Circulating biomarkers for predicting cardiovascular disease risk; a systematic review and comprehensive overview of meta-analyses

Dose-dependent effects of omega-3 polyunsaturated fatty acids on C-reactive protein concentrations in cardiometabolic disorders: a dose-response meta-analysis of randomized clinical trials

BACKGROUND

Based on current knowledge, omega-3 fatty acids help to reduce the concentration of C-reactive protein (CRP). However, the dose-response effect and the strength of this effect are not entirely clear.

METHODS

We systematically searched and screened databases to include eligible studies. This study incorporates a random effect, as well as dose-response meta-analyses using a restricted cubic spline model.

RESULTS

Forty randomized clinical trials were analyzed. Results demonstrated significant non-linear dose-response efficacy in the reduction of CRP concentration in patients with cardiovascular disease, metabolic syndrome, and hypertension up to 1200 mg/day of EPA and DHA. In addition, there was a linear decrease in CRP concentration in the dyslipidemia population. The meta-analysis results did not show any significant reduction of CRP in overweight and obese participants, and the dose-response analysis failed to show any apparent reduction. In type 2 diabetes, pooling the results revealed a significant reduction in CRP; however, the combination of EPA and DHA failed to show significant dose-response efficacy in changing CRP concentration.

CONCLUSION

1200 mg/day of EPA and DHA may help to reduce CRP concentration in patients with cardiometabolic disorders. This reduction is clinically significant, and thus intervention with omega-3 fatty acids should be considered for this population.

Fitness age outperforms body mass index in differentiating aging patterns and health risk profiles of healthy adults aged 51-80 years

Physical fitness has been extensively shown to strongly associate with general health status and major health risks. Here we tested the ability of a novel estimate of fitness age (FitAge) to differentiate aging trajectories.This study aimed at (1) testing the ability of FitAge to differentiate aging patterns among decelerated, normal, and accelerated agers in selected health domains, (2) estimating the risk for developing major health issues depending on the aging trajectory, and (3) comparing FitAge to body mass index (BMI) categorization in differentiating healthy from unhealthy aging patterns.A total of 176 volunteers participated in this cross-sectional study. Participants underwent clinical screening and a comprehensive assessment of body composition, nutritional and health-related status, cognitive functioning, and haematochemical analyses with routine tests, oxidative stress, and inflammation markers. Scores for major health risks were also computed.FitAge outperformed BMI in estimating major health risk scores and was able to differentiate decelerated from normal and accelerated agers for health risk profile and several physiological domains. Body composition, immune system activation, and inflammation markers emerged as those variables flagging the largest differences between decelerated and accelerated aging patterns.The novel estimate of biological aging can accurately differentiate both in women and men decelerated from accelerated agers in almost all the domains scrutinized. Overall, decelerated aging is linked to positively oriented features which associate with reduced risk of developing major health issues.The present findings have potential relevance and practical implications to identify individuals at higher risk of accelerated aging according to their FitAge estimated via simple and cost-effective motor tests.

Old, the new, more or less and the conundrum for biomarkers in cardiovascular diseases?

Biomarkers are critical for diagnostic, monitoring and management of cardiovascular diseases. Opportunities to improve how biomarkers are used are important. This editorial on biomarkers in coronary artery disease provides commentary on the study as well as broad benchmarks on what make ideal biomarkers. Biomarker discovery is difficult and opportunities to expand and improve their use should be encouraged.

Elevated oxidative stress biomarkers in adults with segmented sleep patterns

STUDY OBJECTIVES

We investigated the association between different sleep patterns and inflammatory and oxidative stress biomarkers in adults.

METHODS

A total of 321 consented adults who fulfilled the inclusion criteria were recruited in this cross-sectional study. The inclusion criteria were mainly based on apparently healthy adults aged 18-59 years. To identify sleep patterns, participants were requested to wear the actigraph for 1 week for 24 hours a day. Fasting blood was collected from each participant at day 8. The blood serum was analyzed for inflammatory and oxidative stress biomarkers. Sleep patterns were defined as monophasic (1 episode of night sleep) biphasic (2 episodes of sleep; night and aternoon siesta), and polyphasic sleep pattern (3 or more sleep episodes).

RESULTS

There was no correlation between night sleep duration, total sleep in 24 hours, and napping among inflammatory and oxidative stress biomarkers: high-sensitivity C-reactive protein, malondialdehyde, total glutathione, and basal oxidizability status. Actigraphy reports showed 3 sleep patterns in this cohort, monophasic (24.3%), biphasic-napping (45.2%) and polyphasic (30.5%). Individuals with segmented sleep patterns were significantly associated with oxidative stress biomarkers. A polyphasic sleep pattern was significantly associated with higher basal oxidizability status (P = .023), whereas a biphasic sleep pattern showed higher malondialdehyde (P = .036) as compared to a monophasic sleep pattern. Total glutathione was significantly higher in monophasic sleepers (P = .046). There was no difference in serum high-sensitivity C-reactive protein among all sleep patterns.

CONCLUSIONS

Segmented sleep in polyphasic and biphasic sleep patterns is associated with higher serum malondialdehyde and basal oxidizability status in particular. Further studies are recommended on the cardiometabolic impact of oxidative stress biomarkers in individuals with segmented sleep.

CITATION

Al Lawati I, Zadjali F, Al-Abri MA. Elevated oxidative stress biomarkers in adults with segmented sleep patterns. J Clin Sleep Med. 2024;20(6):959-966.

Current Trends in Biohumoral Screening for the Risk of Sudden Cardiac Death: A Systematic Review

Background and Objectives: Sudden cardiac death (SCD) represents a challenge to health systems globally and is met with increased frequency in the population. Over time, multiple screening methods have been proposed, including the analysis of various plasma biomarkers. This article aims to analyze for illustrative purposes the specialized literature in terms of current biomarkers and testing trends, in the case of cardiovascular diseases and implicitly sudden cardiac death. Materials and Methods: In this regard, we searched the PubMed database from 2010 to the present time using the keywords "sudden cardiac death" and "biomarkers". The inclusion criteria were clinical trials that analyzed the effectiveness of screening methods in terms of biomarkers used in stratifying the risk of cardiac distress and/or sudden cardiac death. We excluded reviews, meta-analyses, and studies looking at the effectiveness of treatments. Results: An extended approach was found, through studies that brought to the forefront both classical markers analyzed by new, more performant methods, markers for other pathologies that also determined cardiovascular impact, non-specific molecules with effects on the cardiovascular system, and state-of-the-art markers, such as microRNA. Some molecules were analyzed simultaneously in certain groups of patients. Conclusion: The observed current trend revealed the tendency to define the clinical-biological particularities of the person to be screened.

Cardiovascular biomarkers: exploring troponin and BNP applications in conditions related to carbon monoxide exposure

BACKGROUND

The diagnosis and prognosis of cardiovascular disorders are greatly aided by cardiovascular biomarkers. The uses of troponin and B-type natriuretic peptide in situations involving carbon monoxide exposure are examined in this narrative review. These biomarkers are important because they help predict outcomes in cardiovascular disorders, track the effectiveness of therapy, and influence therapeutic choices.

MAIN BODY

Clinical practice makes considerable use of B-type natriuretic peptide (BNP), which has diuretic and vasodilatory effects, and troponin, a particular marker for myocardial injury. Carbon monoxide (CO) poisoning is a major worldwide health problem because CO, a "silent killer," has significant clinical consequences. Higher risk of cardiac problems, poorer clinical outcomes, and greater severity of carbon monoxide poisoning are all linked to elevated troponin and B-type natriuretic peptide levels. BNP's adaptability in diagnosing cardiac dysfunction and directing decisions for hyperbaric oxygen therapy is complemented by troponin's specificity in identifying CO-induced myocardial damage. When combined, they improve the accuracy of carbon monoxide poisoning diagnoses and offer a thorough understanding of cardiac pathophysiology.

