Correlation between the plasma fibrinogen concentration and coronary heart disease severity in Moroccan patients with type 2 diabetes. Prospective study

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Annalesd’Endocrinologiexxx(2016)xxx–xxx

Original article

Relation entre taux plasmatiques de ﬁbrinogène et sévérité de l’atteinte coronarienne chez les patients diabétiques de type 2

Souad Kotbi

^a

, Amal Mjabber

^b

, Asma Chadli

^b,∗

, Ayoub El Hammiri

^c

, Siham El Aziz

^b

, Bouchra Oukkache

^d

, Hassan Mifdal

^e

, Nadia Nourichafi

^e

, Nabiha Kamal

^f

, Rachida Habbal

^c

,

Norredine Ghalim

^g

, Ahmed Farouqi

^b

, Mostafa Kabine

^a

aDepartmentofBiology,LaboratoryofBiochemistryandMolecularBiology,AinchockFacultyofScience,Km9,ElJadidaroad,Box5366Maarif,Casablanca, Morocco

bEndocrinologyandMetabolicDiseasesdepartment,IbnRochd,UniversityHospitalCenter1,Hospitalspart,Casablanca,Morocco

cCardiologydepartment,IbnRochduniversity,HospitalCenter,1,Hospitalspart,Casablanca,Morocco

dRegionalbloodtransfusioncentre,1,MohamedElFidouzi-exJennerstreet,Casablanca,Morocco

eHematologylaboratory,IbnRochduniversity,HospitalCenter,Hospitalspart,Casablanca,Morocco

fLaboratoryofbiochemistry,IbnRochduniversity,HospitalCenter,1,Hospitalspart,Casablanca,Morocco

gDepartmentofmedicalbiology,PasteurInstituteofMorocco,1,placeLouis-Pasteur,20360Casablanca,Morocco

Abstract

Aim.–Thepresentstudyaimsatdeterminingtherelationshipbetweentheplasmafibrinogenconcentrationandtheseverityofcoronaryheartdisease intype2diabeticpatients.Methods.–Prospectiveanalyticalsurvey,basedonasampleof120subjectsdividedinfourgroups:30nondiabetic coronarypatients(G1),30coronarydiabeticpatients(G2),30non-coronarydiabeticpatients(G3),and30healthysubjects(G4).Results.–The averageagewas59.58±7.88years;femalegenderpredominatedby52.5%.Theplasmafibrinogenconcentrationcorrespondedto3.46g/L±0.86 inG1;3.73g/L±1.11inG2;3.06g/L±0.98inG3and2.46g/L±0.51inG4;withasignificantdifferencebetweenthefourgroups(P=0.001).

Theplasma fibrinogenconcentration increasedin parallel withthe cardiovascular risk(P=0.0001); therewasalso asignificant correlation betweentheplasmafibrinogenconcentrationandtheclinicalandpara-clinicalcoronarydiseaseseverity(respectivelyP=0.005andP=0.0001).

Apositivecorrelationbetweentheplasmafibrinogenconcentrationandhyperglycemia(P=0.035)wasfoundinG4.Butnocorrelationwiththe lipidsparameters,exceptforthelowdensity-lipoproteinsinG3(P=0.035).Conclusion.–IntheMoroccanpopulation,theplasmafibrinogen concentrationwaspositivelyandsignificantlycorrelatedwiththecoronaryheartdiseaseseverity.

Keywords:Fibrinogen;Type2diabetes;Cardiovasculardisease;Coronarylesions Résumé

But.–Déterminerlarelationentrelestauxplasmatiquesdufibrinogèneetlasévéritédel’atteintecoronariennechezlespatientsdiabétiquesde type2.Méthodes.–Étudeanalytiqueprospective,incluantunéchantillonde120 sujets,répartisenquatregroupes:30 patientscoronariensnon diabétiques(G1),30patientsdiabétiquescoronariens(G2),30patientsdiabétiquesnoncoronariens(G3)et30casnondiabétiquesnoncoronariens indemnesdetoutespathologies(G4).Résultats.–L’âgemoyenaétéde59,58±7,88ans,lesexefémininprédominaitavec52,5%.Danslegroupe G1,letauxdefibrinogèneétaitde3,46g/L±0,86,danslegroupeG2,de3,73g/L±1,11etdanslegroupeG3 de3,06g/L±0,98,tandisdansle groupeG4,ilétaitde2,46g/L±0,51(p=0,001).Letauxdefibrinogèneaugmenteenparallèleaveclerisquecardiovasculaire(p=0,0001)dansles

∗Correspondingauthor.

