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Increased risk of acute myocardial infarction and elevated levels of C-reactive protein in carriersof the Thr-87 variant of the ATP receptor P2Y11

Stefan Amisten , Olle Melander , Anna-Karin Wihlborg , Göran Berglund , David Erlinge
DOI: http://dx.doi.org/10.1093/eurheartj/ehl410 13-18 First published online: 29 November 2006

Abstract

Aims Extracellular ATP acting on the P2Y11 receptor regulates inflammatory cells. We hypothesized that polymorphisms in the receptor could influence the risk of acute myocardial infarction (AMI).

Methods and results In the Malmö diet and cancer AMI case–control study (n = 3732) the P2Y11 gene Thr-87 polymorphism was present in 19.8% of the controls and 22.9% in AMI patients (OR 1.21; P = 0.03). Stronger associations were found in patients with family history (FH) of AMI, 1.32; early-onset (EO) AMI, 1.43; or EO AMI combined with FH, 1.50; supporting a genetic mechanism. The Thr-87 homozygotes had an even greater risk of AMI, 1.94 (P = 0.04); and 2.48 in the EO AMI subgroup, suggesting a genetic dosage effect. In the cardiovascular risk factor group (n = 6055), 21.3% carried the Thr-87 allele. C-reactive protein was elevated in Thr-87 carriers: 1.6 mg/L vs. 1.3 mg/L (P = 0.001). No difference was seen for blood pressure, lipids, body mass index, smoking, or diabetes mellitus.

Conclusion The common Ala-87-Thr polymorphism of the P2Y11 receptor is associated with AMI and increased levels of C-reactive protein. We hypothesize that an inflammatory mechanism might be involved. The P2Y11 receptor is a promising new drug target in the prevention of AMI.

  • P2Y
  • Receptor
  • Myocardial infarction
  • Inflammation
  • Genetics
  • Human

Introduction

Acute myocardial infarction (AMI) is one of the leading causes of death in the Western world and many risk factors, both environmental and genetic, contribute to its pathogenesis.1 Genetic risk factors seem to be particularly strongly related to AMI events earlier in life, while environmental risk factors build up over time.24 In several studies, genetic polymorphisms with emphasis on genes important for platelet aggregation, lipoproteins, the coagulation cascade, and inflammatory processes have been shown to be associated with the incidence of AMI.5,6

Extracellular purines (ATP, ADP, and adenosine) and their purinergic receptors are important cardiovascular regulators and could influence the risk of AMI by several different mechanisms including platelet aggregation, inflammation, vascular, and cardiac regulation.7 So far, the ADP receptor P2Y12 antagonist clopidogrel is used in the clinic to reduce the risk of AMI,8 but several other P2 receptors are possible drug targets.

The P2Y11 receptor is a G-protein coupled receptor of the P2Y receptor family. Binding of its ligand adenosine triphosphate (ATP) activates both adenylyl cyclase and phospholipase C via Gs coupling, a unique feature for a member of the P2Y receptor family.9,10 The human tissue distribution of P2Y11 includes several tissues relevant for the pathophysiology of AMI: myocardium, endothelium, spleen, and several immune cell subtypes, but it is absent in platelets.1115 We recently demonstrated that the P2Y11 receptor has inotropic effects on cardiac myocytes and is expressed in the human heart.16,17

According to NCBI's Single Nucleotide Polymorphism database, the P2RY11 gene contains 16 single nucleotide polymorphisms, three of which are in the coding region. One of the coding region polymorphisms, (rs3745601), causes an alanine to threonine amino acid shift in residue 87 (Ala-87-Thr), near the extracellular end of transmembrane region II of the P2Y11 receptor. It is possible that this non-polar to polar amino acid shift may cause changes in ligand binding affinity or receptor function. Such a change may have effects on cardiac contractility as well as inflammation, both factors known to be associated with the development of AMI.5,6

Studies of polymorphisms in small populations are of limited value and not always reproducible. We therefore used a large patient material: the Malmö diet and cancer study (MDC, n = 28 098) that contains two sub-groups: one AMI case–control study (n = 3732) containing an AMI case group with paired matched controls, and one random sample of the MDC, in which several cardiovascular risk factors were measured (MDC-CV, n = 6103).18,19 Thus, in total we examined the expression of the P2Y11 receptor polymorphism in nearly 10 000 individuals.

