[Microvascular perfusion and cardiac function after revascularization assessed by myocardial contrast echocardiography in patients with acute ST-segment elevation myocardial infarction]

Objectives: To evaluate microvascular perfusion and left ventricular function in patients with acute ST-segment elevation myocardial infarction after revascularization using myocardial contrast echocardiography (MCE), and to explore clinical influencing factors of abnormal microvascular perfusion in these patients. Methods: This is a cross-sectional study. The analysis was performed among patients admitted to Peking University People's Hospital for acute ST-segment elevation myocardial infarction (STEMI) from June 2018 to July 2021. All patients underwent percutaneous coronary intervention (PCI) and completed MCE within 48 hours after PCI. Patients were divided into normal myocardial perfusion group and abnormal perfusion group according to the myocardial perfusion score. The echocardiographic indexes within 48 hours after PCI, including peak mitral valve flow velocity (E), mean value of early diastolic velocity of left ventricular septum and lateral mitral annulus (Em), left ventricular global longitudinal strain (GLS) and so on, were analyzed and compared between the two groups. Multivariate logistic regression analysis was used to evaluate the influencing factors of myocardial perfusion abnormalities. Results: A total of 123 STEMI patients, aged 59±13 years with 93 (75.6%) males, were enrolled. There were 50 cases in the normal myocardial perfusion group, and 73 cases in the abnormal myocardial perfusion group. The incidence of abnormal myocardial perfusion was 59.3% (73/123). The left ventricular volume index ((62.3±18.4)ml/m² vs. (55.1±15.2)ml/m², P=0.018), wall motion score index (WMSI) (1.59 (1.44, 2.00) vs. 1.24(1.00, 1.47), P<0.001) and mitral E/Em (17.8(12.0, 24.3) vs. 12.2(9.2, 15.7), P<0.001) were significantly higher whereas left ventricular global longitudinal strain (GLS) ((-10.8±3.4)% vs. (-13.8±3.5)%, P<0.001) was significantly lower in the abnormal myocardial perfusion group than those in the normal myocardial perfusion group. Multivariate logistic regression analysis showed that left anterior descending (LAD) as culprit vessel (OR=3.733, 95%CI 1.282-10.873, P=0.016), intraoperative no/low-reflow (OR=6.125, 95%CI 1.299-28.872, P=0.022), and peak troponin I (TnI) (OR=1.018, 95%CI 1.008-1.029, P=0.001) were independent risk factors of abnormal myocardial perfusion. As for ultrasonic indexes, deceleration time of mitral E wave (OR=0.979, 95%CI 0.965-0.993, P=0.003), mitral E/Em (OR=1.100, 95%CI 1.014-1.194, P=0.022) and WMSI (OR=7.470, 95%CI 2.630-21.222, P<0.001) were independently related to abnormal myocardial perfusion. Conclusions: The incidence of abnormal myocardial perfusion after PCI is high in patients with acute STEMI. Abnormal myocardial perfusion is related to worse left ventricular systolic and diastolic function. LAD as culprit vessel, intraoperative no/low-reflow and peak TnI are independent risk factors of abnormal myocardial perfusion.

Cooking and future risk of all-cause and cardiopulmonary mortality

Cooking is practiced worldwide and is associated with multiple social, economic and environmental factors; thus, understanding cooking-related health effects would have broad public health implications. Here, we show that after an average 9.9 years of follow-up for 510,106 Chinese adults, always cooking with clean fuels was associated with lower risks of all-cause (0.90 [95% confidence interval 0.87-0.93]; P = 1.39 × 10-9), cardiovascular (0.83 [0.78-0.87]; P = 6.83 × 10-11) and respiratory (0.88 [0.79-0.99]; P = 0.026) mortality compared with non-cooking, of which 50.1% (14.5-85.6%) to 66.0% (38.5-85.8%) could be attributed to increased household physical activity. The mortality risks decreased with extended duration of cooking with clean fuels in dose-response manners, with the lowest hazard ratios of 0.74 (0.68-0.80; P = 1.20 × 10-13) for all-cause and 0.62 (0.55-0.71; P = 3.15 × 10-12) for cardiovascular mortality among never-smokers reported over 25 years of cooking. Our findings suggest lower future mortality risks may be gained only when cooking with clean fuels.

Ideal cardiovascular health and mortality: pooled results of three prospective cohorts in Chinese adults

BACKGROUND

Evidence on the relations of the American Heart Association's ideal cardiovascular health (ICH) with mortality in Asians is sparse, and the interaction between behavioral and medical metrics remained unclear. We aimed to fill the gaps.

METHODS

A total of 198,164 participants without cancer and cardiovascular disease (CVD) were included from the China Kadoorie Biobank study (2004-2018), Dongfeng-Tongji cohort (2008-2018), and Kailuan study (2006-2019). Four behaviors (i.e., smoking, physical activity, diet, body mass index) and three medical factors (i.e., blood pressure, blood glucose, and blood lipid) were classified into poor, intermediate, and ideal levels (0, 1, and 2 points), which constituted 8-point behavioral, 6-point medical, and 14-point ICH scores. Results of Cox regression from three cohorts were pooled using random-effects models of meta-analysis.

RESULTS

During about 2 million person-years, 20,176 deaths were recorded. After controlling for demographic characteristics and alcohol drinking, hazard ratios (95% confidence intervals) comparing ICH scores of 10-14 vs. 0-6 were 0.52 (0.41-0.67), 0.44 (0.37-0.53), 0.54 (0.45-0.66), and 0.86 (0.64-1.14) for all-cause, CVD, respiratory, and cancer mortality. A higher behavioral or medical score was independently associated with lower all-cause and CVD mortality among the total population and populations with different levels of behavioral or medical health equally, and no interaction was observed.

CONCLUSIONS

ICH was associated with lower all-cause, CVD, and respiratory mortality among Chinese adults. Both behavioral and medical health should be improved to prevent premature deaths.

