Hellenic Journal of Cardiology 61 (2020) 99e102

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Hellenic Journal of Cardiology

journal homepage: http://www.journals.elsevier.com/
hellenic-journal-of-cardiology/

Original Article

Effects of levocarnitine on cardiac function, urinary albumin,

hs-CRP, BNP, and troponin in patients with coronary heart disease
and heart failure
Guoliang Zhao a, Haiying Zhang b, Yi Wang c, Xiaohui Gao d, Huaqing Liu e, Wei Liu f, *
a
Emergency Internal Medicine, The First People's Hospital of Jining, Jining 272011, PR China
b
Clinical Laboratory, People's Hospital of Lanshan District, Rizhao 276800, PR China
c
Department of Respiration, People's Hospital of Zhangqiu District, Jinan 250000, PR China
d
Magnetic Resonance, People's Hospital of Zhangqiu District, Jinan 250000, PR China
e
Department of Neurology, People's Hospital of Zhangqiu District, Jinan 250000, PR China
f
Emergent Intensive Care Unit, The First People's Hospital of Jining, Jining 272011, PR China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To investigate the effects of levocarnitine on cardiac function, urinary albumin (ALB), high-
Received 15 January 2018 sensitivity C-reactive protein (hs-CRP), brain natriuretic peptide (BNP), and troponin in patients with
Received in revised form coronary heart disease (CHD) and heart failure (HF).
29 August 2018
Methods: In total, 246 patients with CHD-caused HF were selected and randomly divided into Group A
Accepted 31 August 2018
and Group B. A fully automatic biochemical analyzer was used to measure the levels of ALB, hs-CRP, BNP,
Available online 6 September 2018
and troponin in both groups of patients, and the expression levels of LVDD and LVEF were detected by
cardiac color ultrasonography. Patients in Group B were intravenously injected with 3.0 g of levocarni-
Keywords:
Coronary heart disease-caused heart failure
tine, once per day. After 14 days, changes in levels of ALB, hs-CRP, BNP, troponin, LVDD, and LVEF in Group
Heart function A patients were detected.
BNP Results: The effective cure rates of patients in both groups were 65.8% and 81.3%, respectively, and there
hs-CRP was a statistically significant difference between the two groups (p < 0.05). After administration of
Levocarnitine levocarnitine, all indicators showed decreasing trends, but the LVEF level increased. Among them, pa-
tients treated with levocarnitine showed the most evident decrease in LVEF. Decrease in BNP was the
largest (p < 0.05). Additionally, there was no statistical difference in incidence rate between the two
groups (5.8% vs. 2.5%, p ¼ 0.222).
Conclusion: Levocarnitine can effectively improve ALB, hs-CRP, BNP, troponin, and LVDD levels to
improve cardiac function rating and thus improve cardiac function.
© 2018 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
According to the report of World Health Organization (WHO),
cardiovascular disease is currently the leading cause of death, and
the number of deaths caused by cardiovascular and cerebrovascular
diseases is only smaller than that caused by malignant tumors in
China.1, 2 There are approximately 20 million people suffering from
heart failure (HF) worldwide, with 2 million new cases reported
* Corresponding author. Wei Liu, Emergent Intensive Care Unit, The First People's
Hospital of Jining, No.6 Jiankang Road, Jining 272011, PR China.
E-mail address: weiliu1225@163.com (W. Liu).
Peer review under responsibility of Hellenic Society of Cardiology.
each year.3 In China, there are approximately 4 million people with
chronic heart failure (CHF) in population aged 30-70 years, thus
accounting for 20% of the global cases. The 5 year mortality rate in
patients with moderate and severe HF is 30%-50%. Morbidity rate of
patients with HF is elevated with aging.4-6 Coronary heart disease
(CHD) is the most common cause of HF, and CHD is mainly caused
by myocardial ischemia and infarction.7 In China, the incidence rate
of HF caused by CHD is increasing each year, and the mortality and
prevalence rates that are closely associated with the quality of life
of people are unacceptably high.
Levocarnitine participates in lipid metabolism through the
regulation of lipids.8 Under myocardial ischemia, the level of lev-
ocarnitine in the cytoplasm of myocardial cells is decreased,
thereby leading to the accumulation of fatty acyl coenzyme A and

https://doi.org/10.1016/j.hjc.2018.08.006
1109-9666/© 2018 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
100 G. Zhao et al. / Hellenic Journal of Cardiology 61 (2020) 99e102

