Association of angiotensin I-converting enzyme gene insertion/deletion polymorphism with rheumatic heart disease in Indian population and meta-analysis.

Rheumatic heart disease (RHD) is one of the most severe consequences of rheumatic fever. It has been suggested that angiotensin I-converting enzyme (ACE) may be involved in the increased valvular fibrosis and calcification in the pathogenesis of RHD. We conducted a case-control study to look for association of ACE I/D polymorphism with RHD in Indian population. The study incorporated 300 patients (170 males and 130 females) with RHD, and 200 controls (118 males and 82 females). We also subgrouped RHD patients into mitral valve lesion (MVL) and combined valve lesion (CVL). ACE I/D polymorphism was identified using polymerase chain reaction method. We also performed a meta-analysis of three published studies and the present study (636 RHD cases and 533 controls) to evaluate the association between the ACE I/D polymorphisms and RHD risk. A significant difference in ACE ID and DD genotypes distribution between RHD cases (OR = 1.62, 95% CI = 1.11-2.36 and OR = 2.08, 95% CI = 1.02-4.15, respectively) and corresponding controls was observed. On comparing the ACE genotypes of MVL and CVL subgroups with controls, ID and DD genotypes were also significantly associated with CVL (FDR Pcorr = 0.009, OR = 2.19 and FDR Pcorr = 0.014, OR = 3.29, respectively). Meta-analysis also suggested association of the ACE D allele (FDR Pcorr = 0.036, OR-1.22, 95% CI 1.02-1.45) with RHD. In conclusion, ACE ID and DD genotypes are associated with an increased risk of RHD, particularly CVL. This suggests that the ACE I/D gene polymorphism may play an important role in the pathogenesis of RHD.

Focal adhesion kinase mediates atrial fibrosis via the AKT/S6K signaling pathway in chronic atrial fibrillation patients with rheumatic mitral valve disease.

BACKGROUND: Atrial fibrosis, as a hallmark of atrial structural remodeling, plays a critical role in the maintenance of chronic atrial fibrillation (AF), but the mechanisms responsible for atrial fibrosis are still uncertain. Fibrogenesis represents a complex process in which focal adhesion kinase (FAK) plays an important role. Therefore, we investigated the role of FAK-mediated signaling in atrial fibrosis in patients with chronic AF related to rheumatic mitral valve disease (RMVD). METHODS: Atrial appendages were excised from 45 patients with RMVD and either chronic AF (n=25, AF >6 months) or sinus rhythm (n=20). Fibrosis was assessed by histology, and FAK and its two downstream pathways (AKT/S6K and ERK1/2) were evaluated by western blotting. We further evaluated the role of FAK in fibrogenesis by culturing neonatal rat cardiac fibroblasts to determine the importance of FAK-regulated signaling in cardiac myofibroblast differentiation induced by transforming growth factor-ß1 (TGFß1). RESULTS: Our study revealed that FAK can regulate its downstream signaling to cause fibrosis in atrial tissue and activate isolated fibroblasts. Histology revealed a significant increase in atrial fibrosis in AF patients. The phosphorylation of FAK and its downstream AKT/S6K signaling was increased secondary to TGFß1-induced high expression of α-SMA, a marker of myofibroblast activity. FAK and AKT inhibitors suppressed α-SMA expression in TGFß1-induced fibroblasts. However, ERK1/2 signaling seemed to be unrelated to the fibrotic process in AF patients. CONCLUSION: The FAK-mediated AKT/S6K signaling pathway participated in atrial fibrogenesis and this finding may contribute to the prevention of atrial fibrosis associated with chronic AF in patients with underlying cardiac disease.

No association of PTPN22 R620W gene polymorphism with rheumatic heart disease and systemic lupus erythematosus.

Rheumatic heart disease (RHD) or acute rheumatic fever (ARF) develops as a consequence of an exaggerated immune response to Group A beta haemolytic streptococci causing pharyngitis. The molecular mimicry appears between human cardiac myosin and M protein of group A streptococcal membranes. The polymorphism of the protein tyrosine phosphatase nonreceptor 22 (PTPN22) gene, which encodes an important negative regulator of T cell activation, has been reported to be associated with susceptibility to several autoimmune diseases such as SLE and RA. The objective of this study was to investigate whether PTPN22 R620W polymorphism confers susceptibility to RHD in Turkish population. PTPN 22 R620W (rs2476601, A/G) polymorphism was genotyped by PCR-RFLP in 121 patients with RHD who fulfilling the revised classification criteria of Jones, and 160 healthy control (HC), and also 137 SLE as a diseased-control. The frequency of GG and AG genotypes were found to be 94% (114), 6% (7) in RHD, respectively and 96% (153) and 4% (7) in HC, respectively. The homozygous AA genotype was not present in RHD and HC. There was no statistically significant difference between RHD and HC according to the frequency of AG heterozygote genotype (P = 0.831; OR = 1.13; 95% CI 0.37-3.46). The frequency of the rare allele A was also very similar in RHD patients and HC (3, 2% respectively). A similar result was also found between SLE and HC. Our results demonstrated that the PTPN22 R620W polymorphism is not associated with RHD nor with SLE in Turkish population.

