S100A4-neutralizing monoclonal antibody 6B12 counteracts the established experimental skin fibrosis induced by bleomycin.

OBJECTIVES: Our previous studies have demonstrated that the Damage Associated Molecular Pattern (DAMP) protein, S100A4, is overexpressed in the involved skin and peripheral blood of patients with SSc. It is associated with skin and lung involvement, and disease activity. By contrast, lack of S100A4 prevented the development of experimental dermal fibrosis. Herein we aimed to evaluate the effect of murine anti-S100A4 mAb 6B12 in the treatment of preestablished experimental dermal fibrosis. METHODS: The effects of 6B12 were assessed at therapeutic dosages in a modified bleomycin-induced dermal fibrosis mouse model by evaluating fibrotic (dermal thickness, proliferation of myofibroblasts, hydroxyproline content, phosphorylated Smad3-positive cell count) and inflammatory (leukocytes infiltrating the lesional skin, systemic levels of selected cytokines and chemokines) outcomes, and transcriptional profiling (RNA sequencing). RESULTS: Treatment with 7.5 mg/kg 6B12 attenuated and might even reduce pre-existing dermal fibrosis induced by bleomycin as evidenced by reduction in dermal thickness, myofibroblast count and collagen content. These antifibrotic effects were mediated by the downregulation of TGF-ß/Smad signalling and partially by reducing the number of leukocytes infiltrating the lesional skin and decrease in the systemic levels of IL-1α, eotaxin, CCL2 and CCL5. Moreover, transcriptional profiling demonstrated that 7.5 mg/kg 6B12 also modulated several profibrotic and proinflammatory processes relevant to the pathogenesis of SSc. CONCLUSION: Targeting S100A4 by the 6B12 mAb demonstrated potent antifibrotic and anti-inflammatory effects on bleomycin-induced dermal fibrosis and provided further evidence for the vital role of S100A4 in the pathophysiology of SSc.

Effect of Anti-S100A4 Monoclonal Antibody Treatment on Experimental Skin Fibrosis and Systemic Sclerosis-Specific Transcriptional Signatures in Human Skin.

OBJECTIVE: S100A4 is a DAMP protein. S100A4 is overexpressed in patients with systemic sclerosis (SSc), and levels correlate with organ involvement and disease activity. S100A4-/- mice are protected from fibrosis. The aim of this study was to assess the antifibrotic effects of anti-S100A4 monoclonal antibody (mAb) in murine models of SSc and in precision cut skin slices of patients with SSc. METHODS: The effects of anti-S100A4 mAbs were evaluated in a bleomycin-induced skin fibrosis model and in Tsk-1 mice with a therapeutic dosing regimen. In addition, the effects of anti-S100A4 mAbs on precision cut SSc skin slices were analyzed by RNA sequencing. RESULTS: Inhibition of S100A4 was effective in the treatment of pre-established bleomycin-induced skin fibrosis and in regression of pre-established fibrosis with reduced dermal thickening, myofibroblast counts, and collagen accumulation. Transcriptional profiling demonstrated targeting of multiple profibrotic and proinflammatory processes relevant to the pathogenesis of SSc on targeted S100A4 inhibition in a bleomycin-induced skin fibrosis model. Moreover, targeted S100A4 inhibition also modulated inflammation- and fibrosis-relevant gene sets in precision cut SSc skin slices in an ex vivo trial approach. Selected downstream targets of S100A4, such as AMP-activated protein kinase, calsequestrin-1, and phosphorylated STAT3, were validated on the protein level, and STAT3 inhibition was shown to prevent the profibrotic effects of S100A4 on fibroblasts in human skin. CONCLUSION: Inhibition of S100A4 confers dual targeting of inflammatory and fibrotic pathways in complementary mouse models of fibrosis and in SSc skin. These effects support the further development of anti-S100A4 mAbs as disease-modifying targeted therapies for SSc.

Clinical and pathogenic significance of S100A4 overexpression in systemic sclerosis.

