Myeloperoxidase serum levels predict risk in patients with acute coronary syndromes

Suppression of RAGE as a basis of simvastatin-dependent plaque stabilization in type 2 diabetes

OBJECTIVE

Receptor for advanced glycation end products (AGEs) (RAGE) plays a central role in the process of plaque rupture in diabetic patients. Recently, it has been reported that RAGE may be downregulated by improving glycemic control. In contrast, despite being well known that RAGE may be induced in human vessels in a glucose-independent fashion, also by myeloperoxidase (MPO)-dependent AGE generation, no data exist regarding the possibility of a pharmacological modulation of glucose-independent RAGE generation. Thus, the aim of this study was to characterize the effect of simvastatin on the expression of RAGE and RAGE-dependent plaque-destabilizing genes in human atherosclerotic plaques.

METHODS AND RESULTS

Seventy type 2 diabetic patients with asymptomatic carotid artery stenosis (>70%) were randomized to American Heart Association (AHA) step 1 diet plus simvastatin (40 mg/d) or AHA step 1 diet alone for 4 months before endarterectomy. Plaque expression of MPO, AGEs, RAGE, NF-kappaB, COX-2, mPGES-1, matrix metalloproteinase (MMP)-2 and MMP-9, lipid and oxidized LDL (oxLDL) content, procollagen 1, and interstitial collagen was analyzed by immunohistochemistry and Western blot; zymography was used to detect MMP activity. Plaques from the simvastatin group had less (P<0.0001) immunoreactivity for MPO, AGEs, RAGE, p65, COX-2, mPGES-1, MMP-2, and MMP-9, lipids and oxLDL; reduced (P<0.0001) gelatinolytic activity; increased (P<0.0001) procollagen 1 and collagen content; and fewer (P<0.0001) macrophages, T-lymphocytes, and HLA-DR+ cells. Of interest, RAGE inhibition by simvastatin, observed not only in plaque sections but also in plaque-derived macrophages, was reverted by addition of AGEs in vitro.

CONCLUSIONS

This study supports the hypothesis that simvastatin inhibits plaque RAGE expression by decreasing MPO-dependent AGE generation. This effect in turn might contribute to plaque stabilization by inhibiting the biosynthesis of PGE2-dependent MMPs, responsible for plaque rupture.

Biomarkers in Cardiovascular Disease: Integrating Pathophysiology into Clinical Practice

Biomarkers play an important role in the diagnosis, prognostic assessment, and management of patients with suspected acute coronary syndromes (ACS). Specific biomarkers identify different components of the pathophysiology of ACS: troponins are prototype markers of myocyte necrosis, natriuretic peptides reflect neurohormonal activation and hemodynamic stress, soluble CD40 ligand is an indicator of platelet activation, and C-reactive protein, myeloperoxidase, and monocyte chemoattractant protein-1 reflect various inflammatory processes. When combined, multiple biomarkers reflecting different pathophysiologic processes appear to enhance risk stratification, as compared with using individual markers alone. Advances in proteomic technology promise to identify additional novel biomarkers that facilitate diagnosis, risk stratification, and selection of therapies in ACS. In the future, it is hoped that multiple biomarker panels will form the basis of an individualized approach to the treatment of ACS, in which therapy is tailored to individual biomarker profiles.

Biomarkers for atherosclerosis: pathophysiological role and pharmacological modulation

PURPOSE OF REVIEW

The aim of this article is to discuss the potential value of biomarkers for atherosclerosis in the assessment of risk for cardiovascular disease, in the pathogenesis of atherosclerosis, and in the monitoring of pharmacological treatment.

RECENT FINDINGS

In an attempt to improve global cardiovascular risk prediction, considerable effort has been made in the discovery and characterization of soluble biomarkers which can go beyond the measure of total and LDL cholesterol levels. In particular, circulating molecules related to chronic inflammation have emerged as potential biomarkers for atherosclerosis. Evidence, obtained from in-vitro and in-vivo experimental models, has also documented that the majority of biomarkers play a pathological role in atherogenesis. Multiple screening of different biomarkers may therefore improve the assessment of risk, diagnosis, and prognosis for cardiovascular disease. In addition, soluble biomarkers have been shown to be modulated by hypolipidemic drugs and to be potentially useful in determining the clinical benefits of pharmacological therapies that do not alter serum lipid levels.

SUMMARY

Altered levels of soluble biomarkers are associated with cardiovascular disease, and profiling of multiple biomarkers for atherosclerosis will be a useful indicator for better risk assessment, diagnosis, and prognosis, as well as monitoring pharmacological treatments for atherosclerosis.

Inflammatory and Long-term Risk Markers

Evidence indicates that the process of atherosclerosis has an inflammatory component. Markers of inflammation have been explored as a means for assessing (predicting) risk for the disease. Studies that evaluated the usefulness of fibrinogen, highly sensitive C-reactive protein, interleukin-6, myeloperoxidase, and soluble CD40 ligand for risk prediction are reviewed. Criteria for identifying a clinically useful test are discussed, along with the use of relative risk as a means for making clinically useful comparisons. It is concluded that clinically useful markers for routine screening and risk stratification have not been established, that prospective studies will be necessary to confirm the usefulness of current markers, and that on the basis of current knowledge, it will be a challenge to show that any of those inflammatory markers discussed herein will meet the needed criteria. Continued research into basic mechanisms by which inflammation acts in atherosclerosis may be necessary to identify useful markers for prediction.

The T(-786)C endothelial nitric oxide synthase genotype predicts cardiovascular mortality in high-risk patients

OBJECTIVES

This study sought to investigate the impact of a common T(-786)C single-nucleotide polymorphism (SNP) in the promoter of the endothelial nitric oxide synthase (eNOS, NOS3) gene on cardiovascular (CV) death in a prospective cohort study.

BACKGROUND

The T(-786)C SNP eNOS gene implies a blunted endothelium-dependent vasodilation in hypertensive patients and was associated with multivessel coronary artery disease in cross-sectional studies, but it remained unsettled whether it carried prognostic information.

METHODS

In consecutive white patients of the GENICA (Genetic and Environmental Factors in Coronary Atherosclerosis) study, who underwent coronary angiography between 1999 and 2001, we determined the incidence of CV death at follow-up. The eNOS T(-786)C and the exon 7 G(894)T SNPs were determined by melting curve analysis of amplicons from allele-specific fluorescence resonance energy transfer probes. Plasma levels of nitrate/nitrite, nitrotyrosine, and myeloperoxidase were also measured. The Kaplan-Meier and Cox regression analyses were used to assess the impact of SNPs on event-free survival.

RESULTS

Complete follow-up data were obtained in 1,086 (98%) patients. After a median follow-up of 1,296 days (range 4 to 2,057 days), we observed 85 (8.2%) CV deaths. There was a significant impact of the T(-786)C eNOS genotype on CV death-free (p = 0.0102) survival, but no differences in CV death rates across G(894)T genotypes. The TT individuals, who showed a lower survival, exhibited higher plasma myeloperoxidase (p < 0.0001) and lower levels of nitrotyrosine (p < 0.0001) than CC patients.

