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Cseh D, Climie RE, Offredo L, Guibout C, Thomas F, Zanoli L, Danchin N, Sharman JE, Laurent S, Jouven X, Boutouyrie P, Empana JP. Type 2 Diabetes Mellitus Is Independently Associated With Decreased Neural Baroreflex Sensitivity: The Paris Prospective Study III. Arterioscler Thromb Vasc Biol 2020; 40:1420-1428. [PMID: 32188272 DOI: 10.1161/atvbaha.120.314102] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Impaired baroreflex function is an early indicator of cardiovascular autonomic imbalance. Patients with type 2 diabetes mellitus (T2D) have decreased baroreflex sensitivity (BRS), however, whether the neural BRS (nBRS) and mechanical component of the BRS is altered in those with high metabolic risk (HMR, impaired fasting glucose and metabolic syndrome) or with overt T2D, is unknown. We examined this in a community-based observational study, the Paris Prospective Study III (PPS3). Approach and Results: In 7626 adults aged 50 to 75 years, resting nBRS (estimated by low-frequency gain, from carotid distension rate and RR [time elapsed between two successive R waves] intervals) and mechanical BRS were measured by high-precision carotid echotracking. The associations between overt T2D or HMR as compared with subjects with normal glucose metabolism and nBRS or mechanical BRS were quantified using multivariable linear regression analysis. There were 319 subjects with T2D (61±6 years, 77% male), 1450 subjects with HMR (60±6 years, 72% male), and 5857 subjects with normal glucose metabolism (59±6 years, 57% male). Compared with normal glucose metabolism, nBRS was significantly lower in HMR subjects (β=-0.07 [95% CI, -0.12 to -0.01]; P=0.029) and in subjects with T2D (β=-0.18 [95% CI, -0.29 to -0.07]; P=0.002) after adjustment for confounding and mediating factors. Subgroup analysis suggests significant and independent alteration in mechanical BRS only among HMR patients who had both impaired fasting glucose and metabolic syndrome. CONCLUSIONS In this community-based study of individuals aged 50 to 75, a graded decrease in nBRS was observed in HMR subjects and patients with overt T2D as compared with normal glucose metabolism subjects.
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Esslinger U, Garnier S, Korniat A, Proust C, Kararigas G, Müller-Nurasyid M, Empana JP, Morley MP, Perret C, Stark K, Bick AG, Prasad SK, Kriebel J, Li J, Tiret L, Strauch K, O'Regan DP, Marguiles KB, Seidman JG, Boutouyrie P, Lacolley P, Jouven X, Hengstenberg C, Komajda M, Hakonarson H, Isnard R, Arbustini E, Grallert H, Cook SA, Seidman CE, Regitz-Zagrosek V, Cappola TP, Charron P, Cambien F, Villard E. Correction: Exome-wide association study reveals novel susceptibility genes to sporadic dilated cardiomyopathy. PLoS One 2020; 15:e0229472. [PMID: 32059048 PMCID: PMC7021299 DOI: 10.1371/journal.pone.0229472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Karam N, Bataille S, Marijon E, Tafflet M, Benamer H, Caussin C, Garot P, Juliard JM, Pires V, Boche T, Dupas F, Le Bail G, Lamhaut L, Simon B, Allonneau A, Mapouata M, Loyeau A, Empana JP, Lapostolle F, Spaulding C, Jouven X, Lambert Y. Incidence, Mortality, and Outcome-Predictors of Sudden Cardiac Arrest Complicating Myocardial Infarction Prior to Hospital Admission. Circ Cardiovasc Interv 2020; 12:e007081. [PMID: 30608874 DOI: 10.1161/circinterventions.118.007081] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mortality of ST-segment-elevation myocardial infarction (STEMI) decreased drastically, mainly through reduction in inhospital mortality. Prehospital sudden cardiac arrest (SCA) became one of the most feared complications. We assessed the incidence, outcome, and prognosis' predictors of prehospital SCA occurring after emergency medical services (EMS) arrival. METHODS AND RESULTS Data were taken between 2006 and 2014 from the e-MUST study (Evaluation en Médecine d'Urgence des Strategies Thérapeutiques des infarctus du myocarde) that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Among 13 253 STEMI patients analyzed, 749 (5.6%) presented EMS-witnessed prehospital SCA. Younger age, absence of cardiovascular risk factors, symptoms of heart failure, extensive STEMI, and short pain onset-to-call and call-to-EMS arrival delays were independently associated with increased SCA risk. Mortality rate at hospital discharge was 4.0% in the nonSCA group versus 37.7% in the SCA group ( P<0.001); 26.8% of deaths occurred before hospital admission. Factors associated with increased mortality after SCA were age, heart failure, and extensive STEMI, while male sex and cardiovascular risk factors were associated with decreased mortality. Among patients admitted alive, PCI was the most important mortality-reduction predictor (odds ratio, 0.40; 95% CI, 0.25-0.63; P<0.0001). CONCLUSIONS More than 1 of 20 STEMI presents prehospital SCA after EMS arrival. SCA occurrence is associated with a 10-fold higher mortality at hospital discharge compared with STEMI without SCA. PCI is the strongest survival predictor, leading to a twice-lower mortality. This highlights the persistently dramatic impact of SCA on STEMI and the major importance of PCI in this setting.