CONCLUSIONS

To sum up, this review emphasizes the importance of troponin and B-type natriuretic peptide (BNP) as cardiac indicators during carbon monoxide exposure. While BNP predicts long-term cardiac problems, troponin is better at short-term morbidity and death prediction. When highly sensitive troponin I (hsTnI) and B-type natriuretic peptide are combined, the diagnostic accuracy of carbon monoxide poisoning patients is improved. One of the difficulties is evaluating biomarker levels since carbon monoxide poisoning symptoms are not always clear-cut. Accurate diagnosis and treatment depend on the investigation of new biomarkers and the use of standardized diagnostic criteria. The results advance the use of cardiovascular biomarkers in the intricate field of carbon monoxide exposure.

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Blood-Based and Imaging Biomarkers of Atherosclerosis

Atherosclerosis is the main cause of arterial thrombosis, causing acute occlusive cardiovascular syndromes. Numerous risk prediction models have been developed, which mathematically combine multiple predictors, to estimate the risk of developing cardiovascular events. Current risk models typically do not include information from biomarkers that can potentially improve these existing prediction models especially if they are pathophysiologically relevant. Numerous cardiovascular disease biomarkers have been investigated that have focused on known pathophysiological pathways including those related to cardiac stress, inflammation, matrix remodelling, and endothelial dysfunction. Imaging biomarkers have also been studied that have yielded promising results with a potential higher degree of clinical applicability in detection of atherosclerosis and cardiovascular event prediction. To further improve therapy decision-making and guidance, there is continuing intense research on emerging biologically relevant biomarkers. As the pathogenesis of cardiovascular disease is multifactorial, improvements in discrimination and reclassification in risk prediction models will likely involve multiple biomarkers. This article will provide an overview of the literature on potential blood-based and imaging biomarkers of atherosclerosis studied so far, as well as potential future directions.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Variability in Sleep Duration and Biomarkers of Cardiovascular Disease Across the Menstrual Cycle

Variability in sleep duration and cardiovascular health have been infrequently investigated, particularly among reproductive-age women. We examined these associations across the menstrual cycle among a cohort of 250 healthy premenopausal women, aged 18-44 years. The BioCycle study (New York, 2005-2007) collected cardiovascular biomarkers (serum high- and low-density lipoprotein (HDL, LDL), total cholesterol, triglycerides, and C-reactive protein (CRP)) at key time points along the menstrual cycle (follicular, ovulatory, and luteal phases). Women also recorded sleep duration in daily diaries. From these data, we computed L-moments, robust versions of location, dispersion, skewness, and kurtosis. We fitted linear mixed models with random intercepts and inverse probability weighting to estimate associations between sleep variability and cardiovascular biomarkers, accounting for demographic, lifestyle, health, and reproductive factors. Sleep dispersion (any deviation from mean duration) was associated with lower mean LDL for nonshift workers and non-White women. Skewed sleep duration was associated with higher mean CRP and lower mean total cholesterol. Sleep durations with extreme short and long bouts (kurtosis) were associated with a lower mean HDL, but not mean CRP, LDL, or triglycerides. Sleep duration modified associations between sleep dispersion and LDL, HDL, and total cholesterol. Even in young and healthy women, sleep duration variability could influence cardiovascular health.

Current Toolset in Predicting Acute Coronary Thrombotic Events: The "Vulnerable Plaque" in a "Vulnerable Patient" Concept

Despite major advances in pharmacotherapy and interventional procedures, coronary artery disease (CAD) remains a principal cause of morbidity and mortality worldwide. Invasive coronary imaging along with the computation of hemodynamic forces, primarily endothelial shear stress and plaque structural stress, have enabled a comprehensive identification of atherosclerotic plaque components, providing a unique insight into the understanding of plaque vulnerability and progression, which may help guide patient treatment. However, the invasive-only approach to CAD has failed to show high predictive value. Meanwhile, it is becoming increasingly evident that along with the "vulnerable plaque", the presence of a "vulnerable patient" state is also necessary to precipitate an acute coronary thrombotic event. Non-invasive imaging techniques have also evolved, providing new opportunities for the identification of high-risk plaques, the study of atherosclerosis in asymptomatic individuals, and general population screening. Additionally, risk stratification scores, circulating biomarkers, immunology, and genetics also complete the armamentarium of a broader "vulnerable plaque and patient" concept approach. In the current review article, the invasive and non-invasive modalities used for the detection of high-risk plaques in patients with CAD are summarized and critically appraised. The challenges of the vulnerable plaque concept are also discussed, highlighting the need to shift towards a more interdisciplinary approach that can identify the "vulnerable plaque" in a "vulnerable patient".

Cardiovascular Disease and Thrombosis in HIV Infection

HIV infection has transitioned from an acute, fatal disease to a chronic one managed by antiretroviral therapy. Thus, the aging population of people living with HIV (PLWH) continues to expand. HIV infection results in a dysregulated immune system, wherein CD4+ T cells are depleted, particularly in the gastrointestinal tract, disrupting the gut epithelial barrier. Long-term HIV infection is associated with chronic inflammation through potentially direct mechanisms caused by viral replication or exposure to viral proteins and indirect mechanisms resulting from increased translocation of microbial products from the intestine or exposure to antiretroviral therapy. Chronic inflammation (as marked by IL [interleukin]-6 and CRP [C-reactive protein]) in PLWH promotes endothelial cell dysfunction and atherosclerosis. PLWH show significantly increased rates of cardiovascular disease, such as myocardial infarction (risk ratio, 1.79 [95% CI, 1.54-2.08]) and stroke (risk ratio, 2.56 [95% CI, 1.43-4.61]). In addition, PLWH have increased levels of the coagulation biomarker D-dimer and have a two to ten-fold increased risk of venous thromboembolism compared with the general population. Several small clinical trials analyzed the effect of different antithrombotic agents on platelet activation, coagulation, inflammation, and immune cell activation. Although some markers for coagulation were reduced, most agents failed to reduce inflammatory markers in PLWH. More studies are needed to understand the underlying mechanisms driving inflammation in PLWH to create better therapies for lowering chronic inflammation in PLWH. Such therapies can potentially reduce atherosclerosis, cardiovascular disease, and thrombosis rates in PLWH and thus overall mortality in this population.

