Value of blood pressure measurement earlier versus later in life to predict cardiovascular mortality

 

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality.

The purpose of this study was to compare the value of systolic blood pressure earlier versus later in life to predict cardiovascular mortality.

In a cardiovascular observation study (OS) we prospectively recorded fatal cardiovascular events over up to 19 years in 1282 patients of whom 570 had the Metabolic Syndrome (MetS) at baseline. These patients had participated in a health survey (HS) 15 years prior to the OS baseline. BP was measured both at the HS and at the baseline of the OS.

We found that the increase in cardiovascular mortality matched the increase of BP in the HS in a linear way but this is not the case for BP assessed at the OS (figure). A cox regression analysis revealed that each millimeter of mercury (mm Hg) increased the risk for cardiovascular death by 2% (HR = 1.02 [1.01–1.03], p<0.001). Applying a stratification for the presence of MetS, we found that in both groups BP was a significant predictor of cardiovascular mortality (HRMetS = 1.02 [1.01–1.02], p<0.001 and HRnoMetS = 1.02 [1.01–1.03], p<0.001). In contrast, BP as measured at the baseline of the OS was not significantly associated with cardiovascular death during follow-up neither in the total population nor in any subgroup (HR = 1.00 [0.99–1.01], p=0.652; HRMetS = 1.00 [0.99–1.01], p=0.468 and HRnoMetS = 1.00 [0.99–1.01], p=4.66).

We thus conclude that BP assessed earlier in life is a better predictor of cardiovascular mortality than BP assessed later in life.

Funding Acknowledgement

Type of funding sources: None.

Ceramide-based lipid profiles and the prevalence of type 2 diabetes differ between patients with coronary artery disease and those with peripheral artery disease

Introduction

Serum lipids and metabolic diseases, in particular type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD), predict the atherosclerotic diseases coronary artery disease (CAD) and peripheral arterial disease (PAD).

Purpose

The purpose of this study was to investigate in how far a more detailed characterization including serum lipids improves discrimination of PAD from CAD.

Method

A cohort of 274 statin-naïve patients with either PAD (n=89) or stable CAD (n=185) were referred to metabolic screening and were characterized using nuclear magnetic resonance- and liquid chromatography-tandem mass spectrometry based advanced lipid and lipoprotein analysis. Results were validated in an independent cohort of 1239 patients with PAD or CAD.

Results

We found a significant difference in T2D prevalence and in the ceramide-based lipid profile between PAD and CAD patients. However, neither cholesterol-based markers (including LDL-C, HDL-C) and detailed lipoprotein profiles nor the LD status differed significantly between PAD and CAD patients (figure). The difference between ceramide-based lipid profiles of CAD and PAD remained significant also after adjusting for body composition, smoking, inflammatory parameters, and T2D.

Conclusion

We conclude that PAD and CAD differ in ceramide-based lipid profiles and T2D status, but not in other lipid characteristics or metabolic diseases.

Funding Acknowledgement

Type of funding sources: None.

Remnant cholesterol in patients with established cardiovascular disease predicts cardiovascular events both among patients with type 2 diabetes and among non-diabetic subjects

 

Remnant cholesterol, which is calculated as total cholesterol minus LDL cholesterol minus HDL cholesterol has attracted interest as a marker of cardiovascular event risk.

The purpose of this study was to investiage whether remnant cholesterol has the power to predict cardiovascular events in patients with established cardiovascular disease.

We enrolled 1822 consecutive patients with established cardiovascular disease, including 1472 with angiographically proven stable CAD, 350 with sonographically proven peripheral artery disease. Prospectively, cardiovascular events were recorded over a mean follow-up period of 6.2±3.2 years.

At baseline, remnant cholesterol was significantly higher in patients with T2DM (n=608) than in non-diabetic subjects (27±25 vs. 21±21 mg/dl; p<0.001). During follow-up, 584 of our patients suffered cardiovascular events; the event rate was significantly higher in patients with T2DM than in non-diabetic subjects (45.4 vs. 32.2%; p<0.001). Remnant cholesterol in Cox regression models adjusting for age, sex, hypertension, smoking, body mass index and LDL cholesterol independently predicted cardiovascular events in the total study population (standardized adjusted HR 1.15 [1.07–1.23]; p<0.001), and in patients with T2DM as well as in non-diabetic subjects (standardized adjusted HRs 1.17 [1.03–1.34]; p=0.013 and 1.12 [1.01–1.23]; p=0.028, respectively).

From our data we conclude that remnant cholesterol in patients with established cardiovascular disease predicts cardiovascular events both among patients with T2DM and among non-diabetic subjects.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes, chronic kidney disease and major cardiovascular events in patients with established coronary artery disease

 

Both type 2 diabetes (T2DM) and chronic kidney disease (CKD) confer a high risk of cardiovascular disease (CVD), and these conditions frequently coincide.

