Markers of inflammation and multiple complex stenoses (pancoronary plaque vulnerability) in patients with non-ST segment elevation acute coronary syndromes

Enhanced expression of neopterin in valve tissue of bicuspid aortic stenosis

Background

Aortic valve stenosis (AS) occurs in bicuspid aortic valve (BAV) patients at a relatively young age compared to tricuspid aortic valve (TAV) patients. However, the underlying cause of this phenomenon remains unknown. Neopterin, which is a by-product of the guanosine triphosphate (GTP) pathway, enhances the oxidative potential of reactive oxygen species. To clarify the role of neopterin in the aortic valve, we immunohistochemically studied the presence of neopterin in aortic valve specimens from patients with AS harboring either TAV or BAV.

Methods

Frozen aortic valve samples were surgically obtained from 68 patients with severe AS with TAV (n=34) and BAV (n=34). Normal aortic valves were obtained from cadavers who died of non-cardiovascular causes as controls (n=9). Samples were immunohistochemically stained with antibodies against smooth muscle cells, macrophages, T lymphocytes, neopterin, and 4-hydroxy-2-nonenal (4-HNE).

Results

Quantitative analysis showed that the percentage of macrophages, 4-HNE- and neopterin-positive macrophage score, and the number of T lymphocytes were significantly higher in BAV patients than in TAV patients (macrophages, P=0.013; T lymphocytes, P=0.011; neopterin, P<0.001; 4-HNE, P=0.008). Double immunostaining for neopterin and macrophages demonstrated that most neopterin-positive cells were macrophages in BAV patients.

Conclusions

Neopterin accumulation in macrophages may increase oxidative stress and contribute to the early onset of AS in BAV.

Functional capacity and inflammatory biomarkers as predictors for right atrial volume index in COPD patients

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and right-heart complications. So, this study aimed to evaluate the role of right atrial volume index (RAVI), inflammatory biomarkers and functional capacity in predicting poor outcomes for patients with COPD, classified by COPD assessment test (CAT) questionnaire, as early predictors of right heart diseases.

METHODS

151 patients with COPD with ejection fraction (LVEF) > 55% were enrolled and classified according to CAT questionnaire into CAT ≥ 10 (group I) and CAT < 10 (group II). RAVI was calculated using Echocardiography. Assessment of RV systolic function was done by Doppler imaging. Functional capacity parameters were assessed by modified medical research council dyspnea scale (mMRC). IL-1β, adiponectin, hs-CRP and neopterin were evaluated by ELSA kits.

RESULTS

Group I (CAT ≥ 10) had higher RAVI (73.92 ± 21.20 ml/m2 vs 22.73 ± 6.24 ml/m2, p < 0.001), lower S`tri (0.05 ± 0.01 vs 0.13 ± 0.03 m/s, p < 0.001), lower tricuspid annular plane systolic excursion (TAPSE) (1.20 ± 0.17 cm vs 2.17 ± 0.48 cm, p < 0.001), higher RVSP (54.88 ± 7.97 vs 26.79 ± 9.84 mmHg, p < 0.001) compared with group II (CAT < 10). RAVI was good predictor of CAT (r = 0.954, p < 0.001) and strongly correlated with tricuspid S`tri, RVSP, tricuspid E/e' and Mitral E/e' (r = -0.737, r = 0.753, r = 0.817 and r = 0.515, respectively, p < 0.001). RAVI was correlated with TAPSE (r = -0.673, p < 0.001) and with tricuspid E/A ratio & LVEF (r = 0.628, r = -0.407, respectively, p < 0.001). Hs-CRP: 2.50 ± 1.43 vs 2.03 ± 1.19, IL-1β: 37.96 ± 14.35 vs 27.57 ± 8.06, neopterin: 91.37 ± 17.30 vs 76.90 ± 16.75, p < 0.05) were significantly higher besides lower adiponectin levels (3.19 ± 1.98 vs 5.32 ± 1.33 p < 0.05) in group I as compared to group II.

CONCLUSION

Functional capacity might be useful predictor for right heart diseases in COPD patients. Inflammatory biomarkers, low adiponectin and high Hs-CRP, IL-1β and neopterin levels, might not only be useful to monitor treatment response but may also help to discriminate patients with a worsen prognosis.

Neopterin, the Cell-Mediated Immune Response Biomarker, in Inflammatory Periodontal Diseases: A Narrative Review of a More than Fifty Years Old Biomarker

Neopterin is a biomarker of the activation of cellular immunity. The purpose of this review is to summarise neopterin metabolism, methods of its detection, and its role in inflammation, focusing on periodontal inflammatory diseases. This derivative of guanosine is a non-enzymatic product of 7,8-dihydroneopterin oxidation caused by free radicals which protect activated macrophages from oxidative stress. Various methods, usually based on enzyme-linked immunosorbent essay, high-performance liquid chromatography, or radioimmunoassay were developed for the isolation of neopterin. A wide spectrum of diseases and conditions are known to affect neopterin levels, including cardiovascular, bacterial, viral, and degenerative diseases, as well as malignant tumours. Neopterin levels were found to increase in subjects with periodontitis, especially when the oral fluid and gingival crevicular fluid were evaluated. These findings confirm the role of activated macrophages and cellular immunity in periodontal inflammatory diseases. The gingival crevicular fluid and the oral fluid appear to be the most valuable biologic fluids for the evaluation of neopterin levels in periodontitis. For gingival crevicular fluid, neopterin can be determined as the concentration or the so-called total amount. Nonsurgical periodontal treatment was associated with a decrease in neopterin levels, but an increase was also reported, suggesting the possible role of macrophages in the resolution of the periodontal lesion.

Assessment of Serum Neopterin as a Biomarker in Peripheral Artery Disease

Neopterin (NPT), a pyrazino-pyrimidine compound mainly produced by activated macrophages, has been regarded as a proinflammatory and proatherosclerotic agent. The study was designed to evaluate NPT level and its interaction with conventional peripheral artery disease (PAD) biomarkers and vascular regenerative potential in severe PAD. The study included 59 patients (females n = 17, males n = 42) aged 67.0 ± 8.2 years classified into two groups based on ankle-brachial index (ABI) measurements (ABI ≤ 0.9 n = 43, ABI ≤ 0.5 n = 16). A total of 60 subjects aged 70.4 ± 5.5 years (females n = 42, males n = 18) with ABI > 0.9 constituted a reference group. NPT concentration reached values above 10 nmol/L in patients with PAD, which differed significantly from reference group (8.15 ± 1.33 nmol/L). High levels of CRP > 5 mg/L, TC > 200 mg/dL as well as lipoproteins LDL > 100 mg/dL and non-HDL > 130 mg/dL were found in the same group, indicating the relationship between NPT and conventional atherogenic markers. The endothelial progenitor cells (EPCs) tended toward lower values in patients with ABI ≤ 0.5 when compared to reference group, and inversely correlated with NPT. These findings indicate a crucial role of NPT in atheromatous process and its usefulness in monitoring PAD severity. However, the role of NPT in chronic PAD needs further studies including relatively high number of subjects.

