C-reactive protein, fibrinogen, and cardiovascular disease prediction

Inflammatory/hemostatic biomarkers and coronary artery calcification in midlife women of African-American and White race/ethnicity: the Study of Women's Health Across the Nation (SWAN) heart study

OBJECTIVE

Inflammatory/hemostatic biomarkers are associated with coronary heart disease events, but relationships in asymptomatic midlife women are uncertain. We evaluated separately whether high-sensitivity C-reactive protein (hsCRP), fibrinogen, plasminogen-activator inhibitor 1, tissue plasminogen activator antigen, and circulating factor VII (factor VIIc) were associated with coronary artery calcification (CAC) in healthy midlife women.

METHODS

A cross-sectional study was performed of participants from the Study of Women's Health Across the Nation. Logistic and Tobit regression was used to assess associations between log-transformed biomarkers, and CAC presence (CAC > 0) and extent. Effect modification by race/ethnicity was evaluated.

RESULTS

The study included 372 women (mean age 51.3 y; 35.2% African-American). All biomarkers were positively associated with CAC presence and extent (P < 0.001 for all), adjusting for Framingham risk score, site, race/ethnicity, menopause status, income, and education. Additional adjustment for body mass index explained all associations except for factor VIIc, which remained associated with CAC extent only (P = 0.02). Final adjustment for insulin resistance, family history of cardiovascular disease, and cardiovascular medication use produced similar results. Associations between hsCRP, and CAC presence and extent were modified by race/ethnicity (P < 0.05). Log(hsCRP) was positively associated with CAC presence (odds ratio 3.25; 95% CI, 1.53-6.90; P = 0.002; per 1 log unit increase) and CAC extent (β = 19.66; SE = 7.67; P = 0.01; per 1 log unit increase) in African-Americans only.

CONCLUSIONS

Inflammatory/hemostatic biomarkers were associated with CAC through obesity, except for factor VIIc. Among African-American women only, hsCRP was independently associated with CAC, suggesting that hsCRP may have a role in coronary heart disease prevention in African-American midlife women.

White blood cell count may identify abnormal cardiometabolic phenotype and preclinical organ damage in overweight/obese children

BACKGROUND AND AIMS

Subclinical inflammation is a central component of cardiometabolic disease risk in obese subjects. The aim of the study was to evaluate whether the white blood cell count (WBCc) may help to identify an abnormal cardiometabolic phenotype in overweight (Ow) or obese (Ob) children.

METHODS AND RESULTS

A cross-sectional sample of 2835 Ow/Ob children and adolescents (age 6-18 years) was recruited from 10 Italian centers for the care of obesity. Anthropometric and biochemical variables were assessed in the overall sample. Waist to height ratio (WhtR), alanine aminotransferase (ALT), lipids, 2 h post-load plasma glucose (2hPG), left ventricular (LV) geometry and carotid intima-media thickness (cIMT) were assessed in 2128, 2300, 1834, 535 and 315 children, respectively. Insulin resistance and whole body insulin sensitivity index (WBISI) were analyzed using homeostatic model assessment (HOMA-IR) and Matsuda's test. Groups divided in quartiles of WBCc significantly differed for body mass index, WhtR, 2hPG, HOMA-IR, WBISI, lipids, ALT, cIMT, LV mass and relative wall thickness. Children with high WBCc (≥8700 cell/mm(3)) showed a 1.3-2.5 fold increased probability of having high normal 2hPG, high ALT, high cIMT, or LV remodeling/concentric LV hypertrophy, after adjustment for age, gender, pubertal status, BMI and centers.

CONCLUSIONS

This study shows that WBCc is associated with early derangements of glucose metabolism and preclinical signs of liver, vascular and cardiac damage. The WBCc may be an effective and low-cost tool for identifying Ow and Ob children at the greatest risk of potential complications.

Fibrinogen and the Severity of Coronary Atherosclerosis among Adults with and without Statin Treatment: Lipid as a mediator

BACKGROUND

It has been proposed that plasma fibrinogen is associated with lipid levels and increased cardiovascular risk. However, the interrelationship has not been well-elucidated. We hypothesise that lipids may be potential mediators.

METHODS

We enrolled 4748 consecutive subjects scheduled for coronary angiography in this study. The severity of coronary atherosclerosis was assessed by Gensini score (GS). By principle component analysis, a multi-marker lipid index was extracted weighting the coefficients of six atherogenic lipid parameters: total cholesterol (TC), low-density lipoprotein-cholesterol, non-high-density lipoprotein-cholesterol (non-HDL-C), apolipoprotein (apo) B, apoB/apoA1, and TC/HDL-C ratio. Moreover, using mediation analysis, the relationship between fibrinogen and lipids with high GS was evaluated.

RESULTS

Fibrinogen was positively associated with GS after adjustment (β=0.100, p<0.001). We stratified our analyses by statin use status and found that subjects in the upper fibrinogen tertiles had higher levels of atherogenic lipid parameters irrespective of statin status (p<0.001, all). Significantly, we observed a synergistic effect of fibrinogen and concurrent elevated lipid index for high GS. The adjusted odds ratios were greater in participants who had high fibrinogen levels and also high lipid index compared to those with low lipid index [on statin: 1.725(1.258-2.364) vs. 1.261(0.962-1.652); not on statin: 2.197(1.450-3.328) vs. 1.166(0.417-3.258)]. Specifically, mediation analysis indicated that around 24% of the effect of fibrinogen on high GS was mediated by lipid index, which was attenuated to 13% by statin status.

CONCLUSIONS

The increased risk of fibrinogen on coronary atherosclerosis appeared to be enhanced by the high atherogenic lipid levels, which mediated around 24% of this effect.

Novel Biomarkers to Improve the Prediction of Cardiovascular Event Risk in Type 2 Diabetes Mellitus

BACKGROUND

We evaluated the ability of 23 novel biomarkers representing several pathophysiological pathways to improve the prediction of cardiovascular event (CVE) risk in patients with type 2 diabetes mellitus beyond traditional risk factors.