The aim of this study was to use the AMI case–control material to probe for associations between the Ala-87-Thr polymorphism and AMI, and to use the MDC-CV to investigate if variations in cardiovascular risk factors are associated with the Ala-87-Thr polymorphism of the ATP receptor P2Y11.

Methods

Malmö diet and cancer population

The study population includes 28 098 randomly selected men (born 1923–1945) and women (born 1923–1950) living in the city of Malmö (population 250 000), Sweden. Participation rate was 41%.

A baseline examination was carried out between 1991 and 1996, encompassing assessment of dietary habits, a questionnaire on socio-economic, demographic and lifestyle factors, heredity, medication, previous and current diseases. Blood samples were taken and DNA, lymphocytes, granulocytes, erythrocytes, and plasma/serum were stored in a biological bank.18,19

AMI case–control population

On 31 December 2000, the study population was matched with the Swedish National Board of Health and Welfare's National Patient Registry and Cause of Death Registry. AMI cases (first AMI) were identified using the diagnosis criteria defined by the International Classification of Diseases, ninth and tenth and Revision, Clinical Modification (ICD 9 and 10); ICD 9 codes 410 in the Swedish Patient Registry or 410–414 in the Swedish Cause of Death Registry; ICD 10 codes I21 in the Swedish Patient Registry and I21–I25 in the Swedish Cause of Death Registry.

Two age- ( ± 1 year) and gender-matched AMI-free controls from the MDC were assigned to each AMI case, resulting in a case–control material consisting of 1244 AMI cases and 2488 controls. The MI group was further subdivided into early-onset (EO) AMIs (n = 622), [age at first AMI event < 62.8 years (median age of all first event AMI cases)] and late-onset (LO) AMIs (n = 622, age at first AMI event > 62.8 years). Family history (FH) AMIs (n = 611) were defined as AMI cases where at least one blood-related first degree family member had suffered an AMI, and non-familial AMIs (n = 633) as cases without any first degree family history of AMI. A total of 319 cases had both EO and FH AMI (Table 1). DNA was available from all cases and controls (n = 3732).

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Table 1

MI in case–control and CVG populations for genotyping of the receptor P2Y11 Ala-87-Thr polymorphism derived from the MDC population

Controls (n = 2488)All AMI cases (n = 1244)EO AMI (n = 622)aFH AMI (n = 611)aEO and FH AMI (n = 319)aCVG (n = 6055)
Age (years)62.5 ± 6.562.3 ± 6.559.0 ± 6.362.5 ± 6.558.9 ± 6.357.5 ± 5.9
Sex (% male)747479697542
Systolic blood pressure (mmHg)147 ± 20150 ± 21145 ± 19150 ± 20145 ± 19141 ± 19
Diastolic blood pressure (mmHg)87.4 ± 1088.5 ± 1087.3 ± 1087.9 ± 1086.8 ± 1087.0 ± 9.5
Body mass index (kg/m2)26.1 ± 3.726.9 ± 4.026.9 ± 3.927.0 ± 4.026.9 ± 4.025.9 ± 4.0
Current smokers (%)273438323728
  • The 1244 AMI cases contain two AMI subgroups: EO AMI, defined as AMI occurring earlier than median age for all AMI cases, FH AMI, where at least one blood-related family member also has suffered an MI. These are also combined into the group EO AMI with FH. Data of known cardiovascular risk factors was collected in the CVG only.

  • aSubgroups of all AMI cases.

Cardiovascular group population

Of the MDC, 6103 individuals were randomly selected into a ‘Cardiovascular cohort’ (MDC-CV), a sample thus being representative of MDC, in whom cardiovascular risk factors were measured, including systolic blood pressure, smoking status, and anthropometric data and, in the majority (n = 5540), fasting plasma analyses of glucose, lipids, and C-reactive protein. The analysis of hsC-reactive protein (hsCRP) was performed using the Tina-quant® CRP latex high sensitivity assay (Roche Diagnostics, Basel, Switzerland) on an ADVIA® 1650 Chemistry System (Bayer Healthcare, NY, USA). All samples were measured in one batch. Analytical results were read in 6 s intervals during a 60 s time period following 5 min incubation. The mean value of these measurements was the reported result. DNA for genotyping was obtained from 6055 of the 6101 selected individuals (Table 1).

