723311

research-article2017
TAK0010.1177/1753944717723311Therapeutic Advances in Cardiovascular DiseaseL Goenka, M George

Therapeutic Advances in Cardiovascular Disease Original Research

Do ANGPTL-4 and galectin-3 reflect the

Ther Adv Cardiovasc Dis

2017, Vol. 11(10) 261­–270

severity of coronary artery disease? DOI: 10.1177/

https://doi.org/10.1177/1753944717723311
https://doi.org/10.1177/1753944717723311
1753944717723311

© The Author(s), 2017.

Reprints and permissions:
Luxitaa Goenka, Melvin George, Vishakha Singh, Amrita Jena, Deepika Seshadri, http://www.sagepub.co.uk/
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Vasanth Karunakaran, Dhandapani Vellala Elumalai, Jamuna Rani and Ilango Kaliappan

Abstract Correspondence to:

Melvin George
Background: Coronary artery disease (CAD) is one of the leading causes of mortality and Department of Clinical
Pharmacology, SRM MCH
morbidity worldwide. We thereby sought to investigate whether the biomarkers, angiopoietin- & RC, Kattankulathur,
like 4 (ANGPTL-4) and galectin-3, reflect the severity of CAD. Chennai, Tamil Nadu,
603203, India
Methods: Patients were screened based on inclusion/exclusion criteria and written informed melvingeorge2003@
consent was obtained from the patients. Serum ANGPTL-4 and galectin-3 was quantified using gmail.com
Luxitaa Goenka
enzyme-linked immunosorbent assay (ELISA) and correlated with the Global Registry of Acute Amrita Jena
Coronary Events (GRACE) and GENSINI score using Spearman’s rank correlation coefficient Deepika Seshadri
Department of Clinical
and multivariate analysis. Pharmacology, SRM MCH
Results: A total of 226 patients consisting of ST-segment elevation myocardial infarction & RC, Kattankulathur,
Chennai, Tamil Nadu, India
(STEMI), non-STEMI/unstable angina (USA), chronic stable angina (CSA) and normal controls Vishakha Singh
(NCs) participated in the study. ANGPTL-4 and galectin-3 were significantly higher in CAD Department of
Biotechnology, SRM
than the NC group. ANGPTL-4 showed significant negative correlation with GRACE score in University, Kattankulathur,
Chennai, Tamil Nadu, India
acute coronary syndrome (ACS) (r = −0.211, p = 0.03) patients. ANGPTL-4 showed significant
Vasanth Karunakaran
positive correlation with serum creatinine (r = 0.304, p = 0.056) and body mass index (BMI) (r Ilango Kaliappan
Department of IIISM, SRM
= 0.424, p = 0.009) in CSA patients. A modest positive correlation was observed between the University, Kattankulathur,
serum galectin-3 levels and GRACE score (r = 0.187, p = 0.055) in ACS patients. However, on Chennai, Tamil Nadu, India

multivariate analysis the positive correlation relationship between ANGPTL-4 and galectin-3 Dhandapani Vellala
Elumalai
with the severity of CAD was not sustained. Department of Cardiology,
SRM MCH & RC,
Conclusion: In conclusion, ANGPTL-4 and galectin-3 do not appear to have a promising Kattankulathur, Chennai,
role for assessing the severity of CAD. Nevertheless these biomarkers do warrant further Tamil Nadu, India
Jamuna Rani
exploration in improving the management of CAD. Department of
Pharmacology, SRM MCH
& RC, Kattankulathur,
Keywords:  angiopoietin-like 4, galectin-3, GRACE score, CAD Chennai, Tamil Nadu, India

Received: 7 December 2016; revised manuscript accepted: 10 July 2017.

Introduction CAD in Chennai, South India was about 11%

Despite the significant improvement and devel-
opment in the diagnosis and treatment, coronary
artery disease (CAD) is one of the leading causes
of mortality and morbidity worldwide. According
to the report by the World Health Organization
in 2012 about 7.4 million (31%) deaths occurred
worldwide due to coronary heart disease (CHD).1
In a recent systematic review done on 288 obser-
vational studies conducted in the Indian popula-
tion, it was observed that the prevalence of CAD
in urban and rural areas was 2.5–12.6% and 1.4–
4.6% respectively.2 The overall prevalence rate of
while the age standardized prevalence was 9.0%.3
Many traditional scoring systems like the Global
Registry of Acute Coronary Events (GRACE)
risk score, SYNTAX score and thrombolysis in
myocardial infarction (TIMI) risk score have
been used to measure the severity of CAD.
However, these scoring systems have not been
incorporated into routine clinical practice.4–6
Several cardiac markers like creatine kinase-MB
(CK-MB) and cardiac troponins are being uti-
lized in daily clinical practice for the early diag-
nosis and risk stratification in CAD patients.

