Relation between serum total bilirubin levels and severity of coronary artery disease in patients with non-ST-segment elevation myocardial infarction

Role of bilirubin in the prognosis of coronary artery disease and its relationship with cardiovascular risk factors: a meta-analysis

Background

Bilirubin is a heme catabolism product with antioxidant, anti-inflammatory, and anti-apoptotic properties and is implicated in the prognosis of several diseases. This study evaluates the prognostic role of bilirubin in coronary artery disease (CAD) patients.

Methods

After identifying studies from the literature, meta-analyses were performed to achieve a) overall estimates of serum total bilirubin levels in patients with myocardial infarction (MI), non-MI CAD and healthy individuals; b) odds ratios (OR) of adverse outcomes between higher and lower total bilirubin levels; c) standardized mean difference (SMD) in total bilirubin levels in patients with high vs low CAD severity; and d) correlation between disease severity and total bilirubin. Metaregression analyses were performed to examine the relationship between cardiovascular risk factors and increasing quantiles of total bilirubin levels.

Results

Forty-three studies were identified. Pooled serum total bilirubin levels were 0.72 mg/dl [95% confidence interval (CI): 0.60, 0.83] in MI patients; 0.65 mg/dl [95% CI: 0.60, 0.69] in non-MI CAD patients; and 0.66 mg/dl [95% CI: 0.56, 0.75] in healthy individuals. Higher total bilirubin levels were associated with greater odds of adverse outcomes in MI patients (OR: 1.08 [95% CI: 0.99, 1.18]) but lower odds in non-MI CAD patients (OR: 0.80 [95%CI: 0.73, 0.88]). Compared to non-severe cases, total bilirubin levels were higher in patients with severe MI (SMD 0.96 [95% CI: − 0.10, 2.01]; p = 0.074) but were lower in severe non-MI CAD patients (SMD − 0.30 [95%CI: − 0.56, − 0.03]; p = 0.02). Total bilirubin levels correlated positively with MI severity (r = 0.41 [95% CI: 0.24, 0.59]; p < 0.01) but correlated negatively with non-MI CAD severity (r =  − 0.17 [95% CI: − 0.48, 0.14]; p = 0.28). Female sex was inversely associated with increasing quantiles of bilirubin (meta-regression coefficient: − 8.164 [− 14.531, − 1.769]; p = 0.016) in MI patients.

Conclusion

Prognostic role of bilirubin for CAD appears complicated, as different odds are observed for MI and non-MI CAD patients which weakens the case of causal involvement of bilirubin in CAD etiology or prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02899-w.

Neutrophil-to-lymphocyte ratio predicts coronary artery lesion severity and long-term cardiovascular mortality in patients with unstable angina pectoris

OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR), one of the composite biomarker of systemic inflammatory status, was proved promising in predicting clinical outcomes of acute coronary syndrome (ACS). However, there were no evidences that NLR was directly relative to the clinical outcomes of unstable angina pectoris (UAP). Therefore, this study was aimed to detect whether NLR could predict the coronary artery lesion severity (indicated as SYNTAX score) and clinical outcomes (especially long-term cardiovascular mortality) in patients with.

METHODS

In the single-centre retrospective study, 4110 patients with UAP were enrolled and divided into two groups according to their primary NLR values and followed up at a median time duration of 36 months. The differences of SYNTAX score and cardiovascular mortality between groups were analysed, and the predictive value of NLR was determined.

RESULTS

NLR was positively and linearly correlated with SYNTAX score (r = 0.270). Diabetes (p = 0.049), lymphocyte (p = 0.004), NLR (p = 0.002) and SYNTAX score (p < 0.001) were independent predictors of long-term cardiovascular mortality in patients with UAP. Kaplan-Meier analysis revealed higher occurrence of cardiovascular mortality when NLR > 2.38 (p = 0.015). Receiver operating characteristic (ROC) analysis showed that NLR = 2.76 is an effective cut point for predicting cardiovascular mortality (69.2% sensitivity, 64.8% specificity).

CONCLUSIONS

NLR value was positively related to the severity of coronary artery lesion and proved to be an independent predictor of cardiovascular mortality in patients with UAP. This study would contribute to therapy and prognosis optimisation of UAP.

