Association of inflammatory biomarkers and cardiac troponin I with multifocal activation of coronary artery tree in the setting of non-ST-elevation acute myocardial infarction

C-reactive protein and uric acid roles in distinguishing ST-segment elevation myocardial infarction from non-ST-elevation acute coronary syndrome

Acute coronary syndrome (ACS) is defined as a range of conditions which the blood flow to the heart was reduced or stopped. This disorder is correlated to a systemic inflammatory response and some biochemical factors. Therefore, the aim of this study was investigations of serum C-reactive protein (CRP) and uric acid levels in ST-segment elevation myocardial infarction (STEMI) and non-ST-elevation ACS (NSTE ACS), as common subtypes of ACS. Patients with ACS (n = 140) were assessed with coronary arteriography and divided into STEMI and NSTE ACS groups. The serum levels of hs-CRP and uric acid were investigated using a routine clinical chemistry analyzer. Patients with STEMI showed a significant increase in uric acid level compared to those with NSTE ACS (P < .0001). Other data indicated that hs-CRP level in patients with STEMI was significantly higher than individuals with NSTE ACS (P < .0001). Modeling analysis revealed that the increased levels of acid uric and hs-CRP in patients with STEMI were independent of the effects of age, gender, background diseases, and familial history (P < .001). The current study provides further evidence to indicate that hs-CRP and uric acid may be considered as biofactors for comparing STEMI from NSTE ACS and determining disease outcome.

Relationship of Troponin I with Neutrophil Lymphocyte Ratio and Serum Amyloid A in Acute Coronary Syndrome

Abstract Introduction: Acute coronary syndrome (ACS) is the leading cause of death in the world. Acute myocardial infarction can initiate an acute inflammatory process by inducing pro-inflammatory cytokines at the cellular level measured by NLR, at the biomolecular level characterized by SAA production in liver. The relationship of elevated troponin I levels as a marker of myocardial necrosis with NLR and SAA as inflammatory markers need further discussion. The purpose of this study was to determine the relationship between cardiac necrosis markers and inflammatory parameters in ACS. Methods: An analytic observational study with a cross-sectional approach was conducted from March to May 2019. This study involved 32 patients with ACS at the Emergency Department of Dr.Kariadi Hospital, with the onset of attacks of 4-6 hours which met the inclusion and exclusion criteria. Examination of troponin I level was done using the ELFA method, NLR value was measured using a hematology analyzer, and SAA level was measured using the ELISA method. Statistical test was done using Spearman correlation. Value of p < 0.05 was considered significant. Results: The median (min-max) of troponin I, NLR, and SAA values were 0.617 (0.001-40,000) μg/L, 4.92 (1.38-18.16) and 40.454 (5.879-66.059) μg/ml, respectively. The correlation of troponin I level with NLR and SAA were r=0.180, p=0.243 and r=0.655, p=0.000. Conclusions: There was a significant positive moderate relationship between troponin I level and SAA which could be used as a marker of acute inflammation in ACS, whereas cell inflammation marker of NLR did not provide a significant meaning. Keywords: ACS, NLR, SAA, troponin

Comparison of prognostic significance between serum fibrinogen and Global Registry of Acute Coronary Events score for prognosis of patients with non-ST-elevation acute coronary syndromes undergoing percutaneous coronary intervention

OBJECTIVE

An elevated fibrinogen level has been demonstrated to be a predictor of adverse coronary heart disease outcome. This study aimed to assess whether fibrinogen is a useful marker to predict the prognosis of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). Additionally, the prognostic accuracy of fibrinogen level was compared with that of the Global Registry of Acute Coronary Events (GRACE) score.

METHODS

A total of 1211 patients with NSTE-ACS undergoing PCI were analyzed in a prospective cohort study. The enrolled patients were divided into a low fibrinogen group (n = 826, fibrinogen ≤ 3.49 mg/dl) and a high fibrinogen group (n = 385, fibrinogen > 3.49 mg/dl) based on a receiver operating characteristic (ROC) curve. The clinical endpoints were death and death/nonfatal reinfarction. An ROC curve analysis was performed and the area under the curve with a 95% confidence interval (CI) was derived and compared with those for the GRACE score to determine the diagnostic value of the serum fibrinogen level.

