Uric acid is a biomarker for heart failure, but not therapeutic target: result from a comprehensive meta-analysis

Hyperuricemia and adverse outcomes in patients with cardiorenal syndrome: A nationwide prospective cohort study in China

Background

Serum uric acid (UA) has been associated with adverse outcomes in patients with heart failure. However, it remains inconclusive whether such association persists in patients with cardiorenal syndrome (CRS).

Methods

In a nationwide prospective cohort from China, 4907 adults hospitalized for heart failure were enrolled. Of them, 1284 had an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at admission were included in this study. The Cox regression model was employed to evaluate the relationship between UA levels and mortality, major cardiovascular events (MACE), and hospitalization for heart failure (HHF). Additionally, Harrell's concordance index was utilized to assess the incremental value of UA levels in predicting mortality.

Results

During a median follow-up of 3.28 years, hyperuricemia was associated with a 27 % increased risk of all-cause mortality (HR 1.27, 95 % confidence interval [CI] 1.08-1.49) and a 36 % increased risk of cardiovascular mortality (HR 1.36, 95 % CI 1.11-1.65), regardless of patients' eGFR levels. This relationship remained consistent throughout the whole follow-up period. Hyperuricemia increased the risk of 3-month MACE by 39 % (HR 1.39, 95 % CI 1.03-1.88), 3-month HHF by 47 % (HR 1.47, 95 % CI 1.11-1.95), and 1-year MACE by 26 % (HR 1.26, 95 % CI 1.02-1.57). The additive effect of uric acid levels in predicting mortality was also confirmed.

Conclusions

Serum UA levels possess significant value in prognosis of mortality, MACE, and HHF among patients with CRS. These findings underscore the importance of monitoring serum UA in the management of patients with CRS, as UA may provide valuable insights into risk stratification.

J-shaped association of serum uric acid with all-cause and cardiovascular mortality in patients with diabetic kidney disease

AIMS

The association of serum uric acid (SUA) with mortality remains unclear in patients with diabetic kidney disease (DKD). Thus, this prospective cohort study aimed to explore the association of SUA with all-cause and cardiovascular disease (CVD) mortality among patients with DKD in a large, nationally representative sample.

METHODS

This cohort study included data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 and the National Death Index mortality data until 31 December 2019. The restricted cubic spline and the Cox proportional hazards regression were conducted to describe the association of SUA with all-cause and CVD mortality and evaluate potential nonlinear associations.

RESULTS

The analysis included 3470 patients with DKD from NHANES 1999-2018. During the follow-up time of 24,633 person-years, we recorded 1489 all-cause deaths, including 542 CVD deaths. We identified a J-shaped association of SUA with all-cause and CVD mortality. The corresponding inflection points were observed at 5.1 and 5.7 mg/dL. When SUA were higher than inflection points, each 1 mg/dL increase in SUA was linked to a 13% and 22% higher risk of all-cause (HR: 1.13; 95% CI: 1.07-1.20;P < 0.001) and CVD (HR: 1.22; 95% CI: 1.06-1.41;P = 0.006) mortality, respectively.

CONCLUSIONS

This study indicated the J-shaped association of SUA with all-cause and CVD mortality in patients with DKD. The corresponding inflection points were 5.1 mg/dL for all causes and 5.7 mg/dL for CVD, respectively. More clinical randomized trials are needed to confirm the optimal uric acid-lowering target.

Gender differences in the prognostic impact of uric acid in patients with heart failure and preserved ejection fraction

BACKGROUND

Uric acid has been identified as an independent predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). However, the impact of gender differences on this association is not fully explored.

METHODS

This retrospective cohort study included hospitalized patients with HFpEF from June 2018 to October 2022. The primary outcome was a composite endpoint, defined as the occurrence of all-cause mortality and heart failure readmission. Kaplan-Meier survival analysis and stratified Cox regression examined the combined effect of gender and uric acid on the composite endpoint, and restricted cubic spline curves were applied to visualize the relationship.

RESULTS

The study included 547 patients, with 267 females and 280 males. In the entire cohort, each mg/dL increase in uric acid was associated with a 4% increase in the risk of the composite endpoint (HR: 1.04, 95%CI:1.01-1.09). This association was more pronounced in females, with a 9% increase in the risk of the composite endpoint per mg/dL increase in uric acid (95%CI: 1.02-1.17). Restrict cubic spline curves analysis demonstrated a significant linear correlation between increasing uric acid levels and higher risk of the composite endpoint in female patients (P = 0.028). Kaplan-Meier analysis revealed higher survival probabilities for females compared to males (P = 0.002). However, survival rates for females with high uric acid levels were similar to those for males with high uric acid levels.

CONCLUSIONS

Baseline serum uric acid levels are significantly associated with the composite endpoint in patients with HFpEF, particularly among females.

The Effect of Xanthine Oxidase Inhibitors in the Prevention and Treatment of Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Xanthine oxidase inhibitors (XOIs) may help prevent stroke. However, heterogeneity can be found in the conclusions of different studies. The relevant evidence was summarized in this systematic review and meta-analysis to further clarify the role of XOIs in the prevention and treatment of stroke, with a focus on evaluating the effects of XOIs in primary and secondary prevention of stroke, acute stroke treatment, and reduction of post-stroke complications.