E-mailaddress:drachadli@gmail.com(A.Chadli).

http://dx.doi.org/10.1016/j.ando.2015.02.004

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différentsgroupes.Unecorrélationsignificativeaététrouvéeentreletauxdefibrinogène,lasévéritécliniqueetpara-cliniquedelacoronaropathie, respectivement(p=0,005)et(p=0,0001).DanslegroupecontrôleG4,unecorrélationsignificativeaétéobservéeentrelaglycémieetletauxde fibrinogène.AucunecorrélationaveclesparamètreslipidiquessaufpourleslipoprotéinesdebassedensitédansleG3(p=0,035).Conclusion.– Letauxdefibrinogèneestassociédefac¸onpositiveaurisquecoronarienetàsagravité.

Motsclés:Fibrinogène;Diabètedetype2;Maladiecardiovasculaire;Lésionscoronaires

1. Introduction

InMorocco,overoneandahalfmillionadultsabovetheage of30havediabetes,mostlyoftype2.Thisnumberwillincrease in the coming years due to population aging and lifestyle.

The WHOpredicts nearly 339 million casesby 2030[1].In the population with diabetes, cardiovascular diseases due to atherosclerosisrepresentthemostcommoncomplications[2].

Theyarethefirstcauseofdeathanddisability[3];coronarydis- easeisthefirstcauseofdeathinpatientswithtype2diabetes (T2D)[4].Often,type2diabeticpatients haveahypercoagu- lableblood thatcanbe attributedtochangesininflammatory biomarkers[5],whicharehigherinT2Dpatientswithcardio- vasculardiseasecomparedtounaffectedpatients[6].Recently, newmarkers of possible risk factorshave been suggested to beimportantpredictorsofatherosclerosisanditscomplications [4].Fibrinogen(Fg)playsaparticularactiveroleintheinitia- tionandevolutionoftheatheroscleroticplaque[7–9];andmost of thestudiesunderlinethat ithasacausal [10]orpredictive role [11–14].However other studies reported that fibrinogen wasonlyabiomarker[15,16].Nevertheless,thepotentialrole offibrinogeninatherosclerosisanditscomplicationshasgener- atedconsiderableattention.Studieshaveshownthatformation ofanocclusivethrombus,onadamagedatheroscleroticlesion is the mostcommon precipitating factorof acutemyocardial infarction.Evidencealsosuggeststhatfibrinogenhasarole,both intheearlystagesofplaqueformationandlatecomplications of cardiovascular diseases [17]. The discrepancy in results can be explained by environmental andgenetic determinism [7,8] or by othersfactors. The cardiovascular morbidity and mortality level among diabetics have not been fully related totraditional risk factorssuch as hypertension, smoking and hypercholesterolemia.In diabeticsthereisadisruptionofthe functionalcapacityoffibrinogenthroughitschangeofstructure [2]whichcancausecoagulationandfibrinolysisabnormalities [18].

Forthesereasons,the main objective of thepresent study was to determine the fibrinogen role in the coronary heart disease severity in Moroccan patients with type 2 diabetes, and to analyze the different fluctuations of the fibrinogen bloodlevel,accordingtomodifiableornonmodifiableparam- eters such as age, gender, hypertension, body mass index (BMI),hyperglycemia,dyslipidemiaandsmokers,evenlyand according to the coronary lesions and number of affected truncus.

2. Patientsandmethods 2.1. Patients

This prospective study was conducted from June 2011 to June2012attheIbnRochdUniversityHospitalCentre(UHC) and at the regional blood transfusion center of Casablanca.

A sample of 120 subjects of age 50 and over was used, and was divided into 4 groups: group 1 (G1) included 30 non-T2D coronary patients; group 2 (G2) included 30 T2D coronary patients; group 3 (G3) included 30 non-coronary T2D patients andgroup4 (G4) included 30healthysubjects, non-smokers, non alcoholic, without any drug administra- tion,withoutanyhistoryofhematologicaldiseases.Thelatter groupwasblooddonorsintheregionalbloodtransfusioncen- ter.

Pregnantwomen,andpatientswithinflammatoryorinfec- tious diseases, confirmed by a previous assessment, were excluded.Onlypatientswithtype2diabetes(T2D),and/orcoro- narypatients,patientsfreefromanydiseaseandpostmenopausal women without hormonal treatment, were included. All the patients were eligibleto be included exceptthose presenting theabovementionedexclusioncriteria.

Thisstudywasheldwiththepatient’sfullinformedconsent accordingtotheWorldMedicalAssociationrecommendations [19].

