Fibrinogen: a predictor of vascular disease

Antioxidant Effects of a Polyphenol-Rich Dietary Supplement Incorporating Pinus massoniana Bark Extract in Healthy Older Adults: A Two-Arm, Parallel Group, Randomized Placebo-Controlled Trial

Oxidative stress is a key physiological phenomenon underpinning the ageing process and plays a major developmental role in age-associated chronic diseases. This study investigated the antioxidant effects of a polyphenol-rich dietary supplement containing Pinus massoniana bark extract (PMBE) in healthy older adults. In a double-blinded, placebo-controlled clinical trial, participants were randomised (in a 1:1 ratio) to receive a 50 mL/day dietary supplement containing placebo (0 mg PMBE) or PMBE (1322 mg PMBE) for 12 weeks. The primary outcome was fasting plasma malondialdehyde (MDA) concentrations and secondary outcomes were plasma inflammatory markers. MDA concentrations significantly reduced following PMBE for 6 weeks (−1.19 nmol/mL, 95%CI −1.62, −0.75, p < 0.001) and 12 weeks (−1.35 nmol/mL, 95%CI −1.74, −0.96, p < 0.001) compared to baseline. MDA did not significantly change after the placebo. MDA levels at 6 and 12 weeks were significantly lower following PMBE compared to placebo (p < 0.001). At 12 weeks in the PMBE group, fibrinogen concentrations significantly reduced (−0.25 g/L, 95%CI −0.39, −0.11; p < 0.0001) and interleukin-6 significantly increased compared to placebo (0.30 pg/mL, 95%CI 0.02, 0.59; p < 0.05). PMBE in a polyphenol-rich dietary supplement reduced oxidative stress in healthy older adults. Further studies are warranted to investigate the antioxidant capacity of PMBE in conditions with heightened oxidative stress, such as osteoarthritis, hypertension, type 2 diabetes, or other lifestyle related diseases.

Elevated Plasma Fibrinogen Is Associated With Excessive Inflammation and Disease Severity in COVID-19 Patients

Background

The coronavirus disease-19 (COVID-19) is characterized with intense inflammatory response, cardiac involvement, and coagulopathy. Fibrinogen, as a biomarker for inflammation, cardiovascular disease, and coagulation, has not been fully investigated yet. The aim of this study was to assess the clinical application of fibrinogen in COVID-19 patients.

Methods

We retrospectively analyzed the demographic and laboratory characteristics of 119 COVID-19 patients in the University of Alabama of Birmingham Medical Center. Correlations of fibrinogen on admission with intensive care unit (ICU) admission, disease severity, and laboratory parameters were analyzed.

Results

Among the 119 COVID-19 patients, 77.3% (92/119) had severe disease, and 59.5% (71/119) patients were admitted to the ICU. Elevated fibrinogen was detected in 67.2% (80/119) of the patients. Fibrinogen levels were significantly associated with inflammatory markers and disease severity, but not with cardiac injury biomarker high sensitivity troponin I. Patients with severe disease had increased fibrinogen levels upon admission compared to patients with non-severe disease (P = 0.001). Fibrinogen level at 528.0 mg/dl was the optimal cutoff to predict disease severity, with a sensitivity and specificity of 66.7% and 70.3% (area undty -60er the curve [AUC] 0.72, P = 0.0006).

Conclusions

Fibrinogen is commonly elevated in COVID-19 patients, especially in those with severe disease. Elevated fibrinogen correlates with excessive inflammation, disease severity, and ICU admission in COVID-19 patients.

[Thromboembolic complications in nephrotic syndrome]

This review devoted to the nephrotic syndrome (NS) subsequent thrombotic outcomes. The pathogenesis of hypercoagulation disorders that cause venous and arterial vascular system thrombosis are studied. Discussed procoagulant and anticoagulant mechanisms imbalance due to the anticoagulants natural urinal loss, affected by disfunction of the glomerular filter selective permeability, leading to high molecular weight liver-derived proteins (at least of the albumin size) leakage, fibrinolysis depression, excessive liver synthesis of plasma clotting cascade factors and platelet activation. Presented new data on the thrombogenesis at NS concerning the role of endothelial microparticles with high prothrombogenic activity that go from damaged glomerulus endothelial capillary cells into the systemic circulation, which can turn the local renal hypercoagulation (concomitant to the kidney immune inflammation process) into the generalized, working towards the thrombosis development. The most frequent adverse variants of arterial and venous thromboses are studied, specified their basic and general risk factors, as well as individual, varying in different patients. Indications and prophylactic anticoagulant therapy regimen and thrombosis treatment duration in patients with NS are discussed. It also stressed that the decision on time and method of anticoagulant therapy for a NS patients is still a challenge for healthcare providers.

