Serum C-reactive protein increases the risk of venous thromboembolism: a prospective study and meta-analysis of published prospective evidence

The Impact of Cardiovascular Disease Gene Polymorphism and Interaction with Homocysteine on Deep Vein Thrombosis

Deep vein thrombosis (DVT) affects vascular health and can even threaten life; however, its pathogenesis remains unclear. Cardiovascular disease (CVD) and DVT share common risk factors, such as dyslipidemia, aging, etc. We aimed to investigate the loci of published CVD susceptibility genes and their association with environmental factors that might be related to DVT. Genotyping by Kompetitive Allele Specific PCR (KASP), collection of lifestyle information, and determination of blood biochemical markers were performed in 165 DVT cases and 164 controls. The impact of six single nucleotide polymorphisms (SNPs) and additional potential variables on DVT morbidity was evaluated using unconditional logistic regression (ULR). To explore the high-order interactions related to genetics and the body's internal environment exposure that affect DVT, ULR, crossover analysis, and multifactor dimensionality reduction/generalized multifactor dimensionality reduction (MDR/GMDR) were employed. Sensitivity analyses were performed using the EpiR package. The polymorphisms of FGB rs1800790 and PLAT rs2020918 were significantly associated with DVT. The optimum GMDR interaction model for gene-gene (G × G) consisted of THBD rs1042579, PLAT rs2020918, and PON1 rs662. The PLAT rs2020918 and MTHFR rs1801133 polymorphisms together eliminated the maximum entropy by the MDR method. The optimum GMDR interaction model for gene-environment (G × E) consisted of MTHFR rs1801133, FGB rs1800790, PLAT rs2020918, PON1 rs662, and total homocysteine (tHcy). Those with high tHcy levels and three risk genotypes significantly increased the DVT risk. In conclusion, certain CVD-related SNPs and their interactions with tHcy may contribute to DVT. These have implications for investigating DVT etiology and developing preventive treatment plans.

Identification of key risk factors for venous thromboembolism in urological inpatients based on the Caprini scale and interpretable machine learning methods

PURPOSE

To identify the key risk factors for venous thromboembolism (VTE) in urological inpatients based on the Caprini scale using an interpretable machine learning method.

METHODS

VTE risk data of urological inpatients were obtained based on the Caprini scale in the case hospital. Based on the data, the Boruta method was used to further select the key variables from the 37 variables in the Caprini scale. Furthermore, decision rules corresponding to each risk level were generated using the rough set (RS) method. Finally, random forest (RF), support vector machine (SVM), and backpropagation artificial neural network (BPANN) were used to verify the data accuracy and were compared with the RS method.

RESULTS

Following the screening, the key risk factors for VTE in urology were "(C1) Age," "(C2) Minor Surgery planned," "(C3) Obesity (BMI > 25)," "(C8) Varicose veins," "(C9) Sepsis (< 1 month)," (C10) "Serious lung disease incl. pneumonia (< 1month) " (C11) COPD," "(C16) Other risk," "(C18) Major surgery (> 45 min)," "(C19) Laparoscopic surgery (> 45 min)," "(C20) Patient confined to bed (> 72 h)," "(C18) Malignancy (present or previous)," "(C23) Central venous access," "(C31) History of DVT/PE," "(C32) Other congenital or acquired thrombophilia," and "(C34) Stroke (< 1 month." According to the decision rules of different risk levels obtained using the RS method, "(C1) Age," "(C18) Major surgery (> 45 minutes)," and "(C21) Malignancy (present or previous)" were the main factors influencing mid- and high-risk levels, and some suggestions on VTE prevention were indicated based on these three factors. The average accuracies of the RS, RF, SVM, and BPANN models were 79.5%, 87.9%, 92.6%, and 97.2%, respectively. In addition, BPANN had the highest accuracy, recall, F1-score, and precision.

CONCLUSIONS

The RS model achieved poorer accuracy than the other three common machine learning models. However, the RS model provides strong interpretability and allows for the identification of high-risk factors and decision rules influencing high-risk assessments of VTE in urology. This transparency is very important for clinicians in the risk assessment process.

C-reactive protein is a predictor for lower-extremity deep venous thrombosis in patients with primary intracerebral hemorrhage

OBJECTIVE

Our study aimed to determine whether there exists an association between low-grade systemic inflammation, as measured by serum C-reactive protein (CRP), and the risk of lower-extremity deep venous thrombosis (LEDVT) in patients with primary intracerebral hemorrhage (ICH).

METHODS

This observational study was retrospectively conducted on patients with primary ICH who were presented to two tertiary medical centers between January 2021 and August 2022. The primary outcome was detecting LEDVT occurrence within 14 days from the onset of the acute ICH episode. Weighted logistic regression and restricted cubic spline models were employed to estimate the association between CRP and LEDVT following 1:1 propensity score matching (PSM).

RESULTS

Of the 538 patients with primary ICH who met the inclusion criteria, 76 (14.13%) experienced LEDVT. Based on the cut-off levels of CRP measured upon admission from the receiver operating characteristic (ROC) curve, patients with primary ICH were categorized into two groups: (i) CRP < 1.59 mg/L and (ii) CRP ≥ 1.59 mg/L. After 1:1 PSM, the LEDVT events occurred in 24.6% of patients with CRP ≥ 1.59 mg/L and 4.1% of patients with CRP < 1.59 mg/L (P < 0.001). ROC curve revealed the area under the ROC curve of 0.717 [95% confidence interval (CI) 0.669-0.761, P < 0.001] for CRP to predict LEDVT with a sensitivity of 85.71% and specificity of 56.29%. After adjusting for all confounding variables, the occurrence of LEDVT in ICH patients with higher CRP levels (≥ 1.59 mg/L) was 10.8 times higher compared to those with lower CRP levels (95% CI 4.5-25.8, P < 0.001). A nonlinear association was observed between CRP and an increased risk of LEDVT in the fully adjusted model (P for overall < 0.001, P for nonlinear = 0.001). The subgroup results indicated a consistent positive link between CRP and LEDVT events following primary ICH.

CONCLUSIONS

Higher initial CRP levels (CRP as a dichotomized variable) in patients with primary ICH are significantly associated with an increased risk of LEDVT and may help identify high-risk patients with LEDVT. Clinicians should be vigilant to enable early and effective intervention in patients at high risk of LEDVT.

Pulmonary Thrombotic Complication of Mycoplasma pneumoniae Pneumonia in Chinese Children: Clinical Feature and Risk Factor Analysis

BACKGROUND

Thrombotic disease is a rare but severe complication of Mycoplasma pneumoniae pneumonia in children, with pulmonary thrombosis (PT) being the most frequent type. This study aims to describe the clinical features of pediatric severe Mycoplasma pneumoniae pneumonia (SMPP) patients with PT, and to identify risk factors predictive of PT development in this population.

METHODS

We retrospectively enrolled 60 children with SMPP complicated by PT who were admitted to Children's Hospital Affiliated to Zhengzhou University from January 2019 to October 2023. We reviewed their demographic data, laboratory tests and imaging examinations to describe their clinical features. We used multivariate logistic regression analysis to identify significant risk factors for PT in SMPP.

RESULTS

The PT group exhibited higher incidences of chest pain, hemoptysis, inflammation and elevated D-dimer levels, as well as more severe pulmonary damage and transaminitis complication, compared to the non-PT group. The left pulmonary artery was the predominant location of PT in SMPP children. A multivariate analysis revealed that C-reactive protein (CRP) and D-dimer were significant predictors of PT in SMPP patients, with odds ratios of 1.10 and 3.37, respectively. The optimal cutoff values of CRP and D-dimer for predicting PT in SMPP were 76.73 mg/L and 3.98 µg/mL, respectively.

CONCLUSIONS

In SMPP, CRP >76.73 mg/L and D-dimer >3.98 µg/mL are independent predictors of PT. These findings suggest that SMPP-induced excessive inflammation may contribute to PT pathogenesis. Early and intensive anticoagulant, anti-inflammatory and antimycoplasma therapy may improve the disease course and prognosis.

