The association of uric acid with mortality modifies at old age: data from the uric acid right for heart health (URRAH) study

A Cohort Study on the Correlation Between Serum Uric Acid Trajectory and New-Onset Hypertension Based on Longitudinal Health Examination Data in Henan Area

Objective

To explore the correlation between serum uric acid (SUA) trajectories and new-onset hypertension, to provide scientific basis for the prevention and treatment of hypertension.

Methods

The study cohort was composed of 4372 subjects who met the inclusion criteria in the cohort study of Henan physical examination population. According to the SUA values of the subjects' physical examination from 2017 to 2019, three different SUA trajectory groups were determined by R LCTM tools, namely low stability group, medium stability group and high stability group. The incidence of hypertension during physical examination in 2020 was followed up, the cumulative incidence rate in each group was calculated by product limit method, and the correlation between different SUA trajectories and new-onset hypertension was analyzed by Cox proportional hazards regression model.

Results

The incidence rate of hypertension increased with the increase of SUA locus, which was 4.65%, 9.18% and 12.43% respectively, and the difference was statistically significant (P<0.001). After adjusting multiple confounding factors, such as gender, waist circumference (WC), blood pressure, body mass index (BMI), fasting plasma glucose (FPG) and blood lipid by Cox proportional hazards regression model, the risk of hypertension in SUA medium stability and high stability group was still 1.476 times (95% CI: 1.089~2.000) and 1.692 times (95% CI: 1.152~2.484) of low-stable SUA group (P<0.05).

Conclusion

The risk of hypertension increases with the increase of SUA level in the long-term normal range. It is necessary to carry out the intervention for hypertension with long-term normal high value to avoid the progress of hypertension disease, to achieve the purpose of early prevention of hypertension.

The Results of the URRAH (Uric Acid Right for Heart Health) Project: A Focus on Hyperuricemia in Relation to Cardiovascular and Kidney Disease and its Role in Metabolic Dysregulation

The relationship between Serum Uric Acid (UA) and Cardiovascular (CV) diseases has already been extensively evaluated, and it was found to be an independent predictor of all-cause and cardiovascular mortality but also acute coronary syndrome, stroke and heart failure. Similarly, also many papers have been published on the association between UA and kidney function, while less is known on the role of UA in metabolic derangement and, particularly, in metabolic syndrome. Despite the substantial number of publications on the topic, there are still some elements of doubt: (1) the better cut-off to be used to refine CV risk (also called CV cut-off); (2) the needing for a correction of UA values for kidney function; and (3) the better definition of its role in metabolic syndrome: is UA simply a marker, a bystander or a key pathological element of metabolic dysregulation?. The Uric acid Right for heArt Health (URRAH) project was designed by the Working Group on uric acid and CV risk of the Italian Society of Hypertension to answer the first question. After the first papers that individuates specific cut-off for different CV disease, subsequent articles have been published responding to the other relevant questions. This review will summarise most of the results obtained so far from the URRAH research project.

Association between the Weight-Adjusted Waist Index and Serum Uric Acid: A Cross-Sectional Study

Background

Serum uric acid (SUA) was closely related to body metabolism. This study aimed to investigate the relationship between the adult weight-adjusted waist index (WWI) and SUA.

Methods

In the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2020, 6494 eligible participants aged ≥20  were included. The multivariate logistic regression model was used to test the correlation between WWI and SUA. At the same time, subgroup analysis was carried out by using multivariate logistic regression according to age, sex, and race. Then, the fitting smooth curve was applied to solve the association between WWI and SUA. Finally, the recursive algorithm was used to calculate the inflection point in the nonlinear relationship, and the two-stage piecewise linear regression model was used to analyze the relationship between WWI and SUA on both sides of the inflection point.

Results

In all the 6494 participants, through the fully adjusted model, this study found that there was a positive correlation between WWI and SUA (β = 5.64; 95% CI: 2.62 and 8.66). In addition, this positive correlation still had certain statistical significance in the subgroup analysis stratified by sex, age, and race. Our research team found a significant positive correlation between the WWI and SUA in females, but the correlation was not significant in males. We also found a small inverted U-shaped curve between the WWI and SUA in men when we stratified the sex subgroups. The small inflection point was determined to be 11.5 cm/√ kg. In racial subgroup analysis, we also found a U-shaped relationship between the WWI and SUA in non-Hispanic White and other race/ethnicity (the inflection point was 11.08 cm/√ kg and 12.14 cm/√ kg, respectively).

Conclusion

This study showed that the WWI was a newly developed and new predictor of centripetal obesity independent of body weight and there was a positive correlation between the WWI and SUA.

