Nghiên cứu sự thay đổi nồng độ c3, c4, IL 6 và hsCRP huyết thanh ở bệnh nhân có hội chứng mạch vành cấp tt tiếng anh

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MINISTRY OF TRAINING AND DUCATION MINISTRY OF DEFENSE MILITARY MEDICAL ACADEMY NGUYEN THI THANH THUY STUDY ABOUT CHANGES IN CONCENTRATION OF C3, C4, IL-6 AND hsCRP IN SERUM OF PATIENTS WITH ACUTE CORONARY SYNDROME Speciality: Biomedical Science Code: 9720101 SUMMARY OF THESIS OF DOCTOR IN MEDECINE HANOI – 2019 THE THESIS WAS ACCOMPLISHED AT MILITARY MEDICAL ACADEMY Scientific Instructors: Prof PHAM MANH HUNG, DrSc Assoc.Prof PHAM NGUYEN VINH, Ph.D Reviewer 1: Prof HUYNH VAN MINH, Ph.D Reviewer 2: Assoc.Prof LE VAN DON, Ph.D Reviewer 3: Assoc.Prof PHAM ĐANG KHOA, Ph.D The thesis was well defended in front of institutional committee at: hh:mm dd mm yyyy The thesis may be referred at: National Library Library of Military Medical Academy Library of Heart Institute in Ho Chi Minh City STUDY PROBLEM Coronary artery disease is one of the most increasingly popular diseases in both developed and developing countries, including Vietnam It accounts for a great proportion of fatal hospitalizations Coronary artery disease consists of acute coronary syndrome (ACS) and chronic coronary artery disease [1] Studies have identified important biomarkers related to the process of atherosclerosis and cardiovascular events [2], [3], [4] The data have demonstrated that inflammatory markers are associated with an increased risk of cardiovascular events [5], [6], [7] Therefore, the study of inflammatory markers are drawing more and more attention, it helps not only classify risk factors but also improve prognosis of coronary artery disease Among them, the inflammatory markers and nonspecific immune factors including hsCRP (high sensitive C- reactive protein), complements C3, C4 and interleukin- are of great interest [11], [12], [13], [14] In addition to hsCRP which has a certain prognostic role in ACS, we also need to evaluate other factors as well as the relationship between them for a comprehensive assessment [3], [15], [16] There have been studies about different factors of inflammation from immune cell surface markers, cytokines, coagulation factors, platelet surface receptors [17], [18], [19] Further studies need to be done in order to highlight the role of cytokines in ACS Currently in our country, there is no published study mentioning simultaneously different nonspecific immune factors such as hsCRP, interleukin-6, complements C3, C4 together with the prognostic factors of ACS From these theoretical and practical bases, we conduct the “Study about the changes in concentration of C3, C4, IL-6 and hsCRP in serum of patients with acute coronary syndrome” with the following objectives: Study the variation of nonspecific immune markers C3, C4, interleukin-6, and hsCRP in serum of patients with acute coronary syndrome Evaluate the relationship between the changes of C3, C4, interleukin-6 and hsCRP and several clinical, paraclinical factors in acute coronary syndrome before and after treatment Summary of new contributions of the thesis: This study mentioned changes in nonspecific immune markers ( including C3, C4, interleukin-6, hsCRP) relating to inflammatory reaction in patients with acute coronary syndrome This study analyzes the correlation between factors C3, C4, interleukin-6, hsCRP with some paraclinical and clinical charecteristics and their mutual reactions in acute coronary syndrome The study demonstrated that concentration of interleukin-6 and hsCRP reduced significantly after coronary intervention procedures The study elucidates role of inflammatory response and some immune factors in the pathogenesis of acute coronary syndrome Together with hsCRP, it suggests that interleukin-6 may be valuable in prognosis of acute coronary syndrome Thesis structure: This study paper has 120 pages, including: - Study problem and objectives: pages - Introduction: 38 pages - Study population and methodology: 15 pages - Results: 31 pages - Discussion: 32 pages - Conclusions and suggestions: pages There are also 51 tables, charts, diagrams, 12 pictures, 156 references (specifically 13 Vietnamese references, 143 English references) CHAPTER INTRODUCTION 1.1 EPIDEMIOLOGY OF ACUTE CORONARY SYNDROME Acute coronary syndrome (ACS), one of the leading causes of death, is on the rise [1] Its prevalence is still increasing and a large number of patients are still suffering from ACS and heart attack [21] In Vietnam, this incidence is also augmenting [20] 1.2 PATHOGENESIS OF ACUTE CORONARY SYNDROME WITH THE ROLE OF IMMUNE MARKERS An inflammatory process takes