RESULTS

Multivariate analysis showed that an elevated baseline fibrinogen level was an independent predictor of death/nonfatal reinfarction (hazard ratio = 1.498, 95% CI: 1.030-2.181, P = 0.035). The prognostic performance of fibrinogen was equivalent to that of the GRACE system in predicting clinical endpoints (C-statistic: z = 1.486, P = 0.14).

CONCLUSION

Fibrinogen is an independent predictor of death/nonfatal reinfarction in patients with NSTE-ACS undergoing PCI, and its accuracy is similar to that of the GRACE system.

Predictive Value of C-Reactive Protein to Albumin Ratio in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention

The present study aimed to examine the association of C-reactive protein to albumin ratio (CAR) with short-term major adverse cardiac events (MACEs) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). We included 539 STEMI patient treated with pPCI in this study. Patients were divided into 2 groups according to MACE development. Patients with MACE had higher CAR than those without (1.18 [0.29-1.99] vs 0.21 [0.09-0.49], P < .001). Multivariate analysis showed that The Global Record for Acute Coronary Events score, Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score, glucose and CAR (odds ratio:1.326, 95% CI: 1.212-1452, P < .001) were independent predictors of MACE. The CAR may be proven useful for risk stratification in STEMI patients undergoing pPCI.

Association between inflammation-based prognostic scores and in-hospital outcomes in elderly patients with acute myocardial infarction

Objective

Emerging evidence suggests that systemic inflammation is a predictor of poor prognosis in acute myocardial infarction (AMI). In this study, we sought to assess whether inflammation-based prognostic scores are associated with in-hospital outcomes in elderly patients with AMI.

Methods

In this retrospective study, patients who were over 75-years-old and met the diagnostic criteria for AMI were consecutively recruited from January 1, 2016, to March 31, 2019. Logistic regression and receiver-operating characteristic (ROC) analyses were performed to evaluate the predictive value of the inflammation-based Glasgow Prognostic Score (GPS), Prognostic Index (PI) and Prognostic Nutritional Index (PNI).

Results

A total of 273 patients were enrolled. The incidence of major cardiovascular adverse events (MACEs) and mortality during hospitalization increased significantly with increasing GPS and PI scores. Multiple logistic regression showed that the GPS was independently associated with MACEs (score 1, RR: 6.711, 95% CI: 1.409–31.968; score 2, RR: 14.063, 95% CI: 3.018–65.535) and mortality (score 1, RR: 8.656, 95% CI: 1.068–70.126; score 2, RR: 10.549, 95% CI: 1.317–84.465). The PI was also independently predictive of MACEs (score 2, RR: 5.132, 95% CI: 1.451–18.148). No significant difference was observed in the PNI between patients with different in-hospital outcomes. When in-hospital MACEs were used as an endpoint, the area under the curve (AUC) of the GPS was 0.740 (95% CI 0.678–0.802), and the AUC of the PI was 0.703 (95% CI 0.634–0.773). When mortality was used as an endpoint, the AUC of the GPS was 0.677 (95% CI 0.602–0.753), and the AUC of the PI was 0.667 (95% CI 0.577–0.757).

Conclusion

The severity of systemic inflammation is a strong predictor of poor prognosis in elderly patients with AMI. Among these three inflammation-based prognostic scores, the GPS has a better predictive value than the PI and PNI for in-hospital MACEs and mortality.

The Effect of Thyroid Stimulating Hormone Level Within the Reference Range on In-Hospital and Short-Term Prognosis in Acute Coronary Syndrome Patients