Characterization of thromboelastography of patients with different pathological types of nephrotic syndrome

To investigate the changes in blood coagulability as measured by thromboelastography (TEG) in patients with nephrotic syndrome of different etiologies as well as in patients with venous thromboembolic events (VTE).From January 2013 to October 2017, patients who were diagnosed as idiopathic membranous nephropathy (IMN), minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) were enrolled into this retrospective study in which their clinical characteristics, including TEG variables, were investigated. According to the presence or absence of VTE, the patients with IMN were divided into 2 groups of VTE and non-VTE. The risk factors of VTE were analyzed with logistic regression.Significant differences in TEG parameters were found among the 3 groups of patients with R and K values lower, while the α-angle, maximum amplitude (MA) and confidence interval (CI) values higher, in the IMN group than those in the MCD and FSGS groups (P < .01). Multiple linear regression analysis indicated that the histologic subtype was an independent relevant factor of K time, angle, MA, and CI values. Multivariate logistic regression analysis revealed that serum albumin and CI value were independent risk factors of VTE (P < .05).The results showed that IMN patients may have higher whole blood coagulability than MCD and FSGS patients. The hypercoagulability in IMN patients may be attributed to platelet hyperactivity and the accelerated fibrin-platelet interaction. Hypoproteinemia and increased CI value were independent risk factors of VTE in IMN.

Systemic and ocular fluid compounds as potential biomarkers in age-related macular degeneration

Biomarkers can help unravel mechanisms of disease and identify new targets for therapy. They can also be useful in clinical practice for monitoring disease progression, evaluation of treatment efficacy, and risk assessment in multifactorial diseases, such as age-related macular degeneration (AMD). AMD is a highly prevalent progressive retinal disorder for which multiple genetic and environmental risk factors have been described, but the exact etiology is not yet fully understood. Many compounds have been evaluated for their association with AMD. We performed an extensive literature review of all compounds measured in serum, plasma, vitreous, aqueous humor, and urine of AMD patients. Over 3600 articles were screened, resulting in more than 100 different compounds analyzed in AMD studies, involved in neovascularization, immunity, lipid metabolism, extracellular matrix, oxidative stress, diet, hormones, and comorbidities (such as kidney disease). For each compound, we provide a short description of its function and discuss the results of the studies in relation to its usefulness as AMD biomarker. In addition, biomarkers identified by hypothesis-free techniques, including metabolomics, proteomics, and epigenomics, are covered. In summary, compounds belonging to the oxidative stress pathway, the complement system, and lipid metabolism are the most promising biomarker candidates for AMD. We hope that this comprehensive survey of the literature on systemic and ocular fluid compounds as potential biomarkers in AMD will provide a stepping stone for future research and possible implementation in clinical practice.

Serum biomarkers VEGF-C and IL-6 are associated with severe human Peripheral Artery Stenosis

BACKGROUND

Emerging reports propose possible biomarkers that are related to inflammation, nutrition and lipid parameters for detection of the progression of atherosclerotic plaques, peripheral artery disease (PAD) and particularly peripheral artery stenosis (PAS). However, it remains unclear which biomarkers in serum are associated with the severity of PAS.

FINDINGS

In this study, we measured serum levels of inflammatory biomarkers along with lipid and nutritional parameters in 53 patients who suffered different degrees of PAS. Serum concentrations of vascular endothelial growth factor-c (VEGF-C) and IL-6 (Interleukin 6) were significantly increased in patients showing moderate or severe PAS. Furthermore, the number of blood monocytes from PAS patients was significantly increased, which showed elevated adhesion to plate-coated fibrinogen. Compared to healthy subjects, freshly isolated or LPS (lipopolysaccharide)-stimulated blood monocytes from PAS patients could produce VEGF-C and IL-6 at higher levels.

CONCLUSIONS

Our study suggests that the increased number of blood monocytes might play key roles during the development of severe PAS, which enhance adhesion at the local narrowed peripheral artery and secret high levels of VEGF-C and IL-6. We suggest that serum concentrations of VEGF-C and IL-6 might be used as biomarkers for diagnosis severe PAS in combination with clinical imaging examination.

Relationships between the smoking status and plasma fibrinogen, white blood cell count and serum C-reactive protein in Japanese workers

OBJECTIVE

Confirmation of the association between smoking status and biological inflammatory or anticoagulant markers is required in the field of occupational therapy to promote anti-smoking education. The associations between the smoking status and biological markers were clarified.

METHODS

The study was performed in 5102 working men aged 30-60 years old. The author measured the plasma fibrinogen, white blood cell count (WBC) and serum high-sensitivity C-reactive protein (CRP) as biomarkers of the smoking status.

RESULTS

After adjustment for age, the mean plasma fibrinogen level in never-smokers was significantly lower than that in current smokers. The mean WBC count was also significantly lower in the never-smokers than that in current smokers and ex-smokers who had quit within the previous 1 year. Furthermore, the mean log-transformed serum CRP value in never-smokers was significantly lower than that in current smokers smoking ≥20 cigarettes daily. Spearman's rank correlation coefficients between the plasma fibrinogen and the serum CRP and WBC were 0.561 and 0.243, respectively. The mean plasma fibrinogen, serum CRP and WBC count in the ex-smokers showed a trend toward decreasing as the duration of abstinence became longer.

