Workshop 5: Arteriosclerosis: basic mechanisms and clinical
The gap between evidence based medicine and clinical practice in ACS - the Swedish
Department of Cardiology, University Hospital Linköping, Sweden
Sweden has since 1995 had a national quality assurance registry that records all patients with
suspicion of ischemic heart disease admitted to coronary care units at participating hospitals.
Since the year 2002 the Register of Information and Knowledge about Swedish Heart Intensive
care Admissions has covered over 90% of all ACS patients in Sweden. Data is recorded
prospectively by attending doctors and nurses over the internet. The register includes background
data regarding concomitant diseases and risk factors. During hospital stay interventions,
medications and test results are recorded in the registry. Every year about 60.000 new
hospitalisations are entered into the registry. Today 73 of 75 Swedish hospital participates. This
gives us an unique opportunity to investigate how different hospitals adhere to European and
national guidelines regarding evidence based medicine within a whole country. Due to the use of
personal identification numbers in Sweden, complete follow up regarding new hospitalisations
and death is possible in all Swedish citizens.
Initially there were very large differences between hospitals in adherence to guidelines, ranging
from 10% to 90% at different hospitals. Variations could be seen in all evidence based therapies
including antiplatelet therapy, beta-blockers, ACE-inhibitors, statins, reperfusion therapy, and use
of coronary angiography. To make hospitals aware of this was not enough initiative for the low
achievers to improve. Several measures have been taken and in recent years adherence to
guidelines has improved substantially. We have also been able to correlate better adherence to
guidelines within a hospital to improved outcome in patients with acute myocardial infarction.
Our experience is that quality registries are needed to assure that patients receive evidence based
medicine. Further supportive systems and engaging activities are needed to involve attending
physicians in the improvement of quality of care.
The gap between evidence based medicine and clinical practice in ACS - the European
Institut für Herzinfarktforschung, Universität Heidelberg, Germany
Cardiovascular diseases continue to be the main cause of death, and a major cause of morbidity
and loss of quality of life in Europe. New options for the treatment of cardiovascular diseases
have resulted in an increasing number of patients who survive a cardiovascular event, and who
require subsequent medical or interventional therapy. Due to strict inclusion criteria especially the
elderly, an increasing patient population in clinical practice, are not represented by randomised
The European Society of Cardiology takes responsibility for the development of clinical practice
guidelines to translate the findings of mainly randomised trials into treatment recommendations
for clinical practice. The Euro Heart Survey Programme of the ESC monitors to which extent
clinical practice corresponds with these guidelines. It was developed to achieve three main goals:
1. To assess the adherence of guidelines for the prevention, diagnosis and management of
cardiovascular disease in clinical practice in the ESC member countries. 2. To evaluate to what
extent patients who are seen in the daily clinical practice of cardiology and vascular medicine are
appropriately represented in clinical trials, which are the main source for guideline development.
3. To assess the relation between the adherence to clinical practice guidelines and patient
Within the Euro Heart Survey Programme two ACS-surveys were conducted in 2000 and in 2004
to document presentation of ACS and its treatment and outcome in clinical practice throughout
Europe. The data of both ACS-surveys provide answers to the main questions of the programme:
1. There is a wide variation in practice among hospitals in Europe, as well as among hospitals in
individual countries. Adherence to guidelines is variable and there is still space for improvement.
Comparing both survey periods, in ACS-II, ACS-patients with and without ST-elevation did
receive recommended medical treatment more often during hospitalization and at discharge,
suggesting an improvement in adherence to guidelines as compared to ACS-I. Especially the use
of coronary interventions such as coronary angiography and PCI was more frequent in both ACS
with and without ST-elevation in 2004 as compared to 2000. Although the time from symptom
onset to acute reperfusion therapy was shortened in the second survey, there were still delays
beyond the recommended time for reperfusion therapy. Although acute reperfusion for STEMI
went up from 56% in 2000 to 64% in 2004 with a significant shift from fibrinolytic therapy to
primary PCI, one third of the STEMI patients did not receive any reperfusion treatment, partly
due to late arrival. 2. Patients seen in routine clinical practice differ significantly from those
selected for participation in clinical trials as they are older, more often female, have a more severe
cardiac condition and more often suffer from concomitant diseases. Evidence based medicine
described by guidelines does not cover this specific patient population. 3. Patients managed
according to guidelines have overall best patient outcomes. A total of 34 centres participated in
both surveys in 2000 and in 2004. The documented increases in the use of evidence-based
therapies and interventions were accompanied by a reduction in mortality for ACS-II as
compared to ACS-I. The relative risks of hospital and 30-day mortality were 42% and 34% lower
in ACS-II in comparison with ACS-I.
National ongoing registries enrolling consecutive ACS patients such as the Swedish RIKS-HIA-
Registry or the German MITRAplus-Registry were able to document the influence of improved
guideline adherence on acute and long-term outcome of ACS patients. By documenting daily
practice and benchmarking each hospital against the overall rest of the participating centres, gaps
between guidelines and current real practice in the treatment of ACS patients became visible and
treatable. Based on these experiences the Euro Heart Survey Programme started two ongoing
registries in ACS and PCI in 2006 which will offer “quality assurance” through benchmarking to
the participating hospitals to improve quality of care in Europe.
How to close the gap
Department of Cardiology and Uppsala Clinical Research Center, Uppsala, Sweden
Background: The Swedish National Register of coronary care (RIKS-HIA) and other national
and international registries have repeatedly shown a considerable gap between optimal treatment
of acute myocardial infarction (AMI) according to current guidelines and what is actually given.
