Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
63
Risk Factors in Ischemic He
art Disease: Comparison
between Disturbance in Seru
m Lipid Profile and Total
Homocysteine in Old Myocardial Infarction
Mohamed Ahmed Abd-Elmoaty.
a,
, Ahmed Mohamed Bogdady,
b
Mervat Mohamed Attia
b
, Lotfy Hamed Abo-Dahab
b
and
Ali Mahmoud A. Kassem
b
a
Departments of Biochemistry, and
b
Internal Medicine,
Sohag Faculty of Medicine, Sohag University
ABSTRACT
Objectives:
Disturbance in the
Low-density lipoprotein cholesterol (LDL-C), High-
density lipoprotein cholesterol (HDL-C), to
tal cholesterol (TC), triglyceride (TG) and
serum total homocysteine are predisposing factors in myocardial infarction.
Design
and methods:
The study group consisted of 56 patients 35 male (aged 47.8±4.8
years), and 21 females (aged 46±4.3 years). The entry criterion for the patient group
has a history of typical or atypical chest pain, unequivocal changes in the
electrocardiogram. The control group consisted of 30 normal volunteers, 16 male
(aged 48.4±5.2 years) and 14 females (aged 45.1±4.9 years). Measurement of serum
total homocysteine was performed by enzyme linked immune sorbant assay (ELISA).
Measurement of TC, TG, and HDL-C were performed using spectr
ophotometer. LDL-C
was calculated.
Results:
Patients with myocardial infarction were found to have
higher serum total homocysteine levels (23.93±2.99
mol/L in male and 25.82±3.82
mol/L in female) than controls (10.45±2.73
mol/L and 12.92±0.9
mol/L in both
male and female respectively) (for each comparison; p < 0.001). Serum total
homocysteine levels were significantly co
rrelated with high Triglycerides and low
HDL-C.
Conclusions:
The above mentioned findings suggest the potential usefulness of
Triglycerides, HDL-C and serum total homocys
teine as risk factors in myocardial
infarction patients. These findings should
be used in the future studies on the etiology
and pathogenesis of myocardial infarction and to
ascertain which patients are at risk
for subsequent cardiovascular events and
who will benefit from revascularization.
Abbreviation
: LDL-C (Low density lipoprotein-cholesterol), HDL-C (High density
lipoprotein- cholesterol), MI (Myocardia
l infarction), TG (Triglycerides) and Hcy
(homocysteine)
INTRODUCTION
Moderate hyperhomocysteinemia
is an important cardiovascular risk
factor
(1,2)
. Hcy is toxic to the vascular
endothelium
(3,4)
and can potentiate the
auto-oxidation of low-density
lipoprotein cholesterol
(5,6)
and
promotes thrombosis
(7,8)
. Hyperhomo-
cysteinemia may be an additional risk
factor predisposing individuals to
premature coronary heart disease.
Patients homozygous for cysta-
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
64
thionine-
β
-synthase deficiency, or
who have inherited disorders of
cobalamin metabolism, have very
high plasma Hcy concentrations and
are usually subject to severe
premature atherosclerosis
(9,10)
. The
pathological accumulation of Hcy in
tissues and blood is generally
considered to cause vascular
complications by its injurious effect
upon the endothelial cells
(11)
. The
aetiology and clini
cal significance of
hyperhomocysteinemia are under
intense investigation. The aetiology of
mild to moderate hyperhomo-
cysteinemia commonly found in
patients with coronary artery
disease
(12)
, cerebrovascular disease
(13)
,
peripheral vascular disease
(14)
, and in
patients with end-stage renal disease
is often unclear
(15,16)
. Hcy is a strong
and independent risk factor for
cardiovascular disease, a sensitive
marker of cobalamin and folate
deficiencies
(17,18)
. Results from animal
and cell culture studies indicate that
increased Hcy concentrations may
accelerate coronary heart disease by
various mechanisms, including direct
damage to the vascular
endothelium
(19)
, stimulation of smooth
muscle cell proliferation
(20)
, and
enhanced LDL-C peroxidation
(21)
.
Furthermore, Hcy may interfere with
homeostasis by various mechanisms
thus contributing to a biochemical
environment induction of thrombus
formation
(22–24)
. Hcy has, also, been
shown to increase DNA synthesis in
vascular smooth muscle cells
consistent with early arteriosclerotic
lesions and to induce these cells to
proliferate while impeding the
regeneration of endothelial cells and
to cause oxidation of low-density
lipoprotein
(25-27)
. The effects of Hcy
on vascular hemostatic properties may
be due to decrease in thrombomodulin
cell surface expression and inhibition
of protein C activation, thus probably
contributing to development of
thrombosis
(28,29)
.
