Endothelial dysfunction, increased carotid artery intima-media thickness and pulse wave velocity, and increased level of inflammatory markers are associated with variant angina

Elevated white blood cell count and long-term clinical outcomes of patients with vasospastic angina

OBJECTIVES

Inflammation is known as one of key pathophysiologic mechanisms of coronary artery disease. We aimed to investigate the relationship between white blood cell (WBC) count and long-term clinical outcomes of patients with vasospastic angina (VA).

METHODS

A total of 823 patients who were diagnosed as VA without significant coronary lesion by coronary angiography with ergonovine provocation test were enrolled for analysis. Patients were divided according to WBC count tertile at the time of diagnosis: group I, tertile 1 and 2 (n = 546, <7490/ml); group II, tertile 3 (n = 277, ≥7490/ml). Primary outcome was defined as major adverse cardiovascular events (MACE), a composite outcome of all-cause death, cardiac death, myocardial infarction (MI), readmission due to cardiac symptoms, and revascularization.

RESULTS

Median follow-up duration was 4.3 years. No significant difference of primary outcome was observed between group I and group II (14.7% vs. 20.2%, hazard ratio (HR) 1.29, confidence interval (CI) 0.90-1.83, P  = 0.162), while incidence of cardiac death and MI was significantly higher in group II (1.5% vs. 4.3%, HR 2.86, CI 1.14-7.17), P  = 0.025). In multivariate Cox regression model, elevated WBC count at the time of diagnosis of VA was an independent predictor of MI (HR 3.43, CI 1.02-11.59, P  = 0.047).

CONCLUSION

Elevated WBC count at the time of diagnosis was associated with a significantly increased risk of cardiac death and MI during long-term follow-up in VA patients.

Influence of release rate, dose and co-administration on pharmacokinetics, pharmacodynamics and PK-PD relationship of tanshinone IIA and tanshinol

The present study aims to investigate the influence of release rate, dose and co-administration on pharmacokinetics (PK) and pharmacodynamics (PD) of tanshinone IIA (TA) and tanshinol (TS), and reveal the changes in their PK-PD relationships. Sustained and immediate release pellets of TS and TA were prepared respectively, and oral administrated to angina model rabbits according to the experimental design. The administration dose of TS was 50, 35 or 20 mg/kg and that of TA was 30 mg/kg. Then, plasma concentrations of TS and TA were measured to evaluate the pharmacokinetics. Pharmacodynamic biomarkers including cardiac troponin (cTn-I), creatine kinase (CK-MB), superoxide dismutase (SOD) and nitric oxide (NO) were measured to evaluated the effects of cardioprotection, amelioration of oxidative stress and vasorelaxation of TS and TA. Parameters such as maximum plasma concentration (C_max), maximum effect (E_max), time to C_max or E_max (TC_max or TE_max), areas under the plasma concentration or effect curves (AUC_0-∞ or AUEC) and pharmacodynamic efficiency (EFF) were calculated based on non-compartmental analysis. Beside, PK-PD relationship/hysteresis was evaluated. The TE_max was less sensitive than TC_max to changes in release rate. The E_max, AUEC and EFF showed increasing trend as the decrease of release rate even that the AUC_0-∞ showed no significant difference. In addition, slow drug release decreased the magnitude of hysteresis of TS and TA. The sensitivities of E_max and AUEC of four biomarkers to changes in dose were varied and relatively lower than those of C_max and AUC_0-∞. The EFF decreased and the magnitude of hysteresis increased for high dose. The C_max and AUC_0-∞ of TS and TA showed little difference after co-administration. The E_max and AUEC of four biomarkers increased for immediate release pellets (P < 0.05 or P < 0.01) and generally decreased for sustained release pellets (P < 0.05 or P < 0.01) after co-administration. In addition, the magnitudes of hysteresis of four biomarkers decreased for immediate release pellets and generally increased for sustained release pellets after co-administration. In summary, the dissociated and unstable PK-PD relationship should be considered during optimization of dosage forms and regimens to make sure the rationality, safety and efficacy. These findings could also provide some valuable information for the development and clinical therapy of other drugs.

