Hyperhomocysteinemia Increases Risk of Metabolic Syndrome and Cardiovascular Death in an Elderly Chinese Community Population of a 7-Year Follow-Up Study

Interaction of Genetics and Dietary Patterns Scored by the High Healthy Eating Index in Hyperhomocysteinaemia Influencing Cardiovascular Disease Risk

Hyperhomocysteinaemia has been associated with increased cardiovascular disease (CVD) risk, but the complex interplay between genetic determinants and modifiable lifestyle factors in modulating homocysteine (HC) levels remains incompletely understood. We aimed to investigate the aetiology of hyperhomocysteinaemia by examining the interactions between genetic predisposition, dietary patterns and other lifestyle factors and their potential associations with metabolic syndrome (MetS) and CVD risk. Cross-sectional analysis from the Korean Genome and Epidemiology Study, a hospital-based cohort conducted by the Korean Centers for Disease Control and Prevention from 2012 to 2016. Korean adults (n = 62 743, aged 40-79 years) were categorised into Low-HC (n = 53 450) and High-HC (n = 9293) groups based on a 15 μM serum homocysteine cutoff. Demographic, anthropometric and biochemical data were analysed. Genome-wide association and gene-environment interaction models explored genetic variants influencing hyperhomocysteinaemia and their interplay with lifestyle factors, including nutrient intake. Multivariable logistic regression assessed associations between hyperhomocysteinaemia and metabolic/CVD risks, adjusting for covariates. Genetic variant-environment interaction analyses identified genetic determinants and their interactions with diet/lifestyle. The High-HC group exhibited an elevated MetS risk. Hyperhomocysteinaemia was correlated with liver damage, inflammation and CVD risks. Low vitamin B12 intake (< 5.4 μg/day) showed a stronger association with hyperhomocysteinaemia than low folate intake (< 350 μg/day), with combined deficiencies exacerbating hyperhomocysteinaemia. An inverse relationship was observed between hyperhomocysteinaemia and healthy eating indices like Asian balanced and plant-based diets. Variants in MTHFR, NOX4, PLOD1, MIIP, PAX6 and CBS genes, involved in methionine/cysteine metabolism, exhibited differential expression in skeletal muscle, liver and adipose tissues. High polygenic risk scores interacted with poor diet quality, excess energy intake, a high glycemic index, smoking and heavy alcohol consumption to contribute to hyperhomocysteinaemia. In conclusion, these findings elucidate the complex interplay between genetics, diet and lifestyle in modulating homocysteine levels, providing insights for personalised nutrition strategies to mitigate CVD risk.

Identification of specific risk factors and predictive analytics for cardio-cerebral arterial stenosis: a comparative study utilizing framingham risk stratification insights

Atherosclerotic diseases are systemic, and stroke patients often present with both intracranial artery stenosis (ICAS) and coronary artery stenosis (COAS). This study aimed to investigate the prevalence of ICAS and COAS among ischemic stroke patients across different risk strata and to construct a predictive model for assessing atherosclerosis risk. This retrospective study included patients admitted for ischemic stroke at the Affiliated Hospital of Xuzhou Medical University from December 2020 to December 2021. All patients underwent CTA, with significant stenosis defined as exceeding 50% for both cerebral and coronary arteries.Patients were categorized into low-, moderate-, and high-risk groups on the basis of the Framingham risk scale. A total of 5,816 patients were included, with a mean age of 66.54 years. Dual arterial stenosis was found in 2,258 patients (38.8%), single ICAS in 399 (6.8%), and single COAS in 3,159 (54.3%). The moderate- and high-risk groups had significantly lower risks of single ICAS and COAS. Comparing the differences in risk factors between single arterial stenosis and dual arterial stenosis, the key risk factors included hyperlipidemia, smoking, hypertension, and diabetes, with a model accuracy of 73.61% and an AUC values of 0.8562 for dual stenosis. Significant differences in age, sex, and the risk factors were observed among risk groups. The predictive model demonstrated high accuracy, highlighting the importance of personalized medicine in clinical decision-making.