The purpose of this study was to investigate the single and joint effects of T2DM and CKD on major cardiovascular events (MACE) in a high-risk population of patients with established coronary artery disease (CAD).

We prospectively investigated 1460 patients with angiographically proven CAD over 10.4±4.8 years, of whom 454 (30.8%) had T2DM and 251 (17.1%) had CKD.

MACE occurred more frequently in T2DM patients than in non-diabetic subjects (40.4% vs 28.7%, p<0.001) and in patients with CKD (eGFR <60ml/min/1.73m2) than in those with an eGRF ≥60ml/min/1.73m2 (51.6% vs 28.3%, p<0.001). When both, T2DM and CKD were considered, 863 subjects had neither T2DM nor CKD, 346 had T2DM but not CKD, 148 did not have diabetes but had CKD, and 103 had both T2DM and CKD. When compared with the incidence of MACE among patients with neither T2DM nor CKD (25.3%), MACE occurred more frequently in patients with T2DM who did not have CKD (35.8%; p<0.001) as well as in non-diabetic patients with CKD (47.6%; p<0.001) and occurred most freuently in patients with both, T2DM and CKD (57.4%; p<0.001), in whom the incidence of MACE was higher than in those with T2DM but not CKD (p<0.001) or those without T2DM but with CKD (p=0.025); the incidence of MACE was higher in non-diabetic CKD patients than in T2DM patients who did not have CKD (p=0.041). In Cox regression analysis, T2DM (HR=1.46 [1.20–1.78]; p<0.001) and CKD (HR=1.81 [1.45–2.27]; p<0.001) were mutually independent predictors of MACE after multivariate adjustment.

We conclude that T2DM and CKD are mutually independent risk factors for MACE in patients with established CAD. CAD patients with both CKD and T2DM are an extremely high risk for MACE.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes significantly modulates the power of lipoprotein(a) to predict cardiovascular events and mortality in young coronary artery disease patients

 

Lipoprotein(a) [Lp(a)] is an important cardiovascular risk factor especially in young individuals.

The purpose of this study was to investigate whether Lp(a) has the power to predict cardiovascular events in young coronary artery disease (CAD) patients with type 2 diabetes (T2DM).

Lp(a) was measured in a cohort of 731 patients with angiographically proven CAD who were aged <65 years. Vascular events were recorded over a mean follow-up of 6.6±3.2 years.

At baseline, 216 patients had T2DM, and 515 did not have diabetes. During follow-up, 30.2% of our patients suffered cardiovascular events. Lp(a) proved to be a strong and independent predictor of vascular events in the total study cohort (standardized adjusted HR=1.30 [1.07–1.56]; p=0.007). In subgroup analyses by diabetes status, Lp(a) significantly predicted vascular events in non-diabetic patients (standardized adjusted HR= 1.39 [1.12–1.74]; p=0.003) but not in diabetic patients (standardized adjusted HR=0.93 [0.63–1.38]; p=0.731). An interaction term Lp(a) x T2DM was significant (p=0.002), indicating that T2DM significantly modulated the power of Lp(a) to predict cardiovascular events.

We conclude that Lp(a) significantly modulates the power of Lp(a) to predict cardiovascular events in CAD patients <65 years.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes and risk of major cardiovascular events in peripheral artery disease versus coronary artery disease patients

 

The prevalence of type 2 diabetes (T2DM) is higher in peripheral artery disease (PAD) than in coronary artery disease (CAD) patients, and PAD overall confers higher cardiovascular risk than CAD.

The purpose of this study was to investigate how the incidence of major cardiovascular events compares between PAD and CAD patients when analyses are stratified by the presence of type 2 diabetes (T2DM).

We prospectively recorded major cardiovascular events and death over 10.0±4.7 years in 923 patients with stable CAD, of whom 26.7% had T2DM and in 292 patients with PAD, of whom 42.1% had T2DM. Four groups were analyzed: CAD patients without diabetes (CAD/T2DM-; n=677), CAD patients with T2DM (CAD/T2DM+; n=246), PAD patients without diabetes (PAD/T2DM-; n=169) and PAD patients with T2DM (PAD/T2DM+; n=123).