2023 Guidelines of the Taiwan Society of Cardiology on the Diagnosis and Management of Chronic Coronary Syndrome

Coronary artery disease (CAD) covers a wide spectrum from persons who are asymptomatic to those presenting with acute coronary syndromes (ACS) and sudden cardiac death. Coronary atherosclerotic disease is a chronic, progressive process that leads to atherosclerotic plaque development and progression within the epicardial coronary arteries. Being a dynamic process, CAD generally presents with a prolonged stable phase, which may then suddenly become unstable and lead to an acute coronary event. Thus, the concept of "stable CAD" may be misleading, as the risk for acute events continues to exist, despite the use of pharmacological therapies and revascularization. Many advances in coronary care have been made, and guidelines from other international societies have been updated. The 2023 guidelines of the Taiwan Society of Cardiology for CAD introduce a new concept that categorizes the disease entity according to its clinical presentation into acute or chronic coronary syndromes (ACS and CCS, respectively). Previously defined as stable CAD, CCS include a heterogeneous population with or without chest pain, with or without prior ACS, and with or without previous coronary revascularization procedures. As cardiologists, we now face the complexity of CAD, which involves not only the epicardial but also the microcirculatory domains of the coronary circulation and the myocardium. New findings about the development and progression of coronary atherosclerosis have changed the clinical landscape. After a nearly 50-year ischemia-centric paradigm of coronary stenosis, growing evidence indicates that coronary atherosclerosis and its features are both diagnostic and therapeutic targets beyond obstructive CAD. Taken together, these factors have shifted the clinicians' focus from the functional evaluation of coronary ischemia to the anatomic burden of disease. Research over the past decades has strengthened the case for prevention and optimal medical therapy as central interventions in patients with CCS. Even though functional capacity has clear prognostic implications, it does not include the evaluation of non-obstructive lesions, plaque burden or additional risk-modifying factors beyond epicardial coronary stenosis-driven ischemia. The recommended first-line diagnostic tests for CCS now include coronary computed tomographic angiography, an increasingly used anatomic imaging modality capable of detecting not only obstructive but also non-obstructive coronary plaques that may be missed with stress testing. This non-invasive anatomical modality improves risk assessment and potentially allows for the appropriate allocation of preventive therapies. Initial invasive strategies cannot improve mortality or the risk of myocardial infarction. Emphasis should be placed on optimizing the control of risk factors through preventive measures, and invasive strategies should be reserved for highly selected patients with refractory symptoms, high ischemic burden, high-risk anatomies, and hemodynamically significant lesions. These guidelines provide current evidence-based diagnosis and treatment recommendations. However, the guidelines are not mandatory, and members of the Task Force fully realize that the treatment of CCS should be individualized to address each patient's circumstances. Ultimately, the decision of healthcare professionals is most important in clinical practice.

Coronary Artery Disease and Aortic Valve Stenosis: A Urine Proteomics Study

Coronary artery disease (CAD) and the frequently coexisting aortic valve stenosis (AVS) are heart diseases accounting for most cardiac surgeries. These share many risk factors, such as age, diabetes, hypertension, or obesity, and similar pathogenesis, including endothelial disruption, lipid and immune cell infiltration, inflammation, fibrosis, and calcification. Unsuspected CAD and AVS are sometimes detected opportunistically through echocardiography, coronary angiography, and magnetic resonance. Routine biomarkers for early detection of either of these atherosclerotic-rooted conditions would be important to anticipate the diagnosis. With a noninvasive collection, urine is appealing for biomarker assessment. We conducted a shotgun proteomics exploratory analysis of urine from 12 CAD and/or AVS patients and 11 controls to identify putative candidates to differentiate these diseases from healthy subjects. Among the top 20 most dysregulated proteins, TIMP1, MMP2 and vWF stood out, being at least 2.5× increased in patients with CAD/AVS and holding a central position in a network of protein-protein interactions. Moreover, their assessment in an independent cohort (19 CAD/AVS and 10 controls) evidenced strong correlations between urinary TIMP1 and vWF levels and a common cardiovascular risk factor - HDL (r = 0.59, p < 0.05, and r = 0.64, p < 0.01, respectively).

Interplay of Obesity, Ethanol, and Contaminant Mixture on Clinical Profiles of Cardiovascular and Metabolic Diseases: Evidence from an Animal Study

Obesity, ethanol, and contaminants are known risk factors of cardiovascular and metabolic diseases (CMD). However, their interplay on clinical profiles of these diseases remains unclear, and thus were investigated in this study. Male lean or obese JCR rats were given water or 10% ethanol and orally treated with or without a contaminant mixture (CM) dissolved in corn oil and loaded on two cookies at 0, 1.6, or 16 mg/kg BW/day dose levels for 4 weeks. The CM consisted 22 environmental contaminants found in human blood or serum of Northern populations. Over 60 parameters related to CMD were examined. The results revealed that obesity in JCR rats resembles the clinical profiles of non-alcoholic fatty liver disease in humans. Obesity was also associated with increased serum and organ retention of mercury, one of the chemical components of CM. Exposure to ethanol lightened hyperlipidemia, increased liver retention of mercury, and increased risk for hypertension in the obese rats. CM lessened hyperlipidemia and hyperenzymemia, worsened systemic inflammation and increased the risk for hypertension in the obese rats. CM markedly increased serum ethanol levels with or without ethanol exposure. Tissue total mercury contents significantly correlated with clinical parameters with altered profiles by both ethanol and obesity. These results suggest that obese individuals may be more prone to contaminant accumulation. Ethanol and CM exposure can alter clinical profiles associated with obesity, which may lead to misdiagnosis of CMD associated with obesity. CM can alter endogenous production and/or metabolism of ethanol, further complicating disease progression, diagnosis, and treatment.

Bempedoic acid in patients with type 2 diabetes mellitus, prediabetes, and normoglycaemia: A post hoc analysis of efficacy and glycaemic control using pooled data from phase 3 clinical trials

AIM

To evaluate the effect of bempedoic acid on glycaemic and lipid variables in patients with hypercholesterolaemia.

METHODS

A patient-level pooled analysis of four phase 3, randomized, double-blind, placebo-controlled trials evaluated changes in glycaemia, change from baseline in LDL-C, and adverse events. Patients (N = 3621) on maximally tolerated statins were randomized 2:1 to oral bempedoic acid 180 mg or placebo once daily for 12 to 52 weeks with the results analysed by baseline glycaemic status (diabetes, prediabetes, or normoglycaemia).

RESULTS

The annual rate of new-onset diabetes for bempedoic acid versus placebo in patients with normoglycaemia at baseline (n = 618) was 0.3% versus 0.8%, and for patients with prediabetes at baseline (n = 1868) it was 4.7% versus 5.9%. In patients with diabetes or prediabetes, bempedoic acid significantly (P < .0001) reduced HbA1c by -0.12% and -0.06%, respectively, and did not worsen fasting glucose versus placebo. Bempedoic acid significantly and consistently lowered LDL-C levels versus placebo, regardless of baseline glycaemic status (placebo-corrected difference range, -17.2% to -29.6%; P < .001 for each stratum). The safety of bempedoic acid was comparable with placebo and similar across glycaemic strata.

CONCLUSIONS

Bempedoic acid significantly lowered LDL-C across glycaemic strata and did not worsen glycaemic variables or increase the incidence of new-onset diabetes versus placebo over a median follow-up of 1 year.

The Prognostic value of the Fibrinogen to pre-albumin ratio in malignant tumors of the digestive system: a systematic review and meta-analysis

BACKGROUND

In recent years, the Fibrinogen to pre-albumin ratio (FPR) has been reported in many studies to be significantly associated with the prognosis of various cancers. This systematic review and meta-analysis aimed to investigate the prognostic value of FPR in malignant tumors of the digestive system based on available evidence.

METHODS

The relevant articles published before July 1, 2021, were systematically retrieved from electronic databases to evaluate the effect of Fibrinogen to pre-albumin ratio (FPR) on the prognosis of patients with malignant digestive system tumors and calculate the hazard ratio (HR) and the corresponding 95% confidence interval (CI).

RESULT

Thirteen articles, all from China, including 15 cohort studies and a total of 5116 cases, were included in this study. A high FPR was associated with poor overall survival (HR = 1.88, 95%CI 1.53-2.32, P < 0.001), recurrence-free survival (HR = 2.29, 95%CI 1.91-2.76, P < 0.001), progression-free survival (HR = 1.96, 95%CI: 1.33-2.90, P = 0.001), complications (HR = 1.78, 95%CI: 1.06-3.00, P = 0.029), disease-free survival (HR = 1.46, 95%CI: 1.08-1.97, P = 0.013) was significantly associated with cancer-specific survival (HR = 1.44, 95%CI: 1.15-1.79, P = 0.001). Even though intergroup differences were present, FPR was strongly associated with overall and relapse-free survival, and sensitivity analysis suggested that our results were stable.

