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Abstract
Just as the influence of genetic variation on patient outcomes is being discussed in many other areas of medicine, so too are its effects on cerebral outcome after cardiac surgery now being described. Whereas early studies focused on neurocognitive outcome, where the single nucleotide polymorphisms of APOE4 and PLA2 were the first investigated genetic targets, stroke is now being elaborated on with related single and multi-gene single nucleotide polymorphisms having been identified. Our work has established key links between post-cardiac surgery stroke and C-reactive protein (3’UTR 1846C/T) and interleukin-6 (-174 G/C) single nucleotide polymorphisms.
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Affiliation(s)
- Hilary P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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2
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Floyd CN, Mustafa A, Ferro A. The PlA1/A2 polymorphism of glycoprotein IIIa as a risk factor for myocardial infarction: a meta-analysis. PLoS One 2014; 9:e101518. [PMID: 24988220 PMCID: PMC4079717 DOI: 10.1371/journal.pone.0101518] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 06/06/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The PlA2 polymorphism of glycoprotein IIIa (GPIIIa) has been previously identified as being associated with myocardial infarction (MI), but whether this represents a true association is entirely unclear due to differences in findings from different studies. We performed a meta-analysis to evaluate whether this polymorphism is a risk factor for MI. METHODS Electronic databases (MEDLINE and EMBASE) were searched for all articles evaluating genetic polymorphisms of GPIIIa. For studies where acute coronary events were recorded in association with genetic analysis, pooled odds ratios (ORs) were calculated using fixed-effects and random-effects models. The primary outcome measure was MI, and a secondary analysis was also performed for acute coronary syndromes (ACS) more generally. FINDINGS 57 studies were eligible for statistical analysis and included 17,911 cases and 24,584 controls. Carriage of the PlA2 allele was significantly associated with MI (n = 40,692; OR 1.077, 95% CI 1.024-1.132; p = 0.004) but with significant publication bias (p = 0.040). The degree of association with MI increased with decreasing age of subjects (≤45 years old: n = 9,547; OR 1.205, 95% CI 1.067-1.360; p = 0.003) and with adjustment of data for conventional cardiovascular risk factors (n = 12,001; OR 1.240, 95% CI 1.117-1.376; p<0.001). There was a low probability of publication bias for these subgroup analyses (all p<0.05). CONCLUSIONS The presence of significant publication bias makes it unclear whether the association between carriage of the PlA2 allele and MI is true for the total population studied. However for younger subjects, the relative absence of conventional cardiovascular risk factors results in a significant association between carriage of the PlA2 allele and MI.
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Affiliation(s)
- Christopher N. Floyd
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Agnesa Mustafa
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Albert Ferro
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
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Muehlschlegel JD, Perry TE, Liu KY, Fox AA, Smith SA, Lichtner P, Collard CD, Shernan SK, Hartwig JH, Body SC, Hoffmeister KM. Polymorphism in the protease-activated receptor-4 gene region associates with platelet activation and perioperative myocardial injury. Am J Hematol 2012; 87:161-6. [PMID: 22228373 DOI: 10.1002/ajh.22244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 10/26/2011] [Accepted: 10/28/2011] [Indexed: 12/21/2022]
Abstract
Protease-activated receptors (PAR)-1 and -4 are the principal receptors for thrombin-mediated platelet activation. Functional genetic variation has been described in the human PAR1 gene, but not in the PAR4 gene (F2RL3). We sought to identify variants in and around F2RL3 and to determine their association with perioperative myocardial injury (PMI) after coronary artery bypass graft surgery. We further explored possible mechanisms for F2RL3 single nucleotide polymorphism (SNP) associations with PMI including altered receptor expression and platelet activation. Twenty-three SNPs in the F2RL3 gene region were genotyped in two phases in 934 Caucasian subjects. Platelets from 43 subjects (23 major allele, 20 risk allele) homozygous for rs773857 (SNP with the strongest association with PMI) underwent flow cytometry to assess PAR4 receptor number and response to activation by a specific PAR4 activating peptide (AYPGKF) measured by von Willebrand factor (vWf) binding and P-selectin release and PAC-1 binding. We identified a novel association of SNP rs773857 with PMI (OR = 2.4, P = 0.004). rs773857 risk allele homozygotes have significantly increased platelet counts and platelets showed a significant increase in P-selectin release after activation (P = 0.004). We conclude that rs773857 risk allele homozygotes are associated with risk for increased platelet count and hyperactivity.
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Affiliation(s)
- Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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4
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Kaltman JR, Andropoulos DB, Checchia PA, Gaynor JW, Hoffman TM, Laussen PC, Ohye RG, Pearson GD, Pigula F, Tweddell J, Wernovsky G, Del Nido P. Report of the pediatric heart network and national heart, lung, and blood institute working group on the perioperative management of congenital heart disease. Circulation 2010; 121:2766-72. [PMID: 20585021 DOI: 10.1161/circulationaha.109.913129] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jonathan R Kaltman
- Division of Cardiovascular Sciences, NHLBI/NIH, Bethesda, MD 20892, USA.