METHODS AND RESULTS

We used data from 1002 patients with type 2 diabetes mellitus from the Second Manifestations of ARTertial disease (SMART) study and 288 patients from the European Prospective Investigation into Cancer and Nutrition-NL (EPIC-NL). The associations of 23 biomarkers (adiponectin, C-reactive protein, epidermal-type fatty acid binding protein, heart-type fatty acid binding protein, basic fibroblast growth factor, soluble FMS-like tyrosine kinase-1, soluble intercellular adhesion molecule-1 and -3, matrix metalloproteinase [MMP]-1, MMP-3, MMP-9, N-terminal prohormone of B-type natriuretic peptide, osteopontin, osteonectin, osteocalcin, placental growth factor, serum amyloid A, E-selectin, P-selectin, tissue inhibitor of MMP-1, thrombomodulin, soluble vascular cell adhesion molecule-1, and vascular endothelial growth factor) with CVE risk were evaluated by using Cox proportional hazards analysis adjusting for traditional risk factors. The incremental predictive performance was assessed with use of the c-statistic and net reclassification index (NRI; continuous and based on 10-year risk strata 0-10%, 10-20%, 20-30%, >30%). A multimarker model was constructed comprising those biomarkers that improved predictive performance in both cohorts. N-terminal prohormone of B-type natriuretic peptide, osteopontin, and MMP-3 were the only biomarkers significantly associated with an increased risk of CVE and improved predictive performance in both cohorts. In SMART, the combination of these biomarkers increased the c-statistic with 0.03 (95% CI 0.01-0.05), and the continuous NRI was 0.37 (95% CI 0.21-0.52). In EPIC-NL, the multimarker model increased the c-statistic with 0.03 (95% CI 0.00-0.03), and the continuous NRI was 0.44 (95% CI 0.23-0.66). Based on risk strata, the NRI was 0.12 (95% CI 0.03-0.21) in SMART and 0.07 (95% CI -0.04-0.17) in EPIC-NL.

CONCLUSIONS

Of the 23 evaluated biomarkers from different pathophysiological pathways, N-terminal prohormone of B-type natriuretic peptide, osteopontin, MMP-3, and their combination improved CVE risk prediction in 2 separate cohorts of patients with type 2 diabetes mellitus beyond traditional risk factors. However, the number of patients reclassified to a different risk stratum was limited.

Systemic inflammation in patients with compromised upper airway anatomy and primary snoring or mild obstructive sleep apnea

Our aim was to study associations between serum fibrinogen and C-reactive protein (CRP) levels and respiratory parameters on polysomnography (PSG) in patients with snoring as their main complaint and compromised upper airway anatomy. In this retrospective study, consecutive patients (43 female and 132 male; age range 11-82 years, respiratory distress index-RDI range 0.1-94.4/h) with snoring as their main complaint and compromised upper airway anatomy who underwent PSG were assessed. Spearman's Rho coefficients between RDI, AI (apnea index), hypopnea index (HI), average and lowest SpO2 (in %) and CRP- and fibrinogen serum levels were calculated. Comparisons between groups were made using Wilcoxon-W test. Patients with CRP > 5 mg/dl (22 % of the cohort) had significantly increased RDI, AI, average and lowest SpO2 than patients with CRP < 5 mg/dl. Increased correlation coefficients were observed for average SpO2 (-0.386), RDI (0.355), lowest SpO2 (-0.323) and AI (0.309). Patients with fibrinogen >350 mg/dl (in 33 %) had significantly increased RDI, HI, AI, average and lowest SpO2 than patients with fibrinogen <350 mg/dl. Increased correlation coefficients were found for average (-0.340) and lowest (-0.268) SpO2, RDI (0.236) and AI (0.229). Even patients with RDI < 15/h had increased serum CRP-(in 11 %) and/or fibrinogen-(in 19 %) levels. Simultaneous elevation of both CRP and fibrinogen levels occurred only in patients with RDI > 5/h. Systemic inflammation is strongly associated with average and lowest SpO2, RDI and AI (and with HI) in snorers with compromised upper airway anatomy and is present even in patients with primary snoring and mild obstructive sleep apnea.

Comparison of the Predictive Value of GlycA and Other Biomarkers of Inflammation for Total Death, Incident Cardiovascular Events, Noncardiovascular and Noncancer Inflammatory-Related Events, and Total Cancer Events

BACKGROUND

GlycA is a biomarker that reflects integrated concentrations and glycosylation states of several acute-phase proteins. We studied the association of GlycA and inflammatory biomarkers with future death and disease.

METHODS

A total of 6523 men and women in the Multi-Ethnic Study of Atherosclerosis who were free of overt cardiovascular disease (CVD) and in generally good health had a baseline blood sample taken. We assayed high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and d-dimer. A spectral deconvolution algorithm was used to quantify GlycA signal amplitudes from automated nuclear magnetic resonance (NMR) LipoProfile® test spectra. Median follow-up was 12.1 years. Among 4 primary outcomes, CVD events were adjudicated, death was by death certificate, and chronic inflammatory-related severe hospitalization and death (ChrIRD) and total cancer were classified using International Classification of Diseases (ICD) codes. We used Poisson regression to study baseline GlycA, hsCRP, IL-6, and d-dimer in relation to total death, CVD, ChrIRD, and total cancer.

RESULTS

Relative risk per SD of GlycA, IL-6, and d-dimer for total death (n = 915); for total CVD (n = 922); and for ChrIRD (n = 1324) ranged from 1.05 to 1.20, independently of covariates. In contrast, prediction from hsCRP was statistically explained by adjustment for other inflammatory variables. Only GlycA was predictive for total cancer (n = 663). Women had 7% higher values of all inflammatory biomarkers than men and had a significantly lower GlycA prediction coefficient than men in predicting total cancer.

CONCLUSIONS

The composite biomarker GlycA derived from NMR is associated with risk for total death, CVD, ChrIRD, and total cancer after adjustment for hsCRP, IL-6, and d-dimer. IL-6 and d-dimer contribute information independently of GlycA.