CONCLUSION

Among the three biomarkers, the plasma fibrinogen was the most strongly associated with the smoking status, its value being to be the highest in current smokers smoking ≥20 cigarettes daily. The same trend was also observed for the WBC count.

Haemostatic effects of metformin in simvastatin-treated volunteers with impaired fasting glucose

Our study investigated whether metformin has an impact on haemostasis in patients with pre-diabetes receiving statin therapy. The study included 41 simvastatin-treated patients with impaired fasting glucose who were randomized to either metformin (3 g daily) or placebo. The international normalized ratio, the partial thromboplastin time, fibrinogen, factor VII coagulant activity, plasminogen activator inhibitor-1 and von Willebrand factor were assessed on the day of randomization and after 90 days of treatment. Metformin treatment reduced plasma levels/activity of the assessed haemostatic risk factors, and this effect correlated with the improvement in insulin sensitivity. The obtained results indicate that high-dose metformin produces a multi-directional beneficial effect on coagulation and fibrinolysis in patients with impaired fasting glucose already receiving statin therapy. The effect of metformin on haemostasis may play a role in the prevention of atherosclerosis-related disorders and acute vascular events in this pre-diabetic state.

Plasma metabolomics and proteomics profiling after a postprandial challenge reveal subtle diet effects on human metabolic status

We introduce the metabolomics and proteomics based Postprandial Challenge Test (PCT) to quantify the postprandial response of multiple metabolic processes in humans in a standardized manner. The PCT comprised consumption of a standardized 500 ml dairy shake containing respectively 59, 30 and 12 energy percent lipids, carbohydrates and protein. During a 6 h time course after PCT 145 plasma metabolites, 79 proteins and 7 clinical chemistry parameters were quantified. Multiple processes related to metabolism, oxidation and inflammation reacted to the PCT, as demonstrated by changes of 106 metabolites, 31 proteins and 5 clinical chemistry parameters. The PCT was applied in a dietary intervention study to evaluate if the PCT would reveal additional metabolic changes compared to non-perturbed conditions. The study consisted of a 5-week intervention with a supplement mix of anti-inflammatory compounds in a crossover design with 36 overweight subjects. Of the 231 quantified parameters, 31 had different responses over time between treated and control groups, revealing differences in amino acid metabolism, oxidative stress, inflammation and endocrine metabolism. The results showed that the acute, short term metabolic responses to the PCT were different in subjects on the supplement mix compared to the controls. The PCT provided additional metabolic changes related to the dietary intervention not observed in non-perturbed conditions. Thus, a metabolomics based quantification of a standardized perturbation of metabolic homeostasis is more informative on metabolic status and subtle health effects induced by (dietary) interventions than quantification of the homeostatic situation. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11306-011-0320-5) contains supplementary material, which is available to authorized users.

Differential effect of soluble fibrinogen as a neutrophil activator

A fundamental paradigm involved in acute inflammatory responses to invading pathogens and tissue damage is the migration of specific leukocyte populations to the affected tissues to mount an initial innate response to the aggression. The recruitment of polymorphonuclear neutrophils (PMNs) from the blood is a central event in this respect. The aim of this study was to understand whether fibrinogen is able to modulate the pattern of neutrophil activation and thus contribute to neutrophil recruitment. We demonstrated that fibrinogen induces free radical production by neutrophils without modifying the activation status of Mac-1 (αMβ2, CD11b/CD18), the previously identified neutrophil receptor for fibrinogen. This data indicates that fibrinogen must have an additional different binding site in the neutrophil membrane. Importantly, we propose that as Mac-1 activation was not affected by the binding of fibrinogen, activated neutrophils can further maintain their ability to marginate, roll and adhere to the endothelial walls.

The prothrombotic tendency in metabolic syndrome: focus on the potential mechanisms involved in impaired haemostasis and fibrinolytic balance

The metabolic syndrome is a clinical disorder characterized by impairment of glucose metabolism, increased arterial blood pressure, and abdominal obesity. The presence of these clinical features exposes patients to a high risk of atherothrombotic cardiovascular events. The pathogenesis of atherothrombosis in the metabolic syndrome is multifactorial, requiring a close relationship among the main components of the metabolic syndrome, including insulin resistance, alterations of glycaemic and lipid pattern, haemodynamic impairment, and early appearance of endothelial dysfunction. Furthermore, haemostatic alterations involving coagulation balance, fibrinolysis, and platelet function play a relevant role both in the progression of the arterial wall damage and in acute vascular events. The mechanisms linking abdominal obesity with prothrombotic changes in the metabolic syndrome have been identified and partially elucidated on the basis of alterations of each haemostatic variable and defined through the evidence of peculiar dysfunctions in the endocrine activity of adipose tissue responsible of vascular impairment, prothrombotic tendency, and low-grade chronic inflammation. This paper will focus on the direct role of adipose tissue on prothrombotic tendency in patients affected by metabolic syndrome, with adipocytes being able to produce and/or release cytokines and adipokines which deeply influence haemostatic/fibrinolytic balance, platelet function, and proinflammatory state.

