Interleucina 6 y proteína C reactiva ultrasensible para la predicción de la evolución clínica en síndromes coronarios agudos sin elevación del segmento ST

Myocardial tissue characterization by cardiovascular magnetic resonance T1 mapping and pericardial fat quantification in adolescents with morbid obesity. Cardiac dimorphism by gender

PURPOSE

Changes in the myocardial extracellular matrix (ECM) identified using T1 mapping cardiovascular magnetic resonance (CMR) have been only reported in obese adults, but with opposite conclusions. The objectives are to assess the composition of the myocardial ECM in an obese pediatric population without type 2 diabetes by quantifying native T1 time, and to quantify the pericardial fat index (PFI) and their relationship with cardiovascular risk factors.

METHODS

Observational case-control research of 25 morbidly obese adolescents and 13 normal-weight adolescents. Native T1 and T2 times (ms), left ventricular (LV) geometry and function, PFI (g/ht³) and hepatic fat fraction (HFF, %) were calculated by 1.5-T CMR.

RESULTS

No differences were noticed in native T1 between obese and non-obese adolescents (1000.0 vs. 990.5 ms, p0.73), despite showing higher LV mass values (28.3 vs. 22.9 g/ht³, p0.01). However, the T1 mapping values were significantly higher in females (1012.7 vs. 980.7 ms, p < 0.01) while in males, native T1 was better correlated with obesity parameters, particularly with triponderal mass index (TMI) (r = 0.51), and inflammatory cells. Similarly, the PFI was correlated with insulin resistance (r = 0.56), highly sensitive C-reactive protein (r = 0.54) and TMI (r = 0.77).

CONCLUSION

Female adolescents possess myocardium peculiarities associated with higher mapping values. In males, who are commonly more exposed to future non-communicable diseases, TMI may serve as a useful predictor of native T1 and pericardial fat increases. Furthermore, HFF and PFI appear to be markers of adipose tissue infiltration closely related with hypertension, insulin resistance and inflammation.

Prognostic role of inflammatory cytokines and novel adipokines in acute myocardial infarction: An updated and comprehensive review

Acute myocardial infarction (AMI) is one of the major causes of morbidity and mortality worldwide. The inflammation response during and after AMI is common and seems to play a key role in the peri-AMI period, related with ischaemia-reperfusion injury, adverse cardiac remodelling, infarct size and poor prognosis. In this article, we provide an updated and comprehensive overview of the most important cytokines and adipokines involved in the complex pathophysiology mechanisms in AMI, summarizing their prognostic role post-AMI. Data so far support that elevated levels of the major proinflammatory cytokines TNFα, IL-6 and IL-1 and the adipokines adiponectin, visfatin and resistin, are linked to high mortality and morbidity. In contrary, there is evidence that anti-inflammatory cytokines and adipokines as IL-10, omentin-1 and ghrelin can suppress the AMI-induced inflammatory response and are correlated with better prognosis. Mixed data make unclear the role of the novel adipokines leptin and apelin. After all, imbalance of pro-inflammatory and anti-inflammatory cytokines may result in worst AMI prognosis. The incorporation of these inflammation biomarkers in established prognostic models could further improve their prognostic power improving overall the management of AMI patients.

Meta-analysis of the relationship between interleukin-6 levels and the prognosis and severity of acute coronary syndrome

This study aimed to explore the relationship between plasma interleukin 6 (IL-6) levels, adverse cardiovascular events, and the severity of acute coronary syndrome (ACS). A literature review was performed of studies regarding IL-6 and ACS extracted from databases including EMBASE, Cqvip, MEDLINE, Web of Knowledge, PubMed, Cochrane Library, China National Knowledge Infrastructure, and Wanfang data. The Newcastle-Ottawa scale (NOS) was used to evaluate the quality of the literature. The literature was screened, its quality was evaluated, and relevant data were extracted for performing meta-analysis using RevMan software (version 5.3). A total of 524 studies were included in the initial survey. After several rounds of screening and analysis, six studies met the inclusion criteria and underwent meta-analysis using a fixed-effect model. Patients were divided into non-severe and severe groups based on the concentration of high-sensitivity C-reactive protein. Meta-analysis of the relationship between IL-6 and the severity of ACS showed that the plasma IL-6 level of patients in the severe group was significantly higher than that of patients in the non-severe group (p<0.00001). Additionally, patients with experience of major adverse cardiovascular events had significantly higher plasma IL-6 levels than did patients without experience of such events (p<0.00001). In summary, patients with ACS and high IL-6 levels tended to be in a critical condition, with a higher risk of adverse cardiovascular events and worse prognosis. Thus, IL-6 levels could indicate whether patients with ACS may have adverse cardiovascular events and determine the severity of ACS.

