Plasma Homocysteine and Prognosis of Acute Ischemic Stroke: a Gender-Specific Analysis From CATIS Randomized Clinical Trial

Mild hyperhomocysteinemia alters oxidative stress profile via Nrf2, inflammation and cholinesterases in cardiovascular system of aged male rats

Homocysteine (Hcy) is an independent cardiovascular disease (CVD) risk factor, whose mechanisms are poorly understood. We aimed to explore mild hyperhomocysteinemia (HHcy) effects on oxidative status, inflammatory, and cholinesterase parameters in aged male Wistar rats (365 days old). Rats received subcutaneous Hcy (0.03 μmol/g body weight) twice daily for 30 days, followed by euthanasia, blood collection and heart dissection 12 h after the last injection. Results revealed increased dichlorofluorescein (DCF) levels in the heart and serum, alongside decreased antioxidant enzyme activities (superoxide dismutase, catalase, glutathione peroxidase), reduced glutathione (GSH) content, and diminished acetylcholinesterase (AChE) activity in the heart. Serum butyrylcholinesterase (BuChE) levels also decreased. Furthermore, nuclear factor erythroid 2-related factor 2 (Nrf2) protein content decreased in both cytosolic and nuclear fractions, while cytosolic nuclear factor kappa B (NFκB) p65 increased in the heart. Additionally, interleukins IL-1β, IL-6 and IL-10 showed elevated expression levels in the heart. These findings could suggest a connection between aging and HHcy in CVD. Reduced Nrf2 protein content and impaired antioxidant defenses, combined with inflammatory factors and altered cholinesterases activity, may contribute to understanding the impact of Hcy on cardiovascular dynamics. This study sheds light on the complex interplay between HHcy, oxidative stress, inflammation, and cholinesterases in CVD, providing valuable insights for future research.

Plasma homocysteine level, estradiol level, and brain atrophy: a Mendelian randomization study

OBJECTIVES

Observational studies link elevated plasma homocysteine (Hcy) with vascular disease. Our aim was to assess the gender difference in the association between the plasma tHcy level and brain atrophy and identify the possible influencer. We employed Mendelian randomization (MR) to explore the causal relationship between plasma tHcy level, estradiol level, and brain atrophy.

METHODS

A total of 687 patients with brain atrophy were included, and gender-specific subgroup analyses in association between tHcy and brain atrophy are conducted. From genome-wide association studies, we selected genetic variants (P < 5 × 10-8) for the plasma tHcy level and estradiol level. We investigated the degree of brain atrophy (including gray matter volume and total brain volume) in the UK biobank (n = 7,916). The inverse variance-weighted and several sensitivity MR regression analyses were carried out.

RESULTS

The plasma tHcy level was significantly associated with brain atrophy for females, but not for males. An MR study showed that there was little evidence of the causal link between elevated plasma tHcy and brain atrophy. On the other hand, we found evidence to support causality for genetically decreased estradiol with higher risk of brain atrophy. Furthermore, genetic predisposition to elevated plasma tHcy was associated with a lower estradiol level.

CONCLUSIONS

The influence of estradiol on the association between tHcy and brain atrophy deserves further investigation.

Association of Ferroptosis with Severity and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Case-control Study

Ferroptosis, an iron-dependent form of cell death, is characterized by intracellular accumulation of iron and reactive oxygen species-induced lipid peroxidation. Animal experiments have shown the important roles of ferroptosis in ischemic stroke, but the evidence in human stroke is insufficient. This prospective study evaluated the associations between plasma ferroptosis biomarkers at hyperacute stage and long-term outcomes in patients with acute ischemic stroke undergoing endovascular thrombectomy (EVT). The plasma samples were collected immediately before and after EVT (T1 and T2) and at 24 h (T3) for the 126 stroke patients and once for the 50 stroke-free control subjects. Compared with controls, stroke patients had higher 4-hydroxynonenal (4-HNE) levels at T1 and T2 while lower homocysteine and soluble transferrin receptor (sTfR) levels at T3. In stroke patients, higher National Institutes of Health Stroke Scale scores at admission were correlated with higher 4-HNE and lower sTfR levels. Lower Alberta Stroke Program Early CT (ASPECT) scores and larger infarct core volumes on CT perfusion before EVT were correlated with higher 4-HNE and homocysteine levels. After adjusting for significant parameters, homocysteine levels at T2 were significantly associated with poor functional outcome and mortality at 3 months. In the receiver operating characteristic (ROC) models, adding homocysteine levels at T2 and hemoglobin levels to the reference model for predicting poor functional outcome significantly increased the area under the ROC curve. In summary, this study provides evidence that ferroptosis is associated with stroke severity and outcomes in patients with acute ischemic stroke undergoing EVT.