Pleiotropic benefit of monomeric and oligomeric flavanols on vascular health--a randomized controlled clinical pilot study

Background

Cardiovascular diseases are expanding to a major social-economic burden in the Western World and undermine man's deep desire for healthy ageing. Epidemiological studies suggest that flavanol-rich foods (e.g. grapes, wine, chocolate) sustain cardiovascular health. For an evidenced-based application, however, sound clinical data on their efficacy are strongly demanded.

Methods

In a double-blind, randomized, placebo-controlled intervention study we supplemented 28 male smokers with 200 mg per day of monomeric and oligomeric flavanols (MOF) from grape seeds. At baseline, after 4 and 8 weeks we measured macro- and microvascular function and a cluster of systemic biomarkers for major pathological processes occurring in the vasculature: disturbances in lipid metabolism and cellular redox balance, and activation of inflammatory cells and platelets.

Results

In the MOF group serum total cholesterol and LDL decreased significantly (P≤0.05) by 5% (n = 11) and 7% (n = 9), respectively in volunteers with elevated baseline levels. Additionally, after 8 weeks the ratio of glutathione to glutathione disulphide in erythrocytes rose from baseline by 22% (n = 15, P<0.05) in MOF supplemented subjects. We also observed that MOF supplementation exerts anti-inflammatory effects in blood towards ex vivo added bacterial endotoxin and significantly reduces expression of inflammatory genes in leukocytes. Conversely, alterations in macro- and microvascular function, platelet aggregation, plasma levels of nitric oxide surrogates, endothelin-1, C-reactive protein, fibrinogen, prostaglandin F2alpha, plasma antioxidant capacity and gene expression levels of antioxidant defense enzymes did not reach statistical significance after 8 weeks MOF supplementation. However, integrating all measured effects into a global, so-called vascular health index revealed a significant improvement of overall vascular health by MOF compared to placebo (P≤0.05).

Conclusion

Our integrative multi-biomarker approach unveiled the pleiotropic vascular health benefit of an 8 weeks supplementation with 200 mg/d MOF in humans.

Trial Registration

ClinicalTrials.gov NCT00742287

Fibrinogen as a key regulator of inflammation in disease

The interaction of coagulation factors with the perivascular environment affects the development of disease in ways that extend beyond their traditional roles in the acute hemostatic cascade. Key molecular players of the coagulation cascade like tissue factor, thrombin, and fibrinogen are epidemiologically and mechanistically linked with diseases with an inflammatory component. Moreover, the identification of novel molecular mechanisms linking coagulation and inflammation has highlighted factors of the coagulation cascade as new targets for therapeutic intervention in a wide range of inflammatory human diseases. In particular, a proinflammatory role for fibrinogen has been reported in vascular wall disease, stroke, spinal cord injury, brain trauma, multiple sclerosis, Alzheimer's disease, rheumatoid arthritis, bacterial infection, colitis, lung and kidney fibrosis, Duchenne muscular dystrophy, and several types of cancer. Genetic and pharmacologic studies have unraveled pivotal roles for fibrinogen in determining the extent of local or systemic inflammation. As cellular and molecular mechanisms for fibrinogen functions in tissues are identified, the role of fibrinogen is evolving from a marker of vascular rapture to a multi-faceted signaling molecule with a wide spectrum of functions that can tip the balance between hemostasis and thrombosis, coagulation and fibrosis, protection from infection and extensive inflammation, and eventually life and death. This review will discuss some of the main molecular links between coagulation and inflammation and will focus on the role of fibrinogen in inflammatory disease highlighting its unique structural properties, cellular targets, and signal transduction pathways that make it a potent proinflammatory mediator and a potential therapeutic target.

Population differences in proinflammatory biology: Japanese have healthier profiles than Americans

The pleiotropic cytokine, interleukin-6 (IL-6), has emerged as a key factor in the biology of aging and the physiology of inflammation. Yet much of what we know about the normal functioning of IL-6 has been generated primarily from research on European populations and Americans of European descent. Our analyses compared IL-6 levels in 382 middle-aged and older Japanese to the values found in 1209 Caucasian- and African-Americans from the Midlife in the United States survey (MIDUS). Across the life span from 30 to 80 years of age, mean IL-6 levels were strikingly lower in Japanese individuals. Significantly lower levels of C-reactive protein (CRP) and fibrinogen (FBG) provided confirmatory evidence for a population difference in proinflammatory activity. Because IL-6 release has been associated with obesity, differences in body mass index (BMI) were taken into consideration. Japanese had the lowest, and African-Americans had the highest overall BMIs, but significant group differences in IL-6 persisted even after BMI was included as a covariate in the analyses. Additional support for distinct variation in IL-6 biology was generated when systemic levels of the soluble receptor for IL-6 (sIL-6r) were evaluated. Serum sIL-6r was higher in Japanese than Americans, but was most notably low in African-Americans. Our cytokine data concur with national differences in the prevalence of age-related illnesses linked to inflammatory physiology, including cardiovascular disease. The findings also highlight the importance of broadening the diversity of people included in population studies of health and aging, especially given the relative paucity of information for some Asian countries and on individuals of Asian heritage living in the US.

