Evaluation of Profilin 1 As a Biomarker in Myocardial Infarction

European Review for Medical and Pharmacological Sciences 2020; 24: 8112-8116 Evaluation of profilin 1 as a biomarker in myocardial infarction

1 2 3 2 1 1 E. PASZEK , K ŻMUDKA , K. PLENS , J. LEGUTKO , T. RAJS , W. ZAJDEL

1Department of Interventional Cardiology, Institute of Cardiology, John Paul II Hospital, Kraków, Poland 2Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland 3KCRI, Kraków, Poland

Abstract. – OBJECTIVE: Profilin 1 Pfn1)( is Introduction likely to be involved in atherogenesis and myocardial infarction (MI). Clinical data on this sub- Profilin 1 (Pfn1) is a small, ubiquitous protein ject are very limited. The aim of this study was involved in actin cytoskeleton regulation. Recent to search for associations between serum Pfn1 studies1,2 show a probable link between Pfn1 and and a number of parameters in MI patients: symptom onset to PCI time (OPT), myocardial necrosis the pathogenesis of atherosclerosis and myocar- markers, thrombolysis in myocardial infarction dial infarction. So far, data on this subject are (TIMI) flow, antiplatelet drugs, heparin adminis- very limited and mostly come from in vitro and tration and typical atherosclerosis risk factors. animal models. The time of ischemia duration in PATIENTS AND METHODS: We included pa- myocardial infarction (MI) is a crucial parameter tients with type 1 MI (according to the Third Uni- for clinical decision-making and patient progno- versal Definition of Myocardial Infarction) who sis3. In a clinical setting a parameter derived from were able to precisely determine the time of symp- ischemia time – the time from symptom onset to tom onset. Exclusion criteria involved conditions potentially altering platelet function. We screened percutaneous coronary intervention (OPT) – is 114 patients and included 65. We assessed serum used. OPT is often unavailable, as a significant Pfn1 in three time points: on admission (Pfn1_0), proportion of patients is unable to determine it. 24 hours post PCI (Pfn1_24) and 48 hours post Hence, a biochemical marker of OPT would be a PCI (Pfn1_48) and correlated it with OPT, car- useful tool in the diagnosis and treatment of MI diac necrosis markers (troponin T, CK, CKMB), patients. The aim of this study was to assess the TIMI flow in the infarct-related artery, pre-hospital usefulness of Pfn1 as a biomarker of OPT in myo- P2Y12-antagonist and heparin administration and known atherosclerosis risk factors. cardial infarction (MI) patients. Additionally, we RESULTS: Patients with a shorter OPT had evaluated the relation between Pfn1 and myocar- higher Pfn1_0 (838.5 vs. 687.1 pg/ml, p=0.007). dial necrosis markers, thrombolysis in myocardial Patients with impaired coronary flow post infarction (TIMI) flow in the infarct-related ar- PCI had lower Pfn1_24 (748.2 vs. 925.2 pg/ml, tery (IRA), acute-phase drug administration and p=0.017) and Pfn1_48 (744.5 vs. 879.8, p=0.031. comorbidities. Pfn1_24 and Pfn1_48 were lower in patients who received a P2Y12 antagonist prior to hospital admission. Diabetic patients presented with lower Pfn1_0 concentrations. Patients and Methods CONCLUSIONS: This is the first study assessing Pfn1 in type 1 MI patients in relation to the The study was approved by the Institutional Ethi- chosen parameters. Pfn1 may be a biochemical cs Committee (opinion No. 122.6120.270.2015). tool to objectify information on OPT in MI pa- All study participants were thoroughly informed tients. We found an association between Pfn1 and provided written consent prior to enrollment. and post-PCI TIMI flow, antiplatelet drug admin- We screened consecutive patients with type 1 MI, istration and diabetes mellitus. (both STEMI and NSTEMI) who met the criteria Key Words: of the Third Universal Definition of Myocardial 4 Profilin 1, Myocardial infarction, Biomarker. Infarction . We included patients able to precisely determine the time of symptom onset, rounded up