CONCLUSION

FPR can be used as a valuable indicator to predict the prognosis of patients with malignant digestive system tumors.

Extracellular vesicles in pharmacology: Novel approaches in diagnostics and therapy

Exosomes are nano-sized lipid vesicles that are produced by all eukaryotic cells, and they typically range in size from 30 to 150 nm. Exosomes were discovered almost 40 years ago; however, the last two decades have attracted considerable attention due to exosomes' inherent abilities to shuttle nucleic acids, lipids and proteins between cells, along with their natural affinity to exosome target cells. From a pharmaceutical perspective, exosomes are regarded as naturally produced nanoparticle drug delivery vehicles. The application of exosomes as a means of drug delivery offers critical advantages compared to other nanoparticulate drug delivery systems, such as liposomes and polymeric nanoparticles. These advantages are due to the exosomes' intrinsic features, such as low immunogenicity, biocompatibility, stability, and their ability to overcome biological barriers. Herein, we outline the structure and origin of exosomes, as well as their biological functions. We also touch upon recent advances in exosome labeling, imaging and drug loading. Finally, we discuss exosomes in targeted drug delivery and clinical trial development.

Associations of the BDNF Val66Met Polymorphism With Body Composition, Cardiometabolic Risk Factors, and Energy Intake in Youth With Obesity: Findings From the HEARTY Study

The brain-derived neurotrophic factor (BDNF) Val66Met polymorphism is functionally related to BDNF, and is associated with obesity and metabolic complications in adults, but limited research exists among adolescents. This study comparatively examined carriers and non-carriers of the BDNF Val66Met polymorphism on body composition, energy intake, and cardiometabolic profile among adolescents with obesity. The sample consisted of 187 adolescents with obesity; 99 were carriers of the homozygous Val (G/G) alleles and 88 were carriers of the Val/Met (G/A) or Met (A/A) alleles. Cardiometabolic profile and DNA were quantified from fasted blood samples. Body composition was assessed by magnetic resonance imaging (MRI). Compared to carriers of the homozygous Val (G/G) allele, carriers of the Val/Met (G/A) or Met/Met (A/A) variants exhibited significantly higher protein (p = 0.01) and fat (p = 0.05) intake, C-Reactive protein (p = 0.05), and a trend toward higher overall energy intake (p = 0.07), fat-free mass (p = 0.07), and lower HDL-C (p = 0.07) Results showed for the first time that among youth with obesity, carriers of the Val66Met BDNF Met-alleles exhibited significantly higher C-reactive protein and energy intake in the form of fat and protein compared to Val-allele carriers, thereby providing support for the possible role of BDNF in appetite, weight, and metabolic regulation during adolescence. Clinical Trial Registration: http://clinicaltrials.gov/, identifier NCT00195858.

Health-related quality of life and incident cardiovascular disease events in community-dwelling older people: A prospective cohort study

BACKGROUND

Lower health-related quality of life (HRQoL) has been shown to predict a higher risk of hospital readmission and mortality in patients with cardiovascular disease (CVD). Few studies have explored the associations between HRQoL and incident CVD. We explored the associations between baseline HRQoL and incident and fatal CVD in community-dwelling older people in Australia and the United States.

METHODS

Longitudinal study using ASPirin in Reducing Events in the Elderly (ASPREE) trial data. This includes 19,106 individuals aged 65-98 years, initially free of CVD, dementia, or disability, and followed between March 2010 and June 2017. The physical (PCS) and mental component scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Incident major adverse CVD events included fatal CVD (death due to atherothrombotic CVD), hospitalizations for heart failure, myocardial infarction or stroke. Analyses were performed using Cox proportional-hazard regression.

RESULTS

Over a median 4.7 follow-up years, there were 922 incident CVD events, 203 fatal CVD events, 171 hospitalizations for heart failure, 355 fatal or nonfatal myocardial infarction and 403 fatal or nonfatal strokes. After adjustment for sociodemographic, health-related behaviours and clinical measures, a 10-unit higher PCS, but not MCS, was associated with a 14% lower risk of incident CVD, 28% lower risk of hospitalization for heart failure and 15% lower risk of myocardial infarction. Neither PCS nor MCS was associated with fatal CVD events or stroke.

CONCLUSION

Physical HRQoL can be used in combination with clinical data to identify the incident CVD risk among older individuals.

Exercise and Cardioprotection in Coronary Artery Disease: A Pilot Quasi-Experimental Study

Sirtuin-1 is a protein that may orchestrate the cardioprotective effect of exercise by controlling cellular processes. This pilot study assessed the feasibility of performing a quasi-experimental study in this area. Patients with postacute myocardial infarction were recruited across four hospital sites in the United Kingdom. The participants were offered one weekly exercise session at Phase-III and Phase-IV cardiac rehabilitation (CR). Measurements were obtained pre-Phase-III CR (Week 1), post-Phase-III CR (Week 8), and post-Phase-IV CR (Week 22). Twenty-eight patients were recruited (79% male, 100% White, 60.2 ± 10.5 years old). The recruitment rate was not fulfilled (<70% eligible patients recruited; 0.9 participants recruited per week over 30 weeks). The success criteria for dropout rate, adherence rate, and collection of sirtuin-1 measures were satisfied. A large increase in sirtuin-1 (0.14 ± 0.03, d ≥ 0.8) was seen after Phase-III and Phase-IV CR. Collectively, a quasi-experimental study is feasible with a revised recruitment strategy.

Association between serum α1-antitrypsin levels and all-cause mortality in the general population: the Nagahama study

Circulating levels of inflammatory proteins have to be prognostic markers of all-cause mortality. α1-Antitrypsin (AAT) is a major inflammatory plasma protein, but its association with all-cause mortality is unclear. We aimed to evaluate the prognostic significance of AAT levels for all-cause mortality. Study participants comprised 9682 community residents (53.5 ± 13.3 years old). During the 9.8-year follow-up period, 313 participants died from any cause. The mortality rate increased linearly with AAT quintiles (Q1, 18.2; Q2, 24.7; Q3, 23.8; Q4, 31.9; Q5, 64.6 per 10,000 person-years). There were significant correlations between AAT and high-sensitivity C-reactive protein (hsCRP) levels (correlation coefficient, 0.331; P < 0.001). However, the Cox model analysis, when adjusted for possible covariates including hsCRP, identified the fifth AAT quintile as a risk factor for all-cause death (hazard ratio, 2.12 [95% confidence interval, 1.41–3.18]; P < 0.001). An analysis of participants older than 50 years (hazard ratio, 1.98, P < 0.001) yielded similar results. The hazard ratio increased proportionately in combination with high AAT and high hsCRP levels, and the highest hazard ratio reached 4.51 (95% confidence interval, 3.14–6.54, P < 0.001). High AAT levels were determined to be an independent risk factor for mortality in the general population.

Fibrin(ogen) as a Therapeutic Target: Opportunities and Challenges

Fibrinogen is one of the key molecular players in haemostasis. Thrombin-mediated release of fibrinopeptides from fibrinogen converts this soluble protein into a network of fibrin fibres that form a building block for blood clots. Thrombin-activated factor XIII further crosslinks the fibrin fibres and incorporates antifibrinolytic proteins into the network, thus stabilising the clot. The conversion of fibrinogen to fibrin also exposes binding sites for fibrinolytic proteins to limit clot formation and avoid unwanted extension of the fibrin fibres. Altered clot structure and/or incorporation of antifibrinolytic proteins into fibrin networks disturbs the delicate equilibrium between clot formation and lysis, resulting in either unstable clots (predisposing to bleeding events) or persistent clots that are resistant to lysis (increasing risk of thrombosis). In this review, we discuss the factors responsible for alterations in fibrin(ogen) that can modulate clot stability, in turn predisposing to abnormal haemostasis. We also explore the mechanistic pathways that may allow the use of fibrinogen as a potential therapeutic target to treat vascular thrombosis or bleeding disorders. Better understanding of fibrinogen function will help to devise future effective and safe therapies to modulate thrombosis and bleeding risk, while maintaining the fine balance between clot formation and lysis.

