Prevention of Atrial Fibrillation After Cardiac Surgery: A Review of Literature and Comparison of Different Treatment Modalities

Atrial fibrillation is the most common arrhythmia to occur after cardiac surgery, with an incidence of 10% to 50%. It is associated with postoperative complications including increased risk of stroke, prolonged hospital stays and increased costs. Despite new insights into the mechanisms of atrial fibrillation, no specific etiologic factor has been identified as the sole perpetrator of the arrhythmia. Current evidence suggests that the pathophysiology of atrial fibrillation in general, as well as after cardiac surgery, is multifactorial. Studies have also shown that new-onset postoperative atrial fibrillation following cardiac surgery is associated with a higher risk of short-term and long-term mortality. Furthermore, it has been demonstrated that prophylactic medical therapy decreases the incidence of postoperative atrial fibrillation after cardiac surgery. Of note, the incidence of postoperative atrial fibrillation has not changed during the last decades despite the numerous preventive strategies and operative techniques proposed, although the perioperative and postoperative care of cardiac patients as such has improved.

Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study

In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.

Impact of perfusion method on perioperative red blood cell transfusions and new-onset postoperative atrial fibrillation in mitral valve surgery patients

INTRODUCTION

Red blood cell (RBC) transfusions are common in cardiac surgery and reportedly associated with increased mortality and morbidity, including increased risk of postoperative new-onset atrial fibrillation (NOAF). The aim of this study was to compare minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) in terms of RBC transfusions and the incidence of NOAF in mitral valve surgery.

METHODS

The study population consisted of 89 MiECC and 169 CECC patients undergoing mitral valve surgery as an isolated procedure (80.6% of the patients) or in combination with coronary artery bypass grafting (19.4% of patients). 79.4% of the patients were male and the mean age was 62.1 years.

RESULTS

30.0% of patients aged < 65 years and 48.1% of patients aged ≥ 65 years needed RBC transfusion. The overall need for RBC transfusions did not differ between the treatment groups. Among patients < 65 years of age transfusions of ≥ 3 units were less frequent in MiECC than in CECC patients (OR 0.31, 95% CI 0.10-0.98, p = 0.045). The overall incidence of NOAF was 41.8% with no significant difference between MiECC and CECC groups. Red blood cell transfusions were associated with an increased risk of NOAF in an unadjusted analysis but not after adjustment for age and sex (OR 1.25, 95% CI 0.64-2.43, p = 0.515).

CONCLUSIONS

In mitral valve surgery MiECC compared to CECC was associated with less need of RBC units and platelets, particularly in patients aged < 65 years. Use of RBC transfusions was associated with increased risk of NOAF significantly only in unadjusted analysis.

Association of body mass index with 30-day mortality and red blood cell transfusions in open heart surgery

OBJECTIVES

Obesity is associated with increased burden of cardiovascular risk factors, morbidity and mortality. However, several studies have counterintuitively shown better outcome after cardiac surgery in obese than in normal weight patients, a phenomenon known as obesity paradox. Furthermore, obesity has been linked with decreased need of red blood cell transfusions. The purpose of this study was to evaluate the impact of body mass index on 30-day mortality and red blood cell transfusions in patients undergoing cardiac surgery, a clinically important topic with conflicting previous data.

METHODS

We retrospectively investigated 1691 patients who underwent coronary and/or valve or aortic root surgery using cardiopulmonary bypass between 2013 and 2016. The patients were categorized by body mass index based on World Health Organization classification. For analysis, logistic regression was used with adjustment for potential confounding factors.

RESULTS

Of the patients 28.7% were normal weight, 43.3% overweight, 20.5% mildly obese, and 7.5% severely obese. 30-day mortality was 1.9% without significant differences between the body mass index groups. 41.0% of patients received red blood cell transfusion. Overweight (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56-0.99, P = 0.045), mildly (OR 0.65, 95% CI 0.46-0.92, P = 0.016) and severely obese (OR 0.41, 95% CI 0.24-0.70, P =0.001) patients needed less frequently red blood cell transfusions than patients with normal weight.

CONCLUSIONS

Obesity was not associated with 30-day mortality but was associated with lower use of red blood cell transfusions in cardiac surgery.

Impact of minimal invasive extracorporeal circulation on perioperative intravenous fluid management in coronary artery bypass surgery

OBJECTIVE

Compare the use of blood products and intravenous fluid management in patients scheduled for coronary artery bypass surgery and randomized to minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC).

METHODS

A total of 240 patients who were scheduled for their first on-pump CABG, were randomized to MiECC or CECC groups. The study period was the first 84 hours after surgery. Hemoglobin <80 g/l was used as transfusion trigger.

RESULTS

Red blood cell transfusions intraoperatively were given less often in the MiECC group (23.3% vs 9.2%, p = 0.005) and the total intravenous fluid intake was significantly lower in the MiECC group (3300 ml [2950-4000] vs 4800 ml [4000-5500], p < 0.001). Hemoglobin drop also was lower in the MiECC group (35.5 ± 8.9 g/l vs 50.7 ± 9 g/l, p < 0.001) as was hemoglobin drop percent (25.3 ± 6% vs 35.3 ± 5.9%, p < 0.001). Chest tube drainage output was higher in the MiECC group (645 ml [500-917.5] vs 550 ml [412.5-750], p = 0.001). Particularly, chest tube drainage in up to 600 ml category, was in benefit of CECC group (59.1% vs 40.8%, p = 0.003). ROC curve analysis showed that patients with hemoglobin level below 95 g/l upon arrival to intensive care unit was associated with increased risk of developing postoperative atrial fibrillation (POAF) (p = 0.002, auc = 0.61, cutoff <95, sensitivity = 0.47, positive predictive value = 0.64).

CONCLUSION

MiECC reduced the intraoperative need for RBC transfusion and intravenous fluids compared to the CECC group, also reducing hemoglobin drop compared to the CECC group in CABG surgery patients. Postoperative hemoglobin drop was a predictor of POAF.

Serum caspase-cleaved cytokeratin-18 fragment as a prognostic biomarker in hematological patients with febrile neutropenia

The study aim was to determine the benefit of the measurement of serum caspase-cleaved cytokeratin-18 (CK-18) fragment as a prognostic marker of febrile neutropenia (FN) in hematological patients. The study population consisted of 86 consecutive patients with FN who received intensive chemotherapy for hematological malignancy at the adult hematology ward of Kuopio University Hospital. Twenty-three patients (27%) had acute myeloid leukemia, and 63 patients (73%) were autologous stem cell transplant recipients. Serum caspase-cleaved CK-18 fragment M30, C-reactive protein (CRP) and procalcitonin (PCT) were measured at the onset of FN (d0), on day 1 (d1), and on day 2 (d2). Eight patients (9%) developed severe sepsis, including three patients with septic shock. Eighteen patients (21%) had a blood culture-positive infection. Serum CK-18 fragment peaked on the first day after fever onset in patients with severe sepsis. Higher CK-18 level was associated with severe sepsis, intensive care unit treatment, and fatal outcome, but not with blood culture positivity. In ROC curve analysis, d1 serum CK-18 fragment predicted severe sepsis with an area under the curve (AUC) of 0.767, CRP with an AUC of 0.764, and PCT with an AUC of 0.731. On d2, the best predictive capacity was observed for CRP with an AUC of 0.832. The optimal cutoff of caspase-cleaved CK-18 fragment M30 for predicting severe sepsis was 205 U/L on d1. In hematological patients, serum CK-18 fragment was found to be a potential prognostic marker of severe sepsis at early stages of FN.