http://tac.sagepub.com 261
Therapeutic Advances in Cardiovascular Disease 11(10)
Circulatory biomarkers such as angiopoietin-like
4 (ANGPLT-4) and galectin-3 are newly emerg-
ing biomarkers for CAD. ANGPTL-4 is a multi-
functional protein that is involved in lipid
regulation, energy metabolism, angiogenesis and
inflammation.7–9 Galectin-3 is a β-galactoside-
binding lectin expressed by activated mac-
rophages that regulates inflammation, ventricular
remodeling and fibrosis.10–12 However, it is still
not known if these biomarkers could be used to
assess the severity of CAD in the clinical setting.
The present study aimed to evaluate the concen-
tration of ANGPTL-4 and galectin-3 levels in
patients with CAD and determine the relation of
galectin-3 and ANGPTL-4 with the severity of
CAD. Since there are insufficient data to estab-
lish a link between ANGPTL-4 and CAD, we
also attempted to assess the relationship between
ANGPTL-4, and other routine clinical and
demographic variables. The value of these bio-
markers in predicting the need for angioplasty
was also evaluated.
Methods
Study population
This was a cross-sectional study performed in the
Department of Cardiology and Clinical
Pharmacology of SRM Medical College Hospital
and Research Centre, India, between January and
August 2016. Patients who were diagnosed with
ST-segment elevation myocardial infarction
(STEMI), non-ST-segment myocardial infarc-
tion (NSTEMI)/unstable angina (UA) and
chronic stable angina (CSA) were considered eli-
gible for inclusion into the study as case patients.
STEMI was defined as a clinical syndrome, with
the presence of clinical symptoms of myocardial
ischemia, with constant ST elevation and succes-
sive release of biomarkers associated with myo-
cardial necrosis.13 NSTEMI/UA is defined as a
clinical syndrome with the absence of persistent
ST elevation and presence of cardiac biomarkers
of myocardial necrosis.14 Angina is defined as a
clinical syndrome with discomfort in the chest,
jaw, shoulder, back, or arm. It is a substernal
chest discomfort enraged by exertion or emo-
tional stress and relieved by rest or nitroglycerin.15
Coronary angiography (CAG) was performed on
these patients to determine the presence of block-
age in the coronary vessels. Patients who showed
no evidence of CAD or CAD equivalents with
respect to their symptoms with normal echocardi-
ography (ECG) were considered eligible for
262 http://tac.sagepub.com
inclusion as normal controls (NCs). We excluded
patients with other inflammatory diseases such as
infections, cancer, heart failure (HF) and autoim-
mune diseases.
Clinical collection of data
Clinical and demographic data were collected
on patient age, sex, waist and hip circumfer-
ence and other cardiovascular risk factors such
as diabetes mellitus, hypertension, current/pre-
vious smoker, dyslipidemia, renal disease, fam-
ily history of cardiac disease and sedentary
lifestyle. Vital signs including blood pressure,
heart rate and body mass index (BMI) were
obtained. A 12-lead ECG, including assess-
ment of left ventricular ejection fraction (LVEF)
(%) and regional wall motion abnormality
(RWMA) was done. GENSINI score was cal-
culated using coronary angiographic scoring
systems and GRACE score was calculated to
predict the risk of death in myocardial infarc-
tion (MI) patients. Blood sampling was done to
determine the level of hemoglobin (Hb), serum
creatinine (SCr), glucose and cardiac enzymes
(troponin-T, CK-MB).
Ethical approval
The study was approved by the SRM Medical
College Institutional Ethics Committee (IEC),
India (664/IEC/2014) and all study procedures
were performed in accordance with the provisions
of the Declaration of Helsinki.
Laboratory analysis
After obtaining the written informed consent
from all patients, 4 ml of blood sample was col-
lected from the vein in the forearm prior to CAG.
After adequate centrifugation at 2500 rpm for 10
min, the serum samples were extracted and were
stored in −80°C deep freezer. The serum which
was centrifuged from the blood sample was sub-
jected to enzyme-linked immunosorbent assay
(ELISA) for measurement of biomarkers galec-
tin-3 and ANGPTL-4 with a commercially avail-
able (Ray Biotech Human ANGPTL-4 and
galectin-3 ELISA, GA, USA) kit. The inter-assay
coefficient of variation was 7.6% and 8.8% for
galectin-3 and ANGPTL-4 respectively. The
measurements of ANGPTL-4 and galectin-3
were done in a blinded fashion as the investiga-
tors who performed the ELISA analysis were not
informed about the patient’s diagnosis.

