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Li B, Zhang Y, Zheng Y, Cai H. The causal effect of Helicobacter pylori infection on coronary heart disease is mediated by the body mass index: a Mendelian randomization study. Sci Rep 2024; 14:1688. [PMID: 38243041 PMCID: PMC10798959 DOI: 10.1038/s41598-024-51701-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024] Open
Abstract
The association between Helicobacter pylori (H. pylori) infection and coronary heart disease (CHD) remains controversial, with an unclear causal link. This study employed bidirectional Mendelian randomization (MR) method, using H. pylori infection as the exposure, to investigate its causal relationship with CHD diagnosis, prognosis, and potential pathogenesis. H. pylori infection exhibited a causal association with body mass index (BMI) (β = 0.022; 95% CI 0.008-0.036; p = 0.001). Conversely, there was no discernible connection between H. pylori infection and the diagnosis of CHD (OR = 0.991; 95% CI 0.904-1.078; p = 0.842; IEU database; OR = 1.049; 95% CI 0.980-1.118; p = 0.178; FinnGen database) or CHD prognosis (OR = 0.999; 95% CI 0.997-1.001; p = 0.391; IEU database; OR = 1.022; 95% CI 0.922-1.123; p = 0.663; FinnGen database). Reverse MR analysis showed no causal effect of CHD on H. pylori infection. Our findings further support that H. pylori infection exerts a causal effect on CHD incidence, mediated by BMI. Consequently, eradicating or preventing H. pylori infection may provide an indirect clinical benefit for patients with CHD.
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Affiliation(s)
- Bing Li
- Department of Cardiovascular Diseases, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Yaoting Zhang
- Department of Cardiovascular Diseases, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Yang Zheng
- Department of Cardiovascular Diseases, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
| | - He Cai
- Department of Cardiovascular Diseases, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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Sethi NJ, Safi S, Korang SK, Hróbjartsson A, Skoog M, Gluud C, Jakobsen JC. Antibiotics for secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2021; 2:CD003610. [PMID: 33704780 PMCID: PMC8094925 DOI: 10.1002/14651858.cd003610.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronary heart disease is the leading cause of mortality worldwide with approximately 7.4 million deaths each year. People with established coronary heart disease have a high risk of subsequent cardiovascular events including myocardial infarction, stroke, and cardiovascular death. Antibiotics might prevent such outcomes due to their antibacterial, antiinflammatory, and antioxidative effects. However, a randomised clinical trial and several observational studies have suggested that antibiotics may increase the risk of cardiovascular events and mortality. Furthermore, several non-Cochrane Reviews, that are now outdated, have assessed the effects of antibiotics for coronary heart disease and have shown conflicting results. No previous systematic review using Cochrane methodology has assessed the effects of antibiotics for coronary heart disease. OBJECTIVES We assessed the benefits and harms of antibiotics compared with placebo or no intervention for the secondary prevention of coronary heart disease. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-EXPANDED, and BIOSIS in December 2019 in order to identify relevant trials. Additionally, we searched TRIP, Google Scholar, and nine trial registries in December 2019. We also contacted 11 pharmaceutical companies and searched the reference lists of included trials, previous systematic reviews, and other types of reviews. SELECTION CRITERIA Randomised clinical trials assessing the effects of antibiotics versus placebo or no intervention for secondary prevention of coronary heart disease in adult participants (≥18 years). Trials were included irrespective of setting, blinding, publication status, publication year, language, and reporting of our outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. Our primary outcomes were all-cause mortality, serious adverse event according to the International Conference on Harmonization - Good Clinical Practice (ICH-GCP), and quality of life. Our secondary outcomes were cardiovascular mortality, myocardial infarction, stroke, and sudden cardiac death. Our primary time point of interest was at maximum follow-up. Additionally, we extracted outcome data at 24±6 months follow-up. We assessed the risks of systematic errors using Cochrane 'Rosk of bias' tool. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes. We calculated absolute risk reduction (ARR) or increase (ARI) and number needed to treat for an additional beneficial outcome (NNTB) or for an additional harmful outcome (NNTH) if the outcome result showed a beneficial or harmful effect, respectively. The certainty of the body of evidence was assessed by GRADE. MAIN RESULTS We included 38 trials randomising a total of 26,638 participants (mean age 61.6 years), with 23/38 trials reporting data on 26,078 participants that could be meta-analysed. Three trials were at low risk of bias and the 35 remaining trials were at high risk of bias. Trials assessing the effects of macrolides (28 trials; 22,059 participants) and quinolones (two trials; 4162 participants) contributed with the vast majority of the data. Meta-analyses at maximum follow-up showed that antibiotics versus placebo or no intervention seemed to increase the risk of all-cause mortality (RR 1.06; 95% CI 0.99 to 1.13; P = 0.07; I2 = 0%; ARI 0.48%; NNTH 208; 25,774 participants; 20 trials; high certainty of evidence), stroke (RR 1.14; 95% CI 1.00 to 1.29; P = 0.04; I2 = 0%; ARI 0.73%; NNTH 138; 14,774 participants; 9 trials; high certainty of evidence), and probably also cardiovascular mortality (RR 1.11; 95% CI 0.98 to 1.25; P = 0.11; I2= 0%; 4674 participants; 2 trials; moderate certainty of evidence). Little to no difference was observed when assessing the risk of myocardial infarction (RR 0.95; 95% CI 0.88 to 1.03; P = 0.23; I2 = 0%; 25,523 participants; 17 trials; high certainty of evidence). No evidence of a difference was observed when assessing sudden cardiac death (RR 1.08; 95% CI 0.90 to 1.31; P = 0.41; I2 = 0%; 4520 participants; 2 trials; moderate certainty of evidence). Meta-analyses at 24±6 months follow-up showed that antibiotics versus placebo or no intervention increased the risk of all-cause mortality (RR 1.25; 95% CI 1.06 to 1.48; P = 0.007; I2 = 0%; ARI 1.26%; NNTH 79 (95% CI 335 to 42); 9517 participants; 6 trials; high certainty of evidence), cardiovascular mortality (RR 1.50; 95% CI 1.17 to 1.91; P = 0.001; I2 = 0%; ARI 1.12%; NNTH 89 (95% CI 261 to 49); 9044 participants; 5 trials; high certainty of evidence), and probably also sudden cardiac death (RR 1.77; 95% CI 1.28 to 2.44; P = 0.0005; I2 = 0%; ARI 1.9%; NNTH 53 (95% CI 145 to 28); 4520 participants; 2 trials; moderate certainty of evidence). No evidence of a difference was observed when assessing the risk of myocardial infarction (RR 0.95; 95% CI 0.82 to 1.11; P = 0.53; I2 = 43%; 9457 participants; 5 trials; moderate certainty of evidence) and stroke (RR 1.17; 95% CI 0.90 to 1.52; P = 0.24; I2 = 0%; 9457 participants; 5 trials; high certainty of evidence). Meta-analyses of trials at low risk of bias differed from the overall analyses when assessing cardiovascular mortality at maximum follow-up. For all other outcomes, meta-analyses of trials at low risk of bias did not differ from the overall analyses. None of the trials specifically assessed serious adverse event according to ICH-GCP. No data were found on quality of life. AUTHORS' CONCLUSIONS Our present review indicates that antibiotics (macrolides or quinolones) for secondary prevention of coronary heart disease seem harmful when assessing the risk of all-cause mortality, cardiovascular mortality, and stroke at maximum follow-up and all-cause mortality, cardiovascular mortality, and sudden cardiac death at 24±6 months follow-up. Current evidence does, therefore, not support the clinical use of macrolides and quinolones for the secondary prevention of coronary heart disease. Future trials on the safety of macrolides or quinolones for the secondary prevention in patients with coronary heart disease do not seem ethical. In general, randomised clinical trials assessing the effects of antibiotics, especially macrolides and quinolones, need longer follow-up so that late-occurring adverse events can also be assessed.
