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Introduction
Cardiovascular diseases cause the majority of noncom-
municable disease-related deaths. It aects 17.7 million
people annually, primarily in low- to middle-income
countries (1). Cardiovascular disease has become the most
common cause of death in Iraq (2).
Coronary artery disease (CAD) is a common heart di-
sorder characterized by the narrowing of major blood ves-
sels that supply the heart, known as coronary arteries, due
to atherosclerotic plaque buildup within the inner layer of
the vessel wall (3). It is the leading cause of mortality and
morbidity worldwide (4). Dyslipidemia and lipid oxida-
tion represent a wide range of lipid abnormalities that are
essential contributors to atherosclerosis development and
progression, ultimately resulting in CAD (5).
The natriuretic peptides are a group consisting of three
structurally associated hormones, which include atrial na-
triuretic peptide (ANP), brain natriuretic peptide (BNP),
and C-type natriuretic peptide (CNP), that play critical
roles in the cardiovascular system's function (6).
BNP, primarily produced by the ventricular myocar-
dium, is released in response to volume expansion, pres-
sure overloading, and increasing diastolic pressure (7).
Serum BNP levels are correlated with the extent of ven-
tricular dysfunction (8). Endothelial dysfunction, which
impairs arterial vasodilation, is an early stage of athero-
sclerotic damage; it frequently happens by being exposed
to cardiovascular-related risk factors such as smoking,
hypertension, diabetes, high blood cholesterol, and obe-
sity. The correlation between lipid parameters and CAD
has been extensively explored, in which elevated levels
of total cholesterol, low-densities lipoprotein cholesterol
(LDL), and triglycerides (TG), in addition to a decrease in
levels of high-density lipoprotein cholesterol (HDL), have
been identied as signicant risk factors (9,10). However,
the interplay between dyslipidemia and BNP gene poly-
morphisms in patients with stable CAD remains poorly
understood. On the other hand, the low plasma levels of
HDL cause oxidation of ox-LDL, which causes a proli-
feration of inammation mediators and the production of
reactive oxygen species (ROS), which may inuence car-
diomyocyte functions (11,12).
The potential use of BNP as a cardiac biomarker
is secondary to its activating by the myocardium stretch
and ischemia, as demonstrated in heart failure (HF) and
myocardial infarction (MI). Nevertheless, age and gender
signicantly regulate the plasma BNP (13–15).
BNP/NPPB genes are located on chromosome one
in humans, which contains numerous polymorphisms re-
lated to cardiovascular conditions and their risk factors.
Many single-nucleotide polymorphisms (SNPs) have
been identied for that region, some of which have been
currently correlated with elevated BNP and ANP plasma
levels, decreased blood pressure, and incidence of hyper-
tension (16). In three separate studies, the SNP rs198389
Relationship between lipid prole and B‑type natriuretic peptide T‑381C (rs198389) gene
polymorphism in patients with stable coronary artery disease
Gawhar Ahmed Shekha1,*, Kalthum Asaaf Maulood1, Mudhir Sabir Shekha 2,3
1 Department of Biology, College of Education, Salahaddin University-Erbil, Erbil, Kurdistan Region, Iraq
2 Department of Biology, College of Science, Salahaddin University-Erbil, Erbil, Kurdistan Region, Iraq
3 Department of Medical Cell Biology, Upsala University, Upsala, Sweden
ARTICLE INFO ABSTRACT
Keywords:
CAD, BNP gene promoter T-
381Cpolymorphism,lipidprole
Original paper
Article history:
Received: June 04, 2023
Accepted: August 30, 2023
Published: December 10, 2023
* Corresponding author. Email: Gawhar.shekha@su.edu.krd
Cellular and Molecular Biology, 2023, 69(13): 180-188
The research explored the link between Brain Natriuretic Peptides (BNP) gene promoter T-381C polymor-
phism, serum BNP, and lipid proles in Kurdish people from Iraq with stable coronary artery disease (CAD).
The study was conducted on 62 individuals with CAD and 31 without CAD (control group). DNA was extrac-
ted from each individual's sample using the Sanger sequencing method to study the BNP gene's polymorphism.
