A comparison of the associations between seven hemostatic or inflammatory variables and coronary heart disease

Ethnopharmacology, Phytochemistry, and Pharmacological Properties of Thymus satureioides Coss

Thymus satureioides Coss. (Lamiaceae) is a Moroccan medicinal plant locally known as "Azkouni" or "Zaitra." It is widely used in traditional medicine to treat various ailments, including hypertension, diabetes, cold, fever, dermatological and circulatory disorders, immune problems, bronchitis, nociception, cooling, pharyngitis, cough, and influenza. The current review aims to critically summarize the literature on ethnopharmacological uses, chemical profile, and pharmacological investigations of T. satureioides in order to provide data support and scientific evidences for further investigations. Electronic databases such as Scopus, PubMed, Web of Science, SciFinder, ScienceDirect, Google Scholar, and Medline were used to gather data on T. satureioides. Chemical characterization of T. satureioides essential oils (EOs) and extracts allowed to identify a total of 139 bioactive compounds, mainly belonging to the terpenoids, phenolic acids, and flavonoids classes. T. satureioides especially its essential oils exhibited numerous biological activities such as antibacterial, antifungal, anti-inflammatory, antioxidant, antidiabetic, anticancer, antiparasitic, and hypolipedemic activities. In light of these findings, further studies to transmute the traditional application of T. satureioides into scientific-based information are strongly required. Additional in vivo pharmacological studies are recommended to validate the results of the in vitro studies. Moreover, comprehensive preclinical and clinical trials on the pharmacological mechanisms of action of this plant and its bioactive compounds on molecular targets should be performed. Finally, more efforts must be focused on toxicological assessments and pharmacokinetic studies, in order to ensure the safety and the efficiency of T. satureioides.

Elevated serum YKL40 level is a predictor of MACE during the long-term follow up in hypertensive patients

Background: YKL-40 (human cartilage glycoprotein 39, chitinase-3-like protein 1) is an inflammatory marker secreted mainly by macrophages and has distinctive roles on extracellular matrix remodeling, macrophage maturation, adhesion, and migration. Despite the presence of robust data suggesting the association of YKL-40 with variety of cardiovascular diseases (CV), there is no study up to date evaluating the role of YKL-40 on the long-term prognosis in patients with hypertension (HT).Methods: A single center, prospective, observational cohort study that included 327 consecutive hypertensive patients which were presented to a cardiology outpatient clinic. Patients were followed up for 7.89 ± 0.12 years. Primary outcome of the study was the occurrence of major cardiovascular outcomes (MACE) defined as all-cause mortality, new onset heart failure (HF), and coronary artery disease (CAD) requiring revascularization.Results: A total of 135 patients constituted the final study population [mean age: 52.4 ± 10.2, female: 63 (46%)]. A total of 28 (20.7%) patients had MACE during the follow up. Cox regression analysis revealed that age (HR: 1.046, 1.016-1.093 CI 95%, p = .026), diabetes (HR: 2.278, 1.026-5.057 CI 95%, p = .043), and YKL-40 level (HR: 1.019, 1.013-1.026 CI 95%, p = .005) significantly predicted MACE. We found that sensitivity and specificity of YKL-40 > 93.5 for predicting MACE was 71.4% and 65%, respectively with an area under curve (AUC) 0.723 (0.617-0.828 CI 95%, p < .001)Conclusion: Elevated serum YKL-40 level predicted MACE in hypertensive patients during a long-term follow up.

Association of Total and Differential Leukocyte Counts With Cardiovascular Disease and Mortality in the UK Biobank

OBJECTIVE

Elevated white blood cell count is associated with a higher risk of cardiovascular disease (CVD). We aimed to investigate whether specific leukocyte subpopulations, which may more closely indicate a specific inflammatory pathway, are specifically associated with CVD.

APPROACH AND RESULTS

Participants (478 259) from UK Biobank with data for white blood cell count were included. Death because of CVD (n=1377) and non-CVD causes (n=8987) occurred during median follow-up time of 7.0 years (interquartile range, 6.3-7.6). In Cox models, deciles of leukocyte counts (lymphocytes, monocytes, neutrophils, eosinophils, and basophils) were examined using the fifth decile as the referent group. Models were stratified by sex and adjusted for a range of classical risk factors. A sensitivity analysis excluded participants with baseline comorbidites and the first 2 years of follow-up. Men (hazard ratio [HR], 1.59; 95% confidence interval, 1.22-2.08) and women (HR, 2.15; 95% confidence interval, 1.38-3.35) in the highest decile of neutrophil count were at higher risk of CVD mortality and nonfatal CVD (men HR, 1.28; 95% confidence interval, 1.16-1.42 and women HR, 1.21; 95% confidence interval, 1.06-1.38). In the sensitivity analysis, the power to investigate CVD mortality was limited, but for both sexes combined, the linear HRs for a 1×10⁹/L cell count increase in white blood cell count and neutrophils, respectively, was 1.05 (1.03-1.07) and 1.07 (1.04-1.11).

CONCLUSIONS

Among circulating leukocyte subpopulations, neutrophil count in men was most consistently associated with fatal and nonfatal CVD. Further studies of interventions that lower circulating neutrophils, such as canakinumab, are required to investigate causality.

Targeting inflammation to reduce cardiovascular disease risk: a realistic clinical prospect?

Data from basic science experiments is overwhelmingly supportive of the causal role of immune-inflammatory response(s) at the core of atherosclerosis, and therefore, the theoretical potential to manipulate the inflammatory response to prevent cardiovascular events. However, extrapolation to humans requires care and we still lack definitive evidence to show that interfering in immune-inflammatory processes may safely lessen clinical atherosclerosis. In this review, we discuss key therapeutic targets in the treatment of vascular inflammation, placing basic research in a wider clinical perspective, as well as identifying outstanding questions.

LINKED ARTICLES

This article is part of a themed section on Targeting Inflammation to Reduce Cardiovascular Disease Risk. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.22/issuetoc and http://onlinelibrary.wiley.com/doi/10.1111/bcp.v82.4/issuetoc.

Increased plasma thrombin potential is associated with stable coronary artery disease: An angiographically-controlled study

INTRODUCTION

Coagulation plays a crucial role in coronary artery disease (CAD) contributing to both atherosclerotic plaque development and acute thrombotic complications, like myocardial infarction (MI). Coagulation biomarkers have been linked with ischemic heart disease, but results are still controversial.

MATERIALS AND METHODS

D-dimer and thrombin generation, two "overall" coagulation assays, were evaluated in 775 subjects with or without angiographically-proven CAD (170 CAD-free and 605 CAD, 355 of whom with history of previous MI). Subjects taking anticoagulant drugs or with any acute illness were excluded. D-dimer plasma concentration was determined by an immuno-turbidimetric assay. Thrombin generation was assessed as the ability of plasma to generate thrombin triggered by the addition of tissue factor ex-vivo by means of a chromogenic method.