Higher serum homocysteine levels are associated with an increased risk of hemorrhagic transformation in patients with acute ischemic stroke

BACKGROUND

Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke (AIS), and may develop into parenchyma hemorrhage (PH). We aimed to investigate the association between serum homocysteine levels and HT as well as PH in all AIS patients, and in those with and without thrombolysis by subgroup analysis.

METHODS

AIS patients who were admitted within 24 h after onset were enrolled and categorized into the higher homocysteine level group (≥ 15.5 µmol/L) and the lower homocysteine level group (< 15.5 µmol/L). HT was determined by a second round of brain imaging within 7 days during hospitalization, and PH was defined as hematoma in the ischemic parenchyma. Multivariate logistic regression was used to investigate the associations between serum homocysteine levels and HT and PH, respectively.

RESULTS

Of the 427 included patients (mean age 67.35 years, 60.0% males), 56 (13.11%) developed HT and 28 (6.56%) had PH. Serum homocysteine levels were significantly associated with HT (adjusted OR 1.029, 95%CI 1.003-1.055) and PH (adjusted OR 1.041, 95%CI 1.013-1.070). The higher homocysteine group was more likely to have HT (adjusted OR 1.902, 95% CI 1.022-3.539) and PH (adjusted OR 3.073, 95% CI 1.327-7.120) than the lower homocysteine group. Subgroup analysis of patients without thrombolysis also showed the significant differences in HT (adjusted OR 2.064, 95% CI 1.043-4.082) and PH (adjusted OR 2.926, 95% CI 1.196-7.156) between the two groups.

CONCLUSION

Higher serum homocysteine levels are associated with an increased risk of HT and PH in AIS patients, especially in those without thrombolysis. Monitoring the serum homocysteine may be conducive to determining individuals at a high risk of HT.

Gender difference in association between H-type hypertension and subcortical ischemic vascular disease

Background

Subcortical ischemic vascular disease (SIVD) is a leading cause of vascular dementia. The present study tries to explore not only the gender-specific association between H-type hypertension and SIVD but also the indirect effects of H-type hypertension on cognition through the ischemic brain injury caused by SIVD.

Materials and methods

A total of 601 SIVD patients were included, comprising 322 males and 279 females. H-type hypertension was defined as hypertension accompanied with elevated serum total homocysteine (tHcy) level. The imaging manifestations of ischemic brain injury caused by SIVD were also evaluated, including white matter lesions (WML), lacunar infarction (LI) and brain atrophy (BA). Gender-specific subgroup analyses in association between H-type hypertension and SIVD were conducted, followed by a structural equation model based evaluation of the gender-specific mediating effects of SIVD on the relationship between H-type hypertension and cognition.

Results

For males, there was no noticeable difference in WML, LI and BA scores among control group, isolated hypertension group, isolated high tHcy group, and H-type hypertension group in most brain regions, but significant difference was found in all brain regions for females. Multiple regression analyses showed that H-type hypertension was significantly associated with WML, LI and BA for females, but not for males. For males, H-type hypertension mainly affected cognition through direct effect, while the H-type hypertension effect was mediated by ischemic brain injury caused by SIVD for females.

Conclusion

H-type hypertension was more closely related to SIVD for females than males, suggesting a gender-specific difference in association patterns between H-type hypertension and cognition.

Sex-related differences in plasma amino acids of patients with ST-elevation myocardial infarction and glycine as risk marker of acute heart failure with preserved ejection fraction

Nowadays, the problem of preventing acute heart failure (AHF) in patients with ST-elevation myocardial infarction (STEMI) and preserved left-ventricular ejection fraction (pLVEF) is still not completely resolved, especially in late-presented patients. The purpose of study was: (1) assessment of free plasma amino acid (PAA) alterations in STEMI patients [not receiving reperfusion therapy (RT)], depending on sex and LVEF; (2) analysis of development of late/persistent AHF more than 48 h after admission (pAHF) in STEMI patients with pLVEF depending on PAA levels. This prospective cohort study included 92 STEMI patients (33 women and 59 men), not receiving RT. The free PAA were investigated by ion-exchange liquid-column chromatography. The women had significantly higher PAA levels than men in general cohort and cohort with pLVEF (n = 69). There were associations between female sex and pAHF in general cohort (OR 3.7, p = 0.004) and cohort with pLVEF (OR 11.4, p = 0.0001) by logistic regression. The association between pAHF and glycine level [OR 2.5, p < 0.0001; AUC 0.84, p < 0.0001; 86.7% sensitivity and 77.8% specificity for > 2.6 mg/dL] was revealed in cohort with pLVEF (including female and male). Glycine remained a predictor of pAHF with pLVEF by multivariable logistic regression adjusting for comorbidities, demographic and clinical variables. Higher rate of pAHF in female than in male STEMI patients with pLVEF is associated with higher plasma glycine in women. The glycine level may be genetically determinated by female sex. The plasma glycine > 2.6 mg/dL is a predictor of pAHF in STEMI with pLVEF (including female and male).

