The Role of Serum Tenascin-C in Predicting In-Hospital Death in Acute Aortic Dissection

Impact of D-dimer on in-hospital mortality following aortic dissection: A systematic review and meta-analysis

BACKGROUND

The utility of D-dimer (DD) as a biomarker for acute aortic dissection (AD) is recognized. Yet, its predictive value for in-hospital mortality remains uncertain and subject to conflicting evidence.

AIM

To conduct a meta-analysis of AD-related in-hospital mortality (ADIM) with elevated DD levels.

METHODS

We searched PubMed, Scopus, Embase, and Google Scholar for AD and ADIM literature through May 2022. Heterogeneity was assessed using I 2 statistics and effect size (hazard or odds ratio) analysis with random-effects models. Sample size, study type, and patients' mean age were used for subgroup analysis. The significance threshold was P < 0.05.

RESULTS

Thirteen studies (3628 patients) were included in our study. The pooled prevalence of ADIM was 20% (95%CI: 15%-25%). Despite comparable demographic characteristics and comorbidities, elevated DD values were associated with higher ADIM risk (unadjusted effect size: 1.94, 95%CI: 1.34-2.8; adjusted effect size: 1.12, 95%CI: 1.05-1.19, P < 0.01). Studies involving patients with a mean age of < 60 years exhibited an increased mortality risk (effect size: 1.43, 95%CI: 1.23-1.67, P < 0.01), whereas no significant difference was observed in studies with a mean age > 60 years. Prospective and larger sample size studies (n > 250) demonstrated a heightened likelihood of ADIM associated with elevated DD levels (effect size: 2.57, 95%CI: 1.30-5.08, P < 0.01 vs effect size: 1.05, 95%CI: 1.00-1.11, P = 0.05, respectively).

CONCLUSION

Our meta-analysis shows elevated DD increases in-hospital mortality risk in AD patients, highlighting the need for larger, prospective studies to improve risk prediction models.

A comprehensive exploration of novel biomarkers for the early diagnosis of aortic dissection

Aortic dissection (AD) is a catastrophic life-threatening cardiovascular emergency with a 1-2% per hour mortality rate post-diagnosis, characterized physiologically by the separation of aortic wall layers. AD initially presents as intense pain that can then radiate to the back, arms, neck, or jaw along with neurological deficits like difficulty in speaking, and unilateral weakness in some patients. This spectrum of clinical features associated with AD is often confused with acute myocardial infarction, hence leading to a delay in AD diagnosis. Cardiac and vascular biomarkers are structural proteins and microRNAs circulating in the bloodstream that correlate to tissue damage and their levels become detectable even before symptom onset. Timely diagnosis of AD using biomarkers, in combination with advanced imaging diagnostics, will significantly improve prognosis by allowing earlier vascular interventions. This comprehensive review aims to investigate emerging biomarkers in the diagnosis of AD, as well as provide future directives for creating advanced diagnostic tools and imaging techniques.

Biomechanical dysregulation of SGK-1 dependent aortic pathologic markers in hypertension

Introduction

In hypertension (HTN), biomechanical stress may drive matrix remodeling through dysfunctional VSMC activity. Prior evidence has indicated VSMC tension-induced signaling through the serum and glucocorticoid inducible kinase-1 (SGK-1) can impact cytokine abundance. Here, we hypothesize that SGK-1 impacts production of additional aortic pathologic markers (APMs) representing VSMC dysfunction in HTN.

Methods

Aortic VSMC expression of APMs was quantified by QPCR in cyclic biaxial stretch (Stretch) +/- AngiotensinII (AngII). APMs were selected to represent VSMC dedifferentiated transcriptional activity, specifically Interleukin-6 (IL-6), Cathepsin S (CtsS), Cystatin C (CysC), Osteoprotegerin (OPG), and Tenascin C (TNC). To further assess the effect of tension alone, abdominal aortic rings from C57Bl/6 WT mice were held in a myograph at experimentally derived optimal tension (OT) or OT + 30% +/-AngII. Dependence on SGK-1 was assessed by treating with EMD638683 (SGK-1 inhibitor) and APMs were measured by QPCR. Then, WT and smooth muscle cell specific SGK-1 heterozygous knockout (SMC-SGK-1KO+/-) mice had AngII-induced HTN. Systolic blood pressure and mechanical stress parameters were assessed on Day 0 and Day 21. Plasma was analyzed by ELISA to quantify APMs. Statistical analysis was performed by ANOVA.