Serum total bilirubin and long-term prognosis of patients with new-onset non-ST elevation myocardial infarction: a cohort study

Background

The potential prognostic role of total bilirubin (TBIL) in patients with new-onset non-ST elevation myocardial infarction (NSTEMI) is not fully understood. This study aims to evaluate the potential predictive value of TBIL for long-term prognosis in patients with new-onset NSTEMI.

Methods

Patients with new-onset NSTEMI that underwent emergency coronary angiography in our department from June 2015 to March 2020 were included. Baseline TBIL was measured at admission. SYNTAX scores were used to indicate the severity of coronary lesions. The association between TBIL and SYNTAX scores was analyzed using multivariate logistic regression. The patients were followed for the incidence of major adverse cardiac and cerebrovascular events (MACCEs). The association between TBIL and MACCEs was analyzed using Kaplan–Meier survival methods.

Results

In total 327 patients were included in this study. Patients were divided according to tertiles of TBIL (first tertile < 10.23 µmol/L, n = 109; second tertile 10.23–14.30 µmol/L, n = 109; and third tertile ≥ 14.30 µmol/L, n = 109). TBIL was independently associated with the severity of coronary lesions in patients with NSTEMI, with an adjusted odds ratio (OR) and 95% confidence interval (CI) for the third tertile and the second tertile compared with the first tertile of TBIL of 2.259 (1.197–4.263) and 2.167 (1.157–4.059), respectively (both p < 0.05). After a mean follow-up of 30.33 months, MACCE had occurred in 57 patients. TBIL was independently associated with the increased risk of MACCEs, with an adjusted hazard ratio (HR) and 95% CI for the third tertile and the second tertile compared with the first tertile of TBIL of 2.737 (1.161–6.450) and 3.272 (1.408–7.607), respectively (both p < 0.05).

Conclusions

Higher myocardial infarction admission TBIL might independently predict poor prognosis in patients with NSTEMI.

Effects of bilirubin on perioperative myocardial infarction and its long-term prognosis in patients undergoing percutaneous coronary intervention

BACKGROUND

Although bilirubin is known to be an antioxidant, any relationship with coronary heart disease remains controversial. To the best of our knowledge, no previous study has investigated the association between bilirubin and perioperative myocardial infarction (PMI), including its long-term prognosis.

AIM

To investigate the impact of bilirubin levels on PMI in patients undergoing percutaneous coronary intervention (PCI), and long-term prognosis in post-PMI patients.

METHODS

Between January 2014 and September 2018, 10236 patients undergoing elective PCI were enrolled in the present study. Total bilirubin (TB) and cardiac troponin I (cTnI) levels were measured prior to PCI and cTnI at further time-points, 8, 16 and 24 h after PCI. Participants were stratified by pre-PCI TB levels and divided into three groups: < 10.2; 10.2-14.4 and > 14.4 μmol/L. PMI was defined as producing a post-procedural cTnI level of > 5 × upper limit of normal (ULN) with normal baseline cTnI. Major adverse cardiovascular events (MACEs) included cardiac death, MI, stroke and revascularization during a maximum 5-year follow-up.

RESULTS

PMI was detected in 526 (15.3%), 431 (12.7%) and 424 (12.5%) of patients with pre-PCI TB levels of < 10.2, 10.2-14.4 and > 14.4 μmol/L (P = 0.001), respectively. Multivariate logistical analysis indicated that patients with TB 10.2-14.4 and > 14.4 μmol/L had a lower incidence of PMI [TB 10.2-14.4 μmol/L: Odds ratio (OR): 0.854; 95% confidence interval (CI): 0.739-0.987; P = 0.032; TB > 14.4 μmol/L: OR: 0.846; 95%CI: 0.735-0.975; P = 0.021] compared with patients with TB < 10.2 μmol/L. Construction of a Kaplan-Meier curve demonstrated a higher MACE-free survival time for patients with higher TB than for those with lower TB (log-rank P = 0.022). After adjustment for cardiovascular risk factors and angiographic characteristics, multivariate Cox analysis showed that a TB level > 14.4 μmol/L was associated with a reduced risk of MACEs compared with a TB level < 10.2 μmol/L (hazard ratio 0. 667; 95%CI: 0.485-0.918; P = 0.013).

