Vol.5, No.2, 166-169 (2013) Health
http://dx.doi.org/10.4236/health.2013.52022
The association of adenosine deaminase with
coronary artery disease: Effect of gender and
diabetes
Fulvia Gloria-Bottini1*, Krzysztof Safranow2, Maria Banci3, Agnieszka Binczak-Kuleta4,
Patrizia Saccucci1, Andrzej Ciechanowicz4, Andrea Magrini1, Zdzislawa Kornacewicz-Jach5,
Egidio Bottini1, Dariusz Chlubek2
1Department of Biomedicine and Prevention, School of Medicine, University of Rome Tor Vergata, Rome, Italy;
*Corresponding Author: gloria@med.uniroma2.it
2Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
3Department of Cardiology, Valmontone Hospital, Valmontone, Italy
4Department of Laboratory Diagnostics and Molecular Medicine, Pomeranian Medical University, Szczecin, Poland
5Department of Cardiology, Pomeranian Medical University, Szczecin, Poland
Received 16 June 2012; revised 20 July 2012; accepted 1 August 2012
ABSTRACT
An association between ADA1 and Coronary Ar-
tery Disease (CAD) has been observed in Polish
and in Italian populations but in Italian popula-
tion the association was present in males only.
In order to enlighten these differences we have
carried out a collaborative study in the two po-
pulations. In Italy 215 subjects admitted to the
Hospital for CAD, 275 subjects with Type 2 Dia-
betes (T2D) without CAD and 398 healthy new-
borns were studied. In Poland 173 subjects w ith
CAD and 200 healthy newborns were studied.
Written informed consent was obtained from all
subjects or from their mothers to participate to
the study that was approved by the I.R.B. ADA1
polymorphism was determined by DNA analysis.
Three way contingency table analysis was per-
formed by a log linear model. The association
between CAD and ADA1 is present in non dia-
betic male subject s only : OR = 0.195, p = 0.007 in
the Italian population and OR = 0.163, p = 0.004
in the Polish population. The data suggest a sig-
nificant role of immunological mechanisms in
the pathogenesis of CAD without diabetes. Gen-
der differences in immune diseases could ex-
plain the lack of association in females.
Keywords: ADA; CAD; Gender; Diabetes
1. INTRODUCTION
An association between Adenosine Deaminase locus 1
(ADA1) and Coronary Artery Disease (CAD) has been
described in the Polish population [1] and confirmed in
the Italian population [2]. In Italy, however, a significant
association was found in males only. In order to enligh-
ten these differences we have carried out a collaborative
study involving both populations.
ADA1 is a polymorphic enzyme present in all mam-
malian tissue that catalyzes the irreversible deamination
of adenosine to inosine [3]. It is controlled by a locus
with 2 codominant alleles ADA1*1 and ADA1*2 located
in the long arm of chromosome 20 [4]: the activity asso-
ciated to ADA1*2 is lower than that associated to
ADA1*1.
Adenosine is an important local hormone regulating
blood flow, neurotransmission, physiology of smooth
muscle and platelet aggregation. In the liver adenosine
counteracts insulin action by activating A2B receptors
[5]. ADA1 and CD26 are colocalized on T cell surface
and these cells are much more resistant to the inhibitory
effects of adenosine.
Adenosine is a cardioprotective agent [6], thus re-
duced activity in ADA1*2 allele carriers may have a
beneficial effect on cardiac function. Moreover ecto-
ADA1 interacts with Adenosine receptor A1 [7] which
plays an important role in ischaemic preconditioning [8].
Inhibition of platelet aggregation and adhesion and anti-
inflammatory properties of adenosine [9] may also play
an important role in the susceptibility to CAD [10].
2. MATERIAL AND METHODS
The following samples were considered.
ITALY
215 subjects admitted to the hospital for CAD.
275 subjects with type 2 diabetes without CAD (as
Copyright © 2013 SciRes. OPEN A CCESS
F. Gloria-Bottini et al. / Health 5 (2013) 166-169 167
controls for CAD with T2D).
398 consecutive healthy newborns (as controls for
CAD without diabetes).
POLAND
173 subjects admitted to the hospital for CAD.
200 consecutive healthy newborns (as controls for
CAD without diabetes).
Subjects with type 2 diabetes without CAD were not
available for this population.
Written informed consent was obtained from all sub-
jects or from their mothers to participate to the study that
was approved by the I.R.B.
Adenosine deaminase genotype determination was
carried out as previously described [1]. Three way con-
tingency table analysis was carried out by a log linear
model according to Sokal and Rohlf [11].
3. RESULTS
Table 1 shows the distribution of ADA1 genotypes
(phenotypes) in Coronary Artery Disease (Italy and Po-
land), in type 2 diabetes without CAD (Italy) and in
healthy newborns (Italy and Poland) in relation to gender
and Diabetes. The relationship among the variables con-
sidered i.e. ADA1 genotype, CAD, diabetes, gender and
population have been examined by log linear models.
The analysis of interaction among ADA1, diabetes and
gender (a) within CAD subjects shows a significant in-
teraction among the three variables with a pattern similar
in Italian and Polish samples. The analysis suggests that
the relationship between ADA1 and diabetes depends on
gender.
