VEGF beta is a candidate biomarker for cardiovascular risk stratification

Background

The blood-based transcriptome changes in relation to body weight but longitudinal data on specific transcripts are rare. Monocytes play a crucial role in the development of atherosclerosis and coronary artery disease. Monitoring monocytic gene expression patterns could aid to identify biomarkers for improved cardiovascular risk stratification. BMI and diabetes mellitus (T2DM) are associated with coronary artery disease (CAD). There are mRNAs associated with the development of atherosclerosis and CAD, which can be detected in circulating cells. The exact pathways and direct targets have not been explored.

Objective

To apply transcriptome screening and validation analysis to identify novel biomarker candidates associated with longitudinal changes of BMI as cardiovascular risk factors and test association with clinical endpoints.

Methods

Transcriptome-wide monocytic gene expression changes were screened in relation to changes in BMI over a time period of 5 years in 1,092 participants of the Gutenberg Health Study with available transcriptomics data at baseline investigation and at 5-years follow-up. Functional enrichment of BMI-related genes (FDR <0.01) was tested based on pathway databases and selected gene sets. Serum VEGFB levels were quantified and validated in serum from n=1,895 individuals from an independent cohort study (FinRisk). In-vitro, THP1 cells were stimulated with recombinant VEGFB.

Results

143 transcripts showed a significant association with change in BMI over 5 years. Decreased VEGFB mRNA levels strongly associated with increased BMI (p=2.8x10–9). Lower levels of VEGFB mRNA were associated with increased mortality (HRperSD=0.757, 95% CI: 0.647–0.885, p=0.0005) following adjustment for age and sex and incident diabetes (p=0.01). Circulating VEGFB levels inversely correlated with VEGFB mRNA (r=−0.2, p=0.0024) and positively correlated with an increase in BMI (beta=0.226, p=8.4x10–6), type 2 diabetes mellitus risk (HRperSD=1.279, 95% CI: 1.148–1.425, p=7.8x10–6) and all-cause mortality (HRperSD=1.184, 95% CI: 1.045–1.342, p=0.008). Further exploration in n=1,895 individuals from FinRisk revealed an association of increased VEGFB levels with increased risk for heart failure (HRperSD=1.373, 95% CI: 1.210–1.560, p=1.0x10–6) and coronary artery disease (HR=1.018, 95% CI: 1.003–1.034, p=0.019), even after adjustment for BMI. In THP-1 culture, stimulation with VEGFB resulted in downregulation of VEGFB mRNA levels.

Conclusion

Decreased monocytic gene expression of VEGFB is related to increased BMI, increased risk of T2DM and all-cause mortality. Vice versa,circulating VEGFB levels associates positively with BMI, diabetes, mortality as well as heart failure and coronary heart disease. We hypothesize that monocytes regulate VEGFB expression by a negative feed-back mechanism based. Circulating VEGFB is a potential novel biomarker candidate for weight-related diabetes risk and cardiovascular risk evaluation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DZHK

Patterns of pulmonary function and mortality in chronic heart failure, results from the MyoVasc study

Background

Preclinical evidence suggests that pulmonary fibrosis due to left heart disease may represent end-organ damage in heart failure (HF). Vice versa, decreased pulmonary function is related to worsening of heart failure in the absence of obstructive airway pattern.

Purpose

This study investigated the relationship between patterns of pulmonary function (i.e. obstruction and restriction) and mortality in chronic HF.

Methods

For the present analysis data from the MyoVasc-study (N=3,289) were analysed. During a five-hour examination in the dedicated study center, systematic phenotyping was performed in a highly standardized setting. Chronic HF was defined as American Heart Association HF Stage C/D. Information on pulmonary function was assessed via body plethysmography (MasterScreen Body, Carefusion, Germany). Participants with forced expiratory ratio <0.7 or COPD were categorized as obstructive, while restriction was defined as reduction in total lung capacity. Information on vital status was obtained via registration offices.

