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Loeffen R, van Oerle R, Leers MPG, Kragten JA, Crijns H, Spronk HMH, ten Cate H. Factor XIa and Thrombin Generation Are Elevated in Patients with Acute Coronary Syndrome and Predict Recurrent Cardiovascular Events. PLoS One 2016; 11:e0158355. [PMID: 27419389 PMCID: PMC4946779 DOI: 10.1371/journal.pone.0158355] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 06/14/2016] [Indexed: 11/26/2022] Open
Abstract
Objective In acute coronary syndrome (ACS) cardiac cell damage is preceded by thrombosis. Therefore, plasma coagulation markers may have additional diagnostic relevance in ACS. By using novel coagulation assays this study aims to gain more insight into the relationship between the coagulation system and ACS. Methods We measured plasma thrombin generation, factor XIa and D-dimer levels in plasma from ACS (n = 104) and non-ACS patients (n = 42). Follow-up measurements (n = 73) were performed at 1 and 6 months. Associations between coagulation markers and recurrent cardiovascular events were calculated by logistic regression analysis. Results Thrombin generation was significantly enhanced in ACS compared to non-ACS patients: peak height 148±53 vs. 122±42 nM. There was a significantly diminished ETP reduction (32 vs. 41%) and increased intrinsic coagulation activation (25 vs. 7%) in ACS compared to non-ACS patients. Furthermore, compared to non-ACS patients factor XIa and D-dimer levels were significantly elevated in ACS patients: 1.9±1.1 vs. 1.4±0.7 pM and 495(310–885) vs. 380(235–540) μg/L. Within the ACS spectrum, ST-elevated myocardial infarction patients had the highest prothrombotic profile. During the acute event, thrombin generation was significantly increased compared to 1 and 6 months afterwards: peak height 145±52 vs. 100±44 vs. 98±33 nM. Both peak height and factor XIa levels on admission predicted recurrent cardiovascular events (OR: 4.9 [95%CI 1.2–20.9] and 4.5 [1.1–18.9]). Conclusion ACS patients had an enhanced prothrombotic profile, demonstrated by an increased thrombin generation potential, factor XIa and D-dimer levels. This study is the first to demonstrate the positive association between factor XIa, thrombin generation and recurrent cardiovascular events.
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Affiliation(s)
- Rinske Loeffen
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- * E-mail:
| | - René van Oerle
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mathie P. G. Leers
- Departments of Clinical Chemistry & Hematology, Atrium Medical Center Parkstad, Heerlen, The Netherlands
| | - Johannes A. Kragten
- Department Of Cardiology, Atrium Medical Center Parkstad, Heerlen, The Netherlands
| | - Harry Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henri M. H. Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Takahashi R, Ono K, Ikeda T, Akagi A, Noto D, Nozaki I, Sakai K, Asakura H, Iwasa K, Yamada M. Coagulation and fibrinolysis abnormalities in familial amyloid polyneuropathy. Amyloid 2012; 19:129-32. [PMID: 22624582 DOI: 10.3109/13506129.2012.691918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Familial amyloid polyneuropathy (FAP) is an autosomal dominant form of hereditary amyloidosis. Several studies reported coagulation factor X deficiency and excessive fibrinolysis in immunoglobulin light chain amyloidosis. However, few have investigated coagulation and fibrinolysis in FAP. The objective of this study was to determine abnormalities in plasma biomarkers of coagulation and fibrinolysis in FAP. METHODS We prospectively recruited eight FAP patients with transthyretin mutations and ten age-matched control patients with other neuropathies in our university. We examined plasma biomarkers of coagulation and fibrinolysis including prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin/fibrinogen degradation products, D-dimer, α2-antiplasmin, antithrombin, plasminogen, thrombin-antithrombin complex, plasmin-α2-antiplasmin complex, prothrombin fragment 1+2, and coagulation factor X. The Mann-Whitney U test was performed for statistical comparisons between FAP and control groups. RESULTS FAP patients exhibited significantly decreased levels of coagulation factor X, plasminogen and α2-antiplasmin, and significantly increased levels of prothrombin fragment 1+2 compared to control patients. CONCLUSION Our results indicate abnormalities of coagulation and fibrinolysis in FAP patients.