Baseline and usual triglyceride-glucose index and the risk of chronic kidney disease: a prospective cohort study

Triglyceride-glucose (TyG) index is an emerging marker of adverse cardiometabolic conditions such as cardiovascular disease and type 2 diabetes. The long-term relevance of TyG index to chronic kidney disease (CKD) is uncertain. We aimed to assess the association of TyG index with CKD risk and its utility in risk prediction in a prospective study. The TyG index was calculated using fasting triglycerides and fasting plasma glucose (FPG) levels measured in 2362 men aged 42-61 years with normal kidney function using the formula: Ln (fasting triglycerides [mg/dL] × FPG [mg/dL]/2). Multivariable adjusted hazard ratios (HRs) (95% confidence intervals, CIs) were estimated for CKD. Correction for within-person variability was made using data from repeat measurements of triglycerides and FPG taken 11 years after baseline. Over a median follow-up duration of 17.5 years, 223 CKD cases were recorded. The age-adjusted regression dilution ratio for the TyG index was 0.54 (95% CI, 0.48-0.60). The risk of CKD increased continuously with increasing TyG index across the range 9.3 to 11.6 (p value for nonlinearity<.001). In analysis adjusted for established risk factors, a unit higher TyG index was associated with an increased risk of CKD (HR 1.59, 95% CI 1.24-2.05). Comparing extreme tertiles of the TyG index, the corresponding adjusted HR (95% CI) for CKD was 1.61 (1.15-2.27). Addition of the TyG index to a CKD risk prediction model containing established risk factors improved risk discrimination and reclassification (p value for difference in -2 log likelihood<.001; NRI=47.66%, p=.014; IDI=0.0164, p<.001). Higher TyG index is associated with an increased risk of CKD and improves the prediction and classification of CKD beyond established risk factors. Using single baseline estimations of the TyG index to investigate its association with CKD risk could considerably under-estimate the true association.

Association and Pathways between Dietary Manganese Intake and Incident Venous Thromboembolism

BACKGROUND

 The association between dietary manganese (Mn) intake and the risk of venous thromboembolism (VTE) remains unknown. We aimed to investigate the associations of dietary Mn intake with incident VTE, and the underlying mediating roles of obesity markers (body mass index [BMI] and waist circumference), hemorheological parameters (red cell distribution width [RDW], platelet count [PLT], and mean platelet volume [MPV]), and inflammatory biomarkers (C-reactive protein [CRP] and white blood cell count [WBC]) in this association.

METHODS

 A total of 202,507 adults from the UK Biobank with complete dietary data and without VTE at baseline were included. Dietary information was collected by the online 24-hour diet recall questionnaires (Oxford WebQ). The primary outcome was incident VTE, a composite of incident deep vein thrombosis (DVT) and pulmonary embolism (PE).

RESULTS

 During a median follow-up of 11.6 years, 4,750 participants developed incident VTE. Overall, there were significantly inverse relationships of dietary Mn intake with incident VTE (per 1 mg/day increment; adjusted hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.90-0.95), incident DVT (per 1 mg/day increment; adjusted HR: 0.93; 95% CI: 0. 90-0.96), and incident PE (per 1 mg/day increment; adjusted HR: 0.91; 95% CI: 0.88-0.95). BMI, waist circumference, RDW, CRP, and WBC significantly mediated the association between dietary Mn intake and incident VTE, with the mediated proportions of 36.0, 36.5, 4.2, 4.3, and 1.6%, respectively. However, MPV and PLT did not significantly mediate the association.

CONCLUSION

 Our study shows that dietary Mn intake was inversely associated with incident VTE. The inverse association was mainly mediated by obesity, followed by inflammatory biomarkers and RDW. Our findings are just hypothesis-generating, and further confirmation of our findings in more studies is essential.

Inflammasome Signaling, Thromboinflammation, and Venous Thromboembolism

Venous thromboembolism (VTE) remains a major health burden despite anticoagulation advances, suggesting incomplete management of pathogenic mechanisms. The NLRP3 (NACHT-, LRR- and pyrin domain-containing protein 3) inflammasome, interleukin (IL)-1, and pyroptosis are emerging contributors to the inflammatory pathogenesis of VTE. Inflammasome pathway activation occurs in patients with VTE. In preclinical models, inflammasome signaling blockade reduces venous thrombogenesis and vascular injury, suggesting that this therapeutic approach may potentially maximize anticoagulation benefits, protecting from VTE occurrence, recurrence, and ensuing post-thrombotic syndrome. The nonselective NLRP3 inhibitor colchicine and the anti-IL-1β agent canakinumab reduce atherothrombosis without increasing bleeding. Rosuvastatin reduces primary venous thrombotic events at least in part through lipid-lowering independent mechanisms, paving the way to targeted anti-inflammatory strategies in VTE. This review outlines recent preclinical and clinical evidence supporting a role for inflammasome pathway activation in venous thrombosis, and discusses the, yet unexplored, therapeutic potential of modulating inflammasome signaling to prevent and manage VTE.

Serum C-reactive protein-to-albumin ratio may be a potential risk indicator for venous thromboembolism: Findings from a prospective cohort study

BACKGROUND AND AIMS

Circulating C-reactive protein (CRP) and albumin are commonly used inflammatory biomarkers. C-reactive protein-to-albumin ratio (CAR), a novel inflammatory biomarker, has been suggested to be a more reliable risk indicator compared to CRP or albumin alone. An inflammatory hypothesis has been postulated in VTE aetiology, but the association between CAR and VTE has not been investigated. We aimed to assess the prospective association of CAR with VTE risk.

METHODS AND RESULTS

C-reactive protein and albumin were measured in serum samples at baseline from 2479 men aged 42-61 years. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated. During a median follow-up of 27.0 years, 168 VTE cases were recorded. In analysis adjusted for potential confounders, the HR (95% CI) for VTE comparing extreme tertiles of CAR was 1.49 (1.01-2.21), which was minimally attenuated on further adjustment for prevalent cancer, a potential mediator 1.48 (1.00-2.19). Serum CRP and albumin were each modestly associated with VTE risk in the same set of participants.

CONCLUSION

In middle-aged and older men, elevated serum CAR may be associated with an increased risk of VTE. Further research is needed to replicate or refute these findings in other populations and assess if CAR may be of potential value in VTE management.

Neutrophil levels upon admission for the assessment of acute pulmonary embolism with intermediate- and high-risk: an indicator of thrombosis and inflammation

BACKGROUND

Risk prediction rules are important to establish appropriate treatment and management strategy for patients with different risk classification of pulmonary embolism (PE). Neutrophils are considered to be related to PE as an essential marker of inflammation. However, few studies have reported the association between neutrophil levels and risk classification of acute PE (APE). The aim of this study was to investigate the role of neutrophil levels upon admission in the assessment of risk classification of APE.

METHODS

A total of 299 consecutive APE patients and 90 patients without APE confirmed by computed tomographic pulmonary angiography were retrospectively screened. APE patients were stratified into two subgroups according to clinical guidelines: low- (n = 233) and intermediate- and high-risk (n = 60) APE.

RESULTS

The neutrophil levels in intermediate- and high-risk APE patients were significantly higher compared to low-risk APE or non-APE patients (P < 0.001). In multivariable logistic regression analysis, neutrophil levels were significantly and independently associated with intermediate- and high-risk APE (odds ratio = 1.239, 95% confidence interval [CI] 1.055-1.455, P = 0.009). Neutrophil levels were positively correlated with the pulmonary embolism severity index score (r = 0.357, P < 0.001), high sensitive C-reactive protein, D-dimer and pulmonary artery obstruction index (PAOI), in the overall population of APE patients. Receiver-operating characteristic curve analysis revealed that neutrophils had a better diagnostic value for intermediate- and high-risk APE (area under the curve [AUC] = 0.760, 95% CI 0.695-0.826; P < 0.001) compared to PAOI (AUC = 0.719) and D-dimer (AUC = 0.645).

CONCLUSIONS

High neutrophil levels upon admission were significantly and independently associated with intermediate- and high-risk APE, which could be regarded as an indicator of inflammation and thrombosis in APE simultaneously. The potent diagnostic role of neutrophil levels and their competitive advantage over PAOI and D-dimer for the assessment of APE risk classification are suggested.

The Differential Systemic Biological Effects between Computer Navigation and Conventional Total Knee Arthroplasty (TKA) Surgeries: A Prospective Study

Distal femur reaming-free total knee arthroplasty (TKA) was reported to possess lower risk of acute myocardial infarction (AMI) or venous thromboembolism (VTE) than conventional TKA in a retrospective population-based study. We tried to offer prospective biological evidence by comparing the levels of AMI and VTE serum surrogate markers among the patients undertaking navigation and conventional TKAs to support these observations. Thirty-four participants undertaking navigation TKA and 34 patients receiving conventional TKA were recruited between February 2013 and December 2015. Blood samples were drawn from all participants before TKA, and 24 and 72 h after TKA, to assess the concentration of soluble P-selectin, matrix metalloproteinase-9 (MMP-9), C-reactive protein (CRP), and interleukin-8 (IL-8) between the participants undergoing navigation and conventional TKAs. We showed that significantly lower serum levels of soluble P-selectin 24 h after, as well as CRP 24 and 72 h after TKA could be observed in the navigation cohort. The more prominent surge of serum soluble P-selectin and CRP were perceived 24 and 72 h after TKA among the participants undergoing conventional TKA. Based upon our prospective biological evidence, the merits of navigation TKA are strengthened by lower levels of AMI and VTE serum surrogate markers.

