Are Varicose Veins a Marker for Susceptibility to Coronary Heart Disease in Men? Results from the Normative Aging Study

Demographic and Clinical Risk Factors of Developing Clinically Recognized Varicose Veins in Older Adults

INTRODUCTION

Varicose veins are common in older adults and are associated with adverse clinical outcomes such as deep venous thrombosis. Established risk factors for varicose veins include female sex, height, and obesity, but other risk factors are relatively uncharacterized.

METHODS

This was a prospective cohort analysis of 6,241 participants aged 66-70 years from the Atherosclerosis Risk in Communities (ARIC) Study. Incident varicose veins were defined as two outpatient encounters (at least a week apart) or inpatient diagnoses through 2018 with ICD-9 code 454 or ICD-10 code I83. Participants with a history of clinically recognized varicose veins at baseline were excluded. Cox regression was used to evaluate established (e.g., female, height, BMI) and potential demographic and clinical risk factors.

RESULTS

During a median follow-up of 13 years, 349 (6%) of participants developed clinically recognized varicose veins. Consistent with prior research, female sex, taller height, and higher BMI were associated with incident varicose veins. After accounting for these, White race, prevalent heart failure, loop diuretic use, higher cardiac troponin T, and higher natriuretic peptide were independently associated with incident varicose veins.

CONCLUSIONS

In this community-based cohort study of older adults, known and newly identified risk factors, including cardiac function and heart failure, were independently associated with incidence of clinically recognized varicose veins. The potential usefulness of cardiac biomarkers for prevention and screening of varicose veins requires further investigations.

Cardiometabolic, Lifestyle, and Nutritional Factors in Relation to Varicose Veins: A Mendelian Randomization Study

Background We conducted a 2-sample Mendelian randomization study to assess the associations of cardiometabolic, lifestyle, and nutritional factors with varicose veins. Methods and Results Independent single-nucleotide polymorphisms associated with height (positive control), body mass index, type 2 diabetes, diastolic and systolic blood pressure, smoking, alcohol and coffee consumption, 7 circulating vitamins (A, B6, B9, B12, C, 25-hydroxyvitamin D, and E), and 5 circulating minerals (calcium, iron, magnesium, selenium, and zinc) at the genome-wide significance level were used as instrumental variables. Summary-level data for the genetic associations with varicose veins were obtained from the UK Biobank (8763 cases and 352 431 noncases) and the FinnGen consortium (13 928 cases and 153 951 noncases). Genetically predicted higher height, body mass index, smoking, and circulating iron levels were associated with an increased risk of varicose veins. The odds ratios (ORs) per 1-SD increase in the exposure were 1.34 (95% CI, 1.25-1.43) for height, 1.39 (95% CI, 1.27-1.52) for body mass index, 1.12 (95% CI, 1.04-1.22) for the prevalence of smoking initiation, and 1.24 (95% CI, 1.16-1.33) for iron. Higher genetically predicted systolic blood pressure and circulating calcium and zinc levels were associated with a reduced risk of varicose veins, whereas the association for systolic blood pressure did not persist after adjustment for genetically predicted height. The OR was 0.75 (95% CI, 0.62-0.92) per 1-SD increase in calcium levels and 0.97 (95% CI, 0.95-0.98) for zinc. Conclusions This study identified several modifiable risk factors for varicose veins.

Clinical and Genetic Determinants of Varicose Veins

BACKGROUND

Varicose veins are a common problem with no approved medical therapies. Although it is believed that varicose vein pathogenesis is multifactorial, there is limited understanding of the genetic and environmental factors that contribute to their formation. Large-scale studies of risk factors for varicose veins may highlight important aspects of pathophysiology and identify groups at increased risk for disease.

METHODS

We applied machine learning to agnostically search for risk factors of varicose veins in 493 519 individuals in the UK Biobank. Predictors were further studied with univariable and multivariable Cox regression analyses (2441 incident events). A genome-wide association study of varicose veins was also performed among 337 536 unrelated individuals (9577 cases) of white British descent, followed by expression quantitative loci and pathway analyses. Because height emerged as a new candidate risk factor, we performed mendelian randomization analyses to assess a potential causal role for height in varicose vein development.

