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Gutiérrez-Leonard H, Martínez-Lara E, Fierro-Macías AE, Mena-Burciaga VM, Ronquillo-Sánchez MD, Floriano-Sánchez E, Cárdenas-Rodríguez N. Pregnancy-associated plasma protein-A (PAPP-A) as a possible biomarker in patients with coronary artery disease. Ir J Med Sci 2016; 186:597-605. [PMID: 27730332 DOI: 10.1007/s11845-016-1515-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in the Western world, and a major cause of this disease is atherosclerosis. Research has demonstrated that pregnancy-associated plasma protein A (PAPP-A) plays a role in cardiovascular disease, as evidenced by the association between PAPP-A and severity of heart damage. AIM The aim of this work was to investigate the correlation between PAPP-A concentrations in coronary and peripheral blood and certain clinicopathological factors and antioxidant enzyme activities in patients diagnosed with coronary artery disease. METHODS For 65 patients, arterial blood was obtained by puncturing the femoral or radial artery, and coronary blood was obtained via percutaneous coronary intervention. PAPP-A, catalase (CAT), superoxide dismutase-1 (SOD-1), and superoxide dismutase-2 (SOD-2) levels were measured using spectrometric methods. RESULTS Coronary PAPP-A levels were slightly higher than peripheral PAPP-A levels (81.25 ± 2.34 and 62 ± 3 ng/mL, respectively, P < 0.0001); these levels were correlated with each other (r = 0.6629, P < 0.001) but not with clinicopathological factors (P > 0.05). Coronary PAPP-A levels were significantly elevated among patients at risk for cardiovascular disease (P < 0.05). Antioxidant enzyme activities were significantly higher in coronary samples than in peripheral samples from subjects with ischemic cardiopathy secondary to atherosclerosis (P < 0.001). Neither coronary nor peripheral PAPP-A levels were correlated with antioxidant enzyme activities in patients with cardiopathy secondary to atherosclerosis (P > 0.05). CONCLUSIONS PAPP-A levels could be used as biomarkers to identify patients at risk of coronary artery disease.
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Affiliation(s)
- H Gutiérrez-Leonard
- Interventional Cardiology Laboratory, Hospital Central Militar, Secretaría de la Defensa Nacional, 11649, Mexico City, Mexico
| | - E Martínez-Lara
- Multidisciplinary Research Laboratory, Escuela Militar de Graduados de Sanidad, Secretaría de la Defensa Nacional, 11200, Mexico City, Mexico
| | - A E Fierro-Macías
- Section of Graduate Studies and Research, Escuela Superior de Medicina, Instituto Politécnico Nacional, 11340, Mexico City, Mexico
| | - V M Mena-Burciaga
- Section of Graduate Studies and Research, Escuela Superior de Medicina, Instituto Politécnico Nacional, 11340, Mexico City, Mexico
| | - M D Ronquillo-Sánchez
- Section of Graduate Studies and Research, Escuela Superior de Medicina, Instituto Politécnico Nacional, 11340, Mexico City, Mexico
| | - E Floriano-Sánchez
- Multidisciplinary Research Laboratory, Escuela Militar de Graduados de Sanidad, Secretaría de la Defensa Nacional, 11200, Mexico City, Mexico.
| | - N Cárdenas-Rodríguez
- Laboratory of Neurosciences, Instituto Nacional de Pediatría, 04530, Mexico City, Mexico.
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Zengin E, Sinning C, Zeller T, Rupprecht HJ, Schnabel RB, Lackner KJ, Blankenberg S, Westermann D, Bickel C. The utility of pregnancy-associated plasma protein A for determination of prognosis in a cohort of patients with coronary artery disease. Biomark Med 2015. [DOI: 10.2217/bmm.15.41] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Pregnancy-associated plasma protein-A (PAPP-A) is discussed as a biomarker representing unstable plaques in coronary artery disease (CAD). Methods: In this study 927 patients with CAD (534 with stable angina and 393 with acute coronary syndrome [ACS]) and 217 patients without CAD and measured PAPP-A levels were included. Follow-up for a median of 5 years was documented. Results: Rising quartiles of PAPP-A concentration had a higher cardiovascular mortality in the overall cohort of patients with CAD (p = 0.002) and the cohort with ACS (p = 0.01). Patients with suspected ACS below the LOD for troponin I but elevated PAPP-A levels had an increased cardiovascular mortality. A cut-off of 11.4 IU/l identified patients with a higher mortality during follow-up. Conclusion: Rising PAPP-A levels are prognostic in patients with CAD. PAPP-A levels were especially predictive in ACS patients with troponin below 10% CV of the 99th percentile for cardiovascular mortality.
