Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Myocardial injury defined as elevated high-sensitivity cardiac troponin T is associated with higher mortality in patients seeking care at emergency departments with acute dyspnea

BACKGROUND

Elevated levels of cardiac troponin T has been observed in patients seeking care at the emergency department (ED) presenting with chest pain but without myocardial infarction (MI). The clinical importance of this observation remains, however, still unclear. Our main aim was to study the role of cardiac troponin T in patients admitted to the emergency department with acute dyspnea, a group of patients with a high cardiovascular comorbidity, but no primary acute MI.

POPULATION AND METHODS

Patients from the age of 18 seeking care at the ED for dyspnea, without an acute cardiac syndrome, and with a recorded assessment of high-sensitivity cardiac troponin T (hs-cTnT), were included (n = 1001). Patients were categorized into 3 groups by hs-cTnT level, i.e. <15, 15-100 and > 100 µg/l. Cox regression with Hazard Ratios (HRs) and 95% Confidence Intervals (CI) for 3-months mortality was performed, with adjustment for sex, age, respiratory frequency, saturation, CHF, renal disease, and BMI.

RESULTS

Fully adjusted HRs (95% CI) for 3-month mortality, with hs-cTnT < 15 µg/l as reference level, showed for hs-cTnT 15-100 a HR of 3.682 (1.729-7.844), and for hs-cTnT > 100 a HR of 10.523 (4.465-24.803).

CONCLUSION

Elevated hs-cTnT seems to be a relevant marker of poor prognosis in patients with acute dyspnea without MI and warrants further validation and clinical testing.

Milk intake and incident stroke and CHD in populations of European descent: a Mendelian randomisation study

Higher milk intake has been associated with a lower stroke risk, but not with risk of CHD. Residual confounding or reverse causation cannot be excluded. Therefore, we estimated the causal association of milk consumption with stroke and CHD risk through instrumental variable (IV) and gene-outcome analyses. IV analysis included 29 328 participants (4611 stroke; 9828 CHD) of the European Prospective Investigation into Cancer and Nutrition (EPIC)-CVD (eight European countries) and European Prospective Investigation into Cancer and Nutrition-Netherlands (EPIC-NL) case-cohort studies. rs4988235, a lactase persistence (LP) SNP which enables digestion of lactose in adulthood was used as genetic instrument. Intake of milk was first regressed on rs4988235 in a linear regression model. Next, associations of genetically predicted milk consumption with stroke and CHD were estimated using Prentice-weighted Cox regression. Gene-outcome analysis included 777 024 participants (50 804 cases) from MEGASTROKE (including EPIC-CVD), UK Biobank and EPIC-NL for stroke, and 483 966 participants (61 612 cases) from CARDIoGRAM, UK Biobank, EPIC-CVD and EPIC-NL for CHD. In IV analyses, each additional LP allele was associated with a higher intake of milk in EPIC-CVD (β = 13·7 g/d; 95 % CI 8·4, 19·1) and EPIC-NL (36·8 g/d; 95 % CI 20·0, 53·5). Genetically predicted milk intake was not associated with stroke (HR per 25 g/d 1·05; 95 % CI 0·94, 1·16) or CHD (1·02; 95 % CI 0·96, 1·08). In gene-outcome analyses, there was no association of rs4988235 with risk of stroke (OR 1·02; 95 % CI 0·99, 1·05) or CHD (OR 0·99; 95 % CI 0·95, 1·03). Current Mendelian randomisation analysis does not provide evidence for a causal inverse relationship between milk consumption and stroke or CHD risk.

Selenoprotein-P deficiency is associated with higher risk of incident heart failure

Background

Selenium deficiency has been associated with all-cause and cardiovascular mortality, incident cardiovascular disease (coronary artery disease, myocardial infarction and stroke), and with poor prognosis in patients with acute heart failure (HF). Furthermore, high selenium levels were recently shown to be associated with reduced mortality and reduced incidence of HF in non-smokers.

Purpose

To examine if selenoprotein-P (SELENOP), a main carrier protein of selenium, is associated with incident HF.

Methods

SELENOP concentrations were measured in 5060 randomly selected subjects from the population-based prospective cohort study “the Malmö Preventive Project” (n=18240) using a validated ELISA approach. After exclusion of subjects with prevalent HF (n=230), complete data on all co-variates was available in 4803 subjects (1400 women (29.1%), mean age 69.6±6.2 years, 885 (19.7%) current smokers). SELENOP was continously related to risk of incident HF using Cox regression models adjusted for age, sex, body mass index, systolic blood pressure, anti-hypertensive treatment, smoking status, diabetes status, low-density lipoprotein cholesterol levels, and prevalent coronary events. Further, subjects within the lowest SELENOP quintile were compared to subjects in the remaining four quintiles in an adjusted model.

Results

Each 1 SD increment in SELENOP levels was associated with lower risk of incident HF (n=436) during a median follow-up period of 14.7 years (interquartile range 10.9–15.7 years, hazard ratio (HR) 0.92, 95% confidence interval (95% CI) 0.84–0.99; p=0.049 in a model adjusted for cardiovascular risk factors. Multivariate quintile analyses revealed that the subjects in the lowest SELENOP quintile were at the highest risk of incident HF in an adjusted model (HR 1.46; 95% CI: 1.17–1.83 for incident HF; p for trend 0.039) illustrated in a Kaplan-Meier survival analysis (Figure 1). No interaction effect was seen for sex or smoking.

Conclusion

Low SELENOP levels are associated with a higher risk of incident HF supporting recent studies, which further emphasizes the need for randomly controlled trials to examine if supplementation with selenium improves prognosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Medical Research CouncilSwedish Society of Medicine

Biomarkers associated with prevalent hypertension and higher blood pressure in a population-based cohort: a proteomic approach

Background

Globally, hypertension represents an enormous health issue as it is a major, yet modifiable risk factor for developing cardiovascular disease. Recently, chitinase-3-like protein 1 (CHI3L1) was shown to be positively associated with the incidence of hypertension among prehypertensive subjects, and variants of CHI3L1 gene were associated with both CHI3L1-levels and hypertension.

Purpose

To explore associations between prevalent hypertension and blood pressure, and 92 proteins with involvement in inflammation and cardiovascular disease.

Methods

Plasma samples from 1713 individuals from a Swedish population-based cohort (mean age 67.3±6.0 years; 28.9% women) were analysed with a proximity extension assay panel, consisting of 92 proteins. Prior to all analyses, subjects with prevalent cardiovascular disease, defined as having a history of prevalent coronary or stroke event, were excluded (n=189). Univariate logistic regression models were carried out exploring associations between each of the 92 proteins and prevalent hypertension, defined as systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg, or use of antihypertensive treatment (n=1168, 76.4%). Bonferroni-corrected significant associations between proteins and hypertension were further analysed using stepwise selection of covariates, namely age, body mass index, diabetes status, and cystatin C, in logistic regression models. Proteins with significant adjusted associations with prevalent hypertension were further analysed for associations with systolic and diastolic blood pressure individually in stepwise linear regression models. Complete data on all variables were available in 1527 subjects.

Results

Sixteen proteins were significantly associated with prevalent hypertension in univariate analyses. After adjustment, three proteins remained significantly associated with prevalent hypertension (i.e., CHI3L1, low-density lipoprotein receptor (LDL receptor) and tissue plasminogen activator (tPA); Table 1). In analyses of associations with systolic blood pressure, CHI3L1 and LDL receptor showed significant associations. In analyses of associations with diastolic blood pressure, CHI3L1, LDL receptor and tPA showed significant associations (Table 1).

