Clinical Characteristics Of Patients With Both Coronary Heart Disease And Hypertension And Research On The Predictive Value To Relapsed Cardiac Events

BackgroundNowadays the morbidity of atherosclerosis is more and more all over the world. It has become the main cause of cardiovascular and cerebrovascular disease and is also the cardinal reason of mortality. As a common and important factor among traditional risk factors, hypertension has attracted the widespread concern. But the present situation of the morbidity of hypertension is still not satisfactory, and hypertension is still an important risk factor of cardiovascular and cerebrovascular disease. Therefore it’s clinically significant to analyze the clinical, laboratory, intravascular and carotid ultrasound index of patients with both coronary heart disease and hypertension and to find the factors that affect prognosis and predictive value on relapsed cardiac events.Coronary angiography (CAG) has been considered to be the gold standard in the diagnosis of coronary heart disease. But some CAG results of the patients who have clinical cardiac events appear to have no significant luminal stenosis. So it has been the highlight to find some new reliable clinical or laboratory indicators to predict the relapsed cardiac events of high-risk patients with coronary artery disease.So far, a lot of inflammatory markers have been studied on the predictive value of atherosclerosis, but the research on the predictive value of relapsed cardiac events about some new serum inflammatory markers is rare, such as phosphatidylcholine-specific phospho-lipase C (PC-PLC), secretory phospholipase A2(sPLA2), soluble CD40ligand (sCD40L), myeloperoxidase (MPO), interleukin-6(IL-6), monocyte chemotactic protein-1(MCP-1), and tissue factor (TF). We have still not found exactly reliable indictors to predict atherosclerosis and the relapsed cardiac events of patients with coronary artery disease.Objectives1. To investigate the similarities and differences of clinical risk factors, serum biomarkers, intravascular and carotid ultrasound index between the patients of coronary heart disease with and without hypertension.2. To investigate the predictive value of clinical risk factors, serum biomarkers, intravascular and carotid ultrasound index on relapsed cardiac events in patients with both coronary heart disease and hypertension after adjustment for classical cardiac risk factors.Methods1. Subjects and GroupWe enrolled889patients with coronary heart disease from eight hospitals include Shandong University Qilu Hospital from February2008to June2010. The inclusion criteria is:after coronary angiography (CAG) examination, the patients should have a main stenosis≥50%in the coronary artery and have another stenosis≥30%which need not to be treated(and it should be ruled out by coronary spasm). The situation below should be excluded:1) the patients with moderate or severe heart valve disease;2)the patients with serious arrhythmia;3) the patients who have moderate cardiac dysfunction and above;4)the patients who have serious hypertension and still not get controlled;5) the patients who have the active liver disease, or whose ALT (AST) is more than three times of the normal upper limit;6) the patients with anemia;7) the patients who were in acute or chronic infection status;8) the patients whose expected life period is less than three years because of non-cardiac reasons;9)the patients who have serious mental illness.All the patients enrolled were divided into two groups:group with hypertension and group without hypertension. The diagnosis standard of hypertension is internationally accepted:in resting state, SBP≥140mmHg and/or DBP≥90mmHg.2. Instrument Philips Allura FD20cardiovascular digital silhouette instrument was used in coronary artery angiography; Ilab intravascular Ultrasonic displayer produced by Boston Scientific Company was used in intravascular ultrasound examination; Sequoia C512type ultrasonic diagnostic instrument produced by German Siemens Company was used in carotid ultrasound examination.3. MethodAll the patients enrolled underwent history collection, laboratory examination, coronary artery angiography, intravascular ultrasound examination and carotid ultrasound, and regular follow-up.In laboratory examination, the peripheral total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), apolipoprotein Al (apoAl), apolipoprotein B (apoB), blood sugar, creatinine, uric acid, high sensitivity C-reactive protein (hs-CRP), phosphatidylcholine-specific phospho-lipase C (PC-PLC), secretory phospholipase A2(sPLA2), soluble CD40ligand (sCD40L), myeloperoxidase (MPO) interleukin-6(IL-6), monocyte chemotactic protein-1(MCP-1), and tissue factor (TF) were assayed.In intravascular ultrasound examination, the index recorded include:external elastic membrane area (EEMA), vascular remodeling index (RI), plaque cross-sectional area, plaque volume (PV), plaque burden (PB), plaque rupture