**Meet the editor**

Suna F. Kıraç, MD, Prof, FASNC, completed her post graduation in three steps. First, she got a title of internal medicine specialist and then she educated in nuclear medicine. Later, she studied in nuclear Cardiology Lab in Yale University Medical School, USA and got nuclear cardiology certificate. Prof. Kiraç is a fellow of ASNC. She is generally interested in nuclear cardiology and car-

diac imaging. Currently she is the editor in chief consultant of Anatolian J Cardiology and is responsible for ethical issues, in addition to being a part of the editorial boards of medical journals. Prof. Kiraç contributed as an attendant, presenter and speaker to national and international congress, symposium and courses on nuclear medicine, cardiology, nuclear cardiology and other related subjects.

Her publications in the national and international journals are on general nuclear medicine and cardiac imaging subjects. She has five printed books and book chapters one of which got mansion award from The Turkish Academy of Sciences in 2011.

Contents

**Preface IX**

Chapter 1 **Mechanisms of Disease:**

Chapter 5 **Coronary Angiography -**

Jasmin Čaluk

**Novel Polymorphisms in Coronary Artery Disease 1**  Asghar Ghasemi, Morteza Seifi and Mahmood Khosravi

Katsuhito Mori, Masanori Emoto and Masaaki Inaba

Ryotaro Wake, Minoru Yoshiyama, Hidetaka Iida,

Hitoshi Kanamitsu, Hideya Mitsui, Yukio Yamada,

Chapter 2 **Multifunctional Role of TRAIL in Atherosclerosis and Cardiovascular Disease 19**

Chapter 3 **Indications for Coronary Angiography 33**  Karl Poon and Darren Walters

Hiroaki Takeshita, Takanori Kusuyama,

Shinichi Shimodozono and Kazuo Haze

**Physical and Technical Aspects 81**

Chapter 6 **Procedural Techniques of Coronary Angiography 95**

Chapter 7 **Risks and Complications of Coronary Angiography: Contrast Related Complications 121**

Mariano García-Borbolla, Rafael García-Borbolla

Chapter 8 **Complications of Cardiac Catetherization 149**

Chapter 9 **Diagnosis and Management of Complications of Invasive Coronary Angiography 169**

Jong-Seon Park and Young-Jo Kim

Chapter 4 **History of Coronary Angiography 69**

Maria Anna Staniszewska

S. Mohammad Reza Khatami

and Begoña Balboa

## Contents

### **Preface XI**

X Contents

## Preface

Coronary artery disease (CAD) and its consequences are the most important morbidity and mortality reasons in the developed and developing countries. Advanced imaging techniques (intravascular ultrasound, MR and CT angiography, SPECT/CT, PET/CT, PET/MRI) and novel serologic biomarkers (C-reactive protein, interleukin 6, matrix metalloproteinase, P-selectin, intracellular adhesion molecule 1 and tumor necrosis factor ) provide early diagnosis of CAD and protect patients from hard cardiac events. Non-invasive techniques are being widely used in the diagnosis and management while conventional CAG is still the most commonly performed test in the cases at high risk. Following the first cardiac catheterization performed, first selective CAG has been reported at the end of 1950's. Patient specific and procedure-related complications range widely from minor ones with short term sequelae to life threatening events that may cause irreversible end-point if urgent treatment is not adequately provided. The important risk factors for complications are older age, renal insufficiency, uncontrolled diabetes mellitus, morbid obesity, and iodine allergy. However, operator skills and the type of invasive procedure being performed remain as the most important predictors to undesired outcomes. The risk-to-benefit ratio of the CAG should be considered carefully on an individual basis.

Coronary CTA and CMRA among advanced imaging systems offer anatomical informations not only for coronary vessels but also for peripheral vascular structures, and assessment of the left and right ventricular functions is possible in same image series. Quantified coronary artery calcification and many post-processing images (2-D images and the different 3-D rendering images such as volume rendering, multiplanar reformation, partial maximum intensity projection, curved multiplanar reformation) should be evaluated to increase diagnostic accuracy. High calcification level signs atherosclerotic changes in the coronary arteries, but is not specific for luminal obstruction. Because the absence of detectable calcium deposition has a high negative predictive value for CAD, CAC value is a significant predictive determinant for prognosis in asymptomatic patients. As with coronary angiography, myocardial perfusion abnormality may not be detected even there is coronary lesion causing a luminal narrowing of greater than 50 % defined by CTA and MRA. In asymptomatic and intermediate likelihood patients, assessment of myocardial perfusion by single photon emission computed tomography (SPECT) or positron emission tomography (PET) appears to be valuable even when coronary arteries are normal in angiography.

#### X Preface

If gated study is added, left ventricular systolic and diastolic functions can be investigated simultaneously with myocardial perfusion. This field includes a overview of molecular targeted imaging, permeability of the coronary vessel wall, and interventional coronary MR. Recent developments in the field of ultrasonography have allowed us to objectively quantify global and regional ventricular function, and also, to get real-time evaluation of coronary walls and calcium load of atherosclerotic plaques. While we achieve more knowledge about atherosclerotic lesions by IVUS, tissue Doppler imaging has attempted us to assess myocardial function.

Preface XI

disadvantages and possible complications of invasive and non-invasive cardiac procedures, and test selection criteria based on patient's characterizations, mechanism and definition of contrast induced nephropathy (CIN) and preventive therapy models

Consequently, this book summarized the clinics of atherosclerotic heart diseases, pathogenesis covering possible genetic factors and risk factors, a current view on new biomarkers as a diagnostic, prognostic parameters and future complications, novel diagnostic imaging modalities for CAD, and their advantages and disadvantages. Insight to molecular basis of CAD in a special chapter focusing on the role of on TRAIL (Tumor necrosis factor (TNF)-related apoptosis-inducing ligand) in the cardiovascular disease is really interesting and useful to understand how atherosclerotic plaques occur and what the importance of administration of

**Suna F. Kraç**

Turkey

Pamukkale University, Faculty of Medicine, Denizli

recombinant TRAIL in protective therapy as a powerful approach.

in one more chapters of this task.

On the other hand, radiation exposure is the most limited factor for CTA and MPS gated SPECT procedures and needs particular attention. Ionizing radiation doses, hazardous effects and general radiation protection principles should be known for optimal protection of the patients. Mainly radiation safety rules, various techniques and equipments that may be used to reduce patient and staff radiation exposure during diagnostic and therapeutic procedures especially cardiac interventional fluoroscopic procedures have been detailed discussed in this book. In this field cardiac MR, which is a powerful non-invasive technique for the simultaneously assessment of coronary artery anatomy and function, has a great promise as a radiation-free method. But, it currently lays behind CTA for noninvasive coronary angiography because of some limitation factors such as metallic implants and equipment design.

Selection of the most appropriate diagnostic test in special situations such as chronic kidney disease (CKD) and diabetes mellitus is an other important issue. Although coronary angiography is a valuable tool, the major challenges with coronary angiography relate to when it is appropriate to perform and what the risks are associated with the procedure. Because renal function may be more and more impair with contrast agents used during CAG, and sometimes dialysis may be needed. Therefore, stress echocardiography, MRA and nuclear cardiac tests are often recommended to rule out the presence of CAD in those patients and the presence of any risk factor must be assessed on an individual basis in order to prevent for a soft or hard local or systemic complications. Contrast induced nephropathy (CIN) remains an important clinical issue in these patients, pre-treatment with theophylline combined with volume expansion using sodium bicarbonate; acetylcysteine; use of the lowest possible dose of contrast material (CM), and ISO-osmolar CM or low osmolar CM are advised to prevent CIN. Contrast induced nephropathy is diagnosed if a rapid renal dysfunction is occurred after CM administration without obviously any other cause of acute kidney insufficiency. Serum creatinine (sCr) is the standard marker for detecting CIN; however little changes in sCr after CM exposure may be seen but it is not considered clinically relevant. Therefore, glomerular filtration rate which usually measured by creatinine clearance is usually accepted as the most accurate method for the assessment of kidney function. But, even in patients with stable sCr the GFR may significantly be declined. Recently more sensitive markers (Cystatin-C and Neutrophilic gelatinase associated lipocaline) than sCr for GFR have been developed and validated. Cystatin-C is presented as more accurate marker than sCr for predicting renal function. Readers will get detailed discussions about advantages, disadvantages and possible complications of invasive and non-invasive cardiac procedures, and test selection criteria based on patient's characterizations, mechanism and definition of contrast induced nephropathy (CIN) and preventive therapy models in one more chapters of this task.

X Preface

If gated study is added, left ventricular systolic and diastolic functions can be investigated simultaneously with myocardial perfusion. This field includes a overview of molecular targeted imaging, permeability of the coronary vessel wall, and interventional coronary MR. Recent developments in the field of ultrasonography have allowed us to objectively quantify global and regional ventricular function, and also, to get real-time evaluation of coronary walls and calcium load of atherosclerotic plaques. While we achieve more knowledge about atherosclerotic lesions by IVUS,

On the other hand, radiation exposure is the most limited factor for CTA and MPS gated SPECT procedures and needs particular attention. Ionizing radiation doses, hazardous effects and general radiation protection principles should be known for optimal protection of the patients. Mainly radiation safety rules, various techniques and equipments that may be used to reduce patient and staff radiation exposure during diagnostic and therapeutic procedures especially cardiac interventional fluoroscopic procedures have been detailed discussed in this book. In this field cardiac MR, which is a powerful non-invasive technique for the simultaneously assessment of coronary artery anatomy and function, has a great promise as a radiation-free method. But, it currently lays behind CTA for noninvasive coronary angiography because of

Selection of the most appropriate diagnostic test in special situations such as chronic kidney disease (CKD) and diabetes mellitus is an other important issue. Although coronary angiography is a valuable tool, the major challenges with coronary angiography relate to when it is appropriate to perform and what the risks are associated with the procedure. Because renal function may be more and more impair with contrast agents used during CAG, and sometimes dialysis may be needed. Therefore, stress echocardiography, MRA and nuclear cardiac tests are often recommended to rule out the presence of CAD in those patients and the presence of any risk factor must be assessed on an individual basis in order to prevent for a soft or hard local or systemic complications. Contrast induced nephropathy (CIN) remains an important clinical issue in these patients, pre-treatment with theophylline combined with volume expansion using sodium bicarbonate; acetylcysteine; use of the lowest possible dose of contrast material (CM), and ISO-osmolar CM or low osmolar CM are advised to prevent CIN. Contrast induced nephropathy is diagnosed if a rapid renal dysfunction is occurred after CM administration without obviously any other cause of acute kidney insufficiency. Serum creatinine (sCr) is the standard marker for detecting CIN; however little changes in sCr after CM exposure may be seen but it is not considered clinically relevant. Therefore, glomerular filtration rate which usually measured by creatinine clearance is usually accepted as the most accurate method for the assessment of kidney function. But, even in patients with stable sCr the GFR may significantly be declined. Recently more sensitive markers (Cystatin-C and Neutrophilic gelatinase associated lipocaline) than sCr for GFR have been developed and validated. Cystatin-C is presented as more accurate marker than sCr for predicting renal function. Readers will get detailed discussions about advantages,

tissue Doppler imaging has attempted us to assess myocardial function.

some limitation factors such as metallic implants and equipment design.

Consequently, this book summarized the clinics of atherosclerotic heart diseases, pathogenesis covering possible genetic factors and risk factors, a current view on new biomarkers as a diagnostic, prognostic parameters and future complications, novel diagnostic imaging modalities for CAD, and their advantages and disadvantages. Insight to molecular basis of CAD in a special chapter focusing on the role of on TRAIL (Tumor necrosis factor (TNF)-related apoptosis-inducing ligand) in the cardiovascular disease is really interesting and useful to understand how atherosclerotic plaques occur and what the importance of administration of recombinant TRAIL in protective therapy as a powerful approach.

