Plasma cortisol and prognosis of patients with acute myocardial infarction

High platelet adrenergic activity and concomitant activation of the pituitary/medullar axis as alarming laboratory parameters in ACS survivors-the STRESS-AMI study

Introduction

Kinetics of stress-related biological parameters were determined in acute coronary syndrome (ACS) patients undergoing complex cardiovascular rehabilitation.

Methods

We determined platelet functionality in the absence/presence of a selective alpha-2 adrenergic receptor inhibitor, atipemazole parallel with salivary cortisol levels at enrolment, and at 3- and 12-months follow-up in 75 ACS patients with percutaneous coronary intervention.

Results

Pharmacological/non-pharmacological secondary prevention methods have been efficiently applied. Baseline aggregometry indicated platelet hyperactivity, decreasing gradually and being significantly reduced late, at 12 months (p < 0.05). Cortisol levels followed similar kinetics (p < 0.05). Baseline epinephrine-induced aggregations (EIA) significantly correlated with most of the other platelet agonists, even at subsequent time-points. Patients with upper-quartile EIA at enrolment (EIA-UQ) had significantly higher ADP- and collagen-induced aggregations at enrolment, at 3- and 12-months follow-up as well, indicating that high adrenergic response in the acute phase is accompanied by general platelet hyperactivity and predicts sustained platelet activation. In the EIA-UQ group higher cardiac biomarker release, elevated C-reactive protein and cortisol levels, and lower baseline left ventricular ejection fraction were detected.Atipemazole significantly reduced platelet aggregation induced by several platelet agonists, being most potent and comparable to full in vitro P2Y12 inhibition on collagen-induced aggregations (p < 0.05), indicating that catecholamines might serve as promt/long-term modulators of platelet function.

Discussion

Despite effective CCR programme and dual antiplatelet therapy, prolonged activation of sympathetic neuroendocrine system and general platelet hyperactivity can be detected up to one year in ACS patients with high adrenergic platelet activity. Moreover, initial high adrenergic activity is accompanied by clinical parameters associated to increased cardiovascular risk, therefore early identification of these patients might support complex optimal long-term therapy.

Review of the Association Between Long-Term and Current Systemic Steroid Use With Electromechanical Complications and Inpatient Mortality After ST-Elevation Myocardial Infarction

Background The impact of long-term systemic steroid use on electrical and mechanical complications following ST-segment elevation myocardial infarction (STEMI) has not been extensively studied. Methods In a retrospective cohort study of the National Inpatient Sample (NIS) from 2018 to 2020, adults admitted with STEMI were dichotomized based on the presence of long-term (current) systemic steroid (LTCSS) use. The primary outcome was all-cause mortality. Secondary outcomes included a composite of mechanical complications, electrical, hemodynamic, and thrombotic complications, as well as revascularization complexity, length of stay (LOS), and total charge. Multivariate linear and logistic regressions were used to adjust for confounders. Results Out of 608,210 admissions for STEMI, 5,310 (0.9%) had LTCSS use. There was no significant difference in the odds of all-cause mortality (aOR: 0.89, 95%CI: 0.74-1.08, p-value: 0.245) and the composite of mechanical complications (aOR: 0.74, 95%CI: 0.25-2.30, p-value: 0.599). LTCSS use was associated with lower odds of ventricular tachycardia, atrioventricular blocks, new permanent-pacemaker insertion, cardiogenic shock, the need for mechanical circulatory support, mechanical ventilation, cardioversion, a reduced LOS by 1 day, and a reduced total charge by 34,512 USD (all p-values: <0.05). There were no significant differences in the revascularization strategy (coronary artery bypass graft (CABG) vs. percutaneous coronary interventions (PCI)) or in the incidence of composite thrombotic events. Conclusion LTCSS use among patients admitted with STEMI was associated with lower odds of electrical dysfunction and hemodynamic instability but no difference in the odds of mechanical complications, CABG rate, all-cause mortality, cardiac arrest, or thrombotic complications. Further prospective studies are needed to evaluate these findings further.