Conclusions

Higher CHI3L1, tPA and LDL receptor levels were positively associated with prevalent hypertension after multivariable adjustment, among 1527 elderly subjects without established cardiovascular disease. Furthermore, higher CHI3L and LDL receptor levels were positively associated with mean systolic, as well as mean diastolic blood pressure in multivariable analyses.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Medical Research Council and The Swedish Heart and Lung Foundation

Plasma concentration of proneurotensin and prediction of cause-specific mortality in a middle aged cohort during long-term follow-up

Purpose

To examine the prediction of proneurotensin (Pro-NT) on total and cause-specific mortality in a middle-aged cohort.

Methods

In the population-based middle-aged cohort (n=4632 participants, mean age 57 years) of the Malmo Diet and Cancer (MDC) study, Pro-NT was assessed and total- as well as cause-specific mortality were studied. Main cause of death were based on the International Classification of Diseases (ICD). Assessments were done using Cox proportional hazards models adjusted for age and sex.

Results

During a mean follow-up of 20±3 years, 950 men and 956 women died. There was a significantly increased risk of total mortality in subjects belonging to quartile 4 of Pro-NT (Pro-NT ≥149 pmol/L) compared with quartiles 1–3 (Pro-NT &lt;149 pmol/L), hazard ratio (HR) of 1.29 (95% confidence interval [CI] 1.17–1.42; P&lt;0.001) after adjustment for age and sex. No significant interaction was observed between Pro-NT and gender on total mortality. Individuals within quartile 4 vs. quartiles 1–3 had a HR of 1.41 (95% CI 1.18–1.68; P&lt;0.001) for death due to cardiovascular diseases (n=595/4632), 2.53 (95% CI 1.37–4.67; P=0.003) due to digestive tract diseases (n=42/4632), 1.62 (95% CI 1.04–2.52; P=0.032) due to mental and behavioural diseases (n=90/4632), and 1.91 (95% CI 1.15–3.19; P=0.013) due to unspecific causes of death (n=64/4632). No significant relationships between Pro-NT and deaths due to cancer, infections, neurological or other causes were observed. Adjustments for cardiovascular risk factors only marginally changed these results.

Conclusions

Pro-NT is a predictor of total mortality and the increased risk is driven by deaths due to cardiovascular- digestive tract- mental and behavioural diseases, as well as deaths attributed to unspecific causes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Knut and Alice Wallenberg Foundationthe Swedish Heart and Lung Foundation.

Proteomic and Metabolomic Characterization of Metabolically Healthy Obesity: A Descriptive Study from a Swedish Cohort

METHOD

Associations between different biomarkers (proteomics, lipidomics, and metabolomics) coupled to either MHO or metabolically unhealthy obese (MUO) individuals were analyzed through principal component analysis (PCA). Subjects were identified from a subsample of 416 obese individuals, selected from the Malmö Diet and Cancer study-Cardiovascular arm (MDCS-CV, n = 3,443). They were further divided into MHO (n = 143) and MUO (n = 273) defined by a history of hospitalization, or not, at baseline inclusion, and nonobese subjects (NOC, n = 3,027). Two distinctive principle components (PL2, PP5) were discovered with a significant difference and thus further investigated through their main loadings.

RESULTS

MHO individuals had a more metabolically favorable lipid and glucose profile than MUO subjects, that is, lower levels of traditional blood glucose and triglycerides, as well as a trend of lower metabolically unfavorable lipid biomarkers. PL2 (lipidomics, p=0.02) showed stronger associations of triacylglycerides with MUO, whereas phospholipids correlated with MHO. PP5 (proteomics, p=0.01) included interleukin-1 receptor antagonist (IL-1ra) and leptin with positive relations to MUO and galanin that correlated positively to MHO. The group differences in metabolite profiles were to a large extent explained by factors included in the metabolic syndrome.

CONCLUSION

Compared to MUO individuals, corresponding MHO individuals present with a more favorable lipid metabolic profile, accompanied by a downregulation of potentially harmful proteomic biomarkers. This unique and extensive biomarker profiling presents novel data on potentially differentiating traits between these two obese phenotypes.

The Gly82Ser polymorphism in the receptor for advanced glycation end products is associated with increased risk for coronary events in the general population

Background/Introduction

Activation of the receptor for advanced glycation end products (RAGE) by AGEs and various immune mediators has pro-inflammatory and pro-atherogenic effects. RAGE also exists in a soluble form, sRAGE, that acts as a decoy receptor for RAGE ligands. Low plasma sRAGE has previously been found to be associated with a higher risk for major adverse coronary events (MACE) in the population.

Purpose

The purpose of our study was to examine the causality of the association, by exploring whether genetic variants that influence sRAGE are associated with atherosclerosis progression and incident MACE and mortality in the population.

Methods

We performed a genome-wide association study (GWAS) in 4192 individuals from a randomly selected subgroup of a population-based cohort. Subsequently, we explored the associations between the identified single nucleotide polymorphims (SNPs) associated with plasma sRAGE levels, baseline intima media thickness (IMT) and IMT progression in the common carotid artery during a median follow-up of 16.5 years. Further, we analyzed the prospective relationships between the sRAGE-associated SNPs, incident MACE and mortality in the entire population-based cohort of 29245 individuals. The median follow-up time from baseline was 21.2 years for MACE and 21.6 years for total mortality (time to event or end of follow-up).

Results

We found the minor alleles of two single nucleotide polymorphisms (SNPs), rs2070600 and rs204993, to be independently associated with lower plasma sRAGE. While rs204993 is a silent intronic mutation, rs2070600 is known to cause a Gly82Ser polymorphism in the ligand binding domain, enhancing RAGE propensity for activation. In Cox regression analyses, we found an association between the minor T (vs. C) allele of rs2070600 and increased risk for first-time MACE [HR 1.12 (1.02–1.23); P=0.023]. The association was independent of traditional cardiovascular risk factors, blood pressure-lowering medication and lipid-lowering medication at baseline. rs204993 was not associated with MACE. Neither SNP was associated with carotid IMT at baseline or with IMT progression. We did not identify any relationships with total mortality.

Conclusions

We demonstrate for the first time an independent link between a genetic RAGE determinant and the risk for MACE in the population. Despite both identified SNPs being associated with lower sRAGE levels, only the functional rs2070600 mutation was associated with MACE, suggesting that the link is probably due to the enhancement of RAGE function rather than to the sRAGE lowering effect.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This study was supported by grants from the Swedish Research Council and the Swedish Heart and Lung foundation.

Selfcare management intervention in heart failure (SMART-HF) -a multicentre randomized controlled trial

Background

Clinical studies evaluating home-based interventions for heart failure (HF) patients are performed on patients that are too young, too often male and predominately have reduced ejection-fraction (EF). The Selfcare Management Intervention in Heart Failure (SMART-HF) study was designed to evaluate a digital intervention enhancing self-care behaviour in a more generalizable population. The aim was to see if the intervention could reduce in-hospital care due to HF.

Methods

SMART-HF was a randomized controlled trial, recruiting patients from seven centres in Region Skåne. Patients were randomized 1:1 to a control group (CG) receiving standard care or an intervention group (IG) who were equipped with the digital intervention. The intervention educates the patient about HF and supports the patient with medication and symptom monitoring, also notifying the patient in case of deterioration. The primary outcome was number of in-hospital days due to HF after 240 days follow-up.

