Value of blood pressure measurement earlier versus later in life to predict cardiovascular mortality

 

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality.

The purpose of this study was to compare the value of systolic blood pressure earlier versus later in life to predict cardiovascular mortality.

In a cardiovascular observation study (OS) we prospectively recorded fatal cardiovascular events over up to 19 years in 1282 patients of whom 570 had the Metabolic Syndrome (MetS) at baseline. These patients had participated in a health survey (HS) 15 years prior to the OS baseline. BP was measured both at the HS and at the baseline of the OS.

We found that the increase in cardiovascular mortality matched the increase of BP in the HS in a linear way but this is not the case for BP assessed at the OS (figure). A cox regression analysis revealed that each millimeter of mercury (mm Hg) increased the risk for cardiovascular death by 2% (HR = 1.02 [1.01–1.03], p<0.001). Applying a stratification for the presence of MetS, we found that in both groups BP was a significant predictor of cardiovascular mortality (HRMetS = 1.02 [1.01–1.02], p<0.001 and HRnoMetS = 1.02 [1.01–1.03], p<0.001). In contrast, BP as measured at the baseline of the OS was not significantly associated with cardiovascular death during follow-up neither in the total population nor in any subgroup (HR = 1.00 [0.99–1.01], p=0.652; HRMetS = 1.00 [0.99–1.01], p=0.468 and HRnoMetS = 1.00 [0.99–1.01], p=4.66).

We thus conclude that BP assessed earlier in life is a better predictor of cardiovascular mortality than BP assessed later in life.

Funding Acknowledgement

Type of funding sources: None.

Ceramide-based lipid profiles and the prevalence of type 2 diabetes differ between patients with coronary artery disease and those with peripheral artery disease

Introduction

Serum lipids and metabolic diseases, in particular type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD), predict the atherosclerotic diseases coronary artery disease (CAD) and peripheral arterial disease (PAD).

Purpose

The purpose of this study was to investigate in how far a more detailed characterization including serum lipids improves discrimination of PAD from CAD.

Method

A cohort of 274 statin-naïve patients with either PAD (n=89) or stable CAD (n=185) were referred to metabolic screening and were characterized using nuclear magnetic resonance- and liquid chromatography-tandem mass spectrometry based advanced lipid and lipoprotein analysis. Results were validated in an independent cohort of 1239 patients with PAD or CAD.

Results

We found a significant difference in T2D prevalence and in the ceramide-based lipid profile between PAD and CAD patients. However, neither cholesterol-based markers (including LDL-C, HDL-C) and detailed lipoprotein profiles nor the LD status differed significantly between PAD and CAD patients (figure). The difference between ceramide-based lipid profiles of CAD and PAD remained significant also after adjusting for body composition, smoking, inflammatory parameters, and T2D.

Conclusion

We conclude that PAD and CAD differ in ceramide-based lipid profiles and T2D status, but not in other lipid characteristics or metabolic diseases.

Funding Acknowledgement

Type of funding sources: None.

The ceramide- and phosphatidylcholine- based Coronary Event Risk Test2 (CERT2) and cardiovascular mortality in men and women with type 2 diabetes

 

The recently introduced Coronary Event Risk Test version 2 (CERT2) is a validated cardiovascular risk predictor score that uses circulating ceramide and phosphatidylcholine concentrations.

The purpose of this study was to investigate the power of CERT2 to predict cardiovascular mortality in 280 male and 121 female patients with type 2 diabetes (T2DM).

Prospectively, we recorded 55 cardiovascular deaths in men and 19 in women during a mean follow-up time of 7.6±3.6 and 8.1±3.4 years respectively.

Overall, cardiovascular survival decreased with increasing CERT2 risk categories (figure 1). In Cox regression models, CERT2 significantly predicted the incidence of cardiovascular mortality in male patients with T2DM (unadj. HR 1.82 [1.39–2.37] per standard deviation; p<0.001), the unadj. HR in women was 1.36 [0.83–2.22]; p=0.228). After adjustment for age, BMI, current smoking, LDL cholesterol, HDL cholesterol, hypertension, and statin use the HR in men was 1.73 [1.31–2.29]; p<0.001) and 1.40 [083–2.36]; p=0.210 in women. Interaction terms CERT2 x gender were non-significant both in univariate analysis (p=0.354) and after multivariate adjustment (p=0.359).