Results

The analysis sample comprised 1,509 individuals with chronic heart failure and information on pulmonary function, of whom 286 had HF with reduced ejection fraction (HFrEF), 559 HF with preserved ejection fraction (HFpEF), and 333 HFpEFborderline. The mean age was 64.6±11.3 years, 38.7% were female. In the sample 124 subjects had pulmonary restriction and 400 individuals had an obstruction. During a median time to follow up of 3.70 (inter quartile range 1.25 to 4.00) years, death occurred in 170 individuals. Among clusters of pulmonary function most participants died in the restriction group (25.0%), followed by pulmonary obstruction (12.2%) and normal pulmonary function (7.3%, P for trend <0.001). Cox- regression analysis adjusted for age, sex and height revealed pulmonary restriction (hazard ratio (HR) 3.00 [95% confidence interval 2.04–4.42], P<0.001] and obstruction (HR 1.61 [1.11–2.35], P=0.01) as predictors of all-cause death. After additional controlling for traditional cardiovascular risk factors and the clinical profile only pulmonary restriction remained an independent predictor of mortality (HRrestriction 2.12 [1.50–3.43]; P=0.002; HRobstruction 1.35 [0.91–2.00]; P=0.10). Among HF phenotypes obstruction was only in individuals with HFpEF an independent predictor of all-cause death (HRHFpEF 2.60 [1.29–5.23]; P=0.007; HRHFpEFborderline 1.58 [0.70–3.57]; P=0.27; HRHFrEF 0.96 [0.52–1.78]; P=0.90), while pulmonary restriction was found to be predictive for death only in subjects with HFpEFborderline (HRHFpEF 2.15 [0.70–6.64]; P=0.18; HRHFpEFborderline: HR 5.47 [2.56–11.68]; P<0.001; HRHFrEF 1.74 [0.88–3.46]; P=0.11)

Conclusion

In chronic heart failure, pulmonary restriction was a stronger predictor of mortality than obstructive airway pattern. The present analysis supports the hypothesis of pulmonary fibrosis as end-organ damage in HF, and may potentially represent a therapeutic target.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): German Center for Cardiovascular Research (DZHK)

Aramchol in patients with nonalcoholic steatohepatitis: a randomized, double-blind, placebo-controlled phase 2b trial

Nonalcoholic steatohepatitis (NASH), a chronic liver disease without an approved therapy, is associated with lipotoxicity and insulin resistance and is a major cause of cirrhosis and hepatocellular carcinoma. Aramchol, a partial inhibitor of hepatic stearoyl-CoA desaturase (SCD1) improved steatohepatitis and fibrosis in rodents and reduced steatosis in an early clinical trial. ARREST, a 52-week, double-blind, placebo-controlled, phase 2b trial randomized 247 patients with NASH (n = 101, n = 98 and n = 48 in the Aramchol 400 mg, 600 mg and placebo arms, respectively; NCT02279524 ). The primary end point was a decrease in hepatic triglycerides by magnetic resonance spectroscopy at 52 weeks with a dose of 600 mg of Aramchol. Key secondary end points included liver histology and alanine aminotransferase (ALT). Aramchol 600 mg produced a placebo-corrected decrease in liver triglycerides without meeting the prespecified significance (-3.1, 95% confidence interval (CI) -6.4 to 0.2, P = 0.066), precluding further formal statistical analysis. NASH resolution without worsening fibrosis was achieved in 16.7% (13 out of 78) of Aramchol 600 mg versus 5% (2 out of 40) of the placebo arm (odds ratio (OR) = 4.74, 95% CI = 0.99 to 22.7) and fibrosis improvement by ≥1 stage without worsening NASH in 29.5% versus 17.5% (OR = 1.88, 95% CI = 0.7 to 5.0), respectively. The placebo-corrected decrease in ALT for 600 mg was -29.1 IU l^-1 (95% CI = -41.6 to -16.5). Early termination due to adverse events (AEs) was <5%, and Aramchol 600 and 400 mg were safe, well tolerated and without imbalance in serious or severe AEs between arms. Although the primary end point of a reduction in liver fat did not meet the prespecified significance level with Aramchol 600 mg, the observed safety and changes in liver histology and enzymes provide a rationale for SCD1 modulation as a promising therapy for NASH and fibrosis and are being evaluated in an ongoing phase 3 program.

Global longitudinal strain predicts outcome in chronic heart failure across American Heart Association stages: results from the MyoVasc study

Background

Global longitudinal strain (GLS) demonstrated a superior prognostic value over left ventricular ejection fraction (LVEF) in acute heart failure (HF). Its prognostic value across American Heart Association (AHA) stages of HF – especially under considering of conventional echocardiographic measures of systolic and diastolic function – has not yet been comprehensively evaluated.

Purpose

To evaluate the prognostic value of GLS for HF-specific outcome across AHA HF stages A to D.

Methods

Data from the MyoVasc-Study (n=3,289) were analysed. Comprehensive clinical phenotyping was performed during a five-hour investigation in a dedicated study centre. GLS was measured offline utilizing QLab 9.0.1 (PHILIPS, Germany) in participants presenting with sinus rhythm during echocardiography. Worsening of HF (comprising transition from asymptomatic to symptomatic HF, HF hospitalization, and cardiac death) was assessed during a structured follow-up with subsequent validation and adjudication of endpoints. AHA stages were defined according to current guidelines.