Lower Methylation of the ANGPTL2 Gene in Leukocytes from Post-Acute Coronary Syndrome Patients

DNA methylation is believed to regulate gene expression during adulthood in response to the constant changes in environment. The methylome is therefore proposed to be a biomarker of health through age. ANGPTL2 is a circulating pro-inflammatory protein that increases with age and prematurely in patients with coronary artery diseases; integrating the methylation pattern of the promoter may help differentiate age- vs. disease-related change in its expression. We believe that in a pro-inflammatory environment, ANGPTL2 is differentially methylated, regulating ANGPTL2 expression. To test this hypothesis we investigated the changes in promoter methylation of ANGPTL2 gene in leukocytes from patients suffering from post-acute coronary syndrome (ACS). DNA was extracted from circulating leukocytes of post-ACS patients with cardiovascular risk factors and from healthy young and age-matched controls. Methylation sites (CpGs) found in the ANGPTL2 gene were targeted for specific DNA methylation quantification. The functionality of ANGPTL2 methylation was assessed by an in vitro luciferase assay. In post-ACS patients, C-reactive protein and ANGPTL2 circulating levels increased significantly when compared to healthy controls. Decreased methylation of specific CpGs were found in the promoter of ANGPTL2 and allowed to discriminate age vs. disease associated methylation. In vitro DNA methylation of specific CpG lead to inhibition of ANGPTL2 promoter activity. Reduced leukocyte DNA methylation in the promoter region of ANGPTL2 is associated with the pro-inflammatory environment that characterizes patients with post-ACS differently from age-matched healthy controls. Methylation of different CpGs in ANGPTL2 gene may prove to be a reliable biomarker of coronary disease.

Myocardial dysfunction and cardiovascular disease in type 2 diabetes

Type 2 diabetes mellitus (T2DM) is strongly associated with increased risk of myocardial dysfunction and cardiovascular disease (CVD), two separate conditions which often co-exist and influence each other's course. The prevalence of myocardial dysfunction may be as high as 75% in T2DM populations but is often overlooked due to the initial asymptomatic nature of the disease, complicating co-morbidities such as coronary artery disease (CAD) and obesity, and the lack of consensus on diagnostic criteria. More sensitive echocardiographic applications are furthermore needed to improve detection of early subclinical changes in myocardial function which do not affect conventional echocardiographic parameters. The pathophysiology of the diabetic myocardial dysfunction is not fully elucidated, but involves hyperglycemia and high levels of free fatty acids. It evolves over several years and increases the risk of developing overt HF, and is suggested to at least in part account for the worse outcome seen in T2DM individuals after cardiac events. CAD and stroke are the most frequent CV manifestations among T2DM patients and relate to a large degree to the accelerated atherosclerosis driven by inflammation. Diagnosing CAD is challenging due to the lower sensitivity inherent in the diagnostic tests and there is thus a need for new biomarkers to improve prediction and detection of CAD. It seems that a multi-factorial approach (i.e. targeting several CV risk factors simultaneously) is superior to a strict glucose lowering strategy in reducing risk for macrovascular events, and recent research may even support an effect also on HF outcomes.

Cardiovascular risk prediction: Can Systematic Coronary Risk Evaluation (SCORE) be improved by adding simple risk markers? Results from the Copenhagen City Heart Study

AIM

European society of cardiology (ESC) guidelines recommend that cardiovascular disease (CVD) risk stratification in asymptomatic individuals is based on the Systematic Coronary Risk Evaluation (SCORE) algorithm, which estimates individual 10-year risk of death from CVD. We assessed the potential improvement in CVD risk stratification of 19 easily available risk markers by adding them to the SCORE algorithm.

METHODS AND RESULTS

We followed 8476 individuals without prior CVD or diabetes from the Copenhagen City Heart study. The 19 risk markers were: major and minor electrocardiographic (ECG) abnormalities, heart rate, family history (of ischaemic heart disease), body mass index (BMI), waist-hip ratio, walking duration and pace, leisure time physical activity, forced expiratory volume (FEV)1%pred, household income, education, vital exhaustion, high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB), high-sensitive C-reactive protein (hsCRP) and fibrinogen. With the exception of family history, BMI, triglycerides and minor ECG changes, all risk markers remained significantly associated with CVD mortality after adjustment for SCORE variables. However, the addition of the remaining 15 risk markers resulted in only small changes in discrimination calculated by area under the curve (AUC) and integrated discrimination improvement (IDI) and no improvement in net reclassification improvement (NRI). HsCRP improved AUC by 0.006 (p = 0.015) and IDI by 0.012 (p = 0.002); FEV1%pred improved AUC by 0.006 (p = 0.032) and IDI by 0.006 (p = 0.029). In the intermediate risk group FEV1%pred, education, vital exhaustion and ApoA1 all improved NRI but FEV1%pred was the only risk marker to significantly improve both IDI, AUC and NRI.

CONCLUSION

The SCORE algorithm predicted CVD mortality in a Danish cohort well. Despite strong association with CVD mortality, the individual addition of 19 easily available risk makers to the SCORE model resulted in small risk stratification improvements.

Increased hsCRP is associated with higher risk of aortic valve replacement in patients with aortic stenosis

Objective To investigate relations between inflammation and aortic valve stenosis (AS) by measuring high-sensitivity C-reactive protein, at baseline (hsCRP0) and after 1 year (hsCRP1) and exploring associations with aortic valve replacement (AVR). Design We examined 1423 patients from the Simvastatin and Ezetimibe in Aortic Stenosis study. Results During first year of treatment, hsCRP was reduced both in patients later receiving AVR (2.3 [0.9-4.9] to 1.8 [0.8-5.4] mg/l, p < 0.001) and not receiving AVR (1.90 [0.90-4.10] to 1.3 [0.6-2.9] mg/l, p < 0.001). In Cox-regression analyses, hsCRP1 predicted later AVR (HR = 1.17, p < 0.001) independently of hsCRP0 (HR = 0.96, p = 0.33), aortic valve area (AVA) and other risk factors. A higher rate of AVR was observed in the group with high hsCRP0 and an increase during the first year (AVRhighCRP0CRP1inc = 47.3% versus AVRhighCRP0CRP1dec = 27.5%, p < 0.01). The prognostic benefit of a 1-year reduction in hsCRP was larger in patients with high versus low hsCRP0 eliminating the difference in incidence of AVR between high versus low hsCRP0 (AVRhighCRP0CRP1dec = 27.5% versus AVRlowCRP0CRP1dec = 25.8%, p = 0.66) in patients with reduced hsCRP during the first year. Conclusions High hsCRP1 or an increase in hsCRP during the first year of follow-up predicted later AVR independently of AVA, age, gender and other risk factors, although no significant improvement in C-statistics was observed.

