21 March 2014: Clinical Research
Novel fibro-inflammation markers in assessing left atrial remodeling in non-valvular atrial fibrillation
Osman Sonmez ABCDEF , Furkan U. Ertem BCF , Mehmet Akif Vatankulu BCF , Ercan Erdogan BDF , Abdurrahman Tasal BDF , Sıtkı Kucukbuzcu BCF , Omer Goktekin ADF
DOI: 10.12659/MSM.890635
Med Sci Monit 2014; 20:463-470
Abstract
BACKGROUND: Structural remodeling is associated with the fibroinflammatory process in the atrial extracellular matrix. In the present study we aimed to investigate whether serum levels of new circulating remodeling markers differ in patients with atrial fibrillation (AF) compared to patients with sinus rhythm.
MATERIAL AND METHODS: The study population included 52 patients diagnosed with non-valvular AF and 33 age-matched patients with sinus rhythm. Serum levels of Galectin-3, matrix metalloproteinase-9 (MMP-9), lipocalin-2 (Lcn2/NGAL), N-terminal propeptide of type III procollagen (PIIINP), Hs-Crp, and neutrophil-to-lymphocyte ratio (NLR) were measured. The left atrial volume (LAV) was calculated by echocardiographic method and LAV index was calculated.
RESULTS: Galectin-3, MMP-9, and PIIINP levels were significantly higher in AF patients except NGAL levels (1166 pg/ml (1126–1204) and 1204 pg/ml (1166–1362) p=0.001, 104 (81–179) pg/ml and 404 (162–564) pg/ml p<0.0001, and 1101 (500–1960) pg/ml and 6710 (2370–9950) pg/ml p<0.0001, respectively). The NLR and Hs-CRP levels were also higher in AF (2.1±1.0 and 2.7±1.1 p=0.02 and 4.2±1.9 mg/L and 6.0±4.7 mg/L p=0.04, respectively). In correlation analyses, NLR showed a strongly significant correlation with LAVi, but Hs-CRP did not (p=0.007 r=0.247, Pearson test and p=0.808 r=0.025, Pearson test, respectively). Moreover, Galectin-3, MMP-9, and PIIINP had a strong positive correlation with LAVi (p=0.021 r=640, Spearman test and p=0.004 r=0.319 Pearson test, and p=0.004 r=0.325 Pearson test, respectively).
CONCLUSIONS: Novel fibrosis and inflammation markers in AF are correlated with atrial remodeling. Several unexplained mechanisms of atrial remodeling remain, but the present study has taken the first step in elucidating the mechanisms involving fibrosis and inflammation markers.
Keywords: Aged, 80 and over, Acute-Phase Proteins, Atrial Fibrillation - ultrasonography, Atrial Remodeling, Biological Markers - blood, C-Reactive Protein - metabolism, Electrocardiography, Fibrosis, Heart Valves - physiopathology, Inflammation - pathology, Lipocalins - blood, Matrix Metalloproteinase 9 - blood, Peptide Fragments - blood, Procollagen - blood, Proto-Oncogene Proteins - blood
Background
Atrial fibrillation (AF) is the most common cardiac arrhythmia and increases the risk of stroke and death [1]. Inflammation is an important factor related to the initiation, maintenance, and recurrence of AF. This abnormal inflammation may cause a prothrombotic state, finally resulting in thromboembolism [2]. In persistent AF, atrial enlargement and structural and electrical remodeling form the basis of atrial changes. Structural remodeling is associated with an activated and gradually progressive fibrosis and inflammation process in the atrial extracellular matrix (ECM) [3–5]. Matrix metalloproteinases (MMPs) are major mediators of normal ECM remodeling [3–5, 7]. Moreover, studies have increased our understanding of the role of inflammation in AF by showing that C-reactive protein (CRP) [6–8] and the neutrophil-to-lymphocyte ratio (NLR) are associated with AF [9–11].
