class Hi iTCR
Regulatory T cells
Fig. 12. Importance of inflammatory balance in patients with ACS. The cumulative incidence of death or nonfatal MI at 6 mo of follow-up by baseline levels of hsCRP and IL-10, respectively, is shown. Diagnostic threshold levels were 3.5 ng/L for IL-10 and 10 mg/L for CRP (n = 547). MHC, major histocompatibility complex; TCR, T-cell receptor; GITR, glucocorticoid-induced tumor necrosis factor receptor.
acute ischemic event caused by plaque instability. In addition, the beneficial effect of elevated serum levels of IL-10 was restricted to patients with elevated CRP levels indicative of an enhanced systemic inflammatory response. These data further support the concept that the balance between pro- and anti-inflammatory cytokines is a major determinant of patients' outcome in ACSs.
Consistently, increased IL-10 serum levels in patients with coronary heart disease are also associated with improved systemic endothelial vasoreactivity in patients with elevated CRP serum levels, whereas in patients with high IL-10 serum levels, systemic endothelial vasoreactivity was independent of CRP concentration (Fig. 13) (68). This demonstrates that the balance between pro- and anti-inflammatory mediators is also a major determinant of endothelial function in patients with CAD.
The electrocardiogram (ECG) remains the most useful and cost-effective first-line tool in the evaluation of patients with chest pain. The initial ECG is the "gold standard" for the diagnosis of an AMI. After exclusion of the presence of ST-elevations, repeat quantitative or qualitative troponin measurements provide valuable diagnostic tools for improving efficacy and safety in decision making for patients suspected ofhaving an ACS. Troponins as biomarkers of myocardial necrosis are superior to and independent of elec-trocardiographic findings. Increasing evidence suggests that the combined use of bio-markers reflecting distinct pathophysiological features such as myocardial necrosis, vascular inflammation, oxidative stress, and neurohumoral activation may significantly add to clinicians' ability to correctly identify patients who are at high risk of short- and long-
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