RESULTS

Both D-dimer and thrombin generation parameters were associated with several traditional cardiovascular risk factors. Lag-time, time-to-peak, peak height, and Endogenous Thrombin Potential (ETP), as well as D-dimer levels, were higher in CAD patients than in CAD-free subjects. After adjustment for all the traditional risk factors, only ETP levels remained significantly associated with CAD (the highest versus the lowest tertile: OR 2.61 with 95%CI 1.14-5.99), but without improvement of C-statistic. The association of D-dimer vanished after adjustment for inflammatory markers. No difference of either D-dimer or thrombin generation parameters was found between CAD patients with or without previous MI history.

CONCLUSIONS

Our results suggest that an increased plasma thrombin potential is characteristic in patients with clinically stable CAD, irrespective of previous MI history and independent of traditional cardiovascular risk factors.

Saturated Fat Consumption and Risk of Coronary Heart Disease and Ischemic Stroke: A Science Update

At a workshop to update the science linking saturated fatty acid (SAFA) consumption with the risk of coronary heart disease (CHD) and ischemic stroke, invited participants presented data on the consumption and bioavailability of SAFA and their functions in the body and food technology. Epidemiological methods and outcomes were related to the association between SAFA consumption and disease events and mortality. Participants reviewed the effects of SAFA on CHD, causal risk factors, and surrogate risk markers. Higher intakes of SAFA were not associated with higher risks of CHD or stroke apparently, but studies did not take macronutrient replacement into account. Replacing SAFA by cis-polyunsaturated fatty acids was associated with significant CHD risk reduction, which was confirmed by randomized controlled trials. SAFA reduction had little direct effect on stroke risk. Cohort studies suggest that the food matrix and source of SAFA have important health effects.

Effect of IL-6 receptor blockade on high-sensitivity troponin T and NT-proBNP in rheumatoid arthritis

Background and aims

Observational associations between inflammation and cardiovascular disease are interesting, but randomised experimental data are lacking. We investigated the effect of the IL-6 receptor blocker tocilizumab on N terminal pro B type natriuretic peptide (NT-proBNP) and high sensitivity troponin T (hsTnT) in rheumatoid arthritis (RA) patients.

Methods

A post-hoc study was performed in a subset of patients with moderate to severe RA participating in a randomised controlled trial. The effect of tocilizumab on cardiac biomarkers was determined using stored serum (baseline and 24 weeks) in recipients of tocilizumab (8 mg/kg every 4 weeks plus DMARDs; n = 225) or placebo (every 4 weeks plus DMARDs; n = 132).

Results

Median NT-proBNP and hsTnT concentrations at baseline were 100 pg/ml and 5.7 pg/ml, respectively. NT-proBNP decreased in both study arms (median at 24 weeks 77 pg/ml in the placebo arm, 79 pg/ml in the tocilizumab arm; p<0.001 for the decrease in both arms), and decreased to a similar extent comparing study arms (tocilizumab effect: −5.5%, p=0.55). hsTnT also decreased in both study arms (median at 24 weeks 3.1 pg/ml in the placebo arm, 4.4 pg/ml in the tocilizumab arm; p<0.001 for the decrease in both arms). The extent of the reduction in hsTnT was greater in the placebo group (tocilizumab effect: +23.3%, p=0.002). Change in NT-proBNP, but not hsTnT, correlated modestly with change in CRP (r = 0.17, p=0.013).

Conclusions

These data argue against a rapid preferential benefit of IL-6 blockade on these specific surrogate markers of cardiovascular risk, but may be consistent with a general cardiovascular benefit of improved RA treatment.

Clinical trials.gov identifier

NCT00106574.

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Tocilizumab treatment was associated with a decrease in NT-proBNP, similar in magnitude to the decrease in the placebo arm.

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Troponin T also decreased in both study arms, but decreased slightly more in the placebo arm.

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These data do not support a rapid preferential benefit of tocilizumab treatment on cardiac biomarkers.

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These data may be consistent with the view that improved treatment of rheumatoid arthritis might reduce cardiovascular disease risk.

Plasma Levels of Inflammatory Biomarkers in Peripheral Arterial Disease: Results of a Cohort Study

Previous research analyzed the level of plasma inflammatory markers in patients with coronary disease, but very few studies have evaluated these markers in patients with peripheral arterial disease (PAD). The objective of this study was to investigate the plasma levels of inflammatory markers in patients with PAD and in healthy controls. The following plasma levels of biomarkers were measured in 80 patients with PAD (mean age 68 ± 5 years) and in 72 healthy participants (mean age 67 ± 6 years): interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), L-selectin (LS), neopterin (N), P-selectin (PS), E-selectin (ES), vascular cell adhesion molecule 1 (VCAM-1), intercellular adhesion molecule 1 (ICAM-1), and matrix metalloproteinase 2 (MMP-2), and 9 (MMP-9). Significantly higher levels of IL-6 (P < .001), TNF-α (P < .0001), ES (P < .0001), LS (P < .0001), PS (P < .0001), ICAM-1 (P < .001), VCAM-1 (P < .001), N (P < .001), MMP-2 (P < .001), and MMP-9 (P < .005) were found in the patients with PAD. Patients with PAD show a inflammation marker profile different from that of control participants. Reducing the high plasma levels of inflammatory markers could be a new therapeutic approach both for the prevention and the treatment of PAD.

Plasminogen activator inhibitor and the risk of cardiovascular disease: The Framingham Heart Study

INTRODUCTION

Although plasminogen activator inhibitor (PAI-1) plays a key regulatory role in fibrinolysis, it has not been clearly shown to independently predict cardiovascular disease (CVD) among individuals without prior CVD. We investigated, in the Framingham Heart Study offspring cohort, whether PAI-1 predicted CVD risk among individuals without prior CVD.

METHODS

Plasma PAI-1 antigen and tissue plasminogen activator (TPA) antigen were measured in 3203 subjects without prior CVD between 1991 and 1995; average follow-up of 10 years. PAI-1 was remeasured 4 years after baseline, to determine the effect of serial change on risk.

RESULTS

PAI-1 levels (mean ± SD) were 29.1 ng/ml (19.2) versus 22.1 (16.5) for those and without incident CVD; p<0.001, and TPA levels were 12.0 ng/ml (5.7) versus 9.0 (4.7); p<0.001. PAI-1 and TPA antigen levels had a strong unadjusted linear relation with incident CVD (p<0.001). After adjustment for conventional risk factors, the hazard ratios (HRs) for higher quartiles of PAI-1, compared with the lowest, were 1.9, 1.9, 2.6 (linear trend p=0.006), and 1.6, 1.6, 2.9 (p<0.001) for TPA antigen. The adjusted HRs for increasing quartiles of serial change in PAI-1 at 4 years, compared with the lowest, were 0.9, 0.8, 1.3 (p=0.050). C statistic assessment showed that adding PAI-1 or TPA to conventional risk factors resulted in small increases in discrimination and modest reclassification of risk, which was statistically significant for TPA (net reclassification 6.8%, p=0.037) but not PAI-1 (4.8%, p=0.113).

CONCLUSION

PAI-1 and TPA antigen levels are predictive of CVD events after accounting for established risk factors. A serial increase in PAI-1 is associated with a further increase in risk. These findings support the importance of fibrinolytic potential in CVD.