Development and validation of a nomogram to predict depression in older adults with heart disease: a national survey in China

Background

Comorbid depression, frequently observed in heart disease patients, has detrimental effects on mental health and may exacerbate cardiac conditions. The objective of this study was to create and validate a risk prediction nomogram specifically for comorbid depression in older adult patients suffering from heart disease.

Methods

The 2018 data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) was analyzed and 2,110 older adult patients with heart disease aged 60 and above were included in the study. They were randomly divided in a 7:3 ratio into a training set (n = 1,477) and a validation set (n = 633). Depression symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) and the participants were categorized into depressed (n = 687) and non-depressed (n = 1,423) groups. We collected information regarding general demographics, lifestyle habits, and medical history of the included patients. LASSO regression and binary logistic regression analyses were performed to identify independent risk factors and construct the depression prediction nomogram. Receiver operating characteristic curve analysis and the Hosmer-Lemeshow test were used to assess the model's discrimination and calibration. Decision curve analysis helped evaluate the clinical utility of the predictive nomogram.

Results

Based on the LASSO and multivariable regression analyses, education level, quality of life, sleep quality, frequency of watching TV, and history of arthritis were identified as independent risk factors for comorbid depression in the older adult heart disease patients. A nomogram model was constructed with these five independent risk factors. The nomogram showed good clinical performance with an area under the curve (AUC) value of 0.816 (95% CI: 0.793 to 0.839). The calibration curves and Hosmer-Lemeshow goodness-of-fit test (training setχ t 2 = 4.796, p = 0.760; validation setχ v 2 = 7.236, p = 0.511) showed its satisfactory. Clinical usefulness of the nomogram was confirmed by decision curve analysis.

Conclusions

A five-parameter nomogram for predicting depression in older adult heart disease patients was developed and validated. The nomogram demonstrated high accuracy, discrimination ability, and clinical utility in assessing the risk of depression in the older adult patients with heart disease.

Habitual dietary methyl donor's intake and metabolic profile in obese individuals: a cross-sectional study

Considering the role of dietary methyl donor (DMD) in numerous biochemical processes, we hypothesized that DMD could play an important role in metabolic syndrome such as hyperlipidemia, hypertension, insulin resistance, and appetite in obese individuals. This cross-sectional study was conducted on 335 obese people. We collected dietary data using a valid and reliable 147-question Food Frequency Questionnaire (FFQ). Multivariate multinomial logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for the association between dietary methyl intake and cardio-metabolic risk factors. After adjusting for confounding variables, individuals at the fourth and third quartile of DMD, were more likely to have lower low-density lipoprotein cholesterol (LDL-C) (OR = 0.968, CI = 0.943-0.994, P = 0.015 and OR = 0.978, CI = 0.957-0.998, P = 0.03 respectively) versus first quartile. Also, total cholesterol (TC) showed a significant decrease in forth quartile of DMD in model III (OR = 0.974, CI = 0.951-0.997, P = 0.029). Current results suggested that, high DMDs' consumption, significantly associated with decreased risk of cardiometabolic risk factors.

Nicotinamide N-methyltransferase (NNMT): a novel therapeutic target for metabolic syndrome

