K. Shimada has received lecture fees from Daiichi-Sankyo Pharmaceutical Company Ltd., and Takeda Pharmaceutical Company Ltd. Department of Molecular Medicine and Cardiology was endowed by Kowa Pharmaceutical Co Ltd (to N.O. and K.O.). H. Daida has received remuneration for lectures from Amgen Astellas Biopharma K.K., Astellas Pharma Inc., AstraZeneca Pharma Ltd., GlaxoSmithKline K.K., Sanofi K.K., Shionogi, Daiichi-Sankyo Pharmaceutical Company Ltd., Takeda Pharmaceutical Company Ltd., Terumo Corporation, Medtronic plc., Boehringer Ingelheim GmbH., Bayer AG., and MSD K.K., trust research and joint research funds from Kowa Pharmaceutical Company Ltd., Daiichi-Sankyo Company Ltd., Canon Medical Systems Corporation, Nihon Medi-Physics Company Ltd., Kaken Pharmaceutical Company Ltd., Kirin Holdings Company Ltd., Philips Respironics Ltd., Sanwa Kagaku Kenkyusho Company Ltd., and St. Jude Medical Japan Company Ltd., and scholarship fund from Astellas Pharma Inc., Abbott Laboratories, Otsuka Pharmaceutical Company Ltd., Sanofi K.K., Shionogi & Company Ltd., Sumitomo Dainippon Pharmaceutical Company Ltd., Boehringer Ingelheim GmbH., Bayer AG., Teijin Ltd., Daiichi-Sankyo Company Ltd., Takeda Pharmaceutical Company Ltd., MSD K.K., Tanabe Mitsubishi Pfizer Pharmaceutical Company Ltd., Philips Respironics Ltd., Bristol-Myers Squibb Company Ltd., Boston Scientific Ltd., St. Jude Medical Japan Company Ltd., and Actelion Pharmaceuticals Japan Ltd. He has been in affiliation with some endowed departments including VitalAire Japan Company K.K., Philips Respironics Ltd., Fukuda Denshi Company Ltd., ResMed Ltd. The remaining authors report no conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
Follistatin-like 1 (FSTL1) is a glycoprotein secreted by skeletal muscle cells and cardiac myocytes. Previous studies showed that serum FSTL1 concentrations were increased in acute coronary syndrome and chronic heart failure. The aim of this study was to assess the associations among plasma FSTL1 concentration, clinical parameters, and whether FSTL1 concentration could predict cardiovascular events in patients with elective percutaneous coronary intervention (PCI).
A consecutive series of 410 patients who underwent elective PCI with drug-eluting stents (DES) were enrolled between August 2004 and December 2006 at Juntendo University hospital. We measured plasma FSTL1 levels prior to elective PCI and assessed the association among FSTL1 levels, clinical parameters, and occurrence of major adverse cardiac or cerebrovascular events (MACCE) defined as cardiac death, nonfatal myocardial infarction, unstable angina, stroke, and hospitalization for heart failure. FSTL1 concentration was positively correlated with high-sensitivity C-reactive protein (hsCRP), serum creatinine, and N-terminal pro b-type natriuretic peptide (all
High plasma FSTL1 may be a predictor of cardiovascular events in patients who underwent elective PCI with DES, especially with preserved renal function and low hsCRP.
Follistatin-like 1 (FSTL1) is a glycoprotein, also known as transforming growth factor (TGF)-β1–stimulated clone 36 (TSC-36) [
A consecutive series of 410 patients who underwent elective PCI with first-generation drug-eluting stents (DES) were enrolled at Juntendo University Hospital between August 2004 and December 2006. Patients with ACS, malignant disease, apparent inflammatory disease, active liver disease and/or liver cirrhosis, or acute decompensated heart failure (ADHF) were excluded. The study protocol conforms to the ethical guidelines of the Declaration of Helsinki. The study was approved by the ethics committee of Juntendo University Hospital, and written informed consent was obtained from all patients before participation.
We measured plasma FSTL1 levels prior to elective PCI on the same day. We collected blood samples in the operating room just before the elective PCI was performed, and after centrifugation, the plasma samples were stored at − 80°C. We assessed the association between FSTL1 levels and clinical parameters.
