Usefulness of the white blood cell count as a predictor of angiographic findings in an unselected population referred for coronary angiography

White Blood Cell Counts to High-Density Lipoprotein Cholesterol Ratio, as a Novel Predictor of Long-Term Adverse Outcomes in Patients After Percutaneous Coronary Intervention: A Retrospective Cohort Study

Background: White blood cell (WBC) counts and high-density lipoprotein cholesterol (HDL-C) are widely available in clinical practice. However, the predictive value for cardiovascular disease (CVD) is uncertain. In the present study, we firstly assessed the prognostic value of WBC to HDL-C ratio (WHR) in patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI).

Methods: Six thousand and fifty patients with CAD after PCI from a retrospective cohort study (identifier: ChiCTR-INR-16010153) were evaluated initially. Three hundred and seventy-one patients were excluded due to HDL cholesterol data not available, malignancy, dementia, psoriasis or eczema, systemic connective tissue disorders, multiple sclerosis, chronic liver disease, and chronic obstructive pulmonary disorder. Finally, 5,679 patients were included in the study. The primary outcome was long-term mortality. Secondary endpoints were mainly major adverse cardiovascular and cerebrovascular events (MACCEs), defined as a combination of stroke, cardiac death, stent thrombosis, recurrent myocardial infarction, and target vessel revascularization. The mean follow-up time of this study was 35.9 ± 22.5 months. We defined the best cutoff value of MHR according to the receiver operating curve (ROC), and then patients were divided into high and low WHR groups according to the cutoff value. We analyzed the data in both an acute coronary syndrome group (ACS) and a stable CAD subgroup, respectively.

Results: Overall, there were 293 cases of long-term mortality during the follow-up period. According to the cutoff value (WHR = 8.25), 1,901 ACS patients were divided into high WHR group (n = 724) and low WHR group (n = 1,177). Compared to low WHR group, the incidence of all-cause mortality (ACM, 5.5 vs. 3.6%, p = 0.048) and cardiac death (4.7vs. 2.9%, p = 0.042) were significantly higher in the high WHR group. In stable CAD group, we also found the incidence of ACM and cardiac death were significantly higher in the high group compared to that in the low group. We did not find significant difference between the high and the low WHR group in the incidence of MACCEs. The multivariate Cox proportional hazards model showed that increased WHR level was independently correlated with the mortality. In the high WHR group, the risk of ACM increased two times in ACS [adjusted HR = 2.036 (1.258–3.296), p = 0.004] and 1.5 times in stable CAD [adjusted HR = 1.586 (1.178–2.136), p = 0.002].

Conclusion: The present study indicated that an increased WBC count to HDL-C ratio was independently associated with long-term mortality in CAD patients who underwent PCI.

Elevated White Blood Cell Count Resultant Atherogenesis is Associated With Panoramic-Imaged Carotid Plaque

PURPOSE

Atherosclerotic plaques develop as a result of a low-grade, chronic, systemic inflammatory response to the injury of endothelial cells arising from lipid deposition within the intima. Increased white blood cell count (WBCC) is both a validated "biologic marker" of the extent of this inflammatory process and a key participant in the development of subsequent atherosclerotic ischemic heart disease manifesting as myocardial infarction. We sought to determine if calcified carotid artery plaque (CCAP) on a panoramic image (PI), also a validated risk indicator of future myocardial infarction, is associated with increased WBCC.

PATIENTS AND METHODS

We retrospectively evaluated the PI and medical records of White male military veterans aged 55 years and older treated by a VA dental service. Established were 2 cohorts of patients, 50 having plaques (CCAP+) and 50 without plaques (CCAP-). Predictor variable was CCAP+; outcome variable was WBCC. Bootstrapping analysis determined the differences in mean WBCCs between groups. Statistical significance set at ≤ 0.05.

RESULTS

The study group, (mean age 74; range 59 to 91 years) demonstrated a mean WBCC of 8,062 per mm³. The control group, (mean age 72 range; 57 to 94) evidenced a mean WBCC of 7,058 per mm³. Bootstrapping analysis of WBCC values demonstrated a significant (P = .012) difference (95% confidence interval of difference of mean, -806, 742; observed effect size, 1004) between groups.

CONCLUSIONS

The presence of CCAP demonstrated on PIs of older Caucasian men is associated with elevated WBCC. Concomitant presence of CCAP on PI and increased WBCC (≥7,800 per mm³) amplifies need for medical consultation before intravenous anesthesia and maxillofacial surgical procedures.

Two parameters reflect lipid-driven inflammatory state in acute coronary syndrome: atherogenic index of plasma, neutrophil-lymphocyte ratio

BACKGROUND

Atherosclerosis is a systemic, lipid-driven immune-inflammatory disease.

