Int J Biol Med Res. 202; 3(4): 2570-2574 Int J Biol Med Res Volume 3, Issue, Jan 202 www.biomedsidiret.om BioMedSiDiret Publiations Contents lists available at BioMedSiDiret Publiations International Journal of Biologial & Medial Researh Journal homepage: www.biomedsidiret.om International Journal of BIOLOGICAL AND MEDICAL RESEARCH Original Artile High sensitive C-reative protein, Insulin resistane and Coronary artery disease risk. a b Sowjanya.Bahali, Phanikrishna.Balantrapu, Venkat Rao.Epari a Assoiate Professor, Department of Biohemistry, Narayana Medial College, Nellore-524002, AP.. b Assoiate Professor, Department of Cardiology, Narayana Medial College Hospital, Nellore-524002,AP. Assoiate Professor, Department of Community Mediine, Narayana Medial College, Nellore-524002, AP A R T I C L E I N F O A B S T R A C T Keywords: Coronary artery disease, Inflammation, Insulin resistane, Metaboli syndrome Inflammation and insulin resistane (IR) are forerunners of ardiovasular disease (CVD) and diabetes.asians have an underlying pro inflammatory state that may ontribute to their inreased risk for CVD and type 2 diabetes.this study was aimed at proving high sensitive C- reative protein ( hscrp ),IR as risk fators for CVD, hs CRP is also assoiated with metaboli syndrome. 33 subjets of mean age 48 yrs, both males & females attending ardiology department for master health hek up were inluded in this study. Anthropometri measures (height, weight, body mass index(bmi), waist irumferene(wc), blood pressure), biohemial parameters( fasting plasma gluose(), serum total holesterol (TC), triglyerides(tgl), High density lipoprotein holesterol(hdl), fasting insulin, hs CRP) were measured in all subjets. Insulin resistane is measured by Homeostasis model for assement of insulin resistane( ).Based on hs CRP two groups were divided-group with CRP <3 mg/l, group2 with hs CRP > 3 mg/l. All the parameters were ompared between the groups, orrelation was also observed. Statistial analysis used: Pearson's orrelation oeffiients were used to assess the assoiations, student's t test, and multivariate binary logisti regression analysis was used to ompare the groups p value is signifiant for HDL(p<0.008) fasting gluose ()(p=0.035), HOMA IR(p<0.04).BMI is positively related with hs CRP, the mean hs CRP levels were elevated with inreasing number of metaboli syndrome omponents. Gender speifi analysis showed that HDL, were signifiant preditors of inflammation in males but not in females. Aording to this study, variables like HDL, were signifiant preditors of inflammation. Inflammation is assoiated with metaboli syndrome. Hene,the role of inflammation in CVD an provide new opportunities for diagnosis& treatment. Copyright 200 BioMedSiDiret Publiations IJBMR - ISSN: 0976:6685. All rights reserved.. Introdution Pro-inflammatory state is assoiated with inreased risk for ardiovasular disease (CVD) and diabetes mellitus[]. During inflammation, elevation of aute phase C- reative protein(crp) is evident[2,3]. Enhaned CRP expression is seen in IR[4]. Amerian Heart Assoiation and Center for Disease Control and * Corresponding Author : Dr.Sowjanya Bahali Assoiate Professor Department of Biohemistry Narayana Medial College Nellore, India. Ph : 9989320024. Email:phanisowji@hotmail.om: Copyright 200 BioMedSiDiret Publiations. All rights reserved. Prevention[5] stated that, in healthy men and women, the levels of hs CRP <,-3,>3 mg/l distinguish between low, moderate, high risk for future CVD risk[6]. Several studies had proven hscrp as a signifiant preditor of CVD & diabetes risk.[7] The purpose of this study is to fous on the signifiane of hscrp by omparing the traditional risk fators, in groups and 2, to observe the assoiation of hscrp with BMI and with individual omponents of insulin resistane syndrome.
