(Circulation. 1995;92:2796-2799.)
© 1995 American Heart Association, Inc.
Articles |
Gene Polymorphism but not Catalytic Activity of Angiotensin I–Converting Enzyme Is Associated With Coronary Artery Disease and Myocardial Infarction in Low-Risk Patients
From the Institut für Klinische Chemie und Pathobiochemie (A.G., T.W., O.S., N.K.); Klinik für Herz und Gefäßchirurgie (A.E., F.W.H.); and Abteilung Kardiologie und Angiologie (H.T., W.W., W.H.), Klinikum der Justus-Liebig-Universität Giessen, Germany.
Correspondence to Andreas Gardemann, Institut für Klinische Chemie und Pathobiochemie, Gaffkystr 11, 35392 Giessen, Germany.
 |
Abstract |
|---|
 Top Abstract IntroductionMethods Results Discussion References |
|---|
Background An insertion/deletion (I/D) polymorphism of the angiotensin I–converting enzyme (ACE) gene has been postulated to be associated with an increased risk of coronary artery disease (CAD) and myocardial infarction (MI).
Methods and Results In the present study, the effects of I/D gene polymorphism and of ACE activity on CAD and MI were investigated in 920 individuals who underwent coronary angiography for diagnostic purposes. In the total population and in all CAD and MI groups, a strong association was observed between the gene polymorphism and ACE activities; DD genotypes had approximately twofold higher ACE activities than II genotypes. Although classic risk and protective factors of CAD and MI were identified, associations of ACE genotype and of ACE activity to CAD and MI were not detected in the total population. Among subjects defined to be at lower risk of MI by low body mass index and low cigarette consumption, however, an association of the DD genotype with MI was found. Exclusion of individuals with triglyceride levels >140 mg/dL and cholesterol levels >180 mg/dL revealed an association of the DD genotype with CAD. An association of the ACE activity with CAD or MI could not be demonstrated in any of the low-risk populations.
Conclusions Increased ACE activity obviously is not a risk factor of CAD or MI. The importance of the deletion polymorphism for the development of CAD and MI may be restricted to individuals without classic risk factors.
Key Words: insertion/deletion polymorphism • renin- angiotensin system • gensini score
|
Introduction |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
It has been shown that a gene deletion polymorphism of the ACE gene in intron 16 has been reported to be associated with an increased risk of MI.1 2 3 Studies on its association with CAD revealed controversial results.3 4 5
The contributions of the gene deletion polymorphism and ACE activity to the pathogenesis of CAD and MI have not been studied in a large population of individuals whose coronary anatomy was exactly defined by means of coronary angiography. Therefore, it was the aim of the present study to evaluate the association not only of the ACE gene polymorphism but also of ACE activity with CAD and MI in individuals who underwent coronary angiography for diagnostic purposes.
|
Methods |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Study Population
Gene deletion/insertion polymorphism of the ACE gene was analyzed in 920 white male individuals undergoing coronary angiography for diagnostic purposes. Coronary angiography was performed by the Judkins method. Coronary vessels with at least 50% stenosis were defined as diseased. The GS was calculated as described.6 Angina pectoris and acute MI were diagnosed according to conventional criteria. Mean age was 62±9 years in control subjects (n=470) and 63±9 years in patients with MI (n=450). By means of coronary angiography, the study population could be divided into subjects without detectable CAD (n=80; mean age, 57±10 years), patients with coronary arterial stenoses <50% (n=107, 59±10 years), and CAD patients with single-vessel disease (n=139, 62±9 years), double-vessel disease (n=215, 63±9 years), and triple-vessel disease (n=379, 63±9 years). Control group 1 (n=80) consisted of 32 patients whose coronary anatomy was evaluated for valvular surgery and 48 control subjects who were suspected to have CAD but in whom cardiac diseases were excluded by coronary angiography and other diagnostic interventions. Because the DD genotype has been postulated to be associated with ischemic and idiopathic dilated cardiomyopathy,7 persons with this disorder did not participate in this investigation and therefore were not included in our study population of 920 subjects. Also, patients who received ACE inhibitor medication for >3 months did not participate in the present study because therapy with ACE antagonists could influence the progression of CAD and the development of MI.8
Measurements of Serum Enzymes and Substrates and Definitions
of Variables
Total cholesterol, apoB, apoA1,
and lipoprotein (a) [Lp(a)] were measured by conventional methods of
clinical chemistry. Serum ACE activity was measured in duplicate by a
colorimetric method.9 Because serum ACE
activity is affected by a number of ACE inhibitor
medications, the activity of this enzyme was measured only in sera of
patients without ACE antagonist therapy (n=769).