> **Suna F. Kraç**  Pamukkale University, Faculty of Medicine, Denizli Turkey

**1**

 *Iran*

**Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease**

*2Department of Iranian Legal Medicine Organization 3Hematology Department of Medicine Faculty,*

*Ahvaz University of Medical Sciences*

*1Tabriz Health Center*

Asghar Ghasemi1, Morteza Seifi2 and Mahmood Khosravi3

Coronary artery disease (CAD) is one of the most common cardiovascular diseases and has a high incidence of morbidity and mortality. CAD is a major public health problem in developing and developed countries and its increasing prevalence is a cause of considerable concern in the medical community worldwide (He et al*.*, 2005). CAD involves genetic and environmental factors and their interaction with each other. Traditional risk factors account for at most one-half of the prevalence of CAD (Zdravkovic et al., 2002). Despite attempts to establish the molecular and genetic determinants that could account for variations in CAD (Zdravkovic et al*.*, 2002), the etiology and complex multigenic basis of atherosclerosis is still

Completion of the sequencing of the human genome was a monumental achievement (Venter et al., 2001). Molecular researchers now take for granted the information provided by the sequence, however the clinical applications are not immediately obvious. A limitation of the Human Genome Project was that it produced only a single "reference" sequence. But in order to identify new disease causing mechanisms and cures for disease, we need to go beyond the "reference" and characterize the differences between our genomes, and in turn the effect that these differences have. The Human HapMap consortium (Frazer et al., 2007) and recent genome-wide association studies (GWAS) have set out to capture the interindividual differences that are associated with disease processes, including coronary artery disease. The association between genetic variations and CAD have been reviewed in several previous manuscripts (Lanktree et al., 2008), but in our knowledge so far there has been no study in the field of association between novel gene variations and CAD; therefore we focused on introducing some novel polymorphisms and their relationships with CAD.

The success of CAD gene mapping is dependent on its genetic architecture which refers to the number of disease genes that exist, their allele frequencies, the risks that they confer, and

**1. Introduction**

not completely understood.

**2. Genetics of coronary artery disease**

**2.1 Genetic architecture of CAD**

## **Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease**

Asghar Ghasemi1, Morteza Seifi2 and Mahmood Khosravi3 *1Tabriz Health Center 2Department of Iranian Legal Medicine Organization 3Hematology Department of Medicine Faculty, Ahvaz University of Medical Sciences Iran*

## **1. Introduction**

Coronary artery disease (CAD) is one of the most common cardiovascular diseases and has a high incidence of morbidity and mortality. CAD is a major public health problem in developing and developed countries and its increasing prevalence is a cause of considerable concern in the medical community worldwide (He et al*.*, 2005). CAD involves genetic and environmental factors and their interaction with each other. Traditional risk factors account for at most one-half of the prevalence of CAD (Zdravkovic et al., 2002). Despite attempts to establish the molecular and genetic determinants that could account for variations in CAD (Zdravkovic et al*.*, 2002), the etiology and complex multigenic basis of atherosclerosis is still not completely understood.

Completion of the sequencing of the human genome was a monumental achievement (Venter et al., 2001). Molecular researchers now take for granted the information provided by the sequence, however the clinical applications are not immediately obvious. A limitation of the Human Genome Project was that it produced only a single "reference" sequence. But in order to identify new disease causing mechanisms and cures for disease, we need to go beyond the "reference" and characterize the differences between our genomes, and in turn the effect that these differences have. The Human HapMap consortium (Frazer et al., 2007) and recent genome-wide association studies (GWAS) have set out to capture the interindividual differences that are associated with disease processes, including coronary artery disease.

The association between genetic variations and CAD have been reviewed in several previous manuscripts (Lanktree et al., 2008), but in our knowledge so far there has been no study in the field of association between novel gene variations and CAD; therefore we focused on introducing some novel polymorphisms and their relationships with CAD.

## **2. Genetics of coronary artery disease**

## **2.1 Genetic architecture of CAD**

The success of CAD gene mapping is dependent on its genetic architecture which refers to the number of disease genes that exist, their allele frequencies, the risks that they confer, and

Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease 3

This approach is more directed than is the genome-scan linkage approach, but it is limited by our incomplete knowledge of disease mechanisms and thus may miss important causative genes. It is worth noting that whereas in linkage analyses "disease" alleles are tracked in families, genetic association is a phenomenon of populations and association studies compare populations of subjects with and without the disease of interest (Bernhard

Previous methods for determining genetic linkage of a complex disease relied chiefly upon the technique of genome wide scanning of microsatellites (short tandem repeat sequences). This required the laborious selection of hundreds of families, particularly sib pairs with MI or CAD. Using around 400 microsatellite markers distributed evenly across the genome, the goal was to identify a significant linkage peak defined by a logarithm of odds ratio (LOD) greater than 3.5 corresponding to a p<10-6 indicating a gene that is in linkage disequilibrium (LD) near or even within the microsatellite region. However, identifying disease causing genes interspersed within microsatellites has proved to be quite difficult and studies from different centers reported varying results - Finland (2q21.2-22 and Xq23-26) (Pajukanta et al. 2000), Germany (14q32.2) (Broeckel et al., 2002), Iceland (13q12-13) ( Helgadottir et al., 2004), US (1p34-36 ,3q13 and 5q31)( Hauser et al., 2004) and UK (2p11, 17p11-17q21) (Farrall et al., 2006; Samani et al. 2005). Genomic regions identified in the published linkage studies as being correlated with CHF are largely non-overlapping, suggesting genetic and/or phenotypic heterogeneity. Two genes, *ALOX5AP* and *MEF2A*, have been identified by fine mapping studies following the original linkage analysis. The Icelandic locus was replicated in population-based studies from Iceland and England, with different haplotypes of the *ALOX5AP* gene (encoding 5-lipoxygenase activating protein) associated with CAD in the two countries, and the Icelandic haplotype was also associated with stroke in Iceland and in Scotland (Helgadottir et al., 2004; Helgadottir et al., 2005). MEF2A (myocyte enhancer factor 2A) a transcription factor expressed in coronary artery endothelium was identified by linkage analysis in a pedigree in which 13 members had CAD, nine of whom had MI (Wang

Genome-wide association studies (GWAS) became possible after the publication of the International Haplotype Map Project (HapMap) (International HapMap consortium, 2005; International HapMap consortium, 2007) and the development of array-based platforms that enable the investigation of up to one million variants in cases and controls of a certain disease (or other phenotypic traits). The HapMap was a large collaborative project that described the frequencies of genetic variants with a minor allele frequency above 5% in four distinct populations: Han Chinese, Japanese, Black African from Nigeria, and Caucasian of European ancestryfrom the USA (International HapMap consortium, 2005; International

The first GWAS to be conducted under these modalities was a large case-control study by the Wellcome Trust Case-Control Consortium (WTCCC), in which 14,000 cases affected by 7 among the most common complex diseases (CAD, arterial hypertension, rheumatoid arthritis, Crohn's disease, bipolar disorder, and diabetes mellitus types I and II) were compared with a set of 3,000 healthy controls. (Wellcome trust case control consortium,

et al., 2000).

et al., 2003).

**2.4 Genome-wide association studies**

HapMap consortium, 2007).

**2.3 Linkage studies**

the interactions between multiple genetic and environmental factors (Wright & Hastie, 2001; Reich & Lander, 2001). Although the total genetic contribution to CAD risk can be quantified, the determination of the size and number of contributing effects is impossible without identifying all CAD susceptibility genes. The multiple risk factors for CAD themselves have their own genetic architecture. The heritabilities of some of the risk factors for CAD are considerable - total cholesterol (40 to 60%), HDL-cholesterol (45 to 75%), total triglycerides (40 to 80%), body mass index (25 to 60%), systolic blood pressure (50 to 70%), Lp(a) levels (90%), homocysteine levels (45%), type 2 diabetes (40 to 80%), fibrinogen (20 to 50%) (Lusis et al., 2004). Also, as CAD is rare before the age of 50 yr, it is unlikely to have an effect on reproductive success and hence less likely to have been subject to direct evolutionary selection pressure. Variants that confer susceptibility or protection for CAD might therefore have evolved neutrally in the past, and so could present at a wide range of frequencies.

This is the basis of the Common Disease/Common Variant (CDCV) hypothesis which holds that the genetic variants underlying complex traits occur with a relatively high frequency (>1%), have undergone little or no selection in earlier populations and are likely to date back to >100,000 years ago (Lander et al., 1996).The other competing model is the Common Disease Rare Variant hypothesis, with an inverse relationship between the magnitude of genetic effect and allele frequency (Pritchard et al., 2001). This model argues that diseases are common because of highly prevalent environmental influences, not because of common disease alleles in the population (Wright & Hastie, 2001). A review of candidate gene associations and recent genome wide association study results support the importance of common alleles in CAD. At odds with this, rare allelic variants of three candidate genes (ABCA1, APOA1, LCAT) that influence HDL levels, were jointly found to make a substantial contribution to the population distribution of HDL levels (Cohen et al., 2004; Frikke-Schmidt et al., 2004). The most likely scenario would be that the allelic spectrum of the disease variants is the same as the general spectrum of all disease variants. Under this neutral model, although most susceptibility variants are rare with minor allele frequencies (MAF) <1 per cent, variants with MAF>1 per cent would account for more than 90 per cent of the genetic differences between individuals. It is plausible that these common variants might contribute significantly to those common diseases in which susceptibility alleles might not be under intense negative selection.

#### **2.2 Linkage and association studies**

The 2 general types of studies that evaluate the relation between gene polymorphisms and disease are linkage analysis and association studies. Linkage analysis investigates the cosegregation of polymorphic DNA markers with inheritance of disease in families and has been highly successful in the detection of monogenic disorders. However, it is a tedious and complicated undertaking in the investigation of polygenic diseases such as CHD. Association studies provide an alternative method for dissecting genetically complex diseases and typically use the candidate gene approach for their investigation. Based on the known pathophysiologic characteristics of a disease, assumptions are made about the genes involved in its processes and the hypothesis of the association of these genes with the disease is then tested. For a disease such as CHD it makes sense to analyze genes that contribute to lipoprotein metabolism, blood pressure, and to diseases such as diabetes mellitus, among others.

This approach is more directed than is the genome-scan linkage approach, but it is limited by our incomplete knowledge of disease mechanisms and thus may miss important causative genes. It is worth noting that whereas in linkage analyses "disease" alleles are tracked in families, genetic association is a phenomenon of populations and association studies compare populations of subjects with and without the disease of interest (Bernhard et al., 2000).