METHODS

We retrospectively reviewed institutional electronic medical records to seek chest pain patients who were suspicious of acute coronary syndrome (ACS) between January 2011 and December 2013. All the patients were identified by undergoing coronary angiography. On admission white blood cell and its subtypes were measured as part of the automated complete blood count and fasting venous blood samples were obtained and analyzed for lipids profiles used automated analysis.

RESULTS

A total of 376 consecutive patients with ACS were investigated. In the same period, 378 patients admitted with chest pain suspicious of ACS were also included in this study for control. Blood glucose, serum creatinine, white blood cell, neutrophil and monocyte were insignificantly higher in the ACS group. ACS group had higher total cholesterol and lower high density lipid-cholesterol. However, triglyceride and low density lipid-cholesterol were similar between ACS and control groups. Atherogenic index of plasma (AIP) was significantly higher in ACS group compared to control group (p = 0.029). Similarly, ACS group had higher neutrophil-lymphocyte ratio (NLR) than those in control group. In the subgroups, the NLR were significantly higher in the STEMI group (p < 0.001). However, AIP were similar between the three subgroups (p = 0.748).

CONCLUSIONS

Our data firstly investigated the lipid-driven inflammatory state in acute coronary syndrome through two easily feasible parameters. There suggest that there are higher AIP and NLR in the ACS patients. Moreover, ACS subgroups are all lipid-driven states, but inflammation levels are different in the entity ACS subgroups.

Association between Resting Heart Rate and Inflammatory Markers (White Blood Cell Count and High-Sensitivity C-Reactive Protein) in Healthy Korean People

Background

Inflammation is an important underlying mechanism in the pathogenesis of atherosclerosis, and an elevated resting heart rate underlies the process of atherosclerotic plaque formation. We hypothesized an association between resting heart rate and subclinical inflammation.

Methods

Resting heart rate was recorded at baseline in the KoGES-ARIRANG (Korean Genome and Epidemiology Study on Atherosclerosis Risk of Rural Areas in the Korean General Population) cohort study, and was then divided into quartiles. Subclinical inflammation was measured by white blood cell count and high-sensitivity C-reactive protein. We used progressively adjusted regression models with terms for muscle mass, body fat proportion, and adiponectin in the fully adjusted models. We examined inflammatory markers as both continuous and categorical variables, using the clinical cut point of the highest quartile of white blood cell count (≥7,900/mm³) and ≥3 mg/dL for high-sensitivity C-reactive protein.

Results

Participants had a mean age of 56.3±8.1 years and a mean resting heart rate of 71.4±10.7 beats/min; 39.1% were men. In a fully adjusted model, an increased resting heart rate was significantly associated with a higher white blood cell count and higher levels of high-sensitivity C-reactive protein in both continuous (P for trend <0.001) and categorical (P for trend <0.001) models.

Conclusion

An increased resting heart rate is associated with a higher level of subclinical inflammation among healthy Korean people.

Rapid and non-invasive diagnosis of coronary artery disease via clinical laboratory parameters and1H-NMR spectra of human blood plasma

Coronary artery disease (CAD), one of the most common fatal diseases in the world, was examinedviainvestigation of the¹H-NMR spectra of human blood plasma and clinical laboratory parameters with the aim of early disease diagnosis.

Superiority of total white blood cell count over other leukocyte differentials for predicting long-term outcomes in patients with non-ST elevation acute coronary syndrome

CONTEXT

Leukocytes have been found to be the predictor of outcome following acute coronary syndrome (ACS).

OBJECTIVE

We sought to determine the relationship between leukocyte differentials and developing major adverse cardiac events (MACE) in patients with non-ST elevation ACS (NSTE-ACS).

MATERIALS AND METHODS

A total of 490 consecutive patients were enrolled, and MACE incidence was evaluated at long-term follow-up period.

RESULTS

Total white blood cell (WBC) was higher in subjects occurring MACE. Moreover, elevated total WBC, ≥7.5 × 10(3)/µL, independently predicted MACE.

DISCUSSION AND CONCLUSION

Elevated admission total WBC can predict long-term MACE in NSTE-ACS patients better than other differentials.

A gender-specific blood-based gene expression score for assessing obstructive coronary artery disease in nondiabetic patients: results of the Personalized Risk Evaluation and Diagnosis in the Coronary Tree (PREDICT) trial

BACKGROUND

Currently available noninvasive tests to risk stratify patients for obstructive coronary disease result in many unnecessary cardiac catheterizations, especially in women. We sought to compare the diagnostic accuracy of presenting symptoms, noninvasive test results, and a gene expression score (GES) in identifying obstructive coronary artery disease (CAD) according to gender, using quantitative coronary angiography as the criterion standard.