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Bruno RM, Nilsson P, Ensgrtom G, Wadstrom B, Empana JP, Boutouyrie P, Laurent S. 1.2 Chronological Versus Vascular Age: Predictive Value for Cardiovascular Events and Identification of Patients with SUPERNOrmal Vascular Aging (SUPERNOVA). Artery Res 2020. [DOI: 10.2991/artres.k.191224.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Climie R, Boutouyrie P, Perier MC, Guibout C, van Slotten T, Thomas F, Danchin N, Sharman J, Laurent S, Jouven X, Empana JP. 1.6 Individual and Neighborhood Deprivation and Carotid Stiffness: The Paris Prospective III Study. Artery Res 2020. [DOI: 10.2991/artres.k.191224.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Danchin N, Guibout C, Jouven X, Perier MC, Thomas F, Fortier C, Empana JP, Khettab H, Bruno RM, Boutouyrie P. YI 2.4 Neural Baroreflex Sensitivity and Long-Term Effect of Antihypertensive Agents—A Pharmacological Substudy of the Paris Prospective Study III. Artery Res 2020. [DOI: 10.2991/artres.k.201209.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Climie RE, Boutouyrie P, Perier MC, Chaussade E, Plichart M, Offredo L, Guibout C, van Sloten TT, Thomas F, Pannier B, Sharman JE, Laurent S, Jouven X, Empana JP. Association Between Occupational, Sport, and Leisure Related Physical Activity and Baroreflex Sensitivity. Hypertension 2019; 74:1476-1483. [DOI: 10.1161/hypertensionaha.119.13461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physical activity (PA) is a preventative behavior for noncommunicable disease. However, little consideration is given as to whether different domains of PA have differing associations with health outcomes. We sought to determine the association between occupational, sport, leisure, and total PA with baroreflex sensitivity (BRS), distinguishing between neural (nBRS) and mechanical (mBRS) BRS. In a cross-sectional analysis of 8649 adults aged 50 to 75 years, resting nBRS (estimated by low-frequency gain, from carotid distension rate and heart rate) and mBRS (carotid stiffness) were measured by high-precision carotid echo-tracking. PA was self-reported using the validated Baecke questionnaire. The associations between PA and nBRS and mBRS were quantified using multivariate linear regression analysis, separately in the working and nonworking population. In working adults (n=5039), occupational PA was associated with worse nBRS (unstandardized β=−0.02; [95% CI, −0.04 to −0.003];
P
=0.022) whereas sport PA was associated with better nBRS (β=0.04; [95% CI, 0.02–0.07];
P
=0.003) and mBRS (β=−0.05; [95% CI, −0.09 to −0.00001];
P
=0.049). Neither leisure PA nor total PA was associated with nBRS or mBRS. In nonworking adults (n=3610), sport PA and total PA were associated with better mBRS (β=−0.08; [95% CI, −0.15 to 0.02];
P
=0.012 and β=−0.05; [95% CI, −0.10 to 0.009];
P
=0.018) but not nBRS. These findings suggest differential associations between domains of PA and BRS and may provide insights into the mechanisms underlying the association between occupational PA and cardiovascular disease.
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Adlam D, Olson TM, Combaret N, Kovacic JC, Iismaa SE, Al-Hussaini A, O'Byrne MM, Bouajila S, Georges A, Mishra K, Braund PS, d'Escamard V, Huang S, Margaritis M, Nelson CP, de Andrade M, Kadian-Dodov D, Welch CA, Mazurkiewicz S, Jeunemaitre X, Wong CMY, Giannoulatou E, Sweeting M, Muller D, Wood A, McGrath-Cadell L, Fatkin D, Dunwoodie SL, Harvey R, Holloway C, Empana JP, Jouven X, Olin JW, Gulati R, Tweet MS, Hayes SN, Samani NJ, Graham RM, Motreff P, Bouatia-Naji N. Association of the PHACTR1/EDN1 Genetic Locus With Spontaneous Coronary Artery Dissection. J Am Coll Cardiol 2019; 73:58-66. [PMID: 30621952 PMCID: PMC10403154 DOI: 10.1016/j.jacc.2018.09.085] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes (ACS) afflicting predominantly younger to middle-aged women. Observational studies have reported a high prevalence of extracoronary vascular anomalies, especially fibromuscular dysplasia (FMD) and a low prevalence of coincidental cases of atherosclerosis. PHACTR1/EDN1 is a genetic risk locus for several vascular diseases, including FMD and coronary artery disease, with the putative causal noncoding variant at the rs9349379 locus acting as a potential enhancer for the endothelin-1 (EDN1) gene. OBJECTIVES This study sought to test the association between the rs9349379 genotype and SCAD. METHODS Results from case control studies from France, United Kingdom, United States, and Australia were analyzed to test the association with SCAD risk, including age at first event, pregnancy-associated SCAD (P-SCAD), and recurrent SCAD. RESULTS The previously reported risk allele for FMD (rs9349379-A) was associated with a higher risk of SCAD in all studies. In a meta-analysis of 1,055 SCAD patients and 7,190 controls, the odds ratio (OR) was 1.67 (95% confidence interval [CI]: 1.50 to 1.86) per copy of rs9349379-A. In a subset of 491 SCAD patients, the OR estimate was found to be higher for the association with SCAD in patients without FMD (OR: 1.89; 95% CI: 1.53 to 2.33) than in SCAD cases with FMD (OR: 1.60; 95% CI: 1.28 to 1.99). There was no effect of genotype on age at first event, P-SCAD, or recurrence. CONCLUSIONS The first genetic risk factor for SCAD was identified in the largest study conducted to date for this condition. This genetic link may contribute to the clinical overlap between SCAD and FMD.