Statistical analysis
Continuous variables were summarized as mean ±
standard deviation and categorical data were
expressed as frequency and percentages.
Differences in categorical variables between groups
were evaluated with the Chi-square test and differ-
ences in continuous variables between groups were
analyzed with one-way analysis of variance test.
We assessed the correlation between ANGPTL-4,
galectin-3 and clinical and biochemical parameters
using the Spearman’s rank correlation coefficient.
The optimal cutoff level of ANGPTL-4 and galec-
tin-3 to predict the need for coronary angioplasty
in CAD patients was evaluated using the area
under the receiver operating characteristic (ROC)
curve. We performed a multivariate linear regres-
sion using galectin-3/ANGPTL-4 as dependent
variables and other parameters such as BMI,
GRACE, GENSINI score, age, total count and
blood glucose as independent variables. All statisti-
cal analyses were performed with SPSS software
version 16.0 (SPSS Inc., Chicago, IL, USA). All
p-values were two-sided with a value of <0.05 con-
sidered significant.
Results
The baseline characteristics of the study patients
are shown in Table 1. Patients were divided into
four groups namely STEMI (n = 57), NSTEMI/
UA (n = 63), CSA (n = 42) and NC (n = 64)
(Supplementary Figure 1). As expected, there
was a significant reduction in age in NC versus
other groups. Patients with STEMI and
NSTEMI/UA had a significant increase in
GENSINI score compared with CSA. Significant
correlations were observed between the galectin-3
and age, urea, total leukocyte count, GRACE
score, GENSINI score and ANGPTL-4 (Table
2). Significant correlations were also seen between
ANGPTL-4 and age, serum creatinine, packed
cell volume and waist to hip ratio (Table 3).
The serum ANGPTL-4 and galectin-3 concen-
trations were significantly higher among patients
with STEMI, NSTEMI/UA and CSA than the
NC group (p = 0.0001). There was also a signifi-
cant difference in the galectin-3 concentrations
between STEMI and NSTEMI/UA (p = 0.04;
Figure 1). Based on correlation analysis, signifi-
cant negative correlations were observed between
serum ANGPTL-4 levels and GRACE risk score
in ACS (r = −0.211, p = 0.030; Figure 2(a)) and
STEMI patients (r = −0.324, p = 0.022; Figure
2(b)). The serum ANGPTL-4 levels also showed
http://tac.sagepub.com 263
L Goenka, M George et al.
positive correlation with serum creatinine (r =
0.304, p = 0.056; Figure 3(a)) and BMI (r =
0.424, p = 0.009; Figure 3(b)) in CSA patients.
In addition, a modest positive correlation was
determined between the serum galectin-3 levels
and GRACE risk score (r = 0.187, p = 0.055) in
ACS patients (Figure 4). In contrast, no signifi-
cant association was observed between GENSINI
score and serum ANGPTL-4 (r = 0.100, p =
0.287) and galectin-3 (r = 0.144, p = 0.126).
The mean concentration of galectin-3 and
ANGPTL-4 was comparatively higher among
patients (age > 40 years) STEMI, NSTEMI/UA
and CSA than in the NC group. There was also a
significant difference in galectin-3 concentration
between the groups NC and CSA (p = 0.017),
NC and STEMI (p = 0.0001), NSTEMI and
STEMI (p = 0.018). We also looked at the mean
concentration of galectin-3 and ANGPTL-4
among males and females separately. The mean
concentration of galectin-3 and ANGPTL-4 was
comparatively lower in the control group when
compared with STEMI, NSTEMI/UA and CSA
group among both males and females. A signifi-
cant difference was also observed in the concen-
tration of galectin-3 between the groups NC and
CSA (p = 0.006), NC and STEMI (p = 0.0001),
NSTEMI and STEMI (p = 0.015) and NC and
STEMI (p = 0.0001).
We performed a multivariate linear regression
using galectin-3/ANGPTL-4 as dependent varia-
bles and other parameters such as BMI, GRACE,
GENSINI score, age, total count, blood glucose
as independent variables. We observed that in the
presence of these variables, the relationship
between the biomarkers and the variables that
showed a correlation on univariate correlation
was obfuscated.
The combined ROC curve was plotted to predict
the ability of ANGPTL-4 and galectin-3 in
assessing the need for coronary angioplasty in
CAD patients. The ability of galectin-3 to differ-
entiate whether a person required angioplasty or
medical management was marginal [AUC =
0.585; p = 0.04; 95% confidence interval (CI)
0.498–0.672] (Figure 5) Adjustment of age and
sex was done to predict the ability of ANGPTL-4
and galectin-3 in assessing the need for coronary
angioplasty in MI patients. However, it was
found that galectin-3 and ANGPTL-4 could not
predict whether a person required angioplasty or
medical management.
Therapeutic Advances in Cardiovascular Disease 11(10)

Table 1.  Baseline characteristics including demographics, risk factors and laboratory findings of study participants.