Detection of Insertion/Deletion Polymorphism of the ACE
Gene
Leukocyte DNA was amplified according to Reference 10. Amplified
DNA was electrophoresed in 2% agarose gels and visualized by ethidium
bromide staining. The polymorphism of the amplified ACE gene was
demonstrated in agarose gels by the presence of a 490-bp fragment
(insertion polymorphism, I allele) or of a 190-bp fragment
(deletion polymorphism, D allele). Potential mistyping of I/D
heterozygotes was controlled according to Lindpaintner et
al.5
Statistical Analyses
Data presented are mean±SD.
Distribution of
parameters was checked by the Kolmogorov-Smirnov
goodness-of-fit test. Since BMI, apoB,
apoA1, Lp(a), GS, and ACE activity were not
distributed normally, predominantly nonparametric tests had
to be applied. The effects of variables on MI were tested by
multiple logistic regression and by Kruskal-Wallis one-way ANOVA.
The effects on CAD (defined by the degree of vessel disease and by the
GS6 ) were estimated by Kruskal-Wallis one-way ANOVA.
The correlation between ACE activity and age was tested by multiple
regression analysis.
|
Results |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Relation of Established Risk Factors and of ACE Genotype to MI and CAD
Total cholesterol, triglycerides, apoB, apoA1, Lp(a), prevalence of arterial hypertension, BMI, and cigarette consumption were not different between the ACE genotypes of the total study population and of each subgroup (not shown).
MI
Whereas triglycerides
(P<.05),
cholesterol (P<.05), apoB (P<.05),
diabetes mellitus (P<.05), and cigarette consumption
(P<.05) were identified as risk factors of MI and
apoA1 (P<.05) as a protective factor against
MI, no association was found between the ACE I/D genotype and
risk of MI (Table
). Although in the present study
population, age at first MI ranged from 32 to 86 years, subjects with
the DD genotype did not suffer their first MI at younger ages
than persons with the ID or II genotype either in the total
population (II, 57.6±10 years; ID, 56.6±9 years; and DD,
56.7±10
years) or in low-risk groups (not shown). However, among subjects
defined to be at lower risk of MI by low BMI (<25 kg/m2)
and low cigarette consumption (<5 pack-years), a significant
association of the ACE DD genotype with MI was found
(P<.02). Exclusion of subjects with hypertension and BMI
<25 kg/m2 revealed an association of DD with MI
(P<.05).
|
CAD
Levels of triglyceride
(P<.01),
cholesterol (P<.05), apoB (P<.001),
and Lp(a) (P<.01) as well as diabetes mellitus
(P<.0001), hypertension (P<.01), and cigarette
consumption (P<.001) were demonstrated to be risk factors
for CAD, and apoA1 (P<.01) was demonstrated to
be a protective factor against CAD. In contrast, the I and D allele
frequencies were not only similar between healthy persons and patients
with CAD but also did not exhibit any significant differences among
patients with single-, double-, or triple-vessel disease
(Table
).
In addition, the GSs of II, ID, and DD genotype subjects were
essentially the same in the total population and in each CAD or MI
group (Fig 1). However, among subjects at lower risk of
CAD (levels of triglycerides <140 mg/dL and
cholesterol <180 mg/dL), a significant association of the
ACE DD genotype with CAD was found (degree of vessel disease,
P<.01; GS, P<.002).
|
50%
stenosis were defined as diseased. The GS was calculated as
described previously.
Relation of ACE Activity to MI and CAD
A strong association
between ACE gene polymorphism and
enzymatic activity was observed not only in the total study population
(P<.0001; II genotype, 20.7±13.2 IU/mL; ID
genotype, 27.8±17.4 IU/mL; DD genotype, 38.3±20.8)
but also in all CAD and MI groups (Fig 2). An
interaction of ACE activity with age was not observed either in the
total study population (r=.002, P=.96) or in
the
subgroups of control subjects (r=.01, P=.83)
and
MI patients (r=.01, P=.86).
|
50% stenosis were defined as diseased. Values are mean±SD.
n.s. indicates not significant; NVD, no vessel disease; SVD,
single-vessel disease; DVD, double-vessel disease; and TVD,
triple-vessel disease. Numbers of subjects are given in
parentheses. *P<.05.