Multiple ischemic stroke with pulmonary embolism revealing severe COVID-19 infection in a young healthy patient

Coronavirus 2019 (COVID-19) disease has caused significant morbidity and mortality worldwide since its emergence in December 2019. Despite its respiratory tropism; there is a nontrivial relationship between this virus and the neurovascular system exposing patients to higher morbidity and mortality. We report the case of a young patient admitted for hemiplegia with acute respiratory failure, in whom imaging found multiple ischemic strokes with pulmonary embolism and severe involvement suggestive of COVID-19 pneumopathy. Stroke in the context of COVID-19 infection has distinct characteristics in terms of disease mechanism, patient demographics, but also clinical, biological, and neuroradiological specificities. The pathogenesis and optimal management of COVID-19-associated ischemic stroke remain unclear, but the coagulopathy and endotheliopathy triggered by the cytokine storm represent possible target mechanisms.

The Association of Neutrophil-Lymphocyte Ratio with Venous Thromboembolism: A Systematic Review and Meta-Analysis

The neutrophil–lymphocyte ratio(NLR) has been used for diagnosing venous thromboembolism (VTE). We aimed to assess the accuracy of NLR to diagnose VTE by meta-analysis. Systematic electronic searches were conducted June 2, 2021 in PubMed, Embase(Ovid), and Cochrane Library. The search did not have any language or time restriction applied. Our search strategy was based on keywords in combination with both medical subject headings (MeSH) terms and text words. The diagnostic odds ratio, summary receiver operating characteristics, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were estimated. 10 articles with 1513 VTE participants and 2593 control participants were included for quantitative synthesis. The pooled values were as follows: sensitivity = 0.68(95% CI 0.45-0.84), specificity = 0.73(95% CI 0.6-0.83), positive likelihood ratio = 2.5(95% CI 1.8-3.4), negative likelihood ratio = 0.44(95% CI 0.26-0.75), diagnostic odds ratio = 6(95% CI 3-11), and SROC = 0.76(95% CI: 0.73-0.8). NLR could be diagnostic factor for the detection of potential VTE, the accuracy thereof in the current meta-analysis exhibited moderate accuracy for diagnosing VTE. Furthermore, further large cohort studies are needed to determine optimal cut-off values of NLR.

C-reactive protein, immunothrombosis and venous thromboembolism

C-reactive protein (CRP) is a member of the highly conserved pentraxin superfamily of proteins and is often used in clinical practice as a marker of infection and inflammation. There is now increasing evidence that CRP is not only a marker of inflammation, but also that destabilized isoforms of CRP possess pro-inflammatory and pro-thrombotic properties. CRP circulates as a functionally inert pentameric form (pCRP), which relaxes its conformation to pCRP* after binding to phosphocholine-enriched membranes and then dissociates to monomeric CRP (mCRP). with the latter two being destabilized isoforms possessing highly pro-inflammatory features. pCRP* and mCRP have significant biological effects in regulating many of the aspects central to pathogenesis of atherothrombosis and venous thromboembolism (VTE), by directly activating platelets and triggering the classical complement pathway. Importantly, it is now well appreciated that VTE is a consequence of thromboinflammation. Accordingly, acute VTE is known to be associated with classical inflammatory responses and elevations of CRP, and indeed VTE risk is elevated in conditions associated with inflammation, such as inflammatory bowel disease, COVID-19 and sepsis. Although the clinical data regarding the utility of CRP as a biomarker in predicting VTE remains modest, and in some cases conflicting, the clinical utility of CRP appears to be improved in subsets of the population such as in predicting VTE recurrence, in cancer-associated thrombosis and in those with COVID-19. Therefore, given the known biological function of CRP in amplifying inflammation and tissue damage, this raises the prospect that CRP may play a role in promoting VTE formation in the context of concurrent inflammation. However, further investigation is required to unravel whether CRP plays a direct role in the pathogenesis of VTE, the utility of which will be in developing novel prophylactic or therapeutic strategies to target thromboinflammation.

Plasma lipopolysaccharide-binding protein is a biomarker for future venous thromboembolism: Results from discovery and validation studies

BACKGROUND

Effect-size underestimation impedes biomarker identification. Long follow-up time in prospective studies attenuates effect-size estimates for transient biomarkers, while disease category-specific biomarkers are affected by merging of categories. Venous thromboembolism (VTE) encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE).

OBJECTIVES

(i) To re-analyze untargeted proteomic data to identify biomarker candidates for future VTE that differ between DVT and PE and are attenuated by extended time between sampling and VTE. (ii) To perform targeted candidate validation.

PATIENTS/METHODS

A VTE case-control discovery study and a nested case-control validation study were derived from the general population surveyed in 1994-95. Plasma was obtained at study enrollment, and VTE events were registered until 2007. Untargeted proteomic data were re-analyzed for candidate discovery. Lipopolysaccharide-binding protein (LBP) was validated by enzyme-linked immunosorbent assay.

RESULTS

Elevated LBP was discovered as a candidate DVT biomarker in women with less than 3 years between blood sampling and DVT. In the validation study, the odds ratio (OR) for DVT was 2.03 (95% confidence intervals [CI]: 1.53-2.74) per standard deviation (SD) increase in LBP for women with less than 3 years between blood sampling and DVT. Adjustment for age, body mass index, and C-reactive protein attenuated the OR to 1.79 (95% CI: 1.25-2.62) per SD. In the validation study, we observed an OR for VTE of 0.47 (95% CI: 0.28-0.77) for men in the 25^th to 50^th percentiles when compared to the lowest quartile.

CONCLUSIONS

We discovered and validated increased LBP as a predictive biomarker for DVT in women. We found an increased VTE risk for men in the lowest quartile of LBP.

Cardiorespiratory Fitness, Inflammation, and Risk of Chronic Obstructive Pulmonary Disease in Middle-Aged Men: A COHORT STUDY

PURPOSE

Chronic obstructive pulmonary disease (COPD) is characterized by chronic lung inflammation. The relationship between cardiorespiratory fitness (CRF) and COPD has not been well characterized. We aimed to evaluate the independent and joint associations of inflammation (high-sensitivity C-reactive protein [hsCRP]) and CRF with COPD risk in a cohort of White men.

METHODS

Among 2274 men aged 42-61 yr at baseline, serum hsCRP level was measured using an immunometric assay and CRF was assessed using a respiratory gas exchange analyzer. The level of hsCRP was categorized as normal and high (≤3 and >3 mg/L, respectively) and CRF as low and high. We corrected for within-person variability in exposures using repeat measurements taken several years apart.

RESULTS

A total of 116 COPD cases occurred during a median follow-up of 26.0 yr. The age-adjusted regression dilution ratio of hsCRP and CRF was 0.57 (95% CI, 0.50-0.64) and 0.58 (95% CI, 0.53-0.64), respectively. Comparing high versus normal hsCRP levels, the multivariable-adjusted HR for COPD was 1.79 (95% CI, 1.20-2.68). The COPD risk decreased linearly with increasing CRF. The multivariable-adjusted HR for COPD per 1-SD increase in CRF was 0.75 (95% CI, 0.60-0.95). Compared with men with normal hsCRP-low CRF, high hsCRP-low CRF was associated with an increased COPD risk, 1.80 (95% CI, 1.12-2.89), with no evidence of an association for high hsCRP-high CRF and COPD risk, 1.35 (95% CI, 0.68-2.69).

CONCLUSIONS

Both hsCRP and CRF are associated with COPD risk in middle-aged men. However, high CRF levels attenuate the increased COPD risk related to high hsCRP levels.

Serum copper-to-zinc ratio is associated with heart failure and improves risk prediction in middle-aged and older Caucasian men: A prospective study

BACKGROUND AND AIMS

Serum copper (Cu) and zinc (Zn) may play a role in the development of adverse cardiovascular outcomes including heart failure (HF). Serum Cu/Zn-ratio has been shown to be a risk indicator for cardiovascular disease, but its relationship with HF has not been previously investigated. We aimed to assess the association between Cu/Zn-ratio and incident HF risk using a prospective cohort study.

METHODS AND RESULTS

Study participants were recruited in eastern Finland with baseline examinations carried out between March 1998 and December 2001. Serum levels of Cu and Zn were measured using atomic absorption spectrometry in 1866 men aged 42-61 years without a history of HF at baseline. Multivariable-adjusted hazard ratios (HRs) with confidence intervals (CIs) were calculated for incident HF. During 26.5 years median follow-up, 365 HF cases occurred. Restricted cubic splines suggested linear relationships of serum Cu/Zn-ratio, Cu and Zn with HF risk. A unit increase in Cu/Zn-ratio was associated with an increased HF risk in analysis adjusted for several potential confounders including nutritional factors such as total energy intake, intake of fruits, berries and vegetables, and red meat (HR 1.63; 95% CI 1.06-2.51). The corresponding multivariable-adjusted HRs (95% CIs) for serum Cu and Zn were 2.42 (1.32-4.44) and 1.34 (0.50-3.63), respectively. Addition of Cu/Zn-ratio to a HF risk prediction model was associated with improved risk prediction.