Association between Eosinophil Count and Cortisol Concentrations in Equids Admitted in the Emergency Unit with Abdominal Pain

Stress leukogram includes eosinopenia as one of its main markers (neutrophilia, eosinopenia, lymphopenia, and mild monocytosis). Cortisol is the main stress biomarker, which is also strongly correlated with the severity of gastrointestinal diseases. This study aimed to determine the relationship between salivary cortisol and the eosinophil cell count (EC) in equids with abdominal pain. To do this, 39 horses with abdominal pain referred to an emergency service were included. All samples were taken on admission, and several parameters and clinical data were included. Equids were classified according to the outcome as survivors and non-survivors. Non-surviving equids presented higher salivary cortisol concentrations (Non-Survivors: 1.580 ± 0.816 µg/dL; Survivors 0.988 ± 0.653 µg/dL; p < 0.05) and lower EC (Non-Survivors: 0.0000 × 103/µL (0.000/0.0075); Survivors: 0.0450 × 103/µL (0.010/0.1825); p < 0.01). In addition, the relationship between salivary cortisol concentration, EC, and the WBC was determined. Only a strong correlation (negative) was observed between cortisol and EC (r = -0.523, p < 0.01). Since cortisol is not an analyte that can be measured routinely in clinical settings such as emergencies, the EC could be a good alternative. While the results are promising, further studies are needed before EC can be used confidently in routine practice to predict survival in cases of abdominal pain.

Hematological Parameter as Predictor Mortality in Acute Myocardial Infarction Patients

Purpose

Acute myocardial infarction (AMI) is one of the leading causes of death in the world. Several hematological parameters are involved in AMI conditions and can be explored for their ability to predict in-hospital mortality. We evaluated hematological parameter value as predictors of in-hospital mortality in AMI patients.

Patients and Methods

Analytical observational study on AMI patients that admitted to Dr. Saiful Anwar Hospital, June-August 2021. Complete blood count was taken at the beginning of hospital admission. Patients with sepsis were excluded from the study. The research subjects were divided into two groups, survivor group and non-survivor group (in-hospital mortality). Hematological parameters as predictors of mortality were analyzed using the ROC curve and odds ratio.

Results

Among 44 study subjects, 19 (43.18%) patients were in the non-survivor group and 25 (56.82%) patients were in the survivor group. Hematological parameters that can be predictors of mortality include leukocytes (AUC = 0.744; p = 0.006), neutrophils (AUC = 0.729; p = 0.010), eosinophils (AUC = 0.696; p = 0.028), and eosinophils/leukocytes ratio (AUC = 0.772; p = 0.012). The cut-off value for leukocytes was 13,725/μL (OR: 9), neutrophils was 12,008/μL (OR: 8.14), eosinophils was 58.3/μL (OR: 4.06), and eosinophil/leukocyte ratio was 0.0025 (OR: 4.41) with sensitivity 63.25%, 52.6%, 78.9%, and 63.2%, respectively, and specificity 84%, 88%, 52%, and 72%, respectively.

Conclusion

Leukocyte, neutrophils, eosinophils count and eosinophil/leukocyte ratio can help predict in-hospital mortality of AMI patients.

The Role of Plant-Based Protein Functional Food in Preventing Acute Respiratory Disease: A Case Study

The Kaliningrad region is known for its specific climate, which can negatively affect the adaptive potential of the body. This manifests in an increased incidence of respiratory diseases and skin conditions. To prevent high morbidity, a plant protein product was included in the diet of first-year university students. This study aimed to assess the effectiveness of this food intervention in preventing the most common diseases among Kaliningrad students. Two groups of university students took part in the food trial. In the control group, catabolic processes prevailed in nutrient metabolism. Disadaptation manifested itself in the metabolism of proteins, vitamins, minerals, hematopoiesis and humoral immunity. Inflammation was indicated by α1- and α2-globulins, a weak immune response, and IgM and IgG. High oxidative stress and low antioxidative ability of blood serum were observed. The plant-based protein product (FP) helped preserve testosterone level and prevent an increase in catabolic reactions. Moreover, it had a positive effect on both red blood cell hematopoiesis (a smaller increase in the average volume of erythrocytes, the same average concentration and content of hemoglobin, an increased relative red cell distribution width (RDW) and white blood cell hematopoiesis (a beneficial effect for the immune system: lymphocytes, the relative content of neutrophils, monocytes, basophils and eosinophils). The stimulation of humoral immunity was evidenced by beta- and gamma-globulins, an active immune response, the level of IgM and IgG, antioxidant protection, reduction of peroxides and an increase in antioxidant activity of blood serum. The 34-week observation showed a 1.7-fold decrease in the incidence of respiratory illnesses and a 5.7-fold decrease in skin and subcutaneous tissue diseases. Acute respiratory infections were reduced 1.8-fold. There were no cases of community-acquired pneumonia in the treatment group, compared with 55.1‰ in the control group. The incidence of respiratory diseases was 3.3-10.6 times lower in the treatment group than in the control group in weeks 6-19. The findings testify to the prophylactic effect of functional food during social adaptation and acclimatization of students.

