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Yu L, Allen R, Jia L, Sun T, Isakoff SJ, Scherrer-Crosbie M, Kehlmann AM, Zheng H, Ly A, Walmsley CS, Hesler K, Varasteh AN, Pinto CJ, McLoughlin DE, Wu W, Wang X. An Initial Evaluation of Human Plasma cMLC-1: A Potential Protein Biomarker for Trastuzumab-Induced Cardiotoxicity, Breast Cancer Screening and Progression. Front Oncol 2022; 12:809715. [PMID: 35592673 PMCID: PMC9113547 DOI: 10.3389/fonc.2022.809715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Trastuzumab is a targeted therapy for human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, trastuzumab-induced cardiotoxicity (TIC) has been reported when trastuzumab is administered to patients as a single agent or combined with anthracycline. Currently no means for detecting the early onset of TIC such as a protein biomarker is available. In this regard and based on promising results from a preliminary animal study, the potential of cardiac myosin light chain 1(cMLC-1) as a biomarker to predict TIC, screen patients for breast cancer and monitor tumor progression in breast cancer patients was evaluated. Methods Archived plasma samples collected before and after trastuzumab treatment at various fixed time points from 15 HER2+ patients with or without cardiotoxicity, recently collected plasma samples from 79 breast cancer patients (40 HER2+, 39 HER2-), and 46 healthy donors were analyzed for cMLC-1 levels using an enzyme-linked immunosorbent assay (ELISA). Results An elevated plasma cMLC-1 level was found to be associated with TIC in 3 out of 7 (43%) trastuzumab-treated HER2+ breast cancer patients. However, this study provided an opportunity for us to study plasma cMCL-1 levels in breast cancer patients. It was demonstrated that elevated plasma cMCL-1 is associated with breast cancer. The cutoff cMLC-1 concentration is estimated to be 44.99 ng/mL with a sensitivity of 59.49% (95%CI: 48.47%-69.63%) and specificity of 71.74% (95%CI: 57.45% -82.68%). We also found a noticeable but not significantly more elevated plasma cMCL-1 level in HER2- than in HER2+ breast cancer patients with the given sample sizes. As a result, improved sensitivity of 79.49% (95%CI: 64.47%-89.22%) with the specificity of 63.04% (95%CI:48.60%-75.48%) were obtained for cMLC-1 to predict HER2- breast cancer with the cutoff at 37.17 ng/mL. Moreover, this study determined that cMLC-1 level was significantly higher in patients with metastatic breast cancer than in patients with non-metastatic breast cancer. Conclusions While the analysis of cMLC-1 levels in the plasma of a limited number of trastuzumab-treated HER2+ breast cancer patients failed to fully support its identification as a blood protein biomarker for predicting TIC, additional analyses of plasma cMLC-1 levels did significantly establish its correlations with breast cancer and disease progression. Our findings shed light on and filled, to some extent, the gap of knowledge of the potential of cMLC-1 as a blood protein biomarker for screening breast cancer and monitoring disease progression of breast cancer.
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Affiliation(s)
- Ling Yu
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Key Laboratory of Luminescence Analysis and Molecular Sensing, Ministry of Education, School of Materials and Energy, Southwest University, Chongqing, China
| | - Read Allen
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Lin Jia
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ting Sun
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Isakoff
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Marielle Scherrer-Crosbie
- Perelman Center for Advanced Medicine, Cardiovascular Medicine Division, The Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Allison M Kehlmann
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Charlotte S Walmsley
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Katherine Hesler
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Ava N Varasteh
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Christopher J Pinto
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Daniel E McLoughlin
- Termeer Center for Targeted Therapies, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Wenjin Wu
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, MD, United States
| | - Xinhui Wang
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Koniari I, Artopoulou E, Velissaris D, Ainslie M, Mplani V, Karavasili G, Kounis N, Tsigkas G. Biomarkers in the clinical management of patients with atrial fibrillation and heart failure. J Geriatr Cardiol 2021; 18:908-951. [PMID: 34908928 PMCID: PMC8648548 DOI: 10.11909/j.issn.1671-5411.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.