Novel cardiovascular risk markers in women with ischaemic heart disease

Abstract

The incidence of coronary heart disease in premenopausal women is lower than in men because of their hormonal protection. Angina pectoris occurs in women about 10 years later than in men. However, mortality from ischaemic heart disease remains higher in women than in men. Current studies are focusing on novel cardiovascular risk biomarkers because it seems that traditional cardiovascular risk factors and their assessment scores underestimate the risk in females. Increased plasma levels of these newly established biomarkers of risk have been found to worsen endothelial dysfunction and inflammation, both of which play a key role in the pathogenesis of microvascular angina, which is very common in women. These novel cardiovascular risk markers can be classified into three categories: inflammatory markers, markers of haemostasis, and other biomarkers.

Interplay Between Inflammation and Hemostasis in Patients with Coronary Artery Disease

Coronary artery disease (CAD) is a global epidemic currently. This study was planned to evaluate markers of inflammation and hemostasis and their possible association, if any, in patients with CAD. The study was carried out in 60 patients with acute myocardial infarction (AMI) and 60 age and gender matched controls. The following parameters were assayed in all study subjects-inflammatory-interleukin (IL)-10, high sensitivity C-reactive protein (hs-CRP), tumor necrosis factor (TNF)-α, fibrinogen; hemostatic-fibrinogen, fibrin D-dimer and a novel risk factor-homocysteine. Inflammatory markers (hs-CRP, TNF-α and IL-10), fibrinogen, fibrin D-dimer and homocysteine levels were significantly higher in the patients with AMI, as compared with controls. A positive correlation was observed between D-dimer and the inflammatory markers-hs-CRP and TNF-α. Upon multivariate analysis, TNF-α emerged as the best determinant of CAD in our study. Our results indicate that there is a possible interplay of inflammation and hemostasis in CAD, underlining their synergistic role in the pathogenesis of CAD.

Lifecourse social position and D-dimer; findings from the 1958 British birth cohort

The aim is to examine the association of lifecourse socioeconomic position (SEP) on circulating levels of D-dimer. Data from the 1958 British birth cohort were used, social class was determined at three stages of respondents' life: at birth, at 23 and at 42 years. A cumulative indicator score of SEP (CIS) was calculated ranging from 0 (always in the highest social class) to 9 (always in the lowest social class). In men and women, associations were observed between CIS and D-dimer (P<0.05). Thus, the respondents in more disadvantaged social classes had elevated levels of D-dimer compared to respondents in less disadvantaged social class. In multivariate analyses, the association of disadvantaged social position with D-dimer was largely explained by fibrinogen, C-reactive protein and von Willebrand Factor in women, and additionally by smoking, alcohol consumption and physical activity in men. Socioeconomic circumstances across the lifecourse at various stages also contribute independently to raised levels of D-dimer in middle age in women only. Risk exposure related to SEP accumulates across life and contributes to raised levels of D-dimer. The association of haemostatic markers and social differences in health may be mediated by inflammatory and other markers.

The Northwick Park Heart Study: evidence from the laboratory

The Northwick Park Heart Study (NPHS) has shown associations of high plasma fibrinogen and factor VII (FVIIc) levels with the risk of death from coronary heart disease (CHD). The finding for fibrinogen has been confirmed in many other studies. Whereas one further study has found a similar prospective association for FVIIc, several have not. Experimental studies have demonstrated the impact that the coagulation activity of fibrinogen and FVIIc have on the progression and phenotype of atherosclerotic lesions. FVIIc-driven thrombin generation and fibrin formation within the vessel wall are important determinants of both plaque (in)stability and atherothrombosis. In blood, local concentrations of FVIIc and thrombin may be sufficient to allow interactions between these serine proteases and protease-activated receptors, to drive cellular inflammatory reactions that further promote these processes. Local fibrinogen concentrations dictate fibrin clot structure and resistance to fibrinolysis. Within the atherosclerotic plaque, coagulation reactions driven by proinflammatory stimuli may initially support lesion stability (as part of wound healing), but, with advanced inflammation, thrombin and fibrin generation diminish because of proteolytic activity contributing to plaque instability. The NPHS findings have proved controversial, but, in the light of current knowledge, a reappraisal of the importance of FVIIc and fibrinogen in atherosclerosis, atherothrombosis and CHD is justified. Hypercoagulability, reflected in turn by thrombin generation capacity, and local concentrations of coagulation proteins, including FVIIc and fibrinogen, is linked to plaque phenotype, and even minute local concentrations of fibrinogen and proteases such as FVIIc may affect thrombin generation capacity.

Von Willebrand factor and ADAMTS13 in arterial thrombosis: a systematic review and meta-analysis

Von Willebrand Factor (VWF) plays an important role in hemostasis by mediating platelet adhesion and aggregation. Ultralarge VWF multimers are cleaved by ADAMTS13 in smaller, less procoagulant forms. An association between high VWF levels and cardiovascular disease has frequently been reported, and more recently also an association has been observed between low ADAMTS13 levels and arterial thrombosis. We reviewed the current literature and performed meta-analyses on the relationship between both VWF and ADAMTS13 with arterial thrombosis. Most studies showed an association between high VWF levels and arterial thrombosis. It remains unclear whether ADAMTS13 is a causal independent risk factor because the association between low ADAMTS13 and arterial thrombosis is so far only shown in case-control studies. Prospective studies are awaited. A causal role for ADAMTS13 is supported by mice studies of cerebral infarction where the infusion of recombinant human ADAMTS13 reduced the infarct size.

Physical activity in older men: longitudinal associations with inflammatory and hemostatic biomarkers, N-terminal pro-brain natriuretic peptide, and onset of coronary heart disease and mortality

OBJECTIVES

To examine associations between habitual physical activity (PA) and changes in PA and onset of coronary heart disease (CHD) and the pathways linking PA to CHD.

DESIGN

British Regional Heart Study population-based cohort; men completed questionnaires in 1996 and 1998 to 2000, attended rescreen in 1998 to 2000, and were followed up to June 2010.

SETTING

Community.

PARTICIPANTS

Of 4,252 men recruited from primary care centers (77% of those invited and eligible) who were rescreened in 1998 to 2000, 3,320 were ambulatory and free from CHD, stroke, and heart failure and participated in the current study.

MEASUREMENTS

Usual PA (regular walking and cycling, recreational activity and sport). Outcome was first fatal or nonfatal myocardial infarction.

RESULTS

In 3,320 ambulatory men, 303 first and 184 fatal CHD events occurred during a median of 11 years of follow-up; 9% reported no usual PA, 23% occasional PA, and 68% light or more-intense PA. PA was inversely associated with novel risk markers C-reactive protein, D-dimer, von Willebrand Factor and N-terminal pro-brain natriuretic peptide (NT-proBNP). Compared with no usual PA, hazard ratios (HRs) for CHD events, adjusted for age and region, were 0.52 (95% confidence interval (CI) = 0.34-0.79) for occasional PA, 0.47 (95% CI = 0.30-0.74) for light PA, 0.51 (95% CI = 0.32-0.82) for moderate PA, and 0.44 (95% CI = 0.29-0.65) for moderately vigorous or vigorous PA (P for linear trend = .004). Adjustment for established and novel risk markers somewhat attenuated HRs and abolished linear trends. Compared with men who remained inactive, men who maintained at least light PA had an HR for CHD events of 0.73 (95% CI = 0.53-1.02) and men whose PA level increased had an HR of 0.86 (95% CI = 0.55-1.35).

