Plasma albumin and platelet function: relevance to atherogenesis and thrombosis

C-Reactive Protein to Albumin Ratio in Patients With Saphenous Vein Graft Disease

Atherosclerosis plays an important role in saphenous vein graft disease (SVGD). Previous studies showed that inflammatory blood cells play an active role in this process. C-reactive protein to albumin ratio (CAR) is considered as a novel predictor for cardiovascular risk and an indicator of inflammation. We aimed to assess the relationship between SVGD and CAR. A total of 711 participants with saphenous vein graft (SVG) were included; 348 patients had SVGD and 363 patients had patent (no stenosis) SVG. C-reactive protein to albumin ratio was higher in patients with SVGD (P < .001). There was a significant positive correlation between CAR and the age of SVG (r = 0.123; P = .001) and SYNTAX score (r = 0.568; P < .001). Multivariate logistic regression analyses showed that lymphocyte count, CAR, and SYNTAX score were independent predictors of SVGD (P < .05). C-reactive protein to albumin ratio may be a useful marker after bypass surgery to predict SVGD.

Low serum albumin levels predict poor outcome in patients with acute ischaemic stroke or transient ischaemic attack

BACKGROUND

To examine the relationship of serum albumin with poor functional outcome and mortality in patients with acute ischaemic stroke (AIS) or transient ischaemic attack (TIA), and perform a meta-analysis to summarise the association.

METHODS

We analysed data from the Third China National Stroke Registry (CNSR-Ⅲ). Patients were divided into four groups based on serum albumin levels at admission. The outcomes included poor functional outcome (modified Rankin Scale (mRS) score of 3 to 6) and mortality at 3 months and 1 year. Multiple logistic regression models and Cox regression models were used to evaluate the association, respectively. We used a fixed-effect model to calculate the risk ratio for poor functional outcome and a random-effect model for mortality in the meta-analysis.

RESULTS

A total of 13 618 patients were enrolled. During the 3-month follow-up period, compared with 40 to 44.9 g/L group, patients in <35 g/L group had an increased risk of poor functional outcome and mortality (adjusted OR 1.37 (95% CI 1.12 to 1.67); adjusted HR 2.13 (95% CI 1.41 to 3.23)). The relationship in per 10 g/L decreased serum albumin with prognosis was consistently inversed (adjusted OR 1.17 (95% CI 1.01 to 1.35); adjusted HR 1.86 (95% CI 1.30 to 2.64)). Also, low serum albumin levels were independently correlated with clinical outcomes at 1 year. In the meta-analysis, the OR for poor functional outcome pooled 3 studies per 1 g/L decrease was 1.03 (95% CI 1.02 to 1.05), and the HR for mortality pooled 5 studies was 1.07 (95% CI 1.03 to 1.11).

CONCLUSIONS

Low serum albumin levels predict poor functional outcome and mortality in patients with AIS or TIA.

Association of C-Reactive Protein to Albumin Ratio in Patients with Isolated Coronary Artery Ectasia

Fundamento

A ectasia da artéria coronária (EAC) é definida como a dilatação difusa ou localizada do lúmen da artéria coronária com diâmetro de 1,5 a 2,0 vezes o diâmetro da artéria coronária normal adjacente. A relação proteína C-reativa/albumina (CAR, sigla em inglês) é um marcador inflamatório útil que tem sido documentado em doença arterial coronariana.

Objetivo

Analisar a associação entre a EAC e a CAR.

Métodos

Um protocolo caso-controle foi utilizado neste estudo. Foram incluídos 102 pacientesconsecutivos com EAC isolada sem estenose (56 homens e 46 mulheres; idade média de 60,4 ± 8,8 anos). O grupo controle era constituido pelo mesmo número de pacientes pareados por sexo e idade com artérias coronárias normais (55 homens e 47 mulheres; idade média de 61,2 ± 9,1 anos). Características clínicas, achados laboratoriais e histórico de uso de medicamentos foram registrados. Foram realizados teste t de Student, teste U de Mann-Whitney, teste do qui-quadrado, análise de regressão linear e logística. Foi considerado estatisticamente significativo p bilateral < 0,05.

Resultados

A CAR estava aumentada nos pacientes com EAC em comparação com os controles (32 e 16; p < 0,001). Além disso, foi verificado que a CAR era um preditor independente da EAC (razão de chances = 2,202; intervalo de confiança 95%, 1,184 – 5,365; p < 0,001).

Conclusão

No presente estudo, determinamos que os níveis da CAR estavam significativamente mais altos no grupo EAC que no grupo controle e a CAR estava significativamente correlacionada com a EAC. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Prognostic Significance of Serum Albumin in Patients With Acute Coronary Syndrome

In patients with unstable angina pectoris (UAP) or non-ST elevation myocardial infarction (NSTEMI), long-term mortality remains high despite improvements in the diagnosis and treatment. In this study, we investigated whether serum albumin level is a useful predictor of long-term mortality in patients with UAP/NSTEMI. Consecutive patients (n = 403) who were hospitalized with a diagnosis of UAP/NSTEMI were included in the study. Patients were divided into 2 groups based on the presence of hypoalbuminemia and the relationship between hypoalbuminemia and mortality was analyzed. Hypoalbuminemia was detected in 34% of the patients. The median follow-up period was 35 months (up to 45 months). Long-term mortality rate was 32% in the hypoalbuminemia group and 8.6% in the group with normal serum albumin levels ( P < .001). On multivariate analysis, hypoalbuminemia, decreased left ventricular ejection fraction, and increased age were found to be independent predictors of mortality ( P < .05). The cutoff value of 3.10 g/dL for serum albumin predicted mortality with a sensitivity of 74% and specificity of 67% (receiver-operating characteristic area under curve: 0.753, 95% CI: 0.685-0.822). All-cause long-term mortality rates were significantly increased in patients with hypoalbuminemia. On-admission albumin level was an independent predictor of mortality in patients with UAP/NSTEMI.