2.2. Variables

The fibrinogen was measured the samedayof admission.

Both a clinical evaluation (weight, height, body mass index andbloodpressure),para-clinicalevaluation(electrocardiogram (ECG), stress testing, angiography) and biochemical evaluation (blood glucose (Glu), glycated hemoglobin (HbA1c), highdensitylipoprotein(HDL),lowdensitylipoprotein(LDL), triglyceride(TG),totalcholesterol(TC))havebeenperformed.

The angiography was carried out after an abnormal ECG in most of the coronary patients, evaluatedby two independent cardiologists;theseverityofthecoronarydiseasewasdefined by coronary lesion and the number of affected truncus. The variouspresentationsofthecoronaryheartdisease(CHD)cor- responded to stable angina, unstable angina, acute coronary syndrome with or without-ST segment elevation (STE-ACS, NSTE-ACS).

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Table1

Statisticsdescriptionofthevariousgroups.

Characteristics G1 G2 G3 G4 Total

Number(n) 30 30 30 30 120

Men(%) 37 63.3 30 60 47.5

Women(%) 63 36.7 70 40 52.5

Age(year) 62±8.86 61.23±7.71 60.97±7.98 54.10±3.41 59.58±7.88

BMI(kg/m²) 24.86±4.06 26.80±3.6 28.89±5.9 27.6±3.5 27±4.68

Glu(g/L) 1.28±0.28 2.46±1.41 1.67±0.67 1±0.09 1.59±0.95

T2Dduration(year) – 8.71±0.6 8.16±6.4 – 8.34±7.03

Dyslipidemia(%) 64.28% 72% 60% – 73%

LDL(g/L) 1.49±0.71 1.36±0.58 1.26±0.45 1.35±0.14 1.36±0.61

HDL(g/L) 0.65±0.14 0.42±0.11 0.48±0.09 0.54±0.11 0.52±0.11

TG(g/L) 1.49±0.95 1.86±1.00 1.15±0.57 1.70±0.63 1.52±0.83

Hypertension(%) 40% 73% 55% – 42%

Smokers(%) 56.7% 26.70% 3.70% – 21.7%

Allparticipantsinthestudywerealsoscreenedwithroutine test,suchasnormalliverandkidneyfunctions.

Thecardiovascularrisk(CVR)wasevaluatedforeachpatient accordingtoascorebasedonthe“EuropeanHighRiskChart”

[20],figuringtheconventionalriskfactors(gender,age,hypertension,totalcholesterolandsmoking status).The scorewas calculatedtopredicta10-yearfatalcardiovasculardiseaserisk.

2.3. Assessmentofthevariousparameters

Atthe HematologyLaboratoryof theUHCofCasablanca, fibrinogen test was based on the Clauss method [21] using automatichaemostasis ACLTop ^cts (500) [22]. Sampleswere collectedin5mLsiliconizedglasstubeswithtrisodiumcitrate anticoagulant109m(ratioanticoagulant/blood=1/9),thetubes werecentrifugedat1509gat15^◦Cfor15minutestogetpoor plateletplasma, biochemical assessment (Glu, HbA1c, HDL, LDL,TG,CT)wereperformedattheBiochemistrylaboratoryof theUHCbyanautomatedmethodusingtheMINDRAYBS800 automatedanalysissystem.Alltheseautomaticmethodsmetthe internalmeasuresofqualitycontrol.Biochemicalparametersare considerednormalwhenrespectiverateswererangingfrom2to 4g/Lforfibrinogen,0.7to1.1g/Lforfastingbloodglucose,with HDL>0.44g/L,LDL<1.59g/L,TG<2.01g/LandTC<2g/L.

2.4. Statisticalanalysis

AvarianceanalysisfollowedbyaBonferronitestwasper- formed.To ensurefibrinogen concentration independence we thusconductedthemultivariableanalysis.

The association of fibrinogen with qualitative parameters (gender,hypertension,andsmoking)andvariouspresentations ofthecoronaryheartdiseaseweredeterminedusingStudent’s t-test,ananalysisoftheassociationoffibrinogenwithboththe coronarylesionsandthenumberofaffectedtruncuswascarried out.

Thecorrelationbetweenfibrinogenandthequantitativecar- diovascularriskfactors(age,diabetesduration,hyperglycemia, obesitybasedonthebodymassindex(IMC>30),dyslipidemia manifestedbylowHDL,and/orhighLDL,and/orhighTG)was doneusingPearson’scorrelationcoefficient–1<r<1.