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Affiliation(s)
- Ryoichi Takahashi
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Takara-machi, Kanazawa, Japan
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Biasucci LM, Colizzi C, Rizzello V, Vitrella G, Crea F, Liuzzo G. Role of inflammation in the pathogenesis of unstable coronary artery diseases. Scandinavian Journal of Clinical and Laboratory Investigation 2010. [DOI: 10.1080/00365519909168322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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4
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Ziakas A, Gavrilidis S, Souliou E, Giannoglou G, Stiliadis I, Karvounis H, Efthimiadis G, Mochlas S, Vayona MA, Hatzitolios A, Savopoulos C, Pidonia I, Parharidis G. Ceruloplasmin is a better predictor of the long-term prognosis compared with fibrinogen, CRP, and IL-6 in patients with severe unstable angina. Angiology 2008; 60:50-9. [PMID: 18388036 DOI: 10.1177/0003319708314249] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated the time course and prognostic value of fibrinogen (Fib), C-reactive protein (CRP), interleukin-6 (IL-6), and ceruloplasmin (CP) in patients with severe unstable angina. METHODS All 4 substances were measured on admission and after 6, 12, 24, 48, and 72 hours, and after 7 days and 6 months in 40 patients with Braunwald's classification class IIIB unstable angina. RESULTS All recorded substances increased significantly; 15 patients had cardiovascular events during hospitalization and 11 patients during follow-up. The time course and the mean values of Fib, CRP, and IL-6 were similar in patients with and without complications both during hospitalization and follow-up. However, CP levels from 6 hours until 6 months were significantly higher in patients with complications during follow-up (P < .05). CONCLUSIONS Fib, CRP, IL-6, and CP levels alter in patients with severe unstable angina. However, only CP levels were related to 12-month follow-up prognosis.
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Affiliation(s)
- Antonios Ziakas
- 1st Cardiology Department, AHEPA, University Hospital, Thessaloniki, Greece.
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Nader ND, Karamanoukian HL, Reedy RL, Salehpour F, Knight PR. Inclusion of Sevoflurane in Cardioplegia Reduces Neutrophil Activity During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2006; 20:57-62. [PMID: 16458215 DOI: 10.1053/j.jvca.2005.07.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effects of sevoflurane cardioplegia on neutrophil response and complement activation after cardiopulmonary bypass (CPB). DESIGN A prospective, randomized clinical investigation. SETTING University-affiliated hospital; single institutional. PARTICIPANTS Twenty-one male patients undergoing coronary bypass surgery using CPB. INTERVENTIONS Eleven patients were randomly assigned to receive sevoflurane 2% as a part of the cardioplegic mixture (SEV). The control group (n = 10) received no sevoflurane in their cardioplegia (control). MEASUREMENTS AND MAIN RESULTS Myeloperoxidase activity (MPO) was assayed in coronary sinus blood as a surrogate for neutrophilic response at the termination of CPB. MPO activity in the coronary sinus blood was lower in the patients who received sevoflurane compared with controls. MPO activity was higher in patients with cardiac events at 4-year follow-up when compared with asymptomatic patients. IL-8, C4b, C3d, C5a, and CH50 were assessed in coronary sinus and peripheral blood at time of CPB initiation (T0) and upon the termination of CPB (T2). Peripheral blood sampling occurred at the sixth hour after T0 (T6). IL-8 levels were significantly inhibited in the SEV group when compared with controls at T2 and T6. CH50 (an index of global activation of complement system) decreased 30% at T2 and 52% at T6. The classic component of the complement pathway (C4b) was effectively inhibited in the SEV group, whereas the common pathway (C3d and C5a) was similar in both groups. CONCLUSIONS The addition of sevoflurane to cardioplegia is associated with an inhibition of neutrophils after CPB. A major component of the neutrophil response appears to be IL-8 mediated, although the classic complement pathway is also inhibited by sevoflurane.