Different studies have used
different Hcy levels to mark
"abnormal" levels. However, the
evidence is that Hcy
is a graded risk
factor, with the risk
rising with even
minor elevations of
Hcy. Bostom et
al.
(30)
find that serum Hcy >14 μmol/L
considered a relative risk of vascular
disease, but
Stehouwer
(31)
considered
that >17 μmol/L serum Hcy are highly
risk of dying vascular disease.
Dyslipidemia is a well-
established risk factor for
cardiovascular disease
(32)
. In the
Copenhagen Male Study (CMS),
presence of a high fasting plasma TG
concentration and a low high-density
lipoprotein cholesterol (HDL-C)
concentration, the character-istic
dyslipidemia in the metabolic
syndrome, was associated with a 2–
foldhigher prevalence of
cardiovascular disease (CVD) and a
2–fold-higher incidence of ischemic
heart disease (IHD) in men without
symptoms of CVD at baseline
(33)
. In
addition, a link has been observed
between a high TG level, low HDL-C
level, reduced glucose tolerance,
hyperinsulinemia, obesity, low
physical activity, reduced fibrinolytic
capacity and increased factor VII
level
(34)
.
The purpose of the present study
was to compare serum total Hcy and
TC, TG, LDL-C, and HDL-C as risk
factors in old MI.
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
65
PATIENTS & METHODS
Clinical, ECG changes and Serum
The studied population were
taken from Outpatient Clinic of the
Coronary Diseases, Sohag University
Hospital, Sohag Faculty of Medicine,
Sohag University, in the period from
July 2006 to February 2007. The
study group consisted of 56 patients
suffering from old MI above forty
years old 35 male, and 21 females non
pregnant women. The control group
consisted of 30 normal volunteers, 16
male and 14 non pregnant females of
the same age group. None of the
subjects smoked cigarettes. Diagnosis
was, based on criteria established by
the World Health Organization,
including typical or atypical chest
pain, unequivocal changes in the
electrocardiogram. Single MI was
subsequently confirmed from ECG
criteria, which was the appearance of
pathologic Q wave accompanied by
an elevation of the ST segment one
mm or more in two or more
contiguous leads, often with
reciprocal ST depression in the
contralateral and subsequently
inversion of the T wave. Significant
elevation in serum lactate
dehydrogenase activity and creatine
kinase MB level were associated in
selected patients. Venous blood
samples were obtained after the
subjects had fasted for at least 12
hours and allowed to clot at room
temperature for 30 min, were
immediately centrifuged at 2000 rpm
for 5 min, and the serum was removed
and stored without delay at -20°C
until analysis of Hcy and related lipids
which was performed over a period of
one h at most.
Homocysteine Assay
Axis Hcy enzyme linked immune
sorbant assay (ELISA) is used for the
determination of total Hcy in blood
(
Axis-Shield Diagnostics Ltd, United
Kingdom
)
(35)
. Protein-bound Hcy is
reduced to free Hcy by use of
dithiothreitol (DTT). Free Hcy
converted enzymatically to S-
adenosyl-L-homo-cysteine (SAH) by
the use of SAH hydrolase and excess
adenosine (Ad) in a separate
procedure. The following solid-phase
enzyme immunoassay is based on
competition between SAH in the
sample and immobilised SAH bound
to the walls of the microtitre plate for
binding sites on a monoclonal anti-
SAH antibody. After removal of
unbound anti-SAH antibody, a
secondary rabbit anti-mouse antibody
labelled with the enzyme horse radish
peroxidase (HRP) is added. The
peroxidase activity is measured at 450
nm after addition of substrate (N-
methyl-2-pyrrolidine, propylene-
glycol) and the absorbance is
inversely related to the concentration
of Hcy in the sample.
Cholesterol assay
Enzymatic colorimetric method
was used for cholesterol assay from
Bicon-Diagnostk
(36)
.
This method
depend on the presence of cholesterol
esterase and cholesterol oxidase to
yield cholesten-3-on and H
2
O
2
(Hydrogen peroxide). Hydrogen
peroxide created forms a red dyestuff
by reacting with 4-aminophenazone
and phenol under the catalytic action
of peroxidase. The colour intensity is
directly proportional to the
concentration of cholesterol and can
be determined photometrically at
546nm.
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
66
Triglycerides assay
Enzymatic colorimetric method
was also, used for TG assay from
Bicon-Diagnostk
(37)
.
This method was
based on the using of lipoprotein
lipase from microorganisms for the
rapid and complete hydrolysis of TG
to glycerol followed by oxidation to
dihydroxyacetone
phosphate and
hydrogen peroxide. The hydrogen
peroxide produced then reacts with 4-
aminophenazone and 4-chlorphenol
under the catalytic action of
peroxidase to form a red dyestuff and
measured at 546 nm.