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Affiliation(s)
- Ioanna Koniari
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Eleni Artopoulou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Mark Ainslie
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester
| | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Georgia Karavasili
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Nicholas Kounis
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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Packer M. Tetralogy of Fallow: Four Trials and Tribulations. JACC-HEART FAILURE 2017; 5:408-410. [PMID: 28501525 DOI: 10.1016/j.jchf.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.
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ElZarrad MK, Mukhopadhyay P, Mohan N, Hao E, Dokmanovic M, Hirsch DS, Shen Y, Pacher P, Wu WJ. Trastuzumab alters the expression of genes essential for cardiac function and induces ultrastructural changes of cardiomyocytes in mice. PLoS One 2013; 8:e79543. [PMID: 24255707 PMCID: PMC3821852 DOI: 10.1371/journal.pone.0079543] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 09/23/2013] [Indexed: 11/18/2022] Open
Abstract
Treatment with trastuzumab, a humanized monoclonal antibody directed against the extracellular domain of Human Epidermal Growth Factor Receptor 2 (HER2), very successfully improves outcomes for women with HER2-positive breast cancer. However, trastuzumab treatment was recently linked to potentially irreversible serious cardiotoxicity, the mechanisms of which are largely elusive. This study reports that trastuzumab significantly alters the expression of myocardial genes essential for DNA repair, cardiac and mitochondrial functions, which is associated with impaired left ventricular performance in mice coupled with significant ultrastructural alterations in cardiomyocytes revealed by electron microscopy. Furthermore, trastuzumab treatment also promotes oxidative stress and apoptosis in myocardium of mice, and elevates serum levels of cardiac troponin-I (cTnI) and cardiac myosin light chain-1 (cMLC1). The elevated serum levels of cMLC1 in mice treated with trastuzumab highlights the potential that cMLC1 could be a useful biomarker for trastuzumab-induced cardiotoxicity.
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Affiliation(s)
- M. Khair ElZarrad
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
- Interagency Oncology Task Force (IOTF) Fellowship: Program 4 - Cancer Prevention Fellow, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Partha Mukhopadhyay
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Nishant Mohan
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Enkui Hao
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Milos Dokmanovic
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Dianne S. Hirsch
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Yi Shen
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Pal Pacher
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Wen Jin Wu
- Division of Monoclonal Antibodies, Office of Biotechnology Products, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland, United States of America
- * E-mail:
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6
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Perna ER, Aspromonte N, Cimbaro Canella JP, Di Tano G, Macin SM, Feola M, Coronel ML, Milani L, Parras JI, Milli M, García EH, Valle R. Minor Myocardial Damage is a Prevalent Condition in Patients With Acute Heart Failure Syndromes and Preserved Systolic Function With Long-Term Prognostic Implications. A Report From the CIAST-HF (Collaborative Italo-Argentinean Study on Cardiac Troponin T in Heart Failure) Study. J Card Fail 2012; 18:822-30. [DOI: 10.1016/j.cardfail.2012.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 09/30/2012] [Accepted: 10/02/2012] [Indexed: 11/26/2022]
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From omics to drug metabolism and high content screen of natural product in zebrafish: a new model for discovery of neuroactive compound. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:605303. [PMID: 22919414 PMCID: PMC3420231 DOI: 10.1155/2012/605303] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 04/16/2012] [Indexed: 11/17/2022]
Abstract
The zebrafish (Danio rerio) has recently become a common model in the fields of genetics, environmental science, toxicology, and especially drug screening. Zebrafish has emerged as a biomedically relevant model for in vivo high content drug screening and the simultaneous determination of multiple efficacy parameters, including behaviour, selectivity, and toxicity in the content of the whole organism. A zebrafish behavioural assay has been demonstrated as a novel, rapid, and high-throughput approach to the discovery of neuroactive, psychoactive, and memory-modulating compounds. Recent studies found a functional similarity of drug metabolism systems in zebrafish and mammals, providing a clue with why some compounds are active in zebrafish in vivo but not in vitro, as well as providing grounds for the rationales supporting the use of a zebrafish screen to identify prodrugs. Here, we discuss the advantages of the zebrafish model for evaluating drug metabolism and the mode of pharmacological action with the emerging omics approaches. Why this model is suitable for identifying lead compounds from natural products for therapy of disorders with multifactorial etiopathogenesis and imbalance of angiogenesis, such as Parkinson's disease, epilepsy, cardiotoxicity, cerebral hemorrhage, dyslipidemia, and hyperlipidemia, is addressed.