Results

A total of 124 patients were randomized and 118 (CG: 60, IG: 58) were included in the analysis. The mean age was 79 years, 39% were women and 45% had EF &lt;40%. The groups were well balanced at randomization. A total of 367 HF in-hospital days were registered among 33 patients, and patients in the IG lost on average 2.2 days fewer to HF-hospitalizations than patients in the CG, a reduction by 52%, p&lt;0.001. An unadjusted Cox-regression to analyse the event-free survival yielded a hazard ratio = 0.50 (CI:0,24–0,96), p=0.046. The self-care behaviour was 21% better in the IG, p=0.014. The median system adherence was 85% after 240 days.

Conclusions

The intervention significantly reduced HF-related in-hospital days and improved event-free survival in a representative HF-population. The findings match previous published data from studies evaluating the same intervention.

Funding Acknowledgement

Type of funding source: None

TNFR1 is associated with short-term mortality in patients with diabetes and acute dyspnea seeking care at the emergency department

BACKGROUND

Circulating levels of TNF alpha receptor 1 (TNFR1) and 2 (TNFR2) are associated with increased long-term mortality and impaired kidney function.

AIM

To study association between circulating levels of TNFR1 and TNFR2 and short-term mortality in patients with diabetes and dyspnea.

POPULATION AND METHODS

Patients aged ≥ 18 years seeking at emergency department (ED) during daytime on weekdays between December 2013 and July 2018, with diabetes and acute dyspnea, identified at the triage process, were included. Participants (n = 291) were triaged according to Medical Emergency Triage and Treatment System-Adult score, and blood samples were collected. Association between TNFR1 and TNFR2, respectively, and 90-day mortality were estimated by Cox regression models adjusted for age, sex, BMI, creatinine and CRP.

RESULTS

Univariate models showed significant associations between TNFR1 and TNFR2, respectively, and CRP, age and creatinine. TNFR1 and TNFR2 tended to be elevated in patients with the highest triage level, compared to patients with lower triage levels (ns). In longitudinal analyses, TNFR1 but not TNFR2 was associated with increased short-term mortality, HR adjusted for age, BMI and creatinine 1.43 (95% CI 1.07-1.91), but not in the model also adjusted for CRP, HR 1.29 (95% CI 0.94-1.77). In secondary analysis for quartile 4 versus quartiles 1-3 of TNFR1, corresponding HRs were 2.46 (95% CI 1.27-5.15) and 2.21 (95% CI 1.07-2.56).

CONCLUSIONS

We found a trend for the association between circulating TNFR1 levels and short-term mortality in patients with diabetes and acute dyspnea at the ED, possibly suggesting an inflammatory pathway for the association.

High circulating levels of midregional proenkephalin A predict vascular dementia: a population-based prospective study

Midregional Pro-enkephalin A (MR-PENK A) and N-terminal Protachykinin A (NT-PTA) have been associated with vascular dementia. However, the longitudinal relationship between these biomarkers and incident dementia has not been fully investigated. In the population-based Malmö Preventive Project, circulating levels of MR-PENK A and NT-PTA were determined in a random sample of 5,323 study participants (mean age: 69 ± 6 years) who were followed-up over a period of 4.6 ± 1.6 years. The study sample included 369 patients (7%) who were diagnosed in the same period with dementia. We analyzed relationship of MR-PENK A and NT-PTA with the risk of developing dementia by using multivariable-adjusted Cox regression models adjusted for traditional risk factors. Increased plasma levels of MR-PENK A were associated with higher risk of incident vascular dementia whereas no associations were found with all-cause or Alzheimer dementia. The risk of vascular dementia was mainly conferred by the highest quartile of MR-PENK as compared with lower quartiles. Elevated levels of NT-PTA yielded significant association with all-cause dementia or dementia subtypes. Elevated plasma concentration of MR-PENK A independently predicts vascular dementia in the general population. MR-PENK A may be used as an additional tool for identifying vascular subtype in ambiguous dementia cases.

Periodontal disease is associated with carotid plaque area: the Malmö Offspring Dental Study (MODS)

BACKGROUND

Periodontal disease is associated with cardiovascular disease (CVD) but it is unknown if periodontal disease severity is associated with asymptomatic carotid plaque. The aim of the current population-based, observational study was to investigate if signs of periodontal disease are associated with the occurrence of carotid plaque and total plaque area (TPA).

METHODS

The Malmö Offspring Study (MOS) is a population-based study. MOS participants underwent a thorough cardiovascular phenotyping, including carotid ultrasonography. The Malmö Offspring Dental Study (MODS) invited participants of MOS for dental examination, including periodontal charting. Multivariable regression models were used to analyse the presence of carotid plaque and TPA in relation to periodontal parameters.

RESULTS

In all, 831 MODS participants were recruited, out of which 495 belonged to the children generation with mean age of 53 years, 63% had carotid plaque and 38% had moderate or severe periodontal disease. In models adjusted for CVD risk factors, the OR for having carotid plaque in subjects with vs without periodontal disease was 1.75 (95% CI: 1.11-2.78). In a linear model with TPA as dependent and number of periodontal pockets ≥ 4 mm as independent variable, the adjusted beta-coefficient was 0.34 mm² (95% CI 0.16-0.52).

CONCLUSION

Individuals within the highest quartile of periodontal pockets are expected to have 9 mm² larger TPA compared to those without pockets. Our results suggest that intervention studies addressing periodontal disease could be useful for prevention of CVD.

P1588Beta-blocker therapy and risk of dementia: a population-based prospective study

Introduction

Cerebral side effects have long been recognized as complications to beta-blocker treatment. However, evidence of a longitudinal relationship between the use of beta-blockers and incident dementiais still controversial.

Objective

To evaluate the longitudinal relationship between use of beta-blockers, as a class, and incident risk of all-cause dementia, vascular dementia, Alzheimer and mixed dementia.

Methods

From the prospective, population-based, Malmö Preventive Project, 18,063 individuals (mean age 68.2, males 63.4%) were included at baseline and followed for 84,506 person-years. Patients with prevalent cerebrovascular disease and dementia were excluded. In order to weight the risk of incident dementia associated with beta-blocker consumption, we performed propensity score matching analysis, resulting in 3,720 matched pairs of beta-blocker users and non-users at baseline, and multivariable Cox proportional-hazardsregression.

Results

Overall, 122 study participants (1.6%) were diagnosed with dementia over the course of follow-up. Use of beta-blockers was independently associated with increased risk of developing vascular dementia, regardless of confounding factors (HR: 1.72, 95% CI 1.01–3.78; p=0.048). Conversely, treatment with BB was not associated with increased risk of all-cause, Alzheimer and mixed dementia (HR: 1.15; 95% CI 0.80–1.66; p=0.44; HR: 0.85; 95% CI 0.48–1.54; P=0.59 and HR: 1.35; 95% CI 0.56–3.27; p=0.50, respectively).

Conclusions and relevance

We observed that use of beta-blockers, as a class, is associated with increased longitudinal risk of vascular dementia in the general elderly population, regardless of cardiovascular risk factors, prevalent or incident history of atrial fibrillation, stroke, coronary events and heart failure. Further studies are needed to confirm our findings in the general population and to explore the mechanisms underlying the relationship between use of beta-blockers and increased risk of vascular dementia.