Interleukin-6 Receptor Antibodies for Modulating the Systemic Inflammatory Response after Out-of-Hospital Cardiac Arrest (IMICA): study protocol for a double-blinded, placebo-controlled, single-center, randomized clinical trial

Background

Resuscitated out-of-hospital cardiac arrest (OHCA) patients who remain comatose at admission are at high risk of morbidity and mortality. This has been attributed to the post-cardiac arrest syndrome (PCAS) which encompasses multiple interacting components, including systemic inflammation. Elevated levels of circulating interleukin-6 (IL-6), a pro-inflammatory cytokine, is associated with worse outcomes in OHCA patients, including higher vasopressor requirements and higher mortality rates. In this study, we aim to reduce systemic inflammation after OHCA by administering a single infusion of tocilizumab, an IL-6 receptor antibody approved for use for other indications.

Methods

Investigator-initiated, double-blinded, placebo-controlled, single-center, randomized clinical trial in comatose OHCA patients admitted to an intensive cardiac care unit. Brief inclusion criteria: OHCA of presumed cardiac cause, persistent unconsciousness, age ≥ 18 years. Intervention: 80 patients will be randomized in a 1:1 ratio to a single 1-h intravenous infusion of either tocilizumab or placebo (NaCl). During the study period, patients will receive standard of care, including sedation and targeted temperature management of 36 ° for at least 24 h, vasopressors and/or inotropes as/if needed, prophylactic antibiotics, and any additional treatment at the discretion of the treating physician. Blood samples are drawn for measurements of biomarkers included in the primary and secondary endpoints during the initial 72 h. Primary endpoint: reduction in C-reactive protein (CRP). Secondary endpoints (abbreviated): cytokine levels, markers of brain, cardiac, kidney and liver damage, hemodynamic and hemostatic function, adverse events, and follow-up assessment of cerebral function and mortality.

Discussion

We hypothesize that reducing the effect of circulating IL-6 by administering an IL-6 receptor antibody will mitigate the systemic inflammatory response and thereby modify the severity of PCAS, in turn leading to lessened vasopressor use, more normal hemodynamics, and better organ function. This will be assessed by primarily focusing on hemodynamics and biomarkers of organ damage during the initial 72 h.

In addition, pro-inflammatory and anti-inflammatory cytokines will be measured to assess if cytokine patterns are modulated by IL-6 receptor blockage.

Trial registration

ClinicalTrials.gov Identifier: NCT03863015; submitted February 22, 2019, first posted March 5, 2019.

EudraCT: 2018-002686-19; date study was authorized to proceed: November 7, 2018.

Interleukin-6 level is a powerful predictor of long-term cardiovascular mortality in patients with acute coronary syndrome

BACKGROUND

The interleukin-6 (IL-6) pathway has a crucial role in the pathogenesis of atherosclerosis, the main cause of cardiovascular diseases. We aimed to characterize the predictive value of inflammatory biomarkers on long-term cardiovascular mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

METHODS

This prospective observational study included 322 consecutive patients with ACS undergoing PCI. Blood-derived biomarkers IL-6 and high-sensitivity C-reactive protein (hsCRP) were assessed at the time point of ACS. Patients were followed-up for 6 years. Long-term cardiovascular mortality was our primary endpoint. Adjusted Cox-regression analysis was used for prediction of events.