The Role of C-reactive Protein in Patient Risk Stratification and Treatment

Atherosclerosis is a chronic inflammatory disease. Several circulating inflammatory markers have been proposed for clinical use due to their ability to predict future cardiovascular events and may be useful for identifying people at high risk who might benefit from specific treatment to reduce this risk. Moreover, the identification of new therapeutic targets will allow the development of drugs that can help reduce the high residual risk of recurrence of cardiovascular events in patients with coronary artery disease. The clinical benefits of reducing recurrent major cardiovascular events recently shown by canakinumab and colchicine have renewed the cardiology community’s interest in inflammation as an aetiopathogenic mechanism for atherosclerosis. This review explores the use of C-reactive protein, which is the most frequently studied biomarker in this context; the concept of residual risk in primary and secondary cardiovascular prevention; and the current recommendations in international guidelines regarding the role of this inflammatory biomarker in cardiovascular risk stratification.

Plasma Interleukin-37 is Elevated in Acute Ischemic Stroke Patients and Probably Associated With 3-month Functional Prognosis

Background

Interleukin-37 is a novel cytokine emerging as a natural suppressor of inflammatory responses. Inflammation and the immune response play important roles in acute ischemic stroke. This study aimed at evaluating the plasma levels and the association with 3-month outcomes of interleukin-37 in acute ischemic stroke patients.

Patients and Methods

In total, 152 consecutive patients with acute ischemic stroke and 45 healthy controls were included. Plasma interleukin-37 levels were determined in the first morning after admission using an enzyme-linked immunesorbent assay. The primary outcome was the 3-month functional outcome (modified Rankin Scale score >2). Logistic regression was used to evaluate the risk and 3-month outcome of stroke according to plasma interleukin-37 level.

Results

Plasma interleukin-37 levels were significantly higher in the patients with acute ischaemic stroke than in the healthy controls (182.26 versus 97.89 pg/mL, p<0.001). Patients with large-artery atherosclerosis had significantly higher IL-37 levels than those with small-artery occlusion (202.12±35.82 versus 175.67±33.71pg/mL, p<0.001). Plasma interleukin-37 levels were positively correlated with National Institutes of Health Stroke Scale scores (r=0.521, p<0.0001) and lesion volume (r=0.442, p<0.0001). Ninety-four and 58 patients had favourable and unfavourable 3-month outcomes, respectively. Elevated plasma interleukin-37 levels were independently associated with unfavourable 3-month outcomes (adjusted odds ratio=1.033, p=0.001, 95% confidence interval: 1.015–1.056).

Conclusion

Admission plasma interleukin-37 levels were significantly increased after acute ischemic stroke. Elevated interleukin-37 levels were independently associated with unfavourable 3-month prognoses in acute ischemic stroke patients. Further studies with other populations are needed.

Monocytes may be favorable biomarker and predictor of long-term outcome in patients with chronic heart failure: A cohort study

Although some studies found that an increased monocyte count is a predictive, short-term marker of unfavorable outcomes for patients with acute heart failure (HF), others have reported that monocytosis predicts prolonged survival.The current follow-up study aimed to identify different monocyte count patterns and their prognostic association with HF outcomes.Baseline blood samples for complete blood counts, differential counts, renal function tests, and lipid profiles of 303 chronic HF patients (average NYHA classification 2.8) were prospectively obtained to evaluate whether there is an association between monocyte count and clinical outcomes.Mean follow-up was 11.3 years (range 1 month to 16 years) and 111 (36.6%) patients died during follow-up. Mean monocyte count was 10.6 ± 5.5 and mean left ventricular ejection fraction (LVEF) was 36%. Patients with low monocyte counts (≤6%) had significantly lower survival rates than did those with monocyte counts 6.1% to 14%, or >14% (14.3% vs 70.2% vs. 88%, P < .001). Poorest survival was predicted for patients with NYHA class 3 to 4 and monocyte counts ≤6. Regression analysis showed that monocyte levels, NYHA class, and LVEF values were predictors of mortality, in decreasing importance.The total monocyte count was found to be an important prognostic factor that was inversely associated with predicted long-term mortality among patients with chronic HF. A low total monocyte count was strongly correlated with NYHA class and B-type natriuretic peptide levels, but no correlation was found with LVEF and oxidized low-density lipoproteins. It emerged as an independent risk factor for mortality in patients with chronic HF.

Effect of CD14 polymorphisms on the risk of cardiovascular disease: evidence from a meta-analysis

Background

CD14 polymorphisms are associated with an increased risk of cardiovascular events. So far, many studies have been conducted, whereas the results were not always consistent.

Materials and methods

Twenty-six articles involving thirty-seven datasets were recruited to evaluate the association between rs2569190 (9413 patients and 7337 controls), C-159T (4813 patients and 2852 controls) polymorphisms and cardiovascular diseases in a meta-analysis. The random or fixed effect models were used to evaluate the pooled odds ratios (ORs) and their corresponding 95% confidence intervals.

Results

The strongest association was observed between rs2569190 and CVD in overall population (T vs. C, OR = 1.169, 95% CI: 1.087–1.257, p = 2.44 × 10^− 5). Analysis after stratification by ethnicity indicated that rs2569190 was related to CVD in East Asian population (T vs. C, OR = 1.370, 95% CI; 1.226–1.531, p = 2.86 × 10^− 8) and a potential relationship in European (T vs. C, OR = 1.100, 95% CI: 1.019–1.189, p = 0.015). In the stratification of endpoints, the associations were found in CHD subgroup (T vs. C, OR = 1.357, 95% CI: 1.157–1.592, p = 2.47 × 10^− 7) and in AMI subgroup (T vs. C, OR = 1.152, 95% CI: 1.036–1.281, p = 0.009). However, we did not find any association between C-159T polymorphism with cardiovascular disease under any model.

Conclusions

The SNP rs2569190 significantly contribute to susceptibility and development of cardiovascular disease, particularly in the East Asian population and in the subtype CHD group, in addition, a potential association was observed in the AMI group, T allele acts as a risk factor for cardiovascular disease.

