Increased concentrations of inflammatory mediators in unstable angina: correlation with serum troponin T

Association between Biomarkers of Oxidative Stress and Inflammation with Cardiac Necrosis and Heart Failure in Non-ST Segment Elevation Myocardial Infarction Patients and Various Degrees of Kidney Function

The aim of this study was to explore the possible association between markers of inflammation and oxidative stress (OS) and markers of cardiac function and necrosis in 100 NSTEMI (non-ST-elevation myocardial infarction) patients with various degrees of kidney dysfunction. At admission, ejection fraction (EF), brain natriuretic peptide (BNP), troponin (TnI), creatinine phosphokinase (CPK), alanine transaminase (ALT), aspartate transaminase (AST), high-sensitive C-reactive protein (hs-CRP), interleukins 6 and 10 (IL-6, IL10), myeloperoxidase (MPO), transforming growth factor beta (TGF-β1), glomerular filtration rate (GFR), and albuminuria were assessed. Study participants were divided into 2 subgroups based on the median level of EF. Compared to the high, patients in the low EF group had higher GFR, BNP, CPK, hs-CRP, IL-10, IL-6, and MPO values and lower albuminuria levels. The levels of EF decreased in parallel with the progression of CKD, whereas the levels of BNP, IL-6, and TGF-β were significantly higher in late stages of CKD. Spearman's rho correlation analysis showed that EF was inversely correlated with MPO (r = -0.20, p = 0.05) BNP (r = -0.30, p = 0.002), hs-CRP (r = -0.38, p < 0.0001), IL-10 (r = -0.30, p = 0.003), and IL-6 (r = -0.24, p = 0.02) and positively with GFR (r = 0.27, p = 0.008). TnI was correlated with CPK (r = 0.44, p < 0.0001), CPK-MB (r = 0.31, p = 0.002), ALT (r = 0.50, p < 0.0001), AST (r = 0.29, p = 0.004), IL-10 (r = 0.22, p = 0.03), and MPO (r = -0.28, p = 0.006). In multivariate regression analysis, only BNP (β = -0.011, p = 0.004), hs-CRP (β = -0.11, p = 0.001), and GFR (β = 0.12, p = 0.0029) were independent determinants of EF. Similarly, MPO (β = -1.69, p = 0.02), IL-10 (β = 0.15, p = 0.006), and AST (β = 0.04, p = 0.001) were the 3 major determinants of TnI. Based on these associations, we built a predictive model including markers of inflammation and OS (MPO, IL-10, and hs-CRP) to identify patients with the most severe cardiac injury (combined EF below median and troponin above median values). Receiver-operator characteristic (ROC) analysis showed that the area under the ROC curve of this model to detect patients with low EF and high TnI was 0.67 (p = 0.015, 95%confidence interval = 0.53-0.81).

Is there really a benefit of using minimized cardiopulmonary bypass in CABG? A retrospective propensity score-matched study with 5000 cases

The concept of minimized cardiopulmonary bypass targets at reduction of adverse effects triggered by extracorporeal circulation. In this study, benefits of minimized bypass in CABG were evaluated under particular consideration of patient body mass index and surgeon impact. From 2004 to 2014, 5164 patients underwent coronary bypass surgery (CABG). Conventional cardiopulmonary bypass (CCPB) was used in 2376 patients, minimized cardiopulmonary bypass (MCPB) in 2788 cases. Multivariate regression models were used in the entire cohort and in a propensity score-matched subgroup after expert CABG to figure out clinical differences such as mortality, postoperative renal function, and thromboembolic events. Overall mortality was 1.5% (n = 41) in the MCPB group and 3.5% (n = 82) in CCPB patients (p < 0.001). Postoperative renal failure and hemodialysis occurred in 2.6% (n = 72/MCPB) vs. 5.3% (n = 122/CCPB (p < 0.001). Multivariable regression revealed use of CCPB as risk factor for increased mortality (OR 2.01, p = 0.001), renal failure (OR 1.79, p < 0.001), and myocardial infarction (OR 1.98, p < 0.001) comparable to risk factors such as preoperative ventilation (OR 2.26, p = 0.048), diabetes mellitus (OR 1.68, p = 0.001), and cardiogenic shock (OR 3.81, p = 0.002). Body mass index had no effect on the analyzed outcome parameters (OR 0.92, p = 0.002). Propensity score-matching analysis of an expert CABG subgroup revealed CCPB as risk factor for mortality (OR 2.26, p = 0.004) and postoperative hemodialysis (OR 1.74, p = 0.017). Compared to conventional circuits, minimized bypass use in CABG is associated with lower mortality and less postoperative renal failure. A high body mass index is feasible and not a risk factor for MCPB surgery.

A Meta-Analysis of Miniaturized Versus Conventional Extracorporeal Circulation in Valve Surgery

The effects of miniaturized extracorporeal circulation in patients operated on for heart valve surgery are still inconsistent. We performed a meta-analysis of eight studies involving 1,011 patients to evaluate the comprehensive effects of miniaturized extracorporeal circulation. The results suggested its application significantly reduced the length of stay in the intensive care unit and total hospital stay after heart valve surgery, but no significant effects on reducing postoperative morbidity and mortality were observed. Further studies with long-term follow-up are needed to confirm our results.