CONCLUSIONS

The T(-786)C SNP in the promoter of eNOS bears independent prognostic information and is associated with changes in markers of oxidant stress in high-risk white patients referred for coronary angiography.

Severity of myocardial injury following ischemia-reperfusion is increased in a mouse model of allergic asthma

Cardiovascular disease is common in asthmatic patients but often is attributed to respiratory drug therapy. With mounting evidence for an inflammatory role in the development of cardiovascular disease, we hypothesized that the inflammation associated with asthma adversely affects the cardiovascular system independent of therapeutic interventions. The hypothesis was tested in a murine model of myocardial ischemia-reperfusion injury. BALB/C mice were sensitized by intraperitoneal injection of ragweed (RW) or normal saline (NS) and challenged by intratracheal instillation of RW or NS. Effective allergic sensitization and challenge were confirmed by hyperresponsiveness to aerosolized methacholine and bronchoalveolar lavage. In vivo myocardial ischemia-reperfusion injury was induced by ligation of the left anterior descending artery for 20 min, followed by reperfusion for 2 h. The infarct size (% risk area) and neutrophil density in the myocardial area at risk were significantly higher in the RW/RW group than in the control groups. The tissue neutrophil count correlated with the infarct size but did not correlate with blood neutrophil counts. Furthermore, in the RW/RW group, circulating granulocytes showed an enhanced expression of CD11b and P-selectin glycoprotein ligand-1, enhanced stimulated release of myeloperoxidase, and enhanced expression of P-selectin in the coronary vasculature. These results indicate that allergic responses in the airways enhance expression of attachment molecules in coronary vasculature and activate circulating neutrophils, resulting in recruitment of highly activated neutrophils to the infarct zone during an acute ischemia-reperfusion event, thereby enhancing tissue destruction.

Cardiac markers and their point-of-care testing for diagnosis of acute myocardial infarction

Acute myocardial infarction (AMI) is the world's leading cause of mortality and morbidity. Therefore, quick and reliable diagnostics of AMI is extremely critical. Compared to the traditionally used central laboratory tests (CLT), which can be time-consuming and expensive, point-of-care testing (POCT) for AMI-indicative cardiac markers provides a convenient means for rapid diagnostic assays to be performed at the site of patient care delivery. In this article, the etiology and diagnosis of AMI are introduced, and some typical cardiac markers and their clinical applications are reviewed. Furthermore, the various POC cardiac marker devices that are currently available, the benefits of using cardiac marker POC assays, and challenges that cardiac marker POCT are facing are also discussed.

Imaging of Myeloperoxidase in Mice by Using Novel Amplifiable Paramagnetic Substrates

PURPOSE

To evaluate whether contrast agents for molecular magnetic resonance (MR) imaging can demonstrate the in vivo activity of myeloperoxidase, an enzyme that is secreted by stimulated polymorphonuclear leukocytes, monocytes, and macrophages during inflammation.

MATERIALS AND METHODS

Animal experiments were approved by the animal care committee. Protocols for the procurement and use of human blood were approved by the institutional review board. Informed consent was obtained from each donor, and HIPAA guidelines were followed for humans. Two paramagnetic myeloperoxidase substrates--that is, gadolinium-5-hydroxytryptamide-tetraazacyclododecane tetraacetic acid (Gd-5-HT-DOTA) and Gd-bis-5-HT-diethylenetriaminepentaacetic acid (Gd-bis-5-HT-DTPA)--were synthesized. Indium 111-labeled bis-5-HT-DTPA was used to determine biodistribution and target localization. A total of 22 mice were used in three models. In the first model, human myeloperoxidase was embedded in a basement membrane matrix gel and was injected intramuscularly. In the second model, lipopolysaccharide (LPS) from Escherichia coli was embedded in a basement membrane matrix gel and was injected intramuscularly to induce endogenous myeloperoxidase secretion. In the third model, LPS was injected intramuscularly to induce myositis. Statistical significance was calculated for contrast-to-noise ratio (CNR) curves by using the Kolmogorov-Smirnov test.

RESULTS

After the administration of Gd-bis-5-HT-DTPA, strong MR signal enhancement (up to 2.5-fold increase in CNR, P < .001) was observed in vivo for implants that contained human myeloperoxidase. In the LPS-induced myositis model, a smaller visible difference was seen (1.3-fold increase in CNR, P < .001), which was consistent with the fact that endogenous mouse myeloperoxidase is only about 10%-20% as active as human myeloperoxidase. Prolonged contrast material enhancement was observed in the myeloperoxidase-containing areas that were injected with Gd-5-HT-DOTA or Gd-bis-5-HT-DTPA but was not observed in areas that were injected with Gd-DTPA or Gd-dopamine-DOTA (P < .05). Single photon emission computed tomography combined with computed tomography was used to confirm the increased retention of contrast agents at sites that contained human myeloperoxidase, and the results of biodistribution studies demonstrated a more than fourfold increase radiotracer accumulation at these sites.

CONCLUSION

Human and mouse myeloperoxidase activity in myeloperoxidase implants and inflamed tissues can be visualized and reported in vivo by using myeloperoxidase-sensitive "smart" molecular imaging probes.

Serum myeloperoxidase and mortality in maintenance hemodialysis patients

BACKGROUND

During inflammation, myeloperoxidase (MPO) is released, for which its measurement in systemic circulation may be used as an index of leukocyte activation and oxidant stress. MPO levels correlate with angiographic evidence of coronary atherosclerosis and cardiovascular events in subjects with chest pain within the general population. We hypothesized that serum MPO levels are associated with adverse clinical outcomes in maintenance hemodialysis (MHD) patients.

METHODS

MPO levels were determined in serum samples from 356 MHD patients at the start of a 3-year cohort.

RESULTS

Patients (46% women, 28% blacks, 54% with diabetes) were 54.6 +/- 14.6 (SD) years old and had undergone MHD for a median period of 26 months. Measured serum MPO level was 2,005 +/- 1,877 pmol/L (median, 1,444 pmol/L; interquartile range, 861 to 2,490 pmol/L). MHD patients with greater total body fat had greater MPO levels. MPO level had statistically significant (P < 0.01) and positive correlations with values for serum C-reactive protein (CRP; r = +0.15), interleukin 6 (IL-6; r = +0.23), tumor necrosis factor alpha (TNF-alpha; r = +0.21), and white blood cell count (r = +0.21). A death hazard ratio for each 1,000-pmol/L increase in serum MPO level was 1.14 (95% confidence interval [CI], 1.03 to 1.26; P = 0.01) after controlling for age, race (black), diabetes mellitus, dialysis vintage, Charlson comorbidity score, history of previous cardiovascular disease, blood hemoglobin level, and serum concentrations of albumin, CRP, IL-6, and TNF-alpha. After dividing MPO values into 3 equal groups (tertiles), the death hazard ratio of the highest tertile (versus the middle tertile) was 1.82 (95% CI, 1.07 to 3.10; P = 0.03).

