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ORIGINAL ARTICLE
Year : 2014  |  Volume : 41  |  Issue : 2  |  Page : 118-121

hs-C-reactive protein as an indicator for prognosis in acute myocardial infarction


KLE University, JNMC, Belgaum, Karnataka, India

Date of Web Publication20-May-2014

Correspondence Address:
Raju H. Badiger
Dept of Medicine, J N Medical College, Belgaum, Karnataka. Plot no 2235, MM Extension, Sector-11, Belgaum - 590016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.132859

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  Abstract 

Aims and objectives: The objective of this study is to find the serum high sensitivity-C-reactive protein (hs-CRP) in acute myocardial infarction patients at the time of admission and their association with in - hospital mortality and morbidity. Materials and Methods: A total of 50 patients of acute myocardial patients followed-up for 7 days in hospital with admission of serum hs-CRP levels. Slide agglutination was used to find the serum hs-CRP levels for qualitative and serial dilution method to carry out the semi-quantitative titration. Results: Among 50 Acute myocardial infarction (AMI) patients, 45 patients had an elevated hs-CRP and five patients had minimal or lower level of hs-CRP on the time of admission. On follow-up for 7 days, 35 out of 45 who had elevated hs-C-CRP developed vascular complications such as left ventricular failure, cardiogenic shock, ventricular ectopy, atrio-ventricular block etc. A total of 5 patients who had a minimal or low level of hs-CRP at the time of admission didn't develop any kind of complication during their hospital stay. Conclusion: Higher the serum hs-CRP levels at the time of admission in patients with AMI greater the patients prone to develop a complication during their hospital stay.

Keywords: Acute myocardial infarction, high sensitivity-C-reactive protein, left ventricular failure, cardiogenic shock


How to cite this article:
Badiger RH, Dinesha V, Hosalli A, Ashwin SP. hs-C-reactive protein as an indicator for prognosis in acute myocardial infarction. J Sci Soc 2014;41:118-21

How to cite this URL:
Badiger RH, Dinesha V, Hosalli A, Ashwin SP. hs-C-reactive protein as an indicator for prognosis in acute myocardial infarction. J Sci Soc [serial online] 2014 [cited 2017 Sep 22];41:118-21. Available from: http://www.jscisociety.com/text.asp?2014/41/2/118/132859


  Introduction Top


Acute myocardial infarction (AMI) continues to be a major public health problem in the industrialized and developing countries like India, despite progressive research in diagnosis and management over the last three decades. [1] During the last decades, major improvements have been achieved in management of patients with AMI but despite these developments it remains a major event from clinical, psychological and social point of view. [1],[4],[5]

Myocardial infarction (MI) remain an important health problem and merits continued attention from basic and clinical researchers, epidemiologists and practising physicians as a large number of asymptomatic individuals are at serious risk of developing a first heart attack because of their genetic predisposition, smoking behavior, unhealthy dietary habits or physical inactivity. [2] Evidence is emerging that medical practice does not adequately implement preventive actions in asymptomatic high risk individuals and patients with established coronary disease and thus they remain at substantial risk (recurrent) of disease and death. [3],[5] About a one-third of patients with evolving MI die before they reach hospital to receive any effective treatment. The improved survival of acute coronary syndromes has resulted in a growing population of patients with the chronic conditions, which is amplified by the ageing of the general population.

It is becoming increasingly clear that inflammation is an important factor in AMI. Inherent to the inflammatory process is the occurrence of an acute phase response. This response is induced by pro-inflammatory cytokines, which are released from the inflamed tissue by inflammatory and parenchyma cells and stimulates the liver to synthesize a number of acute phase proteins. High sensitivity-C-reactive protein (hs-CRP) is the classical acute phase reactant, the serum level of which has long been known to increase in AMI. [2],[4],[5]

hs-CRP, the classic acute-phase protein, is not directly involved in the coagulation process but is an exquisitely sensitive objective marker of inflammation, tissue damage and infection. Its plasma half-life (19 h) is rapid, but identical under all conditions, in contrast to the coagulation proteins and virtually all other major acute-phase reactants, so the synthesis rate of hs-CRP is the sole determinant of its plasma concentration. Excellent anti-CRP antibodies and a well-established World Health Organization (WHO) international reference standard for hs-CRP are available, so precise, sensitive and robust clinical serum/plasma assays can be readily undertaken. hs-CRP measurement thus has many advantages in the detection and monitoring of the acute-phase response in general and the relation to atheroma and its complications in particular.