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Bougouin W, Dumas F, Lamhaut L, Marijon E, Carli P, Combes A, Pirracchio R, Aissaoui N, Karam N, Deye N, Sideris G, Beganton F, Jost D, Cariou A, Jouven X, Adnet F, Agostinucci JM, Aissaoui-Balanant N, Algalarrondo V, Alla F, Alonso C, Amara W, Annane D, Antoine C, Aubry P, Azoulay E, Beganton F, Benhamou D, Billon C, Bougouin W, Boutet J, Bruel C, Bruneval P, Cariou A, Carli P, Casalino E, Cerf C, Chaib A, Cholley B, Cohen Y, Combes A, Crahes M, Da Silva D, Das V, Demoule A, Denjoy I, Deye N, Dhonneur G, Diehl JL, Dinanian S, Domanski L, Dreyfuss D, Duboc D, Dubois-Rande JL, Dumas F, Empana JP, Extramiana F, Fartoukh M, Fieux F, Gabbas M, Gandjbakhch E, Geri G, Guidet B, Halimi F, Henry P, Hidden Lucet F, Jabre P, Jacob L, Joseph L, Jost D, Jouven X, Karam N, Kassim H, Lacotte J, Lahlou-Laforet K, Lamhaut L, Lanceleur A, Langeron O, Lavergne T, Lecarpentier E, Leenhardt A, Lellouche N, Lemiale V, Lemoine F, Linval F, Loeb T, Ludes B, Luyt CE, Maltret A, Mansencal N, Mansouri N, Marijon E, Marty J, Maury E, Maxime V, Megarbane B, Mekontso-Dessap A, Mentec H, Mira JP, Monnet X, Narayanan K, Ngoyi N, Perier MC, Piot O, Pirracchio R, Plaisance P, Plu I, Raux M, Revaux F, Ricard JD, Richard C, Riou B, Roussin F, Santoli F, Schortgen F, Sharifzadehgan A, Sideris G, Spaulding C, Teboul JL, Timsit JF, Tourtier JP, Tuppin P, Ursat C, Varenne O, Vieillard-Baron A, Voicu S, Wahbi K, Waldmann V. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J 2019; 41:1961-1971. [DOI: 10.1093/eurheartj/ehz753] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/26/2019] [Accepted: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.
Methods and results
We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).
Conclusions
In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.
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Sharman JE, Boutouyrie P, Perier MC, Thomas F, Guibout C, Khettab H, Pannier B, Laurent S, Jouven X, Empana JP. Impaired baroreflex sensitivity, carotid stiffness, and exaggerated exercise blood pressure: a community-based analysis from the Paris Prospective Study III. Eur Heart J 2019; 39:599-606. [PMID: 29281076 DOI: 10.1093/eurheartj/ehx714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/06/2017] [Indexed: 11/12/2022] Open
Abstract
Aims People with exaggerated exercise blood pressure (BP) have adverse cardiovascular outcomes. Mechanisms are unknown but could be explained through impaired neural baroreflex sensitivity (BRS) and/or large artery stiffness. This study aimed to determine the associations of carotid BRS and carotid stiffness with exaggerated exercise BP. Methods and results Blood pressure was recorded at rest and following an exercise step-test among 8976 adults aged 50 to 75 years from the Paris Prospective Study III. Resting carotid BRS (low frequency gain, from carotid distension rate, and heart rate) and stiffness were measured by high-precision echotracking. A systolic BP threshold of ≥ 150 mmHg defined exaggerated exercise BP and ≥140/90 mmHg defined resting hypertension (±antihypertensive treatment). Participants with exaggerated exercise BP had significantly lower BRS [median (Q1; Q3) 0.10 (0.06; 0.16) vs. 0.12 (0.08; 0.19) (ms2/mm) 2×108; P < 0.001] but higher stiffness [mean ± standard deviation (SD); 7.34 ± 1.37 vs. 6.76 ± 1.25 m/s; P < 0.001) compared to those with non-exaggerated exercise BP. However, only lower BRS (per 1SD decrement) was associated with exaggerated exercise BP among people without hypertension at rest {specifically among those with optimal BP; odds ratio (OR) 1.16 [95% confidence intervals (95% CI) 1.01; 1.33], P = 0.04 and high-normal BP; OR, 1.19 (95% CI 1.07; 1.32), P = 0.001} after adjustment for age, sex, body mass index, smoking, alcohol, total cholesterol, high-density lipoprotein cholesterol, resting heart rate, and antihypertensive medications. Conclusion Impaired BRS, but not carotid stiffness, is independently associated with exaggerated exercise BP even among those with well controlled resting BP. This indicates a potential pathway from depressed neural baroreflex function to abnormal exercise BP and clinical outcomes.
