Low birth weight predicts impaired cardiac structure and function in mid-adulthood

Aims

We sought to determine the relationship of low birth weight (LBW) with adult cardiac structure and function and investigate potential causal pathways.

Methods

We followed 925 Australians (41.3% male) from childhood (7–15 years) to young- (26–36 years) and mid-adulthood (36–50 years). Left ventricular (LV) global longitudinal strain (GLS, %), LV mass index (LVMi, g/m2.7), LV filling pressure (E/e') and left atrial volume index (LAVi, g/m2) were measured by echocardiography in mid-adulthood. Birth weight category was self-reported in adulthood and classified as low (≤5 pounds or ≤2270 g), normal (5–8 pounds or 2271–3630 g) and high (>8 pounds or >3630 g).

Results

7.5% (69/925) reported LBW. Compared with participants with normal birth weight, those with LBW had a 2.01-fold (1.19–3.41, p=0.009) higher risk of impaired GLS (GLS >−18%) and 2.63-fold (0.89–7.81, p=0.08) higher risk of LV hypertrophy (LVMi >48 g/m2.7 in men or >44 g/m2.7 in women) in adulthood independent of age, sex and any measures of socioeconomic status. Participants with LBW significantly increased body fat from childhood to adulthood relative to their peers, which was associated with greater levels of triglycerides, fasting blood glucose and arterial stiffness in adulthood. These factors were the strongest mediators in the association of LBW with impaired GLS in adulthood and together, explained half of the LBW effect size. The remaining half of this association was independent of any measured factors.

Conclusions

LBW was associated with impaired cardiac structure and function in mid-adulthood. This association was only partially explained by known risk factors.

Funding Acknowledgement

Type of funding sources: None.

Prediction of future atherosclerosis in 13 years from young asymptomatic adults

Aim

To compare the Pooled Cohort Equation (PCE) and Ideal Cardiovascular Health Score (ICHS) with a simpler cardiovascular risk score not requiring laboratory tests (the Fuster-BEWAT score, FBS) in predicting the presence and extent of subclinical atherosclerosis 13 years later.

Methods

Data included 894 adults (48% male) who were aged 26–36 years at baseline and 40–50 years at follow-up. The primary outcome was the presence of carotid plaque measured by ultrasound at follow-up. Secondary outcomes were number of arteries affected, plaque thickness and plaque area. All three scores were calculated at both baseline and follow-up.

Results

At follow-up, 86 participants (9.6%) had unilateral carotid plaques and 23 participants (2.6%) had bilateral carotid plaques. At baseline, all three scores were predictive of the presence of carotid plaque at follow-up (PCE odds ratio (OR) = 1.42 [95% CI: 1.19–1.70], ICHS OR=0.87 [0.77–0.99], FBS OR=0.86 [95% CI: 0.77–0.96]) and all secondary outcomes. All baseline scores predicted outcomes more strongly than those at follow-up, and did so independent of any changes over 13 years of follow-up. Similar levels of discriminatory power were found for all three baseline scores in predicting the presence of carotid plaque after 13 years (PCE C-statistic = 0.69 [95% CI: 0.63–0.75], ICHS C-statistic = 0.67 [95% CI: 0.61–0.74] and FBS C-statistic = 0.68 [95% CI: 0.62–0.74])

Conclusions

All baseline scores predicted subclinical atherosclerosis 13 years later. The similar discrimination of the scores highlights the benefit of using FBS as a simpler and more feasible risk score for predicting future cardiovascular risk in low-risk young people.

Funding Acknowledgement

Type of funding sources: None.

Applying the ESC 2016, the H2FPEF, and the HFA-PEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population – a comparative approach

Background

Heart failure with preserved ejection fraction (HFpEF) is common in patients presenting with dyspnoea. Nevertheless, diagnosing HFpEF remains challenging. Recently, different algorithms were developed to predict the likelihood of HFpEF.

Purpose

Our objective was to provide an in-depth comparison of the ESC 2016 algorithm, the H2FPEF- and the HFA-PEFF algorithm for diagnosing and characterising HFpEF in the general population.

Methods

The study included 5,613 participants of the population-based H. City Health Study (HCHS), aged 62±8.7 years (51.1% women), that were enrolled between 2016 and 2019. Exclusion criteria were other common causes of dyspnea. We calculated the prevalence and compared characteristics of HFpEF according to the different diagnostic algorithms applying the ESC 2016 heart failure guidelines and the cut-off values suggested by the authors of the HFA-PEFF and H2FPEF score for defining HFpEF.

