HLC 1791 No. of Pages 7
Heart, Lung and Circulation (2015) xx, 1–7 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.01.019
ORIGINAL ARTICLE
Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities Marcin Kaz´mierczak a, Maciej Ciebiada b*, Anna Pe˛kala-Wojciechowska c, Maciej Pawłowski c, Agnieszka Nielepkowicz-Goz´dzin´ska b, Adam Antczak b a
Department of Internal Medicine, Asthma and Allergy, Lodz, Poland Department of General and Oncological Pneumology, Medical University of Lodz, Lodz, Poland c Department of Internal Medicine and Diabetology, Medical University of Lodz, Lodz, Poland b
Received 29 March 2014; received in revised form 27 January 2015; accepted 29 January 2015; online published-ahead-of-print xxx
Background
Although both chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVD) are characterised by chronic, systemic inflammation, their reciprocal interactions are poorly understood. The purpose of this study was to determine the concentrations of both inflammatory and oxidative stress biomarkers in the serum and exhaled breath condensate (EBC) of COPD patients, either with coexisting CVD or without cardio-vascular comorbidities.
Methods
Twenty-four COPD patients with CVD were allocated to group A, 20 COPD patients without CVD were assigned to group B and 16 healthy patients were included as a control. A medical history and physical examination were performed, and the following were measured: serum CRP concentration, glucose level, uraemic acid level and lipid profile. In addition 8-isoprostane, LTB4 and IL-8 concentrations were measured both in serum and EBC. Spirometry, six-minute walk test and echocardiography were performed in all subjects.
Results
EBC concentrations of 8-isoprostane and LTB4, and serum levels of CRP, 8-soprostane, LTB4, IL-8 were significantly higher in COPD patients than in healthy controls. COPD patients with CVD were not found to have higher concentrations of the assessed markers than those without CVD, neither in the serum nor EBC. CRP, 8-isoprostane and LTB4 levels in serum, and IL-8 concentration in EBC correlated negatively with the value of forced expiratory volume in one second.
Conclusions
Although systemic inflammation coexists with COPD, it is not elevated in COPD patients with CVD. Since this phenomenon may result from treatment with statins, future studies should state whether COPD patients could benefit from the additional statin therapy.
Keywords
Cardiovascular disease Chronic obstructive pulmonary disease Heart failure Inflammation Isoprostane Leukotriene
*Corresponding author at: Medical University of Lodz, Department of General and Oncological Pneumology, Kopcinskego 22, zip code 90-153 Lodz, Poland. Tel.: +48 42 678 21 29, 48 42 677 66 99; fax: +48 42 678 21 [1_TD$IF]29, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Kaz´mierczak M, et al. Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j. hlc.2015.01.019
HLC 1791 No. of Pages 7
2
M. Kaz´mierczak et al.
Background Chronic obstructive pulmonary disease (COPD) is characterised by a progressive and not fully reversible airflow limitation associated with an abnormal inflammatory response of the lungs to noxious particles or gases [1]. The development of airflow limitation is associated with cellular and structural changes to both the peripheral and central airways, but the inflammatory process spreads either to the lung parenchyma, pulmonary arteries and peripheral tissues. Although COPD affects mainly lungs, it also causes also chronic systemic inflammation, which may contribute to such significant extrapulmonary complications as weight loss, skeletal muscle dysfunction, osteoporosis, neoplasmatic disease, infections and cardiovascular diseases (CVD) [2,3]. The mechanisms connecting COPD with CVD are not fully understood. Common risk factors of both diseases and genetic susceptibility are not sufficient enough to clarify these phenomena. Several investigators suggest that systemic inflammation plays a potential role in the development of CVD in COPD patients [1,2]. Studies of c-reactive protein (CRP) levels in the blood have shown that persistent lowgrade systemic inflammation in COPD may contribute to the development of atherosclerosis and ischaemic heart disease [4]. In addition, several reports indicate overproduction of interleukine-8 (IL-8), leukotriene-B4 (LTB-4) and 8-isoprostane in COPD patients caused by inflammation and oxidative stress, and these could be detected both in exhaled breath condensate (EBC), serum and the bronchoalveolar lavage of these patients [5–7]. As the concentrations of these mediators are known to be generally higher in patients with COPD than in healthy individuals, they may serve as markers of inflammation (IL-8, LTB-4) and oxidative stress (8-isoprostane) in patients suffering from COPD [7–9]. The aim of this study was to compare the EBC and serum concentrations of CRP, IL-8, LTB4 and 8-isoprostane in COPD patients with those of healthy individuals, and to assess their concentrations in COPD patients with CVD and those without cardiovascular complications. The results would confirm whether the presence of CVD in COPD patients increases inflammation in the latter group and whether the levels of mediators correlate with the severity of the disease.
