Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2018  |  Volume : 14  |  Issue : 9  |  Page : 480-485

Imbalance of T-helper 1/T-helper 2 cytokines and impaired glucose tolerance among patient with acute coronary syndrome

Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China

Date of Web Publication29-Jun-2018

Correspondence Address:
Zhao-Hui Mo
Department of Endocrinology, Third Xiangya Hospital, Central South University, 138 Tong Zi Po Road, Changsha 410013, Hunan Province
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.194346

Rights and Permissions
 > Abstract 

Purpose: The balance between T helper (Th) cells Th1- and Th2-related cytokines plays a key role in the clinical process of acute coronary syndrome (ACS) and type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT). The objective of this study was to assess the status of Th1/Th2 cytokines in patients with ACS and T2D or IGT.
Methods: A total of 201 ACS patients were enrolled in the study. All ACS patients were divided into three groups: Group I-patients with normal glucose tolerance (NGT), Group II-patients with IGT and Group III-patients with T2D. We measured circulating Th1/Th2-type cytokines (interleukin [IL]-4, IL-13, interferon-gamma [IFN-γ], and tumor-necrosis factor-alpha [TNF-α]) using enzyme-linked immunosorbent assay and calculated the ratio of Th1/Th2.
Results: Significant elevations in serum levels of IL-4, IL-13, IFN-γ, and TNF-α were found in ACS-T2D and ACS-IGT groups compared to that in both ACS-NGT group and healthy individuals. Higher serum levels of IL-4, IL-13, and TNF-α were found in ACS-NGT group than that in the control group. Furthermore, IL-4 and IFN-γ concentrations were significantly higher in ACS-T2D patients than in ACS-IGT patients. IFN-γ/IL-4, IFN-γ/IL-13, and TNF-α/IL-4 ratios as markers of Th1/Th2 ratio were significantly higher for the ACS-T2D group and ACS-IGT group as compared to that in the ACS-NGT group and control group (P < 0.05).
Conclusion: Shifts in the balance of Th1/Th2 toward a predominance of Th1 may represent more severe inflammatory status in ACS patients with type T2D or IGT.

Keywords: Acute coronary syndrome, impaired glucose tolerance, T-helper 1/T-helper 2 profile, type 2 diabetes mellitus

How to cite this article:
Zhao SL, Mo ZH, He HH, Zhao LL, Xie YH. Imbalance of T-helper 1/T-helper 2 cytokines and impaired glucose tolerance among patient with acute coronary syndrome. J Can Res Ther 2018;14, Suppl S2:480-5

How to cite this URL:
Zhao SL, Mo ZH, He HH, Zhao LL, Xie YH. Imbalance of T-helper 1/T-helper 2 cytokines and impaired glucose tolerance among patient with acute coronary syndrome. J Can Res Ther [serial online] 2018 [cited 2020 Apr 9];14:480-5. Available from: http://www.cancerjournal.net/text.asp?2018/14/9/480/194346

 > Introduction Top

Acute coronary syndrome (ACS) is often caused by disruption of an atherosclerotic plaque, resulting in occlusion of the coronary artery [1] and the initial cellular and extracellular events that occur soon after ACS are characterized by a robust expression of a number of inflammatory cytokines.[2] Meanwhile, large evidence revealed that coronary plaque rupture can be triggered by various inflammatory cytokine response [3] and inflammatory cytokines might affect the stability of atherosclerotic plaque. In patients with ACS, type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT) continues to be a major cause of morbidity and mortality.[4] It has been recognized that diabetes is a main risk factor for atherosclerosis process which lead to ACS.[5] Besides, people with IGT have long been considered to be at high risk for both T2D and cardiovascular diseases. Studies have revealed that chronic vascular complications in T2D or IGT are the deteriorating conditions underlined by inflammation [6] and the hyperglycemia associated with T2D or IGT can lead to inflammation.[7] These prior studies suggested that there might be more severe inflammatory status in patients with ACS and T2D or IGT.

T-helper (Th) cells are key regulators of inflammatory response as they secrete a wide array of cytokines.[8] Interleukin-4 (IL-4) and IL-13, which are mainly secreted by Th2 lymphocytes, have been proved to be associated with inflammation reduction and improvement of symptoms in ACS patients; meanwhile Th1 cytokines such as interferon-gamma (INF-γ) and tumor-necrosis factor-alpha (TNF-α) have been considered to increase inflammation, therefore leading to disease progression and worsening of symptoms.[9] Th2 and Th1 cytokines may have mutual effects with each other and together have great influence on the progression of many diseases including ACS.

