Circulating Markers of Liver Function and Cardiovascular Disease Risk

Adding traditional and emerging biomarkers for risk assessment in secondary prevention: a prospective cohort study of 20 656 patients with cardiovascular disease

AIMS

This study aims to explore whether conventional and emerging biomarkers could improve risk discrimination and calibration in the secondary prevention of recurrent atherosclerotic cardiovascular disease (ASCVD), based on a model using predictors from SMART2 (Secondary Manifestations of ARTerial Disease).

METHODS AND RESULTS

In a cohort of 20 658 UK Biobank participants with medical history of ASCVD, we analysed any improvement in C indices and net reclassification index (NRI) for future ASCVD events, following addition of lipoprotein A (LP-a), apolipoprotein B, Cystatin C, Hemoglobin A1c (HbA1c), gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), alanine aminotransferase, and alkaline phosphatase (ALP), to a model with predictors used in SMART2 for the outcome of recurrent major cardiovascular event. We also examined any improvement in C indices and NRIs replacing creatinine-based estimated glomerular filtration rate (eGFR) with Cystatin C-based estimates. Calibration plots between different models were also compared. Compared with the baseline model (C index = 0.663), modest increments in C indices were observed when adding HbA1c (ΔC = 0.0064, P < 0.001), Cystatin C (ΔC = 0.0037, P < 0.001), GGT (ΔC = 0.0023, P < 0.001), AST (ΔC = 0.0007, P < 0.005) or ALP (ΔC = 0.0010, P < 0.001) or replacing eGFRCr with eGFRCysC (ΔC = 0.0036, P < 0.001) or eGFRCr-CysC (ΔC = 0.00336, P < 0.001). Similarly, the strongest improvements in NRI were observed with the addition of HbA1c (NRI = 0.014) or Cystatin C (NRI = 0.006) or replacing eGFRCr with eGFRCr-CysC (NRI = 0.001) or eGFRCysC (NRI = 0.002). There was no evidence that adding biomarkers modified calibration.

CONCLUSION

Adding several biomarkers, most notably Cystatin C and HbA1c, but not LP-a, in a model using SMART2 predictors modestly improved discrimination.

The G allele of the rs4344 polymorphism of the angiotensin-converting enzyme gene is associated with alanine aminotransferase (ALT) and gamma glutamyl transferase (GGT) in Brazilian hypertensive patients

BACKGROUND

The association of genetic variants and environmental factors contribute to increased susceptibility to arterial hypertension (AH). Polymorphisms of the angiotensin-converting enzyme (ACE) gene have been identified as a genetic risk factor related to blood pressure (BP) levels and liver function, since they influence the renin-angiotensin-aldosterone system (RAAS).

OBJECTIVE

To evaluate the influence of the rs4344 polymorphism of the ACE gene on AH and biochemical parameters of liver function (ALT, AST, GGT and ALP) in normotensive and hypertensive patients.

METHOD AND RESULTS

The identification of the polymorphism was performed by qPCR, using the TaqMan® system, in 811 individuals (484 normotensive and 327 hypertensive) and biochemical dosages (AST, ALT, GGT and ALP) were performed by UV/Vis spectrophotometry. A univariate logistic regression model was used to identify factors associated with hypertension and Pearson's chi-square test to assess allele frequency between groups. A multivariate logistic regression model was used to correct confounding factors and assess the association of the variant with hypertension. Data normality was assessed using the Shapiro-Wilk test. Continuous nonparametric variables were expressed as median and interquartile range and analyzed using the Mann-Whitney test and parametric data were expressed as mean and standard deviation and analyzed by unpaired Student's t test. The rs4344 variant was not linked to hypertension in the individuals examined. However, concerning liver function marker enzymes, the G allele was associated with increased levels of GGT and ALT in hypertensive patients.

CONCLUSIONS

Our findings indicated that the rs4344 variant of the ACE gene is linked to impaired liver function in hypertensive individuals.

Associations between Life's Essential 8 and liver function: a cross-sectional study

Background

Life's Essential 8 (LE8) score, developed by the American Heart Association, assesses cardiovascular health using eight components: diet, physical activity, nicotine exposure, sleep health, body mass index, lipids, blood glucose, and blood pressure. Liver function is a critical indicator of overall health, with impairments linked to numerous chronic diseases. While the LE8 score has been extensively studied in relation to cardiovascular outcomes, its association with liver function remains underexplored. Understanding this relationship is crucial for integrating cardiovascular and hepatic health management, particularly given the shared metabolic pathways underlying these systems. This study aims to examine the relationship between LE8 scores and liver function indicators in a large cohort, addressing a critical gap in understanding the interplay between cardiovascular and liver health.

Methods

Data from the 2007-2018 National Health and Nutrition Examination Survey (NHANES) were used in this cross-sectional study. The study included 21,873 participants, stratified into low (0-49), moderate (50-79), and high (80-100) LE8 score categories. The relationship between LE8 scores and liver function markers, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and ALT/AST ratio, was evaluated using multivariable linear regression, smoothed curve fitting, threshold effect analysis, and weighted quantile sum (WQS) regression. Subgroup analyses were performed based on sex and age to assess potential interactions.

Results

Higher LE8 scores were significantly associated with improved liver function, particularly highlighted by two major findings. First, nonlinear associations were observed between LE8 scores and liver function parameters, including ALT and ALT/AST ratio, with stronger effects beyond specific thresholds (ALT: 50.625, ALT/AST: 61.875). Second, subgroup analyses revealed that these associations were more pronounced in younger participants (<60 years), suggesting age-specific differences in the relationship. These age-related differences might be attributed to variations in metabolic function or differences in the severity of cardiovascular and liver-related risk factors between younger and older individuals. WQS regression identified body mass index, blood pressure, blood glucose, and nicotine exposure as the strongest contributors to liver function markers. These findings underscore the potential of LE8 scores as a comprehensive indicator for liver health, particularly in younger populations.

Conclusion

This study suggests that LE8 scores is associated with improved liver function. Clinicians and public health practitioners could consider integrating LE8 scores into routine assessments to help identify individuals at risk for liver dysfunction, particularly among younger populations. Further research should explore whether interventions targeting cardiovascular health could also improve liver function outcomes.

Hepatic T1-time, cardiac structure and function and cardiovascular outcomes in patients with dilated cardiomyopathy

AIM

Liver damage frequently occurs in patients with cardiovascular (CV) disease and is associated with adverse clinical outcomes. The associations of liver damage with cardiac structure/function measures and the risk of adverse CV events in patients with dilated cardiomyopathy (DCM) are poorly known.

METHODS

We retrospectively enrolled consecutive patients with DCM undergoing cardiac magnetic resonance imaging (MRI). In addition to standard cardiac assessment, iron-corrected T1 mapping was also assessed in the liver. Cross-sectional associations between hepatic T1-time and cardiac structure and function were examined accounting for potential confounders. Longitudinal associations between hepatic T1-time and the risk of hospitalization for HF or CV death were also assessed.

RESULTS

Overall, 120 stable patients with established DCM were included in the study (mean age 54.7 years, 26 % women). The mean hepatic iron-corrected T1-time was 563±73 ms. In linear regression analyses, measures of left atrial structure (LA maximal volume, p = 0.035, LA minimal volume=0.012), interventricular septum thickness (p = 0.026), and right ventricular ejection fraction (p = 0.005) were significantly associated with greater hepatic T1-time. Over a mean follow-up of 4.5 ± 1.8 years, 32 (27 %) died or were hospitalized for HF at a rate of 6.7 per 100 person-year. Higher hepatic iron-corrected T1-time was independently associated with a higher risk of adverse events (adjusted-hazard ratio 1.71, 95 % confidence interval: 1.14-2.56, p = 0.009). Patients with a hepatic T1-time ≥563 ms had a higher risk of CV events (log-rank p = 0.03).

CONCLUSION

Among stable patients with DCM, higher hepatic iron-corrected T1-time is associated with worse cardiac size and function and with higher rates of hospitalization for HF or CV death.

CONDENSED ABSTRACT

Limited data exist regarding the clinical value of hepatic T1-time in patients with dilated cardiomyopathy (DCM) undergoing cardiac Magnetic Resonance imaging (MRI). We found that higher hepatic iron-corrected T1-time is associated with worse cardiac size and function, even after accounting for clinical confounders. Over a mean follow-up of 4.5 ± 1.8 years, higher hepatic iron-corrected T1-time was independently associated with a higher risk of hospitalization for heart failure or cardiovascular death. Among stable patients with DCM, the evaluation of liver tissue by cardiac MRI may provide useful clinical information for CV risk stratification.

Associations between exposure to phthalates and liver function among women undergoing assisted reproductive technology

Phthalates can induce hepatotoxicity in animal studies. We aimed to assess the associations of individual and mixture of urinary phthalate metabolites with serum liver function indicators among 764 women undergoing assisted reproductive technology (ART). In linear models, we observed inverse correlations between urinary mono-benzyl phthalate and serum total protein (TP) as well as globulin (β=-0.27 and -0.23, respectively, P<0.05). Additionally, negative associations were identified between mono-isobutyl phthalate and mono-butyl phthalate (MBP) and aspartate aminotransferase-to-alanine transaminase ratio (AST/ALT) (P<0.05). MBP and the sum of all phthalate metabolites (∑all.phth.m) were positively associated with bilirubin, with β ranging from 0.14 to 0.47. Most phthalate metabolites were also positively related to gamma-glutamyl transferase (GGT) (all P<0.05). In Bayesian kernel machine regression models, phthalate mixture was positively associated with bilirubin and GGT, whereas inversely associated with AST/ALT and TP. Our results suggest that phthalate exposure may impair liver function among women undergoing ART.