Electronic supplementary material

The online version of this article (10.1186/s12944-019-1018-3) contains supplementary material, which is available to authorized users.

The Relation Between Echocardiographic Epicardial Fat Thickness and CHA2DS2-VASc Score in Patients with Sinus Rhythm

Objective

To evaluate the predictive value of epicardial fat thickness (EFT) in CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups.

Methods

A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA₂DS₂-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score.

Results

Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA₂DS₂-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA₂DS₂-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA₂DS₂-VASc score.

Conclusion

Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

The utility of high-sensitivity C-reactive protein levels in patients with moderate coronary lesions and gray-zone fractional flow reserve

OBJECTIVE

It remains controversial whether patients with fractional flow reserve (FFR) values of 0.75-0.80 (gray-zone) should be treated with percutaneous coronary intervention (PCI). This study aimed to evaluate the prediction of high-sensitivity C-reactive protein (hs-CRP) levels to guide treatment selection in gray-zone patients.

METHODS

This prospective interventional trial was conducted between January 2015 and March 2016. A total of 785 patients with stable angina and single-vessel stenosis with moderate coronary lesions were admitted to hospital in this period. After measurement of hs-CRP levels, coronary angiography, and FFR, gray-zone patients (n=308) were included in the study and were divided into four groups on the basis of a cutoff hs-CRP level of 3 mg/L and then on the basis of whether they underwent PCI or not. Patients in groups I (≥3 mg/L, n=70) and III (<3 mg/L, n=84) underwent PCI, whereas those in groups II (≥3 mg/L, n=70) and IV (<3 mg/L, n=84) were administered only drugs. Major adverse clinical events (MACEs) included cardiac death, nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and PCI or coronary artery bypass grafting (CABG). These parameters were also evaluated during follow-up.

RESULTS

The total Kaplan-Meier curves showed macrodistribution differences among the four groups (p<0.05). There was a significantly increased MACE incidence in group II compared with group I or IV (p=0.039 or 0.006, respectively), and an increased incidence in group I compared with group III (p=0.028). However, there were no differences in MACE incidence between groups III and IV (p=0.095) despite the fact that these patients received different treatments.

CONCLUSION

Among FFR gray-zone patients, hs-CRP level was a predictor of MACE and risk stratification could guide treatment selection. Increased hs-CRP levels (≥3 mg/L) are an indication for urgent PCI whereas normal levels (<3 mg/L) are an indication for delayed PCI treatment. Patients with identical FFR values could require different treatment.

Incidence and risk of acute coronary syndrome in patients with acute pancreatitis: A nationwide cohort study

BACKGROUND

Studies on the relationship between acute pancreatitis (AP) and acute coronary syndrome (ACS) are scant. We conducted a nationwide cohort study to investigate the incidence and risk of ACS in patients with AP.

METHODS

We enrolled patients newly diagnosed with AP between 2000 and 2010 from the Taiwan National Health Insurance Research Database and randomly selected a control cohort without a history of AP after frequency-matching for age, sex, and index year at a ratio of 4:1 for each patient with AP. The follow-up period was from the index date of new AP diagnosis to the diagnosis of ACS, censoring, or the end of 2011.

RESULTS

We assessed 87 068 patients in the AP cohort and 348 272 participants in the control cohort for 508 991 and 2 301 317 person-years, respectively. The AP cohort exhibited a higher overall incidence of ACS than the control cohort (5.44 vs 3.03 per 1000 person-y). After adjustment for sex, age, and comorbidities, the AP cohort exhibited a 1.24-fold higher adjusted hazard ratio (aHR) of ACS (95% confidence interval = 1.19-1.30) than did the control cohort. When stratified by age, the patients with AP aged ≤39 years presented a 2.37-fold higher aHR of ACS than did their corresponding controls (95% CI = 1.88-2.99). Approximate one third of ACS developed within 1 month of AP occurrence.

CONCLUSIONS

This nationwide cohort study indicated that patients with AP are at an increased risk of ACS compared with those without AP.

A link between platelet to lymphocyte ratio and Helicobacter pylori infection

PURPOSE

Chronic Helicobacter pylori gastritis affects two-thirds of the world's population and is one of the most common chronic inflammatory disorders of humans, the infection clearly results in chronic mucosal inflammation in the stomach and duodenum, which, in turn, might lead to abnormalities in gastroduodenal motility and sensitivity and is the most frequent cause of dyspepsia and peptic disease. Some studies showed that there was a correlation between low-grade inflammation as CRP and HP infection. The purpose of this study was to investigate the relationship between the presence of HP infection and platelet/lymphocyte ratio (PLR).

METHOD

A total of 200 patients who met the HP criteria and 180 age- and gender-matched control subjects were included in this randomized controlled trial. Patients were diagnosed to have HP according stomach biopsy and urea breath test, PLR was calculated from complete blood count at time of diagnosis and before initiating the treatment.

RESULTS

Patients with HP infection had significantly higher PLR compared to those without HP. Moreover, the patients with symptomatic HP had higher PLR than those with asymptomatic HP. While PLR increased as the severity of HP symptoms increased (r=.452, P<.001).

CONCLUSION

Our study indicated, for the first time, a significant association between HP infection and symptoms based on PLR, a simple and reliable indicator of inflammation. Furthermore, there an increase in PLR as the severity of HP increases.

Long-term prognostic implication of coronary plaque characterization as detected by 64-multidetector computed tomography in Egyptian population

OBJECTIVES

We aimed to determine the role of multi-detector computed tomography (MDCT) in prognosis of patients with known or suspected coronary artery disease (CAD) by applying plaque characterization and whether obstructive versus non-obstructive plaque volume is a predictor of future cardiac events.

BACKGROUND

Vulnerable plaques may occur across the full spectrum of severity of stenosis, underlining that also non-obstructive lesions may contribute to coronary events.

METHODS

We included 1000 consecutive patients with intermediate pretest likelihood of CAD who were evaluated by 64-MDCT. Coronary artery calcium scoring, assessment of degree of coronary stenosis and quantitative assessment of plaque composition and volume were performed. The end point was cardiac death, acute coronary syndrome, or symptom-driven revascularization.

RESULTS

After a median follow-up of 16 months, 190 patients had suffered cardiac events. In a multivariate regression analysis for events, the total amount of non-calcified plaque (NCP) in non-obstructive lesions was independently associated with an increased hazard ratio for non-fatal MI (1.01-1.9/100-mm3 plaque volume increase, p = 0.039), total amount of obstructive plaque was independently associated with symptoms driven revascularization (p = 0.04) and coronary artery calcium scoring (CACS) was independently associated with cardiac deaths (p = 0.001).

