Invest Clin 63(2): 156 - 162, 2022 https://doi.org/10.54817/IC.v63n2a05

Corresponding Author. Yingmin Lu. Department of Cardiology, Xinhua Hospital Chongming Branch. Chongming

District, Shanghai, China. Tel: +86 13918182357. Email: luym_2021@yeah.net

Clinical value of combined detection of

thrombus precursor protein and P-selectin

in the diagnosis of acute coronary syndrome.

Xiaojiao Hao, Damin Huang, Zhaoxia Wang, Jinchun Zhang, Hongqiang Liu

and Yingmin Lu

Department of Cardiology, Xinhua Hospital Chongming Branch. Shanghai, China.

Key words: acute coronary syndrome; thrombus precursor protein; P-selectin; molecular

markers of prethrombotic state.

Abstract. Acute coronary syndrome (ACS), including acute myocardial in-

farction (AMI) and unstable angina (UA), is the most threatening and lethal

form of coronary heart disease. ACS has an abrupt onset and rapid develop-

ment, which may lead to fatal conditions at any time. Thus, it is never too early

to detect and diagnose patients with ACS. The objective of this work was to

explore the significance of the combined detection of plasma thrombus precur-

sor protein (TpP) and serum P-selectin (Ps), in the detection and diagnosis of

patients with early ACS. A total of 126 subjects were included in the study, 64

ACS patients, 30 individuals with stable angina (SA) and 32 healthy persons

who were selected as the control groups. There were no differences in gender,

age, ethnicity, or blood glucolipid levels among the groups. Enzyme linked im-

munosorbent assay (Elisa) was used to quantitatively determine the plasma

levels of TpP and Ps. The levels of the two biomarkers in the case group were

significantly higher than those in the control groups. Among the ACS patients,

the levels of TpP and Ps were higher in AMI patients than in the UA patients.

In addition, there was no significant differences in the levels of Ps between

SA patients and healthy persons. In conclusion, plasma TpP and serum Ps are

remarkably increased in patients with ACS. Therefore, TpP and Ps may serve

as ACS indicators, and their measurement may provide a support for an early

clinical identification of ACS.

Exploring the significance of combined detection of TpP and Ps 157

Vol. 63(2): 156 - 162, 2022

Valor clínico de la detección combinada de proteína precursora

de trombo y selectina P en el diagnóstico del síndrome

coronario agudo.

Invest Clin 2022; 63 (2): 156 – 162

Palabras clave: síndrome coronario agudo; proteína precursora de trombo: P-selectina;

marcadores moleculares de estado pretrombótico.

Resumen. El síndrome coronario agudo (SCA), que incluye el infarto

agudo de miocardio (IAM) y la angina inestable (AI), es la forma más amena-

zante y letal de enfermedad coronaria. El SCA tiene un inicio abrupto y un

desarrollo rápido, lo que puede conducir a condiciones fatales en cualquier

momento. Por lo tanto, nunca es demasiado pronto para detectar y diagnosti-

car pacientes con SCA. El objetivo de este trabajo fue explorar la importancia

de la detección combinada de la proteína precursora de trombos plasmáticos

(TpP) y la selectina P sérica (Ps), en la detección y diagnóstico de pacientes

con SCA precoz. Se incluyeron en el estudio un total de 126 sujetos, 64 pa-

cientes con SCA, 30 individuos con angina estable (AE) y 32 personas sanas

que fueron seleccionadas como grupos de control. No hubo diferencias en el

género, la edad, el origen étnico o los niveles de glucolípidos en sangre entre

los grupos. Se usó el ensayo inmunoabsorbente ligado a enzimas (Elisa) para

determinar cuantitativamente los niveles plasmáticos de TpP y Ps. Los niveles

de los dos biomarcadores en el grupo de casos (SCA) fueron significativamen-

te más altos que los de los grupos de control. Entre los pacientes con SCA,

los niveles de TpP y Ps fueron más altos en los pacientes con IAM que en los

pacientes con AI. Además, no hubo diferencias significativas en los niveles de

Ps entre pacientes con SA y personas sanas. En conclusión, la TpP plasmática

y la Ps sérica están notablemente aumentadas en pacientes con SCA. Por lo

tanto, TpP y Ps pueden servir como indicadores de SCA y su medición puede

proporcionar un apoyo para una identificación clínica temprana de SCA.

