C-reactive protein and mortality in patients with acute aortic disease

Serum Sema7A is increased in patients with acute aortic dissection

BACKGROUND

To observe the level of serum Sema7A in acute aortic dissection (AAD) and its diagnostic value for AAD.

RESEARCH DESIGN AND METHODS

Patients with sudden chest pain including AAD, acute myocardial infarction (AMI) or pulmonary embolism (PE) were enrolled. Patients without chest pain or cardiovascular diseases were included as the controls. Serum Sema7A and plasma D-dimer were detected and compared in each group.

RESULTS

85 AAD patients, 55 AMI patients, 15 PE patients, and 30 controls were enrolled. The concentration of Serum Sema7A in the AAD group was significantly higher than that in the control, AMI and PE group. Serum Sema7A was positively correlated with D-dimer. In AAD patients who underwent invasive intervention therapy, serum Sema7A levels were significantly decreased after the intervention. Serum Sema7A was an independent risk factor for the presence of AAD. The areas under the ROC curve of Sema7A and D-dimer for differential diagnosis of AAD from other chest pain disorders were 0.842 (0.776, 0.909) and 0.788 (0.714, 0.862), respectively.

CONCLUSIONS

Sema7A is highly expressed in patients with AAD. Sema7A might be a valuable biomarker for the early diagnosis of AAD and has the potential to differentiate AAD from AMI and PE.

Low Zinc Alleviates the Progression of Thoracic Aortic Dissection by Inhibiting Inflammation

Vascular inflammation triggers the development of thoracic aortic dissection (TAD). Zinc deficiency could dampen tissue inflammation. However, the role of zinc as a nutritional intervention in the progression of TAD remains elusive. In this study, we employed a classical β-aminopropionitrile monofumarate (BAPN)-induced TAD model in mice treated with low zinc and observed that the TAD progression was greatly ameliorated under low zinc conditions. Our results showed that low zinc could significantly improve aortic dissection and rupture (BAPN + low zinc vs. BAPN, 36% vs. 100%) and reduce mortality (BAPN + low zinc vs. BAPN, 22% vs. 57%). Mechanically, low zinc attenuated the infiltration of macrophages and inhibited the expression of inflammatory cytokines, suppressed the phenotype switch of vascular smooth muscle cells from contractile to synthetic types, and eventually alleviated the development of TAD. In conclusion, this study suggested that low zinc may serve as a potential nutritional intervention approach for TAD prevention.

Procalcitonin, Interleukin-6 and C-reactive Protein Levels Predict Renal Adverse Outcomes and Mortality in Patients with Acute Type A Aortic Dissection

Background

Acute type A aortic coarctation (AAAD) is a highly deadly and serious life-threatening disease. The purpose of this study was to estimate the predictive value of peak procalcitonin, interleukin-6, and C-reactive protein levels on adverse renal outcomes and mortality in patients undergoing surgery for AAAD.

Methods

Perioperative peak PCT, CRP, and IL-6 levels were retrospectively collected in 331 patients hospitalized with AAAD from 2009 to 2021. The primary endpoints were AKI stage 2–3 and mortality. The receiver operating characteristic (ROC) curves were used to compare the predictive values of peak PCT, CRP, and IL-6 for different clinical outcomes. Multivariable logistic regression analysis was used to find risk factors for AKI and 30-day mortality.

Results

The incidence of AKI stage 2–3 following AAAD was 50.8% (168/331). The 30-day and overall mortality were significantly greater in the AKI 2–3 group than in the AKI 0–1 group (P = 0.000). ROC curve analysis showed that peak PCT, with an area under the ROC curve (AUC) of 0.712, was a more accurate predictor of adverse renal outcomes than peak IL-6 and CRP. Multivariable logistic regression analysis revealed that PCT > 0.39 ng/mL was an independent risk factor for AKI stage 2–3. Peak IL-6 > 259 pg/mL was found to be an independent risk factor for 30-day mortality.

Conclusion

In patients with surgery for AAAD, peak PCT provides a well-predictive indicator of AKI stage 2–3 and peak IL-6 indicates a favorable predictor of 30-day mortality.

Impacts of eosinophil percentage on prognosis acute type A aortic dissection patients

Background

Eosinophils are pro-inflammatory cells involved in thrombosis and have been proposed as a prognosis marker in acute ischemic stroke and ST-elevation myocardial Infarction. Here, we sought to clarify the prognostic value of eosinophil percentage (EOS%) in patients with acute type A aortic dissection (AAAD).

Methods

We examined 183 consecutive AAAD patients. Based on the optimum cut-off value of EOS% determined by X-tile software, patients were classified into the low EOS% (EOS% ≤ 0.1) and high EOS% groups (EOS% > 0.1). We performed multivariate regression analysis and Kaplan–Meier (KM) survival curves to assess the association between EOS% and mortality. Eosinophil accumulation in aortic dissection intraluminal thrombus was confirmed using hematoxylin–eosin (H&E) staining. An external cohort from Medical Information Mart for Intensive Care IV was performed to validate the results.

Results

Relative to surviving patients, those who died during hospitalization had significantly lower EOS% (p = 0.001) but significantly higher WBC (p = 0.002) and neutrophil (p = 0.001) counts. Multivariate regression analysis identified EOS% as an independent predictor of in-hospital and 1-year mortality. KM curves revealed that 1-year cumulative mortality was significantly higher in the low EOS% group, although it was mainly attributed to the higher 30-day mortality. H&E staining revealed massive infiltration of eosinophils in all 20 thrombus specimens. The external validation confirmed that relative to survivors, patients with in-hospital mortality (p = 0.010) had significantly lower EOS%. Moreover, multivariate regression analyses identified that decreased EOS% was independently significantly associated with in-hospital mortality.

Conclusions

Low EOS% is significantly related to increased mortality rates in AAAD patients.

Assessing serum levels of SM22α as a new biomarker for patients with aortic aneurysm/dissection

Background

Aortic aneurysm/dissection (AAD) is now encountered more often because of the increasing prevalence of atherosclerosis and hypertension in the population. Despite many therapeutic improvements, in particular timely and successful surgery, in-hospital mortality rates are still higher. Timely identification of patients at high risk will help improve the overall prognosis of AAD. Since early clinical and radiological signs are nonspecific, there is an urgent need for accurate biomarkers. Smooth muscle 22α (SM22α) is a potential marker for AAD because of its abundant expression in vascular smooth muscle, which is involved in development of AAD.

Methods

We prepared three different mouse models, including abdominal aortic aneurysm, neointimal hyperplasia and atherosclerosis. SM22α levels were assessed in serum and vascular tissue of the mice. Next, the relationships between serum SM22α level and vascular lesion were studied in mice. Finally, serum from 41 patients with AAD, 107 carotid artery stenosis (CAS) patients and 40 healthy volunteers were tested for SM22α. Serum levels of SM22α were measured using an enzyme-linked immunosorbent assay (ELISA).

