Plasma Levels of Proprotein Convertase Subtilisin/Kexin Type 9 Are Elevated in Patients With Peripheral Artery Disease and Associated With Metabolic Disorders and Dysfunction in Circulating Progenitor Cells

Ting-Hsing Chao, I-Chih Chen, Yi-Heng Li, Po-Tseng Lee, Shih-Ya Tseng, Ting-Hsing Chao, I-Chih Chen, Yi-Heng Li, Po-Tseng Lee, Shih-Ya Tseng

Abstract

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) is involved in cholesterol homeostasis, inflammation, and oxidative stress. This study investigated the association of plasma PCSK9 levels with the presence and severity of peripheral artery disease (PAD) and with parameters of endothelial homeostasis.

Methods and results: A post hoc analysis of 2 randomized trials (115 patients, 44 with PAD and 71 without atherosclerotic disease) was conducted. Patients with PAD had significantly higher plasma PCSK9 levels than those without (471.6±29.6 versus 302.4±16.1 ng/mL, P<0.001). Parameters for glucose homeostasis, endothelial progenitor cell functions, apoptotic circulating endothelial cell counts, and plasma levels of vascular endothelial growth factor-A165 and oxidized low-density lipoprotein were correlated with PCSK9 concentration. By multivariable linear regression analysis, presence of PAD, plasma glucose or hemoglobin A1c levels, apoptotic circulating endothelial cell counts, and vascular endothelial growth factor-A165 concentration were found to be associated with PCSK9 levels after multivariable adjustment. Patients with extensive involvement of PAD or with severe PAD had significantly higher PCSK9 levels than those without PAD. Computed tomographic angiography showed that the numbers of chronic total occlusion sites and vessels involved were positively associated with PCSK9 levels in patients with PAD (r=0.40, P=0.01, and r=0.36, P=0.02, respectively).

Conclusion: PCSK9 levels were significantly higher in patients with PAD, especially those with advanced PAD. Further large-scale studies examining the effect of PCSK9-targeting therapies or the modification of PCSK9 levels on cardiovascular outcomes in this clinical setting are warranted.

Clinical trial registration: Cohort 1: URL: ClinicalTrials.gov. Unique identifier: NCT01952756; cohort 2: URL: ClinicalTrials.gov. Unique identifier: NCT02194686.

Keywords: peripheral artery disease; progenitor cell; proprotein convertase subtilisin/kexin type 9.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Flow cytometry analyses in patients with PAD or without atherosclerotic disease. A, Gating the target cell population by flow cytometry analysis. The percentages of cells that were double positive for KDR and CD34 (KDR + CD34+; left lower panel) or CD146 and annexin V (CD146+annexin V+; right lower panel) are shown. The surface markers were identified while the CD45‐negative subpopulation was gated and adjusted for the isotype IgG control. B, Comparisons of KDR + CD34+ cell counts and CD146+annexin V+ cell counts between both groups. P values were calculated by Mann–Whitney U test. FITC indicates fluorescein isothiocyanate; FSC, forward scatter; KDR, kinase insert domain receptor; No, no preexisting atherosclerotic disease; PAD, peripheral artery disease; PCSK9, proprotein convertase subtilisin/kexin type 9; PE, phycoerythrin; Pre CP, peridinin chlorophyll protein; R, region; SSC, side scatter.
Figure 2
Figure 2
Cell biological studies in patients with PAD or without atherosclerotic disease. Representative photographs and quantitative analyses of colony‐forming units (A) and migrated cells (B). Cells and colonies were fixed with methanol and stained with Giemsa reagent and appeared in purple. Original magnification was ×100 (B). Comparisons of BrdU incorporation (C), XTT (D), and nucleosome fragmentation of EPCs (E) between patients in the nonatherosclerotic disease and PAD groups were shown. P values were calculated by Mann–Whitney U test in panel D and by unpaired Student t test in other panels. BrdU indicates bromodeoxyuridine; CFU, colony‐forming unit; EPC, endothelial progenitor cell; No, no preexisting atherosclerotic disease; PAD, peripheral artery disease; PBMC, peripheral blood mononuclear cell.
Figure 3
Figure 3
PCSK9 levels were compared with the extent (A) and severity (B) of PAD. Severe PAD was defined as having an ankle‐brachial index <0.6, and mild to moderate PAD was defined as having an ankle‐brachial index between 0.6 and 0.9. P values for the trends in panels A and B were calculated by 1‐way ANOVA. No indicates no preexisting atherosclerotic disease; PAD, peripheral artery disease; PCSK9, proprotein convertase subtilisin/kexin type 9.

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