Pathophysiology and natural history 333

Plasma neutrophil gelatinase-associated lipocalin levels

in acute myocardial infarction and stable coronary
artery disease
Asife Sahinarslana, Sinan Altan Kocamana, Duygu Basa, Ahmet Akyela,
Ugur Ercinb, Ozlem Zenginb and Timur Timurkaynaka

Introduction Inflammation and polymorphonuclear of coronary atherosclerosis (P = 0.030), and NGAL levels.
neutrophils are shown to be important in the pathogenesis The plasma NGAL level was independently related to the
of acute myocardial infarction (AMI). Neutrophil gelatinase- existence of AMI (odds ratio: 1.045, 95% confidence
associated lipocalin (NGAL) is secreted from neutrophils interval: 1.019–1.072, P = 0.001). In patients with plasma
and may increase the proteolytic activity within the NGAL level above 127 ng/ml, we observed a 12 times
atherosclerotic plaque. We aimed to investigate whether higher incidence of AMI (odds ratio: 12.2, 95% confidence
the plasma levels of NGAL are higher in patients with interval: 2.3–64, P = 0.003).
AMI compared with stable coronary artery disease (CAD).
Conclusion The plasma level of NGAL is higher in patients
Methods The study population consisted of 128 eligible with AMI compared with the patients with stable CAD. This
patients who underwent coronary angiography with the finding may suggest an active pathophysiological role for
clinical diagnosis of CAD. Of the 128 patients included NGAL in development of acute coronary events. Coron
in the study, the diagnosis was ST-segment elevation Artery Dis 22:333–338 c 2011 Wolters Kluwer Health |
myocardial infarction (STEMI) in 53 patients, non-ST- Lippincott Williams & Wilkins.
elevation myocardial infarction (NSTEMI) in 38 patients Coronary Artery Disease 2011, 22:333–338
and stable CAD in 37 patients. Plasma level of NGAL
was measured in all patients with an enzyme-linked Keywords: biomarkers, inflammation, ischemic heart disease, myocardial
infarction, plaque instability
immunosorbent assay method. We compared the
plasma NGAL levels among the groups. Departments of aCardiology and bBiochemistry, School of Medicine,
Gazi University, Ankara, Turkey
Results We found higher plasma NGAL levels in patients Correspondence to Asife S¸ahinarslan, Gazi University Medical School,
with AMI compared with the patients with stable CAD Gazi Universitesi Hastanesi, Besevler, Ankara 06500, Turkey
Tel: + 90 312 2025629; fax: + 90 312 2129012;
(146 ± 23 vs. 101 ± 53 ng/ml, P < 0.001). The plasma NGAL e-mail: [email protected]
levels between the subgroups of AMI were similar
Received 30 November 2010 Revised 12 March 2011
(145 ± 23.9 vs. 145 ± 23.4 ng/ml, P = not significant). In Accepted 24 March 2011
multivariate analysis, the independent factors related to
AMI were current smoking (P = 0.024), extent and severity

Introduction the enhanced proteolytic activity within the athero-

Inflammation is suggested to be one of the most important sclerotic plaque [9]. MMP-9 contributes to alterations in
mechanisms for atherosclerotic plaque instability [1]. The the atherosclerotic plaque structure such as cap rupture,
leukocytes and the inflammatory mediators secreted by which starts the progression of events leading to myocardial
them play a major role in the pathogenesis of athero- infarction (MI) [10]. Although the increased NGAL level
sclerosis and acute coronary syndrome (ACS) [2,3]. was shown to be related to symptomatic cardiovascular
Neutrophil infiltration into atherosclerotic plaques has diseases and the conventional risk factors for coronary
been shown in atherectomy specimens of the patients with artery disease (CAD) [11,12], the plasma levels of NGAL
ACS [4]. Furthermore, the peripheral neutrophil count and in patients with acute MI (AMI) compared with stable
C-reactive protein (CRP) was found to be increased in CAD have not yet been researched. The purpose of this
patients with ACS [5–7]. study was to compare the plasma levels of NGAL across
the different clinical pictures of the CAD.
Neutrophil gelatinase-associated lipocalin (NGAL) is a
glycoprotein found in neutrophils and responsible for the
regulation of the activity of matrix metalloproteinase nine Methods
(MMP-9), which is an important mediator in athero- The study population consisted of 128 patients who
sclerotic plaque instability [8,9]. NGAL forms a complex underwent coronary angiography with the clinical diag-
with MMP-9 and prevents its degradation. This leads to nosis of CAD. Of the 128 patients included in the study,
0954-6928
c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MCA.0b013e3283472a71