Characteristics STEMI NSTEMI/USA CSA NC p-value

(n = 57) (n = 63) (n = 42) (n = 64)
Age, years 55.39 ± 11.88 54.10 ± 9.76 54.07 ± 10.55 39.59 ± 12.94 0.0001
Male sex, n (%) 49 (86) 42 (66.7) 31 (73.8) 36 (56.2) 0.020
BMI, kg/m2 26.54 ± 4.075 27.58 ± 5.17 27.32 ± 4.28 25.64 ± 4.97 0.174
Blood glucose, mg/dl 166.06 ± 64.92 167.45 ± 80.11 152.64 ± 74.27 144.75 ± 47.93 0.518
Urea, mg/dl 28.58 ± 13.25 24.82 ± 8.80 25.98 ± 9.52 27.04 ± 14.17 0.527
Serum creatinine, mg/dl 0.90 ± 0.24 0.84 ± 0.29 0.85 ± 0.20 0.83 ± 0.31 0.780
Hemoglobin 13.64 ± 2.18 13.40 ± 1.55 12.92 ± 1.66 12.60 ± 2.57 0.135
Packed cell volume 40.38 ± 5.50 39.11 ± 4.81 38.58 ± 4.63 39.16 ± 5.85 0.404
Total leukocyte count 12518 ± 12544.92 10474 ± 9103.99 10834 ± 10695.88 7688.5 ± 3609.15 0.562
GENSINI score 37.38 ± 25.81 34.70 ± 41.64 27.19 ± 32.88 – 0.0001
GRACE score 97.58 ± 36.48 84.41 ± 29.67 – – 0.006
WHR 0.93 ± 0.03 0.91 ± 0.04 0.94 ± 0.07 0.90 ± 0.06 0.034
LVEF (%) 46.00 ± 7.42 57.48 ± 8.56 56.56 ± 7.82 60.13 ± 6.10 0.0001
RWMA 50 (87.7) 19 (30.2) 12 (28.6) 1 (1.6) 0.0001
Diabetes (%) 20 (35.1) 28 (44.4) 23 (54.8) 10 (15.6) 0.0001
Hypertension (%) 15 (26.3) 32 (50.8) 15 (35.7) 13 (20.3) 0.004
Smoking (%) 20 (35.1) 13 (20.6) 8 (19.0) 7 (10.9) 0.008
Dyslipidemia (%) 5 (8.8) 9 (14.3) 9 (21.4) 4 (6.2) 0.091
Renal disease (%) 1 (1.6) 2 (4.8) 1 (1.6) 0.566
F/h/o premature CVD (%) 9 (15.8) 16 (25.4) 8 (19.0) 11 (17.2) 0.706
Sedentary lifestyle (%) 3 (5.3) 4 (6.3) 4 (9.5) 5 (7.8) 0.857
Angio  
Normal and minimal 2 (3.5) 21 (33.3) 17 (40.5) 64 (100) 0.0001
coronaries (%)
SVD (%) 29 (50.9) 17 (27) 6 (14.3) –
DVD (%) 15 (26.3) 11 (17.5) 7 (16.7) –
TVD (%) 10 (17.5) 13 (20.6) 12 (28.6) –
BMI, body mass index; CSA, chronic stable angina; CVD, cardiovascular disease; DVD, double vessel disease; F/h/o, family history of; GRACE,
Global Registry of Acute Coronary Events; LVEF, left ventricular ejection fraction; NC, normal controls; NSTEMI, non-ST-segment elevation
myocardial infarction; RWMA, regional wall motion abnormalities; STEMI, ST-segment elevation myocardial infarction; SVD, single vessel disease;
TVD, triple vessel disease; WHR, waist–hip ratio.

Discussion an earlier study that showed no significant asso-

The main findings of our study were that ciation between ANGPTL-4 and angiographi-
ANGPTL-4 does not show a significant negative cally characterized coronary atherosclerosis.16 In
correlation with GRACE risk score in ACS and contrast a recent study reported that the serum
MI patients. These findings are consistent with ANGPTL-4 levels at baseline was associated

264 http://tac.sagepub.com
 L Goenka, M George et al.

Table 2.  Correlation between galectin-3, and clinical/demographic variables in CAD patients.

Galectin-3, Age, Urea, TLC GENSINI GRACE risk ANGPTL-4,

ng/ml years mg/dl score score ng/ml
r-value 0.244 0.185 0.198 0.220 0.150 0.246
p-value 0.0001 0.009 0.010 0.002 0.054 0.0001
ANGPTL-4, angiopoietin-like 4; CAD, coronary artery disease; GRACE, Global Registry of Acute Coronary Events;
TLC, total leukocyte count.

Table 3.  Correlation between ANGPTL-4, and clinical/demographic variables in CAD patients.

ANGPTL-4, ng/ml Age, years Serum creatinine, mg/dl pcv WHR

r-value 0.134 0.151 0.159 0.239
p-value 0.038 0.034 0.028 0.001
ANGPTL-4, angiopoietin-like 4; CAD, coronary artery disease; pcv, packed cell volume; WHR, waist-hip ratio.

Figure 1.  (a) Mean concentration of ANGPTL-4, ng/ml among the study groups. (b) Mean concentration of
galectin-3, ng/ml among the study groups.
ANGPTL-4, angiopoietin-like 4; CAS, chronic stable angina; NSTEMI/USA, non-ST-elevation myocardial infarction/unstable
angina; STEMI, ST-elevation myocardial infarction.

with the occurrence of myocardial no-reflow in permeability, hemorrhage, edema, inflammation

acute MI patients treated by primary percutane-
ous coronary intervention (PCI). Patients with
no-reflow had lower levels of ANGPTL-4 and
higher levels of vascular endothelial growth
factor (VEGF) compared with patients without
no-reflow.17 In MI patients, a condition known
as microvascular no-reflow prevails even after
successful PCI and its persistence lead to poor
outcomes such as mortality and HF.18 Further,
in a preclinical study it was demonstrated that
ANGPTL-4 had the ability to inhibit the VEGF-
induced vascular permeability; the ANGPTL-
4-deficient mice showed increased vascular
and increase in infarct size. Hence ANGPTL-4
might be incorporated as a relevant therapeutic
target for vascular protection attempting to
nullify the effects of VEGF, for prevention of
no-reflow and cardio protection during acute
myocardial infarction (AMI).19 Our study could
not support the notion that ANGPLT-4 could
reflect the severity of CAD. Thus, there is a defi-
nite need to understand the role of ANGPTL-4
in the pathogenesis of CAD by well designed,
prospective cohort studies where the levels of
ANGPLT-4 are measured serially and are corre-
lated with the disease progression.