However, the exact mechanism of the pathogenesis and progression of AF remains to be elucidated. Various mediators may play a role in the pathogenesis. A growing body of evidence is showing that galectin-3 [12–14], lipocalin-2/neutrophil gelatinase-B-associated lipocalin (Lcn2/NGAL) [15–17] and N-terminal propeptide of type III procollagen (PIIINP) [18–20] seem to play important roles in the cardiovascular inflammation and fibrosis that result in cardiac remodeling.
In the present study, we aimed to investigate whether serum levels of galectin-3, Lcn2/NGAL, PIIINP, and NLR differ in patients with AF compared with patients with a sinus rhythm, with guidance of known markers such as serum MMP-9 and Hs-CRP levels. We also evaluated the associations of these markers with atrial structural remodeling, which was interpreted by measuring the left atrial volume index.
Material and Methods
PATIENT SELECTION:
The study population included 85 patients who were seen in our outpatient clinic between March 2012 and January 2013. Fifty-two patients diagnosed with non-valvular (mitral and aortic valve) persistent AF (AF duration longer than 1 month) were recruited into the AF group. End-stage hepatic or renal disease, malignancy, any prior blood transfusions, carotid artery disease, prior transient ischemic attack and ischemic or hemorrhagic stroke, oral anticoagulant usage, and NYHA functional class III or IV patient were exclusion criteria in our study. Thirty-three age-matched patients with sinus rhythm were recruited into the control group. A clinical history of risk factors such as diabetes mellitus, hypertension, hypercholesterolemia, and cardiovascular disease were recorded. For each patient, we calculated height, weight, body mass index (BMI), and body surface area (BSA). Based on the serum creatinine level on admission, estimated glomerular filtration rate (e-GFR) was calculated by using the Modification of Diet in Renal Disease (MDRD) formula. The ethical implications regarding the study were approved by the local ethics committee and informed consent was obtained from each patient.
ECHOCARDIOGRAPHIC ASSESSMENT:
The LV ejection fraction (EF) was assessed by the modified biplane Simpson method. Cardiac dimensions were measured according to the recommendations of the American Society of Echocardiography by M-mode and 2-dimensional echo [21]. LV mass (LVM) was calculated from 2D echocardiographic measurements by using Devereux formula: LVM=1.04* [(LVsw + LVpw + LVEDD)3 – (LVEDD)3]–13.6 and was indexed to body surface area [22]. Two cardiologists, blinded to patient clinical history, performed the physical examinations, measured outcome variables, interpreted all echocardiograms, and verified LV
volumetric analyses. Left ventricular ejection fraction (LVEF) was calculated using the biplane method of discs (modified Simpson’s rule) in the apical 4- and 2-chamber views at end systole and end diastole. Measurements were obtained as the mean value from the apical 4- and 2-chamber views. The left atrial volume was calculated by using the biplane method of discs (modified Simpson’s rule) in the apical 4- and 2-chamber views at end diastole of the atria. Measurements were obtained as the mean value from the apical 4- and 2-chamber views. The LAVI was then calculated as LAV divided by body surface area [4,23].
BLOOD SAMPLES AND BIOCHEMICAL MEASUREMENTS:
Venous blood samples were drawn after an outpatient clinical examination. The samples were kept at room temperature for 15 min to permit coagulation and were then centrifuged at 1000×
The serum levels of galectin-3, MMP-9, Lcn2/NGAL, and PIIINP were measured using commercial enzyme-linked immunoassay kits, and each assay was carried out in duplicate. The galectin-3 level was determined using sandwich ELISA (Human Galectin-3 ELISA kit; eBioscience), NGAL levels (Human Lipocalin-2/NGAL ELISA kit; BioVendor Research and Diagnostic Products), MMP-9 levels (Human Matrix Metalloproteinase 9; Bio-Medical Assay), and a PIIINP kit (Human Procollagen III N-Terminal Propeptide; Bio-Medical Assay). The minimal measurable concentrations for these detection systems are 120 pg/ml for galectin-3, 20 pg/ml for NGAL, 60 pg/ml for PIIINP, and 50 pg/ml for MMP-9.