Results

Compared with the controls, serum SM22α levels were reduced in the models of aortic aneurysm, neointimal formation and atherosclerosis, and elevated in mice with ruptured aneurysm. Serum SM22α level was negatively correlated with apoptosis rate of vascular smooth muscle cells (VSMC), ratio of intima/ media (I/M) area and plaque size. Patients with AAD had significantly higher serum SM22α levels than patients with only CAS, or normal controls.

Conclusion

Serum SM22α could be a potential predictive marker for AAD, and regulation of VSMC is a possible mechanism for the effects of SM22α.

Ruptured abdominal aortic aneurysm in a young male patient, a rare case report

Introduction and importance

Abdominal aortic aneurysm (AAA) is commonly a disease of the elderly population with an atherosclerotic aorta. We present a rare case scenario of a large ruptured AAA in a young patient.

Case presentation

A 32-year-old man presented to the Emergency Department with abdominal pain. On examination he had hypotension with a severely tender abdomen. Imaging revealed a ruptured 10 cm abdominal aortic aneurysm (AAA). He underwent an emergency open aneurysm repair and was discharged well on post-operative day 12. Apart from smoking, he had no known significant risk factors contributing to an AAA of such size. Clinical features and family history suggested a possible underlying connective tissue disorder.

Clinical discussion

A painful abdomen and hypotension in a young patient should prompt investigations to rule out a rare but life-threatening diagnosis of a ruptured AAA.

Conclusion

A possible underlying connective tissue disorder should be investigated for in any young patient presenting with an AAA.

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Early onset of an abdominal aortic aneurysm is rare

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A painful abdomen with hypotension in a young patient should prompt investigation for a possible underlying ruptured abdominal aortic aneurysm

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Clinical features and family history provide clues for a possible connective tissue disorder as the etiology of the aneurysm in younger 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.

Association Between Red Blood Cell Distribution Width-to-Albumin Ratio and Prognosis of Patients with Aortic Aneurysms

Objective

Red blood cell distribution width (RDW) is a predictor of adverse outcomes in aortic aneurysms. Recent recommendations suggest that combining RDW with other biomarkers could yield better results. We, therefore, propose evaluating the biomarker of vascular aging, albumin with RDW to predict the risk of aortic aneurysms. This study aims to explore whether the combination of RDW with albumin can effectively predict the prognosis of aortic aneurysm patients.

Methods

This retrospective cohort study was conducted among adults (age >18) with aortic aneurysms in the Medical Information Mart for Intensive Care Database III V1.4 (MIMIC-III). RAR was measured according to the red blood cell distribution width and albumin. The primary outcome was the 30-day mortality rate, and the secondary outcome was the 90-day and one-year mortality rates. Estimation of hazard ratios (HR) was obtained from Cox regression models for all-cause mortality related to red cell distribution width-to-albumin ratio (RAR) values.

Results

In total, 312 patients were involved, with an average age of 74.9 ± 10.9 years and an average RAR value of 5.4 ± 1.6 mL/g. In 30 days for all-cause mortality, the HR (95% CI) in the highest RAR group (>5.8 mL/g) in tertiles was 2.54 (1.25, 5.14) in the unadjusted model, with a significant difference compared with the reference group (P < 0.05). After adjusting for race, gender and age, there was still a correlation (P < 0.05), and the HR (95% CI) was 2.51 (1.23, 5.10). Further adjustment of possible covariates showed similar correlation in model 3 (P < 0.05), and HR (95% CI) was 2.66 (1.17, 6.01). Multivariable logistic regression shows that RAR is an independent risk factor for the outcome of aortic aneurysms after adjusting the covariates. In the subgroup analysis, we analyzed the patient’s complications, and no significant interaction was observed.

Conclusion

RAR is a risk factor for patients with aortic aneurysms. However, more in-depth research is warranted to further analyze and substantiate our findings on the role of RAR in aortic aneurysm patients.

Outcomes and risk management in type B aortic dissection patients with acute kidney injury: a concise review

Purpose

Type B aortic dissection is a rare but life-threatening disease. Thoracic endovascular aortic repair (TEVAR) was widely used for Type B aortic dissection patients in the last decade due to the lower mortality and morbidity compared with open chest surgical repair (OCSR). AKI in type B aortic dissection is a well-recognized complication and indicates poor short-term and long-term outcome. The objective of this concise review was to identify the risk factors and the impact of AKI on type B aortic dissection patients.

Methods and results

A literature search was performed using PubMed, Embase, MEDLINE, and Cochrane Library with the search terms ‘type B aortic dissection’ and ‘acute kidney injury’ (AKI), and all English-language literatures published in print or available online from inception through August 2020 were thoroughly reviewed. Studies that reported relative AKI risks and outcomes in type B aortic dissection patient were included. Major mechanisms of AKI in type B aortic dissection included renal hypoperfusion, inflammation response, and the use of contrast medium. Type B aortic dissection patients with AKI significantly had increased hospital stay duration, need of renal replacement therapy, and 30-d and 1-year mortality.

Conclusions

AKI in type B aortic dissection is a well-recognized complication and associated with poor short-term and long-term outcome. Early identification of high-risk patients, early diagnosis of AKI, stabilization of the hemodynamic parameters, avoidance of nephrotoxic drugs, and optimization of the use of contrast agents are the major strategies for the reduction of AKI in type B aortic dissection patients.

The analysis of the levels of plasma inflammation-related cytokines and endotoxins in patients with acute aortic dissection

OBJECTIVE

To investigate the changes in the levels of plasm interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9) and endotoxins in patients with acute aortic dissection (AAD).

METHODS

55 AAD patients who were admitted and scheduled to undergo emergency surgery in our hospital from January 2017 to July 2017 were selected and retrospectively analyzed. They were divided into the survival group (n = 40) and the death group (n = 15). The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins at admission and at 6 h, 12 h and 24 h after admission (T0, T1, T2 and T3) were measured, and the correlations of inflammatory cytokines with endotoxins were analyzed.

RESULTS

At T1, T2 and T3, the levels of inflammatory cytokines and endotoxins were increased. The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins in the death group were significantly higher than those in the survival group at each time point (p < 0.05 in all comparisons). Neutrophil and platelet counts in the death group were higher than those in the survival group (p < 0.05). Correlation analyses indicated that the levels of IL-6, TNF-α, CRP and MMP-9 were positively correlated with the level of endotoxin.

CONCLUSION

Patients with AAD are often accompanied by systemic inflammatory responses, with inflammation-related cytokines (IL-6, TNF-α, CRP and MMP-9) and endotoxins levels significantly elevated. Combined monitoring of dynamic changes in inflammatory cytokines and endotoxins, as well as early interventions, has important clinical implications for evaluating the prognosis of AAD and reducing mortality.

The expression of interleukin 20 increases in plasma and aortic tissues from patients with acute aortic dissection

OBJECTIVE

Acute aortic dissection (AAD) is the most devasting cardiovascular disease associated with high mortality. The occurrence and progression of AAD can be regulated by inflammatory processes, and further understanding of this inflammatory pathogenesis may improve the treatment of AAD. Interleukin 20 (IL-20), as an inflammatory mediator, has been demonstrated to be associated with several inflammatory diseases. However, the association between IL and 20 and AAD is still unknown.

