Biological profiles in subjects with recurrent acute coronary events compared with subjects with long-standing stable angina

Lipoprotein(a)—The Crossroads of Atherosclerosis, Atherothrombosis and Inflammation

Increased lipoprotein(a) (Lp(a)) levels are an independent predictor of coronary artery disease (CAD), degenerative aortic stenosis (DAS), and heart failure independent of CAD and DAS. Lp(a) levels are genetically determinated in an autosomal dominant mode, with great intra- and inter-ethnic diversity. Most variations in Lp(a) levels arise from genetic variations of the gene that encodes the apolipoprotein(a) component of Lp(a), the LPA gene. LPA is located on the long arm of chromosome 6, within region 6q2.6–2.7. Lp(a) levels increase cardiovascular risk through several unrelated mechanisms. Lp(a) quantitatively carries all of the atherogenic risk of low-density lipoprotein cholesterol, although it is even more prone to oxidation and penetration through endothelia to promote the production of foam cells. The thrombogenic properties of Lp(a) result from the homology between apolipoprotein(a) and plasminogen, which compete for the same binding sites on endothelial cells to inhibit fibrinolysis and promote intravascular thrombosis. LPA has up to 70% homology with the human plasminogen gene. Oxidized phospholipids promote differentiation of pro-inflammatory macrophages that secrete pro-inflammatory cytokines (e. g., interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α). The aim of this review is to define which of these mechanisms of Lp(a) is predominant in different groups of patients.

C-Reactive Protein Levels Predict Outcomes in Continuous-Flow Left Ventricular Assist Device Patients: An INTERMACS Analysis

CRP is an established inflammatory biomarker with prognostic value in patients with chronic heart failure, yet its role in continuous-flow left ventricular assist device (LVAD) patients is largely unknown. 5,183 patients from the INTERMACS registry who underwent durable LVAD between 2008 and 2017 and had preimplant CRP levels were included. The sample was stratified into two groups based on preimplant CRP levels: CRP of 0-10 mg/L (low) and >10 mg/L (high). Kaplan-Meier survival estimates were used to assess outcomes at 2 years after LVAD implantation, with log-rank testing used to compare groups. Cox proportional hazard models were used for multivariable adjustment. Patients with high preimplant CRP were younger, more likely to be INTERMACS class I, and had a higher need for temporary mechanical circulatory support before LVAD implant compared to those with lower CRP levels (all P < 0.001). The high CRP group had higher WBC counts and BNP levels (all P < 0.001). After adjustment, higher CRP (>10 mg/L) was associated with greater risk of mortality, RV failure, and stroke postimplant (P < 0.001). In addition, elevated postimplant CRP level at 3 months was associated with increased mortality and stroke on LVAD support (P < 0.001). CRP is a predictor of death and complications on LVAD support. Future studies are necessary to explore the mechanisms underlying this finding and the potential role of antiinflammatory therapies in this population.

Effects of Fatty Acid Therapy in Addition to Strong Statin on Coronary Plaques in Acute Coronary Syndrome: An Optical Coherence Tomography Study

BACKGROUND

Vascular healing response associated with adjunctive n‐3 polyunsaturated fatty acid therapy therapy in patients receiving strong statin therapy remains unclear. The aim of this study was to evaluate the effect of polyunsaturated fatty acid therapy with eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA) in addition to strong statin therapy on coronary atherosclerotic plaques using optical coherence tomography.

METHODS AND RESULTS

This prospective multicenter randomized controlled trial included 130 patients with acute coronary syndrome treated with strong statins. They were assigned to either statin only (control group, n=42), statin+high‐dose EPA (1800 mg/day) (EPA group, n=40), statin+EPA (930 mg/day)+DHA (750 mg/day) (EPA+DHA group, n=48). Optical coherence tomography was performed at baseline and at the 8‐month follow‐up. The target for optical coherence tomography analysis was a nonculprit lesion with a lipid plaque. Between baseline and the 8‐month follow‐up, fibrous cap thickness (FCT) significantly increased in all 3 groups. There were no significant differences in the percent change for minimum FCT between the EPA or EPA+DHA group and the control group. In patients with FCT <120 µm (median value), the percent change for minimum FCT was significantly higher in the EPA or EPA+DHA group compared with the control group.

CONCLUSIONS

EPA or EPA+DHA therapy in addition to strong statin therapy did not significantly increase FCT in nonculprit plaques compared with strong statin therapy alone, but significantly increased FCT in patients with thinner FCT.

Registration

URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN 000012825.

Plasminogen activator inhibitor 1 in acute coronary syndromes

Plasminogen activator inhibitor 1 (PAI-1) is the main regulator of endogenous fibrinolysis, overriding the impact of other constituents of fibrinolysis. In plasma, it can be found in three forms: active, latent and inactive. There are numerous commercially available tests, analysing the activity of PAI-1 or the antigen level, with variable correlations between the two. PAI-1 has been extensively studied regarding incidence and outcomes of acute coronary syndromes, and showed positive association with both in numerous studies. Higher PAI-1 has been associated with worse short- and long-term outcomes. Studies are more consistent in the primary percutaneous coronary intervention era. Higher rise of PAI-1 within the first 24 h of acute myocardial infarction has been linked to some of its high-risk features. The circadian pattern of PAI-1 kinetics has been previously described, and the mechanisms behind this phenomenon and its impact on the incidence of acute coronary syndromes are well known. Further investigations are needed to test the safety and efficacy of PAI-1 as a pharmacological target in cardiovascular diseases.

Association between plasminogen activator inhibitor-1 and cardiovascular events: a systematic review and meta-analysis

Background

Small studies have implicated plasminogen activator inhibitor-1 (PAI-1) as a predictor of cardiovascular events; however, these findings have been inconsistent.

We sought out to examine the potential role of PAI-1 as a marker for major adverse cardiovascular events (MACE).

Methods

We systematically reviewed all indexed studies examining the association between PAI-1 and MACE (defined as death, myocardial infarction, or cerebrovascular accident) or restenosis. EMBASE, Web of Science, Medline, and the Cochrane Library were searched through October 2016 to identify relevant studies, supplemented by letters to authors and review of citations. Studies reporting the results of PAI-1 antigen and/or activity levels in association with MACE in human subjects were included.

Results

Of 5961 articles screened, we identified 38 articles published between 1991 to 2016 that reported PAI-1 levels in 11,557 patients. In studies that examined PAI-1 antigen and activity levels, 15.1% and 29.6% of patients experienced MACE, respectively. Patients with MACE had higher PAI-1 antigen levels with a mean difference of 6.11 ng/mL (95% CI, 3.27-8.96). This finding was similar among patients with and without known coronary artery disease. Comparatively, studies that stratified by PAI-1 activity levels were not associated with MACE. In contrast, studies of coronary restenosis suggest PAI-1 antigen and activity levels are negatively associated with MACE.