8112 Corresponding Author: Elżbieta Paszek, MS, MD, Ph.D; e-mail: [email protected] Evaluation of profilin 1 as a biomarker in myocardial infarction to 15 min. The exclusion criteria involved: a pri- Warszawa, Warsaw, Poland) was used during all or STEMI in the same region, OPT > 24 hours, procedures in a body mass-dependent dose with s/p CABG, active inflammatory processes, any ACT control. thrombosis, any prothrombotic condition (e.g., Leiden mutation, an active neoplasm), an ische- Statistical Analysis mic stroke within three months prior to admis- Normal distribution was assessed using the sion, chronic anticoagulation, stage 4 or 5 kidney Shapiro-Wilk test. Values were presented as me- disease, cardiogenic shock. dian (IQR) as the data did not contain the assu- For each patient three serum samples were mptions of normality of the distribution. The Spe- collected: at the start of percutaneous coronary arman correlation test was used for comparing intervention (PCI), before the artery was reope- two numerical variables and the U-Mann-Whit- ned (Pfn_0), 24 post PCI (Pfn1_24) and 48 hours ney test was used for numerical and categorical post PCI (Pfn1_48). Pfn1 concentrations were variables. An essential level of significance was assessed using ELISA (SEC233Hu Cloud-Clone assumed at α = 0.05. Corp., Houston, TX, USA; 78-5000 pg/ml de- tection range). In the same time points cardiac necrosis markers: hsTnT, CK and CKMB were Results assessed using commercially available analyzers (Cobas 501 c and 601 e, Roche/Hitachi, Basel, 114 consecutive patients were screened and 65 Switzerland). Coronary angiography and PCI were enrolled. The reasons for exclusion were of the IRA were performed. The choice of PCI as follows: inability to precisely define the OPT strategy and equipment were at the operator’s time and/or OPT longer than 24 hours (30 pa- discretion. Abciximab (ReoPro, 2 mg/ml, Jans- tients), s/p CABG (14 patients), chronic anticoa- sen Biologics B.V., Leiden, The Netherlands) gulation therapy (8 patients), cardiogenic shock was administered i.v., in selected cases, as per on admission (7 patients), lack of patient consent European Society of Cardiology guidelines5. (6 patients), s/p ischemic stroke (1 patient), a pre- Unfractionated heparin (Heparinum WZF, Polfa viously sustained STEMI of the same region (1

Table I. Profilin 1 concentration (median; IQR) with respect to given parameters. Pfn1_0 (IQR) p Pfn1_24 (IQR) p Pfn1_ 48 (IQR) p