Elevated Concentration of Interferon-Inducible Protein of 10 kD (IP-10) Is Associated With Coronary Atherosclerosis

Several studies have shown that various chemokines are more highly expressed in atherosclerotic plaques than in normal vessel walls. In the present study, we investigated the relationship between coronary atherosclerosis and noteworthy chemokines, including interferon-inducible protein of 10 kD (IP-10); monocyte chemoattractant protein 1 (MCP-1); regulated on activation, normal T-cell expressed and secreted (RANTES); and high-sensitivity C-reactive protein (hsCRP), an established marker of atherosclerotic disease. We studied 28 patients who underwent coronary angiography because of suspected coronary artery disease (CAD). CAD was defined as stenosis of more than 50% of the vessel diameter on coronary angiograms. Blood samples were obtained both from the aorta and the coronary sinus (CS) just before coronary angiography. Relative to CAD (-) patients, those who were CAD (+) tended to have higher plasma concentrations of IP-10 in the aorta, as well as significantly higher transcoronary concentration gradients of circulating IP-10. There were no significant differences between the two groups in aortic plasma concentrations or transcoronary concentration gradients of MCP-1, RANTES, and hsCRP. Furthermore, both the aortic plasma concentrations and transcoronary concentration gradients of IP-10 correlated with the Gensini score (r = 0.58 and r = 0.63, respectively, P < 0.01), while the plasma MCP-1, RANTES, and serum hsCRP concentrations did not. This study suggests that IP-10 is a good surrogate marker of coronary atherosclerosis.

Synthetic peptide fragment (65-76) of monocyte chemotactic protein-1 (MCP-1) inhibits MCP-1 binding to heparin and possesses anti-inflammatory activity in stable angina patients after coronary stenting

OBJECTIVE AND DESIGN

The peptide from C-terminal domain of MCP-1 (Ingramon) has been shown to inhibit monocyte migration and possess anti-inflammatory activity in animal models of inflammation and post-angioplasty restenosis. Here, we investigate the effect of Ingramon treatment on blood levels of acute-phase reactants and chemokines in patients after coronary stenting and the mechanisms of Ingramon anti-inflammatory activity.

SUBJECTS

Eighty-seven patients with ischemic heart disease (IHD) who faced the necessity of coronary angiography (CA) were enrolled. In 67 patients, one-stage coronary stenting was performed; 33 of them were treated with Ingramon in addition to standard therapy. Twenty patients underwent CA only.

METHODS

High-sensitivity C-reactive protein (hsCRP) and fibrinogen blood levels were detected routinely. The chemokine concentration in plasma was measured by enzyme-linked immunosorbent assay (ELISA) or cytometric bead array-based immunoassay. Intracellular Ca(2+) levels and cell surface integrin exposure were assayed by flow cytometry. MCP-1 dimerization was studied by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). MCP-1-heparin binding was assessed with a biosensor and ELISA.

RESULTS AND CONCLUSIONS

Ingramon treatment was accompanied by less pronounced elevation of hsCRP and fibrinogen levels and decreased MCP-1 concentration in plasma in patients after coronary stenting. Ingramon had no effect on MCP-1 interaction with cell receptors or MCP-1 dimerization, but inhibited MCP-1 binding to heparin. The anti-inflammatory activity of the peptide may be mediated by an impaired chemokine interaction with glycosaminoglycans.

Elevated concentrations of pentraxin 3 are associated with coronary plaque vulnerability

BACKGROUND

Inflammation is a critical contributing factor to the development and progression of atherosclerosis. Pentraxin 3 (PTX3) is produced abundantly in atherosclerotic lesions while C-reactive protein (CRP) is mainly produced in the liver. In this study, we investigated whether plasma levels of PTX3 might be a sensitive marker both for the severity of coronary artery disease and vulnerable plaques. Next, we determined whether assays for inflammatory molecules can be used to monitor the therapeutic effects of telmisartan on stabilization of vulnerable atherosclerotic plaques.

METHODS AND RESULTS

We measured PTX3 concentrations in the peripheral and coronary sinus plasma of 40 patients with angina pectoris (AP) and 20 control subjects. Next, in 28 patients with AP, we determined the correlation between levels of inflammatory molecules and the computed tomography (CT) density of plaques as a quantitative index of plaque vulnerability. There was no significant difference in peripheral plasma PTX3 concentrations between patients with AP and control subjects, while coronary sinus plasma PTX3 concentrations were significantly higher in AP patients than control subjects. The concentrations of PTX3 in coronary sinus and peripheral plasma correlated with Gensini scores as an index of severity of coronary atherosclerosis. Interestingly, there was a significantly negative correlation between plasma PTX3 concentrations and CT density (r=-0.67, p<0.01). On the other hand, CT density did not correlate with the peripheral plasma concentrations of monocyte chemoattractant protein-1 (MCP-1) or high-sensitivity CRP (hsCRP). Furthermore, telmisartan treatment for 6 months decreased plasma concentrations of PTX3 but not those of MCP-1 or hsCRP in 12 patients with essential hypertension. Multivariate regression analysis revealed that changes in PTX3 levels were independent of blood pressure changes.

