Racial differences in prevalence and impact of electrocardiographic subclinical myocardial injury risk factors

BACKGROUND

We explored whether the reported racial differences in subclinical myocardial injury (SCMI) are due to variations in the prevalence or differential impact of the SCMI risk factors.

METHODS

This analysis included 3074 Whites, 1337 Blacks, and 1441 Mexican Americans from the Third National Health and Nutrition Examination Survey who were free of cardiovascular disease. SCMI was defined from standard electrocardiograms as a cardiac infarction/injury score ≥ 10 points. Multivariable logistic regression analysis was used to assess the association of SCMI with its risk factors stratified by race. Multiplicative interaction between each risk factor and race was also examined.

RESULTS

Overall prevalence of SCMI was 20.3%, with Mexican Americans exhibiting a lower prevalence than Whites and Blacks (16.5%, 20.4%, and 20.7%, respectively). Whites had more prevalence of dyslipidemia and smoking. Mexican Americans had more diabetes, while Blacks had more hypertension, obesity, and left ventricular hypertrophy. Significant risk factors for SCMI were older age, lower income (<20 K), smoking, diabetes, and no regular exercise. The association of SCMI with age was more pronounced in Mexican Americans (p-value for interaction 0.03), whereas the associations of SCMI with smoking, no-regular exercise, and diabetes were stronger in Whites (p-value for interaction 0.04, 0.001, 0.007, respectively).

CONCLUSIONS

Heterogeneity in the racial differences in the prevalence of SCMI risk factors exists, but they do not explain racial differences in SCMI. The stronger associations of smoking, diabetes, and no regular exercise with SCMI partially explain the higher prevalence of SCMI in Whites.

Lower alanine aminotransferase levels are associated with increased all-cause and cardiovascular mortality in nonalcoholic fatty liver patients

BACKGROUND

Serum alanine aminotransferase (ALT) levels are often considered a marker to evaluate liver disease and its severity.

AIM

To investigate the association between ALT levels and all-cause and cause-specific mortality in patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

The Third National Health and Nutrition Examination Survey (NHANES-III) from 1988 to 1994 and NHANES-III-related mortality data from 2019 onward were used to obtain the necessary data for the study. NAFLD was defined as hepatic steatosis, as diagnosed by ultrasound, with no other liver diseases. ALT levels were categorized into four groups according to the different recommended upper limits of normal (ULN) in men and women: < 0.5 ULN, 0.5-1 ULN, 1-2 ULN, and ≥ 2 ULN. The hazard ratios for all-cause mortality and cause-specific mortality were analyzed using the Cox proportional hazard model.

RESULTS

Multivariate logistic regression analysis demonstrated that the odds ratio of NAFLD correlated positively with increased serum ALT levels. In patients with NAFLD, all-cause mortality and cardiovascular mortality were the highest when ALT was < 0.5 ULN, yet cancer-related mortality was the highest when ALT was ≥ 2 ULN. The same results could be found in both men and women. Univariate analysis showed that severe NAFLD with normal ALT levels had the highest all-cause and cause-specific mortality, but the difference was not statistically significant after adjustment for age and multivariate factors.

CONCLUSION

The risk of NAFLD was positively correlated with ALT level, but all-cause and cardiovascular mortality were the highest when ALT was < 0.5 ULN. Regardless of the severity of NAFLD, normal or lower ALT levels were associated with higher mortality than elevated ALT levels. Clinicians should be aware that high ALT levels indicate liver injury, but low ALT levels are associated with a higher risk of death.

Association between Periodontitis and Diabetes Mellitus in the General Population

Purpose-

This study aimed to examine the association between periodontitis and diabetes mellitus.

Methods

Participants with natural teeth in one jaw from the Third United States National Health and Nutrition Examination Survey (1988-1994) were included in this analysis. Participants with moderate (> 4mm attachment loss in ≥ 2 mesial sites or 5mm pocket depth in ≥ 2 mesial sites) or severe (> 6mm attachment loss in ≥ 2 mesial sites and > 5mm pocket depth in ≥ 1 mesial site) periodontitis were classified as having periodontal disease. The rest of the participants were considered without periodontal disease. Diabetes mellitus was defined as fasting glucose ≥ 126mg/dL, hemoglobin A1c ≥ 6.5% or the use of antihyperglycemic medications. Multivariable logistic regression was used to examine the association between periodontitis and diabetes mellitus in all study population and subgroups stratified by demographics and comorbidities.