Sowjanya.Bahali et.al Int J Biol Med Res. 202; 3(4): 2570-2574 257 2. Materials and Methods : This study was onduted over a period of one year. It was a ross setional observational study. The study inluded 33 subjets -both males and females. Subjets attending the department of ardiology, for master health hek up without any previous history of aute illness, infetions, post oronary artery bypass graft (or) eletroardiograph evidene of heart disease were inluded in the present analysis. This study was approved by institutional ethial ommittee. Informed onsent was taken and a questionnaire was prepared to eliit the history of smoking, alohol intake, family history of diabetes, CVD, stroke, drug history whih inluded intake of statins and aspirin. Subjets on statins / aspirin were exluded from analysis as they would alter the insulin resistane; female subjets with polyysti ovarian disease were also exluded. In the entral researh lab, fasting and post prandial blood samples were olleted from all the subjets for estimation of Gluose, lipid profile(total holesterol(tc),triglyerides(tgl), high density lipoprotein holesterol (HDL), Insulin, hscrp. Anthropometri measures (height, weight, BMI, waist irumferene were taken from all the subjets. Out of 33 subjets, 29 were diagnosed for the first time as diabetis based on World Health Organisation riteria. All 33 subjets were divided into 2 groups, Group with hscrp <3mg/L and Group 2 with hscrp >3mg/L. Biohemial and anthropometri measures were ompared between the two groups. Gender speifi analysis for females & males was also done. Measuring Insulin resistane: IR was alulated by using the formula based on fasting plasma gluose (mg/dl) & fasting serum insulin (mu/l). 3. Results : HOMA IR = FPG (mg/dl) x FI (mu/l) 405 SPSS2.0 software (SPSS In., Chiago, II, USA) was used for statistial analysis. Continuous variables were expressed as mean values ± SEM. Pearson's orrelation oeffiients were used to assess the assoiations between the ontinuous variables. Differenes between the groups of study subjets (based on hscrp) were examined using student's t-test. Binary logisti regression analysis was performed with study group (based on hscrp) as dependent variable and other signifiantly assoiated variables as independent variables. A p value <0.05 was onsidered statistially signifiant.general profiles of the subjets in terms of the study groups they belong to was desribed in table. HDL holesterol in the subjets with hscrp > 3 mg/l was signifiantly lower than the group of subjets with hscrp < 3mg/L. On the ontrary, the level of HOMA IR and fasting blood gluose was signifiantly higher in subjets with hscrp > 3 mg/l as ompared to their ounterparts. The results of multivariable logisti regression analysis showed that after adjusting for onfounding, HDL holesterol (p < 0.008) and HOMA IR (p < 0.04) were signifiant preditors of inflammatory state(table 2). However gender- segregated multivariable analysis revealed that among males (table:3) the overall negelkeker R square value inreased from 0.45 to 0.286 indiating lesser variability among the study subjets. Variables like HDL (p<0.003), (p=0.02) were signifiant preditors of inflammation. Similar findings were not seen among females with a muh lower negelkeker R square value (0.073). Fig. showing the positive orrelation of log CRP with BMI, Fig.2 explains inreasing levels of mean hs CRP with inreasing number of metaboli syndrome omponents. Table: omparison of parameters in group and group2. Step (a) Male Parameters AGE (yrs ) TC(mg/dl) TGL(mg/dl) HDL(mg/dl) Waist(m) BMI(kg/m2) SBP(mmHg) DBP(mmHg) (mg/dl) Insulin(mU/L) HOMA IR HDL HDL B B Group n=60 Mean ±SEM S.E. S.E. Wald Wald Group 2 n=73 Mean ±SEM t test P value a)p* <0.05 (signifiant). b)n= number of subjets, ) SEM ( standard error of mean) Table 2; Multivariable binary logisti regression analysis of the onfounding variables -.050.03.264.240 a) Nagelkerke R square 0.45 95.0% C.I.for Df Sig. Exp(B) Exp(B) Table 3; Gender Speifi Multivariable binary logisti regression analysis of the onfounding variables -.02.03.557 47.25 ±.47 93.88 ± 5.94 36.98±9.60 44.3±.64 9.5±.68 26.06±0.54 32.66±.34 82.3±0.9 99.83±2.42 9.55±0.93 2.3±0.2.09.009.28.36.045.034.05.222 7.24 2.8 4.232 9.28.836 6.30.54.740.784 Females HDL -.05.028.04.05 -.782.02.85.297.389.326.703.2 47.83 ±.077 88. 