Evaluation of 9 biomarkers for predicting 10-year cardiovascular risk in patients undergoing coronary angiography: findings from the LUdwigshafen RIsk and Cardiovascular Health (LURIC) study

Predicting early-stage coronary artery disease using machine learning and routine clinical biomarkers improved by augmented virtual data

Aims

Coronary artery disease (CAD) is a highly prevalent disease with modifiable risk factors. In patients with suspected obstructive CAD, evaluating the pre-test probability model is crucial for diagnosis, although its accuracy remains controversial. Machine learning (ML) predictive models can help clinicians detect CAD early and improve outcomes. This study aimed to identify early-stage CAD using ML in conjunction with a panel of clinical and laboratory tests.

Methods and results

The study sample included 3316 patients enrolled in the Ludwigshafen Risk and Cardiovascular Health (LURIC) study. A comprehensive array of attributes was considered, and an ML pipeline was developed. Subsequently, we utilized five approaches to generating high-quality virtual patient data to improve the performance of the artificial intelligence models. An extension study was carried out using data from the Young Finns Study (YFS) to assess the results' generalizability. Upon applying virtual augmented data, accuracy increased by approximately 5%, from 0.75 to -0.79 for random forests (RFs), and from 0.76 to -0.80 for Gradient Boosting (GB). Sensitivity showed a significant boost for RFs, rising by about 9.4% (0.81-0.89), while GB exhibited a 4.8% increase (0.83-0.87). Specificity showed a significant boost for RFs, rising by ∼24% (from 0.55 to 0.70), while GB exhibited a 37% increase (from 0.51 to 0.74). The extension analysis aligned with the initial study.

Conclusion

Accurate predictions of angiographic CAD can be obtained using a set of routine laboratory markers, age, sex, and smoking status, holding the potential to limit the need for invasive diagnostic techniques. The extension analysis in the YFS demonstrated the potential of these findings in a younger population, and it confirmed applicability to atherosclerotic vascular disease.

von Willebrand factor, ADAMTS-13, and thrombospondin 1 in relation to clinical outcomes in elderly patients with a recent myocardial infarction

Background

von Willebrand factor (VWF) multimers are cleaved by A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS-13) into less active fragments. Thrombospondin 1 (TSP-1) competes with VWF's cleavage site, protecting it from degradation. Low ADAMTS-13 and high VWF have been associated with cardiovascular disease and atrial fibrillation (AF).

Objectives

We aimed to investigate whether VWF, ADAMTS-13, and TSP-1 are associated with clinical outcome.

Methods

Elderly patients with a recent myocardial infarction (MI) (n = 1027) were followed for 2 years. Blood was collected 2 to 8 weeks after the MI for ADAMTS-13, VWF, and TSP-1 measures. The primary endpoints (major adverse cardiovascular events; n = 210) included the first event of MI, stroke, heart failure hospitalization, coronary revascularization, and all-cause death. Total mortality was also registered (n = 56). The secondary endpoint was new-onset AF (n = 43).

Results

Concentrations of VWF, ADAMTS-13, and TSP-1 did not intercorrelate. The risk of major adverse cardiovascular events was altered in patients with VWF ≥ median (hazard ratio [HR], 1.4; 95% CI, 1.0-1.8; P = .03) and ADAMTS-13 ≥ median (HR, 0.7; 95% CI, 0.5-0.9; P = .02); however, it was not significant in adjusted models. VWF and ADAMTS-13 were significantly associated with total mortality, with a HR of 2.7 (95% CI, 1.6-4.6; P < .001) for VWF (Q4 vs. Q1-Q3) and HR of 0.3 (95% CI, 0.2-0.5; P < .001) for ADAMTS-13 (Q2-4 vs. Q1). The associations persisted in multivariable analysis, but the significance disappeared for VWF after correcting for high-sensitivity C-reactive protein. The risk of new-onset AF was lower in patients with VWF ≥ median (HR, 0.5; 95% CI, 0.3-1.0; P = .04]), and this was still significant after adjustments.

Conclusion

Although low ADAMTS-13 predicted death, the cardiovascular risk associated with VWF and ADAMTS-13 was weaker than previously reported. Low VWF is associated with new-onset AF and needs further research.

Cardiovascular safety of tocilizumab: A systematic review and network meta-analysis

OBJECTIVES

Our objective was to compare the cardiovascular safety of tocilizumab and other biological disease-modifying antirheumatic drugs (bDMARD) in rheumatoid arthritis using a network meta-analysis (NMA).

METHODS

A systematic literature search through May 2018 identified randomized controlled trials (RCT) or observational studies (cohort only) reporting cardiovascular outcomes of tocilizumab (TCZ) and/or abatacept (ABA) and/or rituximab (RTX) and/or tumor necrosis factor inhibitors (TNFi) in rheumatoid arthritis patients. The composite primary outcome was the rate of major adverse cardiovascular outcomes (MACE, myocardial infarction (MI), peripheral artery disease (PAD) and cardiac heart failure (CHF)).

RESULTS

19 studies were included in the NMA, including 11 RCTs and 8 cohort studies. We found less events with RTX (5.41 [1.70;17.26]. We found no difference between TCZ and other treatments. Concerning MI, we found no difference between TCZ and csDMARD (4.23 [0.22;80.64]), no difference between TCZ and TNFi (2.00 [0.18;21.84]). There was no difference between TCZ and csDMARD (1.51[0.02;103.50] and between TCZ and TNFi (1.00 [0.06;15.85]) for stroke event. With cohorts and RCT NMA, we found no difference between TCZ and other treatments for MACE (0.66 [0.42;1.03] with ABA, 1.04 [0.60;1.81] with RTX, 0.78[0.53;1.16] and 0.91 [0.54;1.51] with csDMARD), but the risk of myocardial infarction was lower with TCZ compared to ABA (0.67 [0.47;0.97]). We lacked data to compare TCZ and other bDMARD for stoke and MI. Not enough data was available to perform a NMA for CHF and PAD.