Conclusions

Elevated plasma PAI-1 antigen levels are associated with MACE. Definitive studies are needed to ascertain if PAI-1 acts simply as a marker of risk or if it is indeed a bona fide therapeutic target.

Electronic supplementary material

The online version of this article (10.1186/s12959-018-0166-4) contains supplementary material, which is available to authorized users.

Evolution of nonculprit coronary atherosclerotic plaques assessed by serial virtual histology intravascular ultrasound in patients with ST-segment elevation myocardial infarction and chronic total occlusion

OBJECTIVE

The pathophysiology and natural course of coronary nonculprit plaques remain unclear. We investigated whether the short-term natural course of nonculprit plaques differs between ST-segment elevation myocardial infarction (STEMI) and chronic total occlusion (CTO) patients.

METHODS

We performed serial virtual histology intravascular ultrasound on nonculprit plaques in 26 STEMI and 11 CTO lesions at baseline and the 6-month follow-up.

RESULTS

At baseline, more lesions in the STEMI group were virtual histology intravascular ultrasound-derived thin-cap fibroatheromas (TCFA; 76.9 vs. 18.1%, P=0.002). During the follow-up period, the plaque composition changed dynamically in the STEMI group (fibrofatty: 9.8±1.9 to 17.3±2.9%, P=0.030; dense calcium: 12.7±1.8 to 8.1±1.7%, P=0.026; necrotic core: 21.1±1.8 to 15.4±2.2%, P=0.052), with a consistent plaque size. In the CTO group, the plaque composition and plaque size remained consistent without a significant change. Also, more lesions in the STEMI group remained as or progressed to TCFA, compared with the CTO group (67 vs. 11%, P=0.089). Factors associated with a persistent TCFA or with a new development of TCFA were a large necrotic core volume index and the diagnosis of STEMI, whereas new statin usage was a protective factor.

CONCLUSION

Nonculprit lesions in STEMI patients were more unstable at the baseline compared with those in CTO patients. During follow-up, nonculprit lesions in STEMI and CTO patients showed a distinct pattern of change; the former were stabilized in plaque composition, whereas the latter remained consistent. The diagnosis of STEMI and a large necrotic core volume were predictors of evolution to a TCFA, and new statin usage was a protective factor.

Ankle—brachial index and hemostatic markers in the Atherosclerosis Risk in Communities (ARIC) study cohort

To determine whether elevated levels of hemostatic and inflammatory markers [von Willebrand factor (vWF), fibrinogen, D-dimer, factor VII, factor VIII, PAI-1, tPA, beta-thromboglobulin (β-TG), CRP, and WBC count] are associated with increased peripheral arterial disease (PAD) prevalence, measured by low ABI, we studied 13,778 participants from the ARIC study in a cross-sectional analysis after adjustment for major cardiovascular risk factors. PAD was positively associated with fibrinogen, vWF, factor VIII, WBC count, D-dimer, β-TG, and CRP (p for trend <0.05) but not with the other markers. Adjusted odds ratios for the highest versus the lowest quartile of fibrinogen in men and women, respectively, were 3.49 (95% CI 1.68—7.26) and 2.44 (95% CI 1.58—3.77); for vWF 2.36 (95% CI 1.36—4.07) and 1.45 (95% CI 1.00—2.10); for factor VIII 2.31 (95% CI 1.36—3.94) and 1.68 (95% CI 1.14—2.48). In a smaller subset, the sex and risk factor adjusted odds ratio for the highest versus the lowest quartile of D-dimer was 2.70 (95% CI 1.56—4.65), for β-TG was 1.80 (95% CI 1.12—2.88), and for CRP was 1.57 (95% CI 0.84—2.95). Plasma levels of hemostatic and inflammatory markers are elevated in PAD, suggesting these processes are involved in the pathophysiology of PAD.

Association between platelet to lymphocyte ratio and saphenous vein graft disease in patients with stable angina pectoris

OBJECTIVE

In this study, we aimed to investigate the relation of platelet to lymphocyte ratio (PLR) in saphenous vein graft disease (SVGD) in patients with stable angina pectoris after coronary artery bypass graft surgery.

METHODS

A total of 455 patients were included in the study. There were 210 patients with SVGD and 245 patients without SVGD. The effects of different variables on SVGD were computed in logistic regression analysis.

RESULTS

The platelet count, lymphocyte count, PLR, high-density lipoprotein (HDL), Na, and ALT were significantly associated with SVGD. In multivariate regression analysis, HDL and PLR were found to be significantly associated with SVGD.

CONCLUSION

To the best of our knowledge, this is the first study showing the significant association of PLR with SVGD. This study suggests that PLR can be used as a marker of SVGD because it is an easily available and inexpensive test.

C-reactive protein as a novel biomarker

C-reactive protein (CRP) is a relatively nonspecific marker of inflammation. However, it can be used to monitor the severity and progression of some well-defined cardiovascular diseases. For example, it can predict serious events in patients with coronary artery disease (CAD) who are hospitalized with acute coronary syndrome, myocardial infarction (MI), or advanced peripheral vascular disease. In this article, the authors review the role of CRP in the diagnosis, monitoring, and treatment of various forms of ischemic and inflammatory cardiovascular disease.

Maternal undernutrition and cardiometabolic disease: a Latin American perspective

The current epidemic of obesity and cardiometabolic diseases in developing countries is described as being driven by socioeconomic inequalities. These populations have a greater vulnerability to cardiometabolic diseases due to the discrepancy between the maternal undernutrition and its consequence, low-birth weight progeny, and the subsequent modern lifestyles which are associated with socioeconomic and environmental changes that modify dietary habits, discourage physical activity and encourage sedentary behaviors. Maternal undernutrition can generate epigenetic modifications, with potential long-term consequences. Throughout life, people are faced with the challenge of adapting to changes in their environment, such as excessive intake of high energy density foods and sedentary behavior. However, a mismatch between conditions experienced during fetal programming and current environmental conditions will make adaptation difficult for them, and will increase their susceptibility to obesity and cardiovascular diseases. It is important to conduct research in the Latin American context, in order to define the best strategies to prevent the epidemic of cardiometabolic diseases in the region.

Traditional cardiovascular risk factors and the presence of obstructive coronary artery disease in men and women

BACKGROUND

Extensive research has demonstrated the importance of traditional cardiovascular risk factors in predicting acute coronary events. Our main objective was to evaluate the relationship between traditional risk factors and the presence of obstructive coronary artery disease (CAD), and to explore potential differences in men vs women.

