Risk Factor Clusters and Cardiovascular Disease in High-Risk Patients: The UCC-SMART Study

Background:Clustering of vascular risk factors, i.e., the co-existence of two or more risk factors, has been associated with a higher risk of cardiovascular disease (CVD) in the general population. This study aims to firstly, examine patterns of clustering of major cardiovascular risk factors in high-risk patients and their relation with the risk of recurrent cardiovascular disease and all-cause mortality. Secondly, to assess which combinations are associated with the highest risk of CVD and all-cause mortality and to study population attributable fractions.Methods:A total of 12,616 patients from the Utrecht Cardiovascular Cohort – Second Manifestations of ARTerial diseases (UCC-SMART) study consisting of patients with or a high risk to develop cardiovascular disease were studied. We constructed sixteen clusters based on four individual modifiable risk factors (hypertension, dyslipidemia, current smoking, overweight). Patients were followed from September 1997 to March 2017. Cox proportional hazard models were used to compute adjusted hazard ratios for CVD risk and all-cause mortality and 95% confidence intervals for clusters, with patients without any risk factor as reference group. The population attributable fractions (PAFs) were calculated. Subgroup analyses were conducted by age and sex.Results:During a mean follow-up period of 8.0 years, 1836 CVD events were registered. The prevalence of patients with zero, one, two, three, and four risk factors was 1.4, 11.4, 32.0, 44.8 and 10.4%. The corresponding hazard ratios (HR) for CVD risk and all-cause mortality were 1.65 (95% CI 0.77; 3.54) for one risk factor, 2.61 (1.24; 5.50) for two, 3.25 (1.55; 6.84) for three, and 3.74 (1.77; 7.93) for four risk factors, with patients without any risk factor as reference group. The PAFs were 6.9, 34.0, 50.1 and 22.2%, respectively. The smoking-hypertension-dyslipidemia combination was associated with the highest HR: 4.06 (1.91; 8.63) and the hypertension-dyslipidemia combination with the highest PAF: 37.1%.Conclusion:Clusters including smoking and hypertension contributed to the highest risk of CVD and all-cause mortality. This study confirms that risk factor clustering is common among patients at high-risk for CVD and is associated with an increased risk of CVD and all-cause mortality.     

Prognostic value of adiponectin for cardiovascular disease and mortality

CONTEXT: Low adiponectin concentrations are associated with the presence of an adverse cardiovascular disease (CVD) risk profile. OBJECTIVE: We studied the predictive value of adiponectin levels for all-cause and CVD mortality and CVD morbidity. DESIGN, SETTING, AND PARTICIPANTS: This was a population-based cohort study in Hoorn, The Netherlands, which started in 1989 and included 2484 participants, aged 50-75 yr. MAIN OUTCOME MEASURES: Hazard ratios (HRs) with 95% confidence interval per sd change in log-adiponectin for all-cause and CVD mortality and CVD morbidity were calculated. RESULTS: Adiponectin was determined for 1077 men and 1248 women. Higher adiponectin reduced the risk of nonfatal CVD in women [HR with 95% confidence interval 0.72 (0.61-0.90) in women and 0.92 (0.79-1.06) in men], but not the risk of all-cause or CVD mortality. In contrast, after adjustment for cardiovascular risk factors, higher adiponectin was a significant predictor of all-cause and CVD mortality [HR for CVD mortality 1.45 (1.10-1.92) in women and 1.30 (1.04-1.63) in men]. Higher adiponectin was associated with an increased risk of CVD mortality in people with prevalent CVD [HR 1.27 (0.98-1.63)] and with reduced risk in people without [HR 0.90 (0.73-1.11)]. After adjustment for cardiovascular risk factors, the HRs for CVD mortality were 1.60 (1.14-2.23) for patients with and 1.38 (1.06-1.80) for patients without prevalent CVD. CONCLUSIONS: High levels of adiponectin predict mortality, in particular in patients with prevalent CVD. We hypothesize that adiponectin protects against metabolic and vascular diseases, but in patients already afflicted with CVD, adiponectin is compensatory up-regulated and, therefore, indicates a high mortality risk.     