The identied alleles were TT, TC, and CC. The frequency of the TT genotype decreased signicantly among
the patient group compared to the control group, while the CC genotype's frequency was higher (p<0.05).
However, there was no signicant increase in BNP levels in TC and CC genotypes compared to the TT geno-
type. Lipid prole values were not signicantly dierent among the genotypes. The study utilized a cut-o
value for BNP activity for predicting CAD and found that individuals with a BNP activity value less than the
cut-o had signicantly greater changes in lipid prole and renal function (p<0.05). Stepwise multivariate
regression analysis showed that cholesterol was not the only primary determinant of BNP rate in subjects
with stable CAD; oxidized low-density lipoprotein (Ox-LDL), a history of heart attacks, and oxidative stress
malondialdehyde (MDA) had a signicant eect. Homozygous C allele carriers at position 381 of the BNP
precursors gene promoter were more likely to exhibit atherosclerosis lesions. We found that BNP rs198389
was not correlated with lipid prole and kidney disease.
Doi: http://dx.doi.org/10.14715/cmb/2023.69.13.28 Copyright: © 2023 by the C.M.B. Association. All rights reserved.
Cellular and Molecular Biology
E-ISSN : 1165-158X / P-ISSN : 0145-5680
www.cellmolbiol.org
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Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
(also known as BNP T-381C) in the promoter part of the
BNP gene was found to be correlated with elevated BNP
levels (17–19). Furthermore, it was found that in vitro, the
C allele correlated to more signicant promoter activity
(17). The present research aims to determine the associa-
tion between the BNP gene polymorphism (T-381C) and
BNP levels, lipid prole, and other particular parameters
in individuals with stable CAD.
Materials and Methods
Patient population
The research study on stable coronary artery disease
was conducted in Erbil, Iraq, at the Surgical Specialty Hos-
pital-Cardiac Center, from January to June 2022. Among
the 300 patients who had undergone coronary angiography
in the Department of Cardiology for diagnostic purposes,
93 male participants were selected for the study.
The patient population (Group I) consisted of 62 pa-
tients who had stable coronary artery disease with stenosis
above fty percent (50%) in at least one of their coronary
arteries; the other 31 participants who did not have coro-
nary artery stenosis were assigned to the non-CAD control
group (Group II).
To ensure the homogeneity of the study population,
patients with other heart conditions, participants with
autoimmunity, acute disease of the liver or kidneys, mali-
gnancies, or any other form of chronic medical condition
were excluded from the study. Individuals, who expe-
rienced unstable angina, including STEMI and non-STE-
MI, were also excluded from the study.
Sample collecting
After an overnight fast, venipuncture was performed
to collect 10 mL of whole blood samples, then separated
into two halves. The rst half was collected in an EDTA
tube and processed for hematological and molecular as-
sessments. The second portion was transferred to gel tubes
and centrifuged to separate the serum. The serum was then
kept at -20 degrees Celsius until further use.
Biochemical assay
After centrifuging non-heparinized blood, serum brain
nitric peptide activity was measured using a sandwich en-
zyme immunoassay technique (SL0372Hu-China) with a
1.2pg/mL sensitivity. The intra- and inter-assay coecient
of variation was less than 10% for all assays. A Cobas
e411: 1242-22 analyzer (Roche/ Germany) was utilized
for analyzing the serum biochemical parameters.
Coronary angiography
Diagnostic coronary angiography was performed on
each patient to determine the severity and extent of CAD
through the right femoral approach. Experienced cardiolo-
gists evaluated coronary angiograms to assess the severity
of the CAD, who were unaware of the patient's clinical his-
tory and biochemical results. The severity of the stenosis
has been categorized using the Coronary Artery Disease
Reporting and Data System (CAD-RADS) classication
(20). The study population was divided into two separate
groups; the rst group consisted of 62 patients who were
diagnosed with coronary artery disease (CAD-RADS 3 or
more) with signicant coronary artery stenosis (≥50%);
the second group consisted of 32 subjects who showed no
evidence of CAD (CAD-RADS 0) as determined by coro-
nary angiography.
