Association of Uncontrolled Hypertension or Diabetes Mellitus With Major Adverse Cardiovascular Events and Mortality in South Korea: Population-Based Cohort Study

The role of the control of "life's essential 8" for prevention on heart failure and all-cause mortality in patients with hypertension: the Kailuan cohort study

BACKGROUND

Hypertension can lead to an increased risk of heart failure and death. The life's essential 8 (LE8) is an eight-factor measure of cardiovascular health recently released by the American Heart Association for use in measuring cardiovascular health. However, evidence on the beneficial effects and necessity of LE8 control is still lacking, especially for hypertension.

METHODS

The study population was drawn from the Kailuan cohort, hypertensive population at baseline with the non-hypertensive population matched 1:1 according to age and sex were involved in this analysis. The cut off value for each factor in LE8 was 50 (≥ 50 as controlled, < 50 as uncontrolled). The primary outcomes involved heart failure and all-cause mortality. Cox proportional risk regression models were used to analyze the relationship between the degree of LE8 control and the risk of heart failure and all-cause mortality among hypertensive participants. Hazard ratio (HR) and 95% confidence interval (95% CI) were calculated.

RESULTS

A baseline population of 69,032 Kailuan cohort with a mean age of 53.08 years (SD 10.59) was included in the study. During a mean follow-up period of 13.17 years (SD 2.57), 1308 (3.8%) heart failures and 5391 (15.6%) deaths occurred among hypertensive patients. In the hypertensive population, there was a negative dose response between the degree of LE8 control and the risk of heart failure or death (P for trend < 0.001). Compared with the group with the control less than or equal to 2 risk factors of LE8, the group with 6 or more risk factors of control had a 55% lower risk of heart failure (HR 0.45, 95% CI 0.26-0.77; P < 0.05) and a 31% lower risk of death (HR 0.69, 95% CI 0.50-0.93; P < 0.05). Compared with the non-hypertensive population, the risk of heart failure and death decreased with increasing of the number of risk factor controlled in LE8, down to a minimum of 1.27-fold (HR 1.27, 95%CI 1.13-1.42; P < 0.05) and 1.25-fold (HR 1.25, 95%CI 1.19-1.32; P < 0.05), respectively. In addition, the association between hypertension and heart failure or mortality was higher in participants aged < 60 years compared with older individuals (P for interaction < 0.05).

CONCLUSIONS

Enhanced control of LE8 is significantly associated with a reduced risk of heart failure and mortality in hypertensive patients, as well as a decreased likelihood of hypertension-related heart failure or mortality.

Implications of prognostic nutritional index in predicting adverse outcomes of uncontrolled diabetic patients: a cohort study of the national health and nutrition examination survey from 2005 - 2018

BACKGROUND

Diabetes mellitus (DM) is a metabolic disorder with increasing prevalence and poor control rates, leading to adverse events. Prognostic nutritional value (PNI) has been identified as a protective factor in DM, but its role in uncontrolled DM remains unclear.

METHODS

This study based on the representative cohort of National Health and Nutrition Examination Survey from 2005 to 2018. A total of 3,313 participants with uncontrolled DM were included in our analyses. PNI was calculated as 5×lymphocyte count (109/L)+ 10×serum albumin (g/L). The endpoints were DM-related and cardiovascular mortality, which were obtained from National Death Index. Univariable and multivariable cox proportional hazard regression were performed to investigate prognostic value of PNI.

RESULTS

Among 3,313 patients with uncontrolled DM (mean age of 61.75 ± 12.78 years, 53.4% male), PNI level was negatively associated with inflammatory markers and positively associated with metabolic markers of lipid and protein. During a median follow-up of 77 months, 247 DM-related deaths and 205 cardiovascular deaths occurred. Higher PNI levels independently predicted low DM-related (adjusted Hazard ratio [HR] = 0.872, 95% confidence interval [CI] 0.840-0.906, P < 0.001) and cardiovascular mortality (adjusted HR = 0.872, 95% CI 0.834-0.912, P < 0.001). The prognostic value of PNI significantly varied across different DM treatment conditions, which was more pronounced in patients receiving antidiabetic treatments (adjusted HR: insulin + oral antidiabetic drugs [OADs]: 0.832; insulin: 0.863; OADs: 0.894, all adjusted P < 0.001), but was absent in those without antidiabetic treatment.