Association of hyperuricemia combined with sarcopenia on ASCVD risk

BACKGROUND

Hyperuricemia and sarcopenia are both strongly linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD), and this study was designed to look into the interactive effects of hyperuricemia on ASCVD risk.

METHODS

This study collected information from patients (N = 2647) who underwent health check-ups at the Health Care Building of Wuhan Union Hospital between January 2019 and December 2020. Skeletal muscle mass was measured using bioelectrical impedance methods. The Asian Working Group on Sarcopenia diagnostic criteria were used to classify patients with sarcopenia. ASCVD risk was calculated using the Framingham Heart Study, and ASCVD risk ≥ 20% was considered high risk ASCVD. IBM SPSS 25.0 and GraphPad prism 8.0 software were used for data analysis and graphing.

RESULTS

The prevalence of hyperuricemia and sarcopenia was 23.57% and 15.34%, respectively. The occurrence of cardiovascular risk factors such as obesity, hypertension, diabetes mellitus, chronic kidney disease, and low HDL-Cemia was significantly higher in subjects with hyperuricemia combined with sarcopenia (OR = 1.734, 3.064, 1.61, 8.77 and 1.691 respectively, p < 0.05); Hyperuricemia and high-risk ASCVD were independently associated (OR = 1.355, 95% CI = 1.000-1.838, p = 0.04). Although there was no significant association between sarcopenia and high-risk ASCVD after controlling for confounders (OR = 1.274, 95% CI = 0.828-1.959, p = 0.271), sarcopenia combined with hyperuricemia significantly increased high-risk ASCVD (OR = 3.229, 95% CI 1.544-6.751, p = 0.002).

CONCLUSION

Hyperuricemia is independently associated with high-risk ASCVD; Sarcopenia and high-risk ASCVD did not show an independent relationship, but there was a synergistic effect of the two on ASCVD risk, which may imply that managing both hyperuricemia and sarcopenia may have a greater cardiovascular benefit.

Serum Uric Acid Levels Are Associated with the Echogenic Features of Carotid Plaque Vulnerability in Elderly Patients with Atherosclerotic Disease

Uric acid is a marker of inflammation and a risk factor for atherosclerosis that has been suggested to play a role in carotid plaque instability. Reduced atherosclerotic plaque echogenicity at ultrasound examination is associated with alarming histopathological features and inflammation. In this study, we investigated the relationship between serum uric acid (SUA) levels and echogenic patterns of plaque instability in elderly subjects with carotid atherosclerosis. Since uric acid metabolism largely depends on renal function, SUA levels were indexed for serum creatinine levels (SUA/SCr). We enrolled 108 patients aged 65 years or more (72.7 ± 5.9 years; 50 females and 58 males) who underwent carotid duplex ultrasound to evaluate plaque echogenicity by greyscale median (GSM). The regression analysis demonstrated a significant inverse association between the GSM and the SUA/SCr ratio (β: -0.567; 95% CI -0.751 to -0.384 and p < 0.0001). Stepwise multivariate regression showed that the SUA/SCr ratio explained 30.3% of GSM variability (β: -0.600; 95% CI -0.777/-0.424, p < 0.0001, and semi-partial correlation 0.303). After a mean period of 3.5 ± 0.5 years, 48 patients were reevaluated according to the same baseline study protocol. The regression analysis demonstrated a still significant inverse association between the GSM and the SUA/SCr ratio (β: -0.462; 95% CI -0.745 to -0.178 and p = 0.002). Stepwise multivariate regression showed that the SUA/SCr ratio explained 28.0% of GSM variability (coefficient -0.584, 95% CI -0.848/-0.319, p < 0.0001, and semi-partial R² 0.280). In conclusion, this study demonstrates that SUA levels indexed for serum creatinine are associated with the echogenic features of carotid plaque vulnerability in elderly patients with atherosclerotic disease. These data could suggest an influential role for uric acid metabolism in carotid plaque biology.

Hyperuricaemia: prevalence and association with mortality in an elderly Finnish population

OBJECTIVE

To establish the prevalence of hyperuricaemia in an elderly Finnish cohort and to assess its association with comorbidities and mortality.

DESIGN

Prospective cohort study.

SETTING

Good Ageing in Lahti Region study, Finland 2002-2012 (mortality data analysed until 2018).

PARTICIPANTS

2673 participants (mean age 64 years; 47% men).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of hyperuricaemia in the study population was detected. Associations between hyperuricaemia and mortality were assessed using multivariable adjusted Cox proportional hazards models.

METHODS

Data from a prospective, population-based study of elderly people (52-76 years) in the Lahti region, Finland, were used. Information on serum uric acid (SUA) levels as well as several other laboratory variables, comorbidities, lifestyle habits and socioeconomic factors was collected, and the association between SUA level and mortality in a 15-year follow-up period was analysed.

