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Zhou T, Wan T, Jin X, Chen Y, Shen C. The clinical implications of choroidal thickness combined with tear VEGFA in coronary artery disease. Coron Artery Dis 2023; 34:510-516. [PMID: 37756415 PMCID: PMC10538601 DOI: 10.1097/mca.0000000000001279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the effect of choroidal thickness and tear vascular endothelial growth factor A (VEGFA) as biomarkers of coronary artery disease (CAD). METHODS This study was a retrospective observational case-control trial. A total of 637 patients who underwent coronary angiography to assess their coronary artery status were included. The patients were divided into two groups: 200 people in the No CAD group and 437 people in the CAD group. We evaluated the choroidal thickness of the right foveal membrane in all patients through optical coherence tomography angiography examination. We also collected tear samples from patients to measure VEGFA. The ROC curve and its area under the curve (AUC) were used for analysis. RESULTS The central foveal choroid in the No CAD group was significantly thicker than that in the CAD group (289.09 μm ± 38.41; 229.03 μm ± 33.44, P < 0.01). The tear VEGFA in the CAD group was higher than that in the No CAD group (706.15 ng/mL ± 147.42; 419.66 ng/mL ± 105.85, P < 0.01). Spearman analysis showed that the correlation between choroidal thickness and Gensini score was -0.7387 ( P < 0.01). The correlation between tear VEGFA level and Gensini score was 0.8636 ( P < 0.01). Taking choroidal thickness and tear VEGFA as independent variables, we obtained AUC = 0.9647 (95% CI 0.9506-0.9789, P < 0.01) through binary logic regression and ROC curve analysis. CONCLUSION The combination of choroidal thickness and tear VEGFA in patients can serve as a clinical marker of CAD and its severity.
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Affiliation(s)
- Tingquan Zhou
- Department of Cardiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
| | - Ting Wan
- Department of Ophthalmology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Xian Jin
- Department of Cardiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
| | - Yu Chen
- Department of Cardiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
| | - Chengxing Shen
- Department of Cardiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
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2
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Lehman LL, Kaseka ML, Stout J, See AP, Pabst L, Sun LR, Hassanein SA, Waak M, Vossough A, Smith ER, Dlamini N. Pediatric Moyamoya Biomarkers: Narrowing the Knowledge Gap. Semin Pediatr Neurol 2022; 43:101002. [PMID: 36344019 DOI: 10.1016/j.spen.2022.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Moyamoya is a progressive cerebrovascular disorder that leads to stenosis of the arteries in the distal internal carotid, proximal middle cerebral and proximal anterior cerebral arteries of the circle of Willis. Typically a network of collaterals form to bypass the stenosis and maintain cerebral blood flow. As moyamoya progresses it affects the anterior circulation more commonly than posterior circulation, and cerebral blood flow becomes increasingly reliant on external carotid supply. Children with moyamoya are at increased risk for ischemic symptoms including stroke and transient ischemic attacks (TIA). In addition, cognitive decline may occur over time, even in the absence of clinical stroke. Standard of care for stroke prevention in children with symptomatic moyamoya is revascularization surgery. Treatment of children with asymptomatic moyamoya with revascularization surgery however remains more controversial. Therefore, biomarkers are needed to assist with not only diagnosis but also with determining ischemic risk and identifying best surgical candidates. In this review we will discuss the current knowledge as well as gaps in research in relation to pediatric moyamoya biomarkers including neurologic presentation, cognitive, neuroimaging, genetic and biologic biomarkers of disease severity and ischemic risk.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Matsanga Leyila Kaseka
- Department of Neurology, CHU Sainte-Justine, Montreal, Quebec, Canada; Université de Montréal, Montreal, Quebec, Canada
| | - Jeffery Stout
- Harvard Medical School, Boston, MA; Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Alfred P See
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA; Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Lisa R Sun
- Division of Pediatric Neurology, Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sahar A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Michaela Waak
- Department of Paediatric Intensive Care, Queensland Children's Hospital; Centre for Child Health Research, The University of Queensland, Brisbane, Australia
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, University of Philadelphia, Philadelphia, Pennsylvania
| | - Edward R Smith
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Nomazulu Dlamini
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Faculty of Medicine, University of Toronto, Canada
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3
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Mao Y, Meng L, Liu H, Lu Y, Yang K, Ouyang G, Ban Y, Chen S. Therapeutic potential of traditional Chinese medicine for vascular endothelial growth factor. J Zhejiang Univ Sci B 2022; 23:353-364. [PMID: 35557037 DOI: 10.1631/jzus.b2101055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vascular endothelial growth factor (VEGF) is the main regulator of physiological angiogenesis during embryonic development, bone growth, and reproductive function, and it also participates in a series of pathological changes. Traditional Chinese medicine (TCM), with a history of more than 2000 years, has been widely used in clinical practice, while the exploration of its mechanisms has only begun. This review summarizes the research of recent years on the influence of TCM on VEGF. It is found that many Chinese medicines and recipes have a regulatory effect on VEGF, indicating that Chinese medicine has broad prospects as a complementary and alternative therapy, providing new treatment ideas for clinical applications and the theoretical basis for research on the mechanisms of TCM.