OBJECTIVES: We have studied the damage-associated molecular pattern protein S100A4 as a driver of fibroblast activation in systemic sclerosis (SSc). METHODS: S100A4 protein concentration was measured by ELISA in serum of SSc (n=94) and healthy controls (n=15). Protein expression in skin fibroblast cultures from diffuse cutaneous SSc (SScF, n=6) and healthy controls (normal fibroblasts (NF), n=6) was assessed. Recombinant S100A4 and a high affinity anti-S100A4 neutralising monoclonal antibody (AX-202) were tested on SScF and NF. RESULTS: Median (range) S100A4 (ng/mL) was higher in serum of SSc (89.9 (15.0-240.0)) than healthy controls (71.4 (7.9-131.8); p=0.027). There was association with SSc-interstitial lung disease (p=0.025, n=55), scleroderma renal crisis (p=0.026, n=4). Median (range) S100A4 (ng/mL) was higher in culture supernatants of SScF (4.19 (0.52-8.42)) than NF controls (0.28 (0.02-3.29); p<0.0001). AX-202 reduced the constitutive profibrotic gene and protein expression phenotype of SScF. Genome-wide RNA sequencing analysis identified an S100A4 activated signature in NF overlapping the hallmark gene expression signature of SScF. Thus, 464 differentially expressed genes (false discovery rate (FDR) <0.001 and fold change (FC) >1.5) induced in NF by S100A4 were also constitutively overexpressed, and downregulated by AX-202, in SScF. Pathway mapping of these S100A4 dependent genes in SSc showed the most significant enriched Kegg pathways (FDR <0.001) were regulation of stem cell pluripotency (4.6-fold) and metabolic pathways (1.9-fold). CONCLUSION: Our findings provide compelling evidence for a profibrotic role for S100A4 in SSc and suggest that serum level may be a biomarker of major organ manifestations and disease severity. This study supports examining the therapeutic potential of targeting S100A4 in SSc.

Adherence and persistence to pharmacotherapy in patients with heart failure: a nationwide cohort study, 2014-2020.

AIMS: We aimed to study initiation, adherence, and long-term persistence to beta-blockers (BB), renin-angiotensin system inhibitors (RASi), and mineralocorticoid receptor antagonists (MRA) in a nationwide cohort of patients with heart failure (HF). METHODS: Patients aged 18-80 years in Norway with a first diagnosis of HF from 2014 until 2020 that survived ≥30 days were identified from the Norwegian Patient Registry and linked to the Norwegian Prescription Database. We collected information about BB, RASi [angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and angiotensin receptor-neprilysin inhibitors (ARNI)], and MRA. Dual HF therapy was defined as taking at least two out of three drug classes, whereas triple HF therapy was defined as taking all three. Initiation (time to initiation) and persistence (time to discontinuation using a grace period of 30 days) of HF drugs was calculated by the Kaplan-Meier method, followed to outcome of interest, death, or December 2020. One-year adherence was measured as proportion of days covered (PDC) using a cut-off at 80%. For adherence and persistence measurements, we allowed for maximum 60 days of stockpiling and switching within drug groups. We performed sensitivity analyses to test the robustness of our findings. RESULTS: Out of 54 899 patients included in the cohort, 75%, 69%, and 21% initiated a BB, RASi, and MRA, respectively, whereas 13% did not receive any. Dual and triple HF therapy was prescribed to 61% and 16%, respectively. The proportion of adherent patients during the first year following initiation was 83%, 81%, 84%, and 61% for BB, RASi, ARNI, and MRA, whereas 42% and 5% were adherent to dual and triple HF therapy, respectively. From 2 to 5 years following initiation, persistence decreased from 58% to 38%, 57% to 37%, and 31% to 15% for BB, RASi, and MRA, respectively. Within the RASi group, persistence was higher for ARNI than for ACEI and ARB. There were no major changes in either initiation or adherence of the drug classes from 2014 to 2019, except for an increase in initiation and adherence of MRA. CONCLUSIONS: We found low adherence to dual and triple HF therapies in this nationwide cohort study of newly diagnosed HF patients. Efforts are needed to increase adherence and persistence to HF therapies into clinical practice, emphasizing maintenance of multiple drug therapies in patients with such an indication.