Metabolic syndrome (MetS) represents a constellation of metabolic abnormalities, typified by obesity, hypertension, hyperglycemia, and hyperlipidemia. It stems from intricate dysregulations in metabolic pathways governing energy and substrate metabolism. While comprehending the precise etiological mechanisms of MetS remains challenging, evidence underscores the pivotal roles of aberrations in lipid metabolism and insulin resistance (IR) in its pathogenesis. Notably, nicotinamide N-methyltransferase (NNMT) has recently surfaced as a promising therapeutic target for addressing MetS. Single nucleotide variants in the NNMT gene are significantly correlated with disturbances in energy metabolism, obesity, type 2 diabetes (T2D), hyperlipidemia, and hypertension. Elevated NNMT gene expression is notably observed in the liver and white adipose tissue (WAT) of individuals with diabetic mice, obesity, and rats afflicted with MetS. Knockdown of NNMT elicits heightened energy expenditure in adipose and hepatic tissues, mitigates lipid accumulation, and enhances insulin sensitivity. NNMT catalyzes the methylation of nicotinamide (NAM) using S-adenosyl-methionine (SAM) as the donor methyl group, resulting in the formation of S-adenosyl-l-homocysteine (SAH) and methylnicotinamide (MNAM). This enzymatic process results in the depletion of NAM, a precursor of nicotinamide adenine dinucleotide (NAD+), and the generation of SAH, a precursor of homocysteine (Hcy). Consequently, this cascade leads to reduced NAD+ levels and elevated Hcy levels, implicating NNMT in the pathogenesis of MetS. Moreover, experimental studies employing RNA interference (RNAi) strategies and small molecule inhibitors targeting NNMT have underscored its potential as a therapeutic target for preventing or treating MetS-related diseases. Nonetheless, the precise mechanistic underpinnings remain elusive, and as of yet, clinical trials focusing on NNMT have not been documented. Therefore, further investigations are warranted to elucidate the intricate roles of NNMT in MetS and to develop targeted therapeutic interventions.

Cardiovascular Risk Factors in China

The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. This section dissects cardiovascular risk factors in China which including hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, metabolic syndrome and air pollution. Hypertension prevalence has steadily increased in China, with efforts to control it facing challenges in achieving optimal rates, especially in rural areas. Interventions like salt substitutes and intensive blood pressure control show promise but need improvement. Abnormal lipid levels, indicative of dyslipidemia, have risen significantly, posing a risk for cardiovascular diseases. Despite efforts, many patients struggle to achieve target lipid levels, necessitating improved treatment strategies. Both type 1 and type 2 diabetes mellitus affect millions of adults in China, with long-term complications adding to the disease burden. Early intervention and effective management are crucial to mitigate its impact. Prevalent among older adults, chronic kidney disease is associated with diabetes mellitus, hypertension, and cardiovascular diseases, necessitating comprehensive management approaches. The prevalence of metabolic syndrome, characterized by a cluster of risk factors, has increased in both adults and adolescents, calling for lifestyle modifications and public health interventions. Ambient and household air pollution remain significant environmental risk factors, despite some improvements in air quality. Continued efforts to reduce emissions are essential for mitigating associated health risks. Addressing these risk factors requires a multifaceted approach, including public health initiatives, policy interventions, and individual-level strategies to promote healthy lifestyles and reduce environmental exposures. Surveillance and research efforts are crucial for monitoring trends and developing effective strategies to lessen the burden of cardiovascular diseases in China.