ThetestwasstatisticallysignificantiftheP-valuewasless than0.05andhighlysignificantifP-valuewaslessthan0.01.

3. Results

3.1. Characteristicsofthepatients

The total number of patients was 120 and women repre- sented52.5%.Theaverageageofthepatientsincludedinthis study was 59.58±7.88 years. The average diabetes duration was 8.35±7.03 years. A total of 42% of the patients were hypertensiveand21.7%weresmokers(Table1).

3.2. Cardiovascularrisk

Calculatedcardiovascularriskforeachpatientaccordingto the“EuropeanHighRiskChart”wasgiveninTable2.Inpatients withDT2and/orcoronaryheartdisease;thecardiovascularrisk

Table2

Associationbetweenaverageplasmafibrinogenconcentrationandcardiovascularrisks.

Low Moderate High VeryHigh Total Sumofsquares df Meansquare F P

G1 3.80±1.30 3.50±0.82 3.25±0.70 3 3.46±0.86 1.167 3 0.389 0.498 0.687

G2 – 3.66±0.57 4±1.27 3.50±1.09 3.73±1.11 1.7 3 0.567 0.431 0.73

G3 – 2.83±1.16 3.10±1.10 3.23±0.83 3.06±0.98 1.826 3 0.609 0.608 0.066

G4 2.46±0.51 – – – 2.46±0.51 – – – – –

Allgroups 3.80±1.30 3.36±0.90 3.50±1.14 3.35±0.95 3.18±0.95 21.478 4 5.37 6.27 0.0001^**

P:signification;df:degreesoffreedom;F:Fishertest.

** Verysignificant.

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andlowin7.7%ofthecases.

3.2.1. Plasmaﬁbrinogenconcentrationandcardiovascular risk

In the coronary patient’s group (G1), the plasma fibrinogen concentration in patient with severe CVR was 3g/L, withhighCVRwas3.25±0.70g/L,withmoderateCVRwas 3.5±0.82g/L,andwithlowCVRwas3.80±1.30g/L.Inthis G1group,fibrinogenwasnotassociatedtotheCVR(P>0.05).

In the T2D coronary patient’s group (G2), the plasma fibrinogen concentration in patients with severe CVR was 3.50±1.09g/L,withhighCVRwas4±1.27g/Landwithmod- erateCVRwas3.66±0.57g/L.InthisG2group,fibrinogenwas notassociatedtotheCVR(P>0.05).

IntheT2Dpatient’sgroupwithoutcoronarydisease(G3),the plasma fibrinogen concentration inpatients withsevereCVR was3.23±0.83g/L, withhighCVRwas 3.10±1.10g/Land withmoderateCVRwas2.83±1.16g/L.IntheG3group,fibrin- ogenwasnotassociatedtotheCVR(P>0.05).

Incontrast,whenallthegroupswerepooled,theassociation betweenplasmafibrinogenconcentrationsandCVRwasvery significant(P=0.0001)(Table2).

3.3. Coronaryheartdisease(G1andG2)

Intheonlycoronarypatient’sgroup(G1),stableanginawas present in 16.7% of the cases, unstable angina was present in6.6% of the cases,STE-ACS waspresent in46.7%of the cases and NSTE-ACS was present in 26.7% of the cases.

The coronary angiography was abnormal, showing coronary lesionsin85.7%of thecaseswithsingle-troncularlesionsin 27.7%, bi-troncular lesionsin 22.2%, multi-troncular lesions in 27.7%. No lesion of the common truncus was regis- tered.

In the T2D coronary patient’s group (G2), stable angina was present in 13.3% of the cases. Unstable angina was present in 3.3% of the cases, STE-ACS was present in 53.3% of the cases and NSTE-ACS was present in 20% of the cases. Thecoronary angiographywas abnormal,showing coronary lesions in 76% of the cases with single-troncular lesions in 63.2%, bi-troncular lesions in 13.3%, and multi- troncular lesions in 26.3%; all of the last lesions were also lesionsofthecommontruncus,whichweresevereobstructive lesions.

3.3.1. Plasmaﬁbrinogenconcentrationandcoronaryheart disease

IntheG1group,averageplasmafibrinogenconcentrationwas 3.46±0.86g/L withno significant association withcoronary heartdisease(P>0.05).

In the G2 group,average plasma fibrinogen concentration was 3.73±1.04g/L, fibrinogen wasassociated tothe various presentationofthecoronaryheartdisease(P=0.026)(Table3), butwhenwe adjustedtheCVRFtofibrinogenlevelwedidn’t findanysignificationwithCHD(Table4).

tractSTE-ACSorNSTE-ACSandcoronarylesions(C.L)was significant; respectivelyP=0.005andP=0.005. Theassocia- tionoffibrinogenwiththenumberofaffectedtruncuswasnot significant(P>0.05).

