High heart rate amplifies the risk of cardiovascular mortality associated with elevated uric acid

Risk of Cardiovascular Events in Metabolically Healthy Overweight or Obese Adults: Role of LDL-Cholesterol in the Stratification of Risk

The objective of this study was to investigate the longitudinal association of metabolically healthy overweight/obese adults with major adverse cardiovascular events (MACE) and the effect of LDL-cholesterol levels on this association. This study was conducted with 15,904 participants from the URRAH study grouped according to BMI and metabolic status. Healthy metabolic status was identified with and without including LDL-cholesterol. The risk of MACE during 11.8 years of follow-up was evaluated with multivariable Cox regressions. Among the participants aged <70 years, high BMI was associated with an increased risk of MACE, whereas among the older subjects it was associated with lower risk. Compared to the group with normal weight/healthy metabolic status, the metabolically healthy participants aged <70 years who were overweight/obese had an increased risk of MACE with an adjusted hazard ratio of 3.81 (95% CI, 1.34-10.85, p = 0.012). However, when LDL-cholesterol < 130 mg/dL was included in the definition of healthy metabolic status, no increase in risk was found in the overweight/obese adults compared to the normal weight individuals (hazard ratio 0.70 (0.07-6.71, p = 0.75). The present data show that the risk of MACE is increased in metabolically healthy overweight/obese individuals identified according to standard criteria. However, when LDL-cholesterol is included in the definition, metabolically healthy individuals who are overweight/obese have no increase in risk.

Prolonged elevated heart rate and 90-Day mortality in acute pancreatitis

Prolonged elevated heart rate (peHR) is recognized as a risk factor for poor prognosis among critically ill patients. However, there is currently a lack of studies investigating the association between peHR and patients with acute pancreatitis. Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database was used to identify patients with acute pancreatitis. PeHR was defined as a heart rate exceeding 100 beats per minute for at least 11 out of 12 consecutive hours. Cox regression analysis was used to assess the association between peHR and the 90-Day mortality. A total of 364 patients (48.9%) experienced a peHR episode. The 90-day mortality was 25%. PeHR is an independent risk factor for 90-day mortality (HR, 1.98; 95% CI 1.53-2.56; P < 0.001). KM survival curves exhibited a significant decrease in the survival rate at 90 days among patients who experienced a peHR episode (P < 0.001, 84.5% vs. 65.1%). We revealed a significant association of peHR with decreased survival in a large cohort of ICU patients with acute pancreatitis.

Association between serum uric acid and cardiovascular fitness among US adults: A cross-sectional study

Background

While serum uric acid (SUA) is known as a cardiovascular disease risk factor and is associated with increased cardiovascular mortality, the relationship between SUA and cardiovascular adaptability under exercise stress remains unclear.

Aims

This study aims to elucidate the relationship between SUA levels and cardiovascular fitness, particularly as manifested during cardiopulmonary exercise testing.

Methods

Utilizing data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004, this study included 5765 participants aged 12-49 years. Heart rate recovery (HRR) during cardiopulmonary exercise testing was measured as an indicator of cardiovascular fitness. Multivariate linear regression analysis was used to explore the association between SUA levels and heart rate recovery at 1 min (HRR1) and 2 min (HRR2) post-exercise.

Results

After adjusting for potential confounders, an inverse relationship was found between SUA levels and both HRR1 and HRR2. Multivariate adjusted smoothing spline plots demonstrated a decrease in HRR1 and HRR2 with increasing SUA levels. This negative correlation was observed across nearly all subgroups.

Conclusions

Elevated SUA levels are indicative of poorer cardiovascular adaptability in the adult US population.

Long-term increase in serum uric acid and its predictors over a 25 year follow-up: Results of the PAMELA study

BACKGROUND AND AIMS

Hyperuricemia (HU) has been shown to be associated with an adverse impact on cardiovascular and metabolic risk. Scanty data are available in the general population on the longitudinal changes in serum uric acid (SUA), the occurrence of HU and their potential predictors. We examined during a 25-year follow-up the SUA changes and the factors associated with HU development in the Pressioni Arteriose Monitorate E loro Associazioni (PAMELA) study.

METHODS AND RESULTS

We analyzed data collected in 561 subjects of the PAMELA study evaluated during an average follow-up time amounting to 25.4 ± 1.0 years (mean ± SD). HU was defined by the Uric Acid Right for Heart Health (URRAh) cutoff (5.1 for females and 5.6 mg/dl for males). Mean SUA values during follow-up increased from 4.7 ± 1.1 to 5.0 ± 1.2 mg/dl (P<0.001), the average SUA elevation amounting to of 0.3 ± 1.1 mg/dl 26.7 % of the subjects displayed HU at the follow-up. This was associated at the multivariable analysis with female gender, office, home and 24-h blood pressure, diuretic treatment, serum triglycerides and baseline SUA, as well as the increase in waist circumference and the reduction in renal function.