Even in the best performing hospitals, it is common that no more than two thirds of the patients
receive a recommended treatment. Much of the effort to improve the quality of care has so far
been focused on the development and dissemination of evidence-based guidelines. However,
mere publications of guidelines and other forms of passive diffusion of information have been
ineffective in changing physician’s behaviour, and more successful interventions have instead
relied on a multifaceted approach. In the AMI area, a handful of studies have used various quality
improvement (QI) strategies such as the collaborative approach. A weakness in these studies has
been the lack of properly selected control groups, which has been an important impediment when
interpreting the results. We therefore designed a prospective controlled study with the primary
objective of examining the extent to which a multicentre quality improvement collaborative, in
combination with continuous local feedback by a web-based registry, could increase adherence to
national AMI guidelines.
Methods: Multidisciplinary teams from 19 hospitals participating in RIKS-HIA, ranging from
small to large hospitals, were trained in continuous quality improvement methodology, 19
matched hospitals also participating in RIKS-HIA served as controls. The work was focused on
finding and applying tools and methods suited to the local situation in order to increase adherence
to the national guidelines for 5 different treatments in AMI. The base line level of treatment was
determined during the year prior to start of the project. The initial 6 months were a training and
implementation phase. After this phase the effects were measured for 12 months and compared
with the “spontaneous” changes in the control hospitals.
Results: In the control and QI intervention hospitals, the mean absolute increase of patients
receiving ACE-inhibitors was 1.4% vs 12.6% (p=.002); lipid lowering therapy 2.3% vs 7.2%
(p=.065); clopidogrel 26.3% vs 41.2% (p=.010); heparin/l.m.w.heparin 5.3% vs 16.3% (p=.010)
and coronary angiography 6.2% vs 16.8% (p=.027), respectively.
The number of QI intervention hospitals reaching a treatment level of at least 70% in ≥4 of the 5
indicators stated above was 15 vs. no hospital in the control group.
Conclusions: By combining a systematic and multidisciplinary quality improvement
collaborative with continuous compilations of performance feedback from a web-based quality
registry, major improvements in the adherence to national AMI guidelines were achieved. This
combined model is widely applicable for quality improvement initiatives in cardiac care.
Old and new markers – what does every doctor need to know?
Department of Cardiology, Aarhus University Hospital (Skejby), Aarhus, Denmark
The diagnosis of acute coronary syndrome (ACS) i.e., acute myocardial infarction, unstable
angina pectoris and sudden cardiac death has changed significantly within the recent years. The
background for this is based on the interest in risk stratification of patients with ACS due to
improved knowledge of pathology, progress in immunoassays of already existing biochemical
markers, the introduction of new biochemical markers, especially cardiac troponin I (cTnI) and T
(cTnT)], and new methods of treatments.
This lecture at the 41st Annual Meeting of the ESCI is concentrating on the new definition of
acute MI of 2007, the potential difference of cardiac troponin I and T in diagnosing ACS, and that
old markers is - old. The use of troponins in guidelines from the cardiology community i.e,
European Society of Cardiology, American College of Cardiology/American Heart Association
as well as from the clinical biochemist community i.e, American Association of Clinical
Chemistry, National Academy of Clinical Biochemistry and International Federation of Clinical
Chemistry is aimed clarified as well as the conditions one has to bear in mind regarding the
choice of biomarker including the specific biomarker (s), immunoassay (which generation), the
cut-off value of each biomarker keeping in mind the diagnostic window and the site of
implication (general practitioner, emergency room, chest pain unit, coronary care unit).
The above will be seen from a clinical/cardiologist point of view with the purpose to be employed
in everyday use of diagnosing ACS patients.
Associations between genetic variations and levels of biochemical markers and outcome in
acute coronary syndromes
Clinical Coagulation Science, Uppsala University, Uppsala, Sweden
The underlying cause of acute coronary syndromes (ACS) is the chronic degenerative
inflammatory process of atherosclerosis. The vessel wall injury at the site of plaque rupture
exposes collagen and induces rapid activation of platelets. Rupture of lipid-rich coronary plaques
exposes the highly thrombogenic core with an abundance of tissue factor (TF) to the circulating
blood, thus setting off the coagulation cascade. In ACS, we and others have demonstrated an
activation of coagulation and inflammation that coinsides with an increased activation of platelets
and leukocytes. CD40L is largely expressed by CD4+ T-cells and activated platelets. Coupling of
CD40L to CD40 mediates various proatherogenic processes including expression of TF. IL-6, a
pleiotropic, proinflammatory cytokine, plays an important role in the development and
progression of ACS and plasma levels are independent markers for future events. The
antiinflammatory cytokine IL-10 in vitro inhibits the monocyte/macrophage production of TF and
proinflammatory cytokines. However, in ACS the role of IL-10 is unresolved.
The interindividual variations of phenotypes, including clinical and biochemical risk factors for
ACS, mostly have a genetic cause. Well established classical riskfactors, such as smoking,
diabetes, blood pressure, and genetic factors act in cooperation in the development and
progression of atherothrombosis in these syndromes.
We investigated the importance of a number of single nucleotide polymorphisms (SNPs) in four
candidate genes, i.e TF, CD40L, IL-6 and IL-10, for atherothrombosis and prognosis of ACS
using the well-characterised material from the Fast Revascularisation in InStability in Coronary
disease trial (FRISC-II) including patients with unstable angina or non-ST elevation MI. Plasma
samples and DNA were obtained on admission from 3489 patients in the FRISC-II study. Five
hundred healthy individuals similar in age and gender as the patients served as controls.