04 ± 5.06 36.35±6.9 40.20±.06 9.39±.09 26.58±0.48 34.49±.33 86.3±0.80 0.±3.89 0.7±0.67 2.9±0.20 95.0% C.I.for Df Sig. Exp(B) Exp(B) a) Nagelkerke R Square for males =.286 and b) for females =.073.008.46.040.833.003.36.02.376.585.239.568.646.95.03.302.27.903.03.745 4.669.985.04..458-0.335 0.753 0.54 2.62 0.053-0.724-0.432 -.489-2.29 -.08-2.076 Lower.97.995.03 Lower.846.985.30.933.99.774 0.739 0.453 0.957 0.032* 0.958 0.47 0.667 0.39 0.035* 0.3 0.040* Upper.987.03.675 Upper.965.043 2.696.040.038.595
Sowjanya.Bahali et.al Int J Biol Med Res. 202; 3(4):2570-2574 2572 Figure: orrelation of BMI with log hs CRP Figure: 2, Mean hs CRP with inreasing number of metaboli syndrome omponents Components of Metaboli Syndrome (Modified N C E P ATP III Guidelines) Fasting gluose > 00mg/dl, TGL >50mg/dl, Low HDL(<40mg/dl in males, <50mg/dl in females, Hypertension 35/85 mm Hg / mediation, Waist irumferene > 80m (females), >90m (males) 4. Disussion: The role of inflammation has beome well established over the past deade. Large population based studies suh as MONICA[8], the Atherosleroti risk in ommunities study[9],the NHANES[0], has ompared persons in the lower tertile of hscrp with those in the upper tertiles, showing that major oronary events were observed for the upper tertile with lower tertile used as a referene. Data from Indian Atherosleroti Researh Study (IARS) stated that routine measurement of hscrp will be useful in predition of CVD risk in persons of south Asia who were partiularly high risk for type 2 DM and CVD[,2]. With this bakground, the present study was arried out in south Indian subjets(n = 33) to bring out the importane of inflammation and insulin resistane as ardiovasular disease risk markers. Inflammation involved in atheroslerosis is eliited by many other risk fators like igarette smoking, insulin resistane / diabetes and essential hypertension[3]. Pro-inflammatory state releases one of the important ytokines- tumor nerosis fator- α( T N F - α ), w h i h a t i v a t e s a v a r i e t y o f s e r i n e protein kinases. These ativated protein kinases inrease serine phosphorylation of Insulin Reeptor Substate and 2. This will lead to dereased ativity of Phosphotidylinositol3 kinase. Hene the down stream effets of insulin signaling are inhibited leading to insulin resistane. Thus pro-inflammatory ytokines ontribute to insulin resistane[4]. Hene the ombination of an ative, ongoing inflammatory proess and presene of IR might at synergistially in promoting oronary risk[5]. Yudkin et al [6] showed that CRP levels were assoiated strongly with IR, alulated from. But there are very few studies in south Indians observing the assoiation[7]. This study ould be one of the few whih highlight the role of inflammation in insulin resistane. Insulin resistane will ause hyperglyemia. This is mainly due to dereased transloation of gluose transporter GLUT4 to the membrane for uptake of gluose by the ells. Hyperglyemia will inrease the prodution of Reative Oxygen Speies, Advaned Glyation End produts (AGE) and Sorbitol. AGE inreases oxidative stress by ativation of NADPH oxidase through speifi reeptors for AGE(RAGES). RAGE stimulates proinflammtory signaling, leading to ativation of NFkβ(Nulear fator)[8]. Indeed many ardiovasular events our in individuals with plasma holesterol and low density lipoprotein holesterol levels below National Cholesterol Eduation and treatment Panel threshold. This has enlightened the involvement of inflammation in atheroslerosis and disovery of inflammatory