Coronary Artery Disease In Hemodialysis Patients Research Articles

#941 Pentraxin-3 as a marker of coronary artery disease in hemodialysis patients

Abstract Background and Aims Pentraxin-3 (PTX3), a novel inflammatory biomarker, has been recognized as a predictor of cardiovascular events in the general population, including coronary artery disease (CAD). Although PTX3 is elevated in dialysis patients, its potential diagnostic value for the estimation of CAD severity is still insufficiently studied. The aim of this study was to evaluate the association between PTX3 and CAD in hemodialysis patients. Method This cross-sectional study included 60 angina-free chronic hemodialysis patients (60% men, mean age 60 ± 11 years, mean dialysis vintage 26 ± 14 months). Coronary artery calcium score (CACS) and coronary computed tomography angiography (CCTA) were performed to evaluate CAD burden and stenosis severity, which was defined as significant if obstructing more than 50% of the vessel lumen. PTX3 was quantified using an enzyme-linked immunosorbent assay kit. Results Significant coronary artery stenosis was detected in 24 (40%) patients, of which the majority (17; 70.83%) had one-vessel disease. PTX3 was 194.82 ± 68.58 ng/mL in patients with significant CAD, whereas 83.55 ± 11.89 ng/mL in those without significant coronary artery stenosis (p = 0.028). PTX3 levels tend to increase in patients with CACS higher than 200 Agatston units, however statistically significant difference was not reached (p = 0.504). PTX3 levels correlated with age (p < 0.05) and c-reactive protein (p = 0.007), while negatively correlated with body mass index (p < 0.05). Conclusion PTX3 is significantly increased in hemodialysis patients with coronary artery disease. Further studies should elucidate if including PTX3 as a marker for detecting CAD prior to invasive imaging could improve cardiovascular risk stratification even in angina-free hemodialysis patients.

High-sensitivity cardiac troponin T in detecting obstructive coronary artery disease in hemodialysis patients listed for kidney transplantation.

Cardiovascular diseases are the leading cause of morbidity and mortality in patients with end-stage renal disease. This study aimed to assess the prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) in identifying patients with obstructive coronary artery disease (CAD) among patients on hemodialysis listed for kidney transplantation. The study prospectively enrolled consecutive adult hemodialysis patients listed for kidney transplantation. They underwent laboratory tests and a standardized set of imaging and functional tests, including coronary angiography, according to patient characteristics. The study included 100 consecutive patients (72 men)at a median age of 56.5 years. Ultimately, 48% of the patients were diagnosed with obstructive CAD. Age and plasma hs-cTnT levels predicted the diagnosis of obstructive CAD (OR, 1.13; 95% CI, 1.08-1.20; P < 0.001 and OR, 1.03; 95% CI, 1.01-1.05; P = 0.001, respectively). The calculated cut-off value for age was 53 years, which showed sensitivity of 87.5% and specificity of 76.9% for obstructive CAD diagnosis. The calculated value for hs-cTnT was 0.067 ng/ml, which showed sensitivity of 61.4% and specificity of 82.2% for the detection of obstructive CAD. In patients aged >52 years, 79.2% were diagnosed with obstructive CAD. However, in the group of patients ≤52 years and with hs-cTnT >0.069 ng/ml, the incidence of obstructive CAD was significantly higher than in the group with hs-cTnT level ≤0.069 ng/ml. Baseline hs-cTnT level is a useful prognostic biomarker in the diagnosis of obstructive CAD in hemodialysis patients listed for kidney transplantation.

Cholesterol Metabolism in Patients With Hemodialysis in the Presence or Absence of Coronary Artery Disease

Little is known about the interrelationship between the lipid profile, cholesterol metabolism, and coronary risk factors in patients with hemodialysis (HD) in the presence or absence of coronary artery disease (CAD). Ninety-five patients with HD were selected (HD group). Fifty-eight age-, gender-, and body mass index (BMI)-matched patients who had at least 1 cardiovascular risk factor were selected as a non-HD group. Total cholesterol (TC), triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and the ratio of LDL-C to HDL-C (L/H) in the HD group were significantly lower than those in the non-HD group. All markers of cholesterol absorption (campesterol/TC, sitosterol/TC, and cholestanol/TC) and the ratio of campesterol to lathosterol in the HD group were significantly higher. In addition, in the HD group, L/H was negatively correlated with lathosterol/TC, campesterol/TC, sitosterol/TC, and cholestanol/TC. Finally, CAD was significantly associated with lathosterol/TC (P=0.028), which was positively associated with BMI in the HD group, whereas CAD was significantly associated only with hypertension (P=0.020) in the non-HD group. HD patients showed lower cholesterol concentrations than non-HD patients, and, as compensation, their cholesterol absorption might be accelerated. However, higher cholesterol synthesis, which was correlated with higher BMI, might be an independent predictor for the presence of CAD in HD patients.