Associations of Serum Cortisol with Cardiovascular Risk and Mortality in Patients Referred to Coronary Angiography

CONTEXT

Serum cortisol may be associated with cardiovascular risk factors and mortality in patients undergoing coronary angiography, but previous data on this topic are limited and controversial.

OBJECTIVE

We evaluated whether morning serum cortisol is associated with cardiovascular risk factors, lymphocyte subtypes, and mortality.

METHODS

This is a prospective cohort study performed at a tertiary care centre in south-west Germany between 1997 and 2000. We included 3052 study participants who underwent coronary angiography. The primary outcome measures were cardiovascular risk factors, lymphocyte subtypes, and all-cause and cardiovascular mortality.

RESULTS

Serum cortisol was associated with an adverse cardiovascular risk profile, but there was no significant association with coronary artery disease or acute coronary syndrome. In a subsample of 2107 participants, serum cortisol was positively associated with certain lymphocyte subsets, including CD16+CD56+ (natural killer) cells (P < 0.001). Comparing the fourth versus the first serum cortisol quartile, the crude Cox proportional hazard ratios (with 95% CIs) were 1.22 (1.00-1.47) for all-cause and 1.32 (1.04-1.67) for cardiovascular mortality, respectively. After adjustments for various cardiovascular risk factors, these associations were attenuated to 0.93 (0.76-1.14) for all-cause, and 0.97 (0.76-1.25) for cardiovascular mortality, respectively.

CONCLUSIONS

Despite significant associations with classic cardiovascular risk factors and natural killer cells, serum cortisol was not a significant and independent predictor of mortality in patients referred to coronary angiography. These findings might reflect that adverse cardiovascular effects of cortisol could be counterbalanced by some cardiovascular protective actions.

Cortisol on Circadian Rhythm and Its Effect on Cardiovascular System

The synthesis and secretion of cortisol are controlled by the hypothalamic–pituitary–adrenal axis. Cortisol exhibits a proper 24-h circadian rhythm that affects the brain, the autonomic nervous system, the heart, and the vasculature that prepares the cardiovascular system for optimal function during these anticipated behavioral cycles. A literature search was conducted using databases such as Google Scholar, PubMed, and Scopus. Relevant search terms included “circadian rhythm and cardiovascular”, “cortisol”, “cortisol and acute coronary syndrome”, “cortisol and arrhythmias”, “cortisol and sudden cardiac death”, “cortisol and stroke”, and “cardioprotective agents”. A total of 120 articles were obtained on the basis of the above search. Lower levels of cortisol were seen at the beginning of sleep, while there was a rise towards the end of sleep, with the highest level reached at the moment the individual wakes up. In the present review, we discuss the role of 11β-hydroxysteroid dehydrogenase (11β-HSD1), which is a novel molecular target of interest for treating metabolic syndrome and type-2 diabetes mellitus. 11β-HSD1 is the major determinant of cortisol excess, and its inhibition alleviates metabolic abnormalities. The present review highlights the role of cortisol, which controls the circadian rhythm, and describes its effect on the cardiovascular system. The review provides a platform for future potential cardioprotective therapeutic agents.

Effect of family presence on stress response after bypass surgery

BACKGROUND

Coronary artery bypass grafting (CABG) is a major surgery that may cause severe surgical stress response (SR). Although the presence of family members in intensive care unit (ICU) is known to benefit intensive care patients socially and emotionally, its effects on surgical SR are unknown.