Background and objectives: Despite being within the normal reference range, changes in thyroid stimulating hormone (TSH) levels have negative effects on the cardiovascular system. The majority of patients admitted to hospital with acute coronary syndrome (ACS) are euthyroid. The aim of this study was to investigate the effect of TSH level on the prognosis of in-hospital and follow-up periods of euthyroid ACS patients. Materials and Methods: A total of 629 patients with acute coronary syndrome without thyroid dysfunction were included in the study. TSH levels of patients were 0.3–5.33 uIU/mL. Patients were divided into three TSH tertiles: TSH level between (1) 0.3 uIU/mL and <0.90 uIU/mL (n = 209), (2) 0.90 uIU/mL and <1.60 uIU/mL (n = 210), and (3) 1.60 uIU/mL and 5.33 uIU/mL (n = 210). Demographic, clinical laboratory, and angiographic characteristics were compared between groups in terms of in-hospital and follow-up prognosis. Results: Mean age was 63.42 ± 12.5, and 73.9% were male. There was significant difference between tertiles in terms of TSH level at admission (p < 0.001), the severity of coronary artery disease (p = 0.024), in-hospital mortality (p < 0.001), in-hospital major hemorrhage (p = 0.005), total adverse clinical event (p = 0.03), follow-up mortality (p = 0.022), and total mortality (p < 0.001). In multivariate logistic regression analysis, the high–normal TSH tertile was found to be cumulative mortality increasing factor (OR = 6.307, 95%; CI: 1.769–22.480; p = 0.005) during the 6-month follow-up period after hospitalization and discharge. Conclusions: High–normal TSH tertile during hospital admission in euthyroid ACS patients is an independent predictor of total mortality during the 6-month follow-up period after hospitalization and discharge.

Inflammation-based Glasgow Prognostic Score in patients with acute ST-segment elevation myocardial infarction: A prospective cohort study

The inflammation-based Glasgow Prognostic Score (GPS), which involves C-reactive protein and serum albumin levels, has been reported to be a strong independent predictor of mortality in many cancers. This study aimed to investigate whether the GPS is associated with mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).In this study, 406 consecutive patients with STEMI at our emergency department (ED) who were undergoing pPCI were prospectively enrolled and assigned a GPS of 0, 1, or 2. Kaplan-Meier survival and multivariable Cox regression analyses were used to evaluate the associations between the GPS and long-term mortality.Twenty-three patients (5.7%) died at the hospital, and 37 (9.7%) died during follow-up (14.4 [9.3-17.6] months). Compared with patients with a lower GPS, those with a higher GPS had significantly higher in-hospital mortality (GPS = 0 vs GPS = 1 vs GPS = 2: 3.3% vs 6.3% vs 28.0%, P < .001), follow-up mortality (4.6% vs 14.3% vs 55.6%, P < .001), and cumulative mortality (9.6% vs 21.1% vs 71.1%, P < .001). Multivariable Cox regression analysis revealed that in patients with a GPS of 1 and 2 (versus 0), the multivariable adjusted hazard ratios (HR) for all-cause mortality were 2.068 (95% CI: 1.082-3.951, P = .028) and 8.305 (95% CI: 4.017-17.171, P < .001), respectively, after controlling for all of the confounding factors. Subgroup analysis showed that a higher GPS was associated with an increased risk of cumulative mortality in the different subgroups.The GPS on admission may be useful for stratifying the risk of adverse outcomes in patients with STEMI undergoing pPCI in the ED.

Admission Endocan Level may be a Useful Predictor for In-Hospital Mortality and Coronary Severity Index in Patients With ST-Segment Elevation Myocardial Infarction

We assessed the prognostic role of serum endocan level in patients with ST-segment elevation myocardial infarction (STEMI) and compared the results with a normal coronary angiography group. A total of 133 patients were included in the study (88 patients with STEMI and 45 patients with normal coronary arteries). The SYNTAX score was determined based on the baseline coronary angiogram. Multivariate logistic regression analysis indicated that endocan independently correlated with the presence of STEMI. Moreover, high-sensitivity C-reactive protein (hsCRP), peak troponin I, and left ventricular ejection fraction (LVEF) were found to be independently associated with STEMI. Endocan level correlated significantly with hsCRP and SYNTAX score. We analyzed the discriminatory capability of endocan level for the presence of STEMI using a receiver–operating characteristics curve. A cutoff endocan level of 1.7 (ng/mL) predicted the presence of STEMI with a sensitivity of 76.1% and specificity of 73.6%. In conclusion, a high endocan level on hospital admission is an independent predictor of a worse cardiovascular outcome and a high SYNTAX score in patients with STEMI.