Materials and Methods The study included patients with COPD (stage I-IV) [1], with or without coexisting CVD and 16 healthy individuals as controls. Exacerbation of COPD during the two-week period prior to the study and the presence of tuberculosis, neoplasmatic disease, asthma and pregnancy were exclusion criteria. For the diagnosis of CVD, at least one of the following criteria had to be fulfilled: history of coronary heart disease (myocardial infarction, coronary intervention, positive result
of loading test, stenosis greater than or equal to 50% of coronary artery), history of systolic heart failure (typical signs and symptoms with ejection fraction (EF) less than 45%), history of peripheral arterial disease (PAD) (clinical symptoms, abnormal ankle-brachial index and stenosis of greater than or equal to 50% of peripheral arteries or past interventions for PAD), history of cerebral ischaemia (past ischaemic stroke or transient ischaemic attack or past invasive treatment of cerebral ischaemia). Diastolic heart failure was diagnosed if the typical signs and symptoms were present with EF greater than 45-50%, after exclusion of significant valvular heart disease and symptoms with no cardiac basis: lung disease, for example. Thus, group A did not include patients demonstrating echocardiographic parameters of left ventricular diastolic dysfunction.
Study Protocol Written, informed consent to take part in the study was given by all participants. The study protocol was approved by the local ethics committee. The medical history was taken from all subjects and a physical examination with anthropometrical measurements (body weight, height, waist circumference) was performed. In addition, the CVD criteria were evaluated in all COPD patients. Blood samples and EBC were collected, and echocardiography, spirometry and six-minute walk test (6MWT) were performed. The COPD stage was stratified [1] and BODE index was calculated for each patient.
Spirometry Spirometry was performed using a Lungtest 1000 spirometer (Mes, Krakow, Poland) according to standards [10]. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and FEV1/FVC were discarded from the result and presented as a percentage of predicted value.
BODE Index The BODE index was calculated according to the recommendations [1] based on body mass index (BMI) (B), the value of FEV1 which reflected the severity of obstruction (O), the severity of dyspnoea (D) based on the modified Medical Research Council scale, and the ability to perform effort (E) with 6MWT.
Six-Minute Walk Test The 6MWT was performed by all participants as previously described [11] and the best distance walked in metres was recorded for each subject.
Collection of EBC EBC was collected using the EcoScreen (Jaeger, Hoechberg, Germany) according to the manufacturer’s instructions. Patients were not allowed to smoke cigarettes for at least 12 hours or take vitamins supplements for at least four weeks before collection. After rinsing their mouths, they breathed
Please cite this article in press as: Kaz´mierczak M, et al. Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j. hlc.2015.01.019
HLC 1791 No. of Pages 7
3
Biomarkers in COPD patients with or without cardiovascular diseases
tidally through a mouthpiece connected to the condenser for 10-15 minutes. Approximately 2.5-3.0 ml of condensate was immediately frozen and stored at -20oC.
Blood Sampling Blood samples were collected in the morning after at least eight–hour fasting. The lipid profile, serum concentration of CRP, uraemic acid and glucose were assessed using AU-400 analyser (Beckman Coulter Inc, NY, USA), and part of the serum samples were stored at -20oC for further analysis.
Evaluation of LTB4, IL-8 and 8-isoprotane Serum and EBC levels of LTB4 were determined with a leukotriene-B4 EIA Kit, and 8-isoprostane levels with 8-isoprostane EIA Kit (Cayman Chemical Company, MI, USA), whereas concentrations of IL-8 were assessed using Quantikine, (R&D Systems, MN, USA).
Echocardiography Echocardiography was performed using the Acuson X300 ultrasound machine with a P5-1 1.0-5.6 MHz transducer probe (Siemens, Erlangen, Germany). The patient was examined in a semi-recumbent left lateral position and images were taken from parasternal, apical and subxiphoid routine views. The function of the left and right ventricle was assessed as previously described [12–15].