RESULTS

Elevated IL-6 values (≥3.3 pg/mL) emerged as an independent and the most powerful predictor for cardiovascular mortality: the ROC analysis showed that IL-6 was more accurate for cardiovascular mortality prediction as compared to hsCRP (IL-6: AUC = 0.72; 95%CI: 0.62-0.81; p = 0.009 vs hsCRP: AUC = 0.56; 95%CI: 0.41-0.72; p = 0.445). The positive predictive value of IL-6 for mortality was 9%, the negative predictive value 99%, sensitivity 94% and specificity 48%. The primary endpoint of long-term cardiovascular death occurred more frequently in patients with high vs low IL-6 (9.0% vs 0.5%, p = 0.001). The multivariate Cox regression analysis revealed that patients with high IL-6 (≥3.3 pg/mL) values were at 8.6-fold higher hazard to die than those with low IL-6 (<3.3 pg/mL) levels (adj. hazard ratio [HR] = 8.60, 95%CI: 1.07-69.32; p = 0.043).

CONCLUSION

In the setting of ACS, high IL-6 values are associated with substantial long-term cardiovascular mortality. Further, IL-6 performs as a superior predictor for cardiovascular death as compared to hsCRP.

Predictive Value of Blood Interleukin-6 Level in Patients with Acute Coronary Syndrome: A Meta-analysis

OBJECTIVE

Conflicting results have been reported on the association between blood level of interleukin-6 and adverse outcomes in patients with acute coronary syndrome (ACS). The current meta-analysis aimed to evaluate the predictive utility of elevated blood interleukin-6 level in patients with ACS.

METHODS

A systematically literature search was performed using PubMed and Embase databases up to December 31, 2019. Observational studies or post hoc analysis of randomized controlled trials investigating the values of blood interleukin-6 level for predicting major adverse cardiovascular events (MACE including death, re-infarction, revascularization, angina, heart failure, malignant arrhythmia, or stroke), all-cause mortality or cardiovascular mortality in ACS patients were eligible. The predictive values were summarized by pooling the multivariable-adjusted risk ratio (RR) and 95% confidence intervals (CI) for the highest versus lowest category of interleukin-6 level.

RESULTS

Thirteen studies enrolling 30,289 patients with ACS were included. When comparing the highest with lowest category of interleukin-6 level, the pooled RR was 1.29 (95% CI 1.12-1.48) for MACE, 1.50 (95% CI 1.35-1.67) for all-cause mortality, and 1.55 (95% CI 1.06-2.28) for cardiovascular mortality, respectively. Moreover, the predictive values of interleukin-6 level on MACE were consistently found in different study designs, subtypes of patients, sample sizes, follow-up duration, and cutoff value of interleukin-6 elevation subgroups.

CONCLUSION

Increased blood level of interleukin-6may be independently associated with higher risk of MACE, cardiovascular and all-cause mortality in patients with ACS. Measurement of blood interleukin-6 level has potential to improve risk stratification of ACS.

Tocilizumab in the treatment of myocardial infarction

Tocilizumab (TCZ) is an important biologic response modifier that rheumatologists routinely employ in the treatment of several systemic autoimmune diseases. TCZ binds to interleukin (IL)-6 receptors, inhibits cellular activation, and mitigates inflammation by IL-6. In mid-2017, TCZ was approved by the US Food and Drug Administration for its first nonrheumatologic condition, the treatment of chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome in patients 2 years of age or older. With this approval and with the increasing use of TCZ off-label for other non-rheumatologic conditions such as Castleman's Disease and its variant TAFRO syndrome, where else might TCZ be successfully utilized as treatment? Recently interesting data has been published regarding possible use of TCZ in the treatment of myocardial infarction. This review focuses on the role of IL-6 and its receptor in myocardial inflammation and association with adverse clinical outcomes. Discussed are one animal study and two human trials that have been published studying the effect of TCZ in patients with acute myocardial infarction. Finally, this review summarizes the current data and makes recommendations for future clinical trial development in what hopefully will be a promising application of TCZ for a serious nonrheumatologic condition.

Update on ischemic heart disease and critical care cardiology

This article summarizes the main developments reported in 2013 on ischemic heart disease, together with the most important innovations in the management of acute cardiac patients.