CONCLUSIONS

A higher PNI level is an independent protective predictor for DM-related and cardiovascular mortality in uncontrolled DM patients. Evaluation of PNI level in uncontrolled DM patients could conduce to stringent intervention. Improvement of PNI could enhance the effective of antidiabetic therapy, especially the insulin therapy, and reduce DM-related mortality.

Association between changes in high-density lipoprotein cholesterol and risk of cardiovascular disease

BACKGROUND

The present study was performed to determine the association between changes in the high-density lipoprotein cholesterol (HDL-C) concentration and incident cardiovascular disease (CVD).

METHODS

Time-dependent Cox regression models were used to evaluate the association between changes in the HDL-C concentration and the risk of incident CVD. Participants were followed up from 2015 to 2021.

RESULTS

In total, 24,123 participants with a median follow-up of 4.26 years were analyzed, and the mean age of the cohort was 56.24 years, 57.8% were female, 24.3% were current smokers, and 12.8% had a history of alcohol use. Low, normal, and high HDL-C was defined as < 40, 40-80, and > 80 mg/dL, respectively. The average time for the two HDL-C measurements was 2.8 years. Compared with participants whose HDL-C was maintained at a normal level, the risk of CVD was higher in those whose HDL-C changed to a low level, remained unchanged at a low level (HR, 1.24; 95% CI, 1.01-1.40, P < 0.001), similarly, the risk of CVD was higher in those whose HDL-C changed from very high level to normal level (HR, 0.81; 95% CI, 0.67-0.99, P = 0.039). Also compared with participants whose HDL-C was maintained at a normal level, the risk of CVD was lower in those whose HDL-C increased from low to normal and high (HR, 0.80; 95% CI, 0.66-0.98, P = 0.029).

CONCLUSIONS

Participants whose HDL-C changed to a low level and whose low HDL-C level was maintained had a higher risk of CVD, whereas participants whose HDL-C changed from low to high had a lower risk of CVD.

Information and Communications Technology-Based Monitoring Service for Tailored Chronic Disease Management in Primary Care: Cost-Effectiveness Analysis Based on ICT-CM Trial Results

BACKGROUND

Information and communications technology-based tailored management (TM) intervention is a novel automatic system in which a smartphone app for the management of patients with hypertension and diabetes, the provider web, and Bluetooth devices are linked. However, little evidence exists regarding the cost-effectiveness of the interventions using mobile apps.

OBJECTIVE

This study aimed to assess the cost-effectiveness of TM intervention for adult patients with hypertension or diabetes in primary care compared with usual care (UC).

METHODS

Cost-effectiveness analysis using a Markov model was conducted from the Korean health care system perspective. Based on 6-month outcome data from an information and communications technology-based tailored chronic disease management (ICT-CM) trial, effectiveness over a lifetime beyond the trial periods was extrapolated using a cardiovascular disease risk prediction model. Costs were estimated using ICT-CM trial data and national health insurance claims data. Health utility weights were obtained from the Korea National Health and Nutrition Examination Survey.

RESULTS

In the base-case analysis, compared with UC, TM was more costly (US $23,157 for TM vs US $22,391 for UC) and more effective (12.006 quality-adjusted life-years [QALYs] for TM vs 11.868 QALYs for UC). The incremental cost-effectiveness ratio was US $5556 per QALY gained. Probabilistic sensitivity analysis showed that the probability of TM being cost-effective compared with UC was approximately 97% at an incremental cost-effectiveness ratio threshold of US $26,515 (KRW 35 million) per QALY gained.

CONCLUSIONS

Compared with UC, TM intervention is a cost-effective option for patients with hypertension or diabetes in primary care settings. The study results can assist policy makers in making evidence-based decisions when implementing accessible chronic disease management services.

The impact of triglyceride glucose-body mass index on all-cause and cardiovascular mortality in elderly patients with diabetes mellitus: evidence from NHANES 2007-2016

BACKGROUND

The relationship between triglyceride glucose-body mass index (TyG-BMI) index and mortality in elderly patients with diabetes mellitus (DM) are still unclear. This study aimed to investigate the association between TyG-BMI with all-cause and cardiovascular mortality among elderly DM patients in the United States (US).