CONCLUSION

Bilirubin was a protective factor in PMI prediction. For post-PMI patients, elevated bilirubin levels were independently associated with a reduced risk of MACEs during long-term follow-up.

Direct Bilirubin Levels Predict Long-Term Outcomes in Patients With Acute Coronary Syndrome Under Different Glucose Metabolism Status: A 6.5-Year Cohort Study of Three-Vessel Disease

Background: There is controversy over the relationship between bilirubin and coronary artery disease. This study aimed to evaluate the predictive value of direct bilirubin (DB) in patients with complex acute coronary syndrome (ACS).

Methods: From April 2004 to February 2011, 5,322 ACS patients presenting with three-vessel disease were consecutively enrolled. Disease severity and complexity were determined by SYNTAX score (SS) and SS II. The primary endpoint was all-cause death, and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE). Stratification of normal glucose regulation, prediabetes, and diabetes was based on a previous diagnosis, hypoglycemic medications, fasting blood glucose, and hemoglobin A1c.

Results: Subjects were divided into quartiles according to baseline DB (μmol/L): Q1 (0–1.6), Q2 (1.61–2.20), Q3 (2.21–2.80), and Q4 (>2.80). Multivariable logistic regression analysis showed that DB was an independent predictor of intermediate–high SS. During a median follow-up time of 6.5 years, elevated DB was associated with more all-cause death (p < 0.001) but not MACCE. DB remained to be predictive of all-cause death in the multivariable Cox regression model (Q2 vs. Q1: HR 1.043, 95% CI 0.829–1.312, p = 0.719; Q3 vs. Q1: HR 1.248, 95% CI 1.001–1.155, p = 0.048; Q4 vs. Q1: HR 1.312, 95% CI 1.063–1.620, p = 0.011). When subjects are stratified according to glucose metabolism regulation and treatment strategies, the predictivity of DB was only profound in patients with diabetes or with conservative treatment. Additionally, incorporating DB further improved the discrimination and reclassification abilities of SS II for risk prediction.

Conclusion: DB is a potential biomarker for predicting lesion severity and long-term outcomes in ACS patients.

Association of Total Bilirubin With All-Cause and Cardiovascular Mortality in the General Population

Objective: The study aims to investigate the association of total bilirubin with all-cause and cause-specific mortality in the general population.

Methods: A total of 37,234 adults from the United States National Health and Nutrition Examination Survey 1999–2014 were enrolled. Baseline levels of total bilirubin associated with risk of mortality were evaluated on a continuous scale (restricted cubic splines) and by quartile categories with Cox regression models.

Results: Higher levels of total bilirubin was positively associated with an increased risk of all-cause mortality [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.46–1.72; p < 0.001]. Compared with individuals with the lowest quartile of bilirubin, the multivariable adjusted hazard ratio for all-cause mortality was 1.25 (1.14–1.37) for individuals in the highest quartile. Restricted cubic splines indicated that the association was non-linear in cardiovascular mortality and cancer mortality while linear in all-cause mortality.

Conclusions: Total bilirubin was associated with all-cause and cause-specific mortality in the general population.

Model for End-Stage Liver Disease Score Predicts the Mortality of Patients with Coronary Heart Disease Who Underwent Percutaneous Coronary Intervention

Background

Coronary heart disease (CHD) is caused by the blockage or spasm of coronary arteries. Evidence shows that liver disease is related to CHD. However, the correlation between the Model for End-Stage Liver Disease (MELD) score and outcomes in patients after percutaneous coronary intervention (PCI) was unclear.

Method

A retrospective cohort study involved 5373 patients with coronary heart disease after PCI was conducted from January 2008 to December 2016. Participants were classified to four groups according to the MELD score by quartiles. The primary endpoint was long-term mortality including all-case mortality (ACM) and cardiac mortality (CM). Secondary endpoints included bleeding events, readmission, major adverse cardiovascular events (MACE), major adverse cardiovascular, and cerebrovascular events (MACCE). The longest follow-up time was almost 10 years.