Results

Unexplained dyspnea was present in 407 (7.3%) subjects. In those, the estimated prevalence of HFpEF was 20.4% (ESC 2016), 12.3% (H2FPEF), and 7.6% (HFA-PEFF). The majority of subjects was classified as HFpEF not excludable according to the HFA-PEFF (57.7%) and the H2FPEF (59.2%) score. For all algorithms, subjects diagnosed with HFpEF showed elevated age and body mass index as well as a higher prevalence of atrial fibrillation, diabetes, and arterial hypertension compared to those without HFpEF or HFpEF not excludable. The distribution of those comorbidities and risk factors varied between the differently diagnosed HFpEF groups with the highest burden in the HFpEF group defined by the H2FPEF score. The overlap of subjects diagnosed with HFpEF according to the different algorithms was very limited.

Conclusion

Unexplained dyspnoea is common in the middle-aged general population. The ESC 2016 algorithm, the H2FPEF-, and the HFA-PEFF score detect different, discordant sub-populations of probands with breathlessness. Further classification of the HFpEF syndrome is desirable.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Innovative medicine initiative Figure 1. Prevalence and concordance of the three HFpEF algorithms in subjects with unexplained dyspnea. Of the 407 subjects with unexplained dyspnea, the prevalence ranged from 20.4% (n=83, ESC 2016 guideline) to 12.3% (n=50, H2FPEF score) and 7.6% (n=31, HFA-PEFF score). The concordance was highest between the ESC 2016 guidelines and the HFA-PEFF score reflected by a kappa coefficient of 0.38 and a reclassification rate of 16%. RecR = reclassification rate.

Non-invasive risk prediction based on right ventricular function in patients with pulmonary arterial hypertension

Background

Individual risk assessment in patients with pulmonary arterial hypertension (PAH) is fundamental to improve their outcome. Although right ventricular (RV) dysfunction is a major determinant of outcome in PAH, echocardiographic measures of RV function are poorly represented by current risk models.

Objective

The objective of this study was to identify echocardiographic measures of RV function, which are associated with adverse outcome and to develop a non-invasive, echocardiography-based risk score for PAH patients.

Methods

In 254 patients with PAH we analyzed functional status, laboratory results, pulmonary function and echocardiographic measures. Echocardiographic measures comprised RV chamber diameters, right atrial area, fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), 2D RV strain and pericardial effusion. We used Cox regression models to assess the association with the composite endpoint of 5-year all-cause death or lung transplantation. The analyses included a conventional model using only guideline-recommended variables and a model adding significant echocardiographic measures. Based on the final multivariable model a point risk score was derived, indicating the association with the primary outcome.

Results

Median age was 65.5 years, 33.9% were females. During a median follow-up time of 4.18 years 74 patients died (n=63) or underwent lung transplantation (n=11). In univariable analyses low systolic blood pressure (Hazard ratio [HR] 0.99, 95% Confidence Interval [CI] 0.98,1.00), NYHA functional class IV (HR 3.23, 95% CI 1.48,7.07), 6-minute walk distance (HR 1.00, 95% CI 1.00,1.00), NT-proBNP concentrations (HR 1.00, 95% CI 1.00,1.00), renal impairment (HR 0.99, 95% CI 0.98,1.00), reduced diffusion capacity for carbon monoxide (HR 0.99, 95% CI 0.98,1.00), reduced TAPSE (HR 0.90, 95% CI 0.85,0.96) and reduced FAC (HR 0.97, 95% CI 0.94,1.00) were associated with the endpoint. A multivariable, conventional risk model, including NYHA functional class, 6-minute walk distance, NT-proBNP concentrations, pericardial effusion and right atrial area, resulted in a C-Index of 0.539. Adding TAPSE and FAC to this model improved the performance significantly (C-index 0.639, p-value 0.017). This model was translated to a 12-point score with the highest weighting assigned to TAPSE, FAC, pericardial effusion and 6-minute walk distance (Figure).

Conclusion

An easily applicable score integrating non-invasive, echocardiographic parameters of RV function improves prediction of adverse outcome in PAH patients.