HDL-Cholesterol assay
Chylomicrons, VLDL (very low
density lipoproteions) and LDL-C
were precipitated by phosphotungstic
acid (PTA) and MgCl2 (ADWIC).
After centrifugation the supernatant
fluid contains the HDL-C fraction,
then cholesterol content was
determined enzymatically
(38)
.
LDL-Cholesterol calculation
The LDL-C concentration was
calculated from the difference
between the total serum cholesterol,
HDL-C and TG/5
(39)
.
Statistical analysis
Values were expressed as mean,
and ± standard deviation (SD). For
serum lipids and Hcy in comparisons
of controls and old MI patients,
unpaired Student’s
t
-test was used.
Differences with p values <0.05 were
considered significant by using SPSS
software (release 10.0
).
RESULTS
Fifty six patients (35 male and 21
female) suffering from old MI and 30
normal volunteers (16 male and 14
females) above forty were included in
the study. The mean of age in old MI
was 47.8±4.8 years in males and
46.±4.3 years in females. In the
control group, the mean age was
48.4±5.2 years in males and 45.1±4.9
years in females. Patients with MI
were found to have higher serum total
Hcy levels than controls (
P
<0.01)
(Fig. 2). The mean serum total Hcy
level in control group was 11.6±2.41
μmol/L (10.45 ±2.73 μmol/L for
males and 12.92±0.9 μmol/L for
females), but that in old MI patients
was 24.64±3.42 μmol/L (23.93±2.99
μmol/L for males patients and
25.82±3.82 μmol/L for females)
(fig.1). Serum level of hemocysteine
ranged in MI from 16.78 to 31.55
μmol/L, in control group ranged from
5.99 to 14.82 μmol/L. All MI patients
had serum Hcy >14 μmol/L (100%)
and only 55 of them had serum Hyc
>17 μmol/L (98.2%). In control group
all had serum Hcy below 17 μmol/L
and 25 of them had serum Hyc > 14
μmol/L (83.3%). So, sensitivity and
specificity of serum Hcy level > 14
μmol/L were 91.8% and 100%
respectively. The sensitivity was
higher (100%) with serum
Hcy > 17 μmol/L.
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
67
Serum Homocysteine in Control and old MI.
0
5
10
15
20
25
30
35
Serum level in
mol
Male Female
Fig.(1): Serum homocysteine in control
(Black columns) and old MI (white
columns) of male and female groups
Serum TG levels were higher in
patients with old MI (320.5±10.7
mg/dL) than in controls (139.2±31
mg/dL) (
P
<0.05). The mean serum
TG level was 192.38 ±12.37 mg/dL vs
343.19±34.79 mg/dL for men in the
control and MI groups, respectively;
and 150.41±27.57mg/dL vs
282.75±42.82 mg/dL for women in
the control and MI groups,
respectively,
P
< 0.05 in each groups
(fig.2). 44 patients with MI had serum
TG>200mg/dL (78.6%) but only 2 of
control persons had hypertri-
glyceridemia. (6,7%). So, Sensitivity
and specificity of serum TG
>200mg/dL were 95.8% and 73.7%
respectively.
HDL-cholesterol levels were
lower in patients with old MI
(50.01±9.59 mg/dL) than in controls
(57.53±10.18 mg/dL) (
P
<0.05). Its
mean was lower in men and women
with old MI (48.63±11.1 mg/dL and
52.33±5.83 mg/dL respectively,
P
,
0.05) than in healthy men and women
(55.25±7.58 mg/dL and 60.14±12.3
mg/dL respectively) (fig.2). Only 3
patients with MI had serum HDL-C
<35mg/dL (5.4%) but all the control
persons had serum HDL-C above this
level. The sensitivity and specificity
of serum HDL-C <35mg/dL were
100% and 36.6% respectively.
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
68
0
50
100
150
200
250
300
350
400
Serum level in mg/dL
Male Female
Male Female
Serum Triglycerides and HDL-Cholesterol in control and old MI.
Triglycerides
HDL-Cholesterol
Fig.(2): Serum TG (first four columns) and HDL-C (following four columns) in both
control (Black columns) and old MI (white columns) of male and female groups
DISCUSSION
Although the mortality following
acute MI has decreased, morbidity
remains considerable. The task of
physician is to initiate risk factor
modification, lipid-lowering therapy,
smoking cessation and other
intervention. Post-MI risk factors
evaluation is used to ascertain which
patients are at risk for subsequent
cardiovascular events and who will
benefit from revascularization. All
patients who have had an MI should
undertake aggressive modification of
their risk factors. As seen in the
present work, a relationship between
serum total Hcy and/or one of two
conventional risk factors for MI (TG
and HDL-C) was observed. Results
obtained in the present study, like
those of other authors
(2,21)
; suggest
that the serum total Hcy assay could
be used to predict future risk for MI.