The analysis of interaction among ADA1, CAD (CAD
Table 1. The effect of diabetes and gender on the association between ADA1 and CAD.
Proportion of ADA1*2 allele carriers
CAD Italy CAD Poland T2D without CAD ItalyNewborns Italy Newborns Poland
Gender Diabetes % total n % total n% total n % total n % total n
Yes 14.3% 35 0.0% 8 17.0% 147
Females No 22.2% 63 10.7%28 13.1% 206 11.4%105
Yes 15.6% 45 11.1% 36 20.2% 128
Males No 4.2% 72 3.0% 101 18.2% 192 15.8%95
Statistical analyses: three way contingency table analysis by a log linear model.
(a) Interaction ADA1-Diabetes-Gender in CAD
x = Diabetes; y = ADA1; z = Gender
Italy Poland
G df p G df p
x y z interaction 5.086 1 0.028 3.580 1 0.065
cumulative probability χ2 = 12.610, df = 4, p = 0.014
(b) Interaction ADA1-CAD (CAD vs newborns)-Population in NON DIABETIC SUBJECTS
x = ADA1; y = CAD vs Newborns; z = Population (Italian vs Polish)
Males Females
G df p G df p
x y z interaction 0.039 1 0.650 0.891 1 0.350
x y independence 20.651 2 0.0001 2.903 2 0.260
after correction for multiple comparisons p < 0.001
(c) Interaction ADA1-Gender-Population in CAD DIABETICS
x = ADA1; y = Gender; z = Population (Italian vs Polish)
G df p
x y z interaction 1.398 1 0.270
x y independence 1.717 2 0.450
(d) Interaction ADA1-Gender-Population in CAD NON DIABETICS
x = ADA1; y = Gender; z = Population (Italian vs Polish)
G df p
x y z interaction 0.233 1 0.650
x y independence 12.985 2 0.002
Copyright © 2013 SciRes. OPEN A CCESS
F. Gloria-Bottini et al. / Health 5 (2013) 166-169
168
vs newborns) and population (b) in non diabetic subjects
shows a lack of interaction in both males and females
suggesting that the relationship between ADA1 and CAD
is similar in the two populations studied. The association
between ADA1 and CAD is very strong in males (χ2 =
20.651, df = 2, p 0.0001, after correction for multi-
ple comparison p < 0.001) but is lacking in females.
Since in the Polish population we had no data on dia-
betic subjects without CAD a similar analysis comparing
CAD diabetics with non-CAD diabetics could not be
performed.
The analysis of interaction among ADA1, gender and
population in CAD diabetics (c) shows no significant
association between ADA1 and gender in both Italian and
Polish populations. On the contrary the same analysis in
CAD non diabetics (d) shows a significant association
between ADA1 and gender that shares a similar pattern in
Italian and Polish populations.
From these analyses it can be safely concluded 1) that
the association between CAD and ADA1 is present in
non diabetic subjects only and 2) that the pattern of as-
sociation in non diabetic CAD subjects depends on gen-
der and it is present and very strong among males only:
OR (ADA12-1 vs ADA11/CAD vs controls) = 0.195;
95% C.I. 0.059 - 0.693 (p = 0.007) in the Italian popula-
tion and OR = 0.163; 95% C.I. 0.047 - 0.630 (p = 0.004)
in the Polish population. For both populations combined
O.R. 0.170 95% C.I. 0.064 - 0.425 (p = 0.00002).
4. DISCUSSION
Since a number of newborns will suffer CAD later in
their life, it could be objected that these infants do not
represent a reliable control for our study. However, as-
suming that a given genotype is more susceptible with
respect to other genotypes to CAD, the difference be-
tween cases and newborns would be lower as compared
to the difference between cases and adults without CAD.
Therefore taking newborns as controls the association of
CAD with a given genotype will be underevaluated. If
the association is statistically significant “newborns” can
be considered a reliable control.
The present data collected in two independent White
European populations show that the association between
CAD and ADA1 is present in non diabetic patients only:
moreover such association is present and very marked
among males only. Considering both populations in
males the proportion of genotypes carrying the ADA1*2
allele is much lower among CAD patients than among
controls.
The difference between males and females could be
due to different early fatality rate; such difference, how-
ever, is present in non diabetic but not in diabetic sub-
jects and this seems against such hypothesis. Unfortu-
nately, we have no data on the subjects died during the
early stages of cardiac attack.
The fact that association between CAD and ADA1 is
present in non diabetic subjects only suggests the exis-
tence of different mechanisms leading to CAD. A role of
immunological factors has been suggested for athero-
sclerosis: taking into account the well known role of
ADA1 in immunological diseases, the association of
CAD with ADA1 suggests a prevalent role of immu-
nological factors in the pathogenesis of coronary artery
atherosclerosis in CAD without diabetes. In CAD with
diabetes a role of metabolic factors could be more im-
portant explaining the lack of association with ADA1
polymorphism.
Gender differences in immune diseases are well
documented and it has been suggested that in association
studies concerning immune diseases males and females
should be examined separately [12]. Thus, assuming an
immune component in the association between ADA1
and CAD the differences observed between males and
females are in line with other studies. Hormonal factors
may explain these differences. The immune mechanism,
however, does not exclude a direct role of adenosine as a
cardioprotective agent.
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