C-reactive protein, fibrinogen, interleukin-6 and tumour necrosis factor-alpha in the prognostic classification of unstable angina pectoris

Reduced glucocorticoid sensitivity of monocyte interleukin-6 release in male employees with high plasma levels of tumor necrosis factor-alpha

Cytokine production by monocytes plays a key role in atherosclerosis. In vitro, preincubation of whole blood with tumor necrosis factor (TNF)-alpha regulates interleukin (IL)-6 release from monocytes stimulated with lipopolysaccharide (LPS). We investigated whether plasma levels of TNF-alpha would also relate to LPS-stimulated monocyte IL-6 production and the inhibitory effect of a glucocorticoid on this process. 224 middle-aged men were assigned to three groups according to tertiles of plasma levels of TNF-alpha. Subjects in the highest tertile (high TNF-alpha, n = 75) were compared to those in the lowest (low TNF-alpha, n = 74) and medium tertile (medium TNF-alpha, n = 75), respectively. In vitro monocyte IL-6 release following lipopolysaccharide (LPS)-stimulation was assessed with and without coincubation with incremental doses of dexamethasone. Monocyte glucocorticoid sensitivity was defined as the dexamethasone concentration inhibiting IL-6 release by 50%. Subjects with high TNF-alpha showed more IL-6 release after LPS-stimulation than those with low TNF-alpha (p =.011). Monocyte glucocorticoid sensitivity was lower in subjects with high levels of TNF-alpha than in subjects with low (p =.014) and with medium (p =.044) levels of TNF-alpha. Results held significance when a set of classic cardiovascular risk factors was controlled for. Our findings suggest that elevated plasma levels of TNF-alpha might enhance LPS-stimulated IL-6 release from circulating monocytes. Such a mechanism might contribute to exaggerated monocyte cytokine release in vivo to any LPS-like danger signal such as related to an infection or cellular stress thereby promoting atherosclerosis.

Cumulative biological risk and socio-economic differences in mortality: MacArthur Studies of Successful Aging

Previous research has suggested that socio-economic status (SES) differences in mortality are only partially explained by differences in life-style, psychological and social factors. Seven year mortality data (1988-1995) from the MacArthur Study of Successful Aging, a longitudinal study of adults, aged 70-79, from New Haven, CT; East Boston, MA; and Durham, NC; were used to test the hypothesis that a cumulative measure of biological dysregulation ("allostatic load"), reflecting multiple regulatory systems, would serve as a further mediator of SES differences in mortality. Logistic regression analyses revealed that a cumulative index of biological risk explained 35.4% of the difference in mortality risk between those with higher versus lower SES (as measured by less than high school education versus high school or greater educational attainment). Importantly, the cumulative index provided independent explanatory power, over and above a measure of doctor-diagnosed disease, though the latter also contributed to education-related variation in mortality risks. The summary measure of biological risk also accounted for more variance than individual biological parameters, suggesting the potential value of a multi-systems view of biological pathways through which SES ultimately affects morbidity and mortality.

Traditional cardiovascular risk factors measured prior to the onset of inflammatory polyarthritis

BACKGROUND

Cardiovascular mortality is increased in patients with seropositive inflammatory polyarthritis (IP). We tested the hypothesis that the increased risk of cardiovascular disease (CVD) can be explained by elevated traditional CVD risk factor levels in persons prior to development of IP.

METHODS

In a population-based, prospective nested case-control study, 25 600 people aged 45-75 yr participated in a health survey, including standard CVD risk factor assessment, between the years 1993 and 1997. There were 91 incident IP cases (one-third were seropositive at presentation) identified during follow-up to the end of July 2001. Baseline CVD risk factors in the IP cases were compared with those in two age/gender-matched controls.

RESULTS

Current smokers had an odds ratio of 2.0 (95% CI 1.0-4.0) for IP. Other risk factors, including total and LDL cholesterol, systolic and diastolic blood pressure and obesity, did not differ significantly between cases and controls. Importantly, in combination, using a standard coronary disease risk score, these factors only had a modest association with future IP, and no association when analysis was restricted to the smaller number of cases who were seropositive.