Comparison of N-terminal pro-B-natriuretic peptide, C-reactive protein, and creatinine clearance for prognosis in patients with known coronary heart disease

BACKGROUND: The purpose of this study was to investigate the prognostic role of N-terminal pro-B-natriuretic peptide (NT-proBNP) serum level compared with C-reactive protein (CRP) level and creatinine clearance (CrCl) for the subsequent risk of cardiovascular events in a large cohort of patients with stable coronary heart disease (CHD). METHODS: Serum concentrations of NT-proBNP and CRP and CrCl were measured at baseline in a cohort of 1051 patients aged 30 to 70 years with CHD. The Cox proportional hazards model was used to determine the prognostic value of NT-proBNP, CRP, and CrCl on a combined cardiovascular disease (CVD) end point (fatal and nonfatal myocardial infarction and stroke). RESULTS: During follow-up (mean of 48.7 months), 95 patients (9.0%) experienced a secondary CVD event. Patients in the top quartile of the NT-proBNP distribution at baseline had a hazard ratio (HR) of 3.34 (95% confidence interval [CI], 1.74-6.45) for subsequent secondary CVD events compared with those in the bottom quartile (P for trend <.001) after controlling for age, sex, smoking status, history of diabetes mellitus, initial management of CHD, rehabilitation clinic, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and treatment with lipid-lowering drugs. For CRP, the corresponding HR was 1.76 (95% CI, 0.96-3.24) (P value for trend, .06). Patients with CrCl levels lower than 60 mL/min had an HR of 2.39 (95% CI, 1.06-5.40) compared with patients with a CrCl of 90 mL/min or higher (P for trend, .002). If all 3 markers were included simultaneously in 1 model, NT-proBNP still showed predictive ability for recurrent CVD events. CONCLUSION: N-terminal proBNP may be a clinically useful marker weeks after an acute coronary event and may provide complementary prognostic information to established risk determinants.     

Renal dysfunction, as measured by the modification of diet in renal disease equations, and outcome in patients with advanced heart failure.

AIMS: This study evaluates the prognostic utility of renal dysfunction estimated by the recently validated modification of diet in renal disease (MDRD) equations and compares it with the currently most promising predictor of prognosis in patients with advanced heart failure. METHODS AND RESULTS: We prospectively studied 182 consecutive patients with advanced chronic heart failure (CHF) referred for consideration of cardiac transplantation, with a median follow-up of 642 days. Glomerular filtration rate (GFR) was estimated using the MDRD equations and plasma taken for NT-proBNP analysis. The primary endpoint of all-cause mortality was reached in 40 patients (13.2% crude 1-year mortality), and the combined secondary endpoint of all-cause mortality or urgent CTx was reached in 44 patients. The mean GFR estimated by MDRD-1 was 58 mL/min/1.73 m(2). The median NT-proBNP concentration was 1505 (517-4014) pg/mL. Although GFR estimated by MDRD-1 was a univariate marker of all-cause mortality, the only predictor of either endpoint independent of other variables was an NT-proBNP concentration above the median. CONCLUSION: NT-proBNP appears superior to GFR estimated by MDRD in patients with advanced CHF. Moreover, NT-proBNP was able to identify patients with a poor prognosis whose GFR was already low.     

The association between neutrophil gelatinase-associated lipocalin and clinical outcome in chronic heart failure: results from CORONA*

OBJECTIVE: To study the prognostic value of neutrophil gelatinase-associated lipocalin (NGAL) in chronic heart failure (HF) of ischaemic aetiology. BACKGROUND: Neutrophil gelatinase-associated lipocalin is a marker of kidney injury as well as matrix degradation and inflammation and has previously been shown to be increased in HF. We investigated whether serum NGAL levels could provide prognostic information in chronic HF. METHODS: We assessed NGAL as a predictor of primary outcomes (cardiovascular death, nonfatal stroke and nonfatal myocardial infarction, n = 307) and all-cause mortality (n = 321), cardiovascular mortality (n = 259) and hospitalization (n = 647) as well as the number of hospitalizations during follow-up for all (n = 1934) and CV causes (n = 1204) in 1415 patients with chronic HF (≥60 years, New York Heart Association class II-IV, ischaemic systolic HF) in the CORONA population, randomly assigned to 10 mg rosuvastatin or placebo. Results. Multivariate analysis revealed that NGAL added significant information when adjusting for clinical variables, but was no longer significant when further adjusting for apolipoprotein A-1 (ApoA-1), glomerular filtration rate (GFR), C-reactive protein (CRP) and N-terminal pro-brain natriuretic peptide (NT-proBNP). However, belonging to the highest NGAL tertile was associated with more frequent hospitalization, even after adjusting for clinical variables, GFR and ApoA-1, but not after adjusting for CRP and NT-proBNP. There was no interaction between rosuvastatin treatment and NGAL. Conclusion. Neutrophil gelatinase-associated lipocalin added no significant information to NT-proBNP and GFR in a multivariate model for primary and secondary end-points.     