OPT ≤ 6h (n=39) 838.5 (898.7) 0.007 855.3 (379.8) 0.092 869.1 (411.9) 0.243 OPT > 6h (n=26) 687.1 (226.4) 776.9 (373.1) 805.5 (313.7) post-PCI TIMI 3 (n=55) 836.7 (903.1) 0.094 925.2 (391.9) 0.017 879.8 (487.3) 0.031 post-PCI TIMI 0-2 (n=10) 720.5 (116.8) 748.2 (248.1) 744.5 (254.1) P2Y12 antagonist - (n=56) 787.4 (812.6) 0.081 855.3 (301.9) 0.019 869.7 (355.9) 0.017 P2Y12 antagonist + (n=9) 651.4 (93.0) 728.8 (139.4) 698.7 (119.1) UFH - (n=36) 764.1 (828.3) 0.947 782.0 (424.5) 0.666 838.5 (306.1) 0.938 UFH + (n=29) 752.9 (276.5) 849.9 (235.1) 801.2 (221.6) Abciksimab - (n=59) 787.4 (850.1) 0.282 878.0 (406.7) 0.057 879.8 (478.6) 0.107 Abciksimab + (n=6) 713.6 (110.9) 721.6 (204.8) 769.5 (103.0) Hypertension - (n=13) 752.9 (878.6) 0.838 999.5 (363.0) 0.309 1052.8 (579.5) 0.268 Hypertension + (n=52) 784.4 (827.0) 847.6 (347.0) 838.5 (406.3) dyslipidemia - (n=16) 760.2 (374.5) 0.815 951.9 (179.5) 0.447 893.7 (343.9) 0.383 dyslipidemia + (n=49) 792.3 (863.0) 812.0 (505.0) 822.0 (509.2) DM- (n=45) 834.8 (908.8) 0.047 911.0 (370.9) 0.338 869.7 (462.3) 0.055 DM+ (n=20) 720.3 (282.8) 790.7 (377.9) 797.9 (299.0) Obesity - (n=43) 854.9 (991.3) 0.118 924.8 (542.3) 0.478 869.4 (528.4) 0.668 Obesity + (n=22) 727.2 (157.1) 842.3 (238.8) 843.5 (194.3) Smoking - (n=28) 757.1 (919.2) 0.960 821.0 (443.8) 0.514 869.5 (555.8) 0.900 Smoking + (n=37) 767.1 (501.1) 847.6 (391.9) 838.5 (339.4) Family h/o CAD - (n=46) 774.4 (965.4) 0.256 808.6 (400.2) 0.868 838.5 (622.4) 0.749 Family h/o CAD + (n=19) 713.9 (224.8) 847.6 (211.5) 805.5 (189.0)

“-” indicates the parameter was not present; “+” indicates a parameter was present; DM – diabetes mellitus; h/o CAD – history of coronary artery disease; OPT – onset of symptoms to PCI time; P2Y12 - Pfn1 – profilin 1. P2Y12 antagonist – administered before admission; UFH – unfractionated heparin. p < 0.05 is indicated in bold.

8113 E. Paszek, K. Żmudka, K. Plens, J. Legutko, T. Rajs, W. Zajdel patient). Some patients fulfilled more than one Discussion exclusion criterion. Detailed results have been presented in Table I. Patients with OPTs ≤6 The most probable source of serum Pfn1 are hours had higher Pfn1_0 concentrations in com- platelets activated during thrombogenesis6,7. parison to patients with an OPT>6 hours (Figure Research conducted so far implies that Pfn1, an 1). We also analyzed OPT as a continuous va- actin-associated protein, is released from pla- riable. We found an inverse, monotonous corre- telets during cytoskeletal reorganization8. Our lation between OPT and Pfn1 in all time points results are consistent with such a mechanism (R = -0.42, p < 0.001; R = -0.30, p = 0.02; R = of Pfn1 release. In patients with a shorter OPT, -0.28, p = 0.03 for Pfn1_0, Pfn1_24 and Pfn1_48, freshly released Pfn1 would be detectable. With respectively). Despite no differences in Pfn1_0, symptom elongation, fibrinolytic mechanisms Pfn1_24 and Pfn1_48 were significantly lower