CONCLUSION

Of the traditional cardiovascular risk factors, only smoking increases CVD risk prior to the onset of IP. Therefore the increased CVD observed in these patients is likely to be a consequence of factors operating after the onset of the arthritis.

Increased serum concentrations of soluble CD95/Fas and caspase 1/ICE in patients with acute angina

OBJECTIVES

To investigate the expression of death inducing receptors in the sera of patients with stable and unstable angina.

DESIGN

80 consecutive patients with stable (n = 40) or unstable (n = 40) angina pectoris were studied. Serum concentrations of soluble CD95 (sCD95), soluble CD95 ligand (sCD95L; CD178), tumour necrosis factor (TNF) alpha, soluble TNFalpha receptor type 1 (sTNFR1), and interleukin 1beta converting enzyme (ICE; caspase 1) were measured by enzyme linked immunosorbent assay (ELISA).

RESULTS

Significant increases in the concentrations of sCD95 and ICE (p < 0.001 and p < 0.023, respectively) were found in the serum from patients with unstable angina relative to those with stable angina. There were no significant differences in the concentrations of sCD95L, TNF alpha, and sTNFR1 between the groups.

CONCLUSIONS

These data provide the first evidence that sCD95 and ICE are important serological markers that may help to discriminate between stable and unstable angina. This observation may warrant further clinical study to elucidate the clinical impact of sCD95 and ICE in acute coronary syndromes.

Raised concentrations of macrophage colony stimulating factor in severe unstable angina beyond the acute phase are strongly predictive of long term outcome

OBJECTIVE

To evaluate the long term prognostic value of macrophage colony stimulating factor (MCSF), interleukin-6 (IL-6), and tumour necrosis factor alpha (TNFalpha) measured in serum six weeks after the occurrence of unstable angina.

SUBJECTS

119 consecutive patients, mean (SD) age 58 (10) years, with severe unstable angina (Braunwald class IIIb); controls were 96 subjects of similar age and sex distribution.

DESIGN

MCSF, IL-6, and TNFalpha were measured on admission, at discharge, and six weeks later, and the patients were followed for two years. Clinical end points were: cardiac death, readmission for acute coronary syndromes, and revascularisation.

SETTING

District general hospital.

RESULTS

113 patients completed follow up, during which two died of non-cardiac causes. Of the remaining 111 patients, 39 (35.1%) had a cardiac event (two deaths, 15 revascularisations, and 22 readmissions for acute coronary syndromes). MCSF and IL-6 concentrations at six weeks were higher in patients with cardiac events than in those without (424 v 306 pg/ml, p = 0.0008, and 6.6 v 4.5 pg/ml, p = 0.01, respectively). Cytokine concentrations at six weeks were also significantly higher than in the control group. Logistic regression analysis showed that MCSF concentrations were the only independent predictors of future events, with an adjusted odds ratio for events of 4.1 (95% confidence interval 1.1 to 14.8; p = 0.03). The two year survival free of cardiac events was significantly lower in patients with MCSF concentrations in the highest tertile (values > or = 468 pg/ml) than in those with values < 468 pg/ml.

CONCLUSIONS

Increased MCSF concentrations beyond the acute phase are strongly predictive of long term outcome in patients with severe unstable angina.

Coagulation, inflammation and myocardial dysfunction in unstable coronary artery disease and the influence of glycoprotein IIb/IIIa inhibition and low molecular weight heparin