There is a need to identify the status of Th1/Th2 cytokines in patients with ACS and IGT or T2DM to facilitate screening and the development of novel strategies to prevent disease progression and related complications. In this study, we aimed to investigate the imbalance of Th1/Th2 cytokines in such patients to figure out more evidence about this potential therapeutic and prognostic target.

 > Methods Top

Ethics statement

The study was approved by the authors' hospital, and the study protocol complied with the guidelines set out in the Declaration of Helsinki. All subjects gave written informed consent before participation.

Study population

A total of 201 consecutive patients, admitted with ACS myocardiac infarction with ST segment elevation;[10] myocardiac infarction without ST segment elevation;[11] unstable angina pectoris [11] to the authors' hospital were enrolled in this study. Seventy age- and sex-matched healthy subjects were enrolled as control group. T2D patients were defined as a history of DM, a fasting plasma glucose concentration ≥126 mg/dl, or the use of hypoglycemic medications.[12] IGT can be recognized by the results of an oral glucose tolerance test: 2-h postload plasma glucose ≥7.8 and <11.1 mmol/L (≥140 and <200 mg/dl)[13] and NGT is defined as blood glucose rises no higher than 140 mg/dl 2 h after the drink. Hypertension is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg. Hyperlipidemia is defined as the abnormally elevated levels of any or all lipids and/or lipoproteins in the blood.

The exclusion criteria of this study included pregnancy, previous myocardial infarction, a history of heart failure, patients taking insulin, myocardiopathy or moderate/severe valvular heart disease, prior stroke, arterial or venous thromboembolic disease, peripheral artery disease, impaired renal function, liver dysfunction, active or recent infections (last month), a history of inflammatory or connective tissue disorders, chronic or occasional (last 3 weeks) anti-inflammatory or corticosteroid treatment, cancer, hematological disorders, previous major trauma, or surgery (within 3 months) and those with permanent pacemakers.

Clinical and laboratory assessment

Detailed baseline questionnaires were collected at study entry including age, sex, medical history, smoking history, and medication. Blood glucose levels were measured immediately before the procedure before any intravenous fluids were given to the patients. The levels of total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides, and glycated hemoglobin (HbA1C) were determined using standard laboratory methods. These assays were conducted in the main clinical laboratories of the authors' hospital. The samples for troponin I and creatine kinase myocardial band were collected before the procedure.

Peripheral blood (5–10 ml) was extracted from all the subjects in a fasting state in the following morning of the admission day. The time interval between symptom onset and blood sampling was no more than 24 h in all the included cases. Plasma was stored at −80°C for cytokine measurement. Serum levels of IL-4, IL-13, TNF-α, and IFN-γ were determined using commercially available enzyme-linked immunosorbent assay (ELISA) kits (eBioscience, Inc., San Diego, CA, USA) according to the manufacturers' protocol. Measurements were performed in duplicate, and the results were averaged. The sensitivities of IL-4 and IL-13 ELISA kits are 5 pg/ml and 4 pg/ml, and standard curve ranges are 15–375 pg/ml and 4–500 pg/ml. The sensitivities of IFN-γ and TNF-α ELISA kits are 15 pg/ml and 8 pg/ml, and standard curve ranges are 15–2000 pg/ml and 8–1000 pg/ml.

Coronary angiography and echocardiographic study

All patients had undergone recent coronary angiography before enrolment in the study. Coronary angiography was carried out by left-heart catheterization and arteriography using Judkins method [14] and a diameter stenosis of >70% stenosis on coronary angiography was considered hemodynamically significant.

The echocardiographic scans were analyzed by a reviewer who was blinded to the study design. The left ventricular end-systolic volume (LVESV) and the left ventricular end-diastolic volume (LVEDV) were measured using Simpson's method (Vivid-7; GE Medical System), and the left ventricular ejection fraction (LVEF, %) was calculated by (LVEDV − LVESV)/LVEDV ×100%.

Statistical analysis

All data analyses were performed in the computer package SPSS for Windows (version 17.0, Chicago, IL, USA). Data are presented as proportions, mean ± standard deviation (SD), geometric mean (SD range), or in the case of variables which did not conform to a normal or log-normal distribution, median (inter-quartile range). For independent samples, two-way comparisons for proportions were by Fisher's exact test, for normally distributed variables by Student's t-test, and for nonnormally distributed variables by Mann–Whitney U-test. P < 0.05 was considered statistically significant.