METHODS

Five aortic dissection tissue samples and five control aortic tissue samples were evaluated in our study. The expression of IL-20 and its receptor subunits (IL-20Rα and IL-20Rβ) was detected by immunofluorescence staining. From January 2018 to March 2018, 70 consecutive AAD patients and 25 non-AAD (NAD) patients were enrolled in this study. Diagnosis was based on computed tomography angiography (CTA) results. Blood samples were obtained from the patients on the first day of hospitalization. Plasma IL-20, TNF-α and IL-6 concentrations were evaluated with enzyme-linked immunosorbent assay (ELISA) kits.

RESULTS

The expression levels of IL-20 and its receptor subunits (IL-20Rα and IL-20Rβ) were increased in the sites of arterial wall dissection in the AAD patients. In a separate group, the plasma IL-20, TNF-α and IL-6 concentrations were significantly higher in the AAD patients than in the non-AAD patients. Spearman's correlation analysis showed that plasma IL-20 was positively correlated with plasma TNF-α and IL-6, D-dimer, C-reaction protein (CRP), creatinine, fasting blood glucose, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Multiple linear regression revealed that IL-20, in addition to IL-6, glucose, CRP and D-dimer, was independently associated with the presence of AAD.

CONCLUSION

IL-20 was closely associated with the presence of AAD. IL-20 may contribute to the inflammatory pathogenesis of AAD.

Association of lymphocyte to monocyte ratio and risk of in-hospital mortality in patients with acute type A aortic dissection

Aim: The aim of the study was to evaluate the relationship between lymphocyte to monocyte ratio (LMR) at admission and in-hospital mortality of patients with acute type A aortic dissection (AAAD). Patients & methods: We enrolled 536 patients with AAAD between June 2013 and December 2017. Patients were divided into two groups: the deceased group and the survival group. Results: In multivariable analysis, the association between LMR and in-hospital mortality was still significant. When the Q4 was set as the reference value, the odds ratios values of Q1, Q2 and Q3 were 4.4 (95% CI: 2.2-8.9; p < 0.001), 1.4 (95% CI: 1.1-3.4; p = 0.03) and 1.7 (95% CI: 0.8-2.9; p = 0.158). Conclusion: Lower LMR may be independently associated with in-hospital mortality in AAAD.

Prognostic Role of Admission C-Reactive Protein Level as a Predictor of In-Hospital Mortality in Type-A Acute Aortic Dissection: A Meta-Analysis

BACKGROUND

Acute aortic dissection (AD) is a lethal vascular disease, accounting for over 90% cases of acute aortic syndrome. Despite advances in understanding associated risk factors, the long-term prognosis for AD patients is still poor. Several prognostic biomarkers have been used for AD as per the IRAD, such as older age (>70 years), onset of chest pain and hypotension, but they are not effective in all patients. Instead, C-reactive protein (CRP) is a consistent inflammatory marker. CRP levels are abnormally increased in AD. However, the prognostic value of serum CRP level in AD remains unclear.

OBJECTIVE

To perform a systematic review and meta-analysis (registration no CRD42017056205) to evaluate whether CRP is a biomarker associated with in-hospital mortality in type-A AD.

METHODS

PubMed, Web of Science, CNKI, SciELO, and EMBASE were searched for papers published from January 2000 to October 2017 for studies on the prognostic role of CRP at admission in type-A AD patients. Outcome data were extracted and pooled hazard ratios (HRs) were calculated.

RESULTS

18 (N = 2875 patients) studies met the inclusion criteria. Elevated CRP level was associated with a significantly increased risk of in-hospital mortality in patients with type-A AD (HR = 1.15, 95% CI: 1.06-1.25, p = 0.001). The pooled sensitivity of CRP in type-A AD patients was 77% (95% CI 69%-84%, p < 0.001), and the specificity was 72% (95% CI 66%-78%, p < 0.001).

CONCLUSION

Elevated CRP level is significantly associated with increased risks of in-hospital mortality in patients with type-A AD. CRP is a convenient prognostic factor in type-A AD patients.

Preoperative proteinuria and clinical outcomes in type B aortic dissection after thoracic endovascular aortic repair

Background

Proteinuria is a marker of poor outcomes in several diseases; however, few studies have been conducted to explore the prognostic value of proteinuria, assessed by urine dipstick test, for clinical outcomes in patients with type B acute aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

Methods

Consecutive patients with TBAD undergoing TEVAR were enrolled from January 2010 to July 2015. Proteinuria was defined as trace or higher, according to the results of urine dipstick testing. Associations among proteinuria and adverse events were evaluated.

Results

In total, 671 patients with a mean age of 44±15 years were included in the analysis. Proteinuria was detected in 281 patients (41.9%) before TEVAR. Multivariate logistic regression analysis showed that C-reactive protein and impaired renal function were independent predictors for proteinuria. During hospitalization, 21 patients died. In-hospital mortality was higher in patients with proteinuria (1.5% vs. 5.3%, p=0.005). After a median 3.4 years follow up, the post-TEVAR death rate was 10.4% (85 patients were lost to follow-up). The long-term cumulative mortality was significantly higher in patients with proteinuria (17.2% vs. 8.2%, log-rank=11.36, p=0.001). Multivariate Cox survival modeling indicated that proteinuria was significantly associated with long-term death, after adjustment for potential confounding risk factors (HR=1.92, p=0.012).

Conclusions

Pre-TEVAR proteinuria was identified as a prognostic marker in patients with TBAD and has potential for application as a convenient and simple risk assessment method before TEVAR.

Increased levels of interleukin-22 in thoracic aorta and plasma from patients with acute thoracic aortic dissection

BACKGROUND

Interleukin (IL)-22 plays important roles in the development of arterial disease, including atherosclerosis and hypertension. However, the relationship between IL-22 and acute thoracic aortic dissection (TAD) remains unknown.

METHODS

Blood samples were collected from patients with chest pain who underwent computed tomography angiography of the thoracic aorta but had no known preoperative diagnosis of coronary artery disease, peripheral artery disease, arthritis, and/or membranous nephropathy. Patients were divided into non-AD (NAD) and TAD groups, and the plasma concentrations of IL-22, IL-6 and tumor necrosis factor (TNF)-α were measured. In addition, aortic tissue samples from acute TAD patients and normal donors were collected, and the expression levels of IL-22 and IL-22 receptor 1 (IL-22R1) were measured.