#### **2.3 Linkage studies**

2 Advances in the Diagnosis of Coronary Atherosclerosis

the interactions between multiple genetic and environmental factors (Wright & Hastie, 2001; Reich & Lander, 2001). Although the total genetic contribution to CAD risk can be quantified, the determination of the size and number of contributing effects is impossible without identifying all CAD susceptibility genes. The multiple risk factors for CAD themselves have their own genetic architecture. The heritabilities of some of the risk factors for CAD are considerable - total cholesterol (40 to 60%), HDL-cholesterol (45 to 75%), total triglycerides (40 to 80%), body mass index (25 to 60%), systolic blood pressure (50 to 70%), Lp(a) levels (90%), homocysteine levels (45%), type 2 diabetes (40 to 80%), fibrinogen (20 to 50%) (Lusis et al., 2004). Also, as CAD is rare before the age of 50 yr, it is unlikely to have an effect on reproductive success and hence less likely to have been subject to direct evolutionary selection pressure. Variants that confer susceptibility or protection for CAD might therefore have evolved neutrally in the past, and so could present at a wide range of

This is the basis of the Common Disease/Common Variant (CDCV) hypothesis which holds that the genetic variants underlying complex traits occur with a relatively high frequency (>1%), have undergone little or no selection in earlier populations and are likely to date back to >100,000 years ago (Lander et al., 1996).The other competing model is the Common Disease Rare Variant hypothesis, with an inverse relationship between the magnitude of genetic effect and allele frequency (Pritchard et al., 2001). This model argues that diseases are common because of highly prevalent environmental influences, not because of common disease alleles in the population (Wright & Hastie, 2001). A review of candidate gene associations and recent genome wide association study results support the importance of common alleles in CAD. At odds with this, rare allelic variants of three candidate genes (ABCA1, APOA1, LCAT) that influence HDL levels, were jointly found to make a substantial contribution to the population distribution of HDL levels (Cohen et al., 2004; Frikke-Schmidt et al., 2004). The most likely scenario would be that the allelic spectrum of the disease variants is the same as the general spectrum of all disease variants. Under this neutral model, although most susceptibility variants are rare with minor allele frequencies (MAF) <1 per cent, variants with MAF>1 per cent would account for more than 90 per cent of the genetic differences between individuals. It is plausible that these common variants might contribute significantly to those common diseases in which susceptibility alleles

The 2 general types of studies that evaluate the relation between gene polymorphisms and disease are linkage analysis and association studies. Linkage analysis investigates the cosegregation of polymorphic DNA markers with inheritance of disease in families and has been highly successful in the detection of monogenic disorders. However, it is a tedious and complicated undertaking in the investigation of polygenic diseases such as CHD. Association studies provide an alternative method for dissecting genetically complex diseases and typically use the candidate gene approach for their investigation. Based on the known pathophysiologic characteristics of a disease, assumptions are made about the genes involved in its processes and the hypothesis of the association of these genes with the disease is then tested. For a disease such as CHD it makes sense to analyze genes that contribute to lipoprotein metabolism, blood pressure, and to diseases such as diabetes

frequencies.

might not be under intense negative selection.

**2.2 Linkage and association studies**

mellitus, among others.

Previous methods for determining genetic linkage of a complex disease relied chiefly upon the technique of genome wide scanning of microsatellites (short tandem repeat sequences). This required the laborious selection of hundreds of families, particularly sib pairs with MI or CAD. Using around 400 microsatellite markers distributed evenly across the genome, the goal was to identify a significant linkage peak defined by a logarithm of odds ratio (LOD) greater than 3.5 corresponding to a p<10-6 indicating a gene that is in linkage disequilibrium (LD) near or even within the microsatellite region. However, identifying disease causing genes interspersed within microsatellites has proved to be quite difficult and studies from different centers reported varying results - Finland (2q21.2-22 and Xq23-26) (Pajukanta et al. 2000), Germany (14q32.2) (Broeckel et al., 2002), Iceland (13q12-13) ( Helgadottir et al., 2004), US (1p34-36 ,3q13 and 5q31)( Hauser et al., 2004) and UK (2p11, 17p11-17q21) (Farrall et al., 2006; Samani et al. 2005). Genomic regions identified in the published linkage studies as being correlated with CHF are largely non-overlapping, suggesting genetic and/or phenotypic heterogeneity. Two genes, *ALOX5AP* and *MEF2A*, have been identified by fine mapping studies following the original linkage analysis. The Icelandic locus was replicated in population-based studies from Iceland and England, with different haplotypes of the *ALOX5AP* gene (encoding 5-lipoxygenase activating protein) associated with CAD in the two countries, and the Icelandic haplotype was also associated with stroke in Iceland and in Scotland (Helgadottir et al., 2004; Helgadottir et al., 2005). MEF2A (myocyte enhancer factor 2A) a transcription factor expressed in coronary artery endothelium was identified by linkage analysis in a pedigree in which 13 members had CAD, nine of whom had MI (Wang et al., 2003).

#### **2.4 Genome-wide association studies**

Genome-wide association studies (GWAS) became possible after the publication of the International Haplotype Map Project (HapMap) (International HapMap consortium, 2005; International HapMap consortium, 2007) and the development of array-based platforms that enable the investigation of up to one million variants in cases and controls of a certain disease (or other phenotypic traits). The HapMap was a large collaborative project that described the frequencies of genetic variants with a minor allele frequency above 5% in four distinct populations: Han Chinese, Japanese, Black African from Nigeria, and Caucasian of European ancestryfrom the USA (International HapMap consortium, 2005; International HapMap consortium, 2007).

The first GWAS to be conducted under these modalities was a large case-control study by the Wellcome Trust Case-Control Consortium (WTCCC), in which 14,000 cases affected by 7 among the most common complex diseases (CAD, arterial hypertension, rheumatoid arthritis, Crohn's disease, bipolar disorder, and diabetes mellitus types I and II) were compared with a set of 3,000 healthy controls. (Wellcome trust case control consortium,

Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease 5

der Meer et al., (Van der Meer et al., 2004) found a clear association of G allele of the -1793 C/G polymorphism in the VWF gene with an increased risk of Coronary heart disease.

8q21-q22 Aldosterone Synthase (CYP11B2) *−*344T/C, Lys173Ar

insertion/deletion (intron 16)

Location Gene name/Polymorphisms 17q23 Angiotensin-Converting Enzyme

6p24.1 Endothelin-1 Lys198Asn 7q36 eNOS Glu298Asp, *−*786T/C 17q21.32 Glycoprotein IIIa P1A1/A2 5q23-31 Glycoprotein Ia 807T/C 17pter-p12 Glycoprotein Ib*α* Thr145Met 4q28 *β*fibrinogen *−*455G/A 11p11-q12 Prothrombin 20210G/A

1q42-q43 Angiotensinogen Met235Thr, *−*6G/A 3q21-q25 Angiotensin II type1 Receptor 1166A/C

14q32.1-q32.2 Bradykinin B2 receptor gene *−*58T/C

7q21.3-q22 PAI-1 4G/5G (promoter region) 7q21.3 Paraoxonase1 Arg192Gln, Leu54Met 8p12-p11.2 Werner Helicase Gene Cys1367Arg

5q31.1 CD14 Monocyte Receptor *−*260C/T

9q31.1 ABCA1 gene Ile823Met

myocardial infarction or coronary artery disease.

**4. Novel genetic risk factors**

**4.1 MLXIPL**

20q13.11-q13.13 Prostacyclin synthase gene

20q11.2-q13.1 Gelatinase B (MMP9) *−*1562C/T 19q13.2 ApolipoproteinE E2/E3/E4

3p25 PPAR-gamma Pro12Ala, Pro115Gln

1p36.3 Methylenetetrahydrofolate reductase 677C/T

11q22.3 Stromelysin (MMP3) 5A/6A (promoter region)

16q24 NADH/NADPH oxidase p22phox242C/T, 640A/G

16q21 Cholesteryl Ester Transfer Protein (CETP) Ile405Val

Table 1. The common genetic polymorphisms which are thought to be associated with

Triglycerides are produced from either fatty acids obtained directly from the diet or synthesized *de novo* when excess carbohydrates are consumed. Genes that respond to glucose contain a specific regulatory site, the carbohydrate response element (ChoRE), in their promoter regions. To date, ChoREs have been mapped within the promoter regions of the liver-type pyruvate kinase (PK), S14, fatty acid synthase (FAS), acetyl-CoA carboxylase 1 (ACC), and thioredoxin-interacting protein genes (Towle et al., 2005; Minn et al., 2005). ChREBP is a basic helix-loop helix/leucine zipper transcription factor involved in mediating glucose-responsive gene activation (Yamashita et al., 2001). Mice with a disruption of the

2007) The WTCCC study identified 24 genetic variants associated with at least one of these complex diseases and helped to clarify key methodological issues, setting the stage for the more than 400 GWAS that were to follow. These GWAS have so far identified more than 250 loci at which common variants influence the predisposition to diseases that are common (i.e., diabetes, autoimmune diseases, and several types of cancer), an achievement that by far outweighed that of the previous decade of genetic studies. Results are available in the catalogue of published GWAS prepared by the National Cancer Institute (NCI)-National Human Genome Research Institute (NHGRI). (Hindorff et al., 2010) The genetic variants that can be identified by GWAS are common variants (with at least 5% frequency in the population) and have a low effect size; the conferred relative risks, as expressed by odds ratio, usually range between 1.1 and 1.5. These results confirm the views that the genetic predisposition to common diseases consists of the combined effect of numerous common genetic variants, each of a small effect size. However, it should be noted that GWAS identify regions of the genome (loci) rather than variants of specific genes. Indeed, the specific variant(s) identified by GWAS may simply represent the signal of one or more hidden variant(s) (not typed in the arrays used in GWAS). Limitations of GWAS need to be mentioned. First, these studies need very large samples of cases and controls. Second, DNA and data quality control procedures and statistical analysis need to be carried out by expert centers. Third, the overall cost of GWAS, ranging from hundreds of thousands to millions of US dollars, is prohibitive for most research groups worldwide. And finally, even after and in spite of all quality control procedures, there is still the chance that the results of GWAS include false-positive results, so that an independent replication of these results is still important even after testing thousands of individuals (Pier et al., 2010)

## **3. Candidate genetic factors**

CAD is a complex, multifactorial disorder in which interactions among various genetic and environmental influences play an important role. Many genes are likely to be involved in some way in the process for CAD (Table 1). Some genetic studies have suggested that several gene polymorphisms, including those in the genes for angiotensin-converting enzyme (Samadi et al., 2009) and paraoxonase (Fallah et al., 2010) increase the risk for CAD. Polymorphisms in the genes for insulin-like growth factor-I and lipoprotein lipase have been shown to increase the risk of both CAD and type 2 diabetes (Wang et al., 1996; Vaessen et al., 2001).

There are certain genetic defects that affect activities of some enzymes (cystathionin βsynthase, methyltransferase and 5, 10-methylenetetrahydrofolate reductase) which may lead to homocystinuria. Heterozygosity for deficiency of cystathionin β-synthase is known to be linked with arthrosclerosis and thrombotic disease including CAD (Bakir et al., 2001).

Adiponectin gene locus, chromosome 3q27, is the candidate site for CAD. Adiponectin I164T mutation is associated with the metabolic syndrome and coronary artery disease. The I164T mutation in the adiponectin gene is reported to be a common genetic background associated with the metabolic syndrome and CAD in the Japanese population (Ohashi et al., 2004)

The Von Willebrand factor (VWF) may be causally associated with coronary heart disease or merely be a marker of endothelial damage. The G allele of the -1793 C/G promoter polymorphism in the VWF gene has been associated with higher plasma levels of VWF. Van

der Meer et al., (Van der Meer et al., 2004) found a clear association of G allele of the -1793 C/G polymorphism in the VWF gene with an increased risk of Coronary heart disease.

Table 1. The common genetic polymorphisms which are thought to be associated with myocardial infarction or coronary artery disease.

