Metabolic Syndrome-Associated Risk Factors and High-Sensitivity C-Reactive Protein Independently Predict Arterial stiffness in 9903 Subjects With and Without Chronic Kidney Disease

Early Serum Biomarkers of Cardiovascular Disease in Elderly Patients with Chronic Kidney Disease

BACKGROUND

The global population is aging. It is estimated that by 2050, the proportion of the elderly population will reach 16%. Various studies have suggested that elderly people have a greater incidence of CKD. These elderly patients are also susceptible to cardiovascular disease (CVD), which is the leading cause of death, resulting in poor prognosis in this population. However, CVD in such patients is often insidious and lacks early markers for effective evaluation. Fortunately, several studies have recently proposed biomarkers associated with this process.

SUMMARY

This study aimed to summarize the early biomarkers of CVD in elderly patients with CKD to provide a basis for its prevention and treatment.

KEY MESSAGES

This review outlines four categories of potential early biomarkers. All of them have been shown to have some clinical value for these patients, but more research is still needed.

YAP Targets the TGFβ Pathway to Mediate High-Fat/High-Sucrose Diet-Induced Arterial Stiffness

BACKGROUND

Metabolic syndrome is related to cardiovascular diseases, which is attributed in part, to arterial stiffness; however, the mechanisms remain unclear. The present study aimed to investigate the molecular mechanisms of metabolic syndrome-induced arterial stiffness and to identify new therapeutic targets.

METHODS

Arterial stiffness was induced by high-fat/high-sucrose diet in mice, which was quantified by Doppler ultrasound. Four-dimensional label-free quantitative proteomic analysis, affinity purification and mass spectrometry, and immunoprecipitation and GST pull-down experiments were performed to explore the mechanism of YAP (Yes-associated protein)-mediated TGF (transforming growth factor) β pathway activation.

RESULTS

YAP protein was upregulated in the aortic tunica media of mice fed a high-fat/high-sucrose diet for 2 weeks and precedes arterial stiffness. Smooth muscle cell-specific YAP knockdown attenuated high-fat/high-sucrose diet-induced arterial stiffness and activation of TGFβ-Smad2/3 signaling pathway in arteries. By contrast, Myh11Cre^ERT2-Yap^Tg mice exhibited exacerbated high-fat/high-sucrose diet-induced arterial stiffness and enhanced TGFβ-activated Smad2/3 phosphorylation in arteries. PPM1B (protein phosphatase, Mg²⁺/Mn²⁺-dependent 1B) was identified as a YAP-bound phosphatase that translocates into the nucleus to dephosphorylate Smads in response to TGFβ. This process was inhibited by YAP through removal of the K63-linked ubiquitin chain of PPM1B at K326.

CONCLUSIONS

This study provides a new mechanism by which smooth muscle cell YAP regulates the TGFβ pathway and a potential therapeutic target in metabolic syndrome-associated arterial stiffness.

The association between cumulative C-reactive protein and brachial-ankle pulse wave velocity

BACKGROUND AND AIMS

This study aimed to investigate the association between cumulative C-reactive protein (cumCPR) and arterial stiffness.

METHODS

The cross-sectional study included 15,432 participants from the Kailuan Cohort. The participants were divided into four groups according to cumCRP quartiles. The average brachial-ankle pulse wave velocity (baPWV) and detective rate of increased arterial stiffness were compared between exposure groups. Statistical analysis was performed with multiple logistic regression analysis to estimate the association between cumCRP and arterial stiffness by calculating the odds ratios (ORs) and 95% confidence intervals (CIs). The several sensitivity analyses were performed to test the robustness of our findings.

RESULTS

The average baPWV increased from 1425.70 cm/s of Q1 group to 1626.48 cm/s of Q4 group. And the detective rate of arterial stiffness increased from 44.7 to 70.1% (P < 0.001). Multiple logistic regression analysis showed that after adjusting the confounding factors, compared to the Q1 group, the Q4 group had 42% (adjusted OR 1.42; 95% CI 1.24-1.63) higher arterial stiffness risk. In addition, 10% (adjusted OR 1.10; 95% CI 1.02-1.18) arterial stiffness risk was increased per 1 standard deviation (SD) of cumCRP after a fully adjusted regression model.