Results

There were significant differences in the incidences of ACM (p=0.038) and CM (p=0.027) among the four MELD groups, but there was no significant difference in MACEs (p=0.496), MACCEs (p=0.234), readmission (p=0.684), and bleeding events (p=0.232). After adjusting the age, gender, smoking, drinking status, and diabetes by a multivariable Cox regression analysis, MELD remains independently associated with ACM (HR:1.57, 95%CI 1.052–2.354, p=0.027) and CM (HR:1.434, 95% CI 1.003–2.050, p=0.048).

Conclusion

This study indicated that the MELD score had a strong prediction for long-term mortality in CHD patients who underwent PCI.

Prognostic Value of Serum Total Bilirubin after Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome

Backgrounds

Previous studies have reported a relationship between serum total bilirubin (STB) and coronary artery disease (CAD). However, the relationship between STB and prognosis of patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) remains inconclusive. The present study aimed to evaluate the relationship between STB level and prognosis of PCI in patients with ACS.

Methods

In total, 2850 ACS patients who underwent PCI at the Affiliated Zhongda Hospital of Southeast University from June 2009 to Jan 2017 were included in the study. Twenty-four-hour STB, 30-day, and 1-year postoperative major adverse cardiovascular events (MACE) were recorded. Subjects were assigned to one of three groups based on STB: Group A (STB ≤ 9.6 μmol/L), Group B (9.7 μmol/L < STB ≤ 15.4 μmol/L), and Group C (STB ≥ 15.5 μmol/L). COX survival analysis was subsequently used to investigate the relationship between the incidence of MACE and STB in the three groups.

Results

A total of 2770 subjects were successfully followed up; within 1 year after PCI, 115 (4.15%) subjects died and 191 (6.90%) subjects experienced MACE. One-year follow-up results showed that the incidence of MACE decreased significantly as STB increased; the risk of Group A was 2.002 times that of Group C (95% CI: 1.342-2.986). Cardiac mortality also decreased with increasing STB; the risk of Group A was 3.403 times that of Group C (95% CI: 1.319-8.785).

Conclusion

Lower mortality and MACE incidence rates were found in patients with higher STB within 1 year. Therefore, STB is highly recommended as an independent long-term prognosis predictor of PCI in patients with ACS.

Relation of Direct, Indirect, and Total bilirubin to Adverse Long-term Outcomes Among Patients With Acute Coronary Syndrome

Bilirubin is known as an antioxidant. However, there have been controversies over whether bilirubin is protective against cardiovascular disease or not. In addition, no study has examined the association between subtypes of total bilirubin (direct bilirubin [DB] and indirect bilirubin [IDB]) and long-term outcomes of acute coronary syndrome (ACS) patients. We included 533 consecutive patients with ACS. All the patients were followed up for the composite end point of cardiac death, revascularization, and acute heart failure. At a median follow-up of 2.4 years, Kaplan-Meier curve demonstrated that higher serum DB levels were significantly associated with major adverse cardiac events (MACE) (p <0.05). However, total bilirubin (TB) and IDB were not associated with MACE by Kaplan-Meier analysis. Cox analysis showed that high TB and DB were associated with increased risk of MACE in ACS even after adjustment of cardiovascular risk factors. The receiver operating characteristic curve illustrated that DB had a predictive value of MACE in ACS. In conclusion, we firstly reported that high TB and DB but not IDB were associated with increased risk of MACE in Chinese ACS, and the prognostic value of DB was superior to that of TB or IDB.

The Relationship between Serum Bilirubin and Inflammatory Bowel Disease

The associations between serum total bilirubin (sTB) levels, inflammatory marker levels, and disease activity are not well understood in patients with inflammatory bowel disease (IBD). The present study investigated the association between sTB levels and disease activity in patients with IBD. We conducted a retrospective study with a total of 242 consecutive patients with Crohn's disease (CD) and 211 consecutive patients with ulcerative colitis (UC). The Crohn's Disease Activity Index (CDAI) score was used to assess disease activity in patients with CD and the Mayo score of patients with UC. 255 clinically healthy subjects comprised the control group, which come from the same geographic area as the IBD group. We retrieved the clinical and laboratory parameters of patients with IBD from the medical records. Patients with IBD displayed significantly lower sTB levels than controls. sTB levels were negatively associated with C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fecal calprotectin (FC), and hemoglobin (Hb) levels in patients with IBD. Additionally, there was a negative association between sTB levels and the CDAI score of patients with CD. sTB levels were also negatively associated with the Mayo score of patients with UC. IBD patients had lower sTB levels when compared with controls, and there was a negative correlation between sTB levels and disease activity in patients with IBD. Increased reactive oxygen species production in IBD is likely to be responsible for increased consumption of bilirubin in patients with IBD, leading to further intestinal injury. Reducing oxidative stress may be therapeutic for these patients.