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Affiliation(s)
- Elvin Zengin
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Christoph Sinning
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Tanja Zeller
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Hans-J Rupprecht
- Department of Medicine II, GPR Rüsselsheim, August-Bebel-Straße 59, 65428 Rüsselsheim, Germany
| | - Renate B Schnabel
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Karl-J Lackner
- Institute of Clinical Chemistry & Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Stefan Blankenberg
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Dirk Westermann
- Department of General & Interventional Cardiology, University Heart Center Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Central Hospital, Rübenacher Straße 170, 56072 Koblenz, Germany
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Wlazeł RN, Rysz J, Paradowski M. Examination of serum pregnancy-associated plasma protein A clinical value in acute coronary syndrome prediction and monitoring. Arch Med Sci 2013; 9:14-20. [PMID: 23515702 PMCID: PMC3598147 DOI: 10.5114/aoms.2013.33343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 11/10/2011] [Accepted: 12/20/2011] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Chronic vascular inflammatory process promotes and intensifies all atherogenic events. The aim of this research was to estimate the clinical value of pregnancy-associated plasma protein A (PAPP-A) measurement associated with plaque destabilization and rupture in prediction and monitoring of acute coronary syndromes (ACS) as well as to assess the predictive value of this biomarker in comparison to traditional myocardial infarction (MI) risk markers. MATERIAL AND METHODS The study included 119 patients in 2 investigated groups and one control group. PAPP-A assay was performed using manual ELISA kit, DRG. All other parameters were determined using automatic analyzers: Olympus and Dade Behring. RESULTS A statistically significant difference between PAPP-A concentration median value was found in the investigated group MI individuals' serum and control group individuals' serum (11.42 ng/ml and 7.22 ng/ml respectively, p = 0.003). PAPP-A assay had the highest specificity (83.3%) and sensitivity (53.8%), and therefore the highest clinical value. In patients with clinically and laboratory confirmed MI we proved that PAPP-A serum level is a clinically useful biomarker in ACS prediction, better than C-reactive protein (hsCRP) and fibrinogen (FBG) level. CONCLUSIONS The highest diagnostic efficiency for ACS prediction was proved for simultaneous panel assays consisting of 2-3 parameters (PAPP-A - hsCRP, PAPP-A - FBG, PAPP-A - hsCRP - FBG), while PAPP-A itself does not show characteristics necessary for it to be used as a biomarker for MI dynamic monitoring. It is possible that prothrombotic component is mainly responsible for repeated major adverse cardiac events, more than inflammatory process.
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Affiliation(s)
- Rafał Nikodem Wlazeł
- Department of Laboratory Medicine and Clinical Biochemistry, Medical University of Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Poland
| | - Marek Paradowski
- Department of Laboratory Medicine and Clinical Biochemistry, Medical University of Lodz, Poland
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Gururajan P, Gurumurthy P, Nayar P, Rao GSN, Babu RS, Sarasabharati A, Cherian KM. Pregnancy associated plasma protein-A (PAPP-A) as an early marker for the diagnosis of acute coronary syndrome. Indian Heart J 2012; 64:141-5. [PMID: 22572488 DOI: 10.1016/s0019-4832(12)60049-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AIMS AND OBJECTIVES Pregnancy associated plasma protein-A (PAPP-A), a metalloproteinase plays a pivotal role in the pathogenesis of atherosclerosis. Recent studies have reported that elevated levels of PAPP-A, signal the onset of acute coronary syndrome (ACS). We, therefore, proposed to study the analytical competence of PAPP-A in patients admitted to the emergency department with chest pain and finally diagnosed as ACS. METHODS AND RESULTS Pregnancy associated plasma protein-A was measured using enzyme-linked immunosorbent assay (ELISA) in 485 patients admitted to emergency care unit, of which 89 patients were diagnosed as Non-cardiac chest pain (NCCP). Elevated levels of PAPP-A were observed in patients diagnosed as ACS on comparison with the controls. Receiver operator characteristic (ROC) curve analysis showed PAPP-A to be a good discriminator between ischaemic and non-ischaemic patients. The area under the curve was found to be 0.904, 95% CI (0.874-0.929) with 90% sensitivity and 85% specificity (P< 0.0001). The cut-off value from the ROC curve was 0.55 μg/mL above which PAPP-A was considered to be positive. CONCLUSION Pregnancy associated plasma protein-A seems to be a promising biomarker for identification and risk stratification for patients with ACS.