Prognostic value of N-terminal pro-B-type natriuretic peptide in patients with acute coronary syndromes undergoing left main percutaneous coronary intervention

BACKGROUND: Patients undergoing acute left main (LM) coronary artery revascularization have a high mortality and natriuretic peptides such as N-terminal pro-B-type (NT-proBNP) have been shown to have prognostic value in patients with acute coronary syndromes. The present study looked at the prognostic value of NT-proBNP in these patients. METHODS AND RESULTS: We studied all consecutive patients undergoing acute LM coronary artery percutaneous coronary intervention between January 2005 and December 2008 in whom NT-proBNP was measured (n=71). We analyzed the clinical characteristics and the short- and long-term outcomes in relation to NT-proBNP level at admission. Median NT-proBNP was 1,364 ng/L, ranging from 46 to 70,000 ng/L. NT-proBNP was elevated in 63 (89%) patients and was ≥1,000ng/L in 42 (59%). Log NT-proBNP (hazard ratio [HR] 3.51, 95% confidence interval [CI] 1.55-7.97, P=0.003) and left ventricular ejection fraction (HR 0.95, 95%CI 0.91-0.99, P=0.007) were predictors for all-cause mortality. Log NT-proBNP was the only independent significant predictor of cardiovascular mortality. In-hospital mortality was 0% for patients with NT-proBNP <1,000, but 17% for those with NT-proBNP ≥1,000 (P=0.036). Conclusions: NT-proBNP is a strong predictor of outcome in patients undergoing acute LM coronary artery stenting. Mortality in such patients is high, but those with NT-proBNP < 1,000ng/L may have a favorable short- and long-term prognosis. Further research, including a larger patient population, is needed to determine the optimal cut-off value for NT-proBNP in patients undergoing acute LM coronary artery intervention.     

女性代谢综合征患者踝臂指数与全因及心血管病死亡的关系

目的研究踝臂指数(ABI)与女性代谢综合征(MS)患者全因死亡与心血管病(CVD)死亡之间的关系。方法符合国际糖尿病学会(IDF,2005)MS诊断标准的女性MS患者1049例入选。进行ABI的测量及平均13.6月随访。按ABI水平的不同将研究对象分为外周动脉疾病(PAD)组(ABI≤0.9,共259例)和非PAD组(ABI在0.91～1.40之间,共790例)。结果在基线水平,PAD组的年龄、高血压患病率、收缩压水平、糖尿病患病率、吸烟率均高于非PAD组(P<0.05)。PAD组与非PAD组的全因死亡率分别为10.4%和4.4%(P<0.01),CVD死亡率分别为4.6%和1.6%(P<0.01)。ABI最高第4分位(≤0.40)较最低的第1分位(1.00～1.40)全因死亡增加3.7倍(P=0.012),心血管病死亡率虽有增加但无显著性。通过COX回归分析,调整年龄、高血压史、糖尿病史、吸烟等因素后,显示全因死亡和CVD死亡的相对危险仍呈同样趋势。结论低ABI是预测女性MS患者全因死亡的独立性危险因素,女性MS患者早期常规接受ABI检查,积极预防和治疗PAD对提高生存率具有重要价值。     

Comparative prognostic value of glomerular filtration rate estimating formulas in ischaemic heart disease