Endothelial Dysfunction in Obesity and Therapeutic Targets

Parallel to the increasing prevalence of obesity in the world, the mortality from cardiovascular disease has also increased. Low-grade chronic inflammation in obesity disrupts vascular homeostasis, and the dysregulation of adipocyte-derived endocrine and paracrine effects contributes to endothelial dysfunction. Besides the adipose tissue inflammation, decreased nitric oxide (NO)-bioavailability, insulin resistance (IR), and oxidized low-density lipoproteins (oxLDLs) are the main factors contributing to endothelial dysfunction in obesity and the development of cardiorenal metabolic syndrome. While normal healthy perivascular adipose tissue (PVAT) ensures the dilation of blood vessels, obesity-associated PVAT leads to a change in the profile of the released adipo-cytokines, resulting in a decreased vasorelaxing effect. Higher stiffness parameter β, increased oxidative stress, upregulation of pro-inflammatory cytokines, and nicotinamide adenine dinucleotide phosphate (NADP) oxidase in PVAT turn the macrophages into pro-atherogenic phenotypes by oxLDL-induced adipocyte-derived exosome-macrophage crosstalk and contribute to the endothelial dysfunction. In clinical practice, carotid ultrasound, higher leptin levels correlate with irisin over-secretion by human visceral and subcutaneous adipose tissues, and remnant cholesterol (RC) levels predict atherosclerotic disease in obesity. As a novel therapeutic strategy for cardiovascular protection, liraglutide improves vascular dysfunction by modulating a cyclic adenosine monophosphate (cAMP)-independent protein kinase A (PKA)-AMP-activated protein kinase (AMPK) pathway in PVAT in obese individuals. Because the renin-angiotensin-aldosterone system (RAAS) activity, hyperinsulinemia, and the resultant IR play key roles in the progression of cardiovascular disease in obesity, RAAS-targeted therapies contribute to improving endothelial dysfunction. By contrast, arginase reciprocally inhibits NO formation and promotes oxidative stress. Thus, targeting arginase activity as a key mediator in endothelial dysfunction has therapeutic potential in obesity-related vascular comorbidities. Obesity-related endothelial dysfunction plays a pivotal role in the progression of type 2 diabetes (T2D). The peroxisome proliferator-activated receptor gamma (PPARγ) agonist, rosiglitazone (thiazolidinedione), is a popular drug for treating diabetes; however, it leads to increased cardiovascular risk. Selective sodium-glucose co-transporter-2 (SGLT-2) inhibitor empagliflozin (EMPA) significantly improves endothelial dysfunction and mortality occurring through redox-dependent mechanisms. Although endothelial dysfunction and oxidative stress are alleviated by either metformin or EMPA, currently used drugs to treat obesity-related diabetes neither possess the same anti-inflammatory potential nor simultaneously target endothelial cell dysfunction and obesity equally. While therapeutic interventions with glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide or bariatric surgery reverse regenerative cell exhaustion, support vascular repair mechanisms, and improve cardiometabolic risk in individuals with T2D and obesity, the GLP-1 analog exendin-4 attenuates endothelial endoplasmic reticulum stress.

Vitamin B12, folate, and homocysteine in metabolic syndrome: a systematic review and meta-analysis

Background & aims

Metabolic syndrome (MetS) is associated with life-threatening conditions. Several studies have reported an association of vitamin B12, folic acid, or homocysteine (Hcy) levels with MetS. This systematic review and meta-analysis assessed the association of vitamin B12, folic acid, and Hcy levels with MetS.

Methods

PubMed, Scopus, Embase, Ovid/Medline, and Web of Science were searched up to February 13, 2023. Cross-sectional, case-control, or cohort studies were included. A random-effects model was performed using the DerSimonian and Laird method to estimate the between-study variance. Effect measures were expressed as odds ratios (OR) with their corresponding 95% confidence intervals (95% CI). Between-study heterogeneity was evaluated using Cochran's Q test and the I2 statistic.

Results

Sixty-six articles (n = 87,988 patients) were included. Higher vitamin B12 levels were inversely associated with MetS (OR = 0.87; 95% CI: 0.81-0.93; p < 0.01; I2 = 90%). Higher Hcy levels were associated with MetS (OR = 1.19; 95% CI: 1.14-1.24; p < 0.01; I2 = 90%). Folate levels were not associated with MetS (OR = 0.83; 95% CI: 0.66-1.03; p = 0.09; I2 = 90%).

Conclusion

Higher vitamin B12 levels were inversely associated with MetS, whereas higher Hcy levels were associated with MetS. Studies assessing the pathways underlying this association are required.

Safety and efficacy of anti-inflammatory therapy in patients with coronary artery disease: a systematic review and meta-analysis

Background

The inflammation hypothesis of atherosclerosis has been put forward for more than 20 years. Although many animal experiments have suggested that anti-inflammatory therapy can inhibit the atherosclerotic process, the efficacy of anti-inflammatory therapy for patients with coronary artery disease (CAD) is still controversial. Therefore, this study aims to evaluate the safety and efficacy of anti-inflammatory drugs in patients with CAD.

Method

We conducted this systematic review and meta-analysis of randomized controlled trials by searching PubMed, EMBASE, web of science, and Cochrane Library database. The primary outcome was a composite outcome of cardiovascular death, myocardial infarction (MI), or stroke. The secondary outcomes included individual MI, coronary revascularization, cardiovascular death, all-cause death, and stroke. The relative risk (RR) and 95% confidence intervals (CI) for outcome events were calculated by the fixed effects model, and trial sequential analysis was applied to assess the results.