CONCLUSION

Serum MPO levels correlate with levels of markers of inflammation and prospective mortality risk in MHD patients.

Serum markers of vascular inflammation in dyslipemia

Atherosclerosis is widely recognized as an inflammatory disease because systemic and local inflammatory events mediate all phases of plaque development and progression. Basic and clinical studies have focused on identifying potentially useful markers of inflammation. In this article, we review the inflammatory pathogenesis of atherosclerosis, and highlight recent results of several of the more promising markers of inflammation for cardiovascular risk assessment. Of these markers, the most reliable and accessible for clinical use is currently high-sensitivity C-reactive protein (CRP). At present, most clinical guidelines do not recommend routine measurement of these inflammatory markers. However, these serum markers of vascular inflammation may be useful as an adjunct to lipid screening, especially for patients whose lipid values may not be severely elevated, but who are at intermediate risk according to scoring systems that take into account multiple established risk factors. In addition, since the pleiotropic effects of statins include the inhibition of inflammatory response, serum inflammatory markers could also be useful for monitoring this action. Nevertheless, several issues have to be evaluated before the measurements of inflammatory markers can be used for cardiovascular risk prediction in either clinical practice or in clinical trials evaluating anti-atherosclerotic drugs.

The effect of atorvastatin on serum myeloperoxidase and CRP levels in patients with acute coronary syndrome

BACKGROUND

Inflammation is involved in the atherogenesis and pathogenesis of acute coronary syndrome (ACS). As the acute-phase reaction proteins in ACS, myeloperoxidase (MPO) and C-reactive protein (CRP) may play critical roles. Anti-inflammation may be one of benefits of statin drugs in ACS. Studies have showed that statins can suppress serum CRP concentrations. However, whether statins also reduce serum MPO concentrations in patients with ACS is unknown.

METHODS

Seventy-eight patients with ACS were randomly separated into Group A and Group B, the patients in Group A receiving conventional therapy, which include no cholesterol-lowering drugs, +atorvastatin (10 mg/day, n=40), the patients in Group B receiving conventional therapy (n=38). The serum concentrations of MPO were measured by enzyme-linked immunosorbent assay (ELISA) and CRP were measured by turbidimetric immunoassay.

RESULTS

Serum concentrations of MPO were significantly lower after 1-week therapy in both groups of patients [Group A from 590+/-168 to 496+/-154 microg/l, Group B from 570+/-165 to 521+/-153 microg/l; P<0.01, respectively]. Serum concentrations of CRP also were markedly lower than pretreatment [Group A from 6.56+/-1.87 to 5.14+/-2.07 mg/l; Group B from 6.36+/-1.94 to 5.45+/-1.90 mg/l, P<0.05, respectively]. Compared with conventional therapy alone, atorvastatin significantly further reduced serum MPO [P=0.014] and CRP concentrations [P=0.032]. There were no correlations detected between the reduction of MPO and CRP (r=0.124, P=0.068).

CONCLUSIONS

Atorvastatin reduced serum MPO and CRP concentrations in patients with ACS. These effects may explain some clinical benefits of statins in the treatment of these patients.

Myeloperoxidase Predicts Progression of Carotid Stenosis in States of Low High-Density Lipoprotein Cholesterol

OBJECTIVES

We investigated the effect of myeloperoxidase (MPO) on progression of carotid stenosis in states of high and low high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C) levels.

BACKGROUND

Myeloperoxidase is pivotally involved in the pathogenesis of atherosclerosis. In vitro data suggest that MPO exerts deleterious effects via oxidative modulation of lipoproteins.

METHODS

We prospectively studied 1,019 of 1,268 consecutive patients who were asymptomatic with respect to carotid artery disease. Patients underwent serial carotid ultrasound investigations at baseline and after a follow-up interval of median 7.5 months (range 6 to 9 months), categorizing carotid arteries as 0% to 29%, 30% to 49%, 50% to 69%, 70% to 89%, or 90% to 99% stenosed or occluded. The MPO, HDL-C, and LDL-C levels were measured at baseline, grouped by medians, and correlated with progression of carotid atherosclerosis.

RESULTS

Progression of carotid atherosclerosis was found in 100 of 1,019 patients (9.8%). Myeloperoxidase (p = 0.014) but not HDL-C (p = 0.95) or LDL-C (p = 0.30) were associated with progressive disease. However, MPO > or =310 ng/ml was significantly associated with progressive disease (adjusted odds ratio [OR] 2.57, 95% confidence interval [CI] 1.39 to 4.75) only in patients with HDL-C levels <49 mg/dl. Otherwise, in patients with higher HDL-C levels (> or =49 mg/dl), MPO > or =310 ng/ml did not predict disease progression (adjusted OR 1.42, 95% CI 0.72 to 2.78). No interaction of MPO with LDL-C was observed.

CONCLUSIONS

Myeloperoxidase was associated with progression of carotid atherosclerosis in patients with HDL cholesterol levels below 49 mg/dl.

Angiotensin Type-1 Receptor A1166C Gene Polymorphism Correlates With Oxidative Stress Levels in Human Heart Failure

Oxidative stress plays a critical role in the pathogenesis of cardiovascular disease and diabetes. Studies in vascular cells and experimental animals have demonstrated that the angiotensin type-1 receptor (AT1R) contributes to formation of reactive oxygen species by activating nicotinamide-adenine dinucleotide phosphate oxidases, but the relevance of this pathway to human heart disease has not been established. Here we demonstrate that a polymorphism in the AT1R gene (A1166C), linked to increased receptor activity, is associated with elevated levels of oxidative stress markers in heart failure patients but not in healthy controls. Plasma protein carbonyls (PCs), a marker of oxidative protein modification, were 10-fold higher in heart-failure patients compared with controls [geometric means and 95% CIs for patients, 75 (57 to 100) pmol/mg; controls, 5 (4 to 7) pmol/mg; P <0.001]. Moreover, levels of PCs were 50-fold higher in patients homozygous for the polymorphism (CC) than in controls and significantly higher than the AA and AC genotype patient groups [CC: 273 (135–550); AC: 59 (35–98); AA: 65 (40–106) pmol/mg; P <0.001]. Levels of myeloperoxidase were also modestly increased in heart-failure patients [51 (46–57) ng/mL] compared with controls [37 (32–44) ng/mL; P <0.001], but were especially elevated in patients with a CC genotype [CC: 72 (58–89); AC: 52 (44–61); AA: 39 (34–46) ng/mL; P <0.001]. The AT1R genotype was demonstrated to be an independent predictor of both PCs and myeloperoxidase levels in heart-failure patients. These findings suggest that oxidative stress in human heart failure is regulated via angiotensin signaling and may involve the nicotinamide dinucleotide oxidase pathway.