DNA extraction
The GeneAll® ExgeneTM Genomic DNA Extraction for
Clinic Cell SV mini kit was used to extract DNA from
whole blood specimens to obtain BNP gene polymor-
phisms. Following GeneAll® (Songpa-gu, Seoul, KO-
REA) manufacturer's instruction sets, 50-μL of elution
buer was utilized for DNA extraction. Then genomic ex-
traction was frozen at –20°C before a PCR test.
Genotyping of the BNP gene rs198389 loci
The polymerase chain reaction (PCR) technique was
used to amplify the fragment of target DNA. The primer
sequence, reaction, system and conditions of the PCR ampli-
cation reaction are shown below; the target DNA sequence
was detected by Sanger sequencing. A programmable ther-
mal cycler PCR system was used for amplication. The
forward primer: 5ʹ-CTGTGAGTCACCCCGTGCTC-3ʹ
and reverse primer: 5ʹ-GGCAGGAACGCGCTGGAGAC-
3ʹ; fty µL reaction mixtures were used for preparing the
PCR cocktail, including 25 µL of 2x PCR master mix
(AMPLIQON, Denmark), 1.0 µL of each the primer (10
pmol), and 1.5 µL of template genomic DNA. The total
volume was completed to 50 µL with nuclease-free water.
The PCR started with an initial denaturation step at
95°C for 5 minutes, 35 cycles at 94°C for 30 seconds, an-
nealing at 60°C for 40 seconds, and extension at 72°C for
30 seconds, as well as a nal extension step at 72°C for
10 minutes. The amplied products were then subjected to
electrophoresis on 1.5% agarose gel to verify the fragment
size (21), and the PCR product length was 186 bp.
Statistical analysis
Graph Pad Prism version 9 and MedCalc version 18
were used for the data analysis. Chi-square statistics ana-
lyzed the demographic characteristics. The Kruskal Wallis
test calculated Mean±SEM, p-value≤0.05 was considered
signicant, and the person correlation test was used to
evaluate between-group comparisons for categorical vari-
ables. Additionally, the predictive signicance of the study
determined severity via Receiver Operator Characteristic
(ROC) Curve analysis and the results were expressed as
area under the curve (AUC), cut-o value, specicity
and sensitivity for BNP level. The Hardy-Weinberg equi-
librium was estimated using the H-W calculator for two
alleles. We used stepwise multiple regression modeling to
assess factors aecting serum BNP levels in all patients
with stable CAD.
Results
Subject characteristics
Tables 1 and 2 show the clinical features of 93 male
subjects, distinguishing between those diagnosed with
CAD and those without CAD. The prevalence of high age,
a high body mass index (BMI), smoking habit, elevated
blood pressure, a personal history of diabetes mellitus,
and personal history of heart attack, and a family history
of hypertension and coronary artery disease were signi-
cantly higher among those with CAD patients than in
the non-CAD group. In addition, signicant dierences
were observed in various lipid parameters between the
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Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
In addition, the levels of BNP were slightly elevated in
the CAD group compared to the non-CAD group. Moreo-
ver, Ox-LDL levels showed a signicant decrease among
the CAD group. In addition to cardiovascular markers,
markers of kidney function, including urea and creatinine,
were slightly elevated in the CAD group compared to the
two groups. In the CAD group, TG, total cholesterol to
HDL-ratio (cholesterol/HDL), and the triglycerides to
HDL ratio (TG/HDL) were all signicantly elevated. The
overall cholesterol level and LDL levels also increased,
but non considerably. In contrast, HDL was lower in the
CAD group than in the non-CAD group.