P6223Relationship between platelet indices and future cardiovascular events: results from a population-based cohort study

Background

Studies evaluating the relationship between platelet indices and cardiovascular outcome yielded conflicting results. In particular, the evidence from large, population-based, prospective studies with extended follow-up duration is scarce.

Purpose

We investigated the incidence of major adverse events in relation to baseline values of platelet count, mean platelet volume (MPV) and platelet distribution width (PDW) in the prospective cohort of the Malmö Diet and Cancer Study.

Methods

A total of 30,314 middle-aged individuals (mean age 57±8 years; 40% men) were overall included and followed up for a median of 16 years (in total, 468,490 person-years). The following outcome measures were considered: all-cause death, myocardial infarction (MI) and ischemic stroke.

Results

There was no relationship between increase in MPV or PDW values and adverse events during follow-up. In particular, the incidence of all-cause death, MI and stroke in patients in the 4thquartile of MPV was 19.8% (vs. 20.7% in the 1stquartile; p=0.08), 8.5% (vs. 8.2%; p=0.78) and 7.9% (vs. 7.1%; p=0.09), respectively. The rates of all-cause death, MI and stroke in patients in the 4thquartile of PDW were 20.1% (vs. 20.7% in the 1stquartile; p=0.16), 8.7% (vs. 8.1%; p=0.30) and 8.1% (vs. 7.2%; p=0.09), respectively. There was a significant rise in mortality by platelet count increase (log-rank p<0.001). In multivariable analysis, patients in the 4thquartile of platelet count (>264 x 109/L) showed a significantly higher incidence of all-cause death (HR 1.17, 95% CI 1.07–1.28; p=0.001), MI (HR 1.24, 95% CI 1.08–1.43; p=0.003) and stroke (HR 1.20, 95% CI 1.04–1.39; p=0.014) vs the 1stquartile. The higher mortality in the 4thquartile of platelet count was independent of the history of previous stroke, was significant in patients without prior MI (HR 1.18, 95% CI 1.08–1.29; p<0.001) and non-significant in those with prior MI (HR 0.86, 95% CI 0.56–1.33; p=0.51). The risk of MI in the 4thquartile of platelet count was higher regardless of the history of previous MI (p for interaction=0.11). The risk of stroke in the 4thquartile of platelet count was higher regardless of the history of previous stroke (p for interaction=0.15).

Conclusions

In this population-based, prospective, cohort study there was no difference in the incidence of adverse events across various strata of baseline platelet morphology. However, patients with highest platelet count at baseline showed a significantly higher risk of all-cause death, MI and stroke. Whether or not these individuals should be targeted by more aggressive primary prophylactic measures including antiplatelet treatment, remains to be proven.

P5510High plasma sRAGE is associated with slower carotid intima media thickness progression and lower risk for first-time coronary events and mortality

Background/Introduction

The receptor for advanced glycation end products (RAGE) and the extracellular matrix metalloproteinase inducer (EMMPRIN) are immune receptors for pro-inflammatory mediators. These receptors can also be found in a soluble form in the circulation. Soluble RAGE (sRAGE) has shown atheroprotective properties in animal studies, by acting as a decoy receptor for its ligands. Whether sEMMPRIN has similar roles is unknown.

Purpose

The purpose of our study was to investigate the associations between sRAGE and sEMMPRIN in plasma and the progression of vascular disease, incident coronary events and mortality in the general population.

Methods

We measured baseline sRAGE and sEMMPRIN in 4612 cardiovascular disease-free middle aged individuals from a population-based cohort. Measurements of intima media thickness (IMT) in the common carotid artery were performed at inclusion and after a median of 16.5 years. Incident major adverse coronary events (MACE) and mortality were recorded during a follow-up period of 21 years.

Results

sRAGE was negatively correlated with the progression of carotid IMT, independently of traditional cardiovascular risk factors, kidney function and hsCRP. Additionally, sRAGE was associated with decreased risk for MACE [HR=0.91 (0.83–0.99); p=0.031] and total mortality [HR=0.92 (0.87–0.99); p=0.017] in multivariate Cox regression analyses. We found no correlations between EMMPRIN, IMT progression or prognosis.

Conclusion

We show that individuals with high levels of circulating sRAGE have a slower rate of carotid artery disease progression, and a lower risk for coronary events and mortality. These findings support further research into the potential atheroprotective properties of sRAGE.

Acknowledgement/Funding

This study was supported by grants from the Swedish Research Council, Marianne and Marcus Wallenberg Foundation, Swedish Heart and Lung Foundation

P6352The antimicrobial protein Azurocidin-1 is associated with prevalent diastolic dysfunction and incident congestive heart failure in a Swedish population cohort

Background

Although Azurocidin-1 (Azu-1), also known as heparin binding protein, has been associated with myocardial infarction, possible associations of Azu-1 with congestive heart failure (CHF) remains unknown. Here we tested the possible association of Azu-1 with prevalent diastolic dysfunction and/or incident CHF in a large Swedish prospective population based cohort.

Methods

Azu-1 was analyzed using the Proseek Multiplex CVD III panel in 1737 participants from a subsample of the population (mean age 67 years, 29% women) who underwent a complete echocardiographic examination. All biomarkers were logarithmized and standardized prior to statistical analysis.

Logistic and linear regression were adjusted for age, sex, BMI, diabetes, systolic and diastolic blood, anti-hypertensive treatment and subjects with an ejection fraction below 50% were excluded for the analysis of prevalent diastolic dysfunction and Azu-1. For the linear regression model, we used E/é ratio as a key functional variable in assessing diastolic function according to ESC 2016 Guidelines for Acute and Chronic Heart Failure. Furthermore, we dichotomized the E/é ratio at >13 in another logistic regression model. Finally, in line with ESC Guidelines 2016, we combined the key functional (E/é >13) and key structural (left ventricular mass index (LVMI) ≥115 g/m2 for males and ≥95 g/m2 for females) alterations for diastolic dysfunction and used this variable in both logistic regression for association with Azu-1 and for Cox regression analysis of incident CHF. 1439 subjects (938 cases with some degree of diastolic dysfunction and 501 controls) remained for the analysis.

For the analysis of incident CHF, Cox regression was used excluding subjects with ejection fraction below 50% and prevalent CHF and further adjusted for prevalent coronary disease on top of age, sex, BMI, diabetes, systolic and diastolic blood and anti-hypertensive treatment. 1,511 subjects (64 incident cases of CHF vs 1447 controls; median follow up time 8.9 years) remained.

Results

After adjustment for above mentioned risk factors, each 1 standard deviation (SD) of increase in Azu-1 was associated with any degree of prevalent diastolic dysfunction (odds ratio (OR) 1.13, p=0.048), E/é >13 OR 1.21, p=0.028 and for combined LVMI and E/é OR 1.17, p=0.015. In fully adjusted linear regression Azu-1 was associated with E/é with a β-coefficient of 0.056, p=0.018.

In a fully adjusted Cox regression models Azu-1 was associated with incident CHF (hazard ratio (HR) 1.32, p=0.025). As expected and as proof of concept E/é >13 and combined LVMI with E/é were also associated with incident CHF; HR 2.84, p<0.001 and HR 2.12, p=0.006, respectively.

Conclusion

An inflammatory mediator, Azurocidin-1, is associated with prevalent diastolic dysfunction, E/é, E/é combined with LVMI as well as incident congestive heart failure in a population-based cohort.