To confirm the reported association between hs-CRP levels and coronary heart disease risk in large, unselected populations, serum hs-CRP was measured in 936 initially healthy men (age, 45-64 years) drawn from a random sample of the general population who took part in the first MONICA (monitoring trends and determinants in cardiovascular disease) Augsburg survey in 1984-1985. On the basis of an 8-year follow-up, study reported the prognostic significance of hs-CRP values for the occurrence of a first major coronary event in these men.

In clinical studies, circulating levels of hs-CRP were found to correlate with total infarct size in AMI and with prognosis. Thus, hs-CRP is an indicator of underlying coronary inflammation as well as the extent of myocardial necrosis.

In view of the above context, the present study was done to know the serum concentration of hs-CRP in patients of AMI at the time of admission and to study their subsequent in-hospital morbidity and mortality.


  Materials and methods Top


A total of 50 patients with diagnosis of AMI admitted to intensive coronary care unit of KLE Hospital, Belgaum during the period of October 2010 to September 2011 were studied. The study was approved by Institutional Ethics Committee, KLE Hospital, Belgaum. A written informed consent was obtained from all the patients. The data was recorded on pre-designed and pretested proforma. Patients with diagnosis of AMI based on WHO definition with any two of criteria namely typical ischemic chest pain, raised cardiac enzymes, typical electrocardiography (ECG) findings including development of pathological Q waves were included in the study and patients with non-cardiac chest pain, stable and unstable angina, acute infectious disease, known or suspected neoplastic disease, recent (less than 3 months) major trauma or surgery, burns, immuno-suppressive drug therapy, immunological disorders, osteoarthritis, rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis were excluded from the study.

All the patients underwent clinical examination and detailed history. Laboratory investigations such as routine blood investigations, ECG, echocardiography was done. Patients were followed-up for 7 days in the hospital and observed for complications such as LVF (Left ventricular failure), cardiogenic shock, arrhythmias. hs-C-reactive protein test was done.


  Results Top


Of the 50 patients, 39 (78%) were males and 11 (22%) were females. Maximum patients (34%) were aged between 41 and 50 years followed by 61-70 years (28%), 51-60 years (22%) and 31-40 years (16%). The youngest patients had 35 years of age and oldest was 68 years. Thirty six patients (72%) belonged to the Hindu community and remaining (28%) were Muslims. Almost one-third (70%) consumed mixed diet and remaining (30%) were vegetarians.

Most of the patients (94%) had symptoms of chest pain followed by sweating (66%), vomiting (40%), breathlessness (34%) and giddiness (12%). Smoking was recorded in 74% as a risk factor, whereas hypertension and diabetes mellitus was 40% and 20% respectively. Family history of ischemic heart disease (IHD) was noted in 10% of patients. With regard to the types of AMI 46% had extensive anterior wall, 28% had inferior, 9% had anteroseptal and 8% had anterolateral.

Mean hs-CRP levels at admission 3.706 ± 2.168 mg/dL, whereas on day seven it was 1.311 ± 0.35 mg/dL. In all the 35 patients with complications hs-CRP levels more than 0.6 mg/dL, whereas in patients without having any complication 10 had >0.6 mg/dL and 5 had <0.6 mg/dL. On admission, the mean hs-CRP levels in patients with complications were 4.114 ± 2.29 mg/dL, whereas among those without complication the hs-CRP levels were 2.28 ± 0.379 mg/dL.