A practical means of evaluating the prognosis of acute pancreatitis, as measurement of carotid artery intima-media thickness

BACKGROUND AND STUDY AIMS

Factors such as age, obesity, diabetes mellitus and hyperlipidemia that cause adverse prognosis in acute pancreatitis also cause an increase in carotid intima-media thickness. In this study, we aimed to investigate the usability of the measurement of carotid intima-media thickness, which is an easy to apply, cost-effective means of measurement applied to the patients, in predicting AP prognosis, apart from the criteria currently utilized to predict AP prognosis.

PATIENTS AND METHODS

101 patients diagnosed with acute pancreatitis were prospectively enrolled into the study. Right and left common carotid artery intima-media thickness, right and left internal carotid artery intima-media thickness were measured with ultrasonographic images performed within the first 24 hours of hospitalization. local or systemic complications and organ failure development were monitored in the follow-up of the patients.

RESULTS

After the ROC analysis was performed and the threshold value was determined. The patients with main and internal carotid artery intima-media thickness above 0.775 mm were seen to have a more severe AP (p = 0.000). Local and systemic complications and organ failure were also more common in these patients.

CONCLUSIONS

Measurement of carotid intima-media thickness is a non-invasive method that can be used to predict the prognosis in patients with acute pancreatitis at presentation.

Association Between White Blood Cell Counts and Brachial-Ankle Pulse Wave Velocity in Chinese Hypertensive Adults: A Cross-Sectional Study

Increased arterial stiffness is highly prevalent in patients with hypertension and is associated with cardiovascular (CV) risk. Increased white blood cell (WBC) counts may also be an independent risk factor for arterial stiffness and CV events. The aim of the study was to investigate the relationship between differential WBC counts and brachial-ankle pulse wave velocity (baPWV) in hypertensive adults. A total of 14 390 participants were included in the final analysis. A multivariate linear regression model was applied for the correlation analysis of WBC count and baPWV. Higher WBC counts were associated with a greater baPWV: adjusted β = 10 (95% CI, 8-13, P < .001). The same significant association was also found when WBC count was assessed as categories or quartiles. In addition, the effect of differential WBC subtypes, including neutrophil count and lymphocyte count on baPWV, showed the similar results. These findings showed that baPWV has positive associations with differential WBC counts in hypertensive adults.

Endothelial dysfunction: from the particular to the general. Return to the «Old Paradigm»?

The vascular endothelium is a heterogeneous structure with diverse functions, being an active metabolic system. Endothelial cells mediate inflammatory and immune processes, regulate leukocyte adhesion, permeability and vascular tone, participate in the hemostasis system, stimulate the processes of angiogenesis. Endothelial dysfunction can initiate individual disorders, but more often it is a universal link in the pathogenesis of many diseases. Currently, endothelial dysfunction is presented as an imbalance between the production of vasodilating, angioprotective, antiproliferative factors, on the one hand, and vasoconstrictive, prothrombotic, proliferative factors, on the other hand. The manifestations of endothelial dysfunction, the direction and severity of these changes may vary depending on the disease. The review provides examples of combined endothelial disorders in the most studied and common diseases (essential hypertension, type 2 diabetes, systemic diseases of the connective tissue, atherosclerosis, and malignant tumors). Despite the presence of rare cases of isolated endothelial dysfunction, it can be argued that in the absolute majority of diseases, endothelial dysfunction has combined type of violations. The allocation of individual endothelial disorder spectra, typical for a specific disease, is problematic, due to the universality and nonspecificity of the manifestations of endothelial dysfunction. These conclusions allow us to return to the origins of this problem, considering endothelial dysfunction as a holistic concept, not limited to a certain range of its disorders.