 > Results Top

Baseline patient characteristics

The baseline characteristics of the four groups are shown in [Table 1]. No significant difference of age, sex, SBP, DBP, heart rates, LVEDV, LVESV, and LVEF was observed among the four groups. The ACS-T2D group had more history of hyperlipidemia and hypertension than ACS-IGT group or ACS-NGT group; all three groups of ACS patients had more smoking history than control group. Moreover, patients in ACS-T2D and ACS-IGT groups had significantly higher body mass index (BMI) than patients in ACS-NGT group or control group.
Table 1: Comparison of baseline demographic and clinical characteristics of four groups

Click here to view

Comparisons of serum levels of interleukin-4, interleukin-13, interferon-gamma, and tumor-necrosis factor-alpha among four groups

We found significant elevations in levels of IL-4, IL-13, IFN-γ, and TNF-α in ACS-T2D and ACS-IGT groups compared to that in both ACS-NGT group and healthy individuals. Higher serum levels of IL-4, IL-13, and TNF-α were found in ACS-NGT group than that in control group. In addition, IL-4 and IFN-γ concentrations were significantly higher in ACS-T2D patients than in ACS-IGT patients. Furthermore, higher serum levels of HbA1C, high-sensitivity C-reactive protein (hs-CRP), LDL-C, and N-terminal pro brain natriuretic peptide were found in an ACS-T2D group than that in the other three groups (P < 0.05). On the other hand, serum levels of HDL-C, TC, and TG did not differ significantly among the four groups (P > 0.05) [Table 2].
Table 2: Comparison of serum levels of interleukin-4, interleukin-13, interferon-γ, tumor-necrosis factor-α, and other clinical data of four groups

Click here to view

Association between cytokine concentrations and clinical, metabolic, and inflammatory markers

By Spearman's analysis, we tested whether cytokine levels were correlated with age, key clinical and metabolic markers as well as with hs-CRP [Table 3]. The strongest correlations were observed in the analysis of IL-4 (SBP, r = 0.10; HbA1C, r = 0.16; HDL-C, r = −0.15; LDL-C, r = 0.25). Also notably, BMI (r = 0.25), LDL-C (r = 0.10) and TC (r = 0.33) were correlated with levels of IFN-γ significantly. Besides, correlations between hs-CRP and IL-13 (r = 0.13) as well as HbA1C and TNF-α (r = 0.42) were found significantly different.
Table 3: Correlation of cytokine levels with clinical, metabolic, and inflflammatory parameters

Click here to view

Comparisons of T-helper 1/T-helper 2 ratios in four groups

Th1/Th2 ratio was defined based on the ratio of proinflammatory Th1-related cytokines INF-γ or TNF-α and anti-inflammatory Th2-related cytokines IL-4, or IL-13 and the median Th1/Th2 ratio was calculated for each group. IFN-γ/IL-4, IFN-γ/IL-13, and TNF-α/IL-4 ratios as markers of Th1/Th2 ratio were significantly higher for ACS-T2D group and ACS-IGT group as compared to the ACS-NGT group and control group (P < 0.05) [Table 4]. Moreover, TNF-α/IL-13 ratio was also higher in ACS-T2D group and ACS-IGT group comparing to the ACS-NGT group and control group, although the difference was not significant.
Table 4: Comparison of Th2/Th1 ratios in four groups

Click here to view

 > Discussion Top

The results of this study revealed that ACS patients with T2D or IGT revealed higher levels of IL-4, IL-13, IFN-γ, and TNF-α compared with both ACS-NGT group and healthy individuals, and all three groups with ACS demonstrated higher cytokine levels than the control group. In addition, the findings suggested the potential association between clinical, metabolic, inflammatory markers, and cytokine concentrations. Blood pressure, BMI and concentrations of HbA1C, HDL-C, LDL-C, TC, and hs-CRP were shown to exhibit some effect on the release of Th1 and Th2 cytokines.

Th1 cells, which produce large quantities of IFN-γ and TNF-α, could activate macrophages and promote cell-mediated immunity. Th2 cells, which mainly produce IL-4, IL-5, IL-10, and IL-13, suppress Th1 cell activation and contribute to humoral immunity.[15] The observed significant increase in the level of Th1 and Th2 cytokines indicates enhancement of inflammatory state in ACS patients, supporting the argument that acute ischemia resulted from rupture of unstable atherosclerotic plaque could cause activation of the inflammatory process with subsequent increased synthesis of pro- and anti-inflammatory factors and cytokines secreted by activated leukocytes are critical determinants of tissue inflammation and atherosclerotic plaque stability.[16] Meanwhile, impaired glucose signaling in type 2 diabetes causes hyperglycemia, which stimulates insulin secretion. Sustained physiological hyperinsulinemia activates multiple genes involved in inflammation,[17] resulting in the increased release of inflammatory cytokines and their invasion to the tissues[7] causing functional disruption of the endothelium and accelerating plaque vulnerability in patients with ACS. Therefore, ACS patients with T2D showed higher levels of cytokines than those without T2D. Moreover, IGT is an intermediate condition in the transition between normality and diabetes. Subjects in this state have moderate insulin resistance and impaired insulin secretion,[18] and have a serious possibility of developing T2D. It is, therefore, necessary to take extra notice on this prediabetic states and factors that might influence disease development in ACS patients. Our results suggest that acute ischemia and hyperglycemia are risk factors for the elucidation of Th1/Th2 immune response in lymphocytes during ACS and diabetes.