Association between Fish Consumption and Risk of Chronic Obstructive Pulmonary Disease among Chinese Men and Women: an 11-Year Population-Based Cohort Study

BACKGROUND

Epidemiological evidence on the relation between fish consumption and chronic obstructive pulmonary disease (COPD) is limited, especially among Chinese.

OBJECTIVES

The aim was to explore the prospective association between fish consumption and COPD among a large population-based Chinese cohort.

METHODS

The China Kadoorie Biobank recruited over 0.5 million participants from 10 geographically diverse regions across China from 2004 to 2008. Consumption frequency of fish at baseline was assessed by a validated food-frequency questionnaire. A total of 169,188 men and 252,238 women who had no prior COPD or other major chronic diseases at baseline were included in our analyses. Cox proportional hazard models were used to estimate HRs and 95% CIs for fish consumption categories in relation to incident COPD.

RESULTS

During a median follow-up of 11.1 y, 11,292 incident COPD cases were documented. Fish consumption was inversely associated with COPD risk among women, with a 17% reduction in risk for participants who consumed fish ≥4 d/wk compared with nonconsumption (HR: 0.83; 95% CI: 0.70, 0.99; P-trend = 0.017), whereas we did not observe such a dose-response relation among men (HR: 0.89; 95% CI: 0.76, 1.05; P-trend = 0.373). The joint analysis showed that COPD risk was 38% and 48% lower in men and women who consumed fish ≥4 d/wk and had a healthy lifestyle [having ≥4 of the following healthy lifestyle factors: not smoking currently; never or rarely drinking alcohol; adequate physical activity; BMI (kg/m2): 18.5-23.9; normal waist circumference; reasonable diet], compared with participants with fish consumption <4 d/wk and an unhealthy lifestyle (≤1 factors).

CONCLUSIONS

Higher fish consumption was associated with lower COPD risk among Chinese women but not men. This association was independent of lifestyle factors. Eating adequate fish with an overall healthy lifestyle might help lower the risk of COPD.

Association Between DNA Methylation and Blood Pressure: A 5-Year Longitudinal Twin Study

BACKGROUND

Previous EWASs (Epigenome-Wide Association Studies) have reported hundreds of blood pressure (BP) associated 5'-cytosine-phosphate-guanine-3' (CpG) sites. However, their results were inconsistent. Longitudinal observations on the temporal relationship between DNA methylation and BP are lacking.

METHODS

A candidate CpG site association study for BP was conducted on 1072 twins in the Chinese National Twin Registry. PubMed and EMBASE were searched for candidate CpG sites. Cross-lagged models were used to assess the temporal relationship between BP and DNA methylation in 308 twins who completed 2 surveys in 2013 and 2018. Then, the significant cross-lagged associations were validated by adopting the Inference About Causation From Examination of Familial Confounding approach. Finally, to evaluate the cumulative effects of DNA methylation on the progression of hypertension, we established methylation risk scores based on BP-associated CpG sites and performed Markov multistate models.

RESULTS

16 and 20 CpG sites were validated to be associated with systolic BP and diastolic BP, respectively. In the cross-lagged analysis, we detected that methylation of 2 CpG sites could predict subsequent systolic BP, and systolic BP predicted methylation at another 3 CpG sites. For diastolic BP, methylation at 3 CpG sites had significant cross-lagged effects for predicting diastolic BP levels, while the prediction from the opposite direction was observed at one site. Among these, 3 associations were validated in the Inference About Causation From Examination of Familial Confounding analysis. Using the Markov multistate model, we observed that methylation risk scores were associated with the development of hypertension.

CONCLUSIONS

Our findings suggest the significance of DNA methylation in the development of hypertension.

Association between pneumonia hospitalisation and long-term risk of cardiovascular disease in Chinese adults: A prospective cohort study

BACKGROUND

Lower respiratory tract infections, including pneumonia, have been associated with short-term increased risk of cardiovascular disease (CVD). However, there is only limited evidence about the long-term impact of pneumonia on the cardiovascular system beyond one year.

METHODS

We conducted a prospective matched cohort study based on data from the China Kadoorie Biobank study of 482,017 adults who were enrolled between June 25, 2004, and July 15, 2008, and were free of CVD at baseline and before pneumonia hospitalization. A total of 24,060 patients hospitalised with pneumonia were identified until December 31, 2018, and were matched on age, sex, urban or rural areas, and decile of the frailty index to 223,875 controls. We used the piecewise Cox proportional hazards model to estimate the hazard ratios (HRs) and their 95% confidence intervals (CIs) for pre-specified incident CVD outcomes, including ischaemic heart disease (IHD), arrhythmia, heart failure (HF), ischaemic stroke (IS), and hemorrhagic stroke (HS), at various time intervals through 10 years after pneumonia hospitalization.

FINDINGS

Of the 247,935 pneumonia cases and controls included, the mean age (standard deviation) was 53.5 (10.4), and 40.8% (101,159) were men. During follow-up, 2389 (9.9%) pneumonia cases developed IHD, 489 (2.0%) cases developed arrhythmia, 545 (2.3%) cases developed HF, 1764 (7.3%) cases developed IS, and 348 (1.4%) cases developed HS. After adjustment for sociodemographic characteristics, lifestyle factors, health status and medication, underlying conditions, and family history of CVD, the elevated CVD risk was highest within the first 30 days after pneumonia hospitalisation, with subsequent risk reductions varying by subtypes. The elevated risk remained until the eighth year after pneumonia hospitalisation for IHD, arrhythmia, and HF, with HRs (95% CIs) of 1.48 (1.13-1.93), 2.69 (1.70-4.25), and 4.36 (2.86-6.64), respectively. The risk of stroke associated with pneumonia hospitalisation remained elevated until the seventh year for IS (HR = 1.30; 95% CI: 1.04-1.63), and until the second year for HS (1.39; 1.07-1.80). The above associations were consistently observed across various characteristics of the participants.

INTERPRETATION

In middle-aged and older Chinese adults, pneumonia hospitalisation was associated with short- and long-term CVD risk, with the elevated risk of certain CVD outcomes persisting for up to 8 years.