A nationwide registry study on heart failure in Norway from 2008 to 2018: variations in lookback period affect incidence estimates.

BACKGROUND: The incidence of heart failure (HF) has declined in Europe during the past two decades. However, incidence estimates from registry-based studies may vary, partly because they depend on retrospective searches to exclude previous events. The aim of this study was to assess to what extent different lookback periods (LPs) affect temporal trends in incidence, and to identify the minimal acceptable LP. Further, we wanted to estimate temporal trends in incidence and prevalence of HF in a nationwide population, using the minimal acceptable LP. METHODS: We identified all in- and out-patient contacts for HF in Norway during 2008 to 2018 from the Norwegian Patient Registry. To calculate the influence of varying LP on incident cases, we defined 2018 with 10 years of LP as a reference and calculated the relative difference by using one through 9 years of lookback. Temporal trends in incidence rates were estimated with sensitivity analyses applying varying LPs and different case definitions. Standardised incidence rates and prevalence were calculated by applying direct age- and sex-standardization to the 2013 European Standard Population. RESULTS: The overestimation of incident cases declined with increasing number of years included in the LP. Compared to a 10-year LP, application of 4, 6, and 8 years resulted in an overestimation of incident cases by 13.5%, 6.2% and 2.3%, respectively. Temporal trends in incidence were affected by the number of years in the LP and whether the LP was fixed or varied. Including all available data mislead to conclusions of declining incidence rates over time due to increasing LPs. CONCLUSIONS: When taking the number of years with available data and HF mortality and morbidity into consideration, we propose that 6 years of fixed lookback is sufficient for identification of incident HF cases. HF incidence rates and prevalence increased from 2014 to 2018. TRIAL REGISTRATION: Retrospectively registered.

Incidence, prevalence, and mortality of heart failure: a nationwide registry study from 2013 to 2016.

AIMS: Large-scaled population studies of incidence and prevalence of heart failure (HF) are needed for the development of healthcare policies and priorities. The aim of this study was to estimate the incidence, prevalence, and all-cause mortality of HF in Norway from 2013 to 2016 on the basis of a national registry. METHODS AND RESULTS: Using data from the nationwide Norwegian Prescription Database, we identified all patients ≥18 years of age in Norway with at least one drug prescription with HF during 2013-2016, defined by 10th revision of the International Classification of Diseases (ICD-10) codes I50, I11, I13, or I42. The individual index date was the date of the first prescription. Patients were followed up until death or end of follow-up (31 October 2017). Annual incidence and prevalence were estimated from 2013 to 2016, using a look-back period starting from 1 March 2008. We calculated standardized estimates by applying direct age and sex standardization to the 2013 European standard population. All-cause mortality from 2013 to 2016 was calculated among the prevalent HF patients. Standardized mortality ratio (SMR) was calculated by indirect standardization using general mortality in the Norwegian population as reference. We identified 54 542 unique patients (58% men) with a first-time diagnosis of HF. The median age was 72 ±14 years, and women were older than men (median age 76 vs. 70 years, respectively). The crude (standardized) incidence of HF was 3.44/1000 (4.23/1000) person-years in 2016 and did not increase over the 4 year period, while the prevalence increased from 2.0% (2.3%) to 2.4% (2.8%). Both incidence and prevalence were higher in men than in women and strongly associated with age. Crude mortality rates in the HF population declined from 94 to 82/1000 person-years from 2013 to 2016, and SMR declined from 2.01 to 1.84. Age-adjusted mortality rates were higher in men than in women. CONCLUSIONS: This nationwide registry study in Norway showed an increase in the prevalence of HF from 2013 to 2016, with stable incidence rates and improved survival.