OBJECTIVES

To investigate the effect of an informed family member (IFM)'s presence in the awakening process in ICU on patients' SR after CABG.

METHODS

A nonrandomized controlled clinical study was completed with a total of 73 patients: 37 patients in the control (CG) and 36 in the intervention group (IG) underwent CABG surgery. In the CG patients, no family members were taken into the ICU during the awakening process and routine care and treatment practices were continued. In the IG patients, besides routine care and treatment practices, an IFM was taken into the ICU during the awakening process in accordance with the research method. Groups were statistically compared in terms of serum cortisol level which is the one of the main indicators of surgical SR, state anxiety, sedative drug requirements, and duration of intubation, sedation, and ICU stay. A p value <0.05 was accepted as statistically significant.

RESULTS

Presence of an IFM in the ICU was found to be effective in decreasing serum cortisol level, state anxiety, sedative drug requirements, and the duration of intubation, sedation, and ICU stay (p<0.05).

CONCLUSIONS

In CABG, the presence of IFM in ICU is effective in reducing SR.

Cortisol-Mediated Stress Response and Mortality in Acute Coronary Syndrome

Acute coronary syndrome is a frequent cause of morbidity and mortality, and a known stress response trigger. We aim to investigate the association between cortisol, as a primary stress hormone, and prognosis/mortality in this scenario. Single-center, prospective, observational, and analytical study in patients admitted for acute coronary syndrome. Clinical characteristics and prognosis markers were registered, along with serum cortisol levels on admission and in-hospital mortality. Cortisol levels were higher in patients with a depressed ST segment (18.22 ± 13.38 μg/dL), compared to those with an isoelectric ST segment (12.66 ± 10.47 μg/dL), and highest in patients with an elevated ST segment (22.61 ± 14.45 μg/dL), with P< 0.001. Also, cortisol was significantly increased in patients with elevated troponin I values (18.90 ± 14.19 μg/dL vs 11.87 ± 8.21 μg/dL, P< 0.001). Patients with Killip-Kimball class I or II had a lower mean serum cortisol (14.66 ± 10.82 μg/dL) than those with class III or IV (41.34 ± 15.57 μg/dL), P< 0.001. Finally, we found that patients who died during hospitalization had higher cortisol on admission: 36.39 ± 17.85 μg/dL vs 15.26 ± 11.59 μg/dL, P= 0.003. Cortisol was directly related to the electrocardiographic presentation of ACS and with the maximum troponin I value. This indicates that serum cortisol levels parallel the extension of ischemia and myocardial injury, and in this way affect the clinical prognosis, evidenced by the Killip-Kimball class and the increase in mortality.

Eosinophils count in peripheral circulation is associated with coronary artery disease

BACKGROUND AND AIMS

Allergic asthma can accelerate atherosclerosis, a disease in which plaque is deposited onto arterial walls and that may lead to coronary artery disease (CAD). Eosinophils are the most important effector cells in allergic asthma and are likely to become novel biomarkers for risk stratification of patients with CAD, but the relationship between eosinophil count and CAD remains unclear. We aimed to evaluate this relationship and the use of eosinophils in predicting CAD.

METHODS

A total of 5287 patients who underwent coronary angiography were recruited. Their biochemical parameters, including eosinophil count, were measured and their correlation with the severity of coronary artery stenosis, as quantified by the Gensini score system, was evaluated.

RESULTS

The percentages of eosinophils in leukocytes (PELs) were lower in CAD patients (p < 0.001), and had a significant negative correlation with Gensini scores (r = -0.112, p < 0.001). PELs were also significantly lower in acute myocardial infarction patients (p < 0.001). After adjusting for baseline differences, low PELs remained strongly associated with severe CAD and acute coronary arterial thrombotic event. Receiver-operating characteristic curve analysis showed that combining PELs with traditional risk factors in predictive models for CAD severity (z = 4.470, p < 0.001) or acute coronary arterial thrombotic event (z = 9.435, p < 0.001) improved the predictive capabilities of those models.

CONCLUSIONS

PELs, at least in patients undergoing coronary angiography, may be strongly related to the subtype and severity of CAD and, therefore, eosinophil count may be an accurate and independent biomarker to predict CAD severity and acute coronary arterial thrombotic events.

