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Role of Serum Bilirubin in Coronary Artery Disease

Article · April 2012

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 International Journal of Medical and Health Sciences
Journal Home Page: http://www.ijmhs.net ISSN:2277-4505

Review article

Role of Serum Bilirubin in Coronary Artery Disease

Veerendra Kumar Arumalla*1, Niranjan Gopal 2, Rao BN3

1
Assistant Professor,Department of Biochemistry, 3Associate Professor, Department of Physiology,

Shri Sathya Sai Medical College and Research Institute, Ammapettai, 603108,
Kancheepuram(Dt)Tamil Nadu, India.
2
Assistant professor, Department of Biochemistry, Mahatma Gandhi Medical College and Research
Institute, Sri Balaji Vidyapeeth [SBV] University, Pillaiyarkuppam, Puducherry-607402, India.

ABSTRACT

Lipid oxidation and formation of oxygen radicals are important elements of arterial plaque formation and
atherosclerosis, and are involved in the pathophysiology of coronary artery disease (CAD). Since bilirubin
has antioxidant properties, it has been suggested that it may have a protective role in the atherosclerotic
process by preventing formation of oxidized LDL. The antioxidant capacity of bilirubin and its ability to
provide potent scavenging effect of peroxyl radicals have led to suggest that mild increase in the circulatory
bilirubin may have a physiologic role to protect against the disease processes that involve oxygen and
peroxyl radicals.This review briefly examines the role of bilirubin and its protective function against the
coronary artery disease.

KEYWORDS: Bilirubin, Antioxidant activity, Cardiovascular disease

INTRODUCTION
Bilirubin, the principle bile pigment, is the end
product of heme catabolism. For many years,
bilirubin was considered as toxic waste product
formed during heme catabolism. However, more
recent evidence suggests that bilirubin is a potent
physiological antioxidant that may provide
important protection against the
atherosclerosis, coronary artery disease (CAD),
and inflammation. Further, the development of
CAD involves lipid oxidation and formation of
oxygen radicals and that atherosclerosis and
inflammation are associated with formation of
oxygen and peroxyl radicals [1-3].
Bilirubin as physiologic Antioxidant:
Several studies have found that different
circulating forms of bilirubin are powerful
antioxidants, viz. free bilirubin, albumin-bound
bilirubin, conjugated bilirubin, and unconjugated
bilirubin were all found to be effective scavengers
of peroxyl radicals and able to protect human