FUNDING

National Natural Science Foundation of China, the National Key R&D Program of China, the Chinese Ministry of Science and Technology, the Kadoorie Charitable Foundation in Hong Kong, the UK Wellcome Trust.

Longitudinal Association of DNA Methylation With Type 2 Diabetes and Glycemic Traits: A 5-Year Cross-Lagged Twin Study

Investigators of previous cross-sectional epigenome-wide association studies (EWAS) in adults have reported hundreds of 5'-cytosine-phosphate-guanine-3' (CpG) sites associated with type 2 diabetes mellitus (T2DM) and glycemic traits. However, the results from EWAS have been inconsistent, and longitudinal observations of these associations are scarce. Furthermore, few studies have investigated whether DNA methylation (DNAm) could be modified by smoking, drinking, and glycemic traits, which have broad impacts on genome-wide DNAm and result in altering the risk of T2DM. Twin studies provide a valuable tool for epigenetic studies, as twins are naturally matched for genetic information. In this study, we conducted a systematic literature search in PubMed and Embase for EWAS, and 214, 33, and 117 candidate CpG sites were selected for T2DM, HbA1c, and fasting blood glucose (FBG). Based on 1,070 twins from the Chinese National Twin Registry, 67, 17, and 16 CpG sites from previous studies were validated for T2DM, HbA1c, and FBG. Longitudinal review and blood sampling for phenotypic information and DNAm were conducted twice in 2013 and 2018 for 308 twins. A cross-lagged analysis was performed to examine the temporal relationship between DNAm and T2DM or glycemic traits in the longitudinal data. A total of 11 significant paths from T2DM to subsequent DNAm and 15 paths from DNAm to subsequent T2DM were detected, suggesting both directions of associations. For glycemic traits, we detected 17 cross-lagged associations from baseline glycemic traits to subsequent DNAm, and none were from the other cross-lagged direction, indicating that CpG sites may be the consequences, not the causes, of glycemic traits. Finally, a longitudinal mediation analysis was performed to explore the mediation effects of DNAm on the associations of smoking, drinking, and glycemic traits with T2DM. No significant mediations of DNAm in the associations linking smoking and drinking with T2DM were found. In contrast, our study suggested a potential role of DNAm of cg19693031, cg00574958, and cg04816311 in mediating the effect of altered glycemic traits on T2DM.

Association between metabolically healthy obesity and non-alcoholic fatty liver disease

BACKGROUND

The risks of NAFLD and NAFLD with fibrosis progression among metabolically healthy obesity (MHO) individuals are largely unexplored. This cohort study investigated the association between MHO as well as other metabolic syndrome-obesity combined phenotypes and NAFLD and its fibrosis progression.

METHODS

Participants included 31,010 adults from a health check-up cohort free from NAFLD and intermediate or high probability of advanced fibrosis at baseline. Metabolically healthy was defined as not having any component of metabolic syndrome. Obesity was identified by body mass index (BMI) and waist circumference (WC). Participants were cross-classified by metabolic health and obesity at baseline. The outcomes were NAFLD, and NAFLD with fibrosis progression, as assessed by abdominal B-type ultrasound and noninvasive fibrosis score.

RESULTS

During a median follow-up of 2.2 (interquartile range, 1.2-4.9) years, 7,393 participants developed NAFLD. MHO individuals (HR 5.51, 95% CI 4.98, 6.09 for BMI criteria; HR 6.76, 95% CI 6.04, 7.57 for WC criteria) had a significantly higher risk of NAFLD than those with metabolically healthy normal weight or low WC. The corresponding HRs (95% CIs) for metabolically healthy overweight (defined by BMI) and medium WC were 2.74 (2.49-3.02) and 2.93 (2.65-3.24), respectively. Furthermore, 557 participants developed NAFLD with fibrosis progression. The association between different obesity phenotypes and NAFLD with fibrosis progression also showed a similar pattern.

CONCLUSION

MHO was associated with significantly higher risks of NAFLD and its fibrosis progression, suggesting that regarding NAFLD prevention, MHO individuals might still benefit from lifestyle interventions aimed at body weight and WC maintenance.

Tobacco smoking and risks of more than 470 diseases in China: a prospective cohort study

BACKGROUND

Tobacco smoking is estimated to account for more than 1 million annual deaths in China, and the epidemic continues to increase in men. Large nationwide prospective studies linked to different health records can help to periodically assess disease burden attributed to smoking. We aimed to examine associations of smoking with incidence of and mortality from an extensive range of diseases in China.

METHODS

We analysed data from the prospective China Kadoorie Biobank, which recruited 512 726 adults aged 30-79 years, of whom 210 201 were men and 302 525 were women. Participants who had no major disabilities were identified through local residential records in 100-150 administrative units, which were randomly selected by use of multistage cluster sampling, from each of the ten diverse study areas of China. They were invited and recruited between June 25, 2004, and July 15, 2008. Upon study entry, trained health workers administered a questionnaire assessing detailed smoking behaviours and other key characteristics (eg, sociodemographics, lifestyle, and medical history). Participants were followed up via electronic record linkages to death and disease registries and health insurance databases, from baseline to Jan 1, 2018. During a median 11-year follow-up (IQR 10-12), 285 542 (55·7%) participants were ever hospitalised, 48 869 (9·5%) died, and 5252 (1·0%) were lost to follow-up during the age-at-risk of 35-84 years. Cox regression yielded hazard ratios (HRs) associating smoking with disease incidence and mortality, adjusting for multiple testing.