Circulating Biomarkers in Long-Term Stroke Prognosis: A Scoping Review Focusing on the South African Setting

Cerebrovascular disease, including both ischaemic and haemorrhagic strokes, remains one of the highest causes of global morbidity and mortality. Developing nations, such as South Africa (SA), are affected disproportionately. Early identification of stroke patients at risk of poor clinical prognosis may result in improved outcomes. In addition to conventional neuroimaging, the role of predictive biomarkers has been shown to be important. Little data exist on their applicability within SA. This scoping review aimed to evaluate the currently available data pertaining to blood biomarkers that aid in the long-term prognostication of patients following stroke and its potential application in the South African setting. This scoping review followed a 6-stage process to identify and critically review currently available literature pertaining to prognostic biomarkers in stroke. An initial 1191 articles were identified and, following rigorous review, 41 articles were included for the purposes of the scoping review. A number of potential biomarkers were identified and grouped according to the function or origin of the marker. Although most biomarkers showed great prognostic potential, the cost and availability will likely limit their application within SA. The burden of stroke is increasing worldwide and appears to be affecting developing countries disproportionately. Access to neuroradiological services is not readily available in all settings and the addition of biomarkers to assist in the long-term prognostication of patients following a stroke can be of great clinical value. The cost and availability of many of the reviewed biomarkers will likely hinder their use in the South African setting.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection is Associated with Homocysteine Level and Clinical Outcomes in Ischemic Stroke Patients

BACKGROUND: Since its emergence in December 2019 and declared as pandemic in March 2020, the drastic increase in cases of coronavirus disease 2019 (COVID-19) is alarming the importance of disease monitoring in order to prevent further complication, like ischemic stroke. One of the efforts is utilizing biomarker. For instance, elevated homocysteine level, already known risk factor of ischemic stroke, is currently identified in COVID-19 patients. AIM: To assess factor associated with homocysteine level and clinical outcomes of ischemic stroke patients. Methods: A cross-sectional study was conducted at Dr. Zainoel Abidin Hospital di Indonesia between March and August 2021. Ischemic stroke patients who had physical and neurology examinations, SARS-CoV-2 RT-PCR swab, chest x-ray, electrocardiography, head CT-scan and the total homocysteine level were included. To assess the factors associated with homocysteine level and the outcomes of ischemic stroke patients, the independent Student t-test or Anova and chi-squared were used, respectively. RESULTS: We included 62 ischemic stroke patients of which 32 (51.6%) were male and the age ranged between 30 and 80 years. Out of total, 60 patients (96.8%) were survived after the hospital admission. There was a significant association between gender and having COVID-19 with homocysteine level (p=0.012 and p=0.020, respectively). Having COVID-19 was the only variable significantly associated with the outcome of the ischemic stroke patient (p=0.035). CONCLUSION: COVID-19 is associated with homocysteine level and the clinical outcome in ischemic stroke patients. Therefore, SARS-CoV-2 infection in ischemic stroke or vice versa need to be monitored closely in hospital settings.

Homocysteine Plasmatic Concentration in Brain-Injured Neurocritical Care Patients: Systematic Review of Clinical Evidence

Background: Hyperhomocysteinemia (HHcy) is considered as an independent risk factor for several diseases, such as cardiovascular, neurological and autoimmune conditions. Atherothrombotic events, as a result of endothelial dysfunction and increased inflammation, are the main mechanisms involved in vascular damage. This review article reports clinical evidence on the relationship between the concentration of plasmatic homocysteine (Hcy) and acute brain injury (ABI) in neurocritical care patients. Materials and methods: a systematic search of articles in the PubMed and EMBASE databases was conducted, of which only complete studies, published in English in peer-reviewed journals, were included. Results: A total of 33 articles, which can be divided into the following 3 subchapters, are present: homocysteine and acute ischemic stroke (AIS); homocysteine and traumatic brain injury (TBI); homocysteine and intracranial hemorrhage (ICH)/subarachnoid hemorrhage (SAH). This confirms that HHcy is an independent risk factor for ABI and a marker of poor prognosis in the case of stroke, ICH, SAH and TBI. Conclusions: Several studies elucidate that Hcy levels influence the patient’s prognosis in ABI and, in some cases, the risk of recurrence. Hcy appears as biochemical marker that can be used by neuro-intensivists as an indicator for risk stratification. Moreover, a nutraceutical approach, including folic acid, the vitamins B6 and B12, reduces the risk of thrombosis, cardiovascular and neurological dysfunction in patients with severe HHcy that were admitted for neurocritical care.

