Comparison between myeloperoxidase and high-sensitivity C-creative protein for predicting major adverse cardiovascular events in coronary heart disease patients
Original Article

Comparison between myeloperoxidase and high-sensitivity C-creative protein for predicting major adverse cardiovascular events in coronary heart disease patients

Yan Ma1, Yinzhong Yang2, Wenfang Huang2, Cheng Huang3, Jun Luo1, Duanliang Peng1, Chenggui Liu3

1East Branch, Sichuan Academy of Medical Sciences & Sichuan People’s Hospital, Chengdu 610101, China; 2Department of Clinical Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu 610072, China; 3Department of Clinical Laboratory, Chengdu Women’s and Children’s Central Hospital, Chongqing Medical University, Chengdu 610091, China

Contributions: (I) Conception and design: Y Ma, Y Yang, C Liu; (II) Administrative support: W Huang; (III) Provision of study materials or patients: Y Ma, W Huang, C Huang, J Luo, D Peng, C Liu; (IV) Collection and assembly of data: Y Ma, Y Yang, J Luo; (V) Data analysis and interpretation: C Huang, D Peng, C Liu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Chenggui Liu, MD. Department of Clinical Laboratory, Chengdu Women’s and Children’s Central Hospital, Chongqing Medical University, No. 1617 Ri Yue Avenue, Qingyang District, Chengdu 610091, China. Email: lablcg@126.com.

Background: High-sensitivity C-reactive protein (hs-CRP) has been considered to be an independent predictor of adverse cardiovascular events. Myeloperoxidase (MPO) also plays an important role in atherosclerosis initiation and development of cardiovascular disease. Our objective was to compare the values between MPO and hs-CRP for predicting major adverse cardiovascular events (MACEs) in patients with coronary heart disease (CHD).

Methods: A total of 201 patients with acute coronary syndrome (ACS) and 210 controls (non-ACS patients), whose variables of MPO, hs-CRP, metabolic parameters, anthropometrics and life style habits were analyzed with SPSS software. The incidences of MACEs were investigated during the 4-year period follow-up in 285 CHD patients.

Results: Patients with ACS had significantly higher concentrations of MPO and hs-CRP than patients with non-ACS (P<0.001). The areas under receiver operating characteristic (ROC) curve for diagnosing ACS were 0.888 [95% confidence interval (CI), 0.843–0.933] for MPO, and 0.862 (95% CI, 0.815–0.910) for hs-CRP, respectively. Compared to hs-CRP, MPO had more correlations strongly with ACS-related risk factors of TG, HDL-C and LDL-C in ACS patients (P<0.05). Prospective study demonstrated that the incidences of MACEs associated significantly with elevated MPO baseline concentration [yes vs. no, odds ratio (OR) 7.383, 95% CI, 4.095–13.309] and high hs-CRP baseline concentration (yes vs. no, OR 4.186, 95% CI, 2.469–7.097).

Conclusions: The present study has provided the valuable evidence that MPO has some advantages than hs-CRP for predicting MACEs. Elevated baseline MPO and hs-CRP concentrations are significantly associated with MACEs in CHD patients.

Keywords: Myeloperoxidase (MPO); high-sensitivity c-reactive protein (hs-CRP); inflammatory markers; acute coronary syndrome (ACS); coronary heart disease (CHD); major adverse cardiovascular events (MACEs)


Received: 04 August 2016; Accepted: 12 August 2016; Published: 05 September 2016.

doi: 10.21037/jrh.2016.08.08


Introduction

Acute coronary syndrome (ACS) whose clinical spectrum consists of acute myocardial infarction (AMI) and unstable angina pectoris (UAP) carries the greatest risk of death and severe complications to patients with coronary heart disease (CHD). Early warning of ACS is frequently a challenging task, while immediate risk stratification remains crucial for the prompt implementation of appropriate therapy in this setting. Researches have confirmed that inflammation has been implicated at all stages in the development of atherosclerotic disease, from the early lipid deposition to plaque rupture. Plaque rupture represents the most important changes that underlie the transformation of stable coronary lesions into clinically unstable ones causing the ACS. Atherosclerotic plaque in the recent activation of the inflammatory response can become unstable plaque, in which a large number of inflammatory cells including activated neutrophils, macrophages, lymphocytes and other inflammatory cells focused on the fibrous cap of the vulnerable plaque shoulder (1). The inflammatory process in the atherosclerotic artery may lead to increase the blood concentrations of inflammatory cytokines and other acute-phase reactants (2,3).