L-arginine chlorination results in the formation of a nonselective nitric-oxide synthase inhibitor

Reduced nitric oxide (NO) bioavailability and impaired vascular function are the key pathological characteristics of inflammatory diseases such as atherosclerosis. We have recently found that leukocyte-derived hypochlorous acid is able to react with the nitric-oxide synthase (NOS) substrate L-arginine to produce chlorinated L-arginine (cl-L-Arg). Interestingly, cl-L-Arg potently inhibits the formation of NO metabolites in cultured endothelial cells. It is unknown whether cl-L-Arg has a direct inhibitory effect on endothelial NOS (eNOS). In addition, the effect of cl-L-Arg on the other NOS isoforms, neuronal NOS (nNOS) and inducible NOS (iNOS), is also unknown. Therefore, we designed the current study to test the effects of cl-L-Arg on eNOS, nNOS, and iNOS. Using recombinant NOS, we found that cl-L-Arg had a direct inhibitory effect on the activity of NOS. The effect of cl-L-Arg on NOS activity is nonselective, as all three NOS isoforms were inhibited with a similar IC(50). We further determined the effect of cl-L-Arg on the three NOS isoforms at the tissue level. The results demonstrated that cl-L-Arg potently inhibited all three NOS isoform-mediated vessel reactivities, as well as the NOS signaling molecule cGMP. Cl-L-Arg might serve as a novel endogenous NOS inhibitor and an important mediator for vascular dysfunction under inflammatory conditions such as atherosclerosis. Blocking cl-L-Arg formation may be a new therapeutic approach to cardiovascular diseases.

Heparins Increase Endothelial Nitric Oxide Bioavailability by Liberating Vessel-Immobilized Myeloperoxidase

BACKGROUND

Neutrophils and monocytes are centrally linked to vascular inflammatory disease, and leukocyte-derived myeloperoxidase (MPO) has emerged as an important mechanistic participant in impaired vasomotor function. MPO binds to and transcytoses endothelial cells in a glycosaminoglycan-dependent manner, and MPO binding to the vessel wall is a prerequisite for MPO-dependent oxidation of endothelium-derived nitric oxide (NO) and impairment of endothelial function in animal models. In the present study, we investigated whether heparin mobilizes MPO from vascular compartments in humans and defined whether this translates into increased vascular NO bioavailability and function.

METHODS AND RESULTS

Plasma MPO levels before and after heparin administration were assessed by ELISA in 109 patients undergoing coronary angiography. Whereas baseline plasma MPO levels did not differ between patients with or without angiographically detectable coronary artery disease (CAD), the increase in MPO plasma content on bolus heparin administration was higher in patients with CAD (P=0.01). Heparin treatment also improved endothelial NO bioavailability, as evidenced by flow-mediated dilation (P<0.01) and by acetylcholine-induced changes in forearm blood flow (P<0.01). The extent of heparin-induced MPO release was correlated with improvement in endothelial function (r=0.69, P<0.01). Moreover, and consistent with this tenet, ex vivo heparin treatment of extracellular matrix proteins, cultured endothelial cells, and saphenous vein graft specimens from CAD patients decreased MPO burden.

CONCLUSIONS

Mobilization of vessel-associated MPO may represent an important mechanism by which heparins exert antiinflammatory effects and increase vascular NO bioavailability. These data add to the growing body of evidence for a causal role of MPO in compromised vascular NO signaling in humans.

C-Reactive Protein and Other Emerging Blood Biomarkers to Optimize Risk Stratification of Vulnerable Patients

Several emerging plasma biomarkers may ultimately prove useful in risk stratification and prognosis of cardiovascular disease. The clinical utility of these biomarkers will depend on their ability to provide a reflection of the underlying atherosclerotic burden or activity; the ability to provide reliable, accurate, and cost-effective information; and the ability to predict future events. High-sensitivity C-reactive protein (hs-CRP) fulfills many, if not all, of these criteria, and blood levels of hs-CRP are now commonly used in clinical practice to improve vascular risk prediction in primary and secondary prevention across all levels of low-density lipoprotein-cholesterol (LDL-C), all levels of the Framingham Risk Score, and all levels of metabolic syndrome. High-sensitivity C-reactive protein may also have clinical relevance as an adjunct to LDL-C for both the targeting and monitoring of statin therapy. Accumulating evidence suggests that several other selected emerging biomarkers may also potentially prove useful in the diagnosis and prognosis of cardiovascular disease. Specifically, data are accumulating on the potential clinical utility of lipoprotein-associated lipoprotein-associated phospholipase A2, myeloperoxidase, oxidized LDL, lipoprotein (a), isoprostanes, and small, dense LDL. This review focuses on hs-CRP and these emerging plasma biomarkers, and their potential diagnostic and prognostic utility in cardiovascular disease. Plasma biomarkers that reflect the clinical potential of atherothrombotic disease may allow more precise risk stratification and prognostication in high-risk populations, and perhaps earlier diagnosis and intervention in patients at risk for or with occult cardiovascular disease.

Chest pain unit concept: rationale and diagnostic strategies

Each year in the United States, over 8 million patients present to the emergency department(ED) with complaints of chest discomfort or other symptoms consistent with possible acute coronary syndrome (ACS). While over half of these patients are typically admitted for further diagnostic evaluation, fewer than 20% are diagnosed with ACS. With hospital beds and inpatient resources scarce, these admissions can be avoided by evaluating low- to moderate-risk patients in chest pain units. This large, undifferentiated patient population represents a potential high-risk group for emergency physicians requiring a systematic approach and specific ED resources. This evaluation is required to appropriately determine if a patient is safe to be discharged home with outpatient follow-up versus requiring admission to the hospital for monitoring and further testing.

Antiplatelet Therapy after Percutaneous Coronary Intervention

There is intense interest in the relationship between inflammation, thrombosis, platelet aggregation, and hyperlipidemia in patients with coronary artery disease. The specific role of inflammation with its linkage to the coagulation cascade has been well studied. A number of inflammatory markers have been identified which can be used for risk stratification in patients with acute coronary syndromes. Patients with acute coronary syndromes at the time of presentation often have an underlying inflammatory state which needs therapy with antiplatelet regimens including now increasingly frequently clopidogrel in addition to the standard of aspirin. In those patients who are treated medically for their acute coronary syndromes, long-term treatment with dual antiplatelet therapy has been documented to be associated with improved outcome. In patients who undergo an invasive approach with placement of intracoronary stents, the importance of dual antiplatelet therapy is increased. Drug-eluting stents are now used in approximately 90% of all interventional procedures. There is evidence to suggest that while these patients have improved outcome in terms of a decreased need for subsequent procedures to treat restenosis, there is the potential for late subacute stent thrombosis. When late subacute stent thrombosis occurs, it results in mortality or infarction in 40-60% of patients. Dual antiplatelet therapy is therefore recommended for an increasingly longer time in this patient group. At the present time, protocols indicate 3 months for one of the drug-eluting stents and 6 months for the other. However, increasingly longer antiplatelet therapy is being used clinically. Assessment of platelet function during follow-up is as yet early. There are issues about which specific test to use and the definition of platelet hyperreactivity. In the future, more individually targeted therapy may be possible if we can more adequately assess the degree of hyperreactivity and underlying inflammation.