3.4. Plasmaﬁbrinogenconcentrationandcardiovascular riskfactors

Thecorrelationbetweenfibrinogenandage,BMIandhyper- glycemiawasfoundsignificantonlyinthecontrolgroup(G4), respectivelyP=0.0001,P=0.0001andP=0.035(Table5).

TheAnovatestresultsshowedthataveragefibrinogenplasma concentrationwithineachgrouppresentedsignificantheteroge- neousvariances(P=0.0001)(Table6).Comparedtothecontrol group (G4), the Bonferroni analysis showed that fibrinogen concentrationwassignificantlyhigherinG2,G1andG3,respec- tivelyP=0.0001,P=0.0001andP=0.005(withaconfidence intervalof95%).

Inthevariousgroupsnoassociationbetweenfibrinogenand genderwasfound.

ThecorrelationbetweenfibrinogenandLDLwassignificant (P=0.035)intheT2Dpatient’sgroup(G3),butnotsignificant intheothersgroups(P>0.05)(Table5).

NocorrelationwasfoundbetweenfibrinogenandbothHDL andTGinthevariousgroups(Table5).

Inpatientswithtype2diabetes,theassociationoffibrinogen withdiabetesdurationwassignificant(P=0.036).

Despite the different proportions of both genders within each group; the Bonferroni method at 5% showed that these proportions did not significantly differ from one to another. By studying the association between gender and tobacco, independently of plasma fibrinogen concentration, we found a significant association in patients with only cardiovascular disease (P=0.001) and in patients with cardiovascular disease and diabetes (P=0.0001). Indeed the association of fibrinogen with both hypertension and smoking was significant in all groups, respectively (P=0.01) and (P=0.03).

4. Discussion 4.1. Mainﬁndings

The present study revealed that the association of fibrinogen with various presentation of coronary heart disease was significant in coronary patients. Furthermore the association of fibrinogenwitharisktocontractSTE-ACSorNSTE-ACS andcoronarylesions(C.L)wasstatisticallysignificantinthese patients,butnoassociationwasreportedwithnumberofaffected truncus.

TheassociationbetweenfibrinogenandCVRwassignificant inallgroups.Theplasmafibrinogenconcentrationwashigherin T2Dcoronarypatientsthaninonlycoronarypatientsorpatients withonlyT2D,andhigherinpatientswithonlyT2Dthaninthe controlgroup.Also,apositiveassociationbetweentheplasma

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Table3

AverageplasmafibrinogenconcentrationandvariouspresentationsofCHDincoronarypatientsgroups.

Mean n SD Sumofsquares df Meansquare F P

G1

VariouspresentationofCHD Stableangina

Instableangina 3 2 1.41

ACSST– 3.62 8 0.51

ACSST+ 3.64 14 1.01

Betweengroups(combined) 2.37 4 0.594 0.8 0.55

Withingroups 19.08 25 0.764

Total 21.46 29

G2

VariouspresentationofCHD

Stableangina 3 4 0

Instableangina 6 1

ACSST– 4.5 6 1.05

ACSST+ 3.43 16 1.03

Betweengroups(combined) 12.42 4 3.107 3.3 0.026^*

Total 35.86 29

* Significant.

fibrinogenconcentrationandage,BMI,andhyperglycemia,was foundinthecontrolgroupasinallgroups.

Thecorrelationbetweenfibrinogenandthelipidsparameters wasonlysignificantwithlowdensitylipoprotein(LDL)inthe

patientwithonlyT2D.Anassociation withhypertensionand smokingwasfound.

Ourstudyunderlinedthatthecorrelationbetweenfibrinogen andcoronarylesionswassignificant,whichcanstrengthenthe

Table4

AverageplasmafibrinogenconcentrationwithadjustmentCVRFincoronarypatientsgroups.