Inflammatory Markers in Cardiovascular Disease; Lessons Learned and Future Perspectives

BACKGROUND

Cardiovascular disease (CVD) still remains the leading cause of morbidity and mortality worldwide. It is now established that inflammation plays a crucial role in atherosclerosis and atherothrombosis, and thus, it is closely linked to cardiovascular disease.

OBJECTIVE

The aim of the present review is to summarize and critically appraise the most relevant evidence regarding the potential use of inflammatory markers in the field of CVD.

METHODS

We conducted a comprehensive research of the relevant literature, searching MEDLINE from its inception until November 2018, primarily for meta-analyses, randomized controlled trials and observational studies.

RESULTS

Established markers of inflammation, mainly C-reactive protein, have yielded significant results both for primary and secondary prevention of CVD. Newer markers, such as lipoprotein-associated phospholipase A2, lectin-like oxidized low-density lipoprotein receptor-1, cytokines, myeloperoxidase, cell adhesion molecules, matrix metalloproteinases, and the CD40/CD40 ligand system, have been largely evaluated in human studies, enrolling both individuals from the general population and patients with established CVD. Some markers have yielded conflicting results; however, others are now recognized not only as promising biomarkers of CVD, but also as potential therapeutic targets, establishing the role of anti-inflammatory and pleiotropic drugs in CVD.

CONCLUSION

There is significant evidence regarding the role of consolidated and novel inflammatory markers in the field of diagnosis and prognosis of CVD. However, multimarker model assessment, validation of cut-off values and cost-effectiveness analyses are required in order for those markers to be integrated into daily clinical practice.

Testing the Effects of Disease-Modifying Antirheumatic Drugs on Vascular Inflammation in Rheumatoid Arthritis: Rationale and Design of the TARGET Trial

Individuals with rheumatoid arthritis (RA) are at increased risk for atherosclerotic cardiovascular disease (ASCVD) events relative to the general population, potentially mediated by atherosclerotic plaques that are more inflamed and rupture prone. We sought to address whether RA immunomodulators reduce vascular inflammation, thereby reducing ASCVD risk, and whether such reduction depends on the type of immunomodulator. The TARGET (Treatments Against RA and Effect on 18-Fluorodeoxyglucose [18 F-FDG] Positron Emission Tomography [PET]/Computed Tomography [CT]) trial (NCT02374021) will enroll 150 patients with RA with active disease and an inadequate response to methotrexate. Participants will be randomized to add either a tumor necrosis factor (TNF) inhibitor (etanercept or adalimumab) or sulfasalazine and hydroxychloroquine to their background methotrexate. Participants will undergo full-body 18 F-FDG-labelled PET scanning at baseline and after 6 months. Efficacy and safety evaluations will occur every 6 weeks, with therapy modified in a treat-to-target approach. The primary outcome is the comparison of change in arterial inflammation in the wall of the aorta and carotid arteries between the randomized treatment groups, specifically, the change in the mean of the maximum target-to-background ratio of arterial 18 F-FDG uptake in the most diseased segment of either the aorta and carotid arteries. A secondary analysis will compare the effects of achieving low disease activity or remission with those of moderate to high disease activity on vascular inflammation. The TARGET trial will test, for the first time, whether RA treatments reduce arterial inflammation and whether such reduction differs according to treatment strategy with either TNF inhibitors or a combination of nonbiologic disease-modifying antirheumatic drugs.

Lipid lowering with bempedoic acid added to a proprotein convertase subtilisin/kexin type 9 inhibitor therapy: A randomized, controlled trial

BACKGROUND

Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) lower low-density lipoprotein cholesterol (LDL-C) in patients with hypercholesterolemia. However, some patients receiving PCSK9i therapy might require additional lipid-lowering therapy (LLT) to reach LDL-C goals. Bempedoic acid is an oral, once-daily, ATP-citrate lyase inhibitor that significantly lowers LDL-C in patients with hypercholesterolemia when given alone or as add-on therapy to statins and/or ezetimibe.

OBJECTIVE

Assess safety and efficacy of bempedoic acid added to PCSK9i (evolocumab) background therapy in patients with hypercholesterolemia.

METHODS

This phase 2, randomized, double-blind, placebo-controlled study was conducted in three phases: 1.5-month screening/washout period including discontinuation of all LLTs, a 3-month period wherein patients initiated background PCSK9i therapy, and a 2-month treatment period in which patients were randomized 1:1 to receive bempedoic acid 180 mg or placebo once daily while continuing PCSK9i therapy.

RESULTS

Of 59 patients randomized, 57 completed the study. Mean baseline LDL-C after 3 months of PCSK9i background therapy was 103.1 ± ± 30.4 mg/dL. Bempedoic acid added to background PCSK9i therapy significantly lowered LDL-C by 30.3% (P < .001) vs placebo. Compared with placebo, bempedoic acid significantly lowered apolipoprotein B, non-high-density lipoprotein cholesterol, and total cholesterol (nominal P < .001 for all), and high-sensitivity C-reactive protein (P = .029). When added to background PCSK9i therapy, the safety profile of bempedoic acid was comparable to that observed for placebo.

CONCLUSIONS

When added to a background of PCSK9i therapy, bempedoic acid significantly lowered LDL-C levels with a safety profile comparable to placebo in patients with hypercholesterolemia.

Cost-utility analysis of an integrated genetic/epigenetic test for assessing risk for coronary heart disease

Aim: New epigenetically based methods for assessing risk for coronary heart disease may be more sensitive but are generally more costly than current methods. To understand their potential impact on healthcare spending, we conducted a cost-utility analysis. Methods: We compared costs using the new Epi + Gen CHD™ test with those of existing tests using a cohort Markov simulation model. Results: We found that use of the new test was associated with both better survival and highly competitive negative incremental cost-effectiveness ratios ranging from -$42,000 to -$8000 per quality-adjusted life year for models with and without a secondary test. Conclusion: The new integrated genetic/epigenetic test will save money and lives under most real-world scenarios. Similar advantages may be seen for other epigenetic tests.

Machine learning integration of circulating and imaging biomarkers for explainable patient-specific prediction of cardiac events: A prospective study

BACKGROUND AND AIMS

We sought to assess the performance of a comprehensive machine learning (ML) risk score integrating circulating biomarkers and computed tomography (CT) measures for the long-term prediction of hard cardiac events in asymptomatic subjects.

METHODS

We studied 1069 subjects (age 58.2 ± 8.2 years, 54.0% males) from the prospective EISNER trial who underwent coronary artery calcium (CAC) scoring CT, serum biomarker assessment, and long-term follow-up. Epicardial adipose tissue (EAT) was quantified from CT using fully automated deep learning software. Forty-eight serum biomarkers, both established and novel, were assayed. An ML algorithm (XGBoost) was trained using clinical risk factors, CT measures (CAC score, number of coronary lesions, aortic valve calcium score, EAT volume and attenuation), and circulating biomarkers, and validated using repeated 10-fold cross validation.

RESULTS

At 14.5 ± 2.0 years, there were 50 hard cardiac events (myocardial infarction or cardiac death). The ML risk score (area under the receiver operator characteristic curve [AUC] 0.81) outperformed the CAC score (0.75) and ASCVD risk score (0.74; both p = 0.02) for the prediction of hard cardiac events. Serum biomarkers provided incremental prognostic value beyond clinical data and CT measures in the ML model (net reclassification index 0.53 [95% CI: 0.23-0.81], p < 0.0001). Among novel biomarkers, MMP-9, pentraxin 3, PIGR, and GDF-15 had highest variable importance for ML and reflect the pathways of inflammation, extracellular matrix remodeling, and fibrosis.