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 334 Coronary Artery Disease 2011, Vol 22 No 5

the diagnosis was ST-segment elevation myocardial in patients with AMI. There was an at least 36-h time
infarction (STEMI) in 53 patients, non-ST-segment interval between coronary angiography/PCI procedures
elevation myocardial infarction (NSTEMI) in 38 patients and the collection of blood samples in all patients. In
and stable CAD in 37 patients. The local ethics review patients with stable CAD, the blood samples were
boards approved the study. All the patients had given collected within 1 week after CAD was confirmed by
informed consent before the study. coronary angiography. Whole blood samples were centri-
fuged and the plasma stored at – 801C in aliquots. Plasma
Acute STEMI was diagnosed in the presence of chest
NGAL levels were determined by using standard
pain lasting more than 20 min associated with ST-
enzyme-linked immunosorbent assay kits (Circulex
segment elevation of more than or equal to 1 mm in at
NGAL/lipocalin-2 ELISA kit, Cyclex Co. Ltd, Nagona,
least two extremity electrocardiographical leads or more
Japan). The intra-assay coefficients of variations were 6.2,
than or equal to 2 mm in at least two contiguous
3.4, and 5.1% and the interassay coefficients of variations
precordial leads. Diagnosis of acute NSTEMI was
were 6.0, 3.3, and 5.9%. Troponin T was measured by
established when characteristic chest pain lasted longer
electro chemoluminance technique (Elecsys, Roche
than 20 min with associated ST-segment depression of
Diagnostics, UK) (reference interval = 0–0.03 ng/ml).
more than or equal to 0.1 mV and/or T-wave inversion
in two continuous leads in the electrocardiogram and
increased levels of troponin T was present. Patients with Statistical analysis
chronic kidney disease (serum creatinine > 1.4 mg/dl), Continuous variables were given as mean ± standard
chronic inflammatory disease, active infection, and active deviation; categorical variables were defined as percentage.
malignancy were excluded from the study. Data were tested for normal distribution using the
Kolmogorov–Smirnov test. Student’s t-test was used for
CAD was confirmed by coronary angiography within 12 h of the univariate analysis of the continuous variables and the
presentation in all patients with AMI. All of the stable CAD w2 test for the categorical variables. Mean values were
patients had undergone to coronary angiography too. The compared by analysis of variance among different groups.
severity of coronary atherosclerosis was determined by the An optimal NGAL cut-off value for the detection of AMI
Gensini score [13]. The number of coronary arteries with was determined by receiver operating characteristics
a lesion of 50% luminal obstruction was also determined analysis based on clinical diagnosis of AMI after comparing
to have an idea about the extent of myocardial ischemia sensitivity and specificity at different cut-off values.
(0: < 50% luminal obstruction, 1, 2, and 3: number of Logistic regression analysis with enter method was
vessels with Z 50% luminal obstruction). Primary percu- performed including independent variables being signifi-
taneous coronary intervention (PCI) was performed in 19 cantly different between patients with AMI and stable
patients with AMI at the time of presentation. The rest of CAD and having a possible causative role for AMI. All tests
the PCI procedures performed in patients with AMI were of significance were two-tailed. Statistical significance was
performed during coronary angiography within 12 h. defined as a P value of less than 0.05.
Baseline characteristics that include presence of hyperten-
sion, diabetes mellitus, smoking status, and family history Results
for CAD, lipid parameters and the body mass index were Baseline characteristics are presented in Table 1. The
recorded during the direct interview with the patient. number of male patients (P = 0.001) and the smoking
Hypertension was defined as the active use of antihyper- incidence (P < 0.001) were higher in the AMI group. The
tensive drugs or documentation of blood pressure more body mass index (P = 0.021), the total cholesterol
than 140/90 mmHg. Diabetes mellitus was defined as (P = 0.002), and high-density lipoprotein (P = 0.001)
fasting glucose levels over 126 mg/dl or glucose level over levels were higher in the stable CAD group. Although
200 mg/dl at any measurement or active use antidiabetic the age of study patients in AMI and stable CAD groups
treatment. Smoking was defined as current smoking. The was similar [P = not significant (NS)], the patients were
family history for CAD was defined as a history of CAD or older in NSTEMI subgroup compared with STEMI group
sudden death in a first-degree relatively before the age of (P < 0.001). Estimated glomerular filtration rate was
55 years for men and 65 years for women. similar between the groups.