METHODS

An observational study was conducted in a population-based cohort of stable patients who underwent cardiac catheterization in Ontario, Canada. We examined the relationship of diabetes, hypertension, hyperlipidemia, and smoking with the presence of obstructive CAD in men and women using multivariable logistic regression models.

RESULTS

Of the 46,490 patients who were included in our study, 61.2% were men and 38.8% were women. We found that 97% of patients with obstructive CAD had at least 1 conventional cardiovascular risk factor. The adjusted odds ratios (ORs) for obstructive CAD in women with diabetes (OR, 1.51), hypertension (OR, 1.38), and smoking (OR, 1.39) were statistically significantly greater than in men (OR, 1.20 for diabetes; OR, 1.08 for hypertension; OR, 1.14 for smoking; P < 0.001). The sex difference was even greater for patients with multiple risk factors. For example, the association with obstructive CAD in women with 4 cardiac risk factors (OR, 4.30; 95% confidence interval, 3.49-5.28) was almost doubled compared with men (OR, 2.26; 95%confidence interval, 1.99-2.57; P < 0.001).

CONCLUSIONS

Almost all patients with stable CAD undergoing cardiac catheterization had at least 1 traditional cardiac risk factor. Importantly, the association between multiple cardiac risk factors and the presence of obstructive CAD is substantially stronger in women than men.

The Impact of Ischemic Time on the Predictive Value of High-Sensitivity C-Reactive Protein in ST-Segment Elevation Myocardial Infarction Patients Treated by Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES

The high-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, has been known to be elevated in patients with coronary artery disease. However, there is controversy about the predictive value of hs-CRP after acute myocardial infarction (MI). Therefore, we evaluated the impact of ischemic time on the predictive value of hs-CRP in ST-segment elevation myocardial infarction (STEMI) patients who were treated by primary percutaneous coronary intervention (PCI).

SUBJECTS AND METHODS

We enrolled 5123 STEMI patients treated by primary PCI from the Korean Working Group in Myocardial Infarction and divided enrolled patients into four groups by symptom-to-balloon time (SBT) and level of hs-CRP (Group I: SBT <6 hours and hs-CRP <3 mg/L, Group II: SBT <6 hours and hs-CRP ≥3 mg/L, Group III: SBT ≥6 hours and hs-CRP <3 mg/L, and Group IV: SBT ≥6 hours and hs-CRP ≥3 mg/L). To evaluate the impact of ischemic time on the predictive value of hs-CRP in STEMI patients, we compared the cumulative cardiac event-free survival rate between these four groups.

RESULTS

The sum of the cumulative incidence of all-cause mortality and recurrence of MI was higher in Group IV than in the other groups. However, there was no significant difference among Group I, Group II, and Group III. The Cox-regression analyses showed that an elevated level of hs-CRP (≥3 mg/L) was an independent predictor of long-term cardiovascular outcomes only among late-presenting STEMI patients (p=0.017, hazard ratio=2.462).

CONCLUSION

For STEMI patients with a long ischemic time (≥6 hours), an elevated level of hs-CRP is a poor prognostic factor of long-term cardiovascular outcomes.

Time variability of C-reactive protein: implications for clinical risk stratification

BACKGROUND

C-reactive protein (CRP) is proposed as a screening test for predicting risk and guiding preventive approaches in coronary artery disease (CAD). However, the stability of repeated CRP measurements over time in subjects with and without CAD is not well defined. We sought to determine the stability of serial CRP measurements in stable subjects with distinct CAD manifestations and a group without CAD while carefully controlling for known confounders.

METHODS

We prospectively studied 4 groups of 25 stable subjects each 1) a history of recurrent acute coronary events; 2) a single myocardial infarction ≥7 years ago; 3) longstanding CAD (≥7 years) that had never been unstable; 4) no CAD. Fifteen measurements of CRP were obtained to cover 21 time-points: 3 times during one day; 5 consecutive days; 4 consecutive weeks; 4 consecutive months; and every 3 months over the year. CRP risk threshold was set at 2.0 mg/L. We estimated variance across time-points using standard descriptive statistics and Bayesian hierarchical models.

RESULTS

Median CRP values of the 4 groups and their pattern of variability did not differ substantially so all subjects were analyzed together. The median individual standard deviation (SD) CRP values within-day, within-week, between-weeks and between-months were 0.07, 0.19, 0.36 and 0.63 mg/L, respectively. Forty-six percent of subjects changed CRP risk category at least once and 21% had ≥4 weekly and monthly CRP values in both low and high-risk categories.

CONCLUSIONS

Considering its large intra-individual variability, it may be problematic to rely on CRP values for CAD risk prediction and therapeutic decision-making in individual subjects.

Inflammation and hypertension: are there regional differences?

Hypertension is a chronic disease with global prevalence and incidence rapidly increasing in low and medium income countries. The surveillance of cardiovascular risk factors, such as hypertension, is a global health priority in order to estimate the burden and trends, to appropriately direct resources, and to measure the effect of interventions. We propose here that the adoption of Western lifestyles in low and middle incomes countries has dramatically increased the prevalence of abdominal obesity, which is the main source of proinflammatory cytokines, and that the vascular systemic inflammation produced by adipose tissue contributes to the development of hypertension. The concentration of proinflammatory cytokines is higher in the Latin American population than that reported in developed countries, suggesting a higher susceptibility to develop systemic low-degree inflammation at a given level of abdominal obesity. These particularities are important to be considered when planning resources for health care programs. Moreover, studying these singularities may provide a better understanding of the causes of the burden of cardiovascular risk factors and the remarkable variability in the prevalence of these medical conditions within and between countries.

Interleukin-6 and high-sensitivity C-reactive protein for the prediction of outcomes in non-ST-segment elevation acute coronary syndromes

INTRODUCTION AND OBJECTIVES

High baseline levels of interleukin-6 and C-reactive protein confer an increased risk of mortality in non-ST-segment elevation acute coronary syndrome. The aim of the study was to determine whether serial measurements of interleukin-6 and high-sensitivity C-reactive protein provide additional information to baseline measurements for risk stratification of non-ST-segment elevation acute coronary syndrome.

METHODS

Two hundred and sixteen consecutive patients with non-ST-segment elevation acute coronary syndrome were prospectively included. Blood samples were obtained within 24 h of hospital admission and at 30 days of follow-up. The endpoint was a composite of all-cause death, nonfatal myocardial infarction, or acute decompensated heart failure.

