A study on inflammatory profile among subjects with acute myocardial infraction

 

 

Abstract              Background: Cardiovascular disease especially AMI accounts for approximately 12 million deaths annually and is the commonest cause of death globally. This problem is assuming epidemic propositions in the developing countries. The Asian Indians whether living in their own countries or elsewhere have much higher incidence of CAD as compared to all ethnic groups. Objective: A Study on Inflammatory Profile among subjects with Acute Myocardial Infraction. Methodology: The Present cross-sectional study was conducted at Department of General Medicine in Shri B M Patil Medical College, Bijapur from January 2017 to December 2017.A total of 100 study subjects who met the inclusion criteria were enrolled for the purpose of study during the study period and analyzed and compared with similar number of Control for Inflammatory Markers. Results: There was a significant correlation between AMI and the risk factors smoking and alcohol. The values of hs-CRP were found to have highly significant correlation with AMI. The risk factors smoking and alcohol did not alter inflammatory profile significantly. • Elevation of hs-CRP can be used as adjuncts in the diagnosis of AMI. Conclusion: Among the various inflammatory markers hs-CRP found to be highly significant and it can very well have suggested to be a reliable diagnostic marker of inflammatory process in AMI, after excluding other condition which can produce elevation of hs-CRP.

Keywords: Myocardial Infraction, C Reactive Protein, Inflammation, Coronary Artery Disease

 

INTRODUCTION

Atherosclerotic disease begins as early as the second decade of life with the development of fatty streaks on previously normal vascular endothelium. Disease progression leads to the formation of non-obstructive stable atherosclerotic plaques. These may evolve to obstructive lesions that have the potential to produce symptoms such as angina, transient ischemic attacks (TIAs), or symptomatic peripheral vascular disease (claudication). Alternatively, transition of previously asymptomatic stable plaque to "vulnerable" plaque has the potential to result in plaque fissure or rupture, causing unstable angina, acute myocardial infarction, or stroke.^1,2 Substantial evidence indicates that inflammation plays a significant role in the transition from stable to vulnerable plaque and subsequently to plaque injury. Identification of markers reflecting vascular inflammation has enhanced the ability to evaluate cardiovascular risk in both symptomatic and asymptomatic patients. C-reactive protein (CRP) is one of a number of markers of inflammation that has emerged a useful tool for assessing cardiovascular event risk. ^3,4 Traditional risk factors for coronary artery disease (CAD)) have been used for many years to evaluate individual patient risk and have been incorporated into various diagnostic and therapeutic guidelines for primary and secondary prevention of cardiovascular disease. The Framingham Risk Score utilizes several traditional risk factors to determine cardiovascular risk in the National Cholesterol Education Program's Adult Treatment Panel III report (ATP III).⁵ CRP is an acute phase reactant produced by the liver and was initially understood to bind to complement to assist in the destruction of bacterial cell walls as part of the immune response to infection. Hepatic production of CRP is thought to be a response to the presence of interleukin-6 and other products of the inflammatory cascade. Recently it has been shown that CRP may be produced locally in atherosclerotic plaques by macrophages.¹² The role of CRP as more than a "marker" for vascular inflammation is supported by the knowledge that CRP within plaque induces the production of chemokines and adhesion molecules in a dose dependent fashion, attracting additional monocytes and leading to a self-sustaining inflammatory reaction.^6,7

Objective

To analyze the levels of various Inflammatory markers including hs-CRP in Acute myocardial infarction.

 

MATERIALS AND METHODS

The Present cross sectional study was conducted at Department of General Medicine in Shri B M Patil Medical College, Bijapur from January 2017 to December 2017.

A total of 100 study subjects who met the inclusion criteria were enrolled for the purpose of study during the study period and analyzed and compared with similar number of Control for Inflammatory Markers.

Inclusion Criteria:

Patients presenting with acute myocardial infarction (AMI) with acute ECG changes within 12 hrs. of the onset of chest pain

Exclusion Criteria:

1. 1.Intercurrent inflammatory or neoplastic conditions likely to present with acute phase response by clinical evaluation.
2. Surgery, trauma in the preceding six months.
3. Presence of connective tissue disorders like SLE, Rheumatoid arthritis and other collagen vascular disease
4. Inflammatory bowel disorders, pancreatitis
5. Hepatic failure
6. Renal failure
7. Heart failure
8. Cerebrovascular Accident

 

Detailed history recorded from the patients with reference to the features of the chest pain, location, radiation, aggravating and reliving factors, increase autonomic activity and other clinical features suggestive of acute myocardial infarction (AMI). The diagnosis of myocardial infarction was based on clinical and electrographic evidence using the criteria recommended by W.H.O.¹⁰ The other conditions which are likely to induce acute phase reactants were carefully ruled out by detailed history taking and thorough clinical evaluation. The risk factors associated with, both modifiable like cigarette smoking, alcohol consumption, hypertension, diabetes mellitus and obesity (BMI) and non- modifiable like age, sex, family history were taken into consideration. At the onset standard 12 lead ECG was taken and blood sample was collected for routine investigations, and for acute phase reactants hsCRP (highly sensitive C – reactive protein). The diagnosis is made by internationally accepted criteria recommended by WHO. Descriptive statistics mean and standard deviation was used to summarize normally distributed continuous variables. All statistical analysis was done using SPSS (Statistical Package for Social Sciences) v 1.5. A p value of less than 0.05 was considered statistically significant. Chi square test was used to analyze descriptive variables.