Results

Complete information on GLS was available in 2,400 participants of whom 2,186 categorized to AHA stage A to D were available for analysis. Overall, 434 individuals were classified as AHA stage A, 629 as stage B and 1,123 as stage C/D. Mean GLS increased across AHA stages of HF: it was lowest in stage A (−19.44±3.15%), −18.01±3.46% in stage B and highest in AHA stage C/D (−15.52±4.64%, P for trend &lt;0.0001). During a follow-up period of 3.0 [1.3/4.0] years, GLS denoted an increased risk for worsening of HF after adjustment for age and sex (hazard ratio, HRGLS [per standard deviation (SD)] 1.97 [95% confidence interval 1.73/2.23], P&lt;0.0001) in multivariable Cox regression analysis. After additional adjustment for cardiovascular risk factors, clinical profile, LVEF and E/E' ratio, GLS was the strongest echocardiographic predictor of worsening of HF (HRGLS [per SD] 1.47 [1.20/1.80], P=0.0002) in comparison to LVEF (HRLVEF [per SD] 1.23 [1.02/1.48], P=0.031) and E/E' ratio (HRE/E' [per SD] 1.12 [0.99/1.26], P=0.083). Interestingly, when stratifying for AHA stages, GLS denoted a similar increased risk for worsening of HF in individuals classified as AHA stage A/B (HRGLS [per SD] 1.63 [1.02/2.61], P=0.039) and in those classified as AHA stage C/D (HRGLS [per SD] 1.95 [1.65/2.29], P&lt;0.0001) after adjustment for age and sex. For further evaluation, Cox regression models with interaction analysis indicated no significant interaction for (i) AHA stage A/B vs C/D (P=0.83) and (ii) NYHA functional class &lt;II vs ≥II in individuals classified as AHA stage C/D (P=0.12).

Conclusions

GLS demonstrated a higher predictive value for worsening of HF than conventional echocardiographic measures of systolic and diastolic function. Interestingly, GLS indicated an increased risk for worsening of HF across AHA stages highlighting its potential value to advance risk prediction in chronic HF.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research (DZHK), Center for Translational Vascular Biology (CTVB) of the University Medical Center of the Johannes Gutenberg-University Mainz

Disturbed glucose metabolism and left ventricular geometry in the general population – results from the Gutenberg health study

Background

Prediabetes and type 2 diabetes mellitus (T2DM) have been demonstrated to alter left ventricular geometry and promote left ventricular (LV) hypertrophy (LVH). However, the impact of impaired glucose metabolism on cardiac structure is still not completely understood and controversially discussed.

Purpose

To investigate the impact of prediabetes and T2DM on left ventricular geometry and their potential interaction with LVH in the prediction of survival.

Methods

Data from the Gutenberg Health Study (N=15,010) – a population-based study with highly standardized phenotyping – were analysed. Information was obtained from computer-assisted personal interviews, medical-technical examinations, laboratory measurements in fasting state and echocardiography according to standard operating procedures with detailed quality control. Individuals with other types of diabetes or hyperinsulinemia were excluded from analysis. Study participants aged 35 to 74 years were categorized according to long-term glucose state (HbA1c) into euglycemia, prediabetes and T2DM. LV geometry was assessed according to current guideline recommendations. Multivariable regression analyses were performed to evaluate the association between glucose state and measures of left ventricular geometry. Survival analyses were carried out to assess the prognostic impact dependent on the presence of LVH.

Results

The analysis sample comprised 14,852 individuals aged 55.0±11.1 years (49.5% females). The prevalence of LVH was 10.2% (n=1,227) in euglycaemia, 17.2% in prediabetes and 23.8% in T2DM. Similarly, concentric and eccentric hypertrophy had the highest prevalence in T2DM (13.1% and 10.8%, respectively), followed by prediabetes (9.6% and 8.2%) and euglycaemia (5.7% and 4.5%). In multivariable regression analysis with adjustment for age, sex, traditional cardiovascular risk factors (CVRF), C-reactive protein and LV function, T2DM had a higher impact on relative wall thickness (β: 0.0135 [0.0087; 0.0182]; P&lt;0.0001) and LV mass (β: 5.46 [4.89; 6.03]; P&lt;0.0001) than prediabetes (β-estimaterelative wall thickness 0.00145 [−0.0031; 0.006]; P=0.53; β-estimateLV mass 2.73 [2.19; 3.28]; P&lt;0.0001) compared to euglycemia. During a median follow-up of 9.0 [interquartile range 7.7; 10.4] years, prediabetes did not predict all-cause mortality independent of age, sex and CVRF in Cox regression analysis in individuals without LVH (hazard ratio (HR) 1.15 [0.90; 1.46]; P=0.27) or those with LVH (HR 1.46 [0.97; 2.18]; P=0.069). In comparison, T2DM was a strong and independent predictor of mortality both in absence (HR 1.59 [1.29; 1.96]; P&lt;0.0001) and presence of LVH (HR 2.67 [1.94; 3.66]; P&lt;0.0001).