Statistical Analysis Statistica 6.0PL software was used for all statistical analyses (StatSoft, Krakow, Poland). The Shapiro–Wilk and Kolmogorow–Smirnow tests were used to check the data
distribution: the Student’s t-test being used for differences between normally distributed data and the U Mann–Whitney test for not normally distributed variables. To assess differences between qualitative variables, chi-square tests were used. p
Heart, Lung and Circulation (2015) xx, 1–7 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.01.019
ORIGINAL ARTICLE
Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities Marcin Kaz´mierczak a, Maciej Ciebiada b*, Anna Pe˛kala-Wojciechowska c, Maciej Pawłowski c, Agnieszka Nielepkowicz-Goz´dzin´ska b, Adam Antczak b a
Department of Internal Medicine, Asthma and Allergy, Lodz, Poland Department of General and Oncological Pneumology, Medical University of Lodz, Lodz, Poland c Department of Internal Medicine and Diabetology, Medical University of Lodz, Lodz, Poland b
Received 29 March 2014; received in revised form 27 January 2015; accepted 29 January 2015; online published-ahead-of-print xxx
Background
Although both chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVD) are characterised by chronic, systemic inflammation, their reciprocal interactions are poorly understood. The purpose of this study was to determine the concentrations of both inflammatory and oxidative stress biomarkers in the serum and exhaled breath condensate (EBC) of COPD patients, either with coexisting CVD or without cardio-vascular comorbidities.
Methods
Twenty-four COPD patients with CVD were allocated to group A, 20 COPD patients without CVD were assigned to group B and 16 healthy patients were included as a control. A medical history and physical examination were performed, and the following were measured: serum CRP concentration, glucose level, uraemic acid level and lipid profile. In addition 8-isoprostane, LTB4 and IL-8 concentrations were measured both in serum and EBC. Spirometry, six-minute walk test and echocardiography were performed in all subjects.
Results
EBC concentrations of 8-isoprostane and LTB4, and serum levels of CRP, 8-soprostane, LTB4, IL-8 were significantly higher in COPD patients than in healthy controls. COPD patients with CVD were not found to have higher concentrations of the assessed markers than those without CVD, neither in the serum nor EBC. CRP, 8-isoprostane and LTB4 levels in serum, and IL-8 concentration in EBC correlated negatively with the value of forced expiratory volume in one second.
Conclusions
Although systemic inflammation coexists with COPD, it is not elevated in COPD patients with CVD. Since this phenomenon may result from treatment with statins, future studies should state whether COPD patients could benefit from the additional statin therapy.
Keywords
Cardiovascular disease Chronic obstructive pulmonary disease Heart failure Inflammation Isoprostane Leukotriene
*Corresponding author at: Medical University of Lodz, Department of General and Oncological Pneumology, Kopcinskego 22, zip code 90-153 Lodz, Poland. Tel.: +48 42 678 21 29, 48 42 677 66 99; fax: +48 42 678 21 [1_TD$IF]29, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Kaz´mierczak M, et al. Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j. hlc.2015.01.019
HLC 1791 No. of Pages 7
2
M. Kaz´mierczak et al.
Background Chronic obstructive pulmonary disease (COPD) is characterised by a progressive and not fully reversible airflow limitation associated with an abnormal inflammatory response of the lungs to noxious particles or gases [1]. The development of airflow limitation is associated with cellular and structural changes to both the peripheral and central airways, but the inflammatory process spreads either to the lung parenchyma, pulmonary arteries and peripheral tissues. Although COPD affects mainly lungs, it also causes also chronic systemic inflammation, which may contribute to such significant extrapulmonary complications as weight loss, skeletal muscle dysfunction, osteoporosis, neoplasmatic disease, infections and cardiovascular diseases (CVD) [2,3]. The mechanisms connecting COPD with CVD are not fully understood. Common risk factors of both diseases and genetic susceptibility are not sufficient enough to clarify these phenomena. Several investigators suggest that systemic inflammation plays a potential role in the development of CVD in COPD patients [1,2]. Studies of c-reactive protein (CRP) levels in the blood have shown that persistent lowgrade systemic inflammation in COPD may contribute to the development of atherosclerosis and ischaemic heart disease [4]. In addition, several reports indicate overproduction of interleukine-8 (IL-8), leukotriene-B4 (LTB-4) and 8-isoprostane in COPD patients caused by inflammation and oxidative stress, and these could be detected both in exhaled breath condensate (EBC), serum and the bronchoalveolar lavage of these patients [5–7]. As the concentrations of these mediators are known to be generally higher in patients with COPD than in healthy individuals, they may serve as markers of inflammation (IL-8, LTB-4) and oxidative stress (8-isoprostane) in patients suffering from COPD [7–9]. The aim of this study was to compare the EBC and serum concentrations of CRP, IL-8, LTB4 and 8-isoprostane in COPD patients with those of healthy individuals, and to assess their concentrations in COPD patients with CVD and those without cardiovascular complications. The results would confirm whether the presence of CVD in COPD patients increases inflammation in the latter group and whether the levels of mediators correlate with the severity of the disease.
