| Sažetak | Cilj rada: Odrediti koncentracije cirkulirajućih toplinskih stresnih bjelančevina (HSPs, engl. heat shock proteins) grupa Hsp90, Hsp70, Hsp60 i Hsp27 u bolesnika s akutnim infarktom miokarda s perzistirajućom elevacijom ST segmenta (STEMI, engl. ST Elevation Myocardial Infarction) koji će biti liječeni primarnom perkutanom koronarnom intervencijom (PCI, engl. percutaneus coronary intervention) te bolesnika s akutnim infarktom miokarda bez elevacije ST segmenta (NSTEMI, engl. Non ST Elevation Myocardial Infarction), s nestabilnom i stabilnom anginom pektoris (AP) koji će biti liječeni samo medikamentoznom terapijom i zdravih ispitanika kao kontrolne skupine te ih međusobno usporediti između ispitivanih grupa. Usporediti koncentracije Hsp90, Hsp70, Hsp60 i Hsp27 sa standardnim biljezima nekroze miokarda, kardijalnim troponinom I (cTnI), laktat dehidrogenazom (LDH) i nespecifičnim upalnim pokazateljima: hsC-reaktivnim proteinom (hsCRP), sedimentacijom eritrocita (SE) i brojem leukocita (L) iz svake pojedine skupine bolesnika.
Bolesnici i metode. U prospektivno istraživanje uključeno je 115 bolesnika, podijeljenih u četiri skupine: 34 bolesnika s akutnim STEMI-jem, 32 s akutnim NSTEMI-jem, 29 s nestabilnom AP i 20 sa stabilnom AP te 20 zdravih ispitanika kao kontrolne skupine. Uzorak je prikupljen na Zavodu za kardiovaskularne bolesti, Klinike za internu medicinu, KBC Rijeka. Akutni STEMI i NSTEMI dijagnosticirani su u skladu s trenutnim smjernicama, a bolesnici sa STEMI-jem liječeni su primarnim PCI-om, a s NSTEMI-jem medikamentoznom terapijom. Osim praćenja niza standardnih demografskih i laboratorijskih varijabli (dob, spol, pušenje, arterijska hipertenzija, dijabetes melitus, hiperlipoproteinemija, obiteljsko okupljanje oko kardiovaskularnih bolesti, indeks tjelesne mase, rutinske laboratorijske pretrage), bolesnicima su određivani Hsp90, Hsp70, Hsp60, Hsp27, cTnI, hsCRP pri prijemu u svim skupinama, a u skupini STEMI-ja i NSTEMI-ja još nakon 12 sati i četvrtog dana hospitalizacije. Također se razlučilo vrijeme pojave anginozne boli do dolaska u bolnicu (do 3h, 6h, 12h i >12h) te analizirane su korelacije s HSP-ima, cTnI-om, LDH-om, hsCRP-om. Učinjena je analiza i usporedba Hsp27, Hsp60, Hsp70, Hsp90 sa standardnim biljezima nekroze, cTnI-om i LDH-om te jednostavnim biljezima upale: hsCRP-om, SE i leukocitima te je utvrđena njihova moguća dijagnostička vrijednost. Statistička obrada prikupljenih podataka oblikovana je u MS Excel programu, a obrada i analiza izvršena je korištenjem statističkog programskog paketa STATISTICA (data analysis software system), version 10.0, StatSoft, Inc. (2012). Prikupljeni podaci opisani su i analizirani različitim statističkim metodama ovisno o tipu i raspodjeli varijabli prisutnih u analizi.