place in the pathogenesis of ACS [22], [23], [24] The focal inflammatory cells release cytokines to activate endothelial cells, and proinflammatory cytokines to promote the break off of atherosclerotic plaques Since the 1990s, the role of inflammatory biomarkers in ACS has been clearly indicated [25], [26], [27 Intermediate elements secreted from immune cells promote injury progression and activate inflammation in atherosclerotic plaques, leading to ACS [28], [29] New strategies in prognosis, prevention and treatment have been noticed from the background pathogenesis study [30], [31] 1.2.1 Atherosclerosis in the pathogenesis of acute coronary syndrome Acute coronary syndrome is caused by atherosclerotic process Many factors are responsible for the instability of atherosclerotic plaques resulting in ACS [37], [38], [39] Epidemiological studies have shown a close association between the clinical presentation of atherosclerosis and systemic inflammatory markers Many immune cells have signs of activation and production of inflammatory cytokines at atherosclerotic plaque Most cases of myocardial infarction are due to thrombosis, and the two main causes of coronary artery thrombosis are: atherosclerotic plaque ruptures and endothelial ulcers [40], [41], [42] 1.2.2 Lipoprotein accumulation and role of immune cells 1.2.2.1 Role of endothelial activation, adhesion molecules and chemokines 1.2.2.2 Role of innate immune system and macrophages in the development of atherosclerotic plaques Innate immunity plays an important role in ACS through the activation of monocytes, neutrophils, eosinophils and mastocytes The macrophages activate the production of inflammatory cytokines, protease, cytotoxic oxygen, and nitrogen compounds [43] 1.2.2.3 Role of adoptive immune system and lymphocytes in inflammatory response There is always an infiltration of T cells in atherosclerotic lesion When T cell receptors bind to antigens, the cellular activation leads to the production of cytokines, surface molecules and enzymesConsequently, increased IL-6 and CRP levels in the peripheral blood trigger an effective local and systemic inflammatory cascade [24], [43], [44], [45] 1.2.4 Roles of cytokines and other factors in acute coronary syndrome Proinflammatory cytokines can reduce the synthesis and increase the degradation of the matrix, promoting the rupture of atherosclerotic plaques 1.2.5 Other factors involved in the pathogenesis of acute coronary syndrome - Environment, physique: Environmental, physical, or emotional stress trigger MI by activating a sympathetic overload - Physicochemical changes of atherosclerotic plaques: Environmental changes including saturated cholesterol, temperature, pH and cholesterol crystal increase the volume of atherosclerotic plaques significantly, causing sudden rupture and blood clot formation - Changes in microcirculation function: The coronary vasospasm is activated by the reactions of smooth muscle cells 1.3 CLINICAL PRESENTATION AND DIAGNOSIS OF ACUTE CORONARY SYNDROME Clinical presentation: In MI, the patient feels a deep pain inside the body Other symptoms include: feeling weak, sweating, nausea, vomiting, dizziness and anxiety[1], [21] Paraclinical findings: ECG; changes in biomarkers; chest X-ray; Echocardiography; Stress test; Coronary angiography Diagnosis: Diagnosis is based on clinical symptoms, physical examinations, and paraclinical findings combined with biomarkers, and the ultra-sensitive troponins provide an early and specific diagnosis and evaluation of myocardial injury [50], [51] Treatment of acute coronary syndrome: includes coronary revascularization and internal medicine management [52] 1.4 CHANGES OF THE INFLAMMATORY MARKERS AND CYTOKINES IN ACUTE CORONARY SYNDROME 1.4.1 Interleukin-6: IL-6 is a cytokine which has important effects on inflammation and blood formation IL-6 is encoded by IL-6 gene located on chromosome Its molecular weight is about 22 to 30 kDa IL-6 acts as a proinflammatory cytokine produced by different cell types, including activated T cells, macrophages and some other cells IL-6 has local effects, involved in the formation of atherosclerotic plaques and the progression to ACS MI has a higher level of IL-6 compared with unstable angina [53] Increased IL-6 levels help identify the patient groups who may benefit from the intensive treatment to reduce the mortality [54], [55], [56] The anti- inflammatory drugs aspirin and statin reduce CRP and IL-6, inhibit inflammatory reaction, this knowledge shows the role of the antiinflammatory drugs such as aspirin and statin in ACS [57], [58],[59] 1.4.2 CRP: CRP is an acute-phase protein, belongs