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Chen JM, Zhu GY, Xia WT, Zhao ZQ. Proteomic analysis of rat retina after methanol intoxication. Toxicology 2012; 293:89-96. [PMID: 22257634 DOI: 10.1016/j.tox.2012.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 01/02/2012] [Accepted: 01/03/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE In order to investigate markers of toxic injury and elucidate the mechanisms underlying methanol intoxication at the protein level, proteomics technology was applied to study variations in retinal protein expression between normal rats and rat models of methanol intoxication. METHODS Seven rats were administered saline and methanol respectively by gavage. After seven days, retinal function was assessed by electroretinography and retinal proteins were extracted and separated by two-dimensional gel electrophoresis. The gels were then stained with AgNO₃ and analyzed with Pdquest software. The differential expression of proteins was analyzed by MALDI-TOF-TOF MS, and related proteins were searched in a protein database. RESULTS Twenty-eight spots with significant differences were found, 24 of which were successfully identified. Specifically, there were 14 increased expression proteins, such as aldehyde dehydrogenase, tropomyosin alpha-1 chain, myosin light chain, and crystallin family proteins. There were 10 decreased expression ones, such as glyceraldehyde-3-phosphate dehydrogenase, recoverin, ATP synthase alpha subunit in rats with methanol toxicity. CONCLUSIONS Retinal function was greatly destroyed upon methanol intoxication. Several key proteins were up- or down-regulated upon induced retinal toxicity, indicating that there are other mechanisms underlying methanol poisoning besides oxidative injury. Together, this data provides insight and knowledge for future studies in this field.
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Affiliation(s)
- Jie-Min Chen
- Department of Forensic Medicine, ShangHai Medical College of Fudan University, Shanghai 200032, PR China; Shanghai Key Laboratory of Forensic Medicine, Institute of Forensic Sciences, Ministry of Justice, Shanghai 200063, PR China
| | - Guang-You Zhu
- Shanghai Key Laboratory of Forensic Medicine, Institute of Forensic Sciences, Ministry of Justice, Shanghai 200063, PR China
| | - Wen-Tao Xia
- Shanghai Key Laboratory of Forensic Medicine, Institute of Forensic Sciences, Ministry of Justice, Shanghai 200063, PR China.
| | - Zi-Qin Zhao
- Department of Forensic Medicine, ShangHai Medical College of Fudan University, Shanghai 200032, PR China.
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9
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Dalzell JR, Jackson CE, McDonagh TA, Gardner RS. Novel biomarkers in heart failure: an overview. Biomark Med 2010; 3:453-63. [PMID: 20477516 DOI: 10.2217/bmm.09.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Heart failure is a complex systemic syndrome resulting from significant impairment of cardiac function. A vast array of biological pathways is now known to be involved in heart failure, including deleterious pathways promoting its development and progression, as well as compensatory cardioprotective pathways. Some of the components of these pathways are now recognized as biomarkers of this condition, and can aid diagnosis, prognostication and guide management. As the understanding of the pathophysiology of heart failure progresses, further candidate biomarkers are being identified. This article reviews the literature regarding the more recently identified biomarkers and outlines areas requiring further study.
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Affiliation(s)
- Jonathan R Dalzell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK.
