The main methods of investigation of cardiovascular

system.

Fibrinogen and Atherosclerosis

• Promotes atherosclerosis• Essential component of platelet aggregation• Relates to fibrin deposited and the size of

the clot• Increases plasma viscosity• May also have a proinflammatory role• Measurement of fibrinogen, incl. Test

variability, remains difficult. • No known therapies to selectively lower

fibrinogen levels in order to test efficacy in CHD risk reduction via clinical trials.

Fibrinogen and CHD Risk: Epidemiologic Studies• Recent meta-analysis of 18 studies involving 4018

CHD cases showed a relative risk of CHD of 1.8 (95% CI 1.6-2.0) comparing the highest vs lowest tertile of fibrinogen levels (mean .35 vs. .25 g/dL)

• ARIC study in 14,477 adults aged 45-64 showed relative risks of 1.8 in men and 1.5 in women, attenuated to 1.5 and 1.2 after risk factor adjustment.

• Scottish Heart Health Study of 5095 men and 4860 women showed fibrinogen to be an independent risk factor for new events--RRs 2.2-3.4 for coronary death and all-cause mortality.

AHA / CDC Scientific StatementAHA / CDC Scientific StatementMarkers of Inflammation and Cardiovascular Disease:Markers of Inflammation and Cardiovascular Disease:

Applications to Clinical and Public Health PracticeApplications to Clinical and Public Health Practice

Circulation January 28, 2003Circulation January 28, 2003

“Measurement of hs-CRP is an independent marker of risk“Measurement of hs-CRP is an independent marker of riskand may be used at the discretion of the physician as partand may be used at the discretion of the physician as part

of global coronary risk assessment in adults without knownof global coronary risk assessment in adults without knowncardiovascular disease. Weight of evidence favors use cardiovascular disease. Weight of evidence favors use particularly among those judged at intermediate risk byparticularly among those judged at intermediate risk by

global risk assessment”.global risk assessment”.

Fibrinogen and CHD Risk Factors• Fibrinogen levels increase with age and body

mass index, and higher cholesterol levels• Smoking can reversibly elevated fibrinogen

levels, and cessation of smoking can lower fibrinogen.

• Those who exercise, eat vegetarian diets, and consume alcohol have lower levels. Exercise may also lower fibrinogen and plasma viscosity.

• Studies also show statin-fibrate combinations (simvastatin-ciprofibrate) and estrogen therapy to lower fibrinogen.

P. Ridker

Effects of Weight Loss on CRP

Concentrations in Obese Healthy Women

83 women (mean BMI 33.8, range 28.2-43.8 kg/m2) placed on very low fat, energy-restricted diet (6.0 MJ, 15% fat) for 12 weeks

Baseline CRP positively associated with BMI (r=0.281, p=0.01)

CRP reduced by 26% (p<0.001)

Average weight loss 7.9 kg, associated with change in CRP

Change in CRP correlated with change in TC (r=0.240, p=0.03) but not changes in LDL-C, HDL-C, or glucose

At 12 weeks, CRP concentration highly correlated with TG (r=0.287, p=0.009), but not with other lipids or glucose

Heilbronn LK et al. Arterioscler Thromb Vasc Biol 2001;21:968-970.

A Randomized Trial of Rosuvastatin in the Preventionof Cardiovascular Events Among 17,802 Apparently Healthy

Men and Women With Elevated Levels of C-Reactive Protein (hsCRP):

The JUPITER Trial

Paul Ridker*, Eleanor Danielson, Francisco Fonseca*, Jacques Genest*,Antonio Gotto*, John Kastelein*, Wolfgang Koenig*, Peter Libby*,

Alberto Lorenzatti*, Jean MacFadyen, Borge Nordestgaard*, James Shepherd*, James Willerson, and Robert Glynn*

on behalf of the JUPITER Trial Study Group

An Investigator Initiated Trial Funded by AstraZeneca, USA

* These authors have received research grant support and/or consultation fees from one or morestatin manufacturers, including Astra-Zeneca. Dr Ridker is a co-inventor on patents held by the

Brigham and Women’s Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease that have been licensed to Dade-Behring and AstraZeneca.

CRP Improves Net Reclassification Index

• From the Physicians Health Study: hs CRP and parental history improved risk prediction 5.3% overall and 14.2% for patients at intermediate risk by traditional risk scores (both P<0.001) (Ridker et al., Circulation 2008)

• Framingham Heart Study: hs-CRP improved prediction of cardiovascular disease by 5.6% (P=0.014) and of coronary heart disease by 11.8% (P=0.009) (Wilson et al. Circulation: Cardiovascular Quality and Outcomes 2008).