Result

A total of ten randomized controlled trials and 60,782 patients with CAD was included. Compared with patients receiving placebo, anti-inflammatory therapy significantly reduced the incidence of the primary outcome in patients with CAD (RR 0.93, 0.89–0.98, P = 0.007). In addition, the anti-inflammatory therapy can also reduce the risk of MI (RR 0.90, 0.84–0.96, P = 0.002) and coronary revascularization (RR 0.74, 0.66–0.84, P < 0.00001) remarkably. However, there was no significant difference in the incidence of cardiovascular death (RR 0.94, 0.86–1.02, P = 0.14), all-cause death (RR 1.00, 0.94–1.07, P = 0.98) and stroke (RR 0.96, 0.85–1.09, P = 0.51) between two groups.

Conclusions

Anti-inflammatory therapy can reduce the incidence of the primary outcome in patients with CAD, especially the risk of MI and coronary revascularization. However, anti-inflammatory therapy increases the risk of infection. (Registered by PROSPERO, CRD 420212291032).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02525-9.

The LOX-1 receptor ectopically expressed in the liver alleviates atherosclerosis by clearing Ox-LDL from the circulation

Objective

Oxidized Low-Density-Lipoprotein (Ox-LDL) is the core factor in the development of atherosclerosis. However, there are few therapies aimed at eliminating Ox-LDL. Here in this study, we investigate whether the ectopically expression of the lectin-like oxidized low density lipoprotein receptor (LOX-1) in the liver could lead to the elimination of circulating Ox-LDL and prevent the deposition in the vascular wall, thereby alleviating the progression of atherosclerosis.

Methods

Apolipoprotein E-deficient (ApoE^−/−) mice were randomly divided into three groups, the control group, the AAV8-TBG-eGFP group (eGFP group) and AAV8-TBG-LOX-1 group (LOX-1 group). In the LOX-1 group, mice received an injection of virus dilution AAV8-TBG-LOX-1 (1.16 × 10¹¹ virus genome (v.g)/animal/100 μl). The mice in the control group and eGFP group received the same amount of sterile saline and AAV8-TBG-eGFP virus dilution injections. The expression of LOX-1 in the liver was detected by immunofluorescent, western blot and immunohistochemistry. The safety of the virus was assessed by hematoxylin–eosin (H&E) staining, blood biochemical analyses and immunofluorescent. The function of LOX-1 in the liver was detected by the co-localization of LOX-1 and Dil-labeled Ox-LDL (Dil-Ox-LDL) under laser scanning confocal microscope. The extent of Ox-LDL in plasma was detected by ELISA. Changes in blood lipids were assessed through blood biochemical analysis. The progression of atherosclerotic lesions was detected by Oil red O staining. And the expression of Vascular Cell Adhesion Molecule-1 (VCAM-1) in endothelial cells and the extent and migration of macrophages in atherosclerotic plaque were detected by immunofluorescence staining. The protein expression in liver was assessed by qRT-PCR and western blot.

Results

The expression of LOX-1 was stable in liver within 4 weeks. Ectopically expressed LOX-1 in the liver phagocytosed and degraded Ox-LDL and reduced Ox-LDL from circulation but did not have a significant effect on blood lipid levels. After the expression of LOX-1 in liver, Ox-LDL can be cleared by the hepatocytes, thereby reducing VCAM-1 expression in vascular endothelium and the migration of macrophages in plaques, and eventually alleviating the progression of atherosclerosis. Functional expression of LOX-1 in hepatocytes may facilitate the metabolic clearance of Ox-LDL by upregulating the expression of ATP-binding cassette G5 and G8 (ABCG5/G8), which is the primary neutral sterol transporter in hepatobiliary and transintestinal cholesterol excretion.

Conclusion

Ectopic liver-specific expression of LOX-1 receptor alleviates the progression of atherosclerosis by clearing Ox-LDL from circulation.