CONCLUSIONS

In this prospective study, ML integration of novel circulating biomarkers and noninvasive imaging measures provided superior long-term risk prediction for cardiac events compared to current risk assessment tools.

Efficacy and Safety of Bempedoic Acid in Patients With Hypercholesterolemia and Statin Intolerance

Background

Inability to tolerate statins because of muscle symptoms contributes to uncontrolled cholesterol levels and insufficient cardiovascular risk reduction. Bempedoic acid, a prodrug that is activated by a hepatic enzyme not present in skeletal muscle, inhibits ATP‐citrate lyase, an enzyme upstream of β‐hydroxy β‐methylglutaryl‐coenzyme A reductase in the cholesterol biosynthesis pathway.

Methods and Results

The phase 3, double‐blind, placebo‐controlled CLEAR (Cholesterol Lowering via Bempedoic acid, an ACL‐Inhibiting Regimen) Serenity study randomized 345 patients with hypercholesterolemia and a history of intolerance to at least 2 statins (1 at the lowest available dose) 2:1 to bempedoic acid 180 mg or placebo once daily for 24 weeks. The primary end point was mean percent change from baseline to week 12 in low‐density lipoprotein cholesterol. The mean age was 65.2 years, mean baseline low‐density lipoprotein cholesterol was 157.6 mg/dL, and 93% of patients reported a history of statin‐associated muscle symptoms. Bempedoic acid treatment significantly reduced low‐density lipoprotein cholesterol from baseline to week 12 (placebo‐corrected difference, −21.4% [95% CI, −25.1% to −17.7%]; P<0.001). Significant reductions with bempedoic acid versus placebo were also observed in non–high‐density lipoprotein cholesterol (−17.9%), total cholesterol (−14.8%), apolipoprotein B (−15.0%), and high‐sensitivity C‐reactive protein (−24.3%; P<0.001 for all comparisons). Bempedoic acid was safe and well tolerated. The most common muscle‐related adverse event, myalgia, occurred in 4.7% and 7.2% of patients who received bempedoic acid or placebo, respectively.

Conclusions

Bempedoic acid offers a safe and effective oral therapeutic option for lipid lowering in patients who cannot tolerate statins.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02988115.

See Editorial by Jia and Virani

Statistical analysis plan for "A randomised, controlled study to evaluate the effects of switching from cigarette smoking to using a tobacco heating product on health effect indicators in healthy subjects"

Tobacco harm reduction strategies aim to substitute smoking with potentially reduced risk products (PRRPs) such as e-cigarettes and tobacco-heating products (THPs). The health benefits of switching from smoking to PRRPs is unknown. A randomised controlled trial is being conducted to increase understanding of the health effects of switching from smoking to a THP in a 12-month long ambulatory study (ISRCTN81075760). Here we describe the study endpoints and the statistical analysis plan. Endpoints are divided into biomarkers of exposure (BoE) to tobacco smoke constituents and health effect indicators related to risk of lung cancer, cardiovascular and obstructive lung disease. These have been selected on the basis of extensive literature evidence. Three primary endpoints, augmentation index (risk factor for cardiovascular disease), total NNAL (linked to lung cancer) and 8-Epi-PGF2α type III (indicator of oxidative stress linked to various diseases), and multiple secondary endpoints will be analysed at 90, 180, and 360 days. Changes from baseline will be compared between study arms by specific contrasts in mixed models. Study wise multiple comparisons adjustments will be performed to account for multiplicity of timepoints and comparisons within timepoints. Generalisability of outcomes will be tested by a sensitivity analysis adjusting for age and gender. Importantly, an ancillary analysis will be performed to assess product compliance during the study based on plasma levels of CEVal, a surrogate marker for acrylonitrile exposure. The rationale underlying the selection of BoEs and health effect indicators, coupled with the statistical analysis plan will be central to understanding the potential health effects of replacing smoking with THP use for one year.

Biological variation of cardiac markers in patients with aortic valve stenosis

Objective

Cardiac biomarkers hold promise for follow-up and management of aortic valve stenosis (AVS). When interpreting serial biomarker measurements of patients with AVS, it can be challenging to distinguish ‘real changes’ from ‘random fluctuation’. Hence, robust estimation of the biological variation of these biomarkers is essential. In the present study we assessed biological variation of B-type natriuretic peptide (BNP), N-terminus pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-T and high-sensitivity troponin-I (hs-TnT and hs-TnI), and ST2 in subjects with stable AVS.

Methods

Serial blood sampling was performed in 25 subjects with moderate AVS—confirmed by echocardiography—and all free from acute cardiovascular events in the past 6 months. Blood samples were taken on seven standardised occasions during 1 year. Analytical variation (CV_A), within-subject biological variation (CV_I), between-subject biological variation (CV_G), index of individuality (II) and reference change values were calculated for all cardiac biomarkers.

Results

CV_I was highest for BNP (62.0%, 95% CI 52.5 to 75.4) and lowest for hs-TnI (9.2%, 95% CI 2.8 to 13.8). CV_G exceeded the CV_I for all biomarkers except BNP, and ranged from 19.8% (95% CI 13.8 to 33.4) for ST2 to 57.2% (95% CI 40.4 to 97.3) for hs-TnT. NT-proBNP, hs-TnT and ST2 revealed CV_A <5%, while BNP and hs-TnI showed a higher CV_A (19.7 and 14.9, respectively). All biomarkers except BNP showed marked individuality, with II ranging from 0.21 to 0.67 (BNP 1.34).

Conclusion

This study provides the first biological variation estimates of cardiac biomarkers in patients with stable AVS. These estimates allow a more evidence-based interpretation of biomarker changes in the follow-up and management of patients with AVS.

Trial registration number

NCT02510482

Design and Demonstration of Tunable Amplified Sensitivity of AlGaN/GaN High Electron Mobility Transistor (HEMT)-Based Biosensors in Human Serum

We have developed a swift and simplistic protein immunoassay using aptamer functionalized AlGaN/GaN high electron mobility transistors (HEMTs). The unique design of the sensor facilitates protein detection in a physiological salt environment overcoming charge screening effects, without requiring sample preprocessing. This study reports a tunable and amplified sensitivity of solution-gated electric double layer (EDL) HEMT-based biosensors, which demonstrates significantly enhanced sensitivity by designing a smaller gap between the gate electrode and the detection, and by operating at higher gate voltage. Sensitivity is calculated by quantifying NT-proBNP, a clinical biomarker of heart failure, in buffer and untreated human serum samples. The biosensor depicts elevated sensitivity and high selectivity. Furthermore, detailed investigation of the amplified sensitivity in an increased ionic strength environment is conducted, and it is revealed that a high sensitivity of 80.54 mV/decade protein concentration can be achieved, which is much higher than that of previously reported FET biosensors. This sensor technology demonstrates immense potential in developing surface affinity sensors for clinical diagnostics.

Change in Cardiometabolic Risk Among Blacks, Whites, and Hispanics: Findings From the Health and Retirement Study

Background

Blacks experience greater multisystem physiological dysregulation, or cumulative biological risk, which is associated with poor cardiometabolic health and mortality. In this study, we assess race differences in change in risk over 4 years among older whites, blacks, and Hispanics.