Ten to fifthteen SNPs in each gene were analysed in relation to intermediate phenotypes and
environmental factors. A novel SNP in the TF gene was identified; the 5466A>G SNP was
associated with significantly higher risk of death/MI in ACS. The cardiovascular risk was
explained by a high TF procoagulant activity in monocytes. In contrast to these results, plasma
soluble(s)CD40L concentrations were associated with increased risk of future MI, but not with
death, in the FRISC-II patients. Elevated sCD40L concentrations also identified patients that
benefit from a prolonged treatment strategy. The novel -3459 A>G SNP in the CD40LG gene
was associated with plasma concentrations of sCD40L. The -572 CG genotype in the IL-6 gene
predicted IL-6 concentrations in patients with a subsequent cardiovascular event. One SNP in the
IL-10 gene was associated with IL-10 levels and also with other inflammatory markers. High
Il-10 concentrations were not protective in the context of cardiovascular events, but rather
indicated an increased systemic inflammatory activity.
The genotype/phenotype variants discussed have the potential effects to modify risk, progression
and outcome in ACS and exemplify the interplay of coagulation and inflammation in these
Diabetes and cardiovascular disease
Physiology clinic and Cardiology Unit, Institution of Medicine, Karolinska University Hospital,
Despite improvement in the treatment of cardiovascular disease there is evidence that individuals
with diabetes have not gained the same benefit as their non-diabetic counterparts. In fact the
relative impact of diabetes on cardiovascular mortality is steadily increasing. Cardiologists seem
more focused on measures directed towards the manifestation of the cardiac condition and do not
fully appreciate the need for simultaneous interactions directed towards the underlying metabolic
disorder to reach full effect of the therapy for the cardiac disorders. Diabetologists have
succeeded in improving treatment for insulin dependent diabetes mellitus. As regards non-insulin
dependent diabetes there increased attention has lately been devoted to therapeutic measures that
may decrease the risk for cardiovascular complications, but there is still a need for considerable
improvement. Enhanced co-operation between diabetologists and cardiologists is a key success in
this respect. The prevalence of type 2 diabetes, about 90% of the diabetic population, increases
rapidly due to an ageing population in combination with increasing over weight and decreased
physical activity. The increasing prevalence suggests a considerable rise in diabetes related
cardiovascular disease in the near future.
It is not only overt diabetes that relates to an enhanced risk for cardiovascular disease. This risk
increases continuously throughout a wide spectrum of glycaemia starting already at levels that,
according to present definitions, are considered as normal. The proportion of patient with known
diabetes is around 20-25% among people with acute of stable manifestations of coronary artery
disease. The actual proportion of impaired glucose tolerance or previously undetected diabetes is,
however, considerable higher amounting to around 60%. Screening for diabetes and
hyperglycemia, by means of oral glucose tolerance testing, is therefore recommended in such
In the present coronary care setting it seems that evidence-based treatment of acute coronary
disease in patients with concomitant diabetes is under utilised. Moreover there is a considerable
discrepancy between recommended treatment targets and actual management of traditional risk
factors in particular hypertension and hyperlipidaemia among diabetic high risk patients. It may
be assumed that an improved application of established treatment modalities would improve the
outcome for the diabetic patients, however, only to a certain extent. Diabetes specific
disturbances, including hyperglycemia and a decreased thrombolytic capacity, are certainly
important contributors to the high morbidity and mortality that follows diabetes and impaired
glucose tolerance. The potential for interaction with theses disturbances by means of
metabolically directed treatment will be reviewed.
A limitation when issuing preventive and /or therapeutic recommendations is lack of data from
trials on accurately characterised diabetes. Prospective stratification of diabetic patients in large
clinical trials and documentation of their glucose lowering treatment and metabolic characteristics
or, even better, studies on pure diabetic population are sparse. This is astonishing in the light of
the increasing commonness of diabetes mellitus and the high prevalence of diabetic patients
among those with manifestation of coronary artery disease. It should encourage to further
research in this field.
Reperfusion treatment of STEMI in 2007
Clinic of Cardioangiology, St. Anne University Hospital, Brno, Czech Republic
Primary percutaneous coronary intervention (PCI) is a method of choice for treatment of patients
with acute myocardial infarction with ST segment elevation (STEMI) in Czech Republic. The
PRAGUE-1 study proved that transferring patients from community hospitals to a tertiary
angioplasty centre is feasible and safe. Facilitation with streptokinasis before transport for
primary PCI did not show benefit for the patients with STEMI in PRAGUE-1 study. This data
were confirmed by ASSENT-4 trial which was published recently. So, there is no evidence for
the recommendation of thrombolysis-facilitated PCI at present time.
The PRAGUE-2 and DANAMI-2 studies confirmed, that long distance transport from a
community hospital to tertiary PCI centre in the acute phase of STEMI was not only safe, but also
markedly decreased mortality in patients presenting >3 hrs after symptom onset. For patients
presenting within 3 hrs of symptoms, thrombolysis results were similar to those with long
distance transport for primary PCI. CAPTIM trial proved, that prehospital thrombolysis can be
effective especially in patients presenting in first hours of STEMI. Transport to the PCI centre
directly from the home of the patient is essential to shortcut the treatment delay.