Results

This analysis included 13,000 participants [mean age 43.8 ± 19.1 years, 47.5% male, 30% whites]. About 12.7% (n = 1,656) of the study population had periodontitis, and 9.2% (n = 1,200) had diabetes. In a multivariable-adjusted model, presence (vs. absence) of periodontitis was associated with 66% increased odds of diabetes (OR (95% CI):1.66 (1.43-1.94); p < 0.001). Compared to those without periodontitis, the odds of diabetes among those with severe periodontitis was much higher (OR (95% CI): 2.31(1.72-3.11); p < 0.001) than in those with moderate periodontitis (OR (95% CI): 1.54(1.30-1.82); p < 0.001).

Conclusions

Periodontitis is associated with prevalent diabetes in a dose-response fashion, suggesting a bidirectional relationship between those two diseases. Patients with periodontal disease should be counseled regarding their elevated risk of diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01010-6.

Electrocardiographic myocardial injury and stroke mortality in the general population

BACKGROUND

Recent evidence suggests a link between myocardial infarction and stroke risk, but it is unclear whether such risk exists with electrocardiographic myocardial injury in otherwise healthy individuals. Therefore, we explored the association of myocardial injury with stroke mortality in participants free of cardiovascular disease.

METHODS

This analysis included 6017 participants (58.4 ± 13.4 years, 54.1% women, 50.3% white) from the Third National Health and Nutrition Examination Survey. Cardiac infarction/injury score (CIIS), a weighted scoring system composed of several electrocardiographic waveform components related to myocardial injury and ischemia, was used to define myocardial injury. Stroke mortality was ascertained using the National Death Index during follow-up. Multivariable adjusted Cox proportional hazard analysis was used to examine the association between baseline myocardial injury and risk of stroke mortality.

RESULTS

Over a median follow-up of 14 years, 152 stroke deaths occurred. Stroke mortality was more common in those with than those without myocardial injury (3.8% vs. 2.1%, respectively; p = 0.0003). In a model adjusted for potential confounders, the myocardial injury was associated with a 44% increased risk of stroke mortality (HR (95%CI):1.44(1.02-2.03)). In a similar model, each 1 CIIS score point increase was associated with a 2% increase in the risk of stroke mortality (HR (95%CI):1.02 (1.00-1.04), p = 0.01).

CONCLUSIONS

Electrocardiographic myocardial injury in cardiovascular disease-free adults is associated with an increased risk of stroke mortality suggesting a potential link between asymptomatic myocardial injury and risk of cardiac thromboembolism. Whether screening and management of myocardial injury would reduce such risk requires further investigation.

Atrial cardiopathy and stroke mortality in the general population

BACKGROUND

Prior studies examining the link between atrial cardiopathy and stroke risk have focused mainly on non-fatal stroke.

AIMS

To examine the association between atrial cardiopathy and stroke mortality.

METHODS

This analysis included 8028 participants (60.0 ± 13.4 years, 51.9% women, 49.8% white) from the Third National Health and Nutrition Examination (NHANES III) Survey. Atrial cardiopathy was defined as abnormal deep terminal negativity of the P wave in V1 (DTNPV1 = negative p-wave in V1<-100 µv), an electrocardiographic marker of atrial cardiopathy. Stroke mortality was ascertained using the National Death Index over a median follow-up of 14 years.