CONCLUSION

MDCT is a non-invasive imaging modality with a prognostic utility in patients with known or suspected coronary artery disease by applying plaque characterization and it could identify vulnerable plaques by measuring the total amount of NCP in non-obstructive lesions which could be useful for detecting patients at risk of acute coronary syndrome (ACS) and guide further preventive therapeutic strategies. CACS was shown to be an independent predictor of mortality, while total amount of obstructive volume was shown to be an independent predictor of symptoms driven revascularization.

Proteomic Profile of Unstable Atheroma Plaque: Increased Neutrophil Defensin 1, Clusterin, and Apolipoprotein E Levels in Carotid Secretome

Because of the clinical significance of carotid atherosclerosis, the search for novel biomarkers has become a priority. The aim of the present study was to compare the protein secretion profile of the carotid atherosclerotic plaque (CAP, n = 12) and nonatherosclerotic mammary artery (MA, n = 10) secretomes. We used a nontargeted proteomic approach that incorporated tandem immunoaffinity depletion, iTRAQ labeling, and nanoflow liquid chromatography coupled to high-resolution mass spectrometry. In total, 162 proteins were quantified, of which 25 showed statistically significant differences in secretome levels between carotid atherosclerotic plaque and nondiseased mammary artery. We found increased levels of neutrophil defensin 1, apolipoprotein E, clusterin, and zinc-alpha-2-glycoprotein in CAP secretomes. Results were validated by ELISA assays. Also, differentially secreted proteins are involved in pathways such as focal adhesion and leukocyte transendothelial migration. In conclusion, this study provides a subset of identified proteins that are differently expressed in secretomes of clinical significance.

Incremental prognostic value of high-sensitive C-reactive protein in patients undergoing coronary computed tomography angiography

BACKGROUND

This study was performed to investigate whether combined use of high-sensitivity C-reactive protein (hs-CRP) levels and coronary computed tomography angiography (CCTA) results have additional prognostic value for predicting cardiovascular events in patients with suspected coronary artery disease (CAD).

METHODS

A total of 445 patients (61.6±9.3 years and 62.9% men) with suspected CAD who underwent both CCTA and hs-CRP measurement within one month were evaluated. Information on cardiovascular events, including cardiac death, non-fatal myocardial infarction, unstable angina and late (≥six months after CCTA) coronary revascularization was assessed.

RESULTS

One hundred and eighty-five patients (41.6%) had obstructive CAD on CCTA (stenosis ≥50%). Both high hs-CRP (≥2.25mg/L) and obstructive CAD were the independent predictors of cardiovascular events. Kaplan-Meier analysis showed that event rates were significantly different according to the presence of obstructive CAD and hs-CRP levels. Addition of hs-CRP levels to combined information of clinical factors and CCTA results further increased the predictive power for cardiovascular events (global chi-square ratio, from 13.51 to 19.14, p=0.022). Event risks were approximately 21.0-fold higher in the highest-risk group with both obstructive CAD and high hs-CRP levels than in the lowest-risk group with both insignificant CAD and low hs-CRP levels (p=0.007).

CONCLUSIONS

Combined use of hs-CRP levels and CCTA results provided a significant improvement in prognostic power for cardiovascular events in patients with suspected CAD. hs-CRP measurement may be a simple and useful method for determining risk stratification and treatment strategy in patients undergoing CCTA.

Neopterin as a Predictor of Functional Outcome and Mortality in Chinese Patients with Acute Ischemic Stroke

Immune responses and inflammation play an important role in the pathogenesis of ischemic stroke. We therefore evaluated the 6-month prognostic value of early measurement of serum neopterin levels, a marker of inflammation and immune system activation, in Chinese patients with acute ischemic stroke (AIS). Consecutive AIS patients admitted to the emergency department were identified. Clinical information was collected. Serum concentration of neopterin and NIH stroke scale (NIHSS) were measured at the time of admission. Functional outcome was measured by modified Rankin scale (mRS) 6 months after admission. Multivariate analyses were performed using logistic regression models. During the inclusion period, 312 patients with first-ever AIS were included and 290 completed follow-up. The results indicated that the serum neopterin levels were significantly (P < 0.0001) higher in acutely ischemic stroke patients as compared to normal controls. Neopterin was an independent prognostic marker of 6-month functional outcome and death [odds ratio (OR) 4.33 (1.83-10.32) and 6.68 (2.44-12.13), respectively, P < 0.0001 for both, adjusted for NIHSS, other predictors and vascular risk factors] in patients with AIS. Neopterin improved the area under the receiver operating characteristic curve of the NHISS score for functional outcome from 0.75 (95 % CI 0.69-0.83) to 0.85 (95 % CI 0.79-0.91; P < 0.001) and for mortality from 0.76 (95 % CI 0.68-0.85) to 0.87 (95 % CI 0.81-0.94; P < 0.001). Serum neopterin is a useful, independent tool to predict functional outcome and mortality 6 months after stroke.

Safety, tolerability, pharmacokinetics, and pharmacodynamics of losmapimod in healthy Japanese volunteers

This phase 1 study characterized the safety, tolerability, pharmacokinetics, and pharmacodynamics of losmapimod and its metabolite GSK198602 following single and repeat doses of oral losmapimod in healthy Japanese volunteers. Subjects (n = 41) received single oral doses of losmapimod (2.5, 7.5, 20 mg) or matching placebo on 3 separate days (n = 20) or losmapimod 7.5 mg or matching placebo twice daily for 14 days (n = 21). Assessments included maximum observed plasma concentration (Cmax ), time to Cmax (Tmax ), apparent terminal-phase half-life (t1/ )2 , area under the curve (AUC), and change in C-reactive protein and phosphorylated heat shock protein 27 levels. No serious adverse events occurred during the study, and there were no safety concerns regarding clinical laboratory parameters, 12-lead electrocardiogram, or vital signs. The losmapimod Tmax was 3-4 hours, and the mean t1/2 was approximately 7.9-9.0 hours, with no appreciable difference in Tmax and apparent clearance following oral dosing between dosing regimens. Single and repeat oral doses of losmapimod were well tolerated in healthy Japanese volunteers. The Tmax of GSK198602 was similar to and t1/2 was slightly longer than those of losmapimod. Approximate dose-proportional increases in exposure to losmapimod and GSK198602 were observed in AUC with single-dose administration. Repeat-dose trough concentrations reached steady state within 2 days, with an observed accumulation ratio of 1.56 and 1.91 for losmapimod and GSK198602, respectively.