Patients with unstable coronary artery disease (CAD) have an increased risk of subsequent myocardial infarction and death. This study evaluated the safety and efficacy of treatment with glycoprotein IIb/IIIa inhibition in addition to aspirin, low molecular-weight heparin and its influence on coagulation and inflammation. Also, early and differentiated risk assessment utilising markers of inflammation, myocardial damage and dysfunction were evaluated. The Global Utilisation of Strategies To open Occluded arteries-IV (GUSTO-IV) trial randomised 7800 patients with unstable CAD to 24 or 48 hours infusion of abciximab or placebo in addition to routine treatment with aspirin and heparin or dalteparin. Baseline levels of creatinine, C-reactive protein (CRP), troponin T (TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were analysed. At selected sites, all patients received subcutaneous dalteparin (n=974), in stead of heparin infusion (n=6826). In a sub-population of dalteparin treated patients (n=404), serial measurements of markers of coagulation, fibrinolysis and inflammation were also performed. Addition of abciximab to dalteparin as the primary treatment of unstable CAD was not associated with any significant reduction in cardiac events but a doubled risk of bleedings. The combination of abciximab with dalteparin seemed as safe when used with heparin. Despite full dose dalteparin and aspirin there was a simultaneous activation of the inflammation, coagulation and fibrinolysis systems without any influence of the abciximab treatment. Elevated levels of CRP, TnT, and NT-proBNP and reduced creatinine clearance were independently related to short and long-term mortality. The best prediction of high and low risk was provided by a combination of NT-proBNP and creatinine clearance. Any detectable elevation of TnT and reduced creatinine clearance, but neither elevation of CRP nor NT-proBNP, were also independently associated to a raised risk of subsequent myocardial infarction.

Why does C-reactive protein increase in non-ST elevation acute coronary syndromes?

INTRODUCTION

C-reactive protein is an important prognostic indicator for early risk stratification in patients with an acute coronary syndrome. The mechanisms underlying the elevation of C-reactive protein in these patients have not been fully understood. We studied the factors related to the increase of this acute-phase reactant.

METHODS AND RESULTS

Within a single-centre registry, 419 consecutive patients admitted for a non-ST elevation acute coronary syndrome were studied. Serum high sensitivity C-reactive protein was measured late (median 3 days) after admission. Clinical, electrocardiographic, biochemical and angiographic variables were recorded. In the multivariate analysis, an increased C-reactive protein (n=162) was related to high levels of troponin I (OR 2.5 (1.6-4) P<0.001) and to a Killip class>1 at presentation (OR 2.9 (1.6-5.4) P<0.001). The coronary angiographic characteristics were not related to C-reactive protein. Finally, in 52 patients with no previous heart disease in whom regional dysfunction was quantified by left ventriculography the presence of a significant (>6 chords) regional dysfunction was significantly related to C-reactive protein (OR 5.1 (1.7-15.3) P=0.006)

CONCLUSION

Our results indicate that in acute coronary syndromes elevated levels of C-reactive protein late after admission are mainly related to clinical, biochemical and angiographic evidences of myocardial damage. The prognostic utility of this parameter could be in part explained by its relationship with a major regional dysfunction.

From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II

Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document will focus on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.

Inflammatory markers and onset of cardiovascular events: results from the Health ABC study

BACKGROUND

Inflammation plays an important role in cardiovascular disease. The aim of this study is to investigate the predictive value of several inflammatory markers on the incidence of cardiovascular events in well-functioning older persons.

METHODS AND RESULTS

The subjects were 2225 participants 70 to 79 years old, without baseline cardiovascular disease, who were enrolled in the Health, Aging, and Body Composition study. Incident coronary heart disease (CHD), stroke, and congestive heart failure (CHF) events were detected during an average follow-up of 3.6 years. Blood levels of interleukin-6 (IL-6), C-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-alpha) were assessed. After adjustment for potential confounders, IL-6 was significantly associated with all outcomes (CHD events, per IL-6 SD increase: RR, 1.27; 95% CI, 1.10 to 1.48; stroke events, per IL-6 SD increase: RR, 1.45; 95% CI, 1.12 to 1.86; CHF events, per IL-6 SD increase: RR, 1.72; 95% CI, 1.40 to 2.12). TNF-alpha showed significant associations with CHD (per TNF-alpha SD increase: RR, 1.22; 95% CI, 1.04 to 1.43) and CHF (per TNF-alpha SD increase: RR, 1.59; 95% CI, 1.30 to 1.95) events. CRP was significantly associated with CHF events (per CRP SD increase: RR, 1.48; 95% CI, 1.23 to 1.78). A composite summary indicator of inflammation showed a strong association with incident cardiovascular events, with an especially high risk if all 3 inflammatory markers were in the highest tertile.