Accuracy of 1-Hour Plasma Glucose During the Oral Glucose Tolerance Test in Diagnosis of Type 2 Diabetes in Adults: A Meta-analysis

OBJECTIVE

One-hour plasma glucose (1-h PG) during the oral glucose tolerance test (OGTT) is an accurate predictor of type 2 diabetes. We performed a meta-analysis to determine the optimum cutoff of 1-h PG for detection of type 2 diabetes using 2-h PG as the gold standard.

RESEARCH DESIGN AND METHODS

We included 15 studies with 35,551 participants from multiple ethnic groups (53.8% Caucasian) and 2,705 newly detected cases of diabetes based on 2-h PG during OGTT. We excluded cases identified only by elevated fasting plasma glucose and/or HbA_1c. We determined the optimal 1-h PG threshold and its accuracy at this cutoff for detection of diabetes (2-h PG ≥11.1 mmol/L) using a mixed linear effects regression model with different weights to sensitivity/specificity (2/3, 1/2, and 1/3).

RESULTS

Three cutoffs of 1-h PG, at 10.6 mmol/L, 11.6 mmol/L, and 12.5 mmol/L, had sensitivities of 0.95, 0.92, and 0.87 and specificities of 0.86, 0.91, and 0.94 at weights 2/3, 1/2, and 1/3, respectively. The cutoff of 11.6 mmol/L (95% CI 10.6, 12.6) had a sensitivity of 0.92 (0.87, 0.95), specificity of 0.91 (0.88, 0.93), area under the curve 0.939 (95% confidence region for sensitivity at a given specificity: 0.904, 0.946), and a positive predictive value of 45%.

CONCLUSIONS

The 1-h PG of ≥11.6 mmol/L during OGTT has a good sensitivity and specificity for detecting type 2 diabetes. Prescreening with a diabetes-specific risk calculator to identify high-risk individuals is suggested to decrease the proportion of false-positive cases. Studies including other ethnic groups and assessing complication risk are warranted.

Preoperative atrial fibrillation in association with reduced haemoglobin predicts increased 30-d mortality after cardiac surgery

OBJECTIVES

Atrial fibrillation is the most common arrhythmia occurring after cardiac surgery. Less attention has been focused on preoperative atrial fibrillation and anaemia as risk factors for mortality after cardiac surgery. The aim of this study was to determine preoperative risk factors for 30-d mortality after open-heart surgery. Design. The study population consisted of 2015 patients (73.4% men; mean age 68 years) undergoing coronary artery bypass grafting (CABG) (52.0%), aortic valve replacement (AVR) (18.6%), AVR and CABG (10.0%), mitral valve plasty or replacement (14.0%), and AVR and aortic root reconstruction (ARR) (5.5%) in Kuopio University Hospital from January 2013 to December 2016. Univariate and multivariate Cox proportional hazards models were used for statistical analyses. Kaplan-Meier survival curves were generated. Results. Total 30-d mortality was 1.8%. By Cox regression analysis, predictors of 30-d mortality (hazard ratio [HR] [95% confidence interval [CI]]) included female gender (1.95 [1.00-3.77]), preoperative atrial fibrillation, (2.38 [1.12-5.03]) reduced haemoglobin level (3.40 [1.47-7.90]), and pulmonary congestion (3.16 [1.52-6.55]). The combination of preoperative reduced haemoglobin and preoperative atrial fibrillation was a strong predictor (12.37 [4.40-34.77], p < .001). Estimated glomerular filtration rate (eGFR) predicted 30-d mortality in univariate models but was not an independent predictor in multivariate models. Conclusions. According to the main findings of our study, the combination of preoperative atrial fibrillation and reduced haemoglobin level substantially increase the risk of 30-d mortality after cardiac surgery. Identification of high-risk patients pre-operatively could help to make optimal clinical decisions for timing of operation and perioperative treatment.

Febrile neutropenia in patients with acute myeloid leukemia: Outcome in relation to qSOFA score, C-reactive protein, and blood culture findings

OBJECTIVES

To evaluate quick Sequential Organ Failure Assessment (qSOFA) score during febrile neutropenia (FN) in adult patients receiving intensive chemotherapy for acute myeloid leukemia (AML).

METHODS

qSOFA score, as well as the association of qSOFA score with ICU admission, infectious mortality, blood culture findings, and C-reactive protein (CRP) measurements during FN were assessed among 125 adult AML patients with 355 FN periods receiving intensive chemotherapy in a tertiary care hospital from November 2006 to December 2018.

RESULTS

The multivariate model for qSOFA score ≥ 2 included CRP ≥ 150 mg/L on d0-2 [OR 2.9 (95% CI 1.1-7.3), P = .026], Gram-negative bacteremia [OR 2.7 (95% CI 1.1-6.9), P = .034], and treatment according to AML-2003 vs more recent protocols [OR 2.7 (95% CI 1.0-7.4), P = .047]. Age or gender did not gain significance in the model. qSOFA score ≥ 2 was associated with ICU treatment and infectious mortality during FN with sensitivity and specificity of 0.700 and 0.979, and 1.000 and 0.971, respectively.

CONCLUSION

qSOFA offers a useful tool to evaluate the risk of serious complications in AML patients during FN.

Plasma level of interleukin-18 and complicated course of febrile neutropenia in hematological patients after intensive chemotherapy

In search of a biomarker for complicated course of febrile neutropenia (FN), plasma IL-18 was measured in 92 hematological patients after intensive chemotherapy at the beginning of FN (days 0-3). Complicated course was defined as blood culture positivity or septic shock. IL-18 varied according to background hematological malignancy and showed an inverse correlation with leukocyte count. IL-18 was not associated with complicated course of FN, defined as blood culture positivity or septic shock, in the whole study group, but an association was observed on d1 and d2 after the onset of FN in the subgroup of autologous stem cell transplant recipients with non-Hodgkin lymphoma.

MMP-10 and TIMP-1 as indicators of severe sepsis in adult hematological patients with febrile neutropenia

Commonly used indicators of sepsis are nonspecific and insufficient for predicting the course of febrile neutropenia (FN) in hematological patients. We analyzed data from 91 adult FN patients who received intensive chemotherapy for acute myeloid leukemia or autologous stem cell transplantation. Compared to patients with non-severe sepsis, patients with severe sepsis had significantly higher serum levels of tissue inhibitor of metalloproteinases-1 on the day of first occurrence of fever (day 0: 172 vs. 112 µg/L, p= .002) and for the two following days (day 1: 219 vs. 128 µg/L, p< .001; day 2: 443 vs. 128 µg/L, p= .001), and significantly higher serum levels of matrix metalloproteinase-10 on day 1 (1975 vs. 876 ng/L, p= .001) and day 2 (2020 vs. 841 ng/L, p< .001). We conclude that the measurement of these biomarkers may be useful in predicting the severity of sepsis in FN patients.