Association between a Healthy Lifestyle Score and inflammatory markers among Puerto Rican adults

BACKGROUND AND AIMS

The relationship between multiple lifestyle components analyzed in combination and inflammation remains understudied. We aimed to assess the association between a Healthy Lifestyle Score (HLS) that includes adherence to five behavioral components (diet, physical activity and sedentary behaviors, smoking, social support and network, and sleep) and inflammatory markers, as well as the role of the HLS in inflammation among individuals with cardiometabolic conditions, in Puerto Rican adults.

METHODS AND RESULTS

In a cross-sectional study of 842 Puerto Ricans adults (aged 45-75 y) living in Boston, MA, the HLS (range = 0-190; maximum indicative of healthiest adherence) was analyzed for association with three inflammatory markers: interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). In multivariable-adjusted models, the HLS was inversely associated with IL-6 (β ± SE = -0.55 ± 0.13; P < 0.001) and TNF-α (-0.39 ± 0.13; P = 0.004). The dietary and smoking components were associated with both inflammatory markers independently of the other HLS components. Significant inverse associations were observed for each 20-unit increase in HLS and IL-6 and TNF-α for participants with hypertension (n = 600; β ± SE = -0.58 ± 0.16; -0.46 ± 0.16, respectively) and with overweight/obesity (n = 743; β ± SE = -0.59 ± 0.13; -0.50 ± 0.14, respectively), but not for those with diabetes (n = 187) or heart disease (n = 192). The HLS was not associated with CRP, after adjustment for potential confounders.

CONCLUSION

Higher adherence to multiple lifestyle behaviors was associated with lower concentrations of inflammatory markers. Because low-grade inflammation may precede chronic diseases, following an overall healthy lifestyle may help lower risk of these diseases.

Endothelial dysfunction: a unifying hypothesis for the burden of cardiovascular diseases in sub-Saharan Africa

It is well established that the leading causes of death and disability worldwide are cardiovascular diseases (CVD), chief among which is ischaemic heart disease. However, it is also recognised that ischaemic heart disease frequently coexists with other vascular conditions, such as cerebrovascular, renovascular and peripheral vascular disease, thus raising the notion of a common underlying pathobiology, albeit with differing manifestations, dictated by the implicated vascular bed.

The understanding that common metabolic and behavioural risk factors as well as social determinants and drivers are convergent in the development of CVD evokes the idea that the dysfunction of a common bio-molecular platform is central to the occurrence of these diseases. The state of endothelial activation, otherwise known as endothelial dysfunction, occurs when reactive oxygen signalling predominates due to an uncoupled state of endothelial nitric oxide synthase (eNOS). This can be a physiological response to stimulation of the innate immune system or a pathophysiological response triggered by cardiovascular disease risk factors.

The conventional wisdom is that the endothelium plays an important role in the initiation, progression and development of CVD and other non-communicable diseases. Consequently, the endothelium has remarkable relevance in clinical and public health practice as well as in health education, health promotion, and disease- and risk-factor prevention strategies. It also presents a plausible unifying hypothesis for the burden of CVD seen globally and in sub-Saharan Africa. Importantly, the heterogeneity in individual responses to metabolic, behavioural, and social drivers of CVD may stem from a complex interplay of these drivers with genomic, epigenetic and environmental factors that underpin eNOS uncoupling. Therefore, further biomedical research into the underlying genetic and other mechanisms of eNOS uncoupling may enlighten and shape strategies for addressing the burden of CVD in sub-Saharan Africa and other regions of the world.

Systemic inflammation and lung function: A longitudinal analysis

BACKGROUND

Systemic inflammation is associated with impaired lung function in healthy adults as well as in patients with lung disease. The mechanism for this association is unknown and it is unclear if systemic inflammation leads to impaired lung function or if poor lung function leads to inflammation. We explored the temporal associations between blood C-reactive protein (CRP), fibrinogen, and white blood cells, and lung function in young adults.

METHODS

Spirometry, plethysmography, and diffusion capacity were measured in a population-based cohort at ages 32 and 38 years. High-sensitivity CRP, fibrinogen, and white blood cells were measured at the same ages.

RESULTS

Higher levels of CRP and, to a lesser extent, fibrinogen were associated with lower lung volumes in cross-sectional analyses at both ages 32 and 38 years. Higher CRP and fibrinogen at age 32 were associated with higher FEV1 and FEV1/FVC at age 38, but not other measures of lung function. Lower lung volumes (total lung capacity, functional residual capacity, and residual volume) but not airflow obstruction (FEV1/FVC) at age 32 were associated with higher CRP at age 38. Associations between age 32 lung function and fibrinogen at follow-up were weaker, but consistent. There were no longitudinal associations between white blood cells and lung function.

CONCLUSIONS

We found no evidence that systemic inflammation causes a decline in lung function. However, lower lung volumes were associated with higher CRP and fibrinogen at follow-up indicating that pulmonary restriction may be a risk factor for systemic inflammation. The mechanism for this association remains unclear.

Body mass index, adipokines and insulin resistance in asthmatic children and adolescents

OBJECTIVE

This study aimed to describe the body mass index, insulin resistance, levels of adipokines and inflammatory markers in Brazilian asthmatic children and adolescents and to investigate their possible association with the severity and control of asthma.