Impact of statin therapy on long-term clinical outcomes of vasospastic angina without significant stenosis: A propensity-score matched analysis

BACKGROUND

Limited data are available on the efficacy of statin therapy for secondary prevention in patients with vasospastic angina (VSA). We investigated the association of statin therapy with long-term clinical outcomes in VSA patients without significant coronary artery disease.

METHODS

From January 2003 to June 2014, we enrolled a total of 804 patients with VSA proven by an ergonovine provocation test without significant (≥70% diameter stenosis) coronary artery disease. We classified patients into a statin group (n=330) and a no-statin group (n=474) according to the use of statin. Primary outcome were major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, myocardial infarction, and any revascularization.

RESULTS

Median follow-up duration was 4.5years (interquartile range: 2.0 to 7.3years). MACE occurred in 14 patients (4.2%) in the statin group, and 21 patients (4.4%) in the no-statin group. There were no differences between the two groups (p=0.97). After 1:1 propensity-score matching (281 pairs), MACE (statin versus [vs.] no-statin; 3.2% vs. 4.3%, hazard ratio [HR]; 0.80, 95% confidence interval [CI]; 0.34-1.89, p=0.60) and readmission due to chest pain (17.1% vs. 17.4%, HR; 1.08, 95% CI; 0.72-1.06, p=0.72) were not statistically different between the two groups.

CONCLUSION

Our results suggest that statin therapy could not improve long-term clinical outcomes in VSA patients without significant coronary artery disease.

Association between the Red Cell Distribution Width and Vasospastic Angina in Korean Patients

PURPOSE

The association between the red cell distribution width (RDW) and vasospastic angina (VSA) has not been elucidated. We investigated the association of the RDW with the incidence and angiographic subtypes of VSA in Korean patients.

MATERIALS AND METHODS

A total of 460 patients who underwent intracoronary ergonovine provocation tests were consecutively enrolled and classified into two groups: the VSA group (n=147, 32.0%) and non-VSA group (n=313, 68.0%). The subjects were classified into 3 subgroups (tertiles) according to the baseline level of RDW assessed before the angiographic provocation test.

RESULTS

The VSA group had a higher RDW than the non-VSA group (12.9±0.8% vs. 12.5±0.7%, p=0.013). The high RDW level demonstrated an independent association with the high incidence of VSA [second tertile: hazard ratio (HR) 1.96 (1.13-2.83), third tertile: HR 2.33 (1.22-3.47), all p<0.001]. Moreover, the highest RDW tertile level had a significant association with the prevalence of the mixed-type coronary spasm [HR 1.29 (1.03-1.59), p=0.037].

CONCLUSION

The high level of RDW was significantly associated with the prevalence of VSA and the high-risk angiographic subtype of coronary spasm, suggesting that a proactive clinical investigation for VSA could be valuable in Korean patients with an elevated RDW.

Pitavastatin calcium improves endothelial function and delays the progress of atherosclerosis in patients with hypercholesterolemia

BACKGROUND

Statins have proven efficacy in inhibiting the onset and progress of atherosclerosis. The effectiveness of pitavastatin in reversing carotid atherosclerosis associated with hypercholesterolemia (HC) is unknown.

OBJECTIVES

To explore the simultaneous effects of pitavastatin calcium on brachial arterial flow-mediated vasodilatation (FMD), carotid intima-media thickness (IMT), and arterial stiffness (β), three surrogate markers of atherosclerosis were studied in HC patients.

METHODS

A randomized, double-blind trial was performed with 40 HC subjects who fulfilled the inclusion/exclusion criteria. Patients were given pitavastatin calcium 1 mg/d (Group 1) or 2 mg/d (Group 2) for 8 weeks. There were 20 patients in each group, and 30 gender- and age-matched healthy subjects as controls were recruited. FMD of the brachial artery, carotid IMT, and arterial stiffness indicated by β were measured at baseline and at 8 weeks after starting pitavastatin calcium therapy using ultrasound techniques. Biochemical tests were also made on all subjects.