We conclude that sex does not significantly impact the association of CERT2 with cardiovascular mortality in patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The new myokine myonectin is significantly associated with type 2 diabetes in elderly patients

 

The novel myokine myonectin is predominantly expressed in skeletal muscle and is involved in the regulation of metabolic homeostasis. A putative association between myonectin and type 2 diabetes mellitus (T2DM) has been discussed controversially in current literature.

The purpose of this study was to investigate the association between myonectin and T2DM at different ages.

We measured myonectin in 410 vascular risk patients with a mean age of 66 years.

Myonectin did not correlate with age (r=−0.19; p=0.697). From our patients 219 (53%) were >65 years, with a mean age of 74 years and 191 ≤65 years, with a mean age of 57 years. The prevalence of T2DM was 40.6% vs. 42.4% in the older as compared to the younger age group. Myonectin concentrations were significantly decreased in elderly patients with T2DM compared to non-diabetic subjects (1.8 vs. 4.2 ng/ml; p=0.002), whereas no significant difference was observed in younger patients (2.6 vs. 2.3 ng/ml; p=0.183). Concordantly, regression analysis revealed an unadjusted odds ratio (OR) of 0.24 [0.07–0.81] (p=0.021) for the association between myonectin and T2DM in elderly patients but not in younger patients (OR=1.08 [0.80–1.45]; p=0.609). The association between myonectin and T2D; remained significant after adjusting for sex, body mass index, LDL cholesterol, HDL cholesterol, current smoking, as well as statin intake in elderly but remained non-significant in younger patients (OR=0.23 [0.07–0.81]; p=0.021 vs. OR=1.05 [0.76–1.46]; p=0.769).

We conclude that plasma myonectin levels are significantly associated with T2DM, particularly in elderly vascular risk patients.

Funding Acknowledgement

Type of funding sources: None.

Comparison of two recent ceramide-based coronary risk prediction scores: CERT and CERT-2

 

The Coronary Event Risk Test (CERT) is a validated cardiovascular risk predictor that uses circulating ceramide concentrations to allocate patients into one of four risk categories. This test has recently been updated (CERT-2), now additionally including phosphatidylcholine concentrations.

The purpose of this study was to investigate the power of CERT and CERT-2 to predict cardiovascular mortality in patients with cardiovascular disease (CVD).

We investigated a cohort of 999 patients with established CVD.

Overall, comparing survival curves (figure) for over 12 years of follow up and the predictive power of survival models using net reclassification improvement (NRI), CERT-2 was the best predictor of cardiovascular mortality, surpassing CERT (NRI=0.456; p=0.01) and also the 2019 ESC-SCORE (NRI=0.163; p=0.04). Patients in the highest risk category of CERT as compared to the lowest category had a HR of 3.63 [2.09–6.30] for cardiovascular death; for CERT-2 the corresponding HR was 6.02 [2.47–14.64]. Among patients with T2DM (n=322), the HR for cardiovascular death was 3.00 [1.44–6.23] using CERT and 7.06 [1.64–30.50] using CERT-2; the corresponding HRs among non-diabetic subjects were 2.99 [1.20–7.46] and 3.43 [1.03–11.43], respectively.

We conclude that both, CERT and CERT-2 scores are powerful predictors of cardiovascular mortality in CVD patients, especially in those patients with T2D. Performance is even higher with CERT-2.

Funding Acknowledgement

Type of funding source: None

P4992The ceramide-based Coronary Event Risk Test (CERT) predicts cardiovascular mortality in cardiovascular disease patients with type 2 diabetes mellitus as well as in those without diabetes

Background

The recently introduced Coronary Event Risk Test (CERT) is a validated cardiovascular risk predictor that uses circulating ceramide concentrations to allocate patients into one of four risk categories.

Purpose

The purpose of this study was to investigate the power of CERT to predict cardiovascular mortality in patients with established cardiovascular disease (CVD) including patients with type 2 diabetes (T2DM).

Methods

We investigated a total of 1087 patients with established CVD, including 360 patients with T2DM.

