Jacek Musial

Anti-inflammatory effects of simvastatin in subjects with hypercholesterolemia

AIMS Beneficial effects of statins in preventing cardiovascular events may depend, at least in part, on their anti-inflammatory action. The aim of the study was to assess the influence of simvastatin and aspirin on serum levels of C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in hypercholesterolemic subjects. METHODS AND RESULTS In 33 asymptomatic men with total cholesterol (TC) >6.5 mmol l(-1) and in 25 men with coronary heart disease and borderline-high cholesterol levels (between 5.2 and 6.5 mmol l(-1)) chronically treated with low-dose aspirin (75 mg/d), serum levels of CRP, TNF-alpha, IL-6, and IL-8 were determined before and after a 3-month simvastatin therapy (20-40 mg daily). In the former group, these markers of inflammation were also measured before and after a 2-week treatment with aspirin (300 mg/d), implemented prior to and in combination with simvastatin. A distinct reduction of CRP and TNF-alpha was found in both groups; IL-6 levels were decreased only in subjects with marked hypercholesterolemia. Aspirin had no effect on the anti-inflammatory action of simvastatin. CONCLUSIONS In men with hypercholesterolemia simvastatin treatment lowers serum levels of CRP and proinflammatory cytokines. Low-dose aspirin does not add to the anti-inflammatory action of simvastatin.

Inhibition of thrombin generation by simvastatin and lack of additive effects of aspirin in patients with marked hypercholesterolemia.

OBJECTIVES To assess the effects of aspirin compared with simvastatin on thrombin generation in hypercholesterolemic men, and to establish whether the reduction of elevated blood cholesterol by simvastatin would affect the action of aspirin on thrombin formation. BACKGROUND Aspirin inhibits thrombin formation, but its performance is blunted in hypercholesterolemia. By virtue of altering lipid profile, statins could be expected to influence thrombin generation. METHODS Thirty-three men, aged 34 to 61 years, with minimal or no clinical symptoms, serum total cholesterol >6.5 mmol/liter and serum triglycerides <4.6 mmol/liter, completed the study consisting of three treatment phases. First, they received 300 mg of aspirin daily for two weeks (phase I), which was then replaced by simvastatin at the average dose of 24 mg/d for three months (phase II). In phase III, aspirin, 300 mg/day, was added for two weeks to simvastatin, the dose of which remained unchanged. Thrombin generation was assessed: 1) in vivo, by measuring levels of fibrinopeptide A (FPA) and prothrombin fragment 1+2 (F1+2) in venous blood; and 2) ex vivo, by monitoring the rates of increase of FPA and F1+2 in blood emerging from standardized skin incisions of a forearm. A mathematical model was used to describe the kinetics of thrombin formation at the site of microvascular injury. RESULTS Two-week treatment with aspirin had no effect on thrombin markers in vivo, while ex vivo it depressed the total amount of thrombin formed, though not the reaction rate. After simvastatin treatment, serum cholesterol decreased by 31% and LDL cholesterol by 42%, while thrombin generation became markedly depressed. In venous blood, FPA was significantly reduced. Concomitantly, the initial thrombin concentration and total amount of thrombin generated decreased significantly. Addition of aspirin to simvastatin (phase III) had no further effect on any of these parameters. CONCLUSIONS In men with hypercholesterolemia, lowering serum cholesterol level by a three-month simvastatin treatment is accompanied by a marked reduction of thrombin generation both at basal conditions in venous blood and after activation of hemostasis by microvascular injury. Once blood cholesterol became reduced, adding aspirin to simvastatin did not enhance dampening of thrombin formation.