Bilirubin Elevation During Hospitalization Post Radiofrequency Catheter Ablation of Persistent Atrial Fibrillation: Variation Trend, Related Factors, and Relevance to 1-Year Recurrence

Background

The role of total bilirubin (TBIL) in cardiovascular disease has been increasingly recognized in recent decades. Studies have shown a correlation between total bilirubin levels and the prognosis of patients after heart surgery. This study aimed to investigate the clinical significance of bilirubin elevation in persistent atrial fibrillation (PAF) patients who received radiofrequency catheter ablation (RFCA).

Methods and Results

A total of 184 patients with PAF who received RFCA were retrospectively studied. Laboratory examinations and demographic data were analyzed to identify independent predictors of TBIL elevation. The relationship between TBIL and prognosis was further investigated. Our results indicated that TBIL increased significantly after RFCA. Multiple linear regression analysis showed that TBIL elevation owned a negative correlation with the percentile of low voltage areas (LVAs) in left atria (β=-0.490, P<0.001). In contrast, a positive correlation was observed with the white blood cell (WBC) ratio (β=0.153, P=0.042) and left atrial diameter (LAD) (β=0.232, P=0.025). It was found that postoperative TBIL levels increased and then gradually decreased to baseline within 5 days without intervention. The bilirubin ratio <1.211 indicated the possibility of 1-year AF recurrence after ablation with a predictive value of 0.743 (specificity = 75.00%, sensitivity = 66.67%).

Conclusion

Bilirubin elevation post PAF RFCA was a common phenomenon and was associated with 1-year recurrence of AF in PAF patients after RFCA.

Assessment of the Relationship Between Liver Enzymes and Cardiovascular Disease: A Study in Bangladeshi Adults

OBJECTIVES

Elevated liver enzyme levels are suggested to be associated with an increased risk of cardiovascular disease (CVD). However, few studies have explored the relationship between liver enzymes and myocardial infarction (MI). This study aimed to evaluate the potential association of elevated liver enzymes with MI within a population group in Bangladesh.

METHODS

In this cross-sectional study, 348 participants were enrolled, 189 with MI in the CVD group and 159 in the control group. Serum levels of liver enzymes (AST, ALT and GGT) and other biochemical parameters were measured using standard methods. Multivariate logistic regression models were applied to determine the associations between elevated liver enzymes and CVD.

RESULT

In the CVD group, 51.6%, 30.9% and 67.7% of individuals had elevated serum AST, ALT and GGT levels, respectively. On the contrary, the control group had 17.0%, 15.1% and 35.2% of individuals with high serum AST, ALT and GGT levels, respectively. Overall, 71.8% of the subjects in the CVD group and 44.7% of the subjects in the control group had at least one or more elevated liver enzymes (p < 0.001). The mean level of all three liver enzymes was significantly higher in the CVD group than in the control group (p < 0.001). In both the CVD and control groups, males had higher levels of liver enzymes than females. In the regression models, the serum levels of AST, ALT and GGT showed a positive and independent association with the prevalence of CVD (p < 0.001). However, GGT showed the strongest association among the three enzymes.

CONCLUSIONS

This study shows a high prevalence of liver enzyme abnormalities in individuals with CVD. Serum levels of AST, ALT and GGT were independently associated with the prevalence of CVD. This suggests that measuring liver enzyme levels could be a useful marker in predicting CVD at an early stage.

Overall and individual associations between per- and polyfluoroalkyl substances and liver function indices and the metabolic mechanism

Per- and polyfluoroalkyl substances (PFAS) can disrupt liver homeostasis. Studies have shown that a single exposure to PFAS may provoke abnormal liver function; however, few studies have investigated the overall effect of PFAS mixtures. We aimed to investigate associations between exposure to PFAS mixtures and liver function indices and explore the relevant mechanisms. This study included 278 adult males from Guangzhou, China. Serum metabolite profiles were analyzed using untargeted metabolomics. We applied weighted quantile sum (WQS) regression as well as Bayesian kernel machine regression (BKMR) to analyze the association of nine PFAS mixtures with 14 liver function indices. PFAS mixtures were positively associated with apolipoprotein B (APOB) and gamma-glutamyltransferase (GGT) and negatively associated with direct bilirubin (DBIL) and total bilirubin (TBIL) in both the WQS and BKMR analyses. In addition, Spearman's correlation test showed individual PFAS correlated with APOB, GGT, TBIL, and DBIL, while there's little correlation between individual PFAS and other liver function indices. In linear regression analysis, PFHxS, PFOS, PFHpS, PFNA, PFDA, and PFUdA were associated with APOB; PFOA, PFDA, PFOS, PFNA, and PFUdA were associated with GGT. Subsequently, a metabolome-wide association study and mediation analysis were combined to explore metabolites that mediate these associations. The mechanisms linking PFAS to APOB and GGT are mainly related with amino acid and glycerophospholipid metabolism. High-dimensional mediation analysis showed that glycerophospholipids are the main markers of the association between PFAS and APOB, and that (R)-dihydromaleimide, Ile Leu, (R)-(+)-2-pyrrolidone-5-carboxylic acid, and L-glutamate are the main markers of the association between PFAS and GGT. In summary, overall associations between PFAS and specific indices of liver function were found using two statistical methods; the metabolic pathways and markers identified here may serve to prompt more detailed study in animal-based systems, as well as a similar detailed analysis in other populations.

Human gain-of-function variants in HNF1A confer protection from diabetes but independently increase hepatic secretion of atherogenic lipoproteins

Loss-of-function mutations in hepatocyte nuclear factor 1A (HNF1A) are known to cause rare forms of diabetes and alter hepatic physiology through unclear mechanisms. In the general population, 1:100 individuals carry a rare, protein-coding HNF1A variant, most of unknown functional consequence. To characterize the full allelic series, we performed deep mutational scanning of 11,970 protein-coding HNF1A variants in human hepatocytes and clinical correlation with 553,246 exome-sequenced individuals. Surprisingly, we found that ∼1:5 rare protein-coding HNF1A variants in the general population cause molecular gain of function (GOF), increasing the transcriptional activity of HNF1A by up to 50% and conferring protection from type 2 diabetes (odds ratio [OR] = 0.77, p = 0.007). Increased hepatic expression of HNF1A promoted a pro-atherogenic serum profile mediated in part by enhanced transcription of risk genes including ANGPTL3 and PCSK9. In summary, ∼1:300 individuals carry a GOF variant in HNF1A that protects carriers from diabetes but enhances hepatic secretion of atherogenic lipoproteins.

Association of De Ritis Ratio with Prognosis in Patients with Coronary Artery Disease and Aminotransferase Activity within and outside the Healthy Values of Reference Range

BACKGROUND

The aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (De Ritis ratio), obtained from AST and ALT activities in the healthy range, has not been studied in association with mortality.

METHODS

This study included 3392 patients with stable coronary heart disease and aminotransferase activity in the reference range. Patients are categorized into two groups: a group with AST and ALT activity in the healthy range (n = 1697), and a group with AST and/or ALT activity outside the healthy range but in the reference range (n = 1695). The primary endpoint was all-cause mortality at three years.

RESULTS

The De Ritis ratio (median 5th-95th percentile] was 0.94 [0.61-1.41] in patients with AST and ALT in the healthy range and 0.93 [0.45-1.96] in patients with AST and/or ALT outside the healthy range (p = 0.700). At three years, there were 86 deaths in patients with AST and ALT in the healthy range: 27 deaths (3.9%) in patients with a De Ritis ratio ≤median, and 59 deaths (8.2%) in patients with the De Ritis ratio >median (adjusted hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.94 to 1.42; p = 0.159); in patients with AST and/or ALT outside the healthy range, there were 148 deaths: 49 deaths (6.6%) in patients with a De Ritis ratio ≤median, and 99 deaths (14.1%) in patients with De Ritis ratio >median (adjusted HR = 1.27 [1.09-1.48], p = 0.002), with both HRs calculated per unit higher values of the De Ritis ratio.

CONCLUSIONS

The De Ritis ratio obtained from AST and ALT activity in the healthy range was not independently associated with higher risk of mortality. The De Ritis ratio obtained from aminotransferase activity outside the healthy range (but still in the reference range) was independently associated with the risk of mortality.

Longitudinal trajectory of vascular age indices and cardiovascular risk factors: a repeated-measures analysis

This study aimed to identify the modifiable cardiovascular risk factors associated with longitudinal changes, which are nine functional and structural biological vascular aging indicators (BVAIs), to propose an effective method to prevent biological vascular aging. We conducted a longitudinal study of 697 adults (a maximum of 3636 BVAI measurements) who were, at baseline, aged between 26 and 85 years and whose BVAIs were measured at least twice between 2007 and 2018. The nine BVAIs were measured using vascular testing and an ultrasound device. Covariates were assessed using validated questionnaires and devices. During the mean follow-up period of 6.7 years, the average number of BVAI measurements ranged from 4.3 to 5.3. The longitudinal analysis showed a moderate positive correlation between the common carotid intima-media thickness (IMT) and chronological age in both men (r = 0.53) and women (r = 0.54). In the multivariate analysis, BVAIs were associated with factors such as age, sex, residential area, smoking status, blood clinical chemistry test levels, number of comorbidities, physical fitness, body mass, physical activity, and dietary intake. The IMT is the most useful BVAI. Our findings suggest that modifiable cardiovascular risk factors are associated with longitudinal changes in BVAI as represented by IMT.