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Biasucci LM, Liuzzo G, Colizzi C, Maseri A. The role of cytokines in unstable angina. Expert Opin Investig Drugs 2005; 7:1667-72. [PMID: 15991908 DOI: 10.1517/13543784.7.10.1667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A growing body of evidence suggests that inflammation plays a major role in the pathogenesis of unstable angina; this evidence is mainly derived from the prognostic role of the acute phase reaction proteins, such as C-reactive protein (CRP) and fibrinogen. Since the production of acute phase protein is under the control of the pro-inflammatory cytokines, it is probable that citokines, such as tumour-necrosis factor (TNF)-alpha, interleukin (IL)-1 and IL-6 are involved in the same process. Indeed, elevated levels of IL-1 and IL-6 have been found by our group and by others, in patients with acute coronary syndromes. Cytokines may have procoagulant effects, directly or via endothelial dysfunction, and may induce plaque vulnerability or rupture. They may also be responsible for the activation of other cells, as neutrophils or mast-cells. Although it is conceivable that activated lymphocytes, via interferon-gamma production, are responsible for macrophage activation and cytokine production in unstable angina, the trigger and the precise mechanism of this event are still unknown. The multiple roles of cytokines in unstable angina suggest that a targeted anti-inflammatory therapy might be a novel approach in the future for the treatment of this syndrome.
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Affiliation(s)
- L M Biasucci
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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7
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Hoffmeister HM, Ehlers R, Büttcher E, Steinmetz A, Kazmaier S, Helber U, Szabo S, Beyer ME, Seipel L. Relationship between minor myocardial damage and inflammatory acute-phase reaction in acute coronary syndromes. J Thromb Thrombolysis 2004; 15:33-9. [PMID: 14574074 DOI: 10.1023/a:1026140317777] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND In severe acute coronary syndromes (ACS) elevation of markers of inflammation and acute phase reaction (APR) like C-reactive protein (CRP) as well as a release of troponin have been reported. Using a high sensitivity troponin T (TnT) test we investigated whether an APR occurs in ACS only in the presence of ischemic myocardial damage. METHODS In 85 patients with ACS C-reactive protein (CRP), serum amyloid A (SAA), fibrinogen, thrombin antithrombin III complexes (TAT) and kallikrein were determined vs. high sensitive TnT (> or =0.02 ng/ml) initially and 2 d later vs. 45 patients with stable angina pectoris and 42 controls. RESULTS In stable angina pectoris, markers of inflammation and coagulation were slightly elevated (p < 0.05). Initially in ACS elevations of CRP to 1.2 +/- 0.3 mg/dl, SAA to 4.8 +/- 2.6 mg/dl and fibrinogen to 448 +/- 21 mg/dl (all p < 0.01 vs. controls) were found followed by a significant APR (p < 0.01). In the subgroup of TnT positive ACS patients, an APR with increased CRP (4.1 +/- 1.3 mg/dl), SAA (20.4 +/- 8.3 mg/dl), and fibrinogen (641 +/- 45 mg/dl) was detectable (all p < 0.05 vs. TnT negative patients). In contrast, patients without TnT release showed APR markers comparable to patients with stable angina pectoris. CONCLUSION Our findings demonstrate an association between myocardial injury in ACS and acute phase reaction as evidenced by several molecular markers. A highly sensitive TnT-test identified myocardial injury in about all patients with APR while a standard TnT cut-off (0.1 ng/ml) missed 32% of these patients. Thus, the APR in patients with ACS is strongly associated with at least minor ischemic myocardial damage and prior findings of an APR independent from myocardial injury are probably based on less sensitive troponin tests.
