Association of C-reactive protein and myocardial perfusion in patients with ST-elevation acute myocardial infarction

Serum C-reactive protein is associated with earlier mortality across different interstitial lung diseases

BACKGROUND AND OBJECTIVE

The acute-phase protein C-reactive protein (CRP) is known to be associated with poor outcomes in cancer and cardiovascular disease, but there is limited evidence of its prognostic implications in interstitial lung diseases (ILDs). We therefore set out to test whether baseline serum CRP levels are associated with mortality in four different ILDs.

METHODS

In this retrospective study, clinically measured CRP levels, as well as baseline demographics and lung function measures, were collected for ILD patients first presenting to the Royal Brompton Hospital between January 2010 and December 2019. Cox regression analysis was used to determine the relationship with 5-year mortality.

RESULTS

Patients included in the study were: idiopathic pulmonary fibrosis (IPF) n = 422, fibrotic hypersensitivity pneumonitis (fHP) n = 233, rheumatoid arthritis associated ILD (RA-ILD) n = 111 and Systemic Sclerosis associated ILD (SSc-ILD) n = 86. Patients with a recent history of infection were excluded. Higher CRP levels were associated with shorter 5-year survival in all four disease groups on both univariable analyses, and after adjusting for age, gender, smoking history, immunosuppressive therapy and baseline disease severity (IPF: HR (95% CI): 1.3 (1.1-1.5), p = 0.003, fHP: 1.5 (1.2-1.9), p = 0.001, RA-ILD: 1.4 (1.1-1.84), p = 0.01 and SSc-ILD: 2.7 (1.6-4.5), p < 0.001).

CONCLUSION

Higher CRP levels are independently associated with reduced 5-year survival in IPF, fHP, RA-ILD and SSc-ILD.

ROUTINELY AVAILABLE BIOMARKERS AS LONG-TERM PREDICTORS OF DEVELOPING SYSTOLIC DYSFUNCTION IN COMPLETELY REVASCULARIZED PATIENTS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION

The aim of this study was to assess the efficacy of high-sensitivity C-reactive protein (hsCRP), cardiac troponin T (cTnT) and creatine kinase (CK) as long-term predictors of reduced systolic function in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with complete revascularization. This prospective study evaluated consecutive patients with acute STEMI who had normal left ventricular ejection fraction (LVEF ≥50%) at admission with single-vessel disease and underwent complete revascularization. Blood samples were collected from admission to day 7. The primary endpoint was reduction of LVEF <50% after 12 months. The study included 47 patients, median age 59±10 years, 74.5% of them men. Patients who developed systolic dysfunction (LVEF <50%) had significantly higher mean values of cTnT after 24 hours (5.11 vs. 2.82 µg/L, p=0.010) and peak values of CK (3375.5 vs. 1865 U/L, p=0.008). There was no significant relation between hsCRP and development of reduced LVEF (p=0.541). In conclusion, cTnT and CK could serve as long-term predictors of reduced left ventricular systolic function (<50%) in acute STEMI patients with normal systolic function at admission, single-vessel coronary disease and complete revascularization during primary PCI.

Translational overview of cytokine inhibition in acute myocardial infarction and chronic heart failure

Many cytokines are currently under investigation as potential target to improve cardiac function and outcome in the setting of acute myocardial infarction (MI) or chronic heart failure (HF). Here we aim to provide a translational overview of cytokine inhibiting therapies tested in experimental models and clinical studies. In various experimental studies, inhibition of interleukin-1 (IL-1), -6 (IL-6), -8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), CC- and CXC chemokines, and tumor necrosis factor-α (TNF-α) had beneficial effects on cardiac function and outcome. On the other hand, neutral or even detrimental results have been reported for some (IL-1, IL-6, IL-8, and MCP-1). Ambivalence of cytokine function, differences in study designs, treatment regimens and chosen endpoints hamper the translation of experimental research into clinical practice. Human studies are currently limited to IL-1β inhibition, IL-1 receptor antagonists (IL-1RA), IL-6 receptor antagonists (IL-6RA) or TNF inhibition. Despite favorable effects on cardiovascular events observed in retrospective cohort studies of rheumatoid arthritis patients treated with TNF inhibition or IL-1RA, most prospective studies reported disappointing and inconsistent results. Smaller studies (n < 100) generally reported favorable results of anticytokine therapy on cardiac function, but only one of the larger studies (n > 100) evaluating IL-1β inhibition presented positive results on outcome. In conclusion, of the 10 anticytokine therapies tested in animals models beneficial effects have been reported in at least one setting. In larger clinical studies, findings were unsatisfactory in all but one. Many anticytokine therapies with promising animal experimental data continue to require further evaluation in humans.