CONCLUSIONS

PTX3 is likely more specific than hsCRP as an indicator of coronary plaque vulnerability that could lead to plaque rupture.

Mini extracorporeal circuit cardiopulmonary bypass system: a review

Improved knowledge of the pathophysiological processes experienced in response to cardiopulmonary bypass has led to new developments in extracorporeal technology and understanding. The use of mini extracorporeal circuits (MECC) is rapidly expanding in clinical practice. The mini extracorporeal circuit differs by a greatly reduced tubing length and the number of components when compared with current circuit designs. The MECC is believed to offer potential benefits to the surgical patient by reducing the systemic inflammatory response that remains strongly implicated in post-operative organ dysfunction. We present a review of the available literature and find the MECC to show an acceptable safety profile with a reduction in post-operative complications and transfusion requirements and no evidence of any negative impairment to the surgeon, anaesthetist or perfusionist. The observed post-bypass inflammatory response is seen to be lower after MECC bypass and this is of clear clinical benefit.

The inflammatory response to miniaturised extracorporeal circulation: a review of the literature

Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar to sepsis. Aetiological factors include surgical trauma, reperfusion injury, and, most importantly, contact of the blood with the synthetic surfaces of the heart-lung machine. Recently, a new cardiopulmonary bypass system, mini-extracorporeal circulation (MECC), has been developed and has shown promising early results in terms of reducing this inflammatory response. It has no venous reservoir, a reduced priming volume, and less blood-synthetic interface. This review focuses on the inflammatory and clinical outcomes of using MECC and compares these to conventional cardio-pulmonary bypass (CCPB). MECC has been shown to reduce postoperative cytokines levels and other markers of inflammation. In addition, MECC reduces organ damage, postoperative complications and the need for blood transfusion. MECC is a safe and viable perfusion option and in certain circumstances it is superior to CCPB.

Functional T‐lymphocyte dichotomy in the peripheral blood of patients with unstable angina

OBJECTIVES

Herein, we investigated the percentage of T-helper (Th1) and Th2 cells among the general T-cell population in the peripheral blood of patients with stable angina (SA) and unstable angina (UA).

BACKGROUND

Recent evidence suggests that Th1 cells and the cytokines that they secrete (especially IFN-gamma) have a role in the activation of macrophages, promotion of clot formation and destabilization of atherosclerotic plaques. Thus, Th1 cytokines may contribute to the initiation and progression of UA. In contrast, cytokines secreted by Th2 cells (e.g. IL-10) are known to inhibit activation and proliferation of Th1 cells and the secretion of IFN-gamma, lysosomal enzymes and metalloproteinases. Therefore, we sought to examine whether the ratio of IFN-gamma to IL-10 secreting cells is altered in patients with UA.

METHODS

The percentage of Th1 and Th2 cells among the general T-cell population was determined by fluorescent intracellular cytokine staining (IFN-gamma and IL-10, out of the total CD3 positive cells).

RESULTS

The percentage of T-cells positive for intracellular IFN-gamma was significantly higher in patients with UA (n = 22) in comparison with SA (n = 20) patients (39.0+/-2.8% and 29.6+/-2.7%, respectively. P = 0.02). There was no significant difference in intracellular IL-10 positive cells between the two groups. In addition, there was no significant difference in the ratio between the intracellular IFN-gamma positive cells and the intracellular IL-10 positive cells.

CONCLUSIONS

There is an increased activity of Th1 cells in patients with UA in comparison with patients with SA. There is no evidence of heightened activity of Th2 cells in either group. Thus, IFN-gamma secreted by peripheral blood T-lymphocytes,may be an important immunomodulator contributing to destabilization of the atheromatous plaque lying at the base of the etiopathogenesis of unstable angina.

Non-traditional biomarkers of atherosclerosis in stable and unstable coronary artery disease, do they differ?

BACKGROUND

Biomarkers of atherosclerosis are emerging as a potential tool for assessment of coronary artery disease (CAD) patients. As acute coronary syndrome (ACS), and stable CAD are distinguished in their pathophysiology it is conceivable that they are also characterized by different biomarkers of atherosclerosis.

METHODS

We systematically reviewed the literature for clinical studies of several non-traditional biomarkers of atherosclerosis reflecting various pathophysiological processes, namely macrophage-activity, oxidative-stress, tissue remodeling, and thrombosis in ACS and stable CAD to determine whether circulating biomarkers are differently expressed/predict outcome in these two clinical conditions.

RESULTS

Macrophage-activity (monocyte chemoattractant protein-1, neopterin), tissue-remodeling (matrix metalloproteinase-9) and thrombosis (tissue-factor) related biomarkers were consistently elevated in ACS compared to stable CAD, in accordance with the pathophysiological role of these mediators in plaque rupture, characterizing ACS. Thus, these biomarkers may be applicable for diagnosis of ACS. Additionally, neopterin was consistently shown to predict outcome in both stable and ACS patients and myeloperoxidase was strongly shown to predict outcome in ACS, implying for their potential role in risk stratification of these patients.