CI(95%)forB

Mean SD n B t P Lowerlimit Higherlimit

G1

Sex 0.37 0.490 30 0.259 0.771 0.450 –0.745 1.618

Age 62.00 8.867 30 –0.020 –0.096 0.925 –0.044 0.040

BMI 24.33 4.037 30 0.230 0.882 0.388 –0.064 0.159

Glug/L 1.17 0.379 30 –0.176 –0.707 0.488 –1.515 0.748

LDLg/L 1.53 0.730 30 0.452 1.489 0.152 –0.206 1.231

HDLg/L 0.43 1.135 30 –0.420 –1.479 0.155 –0.738 0.126

TGg/L 1.57 0.898 30 –0.185 –0.702 0.491 –0.676 0.335

Tobacco 0.57 0.504 30 0.279 1.023 0.318 –0.475 1.390

HTA 0.40 0.498 30 –0.079 –0.292 0.773 –1.066 0.804

G2

Sex 0.63 0.490 30 –0.135 –0.390 0.701 –1.883 1.293

Age 61.23 7.709 30 0.184 0.882 0.389 –0.035 0.086

BMI 26.80 3.633 30 0.321 1.154 0.264 –0.078 0.267

Glug/l 1.87 0.776 30 0.482 1.698 0.107 –0.158 1.488

LDLg/L 1.50 0.572 30 0.333 1.089 0.290 –0.578 1.822

HDLg/L 0.17 0.379 30 0.079 0.302 0.766 –1.332 1.780

TGg/L 1.87 0.973 30 0.020 0.070 0.945 –0.634 0.678

Tobacco 0.29 0.460 28 –0.018 –0.053 0.958 –1.699 1.616

HTA 0.71 0.460 28 –0.057 –0.227 0.823 –1.362 1.097

Allgroups

Sex 0.50 0.504 58 0.031 0.150 0.881 –0.757 0.879

Age 61.91 8.219 58 0.072 0.544 0.589 –0.024 0.041

BMI 25.60 4.061 58 0.193 1.262 0.213 –0.028 0.122

Glug/l 1.48 0.682 58 0.250 1.842 0.071 –0.033 0.762

LDLg/l 1.53 0.655 58 0.273 1.808 0.077 –0.046 0.874

HDLg/l 0.31 0.863 58 –0.287 –1.914 0.061 –0.679 0.017

Tobacco 0.43 0.500 58 0.133 0.762 0.450 –0.434 0.963

HTA 0.55 0.502 58 –0.008 –0.048 0.962 –0.684 0.652

SD:standarddeviation;B:standardizedcoefficientBeta;P:signification;IC:confidenceinterval;t:studenttest.

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Correlationbetweenplasmafibrinogenconcentrationandbothage,BMIandbiochemicalparameters(testissignificantatP-value<0.05).

G1(n=30) G2(n=30) G3(n=30) G4(n=30)

r P r P r P r P

Age(years) −0.29 0.87 0.06 0.76 0.17 0.37 0.77 0.0001^**

MI(kg/m²) 0.15 0.44 0.10 0.58 0.05 0.8 0.76 0.0001^**

Glu(g/L) 0.03 0.8 0.25 0.2 0.04 0.8 0.39 0.035^*

HDL(g/L) −0.04 0.06 −0.01 0.9 0.13 0.5 0.03 0.9

LDL(g/L) −0.12 0.5 0.12 0.6 0.39 0.035^* −0.23 0.3

TG(g/L) 0.02 0.9 0.09 0.6 −0.11 0.5 0.08 0.7

* Significant.

**Verysignificant.

prognosisrolethat fibrinogenmayhaveincoronarydiseases.

Theassociationoffibrinogenwithcardiovascularriskwassta- tisticallysignificantwhenallgroupswerepooledforstatistical analysis.Manystudiesconfirmedourresults[23–25].Inpatients withonlyT2D,thefibrinogenincreasedaccordingtocardiovas- cularrisk,butthisincreasewasnotstatisticallysignificant.In each groupnoassociation wasfoundbetweenfibrinogen and CVD;suchobserveddifferencesmaybeduetotheselectionof thevariousgroups.Ontheotherhand,theseincreasesappeared proportionaltoNSTE-ACSandunstableanginaparticularlyin T2Dcoronarypatients.Eventhoughthemechanismsbywhich fibrinogenincreasescardiovascularriskarenotfullyunderstood, theymayincrease CVRinseveral ways. Fibrinogen, besides beingtheprecursorforfibrin[26],isanacutephasereactant,a keyplayerinthecoagulationcascade,whichpromotesatheroge- nesisandthrombogenesis.Fibrinolysisismediatedbyplasmin, whichcirculatesinbloodasitsproenzyme,plasminogen,which isaprocessmediatedinpartbytissue-typeplasminogenacti- vators (tPA). Activation of the fibrinolytic system results in the degradation of fibrin clots and is influenced mainly by these 2 factors, tPAand PAI-1 [27]. Increased concentration of circulatingPlasminogen activatorinhibitor-1(PAI-1) leads tohypofibrinolysis,astateinwhichremoval ofthrombi from thevascularsystemisimpaired.Tissue-typeplasminogenacti- vator antigen circulates in blood largely bound toPAI-1. As PAI-1levelsincrease,ahigherproportionoftPAiscomplexed withPAI-1.The enzymaticallyinactivePAI-1/tPA complexes haveadelayedclearancecomparedwiththatofactive,freetPA.