RESULTS

IL-22, IL-6 and TNF-α levels were significantly higher in acute TAD patients than in NAD patients (IL-22, NAD group: 27.0 (19.1, 38.6) pg/ml vs. TAD group: 32.9 (20.6, 58.3) pg/ml, p<0.0001). The correlation analysis showed that IL-22 levels were positively correlated with levels of IL-6, TNF-α, fasting glucose, blood pressure, white blood cells, C-reactive proteins and D-dimers. Binary logistic regression analyses showed that IL-22 was independently associated with the presence of acute TAD (OR 1.169, 95% CI 1.069 to 1.277; p=0.001). In addition, compared with aortic tissue of normal controls, TAD aortas showed increased expression of IL-22 and IL-22R1, especially in the torn section (IL-22, non-torn section: 2.8±0.5/HPF vs. torn section 2.8±0.5/HPF, p<0.001). Additionally, macrophage but not T lymphocyte infiltration was significantly increased in the torn section (Macrophage, non-torn section: 2.2±0.6/HPF vs. torn section 5.7±1.2/HPF, p<0.001; T lymphocyte, non-torn section: 2.7±0.9/HPF vs. torn section 2.4±0.5/HPF, p=0.28), as evidenced by increased positive staining for the macrophage marker CD68, as opposed to the T cell marker CD3.

CONCLUSION

IL-22 levels may correlate with the presence of acute TAD.

Can Specialized Pro-resolving Mediators Deliver Benefit Originally Expected from Fish Oil?

PURPOSE OF THE REVIEW

Fish oil (FO) supplementation has historically been used by individuals suffering from cardiovascular disease and other inflammatory processes. However, a meta-analysis of several large randomized control trials (RCTs) suggested FO conferred no benefit in reducing cardiovascular risk. Skeptics surmised that the lack of benefit was related to FO dose or drug interactions; therefore, the widely accepted practice of FO consumption was brought into question.

RECENT FINDINGS

Thereafter, Serhan et al. identified specialized pro-resolving mediators (SPMs) to be one of the bioactive components and mechanisms of action of FO. SPMs are thought to enhance resolution of inflammation, as opposed to classic anti-inflammatory agents which inhibit inflammatory pathways. Numerous diseases, including persistent Inflammation, immunosuppression, and catabolic syndrome (PICS), are rooted in a burden of chronic inflammation. SPMs are gaining traction as potential therapeutic agents used to resolve inflammation in cardiovascular disorders, inflammatory bowel disease, sepsis, pancreatitis, and acute respiratory distress syndrome (ARDS). This narrative reviews the history of FO and the various studies that made the health benefits of FO inconclusive, as well as an overview of SPMs and their use in specific disease states.

Changes in coagulation factor XII and its function during aortic arch surgery for acute aortic dissection-a prospective observational study

Background

Changes in the intrinsic coagulation pathway during aortic arch surgery in patients with acute aortic dissection (AAD) have not yet been reported. The aim of this study is to describe the changes in intrinsic coagulation factor XII, explore its function and find a new target for the treatment of coagulopathy during surgery.

Methods

Eighty-eight patients undergoing emergent surgery for AAD were enrolled. Changes in the intrinsic and extrinsic coagulation pathways were evaluated at 5 different timepoints during the perioperative period by measuring intrinsic coagulation factor XII, extrinsic coagulation factor VII and some intrinsic upstream stimulating factors. The 88 patients were also divided into two groups according to whether reoperation for coagulopathy was required after surgery.

Results

Both coagulation factors XII and VII demonstrated a significant and similar change during the perioperative period. These factors decreased significantly during hypothermia circulation arrest (P<0.001) and recovered to normal levels by 24 hours after surgery. Among the intrinsic upstream stimulating factors, bradykinin (BK) demonstrated a similar changing trend with coagulation factors XII and VII, while other stimulating factors did not. However, compared with factor VII, factor XII demonstrated a greater decline during surgery. The proportion of decline of factor XII from anesthesia induction to hypothermia circulation arrest was 42%, whereas the proportion of decline of factor VII during the same period was 20% (P<0.001). Moreover, factor VII recovered to preoperative levels 4 hours after surgery with a relatively faster speed (P<0.001) while factor XII had not recovered (P=0.010). The independent t-test and Wilcoxon test showed that coagulation factor XII levels during hypothermia circulation arrest (P=0.002), total dosage of fibrinogen (P=0.027), total dosage of packed red blood cells (PRBCs) (P=0.006) and total dosage of fresh frozen plasma (FFP) (P=0.022) during the perioperative period were significantly different between the patients who did or did not require reoperation for coagulopathy. Multivariable logistic regression analysis suggested that the factor XII level during hypothermia circulation arrest was an independent risk factor for reoperation for coagulopathy [odds ratio (OR): 1.342, 95% confidence interval (CI): 1.058-1.570; P=0.012].

Conclusions

Factor XII levels are more influenced by surgery and require a longer period of time to recover to preoperative levels compared with factor VII, and the level of factor XII during hypothermia circulation arrest might be an independent risk factor for reoperation for coagulopathy. Therefore, supplementation of coagulation factor XII and its upstream stimulating factors might be a promising therapeutic modality in the future.

Cardiovascular Disease in Ageing: An Overview on Thoracic Aortic Aneurysm as an Emerging Inflammatory Disease

Medial degeneration associated with thoracic aortic aneurysm and acute aortic dissection was originally described by Erdheim as a noninflammatory lesion related to the loss of smooth muscle cells and elastic fibre fragmentation in the media. Recent evidences propose the strong role of a chronic immune/inflammatory process in aneurysm evocation and progression. The coexistence of inflammatory cells with markers of apoptotic vascular cell death in the media of ascending aorta with aneurysms and type A dissections raises the possibility that activated T cells and macrophages may contribute to the elimination of smooth muscle cells and degradation of the matrix. On the other hand, several inflammatory pathways (including TGF-β, TLR-4 interferon-γ, chemokines, and interferon-γ) seem to be involved in the medial degeneration related to aged and dilated aorta. This is an overview on thoracic aortic aneurysm as an emerging inflammatory disease.

Impact of Presurgical Mild Acute Respiratory Distress Syndrome on Surgical Mortality After Surgical Repair of Acute Type A Aortic Dissection

To evaluate the impact of presurgical mild acute respiratory distress syndrome (ARDS) on surgical mortality in patients undergoing surgical repair of acute type A aortic dissection by means of deep hypothermic circulatory arrest (DHCA) in a single-center, retrospective study.From January 2011 to December 2015, 333 eligible patients were divided into either a mild-ARDS group (n = 136) or a no-ARDS group (n = 197). The definition of mild ARDS referred to the recent revision of ARDS definition (Berlin criteria). The surgical mortality and major postoperative morbidity were investigated and analyzed.A total of 136 patients developed presurgical mild ARDS, with an incidence of 40.8%. No significant difference emerged between the 2 groups in major postoperative morbidity except for pulmonary complications. Multivariate logistic regression displayed that the risk of postoperative pulmonary complications in patients with presurgical mild ARDS was 4.25 times that in patients without presurgical ARDS (OR = 4.25, 95% CI 2.05-7.72). Twenty-four patients died after surgery, with significantly higher surgical mortality in the mild-ARDS group compared with the no-ARDS group (12.5% versus 3.6%, P = 0.002). Kaplan-Meier curves showed a poor surgical survival in the mild-ARDS group (χ²=12.958, Log-Rank P < 0.001). And Cox regression revealed the hazard ratio for surgical mortality in the mild-ARDS group compared with the no-ARDS group was 2.52 (95%CI 1.41-5.32, P = 0.016).Presurgical mild ARDS increased postoperative respiratory morbidity, and then increased surgical mortality after surgical repair of acute type A aortic dissection by means of DHCA.