CONCLUSION

Higher cumCRP exposure is associated with increased arterial stiffness.

Risk stratification based on J-ACCESS risk models with myocardial perfusion imaging: Risk versus outcomes of patients with chronic kidney disease

BACKGROUND

This study aimed to validate the accuracy of major-event risk models created in the multicenter J-ACCESS prognostic study in a new cohort of patients with chronic kidney disease (CKD).

METHODS AND RESULTS

Three multivariable J-ACCESS risk models were created to predict major cardiac events (cardiac death, non-fatal acute coronary syndrome, and severe heart failure requiring hospitalization): Model 1, four variables of age, summed stress score, left ventricular ejection fraction and diabetes; Model 2 with five variables including estimated glomerular filtration rate (eGFR, continuous); and Model 3 with categorical eGFR. The validation data used three-year (3y) cohort of patients with CKD (n = 526, major events 11.2%). Survival analysis of low (< 3%/3y), intermediate (3% to 9%/3y), and high (> 9%/3y)-risk groups showed good stratification by all three models (actual event rates: 3.1%, 9.9%, and 15.9% in the three groups with eGFR ≥ 15 mL/min/1.73 m2, P = .0087 (Model 2). However, actual event rates were equally high across all risk groups of patients with eGFR < 15 mL/min/1.73 m2.

CONCLUSION

The J-ACCESS risk models can stratify patients with CKD and eGFR ≥ 15 mL/min/1.73 m2, but patients with eGFR < 15 mL/min/1.73 m2 are potentially at high risk regardless of estimated risk values.

Prognostic study of cardiac events in Japanese patients with chronic kidney disease using ECG-gated myocardial Perfusion imaging: Final 3-year report of the J-ACCESS 3 study

BACKGROUND

Myocardial perfusion imaging (MPI) is considered useful for risk stratification among patients with chronic kidney disease (CKD), without renal deterioration by contrast media.

METHODS AND RESULTS

The Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J-ACCESS 3) is a multicenter, prospective cohort study investigating the ability of MPI to predict cardiac events in 529 CKD patients without a definitive coronary artery disease. All patients were assessed by stress and rest MPI with 99mTc-tetrofosmin and data were analyzed using a defect scoring method and QGS software. Major cardiac events were analyzed for 3 years after registration. The mean eGFR was 29.0 ± 12.8 (mL/minute/1.73 m2). The mean summed stress/rest/difference (SSS, SRS, SDS) scores were 1.9 ± 3.8, 1.1 ± 3.0, and 0.8 ± 1.8, respectively. A total of 60 cardiac events (three cardiac deaths, six sudden deaths, five nonfatal myocardial infarctions, 46 hospitalization cases for heart failure) occurred. The event-free survival rate was lower among patients with kidney dysfunction, higher SSS, and higher CRP values. Multivariate Cox regression analysis independently associated SSS ≥8, eGFR <15 (mL/minute/1.73 m2), and CRP ≥0.3 (mg/dL) with cardiac events.

CONCLUSIONS

Together with eGFR and CRP, MPI can predict cardiac events in patients with CKD.

In HCV-related liver cirrhosis, local pulse wave velocity increases and in decompensated patients correlates with poorer survival

BACKGROUND

Cirrhotic cardiomyopathy (CCM) refers to cardiac dysfunction in patients with liver cirrhosis, in the absence of other known cardiac disease.

METHODS

Control group and patients diagnosed of liver cirrhosis without known cardiac disease or hepatocellular carcinoma were enrolled for this clinical observation study. Patients with diabetes mellitus, hypertension were excluded. Absolute global longitudinal strain, one-point carotid pulse wave velocity (one-point PWV) and various parameters were measured in resting status.

