Circulating Cystatin C Is an Independent Risk Marker for Cardiovascular Outcomes, Development of Renal Impairment, and Long-Term Mortality in Patients With Stable Coronary Heart Disease: The LIPID Study

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.

Infective endocarditis risk scores: a narrative review

Background and Objective

Despite modern advancements, infective endocarditis remains a devastating disease with high mortality and morbidity rates. Given the heterogeneous patient background and the complexity of the condition, the decision for surgery is difficult. Traditional general cardiac surgery risk models, including EuroSCORE and Society of Thoracic Surgeons (STS) score, do not include disease-specific factors that often impact both the operability and frailty of patients. The aim of the study is to review the strength and limitations of current risk scores designed specifically for patients with infective endocarditis.

Methods

A search in PubMed and OVID databases was conducted for articles and abstracts published from inception to 1st June 2024 using the terms "infective endocarditis" AND "risk score" or "surgical futility" or "operative mortality".

Key Content and Findings

Various risk scores have therefore been developed to help stratify the operative risks of these patients by incorporating endocarditis-specific features. This review aims to analyse the applicability and usefulness of risk scores in the setting of surgical management of infective endocarditis, which in turn helps to identify patients who would benefit from interventions. From 2007, a total of 18 risk scores have been designed specifically for patients with infective endocarditis. These scores however have low generalisability since different patient characteristics, disease factors and validation strategies are used. In various validation cohorts and comparative studies, the discrimination performances of these scores are unsatisfactory. Most of the studies focused on early, or in-patient mortality, while the intermediate and long-term mortality was not well studied.

Conclusions

Risk stratification for the group of patients who are indicated for surgery, but only received medical treatment due to perceived futility or were too unstable to proceed to operation, is pertinent. This population is not frequently recruited to current studies, and more research is needed.

Association between serum cystatin C and chronic lung disease in middle-aged and elderly Chinese: a CHARLS cross-sectional study

The dose-response relationship between cystatin C (CysC) levels and chronic lung disease (CLD) development remains unclear and warrants further investigation. A more in-depth study of the relationship between serum CysC levels and CLD prevalence based on data from the China Health and Retirement Longitudinal Study (CHARLS). A cross-sectional analysis of 10,275 middle-aged and older adults aged 45 years and older was conducted using 2015 CHARLS data. Binary logistic regression models, restricted cubic spline curves (RCS), and threshold effects analyses were used to explore the association between different CysC levels and CLD prevalence in the middle-aged and older population, and subgroup analyses were performed to verify the robustness of the findings. When CysC was used as a categorical variable, the risk of CLD was increased by 38% in the T3 group compared with T1 (P < 0.001), and when CysC was used as a continuous variable, the risk of CLD was increased by 96% for each unit increase in CysC level (P < 0.001). In addition, there was a nonlinear relationship between CysC levels and the risk of CLD prevalence (P for non-linearity < 0.012), and the risk of CLD prevalence increased significantly with increasing CysC levels when CysC levels ≥ 0.754 mg/L. When CysC ≥ 0.754 mg/L, we need to be highly concerned about the risk of developing chronic lung disease in middle-aged and older populations, and those aged 45-64 years should be the focus of screening.

Adiponectin and TNF-Alpha Differentially Mediate the Association Between Cystatin C and Oxidized LDL in Type 2 Diabetes Mellitus Patients

In individuals with type 2 diabetes mellitus (T2DM), elevated levels of both plasma and urinary cystatin C (Cys-C) contribute to increased oxidation, which in turn accelerates the oxidation of low-density lipoprotein (LDL). This process may worsen the development of atherosclerosis and cardiovascular disease by promoting endothelial dysfunction and inflammation. Despite its potential significance, the relationship between Cys-C and oxidized LDL (ox-LDL) in T2DM remains poorly understood. This study investigated the relationship between plasma and urinary Cys-C and ox-LDL levels in T2DM patients. The cohort included 57 patients with T2DM (mean age 61.14 ± 9.99 years; HbA1c 8.66 ± 1.60% and BMI 35.15 ± 6.65 kg/m2). Notably, 95% of the patients had hypertension, 82% had dyslipidemia, 59% had an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, 14% had coronary artery disease (CAD), and 5% had a history of stroke. Plasma and urinary Cys-C and ox-LDL levels were measured using ELISA. Adipokine and cytokine levels were measured using the multiplex® MAP Human Adipokine Magnetic Bead Panels. Spearman's correlation analysis revealed a significant positive correlation of plasma and urinary Cys-C with ox-LDL (r = 0.569, p = 0.0001 and r = 0.485, p = 0.0001, respectively). Multivariable regression analysis indicated that both plasma and urinary Cys-C were independently associated with ox-LDL, after adjusting for confounding factors (β = 0.057, p = 0.0001 and β = 0.486, p = 0.003, respectively). Stepwise linear regression identified TNFα and adiponectin as the strongest predictors of the relationship between urinary Cys-C and ox-LDL (β = 0.382, p = 0.0001; r2 = 0.64), while adiponectin alone was the best predictor of the plasma Cys-C and ox-LDL association (β = 0.051, p = 0.005; r2 = 0.46). Furthermore, adiponectin partly mediated the relationship between plasma Cys-C and ox-LDL, explaining 18% of the variance in this association. In contrast, TNFα partly mediated the relationship between urinary Cys-C and ox-LDL, accounting for 28% of the variance. This study emphasizes the complex interaction between Cys-C and ox-LDL in T2DM. It highlights the need for additional research involving larger patient cohorts to improve our understanding of the therapeutic potential of plasma and urinary Cys-C in conjunction with ox-LDL for managing complications associated with T2DM.

Biomarkers for Predicting of Sepsis-Induced Cardiorenal Syndrome in Emergency Settings

INTRODUCTION

Cardiorenal syndrome (CRS) is a common and critical complication of sepsis, with high morbidity and mortality rates. Studies on biomarkers for the early prediction of septic CRS are sporadic. Classic and novel potential biomarkers were identified to explore their diagnostic performance of in patients with septic CRS.