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Lin S, Yokoyama H, Rac VE, Brooks SC. Novel biomarkers in diagnosing cardiac ischemia in the emergency department: a systematic review. Resuscitation 2011; 83:684-91. [PMID: 22200578 DOI: 10.1016/j.resuscitation.2011.12.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 11/25/2011] [Accepted: 12/13/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Novel biomarkers of myocardial ischemia and inflammatory processes have the potential to improve diagnostic accuracy of acute coronary syndrome (ACS) within a shorter time interval after symptom onset. OBJECTIVE The objective was to review the recent literature and evaluate the evidence for use of novel biomarkers in diagnosing ACS in patients presenting with chest pain or symptoms suggestive of cardiac ischemia to the emergency department or chest pain unit. METHODS A literature search was performed in MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED for studies from 2004 to 2010. We used the inclusion criteria: (1) human subjects, (2) peer-reviewed articles, (3) enrolled patients with ACS, acute myocardial infarction or undifferentiated signs and symptoms suggestive of ACS, and (4) English language or translated manuscripts. Two reviewers conducted a hierarchical selection and assessment using a scale developed by the International Liaison Committee on Resuscitation. RESULTS Out of a total 3194 citations, 58 articles evaluating 37 novel biomarkers were included for final review. Forty-one studies did not support the use of their respective biomarkers. Seventeen studies supported the use of 5 biomarkers, particularly when combined with cardiac-specific troponin: heart fatty acid-binding protein, ischemia-modified albumin, B-type natriuretic peptide, copeptin, and matrix metalloproteinase-9. CONCLUSION In patients presenting to the emergency department with chest pain or symptoms suggestive of cardiac ischemia, there is inadequate evidence to suggest the routine testing of novel biomarkers in isolation. However, several novel biomarkers have the potential to improve the sensitivity of diagnosing ACS when combined with cardiac-specific troponin.
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Affiliation(s)
- Steve Lin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Khan DA, Sharif MS, Khan FA. Diagnostic performance of high-sensitivity troponin T, myeloperoxidase, and pregnancy-associated plasma protein A assays for triage of patients with acute myocardial infarction. Korean J Lab Med 2011; 31:172-8. [PMID: 21779191 PMCID: PMC3129348 DOI: 10.3343/kjlm.2011.31.3.172] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 03/02/2011] [Accepted: 05/11/2011] [Indexed: 12/02/2022] Open
Abstract
Background Early diagnosis is the cornerstone of management of acute myocardial infarction (AMI). We aimed to compare the diagnostic accuracy of high-sensitivity troponin T (hs-cTnT) with myeloperoxidase (MPO) and pregnancy-associated plasma protein A (PAPP-A) for early diagnosis of AMI in patients at the time of presentation to the emergency department (ED). Methods We enrolled 289 patients who presented at the ED of the National Institute of Heart Disease (NIHD) Rawalpindi, Pakistan, within 4 hr of onset of chest pain. Clinical assessment, electrocardiography (ECG), and angiography were carried out. Blood samples were collected at 0, 3, 6, and 12 hr. Analyses of plasma hs-cTnT, MPO, and PAPP-A were carried out using commercial kits. Results Out of 289 subjects who presented to the ED, we diagnosed 180 patients with coronary heart disease as having AMI (N= 61) and 119 as without AMI (stable coronary artery disease, N=61; unstable angina, N=58). Compared to non-AMI patients, the patients with AMI had significantly higher levels (represented here as median [inter quartile range]) of plasma hs-cTnT (136 [39-370] vs. 12 [7-21] ng/L), MPO (906 [564-1,631] vs. 786 [351-1,299] pmol/L) and PAPP-A (5.78 [2.67-13.4] vs. 2.8 [1.8-4.9] mIU/L). Receiver operator characteristic curves (95% CI) for hs-cTnT (0.952 [0.909-0.978]) were significantly higher (P<0.001) than those for MPO (0.886 [0.830-0.929]) and PAPP-A (0.797 [0.730-0.854]), with AMI sensitivity and specificity percentages of 87% and 98% (hs-cTnT), 82% and 84% (MPO), and 65% and 87% (PAPP-A), respectively. Conclusions The diagnostic performance of hs-cTnT was superior to that of MPO and PAPP-A for early triage and diagnosis of AMI among patients of coronary heart disease presenting with chest pain to the ED.