Prediction of obstructive coronary artery disease in patients undergoing heart valve surgery: A cross-sectional study in a tertiary care hospital

Introduction: Estimating the probability of obstructive coronary artery disease in patients undergoing noncoronary cardiac surgery should be considered compulsory. Our study sought to evaluate the prevalence of obstructive coronary artery disease in patients undergoing valvular heart surgery and to utilize predictive methodology of concomitant obstructive coronary artery disease in these patients. Methods: The retrospective study cohort was derived from a tertiary care hospital registry of patients undergoing coronary angiogram prior to valvular heart operations. Decision tree, logistic regression, and support vector machine models were built to predict the probability of the appearance of obstructive coronary artery disease. A total of 367 patients from 2016 to 2019 were analyzed. Results: The mean age of the study population was 57.3±9.3 years, 45.2% of the patients were male. Of 367 patients, 76 (21%) patients had obstructive coronary artery disease. The decision tree, logistics regression, and support vector machine models had an area under the curve of 72% (95% CI: 62% - 81%), 67% (95% CI: 56% - 77%), and 78% (95% CI: 68% - 87%), respectively. Multivariate analysis indicated that hypertension (OR 1.98; P=0.032), diabetes (OR 2.32; P=0.040), age (OR 1.05; P=0.006), and typical angina (OR 5.46; P<0.001) had significant role in predicting the presence of obstructive coronary artery disease. Conclusion: Our study revealed that approximately one-fifth of patients who underwent valvular heart surgery had concomitant obstructive coronary artery disease. The support vector machine model showed the highest accuracy compared to the other model.

The interplay between nonalcoholic fatty liver disease and atherosclerotic cardiovascular disease

Therapeutic approaches that lower circulating low-density lipoprotein (LDL)-cholesterol significantly reduced the burden of cardiovascular disease over the last decades. However, the persistent rise in the obesity epidemic is beginning to reverse this decline. Alongside obesity, the incidence of nonalcoholic fatty liver disease (NAFLD) has substantially increased in the last three decades. Currently, approximately one third of world population is affected by NAFLD. Notably, the presence of NAFLD and particularly its more severe form, nonalcoholic steatohepatitis (NASH), serves as an independent risk factor for atherosclerotic cardiovascular disease (ASCVD), thus, raising interest in the relationship between these two diseases. Importantly, ASCVD is the major cause of death in patients with NASH independent of traditional risk factors. Nevertheless, the pathophysiology linking NAFLD/NASH with ASCVD remains poorly understood. While dyslipidemia is a common risk factor underlying both diseases, therapies that lower circulating LDL-cholesterol are largely ineffective against NASH. While there are no approved pharmacological therapies for NASH, some of the most advanced drug candidates exacerbate atherogenic dyslipidemia, raising concerns regarding their adverse cardiovascular consequences. In this review, we address current gaps in our understanding of the mechanisms linking NAFLD/NASH and ASCVD, explore strategies to simultaneously model these diseases, evaluate emerging biomarkers that may be useful to diagnose the presence of both diseases, and discuss investigational approaches and ongoing clinical trials that potentially target both diseases.

Prognostic value of De Ritis ratio with aspartate aminotransferase and alanine aminotransferase within the reference range

BACKGROUND

Whether aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (De Ritis ratio) with AST and ALT activities within the reference range has prognostic value is unknown.

METHODS

This study included 3392 patients with stable coronary artery disease and AST and ALT activities within the reference range. Patients are categorized in groups according to tertiles of the De Ritis ratio: a group with De Ritis ratio in the 1st tertile (De Ritis ratio: 0.22 to 0.81; n = 1131), a group with De Ritis ratio in the 2nd tertile (De Ritis ratio: >0.81 to 1.09; n = 1130) and a group with De Ritis ratio in the 3rd tertile (De Ritis ratio: >1.09 to 3.40; n = 1131). The primary endpoint was 3-year mortality.

RESULTS

The mean value of De Ritis ratio was 1.00 ± 0.39 (range: 0.22-3.40). Overall, there were 234 deaths at 3 years: 43 deaths in patients of 1st tertile, 75 deaths in patients of 2nd tertile and 116 deaths in patients of 3rd tertile of De Ritis ratio (Kaplan-Meier estimates of 3-year mortality, 4.4 %, 7.8 % and 12.5 %, respectively; (adjusted hazard ratio = 1.24, 95 % confidence interval 1.12 to 1.38; P < 0.001 for 1 unit higher De Ritis ratio). The C-statistic of the risk prediction model for mortality with baseline demographical and clinical variables without De Ritis ratio was 0.803 [0.774-0.832] and it increased to 0.810 [0.782-0.839] after inclusion of De Ritis ratio into the model (P = 0.038).

CONCLUSIONS

An elevated De Ritis ratio with aminotransferase levels within the reference range was associated with the increased risk of mortality.

Elevated Levels of Serum Alkaline Phosphatase are Associated with Increased Risk of Cardiovascular Disease: A Prospective Cohort Study

AIM

We aimed to investigate the associations of serum alkaline phosphatase (ALP) levels with incident cardiovascular disease (CVD), coronary heart disease (CHD), and stroke, as well as their subtypes, among men and women in a prospective cohort study.

METHODS

A total of 11,408 men and 14,981 women were included to evaluate the associations between ALP levels and incident CVD. Participants were divided into four groups according to the quartiles of serum ALP levels in men and women separately. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During an average follow-up of 7.3 years, 7,015 incident CVDs (5,561 CHDs and 1,454 strokes) were documented. After adjustments for age, body mass index, smoking status, drinking status, diabetes, hyperlipidemia, hypertension, physical activity, aspirin usage, anticoagulants usage, menopausal status (women only), family history of CVD, estimated glomerular filtration rate, white blood cell counts, and admission batch and comparing the lowest quartile of ALP, the adjusted HRs (95% CIs) of participants in the highest quartile were 1.22 (1.11-1.34) for CVD, 1.14 (1.02-1.28) for CHD, 1.43 (1.18-1.73) for stroke, 1.31 (1.09-1.57) for acute coronary syndrome (ACS), 1.37 (1.11-1.70) for ischemic stroke, and 1.75 (1.10-2.79) for hemorrhagic stroke in men and 1.12 (1.01-1.23) for CVD, 1.10 (0.99-1.23) for CHD, 1.18 (0.92-1.51) for stroke, 1.23 (1.03-1.47) for ACS, 1.10 (0.83-1.45) for ischemic stroke, and 1.54 (0.90-2.65) for hemorrhagic stroke in women. The ALP-CVD associations remained significant even within the normal ranges of ALP levels (40-150 U/L). Moreover, linear dose-response relationships were found between ALP levels and incident CVD.

CONCLUSIONS

Higher ALP levels, even within the normal range, were significantly associated with increased risks of CVD, in a dose-dependent manner. These findings suggested that regular monitoring of ALP levels may help in improving the early identification of the population at higher CVD risk.

Application of the ALBI Scoring System for Mortality Outcome Prediction in Patients with Hypertrophic Cardiomyopathy

Background:

There is no information about the clinical significance of the albumin-bilirubin (ALBI) score in patients with hypertrophic cardiomyopathy (HCM).

Objective:

We retrospectively performed clinical evaluations in 462 patients with HCM to estimate whether the ALBI score could be a new tool to predict mortality in HCM.

Methods and Results:

During a median follow-up of 4.7 years, HCM-related death occurred in 52 (11.3%) patients. Overall, there was a significant positive association between ALBI score and HCM-related death (adjusted hazard ratio [HR]: 1.79 per one standard deviation [SD] increment, 95% confidence interval [CI]: 1.36–2.35). When the score was assessed as tertiles, the adjusted HRs of HCM-related death were 1.30 (95% CI: 0.42–3.99) for the tertile 2 and 4.43 (95% CI: 1.65–11.89) for the tertile 3, compared with the tertile 1. Stratified analysis and E-value analysis suggested the robustness of the above-mentioned results. Meanwhile, time-dependent ROC analysis showed ALBI score could discriminate HCM-related death at various time points (AUC ranges: 0.725–0.850). Furthermore, exploratory analysis indicated the dynamic changes of ALBI score also could predict HCM-related death. Finally, multiple linear regression analysis suggested some pathogenetic pathways associated with HCM-related adverse outcomes significantly correlated with ALBI score, and the pathways included inflammation, myocardial injury, nutritional status and some clinical characteristics, but not abnormal cardiac structure and function itself.

Conclusions:

Higher ALBI score is a strong independent predictor of HCM-related death in patients with HCM.

Liver function markers predict cardiovascular and renal outcomes in the CANVAS Program

Background

Raised liver function tests (LFTs) have been correlated with multiple metabolic abnormalities and variably associated with cardiorenal outcomes. We sought to systematically test the relationship between LFT levels within the accepted range and major cardiorenal outcomes in a large clinical trial in type 2 diabetes, and the possible impact of placebo-controlled canagliflozin treatment.

Methods

We measured serum alanine aminotransferase (ALT), aspartic aminotransferase (AST), gamma-glutamyl transferase (γGT), alkaline phosphatase (ALP), and bilirubin concentrations in 10,142 patients, at baseline and repeatedly over follow-up. The relation of LFTs to first hospitalized heart failure (HHF), cardiovascular (CV) and all-cause mortality, and progression of renal impairment was investigated using multivariate proportional-hazards models.