METHODS

Patients aged over 60 years with DM from the National Health and Nutrition Examination Survey (2007-2016) were included in this study. The study endpoints were all-cause and cardiovascular mortality and the morality data were extracted from the National Death Index (NDI) which records up to December 31, 2019. Multivariate Cox proportional hazards regression model was used to explore the association between TyG-BMI index with mortality. Restricted cubic spline was used to model nonlinear relationships.

RESULTS

A total of 1363 elderly diabetic patients were included, and were categorized into four quartiles. The mean age was 70.0 ± 6.8 years, and 48.6% of them were female. Overall, there were 429 all-cause deaths and 123 cardiovascular deaths were recorded during a median follow-up of 77.3 months. Multivariate Cox regression analyses indicated that compared to the 1st quartile (used as the reference), the 3rd quartile demonstrated a significant association with all-cause mortality (model 2: HR = 0.64, 95% CI 0.46-0.89, P = 0.009; model 3: HR = 0.65, 95% CI 0.43-0.96, P = 0.030). Additionally, the 4th quartile was significantly associated with cardiovascular mortality (model 2: HR = 1.83, 95% CI 1.01-3.30, P = 0.047; model 3: HR = 2.45, 95% CI 1.07-5.57, P = 0.033). The restricted cubic spline revealed a U-shaped association between TyG-BMI index with all-cause mortality and a linear association with cardiovascular mortality, after adjustment for possible confounding factors.

CONCLUSIONS

A U-shaped association was observed between the TyG-BMI index with all-cause mortality and a linear association was observed between the TyG-BMI index with cardiovascular mortality in elderly patients with DM in the US population.

Evaluation of Social Isolation Trajectories and Incident Cardiovascular Disease Among Middle-Aged and Older Adults in China: National Cohort Study

BACKGROUND

Although the association between social isolation and the risk of subsequent cardiovascular disease (CVD) is well documented, most studies have only assessed social isolation at a single time point, and few studies have considered the association using repeatedly measured social isolation.

OBJECTIVE

This study aimed to examine the association between social isolation trajectories and incident CVD in a large cohort of middle-aged and older adults.

METHODS

This study used data from 4 waves (wave 1, wave 2, wave 3, and wave 4) of the China Health and Retirement Longitudinal Study. We defined the exposure period as from June 2011 to September 2015 (from wave 1 to wave 3) and the follow-up period as from September 2015 to March 2019 (wave 4). On the basis of the inclusion and exclusion criteria, our final analytic sample included 8422 individuals who had no CVD in the China Health and Retirement Longitudinal Study in waves 1 to 3 and were fully followed up in wave 4. Social isolation was ascertained using an extensively used questionnaire at 3 consecutive, biennial time points from waves 1 to 3, and individuals were assigned to 3 predefined social isolation trajectories based on their scores at each wave (consistently low, fluctuating, and consistently high). Incident CVD included self-reported physician-diagnosed heart disease and stroke combined. Cox proportional hazard models estimated the associations of social isolation trajectories with risks of incident CVD, adjusting for demographics, health behaviors, and health conditions.

RESULTS

Of the 8422 participants (mean age 59.76, SD 10.33 years at baseline), 4219 (50.09%) were male. Most of the participants (5267/8422, 62.54%) had consistently low social isolation over time and 16.62% (1400/8422) of the participants had consistently high social isolation over the exposure period. During the 4-year follow-up, 746 incident CVDs occurred (heart disease: 450 cases and stroke: 336 cases). Compared with individuals with consistently low social isolation, those with fluctuating social isolation (adjusted hazard ratio 1.27, 95% CI 1.01-1.59) and consistently high social isolation (adjusted hazard ratio 1.45, 95% CI 1.13-1.85) had higher risks for incident CVD after adjusting for demographics (ie, age, sex, residence, and educational level), health behaviors (ie, smoking status and drinking status), and health conditions (ie, BMI; history of diabetes, hypertension, dyslipidemia, chronic kidney disease; use of diabetes medications, hypertension medications, and lipid-lowering therapy; and depressive symptoms scores).

CONCLUSIONS

In this cohort study, middle-aged and older adults with fluctuating and consistently high social isolation exposure had higher risks of the onset of CVD than those without the exposure. The findings suggest that routine social isolation screenings and efforts to improve social connectedness merit increased attention for preventing CVD among middle-aged and older adults.