Influence of angiotensin-converting enzyme gene insertion/deletion polymorphism on rheumatic valve involvement, valve severity and subsequent valve calcification.

BACKGROUND AND AIM OF THE STUDY: The relationship between the severity of chronic rheumatic heart disease (RHD) and predisposing factors is unknown, and genetic predictors for severe scarring and calcification of the mitral valve are not well defined. A high angiotensin-converting enzyme (ACE) activity has been demonstrated in valve tissue. Thus, a case-control study was conducted to investigate any possible relationship between ACE gene polymorphisms and chronic mitral valve disease severity and calcification. METHODS: This case-control study included 82 patients (24 males, 58 females; mean age 40.3 +/- 14.7 years) with chronic rheumatic mitral valve, and 154 control subjects (53 males, 101 females; mean age 43.4 +/- 13.4 years). ACE gene insertion/deletion (I/D) polymorphisms were identified using polymerase chain reaction methods. RESULTS: Among RHD subjects, 31 (30.6%) were D/D, 25 (32.7%) were I/D, and 26 (18.8%) were I/I. Among controls, 57 (57.4%) were D/D, 69 (61.3%) were I/D, and 28 (35.2%) were I/I. The frequency of ACE I/I genotype was higher in RHD subjects than in controls (chi2 = 7.4, df = 2, p < 0.030; D/D versus I/D versus I/I), or (chi2 = 5.5, df = 1, p < 0.019; DD + ID versus II). Predisposition to RHD was significantly less frequent in the D/D genotype. There was no statistically significant difference in the genetic analysis of RHD with respect to mitral valve score, severity of mitral regurgitation and left atrial diameter. Mitral valve calcification was significantly associated with a higher frequency of I/I genotype and I/D genotype than D/D genotype alone (chi2 = 6.2, df = 2, p = 0.043). The ACE I/I genotype was associated with a predisposition to a greater risk of severe calcific valve disease. CONCLUSION: The ACE I/I genotype is more common in patients with rheumatic valve disease than in the normal population. This suggests that the ACE gene polymorphism may be involved in the pathogenesis of rheumatic heart disease.

[Comparison of perioperative myocardial enzyme changes among congenital, rheumatic and coronary artery diseases].

OBJECTIVE: To observe and compare perioperative myocardial enzyme changes in 107 patients with congenital (CHD, n = 53), rheumatic (RHD, n = 40) and coronary artery (CAD, n = 14) diseases, and to find whether different diseases can affect the release and recovery of myocardial enzymes after heart operations. METHODS: On the day before operation and the 1st, 3rd, 5th and the 8th day after operation, the venous blood was taken to measure the release of myocardial enzymes: aspartate aminotransferase (AST), creatine kinase (CK), MB isoenzyme of creatine kinase (CK-MB), lactate dehydrogenase (LDH) and LDH-1. RESULTS: All the enzymes measured before operation in three groups were in the normal range; their release increased abruptly on the 1st day postoperatively to 2 - 15 times of those before operation; on the 3rd day, they recovered to some degrees, and on the 8th day they recovered to normal in all groups except LDH and LDH-1 in rh and CAD groups. Because the aortic cross-clamp time (CCT) had a good positive correlation to the release of myocardial enzymes, those patients whose CCT was over 60 minutes in three groups were compared revealing that the CCT was not different between three groups (P < 0.05). The release of CK, CK-MB and AST was significantly higher in CHD60 group than those in CHD60 and CAD60 groups, they recovered afterwards; while the release of DH and LDH-1 was higher in CAD60 group than those in CAD60 and in CHD60 groups from the 1st day to the 8th day postoperatively. CONCLUSIONS: The release of all the 5 enzymes measured before operation was in normal range in selected CHD, RHD and CAD patients. The release peak and the recovery order of all enzymes were the same in three groups. The release of CK, CK-MB and AST was higher in CHD60 group than those in RHD60 and CAD60 groups on the 1st day. The release of LDH and LDH-1 was higher in RHD60 group than those in CHD60 and CAD60 groups from the 1st day to the 8th day postoperatively. The shorter the CCT is, the less the release of myocardial enzymes. Using the release of LDH and LDH-1 to evaluate the recovery of myocardial injury after open-heart operations was recommended.