The hemoglobin level and white blood cell count were determined as part of the automated complete blood count using a Sysmex XT-1800i (USA) hematology analyzer. The baseline NLR level was measured by dividing the neutrophil count by the lymphocyte count. A white blood cell count of >12,000 cells/μl or <4,000 cells/μl and high body temperature of >38°C were excluded from the study to ensure a subclinical inflammatory status.
STATISTICAL ANALYSES:
Continuous variables are expressed as mean ±SD or median (interquartile range) when appropriate. Categorical variables are expressed as percentages. To compare parametric continuous variables, Student’s t-test was used; to compare nonparametric continuous variables, the Mann-Whitney U-test was used. To compare categorical variables, the chi-square-test was used. The Pearson and Spearman correlation coefficient were used to determine parametric and nonparametric measure of statistical dependence between 2 variables. Multivariate regression analysis was used to identify the independent predictors of higher LAVi value >48 mm3\m2 (mean LAVi value is 48 mm3\m2). All variables showing significance values of less than 0.1 on univariate analysis were included in the model. A 2-tailed P-value of less than 0.05 was considered to indicate statistical significance. The statistical analyses were performed using software (SPSS 15.0, SPSS Inc, Chicago, IL).
Results
BASELINE CHARACTERISTICS:
The baseline characteristics of the groups (mean age, 71±8 years; minimum age, 42 years; maximum age, 85 years; 62% female) are presented in Table 1. There were no differences between the groups in terms of baseline characteristics, excluding congestive heart failure, and no differences in the conventional laboratory findings. Aspirin and digitalis use was significantly higher in the NVAF group, but there were no differences in the remaining medications.
ECHOCARDIOGRAPHIC MEASUREMENTS:
The EF was significantly lower and the LVMass, LAV, and LAVi were significantly higher in patients with NVAF (Table 1).
INFLAMMATORY AND REMODELING MARKERS:
There were significant differences between the groups in terms of inflammatory and remodeling markers, with the exception of the NGAL levels (Table 2). The galectin-3, MMP-9, and PIIINP levels were significantly higher in patients with NVAF (1166 pg/ml (1126–1204) and 1204 pg/ml (1166–1362) p=0.001, 104 (81–179) pg/ml and 404 (162–564) pg/ml p<0.0001, and 1101 (500–1960) pg/ml and 6710 (2370–9950) pg/ml p<0.0001 respectively, Mann-Whitney U test fol all. The NLR and Hs-CRP levels were also higher in patients with NVAF (2.1±1.0 vs. 2.7±1.1 mg/l, p=0.02, Student’s t-test and 4.2±1.9 vs. 6.0±4.7 mg/l, p=0.04, Student’s t-test, respectively) (Figures 1 and 2).
Figures 3 and 4 demonstrate a correlation between LAVi and the inflammatory and remodeling markers as shown by the correlation analyses. NLR showed a significant correlation with LAVi, whereas Hs-CRP did not (p=0.007, r=0.247, Pearson’s test and p=0.808, r=0.025, Pearson’s test, respectively). Moreover, galectin-3, MMP-9, and PIIINP showed a strong positive correlation with LAVi (p=0.021, r=640, Spearman’s test; p=0.004, r=0.319, Pearson’s test; and p=0.004, r=0.325, Pearson’s test, respectively).
In univariate analysis, a cut point was determined as mean LAVi value, MMP-9,PIIINP, NLR, and EF were correlated with high LAVi (LAVi >48 mm3/m2) (Table-3). In multivariate analysis, PIIINP [odds ratio (OR)=1.22, 95% confidence interval (CI) (1.11–1.41), P=0.001] was the only independent factor associated with high LAVi.
Discussion
STUDY LIMITATIONS:
Two limitations must be considered. The main limitation is the lack of histologic correlation, because we did not perform a histopathological examination of atrial tissue. Also, our study included a small population. However, research on fibrosis and inflammation markers at the tissue level would contribute additional information.