Clinical and epidemiological studies have revealed that high-sensitivity C-reactive protein (hs-CRP) as a marker of inflammation is a major cardiovascular risk factor as well as an independent risk factor for prediction of adverse cardiovascular events of CHD (4,5). In addition, current studies have shown that myeloperoxidase (MPO) secreted directly by activated polymorphonuclear neutrophils (PMNs) and macrophages which also play the important roles in atherosclerosis initiation and development of cardiovascular disease, that is a potential marker for diagnosing and predicting ACS (6-8). Our previous studies have demonstrated that elevated serum MPO activities are significantly associated with the prevalence of ACS in CHD patients (9). However, detail comparison between MPO and hs-CRP as inflammatory marker for early warning ACS had not been reported. Therefore, the present study was designed to compare the values between MPO and hs-CRP for early warning ACS and predicting major adverse cardiovascular events (MACEs) in CHD patients.


Methods

Study patients

A total number of 411 patients with chest pain symptom who were admitted to Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital from March 2010 to July 2010 were recruited. All enrolled patients had been checked by coronary angiography and were diagnosed to be 201 ACS (78 AMI and 123 UAP) and 210 non-ACS [84 stable angina pectoris (SAP) and 126 non-CHD] according to 2007 ACC/AHA guidelines, and 285 CHD patients were investigated the combined endpoints (recurrent angina, heart failure, AMI or re-myocardial infarction, death) during the 4-year (48±1.58 months) period follow-up (from March 2010 to May 2014). The presence of specific diseases was established by standardized diagnostic criteria combining the information obtained from self-reported history (among 86.6% patients presenting with chest pain), medical records, and clinical examination. The following diseases were excluded in this study: old myocardial infarction, acute and chronic infections, autoimmune disease, recent surgery, cancer, liver diseases, renal insufficiency, blood diseases, malnutrition, adrenocortical and thyroid dysfunction.

This study was carried out in accordance with the Helsinki Declaration and approved by the Regional Ethics Committee. All participating subjects were explained their participation rights and written informed consent was obtained, and were asked about alcohol intake situation (yes or no, it was defined as yes at least once a week and drinking over 45 degrees of alcohol more than 200 mL) and smoking habits (yes or no, non-smokers including never smoking and stop smoking more than one year). Blood pressure [systolic blood pressure (SBP) and diastolic blood pressure (DBP)], body weight and height were measured with standard techniques. Body mass index (BMI) was calculated as body weight (kg) divided by the square of height (m).

Materials

Instruments: Hitachi 7600 Automatic Biochemistry Analyzer (Hitachi High-Tech Instruments Co., Ltd., Japan) and Immage 800 Immunochemistry System (Beckman Coulter, Inc., USA).

Kit of MPO: reagent and calibrator (lot number: MPO 00110-2, Diazyme Laboratories, USA), the concentrations of calibrator were 129 and 688 ng/mL, respectively. Quality control materials (lot number: MPO 100110-2, Diazyme Laboratories, USA), the concentrations of MPO were 117±23, 265±40 and 782±117 ng/mL, respectively. Reference interval of MPO was 1.9–16.0 U/L and elevated baseline MPO concentration was defined as MPO >16.69 U/L according to the optimal cut-off value of MPO receiver operating characteristic (ROC) curve.

Kit of hs-CRP: reagent and calibrator (lot number: M 001429 and M 004640, Beckman Coulter, Inc., USA), the concentration of calibrator was 35.5 mg/L. VigilTM Serology Control (lot number: M 911600, M 911601 and M 911602), the concentrations of hs-CRP were 0.89 (0.64–1.14), 13.1 (8.1–18.1) and 46.3 (36.3–56.3) mg/L, respectively. Reference interval of hs-CRP was 0.2–3.0 mg/L and high baseline hs-CRP concentration was defined as hs-CRP >3.16 mg/L according to the optimal cut-off value of hs-CRP ROC curve.

The reagents and matched calibrators (Beijing Strong Biotechnologies, Inc., China), and control materials of Liquid Assayed Multiqual® as well as Liquichek™ Homocysteine (Bio-Rad Laboratories, Inc., USA) were used for determining serum glucose (GLU), uric acid (UA), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and homocysteine (Hcy), respectively.