Furthermore, the results of the study suggest a Th1/Th2 balance shift in favor of a Th1 cytokine profile which mainly includes pro-inflammatory cytokines in ACS patients with T2D or IGT versus ACS-NGT group and healthy individuals. In general, Th1 and Th2-mediated immunity are reciprocally regulated and maintain a balance in immune-mediated disease.[15] The balance of Th1/Th2 determines the outcome of a wide variety of immune responses involving infectious, allergic diseases, wound healing and diabetes [19] and Th1 and Th2 reactivities can be considered polarized forms of the immune response,[20] causing great effects on the outcome of vascular complications. In ACS patients with T2D or IGT, enhanced activation of proinflammatory factors augments the generation of reactive oxygen species, leading to increased oxidative stress and inflammation in vital tissues,[21],[22] and ultimately leads to impaired insulin endocytosis in endothelial cells, which in consequence, causing insulin resistance [23] which may influence independently the progression of coronary atherosclerotic plaques.[24] Szodoray et al. had reported that Th1 to Th2 ratio shifted towards a Th1 dominance in both ACS and stable coronary artery disease.[25] Recently, Jagannathan-Bogdan et al. demonstrated that T cells in T2DM patients were skewed toward a proinflammatory phenotype that requires monocytes for maintenance and promotes chronic inflammation through increased IFN-γ production.[26] In this study, the increased IFN-γ/IL-4, IFN-γ/IL-13, TNF-α/IL-4, and TNF-α/IL-13 ratio indicates prevailing activation of proinflammatory factors in ACS patients with T2D or IGT. Accordingly, the enhancement of circulating IFN-γ and TNF-α and the subsequent effect on IL-4 and IL-13 seen in these patients may play an important role in related inflammatory response that might relate to the pathogenesis of this disorder and affect the clinical development of disease in such patients.

 > Conclusion Top

The data from this study demonstrate, for the first time, that imbalance of Th1/Th2 ratio in the systemic circulation of ACS patients with T2D or IGT shifted toward the pro-inflammatory Th1 profile response. The results may serve as a promising diagnostic parameter on disease activity, progression as well as a potential marker of response to therapy in these patients.


This study had some limitations. First, the number of patients was relatively small, and we only conducted a one-point measurement of cytokine patterns. Second, we did not evaluate the long-term outcome of the patients. In the future, we are going to involve larger cohorts of patients and conduct longer follow-up observations to evaluate the prognostic value of Th1/Th2 ratio in these patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