RESULTS

Machine learning confirmed several known (age, sex, obesity, pregnancy, history of deep vein thrombosis) and identified several new risk factors for varicose vein disease, including height. After adjustment for traditional risk factors in Cox regression, greater height remained independently associated with varicose veins (hazard ratio for upper versus lower quartile, 1.74; 95% CI, 1.51-2.01; P<0.0001). A genome-wide association study identified 30 new genome-wide significant loci, identifying pathways involved in vascular development and skeletal/limb biology. Mendelian randomization analysis provided evidence that increased height is causally related to varicose veins (inverse-variance weighted: odds ratio, 1.26; P=2.07×10^-16).

CONCLUSIONS

Using data from nearly a half-million individuals, we present a comprehensive genetic and epidemiological study of varicose veins. We identified novel clinical and genetic risk factors that provide pathophysiological insights and could help future improvements of treatment of varicose vein disease.

Frequency of Peripheral Arterial Disease in Patients With Chronic Venous Insufficiency

Background:

It is estimated that about 15% (10% - 30% in most of the studies) of the total adult population has some aspects of the Chronic Venous Insufficiency (CVI). Frequency of the Peripheral Arterial Disease (PAD) in the adult population is 3% - 4%. Studies dealing with etiopathogenesis of leg ulcers show that between 10% and 18% of all ulcers are of mixed, arterial-venous origin.

Objectives:

The purpose of this study was to find out if there is a higher frequency of PAD among CVI patients in comparison with the control group, as well as to discover some common risk factors for CVI and PAD.

Patients and Methods:

This cross-sectional descriptive study was conducted at the dermatovenereological clinic, clinical center of Vojvodina, Serbia. A total of 162 examinees were included. All patients were examined for the existence of CVI and staged according to CEAP (Clinical, etiology, anatomy and patophysiology) classification. In this way, 3 groups were formed: Patients with the mild forms of CVI (stage 1 - 4 by CEAP classification), 57 patients; patients with the severe forms of CVI (stage 5 and 6 by CEAP classification), 55 patients; control group (no CVI), 50 patients. Also, the Ankle Brachial Pressure Index (ABPI) was assessed in all subjects, and its value of ≤ 0.9 was set as criteria for diagnosis of PAD. The same sample was divided according to the presence of PAD into two groups. The most important risk factors for CVI and PAD were identified for each patient through complete examination, medical record and appropriate questionnaire.

Results:

Our results showed that the risk factors for CVI were high Body Mass Index (BMI), hypertension, predominantly standing position during work and positive family history for CVI. In the same sample it was found that 28 (17.28%) patients had PAD. Relevant risk factors for PAD in the present study were: high BMI, hypertension, diabetes and a positive family history for PAD. Comparison of frequency of PAD among patients with severe forms of CVI and control group showed that this difference was statistically significant (P = 0.0275; OR 3.375; 95% CI 1.125 - 10.12). After multivariate analyses, adjusted odds ratio OR was still statistically significant.

Conclusions:

The peripheral arterial disease is more frequent in patients with the severe form of CVI, than in patients without CVI. Concomitant risk factors for CVI and PAD were high BMI and hypertension. In each patient with severe CVI it is necessary to determine the ABPI, in order to exclude the presence of PAD.

A different way to look at varicose veins

OBJECTIVE

The development of varicose veins is commonly attributed to vessel wall degeneration. The idea that varicose veins occur because of pathological processes, however, is challenged by certain observations. For example, their high prevalence (50% or greater) in many populations makes it statistically "normal" to have varicose veins; their well-established genetic predisposition raises the possibility that this high prevalence reflects a survival benefit. One way to explain this apparent contradiction is to theorize that varicose veins are produced by the same mechanism(s) that lead to the growth and remodeling of other types of blood vessels. If so, being "good" at forming varicose veins may also predispose to being "good" at forming various types of collateral blood vessels when necessary.

METHODS

A selected literature review was conducted. Works chosen for review included those suggesting that: the process of varicose vein formation may share the same basic mechanisms as the formation of collateral veins, arteries, and lymphatic vessels; and clinical outcomes may be different between subjects with and without varicose veins.