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Affiliation(s)
- Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Maria Skoog
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Clinical Study Support, Clinical Studies Sweden - Forum South, Lund, Sweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Orlandi M, Graziani F, D'Aiuto F. Periodontal therapy and cardiovascular risk. Periodontol 2000 2020; 83:107-124. [PMID: 32385887 DOI: 10.1111/prd.12299] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiovascular diseases are the worldwide leading cause of mortality. Cardiovascular diseases are noncommunicable conditions with a complex pathogenesis, and their clinical manifestations include major cardiovascular events such as myocardial infarction and stroke. Epidemiologic evidence suggests a consistent association between periodontitis and increased risk of cardiovascular diseases. Some evidence supports a beneficial effect of the treatment of periodontitis on both surrogate and hard cardiovascular outcomes. This narrative review has been conducted as an update of the most recent evidence on the effects of periodontitis treatment on cardiovascular outcomes since the last commissioned review of the European Federation of Periodontology-American Academy of Periodontology World Workshop in 2012. Newer evidence originating from published randomized controlled trials confirms a positive effect of periodontal treatment on surrogate measures of cardiovascular diseases, whereas there have been no randomized controlled trials investigating the effect of periodontal treatment on the incidence of cardiovascular disease events such as myocardial infarction and stroke. In conclusion, there is sufficient evidence from observational and experimental studies on surrogate cardiovascular measures to justify the design and conduct of appropriately powered randomized controlled trials investigating the effect of effective periodontal interventions on cardiovascular disease outcomes (ie, myocardial infarction and stroke) with adequate control of traditional cardiovascular risk factors.
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Affiliation(s)
- Marco Orlandi
- Periodontology Unit, UCL Eastman Dental Institute, London, UK
| | - Filippo Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.,Sub-Unit of Periodontology, Halitosis and Periodontal Medicine, University Hospital of Pisa, Pisa, Italy
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Fang Y, Fan C, Xie H. Effect of Helicobacter pylori infection on the risk of acute coronary syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e18348. [PMID: 31852134 PMCID: PMC6922357 DOI: 10.1097/md.0000000000018348] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Numerous studies have illustrated the association between Helicobacter pylori (H pylori) infection and acute coronary syndrome (ACS). However, the results are contradictory. Therefore, we conducted the meta-analysis to identify the association between H pylori and ACS. METHODS We performed a systematic search through electronic databases (Excerpta Medica Database, PubMed, Cochrane Library, and Web of Science). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effect model. We also carried out the sensitivity analysis and publication bias. RESULTS Forty-four eligible studies involving 7522 cases and 8311 controls were included. The pooled result showed that H pylori infection was associated with an increase risk of ACS (OR = 2.03, 95% CI 1.66-2.47). In addition, similar results were obtained in subgroups of study quality, area, human development index, and H pylori detection method. The OR for developing countries was significantly higher than developed countries (OR = 2.58 vs OR = 1.69). Moreover, H pylori with cytotoxin-associated antigen A was also significantly associated with an increase risk of ACS (OR = 2.39, 95% CI 1.21-4.74). CONCLUSION The meta-analysis suggested that H pylori infection was associated with an increased risk of ACS, especially in developing countries. H pylori is easily screened and can be treated with a wide range of drugs. Thus, more high-quality and well-designed studies are needed to confirm whether the treatment of H pylori is an effective way to reduce ACS risk.
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Sethi NJ, Safi S, Korang SK, Hróbjartsson A, Skoog M, Gluud C, Jakobsen JC. Antibiotics for secondary prevention of coronary heart disease. Hippokratia 2017. [DOI: 10.1002/14651858.cd003610.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Naqash J Sethi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Asbjørn Hróbjartsson
- Odense University Hospital and University of Southern Denmark; Center for Evidence-Based Medicine; Sdr. Boulevard 29, Gate 50 (Videncenteret) Odense C Denmark 5000
| | - Maria Skoog
- Barsebäcksvägen 39 Löddeköpinge Sweden 24630
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Di Bonaventura G, Piccolomini R, Pompilio A, Zappacosta R, Piccolomini M, Neri M. Serum and Mucosal Cytokine Profiles in Patients with Active Helicobacter Pylori and Ischemic Heart Disease: Is There a Relationship? Int J Immunopathol Pharmacol 2016; 20:163-72. [PMID: 17346440 DOI: 10.1177/039463200702000119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
This study is designed to investigate, for the first time, circulating and gastric mucosal levels of IL1-α, IL-6, IL-8 and TNF-α in patients with ischemic heart disease (IHD) and matched controls, according to the presence or absence of active Helicobacter pylori infection. Furthermore, in order to evaluate whether modified lipid profile was associated to an increased cardiovascular risk, this was determined in the same groups. Cytokine levels were measured using ELISA in 58 patients with IHD and 52 controls. Active H. pylori infection was assessed if either culture of H. pylori or rapid urease test gave a positive result. Our findings indicate increasing cytokine mucosal levels in H. pylori-positive patients compared to H. pylori-negative subjects. However, the increase was statistically significant only for IL-6 and TNF-α in the gastric mucosa of IHD patients. In H. pylori-positive controls, IL-8 mucosal levels positively correlated with both IL-1α (r = 0.98; P = 0.0003) and IL-6 (r = 0.83; P = 0.03) levels. Circulating cytokine levels were comparable in IHD and healthy subjects, regardless of H. pylori status. There were no correlations between mucosal and circulating cytokine levels. Active H. pylori infection was not associated with a modified lipid profile in either controls or IHD patients, although ApoAI levels were significantly higher in H. fly/ort'-positive controls compared to those H. pylori-negative. Taken together, the results of the present study provide evidence that active H. pylori infection may play a role as a trigger factor in the pathophysiology of IHD by inducing an inflammatory cascade concentrated on gastric mucosa.