The patients were grouped according to type of clinical Plasma NGAL levels were higher in patients with AMI
presentation. First group included the patients with stable than the patients with stable CAD (146 ± 23 vs. 101 ±
CAD (stable CAD group; n = 37). The patients with AMI 53 ng/ml, P < 0.001). We did not observe a significant
were included in second group (AMI group; n = 91). The difference in plasma NGAL levels between the sub-
AMI group had been further divided into two subgroups: groups of AMI (145 ± 23.9 vs. 145 ± 23.4 ng/ml, P = NS)
STEMI group (n = 53) and NSTEMI group (n = 38). (Fig. 1). The plasma NGAL levels were not related
with age (P = 0.820), serum creatinine level (P = 0.389),
The blood samples for measurement of plasma NGAL and estimated glomerular filtration rate (P = 0.325).
were collected by venal puncture at 48 h of presentation Furthermore, the plasma NGAL level did not show any

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 NGAL in MI and stable angina Sahinarslan et al. 335

Table 1 Distribution of baseline characteristics in the study population

Acute myocardial infarction

P value
SAP AMI P value NSTEMI STEMI (NSTEMI vs. P value (SAP/
Parameters (N = 37) (N = 91) (SAP vs. ACS) (N = 38) (N = 53) STEMI) NSTEMI/STEMI)

Age (years) 59 ± 10 59 ± 12 NS 64 ± 12 55 ± 11 < 0.001 0.001

Sex (male) 49% 78% 0.001 84% 76% NS 0.003
BMI (kg/m2) 29.8 ± 5.6 27.4 ± 4.4 0.021 27.1 ± 4.0 27.6 ± 4.6 NS 0.033
Hypertension 51% 44% NS 55% 36% 0.066 NS
Diabetes mellitus 30% 22% NS 26% 19% NS NS
Smoking (current) 24% 65% < 0.001 58% 70% NS < 0.001
Family history of CAD 16% 32% 0.072 26% 39% NS NS
Hemoglobin (mg/dl) 14 ± 1.5 14 ± 1.6 NS 14 ± 1.4 15 ± 1.7 0.059 0.035
Platelets (/mm3) 247 ± 61 240 ± 71 NS 224 ± 57 252 ± 78 0.056 NS
Creatinine (mg/dl) 0.95 ± 0.19 0.98 ± 0.29 NS 1.04 ± 0.37 0.94 ± 0.20 NS NS
eGFR (ml/min)a 91 ± 21 95 ± 30 NS 89 ± 30 100 ± 29 0.070 0.098
Total cholesterol (mg/dl) 211 ± 56 180 ± 45 0.002 173 ± 39 185 ± 48 NS 0.004
HDL (mg/dl) 51 ± 22 38 ± 9 0.001 38 ± 8 38 ± 10 NS < 0.001
LDL (mg/dl) 133 ± 50 117 ± 41 NS 111 ± 35 122 ± 44 NS NS
Triglyceride (mg/dl) 134 ± 54 133 ± 72 NS 139 ± 73 129 ± 73 NS NS
NGAL (ng/ml) 101 ± 53 146 ± 23 < 0.001 145.9 ± 23.9 145.6 ± 23.4 NS < 0.001
Troponin T (ng/ml) 0±0 1.06 ± 2.19 < 0.001 0.43 ± 0.63 1.52 ± 2.73 0.013 < 0.001
Leukocytes (per mm3) 8023 ± 2085 10464 ± 3118 < 0.001 9002 ± 2471 11532 ± 3127 < 0.001 < 0.001
Neutrophils (per mm3) 4844 ± 1807 6926 ± 2381 < 0.001 5932 ± 2273 7614 ± 2992 0.008 < 0.001
Lymphocytes (per mm3) 2454 ± 841 2710 ± 1298 NS 2320 ± 1004 2993 ± 1420 0.033 0.016
Monocytes (per mm3) 553 ± 222 814 ± 356 < 0.001 736 ± 341 866 ± 359 0.052 < 0.001
Number of diseased vessels 0.9 ± 1 1.7 ± 0.9 < 0.001 1.9 ± 0.9 1.6 ± 0.8 NS < 0.001
Z 50%
Gensini score 24 ± 35 43 ± 38 0.011 52 ± 51 38 ± 27 NS 0.009
PCI 24% 59% < 0.001 50% 66% NS 0.001