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Affiliation(s)
- Yijia Mao
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
| | - Lingkai Meng
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
| | - Huayi Liu
- Department of Digestive Diseases, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin 300120, China.
| | - Yuting Lu
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
| | - Kuo Yang
- Department of Digestive Diseases, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin 300120, China
| | - Guangze Ouyang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
| | - Yanran Ban
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
| | - Shuang Chen
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301608, China
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4
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Spadaccio C, Nenna A, Rose D, Piccirillo F, Nusca A, Grigioni F, Chello M, Vlahakes GJ. The Role of Angiogenesis and Arteriogenesisin Myocardial Infarction and Coronary Revascularization. J Cardiovasc Transl Res 2022; 15:1024-1048. [PMID: 35357670 DOI: 10.1007/s12265-022-10241-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/18/2022] [Indexed: 12/25/2022]
Abstract
Surgical myocardial revascularization is associated with long-term survival benefit in patients with multivessel coronary artery disease. However, the exact biological mechanisms underlying the clinical benefits of myocardial revascularization have not been elucidated yet. Angiogenesis and arteriogenesis biologically leading to vascular collateralization are considered one of the endogenous mechanisms to preserve myocardial viability during ischemia, and the presence of coronary collateralization has been regarded as one of the predictors of long-term survival in patients with coronary artery disease (CAD). Some experimental studies and indirect clinical evidence on chronic CAD confirmed an angiogenetic response induced by myocardial revascularization and suggested that revascularization procedures could constitute an angiogenetic trigger per se. In this review, the clinical and basic science evidence regarding arteriogenesis and angiogenesis in both CAD and coronary revascularization is analyzed with the aim to better elucidate their significance in the clinical arena and potential therapeutic use.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiac Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, USA. .,Cardiac Surgery, Golden Jubilee National Hospital & University of Glasgow, Glasgow, UK.
| | - Antonio Nenna
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - David Rose
- Cardiac Surgery, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | | | | | | | - Massimo Chello
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Gus J Vlahakes
- Cardiac Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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5
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Isaacs-Trepanier C, Saleem M, Herrmann N, Swardfager W, Oh PI, Goldstein BI, Mitchell J, Sugamori KS, Lanctôt KL. Endostatin as a Mediator Between Endothelial Function and Cognitive Performance in Those at Risk for Vascular Cognitive Impairment. J Alzheimers Dis 2021; 76:601-611. [PMID: 32538839 PMCID: PMC7458520 DOI: 10.3233/jad-200058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: Patients with coronary artery disease have an increased risk for developing vascular cognitive impairment. Endothelial function is often diminished and has been associated with lower cognitive performance in these patients. The link between endothelial function and cognition in coronary artery disease is not fully understood. Angiogenesis may play a role in mediating the association between endothelial function and cognition since angiogenic processes rely heavily on the endothelium. Objective: The aim of this study was to determine if markers of angiogenesis mediate the relationship between endothelial function and cognition in coronary artery disease patients. Methods: In 50 participants with coronary artery disease, endothelial function was assessed using peripheral arterial tonometry. Vascular endothelial growth factor (pro-angiogenic) and endostatin (anti-angiogenic) were measured in peripheral serum samples. Cognition was assessed using the Montreal Cognitive Assessment. A mediation analysis, using a bias corrected inferential bootstrapping method with 10,000 permutations, was used to determine if vascular endothelial growth factor or endostatin mediated an association between peripheral arterial tonometry measures and cognitive performance on the Montreal Cognitive Assessment. Results: Endostatin, but not vascular endothelial growth factor, mediated a relationship between endothelial function and cognitive performance when controlling for total years of education, body mass index, coronary artery bypass graft, stent, diabetes, and diuretic use. This analysis was also significant when delayed recall was substituted for the overall score on the Montreal Cognitive Assessment. Conclusion: These results suggest that endostatin mediates an association between endothelial function and cognitive performance in coronary artery disease.