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Affiliation(s)
- G Di Bonaventura
- Aging Research Center, Ce.S.I., Gabriele d'Annunzio University Foundation, Chieti-Pescara, Italy
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Pedicino D, Giglio AF, Galiffa VA, Cialdella P, Trotta F, Graziani F, Liuzzo G. Infections, immunity and atherosclerosis: Pathogenic mechanisms and unsolved questions. Int J Cardiol 2013; 166:572-83. [DOI: 10.1016/j.ijcard.2012.05.098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 05/02/2012] [Accepted: 05/27/2012] [Indexed: 01/19/2023]
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8
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López NJ, Quintero A, Casanova PA, Ibieta CI, Baelum V, López R. Effects of Periodontal Therapy on Systemic Markers of Inflammation in Patients With Metabolic Syndrome: A Controlled Clinical Trial. J Periodontol 2012; 83:267-78. [DOI: 10.1902/jop.2011.110227] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Christodoulou DK, Milionis HJ, Pappa P, Katsanos KH, Sigounas D, Florentin M, Elisaf M, Tsianos EV. Association of Helicobacter pylori infection with cardiovascular disease--is it just a myth? Eur J Intern Med 2011; 22:191-4. [PMID: 21402252 DOI: 10.1016/j.ejim.2010.11.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 11/21/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To test the hypothesis that Helicobacter pylori infection is associated with a higher rate of documented cardiovascular disease (CVD) in subjects undergoing elective upper gastrointestinal endoscopy. METHODS 202 consecutive patients (median age 60 years, 101 men) were studied. H. pylori infection was established by a rapid urease test in a gastric tissue sample (CLO test) and by histological examination of gastric mucosa from the stomach antrum and body. CVD was documented by completion of the Rose questionnaire. The association of H. pylori infection with CVD was determined by multivariate logistic regression modelling after adjusting for potential confounding factors. RESULTS A total of 104 (51.5%) subjects were found H. pylori positive. Forty patients had a confirmed history of CVD. Multiple logistic regression analysis verified the strong associations of CVD with established risk factors of atherosclerotic disease but not with H. pylori infection. CONCLUSION Our findings suggest that there is no association of H. pylori infection with CVD. Eradication of H. pylori to prevent CVD is not warranted.
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Manolakis A, Kapsoritakis AN, Potamianos SP. A review of the postulated mechanisms concerning the association of Helicobacter pylori with ischemic heart disease. Helicobacter 2007; 12:287-97. [PMID: 17669100 DOI: 10.1111/j.1523-5378.2007.00511.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since its discovery, Helicobacter pylori has been implicated in the pathogenesis of several diseases, both digestive and extradigestive. Interestingly, the majority of the extradigestive-related literature is focused on two vascular manifestations: stroke and ischemic heart disease. Potential mechanisms for the establishment of a H. pylori-induced ischemic heart disease have been proposed with regard to chronic inflammation, molecular mimicry, oxidative modifications, endothelial dysfunction, direct effect of the microorganism on atherosclerotic plaques as well as changes regarding traditional or novel risk factors for ischemic heart disease or even platelet-H. pylori interactions. A positive link between H. pylori infection and ischemic heart disease has been suggested by a series of studies focusing on epidemiologic evidence, dyslipidemic alterations, upregulation of inflammatory markers or homocysteine levels, induction of hypercoagulability, oxidation of low-density lipoprotein, causation of impaired endothelial function, detection of H. pylori DNA in atherosclerotic plaques, and participation of certain antigens and antibodies in a cross-reactivity model. There are studies, however, which investigated the relationship between H. pylori and ischemic heart disease with regard to the same parameters and failed to confirm the suggested positive association. Further studies in the direction of interaction between H. pylori and the host's genotype as well as a quest for evidence towards novel risk factors for ischemic heart disease such as oxidative stress, vascular remodeling, vascular calcification, or vasomotor activity, may reveal a field of great interest, thus contributing to the determination of new potential mechanisms.
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Affiliation(s)
- Anastassios Manolakis
- Department of Gastroenterology, School of Medicine, University of Thessaly, 41110 Larissa, Greece
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11
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Joensen JB, Juul S, Henneberg E, Thomsen G, Ostergaard L, Lindholt JS. Can long-term antibiotic treatment prevent progression of peripheral arterial occlusive disease? A large, randomized, double-blinded, placebo-controlled trial. Atherosclerosis 2007; 196:937-42. [PMID: 17418218 DOI: 10.1016/j.atherosclerosis.2007.02.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Revised: 02/21/2007] [Accepted: 02/26/2007] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose was to investigate in a large, randomized, double-blinded, placebo-controlled trial, whether antibiotic treatment can prevent progression of peripheral arterial disease (PAD). MATERIAL AND METHODS Five hundred and seven patients were included; all patients had an established diagnosis of PAD. Their mean age was 66 years (36-85), and 59% were males. Patients were randomized to Roxithromycin 300 mg daily for 28 days. Baseline investigations were ankle blood pressure, ankle-brachial blood pressure index (ABPI), walking distance, C. pneumoniae serology, cholesterol and medical history. Follow-up was performed every 6 months. Primary events were defined as death, peripheral revascularization and major lower limb amputation. Secondary events were thrombosis, stroke, transient cerebral ischaemic attack and myocardial infarction. Change in ABPI was also investigated. Data were analyzed mainly by Cox regression and linear regression. RESULTS Included patients with PAD were randomized. Two patients withdrew. Of the remaining, 248 received roxithromycin and 257 placebo. In the treatment group 55% were seropositive and 53% in the placebo group. Mean follow-up was 2.1 years (range 0.06-5.1 years). In the placebo group, 26 died and 80 primary events occurred in total. In the treatment group, 28 died and 74 primary events were observed. The hazard ratio of death was 1.13 (95% CI: 0.68; 1.90), and of primary events 0.92 (95% CI: 0.67; 1.26). Also on secondary events and ABPI changes, no significant differences were found. CONCLUSION Long-term treatment with roxithromycin is ineffective in preventing death, amputation, peripheral revascularization, myocardial infarction, stroke, transient cerebral ischaemic attack, thrombosis and decline in ABPI in patients with an established diagnosis of PAD.
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Affiliation(s)
- J B Joensen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.
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12
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Arno G, Kaski JC, Smith DA, Akiyu JP, Hughes SE, Baboonian C. Matrix metalloproteinase-9 expression is associated with the presence of Chlamydia pneumoniae in human coronary atherosclerotic plaques. Heart 2005; 91:521-5. [PMID: 15772219 PMCID: PMC1768801 DOI: 10.1136/hrt.2003.012054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the association between Chlamydia pneumoniae and matrix metalloproteinase-9 (MMP-9) in atherosclerotic plaques. DESIGN 31 coronary atherosclerotic plaque specimens were studied by immunohistochemistry, polymerase chain reaction (PCR), and reverse transcription PCR for the presence of C pneumoniae antigen and genomic DNA, and of MMP-9 protein and transcripts. RESULTS Immunohistochemical analysis identified a strong association between the presence of C pneumoniae antigen and production of MMP-9 in coronary atherosclerotic plaques (p = 0.001). Furthermore, analysis of the intralesional amount of C pneumoniae and MMP-9 indicated an increased number of cells positive for MMP-9 in arterial sections that had increased C pneumoniae positivity (p < 0.05). CONCLUSIONS This study provides evidence of an association between expression of MMP-9 and the intravascular presence of C pneumoniae and may suggest a potential pathological mechanism whereby C pneumoniae may contribute to the progression of coronary atherosclerosis.