Increased Serum CRP-Albumin Ratio Is Independently Associated With Severity of Carotid Artery Stenosis

Carotid artery stenosis (CAS), mainly caused by carotid atherosclerosis, is related to ischemic stroke. We investigated whether C-reactive protein (CRP) to albumin ratio (CAR) was associated with increased severity of carotid stenosis in patients undergoing carotid angiography. A total of 269 patients who were undergoing carotid angiography were included in this study. The patients were divided into 2 groups with respect to the severe CAS: group 1 (stenosis < 70%, n = 189) or group II (stenosis ≥ 70%, n = 80). C-reactive protein to albumin ratio was higher in group II compared to group I (0.56 ± 0.25 vs 0.14 ± 0.01, P < .001). The CAR (odds ratio [OR]: 1.051, 95%CI: 1.027-1.076, P < .001), neutrophil to lymphocyte ratio (NLR), and total cholesterol levels were independent predictors of severe CAS. The area under the receiver operating characteristic curve (area under the curve) for the CAR to predict severe CAS was 0.798 (95% CI: 0.741-0.854, P < .001). C-reactive to protein albumin ratio was an independent risk factor of severe CAS. Therefore, CAR might be considered a potential index in the severity of carotid artery disease.

Assessment of the relation between C-reactive protein to albumin ratio and the severity and complexity of peripheral arterial disease

Background

Peripheral arterial disease is associated with increased cardiovascular mortality and morbidity. C-reactive protein and albumin are biomarkers of inflammation and malnutrition that play key roles in the pathophysiological pathways involved in the progression of atherosclerosis and peripheral arterial disease. In this study, we aimed to assess the relationship between C-reactive protein to albumin ratio and the suprapopliteal peripheral arterial disease severity and complexity as assessed by TransAtlantic Inter-Society Consensus-II (TASC-II) classification.

Method

Our study enrolled 224 consecutive patients referred for peripheral angiography with the clinical features of possible peripheral arterial disease at a tertiary care center between January 2016 and September 2019. Level of disease and lesion characteristics were defined with reference to angiographic findings according to the TASC-II classification.

Results

C-reactive protein/albumin ratio levels were significantly higher in TASC-II class C and D than in TASC-II class B patients with a median level of 1.8 to 2.1 vs 1.4, respectively ( p = 0.018). In multivariate regression analysis, C-reactive protein to albumin ratio remained an independent predictor of severe peripheral arterial disease. The predictive performance of C-reactive protein to albumin ratio, C-reactive protein, and albumin were compared by Receiver Operating Characteristic curve analysis. C-reactive protein to albumin ratio surpassed C-reactive protein and albumin in predicting peripheral arterial disease severity and complexity. A level of C-reactive protein to albumin ratio  > 0.14 predicted a higher grade of suprapopliteal TASC-II class with sensitivity and specificity of 68.2% and 56.0%, respectively.

Conclusion

C-reactive protein to albumin ratio was strongly associated with peripheral arterial disease severity and complexity, as assessed by TASC-II classification. Also, C-reactive protein to albumin ratio was found to be a more accurate marker than C-reactive protein and albumin alone in predicting more severe and complex lesions in patients with peripheral arterial disease.

Characterization of thromboelastography of patients with different pathological types of nephrotic syndrome

To investigate the changes in blood coagulability as measured by thromboelastography (TEG) in patients with nephrotic syndrome of different etiologies as well as in patients with venous thromboembolic events (VTE).From January 2013 to October 2017, patients who were diagnosed as idiopathic membranous nephropathy (IMN), minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) were enrolled into this retrospective study in which their clinical characteristics, including TEG variables, were investigated. According to the presence or absence of VTE, the patients with IMN were divided into 2 groups of VTE and non-VTE. The risk factors of VTE were analyzed with logistic regression.Significant differences in TEG parameters were found among the 3 groups of patients with R and K values lower, while the α-angle, maximum amplitude (MA) and confidence interval (CI) values higher, in the IMN group than those in the MCD and FSGS groups (P < .01). Multiple linear regression analysis indicated that the histologic subtype was an independent relevant factor of K time, angle, MA, and CI values. Multivariate logistic regression analysis revealed that serum albumin and CI value were independent risk factors of VTE (P < .05).The results showed that IMN patients may have higher whole blood coagulability than MCD and FSGS patients. The hypercoagulability in IMN patients may be attributed to platelet hyperactivity and the accelerated fibrin-platelet interaction. Hypoproteinemia and increased CI value were independent risk factors of VTE in IMN.

Changes over time in serum albumin levels predict outcomes following percutaneous coronary intervention

BACKGROUND

Serum albumin (SA) is a powerful prognostic marker in patients with cardiovascular diseases.

OBJECTIVES

To evaluate the prognostic significance of changes in SA levels among patients that underwent percutaneous coronary intervention (PCI).

METHODS

Patients who underwent PCI in a tertiary medical center throughout 2004-2017 were considered for the study. Patients with missing SA values within the year before or 5 years after the PCI were excluded from the study as well as those for whom SA values were obtained throughout an acute infection. Changes in albumin were represented by Δalbumin: Albumin before PCI (closest) minus lowest albumin within the 5 years following the PCI. Δalbumin was categorized into 4 categories as follows: ≤0 g/dL, 0-0.5 g/dL, 0.5-1 g/dL, ≥1 g/dL. Primary outcome was major adverse cardiac events (MACE) that included all-cause mortality, non-fatal myocardial infarction, target vessel re-vascularization, and coronary artery bypass surgery.