Homocysteine

• Intermediary amino acid formed by the conversion of methionine to cysteine

• Moderate hyperhomocysteinemia occurs in 5-7% of the population

• Recognized as an independent risk factor for the development of atherosclerotic vascular disease and venous thrombosis

• Can result from genetic defects, drugs, vitamin deficiencies, or smoking

Homocysteine• Elevated levels appear to be an

independent risk factor, though less important than the classic CV risk factors

• Screening recommended in patients with premature CV disease (or unexplained DVT) and absence of other risk factors

• Treatment includes supplementation with folate, B6 and B12

Current Biomarkers for ACS• Biomarker assessment of high risk

patients may include:– Inflammatory cytokines – Cellular adhesion molecules – Acute-phase reactants– Plaque destabilization and rupture biomarkers– Biomarkers of ischemia – Biomarkers of myocardial stretch (BNP)– Biomarkers of myocardial necrosis (Troponin,

CK-MB, Myoglobin)

Apple Clinical Chemistry March 2005

History: Troponin• Troponin I first described as a

biomarker specific for AMI in 19871; Troponin T in 19892

• Now the biochemical “gold standard” for the diagnosis of acute myocardial infarction via consensus of ESC/ACC

1 Am Heart J 113: 1333-442 J Mol Cell Cardiol 21: 1349-53

Troponins• Elevated serum levels are an

independent predictor of prognosis, morbidity and mortality

• Meta-analysis of 21 studies involving ~20,000 patients with ACS revealed that those with elevated serum troponin had 3x risk of cardiac death or reinfarction at 30 days1

1 Am J Heart (140): 917

BNP

• BNP has also shown utility as a prognostic marker in acute coronary syndrome

• It is associated with increased risk of death at 10 months as concentration at 40 hours post-infarct increased

• Also associated with increased risk for new or recurrent MI

B-Type Natriuretic Peptides and CVD Risk (Circulation 2009; 120:

2177-2187)• Meta-analysis of 40 long-term prospective

studies involving 87,474 patients.• Highest vs. lowest tertile, adjusted

RR=2.82 (2.40-3.33).• RRs similar for BNP (2.89) or NT-pro BNP

(2.82) and in general populations (2.68), increased risk factors (3.35), and stable CVD (2.60).

• Modest improvements in risk discrimination (increase in C-statistic of 0.01 to 0.1).

Myeloperoxidase• MPO is an enzyme that aids white blood cells in destroying bacteria and viral particles

• MPO catalyzes the conversion of hydrogen peroxide and chloride ions (Cl-) into hypochlorous acid

• Hypochlorous acid is 50 times more potent in microbial killing than hydrogen peroxide

• MPO is released in response to infection and inflammation

• EPIC Norfolk Study showed its predictive value for future cardiovascular disease events in asymptomatic adults.

Sugiyama Am J Pathology 2001

Circulation 108: 250-252

A Multimarker Approach Should Focus on Multiple Mechanisms / Pathologies

Summary of MPO and ACS

• MPO leads to oxidized LDL cholesterol – Oxidized LDL is phagocytosed by macrophages

producing foam cells*• MPO leads to the consumption of nitric oxide

– Vasoconstriction and endothelial dysfunction• MPO can cause endothelial denuding and

superficial platelet aggregation• MPO indicates activated immune cells

– Activated immune cells and inflammation lead to unstable plaque*

• Inflammatory plaque is inherently less stable– Thin fibrous cap/fissured/denuded

Brennan, NEJM 2003*Hansson, NEJM 2005

The Future of Cardiac Biomarkers

• Many experts are advocating the move towards a multimarker strategy for the purposes of diagnosis, prognosis, and treatment design

• As the pathophysiology of ACS is heterogeneous, so must be the diagnostic strategies

An Integrated StrategyMultiple Biomarkers

Non-redundant pathobiology

Intermediate Risk Low Risk

Daniels LB. Curr CV Risk Rep 2009.

Potential Components of a“Multimarker” Approach

Malmö, SwedenPopulation-based cohort free of CVD at

baseline (n=4483, mean age 58)

• 5 biomarkers assessed in backward elimination models– CRP, cystatin C, LP-PLA2, MR-proADM, MR-proANP, NT-

proBNP

• Results:• 2 markers retained for CVD events

– NT-proBNP and CRP• 2 markers retained for CHD events

– NT-proBNP and MR-proADMMelander et al. JAMA 2009.

Thank for your attentionThank for your attention!!