Myeloperoxidase and its contributory role in inflammatory vascular disease

Myeloperoxidase (MPO), a heme protein abundantly expressed in polymorphonuclear neutrophils (PMN), has long been viewed to function primarily as a bactericidal enzyme centrally linked to innate host defense. Recent observations now extend this perspective and suggest that MPO is profoundly involved in the regulation of cellular homeostasis and may play a central role in initiation and propagation of acute and chronic vascular inflammatory disease. For example, low levels of MPO-derived hypochlorous acid (HOCl) interfere with intracellular signaling events, MPO-dependent oxidation of lipoproteins modulates their affinity to macrophages and the vessel wall, MPO-mediated depletion of endothelial-derived nitric oxide (NO) impairs endothelium-dependent vasodilatation, and nitrotyrosine (NO(2)Tyr) formation by MPO sequestered into the vessel wall may affect matrix protein structure and function. Future studies are needed to further elucidate the significance of MPO in the development of acute and chronic vascular disease and to evaluate MPO as a potential target for treatment.

Human plasma N-glycoproteome analysis by immunoaffinity subtraction, hydrazide chemistry, and mass spectrometry

The enormous complexity, wide dynamic range of relative protein abundances of interest (over 10 orders of magnitude), and tremendous heterogeneity (due to post-translational modifications, such as glycosylation) of the human blood plasma proteome severely challenge the capabilities of existing analytical methodologies. Here, we describe an approach for broad analysis of human plasma N-glycoproteins using a combination of immunoaffinity subtraction and glycoprotein capture to reduce both the protein concentration range and the overall sample complexity. Six high-abundance plasma proteins were simultaneously removed using a pre-packed, immobilized antibody column. N-linked glycoproteins were then captured from the depleted plasma using hydrazide resin and enzymatically digested, and the bound N-linked glycopeptides were released using peptide-N-glycosidase F (PNGase F). Following strong cation exchange (SCX) fractionation, the deglycosylated peptides were analyzed by reversed-phase capillary liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). Using stringent criteria, a total of 2053 different N-glycopeptides were confidently identified, covering 303 nonredundant N-glycoproteins. This enrichment strategy significantly improved detection and enabled identification of a number of low-abundance proteins, exemplified by interleukin-1 receptor antagonist protein (approximately 200 pg/mL), cathepsin L (approximately 1 ng/mL), and transforming growth factor beta 1 (approximately 2 ng/mL). A total of 639 N-glycosylation sites were identified, and the overall high accuracy of these glycosylation site assignments as assessed by accurate mass measurement using high-resolution liquid chromatography coupled to Fourier transform ion cyclotron resonance mass spectrometry (LC-FTICR) is initially demonstrated.

Inclusion of Sevoflurane in Cardioplegia Reduces Neutrophil Activity During Cardiopulmonary Bypass

OBJECTIVE

The purpose of this study was to examine the effects of sevoflurane cardioplegia on neutrophil response and complement activation after cardiopulmonary bypass (CPB).

DESIGN

A prospective, randomized clinical investigation.

SETTING

University-affiliated hospital; single institutional.

PARTICIPANTS

Twenty-one male patients undergoing coronary bypass surgery using CPB.

INTERVENTIONS

Eleven patients were randomly assigned to receive sevoflurane 2% as a part of the cardioplegic mixture (SEV). The control group (n = 10) received no sevoflurane in their cardioplegia (control).

MEASUREMENTS AND MAIN RESULTS

Myeloperoxidase activity (MPO) was assayed in coronary sinus blood as a surrogate for neutrophilic response at the termination of CPB. MPO activity in the coronary sinus blood was lower in the patients who received sevoflurane compared with controls. MPO activity was higher in patients with cardiac events at 4-year follow-up when compared with asymptomatic patients. IL-8, C4b, C3d, C5a, and CH50 were assessed in coronary sinus and peripheral blood at time of CPB initiation (T0) and upon the termination of CPB (T2). Peripheral blood sampling occurred at the sixth hour after T0 (T6). IL-8 levels were significantly inhibited in the SEV group when compared with controls at T2 and T6. CH50 (an index of global activation of complement system) decreased 30% at T2 and 52% at T6. The classic component of the complement pathway (C4b) was effectively inhibited in the SEV group, whereas the common pathway (C3d and C5a) was similar in both groups.

CONCLUSIONS

The addition of sevoflurane to cardioplegia is associated with an inhibition of neutrophils after CPB. A major component of the neutrophil response appears to be IL-8 mediated, although the classic complement pathway is also inhibited by sevoflurane.

Statin Treatment and Diabetes Affect Myeloperoxidase Activity in Maintenance Hemodialysis Patients

Myeloperoxidase (MPO), which is secreted during activation of neutrophils, may serve as one mechanistic link among persistent inflammation, oxidative stress, and cardiovascular disease. This study related MPO activity to inflammatory and oxidative stress biomarkers, comorbidity, and ongoing medication in prevalent hemodialysis (HD) patients. In a cross-sectional evaluation of 115 prevalent (vintage 25 mo) HD patients (62 men; 63 +/- 1 yr), data on comorbidity (Davies score), diabetes, medication (statins and antihypertensive drugs), nutritional status (subjective global assessment), blood lipids (cholesterol, HDL cholesterol, and triglycerides), inflammatory biomarkers (serum albumin, C-reactive protein, TNF-alpha, and IL-6), oxidative stress biomarkers (pentosidine, 8-hydroxydeoxyguanosine, and MPO activity) were recorded. Patients with MPO activity greater than the median had significantly (P < 0.05) lower serum albumin levels (33.2 +/- 0.7 versus 35.0 +/- 0.5 g/L), higher 8-hydroxydeoxyguanosine levels (1.26 +/- 0.08 versus 1.05 +/- 0.06 ng/ml), and a lower prevalence of statin treatment (18 versus 36%). Therefore, the median MPO activity was significantly (P < 0.05) lower (17.7 versus 26.6 deltaOD630/min per mg protein) in the subgroup of 31 HD patients with ongoing statin treatment. In a multiple regression model, correction for the impact of age, gender, vintage, serum cholesterol, serum albumin, comorbidity, diabetes, and statin use, only diabetes (P < 0.01) and statin use (P < 0.01) were significantly associated to MPO activity. Fourteen patients who had diabetes and were receiving statin treatment had markedly (P = 0.001) lower median (19.9 versus 41.2 deltaOD630/min per mg protein) MPO activity compared with 18 who had diabetes and were not taking statins. This cross-sectional study suggests that both diabetes and statin treatment affect MPO activity in prevalent HD patients.