Results

In univariate association, ALT was reciprocally predictive, and ALP was positively predictive, of all adjudicated outcomes; γGT also was directly associated with CV—but not renal—outcomes. In multivariate models including all 5 LFTs and 19 potential clinical confounders, ALT was independently associated with lower, and γGT with higher, CV outcomes risk. Canagliflozin treatment significantly reduced ALT, AST, and γGT over time. In a fully adjusted model including updated LFT levels and treatment, γGT was independently associated with CV and all-cause mortality, ALP with renal dysfunction progression, and canagliflozin treatment with significant reduction in HHF and renal risk.

Conclusions

Higher γGT levels are top LFT markers of risk of HHF and death in patients with diabetes and high CV risk, while ALT are protective. Canagliflozin lowers the risk of HHF and renal damage independently of LFTs and potential confounders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01558-w.

The Relationship between Plasma Alpha-1-Antitrypsin Polymers and Lung or Liver Function in ZZ Alpha-1-Antitrypsin-Deficient Patients

Alpha-1-Antitrypsin (AAT) is a protein of the SERPINA1 gene. A single amino acid mutation (Lys342Glu) results in an expression of misfolded Z-AAT protein, which has a high propensity to intra- and extra-cellular polymerization. Here, we asked whether levels of circulating Z-AAT polymers are associated with the severity of lung disease, liver disease, or both. We obtained cross sectional data from the Dutch part of the Alpha1 International Registry of 52 ZZ-AAT patients who performed a pulmonary function test and donated a blood sample on the same day. From the Alpha-1 Liver Aachen Registry, we obtained a cohort of 40 ZZ-AAT patients with available data on their liver function. The levels of plasma Z-AAT polymers were determined using a LG96 monoclonal antibody-based sandwich ELISA. In a Dutch cohort, the median plasma level of Z-AAT polymers of patients diagnosed for pulmonary disease was 947.5 µg/mL (733.6−1218 µg/mL (95% CI)), which did not correlate with airflow obstruction or gas transfer value. In the Alpha-1 liver patient cohort, the median polymer level was 1245.9 µg/mL (753−2034 µg/mL (95% CI)), which correlated with plasma gamma-glutamyl transferase (GGT, rs = 0.57, p = 0.001), glutamate dehydrogenase (GLDH, rs = 0.48, p = 0.002) and triglycerides (TG, rs = 0.48, p = 0.0046). A Wilcoxon rank test showed higher Z-AAT polymer values for the liver over the lung group (p < 0.0001). These correlations support a possible link between plasma Z-AAT polymers and the liver function.

Changes in Body Weight and Concurrent Changes in Cardiovascular Risk Profiles in Community Residents in Japan: the Hisayama Study

AIM

We investigated the influence of weight change on concurrent changes in predicted cardiovascular disease (CVD) risk and individual CVD risk factors over time.

METHODS

A total of 2,140 community-dwellers aged 40-74 years participated in both 2002 and 2007 health examinations. Obesity was defined as body mass index ≥ 25 kg/m2. Weight trajectories were classified as: "stable obese" (obese at both examinations), "obese to nonobese" (obese in 2002 but nonobese in 2007), "nonobese to obese" (nonobese in 2002 but obese in 2007), or "stable nonobese" (nonobese at both examinations). We compared changes in the model-predicted risk for CVD and individual CVD risk factors across weight-change categories.

RESULTS

The predicted risk for CVD increased during 5 years in all groups; the increment in the predicted risk for CVD was smallest in the obese to nonobese participants and steepest in the nonobese to obese subjects. Compared with the stable obese participants, the obese to nonobese participants had greater favorable changes in waist circumferences, blood pressure, fasting plasma glucose, serum high-density lipoprotein cholesterol, serum triglycerides, and liver enzymes. For all these parameters, opposite trends were observed when comparing the nonobese to obese participants with the stable nonobese group.

CONCLUSIONS

We demonstrated the favorable association of losing weight in obese people and avoiding excessive weight gain in nonobese people with global risk of future CVD and individual CVD risk factors in a real-world setting. The findings could improve behavioral lifestyle interventions that provide information on the health consequences of weight change at health checkups.

Increased burden of cardiovascular disease in people with liver disease: unequal geographical variations, risk factors and excess years of life lost

Background

People with liver disease are at increased risk of developing cardiovascular disease (CVD), however, there has yet been an investigation of incidence burden, risk, and premature mortality across a wide range of liver conditions and cardiovascular outcomes.

Methods

We employed population-wide electronic health records (EHRs; from 1998 to 2020) consisting of almost 4 million adults to assess regional variations in disease burden of five liver conditions, alcoholic liver disease (ALD), autoimmune liver disease, chronic hepatitis B infection (HBV), chronic hepatitis C infection (HCV) and NAFLD, in England. We analysed regional differences in incidence rates for 17 manifestations of CVD in people with or without liver disease. The associations between biomarkers and comorbidities and risk of CVD in patients with liver disease were estimated using Cox models. For each liver condition, we estimated excess years of life lost (YLL) attributable to CVD (i.e., difference in YLL between people with or without CVD).

Results

The age-standardised incidence rate for any liver disease was 114.5 per 100,000 person years. The highest incidence was observed in NAFLD (85.5), followed by ALD (24.7), HCV (6.0), HBV (4.1) and autoimmune liver disease (3.7). Regionally, the North West and North East regions consistently exhibited high incidence burden. Age-specific incidence rate analyses revealed that the peak incidence for liver disease of non-viral aetiology is reached in individuals aged 50–59 years. Patients with liver disease had a two-fold higher incidence burden of CVD (2634.6 per 100,000 persons) compared to individuals without liver disease (1339.7 per 100,000 persons). When comparing across liver diseases, atrial fibrillation was the most common initial CVD presentation while hypertrophic cardiomyopathy was the least common. We noted strong positive associations between body mass index and current smoking and risk of CVD. Patients who also had diabetes, hypertension, proteinuric kidney disease, chronic kidney disease, diverticular disease and gastro-oesophageal reflex disorders had a higher risk of CVD, as do patients with low albumin, raised C-reactive protein and raised International Normalized Ratio levels. All types of CVD were associated with shorter life expectancies. When evaluating excess YLLs by age of CVD onset and by liver disease type, differences in YLLs, when comparing across CVD types, were more pronounced at younger ages.

Conclusions

We developed a public online app (https://lailab.shinyapps.io/cvd_in_liver_disease/) to showcase results interactively. We provide a blueprint that revealed previously underappreciated clinical factors related to the risk of CVD, which differed in the magnitude of effects across liver diseases. We found significant geographical variations in the burden of liver disease and CVD, highlighting the need to devise local solutions. Targeted policies and regional initiatives addressing underserved communities might help improve equity of access to CVD screening and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-03210-9.

Liver dysfunction in idiopathic pulmonary arterial hypertension: prevalence, characteristics and prognostic significance, a retrospective cohort study in China

OBJECTIVES

The aim was to elucidate the relationship between liver function and idiopathic pulmonary arterial hypertension (IPAH).

DESIGN AND SETTING

Retrospective, longitudinal study in urban tertiary care centre in Shanghai, China.

PARTICIPANTS

407 IPAH consecutive incident patients age 18-65 years were retrospectively enrolled from January 2008 to December 2018.

OUTCOME MEASUREMENTS

The primary endpoint was all-cause mortality. The cut-off value was determined by receiver operating characteristic curve (ROC), which was validated by Cox proportional hazard model was internally validated by bootstrap analysis and used for survival analysis. The Cox model was (internally) validated and cross-validated areas under the curve (AUC) should be reported.

RESULTS

The prevalence of abnormal liver function tests (LFTs) at baseline was 77.6%. Hyperbilirubinaemia is the most common abnormal biochemical liver test: abnormal total bilirubin (TBIL in 51.6% patients). During the follow-up, 160 patients died. Patients with mixed liver dysfunction have worse prognosis than those with normal LFTs or isolated abnormal bilirubin metabolism. Comparing with patients with hepatocellular injury, the survival of patients with abnormal bilirubin metabolism is lower. Multivariable Cox models revealed a positive association between TBIL, γ-glutamyltransferase (GGT) and mortality showing that each Ig increment in TBIL and GGT was associated with a higher all-cause mortality (TBIL: HR 4. 29 (95% CI 1. 21 to 15. 27), p=0. 02; GGT: HR 2. 76 (95% CI 1. 18 to 6. 45), p=0. 02). A novel formula named Liver Function Predict Index (LFPI) was constructed (LFPI=-0.002*6MWD+1.014*lg GGT+1.458*lg TBIL) to predict prognosis. ROC curve analysis did further identify 2.729 as the best cut-off value for LFPI (AUC 0.75, p<0.001, sensitivity 79%, specificity 70%).

CONCLUSIONS

Liver dysfunction is frequent in IPAH, and characterised by a predominantly cholestatic enzyme profile. LFTs abnormalities are associated with worse survival and LFPI was a new and simple predictor for prognosis of IPAH.

Blood urea nitrogen, blood urea nitrogen to creatinine ratio and incident stroke: The Dongfeng-Tongji cohort

BACKGROUND AND AIMS

It remains unclear whether extreme levels of blood urea nitrogen (BUN) and BUN to creatinine ratio (BUN/Cr) can increase future risk of stroke. We conducted this study to investigate the associations of BUN and BUN/Cr with incident stroke and its subtypes.

METHODS

A total of 26,835 and 26,379 participants with a mean follow-up of 7.9 years were included to investigate the associations of BUN and BUN/Cr with incident stroke, respectively. Cox proportional hazard models were used to evaluate hazard ratios (HRs) and 95% confidence intervals (CIs) for incident stroke and its subtypes.

