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8Для дальнейшего обследования больной направлен в Национальный институт фтизиатрии и пульмонологии.
Литература
1. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension
2. Екзогенний алерпчний альвеолгг: етюпа-тогенез, дiагностика, клшка, лшування, О.М. Охотшкова, О.1. Усова УКР. МЕД. ЧАСОПИС, 4 (120) - VII/VIII 2017 | www.umj.com.ua
3. https://www.ersnet.org/
4. https://phassociation.org/
FEATURES OF MYOCARDIAL REMODELING IN MEN WITH POST-INFARCTION CARDIOSCLEROSIS AND ITS RELATIONSHIP WITH TOLL-LIKE RECEPTORS 2 AND 4 IN
SERUM
Nazarova M.
Assistant, Department of internal medicine №1 National Pirogov Memorial Medical University, Vinnytsya, Ukraine
Stanislavchuk M.
MD, PhD, Professor, Head of the Department of internal medicine №1 National Pirogov Memorial Medical University, Vinnytsya, Ukraine
Burdeina L.
MD, PhD, Associate professor, Department of internal medicine №1 National Pirogov Memorial Medical University, Vinnytsya, Ukraine
ABSTRACT
Coronary heart disease (CHD) is the leading cause of mortality amongst the working-age population. Development of heart failure in patients with CHD, is significantly accelerated as a result of maladaptive changes in the structural and functional parameters of the heart that manifested by myocardial infarction (MI). It was recently discovered that toll-like receptors (TLR) play an important role in the mechanisms of myocardial hypertrophy and cardiac fibrosis. The study of the association between TLR levels and features of post-infarction myocardial remodeling in CHD remains relevant.
The aim is to study the relationship between TLR2 and TLR4 receptor levels with features of left ventricle (LV) myocardial remodeling in men with post-infarction cardiosclerosis.
Materials and methods
164 men with stable CHD and post-infarction cardiosclerosis (53.0 ± 9.14 (M ± c) years) were examined. The content of TLR2 and TLR4 in the serum was determined by ELISA (Cloud-Clone Corp., USA). Echocardiography was performed using a standard technique, the type of LV geometry was determined according to Ganau. The study was conducted in compliance with bioethical standards. Statistical processing of the results was performed using SPSS Statistics 22 package.
Results
Men with post-infarction cardiosclerosis showed higher levels of TLR2 and TLR4 (in 1.8 - 2.2 times, p <0.001) in their serum than those of the control group. Increased levels of TLR2 and TLR4 were accompanied by impaired systolic and diastolic function of the LV and increased LV hypertrophy. High TLR4 levels are associated with an increased incidence of maladaptive LV remodeling by eccentric type of hypertrophy (OR 6.03, p <0.001), while high TLR2 levels are more strongly associated with concentric LV hypertrophy (OR 2.91, p <0.005).
Conclusions
In men with post-infarction cardiosclerosis, elevated TLR2 and TLR4 levels are associated with an increase in LV hypertrophy and an impairment of LV systolic and diastolic function. Decrease of ejection fraction and eccentric hypertrophy of LV is associated with an increase of TLR4 than of TLR2. Imbalances in the circulating TLR system should be considered an additional factor in maladaptive cardiac remodeling in patients with CHD.
Keywords: coronary heart disease, myocardial remodeling, toll-like receptors.
Introduction
Coronary heart disease (CHD) remains the leading medical and social problem of recent times due to its high prevalence, rapid disability and high mortality of those of working age. In 2018, 34 cases of primary disability and 694.5 deaths per 100, 000 among the able-bodied population were linked to CHD in Ukraine [1].
The consequence of CHD is heart failure (HF), which occurs as a result of maladaptive changes in the structural and functional parameters of the heart. Typically, HF is diagnosed with clinical symptoms, but simultaneously for a long time asymptomatic changes occur in the myocardium and vessels of organic and / or
functional genesis. [2]. The development of HF in patients with CHD manifested by myocardial infarction (MI) is significantly accelerated. Therefore, the establishment of factors that can modify the course of post-infarction cardiac remodeling remains relevant.