http://tac.sagepub.com 265
Therapeutic Advances in Cardiovascular Disease 11(10)

Figure 2.  (a) ANGPTL-4 versus GRACE risk score in ACS patients. (b) ANGPTL-4 versus GRACE Risk Score in
STEMI patients.
ACS, acute coronary syndrome; ANGPTL-4, angiopoietin-like 4; GRACE, Global Registry of Acute Coronary Events

Figure 3.  (a) ANGPTL-4 versus serum creatinine in CSA patients. (b) ANGPTL-4 versus BMI in CSA patients.
ANGPTL-4, angiopoietin-like 4; BMI, body mass index; CSA, chronic stable angina.

Figure 4. Galectin-3 versus GRACE risk score in ACS patients.

ACS, acute coronary syndrome; GRACE, Global Registry of Acute Coronary Events

The present study also reported that the levels of STEMI (9.42 ng/ml), NSTEMI/UA (10.45 ng/
ANGPTL-4 were significantly lower in the con- ml) and CSA (10.27 ng/ml) groups. Compared
trol group (7.40 ng/ml) when compared with with previous research in the literature where

266 http://tac.sagepub.com

Figure 5.  Combined receiver-opening characteristic
(ROC) curves of galectin-3 and ANGPTL-4 to predict
the need for coronary angioplasty.
Galectin-3: AUC = 0.585; p = 0.049; 95% CI (0.498–0.672).
ANGPTL-4: AUC = 0.0554; p = 0.210; 95% CI (0.467–0.641).
ANGPTL-4, angiopoietin-like 4; AUC, area under the curve;
CI, confidence interval
ANGPTL-4 ranged between 7.2–23.3 ng/ml,16,17
we observed lower ANGPTL-4 levels. The devia-
tions in the ANGPTL-4 levels might be due to
the digression in the characteristics and race of
the study populations. In the studies done by
Muendlein and colleagues16 and Bouleti and col-
leagues,17 the race of study population was White
whereas in our study the race of the study popula-
tion was Asian Indian. It may also be due to the
heterogeneity in the mean age of the study popu-
lation; in the current study the mean age was
below 60 years whereas in other studies the mean
age was above 60 years.16,17 Gender inequality of
the study population may also generate contrast-
ing results in the levels of ANGPTL-4;20 likewise
in the Muendlein and colleagues16 study the
number of males in the study population was
comparatively lower than the present study.
Additionally, the number of diabetic STEMI
patients in our study was more when compared
with the study done by Bouleti and colleagues17
Thus, the presence of diabetes could have an
influence on the levels of ANGPTL-4. Hence,
more well-defined studies with a homogenous
population are required to confirm the role of
ANGPTL-4 and its correlation with the severity
of CAD.
Our study reported a significant positive associa-
tion between ANGPTL-4 and SCr in CSA
patients. Chronic kidney disease (CKD) is defined
by the reduction in the estimated glomerular fil-
tration rate (GFR) and patients with CKD have
an increased risk of cardiovascular diseases and
end-stage renal disease (ESRD).21,22 Our study
results matched the results of study done by
Baranowski and colleagues23 where ANGPTL-4
was quantified in patients on chronic hemodialysis
(CD) and controls (GFR > 50 ml/min). The
http://tac.sagepub.com 267
L Goenka, M George et al.
ANGPTL-4 levels were five-fold higher in CD
patients compared with controls and serum
creatinine independently predicted ANGPTL-4
concentrations in control participants. Thus,
ANGPTL-4 levels were significantly increased in
ESRD and showed an independent association
with markers of renal function in control partici-
pants. Although the study by Baranowski and col-
leagues23 used CD patients, it is worth mentioning
that similar findings were observed in our study,
highlighting the relationship between ANGPTL-4
and renal function. Diabetic nephropathy (DN) is
one of the leading causes of ESRD and albuminu-
ria is an indication of DN which is an independent
risk factor for progression of renal and cardiovas-
cular disease.24 Podocyte injury plays a significant
role in the development of DN.25 In a recent pre-
clinical study done on streptozotocin (STZ), an
induced diabetic model, the researchers observed
that the upregulation of glomerular ANGPTL-4
occurred earlier than that of albuminuria and
podocyte changes in rats. The increase in the glo-
merular ANGPTL-4 mRNA expression was simi-
lar to the albumin-to-creatinine (ACR) ratio and
was closely related to albuminuria and podocyte
injury. This implied that ANGPTL-4 was primar-
ily secreted from the podocyte; the upregulation of
podocyte secreted ANGPTL-4 in DN and its
detection in urine indicates that ANGPTL-4 may
be used as podocyte injury marker and can be a
novel diagnostic and therapeutic marker for DN.26
Since there are insufficient clinical data on the role
of ANGPTL-4 in the pathogenesis of CKD, an
independent risk factor of cardiovascular disease;
there is definite need to understand the associa-
tion between ANGPTL-4 and CKD.
Our data showed a significant positive association
between ANGPTL-4 and BMI in CSA patients.
Besides our study, the Northwick Park Heart
Study II (NPHSII) investigated the relationship
between plasma ANGPTL-4 and CHD. The
results of the (NPHSII) study matched the pre-