to Pentraxin group, and featuring an annular, homopentameric structure CRP is synthesized in acute inflammatory phase in the liver under the influence of IL-6 CRP leads to programmed death of smooth muscle cells, promotes atherosclerosis and contributes to the instability of atherosclerotic plaques [38], [60], [61] 1.4.4 Complements C3, C4 Complements, a group of proteins, are a part of nonspecific innate humoral immune system, they act as chain reaction enzymes, creating effective molecules in the inflammatory process More evidence suggests the important role of complements in the pathogenesis of ACS [62], [63], [64] 1.4.5 Relevancy to treatment Many studies have shown that patients with obstructive atherosclerosis ACS and increased inflammatory marker levels have a worse prognosis Therefore, re-evaluating the inflammatory status after hospital discharge can be helpful in identifying coronary atherosclerotic patients with a high risk of instability recurrence 1.5 OTHER RELEVANT STUDY 1.5.1 International study: Studies conducted that inflammation plays an important role in the onset and progression of atherosclerotic plaques through evaluating inflammatory factors such as the complements C3, C4, hsCRP and IL-6 Studies have demonstrated that hsCRP is the gold standard in assessing risk factors of cardiovascular events in ACS [10], [32] 1.5.2 Domestic study: In Vietnam there have been several separate studies about CRP in ACS The role of cytokine IL-6 has been studied in infectious diseases and cardiovascular surgeries An increased IL-6 level is linked to an increased risk of cardiovascular events [5], [12], [13], [20] Concurrent studies about different nonspecific immune factors in ACS are still limited CHAPTER STUDY SUBJECTS AND METHOD 2.1 STUDY SUBJECTS 2.1.1 Study patients group A group of 100 patients with confirmed diagnosis as acute coronary syndrome were admitted to emergency department of Heart Institute in Ho Chi Minh City from January 2013 to February 2013 All patients were diagnosed upon acute coronary syndrome criteria (as per new definitions of Myocardial Infarction in 2012 from cardiology associations incl ESC/ACCF/AHA/WHF)[65] Those who were admitted to emergency department, eligible for inclusion and exclusion criteria were recruited into study group 2.1.2.Control group: included 50 healthy subjects with no coronary artery disease, selected randomly at the same time from blood donors at Heart Institute in Ho Chi Minh City 2.1.3 Selection criteria: All patients with acute coronary syndrome 2.1.4.Exclusion criteria: Patients with non-infectious inflammation at study time 2.2 STUDY METHOD 2.2.1 Study design Controlled, prospective cohort study This is a prospective longitudinal follow up of 100 patients We used one ratio sample size estimation formula to calculate number of patients with acute coronary syndrome that needed to be followed up Group 1: Patients with acute coronary syndrome, n=100 Group 2: Control group, 50 healthy subjects, selected from blood donors 2.2.2 Study endpoints Quantifying non-specific immune markers: C3, C4, IL-6 hsCRP Other endpoints: hsTroponin T and NT-ProBNP Clinical endpoints collected from patients’ history, medical history in medical records Other paraclinical endpoints gathered from patients’ medical records PATIENT GROUP n=100 patients with Acute Coronary Syndrome(ACS) Collect clinical, paraclinical data and risk factors from medical records Paraclinical and clinical data -ACS: Diagnosis, subgroups - Treatment method - Cardiosonography, ECG, coronary angiography - Hematology tests, routine Risk factor - Antecedent of diabetes - Smoking, - Dyslipidemia - Hypertension Evaluate correlation Take blood sample once at admission for testing non-specific immune markers and myocardial markers C3,C4, IL-6, hsCRP,hsTroponin, NT-ProBNP Compare before and after treatment on the same subjects (37 patients) Take second blood sample months after treatment Testing non-specific immune markers and myocardial markers Compare patient group and control group CONTROL GROUP n=50 healthy blood donors Take blood sample during blood donation Testing non-specific immune markers and myocardial markers C3,C4, IL-6, hsCRP, hsTroponin, NT-ProBNP 12 group and control group showed a statistically significant difference (p < 0,05) 3.2.2 The mean concentration of the complement C3, C4 The mean level in the patient group was higher than in the control group, there was a statistically significant difference of mean serum C3, C4 level between the patient group and control group (p < 0,05) 3.2.3 The concentrations of other markers Including hs-CRP, hs-Troponin T, and NT-pro