would be active. Simultaneously, platelet ag- in patients with impaired flow (TIMI 0-2) in gregation would be decreasing, yielding less the IRA post-PCI, as compared to those with a Pfn1. Also, thrombus formation occurs befo- TIMI 3. There was no correlation between Pfn1 re symptom onset in the course of events lea- and cardiac necrosis markers (TnT, CK, CKMB) ding to MI9. Therefore, the peak of Pfn1 serum both in terms of peak values, as well as area un- concentration might fall before symptom onset der the curve (AUC). and what is detectable on admission might al- All patients had been premedicated with aspi- ready be on the descending slope of the Pfn1 rin. Patients who had additionally received a concentration curve. So far, there has been one P2Y12 antagonist prior to admission, had signi- other study6 on Pfn1 in MI patients. Ramaio- ficantly lower Pfn1_24 and Pfn1_48 concentra- la et al6 report a different phenomenon: serum tions. Pre-hospital heparin administration did not Pfn1 concentration was lower in patients with a influence Pfn1 levels. There was a trend toward shorter OPT compared to persons with a longer lower Pfn1_24 in patients who received abcixi- duration of symptoms. This may result from a mab during PCI (p = 0.057). This result requires different study protocol, in which STEMI pa- further confirmation due to a low number of patients with an OPT 3-6 hours and ≥12 hours tients treated with abciximab. Diabetes mellitus were excluded. Our cohort included patients (DM) patients had lower levels of Pfn1_0. We with an OPT in a continuous range between 0 found no association between other atherosclero- and 24 hours, which seems closer to “real-life” sis risk factors and Pfn1. clinical situations. The occurrence of impaired post-PCI flow (TIMI 0-2) is an indicator of coronary microvascular obstruction (CMVO) and translates into poor prognosis10. Despite no initial differences, patients with a TIMI 0-2 had lower Pfn1 levels post PCI. This could be due to Pfn1 entrapment in the microcirculation or aggregation of its molecules. This is the first study assessing Pfn1 and post PCI coronary flow. Bearing in mind this is a preliminary result, if confirmed, Pfn1 may be a candidate for a biochemical biomarker of CMVO. Lower Pfn1 levels post-PCI in patients who had received a P2Y12 inhibitor prior to hospital admission in comparison to those who received the drug during PCI are consistent with the hypothesis that Pfn1 is released from activated platelets. The same applies to lower Pfn1 concentration 24 hours post-PCI in patients who received abciximab during the procedure. Figure 1. ROC curve for Pfn1 discriminating between Heparin acts mostly as a thrombin generation patients with an OPT less or equal to 6 hours and those with blocker and its influence on platelets is indirect. an OPT longer than 6 hours. Area under the curve (AUC): 0.71. This could be the reason why we did not find