Prognostic value of total bilirubin in patients with acute myocardial infarction: A meta-analysis

BACKGROUND

Experimental data obtained in animal models supported the protective role of bilirubin. However, clinical studies regarding the prognostic role of total bilirubin in patients with acute myocardial infarction (AMI) are conflicting. We, therefore, undertook this meta-analysis to evaluate the prognostic value of serum total bilirubin in AMI patients.

METHODS

Relevant studies were searched from PubMed and EMBASE databases up to April 15, 2018. Studies evaluating the outcomes in relation to serum total bilirubin in AMI patients and reporting multivariable-adjusted risk estimate of the prognostic value were eligible. The outcome measures were major adverse cardiac events (MACEs), cardiovascular death, and all-cause mortality.

RESULTS

Six studies involving 14,554 AMI patients were identified. Meta-analysis indicated that higher total bilirubin was associated with an increased risk of MACEs (risk ratio [RR] 1.65; 95% confidence intervals [CI] 1.25-2.19) and cardiovascular death (RR 2.12; 95%CI 1.24-3.64). However, higher serum total bilirubin did not significantly increase all-cause mortality risk (RR 1.31; 95%CI 0.75-2.28). Subgroup analyses by the types of AMI and study design supported the pooled results.

CONCLUSIONS

Higher serum total bilirubin level is a predictor of MACEs and cardiovascular death in patients with AMI. However, interpretation of these findings should be with caution due to the impact of cardiac dysfunction after AMI.

Decreased Serum Bilirubin Levels and Increased Uric Acid Levels are Associated with Ulcerative Colitis

Background

In recent years, emerging evidence has suggested that ulcerative colitis occurs as a consequence of an imbalance between oxidative stress and antioxidant capacity. The objective of this study was to investigate whether serum total bilirubin and serum uric acid levels were associated with ulcerative colitis.

Material/Methods

We conducted a retrospective case-control study which included 170 patients with ulcerative colitis and 200 healthy individuals. Concentrations of serum total bilirubin and serum uric acid were obtained from biochemical information and segregated into quartiles. Logistic regression analysis was adopted to explore the correlations between levels of the 2 biochemical markers and the risk of ulcerative colitis.

Results

Compared with healthy controls, patients with ulcerative colitis exhibited lower levels of serum bilirubin (9.30 umol/L versus 12.49 umol/L respectively, P<0.001). Multivariate logistic regression showed that the lowest quartile of total serum bilirubin was independently associated with the occurrence of ulcerative colitis (OR=2.56, 95%CI: 1.54–4.25, P<0.001). Similarly, ulcerative colitis patients exhibited higher concentrations of serum uric acid (338 umol/L versus 300 umol/L respectively, P=0.041). Multivariate logistic regression showed that the highest quartile of serum uric acid was independently associated with ulcerative colitis risk (OR=1.20, 95%CI: 1.05–1.77, P=0.045). Furthermore, a negative association was observed between serum total bilirubin and serum uric acid in patients with ulcerative colitis.

Conclusion

Lower levels of serum total bilirubin and higher levels of serum uric acid are associated with ulcerative colitis patients compared to healthy controls.

Combined value of left ventricular ejection fraction and the Model for End-Stage Liver Disease (MELD) score for predicting mortality in patients with acute coronary syndrome who were undergoing percutaneous coronary intervention

Background

The purpose of the study was to investigate whether the addition of left ventricular ejection fraction (LVEF) to the MELD score enhances the prediction of mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

Methods

This retrospective study analyzed 846 consecutive patients with ACS undergoing PCI who were not receiving previous anticoagulant therapy. The patients were grouped as survivors or non-survivors. The MELD score and LVEF were calculated in all patients. The primary end point was all-cause death during the median follow-up of 28 months.

