Significant predictors of poor prognosis in women aged </=65 years hospitalized for an acute coronary event

Behavioral factors predict all-cause mortality in female coronary patients and healthy controls over 26 years - a prospective secondary analysis of the Stockholm Female Coronary Risk Study

OBJECTIVE

The prognosis of coronary artery disease (CAD) is related to its severity and cardiovascular risk factors in both sexes. In women, social isolation, marital stress, sedentary lifestyle and depression predicted CAD progression and outcome within 3 to 5 years. We hypothesised that these behavioral factors would still be associated with all-cause mortality in female patients after 26 years.

METHODS

We examined 292 patients with CAD and 300 healthy controls (mean age of 56 ± 7 y) within the Fem-Cor-Risk-Study at baseline. Their cardiac, behavioral, and psychosocial risk profiles, exercise, smoking, and dietary habits were assessed using standardized procedures. Physiological characteristics included a full lipid profile, the coagulation cascade and autonomic dysfunction (heart rate variability, HRV). A new exploratory analysis using machine-learning algorithms compared the effects of social and behavioral mechanisms with standard risk factors. Results: All-cause mortality records were completed in 286 (97.9%) patients and 299 (99.7%) healthy women. During a median follow-up of 26 years, 158 (55.2%) patients and 101 (33.9%) matched healthy controls died. The annualized mortality rate was 2.1% and 1.3%, respectively. After controlling for all available confounders, behavioral predictors of survival in patients were social integration (HR 0.99, 95% CI 0.99-1.0) and physical activity (HR 0.54, 95% CI 0.37-0.79). Smoking acted as a predictor of all-cause mortality (HR 1.56, 95% CI 1.03-2.36). Among healthy women, moderate physical activity (HR 0.42, 95% CI 0.24-0.74) and complete HRV recordings (≥50%) were found to be significant predictors of survival.

CONCLUSIONS

CAD patients with adequate social integration, who do not smoke and are physically active, have a favorable long-term prognosis. The exact survival times confirm that behavioral risk factors are associated with all-cause mortality in female CAD patients and healthy controls.

Blood derived extracellular vesicles as regenerative medicine therapeutics

The regenerative promise of nanosized extracellular vesicles (EVs) secreted by cells is widely explored. Recently, the capacity of EVs purified from blood to elicit regenerative effect has begun to be evaluated. Blood might be a readily available source of EVs, avoiding need for extensive cell culturing, but there are specific issues that complicate use of the biofluid in this area. We assess the evidence for blood containing regenerative material, progress made towards delivering blood derived EVs as regenerative therapeutics, difficulties that relate to the complexity of blood and the promise of hydrogel-based delivery of EVs.

The role of high-density lipoproteins in the regulation of angiogenesis

Angiogenesis is important for postnatal physiological processes including tissue neovascularization in response to an ischaemic injury. Conversely, uncontrolled inflammatory-driven angiogenesis can accelerate atherosclerotic plaque and tumour growth. Angiogenesis-associated diseases are highly prevalent globally, with cardiovascular-related disorders and cancer being the leading causes of mortality worldwide. A vast amount of research has been conducted on the vasculoprotective effects of high-density lipoproteins (HDLs) and while current HDL-raising therapies to date have not yielded the desired benefits clinically, its role in angiogenesis is yet to be fully elucidated. Epidemiological studies report positive correlations between elevated HDL levels and improved prognosis in both ischaemia- and inflammatory-driven pathologies, in which angiogenesis plays a key role. This review focuses on current evidence from epidemiological and prospective studies, coupled with animal models and mechanistic studies that highlight the ability of HDL to conditionally regulate angiogenesis.

Multifunctional regulation of angiogenesis by high-density lipoproteins

AIMS

High-density lipoproteins (HDL) exert striking anti-inflammatory effects and emerging evidence suggests that they may augment ischaemia-mediated neovascularization. We sought to determine whether HDL conditionally regulates angiogenesis, depending on the pathophysiological context by (i) inhibiting inflammation-induced angiogenesis, but also; (ii) enhancing ischaemia-mediated angiogenesis.