Relationship between homocysteine levels and post-stroke cognitive impairment in female and male population: from a prospective multicenter study

Background and Objectives:

To investigate the relationship between homocysteine levels and post-stroke cognitive impairment (PSCI) in Chinese female and male populations with minor acute ischemic stroke or transient ischemic attack.

Materials and methods:

A total of 1070 participants with clinically confirmed acute minor ischemic stroke or transient ischemic attack and baseline homocysteine information from a nationwide multicenter prospective registry study in China were included in this study. Of these, 919 patients had cognitive assessments at 3-month follow-ups and 584 participants had cognitive assessments at 12-month follow-ups. The incidence of PSCI was defined as a Montreal Cognitive Assessment score ≤22. The differences in homocysteine levels and the incidence of PSCI were compared between female and male populations. Relationships between homocysteine levels and the incidence of PSCI in female and male populations were analyzed using multiple logistic regression, respectively.

Results:

Females had lower baseline homocysteine levels than males. Compared to males, females had lower education levels, lower rates of smoking and alcohol intake, and higher rates of diabetes and hypertension. No relationship was observed between elevated homocysteine level and 3-month PSCI incidence in either females or males. After adjusting the confounders, elevated baseline homocysteine significantly increased the 12-month PSCI risk (odds ratio 3.28, 95% confidence interval 1.47–7.34, P = 0.004) in females, but not in males (odds ratio 0.86, 95% confidence interval 0.49–1.49, P = 0.586).

Conclusion:

Elevated homocysteine levels increased the 12-month PSCI risk in females, but not in males with minor acute ischemic stroke or transient ischemic attack.

Combined Effect of Homocysteine and Uric Acid to Identify Patients With High Risk for Subclinical Atrial Fibrillation

Background

Subclinical atrial fibrillation (SCAF) is often asymptomatic nonetheless harmful. In patients with cardiac implantable electronic devices, we evaluated the combined performance of homocysteine and uric acid (UA) biomarkers to discriminate high‐risk patients for SCAF.

Methods and Results

We enrolled 1224 consecutive patients for evaluation of SCAF in patients with cardiac implantable electronic devices in Dalian, China, between January 2013 and December 2019. Clinical data and blood samples were obtained from patients selected according to the absence or presence of atrial high‐rate episodes >6 minutes. Blood samples were obtained, and homocysteine and UA biomarkers were tested in all patients to distinguish their prognostic performance for SCAF. Homocysteine and UA biomarkers were significantly different in SCAF versus no SCAF. On multivariable Cox regression analysis with potential confounders, elevated homocysteine and UA biomarkers were significantly associated with an increased risk of SCAF. A rise of 1 SD in homocysteine (5.7 μmol/L) was associated with an increased risk of SCAF in men and women regardless of their UA levels. Similarly, a 1‐SD increase in UA (91 μmol/L) was associated with an increased risk of SCAF among the patients with high levels of homocysteine in men (hazard ratio, 1.81; 95% CI, 1.43–2.30) and women (hazard ratio, 2.11; 95% CI, 1.69–2.62). The addition of homocysteine and UA to the atrial fibrillation risk factors recommended by the 2020 European Society of Cardiology Guidelines significantly improved risk discrimination for SCAF.

Conclusions

Homocysteine and UA biomarkers were strongly associated with SCAF. The prediction performance of the European Society of Cardiology model for SCAF was increased by the addition of the selected biomarkers.

Registration

URL: https://www.chictr.org.cn; Unique identifier: Chi‐CTR200003837.