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8
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Angiolillo DJ, Biasucci LM, Liuzzo G, Crea F. La inflamación en los síndromes coronarios agudos: mecanismos e implicaciones clínicas. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77128-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Auer J, Berent R, Lassnig E, Eber B. C-reactive protein and coronary artery disease. JAPANESE HEART JOURNAL 2002; 43:607-19. [PMID: 12558125 DOI: 10.1536/jhj.43.607] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Evidence suggests that inflammation plays a key role in the pathogenesis of atherosclerosis. The chronic inflammatory process can develop to an acute clinical event by the induction of plaque rupture and therefore cause acute coronary syndromes. The aim of this study was to determine the serum levels of the circulating acute-phase reactant C-reactive protein (CRP), which is a sensitive indicator of inflammation, in patients with chronic stable coronary artery disease (CAD) and acute coronary syndromes (ACS). We studied 56 subjects: 1) 25 consecutive patients (18 men, 7 women; mean age, 68.5 +/- 14.3 years, range, 40-86) with unstable angina (UA) or acute myocardial infarction (AMI); 2) 31 consecutive patients (25 men, 6 women; mean age 64 +/- 12.7; range, 47-83, years) with signs and symptoms of clinically stable CAD. High-sensitivity-C-reactive protein (hs-CRP) levels were determined with a commercially available enzyme-linked immunoassay method. In patients with unstable angina and AMI before reperfusion therapy, CRP levels were not significantly different to those in patients with stable CAD (5.96 +/- 2.26 versus 4.35 +/- 2.6 mg/L; P = 0.12), but tended to be higher in patients with unstable angina and AMI. Baseline CRP levels in the subgroup of patients with AMI (6.49 +/- 2.28 mg/L) were significantly higher than levels in patients with stable CAD (4.35 +/- 2.6 mg/L; P = 0.02). CRP levels in patients with unstable angina and AMI were measured four times during a 72-hour period (0, 12, 24, and 72 hours). The lowest value was observed at baseline and differed significantly from values measured at any other time of the observation period (P < 0.001; 5.96 +/- 2.26; 9.5 +/- 9.04, 18.25 +/- 11.02; 20.25 +/- 10.61). CRP levels after 12, 24, and 72 hours were also significantly different to the initial values for patients with stable CAD (P < 0.01). There was no correlation between CRP and creatine kinase (CK), CK-MB isoenzyme, or troponin I positivity as markers for the extent of the myocardial injury during the observation period. Baseline levels of serum CRP tended to be higher in patients with unstable angina or AMI but were not significantly different from levels in patients with chronic stable CAD. In the subgroup of patients with AMI, baseline CRP levels were significantly higher than the levels in patients with stable CAD. CRP as a marker of inflammation is significantly increased in patients with AMI and unstable angina shortly after the onset of symptoms (after a period of 12 hours), supporting the hypothesis of an activation of inflammatory mechanisms in patients with an acute coronary syndrome or AMI.
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Affiliation(s)
- Johann Auer
- Department of Internal Medicine II/Cardiology and Intensive Care, General Hospital Wels, Grieslirchnerstrasse 42, A-4600 Wels, Austria
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10
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Doo YC, Kim DM, Oh DJ, Ryu KH, Rhim CY, Lee Y. Effect of beta blockers on expression of interleukin-6 and C-reactive protein in patients with unstable angina pectoris. Am J Cardiol 2001; 88:422-4. [PMID: 11545768 DOI: 10.1016/s0002-9149(01)01693-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Y C Doo
- Division of Cardiology, Department of Internal Medicine, Kang-Dong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, South Korea.