Treatment of STEMI in 2007 depends on the national specifications very much. In Central
European countries, where distances are small, quality of roads is good and so the time delay can
be minimized, primary PCI is the method of choice. In countries with not sufficient network of
myocardial infarction centers thrombolysis remains a useful therapy for many STEMI patients.
CVD and renal dysfunction: Scope of the problem
BHF Glasgow CRC, University of Glasgow, United Kingdom
Preventative cardiovascular disease is increased in patients with chronic kidney disease (CKD).
The magnitude of the increase in CVD is increased as GFR declines. However, it remains unclear
what the underlying mechanisms for the increased CVD are. In the absence of specific studies in
patients with early CKD we are reliant on sup group analyses of population studies on
interventional trials in other patient groups together with data from patients with end-stage renal
failure. From these data it appears that: 1) CVD in CKD differs from the general population –
although there is an increase in sudden arrhythmic death; 2). There is clustering of conventional
CV risk factors with CKD and 3) CKD is associated with additional risk factors specifically for
arrhythmias and sudden death.
Improved understanding of the pathophysiology of CVD in CKD has important implications for
Inflammation in end-stage renal disease – a fire that burns within
Dept. of Renal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
Cardiovascular disease (CVD) remains the major cause of morbidity and mortality in end-stage
renal disease (ESRD) patients. As traditional risk factors alone cannot alone explain the high
prevalence and incidence of CVD in this high-risk population, inflammation, which is interrelated
to insulin resistance, dyslipidemia, oxidative stress, wasting and endothelial dysfunction, has been
suggested to be a significant contributor. Indeed, several different inflammatory biomarkers, such
as high sensitivity C-reactive protein (hs-CRP), interleukin-6 and white blood cell count, are
independent predictors of mortality in ESRD patients. As CRP is strongly associated with CVD it
has been suggested that this hepatic-derived protein is not only a marker, but also a mediator, of
vascular disease. Although in vitro data from studies on endothelial cells, smooth muscle cells
and monocytes-macrophages support a direct causative role for CRP in atherogenesis data from
studies using the Mendelian randomization approach does not suggest a direct causative role.
There are multiple causes of inflammation in ESRD, including inflammatory signals associated
with the dialysis procedure, decreased renal function, volume overload, co-morbidity and
intercurrent clinical events. The fact that the prevalence of inflammation varies considerable
between continents and races suggests that dietary and/or genetic factors may have an impact on
the pattern of inflammation in ESRD. As interventions directed towards traditional risk factors
has so far not proven to be very effective in controlling vascular disease, randomized controlled
studies are needed to evaluate if various nutritional as well as pharmacological anti-inflammatory
treatment strategies, alone or in combination, may affect the unacceptable high cardiovascular
mortality rate in this patient group.
Vascular calcification in uremia – when men turn to stone
Department of Nephrology, Klinikum Coburg, Germany
Tissue calcification is a complex and coordinated process in bone, teeth as well as at extraosseous
sites. However, the most threatening localization of unwanted calcification is at vascular sites,
where it manifests as both medial and intimal calcification of arteries. Atherosclerotic plaque
calcification is associated with cardiovascular events such as myocardial infarction and stroke.
Medial calcification causes arterial stiffness, increased pulse pressure and increased pulse wave
velocity, and contributes to left ventricular dysfunction. Vascular calcifications are usually
progressive, while their severity is highest in patients with chronic kidney disease (CKD) and
associated with increased mortality in this population. Age, duration of dialysis, inflammation
and diabetes mellitus are major predictors of progressive calcification. Additionally,
hyperphosphatemia and hypercalcemia contribute to extraosseous calcifications. Both trigger
osteogenic differentiation of vascular smooth muscle cell (VSMC) into osteoblast-like cells,
while high phosphate may be a master switch towards unwanted calcification processes. Newly
discovered calcium(Ca)-regulatory factors with calcification-inhibitory properties include the
negative acute-phase protein fetuin-A, the vitamin K-dependent protein matrix Gla protein
(MGP), osteoprotegerin (OPG) and pyrophosphates (PP). In cohorts of dialysis patients, low
serum fetuin-A and high OPG levels were found to be associated with increased extraosseous
calcification as well as mortality, and further clinical data currently emerge for additional Ca-
regulatory factors. Anti-inflammatory drugs, vitamin K and bisphosphonates may have
preventive and therapeutic potential in selected patients in the future.
Renal impairment as prognostic marker in acute coronary syndromes
Department of Cardiology and Uppsala Clinical Research Center, Uppsala, Sweden
Patients presenting with symptoms suggestive of an acute coronary syndrome (ACS), constitute a
diagnostic, prognostic and therapeutic challenge. These patients encompass a broad spectrum of
diagnoses with different prognosis, from relatively large MI over minor MI or UA to chest pain
of noncardiac causes, but must be considered to have an ACS until otherwise is proven. Hence,
early prognostic evaluation is essential for the application of appropriate treatment and further
management. Many clinical variables and biochemical markers have been shown to be predictive
of future events in this group of patients. It has been known for a long time that severe renal
impairment is associated with a strongly increased risk of cardiovascular events. However,
recently it has been shown in several papers, including some from our group, that even a subtle
impairment in renal function is associated with an adverse prognosis after an episode of ACS.
Renal function can be assessed by several different methods. Among them, Cystatin C has been
shown to be at least an accurate marker of renal function as calculated creatinine clearance, and
has in some papers been shown to be superior to creatinine and calculated creatinine clearance as
prognostic marker in patients with ACS. Although markers of renal dysfunction have been shown
to be useful for determining prognosis, they have not so far been shown to be useful for selection
of treatment in ACS. In this workshop the literature will be reviewed and the practical use of
markers of renal dysfunction will be discussed.