Received: 24-08-2021 Accepted: 28-04-2022

INTRODUCTION

Acute Coronary Syndrome (ACS) refers

to a group of clinical syndromes with acute

myocardial ischemic events due to a sudden

obstruction of the coronary blood flow. It is

almost always associated with the rupture

of an atherosclerotic plaque and partial or

complete thrombosis of the infarct-related

artery.

ACS generally is divided into ST-seg-

ment elevation myocardial infarction (STE-

MI), non–ST-segment elevation myocardial

infarction (NSTEMI) and unstable angina

(UA). The occurrence of ACS is primarily

due to plaque erosion or plaque rupture af-

ter coronary atherosclerosis, and can cause

incomplete occlusion of blood vessels or

secondary complete occlusive thrombosis,

which ultimately leads to acute myocardial

158 Hao et al.

Investigación Clínica 63(2): 2022

ischemia1. ACS is easy to be missed in the

clinical area due to the fact that its signs

and symptoms usually begin abruptly. ACS

progresses rapidly, which affects the survival

time and quality of life of ACS patients 2,3.

Therefore, an early diagnosis is very impor-

tant for ACS.

Thrombosis is one of the leading

causes of atherosclerotic plaque forma-

tion. The detection of thrombus markers

can identify whether the patient is in the

prethrombotic state, which is of particu-

lar significance to assess the risk of ACS.

The thrombus precursor protein (TpP) is

a marker, and the most direct evidence,

of impending thrombosis 4. P-selectin (Ps)

is a member of the selectin family of cell

adhesion molecules, which plays a vital

role in the initiation of inflammation, the

mediation of leukocyte adhesion and ag-

gregation on the endothelium, and the

formation of thrombus 5. In this study,

through the determination of the above

two biomarkers in healthy individuals and

patients with ACS or SA in our hospital,

we comprehensively analyzed the differ-

ences in the levels of the two factors in

each studied group and investigated the

significance of combined detection of TpP

and Ps in the early diagnosis of ACS.

MATERIALS AND METHODS

Subjects and study design

Sixty-four patients with ACS treated in

the Shanghai Xinhua Hospital Chongming

Branch, from October 2019 to October

2020, were randomly selected as the case

groups (including 30 patients with unsta-

ble angina (UA) and 34 patients with acute

myocardial infarction (AMI) (18 patients

with NSTEMI, 16 patients with STEMI)).

Thirty patients with stable angina (SA) and

32 healthy people corresponding to the

case group in terms of gender, age, ethnic-

ity, etc. were selected as the control groups.

The study was conducted in accordance with

the Declaration of Helsinki, and the proto-

col was approved by the Ethics Committee

of Xinhua Hospital Chongming Branch. All

subjects gave their informed consent for

inclusion before participating in the study

(on admission). After admission, patients

in each group received a routine electrocar-

diogram (or dynamic electrocardiogram),

and the grouping was determined after the

measurement of myocardial enzymes. Pa-

tients receiving platelet therapy, or with an

abnormal coagulation function (DIC, he-

mophilia, leukemia, abnormal coagulopa-

thy caused by severe liver disease, vitamin

K deficiency) were excluded.

Baseline data were collected, includ-

ing gender, age, nationality, blood glucose,

blood lipids, and myocardial enzyme index-

es. All the candidates had 4 ml of fasting ve-

nous blood drawn at 8:00 in the morning af-

ter admission. The Ps tube was immediately

centrifuged at 3,000 rpm for 10 minutes to

collect serum. The TpP tube was added with

sodium citrate for anticoagulation and cen-

trifuged at 3,000 rpm for 10 minutes to col-

lect plasma. The collected serum and plasma

were stored at –70° for testing.

Biomarker assays

Serum P-selectin was determined using

a kit provided by Wuhan USCN Business Co.,

Ltd., and plasma TpP was measured with a

kit provided by Wuhan Cusabio Technology

LLC. The model of the microplate reader

was Shanghai Kehua st-360.