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Kingue S, Kouam Kouam C, Suliman A, Antignac M, Empana JP, Jolis N, Traore A, Toure IA, Damorou JM, Sidy Ali A, Ikama SM, Niakara A, Balde D, Jouven X, Diop IB. P3344Research network in Africa (RNA): observatory of hospitalizations in cardiology departments in 14 African countries (FEBRUARY Study: 2016, 2017 and 2018). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Epidemiological transition in the developing world has resulted in a shift from infectious to non-communicable diseases as leading causes of morbidity and mortality, cardiovascular (CV) disease (CVD) is the first cause of death in Africa. However, data regarding the characteristic of patients with CVD are scarce, especially in Sub-Saharan Africa.
Purpose
We built an observatory recording the characteristics of all patients admitted to hospital in CV departments and hospital care components in Sub-Saharan Africa (FEBRUARY Study).
Methods
We conducted a transversal and longitudinal study in CV departments of 29 hospitals from 14 African countries. FEBRUARY study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all patients admitted in hospitalization during the month of February every year since 2016 and will continue every year. Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians.
Results
Overall 2680 patients were admitted to hospital in February 2016 (n=736), 2017 (n=967), and 2018 (n=987) in CV departments from 14 countries: Benin, Burkina Faso, Burundi, Cameroon, Congo, Côte d'Ivoire, Gabon, Guinea, Mali, Niger, Dem. Rep of The Congo, Senegal, Togo and Sudan (figure). Men represented 58,8%. Mean age of age was 54 years and Women 52 years. The mean length of stay was 9 days, and death rate 10,1%. The main cause of admission was cardiac failure (40,3%) followed by acute coronary syndrome (10.1%) and stroke (9,3%). Among CV risk factors, high blood pressure, sedentary behavior, diabetes, active tobacco consumption and dyslipidemia were present in 46%, 19%, 13%, 11% and 6% of patients, respectively.
In a longitudinal analysis, hospital admission due coronary syndrome increased from 7% in 2016 to 10.5% in 2018 (p for trend = 0.03). Length of hospital stay and rate of hospital death remain stable.
Hospitalizations by country (FEBRUARY)
Conclusion
The FEBRUARY observatory is an important tool to describe cardiovascular characteristics of patients in transversal analysis, but also the longitudinal evolution over the coming years in Sub-Saharan Africa.
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Diop IB, Antignac M, Nhavoto C, Sidy Ali A, Balde D, Empana JP, Dzudie A, Thiam S, Cavagna P, Adoubi A, Perier MC, Takombe JL, Ikama MS, Houenassi MD, Jouven X. P3459Research Network in Africa (RNA): gender differences in cardiovascular risk factors and complications in 12 African countries. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiovascular diseases are rapidly growing epidemic in Sub-Saharan Africa. Unlike other regions of the world, death rates due to hypertension are greater for women than men in Africa. Scarce data were available on factors associated with gender in cardiovascular risk factors and complications in Sub-Saharan Africa.
Purpose
To assess gender differences in cardiovascular risk factors pattern in patients with hypertension in 12 Sub-Saharan countries.
Methods
We conducted a cross-sectional survey in urban clinics of twelve countries in Africa. Data were collected on demographics, treatment and standardized BP measures were made among the hypertensive patients attending the clinics. BP control was defined as BP<140/90 mmHg and hypertension grades were defined according to European Society of Cardiology guidelines. The separate association between women factors and BP control was investigated using Generalized Linear Mixed-Effects Models adjusted on age; A random effect on the country was added (generalized estimated equation models) to account for inter-country variability.
Results
The EIGHT study enrolled 2198 patients with hypertension in 12 sub-Saharan countries between January 2014 and November 2015. The proportion of women (60,2%) was higher than men and varied significantly according to countries (p<0.001), ranged from 33.7% (Guinea) to 71.9% (Gabon). Mean age was 57.7±12.0 years for women and 59.2±11.4 years for men (p<0.001).
Compared to men, women had a higher rate of family cardiovascular background (79% vs 70%, for women and men respectively) (p<0.0001), cardiovascular risk factors (74.3% vs 68.1) (p=0.008), such as obesity (25.8% vs 12.1%) (p<0.0001), sedentary behavior (42.1% vs 35.0%) (p=0,006). BP control didn't differ according to gender, the repartition of grades of hypertension was similar between women and men and proportion of uncontrolled BP was 77.2% in women and 77.8% in men (p=0.4), with same proportion of women and men receiving antihypertensive treatment (96 vs 97.5%) (NS).
However, African women had less cardiovascular complications than men (39% vs 52.4%) (p<0.0001) (OR: 0.50 [CI 95% 0.41–0.61]).
Conclusions
Our study highlighted gender differences in cardiovascular risk factors pattern in Sub-Saharan hypertensive patients. Tailoring medical (public health) programs to improve cardiovascular disease prevention that take into women characteristics may enhance their effectiveness.