Int J Med Health Sci. April 2012,Vol-1;Issue-2 56

LDL(low density lipoprotein) against peroxidation
[4-8].
On the basis of the known involvement of
oxidized LDL in the formation of atherogenic
plaques and the ability bilirubin to serve as a
potent lipid chain-breaking antioxidant under
physiological conditions, it was suggested that the
increased physiological concentrations of plasma
bilirubin may reduce atherogenic risk [9,10].
Both animal and human studies have substantiated
the suggestion that bilirubin is a physiological
antioxidant. Yamaguchi and co-workers
[11,12] isolated and identified oxidative
metabolites of bilirubin (biotripyrrins) from the
urine of healthy humans and ascorbic acid-
deprived rats treated with endotoxin. Feeding of
ascorbic acid, a documented physiological
antioxidant, reduced the secretion of
bilirubin metabolites and suppressed the
endotoxin-stimulated hepatic concentration of HO
(heme oxygenase) mRNA [12].
Several studies have noted an inverse relationship
between the incidence of CAD and circulatory
total bilirubin [13,14]. This important finding
indicated that a lower than normal serum bilirubin
concentration is associated with the presence of
ischemic heart disease [13] and patients with early
familial CAD have an average total serum
bilirubin of 8.9 ± 6.1 µmol/L compared with 12.4
± 8.1 µmol/L in healthy control subjects [14].
A prospective study in middle-aged British men,
Breimer et al. [15] observed a U-shaped
relationship between circulating bilirubin
concentrations and cardiovascular risk, leading
to the conclusion that low concentrations of serum
bilirubin are associated with increased risk of
ischemic heart disease. These and other
investigators found that plasma bilirubin
correlated inversely with several known risk
factors for CAD, such as smoking, LDL-
cholesterol, diabetes, and obesity, and correlated
directly with the protective factor HDL-
cholesterol [16,17]. The reduced concentration of
total bilirubin in plasma is related univariately and
multivariately to the presence of CAD, and this
relationship remained significant after adjustment
for known CAD risk factors such as age,
Int J Med Health Sci. April 2012,Vol-1;Issue-2
cholesterol, HDL-cholesterol, smoking, and
systolic blood pressure [16].
On the basis of these findings, low bilirubin was
suggested as an independent risk factor for CAD,
and an inverse correlation was demonstrated
between bilirubin concentration and CAD
morbidity. Further support for the existence of this
inverse correlation came from the work of Hunt et
al. [18], who described a genetic variation in
bilirubin concentration, with individuals with early
CAD displaying lower bilirubin than unaffected
persons.
It would be interesting to determine which of the
different entities of circulating bilirubin possesses
cardioprotective capacity and is associated with
the reduced risk for CAD. Antioxidant activity and
cardioprotective potential may be attributed to any
of the bilirubin forms, including free unconjugated
bilirubin, protein-bound unconjugated bilirubin,
delta bilirubin, or mono-/diconjugated
bilirubin[7,10,19]. Under physiological
conditions, the predominant circulatory form of
bilirubin is the unconjugated, albumin-
bound form. It is not known whether conditions
that modify the relative proportions of this form of
bilirubin in the blood, i.e., protein binding,
acidosis, hypoxia, and extent of hemolysis,
affect the cardioprotective potential of bilirubin.
Protein binding, which is modulated by changes in
plasma albumin concentrations, the concentrations
of drugs that compete on binding, acidosis, and
other factors, is expected to affect the balance
between free (diffusible) and bound unconjugated
bilirubin and thereby change the penetration of
unconjugated bilirubin into cells.
Likewise, changes in membrane integrity that are
induced by hypoxia could potentially modulate the
bilirubin transfer capacity of the membrane. In
view of these complex interactions, it is important
to establish the antioxidative capacity of the
different bilirubin forms and to assess how the
circulating concentration of free bilirubin,
circulating albumin, blood pH, and the presence of
drugs modulate bilirubin antioxidative capacity.
57
The proposed mechanism for antioxidant
activity of Bilirubin:
Bilirubin can scavenge the chain-carrying
peroxyl radical by donating a hydrogen atom
attached to the C-10 bridge of the tetrapyrrole
molecule to form a carbon-centered radical Bil
LOO + Bil  LOOH + Bil
Bil + LOO  Bil-OOL
Bil + O2  Bil-OO
LOO + BV  LOO-BV
Both unconjugated bilirubin (BU) and conjugated
bilirubin (BC) can serve as antioxidants,
protecting human LDL from lipid peroxidation in
vitro against peroxyl radicals (generated by 2,2'-
azobis [2-amidinopropane] dihydrochloride). At
concentrations as low as 10nM, Bilirubin can
protect against 10,000-fold greater concentrations
of H2O2. Under physiologic conditions, bilirubin
provides more potent protection against lipid
peroxidation than α-tocopherol, formerly known
to be most effective in preventing lipid
peroxidation [20].
Recent research indicates that bilirubin may be the
most abundant endogenous antioxidant in
mammalian tissues. A linear relationship (R2 =
0.99) has been identified between plasma
antioxidant capacity and unconjugated bilirubin
concentration in newborn infants. This both
confirms bilirubin’s significance as a plasma
antioxidant and suggests that moderate increases
in plasma bilirubin might be favourable to infants
under oxidative stress. A cytoprotective enzyme
that breaks the prooxidant molecule heme into
biliverdin (immediately converted into bilirubin),
iron, and carbon monoxide. HO-2(Heme
Oxygenase-2), the constitutive isoform, is highly
active in neurons and accounts for most of the HO
activity in the brain. Destroying the HO-2 gene
and thus limiting BR production, leads to
increased oxidative damage following cerebral
ischemia [21].
Low serum bilirubin has been shown to be
strongly correlated with several cardiovascular
risk factors, including age, cigarette smoking,
social class, diabetes, serum cholesterol, lower
FEV1, and lower serum albumin. Serum bilirubin
Int J Med Health Sci. April 2012,Vol-1;Issue-2
was found to have a U-shaped relationship with
the events of ischemic heart disease (IHD).
Bilirubin perfusion was shown to decrease infarct
damage significantly caused by IHD. Serum
bilirubin concentrations in the upper range of
normal values protect against the coronary artery
disease (CAD)[22].
However, concentrations in the lower range
