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Ziegler L, Gajulapuri A, Frumento P, Bonomi A, Wallén H, de Faire U, Rose-John S, Gigante B. Interleukin 6 trans-signalling and risk of future cardiovascular events. Cardiovasc Res 2020; 115:213-221. [PMID: 30052808 DOI: 10.1093/cvr/cvy191] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022] Open
Abstract
Aims The pro-inflammatory response to interleukin 6 (IL6) trans-signalling in atherosclerosis is driven by the IL6 and soluble IL6 receptor (sIL6R) binary complex. The binary IL6:sIL6R complex is inactivated by sgp130 through the formation of the ternary IL6:sIL6R:sgp130 complex. The aim of this study was to investigate if IL6 trans-signalling, estimated by a ratio between the binary and ternary complexes, associates with the risk of future cardiovascular events (CVE) in a Swedish cohort of 60-year-old men and women (n = 4232). Methods and results Binary and ternary complex levels expressed in nanomol/Litre were derived from serum concentrations of IL6, sIL6R, and sgp130. Cox regression models were used to assess the risk of CVE (myocardial infarction, angina pectoris, and ischaemic stroke, n = 525), expressed as hazard ratio (HR) with 95% confidence interval (CI), associated with increasing circulating levels of the three molecules and with the binary/ternary complex ratio. Estimates were adjusted for the common cardiovascular (CV) risk factors. To assess the level of IL6-trans-signalling, we estimated the binary/ternary complex ratio and then analysed the association with CVE risk. A ratio higher than the median, representing a relative excess of the active binary complex was associated with increased CVE risk (adjusted HR 1.44, 95% CI 1.21-1.72). Conclusion The ratio between the functional moieties of IL6 trans-signalling, IL6:sIL6R, and IL6:sIL6R:sgp130, was associated with CVE risk indicating that it could be a promising marker of CV risk and possibly be used in selecting patients for anti-inflammatory therapy.
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Affiliation(s)
- Louise Ziegler
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden
| | - Ashwini Gajulapuri
- Swetox, Academic Research Center for Chemicals, Health and Environment, Södertälje, Sweden
| | - Paolo Frumento
- Unit of Biostatistics at the Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alice Bonomi
- Unit of Biostatistics, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Rose-John
- Department of Biochemistry, Christian-Albrechts-University, Kiel, Germany
| | - Bruna Gigante
- Department of Clinical Science, Danderyd Hospital, S-182 88 Stockholm, Sweden.,Unit of Cardiovascular Epidemiology, Karolinska Institutet, Stockholm, Sweden
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Nordenskjöld AM, Hammar P, Ahlström H, Bjerner T, Duvernoy O, Lindahl B. Unrecognized myocardial infarction assessed by cardiac magnetic resonance imaging is associated with adverse long-term prognosis. PLoS One 2018; 13:e0200381. [PMID: 29979788 PMCID: PMC6034881 DOI: 10.1371/journal.pone.0200381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background Unrecognized myocardial infarctions (UMIs) are common. The study is an extension of a previous study, aiming to investigate the long-term (>5 year) prognostic implication of late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) detected UMI in patients with suspected stable coronary artery disease (CAD) without previously diagnosed myocardial infarction (MI). Methods In 235 patients with suspected stable CAD without previous MI, LGE-CMR imaging and coronary angiography were performed. LGE with a subendocardial component detectable in more than one imaging plane was required to indicate UMI. The stenosis grade of the coronary arteries was determined, including in the artery supplying an infarcted area. Stenosis ≥70% stenosis was considered significant. Patients were followed for 5.4 years in mean regarding a composite endpoint of cardiovascular death, MI, hospitalization due to heart failure, stable or unstable angina. Results UMI were present in 58 of 235 patients (25%). Thirty-nine of the UMIs were located downstream of a significant coronary stenosis. During the follow-up 40 patients (17.0%) reached the composite endpoint. Of patients with UMI, 34.5% (20/58) reached the primary endpoint compared to 11.3% (20/177) of patients with no UMI (HR 3.7, 95% CI 2.0–6.9, p<0.001). The association between UMI and outcome remained (HR 2.3, 95% CI 1.2–4.4, p = 0.012) after adjustments for age, gender, extent of CAD and all other variables univariate associated with outcome. Sixteen (41%) of the patients with an UMI downstream of a significant stenosis reached the endpoint compared to four (21%) patients with UMI and no relation to a significant stenosis (HR 2.4, 95% CI 0.8–7.2, p = 0.12). Conclusion The presence of UMI was independently associated with an increased risk of cardiovascular events during long-term follow up.