When compared to the incidence of MACE in CAD+/T2DM- patients (25.1%), it was significantly higher in CAD+/T2DM+ patients (35.4%; p<0.001), in PAD+/T2DM- patients (30.2%; p=0.022) and in PAD+/T2DM+ patients (47.2%; p<0.001). Patients with both PAD and T2DM in turn were at a higher risk than CAD+/T2DM+ or PAD+/T2DM- patients (p=0.001 and p<0.001, respectively). The incidence of MACE did not differ significantly between PAD+/T2DM- and CAD+/T2DM+ patients (p=0.413). Compared to patients with CAD, Cox regression analyses after multivariate adjustment showed an adjusted hazard ratio of 1.46 [1.14–1.87], p=0.002 for the presence of PAD. Conversely, T2DM increased the risk of MACE after multivariate adjustment in CAD and PAD patients (adjusted HR 1.58 [1.27–1.98], p<0.001).

In conclusion, our data show that T2DM and the presence of PAD are mutually independent predictors of MACE. Patients with both PAD and T2DM are at an exceedingly high risk of MACE.

Funding Acknowledgement

Type of funding sources: None.

Comparison of two recent ceramide-based coronary risk prediction scores: CERT and CERT-2

 

The Coronary Event Risk Test (CERT) is a validated cardiovascular risk predictor that uses circulating ceramide concentrations to allocate patients into one of four risk categories. This test has recently been updated (CERT-2), now additionally including phosphatidylcholine concentrations.

The purpose of this study was to investigate the power of CERT and CERT-2 to predict cardiovascular mortality in patients with cardiovascular disease (CVD).

We investigated a cohort of 999 patients with established CVD.

Overall, comparing survival curves (figure) for over 12 years of follow up and the predictive power of survival models using net reclassification improvement (NRI), CERT-2 was the best predictor of cardiovascular mortality, surpassing CERT (NRI=0.456; p=0.01) and also the 2019 ESC-SCORE (NRI=0.163; p=0.04). Patients in the highest risk category of CERT as compared to the lowest category had a HR of 3.63 [2.09–6.30] for cardiovascular death; for CERT-2 the corresponding HR was 6.02 [2.47–14.64]. Among patients with T2DM (n=322), the HR for cardiovascular death was 3.00 [1.44–6.23] using CERT and 7.06 [1.64–30.50] using CERT-2; the corresponding HRs among non-diabetic subjects were 2.99 [1.20–7.46] and 3.43 [1.03–11.43], respectively.

We conclude that both, CERT and CERT-2 scores are powerful predictors of cardiovascular mortality in CVD patients, especially in those patients with T2D. Performance is even higher with CERT-2.

Funding Acknowledgement

Type of funding source: None

P5363Adherence to statin therapy drives survival of patients with symptomatic peripheral artery disease

Background

Statins reduce cardiovascular morbidity and mortality, but adherence is suboptimal. We hypothesized that adherence to statin therapy determines survival in a population at very high cardiovascular risk.

Methods

Single center observational study with 691 symptomatic PAD patients admitted to a tertiary university center between 2010 and 2017. Outcome was evaluated over a mean follow-up of 50±26 months. We related statin adherence and LDL-C target attainment to total mortality.

Results

At the first contact, 73% of our PAD patients were on statins with a significant increase in statin use to 81% (p<0.0001) at follow-up: Statin dosage, normalized to simvastatin 40 mg, increased from 50 to 58 mg/ day (p<0.0001), and was paralleled by a mean decrease of LDL-C from 97 to 82 mg/ dL (p<0.0001). The proportion of patients receiving a high intensity statin increased over time from 38 to 62% (p<0.0001). Percent LDL-C decrease over time was highest in patients with high intensity statin treatment, followed by moderate, low intensity or non-statin treatment, respectively (p=0.01).

Patients never receiving statins had a higher mortality rate (34%) as compared to patients being on statins (20%) or having newly received a statin (15%; p<0.01). Moreover, patients on intensified statin medication had the lowest mortality (10%), whereas patients who terminated statin medication or reduced the statin dosage had a higher mortality rate (33% and 43%, respectively; p<0.05).

Figure 1

Conclusion

Our data prove that statin treatment, particularly high-intensity therapy, reduces mortality in symptomatic PAD. In terms of mortality, patients benefit even from de novo statin therapy (“it is never too late”), whereas dose reduction or statin discontinuation have deleterious effects. A strategy of intensive and sustained statin therapy is worthwhile.

Acknowledgement/Funding

None

P4992The ceramide-based Coronary Event Risk Test (CERT) predicts cardiovascular mortality in cardiovascular disease patients with type 2 diabetes mellitus as well as in those without diabetes

Background

The recently introduced Coronary Event Risk Test (CERT) is a validated cardiovascular risk predictor that uses circulating ceramide concentrations to allocate patients into one of four risk categories.

Purpose

The purpose of this study was to investigate the power of CERT to predict cardiovascular mortality in patients with established cardiovascular disease (CVD) including patients with type 2 diabetes (T2DM).

Methods

We investigated a total of 1087 patients with established CVD, including 360 patients with T2DM.