The relationship between neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and thrombolysis in myocardial infarction risk score in patients with ST elevation acute myocardial infarction before primary coronary intervention

INTRODUCTION

The thrombolysis in myocardial infarction (TIMI) risk score is calculated as the sum of independent predictors of mortality and ischemic events in ST elevation acute myocardial infarction (STEMI). Several studies show that the neutrophil to lymphocyte ratio (NLR) is a prognostic inflammatory marker. In preliminary studies, platelet to lymphocyte ratio (PLR) has been proposed as a pro-thrombotic marker. The relationship between NLR, PLR and TIMI risk score for STEMI has never been studied.

AIM

To evaluate the association between TIMI-STEMI risk score and NLR, PLR and other biochemical indices in STEMI.

MATERIAL AND METHODS

In this retrospective study, we evaluated 390 patients who presented with STEMI within 12 h of symptom onset. Patients were grouped according to low and high TIMI risk scores.

RESULTS

We enrolled 390 patients (mean age 61.9 ±13.6 years; 73% were men). The NLR, platelet distribution width (PDW) and uric acid level (UA) were significantly associated with a high TIMI-STEMI risk score (p = 0.016, p = 0.008, p = 0.030, respectively), but PLR was not associated with a high TIMI-STEMI risk score. Left ventricular ejection fraction was an independent predictor of TIMI-STEMI risk score. A cut-off point of TIMI-STEMI score of > 4 predicted in-hospital mortality (sensitivity 75%, specificity 70%, p < 0.001). We found that NLR, PDW, and UA level were associated with TIMI-STEMI risk score.

CONCLUSIONS

Neutrophil to lymphocyte ratio, PDW and UA level are convenient, inexpensive and reproducible biomarkers for STEMI prognosis before primary angioplasty when these indicators are combined with the TIMI-STEMI risk score. We believe that these significant findings can guide further clinical practice.

Prognostic Value of the Percentage of Neutrophils on Admission in Patients with ST-elevated Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND AND AIMS

An elevated neutrophil count or neutrophil/lymphocyte ratio on admission has been reported to be an independent predictor of adverse cardiac events in patients with acute coronary syndrome (ACS). The relationship between the percentage of neutrophils (N%) at the time of admission and the long-term outcomes in patients with ST-segment elevated myocardial infarction (STEMI) who have undergone primary percutaneous coronary intervention (PCI) remains unclear. The aim of this study was to investigate the usefulness of the admission N% in predicting long-term mortality in patients with STEMI who were undergoing primary PCI.

METHODS

We evaluated 701 consecutive patients admitted to nine medical institutions in northwest China within 24 h after symptom onset from January 1, 2009-December 31, 2011. Using a receiver-operating characteristic analysis, N% ≥82.1% was the best predictor of long-term mortality. Patients were divided into two groups according to this criterion. Mean follow-up time was 39.03 months.

RESULTS

The long-term all-cause mortality rate was significantly higher in patients with a high N% level (7.17 vs. 3.11%, p = 0.015) as was the rate of cardiac mortality (6.48 vs. 2.59%, p = 0.013). In a multivariate logistic analysis, a high N% level was an independent predictor of long-term all-cause mortality (odds ratio 2.59, 95% confidence interval 1.21-5.53, p = 0.002) and long-term cardiac mortality (odds ratio 2.79, 95% confidence interval 1.24-6.28, p = 0.013).

CONCLUSIONS

A high N% level on admission is an independent predictor of long-term mortality in STEMI patients undergoing primary PCI.

Value of pentraxin-3 and galectin-3 in acute coronary syndrome: a short-term prospective cohort study

BACKGROUND

Acute coronary syndrome (ACS) continues to be a leading cause of morbidity and mortality worldwide. Galectin-3 and pentraxin-3 are two prognostic biomarkers that have been studied in heart failure (HF). However, there are limited data on these biomarkers in the ACS population. The objective of the study was to determine the variables that are most affected by high concentrations of pentraxin-3 and galectin-3, and the influence they have on outcomes of all-cause mortality in patients with ACS.