Rezultati. U svih bolesnika i zdravih ispitanika su detektirani cirkulirajući Hsp90, Hsp70, Hsp60, osim Hsp27 koji se pojavio u serumu samo u bolesnika sa STEMI-jem i nestabilnom AP. Pri prijemu, prosječne srednje vrijednosti koncentracija cirkulirajućih Hsp90 bile su statistički značajno više u bolesnika sa STEMI-jem i NSTEMI-jem nego u ostalim skupinama (ANOVA, F=66,72, p<0,00), a koncentracije Hsp90 se ne razlikuju među tim skupinama (post hoc LSD test, p=0,133). Dinamička analiza pokazala je značajni rast koncentracija Hsp90 od drugog na treće mjerenje u skupini STEMI-ja, a u NSTEMI-ju je bilo obrnuto, padaju vrijednosti. Ovakva dinamika vrijednosti Hsp90 dobro je razlikovala skupine STEMI-ja i NSTEMI-ja. Pokazala se pozitivna korelacija cirkulirajućih Hsp90 s cTnI-om, hsCRP-om u skupini NSTEMI-ja, a u skupini STEMI-ja povezanost s cTnI-om. Prosječna inicijalna koncentracija cirkulirajućih Hsp70 u zdravih osoba, ne razlikuje se značajno od bolesnika sa stabilnom i nestabilnom AP (post-hoc LSD, p>0,05). Međutim, u bolesnika s AIM-om, značajno su povišene srednje inicijalne koncentracije (ANOVA, F=38,51, p<0,001), ali nema statitističkih značajnih razlika između skupina STEMI-ja i NSTEMI-ja (post hoc LSD test, p=0,811). U skupini NSTEMI-ja nije dokazana korelacija Hsp70 s promatranim biljezima nekroze miokarda, upalnim parametrima, dobi bolesnika niti ITM-om, a u skupini STEMI-ja utvrđena je povezanost s cTnI-om, SE i ITM-om koja je negativna i slaba (|r|<0,40). Prosječne srednje koncentracije cirkulirajućih Hsp60 su bile niskih vrijednosti i nije bilo statistički značajnih razlika među svim skupinama bolesnih ispitanika i kontrolne skupine zdravih ispitanika (ANOVA, F=1,13, p=0,344). Usporedbene analize nisu dokazale korelaciju cirkulirajućih Hsp60 s cTnI-om, LDH-om, hsCRP-om, SE, L-ma, dobi bolesnika i ITM-om. Koncentracije cirkulirajućih Hsp27 izmjerene su samo u bolesnika sa STEMI-jem i nestabilnom AP, u vrijednostima donje granice detekcije, a izmjerene koncentracije Hsp27 se nisu statistički značajno razlikovale prema ostalim skupinama ispitanika (ANOVA, F=1,43, p=0,229). Za prisutne Hsp27 u serumu bolesnika s AIM-om i nestabilnom AP, nije dokazana povezanost ni s jednim biljegom.
Zaključak. Cirkulirajuće toplinske stresne bjelančevine 90 i 70 povezane su s AKS-om, odnosno značajno su povišene u STEMI-ju i NSTEMI-ju. Dodatna primjena Hsp70, a naročito, Hsp90 kao mogućih, dodatnih, biljega nekroze miokarda, mogla bi značajno poboljšati laboratorijsku dijagnostiku u ranoj fazi AKS-a te razlikovanje bolesnika s nestabilnom anginom pektoris i onih s infarktom miokarda. Cirkulirajući Hsp90 možda imaju ulogu u upalnom odgovoru u NSTEMI-ju koji nisu liječeni PCI-em. Cirkulirajući Hsp60, a posebno, Hsp27 nisu značajno povišeni u NSTEMI-ju liječenih medikamentoznom terapijom niti u STEMI-ju, tretiranih primarnim PCI-em. |
| Sažetak (engleski) | Objectives. To determine the concentration of circulating heat stress proteins (HSPs) group Hsp90, Hsp70, Hsp60, Hsp27, in patients with ST elevation myocardial infarction (STEMI) who will be treated with primary percutaneous coronary intervention (PCI) and in patients with non ST elevation myocardial infarction (NSTEMI) with unstable and stable angina pectoris (AP) who will be treated with drug therapy only and healthy subjects as controls and compare them between examined groups. To compare the concentration of Hsp90, Hsp70, Hsp60 and Hsp27 with standard markers of myocardial necrosis, cardiac troponin I (cTnI), lactate dehydrogenase (LDH) and non - specific inflammatory indicators: hsC-reactive protein (hsCRP), erythrocyte sedimentation rate (SE) and the number of leukocytes (L) from each group of patients.