More and more data is being accumulated, that proves the primary role in the mechanisms of development of cardiovascular pathology is played by toll-like receptors (TLR). They provide innate immunity and are involved in the recognition of numerous exogenous and endogenous ligands [3]. In experimental studies, TLR2 and TLR4 have been implicated in the development of myocardial hypertrophy and cardiac fibrosis [4; 5;6].
For example, removal of TLR2 and TLR4 genes prevented cardiac hypertrophy in mice by experimental ischemia / reperfusion [5]. Blocking TLR4, reduced the signs of systolic and diastolic dysfunction, and also prevented an increase in the production of pro-inflammatory cytokines, development of interstitial fibrosis and cardiac hypertrophy after MI in animals [4]. Antibodies to TLR2 inhibit the activation of nuclear transcription factor kB (NF-kB) and reduce cardiac fibrosis [7]. The relationship between expression of TLR2, TLR4 and features of post-infarction cardiac remodeling in patients with CHD has not yet been established.
The aim is to study the relationship between TLR2 and TLR4 receptor levels with features of left ventricle (LV) myocardial remodeling in men with post-infarction cardiosclerosis.
Materials and methods
164 patients with stable CHD with post-infarction cardiosclerosis, at the age of 53.0 ± 9.14 years and total disease duration 42.0 [14; 99] months were examined. All patients were treated at the cardiology and outpatient departments of Vinnytsia Regional Clinical Hospital named after Pirogov within the years of 20132018. The study was conducted in compliance with bi-
Clinical and demographic features
Blood for the studies was obtained under standard conditions, in the morning on an empty stomach after a night of fasting. The serum was stored in Eppendorf micro-tubes at - 20oC until the study. The determination of TLR2 and TLR4 was performed by ELISA using the Enzyme-linked Immunosorbent Assay Kit For Toll Like Receptor 2 (TLR2) (SEA663Hu, Cloud-Clone Corp.) and Enzyme-linked Immunosorbent Assay Kit For Toll Like Receptor 4 (TLR42) (SEA753Hu, Cloud-Clone Corp.). Concentrations of standard solutions for the construction of calibration curves - 0.0; 0.312; 0.625; 1.25; 2.5; 5; 10 and 20 ng / ml. The determination was performed on a STAT-FAX 303+ analyzer (USA) at a wavelength of 450 nm (differential filter -630 nm). The sensitivity of the method for TLR2 < 0.112 ng / ml, for TLR4 < 0.118 ng / ml, the coefficient of variation < 10%.
Echocardiography in M-, B- and D-modes was performed by the standard method. End-diastolic volume (EDV) and end-systolic volume (ESV); end-dias-tolic volume index (EDVI) and end-systolic volume index (ESVI); end-diastolic diameter (EDD) and end-systolic diameter (ESD); LV posterior wall thickness in diastole (LVPWTd); intraventricle septal thickness in diastole (IVSTd); relative wall thickness (RWT) of LV was determined by the equation RWT = (LVPWTd + IVSTd) / EDD; LV mass (LVM) by the equation ASE; LV mass indexed (LVMI); ejection fraction (EF) were
oethical principles according to the Helsinki Declaration "Ethical Principles for Medical Research Involving Human Subjects" with subsequent revisions, European Convention of Human Rights and Biomedicine.
The diagnosis of stable CHD was established according to the recommendations of the AHA / ACC (2014) and ESC (2013). The criteria for inclusion of patients in the study were as follows: male; age > 25 years; verified post-infarction cardiosclerosis; duration of the disease from 3 months or more after the last MI; presence of patient's consent to participate in the study. Exclusion criteria were the following: female, acute coronary syndrome, uncontrolled arterial hypertension, hemodynamic unstable arrhythmias, type 1 and 2 diabetes mellitus in decompensated stages.