Statistical analyses

The data obtained from the experiment

were analyzed by SPSS 22.0 statistical soft-

ware. The measurement data were expressed

by χ ± SD. The comparison between means

was made by the Student’s t-test (analysis of

variance was used to compare more than two

groups). The counting data was represented

by the composition ratio, and comparison

between groups was by the χ2 test. P<0.05

indicated that the difference was statistical-

ly significant.

Exploring the significance of combined detection of TpP and Ps 159

Vol. 63(2): 156 - 162, 2022

RESULTS

Basic characteristics of the study

participants

The details of demographic data of the

126 study participants are listed in Table 1.

The results showed that there were no sig-

nificant differences in age and sex among

the groups.

Comparison of results between Stable

Angina patients and healthy people

The results in Table 2, show that there

were no statistically significant differences

in age, blood glucose concentration, blood

lipid concentration or the serum Ps levels

between stable angina patients and healthy

people (P>0.05). The serum TpP level of pa-

tients with SA was higher than that of the

healthy people (P<0.05).

Comparison within case groups

In the case groups, there was no signifi-

cant difference in the baseline data between

patients with UA, STEMI and NSTEMI (P>

0.05). The serum levels of Ps and TpP of pa-

tients with NSTEMI and STEMI were higher

than those of patients with UA (P<0.05).

See Table 3.

Comparison of results between case

and control groups

The demographics, clinical, and labora-

tory data (age, gender, blood glucose, blood

lipids, etc.) between case groups and control

groups had no significant difference (P>

0.05). The Ps and TpP levels of case groups

were significantly higher than those of con-

trol groups (P<0.05). See Table 4.

Table 1

Basic information of patients.

Index

ACS Control Groups

(n=30)

NSTEMI

(n=18)

STEMI

(=16)

(n=30)

Healthy

(n=32)

Age 67.40±10.669 61.44±14.454 65.00±8.990 65.97±10.361 62.22±14.988 NS

Gender Male

(n/%)

21/70 13/72 22/73 22/73 19/60 NS

Female

(n/%)

9/30 5/28 8/27 8/27 19/60

ACS: Acute coronary syndrome; UA: unstable angina; NSTEMI: non–ST-segment elevation myocardial infarction;

STEMI: ST-segment elevation myocardial infarction; SA: stable angina.

Table 2

Comparison of results between Stable Angina patients and healthy people.

Index SA Group (30 cases) Healthy Group (32 cases) p

Age (years) 65.97±10.361 62.22±14.988 NS

Blood glucose (mmol/L) 6.54±1.946 6.30±2.257 NS

Blood lipid (mmol/L) 1.69±1.544 1.60±1.069 NS

Ps (ng/mL) 45.74±28.427 58.12±36.322 NS

TpP (ng/mL) 4.27±1.932 2.73±1.159 0.001

SA: stable angina Ps: P-selectin TpP: Thrombus precursor protein.

160 Hao et al.

Investigación Clínica 63(2): 2022

DISCUSSION

Many studies have confirmed that ACS is

caused by unstable plaque, surface rupture,

and breakage in the coronary arteries, which

cause bleeding and thrombosis, leading to

partial or complete occlusion of the coro-

nary arteries. Platelet adhesion, activation,

aggregation, and thrombosis are central to

its pathogenesis 6. Through the detection of

related factors involved in thrombosis, the

early recognition of ACS can be improved.

TpP is a high molecular weight soluble

fibrin polymer, formed by the polymerization

of fibrin monomers produced by the action

of thrombin on fibrinogen and is the direct

precursor of insoluble fibrin. Studies have

confirmed that when the TpP level rises, it

means that the thrombus has started, and

the fibrin monomer has begun to polym-

erize, which can be used as a predictor of

thrombosis 7. Because of the specific anti-

genic determinants on the structure, this

antigenic determinant does not exist on fi-

brinogen and fibrin degradation products. It

may be more clinically significant than other

indicators for diagnosing various thrombotic

diseases 8.

Ps is a member of the selectin family of

adhesion molecules. It plays a vital role in

the process from leukocyte recruitment to

plaque rupture. Related experiments have

shown that Ps expression in platelets near

the ruptured plaque was significantly in-

creased, and there were a large number of

mononuclear macrophages and T lympho-

cytes around it 9. Many studies have also

confirmed that the level of Ps can be used

Table 3

Comparison of the results of UA, NSTEMI and STEMI within the case group.