Application of Speckle-Tracking Echocardiography in Detecting Coronary Artery Disease in Patients with Maintenance Hemodialysis

Background: Satisfactory and noninvasive diagnostic tools for coronary artery disease (CAD) are not available in hemodialysis patients. We aimed to elucidate a reliable tool to diagnose CAD in these patients. Methods: 102 hemodialysis patients received 2D speckle-tracking echocardiography with left ventricular (LV) strain analysis and blood tests for cardiac troponin T, high-sensitive C-reactive protein, interleukin (IL)-6, and IL-18. Results: The levels of biomarkers did not differ between patients with and without CAD. The factors associated with CAD were decreased circumferential strain, decreased global longitudinal strain, and the number of LV segments with decreased longitudinal strain. Logistic regression analyses showed that the number of LV segments with decreased longitudinal strain, over 6 segments, was strongly associated with CAD in hemodialysis patients (OR 12.08, 95% CI 3.724–39.209). Conclusions: The noninvasive modality of speckle-tracking echocardiography with strain analysis is efficient and objective for identifying CAD in hemodialysis patients.

Prediction of Hemodynamically Significant Coronary Artery Disease Using Troponin I in Hemodialysis Patients Presenting with Chest Pain: A Case-Control Study

Objectives: Controversy exists regarding utility of cardiac troponin I (cTnI) in predicting significant coronary artery disease (CAD) in hemodialysis (HD) patients with chest pain and no acute ischemia on electrocardiogram (non-ST segment elevation myocardial infarction, non-STEMI). We sought to determine if cTnI elevation predicts significant CAD (>70% stenosis) in these patients. Methods: Ninety patients with non-STEMI referred for cardiac catheterization were included, divided equally into HD and non-HD groups. Results: Mean age and baseline characteristics were not significantly different between groups, except for left ventricular hypertrophy which was higher in HD patients (56 vs. 27%, p = 0.012). Initial cTnI correlated with obstructive CAD and was stratified into <0.3 and >0.3 ng/ml. By logistic regression, cTnI >0.3 ng/ml was not predictive of CAD in HD patients [odds ratio = 0.87 (95% CI 0.19–4.0), p = 0.8], while non-HD patients had an increased risk of CAD if first cTnI was >0.3 ng/ml [odds ratio = 1.461 (95% CI 1.01–2.11), p = 0.04] as expected. Sensitivity, specificity, negative and positive predictive values of cTnI in predicting obstructive CAD were better in non-HD patients. Conclusion: cTnI in these patients had no predictive value for obstructive CAD. This contrasts with the general population, suggesting a higher index of suspicion for high-grade CAD irrespective of cTnI levels in HD patients.

Assessment of Coronary Artery Disease in Hemodialysis Patients with Delayed Systolic Blood Pressure Response after Exercise Testing

Background: We evaluated usefulness of the postexercise systolic blood pressure (SBP) response for detecting coronary artery disease (CAD) in hemodialysis patients. Methods: A treadmill exercise testing was done, and the SBP response was measured in 44 hemodialysis patients (30 men, 14 women; age 41 to 81 years). The postexercise SBP response was defined as the ratio of SBP after 3 minutes of recovery to SBP at peak exercise. Results: The SBP ratio of the 25 subjects with coronary artery stenosis (1.01 ± 0.13) was significantly greater (p <0.01) than 19 subjects without coronary artery stenosis (0.83 ± 0.10). An SBP ratio greater than 0.92 identified CAD with higher sensitivity, specificity, and accuracy than did the conventional ST-segment depression criterion (76 vs. 56%, 90 vs. 53%, and 82 vs. 55%, respectively). Conclusion: Determination of the SBP ratio is a clinically useful, noninvasive method for accurately detecting CAD in hemodialysis patients.

Circulating levels of plasminogen activator inhibitor type-1, tissue plasminogen activator, and thrombomodulin in hemodialysis patients: biochemical correlations and role as independent predictors of coronary artery stenosis.