Conclusions

Although cardiac geometry is altered both in presence of prediabetes and T2DM, only T2DM is a strong predictor of premature mortality in the general population. This merits consideration for future preventive strategies to decrease the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The study was supported by the Federal Ministry of Education and Research (BMBF), the government of Rheinland-Pfalz and the Center for Translational Vascular Biology (CTVB) of the Johannes Gutenberg-University of Mainz, Germany.

Head-to-head comparison of the incremental value of the three established risk markers hs-troponin I, hs-C-reactive protein and NT-proBNP in secondary prevention of coronary artery disease

Background

Risk stratification among patients with coronary artery disease (CAD) and acute coronary syndrome (ACS) is of considerable interest due to the potential to guide secondary preventive therapies. Cardiac troponins as well as the inflammatory biomarker C-reactive protein (CRP) and natriuretic peptides have now emerged as useful blood-based biomarkers for risk stratification concerning incident cardiac events. Nevertheless, it has not been tested, whether one of these biomarkers yields predictive value beyond the others. Thus, we evaluated the head-to-head potential of high-sensitivity troponin I (hsTnI), high-sensitivity (hs) CRP and NT-proBNP as prognostic biomarkers for adverse outcome in patients with manifest CAD.

Methods

Plasma levels of hsTnI, hsCRP and NT-proBNP were measured in a cohort of 2,193 patients with documented CAD –including 837 patients with ACS and 1,356 patients with stable angina pectoris (SAP). Cardiovascular death and/or non-fatal acute myocardial infarction (MI) were defined as the main outcome measures. The association of circulating biomarker levels, used after log-transformation, with cardiovascular mortality and non-fatal MI during follow-up was assessed by Cox proportional hazards analyses adjusted according to three different models including cardiovascular risk factors and either the biomarkers hsCRP, NT-proBNP or hsTnI. Additionally, the net reclassification index (NRI) was calculated using the category five-year event probabilities for two models.

Results

During a median follow-up of 3.8 years, a total of 231 events were registered (10.5%). All three biomarkers reliably predicted cardiovascular death and/or MI, as evidenced by survival curves stratified for tertiles of circulating levels.

In Cox regression analyses with adjustments for sex, age, and conventional cardiovascular risk factors, the hazard ratio (HR) per standard deviation (SD) for the prediction of cardiovascular (CV) death and/or non-fatal MI during follow-up was 1.39 [95% CI: 1.24–1.57, p&lt;0.001] for hsTnI, 1.41 [95% CI: 1.24–1.60, p&lt;0.001] for hsCRP, and 1.64 [95% CI: 1.39–1.92, p&lt;0.001] for NT-proBNP. Nevertheless, upon further adjustment for the other two biomarkers, the significance of the association for hsTnI got lost, association for hsCRP attenuated, and only NT-proBNP kept its predictive value and was still strongly associated with the combined endpoint (1.47 [95% CI: 1.19–1.82, p&lt;0.001]), but also with CV death alone (2.42 [95% CI: 1.86–3.15, p&lt;0.001]). Moreover, only NT-proBNP significantly improved C-statistics and net reclassification index (NRI) for the prediction of cardiovascular death.

Conclusions

NT-proBNP reliably predicted cardiovascular death and myocardial infarction in patients with manifest CAD and provides incremental value beyond hsCRP and hsTnI.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “Stiftung Rheinland-Pfalz für Innovation”, Ministry for Science and Education

Large-scale identification of functional microRNA targeting reveals cooperative regulation of the hemostatic system