METHODS

Randomized controlled trials (RCTs) or cohort studies on the effect of XOIs in the prevention and treatment of stroke were searched in PubMed, EMBASE, and Cochrane Library from inception to 3 March 2024, along with hand searching. The analyses were carried out using Review Manager 5.4.

RESULTS

The analysis included 14 studies (115,579 patients). While XOIs did not significantly reduce the risk of stroke (RR: 0.89; 95% CI: 0.59-1.34), they improved post-stroke functional outcomes, with a reduction in the modified Rankin scale scores (mean difference: -0.6; 95% CI: -0.8 to -0.4), decreased intercellular adhesion molecule-1 levels (mean difference: -15.2 ng/mL; 95% CI: -22.3 to -8.1), improved augmentation index (AIx) by 4.2% (95% CI: 2.5-5.9%), reduced central blood pressure (mean reduction: 4.8 mmHg; 95% CI: 2.6-6.9), and delayed carotid intima-media thickness progression (mean difference: -0.05 mm/year; 95% CI: -0.08 to -0.02).

Triglyceride-glucose index trajectories predict adverse cardiovascular outcomes in elderly heart failure patients with Diabetes: A retrospective cohort study

Objective

Evaluating the change trajectories of triglyceride-glucose (TyG) index calculated after multiple tests in elderly heart failure (HF) patients may have clinical implications for predicting long-term adverse cardiovascular events (MACEs).

Methods

This retrospective study included 1184 elderly HF (LVEF ≥50%) patients with diabetes admitted to our center between January 2015 and January 2020. Based on the multiple TyG levels detected during the exposure period with annual measurements, three distinct TyG trajectories were determined using latent mixture modeling: low-stable group (TyG index <8.26, n = 367), medium-stable group (TyG index 8.26-9.06, n = 613), and high-increasing group (TyG index >9.06, n = 204). The primary endpoint was the composite outcome of MACEs.

Results

There were significant increases in the prevalence of several cardiovascular risk factors and conditions, such as male gender, BMI, current smoker, hyperlipidemia, atrial fibrillation, old myocardial infarction, fasting glucose, triglycerides, and uric acid levels, from the Low-Stable Group to the High-Increasing Group (all P < 0.05). During a median follow-up of 29 months (range, 18-46 months), 181 MACEs occurred. Kaplan-Meier analyses curve showed a significantly increased risk of MACEs in the medium-stable and high-increasing groups compared to the low-stable group (HR = 2.528, 95%CI: 1.665-3.838; HR = 2.706, 95%CI: 1.722-4.255, respectively). Furthermore, the rates of heart failure-related hospitalizations, nonfatal myocardial infarctions and non-fatal stroke were significantly increased in the medium-stable and high-increasing groups. Multivariable Cox regression analyses revealed that age (HR = 1.728), current smoker (HR = 1.385), old myocardial infarction (HR = 1.593), chronic renal disease (HR = 1.682), HbA1c (HR = 1.816), NT-proBNP (HR = 2.471), TyG trajectory (HR = 2.112) and SGLT2 inhibitors (HR = 0.841) were independently associated with the occurrence of MACEs during follow-up (P < 0.05).

Conclusions

The TyG trajectory is strongly associated with the risk of MACEs during follow-up in elderly patients with T2DM, suggesting that TyG trajectories may further optimize risk stratification model of cardiovascular events.

Cardiovascular Outcomes of Uric Acid Lowering Medications: A Meta-Analysis

BACKGROUND

Although hyperuricemia is a recognized risk factor for cardiovascular diseases, mixed results have been reported regarding the associations between uric acid-lowering medications and cardiovascular events. This meta-analysis compared the cardiovascular outcomes of different uric acid-lowering medications and placebo.

METHODS

Following PRISMA guidelines, we searched OVID Medline, Embase, Web of Science, and Cochrane databases to identify potentially relevant articles until December 2023. Studies must be randomized or observational, report cardiovascular and mortality outcomes, and compare uric acid-lowering medications to placebo or each other. Data was analyzed using Revman (version 5.4) software.

RESULTS

A total of 3,393 studies were searched, after which 47 studies were included, totaling 3,803,509 patients (28 studies comparing xanthine oxidase inhibitors (XOI) versus placebo, 17 studies comparing allopurinol and febuxostat, and 2 studies comparing XOI and uricosuric agents). Overall mean age was 57.3 years, and females comprised 20.8% of all studies. There were no significant differences between XOI and placebo for cardiovascular outcomes (mortality, myocardial infarction, major adverse cardiovascular events, heart failure, or arrhythmia). There was significant heterogeneity in all these pooled analyses. Comparing Allopurinol to Febuxostat, there was a lower risk of heart failure in febuxostat than allopurinol in 3 RCTs (OR 0.66, 95% CI 0.50-0.89, p = 0.006). Other cardiovascular outcomes were not different. Lastly, when comparing XOI and uricosuric agents, no significant differences in MI rates were evident.