RESULTS

There were 29 participants in the control group and 80 patients in the liver cirrhosis group. 27.8% of cirrhotic patients presented with normal systolic but abnormal diastolic functions and QTc prolongation that were compatible with CCM. 34.2% of cirrhotic patients presented with diastolic dysfunction in resting state comparing to 24.1% in control group. Systolic functions did not show conspicuous difference between cirrhosis and control group nor between compensated and decompensated cirrhosis, neither. Furthermore, one-point PWV was significantly higher in liver cirrhosis than in control group and higher in CCM than in non-CCM patients. One-point PWV predicted CCM and diastolic dysfunction in cirrhosis. Most importantly, its value > 1370cm/s predicted overall mortalities in decompensated cirrhosis (multivariable Cox analysis OR = 6.941) in addition to CTP score specifically in HCV related cirrhotic patients (AUC = 0.817).

CONCLUSIONS

In patients with cirrhosis, 27.8% were diagnosed with CCM by resting cardiovascular parameters. One-point PWV increased in CCM, correlated with diastolic dysfunction. It also correlated with overall mortality in patients with hepatitis C virus (HCV) related decompensated cirrhosis. Further study may be needed to confirm its capability for assessing CV and mortality risks in HCV related decompensated cirrhotic patients.

Enhanced ventricular-arterial coupling during a 2-year physical activity programme in patients with rheumatoid arthritis: a prospective substudy of the physical activity in rheumatoid arthritis 2010 trial

OBJECTIVE

To establish how guided physical activity in patients with rheumatoid arthritis (RA) without known cardiovascular disease affected vascular and cardiac function, and how these two entities were prospectively interconnected in this patient group.

METHODS

Prospective substudy of 29 participants in the Physical Activity in RA (PARA) 2010 trial. All subjects were examined at baseline, at year 1 and 2 with measures of pulse wave velocity and arterial augmentation index, as well as echocardiographic evaluation of diastolic parameters and ventricular-arterial coupling. Muscle strength and aerobic exercise capacity were assessed at baseline and yearly. All participants performed physiotherapist-guided aerobic and muscle strength exercise during 2 years and were reminded through SMS to report physical activity progress.

RESULTS

This cohort of patients with RA exhibited increased vascular stiffness despite normal blood pressure. At baseline, lower muscle strength was associated with increased vascular stiffness (β = 0.68; P = 0.004), whereas lower aerobic working capacity was associated with left ventricular diastolic dysfunction (β = 0.85; P = 0.03). There was a significant positive correlation between vascular stiffness and diastolic dysfunction at baseline (R²  = 0.64) and for the changes in those parameters observed during 2 years of guided physical activity. Finally, a significant improvement in ventricular-arterial coupling was observed after exercise (P < 0.001).

CONCLUSION

These results indicate that although differentially associated with physical capacity parameters, improved vascular stiffness and improved diastolic dysfunction are interrelated, and that an optimization of the ventricular-arterial coupling may contribute to the beneficial effects of physical activity in patients with RA.

Metabolic syndrome positively correlates with the risks of atherosclerosis and diabetes in a Chinese population

BACKGROUND

Published studies seldom tested the weight of different waist circumference (WC) cut-off values for the diagnosis of metabolic syndrome (MetS) in predicting clinical outcomes, including cardiovascular disease and diabetes.

METHODS

This is a Chinese population-based cross-sectional study screening subjects from a Health Examination Program since 1999 to 2015. The MetS identification and scores were determined either according to the Adult Treatment Panel III/American Heart Association/National Heart, Lung, and Blood Institute (ATP III/AHA/NHLBI)- or Asian-WC cut-off points. The developments of a higher brachial-ankle pulse wave velocity (baPWV), defined as ≥1400 cm/s, and diabetic-level hyperglycemia, defined as a high fasting glucose level ≥6.99 mmol/L or postprandial glucose level ≧11.10 mmol/L, were surveyed by comparing the areas under receiver operating characteristic curves (AUC-ROC) for both MetS scores.