METHODS

A total of 138 patients with sepsis from Peking University People's Hospital were enrolled in this prospective observational study, which was conducted between May 2019 and June 2022. The patients were divided into non-CRS (n = 106) and CRS (n = 32) groups. Serum levels of cystatin C, KIM-1, neutrophil gelatinase-associated lipocalin (NGAL), and α-Klotho were detected at admission using enzyme-linked immunosorbent assay. The relationship between the biomarker levels and risk factors of CRS were analyzed, as well as discrimination accuracy comparisons were performed.

RESULTS

The incidence of CRS in patients with sepsis was 23.2% (32/138) during hospitalization, with an obvious mortality. Compared with the non-CRS group, serum cystatin C, brain natriuretic peptide (BNP), troponin-I (TNI), KIM-1, and NGAL levels were both significantly elevated at admission in patients with sepsis complicated with CRS. Logistic regression analysis revealed that BNP, TNI, cystatin C, albumin, Lac, D-dimer were risk factors for CRS in sepsis patients. Compared with other biomarkers, serum cystatin C had moderate discriminative power for predicting septic CRS (area under a receiver operating characteristic curve, 0.746; sensitivity, 0.719; specificity, 0.783). BNP combined with cystatin C and D-dimer demonstrated an excellent discrimination performance, for its AUROC was up to 0.878 (sensitivity, 0.844; specificity, 0.759).

CONCLUSION

Serum cystatin C, BNP, TNI, KIM-1, and NGAL levels are elevated in patients with septic CRS. Our study provides reliable evidence that cystatin C in combination with BNP and D-dimer might better predict septic CRS upon admission. Further research on sensitive biomarkers is needed.

Effect of an intensive lifestyle intervention on cystatin C-based kidney function in adults with overweight and obesity: From the PREDIMED-Plus trial

BACKGROUND

Large-scale trials evaluating a multicomponent lifestyle intervention aimed at weight loss on kidney function are lacking.

METHODS

This was a post hoc analysis of the "PREvención con DIeta MEDiterránea-Plus" (PREDIMED-Plus) randomized controlled trial, including patients with overweight/obesity and metabolic syndrome, measured cystatin C and creatinine. Participants were randomly assigned (1:1) to an intensive weight loss lifestyle intervention (intervention group [IG]) consisting of an energy-restricted Mediterranean diet (MedDiet), physical activity promotion and behavioral support, or a control group (CG) receiving ad libitum MedDiet recommendations. The primary outcome was between-group differences in cystatin C-based kidney function (cystatin C-based estimated glomerular filtration rate-eGFRcys-and combined cystatin C-creatinine-based eGFR-eGFRcr-cys) change from baseline to 12 and 36 months. Secondary outcomes included between-group differences in creatinine-based eGFR (eGFRcr) and urinary albumin-to-creatinine ratio (UACR) change and the predictive capacity of these formulas at baseline for new-onset chronic kidney disease (CKD).

RESULTS

A total of 1909 participants (65 ± 5 years, 54% men) were included. Twelve-month decline in eGFRcys, eGFRcr-cys, and eGFRcr was greater in the CG compared to the IG, with between-group differences of -1.77 mL/min/1.73 m2 [95% confidence interval -2.92 to -0.63], -1.37 [-2.22 to -0.53], and -0.91 [-1.74 to -0.71], respectively. At 36 months, the decline in eGFRcr-cys and eGFRcr was greater in the CG. No between-group differences in UACR were found. Significant adjusted areas under the curve for baseline eGFRcys and eGFRcr-cys were observed for incident CKD at 36 months, which were similar to those for eGFRcr and UACR.

CONCLUSIONS

In older adults with overweight/obesity and metabolic syndrome, the PREDIMED-Plus intervention may be an optimal approach to preserve kidney function.

Current and novel biomarkers in cardiogenic shock

Cardiogenic shock (CS) carries a 30-50% in-hospital mortality rate, with little improvement in outcomes in the last decade. Challenges in improving outcomes are closely linked to the frequent late presentation or diagnosis of CS where the 'point of no return' has often passed, leading to haemodynamic dysregulation, progressive myocardial depression, hypotension, and a downward spiral of hypoperfusion, organ dysfunction and decreasing myocardial function, driven by inflammation and metabolic derangements. Novel therapeutic interventions may have varying efficacy depending on the type and stage of shock in which they are applied. Biomarkers that aid prediction and early detection of CS, provide early signs of organ dysfunction and define prognosis could help optimize management. Temporal change in such biomarkers, particularly in response to pharmacological interventions and/or mechanical circulatory support, can guide management and predict outcome. Several novel biomarkers enhance the prediction of mortality in CS, compared to conventional parameters such as lactate, with some, such as adrenomedullin and circulating dipeptidyl peptidase 3, also able to predict the development of CS. Some biomarkers reflect systemic inflammation (e.g. interleukin-6, angiopoietin 2, fibroblast growth factor 23 and suppressor of tumorigenicity 2) and are not specific to CS, yet inform on the activation of important pathways involved in the downward shock spiral. Other biomarkers signal end-organ hypoperfusion and could guide targeted interventions, while some may serve as novel therapeutic targets. We critically review current and novel biomarkers that guide prediction, detection, and prognostication in CS. Future use of biomarkers may help improve management in these high-risk patients.

Blood Biomarkers as a Non-Invasive Method for the Assessment of the State of the Fontan Circulation

The Fontan operation has become the primary palliative treatment for patients with a functionally univentricular heart. The population of patients with Fontan circulation is constantly growing and aging. As the number of Fontan patients surviving into adulthood increases, there is a clear need for research on how best to follow these patients and manage their complications. Monitoring blood biomarkers is a promising method for the non-invasive assessment of the Fontan circulation. In this article, we provide a comprehensive review of the available evidence on this topic. The following biomarkers were included: natriuretic peptides, red blood cell distribution width (RDW), cystatin C, high-sensitivity C-reactive protein, vitamin D, parathyroid hormone, von Willebrand factor, carbohydrate antigen 125, lipoproteins, hepatocyte growth factor, troponins, ST2 protein, galectin-3, adrenomedullin, endothelin-1, components of the renin-angiotensin-aldosterone system, norepinephrine, interleukin 6, tumor necrosis factor α, and uric acid. We did not find strong enough data to propose evidence-based recommendations. Nevertheless, significantly elevated levels of brain natriuretic peptide (BNP)/N-terminal prohormone of BNP (NT-proBNP) are most likely associated with the failure of the Fontan circulation. The use of the RDW is also promising. Several biomarkers appear to be useful in certain clinical presentations. Certainly, robust longitudinal, preferably multicenter, prospective studies are needed to determine the sensitivity, specificity, evidence-based cut-off values and overall predictive value of different biomarkers in monitoring Fontan physiology.