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Affiliation(s)
- Dilshad Ahmed Khan
- Department of Pathology, Army Medical College National University of Sciences and Technology, Islamabad, Pakistan.
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Mei WY, Du ZM, Zhao Q, Hu CH, Li Y, Luo CF, Wu GF, Chen GW, Wang LX. Pregnancy-associated plasma protein predicts outcomes of percutaneous coronary intervention in patients with non-ST-elevation acute coronary syndrome. Heart Lung 2010; 40:e78-83. [PMID: 20723985 DOI: 10.1016/j.hrtlng.2010.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 06/16/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pregnancy-associated plasma protein A (PAPP-A) may play an important role in the development of acute coronary syndrome. This study aimed to investigate the relationship between the levels of circulating PAPP-A and the mid-term outcomes of percutaneous coronary intervention (PCI) in patients with non-ST-elevation acute coronary syndrome. METHODS The circulating PAPP-A levels and high-sensitivity C-reactive protein before PCI were measured in 129 patients with single coronary artery stenosis. The end point of clinical follow-up was cardiac death, nonfatal myocardial infarction, target vessel revascularization, and rehospitalization for angina. RESULTS During the follow-up of an average of 20.3 ± 5.2 months, a cardiac event was recorded in 25 patients (19.4%). The levels of PAPP-A (29.85 ± 19.51 mIu/L vs 20.47 ± 14.33 mIu/L, P = .007) and high-sensitivity C-reactive protein (5.63 ± 2.13 mg/L vs 4.11 ± 1.28 mg/L, P = .014) in patients with cardiac events were higher than in those without cardiac events. PAPP-A ≥ 11.33 mIu/L has a strong predictive value for a combined end point (risk ratio = 4.1; 95% confidence interval, 1.0-16.2; P = .037). Patients with lower PAPP-A levels (<11.33 mIu/L) had higher event-free survivals than patients with higher PAPP-A levels (log rank = 9.334, P = .025). CONCLUSION Circulating PAPP-A levels predict the mid-term outcomes of PCI in patients with non-ST-elevation acute coronary syndrome and single-vessel stenosis.
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Affiliation(s)
- Wei-Yi Mei
- Department of Cardiology, Huangpu Division of The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, PR China
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Conover CA, Mason MA, Bale LK, Harrington SC, Nyegaard M, Oxvig C, Overgaard MT. Transgenic overexpression of pregnancy-associated plasma protein-A in murine arterial smooth muscle accelerates atherosclerotic lesion development. Am J Physiol Heart Circ Physiol 2010; 299:H284-91. [PMID: 20472761 DOI: 10.1152/ajpheart.00904.2009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pregnancy-associated plasma protein-A (PAPP-A) increases local IGF-I bioavailability through cleavage of inhibitory IGF binding protein (IGFBP)-4 in a variety of systems, including the cardiovascular system. To test the hypothesis that expression of PAPP-A promotes the development of atherosclerotic lesions, we generated transgenic mice that express human PAPP-A in arterial smooth muscle. Four founder lines were characterized for transgenic human PAPP-A mRNA and protein expression, IGFBP-4 protease activity, and tissue specificity. In study I, apolipoprotein E knockout (ApoE KO) mice, a well-characterized mouse model of atherosclerosis, and ApoE KO mice expressing the human PAPP-A transgene at relatively high levels (ApoE KO/Tg) were fed a high-fat diet. At harvest, aortas were dissected and opened longitudinally for en face staining of lipid-rich lesions. Lesion area was increased 3.5-fold in aortas from ApoE KO/Tg compared with ApoE KO mice (P < 0.001), but no significant difference was seen in lesion number. In study II, replacement of PAPP-A expression in arterial smooth muscle of double ApoE KO/PAPP-A KO mice resulted in a 2.5-fold increase in lesion area (P = 0.002), without an effect on lesion number. PAPP-A transgene expression was associated with a significant increase in an IGF-responsive gene (P < 0.001), suggesting increased local IGF-I action. We therefore conclude that expression of human PAPP-A localized to arterial smooth muscle accelerates lesion progression in a mouse model of atherosclerosis. These data provide further evidence for the importance of PAPP-A in the cardiovascular system and suggest PAPP-A as a potential therapeutic target in the control of atherosclerosis.