RESULTS

Of 2673 elderly Finnish persons included in the study 1197 (48%) were hyperuricaemic. Hyperuricaemia was extremely prevalent in men (60%). There was an association between elevated SUA and mortality which remained after adjustment for potential confounding factors (age, gender, education, smoking status, body mass index, hypertension and dyslipidaemia). The adjusted HR for all-cause mortality among clearly hyperuricaemic individuals with SUA≥420 µmol/L compared with normouricaemic individuals (SUA<360 µmol/L) was 1.32 (95% CI 1.05 to 1.60) in women and 1.29 (95% CI 1.05 to 1.60) in men. In slightly hyperuricaemic individuals (SUA 360-420 µmol/L) the corresponding HRs were 1.03 (95% CI 0.78 to 1.35) and 1.11 (95% CI 0.89 to 1.39).

CONCLUSIONS

Hyperuricaemia is very prevalent in the elderly Finnish population and is independently associated with increased mortality.

Association of hyperuricemia with cardiovascular diseases: current evidence

The aim of the present study is to present a historical and unified perspective on the association of serum uric acid (SUA) in the cause of cardiovascular diseases (CVDs). The association of hyperuricemia (HUC) with CVD begun to be appreciated in the middle 1950s and early 1990s when clinical evidence was shown on the association of HUC with CVD. However, this association was disputed by several investigators including the Framingham group and by professional societies, like the American Heart Association and the American Society of Hypertension. This dispute was weakened or reversed by later studies, which showed a positive association of HUC with CVD, CHD, HF, CKD, and stroke, mediated by several risk factors, both molecular such as, oxidative stress, inflammatory stress, insulin resistance, and endothelial dysfunction, as well as clinical factors such as, atherosclerosis, hypertension, metabolic syndrome, and type 2 diabetes mellitus. The great majority of recent studies show a positive association of HUC with CVDs, and CKD. However, the cutoff of the damaging levels of SUA have not been established as yet. The European Society of Hypertension (ESH) Treatment Guidelines have proposed a cutoff level of SUA for CVD > 7 mg/dl for men and > 6 mg/dl for women. In contrast, the URRAH study has shown a SUA level of 4.7 mg/dl for all-cause mortality and 5.6 mg/dl for CV mortality. These levels are lower than the SUA levels proposed by the ESH, which are consistent with HUC. For a better understanding of this association, a Medline search of the English literature was conducted between 2015 and 2022 and 44 pertinent papers were selected. These papers together with collateral literature will be discussed in this review.

Serum Uric Acid Predicts All-Cause and Cardiovascular Mortality Independently of Hypertriglyceridemia in Cardiometabolic Patients without Established CV Disease: A Sub-Analysis of the URic acid Right for heArt Health (URRAH) Study

High serum uric acid (SUA) and triglyceride (TG) levels might promote high-cardiovascular risk phenotypes across the cardiometabolic spectrum. However, SUA predictive power in the presence of normal and high TG levels has never been investigated. We included 8124 patients from the URic acid Right for heArt Health (URRAH) study cohort who were followed for over 20 years and had no established cardiovascular disease or uncontrolled metabolic disease. All-cause mortality (ACM) and cardiovascular mortality (CVM) were explored by the Kaplan-Meier estimator and Cox multivariable regression, adopting recently defined SUA cut-offs for ACM (≥4.7 mg/dL) and CVM (≥5.6 mg/dL). Exploratory analysis across cardiometabolic subgroups and a sensitivity analysis using SUA/serum creatinine were performed as validation. SUA predicted ACM (HR 1.25 [1.12-1.40], p < 0.001) and CVM (1.31 [1.11-1.74], p < 0.001) in the whole study population, and according to TG strata: ACM in normotriglyceridemia (HR 1.26 [1.12-1.43], p < 0.001) and hypertriglyceridemia (1.31 [1.02-1.68], p = 0.033), and CVM in normotriglyceridemia (HR 1.46 [1.23-1.73], p < 0.001) and hypertriglyceridemia (HR 1.31 [0.99-1.64], p = 0.060). Exploratory and sensitivity analyses confirmed our findings, suggesting a substantial role of SUA in normotriglyceridemia and hypertriglyceridemia. In conclusion, we report that SUA can predict ACM and CVM in cardiometabolic patients without established cardiovascular disease, independent of TG levels.

