Liuzzo G, Biasucci L M, Gallimore J R, Grillo R L, Rebuzzi A G, Pepys M B, Maseri A
Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Rome, Italy.
N Engl J Med. 1994 Aug 18;331(7):417-24. doi: 10.1056/NEJM199408183310701.
The pathogenesis of unstable angina is poorly understood, and predicting the prognosis at the time of hospital admission is problematic. Recent evidence suggests that there may be active inflammation, possibly in the coronary arteries, in this syndrome. We therefore studied the prognostic value of measurements of the circulating acute-phase reactants C-reactive protein and serum amyloid A protein, which are sensitive indicators of inflammation.
We measured C-reactive protein, serum amyloid A protein, creatine kinase, and cardiac troponin T in 32 patients with chronic stable angina, 31 patients with severe unstable angina, and 29 patients with acute myocardial infarction.
At the time of hospital admission, creatine kinase and cardiac troponin T levels were normal in all the patients, but the levels of C-reactive protein and serum amyloid A protein were > or = 0.3 mg per deciliter (exceeding the 90th percentile of the normal distribution) in 4 of the patients with stable angina (13 percent), 20 of the patients with unstable angina (65 percent), and 22 of the patients with acute myocardial infarction (76 percent). The 20 patients with unstable angina who had levels of C-reactive protein and serum amyloid A protein > or = 0.3 mg per deciliter had more ischemic episodes in the hospital than those with levels < 0.3 mg per deciliter (mean [+/- SD] number of episodes per patient, 4.8 +/- 2.5 vs. 1.8 +/- 2.4; P = 0.004); 5 patients subsequently had a myocardial infarction, 2 died, and 12 required immediate coronary revascularization. In contrast, no deaths or myocardial infarction occurred among the 11 patients with levels of C-reactive protein and serum amyloid A protein < 0.3 mg per deciliter, and only 2 of them required coronary revascularization. Among the patients admitted with a diagnosis of acute myocardial infarction, unstable angina preceded infarction in 14 of the 22 patients (64 percent) with levels of C-reactive protein and serum amyloid A protein > or = 0.3 mg per deciliter but in none of the 7 patients with levels < 0.3 mg per deciliter.
Elevation of the sensitive acute-phase proteins C-reactive protein and serum amyloid A protein at the time of hospital admission predicts a poor outcome in patients with unstable angina and may reflect an important inflammatory component in the pathogenesis of this condition.
不稳定型心绞痛的发病机制尚不清楚，且在入院时预测其预后存在困难。最近的证据表明，该综合征可能存在活动性炎症，可能发生于冠状动脉。因此，我们研究了循环急性期反应物C反应蛋白和血清淀粉样蛋白A的测量值的预后价值，这两种蛋白是炎症的敏感指标。
我们测定了32例慢性稳定型心绞痛患者、31例严重不稳定型心绞痛患者和29例急性心肌梗死患者的C反应蛋白、血清淀粉样蛋白A、肌酸激酶和心肌肌钙蛋白T。
入院时，所有患者的肌酸激酶和心肌肌钙蛋白T水平均正常，但稳定型心绞痛患者中有4例（13%）、不稳定型心绞痛患者中有20例（65%）、急性心肌梗死患者中有22例（76%）的C反应蛋白和血清淀粉样蛋白A水平≥0.3mg/dl（超过正常分布的第90百分位数）。C反应蛋白和血清淀粉样蛋白A水平≥0.3mg/dl的20例不稳定型心绞痛患者在医院内的缺血发作次数多于水平<0.3mg/dl的患者（每位患者发作次数的平均值[±标准差]，4.8±2.5对1.8±2.4；P=0.004）；5例患者随后发生心肌梗死，2例死亡，12例需要立即进行冠状动脉血运重建。相比之下，C反应蛋白和血清淀粉样蛋白A水平<0.3mg/dl的11例患者中无死亡或心肌梗死发生，且其中只有2例需要进行冠状动脉血运重建。在诊断为急性心肌梗死入院的患者中，C反应蛋白和血清淀粉样蛋白A水平≥0.3mg/dl的22例患者中有14例（64%）在梗死前发生过不稳定型心绞痛，而C反应蛋白和血清淀粉样蛋白A水平<0.3mg/dl的7例患者中无一例发生过。
入院时敏感的急性期蛋白C反应蛋白和血清淀粉样蛋白A水平升高预示不稳定型心绞痛患者预后不良，可能反映了该病发病机制中的一个重要炎症成分。