This study investigated the relationship between the circulating levels of the endothelial cell glycoproteins plasminogen activator inhibitor type 1 (PAI-1), tissue plasminogen activator (TPA), and thrombomodulin (TM) and the major vascular risk factors described in dialysis patients. In addition, the role of these endothelial cell products as independent predictors of coronary artery disease (CAD) was analyzed. Levels of TM, TPA antigen (Ag), TPA activity, PAI-1 Ag, PAI-1 activity, TPA/PAI complexes, thrombin-antithrombin complexes, fibrinopeptide A, C-reactive protein (CRP), interleukin-1beta and tumor necrosis factor-alpha, lipids, apoproteins A1 and B, and albumin were measured in a group of 200 nondiabetic dialysis patients and 100 healthy matched volunteers. When compared with healthy controls, dialysis patients showed increased levels of CRP, TM, TPA, and PAI-1 and evidence of increased thrombin-dependent fibrin formation. Increased levels of active PAI-1 were associated to a great extent with major classic vascular risk factors and to a lesser extent with CRP and serum triglycerides. Forty-six patients (23%) had evidence of CAD. Variables associated with CAD in the univariate analysis included age, time on dialysis, male gender, number of packs of cigarettes per year, high BP, fibrinogen, apolipoprotein B, albumin, PAI-1 activity, CRP, thrombin-antithrombin complexes, and fibrinopeptide A. Logistic regression analysis found age, high-density lipoprotein cholesterol, gender, high BP, CRP, time on dialysis, and PAI-1 activity to be independent predictors of CAD. This model classified correctly 85% of patients as having CAD and showed adequate goodness of fit for all risk categories. Our data support a pathogenic link among activated inflammatory response, endothelial injury, and CAD in hemodialysis patients and suggest that assessment of circulating PAI-1 levels could be an additional tool to identify dialysis patients who are at risk for developing atheromatous cardiovascular disease.

Lipoprotein(a) as a risk factor for coronary artery disease in hemodialysis patients

We studied whether lipoprotein(a) [Lp(a)] is an independent risk factor for coronary artery disease (CAD) in hemodialysis (HD) patients. A serum concentration of Lp(a) was measured in 212 patients with chronic glomerulonephritis and 56 patients with diabetic nephropathy (a total of 268 patients). The causes of death during five years of follow-up were studied and classified into either cardiovascular or noncardiovascular events. The mortality of these 268 HD patients during the observation period was 26.1%. Seventy-eight percent were due to cardiovascular events. Those who died of cardiovascular events had significantly higher serum Lp(a) levels than those died of noncardiovascular events. The relative risk of death from CAD was 0.71 in HD patients with a Lp(a) concentration above 30 mg/dl. This study indicates that the serum Lp(a) levels are independent indicators of the future risk of death from CAD in HD patients.

Apolipoprotein B, fibrinogen, HDL cholesterol, and apolipoprotein(a) phenotypes predict coronary artery disease in hemodialysis patients.

Patients with end-stage renal disease have a markedly elevated risk for coronary artery disease (CAD). Lipids and most lipoproteins, however, seem to be not predictive for CAD in these patients. Although there is clear evidence that lipoprotein(a) [Lp(a)] is significantly elevated in these patients, no study with a sufficiently large group of hemodialysis patients has investigated the relationship between CAD and Lp(a), as well as the genetically determined apolipoprotein(a) [apo(a)] phenotype. This cross-sectional study determines the prevalence of CAD in relation to the cardiovascular risk profile in an unselected population of 607 hemodialysis patients, of which 33% were diabetic patients. Twenty-six percent (n = 158) of all patients suffered from CAD as diagnosed by a definitive myocardial infarction (n = 102) and/or at least one stenosis >50% of a coronary artery (n = 143). In univariate analysis, several classic risk factors, including the concentration of lipids, lipoproteins, apolipoproteins, and fibrinogen, correlated with CAD. Lp(a) in patients with CAD showed only a tendency to higher levels, without reaching significance, compared with patients without CAD (26.6 +/- 30.8 mg/dl versus 22.1 +/- 30.4 mg/dl, P = 0.10). The frequency of low molecular weight apo(a) isoforms, however, was significantly greater in the group with CAD (34.8% versus 23.6%, P < 0.01). Stepwise logistic regression analysis found seven variables associated with CAD: apolipoprotein B, the low molecular weight apo(a) phenotype, male sex, age, fibrinogen, diabetes mellitus, and HDL cholesterol. The association of these variables with CAD differed depending on age. These results indicate that, besides classic risk factors such as age, sex, and diabetes mellitus, additional factors of the lipoprotein and fibrinolytic system contribute to the high prevalence of CAD in hemodialysis patients.