High-sensitivity C-reactive protein and long term reperfusion success of primary percutaneous intervention in ST-elevation myocardial infarction

AIMS

In STEMI patients, success of reperfusion of primary PCI predicts cardiac remodeling and clinical outcome. This success may depend on inflammation. We aimed to investigate the association between inflammation and reperfusion success, left ventricular function and long-term mortality in STEMI patients.

METHODS

In 376 consecutive STEMI patients of the GIPS-III trial hs-CRP levels were measured at baseline, 2weeks, 7weeks and 4months post-PCI. Myocardial blush grade was used to determine success of myocardial reperfusion. In multivariate models sex, age, hs-CRP levels at baseline, NT-proBNP levels at baseline, ischemia time, heart rate, TIMI flow, and CK, CKMB and troponin AUC were included. Follow-up was complete until 4months.

RESULTS

Baseline hs-CRP levels were 2.1mg/l (IQR 0.5-4.2mg/l). hs-CRP levels were associated with impaired reperfusion (OR 1.239, 95% CI 1.006-1.527) and remained higher compared to patients with normal reperfusion up to 2months after PCI (hs-CRP 1.9mg/l (IQR 0.9-3.7mg/l) versus 1.5mg/l (IQR 0.7-2.7mg/l), p=0.041). In multivariate analysis baseline hs-CRP levels remained independently associated with impaired reperfusion. In patients with impaired reperfusion, hs-CRP and NT-proBNP levels remained higher during 4months of follow-up. No correlation was observed between hs-CRP at baseline and left ventricular function at 4months. The number of events was small and we observed no differences in mortality.

CONCLUSION

Increased hs-CRP levels at presentation are associated with impaired microvascular reperfusion after PCI in STEMI patients and remain higher until 2months follow-up.

Effect of Baseline Red Blood Cell Distribution Width on Short- and Intermediate-term Mortality of Patients Under Primary Percutaneous Coronary Intervention: A Survival Analysis

OBJECTIVE

Considering the limited studies specifically evaluating the role of Red blood cell distribution width (RDW) in primary percutaneous coronary intervention (PCI), we aimed to investigate the role of baseline RDW in short- and intermediate-term cardiovascular events in ST-elevation myocardial infarction patients under primary PCI.

METHODS

This is a historical cohort registry analysis of 1161 patients with ST-elevation myocardial infarction under primary PCI. According to inclusion criteria, 838 patients were allocated for analysis. Patients with RDW levels of 13.6% or higher were considered as high RDW group (third tertile). All the individuals were followed up for in-hospital and 6-month mortality along with readmission and composite major adverse cardiac events.

RESULTS

In-hospital deaths occurred in 53 (6.3%) patients and at 6-month follow-up 79 (9.4%) cases of mortality were documented. In-hospital and 6-month mortalities showed a significant trend in favor of high RDW group (13.3% vs. 5.9%, P = 0.003; 19.7% vs. 7.9%, P < 0.001, respectively). Multivariate analysis showed that high RDW was significantly and independently associated with higher rates of 6-month mortality (hazard ratio: 2.909; 95% confidence interval: 1.166-7.257; P = 0.022). RDW was also a significant predictor for 6-month mortality independent of anemia (hazard ratio: 2.811; 95% confidence interval: 1.047-7.551; P = 0.040).

CONCLUSIONS

We found a significant association between high RDW and in-hospital and 6-month mortality as well as the occurrence of major adverse cardiac event. Meanwhile RDW was found to be a significant predictor for 6-month mortality independent of anemia. Thus, it would be beneficial to use RDW as a risk stratification index to identify high risk intent-to-treat patients.

Concordance of angiographic and electrocardiographic indexes of microvascular obstruction: myocardial haemorrhage role

BACKGROUND

Angiographic and electrocardiographic (ECG) indexes of microvascular obstruction (MVO) have been described. We aimed at assessing by cardiac magnetic resonance (CMR) anatomical features underlying concordance between them.

METHODS

Forty-one patients were enrolled. Patients presented with neither angiographic nor ECG indexes of MVO (without MVO) (44%), with either angiographic or ECG indexes of MVO (discordant with MVO) (22%) or with both angiographic and ECG indexes of MVO (concordant with MVO) (34%). All patients underwent in-hospital CMR. Echocardiographic data obtained after 6 months were compared with those obtained in hospital.