RESULTS

According to the ATP III/AHA/NHLBI- vs Asian-MetS criteria, 6633 vs 9133 (24.8% vs 34.2%, p < 0.001) subjects were diagnosed as the MetS among 26,735 study subjects with a mean age of 55 ± 12 years. The stepwise increases in baPWV and prevalence of diabetic-level hyperglycemia were associated with both MetS scores after adjusting for age and sex. Both MetS scores yielded similar results for correlation with a higher baPWV (AUC-ROC = 0.685 for ATP III/AHA/HLBI- vs 0.680 for Asian-MetS, p = 0.271) and diabetic-level hyperglycemia (AUC-ROC = 0.791 for ATP III/AHA/HLBI- vs 0.784 for Asian-MetS, p = 0.546).

CONCLUSIONS

In a stepwise manner, both ATP III/AHA/NHLBI- or Asian-MetS scores were strong risk factors for arterial stiffness and diabetes. Through a novel and holistic approach, the performance of the ATP III/AHA/NHLBI-MetS score for the risks of arterial stiffness and diabetes was comparable to the Asian-MetS score among a Chinese population.

Serum leptin is a predictor for central arterial stiffness in hypertensive patients

AIM

Serum adipokines have a role in the development of arterial stiffness. We aimed to investigate the risk factors of developing arterial stiffness and the association of leptin and arterial stiffness in hypertensive (HTN) patients.

METHODS

There were 101 HTN patients enrolled. Fasting blood samples and baseline characteristics were obtained and carotid-femoral pulse wave velocity (cfPWV) was measured with the SphygmoCor system. A cfPWV > 10 m/s was defined as high arterial stiffness, and ≤ 10 m/s as low arterial stiffness.

RESULT

Forty-seven patients (46.5 %) had high arterial stiffness, and had a higher percentage of diabetes (P = 0.044), , older age (P < 0.001), higher pulse pressure (P = 0.049), and higher serum blood urea nitrogen (P = 0.029), creatinine (P = 0.027), intact parathyroid hormone (P = 0.004), serum leptin level (P = 0.002), C-reactive protein (P < 0.001), but lower estimated glomerular filtration rate (P = 0.006) compared to patients with low arterial stiffness. After adjusting for factors significantly associated with arterial stiffness by multivariate logistic regression analysis, it revealed that leptin (aOR = 1.037, 95% CI = 1.007-1.067, P = 0.014), having DM (aOR = 4.885, 95% CI = 1.590-15.006, P = 0.006), and elevated CRP (aOR = 1.503, 95% CI = 1.110-2.0371,P = 0.009) were significant independent predictors of arterial stiffness in HTN patients.

CONCLUSIONS

Serum leptin level could be a predictor for arterial stiffness in HTN patients.

A comparison of different definitions of metabolic syndrome for the risks of atherosclerosis and diabetes

BACKGROUND

The reported outcomes of the metabolic syndrome (MetS), containing atherosclerotic cardiovascular disease and diabetes, vary according to the definitions used. This study was designed to compare the performance of the Adult Treatment Panel III/American Heart Association/National Heart, Lung, and Blood Institute (ATP III/AHA/NHLBI) and International Diabetes Federation (IDF) criteria for the risks of atherosclerosis and diabetes.

METHODS

We sifted subjects from a self-paid Health examination program from 1999 to 2015 in this cross-sectional population-based study. On the basis of the ATP III/AHA/NHLBI and IDF criteria, the MetS diagnosis and scores were concluded. A brachial-ankle pulse wave velocity (baPWV) more than or equal to 1400 cm/s indicated more severe arterial stiffness, and a high fasting glucose level more than or equal to 6.99 mmol/L or postprandial glucose level more than or equal to 11.10 mmol/L indicated diabetic-level hyperglycemia. Comparisons of the areas under receiver operating characteristic curves (AUC-ROC) for both MetS scores to correlate with a higher baPWV and diabetic-level hyperglycemia were evaluated.

RESULTS

In the 26,735 enrolled subjects with an average age of 55 (± 12) years, 6633 and 7388 (24.8% vs. 27.6%, p < 0.001) were classified as having MetS on the basis of the ATP III/AHA/NHLBI and IDF criteria, respectively. The AUC-ROC for the ATP III/AHA/NHLBI-MetS score were higher than those for the IDF-MetS score (0.685 vs. 0.595 to correlate with a higher baPWV, p < 0.001; 0.791 vs. 0.665 to correlate with diabetic-level hyperglycemia, p < 0.001).