RESULTS

Both interleukin-6 and high-sensitivity C-reactive protein levels decreased from day 1 to day 30, regardless of adverse events (both P<.001). Interleukin-6 levels at 2 time points (interleukin-6 day 1, per pg/mL; hazard ratio=1.006, 95% confidence interval, 1.002-1.010; P=.002 and interleukin-6 day 30, per pg/mL, hazard ratio=1.047, 95% confidence interval, 1.021-1.075, P<.001) were independent predictors of adverse events, whereas high-sensitivity C-reactive protein day 1 and high-sensitivity C-reactive protein day 30 levels were not. Patients with interleukin-6 day 1≤8.24 pg/mL and interleukin-6 day 30≤4.45 pg/mL had the lowest event rates (4.7%), whereas those with both above the median values had the highest event rates (35%). After addition of interleukin-6 day 30 to the multivariate model, C-index increased from 0.71 (95% confidence interval, 0.63-0.78) to 0.80 (95% confidence interval, 0.72-0.86), P=.042, and net reclassification improvement was 0.39 (95% confidence interval, 0.14-0.64; P=.002).

CONCLUSIONS

In this population, both interleukin-6 and high-sensitivity C-reactive protein concentrations decreased after the acute phase. Serial samples of interleukin-6 concentrations improved the prognostic risk stratification of these patients.

The impact of diurnal fasting during Ramadan on the lipid profile, hs-CRP, and serum leptin in stable cardiac patients

AIM

To study the effect of strict prolonged fasting on lipid profile, serum leptin, and high- sensitivity C-reactive protein (hs-CRP) in patients with different stable cardiac illnesses and look for associated new cardiac events and any correlation between entire variables.

METHODS

A total of 56 patients of different stable cardiac illnesses were followed in our cardiology outpatient for 3 months. Data concerning their ability to fast were collected: New York Heart Association class of congestive cardiac failure, angina class, previous myocardial infarction, previous coronary artery bypass graft, percutaneous coronary intervention, severity of valvular lesion, metallic prosthetic valve, and traditional risk factors (diabetes mellitus, insulin requirement, hypertension, hypercholesterolemia, smoking habit, and obesity). Detailed clinical examination and electrocardiography were performed in all patients in three consecutive visits before, during, and after Ramadan. Echocardiographic and angiographic findings and medication plans were collected from patient records. Lipid profile, serum leptin, and hs-CRP were assessed before, during, and after Ramadan.

RESULTS

All patients fasted during Ramadan: 80.4% were male, 67.9% were aged >50 years, 71.4% had no change in their symptoms during fasting while 28.6% felt better. No patient has deteriorated. 91.1% of the patients were compliant with medicine during Ramadan, 73.2% after. 89.3% were compliant with diet during Ramadan with no significant change in body weight in the follow-up period. No cardiac or noncardiac morbidity or mortality was reported. High- density lipoprotein-cholesterol (HDL-C) decreased significantly during compared to before fasting (P = 0.012). Low-density lipoprotein-cholesterol (LDL-C) significantly increased during compared to before fasting (P = 0.022). No statistically significant changes were observed in total cholesterol (TC), triglycerides (TG), serum leptin, or hs-CRP. Significant correlation was observed between TC and hs-CRP during fasting (P = 0.036), but not with TG, LDL-C, or HDL-C (P > 0.05). Neither of these correlated with serum leptin (P > 0.05), but significant correlation was observed between hs-CRP and serum leptin (P < 0.05).

CONCLUSION

Ramadan fasting in stable cardiac patients has no effect on their clinical status, serum leptin, or hs-CRP, but results in decrease in HDL-C, increase in LDL-C, with significant correlation between TC and hs-CRP during Ramadan, but not with TG, LDL-C, or HDL-C, and with significant correlation between hs-CRP and serum leptin before, during, and after fasting.

Epidemic of cardiometabolic diseases: a Latin American point of view

Poor early nutrition has varying effects on subsequent cardiometabolic disease (CMD) rates. Fetal and neonatal periods are critical for the development and growth of the systems involved in CMD. The increased rates of hypertension, metabolic syndrome, diabetes mellitus type 2, renal failure and heart failure observed nowadays in Latin America could be the result of the discrepancy between the nutritional environment during fetal and early life and the adult environment. This discrepancy causes a mismatch between the fetal programming of the subject and its adult circumstances created by the imposition of new life styles. The two largest international studies on cardiovascular risk factors for a first myocardial infarction (INTERHEART) and stroke (INTERSTROKE) demonstrated that in Latin America the factor with the highest attributable population risk was abdominal obesity. The conflict between the earlier programming and the later presence of abdominal obesity produced a higher sensitivity of this population to develop a state of low-degree inflammation, insulin resistance and the epidemic of CMD to lower levels of abdominal adiposity. The relative roles played by genetic and environmental factors and the interaction between the two are the still subjects of great debate. We have reviewed the relationship between maternal malnutrition, early growth restriction, epigenetic adaptations, and the later occurrence of abdominal obesity and CMD in Latin America.

Procoagulant activity, but not number, of microparticles increases with age and in individuals after a single venous thromboembolism

The Calibrated Automated Thrombogram (CAT), a plate-based assay that measures thrombin generation and inhibition in plasma samples, is modified to measure the procoagulant activity of phospholipid associated with plasma microparticles (MP). The assay uses a tissue factor trigger without addition of 4 μM exogenous phospholipid (PL) used in the standard CAT. Calibrated with 4:1 posphatidylcholine- phosphatidylserine (PCPS) liposomes, the assay defines a median of 40 nM procoagulant phospholipid (PPL) equivalents in plasma containing MPs from 50 normal donors, with a range from 20 - 200 nM. Like the standard CAT, the modified assay detected no difference in plasma from 36 individuals with a history of a single episode of venous thromboembolism. However the male cases had double the PPL activity, as measured by rate of thrombin generation, of females; and there was a significant correlation among cases of increased thrombin generation with age. In contrast, there were no gender disparities or age correlations among control plasmas. The findings suggest that procoagulant activity of plasma microparticles, facilitated by a simplified, one-stage plate-based assay, offer a promising avenue of investigation of mechanisms and management of venous thromboembolic disorders.

Long-term outcome after drug-eluting stents implantation: target lesion versus nontarget lesion repeated intervention

We sought to investigate the relative clinical significance of target and nontarget lesions repeated percutaneous coronary intervention (re-PCI) in patients implanted with drug-eluting stents (DES). Out of 2626 consecutive DES patients, we retrospectively selected 166 (6.3%; 123 males, aged 65±10 years) who had a clinically-driven re-PCI over a mean follow-up of 15 months. Seventy-five patients (45%) underwent the second procedure for disease progression in nontarget lesions (nontarget lesion re-PCI group) while 91 (55%) showed target lesion in-stent restenosis or thrombosis (target lesion re-PCI group), with no significant intergroup difference in the temporal trends of re-PCI. The prevalence of stable coronary artery disease and acute coronary syndromes (ACS) was 22% and 78% in the target lesion re-PCI vs. 81% and 19% in the nontarget lesion re-PCI group (overall p<0.001), respectively. In-stent restenosis accounted for 75% of second procedures in the target lesion re-PCI group and presented as an ACS in 72% of cases. The need for a new PCI in DES patients is relatively low in a real world setting. Stent-related events in the target lesion and progression of disease in nontarget lesions account to a similar extent for re-PCI, although their clinical presentation is strikingly different. The most common presentation of events related to previously treated lesions is an unstable syndrome, which provides support to the concept that also restenosis in a DES should not be considered a clinically benign entity.