Interleukin-1 receptor antagonist as a biomarker of sepsis in neutropenic haematological patients

OBJECTIVE

The study aim was to compare the performance of interleukin-1 receptor antagonist (IL-1Ra) to C-reactive protein (CRP) and procalcitonin (PCT) in early prediction of the clinical course of febrile neutropenia.

METHODS

The study population consisted of 86 consecutive patients with febrile neutropenia who received intensive chemotherapy for haematological malignancy between November 2009 and November 2012 at the adult haematology ward of Kuopio University Hospital. Twenty-three (27%) patients had acute myeloid leukaemia and 63 (73%) patients were autologous stem cell transplant recipients. IL-1Ra, CRP and procalcitonin were measured at the onset of fever (d0), on day 1 (d1) and on day 2 (d2).

RESULTS

Eight patients developed severe sepsis, including three patients with septic shock. Eighteen patients had bacteraemia. After the onset of febrile neutropenia Youden´s indices (with their 95% confidence intervals) to identify severe sepsis were for IL-1Ra on d0 0.57 (0.20-0.71) and on d1 0.65 (0.28-0.78), for CRP on d0 0.41 (0.04-0.61) and on d1 0.47 (0.11-0.67) and for PCT on d0 0.39 (0.05-0.66) and on d1 0.52 (0.18-0.76).

CONCLUSIONS

In haematological patients, IL-1Ra has a comparable capacity with CRP and PCT to predict severe sepsis at the early stages of febrile neutropenia.

Effector T Cell Resistance to Suppression and STAT3 Signaling during the Development of Human Type 1 Diabetes

Dysregulation of regulatory T cell (Treg)-mediated suppression and, in particular, resistance of CD4⁺ effector T cells (Teffs) to suppression have been implicated in the pathogenesis of human type 1 diabetes (T1D). However, the mechanistic basis behind this resistance and the time frame during which it develops in relation to the onset of clinical T1D remain unclear. In this study, we analyzed the capacity of peripheral blood Teffs isolated both from patients with T1D and from prediabetic at-risk subjects positive for multiple diabetes-associated autoantibodies (AAb⁺) to be suppressed by Tregs. Because STAT3 activation through IL-6 has previously been implicated in mediating Teff resistance, we also investigated the surface expression of IL-6R as well as IL-6- and TCR-mediated phosphorylation of STAT3 in T cells from our study subjects. Teff resistance to suppression was observed both in patients with newly diagnosed and long-standing T1D but not in AAb⁺ subjects and was shown to be STAT3 dependent. No alterations in IL-6R expression or IL-6-mediated STAT3 activation were observed in T cells from patients with T1D or AAb⁺ subjects. However, faster STAT3 activation after TCR stimulation without concomitant increase in IL-6 expression was observed in T cells from patients with T1D. These experiments suggest that Teff resistance in T1D patients is STAT3 dependent but not directly linked with the capacity of Teffs to produce or respond to IL-6. In conclusion, Teff resistance to Treg-mediated suppression is likely a feature of disease progression in human T1D and can potentially be targeted by immune therapies that block STAT3 activation.

Secular Trends in Infection-Related Mortality after Kidney Transplantation

BACKGROUND AND OBJECTIVES

Infections are the most common noncardiovascular causes of death after kidney transplantation. We analyzed the current infection-related mortality among kidney transplant recipients in a nationwide cohort in Finland.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Altogether, 3249 adult recipients of a first kidney transplant from 1990 to 2012 were included. Infectious causes of death were analyzed, and the mortality rates for infections were compared between two eras (1990-1999 and 2000-2012). Risk factors for infectious deaths were analyzed with Cox regression and competing risk analyses.

RESULTS

Altogether, 953 patients (29%) died during the follow-up, with 204 infection-related deaths. Mortality rate (per 1000 patient-years) due to infections was lower in the more recent cohort (4.6; 95% confidence interval, 3.5 to 6.1) compared with the older cohort (9.1; 95% confidence interval, 7.6 to 10.7); the incidence rate ratio of infectious mortality was 0.51 (95% confidence interval, 0.30 to 0.68). The main causes of infectious deaths were common bacterial infections: septicemia in 38% and pulmonary infections in 45%. Viral and fungal infections caused only 2% and 3% of infectious deaths, respectively (such as individual patients with Cytomegalovirus pneumonia, Herpes simplex virus meningoencephalitis, Varicella zoster virus encephalitis, and Pneumocystis jirovecii infection). Similarly, opportunistic bacterial infections rarely caused death; only one death was caused by Listeria monocytogenes, and two were caused by Mycobacterium tuberculosis. Only 23 (11%) of infection-related deaths occurred during the first post-transplant year. Older recipient age, higher plasma creatinine concentration at the end of the first post-transplant year, diabetes as a cause of ESKD, longer pretransplant dialysis duration, acute rejection, low albumin level, and earlier era of transplantation were associated with increased risk of infectious death in multivariable analysis.

CONCLUSIONS

The risk of death due to infectious causes after kidney transplantation in Finland dropped by one half since the 1990s. Common bacterial infections remained the most frequent cause of infection-related mortality, whereas opportunistic viral, fungal, or unconventional bacterial infections rarely caused deaths after kidney transplantation.

Asymmetric dimethylarginine in the assessment of febrile neutropenia in hematological patients

Asymmetric dimethylarginine (ADMA) has been recognized as an independent prognostic factor for sepsis mortality in intensive care units. No data are available on kinetics or prognostic value of ADMA in hematological patients. We evaluated the ability of ADMA to act as a predictor for complicated course of febrile neutropenia, defined as bacteremia and/or septic shock in adult hematological patients receiving intensive chemotherapy. This prospective study included 87 adult hematological patients with febrile neutropenia after an intensive chemotherapy for acute myeloid leukemia (AML) or after an autologous stem cell transplantation (ASCT). Plasma ADMA and serum C-reactive protein (CRP) levels were measured from the onset of fever (d0) and for 2 days (d1-d2) thereafter. The levels of ADMA were stable or had only minimal changes during the study period. There was no difference between the levels at any time-point in patients having complicated course compared to those without it. On the other hand, CRP levels were significantly higher on d1 (p = 0.016) in patients with bacteremia and/or septic shock than in those without. ADMA was not able to differentiate hematological patients with a complicated course from those without complications. Elevated ADMA levels are probably associated with organ dysfunction, which is rare in this group of patients, of whom about 95% can be successfully managed at the hematology ward.