BACKGROUND: Chronic kidney disease is a major risk factor for cardiovascular death and may be detected by measuring serum creatinine levels (SCr). Alternatively, renal function may be evaluated by estimating glomerular filtration rate (GFR) with formulas based on SCr and variables such as age, sex and body weight. The purpose of the study was to compare the predictive value of GFR, calculated with the Cockcroft-Gault (CG) and revised Modification of Diet in Renal Disease formulas, in a population with ischaemic heart disease (IHD). DESIGN: Retrospective observational study. METHODS: Renal function was analysed in 1705 patients (mean age 55+/-9.2 years, 80% male) who had been admitted to our Institute for IHD. The relationship between reduced GFR and outcome was examined through Kaplan-Meier curves and Cox regression analysis. RESULTS: Ten-year mortality was 20% and had as predictors both an abnormal (> or =1.10 mg/dl) SCr and reduced (<60 ml/min/1.73 m2) Modification of Diet in Renal Disease and CG GFR (P<0.0001 for each). Using Cox regression analysis, significant coronary atherosclerosis, defined as a greater than 50% stenosis in at least one major vessel, turned out to be the factor most closely linked to increased mortality [HR corresponds to hazard ratio 4.40, 95% (confidence interval) CI 2.78-6.97, P<0.001], followed by reduced CG GFR (HR 2.08, 95% CI 1.55-2.79, P<0.001) and left bundle branch block (HR 2.00, 95% CI 1.10-3.61, P<0.001). CONCLUSION: GFR, especially if calculated with the CG formula, is an important prognostic indicator for IHD among hospitalized patients, and predicts survival more accurately than SCr and conventional coronary risk factors.     

Diabetes mellitus and risk of fatal ischaemic heart disease by gender: 18 years follow-up of 74,914 individuals in the HUNT 1 Study.

AIM: To study long-term mortality from ischaemic heart disease (IHD) in subjects with and without diabetes and how the association between diabetes and fatal IHD is influenced by gender and established cardiovascular disease (CVD). METHODS AND RESULTS: In 1984-86, all inhabitants aged 20 years or older in Nord-Tr?ndelag County, Norway were invited to the HUNT Study. A total of 74,914 participated in our study, 2100 of them with prevalent diabetes. During 18 years of follow-up, 19,967 persons died. Among people without diabetes or CVD at baseline, men had twice (HR 2.20, CI 2.00-2.41) the rate of fatal IHD compared with women. With diabetes present, the gender gap was substantially reduced (HR 1.25, CI 0.9-1.72), and if both diabetes and CVD were present, IHD mortality in men and women was identical (HR 1.1, CI 0.79-1.64). Gender specific analyses showed a stronger association of diabetes with IHD mortality in women (HR 2.71, CI 2.33-3.16) compared with men (HR 1.98, CI 1.70-2.30, test for interaction, P < 0.01). CONCLUSION: Diabetes is a stronger predictor for IHD mortality in women than in men, and diabetes attenuates the usual gender gap in IHD mortality. With both diabetes and established CVD present, the gender gap is fully attenuated.     

Mortality in diabetes compared with previous cardiovascular disease: A gender-specific meta-analysis

AimsDiabetes has been described as a cardiovascular disease (CVD) risk equivalent. There is evidence, however, that its impact may differ between women and men. For this reason, our study aimed to obtain gender-specific hazard ratios (HRs) comparing diabetes and CVD patients in terms of all-cause, CVD and coronary heart disease (CHD) mortality.MethodsIndividuals with diabetes (without CVD) and those with CVD (without diabetes) were examined through a systematic review of articles that provided gender-specific HRs for mortality. Searches included Medline, Embase and the Cochrane Library database (from January 1998 to December 2009) and exploded MeSH headings [cardiovascular diseases, risk, epidemiologic studies, case-control studies, cohort studies, mortality, outcome assessment (health care), sex factors, survival analysis and diabetes mellitus, type 2]. Two observers selected and reviewed the studies and hierarchical Bayesian random-effects models were used to combine HRs, thereby accommodating any between-study differences through inclusion of a between-study variance in HRs.ResultsOut of 5425 studies, nine were relevant (0.17%). CVD and CHD mortality in men was lower for diabetes alone (CVD mortality HR: 0.82, 95% CrI: 0.69–0.98; CHD mortality HR: 0.73, 95% CrI: 0.65–0.83). In contrast, rates appeared to be higher in women with diabetes alone (CVD mortality HR: 1.29, 95% CrI: 0.79–2.26; CHD mortality HR: 1.28, 95% CrI: 0.75–2.22), although wide credible intervals precluded any definitive conclusions. All-cause mortality in men was similar for diabetes and previous CVD (HR: 1.02, 95% CrI: 0.93–1.12) whereas, among women, it was at least as high and possibly higher for diabetes alone (HR: 1.25, 95% CrI: 0.89–1.76).ConclusionCompared with previous CVD, diabetes alone leads to lower CVD and CHD mortality risk in men, and similar all-cause mortality. In contrast, although further studies are needed, it is possible that diabetes leads to higher CVD, CHD and all-cause mortality in women.     