There is no relation between serum
total Hcy and LDL-C in these
patients. Although hyperhomo-
cysteinemia can potentiate the
oxidation of low-density lipoprotein
cholesterol
(25-27)
that can promotes
thrombosis
(7,8)
but it has no apparent
correlation effect on serum LDL-C.
The average maximal value of all
patients was at least two times greater
than the normal subjects and the more
sensitivity and specificity of serum
Hcy (specially >17μmol/L) explain
the high diagnostic value of the Hcy
assay for MI. The results presented in
the current work indicate that an
elevated total Hcy level with or
without high TG or low HDL-C are
Bull. Egypt. Soc. Physiol. Sci. 27 (2) 2007
Abd-Elmoaty et al.
69
risk factors in IHD but their relations
to prognosis and severity of MI need
further work. The current results were
in good agreement with those reported
previously
(19-22)
. The determination of
serum total Hcy, TG and HDL-C for
the diagnosis of MI patients will be an
important feature of the clinical
chemistry laboratory. Further work on
the mode of action of Hcy in relation
to MI is needed.
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عوامل
الخطر
في
التاجية
الشرايين
قصور
حالات
في
الكلى
الهوموستايين
و
بالدم
الدهون
نسبة
في
الخلل
بين
مقارنة
دراسة
القلب
عضلة
احتشاء
مرض
بغدادي
محمد
احمد
**
،
عطية
محمد
ميرفت
**
،
المعطى
عبد
احمد
محمد
*
،
الدهب
أبو
حامد
لطفي
**
قاسم
محمود
وعلي
**
الحي
الكيمياء
قسمي
الطبية
وية
*
الباطنية
الأمراض
و
**
البشرى
الطب
بكلية
-
سوهاج
جامعة
أهــــم
مــــن
بالــــدم
الهوموســــتايين
نســــبة
وارتفــــاع
الــــدهون
نســــب
معــــدلات
فــــي
الخلــــل
إن
لـذا
التاجيـة
الشـرايين
فـي
والقصـور
القلـب
عضـلة
احتشـاء
مـرض
حدوث
على
المساعدة
العوامل
لم
العـاملين
هـذين
بــين
مقارنـة
بعمـل
قمنـا
فقـد
حــدوث
توقـع
علـي
الدالـة
العوامــل
أدق
مـاهي
عرفـة
علـــي
دراســـة
بعمـــل
وذلـــك
الأمـــراض
هـــذه
مثـــل
٥٦
المركـــزة
العنايـــة
فـــي
حجـــزهم
تـــم
قـــد
مريضـــا
حـــدوث
مـــن
للتأكـــد
اللازمـــة
بالوســـائل
تشخيصـــهم
بعـــد
ســـوهاج
جامعـــة
الطـــب
كليـــة
بمستشـــفي
بعـــدد
ومقـــارنتهم
القلـــب
عضـــلة
فـــي
احتشـــاء
٣٠
إصـــاب
أي
لـــديهم
ليســـت
فـــردا
فـــي
بقصـــور
ات
الهيموســتايين
نســبة
قيــاس
خــلال
مــن
وذلــك
التاجيــة
الشــرايين
,
الكلــي
الكولســترول
(TC)
،
الثلاثيـة
الجلسـريدات
,(TG)
العاليـة
الكثافـة
ذات
الدهنيـة
البروتينـات
,(HDL-C)
ذات
وآخـري
المنخفضـــة
الكثافـــة
(LDL-C)
التعـــرض
خطـــورة
علـــي
الدالـــة
العوامـــل
أهـــم
مـــن
أن
وجـــد
وقـــد
ا
لمـــرض
نســـبة
فـــي
وانخفـــاض
الثلاثيـــة
الجلســـريدات
نســـبة
بارتفـــاع
تـــزداد
القلـــب
عضـــلة
حتشـــاء
بالــدم
الهوموســتايين
نســبة
فــي
المتوســط
الارتفــاع
وأيضــا
العاليــة
الكثافــة
ذات
الدهنيــة
البروتينــات
مقارنــة
القلــب
بعضــلة
الاحتشــاء
حــدوث
نســبة
ارتفــاع
علــي
الدالــة
العوامــل
أكثــر
مــن
يعتبــر
الــذي
الا
بالعوامــل
حساســية
والأكثــر
المرضــية
الحــالات
هــذه
فــي
شــيوعا
الأكثــر
أنهــا
حيــث
مــن
خــري
عضـلة
لاحتشـاء
عرضـة
الأكثـر
وأيضـا
الأربعـين
سـن
فـوق
الأشـخاص
فـي
قياسـه
يمكن
وبذلك
القلب
.