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
To the best creature who is my life, my sole is no thing without thee, I offer this.
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.
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 LDLcholesterol 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.
Topic Dedication Acknowledgement Abstract Content List of figures List of tables Chapter One Introduction and Literature Review 1.1. Normal function & structure of the heart 1.2. Heart failure 1.3. Ischaemic heart disease 1.4. Acute myocardial infarction 1.4.1. Clinical feature 1.4.2. Morphological feature 1.4.3. Complications of myocardial infarction 1.4.4. Diagnosis of myocardial infarction 22.214.171.124. Electrocardiography 126.96.36.199. Cardiac markers 1.4.5. Treatment of myocardial infarction 1.5. Lipids 1.6. Fatty acids 1.7. Triglycerides 1.8. Cholesterol 1.9. Phospholipids 1.10. Apolipoproteins 1.11. Lipoproteins 1.12. Classification of lipoproteins 1.13. Metabolism of lipoproteins 1.13.1. Chylomicrons 1.13.2. Very low density lipoproteins 1.13.3. Low density lipoproteins 1.13.4. High density lipoproteins 1.13.5. Lipoprotein receptors 1.14. Disorders of lipids metabolism 1.14.1. Predominant hypercholesterolaemia 1.14.2. Secondary hypercholesterolaemia 1.14.3. Primary hypercholesterolaemia 1.14.4. Predominant hypertriglyceridaemia 1.14.5. Mixed hyperlipidaemia 1.15. Treatment of hyperlipidaemia
Page II III IV V VII VIII 1 2 3 4 5 5 5 6 8 9 10 12 12 13 13 13 13 13 14 16 18 18 18 18 19 19 21 22 23 23 24 24 25
1.15.1. Treatment of hypercholesterolaemia II.3.4.1 Treatment of hypertriglyceridaemia Chapter Two The Objectives of The Study Chapter Three Materials and Methods 3.1. Patients and Controls 3.2. Samples Collection 3.3. Estimation of lipid profile 3.3.1. Equipments 3.3.2. Reagents 3.4.1. Estimation of total cholesterol 3.4.2. Estimation of HDL-cholesterol 3.4.3. Estimation of LDL-cholesterol 3.4.4. Estimation of triglyceride 3.5. Statistical analysis Chapter Four Results 4.1. Study group 4.2. Estimation of total cholesterol 4.3. Estimation of HDL-cholesterol 4.4. Estimation of LDL-cholesterol 4.5. Estimation of triglycerides Chapter Five Discussion Chapter Six Conclusion and Recommendation Chapter Seven References
25 25 27 28 28 28 28 29 29 30 31 32 33 33 34 34 34 34 34 35 43 45 46
LIST OF FIGURES Fig. Title 1.1 General structure of plasma lipoprotein 4.1 Age distribution in study groups of patients 4.2 Age distribution in control subjects 4.3 Comparison of diabetes in study groups of AMI with control subjects. 4.4 4.5 Comparison of hypertension in study groups of AMI with control subjects. Page 15 33 33 34 36
Comparison of family history in study groups of AMI with 39 control subjects.
Table 1.1. 4.1
LIST OF TABLES Title The Composition of the Major Lipoprotein Complexes Multiple Comparisons of lipid profile level (mg/dL) in study subgroups of patients with AMI and control subjects
Page 17 41
Relationship of lipid profile levels in study groups of AMI with control subjects
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:
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
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:
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 highenergy 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 Ischaemic heart disease can also result from low coronary arterial
plaques. 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”
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
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
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
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 2448 hours after the initial infract. Pericarditis, mitral incompetence and cardiac failure are the important complications in the first week after infraction.
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:
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:
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
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 Unequivocal initial increase and subsequent decrease in the activity
Q or QS waves and evolving injury lasting longer than one day, and
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:
(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
188.8.131.52. 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
184.108.40.206. 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
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
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
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
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 .
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
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:
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
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
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
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
Apolipoproteins (apo) are structural protein elements in the amphipathic shell of lipoprotein particles and help to keep the lipids in solution during
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
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.