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Climie RE, van Sloten TT, Périer MC, Tafflet M, Fayosse A, Dugravot A, Singh-Manoux A, Empana JP. Change in Cardiovascular Health and Incident Type 2 Diabetes and Impaired Fasting Glucose: The Whitehall II Study. Diabetes Care 2019; 42:1981-1987. [PMID: 31416895 PMCID: PMC7364667 DOI: 10.2337/dc19-0379] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/21/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Most previous studies on cardiovascular health (CVH) and incident type 2 diabetes (T2D) have used a single measure of CVH, and none have investigated the association with impaired fasting glucose (IFG). We examined the association between changes in CVH and incident T2D and IFG. RESEARCH DESIGN AND METHODS Within the Whitehall II study, CVH was examined every 5 years from 1991/93 until 2015/16. Subjects with 0-2, 3-4, and 5-6 ideal metrics of CVH from the American Heart Association were categorized as having low, moderate, or high CVH, respectively. RESULTS There were 6,234 participants (mean age 49.8 ± 6.0 years, 70% male) without prior cardiovascular disease and T2D, including 5,015 who were additionally free from IFG at baseline. Over a median follow-up of 24.8 (interquartile range 24.0-25.2) years, 895 and 1,703 incident cases of T2D and IFG occurred, respectively. Change in CVH between 1991/93 and 2002/04 was calculated among 4,464 participants free from CVD and T2D and among 2,795 participants additionally free from IFG. In multivariate analysis, compared with those with stable low CVH, risk of T2D was lower in those with initially high CVH (hazard ratio [HR] 0.21; 95% CI 0.09, 0.51), those who had persistently moderate CVH or changed from moderate to high CVH (moderate-moderate/high; HR 0.53; 95% CI 0.41, 0.69), low-moderate/high (HR 0.62; 95% CI 0.45, 0.86), and moderate-low (HR 0.74; 95% CI 0.56, 0.98). Results were similar for IFG, but the effect sizes were smaller. CONCLUSIONS Compared with stable low CVH, other patterns of change in CVH were associated with lower risk of T2D and IFG.
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Bruno RM, Nilsson P, Engstrom G, Wadstrom B, Empana JP, Boutouyrie P, Laurent S. P1553Differential association between vascular and chronological age with cardiovascular outcomes. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Increased pulse wave velocity (PWV), is a reliable marker of early vascular aging (EVA). However, the identification of individuals whose arteries are abnormally healthy in comparison to their age and cardiovascular (CV) risk profile might be of interest, to discover novel pathways of cardioprotection and provide preventive strategies for successful vascular aging.
Purpose
1) to provide a novel calculation for vascular age and examine his determinants; 2) to test the hypothesis that individuals with the largest difference between chronological and vascular age (C-V age) show a lower rate of CV events than their counterparts, and may thus be defined as the supernormal vascular aging group (SUPERNOVA).
Methods
Vascular age was defined as predicted age based on classical CV risk factors and PWV. The best fitting model for vascular age was investigated in the multicenter, European, cross-sectional Reference Values for Arterial stiffness Collaboration Database (n=11406). Continuous variables were modelled as smoothing splines. Thereafter, the risk of fatal and non-fatal CV events associated with C-V age was examined in the longitudinal cohort of the Malmo Diet and Cancer Study (n=2663) using Cox proprotional hazard regression models. C-V age was examined as a continuous variable (natural splines) and as a 3 levels categorical variables based on the best grouping of the deciles of C-V age and corresponding to the EVA (<3.0 years), normal vascular aging (3.0 to 8.8 years) and SUPERNOVA (>8.8 years) respectively.
Results
In the Reference Values Cohort (age range 17–85 years, 52.4% men, 38.1% hypertensives, 3.9% diabetics, average PWV 7.8 m/s), the most significant predictor of vascular age (full model r2 0.598) was PWV. In the Malmo Diet and Cancer Study Cohort (age 61–89 years, 63.6% men, 64.0% hypertensives, 12.9% diabetics, PWV 11.5 m/s), during follow-up (6.6 years on average), 286 individuals developed a first cardiovascular event. In the Cox survival analysis, C-V age was significantly and inversely associated with CV events. Compare to normal vascular aging, participants with SUPERNOVA had lower risk for CV events [HR 0.51 (0.34–0.76)] whereas those with EVA had a higher risk [HR 2.71 (1.80–4.09)]. Instead, there was no significant association with all-cause mortality.
Conclusions
The use of PWV and CV risk factors may be useful to define early and supernormal vascular aging in particular, and to assess its clinical relevance towards the risk of cardiovascular disease and death.