Study methods

Blood was sampled in the morning after a 12 h fasting, and after the patient had been sedentary in sitting or supine position for at least 15 min. The blood of all subjects must be collected before the coronary angiography. Moreover, the blood of AMI patient was collected before percutaneous coronary intervention and thrombolytic treatment. Sampled blood was transferred, making it flowing down the wall of the tube, never directly squirted into the center in order to minimize the mechanical disruption or turbulence that could be result in hemolysis or activation.

The fresh serums were separated by centrifuging (3,000 r/min) for 10 minutes, and a aliquot serum was used for the determination of GLU, UA, TC, TG, HDL-C, LDL-C and Hcy, respectively, and another aliquot serum was frozen and stored at −80 °C refrigerator till the tests of MPO and hs-CRP were performed. MPO was measured by Hitachi 7600 Automatic Biochemistry Analyzer with selective repression method. Determination of hs-CRP was based on non-competitive near-infrared particle immunoassay with Immage 800 Immunochemistry System. MPO and hs-CRP assays were done in duplicate and were repeated if difference of the second measure was >10% or <10% compared to the first. The average of the two measures was used in the analyses.

Statistical analysis

All analyses were calculated with SPSS software version 16.0 (SPSS, Inc., Chicago, IL, USA). Skewed distribution variables were expressed as median (first-fourth), and differences between two independent samples were compared by Mann-Whitney U rank-sum test. ROC curve analysis for diagnosing ACS was performed to obtain area under ROC curve (AUC) and optimal cut-off values of MPO and hs-CRP. The correlation coefficients between MPO and ACS-related risk factors as well as between hs-CRP and ACS-related risk factors were calculated by Spearman’s analysis because MPO and hs-CRP were skewed. The ratios were compared with chi-square tests, and correlation coefficients were compared with Fisher’s z-transformations. The associations [odds ratio (OR) and 95% confidence interval (CI)] between the combined endpoints of cardiovascular events with elevated baseline concentrations of MPO and hs-CRP (expressed as yes-or-no) were evaluated by univariate logistic regression analysis.


Results

Comparison of the principal characteristics between ACS and non-ACS in patients with chest pain symptom

The principal characteristics were shown in Table 1. Compared to patients with non-ACS, ACS patients were characterized by older ages, males, smokers, diabetes mellitus, hypertension, hypercholesterolemia, hypertriglyceridemia, overweight or obesity, elevated MPO and hs-CRP concentrations. There were no differences in alcohol intake between the two groups.

Table 1
Table 1 Comparison of the principal characteristics between ACS and non-ACS [median (first-fourth) or n (%)] in patients with chest pain symptom
Full table

AUC and cut-off values of MPO and hs-CRP ROC curves for diagnosing ACS in patients with chest pain symptom

ROC curves of MPO and hs-CRP for diagnosing ACS were shown in Figure 1. The AUC of MPO and hs-CRP were 0.888 (95% CI, 0.843–0.933, P<0.001) and 0.862 (95% CI, 0.815–0.910, P<0.001), respectively. The optimal cut-off value (sensitivity; specificity) of MPO was 16.69 U/L (84.6% and 83.3%). When the optimal cut-off value was defined as 3.16 mg/L of hs-CRP, the sensitivity and specificity were 80.1% and 82.1%, respectively.

Figure 1 Receiver operating characteristic curves of MPO and hs-CRP for diagnosing ACS. MPO, myeloperoxidase; hs-CRP, high-sensitivity C-reactive protein; ACS, acute coronary syndrome.

The correlations of MPO or hs-CRP with ACS-related risk factors in patients with chest pain symptom

Table 2 showed the Spearman’s correlation coefficients between MPO and hs-CRP with ACS-related risk factors. There were significantly correlations between MPO and hs-CRP (P<0.001 and P=0.038, respectively) in both ACS and non-ACS group. Regarding to ACS patients, both MPO and hs-CRP were positively correlated with BMI, TC, TG, LDL-C and Hcy, and MPO were positively correlated with age, SBP and DBP (P<0.05), and negatively correlated with HDL-C concentrations (P<0.001), however, hs-CRP was not significantly correlated with age, SBP, DBP and HDL-C (P>0.05).