Demographic data, coronary risk factors, and medication were collected from our institutional database. Blood samples were collected early in the morning after fasting overnight. Plasma total cholesterol (TC) and creatinine were assayed by standard enzymatic methods. Triglycerides (TG) were assayed by visible absorption spectrometry, high-density lipoprotein cholesterol (HDL-C) levels by the direct method, and low-density lipoprotein cholesterol (LDL-C) was determined the Friedewald formula [
Blood pressure (BP) was measured on admission with a mercury sphygmomanometer. Hypertension was defined as a systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or the current use of antihypertensive medications. Dyslipidemia was defined as LDL-C ≥ 140 mg/dL, HDL-C < 40 mg/dL, TGs ≥ 150 mg/dL, or current treatment with statins and/or other lipid-lowering medications. Diabetes mellitus was defined as either HbA1c ≥ 6.5% or current use of insulin or oral hypoglycemic drugs. Chronic kidney disease (CKD) required a creatinine clearance (CCr < 60 mL/min) and was calculated with the Cockroft-Gault equation as [(140 − age) × weight (kg) / 72 × serum creatine (mg/dL)]. For women, the result was multiplied by 0.85 [
Coronary angiography was performed on all patients at baseline. Clinically significant stenosis was measured by the number of stenotic vessels recorded as 1-, 2-, or 3-vessel disease (> 75% narrowing) or as stenosis of the left main coronary artery (> 50% narrowing). All procedural decisions, including device selection and adjunctive pharmacotherapy, were made at the discretion of each PCI operator. Intravenous unfractionated heparin and intracoronary nitroglycerin were administered before PCI procedures. Angiographic optimization of stent implantation was performed using high-pressure dilatation to achieve an acceptable angiographic result. Intravascular ultrasound was performed at the operator’s discretion. Procedural success was defined as residual stenosis of < 20% without major complications. Dual antiplatelet therapy with 100 mg aspirin and 200 mg ticlopidine or 75 mg clopidogrel was prescribed for all patients implanted with a DES for at least 1 year.
The study participants were followed at our hospital or affiliated hospitals until March 2011. The outcomes of patients who died were retrieved from their medical records. Clinical outcomes were collected from the medical records of patients who died. MACCE is defined as cardiac death, ACS, stroke, and hospitalization for ADHF. ACS was defined as unstable angina pectoris (UAP), non-ST segment elevation myocardial infarction (NSTEMI), or ST segment elevation myocardial infarction (STEMI). Myocardial infarction was defined as a ≥ 2-fold increase in serum creatine kinase and troponin T positivity. UAP was diagnosed as angina at rest or in an accelerating pattern with negative cardiac biomarkers with or without electrocardiogram (ECG) changes indicative of myocardial ischemia. ADHF was defined by the Framingham study criteria [
Continuous variables were expressed as means ± standard deviation (SD) or medians with 25th and 75th percentiles. Categorical variables were reported as percentages. Between-group differences were compared with the unpaired Student’s
The characteristics of the 410 study participants are shown in
Parameters | Subjects (n = 410) |
---|---|
Age, (years) | 65.6 ± 8.7 |
Male, n (%) | 352 (85.9) |
Body mass index (kg/m2) | 24.2 ± 3.2 |
Hypertension, n (%) | 308 (75.1) |
Dyslipidemia, n (%) | 298 (72.7) |
Diabetes mellitus, n (%) | 218 (53.2) |
Current smoking, n (%) | 100 (24.4) |
ESKD (CCr < 15/mL/min), n (%) | 21 (5.1) |
Previous myocardial infarction, n (%) | 121 (29.6) |
Previous PCI, n (%) | 166 (40.6) |
Previous CABG, n (%) | 53 (13.0) |
No. of diseased vessels | |
One, n (%) | 133 (32.5) |
Two, n (%) | 149 (36.3) |
Three, n (%) | 128 (31.2) |
Stenosis of LMT, n (%) | 11 (2.7) |
Multi vessel disease, n (%) | 277 (67.6) |
Target lesion | |
LAD, n (%) | 176 (42.9) |
LCX, n (%) | 99 (24.2) |
RCA, n (%) | 124 (30.2) |
LMT, n (%) | 11 (2.7) |
Bifurcation lesion, n (%) | 33 (8.1) |
Number of stents | |
One, n (%) | 322 (78.5) |
Two, n (%) | 74 (18.1) |
Three, n (%) | 13 (3.2) |
Four, n (%) | 1 (0.2) |
Total cholesterol (mg/dL) | 175 ± 33 |
LDL-cholesterol (mg/dL) | 107 ± 30 |
Triglyceride (mg/dL) | 129 ± 65 |
HDL-cholesterol (mg/dL) | 44 ± 12 |
Fasting blood glucose (mg/dL) | 112.3 ± 38.5 |
Hemoglobin A1c (%) | 6.6 ± 1.3 |
Creatinine (mg/dL) | 1.3 ± 2.0 |
Creatinine clearance (mL/min) | 74.8 ± 28.6 |
High-sensitivity CRP (mg/dL) | 0.080 (0.037, 0.21) |
NT-proBNP (pg/mL) | 136.9 (62.8, 436.8) |
Follistatin-like 1 (ng/mL) | 69.1 ± 62.7 |
Left ventricular ejection fraction (%) | 60.8 ± 11.5 |
Medications | |
Antiplatelet, n (%) | 410 (100) |
Calcium channel blocker, n (%) | 165 (40.2) |
β-blocker, n (%) | 236 (57.6) |
ACE inhibitor or ARB, n (%) | 202 (49.3) |
Diuretic, n (%) | 35 (8.5) |
Statin, n (%) | 231 (56.3) |
Values are means ± SD, or medians (25th–75th percentile); ESKD, end stage kidney disease; CCr, creatinine clearance; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; LMT, left main trunk; LAD, left anterior descending artery; LCX, left circumflex; RCA, right coronary artery; LDL, low-density lipoprotein; HDL, high-density lipoprotein; CRP, C-reactive protein; NT-proBNP, N-terminal pro B-type natriuretic peptide; ACE, angiotensin converting enzyme; ARB, angiotensin II receptor blocker.