Heart rate variability and biomarkers of systemic inflammation in patients with stable coronary heart disease: findings from the Heart and Soul Study

BACKGROUND

Chronic low-grade systemic inflammation is a key component in atherogenesis. Decreased heart rate variability (HRV), a strong predictor of cardiovascular events, has been associated with elevations in circulating levels of C-reactive protein (CRP), interleukin (IL)-6, and fibrinogen in apparently healthy individuals. We investigated whether decreased HRV is associated with inflammatory markers in patients with coronary heart disease (CHD).

METHODS

We studied the relationship between HRV and CRP, IL-6, and fibrinogen in 862 outpatients with CHD. All participants provided fasting blood samples and underwent 24-h ambulatory monitoring to assess time-domain measures of HRV (MeanNN, SDNN, SDANN, and RMSSD). Regression analyses were adjusted for age, sex, ethnicity, body mass index, smoking, diabetes, beta blocker use, and cardiopulmonary history.

RESULTS

MeanNN, SDNN, and SDANN were significantly and inversely associated with CRP and IL-6 levels in age-adjusted models and after adjustment for all covariates (p ≤ 0.02). MeanNN, SDNN, and SDANN were also inversely associated with fibrinogen levels in age-adjusted models (p < 0.03), but not significantly so in multivariable-adjusted models. Reduced vagal modulation of heart rate (RMSSD) was not significantly associated with any inflammatory measures.

CONCLUSIONS

Reduced cardiac autonomic control is associated with increased systemic inflammation in patients with stable CHD. This relationship was largely independent of important covariates.

Comparison of plasminogen activator inhibitor-1, tissue type plasminogen activator antigen, fibrinogen, and D-dimer levels in various age decades in patients with type 2 diabetes mellitus and stable coronary artery disease (from the BARI 2D trial)

Advancing age is associated with downregulation of fibrinolysis in normal subjects. This is reflected by high concentrations of plasminogen activator inhibitor-1 (PAI-1) in the blood, which has been implicated in the increasing cardiovascular morbidity and mortality with age. We sought to delineate the relation of PAI-1 to several factors, including age, gender, and ethnicity in patients with type 2 diabetes mellitus (DM) and stable coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. A total of 2,321 patients with DM and stable coronary artery disease in the BARI 2D trial were grouped by age (<50, 50 to 59, 60 to 69, and > or =70 years). Tissue-type plasminogen activator antigen, PAI-1 antigen and activity, fibrinogen, and D-dimer were quantified at baseline. The PAI-1 antigen (p <0.001) and its activity (p <0.001) and their ratios to tissue-type plasminogen activator (p <0.001) were all paradoxically lower with advancing age. In contrast, D-dimer (p <0.0001) was elevated. The fibrinogen level was greatest in the oldest age group (p = 0.01). The level of tissue-type plasminogen activator antigen did not vary with age. These age-related differences were observed primarily in men and non-Hispanic white and Asian/other participants. In conclusion, PAI-1 is inversely related to age in patients with DM and stable coronary artery disease and is associated with elevation of D-dimer, reflecting augmented fibrinolysis. The unexpected profibrinolytic state seen with advancing age and DM might reflect a protective phenomenon resulting from enhanced survival of some older patients with DM that endowed the older patients with longevity sufficient to enable them to participate in the BARI 2D trial. Targeting the factors that led to the downregulation of PAI-1 in older patients with type 2 DM might offer an attractive strategy for reducing cardiovascular risk.

Circulating inflammatory and hemostatic biomarkers are associated with risk of myocardial infarction and coronary death, but not angina pectoris, in older men

AIMS

The extent to which hemostatic and inflammatory biomarkers are related to angina pectoris as compared with myocardial infarction (MI) remains uncertain. We examined the relationship between a wide range of inflammatory and hemostatic biomarkers, including markers of activated coagulation, fibrinolysis and endothelial dysfunction and viscosity, with incident myocardial infarction (MI) or coronary heart disease (CHD) death and incident angina pectoris uncomplicated by MI or CHD death in older men.

METHODS

A prospective study of 3217 men aged 60-79 years with no baseline CHD (angina or MI) and who were not on warfarin, followed up for 7 years during which there were 198 MI/CHD death cases and 220 incident uncomplicated angina cases.

RESULTS

Inflammatory biomarkers [C-reactive protein (CRP), interleukin-6, fibrinogen], plasma viscosity and hemostatic biomarkers [von Willebrand factor (VWF) and fibrin D-dimer] were associated with a significant increased risk of MI/CHD death but not with uncomplicated angina even after adjustment for age and conventional risk factors. Adjustment for CRP attenuated the relationships between VWF, fibrin D-dimer and plasma viscosity with MI/CHD death. Comparisons of differing associations with risk of MI/CHD deaths and uncomplicated angina were significant for the inflammatory markers (P < 0.05) and marginally significant for fibrin D-dimer (P = 0.05). In contrast, established risk factors including blood pressure and high-density lipoprotein (HDL)-cholesterol were associated with both MI/CHD death and uncomplicated angina.

CONCLUSION

Circulating biomarkers of inflammation and hemostasis are associated with incident MI/CHD death but not incident angina uncomplicated by MI or CHD death in older men.

Functional T‐lymphocyte dichotomy in the peripheral blood of patients with unstable angina

OBJECTIVES

Herein, we investigated the percentage of T-helper (Th1) and Th2 cells among the general T-cell population in the peripheral blood of patients with stable angina (SA) and unstable angina (UA).

BACKGROUND

Recent evidence suggests that Th1 cells and the cytokines that they secrete (especially IFN-gamma) have a role in the activation of macrophages, promotion of clot formation and destabilization of atherosclerotic plaques. Thus, Th1 cytokines may contribute to the initiation and progression of UA. In contrast, cytokines secreted by Th2 cells (e.g. IL-10) are known to inhibit activation and proliferation of Th1 cells and the secretion of IFN-gamma, lysosomal enzymes and metalloproteinases. Therefore, we sought to examine whether the ratio of IFN-gamma to IL-10 secreting cells is altered in patients with UA.

METHODS

The percentage of Th1 and Th2 cells among the general T-cell population was determined by fluorescent intracellular cytokine staining (IFN-gamma and IL-10, out of the total CD3 positive cells).