RESULTS

Compared with participants in the third quintile of BUN, the adjusted HRs (95% CIs) for participants in the lowest quintile were 1.21 (1.04-1.40), 1.41 (1.18-1.68) and 1.36 (0.97-1.91) for total, ischemic and hemorrhagic stroke, respectively; while for those in the highest quintile, the corresponding HRs (95% CIs) were 1.16 (1.01-1.32), 1.30 (1.11-1.53), and 1.24 (0.90-1.71). The associations remained robust when restricting the analyses to participants within clinically normal range of BUN. For BUN/Cr, compared with participants in the third quintile, participants in the lowest quintile had significant higher risks of stroke (HRs [95% CIs] were 1.19 [1.04-1.37], 1.26 [1.07-1.48], and 1.22 [0.90-1.67] for total, ischemic and hemorrhagic stroke).

CONCLUSIONS

Both high and low levels of BUN were associated with higher risks of total and ischemic stroke. Low level of BUN/Cr was associated with excess risks of total and ischemic stroke.

Does the risk of cardiovascular events differ between biopsy-proven NAFLD and MAFLD?

BACKGROUND/PURPOSE

Cardiovascular disease (CVD) is the leading cause of death among individuals with non-alcoholic fatty liver disease (NAFLD). Recently, NAFLD was renamed metabolic-associated fatty liver disease (MAFLD). This study aimed to compare cardiovascular risk (CVR) and CVD between patients with NAFLD and MAFLD.

METHODS

Retrospective cross-sectional study of biopsy-proven liver steatosis performed between 2013 and 2018 at a university hospital. Cases were divided into NAFLD or MAFLD and demographic, clinical, and laboratory data were collected to assess CVR (through the atherosclerotic cardiovascular disease risk estimator and atherogenic indices) and CVD.

RESULTS

Out of 1233 liver biopsies, 171 (13.9%) presented steatosis. Of these, 109 patients met diagnostic criteria for NAFLD (63.7%) and 154 (90.1%), for MAFLD. In the NAFLD group, 78% of the cases had steatohepatitis, 24.8% had cirrhosis, and 3.7%, hepatocellular carcinoma (HCC). In the MAFLD group, 72.7% of the cases had liver inflammatory activity, 28.6% had cirrhosis, and 13.6% had HCC. In patients with MAFLD and NAFLD, CVR was intermediate/high (36.4 and 25.7%, p = 0.209) and CVD occurred in 20.1 and 12.8% (p = 0.137) of the cases, respectively, with no influence of liver injury severity. We observed a significant increase in high 10-year CVR (p = 0.020) and CVD (p = 0.007) in patients with MAFLD and concomitant viral infection (HCV and/or HBV) compared to cases with MAFLD only.

CONCLUSION

Patients with both NAFLD and MAFLD had intermediate/high CVR, with a high rate of CVD. Patients with MAFLD and concomitant viral infection showed significantly increased CVR and CVD compared to those without viral infection.

Routinely Measured Hematological Markers Can Help to Predict American Spinal Injury Association Impairment Scale Scores after Spinal Cord Injury

Neurological outcomes following spinal cord injury (SCI) are currently difficult to predict. While the initial American Spinal Injury Association Impairment Scale (AIS) grade can give an estimate of outcome, the high remaining degree of uncertainty has stoked recent interest in biomarkers for SCI. This study aimed to assess the prognostic value of routinely measured blood biomarkers by developing prognostic models of AIS scores at discharge and 12 months post-injury. Routine blood and clinical data were collected from SCI patients (n = 417), and blood measures that had been assessed in less than 50% of patients were excluded. Outcome neurology was obtained from AIS and Spinal Cord Independence Measure III (SCIM-III) scores at discharge and 12 months post-injury, with motor (AIS) and sensory (AIS, touch and prick) abilities being assessed individually. Linear regression models with and without elastic net penalization were created for all outcome measures. Blood measures associated with liver function, such as alanine transaminase, were found to add value to predictions of SCIM-III at discharge and 12 months post-injury. Further, components of a total blood count, including hemoglobin, were found to add value to predictions of AIS motor and sensory scores at discharge and 12 months post-injury. These findings corroborate the results of our previous preliminary study and thus provide further evidence that routine blood measures can add prognostic value in SCI and that markers of liver function are of particular interest.

De-Ritis Ratio Is Associated with Mortality after Cardiac Arrest

INTRODUCTION

The aim of our study was to explore the associations of the aspartate transaminase/alanine transaminase (De-Ritis) ratio with outcomes after cardiac arrest (CA).

METHODS

This retrospective study included 374 consecutive adult cardiac arrest patients. Information on the study population was obtained from the Dryad Digital Repository. Patients were divided into tertiles based on their De-Ritis ratio. The logistic regression hazard analysis was used to assess the independent relationship between the De-Ritis ratio and mortality. The Kaplan-Meier method and log-rank test were used to estimate the survival of different groups. Receiver operating characteristic (ROC) curve analysis was utilized to compare the prognostic ability of biomarkers. A model combining the De-Ritis ratio was established, and its performance was evaluated using the Akaike information criterion (AIC).

RESULTS

Of the 374 patients who were included in the study, 194 patients (51.9%) died in the intensive care unit (ICU), 213 patients (57.0%) died during hospitalization, and 226 patients (60.4%) had an unfavorable neurologic outcome. Logistic regression analysis including potentially confounding factors showed that the De-Ritis ratio was independently associated with mortality, yielding a more than onefold risk of ICU mortality (OR 1.455; 95% CI 1.088-1.946; p = 0.011) and hospital mortality (OR 1.378; 95% CI 1.031-1.842; p = 0.030). Discriminatory performance assessed by ROC curves showed an area under the curve of 0.611 (95% CI 0.553-0.668) for ICU mortality and 0.625 (0.567-0.682) for hospital mortality. Further, the likelihood ratio test (LRT) analysis showed that the model combining the De-Ritis ratio had a smaller AIC and higher likelihood ratio χ 2 score than the model without the De-Ritis ratio. The Kaplan-Meier curves showed that the CA patients in the De-Ritis ratio tertile 3 group clearly had a significantly higher incidence of ICU mortality (log - rank = 0.007).

CONCLUSION

An elevated De-Ritis ratio on admission was significantly associated with ICU mortality and hospital mortality after CA. Assessment of the De-Ritis ratio might help identify groups at high risk for mortality.

Application of Metabolomics in Diagnosis and Treatment of Chronic Liver Diseases

Chronic liver disease represents stepwise destruction of the liver parenchyma after chronic liver injury, which is often difficult to be diagnosed accurately. Thus, the development of specific biomarkers of chronic liver disease is important. Metabolomics is a powerful tool for biomarker exploration, which enables the exploration of disease pathogenesis or drug action mechanisms at the global metabolic level. The metabolomics workflow generally includes collection, preparation, and analysis of samples, and data processing and bioinformatics. A metabolomics study can simultaneously detect the dysfunctions in the glucose, lipid, amino-acid, and nucleotide metabolisms. Hence, it facilitates the obtaining of a better understanding of the pathogenesis of chronic liver disease and its diagnosis. Many effective drugs could reverse the change of comprehensive biochemical phenotypes induced by chronic liver disease. They can even potentially restore the normal metabolic signatures of patients. Increasingly more researchers have begun to apply metabolomics technologies to diagnose chronic liver disease and investigate the mechanism of action of effective drugs or the variations in drug responses. We are convinced that deepening the understanding of the metabolic alterations could extend their use as powerful biomarkers, promoting the more effective clinical diagnosis and treatment of chronic liver disease in the future.

Elevated Serum Levels of Alkaline Phosphatase and the Risk of Low Responsiveness to Clopidogrel

The elevated serum levels of alkaline phosphatase (ALP) serve as independent predictors of stent thrombosis after percutaneous coronary intervention (PCI). Our study aims at investigating the relationship between the serum ALP and the responsiveness to clopidogrel. Patients undergoing elective PCI were enrolled for the study, and all participants received a 300-mg clopidogrel loading dose. The responsiveness to clopidogrel was determined by thromboelastography (TEG), and low responsiveness to clopidogrel was defined based on two aspects: (1) adenosine diphosphate (ADP) -induced platelet-fibrin clot strength (MA_ADP) of > 47 mm and (2) ADP-induced platelet inhibition rate of < 50%. A logistic regression model analysis was used to calculate the risks of responsiveness to clopidogrel as odd ratios (OR) and 95% confidence intervals (CIs). Overall, 809 patients were considered for the study. They were divided into four quartile groups based on the serum ALP levels. A positive linear trend was observed in MA_ADP across the ALP quartiles (P for linear trend < 0.001), whereas ADP-induced platelet inhibition rate decreased across the ALP quartiles (P for linear trend = 0.007). When multiple confounders were adjusted, the highest ALP quartile correlated with an increased risk of low responsiveness to clopidogrel compared to the lowest ALP quartile (OR, 1.423; 95% CI, 1.017-1.991; P = 0.039). In the sensitivity analysis, the association remained significant for different definitions of low responsiveness to clopidogrel. The elevated serum levels of ALP are independently associated with an increased risk of low responsiveness to clopidogrel.