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11
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Affiliation(s)
- O Bazzino
- Servicio de Cardiología. Hospital Italiano de Buenos Aires. Argentina
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12
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Kojima S, Nonogi H, Morii I, Sumida H, Sutani Y, Yasuda S, Daikoku S, Goto Y, Miyazaki S. Is Inflammation Related to the Clinical Severity of Unstable Angina? ACTA ACUST UNITED AC 2001; 65:414-8. [PMID: 11348045 DOI: 10.1253/jcj.65.414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The present study determined the white blood cell (WBC) count and the serum C-reactive protein (CRP) level in 27 patients with coronary spastic angina, 16 with Braunwald class IB unstable angina (UA) and 13 with Braunwald class IIIB. The relationship between the clinical presentation of UA and the requirement for emergency percutaneous transluminal coronary angioplasty (PTCA) was examined, and in patients with medically refractory angina, the determining factor among the clinical manifestations of angina was also investigated. In the acute phase, the WBC count and the serum CRP level were significantly higher in patients with Braunwald class IIIB than in those with coronary spastic angina or Braunwald class IB UA (p<0.001). In the Braunwald class IIIB group, a significantly higher rate of patients required emergency PTCA than that of the coronary spastic angina group (p<0.01). Patients with medically refractory angina had a significantly higher WBC count and higher serum CRP level on admission, and the WBC count on admission was independently associated with medically refractory angina by multivariate analysis (p<0.05). Inflammation may play a major pathological role in the rapid development of acute coronary syndrome.
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Affiliation(s)
- S Kojima
- Department of Medicine, National Cardiovascular Center, Suita, Osaka, Japan
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Liuzzo G, Biasucci LM, Gallimore JR, Caligiuri G, Buffon A, Rebuzzi AG, Pepys MB, Maseri A. Enhanced inflammatory response in patients with preinfarction unstable angina. J Am Coll Cardiol 1999; 34:1696-703. [PMID: 10577559 DOI: 10.1016/s0735-1097(99)00432-5] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We assessed the extent and the time course of the acute phase response following myocardial cell necrosis and its relationship with the presence of preinfarction unstable angina (UA). BACKGROUND Elevated levels of acute phase proteins have been reported in patients with UA and in patients with acute myocardial infarction (MI). METHODS C-Reactive Protein (CRP), serum amyloid A protein (SAA) and interleukin-6 (IL-6) were measured in 36 patients with MI admitted within 3 h from symptoms onset. All patients had normal levels of creatine kinase and of troponin T on admission, rising above diagnostic levels within 6 to 12 h. Blood samples for CRP, SAA and IL-6 measurements were taken on admission, at 6, 24, 48, 72 h and at discharge. RESULTS Twenty of the 36 patients studied presented an unheralded MI (Group 1); the remaining 16 patients had symptoms of unstable angina in the preceding 7 days (Group 2). Group 2 patients have much higher levels of CRP and SAA on admission (median values 8.8 vs. 3 mg/L and 28 vs. 3.4 mg/L, respectively, all p<0.001). Following the necrotic insult, despite similar infarct size and clinical signs of reperfusion, Group 2 patients had strikingly higher peaks of IL-6 (median values 85.2 vs. 19 pg/ml, p<0.05), CRP (50 vs. 31.4 mg/L, p<0.05) and SAA (228 vs. 45 mg/L, p<0.001). CONCLUSIONS Our data demonstrated that the acute phase response is greatly enhanced in patients with preinfarction UA compared with those presenting with an unheralded MI. The significant differences in acute phase response observed in these two clinical presentations of MI indicate a major difference in their underlying pathogenetic components.
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Affiliation(s)
- G Liuzzo
- Department of Cardiology, Catholic University, Rome, Italy
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14
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Milazzo D, Biasucci LM, Luciani N, Martinelli L, Canosa C, Schiavello R, Maseri A, Possati G. Elevated levels of C-reactive protein before coronary artery bypass grafting predict recurrence of ischemic events. Am J Cardiol 1999; 84:459-61, A9. [PMID: 10468087 DOI: 10.1016/s0002-9149(99)00333-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
C-reactive protein was measured in 86 patients undergoing coronary artery bypass graft surgery. Patients were followed up for 3.2 years (range 1 to 6). Patients with C-reactive protein > or = 3 mg/L had significantly increased risk of recurrent ischemia at 1 to 6 years after intervention.