FINDINGS

At baseline, 74·3% of men and 3·2% of women (overall 32·4%) ever smoked regularly. During follow-up, 1 137 603 International Classification of Diseases, 10th revision (ICD-10)-coded incident events occurred, involving 476 distinct conditions and 85 causes of death, each with at least 100 cases. Compared with never-regular smokers, ever-regular smokers had significantly higher risks for nine of 18 ICD-10 chapters examined at age-at-risk of 35-84 years. For individual conditions, smokers had significantly higher risks of 56 diseases (50 for men and 24 for women) and 22 causes of death (17 for men and nine for women). Among men, ever-regular smokers had an HR of 1·09 (95% CI 1·08-1·11) for any disease incidence when compared with never-regular smokers, and significantly more episodes and longer duration of hospitalisation, particularly those due to cancer and respiratory diseases. For overall mortality, the HRs were greater in men from urban areas than in men from rural areas (1·50 [1·42-1·58] vs 1·25 [1·20-1·30]). Among men from urban areas who began smoking at younger than 18 years, the HRs were 2·06 (1·89-2·24) for overall mortality and 1·32 (1·27-1·37) for any disease incidence. In this population, 19·6% of male (24·3% of men residing in urban settings and 16·2% of men residing in rural settings) and 2·8% of female deaths were attributed to ever-regular smoking.

INTERPRETATION

Among Chinese adults, smoking was associated with higher risks of morbidity and mortality from a wide range of diseases. Among men, the future smoking-attributed disease burden will increase further, highlighting a pressing need for reducing consumption through widespread cessation and uptake prevention.

FUNDING

British Heart Foundation, Cancer Research UK, Chinese Ministry of Science and Technology, Kadoorie Charitable Foundation, UK Medical Research Council, National Natural Science Foundation of China, Wellcome Trust.

Healthy lifestyle and life expectancy at age 30 years in the Chinese population: an observational study

BACKGROUND

The improvement of life expectancy is one of the aims of the Healthy China 2030 blueprint. We aimed to investigate the extent to which healthy lifestyles are associated with life expectancy in Chinese adults.

METHODS

We used the prospective China Kadoorie Biobank (CKB) study to examine the relative risk of mortality associated with individual and combined lifestyle factors (never smoking or quitting not for illness, no excessive alcohol use, being physically active, healthy eating habits, and healthy body shape). Participants with coronary heart disease, stroke, cancer, or missing values for body-mass index were excluded. For analysis of chronic respiratory diseases, participants with chronic obstructive pulmonary disease or asthma were excluded. We estimated the national prevalence of lifestyle factors using data from the China Nutrition and Health Surveillance (CNHS; 2015) and derived mortality rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (2015). All three data sources were combined to estimate the life expectancy of individuals at age 30 years following different levels of lifestyle factors by using the life table method. The cause-specific decomposition of the life expectancy differences was analysed using Arriaga's method.

FINDINGS

After the exclusion of CKB participants with coronary heart disease, stroke, cancer, or missing BMI data at baseline, 487 209 were included in the primary analysis. Participants with COPD or asthma at baseline were additionally excluded for chronic respiratory disease-related analysis, leaving 451 233 participants with data available for analysis. Data from 171 127 adults aged 30-84 years from the CNHS 2015 were used to estimate the sex-specific and age-specific prevalence of lifestyle-related factors. There were 42 496 deaths documented over a median follow-up of 11·1 years (IQR 10·2-12·1) in CKB. The adjusted hazard ratios (aHRs) of participants adopting five versus 0-1 low-risk factors was 0·38 (95% CI 0·34-0·43) for all-cause mortality, aHR 0·37 (0·30-0·46) for cardiovascular disease mortality, aHR 0·47 (0·39-0·56) for cancer mortality, and aHR 0·30 (0·14-0·64) for chronic respiratory disease mortality. The life expectancy at age 30 years for individuals with 0-1 low-risk factors was on average 41·7 years (95% CI 41·5-42·0) for men and 47·3 years (46·6-48·0) for women. For individuals with all five low-risk factors, the life expectancy at age 30 was 50·5 years (95% CI 48·5-52·4) for men and 55·4 years (53·5-57·4) for women; meaning a difference of 8·8 years (95% CI 6·8-10·7) for men and 8·1 years (6·5-9·9) for women. The estimated extended life expectancy for men and women was mainly attributable to reduced death from cardiovascular disease (2·4 years [27% of the total extended life expectancy] for men and 3·7 years [46%] for women), cancer (2·6 years [30%] for men and 0·9 years [11%] for women), and chronic respiratory disease (0·6 years [7%] for men and 1·2 years [15%] for women).

INTERPRETATION

Our findings suggest that increasing the adoption of these five healthy lifestyle factors through public health interventions could be associated with substantial gains in life expectancy in the Chinese population.

FUNDING

National Natural Science Foundation of China, National Key Research and Development Program of China, Kadoorie Charitable Foundation, UK Wellcome Trust.

Investigation into the Health Effects of Reduced Chymase Function Using Predicted Loss-of-Function Mutations in CMA1

Tissue remodelling and fibrosis which occur in response to injury play a central role in the development of many diseases. Chymase is a key enzyme believed to mediate these pathological processes. As such, chymase inhibitors have been under active development for the treatment of a number of conditions. To investigate the impact of reduced chymase function, we constructed a genetic score from two pLoF mutations in the gene encoding chymase and tested its association with diseases and biomarkers. Our study found no association between the genetically-predicted reduced chymase function score and heart failure, chronic kidney disease or other predefined conditions. We additionally found no association of the score with any physical measurements or biomarkers. Our results provide no evidence in support of chymase inhibition as a novel therapeutic strategy for the treatment or prevention of heart failure, chronic kidney disease or major cardiovascular events, as previously proposed.

An approach combining bioinformatics and machine learning to identify eight autophagy-related biomarkers and construct molecular mechanisms underlying COVID-19 and major depressive disorders

OBJECTIVE

A lack of objective biomarkers is preventing the screening and diagnosis of COVID-19 combined with major depression disorder (COVID-19-MDD). The purpose of this study was to identify diagnostic biomarkers and gene regulatory mechanisms associated with autophagy; a crucial process significantly involved in the pathogenesis of COVID-19-MDD.