Association of Inflammatory Markers/Cytokines with Cardiovascular Risk Manifestation in Patients with Endometriosis

This study is aimed at determining the association of inflammatory markers and proinflammatory cytokines with cardiovascular risk manifestation in women with endometriosis as compared to healthy controls. A total of 181 females of reproductive age with the absence of other inflammatory or autoimmune disorders and a lack of hormonal therapy for at least 6 months voluntarily participated in this investigation. Patients were 81 females, laparoscopically diagnosed with endometriosis, while the control group comprised 80 healthy females without any pelvic pathology. All subjects were 20-40 years of age. Exclusion criteria were diabetes, obesity, hypertension, metabolic diseases, cardiovascular, and renal disorders. C-reactive protein, fibrinogen, homocysteine, interleukin-17, and interleukin-33 were analyzed using commercially available ELISA kits. For statistical interpretation, the unpaired Student “t” test was used. All inflammatory markers and cytokines demonstrated elevated levels (P < 0.001) in endometriosis patients as compared to healthy controls. The results of the study revealed that the patients with endometriosis demonstrate a hypercoagulable status due to inflammation, which initiates atherosclerosis and associated complications. Hence, endometriosis can cause a risk of cardiovascular disorders in these patients.

Biomarkers Predictive of Long-Term Outcome After Ischemic Stroke: A Meta-Analysis

BACKGROUND AND PURPOSE

The goal of this study was to systematically review the utility of serum biomarkers in the setting of ischemic stroke (IS) to predict long-term outcome.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986-2018. All studies assessing long-term functional outcome (defined as 30 days or greater) following IS with respect to serum biomarkers were included. Data were extracted and pooled using a meta-analysis of odds ratios.

RESULTS

Of the total 2928 articles in the original literature search, 183 studies were ultimately selected. A total of 127 serum biomarkers were included. Biomarkers were grouped into several categories: inflammatory (32), peptide/enzymatic (30), oxidative/metabolic (28), hormone/steroid based (23), and hematologic/vascular (14). The most commonly studied biomarkers in each category were found to be CRP, S100β, albumin, copeptin, and D-dimer. With the exception of S100β, all were found to be statistically associated with >30-day outcome after ischemic stroke.

CONCLUSIONS

Serum-based biomarkers have the potential to predict functional outcome in IS patients. This meta-analysis has identified CRP, albumin, copeptin, and D-dimer to be significantly associated with long-term outcome after IS. These biomarkers have the potential to serve as a platform for prognosticating stroke outcomes after 30 days. These serum biomarkers, some of which are routinely ordered, can be combined with imaging biomarkers and used in artificial intelligence algorithms to provide refined predictive outcomes after injury. Ultimately these tools will assist physicians in providing guidance to families with regards to long-term independence of patients.

The Prognostic Value of Homocysteine in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Background: This comprehensive meta-analysis aimed to assess whether an increased homocysteine (Hcy) level is an independent predictor of unfavorable outcomes in acute ischemic stroke (AIS) patients.

Methods: A comprehensive literature search was conducted up to August 1, 2020 to collect studies reporting Hcy levels in AIS patients. We analyzed all the data using Review Manager 5.3 software.

Results: Seventeen studies with 15,636 AIS patients were selected for evaluation. A higher Hcy level was associated with a poorer survival outcome (OR 1.43, 95% CI: 1.25–1.63). Compared with the AIS group, Hcy levels were significantly lower in the healthy control patients, with an SMD of 5.11 and 95% CI (1.87–8.35). Analysis of the different subgroups of AIS demonstrated significant associations between high Hcy levels and survival outcomes only in Caucasian and Asian patients. Moreover, whereas high Hcy levels were closely associated with gender, B12 deficiency, smoking, and patients who received tissue plasminogen activator treatment, no significant difference was found between increased Hcy levels and age, drinking, hypertension, diabetes mellitus, and hyperlipidemia. In addition, the cut-off value (20.0 μmol/L) might be an optimum cut-off index for AIS patients in clinical practice.

Conclusion: This meta-analysis reveals that the Hcy level may serve as an independent predictor for unfavorable survival outcomes in AIS patients, particularly in Caucasian and Asian AIS patients. Further studies can be conducted to clarify this relationship.

Hyperhomocysteinemia and Cardiovascular Disease: Is the Adenosinergic System the Missing Link?

The influence of hyperhomocysteinemia (HHCy) on cardiovascular disease (CVD) remains unclear. HHCy is associated with inflammation and atherosclerosis, and it is an independent risk factor for CVD, stroke and myocardial infarction. However, homocysteine (HCy)-lowering therapy does not affect the inflammatory state of CVD patients, and it has little influence on cardiovascular risk. The HCy degradation product hydrogen sulfide (H2S) is a cardioprotector. Previous research proposed a positive role of H2S in the cardiovascular system, and we discuss some recent data suggesting that HHCy worsens CVD by increasing the production of H2S, which decreases the expression of adenosine A2A receptors on the surface of immune and cardiovascular cells to cause inflammation and ischemia, respectively.

Relationship Among Homocysteine, Inflammation and Cognitive Impairment in Patients with Acute Ischemic Stroke and Transient Ischemic Attack

PURPOSE

To investigate the associations among homocysteine (Hcy), inflammation and cognitive impairment in patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA).