Plasma Proteomic Biomarkers in Alzheimer's Disease and Cardiovascular Disease: A Longitudinal Study

The co-occurrence of Alzheimer's disease (AD) and cardiovascular diseases (CVDs) in older adults highlights the necessity for the exploration of potential shared risk factors. A total of 566 adults were selected from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database, including 111 individuals with AD, 383 with mild cognitive impairment (MCI), and 410 with CVD. The multivariable linear mixed model (LMM) was used to investigate the associations of AD and CVD with longitudinal changes in 146 plasma proteomic biomarkers (measured at baseline and the 12-month follow-up). The LMM showed that 48 biomarkers were linked to AD and 46 to CVD (p < 0.05). Both AD and CVD were associated with longitudinal changes in 14 biomarkers (α1Micro, ApoH, β2M, BNP, complement C3, cystatin C, KIM1, NGAL, PPP, TIM1, THP, TFF3, TM, and VEGF), and both MCI and CVD were associated with 12 biomarkers (ApoD, AXL, BNP, Calcitonin, CD40, C-peptide, pM, PPP, THP, TNFR2, TTR, and VEGF), suggesting intricate connections between cognitive decline and cardiovascular health. Among these, the Tamm Horsfall Protein (THP) was associated with AD, MCI, CVD, and APOE-ε4. This study provides valuable insights into shared and distinct biological markers and mechanisms underlying AD and CVD.

Association of life's essential 8 with risk of recurrent cardiovascular events among patients with coronary heart disease

AIMS

To examine the association of Life's Essential 8 (LE8) with the risk of recurrent cardiovascular events among patients with CHD.

METHODS

This prospective cohort study included 11,997 patients with CHD from the UK Biobank. The LE8 score was generated using five lifestyle factors (diet, body mass index, physical activity, smoking, and sleep) and three biological factors (blood lipids, blood glucose, and blood pressure). LE8 score ranged from 0 to 100 and was categorized into quartiles. Cox proportional hazards regression models were applied to estimate the hazard ratio (HR) and 95% CI (confidence interval).

RESULTS

During a median follow up of 12.5 years, we documented 3366 recurrent cardiovascular events, 1068 myocardial infarction, 1829 heart failure events, 703 strokes, and 934 cardiovascular deaths. The multivariable-adjusted HR (95% CI) for the highest versus the lowest quartile of LE8 score was 0.57 (0.50, 0.65) for recurrent cardiovascular events, 0.66 (0.52, 0.83) for myocardial infarction, 0.54 (0.45, 0.67) for heart failure, 0.50 (0.36, 0.68) for stroke, and 0.46 (0.37, 0.56) for cardiovascular death. Furthermore, the population attributable fraction of the lowest to the highest quartile of LE8 score were ranged from 16.2% to 32.5% for the various cardiovascular outcomes. In addition, biomarkers including renal function and inflammation collectively explained 47.6%-87.7% of the associations between the lifestyle factors and recurrent cardiovascular events.

CONCLUSIONS

Better cardiovascular health as measured by LE8 was associated with significantly lower risk of recurrent cardiovascular events among patients with CHD. Clinicians should prioritize educating patients with CHD on the importance of optimal cardiovascular health for secondary prevention. In addition, our findings indicated significant mediation effect of biomarkers involving of glycemic control, renal function, liver function, lipid profile, and systemic inflammation on the associations between overall lifestyle factors and recurrent cardiovascular events.

Sex difference in the association between creatinine-to-cystatin C ratio and metabolic syndrome among Chinese adults

Background

Metabolic syndrome (MetS), characterized by central obesity, insulin resistance, dyslipidemia, and hypertension, affects 20-25% of the global population. The creatinine-to-cystatin C ratio (CCR) is an indicator of skeletal muscle mass. While CCR may play a role in MetS development, sex differences in these associations are not fully understood. Therefore, this study aimed to investigate how CCR levels are associated with MetS in a Chinese adult population, focusing on possible sex disparities.

Method

We conducted a retrospective cross-sectional analysis of 9,376 adults from Xiamen Chang Gung Hospital between 2014 to 2016. We examined the relationship between CCR and MetS, adjusting for cardiometabolic risk factors.

Results

The prevalence of MetS was 24.7% in males and 18.0% in females. Interestingly, we observed significant sex differences in the association between CCR quartiles and MetS. Females in the lowest CCR quartile had a significantly higher risk of MetS (odds ratio=1.84). Receiver operating characteristic curve analysis revealed acceptable diagnostic power of CCR for MetS in females (area under the curve=0.65) but not in males.

Conclusion

Our findings suggest that CCR is an independent risk factor for MetS in females, highlighting the importance of sex-specific assessments when evaluating MetS risk.

Prognostic implications of thyroid hormones in acute aortic dissection: mediating roles of renal function and coagulation

Background

Thyroid hormones significantly influence cardiovascular pathophysiology, yet their prognostic role in acute aortic dissection (AAD) remains inadequately explored. This study assesses the prognostic value of thyroid hormone levels in AAD, focusing on the mediating roles of renal function and coagulation.

Methods

We included 964 AAD patients in this retrospective cohort study. Utilizing logistic regression, restricted cubic splines, and causal mediation analysis, we investigated the association between thyroid hormones and in-hospital mortality and major adverse cardiovascular events (MACEs).