CONCLUSION

Even light PA was associated with significantly lower risk of CHD events in healthy older men, partly through inflammatory and hemostatic mechanisms and cardiac function (NT-proBNP).

C-reactive protein levels in patients at cardiovascular risk: EURIKA study

Background

Elevated C-reactive protein (CRP) levels are associated with high cardiovascular risk, and might identify patients who could benefit from more carefully adapted risk factor management. We have assessed the prevalence of elevated CRP levels in patients with one or more traditional cardiovascular risk factors.

Methods

Data were analysed from the European Study on Cardiovascular Risk Prevention and Management in Usual Daily Practice (EURIKA, ClinicalTrials.gov Identifier: NCT00882336), which included patients (aged ≥50 years) from 12 European countries with at least one traditional cardiovascular risk factor but no history of cardiovascular disease. Analysis was also carried out on the subset of patients without diabetes mellitus who were not receiving statin therapy.

Results

In the overall population, CRP levels were positively correlated with body mass index and glycated haemoglobin levels, and were negatively correlated with high-density lipoprotein cholesterol levels. CRP levels were also higher in women, those at higher traditionally estimated cardiovascular risk and those with greater numbers of metabolic syndrome markers. Among patients without diabetes mellitus who were not receiving statin therapy, approximately 30% had CRP levels ≥3 mg/L, and approximately 50% had CRP levels ≥2 mg/L, including those at intermediate levels of traditionally estimated cardiovascular risk.

Conclusions

CRP levels are elevated in a large proportion of patients with at least one cardiovascular risk factor, without diabetes mellitus who are not receiving statin therapy, suggesting a higher level of cardiovascular risk than predicted according to conventional risk estimation systems.

Trial registration

ClinicalTrials.gov Identifier: NCT00882336

Plasma tissue factor pathway inhibitor levels in angiographically defined coronary artery disease among saudis

OBJECTIVES

This study was aimed to determine plasma levels of total (TFPI-T) and free (TFPI-F) tissue factor pathway inhibitor, plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator (t-PA) in a cohort of Saudi patients with chronic stable angiographically defined coronary artery disease (CAD) and to determine its correlation with its severity.

METHODS

This cross sectional study was conducted in the department of physiology and department of cardiology, College of Medicine, and King Khalid University Hospital and King Saud University, Riyadh. Sixty known cases of CAD who had undergone angiography (35 males and 25 females) were selected. A control group included 39 (20 males and 19 females) healthy subjects. Fasting venous blood samples were analyzed for total (TFPI-T) and free (TFPI-F) tissue factor pathway inhibitor, plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator (t-PA). Gensini scores and vessel scores were determined for assessing CAD severity.

RESULTS

There were non-significant differences between age, body mass index (BMI) and Blood pressure between the controls and CAD subjects. A comparison of hemostatic markers between control and CAD patients showed significantly higher levels of Fibrinogen, PAI-1, TFPI-T and TFPI-F in CAD patients compared to control subjects. But there was no difference in plasma t-PA levels. TFPI-T had a significant positive correlation with severity of disease determined by Gensini Scores (r=0.344; p=0.006) and vessel scores (r=0.338; p=0.015).

CONCLUSION

Plasma levels of total tissue factor pathway inhibitor are significantly related with the presence and severity of CAD. Elevated levels of TFPI-T may be considered as useful diagnostic and prognostic markers in patients with CAD.

The late-phase inflammatory response after drug-eluting stent implantation

Recent advances in drug-eluting stent (DES) technology have succeeded in preventing restenosis. In addition to inhibiting smooth muscle cell proliferation, DES greatly inhibits the local inflammatory response in the acute phase after implantation, leading to prevention of restenosis. However, a unique issue in DES implantation is an impairment of reendothelialization, which may result in abnormal wound healing. Consequently, a late-phase inflammatory relapse could appear in the long term after DES implantation. In this study, we measured serum levels of inflammatory markers, including interleukin (IL)-6, IL-8, tumor necrosis factor-α, monocyte chemoattractant protein-1, matrix metalloproteinase-9, and myeloperoxidase, as well as high-sensitivity C-reactive protein at follow-up coronary angiography (mean 9 months) in 54 patients who received DES stenting who did not experience restenosis, and compared them with 51 patients receiving bare-metal stents (BMS) without restenosis. The level of IL-6 was over the measurement threshold (≥2.22 pg/ml) in 12 patients (21 %) in the DES group, but in only 2 patients (4 %) in the BMS group (P = 0.003). IL-8 was significantly higher in the DES group than in the BMS group (4.51 ± 2.40 vs 3.84 ± 1.34 pg/ml, P = 0.015). The levels of other biomarkers were similar between the two groups. DES showed an increase in inflammatory cytokines in the late phase after implantation in comparison with patients who received BMS, suggesting late-stage inflammation. Therefore, the wound-healing response after DES implantation might be different from that after BMS.

Hemostatic factors and risk of coronary heart disease in general populations: new prospective study and updated meta-analyses

BACKGROUND

Activation of blood coagulation and fibrinolysis may be associated with increased risk of coronary heart disease. We aimed to assess associations of circulating tissue plasminogen activator (t-PA) antigen, D-dimer and von Willebrand factor (VWF) with coronary heart disease risk.

DESIGN

Prospective case-control study, systematic review and meta-analyses.

METHODS

Measurements were made in 1925 people who had a first-ever nonfatal myocardial infarction or died of coronary heart disease during follow-up (median 19.4 years) and in 3616 controls nested within the prospective population-based Reykjavik Study.

RESULTS

Age and sex-adjusted odds ratios for coronary heart disease per 1 standard deviation higher baseline level were 1.25 (1.18, 1.33) for t-PA antigen, 1.01 (0.95, 1.07) for D-dimer and 1.11 (1.05, 1.18) for VWF. After additional adjustment for conventional cardiovascular risk factors, corresponding odds ratios were 1.07 (0.99, 1.14) for t-PA antigen, 1.06 (1.00, 1.13) for D-dimer and 1.08 (1.02, 1.15) for VWF. When combined with the results from previous prospective studies in a random-effects meta-analysis, overall adjusted odds ratios were 1.13 (1.06, 1.21) for t-PA antigen (13 studies, 5494 cases), 1.23 (1.16, 1.32) with D-dimer (18 studies, 6799 cases) and 1.16 (1.10, 1.22) with VWF (15 studies, 6556 cases).

CONCLUSIONS

Concentrations of t-PA antigen, D-dimer and VWF may be more modestly associated with first-ever CHD events than previously reported. More detailed analysis is required to clarify whether these markers are causal risk factors or simply correlates of coronary heart disease.