Results

During the follow-up, there were 183 deaths (21.6%). MELD score was significantly higher in non-survivors than survivors (10.1 ± 4.4 vs 7.8 ± 2.4, p <  0.001). LVEF was lower in non-survivors compared with survivors (41.3 ± 11.8% vs. 47.5 ± 10.0%, p <  0.001). In multivariate analysis, both MELD score and LVEF were independent predictors of total mortality. (HR: 1.116, 95%CI: 1.069–1.164, p <  0.001; HR: 0.972, 95%CI: 0.958–0.986, p <  0.001, respectively). The addition of LVEF to MELD score was associated with significant improvement in predicting mortality compared with the MELD score alone (AUC:0.733 vs 0.690, p <  0.05). Also, the combining LVEF with MELD score improved the reclassification (NRI:24.6%, p <  0.001) and integrated discrimination (IDI:0.045, p <  0.001) of patients compared with MELD score alone.

Conclusions

Our study demonstrated that the combining LVEF with MELD score may be useful to predict long-term survival in patients with ACS who were undergoing PCI.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0782-8) contains supplementary material, which is available to authorized users.

The correlation of serum bilirubin levels with disease activity in patients with rheumatoid arthritis

BACKGROUND

We investigated the relationship between serum bilirubin and disease activity in patients with rheumatoid arthritis (RA).

METHODS

We included a total of 173 consecutive RA patients without steroid treatment and 346 healthy subjects; the disease activity score in 28 joints (DAS28) was used to assess disease activity in patients with RA.

RESULTS

Serum bilirubin concentrations were significantly lower in RA patients than in controls. Serum bilirubin was found to be negatively correlated with C-reactive protein (CRP) concentration and erythrocyte sedimentation rate (ESR) (r=-0.165, P=0.030; r=-192, P=0.012) in patients with RA. There was a negative correlation between the serum bilirubin and DAS28 score (r=-0.331, P<0.001). Serum bilirubin was independently associated with the DAS28 score (b=-0.225, P=0.001) in the multiple linear regression analysis.

CONCLUSIONS

Serum bilirubin concentrations are lower in patients with RA compared to controls and correlate with disease activity in patients with RA.

The Role of Serum Bilirubin Levels in Predicting Troponin Positivity in Non-ST-Segment Elevation Acute Coronary Syndrome

Data are scant regarding serum bilirubin levels in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In this study, we evaluated the role of serum bilirubin levels in NSTE-ACS. We enrolled 782 patients who presented to the emergency department with acute chest pain. Patients were divided into 2 groups based on the troponin positivity. Patients with NSTE-ACS who had troponin positivity were included in group 1 (n = 382), and group 2 consisted of the control patients (n = 400). Direct bilirubin (DB) levels (group 1: 0.31 ± 0.37 mg/dL, group 2: 0.20 ± 0.25 mg/dL, P < .001) and total bilirubin (TB) levels (group 1: 0.78 ± 0.56 mg/dL, group 2: 0.62 ± 0.45 mg/dL, P < .001) were significantly higher in group 1. There was a significant and moderate correlation between serum bilirubin levels and admission troponin values ( r = .34, P < .001 for TB and r = .42, P < .001 for DB). These results show that serum bilirubin levels were associated with troponin positivity in patients with NSTE-ACS.

Total Bilirubin Levels Predict Subclinical Atherosclerosis in Patients With Prediabetes

Bilirubin may have important antiatherosclerotic effects. Prediabetes (PD), the intermediate stage before diabetes mellitus, is associated with increased cardiovascular morbidity and mortality. We evaluated the relationship between serum bilirubin levels and carotid intima-media thickness (cIMT), as a surrogate marker of subclinical atherosclerosis, in patients with PD. We enrolled 170 consecutive patients with PD. The patients underwent ultrasonography to evaluate cIMT. The patients were divided into groups according to cIMT values (<0.9 vs ≥0.9 mm). The patients with cIMT ≥ 0.9 mm had significantly higher diastolic blood pressure, neutrophil-lymphocyte ratio (NLR), and glycated hemoglobin values compared with patients having cIMT < 0.9 mm, whereas total and direct bilirubin values were significantly lower in this group. Multivariate regression analyses revealed NLR and total bilirubin as the independent predictors of subclinical atherosclerosis. The present study demonstrated that NLR and lower total bilirubin levels were independent predictors of subclinical atherosclerosis in patients with PD. Simple measures such as NRL and total bilirubin may provide predictive information regarding the risk of cardiovascular disease in patients with PD.