Therefore,thetotalplasmatPAconcentrationincreases,along withthat of plasma tPAand PAI-1[28] because it is widely heldthattPAantigenconcentrationsareparadoxicallyinversely

relatedtofibrinolyticsystemactivity[28,29].D-dimerisanother powerfulmodulatorofthecoagulationsystem;itistheprimary breakdownproductformedwhenplasminactsoncross-linked fibrinandisconsideredahemostasismarkerofongoingfibrin formationanddegradation[30,31].

Other epidemiological studies in adults have shown that PAI-1isassociatedwithexcesscardiovascularriskandtype2 diabetesmellitus[27,32],andreducedbloodfibrinolyticactivity.

ElevatedplasmaPAI-1activity,PAI-1antigen,andtPAantigen are associatedwithanincreasedriskof myocardialinfarction [33].

Ourstudyreportedthattheplasmafibrinogenconcentration washigherinNSTE-ACSthanSTE-ACS,whichsuggestsarole for fibrinogen inthe pathophysiologyof acute coronarysyn- drome.Wefoundnoassociationwiththenumbersofaffected coronary truncus,butthismayberelatedtothelimited number of patients included inthis study. Thisshould befurther investigatedinalargecohort.

Inthepresentstudy,theassociationoffibrinogenwithboth ageandBMIwassignificantinthecontrolgroup,butnoassoci- ationwasfoundwithgender.Increasedfibrinogenconcentration mayalsobeamechanismbywhichobesityincreasestherisk ofcardiovasculardisease[23].Indeed,reductioninbodymass indexafteralow-caloriedietfor6monthshasbeenaccompanied byafallinfibrinogenlevel[34].

Our study showed that, fibrinogen was higher in T2D coronary patients compared to non-T2D coronary patients or non-coronayT2D patients as compared to control healthy patients.Thesefindingsareinagreementwithpreviousstudies [10,23,36].Plasmafibrinogenconcentrationwashigheramong patients with hyperglycemia assessed by HbA1c; this result

Table6

Averageplasmafibrinogenconcentration(g/L)indifferentgroups.

Groups Mean n SD Sumofsquares df Meansquare F P

G1 3.46 30 0.86

G2 3.73 30 1.11

G3 3.06 30 0.98

G4 2.46 30 0.51

Total 3.18 120 1.004

Betweengroups(combined) 27.3 3 9.1 11.39 0.0001^**

**Verysignificant.

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wasalsoreportedbymostpreviousstudies[10,23,36].Indeed, subjectswithdiabetesmellitushavebeenfoundtohavehyper- reactive platelets. This platelet hyperreactivity may result in partfromincreased fibrinogenlevelsassociated withdiabetes becausefibrinogenactsasacrossbridgebetweenplatelets.Poor diabeticcontrolhasalsobeenassociatedwithhigherlevelsof fibrinogen[37].

Inourstudy,theassociationoffibrinogenwithdiabetesdura- tionwassignificant.Thisresultwasn’tmentionedintheRafle et al. and Soliman studies [10,38]. The correlation between fibrinogenandLDLcholesterolwassignificantinthepatients withT2D only. Nakbi etal. [39]confirmed the sameresults withoxidized LDL [39].The correlation between fibrinogen andlowdensitylipoproteinsuggeststhattheincreasedriskof cardiovasculardiseaseassociatedwithelevatedLDLlevelsmay bemediatedinpartthroughfibrinogen.Inadvancedatheroscle- rotic plaques, fibrin participates in the close linkage of low densitylipoprotein(LDL)andlipidaccumulation,leadingtothe creationofthelipidnucleusofatheroscleroticlesions[40,41].

TheProspectiveCardiovascularMunster(PROCAM)[42]study foundthat individualswhohadLDLandfibrinogen levels in the highest tertile had a 6.1-fold increase of coronary risks comparedtothoseinthelowesttertile.Theeventratewassigni- ficantlylowerwhenfibrinogenlevelswereinthelowesttertile eventhoughLDLremainedinthehighest tertile.No correla- tionwasfoundbetweenfibrinogenandbothHDLandTG,this resultcorrespondedwiththosementionedintheothersstudies [10,24].