Chronic kidney disease and risk of incident myocardial infarction and all-cause and cardiovascular disease mortality in middle-aged men and women from the general population.

AIMS: Chronic kidney disease (CKD) was found to be an independent risk factor for all-cause mortality as well as adverse cardiovascular disease (CVD) events in high-risk populations. Findings from population-based studies are scarce and inconsistent. We investigated the gender-specific association of CKD with all-cause mortality, cardiovascular mortality, and incident myocardial infarction (MI) in a population-based cohort. METHODS AND RESULTS: The study was based on 3860 men and 3674 women (aged 45-74 years) who participated in one of the three MONICA Augsburg surveys between 1984 and 1995. CKD was defined by an estimated glomerular filtration rate between 15 and 59 mL/min/1.73 m(2). Hazard ratios (HRs) were estimated from Cox proportional hazard models. In this study, 890 total deaths, 400 CVD deaths, and 321 incident MIs occurred in men up to 31 December 2002; the corresponding numbers in women were 442, 187, and 102. In multivariable analyses, the HR for women with CKD compared to women with preserved renal function was significant for incident MI [HR 1.67; 95% confidence interval (CI) 1.07-2.61] and CVD mortality (HR 1.60; 95% CI 1.17-2.18). In men, CKD was also significantly associated with incident MI (HR 1.51; 95% CI 1.09-2.10) and CVD mortality (HR 1.48; 95% CI 1.15-1.92) after adjustment for common CVD risk factors. In contrast, men and women with CKD had no significant increased risk of all-cause mortality. CONCLUSION: CKD was strongly associated with an increased risk of incident MI and CVD mortality independent from common cardiovascular risk factors in men and women from the general population.     

Pro–A-Type Natriuretic Peptide,Proadrenomedullin, and N-Terminal Pro–B-Type Natriuretic Peptide Used in a Multimarker Strategy in Primary Health Care in Risk Assessment of Patients With Symptoms of Heart Failure

ObjectiveUse of new biomarkers in the handling of heart failure patients has been advocated in the literature, but most often in hospital-based populations. Therefore, we wanted to evaluate whether plasma measurement of N-terminal pro–B-type natriuretic peptide (NT-proBNP), midregional pro–A-type natriuretic peptide (MR-proANP), and midregional proadrenomedullin (MR-proADM), individually or combined, gives prognostic information regarding cardiovascular and all-cause mortality that could motivate use in elderly patients presenting with symptoms suggestive of heart failure in primary health care.Methods and ResultsThe study included 470 elderly patients (mean age 73 years) with symptoms of heart failure in primary health care. All participants underwent clinical examination, 2-dimenstional echocardiography, and plasma measurement of the 3 propeptides and were followed for 13 years. All mortality was registered during the follow-up period. The 4th quartiles of the biomarkers were applied as cutoff values. NT-proBNP exhibited the strongest prognostic information with >4-fold increased risk for cardiovascular mortality within 5 years. For all-cause mortality MR-proADM exhibited almost 2-fold and NT-proBNP 3-fold increased risk within 5 years. In the 5–13-year perspective, NT-proBNP and MR-proANP showed significant and independent cardiovascular prognostic information. NT-proBNP and MR-proADM showed significant prognostic information regarding all-cause mortality during the same time. In those with ejection fraction (EF) <40%, MR-proADM exhibited almost 5-fold increased risk of cardiovascular mortality with 5 years, whereas in those with EF >50% NT-proBNP exhibited >3-fold increased risk if analyzed as the only biomarker in the model. If instead the biomarkers were all below the cutoff value, the patients had a highly reduced mortality risk, which also could influence the handling of patients.ConclusionsThe 3 biomarkers could be integrated in a multimarker strategy for use in primary health care.     

The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality.