METHODS AND RESULTS

Intravenously delivered apolipoprotein (apo) A-I attenuated neovascularization in the murine femoral collar model of inflammation-induced angiogenesis, compared with phosphate-buffered saline infused C57BL6/J mice (58%), P < 0.05. Conversely, apoA-I delivery augmented neovessel formation (75%) and enhanced blood perfusion (45%) in the murine hindlimb ischaemia model, P < 0.05. Reconstituted HDL (rHDL) was tested on key angiogenic cell functions in vitro. rHDL inhibited human coronary artery endothelial cell migration (37.9 and 76.9%), proliferation (15.7 and 40.4%), and tubulogenesis on matrigel (52 and 98.7%) when exposed to two inflammatory stimuli: tumour necrosis factor-α (TNF-α) and macrophage-conditioned media (MCM). In contrast, rHDL significantly augmented hypoxia-stimulated migration (36.9%), proliferation (135%), and tubulogenesis (22.9%), P < 0.05. Western blot and RT-PCR analyses revealed that these divergent actions of rHDL were associated with conditional regulation of hypoxia-inducible factor-1α (HIF-1α), vascular endothelial growth factor (VEGF) and VEGF receptor 2, which were attenuated in response to TNF-α (40.4, 41.0, and 33.2%) and MCM (72.5, 30.7, and 69.5%), but augmented by rHDL in hypoxia (39.8, 152.6, and 15.7%%), all P < 0.05.

CONCLUSION

HDL differentially regulates angiogenesis dependent upon the pathophysiological setting, characterized by suppression of inflammation-associated angiogenesis, and conversely, by the enhancement of hypoxia-mediated angiogenesis. This has significant implications for therapeutic modulation of neovascularization.

High-density lipoproteins augment hypoxia-induced angiogenesis via regulation of post-translational modulation of hypoxia-inducible factor 1α

Increasing evidence suggests that high-density lipoproteins (HDLs) promote hypoxia-induced angiogenesis. The hypoxia-inducible factor 1α (HIF-1α)/vascular endothelial growth factor (VEGF) pathway is important in hypoxia and is modulated post-translationally by prolyl hydroxylases (PHD1-PHD3) and E3 ubiquitin ligases (Siah1 and Siah2). We aimed to elucidate the mechanisms by which HDLs augment hypoxia-induced angiogenesis. Preincubation (16 h) of human coronary artery endothelial cells with reconstituted high-density lipoprotein (rHDL) containing apolipoprotein A-I (apoA-I) and phosphatidylcholine (20 μM, final apoA-I concentration), before hypoxia, increased Siah1 (58%) and Siah2 (88%) mRNA levels and suppressed PHD2 (32%) and PHD3 (45%) protein levels compared with hypoxia-induced control levels. After Siah1/2 small interfering RNA knockdown, rHDL was unable to suppress PHD2/3 and failed to induce HIF-1α, VEGF, and tubulogenesis in hypoxia. Inhibition of the upstream phosphatidylinositol 3-kinase (PI3K)/Akt signaling pathway also abrogated the effects of rHDL. Furthermore, knockdown of the scavenger receptor SR-BI attenuated rHDL-induced elevations in Siah1/2 and tubulogenesis in hypoxia, indicating that SR-BI plays a key role. Finally, the importance of VEGF in mediating the ability of rHDL to drive hypoxia-induced angiogenesis was confirmed using a VEGF-neutralizing antibody. In summary, rHDL augments the HIF-1α/VEGF pathway via SR-BI and modulation of the post-translational regulators of HIF-1α (PI3K/Siahs/PHDs). HDL-induced augmentation of angiogenesis in hypoxia may have implications for therapeutic modulation of ischemic injury.

Prognostic role of the glucometabolic status assessed in a metabolically stable phase after a first acute myocardial infarction: the SHEEP study

OBJECTIVES

Our objective was to examine fasting glucose and insulin levels in patients surviving 3 months after a first AMI in relation to long-term prognosis.

DESIGN

A total of 1167 consecutive patients between 45 and 70 years with a first nonfatal AMI underwent a standardized clinical examination and were followed for a mean of 8 years for total and cardiac mortality and hospitalization for nonfatal cardiovascular disease. Impaired fasting glucose (IFG) was defined as fasting glucose between 5.6 and 7 mmol L(-1) and a level >or=7 mmol L(-1) as newly detected diabetes. Patients with a fasting glucose level <5.6 mmol L(-1) and without a history of diabetes were classified as normoglycemic (NG). An estimate of insulin resistance was calculated using the homeostasis model assessment (HOMA).

RESULTS

We recorded 219 deaths, 121 deaths from cardiac causes, during the follow-up period. After adjustment for several potential confounders, hazard ratios for total mortality were 1.36 (95% confidence interval 0.93-1.99, P=0.11), 2.27 (1.26-4.09, P=0.006) and 2.15 (1.43-3.21, P<0.001) for patients with IFG, newly detected diabetes and history of diabetes when compared to the NG group. Cardiac mortality, risk of hospitalization for recurrent nonfatal AMI, stroke or heart failure generally showed a similar pattern to that of total mortality. Insulin level and HOMA values were also associated with increased risk for recurrent events.