CONCLUSIONS

To the best of our knowledge, this is the first study to demonstrate that through a holistic approach, the performance of the ATP III/AHA/NHLBI-MetS score for the risks of atherosclerosis and diabetes was superior to the IDF-MetS score for Asians.

Insulin resistance and associated factors: a cross-sectional study of bank employees

OBJECTIVE:

Insulin resistance is characterized by the failure of target cells to respond to normal levels of circulating insulin, and this condition is related to cardiovascular disease. This study sought to evaluate the prevalence of insulin resistance and its association with markers of metabolic abnormalities and metabolic syndrome in bank employees.

METHODS:

A cross-sectional study was performed on 498 working men and women aged ≥20 years old. The Homeostasis Model Assessment (HOMA-IR) was used to determine the presence of insulin resistance based on cut-off values of ≤2.71 for normal insulin levels and >2.71 for insulin resistance, as established for the adult Brazilian population.

RESULTS:

It was observed that the 52 (10.4%) overweight individuals with insulin resistance were 4.97 times (95%CI 1.31-18.83) more likely to have high HOMA-IR values than the normal-weight participants; among those who were obese, the likelihood increased to 17.87 (95%CI 4.36-73.21). Individuals with large waist circumferences were 3.27 times (95%CI 1.03-10.38) more likely to develop insulin resistance than those who were within normal parameters. The HOMA-IR values differed between subjects with and without metabolic syndrome, with values of 2.83±2.5 and 1.10±0.81 (p=0.001), respectively. The levels of insulin, ultrasensitive C-reactive protein and uric acid were also associated with insulin resistance.

CONCLUSION:

The prevalence of insulin resistance among bank employees is high, and insulin resistance is associated with and serves as a marker of metabolic syndrome. Cardiovascular disease and metabolic syndrome-associated metabolic abnormalities were observed, and insulin resistance may be a risk factor in this group of professionals.

High Ambulatory Arterial Stiffness Index Is an Independent Risk Factor for Rapid Age-Related Glomerular Filtration Rate Decline in the General Middle-Aged Population

Arterial stiffness is a risk factor for cardiovascular and chronic kidney disease. However, the role of arterial stiffness as a predictor of the age-related glomerular filtration rate (GFR) decline in the general population remains unresolved because of difficulty in measuring GFR with sufficient precision in epidemiological studies. The ambulatory arterial stiffness index (AASI) is a proposed indicator of arterial stiffness easily calculated from ambulatory blood pressure. We investigated whether AASI could predict GFR decline measured as iohexol clearance in the general population. We calculated AASI from baseline ambulatory blood pressure and measured the iohexol clearance at baseline and follow-up in the RENIS-FU study (Renal Iohexol Clearance Survey Follow-Up). AASI was defined as 1 minus the regression slope of the diastolic blood pressure measurement over the systolic blood pressure measurement for each patient. The RENIS cohort included a representative sample of the general middle-aged population without baseline diabetes mellitus, cardiovascular disease, or kidney disease (n=1608). The participant age was 50 to 62 years old at baseline, and the median observation time was 5.6 years. The mean (SD) of the GFR decline rate was 0.95 mL/min per year (2.23) and that of the AASI was 0.38 mL/min per year (0.13). Baseline ambulatory blood pressure or the night/day systolic or diastolic ambulatory blood pressure ratios were not associated with GFR decline. In multivariable-adjusted linear mixed regression analysis, 1 SD of increase in the baseline AASI was associated with a 0.14 mL/min per year (95% confidence interval, -0.26 to -0.02) steeper GFR decline. We conclude that the AASI is an independent risk factor for accelerated age-related GFR decline in the general middle-aged population.