Fibrinogen gene regulation

The Aα, Bβ and γ polypeptide chains of fibrinogen are encoded by a three gene cluster on human chromosome four. The fibrinogen genes (FGB-FGA-FGG) are expressed almost exclusively in hepatocytes where their output is coordinated to ensure a sufficient mRNA pool for each chain and maintain an abundant plasma fibrinogen protein level. Fibrinogen gene expression is controlled by the activity of proximal promoters which contain binding sites for hepatocyte transcription factors, including proteins which influence fibrinogen transcription in response to acute-phase inflammatory stimuli. The fibrinogen gene cluster also contains cis regulatory elements; enhancer sequences with liver activities identified by sequence conservation and functional genomics. While the transcriptional control of this gene cluster is fascinating biology, the medical impetus to understand fibrinogen gene regulation stems from the association of cardiovascular disease risk with high level circulating fibrinogen. In the general population this level varies from about 1.5 to 3.5 g/l. This variation between individuals is influenced by genotype, suggesting there are genetic variants contributing to fibrinogen levels which reside in fibrinogen regulatory loci. A complete picture of how fibrinogen genes are regulated will therefore point towards novel sources of regulatory variants. In this review we discuss regulation of the fibrinogen genes from proximal promoters and enhancers, the influence of acute-phase stimulation, post-transcriptional regulation by miRNAs and functional regulatory variants identified in genetic studies. Finally, we discuss the fibrinogen locus in light of recent advances in understanding chromosomal architecture and suggest future directions for researching the mechanisms that control fibrinogen expression.

Can haemostatic factors predict atherothrombosis?

Thrombosis is "haemostasis in the wrong place", and there is increasing evidence that haemostatic factors are associated with increased risk of atherothrombotic events. Increasing plasma levels of fibrinogen are associated with increased risks of coronary heart disease, stroke and peripheral arterial disease, and with vascular and nonvascular mortality. However, as with other markers of haemostasis (and of inflammation), their additional predictive value to conventional risk factors is small. Ongoing studies of activation markers of coagulation (e.g. fibrin D-dimer), endothelium (e.g. von Willebrand factor, tissue plasminogen activator antigen) and platelets (mean platelet volume) may provide additional predictive value for atherothrombotic events. However, at present there is no sufficient evidence base for their routine measurement in prediction.

Sex differences in the relationship between inflammatory and hemostatic biomarkers and metabolic syndrome: British 1958 Birth Cohort

BACKGROUND

Circulating levels of C-reactive protein (CRP), fibrinogen, fibrin D-dimer, tissue plasminogen activator antigen (t-PA) and von Willebrand factor (VWF) are associated with incident coronary heart disease (CHD). However, their associations with metabolic syndrome and its components in large populations of men and women have not been well defined.

OBJECTIVES

We compare the sex associations of these biomarkers with established CHD risk factors, metabolic syndrome and its components in a large cohort.

PATIENTS AND METHODS

8302 men and women aged 45 years from the British 1958 birth cohort provided a blood sample. Analyses were restricted to 3457 men and 3464 women with complete data on all risk factors and no history of cardiovascular disease. Multiple regression analyses adjusted for smoking, social class, alcohol consumption and variables related to biomarker measurement error.

RESULTS

Adjusted sex differences in levels of all biomarkers (except VWF) varied according to presence/absence of metabolic syndrome, its components and obesity (BMI ≥30 kg m(-) (2)). Associations in women were up to twice as strong for CRP, fibrinogen and t-PA with markers of obesity (body mass index, waist circumference), blood pressure, blood lipids and metabolic syndrome. D-dimer showed weaker associations and less heterogeneity by sex. There was no evidence of sex interaction in associations with VWF.

CONCLUSIONS

Associations between CRP, fibrinogen and t-PA and metabolic syndrome and its components were stronger in women than in men. Understanding the reasons for these differences across sex will be important in understanding the pathophysiology of cardiovascular and metabolic disease in men and women.

Significant associations among hemostatic parameters, adipokines, and components of the metabolic syndrome in Japanese preschool children

Development of cardiovascular diseases could originate in early childhood. However, reference values of hemostatic parameters and adipokines in preschool children remain to be explored. We measured blood levels of adipokines and parameters of the hemostatic/fibrinolytic systems in 167 healthy children aged 4 to 6 years at 9:00 to 10:30 am after a strictly enforced overnight fast. Participants with body mass index (BMI) values ≥90th percentile had significantly higher values of systolic blood pressure and heart rate, as well as blood levels of insulin, coagulation factor (F) VII, FX, protein S, leptin, and homeostasis model assessment of insulin resistance (HOMA-IR), and lower values of desacyl-ghrelin than children with BMI < 90th percentile. Circulating levels of fibrinogen and leptin increased with increased number of cardiovascular risk factors. Stepwise regression analysis identified many hematological variables to be associated with features of the metabolic syndrome. The results implicated the hemostatic/fibrinolytic system or adipokines in the insidious progression of cardiovascular diseases from an early age.

Effects of tesamorelin on inflammatory markers in HIV patients with excess abdominal fat: relationship with visceral adipose reduction

OBJECTIVE

To report the effects of tesamorelin, a growth hormone-releasing hormone analogue, on inflammatory and fibrinolytic markers and to relate these effects to changes in visceral adipose tissue (VAT).

DESIGN AND METHODS

Four hundred and ten HIV-infected patients with abdominal adiposity were randomized to 2 mg tesamorelin (n = 273) or placebo (n = 137) subcutaneously daily for 26 weeks. Circulating plasminogen activator inhibitor-1 (PAI-1) antigen, tissue plasminogen activator (tPA) antigen, C-reactive protein (CRP), and adiponectin were assessed.

RESULTS

At baseline, VAT was significantly associated with PAI-1 antigen (ρ = 0.36, P < 0.001), tPA antigen (ρ = 0.29, P < 0.001), CRP (ρ = 0.18, P < 0.001), and adiponectin (ρ = -0.22, P < 0.001). Treatment with tesamorelin resulted in a significant decrease from baseline in tPA antigen (-2.2 ± 2.5 vs. -1.6 ± 2.9 ng/ml, tesamorelin vs. placebo, P < 0.05). Changes in PAI-1 antigen were not significant in the tesamorelin group compared to placebo. Among patients receiving tesamorelin, changes in inflammatory markers were associated with change in VAT (PAI-1 antigen: ρ = 0.16, P = 0.02; tPA antigen: ρ = 0.16, P = 0.02; adiponectin: ρ = -0.27, P < 0.001), and these associations remained significant when controlling for changes in insulin-like growth factor-1.

CONCLUSION

In HIV patients with abdominal adiposity, tesamorelin may have a modest beneficial effect on adiponectin and fibrinolytic markers in association with changes in VAT. Further studies are needed to determine the clinical significance of these changes. These data further highlight the deleterious role of excessive VAT and the utility of strategies to improve VAT in this population.

Multimarker prediction of coronary heart disease risk: the Women's Health Initiative

OBJECTIVES

The aim of this study was to investigate whether multiple biomarkers contribute to improved coronary heart disease (CHD) risk prediction in post-menopausal women compared with assessment using traditional risk factors (TRFs) only.

BACKGROUND

The utility of newer biomarkers remains uncertain when added to predictive models using only TRFs for CHD risk assessment.