Does the progeny of premature ischemic stroke sufferers need intensive interest of physicians oriented toward primary prevention? A pilot study

BACKGROUND

Few studies focus on the progeny of stroke patients with respect to the occurrence of other potential risk factors.

METHODS

The study group covered 60 males and 62 females whose parents had suffered premature ischemic stroke (PIS); the control group comprised of 41 males and 47 females whose parents had no history of premature vascular event (mean age: 28.4 and 27.1 years, respectively). Examination of both the groups consisted of evaluation of their diet, measurement of arterial blood pressure and body mass index (BMI). Moreover, blood test was carried out and concentration of biochemical stroke risk factors was determined.

RESULTS

The adult progeny of parents with a history of PIS followed a deficient, unbalanced, and nonvaried diet. Their average blood pressure and BMI reached higher values, compared with the results obtained in the control group (125.7±16.06 vs. 122.64±10.83 mmHg; 24.27±3.98 vs. 22.54±2.69 kg/m, respectively; P<0.05). The same applies to average concentrations of the triglycerides 1.22±0.76 vs. 1.06±0.54 mmol/l; total cholesterol (5.34±1.16 vs. 4.82±0.89 mmol/l), low-density lipoprotein-cholesterol (2.95±0.97 vs. 2.52±0.73 mmol/l), total homocysteine (11.22±4.22 vs. 10.18±2.45 μmol/l), and fibrinogen (2.91±0.68 vs. 2.78±0.6 g/l) (P<0.05).

CONCLUSION

Adult children of PIS sufferers show different stroke risk factor profiles than the control group. It may indicate a need for preventive activities for this group in the future. Family occurrence of stroke requires further detailed studies on a larger cohort of patients from risk group.

Cardiovascular Disease and Risk Factors in Patients with Psoriasis and Psoriatic Arthritis

Objective.

Patients with psoriasis and psoriatic arthritis (PsA) have an increased incidence of cardiovascular disease (CVD) and cardiovascular risk factors such as smoking, hypertension, and metabolic syndrome compared to the normal population. Patients with psoriasis and PsA may also have increased risk from nonconventional risk factors such as raised levels of homocysteine and excessive alcohol consumption. We conducted a comprehensive review of the literature on CVD and all cardiovascular risk factors in patients with psoriasis and PsA.

Methods.

Data sources: All studies identified from a Medline (www.ncbi.nlm.nih.gov) search pertaining to CVD, individual risk factors in psoriasis, and PsA were included. Study selection: Studies included a healthy reference population, were published between 1975 and 2009, and were written in English.

Results.

Our search yielded 14 studies that documented rates of CVD in patients with psoriasis and PsA compared to controls. Substantial evidence points to elevated risk of CVD in patients with psoriasis and PsA.

Conclusion.

It remains difficult to conclude if risk factors are caused by psoriasis or share a common pathogenesis. Physicians treating patients with psoriasis and PsA must be aware of all potential cardiovascular risk factors in their patients.

Impact of Fibrinogen Levels on Angiographic Progression and 12-Year Survival in the Armed Forces Regression Study

We assessed the role of fibrinogen levels on angiographic progression and long-term survival among 111 patients with coronary disease enrolled in the Armed Forces Regression Study (AFREGS). Baseline fibrinogen levels and quantitative coronary angiography were performed initially and at 30 months. Progression or nonregression of coronary disease was more prevalent in patients with high fibrinogen than patients with normal fibrinogen (66.1% vs 45.5%; P = .022). Twelve-year cardiovascular (CV) mortality was substantially higher if fibrinogen was elevated (17.9% vs 3.6%, P = .016). Among patients with elevated fibrinogen and angiographic progression or nonregression, there were 10 deaths and all were CV. Elevated levels of fibrinogen predict the angiographic progression of existing coronary disease and likelihood of CV death. Among patients with elevated levels of fibrinogen, angiographic progression identifies a significantly increased likelihood of a fatal CV event.

Diabetes mellitus and cerebrovascular disease: which are the actual data?

Cerebrovascular disease (CeVD) represents a major cause of morbidity and mortality worldwide. Diabetes mellitus (DM) represents an independent risk factor for CeVD. The aim of the present review is to describe the epidemiology of CeVD in patients with DM and to explain how DM and diabetic autonomic neuropathy can increase the risk of CeVD. The prevention and management of CeVD in the diabetic population are also analyzed.

Changes in inflammatory biomarkers across weight classes in a representative US population: a link between obesity and inflammation

BACKGROUND

Obesity has been linked with a chronic state of inflammation which may be involved in the development of metabolic syndrome, cardiovascular disease, non-alcoholic steatohepatitis, and even cancer. The objective of this study was to examine the association between obesity class and levels of inflammatory biomarkers from men and women who participated in the 1999-2004 National Health and Nutrition Examination Survey (NHANES).