ACS, acute coronary syndrome; AMI, acute myocardial infarction; BMI, body mass index; CAD, coronary artery disease; eGFR, estimated glomerular filtration rate; HDL,
high-density lipoprotein; LDL, low-density lipoprotein; NGAL, neutrophil gelatinase-associated lipocalin; NSTEMI, non-ST-segment elevation myocardial infarction; NS,
non-significant; number of diseased vessels Z 50%, 0: < 50% luminal obstruction, 1, 2 and 3: number of vessels with Z 50% luminal obstruction; PCI, percutaneus
coronary intervention; SAP, stable angina pectoris (stable CAD); STEMI, ST-segment elevation myocardial infarction.
a
Cockcroft–Gault formula was used.

Fig. 1 in patients with AMI. However, the relationship between

AMI and NGAL was significant despite the difference in
200 PCI numbers among the groups. Furthermore, PCI did
P = NS not have a significant relationship with NGAL levels in
our study (Table 2).
150
Some of the other circulating inflammatory cells were
NGAL (ng/ml)

higher in patients with AMI compared with stable CAD.

We found significantly higher numbers of leukocytes
100
(10 464 ± 3118 vs. 8023 ± 2085, P < 0.001), neutrophils
(6926 ± 2381 vs. 4844 ± 1807, P < 0.001), monocytes
P < 0.001 (814 ± 356 vs. 553 ± 222, P < 0.001) in AMI group. The
50 number of lymphocytes did not differ between AMI and
stable CAD groups (2710 ± 1298 vs. 2454 ± 841, P = NS),
but when the comparison was made among three groups
0 as stable CAD, NSTEMI, and STEMI, number of lympho-
SAP NSTEMI STEMI cytes was significantly higher in patients with STEMI
Study subgroups (2454 ± 841 vs. 2320 ± 1004 vs. 2993 ± 1420, P = 0.016).

Neutrophil gelatinase-associated lipocalin (NGAL) levels among study The level of NGAL was correlated positively with the
groups. NS, non-significant; NSTEMI, non-ST-segment elevation levels of the each inflammatory cell type (for leukocytes:
myocardial infarction; SAP, stable angina pectoris; STEMI, ST-segment
elevation myocardial infarction.
r = 0.3, P = 0.001; for neutrophils: r = 0.3, P < 0.001; for
monocytes: r = 0.4, P < 0.001) and first positive troponin
T value (r = 0.33, P < 0.001).
relationship neither with the number of coronary arteries We examined the independent factors related to AMI in
with a lesion of more than or equal to 50% luminal the multivariate analysis. All the parameters that have a
obstruction (P = 0.46), nor with the Gensini score potential to have a causal effect on occurrence of AMI
(P = 0.76). The number of PCI procedures was higher had been included in multivariate analysis. We found that

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 336 Coronary Artery Disease 2011, Vol 22 No 5

Table 2 The changes in NGAL levels with presence or absence of PCI in study subgroups
Acute myocardial infarctions

SAP NSTEMI STEMI P valuea P valueb

Parameter (N = 37) (N = 38) (N = 53) (NGAL) (PCI)

N 28 9 19 19 18 35
PCI (0/1) 0 1 0 1 0 1 0.048 NS
NGAL (ng/ml) 98 ± 55 111 ± 48 148 ± 27 144 ± 21 150 ± 21 143 ± 24

Univariate analysis of variance was used for comparisons.

CAD, coronary artery disease; NGAL, neutrophil gelatinase-associated lipocalin; NS, non-significant; NSTEMI, non-ST-segment elevation myocardial infarction; PCI,
percutaneus coronary intervention (0: not performed, 1: performed); SAP, stable angina pectoris (stable CAD); STEMI, ST-segment elevation myocardial infarction.
a
P value, for the relationship between NGAL and the clinical groups of CAD.
b
P value, for the relationship between presence of PCI and NGAL levels in study subgroups.