Results

In cultured aortic VSMCs, expression of all APMs was increased in response to biomechanical stimuli (Stretch +/-AngII,). Integrating the matrix contribution to signal transduction in the aortic rings led to IL-6 and CysC demonstrating SGK-1 dependence in response to elevated tension and interactive effect with concurrent AngII stimulation. CtsS and TNC, on the other hand, primarily responded to AngII, and OPG expression was unaffected in aortic ring experimentation. Both mouse strains had >30% increase in blood pressure with AngII infusion, reduced aortic distensibility and increased PPV, indicating increased aortic stiffness. In WT + AngII mice, IL-6, CtsS, CysC, and TNC plasma levels were significantly elevated, but these APMs were unaffected by HTN in the SMC-SGK-1KO+/- +AngII mice, suggesting SGK-1 plays a major role in VSMC biomechanical signaling to promote dysfunctional production of selected APMs.

Conclusion

In HTN, changes in the plasma levels of markers associated with aortic matrix homeostasis can reflect remodeling driven by mechanobiologic signaling in dysfunctional VSMCs, potentially through the activity of SGK-1. Further defining these pathways may identify therapeutic targets to reduce cardiovascular morbidity and mortality.

The diagnostic value of tenascin-C in acute aortic syndrome

OBJECTIVES

Misdiagnosis of acute aortic syndrome (AAS) significantly increases mortality. Tenascin-C (TN-C) is an extracellular matrix glycoprotein related to cardiovascular injury. The elevation of TN-C in AAS and whether it can discriminate sudden-onset of acute chest pain in Chinese remains unclear.

METHODS

We measured the plasma concentration of TN-C by ELISA in a cohort of 376 patients with chest or back pain. Measures to discriminate AAS from acute coronary syndrome (ACS) were compared and calculated.

RESULTS

From October 2016 to September 2021, 376 undiagnosed patients with chest or back pain were enrolled. 166 of them were finally diagnosed as AAS, 100 were ACS and 110 without cardiovascular diseases (NCV). TN-C was significantly elevated in AAS at 18.18 ng/mL (IQR: 13.10-27.68) compared with 7.51 ng/mL (IQR: 5.67-11.38) in ACS (P < 0.001) and 3.68 ng/mL (IQR: 2.50-5.29) in NCV (P < 0.001). There was no significant difference in TN-C level among the subtypes of AAS. Of the 166 AAS patients, the peaked level of TN-C was at acute stage (P = 0.012), then a slight of decrease was observed at subacute stage. The area under receiver operating characteristic curve for AAS patients versus NCV was 0.979 (95% CI: 0.964-0.994) for TN-C. At a cutoff level of 11.474 ng/mL, TN-C has a sensitivity of 76.0%, specificity of 85.5%, accuracy of 82.0%, positive predictive value (PPV) of 76.0%, negative predictive value (NPV) of 85.5%. Diagnostic performance of TN-C was superior to D-dimer and hs-cTnT.

CONCLUSIONS

The concentration of serum TN-C in AAS patients was significantly higher than that in ACS patients and NCV. TN-C could be a new biomarker to distinguish AAS patients in the early stage after symptoms onset from other pain diseases.

Biomarkers in aortic dissection: Diagnostic and prognostic value from clinical research

ABSTRACT

Aortic dissection is a life-threatening condition for which diagnosis mainly relies on imaging examinations, while reliable biomarkers to detect or monitor are still under investigation. Recent advances in technologies provide an unprecedented opportunity to yield the identification of clinically valuable biomarkers, including proteins, ribonucleic acids (RNAs), and deoxyribonucleic acids (DNAs), for early detection of pathological changes in susceptible patients, rapid diagnosis at the bedside after onset, and a superior therapeutic regimen primarily within the concept of personalized and tailored endovascular therapy for aortic dissection.