Efficacy and safety of serelaxin when added to standard of care in patients with acute heart failure: results from a PROBE study, RELAX-AHF-EU.

AIM: Serelaxin is a recombinant human relaxin-2 hormone, which confers receptor-mediated vasodilatation in a tissue-specific fashion. The RELAX-AHF-EU study assessed the effect of serelaxin when added to standard-of-care (SoC) therapy on worsening heart failure (WHF)/all-cause death through Day 5 in patients hospitalised for acute heart failure (AHF) in Europe. METHODS AND RESULTS: This multicentre, prospective, randomised, open-label, blinded-endpoint validation study enrolled hospitalised AHF patients and randomised (2:1) eligible patients (mild-to-moderate renal impairment and systolic blood pressure ≥ 125 mmHg) within 16 h of presentation with signs/symptoms of AHF, to receive 48 h intravenous infusion of 30 µg/kg/day serelaxin + SoC or SoC alone. The primary endpoint was adjudicated WHF/all-cause death through Day 5. Of 3183 patients targeted, 2666 were randomised when the study was terminated early by the sponsor due to the neutral results of the pivotal RELAX-AHF-2 study. Adjudicated WHF/all-cause death through Day 5 was significantly reduced in the serelaxin + SoC vs. SoC group (5.0% vs. 6.9%; hazard ratio 0.71; 95% confidence interval 0.51-0.98; P = 0.0172) (absolute risk reduction 1.9%, number needed to treat 53). The difference between treatment groups was not significant for WHF/all-cause death/heart failure rehospitalisation through Day 14 and length of hospital stay. A significantly smaller proportion of patients in the serelaxin + SoC vs. SoC group experienced persistent heart failure signs/symptoms at each visit until Day 4, or renal deterioration through Day 5 (all P ≤ 0.01). Overall incidence of treatment-emergent adverse events was comparable between treatment groups. Hypotension and decrease in haemoglobin/haematocrit were more frequent in the serelaxin + SoC group. CONCLUSION: When added to SoC, serelaxin reduced adjudicated WHF or all-cause death through Day 5 in AHF patients. The results from this open-label study should be considered in the context of the totality of the double-blind, randomised evidence on serelaxin in AHF.

Development of triglyceride-lowering drugs to address residual cardiovascular risk: strategic and clinical considerations.

The prevalence of hypertriglyceridaemia is high and growing in several parts of the world. Hypertriglyceridaemia has a well-defined association with the risk of atherosclerotic cardiovascular (CV) disease and triglycerides represent a potential target for drugs aimed at mitigating CV risk. So far, no triglyceride-lowering pharmacological strategy has succeeded in conclusively showing the ability to modify clinical outcomes. This article discusses strategic and clinical aspects of development of triglyceride-lowering drugs to address CV disease.

Icosabutate, a Structurally Engineered Fatty Acid, Improves the Cardiovascular Risk Profile in Statin-Treated Patients with Residual Hypertriglyceridemia.

OBJECTIVES: To evaluate the efficacy and safety of icosabutate, an oral, once-daily, first-in-class medication, in reducing non-high-density lipoprotein cholesterol (non-HDL-C) in patients with persistent hypertriglyceridemia despite statin therapy. METHODS: The study was designed to randomly assign 140 patients with fasting triglyceride levels ≥200 but <500 mg/dl on a stable dose of statin therapy to receive either masked icosabutate 600 mg once daily or a control for 12 weeks. The primary end point was a percentage change in non-HDL-C from baseline to 12 weeks. RESULTS: With icosabutate, non-HDL-C levels were reduced (-9.2%) when compared with the control (-0.4%) for a between-group difference of -7.4% (p = 0.02). Compared with the control, icosabutate reduced triglycerides (-27.0%, p < 0.001), very- low-density lipoprotein (VLDL) cholesterol (-31.5%, p < 0.001) and apolipoprotein C-III (-22.5%, p < 0.001). LDL-C levels did not change (0.5%, p = 0.87). HDL-C (10.2%, p < 0.001) was increased. After 113 subjects had been randomized, the study was terminated due to a partial clinical hold imposed by US regulators after observing QT prolongation at supratherapeutic doses of icosabutate in a dog study. In this study, adverse events were balanced between treatment arms, and there were no discontinuations due to adverse events. CONCLUSIONS: Icosabutate was efficacious in lowering non-HDL-C and other biomarkers of cardiovascular risk and was generally well tolerated.