CONCLUSIONS

Findings suggest that inflammatory markers are independent predictors of cardiovascular events in older persons.

Despite increased plasma concentration, inflammation reduces potency of calcium channel antagonists due to lower binding to the rat heart

1. Rheumatoid arthritis reduces verapamil oral clearance thereby increases plasma concentration of the drug. This coincides with reduced drug effects through an unknown mechanism. 2. The effect of interferon-induced acute inflammation on the pharmacokinetics and electrocardiogram of verapamil (20 mg kg(-1), p.o.) and nifedipine (0.1 mg kg(-1), i.v.) was studied in Sprague-Dawley rats. 3. The effect of both acute and chronic inflammation on radioligand binding to cardiac L-type calcium channels was also investigated. 4. Acute inflammation resulted in increased plasma concentration of verapamil but had no effect on that of nifedipine. Verapamil binding to plasma proteins was unaffected. 5. As has been reported for humans, the increased verapamil concentration coincided with a reduction in the degree to which PR interval is prolonged by the drug. The effect of nifedipine on PR interval was also reduced by inflammation. 6. Maximum binding of (3)H-nitrendipine to cardiac cell membrane was significantly reduced from 63.2+/-2.5 fmol mg(-1) protein in controls to 46.4+/-2.0 in acute inflammation and from 66.8+/-2.2 fmol mg(-1) protein in controls to 42.2+/-2.0 in chronic inflammation. 7. Incubation of the normal cardiac cell membranes with 100 and 1000 pg ml(-1) of rat tissue necrosis factor-alpha did not influence the binding indices to the calcium channels. 8. Our data suggest that the reduced calcium channel responsiveness is because of altered binding to channels.

Reduced glucocorticoid sensitivity of monocyte interleukin-6 production in male industrial employees who are vitally exhausted

OBJECTIVE

Proinflammatory changes are thought to link vital exhaustion with adverse cardiovascular outcomes. Monocytes play a central role in the pathogenesis of atherosclerotic lesions and are a major source of circulating cytokines. We hypothesized that vital exhaustion may alter the regulation of monocyte activity, as measured by lipopolysaccharide (LPS)-stimulated and glucocorticoid inhibited release of the proinflammatory cytokine interleukin-6 (IL-6).

METHODS

In 166 middle-aged apparently healthy men, vital exhaustion was measured by the Shortened Maastricht Exhaustion Questionnaire. Subjects in the highest quartile (highly exhausted, N= 38) were compared with those in the second and third quartiles (moderately exhausted N= 89) vs. those in the lowest quartile (nonexhausted, N= 39) in terms of plasma C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-alpha) levels, and as to IL-6 release after LPS stimulation in vitro. Inhibition of IL-6 release was determined by coincubation with increasing concentrations of dexamethasone. Monocyte glucocorticoid sensitivity was defined as the dexamethasone concentration inhibiting IL-6 release by 50%.

RESULTS

Highly exhausted individuals had higher CRP levels than nonexhausted subjects (p=.008). LPS-stimulated IL-6 release was not significantly different between groups. However, in highly exhausted participants, dexamethasone was less able to inhibit IL-6 release (p=.010), and the glucocorticoid sensitivity was lower (p=.003) than in nonexhausted subjects.

CONCLUSIONS

In highly exhausted individuals, glucocorticoids exert less suppressive action on monocyte IL-6 release than in nonexhausted subjects. This finding points to altered regulation of monocyte cytokine production as one possible pathway linking exhaustion with atherosclerosis.