MATERIALS AND METHODS

In this study, differentially expressed genes (DEGs) were screened using GSE98793 from the GEO2R analysis (GEO) database, and intersected with the COVID-19-related gene (CRGs) and autophagy-related genes (ARGs) to obtain common genes involved in. Then, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses of these common genes were performed. Subsequently, the transcription factor (TF)-gene regulatory network and comorbidity network were constructed. In addition, 10 drug candidates were screened using the DSigDB database. To identify diagnostic markers, we used LASSO regression.

RESULTS

In total, 13 common genes were screened, which were primarily enriched in lysosomes, endoplasmic reticulum membranes, and other endomembrane systems also associated with autophagy. Additionally, these genes were involved in neurological cell signaling and have a functional role in pathways related to vascular endothelial growth factor, tyrosine kinase, autophagy, inflammation, immunity, and carcinogenesis. Tumors and psychiatric disorders were the most highly linked diseases to COVID-19. Finally, ten drug candidates and eight diagnostic markers (STX17, NRG1, RRAGD, XPO1, HERC1, HSP90AB1, EPHB2, and S1PR3) were screened.

CONCLUSIONS

This is the first study to screen eight diagnostic markers and construct a gene regulatory network for COVID-19-MDD from the perspective of autophagy. The findings of our study provide novel insights into the diagnosis and treatment of COVID-19-MDD.

The role of lifestyle factors on comorbidity of chronic liver disease and cardiometabolic disease in Chinese population: A prospective cohort study

Background

Lifestyle factors are associated with chronic liver disease (CLD) and death after CLD diagnosis. However, their associations with pathways of CLD progression have been unclear, particularly transition to cardiometabolic disease (CMD), a major comorbid condition with CLD. We assessed the associations of lifestyle factors with CLD progression.

Methods

The study population involved 486,828 participants of the prospective China Kadoorie Biobank (CKB) aged 30-79 years without a history of cardiovascular disease, diabetes, CLD, or cancer at baseline. Liver-cardiometabolic comorbidity (LCC) was defined as developing CMD subsequently after first CLD (FCLD) in an individual. A multi-state model was used to estimate the associations of high-risk lifestyle factors (smoking, alcohol, physical inactivity, and central adiposity) with CLD progression from healthy to FCLD, subsequently to LCC, and further to death.

Findings

During a median follow-up of 11 years, 5046 participants developed FCLD, 519 developed LCC, and 157 died afterwards. There were positive associations between the number of high-risk lifestyle factors and risks of all transitions. The hazard ratios (95% CIs) per 1-factor increase were 1.30 (1.25-1.35) for transitions from baseline to FCLD, 1.21 (1.09-1.34) for FCLD to LCC, 1.20 (1.17-1.23) for baseline to death, 1.15 (1.09-1.22) for FCLD to death, and 1.17 (1.06-1.31) for LCC to death. For CLD subtypes, lifestyle factors showed different associations with disease-specific transitions even within the same transition stage.

Interpretation

High-risk lifestyle factors played a key role in all disease transition stages from healthy to FCLD, subsequently to LCC, and then to death, with different magnitude of associations.

Funding

Kadoorie Charitable Foundation, Chinese MoST and NSFC.

Temporal associations between leukocytes DNA methylation and blood lipids: a longitudinal study

BACKGROUND

The associations between blood lipids and DNA methylation have been investigated in epigenome-wide association studies mainly among European ancestry populations. Several studies have explored the direction of the association using cross-sectional data, while evidence of longitudinal data is still lacking.

RESULTS

We tested the associations between peripheral blood leukocytes DNA methylation and four lipid measures from Illumina 450 K or EPIC arrays in 1084 participants from the Chinese National Twin Registry and replicated the result in 988 participants from the China Kadoorie Biobank. A total of 23 associations of 19 CpG sites were identified, with 4 CpG sites located in or adjacent to 3 genes (TMEM49, SNX5/SNORD17 and CCDC7) being novel. Among the validated associations, we conducted a cross-lagged analysis to explore the temporal sequence and found temporal associations of methylation levels of 2 CpG sites with triglyceride and 2 CpG sites with high-density lipoprotein-cholesterol (HDL-C) in all twins. In addition, methylation levels of cg11024682 located in SREBF1 at baseline were temporally associated with triglyceride at follow-up in only monozygotic twins. We then performed a mediation analysis with the longitudinal data and the result showed that the association between body mass index and HDL-C was partially mediated by the methylation level of cg06500161 (ABCG1), with a mediation proportion of 10.1%.

CONCLUSIONS

Our study indicated that the DNA methylation levels of ABCG1, AKAP1 and SREBF1 may be involved in lipid metabolism and provided evidence for elucidating the regulatory mechanism of lipid homeostasis.

Maintaining healthy sleep patterns and frailty transitions: a prospective Chinese study

BACKGROUND

Little is known about the effects of maintaining healthy sleep patterns on frailty transitions.

METHODS

Based on 23,847 Chinese adults aged 30-79 in a prospective cohort study, we examined the associations between sleep patterns and frailty transitions. Healthy sleep patterns included sleep duration at 7 or 8 h/d, without insomnia disorder, and no snoring. Participants who persisted with a healthy sleep pattern in both surveys were defined as maintaining a healthy sleep pattern and scored one point. We used 27 phenotypes to construct a frailty index and defined three statuses: robust, prefrail, and frail. Frailty transitions were defined as the change of frailty status between the 2 surveys: improved, worsened, and remained. Log-binomial regression was used to calculate the prevalence ratio (PR) to assess the effect of sleep patterns on frailty transitions.

RESULTS

During a median follow-up of 8.0 years among 23,847 adults, 45.5% of robust participants, and 10.8% of prefrail participants worsened their frailty status, while 18.6% of prefrail participants improved. Among robust participants at baseline, individuals who maintained sleep duration of 7 or 8 h/ds, without insomnia disorder, and no-snoring were less likely to worsen their frailty status; the corresponding PRs (95% CIs) were 0.92 (0.89-0.96), 0.76 (0.74-0.77), and 0.85 (0.82-0.88), respectively. Similar results were observed among prefrail participants maintaining healthy sleep patterns. Maintaining healthy sleep duration and without snoring, also raised the probability of improving the frailty status; the corresponding PRs were 1.09 (1.00-1.18) and 1.42 (1.31-1.54), respectively. Besides, a dose-response relationship was observed between constantly healthy sleep scores and the risk of frailty transitions (P for trend < 0.001).