An international multicentre-laboratory evaluation of a new assay to detect specifically lupus anticoagulants dependent on the presence of anti-beta2-glycoprotein autoantibodies

Summary.  Background: Antiphospholipid syndrome (APS) is diagnosed by the simultaneous presence of vascular thrombosis and/or pregnancy morbidity and detection of antiphospholipid antibodies in plasma. Objectives: We have shown that prolongation of clotting time by anti‐beta2‐glycoprotein I (beta2GPI) antibodies correlates better with thrombosis than a positive classic lupus anticoagulant (LAC) assay in a single center study. To confirm or falsify this finding we have conducted a multicenter study. Methods and results: In 325 LAC‐positive samples, we found that the beta2GPI‐dependent LAC correlated 2.0 times better with thrombosis than the classic LAC assay. Although significant, this was a minimal improvement compared with the ‘classic’ LAC. It was published that calcium influences the behavior of anti‐beta2GPI antibodies in coagulation assays. To investigate whether calcium plays a role in the present study, we divided the patient population into two groups: (i) blood was collected in 0.109 m sodium citrate and (ii) blood was drawn in 0.129 m sodium citrate as anticoagulant. We found that a positive result with the beta2GPI‐dependent LAC assay correlated better with thrombosis [odds ratio (OR): 3.3, 95% confidence interval (CI) 1.9–5.8] when 0.109 m sodium citrate was used compared with 0.129 m sodium citrate (OR: 0.4, 95% CI 0.1–1.1). Conclusion: We were able to confirm in an international multicenter study that a positive result in a beta2GPI‐dependent LAC assay correlates better with thrombosis than the classic LAC assay, but that the assay needs further study as it is sensitive to external factors such as the sodium citrate concentration used as anticoagulant in the test sample.

Beneficial Therapeutic Effect of Plasmapheresis After Unsuccessful Treatment With Corticosteroids in Two Patients With Severe Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a rare, life‐threatening disease with a high mortality rate. It is linked to drug toxicity and characterized by epidermal necrolysis with mucositis and conjunctivitis. Treatment is not established due to the unknown pathogenesis and lack of randomized clinical trials. It is mostly based on withdrawal of the culprit drug and symptom‐related approach. The role of corticosteroids and plasmapheresis in the disease treatment remains controversial. We present two patients with severe TEN (both with >80% body skin surface involvement) treated unsuccessfully with corticosteroids followed by plasmapheresis. Plasmapheresis led to prompt improvement, with extensive reepithealization of the skin, and eventually total recovery of both patients. In severe TEN unresponsive to corticosteroids, treatment with plasmapheresis should be considered.

Two-Dimensional Speckle-Tracking Echocardiography Reveals Systolic Abnormalities in Granulomatosis with Polyangiitis (Wegener’s)

Background: Two‐dimensional speckle‐tracking echocardiography (STE) is a novel technique providing accurate assessment of myocardial function. However, its value in granulomatosis with polyangiitis (Wegener’s) (WG) has not been studied. Objective: To assess the presence and frequency of systolic left ventricular (LV) dysfunction using STE and to determine incremental value of STE over standard echocardiography to detect myocardial abnormalities in WG. Methods: Twenty‐two WG patients (11 males, 11 females, mean age 46.8 ± 12.3 years) and 22 sex‐ and age‐matched healthy subjects underwent standard and STE. Global longitudinal, circumferential, and rotational deformation parameters were calculated. Results: All patients had LV ejection fraction (EF) >50%. LVEF was 65.0 ± 7.5% and LV end‐diastolic volume index 44.8 ± 11.8 mL/m2. Regional LV wall motion abnormalities were found in 7 (32%), while abnormal global STE determined systolic dysfunction in 16 (73%) subjects (P = 0.008). Global longitudinal, circumferential and radial peak‐systolic deformational parameters (strain or strain rate) were decreased in 11 (50%), 9 (41%), and 3 (14%) patients (P = 0.02), respectively. Comparing patients with abnormal and normal STE derived global systolic function, the former had higher cumulative disease extent index (10.6 ± 3.0 vs 7.5 ± 1.8; P = 0.03) and vasculitis damage index (7.9 ± 1.9 vs 6.0 ± 1.7; P = 0.04). Conclusions: Despite normal LVEF the global systolic LV abnormalities detected by STE are common in WG. They correspond to the extent and severity of WG and are more frequent than regional wall motion abnormalities in standard echocardiography.