The roles of a novel inflammatory neopterin in subjects with coronary atherosclerotic heart disease

Coronary atherosclerotic heart disease (CHD) is currently regarded as a chronic inflammatory disease. The inflammatory cytokine neopterin (NP) is a new predictor of the stable type of atherosclerotic plaque, and this study focused on the relationship between neopterin, Gensini score and high-sensitivity C-reactive protein (Hs-CRP) to explore the important role of neopterin in patients with CHD. This study enrolled 176 patients into the control group and 266 patients into the experimental group. The Gensini score was used to assess the severity of the coronary lesions, enzyme-linked immunosorbent assays (ELISAs) were used to measure the serum NP level, and other indicators were assessed using a fully automatic biochemical analyzer. The data were analyzed using SPSS19.0 statistical software. The serum NP level was higher in the experimental group than in the control group (132.23±6.40ng/mL vs. 40.95±2.67ng/mL, P<0.001). Compared with the stable angina (SA) group, the serum NP level was significantly increased in the unstable angina (UA) group (135.99±12.45ng/mL) and the acute myocardial infarction (AMI) group (173.66±13.59ng/mL) (P<0.05). In addition, the serum NP level was positively correlated with the Gensini score (r=0.687, P<0.001) as well as with the level of Hs-CRP (r=0.190, P<0.001). The serum level of NP was significantly higher in patients with CHD and was positively correlated with the severity of CHD. Thus, NP may become a new indicator for the assessment of the inflammatory response in coronary atherosclerosis.

Usefulness of elevated urine neopterin levels in assessing cardiac dysfunction and exercise ventilation inefficiency in patients with chronic systolic heart failure

Neopterin is synthesized by macrophages upon stimulation with gamma-interferon, and high neopterin production is associated with cellular immune activation and increased production of reactive oxygen species (oxidant stress), but the clinical utility of urine neopterin levels in patients with heart failure (HF) has not been explored. Fifty-three ambulatory patients with chronic systolic HF (left ventricular [LV] ejection fraction ≤40%) underwent comprehensive echocardiographic evaluation and cardiopulmonary exercise testing. Urine neopterin levels were quantified by liquid chromatography with tandem mass spectrometric analyses and corrected to urine creatinine (Cr) levels. In our study cohort, median urine neopterin level was 60 μmol/mol Cr (interquartile range 40 to 86). There were modest correlations between urine neopterin levels and abnormalities in cardiac structure and function by echocardiography: LV ejection fraction (r = -0.33, p = 0.017), indexed LV end-diastolic volume (r = 0.31, p = 0.029), indexed LV end-systolic volume (r = 0.32, p = 0.024), and E/septal Ea (r = 0.28, p = 0.041). Although there was no significant correlation between urine neopterin and maximal oxygen uptake (peak VO2: r = -0.25, p = 0.07), there was a modest correlation between urine neopterin and maximal ventilation/carbon dioxide production ratio (VE/VCO2 max: r = 0.38, p = 0.005). In conclusion, increase in urine neopterin levels tracks with disease severity in patients with chronic systolic HF.

Association of neutrophil to lymphocyte ratio with presence and severity of gastritis due to Helicobacter pylori infection

OBJECTIVE

Infection with the bacterial pathogen Helicobacter pylori (HP) clearly results in chronic mucosal inflammation in the stomach and duodenum, which, in turn, might lead to abnormalities in gastroduodenal motility and sensitivity and is the most frequent cause of dyspepsia and peptic disease. Some studies have shown that there was a correlation between low-grade inflammation as C-reactive protein (CRP) and HP infection. The aim of this study was to investigate the relationship between the presence of gastritis due to HP infection and neutrophil/lymphocyte ratio (NLR), a simple and reliable indicator of inflammation.

DESIGN

Fifty patients met the HP criteria and half of them have had severe symptoms and upper endoscopy showed atrophic gastritis, and fifty age- and sex-matched control subjects with gastritis without HP infection were included in this randomized controlled trial. Patients were diagnosed to have HP according to the use of urea breath testing (UBT) and multiple biopsies. NLR was calculated from complete blood count at the time of diagnosis and before initiating the treatment to all groups.

RESULTS

Patients with HP infection had significantly higher NLR compared to those without HP. Moreover, the patients with symptomatic HP and grade 4 gastritis had higher NLR than those asymptomatic with past history of peptic disease (P 0.007 and P 0.068, respectively). Although NLR increased as the severity of gastritis and HP symptoms increased (r = 0.564, P < 0.001), Receiver operating characteristic (ROC) Curve analysis was performed. The cut-off level for NLR with optimal sensitivity and specificity was calculated as 1.82 (area under curve [AUC] = 0.825 [0.753-0.884], P < 0.001).

CONCLUSION

The present study indicated, for the first time, a significant correlation between HP infection and inflammation on the basis of NLR, a simple and reliable indicator of inflammation. Furthermore, there is an increase in NLR as the severity of gastritis with HP increases. This elevated ratio gets normalized with treatment.

Pathophysiological role of neutrophils in acute myocardial infarction

The pathogenesis of acute myocardial infarction is known to be mediated by systemic, intraplaque and myocardial inflammatory processes. Among different immune cell subsets, compelling evidence now indicates a pivotal role for neutrophils in acute coronary syndromes. Neutrophils infiltrate coronary plaques and the infarcted myocardium and mediate tissue damage by releasing matrix-degrading enzymes and reactive oxygen species. In addition, neutrophils are also involved in post-infarction adverse cardiac remodelling and neointima formation after angioplasty. The promising results obtained in preclinical modelswith pharmacological approaches interfering with neutrophil recruitment or function have confirmed the pathophysiological relevance of these immune cells in acute coronary syndromes and prompted further studies of these therapeutic interventions. This narrative review will provide an update on the role of neutrophils in acute myocardial infarction and on the pharmacological means that were devised to prevent neutrophil-mediated tissue damage and to reduce post-ischaemic outcomes.

Neopterin concentrations in synovial fluid may reflect disease severity in patients with osteoarthritis

We aimed to detect neopterin concentrations in serum and synovial fluid (SF) of knee osteoarthritis (OA) patients and to clarify their relationship with clinical severity of the disease. We cross-sectionally enrolled 176 knee OA patients and 63 age- and sex-matched controls. We measured neopterin concentrations by enzyme-linked immunosorbent assay (ELISA) and investigated the correlation between serum/SF neopterin concentrations and Kellgren-Lawrence (KL) grades as well as Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores in OA patients. Our results demonstrated that increased SF neopterin concentrations were independently correlated with greater symptomatic and radiographic severity in OA patients. These results suggested a crucial role of neopterin activation in the development and progression of knee OA. Assessment of neopterin levels in SF is a potential biomarker to evaluate disease severity in OA patients.