RESULTS

Concordant patients with MVO had larger infarct size, lower myocardial salvage index and higher rate of myocardial haemorrhage (all assessed by CMR) [33% (25-41%), 15% (10-29%) and 88%, respectively] as compared with patients without MVO [12% (9-16%), 66% (52-79%) and 0%; Bonferroni-adjusted P < 0.001, Bonferroni-adjusted P < 0.001 and P < 0.001, respectively], or with discordant ones [25% (21-39%), 35% (20-48%) and 7%; Bonferroni-adjusted P = 0.03, Bonferroni-adjusted P = 0.002 and P = 0.04, respectively]. After 6 months, ejection fraction significantly decreased in concordant patients with MVO (P < 0.001) without significant changes in the other groups.

CONCLUSIONS

Concordance of angiographic and ECG indexes of MVO reflects more severe myocardial damage translating into unfavourable left ventricular remodelling.

Development and validation of a clinical risk score predicting the no-reflow phenomenon in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVE

The 'no-reflow' phenomenon after a primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is a strong predictor of both short- and long-term mortality. We therefore developed and prospectively validated a risk score system in order to identify STEMI patients at high risk in terms of no-reflow after primary PCI.

METHODS

The first part of our study used data from 1,615 STEMI patients who underwent primary PCI within 12 h from symptom onset. Using logistic regression, we derived a risk score to predict angiographic no-reflow using baseline clinical variables. From this score, we developed a simplified fast-track screen that can be used before reperfusion. In the second part of our study, we prospectively validated the score system using receiver-operating characteristic (ROC) curves with data from 692 STEMI patients.

RESULTS

The model included six clinical items: age, neutrophil count, admission plasma glucose, β-blocker treatment, time-to-hospital admission and Killip classes. The risk score system demonstrated a good risk prediction with a c-statistic of 0.757 (95% CI 0.732-0.781) based on ROC analysis.

CONCLUSION

A simple risk score system based on clinical variables is useful to predict the risk of developing no-reflow after pPCI in patients with STEMI.

Administration of a loading dose of atorvastatin before percutaneous coronary intervention prevents inflammation and reduces myocardial injury in STEMI patients: a randomized clinical study

BACKGROUND

Administration of a loading dose of atorvastatin 80 mg/d has been shown to be beneficial in patients with stable coronary artery disease and acute coronary syndromes. However, little is known about the impact and mechanism behind the beneficial effects of loading-dose atorvastatin treatment before percutaneous coronary intervention (PCI), especially for those patients experiencing cardiovascular inflammation in ST-segment elevation myocardial infarction (STEMI).

OBJECTIVE

The goal of this randomized clinical study was to investigate whether, before emergency PCI, administration of loading-dose atorvastatin therapy in STEMI patients inhibits inflammation and improves cardiac function during 24 weeks of follow-up.

METHODS

A total of 102 STEMI patients were enrolled into 3 groups: group A (n = 32) received 80 mg of atorvastatin before emergency PCI, post-PCI follow-up atorvastatin 40 mg for 4 weeks, and atorvastatin 20 mg for 20 weeks; group B (n = 32) received no pre-PCI loading dose of atorvastatin but did receive atorvastatin 40 mg for 4 weeks and then atorvastatin 20 mg for 20 weeks; and group C (n = 38) received only post-PCI atorvastatin 20 mg for 24 weeks.

RESULTS

No differences were found in baseline demographic and angiographic characteristics among the 3 groups. Patients in group A had the lowest plasma levels of high-sensitivity C-reactive protein (hs-CRP), B-type natriuretic peptide (BNP), and matrix metalloproteinase type 9 (MMP-9) (P < 0.05). Patients in group A also showed improvement in heart performance, with significant increases in their left ventricular ejection fraction. To a lesser extent, group B displayed reductions in the plasma levels of hs-CRP, BNP, and MMP-9 at later time points (P < 0.05). Compared with those in group C, patients in group B also exhibited significant improvement in left ventricular ejection fraction (P < 0.05).

CONCLUSIONS

Loading-dose atorvastatin therapy before emergency PCI reduced the inflammatory response and myocardial dysfunction in these STEMI patients by lowering hs-CRP, BNP, and MMP-9. Pre-PCI loading-dose atorvastatin treatment may help prevent inflammatory response and improve cardiac function in patients with acute coronary syndromes undergoing emergency PCI. ClinicalTrials.gov identifier: NCT01334671.

Established and novel biomarkers in ST-elevation myocardial infarction

Cardiac biomarkers assist in the diagnosis of and risk stratification in acute coronary syndromes. In ST-elevation myocardial infarction (STEMI), rapid diagnosis and initiation of reperfusion via primary percutaneous coronary intervention or fibrinolysis is often based on the clinical history and presenting ECG, but measurement of biomarkers in the early and/or late phases of STEMI may allow the selection of patients who are at increased or decreased risk of subsequent complications. Although the measurement of only three biomarkers (troponin, natriuretic peptides and C-reactive protein) are currently included in practice guidelines, more than 20 other novel cardiac biomarkers have been proposed to provide improved risk stratification after a STEMI.