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Affiliation(s)
- G Arno
- Department of Cardiological Sciences, St Georges Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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13
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Krayenbuehl PA, Wiesli P, Maly FE, Vetter W, Schulthess G. Progression of peripheral arterial occlusive disease is associated with Chlamydia pneumoniae seropositivity and can be inhibited by antibiotic treatment. Atherosclerosis 2005; 179:103-10. [PMID: 15721015 DOI: 10.1016/j.atherosclerosis.2004.08.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2004] [Revised: 07/21/2004] [Accepted: 08/30/2004] [Indexed: 10/26/2022]
Abstract
A possible influence of Chlamydia pneumoniae seropositivity on the clinical course of peripheral arterial occlusive disease (PAOD) has not been investigated previously. Though roxithromycin therapy was found to inhibit progression of PAOD, the nature of this effect (antibiotic or anti-inflammatory) has remained elusive. The course of PAOD was prospectively assessed in elderly men during 4 years, comparing 51 C. pneumoniae seropositive (IgG>/=1:128) with 46 seronegative patients (IgG<1:64 and IgA<1:32). Twenty of the seropositive patients were treated with roxithromycin (400 mg daily) for 4 weeks. Limitation of the walking distance to 200 m or less was observed in 55% of the seropositive untreated patients as compared to 30% of both, seronegative and macrolide-treated patients. The number of invasive revascularizations per patient was 1.7 in the seropositive untreated group as compared to 0.5 in the seronegative and the macrolide-treated group. Considering possible confounding variables, such as classical vascular risk factors, ordinal regression analyses showed a significant association of C. pneumoniae seropositivity with limitation of the walking distance (p=0.027) and need for invasive revascularization (p=0.037). The effect of macrolide treatment on these outcome measures was marked (p<0.001 and p=0.040, respectively) during 2.7 years but decreased in the second part of the observation period. This study provides good evidence that C. pneumoniae are involved in the progression of PAOD and that antibiotic treatment directed against C. pneumoniae is effective in inhibiting this process.
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Elizalde JI, Pérez-Pujol S, Heras M, Sionis A, Casanovas N, Martorell T, Lozano M, González J, Escolar G, Sanz G, Piqué JM. Effects of Helicobacter pylori eradication on platelet activation and disease recurrence in patients with acute coronary syndromes. Helicobacter 2004; 9:681-9. [PMID: 15610084 DOI: 10.1111/j.1083-4389.2004.00271.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Platelet activation is consistently observed in animal models of Helicobacter pylori infection and could help to explain the alleged epidemiological association between H. pylori and coronary heart disease. MATERIALS AND METHODS Ninety-two patients with recent acute coronary syndromes were enrolled. Helicobacter pylori-positive patients were randomized to receive a 7-day course of omeprazole, amoxycillin and metronidazole or placebos. Two months later, H. pylori status was reassessed and baseline parameters, including soluble P-selectin and platelet surface expression of CD62P, CD63 and CD41, were measured again. Patients were followed-up for 1 year or until death or readmission. RESULTS No baseline differences were observed between H. pylori-positive and -negative cases. Among H. pylori-positive patients, 18 received placebo and 31 received active medication resulting in eradication in 21 cases. No differences were observed in inflammatory parameters or platelet activation markers between patients with persistent or resolved H. pylori infection. However, coronary events recurred at 6 and 12 months, respectively, in 35% and 55% of patients with persisting H. pylori infection compared with 10% and 25% of patients in whom H. pylori was either absent or eradicated (p = .01). Only final H. pylori status [RR 3.07 (95% CI 1.35-98)] and number of coronary risk factors [RR 2.58 (95% CI 1.51-4.41)] were independent predictors of recurrence. CONCLUSIONS Infection with H. pylori does not induce significant platelet activation in patients treated for coronary disease. Helicobacter pylori-infected patients, however, may have an increased risk of recurrence of coronary events.
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Affiliation(s)
- J Ignasi Elizalde
- Gastroenterology Department, Institut Clínic de Malalties Digestives, University of Barcelona, Barcelona, Spain
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15
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Aceti A, Are R, Sabino G, Fenu L, Pasquazzi C, Quaranta G, Zechini B, Terrosu P. Helicobacter pylori active infection in patients with acute coronary heart disease. J Infect 2004; 49:8-12. [PMID: 15194241 DOI: 10.1016/j.jinf.2004.01.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2004] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the possible role of the active Helicobacter pylori infection as a trigger factor in acute coronary heart disease (CHD). METHODS Forty patients with acute coronary syndromes, 40 patients with infections other than H. pylori (control group A) and 40 healthy subjects (control group B), pair matched for age, sex and CHD risk factors were studied. In each patient and control subject the presence of H. pylori stool antigen (HpsA) and serum anti-CagA were tested. RESULTS Twenty-eight of patients with CHD resulted positive for HpSA compared to 14 patients of control group A and 16 subjects of group B (p=0.00095). No significant difference was found in the anti-CagA positivity among patients with CHD and control groups. Concomitant positivity for anti-CagA and HpSA was found in 13 patients with CHD, four controls of group A and five controls of group B (p=0.017) CONCLUSIONS Our findings revealed a higher rate of HpSA positivity and a significantly higher association between HpSA and anti-CagA positivity in patients with acute CHD compared to control groups. These data suggest that active H. pylori infection may play a role as a trigger factor in acute cardiovascular events.
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Affiliation(s)
- Antonio Aceti
- Department of Infectious Diseases, II Faculty of Medicine, University of Rome La Sapienza, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy.
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16
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Abstract
Parallel with the mounting evidence that atherosclerosis has a major inflammatory component, provoking agents that may initiate and drive this process have been sought. Infectious agents such as Chlamydia pneumoniae have been alleged to be activators of inflammation that may contribute to atherosclerosis and thus coronary artery disease (CAD) and its associated complications. A logical pneumoniae extension of this theory whether treating C pneumoniae infection with antibiotics and/or modulating inflammatory processes can affect CAD and its sequelae. This article discusses the potential role of C pneumoniae in atherosclerosis, its detection, and the rationale for antibiotics. Additionally, it summarizes the current randomized clinical trials of antichlamydial antibiotics in patients with CAD and draws conclusions based on the results.
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Affiliation(s)
- John P Higgins
- Department of Medicine, University of Oklahoma, Tulsa, USA.