Conclusions
Certain fibrosis and inflammation markers in AF are correlated with atrial remodeling. Several unexplained mechanisms of atrial remodeling remain, but the present study has taken the first step in elucidating the mechanisms involving fibrosis and inflammation markers. Although targeting fibrosis and inflammation as early anti-remodeling therapy is not supported by the current data, present study findings also suggest that galectin-3, PIIINP, and NLR may contribute to the clinical and therapeutic management of AF as novel targets for therapies that aim to decrease fibrosis and inflammation in the atria.
References
1. Jauch EC, Saver JL, Adams HP, Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association: Stroke, 2013; 44; 870-947, pmid: 23370205
2. Lip GY, Patel JV, Hughes E, Hart RG, High-sensitivity C-reactive protein and soluble CD40 ligand as indices of inflammation and platelet activation in 880 patients with nonvalvular atrial fibrillation: relationship to stroke risk factors, stroke risk stratification schema, and prognosis: Stroke, 2007; 38; 1229-37, pmid: 17332453
3. Gramley F, Lorenzen J, Plisiene J, Decreased plasminogen activator inhibitor and tissue metalloproteinase inhibitor expression may promote increased metalloproteinase activity with increasing duration of human atrial fibrillation: J Cardiovasc Electrophysiol, 2007; 18; 1076-82, pmid: 17655664
4. Kalogeropoulos AS, Tsiodras S, Rigopoulos AG, Novel association patterns of cardiac remodeling markers in patients with essential hypertension and atrial fibrillation: BMC Cardiovasc Disord, 2011; 11; 77, pmid: 22204652
5. Gai X, Lan X, Luo Z, Association of MMP-9 gene polymorphisms with atrial fibrillation in hypertensive heart disease patients: Clin Chim Acta, 2009; 408; 105-59, pmid: 19665460
6. Licata G, Tuttolomondo A, Di Raimondo D, Immuno-inflammatory activation in acute cardio-embolic strokes in comparison with other subtypes of ischaemic stroke: Thromb Haemost, 2009; 101; 929-37, pmid: 19404547
7. Ehrlich JR, Kaluzny M, Baumann S, Biomarkers of structural remodelling and endothelial dysfunction for prediction of cardiovascular events or death in patients with atrial fibrillation: Clin Res Cardiol, 2011; 100; 1029-36, pmid: 21725858
8. Pena JM, MacFadyen J, Glynn RJ, Ridker PM, High-sensitivity C-reactive protein, statin therapy, and risks of atrial fibrillation: an exploratory analysis of the JUPITER trial: Eur Heart J, 2012; 33; 531-37, pmid: 22187510
9. Ertas G, Sonmez O, Turfan M, Neutrophil/lymphocyte ratio is associated with thromboembolic stroke in patients with non-valvular atrial fibrillation: J Neurol Sci, 2013; 324; 49-52, pmid: 23084070
10. Aribas A, Akilli H, Gul EE, Can neutrophil/lymphocyte ratio predict recurrence of non-valvular atrial fibrillation after cardioversion?: Anadolu Kardiyol Derg, 2013; 13; 123-30, pmid: 23228974
11. Bhat T, Teli S, Rijal J, Neutrophil to lymphocyte ratio and cardiovascular diseases: a review: Expert Rev Cardiovasc Ther, 2013; 11; 55-59, pmid: 23259445
12. McCullough PA, Olobatoke A, Vanhecke TE, Galectin-3: a novel blood test for the evaluation and management of patients with heart failure: Rev Cardiovasc Med, 2011; 12; 200-10, pmid: 22249510
13. Gruson D, Ko G, Galectins testing: new promises for the diagnosis and risk stratification of chronic diseases?: Clin Biochem, 2012; 45; 719-26, pmid: 22546645
14. Lok DJ, Van Der Meer P, de la Porte PW, Prognostic value of galectin-3, a novel marker of fibrosis, in patients with chronic heart failure: data from the DEAL-HF study: Clin Res Cardiol, 2010; 99; 323-28, pmid: 20130888