CONCLUSIONS

We confirmed that both known and newly detected diabetes is a strong prognostic factor in AMI. In addition, our findings suggest that glucose levels below the diabetes cut off value might also predict poor long-term prognosis when assessed in a metabolically stable phase.

Prevalence and factors associated with dyslipoproteinemias in Brazilian systemic lupus erythematosus patients

To determine the prevalence of dyslipoproteinemias and their related factors in a Brazilian systemic lupus erythematosus (SLE) population, fasting lipids were measured in 185 female SLE outpatients. Age, BMI, smoking, post-menopausal status, presence of diabetes and hypertension, SLE duration, number of ARA criteria, drug treatment and disease activity (by SLEDAI) were registered. Statistics included uni and multivariate logistic regression. Eighty-nine patients (48.1%) had hypercholesterolemia, 55 (29.7%) had hypertriglyceridemia and 109 (58.9%) had either. On multivariate analysis, 24-h proteinuria (OR = 2.08, 95% CI: 1.11-3.88), BMI (OR = 1.08, 95% CI: 1.01-1.16) and post-menopausal status (OR = 2.48, 95% CI: 1.25-4.92) were associated with hypercholesterolemia. Disease activity was related to low HDL-cholesterol (OR = 2.59, 95% CI: 1.20-5.58) and, in pre-menopausal patients, also to hypertriglyceridemia (OR = 1.16, 95% CI: 1.03-1.30). Antimalarial use was protective for hypertriglyceridemia (OR = 0.44, 95% CI: 0.22-0.90). In conclusion, the increased prevalence of dyslipoproteinemias is due to proteinuria, obesity and SLE activity. Antimalarials have beneficial effect on lipid profile that may be due to reduction in disease activity.

Favourable long term prognosis in stable angina pectoris: an extended follow up of the angina prognosis study in Stockholm (APSIS)

OBJECTIVE

To evaluate the long term prognosis of patients with stable angina pectoris.

DESIGN

Registry based follow up (median 9.1 years) of patients participating in the APSIS (angina prognosis study in Stockholm), which was a double blind, single centre trial of antianginal drug treatment.

PATIENTS

809 patients (31% women) with stable angina pectoris < 70 (mean (SD) 59 (7) years at inclusion) and an age and sex matched reference population from the same catchment area.

INTERVENTIONS

Double blind treatment with metoprolol or verapamil during 3.4 years (median), followed by referral for usual care with open treatment.

MAIN OUTCOME MEASURES

Cardiovascular (CV) death and non-fatal myocardial infarction (MI) in the APSIS cohort and total mortality in comparison with reference subjects.

RESULTS

123 patients died (41 MI, 36 other CV causes) and 72 had non-fatal MI. Mortality (19% v 6%, p < 0.001) and fatal MI (6.6% v 1.6%, p < 0.001) were increased among male compared with female patients. Diabetes, previous MI, hypertension, and male sex independently predicted CV mortality (p < 0.001). Diabetes greatly increased the risk in a small subgroup of female patients. Male patients had higher mortality than men in the reference population during the first three years (cumulative absolute difference 3.8%) but apparently not thereafter. Female patients had similar mortality to women in the reference population throughout the 9.1 years of observation.

CONCLUSIONS

Female patients with stable angina had similar mortality to matched female reference subjects but male patients had an increased risk. Diabetes, previous MI, hypertension, and male sex were strong risk factors for CV death or MI.

Does body mass index, smoking, lipoprotein levels, surgically induced menopause, hormone replacement therapy, years since menopause, or age affect hemostasis in postmenopausal women?

BACKGROUND

Controversy still exists as to the relative importance of menopausal status and lifestyle factors for the risk of coronary heart disease in women.

OBJECTIVE

The purpose of this study was to assess the influence of body mass index (BMI), smoking,lipoprotein levels, surgically induced menopause, hormone replacement therapy (HRT), years since menopause, and age on hemostasis in apparently healthy postmenopausal women.

METHODS

Lipoproteins (total cholesterol [TC], low-density lipoprotein cholesterol, high-density lipoprotein cholesterol [HDL-C], triglycerides [TG]), and hemostatic factors (fibrinogen, von Willebrand factor antigen [vWFag], coagulation factors VIIag [FVIlag] and VIIa [FVIIa], plasminogen activator inhibitor 1 [PAI-1]) were each measured once. A forward, stepwise, multiple regression analysis was used to assess variations in hemostatic parameters.