Genotyping of the P2Y11 receptor Ala-87-Thr polymorphism of the P2RY11 gene

Genotyping of the 3732 samples of the AMI case–control population was performed using Sequenom according to the manufacturer's instructions with the following primers: forward 5′-TTCTCTGTCCAGCTGGCAGT-3′; reverse 5′-TCCCCATAGCGCCAGTGCTT-3′ and extension 5′-CGCTGCCCCCGCTGGCC-3′.

The 6055 samples of the MDC-CV were genotyped using a TaqMan ABI 7900 according to the manufacturer's instructions with the following primers and probes: forward, 5′-CTGTCCAGCTGGCAGTCA-3′; reverse, 5′-CCCATAGCGCCAGTGCTT-3′; probe 1, 5′-CTGGCCGCCTACC-3′; and probe 2, 5′-CTGGCCACCTACC-3′. Two different persons who were unaware of the phenotypic status of the study participants read all genotypes.

Statistical analysis

Conditional logistic regression was used to test for significance of frequency differences between AMI cases and their respective controls and to generate ORs in the paired AMI case–control study. Thus, numbers and percentages of cases and controls according to genotype in Table 2 refers to those case–control pairs constituting of at least one case and one control, taking into account the fact that some pairs had to be excluded due to unsuccessful genotyping (i.e. unsuccessful genotyping of either the case or both control subjects). Two-tailed t-tests were used to probe associations between the P2RY11 genotypes and cardiovascular risk factors with normal distribution (all except C-reactive protein). C-reactive protein data had a log-normal distribution that was analyzed using the Mann–Whitney test. In order to obtain valid tests for the differences in OR between the whole sample and subgroups, we used bootstrap techniques.

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Table 2

Genotyping of Ala-87-Thr in AMI cases and corresponding controls

Ala-87Thr-87aTotal
Control count, n (%)1719 (80.2)425 (19.8)2144 (100)
AMI count, n (%)877 (77.1)261 (22.9)1138 (100)
EO AMI
 EO Control count, n (%)857 (79.8)217 (20.2)1074 (100)
 EO AMI count, n (%)415 (73.4)150 (26.5)565 (100)
LO AMI
 LO Control count, n (%)862 (80.6)208 (19.4)1070 (100)
 LO AMI count, n (%)462 (80.6)111 (19.4)573 (100)
FH AMI
 FH Control count, n (%)861 (80.9)203 (19.1)1064 (100)
 FH AMI count, n (%)432 (76.5)133 (23.5)565 (100)
No FH of AMI
 NFH Control count, n (%)858 (79.4)222 (20.6)1080 (100)
 NFH AMI count, n (%)445 (77.7)128 (22.3)573 (100)
EO and FH of AMI
 EO + FH Control count, n (%)454 (81.2)105 (18.8)559 (100)
 EO + FH AMI count, n (%)216 (73.5)78 (26.5)294 (100)
  • The AMI case group (n = 2144) contains EO, LO, FH, no FH, as well as EO with FH subgroups.

  • aBoth heterozygous and homozygous P2RY11 Thr-87 carriers.

Results

Genotyping

Of the total 3732 subjects, 3466 individuals (92.9%) eligible for the case–control study were genotyped successfully constituting 1138 pairs (in total n = 3282) of one case (n = 1138) and one to two control subjects (n = 2144). Genotype frequencies were in accordance with Hardy–Weinberg Equilibrium.

Using HapMap, we found that P2Y11 is situated on a minor 11 kb haplotype block encompassing the genes PPAN (second-step splicing factor 1) and EIF3S4 (eukaryotic translation initiation factor 3, subunit 4 delta).

AMI case–control study

In the paired conditional logistic regression analysis, 19.8% of the controls and 22.9% of all AMI cases were found to be carriers of at least one threonine in position 87 of the P2Y11 receptor and conferred an OR of 1.21 for AMI (95%CI 1.02–1.44, P = 0.03) (Table 2). Among the EO AMI cases, 26.6% were Thr-87 carriers, compared with 20.2% of their paired controls (Table 3) corresponding to an OR of 1.43 for AMI (1.13–1.82, P = 0.003, Figure 1). The P2RY11 Thr-87 polymorphism showed no association with LO AMI having an OR of 1.0 for AMI (0.77–1.30, P = 1.0, Table 3).