[Cardiac protective effects of tetramethylpyrazine in patients performed open-heart operation with cardiopulmonary bypass].

OBJECTIVE: To study the cardiac protective effects of tetramethylpyrazine (TMP) on patients undergoing cardiac operation. METHODS: Twelve patients with rheumatic heart disease were randomly divided into the TMP group and the control group, 6 in each group. The changes of hemodynamics, serum creatine phosphokinase (CPK), creatine phosphokinase isoenzyme (CPK-MB) levels were observed before, during and 72 hours after operation. RESULTS: The hemodynamic indexes in the TMP group were better than those in the control group after operation, the serum CPK, CPK-MB levels measuring 12 h, 24 h and 48 h after operation in the TMP group were lower than those in the control group. CONCLUSION: TMP has good cardiac protective function in patients undergoing cardiac operation in improving cardial function and reducing the release of myocardial enzymes.

[Immunocytochemical study of CuZn superoxide dismutase in the myocardium of normal subjects and patients of rheumatic heart disease].

Using the methods of immunocytochemistry and immune electron microscopy, we studied the subcellular localization of GuZn superoxide dismutase (CuZn SOD) in the myocardium of 8 normal subjects and the changes of CuZn SOD of the myocardium in 51 patients of rheumatic heart disease, and at same time, we also determined the CuZn SOD contents in the myocardium with radioimmunoassay. This study demonstrated that most normal myocardial cells contained CuZn SOD. The ventricular myocardial cells stained somewhat stronger than the atrial myocardial cells. CuZn SOD was mainly distributed in the cytoplasm and the nucleus, less in mitochondria, a little in lysosomes and almost no gold particle was seen on the membranous structures of sarcoplasmic reticula and Golgi's complex. The positive level of CuZn SOD in rheumatic myocardium had remarkable correlation with myocardial fibrosis and arteriopathy and the recovery of the heart functions after valve replacement. The changes of CuZn SOD in various organelles in the myocardium of patients with rheumatic heart disease may be possibly related to the injuries of their membranous structure.

NADPH oxidase activity in the monocytes and neutrophils of patients with rheumatic fever.

The enzyme NADPH oxidase is involved in the production of oxygen free radicals. We measured its activity in neutrophils and monocytes obtained from patients with acute rheumatic fever, chronic rheumatic heart disease, acute streptococcal pharyngitis and normal controls. Follow up studies were made at 15 days, 3 months and 6 months. Streptococcal membrane antigen, carbohydrate antigens and latex were used to stimulate the oxidative activity in the neutrophils and monocytes. These three agents caused a significant increase in the enzyme activity of the phagocytes of patients with acute rheumatic fever and chronic rheumatic heart disease (p less than 0.001) but not in acute pharyngitis. Maximal NADPH oxidase enzyme activity was observed in patients with acute rheumatic fever. During the follow-up, there was a significant decline in the enzymatic activity in patients with acute rheumatic fever but not in those with chronic rheumatic heart disease. Enzymatic activity was greater when the phagocytic cells were triggered with membrane as compared to carbohydrate antigen and latex in all the groups and at all intervals. The enzymatic response of neutrophils and monocytes was similar although the magnitude of the NADPH oxidase activity was significantly higher in neutrophils than in monocytes.

[Changes in enzyme activity in postoperative myocardial biopsy samples after surgical correction of late-stage rheumatic heart defects]. / Izmenenie aktivnosti fermentov v operatsionnykh biotatakh miokarda pri khirurgicheskoi korrektsii revmaticheskogo poroka mitral'nogo klapana pozdnikh stadii.

A direct statistically reliable correction of decrease of the enzymes with the initial state of the patients has been established in an analysis of 25 patients aged from 18 to 60 years in prosthesis of+ the mitral valve (n-9) and closed mitral commissurotomy (n-16). The enzyme activity after prosthesis of+ the mitral valve was twice lower that after closed commissurotomy. Activity of ATP-ase of myofibrils proved to be most sensitive to negative factors of operation.

[Changes in xanthine oxidase activity in patients with circulatory failure]. / Izmenenie aktivnosti ksantinoksidazy u bol'nykh s nedostatochnost'iu krovoobrashcheniia.