Patients and Methods. The prospective study included 115 patients, divided into four groups: 34 patients with acute STEMI, 32 with acute NSTEMI, 29 with unstable AP, 20 with stable AP and 20 healthy subjects as controls. The sample was collected at the Department of Cardiovascular Diseases, Clinic of Internal Medicine, University Hospital Rijeka. Acute STEMI and NSTEMI were diagnosed in accordance with current guidelines. Patients with STEMI were treated with primary PCI, and patients with NSTEMI with drug therapy. In addition to tracking a range of standard laboratory and demographic variables (age, gender, smoking, hypertension, diabetes mellitus, hyperlipoproteinemia, family gathering around cardiovascular disease, body mass index, routine laboratory tests), patients' Hsp90, Hsp70, Hsp60, Hsp27, cTnI, hsCRP were determined on admission in all groups, and in group of STEMI and NSTEMI again after 12 hours and on the fourth day of hospitalization. Onset of anginal pain prior to arrival at hospital (up to 3 h, 6h, 12 h> 12 hours) was also determined and correlation with HSP, cTnI, LDH, hsCRP was analysed. We performed the analysis and comparison of Hsp27, Hsp60, Hsp70, Hsp90 with a standard necrosis marker (cTnI) and LD and simple markers of inflammation hsCRP, SE and leukocytes. Their possible diagnostic value was determined. Statistical analysis of the collected data is designed in MS Excel program, while processing and analysis was performed using the statistical software package STATISTICA (data analysis software system), version 10.0, StatSoft, Inc. 2012.) The collected data is described and analyzed by various statistical methods depending on the type and distribution of the variables in the present analysis.
Results. In all patients and healthy subjects circulating Hsp90, Hsp70 and Hsp60 were detected, except Hsp27, which appeared only in serum of patients with STEMI and unstable AP. On admission, the average mean concentration of circulating Hsp90 was significantly higher in patients with STEMI and NSTEMI than in the other groups (ANOVA, F = 66.72, p <0.00), and the value of Hsp90 did not differ among these groups (LSD post hoc test, p = 0.133). Dynamic analysis showed a significant increase of Hsp90 in the group of STEMI, from the second to the third measuring. In NSTEMI the situation was reversed, values fell. These dynamics of values of Hsp90 are well distinguishing groups of STEMI and NSTEMI. Positive correlation of circulating Hsp90 with cTnI, hsCRP was present in NSTEMI group, while STEMI group there was association with cTnI. The average initial height of circulating Hsp70 in healthy people, is not significantly different from patients with stable and unstable AP (post-hoc LSD, p> 0.05). However, in patients with AMI, mean initial values Hsp70 (ANOVA, F = 38.51, p <0.001)were significantly elevated, but no significant statistical differences were noticed between STEMI and NSTEMI groups (post-hoc LSD test, p = 0.811). In the group of NSTEMI correlation with Hsp70 observed markers of myocardial damage, inflammatory parameters, the patient's age or body mass index (BMI) has not been proven. In the group of STEMI connections with cTnI, SE and BMI was established, which is negative and weak (|r|<0,40). Average mean values of circulating Hsp60 low and there was no statistically significant difference among all groups of sick patients and a control group of healthy subjects (ANOVA, F = 1.13, p = 0.344). Comparative analysis did not prove the correlation of circulating Hsp60 with cTnI, LDH, hsCRP, SE, L, patient age or BMI. The concentrations of circulating Hsp27 were measured only in patients with STEMI and unstable AP, the values were at the lower limit of detection. The measured values of Hsp27 did not significantly statistically differ in comparison with other groups of patients (ANOVA, F = 1.43, p = 0.229). For present Hsp27 in the serum of patients with AIM and unstable AP the connection with any marker was not determined.
Conclusion. Circulating heat stress proteins 90 and 70 are associated with ACS, i.e. they are significantly elevated in STEMI and NSTEMI. Additional application of Hsp70, and especially, Hsp90, as possible, additional, markers of myocardial necrosis, could significantly improve laboratory diagnosis at an early stage of ACS and distinguish patients with unstable angina and those with myocardial infarctation. Circulating Hsp90 may play a role in the inflammatory response in NSTEMI who are not treated with PCI. Circulating Hsp60, and particularly Hsp27 were not significantly elevated in NSTEMI treated with drug therapy or in STEMI treated with primary PCI. |