## **4. Novel genetic risk factors**

#### **4.1 MLXIPL**

4 Advances in the Diagnosis of Coronary Atherosclerosis

2007) The WTCCC study identified 24 genetic variants associated with at least one of these complex diseases and helped to clarify key methodological issues, setting the stage for the more than 400 GWAS that were to follow. These GWAS have so far identified more than 250 loci at which common variants influence the predisposition to diseases that are common (i.e., diabetes, autoimmune diseases, and several types of cancer), an achievement that by far outweighed that of the previous decade of genetic studies. Results are available in the catalogue of published GWAS prepared by the National Cancer Institute (NCI)-National Human Genome Research Institute (NHGRI). (Hindorff et al., 2010) The genetic variants that can be identified by GWAS are common variants (with at least 5% frequency in the population) and have a low effect size; the conferred relative risks, as expressed by odds ratio, usually range between 1.1 and 1.5. These results confirm the views that the genetic predisposition to common diseases consists of the combined effect of numerous common genetic variants, each of a small effect size. However, it should be noted that GWAS identify regions of the genome (loci) rather than variants of specific genes. Indeed, the specific variant(s) identified by GWAS may simply represent the signal of one or more hidden variant(s) (not typed in the arrays used in GWAS). Limitations of GWAS need to be mentioned. First, these studies need very large samples of cases and controls. Second, DNA and data quality control procedures and statistical analysis need to be carried out by expert centers. Third, the overall cost of GWAS, ranging from hundreds of thousands to millions of US dollars, is prohibitive for most research groups worldwide. And finally, even after and in spite of all quality control procedures, there is still the chance that the results of GWAS include false-positive results, so that an independent replication of these results is still

important even after testing thousands of individuals (Pier et al., 2010)

CAD is a complex, multifactorial disorder in which interactions among various genetic and environmental influences play an important role. Many genes are likely to be involved in some way in the process for CAD (Table 1). Some genetic studies have suggested that several gene polymorphisms, including those in the genes for angiotensin-converting enzyme (Samadi et al., 2009) and paraoxonase (Fallah et al., 2010) increase the risk for CAD. Polymorphisms in the genes for insulin-like growth factor-I and lipoprotein lipase have been shown to increase the risk of both CAD and type 2 diabetes (Wang et al., 1996;

There are certain genetic defects that affect activities of some enzymes (cystathionin βsynthase, methyltransferase and 5, 10-methylenetetrahydrofolate reductase) which may lead to homocystinuria. Heterozygosity for deficiency of cystathionin β-synthase is known to be linked with arthrosclerosis and thrombotic disease including CAD (Bakir et al., 2001). Adiponectin gene locus, chromosome 3q27, is the candidate site for CAD. Adiponectin I164T mutation is associated with the metabolic syndrome and coronary artery disease. The I164T mutation in the adiponectin gene is reported to be a common genetic background associated with the metabolic syndrome and CAD in the Japanese population (Ohashi et al.,

The Von Willebrand factor (VWF) may be causally associated with coronary heart disease or merely be a marker of endothelial damage. The G allele of the -1793 C/G promoter polymorphism in the VWF gene has been associated with higher plasma levels of VWF. Van

**3. Candidate genetic factors**

Vaessen et al., 2001).

2004)

Triglycerides are produced from either fatty acids obtained directly from the diet or synthesized *de novo* when excess carbohydrates are consumed. Genes that respond to glucose contain a specific regulatory site, the carbohydrate response element (ChoRE), in their promoter regions. To date, ChoREs have been mapped within the promoter regions of the liver-type pyruvate kinase (PK), S14, fatty acid synthase (FAS), acetyl-CoA carboxylase 1 (ACC), and thioredoxin-interacting protein genes (Towle et al., 2005; Minn et al., 2005).

ChREBP is a basic helix-loop helix/leucine zipper transcription factor involved in mediating glucose-responsive gene activation (Yamashita et al., 2001). Mice with a disruption of the

Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease 7

With respect to the reported resistin variants, the mostly extensively studied has been the promoter variant SNP-420C>G. Functional binding studies have been done with stimulatory proteins (Sp)-1 and 3, which bind to the promoter. Their binding has been described to be influenced by SNP-420C>G. Sp-1 and 3 were discovered to bind efficiently only to the Gallele sequence and after binding to increase the activity of the promoter. (Chung et al*.,*  2005). It seems likely that the more active promoter with the SNP-420C>G G allele is the reason for several observations of higher plasma resistin concentration in the G allele carriers (Yamauchi et al*.,* 2008). However, in contrast to these studies, it has also been reported that the genotypes of SNP-420C>G do not influence the plasma resistin concentration in Italian subjects (Norata et al*.,* 2007). Furthermore in a small study of polycystic ovary syndrome patients noassociation was detected between SNP-420C>G

Recent studies have shown that the resistin levels are significantly correlated with coronary artery calcification and are predictive of coronary atherosclerosis in humans (Mohty et al., 2009). Previous studies described the association among this -420 (C>G) polymorphism, the resistin levels and cardiovascular risk factors (Ukkola et al*.*, 2006; Norata et al., 2007**)**  However, the association between the serum resistin levels and CHD seemed to be negative, and might be controversial for this polymorphism and CAD. (Norata et al., 2007; *Kunnari et al*. 2005) Differences in the cohorts might explain the different results, depending on which ethnic group was tested (Menzaghi et al., 2006; Hivert et al., 2009). Indeed, methodological limitations in the commercially available ELISA assays might also result in variations among serum levels, which might cause difficulties when comparing results from different

The kidney, in addition to maintaining fluid and electrolyte homeostasis, performs essential endocrine functions (Peart et al., 1977). Patients with end-stage renal disease are at high risk for cardiovascular events, even when provided optimal renal replacement therapy (Go et al., 2004; Anavekar et al., 2004). It has been suggested that failure to replicate the endocrine functions of the kidney may contribute to this risk, in association with heightened sympathetic tone (Joles & Koomans 2004; Neumann et al., 2004; Wolfe et al., 1999). Renalase, a flavin adenine dinucleotide-dependent amine oxidase that is secreted into the blood by the kidney, metabolizes circulating catecholamines, and is deficient in chronic kidney disease (Xu et al., 2005). Excess catecholamines promote the activity, secretion, and synthesis of renalase, providing a novel pathway of negative feedback homeostatic control (Li et al., 2008). In rodents, parenteral administration of renalase lowers blood pressure, heart rate, and cardiac contractility (Xu J, Desir GV 2007). During cardiac ischemia in rats, infusion of recombinant renalase reduces myocardial infarct size whereas neonatal nephrectomy leads to elevated sympathetic nervous system activity, renalase deficiency, and cardiac hypertrophy (Desir 2008; Ghosh et al., 2008). Human renalase is encoded by a 311Kbp gene with 10 exons located on chromosome 10q23.33. The major isoform of renalase contains 342 amino acids comprising a signal peptide (amino acids 1–17), a flavin-adenine dinucleotide (FAD) binding domain (amino acids 4–45), and a monoamine oxidase domain (amino acids 75–342). Evidence exists for at least four alternatively- spliced isoforms of renalase (Desir, 2009). The most common isoform (renalase1) is encoded by exons 1–4, 6–7, and 9. It is the predominant human renalase protein detectable in plasma, kidney, heart, skeletal muscle,

genotype and the serum level of resistin (Escobar-Morreale et al*.,* 2006).

publications.

**4.3 Renalase**

ChREBP gene or hepatocytes treated with siRNA to reduce ChREBP expression cannot induce lipogenic gene expression in response to carbohydrate (Iizuka et al., 2004; Dentin et al., 2004). In hepatocytes prepared from ChREBP null mice, the induction can be restored by the addition of a ChREBP expression vector (Ishii et al., 2004). Thus, ChREBP is essential for regulating lipogenic gene expression. However, it has previously reported that ChREBP requires an interaction partner, Mlx, to efficiently bind to ChoRE sequences and exert its functional activity (Stoeckman et al., 2004).  Expressing a dominant negative form of Mlx in hepatocytes completely inhibits the glucose response of a number of lipogenic enzyme genes, including PK, S14, ACC, and FAS (Ma et al., 2005)**.** This inhibition is rescued by overexpressing ChREBP but not MondoA. Therefore, Mlx is an obligatory partner of ChREBP in regulating glucose-responsive lipogenic enzyme genes.

Recently, SNPs localized within the MLXIPL (MLX intracting protein like; ChREBP, carbohydrate response element binding protein) loci have been associated with plasma triglycerides (Kooner et al., 2008; Kathiresan et al., 2008). The most significant association was described for the rs3812316 SNP (C771G, His241Gln); the CC genotype was associated with elevated TGs. The identified SNP is located at evolutionary conserved domain responsible for glucose dependent activation of MLXIPL. After activation and binding to the MLX, the complex increases the transcription of genes involved, among others, in lipogenesis and triglyceride synthesis. Since, elevated plasma triglycerides (TG) are an independent risk factor for cardiovascular disease development (Sarwar et al., 2007) and MLXIPL loci have been associated with plasma triglycerides, this gene might be a novel genetic risk factor for coronary artery disease ( Pan et al., 2009)

#### **4.2 Resistin**

Resistin is a 10 kDa protein composed of 94 amino acids. It was cloned in 2001 and was shown to be a thiazolidinedione (TZD)-regulated cytokine expressed in adipose tissue (Wolf et al., 2004). The effect of resistin on insulin action has been extensively investigated in laboratory models. It was shown to be involved in hepatic glucose and lipid metabolism and appears to play a pivotal role in hepatic insulin resistance (IR) induced by high-fat diet (Rajala et al., 2003). Resistin was suggested to affect endothelial function and the migration of vascular smooth muscle cells (Cohen & Horel., 2009), which are regarded as key pathophysiological mechanisms of atherosclerosis. Further, resistin has been noted to play a vital role in increasing the level of very low density lipoprotein (VLDL) and low density lipoprotein (LDL) in an obese person (Rizkalla et al., 2009) which is directly atherogenic. Resistin induces increases in MCP-1 and sVCAM-1 expression in vascular endothelial cells which suggest a possible mechanism that contribute to atherogenesis (Cohen & Horel., 2009). Recent reports indicate that resistin promotes proliferation of VSMC that occurs through both ERK 1/2 and Akt signalling pathways (Calabro et al., 2004). Thus resistin is noted to enhance VSMC migration, which is a known component of athermanous plaque synthesis (Verma et al., 2003). Resistin promotes foam cell formation via dysregulation of scavenger receptors (SR-A) and ATP-binding cassette transporter-A1 (ABCA1) (Lee et al., 2009) through PPAR gamma. In atherosclerosis, increased level of resistin causes elevation of soluble TNF-\_ receptor 2, IL-6 and lipoprotein-associated phospholipase A2 (Lp- PLA2) (Reilly et al., 2005).

With respect to the reported resistin variants, the mostly extensively studied has been the promoter variant SNP-420C>G. Functional binding studies have been done with stimulatory proteins (Sp)-1 and 3, which bind to the promoter. Their binding has been described to be influenced by SNP-420C>G. Sp-1 and 3 were discovered to bind efficiently only to the Gallele sequence and after binding to increase the activity of the promoter. (Chung et al*.,*  2005). It seems likely that the more active promoter with the SNP-420C>G G allele is the reason for several observations of higher plasma resistin concentration in the G allele carriers (Yamauchi et al*.,* 2008). However, in contrast to these studies, it has also been reported that the genotypes of SNP-420C>G do not influence the plasma resistin concentration in Italian subjects (Norata et al*.,* 2007). Furthermore in a small study of polycystic ovary syndrome patients noassociation was detected between SNP-420C>G genotype and the serum level of resistin (Escobar-Morreale et al*.,* 2006).

Recent studies have shown that the resistin levels are significantly correlated with coronary artery calcification and are predictive of coronary atherosclerosis in humans (Mohty et al., 2009). Previous studies described the association among this -420 (C>G) polymorphism, the resistin levels and cardiovascular risk factors (Ukkola et al*.*, 2006; Norata et al., 2007**)**  However, the association between the serum resistin levels and CHD seemed to be negative, and might be controversial for this polymorphism and CAD. (Norata et al., 2007; *Kunnari et al*. 2005) Differences in the cohorts might explain the different results, depending on which ethnic group was tested (Menzaghi et al., 2006; Hivert et al., 2009). Indeed, methodological limitations in the commercially available ELISA assays might also result in variations among serum levels, which might cause difficulties when comparing results from different publications.