Results

In AAD patients overall, an increase of one standard deviation in FT4 levels was associated with a 31.9% increased risk of MACEs (OR 1.319; 95% CI 1.098-1.584) and a 36.1% increase in in-hospital mortality (OR 1.361; 95% CI 1.095-1.690). Conversely, a higher FT3/FT4 ratio was correlated with a 20.2% reduction in risk of MACEs (OR 0.798; 95% CI 0.637-0.999). This correlation was statistically significant predominantly in Type A AAD, while it did not hold statistical significance in Type B AAD. Key renal and coagulation biomarkers, including blood urea nitrogen, creatinine, cystatin C, prothrombin time ratio, prothrombin time, and prothrombin time international normalized ratio, were identified as significant mediators in the interplay between thyroid hormones and MACEs. The FT3/FT4 ratio exerted its prognostic influence primarily through the mediation of renal functions and coagulation, while FT4 levels predominantly impacted outcomes via a partial mediation effect on coagulation.

Conclusion

FT4 levels and the FT3/FT4 ratio are crucial prognostic biomarkers in AAD patients. Renal function and coagulation mediate the association between the thyroid hormones and MACEs.

Identification of diagnostic biomarkers used in the diagnosis of cardiovascular diseases and diabetes mellitus: A systematic review of quantitative studies

AIMS

To perform a systematic review of studies that sought to identify diagnostic biomarkers for the diagnosis of cardiovascular diseases (CVDs) and diabetes mellitus (DM), which could be used in low- and middle-income countries (LMICs) where there is a lack of diagnostic equipment, treatments and training.

MATERIALS AND METHODS

Papers were sourced from six databases: the British Nursing Index, Google Scholar, PubMed, Sage, Science Direct and Scopus. Articles published between January 2002 and January 2023 were systematically reviewed by three reviewers and appropriate search terms and inclusion/exclusion criteria were applied.

RESULTS

A total of 18 studies were yielded, as well as 234 diagnostic biomarkers (74 for CVD and 160 for DM). Primary biomarkers for the diagnosis of CVDs included growth differentiation factor 15 and neurogenic locus notch homologue protein 1 (Notch1). For the diagnosis of DM, alpha-2-macroglobulin, C-peptides, isoleucine, glucose, tyrosine, linoleic acid and valine were frequently reported across the included studies. Advanced analytical techniques, such as liquid chromatography mass spectrometry, enzyme-linked immunosorbent assays and vibrational spectroscopy, were also repeatedly reported in the included studies and were utilized in combination with traditional and alternative matrices such as fingernails, hair and saliva.

CONCLUSIONS

While advanced analytical techniques are expensive, laboratories in LMICs should carry out a cost-benefit analysis of their use. Alternatively, laboratories may want to explore emerging techniques such as infrared, Fourier transform-infrared and near-infrared spectroscopy, which allow sensitive noninvasive analysis.

Health-related quality of life and DNA methylation-based aging biomarkers among survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at high risk for morbidity and mortality and poor patient-reported outcomes, typically health-related quality of life (HRQOL). However, associations between DNA methylation-based aging biomarkers and HRQOL have not been evaluated.

METHODS

DNA methylation was generated with Infinium EPIC BeadChip on blood-derived DNA (median for age at blood draw = 34.5 years, range = 18.5-66.6 years), and HRQOL was assessed with age at survey (mean = 32.3 years, range = 18.4-64.5 years) from 2206 survivors in the St Jude Lifetime Cohort. DNA methylation-based aging biomarkers, including epigenetic age using multiple clocks (eg, GrimAge) and others (eg, DNAmB2M: beta-2-microglobulin; DNAmADM: adrenomedullin), were derived from the DNAm Age Calculator (https://dnamage.genetics.ucla.edu). HRQOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey to capture 8 domains and physical and mental component summaries. General linear models evaluated associations between HRQOL and epigenetic age acceleration (EAA; eg, EAA_GrimAge) or other age-adjusted DNA methylation-based biomarkers (eg, ageadj_DNAmB2M) after adjusting for age at blood draw, sex, cancer treatments, and DNA methylation-based surrogate for smoking pack-years. All P values were 2-sided.

RESULTS

Worse HRQOL was associated with greater EAA_GrimAge (physical component summaries: β = -0.18 years, 95% confidence interval [CI] = -0.251 to -0.11 years; P = 1.85 × 10-5; and 4 individual HRQOL domains), followed by ageadj_DNAmB2M (physical component summaries: β = -0.08 years, 95% CI = -0.124 to -0.037 years; P = .003; and 3 individual HRQOL domains) and ageadj_DNAmADM (physical component summaries: β = -0.082 years, 95% CI = -0.125 to -0.039 years; P = .002; and 2 HRQOL domains). EAA_Hannum (Hannum clock) was not associated with any HRQOL.

CONCLUSIONS

Overall and domain-specific measures of HRQOL are associated with DNA methylation measures of biological aging. Future longitudinal studies should test biological aging as a potential mechanism underlying the association between poor HRQOL and increased risk of clinically assessed adverse health outcomes.

Association of the subclinical atherosclerosis with additional risk factors for chronic non-communicable diseases

Classical risk factors and high cardiovascular risk are known to be associated with subclinical atherosclerosis. However, predictive scales do not always identify people with this pathology. Additional risk factors could provide valuable indicators for the presence of asymptomatic atherosclerosis. Several studies demonstrated a close relationship between subclinical atherosclerosis markers and insulin resistance, glycated hemoglobin levels in non-diabetic individuals, growth differentiation factor-15, circulating proteins, cystatin C, and hearing loss determined by audiometry. These impairments can justify a diagnostic search for subclinical atherosclerosis. This review studies the association of subclinical atherosclerosis with additional risk factors.