Figure 1

Association of PRY11 receptor polymorphism Thr-87 with AMI. The association found between Thr-87 and AMI (OR 1.21, 95% CI 1.02–1.44, P = 0.033), family history (FH) AMIs (1.32, 1.02–1.69, P = 0.03), early onset (EO) AMIs (1.43, 1.13–1.82, P = 0.003), and both FH and EO AMIs (1.56, 1.11–2.18, P = 0.01). *P < 0.05; **P < 0.01.

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Table 3

Association of known cardiovascular risk factors with the Thr-87 genotype in the CVG

Cardiovascular risk factorsAla-87-Thr genotypeMean ± SDP-value (two-tailed)
Systolic blood pressure (mm Hg)Ala141 ± 190.84
Thr141 ± 19
Diastolic blood pressure (mm Hg)Ala87 ± 90.64
Thr87 ± 10
Body mass index (weight/kg × kg)Ala25.8 ± 4.00.41
Thr25.9 ± 3.8
Waist (cm)Ala84.2 ± 13.10.50
Thr84.5 ± 12.8
Diabetes mellitus (%)aAla8.60.28
Thr9.6
Cholesterol (mmol/L)aAla6.18 ± 1.090.55
Thr6.15 ± 1.11
Triglycerides (mmol/L)aAla1.37 ± 0.790.70
Thr1.39 ± 0.83
HDL (mmol/L)aAla1.38 ± 0.370.88
Thr1.38 ± 0.38
LDL (mmol/L)aAla4.17 ± 0.990.38
Thr4.14 ± 0.99
LDL/HDL ratioaAla3.24 ± 1.180.65
Thr3.23 ± 1.18
C-reactive protein (mg/L)a,bAla1.3 (0.7–2.8)c0.001
Thr1.6 (0.7–3.0)c
  • n = 6055. Genotypes: Ala-87, Ala-87/Ala-87; Thr-87, Ala-87/Thr-87 or Thr-87/Thr-87 at residue 87 of the P2RY11 receptor protein. No association was found with blood pressure, body size, glucose, or blood fats. An elevated concentration of C-reactive protein was found to be associated with the Thr-87 genotype CRPThr-87 1.6 (0.7–3.0) mg/L, CRPAla-87 1.3 (0.7–2.8) mg/L, P = 0.001. Gaussian distribution was observed for all above risk factors except C-reactive protein that showed a natural logarithmic distribution.

  • an = 5540.

  • bC-reactive protein shows a natural logarithmic distribution.

  • cDenotes median, IQR.

Of the FH AMI cases, the Thr-87 carrier frequency was 23.5% compared with 19.1% in the corresponding control group for AMI giving an OR of 1.32 (1.02–1.69, P = 0.03 in Thr-87 carriers, Table 2 and Figure 1). In contrast, no association was observed between non-familial AMI and Thr-87 (1.12, 0.87–1.43, P = 0.37, Table 2). The frequency of Thr-87 carriers among AMI cases with both EO and FH AMI was 26.5% compared to 18.8% in the corresponding control group for AMI resulting in an OR of 1.56 (95% CI 1.11–2.18, P = 0.01 in carriers of Thr-87) (Table 2 and Figure 1).

Although OR were higher in the subgroups including EO and FH AMIs, there were no statistically significant differences in OR between the whole sample and those including EO AMI (P = 0.09), FH AMI (P = 0.44), or both EO and FH AMI (P = 0.16).

The risk of AMI in homozygotes of Thr-87

Relative to the Ala-87/Ala-87 (n = 877 AMIs, 1719 controls) whose OR for AMI was defined as 1.0, the Thr-87/Thr-87 carriers (n = 20 AMIs, 21 controls), had an increased risk of AMI with an OR of 1.94 (95% CI 1.02–3.66, P = 0.042). Heterozygotes (Ala-87/Thr-87 carriers, n = 241 AMIs, 404 controls) had a slightly weaker association (1.17, 0.98–1.41, P = 0.08) than the whole group of Thr-87 carriers (Figure 2A).