RESULTS

The percentage of T-cells positive for intracellular IFN-gamma was significantly higher in patients with UA (n = 22) in comparison with SA (n = 20) patients (39.0+/-2.8% and 29.6+/-2.7%, respectively. P = 0.02). There was no significant difference in intracellular IL-10 positive cells between the two groups. In addition, there was no significant difference in the ratio between the intracellular IFN-gamma positive cells and the intracellular IL-10 positive cells.

CONCLUSIONS

There is an increased activity of Th1 cells in patients with UA in comparison with patients with SA. There is no evidence of heightened activity of Th2 cells in either group. Thus, IFN-gamma secreted by peripheral blood T-lymphocytes,may be an important immunomodulator contributing to destabilization of the atheromatous plaque lying at the base of the etiopathogenesis of unstable angina.

CRP and the risk of atherosclerotic events

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

[The development and effects of an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention]

PURPOSE

This study was conducted to develop and to determine the effects of an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention.

METHODS

Subjects consisted of 58 CAD patients (experimental group: 30, control group: 28). The experimental group participated in an integrated symptom management program for 6 months which was composed of tailored education, stress management, exercise, diet, deep breathing, music therapy, periodical telephone monitoring and a daily log. The control group received the usual care.

RESULTS

The experimental group significantly decreased symptom experiences and the level of LDL compared to the control group. The experimental group significantly increased self care activity and quality of life compared to the control group. Although no significant difference was found in cardiac recurrence, the experimental group had fewer recurrences.

CONCLUSION

These results suggest that an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention can improve symptom aggravation, recurrent rate, self care activity and quality of life. Nursing interventions are needed to maintain and further enhance the quality of life of these patients and the interventions should be implemented in the overall transition period.

Vascular cells contribute to atherosclerosis by cytokine- and innate-immunity-related inflammatory mechanisms

Cardiovascular diseases are the human diseases with the highest death rate and atherosclerosis is one of the major underlying causes of cardiovascular diseases. Inflammatory and innate immune mechanisms, employing monocytes, innate receptors, innate cytokines, or chemokines are suggested to be involved in atherogenesis. Among the inflammatory pathways the cytokines are central players. Plasma levels of cytokines and related proteins, such as CRP, have been investigated in cardiovascular patients, tissue mRNA expression was analyzed and correlations to vascular diseases established. Consistent with these findings the generation of cytokine-deficient animals has provided direct evidence for a role of cytokines in atherosclerosis. In vitro cell culture experiments further support the suggestion that cytokines and other innate mechanisms contribute to atherogenesis. Among the initiation pathways of atherogenesis are innate mechanisms, such as toll-like-receptors (TLRs), including the endotoxin receptor TLR4. On the other hand, innate cytokines, such as IL-1 or TNF, or even autoimmune triggers may activate the cells. Cytokines potently activate multiple functions relevant to maintain or spoil homeostasis within the vessel wall. Vascular cells, not least smooth muscle cells, can actively contribute to the inflammatory cytokine-dependent network in the blood vessel wall by: (i) production of cytokines; (ii) response to these potent cell activators; and (iii) cytokine-mediated interaction with invading cells, such as monocytes, T-cells, or mast cells. Activation of these pathways results in accumulation of cells and increased LDL- and ECM-deposition which may serve as an 'immunovascular memory' resulting in an ever-growing response to subsequent invasions. Thus, vascular cells may potently contribute to the inflammatory pathways involved in development and acceleration of atherosclerosis.

Are nutrition-induced epigenetic changes the link between socioeconomic pathology and cardiovascular diseases?

The prevalence of cardiovascular diseases (CVD) and diabetes mellitus type 2 (DM 2) is decreasing in developed countries despite the increase in the percentage of subjects with obesity and other well-recognized cardiovascular risk factors. In contrast, the recent transition of the economic model experienced by developing countries, characterized by the adoption of a Western lifestyle, that we have named "socioeconomic pathology," has led to an increase in the burden of CVD. It has been demonstrated that conventional cardiovascular risk factors in developed and developing countries are the same. Why then does the population of developing countries currently have a higher incidence of CVD than that of developed countries if they share the same risk factors? We have proposed the existence of a higher susceptibility to the development of systemic inflammation at low levels of abdominal obesity in the population of developing countries and the consequent endothelial dysfunction, insulin resistance, DM 2, and CVD. In contrast, an important percentage of obese people living in developed countries have a healthy phenotype and low risk of developing CVD and DM 2. Human epidemiologic studies and experimental dietary interventions in animal models have provided considerable evidence to suggest that nutritional imbalance and metabolic disturbances early in life may later have a persistent effect on an adult's health that may even be transmitted to the next generations. Epigenetic changes dependent on nutrition could be key in this evolutionary health behavior, acting as a buffering system, permitting the adaptation to environmental conditions by silencing or increasing the expression of certain genes.

C-reactive protein: the harbinger of cardiovascular diseases

Coronary heart disease remains the major cause of mortality and morbidity in the United States and other western countries despite major advances in its treatment. During the last decades, many markers of coronary artery disease have been found which help predict future risk of cardiovascular events. High-sensitivity C-reactive protein has been studied extensively and was seen to be associated with a higher risk of cardiovascular events in patients with acute coronary syndromes and/or peripheral artery disease. Discussed in this review is the latest literature about this marker and its association with cardiovascular disease, as well as the latest therapeutic options available.

Mild inflammatory activation of mammary arteries in patients with acute coronary syndromes

Acute coronary syndromes (ACS) are characterized by multiple unstable coronary plaques and elevated circulating levels of inflammatory biomarkers. The endothelium of internal mammary arteries (IMA), which are atherosclerosis resistant, is exposed to proinflammatory stimuli as vessels that develop atherosclerosis. Our study investigated the IMA endothelial expression of inflammatory molecules in patients with ACS or chronic stable angina (CSA). IMA demonstrated normal morphology, intact endothelial lining, and strong immunoreactivity for glucose transporter 1. E-selectin expression was observed more frequently in IMA of ACS patiention than CSA patients (ACS 61% vs. CSA 14%, P = 0.01). High fluorescence for major histocompatibility complex (MHC) was significantly more frequent on the luminal endothelium (ACS 66.7% vs. CSA 17.6%, P = 0.001 for class I; and ACS 66.7% vs. CSA 6.2%, P = 0.0003 for class II-DR) and on the vasa vasorum (ACS 92.9% vs. CSA 33.3% and 7.7%, P = 0.0007 and P < 0.0001 for class I and class II-DR, respectively) of ACS patients than CSA patients. ICAM-1, VCAM-1, Toll-like receptor 4, tissue factor, IL-6, inducible nitric oxide synthase, and TNF-alpha expression were not significantly different in ACS and CSA. Circulating C-reactive protein [ACS 4.8 (2.6-7.3) mg/l vs. CSA 1.8 (0.6-3.5) mg/l, P = 0.01] and IL-6 [ACS 4.0 (2.6-5.5) pg/ml vs. CSA 1.7 (1.4-4.0) pg/ml, P = 0.02] were higher in ACS than CSA, without a correlation with IMA inflammation. The higher E-selectin, MHC class I and MHC class II-DR on the endothelium and vasa vasorum of IMA from ACS patients suggests a mild, endothelial inflammatory activation in ACS, which can be unrelated to the presence of atherosclerotic coronary lesions. These findings indicated IMA as active vessels in coronary syndromes.