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17
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Mattila K, Vesanen M, Valtonen V, Nieminen M, Palosuo T, Rasi V, Asikainen S. Effect of treating periodontitis on C-reactive protein levels: a pilot study. BMC Infect Dis 2002; 2:30. [PMID: 12475397 PMCID: PMC138813 DOI: 10.1186/1471-2334-2-30] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2002] [Accepted: 12/10/2002] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Periodontitis is associated with elevated levels of C-reactive protein and fibrinogen and it may be a coronary heart disease risk factor. We wanted to study if treatment of periodontitis can decrease the levels of these inflammatory markers. METHODS C-reactive protein and fibrinogen levels were measured in 35 patients (21 M, 14 F, mean age 50 years) with adult periodontitis, before and after treatment. RESULTS The median baseline C-reactive protein level in the patients was 1.05 mg/l and it decreased to 0.7 mg/l (p = 0.05) after periodontal treatment. Of the 30 patients who could be included in the analyses, 24 patients had a baseline level below 2 mg/l (the 95th percentile limit in Finland); 6 patients had levels higher than this. Elevation of the baseline C-reactive protein level or the magnitude of its decrease were not associated with severe form of periodontitis. The decrease in C-reactive protein levels was at least 50 % in 4/6 of those with elevated baseline levels, as compared with 3/24 of the rest of the patients (p = 0.016). No corresponding effect was observed in fibrinogen levels. CONCLUSIONS Periodontitis seems to increase C-reactive protein only in some individuals, presumably the ones reacting to it with a systemic inflammatory reaction. Periodontal treatment decreases C-reactive protein levels in these individuals and it may thus decrease their risk of coronary heart disease.
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Affiliation(s)
- Kimmo Mattila
- Department of Medicine, Divisions of Infectious Diseases and Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Marja Vesanen
- Institute of Dentistry, University of Helsinki, Finland
| | - Ville Valtonen
- Department of Medicine, Divisions of Infectious Diseases and Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Markku Nieminen
- Department of Medicine, Divisions of Infectious Diseases and Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Timo Palosuo
- National Public Health Institute, Helsinki, Finland
| | - Vesa Rasi
- Finnish Red Cross Blood Transfusion service, Helsinki, Finland
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18
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Abstract
There is growing evidence that inflammatory processes may be involved in the development of atherosclerosis and its complications. Viral and bacterial pathogens have been implicated as possible causative factors in the pathogenesis of coronary artery disease and postangioplasty restenosis. Antibiotic trials have been completed examining which treatment of infection can prevent the complications of coronary artery disease. In high-risk patients, the results of these most recent studies have not revealed any benefit of treatment.
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Affiliation(s)
- William H Frishman
- Department of Medicine and Pharmacology New York Medical College/Westchester Medical Center, Valhalla, New York, USA
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19
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Elizalde JI, Piqué JM, Moreno V, Morillas JD, Elizalde I, Bujanda L, De Argila CM, Cosme A, Castiella A, Ros E. Influence of Helicobacter pylori infection and eradication on blood lipids and fibrinogen. Aliment Pharmacol Ther 2002; 16:577-86. [PMID: 11876713 DOI: 10.1046/j.1365-2036.2002.01202.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND An association between Helicobacter pylori infection and heart disease has been suggested. A potential mechanism may be inflammation-induced atherogenic changes of lipoproteins, but epidemiological studies have provided conflicting results. METHODS In a prospective multicentre study, 830 patients submitted for endoscopy and H. pylori testing were evaluated. Of the 686 H. pylori-positive patients, 487 received and 199 did not receive eradication treatment. Serum lipids and plasma fibrinogen were measured at baseline in all patients and 3 months later in those initially positive for H. pylori. RESULTS H. pylori had no influence on baseline lipid or fibrinogen levels. Increases in high-density lipoprotein cholesterol were observed in 368 patients who received eradication treatment and in 193 untreated patients: 0.06 mmol/L (P=0.000) and 0.07 mmol/L (P=0.009), respectively. Similar minor increases in total cholesterol and triglycerides occurred in both groups. Lipid changes were related to symptom relief and a reduction in smoking. Eradication therapy was associated with a minor decrease in plasma fibrinogen irrespective of the resolution of infection. CONCLUSIONS H. pylori has no influence on blood lipids or fibrinogen. Both the eradication of infection and symptomatic treatment without eradication are associated with minor lipid changes related to symptom relief and lifestyle modifications. Thus, the inflammatory changes associated with H. pylori are unlikely to affect lipoprotein or fibrinogen metabolism.
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Affiliation(s)
- J I Elizalde
- Gastroenterology Department, Institut Malaties Digestive, Hospital Clínic, Barcelona, Spain
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20
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Altman R, Rouvier J, Scazziota A, Gonzalez C. No causal association between inflammation and Chlamydia pneumoniae in patients with chronic ischemic arterial disease. Inflammation 2002; 26:25-30. [PMID: 11936753 DOI: 10.1023/a:1014469712395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The C-reactive protein, Chlamydia-specific IgG antibody, and fibrinogen were assayed in the serum of 159 patients with arterial disease (the arterial group) and 203 patients with heart valve prostheses (the valvular group) and no demonstrable coronary disease. In the arterial group, the Chlamydia pneumoniae antibody was > or = 1:32 for 67.3% (107/159) of the patients, the C-reactive protein was elevated in 41.5% (66/159), and the fibrinogen was elevated in 27.7% (44/159). In the valvular group, the C. pneumoniae antibody was > or = 1:32 for 59.1% (120/203) of the patients; the C-reactive protein was elevated in 34.0% (69/203), and the fibrinogen was elevated in 17.2% (35/203). Of 107 patients in the arterial group with C. pneumoniae titers > or = 1:32, only 26 (24.3%) had elevated fibrinogen (426 +/- 29 mg/dL) and 44 (41.1%) had elevated C-reactive protein (1.06 +/- 0.52 mg/dL). Similarly, of the 120 patients in the valvular group with C. pneumoniae titers > or = 1:32, 17 (14.2%) had elevated fibrinogen (409 +/- 29 mg/dL) and 34 had elevated C-reactive protein (0.99 +/- 1.1 mg/dL). Correlated poorly was C. pneumoniae with C-reactive protein and fibrinogen levels. Only the fibrinogen level could be discriminated between the arterial and the valvular group. These results suggest that no causal association exists between inflammation and C. pneumoniae. A highly significant correlation between C-reactive protein and fibrinogen levels was found.
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Affiliation(s)
- Raúl Altman
- Centro de Trombosis de Buenos Aires, Argentina.