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Affiliation(s)
- D Milazzo
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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15
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Lagrand WK, Visser CA, Hermens WT, Niessen HW, Verheugt FW, Wolbink GJ, Hack CE. C-reactive protein as a cardiovascular risk factor: more than an epiphenomenon? Circulation 1999; 100:96-102. [PMID: 10393687 DOI: 10.1161/01.cir.100.1.96] [Citation(s) in RCA: 589] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Circulating levels of C-reactive protein (CRP) may constitute an independent risk factor for cardiovascular disease. How CRP as a risk factor is involved in cardiovascular disease is still unclear. METHODS AND RESULTS By reviewing available studies, we discuss explanations for the associations between CRP and cardiovascular disease. CRP levels within the upper quartile/quintile of the normal range constitute an increased risk for cardiovascular events, both in apparently healthy persons and in persons with preexisting angina pectoris. High CRP responses after acute myocardial infarction indicate an unfavorable outcome, even after correction for other risk factors. This link between CRP and cardiovascular disease has been considered to reflect the response of the body to the inflammatory reactions in the atherosclerotic (coronary) vessels and adjacent myocardium. However, because CRP localizes in infarcted myocardium (with colocalization of activated complement), we hypothesize that CRP may directly interact with atherosclerotic vessels or ischemic myocardium by activation of the complement system, thereby promoting inflammation and thrombosis. CONCLUSIONS CRP constitutes an independent cardiovascular risk factor. Unraveling the molecular background of this association may provide new directions for prevention of cardiovascular events.
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Affiliation(s)
- W K Lagrand
- Departments of Cardiology, Pathology and Internal Medicine, Free University Hospital, Amsterdam, The Netherlands
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Whicher J, Biasucci L, Rifai N. Inflammation, the acute phase response and atherosclerosis. Clin Chem Lab Med 1999; 37:495-503. [PMID: 10418738 DOI: 10.1515/cclm.1999.080] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is increasing evidence that atherosclerosis is a chronic inflammatory disorder resulting from a combination of processes, and that acute exacerbations of this inflammation are associated with the acute coronary syndromes such as myocardial infarction and unstable angina. Measurement of the serum level of acute phase proteins, such as C-reactive protein and serum amyloid A protein, has been used to predict the risk of acute events in patients with atherosclerosis. Prospective studies have shown that higher serum acute phase protein levels, often within the reference range, are associated with increased risk of myocardial infarction (MI), stroke or peripheral vascular disease and predict risk of infarction and death among high-risk patients. These observations have important implications for the assessment of patients and for treatment.
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Biasucci LM, Liuzzo G, Fantuzzi G, Caligiuri G, Rebuzzi AG, Ginnetti F, Dinarello CA, Maseri A. Increasing levels of interleukin (IL)-1Ra and IL-6 during the first 2 days of hospitalization in unstable angina are associated with increased risk of in-hospital coronary events. Circulation 1999; 99:2079-84. [PMID: 10217645 DOI: 10.1161/01.cir.99.16.2079] [Citation(s) in RCA: 314] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A growing body of evidence suggests a role for inflammation in acute coronary syndromes. The aim of this study was to assess the role of proinflammatory cytokines, their time course, and their association with prognosis in unstable angina. METHODS AND RESULTS We studied 43 patients aged 62+/-8 years admitted to our coronary care unit for Braunwald class IIIB unstable angina. In each patient, serum levels of interleukin-1 receptor antagonist (IL-1Ra), interleukin-6 (IL-6) (which represent sensitive markers of biologically active IL-1beta and tumor necrosis factor-alpha levels, respectively), and troponin T were measured at entry and 48 hours after admission. Troponin T-positive patients were excluded. Patients were divided a posteriori into 2 groups according to their in-hospital outcome: group 1 comprised 17 patients with an uneventful course, and group 2 comprised 26 patients with a complicated in-hospital course. In group 1, mean IL-1Ra decreased at 48 hours by 12%, and IL-6 diminished at 48 hours by 13%. In group 2, IL-1Ra and IL-6 entry levels were higher than in group 1 and increased respectively by 37% and 57% at 48 hours (P<0.01). CONCLUSIONS These findings indicate that although they receive the same medical therapy as patients who do not experience an in-hospital event, patients with unstable angina and with complicated in-hospital courses have higher cytokine levels on admission. A fall in IL-1Ra and IL-6 48 hours after admission was associated with an uneventful course and their increase with a complicated hospital course. These findings may suggest novel therapeutic approaches to patients with unstable angina.