Gemfibrozil reduces release of tumor necrosis factor-alpha in peripheral blood mononuclear cells from healthy subjects and patients with coronary heart disease

BACKGROUND

Inflammatory process plays an important role in the pathogenesis of coronary heart disease (CHD). With the growing use of gemfibrozil and other fibrates, their anti-inflammatory effects have been noted. But little is known about the effect of gemfibrozil on tumor necrosis factor (TNF)-alpha secretion in peripheral blood mononuclear cells (PBMC) from patients with coronary heart disease.

METHODS

PBMC were obtained from CHD patients (n=16) and healthy controls (n=13). PBMC (2x10(6) cells/ml) were cultured in 24-well plates with or without Ang II (10(-8), 10(-7), 10(-6) mol/l), or Ang II (10(-6) mol/l) plus gemfibrozil (10(-6), 10(-5), 10(-4) mol/l). After 24-h incubation, the supernatants were separated, and TNF-alpha was measured by an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Spontaneous release of TNF-alpha was 299.2+/-110.7 pg/ml in PBMC from CHD patients and 179.3+/-78.2 pg/ml in PBMC from control subjects (P<0.05). Incubated with Ang II (10(-8), 10(-7), 10(-6) mol/l), TNF-alpha secretion was 307.7+/-141.8, 318.9+/-135.6, 328.6+/-123.9 pg/ml in PBMC from CHD patients, and 225.3+/-135.4, 224.1+/-141.0,218.7+/-134.8 pg/ml in PBMC from control subjects, respectively. Ang II did not significantly trigger TNF-alpha secretion in both groups. Compared with that incubated with Ang II (10(-6) mol/l) alone, release of TNF-alpha intervened by gemfibrozil (10(-6),10(-5),10(-4) mol/l) decreased to 279.4+/-132.2, 268.0+/-132.7, 226.6+/-102.7 pg/ml in PBMC from CHD patients, and 177.6+/-94.4, 156.1+/-69.4, 105.3+/-52.7 pg/ml in the control group, respectively. Gemfibrozil (10(-5),10(-4) mol/l) significantly inhibited TNF-alpha secretion in both groups (P<0.05).

CONCLUSIONS

Our data demonstrated that gemfibrozil reduced release of TNF-alpha in PBMC both from CHD patients and controls. This effect may partially be relevant to the clinical benefits of gemfibrozil in the treatment of dyslipidemia and atherosclerosis.

Highlights of the 2002 update to the 2000 American College of Cardiology/American Heart Association acute coronary syndrome guidelines

Since the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for acute coronary syndrome (ACS) were published in 2000, a wealth of clinical evidence has accumulated. To incorporate this recent clinical data, an update to the 2000 ACC/AHA guidelines was issued in 2002. The revised ACC/AHA guidelines emphasize risk stratification of ACS patients to help guide therapy. In antiplatelet therapy, clopidogrel has gained a more prominent role in the treatment of ACS, both in breadth of patients and duration of treatment. Ticlopidine is no longer recommended. More guidance is provided with respect to specific glycoprotein IIb/IIIa inhibitor use in subgroups of ACS patients. In anticoagulation therapy, enoxaparin is now favored over unfractionated heparin. Finally, class I indications for an early invasive strategy have been expanded to include patients with elevated cardiac markers or new ST segment depression. Early initiation and continuation of a hepatic hydroxymethyl glutaryl coenzyme A reductase inhibitor is recommended if low-density lipoprotein cholesterol is higher than 100 mg/dL, and the addition of niacin or a fibrate is recommended in patients with isolated low high-density lipoprotein cholesterol. This article summarizes the major modifications to the ACS guidelines and highlights the clinical evidence prompting such changes.

The relation of severity of depressive symptoms to monocyte-associated proinflammatory cytokines and chemokines in apparently healthy men

OBJECTIVE

We examined the relation of severity of depressive symptoms to lipopolysaccharide-stimulated expression of monocyte-associated proinflammatory cytokines and chemokines in 53 nonsmoking, healthy men.