Factor XIII Val34Leu polymorphism and γ‐chain cross‐linking at the site of microvascular injury in healthy and coumadin‐treated subjects

Summary.  Fibrin (Fn) cross‐linking by activated factor (F) XIII is essential for clot stability. In vitro, a common Leu34 polymorphism of the FXIIIA‐subunit increases the rate of thrombin‐mediated FXIII activation, but not cross‐linking activity upon complete FXIII activation. The effect of FXIII Val34Leu polymorphism on fibrin(ogen) cross‐linking in vivo when vascular injury triggers the blood coagulation has not been studied yet. Using quantitative immunoblotting with antibodies raised against FXIIIA‐subunits, fibrinogen, and γ‐γ‐dimers, the rates of FXIIIA cleavage and fibrin(ogen) cross‐link formation in the fluid phase of 30‐s blood samples collected at the site of microvascular injury were compared in the Leu34‐positive and ‐negative healthy individuals and patients on long‐term oral anticoagulation. In addition to accelerated FXIII activation, in healthy subjects the presence of FXIII Leu34 allele was associated with increased soluble γ‐γ‐dimer formation by 40% (1355 ± 17 μg L−1 for Leu34 carriers vs. 804.3 ± 17 μg L−1 for Leu34 non‐carriers; P = 0.028) at the site of microvascular injury. This solution phase effect was abolished in coumadin‐treated patients (369.4 ± 75.9 μg L−1 for Leu34 carriers vs. 290.5 ± 35.9 μg L−1 for Leu34 non‐carriers; P > 0.05). The present study indicates that the Leu34 allele affects soluble γ‐γ‐dimer formation in untreated individuals, but not in those receiving acenocoumarol. Our data may help elucidate the impact of the FXIII Val34Leu polymorphism on Fn cross‐linking in vivo and its modulation by oral anticoagulants.

Reasons for Resistance to Aspirin in Cardiovascular Disease

To the Editor: Aspirin effectively reduces the risk of myocardial infarction and stroke in patients with atherothrombosis. Yet, some patients have recurrent vascular events despite long-term aspirin therapy, raising the possibility that they are resistant to aspirin. The percentage of aspirin-resistance, estimated by platelet function tests, varies between 9% to 24% in stable cardiac patients. John Eikelboom and his colleagues1 reported on the association between urinary thromboxane excretion and risk of cardiovascular events in patients on long-term aspirin therapy. They concluded that resistance to aspirin increased the risk of cardiac death. The authors of this interesting article speculate about the role of nucleated cells (endothelium, monocytes) in resistance to aspirin; these cells could provide prostaglandin H2, a precursor of thromboxane A2 (TXA2), even in the course of aspirin treatment, via cyclooxygenase-1 (COX-1) or cyclooxygenase-2 (COX-2) pathways. We would like to point …

Improved cardiac function in a patient with hypereosinophilic syndrome treated with imatinib