CONCLUSION

The present study provides longitudinal evidence that in the general population during a 25 year follow-up there is a progressive increase in SUA and HU development. Baseline SUA represents the most important factor associated with these modifications. Gender, renal dysfunction, triglycerides, obesity, diuretic treatment and blood pressure represent other variables capable to predict future occurrence of HU.

Hyperuricemia as a Risk Factor in Hypertension among Patients with Very High Cardiovascular Risk

Hypertension remains a global threat to public health, affecting the worldwide population. It is one of the most common risk factors for cardiovascular disease. Today's treatments focus on creating a hypotensive effect. However, there is a constant search for additional factors to reduce the potential of developing hypertension complications. These factors may act as a parallel treatment target with a beneficial effect in specific populations. Some studies suggest that uric acid may be considered such a factor. This study investigated the potential effect of uric acid concentrations over 5 mg/dL on the incidence of hypertension complications among patients with very high cardiovascular risk. A total of 705 patients with hypertension and very high cardiovascular risk were selected and included in the analysis. The patients were divided and compared according to serum uric acid levels. The study showed a higher occurrence of heart failure (OR = 1.7898; CI: 1.2738-2.5147; p = 0.0008), atrial fibrillation (OR = 3.4452; CI: 1.5414-7.7002; p = 0.0026) and chronic kidney disease (OR = 2.4470; CI: 1.3746-4.3558; p = 0.0024) among individuals with serum uric acid levels over 5 mg/dL, males and those with a BMI > 25 kg/m2. These findings suggest that even serum uric acid concentrations over 5 mg/dL may affect the prevalence of hypertension-related complications among patients with very high cardiovascular risk.

The Results of the URRAH (Uric Acid Right for Heart Health) Project: A Focus on Hyperuricemia in Relation to Cardiovascular and Kidney Disease and its Role in Metabolic Dysregulation

The relationship between Serum Uric Acid (UA) and Cardiovascular (CV) diseases has already been extensively evaluated, and it was found to be an independent predictor of all-cause and cardiovascular mortality but also acute coronary syndrome, stroke and heart failure. Similarly, also many papers have been published on the association between UA and kidney function, while less is known on the role of UA in metabolic derangement and, particularly, in metabolic syndrome. Despite the substantial number of publications on the topic, there are still some elements of doubt: (1) the better cut-off to be used to refine CV risk (also called CV cut-off); (2) the needing for a correction of UA values for kidney function; and (3) the better definition of its role in metabolic syndrome: is UA simply a marker, a bystander or a key pathological element of metabolic dysregulation?. The Uric acid Right for heArt Health (URRAH) project was designed by the Working Group on uric acid and CV risk of the Italian Society of Hypertension to answer the first question. After the first papers that individuates specific cut-off for different CV disease, subsequent articles have been published responding to the other relevant questions. This review will summarise most of the results obtained so far from the URRAH research project.

Serum Uric Acid Predicts All-Cause and Cardiovascular Mortality Independently of Hypertriglyceridemia in Cardiometabolic Patients without Established CV Disease: A Sub-Analysis of the URic acid Right for heArt Health (URRAH) Study

High serum uric acid (SUA) and triglyceride (TG) levels might promote high-cardiovascular risk phenotypes across the cardiometabolic spectrum. However, SUA predictive power in the presence of normal and high TG levels has never been investigated. We included 8124 patients from the URic acid Right for heArt Health (URRAH) study cohort who were followed for over 20 years and had no established cardiovascular disease or uncontrolled metabolic disease. All-cause mortality (ACM) and cardiovascular mortality (CVM) were explored by the Kaplan-Meier estimator and Cox multivariable regression, adopting recently defined SUA cut-offs for ACM (≥4.7 mg/dL) and CVM (≥5.6 mg/dL). Exploratory analysis across cardiometabolic subgroups and a sensitivity analysis using SUA/serum creatinine were performed as validation. SUA predicted ACM (HR 1.25 [1.12-1.40], p < 0.001) and CVM (1.31 [1.11-1.74], p < 0.001) in the whole study population, and according to TG strata: ACM in normotriglyceridemia (HR 1.26 [1.12-1.43], p < 0.001) and hypertriglyceridemia (1.31 [1.02-1.68], p = 0.033), and CVM in normotriglyceridemia (HR 1.46 [1.23-1.73], p < 0.001) and hypertriglyceridemia (HR 1.31 [0.99-1.64], p = 0.060). Exploratory and sensitivity analyses confirmed our findings, suggesting a substantial role of SUA in normotriglyceridemia and hypertriglyceridemia. In conclusion, we report that SUA can predict ACM and CVM in cardiometabolic patients without established cardiovascular disease, independent of TG levels.