#### **4.3 Renalase**

6 Advances in the Diagnosis of Coronary Atherosclerosis

ChREBP gene or hepatocytes treated with siRNA to reduce ChREBP expression cannot induce lipogenic gene expression in response to carbohydrate (Iizuka et al., 2004; Dentin et al., 2004). In hepatocytes prepared from ChREBP null mice, the induction can be restored by the addition of a ChREBP expression vector (Ishii et al., 2004). Thus, ChREBP is essential for regulating lipogenic gene expression. However, it has previously reported that ChREBP requires an interaction partner, Mlx, to efficiently bind to ChoRE sequences and exert its functional activity (Stoeckman et al., 2004).  Expressing a dominant negative form of Mlx in hepatocytes completely inhibits the glucose response of a number of lipogenic enzyme genes, including PK, S14, ACC, and FAS (Ma et al., 2005)**.** This inhibition is rescued by overexpressing ChREBP but not MondoA. Therefore, Mlx is an obligatory

Recently, SNPs localized within the MLXIPL (MLX intracting protein like; ChREBP, carbohydrate response element binding protein) loci have been associated with plasma triglycerides (Kooner et al., 2008; Kathiresan et al., 2008). The most significant association was described for the rs3812316 SNP (C771G, His241Gln); the CC genotype was associated with elevated TGs. The identified SNP is located at evolutionary conserved domain responsible for glucose dependent activation of MLXIPL. After activation and binding to the MLX, the complex increases the transcription of genes involved, among others, in lipogenesis and triglyceride synthesis. Since, elevated plasma triglycerides (TG) are an independent risk factor for cardiovascular disease development (Sarwar et al., 2007) and MLXIPL loci have been associated with plasma triglycerides, this gene might be a novel

Resistin is a 10 kDa protein composed of 94 amino acids. It was cloned in 2001 and was shown to be a thiazolidinedione (TZD)-regulated cytokine expressed in adipose tissue (Wolf et al., 2004). The effect of resistin on insulin action has been extensively investigated in laboratory models. It was shown to be involved in hepatic glucose and lipid metabolism and appears to play a pivotal role in hepatic insulin resistance (IR) induced by high-fat diet (Rajala et al., 2003). Resistin was suggested to affect endothelial function and the migration of vascular smooth muscle cells (Cohen & Horel., 2009), which are regarded as key pathophysiological mechanisms of atherosclerosis. Further, resistin has been noted to play a vital role in increasing the level of very low density lipoprotein (VLDL) and low density lipoprotein (LDL) in an obese person (Rizkalla et al., 2009) which is directly atherogenic. Resistin induces increases in MCP-1 and sVCAM-1 expression in vascular endothelial cells which suggest a possible mechanism that contribute to atherogenesis (Cohen & Horel., 2009). Recent reports indicate that resistin promotes proliferation of VSMC that occurs through both ERK 1/2 and Akt signalling pathways (Calabro et al., 2004). Thus resistin is noted to enhance VSMC migration, which is a known component of athermanous plaque synthesis (Verma et al., 2003). Resistin promotes foam cell formation via dysregulation of scavenger receptors (SR-A) and ATP-binding cassette transporter-A1 (ABCA1) (Lee et al., 2009) through PPAR gamma. In atherosclerosis, increased level of resistin causes elevation of soluble TNF-\_ receptor 2, IL-6 and lipoprotein-associated phospholipase A2 (Lp- PLA2)

partner of ChREBP in regulating glucose-responsive lipogenic enzyme genes.

genetic risk factor for coronary artery disease ( Pan et al., 2009)

**4.2 Resistin**

(Reilly et al., 2005).

The kidney, in addition to maintaining fluid and electrolyte homeostasis, performs essential endocrine functions (Peart et al., 1977). Patients with end-stage renal disease are at high risk for cardiovascular events, even when provided optimal renal replacement therapy (Go et al., 2004; Anavekar et al., 2004). It has been suggested that failure to replicate the endocrine functions of the kidney may contribute to this risk, in association with heightened sympathetic tone (Joles & Koomans 2004; Neumann et al., 2004; Wolfe et al., 1999). Renalase, a flavin adenine dinucleotide-dependent amine oxidase that is secreted into the blood by the kidney, metabolizes circulating catecholamines, and is deficient in chronic kidney disease (Xu et al., 2005). Excess catecholamines promote the activity, secretion, and synthesis of renalase, providing a novel pathway of negative feedback homeostatic control (Li et al., 2008). In rodents, parenteral administration of renalase lowers blood pressure, heart rate, and cardiac contractility (Xu J, Desir GV 2007). During cardiac ischemia in rats, infusion of recombinant renalase reduces myocardial infarct size whereas neonatal nephrectomy leads to elevated sympathetic nervous system activity, renalase deficiency, and cardiac hypertrophy (Desir 2008; Ghosh et al., 2008). Human renalase is encoded by a 311Kbp gene with 10 exons located on chromosome 10q23.33. The major isoform of renalase contains 342 amino acids comprising a signal peptide (amino acids 1–17), a flavin-adenine dinucleotide (FAD) binding domain (amino acids 4–45), and a monoamine oxidase domain (amino acids 75–342). Evidence exists for at least four alternatively- spliced isoforms of renalase (Desir, 2009). The most common isoform (renalase1) is encoded by exons 1–4, 6–7, and 9. It is the predominant human renalase protein detectable in plasma, kidney, heart, skeletal muscle,

Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease 9

rabbits. It has been reported that P-selectin-deficient mice on an atherogenic diet develop significantly smaller fatty streaks than non-deficient mice (Johnson, R.C., et al. 1997). In humans, plasma P selectin levels have been shown to be increased in diabetic patients, in patients with unstable angina, post-angioplasty restenosis and after coronary artery spasm

Recent study that genotyped 5 single nucleotide polymorphisms (SNPs) in P-selectin (*SELP*) (V168M, S290N, N592D, V599L, T715P), 2 SNPs (M62I, S273F) in P-selectin glycoprotein ligand-1 (*SELPLG*), 5 SNPs in *CD40LG* (−3459A>G, −122A>C, −123A>C, 148T>C, intr4– 13T>C), the H558R SNP in *SCN5A*, and rs2106261 in *ZFHX3*. In addition, length polymorphisms in *SELPLG* (36bp-tandem repeat) and *CD40LG* (CA-repeat) were genotyped by PCR methods. None of the gene polymorphisms showed significant differences between AMI patients and healthy controls. Among patients with a history of VF (Ventricular fibrillation), however, the SELP 168M variant showed a significantly higher prevalence as compared with patients without VF. This was the first description of an association of the SELP gene variant 168M with primary VF during acute MI. This variant may be a novel polymorphism for evaluating the susceptibility for VF in the setting of acute MI. (Elmas, 2010)

Kinase insert domain-containing receptor/fetal liver kinase-1, also called VEGFR2 (KDR), is expressed in a wide variety of cells such as endothelial progenitor cells (EPCs), endothelial cells, and primitive and more mature hematopoietic cells. Kinase insert domain-containing receptor/ fetal liver kinase-1 is required for the differentiation of EPCs and for the movement of EPCs from the posterior primitive streak to the yolk sac, a precondition for the subsequent formation of blood vessels (Shalaby et al., 1997). Studies with *KDR* knockout mice have found that KDR plays critical roles in the development and formation of blood vessel networks (Fong et al., 1995). Vascular endothelial growth factor binds to 2 tyrosine kinase receptors, VEGF receptor-1 (VEGFR1, Flt-1) and KDR, in endothelial cells. The mitogenic and chemotactic effects of VEGF are mediated mainly through KDR in endothelial cells VEGF receptor signal transduction which is activated through autophosphorylation of tyrosine residues in the cytoplasmic kinase domain of KDR. This event is followed by activation of downstream signaling pathways such as mitogenactivated protein kinases, Akt and eNOS, which are essential for migration and proliferation of endothelial cells, thereby stimulating angiogenesis (Matsumoto & Claesson-Welsh, 2001). After vascular endothelial growth factor (VEGF) binding to KDR, multiple early signaling cascades are activated in EPCs and in endothelial cells. An array of biological activities are subsequently elicited in vivo and in vitro, including angiogenesis, endothelial survival, proliferation, migration, and increased production of nitric oxide and prostaglandin I2 (Gerber et al., 1994). Dysregulated vessel growth is implicated in the pathogenesis of a wide variety of diseases, including proliferative retinopathies, tumors, rheumatoid arthritis, atherosclerosis, as well as CHD. (Dimmeler et al., 2001; Rehman et al., 2004; Werner et al., 2002). The variation of *KDR* gene may change the biological function of KDR. Bioinformatic analysis showed that the single nucleotide polymorphism (SNP) -604T/C (rs2071559) leads to structural alteration of the binding site for transcriptional factor E2F (involving in cell cycle regulation, interacting with Rb p107 protein) in *KDR* gene promoter region, which may alter KDR expression. Exonic polymorphisms SNP1192G/A (rs2305948, in exon 7) and SNP1719A/T (rs1870377, in exon 11) are located in the third and fifth NH2-terminal IG-like

(Kaikita, K. , 1995).

**4.5 KDR**

and liver. The functional significance of the spliced isoforms is not known. It has weak AA similarities to MAO-A and MAO-B and distinct substrate specificity and inhibitor profile, which indicates that it represents a new class of FAD-containing monoamine oxidases. MAO-A and MAO-B are FAD containing, mitochondrial enzymes that metabolize intracellular catecholamines. MAO-A and MAO-B have overlapping substrate specificity; catabolize neurotransmitters such as epinephrine, norepinephrine, serotonin, and dopamine; and are specifically inhibited by clorgyline and deprenyl, respectively. Polyamine oxidase, the other known FAD-containing oxidase, is an intracellular oxidase that metabolizes spermine and spermidine and regulates cell growth (Jalkanen & Salmi, 2001). Unlike MAO-A and MAO-B, which are anchored through the carboxyl terminus to the outer mitochondrial membrane (Binda et al., 2002) and confined to intracellular compartments, renalase is secreted into the blood, where it is detectable by Western blotting. Amine oxidase activity has been measured in human plasma and is believed to be mediated by vascular adhesion protein 1 (VAP-1), a copper-containing semicarbazide-sensitive amine oxidase that is secreted by smooth muscle cells, adipocytes, and endothelial cells (Salmi & Jalkanen, 2001). VAP-1's substrate specificity and inhibitor profile are very different from that of renalase. It metabolizes benzylamine and methylamine and is inhibited by semicarbazide and hydroxylamine. Therefore, renalase is the only known amine oxidase that is secreted into blood and that metabolizes circulating catecholamines. While the hypotensive effect of renalase can be fully accounted for by the observed decrease in contractility and heart rate, we cannot categorically exclude the possibility that renalase's effect may be partly receptor mediated.

A common missense polymorphism in the flavin-adenine dinucleotide-binding domain of human renalase (Glu37Asp) has recently been described. This is the only reported common coding single-nucleotide polymorphism in the renalase gene, and was recently found to be associated with essential hypertension (Zhao et al., 2007). Whether common genetic variation at this locus affects cardiac structure, function, and ischemia in humans is not known.

#### **4.4 P-selectin**

P-selectin (GMP-140; granule membrane protein-140) is an adhesion molecule which mediates the interaction of activated endothelial cells or platelets with leukocytes. The selectin family of adhesion molecules also comprises E- and L-selectin. The genes coding for the three selectins are clustered on chromosome 1q21–q24 (Watson et al., 1990). The Pselectin gene spans >50 kb and contains 17 exons, most of which encode structurally distinct domains. P-selectin is stored in a-granules of platelets and the Weibel–Palade bodies of vascular endothelial cells (McEver et al., 1989) it rapidly shifts from the membranes of secretory granules to the surface of platelets and endothelial cells upon stimulation by oxidized low density lipoprotein (LDL) (Vora et al., 1997), oxygen radicals (Patel et al., 1991), thrombin (Lorant et al., 1991), cytokines and various other stimuli (Zimmermann, et al., 1990). P-selectin is required for efficient recruitment of neutrophils in acute and chronic inflammation (Johnson, R.C., et al. 1995) and recently has been shown to bind T cells on vascular endothelial cells. These properties suggest that P-selectin could contribute to atherogenesis (Hansson, G.K. , 1989, Libby, P. and Hansson, G.K.,1991). Actually, P-selectin expression has been demonstrated to be significantly increased in endothelium overlying atherosclerotic plaques, and it is focally expressed in the aorta of hypercholesterolemic rabbits. It has been reported that P-selectin-deficient mice on an atherogenic diet develop significantly smaller fatty streaks than non-deficient mice (Johnson, R.C., et al. 1997). In humans, plasma P selectin levels have been shown to be increased in diabetic patients, in patients with unstable angina, post-angioplasty restenosis and after coronary artery spasm (Kaikita, K. , 1995).