Variable CAD n=62 (%) non‑CADN (%) n=31 p
Mean ± SE of Age (years) 53 ±1.118 48±1.962 0.030
Smoking Yes 17(27.4 %) 5 (16.12%) 0.027
No 45(72.6%) 26 (83.87%)
BMI (Kg/m2) 29.37±0.596 26.31±0.468 0.0003
SBP (mm Hg) 136.8±2.628 114.2±1.721 0.0001
DBP (mm Hg) 84.94±2.058 77.53±1.118 0.0102
Physical activity Yes 20(32.25%) 11 (35.48%) 0.879
No 42(67.74%) 21 (64.51%)
Fast food intake Yes 22(35.48%) 11 (35.48%) 0.762
No 40(64.51%) 20 (64.51%)
Soft drink Yes 10 (16.12%) 6 (19.35%) 0.599
No 52 (83.87%) 25 (80.64%)
Personal Diabetic Yes 12(19.35%) 0 (0) 0.000
No 50(80.64%) 31 (100%)
Personal stork Yes 3 (4.83%) 0 (0) 0.104
No 59(95.16 %) 31 (100%)
Personal heart attack Yes 12(19.35%) 0 (0) 0.000
No 50(80.64%) 31 (100%)
Family history of Diabetic Yes 32(51.61%) 14 (45.16%) 0.379
No 30(48.38%) 17 (54.83%)
Family history of hypertension Yes 35(56.45%) 12 (38.70%) 0.001
No 30(48.38%) 19 (61.29%)
Family history of hyperlipidemia Yes 14(22.58%) 9 (29%) 0.615
No 48(77.41%) 22 (70.96%)
Family history of heart attack Yes 13(20.96%) 5 (16.12%) 0.132
No 49(79.03%) 26 (83.87%)
Family history of coronary artery Yes 21(33.87%) 3 (9.6%) 0.000
No 41(66.12%) 28 (90.32%)
Table 1. Baseline characteristics of the population.
Variable CAD n=62 (%) non‑CAD (%) n=31 p
Total cholesterol (mg/dL) 148.5±4.462 139.2±3.327 0.582
Triglycerides (mg/dL) 174.1± 8.774 131.4± 2.584 0.0026
HDL-c (mg/dL) 30.83 ±0.824 40.53 ±1.424 0.0001
LDL-c (mg/dL) 90.25±3.887 85.31±3.409 0.6897
Cholesterol/HDL 4.982±0.183 3.633±0.1.6 0.0001
TG/HDL 6.060±0.408 3.435±0.169 0.0001
BNP pg/mL 55.93±2.552 49.05±0836 0.6897
OX-LDL pg/mL 180.7±9.52 191.7±5.04 0.0006
Urea (mg/dL) 37.06±1.524 32.65 ±1.577 0.1301
Creatine (mg/dL) 0.880±0.025 0.8523± 0.026 0.4762
AZGP1 ng/mL 52.52±7.593 81.94±2.174 0.0001
MDA ng/mL 4.487±0.372 3.223±0.142 0.0112
SOD ng/mL 2.630±0.118 4.632±0.762 0.0001
T-AOC U/mL 4.919±0.170 7.494±1.101 0.0001
GPX pmol/mL 16.46±0.666 27.95±3.218 0.0001
Table 2. Biochemical parameters of CAD and non-CAD individuals.
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Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
non-CAD group. In the CAD group, antioxidant capacity,
including 2-glycoprotein 1 (AZGP1), superoxide dismu-
tase (SOD), total antioxidant capacity (T-AOC), and glu-
tathione peroxidase (GPX), were found to be signicantly
less common than in the non-CAD-group. MDA, an in-
dicator of oxidative stress, was found to be higher in the
CAD group than in the non-CAD group.
ROC curve analysis for BNP activity
The evaluation of the ROC curve estimated the cut-o
levels for BNP activities used to distinguish between indi-
viduals with and without CAD. The area under the ROC
curve for BNP activities as a predictor of CAD was 0.526
(p<0.05). Following the analysis of the ROC curve, the
BNP activity level of 54.842 pg/mL had sensitivity and
specicity in predicting CAD (sensitivity = 32.2 6% and
specicity = 96.77 %). Also, the study population has been
divided into two groups based on the cut-o value of the
BNP activity levels. Numeral biomarkers, which include
total cholesterol, TG, cholesterol/HDL-ratio, triglyceride/
HDL-ratio, urea, and creatinine, increased signicantly
(p<0.05) in individuals with BNP activity levels below the
cut-o value. However, age and BMI levels were slightly
elevated in BNP groups below the cut-o value, and no-
signicant decrease in HDL and ox-LDL amounts among
those in low cut-o point groups (Table 3).
Multivariate analysis
Factors aecting serum BNP levels in all patients of
CAD were assessed using stepwise multiple regression
modeling (Table 4). All continuous variables that did
not follow a normal distribution were log-transformed.