Theassociationoffibrinogenwithhypertensionandsmoking wasfound inthisandotherstudies[10,23,43] (Fogariet al).

[44]foundthatfibrinogenlevelsincreasedwiththenumberof cigarettessmoked.Fibrinogenlevelsalsoquicklyreducedafter smokingcessation,suggestingthatthisrapidlevelreductionmay be amechanism for a reduction of cardiovascular risks after smokingcessation.

4.2. Comparisonwithotherstudies

In some studies who focused on the role that may be playedby fibrinogen incoronary disease, we noticed several divergencesin results.Several studies demonstrateda strong association withthe presenceof CHD,while othersfailed to showany significantassociation. Althoughmost ofthe avail- abledatafavorsthe involvementof fibrinogen inCHD,there is still evidence against this hypothesis. Indeed Smith et al.

[6] performed a meta-analysis of case-control and prospec- tivestudies.The19studiesincluded 12,393casesand21,649 controlsandprospective studiesof the investigated G-4553A andC-1483T ␤-fibrinogen promoterregion variants,in rela- tiontocoronaryheartdisease(CHD)risks.Theysuggestedthat loweringthe fibrinogen level maynot, initself,reduce CHD risks.

Incontrast,thestudyofKengneetal.[35]included33,091 individuals(17,965female)takenfromnineprospectiveBritish studies comprised of Scottish Health Surveys (six cohorts:

1994,1998,1999,2000,2003and2004)andtheHealthSurveys forEngland(threecohorts:1995,1998and2003).Fibrinogen

concentrations were determined with a modification of the Claussthrombinclottingmethod.Itwasconcludedinthesestud- iesthattherisk ofmyocardialinfarctionandstrokeincreased progressivelywithfibrinogenlevelsalongwithPlevels.

Stec et al. [23] included 2632 subjects in their study;

fibrinogen levels were determined with a newly developed immunoprecipitationtest(AmericanBiogeneticSciences)and the functional Clauss method. They reported that with the immunoprecipitation method and after covariate adjustment, fibrinogenremainedsignificantlyhigherinthosewithcardiovas- culardiseasetest(P=0.035andP=0.018formenandwomen, respectively).Withtheimmunoprecipitationmethod,therewere significantlineartrendsacrossfibrinogentertiles(P=0.001)for age,bodymassindex,smoking,diabetesmellitus,totalcholesterol,HDLcholesterol,andtriglyceridesinmenandwomen.The Claussmethodprovidedsignificantresults(P=0.030),except for triglyceridesinmen.In addition,theimmunoprecipitation testshowedastrongerassociationwithcardiovasculardisease than the Clauss method, suggesting that it may be a useful screeningtooltoidentifyindividualswithincreasedthrombotic risk.

In our study fibrinogen was performed with the Clauss methodandpatientswithdiabetesand/orcoronarydiseasewith- out others complications were included. We found that the associationoffibrinogenwithdiabetesdurationwassignificant.

ThisresultwasnotmentionedbysomeauthorssuchasSoliman etal.,whoanalyzedthefibrinogenthroughtheWottenmethod inmicroalbuminuricT2Dpatients.

The discrepancy between the different results can be explained, either by the selected sampling, or by subdivided groupaccordingtogenderandageorbytheanalysismethod.

Ontheotherhandfibrinogenseemstoobeytoadoubleenviron- mentalandgeneticdeterminism[5,8,9].Thereareseveralgene polymorphismsoffibrinogenchains,recognizedduringthelast decade,whichseemtoaffectfibrinogenlevelsandconsequently thepresenceofcardiovasculardiseases[9].

4.3. Studylimitations

There are some limitations to our study that have to be mentioned. The patients were included without taking into considerationneither the socialand economicalstatus of the subjects, no ethnic and racial factors, nor any psychological problems anddiets rich in high-fattyacids. All thesefactors mayaffecttheplasmafibrinogenconcentration.

5. Conclusion

The fibrinogen presented an association with clinical and para-clinicalcoronarydiseaseseverityandwithcardiovascular risks.Moreover,thecorrelationbetweenfibrinogenandthelow densitylipoprotein(LDL)wassignificantinpatientswithT2D, whichhadahigherplasmafibrinogenconcentrationthaninthe controlgroup.Theresultsallowedusthereforetoconcludethat fibrinogencouldbeconsideredasaprognosisorseverityfactor ofcoronarydiseaseinMoroccanpatientswithtype2diabetes.

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Theauthorsdeclarethattheyhavenocompetinginterest.

Acknowledgement

ThisworkwasconductedincollaborationwiththeUniversity HospitalCenter.

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