SUDAN UNIVERSITY OF SCIENCE & TECHNOLOGY

COLLEGE OF GRADUATE STUDIES

LIPID PROFILE IN SUDANESE PATIENTS WITH

MYOCARDIAL INFARCTION

Presented by:
Sulieman Mohi-eldin Omar
BSC Medical Laboratory science

Supervisor:
Dr. Badr-eldien Hassan Alabid
MBBS, MD Clinical Pathology
Associate professor of clinical pathology

A Thesis Submitted In Partial Fulfillment For

HD. Degree in Clinical Chemistry

2006

1
 DEDICATION

To the best

creature who is my

life, my sole is no

thing without thee,

I offer this.

2
 Acknowledgement

My first thankful is to Allah all of His affluences, appearing

and disappearing, and my great appreciations and gratuities were
extend to my supervisor Dr. Badr-eldien Hassan Alabid for his
precious advice and guidance upon this study.
Thanks and regards were extend to ICCU of Elshaab
Teaching Hospital staff for helping in sample collection, and
extended the members of the Laboratory of Research Unit for
helping in sample analysis.
I affirm my thanks to my teachers, colleagues and friends for
helping and encouragement.

3
 ABSTRACT

Serum total cholesterol, HDL-cholesterol, LDL-cholesterol

and triglyceride were estimated in 20 patients (12 males, 8
females) with acute myocardial infarction during acute phase (the
first two days). Serum total cholesterol, HDL-cholesterol and LDL-
cholesterol levels showed no significant differences, while
triglycerides level showed significant increased levels when
compared with results of healthy subjects (5 males, 5 females) as
control. The ratios of total cholesterol/HDLc and LDLc/HDLc also
showed no significant differences compared with control ratios. It
is concluded that in exception of triglycerides levels, there is no
change in serum lipid profile in patients with MI during the acute
phase.

4
 CONTENTS
Topic Page
Dedication II
Acknowledgement III
Abstract IV
Content V
List of figures VII
List of tables VIII
Chapter One
Introduction and Literature Review 1
1.1. Normal function & structure of the heart 2
1.2. Heart failure 3
1.3. Ischaemic heart disease 4
1.4. Acute myocardial infarction 5
1.4.1. Clinical feature 5
1.4.2. Morphological feature 5
1.4.3. Complications of myocardial infarction 6
1.4.4. Diagnosis of myocardial infarction 8
1.4.4.1. Electrocardiography 9
1.4.4.2. Cardiac markers 10
1.4.5. Treatment of myocardial infarction 12
1.5. Lipids 12
1.6. Fatty acids 13
1.7. Triglycerides 13
1.8. Cholesterol 13
1.9. Phospholipids 13
1.10. Apolipoproteins 13
1.11. Lipoproteins 14
1.12. Classification of lipoproteins 16
1.13. Metabolism of lipoproteins 18
1.13.1. Chylomicrons 18
1.13.2. Very low density lipoproteins 18
1.13.3. Low density lipoproteins 18
1.13.4. High density lipoproteins 19
1.13.5. Lipoprotein receptors 19
1.14. Disorders of lipids metabolism 21
1.14.1. Predominant hypercholesterolaemia 22
1.14.2. Secondary hypercholesterolaemia 23
1.14.3. Primary hypercholesterolaemia 23
1.14.4. Predominant hypertriglyceridaemia 24
1.14.5. Mixed hyperlipidaemia 24
1.15. Treatment of hyperlipidaemia 25

5
1.15.1. Treatment of hypercholesterolaemia 25
II.3.4.1 Treatment of hypertriglyceridaemia 25
Chapter Two 27
The Objectives of The Study
Chapter Three 28
Materials and Methods
3.1. Patients and Controls 28
3.2. Samples Collection 28
3.3. Estimation of lipid profile 28
3.3.1. Equipments 29
3.3.2. Reagents 29
3.4.1. Estimation of total cholesterol 30
3.4.2. Estimation of HDL-cholesterol 31
3.4.3. Estimation of LDL-cholesterol 32
3.4.4. Estimation of triglyceride 33
3.5. Statistical analysis 33
Chapter Four 34
Results
4.1. Study group 34
4.2. Estimation of total cholesterol 34
4.3. Estimation of HDL-cholesterol 34
4.4. Estimation of LDL-cholesterol 34
4.5. Estimation of triglycerides 35
Chapter Five 43
Discussion
Chapter Six 45
Conclusion and Recommendation
Chapter Seven 46
References

6
 LIST OF FIGURES
Fig. Title Page
1.1 General structure of plasma lipoprotein 15
4.1 Age distribution in study groups of patients 33
4.2 Age distribution in control subjects 33
4.3 Comparison of diabetes in study groups of AMI with 34
control subjects.

4.4 Comparison of hypertension in study groups of AMI with 36

control subjects.

4.5 Comparison of family history in study groups of AMI with 39

control subjects.

LIST OF TABLES
Table Title Page
1.1. The Composition of the Major Lipoprotein 17
Complexes
4.1 Multiple Comparisons of lipid profile level 41
(mg/dL) in study subgroups of patients with AMI
and control subjects

4.2 Relationship of lipid profile levels in study groups 42

of AMI with control subjects

INTRODUCTION

7
 Opinion is divided on the changes that occur in serum lipoproteins
following myocardial infarction (MI). Most workers have reported a
reduction in total cholesterol,1-10 HDL-cholesterol9 and LDL-cholesterol7-9
after acute myocardial infarction. Others have, however, reported no
change in serum total cholesterol11 and HDL-cholesterol.7-11 Similar
variations have also been noted in serum triglyceride levels.4,11,12 From
these reports it is clear that phasic changes do occur in patients following
MI and therefore there is a recommendation for detection of
hyperlipidaemia in patients with AMI that the serum lipid should be
assessed either within 24 hours after infarction or after 2-3 months of
AMI.10,13,14 While the recommendation may hold true for absolute levels
there is no consensus on when ratios of various fractions of lipids should
be assessed. Further, the magnitude, pattern and mechanism of these
changes in lipoproteins are also not clearly outlined for our Sudanese
subjects.
The present study was, therefore, undertaken to examine the change
in serum triglyceride, total cholesterol and lipoproteins including ratios of
total cholesterol/HDL and LDL/HDL in our Sudanese subjects with
myocardial infarction.

CHAPTER ONE
LITERTURE REVIEW
1.1. Normal Function and Structure of the Heart:

8
 The heart is a muscular pump divided on each side into two chambers
(an atrium and a ventricle) each separated by a valve, tricuspid on the right,
mitral on the left. The inner wall of the cardiac chamber and the surface of the
valve cups are lined by a layer of endothelial cells (the endocardium). The
bulk of the chamber (the myocardium) comprises a network of striated muscle
cells, each separated by an intercalated disc. The heart is invested by patches
of adipose tissue and a layer of mesothelium (the epicardium). This layer of
epicardium forms the visceral aspect of the pericardial sac, which normally
contains a small volume of clear fluid to lubricate the surface during cardiac
contraction.
Venous blood from the systemic circulation, drain into the right atrium,
which contract during diastole to force the blood through the tricuspid valve
into the right ventricle. During systole the right ventricle contract, expelling the
blood through the pulmonary valve and into the pulmonary circulation. A
synchronous sequence event takes place on the left side: the pulmonary veins
drain oxygenated blood into the left atrium; in diastole the blood is forced
through the mitral valve; in systole the left ventricle contract to expel blood
through the aortic valve into the aorta. The atria on each side are of similar
dimensions, but the myocardium of the left ventricle is much thicker than that
of the right ventricle; this is commensurate with the relative systolic blood
pressure in the aorta and pulmonary artery trunk.15
The regular and coordinated contraction of the myocardium is
determined by the pacemaker cells in the sino-atrial (AS) and atrio-ventricular
(AV) nodes; the action propagates through the bundle of His and Purkinje
network. The electrical activity of the heart can be monitored on the skin
surface by electrocardiography (ECG).15
Myocardial cell contraction and relaxation is brought about by
changes in the concentration of cytosolic calcium. The cyclical contraction of