At baseline, the prevalence of T2DM increased through CERT categories (29.1, 31.1, 37.4, and 53.4%, respectively, ptrend<0.001). Prospectively, cardiovascular deaths were recorded during a mean follow-up time of 8.1±3.2 years.

Results

A total of 130 cardiovascular deaths occurred. Overall, cardiovascular mortality increased with increasing CERT categories (figure) and was higher in T2DM patients than in those who did not have diabetes (17.7 vs. 9.4%; p<0.001). In Cox regression models, CERT categories predicted cardiovascular mortality in patients with T2DM (unadjusted HR 1.60 [1.28–2.01]; p<0.001; HR adjusted for age, gender, BMI, smoking, LDL cholesterol, HDL cholesterol, hypertension, and statin use 1.65 [1.27–2.15]; p<0.001) and in those without diabetes (unadjusted HR 1.43 [1.10–1.85]; p=0.008 and adjusted HR 1.41 [1.07–1.85]; p=0.015).

Cardiovascular survival of CVD patients

Conclusion

We conclude that CERT predicts cardiovascular mortality in CVD patients with T2DM as well as in those without diabetes.

P4497Serum ceramides and type 2 diabetes are mutually independent predictors of cardiovascular events in patients with peripheral artery disease

Background

Ceramides are enriched in atherosclerotic plaques, and a set of circulating ceramides including Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/24:1), and Cer(d18:1/24:0) has recently emerged as predictors of cardiovascular outcomes in coronary artery disease patients.

Purpose

The purpose of this study was to investigate their power to predict cardiovascular events in patients with peripheral artery disease (PAD).

Methods

We measured the serum concentrations of the above mentioned ceramides in a cohort of 380 patients with sonographically proven PAD, of whom 107 had type 2 diabetes (T2DM). Prospectively, we recorded 221 cardiovascular events over a mean follow-up time of 6.3±2.3 years.

Results

Cardiovascular event risk was higher in T2DM patients than in those who did not have diabetes (69 vs. 52%, p=0.001). The ceramides Cer(18:1/16:0) and Cer(18:1/24:1) and the respective ratios Cer(18:1/16:0) / Cer(18:1/24:0) and Cer(18:1/24:1) / Cer(18:1/24:0) were significant predictors of cardiovascular events both univariately and after multivariate adjustment including the presence of T2DM (figure). Conversely, T2DM predicted cardiovascular events independently from the investigated ceramides (adjusted HR 1.76 [1.31–2.35], p<0.001).

Conclusion

We conclude that the investigated ceramides and T2DM are mutually independent predictors of cardiovascular events in PAD patients.

Pharmacological decrease of liver stiffness is pressure-related and predicts long-term clinical outcome

Liver stiffness (LS) as measured by transient elastography is increasingly used to noninvasively assess liver fibrosis. However, LS is efficiently modulated by confounders like arterial and portal pressure (PP). We here study the effect of acute hemodynamic changes on LS (measured by µFibroscan) in a rodent model of cirrhosis in response to pharmacological modulation of PP by losartan, nitric oxide donors, and propranolol. Additionally, changes of LS and the hepatic venous pressure gradient (HVPG) under propranolol therapy were assessed with regard to clinical outcomes in a human cohort of n = 38 cirrhotic patients. In the animal model, cirrhosis induction resulted in a significant increase of LS and PP. After losartan or NO application, a LS decrease of 25% was strongly correlated with a concomitant decrease of mean arterial pressure (MAP) and PP. In contrast, acute propranolol administration decreased heart rate but not MAP resulting in stable LS. In the human cohort, most patients ( n = 25, 66%) showed a LS decrease after propranolol treatment initiation which significantly correlated to HVPG ( r = 0.518, P < 0.01) but was not accompanied by statistically significant changes in transaminases or model of end-stage liver disease (MELD). On multivariate analysis, patients with decreasing LS on propranolol had a decreased risk for experiencing a transplantation or death than patients with increasing LS irrespective of HVPG. In conclusion, LS changes after pharmacological interventions are influenced by hemodynamic effects on arterial and portal pressure. In humans, a LS decrease may be predictive of improved outcome irrespective of MELD scores and may serve as an additional follow-up tool in the future. NEW & NOTEWORTHY Liver stiffness (LS) is efficiently modulated by changes in portal venous and systemic pressures in an animal model of liver cirrhosis irrespective of baseline LS and portal pressure values. In humans, most patients show a decrease in LS after propranolol treatment initiation without statistically significant changes in transaminases or model of end-stage liver disease (MELD) scores. A decrease in LS may be associated with improved outcome and thus another valuable tool in the follow-up of patients after propranolol treatment initiation.