Icosabutate for the treatment of very high triglycerides: A placebo-controlled, randomized, double-blind, 12-week clinical trial.

BACKGROUND: Icosabutate is a structurally enhanced omega-3 fatty acid molecule developed with the aim of achieving improved triglyceride (TG)-lowering efficacy, increased potency, and preserved safety compared with conventional prescription omega-3 fatty acid. OBJECTIVE: To evaluate the efficacy and safety of icosabutate 600 mg once daily in patients with very high TGs. METHODS: After a 6-8 week run-in period, men and women with TG levels ≥ 500 mg/dL and ≤ 1500 mg/dL were randomized to double-blind treatment with placebo or icosabutate 600 mg for 12 weeks. The primary end point was % change from baseline in TGs at 12 weeks. RESULTS: A total of 87 subjects were randomized. At baseline, median TG (interquartile range) levels were 611 (543-878) and 688 (596-892) mg/dL, and the median change after 12 weeks of treatment was -51% and -17%, respectively, for a placebo-corrected change of -33% (P < .001). Adjusted for placebo, icosabutate significantly reduced very low-density lipoprotein cholesterol (-36%, P < .001), remnant lipoprotein cholesterol (-34%, P < .001), apolipoprotein (Apo) C-III (-35%, P < .001), trended toward reduced non-high-density lipoprotein cholesterol (-7%, P = .064); significantly increased high-density lipoprotein cholesterol (18%, P < .001) and low-density lipoprotein cholesterol (28%, P < .001), with a trend of an increased lipoprotein (a; 10%, P = .054). No changes were observed in total cholesterol, apolipoprotein B, or apolipoprotein A1. Fasting plasma glucose was unchanged, whereas fasting plasma insulin was reduced (P = .001) with icosabutate. Icosabutate was generally well tolerated. CONCLUSION: Treatment with icosabutate once daily significantly reduced TG, very low-density lipoprotein cholesterol, and Apo C-III levels in patients with very high TG levels. This trial was registered at www.clinicaltrials.gov as NCT01893515.

Cardiac troponin I for prediction of clinical outcomes and cardiac function through 3-month follow-up after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

BACKGROUND: Circulating levels of cardiac troponin I (cTnI) after ST-segment elevation myocardial infarction (STEMI) are associated with infarct size and chronic left ventricular dysfunction, but the relation to clinical end points and biochemical measures of global cardiac function remains less well defined. METHODS: One thousand sixty-six patients receiving primary percutaneous coronary intervention (PCI) in the PROTECTION AMI trial were studied in a post hoc analysis. Cardiac troponin I was measured at several time points during the index hospitalization, and patients were followed up for 3 months before reassessment including N-terminal pro-B-type natriuretic peptide (NT-proBNP) and left ventricular ejection fraction (LVEF) measurements. RESULTS: The median (quartile 1-3) cTnI levels were 0.4 (0.1-0.4) µg/L at admission, 33.1 (12.8-72.1) µg/L after 16 to 24 hours, and 9.1 (3.9-17.5) µg/L after 70 to 80 hours. In adjusted models, all post-PCI single points, peak, and area under curve were found to be independently associated with clinical events, NT-proBNP >118 pmol/L, or LVEF <40% (P for all <.001). When cTnI was added to a baseline risk model for prediction of clinical events, the C statistic improved from 0.779 to 0.846 (16-24 hours) and 0.859 (70-80 hours). Quantified by integrated discrimination improvement, the addition of cTnI significantly augmented prediction ability (relative integrated discrimination improvement 44%-154%; P for all ≤.001). Consistent improvements in discrimination of NT-proBNP >118 pmol/L and LVEF <40% were observed. CONCLUSIONS: Cardiac troponin I measured after primary PCI for STEMI is independently associated with clinical outcomes and cardiac function through 3-month follow-up. These results suggest that cTnI levels are a useful risk stratification tool in STEMI patients.