Association of gamma-glutamyl transferase with subclinical coronary atherosclerosis and cardiac outcomes in non-alcoholics

In an asymptomatic population, we determined the relationship between serum gamma-glutamyl transferase (GGT) and subclinical atherosclerosis, using coronary computed tomography angiography (CCTA). This was a retrospective observational cohort study which analyzed 5120 consecutive asymptomatic individuals with no prior history of coronary artery disease or significant alcohol intake who voluntarily underwent CCTA as part of a general health examination. All subjects were stratified into tertiles based on GGT levels. Degree and extent of subclinical coronary atherosclerosis were evaluated using CCTA. Cardiac events were a composite of all-cause death, myocardial infarction, unstable angina, and coronary revascularization. After adjustment for cardiovascular risk factors, there were no significant differences among GGT tertiles in terms of adjusted odds ratios for non-calcified and mixed plaques. The risk of any atherosclerotic and calcified plaques, significant stenosis, multi-vessel disease, and significant stenosis in the left main or proximal left anterior descending artery was higher in the third GGT tertile than in the first tertile (all p < 0.05). Over a median 5.4-year follow-up, the third GGT tertile had significant adjusted hazards ratios for cardiac events than did the first GGT tertile, even after stepwise adjustment for cardiovascular risk factors (all p < 0.01). In asymptomatic individuals, elevated GGT was independently associated with high-risk feature atherosclerosis and poorer cardiac outcomes.

Lifetime duration of lactation and chronic inflammation among middle-aged women with a history of gestational diabetes

INTRODUCTION

Longer duration of lactation is associated with lower cardiometabolic disease risk, but pathogenic pathways involved in the disease progression are unclear, especially among high-risk women. We aimed to examine the associations of lifetime lactation duration with cardiometabolic biomarkers among middle-aged women with a history of gestational diabetes (GDM).

RESEARCH DESIGN AND METHODS

Women with a history of GDM participating in the Nurses' Health Study II, a prospective cohort study, were identified and followed through biennial questionnaires beginning in 1991. Lactation history was asked in three follow-up questionnaires to calculate lifetime duration. In 2012-2014, fasting blood samples were collected through the Diabetes & Women's Health Study to measure inflammatory (C-reactive protein (CRP), interleukin (IL) 6), liver enzyme (alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase), and lipid biomarkers (total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol).

RESULTS

At follow-up blood collection, women were at median age 58.2 (95% CI 51 to 65) years and 26.3 (95% CI 15.7 to 34.1) years since GDM index pregnancy. After multiple adjustment including prepregnancy body mass index (BMI), longer duration of lactation was significantly associated with lower CRP (least squares (LS) mean 1.90 mg/L (95% CI 1.47 to 2.45) for 0-month lactation, 1.98 mg/L (95% CI 1.68 to 2.32) for up to 12-month lactation, 1.67 mg/L (95% CI 1.42 to 1.97) for 12-24 month lactation, and 1.39 mg/L (95% CI 1.19 to 1.62) for >24-month lactation; p trend=0.003) and IL-6 (1.25 pg/L (95% CI 0.94 to 1.68), 1.19 pg/L (95% CI 0.99 to 1.42), 1.04 pg/L (95% CI 0.87 to 1.25), and 0.93 pg/L (95% CI 0.78 to 1.11); p trend=0.04). Longer duration of lactation was associated with lower risk for chronic inflammation using CRP 3 mg/L cut-off in middle-aged women (OR 0.81 (95% CI 0.69 to 0.940 per 1-year increase) with multiple adjustment.

CONCLUSIONS

Longer lifetime duration of lactation was associated with favorable inflammatory biomarker concentrations in middle-aged women with a history of GDM. Chronic inflammatory pathways may be responsible for previously reported associations between lactation and long-term risk for cardiometabolic diseases.

Gamma-glutamyl transferase variability can predict the development of end-stage of renal disease: a nationwide population-based study

The aim of this study is to investigate whether GGT variability is able to predict the risk of end-stage renal disease (ESRD). The study subjects were Koreans who conducted health exams supported by the Korean National Health Insurance Corporation during 2009-2012 (baseline). After excluding individuals aged < 40 years, heavy alcoholics, or those with histories of chronic liver disease or ESRD, we followed 6,058,995 individuals. We calculated the average successive variability (ASV) of GGT values during the 5 years before the baseline as a parameter of variability. Using Cox proportional analyses, we evaluated the risk of ESRD according to GGT ASV quartiles, defined as the initiation of renal replacement therapy or kidney transplantation, or December 31, 2016. During 38,663,279.3 person-years of follow-up, 12,057 cases of ESRD were identified. Compared with GGT ASV quartile 1, the risk of ESRD was higher in ASV quartiles 3-4 and increased serially, even after adjustment for several metabolic parameters, baseline renal function, presence of comorbidities, low income, and baseline GGT and hemoglobin level. The fully adjusted hazard ratios (95% confidence intervals) of GGT ASV quartiles 3 and 4 were 1.06 (1.01-1.12) and 1.12 (1.06-1.18), respectively. In conclusion, GGT variability is a putative risk factor for ESRD in Koreans.

Gamma-glutamyl transferase and cardiovascular risk in nonalcoholic fatty liver disease: The Gut and Obesity Asia initiative

BACKGROUND

Gamma-glutamyl transferase (GGT) is associated with the risk of cardiovascular disease (CVD) in the general population.

AIM

To identify the association of baseline GGT level and QRISK2 score among patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD).

METHODS

This was a retrospective study involving 1535 biopsy-proven NAFLD patients from 10 Asian centers in 8 countries using data collected by the Gut and Obesity in Asia (referred to as "GO ASIA") workgroup. All patients with available baseline GGT levels and all 16 variables for the QRISK2 calculation (QRISK2-2017; developed by researchers at the United Kingdom National Health Service; https://qrisk.org/2017/; 10-year cardiovascular risk estimation) were included and compared to healthy controls with the same age, sex, and ethnicity. Relative risk was reported. QRISK2 score > 10% was defined as the high-CVD-risk group. Fibrosis stages 3 and 4 (F3 and F4) were considered advanced fibrosis.

RESULTS

A total of 1122 patients (73%) had complete data and were included in the final analysis; 314 (28%) had advanced fibrosis. The median age (interquartile range [IQR]) of the study population was 53 (44-60) years, 532 (47.4%) were females, and 492 (43.9%) were of Chinese ethnicity. The median 10-year CVD risk (IQR) was 5.9% (2.6-10.9), and the median relative risk of CVD over 10 years (IQR) was 1.65 (1.13-2.2) compared to healthy individuals with the same age, sex, and ethnicity. The high-CVD-risk group was significantly older than the low-risk group (median [IQR]: 63 [59-67] vs 49 [41-55] years; P < 0.001). Higher fibrosis stages in biopsy-proven NAFLD patients brought a significantly higher CVD risk (P < 0.001). Median GGT level was not different between the two groups (GGT [U/L]: Median [IQR], high risk 60 [37-113] vs low risk 66 [38-103], P = 0.56). There was no correlation between baseline GGT level and 10-year CVD risk based on the QRISK2 score (r = 0.02).

CONCLUSION

The CVD risk of NAFLD patients is higher than that of healthy individuals. Baseline GGT level cannot predict CVD risk in NAFLD patients. However, advanced fibrosis is a predictor of a high CVD risk.

Borderline-High Mean Corpuscular Volume Levels Are Associated with Arterial Stiffness among the Apparently Healthy Korean Individuals

BACKGROUND

High mean corpuscular volume (MCV) has been implicated in various health problems, such as anemia, liver disease, and thyroid disease. However, the clinical significance of borderline-high MCV is poorly understood in the primary care setting. This study aimed to investigate whether borderline-high MCV was related to arterial stiffness in Korean adults as measured by brachial-ankle pulse wave velocity (baPWV).

METHODS

This cross-sectional study comprised 582 participants aged >30 years who underwent routine health examinations. Borderline-high MCV was defined as over 95.0 fl (>90th percentile) after excluding participants with MCV of ≥100 fl or ≤80 fl, and high baPWV was defined as >1,600 cm/s (>90th percentile). The odds ratios (ORs) and 95% confidence intervals (CIs) for high baPWV according to borderline-high MCV were calculated using multiple logistic regression analyses after adjusting for the confounding variables.

RESULTS

The mean age of the study population was 47.8±11.7 years, and 56.9% of the participants were male. Compared to that in the control group, the OR (95% CI) of high baPWV in those with a borderline-high MCV was 3.68 (1.39-9.74) after adjusting for age, sex, body mass index, alcohol intake, smoking status, regular exercise, mean blood pressure, fasting plasma glucose, triglyceride, high-density lipoprotein cholesterol, C-reactive protein, γ-glutamyltransferase, uric acid, hypertension medication, and diabetes medication.

CONCLUSION

Borderline-high MCV was independently associated with arterial stiffness among apparently healthy Korean individuals.

Association of High-Intensity Binge Drinking With Lipid and Liver Function Enzyme Levels

Importance

The prevalence of high-intensity binge drinking (HIBD), defined as consuming 2 or more times the binge threshold defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is rapidly increasing in the United States. While the relationship between alcohol consumption and lipid and liver function enzyme (LFT) biomarkers has been previously examined, the associations of HIBD with those biomarkers remain unknown.

Objective

To examine associations of HIBD with lipid and LFT levels in a cross-sectional sample enriched with participants who engage in HIBD.

Design, Setting, and Participants

Cross-sectional study using data from the NIAAA clinical sample collected from March 3, 2005, to August 21, 2017, with participants recruited for either the NIAAA screening protocols or inpatient alcohol treatment program. For this study, participants were stratified by self-reported alcohol consumption into 4 sex-specific binge levels: nonbinge and 1, 2, and 3 or more times the binge threshold (levels I, II, and III). Multivariable analyses examined the odds of clinically high levels of lipids and LFTs across binge levels. Analyses were performed from December 3, 2018, to January 30, 2019.

Main Outcomes and Measures

Serum levels of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, total cholesterol, triglycerides, alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase.