CONCLUSIONS

Maintaining a comprehensive healthy sleep pattern was positively associated with a lower risk of worsening frailty status and a higher probability of improving frailty status among Chinese adults.

Association of anxiety with cardiovascular disease in a Chinese cohort of 0.5 million adults

BACKGROUND

Anxiety might be a potentially modifiable risk factor of cardiovascular diseases (CVDs). Evidence relating anxiety symptoms and generalized anxiety disorder (GAD) to CVDs from prospective cohort study was still lacking in China.

METHODS

Participants aged 30 to 79 years old from 10 areas across China were recruited during 2004-2008 and were followed up until 2017. 487,209 participants without CVDs at baseline remained for analyses. Anxiety symptoms (panic attacks and continuous anxiety) during the past 12 months were identified in a face-to-face interview. Participants with continuous anxiety were further assessed for GAD using Composite International Diagnostic Interview-Short Form. The primary outcomes were incident CVD, ischaemic heart disease (IHD), haemorrhagic stroke (HS), and ischaemic stroke (IS).

RESULTS

During 4.7 million person-years of follow-up, we documented 140,365 incident cases of CVD. For panic attacks, the multivariable-adjusted HRs (95 % CI) were 1.08 (1.04-1.13), 1.10 (1.02-1.19), 1.20 (1.05-1.38) and 1.20 (1.11-1.30) for CVD, IHD, HS and IS, respectively. Continuous anxiety was positively associated with incident CVD and IHD, and the corresponding HRs were 1.12 (1.04-1.20) and 1.21 (1.07-1.37).

LIMITATIONS

Anxiety symptoms were examined according to self-reported questionnaires, which could constitute key study limitations.

CONCLUSIONS

Among the Chinese adults, those with anxiety symptoms or GAD might be important at-risk population of CVD.

Left atrial appendage mechanical dispersion assessed by speckle-tracking echocardiography as a determinant of left atrial appendage stasis in patients with non-valvular atrial fibrillation

Background

We sought to investigate the relationship of left atrial appendage (LAA) mechanical dispersion (MD) with LAA dense spontaneous echo contrast (SEC) or thrombus, and to compare its usefulness in the identification of thrombogenesis with left atrial (LA) MD or LA/LAA strain parameters in patients with nonvalvular atrial fibrillation (AF).

Methods

We conducted a cross-sectional study of 493 consecutive patients with AF (median age 65, male 66.9%) who underwent echocardiography prior to catheter ablation. We measured the LAA and LA global longitudinal strain (GLS) using speckle-tracking echocardiography (STE). LAA MD and LA MD was defined as the standard deviation (SD) of time to peak positive strain corrected by the R-R interval.

Results

Patients with LAA dense SEC/thrombus (n=70) had significantly higher LAA MD than controls (n=423) (median 14.20% vs 9.35%). Areas under the receiver-operating curve for CHA2DS2-VASc score plus LAA MD, LAA GLS or LA GLS were comparable (0.830, 0.843 and 0.809) and superior to that combined with LA MD (0.762, all p&lt;0.01). Multivariable analysis showed that LAA MD was an independent determinant of LAA dense SEC/thrombus in four different models (Odds ratio, 1.23–1.24; P&lt;0.001), and provided additional diagnostic value over clinical and standard echocardiographic parameters. Whereas LA MD was not independently associated with LAA dense SEC/thrombus and had no incremental predictive value.

Conclusion

LAA mechanical dispersion provided incremental information over conventional risk factors in the identification of LAA dense SEC or thrombus in AF patients and is superior to LA mechanical dispersion.

Funding Acknowledgement

Type of funding sources: None.

Cardiac magnetic resonance relaxometry compared to left ventricular ejection fraction in the identification of anthracycline related cardiac changes: a systematic review and meta-analysis

Background

Anthracyclines are associated with cancer therapeutics related cardiac dysfunction (CTRCD). The identification of CTRCD currently uses a change in left ventricular ejection fraction (LVEF). Myocardial damage associated with anthracyclines include myocardial inflammation and oedema. This can be assessed using cardiac magnetic resonance (CMR) relaxometry techniques; T1 and T2 mapping and extracellular volume (ECV) fraction.

Purpose

In this meta-analysis, we compared the magnitude of the changes in LVEF and CMR relaxometry techniques wihtin a month of anthracycline therapy completion.

Methods

We performed a structured literature review as per the PRISMA guidelines across three databases (EMBASE, MEDLINE, and SCOPUS) for studies evaluating CMR relaxometry parameter at baseline and soon after completion of anthracycline therapy (3–5 months post baseline). CMR parameters pre and post anthracycline-based chemotherapy were abstracted. A random effects model was used to pool mean difference (MD) in LVEF and ECV given standardisation in imaging acquisition techniques. A random effects model was used to pool standardized mean difference (SMD) in LVEF, T1, T2 and ECV after anthracycline to adjust for variations in imaging techniques and comparison between techniques.

Results

A total of 174 patients were included from seven studies. 91% were female with a mean age of 55.6 years. The pooled MD in LVEF and ECV was −3.15% [95% CI −4.99, −1.31] and 1.61% [0.90, 2.32], respectively. The pooled SMD in LVEF, T1, T2 and ECV was −0.61 [−0.96, −0.25] 0.34 [0.04, 0.63], 0.67 [0.12,1.21], 0.6 [0.31, 0.89], respectively (Table 1).

Conclusions

T2 mapping, ECV and LVEF can identify early myocardial changes better than T1 mapping. These changes suggest there is marked oedema in the myocardial injury from anthracycline therapy. Whilst these findings support the role of CMR relaxometry in identifying CTRCD, further studies are required.

Funding Acknowledgement

Type of funding sources: None.