5949Interleukin-6 and growth differentiation factor-15 in hypertensive heart failure

Background

Hypertension is the leading cause for the development of heart failure (HF). Increased hemodynamic load, including mechanical stretch and neurohumoral factors, is able to trigger hypertrophic growth of cardiac myocytes. Although hypertensive HF is prevalent, there is no useful biomarker to identify HF due to chronic hypertension.

Aims

To identify plasma markers associated with incidence of hypertensive HF.

Methods

Circulating levels of 149 proteins were measured by proximity extension assay at baseline examination in 4469 individuals from the Malmö Diet and Cancer study. Protein levels were compared to stretch-activated gene expression changes in cultured neonatal rat ventricular myocytes (NRVM) in response to 1, 4, 12, 24 or 48 hours of cyclic mechanical stretch. Association between plasma proteins level and HF incidence and hypertension was studied using respectively Cox proportional hazards model and binary logistic regressions.

Results

After Bonferroni correction, 44 circulating proteins were significantly differentially expressed in individuals who developed HF during follow-up versus controls (P<3.4E-4). Out of these, 5 proteins (Interleukin-6 (IL-6), Growth Differentiation Factor-15 (GDF15), Interleukin-1 Receptor-Like-1 (ST2), Plasminogen Activator Urokinase Receptor (U-PAR), Transforming Growth Factor-α (TGF-α)), corresponding mRNA levels were upregulated by mechanical stretch in NRVM at all time points (P<0.05). Similar upregulation for the 5 proteins was shown in hypertensive versus normotensive individuals (P≤8.05E-4). In a model with all 5 proteins entered simultaneously, GDF15 and IL-6 were predictive of incident HF after adjustment for age, sex and NT-BNP levels (205 events; hazard ratio [HR] per SD increment of protein: HR=1.29, CI=1.05–1.58, P=0.013 and HR=1.16, CI=1.02–1.33, P=0.028). Using the same model, IL-6 but not GDF15 associated with hypertension (Odds ratio [OR] per SD increment of IL-6: OR=1.18, CI=1.09–1.27, P=3.3E-5). In hypertensive individuals GDF15 and IL-6 were individually predictive of future HF after adjustment for age, sex, NT-BNP levels, smoking, BMI and diabetes (183 events; HR=1.36, CI=1.16–1.60, P=1.64E-4 and HR=1.21, CI=1.05–1.40, P=0.008). Furthermore, in these hypertensive individuals, GDF15 and IL-6 were predictive of HF in a model with IL-6, GDF15, ST2 and TGF-α entered simultaneously after adjustment for age, sex and NT-BNP levels (176 events; HR=1.36, CI=1.13–1.64, P=0.001 and HR=1.16, CI=1.01–1.34, P=0.041).

Conclusions

Circulating levels of IL-6 and GDF15 might be used as NT-BNP independent biomarkers for HF development in hypertensive patients.

Acknowledgement/Funding

Påhlsson, Crafoord, Lundström, Åke Wiberg, Royal Physiographic Society and the Swedish Foundation for Strategic Research for IRC15-0067

P4495Dimethylguanidino valerate a lifestyle related metabolite associated with future coronary artery disease and cardiovascular mortality

Background

Identification of lifestyle modifiable metabolic pathways related to cardiometabolic disease risk is essential for improvement of primary prevention in susceptible individuals. It was recently shown that plasma dimethylguanidino valerate (DMGV) levels are associated with incident type 2 diabetes (T2DM). Our aims were to investigate if plasma DMGV is related to risk of future coronary artery disease (CAD) and with cardiovascular mortality and to replicate the association with T2DM and to pinpoint candidate lifestyle interventions susceptible to modulate DMGV levels.

Methods

Plasma DMGV levels were measured using liquid chromatography-mass spectrometry (LC-MS) in a total of 5768 participants from the Malmö Diet and Cancer Study – Cardiovascular Cohort (MDC), the Malmö Preventive Project (MPP) and the Malmö Offspring Study (MOS). Dietary intake assessment was performed in MOS.

Results

Baseline levels of DMGV associated with incident CAD in both MDC (HR=1.29, C.I= 1.16–1.43, P=3.3e-6) and MPP (OR=1.25, C.I=1.08–1.44, P=2.4e-3). In MDC, DMGV was associated with cardiovascular mortality and incident CAD, independently of traditional risk factors. Furthermore, the association between DMGV and incident T2DM was replicated in both MDC (HR=1.83, C.I=1.63–2.05, P=8.7e-25) and MPP (OR=1.65, C.I=1.38–1.98, P=8.7e-8). Intake of sugar-sweetened beverages (SSB) associated with increased levels of DMGV, while intake of vegetables and level of physical activity associated with lower DMGV.

Conclusions

We discovered novel independent associations between plasma DMGV and incident CAD and cardiovascular mortality, while replicating the previously reported association with incident T2DM. Additionally, strong associations with SSB, vegetable intake and physical activity suggest the potential to modify DMGV levels using lifestyle interventions.

Acknowledgement/Funding

Knut and Alice Wallenberg Foundation, Göran Gustafsson Foundation, the Swedish Heart- and Lung Foundation, the Swedish Research Council

The association between plasma proneurotensin and glucose regulation is modified by country of birth

The prevalence of type 2 diabetes (T2D) has increased dramatically in Middle Eastern populations that represent the largest non-European immigrant group in Sweden today. As proneurotensin predicts T2D, the aim of this study was to investigate differences in proneurotensin levels across populations of Middle Eastern and Caucasian origin and to study its associations with indices of glucose regulation. Participants in the age 30 to 75 years, living in Malmö, Sweden, and born in Iraq or Sweden, were recruited from the census register. Anthropometrics and fasting samples were collected and oral glucose tolerance tests conducted assessing insulin secretion (DIo) as well as insulin sensitivity (ISI). A total of 2155 individuals participated in the study, 1398 were Iraqi-born and 757 were Swedish-born participants. Higher fasting proneurotensin levels were observed in Iraqi- compared to Swedish-born participants (137.5 vs. 119.8 pmol/L; p < 0.001) data adjusted for age, sex and body mass index. In Iraqi participants only, plasma proneurotensin was associated with impaired glucose regulation assessed as ISI, DIo and HbA1c, and significant interactions between country of birth and proneurotensin were observed (Pinteraction ISI = 0.048; Pinteraction DIo = 0.014; PinteractionHbA1c = 0.029). We report higher levels of proneurotensin in the general Middle Eastern population. The finding that Middle Eastern origin modifies the relationship of proneurotensin with indices of glucose regulation suggests that proneurotensin may be a stronger determinant of T2D in Middle Eastern as compared to Caucasian populations. These findings may explain part of the excess T2D risk in the Middle Eastern population but needs to be explored further.

Monitoring of cerebral oximetry during head-up tilt test in adults with history of syncope and orthostatic intolerance

Aims

We applied near-infrared-spectroscopy (NIRS) to measure absolute frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients investigated for unexplained syncope.