RESULTS

The study included 5449 out of 21,763 (25%) patients, mean age 66.8 ± 12 years, 26% women. Patients with greater Δalbumin were older with higher prevalence of most cardiovascular risk factors and comorbidity. The follow-up period was 7 years (median), with cumulative MACE rate of 49.5%. MACE rates and the rates of all the MACE components increased gradually with the increase in Δalbumin. Multivariate adjusted analysis showed that Δalbumin is an independent predictor of long-term MACE following PCI [HR = 1.4 (95%CI:1.3-1.6), HR = 2.2 (95%CI:1.9-2.5), HR = 3.8 (95%CI:3.3-4.35) for Δalbumin of 0-0.5 g/dL, 0.5-1 g/dL, ≥1 g/dL, respectivelyp < 0.001 for all].

CONCLUSIONS

A decrease in albumin levels following PCI is an independent prognostic marker of worse long-term outcomes.

Inverse relationship of serum albumin to the risk of venous thromboembolism among acutely ill hospitalized patients: Analysis from the APEX trial

Hypoalbuminemia is a common finding and independent predictor for unfavorable prognosis. The prognostic value of albumin measurement for short-term VTE prediction in hospitalized patients remains unclear. In the APEX trial (ClinicalTrials.gov identifier: NCT01583218), medical inpatients were randomized to receive either extended-duration betrixaban or shorter-duration enoxaparin and followed for 77 days. Baseline albumin concentrations were obtained in 7266 subjects with evaluable VTE endpoints. The association of baseline albumin to VTE was assessed, with adjustment for patient characteristics, thromboprophylaxis, and biomarkers for fibrinolysis and inflammation (ie, D-dimer and C-reactive protein [CRP]). VTE risk refinement was evaluated by incorporation of albumin to well-validated risk assessment models. A stepwise increase in the risk of VTE (P < .0001) was observed with lower levels of albumin. Patients at the bottom albumin quartile (<35 g/L) had a two-fold greater odds for developing VTE compared with the top quartile (≥42 g/L) (OR = 2.119 [95% CI, 1.592-2.820]; adjusted OR = 2.079 [1.485-2.911]). The odds for VTE increased by 1.368 (95% CI, 1.240-1.509) times per SD decrement of albumin (5.24 g/L). Compared with the propensity score-matched pairs of patients with albumin ≥35 g/L, patients with albumin <35 g/L had a greater risk of VTE (OR = 1.623 [1.260-2.090]; adjusted OR = 1.658 [1.209-2.272]). Albumin measurement also refined VTE risk discrimination and reclassification after inclusion in the risk assessment models. In conclusion, acutely ill hospitalized patients with low serum albumin had an increased VTE risk through 77 days. VTE risk assessment models for medical inpatients should consider incorporation of baseline albumin measurement.

Relationship between C-reactive protein/albumin ratio and coronary artery disease severity in patients with stable angina pectoris

BACKGROUND

Syntax score (SS), which is an angiographic tool used in grading the complexity of coronary artery disease (CAD), has prognostic importance in coronary artery disease (CAD) and provides important information regarding selection of revascularization strategy. C-reactive protein (CRP) and albumin are indicators of inflammation, and high levels of them are associated with high SS. We aimed to investigate whether baseline CRP to albumin ratio C-Reactive Protein/Albumin Ratio (CAR), an easily available and novel inflammatory marker, is associated with SS.

METHOD

A total 403 consecutive patients with stabile angina pectoris, who underwent coronary angiography for suspected CAD from January 2015 to June 2016, were classified into two groups, low SS (≤22) and intermediate-high SS (>22).

RESULTS

C-Reactive Protein/Albumin Ratio was significantly higher in patients with intermediate-high SS group (P < .001). In multivariate regression analysis, CAR remained an independent predictor of intermediate-high SS group together with hypertension and LDL. The predictive performance of CAR, CRP, and albumin was compared by ROC curve analysis. CAR surpassed CRP and albumin in predicting intermediate-high SS group. CAR >6.3 predicted an intermediate-high SS with sensitivity and specificity of 86.8% and 43.4%, respectively.

CONCLUSION

C-Reactive Protein/Albumin Ratio was more tightly associated with the complexity and severity of CAD than CRP and albumin alone and was found to be an independent predictor for intermediate-high SS group.

New Insights About Albumin and Liver Disease

Decompensated liver cirrhosis has a dismal prognosis, with an overall survival of 2-4 years, which is worse than for many oncological diseases. Albumin is an important tool in the management of patients with cirrhosis, since it decreases for less than half the risk for post-paracentesis cardiocirculatory dysfunction and mortality associated with spontaneous bacterial infection, as well as, it triplicates the response to terlipressin in patients with hepatorenal syndrome. Recently, research on albumin has been a hot topic, with important new insights such as the characterization of the pleiotropic effects of albumin (which surpass its oncotic properties) and the concept of effective albumin concentration. In fact, patients with liver cirrhosis present posttranslational modifications on albumin that compromises its function. Those modified albumin forms were proved to have prognostic value and its knowledge may change the paradigm of albumin treatment. In this review, we critically summarize the latest evidence on the potential benefits of albumin in patients with end-stage liver disease.

A population pharmacokinetic/toxicity model for the reduction of platelets during a 48-h continuous intravenous infusion of the histone deacetylase inhibitor belinostat

PURPOSE

Belinostat is a second-generation histone deacetylase inhibitor (HDI) predominantly metabolized by UGT1A1-mediated glucuronidation. Two common polymorphisms (UGT1A1*28 and UGT1A1*60) were previously associated with impaired drug clearance and thrombocytopenia risk, likely from increased drug exposure. This latter phenomenon has been observed with other HDIs such as abexinostat, panobinostat, romidepsin, and vorinostat. It was the intention of this brief report to expand a population pharmacokinetic (PPK) model to include a pharmacodynamic (PD) model describing the change in platelet levels in patients with cancer administered belinostat as a 48-h continuous intravenous infusion, along with cisplatin and etoposide.