Importance of prognostic value of neutrophil to lymphocyte ratio in patients with ST-elevation myocardial infarction

The ratio between the absolute number of neutrophils and the number of lymphocytes (NLR) has recently emerged as a potential new biomarker predicting worse clinical conditions ranging from infectious disease to cardiovascular disease. Prognostic significance of NLR in patients with ST-elevation myocardial infarction (STEMI) is not established. This study aimed to investigate prognostic impact of NLR in patients with STEMI.We analyzed the data and clinical outcomes of 30-day survivors with STEMI who received successful coronary intervention from 2006 to 2010. NLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count at admission. Occurrence of major adverse cardiovascular events (MACEs; death, recurrent MI, target vessel revascularization (TVR)) at 5 years was evaluated.We enrolled 326 patients and mean follow-up duration was 68 ± 36 months. The mean NLR was 4.7 ± 5.2. Among all patients, all-cause mortality occurred in 46 patients (14%). Initial NLR was higher in patients who experienced all-cause mortality (6.39 ± 8.9 vs 4.2 ± 3.1, P = .004). In a multivariate regression model, the higher NLR was independently associated with increased risk for all-cause mortality (Hazard ratio, 1.085; 95% confidence interval, 1.002-1.174, P = .044).Increased NLR was associated increased rate of all-cause mortality in 30-day survivors after index STEMI, who received successful coronary intervention.

Adrenal, thyroid and gonadal axes are affected at high altitude

Humans cannot live at very high altitude for reasons, which are not completely understood. Since these reasons are not restricted to cardiorespiratory changes alone, changes in the endocrine system might also be involved. Therefore, hormonal changes during prolonged hypobaric hypoxia were comprehensively assessed to determine effects of altitude and hypoxia on stress, thyroid and gonadal hypothalamus-pituitary hormone axes. Twenty-one male and 19 female participants were examined repetitively during a high-altitude expedition. Cortisol, prolactin, thyroid-stimulating hormone (TSH), fT4 and fT3 and in males follicle-stimulating hormone (FSH), luteinizing hormone (LH) and total testosterone were analysed as well as parameters of hypoxemia, such as SaO2 and paO2 at 550 m (baseline) (n = 40), during ascent at 4844 m (n = 38), 6022 m (n = 31) and 7050 m (n = 13), at 4844 m (n = 29) after acclimatization and after the expedition (n = 38). Correlation analysis of hormone concentrations with oxygen parameters and with altitude revealed statistical association in most cases only with altitude. Adrenal, thyroid and gonadal axes were affected by increasing altitude. Adrenal axis and prolactin were first supressed at 4844 m and then activated with increasing altitude; thyroid and gonadal axes were directly activated or suppressed respectively with increasing altitude. Acclimatisation at 4844 m led to normalization of adrenal and gonadal but not of thyroid axes. In conclusion, acclimatization partly leads to a normalization of the adrenal, thyroid and gonadal axes at around 5000 m. However, at higher altitude, endocrine dysregulation is pronounced and might contribute to the physical degradation found at high altitude.

Neuroendocrine System Regulatory Mechanisms: Acute Coronary Syndrome and Stress Hyperglycaemia

Neurohormonal systems are activated in the early phase of acute coronary syndromes to preserve circulatory homeostasis, but prolonged action of these stress hormones might be deleterious. Cortisol reaches its peak at 8 hours after the onset of symptoms, and individuals who have continued elevated levels present a worse prognosis. Catecholamines reach 100-1,000-fold their normal plasma concentration within 30 minutes of ischaemia, therefore inducing the propagation of myocardial damage. Stress hyperglycaemia induces inflammation and endothelial dysfunction, and also has procoagulant and prothrombotic effects. Patients with hyperglycaemia and no diabetes elevated in-hospital and 12-month mortality rates. Hyperglycaemia in patients without diabetes has been shown to be an appropriate independent mortality prognostic factor in this type of patient.