At baseline, the prevalence of T2DM increased through CERT categories (29.1, 31.1, 37.4, and 53.4%, respectively, ptrend<0.001). Prospectively, cardiovascular deaths were recorded during a mean follow-up time of 8.1±3.2 years.

Results

A total of 130 cardiovascular deaths occurred. Overall, cardiovascular mortality increased with increasing CERT categories (figure) and was higher in T2DM patients than in those who did not have diabetes (17.7 vs. 9.4%; p<0.001). In Cox regression models, CERT categories predicted cardiovascular mortality in patients with T2DM (unadjusted HR 1.60 [1.28–2.01]; p<0.001; HR adjusted for age, gender, BMI, smoking, LDL cholesterol, HDL cholesterol, hypertension, and statin use 1.65 [1.27–2.15]; p<0.001) and in those without diabetes (unadjusted HR 1.43 [1.10–1.85]; p=0.008 and adjusted HR 1.41 [1.07–1.85]; p=0.015).

Cardiovascular survival of CVD patients

Conclusion

We conclude that CERT predicts cardiovascular mortality in CVD patients with T2DM as well as in those without diabetes.

P4497Serum ceramides and type 2 diabetes are mutually independent predictors of cardiovascular events in patients with peripheral artery disease

Background

Ceramides are enriched in atherosclerotic plaques, and a set of circulating ceramides including Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/24:1), and Cer(d18:1/24:0) has recently emerged as predictors of cardiovascular outcomes in coronary artery disease patients.

Purpose

The purpose of this study was to investigate their power to predict cardiovascular events in patients with peripheral artery disease (PAD).

Methods

We measured the serum concentrations of the above mentioned ceramides in a cohort of 380 patients with sonographically proven PAD, of whom 107 had type 2 diabetes (T2DM). Prospectively, we recorded 221 cardiovascular events over a mean follow-up time of 6.3±2.3 years.

Results

Cardiovascular event risk was higher in T2DM patients than in those who did not have diabetes (69 vs. 52%, p=0.001). The ceramides Cer(18:1/16:0) and Cer(18:1/24:1) and the respective ratios Cer(18:1/16:0) / Cer(18:1/24:0) and Cer(18:1/24:1) / Cer(18:1/24:0) were significant predictors of cardiovascular events both univariately and after multivariate adjustment including the presence of T2DM (figure). Conversely, T2DM predicted cardiovascular events independently from the investigated ceramides (adjusted HR 1.76 [1.31–2.35], p<0.001).

Conclusion

We conclude that the investigated ceramides and T2DM are mutually independent predictors of cardiovascular events in PAD patients.

Hypoxia induces apelin expression in human adipocytes

Adipokines play a central role in the development of diseases associated with insulin resistance and obesity. Hypoxia in adipose tissue leads to a dysregulation of the expression of adipokines. The effect of hypoxia on the more recently identified adipokine apelin in human adipocytes is unclear. Therefore, we aimed at investigating the role of hypoxia on the expression of the adipokine apelin. Differentiated human Simpson-Golabi-Behmel syndrome (SGBS) adipocytes were cultured under hypoxic conditions for varying time periods. A modular incubator chamber was used to create a hypoxic tissue culture environment (defined as 1% O(2), 94% N, and 5% CO(2)). In addition, hypoxic conditions were mimicked by using CoCl(2). The effect of hypoxia on the expression of the investigated adipokines was measured by real-time PCR and the secretion of apelin was quantified by ELISA. Induction of hypoxia significantly induced mRNA expression of leptin and apelin in differentiated SGBS adipocytes compared with the normoxic control condition. Expression of adiponectin was significantly decreased by hypoxia. In addition, the amount of secreted apelin protein in response to hypoxia was elevated compared to untreated cells. Furthermore, we could demonstrate that the observed hypoxia-induced induction of apelin mRNA expression is in the first phase dependent on HIF-1α. In our study, we could demonstrate for the first time that apelin expression and secretion by human adipocytes are strongly induced under hypoxic conditions and that the early response on hypoxia with apelin induction is dependent on HIF-1α.