RESULTS

At baseline, higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C), reduced FMD, and increased β and IMT were observed in HC patients (P<0.001 for all) compared with controls. After 8 weeks, TC was decreased by 20.59%/27.56% and LDL-C 30.92%/35.64%, respectively, in comparison to baseline groups; the HC groups had reduced β and improved endothelial function over the 8-week follow-up (P<0.05-0.001); nonetheless, no significant alterations of IMT were found (P>0.05). Significant negative interactions between TC/LDL and FMD (P<0.05-0.001), positive interactions between TC and IMT (P=0.003) and between TC/LDL and β (P<0.001-0.000) were found.

CONCLUSIONS

Treatment with pitavastatin calcium exerted favorable effects on endothelial function and arterial stiffness. It also improved carotid atherosclerosis in patients with HC.

Effects of Low Dose versus High Dose Statin Therapy on the Changes of Endothelial Function and Carotid Intima-Media Thickness in Patients with Variant Angina

BACKGROUND

To compare the effects of low dose and high dose of statin treatment on endothelial function and carotid intima-media thickness (IMT) in patients with variant angina (VAP).

METHODS

A total of 70 patients with VAP were divided into two groups; atorvastatin 10 mg treatment group (group I: n = 35, 54.2 ± 12.5 years) versus atorvastatin 40 mg treatment group (group II: n = 35, 52.6 ± 9.8 years). Flow mediated vasodilation (FMD) of the brachial artery and IMT of the carotid artery were compared between the groups after 6 months of statin treatment.

RESULTS

The baseline FMD and carotid IMT were not different between the groups. After 6 months of statin therapy, FMD was significantly improved in both groups (7.7 ± 2.5% to 8.9 ± 2.2% in group I, p = 0.001, 7.9 ± 2.7% to 9.5 ± 2.8% in group II, p < 0.001), but the degree of FMD change and FMD at 6 month were not different between the groups. Carotid IMT were not changed in both groups after 6 months of statin therapy.

CONCLUSION

The use of statin for 6 months significantly improved endothelial function in patients with VAP, but carotid IMT was not changed. The use of high dose statin did not show significant additional benefit as compared with the use of low dose statin. The present study suggested that statin therapy would be beneficial in the treatment of VAP.

Chlamydia pneumoniae heat shock protein 60 is associated with apoptotic signaling pathway in human atheromatous plaques of coronary artery disease patients

BACKGROUND

Chlamydia pneumoniae heat shock protein (HSP) 60 is known to contribute to the activation of inflammation. In addition, there are contradictory reports on C. pneumoniae and their role in activation of pathways (apoptotic/antiapoptotic/necrosis) in coronary artery disease (CAD). Hence, more studies are required to know the actual role of C. pneumoniae in activation of apoptotic/antiapoptotic/necrosis pathways.

METHODS AND RESULTS

In this study, two sets of patient groups (cHSP60 positive and cHSP60 negative) were included and gene expression was studied by cDNA micro array and real time polymerase chain reaction arrays. Expression of Caspase-3, 8, 9, c-FLIP, PPAR-γ, PGC-1α, and Gsk-3b were also evaluated at protein level by immunoblotting. In cHSP60 positive CAD patients significantly higher (p<0.001) mRNA expression was found for CCL4, CXCL4, CXCL9, IL-8, CD40LG, CD8, TGFβ1, TGFβ2, APOE, EGR1, CTGF, APOB, LDLR, LPA, and LPL, whereas significantly lower (p<0.001) mRNA expression was detected for CD4, IL1F10, IFNA2, and IL-10 as compared to cHSP60 negative CAD patients. Additionally, at protein level expression of Caspase-3 (p=0.027), 8 (p=0.028), and 9 (p=0.037) were higher and c-FLIP (p=0.028) and PPAR-γ (p=0.95) expression were comparable in cHSP60 positive CAD patients compared to cHSP60 negative CAD patients.

CONCLUSION

Genes/proteins of pre-apoptotic caspase dependent/independent pathways, chemokines, and inflammatory cytokines receptors were significantly up-regulated in human atheromatous plaques of cHSP60 positive CAD patients suggesting an association of cHSP60 with CAD.