As many as 76 patients suffering from inactive rheumatic fever associated with different stages of heart failure were examined for uricemia, diurnal uricosuria, and xanthine oxidase activity in blood serum. It was established that in rheumatic fever, the activity of xanthine oxidase increased even at the early stages of heart failure. The presence in some of the patient of the enzyme activation combined with hyperuricosuria and normal content of uric acid in blood serum suggests "latent" hyperuricemia. In patients with severe heart decompensation, there was an appreciable activation of xanthine oxidase, which correlated, as a rule, with high hyperuricemia. Activation of xanthine oxidase in patients with rheumatic fever evidences hyperproduction of uric acid. It is advisable that in such cases the uricodepressive treatment may be indicated.

[Blood serum creatine kinase in diseases of the cardiovascular system]. / Kreatinkinaza syvorotki krovi pri zabolevaniiakh serdechno-sosudistoi sistemy.

Serum creatine-kinase activity was above the upper normal limit in 40-80% of the 632 patients admitted to hospital for angina pectoris and deteriorating essential hypertension. The highest (4-6-fold) increase over the mean control values was associated with myocardial ischemia, paroxysmal tachycardia and hypertensive crises. Intramuscular injections were shown to be unrelated to increased incidence or magnitude of creatine-kinase activation in the examined patients. Creatine-kinase levels were particularly high in cases of cerebral stroke (a 7-fold increase above normal) and alcoholic cardiopathies (a 8-fold increase).

[Total proteolytic activity of the blood and its inhibitors in patients following heart operations]. / Obshchaia proteoliticheskaia aktivnost' krovi i ee ingibitorov u bol'nykh posle operatsii na serdtse.

The examination of 40 patients operated upon for rheumatic and congenital heart diseases has shown general proteolytic activity to be increased in patients with a rheumatic heart disease. The antitrypsin and antichymotrypsin activity were increased both in rheumatic and in congenital heart diseases. The changes were more pronounced in the development of pyo-septic and thromboembolic complications and they were found to appear earlier than clinical manifestations of the complications and can be used for prognosis of complications. To interpret the data obtained an original scheme is proposed which demonstrates a biochemical unity of the system of humoral regulation of microcirculation, inflammation and immunity.

Serum MB-creatine kinase is not elevated in active rheumatic carditis.

Total serum creatine kinase (CK) and the MB fraction of CK (CK-MB) activities were measured in 36 patients with active rheumatic carditis and on 33 controls. There were no significant differences in either the total CK or the CK-MB between the two groups. However, eight out of the 36 carditis patients had received intramuscular injections (IMI) prior to the assay: this sub-group showed a significant elevation of the total CK but not the CK-MB. Ten carditis patients (without prior IMI) had repeat assays done after their rheumatic activity had subsided: the mean total CK, but not the CK-MB, fell to levels below control values although these were not statistically significant. The results show that CK-MB is not of value in assessing activity in rheumatic carditis. Further, in assessing the significance of elevated total CK in any clinical situation, the influence of IMI and of bed rest should be taken into account.

Five creatine kinase isoenzymes in serum of a patient with severe heart disease.

Abnormal creatine kinase (CK) isoenzyme patterns were observed in the serum of a 64-year-old woman with severe heart disease. Agarose electrophoresis revealed the presence of all the usual CK isoenzymes (MM, MB, and BB) plus an extra band between MM and MB. Total serum CK activity was within the normal range. Within 2 h after the patient suffered cardiorespiratory arrest, a fifth CK isoenzyme appeared, cathodal to MM. After cardiac valve replacement, the patient's serum showed a high activity of CK, but the isoenzyme pattern showed only MM and, transiently, an MB band. With return of the serum CK activity to normal, the CK isoenzymes pattern also became normal, virtually ruling out genetic variant(s). The abnormal CK isoenzyme patterns might have been the consequence of severe hypoxemia in the patient, thus such patients may represent an ominous prognostic sign. The association of the abnormal pattern upon admission with rapid deterioration of the condition of the patient suggests prompt attention for the prevention of complications.

[Lactae dehydrogenase activity and its isoenzymatic spectrum in the myocardium in rheumatic heart defects]. / Aktivnost' laktatdegidrogenay i ee izofermentnyi spektr v miokarde bol'nykh revmaticheskimi porokami serdtsa.

The activity of lactate dehydrogenase (LDH) and its isoenzymatic spectrum were studied in biopsy specimen of the myocardium of 35 patients with mitral valvular disease who underwent operation. Starch gel electrophoresis was used. Four fractions of LDH isoenzymes were detected: LDH1, LDH2, LDH3, and LDH4. A definite metabolic trend of their changes in different stages of the disease was determined. LDH1 activity was considerably increased in patients with stage III mitral stenosis who had complications in the postoperative period. This is evidence of unstable compensation in patients of this group and may indicate the possible development of complications in the early postoperative period.