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Abstract
Coronary artery bypass graft surgery is associated with several frequent postoperative adverse events. Outcome prediction is valued by patients and practitioners, because it provides some measure of balancing risks and benefits and provides expensive or higher-risk therapies to individuals at highest risk. Surgeons and anesthesiologists traditionally have relied on demographic, preoperative, and intraoperative risk factors to predict outcomes after cardiac surgery. Yet, such predictions often have poor positive and negative predictive value for the individual patient. Perioperative genetics attempts to determine the impact of an individual's genetic variation on the risk of developing adverse postoperative outcomes. In this article, the authors discuss emerging evidence that a patient's genetic makeup predisposes him or her to adverse outcomes following cardiac surgery and provide examples from perioperative bleeding, myocardial injury/infarction, and atrial fibrillation.
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Affiliation(s)
- Tjorvi E Perry
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
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McCaslin J, Ashour H, Bhattacharya V, Cleanthis M, Daly A, Stansby G. Increased Platelet-monocyte Aggregation in Male Claudicants with the PlA1/A2 Polymorphism of Gp IIb/IIIa. Eur J Vasc Endovasc Surg 2008; 36:132-137. [DOI: 10.1016/j.ejvs.2008.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 02/15/2008] [Indexed: 10/22/2022]
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Schwinn DA, Podgoreanu M. Pharmacogenomics and end-organ susceptibility to injury in the perioperative period. Best Pract Res Clin Anaesthesiol 2008; 22:23-37. [PMID: 18494387 PMCID: PMC2603024 DOI: 10.1016/j.bpa.2007.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Genomic medicine has provided new mechanistic understanding for many complex diseases over the last 5-10 years. More recently genomic approaches have been applied to the perioperative paradigm, facilitating identification of patients at high risk for adverse events, as well as those who will respond better/worse to specific pharmacologic therapies. The consistent biological theme emerging is that while inflammation is important in healing from surgical trauma, patients who are too robustly proinflammatory appear to be at higher risk for adverse perioperative events. Precise predictors of each adverse event are being elucidated so that corrective therapeutics can be instituted to improve outcomes in high-risk patients. While the field of perioperative genomics could be considered in its infancy, such approaches are the wave of the future.
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Affiliation(s)
- Debra A. Schwinn
- Professor and Chair of Anesthesiology, Adjunct Professor of Pharmacology & Genome Sciences, Box 356540, University of Washington, 1959 NE Pacific Street, Seattle WA 98195-6540 USA, Phone: (206) 543 – 2673|Fax (206) 543 – 2958,
| | - Mihai Podgoreanu
- Assistant Professor of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710 USA,
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Corsetti JP, Ryan D, Moss AJ, Rainwater DL, Zareba W, Sparks CE. Glycoprotein Ibalpha polymorphism T145M, elevated lipoprotein-associated phospholipase A2, and hypertriglyceridemia predict risk for recurrent coronary events in diabetic postinfarction patients. Diabetes 2007; 56:1429-35. [PMID: 17303802 DOI: 10.2337/db06-1573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To explore altered platelet function in recurrent coronary event risk among diabetic postinfarction patients, we investigated a function-altering genetic polymorphism (T145M) in the von Willebrand factor binding region of the platelet glycoprotein Ibalpha (GPIbalpha) subunit. The study comprised diabetic and nondiabetic patients of the Thrombogenic Factors and Recurrent Coronary Events postinfarction study. Cox proportional hazards multivariable modeling, adjusted for significant clinical covariates, was performed using the polymorphism and metabolic, inflammatory, and thrombogenic blood markers. Nondiabetic patients demonstrated risk for elevated lipoprotein-associated phospholipase A(2) (Lp-PLA(2)). In contrast, diabetic patients demonstrated significant and independent risk for the M allele of the T145M polymorphism (MT plus MM versus TT, hazard ratio [HR] 3.73, 95% CI 1.90-7.33, P < 0.001), hypertriglyceridemia (2.91, 1.52-5.56, P = 0.001), and elevated Lp-PLA(2) (2.78, 1.45-5.35, P = 0.002). Joint risk (one, two, or three risk factors) expressed as relative outcome rates (compared with no risk factors) were 2.4, 4.0, and 8.2, respectively. We conclude that the M allele of the T145M polymorphism of the GPIbalpha subunit predicts risk for recurrent coronary events in diabetic postinfarction patients, but not in nondiabetic postinfarction patients, supportive of an important role for platelet hyperactivation in diabetic coronary heart disease.