METHODS

We included a total of 160 patients [ST elevation myocardial infarction (STEMI),n = 64; non STEMI/unstable angina (NSTEMI/UA), n = 38; and control subjects with chronic stable angina (CSA)/microvascular angina (MVA) n = 58]. Plasma pentraxin-3 and galectin-3 levels were assessed from these patients at the time of hospital admission. Major adverse cardiovascular events including all-cause mortality, rehospitalizations and coronary artery bypass graft surgery (CABG) were assessed at 6 months.

RESULTS

The median concentration of pentraxin-3 and galectin-3 were significantly higher in STEMI than in NSTEMI patients (p < 0.005) or controls (p < 0.005). Greater numbers of deaths (4 versus 0) were observed in STEMI patients with higher levels of these biomarkers. In addition, ACS patients with high levels of pentraxin-3 and galectin-3 had lower left ventricular ejection fraction (LVEF) (p < 0.005), and a moderate correlation was observed between LVEF and pentraxin-3 levels (r = -0.45, p < 0.005). Patients with higher galectin-3 levels were also observed to have a lower estimated glomerular fraction rate (eGFR), and a moderate correlation was observed between them (r = -0.34, p < 0.005).

CONCLUSION

Pentraxin-3 and galectin-3 hold much promise in the ACS population as prognostic biomarkers.

Efficacy of an early invasive strategy after fibrinolysis in ST-elevation myocardial infarction relative to the extent of coronary artery disease

BACKGROUND

A strategy of early transfer for coronary angiography and intervention is superior to a standard approach of delayed coronary angiography after fibrinolysis for ST-elevation myocardial infarction (STEMI). STEMI patients with lesions in noninfarct-related arteries have a worse prognosis compared with patients with single vessel disease. This study aimed to assess whether the benefits of an early invasive strategy differ in patients with single vessel and multivessel disease.

METHODS

The Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized STEMI patients receiving fibrinolysis to a strategy of early transfer and coronary angiography vs a standard approach. In this post hoc analysis, we stratified 992 patients into 2 groups according to the presence or absence of multivessel disease. We compared the 2 groups in terms of baseline characteristics, in-hospital management, and patient outcomes, and tested for treatment heterogeneity.

RESULTS

Multivessel disease was present in 369 (37%) patients. Patients with multivessel disease had a greater rate of the primary composite end point of in-hospital death, recurrence of infarction, recurrent ischemia, shock, or heart failure at 30 days (18.2% vs 10.8%; P < 0.001). An early invasive strategy was efficacious in both groups for the primary outcome. In multivariable analysis adjusting for Global Registry of Acute Coronary Events (GRACE) risk score, there was no significant treatment heterogeneity (all P interaction > 0.40) for the primary end point, or death/recurrence of infarction at 6 months and 1 year.

CONCLUSIONS

Multivessel disease is present in a significant proportion of STEMI patients treated with fibrinolysis and is associated with worse outcomes. A strategy of early transfer and coronary intervention after fibrinolysis was beneficial regardless of the presence or absence of multivessel disease.

Relationship Between Hematologic Indices and Global Registry of Acute Coronary Events Risk Score in Patients With ST-Segment Elevation Myocardial Infarction

The aim of this study was to evaluate the relationship between hematologic indices and the Global Registry of Acute Coronary Events (GRACE) score in patients with ST-segment elevation myocardial infarction (STEMI). A total of 800 patients who consecutively and retrospectively presented with STEMI within 12 hours of symptom onset. After accounting for exclusion criteria, a total of 379 patients remained in the study. We enrolled 379 patients with STEMI (mean age 61.7 ± 13.6 years; men 73%). Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), red cell distribution width (RDW), and monocyte count were associated with increased worse GRACE risk score (P = .008, P = .012, P = .005, P = .022, respectively). In multivariate linear regression analysis, NLR, PLR, RDW, and monocyte count were found to be independent predictors of GRACE risk score. We demonstrate for the first time that PLR, RDW, and monocyte were associated with the GRACE score in patients with STEMI.