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Chow AK, Cena J, Schulz R. Acute actions and novel targets of matrix metalloproteinases in the heart and vasculature. Br J Pharmacol 2007; 152:189-205. [PMID: 17592511 PMCID: PMC1978261 DOI: 10.1038/sj.bjp.0707344] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Matrix metalloproteinases (MMPs) have been shown to play significant roles in a number of physiological as well as pathological processes. Best known to proteolyse components of the extracellular matrix, MMPs have recently been discovered to also target a growing list of proteins apart from these, both inside and outside the cell. MMPs have also been traditionally thought of as enzymes involved in chronic processes such as angiogenesis, remodelling and atherosclerosis on a days-week time-scale. However they are now understood to also act acutely in response to oxidative stress on a minutes time-scale on non-extracellular matrix substrates. This review focuses on the acute actions and both extracellular and intracellular targets of two prominent MMP family members, MMP-2 and -9, in cardiovascular diseases including ischaemia/reperfusion injury, inflammatory heart disease, septic shock and pre-eclampsia. Also discussed are various ways of regulating MMP activity, including post-translational mechanisms, the endogenous tissue inhibitors of metalloproteinases and pharmacological inhibitors. A comprehensive understanding of MMP biology is necessary for the development of novel pharmacological therapies to combat the impact of cardiovascular disease.
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Affiliation(s)
- A K Chow
- Department of Pediatrics, Cardiovascular Research Group, University of Alberta Edmonton, Alberta, Canada
| | - J Cena
- Department of Pharmacology, Cardiovascular Research Group, University of Alberta Edmonton, Alberta, Canada
| | - R Schulz
- Department of Pediatrics, Cardiovascular Research Group, University of Alberta Edmonton, Alberta, Canada
- Department of Pharmacology, Cardiovascular Research Group, University of Alberta Edmonton, Alberta, Canada
- Author for correspondence:
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Schulz R. Intracellular targets of matrix metalloproteinase-2 in cardiac disease: rationale and therapeutic approaches. Annu Rev Pharmacol Toxicol 2007; 47:211-42. [PMID: 17129183 DOI: 10.1146/annurev.pharmtox.47.120505.105230] [Citation(s) in RCA: 221] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A new paradigm of matrix metalloproteinase-2 (MMP-2) action in the heart undergoing oxidative stress has emerged. Although best known for its role in the proteolysis of extracellular protein targets, MMP-2 is also localized to the sarcomere within the cardiomyocyte. Oxidative stress activates full-length MMP-2 without need for proteolytic processing and inactivates an endogenous inhibitor, tissue inhibitor of metalloproteinase-4. MMP-2 proteolyzes specific targets within the cell to cause acute, reversible contractile dysfunction. Inhibitors of MMPs are discussed and their possible use for the therapy of acute heart injury caused by oxidative stress is examined.
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Affiliation(s)
- Richard Schulz
- Cardiovascular Research Group, Departments of Pediatrics and Pharmacology, University of Alberta, Edmonton, Alberta, Canada.
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Stejskal D, Lacnak B, Karpisek M, Kaminek M. OUR EXPERIENCES WITH MEASUREMENT OF NEW POTENTIAL BIOMARKERS IN THE DIAGNOSIS OF LATENT FORMS OF MYOCARDIAL ISCHEMIA. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2006; 150:239-44. [PMID: 17426785 DOI: 10.5507/bp.2006.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The need for a laboratory marker of myocardial ischemia has been alluded to for at least the last decade. AIM The aim of this study was to evaluate the diagnostic importance of the myosin light chain-1 (MLC-1), clusterin and Reg-Ialpha in patients with suspected myocardial ischemia. METHODS A group of 176 at high-risk for myocardial ischemia subjects was evaluated and divided into two subgroups using myocardial SPECT (Single Photon Emission Computed Tomography) - individuals with and without signs of myocardial ischemia. Laboratory markers in venous blood were repeatedly examined in all subjects: a) immediately prior to SPECT: C-reactive protein, Haemoglobin, Hematocrite, Lactate, MLC-1, Clusterin, Reg-Ialpha b) at subjective maximum: Hb, Htc, lactate, MLC-1, Clusterin, Reg-Ialpha c) 30 min after stress levels reached their peak: MLC-1, Clusterin, Reg-Ialpha and d) 60 min after peak stress levels: MLC-1, Clusterin, Reg-Ialpha. RESULTS Patients were divided into subgroups according to their positive and negative SPECT results (positive: n = 37; negative: n = 139). MLC-1 values were different for all 4 blood collections. An increase in MLC-1 > 2.2 mg/l showed 64 % sensitivity and 88 % specificity for the diagnosed presence of myocardial ischemia (AUC 0.81; LR+ 5.9; PPV+ 68 % and NPV- 87 %). There was no significant difference between the groups in terms of Clusterin and Reg-Ialpha for any of the sampling periods. CONCLUSIONS High diagnostic efficacy of detectable MLC-1 was shown for the diagnosis of latent myocardial ischemia. Measurement of serum Clusterin or Reg-Ialpha did not sufficient for the diagnosis of latent myocardial ischemia.