Age | 0.10 | < 0.05 |
Body mass index | −0.04 | 0.46 |
Creatinine | 0.27 | < 0.0001 |
Creatinine clearance | −0.23 | < 0.0001 |
Hemoglobin A1c | −0.08 | 0.09 |
Total cholesterol | −0.06 | 0.23 |
LDL-cholesterol | −0.02 | 0.74 |
Triglyceride | −0.04 | 0.42 |
HDL-cholesterol | −0.18 | < 0.001 |
Log High-sensitivity CRP | 0.26 | < 0.0001 |
Log NT-proBNP | 0.29 | < 0.0001 |
LVEF | −0.08 | 0.15 |
Single linear regression analysis association with Log FSTL1. FSTL1, follistatin-like 1; LDL, low-density lipoprotein; HDL, high-density lipoprotein; CRP, C-reactive protein; NT-proBNP, N-terminal pro-B-type natriuretic peptide; LVEF, left ventricular ejection fraction.
In line with previous reports, FSTL1 was elevated in patients with CKD and/or high levels of systemic inflammation [
Those with CCr < 60 mL/min and hsCRP ≥ 0.2 mg/dL were excluded. During a median 5.1-year follow-up, 20 patients experienced MACCE. CAD, coronary artery disease; PCI, percutaneous coronary intervention; hsCRP, high-sensitivity C-reactive protein; CCr, creatinine clearance; MACCE, major adverse cardiac or cerebrovascular events; ACS, acute coronary syndrome; CHF, congestive heart failure.
Kaplan–Meier analysis revealed that the MACCE rate was significantly higher in patients with FSTL1 (≥ 41.1 ng/mL) than in those FSTL1 < 41.1 ng/mL (
All patients |
No MACCE |
MACCE |
||
---|---|---|---|---|
Age, (years) | 63.8 ± 7.9 | 64.0 ± 7.9 | 61.6 ± 8.0 | 0.13 |
Male, n (%) | 189 (88.3) | 173 (89.2) | 16 (80.0) | 0.26 |
Body mass index (kg/m2) | 24.6 ± 2.9 | 24.5 ± 2.8 | 25.2 ± 3.3 | 0.45 |
Hypertension, n (%) | 164 (76.6) | 147 (75.8) | 17 (85.0) | 0.42 |
Dyslipidemia, n (%) | 157 (73.4) | 141 (72.7) | 16 (80.0) | 0.60 |
Diabetes mellitus, n (%) | 115 (53.7) | 101 (52.1) | 14 (70.0) | 0.15 |
Current smoking, n (%) | 49 (22.9) | 42 (21.7) | 7 (35.0) | 0.17 |
Previous MI, n (%) | 63 (29.4) | 55 (28.4) | 8 (40.0) | 0.30 |
Previous PCI, n (%) | 89 (41.6) | 77 (39.7) | 12 (60.0) | 0.09 |
Previous CABG, n (%) | 26 (12.2) | 24 (12.4) | 2 (10.0) | 0.99 |
No. of diseased vessels | 0.80 | |||
One, n (%) | 78 (36.5) | 72 (37.1) | 6 (30.0) | |
Two, n (%) | 71 (33.1) | 64 (33.0) | 7 (35.0) | |
Three, n (%) | 65 (30.4) | 58 (29.9) | 7 (35.0) | |
Stenosis of LMT, n (%) | 5 (2.3) | 4 (2.1) | 1 (5.0) | 0.40 |