Pathophysiological roles and clinical importance of biomarkers in acute coronary syndrome

Early diagnosis of acute coronary syndrome (ACS) is important to guide appropriate therapy at a time when it is most likely to be of value. Accurate prognostic and risk stratification will facilitate high-risk patients to have early advanced diagnostic investigations and early appropriate interventions in a cost-effective and efficient manner, while those patients at low risk of ACS complications do not need such costly diagnostic tests and unnecessary hospital admission. Recent investigations have demonstrated that elevation of biomarkers upstream from acute-phase biomarkers, biomarkers of plaque destabilization and rupture, biomarkers of myocardial ischemia, necrosis, and dysfunction may provide an earlier assessment of patient risk and identify patients with higher risk of having an adverse event. This review provides an overview of the pathophysiology and clinical characteristics of several well-established biomarkers as well as emerging biomarkers that may have potential clinical utility in patients with ACS. Such emerging biomarkers hold promise and need to be more thoroughly evaluated before utilization in routine clinical practice.

Neopterin: a potential marker in chronic peripheral arterial disease

Neopterin is a marker of macrophage activation that has exhibited high plasma levels in atherosclerotic diseases including coronary heart disease and critical limb ischemia. The role of neopterin in chronic peripheral arterial disease (PAD) has yet to be elucidated. In the present study, neopterin (Ν) serum concentrations were analyzed in asymptomatic (AsP) and symptomatic (SyP) patients with PAD as well as controls (C). In total 120 subjects, 40 AsP [ankle brachial index (ABI) ≤0.90], 40 SyP (ABI ≤0.90 plus pain in legs) and 40 controls (ABI >0.9) were enrolled. The results of the present study showed that neopterin plasma levels were statistically different among the groups. These findings demonstrated that activation of N‑mediated monocyte‑macrophage, was also observed in chronic PAD.

Leukocyte and leukocyte subset counts reveal compensatory mechanisms in coronary heart disease

BACKGROUND

Leukocyte number in the circulation plays a central role in inflammatory diseases, such as coronary heart disease (CHD). Increased counts are correlated with the intensity of the peri-infarction inflammatory response and adverse outcomes. We investigated leukocyte and leukocyte subset counts in dyslipidaemia patients and their relationship with LDL oxidation.

METHODS

Dyslipidaemia patients (207) were selected for blood counts and LDL-C testing. The level of HNP-1and myeloperoxidase in subsets of leukocytes and their relationship with LDL oxidation were compared between 24 CHD patients and 24 normal controls.

RESULTS

In dyslipidaemia patients, total leukocyte and neutrophil counts increased with LDL-C (p=0.001). Monocyte counts showed the opposite trend (p=0.001). Although serum HNP-1 levels were not different between CHD patients and normal controls (p=0.558), neutrophil HNP-1 mRNA levels were 2.13-fold greater than those of normal controls. However, monocyte HNP-1 mRNA levels were lower (p=0.005). The distribution of myeloperoxidase in monocytes and neutrophils is different, myeloperoxidase locates mainly in the cytoplasm of monocytes, on the cell membrane of neutrophils.

CONCLUSIONS

Leukocyte and leukocyte subset counts may correlate with LDL-C levels and LDL oxidation. The monocyte-neutrophil interaction reveals a potential compensatory mechanism associated with LDL oxidation in CHD that may be a prognostic factor of CHD.

Components of the complete blood count as risk predictors for coronary heart disease: in-depth review and update

Atherosclerosis is an inflammatory disease, and several inflammatory biomarkers, such as C-reactive protein, have been used to predict the risk of coronary heart disease. High white blood cell count is a strong and independent predictor of coronary risk in patients of both sexes, with and without coronary heart disease. A high number of white blood cells and their subtypes (for example, neutrophils, monocytes, lymphocytes, and eosinophils) are associated with the presence of coronary heart disease, peripheral arterial disease, and stroke. The coronary heart disease risk ratios associated with a high white blood cell count are comparable to those of other inflammatory markers, including C-reactive protein. In addition, other components of the complete blood count, such as hematocrit and the erythrocyte sedimentation rate, also are associated with coronary heart disease, and the combination of the complete blood count with the white blood cell count can improve our ability to predict coronary heart disease risk. These tests are inexpensive, widely available, and easy to order and interpret. They merit further research.

Update on acute coronary syndromes: the pathologists' view

Although mortality rates from coronary heart disease in the western countries have declined in the last few decades, morbidity caused by this disease is increasing and a substantial number of patients still suffer acute coronary syndrome (ACS) and sudden cardiac death. Acute coronary syndrome occurs as a result of myocardial ischaemia and its manifestations include acute myocardial infarction and unstable angina. Culprit plaque morphology in these patients varies from thrombosis with or without coronary occlusion to sudden narrowing of the lumen from intraplaque haemorrhage. The coronary artery plaque morphologies primarily responsible for thrombosis are plaque rupture, and plaque erosion, with plaque rupture being the most common cause of acute myocardial infarction, especially in men. Autopsy data demonstrate that women <50 years of age more frequently have erosion, whereas in older women, the frequency of rupture increases with each decade. Ruptured plaques are associated with positive (expansive) remodelling and characterized by a large necrotic core and a thin fibrous cap that is disrupted and infiltrated by foamy macrophages. Plaque erosion lesions are often negatively remodelled with the plaque itself being rich in smooth muscle cells and proteoglycans with minimal to absence of inflammation. Plaque haemorrhage may expand the plaque rapidly, leading to the development of unstable angina. Plaque haemorrhage may occur from plaque rupture (fissure) or from neovascularization (angiogenesis). Atherosclerosis is now recognized as an inflammatory disease with macrophages and T-lymphocytes playing a dominant role. Recently at least two subtypes of macrophages have been identified. M1 is a pro-inflammatory macrophage while M2 seems to play a role in dampening inflammation and promoting tissue repair. A third type of macrophage, termed by us as haemoglobin associated macrophage or M(Hb) which is observed at site of haemorrhage also can be demonstrated in human atherosclerosis. In order to further our understanding of the specific biological events which trigger plaque instability and as well as to monitor the effects of novel anti-atherosclerotic therapies newer imaging modalities in vivo are needed.