CONCLUSIONS

Despite an increase in cholesterol levels, TCZ has safe cardiovascular outcomes compared to other bDMARD.

Clinical utility of serum 25-hydroxyvitamin D in the diagnosis of insulin resistance and estimation of optimal 25-hydroxyvitamin D in U.S. adults

AIMS

To assess the clinical utility of measuring serum 25-hydroxyvitamin-D [25(OH)D] along with traditional risk factors in the diagnosis of insulin resistance (IR) and to estimate the optimal 25(OH)D level associated with normal glucose and insulin homeostasis.

METHODS

A cross-sectional analysis of 6868 adults aged≥20years without diagnosed diabetes in the National Health and Nutrition Examination Survey, with available standardized 25(OH)D data (2001-2010). IR was defined by the homeostatic-model-assessment of insulin resistance (HOMA-IR; ≥75th percentile, sex-specific: 3.9 in men or 3.6 in women). Using logistic regression, two risk models were developed to estimate the risk of IR: Model 1 included established risk factors, and Model 2 additionally included serum 25(OH)D. Predictiveness curves and decision-curve analysis were used to assess differences in IR detection among models. Receiver-operating-characteristic curves were used to estimate the lower threshold for 25(OH)D. Results were validated in a testing sample.

RESULTS

Model 2 marginally improved detection of IR: at a risk threshold of 0.2, adding 25(OH)D would identify an additional 2 to 4 cases per 1000 people. Overall, the lower 25(OH)D threshold was estimated at 60nmol/L, however, the threshold differed by ethnicity (Mexican-Americans: 54nmo/L, non-Hispanic whites: 68nmol/L, and non-Hispanic blacks: 41nmol/L).

CONCLUSION

Addition of serum 25(OH)D to traditional risk factors provided small incremental improvement in detection of IR in asymptomatic adults. The optimal 25(OH)D threshold was estimated to be at least 60nmol/L, however, the threshold may differ by ethnic-background. Further research is needed to validate these results in other populations.

Von Willebrand Factor, ADAMTS13, and the Risk of Mortality

Objective—

Von Willebrand Factor (VWF) is a plasma protein that plays a major role in platelet adhesion and aggregation. Large VWF multimers are cleaved into smaller, less coagulant forms by the metalloprotease ADAMTS13 (A Disintegrin And Metalloprotease with ThromboSpondin motif repeats 13). Previous studies have shown that high VWF and low ADAMTS13 levels are associated with cardiovascular disease, but whether these factors are associated with mortality is unclear. Our aim is to establish the association between VWF antigen (VWF:Ag) levels, ADAMTS13 activity, and mortality.

Approach and Results—

We included 6130 participants of the Rotterdam study, a population-based cohort study among individuals aged ≥55 years. We determined the association between ADAMTS13 activity, VWF:Ag levels, and all-cause and cardiovascular mortality by Cox proportional hazard regression analysis. During a median follow-up time of 11.3 years and a total of 90 635 person years, 1868 of the 6130 individuals died (30.5%), of whom 442 (23.7%) died because of cardiovascular disease. In individuals with low ADAMTS13 activity, the risk of cardiovascular mortality (hazard ratio, 1.46; 95% confidence interval, 1.09–1.96) was higher than that in individuals with high ADAMTS13 activity. The risk of cardiovascular mortality (hazard ratio, 1.29; 95% confidence interval 0.98–1.70) was higher in individuals with the highest VWF:Ag levels than in those with the lowest levels. In individuals with both low ADAMTS13 activity and high VWF:Ag levels, the risk of cardiovascular mortality was even higher (hazard ratio, 1.73 95% confidence interval, 1.28–2.35).

Conclusions—

In this large prospective cohort study, ADAMTS13 activity and VWF:Ag levels are both associated with an increased risk of all-cause and cardiovascular mortality.

Biobanks for cardiovascular epidemiology and prevention

Biobanks for medical research are organized collections of biological samples associated with personal data and information on their donors, to be stored for an indefinite period of time. The storage of biological samples has varied considerably over time, ranging from the informal storage of tissue specimens in a researcher's freezer in the past, to the present well-structured formal repositories. Large-scale population-related biobanks are being set up in several countries and will allow not only research into individual diseases, but also approaches to a wide range of health-related issues, such as physical activity, eating, drinking, education and pollution, among others. The purpose of this article is to discuss how biobanks have improved research in cardiovascular disease epidemiology and prevention, by describing the most relevant population-based epidemiological studies that used set-up biobanks and stored samples for research. The selection of epidemiological studies and biobanks was based on their dimensions and their contribution to the field.

Von Willebrand factor and ADAMTS13 in arterial thrombosis: a systematic review and meta-analysis

Von Willebrand Factor (VWF) plays an important role in hemostasis by mediating platelet adhesion and aggregation. Ultralarge VWF multimers are cleaved by ADAMTS13 in smaller, less procoagulant forms. An association between high VWF levels and cardiovascular disease has frequently been reported, and more recently also an association has been observed between low ADAMTS13 levels and arterial thrombosis. We reviewed the current literature and performed meta-analyses on the relationship between both VWF and ADAMTS13 with arterial thrombosis. Most studies showed an association between high VWF levels and arterial thrombosis. It remains unclear whether ADAMTS13 is a causal independent risk factor because the association between low ADAMTS13 and arterial thrombosis is so far only shown in case-control studies. Prospective studies are awaited. A causal role for ADAMTS13 is supported by mice studies of cerebral infarction where the infusion of recombinant human ADAMTS13 reduced the infarct size.