Dysregulation of interaction between LOXhigh fibroblast and smooth muscle cells contributes to the pathogenesis of aortic dissection

Rationale: While cell-cell interaction plays a critical role in physiology and disease, a comprehensive understanding of its dynamics in vascular homeostasis and diseases is yet absent. Methods: Here, by use of single-cell RNA-sequencing and multi-color staining, we delineate the cellular composition and spatial characterization of human aorta with or without aortic dissection (AD). Results: Scrutinization of cell subtype alterations revealed significantly changed fibroblast (FB)-smooth muscle cell (SMC) interactions in AD. Of these cellular interactions, LOX^high fibroblast (fibroblast subtype 2, FB2) in diseased state exerted the most pronounced effects on pathological deterioration of SMCs in AD. In addition, pharmacologically targeting the BMP (bone morphogenetic protein) signaling pathway effectively suppressed FB2 state transition and reduced AD incidence in mice. Finally, COL5A1 (collagen type V alpha 1 chain), one of the secreted proteins released from FB2, was significantly higher in the plasma of AD patients than in control patients, suggesting its potential use as a biomarker for AD diagnosis. Conclusions: Our work not only identified a pivotal role of a specific FB subtype in AD progression, but also shed light on cell interaction dynamics in vascular diseases.

Serum sodium on admission affects postoperative in-hospital mortality in acute aortic dissection patients

Background

Acute aortic dissection (AAD) is very fatal without surgical treatment. Higher serum sodium can increase in-hospital mortality of many diseases; however, the effect of serum sodium on postoperative in-hospital mortality in AAD patients remains unknown.

Methods

We collected a total of 415 AAD patients from January 2015 to December 2019. Patients were classified into four categories (Q1-Q4) according to the admission serum sodium quartile. The cox proportional hazards model evaluated the association between serum sodium and in-hospital mortality. All-cause in-hospital mortality was set as the endpoint.

Results

By adjusting many covariates, cox proportional hazards model revealed the in-hospital mortality risk of both Q3 and Q4 groups was 3.086 (1.242–7.671, P = 0.015) and 3.370 (1.384–8.204, P = 0.007) respectively, whereas the risk of Q2 group was not significantly increased. Univariate and multiple Cox analysis revealed that Stanford type A, serum glucose, α-hydroxybutyrate dehydrogenase and serum sodium were risk factors correlated with in-hospital death in AAD patients.

Conclusion

The study indicates that the admission serum sodium of AAD patients has a vital impact on postoperative hospital mortality.

Elevated Serum Tenascin-C Predicts Mortality in Critically Ill Patients With Multiple Organ Dysfunction

Background: Multiple organ dysfunction is a complex and lethal clinical feature with heterogeneous causes and is usually characterized by tissue injury of multiple organs. Tenascin-C (TNC) is a matricellular protein that is rarely expressed in most of the adult tissues, but re-induced following injury. This study aimed to evaluate serum TNC in predicting mortality in critically ill patients with multiple organ dysfunction. Methods: Adult critically ill patients with at least two organs dysfunction and an increase of Sequential Organ Failure Assess (SOFA) score ≥ 2 points within 7 days were prospectively enrolled into two independent cohorts. The emergency (derivation) cohort was a consecutive series and the patients were from Emergency Department. The inpatient (validation) cohort was a convenience series and the patients were from medical wards. Their serum samples at the first 24 h after enrollment were collected and subjected to TNC measurement using ELISA. The association between serum TNC level and 28-day all-cause mortality was investigated, and then the predictive value of serum TNC was analyzed. Results: A total of 110 patients with a median age of 64 years (53, 73) were enrolled in the emergency cohort. Compared to the survivors, serum TNC in the non-survivors was significantly higher (467.7 vs. 197.5 ng/ml, p < 0.001). Multivariate logistic regression analysis revealed that the association between serum TNC and 28-day mortality was independent of sepsis or critical illness scores such as SOFA, Acute Physiology and Chronic Health Evaluation (APACHE II), and Simplified Acute Physiology Score (SAPS II), respectively (p < 0.001 for each). The area under receiver operating characteristic curve of serum TNC for predicting mortality was 0.803 (0.717-0.888) (p < 0.001), similar with SOFA 0.808 (0.725-0.891), APACHE II 0.762 (0.667-0.857), and SAPS II 0.779 (0.685-0.872). The optimal cut-off value of serum TNC was 298.2 ng/ml. Kaplan-Meier analysis showed that the survival of patients with serum TNC ≥ 300 ng/ml was significantly worse than that of patients with serum TNC < 300 ng/ml. This result was validated in the inpatient cohort. The sensitivity and specificity of serum TNC ≥ 300 ng/ml for predicting mortality were 74.3 and 74.7% in the emergency cohort, and 63.0 and 70.1% in the inpatient cohort, respectively. Conclusion: Serum TNC was associated with mortality in critically ill patients with multiple organ dysfunction, and would be used as a prognostic tool for predicting mortality in this population.