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Affiliation(s)
- David Stejskal
- Department of Laboratory Medicine and Internal Department, Sternberk Hospital, Czech Republic.
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de Virginy DRB. Novel and potential future biomarkers for assessment of the severity and prognosis of chronic heart failure. Heart Fail Rev 2006; 11:333-4. [PMID: 17131079 DOI: 10.1007/s10741-006-0234-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Over the last two decades, the pathophysiology and biomolecular basis of heart failure syndrome has reached sound and more comprehensive understanding. This knowledge has allowed expert researchers and clinicians to explore an entirely new spectrum of potential biochemical markers derived from different cellular and signaling pathways that lead to myocardial hypertrophy, chronic damage of the myocyte, apoptosis, and, ultimately, myocardial remodeling. Indeed, the link between myocardial remodeling and adverse outcomes, as well as the recognition of the myocardial interstitium as a multifunctional dynamic entity strongly influenced by systemic neurohormonal and inflammatory activation, has provided a solid ground for research of biomarkers that might correlate with severity and prognostication in chronic heart failure. This paper reviews and summarize recent literature on some of the most interesting circulating biomarkers with potential use for the stratification of patients with chronic heart failure.
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Affiliation(s)
- David R Buvat de Virginy
- Department of Internal Medicine, St. John's Clinic, 1100 West 10th Street, Suite 270, Rolla, Missouri 65401, USA.
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Sugiura T, Takase H, Toriyama T, Goto T, Ueda R, Dohi Y. Circulating levels of myocardial proteins predict future deterioration of congestive heart failure. J Card Fail 2006; 11:504-9. [PMID: 16198245 DOI: 10.1016/j.cardfail.2005.04.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Revised: 04/18/2005] [Accepted: 04/27/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study was designed to test whether circulating levels of myocardium-specific proteins serve as useful markers for the prognosis of patients with congestive heart failure. METHODS AND RESULTS Seventy-eight patients with congestive heart failure from dilated cardiomyopathy but in a stable condition were enrolled, and their blood was sampled for measurements of myosin light chain-I (MLC-I), troponin T (TnT), heart fatty-acid-binding protein (H-FABP), and creatine kinase isoenzyme MB (CK-MB). The patients were then followed up for 951 +/- 68 days, with the endpoint being acute deterioration. A univariate analysis revealed that MLC-I, TnT, H-FABP, and CK-MB were significant predictors for acute deterioration of heart failure. Application of the Kaplan-Meier method using cutoff values determined by analysis of receiver operating characteristics curves demonstrated that the incidence of acute deterioration was significantly higher in patients with higher values of MLC-I (61.9%), TnT (52.4%), H-FABP (50.0%), or CK-MB (38.6%) than in those with lower values of these markers (15.8%, 20.4%, 13.6%, and 16.1%, respectively). CONCLUSIONS Increased circulating levels of the specific myocardial proteins are related to a higher probability of future acute deterioration of congestive heart failure in patients in a stable condition associated with dilated cardiomyopathy.