toxic metabolites in the cytoplasm, resulting in cell damage, and Table 1

ultimately leading to myocardial apoptosis. Some studies showed Clinical data of patients [n (%)]

that in vitro supplementation of levocarnitine improves and regu- Group Group A Group B
lates both glycometabolism and lipid metabolism, reduces the Gender
metabolism of toxic products, and relieves the burden on heart Male 57 (45.23) 69 (54.77)
function.9, 10 Therefore, in this study, patients with CHD-caused HF Female 66 (55.00) 54 (45.00)
were injected with levocarnitine, and changes in expression levels Age (years old) 63.1±4.7 61.2±4.9
Body mass index (BMI) (kg/m3) 24.50±1.24 24.10±0.94
of high-sensitivity C-reactive protein (hs-CRP), brain natriuretic
Diabetes mellitus
peptide (BNP), troponin, left ventricular end diastolic dimension Yes 58 (47.15) 69 (56.09)
(LVDD), and left ventricular ejection fraction (LVEF) were observed No 65 (52.85) 54 (43.91)
to evaluate its clinical value. Hypertension
Yes 101 (83.11) 97 (78.86)
No 22 (17.89) 26 (21.14)
2. Materials and methods Place of residence
Countryside 87 (70.73) 71 (57.72)
2.1. Data of patients City 36 (29.27) 52 (42.28)
Degree of education
<Junior college 94 (76.42) 88 (71.54)
In total, 246 patients with HF caused by CHD who were treated
Junior college 26 (23.58) 35 (28.46)
in The First People's Hospital of Jining from March 2014 to February Smoking
2015 were enrolled in this study. Among them, there were 126 Yes 60 (48.78) 70 (56.91)
males and 120 females, and the age ranged from 45 to 74 years, No 63 (51.22) 53 (43.09)
with a mean age of 64.6 ± 5.1 years. Patients were randomly Excessive drinking
Yes 38 (30.89) 44 (35.77)
divided into Group A (n ¼ 123) and Group B (n ¼ 123), and heart No 85 (69.11) 79 (64.23)
functions were graded according to the standards established by Dietary habit
New York Heart Association (NYHA), USA,11 and results of cardiac Spicy 18 (14.63) 23 (18.69)
color ultrasonography. Group A included 57 males and 66 females, Light 105 (85.37) 100 (81.31)
and the age ranged from 45 to71 years, with a mean age of Note: For all indexes, p>0.05.
63.1 ± 4.7 years; in this group, there were 37 patients in grade II, 56
in grade III, and 30 in grade IV. Group B had 69 males and 54 fe-
males, and the age ranged from 48 to 74 years, with a mean age of troponin in the blood samples of patients from both groups. LVDD
61.2 ± 4.9 years; in this group, there were 30 patients in grade II, 70 and LVEF were measured in patients of both groups and analyzed
in grade III, and 23 in grade IV. This study was approved by the using a cardiac color Doppler ultrasound instrument.
Medical Ethics Committee of The First People's Hospital of Jining.
All patients and their families signed the written informed consent.
Clinical data of patients in the two groups are shown in Table 1. 2.5. Treatment efficacy evaluation