9
the heart is initiated by the spontaneous depolarization of the pacemaker cells
in the SA node during diastole.
The myocardium is supplied by the coronary arteries originating from
the root of the aorta just above the aortic valve cusps. The right coronary
artery supplies the right ventricle, the posterior part of the interventricular
septum, and part of the posterior wall of the left ventricle. The left coronary
artery, via its principal branches supplies the interior part of the interventricular
septum and most of the left ventricular myocardium. Blood flow through the
coronary arteries is maximal during diastole when the ventricular myocardium
is relaxed.15
The cardiac myocytes are permanent cells; if some die, as in
myocardial infarction, the others cannot regenerate to replace those that are
lost and the defect is repaired by fibrosis. Similarly, in either hypertension or
narrowing of the ventricular outflow tract, the myocardium of the appropriate
chamber becomes correspondingly thicker due the hypertrophy rather than
hyperplasia.15
1.2. Cardiac Failure:
Cardiac failure complicates all forms of severe cardiac diseases.
It exists when the heart is unable to pump blood at the rate required for normal
metabolism. In the early stages the pumping action of the heart may be
maintained by compensatory mechanism such as increased ventricular filling.
The clinical diagnosis of early, compensated heart failure is very difficult and
there is no laboratory test, which is helpful in this regard.15
Ischaemic heart disease, systemic hypertension and valvular heart
disease, either singly or in combination, is responsible for the vast majority of
clinical cases of cardiac failure.
1.3. Ischaemic Heart Disease:

10
 Ischaemic heart disease result when the blood supply becomes
insufficient, because; either the blood supply is impaired or, the myocardium
becomes hypertrophic and makes a greater demand on the blood supply.
When the vessel lumen is more than 75% occluded, ischaemia develops.
Aerobic metabolism is essential, as there are very poor reserves of high-
energy phosphates. Cardiac muscle death occurs when tissue adenosine
triphosphate (ATP) levels are very low and when anaerobic glycolysis has
virtually ceased. As with other tissues, the precise cause of death is uncertain,
but lethal cardiac muscle injuries are associated with membrane damage and
the sudden entry of calcium into the cell cytoplasm. After brief periods of
ischaemia cardiac blood flow can be re-established. However, after a critical
interval reperfusion is impossible, as a result of swelling of capillary
endothelial cells.15
The sub-endocardial layers of the myocardium are at risk from
ischaemia. Even through there is a well developed sub-endocardial plexus of
blood vessels, flow in this part of the myocardium is restricted to diastole.
Blood vessels are collapsible tubes and are susceptible to compression when
tension within the myocardial wall increases. Ischaemia is produced by:
• progressive atherosclerotic stenosis
• atherosclerosis with superimposed thrombosis
• haemorrhage into the intima beneath and around atherosclerotic
plaques.
Ischaemic heart disease can also result from low coronary arterial
perfusion. Shock, is a frequent cause of this. Some patient with anaemia can
develop symptoms of Ischaemic diseases.15
1.4. Acute Myocardial Infarction:
Acute myocardial infarction (AMI), commonly known as heart attack. The
term myocardial infarction comes from “myo” referring to muscles, “cardium”

11
referring to the heart and “infarction” meaning tissue death. As a disease
entity, Dr James Herrick described myocardial infarction in full in 1912.15
A myocardial infarction is an area of necrosis of heart muscles resulting
from a sudden reduction in the coronary blood supply. The commonest
precipitating cause is thrombosis superimposed on, or hemorrhage within, an
atheromatus plaque in an epicardial coronary artery.
1.4.1. Clinical Feature:
The most frequent symptom of myocardial infarction is central
chest pain, which is present in 2/3 of all cases. The chest discomfort may
radiate to the shoulders or arms, neck or the back and can be slight, moderate
or severe. Pain is usually accompanied by nausea, vomiting, shortness of
breath, diaphoresis, palpitation and dizziness. In at least 10% of patients,
myocardial infarction is painless or silent.
Some patients present with acute arrhythmia, mainly ventricular
fibrillation or ventricular taychcardia, but occasionally pulse less electrical
activity, which can rapidly lead to death if untreated.15
1.4.2. Morphology:
The location and size of the infract depends on:
• the site of the coronary artery occlusion
• the anatomical pattern of blood supply
• the presence or absence of an anastomotic circulation within the
coronary arterial tree.
When coronary angiograms are performed in patients with signs of acute
myocardial infarction, a complete obstruction of a major coronary artery can
be demonstrated in up to 90% of cases within 3-4 hours of the initial episode
of pain. At later intervals fewer patients have complete obstructions,
suggesting that coronary artery spasm may also be involved. Coronary artery
thrombi may dissolve, and this may account for much lower incidence of

12
coronary thrombi observed when careful autopsies are performed on patients
dying of myocardial infarcts.
The chief features are necrosis, inflammatory cell infiltration and, as cardiac
muscle cannot regenerate, repair by fibrous tissue. The extensive necrosis of
cardiac muscle is associated with the release of cardiac enzymes into the
circulation. Most patients show a transient leukocytosis in the first 1-3 days.15
1.4.3. Complication:
Early detection and prompt treatment of complications is important in the
management of patients with myocardial infarction. Cardiac arrhythmias,
leading to ventricular fibrillation and sudden death, are frequent in the first 24-
48 hours after the initial infract. Pericarditis, mitral incompetence and cardiac
failure are the important complications in the first week after infraction.
I. Arrhythmias:
Ventricular fibrillation is by far the commonest cause of death in MI.
Primary ventricular fibrillation occurs in first 24 hours after infarction (usually
with the first hour) and is thought to be responsible for most sudden deaths.
Secondary ventricular fibrillation occurs some days later and is associated
with extensive infarction and a significantly reduced short-and long-term
prognosis. The occurrence of frequent premature ventricular beats after the
first month or so indicates a particular liability to ventricular fibrillation. By
involving the conducting system, MI may also cause various grades of heart
block and other arrhythmias.16
II. Cardiac failure:
Extensive infarction of left ventricular muscle can cause acute heart
failure. If this progresses to cardiogenic shock the mortality rate is 80%.
Infarction also predisposes to heart failure which may develop at any time
after infarction and indicates a poor prognosis.
III. Mural thrombosis:

13
 Following acute myocardial infarction, release of tissue thomboplastin
from the damaged muscle, damage to the endocardium and localized adding
of blood predispose to mural thrombosis in the ventricles. This is seen at
autopsy in about 30% of cases who have had and MI, in patients who survive,
the thrombus is eventually organized systemic emboli can result from mural
thrombosis, but are less frequent than might be expected.
IV. Venous thrombosis:
Systemic venous thrombosis usually affecting the leg veins occurs in
up to 30% of cases but fatal pulmonary embolism is an uncommon cause of
death in myocardial infarction.
V. Rupture of infracted myocardium:
This occurs in about 5% of cases, at any time within the first ten days.
Most often the rupture occurs in the wall of the left ventricle and causes
hemopericardium and death from cardiac tamponate. Rupture of either the
interventricular septum or of a mitral papillary muscle may also occur,
precipitating or aggravating acute heart of failure. These compilations can be
confirmed and assessed using two-dimensional and Doppler
echocardiography. Surgery is lifesaving in selected cases but the mortality
rate is high.
VI. Cardiac aneurysm:
The healing infarct of the left ventricle may stretch to form a cardiac
aneurysm. This occurs in 12-15% of long-term survivors. Laminated thrombus
tends to form in the cavity and may cause embolism. The aneurysm impairs
ventricular function, causing cardiac failure which in some cases can be
corrected by surgical excision of the aneurysm.
VII. Angina pectoris:

14
 In some patients angina pectoris dates from a myocardial infarction
because occlusion of a major coronary artery may render the surrounding
areas of myocardium chronically ischemic.
VIII. Recurrence of infarction:
Individuals who have had a myocardial infarct are prone to re-infarction
because of the underlying coronary artery disease. Cigarette smoking greatly
increases and beta blockers significantly reduce this risk.
IX. Post-infarction (Dressler’s) syndrome:
Occasionally patients may develop pericardial and pleural effusions a
raised ESR, fever and leucocytosis up to 10 weeks following infarction, raised
titers of myocardial antibodies and resolution of the symptoms following
corticosteroid therapy suggest and autoimmune response.16
1.4.4. Diagnosis:
The diagnosis of AMI was established by the World Health Organization
(WHO) in 1979, requiring the presence of two of the following three criteria:
• History of severe and prolonged chest pain,
• Unequivocal electrocardiographic (ECG) changes such as persistent
Q or QS waves and evolving injury lasting longer than one day, and
• Unequivocal initial increase and subsequent decrease in the activity
of enzymes collected on serial basis. The change must be properly related to
the particular enzyme with the delay between onset of symptoms and blood
sampling.17
Because of the emergence of new biochemical markers, the
European Society of Cardiology and the American College of Cardiology
redefined the criteria for diagnosis of AMI in 2000 :
• Typical increase and gradual decrease of troponin or more rapid
increase and decrease of creatine kinase (CK-MB) with at least one of the
following:

15
(a) ischemic symptoms,
(b) development of pathologic Q waves on the ECG,
(C)ECG change indicative of ischemia (ST-segment elevation or depression),
(d) coronary artery intervention;
• Pathologic finding of an AMI.
It was recognized that many AMIs were missed by using the WHO
guidelines because of the reliance on clinical history and ECG, both of which
are present in only about half of all cases. The new guidelines place more
emphasis on biochemical markers.17
1.4.4.1. Electrocardiography (ECG):
The classical evaluation of ECG changes in Myocardial infarction is:
• peaked (hyperacute) T waves,
• ST segment elevation,
• formation of Q waves and T waves inversion.
These changes may occur over a few hours to several days18. On the bases
of their associated ECG finding acute Myocardial infarction can be divided into
two groups:
I. Q wave infarction (transmural infarction):
In this type of Myocardial infarction pathological Q wave develop on ECG.
These infarction result from complete thrombotic occlusion of coronary artery
and manifest on ECG by symmetrically peaked T waves replaced after several
minutes by ST segment elevation.
II. Non- Q wave infarction (subendocardial infarction):
This type of infarction develops from high- grade but non-occlusive
thrombi (obstruction of coronary artery is not complete).
This infarction is associated with ST- segment depression and for T wave
inversion without evaluation of pathologic Q- wave. There is also some lost of
Q- waves in leads facing the infarct.18

16
1.4.4.2. Cardiac Markers:
I. Aspartate Aminotransferase (AST):
The first marker of myocardial damage was aspartate aminotransferase
(AST). Although serum assays for (AST) have high sensitivity for cardiac
disease, they are not specific, as increased activities can be observed in
patient with skeletal muscle disease, hemolysis, and chronic hepatocellular
diseases. Although (AST) has cytosolic and mitochondrial isoenzymes, their
measurement dose not improve the specificity of this assay, as they are not
tissue specific to the myocardium.17
II. Lactate Dehydrogenase (LDH):
Lactate dehydrogenase (LDH) is found in cytoplasm of all human cells,
tissues and organs. In addition to myocardial disease, increases in serum
(LDH) activities can be observed in patient with hemolysis, malignancy, and
diseases of liver, lung, skeletal muscle, and kidney. The five LDH isoenzymes
consist of tetrameric combinations of M and H subunits. Interest in LDH stems
from the fact that the heart contains high concentration of the LDH1 (H4)
isoenzyme. LDH has a molecular mass of 134 kDa, which is high relative to
other cardiac markers and this made it useful as a late marker of AMI. The
LDH activity in serum remains abnormal after MI for 5 days after onset.17
III. Creatine Kinase (CK):
Creatine kinase (CK) has two subunits of 84 kDa. After myocardial injury,
CK and other cytoplasmic proteins pass through the damaged cell membrane
and enter the cardiac lymphatics to the nodes positioned between the superior
vena cava and ascending aorta, and gradually drain into the systemic
circulation. The release of mitochondrial CK is further delayed because these
proteins must also pass through the mitochondrial membrane.
CK isoenzymes measurement is useful because skeletal muscle and
myocardial tissue have different distributions of the isoenzymes. cytoplasmic

17
CK consist of dimeric combinations of either M or B subunits in the three
major forms: MM, MB and BB. In addition, posttranslational modifications of
isoenzymes will produce at least three MM and two MB isoforms.
The CK-MM isoenzyme is the predominant form found in skeletal muscle,
with trace amount (1%) of CK-MB present. In the myocardium, CK-MM also is
found in the highest concentration; however, the percentage of CK-MB is 10 to
20 fold higher than that found in the skeletal muscle. Thus in patient with
acute myocardial damage, both the total CK and the ratio of CK-MB/total CK
are abnormal.
CK-BB is found in brain and sooth muscle and is the predominant form
found in fetal muscle. Increases in the BB isoenzyme are observed in patient
with cerebral disease, trauma and certain neoplasm.17
IV. Myoglobin:
Myoglobin is a low molecular mass heme protein (17.8 kDa) found in
skeletal muscle and heart. It constitutes 2% of the total muscle protein and is
found entirely within the cytoplasm. There are no tissue-specific isoenzymes,
thus the myoglobin released from the heart is indistinguishable from that
released from skeletal muscle tissue. After AMI, myoglobin appears in the
serum earlier than dose CK-MB because of its smaller size.17
V. Troponin:
Troponin is a regulatory protein complex located on the thin filament
(actin) of striated muscles. It consists of three subunits: troponin-T, 37kDa,
troponin-I,24kDa, and troponin-C,18kDa. The majority of intracellular troponin
of muscle cells exists as a ternary T-I-C complex that is bound to actin.
Because the tissue content of troponin is higher than that of CK-MB, troponin
is a more sensitive marker for cardiac damage.17

18
 Troponin-I regulates striated muscle contraction by preventing the
binding of the myosin head to actin and thus inhibiting myosin ATPase activity.
TnI also serves to bind the actin filament TnC.
The function of TnT is to bind to tropomyosin and position the
Troponin complex along the actin filament. The isoforms have different amino
acid structures and are biochemically distinct and there fore can be
differentiated from one another of particular interest are the cardiac isoforms
of troponin-T (cTnT) and Troponin-I (cTnI). Cardiac troponin-T levels in serum
begin to rise within 3- 4 hours following the onset of myocardial damage, peak
in the 10 days to 14 days following an AMI.17 .
1.4.5. Treatment:
Multidrug treatment is routine to control the many problems associated
with cardiac disease. It usually consist of compensation of vasodilators,
diuretics, beta-blockers, calcium channel antagonists, cardiac glycosides and
anticoagulants.19
Coronary artery bypass graft surgery (CABG) was introduced in the late
1960s and has become a standard treatment for ischemic heart disease since.
Percutaneous transluminal coronary angioplasty (PTCA) is a surgical
procedure in which an angioplasty balloon is inserted into a coronary artery
and expanded. this should open the lumen of the obstructed vessel and
restore blood flow to the affected area.19
1.5. Lipids:
The major lipids present in the are fatty acids, triglycerides, cholesterol
and phospholipids . Other lipid soluble substances, present in much smaller
amounts but of considerable physiological importance, include steroid
hormones and fat-soluble vitamins.19
1.6. Fatty Acids:

19
 They are straight-chain carbon compounds of varying lengths with
the carboxyl end to one end and the methyl to the other end. They may be
saturated containing no double bonds, monounsaturated with one, or
polyunsaturated with more than one, double bond. Fatty acids may be
esterified with glycerol to form triglycerides, or be nonesterified or free.19
1.7. Triglycerides:
They consist of glycerol esterified with three long-chain fatty acid. They are
present in dietary fat and can be synthesized in the liver and adipose tissue to
provide a source of stored energy. Triglycerides containing both saturated and
unsaturated fatty acids are important components of cell membranes.19
1.8. Cholesterol:
They are composed of a sterol nucleus with 27 carbon atoms. It can be
synthesized de novo from the accumulation of two carbon units. And it is the
precursor to many important steroids, such as bile acids and steroid
hormones. Cholesterol esters are produced by esterification of the third
carbon in the cholesterol molecule with a fatty acid.19
1.9. Phospholipids:
They are complex lipids, resembling triglycerides, but contain phosphate
and a nitrogenous base in place of one of the fatty acids. They are important
component of cell membranes.
A common feature of lipid is their limited solubility in water. So lipids
transport in the plasma in association with proteins. Albumin is the principle
carrier of free fatty acids; the other lipids circulate in complexes known as
lipoproteins.19
1.10. Apolipoproteins:
Apolipoproteins (apo) are structural protein elements in the amphipathic
shell of lipoprotein particles and help to keep the lipids in solution during

20
circulation through the blood stream. They interact with specific cell-surface
receptors and direct the lipids to the target organs and tissues in the body.
Apo-A is the major apo of HDL. Apo-B, which is responsible for the
binding of LDL to LDL-receptors is the functional protein for transporting
cholesterol to cells. Apo B is synthesized in two forms: Apo B-100 in the liver
and Apo B-48 in the intestine. Apo B-100 is found in VLDL, IDL and LDL,
whereas Apo B-48 is found in chylomicrons. Apo-E, which promotes binding of
lipoproteins to the LDL-receptor, is also associated both with transport of
cholesterol ester in plasma and with the redistribution of cholesterol in
tissues.19
1.11. Lipoproteins:
These consist of a non-polar core of triglyceride and cholesterol esters
surrounded by a surface layer of phospholipids, cholesterol and proteins
known as apolipoproteins. There are multiple subtypes of the apolipoproteins,
and each of the lipoprotein classes exists in a continuum of size of sizes and
densities because of differences in the contents of the core lipids. In addition
there is a long list of apolipoproteins.19 Figure 1.1 shows the structure of a
lipoprotein.

21
 FIGURE 1.1:

1.12. Classification of Lipoproteins:

22
 Lipoproteins are classified on the bases of their densities as
demonstrated by their ultracentrifugal separation. Density increases from
chylomicrons (CM, of lowest density) through lipoprotein of very low density
(VLDL), intermediate density (IDL) and low density (LDL) to high density
lipoproteins (HDL). HDL can be separated into two metabolically subtypes,
HDL2 and HDL3. Distinct sub-types of LDL(LDL-I,II and III in increasing order
of density) are also recognized. IDL are normally present in plasma in small
amounts but can accumulate in pathological disturbances of lipoprotein
metabolism. However, it is important to appreciate that the composition of the
circulating lipoproteins is not static. They in dynamic state with continuous
exchange of component between the various types.20
Lipoprotein(a), is an atypical lipoprotein of unknown function. It is larger
and more dense than LDL but has a similar composition, except that it contain
in addition one molecule of apo(a) for every molecule of apo (B-100). The
apolipoprotein(a) structure is analogous to plasminogen which dissolve clots.
It has been demonstrated in multiple studies that an elevated Lp(a) level
presents an increased risk for myocardial infarction.20 The composition of the
major lipoprotein is shown in table (1.1).

Table 1.1 The Composition of the Major Lipoprotein Complexes

23
 Density Protein TGa PLb CEc Cd FFAe
Complex Source
(g/ml) % % % % % %

Chylomicron Intestine <0.95 1.5 86 8 3 1 0

VLDL Liver 1.006 8.5 53 19 13 9 1

IDL VLDL 1.019 11 2 26 33 9 1

LDL VLDL 1.063 21 12 24 42 9 1

Intestine, liver
*HDL2 (chylomicrons , 1.125 34 10 38 25 7 0
VLDLs)
Intestine, Liver
*HDL3 (chylomicrons, 1.21 56 8 36 28 4 6
VLDLs)

Adipose
Albumin-FFA >1.281 99 0 0 0 0 100
tissue
a
Triacylglycerols, bPhospholipids, cCholesteryl esters, dFree cholesterol, eFree
fatty acids*HDL2 and HDL3 derived from nascent HDL as a result of the
acquisition of cholesteryl esters

1.13. lipoprotein metabolism:

24
1.13.1. Chylomicrons(CM):
Chylomicrons are the major transport form of exogenous (dietary) fat.
Triglycerides (90% of CM) are removed from chylomicrons by the action of the
enzyme lipoprotein lipase (LPL) with the result that free fatty acids are
delivered to be used as energy or stored in various tissues. LPL is activated
by apoC-II which transferred to chylomicrons from HDL with esterified
cholesterol in exchange for triglyceride. The chylomicron remnants are cleared
from the circulation by hepatic uptake depending on recognition of apo E by
hepatic receptors (LDL-related receptor protein). Under normal circumstances,
chylomicrons cannot be detected in plasma in the fasting state.20
1.13.2. Very low density lipoproteins(VLDL):
VLDL are formed from triglycerides synthesized in the liver either do novo
or by re-esterification of free fatty acids. VLDL are the principal transport form
of endogenous triglycerides and removed by the action of LPL. As the VLDL
particles become smaller, phospholipids, tree cholesterol and apolipoproteins
are released from their surfaces and taken up by HDL, thus converting the
VLDL to denser particles, IDL. Cholesterol ester is transferred back to IDL in
exchange for triglyceride and more triglycerides removed by hepatic lipase
and IDL are thereby converted to LDL. Under normal circumstances, there are
very few IDL in the circulation because of their rapid removal or conversion to
LDL.20
1.13.3. Low density lipoproteins(LDL):
LDL are the principal carrier of cholesterol esters and they are formed
from VLDL via IDL. Free cholesterol also stimulates its own esterification by
stimulating the enzyme acyl CoA:cholesterol acyl transferase(ACAT).
LDL receptors are saturable and subject to down regulation by an
increase in intracellular cholesterol. Macrophages can take up LDL via
scavenger receptors. This process occurs at normal LDL concentrations but is