CONCLUSION

XOI was not associated with reduced cardiovascular events compared to placebo. When comparing XOI agents, Febuxostat might reduce the risk of HF, but future studies are required to confirm the findings from the current study.

Relationship between serum uric acid levels and uric acid lowering therapy with the prognosis of patients with heart failure with preserved ejection fraction: a meta-analysis

Aims

This meta-analysis aimed to explore the association between serum uric acid levels and the efficacy of uric acid-lowering therapies on clinical outcomes among patients with heart failure with preserved ejection fraction (HFpEF).

Methods

A comprehensive literature search was conducted through October 21, 2023, across PubMed, Embase, Cochrane Library, and Web of Science databases. The pooled effect sizes were estimated and presented with their respective 95% confidence intervals (CI). Subgroup analyses were conducted based on various factors, including sample size (<1,000 vs. ≥1,000), follow-up duration (<2 years vs. ≥2 years), study quality (assessed by a score of <7 vs. ≥7), ethnicity (Non-Asian vs. Asian), study design (prospective vs. retrospective), type of heart failure (HF) (acute vs. chronic), presence of hyperuricemia (yes or no), left ventricular ejection fraction (LVEF) thresholds (≥45% vs. ≥50%), and the type of uric acid-lowering therapy (traditional vs. novel).

Results

The analysis included a total of 12 studies. Elevated serum uric acid levels were significantly linked to an increased risk of all-cause mortality [relative risk (RR): 1.21, 95% CI: 1.06-1.37, P = 0.004] and cardiovascular (CV) mortality (RR: 1.71, 95% CI: 1.42-2.04, P < 0.001) in HFpEF patients. Subgroup analyses confirmed this association, particularly in non-Asian populations, those with chronic HFpEF, and studies with a follow-up duration of two years or more. Additionally, higher uric acid levels were associated with an increased risk of HF-related hospitalization [hazard ratio (HR): 1.61, 95% CI: 1.12-2.34, P = 0.011]. Regarding treatment, uric acid-lowering therapy did not show a significant effect on reducing mortality in HFpEF patients. However, it was associated with a decreased risk of hospitalization due to HF (RR: 0.85, 95% CI: 0.79-0.91, P < 0.001).

Conclusion

The findings of this study highlight the prognostic significance of serum uric acid levels in HFpEF and suggest that uric acid-lowering therapy may be beneficial in reducing the incidence of HF hospitalizations. Further research is warranted to elucidate the mechanisms by which uric acid-lowering therapy confers its potential benefits.

Gender differences in the relationship between serum uric acid and the long-term prognosis in heart failure: a nationwide study

BACKGROUND

Serum uric acid (SUA) is an important pathogenetic and prognostic factor for heart failure (HF). Gender differences are apparent in HF. Furthermore, gender differences also exist in the association between SUA and prognosis in various cardiovascular diseases. However, the gender difference for SUA in the prediction of long-term prognosis in HF is still ambiguous.

METHODS

A total of 1593 HF patients (897 men, 696 women) from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 cycle were enrolled in our final analysis. Participants were categorized according to gender-specific SUA tertile. We assessed the association between SUA and long-term prognosis of HF patients, defined as all-cause mortality and cardiovascular mortality, in different genders via Kaplan-Meier curve analysis, Cox proportional hazard model, and Fine-Gray competing risk model. The restricted cubic spline (RCS) was performed to investigate the dose-response relationship between SUA and outcomes.

RESULTS

Gender differences exist in demographic characteristics, clinical parameters, laboratory tests, and medication of HF patients. After a median follow-up of 127 months (95% CI 120-134 months), there were 853 all-cause deaths (493 events in men, 360 events in women) and 361 cardiovascular deaths (206 events in men, 155 events in women). Kaplan-Meier analysis showed that SUA had gender difference in the prediction of cardiovascular mortality (Log-rank p < 0.001, for male, Log-rank p = 0.150, for female), but not in all-cause mortality. Multivariate Cox regression analysis revealed that elevated SUA levels were associated with higher all-cause mortality and cardiovascular mortality in men (HR 1.11, 95% CI 1.05-1.18, p < 0.001, for all-cause death; HR 1.18, 95% CI 1.09-1.28, p < 0.001, for cardiovascular death), but not in women (HR 1.05, 95% CI 0.98-1.12, p = 0.186, for all-cause death; HR 1.01, 95% CI 0.91-1.12, p = 0.902, for cardiovascular death). Even using non-cardiovascular death as a competitive risk, adjusted Fine-Gray model also illustrated that SUA was an independent predictor of cardiovascular death in men (SHR 1.17, 95% CI 1.08-1.27, p < 0.001), but not in women (SHR 0.98, 95% CI 0.87 - 1.10, p = 0.690).

CONCLUSIONS

Gender differences in the association between SUA and long-term prognosis of HF existed. SUA was an independent prognostic predictor for long-term outcomes of HF in men, but not in women.