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Affiliation(s)
| | - Mahwesh Saleem
- Department of Psychiatry, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Department of Psychiatry, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Walter Swardfager
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Paul I Oh
- KITE, UHN-Toronto Rehab, Toronto, Ontario, Canada
| | - Benjamin I Goldstein
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jane Mitchell
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Kim S Sugamori
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,KITE, UHN-Toronto Rehab, Toronto, Ontario, Canada
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6
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Sesen J, Driscoll J, Moses-Gardner A, Orbach DB, Zurakowski D, Smith ER. Non-invasive Urinary Biomarkers in Moyamoya Disease. Front Neurol 2021; 12:661952. [PMID: 33868159 PMCID: PMC8047329 DOI: 10.3389/fneur.2021.661952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: A major difficulty in treating moyamoya disease is the lack of effective methods to detect novel or progressive disease prior to the onset of disabling stroke. More importantly, a tool to better stratify operative candidates and quantify response to therapy could substantively complement existing methods. Here, we present proof-of-principle data supporting the use of urinary biomarkers as diagnostic adjuncts in pediatric moyamoya patients. Methods: Urine and cerebrospinal fluid specimens were collected from pediatric patients with moyamoya disease and a cohort of age and sex-matched control patients. Clinical and radiographic data were paired with measurements of a previously validated panel of angiogenic proteins quantified by ELISA. Results were compared to age and sex-matched controls and subjected to statistical analyses. Results: Evaluation of a specific panel of urinary and cerebrospinal fluid biomarkers by ELISA demonstrated significant elevations of angiogenic proteins in samples from moyamoya patients compared to matched controls. ROC curves for individual urinary biomarkers, including MMP-2, MMP-9, MMP-9/NGAL, and VEGF, showed excellent discrimination. The optimal urinary biomarker was MMP-2, providing a sensitivity of 88%, specificity of 100%, and overall accuracy of 91%. Biomarker levels changed in response to therapy and correlated with radiographic evidence of revascularization. Conclusions: We report, for the first time, identification of a panel of urinary biomarkers that predicts the presence of moyamoya disease. These biomarkers correlate with presence of disease and can be tracked from the central nervous system to urine. These data support the hypothesis that urinary proteins are useful predictors of the presence of moyamoya disease and may provide a basis for a novel, non-invasive method to identify new disease and monitor known patients following treatment.
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Affiliation(s)
- Julie Sesen
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jessica Driscoll
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alexander Moses-Gardner
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Departments of Surgery and Anesthesiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Edward R Smith
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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7
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Serum VEGF: Diagnostic Value of Acute Coronary Syndrome from Stable Angina Pectoris and Prognostic Value of Coronary Artery Disease. Cardiol Res Pract 2020; 2020:6786302. [PMID: 32411449 PMCID: PMC7199618 DOI: 10.1155/2020/6786302] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background Although the level of serum vascular endothelial growth factor (VEGF) is elevated in coronary artery disease (CAD) patients, its potential role in acute coronary syndrome (ACS) or stable angina pectoris (SAP) patients remains unclear. Objectives To evaluate diagnostic accuracy of serum VEGF in determining ACS patients from SAP and analyze the association of serum VEGF with coronary artery lesions in SAP or the GRACE score in ACS, which is involved in the poor prognosis of low serum VEGF. Methods 248 CAD patients and 48 healthy subjects were enrolled in this study. Serum VEGF levels were detected by using ELISA. The Gensini score or GRACE score was calculated among SAP or ACS patients. All the patients were followed up for a period of 12 months (mean: 10.77 months). Results VEGF serum concentrations were higher in the ACS subgroup than in the SAP subgroup (P < 0.001) with diagnostic accuracy of ACS from SAP (AUC: 0.667, sensitivity: 68.5%, specificity: 60.1%, P < 0.001). Patients with high risk of Gensini score showed reduced VEGF levels (P < 0.001) accompanied by a negative correlation (r = -0.396, P < 0.001). Patients with a higher GRACE score indicated lower VEGF levels (P < 0.001). Low serum VEGF was one of the potential risk factors with adjusted HR of 0.531 (P=0.048). Conclusion Serum VEGF exhibits efficient diagnostic value for detection of ACS from SAP with a cutoff value of 648.75 pg/mL. Low serum VEGF indicates severe coronary artery lesions and a higher GRACE score, which suggests poor clinical outcomes.