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21
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Boman J, Hammerschlag MR. Chlamydia pneumoniae and atherosclerosis: critical assessment of diagnostic methods and relevance to treatment studies. Clin Microbiol Rev 2002; 15:1-20. [PMID: 11781264 PMCID: PMC118057 DOI: 10.1128/cmr.15.1.1-20.2002] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
A number of studies have found that inflammation of the vessel wall plays an essential role in both the initiation and progression of atherosclerosis and erosion and fissure and the eventual rupture of plaques. Chlamydia pneumoniae is one of the infectious agents that have been investigated as possible causes of this inflammation. Initial studies of the association of C. pneumoniae and cardiovascular disease (CVD) were seroepidemiologic, and these were followed by studies in which the organism was identified in vascular tissue from patients with CVD by electron microscopy, PCR and immunocytochemical staining (ICC). C. pneumoniae has also been isolated by culture from vascular tissue in a small number patients. However, no single serologic, PCR, or ICC assay has been used consistently across all studies. The assays used are also not standardized. Recent studies of serologic and PCR assays for diagnosis of C. pneumoniae infection have suggested that there may be substantial interlaboratory variation in the performance of these tests. It now appears that some of the inconsistency of results from study to study may be due, in part, to lack of standardized methods. Although initial seroepidemiologic studies demonstrated a significantly increased risk of adverse cardiac outcome in patients who were seropositive, subsequent prospective studies found either small or no increased risk. In addition to the lack of consistent serologic criteria, recent evaluations have demonstrated inherent problems with performance of the most widely used serologic methods. Most importantly, we do not have a reliable serologic marker for chronic or persistent C. pneumoniae infection.
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Affiliation(s)
- Jens Boman
- Department of Virology, Umeå University, Umeå, Sweden
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22
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Leinonen M, Saikku P. Evidence for infectious agents in cardiovascular disease and atherosclerosis. THE LANCET. INFECTIOUS DISEASES 2002; 2:11-7. [PMID: 11892489 DOI: 10.1016/s1473-3099(01)00168-2] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
During the past decade, several novel risk factors for atherosclerosis, including inflammation and infections, have been reported. Seroepidemiological studies suggest an association between several microbes and coronary heart disease. Microbes or their structural components are found in atherosclerotic plaques, but the only intact microbes commonly present are herpes viruses and Chlamydia pneumoniae. These agents are able to initiate and accelerate atherosclerosis in animal models. If they cause persistent infection in the vessel wall, they can directly promote a proinflammatory, procoagulant, and proatherogenic environment. Microbes could also have a remote effect--e.g., bacterial heat shock proteins with high sequence homology with human counterpart could, in the presence of a chronic infection, induce autoimmunity against vascular cells, and lead to an atherosclerotic process. Several intervention trials with antibiotics are underway, and will hopefully shed new light on the role of bacteria in atherosclerosis. The causal relationship can be proved by use of vaccination to prevent infections.
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Affiliation(s)
- Maija Leinonen
- National Public Health Institute, PO Box 310, FIN-90101 Oulu, Finland.
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23
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Baena Díez J, López Gosp D, De La Poza Abad M, Raidó Quintana E, Vila Capdevila M, Martínez Martínez J. [Association between ischemic heart disease and peptic ulcer. A case-control study]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:421-6. [PMID: 11722817 DOI: 10.1016/s0210-5705(01)78996-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM To determine whether patients with ischemic heart disease (IHD) are at higher risk for peptic ulcer (PU). MATERIAL AND METHODS We performed a case-control study. The patients were selected by simple random sampling of clinical histories. CASES 310 patients with IHD (angina pectoris, myocardial infarct or both). CONTROLS 310 patients without IHD, paired by age, sex and tobacco consumption. Data were obtained by review of the patients' clinical histories. Response variable: diagnosis of peptic ulcer by endoscopy, esophagogastroduodenal transit or surgery. The odds ratio (OR) was determined by logistic regression, adjusting for the effect of confounding variables and risk for PU. RESULTS The mean age of the patients was 72.7 years (SD 8.6) and 70% were men. PU was found in 18.7% of the patients and in 12.3% of the controls with an adjusted OR of 1.77 (95% CI: 1.12-2.77; p = 0.01). This effect was produced at the expense of duodenal ulcer with an adjusted OR of 2.22 (95% CI: 1.29-3.74; p = 0.003). The adjusted OR of gastric ulcer was 1.13 (95% CI: 0.45-2.82; p = 0.8). CONCLUSIONS After adjusting for the effect of confounding variables and risk factors for the development of PU, this disease was more frequent in the group of patients with IHD.
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24
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Tanne D, Benderly M, Goldbourt U, Boyko V, Brunner D, Graff E, Reicher-Reiss H, Shotan A, Mandelzweig L, Behar S. A prospective study of plasma fibrinogen levels and the risk of stroke among participants in the bezafibrate infarction prevention study. Am J Med 2001; 111:457-63. [PMID: 11690571 DOI: 10.1016/s0002-9343(01)00914-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Plasma fibrinogen has emerged as an important predictor of cardiovascular disease, but few data are available on its association with stroke. We sought to determine if plasma fibrinogen is a marker of increased risk or a direct causative risk factor for stroke. SUBJECTS AND METHODS Patients from the Bezafibrate Infarction Prevention Study, a placebo-controlled, randomized clinical trial of secondary prevention of coronary heart disease by lipid modification with bezafibrate retard (400 mg daily), were studied. Plasma fibrinogen levels were measured at baseline and yearly thereafter. Stroke, a prospectively monitored endpoint, was systematically assessed regarding stroke type, subtype, and functional outcome. RESULTS Mean baseline fibrinogen levels were significantly higher in patients subsequently having a cerebrovascular event (140 strokes, 36 transient ischemic attacks; mean follow-up, 6.2 years) than in patients who did not (375 vs. 349 mg/dL, P <0.0001). Fibrinogen levels did not differ significantly by the type, subtype, or severity of the cerebrovascular event. Risk of ischemic stroke increased from 3.3% in the lowest tertile (baseline fibrinogen <314 mg/dL) to 7.% in the middle tertile (fibrinogen 314 to 373 mg/dL) to 10% in the upper tertile (fibrinogen >373 mg/dL, P <0.001). Adjusting for age, blood pressure, and other covariates, fibrinogen levels in the upper tertile were associated with more than a twofold increase in risk of ischemic stroke compared with in the lowest tertile (hazard ratio = 2.6; 95% confidence interval: 1.5 to 4.3). We did not find fibrinogen change from baseline to be related to subsequent ischemic stroke events. CONCLUSION Plasma fibrinogen is a strong predictor of, rather than a direct causative factor for, subsequent stroke among patients at increased risk owing to manifest coronary heart disease.