Myeloid-related protein-8/14 and C-reactive protein in individuals evaluated for obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) and obesity are often present concomitantly. Their potential contribution to inflammation remains an ongoing debate. The objectives of this study were to investigate whether variables of sleep-disordered breathing are associated with levels of myeloid-related protein-8/14 (MRP-8/14) or C-reactive protein (CRP), and to characterize how adiposity interacts with these associations in individuals evaluated for possible OSA. METHODS: Consecutive individuals referred to Lovisenberg Diakonale Hospital's sleep laboratory between 1st October 2009 and 1st March 2010 were included. We characterized the biomarker distribution sampled the morning after sleep and related these to clinical characteristics and variables recorded during polygraphy or polysomnography. RESULTS: Of the total study population of 222 individuals, 161 (72.5%) were diagnosed with OSA (apnea-hypopnea index (AHI) > or = 5/h). In baseline models (multiple median regression adjusted for age and sex), AHI was independently associated with MRP-8/14 (P=0.025) and CRP (P<0.001). The associations were attenuated after the addition of body mass index (BMI), but remained statistically significant for CRP (P=0.025). However, in final models adjusted for additional factors (systolic blood pressure, cholesterol:high-density lipoprotein ratio, glycosylated haemoglobin, smoking, and cardiovascular disease), only average oxygen saturation for MRP-8/14 (P=0.028) and oxygen desaturation index (ODI) for CRP (P=0.037) remained independent predictors of inflammation, whereas AHI lost its predictive value (MRP-8/14; P=0.30 and CRP; P=0.092). The association between several variables of sleep-disordered breathing and inflammation were stronger in individuals with a higher BMI (P for interaction <0.05 for AHI, nadir oxygen saturation, and time <90% oxygen saturation). CONCLUSIONS: No definitive indication of independent immunological activity resulting from apneas and hypopneas was found in final models adjusted for other factors associated with inflammation, whereas average oxygen saturation for MRP-8/14 and ODI for CRP remained statistically significant predictors. Interactions were observed between BMI and several variables of sleep-disordered breathing on MRP-8/14 and CRP levels.

Obstructive sleep apnea: no independent association to troponins.

BACKGROUND: Cardiac troponins (cTn) are to date the most sensitive and specific biochemical markers of myocardial injury. Abnormal breathing patterns in patients with obstructive sleep apnea (OSA) may cause myocardial cell stress detectable by novel cTn assays. The objectives of this study were to investigate whether a new single-molecule cTnI (S-cTnI) assay and a commercially available high-sensitivity cTnT (hs-cTnT) assay would detect myocyte injury in individuals evaluated for possible OSA, and to explore their relation to variables of disordered breathing during sleep. METHODS: Consecutive individuals referred to Lovisenberg Diakonale Hospital's sleep laboratory between 1 October 2009 and 1 March 2010 were included. We measured cTn in specimens collected the morning after sleep and studied these in relation to variables recorded during polygraphy or polysomnography. RESULTS: All 222 (100 %) individuals had measurable cTn levels using either assay. Stratified into categories according to the apnea-hypopnea index (AHI), patients with OSA (AHI ≥5) had a different distribution of S-cTnI (P = 0.036) and hs-cTnT (P = 0.002) compared to those without (AHI <5). The median (quartiles 1-3) were 3.0 (1.9-6.0) versus 2.3 (1.6-3.8) ng/l for S-cTnI, and 7.0 (5.5-8.7) versus 6.2 (4.9-7.2) ng/l for hs-cTnT. However, in multiple median regression analyses adjusted for conventional predictors, neither S-cTnI (P = 0.57) nor hs-cTnT (P = 0.80) were significantly associated with AHI. CONCLUSIONS: This study reveals no association independent of conventional predictors between OSA and myocardial cell injury measured by S-cTnI and hs-cTnT assays. Our findings support a search for novel biomarkers for prognostication of OSA.