[Pathophysiology of sepsis and possible influence of statins]

Severe sepsis and septic shock are common complications in the intensive care unit and associated with high mortality. Early antimicrobial therapies together with organ-supportive measures are the major therapeutic approaches. However in the last decades immunomodulatory therapies have been investigated due to the notion of a compromised inflammatory response in septic patients. In addition to lowering circulating cholesterol, statins (HMG-CoA-reductase-inhibitors) have also been shown to possess pleiotropic anti-inflammatory potential. Recent studies indicate that these anti-inflammatory effects also modulate acute inflammatory response and therefore may play a protective role in septic patients. In this review, the pathophysiological background and first clinical trials of statins as a new adjuvant therapy in sepsis are summarized.

Procalcitonin for differential diagnosis of graft rejection and infection in patients with heart and/or lung grafts

OBJECTIVES

Investigation of the reliability of Procalcitonin (PCT) for differential diagnosis of acute rejections and non-viral infections in heart and lung transplanted patients.

DESIGN

Retrospective study.

SETTING

Transplant intensive care unit (ICU) at a university hospital.

PATIENTS

57 heart, 18 lung and 3 heart-lung transplant patients.

MEASUREMENTS

PCT was measured in plasma samples of heart and lung transplanted patients using a commercial immuno-luminescence assay and was compared with values of C-reactive protein (CRP) and leukocytes (WBC).

RESULTS

PCT was elevated in patients suffering from bacterial and fungal infections. The magnitude of values was clearly associated with the severity of the infection. Rejections and viral infections did not interfere with the PCT release.

CONCLUSION

PCT is a reliable predictor with discriminating power for non-viral systemic infections in patients after heart and/or lung transplantation. PCT allows an early differential diagnosis between rejection (AR) and bacterial/fungal infection (IF) and thus a rapid and focused therapeutic intervention. It avoids unnecessary antibiotic treatment which could be toxic for the graft itself in patients with rejection only. PCT provides vital information early to clinicians and allows them to improve the management of bacterial/fungal infections in immunocompromized transplant patients. PCT thus facilitates and improves the outcome of survival rate and the quality of life in the postoperative period of patients with heart and/or lung grafts.

Procalcitonin for differential diagnosis of graft rejection and infection in patients with heart and/or lung grafts

OBJECTIVES

Investigation of the reliability of Procalcitonin (PCT) for differential diagnosis of acute rejections and non-viral infections in heart and lung transplanted patients.

DESIGN

Retrospective study.

SETTING

Transplant intensive care unit (ICU) at a university hospital.

PATIENTS

57 heart, 18 lung and 3 heart-lung transplant patients.

MEASUREMENTS

PCT was measured in plasma samples of heart and lung transplanted patients using a commercial immuno-luminescence assay and was compared with values of C-reactive protein (CRP) and leukocytes (WBC).

RESULTS

PCT was elevated in patients suffering from bacterial and fungal infections. The magnitude of values was clearly associated with the severity of the infection. Rejections and viral infections did not interfere with the PCT release.

CONCLUSION

PCT is a reliable predictor with discriminating power for non-viral systemic infections in patients after heart and/or lung transplantation. PCT allows an early differential diagnosis between rejection (AR) and bacterial/fungal infection (IF) and thus a rapid and focused therapeutic intervention. It avoids unnecessary antibiotic treatment which could be toxic for the graft itself in patients with rejection only. PCT provides vital information early to clinicians and allows them to improve the management of bacterial/fungal infections in immunocompromized transplant patients. PCT thus facilitates and improves the outcome of survival rate and the quality of life in the postoperative period of patients with heart and/or lung grafts.