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Affiliation(s)
- D Tanne
- Acute Stroke Unit, Department of Neurology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel
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25
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Abstract
In the past decade there has been renewed interest in the old hypothesis that infections increase the risk of developing cardiovascular disease and stroke. There is now a convincing body of evidence that atherosclerosis has a major inflammatory component and is much more than the simple vascular accumulation of lipids. Infectious agents that have been linked to an increased risk of coronary heart disease (CHD) include Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpesviruses. The concept has emerged that each of these agents is an independent risk factor for CHD and that common chronic infections are important. In addition, periodontal infections have also been implicated as one of several factors contributing to the development of CHD. Evidence supporting a causative role of chronic infections in CHD is largely circumstantial. However, the evidence is sufficiently strong to warrant further examination of the possible link between chronic infections and CHD. In this review the lines of evidence for a causative role of C. pneumoniae in the development of CHD are summarized and contrasted with the lines of evidence suggesting a periodontal infection--CHD association. If common or widespread chronic infections are truly important risk factors for CHD, it is unlikely that a single infection will be shown to be causative. It is likely that the entire microbial burden of the patient from several simultaneous chronic infections is more important (e.g., H. pylori-caused gastric ulcers + C. pneumoniae-caused bronchitis + periodontitis). Increased cooperation between cardiologists and periodontists will be required to determine if, and what, combinations of common chronic infections are important in the pathogenesis of CHD and stroke.
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Affiliation(s)
- G C Armitage
- Division of Periodontology, Department of Stomatology, University of California, 521 Parnassus Avenue, C-628, Box 0650, UCSF School of Dentistry, San Francisco, CA 94143-0650, USA.
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26
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Khogali SE, Alyousuf HS, Cheung ST, Cameron RE, Parratt D, Pringle SD. Should antibiotics now be part of routine treatment of coronary heart disease? Scott Med J 2000; 45:163-6. [PMID: 11216304 DOI: 10.1177/003693300004500601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- S E Khogali
- Department of Cardiology, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
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27
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Abstract
Basic science research has revealed that monocytes and macrophages are important factors in atherogenesis. Immune system activation occurs at all stages of plaque formation, from the fatty streak to an advanced, complicated lesion. The inflammatory response not only stimulates changes in coronary artery endothelial cells causing endothelial injury and dysfunction, but also plays a role in plaque instability and rupture. New perspectives of atherosclerosis and acute coronary syndromes will be discussed in relation to inflammation. In addition, discussion will focus on bacterial and viral infectious microorganisms as a potential factor that may induce and promote inflammation and lead to acute coronary events. Clinical studies in humans have provided insight relating inflammation and infectious agents to atherosclerosis and plaque vulnerability. Other studies focus on specific interventions that may aid in diagnosis and treatment.
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Affiliation(s)
- N M Albert
- Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, Ohio 44195, USA.
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28
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Abstract
More than a century ago, inflammation and infection were considered to have atherogenic effects. During last century, however, this hypothesis was completely abandoned, and the old idea that coronary heart disease (CHD) possibly has an infectious etiology has only re-emerged in recent years. Both viral and bacterial pathogens have been proposed to be associated with the inflammatory changes found in atherosclerosis. Herpes group viruses, especially cytomegalovirus (CMV) and herpes simplex virus type 1 (HSV1), have been associated with both atherosclerosis and restenosis. Helicobacter pylori and dental infections have also been linked to CHD, but the evidence is strongest for a respiratory tract bacterium, Chlamydia pneumoniae. The association was originally found in seroepidemiological studies, but the presence of organisms in atherosclerotic lesions, the first animal studies and preliminary successful intervention trials with antibiotics suggest that C. pneumoniae may have a pathogenetic role in the disease. The causal relationship has not yet been proven, but ongoing large intervention trials and research on pathogenetic mechanisms may lead to the use of antimicrobial agents in the treatment of CHD in the future.
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Affiliation(s)
- M Leinonen
- Department in Oulu, KTL, National Public Health Institute, Finland.
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29
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Blasi F, Fagetti L, Allegra L. Chlamydia pneumoniae detection in atherosclerotic plaques in Italy. J Infect Dis 2000; 181 Suppl 3:S444-6. [PMID: 10839734 DOI: 10.1086/315621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Italian investigations have shown an association between Chlamydia pneumoniae infection and atherosclerosis. With the use of several diagnostic techniques, including serology, a microimmunofluorescence test, and nucleic acid amplification methods, a temporal association was found between acute C. pneumoniae reinfection and acute myocardial infarction, suggesting that an acute infection superimposed on a chronic or latent infection may trigger the onset of acute myocardial infarction. C. pneumoniae but not Helicobacter pylori or Mycoplasma pneumoniae was found in atherosclerotic plaques of abdominal aortic aneurysms and the carotid artery. A reverse transcriptase-polymerase chain reaction process confirmed the presence of viable C. pneumoniae in carotid atheromas. Nucleic amplification of peripheral blood mononuclear cells may enable the identification of subjects carrying C. pneumoniae in the vascular wall. Macrolide treatment reduced fibrinogen and C-reactive protein plasma levels and C. pneumoniae burden in patients with atherosclerotic diseases.
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Affiliation(s)
- F Blasi
- Istituto di Tisiologia e Malattie dell'Apparato Respiratorio, Università degli Studi di Milano, Pad. Litta, IRCCS Ospedale Maggiore di Milano, I-20122 Milan, Italy.
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30
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Leinonen M. Chlamydia pneumoniae and other risk factors for atherosclerosis. J Infect Dis 2000; 181 Suppl 3:S414-6. [PMID: 10839726 DOI: 10.1086/315624] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Seroepidemiologic studies have provided information on the association of Chlamydia pneumoniae with the classical risk factors of coronary heart disease (CHD). C. pneumoniae infections are more common in smokers than in nonsmokers, suggesting that smoking predisposes to the development of chronic infection. Infections may also affect lipid metabolism. In persons with acute pneumonia caused by C. pneumoniae, high-density lipoprotein (HDL) values are lower and triglyceride values higher than seen in pneumonia caused by viruses and other bacteria. Furthermore, chronic C. pneumoniae infection is associated with elevated triglyceride and lowered HDL levels in healthy Finnish men. Recent studies also suggest that chronic C. pneumoniae infection considerably enhances the effect of the metabolic syndrome on the CHD risk. Thus, known CHD risk factors may be partly explained by their association with chronic C. pneumoniae infection. Further studies are needed to elucidate the pathogenetic mechanisms underlying these associations.
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Affiliation(s)
- M Leinonen
- National Public Health Institute, Department in Oulu, FIN-90101 Oulu, Finland.