Multi vessel disease, n (%) | 136 (63.6) | 122 (62.9) | 14 (70.0) | 0.63 |
Target lesion | 0.71 | |||
LAD, n (%) | 91 (42.5) | 82 (42.2) | 9 (45.0) | |
LCX, n (%) | 57 (26.7) | 51 (26.3) | 6 (30.0) | |
RCA, n (%) | 61 (28.5) | 57 (29.4) | 4 (20.0) | |
LMT, n (%) | 5 (2.3) | 4 (2.1) | 1 (5.0) | |
Bifurcation lesion, n (%) | 16 (7.5) | 15 (7.7) | 1 (5.0) | 0.99 |
Number of stents | 0.058 | |||
One, n (%) | 176 (82.3) | 161 (83.0) | 15 (75.0) | |
Two, n (%) | 33 (15.4) | 30 (15.5) | 3 (15.0) | |
Three, n (%) | 5 (2.3) | 3 (1.5) | 2 (10.0) | |
Total cholesterol (mg/dL) | 173 ± 31 | 173 ± 31 | 176 ± 31 | 0.58 |
LDL-cholesterol (mg/dL) | 106 ± 28 | 106 ± 28 | 106 ± 28 | 0.90 |
Triglyceride (mg/dL) | 128 ± 61 | 125 ± 57 | 160 ± 85 | < 0.05 |
HDL-cholesterol (mg/dL) | 44 ± 11 | 45 ± 11 | 40 ± 10 | 0.065 |
Hemoglobin A1c (%) | 6.6 ± 1.4 | 6.5 ± 1.4 | 7.3 ± 1.8 | < 0.05 |
Creatinine (mg/dL) | 0.83 ± 0.17 | 0.83 ± 0.17 | 0.82 ± 0.17 | 0.70 |
CCr (mL/min) | 85.6 ± 21.7 | 85.0 ± 20.5 | 91.7 ± 31.1 | 0.48 |
High-sensitivity CRP (mg/dL) | 0.052 (0.028, 0.092) | 0.052 (0.026, 0.092) | 0.061 (0.032, 0.11) | 0.31 |
NT-proBNP (pg/mL) | 90 (45, 200) | 83 (44, 180) | 189 (80, 794) | < 0.01 |
FSTL1 (ng/mL) | 57.0 ± 48.5 |
54.0 ± 40.5 |
86.0 ± 93.8 |
< 0.01 |
LVEF (%) | 62.3 ± 10.3 | 62.8 ± 10.1 | 57.2 ± 11.6 | < 0.05 |
Medications | ||||
Antiplatelet, n (%) | 214 (100) | 194 (100) | 20 (100) | 1.0 |
CCB, n (%) | 86 (40.2) | 78 (40.2) | 8 (40.0) | 1.0 |
β-blocker, n (%) | 128 (59.8) | 118 (60.8) | 10 (50.0) | 0.35 |
ACE inhibitor or ARB, n (%) | 110 (51.4) | 97 (50.0) | 13 (51.4) | 0.24 |
Diuretic, n (%) | 13 (6.1) | 7 (3.6) | 6 (30.0) | < 0.001 |
Statin, n (%) | 127 (59.3) | 113 (58.3) | 14 (70.0) | 0.34 |
Values are means ± SD, or medians (25th–75th percentile), MACCE, major adverse cardiac or cerebrovascular events; MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; LMT, left main trunk; LAD, left anterior descending artery; LCX, left circumflex; RCA, right coronary artery; LDL, low-density lipoprotein; HDL, high-density lipoprotein; CCr, creatinine clearance; CRP, C-reactive protein; NT-proBNP, N-terminal pro-B-type natriuretic peptide; FSTL1, follistatin-like 1; LVEF, left ventricular ejection fraction; CCB, calcium channel blocker; ACE, angiotensin converting enzyme; ARB, angiotensin II receptor blocker.