Work stress and the risk of recurrent coronary heart disease events: A systematic review and meta-analysis

Though much evidence indicates that work stress increases the risk of incident of coronary heart disease (CHD), little is known about the role of work stress in the development of recurrent CHD events. The objective of this study was to review and synthesize the existing epidemiological evidence on whether work stress increases the risk of recurrent CHD events in patients with the first CHD. A systematic literature search in the PubMed database (January 1990 - December 2013) for prospective studies was performed. Inclusion criteria included: peer-reviewed English papers with original data, studies with substantial follow-up (> 3 years), end points defined as cardiac death or nonfatal myocardial infarction, as well as work stress assessed with reliable and valid instruments. Meta-analysis using random-effects modeling was conducted in order to synthesize the observed effects across the studies. Five papers derived from 4 prospective studies conducted in Sweden and Canada were included in this systematic review. The measurement of work stress was based on the Demand- Control model (4 papers) or the Effort-Reward Imbalance model (1 paper). According to the estimation by meta-analysis based on 4 papers, a significant effect of work stress on the risk of recurrent CHD events (hazard ratio: 1.65, 95% confidence interval: 1.23-2.22) was observed. Our findings suggest that, in patients with the first CHD, work stress is associated with an increased relative risk of recurrent CHD events by 65%. Due to the limited literature, more well-designed prospective research is needed to examine this association, in particular, from other than western regions of the world.

Prognostic Value of Eosinophil to Leukocyte Ratio in Patients with ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Aim: Leukocyte profile has been related to clinical outcome in patients with ST-segment elevation (STE) myocardial infarction (MI). However, whether eosinophil to leukocyte ratio (ELR) predicts clinical outcome in patients who have undergone primary percutaneous coronary intervention (PCI) remains unclear. Therefore, we examined the prognostic value of ELR in this patient population.

Methods: We retrospectively analyzed the data of 331 consecutive patients who underwent primary PCI for STEMI between January 2009 and March 2015. All leukocyte types were counted and ELR was calculated for all patients 24 h after hospital admission. The primary study endpoint was major adverse cardiac events (MACEs) within up to one year of follow-up duration.

Results: MACEs including cardiac deaths in 9.4% of the patients, MI in 1.5%, and target lesion or vessel revascularization in 10.3%, occurred within one year in 68 patients (20.5%). The mean ELR was significantly lower in patients with MACEs than in patients without MACEs (0.20 ± 0.51 vs. 0.49 ± 0.66, respectively; p < 0.001). An ELR < 0.1 at 24 h was identified as the best cut-off value for mortality prediction. Multivariate analysis identified that an ELR < 0.1 (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.22–0.67; p < 0.001) and chronic kidney disease (OR = 2.38; CI = 1.33–4.24; p = 0.003) are independent predictors of MACEs.

Conclusion: In primary PCI patients with STEMI, ELR at 24 h was an independent predictor of MACEs in addition to the usual coronary risk factors and commonly used biomarkers.

Diurnal Cortisol Rhythm Is Associated With Adverse Cardiac Events and Mortality in Coronary Artery Bypass Patients

PURPOSE

There is growing evidence that the hypothalamic-pituitary-adrenal axis plays a role in the progression of cardiovascular disease. We examined the relationship between diurnal cortisol rhythm and adverse events in patients undergoing coronary artery bypass graft (CABG) surgery. We hypothesized that a flatter presurgical diurnal cortisol slope would be associated with higher rates of adverse cardiac events and death in the years following the CABG procedure.

METHODS

Repeated measures of saliva were taken over the day from 250 CABG patients 1 month before surgery to assess diurnal cortisol slope and overall output (area under the curve). Long-term clinical outcomes were occurrence of a major adverse cardiac event (MACE) and death, and were collected up to 2.68 (SD = 0.40) years after surgery. Cox proportional hazard models were used to determine relationships between presurgical cortisol and clinical outcomes. EuroSCORE, chronic illness burden, and whether or not the patient had undergone cardiopulmonary bypass were included as covariates in the models.

RESULTS

Diurnal cortisol slope predicted the occurrence of MACE or death after surgery (hazard ratio = 0.73; 95% confidence interval = 0.56-0.96; P = .023). Patients with a steeper slope were at reduced risk of adverse outcomes. This association was driven by changes in both waking and evening cortisol levels.

CONCLUSION

These results provide evidence for a link between diurnal cortisol rhythm and recovery after CABG. Measuring diurnal cortisol slope before surgery may help to identify those patients at risk of adverse outcomes in the years after the procedure.