Modification of amino acid residues in human serum albumin by myeloperoxidase

Myeloperoxidase is released from stimulated polymorphonuclear leukocytes at inflammatory loci. Besides its bactericidal activity, it interacts with human serum albumin that is essential for the endothelial uptake of myeloperoxidase and its contribution in regulation of the blood vessel tonus. Here, we investigated which kinds of modification dominate in the albumin protein by the myeloperoxidase-hydrogen peroxide system at physiological pH. In the presence of chloride, bromide, and nitrite, the myeloperoxidase-hydrogen peroxide system caused an oxidation, bromination, and nitrosylation/nitration of eight amino acid residues of albumin as detected by fragment analysis of tryptic digests with matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. An oxygen was incorporated into the methionines Met147, Met353, and Met572 as well as into the tryptophan Trp238. In the case of methionine residues, this oxygen was derived from the water phase as shown using 18O-enriched water. Nitrosylation/nitration was observed at the tryptophan Trp238 and the tyrosines Tyr162, Tyr425, and Tyr476 according to the mass shift of 29 Da and 45 Da. The incorporation of one or two bromines was found into the tyrosines Tyr425 and Tyr476. We did not observe any chlorination of albumin fragments. Thus, myeloperoxidase modifies in multiple ways amino acid residues in human serum albumin.

Integrating Soluble Biomarkers and Imaging Technologies in the Identification of Vulnerable Atherosclerotic Patients

The clinical utility of a biomarker depends on its ability to identify high-risk individuals to optimally manage the patient. A new biomarker would be of clinical value if it is accurate and reliable, provides good sensitivity and specificity, and is available for widespread application. Data are accumulating on the potential clinical utility of integrating imaging technologies and circulating biomarkers for the identification of vulnerable (high-risk) cardiovascular patients. A multi-biomarker strategy consisting of markers of inflammation, hemostasis and thrombosis, proteolysis and oxidative stress, combined with new imaging modalities (optical coherence tomography, virtual histology plus IVUS, PET) can increase our ability to identify such thombosis-prone patients. In an ideal scenario, cardiovascular biomarkers and imaging combined will provide a better diagnostic tool to identify high-risk individuals and also more efficient methods for effective therapies to reduce such cardiovascular risk. However, additional studies are required in order to show that this approach can contribute to improved diagnostic and therapeutic of atherosclerotic disease.

Acute Coronary Syndromes: From the Laboratory Markers to the Coronary Vessels

Summary

A number of “interesting” risk markers have been proposed as providing prognostic informations in acute coronary syndromes (ACS). Elevation in plasma inflammatory and necrosis biomarkers have been related to future cardiovascular events in individuals with or without prior myocardial infarction. Recently BNP and pro-BNP are entered in clinical practice to recognize patients at major risk, providing incremental information respect to the traditional markers. Together with these laboratory indexes, a few of promising laboratory markers once easily available, could become usefull in identification of patients at high risk. Several studies evaluated many markers of platelet aggregation, endothelial dysfunction and vascular thrombosis, but it is not yet clear whether each of the proposed markers may provide incremental predictive information. We describe, following the most studies reported in literature, the laboratory markers with potential clinical and prognostic power that could early help physicians in the identification of patients with impaired coronary disease and more narrowed coronary arteries.

Aktuelle Konzepte der diabetischen Atherogenese

Morbidity and mortality in patients with diabetes is mainly driven by its vascular manifestations. The underlying pathophysiology of diabetes is centrally linked to increased generation of reactive oxygen species, namely superoxide and hydrogen peroxide. Superoxide, generated upon uncoupling of the mitochondrial respiratory chain, oxidizes endothelial-derived nitric oxide and thus impairs endothelial function. Superoxide-derived hydrogen peroxide is the principal substrate for leukocyte-derived peroxidases, in particular myeloperoxidase, which associates with endothelial cells and has been shown to catalytically oxidize nitric oxide in vivo. Superoxide also promotes synthesis of advanced glycation endproducts, which also exert potent proatherogenic properties. Moreover, superoxide and hydrogen peroxide activate the redox-sensitive transcription factors NF-kappaB and thus mediates expression of proinflammatory proteins like adhesion molecules. Herein some the most recent discoveries in the pathophysiology of diabetic vasculopathy are reviewed.

Cardiac biomarkers: a contemporary status report

The field of cardiac biomarkers has grown by leaps and bounds in the past two decades. In this review we try to summarize the explosion of emerging knowledge and address the roles of some of the biomarkers that have either proven or potential utility. We detail some of the markers of ischemia, hemodynamic markers of heart failure, inflammatory markers, and the novel and innovative approach of combining these for a multimarker strategy. At the end of this review we highlight some of the biomarker-guided approaches and strategies that might lead to better and more-effective care of patients.

CRP is or is not a reliable marker of ischaemic heart disease?

In recent years a growing body of evidence has emphasized the role of C-reactive protein (CRP) as a marker of future cardiovascular events. CRP is a pentameric molecule widely utilized as a marker of infections and inflammation. The evidence that inflammation plays an important role in the pathogenesis of coronary artery disease and in plaque destabilization has lead to use of CRP as a marker of cardiovascular disease as well. First described as a component of the inflammatory pathway in acute coronary syndromes, CRP has been consistently found to be associated with the risk of future events in no-ST elevation acute coronary syndromes, independently of other risk factors, including troponine. Subsequently CRP has been described as a powerful marker of risk of future events in large populations of apparently healthy subjects. So far there is very little doubt that CRP represents a reliable marker of cardiovascular events, but some issues remain unanswered such as why CRP is a good marker of cardiovascular events and whether or not a better inflammatory marker exists. It must be stressed that CRP, because of its analytical and biological properties and the large amount of available data, is the only inflammatory marker accepted for clinical use.

Is there more than C-reactive protein and fibrinogen? The prognostic value of soluble CD40 ligand, interleukin-6 and oxidized low-density lipoprotein with respect to coronary and cerebral vascular disease

Incidence of atherosclerosis and atherosclerosis-related complications will increase significantly in the coming decennia. Research identified many serum and plasma markers that are associated with cardiovascular disease. However, little is known about the prognostic value of these markers to identify patients at risk for future cardiovascular events. Therefore, we aimed to investigate the prognostic value of three of these markers (soluble CD40 ligand (sCD40L), interleukin-6 (IL-6) and oxidized low-density lipoprotein (oxLDL)) with respect to coronary vascular disease and stroke. For this reason the Medline database was searched for the period January 1999-January 2005. To be selected in our study, concentration of the marker had to be determined at baseline, follow-up period had to be longer than 3 months and an estimate of relative risk had to be available. Based on these criteria, 4 studies for sCD40L, 10 for IL-6 and 2 for oxLDL were selected. Relative risk estimates adjusted for potential confounders varied between 1.9 and 2.8 for sCD40L, between 1.1 and 3.1 for IL-6 and between 1.9 and 3.2 for oxLDL. In conclusion, this systematic review shows that sCD40L, IL-6 and oxLDL are associated with an increased relative risk of developing cardiovascular disease.