Fate of incidental, asymptomatic lesions discovered during percutaneous coronary intervention

The authors aimed to determine the incidence and angiographic features associated with plaque progression requiring nontarget lesion percutaneous coronary intervention after culprit lesion percutaneous coronary intervention. Of 945 consecutive percutaneous coronary interventions reviewed, 100 patients who required nontarget lesion percutaneous coronary intervention in the following year of the index percutaneous coronary intervention were found and compared with 100 consecutive patients who did not require nontarget lesion percutaneous coronary intervention. Patients with restenosis were excluded. Incidence of clinical plaque progression leading to additional nontarget lesion percutaneous coronary intervention in the year after an index percutaneous coronary intervention was found to be 10.5%. In multivariable logistic regression analyses, the predictors of plaque progression were multivessel disease, unstable angina pectoris, diabetes mellitus, prior percutaneous coronary intervention, and lack of statin use. Initially, lesions that lead to repercutaneous coronary intervention were mostly nonsignificant. Clinical presentation of plaque progression was mostly acute coronary syndrome. Results emphasize the need for further study to refine the methods to identify potentially vulnerable but clinically silent plaques.

Comparison of serum levels of inflammatory markers and allelic variant of interleukin-6 in patients with acute coronary syndrome and stable angina pectoris

OBJECTIVES

Although the relationship between atherosclerosis and inflammatory cells has been recognized in recent years, the effect of interleukin-6 (IL-6) genetic variants associated with atherosclerosis is still controversial. Therefore, we investigated the association between IL-6 polymorphism and levels of IL-6 in patients with coronary artery disease (CAD).

METHODS

We conducted a case-control study on 294 unrelated participants who were referred to the cardiology department of the university hospital for coronary angiography because of suspected ischemic heart disease. Group I comprised patients with clinically acute coronary syndrome, and group II comprised patients (individuals matched for age and sex) with clinically stable angina pectoris; both groups were categorized, based on their angiographic findings, as either having angiographically documented less extensive CAD (1 vessel narrowed) or extensive CAD (> or =2 vessels narrowed). They were studied to examine effect of the IL-6 gene variants in CAD. Genotyping was determined by polymerase chain reaction.

RESULTS

The IL-6 G/C-174 polymorphism was found in 19 of 106 (18%) in group I and in four of 188 (2%) in group II (P<0.001). Median IL-6 levels were significantly higher in group I (6.7+/-13.6 pg/ml) than in group II (4.1+/-3.8 pg/ml) (P<0.05). In addition, high sensitivity C-reactive protein levels were significantly higher in group I (8.2+/-6.2 mg/dl) than in group II (4.6+/-3.4 mg/dl) (P<0.001).

CONCLUSION

These results demonstrated that the presence of the IL-6 G/C-174 polymorphism and increased IL-6 and high sensitivity C-reactive protein levels are strongly associated with the inflammatory system and the course of clinical and hemodynamically significant CAD.

Inflammation and ageing

An enhanced inflammatory state - i.e. "inflammatory/pathogen burden" - in the elderly on the one hand results from physiological immunosenescence and on the other hand is modified by the individual immune history: the latter is determined by sequential infectious/pathogenic events ("multiple hits"). Immunosenescence may prompt ageing of other organs. Cardiac ageing can be assessed by analysing heart rate variability. We present our hypothesis that the increasing "inflammatory/pathogen burden" of each organism during a lifetime significantly contributes to the cardiac ageing process. This hypothesis is grounded on the fact that a characteristic feature of the ageing heart - a narrowed heart rate variability - can be experimentally induced in humans by an inflammatory stimulus (endotoxin).

Culprit only versus complete coronary revascularization during primary PCI

BACKGROUND

Primary percutaneous intervention (PCI) is the treatment of choice for acute ST elevation myocardial infarction. Currently it is recommended to treat only the culprit artery during the acute procedure. Only few reports describe the results of simultaneous non-culprit vessel PCI. The study hypothesizes that complete revascularization during primary PCI can be achieved safely with an improved clinical outcome during the indexed hospitalization.

METHODS

One hundred and twenty consecutive patients presented with acute ST elevation myocardial infarction (STEMI) and multivessel coronary stenosis. Ninety five underwent complete revascularization (CR): the culprit artery was opened first followed by dilatation of the other significantly narrowed arteries. Twenty five had culprit only revascularization (COR): the culprit artery only was dilated and the other arteries were left untreated during the primary PCI.

RESULTS

Complete revascularization (CR) was associated with reduced incidence of major cardiac events (recurrent ischemia, reinfarction, acute heart failure and in-hospital mortality 16.7 versus 52%, P=0.0001). There was a significant lower rate of recurrent ischemic episodes (4.2% versus 32%, P=0.002), myocardial reinfarction (3.1% versus 16%, P=0.01), reintervention (7.3% versus 32%, P=0.001), acute heart failure (9.4% versus 32%, P=0.01) during the indexed hospitalization and shorter hospitalization (4.4+/-1.27 versus 9.6+/-2.3, P=0.001) in the CR group. Transient renal dysfunction was more common in CR patients (8.4% versus 4% P=0.01). In-hospital and one year mortality were similar between the two groups.

CONCLUSION

Multivessel PCI during acute myocardial infarction is feasible and safe. Complete revascularization resulted in an improved acute clinical course. These data support a policy of complete revascularization during primary PCI for STEMI.

The Quebec Heart Institute: 50 years of excellence in cardiology

The Quebec Heart Institute was established in 1957 at the Laval Hospital in Sainte-Foy, Quebec. Since then, clinical and research activities have made this Institute one of the largest tertiary care cardiology centres in Canada. With its vast catchment area of more than 3,000,000 people, the Institute has developed a strong collaboration with referral physicians centred on clinical, teaching and research interests. The Institute pioneered several aspects of cardiac surgery, invasive cardiology, echocardiography, basic research and, more recently, a network of researchers and clinicians working in the field of 'metabolic cardiology'. The first 50 years of the Quebec Heart Institute are depicted in this overview, which will also introduce this special supplement to The Canadian Journal of Cardiology.