Cardioprotection against cardiac dysfunction from breast cancer chemotherapy: a bayesian and frequentist network meta-analysis of randomised controlled trials

Background

Anthracyclines (ANT) are the cornerstone of multiple chemotherapy regimens but at the risk of potential cardiotoxicity. Previous RCTs have tested the prophylactic effects of multiple cardioprotective agents to prevent ANT-related cardiotoxicity. Unfortunately, attempts to combine RCT findings in previous meta-analyses have been heterogeneous, creating further uncertainty. There remains an unmet need to determine the role of cardio-protective agents in breast cancer.

Purpose

To assess the comparative efficacy of cardioprotective drugs in patients with breast cancer using both Bayesian and frequentist analyses of randomised controlled trials

Methods

We performed a systematic review using four databases (CENTRAL, Cochrane Reviews, MEDLINE, SCOPUS), to find RCTs evaluating cardio protective drugs in breast cancer patients without prior ANT exposure. The population included was anthracycline naïve, and trials were excluded if cardio-protective agents were commenced post anthracycline treatment. The primary outcome was a mean change in LVEF pre and post ANT dosing. Results were pooled with both Bayesian and frequentist approaches using random effects models in R statistical software.

Results

We identified 12 RCTs from 2807 search results (n=1126, Age 51 years, ANT dose 412m/m2, baseline LVEF 62.6%) with comparisons including beta-blockers (BB) (n=9), Angiotensin Converting Enzyme inhibitors (ACEi)/Angiotensin Receptor Blockers (ARB) (n=3), combination BB + AA (n=2), spironolactone (n=1) and statins (n=1). All included trials had either intermediate or high risk of bias, with marked heterogeneity in ANT dosing and LVEF monitoring. Overall, our Bayesian network meta-analysis showed no statistically significant difference in mean LVEF preservation between AA (1.3%, 95% credible interval [−0.20, 2.9]), BB (0.77, [−0.21, 1.8]), AABB (0.84 [−1.1, 2.8]), SPR (0.72, [−2.3, 3.7]) or statin (0.60, [−2.4, 3.6]) when compared against placebo. After ranking for efficacy, ACEi/ARBs achieved the most protection against LVEF decline of 1.3% [95% CI: −0.2, 2.9] although still not significant. Conversely, frequentist analysis showed benefit in using AA (Standardised Mean Difference (SMD) 1.32% [0.32, 2.33]) and BB (SMD 0.76% [0.12, 1.4]).

Conclusion

Bayesian analysis demonstrated no difference in LVEF with cardio-protective agents. In contrast, frequentist analysis showed that AA and BB may provide significant cardio-protection. The quality of RCT data to date is limited by a high risk of bias and significant heterogeneity between RCA reporting. Larger trials with clear population definition are required to determine whether any drug class provides benefit in this setting.

Funding Acknowledgement

Type of funding sources: None.

Long-Term Exposure to Ambient Fine Particulate Matter and Incidence of Major Cardiovascular Diseases: A Prospective Study of 0.5 Million Adults in China

Few cohort studies explored the long-term effects of ambient fine particulate matter (PM_2.5) on incidence of cardiovascular diseases (CVDs), especially in countries with higher levels of air pollution. We aimed to evaluate the association between long-term exposure to PM_2.5 and incidence of CVD in China. We performed a prospective cohort study in ten regions that recruited 512,689 adults during 2004-2008, with follow-up until 2017. Annual PM_2.5 concentrations were estimated using a satellite-based model with national coverage and 1 x 1 km spatial resolution. Time-varying Cox proportional hazard regression models were used to estimate hazard ratios (HRs) for all-cause and cause-specific CVDs associated with PM_2.5, adjusting for conventional covariates. During 5.08 million person-years of follow-up, 148,030 incident cases of CVD were identified. Long-term exposure to PM_2.5 showed positive and linear association with incidence of CVD, without a threshold below any concentration. The adjusted HRs per 10 μg/m³ increase in PM_2.5 was 1.04 (95%CI: 1.02, 1.07) for total CVD. The risk estimates differed between certain population subgroups, with greater HRs in men, in household with higher income, and in people using unclean heating fuels. This prospective study of large Chinese population provided essential epidemiological evidence for CVD incident risk associated with PM_2.5.

External validation of models for predicting risk of colorectal cancer using the China Kadoorie Biobank

BACKGROUND

In China, colorectal cancer (CRC) incidence and mortality have been steadily increasing over the last decades. Risk models to predict incident CRC have been developed in various populations, but they have not been systematically externally validated in a Chinese population.  This study aimed to assess the performance of risk scores in predicting CRC using the China Kadoorie Biobank (CKB), one of the largest and geographically diverse prospective cohort studies in China.

METHODS

Nine models were externally validated in 512,415 participants in CKB and included 2976 cases of CRC. Model discrimination was assessed, overall and by sex, age, site, and geographic location, using the area under the receiver operating characteristic curve (AUC). Model discrimination of these nine models was compared to a model using age alone. Calibration was assessed for five models, and they were re-calibrated in CKB.

RESULTS

The three models with the highest discrimination (Ma (Cox model) AUC 0.70 [95% CI 0.69-0.71]; Aleksandrova 0.70 [0.69-0.71]; Hong 0.69 [0.67-0.71]) included the variables age, smoking, and alcohol. These models performed significantly better than using a model based on age alone (AUC of 0.65 [95% CI 0.64-0.66]). Model discrimination was generally higher in younger participants, males, urban environments, and for colon cancer. The two models (Guo and Chen) developed in Chinese populations did not perform better than the others. Among the 10% of participants with the highest risk, the three best performing models identified 24-26% of participants that went on to develop CRC.

CONCLUSIONS

Several risk models based on easily obtainable demographic and modifiable lifestyle factor have good discrimination in a Chinese population. The three best performing models have a higher discrimination than using a model based on age alone.