Myeloperoxidase generates 5-chlorouracil in human atherosclerotic tissue: a potential pathway for somatic mutagenesis by macrophages

Somatic mutations induced by oxidative damage of DNA might play important roles in atherogenesis. However, the underlying mechanisms remain poorly understood. Myeloperoxidase, a heme protein expressed by select populations of artery wall macrophages, initiates one potentially mutagenic pathway by generating hypochlorous acid. This potent chlorinating agent reacts rapidly with primary amines to yield long-lived, selectively reactive N-chloramines. In the current studies, we demonstrate that myeloperoxidase produced by human macrophages differentiated in the presence of granulocyte macrophage colony-stimulating factor generates 5-chlorouracil, a mutagenic thymine analog. The primary amine taurine fails to block the reaction, suggesting that N-haloamines produced by macrophages might oxidize uracil. Model system studies demonstrated that N-chloramines convert uracil to 5-chlorouracil. Interestingly, the tertiary amine nicotine dramatically enhances uracil chlorination, suggesting that cigarette smoke might promote nucleobase oxidation by N-chloramines. To look for evidence that myeloperoxidase promotes uracil oxidation in vivo, we measured 5-chlorouracil levels in human aortic tissue, using isotope dilution gas chromatography-mass spectrometry. The level of 5-chlorouracil was 10-fold higher in atherosclerotic aortic tissue obtained during vascular surgery than in normal aortic tissue, suggesting that halogenated nucleobases produced by macrophages might contribute to atherogenesis. Because 5-chlorouracil can be incorporated into nuclear DNA, our observations raise the possibility that halogenation reactions initiated by phagocytes provide one pathway for mutagenesis, phenotypic modulation, and cytotoxicity during atherogenesis.

Acute neutrophil activation in direct stenting: comparison of stable and unstable angina patients

BACKGROUND

Polymorphonuclear neutrophils have been implicated in the pathophysiology of atherosclerosis. A substantial body of evidence has emerged to implicate the role of specific leucocyte derived enzyme myeloperoxidase in atherogenesis, since its initiation through progression until destabilization. The aim of the study was to determine the presence of polymorphonuclear neutrophils activation after coronary stenting, to compare this activation between stable and unstable setting and to evaluate the kinetic relation of this activation with inflammatory response following atherosclerotic plaque rupture.

METHODS

Myeloperoxidase, lactoferrin, elastase, C-reactive protein and cytokine plasma levels were assessed in 15 patients undergoing direct coronary stenting for unstable angina (Group A) and compared to 11 patients undergoing this procedure for stable angina (Group B). Serial sampling starting before arteriography and continued for 24 h was carried out in all patients.

RESULTS

A significant elevation in myeloperoxidase and lactoferrin levels was observed after stenting in both group A (p<0.0001) and group B (p<0.0001), but was higher in group A. Interleukin-8, interleukin-12 and interleukin-6 levels increased temporarily after stenting in the 2 groups. Baseline values of C-reactive protein were similar in the 2 groups and a progressive increase was observed after the intervention.

CONCLUSIONS

Direct coronary artery stenting is associated with an early polymorphonuclear neutrophils activation followed by release of inflammatory cytokines (interleukin-6, interleukin-8, interleukin-12) and C-reactive protein elevation in both stable and unstable patients. We conclude that stenting by itself is associated with myeloperoxidase liberation with a significantly enhanced response in unstable patients.

Prospects for Personalized Cardiovascular Medicine

Sequencing of the human genome has ushered in prospects for individualizing cardiovascular health care. There is growing evidence that the practice of cardiovascular medicine might soon have a new toolbox to predict and treat disease more effectively. The Human Genome Project has spawned several important "omic" technologies that allow "whole genome" interrogation of sequence variation (re-sequencing, genotyping, comparative genome hybridization), transcription (expression profiling, tissue arrays), proteins (gas or liquid chromatography and tandem mass spectroscopy [MS]), and metabolites (MS or nuclear magnetic resonance profiling); deoxyribonucleic acid, ribonucleic acid, protein, and metabolic approaches all provide more exacting detail of cardiovascular disease mechanisms and, in some cases, are redefining its taxonomy. Pharmacogenomic approaches are emerging across broad classes of cardiovascular therapeutics to assist practitioners in making more precise decisions about which drugs to give to which patients to optimize the benefit-to-risk ratio. Molecular imaging is developing chemical and biological probes that can sense molecular pathway mechanisms that will allow us to monitor health and disease. Together, these tools will enable a paradigm shift from genetic medicine--on the basis of the study of individual inherited characteristics, most often single genes--to genomic medicine, which by its nature is comprehensive and focuses on the functions and interactions of multiple genes and gene products, among themselves and with their environment. The information gained from such analyses, in combination with clinical data, is now allowing us to assess individual risks and guide clinical management and decision-making, all of which form the basis for cardiovascular genomic medicine.

Advances in cardiac biomarkers

The diagnostic and prognostic roles of new and established cardiac biomarkers are continually changing. This update article discusses clinical diagnosis as a framework for directing biomarker testing. Markers are reviewed in the settings of acute coronary syndromes, decompensated heart failure, and noncardiac clinical scenarios.

The Potential Relevance of the Multiple Lipid-Independent (Pleiotropic) Effects of Statins in the Management of Acute Coronary Syndromes

Emerging data suggest that acute presentations of coronary artery disease may involve a complex interplay between the vessel wall, inflammatory cells, and the coagulation cascade. Although a culprit thrombotic lesion may be treated effectively by antithrombotic therapy and revascularization, this will have little effect on the global processes that determine recurrent events at non-culprit sites. Thus, additional systemic treatment is required to modulate the adverse biological features that are the hallmark of acute coronary syndromes (ACS). Statins possess multiple beneficial effects that are independent of low-density-lipoprotein cholesterol (LDL-C) lowering and that have favorable effects on inflammation, the endothelium, and the coagulation cascade. In the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE IT-TIMI 22) trial, differences were seen based on achieved LDL-C that could be further discriminated by the achieved C-reactive protein level. Studies of non-vascular disease such as multiple sclerosis have shown that statins reduce inflammation, supporting the presence of lipid-independent effects of statins. This review focuses on the potential importance of these effects in the management of ACS.

Inducible nitric oxide synthase expression is inhibited by myeloperoxidase

Nitric oxide (NO) plays key roles in vasodilation and host defense, yet the overproduction of NO by inducible nitric oxide synthase (iNOS) at inflammatory sites can also be pathogenic. Here, we investigate the role of MPO in modulating the induction of iNOS by IFNgamma/LPS (IL). In monocyte-macrophages (Mvarphi) treated with IL, MPO gene expression was found to be downregulated as iNOS was upregulated. In Mvarphi from MPO-knockout (KO) mice, the induction of iNOS by IL was earlier and higher than in MPO-positive cells, suggesting MPO is inhibitory. Consistent with that interpretation, the addition of purified MPO enzyme to cultured macrophages inhibited iNOS induction by IL. In addition, an inhibitor of MPO enzyme, 4-aminobenzohydrazide, enhanced iNOS induction in MPO-positive cells, but not in MPO-KO cells. Similarly, taurine, a scavenger of MPO-generated HOCl, enhanced iNOS induction in MPO-positive cells, but not in MPO-KO cells. MPO affects an early event, suppressing iNOS induction when added within 2h of IL, but not when added several hours after IL. The suppression by MPO was alleviated by NO donor, sodium nitroprusside, suggesting the suppression results from scavenging of NO by MPO. This interpretation is consistent with earlier reports that MPO consumes NO, and that low levels of NO donor augment induction of iNOS by IFNgamma/LPS. The implication of these findings is that MPO acts as gatekeeper, suppressing the deleterious induction of iNOS at inflammatory sites by illegitimate signals. The combined signaling of IFNgamma/LPS overrides the gatekeeper function by suppressing MPO gene expression.