Vascular function in renal dysfunction
Dept. of Medicine, Uppsala University Hospital, Uppsala, Sweden
Background: Renal dysfunction is a condition known to be associated with an increased risk for
atherosclerosis-related cardiovascular disorders.
Methods: The present presentation will review studies that have investigated endothelium-
dependent vasodilation and arterial compliance in subjects with renal dysfunction. Also the
pathophysiological links between a reduced kidney function and impairments in endothelium-
dependent vasodilation and arterial compliance will be discussed.
Conclusion: Existing data clearly indicate that renal dysfunction has a deleterious effect on
endothelium-dependent vasodilation and arterial compliance, two main characteristics of arterial
Lipoprotein abnormalities and cardiovascular disease in chronic renal disease
Dept. of Nephrology, Sahlgrenska Hospital, Göteborg, Sweden
Chronic renal insufficiency is associated with several metabolic abnormalities. Already at mildly
reduced renal function the patients are insulin resistant, and have lipoprotein alterations. With
more advanced renal functional impairment this, so called, renal dyslipidemia becomes more
pronounced. It is characterized by an accumulation of triglyceride-rich lipoproteins, whereas
cholesterol-rich lipoproteins are in the normal range or only slightly increased.
In contrast to the epidemiological evidence in the general population the relation between
lipoprotein abnormalities and cardiovascular disease (CVD) still remains to be clarified in
patients with chronic renal disease. In patients with end-stage renal disease neither increased
cholesterol nor increased triglyceride levels have been shown to correlate with CVD mortality
Post-hoc, subgroup analyses from the CARE and VA-HIT trials suggest that both statin and
fibrate therapy have beneficial effects on CVD in patients with mild renal insufficiency.
However, in patients on renal replacement therapy both the 4D- and the ALERT study, which
both used statins, were disappointingly negative in this regard. Since statins primarily reduce
cholesterol-rich lipoproteins, and the majority of patients with such advanced renal insufficiency
have normal levels of these lipoproteins this poor outcome may not be surprising.
Treatment with a PPAR agonist with dual actions on both PPARα and PPARγ seems to be
superior to both statin and fibrate therapy in normalizing the lipoprotein abnormalities of renal
failure. However, there is presently no such drug in development for clinical use. Thus, the
appropriate way to handle renal dyslipidemia is far from being established. Therefore, the
widespread recommendations from various national boards and nephrology societies to prescribe
statins to all patients with chronic renal disease must be questioned.
Ischemia-modified albumin does not detect acute coronary syndrome
S. C. Martin, S. C. Pallant & D. Stuart-Thompson
West Suffolk Hospital, Bury St. Edmunds, UK.
Background: Ischemia-modified albumin (IMA) has been proposed as an early marker of acute
coronary syndrome allowing early risk stratification in the Emergency Room.
Materials and methods: Every patient attending the hospital’s Emergency Room with “Chest
pain” over a 3 week period had an IMA analysis (Inverness Medical) performed on the first blood
sample using a Roche Modular analyser (in accordance with the manufacturer’s instructions).
Results: There was no relationship between IMA levels and troponin I, CRP, albumin, d-dimer or
white cell counts. The closest relationship was a negative one between IMA and CRP with an R 2
value of 0.021.
Conclusions: IMA is not a useful test for acute coronary syndrome.
Impact of posttransplant weight gain on cardiac allograft vasculopathy
G. Höfle1,2,3, C.H. Saely2, M. Martinelli1,, R. Hullin1, B. Meier1, T. Carrel4, M. Seitz3, P.M.
Villiger3 & P. Mohacsi1
Dept. of Cardiology, Swiss Cardiovascular Center Bern, University Hospital, Bern, Switzerland;
Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT) and Academic Teaching
Hospital Feldkirch, Feldkirch, Austria; 3Dept. of Rheumatology and Clinical
Immunology/Allergology, University Hospital, Bern, Switzerland; 4Dept. of Cardiovascular
Surgery, University Hospital, Bern, Switzerland
Background: Excessive weight gain and obesity are commonly reported after heart
transplantation (HTx). Currently, it is not clear whether weight gain is a risk factor of cardiac
allograft vasculopathy (CAV) in heart transplant recipients.
Materials and methods: We studied all patients (n = 95; mean age 50 ± 13 years) who
underwent orthotopic cardiac transplantation at the Swiss Cardiovascular Center Bern since 1994
and survived for ≥1 year. Vascular risk factors were registered before transplantation and at
regular follow-up visits. Coronary angiography was performed yearly for the evaluation of CAV.
The follow-up period was 6 ± 3 years.
Results: Baseline body mass index (BMI) was 24 ± 3 kg/m² and increased to 28 ± 4 kg/m² at
follow-up year 10 (+4; p<0.001). Weight gain proved inversely associated with incident CAV
(hazard ratio 0.78, 95% confidence interval (CI) 0.64 – 0.94; p=0.01) in Cox regression analysis
adjusting for type 2 diabetes, BMI preHTx, hypertension, recipient ischemic heart disease
preHTx, number of cardiac allograft rejection episodes, lipids, statin use, recipient age and
gender. In contrast, recipient preHTx ischemic heart disease was positively predictive of the
incidence of CAV (hazard ratio 7.22; 95% CI 1.70 – 30.61; p<0.01). No significant associations
between hypertension, lipid parameters, gender, type 2 diabetes, or recipient age at the time of
HTx with CAV were observed.