25
enhanced when LDL concentration are increased and by modification of LDL.
Uptake of LDL by macrophages in arterial wall is an important event in the
pathogenesis of atherosclerosis. When macrophages becomes overloaded
with cholesterol esters, they are converted to "foam cells" the basic
component of atheromatous plaques. LDL concentrations increase during
childhood and reach adult level after puberty.20
1.13.4. High density lipoproteins(HDL):
HDL are synthesized primarily in the liver and, to lesser extent, in small
intestines, as a precursor (nascent HDL). The free cholesterol is esterified by
the enzyme lecithin-cholesterol acyltransferase (LCAT), this increases the
density of the HDL particles, which are thus converted from HDL3 to HDL2.
cholesteryl esters are transferred from HDL2 to remnant particles in exchange
for triglyceride, and also are taken up by the liver in chylomicron and IDL
remnant and excreted in bile. The HDL2 is converted back to HDL3 by the
removal of triglycerides by the enzyme hepatic lipase. Some HDL2 is removed
from the circulation by the liver, through receptors that recognize apo A-I.
Thus HDL has two important functions: it is a source of apoproteins for
chylomicrons and VLDL, and it mediates reverse cholesterol transport from
senescent cells and other lipoproteins and transferring it to remnant particles,
which are up by the liver.20
1.13.5. Lipoprotein Receptors:
The most important mechanism involving lipoprotein metabolism is the
interaction between apolipoproteins on the lipoprotein surfaces and the
receptors on various cell surfaces. Lipoprotein receptors are plasma
membrane proteins that are capable of binding with high affinity to circulating
lipoprotein particles through their interaction with apolipoproteins. The
following paragraphs discuss the major receptors.
I. LDL Receptors (LDLs):

26
 LDLs are the principal plasma carriers of cholesterol delivering cholesterol
from the liver (via hepatic synthesis of VLDL) to peripheral tissues, primarily
the adrenals and adipose tissue. LDLs also return cholesterol to the liver. The
cellular uptake of cholesterol from LDLs occurs following the interaction of
LDLs with the LDL receptor (also called the apoB-100/apoE receptor). The
sole apoprotein present in LDLs is apoB-100, which is required for interaction
with the LDL receptor.20
The LDL receptor is a polypeptide of 839 amino acids that spans the
plasma membrane. An extracellular domain is responsible for apoB-100/apoE
binding. The intracellular domain is responsible for the clustering of LDL
receptors into regions of the plasma membrane termed coated pits. Once LDL
binds the receptor, the complexes are rapidly internalized. ATP-dependent
proton pumps lower the pH in the endosomes, which results in dissociation of
the LDL from the receptor. The portion of the endosomal membranes
harboring the receptor are then recycled to the plasma membrane and the
LDL-containing endosomes fuse with lysosomes. Acid hydrolases of the
lysosomes degrade the apoproteins and release free fatty acids and
cholesterol. As indicated above, the free cholesterol is either incorporated into
plasma membranes or esterified and stored within the cell.20
The level of intracellular cholesterol is regulated through cholesterol-
induced suppression of LDL receptor synthesis and cholesterol-induced
inhibition of cholesterol synthesis. The increased level of intracellular
cholesterol that results from LDL uptake has the additional effect of activating
ACAT, thereby allowing the storage of excess cholesterol within cells.
However, the effect of cholesterol-induced suppression of LDL receptor
synthesis is a decrease in the rate at which LDLs and IDLs are removed from
the serum. This can lead to excess circulating levels of cholesterol and
cholesteryl esters when the dietary intake of fat and cholesterol exceeds the

27
needs of the body. The excess cholesterol tends to be deposited in the skin,
tendons and, more gravely, within the arteries, leading to atherosclerosis.20
II. Remnant Receptors:
Remnant receptors recognize apo E and are the major receptors for the
clearance of chylomicron remnants and VLDL from blood circulation.19
III. Scavenger Receptors:
Scavenger receptors can be found on the surfaces of macrophages and
muscle cells. These receptors mediate the removal of modified LDL from
blood circulation. Macrophages can take up cholesterol from modified LDL
through scavenger receptors, resulting in cholesterol accumulation and the
formation of foam cells, which is the hallmark of early atherosclerotic lesions.19
1.14. Disorders of lipid metabolism:
Most common disorders of lipid metabolism are associated with
hyperlipidaemia. Very rare inherited disorders may be associated with
accumulation of lipid in tissues and not in plasma. The accumulation of lipid in
tissues is usually the result of severe and prolonged hyperlipidaemia and
causes cell damage.21 Lipid may accumulate in:
I. Arterial walls. This is the most important manifestation of lipid

disorders producing atherosclerosis. Atherosclerosis is due to distortion and

obstruction of the artery which may result from calcification and ulceration of
plaques. The small lipoproteins LDL and IDL are atherogenic.
II. Subcutaneous tissue, causing xanthomatosis. The nature of the lipid

fraction most affected usually determines the clinical appearance:

• Eruptive xanthomata are small, itchy, yellow nodules. They are
associated with very high plasma VLDL or chylomicron (triglyceride)
concentrations, which disappear if plasma lipid concentrations fall to normal;
• Tuberous xanthomata are yellow plaques found over the elbows and
knees. They are associated with high plasma concentrations of IDL;

28
 • Xanthelasma are lipid deposits under the periorbital skin and may be
associated with high plasma LDL concentrations.
III. Tendons. Xanthomata, usually on the Achilles tendons or the extensor

tendons of the hands, occur in familial hypercholesterolaemia;

IV. Cornea. Corneal arcus may be caused by deposition of lipid and

associated with high plasma LDL concentrations.

There is a positive correlation between the risk of developing ischaemic
heart disease and a raised plasma total cholesterol and LDL concentrations
and a negative one with plasma HDL. Hypercholesterolaemia is one of the
major risk factors of cardiovascular disease; others include smoking and
hypertension.21
1.14.1. Predominant hypercholesteraemia:
Plasma cholesterol levels at birth are usually below 100 mg/dl (2.5
mmol/l). they increase during the first year of life, but not exceed 160 mg/dl (4
mmol/l) in children. in most affluent populations plasma levels increase after
the second decade, more in men than in women during the reproductive
years. The upper limit of the reference range in many societies is about 330
mg/dl (8.5 mmol/l) in the fifth and sixth decades. It is likely that the
progressive rise in plasma cholesterol levels reflect a decreasing
concentration of LDL receptors in the liver. The risk of developing
cardiovascular disease increase as the plasma cholesterol level rise above
about 200 mg/dl (5.2 mmol/l).21
It is almost always due to a raised plasma LDL concentration, or the
development of a disorder that affects plasma LDL concentrations.

29
1.14.2. Secondary hypercholesterolaemia:
The commonest disorders that may cause a secondary increase in
plasma total and LDL-cholesterol levels are:
• Primary hypothyroidism;
• Diabetes mellitus;
• Nephritic syndrome;
• Cholestasis;
• Some drugs.
1.14.3. Primary hypercholesterolaemia:
the familial incidence of hypercholesterolaemia, often associated with an
increased risk of ischaemic heart disease. The following two disorders
associated with moderate to severe hypercholesterolaemia, the pattern of
inheritance is autosomal dominant.21
I. Familial combined hyperlipidaemia, is associated with excessive
hepatic production of apoB, and therefore of LDL, and VLDL-triglyceride
synthesis due to either primary or secondary disorder. The lipid abnormalities
become apparent after the third decade. High plasma triglyceride level may
cause eruptive xanthomata.21
II. Familial (monogenic) hypercholesterolaemia, is caused by a LDL
receptor defect. The reduced cellular uptake of LDL by the liver causes an
increase in plasma total and LDL-cholesterol concentrations.
• In homozygotes LDL receptors are virtually absent and plasma LDL-
cholesterol concentrations are three or four times higher than those in normal
subjects; patient rarely survive beyond the age of 20 and usually die from
ischaemic heart disease.
• In heterozygotes the number of LDL receptors is reduced by about
50% and the plasma cholesterol concentrations are about twice those in
normal subjects.21