increase the atherogenic risk and thus risk of IHD.
Schwertner et al, found an unexpected inverse
association between serum total bilirubin and
CAD. The strength of the association with CAD
was similar to that of smoking or of systolic blood
pressure.
Plausible Mechanisms of Bilirubin Action
in Prevention of Atherosclerosis:
Several mechanisms have been suggested to
play a potential role in the antiatherogenic and
cardioprotective effects of bilirubin.
a) Bilirubin-mediated inhibition of lipid
oxidation
Lipoproteins, particularly LDL, are highly
susceptible to oxidation, and it is known that the
atherogenic process involves uptake of oxidized
LDL by intimal macrophages, leading to the
accumulation of lipid-rich foam cells. Given the
antioxidant capacity of bilirubin, it is plausible
that bilirubin protects lipids and lipoproteins
against oxidation and thereby offers
protection against atherogenesis. Accordingly, low
bilirubin concentrations may be associated with
increase in the oxidized lipids and lipoproteins and
therefore, with enhanced atherogenic plaque
formation [13,23].
b) Bilirubin as reflection of enhanced HO
(Heme Oxygenase) activity
Increased HO activity may account for the
antiatherogenic and cardioprotective effects of
bilirubin through increased elimination of heme
and/or enhanced production of CO (Carbon
Monoxide), iron, and biliverdin. Changes in the
concentration of any of these metabolites could
affect the pathophysiology of atherosclerosis
[5,24]. For example, HO-1-mediated consumption
of heme may reduce heme-induced toxic cell
injury, and decreased hemoglobin concentrations
may enhance vasodilatation. Furthermore,
58
hemoglobin is a scavenger of NO (Nitric oxide)
that blunts NO-dependent vasodilatation. CO
could affect cardiovascular function through
activation of soluble guanylate cyclase and the
consequent increase in the intracellular cGMP
concentrations. CO is also an active vasodilator
involved in the regulation of vasomotor tone,
platelet aggregation, and vascular smooth muscle
cell proliferation [5,25].
Another potential mechanism explaining the
association between HO activity and CAD risk
may be related to the ability of HO-1 to release
iron and change the concentrations of iron stores
[13,9,26]. Mice lacking functional HO-1 develop
an anemia associated with abnormally low serum
iron concentrations and accumulate iron in the
liver and kidney. These iron stores may contribute
to tissue injury and chronic inflammation
associated with the oxidative damage that
characterizes HO-1-deficient animals [27].The
induction of HO by heme is associated with
increased expression of ferritin [28]. On the basis
of this finding it was suggested that iron released
through HO activity drives the synthesis of ferritin
and that ferritin, by virtue of its iron-binding
capacity, provides protection to endothelial cells
against oxidative damages [28].
c) Immune reactions and inflammatory
processes
The involvement of bilirubin in immune reactions
and inflammatory processes has also been
documented. Nakagami et al.[29] noted that
biliverdin and bilirubin inhibit complement-
dependent reactions in vitro and that biliverdin
administration inhibits Forssmann anaphylaxis in
guinea pigs. On the basis of these findings it is
possible that bile pigments are endogenous tissue
protectors by virtue of their anticomplement
activity [29]. A correlation between
bilirubin metabolism and inflammatory processes
is also supported by observations that high HO
activity is linked to a faster resolution of
inflammation, whereas inhibition of this enzyme
appears to potentiate the inflammatory responses
[30].
Both endothelial and inflammatory cells [31]
express all of the necessary enzymes involved in
Int J Med Health Sci. April 2012,Vol-1;Issue-2
bilirubin synthesis and degradation, implies a high
degree of regulation of cellular bilirubin levels
and supports a potentially broad role for this
endogenous bile pigment as a physiological
regulator of inflammation.VCAM-1-(Vascular
cell adhesion molecule-1) mediated leukocyte
recruitment is implicated in the pathogenesis of a
number of inflammatory conditions, including
atherosclerosis [32,33] and inflammatory bowel
disease [34 - 36]. With regard to the former,
VCAM-1 is detectable in atherosclerotic plaques
[37] and endothelial expression of this adhesion
molecule has been shown to be an early event at
sites predisposed to atherosclerosis [38].
Moreover, disruption of VCAM-1 expression in
the atherosclerosis-prone low density lipoprotein
receptor knockout mouse is associated with a
significant decrease in the number of vascular
lesions. Consistent with the hypothesis that
bilirubin may modulate the process of
atherogenesis by inhibiting VCAM-1 signaling, a
host of epidemiological analyses have identified
an inverse correlation between serum bilirubin
levels and both the risk and severity of
cardiovascular disease [39 – 42].
CONCLUSION
The distinct inverse correlation between plasma
bilirubin concentration and CAD morbidity may
have an important clinical and diagnostic
implication. The clinical relevance relates to
potential preventive and therapeutic approaches,
whereas the diagnostic relevance stresses the
plasma bilirubin concentration as a
provisional new marker of atherogenic risk that
can be measured easily in the clinical laboratory
and applied in medical practice.
FUTURE SCOPE
Although the mechanism(s) underlying the ability
of circulating forms of bilirubin concentrations in
protecting against the CAD remain to be clarified,
it is possible to say that either the bilirubin
concentration itself or changes in the
concentrations of other component(s) in the
bilirubin synthetic pathway are involved in the
protective action. These additional components
may include heme, biliverdin, CO, and iron, which
are regulated by the activity of HO and have all
been implicated in the physiology and pathology
of the cardiovascular system. HO is expressed at
59
low basal concentrations in vascular endothelial
and smooth muscle cells and is induced by
oxidative stress, inflammatory mediators, and
oxidized LDL. The complex interactions between
HO expression, the circulating concentrations of
its substrate and products, and the effect of these
components, and specifically of bilirubin, on the
vasculature, on lipid metabolism, and on the
cardiovascular system will hopefully be the focus
of extensive research in the coming years.
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*Corresponding author: Dr.Veerendra Kumar
Arumalla
E-mail: drveerendraarumalla@gmail.com
62