CONCLUSION

In middle-aged and older Finnish men, increased serum Cu/Zn-ratio is associated with an increased risk of HF in a linear dose-response fashion and might improve HF risk assessment.

Cardiorespiratory Fitness, Inflammation, and Risk of Sudden Cardiac Death in Middle-Aged Men

Inflammation and cardiorespiratory fitness (CRF) are each independently related to the risk of sudden cardiac death (SCD). The interplay between CRF, inflammation and SCD is not well understood. We aimed to study the separate and joint associations of inflammation (high-sensitivity C-reactive protein [hsCRP]) and CRF with SCD risk in a cohort of Caucasian men. In 1,749 men aged 42 to 61 years without a history of coronary heart disease at baseline, serum hsCRP was measured using an immunometric assay, and CRF was assessed using a respiratory gas exchange analyzer during exercise testing. hsCRP was categorized as normal and high (≤3 and >3 mg/L, respectively) and CRF as low and high (median cutoff). A total of 148 SCD events occurred during a median follow-up of 28.9 years. Comparing high versus normal hsCRP, the multivariable-adjusted hazard ratio (95% confidence interval) for SCD was 1.65 (1.11 to 2.45), which remained similar on further adjustment for CRF 1.62 (1.09 to 2.40). Comparing high versus low CRF, the multivariable-adjusted hazard ratio for SCD was 0.61 (0.42 to 0.89), which remained persistent after adjustment for hsCRP 0.64 (0.44 to 0.93). Compared with normal hsCRP-low CRF, normal hsCRP-high CRF was associated with a decreased SCD risk of 0.65 (0.43 to 0.99), high hsCRP-low CRF was associated with an increased SCD risk of 1.72 (1.10 to 2.69), with no evidence of a relationship between high hsCRP-high CRF and SCD risk 0.86 (0.39 to 1.88). Positive additive and multiplicative interactions were found between hsCRP and CRF. In a middle-aged Finnish male population, both hsCRP and CRF are independently associated with SCD risk. However, high CRF levels appear to offset the increased SCD risk related to high hsCRP levels.

No evidence of a prospective relationship between serum zinc and venous thromboembolism in Caucasian men: a cohort study

Serum zinc has been implicated as an important mediator of haemostasis and thrombosis. However, the nature and magnitude of any potential relationship between serum zinc and venous thromboembolism (VTE) is unknown. We aimed to evaluate the prospective association between serum zinc and VTE risk. We analyzed data involving 2472 men aged 42-61 years without a history of VTE in the Kuopio Ischemic Heart Disease population-based cohort study, with the assessment of serum zinc concentrations using atomic absorption spectrometry. Hazard ratios (95% confidence intervals [CIs]) for incident VTE were estimated. A total of 166 VTE cases occurred during a median follow-up of 27.1 years. The risk of VTE per 1 standard deviation increase in serum zinc in analysis adjusted for systolic blood pressure, body mass index, total cholesterol, triglycerides, smoking status, histories of type 2 diabetes and coronary heart disease, medication for dyslipidaemia, alcohol consumption, physical activity, and socioeconomic status was (HR 1.03; 95% CI 0.86-1.22), which remained similar (HR 1.04; 95% CI 0.87-1.23) following further adjustment for inflammation and history of cancer. Comparing the extreme tertiles of serum zinc, the corresponding adjusted HRs (95% CIs) were 0.92 (0.63-1.36) and 0.94 (0.64-1.39), respectively. Imputed results based on 2682 participants and 176 VTE events were consistent with the observed results. In middle-aged and older Finnish men, serum zinc is not associated with future VTE risk. Other large-scale prospective studies conducted in other populations are needed to confirm or refute these findings.

Disease activity as a risk factor for venous thromboembolism in rheumatoid arthritis analysed using time-averaged DAS28CRP: a nested case-control study

The objective of this study is to clarify the clinical features and risk factors of venous thromboembolism (VTE) in patients with rheumatoid arthritis (RA). We retrospectively reviewed the prevalence of VTE in RA patients who visited Hokkaido University Hospital from 2010 to 2019 and had more than 2 years of follow-up. To explore the risk to develop VTE, we selected 260 RA patients without VTE (non-VTE) via density sampling and identified the risk factors for VTE by multivariate logistic regression analysis. Univariate conditional logistic regression analysis showed older age (p < 0.0001, Odds Ratio [OR] 1.08, 95% Confidence Interval [CI] 1.04-1.14), increase of the body mass index (BMI) (p = 0.001, OR 1.17, 95% CI 1.06-1.31), higher prevalence of RA-associated lung disease (p = 0.002, OR 2.10, 95% CI 1.33-3.30) and more frequent glucocorticoid usage (p = 0.001, OR 2.09, 95% CI 1.34-3.51) in RA patients was associated with the development of VTE significantly. Furthermore, patients with higher time-averaged disease activity score 28 (DAS28) CRP were at elevated risk (p < 0.0001, OR 3.25, 95% CI 1.94-6.12). In conditional multivariate logistic regression analysis, time averaged DAS28CRP was significantly associated with the development of VTE (p = 0.0001, adjusted OR 3.40, 95% CI 1.77-7.85). Disease activity was identified as a major risk factor of VTE in patients with RA, suggesting that sustained clinical remission could be beneficial for decrease the risk of VTE.

Circulating Serum Copper Is Associated with Atherosclerotic Cardiovascular Disease, but Not Venous Thromboembolism: A Prospective Cohort Study

Background and Objective

Serum copper has been linked to the risk of atherosclerotic cardiovascular disease (CVD). However, the potential association between serum copper and venous thromboembolism (VTE) is not known. The principal aim was to evaluate the potential prospective association between serum copper and VTE risk. A secondary aim was to confirm or refute previously reported associations between serum copper and atherosclerotic CVD.

Methods

Serum copper was measured at baseline using atomic absorption spectrometry in 2,492 men aged 42-61 years without a history of VTE in the Kuopio Ischemic Heart Disease prospective cohort study. Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence interval (CI) for VTE.

Results

During a median follow-up of 27.0 years, 166 VTE events occurred. The risk of VTE per 1 standard deviation increase in serum copper in age-adjusted analysis was HR: 1.02; 95% CI: 0.88-1.20, which was attenuated to HR: 0.99; 95% CI: 0.82-1.19, following further adjustment for several established and emerging risk factors. Comparing the top versus bottom tertiles of serum copper, the corresponding adjusted HRs were 1.16 (95% CI: 0.80-1.66) and 1.11 (95% CI: 0.74-1.68), respectively. In 1,901 men without a history of coronary heart disease (CHD), the multivariable-adjusted HR for CHD was 1.32 (95% CI: 1.10-1.59) comparing extreme tertiles of serum copper.

Conclusion

In middle-aged Finnish men, we confirmed previously reported associations between high serum copper levels and increased risk of atherosclerotic CVD, but serum copper was not associated with future VTE risk. Other large-scale prospective studies conducted in women, other age-groups, and other populations are needed to confirm or refute these findings.

Targeting the NLRP3 inflammasome in cardiovascular diseases

The NACHT, leucine-rich repeat (LRR), and pyrin domain (PYD)-containing protein 3 (NLRP3) inflammasome is an intracellular sensing protein complex that plays a major role in innate immunity. Following tissue injury, activation of the NLRP3 inflammasome results in cytokine production, primarily interleukin(IL)-1β and IL-18, and, eventually, inflammatory cell death - pyroptosis. While a balanced inflammatory response favors damage resolution and tissue healing, excessive NLRP3 activation causes detrimental effects. A key involvement of the NLRP3 inflammasome has been reported across a wide range of cardiovascular diseases (CVDs). Several pharmacological agents selectively targeting the NLRP3 inflammasome system have been developed and tested in animals and early phase human studies with overall promising results. While the NLRP3 inhibitors are in clinical development, multiple randomized trials have demonstrated the safety and efficacy of IL-1 blockade in atherothrombosis, heart failure and recurrent pericarditis. Furthermore, the non-selective NLRP3 inhibitor colchicine has been recently shown to significantly reduce cardiovascular events in patients with chronic coronary disease. In this review, we will outline the mechanisms driving NLRP3 assembly and activation, and discuss the pathogenetic role of the NLRP3 inflammasome in CVDs, providing an overview of the current and future therapeutic approaches targeting the NLRP3 inflammasome.

Risk of venous thromboembolism associated with methotrexate versus hydroxychloroquine for rheumatoid arthritis: A propensity score-matched cohort study

AIMS

Patients with rheumatoid arthritis (RA) have an increased risk of venous thromboembolism (VTE), likely related to underlying inflammation. We examined VTE risk associated with two commonly used immunomodulators in RA patients, methotrexate and hydroxychloroquine.