METHODS

Serum concentrations of C-reactive protein (CRP) and fibrinogen were measured among US participants of the 1999-2004 NHANES. We examined biomarker levels across different weight classes with normal weight, overweight, and obesity classes 1, 2, and 3 were defined as BMI of < 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, and > or = 40.0, respectively.

RESULTS

With CRP levels for normal weight individuals as a reference, CRP levels nearly doubled with each increase in weight class: +0.11 mg/dl (95% CI, 0.06-0.16) for overweight, +0.21 mg/dl (95% CI, 0.16-0.27) for obesity class 1, +0.43 mg/dl (95% CI, 0.26-0.61) for obesity class 2, and +0.73 mg/dl (95% CI, 0.55-0.90) for obesity class 3. With normal weight individuals as a reference, fibrinogen levels increase with increasing weight class and were highest for obesity class 3 individuals, +93.5 mg/dl (95% CI, 72.9-114.1). Individuals with hypertension or diabetes have higher levels of CRP and fibrinogen levels compared to individuals without hypertension or diabetes, even when stratified according to BMI.

CONCLUSIONS

There is a direct association between increasing obesity class and the presence of obesity-related comorbidities such as diabetes and hypertension with high levels of inflammatory biomarkers.

Kidney function and estimated vascular risk in patients with primary dyslipidemia

Background:

Chronic kidney disease (CKD) is associated with increased vascular risk. Some studies suggested that considering markers of CKD might improve the predictive accuracy of the Framingham risk equation.

Aim:

To evaluate the links between kidney function and risk stratification in patients with primary dyslipidemia.

Methods:

Dyslipidemic patients (n = 156; 83 men) who were non-smokers, did not have diabetes mellitus or evident vascular disease and were not on lipid-lowering or antihypertensive agents were recruited. Creatinine clearance (CrCl) was estimated using the Cockcroft-Gault equation. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. We estimated vascular risk using the Framingham equation.

Results:

In both men and women, there was a significant negative correlation between estimated Framingham risk and both eGFR and CrCl (p < 0.001 for all correlations). When men were divided according to creatinine tertiles, there were no significant differences in any parameter between groups. When men were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined (p<0.001 for all trends). When women were divided according to creatinine tertiles, all estimated Framingham risks except for stroke significantly increased as creatinine levels increased. When women were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined.

Conclusions:

Estimated vascular risk increases as renal function declines. The possibility that incorporating kidney function in the Framingham equation will improve risk stratification requires further evaluation.

Variations in C-reactive protein, plasma free radicals and fibrinogen values in patients with osteoarthritis treated with Pycnogenol

In a previous, double-blind, placebo-controlled study we evaluated the efficacy of a 3-month treatment with Pycnogenol for 156 patients with osteoarthritis of the knee. Pycnogenol significantly decreased joint pain and improved joint function as evaluated using the WOMAC score and walking performance of patients on a treadmill. In this study, we further investigated the anti-inflammatory and antioxidant activity of Pycnogenol in a subset of the osteoarthritis patients presenting with elevated C-reactive protein (CRP) and plasma-free radicals. Elevated CRP levels have been suggested to be associated with disease progression in osteoarthritis. In our study, 29 subjects of the Pycnogenol group and 26 patients in the placebo group showed CRP levels higher than 3 mg/l at baseline. Comparison of blood specimens drawn at baseline and after 3-month treatment showed that Pycnogenol significantly decreased plasma free radicals to 70.1% of baseline values. Plasma CRP levels decreased from baseline 3.9 mg/l to 1.1 mg/l in the Pycnogenol group whereas the control group had initial values of 3.9 mg/l which decreased to 3.6 mg/l. The CRP decrease in the Pycnogenol was statistical significant as compared to the control group (P < 0.05). Fibrinogen levels were found to be lowered to 62.8% of initial values (P < 0.05) in response to Pycnogenol. No significant changes for plasma free radicals, CRP and fibrinogen were found in the placebo-treated group. The decrease of systemic inflammatory markers suggests that Pycnogenol may exert anti-inflammatory activity in osteoarthritic joints and patients did not present with other ailments or infections. The nature of the anti-inflammatory effects of Pycnogenol with regard to CRP warrants further investigation.

Practical management of dyslipidemia with elevated lipoprotein(a)

OBJECTIVE

To report a case and describe a practical approach to treating dyslipidemia in a very-high-risk patient with elevated lipoprotein(a) [Lp(a)].

SETTING

Pharmacist-managed lipid clinic, from November 2006 to July 2007.

PATIENT DESCRIPTION

A 50-year-old white woman with a recent history of multiple myocardial infarctions presented for management of dyslipidemia.

CASE SUMMARY

At baseline, the patient had elevated low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC), and Lp(a) (306 nmol/L) levels and low high-density lipoprotein cholesterol (HDL-C) levels. Early initiation of combination therapy with a statin and niacin extended release (ER) titration was started. After 3 months, despite progressive weight gain caused by dietary indiscretion, LDL-C decreased by 24% and TG and TC levels reached goal. Lp(a) levels did not change. Niacin ER titration continued, pravastatin was maximized, and ezetimibe 10 mg daily was started. Despite dramatic 9-month weight gain (68 lb total), LDL-C and HDL-C reached goal and Lp(a) levels decreased by 33% (204 nmol/L) after niacin ER maximization.