CONCLUSIONS

As ACS and stable CAD are characterized by different pathophysiological processes, it appears that the biomarkers that are associated with them are differently expressed in these two clinical conditions

The peptide analogue of MCP-1 65-76 sequence is an inhibitor of inflammation

Inflammation plays an important role in vessel wall remodeling that occurs in atherosclerosis and postangioplasty restenosis. Monocytic chemoattractant protein-1 (MCP-1) is one of the main attractors of monocytes and some lymphocyte subsets to the damaged vessel. The aims of the study were to confirm MCP-1 participation in the development of acute coronary syndromes, to produce the potential MCP-1 peptide antagonist, and to investigate its effects in vitro and in vivo in different animal models of inflammation. MCP-1 plasma concentration was measured by ELISA (enzyme-linked immunosorbent assay). Chemokine receptor expression by cells isolated from human atherosclerotic lesions was assessed by direct immunofluorescence and flow cytometry. MCP-1 sequence was analyzed with Peptide Companion software and peptides were synthesized using Fmoc strategy. The peptide resistance to degradation was checked by 1H-NMR spectroscopy. The peptide effect on MCP-1-stimulated cell migration was studied in Boyden chamber and in mouse air pouch model, and its influence on lipopolysaccharide (LPS)-induced inflammatory cell recruitment was investigated in models of subcutaneous inflammation in rats and nonhuman primates. We revealed nearly a 2-fold increase of MCP-1 plasma level in patients with unstable angina in comparison with patients with stable angina. The atherosclerotic plaque specimens obtained from patients with unstable angina contained a significant amount of chemokine receptor-expressing leukocytes. Peptide from MCP-1 C-terminal 65-76 sequence (peptide X) inhibited MCP-1-stimulated monocytic cell migration in vitro and in vivo. Peptide X labeled with 99mTc accumulated specifically at sites of inflammation in rats. Peptide X administrated i.m and i.v. suppressed monocyte and granulocyte recruitment induced by subcutaneous injection of LPS in the back of rats and non-human primates. Our data demonstrate that MCP-1-mediated chemotaxis could be responsible for atherosclerotic plaque "destabilization". Peptide X may represent a new class of anti-inflammatory drugs to be used in cardiology.

Inflammatory Cytokine Imbalance after Coronary Angioplasty: Links with Coronary Atherosclerosis

AIM

To investigate release of some inflammatory cytokines (Cys) after coronary angioplasty and its links with coronary atherosclerosis.

METHODS

Twenty-seven consecutive subjects with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) were enrolled in the study: serial blood samples were taken in order to evaluate plasma concentrations of Interleukin (IL)-2, IL-10, IL-18, TNFalpha, and IFNgamma just before PCI at 12 and 24 hours. Patients were then divided, considering balance between each inflammatory Cy and IL-10, an antiinflammatory Cy, into four groups, ranging from a prevalent antiinflammatory response (stable inflammatory Cy-increasing IL-10 values) to a marked inflammatory imbalance (increasing inflammatory Cy-stable IL-10 values).

RESULTS

All Cys showed significant increases in plasma concentrations if compared with baseline values. Release curves were not significantly different when comparing subjects with ST-elevation myocardial infarction (STEMI) versus unstable angina-non-STEMI (UA-NSTEMI), diabetics versus controls. Subjects with marked inflammatory response showed a higher incidence of stenosis on left anterior descending (LAD) coronary artery (IL-2 chi(2) and IFNgamma P < 0.05); Cy release was higher in patients with multivessel coronary disease (IL-2 and IFNgamma, ANOVA P < 0.01). Correlations were also referable between Cys and myocardial enzyme release. Subjects treated with sirolimus-eluting stents (SES) showed significantly lower Cy periprocedure ratio if compared with those treated with bare metal stents.

CONCLUSIONS

A significant Cy release is detectable after PCI: inflammatory response seems to correlate with both PCI due to plaque instabilization and coronary atherosclerosis. A blunted inflammatory response is detectable in subjects treated with SES.

Chemokines and left ventricular function in patients with acute myocardial infarction

BACKGROUND

Leukocytes are activated in the inflammatory process involving locally atherosclerotic lesions through adhesive molecules attaching to the surface of endothelial cells, especially during acute myocardial infarction. The aim of the study was to assess MCP-1, MIP-1alpha, and RANTES serum levels in patients with STEMI and to correlate them with the severity of left ventricle (LV) dysfunction.

METHODS

Forty patients were initially divided into two groups, with group 1 having an ejection fraction (EF) above 40% and group 2 an EF of 40% or less. Next, the patients were divided on the basis of wall motion score index (WMSI): group 3 had a WMSI of 1.3 or lower and group 4 had a WMSI above 1.3. A control group of ten volunteers was also included in the study. Serum samples were taken at admission as well as 3, 24, 48, 72 h, and 7 days after.

RESULTS

The baseline serum levels of MCP-1 and RANTES in group 1 were significantly higher than in the controls (p<0.05 and p<0.005, respectively). The highest concentrations of chemokines were observed 3 h after admission. The serum levels of MIP-1alpha on admission and 3 h later were significantly higher in group 1 than in group 2 (p<0.03 and p<0.01, respectively). Maximum MIP-1 concentrations were observed 3 h after admission in group 3 and 24 h after admission in group 4 (p<0.006). In group 1, MIP-1alpha 3 h after admission correlated positively with the EF (r=0.444, p<0.05). In group 1 there was a negative correlation between MIP-1alpha concentration 3 h after admission and LV end-diastolic dimension (r=-0.492, p<0.02).