METHODS

The Women's Health Initiative Hormone Trials enrolled 27,347 post-menopausal women ages 50 to 79 years. Associations of TRFs and 18 biomarkers were assessed in a nested case-control study including 321 patients with CHD and 743 controls. Four prediction equations for 5-year CHD risk were compared: 2 Framingham risk score covariate models; a TRF model including statin treatment, hormone treatment, and cardiovascular disease history as well as the Framingham risk score covariates; and an additional biomarker model that additionally included the 5 significantly associated markers of the 18 tested (interleukin-6, d-dimer, coagulation factor VIII, von Willebrand factor, and homocysteine).

RESULTS

The TRF model showed an improved C-statistic (0.729 vs. 0.699, p = 0.001) and net reclassification improvement (6.42%) compared with the Framingham risk score model. The additional biomarker model showed additional improvement in the C-statistic (0.751 vs. 0.729, p = 0.001) and net reclassification improvement (6.45%) compared with the TRF model. Predicted CHD risks on a continuous scale showed high agreement between the TRF and additional biomarker models (Spearman's coefficient = 0.918). Among the 18 biomarkers measured, C-reactive protein level did not significantly improve CHD prediction either alone or in combination with other biomarkers.

CONCLUSIONS

Moderate improvement in CHD risk prediction was found when an 18-biomarker panel was added to predictive models using TRFs in post-menopausal women.

The value of C-reactive protein in screening for future coronary heart disease events

Measurement of C-reactive protein (CRP), an inflammatory marker associated with coronary heart disease (CHD) events, has been proposed as a means of screening for future CHD. In prospective studies about a three-fold increase in risk of CHD observed between the top fifth and bottom fifth of the CRP distribution has been taken to support the use of CRP as a screening test. This however gives an over-optimistic impression of its value, because people in the middle of the distribution, where most CHD events occur, are excluded from the analysis. A different analysis is needed to assess whether screening is worthwhile. Examination of the relative frequency distributions of CRP in individuals from 22 prospective studies of individuals without previous cardiovascular disease who subsequently did and did not have a CHD event shows that the detection rate (or sensitivity) was 18% for a false-positive rate of 10% (CRP cut-off 6.65 mg/L); a poor screening test. Whatever CRP cut-off is used, the overlap in CRP values between affected and unaffected individuals is too great for CRP to usefully discriminate between those who will and will not have a CHD event.

Does interleukin-18 or tumour necrosis factor-alpha have an independent association with the risk of coronary heart disease? Results from a prospective study in New Zealand

BACKGROUND

The pro-inflammatory cytokines, interleukin (IL)-18 and tumour necrosis factor-alpha (TNFalpha) may play a role in coronary heart disease (CHD). We aimed to extend data on their relationships to the risk of CHD in generally healthy populations.

METHODS

During 5.5years follow-up in the Fletcher Challenge general population cohort there were 256 CHD cases, and 615 controls were matched for age and sex. Baseline plasma levels of IL-18 and TNFalpha were related to CHD risk in available samples (77%).

RESULTS

Plasma levels of IL-18 (11% increase in mean, p=0.01) and TNFalpha (10% increase in mean p=0.024) were significantly elevated in CHD cases versus controls. In univariable models IL-18 was associated with CHD risk (odds ratio [OR] upper third to lower third, 1.63; 95% CI 1.08, 2.46), but TNFalpha was not (OR 1.33; 95% CI 0.87, 2.02).After adjusting for major CHD risk factors and CRP, the association of IL-18 with CHD risk was attenuated (OR 1.69; 95% CI 0.94, 3.03).

CONCLUSIONS

IL-18, but not TNFalpha, had a non-negligible association with CHD risk, although the association of IL-18 with risk was weak after full adjustment. These cytokines may play a role in CHD pathology, but may not be robust risk biomarkers.

Hemostasis, inflammation, and fatal and nonfatal coronary heart disease: long-term follow-up of the atherosclerosis risk in communities (ARIC) cohort

OBJECTIVE

This study examines the hypothesis that chronic inflammation is associated with a higher risk of cardiac death compared to the risk of nonfatal myocardial infarction.

METHODS AND RESULTS

Cardiac death and nonfatal MI events were identified in the ARIC cohort during follow-up from 1987 through 2001. Markers of inflammation and hemostasis were determined at baseline using standardized procedures. Cox proportional hazard regression and polytomous logistic regression were used to estimate associations. We observed a positive gradient in incidence of sudden cardiac death (SCD), nonsudden cardiac death (NSCD), and nonfatal MI in association with decreasing levels of albumin and increasing levels of white blood cell count and of markers of hemostasis (fibrinogen, von Willebrand factor, factor VIIIc). Associations for von Willebrand factor were stronger for fatal relative to nonfatal events (3rd versus 1st tertile hazard ratios: SCD 3.11 [95% CI 2.10, 4.59], NSCD 2.12 [95% CI 1.28, 3.49], nonfatal MI 1.42 [95% CI 1.19, 1.70]). For factor VIIIc those associations were strongest for sudden cardiac death: SCD 3.16 (95% CI 2.18, 4.58), NSCD 1.44 (95% CI 0.93, 2.24), nonfatal MI 1.54 (95% CI 1.29, 1.84). Gradients of association for fibrinogen and white blood cell count, examined over tertiles of distribution and per one SD increase, were similar for the 3 end points. All associations were independent of smoking status.

CONCLUSIONS

von Willebrand factor and factor VIIIc are associated with an increased risk of cardiac death as compared to the risk of nonfatal MI.

Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality

CONTEXT

Circulating concentration of lipoprotein(a) (Lp[a]), a large glycoprotein attached to a low-density lipoprotein-like particle, may be associated with risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationship of Lp(a) concentration with risk of major vascular and nonvascular outcomes.

STUDY SELECTION

Long-term prospective studies that recorded Lp(a) concentration and subsequent major vascular morbidity and/or cause-specific mortality published between January 1970 and March 2009 were identified through electronic searches of MEDLINE and other databases, manual searches of reference lists, and discussion with collaborators.

DATA EXTRACTION

Individual records were provided for each of 126,634 participants in 36 prospective studies. During 1.3 million person-years of follow-up, 22,076 first-ever fatal or nonfatal vascular disease outcomes or nonvascular deaths were recorded, including 9336 CHD outcomes, 1903 ischemic strokes, 338 hemorrhagic strokes, 751 unclassified strokes, 1091 other vascular deaths, 8114 nonvascular deaths, and 242 deaths of unknown cause. Within-study regression analyses were adjusted for within-person variation and combined using meta-analysis. Analyses excluded participants with known preexisting CHD or stroke at baseline.

DATA SYNTHESIS

Lipoprotein(a) concentration was weakly correlated with several conventional vascular risk factors and it was highly consistent within individuals over several years. Associations of Lp(a) with CHD risk were broadly continuous in shape. In the 24 cohort studies, the rates of CHD in the top and bottom thirds of baseline Lp(a) distributions, respectively, were 5.6 (95% confidence interval [CI], 5.4-5.9) per 1000 person-years and 4.4 (95% CI, 4.2-4.6) per 1000 person-years. The risk ratio for CHD, adjusted for age and sex only, was 1.16 (95% CI, 1.11-1.22) per 3.5-fold higher usual Lp(a) concentration (ie, per 1 SD), and it was 1.13 (95% CI, 1.09-1.18) following further adjustment for lipids and other conventional risk factors. The corresponding adjusted risk ratios were 1.10 (95% CI, 1.02-1.18) for ischemic stroke, 1.01 (95% CI, 0.98-1.05) for the aggregate of nonvascular mortality, 1.00 (95% CI, 0.97-1.04) for cancer deaths, and 1.00 (95% CI, 0.95-1.06) for nonvascular deaths other than cancer.