Recent study that genotyped 5 single nucleotide polymorphisms (SNPs) in P-selectin (*SELP*) (V168M, S290N, N592D, V599L, T715P), 2 SNPs (M62I, S273F) in P-selectin glycoprotein ligand-1 (*SELPLG*), 5 SNPs in *CD40LG* (−3459A>G, −122A>C, −123A>C, 148T>C, intr4– 13T>C), the H558R SNP in *SCN5A*, and rs2106261 in *ZFHX3*. In addition, length polymorphisms in *SELPLG* (36bp-tandem repeat) and *CD40LG* (CA-repeat) were genotyped by PCR methods. None of the gene polymorphisms showed significant differences between AMI patients and healthy controls. Among patients with a history of VF (Ventricular fibrillation), however, the SELP 168M variant showed a significantly higher prevalence as compared with patients without VF. This was the first description of an association of the SELP gene variant 168M with primary VF during acute MI. This variant may be a novel polymorphism for evaluating the susceptibility for VF in the setting of acute MI. (Elmas, 2010)

#### **4.5 KDR**

8 Advances in the Diagnosis of Coronary Atherosclerosis

and liver. The functional significance of the spliced isoforms is not known. It has weak AA similarities to MAO-A and MAO-B and distinct substrate specificity and inhibitor profile, which indicates that it represents a new class of FAD-containing monoamine oxidases. MAO-A and MAO-B are FAD containing, mitochondrial enzymes that metabolize intracellular catecholamines. MAO-A and MAO-B have overlapping substrate specificity; catabolize neurotransmitters such as epinephrine, norepinephrine, serotonin, and dopamine; and are specifically inhibited by clorgyline and deprenyl, respectively. Polyamine oxidase, the other known FAD-containing oxidase, is an intracellular oxidase that metabolizes spermine and spermidine and regulates cell growth (Jalkanen & Salmi, 2001). Unlike MAO-A and MAO-B, which are anchored through the carboxyl terminus to the outer mitochondrial membrane (Binda et al., 2002) and confined to intracellular compartments, renalase is secreted into the blood, where it is detectable by Western blotting. Amine oxidase activity has been measured in human plasma and is believed to be mediated by vascular adhesion protein 1 (VAP-1), a copper-containing semicarbazide-sensitive amine oxidase that is secreted by smooth muscle cells, adipocytes, and endothelial cells (Salmi & Jalkanen, 2001). VAP-1's substrate specificity and inhibitor profile are very different from that of renalase. It metabolizes benzylamine and methylamine and is inhibited by semicarbazide and hydroxylamine. Therefore, renalase is the only known amine oxidase that is secreted into blood and that metabolizes circulating catecholamines. While the hypotensive effect of renalase can be fully accounted for by the observed decrease in contractility and heart rate, we cannot categorically exclude the possibility that renalase's

A common missense polymorphism in the flavin-adenine dinucleotide-binding domain of human renalase (Glu37Asp) has recently been described. This is the only reported common coding single-nucleotide polymorphism in the renalase gene, and was recently found to be associated with essential hypertension (Zhao et al., 2007). Whether common genetic variation at this locus affects cardiac structure, function, and ischemia in humans is not

P-selectin (GMP-140; granule membrane protein-140) is an adhesion molecule which mediates the interaction of activated endothelial cells or platelets with leukocytes. The selectin family of adhesion molecules also comprises E- and L-selectin. The genes coding for the three selectins are clustered on chromosome 1q21–q24 (Watson et al., 1990). The Pselectin gene spans >50 kb and contains 17 exons, most of which encode structurally distinct domains. P-selectin is stored in a-granules of platelets and the Weibel–Palade bodies of vascular endothelial cells (McEver et al., 1989) it rapidly shifts from the membranes of secretory granules to the surface of platelets and endothelial cells upon stimulation by oxidized low density lipoprotein (LDL) (Vora et al., 1997), oxygen radicals (Patel et al., 1991), thrombin (Lorant et al., 1991), cytokines and various other stimuli (Zimmermann, et al., 1990). P-selectin is required for efficient recruitment of neutrophils in acute and chronic inflammation (Johnson, R.C., et al. 1995) and recently has been shown to bind T cells on vascular endothelial cells. These properties suggest that P-selectin could contribute to atherogenesis (Hansson, G.K. , 1989, Libby, P. and Hansson, G.K.,1991). Actually, P-selectin expression has been demonstrated to be significantly increased in endothelium overlying atherosclerotic plaques, and it is focally expressed in the aorta of hypercholesterolemic

effect may be partly receptor mediated.

known.

**4.4 P-selectin**

Kinase insert domain-containing receptor/fetal liver kinase-1, also called VEGFR2 (KDR), is expressed in a wide variety of cells such as endothelial progenitor cells (EPCs), endothelial cells, and primitive and more mature hematopoietic cells. Kinase insert domain-containing receptor/ fetal liver kinase-1 is required for the differentiation of EPCs and for the movement of EPCs from the posterior primitive streak to the yolk sac, a precondition for the subsequent formation of blood vessels (Shalaby et al., 1997). Studies with *KDR* knockout mice have found that KDR plays critical roles in the development and formation of blood vessel networks (Fong et al., 1995). Vascular endothelial growth factor binds to 2 tyrosine kinase receptors, VEGF receptor-1 (VEGFR1, Flt-1) and KDR, in endothelial cells. The mitogenic and chemotactic effects of VEGF are mediated mainly through KDR in endothelial cells VEGF receptor signal transduction which is activated through autophosphorylation of tyrosine residues in the cytoplasmic kinase domain of KDR. This event is followed by activation of downstream signaling pathways such as mitogenactivated protein kinases, Akt and eNOS, which are essential for migration and proliferation of endothelial cells, thereby stimulating angiogenesis (Matsumoto & Claesson-Welsh, 2001). After vascular endothelial growth factor (VEGF) binding to KDR, multiple early signaling cascades are activated in EPCs and in endothelial cells. An array of biological activities are subsequently elicited in vivo and in vitro, including angiogenesis, endothelial survival, proliferation, migration, and increased production of nitric oxide and prostaglandin I2 (Gerber et al., 1994). Dysregulated vessel growth is implicated in the pathogenesis of a wide variety of diseases, including proliferative retinopathies, tumors, rheumatoid arthritis, atherosclerosis, as well as CHD. (Dimmeler et al., 2001; Rehman et al., 2004; Werner et al., 2002). The variation of *KDR* gene may change the biological function of KDR. Bioinformatic analysis showed that the single nucleotide polymorphism (SNP) -604T/C (rs2071559) leads to structural alteration of the binding site for transcriptional factor E2F (involving in cell cycle regulation, interacting with Rb p107 protein) in *KDR* gene promoter region, which may alter KDR expression. Exonic polymorphisms SNP1192G/A (rs2305948, in exon 7) and SNP1719A/T (rs1870377, in exon 11) are located in the third and fifth NH2-terminal IG-like

Mechanisms of Disease: Novel Polymorphisms in Coronary Artery Disease 11

genetic and clinical data need to be established and since genes and environmental factors are both involved in this disease; environmental causes and gene-environment interactions must be carefully assessed. These results will provide clues to the involvement and investigation of novel candidate genes in association studies. Large replication studies with different ethic samples are needed to investigate whether there are ethnic differences in the influence of novel polymorphisms on coronary artery disease. This issue should be investigated with different ethnic samples in the future. Therefore studies with large sample size of coronary artery disease and different ethnicity will be welcome to help elucidate the

interconnection between novel genetics and pathogenesis of coronary artery disease.

**7.

ChREBP: Carbohydrate response element binding protein

domains within the extracellular region, which are important for ligand binding, and result in nonsynonymous amino acid changes at residue 297V/I and 472H/Q, respectively. It is showed that patients carrying the KDR mutations are more susceptible to CHD. The higher CHD risk could be due to downregulation of the VEGF/KDR signaling pathway. However, the angiogenesis preceded by VEGF/KDR signaling pathway could be decreased due to low KDR activity. The SNP-604T/C decreases mRNA levels of KDR and both SNP1192G/A and SNP1719T/A resulted in slight but significant decrease in the VEGF binding efficiency to KDR. One can speculate that the decrease in KDR function is correlated with vascular dysfunction, including endothelial cell damage, impaired endothelial cell survival, decreased antiapoptotic effects of VEGF, and abnormal vascular repair. All of these can promote the progression of atherosclerotic disease. A previous study has suggested that - 907T/C, -11903G/A, and -18487A/T (now called SNP-604, SNP1192, and SNP1719, respectively) have no significant association with the development of coronary artery lesion in Japanese subjects with Kawasaki disease (Kariyazono et al., 2004). The differences between the studies could be due to the different pathologic mechanism between the coronary artery lesion with Kawasaki disease and CHD, different genetic background of the populations as well as the sample size in different studies. (Schmidt-Lucke et al., 2005). The genotype frequencies of the 3 SNPs from the HapMap data were similar to others. The rs2071559 can capture rs7667298 (exon\_1, untranslated). No linkage disequilibrium was found in rs2305948 with other SNPs in HapMap CHB data. The rs1870377 (exon\_11) can capture rs10016064 (intron\_13), rs17085265 (intron\_21), rs3816584 (intron\_16), rs6838752 (intron\_17), rs1870379 (intron\_15), rs2219471 (intron\_20), rs1870378 (intron\_15), rs13136007 (intron\_13), and rs17085262 (intron\_21). The results showed that 2 blocks were captured by SNP-604 (rs2071559) and SNP1719 (rs1870377), respectively, and SNP1192 (rs2305948) were associated with CHD.

## **5. Other novel polymorphisms**

Asymmetrical dimethylarginine (ADMA), an endogenous arginine analogue, inhibits nitric oxide synthases and plays an important role in endothelial dysfunction. The results suggest that the DDAH1 (dimethylarginine dimethylaminohydrolase 1) loss-of-function polymorphism is associated with both increased risk of thrombosis stroke and CAD (Ding et al., 2010). Growing evidence has shown that inflammation plays crucial roles in the development of coronary artery disease. Interleukin-16 (IL-16), a multifunctional cytokine, is involved in a series of inflammatory disorders. One finding indicates that *IL-16* may be used as a genetic marker for CAD susceptibility (Wu et al., 2010). Two single-nucleotide polymorphisms (SNPs), rs1746048 and rs501120, from genome wide association studies of coronary artery disease map to chromosome 10q11 ~80 kb downstream of chemokine *CXCL12*. Coronary artery disease risk alleles downstream of *CXCL12* are associated with plasma protein levels of CXCL12 and appear to be related to *CXCL12* transcript levels in two human cell lines. This implicates *CXCL12* as potentially causal and supports CXCL12 as a potential therapeutic target for CAD ( Nehal et al., 2011).

## **6. Conclusion**

Studying only one SNP may be an overly simplistic method in investigating a complex disease such as CAD. Complex traits such as CAD, more large databases of high-quality genetic and clinical data need to be established and since genes and environmental factors are both involved in this disease; environmental causes and gene-environment interactions must be carefully assessed. These results will provide clues to the involvement and investigation of novel candidate genes in association studies. Large replication studies with different ethic samples are needed to investigate whether there are ethnic differences in the influence of novel polymorphisms on coronary artery disease. This issue should be investigated with different ethnic samples in the future. Therefore studies with large sample size of coronary artery disease and different ethnicity will be welcome to help elucidate the interconnection between novel genetics and pathogenesis of coronary artery disease.