METHODS AND RESULTS

Using U.S. Medicare claims data (2008-2017), we identified RA patients (≥65 years) who initiated methotrexate or hydroxychloroquine without prior use of any immunomodulators. The primary outcome was VTE, a composite of pulmonary embolism (PE) or deep vein thrombosis (DVT). Secondary outcomes included PE, DVT, and all-cause mortality. After 1:1 propensity score matching for confounding control, we identified 26,534 pairs of methotrexate and hydroxychloroquine initiators (mean (SD) age 74 (7) years; 79% female). During a total of 56,686 person-years of follow-up, 208 methotrexate and 83 hydroxychloroquine initiators developed VTE. The incidence rate of VTE was higher among methotrexate initiators (6.94/1,000 person-years) than hydroxychloroquine initiators (3.11/1,000 person-years) with a hazard ratio (HR) of 2.26 (95% CI 1.75, 2.91). Methotrexate initiators had a greater risk of PE (HR 3.30, 95% CI 2.28, 4.77) and DVT (HR 1.53, 95% CI 1.07, 2.19) than hydroxychloroquine initiators. All-cause mortality was similar between the two groups (HR 0.91, 95% CI 0.83, 1.00).

CONCLUSION

In this large real-world cohort of older RA patients, treatment with methotrexate was associated with a 2-fold increased risk of VTE relative to hydroxychloroquine, although all-cause mortality was similar. Future experimental studies with non-user control groups are needed to determine the causal relationships between the study drugs and VTE and whether methotrexate elevates or hydroxychloroquine reduces the risk of VTE.

Advances in aptamer-based sensing assays for C-reactive protein

C-reactive protein (CRP), a non-specific acute-phase indicator of inflammation, has been widely recognized for its value in clinical diagnostic applications. With the advancement of testing technologies, there have been many reports on fast, simple, and reliable methods for CRP testing. Among these, the aptamer-based biosensors are the focus and hotspot of research for achieving high-sensitivity analysis of CRP. This review summarizes the progress of in vitro aptamer screening for CRP and the recent advances in aptamer-based CRP sensor applications, thus developing insight for the new CRP aptasensor design strategy.

Anti-inflammatory diet and venous thromboembolism: Two prospective cohort studies

BACKGROUND AND AIMS

Inflammation has been revealed to facilitate thrombogenesis and to increase the risk of venous thromboembolism (VTE). However, limited data are available on the association between the anti-inflammatory diet and incident VTE. We conducted a cohort analysis to examine this association and to further examine whether this association is modified by smoking status, a trigger of systemic inflammation.

METHODS AND RESULTS

We used data from two cohorts including 81,507 middle-aged and older Swedish adults without previous VTE at baseline. An empirically validated anti-inflammatory diet index (AIDI), based on 12 foods with anti-inflammatory potential and 5 foods with pro-inflammatory potential, was employed to estimate the anti-inflammatory potential of diet. Hazard ratios (HRs), with corresponding 95% confidence intervals (CIs), of VTE were estimated by Cox proportional hazards regression models. During a mean follow-up of 17.8-years, 5241 VTE cases were diagnosed. Compared with individuals in the lowest quartile of the AIDI (score ≤4), those in the highest quartile (score ≥8) had a 9% (95% CI, 0-17%) lower risk of VTE. The inverse association was observed in current and past smokers (HR between the two extreme quartiles, 0.80, 95% CI, 0.70-0.91) but not in never smokers (HR, 1.03, 95% CI, 0.91-1.17). French fries (HR per serving, 1.33, 95% CI, 1.06, 1.67) but no other foods included in AIDI was associated with VTE.

CONCLUSION

The study suggests that a consumption of foods with high anti-inflammatory potential may play a role in the prevention of VTE in smokers.

Risk factors for venous thromboembolism and atherosclerotic cardiovascular disease: do they differ in patients with rheumatoid arthritis?

OBJECTIVE

Venous thromboembolism (VTE) is an increasing concern in rheumatoid arthritis (RA) with little known about risk factors. We aimed to compare risk factors for unprovoked VTE and atherosclerotic cardiovascular disease (ASCVD) in patients with RA and to assess subsequent ASCVD risk after an unprovoked VTE.

METHODS

People with RA participating in a US-wide longitudinal observational registry from 1998 to 2018 were assessed for incident unprovoked VTE (deep venous thrombosis and pulmonary emboli not associated with cancer, recent surgery, hospitalisation, fracture and pregnancy) and ASCVD (myocardial infarction and stroke) validated from hospital/death records. Risk factors for VTE and ASCVD and the risk of ASCVD after an unprovoked VTE were determined using Cox proportional hazards models.

RESULTS

During median (IQR) 4 (1.5-7) years of follow-up in 31 366 patients with RA, 539 unprovoked VTE and 1648 ASCVD events were identified. The adjusted models showed increased VTE and ASCVD risk with older age, male sex, comorbidities, prior fracture, worse disability, higher disease activity and glucocorticoids. Traditional cardiovascular disease risk factors were common in both ASCVD and VTE but only increased ASCVD risk with obesity as the exception (VTE HR (95% CI), 1.46 (1.13-1.87)) and ASCVD, 0.58 (0.50-0.68)). ASCVD risk doubled after an unprovoked VTE (HR (95% CI), 2.05 (1.43-2.95)).

CONCLUSION

Our findings suggest that unprovoked VTE is mediated by inflammation of RA and may be considered a spectrum of pan-cardiovascular syndrome.

Cardiorespiratory fitness is not associated with reduced risk of prostate cancer: A cohort study and review of the literature

BACKGROUND

Cardiorespiratory fitness (CRF) has a strong inverse relationship with several chronic disease outcomes, including some cancers. The association between CRF and prostate cancer is controversial. We aimed to assess the prospective association of CRF with prostate cancer risk using a cohort study and review of the literature.

MATERIAL AND METHODS

Cardiorespiratory fitness was assessed using a respiratory gas exchange analyser during exercise testing in 2204 cancer-free middle-aged men. Hazard ratios (HRs) with 95% confidence interval (CIs) were estimated. We corrected for within-person variability in CRF levels using repeat measurements.

RESULTS

During a median follow-up of 24.9 years, 216 prostate cancer cases occurred. The age-adjusted regression dilution ratio of CRF was 0.58 (95% CI: 0.53-0.64). The HR (95% CI) of prostate cancer per 1 standard deviation increase in CRF in age-adjusted analysis was 1.10 (0.95-1.27). The association remained consistent after further adjustment for several risk factors (HR 1.13; 95% CI 0.96-1.33). The corresponding adjusted HRs were 1.24 (95% CI: 0.87-1.77) and 1.28 (95% CI: 0.87-1.88), respectively, when comparing the extreme tertiles of CRF levels. Previous studies mostly reported no evidence of an association or an increased risk of prostate cancer in relation to high CRF. Studies reporting positive associations had short-term follow-up durations (<10 years).

CONCLUSIONS

Primary data and a review of previous studies suggest that elevated CRF is not associated with reduced prostate cancer risk. Previous findings of significant evidence of associations could be attributed to increased screening and detection as well as reverse causation bias.

Monomeric C-reactive protein promotes platelets to release mitochondrial DNA in anti-neutrophil cytoplasmic antibody-associated vasculitis

Although high level of circulating C-reactive protein (pCRP) is considered as a biomarker for disease activity, the significance of CRP in the pathogenesis of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has not been clarified. We once reported in AAV, pentameric CRP (pCRP) could dissociate into monomeric CRP (mCRP) and activate platelets. Recent studies have demonstrated that the activated platelets can release mitochondrial DNA (mtDNA). The purpose of this study was to further study the relationship between mCRP and platelets in AAV. We found the plasma level of mCRP in AAV patients was significantly higher than that of normal control and positively correlated with the proportion of mCRP-positive platelets. Platelets isolated from one normal donor could be activated by plasma from 5 AAV patients and this effect could be attenuated when mCRP had been removed. Only 0.1 μg/mL of recombinant mCRP was needed for inducing platelets to release mtDNA via interaction with lipid raft and through p38 MAPK/NF-κB pathway. The mCRP binding on platelets depended on the C-terminal octapeptide (aa 199-206). The released mtDNA did not induce respiratory burst alone, but enhanced the ANCA-induced neutrophils respiratory burst after binding Toll-like receptor 9 (TLR9). The mtDNA released by mCRP-activated platelets also enhanced thrombin generation of plasma. In conclusion, our data demonstrate that mCRP can bind platelets via interaction with lipid raft and induce the release of mtDNA. The released mtDNA can enhance the pathogenicity of ANCA and promote activation of coagulation system in AAV.

Circulating Serum Magnesium and the Risk of Venous Thromboembolism in Men: A Long-Term Prospective Cohort Study

Background and Objective

Serum magnesium, an essential trace element involved in processes that regulate cardiovascular function, has been linked to the risk of atherosclerotic cardiovascular disease. However, the potential association between serum magnesium and venous thromboembolism (VTE) has not been previously investigated. We aimed to assess the prospective association of serum magnesium with the risk of VTE.

Methods

Serum magnesium was measured using atomic absorption spectrometry in 2,361 men aged 42-61 years with no history of VTE at baseline in the Kuopio Ischemic Heart Disease prospective cohort. Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE.