Our stepwise multiple regression analysis showed that
several independent variables signicantly aected serum
BNP levels in patients with stable CAD. In Model 1, to-
tal cholesterol signicantly predicted serum BNP levels
(βeta=0.998, p<0.05). However, introducing OX-LDL in
Model 2 signicantly reduced the eect of cholesterol on
BNP levels (βeta=0.519, p<0.05), indicating that OX-LDL
may be a more important predictor of BNP levels in CAD
patients than cholesterol.
Ox-LDL has a crucial role in the pathogenesis of CAD.
Indeed, the eect of Ox-LDL on serum BNP levels in the
second model was almost the same as that of total choles-
terol. Moreover, the impact of Ox-LDL on serum BNP le-
vels did not decrease in the subsequent models but remai-
ned a signicant predictor of serum BNP levels even after
the inclusion of other independent variables. The inclusion
of the personal history of heart attack and MDA in the third
and fourth models also had a signicant impact on serum
BNP levels, leading to a further reduction in the eect of
cholesterol on serum BNP levels (βeta=0.443, p<0.05) and
(βeta=0.313, p<0.05) respectively.
BNP rs198389 genotype
The amplication of the BNP gene was carried out,
and the amplicons were gel electrophoresed, as shown in
Figure 1. The rs198389 polymorphism of BNP was ge-
notyped. As illustrated in Figure 2, the heterozygous and
homozygous variants of BNP rs198389 were determined
Categorical Variables BNP>54.842BNP ≤ 54.842 p
Total cholesterol (mg/dL) 141.3±3.333 158.7±8.032 0.0416
TG (mg/dL) 154.1±7.184 180.5 ±12.59 0.033
HDL (mg/dL) 34.65±1.151 32.23±1.493 0.3074
LDL (mg/dL) 85.72±2.958 97.08±7.262 0.155
Cholesterol/HDL 4.351±0.164 5.117±0.336 0.0483
TG/HDL 4.961±0.363 5.988±0.549 0.0472
OX-LDL pg/mL 179.8±8.699 170.9±7.680 0.8807
Urea (mg/dL) 33.94±1.203 41.38±2.839 0.0332
Creatinine (mg/dL) 0.857±0.020 0.917±0.050 0.3605
Age (year) 50.81±1.160 52.10±2.093 0.529
BMI (kg/m2) 29.53±1.03 28.01±0.49 0.103
Table 3. Risk factors predicted by the cut-o value of BNP activity in the study population.
Model B beta Partial correlation 95%CI Adjusted R2Fp
Lower Upper
1Cholesterol 0.935 0.998 0.998 0.923 0.946 0.996 2556 0.000
2Cholesterol
Ox-LDL
0.486
0.431
0.519
0.481
0.568
0.539
0.339
0.291
0.632
0.571
0.997
37.205
0.000
3
Cholesterol
Ox-LDL
Personal heart
attack
0.415
0.489
0.088
0.443
0.546
0.022
0.52
0.604
0.363
0.284
0.334
0.015
0.58
0.615
0.109
0.998
13.626
0.000
4
Cholesterol
Ox-LDL
Personal heart
attack
MDA
0.293
0.407
0.094
0.202
0.313
0.454
0.023
0.221
0.3335
0.497
0.391
0.239
0.118
0.302
0.015
0.011
0.492
0.583
0.108
0.308
0.998
5.393
0.022
Table 4. Stepwise multiple regression analysis on serum BNP as a dependent variable in a whole study population.
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Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
to be TC and CC, while the TT genotype was considered
a reference allele.
BNP rs198389 genotype polymorphism with CAD
Results showed that the wild homogeneous TT geno-
type was less common in stable CAD patients than non-
CAD with signicant change. The OR: 0.23, CI 95%:
0.08 to 0.64. They indicated a signicant protective factor
against getting the disease. The mutant heterogeneous TC
was a risk factor for the disease with OR: 1.73, CI 95%:
0.65 to 4.81. While the mutant homogenous CC genotype
was also the risk factor with nearly three folded impacts
on getting the disease, OR: 2.86, CI95%: 0.98 to 9.33. The
dominant genotype of stable CAD patients and non-CAD
has a signicant impact as a protective eect against the
developing the disease, p<0.05, while the recessive geno-
type variants TC+CC has an impact as a risk factor for the
disease progression with a 4.4 fold eect, and p<0.05.