Methods and results

Synchronized non-invasive beat-to-beat haemodynamic monitoring, ECG, SctO2 (NIRS; normal range: 60-80%), and peripheral oxygen saturation (left hand, SpO2) were applied during HUT in a random sample of patients with unexplained syncope. Tracings of 54 patients (mean-age: 55 ± 19 years, 39% male) with negative HUT, vasovagal syncope (VVS), or orthostatic hypotension (OH) were analysed. In 44 patients HUT was diagnostic, in 10 HUT was negative. Thirty-one experienced VVS. Of these, 6 had spontaneous and 25 nitroglycerin-induced syncope. Thirteen patients had orthostatic hypotension (OH). Although there was no significant change in mean-arterial pressure from baseline to 1 min before syncope or end of passive HUT phase (-1.4 ± 13.9 mmHg; P = 0.45), there was a significant fall in SctO2 during the same period (-3.2 ± 3.2%; P ≤ 0.001). Among patients who experienced syncope, a decrease in SctO2 from 71 ± 5% at baseline to 53 ± 9% (P < 0.001) at syncope was observed. During HUT, there was a significant difference in delta SctO2 between spontaneous VVS (-4.5 ± 3.0%) and negative HUT (-1.3 ± 1.9%; P  = 0.021), but not between spontaneous VVS and OH (-5.4 ± 4.2%; P = 0.65). In spontaneous VVS, progressive decrease of SctO2 was independent of mean arterial pressure decrease (P  = 0.22).

Conclusions

Progressive decrease in cerebral tissue oxygenation independent of mean-arterial pressure may precede spontaneous vasovagal reflex during tilt. Patients experience syncope when SctO2 falls below 60%. These data confirm clinical utility of absolute cerebral oximetry monitoring for syncope investigation. We applied NIRS to measure frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients with unexplained syncope. In 44 of 54 patients, HUT was diagnostic. In patients with syncope, a significant SctO2-decrease was observed. Different patterns of SctO2 can be detected.

A genetic risk score for hypertension is associated with risk of thoracic aortic aneurysm

A genetic risk score (GRS) based on 29 single nucleotide polymorpysms (SNPs) associated with high blood pressure (BP) was prospectively associated with development of hypertension, stroke and cardiovascular events. The aim of the present study was to evaluate the impact of this GRS on the incidence of aortic disease, including aortic dissection (AD), rupture or surgery of a thoracic (TAA) or abdominal (AAA) aortic aneurysm. More than 25,000 people from the Swedish Malmo Diet and Cancer Study had information on at least 24 SNPs and were followed up for a median ≥ 18 years. The number of BP elevating alleles of each SNPs, weighted by their effect size in the discovery studies, was summed into a BP-GRS. In Cox regression models, adjusted for traditional cardiovascular risk factors including hypertension, we found significant associations of the BP-GRS, prospectively, with incident TAA (hazard ratio (HR) 1.64 (95% confidence interval (CI) 1.081-2.475 comparing the third vs. the first tertile; p = 0.020) but not with either AAA or aortic dissection. Calibration, discrimination and reclassification analyses show modest improvement in prediction using the BP-GRS in addition to the model which used only traditional risk factors. A GRS for hypertension associates with TAA suggesting a link between genetic determinants of BP and aortic disease. The effect size is small but the addition of more SNPs to the GRS might improve its discriminatory capability.

Anti-ApoA-I IgG antibodies are not associated with carotid artery disease progression and first-time cardiovascular events in middle-aged individuals

OBJECTIVE

IgG antibodies against apolipoprotein A-I (ApoA-I) have been found to be elevated in subjects from the general population with clinically manifest cardiovascular disease and in myocardial infarction patients with an adverse prognosis. Here, we investigated whether these antibodies are prospectively associated with carotid artery disease progression and with the risk for first-time cardiovascular events in individuals with no previous history of cardiovascular disease.

APPROACH AND RESULTS

We selected 383 subjects from the cardiovascular cohort of Malmö Diet and Cancer study who suffered a coronary event during a median follow-up period of 15.4 (10.3-16.4) years and 395 age- and sex-matched controls. None of the study participants had a previous history of coronary artery disease or stroke. Anti-ApoA-I IgG were measured by ELISA in serum samples collected at baseline. Intima-media thickness (IMT) was measured in the common carotid artery and in the carotid bifurcation at baseline and after 15.9 (±1.5) years. We found no associations between anti-ApoA-I IgG and carotid artery IMT at baseline or with IMT progression during follow-up. In Cox proportional hazards analyses adjusted for traditional cardiovascular risk factors, the hazard ratio (HR 95%CI) for the primary outcome, incident coronary events, was 0.97 (0.75-1.25), P = 0.782, in subjects with anti-ApoA-I IgG within the highest tertile compared with the lowest tertile. Similarly, we did not find any associations with the secondary outcome, incident first-time stroke.

CONCLUSIONS

Serum autoantibodies against ApoA-I do not correlate with disease progression and adverse events in cardiovascular disease-free individuals from the general population.

Plasma levels of the proprotein convertase furin and incidence of diabetes and mortality

BACKGROUND

Diabetes mellitus is linked to premature mortality of virtually all causes. Furin is a proprotein convertase broadly involved in the maintenance of cellular homeostasis; however, little is known about its role in the development of diabetes mellitus and risk of premature mortality.

OBJECTIVES

To test if fasting plasma concentration of furin is associated with the development of diabetes mellitus and mortality.

METHODS

Overnight fasted plasma furin levels were measured at baseline examination in 4678 individuals from the population-based prospective Malmö Diet and Cancer Study. We studied the relation of plasma furin levels with metabolic and hemodynamic traits. We used multivariable Cox proportional hazards models to investigate the association between baseline plasma furin levels and incidence of diabetes mellitus and mortality during 21.3-21.7 years follow-up.

RESULTS

An association was observed between quartiles of furin concentration at baseline and body mass index, blood pressure and plasma concentration of glucose, insulin, LDL and HDL cholesterol (|0.11| ≤ β ≤ |0.31|, P < 0.001). Plasma furin (hazard ratio [HR] per one standard deviation increment of furin) was predictive of future diabetes mellitus (727 events; HR = 1.24, CI = 1.14-1.36, P < 0.001) after adjustment for age, sex, body mass index, systolic and diastolic blood pressure, use of antihypertensive treatment, alcohol intake and fasting plasma level of glucose, insulin and lipoproteins cholesterol. Furin was also independently related to the risk of all-cause mortality (1229 events; HR = 1.12, CI = 1.05-1.19, P = 0.001) after full multivariable adjustment.

CONCLUSION

Individuals with high plasma furin concentration have a pronounced dysmetabolic phenotype and elevated risk of diabetes mellitus and premature mortality.

Genome-wide analysis of genetic determinants of circulating factor VII-activating protease (FSAP) activity

Essentials Knowledge of genetic regulators of plasma factor VII activating protease (FSAP) levels is limited. We performed a genome-wide analysis of variants influencing FSAP activity in Scandinavian cohorts. We replicated an association for Marburg-1 and identified an association for a HABP2 stop variant. We identified a novel locus near ADCY2 as a potential additional regulator of FSAP activity.