NEW PREDICTIVE BIOMARKERS FOR SCREENING COVID-19 PATIENTS WITH RHABDOMYOLYSIS IN COMBINATION WITH CYSTATIN C

ABSTRACT

Purpose: Cystatin C (CysC) has been linked to the prognosis of corona virus disease 2019 (COVID-19). The study aims to investigate a predictor correlated with CysC screening for poor prognosis in COVID-19 patients combined with skeletal muscle (SKM) impairment and rhabdomyolysis (RM). Methods: A single-center retrospective cohort analysis was carried out. Demographic information, clinical data, laboratory test results, and clinical outcome data were gathered and analyzed. Results: According to the inclusion and exclusion criteria, 382 patients were included in this study. The subjects were divided into three groups based on CysC tertiles. Multivariate analysis revealed that SaO 2 (hazard ratio [HR], 0.946; 95% confidence interval [CI], 0.906-0.987; P = 0.011), CysC (HR, 2.124; 95% CI, 1.223-3.689; P = 0.008), aspartate aminotransferase (AST) (HR, 1.009; 95% CI, 1.000-1.018; P = 0.041), and hypersensitive C-reactive protein (HR, 1.005; 95% CI, 1.000-1.010; P = 0.045) were significantly associated with survivals. The area under curve (AUC) in the model characterized by RM incidence was 0.819 (0.698-0.941), as shown by CysC receiver operating characteristic curves. LDH*CysC and AST*CysC had better predictive values than CysC and the best prediction for RM, with an AUC of 0.880 (0.796,0.964) for LDH*CysC ( P < 0.05, vs CysC) and 0.925 (0.878,0.972) for AST*CysC ( P < 0.05, vs CysC). Conclusion: CysC is an essential evaluation indicator for COVID-19 patients' prognosis. AST*CysC and LDH*CysC have superior predictive value to CysC for SKM, RM, and death, and optimal classification for RM.

Multiplexed MRM-based proteomics for identification of circulating proteins as biomarkers of cardiovascular damage progression associated with diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) increases the risk of coronary heart disease (CHD) by 2-4 fold, and is associated with endothelial dysfunction, dyslipidaemia, insulin resistance, and chronic hyperglycaemia. The aim of this investigation was to assess, by a multimarker mass spectrometry approach, the predictive role of circulating proteins as biomarkers of cardiovascular damage progression associated with diabetes mellitus.

METHODS

The study considered 34 patients with both T2DM and CHD, 31 patients with T2DM and without CHD, and 30 patients without diabetes with a diagnosis of CHD. Plasma samples of subjects were analysed through a multiplexed targeted liquid chromatography mass spectrometry (LC-MS)-based assay, namely Multiple Reaction Monitoring (MRM), allowing the simultaneous detection of peptides derived from a protein of interest. Gene Ontology (GO) Analysis was employed to identify enriched GO terms in the biological process, molecular function, or cellular component categories. Non-parametric multivariate methods were used to classify samples from patients and evaluate the relevance of the analysed proteins' panel.

RESULTS

A total of 81 proteins were successfully quantified in the human plasma samples. Gene Ontology analysis assessed terms related to blood microparticles, extracellular exosomes and collagen-containing extracellular matrix. Preliminary evaluation using analysis of variance (ANOVA) of the differences in the proteomic profile among patient groups identified 13 out of the 81 proteins as significantly different. Multivariate analysis, including cluster analysis and principal component analysis, identified relevant grouping of the 13 proteins. The first main cluster comprises apolipoprotein C-III, apolipoprotein C-II, apolipoprotein A-IV, retinol-binding protein 4, lysozyme C and cystatin-C; the second one includes, albeit with sub-grouping, alpha 2 macroglobulin, afamin, kininogen 1, vitronectin, vitamin K-dependent protein S, complement factor B and mannan-binding lectin serine protease 2. Receiver operating characteristic (ROC) curves obtained with the 13 selected proteins using a nominal logistic regression indicated a significant overall distinction (p < 0.001) among the three groups of subjects, with area under the ROC curve (AUC) ranging 0.91-0.97, and sensitivity and specificity ranging from 85 to 100%.

CONCLUSIONS

Targeted mass spectrometry approach indicated 13 multiple circulating proteins as possible biomarkers of cardiovascular damage progression associated with T2DM, with excellent classification results in terms of sensitivity and specificity.

Targeting inflammation in atherosclerosis: overview, strategy and directions

Atherosclerosis is a chronic condition characterised by the build-up of plaque in the inner lining of the blood vessels and it is the main underlying cause of cardiovascular disease. The development of atherosclerosis is associated with the accumulation of cholesterol and inflammation. Although effective therapies exist to lower low-density lipoprotein cholesterol (LDL-C) levels, some patients still experience cardiovascular events due to persistent inflammation, known as residual inflammatory risk (RIR). Researchers have conducted laboratory and animal studies to investigate the measurement and targeting of the inflammatory cascade associated with atherosclerosis, which have yielded promising results. In addition to guideline-directed lifestyle modifications and optimal medical therapy focusing on reducing LDL-C levels, pharmacological interventions targeting inflammation may provide further assistance in preventing future cardiac events. This review aims to explain the mechanisms of inflammation in atherosclerosis, identifies potential biomarkers, discusses available therapeutic options and their strengths and limitations, highlights future advancements, and summarises notable clinical studies. Finally, an evaluation and management algorithm for addressing RIR is presented.

Association of beta-2-microglobulin, cystatin C and lipocalin-2 with stroke risk in the general Chinese population

INTRODUCTION

Beta-2-microglobulin (B2M), cystatin C and lipocalin-2 (LCN-2) are established renal biomarkers, yet their roles in stroke have not been fully evaluated. We aimed to investigate the relationship of B2M, cystatin C, and LCN-2 with stroke risk in a general Chinese population.

METHODS

We used ordinal regression to study the relationship between serum B2M, cystatin C, and LCN-2 with stroke risk in 1060 participants (mean age 45.4 ± 10.8 years, 46% male) from the Shenzhen-Hong Kong United Network on Cardiovascular Disease (SHUN-CVD) study. Stroke risk was classified into low-risk, middle-risk and high-risk groups according to the China National Stroke Screening Survey criteria. Serum biomarker levels were measured using immunoturbidimetric assays. Participants with valid data on serum biomarker levels and stroke risk were included in the analysis.