1.12. Classification of Lipoproteins:
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
Density Protein (g/ml) %
VLDL Intestine, liver
(chylomicrons , VLDLs) Intestine, Liver
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:
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
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):
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 cholesterolinduced 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
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;
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.
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 LDLcholesterol 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
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.
Familial combined hyperlipidaemia, has been discussed above. Familial endogenous hypertriglyceridaemia, is caused by
One-third of affected individuals have raised plasma VLDL concentration.
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
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 Carbohydrate restriction reduces endogenous triglyceride chylomicron concentrations; 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
plasma. They also lower LDL-cholesterol by enhancing liver uptake and increase HDL-cholesterol.21
CHAPTER TWO THE OBJETIVES OF THE STUDY
This study aims to:
assess the levels of serum triglyceride, cholesterol, HDL and compare the mean of serum lipoproteins levels in patients with evaluate the significance of using serum lipoproteins levels in estimate the normal range of serum lipoproteins in healthy study the variations of serum lipoproteins level with reference to
LDL lipoproteins in Sudanese subjects with myocardial infarction;
that of the normal subject;
diagnosis of the acute phase of myocardial infarction;
some risk factors i.e. diabetes mellitus, family history, and hypertension.
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.
I. II. III.
Chemistry Analyzer (HITACHI-902), ROCHE Diagnostics Co; LTD. USA. Centrifuge (C-700), APEL Co; LTD. Tokyo. Japan. 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.
Total cholesterol Reagent (1):
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 Cholesterol Esterase Cholesterol Oxidase 30 mmol/L 4000 U/L 20000 U/L
• Good's Buffer, PH 6.7 • Phenol • 4-Aminoantipyrine • Cholesterol Esterase • Cholesterol Oxidase • Peroxidase
50 mmol/L 5 mmol/L 0.3 mmol/L ≥ 200 U/L ≥ 50 U/L ≥ 3 U/L
N-ethyl(2-hydroxy-3-sulfopropyl)-dimethoxyflouroaniline,sodium salt 0.8 mmol/L III. LDL-cholesterol reagents: Reagent (4) • Good's Buffer, PH 6.8 25 mmol/L
• • •
5000 U/L 0.64 mmol/L 1000 KU/L
Catalase 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): • • •
2-Hydroxy sulfopropyl dimethoxyaniline
• • • •
Good's Buffer, PH 7.0 ATP 3-Hydroxy tribomobenzoic acid Glycerophosphate oxidase Lipase Gkycerol Kinase Peroxidase Sodium azide 0.1%
25 mmol/L 1.0 mmol/L 2.0 mmol/L ≥ 2000 U/L ≥ 200 KU/L 6000 U/L ≥ 500 U/L
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
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 HDL + H2O + O2 Ah β-L Ab CHE& CHO POD HDL + Ag-Ab complex cholesten + fatty acid + H2O2 blue colored complex + H2O
H2O2 + DAOS + 4-Aminoantipyrine
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.
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) HDL,VLDL,chylomicrons H2O2 + Catalase (2) protected LDL + releasing reagent(5) LDL-cholesterol CHO CHE H2O2 + DAOS + 4-Aminoantipyrine POD LDL-cholesterol cholestenone + H2O2 blue colored complex + H2O CHO CHE protected LDL cholestenone + H2O2 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.
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).
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:
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.
Std. Dev = 9.19 Mean = 56.3 N = 20.00 40.0 45.0 50.0 55.0 60.0 65.0 70.0
FIGURE 4.1: Age distribution in study groups of patients
.5 0.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0
Std. Dev = 10.34 Mean = 56.3 N = 10.00
FIGURE 4.2: Age distribution in control subjects
0 AMI CONTROL
FIGURE 4.3: Comparison of diabetes in study groups of AMI with control subjects.
no 0 AMI CONTROL yes
FIGURE 4.4: Comparison of hypertension in study groups of AMI with control subjects.
0 AMI CONTROL
FIGURE 4.5: Comparison of family history in study groups of AMI with control subjects.