CONCLUSIONS

Patients with myocardial infarction with an elevated ST segment had a significant increase in MCP-1, MIP-1alpha, and RANTES serum levels.

Minimizing Cardiopulmonary Bypass Attenuates Myocardial Damage After Cardiac Surgery

The standard heart-lung machine is deemed a major trigger of systemic inflammatory reactions, potentially inducing organ failure. The strict reduction of blood-artificial surface and blood-air contact might represent meaningful improvements of the extracorporeal technology with respect to organ preservation. In this study, we assessed perioperative myocardial damage by using a novel minimal extracorporeal circuit (MECC) and a conventional cardiopulmonary bypass (CPB) system. Sixty patients scheduled for coronary artery bypass surgery were randomly assigned to either the MECC or the standard CPB system. Myocardial markers were determined by specific immunoassays 6, 12, and 24 hours after CPB initiation. Results were corrected for hemodilution.Demographics, hemodynamics, the number of anastomoses, CPB, and cross-clamp time were comparable between the groups. MECC patients demonstrated significantly lower levels of Troponin T (ng/ml) at 6, 12, and 24 hours (0.07 +/- 0.01 vs. 0.16 +/- 0.04, p < 0.005; 0.12 +/- 0.03 vs. 0.28 +/- 0.08, p < 0.008; 0.21 +/- 0.05 vs. 0.35 +/- 0.09, p < 0.03, respectively) and creatine kinase-MB (U/l) at 6 and 12 hours (22.5 +/- 1.5 vs. 40.6 +/- 3.3, p < 0.0001; 23.3 +/- 3.4 vs. 40.8 +/- 8.0, p < 0.001, respectively). Creatine kinase-MB at 24 hours tended to lower values in the MECC group but did not quite reach statistical significance. The MECC system may not only provide a less invasive solution to meet the requirements during cardiac surgery but also a more organ-preserving alternative to standard CPB.

Examination of genetic effects of polymorphisms in the MCP-1 and CCR2 genes on MI in the Icelandic population

Monocyte chemotactic protein-1 (MCP-1) and its receptor CCR2 may play a role in mediating atherosclerosis. The polymorphisms MCP-1 -2518A>G and CCR2 190G>A have been reported to be associated with increased risk for developing atherosclerosis. The aim of this study was to investigate the effect of these polymorphisms and the MCP-1 -2076A>T polymorphism on the development of myocardial infarction (MI) in an Icelandic cohort. Four hundred and sixty MI survivors and 1842 disease free controls were genotyped. No significant difference in the frequencies of any of the polymorphisms between the cases and the controls was found, with OR=0.87 (95% CI 0.71-1.08) for MCP-1 -2518G, OR=1.05 (95% CI 0.84-1.33) for MCP-1 -2076T and OR=0.93 (95% CI 0.71-1.23) for CCR2 190A. An effect of an OR for MI of 1.4 for the MCP-1 -2518G, MCP-1 -2076T and CCR2 190A alleles could be detected in a cohort of the size of this study with power=0.8 and alpha=0.05. In our cohort we were unable to demonstrate a significant association of the MCP-1 -2518A>G, MCP-1 -2076A>T or CCR2 190G>A polymorphisms with MI. These results do not support the extent of risk associated with developing MI previously reported for the CCR2 190 and MCP-1 -2518 polymorphisms.

Leukocyte count predicts microembolic Doppler signals during carotid stenting: a link between inflammation and embolization

BACKGROUND AND PURPOSE

Protected stenting has emerged as a safe and effective alternative to endarterectomy for the treatment of carotid stenosis in patients at high operative risk. Distal microembolization occurs invariably during carotid stenting. Little is known about the relationship between systemic inflammation and embolization during carotid stenting.

METHODS

We examined 43 consecutive patients who underwent carotid stenting with simultaneous transcranial Doppler (TCD) monitoring of the ipsilateral middle cerebral artery. Embolization was quantified by measuring microembolic signals (MES) on TCD. Preprocedure leukocyte counts were related to MES.

RESULTS

In unadjusted analyses, preprocedure leukocyte count was positively correlated with total procedural MES (r2= 0.16; P=0.008). After considering age, gender, comorbidities, concomitant medical therapies, and the use of emboli prevention devices, increasing leukocyte count (beta=35 for each 1000/microL increment; P=0.018) remained a significant and independent predictor of embolization (model-adjusted r2=0.365; P=0.0005).

CONCLUSIONS

Increasing preprocedure leukocyte count independently predicted more frequent MES during carotid stenting. These data suggest that systemic inflammation may influence the degree of procedural embolization.