Correlation of Neutrophil to Lymphocyte Ratio With the Presence and Severity of Metabolic Syndrome

Purpose: The aim of this study is to investigate the relationship between the criteria comprising metabolic syndrome (MS) and neutrophil–lymphocyte ratio (NLR), a simple and reliable indicator of inflammation. Method: Seventy patients with MS and 71 age- and sex-matched control participants were included. Patients were classified into 3 groups based on the number of MS criteria: group 1 (with 3 criteria), group 2 (with 4 criteria), and group 3 (with 5 criteria). The NLR was calculated from complete blood count. Results: Patients with MS had significantly higher NLR compared to the control group. Moreover, the group 3 patients had higher NLR than those in groups 2 and 1 ( P = .008 and P = .078, respectively), whereas there was no difference between the patients meeting 3 and 4 MS criteria ( P = .320). Besides, NLR increased as the severity of MS increased ( r = .586, P < .001). The cutoff level for NLR with optimal sensitivity and specificity was calculated as 1.84. Serum glucose and high-sensitive C-reactive protein level were found to be independent predictors of an NLR value greater than 1.84. Conclusion: The present study indicated a significant correlation between the criteria of MS and inflammation on the basis of NLR. Furthermore, there an increase in NLR as the severity of MS increases.

Periodontal disease: a new factor associated with the presence of multiple complex coronary lesions

BACKGROUND AND AIM

Periodontal disease, including bone loss, is thought to be involved in coronary artery disease. Multiple complex coronary lesions relate to multifocal destabilization of coronary plaques. We investigated whether bone loss could be associated with the presence of multiple complex coronary lesions.

METHODS

This cross-sectional study included 150 patients with recent myocardial infarction (<1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss >50% was performed. Patients with no or simple complex lesions were compared to patients with multiple complex lesions.

RESULTS

Over 20% of patients had multiple complex coronary lesions. Patients with multiple complex lesion were less likely to be women and more likely to have multivessel disease or elevated C-reactive protein (CRP) than patients with no or single complex lesion. Bone loss >50% tended to be more frequent in patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion. Bone loss >50% increased the risk of multiple complex lesion.

CONCLUSION

Bone loss was associated with complex multiple coronary lesions, beyond systemic inflammation. These findings may bear important clinical implications for the prevention and treatment of coronary artery disease.

Neutrophils and clinical outcomes in patients with acute coronary syndromes and/or cardiac revascularisation. A systematic review on more than 34,000 subjects

Some studies have suggested that high levels of total white blood cell (WBC) count and C-reactive protein (CRP) may be considered as independent prognostic factors in patients with acute coronary syndromes (ACS) and/or after cardiac revascularisation by percutaneous coronary intervention or coronary artery bypass grafting surgery. Evidence on the role of neutrophils in cardiovascular disease is less compelling. Therefore, we conducted a systematic review of the literature with the aim of identifying all the available evidence to clarify the role of neutrophils (absolute or relative count, neutrophil/lymphocyte ratio) as a prognostic risk factor in patients with ACS and/or cardiac revascularisation. All published studies evaluating the role of neutrophils as a risk factor for clinical outcomes were assessed using the MEDLINE and EMBASE databases. Study selection, data extraction and validity assessment was performed independently by two reviewers. Twenty-one studies (17 of which had positive results) for a total of more than 34,000 patients were included. Ten of 13 studies in ACS patients found that neutrophils measured on-admission are related to mortality rate and/or to major adverse clinical events. A predictive value of neutrophils after cardiac revascularisation procedures was reported in seven out of eight studies. Most of the studies showed that neutrophils were independent predictors of cardiovascular outcomes when analysed concomitantly with other markers of inflammation (WBC, CRP). The findings of our systematic review highlight the potential application of this inexpensive and readily available inflammatory marker for risk stratification in patients with ACS and/or cardiac revascularisation.

Human neutrophil peptides mediate endothelial-monocyte interaction, foam cell formation, and platelet activation

OBJECTIVE

Neutrophils are involved in the inflammatory responses during atherosclerosis. Human neutrophil peptides (HNPs) released from activated neutrophils exert immune modulating properties. We hypothesized that HNPs play an important role in neutrophil-mediated inflammatory cardiovascular responses in atherosclerosis.

METHODS AND RESULTS

We examined the role of HNPs in endothelial-leukocyte interaction, platelet activation, and foam cell formation in vitro and in vivo. We demonstrated that stimulation of human coronary artery endothelial cells with clinically relevant concentrations of HNPs resulted in monocyte adhesion and transmigration; induction of oxidative stress in human macrophages, which accelerates foam cell formation; and activation and aggregation of human platelets. The administration of superoxide dismutase or anti-CD36 antibody reduced foam cell formation and cholesterol efflux. Mice deficient in double genes of low-density lipoprotein receptor and low-density lipoprotein receptor-related protein (LRP), and mice deficient in a single gene of LRP8, the only LRP phenotype expressed in platelets, showed reduced leukocyte rolling and decreased platelet aggregation and thrombus formation in response to HNP stimulation.

CONCLUSIONS

HNPs exert proatherosclerotic properties that appear to be mediated through LRP8 signaling pathways, suggesting an important role for HNPs in the development of inflammatory cardiovascular diseases.

IL-6-independent association of elevated serum neopterin levels with prevalent frailty in community-dwelling older adults

BACKGROUND

neopterin is a monocyte/macrophage-derived immune activation marker and its levels increase with age. Frailty is an important clinical syndrome of old age. Previous studies have shown significant association between elevated interleukin-6 (IL-6) levels and frailty. The objective of this study was to evaluate IL-6-independent association of serum neopterin levels with prevalent frailty.

METHODS

this is a cross-sectional study in community-dwelling older adults recruited from residential and retirement communities in Baltimore, MD, USA. Frailty was determined using validated screening criteria. Serum neopterin and IL-6 levels were measured using standard enzyme-linked immunosorbent assay. Pearson correlation and multivariate linear regression analysis was performed to assess the relationship between log(neopterin) and log(IL-6). Odds ratios (ORs) for frailty were calculated using log(neopterin) and log(IL-6) as continuous measures and across tertiles of neopterin and IL-6 levels, adjusting for age, race, sex, education and body mass index.

RESULTS

one hundred and thirty-three individuals with a mean age of 84 years (range 72-97) completed the study. Neopterin levels were significantly higher in frail older adults than those in non-frail controls [median: 8.94 versus 8.35 nM, respectively, P < 0.001 t-test on log(neopterin)]. Log(neopterin) was significantly associated with prevalent frailty, adjusting for log(IL-6). Participants in the top tertile of neopterin had OR of 3.80 [95% confidence interval (CI) = 1.36-10.6, P < 0.01] for frailty. As expected, participants in the top tertile of IL-6 had OR of 3.29 (95% CI = 1.21-7.86, P < 0.05) for frailty. Log(neopterin) correlated with log(IL-6) (correlation coefficient = 0.19, P < 0.05). Moreover, OR for participants in the top neopterin tertile remained significant after adjusting for IL-6 (OR = 3.97, 95% CI = 1.15-13.72, P < 0.05).