METHODS

Assessments of cytokine and chemokine expression and severity of depressive symptoms were conducted on the same day. The 21-item Beck Depression Inventory (BDI) was used to assess severity of depressive symptoms experienced during the week before study participation. Dual-color flow cytometry was used to determine monocyte-associated (CD14+) expression of interleukin-1alpha (IL-1alpha), IL-1beta, tumor necrosis factor-alpha (TNF-alpha), IL-8, and monocyte chemotactic protein-1 (MCP-1) after in vitro lipopolysaccharide stimulation of undiluted whole blood.

RESULTS

Calculations of partial correlation coefficients controlling for age, race, body mass index, and alcohol use indicated that BDI score was significantly associated with IL-1alpha (r = 0.27), IL-1beta (r = 0.44), TNF-alpha (r = 0.57), MCP-1 (r = 0.52), and IL-8 (r = 0.33). In addition, relative to men with BDI scores below 10, men with BDI scores of 10 or above exhibited an overexpression of IL-1beta (p =.004), TNF-alpha (p =.005), IL-8 (p =.002), and MCP-1 (p =.025).

CONCLUSIONS

Relative to men with no or minimal symptoms of depression, men with mild to moderate levels of depressive symptoms showed overexpression of monocyte-associated proinflammatory cytokines and chemokines.

Elevated cardiac troponin T in predialysis patients is associated with inflammation and predicts mortality

OBJECTIVES

Cardiac troponin T (cTnT) is a highly sensitive and specific marker of myocardial damage. It has been shown that elevated serum concentrations of cTnT in haemodialysis (HD) patients are associated with poor prognostic outcome. The aim of the present study was to investigate the predictive value of cTnT in samples from predialysis patients and to investigate associations between cTnT and inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6).

DESIGN

Cohort, follow-up study.

SETTING

Huddinge University Hospital, Sweden.

SUBJECTS

A total of 115 (62% males, 28% diabetic patients) end-stage renal disease (ESRD) patients (52 +/- 1 years), of which 29% had cardiovascular disease (CVD), were studied shortly before the onset of dialysis therapy. Sixty-four patients started peritoneal dialysis (PD) as renal replacement therapy, whilst 49 started HD during the follow-up.

MAIN OUTCOME MEASURES

The cTnT was analysed with the third generation TnT assay on Elecsys 2010. The prognostic value was calculated for cTnT, IL-6, age, CVD, malnutrition, diabetes mellitus (DM) and gender. Survival analyses were made with Kaplan-Meier and Cox regression analyses, with all-cause mortality as the clinical end point (mean follow-up period 2.7 +/- 0.1 years).

RESULTS

Significant correlations were found between cTnT and CKMB (rho = 0.52, P < 0.0001), IL-6 (rho = 0.23, P < 0.05), CRP (rho = 0.30, P < 0.05), and serum albumin (rho = -0.31, P < 0.001), respectively. Diabetic patients had higher median serum cTnT level (0.09 microg L-1; range <0.01-0.51 vs. 0.04 microg L-1; range <0.01-0.67 microg L-1; P < 0.005) compared with nondiabetic patients. Likewise, patients with CVD had a significantly higher median level (0.08 microg L-1; range <0.01-0.67 microg L-1 vs. 0.04 microg L-1; range <0.01-0.61 microg L-1; P < 0.01) of cTnT compared with patients without CVD. Patients with cTnT > or =0.10 microg L-1 had a higher cumulative mortality rate than patients with cTnT < 0.10 microg L-1 (chi2 = 7.04; P < 0.01). Whilst age, CVD, malnutrition, DM, IL-6, cTnT and male gender were associated with poor outcome in the univariate analysis, only DM (P < 0.05) and cTnT (P < 0.05) were independently associated with mortality in a multivariate analysis.

CONCLUSIONS

The present study demonstrates that serum concentrations of cTnT > or =0.10 microg L-1 is a significant predictor of mortality in patients starting dialysis. Moreover, the positive correlations between cTnT and IL-6, and CRP, respectively, suggest an association between inflammation and cTnT levels. Finally, the results of the present study suggest that cTnT is an independent predictor of mortality in ESRD patients starting dialysis.