BNP The mean level in the patient group was statistically higher than in the control group, p < 0,05 3.3.STUDY THE RELATIONSHIP BETWEEN THE CONCENTRATIONS OF C3, C4, IL-6, hsCRP MARKERS IN ACUTE CORONARY SYNDROME WITH SOME RISK FACTORS AND THE DISEASE STATES 3.3.1 The change of markers concentration upon age groups Comparison the factors concentration between two age groups (less than or equal to 60 years old and greater than 60 years) Before and after treatment: IL-6 median level showed a statistically significant difference (p < 0,05); C3 mean level showed a statistically significant difference (p < 0,05); mean C4 level didn’t show statistically significant difference (p > 0,05); median hs-CRP level didn’t show statistically significant difference (p > 0,05); NT-pro BNP median level showed a statistically significant difference (p < 0,05) Median hs-Troponin T level was showed a statistically significant difference after treatment between two age groups (p < 0,05) 3.3.2 The change of markers concentration between male and female 13 Median IL-6, hs-CRP level in male and female group didn’t show a statistically significant difference before and after treatment (p > 0,05) Mean C3 level before treatment was statistically significant different (p < 0,05), Median hs-Troponin T level was statistically higher in the male group before and after treatment (p < 0,05) Median NT-pro BNP level didn’t show a statistically significant difference before and after treatment in both groups (p > 0,05) 3.3.3 The change of markers concentration upon hypertension factor Median IL-6 level in the hypertensive patient group was higher than in the non-hypertensive patient group, however, the difference was statistically non-significant before and after treatment (p > 0,05) Mean C3, C4 level between two group were not statistically different (p > 0,05) Median hs-Troponin T level in the hypertensive patient group was lower before treatment with a statistically significant difference (p < 0,05) Before and after treatment, median hs-CRP, NT-pro BNP level were lower in the hypertensive patient group with no statistically significant difference, (p > 0,05) 3.3.4 The change of markers concentration upon dyslipidemia condition In dyslipidemia group and non-dyslipidemia group, median IL-6 level in dyslipidemia groups was higher but no statistically significant difference (p > 0,05) Mean C3, C4 level didn’t show statistically significant difference (p > 0,05) Before and after treatment, median hs-CRP, hsTroponin T and NT-pro BNP level didn’t show statistically significant between two groups (p > 0,05) 3.3.5 The changes of markers concentration upon smoking history In the smoking group and the non-smoking group, median IL-6 level didn’t show a statistically significant difference (p > 0,05) Before 14 treatment, mean C4 level in smoking group was higher than non smoking group with a statistically significant difference (p < 0,05) Before and after treatment, mean C3 level and median hs-CRP, hs-Troponin T, NT-pro BNP level didn’t show a statistically significant difference between smoking group and non-smoking group (p > 0,05) 3.3.6 The changes of markers concentration upon diabetes In the diabetes group and the non-diabetes group: Before and after treatment, median IL-6 level in the non-diabetes group was higher than the diabetes group but no statistically significant difference (p > 0,05) Mean C3, C4 level didn’t show a statistically significant difference between two groups (p > 0,05) Before treatment, median hs-Troponin T level in nondiabetes group was higher with a statistically significant difference (p < 0,05) Before and after treatment, median hs-CRP, NT-pro BNP level didn’t show statistically significant difference between two group ( p > 0,05) 3.3.7 The changes of markers concentration upon number of narrowed coronary artery branch Median IL-6 level between one narrowed branch group and multiple narrowed branches group didn’t show statistically significant difference (p > 0,05) Mean C3, C4 levels didn’t show statistically significant difference between two groups (p > 0,05) Median hs-Troponin level was statistically significant different(p < 0,05) hs-CRP, NT-pro BNP factors between two group showed no statistically significant difference (p > 0,05) 3.3.8 The changes of C3, C4, IL-6, hsCRP marker concentration and other factors among patient groups in acute coronary syndrome 3.8.1 The difference of factors level between the STEMI group and the unstable angina group Median IL-6 level didn’t show statistically significant difference between STEMI group and unstable angina group (p > 0,05) Mean C3, C4 15 level in