MI
A significant difference in ACE activities between control
subjects and MI patients was not observed (P=.73; II
genotype, P=.49; ID genotype,
P=.68; DD genotype, P=.52) either in the
total population (Fig 2) or in low-risk groups (not shown).
CAD
An association of ACE activity with CAD was not
detected either in
the total population (degree of vessel disease, P=.89; GS,
P=.83) or in groups of II genotype subjects (degree
of vessel disease, P=.63; GS, P=.28), ID
genotype subjects (degree of vessel disease, P=.66;
GS, P=.66), and DD genotype subjects (degree of
vessel disease, P=.53; GS, P=.23) (Fig
3). Also, no interaction of ACE activity with CAD was
observed in low-risk groups (not shown).
|
Discussion |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
MI
Cambien et al1 were the first to report on an association of gene deletion polymorphism with an increased risk of MI. The results of the present study demonstrate that in the total population gene deletion polymorphism of the ACE gene was not associated with an increased risk for MI. These results are in line with those of Cambien and colleagues,11 who reported that ACE gene I/D polymorphism was only weakly associated with MI in the whole population. Furthermore, not only in Cambien et al1 but also in our study, an association of the DD genotype to an increased risk for MI was found in low-risk groups. In contrast to the findings of Cambien et al, we did not detect an association in low-risk patients defined by apoB <1.25 g/L and BMI <26 kg/m2.
The findings of Cambien et al11 suggest that increased ACE activity may be an independent risk factor for MI in subjects younger than age 55 years. In contrast, in our investigation, an association of ACE activity to MI was not found clearly either in young or in old patients. Reasons for these discrepancies are not known.
CAD
Studies on the association of gene deletion polymorphism
with
CAD revealed controversial results. It was reported in a rather small
population of individuals (n=245) that the DD genotype was more
closely associated with CAD compared with ID and II
genotypes.2 In other
studies3 4 5 and
the present investigation, an association of the ACE I/D
genotype with CAD in the total population was not observed.
Similar to the report of Mattu et al,4 in the present
study the DD genotype was associated with CAD only in
low-risk patients.
Potential interactions of ACE activity with CAD have not been investigated yet. The present results clearly demonstrate that ACE activity in healthy persons without CAD and in patients with single-vessel or multivessel disease was essentially the same. This conclusion can be drawn for subjects with II, ID, or DD genotypes.
In general, the results of the present study and of published investigations allow the assumption that the importance of gene deletion polymorphism may be restricted to individuals without classic risk factors. Indeed, it is a common observation that there is a population of patients who develop CAD and MI without having classic risk factors. The identification of the deletion polymorphism in these individuals, and possibly of other polymorphisms, such as the A/C polymorphism of the angiotensin II type 1 receptor gene,12 may be important for primary or secondary prevention of CAD and MI.
|
Selected Abbreviations and Acronyms |
|---|
|
|
Acknowledgments |
|---|
The authors gratefully acknowledge the excellent technical assistance of Monika Fink.
Received July 20, 1995; revision received September 11, 1995; accepted September 21, 1995.
|
References |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
-
Cambien F, Poirier O, Lecerf L, Evans A, Cambou
JP, Arveiler D, Luc G, Bard JM, Bara L, Ricard S, Tiret L, Amouyel P,
Alhenc-Gelas F, Soubrier F. Deletion polymorphism in the
gene for angiotensin-converting enzyme is a potent risk
factor for myocardial infarction. Nature. 1992;359:641-644. [Medline]
[Order article via Infotrieve]
-
Nakai K, Itoh C, Miura Y, Hotta K, Musha T, Itoh T,
Miyakawa T, Iwasaki R, Hiramori K. Deletion polymorphism of
the angiotensin I–converting enzyme gene is associated
with serum ACE concentration and increased risk for CAD in the
Japanese. Circulation. 1994;90:2199-2202.
[Abstract/Free Full Text]
-
Ludwig EH, Comeli PS, Anderson JL, Marshall HW,
Lalouel JM, Ward RH. Angiotensin-converting
enzyme gene polymorphism is associated with myocardial infarction
but not with development of coronary stenosis.
Circulation. 1995;91:2120-2124.