sent study results where plasma ANGPTL-4 lev-
els positively correlated with measures of obesity,
such as BMI and body fat mass.27 However, only
middle aged healthy men between (50–63 years)
were included in the NPHSII study and the pre-
sent study comprised of CAD patients. It is
known that hypothalamic ANGPTL-4 acts as a
downstream mediator of anorexigenic physiologi-
cal factors. Kim and colleagues28 have shown that
the hypothalamic over-expression of ANGPTL-4
lowered food-intake, body weight gain and
increased energy expenditure through regulation
of hypothalamic AMP-activated protein kinase
Therapeutic Advances in Cardiovascular Disease 11(10)
(AMPK) pathway and acetyl-CoA carboxylase
(ACC) activities. However, this inhibitory effect
of hypothalamic ANGPTL-4 was attenuated in
obese mice. Thus, the dysregulation of hypotha-
lamic ANGPTL-4 contributed to the pathogene-
sis of obesity which is one of the risk factors for
CAD.29 Furthermore, the over-expression of
ANGPTL-4 suppressed the clearance of triglyc-
erides (TGs) by inhibition of lipoprotein lipase
(LPL) and the effect of over-expression of
ANGPTL-4 was more pronounced by high fat
diet resulting in elevated levels of TGs, free fatty
acids and impaired glucose tolerance. Thus, it
appears that perturbation in ANGPTL-4 signal-
ing leads to the development of dyslipidemia and
obesity.29 Based on these findings we believe that
manipulating the ANGPTL-4 action may serve
as therapeutic potential for obesity.
Although several studies have investigated the
role of galectin-3 in HF in the past,30,31 there are
insufficient data about the role of galectin-3 in
CAD. Galectin-3 is a macrophage and endothe-
lium-derived mediator and regulates inflamma-
tion that amplifies atherosclerotic plaque
progression.32 We found elevated levels of serum
galectin-3 in patients with CAD as compared
with the NC group. Previous studies also reported
similar findings where galectin-3 levels were sig-
nificantly higher in CAD patients when compared
with non-CAD patients and was an independent
predictor of cardiovascular death.33–38 Compared
with previous studies36,39 we observed higher con-
centrations of galectin-3 in CAD patients. Unlike
these studies, we used serum instead of plasma to
measure the levels of galectin-3 which could pos-
sibly affect the concentration of galectin-3. In an
earlier study performed by us in MI patients, the
median galectin-3 concentration was reported to
be much lower (12.3 ng/ml).40
In the current study, we observed a moderate
correlation between galectin-3 and GRACE
risk score in ACS patients. Recent studies by
Aksan and colleagues34 and Gucuk Ipek E and
colleagues investigated the link between galec-
tin-3 with the severity of CAD and reported that
galectin-3 have a significant positive correlation
with GENSINI score. This association between
galectin-3 and GENSINI score indicates the role
of galectin-3 in chronic inflammation and athero-
genesis.41 In the present study a moderate signifi-
cant positive association was seen between
galectin-3 and GRACE risk score which reflected
the severity of CAD. However on multivariate
268 http://tac.sagepub.com
analysis this positive correlation was no longer
sustained. Thus, galectin-3 may not be useful as
an additional assessment in daily clinical practice
to detect the severity of CAD and identifying
patients with high risk.
Limitations
The main limitation of the current study is that
we did not measure the levels of ANGPTL-4 and
galectin-3 serially and correlate with the disease
progression. Moreover, the duration of symptoms
before admission varied from few hours to few
days for each patient. Due to logistical reasons,
we were unable to perform stress ECG for the 31
control patients. Another limitation of the present
study is the small sample size and no follow up
was done for the study patients. Thus, future pro-
spective cohort studies with large sample size are
needed to confirm our findings.
Conclusion
Our findings revealed that serum ANGPTL-4
and galectin-3 levels are higher in CAD patients
than patients with normal coronary arteries.
Although circulatory biomarker ANGPTL-4 and
galectin-3 significantly correlated with GRACE
risk score, these findings were abolished in multi-
variate analysis. In conclusion, ANGPTL-4 and
galectin-3 does not appear to reflect the severity
of CAD. Nevertheless these biomarkers do war-
rant further exploration in improving the man-
agement of CAD.
Acknowledgements
We thank Dr A. Kalaiselvi and Ms M. Kamatchi
for their assistance in collection of samples. All
the authors reviewed and approved the final sub-
mitted version of the manuscript.
Funding
We thank the office of the Dean (Medical), SRM
Medical College Hospital and Research Centre,
Kattankulathur, India for financial support (Ref:
CP87/05/2016).
Conflict of interest statement
The authors declare no conflicts of interest in
preparing this article.
References
1. Krishnan MN. Coronary heart disease and risk
factors in India – on the brink of an epidemic?
Indian Heart J 2012; 64: 364–367.