Effects of FX06 in vitro on platelet, coagulation, and fibrinolytic biomarkers in volunteers and patients with documented coronary artery disease.

FX06 is a naturally occurring fibrin-derived peptide demonstrated to confer cytoprotection in the setting of primary percutaneous coronary intervention. Because the effect of FX06 on human platelet, coagulation, and fibrinolysis biomarkers (PCFB) is unknown but is important for further clinical development, we evaluated how FX06 affects PCFB. The in vitro effects of the whole-blood pre-incubation with escalating concentrations of FX06 (4, 25, and 75 µg/mL) were assessed in aspirin-naïve healthy volunteers (n = 10), those with multiple risk factors for vascular disease (n = 10), and patients with documented coronary artery disease (n = 10). The last two groups were treated with aspirin (81 mg/daily). Thirty-two variables of PCFB were measured with the vehicle and for each chosen FX06 dose. Pretreatment of blood samples with FX06 resulted in a moderate but significant and mostly dose-dependent increases of platelet aggregation induced by adenosine diphosphate and collagen. Similarly, the closure time was reduced, suggesting share-induced activation, PECAM-1, GP Ib, GP IIb/IIIa activity, and vitronectin receptors, which were also up-regulated. In contrast, P-selectin and GPIIb antigen expression were reduced after FX06. All other PCFB were predominantly unaffected by FX06, with the exception of the increased plasminogen, decreased protein C activity, and activated von Willebrand factor. We conclude that in the therapeutic range, FX06 in vitro mildly affects hemostasis by way of mostly activating platelets. Applying moderate concomitant antiplatelet strategies should be considered for the adequate protection from vascular thrombotic events in patients treated with FX06. Similar ex vivo study in patients receiving aspirin and clopidogrel is warranted.

Matrix metalloproteinases and the activity of their tissue inhibitors in patients with ST-elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) play a role in heart remodelling after acutemyocardial infarction (MI). Their activity is connected with outcome and heart failure development. There is little data on MMP and TIMP activity changes in the setting of ST elevation MI (STEMI) treated with primary percutaneous coronary intervention (pPCI). AIM: To assess the dynamics of activity of MMP-2 and MMP-9 and their endogenous inhibitors TIMP-1 and TIMP-2 in the course of invasive treatment of STEMI. METHODS: The study included 95 patients (age 61.8 ± 12.4 years; 35 women) treated with pPCI with stent implantation due to 100% closure of the target vessel in a setting of STEMI. We measured the activity of MMP-2 and MMP-9 (by zymography,expressed with arbitrary units, AU), CK-MB (U/L), troponin I (ng/mL), TIMP-1, TIMP-2 (ng/mL) concentrations in a peripheral blood before the pPCI, immediately after and 3, 6, 12, 24 and 48 h after the procedure. Left ventricular ejection fraction(LVEF) was estimated at the hospital discharge using the Simpson method. There were two control groups: 15 healthy persons and 15 patients with stable coronary artery disease matched for age and sex with the studied group. RESULTS: The abrupt opening of the target vessel did not produce an early increase in the activity of the MMPs. Their activity was high at the beginning and slowly lowered with time after pPCI so that at 12, 24 and 48 h after pPCI their activity was significantly lower than before and immediately after the pPCI (p < 0.05 for all comparisons). The abrupt opening of the target vessel did not produce significant changes in the TIMP concentration. Only the TIMP-1 showed a slow increase in concentration and achieved a significantly higher level 48 h after the procedure compared to its concentration before and immediately after pPCI (p < 0.05). In 14 patients (15% of the studied group), the post procedure TIMI flow was estimated as lower than 3 (TIMI 1 or 2). There was significantly higher MMP-9 activity in this group before, immediately after and up to 3 h after PCI compared to the group with good angiographic effect (TIMI = 3 after procedure). Patients with lowered LVEF(< 50%) at hospital discharge had higher MMP-9 activity immediately after and 3 h after pPCI compared to patients with preserved LVEF. The same relation was observed for TIMP-2 level, where patients with a higher level before and immediately after pPCI had lowered LVEF at discharge. CONCLUSIONS: 1. The activity level of MMP-2 and MMP-9 is elevated during the STEMI acute phase and falls 12 h after successful pPCI, while TIMP-1 concentration only rises 48 h after the procedure. 2. The abrupt opening of the target vessel in STEMI does not produce acute changes in MMP-2, MMP-9 activity or TIMP-1 and TIMP-2 concentration. 3. The 'no-reflow'phenomenon in STEMI patients occurs more often in those with higher MMP-9 activity before pPCI. 4. Lowered LVEF at hospital discharge is observed in patients with higher periprocedural MMP-9 activity and TIMP-2 level.