Table 3 Multivariate analysis using the logistic regression methoda for acute myocardial infarction
Independent variables b ± SE Wald P value Odds ratio 95% confidence interval

Sex (male) 0.9 ± 0.9 0.9 0.342 2.432 0.389–15.2

BMI (kg/m2) – 0.1 ± 0.1 0.5 0.488 0.943 0.798–1.1
Smoking (current) 2.0 ± 0.9 5.1 0.024 7.426 1.297–42.5
HDL (mg/dl) – 0.1 ± 0.1 3.6 0.059 0.953 0.907–1.002
NGAL (ng/ml) 0.1 ± 0.1 11.8 0.001 1.045 1.019–1.072
NGALb (cutoff: 127 ng/ml) 2.5 ± 0.8 8.8 0.003 12.233 2.327–64.3
Neutrophils (per mm3) 0.1 ± 0.2 0.4 0.524 1.114 0.799–1.553
Monocytes (per mm3) – 0.3 ± 1.5 0.1 0.862 0.773 0.043–13.9
Number of diseased vessels Z 50%
0 Ref 11.2 0.011 — —
1 2.1 ± 1.0 4.6 0.033 7.760 1.181–50.9
2 4.6 ± 1.5 9.3 0.002 96.9 5.134–1827.5
3 3.6 ± 1.3 7.7 0.006 37.3 2.893–480.7
Gensini scorec 0.1 ± 0.1 4.7 0.030 1.029 1.003–1.055

AMI, acute myocardial infarction; b ± SE, beta ± standard error; BMI, body mass index; CAD, coronary artery disease; HDL, high-density lipoprotein; NGAL, neutrophil
gelatinase-associated lipocalin; Ref, reference value; number of diseased vessels Z 50%, 0: < 50% luminal obstruction, 1, 2, and 3: number of vessels with Z 50%
luminal obstruction.
a
Logistic regression analysis with enter method was performed including independent variables being significantly different between patients with AMI and stable CAD
and having a possible causative role for AMI in Table 1.
b
When NGAL was used as categorical variable instead of continuous variable (the cut-off value for categorization of NGAL was 127 ng/ml).
c
When the Gensini score was used instead of number of diseased vessels Z 50%.

current smoking [odds ratio (OR): 7.4, 95% confidence incidence of MI. Plasma NGAL level was a better
interval (CI): 1.3–42.5, P = 0.024] and extent and severity independent indicator than the subtypes of circulating
of coronary atherosclerosis determined by the Gensini score inflammatory cells to detect MI.
(P = 0.030) were independent factors related to AMI. In
contrast, increased high-density lipoprotein level was The relationship between inflammation and atherosclero-
related to decreased incidence of AMI (OR: 0.9, 95% CI: sis was shown in several studies [14,15]. Inflammation
0.9–1.0, P = 0.059) but this change was only a tendency, within the atherosclerotic plaques is known to promote
not significant. We also found that plasma NGAL level was plaque instability. MMPs are endopeptidases, which play
independently related to the existence of AMI (OR: 1.045, a major role in atherosclerosis by degrading the extra-
95% CI: 1.019–1.072, P = 0.001). Furthermore, when the cellular matrix and causing cap rupture and intraplaque
plasma NGAL level above 127 ng/ml is taken as a cut-off hemorrhage. MMP-9 is one of the MMPs, which are
point, we observed a 12 times higher incidence of AMI expressed in the vulnerable atherosclerotic plaque. Thus,
(OR: 12.2, 95% CI: 2.3–64, P = 0.003) (Table 3). The it has been suggested to be causally involved in the
numbers of circulating neutrophils and monocytes were not remodeling processes associated with plaque rupture
independently related to ACSs in the analysis, which [16,17]. Furthermore, the results of the study by
includes NGAL level. Hemdahl et al. [10], which was done in atherosclerotic
mice model with AMI, showed that MMP-9 was highly
Discussion expressed in areas with increased proteolytic activity.
This study aimed to compare the plasma level of NGAL The plasma levels of MMP-9 were found to show
in patients with different clinical forms of AMI with the cardiovascular mortality in a large cohort of patients with
patients with stable CAD. We found that plasma NGAL CAD [18]. The main mechanism responsible for the
level was significantly higher in the patients with AMI. inactivation of MMP-9 is inhibition by tissue inhibitor
When the plasma NGAL level above 127 ng/ml is taken as of metalloproteinase (TIMP-1) [9]. The imbalance
a cut-off point, we observed a 12 times increased rate in between proteolysis by MMP-9 and, its inhibition by

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 NGAL in MI and stable angina Sahinarslan et al. 337