Circulating CXCR5+PD-1+ICOS+ Follicular T Helper Cells Are Increased Close to the Diagnosis of Type 1 Diabetes in Children With Multiple Autoantibodies

Although type 1 diabetes (T1D) is primarily perceived as a T cell-driven autoimmune disease, islet autoantibodies are the best currently available biomarker for autoimmunity and disease risk. These antibodies are produced by autoreactive B cells, the activation of which is largely dependent on the function of CD4⁺CXCR5⁺ follicular T helper cells (Tfh). In this study, we have comprehensively characterized the Tfh- as well as B-cell compartments in a large cohort of children with newly diagnosed T1D or at different stages of preclinical T1D. We demonstrate that the frequency of CXCR5⁺PD-1⁺ICOS⁺-activated circulating Tfh cells is increased both in children with newly diagnosed T1D and in autoantibody-positive at-risk children with impaired glucose tolerance. Interestingly, this increase was only evident in children positive for two or more biochemical autoantibodies. No alterations in the circulating B-cell compartment were observed in children with either prediabetes or diabetes. Our results demonstrate that Tfh activation is detectable in the peripheral blood close to the presentation of clinical T1D but only in a subgroup of children identifiable by positivity for multiple autoantibodies. These findings suggest a role for Tfh cells in the pathogenesis of human T1D and carry important implications for targeting Tfh cells and/or B cells therapeutically.

Biomarkers of neutropenic sepsis

Neutropenic sepsis is a common clinical problem in hematological patients receiving intensive chemotherapy. Complications will develop in a minority of these patients. Biomarkers can be used for the recognition of infection as well as to estimate its severity and risk of complications and also to assess treatment response. Experience gained from other patient groups or sepsis patients treated in intensive care units cannot be directly extrapolated to hematological patients. Numerous biomarkers of infections have been investigated in hematological patients, but no optimal marker has been found. C-reactive protein is still the most commonly used biomarker in hematological patients, but procalcitonin may be a real challenger, although more studies are still needed.

Human plasma cell-free DNA as a predictor of infectious complications of neutropenic fever in hematological patients

Neutropenic fever is common in patients receiving intensive chemotherapy for hematological malignancies. The clinical course may be aggravated by infectious complications like severe sepsis, septic shock or even death. We prospectively studied 100 patients with neutropenic fever and evaluated human plasma cell-free DNA (cfDNA) during the first 3 days after the onset of fever as a prognostic biomarker for complicated clinical course, defined as sepsis or septic shock. Complicated course was observed in 21 patients (21%). There were no significant differences in cfDNA levels between the patients with or without complications on any study day when all the patients were analyzed as one group. In subgroups according to hematological malignancy, patients with acute myeloid leukemia (AML) had lower cfDNA levels than patients with lymphoma. Among AML patients d0 cfDNA/leukocyte ratio and among lymphoma patients d0 cfDNA was associated with subsequent development of sepsis or septic shock. cfDNA deserves further studies in hematological patients with sepsis.

Proteinuria modifies the effect of systolic blood pressure on total and cardiovascular disease mortality in patients with type 2 diabetes

OBJECTIVES

Hypertension and proteinuria are major risk factors for cardiovascular disease (CVD) mortality in patients with type 2 diabetes. Blood pressure (BP) targets have been progressively lowered in these patients to prevent or delay the progression of nephropathy. However, no long-term population-based studies have been reported on the interaction between BP and proteinuria with respect to total and CVD mortality in patients with type 2 diabetes.

DESIGN

We prospectively followed 881 middle-aged type 2 diabetic patients, free of CVD events at baseline, for up to 18 years. Participants were categorized into four groups according to baseline systolic BP (<130, 130-139, 140-159 and ≥160 mmHg) and further stratified by proteinuria (≤150 or >150 mg L(-1)). Cox proportional hazards model was used to estimate the joint association between systolic BP and proteinuria and the risk of mortality.

RESULTS

During follow-up, 607 patients died including 395 because of CVD. After adjustment for confounding factors, total and CVD mortality were significantly higher in patients with proteinuria and systolic BP <130 mmHg compared with those with systolic BP between 130 and 160 mmHg. The prognosis was similar in patients with systolic BP <130 mmHg or ≥160 mmHg. Among patients without proteinuria, systolic BP <130 mmHg was associated with a nonsignificant reduction in mortality.

CONCLUSIONS

Type 2 diabetic patients with proteinuria and with systolic BP <130 mmHg may have an increased risk of CVD mortality. The presence of proteinuria should be taken into account when defining the target systolic BP level for the prevention of fatal CVD events in patients with type 2 diabetes.

Trends in estimated kidney function: the FINRISK surveys

We evaluated the temporary trend in estimated glomerular filtration rate (eGFR) of subjects aged from 25 to 74 years between two cross-sectional population surveys in 2002 and in 2007. The mean eGFR across age-groups, the prevalences of eGFR categories, and the prevalence of chronic kidney disease (CKD) stage 3–5 defined by eGFR\60 mL/min/1.73 m2 were defined in sex- and age-specific groups using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Study equation. The eGFR decreased from year 2002 to 2007 across the age-groups in both genders. The prevalence of CKD stage 3–5 (eGFR\60 mL/min/1.73) increased in women from 1.8 to 3.1% (P=0.017), but not in men. In the combined analysis of both genders, CKD stage 3–5 was markedly more common in 2007 compared to 2002, with odds ratio (OR) 1.59 (95% confidence interval (CI) 1.22–2.08) remaining significant after adjusting the model for age, gender, study area, hypertension, obesity, prior cardiovascular disease, and diabetes mellitus, and being at lowest when only age, gender and waist circumference were included in the model (OR 1.34; 95% CI 1.02–1.76). To conclude, the mean eGFR decreased significantly during 2002–2007 in both sexes, and CKD stage 3–5 increased in women. This trend was concurrent with increases in mean waist circumference and in the prevalence of diabetes mellitus.

IL-10 combined with procalcitonin improves early prediction of complications of febrile neutropenia in hematological patients

Early diagnosis of complicated course in febrile neutropenia is cumbersome due to the non-specificity of clinical and laboratory signs of severe infection. This prospective study included 100 adult hematological patients with febrile neutropenia after intensive chemotherapy at the onset of fever (d0) and for 3 days (d1-d3) thereafter. The study aim was to find early predictors for complicated course of febrile neutropenia, defined as bacteremia or septic shock. Interleukin 6 (IL-6), interleukin 10 (IL-10), procalcitonin (PCT) and C-reactive protein (CRP) all predicted complicated course of febrile neutropenia on d0, but only PCT was predictive throughout the study period. For IL-10 on d0-1 with cut-off 37 ng/L, sensitivity was 0.71, specificity 0.82, positive predictive value 0.52 and negative predictive value 0.92. For PCT on d0-1 with cut-off 0.13 μg/L, the respective measures were 0.95, 0.53, 0.36, and 0.98. For the combination of IL-10 and PCT on d0-1 with the same cut-offs, specificity improved to 0.85 and positive predictive value to 0.56. In conclusion, the present study confirms the high negative predictive value of PCT and provides new evidence for IL-10 as an early predictor for complicated course of febrile neutropenia in hematological patients. Combining IL-10 with PCT improves the early prediction for complicated course of febrile neutropenia.