CONCLUSION

Under a wide range of circumstances, there are continuous, independent, and modest associations of Lp(a) concentration with risk of CHD and stroke that appear exclusive to vascular outcomes.

Genetic Loci associated with C-reactive protein levels and risk of coronary heart disease

CONTEXT

Plasma levels of C-reactive protein (CRP) are independently associated with risk of coronary heart disease, but whether CRP is causally associated with coronary heart disease or merely a marker of underlying atherosclerosis is uncertain.

OBJECTIVE

To investigate association of genetic loci with CRP levels and risk of coronary heart disease.

DESIGN, SETTING, AND PARTICIPANTS

We first carried out a genome-wide association (n = 17,967) and replication study (n = 13,615) to identify genetic loci associated with plasma CRP concentrations. Data collection took place between 1989 and 2008 and genotyping between 2003 and 2008. We carried out a mendelian randomization study of the most closely associated single-nucleotide polymorphism (SNP) in the CRP locus and published data on other CRP variants involving a total of 28,112 cases and 100,823 controls, to investigate the association of CRP variants with coronary heart disease. We compared our finding with that predicted from meta-analysis of observational studies of CRP levels and risk of coronary heart disease. For the other loci associated with CRP levels, we selected the most closely associated SNP for testing against coronary heart disease among 14,365 cases and 32,069 controls.

MAIN OUTCOME MEASURE

Risk of coronary heart disease.

RESULTS

Polymorphisms in 5 genetic loci were strongly associated with CRP levels (% difference per minor allele): SNP rs6700896 in LEPR (-14.8%; 95% confidence interval [CI], -17.6% to -12.0%; P = 6.2 x 10(-22)), rs4537545 in IL6R (-11.5%; 95% CI, -14.4% to -8.5%; P = 1.3 x 10(-12)), rs7553007 in the CRP locus (-20.7%; 95% CI, -23.4% to -17.9%; P = 1.3 x 10(-38)), rs1183910 in HNF1A (-13.8%; 95% CI, -16.6% to -10.9%; P = 1.9 x 10(-18)), and rs4420638 in APOE-CI-CII (-21.8%; 95% CI, -25.3% to -18.1%; P = 8.1 x 10(-26)). Association of SNP rs7553007 in the CRP locus with coronary heart disease gave an odds ratio (OR) of 0.98 (95% CI, 0.94 to 1.01) per 20% lower CRP level. Our mendelian randomization study of variants in the CRP locus showed no association with coronary heart disease: OR, 1.00; 95% CI, 0.97 to 1.02; per 20% lower CRP level, compared with OR, 0.94; 95% CI, 0.94 to 0.95; predicted from meta-analysis of the observational studies of CRP levels and coronary heart disease (z score, -3.45; P < .001). SNPs rs6700896 in LEPR (OR, 1.06; 95% CI, 1.02 to 1.09; per minor allele), rs4537545 in IL6R (OR, 0.94; 95% CI, 0.91 to 0.97), and rs4420638 in the APOE-CI-CII cluster (OR, 1.16; 95% CI, 1.12 to 1.21) were all associated with risk of coronary heart disease.

CONCLUSION

The lack of concordance between the effect on coronary heart disease risk of CRP genotypes and CRP levels argues against a causal association of CRP with coronary heart disease.

Effects of gender and dementia severity on Alzheimer's disease caregivers' sleep and biomarkers of coagulation and inflammation

BACKGROUND

Being a caregiver for a spouse with Alzheimer's disease is associated with increased risk for cardiovascular illness, particularly for males. This study examined the effects of caregiver gender and severity of the spouse's dementia on sleep, coagulation, and inflammation in the caregiver.

METHODS

Eighty-one male and female spousal caregivers and 41 non-caregivers participated (mean age of all participants 70.2 years). Full-night polysomnography (PSG) was recorded in each participants home. Severity of the Alzheimer's disease patient's dementia was determined by the Clinical Dementia Rating (CDR) scale. The Role Overload scale was completed as an assessment of caregiving stress. Blood was drawn to assess circulating levels of D-dimer and Interleukin-6 (IL-6).

RESULTS

Male caregivers who were caring for a spouse with moderate to severe dementia spent significantly more time awake after sleep onset than female caregivers caring for spouses with moderate to severe dementia (p=.011), who spent a similar amount of time awake after sleep onset to caregivers of low dementia spouses and to non-caregivers. Similarly, male caregivers caring for spouses with worse dementia had significantly higher circulating levels of D-dimer (p=.034) than females caring for spouses with worse dementia. In multiple regression analysis (adjusted R(2)=.270, p<.001), elevated D-dimer levels were predicted by a combination of the CDR rating of the patient (p=.047) as well as greater time awake after sleep onset (p=.046).

DISCUSSION

The findings suggest that males caring for spouses with more severe dementia experience more disturbed sleep and have greater coagulation, the latter being associated with the disturbed sleep. These findings may provide insight into why male caregivers of spouses with Alzheimer's disease are at increased risk for illness, particularly cardiovascular disease.

Association between von Willebrand factor gene polymorphism and preeclampsia

AIMS

The aims of this study were to assess whether the Msp I polymorphism of von Willebrand factor (vWF)(intron 19) gene differs between patients with preeclampsia and normal pregnancies in Chinese Han population, and to study the relationship between the Msp I polymorphism in the vWF(intron 19) gene and severity of preeclampsia symptoms within the preeclampsia group.

METHODS

In this case-control study, peripheral blood samples of 70 patients with preeclampsia and 82 normal pregnancies were genotyped for the Msp I polymorphism in vWF(intron 19) gene on the basis of a hospital-based study. The genotyping was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and direct sequencing techniques.

RESULTS

The genotype frequencies for M+/M+, M+/M- and M-/M- were 22.9, 45.7 and 31.4% in patients with preeclampsia, and 1.2, 36.6 and 62.2% in normal pregnancies, respectively. The frequency of the M+ allele in patients with preeclampsia was significantly higher than in normal pregnancies (45.7 vs. 19.5%).

CONCLUSIONS

The Msp I polymorphism in intron 19 (M+ allele) of vWF gene is associated with the development and the severity of preeclampsia, and may be a susceptibility factor for preeclampsia.

Cardiovascular disease and periodontitis: an update on the associations and risk

BACKGROUND

Associations between periodontitis and cardiovascular diseases have been recognized.

MATERIAL AND METHODS

New literature since the last European Workshop on Periodontology has been reviewed.

RESULTS

The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1-2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear.

CONCLUSIONS

Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case-control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

C-reactive protein and coronary heart disease: predictive test or therapeutic target?