Conclusions: Weight gain after heart transplantation is common but does not necessarily reflect a
risk factor for CAV in heart transplant recipients. Recipient preHTx ischemic heart disease is
positively predictive of the incidence of CAV.
Healthy postmenopausal women with higher index of androgenicity exhibit a pro-
atherogenic risk profile
I. Lambrinoudaki(1), G. Christodoulakos(1), S. Vlachou(1), D. Rizos(2), E. Economou(2), J.
Argeitis(1), M. Creatsa(1), E. Kouskouni(2), A. Augoulea(1) & D. Botsis(1)
(1) 2nd Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital,
Athens, Greece; (2) Hormonal and biochemical Laboratory, University of Athens, Aretaieion
Hospital, Athens, Greece
Background: Cross-sectional study in order to assess the association between endogenous sex
hormones and risk factors for atherosclerosis in healthy postmenopausal women.
Material and methods: Serum sex hormones and lipid-lipoprotein profile, arterial pressure,
homocysteine and insulin resistance by the HOMA-IR model were assessed in 626 healthy
postmenopausal women not on hormone therapy.
Results: Testosterone showed a strong positive association with total and LDL-cholesterol,
triglycerides, AIP, apoB and HOMA-IR and a negative association with HDL-cholesterol and
apoA. Compared to women in the lowest testosterone quartile, women in the highest testosterone
quartile had higher total cholesterol (Q1:226.4 +/- 41.0 vs Q4:245.8+/-38.1 mg/dL, p<0.001),
LDL-cholesterol (Q1:148.5 +/- 37.8 vs Q4:170.0 +/- 35.3 mg/dL, p<0.001), Atherogenic Index of
Plasma (AIP Q1:-0.231 +/- 0.235 vs Q4:-0.058+/-0.263, p<0.001), apolipoprotein B
(ApoBQ1:226.4 +/- 41 vs Q4:245.8+/-38.1 mg/dL, p<0.001) and higher HDL-cholesterol
(Q1:60.7 +/- 14.4 vs Q4:52.3+/-13.2 mg/dL, p<0.001). Free Androgen Index (FAI) exhibited the
same associations as total testosterone and moreover it associated positively with both systolic
and diastolic arterial pressure. Women in the highest FAI quartile had higher AIP (Q1:-0.242 +/-
0.252 vs Q4:-0.068+/-.263, p<0.001) and ApoB (Q1:102.4 +/- 25.4 vs Q4:114.4+/-25.6 mg/dL,
p<0.001) and lower HDL-cholesterol (Q1: 62.1 +/- 15.6 vs Q4: 52.0+/-12.1 mg/dL, p<0.001) and
apolipoprotein A (Q1:158.8 +/- 24.8 vs Q4:148.6+/-24.1mg/dL, p<0.001) compared to women in
the lowest FAI quartile. These differences remained significant after adjustment for age, BMI,
insulin resistance and social habits. Estradiol showed a negative association only with Lp(a),
while Free Estrogen Index (FEI) exhibited similar associations as FAI, which, however, were
rendered non-significant in multivariate analysis. HOMA-IR showed an independent positive
association with total testosterone (Q1:1.98+/-1.33 vs Q4:2.68+/-1.59, p<0.001), FAI
(Q1:1.64+/-1.10 vs Q4:2.94+/-1.63, p<0.001) and FEI (Q1:1.76+/-0.92 vs Q4:2.92+/-1.38,
Conclusions: Increased androgenicity in healthy postmenopausal women, indicated by higher
total testosterone, higher FAI and lower SHBG, is associated with an unfavourable cardiovascular
risk profile. On the contrary, estradiol and FEI is not associated significantly with most of the
cardiovascular risk factors assessed. The association of endogenous estradiol with lipids,
lipoproteins, blood pressure or insulin resistance seems to be mediated primarily by body mass
Platelet activation is associated with generation of microparticles of different origin in
patients with acute myocardial infarction
E.Stankiewicz, E. Stepien, A. Undas, J. Zalewski, J. Godlewski & K. Zmudka
Institute of Cardiology, Krakow, Poland
Background: Increased amounts of endothelial, platelets, monocytes and neutrophils
microparticles (MP), accompanied by platelet activation and enhanced inflammation were
reported in patients with myocardial infarction (AMI) and stable angina.
Materials and methods: Microparticle counts were determined in 12 patients with documented
ST-elevation AMI, 10 patients with stable angina, and 9 healthy controls. MP were assayed by
flow cytometry. Platelet activation was determined by the expression of surface and soluble P-
selectin, along with monocyte- and neutrophil-platelet aggregates. Interleukin 6 (IL-6) and CD40
ligand (CD40L) levels were measured by ELISAs.
Results: Patients with AMI displayed higher levels of all microparticles than patients with stable
angina, however the only statistical difference was observed in CD31 MP levels (p=0.03).
Expression of surface P-selectin was raised in both patient groups as compared to healthy
controls. Soluble P-selectin levels and monocyte-platelets aggregates were increased in patients
with AMI. Significant elevations of IL-6 (p=0.05) and CD40L (p=0.0001) were observed in AMI
patients as compared to patients with stable angina. In patients with AMI were significant
correlations between both the total number as well as the level of CD34, CD51, CD142, CD42
MP and expression of surface P-selectin. Similarly CD40L levels correlated with surface P-
Conclusions: We conclude that in AMI, platelet activation is associated with increased
generation of MP from not only platelets, but also monocytes and endothelial cells. It suggests
that interactions between platelets, monocytes and endothelial cells play an important role in the
pathogenesis of myocardial ischemia.
