The development of anemia of inflammation during acute myocardial infarction

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Abstract

Background

Anemia is associated with an unfavorable outcome in acute myocardial infarction (AMI). An acute phase response could contribute to the development of anemia in AMI patients.

Methods

We have performed a cross-sectional analysis on prospectively collected data at a tertiary hospital catheterization laboratory. Multi-adjusted linear regression models were fitted for hemoglobin as the dependent variable. ANOVA tests were used to determine interactions between time cutoffs of the respective hemoglobin and the concentrations of two inflammatory proteins, namely C-reactive protein and fibrinogen. Anemia indices were analyzed in a subgroup of 138 male AMI patients for whom frozen serum samples were available.

Results

Enrolled were 1017 patients (340 with unstable angina pectoris [UAP] and 677 with AMI). Correlates of hemoglobin in the AMI group included age, male gender, the inflammatory proteins, as well as time from symptom onset to angiography (r2 = 0.47; p < 0.001). A significant decrease in the concentration of hemoglobin with a parallel increase in the inflammatory proteins was observed between the time cutoff from symptom onset to angiography only in the AMI group for males and females, respectively. A pattern suggestive of anemia of inflammation including higher ferritin, lower transferring, lower transferrin saturation, and lower serum iron concentrations has been observed in anemic AMI patients ( all p < 0.05).

Conclusions

Inflammation-sensitive proteins are associated with lower hemoglobin concentrations in AMI patients. We therefore suggest the possibility that at least part of the hemoglobin drop in AMI prior to angiography is related to the anemia of inflammation.

Introduction

There are multiple lines of evidence to suggest that the presence of anemia in patients with acute myocardial infarction (AMI) is detrimental [1], [2], [3], [4], [5]. Although several authors suggest that bleeding episodes during invasive procedures and intensive anticoagulation contribute to the development of anemia [6], [7], anemia develops in nearly half of AMI hospitalizations among patients treated medically or with percutaneous coronary intervention, commonly in the absence of documented bleeding, and is associated with worse mortality and health status [8]. Thus, better understanding of how anemia can be prevented and whether its prevention can improve patient outcomes is needed.

The inflammatory response is an integral component of the reaction to tissue injury in patients with acute myocardial infarction (AMI) and persists for several weeks [9]. It has been shown that inflammation and acute phase response interact with the hematopoietic system at several levels resulting in reduced erythropoieses, accelerated destruction of erythrocytes and erythropoietin resistance [10], [11], [12]. We have presently explored the possibility that at least part of the anemia in patients with AMI is related to the presence of an inflammatory response, as well as the possibility that the timing from symptom onset till the time of angiographic intervention is related to the appearance of both an inflammatory response and a concomitant state of anemia.

Section snippets

Study population

We have presently analyzed data which was collected in the time period of March 1, 2006 to February 3, 2010, at the catheterization laboratory of the department of cardiology at the Tel-Aviv Sourasky medical center, Tel-Aviv, Israel. Informed consent was obtained from each patient as approved by the institutional ethics committee. Patients were recruited during their participation in the Tel-Aviv Angiogrpahy Prospective Study (TAPAS) [13]. The diagnosis of unstable angina pectoris (UAP) and AMI

Results

We have presently analyzed the data of 1017 ACS patients presenting with UAP (340) and AMI (677). The baseline characteristics and relevant medications used by these patients are reported in Table 1. It can be seen that the UAP patients had more co-morbidities, whereas the AMI group were treated more aggressively with anti-thrombotics. As a group, the mean baseline hemoglobin level did not differ between AMI and UAP patients. Acute myocardial patients had increased levels of both CRP and

Discussion

In the present study we have shown that the time from onset of precordial pain to coronary angiography in patients with AMI is associated with the appearance of an acute phase response and a drop of hemoglobin concentration. We raise therefore the possibility that the anemia seen in patients with AMI could be, at least in part, an anemia of inflammation.

This possibility has been thought up previously. In 665 chronic dialysis patients with AMI, Nissenson et al. [20] have shown that

Acknowledgments

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [30].

Grant support: none.

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