Funding Acknowledgement

Type of funding sources: None. Risk prediction chart

P6310Risk predictors of cardiac allograft vasculopathy after heart transplantation: results from the United States Organ Procurement and Transplantation Network

Background

Cardiac allograft vasculopathy (CAV) is a major long-term complication after heart transplantation leading to chronic graft failure and increased mortality.

Purpose

The aim of this study was to determine recipient- and donor-related risk factors for the development of CAV in patients after heart transplantation.

Methods

Overall, data from 34,994 heart transplant recipients prospectively enrolled from July 2004 to March 2015 in the Organ Procurement and Transplantation Network (OPTN) were analyzed. Patients aged <18 years and those without information about CAV and re-transplantation were excluded. Multivariable-adjusted analyses were performed to identify recipient- and donor-related risk factors for new-onset CAV. The mean follow-up time was 66.8 months. Analyses are based on OPTN data as of March 6, 2017.

Results

Of 34,994 patients after heart transplantation, 12,668 (36.2%) patients developed CAV. Mean age was 52±12 years for the recipients (76.1% men) and 31±12 years for the donors (71.0% men), respectively.

In recipients, male sex (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.09–1.19, p<0.001), African American ethnicity (HR 1.11, 95% CI 1.06–1.17, p<0.001), body mass index (BMI) (HR per 5 kg/m2 increase 1.08, 95% CI 1.06–1.11, p<0.001) and smoking (HR 1.07, 95% CI 1.01–1.13, p=0.03) were associated with incident CAV. Moreover, recipients with ischemic (HR 1.30, 95% CI 1.09–1.55, p=0.003) and hypertrophic cardiomyopathy (HR 1.26, 95% CI 1.02–1.57, p=0.03) had a higher risk for new-onset CAV than patients with other cardiomyopathies.

In donors, age (HR 1.11, 95% CI 1.10–1.11, p<0.001), male sex (HR 1.28 95% CI 1.22–1.34, p<0.001), BMI (HR per 5 kg/m2 increase 1.04, 95% CI 1.02–1.05, p<0.001), smoking (HR 1.09, 95% CI 1.04–1.13, p<0.001), diabetes (HR 1.21 95% CI 1.09–1.36, p<0.001) and arterial hypertension (HR 1.13, 95% CI 1.07–1.20, p<0.001) were associated with new-onset CAV. Contrarily, African American (HR 0.93, 95% CI 0.88–0.98, p=0.007) and Hispanic ethnicity (HR 0.94, 95% CI 0.89–0.99, p=0.03) seemed to be protective.

Conclusion

Both recipient and donor male sex as well as the classical cardiovascular risk factors BMI and smoking were associated with incident CAV. On the donor side, additionally, diabetes and arterial hypertension were related to new-onset CAV. Diverse ethnicities were differentially related to new-onset CAV. Further studies are needed to clarify whether modification of cardiovascular risk factors as well as improved donor selection will reduce CAV burden.

P2449Different associations of cardiovascular risk factors with markers of subclinical myocardial disease over the life course

Background

Asymptomatic myocardial disease is the precursor to heart failure, but changes in myocardial markers such as global longitudinal strain (GLS), left ventricular hypertrophy (LVH), diastolic dysfunction and left atrial (LA) enlargement are not necessarily congruent. Cardiorespiratory fitness (CRF), body mass index (BMI) and mean arterial pressure (MAP) are common predictors of cardiovascular disease. This study investigated the association of markers of myocardial disease with these predictors across the life-course.

Methods

This study followed 562 participants from childhood (aged 7–15 years in 1985) who were followed-up into adulthood at aged 26–36 years during 2004-06 and 39–49 years during 2017-19. CRF, BMI and blood pressure were measured at baseline and follow-up. Echocardiogram was used to identify asymptomatic myocardial disease at the latest follow-up, including abnormal GLS (GLS greater than −18% in 102/562 participants), LVH (55/562), dilated LA (LA volume index >34 in 268/562) and increased LV filling pressure (E/e' >8 in 32/562).