The investigations showed raised leukocyte count (>11000/mm) in 56% patients. With regard to the lipid profile, 32% of patients had elevated cholesterol (>250 mg/dL) levels, 6% had elevated triglycerides (>170 mg/dL), 50% had very low high-density lipoprotein (HDL) (<35 mg/dL) and 20% had borderline HDL (between 40 and 50 mg/dL). Random blood sugar findings revealed 20% had diabetes mellitus and it was high.


  Discussion Top


Out of 50 patients taken in this study 78% were males and 22% were females. The current view to explain the lower incidence in females is that the females are protected by the sex hormones (estrogen) and also by the relatively lower rates of exposure to certain risk factors like smoking.

In the study group mean age of occurrence of AMI was 52.2 years. In Indian sub-continent, the CAD is said to peak between 50 and 60 years. As mentioned by Park et al. this is about a decade earlier compared to the Western developed countries. The sex distribution in the study group was 78% of patients were male and 22% were female. This was similar to that described in Stamler et al.

The mean age of the female patients was 62.63 years and that of male was 49.28 years. As mentioned by Park et al. they found that female patients present a decade later than male patients of AMI. In our study, also we found the difference more than a decade.

In this study, 72% belonged to the Hindu community and remaining (28%) were Muslims. Here, it may be argued that the apparent higher incidents among Hindus is not a factual one but reflects the difference in the population. Almost one-third (70%) consumed mixed diet and remaining (30%) were vegetarians. Non-vegetarians run a higher risk of AMI owing to higher content of cholesterol in their diet. The vegetarian who consume a large quantity of saturated food, such as ghee, coconut oil are prone for obesity which is also a risk factor for IHD.

The classical symptoms of AMI were found in 94% of patients in our study group. This was similarly described by Huggins et al. The onset of AMI was more in the morning hours. Muller et al. also described the circadian variation in the frequency on the onset of AMI.

In this study, smoking was present in 74% patients, whereas in MMWR, USA described the prevalence of smoking in US to be approximately 25%, smoking accounts for approximately 20% of all deaths of cardiovascular diseases in US. Hypertension was present in 40% patients. National Health and Nutritional Examination Survey documented prevalence of hypertension in adult Americans at 24%. Diabetes mellitus was present in 20% of patients. The relation between diabetes and cardiovascular disease is not uniform in all populations. WHO multinational injury of vascular disease in diabetes has shown the incidence of diabetes in atherosclerotic arterial disease from 32% to 67%. Barrett Conor LE described the relative risk of diabetes mellitus in cases of coronary artery disease.

Erythrocyte sedimentation rate (ESR) is a marker of acute inflammation. It is raised in AMI. Kushneri et al. described the acute phase proteins and other systemic responses to inflammation including the rise in ESR. In this study, ESR was found to be raised in 54% patients. This was described earlier by Hershberg et al.

Total leukocyte count was raised in about 56% patients. This was accompanied by a predominance of neutrophils. Thompson et al. found and described the increase in total leukocyte and differential leukocyte count. The peak white blood cell count usually ranges between 12 and 15 × 10 3 /mm 3 but can increase up to 20 × 10 3 /mm 3 .

With regard to lipid profile 32% had elevated cholesterol, 6% had elevated triglycerides, 42% had elevated low-density lipoprotein and 70% had lower HDL. These findings were comparable to the study carried by Goldstein et al.

The markers of acute inflammation ESR and hs-CRP were raised in the study group. hs-CRP was more than 0.6 mg/dL in 90% and ESR was found to be raised in 54% patients. Pietila et al. found elevations of markers of acute inflammation in patients with AMI. We have studied 50 patients within 50 h of onset of chest pain. Among them, 90% had raised hs-CRP (>0.6 mg/dL) and on 7 th day in most of patients in whom hs-CRP was elevated was coming to normal. Among 45 patients who had raised hs-CRP on admission 35 (70%) developed complications. Out of these two patients (4%) succumbed to death.