Results

A total of 2065 participants underwent protocol screening; 1519 with data available on alcohol consumption, body mass index, lipid levels, and LFT levels were included in the final analyses. Mean (SD) age was 39.7 (12.1) years; mean (SD) body mass index was 26.6 (5.1); 978 (64.4%) were male; 718 (47.3%) were white; and 578 (31.1%) consumed alcohol at the nonbinge level, 321 (21.2%) at level I, 239 (15.7%) at level II, and 318 (25.1%) at level III. High-intensity binge drinking was associated with 2- to 8-fold increased odds for clinically high levels of HDL-C, total cholesterol, triglycerides, and all LFTs (eg, for HDL-C: level III odds ratio [OR], 8.65; 95% CI, 4.75-15.77 and for γ-glutamyltransferase: level III OR, 8.21; 95% CI, 5.90-11.43). Increased HIBD frequency (days consuming at levels II and III) was associated with increased odds for clinically high levels of HDL-C, total cholesterol, and all LFTs (per unit increase in days consuming at the respective binge level) (eg, for HDL-C: level II OR, 1.025; 95% CI, 1.014-1.036 and level III OR, 1.033; 95% CI, 1.019-1.047 and for γ-glutamyltransferase: level II OR, 1.028; 95% CI, 1.019-1.037 and level III OR, 1.033; 95% CI, 1.019-1.047).

Conclusions and Relevance

High-impact binge drinking was significantly associated with increased odds for clinically high levels of lipids and LFTs. Given that HIBD is increasingly common among US adults, targeted interventions aimed at reducing HIBD may have important health benefits.

Discovery and Validation of a Novel Neutrophil Activation Marker Associated with Obesity

Obesity is accompanied by low-grade systemic inflammation that etiologically contributes to obesity-induced cardiovascular disease (CVD). Growing evidence supports that neutrophil, the most abundant type of leukocytes in human, is most likely to be the target peripheral leukocyte subtype initiating the inflammatory cascade in obesity. However, few studies have systematically assessed the genome wide changes in neutrophils associated with obesity. In this study, a hypothesis-free OMIC approach (i.e. the discovery phase) and a target approach (i.e. the validation phase) were used to identify obesity related neutrophil activation markers and their roles on CVD risks. In the discovery phase, genome wide DNA methylation, RNA-sequencing and quantitative proteomics were obtained from purified neutrophils (12 obese vs. 12 lean). In the validation phase, gene expression levels of the promising genes from the OMIC platforms were measured in 81 obese cases vs. 83 lean controls, and the association between the expression levels and CVD risks were evaluated. Significant difference was found for one gene, alkaline phosphatase, liver/bone/kidney (ALPL), across 3 OMIC platforms. In the validation phase, the gene expression levels of ALPL in leukocytes were significantly higher in obese compared with lean subjects (p < 0.05). Within the obese population, we observed that ALPL expression level showed significantly positive association with CVD risk factors (p < 0.05) including systolic blood pressure, diastolic blood pressure, mean arterial pressure, carotid intima–media thickness and borderline significance with fasting insulin (p = 0.08). This study identified one novel marker ALPL of neutrophil activation in response to obesity and provided evidence that obesity induced change in ALPL expression was associated with CVD risk factors.

A link between bilirubin levels and atrial fibrillation recurrence after catheter ablation

BACKGROUND

Bilirubin is associated with different cardiovascular diseases. The relationship between bilirubin and atrial fibrillation (AF) remains unclear. The aim of this study is to determine the association between bilirubin and AF recurrence after catheter ablation.

METHODS

A total of 212 patients who received AF ablation were retrospectively studied. The total bilirubin level, clinical characteristics, and echocardiographic findings were analyzed to predict the outcome of AF ablations.

RESULTS

During a mean follow-up period of 12.2 ± 5.8 months, 61 (28.8%) patients had AF recurrence after catheter ablation. The patients with AF recurrence had a larger left atrial (LA) diameter (39.8 ± 6.3 versus 36.7 ± 5.8 mm; p = 0.001) and higher total bilirubin levels (0.82 ± 0.37 versus 0.63 ± 0.29 mg/dL; p < 0.001) than those without recurrence. The patients with recurrence had higher direct and indirect bilirubin levels than patients without recurrence. The total bilirubin level remained an independent predictor of AF recurrence after multivariate analysis (odds ratio, 4.95; 95% CI, 1.65-14.83; p = 0.004). We identified a cut point of the total bilirubin level for predicting AF recurrence by receiver operator characteristic curve (cut point, 0.7 mg/dL; area under the curve, 0.65; p < 0.001). The total bilirubin levels were positively correlated with the neutrophil counts. However, there were no associations among the total bilirubin level, left atrial (LA) diameter, and voltage.

CONCLUSION

Higher serum bilirubin levels were associated with AF recurrence in paroxysmal AF patients following catheter ablation.

Impact of Non-Alcoholic Fatty Liver Disease on Cardiovascular Outcomes in Patients With Stable Coronary Artery Disease: A Matched Case-Control Study

INTRODUCTION

Whether non-alcoholic fatty liver disease (NAFLD) is associated with cardiovascular risk has still been controversial. The reasons for this disparity may be associated with subject selection, events definition, diagnostic criteria of NAFLD, or research methods. The aim of this study was to determine the relationship of NAFLD to cardiovascular disease (CVD) outcomes in patients with stable, new-onset coronary artery disease (CAD).

METHODS

A matched case-control study based on the cohort with stable, new-onset CAD was implemented in 162 cases (patients who developed all-cause death, non-fatal myocardial infarction and stroke during an average of 11,484 patient-years of follow-up) and 162 controls without cardiovascular events matched with the same sex, the age difference ≤3 years old, and the admission date within 3 months. Abdominal ultrasonography and coronary angiography were performed at admission. COX proportional hazard models and conditional logistic regression analysis were used to assess the effect of NAFLD on CVD outcomes.

RESULTS

NAFLD was more common in the event group than in the control group (P = 0.012). Kaplan-Meier analysis showed a significant association between NAFLD and CVD outcomes (P = 0.007). Moreover, Cox regression (hazard ratios 1.56; 95% confidence interval, 1.04-2.34, P = 0.031) and conditional logistic regression (odds ratio 2.72, 95% confidence interval, 1.16-6.39, P = 0.022) analyses further demonstrated that NAFLD was an independent risk factor for CVD outcomes.

CONCLUSIONS

NAFLD is indeed an independent predictor of CVD outcomes in patients with stable, new-onset CAD. Further randomized controlled trials may be needed to confirm our findings.

Prepregnancy liver enzyme levels and risk of preeclampsia in a subsequent pregnancy: A population-based cohort study

BACKGROUND & AIMS

Preeclampsia is a serious multisystemic disorder leading to maternal and neonatal adverse outcomes. However, little is known about the early markers of this disease. The aim of this study was to investigate the association between prepregnancy liver function and the development of preeclampsia.

METHODS

We enrolled 192 571 Korean women who had their first delivery between January 1, 2008, and December 31, 2014, and had undergone a national health screening examination through the National Health Insurance Corporation during 1-2 years before delivery.

RESULTS

Preeclampsia developed in 3973 (2.0%) women. The rate of development of preeclampsia was higher in women with abnormal prepregnancy liver enzyme levels than in those with normal liver enzyme levels before pregnancy. On multivariate analysis, women with abnormal alanine aminotransferase level before pregnancy had a 1.21-fold increased risk of developing preeclampsia than those with normal alanine aminotransferase level before pregnancy, after adjusting for age, family history of hypertension, hepatitis B virus carrier status, smoking, alcohol status, prepregnancy body mass index and blood pressure. Prepregnancy γ-glutamyltransferase and aspartate aminotransferase levels were not associated with the risk of preeclampsia development.

CONCLUSION

Abnormal prepregnancy alanine aminotransferase level was associated with the development of preeclampsia in a subsequent pregnancy. Further studies are needed to evaluate whether early intervention for liver function before pregnancy can decrease the risk of preeclampsia.

A comparison of gamma-glutamyl transferase and alkaline phosphatase as prognostic markers in patients with coronary heart disease

BACKGROUND AND AIMS

Whether gamma-glutamyl transferase (GGT) or alkaline phosphatase (ALP) is a better prognostic marker in patients with coronary heart disease (CHD) remains unknown. The aim of this study was to compare the prognostic value of GGT and ALP in patients with CHD.

METHODS AND RESULTS

This study included 3768 patients with CHD. The main study outcome was 3-year all-cause mortality. The median values of GGT and ALP were 36.2 U/L and 69.3 U/L. Patients were divided into subgroups according to GGT or ALP activity > or ≤median. Overall, there were 304 deaths: 195 deaths occurred in patients with GGT >median (n = 1882) and 109 deaths occurred in patients with GGT ≤median (n = 1886); Kaplan-Meier [KM] estimates of all-cause mortality were 11.9% and 6.4% (unadjusted hazard ratio [HR] = 1.85, 95% confidence interval [CI], 1.46 to 2.34]; P < 0.001). According to ALP activity, 186 deaths occurred in patients with ALP >median (n = 1883) and 118 deaths occurred in patients with ALP ≤median (n = 1885); KM estimates of all-cause mortality were 11.4% and 7.1% (unadjusted HR = 1.64 [1.30-2.06]; P < 0.001). After adjustment, GGT (adjusted HR = 1.32 [1.11-1.58]; P = 0.002) but not ALP (adjusted HR = 1.20 [1.00-1.43]; P = 0.051, with both HR calculated per 1 unit increment in logarithmic GGT or ALP scale) remained significantly associated with the risk for mortality. The C statistic of the mortality model with GGT was greater than the C statistic of the model with ALP (0.831 [0.802-0.859] vs. 0.826 [0.793-0.855]; P < 0.001).