SUMMARY

Background Factor VII-activating protease (FSAP) has roles in both coagulation and fibrinolysis. Recent data indicate its involvement in several other processes, such as vascular remodeling and inflammation. Plasma FSAP activity is highly variable among healthy individuals and, apart from the low-frequency missense variant Marburg-I (rs7080536) in the FSAP-encoding gene HABP2, determinants of this variation are unclear. Objectives To identify novel genetic variants within and outside of the HABP2 locus that influence circulating FSAP activity. Patients/Methods We performed an exploratory genome-wide association study (GWAS) on plasma FSAP activity amongst 3230 Swedish subjects. Directly genotyped rare variants were also analyzed with gene-based tests. Using GWAS, we confirmed the strong association between the Marburg-I variant and FSAP activity. HABP2 was also significant in the gene-based analysis, and remained significant after exclusion of Marburg-I carriers. This was attributable to a rare HABP2 stop variant (rs41292628). Carriers of this stop variant showed a similar reduction in FSAP activity as Marburg-I carriers, and this finding was replicated. A secondary genome-wide significant locus was identified at a 5p15 locus (rs35510613), and this finding requires future replication. This common variant is located upstream of ADCY2, which encodes a protein catalyzing the formation of cAMP. Results and Conclusions This study verified the Marburg-I variant to be a strong regulator of FSAP activity, and identified an HABP2 stop variant with a similar impact on FSAP activity. A novel locus near ADCY2 was identified as a potential additional regulator of FSAP activity.

Association between systemic leptin and neurotensin concentration in adult individuals with and without type 2 diabetes mellitus

PURPOSE

Leptin is an adipokine which regulates appetite and energy balance through a mechanism partially mediated by neurotensin (NT) in central nervous system. Besides acting as a neurotransmitter, NT is expressed in human intestine where it promotes fat absorption and its circulating levels associate with obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease. Whether a relation exists between circulating leptin and NT levels has not been investigated yet. The aim of this study was to test the hypothesis of an association between plasma leptin and NT concentration in adults with or without T2DM.

METHODS

We recruited a population of 72 subjects (M/F: 39/33; age: 49.5 ± 10.6 years; BMI: 26.5 ± 4.7 kg/m²) including individuals with T2DM (n = 32) referring to our Diabetes Outpatient Clinics, Sapienza University of Rome, and healthy controls. Study participants underwent metabolic characterization; plasma leptin was measured by MILLIPLEX, Luminex, and proneurotensin (proNT), a stable precursor of NT, by chemiluminometric sandwich immunoassay.

RESULTS

Circulating median (25°-75°) leptin levels were 2.75 (1.27-4.93) ng/mL and did not differ between T2DM and non-diabetic subjects. Leptin concentration directly correlated with proNT (r = 0.41; p = 0.015); higher leptin levels were also associated with age, male gender, obesity, higher HOMA-IR, systolic blood pressure and C-reactive protein. Belonging to the highest pro-NT quartile correlated with greater leptin levels independent of age, gender and other confounders (r² = 0.82, p = 0.02).

CONCLUSIONS

Circulating leptin is associated with higher proNT levels independent of diabetes, obesity and metabolic syndrome components; besides its effects on central leptin signaling, NT may influence energy balance by modulating circulating leptin concentration likely through a mechanism involving gut fat absorption.

Plasma stem cell factor levels are associated with risk of cardiovascular disease and death

OBJECTIVE

Stem cell factor (SCF) is a key growth factor for several types of stem and progenitor cells. There is experimental evidence that such cells are of importance for maintaining the integrity of the cardiovascular system. We investigated the association between circulating levels of SCF and risk for development of cardiovascular events and death.

METHODS

SCF was analysed by the proximity extension assay technique in plasma from 4742 subjects participating in the Malmö Diet and Cancer Study. Cardiovascular events and death were monitored through national registers with a mean follow-up time of 19.2 years.

RESULTS

Subjects with high baseline levels of SCF had lower cardiovascular (n = 340) and all-cause mortality (n = 1159) as well as a lower risk of heart failure (n = 177), stroke (n = 318) and myocardial infarction (n = 452). Smoking, diabetes and high alcohol consumption were associated with lower levels of SCF. Single nucleotide polymorphisms in the gene region encoding PDX1 C-terminal inhibiting factor 1 (PCIF1) and matrix metalloproteinase-9 were associated with plasma SCF levels. The highest SCF quartile remained independently associated with a lower risk of a lower risk of cardiovascular [hazard ratio and 95% confidence interval 0.59 (0.43-0.81)] and all-cause mortality [0.68 (0.57-0.81)], heart failure [0.50 (0.31-0.80)] and stroke [0.66 (0.47-0.92)], but not with MI [0.96 (0.72-1.27)] as compared with the lowest quartile when adjusting for traditional cardiovascular risk factors in Cox proportional hazard regression models.

CONCLUSIONS

This prospective population-based study demonstrates that subjects with high levels of SCF have a lower risk of cardiovascular events and death. The findings provide clinical support for a protective role of SCF in maintaining cardiovascular integrity.

Biomarkers of microvascular endothelial dysfunction predict incident dementia: a population-based prospective study

BACKGROUND

Cerebral endothelial dysfunction occurs in a spectrum of neurodegenerative diseases. Whether biomarkers of microvascular endothelial dysfunction can predict dementia is largely unknown. We explored the longitudinal association of midregional pro-atrial natriuretic peptide (MR-proANP), C-terminal endothelin-1 (CT-proET-1) and midregional proadrenomedullin (MR-proADM) with dementia and subtypes amongst community-dwelling older adults.

METHODS

A population-based cohort of 5347 individuals (men, 70%; age, 69 ± 6 years) without prevalent dementia provided plasma for determination of MR-proANP, CT-proET-1 and MR-proADM. Three-hundred-and-seventy-three patients (7%) were diagnosed with dementia (120 Alzheimer's disease, 83 vascular, 102 mixed, and 68 other aetiology) over a period of 4.6 ± 1.3 years. Relations between baseline biomarker plasma concentrations and incident dementia were assessed using multivariable Cox regression analysis.

RESULTS

Higher levels of MR-proANP were significantly associated with increased risk of all-cause and vascular dementia (hazard ratio [HR] per 1 SD: 1.20, 95% confidence interval [CI], 1.07-1.36; P = 0.002, and 1.52; 1.21-1.89; P < 0.001, respectively). Risk of all-cause dementia increased across the quartiles of MR-proANP (p for linear trend = 0.004; Q4, 145-1681 pmol L^-1 vs. Q1, 22-77 pmol L^-1 : HR: 1.83; 95%CI: 1.23-2.71) and was most pronounced for vascular type (p for linear trend = 0.005: HR: 2.71; 95%CI: 1.14-6.46). Moreover, the two highest quartiles of CT-proET-1 predicted vascular dementia with a cut-off value at 68 pmol L^-1 (Q3-Q4, 68-432 pmol L^-1 vs. Q1-Q2,4-68 pmol L^-1 ; HR: 1.94; 95%CI: 1.12-3.36). Elevated levels of MR-proADM indicated no increased risk of developing dementia after adjustment for traditional risk factors.

CONCLUSIONS

Elevated plasma concentration of MR-proANP is an independent predictor of all-cause and vascular dementia. Pronounced increase in CT-proET-1 indicates higher risk of vascular dementia.

Exome array analysis of ischaemic stroke: results from a southern Swedish study

BACKGROUND AND PURPOSE

Genome-wide association (GWA) studies have identified a few risk loci for ischaemic stroke, but these variants explain only a small part of the genetic contribution to the disease. Coding variants associated with amino acid substitutions or premature termination of protein synthesis could have a large effect on disease risk. We performed an exome array analysis for ischaemic stroke.

METHODS

Patients with ischaemic stroke (n = 2385) and control subjects (n = 6077) from three Swedish studies were genotyped with the Illumina HumanOmniExpressExome BeadChip. Single-variant association analysis and gene-based tests were performed of exome variants with minor allele frequency of < 5%. A separate GWA analysis was also performed, based on 700 000 genotyped common markers and subsequent imputation.