2.2. Inclusion and exclusion criteria
Inclusion criteria: Patients without diseases of the respiratory or
digestive systems, patients without diabetes or genetic disorders,
patients without blood relationship, and patients who recently did
not receive blood transfusions.
Exclusion criteria: Patients with a course of disease beyond
1 year; patients who received drug treatment recently; patients
who received radiotherapy and chemotherapy; patients with
autism, memory disorders, or hearing disorders; and patients who
failed to cooperate with researchers during the follow-up or had
incomplete clinical data.
2.3. Therapeutic methods
Exercise and daily diet of each patient were controlled in strict
accordance with the doctor's advice. Patients in Group B received
routine nursing and treatment [aldosterone antagonists,
angiotensin-converting enzyme inhibitors (ACEIs), etc.]. In addition
to routine nursing and treatment, patients in Group A were intra-
venously injected with 3.0 g of levocarnitine (NMPN H20050443,
diluted by adding 100 mL of 0.9 NaCl injection) once per day for
2 weeks.
2.4. Detection methods
Venous blood (3-5 mL) was collected from patients of both
groups before and after treatment; the blood samples were
centrifuged at 5000 r/min for 10 min. A fully automatic biochemical
analyzer was used to measure the content of hs-CRP, BNP, and
Post-treatment evaluation was performed using NYHA grading
criteria: daily life returns to normal, routine physical activity can be
achieved without causing fatigue and angina, level I; daily life was
restricted to certain extents, fatigue happens in general physical
activity but no obvious symptoms were observed at rest, level II;
conventional physical activity is significantly limited and fatigue
can easily happen, level III; physical activity cannot be performed
and symptoms of HF are observed at rest.
Rehabilitation of patients was graded as excellent, good, and
poor in the three respective groups: (1) clinical condition has been
completely relieved; heart function improvement  level 2; and
heart palpitations, chest pain, and other basic symptoms are
eliminated; (2) some of the patient's clinical symptoms have been
relieved; heart function improvement  level 1; and heart palpi-
tations, chest pain, and other basic symptoms are improved; (3)
patient's symptoms are not alleviated; heart function not
improved; and heart palpitations, chest pain, and other basic
symptoms are not improved; and the condition is worsened.
2.6. Statistical method
In this study, the Statistical Product and Service Solutions (SPSS)
20.0 (Shanghai Cabit Information Technology Co., Ltd.) software
package was used for statistical analyses of all collected data.
Measurement data were expressed as mean ± standard deviation
(‾x ± s). Data were subjected to normal distribution test. t-test was
used for normally distributed data, and c2 test was used for non-
normally distributed data. Enumeration data were expressed as %.
p < 0.05 indicated that the difference was statistically significant.
 G. Zhao et al. / Hellenic Journal of Cardiology 61 (2020) 99e102
Fig. 1. Treatment efficacy in both groups of patients after treatment. Through
comparisons of different treatment methods in patients of both groups, the effective
cure rate in Group A patients receiving routine nursing and treatment is 65.8% and that
in Group B patients receiving levocarnitine in addition to routine nursing and treat-
ment is 81.3% (p < 0.05).
3. Results
3.1. Comparison of treatment efficacy between both groups of
patients
After treatment, there were 81 (65.8%) cases of excellent, 35
(28.4%) cases of good, and 7 (5.8%) cases of poor treatment efficacy
in Group A, whereas 100 (81.3%) cases of excellent, 20 (16.2%) cases
of good, and 3 (2.5%) cases of poor treatment efficacy in Group B.
The effective cure rates of Groups A and B were 65.8% and 81.3%,
respectively, and a statistically significant difference was found
between the two groups (p < 0.05) (Fig. 1).
3.2. Comparisons of indicators in patients
ALB, hs-CRP, BNP, troponin, LVDD, and LVEF were measured in
patients of both groups. The results showed that all indicators in
Group A patients were significantly improved after treatment as
compared to those before treatment (p < 0.05). Moreover, patients
receiving levocarnitine instillation in addition to routine nursing
and treatment showed evident improvement of indicators
(p < 0.05). By contrast, in Group B patients, only BNP showed the
largest decrease (Table 2).
3.3. Comparisons of adverse events during treatment between the
two groups
Patients in both groups were hospitalized for 2 weeks. In Group
A, 10 patients had adverse events including 1 (10%) case of cardiac
death, 7 (70%) cases of severe HF, 1 (10%) case of myocardial
infarction, and 1 (10%) case of malignant arrhythmia. By contrast, in
Group B, there were 0 (0%) case of cardiac death, 1 (33.33%) case of
severe HF, 1 (33.33%) case of myocardial infarction, and 1 (33.34%)
case of malignant arrhythmia. No statistical difference was found in
the incidence of adverse effects between the two groups (5.8% vs.
2.5%, p ¼ 0.222) (Fig. 2).
Table 2
Comparisons of biochemical indicators in patients
Group Hs-CRP (mg/L) BNP (pg/mL)
Group A Before treatment 7.62±1.46 3689.37±198.61
After treatment 4.15±1.28a 1187.56±108.40a
Group B Before treatment 7.51±1.43 3691.52±203.26