Method

We examined race differences in 4-year change in individual biomarkers and a cumulative measure of risk-cardiometabolic risk (CMR)-using data for each respondent from two waves of the Health and Retirement Study's biomarker assessment (n = 5,512). CMR is a count of high-risk cardiovascular and metabolic biomarkers. We estimated mean CMR at baseline and follow-up by race/ethnicity, and used logistic regression to determine whether race differences exist in 4-year transitions between high- and low-risk states for individual biomarkers.

Results

Blacks had higher baseline CMR than whites and Hispanics and experienced an increase in risk over 4 years; conversely, CMR decreased among whites and Hispanics. Blacks were more likely to develop high-risk pulse pressure and high-risk hemoglobin A1c, which contributed to increases in CMR. Whites and Hispanics were more likely to become low-risk on C-reactive protein and high-density lipoprotein cholesterol which contributed to declines in CMR. Race differences in transitions between risk states remained after controlling for social, behavioral, and health care-related factors. However, the racial patterning of these differences was influenced by disease diagnosis and medication use.

Conclusions

We show that the cardiometabolic health of older blacks worsens as they age both absolutely and relative to that of whites and Hispanics because of poor blood pressure control and diabetes prevention.

Relationship of Postpartum Levels of Cystatin and High-Sensitivity C-Reactive Protein and Duration of Lactation in Mothers with Previous Gestational Hypertension or Preeclampsia

Background: Women with hypertensive disorders of pregnancy are at increased risk of cardiovascular disease in later life. We sought to determine the association between lactation and markers of maternal cardiovascular health among postpartum women with and without hypertensive disorders of pregnancy via measures of inflammation (high-sensitivity C-reactive protein [hsCRP]) and renal function (cystatin C). Materials and Methods: This prospective cohort study enrolled primarily overweight and obese women during early pregnancy. At a postpartum study visit occurring 6-24 months after delivery, we collected data on lactation duration and measured hsCRP and cystatin C. We assessed associations between lactation duration and levels of hsCRP and cystatin C among normotensive women and women with preeclampsia or gestational hypertension using analysis of variance and chi-squared tests. Linear regression models adjusted for age, race, education, prepregnancy body mass index, current smoking, and time since delivery. Results: Of 425 women, 37 (9%) had preeclampsia and 48 (11%) had gestational hypertension during enrollment pregnancy. The postpartum visit occurred at a mean of 8.6 ± 4.4 months after delivery. Women with a history of preeclampsia had significantly higher levels of cystatin C (mean 0.86 versus 0.78 mg/L; p = 0.03) compared with normotensive women, but nonsignificant elevation in hsCRP (mean 8.39 versus 6.04 mg/L; p = 0.08). Women with gestational hypertension had no differences in mean hsCRP or cystatin C compared with normotensive women. Among the 237 women with any lactation, 78 (18%) lactated for at least 6 months. Lactation duration both in the overall sample and among women with gestational hypertension or preeclampsia was not associated with levels of hsCRP or cystatin C. Conclusions: Preeclampsia history was associated with elevated postpartum levels of cystatin C; however, duration of lactation was not associated with postpartum hsCRP or cystatin C, regardless of history of gestational hypertension or preeclampsia. Further research is needed on mechanisms through which lactation may affect maternal risk of cardiovascular disease.

Risk of hypertension and abnormal biomarkers in the first year postpartum associated with hypertensive disorders of pregnancy among overweight and obese women

OBJECTIVES

Hypertension and obesity are common cardiometabolic risk factors in reproductive age women. The association of hypertensive disorders of pregnancy with later-life cardiovascular disease is well-established, however, it is unknown how obesity and hypertensive disorders of pregnancy converge to accelerate development of hypertension in the postpartum period. The aim of this study was to characterize rates of sustained hypertension at one year postpartum using the new American Heart Association/American College of Cardiology Guidelines among overweight and obese women with a normotensive pregnancy or hypertensive disorder of pregnancy.

STUDY DESIGN

315 early pregnant women were enrolled prospectively and followed up to 12 months after delivery (mean 7.0 ± 1.8 months). At a postpartum research visit, we measured blood pressure and collected blood samples to measure cystatin C and high sensitivity C-reactive protein.

RESULTS

A total of 254 women had a normotensive pregnancy, 39 had gestational hypertension (12.4%) and 22 had preeclampsia (7.0%). 91 women had hypertension at the postpartum study visit (28.9%). After adjustment for maternal age, BMI, lactation and time postpartum, preeclampsia was associated with an aOR 2.35 (95%CI 1.63-3.41) of development of sustained hypertension and an aOR 3.23 (95%CI 1.56-6.68) of hypertension with abnormal biomarkers compared to women with normotensive pregnancies.

CONCLUSIONS

We demonstrate a high prevalence of hypertension and abnormal biomarkers associated with hypertensive disorders of pregnancy among overweight and obese women. Our findings support the need for structured follow up and risk reduction in overweight and obese women with hypertensive disorders of pregnancy as early as the first year postpartum.

Global genetic diversity of human apolipoproteins and effects on cardiovascular disease risk

Abnormal plasma apolipoprotein levels are consistently implicated in CVD risk. Although 30% to 60% of their interindividual variability is genetic, common genetic variants explain only 10% to 20% of these differences. Rare genetic variants may be major sources of the missing heritability, yet quantitative evaluations of their contribution to phenotypic variability are lacking. Here, we analyzed whole-genome and whole-exome sequencing data from 138,632 individuals across seven major human populations to present a systematic overview of genetic apolipoprotein variability. We provide population-specific frequencies of 38 clinically important apolipoprotein alleles and identify further 6,875 genetic variants, 33% of which are novel and 98.7% of which are rare with minor allele frequencies <1%. We predicted the functional impact of rare variants and found that their relative importance differed drastically between genes and among ethnicities. Importantly, we validated the clinical relevance of multiple variants with predicted effects by leveraging association data from the CARDIoGRAM (Coronary Artery Disease Genomewide Replication and Meta-analysis) and Global Lipids Genetics consortia. Overall, we provide a consolidated overview of population-specific apolipoprotein genetics as a valuable data resource for scientists and clinicians, estimate the importance of rare genetic variants for the missing heritability of apolipoprotein-associated disease traits, and pinpoint multiple novel apolipoprotein variants with putative population-specific impacts on serum lipid levels.

Non-Traditional Cardiovascular Risk Markers in the Era of Established Major Risk Factors and Multiple Guidelines

The non-traditional cardiovascular (CV) risk factors that appear to be of most clinical interest include: apolipoprotein A (ApoA), apolipoprotein B (ApoB), high-sensitivity C-Reactive protein (hsCRP), homocysteine, interleukin 1 (IL1), lipoprotein (a) [Lp(a)], the density of low-density lipoprotein (LDL) particles, the LDL particle number, tissue/tumor necrosis factor-α (TNF-α) and uric acid. These non-traditional risk factors may be of value in adding further confirmation and attention to suspected significant CV risk. They can also provide a better understanding of current concepts of atherogenesis (e.g. various potential mechanisms associated with inflammation) as an etiology and in guiding current plus future therapies. In the mid-20th century, atherosclerosis and CV disease were considered mechanistic occurrences with essentially no attention to possible metabolic and molecular etiologies. Therefore, the only treatments then centered around mainly surgical procedures to try to improve blood flow, first with peripheral arterial disease (PAD) and later coronary artery disease (CAD). Now, failure to treat CV risk factors, especially where there is good evidence-based medicine, as in the case of statins for high CV risk patients, is considered medical negligence. Nevertheless, many problems remain to be solved regarding atherosclerosis prevention and treatment.