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Affiliation(s)
- Cheryl A Conover
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Furenes EB, Arnesen H, Solheim S, Grøgaard HK, Hoffmann P, Seljeflot I. The profile of circulating metalloproteinases after PCI in patients with acute myocardial infarction or stable angina. Thromb Res 2009; 124:560-4. [DOI: 10.1016/j.thromres.2009.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 03/13/2009] [Accepted: 04/05/2009] [Indexed: 10/20/2022]
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Tertti R, Wittfooth S, Porela P, Airaksinen KE, Metsärinne K, Pettersson K. Intravenous administration of low molecular weight and unfractionated heparin elicits a rapid increase in serum pregnancy-associated plasma protein A. Clin Chem 2009; 55:1214-7. [PMID: 19325014 DOI: 10.1373/clinchem.2008.108738] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a useful diagnostic and prognostic marker in acute coronary syndromes. Because low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are commonly used in these cases, we analyzed the effects of intravenous administration of these heparins on serum PAPP-A concentrations. METHODS Serum concentrations of total and free PAPP-A were analyzed in 14 patients on chronic hemodialysis and in 10 coronary angiography patients. Ten of the dialysis patients received standard LMWH anticoagulation at the start of dialysis, and 4 were treated with a heparin-free method. Two of the patients on heparin-free hemodialysis received a reduced LMWH bolus 2 h after the start of dialysis. All angiography patients received UFH at the start of the procedure, and 1 patient received 2 extra boluses of UFH. Serum PAPP-A concentrations were analyzed before and during the dialysis session and during the coronary angiography examination. RESULTS A rapid increase in total PAPP-A (median, 25-fold) was seen in all patients within 5 min of administration for both LMWH and UFH boluses. This response was due to an increase in free PAPP-A in the serum. PAPP-A did not increase significantly in the patients who underwent heparin-free hemodialysis. Repeated heparin boluses induced a new PAPP-A release. In vitro addition of heparins to samples of whole blood did not increase PAPP-A concentrations. CONCLUSIONS Intravenous administration of heparin induces an intense and rapid increase in free PAPP-A in the serum. We recommend that this effect be considered when PAPP-A is assessed as a biomarker in acute coronary syndromes.
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Affiliation(s)
- Risto Tertti
- Department of Internal Medicine, Turku University Hospital, Turku, Finland.
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Consuegra-Sanchez L, Fredericks S, Kaski JC. Pregnancy-associated plasma protein-A (PAPP-A) and cardiovascular risk. Atherosclerosis 2008; 203:346-52. [PMID: 18789800 DOI: 10.1016/j.atherosclerosis.2008.07.042] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 07/28/2008] [Accepted: 07/31/2008] [Indexed: 11/30/2022]
Abstract
The search for markers to improve risk prediction for individuals at risk of developing serious cardiovascular events is ongoing. New markers of coronary artery disease progression have been identified in recent years, among which, circulating levels of pregnancy-associated plasma protein-A (PAPP-A) offer an interesting profile. PAPP-A may play a role in the development of atherosclerotic lesions and represent also a marker of atheromatous plaque instability and extent of cardiovascular disease. PAPP-A has been shown to be a marker of adverse outcome in both acute coronary syndrome and stable coronary disease patients. The present article reviews currently available evidence supporting a role for PAPP-A as a marker of cardiovascular risk and discusses some of the pitfalls that may limit its use in clinical practice.
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