30
1.14.4. Predominant hypertriglyceridaemia:
Elevated plasma triglyceride levels may be due to an increase in
plasma VLDL or chylomicrons or both. Hypertriglyceridaemia is usually
secondary to another disorders. Primary hypertriglyceridaemia is less
common than hypercholesterolaemia.
I. Familial combined hyperlipidaemia, has been discussed above.
One-third of affected individuals have raised plasma VLDL concentration.
II. Familial endogenous hypertriglyceridaemia, is caused by
hepatic triglyceride overproduction with increased VLDL secretion. The
condition is transmitted as an autosomal dominant trait and usually apparent
after the fourth decade. It may be associated with:
• Obesity;
• Glucose intolerance;
• Decrease in plasma HDL-cholesterol levels;
• Hyperuricaemia.
Hyperchylomicronaemia is usually due either to an acquired or inherited
deficiency of lipoprotein lipase. Insulin is needed for optimal enzyme activity.
Consequently, hyperchylomicronaemia may occur in poorly controlled diabetic
patients. It may also be found with acute pancreatitis.21
1.14.5. Mixed Hyperlipidaemia:
Raised plasma concentrations of both cholesterol and triglycerides are
commonest in patients with poorly controlled diabetes mellitus, severe
hypothyroidism or the nephrotic syndrome.
The commonest primary cause is familial combined hyperlipidaemia with
elevated plasma LDL and VLDL concentrations. Less commonly, mixed
hyperlipidaemia may be caused be the accumulation of IDL and chylomicron
remnants in plasma.21

31
1.15. Treatment of Hyperlipidaemia:
Secondary causes of hyperlipidaemia and aggravating factors should be
treated. And the diet should be regulated and obese patients encouraged to
reduce body weight.
1.15.1. Treatment of Hypercholesterolaemia:
Restriction of dietary animal fats products reduces the intake of both
cholesterol and saturated fatty acids.
Drugs treatment includes:
• Bile-salt sequestrants, such as cholestyramine and colestipol. These
are resins that bind bile salts in the intestinal lumen and prevent their
reabsorption and reutilization and so stimulate the hepatic synthesis of
cholesterol and the hepatic cell content is decreased. The increase of hepatic
LDL receptors lead to a fall in plasma LDL concentrations;
• Hydroxyl-methyl glutaryl coenzyme A reductase inhibitors
(Simvastatin or Lovastatin), inhibit the enzyme in the cholesterol synthetic
pathway and so reduce endogenous production. As the intracellular level of
cholesterol falls the rate of synthesis of LDL receptors increases, with a
consequent fall in plasma LDL-cholesterol concentration;
• Nicotinic acid may VLDL secretion and therefore the formation of
LDL. It also reduces the plasma level of lipoprotein(a).21
1.15.2. Treatment of Hypertriglyceridaemia:
Dietary restriction may be the only treatment need:
• Triglyceride restriction may be effective in lowering plasma
chylomicron concentrations;
• Carbohydrate restriction reduces endogenous triglyceride
synthesis and can be used to treat high VLDL concentrations.
Fibric acid derivitives are a group of drugs that activate lipoprotein lipase,
and so increase the rates of clearance of VLDL and chylomicrons from the

32
plasma. They also lower LDL-cholesterol by enhancing liver uptake and
increase HDL-cholesterol.21

33
 CHAPTER TWO
THE OBJETIVES OF THE STUDY

This study aims to:

• assess the levels of serum triglyceride, cholesterol, HDL and
LDL lipoproteins in Sudanese subjects with myocardial infarction;
• compare the mean of serum lipoproteins levels in patients with
that of the normal subject;
• evaluate the significance of using serum lipoproteins levels in
diagnosis of the acute phase of myocardial infarction;
• estimate the normal range of serum lipoproteins in healthy
control subjects;
• study the variations of serum lipoproteins level with reference to
some risk factors i.e. diabetes mellitus, family history, and
hypertension.

34
 CHAPTER THREE
MATERIALS AND METHODS

3.1. Patients and Controls:

The study was carried in 20 patients (12male and 8 female) aged
between 40 to 70 years, admitted to intensive coronary care unit of El Shaab
Teaching Hospital during the period January -April 2006 with acute myocardial
infarction. The diagnosis of MI was established by clinical, ECG, serum
cardiac enzymes and troponin examination. None of the patients had thyroid
dysfunction, liver or kidney disease. Only those patients where finally included
who were not taking any hypolipidemic drug. A separated samples of 10
healthy subjects (5 males and 5 females) was taken a control group.
3.2. Sample Collection:
Blood samples (3mL) were taken as soon as possible after admission (the
first 48 hours after chest pain) form each patients as well as control subjects
using disposable syringes. All blood samples were allowed to clot at room
temperature and then centrifuged at 4000 R.P.M to obtain the serum.
Specimens of serum were preserved at 2-8 Cْ prior to processing. The clear
serum was taken immediately for analysis of cardiac markers or stored at 2-8
Cْ for 24 hrs.
3.3. Estimation of Lipid Profile:
Cholesterol, triglyceride, HDL and LDL were estimated by using
automated microprocessor-controlled robotic chemistry analyzer.
All patients and control subjects samples were labeled and placed in
bar-coded sample cup holders and included in test panel on the automated
chemistry analyzer. Serum total cholesterol, serum HDL-cholesterol, serum
LDL-cholesterol and triglyceride were measured by readymade kits using
enzymatic method.

35
3.3.1. EQUIPMENTS:
I. Chemistry Analyzer (HITACHI-902), ROCHE Diagnostics Co;
LTD. USA.
II. Centrifuge (C-700), APEL Co; LTD. Tokyo. Japan.

III. Disposable Syringes, JK Medical Equipment Co; LTD. China.

IV. Plane containers, JK Medical Equipment Co; LTD. China.

3.3.2. REAGENTS: DIALAB Production Co; Austria.
I. Total cholesterol Reagent (1):

• Good's Buffer, PH 6.7 50 mmol/L

• Phenol 5 mmol/L
• 4-Aminoantipyrine 0.3 mmol/L
• Cholesterol Esterase ≥ 200 U/L
• Cholesterol Oxidase ≥ 50 U/L
• Peroxidase ≥ 3 U/L
II. HDL-cholesterol reagents:
Reagent (2):
• Good's Buffer, PH 7.0 30 mmol/L
• 4-Aminoantipyrine 0.9 mmol/L
• Peroxidase 2400 U/L
• Ascorbate Oxidase 2700 U/L
• Anti-human β-lipoprotein Ab.
Reagent (3)
• Good's Buffer, PH 7.0 30 mmol/L
• Cholesterol Esterase 4000 U/L
• Cholesterol Oxidase 20000 U/L
• N-ethyl(2-hydroxy-3-sulfopropyl)-dimethoxy-
flouroaniline,sodium salt 0.8 mmol/L
III. LDL-cholesterol reagents:
Reagent (4)
• Good's Buffer, PH 6.8 25 mmol/L
• Cholesterol Esterase 5000 U/L