METHODS

The PREDICT trial is a prospective multicenter observational study designed to develop and validate gene expression algorithms to assess obstructive CAD, defined as at least one ≥50% diameter stenosis measured by quantitative coronary angiography. Patients referred for diagnostic cardiac catheterization with suspected but previously unknown CAD were enrolled. Noninvasive myocardial perfusion imaging (MPI) was available in 60% of patients. The GES, comprising gender-specific age functions and 6 gene expression terms containing 23 genes, was performed for all patients.

RESULTS

A total of 1,160 consecutive patients (57.6% men and 42.4% women) were enrolled in PREDICT. The prevalence of obstructive CAD was 46.7% in men and 22.0% in women. Chest pain symptoms were a discriminator of obstructive CAD in men (P < .001) but not in women. The positive predictive value of MPI was significantly higher in men (45%) than in women (22%). An abnormal site-read MPI was not significantly associated with obstructive or severity of CAD. The GES was significantly associated with a 2-fold increase in the odds of obstructive CAD for every 10-point increment in the GES and had a significant association with all measures of severity and burden of CAD. By multivariable analysis, GES was an independent predictor of obstructive CAD in the overall population (odds ratio [OR] 2.53, P = .001) and in the male (OR 1.99, P = .001) and female (OR 3.45, P = .001) subgroups separately, whereas MPI was not.

CONCLUSIONS

Commonly used diagnostic approaches including symptom evaluation and MPI performed less well in women than in men for identifying significant CAD. In contrast, gender-specific GES performed similarly in women and men. Gene expression score offers a reliable diagnostic approach for the assessment of nondiabetic patients and, in particular, women with suspected obstructive CAD.

Impulsivity-related traits are associated with higher white blood cell counts

A chronically elevated white blood cell (WBC) count is a risk factor for morbidity and mortality. The present research tests whether facets of impulsivity-impulsiveness, excitement-seeking, self-discipline, and deliberation-are associated with chronically elevated WBC counts. Community-dwelling participants (N = 5,652) from Sardinia, Italy, completed a standard personality questionnaire and provided blood samples concurrently and again 3 years later. Higher scores on impulsivity, in particular impulsiveness and excitement-seeking, were related to higher total WBC counts and higher lymphocyte counts at both time points. Impulsiveness was a predictor of chronic inflammation: for every standard deviation difference in this trait, there was an almost 25% higher risk of elevated WBC counts at both time points (OR = 1.23, 95% CI = 1.10-1.38). These associations were mediated, in part, by smoking and body mass index. The findings demonstrate that links between psychological processes and immunity are not limited to acute stressors; stable personality dispositions are associated with a chronic inflammatory state.

Elevated resting heart rate is associated with white blood cell count in middle-aged and elderly individuals without apparent cardiovascular disease

We investigated the association between resting heart rate (HR) and inflammation markers in a healthy population. White blood cell (WBC) count was used as a surrogate marker of subclinical inflammation. Smoking status, body mass index, resting HR, high-density lipoprotein cholesterol, triglycerides, uric acid, and glycated hemoglobin were significantly associated with WBC in both men and women. Blood pressure and fasting plasma glucose levels, however, were associated with WBC only in women. Logistic regression analysis indicated that for every 10 beats per minute increase in HR, the odds ratio of an increase in the WBC was approximately 1.3 in both men and women. These findings indicate the clinical significance of resting HR for identifying individuals at risk of subclinical inflammation and a future cardiovascular event.

Association between laboratory markers and presence of coronary artery disease

The aim of this paper is to elucidate the relation between laboratory markers and coronary artery disease (CAD).

METHODS

The study involved 1254 consecutive patients with suspected or known CAD referred for coronary angiography. The blood samples including blood cell count, C-reactive protein, fibrinogen, uric acid, creatinine, and lipid spectrum were obtained after overnight fasting. One hundred and thirty-three patients were excluded due to incomplete records or inacceptable laboratory values. Differences among groups were tested with one-way ANOVA and Bonferroni post-hoc test for continuous variables and with chi-square test for categorical variables. Univariate and multivariate logistic regression was adopted for the analysis of risk factors and development of models for classification of patients into clinical categories.

RESULTS

The linear logistic regression showed association of patient's biochemical markers with the presence of disease. Both acute and chronic CAD were associated with leukocyte count (Odds ratios 1.45 and 1.26), CRP (1.13; 1.05), fibrinogen (4.23; 1.95), uric acid (1.27; 1.38), creatinine (1.04; 1.04), HDL cholesterol (0.07; 0.12), triglycerides (1.4; 1.52) and glucose (1.56; 1.39). Presence of insignificant atherosclerosis was influenced only by fibrinogen (OR 1.73), creatinine (1.02), HDL cholesterol (0.5) and glucose level (1.23). There was no difference between one- and multivessel disease in laboratory values.