Regarding the allele frequency, the T allele had a pro-
tective eect against the disease with the OR: 0.34, CI
95%: 0.17 to 0.68. While the C allele is the risk factor for
getting the disease with almost three-folded impacts, OR:
2.91, CI95%: 1.47 to 5.84. Table (5)
The interaction between the BNP rs198389 polymor‑
phism and CAD risk factors.
The combined impacts of BNP genotype and specic
CAD risk factors were determined; Coronary artery di-
sease is inuenced by factors such as dyslipidemia, kidney
dysfunction, and BNP SNPs. In this research, we exami-
ned the impact of specic risk factors in individuals with
dierent genotypes, specically focusing on the C allele
(variants TC and CC) and the reference allele (TT) of the
BNP rs198389 polymorphism (Figure 3). Those partici-
pants with CAD and the TT or TC and CC genotype exhi-
bited a signicant increase in triglycerides, cholesterol/
HDL-ratio, and TG/HDL-ratio, urea compared to the non-
CAD group with the TT or TT ad TC genotype. Moreover,
individuals with CAD and the TT or TC and CC genotype
demonstrated signicantly lower HDL levels than ' 'the
participant's non-CAD group with the TT or TC and CC
genotype. Additionally, Total Cholesterol was non-signi-
cantly lower in CAD individuals with the TC and CC
genotypes compared to the CAD group with the TT geno-
type.
Furthermore, our study revealed a non-signicantly
elevation in levels of BNP and OX-LDL in CAD parti-
cipants with the TT or TC and CC genotypes compared
to the non-CAD group with the TT or TC and TT geno-
type. However, the two groups observed no signicant
dierences in creatinine levels. High lipid prole, kidney
dysfunction, increased BNP, and OX-LDL were risks for
developing CAD. These changes were observed in the
reference and mutated genotypes among individuals with
CAD and those without CAD. Thus, we did not identify
any signicant interactions between the BNP rs198389
polymorphism and risk factors.
Discussion
The main ndings of the present study are; rst, our re-
Figure 1. Gel-electrophoresis documentation. Lane L: a standard
100-bp marker, Lane 1 to 20 BNP gene (186 bp). Lanes 21: negative
control.
Figure 2. DNA sequencing chromatograph for the BNP gene rs198389
(A) reference allele, homozygous genotype: TT; (B) heterozygous
genotype: TC; (C) homozygous genotype: CC.
Genotypes Patients Control OR CI 95% P value X2
N=62 N=31
TT 12 16 0.23 0.08 to 0.64 0.002 10.11
TC 28 10 1.73 0.65 to 4.81 0.16 1.4
CC 22 5 2.86 0.98 to 9.33 0.042 3.717
TT 12 16 0.23 0.08 to 0.64 0.002 10.11
TC+CC 50 15 4.44 1.56 to 12.72 0.002 10.11
T 52 42 0.34 0.17 to 0.68 0.001 10.95
C72 20 2.91 1.47 to 5.84 0.001 10.95
Table 5. The frequency distribution of genotype BNP T-381C promoter region between CAD patient and
control BNP gene with odd ratio.
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Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
sults veried previous ndings regarding the relationship
between traditional risk factors and CAD. Specically,
we observed a higher prevalence of BMI, smoking habit,
hypertension, advanced age, personal history of diabetes
mellitus, personal history of heart attack, and family histo-
ry of hypertension in the CAD group compared to the non-
CAD group. These ndings underscore the importance of
comprehensive risk assessment and management of these
modiable risk factors in preventing and controlling CAD
(22).
Second, BNP activity levels in a group with the below
cut-o BNP≤ 54.842 displayed elevated levels of total cho-
lesterol, TG, cholesterol/HDL-ratio, TG/HDL-ratio, urea,
and creatinine. Low BNP activity levels could be related
to lipid disorders and impaired kidney function, both of
which have been identied as risk factors for cardiovascu-
lar disease. Several organs and tissues express natriuretic
peptide (NP) receptors, including blood vessels, kidneys,
skeletal muscle, and adipose tissue (23). BNP inhibits cho-
lesterol synthesis in human adrenocortical cells, especially
when stimulated by angiotensin II (24). According to Pot-
ter et al. (25), NP receptors, which include the BNP recep-
tor, are predominantly expressed in the adipose tissue and
the kidneys.