Aortic Dissection and Severe Renal Failure 6 Years After Kidney Transplantation

We report the case of a patient with long-term history of hypertension, presenting with transient neurological disorders and severe graft failure several years after kidney transplantation. Cause of end-stage renal disease was hypertensive nephrosclerosis. Chronic hemodialysis lasted for 1 year. After transplantation and throughout follow-up, serum creatinine ranged from 200 to 230 μmol/L and maintenance immunosuppression included sirolimus and low-dose steroids. Six years after transplantation, the patient presented with right hip pain radiating to the lower back, transient aphasia, confusion, and hemiparesis. Surprisingly, progressive anuria was established requiring dialysis. After numerous nonconclusive investigations including renal histology, a contrast computed tomography scan discovered a Stanford B aortic dissection from the left common carotid artery and left subclavian artery to bilateral internal and external iliac arteries, including the right femoral artery. No surgical treatment was opted and hemodialysis, tight control of blood pressure and oral anticoagulation were established. Immunosuppression was lightened to low-dose steroids alone. After 8 months, chronic dialysis was stopped, and today, 22 months after the diagnosis of aortic dissection, the patient is doing well with a still functioning graft (creatinine, 377 μmol/L; modification of diet in renal disease-glomerular filtration rate, 15 mL/min), and without any other immunosuppression than low-dose steroids.

Adaptive servo-ventilation suppresses elevation of C-reactive protein and sympathetic activity in acute uncomplicated type B aortic dissection

OBJECTIVES

The aim of this prospective, randomized study was to investigate the effects of adaptive servo-ventilation (ASV), based on haemodynamic parameters, sympathetic status and respiratory conditions in patients with acute uncomplicated type B aortic dissection.

METHODS

We enrolled 28 patients with acute uncomplicated type B aortic dissection requiring antihypertensive therapies, who had been admitted within 24 h from onset. Study subjects were randomly assigned either to the ASV group (n = 14) or to the non-ASV group (n = 14).

RESULTS

Antihypertensive therapy at an acute phase led to significant reduction in blood pressure in both groups. Heart rate significantly dropped in the ASV group. In the non-ASV group, noradrenaline (746 ± 343 to 912 ± 402 pg/ml, P = 0.033) and dopamine (30 ± 21 to 42 ± 28 pg/ml, P = 0.015) significantly increased at 1 h after admission. Low frequency/high frequency ratios significantly decreased in the ASV group (2.1 ± 1.6 to 1.7 ± 1.1, P = 0.045). During follow-up at the subacute period, pleural effusion significantly increased in the non-ASV group (649 ± 611 vs 190 ± 292%, P = 0.033). Peak C-reactive protein (CRP) had a significant positive correlation with pleural effusion volume (P = 0.039) and was significantly greater in the non-ASV group (15.5 ± 6.3 vs 8.5 ± 6.1 mg/dl, P= 0.009).

CONCLUSIONS

In acute type B aortic dissection, ASV was considered to have suppressed the development of sympathetic nervous activity, pleural effusion and elevation of peak CRP.

The hemostatic disturbance in patients with acute aortic dissection: A prospective observational study

Coagulopathy is still a frequent complication in the surgical treatment of acute aortic dissection. However, the physiopathology of surgically induced coagulopathy has never been systematically and comprehensively studied in patients with acute aortic dissection. The aim of the present study was to describe the perioperative hemostatic system in patients with acute aortic dissection.The 87 patients who underwent aortic arch surgery for acute Stanford type A aortic dissection from January 2013 to September 2015 were enrolled in this study. The perioperative biomarkers of hemostatic system were evaluated using standard laboratory tests and enzyme-linked immunosorbent assays (ELISAs) at 5 time points: anesthesia induction (T1), lowest nasopharyngeal temperature (T2), protamine reversal (T3), 4 hours after surgery (T4), and 24 hours after surgery (T5).The ELISAs biomarkers revealed activation of coagulation (thrombin-antithrombin III complex [TAT] and prothrombin fragment 1 + 2 [F1 + 2] were elevated), suppression of anticoagulation (antithrombin III [AT III] levels were depressed), and activation of fibrinolysis (plasminogen was decreased and plasmin-antiplasmin complex [PAP] was elevated). The standard laboratory tests also demonstrated that surgery resulted in a significant reduction in platelet counts and fibrinogen concentration.Systemic activation of coagulation and fibrinolysis, and inhibition of anticoagulation were observed during the perioperative period in patients with acute aortic dissection. Indeed, these patients exhibited consumption coagulopathy and procoagulant state perioperatively. Therefore, we believe that this remarkable disseminated intravascular coagulation (DIC)-like coagulopathy has a high risk of bleeding and may influence postoperative outcome of patients with acute aortic dissection.

Preoperative Predictors of Long-Term Mortality after Elective Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm

OBJECTIVE

This study aimed to clarify long-term mortality and its predictors in patients with abdominal aortic aneurysm (AAA) who underwent endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

Patients with AAA who underwent elective EVAR at Tokyo Medical and Dental University hospital between 2008 and 2011 were reviewed. The patients' data were retrospectively collected from medical records.

RESULTS

Sixty-four patients were identified for this study. In long-term follow-up, the survival rate was significantly lower in patients with high preoperative C-reactive protein (CRP) levels. Patients with obstructive lung disease (FEV1/FVC <70%) or anemia tended to have a poorer prognosis but the association was not statistically significant. Age, concurrent hyperlipidemia, and blood pressure levels were not predictors of mortality rates.

DISCUSSION

High CRP level, COPD, and anemia reflect inflammation, which is associated with the pathogenesis of AAA. These inflammatory markers are predictors of long-term mortality after EVAR for AAA as well as for other diseases.

CONCLUSIONS

A high preoperative CRP level was a predictor of increased long-term mortality in patients with AAA who underwent EVAR. No specific leading causes of death were identified for this increase in the mortality rate.

Neutrophil to lymphocyte ratio: a novel marker for predicting hospital mortality of patients with acute type A aortic dissection

Introduction:

The inflammatory process has been reported to be associated with aortic dissection (AD) from the development to the prognosis. The aim of the study was to investigate a relationship between the neutrophil to lymphocyte ratio (NLR) and in-hospital outcomes in patients with acute aortic dissection (AAD) who underwent surgical repair.

Methods:

One hundred and eighty-four patients who were admitted with the diagnosis of type A AAD who underwent surgical repair at two large tertiary hospitals. According to their NLR, 91 patients had high NLR (>6.0) and 93 patients had low NLR (⩽6.0).

Results:

The frequency of major bleeding, hospital-related infection, multi-organ dysfunction and mortality in hospital were higher in the high NLR group compared to the low NLR group. NLR, WBC count and operation duration were found to be independent predictors for in-hospital mortality.