RESULTS

The number of participants in the low-risk, middle-risk and high-risk stroke risk groups were 663, 143 and 254 respectively. Elevated serum B2M, cystatin C, and LCN-2 levels were associated with being male, overweight/obesity, hypertension, alcohol consumption and smoking. Serum B2M, cystatin C and LCN-2 levels were significantly associated with stroke risk in the overall population (B2M: β = 0.595, p < .001; cystatin C: β = 3.718, p < .001; LCN-2: β = 0.564, p < .001) after adjustment for age.

CONCLUSION

Elevated serum B2M, cystatin C and LCN-2 levels are associated with stroke risk. They may be novel biomarkers for clinicians to assess stroke risk.Key messagesSerum beta-2-microglobulin, cystatin C and lipocalin-2 levels are significantly associated with stroke risk.Beta-2-microglobulin, cystatin C and lipocalin-2 may serve as useful biomarkers for stroke risk stratification in the general population.

Joint Associations of Pregnancy Complications and Postpartum Maternal Renal Biomarkers With Severe Cardiovascular Morbidities: A US Racially and Ethnically Diverse Prospective Birth Cohort Study

BACKGROUND

Pregnancy complications are risk factors for cardiovascular disease (CVD). Little is known about the role of renal biomarkers measured shortly after delivery, individually or in combination with pregnancy complications, in predicting subsequent severe maternal CVD.

METHODS AND RESULTS

This study included 566 mothers of diverse races and ethnicities from the Boston Birth cohort, enrolled at delivery and followed prospectively. Plasma creatinine and CysC (cystatin C) were measured 1 to 3 days after delivery. CVD during follow-up was defined by physician diagnoses in electronic medical records. Associations of renal biomarkers and pregnancy complications with time-to-CVD events were assessed using Cox proportional hazards models. During an average of 10.3±3.2 years of follow-up, 30 mothers developed 1 or more CVDs. Only a modest association was observed between creatinine and risk of CVD. In comparison, we found that per 0.1 mg/L increase of CysC was associated with a hazard ratio (HR) of 1.2 (95% CI, 1.1-1.4) for CVD after adjusting for covariates. Compared with those without preeclampsia and with normal CysC level (≤75th percentile), mothers with preeclampsia and elevated CysC (>75th percentile) had the highest risk of CVD (HR, 4.6 [95% CI, 1.7-17.7]), whereas mothers with preeclampsia only or with elevated CysC only did not have significantly increased CVD risk. Similar synergistic effects for CVD were observed between CysC and preterm delivery.

CONCLUSIONS

In this sample of US, traditionally underrepresented multiracial and multiethnic high-risk mothers, elevated maternal plasma CysC, independently and jointly with pregnancy complications, increased risk of CVD later in life. These findings warrant further investigation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03228875.

Predictive value of serum human epididymis protein 4 for heart failure in patients with chronic kidney disease

AIM

To investigate the predictive value of human epididymis protein 4 (HE4) for heart failure in patients with chronic kidney disease (CKD).

METHODS

This study retrospectively analyzed the data of 241 patients with CKD admitted to Zhangjiakou First Hospital from January 2019 to January 2021. The subjects were divided into a heart failure (HF) group (n=117) and a non-HF group (n=124) according to whether heart failure occurred. The baseline data and laboratory hematologic indicators (complete set of HE4, blood routine and biochemistry) were collected and analyzed by univariate analysis. Subsequently, the variables that were significant in the correlation analysis were included in a multi-factor logistic regression analysis.

RESULTS

The HF group exhibited higher serum creatinine, HE4, hemoglobin, total cholesterol, triglycerides (TG), high-density lipoprotein (P<0.05), as well as higher B-type natriuretic peptide (BNP), creatine kinase, and creatine kinase-MB than the non-HF group, with significant differences (P<0.05). Spearman's rank correlation analysis revealed that age, HE4, calcium, TG, BNP and left ventricle ejection fraction were associated with the occurrence of heart failure (P<0.05). Multivariate analysis demonstrated that HE4 was a significant factor that could predict the development of heart failure in CKD patients (P<0.01), and the risk of heart failure was higher when HE4>27.2368 pmol/L.

CONCLUSIONS

HE4 is an important factor for predicting the occurrence of heart failure in CKD patients. A higher HE4 level predicts greater possibility of heart failure.

eGFRcystatinC/eGFRcreatinine ratio < 0.6 in patients with SARS-CoV-2 pneumonia: a prospective cohort study

BACKGROUND

Shrunken Pore Syndrome (SPS), defined as a reduced ratio between two estimated filtration rates (based on cystatin C and creatinine) is an increasingly recognized risk factor for long-term mortality. Although some patients with other conditions might be erroneously identified as SPS. Our aim was to bring the focus on possible pathophysiologic mechanisms influencing the ratio in the setting of SARS-CoV-2 pneumonia and acute kidney injury.

METHODS

A single-centered prospective cohort study was conducted to investigate biomarkers in symptomatic COVID-19 pneumonia patients admitted to a hospital in Latvia. Nineteen biomarkers were measured in blood and three in urine samples. Associations were sought between these biomarkers, chronic diseases and the estimated GFRcystatinC/eGFRcreatinine ratio < 0.6, mortality rates, and acute kidney injury development. Data analysis was performed using SPSS Statistics, with significance set at p < 0.05.

RESULTS

We included 59 patients (average age 65.5 years, 45.8% female) admitted with COVID-19. Acute kidney injury occurred in 27.1%, and 25.4% died. Ratio < 0.6 was seen in 38.6%, associated with female sex, diabetes, hypothyroidism, and higher age. Ratio < 0.6 group had mortality notably higher - 40.9% vs. 16.2% and more cases of acute kidney injury (40.9% vs. 18.9%). Cystatin C showed strong associations with the ratio < 0.6 compared to creatinine. Urea levels and urea/creatinine ratio were higher in the ratio < 0.6 group. After excluding acute kidney injury patients, ratio < 0.6 remained associated with higher cystatin C and urea levels. Other biomarkers linked to a kidney injury as NGAL, and proteinuria did not differ.

