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(Circulation. 2000;101:e195.)
© 2000 American Heart Association, Inc.

Circulation Electronic Pages

Hemostatic Function and Coronary Artery Disease

John B. Kostis, MD; Clifton R. Lacy, MD

Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ

	Introduction

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To the Editor:

The lack of an independent relationship between fibrinogen level and recurrent coronary events reported by Moss et al¹ in their recent article is at variance with previous evidence linking fibrinogen to coronary artery disease in individuals with and without preexisting cardiovascular disease.² The fibrinogen levels reported by Moss et al are high in both patients who had recurrent events (387±112 mg/dL) and in those who did not (350±85 mg/dL; P<0.05; upper limit of normal for the method used, 300 mg/dL). These high values may be due, in part, to the acute phase reaction of the index infarction. If so, these values obtained 2 months after the event do not accurately represent fibrinogen levels during the mean 26-month follow-up. A strong relationship between fibrinogen and reinfarction was observed when fibrinogen was measured an average of 23.5 months after the index event.³ These findings are further supported by the consistency of previous reports linking fibrinogen to coronary artery disease and the biological plausibility of such an association (increased blood viscosity, platelet aggregation, coagulation, etc). Fibrinogen is a risk factor for infarction and reinfarction in both population-based studies and those performed on patients with preexisting cardiovascular disease.

	References

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1. Moss AJ, Goldstein RE, Marder VJ, et al. Thrombogenic factors and recurrent coronary events. Circulation. 1999;99:2517–2522.[Abstract/Free Full Text]

2. Danesh J, Collins R, Appleby P, et al. Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies. JAMA. 1998;279:1477–1482.[Abstract/Free Full Text]

3. Kostis JB, Baughman DJ, Kuo PT. Association of recurrent myocardial infarction with hemostatic factors: a prospective study. Chest. 1982;81:571–575.[Abstract/Free Full Text]

Response

Arthur J. Moss, MD; Robert E. Goldstein, MD; Victor J. Marder, MD; Charles E. Sparks, MD; David Oakes, PhD; Henry Greenberg, MD; Jarvey J. Weiss, MD; Wojciech Zareba, MD, PhD; Mary W. Brown, MD; Chang-Seng Liang, MD; Edgar Lichstein, MD; William C. Little, MD; John A. Gillespie, MD; Lucy Van Voorhees, MD; Ronald J. Krone, MD; Monty M. Bodenheimer, MD; Judith Hochman, MD; Edward M. Dwyer, Jr, MD; Rohit Arora, MD; Frank I. Marcus, MD; Luc F. Miller Watelet, PhD; Robert B. Case, MD

University of Rochester Medical Center Rochester, NY

	Introduction

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We thank Drs Kostis and Lacy for their comments and focus on fibrinogen. Our post-myocardial infarction cohort^R1 differed considerably from the one reported by Kostis et al^R2 in terms of size of population (1045 versus 147 patients), number of cardiac end points (81 versus 20), average enrollment time after infarction (2 months versus 23.5 months), follow-up duration (26 months versus 38 months), use of adjustment for confounding covariates (yes versus no), use of life-table survivorship analysis (yes versus no), and time frame (1990s versus 1970s), respectively. Our cumulative cardiac event rate was somewhat higher for the top fibrinogen quartile than for the lower 3 quartiles (P=0.07; see Figure 1^R1 ), but this effect was markedly diminished after adjustment for relevant covariates (diabetes mellitus, prior myocardial infarction before the index infarction, infarct type by ECG, pulmonary congestion on chest x-ray, sex, and ejection fraction 0.30). Of note, in the meta-analysis by Danesh et al,^R3 5 of the 6 studies evaluating patients with coronary heart disease had calculated 99% confidence intervals for fibrinogen that touched on or overlapped the null risk ratio of 1.0.

We agree with Drs Kostis and Lacy that elevated fibrinogen levels have some association with recurrent coronary events, but the strength and significance of this association in our prospective study were weak at best, and the causality is less than clear cut. After adjustment for covariates, fibrinogen level was not a significant risk factor for recurrent cardiac events in our 1990s cohort. Elevated levels of D-dimer and apoB and reduced levels of apoA-I were the only independent risk factors in our study.

	References

Top Introduction References Introduction  References

 
1. Moss AJ, Goldstein RE, Marder VJ, et al. Thrombogenic factors and recurrent coronary events. Circulation. 1999;99:2517–2522.

2. Kostis JB, Baughman DJ, Kuo PT. Association of recurrent myocardial infarction with hemostatic factors: a prospective study. Chest. 1982;5:571–575.

3. Danesh J, Collins R, Appleby P, et al. Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies. JAMA. 1998;279:1477–1482.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kostis, J. B. Articles by Case, R. B. Search for Related Content PubMed PubMed Citation Articles by Kostis, J. B. Articles by Case, R. B. Pubmed/NCBI databases Substance via MeSH Related Collections Acute coronary syndromes Acute myocardial infarction Chronic ischemic heart disease Coagulation and fibronolysis Lipid and lipoprotein metabolism