CONCLUSION

Leukocyte count, CRP level, triglycerides and uric acid are associated with the presence of both acute and chronic ischaemic heart disease, but not with number of stenosed vessels. In addition, glycemia, HDL cholesterol and namely fibrinogen and creatinine have relation to occurence of insignificant atherosclerosis.

Lack of association between plasma myeloperoxidase levels and angiographic severity of coronary artery disease in patients with acute coronary syndrome

OBJECTIVE

To evaluate the association between plasma myeloperoxidase (MPO) levels and angiographic severity of coronary atherosclerotic lesions in patients with non-ST elevation acute coronary syndrome (ACS).

DESIGN AND METHODS

This cross-sectional study examined high-risk ACS patients who underwent coronary angiography within 72 h of the onset of symptoms by measuring their plasma MPO levels after sheath insertion. Gensini score was used to evaluate angiographic severity of coronary artery disease.

RESULTS

A total of 48 patients were included in the study. Median MPO levels and Gensini scores were 6.9 ng/mL (4.4-73.5 ng/mL) and 10 (0-87.5), respectively. Spearman's correlation coefficient did not show a significant association between MPO levels and Gensini scores (r (s) = 0.2; p = 0.177). There was no correlation between MPO and age, hypertension, diabetes, leukocyte count, troponin I, CK-MB ≥ 2 × ULN (upper limit of normal), TIMI risk score ≥ 4 and Gensini score in the multivariate analysis.

CONCLUSION

Our findings indicate that MPO expression is not associated with anatomical severity of coronary lesions in ACS.

Smoking and atherosclerotic cardiovascular disease: part II: role of cigarette smoking in cardiovascular disease development

Potential mechanisms and biomarkers of atherosclerosis related to cigarette smoking - a modifiable risk factor for that disease - are discussed in this article. These include smoking-associated inflammatory markers, such as leukocytes, high-sensitivity C-reactive protein, serum amyloid A, ICAM-1 and IL-6. Other reviewed markers are indicative for smoking-related impairment of arterial endothelial function (transcapillary leakage of albumin, inhibition of endogenous nitric oxide synthase activity and reduced endothelium-dependent vasodilation) or point to oxidative stress caused by various chemicals (cholesterol oxidation, autoantibodies to oxidized low-density lipoprotein, plasma levels of malondialdehyde and F(2)-isoprostanes and reduced antioxidant capacity). Smoking enhances platelet aggregability, increases blood viscosity and shifts the pro- and antithrombotic balance towards increased coagulability (e.g., fibrinogen, von Willebrand factor, ICAM-1 and P-selectin). Insulin resistance is higher in smokers compared with nonsmokers, and hemoglobin A1c is dose-dependently elevated, as is homocysteine. Smoke exposure may influence the kinetics of markers with different response to transient or chronic changes in cigarette smoking behavior.

Leukocytosis as a predictor for non-infective mortality and morbidity

Leukocytosis (raised concentration of white cells in the blood) is commonly associated with infection or inflammation, but can occur in a wide variety of other conditions. Leukocytosis has also been linked with increased mortality and morbidity in a number of studies. We have systematically reviewed the relevant literature, which clearly demonstrates an association between leukocytosis and mortality-particularly due to cardiovascular or cerebrovascular causes. The mechanisms of this effect are uncertain but, when combined with other markers predictive of death, leukocytosis may contribute to modelling systems to predict in-patient mortality risk.

Short term effects of reduced exposure to cigarette smoke on white blood cells, platelets and red blood cells in adult cigarette smokers

Previous studies indicate that cigarette smokers have a 5-30% higher white blood cell counts (WBC) compared to non-smokers and higher red blood cell counts.

METHODS

This study was to pool hematology data from three similar studies and analyze the data for effects on WBC, its subpopulations, platelets, red blood cell count (RBC) and hematocrit in adult cigarette smokers three days after using an electrically heated cigarette smoking system (EHCSS) as a potential reduced exposure product (PREP) or no-smoking compared to smoking a conventional cigarette.

RESULTS

Lower exposure to cigarette smoke in adult, long term smokers, by using an EHCSS or stopping smoking, leads to statistically significant decreases of up to 9% in WBC, neutrophils, lymphocytes, platelets, RBC and hematocrit within three days. Switching from CC-smoking to EHCSS-smoking or no-smoking resulted in lower WBC and vice versa within 3 days.