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Affiliation(s)
- Tomonori Sugiura
- Department of Internal Medicine, Enshu General Hospital, Hamamatsu, Shizuoka, Japan
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Sawicki G, Leon H, Sawicka J, Sariahmetoglu M, Schulze CJ, Scott PG, Szczesna-Cordary D, Schulz R. Degradation of myosin light chain in isolated rat hearts subjected to ischemia-reperfusion injury: a new intracellular target for matrix metalloproteinase-2. Circulation 2005; 112:544-52. [PMID: 16027249 DOI: 10.1161/circulationaha.104.531616] [Citation(s) in RCA: 202] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Matrix metalloproteinase-2 (MMP-2) contributes to cardiac dysfunction resulting from ischemia-reperfusion (I/R) injury. MMP-2 not only remodels the extracellular matrix but also acts intracellularly in I/R by degrading troponin I. Whether other intracellular targets exist for MMP-2 during I/R is unknown. METHODS AND RESULTS Isolated rat hearts were subjected to 20 minutes of ischemia and 30 minutes of reperfusion. The impaired recovery of mechanical function of the heart was attenuated by the MMP inhibitors o-phenanthroline or doxycycline. Quantitative 2D electrophoresis of homogenates of aerobically perfused hearts (control) or those subjected to I/R injury (in the presence or absence of MMP inhibitors) showed 3 low-molecular-weight proteins with levels that were significantly increased upon I/R injury and normalized to control levels by MMP inhibitors. Mass spectrometry analysis identified all 3 proteins as fragments of myosin light chain 1, which possesses theoretical cleavage recognition sequences for MMP-2 and is rapidly degraded by it in vitro. The association of MMP-2 with the thick myofilament in fractions prepared from I/R hearts was observed with immunogold electron microscopy, gelatin zymography for MMP-2 activity, and immunoprecipitation. MMP-2 was found to cleave myosin light chain 1 between tyrosine 189 and glutamine 190 at the C terminus. CONCLUSIONS Our results demonstrate that myosin light chain 1 is another novel substrate for MMP-2 in the cardiomyocyte and that its degradation may contribute to contractile dysfunction resulting from I/R injury to the heart.
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Affiliation(s)
- Grzegorz Sawicki
- Department of Pharmacology, University of Alberta, Edmonton, Alberta, Canada
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Stejskal D, Lacnák B, Andelová K, Skvarilová M, Bartek J. MCL-1 (myosin light chains-1) in differential diagnosis of dyspnea. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2005; 149:89-91. [PMID: 16170394 DOI: 10.5507/bp.2005.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Myosin light chains-1 (MLC-1) have been recently associated with the markers of heart function (NYHA, LVEF, NT-proBNP). Verification of the relationship between markers of heart function (New York Heart Association classification (NYHA), left ventricle ejection fraction determination (LVEF), N terminal prohormone of natriuretic peptide B type BNP (NT-proBNP) and concentrations of myosin light chains-1 (MLC-1) was assessed. Patients examined for dyspnea without signs of acute coronary syndrome. All patients underwent echocardiography (calculation of left ventricle ejection fraction--LVEF) and in the serum of all subjects NT-proBNP (ELEIA) and MLC-1 (ELISA) were determined. In the 38 patients (21 men, 17 women), mean age of 58 years (+/-12 years as 1 SD), a significant negative correlation was found between NT-proBNP and LVEF (r = - 0.47; p = 0.02, Spearman). The median levels of NT pro-BNP were closely associated with NYHA classification (type II--584 ng/l, type III--2792 ng/l, type IV--6400 ng/l; p < 0.05). Individuals with clinical NYHA IV differed significantly in median MLC-1 concentrations from persons with clinical NYHA classification II and III (type II--5.7 ng/l, type III--8.9 ng/l, type IV--17 ng/l; p < 0.05). A significant negative correlation between MLC-1 and LVEF (-0.35; p < 0.03) and significant positive correlations between MLC-1 and NT-proBNP (0.42; p < 0.012) were found. In conclusion MLC-1 cannot be used as a diagnostic marker in differential diagnosis of dyspnea.
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Affiliation(s)
- David Stejskal
- Department of Laboratory Medicine, Hospital Sternberk, Czech Republic.