Results

A total of 159 incident VTE events were recorded during a median follow-up of 27.1 years. The risk of VTE per 1 SD increase in serum magnesium in the age-adjusted analysis was (HR 1.30; 95% CI 0.46-3.69). The association remained consistent in analyses adjusted for systolic blood pressure, body mass index, total cholesterol, triglycerides, smoking status, a history of type 2 diabetes, a history of coronary heart disease, medication for dyslipidemia, alcohol consumption, physical activity, socioeconomic status, serum active calcium, high-sensitivity C-reactive protein, and a history of cancer (HR 1.38; 95% CI 0.48-3.96). Comparing the extreme tertiles of serum magnesium, the corresponding adjusted HRs were 1.17 (95% CI 0.81-1.70) and 1.17 (95% CI 0.81-1.70), respectively.

Conclusion

In a middle-aged Caucasian male population, serum-circulating magnesium was not associated with a future risk of VTE. Further studies in women, other age groups, and other populations are required to generalize these findings.

Predictive role of the modified Glasgow prognostic score for in-hospital mortality in stable acute pulmonary embolism

BACKGROUND AND IMPORTANCE

The modified Glasgow prognostic score (mGPS) has been reported to have a prognostic value in various patient populations. However, the prognostic significance of mGPS has not been studied inacute pulmonary embolism (APE).

OBJECTIVE

This study aimed to investigate the predictive value of mGPS on in-hospital mortality in patients with hemodynamically stableAPE.

METHODS

We retrospectively included 258 hemodynamically stableAPE patients. Clinical, echocardiographic, and laboratory data recorded on admission. The mGPS scored as 0, 1, or 2 based on the C-reactive protein (CRP) and albumin levels.

RESULTS

A total of 258hemodynamically stableAPE patients were included, and 28 (10.9%) died during the hospital stay. Compared with survivors, non-survivors were older, had higher N-terminal pro-B-type natriuretic peptide, CRP, creatinine, high-sensitive cardiac troponin T (hs-cTnT), and mGPS levels, and had higher pulmonary embolism severity index (PESI) at study entry. In the multivariate logistic regression analysis, NT-proBNP>2350pg/mL (OR: 2.180, 95% CI 1.102-5.213, p<0.001), hs-cTnT>21pg/mL (OR: 1.426, 95% CI 0.951-3.751, p=0.001), CRP>3.1mg/dL (OR: 1.567, 95% CI 1.072-4.429, p=0.001), PESI>139 (OR: 2.745, 95% CI 0.869-6.369, p=0.001), systolic blood pressure<100mmHg (OR: 3.465, 95% CI 0.867-8.934, p<0.001), mGPS=1 (OR: 2.120, 95% CI 1.089-3.754, p=0.011), and mGPS=2 (OR: 3.350, 95% CI 1.457-5.367, p<0.001) were independently associated with in-hospital mortality.

CONCLUSION

This study demonstrates the mGPS, which is a new and easily measurable marker, is a useful predictor in-hospital mortality in hemodynamically stableAPE.

Attenuated Risk of Pneumonia Due to Inflammation by Frequent Sauna Baths: A PROSPECTIVE COHORT STUDY

PURPOSE

Inflammatory pathways are involved in the pathogenesis of pneumonia. Frequent sauna sessions may reduce the risk of respiratory tract infections including pneumonia independent of inflammation. We aimed to evaluate the independent and joint associations of high-sensitivity C-reactive protein (hsCRP) and frequency of sauna bathing (FSB) with risk of pneumonia in a prospective cohort study.

METHODS

Serum hsCRP as an inflammatory marker was measured using an immunometric assay and FSB was assessed by self-reported sauna bathing habits at baseline in 2264 men aged 42-61 yr. Serum hsCRP was categorized as normal and high (≤3 and >3 mg/L, respectively) and FSB as low and high (defined as ≤1 and 2-7 sessions/wk, respectively). Multivariable-adjusted HRs (CIs) were calculated for incident pneumonia.

RESULTS

A total of 528 cases of pneumonia occurred during a median follow-up of 26.6 yr. Comparing high versus normal hsCRP, the multivariable-adjusted risk for pneumonia was HR = 1.30 (95% CI, 1.04-1.62). The corresponding risk was HR = 0.79 (95% CI, 0.66-0.95) comparing high versus low FSB. Compared with men with normal hsCRP and low FSB, high hsCRP and low FSB was associated with an increased risk of pneumonia in multivariable analysis (HR = 1.67: 95% CI, 1.21-2.29), with no evidence of an association for high hsCRP and high FSB and pneumonia (HR = 0.94: 95% CI, 0.69-1.29).

CONCLUSIONS

In a general middle-aged to older male Caucasian population, frequent sauna baths attenuated the increased risk of pneumonia due to inflammation.

Inflammatory Biomarkers in the Short-Term Prognosis of Venous Thromboembolism: A Narrative Review

The relationship between inflammation and venous thrombosis is not well understood. An inflammatory response may be both the cause and consequence of venous thromboembolism (VTE). In fact, several risk factors of VTE modulate thrombosis through inflammatory markers. Acute pulmonary embolism (PE) is burdened by a remarkable mortality rate, up to 34% in severely ill patients presenting with hemodynamic instability. Initial mortality risk stratification is based on hemodynamic instability. Patients with a situation of hemodynamic stability require immediate further risk assessment based on clinical, imaging, and circulating biomarkers, as well as the presence of comorbidities. Some inflammatory biomarkers have shown potential usefulness in the risk stratification of patients with VTE, especially acute PE. C-reactive protein on admission is associated with 30-day mortality and bleeding in VTE patients. P-selectin is associated with right ventricle dysfunction in PE patients and might be associated with VTE recurrences and the extension of thrombosis. Tissue factor microparticles are associated with VTE recurrence in cancer-associated thrombosis. Other inflammatory biomarkers present scarce evidence (inflammatory cytokines, erythrocyte sedimentation rate, fibrinogen, leukocyte count). In this manuscript, we will review the prognostic role of different inflammatory biomarkers available both for clinical practice and research in VTE patients.

COVID-19 Pathophysiology Predicts That Ischemic Stroke Occurrence Is an Expectation, Not an Exception-A Systematic Review

Clinical reports of neurological manifestations associated with severe coronavirus disease 2019 (COVID-19), such as acute ischemic stroke (AIS), encephalopathy, seizures, headaches, acute necrotizing encephalitis, cerebral microbleeds, posterior reversible leukoencephalopathy syndrome, hemophagocytic lymphohistiocytosis, peripheral neuropathy, cranial nerve palsies, transverse myelitis, and demyelinating disorders, are increasing rapidly. However, there are comparatively few studies investigating the potential impact of immunological responses secondary to hypoxia, oxidative stress, and excessive platelet-induced aggregation on the brain. This scoping review has focused on the pathophysiological mechanisms associated with peripheral and consequential neural (central) inflammation leading to COVID-19-related ischemic strokes. It also highlights the common biological processes shared between AIS and COVID-19 infection and the importance of the recognition that severe respiratory dysfunction and neurological impairments associated with COVID and chronic inflammation [post-COVID-19 neurological syndrome (PCNS)] may significantly impact recovery and ability to benefit from neurorehabilitation. This study provides a comprehensive review of the pathobiology of COVID-19 and ischemic stroke. It also affirms that the immunological contribution to the pathophysiology of COVID-19 is predictive of the neurological sequelae particularly ischemic stroke, which makes it the expectation rather than the exception. This work is of fundamental significance to the neurorehabilitation community given the increasing number of COVID-related ischemic strokes, the current limited knowledge regarding the risk of reinfection, and recent reports of a PCNS. It further highlights the need for global collaboration and research into new pathobiology-based neurorehabilitation treatment strategies and more integrated evidence-based care.

Global assessment of C-reactive protein and health-related outcomes: an umbrella review of evidence from observational studies and Mendelian randomization studies

C-reactive protein (CRP) has been studied extensively for association with a large number of non-infectious diseases and outcomes. We aimed to evaluate the breadth and validity of associations between CRP and non-infectious, chronic health outcomes and biomarkers. We conducted an umbrella review of systematic reviews and meta-analyses and a systematic review of Mendelian randomization (MR) studies. PubMed, Scopus, and Cochrane Database of Systematic Reviews were systematically searched from inception up to March 2019. Meta-analyses of observational studies and MR studies examining associations between CRP and health outcomes were identified, excluding studies on the diagnostic value of CRP for infections. We found 113 meta-analytic comparisons of observational studies and 196 MR analyses, covering a wide range of outcomes. The overwhelming majority of the meta-analyses of observational studies reported a nominally statistically significant result (95/113, 84.1%); however, the majority of the meta-analyses displayed substantial heterogeneity (47.8%), small study effects (39.8%) or excess significance (41.6%). Only two outcomes, cardiovascular mortality and venous thromboembolism, showed convincing evidence of association with CRP levels. When examining the MR literature, we found MR studies for 53/113 outcomes examined in the observational study meta-analyses but substantial support for a causal association with CRP was not observed for any phenotype. Despite the striking amount of research on CRP, convincing evidence for associations and causal effects is remarkably limited.