CONCLUSION

We prove that reduced ratio is common in hospitalized patients with SARS-CoV-2 pneumonia and is associated with increased mortality during hospitalization. Factors that influence this ratio are complex and, in addition to the possible shrinkage of pores, other conditions such as thickening of glomerular basal membrane, comorbidities, prerenal kidney failure and others may play an important role and should be addressed when diagnosing SPS. We highlight the need for additional diagnostic criteria for SPS and larger studies to better understand its implications in acute COVID-19 settings.

The potential of cystatin C as a predictive biomarker in pulmonary hypertension

BACKGROUND

Cystatin C is a novel biomarker to identify renal dysfunction and cardiovascular risk.

OBJECTIVE

The aim of this study was to investigate the role of cystatin C in non-invasive risk prediction in a large cohort of patients with pre-capillary pulmonary hypertension (PH).

METHOD

We retrospectively analyzed pre-capillary PH patients with available cystatin C and hemodynamic data derived from right heart catheterization.

RESULTS

A total of 398 consecutive patients with confirmed pre-capillary PH were recruited from Fuwai Hospital between November 2020 and November 2021. Over a median duration of 282 days, 72 (18.1%) of these patients experienced clinical worsening. Cystatin C levels significantly correlated with cardiac index (r = -0.286, P < 0.001), mixed venous oxygen saturation (r = -0.216, P < 0.001), and tricuspid annular plane systolic excursion (r = -0.236, P < 0.001), and high cystatin C levels independently predicted a poor prognosis after adjusting potential confounders in different models (all P < 0.05). A three-group non-invasive risk model was constructed based on the combined assessment of the cystatin C and WHO-FC using dichotomous cut-off value. Those patients with higher cystatin C (≥ 1.0 mg/L) and a worse WHO-FC experienced the highest risk of endpoint occurrence. The predictive capacity of this model was comparable to that of an existing invasive risk stratification model (area under curve: 0.657 vs 0.643, P = 0.619).

CONCLUSIONS

Cystatin C levels were associated with disease severity and prognosis in patients with pre-capillary PH. A combination of high cystatin C and advanced WHO-FC identifies patients at particularly high risk of clinical deterioration.

Antiretroviral Treatment-Induced Galectin-9 Might Impact HIV Viremia in Addition to Contributing to Inflammaging

BACKGROUND

Galectin-9 induces HIV reactivation and also contributes to non-AIDS events through inflammaging. Hence, it is important to assess its levels in HIV-infected individuals to determine their association with HIV viremia and other comorbidities.

METHODS

Plasma galectin-9 levels were estimated in viremic (n = 152) and aviremic (n = 395) individuals on first-line antiretroviral therapy (ART). They were assessed for correlation with HIV-1 viral load (VL), CD4 count, and ART duration, as well as for receiver operating characteristic curve analysis.

RESULT

Plasma galectin-9 levels correlated positively with VL (r = 0.507, p < 0.0001) and ART duration (r = 0.308, p = 0.002) and negatively with CD4 count (r = -0.186, p < 0.0001). Area under the curve for galectin-9/CD4 count ratio for identifying viremic individuals was 0.906. Sensitivity and specificity of the ratio at a cutoff of 14.47 were 90.13% and 70.05%, respectively, for detecting viremic individuals. Further, galectin-9 levels correlated with cystatin C (r = 0.239, p = 0.0183), IL-18 (r = 0.311, p = 0.006), and systolic blood pressure (r = 0.220, p = 0.0355). Galectin-9-induced HIV reactivation was significantly lower in individuals on long-term ART than those on short-term ART.

CONCLUSION

The galectin-9-to-CD4 count ratio indicated the potential of galectin-9 as a cheaper monitoring tool to detect HIV viremia. Strategies for countering the effects of galectin-9 for controlling HIV viremia and non-AIDS events are urgently warranted.

Correlation Analysis and Diagnostic Value of Serum Homocysteine, Cystatin C and Uric Acid Levels with the Severity of Coronary Artery Stenosis in Patients with Coronary Heart Disease

Background

Coronary angiography (CAG) is an invasive examination with high risks and costs and various complications may occur. It is necessary to find a diagnostic method, non-invasiveness, inexpensive with low risk. This study aims to analyze the correlation between the levels of serum homocysteine (Hcy), cystatin C (Cys C) and uric acid (UA) and Gensini score in patients with coronary heart disease (CHD) and assess their diagnostic value for CHD.

Methods

A retrospective analysis was conducted on 1412 patients underwent CAG from October 2019 to December 2021, and we conducted this study from January to July 2022. A total of 765 patients with CHD confirmed by CAG were selected as the research group, while 647 patients revealed as non-obstructive stenosis by CAG as the control group. The serum Hcy, Cys C and UA levels were detected and the correlation between Gensini score and variables was analyzed. The receiver-operating characteristic (ROC) curve was performed to assess the diagnostic value of the Hcy, Cys C and UA for CHD.

Results

The serum Hcy, Cys C and UA levels in the research group were higher as compared with the control group (p<0.05). Spearman correlation and multivariate linear regression analysis showed that there was a significantly positive correlation between Gensini score and serum Hcy, Cys C and UA levels (p<0.05). The ROC curve analysis presented the combined Hcy and Cys C with UA having the highest specificity of diagnostic value for CHD (area under the curve (AUC)=0.768, 95% CI 0.706-0.823, specificity = 72.34%, sensitivity = 67.88%, Youden Index = 0.4022).

Conclusion

The serum Hcy, Cys C and UA levels in patients with CHD were significantly increased, positive correlation with Gensini score. The combined Hcy and Cys C with UA could be used to assess the severity of coronary artery stenosis and provide predictive and early intervention treatment values for CHD and a new way of diagnosing CHD, which is cheap, safe, effective and deserving of clinical application.

Volunteering and Changes in Cardiovascular Biomarkers: Longitudinal Evidence From the Health and Retirement Study

Background and Objectives

Growing body of research shows that volunteering is beneficial for those served, the volunteers, and the larger communities. However, major challenges remain that hinder the practical implications for volunteer activity as a public health intervention, including potential selection effects, lack of longitudinal studies that adjust for baseline characteristics, and a paucity of studies that consider multiple physical health outcomes in a single model.