Kinetics of blood CD34(+) cells after chemotherapy plus G-CSF in poor mobilizers: implications for pre-emptive plerixafor use

Mobilization and collection of stem cells is difficult in a proportion of patients intended for autologous stem cell transplantation (ASCT). We have evaluated mobilization kinetics of blood CD34(+) cells (B-CD34(+)) to form basis for algorithm to facilitate rational pre-emptive plerixafor use. Altogether 390 chemomobilized patients were included.Forty-three patients (11%) did not reach BCD34+count ≥10×10(6)/l. Mobilization kinetics differed according to the mobilization capacity observed. Among those who were very poor or inadequate mobilizers (peak BCD34(+)count ≤5×10(6)/l and 6–10×10(6)/l, respectively), BCD34+counts rarely rose after white blood cells (WBC) >5–10×10(9)/l, whereas in many standard mobilizers a later rise in CD34(+) counts could be observed. Four algorithms based on WBC and CD34(+) counts were constructed. According to this patient series, algorithm II (WBC >5×109/l and BCD34+≤10×10(6)/l) and algorithm IV (WBC >10×10(9)/l andB-CD34(+) ≤10×10(9)/l) were the most applicable. For algorithm II the sensitivity was 0.97 and specificity 1.00, respectively, to identify patients for plerixafor use provided that all patients with B-CD34+ maximum ≤10×10(6)/l would have needed plerixafor.This simple model needs a prospective validation.

Plasma copeptin in the assessment of febrile neutropenia

Copeptin, the surrogate marker of arginine vasopressin (AVP), has been suggested to be a useful biomarker in monitoring sepsis reflecting hemodynamic imbalance and stress state. This prospective study conducted at a hematology ward in a Finnish University Hospital aimed to investigate whether plasma copeptin predicts the development of complicated course of neutropenic fever (bacteremia or need for treatment at intensive care unit) in 100 hematological patients experiencing their first neutropenic fever episode after intensive chemotherapy for hematological malignancy. Contrary to study presumptions, not elevated copeptin but the lack of a proper initial increase of plasma copeptin (<0.02 ng/mL from day 0 to day 1) predicted blood culture positive sepsis (p=0.023) and gram-negative bacteremia (p=0.045). No correlation was observed with plasma sodium, blood pressure or evaluated osmolality. Plasma copeptin correlated inversely with the same day pentraxin 3 on day 0-day 2 (all p-values <0.001) and with C-reactive protein on day 1 (p=0.015). In conclusion, copeptin did not correlate with disease severity, but the lack of a proper initial increase was associated with bacteremic complications of febrile neutropenia in hematological patients. The findings suggest the possibility of central dysregulation of AVP release and do not support the use of copeptin as a biomarker of septic complications in this patient group.

Comparison of the MDRD Study and the CKD-EPI Study equations in evaluating trends of estimated kidney function at population level: findings from the National FINRISK Study

BACKGROUND

There are no data comparing the Modification of Diet in Renal Disease (MDRD) Study and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Study equations in the evaluation of time-dependent trend of estimated glomerular filtration rate (eGFR) in the general population.

METHODS

Changes in eGFR and in the association of eGFR with kidney disease and cardiovascular disease (CVD) risk factors across age groups were estimated in two independent cross-sectional population surveys in Finland in 2002 and 2007 with 11 277 study participants, aged 25-74 years, using both the MDRD and the CKD-EPI equations.

RESULTS

A trend towards decreasing eGFRs between the study years was observed using both equations, but the trend was more substantial when using the MDRD equation. The MDRD equation yielded lower estimates of eGFR than the CKD-EPI equation, with small mean difference between the equations at low eGFR level but substantial at the level of only mildly decreased or near-normal to normal kidney function. Decrease of eGFR was associated with an increase in CKD and CVD risk factors. However, an increase of risk factors was not observed among those who had mildly decreased eGFR by only the MDRD equation but not by the CKD-EPI equation.

CONCLUSION

In comparison with the CKD-EPI equation, the MDRD equation augmented the trend of increasing prevalence of CKD, showed a weaker association with risk factors and tended to assign impaired renal function to individuals without an excess of cardiovascular risk factors.

High pentraxin 3 level predicts septic shock and bacteremia at the onset of febrile neutropenia after intensive chemotherapy of hematologic patients

We evaluated pentraxin 3 as a marker for complications of neutropenic fever in 100 hematologic patients receiving intensive chemotherapy. Pentraxin 3 and C-reactive protein were measured at fever onset and then daily to day 3. Bacteremia was observed in 19 patients and septic shock in 5 patients (three deaths). In comparison to C-reactive protein, pentraxin 3 achieved its maximum more rapidly. Pentraxin 3 correlated not only with the same day C-reactive protein but also with the next day C-reactive protein. High pentraxin 3 on day 0 was associated with the development of septic shock (P=0.009) and bacteremia (P=0.046). The non-survivors had constantly high pentraxin 3 levels. To conclude, pentraxin 3 is an early predictor of complications in hematologic patients with neutropenic fever. High level of pentraxin 3 predicts septic shock and bacteremia already at the onset of febrile neutropenia. (ClinicalTrials.gov Identifier: NCT00781040.).

Biomarkers for bacteremia and severe sepsis in hematological patients with neutropenic fever: multivariate logistic regression analysis and factor analysis

We compared biomarkers and their changes as predictors for bacteremia and severe sepsis during neutropenic fever after intensive chemotherapy in hematological patients. Serum C-reactive protein (CRP), semi-quantative procalcitonin, aminoterminal pro-brain natriuretic peptide (NT-proBNP), cortisol, lactate, plasma antithrombin and fibrinogen were measured daily from day 0 to day 3/day 4 in 89 neutropenic fever episodes of 65 hematological patients. The best predictors for bacteremia and gram-negative bacteremia were procalcitonin and its change, with odds ratios (ORs) and 95% confidence intervals of 2.63 (1.56-4.44) and 3.20 (1.77-5.80) for bacteremia and 4.14 (2.00-8.58) and 5.04 (2.18-11.63) for gram-negative bacteremia, respectively. For severe sepsis, the best predictors were CRP and fibrinogen, with ORs of 1.94 (1.07-3.52) and 1.92 (1.05-3.54). Factor analysis provided two predictive factors: procalcitonin-NT-proBNP-antithrombin factor predicted gram-negative bacteremia and CRP-fibrinogen predicted severe sepsis. Applying a combination of markers reflecting different aspects of infection might improve the recognition of risk for complications in patients with neutropenic fever.

Physical activity, high-sensitivity C-reactive protein, and total and cardiovascular disease mortality in type 2 diabetes

OBJECTIVE

Physical activity reduces high-sensitivity C-reactive protein (hs-CRP), cardiovascular disease (CVD), and total mortality in type 2 diabetic patients. However, it is not known whether the effects of physical activity on mortality depend on the levels of hs-CRP in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We prospectively followed-up on 569 type 2 diabetic patients, aged 45-64 years, who were free of CVD at baseline. Participants were stratified according to the level of hs-CRP (<1.0, 1.0-3.0, or >3.0 mg/L) and the degree of physical activity (0-4 metabolic equivalent tasks [METs] or >4 METs). The Cox proportional hazards model was used to estimate the joint association between physical activity and hs-CRP levels and the risk of mortality.

RESULTS

During an 18-year follow-up, 356 patients died, 217 of whom died of CVD. Those who were physically more active had significantly reduced total, CVD and coronary heart disease (CHD) mortality among patients with elevated hs-CRP levels (>3 mg/L). These findings persisted in multivariable analyses. However, in patients with an hs-CRP level<1 mg/L or between 1 and 3 mg/L, there was no statistically significant relationship between physical activity and CVD or CHD mortality.