Initial Total Bilirubin and Clinical Outcome in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention With Drug-Eluting Stents

BACKGROUND

Total bilirubin (TB) concentration is inversely associated with stable coronary artery disease, but there have been few studies on initial TB in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

A total of 1,111 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with drug-eluting stents (DES) were divided into a high TB group (n=295) and a low TB group (n=816) according to the optimal cut-off 0.79 mg/dl. The high TB group had a higher rate of in-hospital major adverse cardiac events (MACE), a composite of cardiac death, non-fatal MI, and definite/probable stent thrombosis (14.2% vs. 4.2%, P<0.001) and cardiac death (13.9% vs. 3.9%, P<0.001) compared with the low TB group. The 30-day MACE-free survival rate was also significantly different between the groups (P<0.001, log-rank test). On multivariate Cox regression, initial high TB was a significant predictor of in-hospital MACE (HR, 2.69; 95% CI: 1.67-4.34, P=0.010) and of cardiac death (HR 2.72, 95% CI: 1.67-4.44, P=0.012). Adding initial TB to TIMI risk score significantly improved prediction for in-hospital MACE according to net reclassification improvement (NRI=5.2%, P=0.040) and integrated discrimination improvement (IDI=0.027, P=0.006).

CONCLUSIONS

Initial TB is a powerful prognostic marker, and inclusion of this can improve prediction of in-hospital MACE in patients with STEMI undergoing primary PCI with DES. (Circ J 2016; 80: 1437-1444).

Usefulness of monocyte to HDL-cholesterol ratio to predict high SYNTAX score in patients with stable coronary artery disease

AIM

We aimed to investigate whether baseline monocyte to high-density lipoprotein cholesterol ratio (MHR), an easily available inflammatory and oxidative stress marker, is associated with SYNTAX score.

PATIENTS & METHODS

In this cross-sectional study, n = 1229 consecutive patients with coronary artery disease were classified into two groups, low SYNTAX score (≤22) and high SYNTAX score (≥23).

RESULTS

MHRs were significantly higher in patients with high SYNTAX score (p < 0.05). In multivariate regression analysis, MHR remained as independent predictor of high SYNTAX score together with C-reactive protein (CRP), hypertension and diabetes mellitus. In correlation analysis, MHR showed significant positive correlations with SYNTAX score (r = 0.371, p < 0.001) and CRP level (r = 0.336, p < 0.001).

CONCLUSION

This study suggests MHR is independently associated with burden of coronary atherosclerosis.

Comparison of Serum Uric Acid, Bilirubin, and C-Reactive Protein as Prognostic Biomarkers of In-Hospital MACE Between Women and Men With ST-Segment Elevation Myocardial Infarction

Levels of C-reactive protein (CRP), uric acid (UA), and total bilirubin (TB) are associated with coronary artery disease and major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction (STEMI). We retrospectively included 1167 patients with STEMI who underwent percutaneous coronary intervention and routine blood sampling. The study cohort consisted of 803 patients (73.1% male, mean age 62.5 ± 13.4 years). In men, the levels of CRP, TB, and UA were significantly higher in the MACE than in the non-MACE group (P < .05). The receiver-operating characteristic (ROC) analysis shows that CRP (area under the curve [AUC]: 0.59; 95% confidence interval [CI]: 0.53-0.66; P = .014) and TB (AUC: 0.58; 95% CI: 0.51-0.65; P = .019) are significantly associated with MACE but not UA (AUC: 0.61; 95% CI: 0.42-0.76; P = .083). Logistic regression revealed CRP (odds ratio [OR] 1.01; 95% CI: 1.00-1.01; P = .006) and TB (OR 2.03; 95% CI: 1.12-3.40; P = .007) as an independent predictor for MACE. In women, none of the biomarkers was associated with MACE by ROC analysis or logistic regression analysis. This study demonstrated that high CRP and TB serum levels have a prognostic association with in-hospital MACE in male patients with STEMI.