After treatment 3.91±1.44ab 865.15±102.22ab
Note: “a” represents the comparisons of the expression levels of indicators between Group A and Group B before and after treatment (p<0.05), and “b” represents the
comparisons of the expression levels of indicators after treatment between Group B and Group A (p<0.05).
101
Fig. 2. Comparisons of adverse events during treatment between the two groups. A
comparison of the incidence rate of adverse events found in patients during hospi-
talization between the two groups shows that there is no statistical difference between
the two groups (p < 0.05).
4. Discussion
Pathogenesis of CHD involves the formation of hemadostenosis
and atheromatous plaque ulceration caused by coronary artery
atherosclerosis in the body, thus leading to thrombus formation,
and eventually resulting in clinical syndromes such as blood flow
obstruction or severe reduction in coronary artery.12 Atheroscle-
rosis may cause coronary artery stenosis, which will further cause
complete occlusion in severe cases and lead to stroke or even
death.13 With disease progression, clinical features such as angina
and myocardial ischemia may be observed, and at the end stage of
the disease, HF eventually occurs. HF is a relatively complex clinical
syndrome caused by ventricular filling and impaired ejection
ability owing to abnormalities in cardiac structure and function. Its
clinical manifestations mainly include dyspnea, weakness, and
fluid retention.14 With the growth of aging population, prevention
and treatment of cardiovascular events have attracted increasing
attentions. HF as a chronic disease negatively affects cardiac func-
tion even in the absence of cardiac injury.15
Levocarnitine is a small-molecule amino acid derivative that
plays a role in the regulation of energy metabolism, especially fatty
acid metabolism, and it is a very important substance in promoting
the fatty acid oxidation process in human myocardial cells.16 A
previous study17 reported that in an oxygen-deficient environment,
long-chain fatty acyl coenzyme A and toxic metabolites were
accumulated in myocardial cells, which in turn led to intracellular
environmental disorders and poor apoptosis. Moreover, levo-
carnitine can bind to long-chain fatty acyl coenzyme A to form
long-chain fatty acid carnitine, which can penetrate the cell
membrane and enter the bloodstream of the body to be discharged
through the urine to effectively reduce the serious consequences of
free accumulation of long-chain fatty acyl coenzyme A and other
toxic metabolites.
In this study, 246 patients were treated by different methods,
and it was found that Group A patients had a relatively lower
Troponin (mg/L) ALB (mg/mL) LVDD (mm) LVEF (%)
0.23±0.030 7.58±4.54 62.50±5.8 40.9±7.6
0.12±0.004a 3.04±1.35 61.30±4.2a 42.5±6.4a
0.24±0.020 7.43±4.21 62.70±5.5 41.1±7.3
0.07±0.001ab 2.54±1.22 54.50±5.1ab 50.1±7.2ab
102 G. Zhao et al. / Hellenic Journal of Cardiology 61 (2020) 99e102
cure rate than Group B patients. It has been reported that18
levocarnitine is effective in the treatment of other cardiovascu-
lar diseases such as stable angina and HF. Effects of different
treatment methods on patients with CHD-caused HF were
observed in this study, and results revealed that patients in
Group A who received conventional nursing and treatment had
significantly improved indicator levels compared with the levels
before treatment (p < 0.05), and the indicator levels in Group B
patients who received both levocarnitine treatment and con-
ventional nursing and treatment were evidently improved
(p < 0.05). In addition, significant differences in levels of the
indicators were found between the two groups of patients at the
end of treatment, and among all indicators, the BNP level showed
the largest decrease in Group B (p < 0.05). BNP is a human skin
hormone that is massively secreted when ventricular dilatation
and overload occur; therefore, it can be used as an important
indicator for heart function assessment. The data suggest that
levocarnitine has a satisfactory efficacy in the treatment of pa-
tients with CHD-caused HF. It is reported that levocarnitine can
effectively improve the survival of patients with HF, and it is also
reported that after treatment of HF with levocarnitine, LVEF is
significantly elevated, which is consistent with the findings re-
ported in this study19. Gürlek et al20 showed that levocarnitine is
effective in the treatment of patients with CHF, and the efficacy is
significantly higher than that observed in our study, which may
be due to different sample size and experimental design. How-
ever, our data and the data recorded in previous studies show
that levocarnitine is effective in the treatment of HF.
This study still has some shortcomings. Only a single-blind
trial as performed in this study may be affected by subjective
factors and personal preferences. In addition, the small sample
size in this study may also affect the results. Additionally, LV
dysfunction was not analyzed at different levels. Therefore, more
studies are needed to further confirm the conclusions reported in
this study.
In summary, levocarnitine has satisfactory curative effects in the
treatment of patients with CHD-caused HF and is shown to be a
promising agent in clinical practice.
Conflicts of interest
The authors have no conflicts of interest to declare.
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