Diagnostic value of nitroglycerin-induced headache as a negative predictor of coronary atherosclerosis

The purpose of the present study was to clarify the possible relationship between nitroglycerin (NTG)-induced headache and both vascular functional and organic atherosclerosis. The study included 96 patients with NTG-induced headache (group I: 54.7±9.5 years, 52 males) and 204 patients without headache (group II: 58.1±9.1 years, 127 males) who suffered from new-onset chest pain. Flow-mediated dilation and nitroglycerin-mediated dilation were significantly greater in group I than in group II (8.8±4.1% vs. 7.1±3.5%, p=0.001, and 23.1±7.3% vs. 17.1±11.8%, p<0.001, respectively). The carotid intima-media thickness was significantly smaller in group I than in group II (0.55±0.15 mm vs. 0.67±0.22 mm, p=0.001). Heart-carotid pulse wave velocity was significantly lower in group I than in group II (784.5±160.1 m/s vs. 979.1±215.6 m/s, p=0.003). In the multiple regression analysis, the absence of NTG-induced headache was a predictor of coronary artery disease (CAD) (odds ratio: 17.89, 95% confidence interval: 7.89-40.02, p<0.001). NTG-induced headache developed more frequently in patients with normal coronary arteries or minimal CAD than in patients with obstructive CAD. The presence of NTG-induced headache might be helpful and provide additional information in evaluating patients with chest pain syndrome.

Current advances in the understanding of coronary vasospasm

Recent years have witnessed progress in our understanding of coronary vasospasm (CVS). It is evident that this is not only an East Asian but also a global disease associated with significant symptoms and possible lethal sequelae for afflicted individuals. A correct diagnosis depends on the understanding of pathogenesis and symptomatology of CVS. With the correct diagnosis, we can manage CVS patients effectively and promptly, providing optimal patient safety. Advances in our understanding of interactions between inflammation, endothelium, and smooth muscle cells have led to substantial progress in understanding the pathogenesis of symptoms in CVS and have provided some insights into the basic etiology of this disorder in some patient subpopulations. We look forward to a time when therapy will address pathophysiology and perhaps, even the primary etiology.

Waist circumference reduction is more strongly correlated with the improvement in endothelial function after acute coronary syndrome than body mass index reduction

BACKGROUND

Endothelial function predicts recurrence of adverse cardiac events in patients with acute coronary syndromes (ACS). Moreover, the recovery of endothelial function correlates with cardiac event-free survival.

OBJECTIVES

The aim of this study was to determine which clinical factors correlate with the improvement in endothelial function after ACS.

METHODS

Vascular endothelial function was assessed in 98 patients with ACS by flow-mediated dilation (FMD) of the brachial artery using high-resolution ultrasound at 2 weeks and 6 months after ACS. We measured several risk parameters including plasma markers of glucose homeostasis, lipids, and blood pressure at baseline and at 6 months after ACS. Body mass index (BMI) and waist circumference (WC) were also measured as anthropometric assessments.

RESULTS

At baseline, FMD was significantly correlated with BMI, WC, high-density lipoprotein cholesterol, the homeostasis model assessment of insulin resistance, and brachial artery diameter (r=-0.32, p=0.001; r=-0.44, p<0.0001; r=0.34, p=0.0006; r=-0.21, p=0.04; r=-0.47, p<0.0001, respectively). In a stepwise multivariate regression analysis at baseline, larger WC and brachial artery diameter were independently correlated with lower brachial artery FMD (R(2)=0.319, p<0.0001). At 6 months, the change in FMD was significantly correlated with the change in WC and BMI (r=-0.59, p<0.0001; r=-0.33, p=0.001, respectively). In a stepwise multivariate regression analysis, WC reduction was independently correlated with improved FMD (R(2)=0.349, p<0.0001).

CONCLUSIONS

WC reduction is more strongly correlated with the improvement of endothelial function after ACS than BMI reduction.