Table 2
Table 2 Spearman’s correlation coefficients between MPO or hs-CRP and ACS-related risk factors
Full table

The Spearman’s correlation coefficients between TG, HDL-C and LDL-C with MPO were significantly stronger than those with hs-CRP in ACS group (P<0.05). Compared to patients with non-ACS, patients with ACS had significantly higher correlation coefficients of MPO with TC, TG and LDL-C as well as hs-CRP with TC (P<0.05).

Incidences of MACEs during the 4-year period follow-up in CHD patients according to baseline MPO and hs-CRP concentrations

The incidences of MACEs during the 4-year period follow-up in 285 CHD patients age 38–85 years according to baseline MPO and hs-CRP concentrations were shown in Table 3 and Figure 2, respectively. The prospective study demonstrated that CHD patients with elevated baseline MPO concentrations had higher incidences of MACEs compared to CHD patients with normal-low baseline MPO concentrations (60.87% vs. 16.83%, χ2=51.041, P<0.001). Similarly, elevated baseline hs-CRP concentrations in CHD patients had higher incidences of MACEs than normal-low baseline MPO concentrations (57.95% vs. 24.77%, χ2=29.917, P<0.001). There were significant associations between the combined endpoints of MACEs with elevated MPO baseline concentration (yes vs. no, OR 7.383, 95% CI, 4.095–13.309, P<0.001) as well as high hs-CRP baseline concentration (yes vs. no, OR 4.186, 95% CI, 2.469–7.097, P<0.001).

Table 3
Table 3 Incidences of MACEs during the 4-year period follow-up in 285 CHD patients according to baseline MPO and hs-CRP concentrations
Full table
Figure 2 The incidences of MACEs during the 4-year period follow-up in 285 CHD patients. MACE, major adverse cardiovascular event; CHD, coronary heart disease.

Discussion

ACS affects millions of individuals annually by causing considerable morbidity and mortality in both developing and developed countries. A large number of studies have demonstrated that inflammation plays a pivotal role in all phases of atherosclerosis, from the fatty streak lesion formation to the acute coronary event due to vulnerable plaque rupture (10,11). Inflammatory cells including PMNs and macrophages dominate early atherosclerotic lesions and vulnerable plaque, their effector molecules contribute to the pathogenesis of atherosclerosis, especially in the plaque rupture process, which are the major determinants for the ACS (12,13).

Studies have shown that elevated baseline concentrations of hs-CRP were associated with the risk of atherosclerotic events and show a predictive value even in terms of secondary prevention, both in patients with chronic stable angina and ACS (14,15). Otake et al. (16) reported that concentrations of hs-CRP were elevated in patients with unstable angina and myocardial infarction, with high concentrations hs-CRP predicting worse prognosis, and there was a relationship between elevated hs-CRP concentrations and the progression of ACS. A meta-analysis of longitudinal studies revealed that greater early blood CRP moderately increased long-term risk of recurrent cardiovascular events or death, which was a valuable prognostic predictor in patients with ACS (17).

Recent studies have also suggested that MPO is a useful risk marker and diagnostic tool in ACS and in patients admitted to emergency department for chest pain. A case-control study showed that MPO concentrations were significantly elevated in ACS patients compared to the patients with stable angina and the healthy control subjects (18). Another study during a mean follow-up period of 13±4 months in two cohorts of coronary artery disease patients (178 SAP and 130 ACS) revealed that baseline MPO concentration in ACS patients was an independent predictor of major adverse cardiac events during hospitalization, OR of 3.8 (95% CI, 1.2–12) for the combined endpoint (death, recurrent angina, heart failure, and arrhythmia) (19).

The present study revealed that patients with ACS had significantly higher concentrations of MPO and hs-CRP compared to patients with non-ACS (P<0.001). MPO and hs-CRP as inflammatory markers for diagnosing ACS, the AUC of ROC curves were 0.888 (95% CI, 0.843–0.933) for MPO and 0.862 (95% CI, 0.815–0.910) for hs-CRP, respectively. The prospective study during the 4-year period follow-up demonstrated that CHD patients with elevated baseline MPO and hs-CRP concentrations had higher incidences of MACEs compared to CHD patients with normal-low baseline MPO and hs-CRP concentrations. Elevated MPO baseline concentration (yes vs. no, OR 7.383, 95% CI, 4.095–13.309) and high hs-CRP baseline concentration (yes vs. no, OR 4.186, 95% CI, 2.469–7.097) were significantly associated with the combined endpoints of cardiovascular events. These findings suggest that both MPO and hs-CRP are valuable inflammatory markers for early warning ACS in CHD patients.