Essentials MicroRNAs (miRNAs) regulate the molecular networks controlling biological functions such as hemostasis. We utilized novel methods to analyze miRNA-mediated regulation of the hemostatic system. 52 specific miRNA interactions with 11 key hemostatic associated genes were identified. Functionality and drugability of miRNA-19b-3p against antithrombin were demonstrated in vivo. SUMMARY: Background microRNAs (miRNAs) confer robustness to complex molecular networks regulating biological functions. However, despite the involvement of miRNAs in almost all biological processes, and the importance of the hemostatic system for a multitude of actions in and beyond blood coagulation, the role of miRNAs in hemostasis is poorly defined. Objectives Here we comprehensively illuminate miRNA-mediated regulation of the hemostatic system in an unbiased manner. Methods In contrast to widely applied association studies, we used an integrative screening approach that combines functional aspects of miRNA silencing with biophysical miRNA interaction based on RNA pull-downs (miTRAP) coupled to next-generation sequencing. Results Examination of a panel of 27 hemostasis-associated gene 3'UTRs revealed the majority to possess substantial Dicer-dependent silencing capability, suggesting functional miRNA targeting. miTRAP revealed 150 specific miRNA interactions with 14 3'UTRs, of which 52, involving 40 miRNAs, were functionally confirmed. This includes cooperative miRNA regulation of key hemostatic genes comprising procoagulant (F7, F8, F11, FGA, FGG and KLKB1) and anticoagulant (SERPINA10, PROZ, SERPIND1 and SERPINC1) as well as fibrinolytic (PLG) components. Bioinformatic analysis of miRNA functionality reveals established and potential novel links between the hemostatic system and other pathologies, such as cancer, bone metabolism and renal function. Conclusions Our findings provide, along with an in-vivo proof of concept, deep insights into the network of miRNAs regulating the hemostatic system and present a foundation for biomarker discovery and novel targeted therapeutics for correction of de-regulated hemostasis and associated processes in the future. A repository of the miRNA targetome covering 14 hemostatic components is provided.

Prevalence of depression and anxiety among participants with glaucoma in a population-based cohort study: The Gutenberg Health Study

Background

To investigate the prevalence of depression and anxiety among subjects with self-reported glaucoma and the association between self-reported glaucoma and depression respectively anxiety in a European cohort.

Methods

A study sample of 14,657 participants aged 35 to 74 years was investigated in a population-based cohort study. All participants reported presence or absence of glaucoma. Ophthalmological examinations were carried out in all participants and demographic and disease related information were obtained by interview. Depression was assessed with the Patient Health Questionnaire (PHQ-9), and generalized anxiety with the two screening items (GAD-2) of the short form of the GAD-7 (Generalized Anxiety Disorder-7 Scale). Prevalence of depression and generalized anxiety were investigated for subjects with and without self-reported glaucoma. Logistic regression analyses with depression, respectively anxiety as dependent variable and self-reported glaucoma as independent variable were conducted and adjusted for socio-demographic factors, systemic comorbidities (arterial hypertension, myocardial infarction, stroke, diabetes mellitus, chronic obstructive pulmonary disease, cancer), ocular diseases (cataract, macular degeneration, corneal diseases, diabetic retinopathy), visual acuity, intraocular pressure, antiglaucoma eye drops (sympathomimetics, parasympathomimetics, carbonic anhydrase inhibitors, beta-blockers, prostaglandins) and general health status.

Results

293 participants (49.5% female) reported having glaucoma. Prevalence of depression among participants with and without self-reported glaucoma was 6.6% (95%-CI 4.1–10.3) respectively 7.7% (95%-CI 7.3–8.2), and for anxiety 5.3% (95%-CI 3.1–8.7) respectively 6.6% (95%-CI 6.2–7.1). Glaucoma was not associated with depression (Odds ratio 1.10, 95%-CI 0.50–2.38, p = 0.80) or anxiety (1.48, 95%-CI 0.63–3.30, p = 0.35) after adjustment for socio-demographic factors, ocular/systemic diseases, ocular parameters, antiglaucoma drugs and general health status. A restriction to self-reported glaucoma cases either taking topical antiglaucoma medications or having a history of glaucoma surgery did not alter the result.

Conclusions

This is the first study analyzing both depression and anxiety among glaucoma patients in a European cohort. Subjects with and without self-reported glaucoma had a similar prevalence of depression and anxiety in our population-based sample. Self-reported glaucoma was not associated with depression or anxiety. A lack of a burden of depressive symptoms may result from recruitment from a population-based sample as compared to previous study groups predominantly recruited from tertiary care hospitals.