RESULTS

A group of 292 healthy Stockholm women recruited from the census register participated in the Stockholm Female Coronary Risk Study as controls. Of these women, 260 participated in the present study. BMI, smoking, lipoprotein levels, surgically induced menopause, and years since menopause (1-5 y) were found to be associated with a 31% increase in fibrinogen levels. A 7% increase in FVIIa levels was attributed to TC, BMI, and HRT. Years since menopause (1-15 y), TG, TC, BMI, and HRT were associated with an increase of up to 26% in FVIIag levels. A 9% increase in vWFag correlated with HDL-C and years since menopause (1-10, 11-14, and > or =15 y). BMI and TG explained a 21% and 3% increase, respectively, in PAI-1 levels. Neither the use of HRT nor years since menopause had any influence on hemostasis.

CONCLUSION

BMI, high levels of TC and TG, and low HDL-C levels appear to be more important than hormonal status in their impact on hemostatic variables in healthy postmenopausal women.

Heart rate variability in long-term risk assessment in middle-aged women with coronary heart disease: The Stockholm Female Coronary Risk Study

OBJECTIVES

Low heart rate variability (HRV) is associated with poor prognosis after acute coronary events in men. In women, the prognostic impact is not well documented. The objective of this study was to assess the long-term predictive power of HRV on mortality amongst middle-aged women with coronary heart disease (CHD). DESIGN, SETTINGS AND SUBJECTS: Consecutive women below 65 years hospitalized for an acute coronary syndrome during a 3-year period in Stockholm were examined for cardiovascular prognostic factors including HRV, and followed for a median of 9 years. An ambulatory 24-h electrocardiograph was recorded during normal activities, 3-6 months after hospitalization. SDNN index (mean of the standard deviations of all normal to normal intervals for all 5-min segments of the entire recording) and the following frequency domain parameters were assessed: total power, high-frequency (HF) power, low-frequency (LF) power, very-low frequency (VLF) power and LF/HF ratio. Using Cox proportional hazards regression, the hazard ratios (HR) for each 25% decrease of the HRV parameters were assessed.

RESULTS

After controlling for the independent, significant predictors of mortality amongst the clinical variables, the following HRV parameters were found to be significant predictors of all-cause mortality: SDNN index [HR 1.56, 95% confidence intervals (CI) 1.19-2.05], total power (HR 1.21, 95% CI 1.08-1.35), VLF power (HR 1.22, 95% CI 1.09-1.36), LF power (HR 1.18 95%, CI 1.07-1.30) and HF power (HR 1.18, 95% CI 1.05-1.33). The results were essentially the same when cardiovascular mortality was used as end-points. The HRV parameters were stronger predictors of mortality in the first 5 years following the index event.

CONCLUSION

Low HRV is a predictor of long-term mortality amongst middle-aged women with CHD when measured 3-6 months after hospitalization for an acute coronary syndrome, even after controlling for established clinical prognostic markers.

TNF-alpha: a link between hypertriglyceridaemia and inflammation in SLE patients with cardiovascular disease

Patients with systemic lupus erythematosus (SLE) are at high risk of cardiovascular disease (CVD). Tumour necrosis factor-alpha (TNF-alpha) has been implicated in the pathophysiological processes of both SLE and CVD. This study focuses on the role of TNF-alpha and its soluble receptors in SLE-related CVD. In summary, 26 women (52 +/- 8.2 years) with SLE and a history of CVD (SLE cases) we compared with 26 age-matched women with SLE and no clinical manifestations of CVD (SLE controls) and 26 age-matched population-based control women (population controls). Plasma concentrations of circulating TNF-alpha, TNF-alpha receptor 1 (sTNFR1) and TNF-a receptor 2 (sTNFR2) were determined by ELISA. TNF-alpha, sTNFR1 and sTNFR2 were raised in SLE cases as compared to SLE controls (P = 0.009; P = 0.001; P = 0.001, respectively), and SLE controls had higher levels than population controls (P = 0.001; P = 0.02; P = 0.001, respectively). Exclusively in the SLE case group there was a striking positive correlation between TNF-alpha and plasma triglycerides (r = 0.57, P < 0.002), VLDL triglycerides (r = 0.54, P = 0.004) and VLDL cholesterol (r = 0.58, P = 0.002). Furthermore, TNF-alpha correlated with the waist-hip ratio but not with estimated insulin resistance. TNF-alpha may thus be a major factor in SLE-related CVD acting both by contributing to hypertriglyceridaemia and by promoting atherosclerosis-related inflammation. sTNFR1 and sTNFR2 are strongly associated with CVD in SLE but their exact roles in disease development remain to be elucidated.