## **7. Abbreviations**

10 Advances in the Diagnosis of Coronary Atherosclerosis

domains within the extracellular region, which are important for ligand binding, and result in nonsynonymous amino acid changes at residue 297V/I and 472H/Q, respectively. It is showed that patients carrying the KDR mutations are more susceptible to CHD. The higher CHD risk could be due to downregulation of the VEGF/KDR signaling pathway. However, the angiogenesis preceded by VEGF/KDR signaling pathway could be decreased due to low KDR activity. The SNP-604T/C decreases mRNA levels of KDR and both SNP1192G/A and SNP1719T/A resulted in slight but significant decrease in the VEGF binding efficiency to KDR. One can speculate that the decrease in KDR function is correlated with vascular dysfunction, including endothelial cell damage, impaired endothelial cell survival, decreased antiapoptotic effects of VEGF, and abnormal vascular repair. All of these can promote the progression of atherosclerotic disease. A previous study has suggested that - 907T/C, -11903G/A, and -18487A/T (now called SNP-604, SNP1192, and SNP1719, respectively) have no significant association with the development of coronary artery lesion in Japanese subjects with Kawasaki disease (Kariyazono et al., 2004). The differences between the studies could be due to the different pathologic mechanism between the coronary artery lesion with Kawasaki disease and CHD, different genetic background of the populations as well as the sample size in different studies. (Schmidt-Lucke et al., 2005). The genotype frequencies of the 3 SNPs from the HapMap data were similar to others. The rs2071559 can capture rs7667298 (exon\_1, untranslated). No linkage disequilibrium was found in rs2305948 with other SNPs in HapMap CHB data. The rs1870377 (exon\_11) can capture rs10016064 (intron\_13), rs17085265 (intron\_21), rs3816584 (intron\_16), rs6838752 (intron\_17), rs1870379 (intron\_15), rs2219471 (intron\_20), rs1870378 (intron\_15), rs13136007 (intron\_13), and rs17085262 (intron\_21). The results showed that 2 blocks were captured by SNP-604 (rs2071559) and SNP1719 (rs1870377), respectively, and SNP1192 (rs2305948) were

Asymmetrical dimethylarginine (ADMA), an endogenous arginine analogue, inhibits nitric oxide synthases and plays an important role in endothelial dysfunction. The results suggest that the DDAH1 (dimethylarginine dimethylaminohydrolase 1) loss-of-function polymorphism is associated with both increased risk of thrombosis stroke and CAD (Ding et al., 2010). Growing evidence has shown that inflammation plays crucial roles in the development of coronary artery disease. Interleukin-16 (IL-16), a multifunctional cytokine, is involved in a series of inflammatory disorders. One finding indicates that *IL-16* may be used as a genetic marker for CAD susceptibility (Wu et al., 2010). Two single-nucleotide polymorphisms (SNPs), rs1746048 and rs501120, from genome wide association studies of coronary artery disease map to chromosome 10q11 ~80 kb downstream of chemokine *CXCL12*. Coronary artery disease risk alleles downstream of *CXCL12* are associated with plasma protein levels of CXCL12 and appear to be related to *CXCL12* transcript levels in two human cell lines. This implicates *CXCL12* as potentially causal and supports CXCL12 as a

Studying only one SNP may be an overly simplistic method in investigating a complex disease such as CAD. Complex traits such as CAD, more large databases of high-quality

associated with CHD.

**6. Conclusion**

**5. Other novel polymorphisms**

potential therapeutic target for CAD ( Nehal et al., 2011).

ABCA1: ATP-binding cassette transporter 1 ACC: acetyl-CoA carboxylase ALOX5AP: Arachidonate 5-lipoxygenase-activating protein. APOA1: Apolipoprotein A1 CAD: Coronary artery disease LCAT: Lecithin-cholesterol acyltransferase CHD: Coronary heart disease ChoRE: Carbohydrate response element ChREBP: Carbohydrate response element binding protein ELISA: Enzyme-linked immunosorbent assay EPCs: Endothelial progenitor cells ERK 1/2 : Extracellular signal-regulated kinases1/2 FAD: Flavin-adenine dinucleotide FAS: Fatty acid synthase GWAS: Genome-wide association Studies HDL: High-density lipoprotein KDR: Kinase insert domain-containing receptor Lp- PLA2: Lipoprotein-associated phospholipase A2 Mad1: Mitotic arrest deficient-like 1 Mad4: Mitotic arrest deficient-like 4 MAO-A: L-Monoamine oxidases A MAO-B : L-Monoamine oxidases B MEF2A: Myocyte enhancer factor 2A MlX: Max-like x protein PPAR: Peroxisome proliferator-activated receptors PK : Pyruvate kinase siRNA: Small interfering RNA SNPs: Single nucleotide polymorphisms Sp1: stimulatory proteins 1 SR-A: Scavenger receptors A TNF: Tumor necrosis factors VAP-1: vascular adhesion protein 1 VCAM-1: Vascular cell adhesion protein 1 VF: Ventricular fibrillation VLDL: Very low density lipoprotein VWF: Von Willebrand factor

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**2**

 *Japan*

**Multifunctional Role of TRAIL**

Katsuhito Mori, Masanori Emoto and Masaaki Inaba

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) belongs to the TNF ligand superfamily. As the name suggests, TRAIL was identified and cloned based on its sequence homology to the extracellular domain of TNF ligand family members (Pitti et al., 1996; Wiley et al., 1995). Human TRAIL consists of 281 amino acids. TRAIL is a type II transmembrane protein with a short intracellular amino-terminal domain and an extracellular carboxy-terminal domain (Fig. 1). TRAIL is cleaved by cysteine proteases from the cell surface to form a soluble ligand, and when released soluble TRAIL is measurable in human blood. TRAIL contains cysteine residue (Cys 230) that interacts with the zinc ion, resulting in the formation of a TRAIL homotrimer (Hymowitz et al., 1999) (Fig. 1). This trimerization is necessary for TRAIL to bind to its receptors and to exert optimal biological activity, as is

described below. (Hao et al., 2004; Johnstone et al., 2008; Wang, 2008; Wu et al., 2004).

TRAIL binds to five different receptors found on a variety of cells. Of these receptors, two, TRAIL-R1 (DR4) and TRAIL-R2 (DR5), contain a cytoplasmic death domain and trigger TRAIL-induced apoptosis. Two decoy receptors lacking a functional death domain, TRAIL-R3 (DcR1) and TRAIL-R4 (DcR2), compete with TRAIL-R1 and TRAIL-R2 for TRAIL binding, possibly antagonizing apoptotic signaling. In addition, osteoprotegerin (OPG) is a fifth soluble decoy receptor. Briefly, the TRAIL apoptosis pathway is initiated by the binding of a TRAIL trimer to TRAIL-R1 or TRAIL-R2, which leads to receptor trimerization. This receptor conformational change recruits the adaptor protein Fas-associated death domain (FADD) through the death domains (DD) of each protein. Subsequently, FADD interacts with caspase-8 and/or -10 through the death effector domain (DED) of each protein, resulting in the assembly of a death-inducing signaling complex (DISC). In the type I pathway, extrinsic signals proteolytically activate caspase-8 and/or -10 followed by stimulation of effector caspase-3 and -7, the key mediators of apoptosis, triggering apoptosis. In the type II intrinsic pathway, however, apoptotic commitment requires an amplification step involving the mitochondrial pathway triggered by caspase-8-dependent cleavage of the Bid protein to its active form, t-Bid (Corallini et al., 2006; Hao et al., 2004; Testa, 2010; Wang, 2008). Since TRAIL-R3, TRAIL-R4, and OPG lack intracellular functional

**1. Introduction**

**in Atherosclerosis and**

**Cardiovascular Disease**

*Department of Metabolism, Endocrinology and Molecular Medicine Osaka City University*

*Graduate School of Medicine, Osaka*

hydroxy-3-methylglutaryl coenzyme A reductase inhibition, Arterioscler *Thromb Vasc Biol* 22: 1567–72.

## **Multifunctional Role of TRAIL in Atherosclerosis and Cardiovascular Disease**

Katsuhito Mori, Masanori Emoto and Masaaki Inaba *Department of Metabolism, Endocrinology and Molecular Medicine Osaka City University Graduate School of Medicine, Osaka Japan*

## **1. Introduction**

18 Advances in the Diagnosis of Coronary Atherosclerosis

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Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) belongs to the TNF ligand superfamily. As the name suggests, TRAIL was identified and cloned based on its sequence homology to the extracellular domain of TNF ligand family members (Pitti et al., 1996; Wiley et al., 1995). Human TRAIL consists of 281 amino acids. TRAIL is a type II transmembrane protein with a short intracellular amino-terminal domain and an extracellular carboxy-terminal domain (Fig. 1). TRAIL is cleaved by cysteine proteases from the cell surface to form a soluble ligand, and when released soluble TRAIL is measurable in human blood. TRAIL contains cysteine residue (Cys 230) that interacts with the zinc ion, resulting in the formation of a TRAIL homotrimer (Hymowitz et al., 1999) (Fig. 1). This trimerization is necessary for TRAIL to bind to its receptors and to exert optimal biological activity, as is described below. (Hao et al., 2004; Johnstone et al., 2008; Wang, 2008; Wu et al., 2004). TRAIL binds to five different receptors found on a variety of cells. Of these receptors, two, TRAIL-R1 (DR4) and TRAIL-R2 (DR5), contain a cytoplasmic death domain and trigger TRAIL-induced apoptosis. Two decoy receptors lacking a functional death domain, TRAIL-R3 (DcR1) and TRAIL-R4 (DcR2), compete with TRAIL-R1 and TRAIL-R2 for TRAIL binding, possibly antagonizing apoptotic signaling. In addition, osteoprotegerin (OPG) is a

fifth soluble decoy receptor. Briefly, the TRAIL apoptosis pathway is initiated by the binding of a TRAIL trimer to TRAIL-R1 or TRAIL-R2, which leads to receptor trimerization. This receptor conformational change recruits the adaptor protein Fas-associated death domain (FADD) through the death domains (DD) of each protein. Subsequently, FADD interacts with caspase-8 and/or -10 through the death effector domain (DED) of each protein, resulting in the assembly of a death-inducing signaling complex (DISC). In the type I pathway, extrinsic signals proteolytically activate caspase-8 and/or -10 followed by stimulation of effector caspase-3 and -7, the key mediators of apoptosis, triggering apoptosis. In the type II intrinsic pathway, however, apoptotic commitment requires an amplification step involving the mitochondrial pathway triggered by caspase-8-dependent cleavage of the Bid protein to its active form, t-Bid (Corallini et al., 2006; Hao et al., 2004; Testa, 2010; Wang, 2008). Since TRAIL-R3, TRAIL-R4, and OPG lack intracellular functional

Multifunctional Role of TRAIL in Atherosclerosis and Cardiovascular Disease 21

Adams, 2005; Benito-Martin et al., 2009; Corallini et al., 2006; Testa, 2010; Vaccarezza et al., 2007). Recently, the involvement of TRAIL in atherosclerosis and cardiovascular diseases has been at the forefront of research efforts (Corallini et al., 2008; Kavurma and Bennett, 2008; Martin-Ventura et al., 2007). In this review, we focus on the role of TRAIL in the

**TRAIL-R3 TRAIL-R4**

**OPG**

**Mitochondria**

Among the five known TRAIL receptors, TRAIL-R1 and –R2 can induce intracellular apoptotic signaling. Upon binding of TRAIL to TRAIL-R1 or –R2, a death-inducing signaling complex (DISC) is formed through the recruitment of Fas-associated death domain (FADD), and subsequently results in the activation of caspase-8/10. In the type I intrinsic pathway, this activation is sufficient to conduct apoptosis through downstream effector caspases. On the other hand, activated Bid by caspase-8 amplifies apoptotic signaling through the mitochondria, which is a necessary step to induce effective downstream signaling in the type II extrinsic pathway. In addition to this activation process, it appears that at least a few other factors, such as receptor-interacting protein (RIP), cellular FLICE-like inhibitory protein (cFLIP), and

**Bid**

**Type II**

**apoptosis**

TRAIL and its receptors are known to be expressed in the cardiovascular system. Therefore, it is easily hypothesized that TRAIL systems may be involved in cardiovascular homeostasis and disorders. To begin with, we will summarize several *in vitro* findings that demonstrate

phosphoprotein enriched in diabetes (PED), are antagonistic to TRAIL-induced apoptosis.