Intra- und extrahepatische Shunts der zirrhotischen Leber -Bestimmung mittels kombinierter invasiv-nuklearmedizinischer Methoden

Mittels kombinierter invasiv-nuklearmedizinischer Methoden lassen sich intra-und extrahepatischer Shuntfluß bei Patienten mit Leberzirrhose quantitativ bestimmen. Im Rahmen transhepatischer Portographien erfolgte die Injektion von 99mTc-MAA in die periphere Pfortader (Milzhilus) sowie auch in den zentralen Pfortaderstamm (Leberhilus). Durch Subtraktionstechnik ließ sich anschließend der Shuntfluß errechnen. Bei insgesamt 32 auswertbaren Untersuchungen (von 36) konnte ein extrahepatischer Shuntfluß von im Mittel 29,2% (0%-84%) und ein intrahepatischer Shuntfluß von 23,6% (0%—81 %) ermittelt werden. Das Verfahren kann möglicherweise die Indikation zur Shuntchirurgie beeinflussen.

Assessment of Regional Myocardial Uptake and Metabolism of ω-(p-123I-Phenyl) Pentadecanoic Acid with Serial Single-Photon Emission Tomography

The utility of myocardial imaging and assessment of regional myocardial metabolism of ω-(123I-paraphenyl-)pen-tadecanoic acid (I-PPA) by means of serial single-photon tomography is demonstrated in animal experiments. High quality cross sectional images of dog hearts with clear delineation of left ventricular walls are obtained. Myocardial infarcts are visualized as areas of deficient radioactivity uptake. I-PPA elimination from non-infarcted myocardial regions is significantly (p < 0.001) prolonged when compared with unaffected controls. Hence, not only localized absence of uptake of free fatty acid by infarcted myocardium can be demonstrated with serial single-photon tomography but also general impairment of cardiac FFA-metabolism.

Homocysteine concentration in coronary artery disease: Influence of three common single nucleotide polymorphisms

BACKGROUND AND AIMS

Whether single nucleotide polymorphisms (SNPs) of homocysteine metabolism enzymes influence the rate of cardiovascular (CV) events in coronary artery disease (CAD) patients remains controversial.

METHODS AND RESULTS

In this analysis, 1126 subjects from the AtheroGene study with CAD and 332 control subjects without known CAD were included. The following SNPs were investigated: methylentetrahydrofolate reductase (MTHFR-C667T), methionin synthetase (MS-D919G), and cystathionin beta synthetase (CBS-I278T). The endpoint was the combination of cardiovascular death, stroke, and non-fatal myocardial infarction (N = 286). The median follow-up time was 6.4 years. Kaplan-Meier curve analysis showed an increasing event rate with rising homocysteine levels (p < 0.001) in CAD patients. Further, in Cox-Regression analysis homocysteine was a predictor of the endpoint with a hazard ratio (HR) of 6.5 (95% CI: 2.9-14.6, p < 0.001) in the adjusted model including cardiovascular risk factors. Of the three SNPs, homozygous MTHFR SNP increased homocysteine levels significantly in patients with CAD and individuals without CAD (both p < 0.001). The SNPs in MS and CBS were not related to relevant changes in homocysteine levels in CAD patients or controls. The different SNPs of MTHFR, MS, and CBS were not related to an increased event rate.

CONCLUSION

Homocysteine level is a strong predictor of CV events. Subjects with and without CAD and SNPs in the enzyme MTHFR had increased homocysteine levels. This was not observed for MS and CBS SNPs. Although MTHFR SNPs alter homocysteine levels in patients and controls, these polymorphisms had no impact on prognosis in CAD patients.

Inadequacies of repeated radiological examinations in a university hospital

Purpose: To establish why 16% of 1,045 patients undergoing abdominal and/or vascular surgery referred to the University Department of Radiology for a B-image sonogram reported that a US of the same regions of the body had been conducted during the previous 6 weeks without any changes in the clinical status.Statement of the problem: Evaluation of the reasons for these superfluous examinations and analysis of the consequences that the US follow-up examinations implied for the patient.

Material and Methods: One senior resident radiologist and one senior resident surgeon reviewed the medical records of the patients reporting previous examinations and examinations scheduled at the time of the questioning of the patients.

Results: One hundred and eight (63%) of the 171 medical records were available. Data on previous examinations mentioned in the report forms were incorrect in 14 cases (13%). Therefore, further evaluations were based on 94 patients. Ten (8%) out of 121 sonograms, 4 (10%) out of 40 CT and 2 (20%) out of 10 MR investigations documented in the medical records had not been mentioned by the patients. As many as 41 (75%) of the 55 preliminary sonograms performed by general practitioners and specialists in private practice were not documented in the medical records. Even though records existed of clinically plausible findings, 36 (84%) of the 43 preliminary US investigations performed by doctors in the University Hospital were repeated to verify the diagnosis without any further diagnostic benefit.