Research Design and Methods

Data from 2006 to 2016 waves of the Health and Retirement Study (2006-2016) were used (N = 18,847). Outcome-wide analyses were utilized to evaluate if changes in volunteering between 2006/2008 (t0) and 2010/2012 (t1) were associated with 7 cardiovascular disease biomarkers 4 years later (2014/2016, t2). These models were adjusted for demographic factors, socioeconomic status, health behaviors, chronic conditions, baseline biomarkers, and volunteering. Additionally, selection into volunteering and attrition were taken into account.

Results

Compared with nonvolunteers, volunteering more than 200 hr a year was associated with a lower risk for clinically high diastolic blood pressure. In addition, increased volunteering effort (change from 1 to 99 hr at t0 to >100 hr at t1) was associated with a lower likelihood of clinically high systolic and diastolic blood pressure levels. Sustained high volunteering (>100 hr at both t0 and t1) was associated with lower diastolic blood pressure.

Discussion and Implications

The current study adds to the evidence on the health benefits of volunteering for adults 50 and older by inferring a potential causal link between high-intensity volunteering and reduced blood pressure.

Joint associations of pregnancy complications and postpartum maternal renal biomarkers with severe cardiovascular morbidities: A US racially diverse prospective birth cohort study

Rationale & Objective

Pregnancy complications are risk factors for cardiovascular diseases (CVD). Little is known about the role of renal biomarkers measured shortly after delivery, individually or in combination with pregnancy complications, in predicting subsequent severe maternal CVD.

Methods

This study included 576 mothers of diverse ethnicities from the Boston Birth cohort, enrolled at delivery and followed prospectively. Plasma creatinine and cystatin C were measured 1-3 days after delivery. CVD during follow-up was defined by physician diagnoses in electronic medical records. Associations of renal biomarkers and pregnancy complications with time-to-CVD events were assessed using Cox proportional hazards models.

Results

During an average of 10.3±3.2 years of follow-up, 34 mothers developed one or more CVD events. Although no significant associations were found between creatinine and risk of CVD, per unit increase of cystatin C (CysC) was associated with a hazard ratio (HR) of 5.21 (95%CI = 1.49-18.2) for CVD. A borderline significant interactive effect was observed between elevated CysC (≥75th percentile) and preeclampsia. Compared to those without preeclampsia and with normal CysC level (<75 th percentile), mothers with preeclampsia and elevated CysC had the highest risk of CVD (HR=3.8, 95%CI = 1.4-10.2), while mothers with preeclampsia only or with elevated CysC only did not have significantly increased CVD risk. Similar synergistic effects for CVD were observed between CysC and preterm delivery.

Conclusions

In this sample of US, traditionally under-represented multi-ethnic high-risk mothers, elevated maternal plasma cystatin C and pregnancy complications synergistically increased risk of CVD later in life. These findings warrant further investigation.

Clinical Perspectives

What is new?Maternal postpartum elevated levels of cystatin C are independently associated with higher risk of cardiovascular diseases (CVD) later in life.Maternal pregnancy complications coupled with postpartum elevated levels of cystatin C synergistically increased future risk of CVD.What are the clinical implications?These findings, if further confirmed, suggest that women with pregnancy complications and elevated postpartum cystatin C may be at particular high risk for CVD later in life compared to women without these risk factors.

The Mediating Role of Biomarkers in the Association Between Subjective Aging and Episodic Memory

OBJECTIVES

Subjective aging, indexed by subjective age and self-perceptions of aging (SPA), is consistently related to cognition in adulthood. The present study examined whether blood biomarkers mediate the longitudinal associations between subjective aging indices and memory.

METHODS

Data of 5,369 individuals aged 50-94 years (mean = 66.89 years, SD = 9.22; 60% women) were drawn from the Health and Retirement Study (HRS). Subjective age, SPA, and demographic factors were assessed in 2012/2014. Interleukin-6, C-reactive protein, albumin, cystatin C, N-terminal pro B-type natriuretic peptide (NT-proBNP), fasting glucose, Vitamin D, hemoglobin, red cells distribution width, and epigenetic aging were assessed as part of the HRS Venuous Blood Study in 2016. Memory was measured in 2018. The mediators (except for epigenetic aging, which was assessed in a subsample) were tested simultaneously in models that accounted for demographic covariates.

RESULTS

An older subjective age was related to worse memory partially through higher fasting glucose, higher cystatin C, higher NT-proBNP, and accelerated epigenetic aging. Negative SPA was related to worse memory through lower Vitamin D3, higher fasting glucose, higher cystatin C, higher NT-proBNP, and accelerated epigenetic aging. The biomarkers explained between 2% and 10% of subjective age and between 1% and 8% of SPA associations with memory. Additional analysis revealed that biomarkers continued to be significant mediators when physical inactivity and depressive symptoms were included as additional mediators.

CONCLUSION

The present study adds to existing research on the association between subjective aging and memory by providing new evidence on the biological mediators of this association.

Advances in congestive heart failure biomarkers

Congestive heart failure (CHF) is the leading cause of morbidity and mortality in the elderly worldwide. Although many biomarkers associated with in heart failure, these are generally prognostic and identify patients with moderate and severe disease. Unfortunately, the role of biomarkers in decision making for early and advanced heart failure remains largely unexplored. Previous studies suggest the natriuretic peptides have the potential to improve the diagnosis of heart failure, but they still have significant limitations related to cut-off values. Although some promising cardiac biomarkers have emerged, comprehensive data from large cohort studies is lacking. The utility of multiple biomarkers that reflect various pathophysiologic pathways are increasingly being explored in heart failure risk stratification and to diagnose disease conditions promptly and accurately. MicroRNAs serve as mediators and/or regulators of renin-angiotensin-induced cardiac remodeling by directly targeting enzymes, receptors and signaling molecules. The role of miRNA in HF diagnosis is a promising area of research and further exploration may offer both diagnostic and prognostic applications and phenotype-specific targets. In this review, we provide insight into the classification of different biochemical and molecular markers associated with CHF, examine clinical usefulness in CHF and highlight the most clinically relevant.