METHODS

The PPK/PD model developed here introduced an additional rate constant to a commonly used mechanistic myelosuppression model to better describe the maturation of megakaryocytes into platelets before degradation and a feedback mechanism. The model employed a proportional error model to describe the observed circulating platelet data.

RESULTS

Several covariates were explored, including sex, body weight, UGT1A1 genotype status, liver, and kidney function, but none significantly improved the model. Platelet levels rebounded to baseline within 21 days, before the next cycle of therapy. Simulations predicted that higher belinostat drug exposure does cause lower thrombocyte nadirs compared to lower belinostat levels. However, platelet levels rebound by the start of the next belinostat cycle.

CONCLUSIONS

This model suggests a q3week schedule allows for sufficient platelet recovery before the next belinostat infusion is optimal.

Impact of serum albumin levels on long-term all-cause, cardiovascular, and cardiac mortality in patients with first-onset acute myocardial infarction

BACKGROUND

To evaluate the association of serum albumin (SA) with long-term all-cause, cardiovascular, and cardiac mortality in patients with first-onset acute myocardial infarction (AMI).

METHODS

The cohort study enrolled 2305 patients with first-onset AMI. The median follow-up was of 1088days (3years). Impacts of SA on long-time mortality after AMI were determined using multivariate Cox proportional hazard regression analysis with backward selection.

RESULTS

The patients were divided into three categories by SA tertiles (≤3.62, 3.63-4.08, >4.08g/dl). High tertile group was used as reference, the adjusted HRs for all-cause death were 1.21 (P=0.338) and 1.74 (P=0.003) for intermediate and low tertile, respectively (p-for-trend=0.001); The equivalent values for cardiovascular death were 1.13 (P=0.588) and 1.64 (P=0.022), respectively (p-for-trend=0.009); The corresponding values for cardiac death were 1.07 (P=0.806) and 1.59 (P=0.048), respectively (p-for-trend=0.022). Moreover, adjusted HRs per 1-g/dl decrease in SA concentrations were 1.66 (P=0.001) for all-cause death, 1.47 (P=0.024) for cardiovascular death, and 1.61 (P=0.012) for cardiac death.

CONCLUSIONS

Low SA level (≤3.62g/dl) on admission was an independent predictor of long-term all-cause, cardiovascular, and cardiac mortality in patients with first-onset AMI. There was a dose-response relationship between decreased SA concentrations and increased long-term all-cause, cardiovascular, and cardiac mortality.

Assessment of Relationship Between C-Reactive Protein to Albumin Ratio and Coronary Artery Disease Severity in Patients With Acute Coronary Syndrome

The association of coronary artery disease (CAD) severity with increased C-reactive protein (CRP) and decreased albumin levels has been reported. However, to our knowledge, no study has investigated the usefulness of the CRP to albumin ratio (CAR) in predicting intermediate-high SYNergy between Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score (SS) and high SS II. Consecutive patients (n = 344) treated with percutaneous coronary intervention comprised the study population. The study population was divided into 2 groups according to SS >22 and mean SS II values, respectively. Patients with intermediate-high SS and high SS II had higher CAR than patients with low SS and SS II. History of diabetes mellitus, decreased albumin, lower left ventricular ejection fraction, and elevated CAR (odds ratio [OR]: 1.020; 95% confidence interval [CI], 1.009-1.031; P < .001) were independent predictors of high SS. The presence of hypertension, decreased hemoglobin and albumin levels, and increased CAR (OR: 1.014; 95% CI, 1.004-1.023; P < .001) were independent predictors of SS II. In receiver operating characteristic curve comparison, CAR was superior to CRP and albumin in prediction of intermediate-high SS, but only CRP in prediction of high SS II. The CAR calculated from the admission blood samples could be a useful parameter for predicting CAD severity using SS and SS II.

Association of serum albumin level and venous thromboembolic events in a large cohort of patients with nephrotic syndrome

Background

Prior small studies have suggested an association between low serum albumin and increased risk of venous thromboembolic (VTE) events in patients with nephrotic syndrome (NS).

Methods

From a nationally representative prospective cohort of over 3 million US veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m 2 , we identified 7037 patients with NS based on ICD-9 codes. Association between serum albumin and risk of incident VTE was assessed using Cox regression analysis with adjustments for age, gender, race, comorbidities, eGFR, body mass index and anticoagulant treatment.

Results

Mean age was 57 ± 11 years, patients were 96% male, 32% African-American and 60% diabetic. There were a total of 158 VTE events over a median follow-up of 8.1 years; 16 events [absolute event rate (AER) 4.1%, event rate 8.5/1000 patient-years (PY)] in patients with albumin <2.5 g/dL, 18 events (AER 3.4%, event rate 5.7/1000 patient-years) in patients with albumin 2.5-2.99 g/dL, 89 events (AER 2.5%, event rate 3.4/1000 patient-years) in patients with albumin 3-3.99 g/dL and 35 events (AER 1.4%, event rate 1.9/1000 patient-years) in patients with albumin ≥4 g/dL. Compared with patients with albumin ≥4 g/dL, those with albumin levels of 3-3.99 g/dL [adjusted hazard ratio (HR): 1.51, 95% confidence interval (CI): 1.01-2.26], 2.5-2.99 g/dL (HR: 2.24, 95% CI: 1.24-4.05) and <2.5 g/dL (HR: 2.79, 95% CI: 1.45-5.37) experienced a linearly higher risk of VTE events.

Conclusions

Lower serum albumin is a strong independent predictor for VTE events in NS. The risk increases proportionately with declining albumin levels. Clinical trials are needed to determine benefit of prophylactic anticoagulation in NS patients with moderately lower serum albumin levels.

Low serum albumin predicts early mortality in patients with severe hypoxic hepatitis

AIM

To evaluate the incidence, etiology, and predictors of mortality of severe hypoxic hepatitis.