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Affiliation(s)
- James P Corsetti
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Yende S, Wunderink RG. Genetic polymorphisms that predict outcome and need for treatment in cardiovascular disease. Curr Opin Crit Care 2007; 12:420-5. [PMID: 16943719 DOI: 10.1097/01.ccx.0000244120.54495.be] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Interest in the genetic determinants of complications of cardiovascular disease, and the resultant influence on management, has increased. We have therefore reviewed the literature in the last 12-16 months for studies documenting genetic risk of complications. The focus is on risk of complications or differences in management, rather than only susceptibility to cardiovascular disease itself. RECENT FINDINGS Polymorphisms in myocyte enhancer factor 2A, a transcription factor, tumor necrosis factor (ligand) superfamily, member 4, the OX40 ligand, and proprotein convertase subtilisin/kexin type 9, which affect low-density lipoprotein levels, have all been associated with an altered risk of coronary artery disease and myocardial infarction. A preliminary study of genotype-specific therapy of the 5-lipoxygenase pathway has shown benefit in the intermediate endpoint of reduction in inflammatory markers in patients at risk of myocardial infarction and stroke. Bleeding and renal complications after coronary artery bypass surgery have also been associated with genetic polymorphisms. A familial study confirms a genetic association with thoracic aortic aneurysms. SUMMARY A familial risk of cardiovascular disease is well known. The specific genotypes at risk are increasingly being discovered. The science has progressed to the point that genotype-specific interventions are increasingly feasible.
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Affiliation(s)
- Sachin Yende
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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London MJ. Beta-blockade in the perioperative period: where do we stand after all the trials? Semin Cardiothorac Vasc Anesth 2006; 10:17-23. [PMID: 16703230 DOI: 10.1177/108925320601000105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perioperative myocardial infarction following noncardiac surgery is a complex process with a variety of proposed etiologic factors. Perioperative beta-blockade has been reported to reduce perioperative myocardial infarction and cardiac death, with possible direct effects on longer-term outcome, particularly after vascular surgery. Despite two high-profile studies that have pushed this topic into the mainstream of medicine, the number of patients studied and outcomes observed remains limited, especially for a therapy recommended for widespread adoption in millions of patients globally. Observational analyses, small meta-analyses, and newer randomized trial data (primarily in abstract format) suggest the therapy is of benefit in high-risk patients, whereas in patients at intermediate or low risk, it is either mildly efficacious or neutral in effect. Adverse effects appear to be limited to the expected primary hemodynamic side effects of bradycardia and hypotension, although a suggestion of increased mortality has been reported in one observational analysis in the lowest-risk group. beta-Blockade may be associated with reduction in length of stay and reduced analgesic requirements, although these effects remain controversial. A single mega-trial being conducted outside of the United States with a target goal of 10,000 patients is ongoing and promises to provide definitive data within the next few years. Ongoing research into various etiologies of perioperative myocardial infarction and other medications with potential efficacy in this setting, including the important antiplatelet agents, must also be considered in developing recommendations for widespread adoption of perioperative beta-blockade.
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Hecker JG, Laslett L, Campbell E, Nunnally M, O'Connor A, Ellis JE, Frogel JK, Fleisher LA. Case 2-2006: Catastrophic cardiovascular collapse during carotid endarterectomy. J Cardiothorac Vasc Anesth 2006; 20:259-68. [PMID: 16616674 DOI: 10.1053/j.jvca.2005.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Indexed: 11/11/2022]
Affiliation(s)
- James G Hecker
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104-6112, USA.
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12
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Podgoreanu MV, Schwinn DA. New Paradigms in Cardiovascular Medicine. J Am Coll Cardiol 2005; 46:1965-77. [PMID: 16325027 DOI: 10.1016/j.jacc.2005.08.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 08/05/2005] [Accepted: 08/17/2005] [Indexed: 12/26/2022]
Abstract
Considerable progress has been made in understanding the pathophysiology of perioperative stress responses and their impact on the cardiovascular system; however, researchers are just beginning to unravel genetic and molecular determinants that predispose to increased risk for postoperative cardiovascular adverse events. A new field, coined perioperative genomics, aims to apply functional genomic approaches to uncover the biological reasons why similar patients can have dramatically different clinical outcomes after surgery. For the perioperative physician, such findings may soon translate into prospective risk assessment incorporating genomic profiling of markers important in inflammatory, thrombotic, vascular, and neurologic responses to perioperative stress, with implications ranging from individualized additional pre-operative testing and physiological optimization, to perioperative decision-making, choice of monitoring strategies, and critical care resource utilization. We review current knowledge regarding genomic technologies in perioperative cardiovascular disease characterization and outcome prediction, as well as discuss future trends/challenges for translating integrated "omic" information into daily clinical management of the surgical patient.
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Affiliation(s)
- Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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