CONCLUSIONS

Physical activity reduces total, CVD, and CHD mortality in type 2 diabetic patients with elevated hs-CRP levels. This suggests that the anti-inflammatory effect of physical activity may counteract increased CVD and CHD morbidity and mortality associated with high CRP levels.

Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up

PURPOSE

To prospectively evaluate the primary and long-term venographic and clinical results of catheter-directed thrombolysis in the treatment of proximal deep vein thrombosis (DVT) of lower extremity.

MATERIALS AND METHODS

Fifty-six patients with mean age of 48 (range 15-81) years with acute DVT (symptom duration of less than 2 weeks), extending to high femoral (16 patients) or iliac vein (40 patients) were treated with selective catheter-directed thrombolysis. The mean total dose of 3.8 (range 1.0-8.1) million units of urokinase was administered during a mean of 39 (range 6-72) hours. Endovascular stenting was performed in 9 of the iliac DVT patients.

RESULTS

Complete procedural venographic success was achieved in 79% of patients. Major complications were noted in 7% of patients and the total rate of complications was 13%. Mean venographic follow-up was 3.5 years (range 3 months to 9.6 years); well preserved femoral vein valves and fully recanalized deep crural veins were observed in 83% and 57% of patients. Normal clinical findings in the affected limb were noted during the latest follow-up visit in 67% of patients. Clinical post-thrombotic syndrome occurred in 9% of patients.

CONCLUSION

Catheter-directed thrombolysis achieves good primary success with acceptable complication rate and effectively reduces prevalence of post-thrombotic syndrome.

Elevated procalcitonin predicts Gram-negative sepsis in haematological patients with febrile neutropenia

OBJECTIVE

To compare semi-quantitative procalcitonin with C-reactive protein in predicting bacteraemia in haematological patients with neutropenic fever.

METHODS

A total of 77 patients treated with intensive chemotherapy for haematological malignancy at Kuopio University Hospital were candidates for study entry. Eleven of these patients did not fulfil the criteria for neutropenic fever, and 66 patients were finally included. Nineteen patients had acute myeloid leukaemia and 47 had received high-dose chemotherapy supported by autologous stem cell transplant. Ninety neutropenic fever episodes in these 66 patients fulfilled the study entry criteria, with microbiological cultures, procalcitonin and C-reactive protein measurements available. Serum procalcitonin and C-reactive protein were analyzed at the onset of each neutropenic fever episode on day 0, and then daily from days 1 to 4.

RESULTS

Bacteraemia was observed in 21 episodes (23%) and the criteria for severe sepsis were fulfilled in 13 episodes (14%). Half of the bacteraemic episodes were caused by Gram-negative bacteria. The kinetics of procalcitonin and C-reactive protein were similar, with increasing levels for 2 to 4 days after the onset of fever. The procalcitonin level on days 1, 2, 3 and 4 was associated with bacteraemia and Gram-negative bacteraemia, but not with the development of severe sepsis. On day 1, a procalcitonin level above 0.5 ng/ml had a sensitivity of 57% and 70% and specificity of 81% and 77% to predict bacteraemia and Gram-negative bacteraemia, respectively.

CONCLUSIONS

An elevated level of procalcitonin within 24 h after the onset of neutropenic fever predicts bacteraemia and Gram-negative bacteraemia in haematological patients.

Serum amino-terminal pro-brain natriuretic peptide in hematological patients with neutropenic fever: a prospective comparison with C-reactive protein

Serum amino-terminal pro-brain natriuretic peptide (NT-proBNP) is considered as a prognostic marker in patients with severe sepsis or septic shock, but no data are available on NT-proBNP kinetics in hematological patients with neutropenic fever. Altogether 70 hematological patients with neutropenic fever were included in this prospective study. NT-proBNP and C-reactive protein (CRP) were determined at the beginning of the neutropenic fever (d0) and then daily up to 3-4 days. The median NT-proBNP (interquartile range) increased from 127 (57-393) ng/L on d0 to 542 (194-1385) ng/L on d4. The increment of CRP was from 35 (17-61) mg/L on d0 to 109 (56-109) mg/L on d2. Neither serial NT-proBNP nor CRP predicted development of severe sepsis, but NT-proBNP was significantly higher in patients with previous cardiovascular disease than in those without. NT-proBNP seemed to reflect cardiac distress, but it did not help to predict the development of severe sepsis in this patient group.

Proteinuria modifies the effects of physical activity on total and cardiovascular disease mortality rates in patients with type 2 diabetes

AIMS/HYPOTHESIS

Physical activity reduces cardiovascular disease (CVD) and total mortality rates in patients with type 2 diabetes. However, it is not known whether or not the effects of physical activity on mortality rates depend on the presence of proteinuria in type 2 diabetic patients.

METHODS

We prospectively followed up 577 patients with type 2 diabetes who were aged 45 to 64 years and were free of CVD at baseline. Participants were stratified according to the presence of proteinuria (<or=300 or >300 mg/l) and the degree of physical activity (0-4 metabolic equivalent tasks [MET] or >4 MET). The Cox proportional hazards model was used to estimate the association of physical activity and proteinuria with risk of mortality.

RESULTS

During the 18-year follow-up, 356 patients died, of whom 217 died from CVD. Physically more active patients had significantly reduced total, CVD and CHD mortality rates if they did not have proteinuria. In contrast, physically active proteinuric patients had significantly increased total and CVD mortality rates (HR 1.83, 95% CI 1.00-3.36, p=0.049) in univariate analyses, with HR 2.43 (95% CI 1.09-5.40, p=0.030) in multivariate analyses.

CONCLUSIONS/INTERPRETATION

Physical activity reduces total and CVD mortality rates in type 2 diabetic patients without proteinuria. However, in proteinuric patients, no protective effect was observed. Larger studies are needed to confirm the latter finding and to define which exercise intensity leads to possible harmful effects.

Risk factors for end-stage renal disease in a community-based population: 26-year follow-up of 25,821 men and women in eastern Finland

BACKGROUND AND OBJECTIVE

There are very few European cohort studies assessing the risk factors of end-stage renal disease (ESRD) in a community-based population. This study investigated the predictors of ESRD in Finland.

DESIGN

Prospective cohort study.

SETTING

Eastern Finland.

SUBJECTS

A random sample of 25,821 men and women aged 25-64 years from the national population register participating in three independent cross-sectional population surveys in 1972, 1977 and 1982. Only the subjects without diagnosis of ESRD or chronic kidney disease based on the national register data were included in the study.

MAIN OUTCOME MEASURE

Initiation of renal replacement therapy (dialysis or kidney transplantation) identified from the Finnish Registry for Kidney Diseases through December 31, 2006.