The study included 123 (75%) patients who underwent Q-MI and 41 (25%) patients who underwent non-Q-MI, including 17 (10.4%) patients who had recurrent MI (Table I). Comorbid conditions were found in 143 (87.2%) patients, the most common being arterial hypertension (AH) (85.4%) and abdominal obesity (50.6%). The control group consisted of 48 men aged 52.1 ± 8.69 years and corresponded to the main group by clinical and demographic parameters.
Table 1
of CHD group and control group
evaluated. LV hypertrophy in men was diagnosed with LVMI > 115 g / m2 [8]. LVMI 115.1 - 131.9 g / m2 was regarded as a mild LV hypertrophy (LVH), LVMI 132 - 148.9 g / m2 as a moderate, LVMI > 149 g / m2 as a severe LVH.
The type of structural-geometric remodeling of the LV was determined by the Ganau principle: normal geometry of LV (NG LV): LVMI < 115 g / m2, RWT < 0.42; concentric remodeling of LV (CR LV): LVMI < 115 g / m2, RWT > 0.42; concentric hypertrophy of LV (CH LV): LVMI > 115 g / m2, RWT > 0.42; eccentric hypertrophy of LV (EH LV) LVMI > 115 g / m2, RWT < 0.42.
Statistical processing was performed using SPSS Statistics 22.0. Student's t-test was used to estimate the difference between groups in the normal distribution, and Mann-Whitney U-test was used for the distribution which differed from the norm. The normality of the distribution was checked using Kolmogorov-Smirnov and Shapiro-Wilk criteria. Pearson correlation analysis was used to determine relationships between indicators, using Fisher's exact method when comparing the frequency of changes. The odds ratio (OR), confidence intervals (95% CI) were evaluated. The difference at p < 0.05 was considered significant.
Results
It was found (Table 2) that TLR2 level in control group was 0.21 ± 0.10 ng / ml with fluctuations from
Patients with CHD, n=164 Control, n=48 p value
Age, years (M±c) 53.0±9.14 52.1±8.69 0.860
Body mass index, kg / m2 (M±c) 29.9±3.74 29.2±2.68 0.141
Waist circumference, sm (M±c) 102.9±9.0 100.5±9.9 0.110
SBP, mm Hg (M±g) 138.4±15.5 134.7±12.5 0.261
DBP, mm Hg. (M±c) 86.9±10.1 85.6±10.2 0.592
Smoking, n (%) 67 (40.9 %) 15 (31.3 %) 0.243
Notes: systolic blood pressure (SBP), diastolic blood pressure (DBP)
0.0 to 0.38 ng / ml (95% CI). The level of TLR4 in the control group was 0.32 ± 0.16 ng / ml with fluctuations from 0 to 0.55 ng / ml (95% CI). TLR2 and TLR4 levels above the 95th percentile values (> 0.38 and 0.55 ng / ml, respectively) were considered high. In patients with CHD, TLR2 and TLR4 levels were significantly 2.2 and 1.8 times higher, respectively, then in the control group. Among patients with CHD there were 59.8%
and 52.4% of persons with high levels of TLR2 and TLR4, while in the control group - 6.3% and 8.3% (p <0.001), respectively. It was found that the control group and the group of patients with CHD differ not only in absolute values of levels TLR2 and TLR4, but also in their ratio. Thus, in patients with CHD, the ratio of TLR2 / TLR4 was 1.33 times higher than in the control group.