METHODS

We used computerized patient records to identify consecutive cases of severe hypoxic hepatitis admitted to a tertiary hospital in Singapore over a one-year period. We defined severe hypoxic hepatitis as elevation of serum transaminases more than 100 times upper limit of normal in the clinical setting of cardiac, circulatory or respiratory failure after exclusion of other causes of hepatitis. We used multivariable regression analysis to determine predictors for mortality.

RESULTS

We identified 75 cases of severe hypoxic hepatitis out of 71380 hospital admissions over one year, providing an incidence of 1.05 cases per 1000 admissions. Median age was 65 years (range 19-88); 57.3% males. The most common etiologies of severe hypoxic hepatitis were acute myocardial infarction and sepsis. Fifty-three patients (71%) died during the hospitalization. The sole independent predictive factor for mortality was serum albumin measured at the onset of severe hypoxic hepatitis. Patients with low serum albumin of less than 28 g/L have more than five-fold increase risk of death (OR = 5.39, 95%CI: 1.85-15.71).

CONCLUSION

Severe hypoxic hepatitis is uncommon but has a high mortality rate. Patients with low serum albumin are at highest risk of death.

Platelets as Predictors of Vascular Risk: Is There a Practical Index of Platelet Activity?

Activated platelets play a role in the pathogenesis of coronary heart disease (CHD). Following activation, platelets change shape, aggregate, and release several bioactive substances. The aim of this review is to identify if there is a simple and cost-effective method that indicates platelet activation and predicts the risk of CHD and vascular events. The rationale for identifying high-risk patients is to reduce their risk of vascular events by administering appropriate and effective antiplatelet treatment, like aspirin, clopidogrel, or combination regimens. Many laboratory tests estimating platelet activity have been described. Some are relatively simple, such as spontaneous or agonist-induced platelet aggregation. Other tests include measuring the mean platelet volume (MPV) or plasma soluble P-selectin levels. Some more complex tests include flow cytometry to determine platelet GP Ilb/Illa receptors, platelet surface P-selectin, plateletmonocyte aggregates, and microparticles. Only few prospective studies assessed the predictive value of platelet activation in healthy individuals. Although the MPV seems an 'easy method, there are insufficient data supporting its ability to predict the risk of a vascular event in healthy adults. Platelet aggregation, in whole blood or in platelet-rich plasma was not consistently predictive of vascular risk. Soluble P-selectin measurement is a promising method but it needs further evaluation. Flow cytometry methods are costly, time-consuming, and need specialized equipment. Thus, they are unlikely to be useful in estimating the risk in large numbers of patients. There is as yet no ideal test for the detection of platelet activation. Each currently available test has merits and disadvantages. Simple methods such as the MPV and the determination of platelet release products need further evaluation.

Decreased admission serum albumin level is an independent predictor of long-term mortality in hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction II (SAMI-II) project

BACKGROUND

Decreased serum albumin level (SAL) was reported to be associated with increased risk of cardiovascular events and short term-mortality in patients with acute myocardial infarction (AMI).

OBJECTIVES

To evaluate the association between SAL and long-term mortality in AMI hospital survivors.

METHODS

Retrospective analysis of patients admitted in a tertiary medical center for AMI 2002-2012 and discharged alive.

EXCLUSION CRITERIA

active infections, inflammatory diseases, significant liver or kidney failure, malignancy, ejection-fraction <20%, severe heart valvular-disease and missing SAL. SAL was categorized as following: <3.4, 3.4-3.7, 3.7-3.9, 3.9-4.1 and >4.1g/dL. The primary outcome was all-cause mortality for up-to 10-years post-AMI.

RESULTS

Out of 12,535 patients, 8750 were included. Patients with reduced SAL were older, higher rate of women, increased prevalence of severe left ventricular dysfunction, chronic renal failure, diabetes mellitus and ST-elevation AMI, 3-vessel coronary artery disease, and in-hospital complications. While the prevalence of chronic ischemic coronary disease, dyslipidemia, smokers and obesity, was lower. Mortality rates throughout the follow-up period increased as SAL decreased with 17.6%, 24%, 28.5%, 38.6%, and 57.5% for SAL of >4.1, 3.9-4.1, 3.7-3.9, 3.4-3.7 and <3.4g/dL respectively (p-for-trend <0.001). Using the SAL category of >4.1g/dL as the reference group, Adjusted Hazard Ratio values were 1.14 (p=0.107), 1.23 (p=0.007), 1.39 (p<0.001) and 1.70 (p<0.001) for the SAL categories of 3.9-4.1, 3.7-3.9, 3.4-3.7 and <3.4g/dL respectively.

CONCLUSIONS

Decreased SAL on admission, including levels within "normal" clinical range, is significantly associated with long-term all-cause mortality in hospital survivors of AMI with a "dose-response" type association.

Ischemia-Modified Albumin and Atherosclerosis in Patients With Familial Mediterranean Fever

The constriction of vessels due to atherosclerotic lesions causes hypoxia/ischemia and oxidative changes resulting in transformation of free albumin to ischemia-modified albumin (IMA) in the circulation and increased carotid intima–media thickness (cIMT). We investigated the reliability of IMA increase in evaluating atherosclerosis in patients with familial Mediterranean fever (FMF) compared with cIMT. Patients with FMF (n = 58) diagnosed by the Tel-Hashomer criteria in attack-free period and 38 healthy people were included in the study. Patient demographics as well as the clinical and laboratory characteristics of the healthy controls and patients with FMF were noted. The IMA levels and cIMT in patients with FMF were 0.30 ± 0.09 absorbance units (ABSUs) and 1.12 ± 0.27 mm, respectively, and in the control group, IMA levels and cIMT were 0.25 ± 0.07 ABSU and 0.74 ± 0.26 mm, respectively. The IMA levels and cIMT were significantly higher in patients with FMF than in controls ( P = .020 and P < .0001, respectively). The IMA values showed positive correlation with cIMT in patients with FMF( r = .302, P = .041). Our results reveal that IMA—an oxidative stress marker—may be an indicator of atherosclerosis in patients with FMF. This finding deserves further investigation.