RESULTS

2.95% (n = 237) of the participants had atrial cardiopathy, and the prevalence was slightly higher in blacks (4%) versus whites (3%). During follow-up, stroke mortality was more common in those with (5.9%) than those without (2.7%) atrial cardiopathy; p = .004. In a multivariable adjusted model, atrial cardiopathy was associated with a 76% increased risk of stroke mortality (HR (95% CI): 1.76 (1.02-3.04)]. This association was stronger in non-whites than whites (HR (95% CI): 3.50 (1.74-7.03) vs. 0.98 (0.40-2.42), respectively; interaction p = 0.03). Among those with baseline atrial cardiopathy, the annualized stroke mortality rates/1000 participants across CHA₂DS₂-VASc scores of 0, 1, and ≥2 were 0.0, 2.2, and 7.8, respectively.

CONCLUSIONS

Atrial cardiopathy is associated with an increased risk of stroke mortality, especially among non-whites. Among those with atrial cardiopathy, the risk of stroke mortality exponentially increases as the CHA₂DS₂-VASc score becomes 2 or above. Randomized controlled trials are needed to assess the efficacy of anticoagulation in the prevention of ischemic stroke and thus, stroke mortality in the presence of atrial cardiopathy.

Relation of total bilirubin and QT interval prolongation (from the Third National Health and Nutrition Examination Survey)

OBJECTIVE

The association of bilirubin with cardiovascular disease (CVD) is controversial. We sought to explore the association of total bilirubin (TB) levels with QT interval in a multiracial cohort.

METHODS

A total of 6,627 participants (59.0 ± 13.3 years; 52.6% women, 49.7% Non-Hispanic Whites) without CVD from the Third National Health and Nutrition Examination Survey were included in this analysis. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. A multivariable logistic regression model was used to examine the cross-sectional association between tertiles of TB and prolonged QT interval (≥450 ms in men and ≥460 ms in women).

RESULTS

The prevalence of prolonged QT was higher among those with higher levels of TB (prolonged QT prevalence was 4.7%, 6.8%, and 7.0% across TB lower (0-0.4 mg/dl), middle (0.5-1.6 mg/dl), and higher (0.70-4.30 mg/dl) tertiles, respectively). In a model adjusted for potential confounders, participants within the highest TB tertile had significantly greater odds of the prolonged QT interval (Odds ratios [95% confidence interval] 1.53 [1.16-2.02]) compared to those with bilirubin levels in the first tertile. Each 0.29 mg/dl increase in TB levels was associated with a 12% (p-value <.0001) increase in the prevalence of prolonged QT interval. This association was stronger in men than in women (interaction p-value = .04).

CONCLUSION

Elevated bilirubin levels are associated with a prolonged QT interval. This finding extends our current knowledge on the relationship between serum bilirubin and CVD by demonstrating a link between higher TB and abnormal cardiac repolarization.

Prognostic significance of electrocardiographic right ventricular hypertrophy in the general population

BACKGROUND

Echocardiographically detected right ventricular hypertrophy (RVH) is associated with cardiovascular disease (CVD) and mortality. However, the prognostic significance of electrocardiographic (ECG)RVH criteria as predictors of poor outcomes in the general population is unclear.

METHODS

This study included 7857 participants (59.8 ± 13.4 years, 52.6% women) from the Third National Health and Nutrition Examination Survey. Sixteen different ECG-RVH criteria were created from digitally recorded and centrally processed electrocardiograms. All-cause mortality was ascertained using the National Death Index. Cox proportional hazards analysis was used to examine the association between baseline ECG-RVH criteria and all-cause mortality.

RESULTS

The prevalence of RVH varied widely among the criteria. The lowest ECG-RVH prevalence was 0.09% (using S > R in I, II, III) while the highest prevalence was 20.7% (using (R I + S III) - (S I + R III) < 15 mm). During a median follow-up of 14 years, 2812 deaths occurred. The mortality rate was highest among participants with ECG-RVH defined as R:S ratio V₅ < 0.75. In multivariable adjusted models, 9 out of the 16 ECG-RVH criteria were significantly associated with all-cause mortality. When ECG-RVH was defined as the presence of any ECG-RVH criteria, each additional ECG-RVH criteria was associated with 6% increased risk of all-cause mortality (HR (95% CI):1.06(1.03,1.10)).