Figure 2

(A) Genetic dosage effect of the P2Y11 receptor polymorphism Thr-87. Compared with the P2RY11 Ala-87/Ala-87 group (OR defined as 1.0, n = 877 AMIs, 1719 controls), the heterozygous Ala-87/Thr-87 group showed an intermediate association with AMI (OR 1.175, 95% CI 0.98–1.41, P = 0.08, n = 241 AMIs, 404 controls). An even stronger association was observed in the homozygous P2RY11 Thr-87/Thr-87 AMI group (n = 20 AMIs, 21 controls, OR 1.94, 1.02–3.66, P = 0.042). (B) Early onset (EO) AMI. Compared with the EO P2Y11 Ala-87/Ala-87 group (OR defined as 1.0, n = 415 AMIs, 857 controls), the heterozygous Ala-87/Thr-87 group showed an intermediate association with AMI (OR 1.39, 95% CI 1.08–1.78 P = 0.009, n = 139 AMIs, 207 controls). An even stronger association was seen in the homozygous P2Y11 Thr-87/Thr-87 AMI group (2.48, 1.02–6.05, P = 0.046, n = 11 AMIs, 10 controls). *P < 0.05, **P < 0.01.

When the study population was restricted to the EO AMIs and their respective controls (n = 415 AMIs, 857 controls) the association with AMI was even stronger in Thr-87/Thr-87 carriers (n = 11 AMIs, 10 controls) with an OR of 2.48 (95%CI 1.02–6.05, P = 0.046). Ala-87/Thr-87 carriers (n = 139 AMIs, 207 controls) had an OR of 1.39 (1.08–1.78, P = 0.009) when compared with carriers of the Ala-87-Ala genotype (Figure 2B).

MDC-CV

In the cardiovascular group (CVG), 5969 individuals (98.6%) of 6055 were genotyped successfully. An elevated concentration of C-reactive protein was found to be associated with the Thr-87 allele when compared with Ala-87 (median, IQR) [CRPThr-87 1.6 (0.7–3.0) mg/L, CRPAla-87 1.3 (0.7–2.8) mg/L, P = 0.001] (Table 3). This association was independent of age.

No differences were seen between the two P2Y11 receptor variants regarding blood pressure, lipids, body mass index, or diabetes mellitus (Table 3). Furthermore, there was no difference in smoking habits or alcohol intake habits between Ala87/Ala87 when compared with carriers of the Thr87 allele.

Discussion

In this study we have shown that the common G-459-A polymorphism causing an Ala-87-Thr substitution in the G-protein-coupled ATP receptor P2Y11 is associated with AMI. The OR for AMI increased stepwise depending on the number of Thr-87 alleles carried, and in subgroups in which the genetic influence is known to be of increased importance; FH AMI, EO AMI, or the combined group of EO AMI with FH AMI. The mechanism by which the polymorphism causes AMI seems to be coupled to increased inflammation because the Thr-87 variant of the P2Y11 receptor was associated with elevated C-reactive protein levels.

In studies on the effects of genetic polymorphisms, small sample sizes carry the risk of both false positive and false negative findings, stressing the need to use large populations in the study groups.20,21 Therefore, we decided to examine the P2Y11 receptor Ala-87-Thr polymorphism in the MDC population including 1244 AMI cases and 2488 paired controls.

The Thr-87 polymorphism was relatively common, present in approximately one-fifth of the population. Thus, the evidence of a role as a risk factor for the development of AMI will be of relevance to large patient groups. In the whole case–control study, the carriers of Thr-87 had an increased risk of developing AMI, with an OR of 1.21. This is a reasonable increase in risk for a single common polymorphism given that environmental factors are the major reasons for AMI and that the genetic component is mediated by several different genes and polymorphisms.

Known MI risk factors include both genetic and environmental components. In previous studies, genetic factors have been shown to have a greater impact on the development of AMI early in life, whereas environmental risk factors have a cumulative effect over time.2,3 To examine groups in which the genetic influence is known to be enhanced, we made a predefined subgroup evaluation of individuals with EO AMI, FH AMI, or both. In these groups, the OR increased in a stepwise pattern to 1.32 in the FH group, 1.43 in the EO group, and 1.52 in individuals with both FH and EO. Thus, our subgroup analysis supports a genetic mechanism. Because of the low participation rate in MDC (41%), it is likely that our study population is healthier and have a lower load of environmental risk factors such as smoking and psychosocial stress than the general population of Malmö. Although being a disadvantage in extrapolation of our results to the general population, a lesser degree of exposure to these environmental risk factors could be an advantage in genetic studies by unmasking genetic factors otherwise hidden in the background noise of such environmental cardiovascular risk factors.