36
 • Cholesterol Oxidase 5000 U/L
• 2-Hydroxy sulfopropyl dimethoxyaniline 0.64 mmol/L
•
Catalase 1000 KU/L
Reagent (5):
• Good's Buffer, PH 7.0 25 mmol/L
• 4-Aminoantipyrine 3.4 mmol/L
• Peroxidase 20 KU/L
• Sodium azide 0.1%
IV. Triglyceride Reagent (6):
• Good's Buffer, PH 7.0 25 mmol/L
• ATP 1.0 mmol/L
• 3-Hydroxy tribomobenzoic acid 2.0 mmol/L
• Glycerophosphate oxidase ≥ 2000 U/L
• Lipase ≥ 200 KU/L
• Gkycerol Kinase 6000 U/L
• Peroxidase ≥ 500 U/L
• Sodium azide 0.1%

3.4.1. Estimation of cholesterol:

PRINCIPLE:
Cholesterol-esters were hydrolyzed by Cholesterol esterase to fatty
acids and cholesterol, which then converted to cholestenone and H2O2 by
the action of Cholesterol oxidase. The hydrogen peroxide then catalyzed by
peroxidase to yield a red colored quinonimine. The intensity of the pink/red
color is proportional to the cholesterol concentration in the sample.
PROCEDURE:
The automated chemistry analyzer was programmed to operate the
procedure automatically as follow: Specimens of serum or cholesterol
standard (10µL) were added to 1.0ml of the working reagent (1) and
incubated for 10 minutes at 37ْC. The absorbance (A) of the sample and
the standard were measured at 500nm against the blank with a 500nm

37
filter. The measured absorbances converted to estimate concentrations
using stored data base.
3.4.2. Estimation of HDL-CHOLESTEROL:
PRINCIPLE:
Separation of the lipoprotein fractions is achieved by adding antibodies,
which absorb to the surface of chylomicrons, VLDL and LDL. In a second
step, added detergent breaks up the HDL lipoproteins, and therefore
making HDL-cholesterol available for quantitation, using an enzymatic
system.

LDL, VLDL, Chylomicrons Ah β-L Ab HDL + Ag-Ab complex

HDL + H2O + O2 CHE& CHO cholesten + fatty acid + H2O2
H2O2 + DAOS + 4-Aminoantipyrine POD blue colored complex + H2O

The intensity of the blue color is proportional to the cholesterol

concentration in the sample.
PROCEDURE:
The automated chemistry analyzer was programmed to operate the
procedure automatically as follow: Specimens of serum or HDL-cholesterol
standard (10µL) were added to 900 µL of the working reagent (2) and
incubated for 5 minutes at 37ْC. The absorbance (A1) of the sample and
the standard were measured against reagent blank at 500nm, then 300 µL
of reagent (3) was added and incubated for 5 minutes at 37ْC and the
absorbance (A2) of the sample and the standard were measured.
The measured absorbances converted to estimate concentrations
using stored data base.

38
3.4.3. Estimation of LDL-CHOLESTEROL:
PRINCIPLE:
Non LDL-lipoproteins were enzymatically processed, while LDL was
selectively protected (in the first incubation with reagent 3). In the second
step LDL was released and selectively determined.

(1)
LDL + protecting reagent(4) protected LDL
HDL,VLDL,chylomicrons CHO CHE cholestenone + H2O2
H2O2 + Catalase H2O
(2)
protected LDL + releasing reagent(5) LDL-cholesterol
LDL-cholesterol CHO CHE cholestenone + H2O2
H2O2 + DAOS + 4-Aminoantipyrine POD blue colored complex + H2O

The intensity of the blue color is proportional to the LDL-cholesterol

concentration in the sample.
PROCEDURE:
The automated chemistry analyzer was programmed to operate the
procedure automatically as follow: Specimens of serum or LDL-cholesterol
standard (10µL) were added to 900 µL of the working reagent (4) and
incubated for 5 minutes at 37ْC. The absorbance (A1) of the sample and
the standard were measured against reagent blank at 500nm, then 300 µL
of reagent (5) was added and incubated for 5 minutes at 37ْC and the
absorbance (A2) of the sample and the standard were measured. The
measured absorbances converted to estimate concentrations using stored
data base.

39
3.4.4. Estimation of triglyceride:
PRINCIPLE:
Triglycerides in the sample were hydrolyzed by lipase to fatty acids
and glycerol, which then phosphorylated by ATP to glycerol-3-phosphate
and ADP in a reaction catalyzed by glycerol kinase. Glycerol-3-phosphate
was then converted by the action glycerophosphate oxidase into
dihydroxyacetone phosphate and hydrogen peroxide, which was catalyzed
by peroxidase to yield a red colored quinonimine. The intensity of the
pink/red color is proportional to the triglyceride concentration in the sample.
PROCEDURE:
The automated chemistry analyzer was programmed to operate the
procedure automatically as follow: Specimens of serum or cholesterol
standard (10µL) were added to 1.0ml of the working reagent (6) and
incubated for 10 minutes at 37ْC. The absorbance (A) of the sample and
the standard were measured at 500nm against the blank with a 500nm
filter. The measured absorbances converted to estimate concentrations
using stored data base.
3.5. Statistical Analysis:
Appropriate descriptive and analytical statistical procedures were
followed using statistical package for social sciences (SPSS. Version 10).
Independent samples T-test was applied to compare the levels of total
cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride and Troponin in
study groups of AMI patients and control healthy subjects. Association of
serum lipids with other variables had been studied using correlation
analysis. The level of significance was expressed as (P <0.05).

40
 CHAPTER FOUR
RESULTS
4.1. Study Group:
In the present study, a total number of 20 patients (12male and 8
female) aged between 40 to 70 years, admitting to intensive coronary care
unit of El Shaab Teaching Hospital during the period January -April 2006
had been enrolled for the assessment of the serum lipids. The level of
serum lipids of patients and control groups of healthy subjects was
measured using automated microprocessor-controlled robotic chemistry
analyzer.
As illustrated in figures (4.1.) and (4.2.) the patients and also the
control subjects had an average age of 56 year with a range of 40-70year.
About 30%(n=6) of patients had diabetes mellitus, 60%(n=12) of
patients were hypertensive and 30 %(n=6) of patients had family history of
cardiac disease as showed in figures (4.3),(4.4) and(4.5) respectively.
4.2. Estimation of total cholesterol:
The male patients showed total cholesterol levels with the mean197±34
mg/dL, and the mean of male control subjects levels was163±24 mg/dL.
while female patients had the mean of202±69 mg/dL, and the mean of
female control subjects levels was179±23 mg/dL.
4.3. Estimation of HDL-cholesterol:
The male patients had HDL-cholesterol levels mean 56±16 mg/dL, and the
mean of male control subjects levels was 44±6 mg/dL. While female
patients showed the mean 52±14 mg/dL, while the mean of female control
subjects levels was 54±10 mg/dL.
4.4. Estimation of LDL-cholesterol:

41
The male patients had LDL-cholesterol levels with the mean 122±31
mg/dL, and the mean of male control subjects levels was105±25 mg/dL.
while female patients showed the mean 137±54 mg/dL, while the mean of
female control subjects levels was114±32 mg/dL.
4.5. Estimation of triglyceride:
The male patients showed triglyceride levels with the mean 186±139
mg/dL, while the mean of male control subjects levels was 80±61 mg/dL.
The female patients showed triglyceride levels with the mean 120±45
mg/dL, while the mean of female control subjects levels was56±62 mg/dL.

42
 6

1 Std. Dev = 9.19

Mean = 56.3
0 N = 20.00
40.0 45.0 50.0 55.0 60.0 65.0 70.0

AGE(years)

FIGURE 4.1: Age distribution in study groups of patients

43
 3.5

3.0

2.5

2.0

1.5

1.0

.5 Std. Dev = 10.34

Mean = 56.3

0.0 N = 10.00
40.0 45.0 50.0 55.0 60.0 65.0 70.0

AGE(years)

FIGURE 4.2: Age distribution in control subjects

44
 30

20
14

10
10

diabetes
6

no
Count

0 yes
AMI CONTROL

FIGURE 4.3: Comparison of diabetes in study groups

of AMI with control subjects.