Elevated levels of D-dimers increase the risk of ischaemic and haemorrhagic stroke

Elevated D-dimer levels are reportedly associated with coronary artery disease. It was the study objective to investigate the association of baseline D-dimer levels with strokes that occurred in the European Prospective Investigation into Cancer and Nutrition-Italy cohort. Using a nested case-cohort design, a centre-–stratified sample of 832 subjects (66 % women, age 35–71) was selected as subcohort and compared with 289 strokes in a mean follow-up of nine years. D-dimers were measured by an automated latex-enhanced immunoassay (HemosIL-IL). The multivariable hazard ratios were estimated by a Cox regression model using Prentice method. Individuals with elevated D-dimer levels had significantly higher risk of incident stroke. It was evident from the second quartile (D-dimers > 100 ng/ml) and persisted almost unchanged for higher D-dimers (hazard ratio [HR] 2.10, 95 % confidence interval [CI]: 1.28–3.47; 2.42, 95 %CI: 1.44–4.09 and 2.10, 95 %CI: 1.27–3.48 for the second, third or fourth quartile compared with the lowest quartile, respectively). The association was independent of several confounders, including triglycerides and C-reactive protein. No differences were observed in men and women (P for interaction= 0.46), in hypertensive or non-hypertensive subjects (P for interaction= 0.88) or in subjects with low (< 1 mg/l) or elevated (≥ 1 mg/l) C-reactive protein (P for interaction=0.35). After stratification for stroke type, the hazard ratio for every standard deviation increase was statistically significant both for ischaemic (1.21; 95 %CI: 1.01 to 1.45) and haemorrhagic (1.24; 95 %CI: 1.00 to 1.65) strokes. In conclusion, our data provide clear evidence that elevated levels of D-dimers are potential risk factors not only for ischaemic but also for haemorrhagic strokes.

Pregnancy associated plasma protein-A as a prognostic biomarker of all-cause mortality and cardiovascular events in patients presenting with chest pain: a systematic review

AIM

Novel biomarkers have been proposed for identification of patients at greater risk of future adverse events among those presenting with chest pain. In this review, we aim to elucidate the ability of pregnancy associated plasma protein-A (PAPP-A) to predict mortality and other cardiovascular events in this patient population.

METHODS

A literature search of the electronic databases Medline, Scopus, Cochrane Library and ClinicalTrials.gov was performed in order to identify studies investigating the utility of PAPP-A to predict mortality and adverse cardiovascular events in patients with chest pain.

RESULTS

Eight studies met our inclusion criteria. Five of these studies pertained to patients with confirmed ischemic chest pain, while the rest included patients presenting with chest pain possibly due to acute coronary syndrome, irrespectively of the underlying cause. Although the results for long-term events were inconclusive in both groups of patients, higher PAPP-A concentrations were found to be a significant predictor of short-term adverse events in patients with confirmed ischemic chest pain.

CONCLUSIONS

PAPP-A appears to be a potentially useful biomarker for short-term risk stratification of patients presenting with chest pain of ischemic origin. However, there is an eminent need for more standardized clinical studies investigating the prognostic value of this biomarker.

Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association

BACKGROUND AND PURPOSE

Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management.

METHOD

The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention.

RESULTS

The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment.

CONCLUSIONS

The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.

Circulating miRNA‑21 is a promising biomarker for heart failure

microRNA 21 (miRNA‑21) promotes the development of cardiac fibrosis, hypertrophy and heart failure. However, whether it can be used as a biomarker for the diagnosis and prognosis of heart failure remains unclear. The current study assessed circulating miRNA‑21 as a viable indicator for diagnosis and prognosis of heart failure. The levels of miRNA‑21 and brain natriuretic peptide were measured in serum obtained from the peripheral vein (miRNA‑21‑PV) and coronary sinus (miRNA‑21‑CS) of 80 patients with heart failure and 40 control individuals via reverse transcription‑quantitative polymerase chain reaction and ELISA, respectively. The correlations between circulating miRNA‑21 and diagnosis, severity, prognosis and re‑hospitalization rate of heart failure were evaluated using statistical analysis. Serum miRNA‑21‑PV and miRNA‑21‑CS levels of patients with heart failure were significantly higher than that of control subjects, and were also correlated with ejection fraction and brain natriuretic peptide. Both were determined to have high levels of sensitivity and specificity for diagnosing heart failure. Follow‑up of the patients with heart failure indicated that miRNA‑21‑PV and miRNA‑21‑CS were correlated with prognosis, and miRNA‑21‑CS was efficient in predicting re‑hospitalization for heart failure. Circulating miRNA‑21 has potential to be a biomarker of heart failure.

Ideal cardiovascular health and inflammation in European adolescents: The HELENA study

BACKGROUND AND AIMS

Inflammation plays a key role in atherosclerosis and this process seems to appear in childhood. The ideal cardiovascular health index (ICHI) has been inversely related to atherosclerotic plaque in adults. However, evidence regarding inflammation and ICHI in adolescents is scarce. The aim is to assess the association between ICHI and inflammation in European adolescents.

METHODS AND RESULTS

As many as 543 adolescents (251 boys and 292 girls) from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study, a cross-sectional multi-center study including 9 European countries, were measured. C-reactive protein (CRP), complement factors C3 and C4, leptin and white blood cell counts were used to compute an inflammatory score. Multilevel linear models and multilevel logistic regression were used to assess the association between ICHI and inflammation controlling by covariates. Higher ICHI was associated with a lower inflammatory score, as well as with several individual components, both in boys and girls (p < 0.01). In addition, adolescents with at least 4 ideal components of the ICHI had significantly lower inflammatory score and lower levels of the study biomarkers, except CRP. Finally, the multilevel logistic regression showed that for every unit increase in the ICHI, the probability of having an inflammatory profile decreased by 28.1% in girls.

CONCLUSION

Results from this study suggest that a better ICHI is associated with a lower inflammatory profile already in adolescence. Improving these health behaviors, and health factors included in the ICHI, could play an important role in CVD prevention.

Impact of different dietary approaches on glycemic control and cardiovascular risk factors in patients with type 2 diabetes: a protocol for a systematic review and network meta-analysis

BACKGROUND

Dietary advice is one of the cornerstones in the management of type 2 diabetes mellitus. The American Diabetes Association recommended a hypocaloric diet for overweight or obese adults with type 2 diabetes in order to induce weight loss. However, there is limited evidence on the optimal approaches to control hyperglycemia in type 2 diabetes patients. The aim of the present study is to assess the comparative efficacy of different dietary approaches on glycemic control and blood lipids in patients with type 2 diabetes mellitus in a systematic review including a standard pairwise and network meta-analysis of randomized trials.

METHODS AND DESIGN

We will conduct searches in Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, PubMed (from 1966), and Google Scholar. Citations, abstracts, and relevant papers will be screened for eligibility by two reviewers independently. Randomized controlled trials (with a control group or randomized trials with at least two intervention groups) will be included if they meet the following criteria: (1) include type 2 diabetes mellitus, (2) include patients aged ≥18 years, (3) include dietary intervention (different type of diets: e.g., Mediterranean dietary pattern, low-carbohydrate diet, low-fat diet, vegetarian diet, high protein diet); either hypo, iso-caloric, or ad libitum diets, (4) minimum intervention period of 12 weeks. For each outcome measure of interest, random effects pairwise and network meta-analyses will be performed in order to determine the pooled relative effect of each intervention relative to every other intervention in terms of the post-intervention values (or mean differences between the changes from baseline value scores). Subgroup analyses are planned for study length, sample size, age, and sex.

DISCUSSION

This systematic review will synthesize the available evidence on the comparative efficacy of different dietary approaches in the management of glycosylated hemoglobin (primary outcome), fasting glucose, and cardiovascular risk factors in type 2 diabetes mellitus patients. The results of the present network meta-analysis will influence evidence-based treatment decisions since it will be fundamental for based recommendations in the management of type 2 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 42016047464.