Changes in diagnosing non-ST-segment elevation myocardial infarction after the introduction of a new high-sensitivity cardiac troponin T assay: a single-centre experience.

BACKGROUND: Cardiac troponins are the most sensitive and specific biochemical markers of myocardial injury and with the new high-sensitivity troponin methods very minor injuries of the heart muscle can be detected. The introduction of high-sensitivity assays has facilitated reference range adjustments and a revised cut-off point for myocardial infarction (MI) due to an improved performance in the lower concentration range. The objective of this study was to investigate whether implementing a high-sensitivity cardiac troponin T (hs-cTnT) assay with subsequent lowering of the cut-off point changed the hospital evaluation and diagnosis of acute non-ST-segment elevation myocardial infarction (NSTEMI) in a general hospital population. METHODS: NSTEMI patients admitted to our hospital during two periods each lasting one year were retrospectively compared. During period 1 (August 2007 - July 2008) patients were diagnosed with a conventional troponin T assay, and during period 2 (August 2009 - July 2010) patients were diagnosed using an hs-cTnT assay. RESULTS: A significant increase in the number of NSTEMI admissions was observed using the hs-cTnT assay (225 vs. 341, risk ratio 1.57, 95% confidence interval 1.33 to 1.85). The proportion of patients examined with acute coronary angiography was similar (25.8% vs. 23.8%). Due to the higher number of NSTEMI admissions the total number of angiographies was higher in period 2 (58 vs. 81, p < 0.05), and significantly more patients were examined without signs of coronary artery disease (CAD) (0% vs. 8.6%, p < 0.05). A smaller proportion diagnosed with the high-sensitivity assay had significant dynamic cTnT changes between the highest and lowest cTnT measurement during each admission (96.2% vs. 88.7%, p < 0.01). CONCLUSIONS: More patients were diagnosed with NSTEMI and underwent coronary angiography after introducing the hs-cTnT assay. At the same time there was an increase in the frequency of coronary angiograms without signs of CAD, and fewer had significant dynamic cTnT concentration changes.

Troponin for the estimation of infarct size: what have we learned?

In acute myocardial infarction (AMI), the extent of myocardial damage is closely linked to prognosis. Early determination of infarct size is therefore key to assessing the future risk of patients and instructive for optimization of therapeutic strategies. The cardiac troponins, by allowing the physician to track the extent of injury suffered by the myocardium, provide a window into the heart. This article addresses the relationship between the cardiac troponins and the infarct size in AMI. Taken together, the data suggest that the cardiac troponins provide very useful information in this respect and especially in patients with ST elevation myocardial infarction. More studies are needed to understand how cardiac troponin-estimated infarct size may be integrated with other prognostic assessments and employed systematically in risk stratification. Early data are promising and indicate that cardiac troponins could provide useful information for early risk assessment that is complementary to the determination of cardiac function and volumes.