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31
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Carlsson J, Miketic S, Brom J, Ross R, Bachmann H, Tebbe U. Prior cytomegalovirus, Chlamydia pneumoniae or Helicobacter pylori infection and the risk of restenosis after percutaneous transluminal coronary angioplasty. Int J Cardiol 2000; 73:165-71. [PMID: 10817856 DOI: 10.1016/s0167-5273(00)00216-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We investigated a possible correlation between the serologic status concerning Cytomegalovirus (CMV), Chlamydia pneumoniae (CP) and Helicobacter pylori (HP) and the occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty for symptomatic coronary artery disease. Tests for anti-CMV IgG, anti-Chlamydia pneumoniae IgG and IgA and HP IgG and IgA were performed with an enzyme-linked immunosorbent assay (ELISA). Restenosis was defined as >/=50% stenosis at follow-up angiography in a vessel with less than 50% stenosis immediately after PTCA. Of 148 patients, 112 (75.7%) were seropositive for CMV, 75 (50.7%) were seropositive for CP and 78 (52.7%) were seropositive for HP. Restenosis occured in 31.8% of patients. CMV seropositivity was established in 74.5% of patients with restenosis versus 76.2% without restenosis (P=0.82), CP seropositivity was established in 44. 7% of patients with restenosis versus 53.5% without restenosis (P=0. 32), HP seropositivity was established in 53.2% of patients with restenosis versus 52.5% without restenosis (P=0.94). In contrast to some earlier studies CMV or HP seropositivity could not be found to be associated with the risk of restenosis after coronary intervention. An association between the serological status of CP and restenosis could also not be established.
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Affiliation(s)
- J Carlsson
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany.
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32
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Schweeger I, Fitscha P, Sinzinger H. Successful eradication of Helicobacter pylori as determined by ((13))C-urea breath test does not alter fibrinogen and acute phase response markers. Thromb Res 2000; 97:411-20. [PMID: 10704650 DOI: 10.1016/s0049-3848(99)00230-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In this study we examined in 100 patients testing positive for Helicobacter pylori infection whether successful eradication therapy with pantoprazole, clarithromycin, and metronidazole alters fibrinogen and other acute phase response markers. Of 100 patients, only 11 showed a fibrinogen level above 300 mg/dL. Successful eradication proven by the 13C-urea breath test does not alter acute phase response markers. These findings indicate that Helicobacter pylori infection is unlikely to affect atherosclerosis unfavourably via acute phase response.
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Affiliation(s)
- I Schweeger
- ISOTOPIX, Institute for Nuclear Medicine, Vienna and Department of Nuclear Medicine, University of Vienna, Vienna, Austria
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Cammarota G, Pasceri V, Gasbarrini A, Gasbarrini G. Helicobacter pylori is an aetiological factor for ischaemic heart disease: the case against. Dig Liver Dis 2000; 32:65-8. [PMID: 10975758 DOI: 10.1016/s1590-8658(00)80047-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Helicobacter pylori is one of four organisms often investigated for ari association with ischaemic heart disease. The four, including Chlamydia pneumoniae, Cytomegalovirus and Herpes virus, cause low-grade, life-long infections that can produce a persistent inflammation, the kind that leads to heart disease. Several studies suggest an association, but others suggest none. Patients with poor access to medical care are more likely to become infected and also more likely to suffer from coronary artery disease. Although the literature data are provocative and interesting, the two things may not be related. Helicobacter pylori infection is quite prevalent among individuals without ischaemic heart disease and absent in many of those with ischaemic heart disease. Thus, more definite answers about whether there is any link between Helicobacter pylori and cardiovascular disease are needed. It would be essential to establish the specific mechanisms that possibly confer vulnerability or protection toward coronaropathy. But a definite answer could come from clinical trials designed to test whether antibiotics can prevent the disease. Until now, no randomised trial has suggested a positive effect of Helicobacter pylori eradication in reducing the incidence of cardiac events.
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Affiliation(s)
- G Cammarota
- Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Italy
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Abstract
The evidence to date concerning the association between Helicobacter pylori infection and coronary heart disease is consistent with a modest increased risk. Research is currently being undertaken into factors which may modify this association. Probably, there is sufficient evidence given the ease of the proposed intervention to make it worthwhile to undertake a trial of eradication therapy.
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Affiliation(s)
- A F Stone
- Mayday University Hospital, Thornton Heath, Surrey and St. George's Hospital Medical School, Tooting, London, UK
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Quaschning T, Wanner C. The role of Chlamydia in coronary heart disease-fact or fiction? Nephrol Dial Transplant 1999; 14:2800-3. [PMID: 10570071 DOI: 10.1093/ndt/14.12.2800] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Abstract
Cardiovascular diseases, particularly coronary heart disease (CHD) and myocardial infarction (MI), are among the leading causes for morbidity and mortality in industrialized countries [2, 77]. During the past decades, various clinical or lifestyle risk factors for myocardial infarction such as hyperlipidemia, hypertension, obesity, lack of physical exercise and smoking have been identified. However, it is also recognized that these well-documented risk factors do not sufficiently account for all new cases of myocardial infarction [77]. Many patients with myocardial infarction have only a borderline risk profile or even lack known risk factors. The question arises: What additional risk factors may play a role in the etiology of atherosclerosis and ischemic heart disease?
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Affiliation(s)
- C R Meier
- Basel Pharmacoepidemiology Unit, Department of Internal Medicine, University Hospital, Switzerland
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MacCallum PK, Meade TW. Haemostatic function, arterial disease and the prevention of arterial thrombosis. Best Pract Res Clin Haematol 1999; 12:577-99. [PMID: 10856986 DOI: 10.1053/beha.1999.0041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Recent years have seen the expansion of information linking raised plasma levels of individual clotting factors and evidence of disturbances of fibrinolytic activity with the risk of thrombotic manifestations of arterial disease, both in community-based, apparently healthy populations and in patients with known atherosclerosis. Some of these prothrombotic changes in the haemostatic system may result partly from underlying chronic inflammation or acute infection and may, in turn, contribute substantially to the thrombotic risk which accompanies these underlying processes. The importance of the coagulation system in the pathogenesis of arterial thrombosis is further illustrated by the benefit in the Thrombosis Prevention Trial of low-intensity, dose-adjusted warfarin in the primary prevention of ischaemic heart disease. Clinical trials of bezafibrate, which is being used for its fibrinogen-lowering as well as lipid-modifying properties, are in progress.
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Affiliation(s)
- P K MacCallum
- Department of Haematology, St Bartholomew's and The Royal London School of Medicine and Dentistry, UK
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Behbahani R, Verme-Gibboney C, Romanelli AM. Chlamydia pneumoniae and anti-infective therapy: their role in the pathogenesis and treatment of coronary artery disease. Clin Ther 1999; 21:1286-300; discussion 1285. [PMID: 10485501 DOI: 10.1016/s0149-2918(99)80030-7] [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: 11/21/2022]
Abstract
Cardiovascular disease remains the most common cause of death in the United States; however, conventional cardiovascular risk factors fail to explain completely the pathogenesis of atherosclerosis and coronary artery disease. There has been recent interest in the association between Chlamydia pneumoniae and the risk of development or progression of atherosclerotic disease. This association has become evident through serologic, pathologic, and animal-based models and, more recently, through limited trials of antichlamydial antibiotics in humans. Whether C. pneumoniae is a causative agent or "innocent bystander" or whether antibiotic therapy has any role in the treatment of cardiovascular disease remains to be determined.
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Affiliation(s)
- R Behbahani
- Product Information Department, SmithKline Beecham Pharmaceuticals, Philadelphia, Pennsylvania 19101, USA
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