Toutouzas K, Stathogiannis K, Synetos A, Karanasos A, Stefanadis C. Vulnerable atherosclerotic plaque: From the basic research laboratory to the clinic. Cardiology 2012;123:248-53.  Back to cited text no. 1
Spinale FG. Epilysin (matrix metalloproteinase-28) joins the matrix metalloproteinase team on the field of postmyocardial infarction remodeling. Circ Res 2013;112:579-82.  Back to cited text no. 2
Koten K, Hirohata S, Miyoshi T, Ogawa H, Usui S, Shinohata R, et al. Serum interferon-gamma-inducible protein 10 level was increased in myocardial infarction patients, and negatively correlated with infarct size. Clin Biochem 2008;41:30-7.  Back to cited text no. 3
Buse JB, Ginsberg HN, Bakris GL, Clark NG, Costa F, Eckel R, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007;115:114-26.  Back to cited text no. 4
Onat A, Sari I, Hergenç G, Yazici M, Uyarel H, Can G, et al. Predictors of abdominal obesity and high susceptibility of cardiometabolic risk to its increments among Turkish women: A prospective population-based study. Metabolism 2007;56:348-56.  Back to cited text no. 5
Ceriello A, Motz E. Is oxidative stress the pathogenic mechanism underlying insulin resistance, diabetes, and cardiovascular disease? The common soil hypothesis revisited. Arterioscler Thromb Vasc Biol 2004;24:816-23.  Back to cited text no. 6
Shanmugam N, Reddy MA, Guha M, Natarajan R. High glucose-induced expression of proinflammatory cytokine and chemokine genes in monocytic cells. Diabetes 2003;52:1256-64.  Back to cited text no. 7
Kumar P, Natarajan K, Shanmugam N. High glucose driven expression of pro-inflammatory cytokine and chemokine genes in lymphocytes: Molecular mechanisms of IL-17 family gene expression. Cell Signal 2014;26:528-39.  Back to cited text no. 8
Murphy KM, Reiner SL. The lineage decisions of helper T cells. Nat Rev Immunol 2002;2:933-44.  Back to cited text no. 9
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction; Authors/Task Force Members Chairpersons, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012;60:1581-98.  Back to cited text no. 10
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr., et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007;50:e1-157.  Back to cited text no. 11
International Diabetes Federation Guideline Development Group. Global guideline for type 2 diabetes. Diabetes Res Clin Pract 2014;104:1-52.  Back to cited text no. 12
Authors/Task Force Members, Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, et al. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The task force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J 2013;34:3035-87.  Back to cited text no. 13
Bush CA, VanFossen DB, Kolibash AJ Jr., Magorien RD, Bacon JP, Ansel GM, et al. Cardiac catheterization and coronary angiography using 5 French preformed (Judkins) catheters from the percutaneous right brachial approach: A comparative analysis with the femoral approach. Cathet Cardiovasc Diagn 1993;29:267-72.  Back to cited text no. 14
Abbas AK, Murphy KM, Sher A. Functional diversity of helper T lymphocytes. Nature 1996;383:787-93.  Back to cited text no. 15
Morigi M, Angioletti S, Imberti B, Donadelli R, Micheletti G, Figliuzzi M, et al. Leukocyte-endothelial interaction is augmented by high glucose concentrations and hyperglycemia in a NF-kB-dependent fashion. J Clin Invest 1998;101:1905-15.  Back to cited text no. 16
Coletta DK, Balas B, Chavez AO, Baig M, Abdul-Ghani M, Kashyap SR, et al. Effect of acute physiological hyperinsulinemia on gene expression in human skeletal muscle in vivo. Am J Physiol Endocrinol Metab 2008;294:E910-7.  Back to cited text no. 17
DeFronzo RA, Abdul-Ghani M. Assessment and treatment of cardiovascular risk in prediabetes: Impaired glucose tolerance and impaired fasting glucose. Am J Cardiol 2011;108 3 Suppl:3B-24B.  Back to cited text no. 18
Park JE, Barbul A. Understanding the role of immune regulation in wound healing. Am J Surg 2004;187:11S-6S.  Back to cited text no. 19
Pickup JC. Inflammation and activated innate immunity in the pathogenesis of type 2 diabetes. Diabetes Care 2004;27:813-23.  Back to cited text no. 20
Dey A, Lakshmanan J. The role of antioxidants and other agents in alleviating hyperglycemia mediated oxidative stress and injury in liver. Food Funct 2013;4:1148-84.  Back to cited text no. 21
Neri S, Calvagno S, Mauceri B, Misseri M, Tsami A, Vecchio C, et al. Effects of antioxidants on postprandial oxidative stress and endothelial dysfunction in subjects with impaired glucose tolerance and type 2 diabetes. Eur J Nutr 2010;49:409-16.  Back to cited text no. 22
Karpinski L, Plaksej R, Derzhko R, Orda A, Witkowska M. Serum levels of interleukin-6, interleukin-10 and C-reactive protein in patients with myocardial infarction treated with primary angioplasty during a 6-month follow-up. Pol Arch Med Wewn 2009;119:115-21.  Back to cited text no. 23
Lee KK, Fortmann SP, Fair JM, Iribarren C, Rubin GD, Varady A, et al. Insulin resistance independently predicts the progression of coronary artery calcification. Am Heart J 2009;157:939-45.  Back to cited text no. 24
Szodoray P, Timar O, Veres K, Der H, Szomjak E, Lakos G, et al. TH1/TH2 imbalance, measured by circulating and intracytoplasmic inflammatory cytokines – Immunological alterations in acute coronary syndrome and stable coronary artery disease. Scand J Immunol 2006;64:336-44.  Back to cited text no. 25
Jagannathan-Bogdan M, McDonnell ME, Shin H, Rehman Q, Hasturk H, Apovian CM, et al. Elevated proinflammatory cytokine production by a skewed T cell compartment requires monocytes and promotes inflammation in type 2 diabetes. J Immunol 2011;186:1162-72.  Back to cited text no. 26


  [Table 1], [Table 2], [Table 3], [Table 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Methods>Results>Discussion>Conclusion>Article Tables
  In this article

 Article Access Statistics
    PDF Downloaded88    
    Comments [Add]    

Recommend this journal