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Inverse Relationship between Serum VEGF Levels and Late In-Stent Restenosis of Drug-Eluting Stents. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8730271. [PMID: 28373989 PMCID: PMC5360953 DOI: 10.1155/2017/8730271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/20/2017] [Indexed: 11/19/2022]
Abstract
Late in-stent restenosis (ISR) has raised concerns regarding the long-term efficacy of drug-eluting stents (DES). The role of vascular endothelial growth factor (VEGF) in the pathological process of ISR is controversial. This retrospective study aimed to investigate the relationship between serum VEGF levels and late ISR in patients with DES implantation. A total of 158 patients who underwent angiography follow-up beyond 1 year after intervention were included. The study population was classified into ISR and non-ISR groups. The ISR group was further divided according to follow-up duration and Mehran classification. VEGF levels were significantly lower in the ISR group than in the non-ISR group [96.34 (48.18, 174.14) versus 179.14 (93.59, 307.74) pg/mL, p < 0.0001]. Multivariate regression revealed that VEGF level, procedure age, and low-density lipoprotein cholesterol were independent risk factors for late ISR formation. Subgroup analysis demonstrated that VEGF levels were even lower in the very late (≥5 years) and diffuse ISR group (Mehran patterns II, III, and IV) than in the late ISR group (1–4 years) and the focal ISR group (Mehran pattern I), respectively. Furthermore, significant difference was found between diffuse and focal ISR groups. Serum VEGF levels were inversely associated with late ISR after DES implantation.
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Han X, Liu L, Niu J, Yang J, Zhang Z, Zhang Z. Serum VEGF Predicts Worse Clinical Outcome of Patients with Coronary Heart Disease After Percutaneous Coronary Intervention Therapy. Med Sci Monit 2015; 21:3247-51. [PMID: 26501555 PMCID: PMC4627363 DOI: 10.12659/msm.894803] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Percutaneous coronary intervention (PCI) is an effective treatment for coronary heart disease (CHD) patients. However, patients after PCI treatment often have ischemic events that result in poor prognosis. Our study aimed to investigate the effects of vascular endothelial growth factor (VEGF) level on the prognosis of CHD patients. Material/Methods We enrolled 114 CHD patients in the study. Serum VEGF level was measured by enzyme-linked immunosorbent assay (ELISA). Total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and Hs-CRP were also tested in patients. The patients were divided into 2 groups according to the level of VEGF. Kaplan-Meier curve was used to observe the differences in survival situation of patients of the 2 groups. Cox regression analysis was conducted to judge whether VEGF was an independent biomarker for prognosis in CHD. Results We included 104 patients for survival analysis. VEGF level in CHD patients was significantly lower than that of healthy individuals (P<0.05). In the analysis of basic information, we found differences in sex distribution and hypertension between groups (P<0.05 for both). Kaplan-Meier curve indicated that patients with low expression of VEGF presented with poor prognosis. The mortality rate of the low-expression group was 37.71%, higher than that of the high-expression group (14.3%). Cox analysis suggested that VEGF could serve as a biomarker for prognosis in CHD (HR: 3.014, P: 0.019). Conclusions Low level of VEGF may predict poor clinical outcome of CHD patients after PCI treatment.
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Affiliation(s)
- Xia Han
- Department of Cardiology, Laiwu People's Hospital, Laiwu, Shandong, China (mainland)
| | - Lili Liu
- Special department of Laiwu People's Hospital, Laiwu, Shandong, China (mainland)
| | - Jiamin Niu
- Department of Cardiology, Laiwu People's Hospital, Laiwu, Shandong, China (mainland)
| | - Jun Yang
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China (mainland)
| | - Zengtang Zhang
- Department of Cardiology, Laiwu People's Hospital, Laiwu, Shandong, China (mainland)
| | - Zhiqiang Zhang
- Department of Cardiology, Laiwu People's Hospital, Laiwu, Shandong, China (mainland)
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