Preprocedural Albumin Levels and Risk of In-Stent Restenosis After Coronary Stenting With Bare-Metal Stent

In-stent restenosis (ISR) remains a significant clinical problem in patients with coronary artery disease treated with percutaneous coronary intervention. Decreased serum albumin (SA) level is related to an increased risk of cardiovascular events. The aim of the present study was to assess whether SA levels at admission are an independent predictor of ISR in patients undergoing bare-metal stent (BMS) implantation. A total of 341 patients (aged 61 ± 11, 65.4% men) with a history of BMS implantation and a further control coronary angiography due to stable angina pectoris (SAP) were included. The study population was classified into 2 groups: patients with and without ISR. The ISR was observed in 140 (41.1%) patients. We found significantly lower SA levels in patients who developed ISR than in those who did not (3.69 ± 0.41 vs 4.07 ± 0.35 mg/dL,P< .001). Multivariate analysis revealed that SA level (odds ratio 0.109, 95% confidence interval 0.017-0.700,P= .020), stent diameter, reason for stent implantation, and body mass index were independent risk factors for the development of ISR. The SA level at admission is inversely associated with ISR in patients with SAP.

Testing Clinical Scores to Diagnose Incident Deep Vein Thrombosis in Patients Hospitalized in a Department of Medicine: Can Biomarkers Improve Accuracy?

Shifting the context from the emergency department to the department of medicine, we compared different scores to diagnose deep vein thrombosis (DVT) in patients with several comorbidities, hospitalized in a department of internal medicine. We prospectively recruited 178 consecutive hospitalized patients in whom clinical suspicion of DVT was assessed by Wells modified score for DVT, Hamilton, Kahn, and St Andrè Hospital scores. Deep vein thrombosis was confirmed in 85 (48%) patients by both echocolor Doppler and angiocomputed tomography scan. The use of risk scores based on symptoms and clinical signs was weakly useful (area under the curve [AUC]: 0.69, positive predictive value: 59%, and negative predictive value: 74%). Patients with DVT had significantly (P < .0001) lower serum albumin and protein S levels compared to those without DVT. Moreover, serum protein S (AUC: 0.82) and albumin in percentage (AUC: 0.80) showed a better accuracy than clinical scores (P < .001) in assessing the diagnosis of DVT. Therefore, serum albumin and protein S improved the accuracy of clinical scores for the diagnosis of incident DVT in patients hospitalized in a department of medicine.

Usefulness of Serum Albumin Concentration to Predict High Coronary SYNTAX Score and In-Hospital Mortality in Patients With Acute Coronary Syndrome

High SYNTAX score is a predictor of adverse cardiovascular events, including mortality, in acute coronary syndromes (ACSs). Decreased serum albumin (SA) concentration is associated with an increased risk of cardiovascular events. We aimed to investigate whether SA levels at admission are associated with high SYNTAX score and in-hospital mortality in patients with ACS. The study included 1303 patients with ACS who underwent coronary angiography (CA). The patients were divided into 2 groups as high SYNTAX score (≥33) and lower SYNTAX score (≤32). Baseline SA levels were significantly lower in patients with high SYNTAX score than with lower SYNTAX score (3.46 ± 0.42 mg/dL vs 3.97±0.37 mg/dL, respectively; P < .001). On multivariate logistic regression, SA (<3.65 mg/dL) was an independent predictor of high SYNTAX score (odds ratio 4.329, 95% confidence interval 2.028-8.264; P < .001) together with admission glucose, estimated glomerular filtration rate, and left ventricular ejection fraction. In Cox regression analyses, systolic blood pressure, high SYNTAX score, and SA (<3.65 mg/dL) were found as independent predictors of in-hospital all-cause mortality. In conclusion, SA concentration on admission is inversely associated with high SYNTAX score and in-hospital mortality in ACS.

Impact of Serum Albumin Levels on Contrast-Induced Acute Kidney Injury in Patients With Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention

Patients with acute coronary syndromes (ACSs) undergoing percutaneous coronary intervention (PCI) are at high risk of contrast-induced acute kidney injury (CI-AKI), a complication associated with poor clinical outcomes. Serum albumin (SA) levels are associated with cardiovascular mortality. We assessed the association between SA levels and the risk of CI-AKI in patients with ACS (n = 890) treated with PCI. Patients were divided into 2 groups: patients with and without CI-AKI. Contrast-induced acute kidney injury was defined as an increase in serum creatinine (≥25% or ≥0.5 mg/dL) from baseline occurring 72 hours after PCI. The SA levels were significantly lower in patients with CI-AKI than in those without CI-AKI (3.52 ± 0.40 vs 3.94 ± 0.39 mg/dL, P < .001). On multivariate analysis, SA was an independent predictor of CI-AKI (odds ratio 0.177, 95% confidence interval 0.080-0.392, P < .001) together with age, female gender, creatine kinase-myocardial band, and glomerular filtration rate. Baseline SA levels are inversely associated with CI-AKI after PCI for ACS.

Primary Nephrotic Syndrome in Adults as a Risk Factor for Pulmonary Embolism: An Up-to-Date Review of the Literature

Patients with nephrotic syndrome are at an increased risk for thrombotic events; deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are quite common in patients with nephrotic syndrome. It is important to note that nephrotic syndrome secondary to membranous nephropathy may impose a greater thrombotic risk for unclear reasons. Increased platelet activation, enhanced red blood cell aggregation, and an imbalance between procoagulant and anticoagulant factors are thought to underlie the excessive thrombotic risk in patients with nephrotic syndrome. The current scientific literature suggests that patients with low serum albumin levels and membranous nephropathy may benefit from primary prophylactic anticoagulation. A thorough approach which includes accounting for all additional thrombotic risk factors is, therefore, essential. Patient counseling regarding the pros and cons of anticoagulation is of paramount importance. Future prospective randomized studies should address the question regarding the utility of primary thromboprophylaxis in patients with nephrotic syndrome.