Several factors are correlated with B-type natriuretic
peptide and N-terminal pro-B-type natriuretic peptide
(NT-proBNP), including sex, high age, and renal dysfunc-
tion (26). Additionally, BMI and NT-proBNP levels were
identied as potential factors inuencing the associations
between cardiac natriuretic peptides and lipid proles,
particularly total cholesterol. Notably, the strength of this
association was found to be stronger in older subjects than
younger ones. This observation can be partly explained by
the fact that older patients are more likely to have higher
levels of natriuretic peptides due to an increased prevalence
of cardiovascular comorbidities and age-related changes
in cardiac structure and function (27). Furthermore, older
individuals commonly exhibit lower total cholesterol le-
vels, which may be inuenced by lipid-lowering therapy
or clinical conditions such as malnutrition and frailty
(28,29). On the other hand, increased expression of BNP
or genetic/pharmacological cyclic guanosine 3′,5′-mono-
phosphate (cGMP) enhancement in multiple animal stu-
dies model stimulates adipose tissue browning and lipid
oxidation, which promoted the biosynthesis of mitochon-
dria and fat oxidation in skeletal muscles, which prevented
obesity and glucose intolerance (30–32). Van Kimmenade
RRJ et al. observed that cardiac NPs directly impact the
major determinants of LDL levels, including LDL recep-
tor (LDLR) and (PCSK9). PCSK9 receptor is expressed in
the adipose tissues of humans and has to be regulated in
opposing ways by insulin and ANP (32,33). An increase in
BNP level with age is partly related to a drop in the esti-
mated glomerular ltration rate (eGFR). This age-related
rise in BNP could be a protective mechanism promoting
favorable lipid metabolism. In obese individuals, never-
theless, the concentration of natriuretic peptides is lower.
One possible explanation for this is increases in clearance
as natriuretic peptides are involved in lipolysis, and BNP
receptors have been detected in adipose tissue (34,35).
Third, a multivariate stepwise regression model was
employed to identify which clinical and anthropometric
variables were independently correlated with BNP. Nu-
merous anthropometric and biochemical variables have
been individually introduced to the model. Among these
variables, total cholesterol, OX-LDL, personal history of
heart attack, and MDA revealed a direct association with
BNP among all of these variables. Interestingly, OX-LDL
was a more signicant predictor of BNP levels in patients
with CAD. Furthermore, ox-LDL's eect on BNP levels
remained signicant even when other independent va-
riables were accounted for in subsequent models. Notably,
including heart attack history and MDA in the analysis
models showed substantial eects on serum BNP levels.
Acute exposure of adult rat ventricular cardiomyocytes
to ox-LDL alters intracellular calcium handling. The n-
dings of this study suggest that increased levels of ox-LDL
could lead to ventricular dysfunction before a coronary
event, especially in people with a high risk of cardiovas-
cular disease, even at young ages. Ox-LDL also inhibits
systolic Ca2+ release and induces abnormal diastolic
Ca2+ release, which raises the risk of arrhythmias. These
detrimental eects on Ca2+ cycling in cardiomyocytes
may lead to abnormal intracellular Ca2+ dynamics, impai-
ring cardiac function resulting from abnormal intracellular
Ca2+ cycling (36).
Studies on the young cohort showed ox-LDL levels
elevated with cardiovascular risk over a lifetime. The one
exception was individuals with stable CAD, which had
lowered ox-LDL levels than those with low lifetime car-
diovascular risk despite having a high BMI and increased
prevalence of males and hypertension. Individuals with
stable CAD are observed to be at high risk for cardiovascu-
Figure 3. Relationships between the BNP rs198389 polymorphism
genotype in stable coronary artery disease risk factors. CAD (refe-
rence allele TT; variant TC CC) groups.