Adhesive molecules, cytokines and uric acid in patients with stable coronary artery disease
D. Drobniak-Hełdak 1, R. Rajtar 1, W. Kolasińska-Kloch 1, A. Furgała 3, M. Kloch 2, B. Kieć-Wilk
& A. Dembińska-Kieć 2
2nd Dept. of Cardiology, 2) Dept. of Clinical Biochemistry, 3) Dept. of Pathophysiology, Medical
College of Jagiellonian University, Cracow, Poland
Background: Chronic inflammatory reaction initiates systemic inflammatory response and leads
to an increase of adhesive molecules and cytokines. In some studies also elevated levels of uric
acid have been shown in patients with stable coronary artery disease (CAD).
Materials and methods: 71 men aged 37-53 years: 40 men (mean age 47.07 ± 4.23) with stable
CAD confirmed by coronary angiography (26 men with CCS I and 14 men with CCS II) and 31
healthy, non-smoking men (mean age 44.96± 5.37), with normal lipid levels, blood pressure and
body mass. Subjects with active inflammatory process, hypertension, diabetes mellitus,
autoimmunological disorders and neoplasms were not included. Levels of ICAM-1, VCAM-1,
TNFα, thrombomodulin, von Willebrand factor, IL-6, fibrinogen, hsCRP, uric acid and
leucocytes were measured in all subjects.
Results: The study confirmed:
1. Significantly higher levels of ICAM-1 (267,5±68,61ng/ml vs 203,13±36,92ng/ml; p<0,0001),
IL-6 (1,72±1,04pg/ml vs 1,04±0,65pg/ml; p=0,02), fibrinogen(3,96±0,99g/l vs 3,1±0,35g/l;
p=0,0003), hs-CRP (2,72±2,33ng/ml vs 1,37±1,4ng/ml; p=0,0027), leucocytes (6,88 x103±1,38 vs
5,19x103±0,85; p<0,0001) in patients with stable CAD as compared with healthy subjects.
2. Significantly lower level of thrombomodulin (32,31±8,13ng/ml vs 40,25±8,71ng/ml;
p=0,0002) in patients with stable CAD.
3. The elevated levels of VCAM-1, TNFα, von Willebrand factor and uric acid were not detected
in patients with stable CAD as compared with healthy subjects.
Conclusions: 1. Concentrations of the inflammatory markers (fibrinogen, hsCRP, IL-6, ICAM-1,
leucocytes) are significantly elevated whereas thrombomodulin is decreased in patients with
stable CAD as compared with healthy subjects.
2. Role of uric acid in the pathogenesis in atherosclerosis needs further investigations.
Serum high total cholesterol level in postmenopausal women is associated with high Tumor
Necrosis Factor - alpha and Vascular Cell Adhesion Molecule - 1 levels during standard
D. Drobniak-Hełdak, 1T. Milewicz, 2R. Rajtar, 3D. Fedak, 2W. Kolasinska-Kloch, 4A. Furgała, 1
J. Krzysiek & 4P. Thor
Department of Gynecological Endocrinology, 2) 2nd Department of Cardiology, 3) Department of
Clinical Biochemistry, 4) Department of Pathophysiology, Medical College of Jagiellonian
University, Cracow, Poland
Background: The evaluation of serum ICAM-1, VCAM-1, endothelin-1 (Et-1), TNF-alpha and
its soluble receptor levels and the secretion of nitric oxide in postmenopausal women with
Materials and methods: 26 postmenopausal patients who neither received replacement
hormonal therapy nor cholesterol lowering treatment. Group A consisted of 16 women with high
serum total cholesterol and group B of 10 women with normal cholesterol level. Basic fasting
serum FSH, 17b-estradiol, as well as total cholesterol, HDL-cholesterol, LDL-cholesterol and
triglyceride levels were measured. Standard exercise test was performed according to Bruce
protocol. Blood samples were taken thrice (prior to, at peak exercise, 15th min of recovery)
during the test to evaluate the serum levels of ICAM-1, VCAM-1, ET-1, TNF-alpha and its
soluble receptors as well as secretion of nitric oxide.
Results: In group A VCAM-1 (660.0 ± 106.4 mg/l vs 518.6 ± 65.4 mg/l; p<0.05) and TNF-alpha
serum levels (2.2 ±1.0 ng/l versus 1.2 ± 0.4 ng/l; p<0.05) at peak exercise were higher as
compared with group B. There was a tendency (p>0.05) towards higher ET-1 plasma levels in
Conclusions: Serum levels of adhesion molecules and inflammatory mediators were higher
during physical exercise in postmenopausal women with atherosclerosis risk factors.
Polymorphism of AGT and ATPA2 genes, essential hypertension and left ventricular
B. Kieć-Wilk, 1A. Olszanecka, 1K. Stolarz, 1K. Kawecka-Jaszcz & A. Dembińska-Kieć
Dept. of Clinical Biochemistry and 1Ist Cardiac Dept. Jagiellonian University Medical College,
Introduction: Angiotensinogen gene (AGT) polymorphism as well as SERCA2a reticular
endoplasmic Ca channel gene (ATP2A2) polymorphisms may be responsible for, hypertension
and left ventricular hypertrophy (LVH).