TIMP-1 may lead to plaque rupture. In a study with Previous studies attributed an important role to neutro-
carotid plaques, MMP-9 was found to be increased with a phils for progression of atherosclerosis and ACSs [22,23].
significant increase in MMP-9/TIMP-1 ratio in patients Neutrophils release inflammatory molecules that con-
with unstable plaques and spontaneous embolization tribute to progression of CAD and occurrence of ACS
[17]. NGAL prevents inhibition of MMP-9 by TIMP-1 such as oxygen radicals, NGAL, and MMPs [24].
and may increase MMP-9/TIMP-1 ratio leading to an Significant neutrophil infiltration within atherosclerotic
imbalance in proteolytic activity and inhibition [9]. Thus, plaques responsible for the ACSs has been shown in
serum NGAL level may differ in different clinical immunohistochemistry of atherectomy specimens [25].
pictures of CAD. In concordance with this hypothesis Several studies showed that both total white blood cell
we found higher serum NGAL level in patients with AMI count and isolated neutrophil count can predict the
compared with stable CAD. outcome in ACSs. As NGAL is a mediator secreted from
neutrophils, one may think that NGAL may not add to
Our study is not the first study indicating a relationship risk stratification beyond routine complete blood count,
between NGAL level and coronary atherosclerosis. In which shows levels of certain inflammatory cells. But in
a recent study, the researchers demonstrated that serum our study, the relationship between NGAL and AMI was
NGAL level was related to angiographical severity of independent, but numbers of neutrophil and other
coronary atherosclerosis [19]. Therefore, the finding of circulating inflammatory cells was not in multivariate
higher plasma NGAL level in patients with AMI in our analysis that included NGAL.
study may be suggested to be the result of higher severity
of coronary atherosclerosis in these patients. But in our Indeed, the timing of blood samples is a limitation in our
study, we did not find a relationship between plasma study too. We measured serum NGAL level for once in
NGAL level and the number of significantly diseased patients. Although this measurement may provide an
coronary vessels or the Gensini score. Thus, the increased accurate result in patients with stable CAD, the reliability
plasma levels of NGAL in patients with AMI in our study, of the measurement is less accurate in patients with AMI.
seems to be the result of higher degree of inflammation in As the degree of inflammation may change among these
patients with AMI rather than the extent of myocardial patients, it is possible to find different NGAL level on
ischemia or severity of coronary atherosclerosis. different occasions. In previous studies, inflammation was
shown to reach its peak value at 48 h after the presentation
In another study, Choi et al. [20] found that serum NGAL in ACSs [23,26,27]. Therefore, we collected blood samples
level was higher in patients with CAD compared with the for NGAL measurement 48 h after presentation in patients
control group. Although they did not find a statistically with MI. There are several reports in the literature, which
significant difference between NGAL levels of the patients suggests an increase in serum NGAL levels after coronary
with chronic CAD and AMI, they showed a tendency to angiography and PCI due to contrast material and
higher NGAL levels in patients with AMI. However, the activation of neutrophils by direct tissue damage in PCI
researchers did not mention the renal function of the study [2,28,29]. These reports suggest that angiography induced
population. In that study, the fasting glucose levels and increase in serum NGAL level lasts at most 24 h. As we had
incidence of insulin resistance were significantly higher in collected the blood samples at 48 h of presentation, we
CAD group. These factors are closely related to the renal think that we had excluded the confounding effect of
function. In previous studies, renal dysfunction was shown angiography and contrast material on NGAL levels. In any
to be associated with increased plasma NGAL level [21]. case, PCI did not have any significant relationship with
This limitation may be responsible for the decreased NGAL levels in our study. Furthermore, none of our
significance of the difference between NGAL levels in patients had developed contrast-induced nephropathy
the chronic CAD group and AMI group. In our study, the based on definition, which is an increase of 25% over
estimated glomerular filtration rate was similar among the baseline at 48 h after coronary angiography or PCI.
groups. Another explanation for the inconsistency between
our results and the study by Choi et al. [20] may be the The main limitation of our study is that it does not explain
limited number of the patients with ACS (n = 11) in that the exact mechanism of relationship between elevated
study. In our study, the number of the patients with AMI serum NGAL levels and AMI. Although we found a
was relatively higher (n = 91) and the AMI group included relationship between NGAL and AMI, which is indepen-
only the patients with increased levels of cardiac enzymes dent of other circulating inflammatory cell subtypes, we do
and not the patients with unstable angina. The other not have any data regarding other markers of neutrophil
difference is the timing of blood sampling. In the study by activation such as MMPs or other markers of inflammation
Choi et al. [20] the blood samples for measurement of such as CRP. As production of NGAL is not related directly
NGAL were collected at least 3 months after the acute to CRP or MMPs, we did not search the levels of CRP
event. Therefore, probably the plaque was stabilized and and MMPs. CRP and NGAL play different roles in
inflammation was subsided. But we obtained the blood inflammatory process and they do not have direct causal
samples in the acute phase. relationship to affect levels of each other [8,9]. In contrast,