RESULTS

Evidence suggests that subjects who are "good" at forming varicose veins may also be "good" at forming various types of collateral vessels, and they may have better overall survival (with less cardiovascular morbidity) than those without varicose veins.

CONCLUSIONS

Varicose veins may be "the price we pay" for an enhanced ability to form collateral vessels when necessary.

Folate network genetic variation predicts cardiovascular disease risk in non-Hispanic white males

Genes functioning in folate-mediated 1-carbon metabolism are hypothesized to play a role in cardiovascular disease (CVD) risk beyond the current narrow focus on the MTHFR 677 C→T (rs1801133) polymorphism. Using a cohort study design, we investigated whether sequence variants in the network of folate-related genes, particularly in genes encoding proteins related to SHMT1, predict CVD risk in 1131 men from the Normative Aging Study. A total of 330 single nucleotide polymorphisms (SNPs) in 52 genes, selected for function and gene coverage, were assayed on the Illumina GoldenGate platform. Age- and smoking-adjusted genotype-phenotype associations were estimated in regression models. Using a nominal P ≤ 5.00 × 10(-3) significance threshold, 8 SNPs were associated with CVD risk in single locus analyses. Using a false discovery rate (FDR) threshold (P-adjusted ≤1.00 × 10(-1)), a SNP in the GGH gene remained associated with reduced CVD risk, with a stronger association in early onset CVD cases (<55 y). A gene × folate interaction (MAT2B) and 2 gene × vitamin B-12 interactions (BHMT, SLC25A32) reached the FDR P-adjusted ≤2.00 × 10(-1) threshold. Three biological hypotheses related to SHMT1 were explored and significant gene × gene interactions were identified for TYMS by UBE2N, FTH1 by CELF1, and TYMS by MTHFR. Variations in genes other than MTHFR and those directly involved in homocysteine metabolism are associated with CVD risk in non-Hispanic white males. This work supports a role for SHMT1-related genes and nuclear folate metabolism, including the thymidylate biosynthesis pathway, in mediating CVD risk.

Lifestyle factors and varicose veins: does cross-sectional design result in underestimate of the risk?

OBJECTIVES

To assess whether smoking, alcohol drinking and dietary factors are linked with varicose veins.

METHODS

A middle-aged general population of 4903 was studied, and prevalence rates at entry and five-year incidence of varicose veins were assessed. Lifestyle habits were recorded at entry and at the end of the follow-up.

RESULTS

New varicose veins were significantly more common in individuals with regular alcohol intake, incidence odds ratio (OR) 1.5 (95% confidence interval [CI]: 1.05-2.3) in a multivariate analysis (of 2202 individuals). The association was particularly strong in women. Smokers had a higher incidence of varicose veins compared with non-smokers, OR 1.3 (95% CI: 0.9-1.8), but without statistical significance. Having daily meals of meat implied less new varicose veins than having 0-2 weekly meals of meat.

CONCLUSION

Alcohol was likely to increase the risk of varicose veins in women and smoking in both genders. These findings were seen in the follow-up design, but not when the data of these risk factors were compared with varicose veins prevalent at entry.

Arterial disease but not hypertension predisposes to varicose veins

Objectives

The aim of the study was to find out if persons with cardiovascular diseases (CVD) (arterial disease or hypertension) have additional risk of varicose veins (VV) compared with those without arterial disease (AD) or hypertension.

Methods

We studied, using a validated questionnaire, the prevalence and incidence of VVs in those with and without CVD in a population of 4903 including 40-, 50- and 60-year-old men and women in Tampere, Finland. During the five years of follow-up, we had a special interest on the appearance of new VVs in those without VVs at entry ( n = 3065).

Results

We found a higher prevalence of VVs in persons with CVD than in those without CVD (with sex and age adjusted odds ratio [OR] 1.3 [95% confidence interval, CI 1.1–1.5]). The prevalence of VVs was higher in persons with AD (OR 1.7 [CI 1.4–2.2]), but not in persons with hypertension (OR 1.1 [CI 0.9–1.2]) than in those who were free of AD or hypertension, respectively. Subjects with AD had higher incidence of VVs (incidence odds ratio, IOR 1.4 [CI 0.8–2.7]) than subjects without AD and the effect was statistically significant in women (IOR 2.2 [CI 1.1–4.5]). Also the incidence of VVs was more affected by AD than by hypertension (IOR 1.1 [CI 0.7–1.8]).