8114 Evaluation of profilin 1 as a biomarker in myocardial infarction any association between the time of heparin ad- filin-1 is expressed in human atherosclerot- ministration and Pfn1 concentrations. ic plaques and induces atherogenic effects on The extent of myocardial damage does not vascular smooth muscle cells. PLoS One 2010; have to reflect the intensity of thrombosis. This is 5: e13608. Hao P, Fu K, Wang S-P, Ma C-Y, Xu Z-Y, Cao F-Y, Liu in agreement with the lack of correlation between 2) J-H. Expression of profilin-1 in endothelial cells Pfn1 and myocardial necrosis markers. of rats with acute myocardial infarction. Eur Rev There is some data linking Pfn1 to DM, Med Pharmacol Sci 2017; 21: 1318-1322. especially to the detrimental role of advanced 3) Stone GW, Dixon SR, Grines CL, Cox DA, Webb JG, glycation end-products in endothelial dysfun- Brodie BR, Griffin JJ, Martin JL, Fahy M, Mehran R, ction11. Lower Pfn1_0 concentrations in DM pa- Miller TD, Gibbons RJ, O’Neill WW. Predictors of tients are surprising and require further investi- infarct size after primary coronary angioplasty in gation. One explanation could be an alteration acute myocardial infarction from pooled analysis from four contemporary trials. Am J Cardiol 2007; in Pfn1 structure due to carbonylation, which 100: 1370-1375. is a common post-translational modification of 4) Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chait- serum proteins in DM. Carbonylation leads to man BR, White HD; Writing Group on the Joint ESC/ changes in the tertiary structure and function ACCF/AHA/WHF Task Force for the Universal Defini- of serum proteins12. In such a case a part of the tion of Myocardial Infarction, Thygesen K, Alpert JS, Pfn1 pool could be undetectable by ELISA lea- White HD, Jaffe AS, Katus HA, Apple FS, Lindahl B, Morrow DA, Chaitman BA, Clemmensen PM, Johan- ding to lower readings in DM patients. son P, Hod H, Underwood R, Bax JJ, Bonow RO, Pin- to F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand Conclusions JP, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, To our knowledge, this is the first clinical stu- Fortmann SP, Rosamond WD, Levy D, Wood D, Smith dy examining associations between serum Pfn1 SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver and the given parameters in STEMI and NSTEMI D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva patients. We found an inverse relationship betwe- EJ, Mendis S; ESC Committee for Practice Guidelines en Pfn1 and the duration of MI symptoms. This (CPG). Third universal definition of myocardial in- is the first report on an association between the farction. J Am Coll Cardiol 2012; 60: 1581-1598. occurrence of impaired flow in the IRA post-PCI 5) Ibanez B, James S, Agewall S, Antunes MJ, Buc- ciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, and decreased Pfn1 levels post-PCI. Pfn1 is a new Goudevenos JA, Halvorsen S, Hindricks G, K as- candidate biomarker of symptom onset-to-PCI trati A, Lenzen MJ, Prescott E, Roffi M, Valgimi- time in type 1 MI, as well as CMVO. Early ad- gli M, Varenhorst C, Vranckx P, Widimský P; ESC ministration of P2Y12-antagonists was associated Scientific Document Group. 2017 ESC Guidelines with reduced levels of serum Pfn1. Diabetic pa- for the management of acute myocardial infarc- tients presented with lower Pfn1 concentrations tion in patients presenting with ST-segment elevation: The Task Force for the management of on admission. acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; Conflict of Interest 39: 119 -177. The Authors declare that they have no conflict of interests. 6) Ramaiola I, Padró T, Peña E, Juan-Babot O, Cubedo J, Martin-Yuste V, Sabate M, Badimon L. Changes in thrombus composition and profilin-1 release in Funding acute myocardial infarction. Eur Heart J 2015; 36: This study was supported by a research grant from the Jagiel- 965-975. lonian University Medical College no. K/DSC/003586 to E.P. 7) Piersma SR, Broxterman HJ, Kapci M, Haas RR de, This article was supported by the Science Found of John Paul Hoekman K, Verheul HMW, Jiménez CR. Proteom- II Hospital, Kraków, Poland (No. FN4/2020 to E.P. ics of the TRAP-induced platelet releasate. J Pro- teom 2009; 72: 91-109. 8) Paknikar AK, Eltzner B, Köster S. Direct charac- References terization of cytoskeletal reorganization during blood platelet spreading. Progress in Biophys- ics and Molecular Biology 2018. Available at: Caglayan E, Romeo GR, Kappert K, Odenthal M, 1) http://www.sciencedirect.com/science/article/ Südkamp M, Body SC, Shernan SK, Hackbusch pii/S0079610718300609. Accessed November D, Vantler M, Kazlauskas A, Rosenkranz S. Pro- 24, 2018.

8115 E. Paszek, K. Żmudka, K. Plens, J. Legutko, T. Rajs, W. Zajdel

9) Carol A, Bernet M, Curós A, Rodríguez-Leor O, Ser- 11) Li Z, Zhong Q, Yang T, Xie X, Chen M. The role of ra J, Fernández-Nofrerías E, Mauri J, Bayes-Genís A. profilin-1 in endothelial cell injury induced by ad- Thrombus age, clinical presentation, and reper- vanced glycation end products (AGEs). Cardio- fusion grade in myocardial infarction. Cardiovasc vasc Diabetol 2013; 12: 141. Pathol 2014; 23: 126-130. 12) Bollineni RC, Fedorova M, Blüher M, Hoffmann R. 10) Niccoli G, Scalone G, Lerman A, Crea F. Coronary Carbonylated plasma proteins as potential bio- microvascular obstruction in acute myocardial markers of obesity induced type 2 diabetes melli- infarction. Eur Heart J 2016; 37: 1024-1033. tus. J Proteome Res 2014; 13: 5081-5093.

8116