METHODS

Cross-sectional study (n = 92; age: 3-18 years). Assessed data: Body weight and height, used to calculate the body mass index (BMIZ) and height-for-age (HAZ). Laboratory measurements: Lipid profile; glycemia and insulin for homeostasis model assessment (HOMA); adipokines; tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1); total immunoglobulin E (IgE) and specific IgE against aeroallergens.

RESULTS

The median age was 9.6 years (3.0-16.6); most participants were male (n = 52, 56.5%), pre-pubertal (n = 54, 58.6%) and had atopic asthma (n = 85, 92.4%). Overweight/obesity (38%) showed an inverse correlation with age (adjusted odds ratio [OR] = 0.781; 95% confidence interval [CI] 0.66-0.92) and a direct correlation with the leptin concentration (adjusted OR = 1.13; 95% CI 1.04-1.22). Insulin concentration was independently associated with moderated persistent asthma (adjusted OR = 1.31; 95% CI 1.09-1.52). HOMA showed a direct correlation with the leptin (β = 0.475; 95% CI 0.117-0.268) and total IgE (β = 0.197; 95% CI 0.002-0.096) levels and an inverse correlation with the TNF-α levels (β = -0.255; 95% CI;-0.366-0.055).

CONCLUSIONS

Asthma was associated with insulin resistance and a systemic inflammatory response possibly mediated by adipokines, with leptin levels standing out among the participants with excess weight.

Postpartum Circulating Markers of Inflammation and the Systemic Acute-Phase Response After Early-Onset Preeclampsia

Preeclampsia is an inflammatory-mediated hypertensive disorder of pregnancy and seems to be an early indicator of increased cardiovascular risk, but mechanisms underlying this association are unclear. In this study, we identified levels of circulating inflammatory markers and dynamic changes in the systemic acute-phase response in 44 women with a history of severe early-onset preeclampsia, compared with 29 controls with only uneventful pregnancies at 1.5 to 3.5 years postpartum. Models used were in vivo seasonal influenza vaccination and in vitro whole-blood culture with T-cell stimulants and the toll-like receptor-4 ligand lipopolysaccharide. Outcome measures were C-reactive protein, interleukin-6 (IL-6), IL-18, fibrinogen, myeloperoxidase, and a panel of 13 cytokines representative of the innate and adaptive inflammatory response, in addition to established cardiovascular markers. The in vivo acute-phase response was higher for women with previous preeclampsia than that for controls without such a history, although only significant for C-reactive protein (P=0.04). Preeclampsia was associated with higher IL-1β (P<0.05) and IL-8 (P<0.01) responses to T-cell activation. Hierarchical clustering revealed 2 distinct inflammatory clusters associated with previous preeclampsia: an adaptive response cluster associated with increased C-reactive protein and IL-6 before and after vaccination, increased weight, and low high-density lipoprotein cholesterol; and a toll-like receptor-4 mediated the cluster associated with increased IL-18 before and after vaccination but not associated with other cardiovascular markers. Furthermore, we found interactions between previous preeclampsia, common TLR4 gene variants, and the IL-18 response to vaccination. In conclusion, preeclampsia is associated with alterations in the inflammatory response postpartum mostly independent of other established cardiovascular risk markers.

Hemorheological and Glycemic Parameters and HDL Cholesterol for the Prediction of Cardiovascular Events

BACKGROUND

Hemorheological and glycemic parameters and high density lipoprotein (HDL) cholesterol are used as biomarkers of atherosclerosis and thrombosis.

OBJECTIVE

To investigate the association and clinical relevance of erythrocyte sedimentation rate (ESR), fibrinogen, fasting glucose, glycated hemoglobin (HbA1c), and HDL cholesterol in the prediction of major adverse cardiovascular events (MACE) and coronary heart disease (CHD) in an outpatient population.

METHODS

708 stable patients who visited the outpatient department were enrolled and followed for a mean period of 28.5 months. Patients were divided into two groups, patients without MACE and patients with MACE, which included cardiac death, acute myocardial infarction, newly diagnosed CHD, and cerebral vascular accident. We compared hemorheological and glycemic parameters and lipid profiles between the groups.

RESULTS

Patients with MACE had significantly higher ESR, fibrinogen, fasting glucose, and HbA1c, while lower HDL cholesterol compared with patients without MACE. High ESR and fibrinogen and low HDL cholesterol significantly increased the risk of MACE in multivariate regression analysis. In patients with MACE, high fibrinogen and HbA1c levels increased the risk of multivessel CHD. Furthermore, ESR and fibrinogen were significantly positively correlated with HbA1c and negatively correlated with HDL cholesterol, however not correlated with fasting glucose.

CONCLUSION

Hemorheological abnormalities, poor glycemic control, and low HDL cholesterol are correlated with each other and could serve as simple and useful surrogate markers and predictors for MACE and CHD in outpatients.

Women with a history of gestational diabetes on long-term follow up have normal vascular function despite more dysglycemia, dyslipidemia and adiposity

AIMS

Previous gestational diabetes (GDM) is a risk factor for type 2 diabetes and increased metabolic risk, but the link with vascular dysfunction is not clear. This study examined vascular function in women 4-10 years after a diagnosis of GDM who had a normal oral glucose tolerance test (OGTT) in the first postpartum year.

METHODS

We studied 90 women with a history of GDM and 59 age-matched controls, examining differences in insulin resistance as measured by the Homeostatic Model Assessment (HOMA-IR) and glucose responses during an OGTT, adiposity, lipid profile and C-reactive protein (CRP). Using pulse wave analysis, we also measured cardiac function, vascular compliance, and systemic vascular resistance.

RESULTS

Women with a history of GDM had higher measures of adiposity (body mass index 28.9 ± 6.5 vs. 26.6 ± 6.9 kg/m(2), P=0.04, waist-hip ratio 0.85 ± 0.06 vs. 0.79 ± 0.07, P<0.001), dyslipidemia (LDL cholesterol 2.78 ± 0.64 vs. 2.41 ± 0.56 mmol/L, P<0.001, total cholesterol: HDL cholesterol 3.93 ± 1.2 vs. 3.21 ± 0.82 mmol/L, P<0.001) and abnormal glucose metabolism (50% vs. 12%, P<0.001). However, there was no difference in CRP, HOMA-IR, or measures of cardiovascular function including pulse rate, pulse pressure, mean arterial pressure, cardiac output, systemic vascular resistance, small and large artery elasticity index. After controlling for adiposity, blood pressure, lipids and CRP, glycemic status did not contribute to vascular function.