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Loupy A, Aubert O, Orandi BJ, Naesens M, Bouatou Y, Raynaud M, Divard G, Jackson AM, Viglietti D, Giral M, Kamar N, Thaunat O, Morelon E, Delahousse M, Kuypers D, Hertig A, Rondeau E, Bailly E, Eskandary F, Böhmig G, Gupta G, Glotz D, Legendre C, Montgomery RA, Stegall MD, Empana JP, Jouven X, Segev DL, Lefaucheur C. Prediction system for risk of allograft loss in patients receiving kidney transplants: international derivation and validation study. BMJ 2019; 366:l4923. [PMID: 31530561 PMCID: PMC6746192 DOI: 10.1136/bmj.l4923] [Citation(s) in RCA: 193] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To develop and validate an integrative system to predict long term kidney allograft failure. DESIGN International cohort study. SETTING Three cohorts including kidney transplant recipients from 10 academic medical centres from Europe and the United States. PARTICIPANTS Derivation cohort: 4000 consecutive kidney recipients prospectively recruited in four French centres between 2005 and 2014. Validation cohorts: 2129 kidney recipients from three centres in Europe and 1428 from three centres in North America, recruited between 2002 and 2014. Additional validation in three randomised controlled trials (NCT01079143, EudraCT 2007-003213-13, and NCT01873157). MAIN OUTCOME MEASURE Allograft failure (return to dialysis or pre-emptive retransplantation). 32 candidate prognostic factors for kidney allograft survival were assessed. RESULTS Among the 7557 kidney transplant recipients included, 1067 (14.1%) allografts failed after a median post-transplant follow-up time of 7.12 (interquartile range 3.51-8.77) years. In the derivation cohort, eight functional, histological, and immunological prognostic factors were independently associated with allograft failure and were then combined into a risk prediction score (iBox). This score showed accurate calibration and discrimination (C index 0.81, 95% confidence interval 0.79 to 0.83). The performance of the iBox was also confirmed in the validation cohorts from Europe (C index 0.81, 0.78 to 0.84) and the US (0.80, 0.76 to 0.84). The iBox system showed accuracy when assessed at different times of evaluation post-transplant, was validated in different clinical scenarios including type of immunosuppressive regimen used and response to rejection therapy, and outperformed previous risk prediction scores as well as a risk score based solely on functional parameters including estimated glomerular filtration rate and proteinuria. Finally, the accuracy of the iBox risk score in predicting long term allograft loss was confirmed in the three randomised controlled trials. CONCLUSION An integrative, accurate, and readily implementable risk prediction score for kidney allograft failure has been developed, which shows generalisability across centres worldwide and common clinical scenarios. The iBox risk prediction score may help to guide monitoring of patients and further improve the design and development of a valid and early surrogate endpoint for clinical trials. TRIAL REGISTRATION Clinicaltrials.gov NCT03474003.
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Sabia S, Fayosse A, Dumurgier J, Schnitzler A, Empana JP, Ebmeier KP, Dugravot A, Kivimäki M, Singh-Manoux A. Association of ideal cardiovascular health at age 50 with incidence of dementia: 25 year follow-up of Whitehall II cohort study. BMJ 2019; 366:l4414. [PMID: 31391187 PMCID: PMC6664261 DOI: 10.1136/bmj.l4414] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To examine the association between the Life Simple 7 cardiovascular health score at age 50 and incidence of dementia. DESIGN Prospective cohort study. SETTING Civil service departments in London (Whitehall II study; study inception 1985-88). PARTICIPANTS 7899 participants with data on the cardiovascular health score at age 50. EXPOSURES The cardiovascular health score included four behavioural (smoking, diet, physical activity, body mass index) and three biological (fasting glucose, blood cholesterol, blood pressure) metrics, coded on a three point scale (0, 1, 2). The cardiovascular health score was the sum of seven metrics (score range 0-14) and was categorised into poor (scores 0-6), intermediate (7-11), and optimal (12-14) cardiovascular health. MAIN OUTCOME MEASURE Incident dementia, identified through linkage to hospital, mental health services, and mortality registers until 2017. RESULTS 347 incident cases of dementia were recorded over a median follow-up of 24.7 years. Compared with an incidence rate of dementia of 3.2 (95% confidence interval 2.5 to 4.0) per 1000 person years among the group with poor cardiovascular health, the absolute rate differences per 1000 person years were -1.5 (95% confidence interval -2.3 to -0.7) for the group with intermediate cardiovascular health and -1.9 (-2.8 to -1.1) for the group with optimal cardiovascular health. Higher cardiovascular health score was associated with a lower risk of dementia (hazard ratio 0.89 (0.85 to 0.95) per 1 point increment in the cardiovascular health score). Similar associations with dementia were observed for the behavioural and biological subscales (hazard ratios per 1 point increment in the subscores 0.87 (0.81 to 0.93) and 0.91 (0.83 to 1.00), respectively). The association between cardiovascular health at age 50 and dementia was also seen in people who remained free of cardiovascular disease over the follow-up (hazard ratio 0.89 (0.84 to 0.95) per 1 point increment in the cardiovascular health score). CONCLUSION Adherence to the Life Simple 7 ideal cardiovascular health recommendations in midlife was associated with a lower risk of dementia later in life.