AIMS: To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease (IHD) and all-cause mortality. METHODS AND RESULTS: Prospective cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD. During approximately 20 years of follow-up, 1242 cases of fatal IHD occurred and 5901 died from all causes. Within both genders, being physically active was associated with lower hazard ratios (HR) of both fatal IHD and all-cause mortality than being physically inactive. Further, weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality. Within level of physical activity, non-drinkers had the highest HR of fatal IHD, whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality. Further, the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake. Thus, the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake. Conclusion Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality.     

Risk factors of peripheral arterial disease and relationship between low ankle brachial index and mortality from all-cause and cardiovascular disease in Chinese patients with hypertension

The aim of this study was to evaluate the risk factors of peripheral arterial disease (PAD) and the relationship between ankle brachial index (ABI) and mortality from all-cause and cardiovascular disease (CVD) in Chinese patients with hypertension. The ABI cohort Study was designed to investigate risk factors of PAD and the relationship between ABI and mortality from all-cause and CVD in Chinese patients. ABI was identified at baseline by measuring systolic pressure at bilateral brachial and tibial arteries. Mortality surveillance was completed from November 2005 to January 2006. Among 3047 participants with hypertension at baseline, 839 (27.5%) were in the low-ABI group. Older age, female gender, higher serum level of triglycerides, lower serum level of high-density lipoprotein, a history of diabetes and a history of smoking were associated with low ABI. During the 13-month follow-up, there were 252 deaths, of which 100 died of CVD. Low ABI was associated with mortality from all-cause and CVD, whose adjusted relative risk was 1.619 (95% confidence interval 1.190-2.203) and 2.454 (1.531-3.933), respectively, in Cox regression models. The survival rate was significantly lower in the low-ABI group than in the normal-ABI group. This study demonstrated that low ABI was independently associated with a high risk of all-cause and CVD mortality in Chinese patients with hypertension. ABI should be promoted as an ideal tool to predict mortality in diabetic patients.     

Serum creatinine predicts mortality in patients with peripheral artery disease: influence of diabetes and hypertension

BACKGROUND: Patients with renal insufficiency tend to suffer from advanced atherosclerosis and exhibit a reduced life expectancy. We investigated the association of renal impairment, traditional cardiovascular risk factors and all-cause mortality in patients with symptomatic peripheral artery disease (PAD). METHODS: We studied 515 patients with advanced PAD (intermittent claudication, n = 410; critical ischemia, n = 105). Cardiovascular risk profile and calculated glomerular filtration rate (GFR) were obtained at baseline and patients were followed for median 21 months (interquartile range 12 to 25) for mortality. RESULTS: Sixty-five patients (13%) died. Cumulative survival rates at 6, 12, and 24 months were 97%, 95%, and 89%, respectively. Adjusted hazard ratios for mortality according to decreasing quartiles of GFR were 1.2, 2.5, and 5.9 compared to the highest quartile (P < 0.001). The association between renal impairment and mortality was independent of diabetes and hypertension, suggesting that decreased GFR adds to the prognostic value of traditional cardiovascular risk factors. CONCLUSION: Renal impairment is associated with an increased risk for mortality in patients with advanced peripheral artery disease, irrespective of the coincidence of arterial hypertension and diabetes mellitus. This suggests that impaired renal function exerts an unfavorable effect on patient's outcome, independently of these cardiovascular and renal risk factors.     

Incident Clinical and Mortality Associations of Myocardial Native T1 in the UK Biobank