CONCLUSION

This clinical model may be used as a screening tool to find new technologies that could provide insights on changes in inflammation resulting from the change in cigarette smoke.

Neutrophil to lymphocyte ratio as a predictor of long-term mortality in African Americans undergoing percutaneous coronary intervention

BACKGROUND

Neutrophil to lymphocyte ratio (N/L ratio) has been shown to predict long-term mortality in patients undergoing percutaneous coronary intervention (PCI). African Americans have been shown to have lower mean neutrophil counts compared to whites. The usefulness of the N/L ratio in predicting long-term mortality in African Americans undergoing PCI is unknown.

METHODS

We evaluated a total of 372 African American patients (327 patients with lower N/L ratio [<3.5] and 45 patients with higher N/L ratio [> or =3.5]) who underwent PCI during January 2003 to August 2005. The primary endpoint was all-cause mortality at a median follow-up to 3.6 years.

RESULTS

During the median ( +/- SD) follow-up period of 3.6 +/- 1 years, there were a total of 48 deaths. The mortality rate was 10.4% in the group with a lower N/L ratio and 31.1% in the group with a higher N/L ratio (unadjusted p < 0.001). After adjustment for covariates with significant impact on mortality, N/L ratio was still a strong and independent predictor of long-term mortality with a hazard ratio (HR) of 2.1 (95% confidence interval [CI]: 1.1-4; p = 0.02). N/L ratio was also found to be a strong and independent predictor of long-term mortality even when analyzed as a categorical variable with 3 groups (HR of 0.39 for lower tertile compared to the upper tertile, 95% CI: 0.19-0.81; p = 0.012) and as a continuous variable (p = 0.002).

CONCLUSION

N/L ratio is a powerful independent predictor of long-term mortality in African Americans undergoing PCI.

Role of myeloperoxidase as predictor of systemic inflammatory response syndrome in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

Elevated cytokine levels have been reported after ischemia/reperfusion injury and might cause a systemic inflammatory response syndrome (SIRS) after primary percutaneous coronary intervention (PPCI). High myeloperoxidase (MPO) levels are reported to be a risk factor for early cardiac events in patients with acute coronary syndrome. Its role as a predictor of SIRS in patients with ST-segment elevation myocardial infarction treated with PPCI is unclear. Therefore, the aim of the present study was to investigate the role of MPO as a predictor of SIRS in patients with ST-segment elevation myocardial infarction treated with PPCI. A total of 250 patients with ST-segment elevation myocardial infarction treated with PPCI were admitted to our coronary care unit. The serum MPO levels were measured at admission using a commercially available enzyme-linked immunosorbent assay. Of the 250 patients, 47 developed SIRS within 48 hours after their admission to the coronary care unit; 10 of these patients were excluded from analysis because of the suspicion of sepsis. The remaining 203 patients had no SIRS during their coronary care unit stay. Compared to patients without SIRS, those with SIRS had greater serum MPO values (81.35 +/- 18.07 vs 67.03 +/- 16.98 ng/ml, p <0.0001) after PPCI. After controlling for different baseline clinical, laboratory, and angiographic variables, the baseline serum MPO levels were an independent predictor of SIRS (odds ratio 4.2, 95% confidence interval 1.9 to 8.4, p <0.001). In conclusion, our results have demonstrated that MPO is an independent predictor of SIRS after PPCI, suggesting a new clue for the interpretation of this phenomenon.

Relation of baseline serum potassium levels to angiographic findings in patients with known or suspected coronary artery disease

BACKGROUND

In experimental animal studies, potassium has been demonstrated to protect against the development of atherosclerosis through a variety of mechanisms. Data regarding the role of potassium in the development of human atherosclerosis are sparse. The objective of this study was to determine the association between plasma potassium levels and angiographically defined coronary artery disease (CAD).

METHODS

In a cohort of 389 male patients undergoing coronary angiography for a variety of clinical indications, the association between baseline serum potassium levels and the extent of angiographically defined atherosclerosis was analyzed. Adjustments were made for clinical and laboratory variables (including inflammatory markers) known to be associated with atherosclerosis.

RESULTS

By multivariate logistic regression analysis, baseline serum potassium levels were an independent predictor of the presence of multivessel disease (odds ratio (OR) 1.31, 95% confidence interval (CI) 1.01-1.69; P < 0.05). In addition, in the non-myocardial infarction subpopulation of patients, serum potassium was also an independent predictor of the presence of multivessel disease by multivariate logistic regression analysis (OR 1.34, 95% CI, 1.02-1.76; P < 0.05). In the myocardial infarction (MI) subpopulation, serum potassium was not a predictor of multivessel disease, possibly due to the confounding effect of hypokalemia known to be present during MI.