Tunnel enlargement and changes in synovial fluid cytokine profile following anterior cruciate ligament reconstruction with patellar tendon and hamstring tendon autografts

There is growing evidence that cytokines such as tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta, IL-6, bone morphogenetic proteins (BMP), and nitric oxide (NO) play an important role in the pathogenesis of bone tunnel enlargement following anterior cruciate ligament (ACL) reconstruction. Furthermore, the release of these mediators has been considered a possible reason for the higher incidence of bone tunnel enlargement following hamstring tendon (HST) than following patellar tendon (PT) ACL reconstruction observed in several studies. In this investigation synovial fluid samples from 13 patients were collected immediately before (24+/-7 days after ACL rupture) and 7 days after ACL surgery and values of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2 were analyzed. Furthermore, the incidence of bone tunnel enlargement was assessed using radiographs 38+/-7 weeks after surgery. Six patients underwent autologous HST ACL reconstruction, and in seven patients an PT autograft was used. In the overall patient population there were significantly higher synovial fluid concentrations of IL-6 and BMP-2 postoperatively than preoperatively; TNF-alpha showed a trend towards lower postoperative levels while IL-1beta and NO remained unchanged. The concentrations of NO, TNF-alpha, and IL-6 found in the present study were clearly higher than normal values given in the literature. Assessment of bone tunnel enlargement revealed an average increase in tibial tunnel width of 28.4+/-3.1% with comparable values for HST and PT ACL reconstructions. There was no significant correlation between bone tunnel enlargement and postoperative synovial fluid concentrations of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2. However, all patients with bone tunnel enlargement had higher postoperative concentrations of TNF-alpha, IL-6, and NO in the synovial fluid. There were no significant differences in concentrations between HST and PT groups. In conclusion, we observed an association between tibial bone tunnel enlargement and elevated synovial fluid concentrations of IL-6, TNF-alpha, and NO 7 days after ACL surgery indicating the potential involvement of these biological mediators in the pathogenesis of bone tunnel enlargement. However, there was no difference between HST and PT ACL reconstructions regarding synovial fluid contents of IL-6, TNF-alpha, IL-1beta, NO, and BMP-2, suggesting a comparable biological response between these autografts following their use in ACL reconstruction.

Lack of an association of urinary albumin excretion with interleukin-6 or C-reactive protein in patients with type 2 diabetes

The reason for the elevation of fibrinogen concentration in diabetic patients with nephropathy is not known so far. In order to elucidate the mechanism of such an increase in fibrinogen levels, we investigated haemorheological and inflammatory markers in type 2 diabetic patients in a cross-sectional design. Thirty-two non-smoking type 2 diabetic patients (13 women, 19 men; body mass index 29.1+/-5.4 kg/m2, age 62.8+/-12.1 years) were investigated. Patients with C-reactive protein levels >1.5 mg/dl were excluded from the study. Concentration of fibrinogen was measured by immunonephelometry, C-reactive protein by immunoturbidimetry, and interleukin-6 (IL-6) by an enzyme-linked immunosorbent assay, and viscosity of plasma and of whole blood was determined by rotation viscosimetry. Concentrations of inflammatory parameters were well correlated with each other (p<0.05 for all correlations): IL-6 with C-reactive protein (r=0.48), and C-reactive protein with fibrinogen (r=0.41). While no associations were found with concentrations of C-reactive protein or IL-6, urinary albumin excretion was correlated with erythrocyte sedimentation rate (r=0.47) and with fibrinogen concentration (r=0.39; p<0.05). In patients with type 2 diabetes mellitus, urinary albumin excretion was not associated with concentrations of IL-6 or C-reactive protein. These results suggest an IL-6-independent mechanism for increased fibrinogen levels and erythrocyte sedimentation rate in type 2 diabetic patients with increased urinary albumin excretion.

Interferon-gamma modifies cytokine release in vitro by monocytes from surgical patients

BACKGROUND

Treatment with interferon-gamma (IFN-gamma), a key mediator for adequate forward-regulatory monocyte immune capability, has been advocated to overcome posttraumatic mononuclear leukocyte paralysis. Conversely, IFN-gamma also is a potent proinflammatory mediator contributing to capillary leakage in sepsis-driven organ failure. The objective of this investigation was to further define the potential of IFN-gamma as a modifier of monocyte activity before and after injury.

METHODS

Whole blood samples from 19 patients (7 female and 12 male patients; age, 68 +/- 5 years) before and after cardiac surgery with extracorporeal circulation were incubated under continuous rotation with lipopolysaccharide for 12 hours in the presence or absence of human recombinant IFN-gamma. Pro- and anti-inflammatory cytokines were determined in the plasma.