CONCLUSION

elevated neopterin levels had IL-6-independent association with prevalent frailty, suggesting potential monocyte/macrophage-mediated immune activation in the frail elderly.

Association between high-sensitivity C-reactive protein and coronary plaque subtypes assessed by 64-slice coronary computed tomography angiography in an asymptomatic population

BACKGROUND

Elevated levels of C-reactive protein (CRP) are associated with poor cardiovascular outcomes, even after accounting for traditional cardiovascular risk factors. We sought to analyze the relationship between levels of CRP and coronary plaque subtypes as assessed by coronary computed tomography angiography.

METHODS AND RESULTS

We evaluated 1004 asymptomatic South Korean subjects (mean age, 49±9.3 years) who underwent coronary computed tomography angiography as part of a health screening evaluation. We examined the association between increasing CRP levels and plaque subtypes using multivariable linear and logistic regression analysis. Coronary plaque was observed in 211 of 1004 individuals (21%). Subjects with high CRP (≥2 mg/L) had an increased prevalence of any plaque type (30.7% versus 16.7% P<0.001) and mixed calcified arterial plaque (MCAP) (19.3% versus 6.3% P<0.001) as compared with subjects with low-normal CRP. Multivariable logistic regression analysis demonstrated that elevated CRP predicted the presence of any MCAP (high versus low-normal CRP group; odds ratio, 2.81; 95% confidence interval, 1.62 to 4.89). When examining the multivariable logistic regression analysis between the presence of ≥2 plaques and CRP, subjects with high CRP were more likely to have MCAP than those with low-normal CRP levels (odds ratio, 3.78; 95% confidence interval, 1.49 to 9.55).

CONCLUSIONS

Elevated levels of CRP are associated with an increased prevalence of MCAP as assessed by coronary computed tomography angiography. Longitudinal studies will determine if the excess risk observed in persons with elevated CRP may be mediated, at least in part, by an increased burden of MCAP.

Neopterin and atherosclerotic plaque instability in coronary and carotid arteries

Inflammation plays a key role in atherosclerosis and plaque vulnerability, and monocyte/macrophage activation contributes to these processes. Neopterin, a by-product of the guanosine triphosphate pathway, is produced by activated macrophages on stimulation with interferon-γ released from T lymphocytes, and is an activation marker for monocytes/macrophages. Coronary angiographic studies have shown a relationship between increased circulating levels of neopterin and the presence of complex coronary lesions in patients with unstable angina pectoris (UAP). Furthermore, in an immunohistochemical study performed using coronary atherectomy specimens, a significantly higher prevalence of neopterin-positive macrophages was found in culprit lesions in patients with UAP than in those with stable angina pectoris (SAP). We recently clarified that the presence of complex carotid plaques detected by carotid ultrasound was related to increased circulating levels of neopterin, and immunohistochemical localization of neopterin was observed in complex carotid lesions obtained from carotid endarterectomy in patients with SAP. These findings suggest that neopterin is an important biomarker of plaque instability in both coronary and carotid atherosclerotic lesions.

Acute infection-inflammation and coronary stent thrombosis: an observational study

Coronary stent thrombosis (CST) is a major concern of interventional cardiology. Several risk factors for CST have been identified, but as a whole they do not explain the pathophysiology of CST. This study was designed to investigate whether acute infection-inflammation could facilitate the occurrence of CST. Forty-one patients, aged 66.6 +/- 11 years, consecutively admitted to our catheterization laboratory for acute, subacute or late CST, were retrospectively analysed. Transient acute infection-inflammation on admission for CST was diagnosed by predefined criteria. Prevalence of known risk factors for CST was also investigated. Twenty-one patients (51%) met predefined criteria for the occurrence of acute infection-inflammation. On admission, in these patients, levels of systemic humoral and cellular inflammatory markers were significantly higher than those of patients without recent or ongoing acute infection-inflammation (p < 0.05 for all). 62% of patients with acute infection-inflammation had less than two known risk factors for CST whereas only 37% patients without infection-inflammation showed less than two risk factors (p = 0.03) and showed more frequent interruption of antiplatelet treatment (17 vs. 2.4%, p = 0.02), mean longer stent length (20.5 +/- 4.8 vs. 16.5 +/- 5.1 mm, p = 0.02) and lower left ventricular ejection fraction before CST (42.9 +/- 14 vs. 47.3 +/- 11%, p = 0.02). In conclusion, acute infection-inflammation could play a role in facilitating the occurrence of CST in a subgroup with low risk profile for known risk factors. Our findings, if confirmed, could suggest new opportunities for prevention and treatment of CST.

C-reactive protein in unstable angina: clinical and angiographic correlation

OBJECTIVE

To assess prevalence, in-hospital prognostic significance and angiographic correlation of C-reactive protein (CRP) elevation in patients with unstable angina.

DESIGN

Prospective observational study.

SETTING

Royal Hospital, Muscat, Oman.

PATIENTS

100 patients admitted between July 2008 and January 2009.

INTERVENTIONS

Patients with unstable angina and ECG changes without biochemical evidence of necrosis (negative first troponin T), had CRP measured at admission by rate nephelometry (≥10 mg/l abnormal).

MAIN OUTCOME MEASURES

In-hospital cardiac events and severity of coronary artery disease (CAD) in patients with and without CRP elevation.

RESULTS

42% had CRP elevation ≥10 mg/l (Group I), and 58% had levels <10 mg/l (Group II). When compared with Group II, Group I patients had more anginal episodes (mean=4.6±2.5 episodes/patient vs 1.6±2.4; p<0.0001), myocardial infarction (58% vs 17%; p<0.01), in-hospital mortality (9% vs 0%; p=0.03) and severe triple vessel disease (71% vs 24%; p<0.01), and a higher total number of events (86% vs 24%; p<0.0001). Elevated admission CRP as a marker of in-hospital cardiac events showed a sensitivity of 72%, specificity of 88% and positive predictive value of 85%, and, as a marker of significant CAD, showed a specificity of 83% and a positive predictive value of 85%.

CONCLUSIONS

Raised admission CRP level is predictive of increased in-hospital cardiac events and severe CAD in patients with unstable angina. CRP can be used to risk-stratify unstable angina patients independent of troponin levels. Patients with abnormal CRP should undergo coronary angiography either on-site or transferred to a centre with catheterisation facility during the index hospital admission.