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Climie RE, Empana JP. Response by Climie et al to Letter Regarding Article "Individual and Neighborhood Deprivation and Carotid Stiffness: The Paris Prospective Study III". Hypertension 2019; 74:e30. [PMID: 31230543 DOI: 10.1161/hypertensionaha.119.13392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Climie RE, Boutouyrie P, Perier MC, Guibout C, van Sloten TT, Thomas F, Danchin N, Sharman JE, Laurent S, Jouven X, Empana JP. Individual and Neighborhood Deprivation and Carotid Stiffness. Hypertension 2019; 73:1185-1194. [DOI: 10.1161/hypertensionaha.118.12186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Climie RE, van Sloten TT, Bruno RM, Taddei S, Empana JP, Stehouwer CD, Sharman JE, Boutouyrie P, Laurent S. Macrovasculature and Microvasculature at the Crossroads Between Type 2 Diabetes Mellitus and Hypertension. Hypertension 2019; 73:1138-1149. [DOI: 10.1161/hypertensionaha.118.11769] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lindström S, Brody JA, Turman C, Germain M, Bartz TM, Smith EN, Chen MH, Puurunen M, Chasman D, Hassler J, Pankratz N, Basu S, Guan W, Gyorgy B, Ibrahim M, Empana JP, Olaso R, Jackson R, Brækkan SK, McKnight B, Deleuze JF, O’Donnell CJ, Jouven X, Frazer KA, Psaty BM, Wiggins KL, Taylor K, Reiner AP, Heckbert SR, Kooperberg C, Ridker P, Hansen JB, Tang W, Johnson AD, Morange PE, Trégouët DA, Kraft P, Smith NL, Kabrhel C. A large-scale exome array analysis of venous thromboembolism. Genet Epidemiol 2019; 43:449-457. [PMID: 30659681 PMCID: PMC6520188 DOI: 10.1002/gepi.22187] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/26/2018] [Accepted: 12/11/2019] [Indexed: 01/12/2023]
Abstract
Although recent Genome-Wide Association Studies have identified novel associations for common variants, there has been no comprehensive exome-wide search for low-frequency variants that affect the risk of venous thromboembolism (VTE). We conducted a meta-analysis of 11 studies comprising 8,332 cases and 16,087 controls of European ancestry and 382 cases and 1,476 controls of African American ancestry genotyped with the Illumina HumanExome BeadChip. We used the seqMeta package in R to conduct single variant and gene-based rare variant tests. In the single variant analysis, we limited our analysis to the 64,794 variants with at least 40 minor alleles across studies (minor allele frequency [MAF] ~0.08%). We confirmed associations with previously identified VTE loci, including ABO, F5, F11, and FGA. After adjusting for multiple testing, we observed no novel significant findings in single variant or gene-based analysis. Given our sample size, we had greater than 80% power to detect minimum odds ratios greater than 1.5 and 1.8 for a single variant with MAF of 0.01 and 0.005, respectively. Larger studies and sequence data may be needed to identify novel low-frequency and rare variants associated with VTE risk.
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van Sloten TT, Boutouyrie P, Lisan Q, Tafflet M, Thomas F, Guibout C, Climie RE, Pannier B, Sharman JE, Laurent S, Jouven X, Empana JP. Body Silhouette Trajectories Across the Lifespan and Vascular Aging. Hypertension 2019; 72:1095-1102. [PMID: 30354814 DOI: 10.1161/hypertensionaha.118.11442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Vascular aging is a major contributor to cardiovascular disease and can be quantified by higher carotid stiffness, intima-media thickness and diameter, and hypertension. Weight gain across the lifetime may be an important, modifiable determinant of vascular aging. We therefore aimed to assess lifetime body silhouette trajectories (a marker of weight change across the lifespan) in relation to vascular aging in late adulthood. We used cross-sectional data from a community-based cohort study (n=8243; age, 59.4; 38.7% women). A linear mixed model was used to assess trajectories of recalled body silhouettes from age 8 to 45 years. We assessed carotid artery properties (ultrasonography), resting hypertension (blood pressure ≥140/90 mm Hg or use of antihypertensives), and exaggerated exercise blood pressure, a marker of masked hypertension (systolic blood pressure ≥150 mm Hg during submaximal exercise) at study recruitment when the participants were 50 to 75 years of age. We identified 5 distinct body silhouette trajectories: lean stable (32.0%), lean increase (11.1%), moderate stable (32.5%), lean-marked increase (16.3%), and heavy stable (8.1%). Compared with individuals in the lean-stable trajectory, those in the moderate-stable, lean-marked increase, and heavy-stable trajectories had higher carotid stiffness, intima-media thickness and diameter (odds ratios between 1.23 and 2.10 for highest quartile versus lowest quartile of manifestations of vascular aging; P<0.05) and were more likely to have resting hypertension and exaggerated exercise blood pressure, after adjustment for potential confounders (odds ratios between 1.31 and 1.60; P<0.05). Vascular aging was most prominent among individuals who were lean in early life but markedly gained weight during young adulthood and among those who were heavy in early life and maintained weight.
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Hausler N, Lisan Q, Van Sloten T, Haba-Rubio J, Perier MC, Thomas F, Danchin N, Guibout C, Boutouyrie P, Heinzer R, Jouven X, Marques-Vidal P, Empana JP. Cardiovascular health and sleep disturbances in two population-based cohort studies. Heart 2019; 105:1500-1506. [PMID: 30962189 DOI: 10.1136/heartjnl-2018-314485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/14/2019] [Accepted: 03/21/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to investigate the association between cardiovascular health (CVH), as defined by the American Heart Association, and several sleep disturbances. METHODS Two community-based cohorts, the Paris Prospective Study 3 (PPS3, France, n=6441) and the CoLaus study (Switzerland, n=2989) were analysed. CVH includes 7 metrics which all can be classified as poor, intermediate and ideal. Global CVH score was categorised into poor (0-2 ideal metrics), intermediate (3-4 ideal metrics) and ideal (≥5 ideal metrics). Associations between global CVH and self-reported sleep disturbances (proxy of sleep-disordered breathing [SDB], excessive daytime sleepiness, insomnia symptoms and short/long sleep duration) and SDB severity measured by polysomnography (PSG) were investigated. Adjusted OR/relative risk ratio (RRR) and 95% CIs were estimated. Subjects with previous cardiovascular disease were excluded. RESULTS Compared with poor CVH, subjects with intermediate and ideal global CVH had lower odds of self-reported SDB in both cohorts (ORs 0.55; 95% CI 0.44 to 0.68 and 0.35; 95% CI 0.22 to 0.53, respectively) and had lower SDB severity measured by PSG (RRR 0.07; 95% CI 0.02 to 0.20) in CoLaus. Subjects with intermediate and ideal global CVH had lower odds of excessive daytime sleepiness in PPS3 (ORs 0.82; 0.72 to 0.95 and 0.80; 0.82 to 1.02, respectively). No consistent associations were found between CVH and sleep duration or insomnia symptoms. CONCLUSIONS Higher levels of CVH are associated with lower odds of SDB and excessive daytime sleepiness. However, causal interpretation cannot be made and associations might be bidirectional.