Conclusions:

The novel inflammatory marker NLR may be used to predict worse outcomes and hospital mortality in patients with AAD treated by surgical repair.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective

Acute kidney injury (AKI) frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair (TEVAR) of type B acute aortic dissection (AAD) remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD.

Methods

Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease: improving global outcomes criteria before TEVAR.

Results

The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI (50.0% vs. 4.2%, respectively; P < 0.001), including acute renal failure (21.4% vs. 0, respectively; P < 0.001), and they increased with severity of AKI (P < 0.001). The maximum levels of body temperature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission (OR: 1.023; 95% CI: 1.003–1.044; P = 0.0238) and bilateral renal artery involvement (OR: 19.076; 95% CI: 1.914–190.164; P = 0.0120) were strong predictors of preoperative AKI.

Conclusions

Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Impact of d-Dimer Levels on Admission on Inhospital and Long-Term Outcome in Patients With Type A Acute Aortic Dissection

Limited studies with relatively small sample sizes have reported that elevated d-dimer levels on admission were associated with increased risk of short-term mortality in patients with type A acute aortic dissection (AAD). However, there were unavailable data regarding the impact of admission d-dimer levels on long-term outcomes. Our present study aimed to evaluate the association of admission d-dimer levels with both inhospital and long-term all-cause mortality in patients with type A AAD. A total of 212 consecutive patients with type A AAD were enrolled. d-Dimer levels were measured on admission, and patients were followed up prospectively. The primary end points were inhospital and long-term all-cause mortality. The median length of follow-up was 18.8 months (interquartile range 6.7 to 24.4 months). The inhospital and long-term all-cause mortality rates were 12.7% and 12.4%, respectively. Compared with the survivors, the nonsurvivors had significantly higher d-dimer levels (p <0.001). When divided into 4 groups according to admission d-dimer quartiles, patients in Q4 (>6.10 μg/ml) had the highest inhospital and long-term mortality among groups. After multivariate adjustment, the d-dimer level in Q4 (>6.10 μg/ml) was an independent risk factor for inhospital mortality (hazard ratio [HR] 6.12, 95% confidence interval 1.35 to 27.89, p = 0.019) in addition to surgical treatment; however, this was not an independent predictor for long-term mortality. In conclusion, our study with a relatively large sample size suggested that elevated admission d-dimer levels (>6.10 μg/ml) might be a predictor for increased risk of inhospital mortality, and urgent-emergent surgery might be needed in patients with elevated d-dimer levels on admission. However, d-dimer levels at admission failed to predict long-term mortality.

C-reactive protein, not cardiac troponin T, improves risk prediction in hypertensives with type A aortic dissection

BACKGROUND

The aim of the study was to evaluate prognostic role of inflammatory biomarkers, cardiac troponin T (cTnT) and D-dimer in type A acute aortic dissection (AAD) and to examine whether they might help in risk stratification beyond values of International Registry of Acute Aortic Dissection (IRAD) score.

METHODS

Baseline biomarkers were determined in 54 consecutive predominantly hypertensive patients with type A AAD and evaluated for in-hospital mortality.

RESULTS

After multivariable adjustment, the independent predictors of outcome were age (OR = 1.09; 95% CI 1.02-1.18), treatment strategy (OR = 0.11; 95% CI 0.02-0.06) and C-reactive protein (CRP) either as binary (OR = 7.06; 95% CI 1.34-37.36) or continuous variable (OR = 1.10; 95% CI 1.01-1.21). cTnT did not independently influence mortality. Receiver- operating characteristic (ROC) curve analysis showed significant link between CRP and outcome (area under the ROC curve, AUC = 0.79; p < 0.01). Values of CRP > 9.8 mg/l had 83% sensitivity and 80% specificity for predicting in-hospital mortality. Addition of CRP to IRAD score improved prediction of short-term outcome, AUC increased from 0.74 to 0.89 (p = 0.004).

CONCLUSION

Admission CRP has independent prognostic value in type A AAD and the addition of CRP to IRAD score improved discriminative capacity of in-hospital mortality irrespective of symptom duration and treatment strategy.

Biomarkers for diagnosis and prognostic stratification of aortic dissection: challenges and perspectives

Aortic dissection (AD) is a severe vascular disease associated with major morbidity and mortality. The diagnosis of AD requires the performance of urgent aortic imaging exams such as computed tomography angiography, but the decision to perform these exams now essentially relies on clinical judgment. Several studies have identified a range of potential biomarkers stemming from the aortic extracellular matrix (matrix metalloproteinases, TGF-β, soluble elastin fragments), vascular smooth muscle cells (smooth muscle myosin heavy chain, creatine kinase, calponin), coagulation (d-dimer, platelets) and inflammation (C-reactive protein), whose circulating levels increase in patients affected by AD. Biomarkers of AD could be potentially used to screen patients with compatible symptoms, to identify patients at higher risk of AD, to rule out AD in patients with non-high clinical probability of AD and/or to obtain prognostic stratification of affected patients. This review will summarize available data and discuss present and future perspectives of circulating biomarkers for the diagnosis and prognostic stratification of AD.

Neutrophil-lymphocyte ratio may predict in-hospital mortality in patients with acute type A aortic dissection

INTRODUCTION

Inflammation has been reported to be associated with aortic dissection (AD), from the development to the prognosis of AD. In this study we aimed to find the role of the neutrophil-lymphocyte ratio (NLR) in the prediction of clinical events in patients with acute AD type A.

PATIENTS AND METHODS

The study comprised 37 patients who were hospitalized at our center between 2009 and 2013 with the diagnosis of acute AD type A.

RESULTS

The mean NLR was significantly higher in patients with pericardial effusion than those without effusion (15.6 ± 11.4 vs. 7.5 ± 4.8, p = 0.005). An NLR value > 8.51 yielded an area under the curve (AUC) value of 0.829 [95 % confidence interval (CI) 0.674-0.984, p = 0.004], which demonstrated a sensitivity of 77 % and specificity of 74 % for the prediction of mortality.

CONCLUSIONS

The novel inflammatory marker NLR could be used to predict pericardial effusion and in-hospital mortality in patients with acute AD type A.

Novel biomarkers for risk stratification and identification of life-threatening cardiovascular disease: troponin and beyond

Chest pain and other symptoms that may represent acute coronary syndromes (ACS) are common reasons for emergency department (ED) presentations, accounting for over six million visits annually in the United States [1]. Chest pain is the second most common ED presentation in the United States. Delays in diagnosis and inaccurate risk stratification of chest pain can result in serious morbidity and mortality from ACS, pulmonary embolism (PE), aortic dissection and other serious pathology.

Because of the high morbidity, mortality, and liability issues associated with both recognized and unrecognized cardiovascular pathology, an aggressive approach to the evaluation of this patient group has become the standard of care. Clinical history, physical examination and electrocardiography have a limited diagnostic and prognostic role in the evaluation of possible ACS, PE, and aortic dissection, so clinicians continue to seek more accurate means of risk stratification. Recent advances in diagnostic imaging techniques particularly computed-tomography of the coronary arteries and aorta, have significantly improved our ability to diagnose life-threatening cardiovascular disease.