Univariate | Multivariate | |||||
---|---|---|---|---|---|---|
HR | 95% CI | HR | 95% CI | |||
Age, 1year increase | 0.96 | 0.91–1.02 | 0.16 | 0.97 | 0.91–1.03 | 0.28 |
Gender (Male) | 0.50 | 0.18–1.75 | 0.24 | 0.37 | 0.11–1.50 | 0.12 |
Body mass index, 1kg/m2 increase | 1.10 | 0.94–1.25 | 0.20 | 1.04 | 0.88–1.20 | 0.65 |
Triglyceride, 1 mg/dL increase | 1.01 | 1.00–1.01 | <0.05 | 1.01 | 0.99–1.01 | 0.08 |
Hemoglobin A1c, 1% increase | 1.28 | 1.00–1.57 | <0.05 | 1.03 | 0.75–1.37 | 0.82 |
NT-pro BNP, 1 pg/mL increase | 1.001 | 1.000–1.002 | <0.01 | 1.001 | 0.999–1.002 | 0.41 |
Diuretic usage | 6.90 | 2.44–17.22 | <0.001 | 2.98 | 0.51–13.38 | 0.21 |
FSTL1 ≥ 41.1 ng/mL | 5.43 | 1.82–23.25 | <0.01 | 4.54 | 1.45–20.07 | <0.01 |
MACCE, major adverse cardiac or cerebrovascular events; HR, hazard ratio; CI, confidence interval; NT-proBNP, N terminal pro brain natriuretic peptide; FSTL-1, follistatin-like 1.
The present study demonstrated that plasma FSTL1 was significantly increased in CKD patients and was positively correlated with hsCRP in patients with CAD. After excluding patients with CKD and relatively high systemic inflammation, those with FSTL1 ≥ 41.1 ng/mL had a significantly higher rate of MACCE occurrence than those with FSTL1 < 41.1 ng/mL. High plasma FSTL1 predicted cardiovascular events in patients who underwent elective PCI with first-generation DES, especially with preserved renal function and relatively low-grade systemic inflammation.
Although the effects of Fstl1 in cardiovascular and inflammatory disorders have been previously demonstrated in basic studies including animal models, clinical function and evidence of FSTL1 are limited. Widera et al. reported that serum FSTL1 levels were significantly higher and related to all-cause mortality in patients with ACS [
In this study, plasma FSTL1 ≥ 41.1 ng/mL was associated with MACCE including those patients admitted with ADHF. El-Armouche et al. reported that serum FSTL1 levels were significantly increased in chronic HF patients with reduced systolic function and was associated with LVH and NT-proBNP [
The function of FSTL1 in the cardiovascular system seems to be poorly understood in patients with cardiovascular disease. It is still unknown whether a high plasma FSTL1 concentration simply reflects underlying disease processes or has a maladaptive and/or compensatory role in modulating the pathogenesis of cardiac dysfunction in patients with cardiovascular disease. Fstl1 is secreted by skeletal muscle cells and cardiac myocytes in response to hypertrophy and ischemic injury [
This study had several limitations. First, the study was conducted in a single institution and the study population was relatively small. Studies with a larger sample size, racial diversity, and multicenter will be required to better define the role of plasma FSTL1 as a prognostic biomarker for patients with stable CAD. Second, we measured plasma FSTL1 level only in patients with CAD. Further studies are needed to assess the role of FSTL1 on the initiation of CAD. Third, we measured plasma FSTL1 levels just before elective PCI. We did not assess the changes in plasma FSTL1 levels between the baseline and follow-up. Fourth, the sample size for women was relatively small. However, it tended to be similar to the proportion of men and women reported in a previous study [
A high plasma FSTL1 concentration may be a predictor of cardiovascular events only in patients with CAD who underwent elective PCI with DES and with preserved renal function and a relatively low-grade inflammatory state. Future studies are needed to validate its usefulness as a biomarker in patients with CAD.
Patients with CCr < 60 mL/min had higher mean plasma FSTL1 than those with CCr ≥ 60 mL/min. FSTL1 levels were expressed as medians with the 25th and 75th percentiles. FSTL1, follistatin-like 1; CCr: creatinine clearance.
(TIF)
Kaplan–Meier analysis revealed that the MACCE rate was significantly higher in patients with FSTL1 (≥ 43.2 ng/mL) than in those FSTL1 < 43.2 ng/mL (
(TIF)
Kaplan–Meier analysis showed a trend but not a significant difference was noted among the three groups based on the tertiles FSTL1 levels. FSTL1, follistatin-like 1; MACCE, major adverse cardiac or cerebrovascular events.
(TIF)
Receiver operating characteristics curve analysis estimated that an FSTL1 concentration of 41.1 ng/mL (area under the curve 0.68) had a sensitivity of 85% and specificity 49% for predicting MACCE (
(TIF)
MACCE, major adverse cardiac or cerebrovascular events; HR, hazard ratio; CI, confidence interval; NT-proBNP, N terminal pro brain natriuretic peptide; FSTL-1, follistatin-like 1.
(DOCX)
We gratefully thank for the technical assistance of Yoko Inoue and Minako Tatsumi.