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 S ig . ( 2 - ta ile d )D iffe r e n c e D iffe r e n c e 28 2 7 .4 0 9 28 2 6 .1 3 2 28 2 5 .7 1 3 28 2 7 .9 1 4 28 2 0 .0 3 2 28 1 9 .1 4 9 .1 0 6 .0 5 6 .3 1 7 .2 4 9 .2 8 2 .2 1 9 .0 2 4 .0 0 7 .5 5 6 .5 4 2 2 8 .2 0 0 2 8 .2 0 0 5 .3 5 0 5 .3 5 0 1 5 .6 5 0 1 5 .6 5 0 9 2 .5 0 0 9 2 .5 0 0 .2 1 1 .2 1 1 1 6 .8 6 6 1 4 .1 0 5 5 .2 5 3 4 .5 3 4 1 4 .2 7 1 1 2 .4 2 2 3 8 .8 6 4 3 1 .7 7 4 .3 5 4 .3 4 1 .2 8 6 .2 8 0
F T .c h o le s te r o l( m g /d Lq)u a l v a r ia n c e s E 3 .9 0 0 assum ed E q u a l v a r ia n c e s 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 assum ed E q u a l v a r ia n c e s 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 assum ed E q u a l v a r ia n c e s n o t a ssu m e d T r ig ly c e r id e ( m g /d L )q u a l v a r ia n c e s E .8 8 7 assum ed E q u a l v a r ia n c e s 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 assum ed E q u a l v a r ia n c e s 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 assum ed E q u a l v a r ia n c e s n o t a ssu m e d
S ig . .0 5 8
t 1 .6 7 2 1 .9 9 9
.1 7 0
1 .0 1 8 1 .1 8 0
.1 3 2
1 .0 9 7 1 .2 6 0
.3 5 4
2 .3 8 0 2 .9 1 1
.7 2 1
.5 9 7 .6 2 0
.8 9 4
.2 7 3 .2 7 9
.7 8 7 7 .8 3 0 E - 0 2 .7 8 3 7 .8 3 0 E - 0 2
Table 4.2: Relationship of lipid profile levels in study groups of AMI with control subjects
C r e tio s o r la n S d g u tu y ro p P a o C rre tio e rs n o la n S . (2 ile ) ig -ta d N P a o C rre tio e rs n o la n S . (2 ile ) ig -ta d N P a o C rre tio e rs n o la n S . (2 ile ) ig -ta d N P a o C rre tio e rs n o la n S . (2 ile ) ig -ta d N P a o C rre tio e rs n o la n S . (2 ile ) ig -ta d N S d g u tu y ro p 1 0 .0 0 . 3 0 -.3 1 0 .1 6 0 3 0 -.1 9 8 .3 7 1 3 0 -.2 3 0 .2 2 8 3 0 -.4 0 * 1 .0 4 2 3 0
T h le te l(m /d ) .c o s ro g L
H L g L D (m /d )
L L g L D (m /d )
T ly e e g L rig c rid (m /d )
* C rre tio is s n a t a th 0 5 le e (2 ile ). . o la n ig ific n t e .0 v l -ta d
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.
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.
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.
CHAPTER SEVEN REFERENCES
Biorch, G., Blomquist, G. and Sievers, J. (1957) Cholesterol
values in patients with myocardial infarction and normal control group. Acta. Med. Scand. 156,493-497. 2. Bjorntrop, P. and Mmalmcrone, R. (1960) Serum cholesterol in patients with myocardial infarction in younger ages. Acta. Med. Scand. 168,151-155.
Dodds, C. and Mills, G.L. (1959) Influence of myocardial Tibblin, G. and Cramer, K. (1963) Serum lipids during the
infarction on plasma lipoprotein concentration. Lancet i,1160-1163.
course of acute myocardial infarction and one year afterwards. Acta. Med. Scand. 192,523-528. 5.