CONCLUSIONS

There is a wide variation in the prevalence of ECG-RVH when different criteria are applied in the general population. However, the presence of ECG-RVH by most criteria regardless of prevalence was associated with poor prognosis suggesting that appropriate choice of criteria may enhance the utilization of these ECG markers in risk stratification.

Association of obesity phenotypes with electrocardiographic left ventricular hypertrophy in the general population

OBJECTIVE

Increasing evidence doubts the benign nature of metabolically healthy obesity (MHO). An investigation of the association of MHO and other obesity phenotypes with electrocardiographic left ventricular hypertrophy (ECG-LVH), a risk factor for cardiovascular disease (CVD), can give insight into the pathophysiological basis for increased risk of CVD linked to these phenotypes.

METHODS

This analysis included 3997 participants (58.7 ± 13.6 years; 51.8% women) without CVD from the NHANES-III. Metabolic syndrome was defined according to the Adult Treatment Panel III. Obesity was defined as body mass index ≥30 kg/m2. Multivariable logistic regression was used to examine the cross-sectional association between 4 obesity phenotypes (metabolically healthy non-obese (MHNO) (reference), metabolically unhealthy non-obese (MUNO), MHO and metabolically unhealthy obese (MUO) with Cornell voltage ECG-LVH.

RESULTS

There was an incremental increase in the prevalence of ECG-LVH across obesity phenotypes with the highest prevalence in the MUO followed by MHO, MUNO and then MHNO (ECG-LVH = 6.45%, 5%, 4.71%, and 1.69%, respectively, trend p-value < 0.001). Also, there was incremental increase in the strength of associations with ECG-LVH across obesity phenotypes with higher odds of ECG-LVH in the MUO (OR (95% CI): 4.12 (2.30-7.39) followed by MUNO (OR (95% CI): 2.62 (1.45-4.73) then MHO (OR (95% CI): 2.45 (1.11-5.43) compared to MHNO. The MHO association with ECG-LVH was stronger in men than women (OR (95% CI): 5.55 (1.49-20.70) vs. 1.94 (0.71-5.24) respectively; interaction p-value = 0.04).

CONCLUSIONS

Obesity phenotypes including MHO are associated with ECG-LVH, thus further questioning the concept of benign obesity.

Peguero Electrocardiographic Left Ventricular Hypertrophy Criteria and Risk of Mortality

Background: Peguero electrocardiographic left ventricular hypertrophy (ECG-LVH) criteria are newly developed criteria that have shown better diagnostic performance than the traditional Cornell-voltage and Sokolow-Lyon criteria. However, prediction of poor outcomes rather than detection of increased left ventricular mass is becoming the primary use for ECG-LVH criteria which requires investigating any new ECG-LVH criteria in terms of prediction.

Aims: To examine the prognostic significance of the newly developed Peguero ECG-LVH criteria.

Methods: We compared the prognostic significance of Peguero ECG-LVH with Cornell-voltage and Sokolow-Lyon ECG-LVH criteria in 7,825 participants (age 59.8 ± 13.4 years; 52.7% women) from the third National Health and Nutrition Examination Survey who were free of major intraventricular conduction defects. ECG-LVH criteria were derived from digital ECG tracings processed at a central core laboratory.

Results: At baseline, ECG-LVH was detected in 11.8% by Peguero; in 4.3% by Cornell voltage and in 6.4% by Sokolow-Lyon. During a median follow up of 13.8 years, 2,796 all-cause mortality events occurred. In multivariable models adjusted for demographics and cardiovascular risk factors, presence of Peguero ECG-LVH was associated with increased risk of all-cause mortality [HR (95% CI): 1.29 (1.16, 1.44)]. This association was not significantly different from the associations of Cornell voltage-LVH or Sokolow-Lyon LVH with all-cause mortality [HR (95%CI): 1.32 (1.12, 1.55) and 1.24 (1.07, 1.43), respectively; p-values for comparisons of these HRs with the HR of Peguero ECG-LVH 0.817 and 0.667, respectively]. Similar patterns of associations were observed with cardiovascular, ischemic heart disease and heart failure mortalities.

Conclusion: Peguero ECG-LVH is predictive of increased risk of death similar to the traditional ECG-LVH criteria.