Table 2
Levels of TLR 2 and 4 in patients with CHD depending on the severity of LVH
Group TLR2, ng / ml TLR4, ng / ml TLR2 / TLR4
Control group, n=48 0.21±0.10 0.32±0.16 0.63±0.24
Patients with CHD, n=164 0.46±0.17 0.58±0.21 0.84±0.46
P <0.001 <0.001 <0.01
No LVH, n=89 0.42±0.16 0.52±0.19 0.79±0.19
LVH, n=75 0.51±0.18 0.64±0.21 0.82±0.20
p 1 < 0.01 < 0.01 > 0.05
Distribution by the severity of LVH
Mild LVH, n=52 0.47±0.16 0.61±0.21 0.80±0.20
p i < 0.05 < 0.05 > 0.05
Moderate LVH, n=13 0.55±0.14 0.66±0,21 0.86±0.16
P i < 0.01 < 0.05 > 0.05
P 2 > 0.05 > 0.05 > 0.05
Severe LVH, n=10 0.69±0.20 0.74±0.19 0.94±0.17
P i < 0.001 < 0.01 < 0.05
P 2 < 0.01 > 0.05 < 0.05
Notes: the results are given as M±c; p: - authenticity about «No LVH», p2 - authenticity about «Mild LVH».
Patients with CHD with LVH (LVMI > 115 g / m2) showed significantly higher levels of TLR2 and TLR4 (21.4% and 23.1%, respectively) than in patients without LVH. The increase of LVH was accompanied by a statistically significant rise of TLR2 and TLR4, with a tendency to increase the ratio of TLR2 / TLR4. TLR2, TLR4 and TLR2 / TLR4 ratio were significantly higher in patients with severe LVH by 46.8%, 21.3%, and
17.5%, respectively, than in patients with mild LVH. An association was found between an increase levels of TLR and a decrease LV EF (Table 3): in patients with LV EF < 40%, the TLR 4 level was significantly (22.2%) higher than in patients with LV EF > 50%. Also there was a trend toward an increase in TLR2 levels with impaired LV systolic function.
Table 3
Levels of TLR 2 and 4 in patients with CHD with normal and reduced ejection fraction (EF)
Group TLR2, ng / ml TLR4, ng / ml TLR2 / TLR4
EF > 50%, n=91 0.45±0.17 0.56±0.18 0.81±0.17
EF 40 - 49,9 %, n=57 0.47±0.15 0.60±0.23 0.79±0.20
P 1 > 0.05 > 0.05 > 0.05
EF < 40 %, n=16 0.55±0.05 0.71±0.22 0.81±0.26
P 1 > 0.05 < 0.05 > 0.05
P 2 > 0.05 > 0.05 > 0.05
Notes: the results are given as M±c; p1 - authenticity about «EF > 50%», p2 - authenticity about «EF 40 -49.9 %».
Increased expression of TLR2 and TLR4 in men with post-infarction cardiosclerosis was associated with the development of maladaptive myocardial remodeling (Table 4): levels of these receptors were significantly higher in patients with CR LV (38.2% and
34.9%, respectively), CH LV (50.0% and 44.1%, respectively) and EH LV (55.9% and 60%, respectively) than in patients with NG LV. Also, in patients with CH LV the TLR2 / TLR4 ratio was significantly higher by 10.4% than in patients with NG LV.
Table 4
Levels of TLR 2 and 4 in patients with CHD depending on the type of LV remodeling_
Group TLR2, ng / ml TLR4, ng / ml TLR2/TLR4
NG LV, n=36 0.34±0.12 0.43±0.17 0.77±0.12
CR LV, n=53 0.47±0.15 0.58±0.18 0.80±0.21
P 1 < 0.01 < 0.01 > 0.05
CH LV, n=53 0.51±0.18 0.62±0.23 0.85±0.16
P 1 < 0.001 < 0.01 < 0.01
P 2 > 0.05 > 0.05 > 0.05
EH LV, n=22 0.53±0.16 0.69±0.17 0.79±0.24
P 1 < 0.01 < 0.001 > 0.05
P 2 < 0.01 < 0.05 > 0.05
P 3 > 0.05 > 0.05 > 0.05
Notes: the results are given as M±c; p1 - authenticity about «NG LV», p2 - authenticity about «CR LV», p3 -authenticity about «CH LV».
