Circulation. 2000;101:e195
(Circulation. 2000;101:e195.)
© 2000 American Heart Association, Inc.
Circulation Electronic Pages |
Hemostatic Function and Coronary Artery Disease
John B. Kostis, MD;
Clifton R. Lacy, MD
Department of Medicine,
UMDNJ-Robert Wood Johnson Medical School,
New Brunswick, NJ
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Introduction
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To the Editor:
The lack of an independent relationship between fibrinogen level and
recurrent coronary events reported by Moss et al1
in their recent article is at variance with previous evidence linking
fibrinogen to coronary artery disease in individuals with and
without preexisting cardiovascular
disease.2 The fibrinogen levels reported by Moss et al are
high in both patients who had recurrent events (387±112 mg/dL) and in
those who did not (350±85 mg/dL; P<0.05; upper limit of
normal for the method used, 300 mg/dL). These high values may be due,
in part, to the acute phase reaction of the index infarction. If so,
these values obtained 2 months after the event do not accurately
represent fibrinogen levels during the mean 26-month follow-up.
A strong relationship between fibrinogen and reinfarction was observed
when fibrinogen was measured an average of 23.5 months after the index
event.3 These findings are further supported by the
consistency of previous reports linking fibrinogen to
coronary artery disease and the biological plausibility of such
an association (increased blood viscosity, platelet aggregation,
coagulation, etc). Fibrinogen is a risk factor for infarction and
reinfarction in both population-based studies and those performed on
patients with preexisting cardiovascular disease.
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References
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Moss AJ, Goldstein RE, Marder VJ, et
al. Thrombogenic factors and recurrent coronary
events. Circulation. 1999;99:2517–2522.[Abstract/Free Full Text]
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Danesh J, Collins R, Appleby P, et al. Association of
fibrinogen, C-reactive protein, albumin, or leukocyte count
with coronary heart disease: meta-analyses of
prospective studies. JAMA. 1998;279:1477–1482.[Abstract/Free Full Text]
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Kostis JB, Baughman DJ, Kuo PT. Association of
recurrent myocardial infarction with hemostatic factors: a prospective
study. Chest. 1982;81:571–575.[Abstract/Free Full Text]
Response
Arthur J. Moss, MD;
Robert E. Goldstein, MD;
Victor J. Marder, MD;
Charles E. Sparks, MD;
David Oakes, PhD;
Henry Greenberg, MD;
Jarvey J. Weiss, MD;
Wojciech Zareba, MD, PhD;
Mary W. Brown, MD;
Chang-Seng Liang, MD;
Edgar Lichstein, MD;
William C. Little, MD;
John A. Gillespie, MD;
Lucy Van Voorhees, MD;
Ronald J. Krone, MD;
Monty M. Bodenheimer, MD;
Judith Hochman, MD;
Edward M. Dwyer, Jr, MD;
Rohit Arora, MD;
Frank I. Marcus, MD;
Luc F. Miller Watelet, PhD;
Robert B. Case, MD
University of Rochester Medical Center Rochester, NY
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Introduction
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We thank Drs Kostis and Lacy for their comments and focus on
fibrinogen.
Our post-myocardial infarction cohort
R1
differed considerably
from the one reported by Kostis et
al
R2 in terms of size of
population (1045 versus 147
patients), number of cardiac end
points (81 versus 20), average
enrollment time after infarction
(2 months versus 23.5 months),
follow-up duration (26 months
versus 38 months), use of adjustment for
confounding covariates
(yes versus no), use of life-table survivorship
analysis (yes
versus no), and time frame (1990s versus 1970s),
respectively.
Our cumulative cardiac event rate was somewhat higher for
the
top fibrinogen quartile than for the lower 3 quartiles
(
P=0.07;
see Figure 1
R1 ), but this effect
was markedly diminished after
adjustment for relevant covariates
(diabetes mellitus, prior
myocardial infarction before the index
infarction, infarct type
by ECG, pulmonary congestion on chest
x-ray, sex, and ejection
fraction
0.30). Of note, in the
meta-analysis by Danesh et al,
R3 5 of the 6 studies
evaluating patients with coronary heart
disease had calculated
99% confidence intervals for fibrinogen
that touched on or
overlapped the null risk ratio of 1.0.
We agree with Drs Kostis and Lacy that elevated fibrinogen levels have
some association with recurrent coronary events, but the
strength and significance of this association in our prospective study
were weak at best, and the causality is less than clear cut. After
adjustment for covariates, fibrinogen level was not a significant risk
factor for recurrent cardiac events in our 1990s cohort. Elevated
levels of D-dimer and apoB and reduced levels of apoA-I were the only
independent risk factors in our study.
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References
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|---|
-
Moss AJ, Goldstein RE, Marder VJ, et
al. Thrombogenic factors and recurrent coronary
events. Circulation. 1999;99:2517–2522.
-
Kostis JB, Baughman DJ, Kuo PT. Association of
recurrent myocardial infarction with hemostatic factors: a prospective
study. Chest. 1982;5:571–575.
-
Danesh J, Collins R, Appleby P, et al. Association of
fibrinogen, C-reactive protein, albumin, or leukocyte count
with coronary heart disease: meta-analyses of
prospective studies. JAMA. 1998;279:1477–1482.
Top
Introduction
References