The diagnostic value of D-dimer in acute aortic dissection: a meta-analysis

Objective

This study aims to evaluate the diagnostic value of D-dimer for acute aortic dissection (AAD) by the method of meta-analysis.

Methods

PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang databases from the establishment of the databases to December 2020 were systematically searched, and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) system was used to evaluate the quality of the literature. STATA 15.0 software was applied to calculate the pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (+LR), negative likelihood ratio (−LR) to draw summary receiver operating characteristics (SROC) curve and calculate the area under the curve (AUC). Meta-regression and subgroup analyses were used to explore the source of heterogeneity.

Results

A total of 16 clinical studies were enrolled in this study, including 1135 patients. The results of the meta-analysis showed that the pooled sensitivity was 0.96 (95% CI 0.91–0.98), the pooled specificity was 0.70 (95% CI 0.57–0.81), and the pooled DOR was 56.57 (95% CI 25.11–127.44), the pooled +LR was 3.25 (95% CI 2.18–4.85), the pooled −LR was 0.06 (95% CI 0.03–0.12), and the AUC was 0.94 (95% CI 0.91–0.95). Meta-regression and subgroup analysis results showed that publication year, sample size and cutoff value might be sources of heterogeneity. When the concentration of D-dimer was less than or equal to 500 ng/ml, the sensitivity significantly increased.

Conclusion

D-dimer has an excellent diagnostic value for AAD. It is a useful tool for detecting suspected AAD because of the excellent pooled sensitivity. D-dimer ≤ 500 ng/ml increases the potential to identify the suspected patients with AAD.

Could we adopt serum Tenascin-C assays to determine prognosis in aortic aneurysms and dissections?

Abdominal aortic aneurysm is an abnormal dilatation, while acute aortic dissection is a delamination of the tunica media, forming a false lumen. Tenascin-C is a glycoprotein that can be found in situations involving tissue damage. The objective of this article is to evaluate whether Tenascin-C assays could be of use for predicting prognosis in abdominal aortic aneurysms and acute aortic dissection. We conducted an integrative literature review, for which four articles were considered eligible. Two of these studies associated higher Tenascin-C levels with protective factors and lower risk of injury, whereas the other two correlated them with worse prognosis. Some authors believe that Tenascin-C could be a candidate biomarker, but these studies are still inconclusive with regard to its role in the clinical outcomes of patients with aneurysms.

The potential value of the neutrophil to lymphocyte ratio for early differential diagnosis and prognosis assessment in patients with aortic dissection

OBJECTIVES

The aim of the study was to assess the diagnostic performance and clinical utility of the neutrophil to lymphocyte ratio (NLR) in patients with suspected aortic dissection (AD) and investigate its role in predicting in-hospital mortality in AD.

METHODS

NLR values were calculated and compared in 467 consecutive patients with initially suspected AD. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of the NLR for AD. Clinical utility was determined by decision curve analysis (DCA). The association between NLR and in-hospital mortality was investigated by logistic regression analyses in patients diagnosed with AD.