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Abstract
PURPOSE OF REVIEW This paper reviews recent advances in heart failure biomarkers for identification of disease precursors, subclinical disease, and onset or progression of overt disease. RECENT FINDINGS Heart failure biomarkers can be categorized empirically as neurohormonal mediators, markers of myocyte injury and remodeling, and indicators of systemic inflammation. Brain natriuretic peptide is the most widely studied, with a potentially important but evolving role for determining prognosis and as a surrogate endpoint in clinical trials. Strong evidence exists for use of brain natriuretic peptide in the diagnosis of acute heart failure and for improved clinical outcomes with a brain natriuretic peptide-guided approach to heart failure care. The use of brain natriuretic peptide as a screening tool for asymptomatic left ventricular systolic dysfunction, or to distinguish systolic from diastolic heart failure, is not supported by current data. Markers of myocyte injury, including troponins, heart-type fatty acid binding protein, and myosin light chain-1, may further improve heart failure prognostication in conjunction with plasma brain natriuretic peptide. Biomarkers of matrix remodeling and inflammation have emerged as potential preclinical indicators to identify individuals at risk of developing clinical heart failure. A role for cellular adhesion molecules may also emerge in identifying those at risk for cardiovascular thrombotic complications, such as stroke. SUMMARY The spectrum of heart failure biomarkers and their potential clinical applications continues to grow. Ongoing research on multimarker strategies will likely identify biomarker combinations that are optimal at various stages during the evolution of heart failure, ranging from their use for screening, diagnosis, determining prognosis, and guiding management.
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Affiliation(s)
- Douglas S Lee
- National Heart, Lung and Blood Institutes, Framingham Heart Study, Framingham, MA 01702-5827, USA
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Amsallem E, Kasparian C, Haddour G, Boissel J, Nony P. Phosphodiesterase III inhibitors for heart failure. Cochrane Database Syst Rev 2005; 2005:CD002230. [PMID: 15674893 PMCID: PMC8407097 DOI: 10.1002/14651858.cd002230.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In the treatment of chronic heart failure, vasodilating agents, ACE inhibitors and beta-blockers have shown an increase of life expectancy. Another strategy is to increase the inotropic state of the myocardium : phosphodiesterase inhibitors (PDIs) act by increasing intra-cellular cyclic AMP, thereby increasing the concentration of intracellular calcium, and lead to a positive inotropic effect. OBJECTIVES This overview on summarised data aims to review the data from all randomised controlled trials of PDIs III versus placebo in symptomatic patients with chronic heart failure. The primary endpoint is total mortality. Secondary endpoints are considered such as cause-specific mortality, worsening of heart failure (requiring intervention), myocardial infarction, arrhythmias and vertigos. We also examine whether the therapeutic effect is consistent in the subgroups based on the use of concomitant vasodilators, the severity of heart failure, and the type of PDI derivative and/or molecule. This overview updates our previous meta-analysis published in 1994. SEARCH STRATEGY Randomised trials of PDIs versus placebo in heart failure were searched using MEDLINE (1966 to 2004 January), EMBASE (1980 to 2003 December), Cochrane CENTRAL trials (The Cochrane Library Issue 1, 2004) and McMaster CVD trials registries, and through an exhaustive handsearching of international abstracting publications (abstracts published in the last 22 years in the "European Heart Journal", the "Journal of the American College of Cardiology" and "Circulation"). SELECTION CRITERIA All randomised controlled trials of PDIs versus placebo with a follow-up duration of more than three months. DATA COLLECTION AND ANALYSIS 21 trials (8408 patients) were eligible for inclusion in the review. 4 specific PDI derivatives and 8 molecules of PDIs have been considered. MAIN RESULTS As compared with placebo, treatment with PDIs was found to be associated with a significant 17% increased mortality rate (The relative risk was 1.17 (95% confidence interval 1.06 to 1.30; p<0.001). In addition, PDIs significantly increase cardiac death, sudden death, arrhythmias and vertigos. Considering mortality from all causes, the deleterious effect of PDIs appears homogeneous whatever the concomitant use (or non-use) of vasodilating agents, the severity of heart failure, the derivative or the molecule of PDI used. AUTHORS' CONCLUSIONS Our results confirm that PDIs are responsible for an increase in mortality rate compared with placebo in patients suffering from chronic heart failure. Currently available results do not support the hypothesis that the increased mortality rate is due to additional vasodilator treatment. Consequently, the chronic use of PDIs should be avoided in heart failure patients.