RESULTS

Lp(a) is an emerging risk factor in cardiovascular disease (CVD). Elevated Lp(a) (>30 mg/dL) has been implicated as both an independent and an additive risk factor for CVD and stroke, particularly in women. In this case, the patient did not reach the optimal goal (<30 mg/dL) but did experience more than 30% reduction in Lp(a) levels. Although multiple factors, including subclinical hypothyroidism, hormonal changes, and renal disease, increase Lp(a) levels, few beneficial treatment options exist (i.e., estrogen and niacin). Although the exact mechanism of action is unknown, niacin ER has been documented to reduce Lp(a) by 36% to 38%. Some effect of ezetimibe on Lp(a) in this patient cannot be ruled out.

CONCLUSION

This case illustrates a practical use of currently available therapy options to address Lp(a) as a secondary cardiovascular risk factor. Niacin is a preferred option for Lp(a) lowering in very-high-risk patients with coronary heart disease and dyslipidemia. The importance of moderate reductions in Lp(a) is not known.

An altered pattern of circulating apolipoprotein E3 isoforms is implicated in preeclampsia

Preeclampsia is a common pregnancy complication that is an important cause of preterm birth and fetal growth restriction. Because there is no diagnostic test yet available for preeclampsia, we used a proteomic approach to identify novel serum/plasma biomarkers for this condition. We conducted case control studies comparing nulliparous women who developed preeclampsia at 36-38 weeks of gestation with healthy nulliparous women matched by gestational age at sampling. Serum/plasma was depleted of six abundant proteins and analyzed by two-dimensional gel electrophoresis (n = 12 per group) and difference gel electrophoresis (n = 12 per group). Differences in abundance of protein spots were detected by univariate and multivariate statistical analyses. Proteins were identified by mass spectrometry and expression of selected proteins was validated by immunoblotting. Proteins whose concentrations were selectively associated with preeclampsia included apolipoprotein E (apoE), apoC-II, complement factor C3c, fibrinogen, transthyretin, and complement factor H-related protein 2. An increase in a deglycosylated isoform of apoE3 and concomitantly decreased amounts of one apoE3 glycoisoform were identified in preeclamptic plasma and confirmed by immunoblotting. Altered production of these preeclampsia-related apoE3 isoforms might impair reverse cholesterol transport, contributing to arterial damage. These findings point to a novel mechanistic link between preeclampsia and subsequent cardiovascular disease.

Urotensin-II and cardiovascular remodeling

Urotensin-II (U-II), a cyclic undecapeptide, and its receptor, UT, have been linked to vascular and cardiac remodeling. In patients with coronary artery disease (CAD), it has been shown that U-II plasma levels are significantly greater than in normal patients and the severity of the disease is increased proportionally to the U-II plasma levels. We showed that U-II protein and mRNA levels were significantly elevated in the arteries of patients with coronary atherosclerosis in comparison to healthy arteries. We observed U-II expression in endothelial cells, foam cells, and myointimal and medial vSMCs of atherosclerotic human coronary arteries. Recent studies have demonstrated that U-II acts in synergy with mildly oxidized LDL inducing vascular smooth muscle cell (vSMC) proliferation. Additionally, U-II has been shown to induce cardiac fibrosis and cardiomyocyte hypertrophy leading to cardiac remodeling. When using a selective U-II antagonist, SB-611812, we demonstrated a decrease in cardiac dysfunction including a reduction in cardiomyocyte hypertrophy and cardiac fibrosis. These findings suggest that U-II is undoubtedly a potential therapeutic target in treating cardiovascular remodeling.

The effect of tirofiban on fibrinogen/agonist-induced platelet shape change and aggregation

There is evidence linking raised plasma fibrinogen (fib) and platelet hyperactivity with vascular events. One way to inhibit platelets is to block the platelet membrane glycoprotein (GP) IIb/IIIa receptor, which binds circulating fib or von Willebrand factor and cross-links platelets at the final common pathway to platelet aggregation. Tirofiban is a potent and specific fib receptor antagonist, used in the treatment of unstable angina. The authors assessed the effect of tirofiban on spontaneous platelet aggregation (SPA), fib-induced, serotonin (5HT)-induced, and adenosine diphosphate (ADP)-induced aggregation in whole blood by calculating the percentage free platelet count. These various agonists were used alone and in combination. The authors also measured the effect of tirofiban on agonists-induced (ADP, 5HT) platelet shape change (PSC). The effect of fib on PSC was also evaluated in platelet-rich plasma using a high-resolution (0.07 fL) channelyzer. Tirofiban significantly inhibited SPA, fib (2, 4, 8 g/L), ADP, ADP + fib combination, and 5HT-induced aggregation. Tirofiban had no effect on agonist-induced PSC. There was no apparent change in platelet volume with fib. In conclusion, tirofiban does not appear to have an effect on PSC, an early phase of platelet activation. Tirofiban seems to be a nonspecific and an effective inhibitor of platelet aggregation (a later phase of platelet activation) in whole blood. The clinical significance of these findings remains to be established.