BackgroundCardiac magnetic resonance native T1-mapping provides noninvasive, quantitative, and contrast-free myocardial characterization. However, its predictive value in population cohorts has not been studied.ObjectivesThe associations of native T1 with incident events were evaluated in 42,308 UK Biobank participants over 3.17 ± 1.53 years of prospective follow-up.MethodsNative T1-mapping was performed in 1 midventricular short-axis slice using the Shortened Modified Look-Locker Inversion recovery technique (WIP780B) in 1.5-T scanners (Siemens Healthcare). Global myocardial T1 was calculated using an automated tool. Associations of T1 with: 1) prevalent risk factors (eg, diabetes, hypertension, and high cholesterol); 2) prevalent and incident diseases (eg, any cardiovascular disease [CVD], any brain disease, valvular heart disease, heart failure, nonischemic cardiomyopathies, cardiac arrhythmias, atrial fibrillation [AF], myocardial infarction, ischemic heart disease [IHD], and stroke); and 3) mortality (eg, all-cause, CVD, and IHD) were examined. Results are reported as odds ratios (ORs) or HRs per SD increment of T1 value with 95% CIs and corrected P values, from logistic and Cox proportional hazards regression models.ResultsHigher myocardial T1 was associated with greater odds of a range of prevalent conditions (eg, any CVD, brain disease, heart failure, nonischemic cardiomyopathies, AF, stroke, and diabetes). The strongest relationships were with heart failure (OR: 1.41 [95% CI: 1.26-1.57]; P = 1.60 × 10^-9) and nonischemic cardiomyopathies (OR: 1.40 [95% CI: 1.16-1.66]; P = 2.42 × 10^-4). Native T1 was positively associated with incident AF (HR: 1.25 [95% CI: 1.10-1.43]; P = 9.19 × 10^-4), incident heart failure (HR: 1.47 [95% CI: 1.31-1.65]; P = 4.79 × 10^-11), all-cause mortality (HR: 1.24 [95% CI: 1.12-1.36]; P = 1.51 × 10^-5), CVD mortality (HR: 1.40 [95% CI: 1.14-1.73]; P = 0.0014), and IHD mortality (HR: 1.36 [95% CI: 1.03-1.80]; P = 0.0310).ConclusionsThis large population study demonstrates the utility of myocardial native T1-mapping for disease discrimination and outcome prediction.     

The metabolic syndrome predicts cardiovascular mortality: a 13-year follow-up study in elderly non-diabetic Finns.

AIMS: The metabolic syndrome (MetS) is defined as a clustering of cardiovascular risk factors characterized by insulin resistance. We investigated the relationship of the MetS and its single components, defined by all six different criteria, with coronary heart disease (CHD), cardiovascular disease (CVD), and all-cause mortality in a prospective population-based study. METHODS AND RESULTS: The MetS was defined according to the World Health Organization (WHO), the European Group for the Study of Insulin Resistance (EGIR), the National Cholesterol Education Program (NCEP), the American College of Endocrinology (ACE), the International Diabetes Federation (IDF), and the American Heart Association (updated NCEP) criteria. We investgated the relationship of the MetS defined by aforementioned six criteria with CHD, CVD, and all-cause mortality with Cox regression analyses in a non-diabetic Finnish population of 1025 subjects, aged 65-74 years, during the 13-year follow-up. The MetS defined by all aforementioned criteria was associated with a statistically significant risk for CVD mortality when adjusted for all confounding variables (Hazards Ratios, HRs from 1.31 to 1.51). The MetS defined by the WHO, ACE, and IDF criteria was associated with an increased risk of CHD mortality (HRs from 1.42 to 1.58). There was no association between the MetS by any criteria and all-cause mortality. Of the single components of the MetS, the following predicted CVD mortality in multivariable models: impaired fasting glucose by the WHO, NCEP, and ACE criteria (HR 1.34) and by the IDF and updated NCEP criteria (HR 1.29); impaired glucose tolerance by the WHO and ACE criteria (HR 1.55); low HDL cholesterol by the EGIR criteria (HR 1.50) and by the NCEP, IDF, and updated NCEP criteria (HR 1.29); and microalbuminuria according to the WHO definition (HR 1.86). CONCLUSION: The MetS defined by all six current criteria predicts CVD mortality in elderly subjects. However, of the single components of the MetS, IFG, IGT, low HDL cholesterol, and microalbuminuria predicted CVD mortality with equal or higher HRs when compared with the different definitions of the MetS. Therefore, our study suggests that the MetS is a marker of CVD risk, but not above and beyond the risk associated with its individual components.     

Análisis de la relación dosis-respuesta de la actividad física recreativa con los eventos cardiovasculares y la mortalidad por todas las causas: el estudio REGICOR