In an era where health care utilization and cost are major considerations in how disease is managed, it is crucial to risk-stratify patients quickly and efficiently. Historically, biomarkers have played a significant role in the diagnosis and risk stratification of several cardiovascular disease states including myocardial infarction, congestive heart failure, and pulmonary embolus. Multiple biomarkers have shown early promise in answering questions of risk stratification and early diagnosis of cardiovascular pathology however many do not yet have wide clinical availability. The goal of this review will be to discuss these novel biomarkers and describe their potential role in direct patient care.

Biological features of thoracic aortic diseases. Where are we now, where are we heading to: established and emerging biomarkers and molecular pathways

Thoracic aortic aneurysms (TAAs) and aortic dissections (ADs) are among the main causes of mortality and morbidity in Western countries. For this reason, the diagnosis, prevention and prediction of TAAs and ADs have become a very active area of research; in fact, it is important to monitor and predict the evolution of these diseases over time. It is also critical, in cases of doubtful diagnosis, to receive some guidance from biochemical assays, particularly in the case of ADs. Although biological testing for disease prediction has already been discussed several times, the role of biomarkers in TAAs and ADs is still under discussion for routine patient screening, periodical follow-up or for prompt diagnosis in emergency conditions. In this review, we update the current knowledge and new trends regarding the role of biomarkers in thoracic aortic diseases, focusing on established and emerging biomarkers in the fields of genetics, inflammation, haemostasis and matrix remodelling as well as on substances released upon cell damage. Other than D-dimer, a sensitive but not a specific marker for the diagnosis of AD that has been widely tested by several authors and currently seems a viable option in ambiguous cases, the remaining markers have been most frequently assessed in limited or mixed patient populations. This currently precludes their widespread adoption as diagnostic or prognostic tools, even if many of these markers are conceptually promising. In years to come, we expect that future studies will further clarify the diagnostic and prognostic features of several established and emerging biomarkers that, to date, are still in the translational limbo separating biological discovery from a practical clinical role.

Current imaging techniques and potential biomarkers in the diagnosis of acute aortic dissection

Acute dissection of the thoracic aorta (AAD) is a potentially catastrophic disease, with significant morbidity and mortality, which remain unchanged over the last decade. Survival rate has been shown to be directly related to prompt diagnosis and precise management; however diagnosis of the disease remains time-consuming, not readily available, and lacking in sensitivity and specificity. The current approach when diagnosing AAD relies heavily on various imaging techniques, including chest radiograph, echocardiography, computed tomography and magnetic resonance imaging scans. Nevertheless, the door remains open for the incorporation of biochemical tests to aid in detecting AAD. This article will review the imaging modalities currently employed in the management of AAD, as well as a discussion of the potential role of several biomarkers in AAD. To date, imaging is the diagnostic tool for AAD however, technical and logistical limitations limit the use of imaging in various circumstances. Current available biomarkers such as D-dimer and C-reactive protein are under-utilized in many cases, mainly due to their non-specificity in diagnosing AAD. Over the last decade, many biomarkers have been proposed for use in AAD, with several showing promising results – including: smooth muscle myosin heavy chain, calponin, soluble elastin fragments and transforming growth factor β. Extensive research is being undertaken to define the roles of these novel biomarkers in the management of AAD.

Elevated plasma D-dimer and hypersensitive C-reactive protein levels may indicate aortic disorders

OBJECTIVE

D-dimer and C-reactive protein are of diagnostic and predictive values in patients have thrombotic tendency, such as vascular thrombosis, coronary artery disease and aortic dissection. However, the comparative study in these biomarkers between the patients with acute aortic dissection and coronary artery disease has not been sufficiently elucidated.

METHODS

Consecutive surgical patients for acute type A aortic dissection (20 patients), aortic aneurysm (nine patients) or coronary artery disease (20 patients) were selected into this study. Plasma from preoperative blood samples and supernatant of aortic homogenate of the surgical specimens were detected for D-dimer and hypersensitive C-reactive protein (hs-CRP).

RESULTS

Plasma D-dimer and hs-CRP values in type A aortic dissection or aortic aneurysm were much higher than in coronary artery disease patients or the healthy control (for D-dimer, aortic dissection: coronary artery disease, 0.4344 ± 0.2958 µg/ml vs. 0.0512 ± 0.0845 µg/ml, P < 0.0001; aortic dissection: healthy control, 0.4344 ± 0.2958 µg/ml vs. 0.1250 ± 0.1295 µg/ml, P = 0.0005; aortic aneurysm: coronary artery disease, 0.4200 ± 0.4039 µg/ml vs. 0.0512 ± 0.0845 µg/ml, P = 0.0013; and aortic aneurysm: healthy control, 0.4200 ± 0.4039 µg/ml vs. 0.1250 ± 0.1295 µg/ml, P = 0.0068; and for hs-CRP, aortic dissection: coronary artery disease, 4.400± 3.004 mg/L vs. 1.232±0.601 mg/L, P < 0.0001; aortic dissection:healthy control, 4.400 ± 3.004 mg/L vs. 0.790 ± 0.423 mg/L, P < 0.0001; aortic aneurysm: coronary artery disease, 2.314 ± 1.399 mg/L vs. 1.232 ± 0.601 mg/L, P = 0.0084; aortic aneurysm: healthy control, 2.314 ± 1.399 mg/L vs. 0.790 ± 0.423 mg/L, P = 0.0002; and coronary artery disease: healthy control, 1.232 ± 0.601 mg/L vs. 0.790 ± 0.423 mg/L, P = 0.0113). Besides, there were close correlations between plasma D-dimer and hs-CRP in overall (Y = 4.8798X + 0.8138, r² = 0.4497, r = 0.671, P < 0.001), aortic dissection (Y = 2.6298X + 1.2098, r² = 0.5762, r = 0.759, P < 0.001), and aortic aneurysm (Y = 7.1341X + 1.3006, r² = 0.4935, r = 0.7025, P = 0.048) groups rather than in the coronary artery disease or healthy control subjects. In addition, there were no significant differences between D-dimer and hs-CRP values of the aortic supernatant among groups except for undetectable D-dimer in the aortic supernatant of the coronary artery disease group.

CONCLUSIONS

The patients with acute aortic dissection and aortic aneurysm may reflect the extensive inflammatory reaction and severe coagulopathies in the patients with acute type A aortic dissection, and thoracic aortic aneurysm in comparison to the coronary patients and healthy control individuals. The detections after onset in the patients with acute chest pain may help making a differential diagnosis between the aortopathies and ischemic heart disease. The scanty significance of the tissue biomarkers may preclude their diagnostic value in clinical practice.