RESULTS

The NLR was significantly elevated in patients with AD, and the optimal cut-off point for the NLR to distinguish AD from other acute chest pain diseases was 5.67 [AUC (95% CI): 0.877 (0.844-0.905)]. We recommended an NLR of 2.43 as the appropriate cut-off point with 96.9% sensitivity and a negative likelihood ratio (LR) of 0.09 to satisfy clinical requirements for diagnosis. DCA showed that the use of NLR had a positive net benefit. The deceased patients with AD had a higher NLR than the discharged patients. Moreover, the NLR was an independent predictor of in-hospital mortality for AD [adjusted odds ratio (OR): 1.084 (1.029-1.142)], and patients with higher NLR values tended to have a higher risk of in-hospital mortality. The optimal cut-off point for the NLR to predict in-hospital mortality was 9.20 [AUC (95% CI): 0.695 (0.619-0.765)].

CONCLUSIONS

As an easily available and inexpensive parameter, the NLR could serve as a valuable clinical biomarker for early differential diagnosis and prognosis assessment of AD.

Prognostic factors and prediction models for acute aortic dissection: a systematic review

OBJECTIVE

Our study aimed to systematically review the methodological characteristics of studies that identified prognostic factors or developed or validated models for predicting mortalities among patients with acute aortic dissection (AAD), which would inform future work.

DESIGN/SETTING

A methodological review of published studies.

METHODS

We searched PubMed and EMBASE from inception to June 2020 for studies about prognostic factors or prediction models on mortality among patients with AAD. Two reviewers independently collected the information about methodological characteristics. We also documented the information about the performance of the prognostic factors or prediction models.

RESULTS

Thirty-two studies were included, of which 18 evaluated the performance of prognostic factors, and 14 developed or validated prediction models. Of the 32 studies, 23 (72%) were single-centre studies, 22 (69%) used data from electronic medical records, 19 (59%) chose retrospective cohort study design, 26 (81%) did not report missing predictor data and 5 (16%) that reported missing predictor data used complete-case analysis. Among the 14 prediction model studies, only 3 (21%) had the event per variable over 20, and only 5 (36%) reported both discrimination and calibration statistics. Among model development studies, 3 (27%) did not report statistical methods, 3 (27%) exclusively used statistical significance threshold for selecting predictors and 7 (64%) did not report the methods for handling continuous predictors. Most prediction models were considered at high risk of bias. The performance of prognostic factors showed varying discrimination (AUC 0.58 to 0.95), and the performance of prediction models also varied substantially (AUC 0.49 to 0.91). Only six studies reported calibration statistic.

CONCLUSIONS

The methods used for prognostic studies on mortality among patients with AAD-including prediction models or prognostic factor studies-were suboptimal, and the model performance highly varied. Substantial efforts are warranted to improve the use of the methods in this population.

The Roles of Tenascins in Cardiovascular, Inflammatory, and Heritable Connective Tissue Diseases

Tenascins are a family of multifunctional extracellular matrix (ECM) glycoproteins with time- and tissue specific expression patterns during development, tissue homeostasis, and diseases. There are four family members (tenascin-C, -R, -X, -W) in vertebrates. Among them, tenascin-X (TNX) and tenascin-C (TNC) play important roles in human pathologies. TNX is expressed widely in loose connective tissues. TNX contributes to the stability and maintenance of the collagen network, and its absence causes classical-like Ehlers-Danlos syndrome (clEDS), a heritable connective tissue disorder. In contrast, TNC is specifically and transiently expressed upon pathological conditions such as inflammation, fibrosis, and cancer. There is growing evidence that TNC is involved in inflammatory processes with proinflammatory or anti-inflammatory activity in a context-dependent manner. In this review, we summarize the roles of these two tenascins, TNX and TNC, in cardiovascular and inflammatory diseases and in clEDS, and we discuss the functional consequences of the expression of these tenascins for tissue homeostasis.