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Affiliation(s)
- L M Biasucci
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
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Biasucci LM, Liuzzo G, Grillo RL, Caligiuri G, Rebuzzi AG, Buffon A, Summaria F, Ginnetti F, Fadda G, Maseri A. Elevated levels of C-reactive protein at discharge in patients with unstable angina predict recurrent instability. Circulation 1999; 99:855-60. [PMID: 10027805 DOI: 10.1161/01.cir.99.7.855] [Citation(s) in RCA: 368] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND In a group of patients admitted for unstable angina, we investigated whether C-reactive protein (CRP) plasma levels remain elevated at discharge and whether persistent elevation is associated with recurrence of instability. METHODS AND RESULTS We measured plasma levels of CRP, serum amyloid A protein (SAA), fibrinogen, total cholesterol, and Helicobacter pylori and Chlamydia pneumoniae antibody titers in 53 patients admitted to our coronary care unit for Braunwald class IIIB unstable angina. Blood samples were taken on admission, at discharge, and after 3 months. Patients were followed for 1 year. At discharge, CRP was elevated (>3 mg/L) in 49% of patients; of these, 42% had elevated levels on admission and at 3 months. Only 15% of patients with discharge levels of CRP <3 mg/L but 69% of those with elevated CRP (P<0.001) were readmitted because of recurrence of instability or new myocardial infarction. New phases of instability occurred in 13% of patients in the lower tertile of CRP (</=2.5 mg/L), in 42% of those in the intermediate tertile (2.6 to 8.6 mg/L), and in 67% of those in the upper tertile (>/=8.7 mg/L, P<0.001). The prognostic value of SAA was similar to that of CRP; that of fibrinogen was not significant. Chlamydia pneumoniae but not Helicobacter pylori antibody titers significantly correlated with CRP plasma levels. CONCLUSIONS In unstable angina, CRP may remain elevated for at >/=3 months after the waning of symptoms and is associated with recurrent instability. Elevation of acute-phase reactants in unstable angina could represent a hallmark of subclinical persistent instability or of susceptibility to recurrent instability and, at least in some patients, could be related to chronic Chlamydia pneumoniae infection.
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Affiliation(s)
- L M Biasucci
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
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Liuzzo G, Buffon A, Biasucci LM, Gallimore JR, Caligiuri G, Vitelli A, Altamura S, Ciliberto G, Rebuzzi AG, Crea F, Pepys MB, Maseri A. Enhanced inflammatory response to coronary angioplasty in patients with severe unstable angina. Circulation 1998; 98:2370-6. [PMID: 9832480 DOI: 10.1161/01.cir.98.22.2370] [Citation(s) in RCA: 208] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic markers of inflammation have been found in unstable angina. Disruption of culprit coronary stenoses may cause a greater inflammatory response in patients with unstable than those with stable angina. We assessed the time course of C-reactive protein (CRP), serum amyloid A protein (SAA), and interleukin-6 (IL-6) after single-vessel PTCA in 30 patients with stable and 56 patients with unstable angina (protocol A). We also studied 12 patients with stable and 15 with unstable angina after diagnostic coronary angiography (protocol B). METHODS AND RESULTS Peripheral blood samples were taken before and 6, 24, 48, and 72 hours after PTCA or angiography. In protocol A, baseline CRP, SAA, and IL-6 levels were normal in 87% of stable and 29% of unstable patients. After PTCA, CRP, SAA, and IL-6 did not change in stable patients and unstable patients with normal baseline levels but increased in unstable patients with raised baseline levels (all P<0.001). In protocol B, CRP, SAA, and IL-6 did not change in stable angina patients after angiography but increased in unstable angina patients (all P<0.05). Baseline CRP and SAA levels correlated with their peak values after PTCA and angiography (all P<0.001). CONCLUSIONS Our data suggest that plaque rupture per se is not the main cause of the acute-phase protein increase in unstable angina and that increased baseline levels of acute-phase proteins are a marker of the hyperresponsiveness of the inflammatory system even to small stimuli. Thus, an enhanced inflammatory response to nonspecific stimuli may be involved in the pathogenesis of unstable angina.