The analysis of OR (Table 5) showed, that in the presence of high levels of TLR2 (above 0.38 ng / ml) and TLR4 (above 0.55 ng / ml) the chances of formation of LVH significantly increase (OR 2.89 and
2.90 , p = 0.001). It should be noted that the increase in TLR2 level was more closely associated with CH LV (OR 2.61, p = 0.005), and the increase in TLR4 level -with EH LV (OR 2.23, p = 0.0001).
Table 5
Odds ratio of LV remodeling type in men with CHD with post-infarction cardiosclerosis depending on levels
TLR 2 and 4
Group Levels of TLR, n (%) OR (95% CI) P
High Normal
TLR2
No LVH 43 (48.3 %) 46 (51.7 %) 1
LVH 55 (73.3 %) 20 (26.7 %) 2.89 (1.51- 5.57) 0.001
CH LV 39 (73.6 %) 14 (26.4 %) 2,91 (1.40 - 6.04) < 0.005
EH LV 16 (72.7 %) 6 (27.3 %) 2.71 (1.00 - 7.36) 0.056
TLR4
No LVH 36 (39.3 %) 53 (60.7 %) 1
LVH 50 (77.3 %) 25 (22.7 %) 2.90 (1.54 - 5.48) 0.001
CH LV 32 (83.0 %) 21 (17.0 %) 2.22 (1.11 - 4.41) 0.025
EH LV 18 (63.6 %) 4 (36.4 %) 6.03 (1.98 - 18.3) < 0.001
Correlation analysis (Table 6) confirmed the pres- levels (r > 0.3, p < 0.0001), and reliable correlation of ence of statistically significant relationships between EDD, EDV and EDVI with TLR4 (r = 0.20-0.22, p < the mass index and thickness of the LV myocardium 0.01). (LVM, LVMI, LVPWTd, IVSTd) and TLR2, TLR4
Table 6
Pearson correlation coefficients between LV echocardiography parameters and TLR 2 and 4 levels (n = 164)
TLR2 TLR4
r P r P
ESD 0.176 0.025 0.240 0.002
ESV 0.151 0.054 0.229 0.003
ESVI 0.139 0.075 0.218 0.005
EDD 0.145 0.063 0.203 0.009
EDV 0.148 0.058 0.211 0.007
EDVI 0.131 0.095 0.200 0.010
LVPWTd 0.271 < 0.0001 0.279 < 0.0001
IVSTd 0.308 < 0.0001 0.268 0.001
LVM 0.306 < 0.0001 0.295 < 0.0001
LVMI 0.295 < 0.0001 0.296 < 0.0001
EF LV -0.133 0.090 -0.179 0.021
Notes: The Pearson correlation coefficients ( % ) and their significance (p).
Discussion
According to the results of this study, increases of TLR2 and TLR4 levels in men with post-infarction cardiosclerosis are consistent with previous findings. For
example, Gurses K.M. and al. (2015) showed that patients with various forms of CHD have increased expression of TLR2 and TLR4, with the highest rates in patients who underwent acute coronary syndrome [9].
In patients with CHD, an increase in TLR4 expression in monocytes and tissue of the heart was associated with LV dysfunction, and after surgical coronary circulation recovery, TLR4 expression decreased [10]. TLR2 and TLR4 have been found to be expressed directly in the vessels [11] and were associated with hypertension [12], which plays a key role in CR and LVH.
Thus, increased expression of toll-like receptors (TLR2 and TLR4) should be considered as additional pathogenetic factors for the maladaptation of LV remodeling and LVH in men with post-infarction cardio-sclerosis.
Conclusions
In men with post-infarction cardiosclerosis, there is a rise in TLR2 and TLR4 levels, which is associated with an increase in the severity of LVH, impaired LV systolic and diastolic function. Decreased EF and EH LV are more closely associated with an increase in TLR4 than TLR2. Imbalances in the circulating TLR system should be considered as an additional factor in maladaptive cardiac remodeling and accelerated development of HF in patients with CHD with post-infarction cardiosclerosis.
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