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 338 Coronary Artery Disease 2011, Vol 22 No 5

NGAL is closely related to MMP-9 to show its effect, but 13 Gensini GG. A more meaningful scoring system for determining the severity
in this relationship the determinant is NGAL and not of coronary artery disease. Am J Cardiol 1983; 51:606.
14 Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of C-reactive
MMP-9. NGAL determines the MMP-9 level by inhibiting protein and low density lipoprotein cholesterol levels in the prediction of first
degradation of MMP-9 by TIMP-1 [9]. cardiovascular events. N Engl J Med 2002; 347:1557–1565.
15 Sabatine MS, Morrow DA, Cannon CP, Murphy SA, Demapoulos LA,
In conclusion, our results show that the plasma NGAL level DiBattiste PM, et al. Relationship between baseline white blood cell count
and degree of coronary artery disease and mortality in patients with acute
is significantly higher in patients with AMI. This finding
coronary syndromes: a TACTICS-TIMI 18 (Treat Angina with Aggrastat and
is important, because the serum NGAL level may have a determine Cost of Thearpy with an Invasive or Conservative Strategy-
potential to detect the patients who are under risk of AMI Thrombolysis in Myocardial Infarction 18 trial) substudy. J Am Coll Cardiol
2002; 40:1761–1768.
and vulnerable plaque. Although we cannot conclude a
16 Brown DL, Hibbs MS, Kearney M, Loushin C, Isner JM. Identification of
definite clinical benefit of NGAL, we believe that these 92-kD gelatinase in human coronary atherosclerotic lesions: association of
findings may pave the way for further studies searching the active enzyme synthesis with unstable angina. Circulation 1995;
91:2125–2131.
role of NGAL in ACS and plaque vulnerability. 17 Loftus IM, Naylor AR, Goodall S, Crowther M, Jones L, Bell PR, Thompson
MM. Increased matrix metalloproteinase-9 activity in unstable carotid
Acknowledgement plaques: a potential role in acute plaque disruption. Stroke 2000;
31:40–47.
This study was funded by the Turkish Vascular Biology 18 Blankenberg S, Rupprecht HJ, Poirier O, Bickel C, Smieja M, Hafner G, et al.
Foundation. Plasma concentrations and genetic variation of matrix metalloproteinase 9
and prognosis of patients with cardiovascular disease. Circulation 2003;
107:1579–1585.
References 19 Zografos T, Haliassos A, Korovesis S, Giazitzoglou E, Voridis E, Katritsis D.
1 Libby P, Aikawa M. Stabilization of atherosclerotic plaques: new Association of neutrophil gelatinase-associated lipocalin with the severity of
mechanisms and clinical targets. Nat Med 2002; 8:1257–1262. coronary artery disease. Am J Cardiol 2009; 104:917–920.
2 Rudolph V, Steven D, Gehling UM, Goldmann B, Rudolph TK, Friedrichs K, 20 Choi KM, Lee JS, Kim EJ, Baik SH, Seo HS, Choi DS, et al. Implication of
et al. Coronary plaque injury triggers neutrophil activation in patients with lipocalin-2 and visfatin levels in patients with coronary heart disease. Eur J
coronary artery disease. Free Radic Biol Med 2007; 42:460–465. Endocrinol 2008; 158:203–207.
3 Baldus S, Heeschen C, Meinertz T, Zeiher AM, Eiserich JP, Münzel T, et al.; 21 Bolignano D, Lacquaniti A, Coppolino G, Campo S, Arena A, Bluemi M.
CAPTURE Investigators. Myeloperoxidase serum levels predict risk in patients Neutrophil gelatinase-associated lipocalin reflects the severity of renal
with acute coronary syndromes. Circulation 2003; 108:1440–1445. impairment in subjects affected by chronic kidney disease. Kidney Blood
4 Naruko T, Ueda M, Haze K, Van der Wal AC, Van der Loos CM, Itoh A, et al. Pres Res 2008; 31:255–258.