Introduction and objectivesRegular leisure-time physical activity (LTPA) has been consistently recognized as a protective factor for cardiovascular diseases (CVD) and all-cause mortality. However, the pattern of this relationship is still not clear. The aim of this study was to assess the relationship of LTPA with incident CVD and mortality in a Spanish population.MethodsA prospective population-based cohort of 11 158 randomly selected inhabitants from the general population. LTPA was assessed by a validated questionnaire. Mortality and CVD outcomes were registered during the follow-up (median: 7.24 years). The association between LTPA and outcomes of interest (all-cause mortality and cardiovascular disease) was explored using a generalized additive model with penalized smoothing splines and multivariate Cox proportional hazard models.ResultsWe observed a significant nonlinear association between LTPA and all-cause and CVD mortality, and fatal and nonfatal CVD. Moderate-vigorous intensity LTPA, but not light-intensity LTPA, were associated with beneficial effects. The smoothing splines identified a cutoff at 400 MET-min/d. Below this threshold, each increase of 100 MET-min/d in moderate-vigorous LTPA contributed with a 16% risk reduction in all-cause mortality (HR, 0.84; 95%CI, 0.77-0.91), a 27% risk reduction in CVD mortality (HR, 0.73; 95%CI, 0.61-0.87), and a 12% risk reduction in incident CVD (HR, 0.88; 95%CI, 0.79-0.99). No further benefits were observed beyond 400 MET-min/d.ConclusionsOur results support a nonlinear inverse relationship between moderate-vigorous LTPA and CVD and mortality. Benefits of PA are already observed with low levels of activity, with a maximum benefit around 3 to 5 times the current recommendations.Full English text available from:www.revespcardiol.org/en     

The influence of age on the clinical implications of N-terminal pro-B-type natriuretic peptide in acute coronary syndrome

Currently, there are no studies addressing the influence of age on the prognostic information of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in Asian population with acute coronary syndrome (ACS). The purpose of this study was to investigate the prognostic performance of NT-proBNP in Chinese patients with ACS across different age groups. A total of 1512 ACS patients with venous blood NT-proBNP measured were enrolled. Patients were divided into tertiles based on their ages (<61, 61–71, ≥72 years). The median NT-proBNP concentrations in the three groups (T1–T3) were 406, 573, and 1288 pg/ml (p < 0.001), respectively. During a median follow-up of 23 months, 150 all-cause deaths occurred, and 88 (58.7 %) were attributed to cardiovascular cause. NT-proBNP levels are independently associated with mortality in each age group [1st group: HR 2.19 95 % CI (1.17–4.10); 2nd group: HR 1.82 95 % CI (1.04–3.20); 3rd group: HR 1.48 95 % CI (1.09–2.01), P interaction = 0.062]. NT-proBNP improves discrimination and reclassification for mortality beyond thrombolysis in myocardial infarction score in patients of all ages. The optimal NT-proBNP cutoff points for predicting mortality in three age groups are 1511, 2340, and 2883 pg/ml, respectively. In conclusion, NT-proBNP is a valuable biomarker in predicting long-term mortality and provides an improvement in discrimination and reclassification for prognosis in ACS patients of all ages.     

Chronic leg ulcer is a strong predictor to determine the major cardiovascular events in diabetic patients with peripheral arterial disease in Thailand

Peripheral arterial disease (PAD) in patients with diabetic mellitus (DM) is a fatal condition. The most common causes of morbidity and mortality in these patients are major adverse cardiovascular events (MACE) such as myocardial infarction and death. Therefore, the study on prognostic factors of MACE in these patients is important. A multi-center, prospective cohort study of 500 DM patients with PAD, between June 2014 and July 2016, were followed up in 18 months. Primary end point was MACE, which included non-fatal myocardial infarction, stroke, worsening PAD, and death. The prognostic factors, which aggregated from recent literatures, were entered into a Cox proportional hazard model. The adequacies of treatments were evaluated by assessing the risk factor control for atherosclerosis. This project was supported by the Health System Research Institute (HSRI) Thailand. Ninety-five MACE occurred. The prognostic factors associated with MACE were chronic kidney disease (CKD) (HR 2.32, 95% CI 1.41–3.80), gangrene/chronic ulcer (HR 3.03, 95% CI 1.82–5.06), history of aortic surgery (HR 24.07, 95% CI 5.28–109.71), history of taking clopidogrel (HR 2.16, 95% CI 1.13–4.12), and history of taking warfarin (HR 3.24, 95% CI 1.50–7.02). In atherosclerosis risk factor management, patients had reached the target in the control of diastolic blood pressure (73.10%) and stopped smoking (91.83%). In summary, the prognostic factors for MACE in Thai DM patients with PAD were CKD, gangrene/chronic ulcer, history of aortic surgery, and patients with history of taking clopidogrel or warfarin. The optimization of prognostic factors and atherosclerosis risk factor should be campaigned to reduce the morbidity and mortality of these patients.