PATIENTS AND METHODS

Patients included were enrolled from a subgroup of China National Stroke Registry-III (CNSR-III). We used a Chinese version of Montreal Cognitive Assessment (MoCA) to screen for cognitive impairment. We used high-sensitivity C-reactive protein (hsCRP) level to reflect the inflammatory status, which was assessed at baseline together with Hcy concentration. The primary outcome was the incidence of post-stroke cognitive impairment (PSCI) at 3 months after AIS and TIA. Multivariable logistic regression analysis was used to evaluate the correlation between Hcy and hsCRP, and their effects on cognition.

RESULTS

We enrolled 1466 patients with a median age of 62 (54-70) years old, including 895 (61.05%) patients with elevated Hcy levels, 466 (31.79%) with increased hsCRP concentrations, and 755 (51.50%) with PSCI. In the group of patients with hyperhomocysteinemia (HHcy), higher hsCRP levels were related to cognitive impairment, whether or not adjusted for multiple potential confounders (crude OR: 1.71,95% CI: 1.29-2.27, p < 0.01; adjusted OR: 1.42, 95% CI: 1.04-1.93, p = 0.03). No significant interactions for the impact on PSCI were observed in subgroups stratified by age, sex or Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification (P interaction > 0.05 for all).

CONCLUSION

High inflammatory levels increase the risk of cognitive impairment in HHcy patients after AIS and TIA.

Value of plasma homocysteine to predict stroke, cardiovascular diseases, and new-onset hypertension: A retrospective cohort study

The influences of hyperhomocysteinemia on cardiovascular diseases (CVDs), stroke and new-onset hypertension are unclear. The aim of the study is to explore the associations of homocysteine levels with stroke, CVDs, and new-onset hypertension in Chinese individuals.This retrospective cohort study included outpatients and inpatients from the Department of Geriatrics at Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine from January to December 2000. They were divided based on their homocysteine (Hcy) levels in 2000: Q1 (<10 μmol/L), Q2 (10-15 μmol/L), and Q3 (>15 μmol/L) and according to whether they had hypertension at baseline. Information about stroke, mortality and major adverse cardiac events, and newly onset hypertension was gathered in December each year until 2017. The effects of Hcy levels on the risk for stroke and CVDs among all patients, and new-onset hypertension among patients without hypertension at baseline were evaluated.After adjustment for confounders, compared with the Q1 group (Hcy <10 μmol/L), when the Hcy increased to 10 to 15 μmol/L, the risks for stroke, CVDs, and new-onset hypertension significantly increased, and the hazard ratio and 95% confidence interval were 2.02 (1.35-3.05, P = .001), 2.22 (1.32-3.76, P = .003), and 7.20 (4.52-11.48, P < .001), respectively. Hcy improved the predictive capability of traditional risk factors for stroke. The optimal cut-off value of Hcy for predicting stroke was 13.4 μmol/L (sensitivity: 70.9%, specificity: 62.2%).Hcy 10 to 15 μmol/L is significantly associated with the risks for stroke, mortality and major adverse cardiac events, and hypertension. The best cut-off point of Hcy for predicting stroke is 13.4 μmol/L.

Elevated homocysteine as an independent risk for intracranial atherosclerotic stenosis

To investigate the association of homocysteine concentration with intracranial atherosclerotic stenosis (ICAS), we assessed 933 acute ischemic stroke patients (346 with ICAS, 587 without ICAS) and 798 non-stroke controls (175 with ICAS, 623 without ICAS) with magnetic resonance angiography (MRA). Homocysteine concentration was found to be significantly higher in participants with ICAS than those without ICAS. In logistic regression analyses, homocysteine concentration was significantly associated with ICAS both in patients (OR: 1.04; 95% CI: 1.01–1.08; P=0.008) and controls (OR: 1.10; 95% CI: 1.06–1.15; P<0.001) for 1 μmol/L increment in homocysteine. Compared with the lowest quartile, the second (OR:1.53; 95% CI: 1.01-2.33), third (OR:1.71; 95% CI: 1.14 -2.60) and fourth (OR:2.48; 95%CI: 1.63-3.81) quartiles were independent predictors of ICAS in patients (P for trend<0.001); the third (OR:1.99; 95% CI: 1.18-3.40) and fourth (OR:2.36; 95%CI: 1.38-4.10) quartiles were independent predictors of ICAS in controls (P for trend<0.001). Hence, elevated homocysteine might be an independent risk for ICAS.