15. Vanhoutte PM, Endothelial dysfunction in obesity: Ann Pharm Fr, 2013; 71; 42-50, pmid: 23348855
16. Ding L, Hanawa H, Ota Y, Lipocalin-2/neutrophil gelatinase-B associated lipocalin is strongly induced in hearts of rats with autoimmune myocarditis and in human myocarditis: Circ J, 2010; 74; 523-30, pmid: 20057160
17. Choi KM, Lee JS, Kim EJ, Implication of lipocalin-2 and visfatin levels in patients with coronary heart disease: Eur J Endocrinol, 2008; 158; 203-7, pmid: 18230827
18. Diez J, Laviades C, Mayor G, Increased serum concentrations of procollagen peptides in essential hypertension. Relation to cardiac alterations: Circulation, 1995; 91; 1450-56, pmid: 7867186
19. Dellegrottaglie S, Sands RL, Gillespie BW, Association between markers of collagen turnover, arterial stiffness and left ventricular hypertrophy in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study: Nephrol Dial Transplant, 2011; 26; 2891-98, pmid: 21562144
20. Gluba A, Bielecka A, Mikhailidis DP, An update on biomarkers of heart failure in hypertensive patients: J Hypertens, 2012; 30; 1681-89, pmid: 22828089
21. Schiller NB, Shah PM, Crawford M, Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms: J Am Soc Echocardiogr, 1989; 2; 358-67, pmid: 2698218
22. Devereux RB, Reichek N, Echocardiographic determination of left ventricular mass in man. Anatomic validation of the method: Circulation, 1977; 55; 613-18, pmid: 138494
23. Staszewsky L, Wong M, Masson S, Left atrial remodeling and response to valsartan in the prevention of recurrent atrial fibrillation: the GISSI-AF echocardiographic substudy: Circ Cardiovasc Imaging, 2011; 4; 721-28, pmid: 21926261
24. Zhu H, Zhang W, Guo CH, Effects of matrix metalloproteinase-9 and tissue inhibitor-1 of metalloproteinase expression on atrial structural remodeling during chronic atrial fibrillation: Zhonghua Yi Xue Za Zhi, 2005; 85; 45-48, pmid: 15808077
25. Zhao Y, Zhou X, Liao X, Yang Z, Expression and significance of matrix metalloproteinase-1,9, tissue inhibitor of metalloproteinase-4 and extracellular matrix metalloproteinase inducer in the myocardium of congestive heart failure in patients with rheumatic heart diseases: Zhong Nan Da Xue Xue Bao Yi Xue Ban, 2009; 34; 790-95, pmid: 19734590
26. Lin YH, Lin LY, Wu YW, The relationship between serum galectin-3 and serum markers of cardiac extracellular matrix turnover in heart failure patients: Clin Chim Acta, 2009; 409; 96-99, pmid: 19747906
27. Park M, Sweeney G, Direct effects of adipokines on the heart: focus on adiponectin: Heart Fail Rev, 2013; 18(5); 631-44, pmid: 22893246
28. Fassett RG, Robertson IK, Ball MJ, Effects of atorvastatin on NGAL and cystatin C in chronic kidney disease: a post hoc analysis of the LORD trial: Nephrol Dial Transplant, 2012; 27; 182-89, pmid: 21543653
29. Romero JR, Vasan RS, Beiser AS, Association of carotid artery atherosclerosis with circulating biomarkers of extracellular matrix remodeling: the Framingham Offspring Study: J Stroke Cerebrovasc Dis, 2008; 17; 412-17, pmid: 18984437
30. Swartz MF, Fink GW, Sarwar MF, Elevated pre-operative serum peptides for collagen I and III synthesis result in post-surgical atrial fibrillation: J Am Coll Cardiol, 2012; 60(18); 1799-806, pmid: 23040566
31. Edwards NC, Ferro CJ, Kirkwood H, Effect of spironolactone on left ventricular systolic and diastolic function in patients with early stage chronic kidney disease: Am J Cardiol, 2010; 106; 1505-11, pmid: 21059444