RESULTS

No exome variant or gene was significantly associated with all ischaemic stroke after Bonferroni correction (all P > 1.8 × 10^-6 for single-variant and >4.15 × 10^-6 for gene-based analysis). The strongest association in single-variant analysis was found for a missense variant in the DNAH11 gene (rs143362381; P = 5.01 × 10^-6 ). In gene-based tests, the strongest association was for the ZBTB20 gene (P = 7.9 × 10^-5 ). The GWA analysis showed that the sample was homogenous (median genomic inflation factor = 1.006). No genome-wide significant association with overall ischaemic stroke risk was found. However, previously reported associations for the PITX2 and ZFHX3 gene loci with cardioembolic stroke subtype were replicated (P = 7 × 10^-15 and 6 × 10^-3 ).

CONCLUSIONS

This exome array analysis did not identify any single variants or genes reaching the pre-defined significance level for association with ischaemic stroke. Further studies on exome variants should be performed in even larger, well-defined and subtyped samples.

Gene variance in the nicotinic receptor cluster (CHRNA5-CHRNA3-CHRNB4) predicts death from cardiopulmonary disease and cancer in smokers

BACKGROUND

Genetic variation in the cluster on chromosome 15, encoding the nicotinic acetylcholine receptor subunits (CHRNA5-CHRNA3-CHRNB4), has shown strong associations with tobacco consumption and an additional risk increase in smoking-related diseases such as chronic obstructive pulmonary disease (COPD), peripheral artery disease and lung cancer.

OBJECTIVES

To test whether rs1051730 (C/T), a tag for multiple variants in the CHRNA5-CHRNA3-CHRNB3 cluster, is associated with a change in risk of smoking-related mortality and morbidity in the Malmö Diet and Cancer study, a population-based prospective cohort study.

METHODS

At baseline participants were classified as current (n = 6951), previous (n = 8426) or never (n = 9417) smokers. Cox-proportional hazards models were used to determine the correlation between rs1051730 and incidence of first COPD, tobacco-related cancer, other cancer and cardiovascular disease (CVD), and total mortality due to these causes, during approximately 14 years of follow-up.

RESULTS

Amongst current smokers there were 480 first incident COPD events, 852 tobacco-related cancers, 810 other cancers and 1022 CVD events. A total of 1508 deaths occurred, including 500 due to CVD, 102 due to respiratory diseases and 677 due to cancer. In adjusted additive models, an increasing number of T alleles were associated with a gradual increase in total mortality, incident COPD and tobacco-related cancer, even after adjustment for smoking quantity. No significant associations were observed amongst never smokers.

CONCLUSION

Our data suggest that gene variance in the CHRNA5-CHRNA3-CHRNB4 cluster is associated with an increased risk of death, incidence of COPD and tobacco-related cancer in smokers. These findings indicate an individual susceptibility to tobacco use and its complications; this may be important when targeting and designing smoking cessation therapies.

The Swedish CArdioPulmonary BioImage Study: objectives and design

Cardiopulmonary diseases are major causes of death worldwide, but currently recommended strategies for diagnosis and prevention may be outdated because of recent changes in risk factor patterns. The Swedish CArdioPulmonarybioImage Study (SCAPIS) combines the use of new imaging technologies, advances in large-scale 'omics' and epidemiological analyses to extensively characterize a Swedish cohort of 30 000 men and women aged between 50 and 64 years. The information obtained will be used to improve risk prediction of cardiopulmonary diseases and optimize the ability to study disease mechanisms. A comprehensive pilot study in 1111 individuals, which was completed in 2012, demonstrated the feasibility and financial and ethical consequences of SCAPIS. Recruitment to the national, multicentre study has recently started.

Association between copeptin and declining glomerular filtration rate in people with newly diagnosed diabetes. The Skaraborg Diabetes Register

AIMS

Copeptin has shown association with development of chronic kidney disease (CKD) in people with diabetes. Early detection of individuals having the highest risk could help avoid this complication. Therefore we decided to study copeptin concentrations and estimated glomerular filtration rate (eGFR) retrospectively in people with newly diagnosed diabetes.

METHODS

People with newly diagnosed type 2 diabetes in 1996-1998 from Skaraborg Diabetes Register (SDR) were reinvestigated in 2008-2010. Copeptin concentration at the time of diagnosis was determined. Creatinine and cystatin C were used for determination of eGFR at baseline and at reinvestigation (n=161). Data on cardiovascular complications were extracted from national registers. Analyzes were done with logistic regression.

RESULTS

From baseline to follow up eGFR decreased with 33ml. Twenty-nine individuals (18.1%) developed CKD stage 3. There was a significant association between elevated copeptin concentrations and development of CKD stage 3 (OR=1.78, 95% CI=1.01-3.16). When adjusting for GFR at baseline the association between copeptin and GFR decline was borderline significant (OR=1.79, 95% CI=0.99-3.25, p=0.055).

CONCLUSIONS

Determination of copeptin may early identify people with diabetes and high risk for CKD. To prevent complications for these individuals aggressive treatment should be discussed.

Inverse relationship between a genetic risk score of 31 BMI loci and weight change before and after reaching middle age

Background/Objective:

Genome-wide-association studies have identified numerous body mass index (BMI)-associated variants, but it is unclear how these relate to weight gain in adults at different ages.

Methods:

We examined the association of a genetic risk score (GRS), consisting of 31 BMI-associated variants, with an annual weight change (AWC) and a substantial weight gain (SWG) of 10% by comparing self-reported weight at 20 years (y) with baseline weight (mean: 58 y; s.d.: 8 y) in 21407 participants from the Malmö Diet and Cancer Study (MDCS), and comparing baseline weight to weight at follow-up (mean: 73 y; s.d.: 6 y) among 2673 participants. Association between GRS and AWG and SWG was replicated in 4327 GLACIER (Gene x Lifestyle interactions And Complex traits Involved in Elevated disease Risk) participants (mean: 45 y; s.d.: 7 y) with 10 y follow-up. Cohort-specific results were pooled by fixed-effect meta-analyses.

Results:

In MDCS, the GRS was associated with increased AWC (β: 0.003; s.e: 0.01; P: 7 × 10⁻⁸) and increased odds for SWG (odds ratio (OR) 1.01 (95% confidence interval (CI): 1.00, 1.02); P: 0.013) per risk-allele from age 20y, but unexpectedly with decreased AWC (β: −0.006; s.e: 0.002; P: 0.009) and decreased odds for SWG OR 0.96 (95% CI: 0.93, 0.98); P: 0.001) between baseline and follow-up. Effect estimates from age 20 y to baseline differed significantly from those from baseline to follow-up (P: 0.0002 for AWC and P: 0.0001 for SWG). Similar to MDCS, the GRS was associated with decreased odds for SWG OR 0.98 (95% CI: 0.96, 1.00); P: 0.029) from baseline to follow-up in GLACIER. In meta-analyses (n=7000), the GRS was associated with decreased AWC (β: −0.005; s.e.m. 0.002; P: 0.002) and decreased odds for SWG OR 0.97 (95% CI: 0.96, 0.99); P: 0.001) per risk-allele.

Conclusions:

Our results provide convincing evidence for a paradoxical inversed relationship between a high number of BMI-associated risk-alleles and less weight gain during and after middle-age, in contrast to the expected increased weight gain seen in younger age.