Results

Current physical measurements were generally stronger than previous measurements in predicting myocardial function and structure. Abnormal GLS was associated with childhood CRF (OR=0.77 [95% CI: 0.62, 0.96]) independently of adult CRF. While the association of abnormal GLS with BMI was influenced primarily by the most current BMI, its association with MAP appeared to be similar over the life-course. Dilated LA was associated with childhood CRF (OR=1.32 [95% CI: 1.08, 1.60]) independently of adult CRF, and was not associated with BMI or MAP in either childhood or adulthood. The associations of LVH with CRF, BMI and MAP were primarily dependent on current rather than earlier CRF, BMI and MAP. LV filling pressure was not associated with any childhood measurements but was associated with current BMI and MAP.

Conclusions

Different aspects of myocardial physiology appear to have different associations over the lifecycle, supporting the concept of different phenotypes of asymptomatic myocardial disease.

Dilated cardiomyopathy: from epidemiologic to genetic phenotypes: A translational review of current literature

Dilated cardiomyopathy (DCM) is characterized by left ventricular dilatation and, consecutively, contractile dysfunction. The causes of DCM are heterogeneous. DCM often results from myocarditis, exposure to alcohol, drugs or other toxins and metabolic or endocrine disturbances. In about 35% of patients, genetic mutations can be identified that usually involve genes responsible for cytoskeletal, sarcomere and nuclear envelope proteins. Due to its heterogeneity, a detailed diagnostic work-up is necessary to identify the specific underlying cause and exclude other conditions with phenotype overlap. Patients with DCM show typical systolic heart failure symptoms, but, with progress of the disease, diastolic dysfunction is present as well. Depending on the underlying pathology, DCM patients also become apparent through arrhythmias, thromboembolic events or cardiogenic shock. Disease progression and prognosis are mostly driven by disease severity and reverse remodelling within the heart. The worst prognosis is seen in patients with lowest ejection fractions or severe diastolic dysfunction, leading to terminal heart failure with subsequent need for left ventricular assist device implantation or heart transplantation. Guideline-based heart failure medication and device therapy reduces the frequency of heart failure hospitalizations and improves survival.

P2505Cardiorespiratory fitness in childhood is an independent predictor of subclinical cardiovascular disease in adulthood: The Childhood Determinants of Adult Health Study

Background

Asymptomatic myocardial disease is the precursor to heart failure – to which cardiorespiratory fitness (CRF) is an important contributor. It is however unclear if CRF in childhood can predict cardiovascular disease in adulthood and whether it can do so independently of adult risk factors.

Methods

This study followed 562 participants from childhood (aged 7–15 years in 1985) to adulthood (aged 36–49 years in 2017–19). Time to finish a 1.6km run was standardised by age and sex to estimate CRF in childhood. CRF in adulthood was estimated using physical working capacity at a heart rate of 170bpm. Echocardiogram was used to identify abnormal myocardial function and structure in adulthood, including reduced global longitudinal strain (abnormal GLS greater than −18% in 102/562 participants), left ventricular hypertrophy (LVH in 55/562), dilated left atrial (LA volume index>34 in 268/562) and increased LV filling pressure (E/e'>8 in 32/562).

Results

CRF tracks weakly through the life-course (r=0.14, p<0.001). Childhood CRF was negatively associated with abnormal GLS (OR=0.76 [95% CI: 0.62, 0.92]), and was positively associated with dilated LA (OR=1.33 [95% CI: 1.12, 1.59]) and LV hypertrophy (OR=1.39 [95% CI: 1.01, 1.92]) in adulthood. There was no association with increased LV filling pressure. While the associations with abnormal GLS and dilated LA were independent of adult CRF, the association of LV hypertrophy was attenuated and rendered insignificant after adjusting for adult CRF. A simple predictive model including age, sex and childhood CRF could predict abnormal GLS in adulthood with good discrimination (C-statistic=0.71 [95% CI: 0.66, 0.77]) – which was not significantly different from a predictive model using adult risk factors (p=0.53).

Conclusions

CRF in childhood is an important and independent predictor of subclinical cardiovascular disease in adulthood.

404Impact of cardiovascular risk factors for the development of cardiovascular disease: Results from MORGAM and BiomarCaRE consortia

Background

Knowledge about the impact of modifiable risk factors for cardiovascular disease (CVD) onset is essential to improve CVD prevention.

Purpose

We estimated population-attributable fractions (PAFs) of body-mass-index (BMI), systolic blood pressure (SBP), diabetes, blood lipids (non-high-density lipoprotein cholesterol; non-HDL-C) and daily smoking for CVD.