RESULTS

Lipopolysaccharide-induced release of tumor necrosis factor-alpha, interleukin (IL)-6, IL-12, and IL-1Ra, and prostaglandin E2 was clearly augmented with IFN-gamma most strikingly postoperatively (p < 0.05). There was no effect on IL-1beta, neopterin, and soluble tumor necrosis factor-R release.

CONCLUSION

Thus there is a wide spectrum of IFN-gamma activity on monocyte activation including anti-inflammatory properties. Since cellular preactivation facilitates monocyte reactivity toward IFN-gamma, we conclude that exogenous administration should be effective but must be carried out with great caution in patients with profound inflammation.

Local immunotherapy of glioma patients with a combination of 2 bispecific antibody fragments and resting autologous lymphocytes: evidence for in situ t-cell activation and therapeutic efficacy

After adoptive transfer of pre-activated lymphocytes into the operation cavity of glioma patients, tumor regression and improved survival have been reported in some patients. Results were most impressive when bispecific antibodies with tumor x CD3 specificity were also applied. In this study, we attempted to avoid time-consuming pre-activation procedures for adoptively transferred cells by using a combination of bispecific antibodies directed to the EGF receptor (EGFR) on tumor cells and to CD3 and CD28 on T cells. Eleven patients with high-grade malignant glioma received 3 injections of 2 bispecific antibody fragments (EGFR x CD3 and EGFR x CD28) together with freshly isolated autologous lymphocytes via an Ommaya reservoir. Intracavitary fluid aspirated during immunotherapy was examined for markers of T-cell activation. Increased levels of soluble IL-2 receptor and TNF-alpha were detected in the intracavitary fluid of all patients tested. Two of the 11 treated patients experienced a beneficial response to therapy as defined by a transient contrast enhancement in subsequent MRI scans and prolonged survival. Side effects were transient and consisted of fever, nausea, headache and aggravation of pre-existing neurologic deficits. These adverse effects were most likely due to the antibody construct containing anti-CD3 specificity. Two patients developed cerebral edema and required steroid treatment.

Procalcitonin, a new indicator for non-viral infections in heart, lung or liver transplant patients

PCT is a highly specific analyse which shows significant diagnostic validities when non-viral infections are compared with rejection episodes. PCT discriminates inflammatory events such as rejection or viral infections and non-viral infections including bacterial, fungal and protozoal infections. The half-life of PCT is 24 h indicating a clearly competent antibiotic treatment. PCT provides vital information early to clinicians and allows them to improve the management of bacterial/fungal infection in immunocompromised transplant patients. PCT thus facilitates and improves the outcome of survival rate and the quality of life in the postoperative period of patients with heart, lung or liver grafts.

Evaluation of the ADVIA Centaur TSH-3 assay

An analytical evaluation of the thyroid stimulating hormone (TSH-3) assay on the Bayer ADVIA Centaur immunoassay system was performed. General analytical requirements (linearity, resistance to typical interferences, absence of a carry-over effect) were fulfilled and reproducibility was satisfactory. Inter-assay coefficient of variation (CV) of a human serum pool with a concentration of 0.014 mU/l was 22.3%; at concentrations between 0.26 and 83 mU/l CV was below 6%. Method comparison study demonstrated close agreement of TSH results compared to those obtained with the Roche Elecsys 2010 TSH assay (ADVIA Centaur = 1.08 x Elecsys - 0.18 mU/l; r=0.987; n=324). Handling and practicability of the ADVIA Centaur system proved to be convenient with a very high sample throughput. We conclude that the ADVIA Centaur TSH-3 assay meets requirements for clinical use.

Modulation of coronary vasomotor tone by cytokines in cardiac transplant recipients

BACKGROUND

Upon exposure to cytokines, endothelial cells may undergo profound alterations of vasomotor function. In this study, we characterized the relationship between coronary epicardial and microvascular vasomotor function and expression of specific cytokine patterns in human heart transplant recipients.