RESULTS

A total of 94 cases with ESRD were identified during a mean follow-up period of 26.5 years. In a multivariate proportional subdistribution hazard regression analysis, taking into account death as a competing risk event, diabetes (hazard ratio [HR] 4.76, 95% confidence interval [CI] 2.32-9.79), hypertension (HR 2.21, 95% CI 1.19-4.12), obesity defined as body mass index > or =30 kg m(-2) (HR 2.02, 95 %CI 1.10-3.71) and male gender (HR 1.68, 95% CI 1.19-4.12) were independent risk factors for ESRD.

CONCLUSION

The findings of the present study confirm that modifiable risk factors play a major role in the development of ESRD in the North-European population. People with diabetes, hypertension or obesity should be considered as the target groups when planning preventive measures to control the future epidemic of ESRD.

Thoracoabdominal calcifications predict cardiovascular disease mortality in type 2 diabetic and nondiabetic subjects: 18-year follow-up study

OBJECTIVE To evaluate cardiovascular disease (CVD) and total mortality associated with thoracoabdominal calcifications. RESEARCH DESIGN AND METHODS Thoracoabdominal calcifications of native radiograms were evaluated in 833 subjects with type 2 diabetes and 1,292 subjects without diabetes, aged 45-64 years, without prior evidence of CVD. The type 2 diabetic and nondiabetic study cohorts were followed up for 18 years. RESULTS After adjustment for conventional risk factors, marked thoracoabdominal calcifications predicted CVD/total mortality with hazard ratio (HR) (95% CI) of 1.5 (0.8-3.0)/1.8 (1.1-2.9) in type 2 diabetic men, 3.0 (1.6-5.7)/3.1 (1.9-5.0) in type 2 diabetic women, 5.0 (2.2-12)/4.0 (2.2-7.4) in nondiabetic men, and 7.8 (1.8-34)/3.0 (1.3-7.0) in nondiabetic women and in the presence of C-reactive protein below/over 3 mg/l with HR of 2.4 (1.3-4.4)/3.0 (1.4-6.1) in type 2 diabetic subjects and 4.0 (1.5-10.8)/6.6 (2.7-16.0) in nondiabetic subjects. CONCLUSIONS Thoracoabdominal calcifications in native radiograms are significant predictors of CVD and total mortality, especially in type 2 diabetic and nondiabetic women with elevated high-sensitivity C-reactive protein level.

Increased serum levels of methylglyoxal-derived hydroimidazolone-AGE are associated with increased cardiovascular disease mortality in nondiabetic women

OBJECTIVE

To investigate the association of the levels of methylglyoxal-derived hydroimidazolone AGE modified proteins (MG-H1-AGE) with cardiovascular disease (CVD) mortality in an 18-year follow-up study in Finnish nondiabetic and diabetic subjects.

METHODS

The study design was a nested case-control study. Serum MG-H1-AGE levels in samples drawn at baseline were measured with a DELFIA type immunoassay in 220 diabetic subjects and 61 nondiabetic subjects who died from CVD during the follow-up, and age- and gender-matched 157 diabetic subjects and 159 nondiabetic subjects who did not die from CVD.

RESULTS

In type 2 diabetic subjects serum MG-H1-AGE levels were similar in subjects who died from CVD and in subjects who did not, 32.6 (24.6-42.1) (median (interquartile range)) vs. 31.3 (22.5-40.7)U/mL (p=0.281). In nondiabetic subjects serum MG-H1 levels were significantly higher in subjects who died from CVD than in subjects who were alive, 35.4 (28.1-44.7) vs. 31.3 (24.2-38.6)U/mL (p=0.025). Corresponding MG-H1 levels were 41.2 (35.6-58.7) vs. 31.1 (26.7-35.7)U/mL, p=0.003, in women, and 34.4 (26.3-41.2) vs. 32.0 (22.8-40.3)U/mL, p=0.270, in men. Multivariate logistic regression analysis showed a significant association of serum levels of MG-H1-AGE with CVD mortality in nondiabetic women (adjusted p=0.021), but not in nondiabetic men.

CONCLUSIONS

Our 18-year follow-up study shows that high baseline serum levels of MG-H1 type of AGE modified proteins were associated with CVD mortality in nondiabetic women, but not in nondiabetic men or in diabetic subjects.

Similarity of the impact of type 1 and type 2 diabetes on cardiovascular mortality in middle-aged subjects

OBJECTIVE

To compare the risk of cardiovascular disease (CVD) death and the impact of hyperglycemia on the risk of CVD mortality associated with type 1 diabetes to that associated with type 2 diabetes.

RESEARCH DESIGN AND METHODS

The study comprised 173 participants with type 1 diabetes, 834 participants with type 2 diabetes, and 1,294 nondiabetic participants, aged 45-64 years at baseline and free of CVD. The age of onset of diabetes was >30 years in both diabetic groups.

RESULTS

During an 18-year follow-up, 86 participants with type 1 diabetes, 567 participants with type 2 diabetes, and 252 nondiabetic participants died. CVD mortality rates per 1,000 person-years were 23.1 (95% CI 16.9-31.9) in type 1 diabetic, 35.3 (30.8-40.4) in type 2 diabetic, and 4.6 (3.8-5.7) in nondiabetic participants. Adjusted hazard ratios for CVD mortality in participants with type 1 diabetes versus no diabetes was 3.6 (95% CI 2.2-5.7) in men and 13.3 (6.9-22.5) in women and in participants with type 2 diabetes versus no diabetes 3.3 (2.5-4.5) in men and 10.1 (6.7-17.4) in women. An increment of 1 unit (%) of GHb increased CVD mortality by 52.5% (95% CI 28.4-81.3) in type 1 diabetic subjects and by 7.5% (4.3-10.8) in type 2 diabetic participants.

CONCLUSIONS

The impact of type 1 and type 2 diabetes on CVD mortality was similar. The effect of increasing hyperglycemia on the risk of CVD mortality was more profound in type 1 than in type 2 diabetic subjects.

Increased serum levels of advanced glycation endproducts predict total, cardiovascular and coronary mortality in women with type 2 diabetes: a population-based 18 year follow-up study

AIMS/HYPOTHESIS

AGEs, modification products formed by glycation or glycoxidation of proteins and lipids, have been linked to premature atherosclerosis in patients with diabetes. We investigated whether increased serum levels of AGEs predict total, cardiovascular (CVD) or CHD mortality in a population-based study.

SUBJECTS AND METHODS

Serum levels of AGEs were determined by immunoassay in a random sample of 874 Finnish diabetic study participants (488 men, 386 women), aged 45-64 years. These participants were followed for 18 years for total, CVD and CHD mortality.

RESULTS

Multivariate Cox regression models revealed that serum levels of AGEs were significantly associated with total (p = 0.002) and CVD mortality (p = 0.021) in women, but not in men. Serum levels of AGEs in the highest sex-specific quartile predicted all-cause (hazards ratio [HR] 1.51; 95% confidence intervals [CI], 1.14-1.99; p = 0.004), CVD (HR 1.56; 95% CI 1.12-2.19; p = 0.009), and CHD (HR 1.68; 95% CI 1.11-2.52; p = 0.013) mortality in women, even after adjustment for confounding factors, including high-sensitivity C-reactive protein.

CONCLUSIONS/INTERPRETATION

Increased serum levels of AGEs predict total and CVD mortality in women with type 2 diabetes.