Genetic Association of Plasma Homocysteine Levels with Gastric Cancer Risk: A Two-Sample Mendelian Randomization Study

BACKGROUND

The association of plasma homocysteine level (PHL) with gastric cancer risk was reported in observational studies. However, the causality is challenging due to confounding factors and the lack of evidence from well-designed cohort studies. Herein, we performed a two-sample Mendelian randomization (MR) analysis to investigate whether PHL is causally related to gastric cancer risk.

METHODS

We performed the MR analysis based on the results from genome-wide association studies consisting of 2,631 patients with gastric cancer and 4,373 controls. An externally weighted genetic risk score (wGRS) was constructed with 15 SNPs with well-established associations with PHL. We utilized logistic regression model to estimate associations of PHL-related SNPs and wGRS with gastric cancer risk in total population and in strata by sex, age, and study site, in addition to a series of sensitivity analyses.

RESULTS

High genetically predicted PHL was associated with an increased gastric cancer risk (per SD increase in the wGRS: OR = 1.07; 95% confidence interval, 1.01-1.12; P = 0.011), which was consistent in sensitivity analyses. Subgroup analyses provided evidence of a stronger association with gastric cancer risk in women than in men. MR-Egger and weighted median regression suggested that potentially unknown pleiotropic effects were not biasing the association between PHL and gastric cancer risk.

CONCLUSIONS

These results revealed that genetically predicted high PHL was associated with an increased gastric cancer risk, suggesting that high PHL may have a causal role in the etiology of gastric cancer.

IMPACT

These findings provide causal inference for PHL on gastric cancer risk, suggesting a causal role of high PHL in the etiology of gastric cancer.

Sex differences in risk factors for stroke in patients with hypertension and hyperhomocysteinemia

Data on the sex-specific differences in risk of stroke among patients with H-type hypertension are limited. We aimed to analyze interactions between sex and other risk factors on stroke, including the sex-methylenetetrahydrofolate reductase (MTHFR) interaction. A retrospective analysis of baseline data from 2040 patients with hypertension and hyperhomocysteinemia (HHcy) included demographic characteristics, biomarkers, history of chronic diseases and lifestyle factors. Polymerase chain reaction-restriction fragment length polymorphism method was used to investigate the C677T polymorphism of MTHFR gene. We examined independent effects and interactions between sex and stratified factors on the risk of stroke by logistic regression model. A total of 1412 patients suffered stroke, and the prevalence of stroke was 70.65% in men and 66.53% in women. Both men and women had independent risk factors for stroke, including diabetes mellitus, atrial fibrillation, smoking, increased level of systolic blood pressure (SBP) and plasma total homocysteine (tHcy), as well as the decreased level of high-density lipoprotein cholesterol. Diastolic blood pressure (DBP) -specific risk of stroke was unique to men. Interactions between sex and other risk factors on stroke risk were statistically significant: age, fasting plasma glucose (FPG), SBP, DBP, triglycerides (TG) and tHcy. Furthermore, tHcy interacted with age, SBP and DBP in men, and age, SBP, DBP, FPG, and TG in women to modulate the risk of stroke. Although TT genotype did not have an independent effect on stroke, it could interact with sex and FPG, TG and SBP to increase stroke. In conclusion, sex-specific differences are useful to stratify the risk of stroke and assist clinicians in the decision to select a reasonable therapeutic option for high-risk patients.

The design of a homocysteine fluorescent probe based on Rhodamine B and its responsiveness in the serum of cerebral infarction patients

High levels of homocysteine (Hcy) is closely associated with the onset of cerebral infarction. The present study aimed to synthesize a novel Hcy probe based on Rhodamine B, named S1-4, a new compound that has not been previously reported. This probe exhibited good linear range under physiological fluid viscosity and pH; it has good selectivity for Hcy, and is able to avoid interference from other amino acids and metal ions. This probe can effectively measure the level of Hcy in the blood sera of healthy people and in patients with transient cerebral ischemia and cerebral infarction. However, satisfactory specificity and sensitivity to Hcy was not achieved according to receiver operating characteristic curve analysis. Overall, results from the present study suggested that following further optimization, this probe may be potentially applied in the diagnosis of cerebral infarction.

Intravenous Thrombolysis for Acute Ischemic Stroke: Review of 97 Patients

BACKGROUND

Intravenous thrombolysis (IVT) has now become a standard treatment in eligible patients with acute ischemic stroke (AIS) who present within 4.5 h of symptom onset.

OBJECTIVE

To determine the usefulness of IVT and the subset of patients who will benefit from IVT in AIS within 4.5 h.