CONCLUSIONS

These data demonstrate that a simple baseline serum potassium level is independently associated with the presence of multivessel disease, even in the context of clinical CAD risk factors and other established inflammatory markers.

Significance of white blood cell count and its subtypes in patients with acute coronary syndrome

BACKGROUND

Inflammation plays a role in the pathogenesis of coronary atherosclerosis.

MATERIALS AND METHODS

Six hundred twenty-three patients with acute coronary syndrome (ACS) referred for coronary angiography for the first time in our hospital were enrolled in this study. White blood cell and its subtypes were measured on admission. The study population was divided into three groups based on total white blood cell count and followed up. Clinical end points were major adverse cardiac events (MACEs), including cardiogenic death, stroke, heart failure, non-fatal myocardial infarction, rehospitalization for angina pectoris.

RESULTS

The median age was 68 years (range 31-92) and 64.2% of the patients were men. The median white blood cell count was 6.48 x 10(9 )L(-1) (range 2.34-27.10 x 10(9 )L(-1)). The median follow-up duration was 21 months (range 1-116) and MACEs occurred in 167 patients. The multivariable Cox proportional hazards regression model revealed that neutrophil count [Relative risk = 1.098, 95% Confidence interval (CI): 1.010-1.193, P = 0.029) was a risk factor for MACEs. The logistic regression model revealed that lymphocyte count [Odds ratio (OR) = 1.075, 95% CI: 1.012-1.142, P = 0.018] and monocyte count (OR = 8.578, 95% CI: 2.687-27.381, P < 0.001) were predictive of stenosis >or= 75%; Neutrophil proportion (OR = 1.060, 95% CI: 1.007-1.115, P = 0.026), monocyte count (OR = 12.370, 95% CI: 1.298-118.761, P = 0.029) were predictive of the presence of multivessel disease. Kaplan-Meier analysis of short-term and long-term cumulative survival showed no significant statistical differences among three groups.

CONCLUSIONS

Neutrophil count adds prognostic information to MACEs in ACS. Monocyte count and lymphocyte count are predictive of severity of coronary atherosclerosis.

Relation of baseline plasma phospholipid transfer protein (PLTP) activity to left ventricular systolic dysfunction in patients referred for coronary angiography

Phospholipid transfer protein (PLTP) is an important modulator of phospholipid transfer and exchange among proteins. It also plays a role in inflammation and oxidative stress. Accordingly, PLTP has been implicated in the development of atherosclerosis. Left ventricular (LV) systolic dysfunction is common in patients with atherosclerosis, and both inflammation and oxidative stress have also been implicated in its development and progression. The goal of the present study was to examine the relation between plasma PLTP activity and LV systolic function. Baseline plasma PLTP activity was measured in 389 male patients referred for coronary angiography for a variety of indications. Detailed clinical, angiographic and laboratory characteristics were available for the patients. Compared to those patients with normal LV function (defined as an ejection fraction of >or=55% on ventriculography), patients with any degree of LV dysfunction had elevated PLTP activity (median PLTP 17.8 pmol/microl/h versus 15.9 pmol/microl/h, p=0.0038). Using multivariate analysis, and adjusting for a variety of confounding variables known to affect both LV function and PLTP activity, PLTP activity was an independent predictor of the presence of any left ventricular systolic dysfunction in the entire population (OR 1.47, 95% CI 1.12-1.93, p=0.0052). Furthermore, PLTP activity was an independent predictor of the presence of LV dysfunction in both patients with and without myocardial infarction on presentation (OR 2.39, 95% CI 1.18-4.86, p=0.0161 and OR 1.41, 95% CI 1.05-1.89, p=0.0206, respectively). In conclusion, PLTP activity may represent a novel marker of LV systolic dysfunction in patients with known or suspected coronary artery disease.

Review: Endothelial progenitor cells: markers of vascular reparative capacity

Assessment of the propensity for vascular events has been based on measurement of risk factors predisposing one to vascular injury. These assessments are based on the strong associations between risk factors such as hypertension, cholesterol levels, smoking, and diabetes which were first described almost a half century ago. The more recent discovery of the relationship between ongoing inflammation and clinical outcomes has led to a variety of blood-based assays which may impart additional knowledge about an individual's propensity for future cardiovascular events. Vascular health is now better represented as a balance between ongoing injury and resultant vascular repair, mediated at least in part by circulating endothelial progenitor cells. To date, one's risk for vascular events has focused exclusively on assessing propensity for vascular damage, either by assessing conventional risk factors which were initially identified over half a century ago, or more recently by assessing markers of inflammation and other circulating factors which area related to subsequent clinical events. Circulating endothelial progenitor cells play important roles in accelerating endothelialization at areas of vascular damage, and EPC enumeration is a viable strategy for assessing reparative capacity. To date, EPC numbers have been correlated with the numbers of cardiovascular risk factors, extent of coronary disease, and future cardiovascular events. Given that EPC enumeration and functional characterization represent the only assessment of the reparative side of the balance between damage and renovation, this technique may offer independent and different assessment of propensity to cardiovascular injury, greatly improving risk stratification of patients.