Index UA

(30 cases)

NSTEMI

(18 cases)

STEMI

(16 cases)

(a and c1) (a and c2) (c1 and c2)

Blood glucose

(mmol/L)

6.57±2.253 8.52±4.150 7.09±2.041 NS NS NS

Blood lipids

(mmol/L)

1.81±1.504 1.91±1.198 1.99±1.168 NS NS NS

Ps (ng/mL) 39.09±12.139 87.40±37.413 93.39±39.000 <0.001 <0.0010 NS

TpP (ng/mL) 6.03±2.033 9.82±3.659 10.93±3.725 0.001 0.001 NS

UA: unstable angina NSTEMI: non–ST-segment elevation myocardial infarction; STEMI: ST-segment elevation myo-

cardial infarction Ps: P-selectin TpP: Thrombus precursor protein.

Table 4

Comparison of results between case and control groups.

Index Case Control p

Age (years) 65.23±11.396 64.03±12.990 0.581

Blood glucose (mmol/L) 7.20±2.886 6.41±2.103 0.090

Blood lipids (mmol/L) 1.89±1.326 1.64±1.318 0.319

Ps (ng/mL) 66.25±38.39 52.13±33.07 0.029

TpP (ng/mL) 8.32±3.69 3.47±1.746 <0.001

Ps: P-selectin TpP: Thrombus precursor protein.

Exploring the significance of combined detection of TpP and Ps 161

Vol. 63(2): 156 - 162, 2022

to determine the incidence and severity of

coronary heart disease 10,11.

The levels of the two indicators in the

case group, were generally higher than those

of healthy individuals and SA patients, which

were similar to the results of Atalar 12 and

Kayikcioglu et al. 13. In addition, this study

found that the levels of Ps and TpP in pa-

tients with acute myocardial infarction were

significantly higher than those in patients

with unstable angina. This indicated that

there is a significant correlation between the

changes in the levels of the two and AMI, but

there is little difference between petients

with STEMI and NSTEMI. There was no sig-

nificant difference between healthy people

and SA patients. Ps and TpP may play a role

in early detection of ACS, but they cannot

distinguish between NSTEMI and STEMI.

The concentration of TpP in plasma re-

flects the activity of thrombin in circulation.

The increase of TpP indicates that the fibrin

monomer has polymerized, which indicates

that the thrombus is about to form (and is

an indicator of thrombus activity this is a rep-

etition). Stimulated by hypoxia, free radicals,

and thrombin, the expression of Ps increases,

which mediates the adhesion of leukocytes

and endothelial cells and plays a central role

in thrombosis 14,15. Therefore, in patients

with ACS caused by thrombosis, the expres-

sion levels of TpP and Ps may be significantly

up-regulated. TpP is of great significance not

only for the early diagnosis but also for the

severity and prognosis of ACS 16. Thus, TpP

cannot only be used for the diagnosis but also

for the classification of ACS in the future.

In summary, through the detection

of molecular markers of the prethrombot-

ic state, the early diagnosis of ACS can be

achieved. It provides crucial guidance for

further decisions on treatment options in

clinical work, reduces the risk of premature

death, improves the survival rate of patients,

and brings greater benefits to the clinical re-

sponse in the occurrence of acute cardiovas-

cular events.

Funding

This study was not funded.

Conflict of interests

All of the authors had no any personal,

financial, commercial or academic conflicts

of interest separately.

Author’ORCID numbers

• Xiaojiao Hao (HXJ):

0000-0001-9295-7827

• Damin Huang (HDM):

0000-0002-7406-6585

• Zhaoxia Wang (WZX):

0000-0002-9513-0953

• Jinchun Zhang (ZJH):

0000-0002-5832-2526

• Hongqiang Liu(LHQ):

0000-0002-9158-7032

• Yingmin Lu (LYM):

000-0003-1643-165X

Contribution of each author

in the development of the work

and writing the paper

HXJ and HDM conceived of the study,

and WZX and ZJH participated in its design

and coordination and LHQ and LYM helped

to draft the manuscript. All authors read and

approved the final manuscript.

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