Markers of inflammation and their clinical significance

Inflammation plays an important role in the initiation and progression of atherosclerosis and the development of atherosclerotic events. Understanding the molecular basis of inflammation has led to the identification of markers that may also serve as new targets of therapy in the management of atherothrombotic disease. Inflammatory markers, such as C-reactive protein (CRP), have been shown to predict future cardiovascular events in individuals with and without established cardiovascular disease (CVD). Statins substantially reduce cardiovascular morbidity and mortality, and recently their anti-inflammatory properties have been investigated. In this paper, we discuss biomarkers implicated in the inflammatory process leading to atherothrombosis, including CRP, adiponectin, monocyte chemoattractant protein 1 (MCP-1), CD40 ligand and lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), and the effect of statins on these markers and their potential relationship to cardiovascular events.

Peripheral levels of matrix metalloproteinase-9, interleukin-6, and C-reactive protein are elevated in patients with acute coronary syndromes: correlations with serum troponin I

BACKGROUND

Acute coronary syndromes (ACS) are characterized by activation of systemic and local inflammatory mediators. The interrelation between these soluble inflammatory markers and their association with markers of myocardial necrosis have not been extensively studied.

HYPOTHESIS

The study was undertaken to evaluate the association of the systemic levels of matrix metalloproteinase-9 (MMP-9) and the tissue inhibitor of metalloproteinase-1 (TIMP-1), with C-reactive protein (CRP), interleukin-6 (IL-6), and serum troponin-I in patients admitted with ACS.

METHODS

Analysis of serum concentrations of the above inflammatory markers was performed in 53 patients with unstable angina (UA) and in 15 with non-ST-segment elevation myocardial infarction (NSTEMI) within 48 h of admission, and 34 patients with stable coronary artery disease.

RESULTS

Compared with patients with stable angina, those with ACS had elevated admission levels of MMP-9 (p = 0.04), CRP (p < 0.001), and IL-6 (p = 0.001), but not TIMP-1 (p = 0.55). Compared with patients with UA, those with NSTEMI also had higher levels of IL-6 (p < 0.001), CRP (p = 0.002), and MMP-9 (p = 0.05).

CONCLUSIONS

In patients with ACS, the admission levels of inflammatory mediators, including MMP-9, CRP, and IL-6 are significantly elevated, specifically in association with serum troponin I. Systemic and local markers of inflammatory activity may be directly associated with myocardial injury.

An acute inflammatory reaction induced by myocardial damage is superimposed on a chronic inflammation in unstable coronary artery disease

BACKGROUND

Inflammation plays an important role in unstable coronary artery disease (CAD). We assessed the kinetics of inflammatory markers from symptom onset in patients with unstable CAD and their relation to myocardial damage.

METHODS

Serial measurements of inflammatory mediators were performed in consecutive patients with unstable CAD enrolled at selected sites in the FRISC II (n = 558) and the GUSTO IV (n = 404) trials. The time from symptom onset was calculated for every serum sample (total 4400 samples).

RESULTS

Median levels of interleukin 6 and C-reactive protein reached their peaks at 36 to 42 hours and at 48 to 54 hours, respectively, from symptom onset and returned to early postsymptom levels within 6 weeks. The early increase occurred almost exclusively in patients with baseline troponin T elevation (>0.01 microg/L). In contrast, median levels of fibrinogen increased continuously up to 120 hours after symptom onset, independently of myocardial damage. At 6 months, fibrinogen levels were still higher than in the early phase after symptom onset. The median levels of interleukin 6, C-reactive protein, and fibrinogen were still higher at 6 months than in healthy controls matched for age and sex to a population with unstable CAD.

CONCLUSIONS

An early acute inflammatory reaction induced by myocardial damage seems to be superimposed on a chronic inflammatory condition, both of which might influence long-term outcome in unstable CAD.

Modulation of tachykinin and cytokine release in patients with coronary disease undergoing percutaneous revascularization

Plasma levels of substance P (SP) and neurokinin A (NKA) tachykinin and of gamma interferon (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha) cytokines were assayed in plasma obtained from peripheral blood of 19 patients presenting with stable chronic coronary stenosis and 12 patients with acute coronary syndrome (ACS). Plasma samples were obtained before, during, and after percutaneous coronary intervention (PCI) consisting of implantation of a metallic stent. Fourteen healthy subjects without any evident risk factors for coronary artery disease (CAD) were also included for comparison at basal time. We found that plasma levels of both IFN-gamma and TNF-alpha were significantly higher in patients with chronic or acute CAD than those in control subjects at the time of presentation. NKA and IFN-gamma levels were also significantly increased in ACS patients compared with those in patients with stable disease. The analysis performed during and after PCI revealed that IFN-gamma levels increased 15 min after stent implantation in both chronic and ACS patients and that TNF-alpha levels increased in chronic patients only compared to basal values. In addition, a significant decrease of both NKA and SPA levels 48 h after the end of the revascularization procedure was observed in ACS patients. These data suggest that modulation of tachykinin and/or cytokine release with proinflammatory activity in chronic or acute cardiac ischemia and during following coronary stenting might play an important role in heart tissue damage and in long-term inflammatory complications of PCI.

Inflammatory cytokines provide limited early prognostic information in emergency department patients with suspected myocardial ischemia

STUDY OBJECTIVE

The aim of this study was to assess the early prognostic value of the inflammatory cytokines interleukin 6, interleukin 8, and tumor necrosis factor alpha in a cohort of emergency department (ED) patients with chest pain who have suspected myocardial ischemia.