Vital roles of age and metabolic syndrome-associated risk factors in sex-specific arterial stiffness across nearly lifelong ages: Possible implication of menopause and andropause

BACKGROUND AND AIMS

Postmenopausal status is correlated with increased metabolic syndrome (MetS) and cardiovascular risks. However, the vital roles of age and MetS-associated risk factors in sex-specific arterial stiffness remain unclear.

METHODS

In this population-based cross-sectional study of the general population, we enrolled in our Health Examination Program 9812 adult participants who were measured for brachial-ankle pulse wave velocity (baPWV) to assess arterial stiffness. Piecewise linear regression models were used to survey pre-defined ages associated with menopause and andropause in relation to arterial stiffness. Multivariate linear regression analyses were used to evaluate independent determinants.

RESULTS

Across gender, stepwise increases in baPWV corresponded to increased MetS-associated risk scores (MetSRS) and aging (all p for trend < 0.001), while a turning point was found at 50 years of age (50age). The incremental ratios of baPWV presented inverse U curves with aging, whereas the highest R² values and incremental ratios of baPWV were found at 50age across gender. Comparing men with women, a 1.4-fold higher incremental ratio of baPWV was observed before 50age, compared to a 1.3-fold after 50age, respectively. MetS risk group and over 50age were associated with stepwise increased baPWV across gender (both p for trend < 0.001). Before 50age, the determinants did not include hs-CRP for women compared with men, while MetSRS was lost as a determinant across gender. In contrast with men, in women after 50age, HDL-C was an additional determinant and triglyceride was not, while MetSRS remained a determinant across gender.

CONCLUSIONS

Arterial stiffness increased with aging across nearly lifelong ages more in women than in men. While menopause and andropause may both play a role, 50age was the most critical factor across gender. The sex-specific differences in determinants of arterial stiffness may remind us of sex-specific targets for further interventional studies associated with arterial stiffness.

Salusins and adropin: New peptides potentially involved in lipid metabolism and atherosclerosis

Dyslipidemia is one of the most potent risk factors for the development of atherosclerosis. The high atherosclerotic risk in dyslipidemic patients is associated with endothelial dysfunction. During the last two decades, novel bioactive peptides have emerged as potential biomarkers of endothelial dysfunction and dyslipidemia-salusins and adropin. Salusin-alpha is likely to prevent atherosclerosis, while salusin-beta may act as a potential proatherogenic factor. Adropin was recently identified as important for energy homeostasis and lipid metabolism. Adropin is closely related to the inhibition of atherosclerosis by up-regulation of the endothelial nitric oxide synthase expression through the vascular endothelial growth factor receptor-2. These peptides represent a novel target to limit diseases characterized by endothelial dysfunction and may form the basis for the development of new therapeutic agents for treating metabolic disorders associated with atherosclerosis.

Can milk proteins be a useful tool in the management of cardiometabolic health? An updated review of human intervention trials

The prevalence of cardiometabolic diseases is a significant public health burden worldwide. Emerging evidence supports the inverse association between greater dairy consumption and reduced risk of cardiometabolic diseases. Dairy proteins may have an important role in the favourable impact of dairy on human health such as blood pressure (BP), blood lipid and glucose control. The purpose of this review is to update and critically evaluate the evidence on the impacts of casein and whey protein in relation to metabolic function. Evidence from short-term clinical studies assessing postprandial responses to milk protein ingestion suggests benefits on vascular function independent of BP, as well as improvement in glycaemic homeostasis. Long-term interventions have been less conclusive, with some showing benefits and others indicating a lack of improvement in vascular function. During chronic consumption BP appears to be lowered and both dyslipidaemia and hyperglacaemia seem to be controlled. Limited number of trials investigated the effects of dairy proteins on oxidative stress and inflammation. Although the underlying mechanisms of milk proteins on cardiometabolic homeostasis remains to be elucidated, the most likely mechanism is to improve insulin resistance. The incorporation of meals enriched with dairy protein in the habitual diet may result in the beneficial effects on cardiometabolic health. Nevertheless, future well-designed, controlled studies are needed to investigate the relative effects of both casein and whey protein on BP, vascular function, glucose homeostasis and inflammation.