Inflammatory imbalance between IL-10 and TNFalpha in unstable angina potential plaque stabilizing effects of IL-10

BACKGROUND

The pathogenesis of atherosclerosis and acute coronary syndromes involves inflammation and immunological mechanisms. We hypothesized that patients with unstable angina may have an imbalance between inflammatory and anti-inflammatory cytokines.

DESIGN

Plasma levels of tumour necrosis factor (TNF)alpha and interleukin (IL)-10 were analyzed in 44 patients with stable angina, 29 patients with unstable angina and 20 controls. mRNA levels of these cytokines were analyzed in peripheral blood mononuclear cells (PBMC). We also studied the in vitro effects of IL-10 in PBMC from unstable angina patients.

RESULTS

Our main findings were: (1) the angina patients and particularly those with unstable disease had significantly raised TNFalpha in comparison with the controls, both at the protein and mRNA level; (2) in contrast, the levels of IL-10 were not different in the angina patients in comparison with the healthy controls, resulting in a markedly enhanced TNFalpha:IL-10 ratio, particularly in the unstable angina patients; (3) while exogenously added IL-10 markedly inhibited the release of TNFalpha, IL-8 and tissue factor as well as impairing the gelatinolytic activity and mRNA production of matrix metalloproteinase-9, it enhanced the tissue inhibitor of this metalloproteinase (i.e. TIMP-1) in PBMC from the unstable angina patients.

CONCLUSION

Patients with unstable angina appear to have an imbalance between TNFalpha and IL-10, possibly favouring inflammatory net effects. IL-10 may have beneficial effects on mechanisms that are important in plaque rupture and thrombus formation.

Laboratory evaluation of hypercoagulability with venous or arterial thrombosis

OBJECTIVE

To provide recommendations for hypercoagulation testing for patients with venous, arterial, or neurovascular thrombosis, as reflected in the medical literature and the consensus opinion of recognized experts in the field.

DATA SOURCES, EXTRACTION, AND SYNTHESIS

The authors extensively examined the literature and current practices, and prepared a draft manuscript with preliminary recommendations. The draft manuscript was circulated to each of the expert participants (n = 30) in the consensus conference prior to the convening of the conference. The manuscript and recommendations were then presented at the conference for discussion. Recommendations were accepted if a consensus of the 28 experts attending the conference was reached. The discussions were also used to revise the manuscript into its final form.

CONCLUSIONS

The resulting article provides 17 recommendations for hypercoagulation testing in the setting of venous, arterial, or neurovascular thrombosis. The supporting evidence for test selection is analyzed and cited, and consensus recommendations for test selection are presented. Issues for which a consensus was not reached at the conference are also discussed.

Inflammatory response to coronary stent implantation in patients with unstable angina

Previous evidence has shown that coronary angioplasty leads to the release of inflammatory mediators. In this study, we sought to characterize the systemic inflammatory response after coronary stent implantation in patients with unstable angina by measuring different protein markers. Peripheral blood samples were taken before and 24 h, 48 h, and 7 days after successful coronary stenting in 58 patients. Several markers of acute-phase response were determined: C-reactive protein (CRP), alpha2-macroglobulin, haptoglobin, acid alpha1-glycoprotein, prealbumin and albumin. Besides, proinflammatory cytokines (tumor necrosis factor-alpha, IL-6, IL-8) and the anti-inflammatory cytokine IL-10 were also measured. We have found that coronary angioplasty with stent implantation produces a systemic inflammatory response with a rise in inflammation markers concentration. CRP plasma levels declined 1 week after the intervention, but the other marker levels were even higher after 7 days. IL-6 was the only cytokine whose plasma levels significantly increased in peripheral blood after stenting, with a rise after 24 h, maintained after 48 h, and decreased to near-basal levels after 1 week. There was a good correlation between CRP and IL-6 plasma levels (r=0.5, p<0.001). IL-10 levels were slightly decreased after 24 h. Although no significant differences in the means at different time points were found, there was a decrease in IL-10 in most patients 24 h after the intervention. These results indicate that coronary stent implantation induces a systemic inflammatory reaction, with a temporal increase in the concentration of the inflammation markers, especially CRP and IL-6. Since these markers had been previously used as prognostic markers, this needs to be taken into account in patients undergoing stent implantation.