Neutrophil infiltration of culprit lesions in acute coronary syndromes. 22 Paulsson J, Dadfar E, Held C, Jacobson SH, Lundhal J. Activation of
Circulation 2002; 106:2894–2900. peripheral and in vitro transmigrated neutrophils in patients with stable
5 Nijm J, Wikby A, Tompa A, Olsson AG, Jonasson L. Circulating levels of coronary artery disease. Atherosclerosis 2007; 192:328–334.
proinflammatory cytokines and neutrophil-platelet aggregates in patients 23 Mariani M, Fetiveau R, Rossetti E, Poli A, Poletti F, Vandoni P, et al.
with coronary artery disease. Am J Cardiol 2005; 95:452–456. Significance of total and differential leucocyte count in patients with acute
6 Singh U, Devaraj S, Jialal I. C-reactive protein stimulates myeloperoxidase myocardial infarction treated with primary coronary angioplasty. Eur Heart J
release from polymorphonuclear cells and monocytes: implications for acute 2006; 27:2511–2515.
coronary syndromes. Clin Chem 2009; 55:361–364. 24 Kai H, Ikeda H, Yusukawa H, Matsumoto T, Murohara T, Haramaki N, et al.
7 Kobayashi S, Inoue N, Ohashi Y, Terashima M, Matsui K, Mori T, et al. Peripheral blood levels of matrix metalloproteinases-2 and -9 are elevated in
Interaction of oxidative stress and inflammatory response in coronary plaque patients with acute coronary syndromes. J Am Coll Cardiol 1998;
instability: important role of C-reactive protein. Arterioscler Thromb Vasc 32:368–372.
Biol 2003; 23:1398–1404. 25 Dedobbeleer C, Melot C, Renard M. C-reactive protein increase in acute
8 Kjeldsen L, Johnsen AH, Sengelov H, Borregaard N. Isolation and primary myocardial infarction. Acta Cardiol 2004; 59:291–296.
structure of NGAL, a novel protein associated with human neutrophil 26 Berton G, Cordiano R, Palmieri R, Pianca S, Pagliara V, Palatini P. C-reactive
gelatinase. J Biol Chem 1993; 268:10425–10432. protein in acute myocardial infarction: association with heart failure. Am
9 Yan L, Borregaard N, Kjeldsen L, Moses MA. The high molecular weight Heart J 2003; 145:1094–1101.
urinary matrix metalloproteinase (MMP) activity is a complex of gelatinase B/ 27 Bachorzewska-Gajewska H, Malyszko J, Sitniewska E, Malyszko JS,
MMP-9 and neutrophil gelatinase-associated lipocalin (NGAL). Modulation Poniatowski B, Pawlak K, Dobrzycki S. NGAL (neutrophil gelatinase-
of MMP-9 activity by NGAL. J Biol Chem 2001; 276:37258–37265. associated lipocalin) and cystatin C: are they good predictors of contrast
10 Hemdahl AL, Gabrielsen A, Zhu C, Eriksson P, Hedin U, Kastrup J, et al. nephropathy after percutaneous coronary interventions in patients with
Expression of neutrophil gelatinase–associated lipocalin in atherosclerosis and stable angina and normal serum creatinine? Int J Cardiol 2008;
myocardial infarction. Arterioscler Thromb Vasc Biol 2006; 26:136–142. 127:290–291.
11 Elneihoum AM, Falke P, Hedblad B, Lindgarde F, Ohlsson K. Leukocyte 28 Bachorzewska-Gajewska H, Malyszko J, Sitniewska E, Malyszko JS,
activation in atherosclerosis: correlation with risk factors. Atherosclerosis Dobrzycki S. Neutrophil-gelatinase-associated lipocalin and renal function
1997; 131:79–84. after percutaneous coronary interventions. Am J Nephrol 2006;
12 Elneihoum AM, Falke P, Axelsson L, Lundberg E, Lindgarde F, Ohlsson K. 26:287–292.
Leukocyte activation detected by increased plasma levels of inflammatory 29 Shaker OG, El-Shehaby A, El-Khatib M. Early diagnostic markers for
mediators in patients with ischemic cerebrovascular diseases. Stroke 1996; contrast nephropathy in patients undergoing coronary angiography.
27:1734–1738. Angiology 2010; 61:731–736.

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