Serum albumin levels on admission are associated with angiographic no-reflow after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

Low serum albumin (SA) levels are associated with increased cardiovascular mortality. We investigated whether baseline SA levels are associated with no-reflow following primary percutaneous coronary intervention (pPCI). A total of 536 patients (aged 60 ± 13 years; 74% men) who underwent pPCI were enrolled. The patients were divided into 2 groups: no-reflow and normal-reflow. No-reflow was defined as thrombolysis in myocardial infarction ≤2 flow. Admission SA levels were significantly lower in the no-reflow group than in the normal-reflow group (3.55 ± 0.44 vs 4.01 ± 0.32 mg/dL, P < .001). Also, high-sensitivity C-reactive protein (hsCRP), creatinine, creatine kinase myocardial band isoenzyme, and troponin T were significantly higher while hemoglobin and left ventricular ejection fraction (LVEF) were significantly lower in the no-reflow group. In multivariate analysis, SA level remained an independent predictor of angiographic no-reflow (odds ratio 0.114, 95% confidence interval 0.032-0.405, P = .001) together with LVEF, hsCRP, and baseline culprit artery patency. Admission SA level was an independent predictor of no-reflow after pPCI.

Effect of Melothria maderaspatana leaf-tea consumption on blood pressure, lipid profile, anthropometry, fibrinogen, bilirubin, and albumin levels in patients with hypertension

OBJECTIVE

To determine the effect of Melothria maderaspatana (Linn.) leaf-tea on blood pressure, plasma lipid profile, fibrinogen, albumin together with serum bilirubin and anthropometric measurements in volunteer participants with hypertension, because all these variables have been shown to influence vascular events.

SUBJECTS AND DESIGN

A total of 50 subjects-25 (mean age of 58 +/- 9.0 years; 12 were women) with mild-to-moderate hypertension (systolic blood pressure [SBP] >or= 140 mm Hg; diastolic blood pressure [DBP] >or= 90 mm Hg) and 25 normotensives (mean age of 48 +/- 8.0 years; 11 women)-were selected for this study. Plasma lipid profile, fibrinogen, albumin, serum bilirubin, and anthropometric measurements were measured at baseline and after leaf-tea consumption by the patient with hypertension for 45 days.

RESULTS

SBP and DBP gradually decreased and pulse rate decreased. The total cholesterol, low-density lipoprotein cholesterol and triglycerides, and phospholipids levels decreased significantly and high-density lipoprotein cholesterol and serum bilirubin levels increased after tea consumption in patients with hypertension. We also observed significant body weight loss and reduction in fibrinogen levels. There was no significant difference in plasma level of albumin.

CONCLUSIONS

Thus, M. maderaspatana leaf-tea consumption gradually decreased BP and showed beneficial effects on blood lipid profile, fibrinogen, bilirubin, and body mass index in patients with hypertension.

Coagulation, platelets, and acute pancreatitis

Acute pancreatitis generates a complex cascade of immunological events that affect the pathogenesis and the progression of this disease. Several inflammatory mediators seem to play a critical role in the pathogenesis of pancreatitis and the subsequent inflammatory response. In turn, these mediators can influence hemostasis. Coagulation abnormalities occur in acute pancreatitis and are related to its severity. The contribution of blood platelets in the disturbed hemostasis in acute pancreatitis, although extensively studied, remains obscure. This article reviews the local and systemic implications of hemostatic abnormalities during acute pancreatitis. Furthermore, we discuss the prognostic value and the potential therapeutic implications of platelet activation and other hemostatic variables.

Adhesion of human platelets to albumin is synergistically increased by lysophosphatidic acid and adrenaline in a donor-dependent fashion

Lysophosphatidic acid (LPA) and adrenaline are weak platelet activators considered important for thrombus formation, and were previously shown to synergistically increase platelet aggregation. Here we investigate synergistic activation by LPA and adrenaline when measuring platelet adhesion. Platelet-rich plasma from healthy blood donors together with adrenaline and/or LPA were added to protein-coated microplates. Platelets were allowed to adhere and the amount of adhesion detected enzymatically. The LPA and adrenaline combination induced a synergistic increase of platelet adhesion to a normally non-adhesive albumin surface. The degree of synergy varied markedly between individuals; these variations could not be explained by age, gender, blood type or different amounts of platelets, oxidized low-density lipoprotein, insulin or glucose in plasma. There was a trend indicating increased synergistic effect for platelets sensitive to adrenaline stimulation. The synergistic effect was blocked by the alpha2-adrenoceptor antagonist yohimbine and inhibited by the ADP scavenger system creatine phosphate/creatine phosphokinase and antibodies against alphaIIbbeta3. Furthermore, platelets adhering to albumin after adrenaline and LPA treatment expressed P-selectin. In conclusion, LPA and adrenaline act synergistically to increase alphaIIbbeta3-mediated platelet adhesion to albumin, dependent on alpha2-adrenoceptor signalling and platelet secretion. We also confirm that synergistic platelet activation achieved with LPA and adrenaline is highly donor dependent.

Prognostic value of serum albumin combined with serum C-reactive protein levels in older hospitalized patients: continuing importance of serum albumin

BACKGROUND AND AIMS

Although both serum albumin and C-reactive protein (CRP) levels are separately recognized as predictors of adverse outcomes in many illnesses, the predictive value of their combination for adverse outcomes has not been evaluated. We therefore sought to examine the prognostic value of serum albumin for in-hospital mortality in the presence or absence of severe inflammation, as indicated by high CRP levels.