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

Corona virus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) is recognized as a global pandemic by WHO 2020 with 5,934 936 infections, 367,166 deaths and affecting over 200 countries as of 30th May 2020. Acute Ischemic Stroke (AIS) in brain is also emerging as an important neurovascular/neurological complication of COVID-19, associated with extreme immune responses leading to dysregulated coagulation system and generalized thrombo-embolic status and increased risk of AIS especially among usually less vulnerable younger adults in this cohort. Thus, in early June 2020, we aimed to review the clinical data on all published cases of COVID-19 and concomitant AIS, with a view to understanding the pertinent clinical, laboratory and imaging features. The neutrophil-lymphocyte ratio (NLR) at time of hospital admission for COVID infection correlates positively with the duration of time before onset of clinical features of AIS. Higher NLR, C-Reactive protein, serum ferritin, D-dimer and fibrinogen levels are associated with poor prognosis of AIS in COVID-19 with 75% of patients dying or being severely disabled at present. Currently it is too early to comment on the long-term outcomes for survivors.

Metabolomic Biomarkers in Anxiety Disorders

Anxiety disorders range among the most prevalent psychiatric disorders and belong to the leading disorders in the study of the total global burden of disease. Anxiety disorders are complex conditions, with not fully understood etiological mechanisms. Numerous factors, including psychological, genetic, biological, and chemical factors, are thought to be involved in their etiology. Although the diagnosis of anxiety disorders is constantly evolving, diagnostic manuals rely on symptom lists, not on objective biomarkers and treatment effects are small to moderate. The underlying biological factors that drive anxiety disorders may be better suited to serve as biomarkers for guiding personalized medicine, as they are objective and can be measured externally. Therefore, the incorporation of novel biomarkers into current clinical methods might help to generate a classification system for anxiety disorders that can be linked to the underlying dysfunctional pathways. The study of metabolites (metabolomics) in a large-scale manner shows potential for disease diagnosis, for stratification of patients in a heterogeneous patient population, for monitoring therapeutic efficacy and disease progression, and for defining therapeutic targets. All of these are important properties for anxiety disorders, which is a multifactorial condition not involving a single-gene mutation. This review summarizes recent investigations on metabolomics studies in anxiety disorders.

Predicting the Risk of Recurrent Venous Thromboembolism: Current Challenges and Future Opportunities

Acute venous thromboembolism (VTE) is a commonly diagnosed condition and requires treatment with anticoagulation to reduce the risk of embolisation as well as recurrent venous thrombotic events. In many cases, cessation of anticoagulation is associated with an unacceptably high risk of recurrent VTE, precipitating the use of indefinite anticoagulation. In contrast, however, continuing anticoagulation is associated with increased major bleeding events. As a consequence, it is essential to accurately predict the subgroup of patients who have the highest probability of experiencing recurrent VTE, so that treatment can be appropriately tailored to each individual. To this end, the development of clinical prediction models has aided in calculating the risk of recurrent thrombotic events; however, there are several limitations with regards to routine use for all patients with acute VTE. More recently, focus has shifted towards the utility of novel biomarkers in the understanding of disease pathogenesis as well as their application in predicting recurrent VTE. Below, we review the current strategies used to predict the development of recurrent VTE, with emphasis on the application of several promising novel biomarkers in this field.

Effects of ABCA1 gene polymorphisms on risk factors, susceptibility and severity of coronary artery disease

BACKGROUND

The relationships between the rs1800976, rs4149313 and rs2230806 polymorphisms in ATP binding cassette protein A1 and severity of coronary artery disease (CAD) remain unclear.

METHODS

Four hundred and forty-two patients with CAD and 217 CAD-free subjects were enrolled in this study. The rs1800976, rs4149313 and rs2230806 polymorphisms were genotyped by PCR-RFLP. Severity of CAD was evaluated by Gensini score system, number of stenotic coronary vessels and extent of coronary stenosis.

RESULTS

C allele of the rs1800976 polymorphism, G allele of the rs4149313 polymorphism and A allele of the rs2230806 polymorphism were found to be risk alleles for CAD (p<0.05 for all). In patients with CAD, C allele of the rs1800976 polymorphism was associated with high levels of hypersensitive C reactive protein (hs-CRP) and cystatin c (CysC), and its frequency increased with percentiles of Gensini score, number of stenotic coronary vessels and extent of coronary stenosis (p<0.05 for all). The subjects with GA genotype of the rs4149313 polymorphism had higher levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B and hs-CRP than those with AA genotype (p<0.05 for all). The subjects with AA genotype of the rs2230806 polymorphism had higher levels of TC, LDL-C and uric acid than those with GA genotype (p<0.05 for all). No associations between the rs4149313 or rs2230806 polymorphism and severity of CAD were detected.

CONCLUSIONS

The rs1800976 polymorphism is significantly associated with the occurrence and severity of CAD, which is possibly mediated by hs-CRP and CysC.

C-reactive protein level predicts 30-day mortality and bleeding in patients with venous thromboembolism: A prospective single-center study

AIMS

The association of on-admission CRP and early adverse outcomes in acute venous thromboembolism (VTE) has not been investigated. We hypothesized that increased on-admission CRP levels would correlate with adverse outcomes in patients with acute VTE.

METHOD

In this prospective observational study, consecutive patients with acute VTE were enrolled and CRP levels were measured within the first 24h after diagnosis. Mortality, bleeding and recurrence were recorded during a 30-day follow-up.

RESULTS

586 patients were included. Higher CRP levels were found in patients with mortality (7.5 vs 4.0mg/dL; p=0.01) and bleeding (7.8 vs 3.9mg/dL; p=0.03). Multivariable logistic regression showed that CRP levels >5mg/dL were associated with higher mortality (OR 6.25; 95% CI, 2.1-18.6) and bleeding (OR 2.7; CI 95% 1.3-5.7). These results were independent to ESC risk score and simplified PESI score for mortality prediction. The predictive capacity of CRP showed an area under the ROC curve - AUC - of .7 (CI 95% .56-.85) for mortality and .65 (CI 95% .54-.75) for bleeding. The prognostic capacity of the ESC risk score and simplified PESI score was improved after adding the CRP cutoff of 5mg/dL (AUC of .87 CI 95% .79-.95).

CONCLUSION

Our findings suggest that on-admission CRP level may be a simple, widely available and valuable biomarker to identify high-risk VTE patients for early mortality and bleeding. CRP ≥5mg/dL was independently associated with 30-day VTE related death and bleeding.

Finnish sauna bathing does not increase or decrease the risk of cancer in men: A prospective cohort study

INTRODUCTION

Evidence suggests that heat therapy can be used to prevent and treat cancer; anecdotal reports suggest passive heat therapies may increase cancer risk. Finnish sauna bathing has been linked to a reduced risk of chronic diseases, but its association with cancer risk is unknown. We aimed to assess the prospective association between frequency of sauna bathing and the risk of all-cause and site-specific cancers using the Kuopio Ischemic Heart Disease prospective cohort.

METHODS

Baseline sauna bathing habits were assessed in 2173 men aged 42-61 years with no history of cancer. Hazard ratios (HRs) with 95% confidence intervals (CIs) for cancer were calculated using Cox proportional hazard models. We corrected for within-person variability in sauna bathing habits using data from repeat assessments taken 11 years apart.

RESULTS

During a median follow-up of 24.3 years, 588 (27.1%) all-cause cancer cases were recorded. The age-adjusted regression dilution ratio of sauna bathing frequency was 0.69 (0.62-0.76). In multivariable-adjusted analyses, the HRs (95% CIs) of all-cause cancer were 0.92 (0.76-1.11) and 0.92 (0.66-1.27) for men who had 2-3 and ≥4 sauna sessions per week, respectively, compared with men who had ≤1 sauna session per week. The non-significant findings were consistent for prostate, gastrointestinal and lung cancers on multivariate adjustment.

CONCLUSION

Frequent Finnish sauna bathing is not associated with the risk of cancer in a middle-aged male Caucasian population. Further studies are required to confirm or refute these findings, particularly in women and other age groups.