[Abstract/Free Full Text]
-
Mattu RK, Needham EWA, Galton DJ, Frangos E, Clark
AJL, Caulfield M. A DNA variant at the
angiotensin-converting enzyme gene locus associates
with coronary artery disease in the Caerphilly heart
study. Circulation. 1995;91:270-274.
[Abstract/Free Full Text]
-
Lindpaintner K, Pfeffer MA, Kreutz R, Stampfer M,
Grodstein F, LaMotte F, Buring J, Hennekens CH. A prospective
evaluation of an angiotensin-converting-enzyme gene
polymorphism and the risk of ischemic heart
disease. N Engl J Med. 1995;332:706-711.
[Abstract/Free Full Text]
-
Gensini GG. A more meaningful scoring system
for determining the severity of coronary heart disease.
Am J Cardiol. 1983;51:606. [Medline]
[Order article via Infotrieve]
-
Raynolds MV, Bristow MR, Bush EW, Abraham WR, Lowes
BD, Zisman LS, Taft CS, Perryman MB.
Angiotensin-converting enzyme DD
genotype in patients with ischemic or idiopathic
dilated cardiomyopathy. Lancet. 1993;342:1073-1075. [Medline]
[Order article via Infotrieve]
-
Kurtz TW. The ACE of hearts.
Nature. 1992;359:588-589. [Medline]
[Order article via Infotrieve]
-
Neels HM. Improved micromethod for assay of
serum angiotensin converting enzyme. Clin
Chem. 1982;28:1352-1355.
[Abstract/Free Full Text]
-
Rigat B, Hubert C, Corvol P, Soubrier F. PCR
detection of the insertion/deletion polymorphism of the human
angiotensin converting enzyme gene (DCP1) (dipeptidyl
carboxypeptidase 1). Nucleic Acids Res. 1992;20:1433.
[Free Full Text]
-
Cambien F, Costerousse O, Tiret L, Poirier O, Lecerf L,
Gonzales MF, Evans A, Arweiler D, Cambou JP, Luc G, Rakotovao R,
Ducimetiere P, Soubrier F, Alhenc-Gelas F. Plasma level and gene
polymorphism of angiotensin-converting enzyme in
relation to myocardial infarction.
Circulation. 1994;90:669-676.
[Abstract/Free Full Text]
-
Tiret L, Bonnardeaux A, Poirier O, Ricard S,
Marques-Vidal P, Evans A, Arveiler D, Luc G, Kee F, Ducimetiere P,
Soubrier F, Cambien F. Synergistic effects of
angiotensin-converting enzyme and
angiotensin-II type 1 receptor gene polymorphisms on
risk of myocardial infarction. Lancet. 1994;344:910-913.[Medline]
[Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  F. L Ruberg and J. Loscalzo Prothrombotic determinants of coronary atherothrombosis Vascular Medicine, November 1, 2002; 7(4): 289 - 299. [Abstract] [PDF]
|
|
|
|
 |
|
 H. Volzke, J. Engel, V. Kleine, C. Schwahn, J. B. Dahm, L. Eckel, and R. Rettig Angiotensin I-Converting Enzyme Insertion/Deletion Polymorphism and Cardiac Mortality and Morbidity After Coronary Artery Bypass Graft Surgery* Chest, July 1, 2002; 122(1): 31 - 36. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. P. Rossi, S. Taddei, A. Virdis, L. Ghiadoni, G. Albertin, S. Favilla, I. Sudano, A. C. Pessina, and A. Salvetti Exclusion of the ACE D/I Gene Polymorphism as a Determinant of Endothelial Dysfunction Hypertension, February 1, 2001; 37(2): 293 - 300. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Agerholm-Larsen, B. G. Nordestgaard, and A. Tybjarg-Hansen ACE Gene Polymorphism in Cardiovascular Disease : Meta-Analyses of Small and Large Studies in Whites Arterioscler. Thromb. Vasc. Biol., February 1, 2000; 20(2): 484 - 492. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S JEFFERY, A K S. MALIK, A CROSBY, M BLAND, J B EASTWOOD, J AMOAH-DANQUAH, J W ACHEAMPONG, and J PLANGE-RHULE A dominant relationship between the ACE D allele and serum ACE levels in a Ghanaian population J. Med. Genet., November 1, 1999; 36(11): 869 - 870. [Full Text]
|
|
|
|
 |
|