Materials and Methods The study included patients with COPD (stage I-IV) [1], with or without coexisting CVD and 16 healthy individuals as controls. Exacerbation of COPD during the two-week period prior to the study and the presence of tuberculosis, neoplasmatic disease, asthma and pregnancy were exclusion criteria. For the diagnosis of CVD, at least one of the following criteria had to be fulfilled: history of coronary heart disease (myocardial infarction, coronary intervention, positive result
of loading test, stenosis greater than or equal to 50% of coronary artery), history of systolic heart failure (typical signs and symptoms with ejection fraction (EF) less than 45%), history of peripheral arterial disease (PAD) (clinical symptoms, abnormal ankle-brachial index and stenosis of greater than or equal to 50% of peripheral arteries or past interventions for PAD), history of cerebral ischaemia (past ischaemic stroke or transient ischaemic attack or past invasive treatment of cerebral ischaemia). Diastolic heart failure was diagnosed if the typical signs and symptoms were present with EF greater than 45-50%, after exclusion of significant valvular heart disease and symptoms with no cardiac basis: lung disease, for example. Thus, group A did not include patients demonstrating echocardiographic parameters of left ventricular diastolic dysfunction.
Study Protocol Written, informed consent to take part in the study was given by all participants. The study protocol was approved by the local ethics committee. The medical history was taken from all subjects and a physical examination with anthropometrical measurements (body weight, height, waist circumference) was performed. In addition, the CVD criteria were evaluated in all COPD patients. Blood samples and EBC were collected, and echocardiography, spirometry and six-minute walk test (6MWT) were performed. The COPD stage was stratified [1] and BODE index was calculated for each patient.
Spirometry Spirometry was performed using a Lungtest 1000 spirometer (Mes, Krakow, Poland) according to standards [10]. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and FEV1/FVC were discarded from the result and presented as a percentage of predicted value.
BODE Index The BODE index was calculated according to the recommendations [1] based on body mass index (BMI) (B), the value of FEV1 which reflected the severity of obstruction (O), the severity of dyspnoea (D) based on the modified Medical Research Council scale, and the ability to perform effort (E) with 6MWT.
Six-Minute Walk Test The 6MWT was performed by all participants as previously described [11] and the best distance walked in metres was recorded for each subject.
Collection of EBC EBC was collected using the EcoScreen (Jaeger, Hoechberg, Germany) according to the manufacturer’s instructions. Patients were not allowed to smoke cigarettes for at least 12 hours or take vitamins supplements for at least four weeks before collection. After rinsing their mouths, they breathed
Please cite this article in press as: Kaz´mierczak M, et al. Evaluation of Markers of Inflammation and Oxidative Stress in COPD Patients with or without Cardiovascular Comorbidities. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j. hlc.2015.01.019
HLC 1791 No. of Pages 7
3
Biomarkers in COPD patients with or without cardiovascular diseases
tidally through a mouthpiece connected to the condenser for 10-15 minutes. Approximately 2.5-3.0 ml of condensate was immediately frozen and stored at -20oC.
Blood Sampling Blood samples were collected in the morning after at least eight–hour fasting. The lipid profile, serum concentration of CRP, uraemic acid and glucose were assessed using AU-400 analyser (Beckman Coulter Inc, NY, USA), and part of the serum samples were stored at -20oC for further analysis.
Evaluation of LTB4, IL-8 and 8-isoprotane Serum and EBC levels of LTB4 were determined with a leukotriene-B4 EIA Kit, and 8-isoprostane levels with 8-isoprostane EIA Kit (Cayman Chemical Company, MI, USA), whereas concentrations of IL-8 were assessed using Quantikine, (R&D Systems, MN, USA).
Echocardiography Echocardiography was performed using the Acuson X300 ultrasound machine with a P5-1 1.0-5.6 MHz transducer probe (Siemens, Erlangen, Germany). The patient was examined in a semi-recumbent left lateral position and images were taken from parasternal, apical and subxiphoid routine views. The function of the left and right ventricle was assessed as previously described [12–15].
Statistical Analysis Statistica 6.0PL software was used for all statistical analyses (StatSoft, Krakow, Poland). The Shapiro–Wilk and Kolmogorow–Smirnow tests were used to check the data
distribution: the Student’s t-test being used for differences between normally distributed data and the U Mann–Whitney test for not normally distributed variables. To assess differences between qualitative variables, chi-square tests were used. p