Do plasma biomarkers of coagulation and fibrinolysis differ between patients who have experienced an acute myocardial infarction versus stable exertional angina?

BACKGROUND

Circulating concentrations of proteins associated with coagulation and fibrinolysis may differ between individuals with coronary artery disease (CAD) who develop an acute myocardial infarction (AMI) rather than stable exertional angina.

METHODS

We compared plasma concentrations of fibrinogen, d-dimer, tissue-type plasminogen activator, and plasminogen activator inhibitor-1 (PAI-1) between patients whose first clinical manifestation of CAD was an AMI (n = 198) rather than stable exertional angina (n = 199). We also compared plasma concentrations of these proteins between patients with symptomatic CAD (either AMI or stable angina; n = 397) and healthy, control subjects (n = 197) to confirm the sensitivity of these assays to detect epidemiologic associations.

RESULTS

At a median of 15 weeks after presentation, patients with AMI had slightly higher d-dimer concentrations than patients with stable angina (P = .057), but were not significantly different in other markers. By contrast, fibrinogen, d-dimer, and tissue-type plasminogen activator were significantly higher (P < .001) and PAI-1 lower in patients with CAD than in healthy control subjects. After statistical adjustment for clinical covariates, cardiac risk factors, medications, and other confounders, fibrinogen, d-dimer, and PAI-1 remained significantly associated with CAD.

CONCLUSION

Selected plasma markers of coagulation and fibrinolysis did not distinguish patients presenting with AMI from those with stable exertional angina.

C-reactive protein, bezafibrate, and recurrent coronary events in patients with chronic coronary heart disease

BACKGROUND

Elevated C-reactive protein (CRP) levels are related to increased coronary risk in healthy subjects and in patients with acute coronary syndromes. The aims of the present study were to assess the following: (1) the association between CRP and subsequent coronary risk in patients with chronic coronary heart disease (CHD), (2) the effect of long-term bezafibrate treatment on CRP levels, and (3) to evaluate the consequences of change in CRP level over time on subsequent risk.

METHODS

Patients with chronic CHD (n = 3122) were recruited to a secondary prevention study that assessed the efficacy of bezafibrate versus placebo. C-reactive protein was measured in plasma samples collected at prerandomization and after 2 years of follow-up. Mean follow-up time was 6.2 years. Primary end point was fatal and nonfatal myocardial infarction and sudden cardiac death.

RESULTS

Increased baseline CRP levels were associated with increased risk (hazard ratios [HRs] per unit of log-transformed CRP level change) of myocardial infarction (HR 1.17, 95% CI 1.03-1.33), the primary end point (HR 1.19, 95% CI 1.06-1.34), total death (HR 1.19, 95% CI 1.02-1.40) and cardiac death (HR 1.28, 95% CI 1.04-1.59). After 2 years, CRP levels increased by 3.0% (from a mean level of 3.44 mg/L) in the bezafibrate group and by 3.7% (from 3.49 mg/L) in the placebo group. C-reactive protein levels after 2 years were associated with increased subsequent cardiovascular risk.

CONCLUSIONS

Baseline CRP and 2-year CRP levels were associated with subsequent risk of myocardial infarction and death in patients with chronic CHD. Bezafibrate did not reduce CRP levels as compared with placebo.

Premature compared with late onset of coronary artery disease: young patients show a severe defect in fibrinolytic response to venous occlusion

Inflammatory processes play a role in the onset of acute cardiovascular events associated with activation of the coagulation system whereas the fibrinolytic system may prevent local thrombus formation. We compared 25 patients with premature coronary artery disease (CAD) (first ST-elevation myocardial infarction, < 55 years old) with 25 sex-matched patients older than 55 years at their first myocardial infarction. Six months after the acute event, patients with late onset of CAD showed a significantly higher increase of tissue-type plasminogen activator activity during venous occlusion compared with patients with premature CAD (P < 0.005). Prothrombin fragment 1+2 was higher in patients with late-onset CAD (P < 0.05), whereas the inflammatory markers C-reactive protein and soluble intercellular cell adhesion molecule-1 were not different in both groups. A multivariate analysis including cardiovascular risk factors showed that the tissue-type plasminogen activator response to venous occlusion was independently associated with patient age at onset of first ST-elevation myocardial infarction. Although in our series high age was associated with a prothrombotic state, a high fibrinolytic capacity might have some beneficial effect and contribute to a delayed onset of adverse cardiovascular events in these patients.

Predictive Value of Biphasic Response During Dipyridamole Echocardiography Test in the Low-risk Group of Patients After Acute Myocardial Infarction

To investigate whether biphasic response during dipyridamole echocardiography test (DET), which represents viable but potentially ischemic myocardium in the infarcted region, affects prognosis of patients after uncomplicated acute myocardial infarction, we performed high-dose DET in 80 consecutive patients younger than 65 years with first acute myocardial infarction and preserved left ventricular function. Patients were followed up for 27 +/- 12 months for new coronary events. According to DET results all patients were classified into 4 groups: group 1 consisted of 20 patients with biphasic response; group 2 included 14 patients with sustained improvement in regional contractility; group 3 consisted of 24 patients showing no change in contractility; and group 4 included 22 patients with worsening response. Cumulative survival free of total coronary events was significantly lower in group 1 patients compared with all other groups (P < .05). By multivariate Cox analysis biphasic response was the strongest independent predictor of stable angina pectoris (odds ratio = 12.1, P = .0002), followed by hyperlipoproteinemia (odds ratio = 5.9, P = .006). On the other hand, development of acute coronary syndromes could not have been predicted by actual clinical or DET parameters.

The Potential Relevance of the Multiple Lipid-Independent (Pleiotropic) Effects of Statins in the Management of Acute Coronary Syndromes

Emerging data suggest that acute presentations of coronary artery disease may involve a complex interplay between the vessel wall, inflammatory cells, and the coagulation cascade. Although a culprit thrombotic lesion may be treated effectively by antithrombotic therapy and revascularization, this will have little effect on the global processes that determine recurrent events at non-culprit sites. Thus, additional systemic treatment is required to modulate the adverse biological features that are the hallmark of acute coronary syndromes (ACS). Statins possess multiple beneficial effects that are independent of low-density-lipoprotein cholesterol (LDL-C) lowering and that have favorable effects on inflammation, the endothelium, and the coagulation cascade. In the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE IT-TIMI 22) trial, differences were seen based on achieved LDL-C that could be further discriminated by the achieved C-reactive protein level. Studies of non-vascular disease such as multiple sclerosis have shown that statins reduce inflammation, supporting the presence of lipid-independent effects of statins. This review focuses on the potential importance of these effects in the management of ACS.