Loss of pentameric symmetry in C-reactive protein induces interleukin-8 secretion through peroxynitrite signaling in human neutrophils

Plasma levels of C-reactive protein (CRP), nitrotyrosine, and interleukin-8 (IL-8) are known predictors of acute cardiovascular events. Peroxynitrite (ONOO-) may function as an intracellular signal for the production of IL-8; however, it is not known whether CRP regulates these events. Emerging evidence suggests that some bioactivities of CRP are expressed only when the pentameric structure of CRP is lost, resulting in formation of monomeric or modified CRP (mCRP). We studied the impact of human native CRP and bioengineered mCRP that cannot rearrange into the pentameric structure on ONOO- formation and ONOO--mediated IL-8 gene expression in human leukocytes. Incubation of human whole blood or isolated neutrophils with mCRP (0.1 to 100 microg/mL) for 4 hours increased IL-8 gene expression and secretion that was blocked approximately 70% by the NO synthase inhibitor Nomega-nitro-L-arginine methyl ester (L-NAME). In neutrophils, mCRP simultaneously increased superoxide production and endothelial nitric oxide synthase-mediated NO formation, leading to enhanced ONOO- formation, and consequently activation of nuclear factor-kappaB and activator protein-1. Native CRP had no detectable effect at 4 hours, whereas it enhanced IL-8 release after a 24-hour incubation that was blocked by L-NAME. An anti-CD16 antibody, but not an anti-CD32 antibody, produced 60% to 70% reductions in mCRP-stimulated NO formation and IL-8 release (both P<0.05). These results suggest that loss of the pentameric symmetry in CRP, resulting in formation of mCRP, leads to IL-8 release from human neutrophils via peroxynitrite-mediated activation of nuclear factor-kappaB and activator protein-1.

Formation of Dysfunctional High-Density Lipoprotein by Myeloperoxidase

Recent studies identify the presence of high-density lipoprotein (HDL) particles in patients with cardiovascular disease, which are "dysfunctional," lacking in typical atheroprotective properties, and promoting proinflammatory effects. The mechanisms for generating dysfunctional HDL have been unclear. New evidence points to a role for myeloperoxidase (MPO)-generated oxidants as participants in rendering HDL dysfunctional within human atherosclerotic plaque. Myeloperoxidase was recently shown to bind to HDL within human atherosclerotic lesions, and biophysical studies reveal MPO binding occurs via specific interactions with apolipoprotein (apo) A-I, the predominant protein of HDL. This likely facilitates the observed selective targeting of apoA-I for site-specific chlorination and nitration by MPO-generated reactive oxidants in vivo. One apparent consequence of MPO-catalyzed apoA-I oxidation includes the functional impairment of the ability of HDL to promote cellular cholesterol efflux via the adenosine triphosphate binding cassette-1 transport system. Myeloperoxidase-mediated loss of the atheroprotective functional properties of HDL may thus provide a novel mechanism linking inflammation and oxidative stress to the pathogenesis of atherosclerosis.

Vulnerable Plaque Imaging

The concept of vulnerable plaque is well established with increasing evidence from clinical and basic research. The paradigm has shifted from focusing exclusively on the hemodynamic effects of plaque (ie, resulting lumenal stenosis alone as a predictor of stroke risk) to assessment of the structure and composition of plaque (eg, denuded endothelium with inflammatory elements as a nidus for platelet-fibrin clumping). It is increasingly evident that methods to detect and characterize vulnerable plaque must be developed and optimized. Although MR imaging, CT, and ultrasound provide data regarding single lesions, future investigations relying heavily on nuclear medicine techniques may offer functional assessment of the entire cardiovascular system.

Statins downregulate myeloperoxidase gene expression in macrophages

Statins, inhibitors of HMG-CoA reductase, have pleiotropic benefits independent of cholesterol levels, including anti-oxidant and anti-inflammatory effects. Here, we investigate the effect of statins on myeloperoxidase (MPO) expression. MPO, expressed in foam cell macrophages, was recently shown to oxidize the ApoA-1 component of HDL, impairing ABCA-1 mediated cholesterol efflux. High levels of serum MPO correlate with increased risk of CAD events. Findings here show that statins strongly inhibit MPO mRNA expression in human and murine monocyte-macrophages. Suppression was reversed by downstream intermediates of HMG-CoA reductase, mevalonate, and geranylgeranylpyrophosphate, but not farnesylpyrophosphate. An inhibitor of geranylgeranyltransferase, GGTI-286, mimics the effects of statins, indicating geranylgeranylation is key to MPO expression. Reduction of MPO mRNA levels was observed in vivo in leukocytes from statin-fed mice, correlating with reductions in MPO protein and enzyme activity. These findings suggest that the pleiotropic protections afforded by statins may be due in part to suppression of MPO expression.

Gene Polymorphism Association Studies in Dialysis: The Nutrition-Inflammation Axis

Although traditional risk factors for cardiovascular disease are common in dialysis patients, they alone cannot explain the unacceptably high prevalence of vascular disease in this patient group. Much recent interest has therefore focused on the role of various nontraditional cardiovascular risk factors, such as inflammation, wasting, obesity, vascular calcification, and oxidative stress. In addition, genetic factors such as single nucleotide polymorphisms (SNPs) may significantly influence the immune response, the levels of inflammatory markers and body composition, as well as the prevalence of vascular calcification in this patient group. While genetic variations in the tumor necrosis factor (TNF)-alpha-308 and interleukin (IL)-10 -1082 SNPs seem to be consistently associated with adverse clinical outcome in end-stage renal disease (ESRD) patients, the results regarding genetic variations in the IL-6 gene have been conflicting. To elucidate the respective role of DNA polymorphisms in the IL-6 and C-reactive protein (CRP) genes, as well as genes that encode vascular calcification inhibitors (such as fetuin-A, matrix Gla protein, and osteoprotegerin), sufficiently powered studies are needed in which both the protein product and the specific phenotype are determined. In addition, polymorphisms in genes related to body composition may be excellent candidates for analysis in the ESRD population, since nutritional parameters are strongly associated with adverse events in these patients. It seems conceivable that in the future, prognostic or predictive multigene DNA assays (which allow a simultaneous and rapid assessment of multiple genetic variants) will provide nephrologists with a more precise approach for the identification of "high-risk" ESRD patients and the development of accurate individualized treatment strategies.