently of possible confounders, including the presence of chronic diseases and a number of health-related behaviors. The magnitude of the association of low-grade inflammation with mortality was relatively higher in type 2 diabetic patients (HR=2.90; 1.74-4.84) and in individuals with a history of cardiovascular disease (HR=2.48; 1.50-4.11) as compared to their counterparts who were free from the disease. In conclusion, an elevated degree of low-grade inflammation, as measured by a composite score of inflammatory biomarkers, is an independent risk factor for total mortality in an apparently healthy adult general population.