METHODS

We studied 49 cardiac transplant recipients, without acute rejection or infection at an average of 6+/-3 months after transplantation. Coronary resistance vessel function was measured in an endothelium-dependent manner with acetylcholine (5 and 150 microg/5 min; intracoronary injection) and in an endothelium-independent manner with adenosine (400 and 800 microg/5 min; intracoronary injection) using an intracoronary Doppler flow wire. Simultaneous epicardial diameter changes were measured using quantitative coronary angiography. Coronary sinus and aortic serum levels of soluble interleukin (IL)-2 receptor and soluble tumor necrosis factor-a receptors (sTNF-R1 and sTNF-R2), TNF-alpha, and IL-6 were determined. Transcardiac cytokine release (coronary sinus minus aortic levels) was correlated with coronary vasomotor function.

RESULTS

The highest amounts of cardiac cytokine release were observed for IL-6 (32+/-14% increase) and sTNF-R1 (26+/-13% increase). A significant inverse correlation between microvascular endothelial function and cardiac release of soluble IL-2 receptor (P=0.04) and IL-6 (P=0.03) was detected, whereas a positive correlation was observed to sTNF-R1 (P=0.004). Distal epicardial endothelial vasomotion was inversely correlated to transcardiac sTNF-R2 release (P=0.03).

CONCLUSIONS

Cytokine production and activation, a common phenomenon early after heart transplantation, is related at least in part to endothelial vasomotor dysfunction of the epicardial and microvascular compartment. These results support the hypothesis that coronary endothelial dysfunction after cardiac transplantation is an immunologic phenomenon. Since endothelial dysfunction seems to be a crucial step in the pathogenesis of cardiac allograft vasculopathy, coronary cytokine suppression should be a therapeutic target of improved future immunosuppressive regimens.

Corticosteroid-binding globulin and free cortisol in the early postoperative period after cardiac surgery

OBJECTIVES

To characterize concentrations of corticosteroid-binding globulin (CBG), total and free serum cortisol, and free urinary cortisol in patients during the postoperative period of cardiac surgery.

DESIGN AND METHODS

In 24 patients serum was sampled on the first and second postoperative day after cardiac surgery (21 procedures with thoracotomy, 3 thoracoscopic procedures); urine was collected for two 10-h periods (8 P.M. until 6 A.M.) on the respective postoperative days. Total serum cortisol and free urinary cortisol were measured with an automated chemiluminescence assay (analysis of urine after extraction with dichloromethane), and CBG using a coated-tube RIA. Free serum cortisol was calculated from the concentrations of total serum cortisol and CBG as described previously. Thirty healthy volunteers were studied as controls.

RESULTS

CBG was reduced to about one-half of the normal concentration on both postoperative days. Whereas total cortisol was about two-fold increased on the first postoperative day compared to controls extremely high concentrations of free serum cortisol were calculated from CBG and total cortisol [median 136 nmol/L (interquartile range 100-185); controls 21.8 nmol/L (interquartile range 16.9-29.8)]. On the second postoperative day, median total serum cortisol was within the interquartile range of the controls, free serum cortisol in contrast was still two-fold increased. Free serum cortisol and free urinary cortisol were significantly correlated (r = 0.60).

CONCLUSIONS

Extremely high concentrations of free serum cortisol are typically found in the postoperative period of cardiac surgery; under these conditions the mere consideration of total cortisol does not appropriately display the activation of the adrenal cortex.

Reduction of circulating cholesterol and apolipoprotein levels during sepsis

Sepsis with multiple organ failure is frequently associated with a substantial decrease of cholesterol levels. This decrease of cholesterol is strongly associated with mortality suggesting a direct relation between inflammatory conditions and altered cholesterol homeostasis. The host response during sepsis is mediated by cytokines and growth factors, which are capable of influencing lipid metabolism. Conversely lipoproteins are also capable of modulating cytokine production during the inflammatory response. Therefore the decrease in circulating cholesterol levels seems to play a crucial role in the pathophysiology of sepsis. In this review the interaction between cytokines and lipid metabolism and its clinical consequences will be discussed.

[Significance of the heart-lung machine for the concept of minimal invasive heart surgery]

Proinflammatory cytokines have been implicated in mediating myocardial dysfunction in a systemic inflammatory reaction following open heart surgery with extracorporeal circulation (ECC). The present study aimed to distinguish the surgical impact on cytokine release from the influence of ECC in a model of supported angioplasty. The extracorporeal circulation and not surgical trauma was found to be the main trigger of the systemic inflammatory response.