Methods

Harmonized data from MOnica Risk, Genetics, Archiving and Monograph (MORGAM) and Biomarkers for Cardiovascular Risk Assessment in Europe (BiomaCaRE) consortia were used to calculate hazard ratios (HRs; 95% CI) and PAFs for incident CVD (myocardial infarction or coronary death, unstable angina, cardiac revascularization, ischemic stroke). PAFs for single risk factors or any combination of them were estimated using methods by Laaksonen 2011.

Results

We included 150,190 participants (77,801 men and 72,389 women) without CVD at baseline. Strongest associations were seen for SBP ≥160 mmHg (HR 1.79, 1.67–1.92 men; HR 1.93, 1.75–2.14 women), diabetes (HR 2.02, 1.86–2.20 men; HR 2.29, 2.06–2.55 women), non-HDL-C ≥220 mg/dL (HR 3.11, 2.49–3.88 men; HR 2.27, 1.68–3.05 women), daily smoking (HR 1.82, 1.73–1,90 men; HR 2.16, 2.0–2.33 women). Table 1 provides PAFs for incident CVD. Overall PAFs for men and women were 73.7% (67.7–79.1) and 73.3% (64.9–80.9).

Table 1. PAFs (%) for 5-year incident CVD Risk factor/category PAFs (95% CI), men PAFs (95% CI), women Underweight 0.1 (−0.1, 0.3) 0.2 (−0.1, 0.6) Pre-obesity 6.6 (4.3, 8.9) 4.3 (1.5, 6.9) Obesity 3.9 (2.7, 5.3) 8.0 (5.3, 10.5) SBP 130 to <140 mmHg 2.8 (1.7, 4.0) 2.7 (1.3, 4.0) SBP 140 to <160 mmHg 9.7 (8.1, 11.3) 9.3 (6.7, 11.6) SBP ≥160 mmHg 11.3 (9.7, 12.8) 18.9 (16.2, 21.8) Diabetes 5.2 (4.5, 6.2) 7.8 (6.5, 9.4) non-HDL-C 100 to <145 mg/dL 4.3 (1.8, 6.4) 3.3 (0.5, 6.5) non-HDL-C 145 to <185 mg/dL 13.9 (9.8, 17.5) 11.3 (6.0, 16.2) non-HDL-C 185 to <220 mg/dL 15.8 (12.8, 18.4) 12.8 (8.8, 17.0) non-HDL-C ≥220 mg/dL 16.7 (14.6, 18.5) 17.0 (12.5, 21.1) Daily smoking 16.5 (15.0, 18.3) 12.3 (10.7, 13.7) The N CVD events/N used was 8,302/77,801 for men and 4,071/72,389 for women.

Conclusion

Uncontrolled risk factors, especially non-HDL-C and SBP in the highest category, daily smoking and diabetes had the highest impact for incident CVD. All risk factors combined accounted for a PAF of 73%. Targeting risk factors would lead to a substantial reduction of CVD onset.

Acknowledgement/Funding

BiomarCaRE: EU Seventh Framework Programme (FP7/2007-2013), No. HEALTH-F2-2011-278913. MORGAM: EU FP 7 CHANCES (HEALTH-F3-2010-242244).

Biomarkers for heart failure: small molecules with high clinical relevance

Heart failure (HF) is a rising epidemic due to the ageing population and progress in all areas of medicine. Thus, research efforts are made to ensure a timely diagnosis, to improve prognosis and treatment of the disease and to facilitate risk prediction at the population level. Because of their noninvasive determination with mostly high sensitivity and accuracy, circulating blood biomarkers are becoming increasingly important for daily clinical practice. Natriuretic peptides, especially B-type natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (Nt-proBNP) and midregional pro-atrial natriuretic peptide (MR-proANP) and cardiac troponins are established blood biomarkers in HF diagnosis and prognosis of HF-related outcomes. Inflammatory molecules as C-reactive protein (CRP) may have added value in anti-inflammatory therapy guidance. Next-generation biomarkers including soluble source of tumorigenicity 2 (sST2), growth differentiation factor-15 (GDF-15), galectin-3 (Gal-3) and diverse microribonucleic acids (miRNAs) may have additional benefit in assessment of cardiac remodeling or differentiation of HF subtypes. Multimarker approaches containing different combinations of established and novel biomarkers might improve HF risk prediction at the population level once they are used on top of clinical variables.