186
Gawhar Ahmed Shekha et al. / Relationship between lipid prole and B‑type natriuretic peptide T‑381C, 2023, 69(13): 180‑188
lar disease, but this risk might be reduced through pharma-
cological and lifestyle management (36,37). Young indi-
viduals with stable CAD expertise had the same systemic
oxidative stress as those with low cardiovascular risk and
a healthy lifestyle. All participants in this research with
stable CAD had taken statins, which have been shown to
reduce ox-LDL levels (38). Thus, the lipid-lowering and
antioxidant capabilities of statins; might contribute to
maintaining low ox-LDL levels in individuals with stable
CAD that have been well-controlled (39,40). The rela-
tionship between NT-pro-BNP and ox-LDL suggests that
ox-LDL may be directly associated with cardiac function
before and after the onset of cardiovascular disease. Ox-
LDL has been linked to reduced cardiac function in the po-
pulation and patients with congestive heart failure (41,42).
The association between NT-proBNP levels and ox-LD-
Lwhich typically correlates with oxidative stress, may be
inuenced by conventional cardiovascular risk factors. In
addition, it has been stated that LDL levels directly aect
ox-LDL levels, whereas hypertension is associated with
volume overload and controls NT-proBNP levels. The
multivariate regression analysis was estimated to deter-
mine whether NT-proBNP has been aected by ox-LDL
independently of LDL, systolic blood pressure, and tra-
ditional cardiovascular risk factors. Positive correlations
were found between NT-proBNP levels, ox-LDL, and
systolic blood pressure, indicating that each variable inde-
pendently aected NT-proBNP levels. Even with control-
ling for LDL and traditional cardiovascular risk factors,
the relationship between NT-proBNP and ox-LDL remains
signicant (43-45).
Fourth, BNP rs198389 genotype polymorphism and
relationship with CAD risk factors, the wild homoge-
neous TT genotype was less common in stable CAD pa-
tients than non-CAD with signicant change, which is the
protective factor against getting the disease. The mutant
heterogeneous TC and homogenous CC genotypes were
risk factors for getting the disease. Pster et al. (46) deter-
mined that genotypes of the rs198389 (T-381C polymor-
phism) were correlated with BNP levels. There was no
relationship between these genotypes and the risk of heart
failure (HF). Costello-Boerrigter (47) identied non-signi-
cant variants in genotype frequencies of the BNP gene
polymorphism (T-381C) between dierent study groups,
which includes patients with HF and CAD (p>0.05). No-
netheless, a correlation was found between genotypes and
BNP and NT-proBNP levels. Particularly, the CC genotype
was correlated with higher BNP and NT-proBNP levels
than the TT and TC genotypes (CC > TC > TT, p<0.05 for
all assays). Takeishi et al. (18) found in a separate study
that participants who carried the homozygous C allele had
more BNP levels compared to individuals with the homo-
zygous T allele and those who were heterozygous, and the
study showed the fact that the -381C allele was associated
with higher BNP levels and increased BNP promoter acti-
vity within reporter gene assays in a large Japanese adult
general population.
In summary, this study investigated the ndings that
BNP activity levels below the established cut-o value,
along with elevated levels of lipid proles and oxidative
stress markers, are associated with an increased risk of
developing CAD. Ox-LDL plays a more crucial role in the
pathogenesis of CAD. On the other hand, the TC and CC
genotypes were identied as risk factors for CAD develop-
ment. While the T allele was associated with a protective
eect, and the C allele increased the risk of developing
CAD. No signicant interactions were observed between
this study's BNP rs198389 polymorphism and risk factors.
Conict of competence
The authors declare that they have no conict of interest.
Source of funding
This research received no dedicated funding from public,
commercial, or not-for-prot sectors.
Orcid ID of the authors
Gawhar Ahmed Shekha; https://orcid.org/0000-0001-
8626-7117
Kalthum Asaaf Maulood; https://orcid.org/ 0000-0002-
4023-267X
Mudhir Sabir Shekha ; https://orcid.org/0000-0002-9552-
838X
Contribution of all authors to the papers
All authors have contributed signicantly to this research.
(G.A. Sh.) took responsibility for collecting samples, la-
boratory investigations, statistical assessment, and manus-
cript composition. (M.S. Sh.) and (K.A. M.) played roles
in the conception, and design, with the interpretation of the
research's results and oered valuable input and feedback
throughout the development of the manuscript. All the au-
thors carefully reviewed and approved the nal draught of
the manuscript.
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