Conclusion: A cross-speciality consensus over the diagnostic value of B-image sonography and management of the findings obtained is of paramount importance.

MRA in patients with cerebrovascular disease: Considerations of clinical effectiveness

Objective: To establish in which clinical contexts cerebral MR angiography (MRA) is routinely carried out in a neurological university department and to describe its clinical impact.

Material and Methods: Medical records, reports of findings and documentation of imaging examinations carried out in all 69 patients referred to the Department of Radiology from the Department of Neurology between 1995 and 1998 for cerebral MRA were evaluated. The clinical impact of all imaging findings was assessed on the basis of the medical records.

Results: Circulatory disturbances in the vertebrobasilor arteries (n=4) were the most frequent indication for investigation. MRA followed CT or duplex sonography in 66 of the 69 patients with a mean delay of 8 days. MRA was considered diagnostically inferior to conventional MR in 11 cases, comparable in 30 and superior in 25. Comparing MRA and duplex sonography, the corresponding figures were 12, 29 and 23. In retrospect, 56 MRAs were judged unnecessary.

Conclusion: Controlled clinical studies on optimal use of MRA are needed to avoid wasting resources and to exploit the method's full diagnostic potential in appropriate cases.

Prevalence and risk factors of retinal vein occlusion: the Gutenberg Health Study

OBJECTIVE

To determine the age- and sex-specific prevalence and determinants of retinal vein occlusions (RVOs) in a large population-based German cohort.

METHODS

The investigation included 15,010 participants (aged 35-74 years) from the Gutenberg Health Study. We determined the prevalence of RVO (central retinal vein occlusion [CRVO] and branch retinal vein occlusion [BRVO]) for the local population by assessing fundus photographs of 12 954 (86.3%; 49.8% women and 50.2% men) participants. Further, we analyzed the associations of RVO with cardiovascular, anthropometric, and ophthalmic parameters.

RESULTS

The weighted prevalences of RVO, CRVO, and BRVO were 0.40%, 0.08%, and 0.32%, respectively. Men were 1.7 times more frequently affected by RVO than were women. Prevalence of RVO was 0.2% in participants aged 35-44 and 45-54 years, respectively, 0.48% in those aged 55-64 years, and 0.92% in those aged 65-74 years. Of persons with RVO, 91.5% had one or more cardiovascular risk factor or disease vs. 75.9% of persons without RVO. BRVO was associated with arterial hypertension (odds ratio 2.69, 95% confidence interval 1.27-5.70) and atrial fibrillation (3.37, 1.24-9.12) and CRVO with higher age (7.02, 1.63-30.19) and a family history of stroke (4.64, 1.18-18.25). Median visual acuity (base 10 logarithm of minimum angle of resolution) was 0.2 in persons with RVO vs. 0.05 in those without.

CONCLUSION

The prevalence of RVO in this German population was 0.4%, and men were 1.7 times more frequently affected than women. CRVO was associated with higher age and a family history of stroke, and BRVO was associated with arterial hypertension and atrial fibrillation.

Combining cross-sectional data on prevalence with risk estimates from a prediction model. A novel method for estimating the attributable risk

OBJECTIVES

Estimation of the attributable risk for fatal diseases by combining two different data sources.

METHODS

We derive a method to estimate the attributable risks of different risk factors by combining general mortality risks with up-to-date prevalences of the risk factors using estimates from a risk prediction model and cross-sectional data of a cohort study. Partial attributable risks have been used to illustrate the proportions of the different risk factors for the attributable risk. In addition we derive standard errors for the attributable risk based on the Taylor series expansion. Since the data of our cohort study was sampled with the same size in each 10 years age stratum which does not reflect the age-structure of the general population, the attributable risk and its standard errors are calculated using an approach that allows the weighting of the data according to population proportions of age. The formula for the standard errors has been evaluated using bootstrap-techniques.

RESULTS

We successfully implemented the method for the estimation of the attributable risk and its standard errors by integrating risk information using data of the HeartScore Germany and cross-sectional data emerging from the Gutenberg Health Study. The attributable risk can now be calculated without using the information of the overall disease rate. The bootstrap method shows, that the formula for the standard errors is useful.

CONCLUSION

Our method allows for the combination of different data sources in order to estimate attributable risks and our formula for the standard errors seems to yield a good approximation. But the validity of our method highly depends on the validity of the underlying data sources.