these two groups were different but not statistically significant (p > 0,05) Before treatment, median hs-Troponin and NT-pro BNP level was statistically significant different between two groups (p < 0,05) with median NT-pro BNP higher in unstable angina group Before and after treatment, median hs-CRP level didn’t show statistically significant difference between s two groups (p > 0,05) 3.3.8.2 The difference of markers level between the NSTEMI group and the unstable angina group Median IL-6 level didn’t show a statistically significant difference between NSTEMI group and unstable angina group (p > 0,05) Mean C3, C4 level in these two groups were different but not statistically significant (p > 0,05) Median hs-CRP, hs-Troponin and NT-pro BNP didn’t show statistically significant difference between NSTEMI group and unstable angina group (p > 0,05) 3.3.8.3 The difference of markers level between the MI group and the unstable angina group Median IL-6 level didn’t show statistically significant difference between two groups (p > 0,05) Mean C3, C4 level between MI group and unstable angina group were different but not statistically significant (p > 0,05) Before treatment, median NT-pro BNP level in unstable angina group was higher than in MI group with a statistically significant difference (p < 0,05) After treatment, mean hs-Troponin T level in unstable angina group was higher with a statistically significant difference (p < 0,05) Median hs-CRP level didn’t show statistically significant difference between two groups(p > 0,05) 3.4 STUDY THE RELATIONSHIP AMONG MARKERS IN ACUTE CORONARY SYNDROME 3.4.1 Analysis of the relationship among markers 16 Analyzing the mono-variate correlation among factors: There was proportional correlation between C3 and C4; hsCRP and IL-6; hs-Troponin T and NT-pro BNP with statistical significance (p < 0,05) 3.4.2 Analysis of the relationship among all inflammatory markers Analyzing the multi-variate correlation among the inflammatory factors C3, C4, IL-6, hs-CRP: When testing the relationship among all inflammatory factors, there was correlation between C3 and C4; IL-6 and hs-CRP with statistical significance (p < 0,05) 3.4.3 The relationship between the inflammatory markers and other markers Analysis of the relationship among all factors (C3, C4, IL-6, hs-CRP, hs-Troponin, and NT-pro BNP): when considering the correlation among all factors (multi-variate correlation), there was correlation between two inflammatory factors C3 and C4 with statistical significance (p < 0,05) No correlation between inflammatory factors and hs-Troponin/ NT-pro BNP 3.5 THE CHANGE OF NONSPECIFIC IMMUNE MARKERS CONCENTRATION BEFORE AND AFTER TREATMENT 3.5.1 The change of median IL-6 cytokine level before and after treatment Median IL-6 level before treatment was 16,59pg/ml, after treatment was 3,99 pg/ml, decreased clearly with a statistically significant difference (p < 0,05) 3.5.2 The change of mean C3, C4 complement level before and after treatment Mean C3, C4 level tended to decrease after treatment but the difference was not statistically significant (p > 0,05) 3.5.3 The change of other markers level before and after treatment 17 After treatment, median hs-CRP, hs-Troponin, NT-pro BNP level decreased clearly – the difference was statistically significant (p < 0,05) 3.6 THE CHANGE OF NONSPECIFIC IMMUNE MARKERS CONCENTRATION BEFORE AND AFTER TREATMENT UPON DIFFERENT TREATMENT METHODS 3.6.1 Internal medicine management By internal medicine management , median IL-6 level didn’t show a statistically significant difference before and after treatment (p > 0,05) Mean C3, C4 level did not show statistically significant difference before and after treatment (p > 0,05) Median level of other factor as hs-CRP, hsTroponin, NT-pro BNP didn’t show statistically significant difference before and after treatment (p > 0,05) 3.6.2 Coronary artery intervention After treatment by coronary artery intervention method, median IL-6 level dramatically reduced – the difference was very statistically significant between before and after treatment (p < 0,001) Mean C3, C4 level had the decreasing trend, however, the difference was not statistically significant (p > 0,05) hs-CRP, hs-Troponin, NT-pro BNP level reduced clearly with a statistically significant difference (p < 0,05) 3.6.3 Surgery After CABG treatment, median IL-6 level decreased but the difference was not statistically significant between before and after treatment (p > 0,05) In the CABG group, C3 and C4 level did not show statistically significant difference between before and after treatment (p > 0,05) Median hsCRP level did not show statistically