Bilirubin provides perforator flap protection from ischaemia-reperfusion injury in a rat model: a preliminary result

The use of bilirubin, a well-known and powerful antioxidant, has gained popularity in recent years because of its role in the prevention of ischaemic heart disease in patients with Gilbert's syndrome. We investigate the effects of bilirubin on ischaemia-reperfusion (I/R) injury using a rat perforator flap model. Forty-eight rats were randomly divided into two groups: experimental (bilirubin) group (n = 24) and control group (n = 24). In each group, elevated bilateral deep inferior epigastric perforator (DIEP) flaps were created. The right (no ischaemia side) and left (ischaemia side) DIEP flaps were separated according to the presence of ischaemia induction. Ischaemia was induced in anaesthetised rats by perforator clamping for 15 or 30 minutes. After surgery, the flap survival was assessed daily on postoperative days 0 to 5, and overall histological changes of DIEP flaps above the perforator were analysed at postoperative day 5. The flap survival rate in the bilirubin group was significantly higher than that in the control group at the ischaemia side following perforator clamping for 15 or 30 minutes (93·42 ± 4·48% versus 89·63 ± 3·98%, P = 0·002; and 83·96 ± 4·23% versus 36·46 ± 6·38%, P < 0·001, respectively). The difference in flap survival between the two groups was the most prominent on the ischaemic side following 30 minutes of perforator clamping. From a morphologic perspective, pre-treatment with bilirubin was found to alleviate perforator flap necrosis caused by I/R injury in this experimental rat model.

Acute Effects of Intracoronary Tirofiban on No-Reflow Phenomena in Patients With ST-Segment Elevated Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

We evaluated the acute effect of intracoronary administration of tirofiban on no-reflow phenomenon in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention. Consecutive patients (n = 162) were randomized into 2 groups based on whether intracoronary tirofiban was administered. After the administration of intracoronary tirofiban, thrombolysis in myocardial infarction (TIMI) flow grade significantly increased ( P < .001) and successful reperfusion was achieved in 26 (32%) patients. In the placebo group, however, after the administration of intracoronary placebo the TIMI flow grade did not change ( P = .070), and successful reperfusion was achieved only in 8 (10%) patients. In-hospital major adverse cardiac events (MACE) were significantly lower in the tirofiban group (36% vs 19%, P = .013). Intracoronary administration of tirofiban significantly improves TIMI flow grade and is associated with a lower in-hospital rate of MACE.

The relationship between total bilirubin levels and total mortality in older adults: the United States National Health and Nutrition Examination Survey (NHANES) 1999-2004

Objective

Due to its anti-oxidant and anti-inflammatory properties, bilirubin has been associated with reduced cardiovascular risk. A recent study demonstrated an L-shaped association of pre-treatment total bilirubin levels with total mortality in a statin-treated cohort. We therefore investigated the association of total bilirubin levels with total mortality in a nationally representative sample of older adults from the general population.

Methods

A total of 4,303 participants aged ≥60 years from the United States National Health and Nutrition Examination Survey 1999–2004 with mortality data followed up through December 31, 2006 were included in this analysis, with a mean follow-up period of 4.5 years.

Results

Participants with total bilirubin levels of 0.1–0.4 mg/dl had the highest mortality rate (19.8%). Compared with participants with total bilirubin levels of 0.5–0.7 mg/dl and in a multivariable regression model, a lower total bilirubin level of 0.1–0.4 mg/dl was associated with higher risk of total mortality (hazard ratios, 1.36; 95% confidence interval, 1.07–1.72; P = 0.012), while higher levels (≥0.8 mg/dl) also tended to be associated with higher risk of total mortality, but this did not reach statistical significance (hazard ratios, 1.24; 95% confidence interval, 0.98–1.56; P = 0.072).

Conclusion

In this nationally representative sample of older adults, the association of total bilirubin levels with total mortality was the highest among those with a level between 0.1 and 0.4 mg/dl. Further studies are needed to investigate whether higher total bilirubin levels could be associated with a higher mortality risk, compared to a level of 0.5–0.7 mg/dl.