Hyperuricemia increases the risk of cardiovascular mortality associated with very high HdL-cholesterol level

BACKGROUND AND AIMS

Whether the association between very high HDL-cholesterol levels and cardiovascular mortality (CVM) is modulated by some facilitating factors is unclear. Aim of the study was to investigate whether the risk of CVM associated with very high HDL-cholesterol is increased in subjects with hyperuricemia.

METHODS AND RESULTS

Multivariable Cox analyses were made in 18,072 participants from the multicentre URRAH study stratified by sex and HDL-cholesterol category. During a median follow-up of 11.4 years there were 1307 cases of CVM. In multivariable Cox models a J-shaped association was found in the whole population, with the highest risk being present in the high HDL-cholesterol group [>80 mg/dL, adjusted hazard ratio (HR), 1.28; 95%CI, 1.02-1.61; p = 0.031)]. However, a sex-specific analysis revealed that this association was present only in women (HR, 1.34; 95%CI, 1.02-1.77; p = 0.034) but not in men. The risk of CVM related to high HDL-cholesterol was much greater in the women with high uric acid (>0.30 mmol/L, HR 1.61; 95%CI, 1.08-2.39) than in those with low uric acid (HR, 1.17; 95%CI, 0.80-1.72, p for interaction = 0.016). In women older than 70 years with hyperuricemia the risk related to high HDL-cholesterol was 1.83 (95%CI, 1.19-2.80, p < 0.005). Inclusion of BMI in the models weakened the strength of the associations.

CONCLUSION

Our data indicate that very high HDL-cholesterol levels in women are associated with CVM in a J-shaped fashion. The risk of CVM is increased by concomitant hyperuricemia suggesting that a proinflammatory/oxidative state can enhance the detrimental cardiovascular effects associated with high HDL-cholesterol.

Impact of febuxostat on visit-to-visit blood pressure variability: insights from the randomised PRIZE Study

Objectives

Although uric acid lowering therapies, including xanthine oxidase (XO) inhibition, may reduce the absolute level of blood pressure (BP), the effect of XO inhibition on BP variability is largely unknown. The aim of the present analysis was to evaluate the impact of febuxostat, an XO inhibitor, on BP variability in a randomised trial setting.

Methods

This was a subanalysis of the PRIZE Study, a randomised trial to evaluate the potential effect of febuxostat on carotid intima–media thickness progression. Patients with hyperuricemia and carotid plaques were randomly assigned to the febuxostat or control group. During a 24-month period, office BP and pulse rate (PR) were measured ≥3 times. BP and PR variabilities were assessed with SD and coefficient of variation (CV). The effect of febuxostat on BP and PR variabilities was adjusted with age, sex and baseline BP or PR, expressed with 95% CIs.

Results

A total of 472 patients were included into the present subanalysis. During the 24-month follow-up period, the febuxostat group had a significantly lower adjusted mean systolic BP (128.4 (126.8–130.0) vs 130.7 (129.1–132.2) mm Hg, p=0.04) and CV of systolic BP (7.4 (6.7–8.0) vs 8.2 (7.6–8.8), p=0.04) than the control group. Adjusted SD of PR was also lower in the febuxostat group than their counterpart (5.95 (4.93–6.97) vs 7.33 (6.32–8.33), p=0.04).

Conclusion

XO inhibition with febuxostat was associated with reduced visit-to-visit BP variability as well as reduced PR variability in patients with hyperuricemia and carotid plaques.

Trial registration numbers

University Hospital Medical Information Network Clinical Trial Registry (UMIN000012911 and UMIN000041322).

Serum uric acid levels threshold for mortality in diabetic individuals: The URic acid Right for heArt Health (URRAH) project

BACKGROUND AND AIM

The URRAH (URic acid Right for heArt Health) Study has identified cut-off values of serum uric acid (SUA) predictive of total mortality at 4.7 mg/dl, and cardiovascular (CV) mortality at 5.6 mg/dl. Our aim was to validate these SUA thresholds in people with diabetes.

METHODS AND RESULTS

The URRAH subpopulation of people with diabetes was studied. All-cause and CV deaths were evaluated at the end of follow-up. A total of 2570 diabetic subjects were studied. During a median follow-up of 107 months, 744 deaths occurred. In the multivariate Cox regression analyses adjusted for several confounders, subjects with SUA ≥5.6 mg/dl had higher risk of total (HR: 1.23, 95%CI: 1.04-1.47) and CV mortality (HR:1.31, 95%CI:1.03-1.66), than those with SUA <5.6 mg/dl. Increased all-cause mortality risk was shown in participants with SUA ≥4.7 mg/dl vs SUA below 4.7 mg/dl, but not statistically significant after adjustment for all confounders.

CONCLUSIONS

SUA thresholds previously proposed by the URRAH study group are predictive of total and CV mortality also in people with diabetes. The threshold of 5.6 mg/dl can predict both total and CV mortality, and so is candidate to be a clinical cut-off for the definition of hyperuricemia in patients with diabetes.