Prevalence, Predictors, and Early Outcomes of Post-operative Delirium in Patients With Type A Aortic Dissection During Intensive Care Unit Stay

Objectives: The aim of this study was to investigate the prevalence and explore the predictors and early outcomes of post-operative delirium (POD) in patients with type A aortic dissection (AAD) during intensive care unit (ICU) stays.

Methods: We retrospectively reviewed the records of 301 patients with AAD who underwent surgical treatment in our institution from January 2017 to December 2018.

Results: Delirium developed in 73 patients (24.25%) during the ICU stay. Patients with lower estimated glomerular filtration rates [odds ratio (OR) 0.84, 95% CI 0.74–0.94, p = 0.003], post-operative midazolam use (OR 2.37, 95% CI 1.33–4.23, p = 0.004), and post-operative morphine use (OR 1.87, 95% CI 1.07–3.29, p = 0.029) were more susceptible to developing POD. Patients who developed POD had a longer ICU stay (11.52 vs. 7.22 days, p < 0.001) and hospital stay (23.99 vs. 18.91, p = 0.007) with higher hospitalization costs (48.82 vs. 37.66 thousand dollars, p < 0.001) than those without POD. The in-hospital mortality rate was higher in the delirium group, but the difference was not significant (6.85 vs. 4.82%, p = 0.502).

Conclusions: The incidence of POD in patients with AAD was high and was associated with renal dysfunction and the use of midazolam and morphine. POD was associated with poor early outcomes, suggesting the importance of early screening, such as for renal dysfunction, and prevention by using sedation scales to minimize the use of midazolam and morphine in these patients.

Increased Circulating Angiopoietin-Like Protein 8 Levels Are Associated with Thoracic Aortic Dissection and Higher Inflammatory Conditions

Purpose

Thoracic aortic dissection (TAD) is characterized by an inflammatory response. Angiopoietin-like protein 8 (ANGPTL8) is a hormone involved in the regulation of lipid metabolism and inflammation. However, the relationship between ANGPTL8 and TAD remains unknown.

Methods

This case-control study included 78 TAD patients and 72 controls. The aortic diameter was evaluated by computed tomography and used to assess TAD severity. Circulating ANGPTL8 levels were measured by enzyme-linked immunosorbent assay. Associations of ANGPTL8 with TAD were determined by multivariate logistic regression.

Results

Serum ANGPTL8 levels were significantly higher in TAD patients compared with controls (562.50 ± 20.84 vs. 419.70 ± 22.65 pg/mL, respectively; P < 0.001). After adjusting for confounding factors, circulating ANGPTL8 levels were an independent risk factor for TAD (odds ratio = 1.587/100 pg ANGPTL8, 95% confidence interval [CI] = 1.121–2.247, P < 0.001) and positively associated with diameter (β = 1.081/100 pg ANGPTL8, 95% CI = 0.075–2.086, P = 0.035) and high-sensitivity C-reactive protein (hs-CRP) (β = 0.845/100 pg ANGPTL8, 95% CI = 0.020–1.480, P = 0.009). The area under the curve (AUC) on receiver operating characteristic (ROC) analysis of the combination of ANGPTL8, hs-CRP, and D-dimer was 0.927, and the specificity and sensitivity were 98.46% and 79.49%, respectively. ANGPTL8 was significantly increased in TAD tissue compared with controls. In vitro, ANGPTL8 was increased in angiotensin II (AngII)-treated macrophages and vascular smooth muscle cells (VSMCs), while ANGPTL8 siRNA-mediated knockdown decreased inflammatory factors in AngII-treated macrophages and decreased apoptosis in AngII-treated VSMCs.

Conclusion

ANGPTL8 is associated with TAD occurrence and development, which may involve pro-inflammatory effects on macrophages. ANGPTL8 combined with D-dimer and hs-CRP might be a useful clinical predictor of TAD.

Trial Registration

ChiCTR-COC-17010792 http://www.chictr.org.cn/showproj.aspx?proj=18288

Electronic supplementary material

The online version of this article (10.1007/s10557-019-06924-7) contains supplementary material, which is available to authorized users.