The regulation of ischemic acute renal failure by extrarenal organs

PURPOSE OF REVIEW

Recent work suggests that extrarenal organs, such as the liver, lung, spleen, brain, lymphoid tissues, and bone marrow, regulate acute renal failure. We now review several examples of such regulation.

RECENT FINDINGS

First, we demonstrate kidney-liver crosstalk during ischemic renal failure. Renal ischemia induces the renal production of interleukin 6 and the renal expression of interleukin 10 receptors; interleukin 6 stimulates the production of interleukin 10 by the liver; interleukin 10 ameliorates renal injury. The potential mechanisms of interleukin 6 and 10 are discussed. Second, we review the possible effects of the acute phase response on renal ischemic injury. We point out potential analogies between the recently reported association of increased interleukin 6 and C-reactive protein with myocardial ischemia, and renal ischemia. Third, we briefly review the salutary effects of hepatocyte growth factor, produced by the lung, spleen, and liver, on ischemic renal injury. Finally, we discuss how renal ischemia elicits an inflammatory response of neutrophils, macrophages, and T cells that may exacerbate the injury. Granulocyte-colony stimulating factor, produced by the kidney in response to ischemia, may participate in eliciting this inflammation. Such inflammation may be exacerbated by cytokines and growth factors released by the brain after traumatic injury.

SUMMARY

We discuss the existing evidence for extrarenal regulation of acute renal failure. This suggests that concurrent disease of those extrarenal organs might alter the course of acute renal failure.

Atherosclerosis and inflammation

The pathophysiology of coronary atherosclerosis is complex and multifactorial. The probability of the development of symptomatic coronary heart disease may be predicted by standard risk factor stratification involving hypertension, dyslipidemia, age, positive family history, and diabetes. However, risk factor stratification has been demonstrated to have significant limitations in the individual patient, which has generated a search for more specific and sensitive markers. Evidence is increasing that atherosclerosis is a disease characterized by inflammation, beginning with the earliest identifiable lesion (fatty streak) to the advanced vulnerable plaque. Clinical markers of inflammation, including C-reactive protein, modified low-density lipoprotein, homocysteine, tumor necrosis factor, and thermogenicity, have been identified as emerging risk factors that may add prognostic information in patient management. This review centers on inflammation as a potential pathogenetic factor in atherosclerosis and the role that clinical markers may play in the identification of patients at risk.

Ruling out myocardial infarction with troponin T and creatine kinase MB mass: diagnostic and prognostic aspects

OBJECTIVE

To investigate the time window for ruling out myocardial infarction (MI) with troponin T (TnT) and creatine kinase isoenzyme MB mass (CK-MBm) and the prognosis of patients with ruled-out MI diagnosis.

DESIGN

The study was based on 397 patients admitted with a suspected acute coronary syndrome but with relief of symptoms within 24 h.

RESULTS

MI diagnosis was confirmed with elevated TnT (>0.10 microg/l) in 108 patients. in 91% within 12-24 h from the onset of symptoms, and in 99% within 12 h from admission. In 94 of these patients CK-MBm became elevated (>5.0 microg/l). in 95% within 10-12 h from the onset of symptoms, and in 99% within 6 h from admission. Among patients with ruled-out MI diagnosis, the 1-year incidence of recurrent coronary events was 29% in those with positive history of coronary heart disease (CHD) but only 7% in those without prior CHD (p < 0.001).

CONCLUSION

Using TnT or CK-MBm, MI can be ruled out within 12 h from admission in the majority of patients. Among patients with ruled-out MI diagnosis, positive history of CHD is an important determinant of prognosis.