 B. T. Heijmans, R. G. J. Westendorp, D. L. Knook, C. Kluft, and P. E. Slagboom Angiotensin I-converting enzyme and plasminogen activator inhibitor-1 gene variants: risk of mortality and fatal cardiovascular disease in an elderly population-based cohort J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1176 - 1183. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Pfohl, M. Koch, S. Prescod, K.K. Haase, H.U. Haring, and K.R. Karsch Angiotensin I-converting enzyme gene polymorphism, coronary artery disease and myocardial infarction. An angiographically controlled study Eur. Heart J., September 2, 1999; 20(18): 1318 - 1325. [Abstract] [PDF]
|
|
|
|
 |
|
 G. I. Rice, C. A. Foy, and P. J. Grant Angiotensin converting enzyme and angiotensin II type 1-receptor gene polymorphisms and risk of ischaemic heart disease Cardiovasc Res, March 1, 1999; 41(3): 746 - 753. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. J. O'Donnell, K. Lindpaintner, M. G. Larson, V. S. Rao, J. M. Ordovas, E. J. Schaefer, R. H. Myers, and D. Levy Evidence for Association and Genetic Linkage of the Angiotensin-Converting Enzyme Locus With Hypertension and Blood Pressure in Men but Not Women in the Framingham Heart Study Circulation, May 19, 1998; 97(18): 1766 - 1772. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Ribichini, G. Steffenino, A. Dellavalle, G. Matullo, E. Colajanni, T. Camilla, A. Vado, G. Benetton, E. Uslenghi, and A. Piazza Plasma Activity and Insertion/Deletion Polymorphism of Angiotensin I–Converting Enzyme : A Major Risk Factor and a Marker of Risk for Coronary Stent Restenosis Circulation, January 20, 1998; 97(2): 147 - 154. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D.-K. Kim, J.-W. Kim, S. Kim, H.-C. Gwon, J.-C. Ryu, J.-E. Huh, J.-A Choo, Y. Choi, C.-H. Rhee, and W.-R. Lee Polymorphism of Angiotensin Converting Enzyme Gene Is Associated With Circulating Levels of Plasminogen Activator Inhibitor-1 Arterioscler. Thromb. Vasc. Biol., November 1, 1997; 17(11): 3242 - 3247. [Abstract] [Full Text]
|
|
|
|
 |
|
 X.-H. Huang, A. Salomaki, R. Malin, T. Koivula, H. Jokela, and T. Lehtimaki Rapid Identification of Angiotensin-Converting Enzyme Genotypes by Capillary Electrophoresis Clin. Chem., November 1, 1997; 43(11): 2195 - 2196. [Full Text]
|
|
|
|
|
|
B. Tian, Q. C. Meng, Y.-F. Chen, J. H. Krege, O. Smithies, and S. Oparil Blood Pressures and Cardiovascular Homeostasis in Mice Having Reduced or Absent Angiotensin-Converting Enzyme Gene Function Hypertension, July 1, 1997; 30(1): 128 - 133. [Abstract] [Full Text]
|
|
|
|
|
|
J. H. Krege, H.-S. Kim, J. S. Moyer, J. C. Jennette, L. Peng, S. K. Hiller, and O. Smithies Angiotensin-Converting Enzyme Gene Mutations, Blood Pressures, and Cardiovascular Homeostasis Hypertension, January 1, 1997; 29(1): 150 - 157. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T.-R. Kiema, H. Kauma, A. O. Rantala, M. Lilja, A. Reunanen, Y. A. Kesaniemi, and M. J. Savolainen Variation at the Angiotensin-Converting Enzyme Gene and Angiotensinogen Gene Loci in Relation to Blood Pressure Hypertension, December 1, 1996; 28(6): 1070 - 1075. [Abstract] [Full Text]
|
|
|
|
 |
|
 K.-P. Lesch, D. Bengel, A. Heils, S. Z. Sabol, B. D. Greenberg, S. Petri, J. Benjamin, C. R. Müller, D. H. Hamer, and D. L. Murphy Association of Anxiety-Related Traits with a Polymorphism in the Serotonin Transporter Gene Regulatory Region Science, November 29, 1996; 274(5292): 1527 - 1531. [Abstract] [Full Text]
|
|
|
|
|
|
D. R.J. Singer, C. G. Missouris, and S. Jeffery Angiotensin-Converting Enzyme Gene Polymorphism: What to Do About All the Confusion? Circulation, August 1, 1996; 94(3): 236 - 239. [Full Text]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||