 

RESULTS

A total of 100 study subjects were analyzed during the study period

Table 1: Social Profile of Study subjects

In the present study nearly 42 % of the study subjects were aged more than 55 years of age and nearly 63% of them were Male. The BMI was found to be more than 30 in nearly 40% of the study subjects.

 

Table 2: Risk Factors among study subjects

Among the study subjects on detailed history taking nearly 15% of them had habit of only smoking and 20% of them consumed only Alcohol and 47 % of them consumed both alcohol and smoking.

 

Table 3: Inflammatory Profile of Study subjects

On comparing mean value of Inflammatory mediators between case and control it was observed that hs CRP, TC and ESR were found to be statistically significant

 

Table 4: Inflammatory Profile and Risk factors among the study subjects

It was also observed that in our study, the subjects who had history of risk factors of Smoking and Alcohol consumption had higher values of inflammatory mediators when compared with those subjects with no risk factors and the association was also found to be statistically insignificant.

 

DISCUSSION

The present study was conducted on 100 study subjects with history of Acute Myocardial Infraction and were compared with equal number of control for the mean inflammatory mediators among the subjects. The age group of study subjects in our study found that majority of them were aged more than 55 years of age and the age group of our study was found to be comparable to the study done by Arunkumar et al. ⁸. In our study also majority of the study subjects were male which was reported in many studies. On comparing these two groups statistically significant difference was noted in hs-CRP levels. The values (Mean ± SD) for cases and controls were 9.12+2.45 mg/L vs 4.12+2.74 mg/L with highly significant P values (P=0.000). This is in consistent with various other studies.⁸ A study conducted by Sreekanth K Sivaraman ⁹ et al. in 2004 CRP levels were elevated in AMI (40.8± 15.4 mg/L) when compare to controls with normal heart (12.6± 2.8 mg/L). There was a statistically significant difference between cases and controls with P values <0.001 In a study conducted by A.L. Pasqui ¹⁰ et al. in 2005 hs-CRP levels in AMI was 4.3 ± 2.8 and for controls was 1.2 ± 0.4. A statistically significant difference observed in this study (P<0.01) In a study conducted by Dr. Arunkumar et al. ⁸ in 2002-2006 higher plasma levels of CRP was found in Pts with AMI when compare to control. The CRP levels for controls 1.12± 0.33 while for the patients with AMI it was 2.97 ± 1.11. This was statistically significant with P= <0.001. In a study conducted by YIP HK, 100 Wu CJ, Chang HW et al. 11(CRP 3) Serum levels of hs-CRP was significantly higher in patients with an onset of MI < 6 hours when compared to healthy subjects (2.7 + 2.3 mg/l vs 1.0 + 0.6 mg/L with p < 0.0001). In the present study TC was not found to be statistically significant. The values for TC (Mean ± SD) for cases and controls was (10547.00 ± 2145.5 vs 9524.00 ± 895.5) with P values 0.04. The ESR was also not found to be varying significantly when AMI patients were compared with controls in our present study. The values for ESR (Mean ± SD) for cases and controls in our study were 22.14 ± 20.58 vs 15.26 ± 12.5 respectively. This is in contrast to a study conducted by Srikanth K. Sivaraman ⁹ et al. There the values for total WBC count and ESR varied significantly with controls. The values for ESR in patients with MI compared with controls was 55.2 ± 28.0 vs 25.2 ± 10.3, and for total WBC count the values were 11480.8 ± 4345 vs 8949.6 ± 1853. The P values for both were significant. In the present study the inflammatory markers hs-CRP, Total count, ESR a were compared with various risk factors. The levels of these markers were not found to vary significantly in smokers and alcoholic when compared with patients with nonsmokers/nonalcoholic. This is in contrast with the study conducted by Moghbeli N et al. ¹², where smokers with Acute coronary syndrome had higher CRP levels than nonsmokers (P <0.001). While comparing these inflammatory markers with DM and HTN only ESR found to be vary statistically significant manner (P=0.014).

 

CONCLUSION

Our study clearly indicated that hs-CRP is elevated in most of the cases of AMI and supporting the view that inflammation in the coronary vessels plays a very important role in the pathogenesis of AMI and other cardiac events. But AMI is not an overt inflammatory disease but events leading to AMI are every much influenced by the inflammatory process especially the plaque rupture. The hs-CRP measured by high sensitive assay is capable of detecting the ongoing inflammation in the coronary arteries. By considering hs-CRP as a diagnostic and therapeutic marker, added with the clear understanding of vascular biology, atherosclerosis and inflammation, our diagnostic and therapeutic methods will move in to new level in the management of CAD and AMI

 

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