P11.75.B Survival benefit of radiotherapy and surgery in patients with lung cancer brain metastases with poor prognosis factors

Background

Radiotherapy and surgery are the standard treatments for lung cancer brain metastases (BMs). However, limitted studies focused on the treatments for patients with lung cancer BMs with poor prognosis factors. The purpose of this study was to investigate the effects of radiotherapy and surgery in patients with lung cancer BMs with poor prognosis factors, providing reference for clinical strategies.

Material and Methods

We analyzed retrospectively 714 patients with lung cancer BMs. A 1:1 propensity score matching (PSM) was performed to balance potential confounders. Analyses of overall survival (OS) and risk factors for OS were assessed by log-rank test and Cox proportional hazard model.

Results

Age ≥65 years, Karnofsky Performance Scale (KPS) score ≤70, anaplastic large-cell lymphoma kinase (ALK)/epidermal growth factor receptor (EGFR) wild type, extracranial metastases, non-surgery and non-radiotherapy led to poor prognosis. Patients were stratified according to these factors. Radiotherapy and surgery showed no survival benefit in patients with aged ≥65 years or pretreatment KPS score ≤70 before and after PSM. Before PSM, whole brain radiotherapy (WBRT) improved the OS and predicted good prognosis in patients with ALK/EGFR wild type or extracranial metastases. WBRT also predicted good prognosis in patients with non-surgery. Stereotactic radiosurgery (SRS) improved the OS and predicted good prognosis in patients with ALK/EGFR wild type or non-surgery. WBRT plus SRS improved the OS and predicted good prognosis in patients with extracranial metastases or non-surgery. WBRT plus SRS also predicted good prognosis in patients with ALK/EGFR wild type. Surgery improved the OS and predicted good prognosis in patients with non-radiotherapy. After PSM, SRS improved the OS and predicted good prognosis in patients with non-surgery. WBRT plus SRS improved the OS and predicted good prognosis in patients with non-surgery or extracranial metastases. WBRT plus SRS also predicted good prognosis in patients with ALK/EGFR wild type. Surgery improved the OS of patients with non-radiotherapy. We defined that the treatment would provide significant survival benefit if it both prolonged the OS and predicted good prognosis. Meanwhile, the results after PSM were more convincing than the results before PSM.

Conclusion

Radiotherapy has significant survival benefit in patients with lung cancer BMs with poor prognosis factors, including patients with ALK/EGFR wild type or extracranial metastases or non-surgery. Surgery only has significant survival benefit in patients with non-radiotherapy.

The role of NMR-based circulating metabolic biomarkers in development and risk prediction of new onset type 2 diabetes

Associations of circulating metabolic biomarkers with type 2 diabetes (T2D) and their added value for risk prediction are uncertain among Chinese adults. A case-cohort study included 882 T2D cases diagnosed during 8-years' follow-up and a subcohort of 789 participants. NMR-metabolomic profiling quantified 225 plasma biomarkers in stored samples taken at recruitment into the study. Cox regression yielded adjusted hazard ratios (HRs) for T2D associated with individual biomarkers, with a set of biomarkers incorporated into an established T2D risk prediction model to assess improvement in discriminatory ability. Mean baseline BMI (SD) was higher in T2D cases than in the subcohort (25.7 [3.6] vs. 23.9 [3.6] kg/m²). Overall, 163 biomarkers were significantly and independently associated with T2D at false discovery rate (FDR) controlled p < 0.05, and 138 at FDR-controlled p < 0.01. Branched chain amino acids (BCAA), apolipoprotein B/apolipoprotein A1, triglycerides in VLDL and medium and small HDL particles, and VLDL particle size were strongly positively associated with T2D (HRs 1.74-2.36 per 1 SD, p < 0.001). HDL particle size, cholesterol concentration in larger HDL particles and docosahexaenoic acid levels were strongly inversely associated with T2D (HRs 0.43-0.48, p < 0.001). With additional adjustment for plasma glucose, most associations (n = 147 and n = 129 at p < 0.05 and p < 0.01, respectively) remained significant. HRs appeared more extreme among more centrally adipose participants for apolipoprotein B/apolipoprotein A1, BCAA, HDL particle size and docosahexaenoic acid (p for heterogeneity ≤ 0.05). Addition of 31 selected biomarkers to an established T2D risk prediction model modestly, but significantly, improved risk discrimination (c-statistic 0.86 to 0.91, p < 0.001). In relatively lean Chinese adults, diverse metabolic biomarkers are associated with future risk of T2D and can help improve established risk prediction models.

Association between involuntary smoking and risk of cervical cancer in Chinese female never smokers: A prospective cohort study

Involuntary smoking was a major public health problem for women in China. Previous studies mainly focused on secondhand smoke (SHS), which referred to direct exposure to smoke from burning cigarettes. Little evidence existed about the relationship between thirdhand smoke (THS), the residual tobacco smoke remaining in the environment after tobacco had been smoked, and cervical cancer. The China Kadoorie Biobank (CKB) study recruited 0.3 million female participants from 10 areas across China during 2004-2008. After an 11.2-year median follow-up, we documented 1094 cervical cancer cases. Multivariable Cox regression yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations of SHS and THS with cervical cancer incidence, respectively and jointly. Overall, 60.3% reported weekly SHS exposure, and 83.2% had been exposed to THS. Daily SHS exposure and THS exposure at the enrollment were associated with elevated risks of cervical cancer incidence, with adjusted HRs (95% CI) of 1.22 (1.06,1.42) and 1.24 (1.03,1.49), respectively. The longer the exposure duration, the higher the risks (P for trend = 0.006, 0.035, respectively). Compared with those who were neither exposed to SHS nor THS, those exposed to both SHS and THS had the highest risk, with adjusted HRs (95% CI) of 1.29 (1.05,1.58). Area of residence, breastfeeding duration and heating fuel types are potential effect modifiers. Among Chinese females, both SHS and THS were associated with higher risks of cervical cancer incidence, and a dose-response relationship was found between the exposure duration and cervical cancer risk. Our findings reinforce the need for proactive strategies for tobacco control, to protect women health.