Fig. 2. TRAIL receptors and downstream apoptotic signaling.

**2. TRAIL and the cardiovascular system**

cardiovascular system.

**RIP cFLIP PED**

**TRAIL-R1 TRAIL-R2**

**FADD**

DED

DED

**Caspase-8, 10**

**Type I**

**Caspase-3, 7**

**DD**

**DD**

DED

**DD**

DED

DED

**DD**

**DD**

DED

DED **DISC**

DED

portions, it is conceivable that they do not mediate apoptosis (Fig. 2.). However, even binding of TRAIL to death receptors such as TRAIL-R1 or TRAIL-R2 can antagonize apoptosis and induce cell proliferation under certain conditions in some cells. For example, TRAIL-R1 and TRAIL-R2 recruit receptor-interacting protein (RIP) through their DD, which can activate nuclear factor B (NFB). RIP-mediated NFB activation appears to induce cell proliferation by TRAIL (Hao et al., 2004). TRAIL triggers recruitment of cellular FLICE-like inhibitory protein (cFLIP) to DISC through their DED in some instances. Some cFLIPs appear to prevent TRAIL-induced apoptosis (Hao et al., 2004; Wang, 2008). TRAIL stimulation also recruits phosphoprotein enriched in diabetes (PED) to the DISC. This process inhibits downstream caspase activation in some cases (Hao et al., 2004) (Fig. 2.). Therefore, two contradictory steps should be considered when determining the biological effects of TRAIL besides simple apoptotic signaling. First, TRAIL has death receptors (TRAIL-R1 and TRAIL-R2) and antagonized decoy receptors (TRAIL-R3, TRAIL-R4, and OPG) at the cell surface level. Second, these death receptors can counteract apoptotic signaling at the intracellular level in certain contexts. Thus, TRAIL signaling is very complicated.

**Formation of homotrimer**

TRAIL consists of 281 amino acids with a transmembrane domain that separates the short intracellular and extracellular domains. The extracellular domain of TRAIL is cleaved and released into the bloodstream. TRAIL forms a homotrimer through interactions between zinc ions and each cysteine residue.

Fig. 1. The Structure of TRAIL.

TRAIL has attracted clinical attention as a promising agent for the treatment of cancer since it can induce apoptosis in various tumor cells without having any toxic effects on normal cells (Finnberg and El-Deiry, 2008; Wang, 2008; Wu et al., 2004). Apart from high expectations in the field of cancer, TRAIL also exhibits diverse biological effects on the immune system, hematopoiesis, and metabolic disorders, including diabetes (Afford and

portions, it is conceivable that they do not mediate apoptosis (Fig. 2.). However, even binding of TRAIL to death receptors such as TRAIL-R1 or TRAIL-R2 can antagonize apoptosis and induce cell proliferation under certain conditions in some cells. For example, TRAIL-R1 and TRAIL-R2 recruit receptor-interacting protein (RIP) through their DD, which can activate nuclear factor B (NFB). RIP-mediated NFB activation appears to induce cell proliferation by TRAIL (Hao et al., 2004). TRAIL triggers recruitment of cellular FLICE-like inhibitory protein (cFLIP) to DISC through their DED in some instances. Some cFLIPs appear to prevent TRAIL-induced apoptosis (Hao et al., 2004; Wang, 2008). TRAIL stimulation also recruits phosphoprotein enriched in diabetes (PED) to the DISC. This process inhibits downstream caspase activation in some cases (Hao et al., 2004) (Fig. 2.). Therefore, two contradictory steps should be considered when determining the biological effects of TRAIL besides simple apoptotic signaling. First, TRAIL has death receptors (TRAIL-R1 and TRAIL-R2) and antagonized decoy receptors (TRAIL-R3, TRAIL-R4, and OPG) at the cell surface level. Second, these death receptors can counteract apoptotic signaling at the intracellular level in certain contexts. Thus, TRAIL signaling is very

TRAIL consists of 281 amino acids with a transmembrane domain that separates the short intracellular and extracellular domains. The extracellular domain of TRAIL is cleaved and released into the bloodstream. TRAIL forms a homotrimer through interactions between zinc ions and each cysteine

**NH2 COOH 1 18 38 114 281**

**Cysteine proteases**

**Soluble TRAIL**

**cleavage**

**Receptor Binding Region**

**Formation of homotrimer**

**Cys 230**

**Zn**

TRAIL has attracted clinical attention as a promising agent for the treatment of cancer since it can induce apoptosis in various tumor cells without having any toxic effects on normal cells (Finnberg and El-Deiry, 2008; Wang, 2008; Wu et al., 2004). Apart from high expectations in the field of cancer, TRAIL also exhibits diverse biological effects on the immune system, hematopoiesis, and metabolic disorders, including diabetes (Afford and

complicated.

residue.

Fig. 1. The Structure of TRAIL.

**Transmembrane Domain**

Adams, 2005; Benito-Martin et al., 2009; Corallini et al., 2006; Testa, 2010; Vaccarezza et al., 2007). Recently, the involvement of TRAIL in atherosclerosis and cardiovascular diseases has been at the forefront of research efforts (Corallini et al., 2008; Kavurma and Bennett, 2008; Martin-Ventura et al., 2007). In this review, we focus on the role of TRAIL in the cardiovascular system.

Among the five known TRAIL receptors, TRAIL-R1 and –R2 can induce intracellular apoptotic signaling. Upon binding of TRAIL to TRAIL-R1 or –R2, a death-inducing signaling complex (DISC) is formed through the recruitment of Fas-associated death domain (FADD), and subsequently results in the activation of caspase-8/10. In the type I intrinsic pathway, this activation is sufficient to conduct apoptosis through downstream effector caspases. On the other hand, activated Bid by caspase-8 amplifies apoptotic signaling through the mitochondria, which is a necessary step to induce effective downstream signaling in the type II extrinsic pathway. In addition to this activation process, it appears that at least a few other factors, such as receptor-interacting protein (RIP), cellular FLICE-like inhibitory protein (cFLIP), and phosphoprotein enriched in diabetes (PED), are antagonistic to TRAIL-induced apoptosis.

Fig. 2. TRAIL receptors and downstream apoptotic signaling.

## **2. TRAIL and the cardiovascular system**

TRAIL and its receptors are known to be expressed in the cardiovascular system. Therefore, it is easily hypothesized that TRAIL systems may be involved in cardiovascular homeostasis and disorders. To begin with, we will summarize several *in vitro* findings that demonstrate

Multifunctional Role of TRAIL in Atherosclerosis and Cardiovascular Disease 23

2005). Taken together, these results suggest that the effects of TRAIL on ECs appear to depend on cell culture conditions. Aside from cell apoptosis/proliferation, ECs have a protective role against atherosclerosis by producing nitric oxide (NO), one of the most important vasoactive factors. NO, a potent vasodilator, has antithrombotic and antiinflammatory activity (Sandoo et al., 2010). Interestingly, TRAIL stimulates NO production through activation of endothelial NO synthase (eNOS) in HUVECs (Zauli et al., 2003). In particular, eNOS trafficking appears to be involved in TRAIL-induced eNOS activation. TRAIL can translocate eNOS from the cell membrane to the cytoplasm in HUVECs (Di Pietro et al., 2006). However, microtubule disruption with nocodazole inhibits the eNOS activity induced by TRAIL, suggesting that translocation of eNOS through cytoskeletal reorganization may be necessary for TRAIL-induced NO production (Di Pietro et al., 2006). NO synthesis with cytoskeletal alteration by TRAIL is possibly linked to the migration of

In terms of atherosclerosis, attachment of blood leukocytes to ECs is recognized as the first step in the initiation of this phenomenon (Libby, 2002). It is probable that TRAIL regulates this process as well. An adhesion assay using co-cultured HUVECs and HL-60 leukocytes showed that TRAIL increased the binding of leukocytes to ECs (Li et al., 2003). A later report reproduced the pro-adhesive activity of TRAIL, although its effect was much less than that of pro-inflammatory cytokines such as TNF and interleukin-1 (Secchiero et al., 2005). When TRAIL and pro-inflammatory cytokines were evaluated at the same time, TRAIL pretreatment showed reverse inhibition of TNF and IL 1 induced HL-60 leukocyte adhesion to HUVECs. This inhibitory effect of TRAIL on cell attachment was mediated by down-regulation of the inflammatory chemokines CCL8 and CXCL10, which were stimulated by TNF (Secchiero et al., 2005). In particular, TRAIL-R1 and TRAIL-R2 contributed to the TRAIL-induced down-regulation of chemokine release (Secchiero et al., 2005). Again, TRAIL has multiple context-dependent effects. At any rate, TRAIL may play

Another physiological cellular component is the VSMCs, which are mainly localized in the media and constitute the vascular structure. Once VSMCs are transformed, however, they proliferate and migrate, contributing to the development of atherosclerosis (Ross, 1993). In advanced atheromatous plaques, apoptosis of VSMCs in the fibrous cap may be involved in plaque rupture. The former transformation exacerbates atherosclerosis (Libby, 2002), whereas the latter leads to poorer outcome (Clarke et al., 2006). TRAIL participates in the apoptosis and proliferation of VSMCs as well as ECs. For example, plaque-derived CD4 T cells expressing TRAIL induce apoptosis of VSMCs, probably through the interaction of TRAIL with TRAIL-R2 (Sato et al., 2006). On the other hand, TRAIL has been reported to act on human and rat VSMCs as an anti-apoptotic factor through TRAIL-R1 and –R2 (Secchiero et al., 2004). TRAIL promotes proliferation and migration of VSMCs through activation of ERK (Secchiero et al., 2004). Furthermore, Kavurma et al. reported that TRAIL stimulated proliferation of human VSMCs, although it induced apoptosis at high concentrations (Kavurma et al., 2008). Interestingly, they showed the importance of insulin-like growth factor-1 (IGF-1), one of the most potent growth factors, in TRAIL-induced proliferation of VSMCs. Thus, TRAIL up-regulates expression of the IGF-1 receptor in an NFB-dependent manner (Kavurma et al., 2008). It is thus too soon to decide whether TRAIL causes apoptosis

In addition to the seemingly contradictory findings in ECs and VSMCs, a few reports have suggested that TRAIL has a pro-apoptotic effect on inflammatory lymphocytes (Janssen et

HUVECs stimulated by TRAIL treatment (Zauli et al., 2003).

an important role in EC function, both physiologically and pathologically.

or proliferation in VSMCs, even *in vitro*.

the direct effects of TRAIL on each cellular component in the arterial wall. We will then discuss how TRAIL can act on the cardiovascular system based on evidence from animal models. Subsequently, we try to make causal inferences relating to TRAIL's role in cardiovascular diseases from cross-sectional and longitudinal clinical studies in humans. Finally, we report our recent clinical findings and debate whether TRAIL could be a common biomarker that reflects early to advanced stage atherosclerotic changes.

## **2.1 Effects of TRAIL on cellular components in the arterial wall (***in vitro* **findings)**

Endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) are the principal cellular components of the normal arterial wall. Immune-inflammatory infiltrates such as activated T lymphocytes and macrophages play crucial roles in the onset and development of atherosclerosis (Libby, 2002; Weyand et al., 2008). This process is triggered and exacerbated by complicated interactions between modified lipoproteins and various cellular components. Since TRAIL and its receptors are expressed in both physiological and pathological arterial walls (Corallini et al., 2008; Kavurma and Bennett, 2008; Martin-Ventura et al., 2007; Schoppet et al., 2004), it is hypothesized that TRAIL signaling could regulate vascular wall homeostasis and morbid atherosclerosis. TRAIL is expressed in each cellular component, both in resident cells (ECs, VSMCs) and in infiltrating cells (T lymphocytes and macrophages) (Corallini et al., 2008; Kavurma and Bennett, 2008). To determine the role of TRAIL in atherosclerosis, we must first determine the effects of TRAIL on each cellular component based on results from *in vitro* studies.