METHODS

One hundred eighteen patients with chest pain presenting to 2 urban EDs were studied. Interleukin 6, interleukin 8, and tumor necrosis factor alpha levels were assayed at presentation. The end point was the occurrence of a serious cardiac event (death, nonfatal acute myocardial infarction, myocardial revascularization, or readmission with an acute coronary syndrome) during the index admission or subsequent 3 months.

RESULTS

Mean levels of all 3 cytokines were higher among patients experiencing a serious cardiac event, with the greatest differences observed in levels of interleukin 6 (mean 2.5 pg/mL [95% confidence interval (CI) 1.2 to 3.7 pg/mL] versus mean 9.8 pg/mL [95% CI 2.4 to 17.2 pg/mL]). Interleukin 6 had a sensitivity of 35% (95% CI 20% to 54%), a specificity of 86% (95% CI 76% to 92%), and an overall prognostic accuracy of 71% (95% CI 63% to 79%) for predicting serious cardiac events. However, logistic regression analysis revealed that the only independent predictor of an adverse outcome was an ECG suggestive of ischemia at presentation.

CONCLUSION

Among patients presenting to the ED with suspected myocardial ischemia, higher levels of inflammatory cytokines are associated with an increased risk of a serious cardiac event during the subsequent 3 months. There is, however, considerable overlap in levels among patients who do and do not have a serious cardiac event, limiting their utility as predictors of outcome in individual patients.

Coronary microembolization

Atherosclerotic plaque rupture is a key event in the pathogenesis of acute coronary syndromes and during coronary interventions. However, it does not always result in complete thrombotic occlusion of the entire epicardial coronary artery with subsequent acute myocardial infarction; in milder forms the result can be embolization of atherosclerotic and thrombotic debris into the coronary microcirculation. This review summarizes the available morphological evidence for coronary microembolization in patients who died from coronary artery disease, most notably from sudden death, and then goes on to address the experimental pathophysiology of coronary microembolization in animal models of acute coronary syndromes and heart failure. Finally, the review presents the available clinical evidence for coronary microembolization in patients, highlights its key features (ie, arrhythmias, contractile dysfunction, infarctlets and reduced coronary reserve) and addresses its prevention by mechanical protection devices and glycoprotein IIb/IIIa antagonism.

Elevated cardiac troponin T in predialysis patients is associated with inflammation and predicts mortality

OBJECTIVES

Cardiac troponin T (cTnT) is a highly sensitive and specific marker of myocardial damage. It has been shown that elevated serum concentrations of cTnT in haemodialysis (HD) patients are associated with poor prognostic outcome. The aim of the present study was to investigate the predictive value of cTnT in samples from predialysis patients and to investigate associations between cTnT and inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6).

DESIGN

Cohort, follow-up study.

SETTING

Huddinge University Hospital, Sweden.

SUBJECTS

A total of 115 (62% males, 28% diabetic patients) end-stage renal disease (ESRD) patients (52 +/- 1 years), of which 29% had cardiovascular disease (CVD), were studied shortly before the onset of dialysis therapy. Sixty-four patients started peritoneal dialysis (PD) as renal replacement therapy, whilst 49 started HD during the follow-up.

MAIN OUTCOME MEASURES

The cTnT was analysed with the third generation TnT assay on Elecsys 2010. The prognostic value was calculated for cTnT, IL-6, age, CVD, malnutrition, diabetes mellitus (DM) and gender. Survival analyses were made with Kaplan-Meier and Cox regression analyses, with all-cause mortality as the clinical end point (mean follow-up period 2.7 +/- 0.1 years).

RESULTS

Significant correlations were found between cTnT and CKMB (rho = 0.52, P < 0.0001), IL-6 (rho = 0.23, P < 0.05), CRP (rho = 0.30, P < 0.05), and serum albumin (rho = -0.31, P < 0.001), respectively. Diabetic patients had higher median serum cTnT level (0.09 microg L-1; range <0.01-0.51 vs. 0.04 microg L-1; range <0.01-0.67 microg L-1; P < 0.005) compared with nondiabetic patients. Likewise, patients with CVD had a significantly higher median level (0.08 microg L-1; range <0.01-0.67 microg L-1 vs. 0.04 microg L-1; range <0.01-0.61 microg L-1; P < 0.01) of cTnT compared with patients without CVD. Patients with cTnT > or =0.10 microg L-1 had a higher cumulative mortality rate than patients with cTnT < 0.10 microg L-1 (chi2 = 7.04; P < 0.01). Whilst age, CVD, malnutrition, DM, IL-6, cTnT and male gender were associated with poor outcome in the univariate analysis, only DM (P < 0.05) and cTnT (P < 0.05) were independently associated with mortality in a multivariate analysis.

CONCLUSIONS

The present study demonstrates that serum concentrations of cTnT > or =0.10 microg L-1 is a significant predictor of mortality in patients starting dialysis. Moreover, the positive correlations between cTnT and IL-6, and CRP, respectively, suggest an association between inflammation and cTnT levels. Finally, the results of the present study suggest that cTnT is an independent predictor of mortality in ESRD patients starting dialysis.