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Affiliation(s)
- G Liuzzo
- Istituto di Cardiologia, Universitá Cattolica, Roma, Italy
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Caligiuri G, Liuzzo G, Biasucci LM, Maseri A. Immune system activation follows inflammation in unstable angina: pathogenetic implications. J Am Coll Cardiol 1998; 32:1295-304. [PMID: 9809939 DOI: 10.1016/s0735-1097(98)00410-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to assess the relations between inflammation, specific immune response and clinical course in unstable angina (UA). BACKGROUND Several studies suggest that either inflammation and/or T-cell activation might have a pathogenetic role in UA, but neither their potential reciprocal connection nor their relation to the clinical course is known. METHODS Serum levels of C-reactive protein (CRP) (inflammation), IgG, IgA, IgM, C3, C4 (humoral immunity), IL-2 and the percentage of CD4+, CD8+ and CD3+/DR+ T-cells (cell-mediated immunity) were measured in 35 patients with UA and 35 patients with chronic stable angina (CSA) during a period of 6 months. RESULTS The CRP levels and the main specific immune markers (CD4+ and CD3+/DR+ cells, IL-2 and IgM) were higher in unstable than in stable angina. In UA, the serum levels of IgM and IL-2 and the percentage of double positive CD3+/DR+ significantly increased at 7 to 15 days, and returned to baseline at 6 months. The increment of circulating activated T cells (CD3+/ DR+) in UA was inversely related to the admission levels of CRP (r=-0.63, p=0.003) and associated with a better outcome. CONCLUSIONS Our data suggest that the inflammatory component systemically detectable in UA may be antigen-related and that the magnitude of the immune response correlates with the clinical outcome of instability.
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Affiliation(s)
- G Caligiuri
- Department of Cardiology, Catholic University, Rome, Italy.
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Crea F, Biasucci LM, Buffon A, Liuzzo G, Monaco C, Caligiuri G, Kol A, Sperti G, Cianflone D, Maseri A. Role of inflammation in the pathogenesis of unstable coronary artery disease. Am J Cardiol 1997; 80:10E-16E. [PMID: 9296463 DOI: 10.1016/s0002-9149(97)00483-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In this article, the clinical, angiographic, and postmortem features of unstable angina are reviewed and its pathogenesis is discussed. Coronary plaque inflammation may play a key role in the pathogenesis of unstable angina and the evidence for this assertion is examined. Finally, the therapeutic implications of the involvement of inflammation in acute coronary syndromes are outlined.
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Affiliation(s)
- F Crea
- Istituto di Cardiologia, Universita' Cattolica del Sacro Cuore, Rome, Italy
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Coronary artery disease and inflammation: reflection of underlying disease or repetitive ischemia. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0268-9499(97)80043-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Maseri A, Biasucci LM, Liuzzo G. Inflammation in ischaemic heart disease. BMJ (CLINICAL RESEARCH ED.) 1996; 312:1049-50. [PMID: 8616394 PMCID: PMC2350907 DOI: 10.1136/bmj.312.7038.1049] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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