Conclusion

There seems to exist a relatively strong additional risk of VVs in persons with AD and practically none in those with hypertension compared to those without.

Persons with varicose veins have a high subsequent incidence of arterial disease: a population-based study in Tampere, Finland

The aim of this population research was to find out the risk of arterial disease (defined as angina pectoris, myocardial infarction, peripheral occlusive arterial disease, and cerebrovascular disease) and hypertension in persons with varicose veins. A 5-year follow-up study was conducted in Tampere, Finland. A validated questionnaire was used in 3 middle-aged cohorts (40, 50, and 60 year olds) in a general population of 6,874. In the follow-up study, 71% (n = 4,903) replied. The incidence of arterial disease and hypertension was studied in those with varicose veins and those without at the entry to the study. During the follow-up, new arterial disease occurred significantly more often in individuals with varicose veins. The incidence odds ratio was 2.0 (95% confidence interval, 1.5-2.7; n = 3,032), but the incidence odds ratio of new hypertension was 1.0 (95% confidence interval, 0.8-1.3; n = 2,915). Varicose veins are a risk indicator of arterial disease but not of hypertension. Varicose veins likely do not cause arterial disease, but they may have common causes that, however, are not related with hypertension.

Selective loss of extracellular matrix proteins is linked to biophysical properties of varicose veins assessed by ultrasonography

BACKGROUND

Dilatation and enhanced distensibility are specific biophysical properties of varicose veins. Both can be assessed by ultrasonography. The aim of this study was to analyse correlations between the vein wall protein content and these two biophysical properties of varicose veins.

METHODS

Twenty-seven patients having surgery for varicose veins and six control patients with normal veins undergoing arterial bypass surgery were examined clinically and with ultrasonography the day before surgery. Fifty-two varicose and six control vein rings were harvested and analysed histopathologically and morphometrically; vascular tissue microarrays incorporated 116 vein wall sectors.

RESULTS

Elastin loss in the adventitia (P = 0.010) and reduction of type III collagen in the intima and media (P = 0.004) were observed in varicose veins. Elastin loss correlated negatively with vein diameter at rest (P = 0.005), whereas loss of type III collagen in the intima correlated negatively with the increase in vein diameter at the Valsalva manoeuvre (P < 0.001).

CONCLUSION

Loss of elastin and type III collagen occurs in varicose veins and can be assessed with ultrasonography in vivo by measuring vein diameter and distensibility.

Cardiovascular evaluation of young patients with varicocele

OBJECTIVE

To evaluate cardiovascular risk factors and demographic parameters in patients with varicocele.

DESIGN

Although some pathophysiologic hypotheses have been suggested to explain the etiology of varicocele, the exact mechanism underlying varicocele is not yet known. The coexistence of arterial and venous system pathologic conditions has been reported recently, including varicosities of the coronary venous system and leg veins. Cardiovascular risk factors have not been evaluated previously in patients with varicocele. In addition to the presence of cardiovascular risk factors and demographic parameters, we assessed the prevalence of peripheral varicose veins in patients with and without varicocele.

PATIENT(S)

Study groups consisted of 52 patients with varicocele and 100 patients without varicocele younger than 50 years old.

RESULT(S)

There were no statistically significant differences between the two groups with respect to presence of hypertension, diabetes mellitus, hyperlipidemia, family history of coronary artery disease, body mass index, age, and height. The weight and presence of peripheral varicose veins in the patients with varicocele were significantly higher than in those without varicocele. It was found that presence of peripheral varicose veins was independently and positively associated with varicocele.

CONCLUSION(S)

We have demonstrated that varicocele is not associated with cardiovascular risk factors or demographic parameters. However, the presence of peripheral varicose veins is positively associated with varicocele, suggesting a possible common pathologic step.