2. Rao M, Xavier D, Devi P, et al. Prevalence,
treatments and outcomes of coronary artery
disease in Indians: A systematic review. Indian
Heart J 2015; 67: 302–310.
3. Mohan V, Deepa R, Rani SS, et al; Chennai
Urban Population Study (CUPS No. 5).
Prevalence of coronary artery disease and its
relationship to lipids in a selected population in
South India: The Chennai Urban Population
Study (CUPS No. 5). J Am Coll Cardiol 2001; 38:
682–687.
4. Fuchs FC, Ribeiro JP, Fuchs FD, et al. Syntax
score and major adverse cardiac events in patients
with suspected coronary artery disease: Results
from a cohort study in a university-affiliated
hospital in Southern Brazil. Arq Bras Cardiol
2016; 107: 207–215.
5. Bekler A, Altun B, Gazi E, et al. Comparison of
the GRACE risk score and the TIMI risk index
in predicting the extent and severity of coronary
artery disease in patients with acute coronary
syndrome. Anatol J Cardiol 2015; 15: 801–806.
6. Prabhudesai AR, Srilakshmi MA, Santosh
MJ, et al. Validation of the GRACE score for
prognosis in Indian patients with acute coronary
syndromes. Indian Heart J 2012; 64: 263–269.
7. Catoire M, Alex S, Paraskevopulos N, et al.
Fatty acid-inducible ANGPTL4 governs lipid
metabolic response to exercise. Proc Natl Acad Sci
USA 2014; 111: e1043–e1052.
8. Yokouchi H, Eto K, Nishimura W, et al.
Angiopoietin-like protein 4 (ANGPTL4) is
induced by high glucose in retinal pigment
epithelial cells and exhibits potent angiogenic
activity on retinal endothelial cells. Acta
Ophthalmol 2013; 91: e289–e297.
9. Tjeerdema N, Georgiadi A, Jonker JT, et al.
Inflammation increases plasma angiopoietin-like
protein 4 in patients with the metabolic syndrome
and type 2 diabetes. BMJ Open Diabetes Res Care
2014; 2: e000034.
10. Breuilh L, Vanhoutte F, Fontaine J, et al.
Galectin-3 modulates immune and inflammatory
responses during helminthic infection: Impact of
galectin-3 deficiency on the functions of dendritic
cells. Infect Immun 2007; 75: 5148–5157.
11. Yu L, Ruifrok WPT, Meissner M, et al. Genetic
and pharmacological inhibition of galectin-3
prevents cardiac remodeling by interfering with
myocardial fibrogenesis. Circ Heart Fail 2013; 6:
107–117.
12. Martínez-Martínez E, Calvier L, Fernández-
Celis A, et al. Galectin-3 blockade inhibits
cardiac inflammation and fibrosis in experimental
http://tac.sagepub.com 269
L Goenka, M George et al.
hyperaldosteronism and hypertension. Hypertens
2015; 66: 767–775.
13. O’Gara PT, Kushner FG, Ascheim DD, et al.
2013 ACCF/AHA guideline for the management
of ST-elevation myocardial infarction: Executive
summary: A report of the American College
of Cardiology Foundation/American Heart
Association Task Force on practice guidelines:
Developed in collaboration with the American
College of Emergency Physicians and Society for
Cardiovascular Angiography and Interventions.
Catheter Cardiovasc Interv 82: 2013; e1–e27.
14. Amsterdam EA, Wenger NK, Brindis RG, et al.
2014 AHA/ACC guideline for the management
of patients with non-ST-elevation acute coronary
syndromes: A report of the American College of
Cardiology/American Heart Association Task
Force on practice guidelines. J Am Coll Cardiol
2014; 64: e139–e228.
15. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/
AHA/ACP–ASIM guidelines for the management
of patients with chronic stable angina: Executive
summary and recommendations a report of the
American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
(Committee on Management of Patients with
Chronic Stable Angina). Circulation 1999; 99:
2829–2848.
16. Muendlein A, Saely CH, Leiherer A, et al.
Angiopoietin-like protein 4 significantly predicts
future cardiovascular events in coronary patients.
Atherosclerosis 2014; 237: 632–638.
17. Bouleti C, Mathivet T, Serfaty J-M, et al.
Angiopoietin-like 4 serum levels on admission for
acute myocardial infarction are associated with
no-reflow. Int J Cardiol 2015; 187: 511–516.
18. Kim MC, Cho JY, Jeong HC, et al. Long-term
clinical outcomes of transient and persistent
no reflow phenomena following percutaneous
coronary intervention in patients with acute
myocardial infarction. Korean Circ J 2016; 46:
490–498.
19. Galaup A, Gomez E, Souktani R, et al. Protection
against myocardial infarction and no-reflow
through preservation of vascular integrity by
angiopoietin-like 4. Circulation 2012; 125:
140–149.
20. Schoos MM, Mehran R, Dangas GD, et al.