Utility of measuring C-reactive protein for prediction of in-hospital events in patients with acute aortic dissection

Controlling blood pressure is essential for prevention of events after acute aortic dissection (AAD). However, in some instances a cardiac event occurs despite controlled blood pressure, and its prediction is difficult. We continuously monitored C-reactive protein (CRP) in patients receiving medical treatment for AAD and retrospectively examined the utility of CRP measurement for prediction of in-hospital events. Five hundred and eight patients were diagnosed as having AAD between 1993 and 2009, 240 of whom underwent antihypertensive medical therapy. These subjects were 156 males and 84 females, average age 67.4 years, with 68 cases of Stanford type A and 172 cases of Stanford type B. C-reactive protein was measured in all patients daily until a peak; subsequently, CRP was measured 2-3 times per week following the peak until discharge. In the event-free group CRP demonstrated a peak on the 4th day after the onset (average 13.7 mg/dl), then gradually decreased to an average of 4.6 mg/dl 4 weeks later, displaying a "gradual decay" pattern. Despite controlled systolic arterial pressure of approximately 120 mmHg, 7 of 68 Stanford A cases (10.3 %) and 8 of 172 Stanford B cases (4.7 %) developed cardiovascular events. The group characterized by events exhibited a CRP pattern distinct from that of the event-free group, i.e., prolonged elevation and/or re-elevation. We demonstrated that the CRP pattern could provide information regarding prediction of cardiovascular events. Prolonged elevation or re-elevation of CRP may indicate the necessity of (1) application of computed tomography or magnetic resonance imaging, (2) more rigorous blood pressure management, or (3) early surgical intervention.

Coronary artery bypass graft surgery up-regulates genes involved in platelet aggregation

BACKGROUND

During and shortly after coronary artery bypass graft (CABG) surgery, there is an increase in thromboembolic events. CABG, a strong inflammatory stimulus, is associated with a hypercoaguable state. Platelets might contribute to this hypercoaguable state because they have a pivotal role in thrombosis. In the days following surgery there is augmented platelet regeneration in response to the inflammatory stimulus.

OBJECTIVES

The aim of this study was to investigate any changes in platelet mRNA profiles to test the hypothesis that post-CABG surgery platelets are associated with a prothrombotic state.

METHODS

Blood was sampled and platelets purified from 11 patients before and 3-6 days after CABG. Gene expression profiling was performed using low density array (LDA) plates for seven of the patients.

RESULTS

Forty-five genes were examined and those significantly up-regulated were glycoprotein (GP)IIb, GPIIIa and cyclooxygenase-1 (COX-1). These findings were confirmed in four more patients, including flow cytometry analysis of the GPIIb/IIIa receptor.

CONCLUSIONS

CABG surgery up-regulates mRNA and protein levels of proteins that are key players in platelet aggregation. Marked elevation of GPIIb/IIIa mRNA levels results in significantly increased GPIIb/IIIa expression in platelets post-CABG surgery, which may be a reason for increased thrombus formation and myocardial infarction after CABG.

Plasma concentrations of interleukin-6, C-reactive protein, tumor necrosis factor-α and matrix metalloproteinase-9 in aortic dissection

BACKGROUND

The role of inflammation in aortic dissection (AD) has not fully been investigated. We evaluated the potential relationships between interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and matrix metalloproteinase-9 (MMP-9) and AD.

METHODS

Plasma concentrations of IL-6, TNF-α, MMP-9 and CRP were determined in 64 acute AD patients, 42 patients with chronic AD, 98 patients with hypertension alone, and 96 healthy subjects.

RESULTS

IL-6 concentrations were higher in acute AD than that in hypertension and healthy controls (10.98±2.38 vs. 3.79±1.56 and 3.32±1.60 pg/ml, P<0.05, respectively). Increased CRP concentrations were found in acute AD compared with chronic AD and hypertension as well as healthy subjects (13.48±3.74 vs. 4.12±2.99, 1.62±0.65 and 1.12±0.35 mg/l, P<0.001, respectively). Higher MMP-9 concentrations were detected in acute AD, chronic AD and hypertension compared with healthy controls (37.75±9.38, 55.78±6.41 and 31.03±7.94 vs. 21.24±7.28 ng/ml, P<0.05, P<0.001 and P<0.05, respectively), and in the dead compared to the survived (107.29±9.38 vs. 86.80±7.93 ng/ml, P<0.001) among acute AD patients. In acute AD, the time after onset had positive correlation with TNF-α (r=0.497, P=0.000), and negative correlation with CRP (r=-0.424, P=0.000). Plasma CRP levels decreased significantly when the onset time increased (P=0.013). Moreover, in the patients with acute AD who underwent surgery and stenting, plasma MMP-9 concentrations increased immediately after surgical treatment and stenting, and reached the peak values at 24h, then decreased at 1 week (P<0.001).

CONCLUSIONS

Our findings confirmed and extended previous studies that increased plasma inflammatory markers were significantly associated with AD.

Acute phase protein concentrations in dogs with nasal disease

The concentrations of C-reactive protein (CRP), serum amyloid A, haptoglobin (Hp) and α(1)-acid glycoprotein were measured in dogs with clinical signs of nasal disease and compared with those of healthy dogs in order to determine the expression of these proteins in cases of canine nasal disease. A significant difference (P<0.001) between the symptomatic group and the control group was found for both CRP and Hp. Among the animals with nasal disease, a significant intergroup difference (P<0.05) was found in the expression of Hp between dogs with aspergillosis and those with chronic rhinitis.

Biomarkers in aortic dissection

Aortic dissection (AD) is a severe cardiovascular disease with high mortality and morbidity, which is characterized by acute onset and rapid progress. Mechanically, it has been considered that circulating blood flows into the media of the aorta through the rupture of the intima forming true and false lumens. Generally, its pathologic process is considered as follows: initially, inflammatory reaction, inflammatory cells infiltration in aortic wall, and then apoptosis of vascular smooth muscle cells, degenerating of aortic media, elastin fracture, and degradation. At last, the ingredients of the aorta are destroyed and lead to aortic dilatation, aneurysm formation, dissection and rupture. Currently, several biomarkers in peripheral blood including C-reactive protein (CRP), matrix metalloproteinases (MMPs), soluble elastin fragments (sELAF), D-dimer, smooth muscle myosin heavy chain, calponin, N-terminal pro-brain natriuretic peptide (NT-proBNP), big endothelin-1 (Big ET-1), genetic markers and so on, have been demonstrated to play a major role in evaluation of AD, for example, making early diagnosis and classifying of AD. Additionally, those markers may also guide our treatment therapies and predict the prognosis. The aims of this review mainly focus on the clinical implications of the biomarkers in AD.

Biomarkers in acute aortic dissection and other aortic syndromes

Acute aortic syndromes have an incidence of >30 per million per annum and a high mortality without definitive treatment. Survival may relate to the speed of diagnosis. Although pain is the most common symptom, there is a large fraction of patients in whom the diagnosis may be mistaken or overlooked. Currently, a high index of clinical suspicion is the chief prompt that diverts a patient into a definitive algorithm of imaging investigations. Although there is no point-of-care biochemical test that can be reliably used to positively identify dissection, biomarkers are available that could accelerate the diagnostic pathway and thereby expedite treatment.