Fyfe, T., Baxter, R.H., Cochran, K.M. and Booth, E.M. (1971) Kerkeby, K. (1972) Disturbances in serum lipids and in their
Plasma lipid changes after myocardial infarction. Lancet ii, 997-1001. fatty acid composition following acute myocardial infarction. Acta. Med. Scand. 192,523-528. 7. Avogaro, A., BittilinBon, G., Cazzalato, C., Quinci,G.B., Sanson, A., Sparla, H. and Zagatti, G.C.(1978) Variation in apolipoproteins B and A during the course of myocardial infarction. Eur. J. Clin. Invest. 8,121-129.
Ballantyne, F.C., Melville.D.A., Mc Kenna, J.P. and Morrison,
B.A. (1979) Response of plasma lipoproteins and acute phase proteins to myocardial infarction. Clin. Chem. Acta 99,85-92. 9. Ryder, R.E., Hayes, T.M. and Owens, D.R. (1984) How soon after myocardial infarction should plasma lipid values be assessed? Br. Med. J. 289,1651-1653.
Jackson, R., Scragg, R., Marshall, R. and Small, C. (1987) Changes in serum lipid concentrations during first 24 hours after myocardial infarction. Br. Med. J. 294,1588-1589.
Heldenburg, D., Rubenstein, A., Levtov, O. and Tamir, L.(1980) Serum lipids and lipoprotein concentrations during the acute phase of myocardial infarction. Atherosclerosis 35,433-437.
Fredrickson, D.S. (1969) The role of lipids in acute myocardial infarction. Circulation 39,99.
13. Swedarsen, M., Vythilingum, S. and Nadar, R.(1988) Plasma lipids can be reliably assessed within 24 hours after acute myocardial infarction. Postgrad. Med. J. 64,352-356. 14. Wastson, W.C., Buchman, K.D. and Dickson, C.(1963) Serum cholesterol levels after myocardial infarction. Br. Med. J. 2,709-712.
Underwood, J.C.E. (1996) . Cardiac disease. General and systemic pathology. 2nd edition,331-340.
16. Mac Sween RMN, Khaley K, Lindop GBM, and Dargie JH, Muir’s Textbook of Pathology. Cardiovascular System. Myocardial Infarction; 1992.
Kent Lewandrowski. (2002) Clinical Chemistry. Lipids, lipoproteins and cardiovascular risk assessmet.574-591. Fischbach, F. Electrocardiography.Manual of laboratory and diagnostic tests. 6th edition. 1024-1033. Michael L. Bishop, Janet L. Duben-Engelkirk and Edward P. Fody. Lipids and lipoproteins. Clinical chemistry. 4th edition. 232-259. William J. Marshall and Stephen K. Bangert. Lipids lipoproteins and cardiovascular disease. Clinical chemistry. 5th edition. 255-277. Philip D. Mayne. Plasma lipids and lipoproteins.Clinical chemistry in diagnosis and treatment. 6th edition. 224-238.
22. Natio, H. K. (1985) The association of serum lipids, lipoproteins and apolipoproteins with coronary artery disease assessed by coronary arteriography. Ann. N.Y. Acad. Sci. 454,230-238. 23. Vetter, N.J., Adams, W. Strange, R. C. and Oliver, M. F. (1974) Initial metabolic and hormonal response to acute myocardial infarction. Lancet I, 284-289. 24. Zampogna, A. and Luria , M.A. (1980) Relationship between lipids and occlusive coronary disease. Arch. Intern. Med. J. 140,1067-1069. 25. Luria, M. H. and Gotsman, M. S. (1991) Cardiovascular risk factor clustering and ratio of total cholesterol to HDL inangiographically documented coronary artery disease. Am. J. Cardiol 67,31-36. 26. Schreiber, I. Liebich, H.M. and haffmeister, H.M. (1999) Upregulation of cholesterol synthesis after acute myocardial infarction. Atherosclerosis 142,389-393.
Nigam, P. K., Narain, V. S. and HASAN, M. Serum lipid profile in patients with acute myocardial infarction. Indian j. of Clin. Biochem. 2004,67-70.