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van Sloten TT, Boutouyrie P, Tafflet M, Offredo L, Thomas F, Guibout C, Climie RE, Lemogne C, Pannier B, Laurent S, Jouven X, Empana JP. Carotid Artery Stiffness and Incident Depressive Symptoms: The Paris Prospective Study III. Biol Psychiatry 2019; 85:498-505. [PMID: 30409381 DOI: 10.1016/j.biopsych.2018.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/27/2018] [Accepted: 09/11/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Arterial stiffness may contribute to late-life depression via cerebral microvascular damage, but evidence is scarce. No longitudinal study has evaluated the association between arterial stiffness and risk of depressive symptoms. Therefore, we investigated the association between carotid artery stiffness and incident depressive symptoms in a large community-based cohort study. METHODS This longitudinal study included 7013 participants (mean age 59.7 ± 6.3 years; 35.8% women) free of depressive symptoms at baseline. Carotid artery stiffness (high-resolution echo tracking) was determined at baseline. Presence of depressive symptoms was determined at baseline and at 4 and 6 years of follow-up, and was defined as a score ≥7 on the validated Questionnaire of Depression, Second Version, Abridged and/or new use of antidepressant medication. Logistic regression and generalized estimating equations were used. RESULTS In total, 6.9% (n = 484) of the participants had incident depressive symptoms. Individuals in the lowest tertile of carotid distensibility coefficient (indicating greater carotid artery stiffness) compared with those in the highest tertile had a higher risk of incident depressive symptoms (odds ratio: 1.43; 95% confidence interval: 1.10-1.87), after adjustment for age, sex, living alone, education, lifestyle, cardiovascular risk factors, and baseline Questionnaire of Depression, Second Version, Abridged scores. Results were qualitatively similar when we used carotid Young's elastic modulus as a measure of carotid stiffness instead of carotid distensibility coefficient, and when we used generalized estimating equations instead of logistic regression. CONCLUSIONS Greater carotid stiffness is associated with a higher incidence of depressive symptoms. This supports the hypothesis that carotid stiffness may contribute to the development of late-life depression.
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Lisan Q, Tafflet M, Thomas F, Boutouyrie P, Guibout C, Haba-Rubio J, Climie R, Périer MC, Van Sloten T, Pannier B, Marques-Vidal P, Jouven X, Empana JP. Body Silhouette Trajectories Over the Lifespan and Insomnia Symptoms: The Paris Prospective Study 3. Sci Rep 2019; 9:1581. [PMID: 30733545 PMCID: PMC6367427 DOI: 10.1038/s41598-018-38145-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/23/2018] [Indexed: 02/03/2023] Open
Abstract
Insomnia symptoms are highly prevalent and associated with several adverse medical conditions, but only few determinants, including non-modifiable ones, have been highlighted. We investigated associations between body silhouette trajectories over the lifespan and insomnia symptoms in adulthood. From a community-based study, 7 496 men and women aged 50–75 years recalled their body silhouette at age 8, 15, 25, 35 and 45, and rated the frequency of insomnia symptoms on a standardized sleep questionnaire. An Epworth Sleepiness Scale ≥11 defined excessive daytime sleepiness (EDS). Using a group-based trajectory modeling, we identified five body silhouette trajectories: a ‘lean-stable’ (32.7%), a ‘heavy-stable’ (8.1%), a ‘moderate-stable’ (32.5%), a ‘lean-increase’ (11%) and a ‘lean-marked increase’ (15.7%) trajectory. In multivariate logistic regression, compared to the ‘lean-stable’ trajectory, the ‘lean-marked increase’ and ‘heavy-stable’ trajectories were associated with a significant increased odd of having ≥1 insomnia symptoms as compared to none and of having a proxy for insomnia disorder (≥1 insomnia symptom and EDS). The association with the ‘lean-marked increase' trajectory’ was independent from body mass index measured at study recruitment. In conclusion, increasing body silhouette over the lifespan is associated with insomnia symptoms in adulthood, emphasizing the importance of weight gain prevention during the entire lifespan.
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Samieri C, Empana JP. Cardiovascular Health and Cognitive Decline-Reply. JAMA 2018; 320:2483-2484. [PMID: 30561478 DOI: 10.1001/jama.2018.17566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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