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Affiliation(s)
- Anna M. Nordenskjöld
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- * E-mail:
| | - Per Hammar
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Håkan Ahlström
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Tomas Bjerner
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Olov Duvernoy
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
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Hjort M, Lindahl B, Baron T, Jernberg T, Tornvall P, Eggers KM. Prognosis in relation to high-sensitivity cardiac troponin T levels in patients with myocardial infarction and non-obstructive coronary arteries. Am Heart J 2018; 200:60-66. [PMID: 29898850 DOI: 10.1016/j.ahj.2018.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 03/03/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a recently recognized condition where biomarkers and prognosis are less well studied than in MI with obstructive coronary artery disease (MI-CAD). We therefore aimed to investigate the one-year prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) levels in MINOCA in comparison to MI-CAD. METHODS In this registry-based cohort study, we used data from patients with a discharge diagnosis of MI, admitted between 2009 and 2013 to Swedish hospitals using the hs-cTnT assay. Only patients without previously known coronary artery disease were considered. Patients with and without coronary stenosis >50% were regarded to have MI-CAD and MINOCA, respectively. Assessed outcomes included all-cause mortality, cardiovascular (CV) mortality and major CV events (MACE), defined as the composite of CV death or admissions for non-fatal MI, heart failure (HF) or ischemic stroke. RESULTS The study cohort consisted of 1639 MINOCA and 17,304 MI-CAD patients. In adjusted analyses, hs-cTnT (ln) in MINOCA patients predicted all-cause mortality (HR 1.32 [95% CI 1.11-1.56]), CV mortality (HR 2.11 [95% CI 1.51-2.96]) and MACE (HR 1.44 [95% CI 1.20-1.72]). Hs-cTnT (ln) also predicted readmissions for HF (HR 1.51 [95% CI 1.51-2.96]) but not non-fatal MI or stroke. Interaction analyses suggested that hs-cTnT (ln) was at least as prognostic in patients with MINOCA compared to MI-CAD. CONCLUSIONS Hs-cTnT levels in MINOCA patients are strong and independent predictors of adverse outcome. Consideration of hs-cTnT levels is important for risk assessment of MINOCA patients.
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Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjöld A, Gard A, Jernberg T. Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease. Circulation 2017; 135:1481-1489. [PMID: 28179398 DOI: 10.1161/circulationaha.116.026336] [Citation(s) in RCA: 295] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 5% to 10% of all patients with myocardial infarction. Clinical trials of secondary prevention treatment in MINOCA patients are lacking. Therefore, the aim of this study was to examine the associations between treatment with statins, renin-angiotensin system blockers, β-blockers, dual antiplatelet therapy, and long-term cardiovascular events. METHODS This is an observational study of MINOCA patients recorded in the SWEDEHEART registry (the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapy) between July 2003 and June 2013 and followed until December 2013 for outcome events in the Swedish Cause of Death Register and National Patient Register. Of 199 162 myocardial infarction admissions, 9466 consecutive unique patients with MINOCA were identified. Among those, the 9136 patients surviving the first 30 days after discharge constituted the study population. Mean age was 65.3 years, and 61% were women. No patient was lost to follow-up. A stratified propensity score analysis was performed to match treated and untreated groups. The association between treatment and outcome was estimated by comparing between treated and untreated groups by using Cox proportional hazards models. The exposures were treatment at discharge with statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and dual antiplatelet therapy. The primary end point was major adverse cardiac events defined as all-cause mortality, hospitalization for myocardial infarction, ischemic stroke, and heart failure. RESULTS At discharge, 84.5%, 64.1%, 83.4%, and 66.4% of the patients were on statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and dual antiplatelet therapy, respectively. During the follow-up of a mean of 4.1 years, 2183 (23.9%) patients experienced a major adverse cardiac event. The hazard ratios (95% confidence intervals) for major adverse cardiac events were 0.77 (0.68-0.87), 0.82 (0.73-0.93), and 0.86 (0.74-1.01) in patients on statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and β-blockers, respectively. For patients on dual antiplatelet therapy followed for 1 year, the hazard ratio was 0.90 (0.74-1.08). CONCLUSIONS The results indicate long-term beneficial effects of treatment with statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on outcome in patients with MINOCA, a trend toward a positive effect of β-blocker treatment, and a neutral effect of dual antiplatelet therapy. Properly powered randomized clinical trials to confirm these results are warranted.
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Affiliation(s)
- Bertil Lindahl
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.).
| | - Tomasz Baron
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
| | - David Erlinge
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
| | - Nermin Hadziosmanovic
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
| | - Anna Nordenskjöld
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
| | - Anton Gard
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
| | - Tomas Jernberg
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (B.L., T.B., A.G.); Uppsala Clinical Research Center, Uppsala University, Sweden (B.L., T.B., N.H., A.G.); Department of Cardiology, Lund University, Sweden (D.E.); Örebro University, Faculty of Health, Department of Cardiology, Sweden (A.N.); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (T.J.)
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