BACKGROUND

The hepatocyte-derived acute-phase reactant C-reactive protein (CRP) has been the subject of intense research over the last 2 decades for its possible role in the pathogenesis of cardiovascular diseases. This research has spawned interest in the use of the blood concentration of CRP for predicting a first coronary heart disease (CHD) event, which has been made possible with the development of high-sensitivity CRP (hsCRP) assays that can measure the typically low concentrations of CRP that circulate in the absence of an overt infective or inflammatory episode, and as a potential causal factor that might be targeted therapeutically. The research has encompassed observational and genetic epidemiology, basic science studies with cells and tissues, experiments with animal models and humans, and randomized trials (although not of specific CRP-lowering therapies as yet).

CONTENT

We focus on investigations of the potential role of small differences in basal hsCRP concentration seen in healthy individuals and the relationship of such differences to the long-term risk of a first CHD event, rather than on research devoted to the high acute-phase CRP concentrations, which occur after acute atherothrombotic events and can influence the severity of ischemic tissue damage and the subsequent prognosis. We concentrate mainly on research findings at the translational interface and draw on evidence from human observational and genetic epidemiology, as well as from randomized trials.

CONCLUSIONS

As the field matures from one of discovery to an evaluative science, the development of possible clinical applications requires a sharpening of focus on and a critical appraisal of the strengths and deficiencies of the accumulated evidence. Such assessments require attention to both the current state of affairs and the design of future research, so that the existing uncertainties about the utility of CRP in predicting CHD and its role in causing this disease can be resolved.

Association between both lipid and protein oxidation and the risk of fatal or non-fatal coronary heart disease in a human population

The role of oxidative damage in the aetiology of coronary disease remains controversial, as clinical trials investigating the effect of antioxidants have not generally been positive. In the present study, 227 coronary cases, identified from a cohort study, were matched, by age and gender, with 420 controls in a nested case-control design. Stored plasma samples were analysed for F2-isoprostanes by stable isotope dilution MS, and specifically oxidized forms of apoA-I (apolipoprotein A-I) by HPLC of HDL (high-density lipoprotein). Median values of F2-isoprostanes were higher in plasma samples that contained oxidized apoA-I compared with samples with undetectable oxidized apoA-I (1542 compared with 1165 pmol/l). F2-Isoprostanes were significantly correlated with variants of non-oxidized apoA-II (r=−0.15) and were associated with HDL-cholesterol (P<0.0001). F2-Isoprostanes in cases (median, 1146 pmol/l) were not different from controls (1250 pmol/l); the odds ratio (95% confidence interval) for a 1 S.D. increase in F2-isoprostanes was 1.08 (0.91–1.29). Similarly, there was no independent association between the presence of oxidized apoA-I, detected in approx. 20% of the samples, and coronary risk. In conclusion, we found no evidence of associations between markers of lipid (F2-isoprostanes) and protein (oxidized apoA-I) oxidation and the risk of fatal or non-fatal coronary heart disease in a general population. This may be due to a true lack of association or insufficient power.

C-reactive protein and coronary heart disease: a critical review

Modestly elevated baseline concentrations of C-reactive protein (CRP), the classical acute phase protein, are associated with the long-term risk of coronary heart disease in general populations, whilst the major acute phase response of CRP following myocardial infarction is associated with death and cardiac complications. The pathogenic and clinical significance of these associations is controversial. Here we critically review the evidence and describe large-scale epidemiological studies, novel experiments and possible specific therapies which will rigorously inform the debate. We distinguish between the potential pathogenicity of high acute phase circulating CRP concentrations in individuals with substantial tissue damage and modest but persistent increases in baseline values in generally healthy subjects.

Derived fibrinogen compared with C-reactive protein and brain natriuretic peptide for predicting events after myocardial infarction and coronary stenting

BACKGROUND

After myocardial infarction (MI), biomarkers can be helpful to identify patients who might benefit from more intensive therapies. The prothrombin time-derived fibrinogen (PTDF) assay is widely available and relatively inexpensive. We determined whether PTDF predicts events in patients with MI and compared this assay with brain natriuretic peptide (BNP) and C-reactive protein (CRP).

METHODS

We retrospectively analyzed data from 915 patients admitted with MI. Follow-up was collected at 1 year for major adverse cardiac events (MACE) defined as death from any cause, nonfatal MI or death, target vessel revascularization, or coronary artery bypass grafting.

RESULTS

Patients in the fourth quartile of PTDF were older and had more risk factors but fewer ST-elevation MI and lower peak troponin values. The fourth quartiles of PTDF, CRP, and BNP were associated with increased MACE compared with the first quartiles with hazard ratios of 2.08 (1.30-3.33), 1.94 (1.22-3.07), and 2.56 (1.57-4.18), respectively, findings that remained significant after adjustment. When outcomes by strata of PTDF were examined, CRP failed to add additional prognostic value. Higher BNP levels predicted MACE in the upper but not lower stratum of PTDF.

CONCLUSION

In patients with MI, PTDF is a predictor of MACE at 1 year, with equivalent value compared to BNP and CRP. With low PTDF levels, neither BNP nor CRP adds prognostic value. At elevated PTDF values, higher BNP, but not CRP, identifies a higher-risk population. Therefore, PTDF can be substituted for CRP, with BNP being useful in the presence of elevated PTDF.

Intrinsic pathway of coagulation and arterial thrombosis

Formation of a fibrin clot is mediated by a group of tightly regulated plasma proteases and cofactors. While this system is essential for minimizing blood loss from an injured blood vessel (hemostasis), it also contributes to pathologic fibrin formation and platelet activation that may occlude vessels (thrombosis). Many antithrombotic drugs target key elements of the plasma coagulation mechanism such as thrombin and factor Xa, based on the premise that plasma elements contributing to thrombosis are primarily those involved in hemostasis. Recent studies with genetically altered mice raise questions about this paradigm. Deficiencies of the intrinsic pathway proteases factor XII and factor XI are not associated with abnormal hemostasis in mice, but impair formation of occlusive thrombi in arterial injury models, indicating that pathways not essential for hemostasis participate in arterial thrombosis. If factor XII or factor XI make similar contributions to thrombosis in humans, these proteases could be ideal targets for drugs to treat or prevent thromboembolic disease with minimal risk of therapy-associated bleeding.

Trends in coronary risk factors in the WHO MONICA project

BACKGROUND

The World Health Organization (WHO) MONICA Project was established to determine how trends in event rates for coronary heart disease (CHD) and, optionally, stroke were related to trends in classic coronary risk factors. Risk factors were therefore monitored over ten years across 38 populations from 21 countries in four continents (overall period covered: 1979-1996).

METHODS

A standard protocol was applied across participating centres, in at least two, and usually three, independent surveys conducted on random samples of the study populations, well separated within the 10-year study period.

RESULTS

Smoking rates decreased in most male populations (35-64 years) but in females the majority showed increases. Systolic blood pressure showed decreasing trends in the majority of centres in both sexes. Mean levels of cholesterol generally showed downward trends, which, although the changes were small, had large effects on risk. There was a trend of increasing body mass index (BMI) with half the female populations and two-thirds of the male populations showing a significant increase.

CONCLUSIONS

It is feasible to monitor the classic CHD risk factors in diverse populations through repeated surveys over a decade. In general, the risk factor trends are downwards in most populations but in particular, an increase in smoking in women in many populations and increasing BMI, especially in men, are worrying findings with significant public health implications.