32. Udelson JE, Feldman AM, Greenberg B, Randomized, double-blind, multicenter, placebo-controlled study evaluating the effect of aldosterone antagonism with eplerenone on ventricular remodeling in patients with mild-to-moderate heart failure and left ventricular systolic dysfunction: Circ Heart Fail, 2010; 3; 347-53, pmid: 20299607
33. Sahin T, Acar E, Celikyurt U, Relation of hs-CRP and BNP levels with the atrial spontaneous echo contrast and thrombi in permanent atrial fibrillation patients with different etiologies: Med Sci Monit, 2012; 18(2); CR78-87, pmid: 22293881
34. Canpolat U, Aytemir K, Yorgun H, Role of Preablation Neutrophil/Lymphocyte Ratio on Outcomes of Cryoballoon-Based Atrial Fibrillation Ablation: Am J Cardiol, 2013 pii: S0002-9149(13)00989-2
35. Goette A, Staack T, Rocken C, Increased expression of extracellular signal-regulated kinase and angiotensin-converting enzyme in human atria during atrial fibrillation: J Am Coll Cardiol, 2000; 35; 1669-77, pmid: 10807475
36. Zhang Y, Zhang P, Mu Y, The role of renin-angiotensin system blockade therapy in the prevention of atrial fibrillation: a meta-analysis of randomized controlled trials: Clin Pharmacol Ther, 2010; 88; 521-31, pmid: 20811347
37. Durin O, Pedrinazzi C, Inama G, Focus on renin-angiotensin system modulation and atrial fibrillation control after GISSI AF results: J Cardiovasc Med (Hagerstown), 2010; 11; 912-18, pmid: 20729747
38. Sasamura H, Kitamura Y, Nakamura M, Effects of the angiotensin receptor blocker candesartan on arterial stiffness and markers of extracellular matrix metabolism in patients with essential hypertension: Clin Exp Hypertens, 2006; 28; 511-20, pmid: 16820347
39. Yoon N, Cho JG, Kim KH, Beneficial effects of an angiotensin-II receptor blocker on structural atrial reverse-remodeling in a rat model of ischemic heart failure: Exp Ther Med, 2013; 5; 1009-16, pmid: 23599726
40. Camm AJ, Al-Khatib SM, Calkins H, A proposal for new clinical concepts in the management of atrial fibrillation: Am Heart J, 2013; 164; 292-302, pmid: 22980294
In Press
Clinical Research
Institutional and Regional Variations in Access to Clinical Trials and Next-Generation Sequencing in Turkis...Med Sci Monit In Press; DOI: 10.12659/MSM.951027
Clinical Research
Low-Intensity Blood Flow-Restricted Multi-Joint Exercise Improves Muscle Function in Patients With Patellof...Med Sci Monit In Press; DOI: 10.12659/MSM.950516
Review article
Musculoskeletal Ultrasound and MRI in the Evaluation of Chemotherapy-Induced Peripheral Neuropathy: A ReviewMed Sci Monit In Press; DOI: 10.12659/MSM.951283
Clinical Research
Sensory Processing, Dissociation, and Affective Symptoms in Misophonia: A Cross-Sectional Study of 35 AdultsMed Sci Monit In Press; DOI: 10.12659/MSM.950938
Most Viewed Current Articles
17 Jan 2024 : Review article 10,187,196
Vaccination Guidelines for Pregnant Women: Addressing COVID-19 and the Omicron VariantDOI :10.12659/MSM.942799
Med Sci Monit 2024; 30:e942799
13 Nov 2021 : Clinical Research 3,708,487
Acceptance of COVID-19 Vaccination and Its Associated Factors Among Cancer Patients Attending the Oncology ...DOI :10.12659/MSM.932788
Med Sci Monit 2021; 27:e932788
14 Dec 2022 : Clinical Research 2,341,643
Prevalence and Variability of Allergen-Specific Immunoglobulin E in Patients with Elevated Tryptase LevelsDOI :10.12659/MSM.937990
Med Sci Monit 2022; 28:e937990
16 May 2023 : Clinical Research 706,524
Electrophysiological Testing for an Auditory Processing Disorder and Reading Performance in 54 School Stude...DOI :10.12659/MSM.940387
Med Sci Monit 2023; 29:e940387