Retinopathy predicts cardiovascular mortality in type 2 diabetic men and women

OBJECTIVE

To investigate the association of retinopathy with the risk of all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in type 2 diabetic subjects in a population-based 18-year follow-up study with particular emphasis on sex differences.

RESEARCH DESIGN AND METHODS

Our study cohort comprised 425 Finnish type 2 diabetic men and 399 type 2 diabetic women who were free of CVD at baseline. The findings were classified based on standardized clinical ophthalmoscopy to categories of no retinopathy, background retinopathy, and proliferative retinopathy. The study end points were all-cause, CVD, and CHD mortality.

RESULTS

Adjusted Cox model hazard ratios (95% CIs) of all-cause, CVD, and CHD mortality in men were 1.34 (0.98-1.83), 1.30 (0.86-1.96), and 1.18 (0.74-1.89), respectively, for background retinopathy and 3.05 (1.70-5.45), 3.32 (1.61-6.78), and 2.54 (1.07-6.04), respectively, for proliferative retinopathy and in women 1.61 (1.17-2.22), 1.71 (1.17-2.51), and 1.79 (1.13-2.85), respectively, for background retinopathy and 2.92 (1.41-6.06), 3.17 (1.38-7.30), and 4.98 (2.06-12.06), respectively, for proliferative retinopathy.

CONCLUSIONS

Proliferative retinopathy in both sexes and background retinopathy in women predicted all-cause, CVD, and CHD death. These associations were independent of current smoking, hypertension, total cholesterol, HDL cholesterol, glycemic control of diabetes, duration of diabetes, and proteinuria. This suggests the presence of common background pathways for diabetic microvascular and macrovascular disease other than those included in the conventional risk assessment of CVD. The sex difference observed in the association of background retinopathy with macrovascular disease warrants closer examination.

Proteinuria and metabolic syndrome as predictors of cardiovascular death in non-diabetic and type 2 diabetic men and women

AIMS/HYPOTHESIS

Proteinuria predicts cardiovascular disease (CVD), but it is unclear whether this is explained by the association of the metabolic syndrome with proteinuria. Therefore, we investigated proteinuria and the metabolic syndrome as independent predictors of CVD death in men and women.

METHODS

The cohort comprised 574 non-diabetic men, 707 non-diabetic women, 371 diabetic men and 349 diabetic women, all free of CVD at baseline. Modified World Health Organization criteria were used to define the metabolic syndrome, and a urinary protein concentration of >or=0.1 g/l (or >or=0.2 g/l) to define proteinuria. The endpoint was CVD mortality during the 18-year follow-up.

RESULTS

Among non-diabetic men, CVD mortality per 1,000 person-years was as follows: no metabolic syndrome, no urinary protein group: 5.3; no metabolic syndrome, positive for urinary protein: 8.9; positive for metabolic syndrome, no urinary protein: 13.3; and positive for metabolic syndrome and urinary protein: 14.9. For non-diabetic women the corresponding values were: 0.9, 2.3, 4.9 and 7.9, respectively. Among diabetic men, CVD mortality per 1,000 person-years was 15.2, 32.5, 23.6 and 42.0 for the respective groups. Among diabetic women it was 25.3, 38.0, 26.3 and 40.3 (urinary protein in all cases defined as >or=0.1 g/l). In multivariate Cox models including both urinary protein and metabolic syndrome, the hazard ratios (HRs, 95% CI) of proteinuria for CVD mortality were 1.5 (0.9-2.4) in non-diabetic men, 1.8 (0.8-4.2) in non-diabetic women, 1.6 (1.0-2.6) in diabetic men and 1.6 (1.1-2.3) in diabetic women. Urinary protein as a continuous variable was associated with CVD mortality in all groups. The corresponding HRs for metabolic syndrome were: 1.6 (0.9-2.7), 4.0 (1.7-9.7), 1.5 (1.1-2.0) and 1.1 (0.8-1.5).

CONCLUSIONS/INTERPRETATION

Proteinuria predicted CVD mortality independently of the presence of metabolic syndrome in non-diabetic and diabetic subjects. Metabolic syndrome predicted CVD mortality in non-diabetic women and in diabetic men, independently of the presence of proteinuria.

Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects

OBJECTIVE

The purpose of this study was to investigate the hypothesis that coronary heart disease (CHD) mortality in diabetic subjects without prior evidence of CHD is equal to that in nondiabetic subjects with prior myocardial infarction or any prior evidence of CHD.

RESEARCH DESIGN AND METHODS

During an 18-year follow-up total, cardiovascular disease (CVD) and CHD deaths were registered in a Finnish population-based study of 1,373 nondiabetic and 1,059 diabetic subjects.

RESULTS

Adjusted multivariate Cox hazard models indicated that diabetic subjects without prior myocardial infarction, compared with nondiabetic subjects with prior myocardial infarction, had a hazard ratio (HR) of 0.9 (95% CI 0.6-1.5) for the risk of CHD death. The corresponding HR was 0.9 (0.5-1.4) in men and 1.9 (0.6 -6.1) in women. Diabetic subjects without any prior evidence of CHD (myocardial infarction or ischemic electrocardiogram [ECG] changes or angina pectoris), compared with nondiabetic subjects with prior evidence of CHD, had an HR of 1.9 (1.4-2.6) for CHD death (men 1.5 [1.0-2.2]; women 3.5 [1.8-6.8]). The results for CVD and total mortality were quite similar to those for CHD mortality.

CONCLUSIONS

Diabetes without prior myocardial infarction and prior myocardial infarction without diabetes indicate similar risk for CHD death in men and women. However, diabetes without any prior evidence of CHD (myocardial infarction or angina pectoris or ischemic ECG changes) indicates a higher risk than prior evidence of CHD in nondiabetic subjects, especially in women.

High serum levels of advanced glycation end products predict increased coronary heart disease mortality in nondiabetic women but not in nondiabetic men: a population-based 18-year follow-up study

BACKGROUND

Advanced glycation end products (AGEs), modification products of glycation or glycoxidation of proteins and lipids, have been linked to premature atherosclerosis in patients with diabetes as well as in nondiabetic subjects.

METHODS AND RESULTS

Serum levels of AGEs were measured with an immunoassay in samples obtained at baseline examination of a random sample of 1141 nondiabetic individuals (535 men and 606 women), aged 45 to 64 years, living in Kuopio, East Finland, or Turku, West Finland in 1982 to 1984. After 18 years of follow-up, all-cause mortality, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality were registered on the basis of copies of death certificates. Multivariate Cox regression model showed a significant association of serum AGEs with all-cause (P=0.012), CVD (P=0.018), and CHD (P=0.008) mortality in women but not in men. Fasting serum AGEs in the highest quartile were an independent risk factor for all-cause (hazards ratio [HR], 1.90; 95% CI, 1.16 to 3.11; P=0.011) and CHD (HR, 6.51; 95% CI, 1.78 to 23.79; P=0.005) mortality in women, even after the adjustment for confounding factors, including highly sensitive C-reactive protein.

CONCLUSIONS

The present study is the first to show that serum levels of AGEs can predict total, CVD, and CHD mortality in nondiabetic women.