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Affiliation(s)
- Emmanuel Amsallem
- CETAFQuality ‐ Evaluation ‐ Etudes67‐69 Avenue de Rochetaillée ‐ BP 167Saint‐Etienne Cedex 02France42012
| | - Christelle Kasparian
- APRET/EZUSClinical Pharmacology Unit (EA 3736)Faculte RTH LaennecRue Guillaume Paradin ‐ BP 8071LyonFrance69 376
| | - G Haddour
- Hospices Civils de LyonCardiovscular Hospital Louis PradelLyonFrance69 003
| | - Jean‐Pierre Boissel
- Hopital Cardio‐Vasculaire et Pneumologique Louis PradelCentre d'Investigation Clinique ‐ CIC de LyonBronCEDEXFrance69677
| | - Patrice Nony
- Hopital Neurocardiologique28 avenue Doyen LepineLyonFrance69003
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Abstract
This review discusses the role of biochemical markers of myocyte injury in patients with chronic congestive heart failure. Heart specific assays have been developed for the measurement of cardiac troponin T (cTnT), cardiac troponin I (cTnI), heart type fatty acid binding protein (H-FABP), and myosin light chain 1 (MLC-1). Concentrations of these biochemical markers increase in the absence of ischaemic events in the subset of patients with heart failure whose long term outcomes are most adverse. The markers are easy to measure serially and it is therefore easy to follow patients without inter-observer variability. The serial clinical use of these markers, separately or in combination, will sharpen our understanding of the state of heart failure.
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Affiliation(s)
- Y Sato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Kawaracho Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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Okumiya T, Ishikawa-Nishi M, Doi T, Kamioka M, Takeuchi H, Doi Y, Sugiura T. Evaluation of Intravascular Hemolysis With Erythrocyte Creatine in Patients With Cardiac Valve Prostheses. Chest 2004; 125:2115-20. [PMID: 15189930 DOI: 10.1378/chest.125.6.2115] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To detect intravascular hemolysis in patients with cardiac valve prostheses. Erythrocyte creatine, a marker of erythrocyte age that increases with shortening erythrocyte survival, was evaluated with other hemolytic markers and hemodynamic parameters. DESIGN Prospective study. PATIENTS AND MEASUREMENTS Erythrocyte creatine was enzymatically assayed in 33 patients with prosthetic valves, including 15 patients with aortic valve replacement, 13 patients with mitral valve replacement, and 5 patients with double-valve (aortic and mitral) replacement, and 33 control subjects. Blood flow velocity and valvular regurgitation were determined by Doppler echocardiography. Other hemolytic markers (lactate dehydrogenase [LDH], reticulocyte count, and haptoglobin) and cardiac muscle markers (myoglobin and myosin light chain 1) were also measured. RESULTS Erythrocyte creatine and LDH levels were significantly higher (p < 0.0001) and the haptoglobin level was lower (p < 0.0001) in patients with a prosthetic valve as compared with control subjects. However, there were no significant differences in these markers between those with (n = 17) and without (n = 16) regurgitation. Patients with high erythrocyte creatine levels (> 1.8 micro mol/g hemoglobin) exhibited significantly higher total peak flow velocity (sum of peak flow velocities at mitral and aortic valves) than those with normal erythrocyte creatine levels (p = 0.006). Erythrocyte creatine had a significant correlation with total peak flow velocity (r = 0.64, p < 0.0001), but LDH and haptoglobin had no significant correlation with total peak flow velocity. Patients with high LDH levels (> 460 IU/L) showed significantly higher myoglobin (p = 0.008) and myosin light chain 1 (p = 0.02) than those with normal LDH levels, whereas erythrocyte creatine was not related to cardiac muscle markers. CONCLUSIONS Erythrocyte creatine is a quantitative and reliable marker for intravascular hemolysis in patients with prosthetic valves. Mild hemolysis is ascribable to valvular flow velocity rather than regurgitation.
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Affiliation(s)
- Toshika Okumiya
- Department of Laboratory Medicine, Faculty of Medicine, Kochi Medical School, Nankoku, Japan.
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