Heart failure is associated with impaired anti-inflammatory and antioxidant properties of high-density lipoproteins

Oxidative stress and inflammation are hallmarks of the heart failure (HF) disease state. In the present study, we investigated the inflammatory/anti-inflammatory characteristics of high-density lipoproteins (HDL) in patients with HF. Ninety-six consecutive patients with systolic HF were followed in an advanced HF center, and 21 healthy subjects were recruited. Plasma was tested for HDL inflammatory index (HII) using a monocyte chemotactic activity assay, with HII >1.0 indicating proinflammatory HDL. We found significantly increased inflammatory properties of HDL in patients with HF (median HII 1.56 vs 0.59 in controls; p <0.0001). Serum amyloid A level was markedly elevated and the activity of paraoxonase-1, an HDL antioxidant enzyme, was significantly reduced in patients versus controls. HDL and albumin from patients with HF contained markedly elevated levels of oxidized products of arachidonic and linoleic acids. HDL function improved when plasma was treated in vitro with 4F, an apolipoprotein A-I mimetic peptide (40% reduction in HII, p <0.0001). There was no correlation found between HII level and ejection fraction or New York Heart Association functional class. In conclusion, HDL function is significantly impaired and oxidation products of arachidonic and linoleic acids are markedly elevated in patients with HF compared with non-HF controls.

Relation of Neutrophil-to-Lymphocyte Ratio With GRACE Risk Score to In-Hospital Cardiac Events in Patients With ST-Segment Elevated Myocardial Infarction

In this study, we aimed to investigate the association of the neutrophil-to-lymphocyte ratio (NLR) with Global Registry of Acute Coronary Events (GRACE) risk score in patients with ST-segment elevated myocardial infarction (STEMI). We analyzed 101 consecutive patients with STEMI. Patients were divided into 3 groups by use of GRACE risk score. The association between NLR and GRACE risk score was assessed. The NLR showed a proportional increase correlated with GRACE risk score ( P < .001). The occurrence of in-hospital cardiac death, reinfarction, or new-onset heart failure was significantly related to NLR at admission ( P < .001). Likewise, NLR and GRACE risk score showed a significant positive correlation ( r = .803, P < .001). In multivariate analysis, NLR resulted as a predictor of worse in-hospital outcomes independent of GRACE risk score. Our study suggests that the NLR is significantly associated with adverse in-hospital outcomes, independent of GRACE risk score in patients with STEMI.

Inflammatory biomarkers, death, and recurrent nonfatal coronary events after an acute coronary syndrome in the MIRACL study

Background

In acute coronary syndromes, C‐reactive protein (CRP) strongly relates to subsequent death, but surprisingly not to recurrent myocardial infarction. Other biomarkers may reflect different processes related to these outcomes. We assessed 8 inflammatory and vascular biomarkers and the risk of death and recurrent nonfatal cardiovascular events in the 16 weeks after an acute coronary syndrome.

Methods and Results

We measured blood concentrations of CRP, serum amyloid A (SAA), interleukin‐6 (IL‐6), soluble intercellular adhesion molecule (ICAM), soluble vascular cell adhesion molecule (VCAM), E‐selectin, P‐selectin, and tissue plasminogen activator antigen (tPA) 24 to 96 hours after presentation with acute coronary syndrome in 2925 subjects participating in a multicenter study. Biomarkers were related to the risk of death, and recurrent nonfatal acute coronary syndromes (myocardial infarction or unstable angina) over 16 weeks using Cox proportional hazard models. On univariate analyses, baseline CRP (P=0.006), SAA (P=0.012), and IL‐6 (P<0.001) were related to death, but not to recurrent nonfatal acute coronary syndromes. VCAM and tPA related to the risk of death (P<0.001, P=0.021, respectively) and to nonfatal acute coronary syndromes (P=0.021, P=0.049, respectively). Adjusting for significant covariates reduced the strength of the associations; however, CRP and SAA continued to relate to death.

Conclusions

In acute coronary syndromes, the CRP inflammatory axis relates to the risk of death and may reflect myocardial injury. VCAM and tPA may have greater specificity for processes reflecting inflammation and thrombosis in the epicardial arteries, which determine recurrent coronary events.