Methods: Hypertensive participants were divided into groups with LVH(+) (n=52) and without
LVH(-) (n=55). Control group (n=50) consisted of healthy volunteers. The 24-hour ambulatory
blood pressure monitoring, ABPM and echocardiography were done. The M235T polymorphism
of AGT gene was analysed with real-time PCR and TaqMan. The genotyping of ATP2A2 was
performed by dHPLC and sequencing analysis.
Results: The frequency of homozygotes CC of M235T AGT polymorphism was the highest in
LVH(+) group in comparison with LVH(-) (p=0.679) and controls (p=0.645). The allel T carriers
of M235T polymorphism had higher value of office blood pressure (p=0.878 SBP, p=0.319
DBP), and mean systolic blood pressure in ABPM analysis. In ATP2A2 gene the new c.2171G>A
polymorphism was detected. The G to A substitution was present in 18% of control, 6% of
LVH(+) and in 5,2% of LVH(-) group. The allele A frequency was significantly higher in control
group vs. the hypertensive group (p=0,017). The GA carriers demonstrated lower blood pressure
level than GG homozygotes (p=0.367 SBP, p=0.439 DBP). The LVM and LVMI were lower in
GA than in GG carriers (p=0.107 LVM, p=0.154 LVMI).
Conclusions: The M235T (c.704 C>T) polymorphism of AGT does not play an essential role in
hypertension and LVH. However the G724A (c.2171G>A) ATP2A2 polymorphism, protects
against hypertension and the LVH development in hypertensives.
Proangiogenic activity of progenitor cells isolated from human adipose tissue
A. Balwierz1, A. Dembińska-Kieć1, A. Polus1, L. Kaczmarek2 & J. Pryjma3
1. Dept. Clinical Biochemistry Collegium Medicum, Jagiellonian University, Krakow, 2. Dept.
Molecular and Cellular Neurobiology, Laboratory of Molecular Neurobiology, Nencki Institute,
Warsaw; 3. Dept. Immunology, Faculty of Biotechnology, Jagiellonian University, Krakow,
Poland; Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow,
Introduction: Adipose tissue contains a population stromal vascular fraction (SVF), cells, which
differentiate to several lineages. Development of a microvascular network precedes the
Aim of the study was to confirm the proangiogenic properties of the human subcutaneous adipose
tissue SVF cells.
Methods: SVF cells isolated according to Hauner`s were cultured in proangiogenic (EBM with
2% FCS), or proadipogenic (DMEM plus hydrocortisone, insulin, transferrin, triiodothronine
after stimulation with dexamethasone, IBMX, insulin) medium. Phenotype were characterized by
flow cytometry or expression of genes characteristic for endothelial progenitors (CD34, CD31,
vWF, eNOS, CXCR4, CXCR12, Jagged, Notch4) as well as for preadipocytes (PPARγ1,
PPARγ2, CEBPα, CD36, LPL, ap2, adiponectin, leptin) (real-time PCR). Assay of proliferation
and migration was performed. Tubulogenesis of co-cultured the GFP transfected SVF with
HUVEC, was measured in 3D matrigel model. Differentiation to adipocyte was confirmed by the
Results: Growing of SVF cells in serum-free hormone-supplemented medium or incubation of
cells in serum-containing medium changes the cell from adipogenic to proangiogenic phenotype.
Such SVF cells proliferate, migrate and form the tube-like structure in in vitro 3D model of
Conclusions: The differentiation of SVF cells towards endothelium is stimulated by the presence
of human serum and argues for the deep influence of the environment on the differentiation of
progenitors towards adipose versus proangiogenic cells.
Sponsored by MNiI grant PBZ-MIN-005/P04/2002/5
Evaluation of genetic predisposition to insulin resistance by nutrient-induced insulin output
I. Wybranska, M. Malczewska-Malec, L. Partyka, B. Kiec-Wilk, I. Leszczyńska-Gołąbek & A.
Department of Clinical Biochemistry, Jagiellonian University, Medical College, Krakow, Poland
Background: There is a necessity to implement the new tools to identify the genotype-phenotype
interactions. The aim of this study was to find the correlation between risk originating from gene
variation and diet-dependent development of insulin resistance.
Methods: Estimation of the 18 common of “obesity risk-genes” polymorphisms and standard
phenotyping was performed within the 322 patients with familiar obesity. The insulin output as
area under insulin curve after glucose tolerance test (AUCIns OGTT) and lipid tolerance test
(AUCIns OLTT) were measured within 165 members of the study group.
Results: Insulin output during oral glucose tolerance test (AUCIns OGTT) correlated strongly
with insulin output after standard high fat meal (AUCIns OLTT) in the whole group. However,
within the genotypic sub-groups the correlation was lower or even does not exist. The
implemented AUCIns OLTT/AUCIns OGTT output ratio (NIOR) was implemented. Its value
ranged from 0,42 to 5,83 and significantly correlated with BMI and leptin, but not with age,
gender, WHR, HOMA or adiponectin level. The high NIOR value was found in the subgroup of
carriers of rare allelic variants of genes characteristic for the worse tolerance to lipids in the diet,
when the low NIOR value was found for the sub-group of the rare genetic variants regulating
Thus the new insulin index NIOR segregated the gene variant carriers into the groups of the
glucose, or the lipid content sensitive phenotypes.
Conclusion: We suggest that the OLTT/OGTT insulin output ratio (NIOR) may have the
predictive value for discrimination between the phenotype of insulin resistance susceptible to fat
or carbohydrate containing diet.
Granted by Polish MNiI: Nr 3PO5D08424 and Nr 501/NKL/49/L