CONCLUSION

Despite a higher incidence of adiposity, dyslipidemia, and impaired glycemia, women with a history of GDM who had a normal postpartum OGTT did not have impaired vascular function 4-10 years postpartum, when compared to healthy controls.

TLR4 Asp299Gly (rs4986790) polymorphism and coronary artery disease: a meta-analysis

Background. Previous studies have shown conflicting results on the association between toll-like receptor 4 (TLR4) Asp299Gly (rs4986790) polymorphism and coronary artery disease (CAD). The aim of this study was to evaluate the influence of TLR4 Asp299Gly polymorphism on CAD risk, CRP level and the number of stenotic coronary arteries, as well as to investigate whether G allele carriers would benefit more from statin treatment. Methods. PubMed, EMBASE, and CNKI databases were searched until May 2015. All the statistical tests were performed using R version 3.1.2. Odds ratio (OR) and 95% confidence interval (CI) were used to assess the association between TLR4 Asp299Gly polymorphism and CAD risk, the number of stenotic vessels, and the incidence of cardiovascular events according to statin-treated patients. Weighted mean difference (WMD) was calculated for the association between Asp299Gly and CRP level. Results. Overall, 12 case-control studies with 10,258 cases and 5,891 controls were included, and no association of TLR4Asp299Gly polymorphism with CAD was found (G allele vs. A allele: OR = 0.97, 95% CI [0.81-1.17], P = 0.75; AA vs. GG + AG: OR = 0.97, 95% CI [0.80-1.18], P = 0.76; GG vs. AG + AA: OR = 1.08, 95% CI [0.57-2.02], P = 0.82; AG vs. AA + GG: OR = 1.03, 95% CI [0.85-1.25], P = 0.74). Also, no association was noted between Asp299Gly and CRP level (WMD = -0.10, 95% CI [-0.62, 0.41], P = 0.69). Furthermore, no synergistic effect of statin and 299Gly was reported (Statin_AA vs. Statin_

AG/GG

OR = 1.12, 95% CI [0.41-3.09], P = 0.82). Discussion. This meta-analysis suggests no association of TLR4 Asp299Gly polymorphism with CAD and CRP level. It is further indicated that the G allele carriers may not benefit more from statin treatment. Further studies should include large sample size and high-quality literature to understand this issue in depth.

A meta-analysis of 120 246 individuals identifies 18 new loci for fibrinogen concentration

Genome-wide association studies have previously identified 23 genetic loci associated with circulating fibrinogen concentration. These studies used HapMap imputation and did not examine the X-chromosome. 1000 Genomes imputation provides better coverage of uncommon variants, and includes indels. We conducted a genome-wide association analysis of 34 studies imputed to the 1000 Genomes Project reference panel and including ∼120 000 participants of European ancestry (95 806 participants with data on the X-chromosome). Approximately 10.7 million single-nucleotide polymorphisms and 1.2 million indels were examined. We identified 41 genome-wide significant fibrinogen loci; of which, 18 were newly identified. There were no genome-wide significant signals on the X-chromosome. The lead variants of five significant loci were indels. We further identified six additional independent signals, including three rare variants, at two previously characterized loci: FGB and IRF1. Together the 41 loci explain 3% of the variance in plasma fibrinogen concentration.

Hypertension in pregnancy is associated with elevated C-reactive protein levels later in life

OBJECTIVES

We assessed whether hypertension in pregnancy is associated with elevated C-reactive protein (CRP) levels in later life, possibly reflecting an increased risk of cardiovascular disease (CVD).

BACKGROUND

Elevated CRP levels have been associated with hypertension in pregnancy and with CVD.

METHODS

We studied 2463 women from the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Participants were categorized as nulliparous women (n = 219), women with a history of normotensive pregnancies (n = 1839), or women with a history of a hypertensive pregnancy (n = 405). Using multiple linear regression models, we compared mean CRP levels among the groups after adjusting for age, race, education, smoking, hypertension, personal history of coronary heart disease (CHD) or stroke, diabetes, dyslipidemia, statins, hormone replacement therapy, and family history of CHD or stroke. As CRP levels may be influenced by BMI, the model was fit both with and without adjusting for BMI.

RESULTS

There was no significant difference in CRP levels between nulliparous women and those with a history of normotensive pregnancies, either with (P = 0.82) or without (P = 0.46) adjusting for BMI. In contrast, women with hypertensive pregnancies, compared with those with normotensive pregnancies, had higher CRP levels, both with (P = 0.009) and without (P < 0.001) adjusting for BMI.

CONCLUSION

A history of hypertension in pregnancy is associated with elevated CRP levels later in life, independent of traditional CVD risk factors and BMI. An elevated CRP may reflect an inflammatory state in women with a history of hypertensive pregnancy disorders who are at increased risk for CVD.

The acute phase inflammatory response to maximal exercise testing in children and young adults with sickle cell anaemia

Although individuals with sickle cell anaemia (SCA) have elevated baseline inflammation and endothelial activation, the acute phase response to maximal exercise has not been evaluated among children with SCA. We measured the acute phase response to maximal exercise testing for soluble vascular cell adhesion molecule (sVCAM) as well as interleukin 6 (IL6), total white blood cell (WBC) count, C-reactive protein (CRP) and D-dimer in a cohort of children with SCA and matched controls at baseline, immediately after, and 30, 60 and 120 min following exercise. Despite higher baseline levels of all biomarkers except CRP, the acute phase response from baseline to immediately after exercise was significantly greater in subjects versus controls for CRP (2·1 vs. 0·2 mg/l, P = 0·02) and D-dimer (160 vs. 10 μg/l, P < 0·01) only. Similar between-group trends were observed over time for all biomarkers, including sVCAM, IL6, total WBC, CRP and D-dimer. Lower fitness, defined by peak oxygen consumption (VO2 ), was independently associated with greater acute phase responses to exercise for sVCAM. Our results suggest maximal exercise may not be associated with any greater escalation of endothelial activation or inflammation in SCA and provide preliminary biomarker evidence for the safety of brief, high-intensity physical exertion in children with SCA.