Enhanced Expression of the Apoptosis Inducing Ligand TRAIL in Mononuclear Cells After Myocardial Infarction

Tumor necrosis factor (TNF) family proteins including TNF-alpha and Fas (CD95)-ligand have been implicated in the development of acute myocardial infarction (AMI). We studied whether AMI patients displayed up-regulation of another TNF family member, TNF-related-apoptosis-inducing ligand (TRAIL), on peripheral blood mononuclear cells (PBMCs). We compared expression of TRAIL on PBMCs from 26 patients in the acute phase of AMI with that on PBMCs from 16 healthy control subjects using flow cytometry and RT-PCR. In addition, expression of TRAIL protein on PBMCs from patients in the acute phase of AMI was also compared with that from the same patients 7 days later. Furthermore, we compared the expression of TRAIL protein on CD4+, CD8+, CD14+, and CD19+ cells from patients in the acute phase of AMI with that from control subjects using flow cytometry. Finally, expression of the TRAIL receptors (TRAILR)-1 and TRAILR-2 in human cardiomyocytes was examined immunohistochemically. Expression of TRAIL protein was significantly higher in the acute phase of AMI than in control subjects. Expression of TRAIL protein was significantly higher in the acute phase of AMI than 7 days later. TRAIL mRNA expression in the acute phase of AMI was higher than in control subjects. Expression of TRAIL protein on CD4+ and CD14+ cells from AMI patients was significantly higher than that from control subjects. Expression of TRAILR-1 and TRAILR-2 in human cardiomyocytes was confirmed immunohistochemically. TRAIL on infiltrating CD4 and CD146 cells may be involved in the induction of cardiomyocyte apoptosis after AMI.

Effects of iloprost on adhesion molecules and F1 + 2 in peripheral ischemia

BACKGROUND

Iloprost has beneficial effects on microcirculation by preventing platelet and leukocyte reciprocal activation, which is known to lead to endothelial damage and acute thrombosis. This drug also reduces inflammatory system activation by decreasing alpha M beta 2 integrin expression on the phagocyte membrane, might have a role in the protection and restoration of endothelial integrity and might interact with coagulation cascade activation.

DESIGN

Forty patients were enrolled: 29 with systemic sclerosis (SSc) and 11 with peripheral artery disease (PAD). Iloprost was administered for 5 days in the first group and for 21 days in second group of patients. To ascertain whether iloprost modifies the parameters of endothelial and coagulation cascade activations, the plasma concentrations of S-ICAM-1 and F1 + 2 were detected in patients at baseline, after 5 days and, in PAD patients only, after 21 days of iloprost therapy. S-ICAM-1 is the endothelial counter receptor for alpha M beta 2 integrin and is a marker of endothelial cell activation; and F1 + 2 is a marker of coagulation cascade activation.

RESULTS

After infusion of iloprost a significant decrease of S-ICAM-1 was observed in both the SSc (P < 0.002) and PAD patients (P < 0.004). Similarly, a significant decrease of F1 + 2 was observed in the SSc (P < 0.0004) and PAD patients (P < 0.003).

CONCLUSIONS

The study provides evidence that iloprost reduces endothelial cells and coagulation cascade activations. Both of these mechanisms are responsible for improvement in microvascular functional capacity and for the long-term clinical benefit observed. After iloprost infusion, the SSc patients showed marked reductions in F1 + 2 and S-ICAM-1 concentrations that were statistically more significant relative to the PAD patients.

Statins and inflammatory markers

Inflammation is involved in the initiation and progression of atherosclerosis and the development of atherosclerotic events. Understanding of the molecular basis of inflammation has led to the identification of markers that may be important new targets in atherothrombotic disease. Inflammatory markers, such as cell adhesion molecules, cytokines, and high-sensitivity C-reactive protein, have been shown to predict future cardiovascular events in individuals with and without established disease. 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors, or statins, inhibit the synthesis of cholesterol and have been demonstrated to reduce cardiovascular morbidity and mortality. Recently, statins have been shown to modulate several of the mechanisms of inflammation in atherosclerosis in vitro and in vivo, including reduction of inflammatory markers in clinical trials. In this article, we briefly review the biology, epidemiology, and clinical trial data on the effects of statins on some of the more promising inflammatory markers.

Coronary microembolization

Atherosclerotic plaque rupture is a key event in the pathogenesis of acute coronary syndromes and during coronary interventions. Atherosclerotic plaque rupture does not always result in complete thrombotic occlusion of the entire epicardial coronary artery with subsequent acute myocardial infarction; however, in milder forms it may result in the embolization of atherosclerotic and thrombotic debris into the coronary microcirculation. The present report summarizes the available morphologic evidence for coronary microembolization in patients who died of coronary artery disease, especially sudden death. The report then goes on to address the experimental pathophysiology of coronary microembolization in animal models of acute coronary syndromes and heart failure. Finally, the report presents the available clinical evidence for coronary microembolization, highlights its key features--arrhythmias, contractile dysfunction, infarctlets and reduced coronary reserve--and addresses prevention by mechanical protection devices and glycoprotein IIb/IIIa antagonism.