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Infection and atherosclerosis
- Syed Wamique Yusuf (14 April 2004)
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Suspected Myocarditis in Sri Lanka
- Friedrich Flachsbart (21 March 2005)
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Syed Wamique Yusuf, Assistant Professor of Medicine Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas77030, USA
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Dear Sir The editorial and the article in BMJ (1, 2), has nicely covered the issue of cardiovascular and infectious disease in South Asia. Interestingly no mention was made of association between infection and heart disease. Apart from causing endocardits and myocarditis, infection has also been lined with Ischaemic heart disease (IHD) and atherosclerosis (3), and there is a strong association between development of new atherosclerotic lesion and chronic infection (4). IHD is increasingly being recognized as an inflammatory disease, and both C-reactive protein and fibrinogen is significantly elevated in chronic infections (4). Even young otherwise healthy patients with only periodontal disease show evidence of endothelial dysfunction and systemic inflammation (5). Although studies have not shown a conclusive causal link between infection and IHD, it is known that an increase in inflammatory markers are prognostically important, both in healthy population and in patients with IHD (6, 7). There are reports of lowering of fibrinogen with treatment of infection (8, 9). Your editorial (1) points out that coronary death in India are expected to double over 20 years and reach 2 million by 2010. The increase in IHD in India and other third world countries may be due to an increase in Diabetes Mellitus and metabolic syndrome, but as association between infection and heart disease remains an important contributing factor. A lot of these infectious processes could begin in early childhood and by inducing low grade inflammation could manifest or precipitate atherosclerosis at older age. Alternatively an acute infection can generate intense inflammatory response and precipitate an acute coronary event. There are no large scale prospective studies, especially among healthy individuals showing that lowering of fibrinogen level would lower the risk of death, but this hypothesis needs to be tested in well controlled trials. As mentioned in your editorial, “preventive cardiology has to be integrated into primary health care” and tackling and preventing infection may be helpful in prevention of atherosclerosis and cardiovascular disease. 1.Basnyat B. Cardiovascular and infectious disease in South Asia; the double whammy. BMJ 2004; 328:781 2.Zaidi AKM, Awasthi S, DeSliva HJ. Burden of infectious disease in South Asia. BMJ 2004; 328:811-815 3.Leinonen M, Saikku. Evidence for infectious agents in cardiovascular disease and atherosclerosis. Lancet Infect Dis 2002; 2:11- 16 4.Kiechl S, Egger G, Mayr M, Weidermann CJ et al. Chronic infections and risk of carotid atheroscelrosis. Prospective results from a large population study. Circulation 2001; 103:1064-70) 5.Amar S, Gokce N, Morgan S, Luokideli M et al. Periodontal disease is associated with brachial artery endothelial dysfu7nstion and systemic inflammation. Arterioscler Thromb Vasc Biol 2003; 23:1245-49). .6.Toss H, Lindahl B, Siebahn A, Wallentin L. For the FRISC Study Group. Prognostic influence of increase fibrinogen and C-reactive protein in unstable coronary artery disease. Circulation 1997; 96:4204-10, 7. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin and risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997; 336:973-9 8.Yusuf SW, Mishra. Effect of Helicobacter infection on fibrinogen level in elderly population with Ischaemic heart disease. Acta Cardiol 2002; 57(5): 317-322 9. Torgano G, Cosentini R, Mandelli C, Perondi R et al. Treatment of Helicobacter pylori and chlamydia pneumoniae infection decreases fibrinogen level in patients with Ischaemic heart disease. Circulation 1999; 99:1555-1559. Competing interests: None declared |
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Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen
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Dear Sir, The World Health Organization published the first steps of investigations 17 March 2005. But in Rheumatic Heart Disease You will not find the pathogen: RHD is a post-streptococcal-reactive-disease. The pathogen streptococcus is not there, but it has been there. Like a Tsunami the post-streptococcal-reactive-disease are on high- tide in the Northern Territory of Australia, where many children in the Torres Strait are hospitalized after an outbreak of post-stretptococcal- reactive-glomerulonephritis. The children of Sri Lanka suffer from myocarditis. And Prof. Dr. A. Charles Yankah gave an African Heart Seminar March 2005 in Cape Town, because rheumatic fever and subsequent heart disease and congestive heart failure will kill millions of children in Africa. It is one world, and streptococci kill like a Tsunami. Sincerely Yours Friedrich Flachsbart Suspected myocarditis in Sri Lanka. www.who.int/csr/don/2005_03_17a/en/print.html African Heart Seminar 2005: 7-11 March 2005. www.netcare.co.za/default.asp?currentpage=viewArticle§ion=1&article=46 Competing interests: None declared |
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