Serum uric acid / serum creatinine ratio as a predictor of cardiovascular events. Detection of prognostic cardiovascular cut-off values

OBJECTIVE

In the frame of the Uric Acid Right for Heart Health (URRAH) study, a nationwide multicenter study involving adult participants recruited on a regional community basis from all the territory of Italy under the patronage of the Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension, we searched for the cut-off values of the ratio between serum uric acid (SUA) and serum creatinine (sCr) able to predict cardiovascular (CV) events.

METHODS

Among 20 724 participants followed-up for 126 ± 64 months, after detecting cut-off by the receiver operating characteristic curves, we calculated by Cox models adjusted for confounders having CV events as dependent variable the hazard ratio (HR) of SUA/sCr > cut-off. We also verified if the role of cut-off varied with increasing SUA/sCr.

RESULTS

A plausible prognostic cut-off of SUA/sCr was found and was the same in the whole database, in men and in women (>5.35). The HR of SUA/sCr > cut-off was 1.159 (95% confidence interval [CI] 1.092-1.131, P < 0.03) in all, 1.161 (95% CI 1.021-1.335, P < 0.02) in men, and 1.444 (95% CI 1.012-1.113, P < 0.03) in women. In increasing quintiles of SUA/sCr the cut-offs were >3.08, >4.87, >5.35, >6.22 and >7.58, respectively. The HRs significantly increased from the 3rd to the 5th quintile (1.21, 95% CI 1.032-1.467, P = 0.018; 1.294, 95% CI 1.101-1.521, P = 0.002; and 1.642, 95% CI 1.405-1.919, P < 0.0001; respectively), that is, over 5.35, whereas the 2nd quintile was not significantly different from the 1st (reference).

CONCLUSION

Having SUA/sCr >5.35 is an independent CV risk indicator both in men and women. The cut-off is dynamic and significantly increases with increasing SUA/sCr.

Gender-Specific and U-Shaped Relationship Between Serum Uric Acid and All-Cause Mortality Among Chinese Older Adults: A National Population-Based Longitudinal Study

Objectives: This study aimed to prospectively investigate gender-specific relationship between hyperuricemia and all-cause mortality among Chinese older adults. Methods: The study was based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2008-2018, a prospective nationwide cohort of older adults in China. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for all-cause mortality. Restricted cubic splines (RCS) were conducted to explore the dose-response relationship between SUA levels and all-cause mortality. Results: For older women, compared to the participants in the third quartile of SUA level, those in the highest quartile of SUA was associated with significantly higher risk of all-cause mortality in the fully adjusted model (HR: 1.41, 95% CI: 1.03-1.92). No significant associations between SUA levels and all-cause mortality were observed in older men. The present study further found a U-shaped non-linear relationship between SUA levels and all-cause mortality in both sexes of older population (P for non-linear <0.05). Conclusions: This study provided prospective epidemiological evidence for the predictive role of SUA on all-cause mortality among the Chinese aging population over 10 years of follow-up, while revealing considerable gender-related differences.

Correlation Analysis between Uric Acid and Metabolic Syndrome in the Chinese Elderly Population: A Cross-Sectional Study

BACKGROUND

Currently, both metabolic syndrome and hyperuricaemia have attracted extensive attention in public health. The correlation between uric acid and metabolic syndrome is controversial. Research on the relationship between uric acid and metabolic syndrome in community-dwelling elderly people is relatively lacking. The purpose of this study is to explore the relationship between uric acid and metabolic syndrome in the community-dwelling elderly people.

DESIGN

Cross-sectional study.

METHODS

We collected the physical examination data of 1,267 elderly people in Gutian community in Wuhan and used SPSS IBM 25.0 for data analysis. Correlation and logistic regression analyses were performed, and ROC curves were drawn.

RESULTS

The uric acid level of the nonmetabolic syndrome group was lower than that of the metabolic syndrome group (337.31 vs. 381.91 µmol/L; P < 0.05). Uric acid was positively correlated with systolic blood pressure (r = 0.177, P < 0.001), diastolic blood pressure (r = 0.135, P < 0.001), body mass index (r = 0.234, P < 0.001), waist circumference (r = 0.283, P < 0.001), and triglycerides (r = 0.217, P < 0.05). High-density lipoprotein cholesterol (r = -0.268, P < 0.001) showed the opposite trend. Logistic regression analysis results suggested that uric acid is a risk factor for metabolic syndrome. The result is described as exp (B) and 95% CI (1.003 [1.001, 1.005]). Based on the receiver operating characteristic curve, we found that the area under the curve of uric acid to diagnose metabolic syndrome was 0.64 (sensitivity: 79.3%, specificity: 45.1%).

CONCLUSION

We observed an association between uric acid levels and metabolic syndrome in the elderly Chinese population. The best threshold value for uric acid in predicting metabolic syndrome diagnosis was 314.5 μmol/l.