and plaque type.In carotid ultrasound examination, intima-medial thickness (IMT), carotid artery systolic peak velocity (SPV), carotid artery compliance (EP), carotid artery systolic shear rate (SRs), the incidence of plaques in common carotid artery and the bifurcate place of carotid artery were measured.4. Statistical analysisData were analyzed with SPSS software version16.0. Numerical variables were demonstrated as means±standard deviation (SD). Categorical variables were demonstrated as number (percentage). Measurement features between patients with hypertension and without hypertension were evaluated with Independent-samples t test, while Chi-square test was used for the categorical variables. Pearson bivariate correlation was used to analyze the correlation between variables. Binary logistic regression model was used to evaluate the predict power of all the indexes on relapsed cardiac events in patients with both coronary heart disease and hypertension. After that a receiver operating characteristic curve (ROC curve) was plotted to compare the predictive value of the indexes. Only when p<0.05, results were considered as statistically significant.Results1. The general situations of the patientsThe average age of the patients was59.3±10.2years old, including381cases of male and449cases of female. The number of patients with hypertension history were485(54.6%), and myocardial infarction, unstable angina pectoris, history of diabetes and history of percutaneous coronary intervention was68(7.6%),144(16.2%),199(22.4%) and169(19.0%), respectively.2. Comparison between the hypertension group and non-hypertensive groupThe average age, BMI, and history of unstable angina, history of diabetes, the proportion of stent implantation history and the proportion of relapsed cardiac events of the group of hypertension is significantly higher than that of non-hypertension group (P<0.05). The average height of hypertension group was significantly lower than non-hypertension group (P=0.004). The serum level of high-sensitivity C-reactive protein (hs-CRP), secretory phospholipase A2(sPLA2) and interleukin-6(IL-6) of hypertension group is significantly increased than non-hypertension group (P<0.05). Intima-media thickness (IMT), plaque incidence of common carotid artery and bifurcation was significantly higher than that of non-hypertension group (P<0.05). The number of soft plaque of hypertension group was significantly higher than that of non-hypertension group (P=0.036); 3. Predictive value on cardiac events of clinical and serum parameters in the hypertensive groupAmong Traditional risk factors of coronary heart disease, age, smoking and diabetes have significant predictive value on relapsed cardiac events in the hypertensive group (P<0.05). After adjustment for traditional coronary heart disease risk factors, total plasma cholesterol levels (TC), low-density lipoprotein cholesterol (LDL-C), high-sensitivity C-reactive protein (hs-CRP), and monocyte chemotactic protein-1(MCP-1) levels, have independent predictive value on relapsed cardiac events in the hypertensive group (P<0.05).4. ROC curve C statistical analysisOn the basis of traditional risk factors, we introduced other variables to the model separately according to the probability results saved in the logistic regression analysis. And then we plotted the ROC curve to compare the predictive value of each variable on the relapsed cardiac events. On the basis of traditional risk factors,total cholesterol (TC), high-sensitivity C-reactive protein (hs-CRP), monocyte chemotactic protein-1(MCP-1), plaque burden (PB), plaque rupture rate and plaque type can significantly increase the predictive ability of traditional risk factors (P<0.05).Conclusions1. In the patients with coronary artery disease and hypertension, average age, BMI, and history of unstable angina, the proportion of history of diabetes, the probability of stent implantation history, of the proportion of relapsed cardiac events, hs-CRP, sPLA2, IL-6, IMT, carotid plaque, the proportion of soft plaques are significantly improved, compared with the non-hypertension group.2. Among the traditional coronary risk factors, age, smoking, and diabetes have independent predictive value on relapsed cardiac events for patients with both coronary heart disease and hypertension. 3. After adjustment for traditional risk factors for coronary heart disease(gender, age, smoking, diabetes and body mass index), serum TC, LDL-C, hs-CRP and MCP-1levels have independent predictive value on relapsed cardiac events for patients with both coronary heart disease and hypertension.4. On the basis of traditional risk factors, total cholesterol (TC), high-sensitivity C-reactive protein (hs-CRP), monocyte chemotactic protein-1(MCP-1), plaque burden (PB), plaque rupture rate and plaque type can significantly increase the predictive ability of traditional risk factors for patients with both coronary heart disease and hypertension.