When compared to other studies, present study also found similar results indicating that higher serum hs-CRP levels on admission in patients with AMI are prone for developing complications during their hospital stay. Zairis et al. studied serum hs-CRP levels on admission in 319 patients of AMI and concluded that these levels predict reperfusion failure and short and long-term prognosis after ST elevation in AMI. Mishra et al. studied 50 cases of AMI and observed that serum hs-CRP concentration on admission was significant prognostic indicator of their in hospital stay. Tomoda et al. measured hs-CRP levels in 234 patients of AMI and suggested that these levels reflect vulnerability of culprit coronary lesion and predicted adverse coronary events after primary PTCA (percutaneous trans-coronary angioplasty) or stenting. Gheno et al. studied serum hs-CRP levels in 205 old women of AMI and observed that hs-CRP levels were raised in many patients and independently stratified patients with in hospital mortality risk. Ueda et al. studied nine patients of AMI with cardiac rupture and 28 patients of AMI without cardiac rupture retrospectively and concluded that patients with persistently high hs-CRP levels had a high probability of sub-acute cardiac rupture.

Frits Haverkate et al. measured hs-CRP in 2121 outpatients with angina and followed them up to 2 years. They found that raised circulating concentrations of hs-CRP are predictors of coronary events in patients with stable or unstable angina. The results of the present study were similar to this study.

Volgari et al. measured hs-CRP in 17 patients with MI and were elevated in all patients. A raised serum hs-CRP levels was found on admission in four patients before a rise in creatinine kinase MB isoenzyme. They found that serial monitoring of serum hs-CRP in parallel with cardiac proteins of short and long half-life provides information for diagnosis and for detecting post infarct complications.

Pietila et al. measured hs-CRP in 23 patients with AMI. They found that in 14 patients who did not receive thrombolytic treatment there was a linear relation between infarct size and hs-CRP response. Therefore, they concluded that daily measurement of serum hs-CRP is useful in evaluating infarct size in patients with AMI, who do not receive thrombolytic therapy.

In patients treated with streptokinase, hs-CRP concentrations may be used to assess the success of thrombolysis. In our study also we found raised hs-CRP levels on admission coming to normal on 7 th day in patients treated with streptokinase.


  Conclusion Top


The raised hs-CRP level in the majority of patients with AMI suggests involvement of inflammation in the etiopathogenesis of MI and has prognostic utility in AMI. Serum hs-CRP levels are potent predictors of prognosis in patients with AMI and elevated levels of hs-CRP at the time of admission indicates a poor prognosis in patients with AMI. Hence the present study concluded that, higher the serum hs-CRP levels on admission in patients of AMI the more the patient is prone for developing complications during their hospital stay.

 
  References Top

1.Kushner I, Feldmann G. Control of the acute phase response. Demonstration of C-reactive protein synthesis and secretion by hepatocytes during acute inflammation in the rabbit. J Exp Med 1978;148:466-77.  Back to cited text no. 1
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2.Merriman CR, Pulliam LA, Kampschmidt RF. Effect of leukocytic endogenous mediator on C-reactive protein in rabbits. Proc Soc Exp Biol Med 1975;149:782-4.  Back to cited text no. 2
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3.Osmand AP, Friedenson B, Gewurz H, Painter RH, Hofmann T, Shelton E. Characterization of C-reactive protein and the complement subcomponent C1t as homologous proteins displaying cyclic pentameric symmetry (pentraxins). Proc Natl Acad Sci U S A 1977;74:739-43.  Back to cited text no. 3
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4.Oliveira EB, Gotschlich C, Liu TY. Primary structure of human C-reactive protein. J Biol Chem 1979;254:489-502.  Back to cited text no. 4
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5.Oliveira EB, Gotschlich EC, Liu TY. Comparative studies on the binding properties of human and rabbit C-reactive proteins. J Immunol 1980;124:1396-402.  Back to cited text no. 5
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Abstract
Introduction
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