METHODS

In this cohort study, we measured serum albumin and CRP levels in 1638 older patients (aged 65 years or older) hospitalized for medical problems, and examined their utility, both separately and in combination, for predicting in-hospital mortality.

RESULTS

In separate analyses of CRP and albumin, both high CRP levels (> or =5 mg/dl) and hypoalbuminemia (<3.5 g/dl) were associated with risk of in-hospital death. After dividing participants into four groups based on CRP and albumin levels (<5 mg/dl CRP and <3.5 mg/dl albumin), subjects with severe inflammation (CRP > or =5 mg/dl) and hypoalbuminemia were associated with an adjusted relative risk (ARR) of 3.8 for in-hospital mortality when compared with the reference (high albumin and low CRP). Even in the absence of severe inflammation, the presence of severe hypoalbuminemia was associated with an ARR of 2.6 for in-hospital mortality, when compared with patients without hypoalbuminemia.

CONCLUSIONS

Both serum CRP and albumin levels are predictors of in-hospital mortality. However, high serum albumin levels may have a protective effect in older patients, regardless of degree of inflammation. Serum albumin levels remain a useful predictor for in-hospital mortality in older hospitalized patients.

Influence of smoking on predictors of vascular disease

Beyond the already well-established strong causative relationship with cancer, smoking increases the risk for vascular disease. Smoking may act directly or adversely influence risk factors contributing to the development of vascular disease. Smoking causes endothelial dysfunction, dyslipidemia (decreased high-density lipoprotein cholesterol levels, hypertriglyceridemia and increased oxidation of low-density lipoprotein cholesterol) and platelet activation leading to a prothrombotic state. Smoking increases emerging risk factors (eg, fibrinogen, homocysteine, and high-sensitivity C-reactive protein) and increases insulin resistance and the risk of developing type 2 diabetes mellitus. The beneficial effects of statins and antioxidants (eg, vitamins C and E, beta-carotene) are counteracted by smoking. Smoking-induced alterations in growth factors, adhesion molecules, and even in genes can accelerate the progression of atherosclerosis. The aim of this review is to consider the adverse consequences of smoking on the factors predisposing to vascular disease and to emphasize the beneficial effects of smoking cessation.

Prospective double-blind randomized study of the effects of four intravenous fluids on platelet function and hemostasis in elective hip surgery

A prospective randomized double-blind study was performed to determine the effects of three colloids, Haemaccel, Gelofusine and albumin, and also saline on platelet activation, platelet aggregation (induced by adenosine diphosphate (ADP), epinephrine, collagen) platelet agglutination by ristocetin and other hemostatic variables in 55 patients undergoing primary unilateral total hip replacement. The fluids were administered according to normal clinical practice and assessments were made immediately before, at the end, and 2 h after the end of surgery. Surgery was accompanied by thrombin generation (increases in thrombin/antithrombin III complex, prothrombin F1 +2 fragment) platelet activation (betaTG) and compromised coagulation. Generally, the platelet activation appeared to result in platelet desensitization and brought about a persistent reduction in platelet aggregation to ADP and epinephrine, irrespective of the fluid used. Additionally, Haemaccel and Gelofusine inhibited ristocetin-induced platelet agglutination and albumin inhibited collagen-induced platelet aggregation. Gross inhibitory effects of Haemaccel that had been predicted from an earlier in vitro study did not occur. Particular fluids had selective additional effects on the hemostatic system. Albumin infusion served to maintain plasma albumin at normal concentrations postsurgery. The two gelatin preparations, Haemaccel and Gelofusine, maintained plasma viscosity. All three colloids led to a transient increase in activated partial thromboplastin time postsurgery and also a transient fall in the concentration of factor VIII, which were accompanied by a transient increase in bleeding time, but there was no measurable increase in blood loss. Inhibition of platelet aggregation by certain colloids may provide additional protection against the increased thrombotic risk in patients following major surgery.

Can the effects of clinical reperfusion fluids on platelet aggregation in vitro predict the effects of administration of such fluids in a clinical study ex vivo?

Reperfusion fluids are administered routinely during surgical operations and following trauma. Studies performed wholly in vitro have indicated effects of some fluids on haemostasis through inhibition of platelet aggregation. Recently we performed a study to further evaluate the effects of reperfusion studies in vitro and also a study in a clinical setting to determine the extent to which the results of in vitro experiments can be extrapolated to the clinical situation. The results indicate that a combination of homeostatic and trauma response mechanisms complicate the ability to extrapolate from the findings in vitro.

The prognostic value of serum albumin in healthy older persons with low and high serum interleukin-6 (IL-6) levels

OBJECTIVE

We sought to determine the prognostic value of serum albumin for 4-year mortality among high-functioning persons who did or did not have evidence of inflammation as indicated by high interleukin-6 (IL-6) levels.

DESIGN

We used a case-cohort design of healthy, nondisabled older persons who had serum albumin and plasma IL-6 measured at baseline. Crude and multiply adjusted (for sociodemographics and chronic diseases) proportional hazards models were used to identify the effect of baseline levels of serum albumin level on 4-year mortality among those with higher and lower levels of IL-6.

RESULTS

Among subjects without evidence of IL-6-mediated inflammation (IL-6 < 3.20 pg/mL), having a lower (< or = 4.4 g/dL) albumin level was associated with a multiply adjusted relative risk of 2.1 for 4-year mortality compared with those with higher albumin. In the presence of inflammation (IL-6 > or = 3.20 pg/mL), higher and lower serum albumin levels had similar risks (adjusted relative risks 4.0 and 3.8, respectively) compared with the referent group (higher albumin and low IL-6).

CONCLUSIONS

High serum albumin has a protective effect in healthy older persons who do not have evidence of cytokine-mediated inflammation. This protective effect is not conferred in presence of inflammation. The mechanisms by which inflammation eliminates the protective effect of high albumin remain to be determined.