45
 30

20
8

12
10
10

hypertension

no
Count

0 yes
AMI CONTROL

FIGURE 4.4: Comparison of hypertension in study

groups of AMI with control subjects.

46
 30

20
14

10
10

family history
6
no
Count

0 yes
AMI CONTROL

FIGURE 4.5: Comparison of family history in study

groups of AMI with control subjects.

47
Table 4.1: Multiple Comparisons of lipid profile level (mg/dL) in
study subgroups of patients with AMI and control subjects
In d e p e n d e n t S a m p le s T e s t

L e v e n e 's T e s t fo r
E q u a lity o f V a r ia n c e s t- te s t fo r E q u a lity o f M e a n s

M ean S td . E r r o r
F S ig . t df S ig . ( 2 - ta ile d )D iffe r e n c e D iffe r e n c e
T .c h o le s te r o l( m g /dELq)u a l v a r ia n c e s
3 .9 0 0 .0 5 8 1 .6 7 2 28 .1 0 6 2 8 .2 0 0 1 6 .8 6 6
assum ed
E q u a l v a r ia n c e s
1 .9 9 9 2 7 .4 0 9 .0 5 6 2 8 .2 0 0 1 4 .1 0 5
n o t a ssu m e d
H D L ( m g /d L ) E q u a l v a r ia n c e s
1 .9 8 1 .1 7 0 1 .0 1 8 28 .3 1 7 5 .3 5 0 5 .2 5 3
assum ed
E q u a l v a r ia n c e s
1 .1 8 0 2 6 .1 3 2 .2 4 9 5 .3 5 0 4 .5 3 4
n o t a ssu m e d
L D L ( m g /d L ) E q u a l v a r ia n c e s
2 .4 0 2 .1 3 2 1 .0 9 7 28 .2 8 2 1 5 .6 5 0 1 4 .2 7 1
assum ed
E q u a l v a r ia n c e s
1 .2 6 0 2 5 .7 1 3 .2 1 9 1 5 .6 5 0 1 2 .4 2 2
n o t a ssu m e d
T r ig ly c e r id e ( m g /d LE)q u a l v a r ia n c e s
.8 8 7 .3 5 4 2 .3 8 0 28 .0 2 4 9 2 .5 0 0 3 8 .8 6 4
assum ed
E q u a l v a r ia n c e s
2 .9 1 1 2 7 .9 1 4 .0 0 7 9 2 .5 0 0 3 1 .7 7 4
n o t a ssu m e d
RTCHDL E q u a l v a r ia n c e s
.1 3 0 .7 2 1 .5 9 7 28 .5 5 6 .2 1 1 .3 5 4
assum ed
E q u a l v a r ia n c e s
.6 2 0 2 0 .0 3 2 .5 4 2 .2 1 1 .3 4 1
n o t a ssu m e d
RLDHDL E q u a l v a r ia n c e s
.0 1 8 .8 9 4 .2 7 3 28 .7 8 7 7 .8 3 0 E - 0 2 .2 8 6
assum ed
E q u a l v a r ia n c e s
.2 7 9 1 9 .1 4 9 .7 8 3 7 .8 3 0 E - 0 2 .2 8 0
n o t a ssu m e d

48
Table 4.2: Relationship of lipid profile levels in study
groups of AMI with control subjects
Correlations

Study group
Study group Pearson Correlation 1.000
Sig. (2-tailed) .
N 30
T.cholesterol(mg/dL) Pearson Correlation -.301
Sig. (2-tailed) .106
N 30
HDL(mg/dL) Pearson Correlation -.189
Sig. (2-tailed) .317
N 30
LDL(mg/dL) Pearson Correlation -.203
Sig. (2-tailed) .282
N 30
Triglyceride(mg/dL) Pearson Correlation -.410 *
Sig. (2-tailed) .024
N 30
*. Correlation is significant at the 0.05 level (2-tailed).

49
 CHAPTER FIVE
DISCUSSION
The study dealt with myocardial infarction patients admitted to
Intensive Coronary Care Unit of El Shaab Teaching Hospital. Soon after
hospital admission, blood samples were taken form patients for measuring
lipid profile. The majority of patients admitted ICCU of El Shaab Hospital
suffering from chest pain attack were at advanced ages with range of 40
-70 years. These findings are in agreement with the result of who claimed
that cardiovascular disease is associated with old age than younger.
The study also revealed that clinical assessment showed that about
30% of patients who diagnosed, as having Myocardial infarction were
diabetic, about 30% of patients had family history and about 60% are
hypertensive.
The study found no significant difference in serum total cholesterol
levels in patients with acute MI when compared with healthy control
subjects(p>0.05) table4.1. While confirming the findings of Berlin19 and
Heldenberg et al.11, the study provides information which is in direct
contrast to that by others who found either a decrease2,4,6,9,10 or an
increase20 during the acute phase of MI. Moreover, the pattern was almost
the same in males and females.
Although there was a decrease in HDL-cholesterol levels when
compared with control subjects but it failed to reach statistical significance
(p>0.05) table4.1. Heldenberg et al.11 also reported no significant
difference. In contrast to our findings other studies have shown either a
rise10 or a decrease9 in HDL.
LDL-cholesterol, in this study, recorded no significant difference when
compared with control subjects(p>0.05) table4.1. However, a significant
decrease in LDL following MI has been reported by others8,9.

50
 Serum triglycerides showed a significant increasing levels after MI
when compared with control subjects(p<0.05) table4.1. This finding was in
accordance with those mentioned by others8,11. On the contrary, Vetter et
al.23 recorded a progressive fall in triglycerides levels after MI and Ryder et
al.9 found no significant difference in triglycerides. The mechanism of
increase in triglycerides after MI may be due to elevated flux of fatty acids
and impaired removal of VLDL from the plasma12. Another possible
mechanism for elevated triglycerides levels may be the effect of β-blockers
but this contention seems to be invalid for increased triglycerides levels on
the first week as β-blockers take about two weeks to show their effect on
serum lipids27.
Several studies have advocated the value of ratios of LDL/HDL and
total-cholesterol/HDL as a correlate of the severity and extent of coronary
artery stenosis22,24,25. The present study showed no significant differences in
the ratios of LDL/HDL and total-cholesterol/HDL in the patients when
compared with control subjects(p>0.05) table4.1. while others found an
increase in these ratios27.

51
 CHAPTER SIX
CONCLUSIONS & RECOMMENDATIONS

The study reveals some significant alterations in triglycerides after MI.

However, we did not find significant differences in serum total cholesterol,
LDL and HDL. To the best of my knowledge there is no such study
available in Sudanese subjects residing in Sudan. The mechanism of these
changes is still not clear. Could it be a metabolic effect of stress, hormones
etc.? One recent study has shown that acute myocardial infarction causes
a profound up regulation of cholesterol synthesis as acute phase response
and the observed plasma cholesterol levels after acute myocardial
infarction must, therefore, be explained by the parallel increase of LDL
receptor activity and thus increased cholesterol catabolism26.
The mechanistic aspect of these changes deserves further
investigations of apolipoproteins, lipoprotein(a) and lipoprotein-receptors
with larger number of patients including patients with unstable angina and
atherosclerosis.

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 CHAPTER SEVEN
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