High-Sensitivity C-Reactive Protein is a Predictor of In-Hospital Cardiac Events in Acute Myocardial Infarction Independently of GRACE Risk Score

High-sensitivity CRP (hsCRP) is being increasingly used as a marker for cardiac risk assessment and as a prognostic tool in acute coronary syndrome. We analyzed the relation between hsCRP values at admission and in-hospital outcomes in 98 consecutive patients with acute myocardial infarction (AMI) undergoing catheterization. Patients with cardiac events had more advanced Killip class, more proportion of depressed left ventricular ejection fraction (LVEF), higher Global Registry of Acute Coronary Events (GRACE) risk score, and higher hsCRP levels. High-sensitivity CRP and GRACE risk score showed a significant positive correlation ( r = .320, P = .002). In multivariate analysis, hsCRP resulted as a predictor of worse in-hospital outcomes independently of GRACE risk score (OR 1.122, CI95%:1.005-1.252, P = .040). The hsCRP value showing the maximum likelihood ratio for predicting cardiac events was 1.45 mg/dL. High levels of hsCRP were also associated with development of contrast-induced nephropathy but not with bleeding events.

C-reactive protein elevation and rapid angiographic progression of nonculprit lesion in patients with non-ST-segment elevation acute coronary syndrome

BACKGROUND

In non-ST-segment elevation acute coronary syndromes (NSTE-ACS), the relation of the level of high-sensitivity C-reactive protein (CRP) to the progression of atherosclerosis remains unclear.

METHODS AND RESULTS

The study group comprised 153 patients with NSTE-ACS who underwent percutaneous coronary interventions (PCI) and follow-up (mean interval, 7 months) coronary angiography. Rapid progression was defined as > or =10% diameter reduction of a preexisting stenosis > or =50%, > or =30% diameter reduction of a stenosis <50%, development of a new stenosis > or =30% in a previously normal segment, or progression of any stenosis to total occlusion. Progressors had higher CRP levels on admission and at 48 h after PCI, a higher level of low-density lipoprotein cholesterol at follow-up, a higher rate of multiple complex lesions, and a lower frequency of statin use at follow-up than nonprogressors. Multivariate analysis showed that admission CRP elevation (CRP level on admission > or =0.166 mg/dl, median value; odds ratio (OR) 2.92, p=0.010), post-PCI CRP elevation (CRP level 48 h after PCI > or =1.586 mg/dl, median value; OR 2.67, p=0.022), and multiple complex lesions (OR 2.66, p=0.017) were independent predictors of rapid progression of nonculprit lesions.

CONCLUSIONS

Enhanced inflammatory response to PCI, as well as baseline inflammatory activity as reflected by CRP level, may be involved in the progression of atherosclerosis in NSTE-ACS.

The impact of hs C-reactive protein and other inflammatory biomarkers on long-term cardiovascular mortality in patients with acute coronary syndromes

We evaluated whether high circulating levels of serum amyloid A (SAA), fibrinogen, interleukin-6 (IL-6) or leukocytes count (LC), can provide any additional predictive value over that provided by hs C-reactive protein (hs-CRP) for the incidence of 5-year cardiovascular mortality, in 458 and 476 consecutive patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS), respectively. By 5 years the incidence of cardiovascular mortality was 37.3% and 35.5% in patients with STEMI and NSTE-ACS, respectively. Each of the study inflammatory biomarkers conferred independent to clinical risk predictors (and to cardiac troponin I) long-term prognostic information (all p<0.05), but only LC provided additional predictive value over that provided by hs-CRP, in either cohort (p<0.05). By multivariate Cox regression analysis, hs-CRP (p<0.001 for both cohorts) and LC (p=0.009 and p<0.001 for STEMI and NSTE-ACS, respectively) were the only inflammatory biomarkers independently associated with the incidence of 5-year cardiovascular mortality. According to the present results high circulating levels of LC but not of SAA, fibrinogen or IL-6 can provide additional long-term predictive value over that provided by hs-CRP in patients with acute coronary syndromes.