Prognostic value of admission myeloperoxidase levels in patients with ST-segment elevation myocardial infarction and cardiogenic shock

Inflammation plays a critical role in acute myocardial infarction. One inflammatory marker is myeloperoxidase (MPO). Its role as a predictor of in-hospital death in patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) is unclear. Therefore, the aim of this study was to investigate the role of MPO as a predictor of in-hospital death in patients with STEMIs presenting with CS and treated with primary percutaneous coronary intervention. In 38 consecutive patients with CS complicating STEMIs who were treated with primary percutaneous coronary intervention, serum MPO levels were measured at coronary care unit admission using a commercially available enzyme-linked immunosorbent assay. The primary study end point was in-hospital cardiac death. Among the 38 patients included in the study, 20 died during their coronary care unit stays, whereas 18 survived. Compared with patients who survived, patients who died showed, at coronary care unit admission, higher serum MPO levels (81 +/- 28 vs 56 +/- 23 ng/ml, p <0.006). After controlling for different baseline clinical, laboratory, and angiographic variables, baseline serum MPO level was an independent predictor of in-hospital mortality on multivariate analysis (odds ratio 3.9, 95% confidence interval 1.8 to 7.5, p <0.001). In conclusion, admission MPO concentration is an independent predictor of in-hospital mortality in patients with STEMIs presenting with CS.

Inflammation and cardiovascular events in individuals with and without chronic kidney disease

Inflammation and chronic kidney disease predict cardiovascular events. Here we evaluated markers of inflammation including fibrinogen, albumin and white blood cell count in individuals with and without stages 3-4 chronic kidney disease to assess inflammation as a risk factor for adverse events, the synergy between inflammation and chronic kidney disease, and the prognostic ability of these inflammatory markers relative to that of C-reactive protein. Using Atherosclerosis Risk in Communities and Cardiovascular Health Study data, inflammation was defined by worst quartile of at least 2 of these 3 markers. In Cox regression models, inflammation was assessed as a risk factor for a composite of cardiac events, stroke and mortality as well as components of this composite. Among 20 413 patients, inflammation was identified in 3594 and chronic kidney disease in 1649. In multivariable analyses, both inflammation and chronic kidney disease predicted all outcomes, but their interaction was non-significant. In 5597 patients with C-reactive protein levels, inflammation and elevated C-reactive protein had similar hazard ratios. When focusing only on individuals with the worst quartile of white cell count and albumin, results remained consistent.

Myeloperoxidase level in patients with stable coronary artery disease and acute coronary syndromes

BACKGROUND

No studies have measured plasma myeloperoxidase (MPO) across the entire spectrum of patients with coronary artery disease (CAD). The aim of the study was to compare MPO level across the entire spectrum of CAD, to assess the accuracy of MPO in predicting acute coronary syndromes and to define independent correlates of MPO level.

DESIGN

This case-control study included 874 patients with angiographically proven CAD. Cases included 680 patients with CAD (382 patients with stable CAD, 107 patients with non-ST-segment elevation acute coronary syndromes and 191 patients with ST-segment elevation acute myocardial infarction). Controls included 194 subjects with normal coronary angiograms. MPO was measured using an enzyme immunoassay before angiography and heparin administration.

RESULTS

MPO level [median (25th-75th percentiles)] was 74.5 (52.5-135.3) microg L(-1) in cases vs. 61.2 (44.6-80.9), microg L(-1) in controls (P < 0.001). MPO level was 61.2 (47.5-85.8), microg L(-1) in patients with stable CAD, 99.2 (62.2-154.9), microg L(-1) in patients with non-ST-segment elevation acute coronary syndromes and 129.5 (72.2-216.0) microg L(-1) in patients with acute myocardial infarction (P < 0.001). Elevated MPO level was associated with acute coronary syndromes with an area under receiver operating characteristic (ROC) curve of 0.731 (95% confidence interval 0.692-0.770; P < 0.001). Independent correlates of MPO level were acute coronary syndrome (P < 0.001), high-sensitivity C-reactive protein (P = 0.007), creatinine (P = 0.026), left ventricular ejection fraction (P = 0.027, negative association) and smoking (P = 0.028).