Bullying victimization in childhood predicts inflammation and obesity at mid-life: a five-decade birth cohort study

BACKGROUND

We aimed to test whether childhood bullying victimization increases risk for age-related disease at mid-life using biological markers including inflammation and adiposity, independent of other childhood risk factors and key adult variables.

METHOD

The present study was a 50-year prospective longitudinal birth cohort study of all births in Britain in 1 week in 1958. Exposure to bullying was assessed prospectively when participants were aged 7 and 11 years (27.7% occasionally bullied; 14.6% frequently bullied). Blood inflammation biomarkers [C-reactive protein (CRP) and fibrinogen] and adiposity [body mass index (BMI) and waist:hip ratio] were measured at age 45 years.

RESULTS

Participants who had been frequently bullied in childhood showed increased levels of CRP at mid-life [β = 0.07, 95% confidence interval (CI) 0.04-0.10] and higher risk for clinically relevant inflammation cut-off [CRP > 3 mg/l: 20.4% v. 15.9%, odds ratio (OR) = 1.35, 95% CI 1.12-1.64]. Women who were bullied in childhood had higher BMI than non-bullied participants and were at increased risk of being obese (BMI ≥ 30 kg/m2: occasionally bullied: 26.0% v. 19.4%, OR = 1.45, 95% CI 1.18-1.77; frequently bullied: 26.2% v. 19.4%, OR = 1.41, 95% CI 1.09-1.83). Findings remained significant when controlling for childhood risk factors (e.g. parental social class; participants' BMI and psychopathology in childhood) and key adult variables (e.g. adult social class, smoking, diet and exercise).

CONCLUSIONS

Bullied children show increases in risk factors for age-related disease in middle adulthood, independent of co-occurring childhood and adult risks. Given the high prevalence of bullying victimization in childhood, tackling this form of psychosocial stress early in life has the potential of reducing risk for age-related disease and its associated burden.

Sedentary behaviour is associated with elevated C-reactive protein levels in people with psychosis

Psychosis is associated with elevated inflammatory markers including C-reactive protein (CRP), a marker of cardiovascular disease (CVD) risk. Using a cross sectional design, 250 participants with established psychosis (48.2years (SD 10.2), 39.2% female) were classified as having normal (<5.0mg/μl, N=159) or high CRP levels (>5.0mg/μl, N=91). Regression analysis demonstrated that higher sedentary behaviour was associated with elevated CRP levels (β=.155, p=.01) after adjustment for confounding variables. Female gender (β=.229, p=.001), waist circumference (β=.205, p=.003) and non-white ethnicity (β=.181, p=.005) were also associated with elevated CRP. Sedentary behaviour is modifiable and increasing physical activity may reduce CRP levels.

Cardiovascular risk models for South Asian populations: a systematic review

OBJECTIVES

To review existing cardiovascular risk models applicable to South Asian populations.

METHODS

A systematic review of the literature using a combination of search terms for "South Asian", "cardiovascular", "risk"/"score" and existing risk models for inclusion. South Asian was defined as those residing in or with ancestry belonging to the Indian subcontinent.

RESULTS

The literature search including MEDLINE and EMBASE identified 7560 papers. After full-text review, 4 papers met the inclusion criteria. Only 1 reported formal measures of model performance. In that study, both a modified Framingham model and QRISK2 showed similar good discrimination with AUROCs of 0.73-0.77 with calibration also reasonable in men (0.71-0.93) but poor in women (0.43-0.52).

CONCLUSIONS

Considering the number of South Asians and prevalence of cardiovascular disease, very few studies have reported performance of risk scores in South Asian populations. Furthermore, it was difficult to make comparisons, as many did not provide measures of discrimination, accuracy and calibration. There is a need for further research to evaluate risk models in South Asians, and ideally derive and validate cardiovascular risk models within South Asian populations.

Impact of inflammatory markers on the relationship between sleep quality and incident cardiovascular events in type 2 diabetes

AIMS

To analyze relevance of sleep quality with CVD in T2D patients and determine whether inflammation prompted by poor sleep has impact on the CVD.

METHODS

332 T2D patients were recruited and their sleep qualities were evaluated by PSQI. The patients with PSQI score >7 were in the poor sleep group, and the others were in the good sleep group. Plasma samples of the patients were obtained to measure inflammatory markers. Correlation analyses and regression analyses were performed to examine the cross-sectional relationships among the poor sleep, inflammatory markers and CVD.

RESULTS

The morbidity of CVD was significantly higher in the poor sleep patients compared to the good sleep patients (P=0.000). PSQI score ORs were both >1 for CVD in model 1 and model 2 (P<0.05). PSQI score were positively related to IL-6 and ICAM-1(P<0.05), negatively to FBI (P<0.05), but not related to CRP in linear regression models. Multiple logistic regression analysis showed IL-6 and ICAM-1, but not FBI and CRP, were related to CVD (P<0.05).

CONCLUSIONS

Poor sleep is regarded as a plausible risk factor for CVD in T2D patients, and may be mediated by certain inflammatory markers.

The association between fibrinogen reactivity to mental stress and high-sensitivity cardiac troponin T in healthy adults

BACKGROUND

Plasma fibrinogen is considered as a positive mediator between mental stress and cardiovascular disease because it is an acute-phase protein released in response to mental stress and a coagulation factor. However those three factors have never been studied together within a single integrated framework, using cardiac troponin T as a marker of cardiovascular risk.

METHODS

491 disease-free men and women aged 53-76 were tested for fibrinogen levels before, immediately after, and following recovery from standardized mental stress tasks. We measured plasma cardiac troponin T using a high-sensitivity assay (HS-CTnT) and coronary calcification using electron-beam dual-source computed tomography.