C-reactive protein and angiographic characteristics of stable and unstable coronary artery disease: data from the prospective PREVEND cohort

AIMS

High sensitive-C-reactive protein (hs-CRP) is associated with coronary risk, which may be explained by an association with (unstable) coronary artery disease (CAD). Until now, histopathological and angiographic studies have failed to consistently demonstrate a strong relationship. However, most of these studies were limited by a cross-sectional design. Our aim was to prospectively evaluate the association between hs-CRP and plaque instability. Therefore, firstly, we investigated the relation between hs-CRP measured long before coronary angiography (CAG) and angiographic characteristics of stable and unstable CAD. In addition, we investigated the association with coronary events during follow up in the total PREVEND population.

METHODS AND RESULTS

Of the population based Prevention of Renal and Vascular Endstage Disease (PREVEND) study, 8139 subjects without previous documented CAD were followed for the incidence of CAG and coronary events from 1997 to 2003. For the qualitative angiographic analysis, 216 CAGs were available. Mean time to CAG was 37+/-19 months. The 864 coronary vessels were graded as follows: 436 coronary vessels as normal, 175 as non-obstructive CAD, 179 as stable obstructive CAD and 74 as unstable obstructive CAD. Multilevel ordinal regression analysis was performed to study associations between baseline clinical variables and angiographic findings. Hs-CRP contributed significantly to the multivariate model after adjustment for age, gender, smoking, lipids and blood pressure. In 8139 subjects, 201 (2.5%) first coronary events occurred during follow up. Cox survival analysis showed age- and sex-adjusted hazard ratios for hs-CRP 1-3 and >3mg/L of, respectively, 1.26 (95% CI 0.67-2.40) and 3.16 (95% CI 1.26-3.16), relative to hs-CRP <1mg/L.

CONCLUSION

In the prospective PREVEND study of subjects without previous documented CAD, hs-CRP levels at baseline were associated with angiographic characteristics and clinical consequences of plaque instability during follow up. This observation supports the concept that hs-CRP significantly contributes to coronary atherogenesis.

Brain natriuretic peptide and other risk markers for outcome assessment in patients with non-ST-elevation coronary syndromes and preserved systolic function

Several emerging cardiac markers constitute strong predictors among patients with coronary artery disease. In particular, brain natriuretic peptide (BNP), troponin T (TnT), and C-reactive protein (CRP) are related to increased risk of recurrent ischemic events and death. However, little is known about the utility of these biomarkers in combination. This study examined risk assessment in patients with coronary artery disease and preserved systolic function. We studied 208 consecutive patients (138 men, 70 women) with stable angina, unstable angina, and non-Q-wave myocardial infarction whose plasma BNP, TnT, and CRP levels were measured at hospital admission. All recruited patients underwent echocardiographic examination, and selective coronary angiography was performed. After adjusting for clinical presentation, age, gender, and common risk factors, BNP was demonstrated as a strong predictor of heart failure (6 months, odds ratio [OR] 2.03, 95% confidence interval [CI] 1.24 to 2.9, p <0.01; 12 months, OR 2.65, 95% CI 1.69 to 3.5, p <0.001) and mortality at 3, 6, and 12 months (p <0.001). BNP was also significantly related to extent of coronary artery disease and left anterior descending artery involvement (p <0.01). Patients with a BNP level >80 pg/ml in all 3 groups had a significantly poorer prognosis with increased incidence of heart failure and death. CRP was related to recurrent ischemic events (infarct or recurrent angina, OR 1.4, 95% CI 1.14 to 2.08, p <0.01) and was associated with major cardiac revascularization at 12 months (OR 1.51, 95% CI 1.29 to 1.73, p <0.001). TnT demonstrated a mild correlation with recurrent infarct or angina at 12 months (OR 1.1, 95% CI 0.96 to 1.22, p <0.05) but appeared related to multivessel coronary artery disease (OR 1.47, 95% CI 1.05 to 1.99, p <0.01). In conclusion, BNP appears to be associated with a long-term increased risk of mortality and heart failure in patients with apparently mild risk. BNP is also associated with a larger extent and greater severity of myocardial ischemia. Early BNP measurement could provide incremental information to TnT and CRP, and it may be the strongest independent predictor of cardiac outcome in subjects without left ventricular dysfunction or enlargement.