CONCLUSIONS

MPO level is elevated in patients with CAD and higher levels of MPO were found with progression of CAD from stable CAD to non-ST-segment elevation acute coronary syndromes and to acute myocardial infarction.

Usefulness of the serum complement component C4 as a predictor of stroke in patients with known or suspected coronary artery disease referred for coronary angiography

The complement system has been implicated in the pathogenesis of atherosclerosis. In addition, complement activation and complement-mediated brain injury have been found in a variety of central nervous system diseases, including stroke. However, there are limited data about the value of complement components for prediction of stroke. Complement C3 and C4 levels, in addition to a variety of established biomarkers, were measured in 389 men with known or suspected coronary artery disease referred for coronary angiography for a variety of indications at a Veterans Affairs Medical Center. Patients were followed prospectively for the development of stroke, which was defined and classified according to criteria of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). All strokes were confirmed with magnetic resonance imaging or computed tomography. For the 97% of patients in whom 24-month follow-up data were available, there were 23 strokes (5.9%). By multivariate Cox proportional hazard analysis, complement C4 was an independent predictor of stroke, with a hazard ratio of 1.57 (95% confidence interval 1.03 to 2.39, p = 0.0358). The 24-month stroke-free survival rate for the patients whose complement C4 levels were equal to or below the median value for the entire cohort was 96.1% compared with 90.1% for patients whose complement C4 levels were above the median value, p = 0.0127 by log rank test). In conclusion, in a cohort of men across a spectrum of risk referred for coronary angiography, a single baseline determination of serum complement C4 level is an independent predictor of the future development of stroke.

Usefulness of baseline plasma myeloperoxidase levels as an independent predictor of myocardial infarction at two years in patients presenting with acute coronary syndrome

Baseline plasma myeloperoxidase (MPO) levels have been shown to independently predict the early risk of myocardial infarction (MI) in patients presenting with chest pain. In addition, baseline MPO levels have been demonstrated to predict the development of adverse cardiac events up to 6 months after an acute coronary syndrome (ACS). However, in contrast to other biomarkers, there are no data about the long-term independent predictive value of baseline MPO values in patients with ACS. The present study investigated the long-term prognostic significance of baseline MPO levels in a well-characterized cohort of 193 men with ACS who were referred for coronary angiography at a Veterans Administration Medical Center. All patients were followed prospectively for the development of death and MI, and follow-up data were available for all patients at 24 months. After controlling for different baseline clinical, laboratory, and angiographic variables, baseline plasma MPO values were a strong and independent predictor of MI at 24 months by multivariate analysis. Using the median MPO value of the entire cohort of patients (i.e., 20.34 ng/ml) as a prespecified cutoff, the MI-free survival at 24 months for the group whose baseline MPO values were < or =20.34 ng/ml was 88% compared with 74% in those whose values were >20.34 ng/ml (p = 0.0249 by log-rank test). In conclusion, these data demonstrate that baseline MPO levels independently predict MI at 2 years in patients with ACS.

Cytotoxic T Lymphocyte Antigen 4 Gene Polymorphism Associated With ST-Segment Elevation Acute Myocardial Infarction

BACKGROUND

Cytotoxic T lymphocyte antigen 4 (CTLA-4) is a particularly important molecule in down-regulating T-cell expansion and cytokine production. The purpose of the present study was to determine the frequency distribution of an A/G single nucleotide polymorphism at position 49 in exon 1 of the CTLA-4 gene, which may be a functional related-genetic risk marker for the development of ST-segment elevation (ST-se) acute myocardial infarction (AMI).

METHODS AND RESULTS

A total of 503 consecutive patients, consisting of 250 ST-se AMI patients undergoing primary coronary angioplasty (group 1), 203 angina pectoris patients undergoing elective coronary angioplasty (group 2) and 50 patients with chest pain and normal coronary angiographic findings (group 3), were enrolled in the present study. The frequency of the G/G genotype was significantly higher in group 1 (53.2%) than in groups 2 (33.0%) and 3 (36.0%) (p=0.0005). In group 1, patients with a G/G genotype had significantly higher levels of high-sensitivity C-reactive protein and white blood cell counts, and much higher incidences of multi-vessel disease, greater lesion lengths, advanced congestive heart failure (>or=class 3) and 30-day mortality, than patients with G/A or A/A genotypes (p values<0.05 in all cases). Multivariate analysis of the enrolled baseline variables (age, gender, diabetes mellitus, smoking, hypertension and hypercholesterolemia) and the genotypes (G/G, A/G and A/A) demonstrated that G/G genotype is the only independent predictor of development of AMI (p<0.0001).

CONCLUSION

The G/G genotype polymorphism of the CTLA-4 gene is associated with increased risk of AMI.