Studies have shown that CRP, an acute phase reaction protein, directly involved in atherosclerotic plaque formation and endothelial cell dysfunction (20,21). Firstly, CRP binding with complement C1q leads to complement pathway activation. Secondly, CRP stimulates macrophages to synthesize interleukin-6, interleukin-1β, tumor necrosis factor-a and other pro-inflammatory molecules, which accelerate atherosclerotic plaque injury. Thirdly, CRP induces endothelial cells to express vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1), which cause monocyte migrating into arterial intima and macrophages increasing uptake of LDL.

Accumulating evidences have also implicated a role for MPO in the pathogenesis of atherosclerosis. Enriched within arterial intima and atherosclerotic plaque, MPO serves as an enzymatic source of eicosanoids and bioactive lipids and generates atherogenic forms of both LDL and HDL. For one thing, MPO has emerged as one enzymatic catalyst for LDL oxidation and carbamylation and conversion into more atherogenic high-uptake forms (oxidized-LDL and carbamylated-LDL) within the artery wall in vivo (22,23). For another, MPO-generated products promote the impairment of the ability of apolipoprotein A1 (apoA-1) via its site-specific modification and dysfunction of HDL, which result in the reduction of cholesterol efflux, and the increase of lipid accumulation and foam cell formation (24,25). Furthermore, MPO accelerates tissue damage of atherosclerotic artery and affects the transformation from stable coronary artery plaques to unstable lesions, results in ACS by oxidative stress (26).

In our study, not only in ACS group, but also in non-ACS group, there were significantly correlations between MPO and hs-CRP. The ACS patients had significantly higher correlation coefficients of MPO with TC, TG and LDL-C as well as hs-CRP with TC than non-ACS patients. Comparison of correlations between MPO and hs-CRP with ACS-related risk factors, it was found that the Spearman’s correlation coefficients between TG, HDL-C and LDL-C with MPO were significantly stronger than those with hs-CRP in ACS group (P<0.05). The present study provided the evidence that compared to hs-CRP, MPO was stronger correlated with some ACS-related risk factors, especially LDL-C and HDL-C, which was confirmed to be directly involved the foam cell formation of atherosclerosis.

Limitations

Since present study was just a single site study, and the follow-up period was short and the number of MACEs events was too small to perform multivariate analysis, the larger sample number of multicenter study and longer prospective investigation is necessary to compare the values between MPO and hs-CRP for predicting MACEs in CHD patients.


Conclusions

The present study demonstrates that patients with ACS had significantly higher concentrations of MPO and hs-CRP than patients with non-ACS (P<0.001). The AUC for diagnosing ACS were 0.888 (95% CI, 0.843–0.933) for MPO, and 0.862 (95% CI, 0.815–0.910) for hs-CRP, respectively. Compared to hs-CRP, MPO had more correlations strongly with ACS-related risk factors of TG, HDL-C and LDL-C in ACS patients. The incidences of MACEs associated significantly with elevated MPO baseline concentration (yes vs. no, OR 7.383, 95% CI, 4.095–13.309) and high hs-CRP baseline concentration (yes vs. no, OR 4.186, 95% CI, 2.469–7.097). These findings suggest that MPO has some advantages than hs-CRP for predicting MACEs. Elevated baseline MPO and hs-CRP concentrations are significantly associated with MACEs in CHD patients.


Acknowledgements

The authors would like to appreciate the staff in the Department of Clinical Laboratory and Department of Cardiovascular at the Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital for their support and guidance.

Funding: This research was supported by Sichuan Provincial Science and Technology Department Research Foundation of China (No. 2013FZ0080).


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The study was approved by the Medical Ethics Committee at Chengdu Women’s and Children’s Central Hospital, Chengdu, China [(2013)2, Medical Ethics Committee, CWCCH]. Written informed consent was obtained from all participants in the study.


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doi: 10.21037/jrh.2016.08.08
Cite this article as: Ma Y, Yang Y, Huang W, Huang C, Luo J, Peng D, Liu C. Comparison between myeloperoxidase and high-sensitivity C-creative protein for predicting major adverse cardiovascular events in coronary heart disease patients. J Res Hosp 2016;1:6.

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