The association was even stronger in subgroups containing EO AMI, FH AMI, or both EO and FH AMI. Also, despite the small numbers of Thr-87 homozygotes in the case and control groups, we could establish that Thr-87/Thr-87 carriers had an even stronger association with MI than Ala-87/Thr-87 heterozygous with an OR of 1.94 in the whole material and 2.48 in the EO AMI group. These values should be interpreted with caution because the groups are small. However, the pattern of a genetic dosage effect is striking and in agreement with the abovementioned increases in risk for EO and FH groups. This strongly supports that the increase in AMI in Thr-87 carriers is dependent on a genetic mechanism.

The P2Y11 receptor is expressed in both myocardium, endothelium, and in various immune system cells, but not in platelets.1115 ATP, the natural ligand of P2Y11, has been shown to have a regulatory effect on the immune system.22,23 Also, P2Y11-like positive inotropic effects have been demonstrated in mouse cardiomyocytes and P2Y11 receptor expression has been shown in human myocardium.16,17

In an attempt to differentiate between myocardial and immune system functions, the P2Y11 receptor the Ala-87-Thr polymorphism was genotyped in the population-based MDC-CV. There was no difference in cardiovascular risk factors examined except for the inflammatory marker C-reactive protein24 that was elevated in the Thr-87 group. The difference was small but highly significant and could be important. C-reactive protein has been shown to be a strong prognostic factor for the development of AMI, and atherosclerosis is now considered to be an inflammatory disease.25 Based on these findings, we hypothesize that the major effects of the Thr-87 variant of the P2Y11 receptor on AMI stem from a proinflammatory status. However, additional changes of inotropic effects on the myocardium itself cannot be excluded.

Carriers of the Thr-87 P2Y11 receptor variant have a polar threonine instead of a hydrophobic alanine residue at position 87, near the extracellular end of transmembrane region II of the P2Y11 receptor. This may affect the three-dimensional structure of the receptor and thereby interfere with ligand binding and signalling. ATP acting on P2Y11 receptors regulates the maturation of human monocyte-derived dendritic cells and induces immunosuppression by inhibiting T-helper 1 cytokines and promoting T-helper 2 cytokines.22,23 Dendritic cells are potent antigen-presenting cells that are important in the atherosclerotic plaque causing plaque stabilization, which in turn causes plaque rupture, local thrombosis, and MI. Our data indicates that the Thr-87 polymorphism in the P2Y11 receptor could influence the risk of AMI by altering the inflammatory regulation in the atherosclerotic plaque.25,26

One possibility is that the Thr-87 P2Y11 receptor variant is in linkage disequilibrium with another gene responsible for the increased risk of MI. However, haplotype block analysis using HapMap demonstrated that P2Y11 is situated in a minor haplotype block flanked by the genes PPAN (second-step splicing factor 1) and EIF3S4 (eukaryotic translation initiation factor 3, subunit 4 delta). Neither of these genes has been suggested to be involved in atherosclerotic or inflammatory disease. Because of their involvement in RNA splicing and initiation of translation, PPAN and EIF3S4 seem less likely to be associated with an increased level of C-reactive protein than would the immune system regulatory receptor P2Y11.

The major limitation of this study is our lack of knowledge of the functional effects of the polymorphism and such studies are planned. However, we do have a strong indication that the increased risk of MI is caused by an increased inflammatory response. Together with previous studies on the importance of the P2Y11 receptor for regulation of human inflammatory cells,22,23 this provides a probable mechanism of action and new link between inflammation and cardiovascular disease.

In summary, we have demonstrated that the G-protein-coupled ATP receptor P2Y11 polymorphism Ala-87-Thr is associated with both increased C-reactive protein and increased risk of developing MI. Based on this association, we hypothesize that the P2Y11 receptor plays an important role in cardiovascular biology and in inflammatory disease.

We propose the G-protein-coupled receptor P2RY11 as a promising drug target candidate for novel therapeutic interventions aimed at MI and cardiovascular inflammatory disease. This P2Y11 receptor polymorphism could be used in risk evaluation of patients, at least in a panel together with other genetic risk factors. The common prevalence of the Thr-87 allele, in nearly one-fifth of the population, stresses the need to develop a causal treatment for those who carry the allele.

Acknowledgement

The study has been supported by the Swedish Scientific Research Council, the Swedish Heart and Lung Foundation, the Vascular Wall program (Lund Medical faculty), Franke and Margareta Bergqvist Foundation, the Söderberg Foundation and the Zoegas Foundation.

Conflict of interest: none declared.

References

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