significant difference between before and after treatment (p > 0,05) Median hsTroponin, NT-pro BNP 18 factor level decreased after treatment – the difference was statistically significant (p < 0,05) CHAPTER DISCUSSIONS 4.1.GENERALCHARACTERISTICS OF THE STUDY POPULATION 4.1.1 Age and sex In this study, the mean age of patients with ACS is 63,67 years old There are more males than females (76% and 24% respectively) These results are consistent with previous studies [12], [13], [66] The mean age of the control group is younger than that of the patient group with a similar sex ratio The results show a high proportion of patients over 60 years old, consistent with the studies [14], [20] 4.1.2 Risk factors and other factors A great proportion of patients with acute coronary syndrome are hypertensive, which was shown similarly in other studies [67], [68], [69] In the pathophysiologic process, atherosclerotic lesions of large arteries lead to hypertension, then continue to progress in small vessels including coronary arteries [4], [15],[18] Other risk factors, dyslipidemia, diabetes, smoking have the same rates as in other studies [69], [70], [71] Patients with increased lymphocyte count account for 59,4%, in atherosclerotic plaques, the presence of immune cells stimulate the inflammatory process, there is infiltration and mobilization of lymphocytes into the unstable atherosclerotic plaques, and this can lead to a response to increase the number of lymphocytes in peripheral blood, in addition to monocytes, mastocytes, neutrophils which are of interest in acute coronary syndrome, releasing inflammatory cytokines in atherosclerotic plaques which will then cause 19 instability and rupture of these plaques [40], [72], [73], in the inflammatory response of acute coronary syndrome there is an increase of monocytes, T cells, neutrophils and chemokines [74], [75] Percutaneous coronary angiography results show single stenosis or multiple stenosis, but most patients have multiple stenosis, accounting for 83,1%, and this is in line with the pathogenesis of acute coronary syndrome with stenosis[38], [41], [46], coronary artery stenosis is due to different mechanisms including inflammation and thrombosis When evaluating changes in myocardial dynamics by echocardiography: myocardial wall dyskinesia and akinesia are seen in most ACS cases,consequently myocardial and left ventricular systolic dysfunction [50] The majority of the patients have non ST elevation MI, followed by ST elevation MI with a clinical increase in myocardial necrosis biomarkers, Troponin Ultrasensitive Troponins are important biomarkers which aid in the diagnosis [76], [77], [78], [79] Tỷ lệ nhóm bệnh phụ thuộc vào thời gian bệnh nhân nhập viện, theo diễn tiến tổn thương động mạch vành [80], [81] Regarding the treatment methods, coronary intervention accounts for the highest proportion Evaluating the mean number and concentration of several related factors Creatinine concentration, glomerular filtration rate, HDL and LDL concentration provide overall information about their characteristics in patients with ACS The mean concentration of Creatinin does not increase significantly; and the mean glomerular filtration rate does not decrease much in the study population LDL- cholesterol mean levels increase and HDL- Cholesterol levels decrease With regard to the pathophysiologic mechanism, LDL is an important part involved in the formation, progression and rupture of atherosclerotic plaques, the role of LDL has been much mentioned in the pathogenesis of ACS as a criteria for treatment monitoring 20 4.2 CHANGES OF NONSPECIFIC IMMUNE MARKER LEVELS IN ACUTE CORONARY SYNDROME 4.2.1 Cytokine and inflammatory markers The study results show an obvious increase of IL-6 levels in patients with ACS, there is a statistically significant difference between patient group and control group with p0,05 although they tend to decrease After treatment, the levels of IL-6 and CRP show an obvious and statistically significant reduction, while C3, C4 levels tend to decrease but not statistically significant These results are in accordance with other studies [5], [98] Studies have noticed an obvious increase of IL-6 in ACS with a prognostic role on cardiovascular events [133], [134], [135] The overall studies have shown the role of inflammatory markers in classifying ACS, IL-6 was found to play a decisive role in the therapeutic application of ACS, however more study is needed [136], [137], [138] hsTroponin and NT-ProBNP levels decrease remarkably after treatment, with a statistically significant difference p
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