CONCLUSIONS

In patients with CHD, GGT was a stronger correlate of all-cause mortality than ALP.

Alkaline phosphatase and prognosis in patients with coronary artery disease

BACKGROUND

The evidence on the association between alkaline phosphatase (ALP) and prognosis of patients with coronary artery disease (CAD) is limited. The aim of this study was to assess the association of ALP with the risk of mortality or coronary events in patients with CAD.

MATERIALS AND METHODS

The study included 5540 patients with angiography-proven CAD treated with catheter-based coronary revascularization. Baseline ALP measurements were available for analysis in all patients. Patients were divided into three groups: a group with an ALP activity in the 1st tertile (ALP ≤ 65·5 U/L; n = 1855), a group with an ALP activity in the 2nd tertile (ALP > 65·5 to 85·7 U/L; n = 1839) and a group with an ALP in the 3rd tertile (ALP > 85·7 U/L; n = 1846). The primary outcome was all-cause mortality at 3-year follow-up.

RESULTS

All-cause deaths (number [Kaplan-Meier estimates]) occurred in 443 patients: 117 (7·2%), 130 (8·1%) and 196 deaths (11·8%) among patients of the 1st, 2nd and 3rd ALP tertiles (unadjusted hazard ratio [HR] = 1·33, 95% confidence interval [CI]: 1·19 to 1·50; P < 0·001, calculated per tertile increment in the ALP activity). After adjustment in multivariable Cox proportional hazards model, ALP was independently associated with the risk of all-cause mortality (adjusted HR = 1·33 [1·18-1·51], P < 0·001, calculated per unit increment in log ALP). The multivariable model for all-cause mortality with baseline variables without ALP had a C statistic of 0·820 [0·797-0·843] which increased to 0·825 [0·804-0·849] after ALP inclusion; delta C statistic 0·005 [0·001-0·011]; P < 0·001.

CONCLUSIONS

In patients with CAD, elevated ALP activity was independently associated with the risk of 3-year all-cause mortality.

Role of circulating factors in cardiac aging

Worldwide increase in life expectancy is a major contributor to the epidemic of chronic degenerative diseases. Aging, indeed, simultaneously affects multiple organ systems, and it has been hypothesized that systemic alterations in regulators of tissue physiology may regulate this process. Cardiac aging itself is a major risk factor for cardiovascular diseases and, because of the intimate relationship with the brain, may contribute to increase the risk of neurodegenerative disorders. Blood-borne factors may play a major role in this complex and still elusive process. A number of studies, mainly based on the revival of parabiosis, a surgical technique very popular during the 70s of the 20th century to study the effect of a shared circulation in two animals, have indeed shown the potential that humoral factors can control the aging process in different tissues. In this article we review the role of circulating factors in cardiovascular aging. A better understanding of these mechanisms may provide new insights in the aging process and provide novel therapeutic opportunities for chronic age-related disorders.

The aspartate aminotransferase-to-alanine aminotransferase ratio predicts all-cause and cardiovascular mortality in patients with type 2 diabetes

An increased aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) has been widely used as a marker of advanced hepatic fibrosis. Increased AAR was also shown to be significantly associated with the risk of developing cardiovascular (CV) disease. The aim of this study was to assess the relationship between the AAR and mortality risk in a well-characterized cohort of patients with type 2 diabetes.A cohort of 2529 type 2 diabetic outpatients was followed-up for 6 years to collect cause-specific mortality. Cox regression analyses were modeled to estimate the independent association between AAR and the risk of all-cause and CV mortality.Over the 6-year follow-up period, 12.1% of patients died, 47.5% of whom from CV causes. An increased AAR, but not its individual components, was significantly associated with an increased risk of all-cause (adjusted-hazard risk 1.83, confidence interval [CI] 95% 1.14-2.93, P = 0.012) and CV (adjusted-hazard risk 2.60, CI 95% 1.38-4.90, P < 0.003) mortality after adjustment for multiple clinical risk factors and potential confounding variables.The AAR was independently associated with an increased risk of both all-cause and CV mortality in patients with type 2 diabetes. These findings suggest that an increased AAR may reflect more systemic derangements that are not simply limited to liver damage. Further studies are needed to elucidate the pathophysiological implications of an increased AAR.

Non-alcoholic fatty liver disease and risk of cardiovascular disease

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver diseases worldwide, causing considerable liver-related mortality and morbidity. During the past decade, it has also become increasingly evident that NAFLD is a multisystem disease that affects many extra-hepatic organ systems, including the heart and the vascular system. In this updated clinical review, we discuss the rapidly expanding body of clinical and epidemiological evidence that supports a strong association of NAFLD with cardiovascular diseases (CVDs) and other functional and structural myocardial abnormalities. We also discuss some recently published data that correlate NAFLD due to specific genetic polymorphisms with the risk of CVDs. Finally, we briefly examine the assessment tools for estimating the global CVD risk in patients with NAFLD as well as the conventional and the more innovative pharmacological approaches for the treatment of CVD risk in this group of patients.

Non-alcoholic fatty liver disease and dyslipidemia: An update

Non-alcoholic fatty liver (NAFLD) is the most common liver disease worldwide, progressing from simple steatosis to necroinflammation and fibrosis (leading to non-alcoholic steatohepatitis, NASH), and in some cases to cirrhosis and hepatocellular carcinoma. Inflammation, oxidative stress and insulin resistance are involved in NAFLD development and progression. NAFLD has been associated with several cardiovascular (CV) risk factors including obesity, dyslipidemia, hyperglycemia, hypertension and smoking. NAFLD is also characterized by atherogenic dyslipidemia, postprandial lipemia and high-density lipoprotein (HDL) dysfunction. Most importantly, NAFLD patients have an increased risk for both liver and CV disease (CVD) morbidity and mortality. In this narrative review, the associations between NAFLD, dyslipidemia and vascular disease in NAFLD patients are discussed. NAFLD treatment is also reviewed with a focus on lipid-lowering drugs. Finally, future perspectives in terms of both NAFLD diagnostic biomarkers and therapeutic targets are considered.

Nonalcoholic Fatty Liver Disease Is Associated With Ventricular Arrhythmias in Patients With Type 2 Diabetes Referred for Clinically Indicated 24-Hour Holter Monitoring

OBJECTIVE

Recent studies have suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of heart rate-corrected QT interval prolongation and atrial fibrillation in patients with type 2 diabetes. Currently, no data exist regarding the relationship between NAFLD and ventricular arrhythmias in this patient population.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed the data of 330 outpatients with type 2 diabetes without preexisting atrial fibrillation, end-stage renal disease, or known liver diseases who had undergone 24-h Holter monitoring for clinical reasons between 2013 and 2015. Ventricular arrhythmias were defined as the presence of nonsustained ventricular tachycardia (VT), >30 premature ventricular complexes (PVCs) per hour, or both. NAFLD was diagnosed by ultrasonography.

RESULTS

Compared with patients without NAFLD, those with NAFLD (n = 238, 72%) had a significantly higher prevalence of >30 PVCs/h (19.3% vs. 6.5%, P < 0.005), nonsustained VT (14.7% vs. 4.3%, P < 0.005), or both (27.3% vs. 9.8%, P < 0.001). NAFLD was associated with a 3.5-fold increased risk of ventricular arrhythmias (unadjusted odds ratio [OR] 3.47 [95% CI 1.65-7.30], P < 0.001). This association remained significant even after adjusting for age, sex, BMI, smoking, hypertension, ischemic heart disease, valvular heart disease, chronic kidney disease, chronic obstructive pulmonary disease, serum γ-glutamyltransferase levels, medication use, and left ventricular ejection fraction (adjusted OR 3.01 [95% CI 1.26-7.17], P = 0.013).

CONCLUSIONS

This is the first observational study to show that NAFLD is independently associated with an increased risk of prevalent ventricular arrhythmias in patients with type 2 diabetes.

Opposite associations between alanine aminotransferase and γ-glutamyl transferase levels and all-cause mortality in type 2 diabetes: Analysis of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study

AIMS

Reported associations between liver enzymes and mortality may not hold true in type 2 diabetes, owing to a high prevalence of non-alcoholic fatty liver disease, which has been linked to cardiovascular disease and mortality in its own right. Our study aimed to determine whether alanine aminotransferase (ALT) or γ-glutamyl transferase (GGT) levels predict mortality in type 2 diabetes, and to examine possible mechanisms.

METHODS

Data from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study were analyzed to examine the relationship between liver enzymes and all-cause and cause-specific mortality over 5years.

RESULTS

Over 5years, 679 (6.9%) individuals died. After adjustment, for every standard deviation increase in ALT (13.2U/L), the HR for death on study was 0.85 (95% CI 0.78-0.93), p<0.001. Conversely, GGT >70U/L, compared with GGT ≤70U/L, had HR 1.82 (1.48-2.24), p<0.001. For cause-specific mortality, lower ALT was associated with a higher risk of cardiovascular death only, whereas GGT >70U/L was associated with higher risks of death due to cardiovascular disease, cancer and non-cancer/non-cardiovascular causes. The relationship for ALT persisted after adjustment for indirect measures of frailty but was attenuated by elevated hsCRP.

CONCLUSIONS

As in the general population, ALT has a negative, and GGT a positive, correlation with mortality in type 2 diabetes when ALT is less than two times the upper limit of normal. The relationship for ALT appears specific for death due to cardiovascular disease. Links of low ALT with frailty, as a potential mechanism for relationships seen, were neither supported nor conclusively refuted by our analysis and other factors are also likely to be important in those with type 2 diabetes.