Do Different Vascular Risk Factors Affect All Arteries Equally?

Established vascular risk factors (ie, smoking, hypertension, diabetes mellitus, and dyslipidemia) play an important role in the development of vascular disease. Emerging evidence suggests that some of these risk factors may have a more intense effect on specific arterial beds, a finding that holds implications for a prognostic role for certain types of vascular disease.

Ceruloplasmin is a better predictor of the long-term prognosis compared with fibrinogen, CRP, and IL-6 in patients with severe unstable angina

BACKGROUND

We investigated the time course and prognostic value of fibrinogen (Fib), C-reactive protein (CRP), interleukin-6 (IL-6), and ceruloplasmin (CP) in patients with severe unstable angina.

METHODS

All 4 substances were measured on admission and after 6, 12, 24, 48, and 72 hours, and after 7 days and 6 months in 40 patients with Braunwald's classification class IIIB unstable angina.

RESULTS

All recorded substances increased significantly; 15 patients had cardiovascular events during hospitalization and 11 patients during follow-up. The time course and the mean values of Fib, CRP, and IL-6 were similar in patients with and without complications both during hospitalization and follow-up. However, CP levels from 6 hours until 6 months were significantly higher in patients with complications during follow-up (P < .05).

CONCLUSIONS

Fib, CRP, IL-6, and CP levels alter in patients with severe unstable angina. However, only CP levels were related to 12-month follow-up prognosis.

Effect of psyllium fiber supplementation on C-reactive protein: the trial to reduce inflammatory markers (TRIM)

PURPOSE

Recent evidence supports a significant association between the intake of dietary fiber and levels of inflammatory markers. The objective of this study was to determine whether daily fiber supplementation would reduce levels of inflammatory markers.

METHODS

This study was a prospective randomized controlled trial at a single university medical center. Participants were overweight or obese adults with no history of heart disease. The intervention was psyllium supplementation at either 7 or 14 g/d for 3 months compared with no supplements in a control group. The main outcome measure was change in level of high-sensitivity C-reactive protein (hsCRP) concentration; secondary outcomes included changes in interleukin-6 (IL-6) levels, fibrinogen levels, and white blood cell (WBC) count. Protocol completers attended at least 2 visits and took more than 75% of the prescribed fiber dose.

RESULTS

In this intent-to-treat analysis (n = 158), there were no significant differences between either of the 2 treatment groups and the control group in the amount of change in CRP, fibrinogen, or IL-6 levels or in WBC count (P>.05). In the analysis of protocol completers (n = 132), there also were no significant differences between the groups except for a small decrease in fibrinogen level in the high-fiber group (-6 mg/dL [-0.18 micromol/L] compared with 13 mg/dL [0.38 micromol/L] in the control group, P<.05).

CONCLUSION

Psyllium fiber supplementation did not significantly reduce CRP levels in overweight or obese individuals in this trial, and changes in other markers were not consistent. Further research is needed to determine whether other fibers or nutrients can reduce inflammatory markers.

Prediction of cardio- and cerebro-vascular events in patients with subclinical carotid atherosclerosis and low HDL-cholesterol

Low HDL-cholesterol concentrations are associated with increased cardiovascular risk and recent evidences suggest that HDL may aggravate the atherosclerotic process promoting inflammation: HDL are anti-inflammatory in the absence of inflammation but can become proinflammatory in the presence of atherosclerosis. Yet, no data is available on the cardiovascular outcome in subjects with low HDL-cholesterol and early stages of atherosclerosis. Therefore, we included in a prospective 5-year follow-up study 150 subjects with low HDL-cholesterol concentrations and subclinical carotid atherosclerosis, as assessed by carotid colour doppler, evaluating at baseline all the established traditional cardiovascular risk factors (e.g. male gender, older age, obesity, hypertension, diabetes, smoking, family history of coronary artery disease, hypercholesterolemia), as well as levels of two markers of inflammation (C-reactive protein and fibrinogen). At the end of the follow-up we registered vascular events in the 21% of patients and we found that lower HDL-cholesterol concentrations were associated with ischemic stroke (p=.0164), peripheral arterial disease (p=.0248) and the presence of any clinical event (p=.0105). By multivariate analysis we searched, among all baseline parameters, for independent variables associated with the events and we found a predictive role for elevated fibrinogen concentrations (OR 6.3, 95% CI 2.0-19.6, p=.0016), family history of coronary artery disease (OR 4.5, 95% CI 1.7-12.8, p=.0045) and lower HDL-cholesterol levels (OR 1.4, 95% CI 1.1-1.9, p=.0278). These findings further suggest a synergistic role of low-HDL and inflammation on the atherosclerotic disease progression from subclinical lesions to clinical events. Yet, their therapeutical implications remain to be established in future studies.