Sauna bathing reduces the risk of venous thromboembolism: a prospective cohort study

Emerging evidence suggests there is an inverse and independent association between sauna bathing and arterial thrombotic disease. However, the potential association between sauna bathing and venous thromboembolism (VTE) has not yet been investigated. We aimed to assess the prospective association between frequency of sauna bathing and the risk of VTE. Baseline sauna bathing habits were assessed in 2242 men aged 42-61 years without a history of VTE in the Kuopio Ischemic Heart Disease prospective cohort. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for VTE. During a median follow-up of 24.9 years, 146 (6.5%) incident VTE events were recorded. In age-adjusted analyses, the HRs 95% (CIs) of VTE were 0.67 (0.47-0.96) and 0.95 (0.53-1.70) for participants who had 2-3 and ≥ 4 sauna sessions per week respectively compared with participants who had ≤ 1 sauna session per week. After further adjustment for several established risk factors including lifestyle factors, the corresponding HRs (95% CIs) were 0.67 (0.46-0.96) and 0.92 (0.51-1.68) respectively. Having sauna baths was associated with a reduced risk of VTE in a middle-aged male Caucasian population. Further studies in other populations and age groups are required to confirm these findings.

Cardiorespiratory fitness is not associated with risk of venous thromboembolism: a cohort study

Objectives. The inverse and independent association between cardiorespiratory fitness (CRF) and arterial thrombotic disease is well established. However, the potential association between CRF and venous thromboembolism (VTE) is not well known. We aimed to assess the prospective association of CRF with the risk of VTE. Design. Cardiorespiratory fitness, as measured by maximal oxygen uptake (VO_2max), was assessed using a respiratory gas exchange analyser in 2,249 men aged 42-61 years without a history of VTE at baseline in the Kuopio Ischemic Heart Disease prospective cohort. Cox-regression models were used to calculate hazard ratios (HR) with 95% confidence interval (CI) for VTE. We corrected for within-person variability in CRF levels using data from repeat measurements taken several years apart. Results. There were 144 (6.4%) incident VTE events recorded during a median follow-up of 25.2 years. The age-adjusted regression dilution ratio of CRF was 0.58 (95% CI: 0.53-0.64). The risk of VTE did not significantly decrease per 1 standard deviation increase in CRF in age-adjusted analysis (HR 0.90; 95% CI 0.75-1.08). The association remained consistent in analyses adjusted for several established and emerging risk factors (HR 0.90; 95% CI 0.73-1.12). The corresponding adjusted HRs were 0.80 (95% CI: 0.52-1.23) and 0.82 (95% CI: 0.51-1.32) respectively, when comparing the extreme tertiles of CRF levels. Conclusions. In a middle-aged Caucasian male population, CRF was not associated with future risk of VTE. Further studies are required to confirm and to generalize these findings, particulary in women and other age groups.

Lipoprotein(a) is not associated with venous thromboembolism risk

Objectives. Evidence from case-control studies as well as meta-analyses of these study designs suggest elevated lipoprotein(a) [Lp(a)] to be associated with an increased risk of venous thromboembolism (VTE). Prospective evidence on the association is limited, uncertain, and could be attributed to regression dilution bias. We aimed to assess the prospective association of Lp(a) with risk of VTE and correct for regression dilution. Design. We related plasma Lp(a) concentrations to the incidence of VTE in 2,180 men of the Kuopio Ischemic Heart Disease cohort study. Hazard ratios (HRs) (95% confidence intervals [CI]) were assessed and repeat measurements of Lp(a) at 4 and 11 years from baseline, were used to correct for within-person variability. Results. After a median follow-up of 24.9 years, 110 validated VTE cases were recorded. The regression dilution ratio of log_e Lp(a) adjusted for age was 0.85 (95% CI: 0.82-0.89). In analyses adjusted for several established risk factors and potential confounders, the HR (95% CI) for VTE per 1 SD (equivalent to 3.56-fold) higher baseline log_e Lp(a) was 1.06 (0.87-1.30). In pooled analysis of five population-based cohort studies (including the current study) comprising 66,583 participants and 1314 VTE cases, the fully-adjusted corresponding HR for VTE was 1.00 (95% CI: 0.94-1.07), with no evidence of heterogeneity between studies. Conclusions. Primary analysis as well as pooled evidence from previous studies suggest circulating Lp(a) is not prospectively associated with future VTE risk, indicating that evidence of associations demonstrated in case-control designs may be driven by biases such as selection bias.

The role of serum bilirubin levels in determining venous thromboembolism

OBJECTIVE

Venous thromboembolism (VTE) is a disease that includes both deep venous thrombosis (DVT) and pulmonary embolism (PE). Bilirubin is an endogenous anti-inflammatory marker associated with atherothrombosis. The purpose of our study was to investigate the association of serum bilirubin levels with the presence of VTE.

METHODS

A total of 103 patients with VTE (distal DVT, n = 34; proximal DVT, n = 30; PE, n = 39) and 50 control patients were cross-sectionally enrolled. Peripheral venous duplex ultrasound and computed tomography were used for the diagnosis of VTE. Fasting blood samples were drawn for biochemical analyses.

RESULTS

Baseline characteristics were not different between groups. The VTE group had lower bilirubin level (9.0 ± 2.6 μmol/L vs 7.3 ± 3 μmol/L; P = .001) and higher high-sensitivity C-reactive protein (hs-CRP) concentration (0.8 [0.3-2] mg/L vs 1.1 [0.2-3] mg/L; P = .008) and white blood cell count (7.4 ± 1.5 × 10⁹/L vs 8.2 ± 2.7 × 10⁹/L; P = .02) compared with control patients. In the analysis of variance, the levels of total direct bilirubin and hs-CRP were clearly different between the control group and VTE subgroups (distal and proximal DVT and PE). The receiver operating characteristic curve analysis showed a cutoff value of 8.9 μmol/L for total bilirubin (sensitivity, 74%; specificity, 55%) and an area under the curve of 0.659 (P < .001).

CONCLUSIONS

Bilirubin level, hs-CRP concentration, and white blood cell count were independently associated with VTE.

Clozapine-Associated Pulmonary Embolism: A High-Mortality, Dose-Independent and Early-Onset Adverse Effect

BACKGROUND

Recent epidemiological studies have identified an excess of pulmonary embolism (PE) cases in patients treated with antipsychotic drugs. The findings are particularly relevant for patients treated with clozapine, which has many potentially life-threatening adverse drug effects. Among these adverse drug effects are myocarditis and agranulocytosis that have early onset and are dose independent, but also seizures and myocardial repolarization delay, which are dose dependent and may occur at any time. Together with death rates, these variables have important implications for clinical practice.

AREAS OF UNCERTAINTY

Study Question: What are the time of onset, dose relationship, and mortality of clozapine-associated PE?

DATA SOURCES

The published case reports of clozapine-associated PE were identified in a MEDLINE search. Cases occurring within 6 months of starting clozapine were considered to have early onset. Dosages of clozapine at the time of PE were defined as low (200 mg/d or less) or high (300 mg/d or greater). Patient outcome was divided into survival of the PE event and death.

RESULTS

The search identified 23 cases of clozapine-associated PE. The PE had early onset (6.4 ± 7.0 weeks) in 20 patients (87%, 95% confidence interval 67.9%-95.5%). PE occurred in 9 patients treated with low doses (152.8 ± 50.7 mg/d) and in 11 patients on high doses (372.7 ± 127.2 mg/d) of clozapine. Six patients (26.1%, 95% confidence interval 12.6%-46.5%) died.

CONCLUSIONS

A systematic review of the published case reports of clozapine-associated PE indicates that this adverse effect is highly lethal, has early onset and is dose independent. The findings should prompt careful monitoring and consideration of prophylactic treatment for venous thromboembolism for 6 months after starting treatment with clozapine.

Inverse association between serum albumin and future risk of venous thromboembolism: interrelationship with high sensitivity C-reactive protein

PURPOSE

We aimed to assess the prospective association of serum albumin with venous thromboembolism (VTE) risk and evaluate if the association is independent of or modified by inflammation, as measured by high sensitivity C-reactive protein (hsCRP).

DESIGN

We analysed data of 2176 men aged 42-61 years free from VTE in the Kuopio Ischemic Heart Disease study, with serum albumin concentrations measured at baseline using Coulter's bromocresol purple colorimetric assays. Hazard ratios (HRs) (95% confidence intervals [CI]) were calculated for VTE.

RESULTS

There were 109 validated cases of VTE recorded during a median follow-up of 24.9 years. The risk of VTE increased linearly below a serum albumin concentration of ∼48 g/l. In Cox regression analysis adjusted for established risk factors and other potential confounders, the HR (95% CI) for VTE per 1 standard deviation lower serum albumin was 1.23 (1.02-1.47). The association remained persistent on further adjustment for hsCRP 1.22 (1.01-1.46). Furthermore, the association was not modified by hsCRP and persisted on exclusion of men with elevated hsCRP levels.

CONCLUSIONS

In middle-aged Caucasian men, low serum albumin is associated with an increased risk of VTE, consistent with a linear dose-response relationship. The association is independent of and not modified by inflammation. Key messages   • Serum albumin may be associated with future risk of venous thromboembolism (VTE); however, the shape, nature, magnitude and consistency of the association is uncertain.   • In a population-based prospective cohort study, low serum albumin was associated with an increased risk of VTE in a linear dose-response manner and this association was independent of and not modified by inflammation.   • Serum albumin concentrations may play a role in the development of VTE.