Gender differences in associations between
intraprocedural thrombotic events during
percutaneous coronary intervention and adverse
outcomes. Am J Cardiol 2016; 118: 1661–1668.
21. Lee E, Collier CP and White CA. Interlaboratory
variability in plasma creatinine measurement and
the relation with estimated glomerular filtration
Therapeutic Advances in Cardiovascular Disease 11(10)
Visit SAGE journals online
journals.sagepub.com/
home/tac
SAGE journals
270 http://tac.sagepub.com
rate and chronic kidney disease diagnosis. Clin J
Am Soc Nephrol 2016; 12: 29–37.
22. Sarnak MJ, Levey AS, Schoolwerth AC, et al.
Kidney disease as a risk factor for development
of cardiovascular disease: A statement from the
American Heart Association Councils on kidney
in cardiovascular disease, high blood pressure
research, clinical cardiology, and epidemiology
and prevention. Hypertens 2003; 42: 1050–
1065.
23. Baranowski T, Kralisch S, Bachmann A, et al.
Serum levels of the adipokine fasting-induced
adipose factor/angiopoietin-like protein 4 depend
on renal function. Horm Metab Res 2011; 43:
117–120.
24. Gross JL, de Azevedo MJ, Silveiro SP, et al.
Diabetic nephropathy: Diagnosis, prevention, and
treatment. Diabetes Care 2005; 28: 164–176.
25. Huang G, Lv J, Li T, et al. Notoginsenoside R1
ameliorates podocyte injury in rats with diabetic
nephropathy by activating the PI3K/Akt signaling
pathway. Int J Mol Med 2016; 38: 1179–1189.
26. Ma J, Chen X, Li J-S, et al. Upregulation of
podocyte-secreted angiopoietin-like-4 in diabetic
nephropathy. Endocrine 2015; 49: 373–384.
27. Smart-Halajko MC, Robciuc MR, Cooper
JA, et al. The relationship between plasma
angiopoietin-like protein 4 levels, angiopoietin-
like protein 4 genotype, and coronary heart
disease risk. Arterioscler Thromb Vasc Biol 2010;
30: 2277–2282.
28. Kim H-K, Youn B-S, Shin M-S, et al.
Hypothalamic Angptl4/Fiaf is a novel regulator of
food intake and body weight. Diabetes 2010; 59:
2772–2780.
29. Mandard S, Zandbergen F, van Straten E, et al.
The fasting-induced adipose factor/angiopoietin-
like protein 4 is physically associated with
lipoproteins and governs plasma lipid levels and
adiposity. J Biol Chem 2006; 281: 934–944.
30. Feola M, Testa M, Leto L, et al. Role of
galectin-3 and plasma B type-natriuretic peptide
in predicting prognosis in discharged chronic
heart failure patients. Medicine 2016; 95: e4014.
31. Bayes-Genis A, de Antonio M, Vila J, et al.
Head-to-head comparison of 2 myocardial
fibrosis biomarkers for long-term heart failure risk
stratification: ST2 versus galectin-3. J Am Coll
Cardiol 2014; 63: 158–166.
32. Papaspyridonos M, McNeill E, de Bono JP,
et al. Galectin-3 is an amplifier of inflammation
in atherosclerotic plaque progression through
macrophage activation and monocyte
chemoattraction. Arterioscler Thromb Vasc Biol
2008; 28: 433–440.
33. Ozturk D, Celik O, Satilmis S, et al. Association
between serum galectin-3 levels and coronary
atherosclerosis and plaque burden/structure in
patients with type 2 diabetes mellitus. Coron
Artery Dis 2015; 26: 396–401.
34. Aksan G, Gedikli Ö, Keskin K, et al. Is galectin-3
a biomarker, a player-or both-in the presence of
coronary atherosclerosis? J Investig Med 2016; 64:
764–770.
35. Falcone C, Lucibello S, Mazzucchelli I, et al.
Galectin-3 plasma levels and coronary artery
disease: A new possible biomarker of acute
coronary syndrome. Int J Immunopathol Pharmacol
2011; 24: 905–913.
36. Gucuk Ipek E, Akin Suljevic S, Kafes H, et al.
Evaluation of galectin-3 levels in acute coronary
syndrome. Ann Cardiol Angeiol 2016; 65: 26–30.
37. Kusaka H, Yamamoto E, Hirata Y, et al. Clinical
significance of plasma galectin-3 in patients with
coronary artery disease. Int J Cardiol 2015; 201:
532–534.
38. Maiolino G, Rossitto G, Pedon L, et al.
Galectin-3 predicts long-term cardiovascular
death in high-risk patients with coronary artery
disease. Arterioscler Thromb Vasc Biol 2015; 35:
725–732.
39. Milner TD, Viner AC, MacKinnon AC, et al.
Temporal expression of galectin-3 following
myocardial infarction. Acta Cardiol 2014; 69:
595–602.
40. George M, Shanmugam E, Srivatsan V, et al.
Value of pentraxin-3 and galectin-3 in acute
coronary syndrome: A short-term prospective
cohort study. Ther Adv Cardiovasc Dis 2015; 9:
275–284.
41. Menini S, Iacobini C, Ricci C, et al. The
galectin-3/RAGE dyad modulates vascular
osteogenesis in atherosclerosis. Cardiovasc Res
2013; 100: 472–480.