To the Editor: Hypereosinophilic syndrome (HES) is a heterogeneous myeloproliferative disorder characterized by marked eosinophilia and organ dysfunction in absence of other causes of eosinophilia (1, 2). One form is associated with a presence of fusion between Fip1-like 1 (FIP1L1) and platelet derived growth factor receptor a (PDGFRA) gene (3, 4), and a good laboratory and symptomatic response to imatinib mesylate therapy (5, 6). The ultimate goal of therapy should be the control of organ damage (1, 3). We present data in favor of such effects. The diagnosis of HES was made in a 41-year-old male patient with dyspnoea, hepatosplenomegaly, and three episodes of left ventricular (LV) failure. Transthoracic echocardiography showed LV ejection fraction (EF) 45% and large LV fixed thrombus 4.24 · 3.97 cm, mild anemia and marked eosinophilia (Table 1). Treatment with corticosteroids, interferon a (3 timesa week 3 000 000 Us.c.), hydroxyurea and acenocoumarol was initiated. Results of 21-month treatment were not satisfactory (Table 1). The EF was 45%; the LV thrombus size was unaltered. Stress Tc-MIBI myocardial perfusion SPECT with adenosine disclosed moderate irreversible perfusion abnormalities in the anterior wall and antero-septal and lateral segments. Genetic analysis revealed FIP1L1-PDGFRA fusion gene (4), confirmed by a direct sequencing. However, bone marrow biopsy did not show any mast cell infiltration, which might suggest systemic mast cell disease associated with eosinophilia (7). Interferon replaced imatinib mesylate: 100 mg/d the first 3 months and 100 mg every second day the following 3 months. Already after the first week of imatinib treatment WBC fall to 5500/mm and eosinophil number to 320/mm. Following the 6 months treatment, peripheral blood rearrangement products of the two genes disappeared; WBC and eosinophil count was normal, vitamin B12, pro-BNP and PGD2 metabolite all decreased markedly. The EF was 65%. The LV thrombus became split into three fragments (3.2 · 1.34; 1.05 · 0.87; and 2.28 · 0.7 cm). Wall motion abnormalities were absent. The SPECT showed stress images unaltered, with better tracer uptake in the anterior wall. At rest remarkable improvement was noted in anterior and lateral LV segments. Full hematologic and molecular remission was accompanied by spectacular improvement in cardiac function, probably due to decreased eosinophilic infiltration, and in improved renal function. In HES with FIP1L1-PDGFRA fusion gene, imatinib offers an advantage beyond symptomatic, molecular and laboratory improvement. Our observation provides evidence for the postulated (1, 3) organ function improvement with imatinib therapy.

More on: fluvastatin inhibits upregulation of tissue factor expression by antiphospholipid antibodies on endothelial cells

apoptotic bodies. Not only has their numeration to be accomplished, but the main associated biological functions have to be assessed in the light of their composition. The Forum appears timely in that it emphasizes that instrumentation (flow cytometer capacities and limitations) and reagents (antibody specificity and enzyme and cofactor quality for functional assays) have to be considered as primary sources of interlaboratory variability. In order to identify the different groups interested in this standardization goal, an extended version of the first questionnaire is being prepared and will be available at http://www. med.unc.edu/isth/SSC/WG_Vascular_Biology-Questionnaire.doc. The replies should be returned as soon as possible to nadege.marchetto@pharmacie.univ-mrs.fr This detailed survey should prove of prime interest to enter the second phase of standardization with specific tasks to be discussed at the 51st annual SSC Meeting scheduled on 6–7 August 2005, in Sydney. References

Renal interstitial mast cell counts differ across classes of proliferative lupus nephritis

Systemic lupus erythematosus frequently involves the kidneys leading to significant morbidity and mortality. It is classified according to glomerular involvement pattern but tubulointerstitial lesions are also important for progression and prognosis, as seen in other kidney glomerular diseases. One of the cell types which participate in this process are mast cells. The aim of the study was to analyze the counts of tryptase-positive and chymase-positive mast cells in lupus nephritis classes II, III and IV. Material consisted of 42 renal biopsies from patients with lupus nephritis; 11 class II, 9 class III and 22 class IV. Chymase- and tryptase-containing cells were stained by immunohistochemistry and counted microscopically. Mean count of chymase-positive mast cells was 9.8/10 high power fields (hpf) for the whole group, 4.66 for class II, 11.89 for class III, and 11.51 for class IV. The mean count of tryptase-positive cells was 18.6/10 hpf for the whole group, 7.65 for class II, 25.57 for class III, and 21.23 for class IV. The differences between lupus nephritis classes were significant both for chymase- and tryptase-positive cells. Tryptase- but not chymase-positive cell counts showed a correlation with the creatinine level (R = 0.35). These results suggest that mast cells are involved to a different degree in the pathogenesis of lupus nephritis depending on the class of the disease.