biomarkers for CVD risk predition. During aute phase reation(apr) plasma TGL inreases and HDL onentration dereases. Festa et al from IRAS[9] showed that CRP positively orrelated with BMI, TGL and inversely with HDL. The assoiation was proved in present analysis also. But there is no signifiant differene in TGL levels in between the study groups. This may be due to relatively small sample size, TGL is not normally distributed in this study group. Where as HDL showed statistial signifiane. This ould be explained by the role of APR on HDL metabolism. Aute phase HDL is harateristially dereased of apoai ontent.saa(serum amyloid A), an aute phase response protein beomes the major apoprotein of HDL during inflammation[20,2]. In APR, HDL levels derease in the irulation due to remodeling of HDL by an aute phase protein group II a seretory phospholipase A2(SPLAr IIa), whih inreases HDL atabolism[22]. Obesity exhibits a distint effet on inflammation. But how and when obesity might initiate an inflammatory response remains inompletely understood. The inrease
Sowjanya.Bahali et.al Int J Biol Med Res. 202; 3(4): 2570-2574 2573 in adipose tissue ontributes to proinflammatory mileu and inflammatory adipokines may promote insulin resistane, endothelial dysfuntion and finally atheroslerosis. The inverse assoiation between high levels of physial ativity or exerise training and markers of hroni inflammation suh as hs CRP has been onsistently reported[23]. Several previous studies had reported stronger orrelation between BMIandCRP[24]. Metaboli syndrome(ms) - onstellation of ardiometaboli disease risk fators has beome a global epidemi[25]. Inflammation may be an important etiology of MS. Chemokines sereted from the adipoytes attrat the marophages around the dying tissue. These marophages release ytokines (TNF-α &IL-6) that further ativate inflammatory response and worsen insulin resistane. IR at the level of adipoytes leads to dyslipidemia and hyperglyemia whih may further progress to MS. The III NHANES, showed that subjets with MS were more likely to have elevated levels of markers of inflammation[26]. In the present analysis also, it was learly demonstrated that inreasing number of ompounds of IRS (, HDL, TGL, WC, hypertension ) paralleled inreasing levels of mean hs CRP. Thus this study reiterates the role of hs CRP in MS in south Indian subjets. But the limitations of our study were. Desriptive study 2. Relatively small number of subjets 3. Can not estimate the future risk. 4.Assoiation proven,longitudinal studies are required.5.history on Hormone replaement therapy / Oral ontraeptive usage in ase of females was not taken, whih may influene hs CRP levels. The important findings of our study. Mean hs CRP of the study subjets was relatively high, this may be due to ethniity, south Indians will have high waist to hip ratio and abdominal obesity whih will lead to adipoytokine prodution. 2. Inflammation & insulin resistane were losely assoiated. 3. hs CRP has a great influene on metaboli syndrome. Hene by this study it is onluded that HDL, were signifiant preditors of inflammation. hs CRP is also assoiated with metaboli syndrome whih is again onsidered a risk fator for CVD. Hene new knowledge about inflammation in CVD and insulin resistane will provide new opportunities for diagnosis and predition of CVD risk. This may lead to new treatments for this life threatening disease. 5. Referenes [] Chandalia M, Cabo-Chan AV, Sridevi Devaraj JS, Jialal I, Grundy SM, Abate N et al. Elevated plasma high-sensitivity C-reative protein onentrations in Asian Indian living in the United States. J Clin Endorinol Metab 2003;88: 3773-76. [2] Claudine A. Blum, Beat Muller, Peter Huber, Marius Kraenzlin, Christian Shindler, Christian De Geyter et al. Low-grade inflammation and estimates of insulin resistane during the menstrual yle in lean and overweight women. 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