RESULTS

The average fibrinogen concentration increased by 5.1% (s.d.=7.3) in response to stress and then tended to return to baseline values. People with higher baseline fibrinogen values had smaller increases (blunted responses) following the stress task (P=0.001), and people with higher stress responses showed better recovery (P<0.001). In unadjusted analyses, higher baseline fibrinogen was associated with higher chances of having detectable HS-CTnT (P=0.072) but, conversely, higher fibrinogen response was associated with lower chances of having detectable HS-CTnT (P=0.007). The adjustment for clinical, inflammatory, and haemostatic factors, as well as for coronary calcification eliminated the effect of baseline fibrinogen, whereas the negative association between fibrinogen response and HS-CTnT remained robust: the odds of detectable HS-CTnT halved for each 10% increase in fibrinogen concentration due to stress (OR=0.49, P=0.007, 95% CI=0.30-0.82).

CONCLUSIONS

Greater fibrinogen responses to mental stress are associated with lower likelihood of detectable high-sensitivity troponin T plasma concentration. A more dynamic fibrinogen response appears to be advantageous for cardiovascular health.

Health consequences of same and opposite-sex unions: partnership, parenthood, and cardiovascular risk among young adults

We use the National Longitudinal Survey of Adolescent to Adult Health to examine union and parenthood differences across same and opposite-sex couples in systolic and diastolic blood pressure (SBP and DBP), C-reactive protein (CRP), and abdominal adiposity (waist circumference) among partnered (dating, cohabiting, married) young adults ages 25-33. Relative to women dating men, women cohabiting with women reported lower DBP and were less likely to have high CRP. Mothers reported lower SBP and DBP than non-mothers, but were more likely to have high waist circumference if they lived with a biological or step-child. Among men, nonresidential fathers reported higher DBP than nonfathers, and married men were more likely to have high waist circumference than men dating an opposite-sex partner. Same-sex cohabitation was neither a risk factor nor a health resource for men. Although the sample sizes for same-sex couples are quite small compared with those for opposite-sex couples, this study provides initial insight that occupying a sexual minority status while partnered is associated with some health benefits and few or no health risks relative to those who are dating an opposite sex partner.

Novel biomarkers for cardiovascular risk assessment: current status and future directions

Cardiovascular disease (CVD) is the leading cause of mortality in the modern world. Traditional risk algorithms may miss up to 20% of CVD events. Therefore, there is a need for new cardiac biomarkers. Many fields of research are dedicated to improving cardiac risk prediction, including genomics, transcriptomics and proteomics. To date, even the most promising biomarkers have only demonstrated modest associations and predictive ability. Few have undergone randomized control trials. A number of biomarkers are targets to new therapies aimed to reduce cardiovascular risk. Currently, some of the most promising risk prediction has been demonstrated with panels of multiple biomarkers. This article reviews the current state and future of proteomic biomarkers and aggregate biomarker panels.

Cigarette smoking is associated with dose-dependent adverse effects on paraoxonase activity and fibrinogen in young women

CONTEXT

Smoking is associated with increased fibrinogen and decreased paraoxonase (PON) activity, markers of inflammation and oxidative stress, in patients with coronary artery disease.

OBJECTIVE

We tested the hypothesis that the adverse effect of smoking on these biomarkers of inflammation and oxidative stress would be detectable in otherwise healthy young female habitual smokers.

MATERIALS AND METHODS

Thirty-eight young women participated in the study (n = 20 habitual smokers, n = 18 non-smokers). Fibrinogen, PON-1 activity and HDL oxidant index (HOI) were measured.

RESULTS

Mean values of fibrinogen, PON-1 activity and log HOI were not different between the groups. Importantly, however, decreased PON-1 activity (rs = -0.51, p = 0.03) and increased fibrinogen (rs = 0.49, p = 0.04) were significantly correlated with increasing number of cigarettes smoked per day in habitual smokers.

DISCUSSION AND CONCLUSION

Cigarette smoking is associated with a dose-dependent adverse effect on PON-1 activity and fibrinogen in young women, which may have implications for future cardiovascular risk.

Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline

DESCRIPTION

In December 2014, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of dyslipidemia for cardiovascular disease risk reduction in adults. This synopsis summarizes the major recommendations.

METHODS

On 30 September 2013, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, developed a simple 1-page algorithm, and rated each of 26 recommendations by using the Grading of Recommendations Assessment, Development, and Evaluation system.

RECOMMENDATIONS

This synopsis summarizes key features of the guideline in 5 areas: elimination of treatment targets, additional tests for risk prediction, primary and secondary prevention, and laboratory testing.

Meta-Analysis Comparing Rosuvastatin and Atorvastatin in Reducing Concentration of C-Reactive Protein in Patients With Hyperlipidemia

We conducted a meta-analysis of 13 randomized trials comparing the efficacy of rosuvastatin versus atorvastatin in reducing concentrations of C-reactive protein (CRP). We searched PubMed, Ovid, and Elsevier databases until June 2014. Search terms included C-reactive protein or CRP, rosuvastatin, atorvastatin, randomized, randomly, and randomization; 13 trials (3798 patients) were included. Funnel plots for CRP were inspected to assess publication bias. The pooled analysis demonstrated the benefit of rosuvastatin over atorvastatin therapy for all 13 trials (mean difference [MD] = −0.11, which is standardized mean with no unit although the raw data before pooling is mg/L, 95% confidence interval −0.15 to −0.07, P < .0001) with no evidence of significant publication bias (I2 = 6.9%, P = .377). Subgroup analysis indicated a significant benefit of rosuvastatin over atorvastatin regarding the 1/1 dose ratio (MD = −0.14, 95% CI −0.21 to −0.06) and 1/2 dose ratio (MD= −0.11, 95% CI −0.16 to −0.05). Cumulative and influence analyses showed accuracy and stability for the estimation mentioned earlier. Our meta-analysis shows that rosuvastatin produces better reduction in CRP concentrations than atorvastatin at a dose ratio of 1/1 and 1/2 (rosuvastatin/atorvastatin), respectively.