Late onset and pregnancy-induced congenital thrombotic thrombocytopenic purpura

We report on our patient (case 2) who experienced a first acute episode of thrombotic thrombocytopenic purpura (TTP) at the age of 19 years during her first pregnancy in 1976 which ended in a spontaneous abortion in the 30th gestational week. Treatment with red blood cell concentrates was implemented and splenectomy was performed. After having suffered from several TTP episodes in 1977, possibly mitigated by acetylsalicylic acid therapy, an interruption and sterilization were performed in 1980 in her second pregnancy thereby avoiding another disease flare-up. Her elder sister (case 1) had been diagnosed with TTP in 1974, also during her first pregnancy. She died in 1977 during her second pregnancy from a second acute TTP episode.

DIAGNOSIS

In 2013 a severe ADAMTS13 deficiency of <10% without detectable ADAMTS13 inhibitor was repeatedly found. Investigation of the ADAMTS13 gene showed that the severe ADAMTS13 deficiency was caused by compound heterozygous ADAMTS13 mutations: a premature stop codon in exon 2 (p.Q44X), and a missense mutation in exon 24 (p.R1060W) associated with low but measurable ADAMTS13 activity.

CONCLUSION

Genetic analysis of the ADAMTS13 gene is important in TTP patients of all ages if an ADAMTS13 inhibitor has been excluded.

History of depression but not current depression is associated with signs of atherosclerosis: data from the Gutenberg Health Study

OBJECTIVES

To test the vascular depression hypothesis in the general population, we analyzed the association between current depression, medical history of depression, cognitive and somatic depressive symptom dimensions and measures of atherosclerosis [intima-media thickness (IMT) and carotid plaques].

METHOD

We included a representative sample of 5000 participants from the Gutenberg Health Study (GHS). Depression was assessed by the nine-item Patient Health Questionnaire (PHQ-9), and IMT and carotid plaques were measured at both common carotid arteries using an edge detection system. Regression analyses were performed separately for participants with and without cardiovascular disease, adjusting for medical history, cardiovascular risk factors and psychotropic medication.

RESULTS

Contrary to hypotheses, we found no increased IMT for somatic symptoms of depression; the same was true for depression and cognitive symptoms in the fully adjusted model. Only a moderate relationship between medical history of depression and the presence of atherosclerotic plaques was maintained after correction.

CONCLUSIONS

The relationship between depression and atherosclerosis may be more complex than previously assumed. Although the vascular depression hypothesis was not supported, our results support the hypothesis that lasting depression leads to arteriosclerosis.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Type D personality as a cardiovascular risk marker in the general population: results from the Gutenberg health study

BACKGROUND

Type D personality is considered as an independent risk factor for morbidity and mortality in cardiovascular patients and a vulnerability factor for distress in the general population. Because representative community studies are rare, we sought to determine the prevalence of type D personality and its relationship with demographic characteristics, different features of mental disorders, cardiovascular risk factors, health behavior, endothelial function and cardiovascular biomarkers in the general population.

METHODS

The prevalence of type D personality and its correlates were analyzed cross-sectionally in a population-based sample of 5,000 Mid-Europeans aged 35-74 years from the Gutenberg Health Study.

RESULTS

The prevalence of type D personality was 22.2% without remarkable differences in sex distribution. Type D subjects were characterized by lower socioeconomic status, lack of a partnership, increased depression, anxiety, depersonalization and health care utilization. Despite its strong association with mental disorders, type D personality emerged as psychometrically distinct. Although type D personality was independently associated with coronary heart disease (OR = 1.54, p = 0.044), no associations with traditional cardiovascular risk factors were found independently from depression or anxiety.

CONCLUSIONS

Although type D personality is strongly associated with depression, anxiety, impaired mental and somatic health status, and increased health care utilization, the type D construct seems to comprise dysfunctional personality patterns not covered by depression and anxiety scales. Beyond these associations, the pathways of the cardiotoxic impact of type D personality remain to be elucidated. There is a need for prospective population studies on potential links between type D personality and cardiac disease.

[Successful retrieval of a portcatheter from the pulmonary artery]

We report on a 66-years-old oncological patient with a spontaneous dislocation of a portcatheter into the pulmonary artery. The catheter fragment had a loop formation, both ends were located in the proximal right segment arteries. The first attempt of a removal of the catheter via the right heart into the inferior caval vein by means of a hooked pulmonalis-catheter failed. In a second manoeuvre, the catheter fragment was successfully fixed by means of a catheter with an extendable loop configuration (goose-neck) and retrieved from the pulmonal artery into the inferior caval vein. Then, the entire system could be removed together with the introducer sheet under mild traction from the femoral vein without any complications. In conclusion, the percutaneous interventional method appears to be a minimally-invasive approach to deal with catheter fragments dislocated in the central veins and the pulmonary arteries.