Myocardial no-reflow in humans

In a variable proportion of patients presenting with ST-segment elevation myocardial infarction, ranging from 5% to 50%, primary percutaneous coronary intervention achieves epicardial coronary artery reperfusion but not myocardial reperfusion, a condition known as no-reflow. Of note, no-reflow is associated with a worse prognosis at follow-up. The phenomenon has a multifactorial pathogenesis including: distal embolization, ischemia-reperfusion injury, and individual predisposition of coronary microcirculation to injury. Moreover, it is spontaneously reversible in some patients, thus suggesting that it might be amenable to treatment also when we fail to prevent it. Several recent studies have shown that biomarkers and other easily available clinical parameters can predict the risk of no-reflow and can help in the assessment of the multiple mechanisms of the phenomenon. Several therapeutic strategies have been tested for the prevention and treatment of no-reflow. In particular, thrombus aspiration before stent implantation prevents distal embolization and has been recently shown to improve myocardial perfusion and clinical outcome as compared with the standard procedure. However, it is conceivable that the relevance of each pathogenetic component of no-reflow is different in different patients, thus explaining the occurrence of no-reflow despite the use of mechanical thrombus aspiration. Thus, in this review article, for the first time, we propose a personalized management of no-reflow on the basis of the assessment of the prevailing mechanisms of no-reflow operating in each patient.

CRP and the risk of atherosclerotic events

A large body of literature supports the idea that inflammation plays a pivotal role in all phases of atherosclerosis, from the fatty streak lesion formation to the acute coronary event due to vulnerable plaque rupture. Indeed, vascular inflammation contributes to the pathogenesis of atherosclerosis, and later in the disease process, it is a major determinant for the acute coronary syndromes. There are various inflammatory markers that have been shown to predict cardiovascular events. These include high-sensitivity C-reactive protein (hs-CRP), a simple downstream marker of inflammation, recently emerged as a major cardiovascular risk factor. Elevated baseline concentrations of hs-CRP are associated with the risk of atherosclerotic events in general populations and show a predictive value even in terms of secondary prevention, both in patients with chronic stable angina and acute coronary syndromes. In recent year, a lot of concerns have emerged about the experimental models used to study the role of CRP in atherosclerosis; moreover, the results of trials evaluating the clinical association between this molecules and outcome are still controversial. In this paper, we attempt to review the pathophysiological evidences about the link between CRP and atherosclerosis and, most notably, about its utility as a marker and risk predictor in various clinical settings. The identification of specific triggers and mechanisms of underlying inflammation and a better understanding of each step involved in this complex process might lead to new ways to manage patients with atherosclerosis, both in terms of primary and secondary prevention, and CRP still appears to be a suitable candidate for this purpose.

Biomarkers on admission for the prediction of cardiovascular events after primary stenting in patients with ST-elevation myocardial infarction

BACKGROUND

Several cardiac biomarkers have been shown to have predictive values for the development of cardiovascular disease and clinical outcome after events, and are now broadly used by clinicians. Little is known about the utility of these biomarker values on admission in ST-elevation myocardial infarction (STEMI) cases of primary drug-eluting stent (DES) implantation and intense medical therapy.

HYPOTHESIS

Because little is known about the utility of these biomarkers on admission in ST-elevation myocardial infarction (STEMI) in cases primary drug-eluting stent (DES) implantation and intense medical therapy, we evaluated clinical outcomes.

METHODS

We enrolled 207 consecutive STEMI patients treated with primary stenting (mean age, 57.3 +/- 12.0 y). We evaluated the association between B-type natriuretic peptide (BNP), cardiac troponin I (cTnI), high-sensitivity C-reactive protein (hs-CRP) on admission, and death, reinfarction, and new or worsening congestive heart failure (CHF) through 1 y.

RESULTS

In backward-elimination models including all biomarkers, only the cTnI level was retained as a predictor of 1-y CHF (odds ratio [OR]: 1.017, 95% confidence interval [CI]: 1.001-1.034, p = 0.039). There were no predictors in terms of 1-y death, reinfarction, and composite endpoint. When we applied a simple score system, in which patients were categorized on the basis of the number of elevated biomarkers, the 1-y risks of death (p = 0.600), reinfarction (p = 0.185), and composite endpoint (p = 0.620) did not increase in proportion to the number of elevated biomarkers on admission. One-y CHF only tended to increase according to the number of elevated biomarkers (p = 0.067).

CONCLUSIONS

The use of cardiac biomarkers on admission, in each or in combination, had only a minimal impact for the prediction of long-term cardiovascular events after primary stenting in STEMI patients.