MATERIALS AND METHODS

Patients with AIS within 4.5 h of symptom onset who underwent IVT were studied prospectively. The study period was from October 2011 to October 2015.

RESULTS

A total of 97 patients were thrombolysed intravenously. The mean onset to needle time in all patients was 177.2 ± 62 min (range: 60-360). At 3 months follow-up, favorable outcome was seen in 65 patients (67.1%) and poor outcome including death in the remaining 32 patients (32.9%). Factors predicting favorable outcome was age <65 years (P = 0.02), the National Institute of Health Stroke Scale (NIHSS) <15 (P < 0.001), small vessel occlusion (P = 0.006), cardioembolism (P = 0.006), and random blood sugar (RBS) <250 mg/dl (P < 0.001). Factors predicting poor outcome was diabetes mellitus (P = 0.01), dyslipidemia (P = 0.01), NIHSS at admission >15 (P = 0.03), RBS >250 mg/dl (P = 0.01), Dense cerebral artery sign, age, glucose level on admission, onset-to-treatment time, NIHSS on admission score >5 (P = 0.03), and occlusion of large artery (P = 0.02).

CONCLUSION

Milder baseline stroke severity, blood glucose <250 mg/dL, younger patients (<65 years), cardioembolic stroke, and small vessel occlusion benefit from recombinant tissue plasminogen activator.

Reduced risk of new onset stroke after kidney transplantation in Asian dialysis patients: a propensity score-matched, competing risk study in Taiwan

BACKGROUND

Kidney transplantation (KT) has been found to reduce cardiovascular events and mortality in chronic dialysis patients. There is little data, however, regarding the risk reduction of cerebrovascular events after KT in Asian populations. This study evaluates the risk of cerebrovascular events after KT in Taiwan.

METHODS

Tapping Taiwan's National Health Insurance claims data of patients with a diagnosis of end-stage renal disease (ESRD), we enrolled all KT recipients from 1999 to 2011 (n = 2908). For each KT patient, four controls (patients also diagnosed with ESRD) without KT were propensity matched by birth date, sex, selected comorbidities and duration of dialysis. All subjects were followed to the end of 2011.

RESULTS

The incidence rate for stroke in the KT recipients and comparison group were 52.63 and 137.26 per 10 000 person-years, respectively. After adjustment for age, gender and comorbidities with competing mortality, KT recipients had 60% reduction in all kinds of stroke, compared to those who did not receive procedure. They were found to have a 48 and 74% reduction in ischemic and hemorrhagic stroke risk, respectively. Subgroup analyses also showed similar trends in the improvement of stroke after KT. While elderly patients, men, and those with diabetes, hypertension and coronary artery disease are at increased risk for stroke, our log-rank test revealed those that received KT had significantly lower cumulative incidence rates of stroke than those that did not (P < 0.001).

CONCLUSIONS

KT was associated with reduced risk of new onset stroke in chronic dialysis patients in Taiwan.

Sex differences in blood pressure after stroke: a systematic review and meta-analysis

OBJECTIVES

Evidence about sex differences in blood pressure (BP) at the time of acute stroke presentation is scarce. We aimed to summarize available data on sex differences in BP at the time of acute stroke presentation, including stratification by prior history of hypertension and stroke subtype.

METHODS

We performed a systematic literature search across MEDLINE and Embase, from inception to 21 December 2018, to identify all population-based observational studies that reported BP at the time of acute stroke presentation. We extracted data on patient demographics, stroke-type (ischaemic or haemorrhagic), stroke severity, vascular risk factors, and SBP and DBP at the time of stroke presentation. Wherever possible, data were pooled for meta-analysis with weighted mean difference (WMD) and corresponding 95% confidence intervals (CI) using random effects meta-analysis.

RESULTS

We included 128 138 stroke patients from 43 studies. Women had higher SBP at presentation than men (WMD, 1.46; 95% CI, 0.65-2.26); this difference was significant in ischaemic stroke (1.49; 0.25-2.72 mmHg), but not in intracerebral haemorrhage (0.19; -4.21 to 4.59 mmHg). Meta regression show that sex differences in SBP were consistent with increasing age, stroke severity, other comorbidities and medication history.

CONCLUSION

This systematic review and meta-analysis indicates that women have higher SBP at the time of presentation with acute stroke. These differences are consistent with sex differences in hypertension patterns in older age, and may be explained by the fact that women are more likely to have a premorbid hypertension. This highlights the need for effective sex-specific blood pressure control in patients at high risk for stroke.

Acute exercise alters homocysteine plasma concentration in an intensity-dependent manner due increased methyl flux in liver of rats

PURPOSE

We aimed to determine the effects of different intensities of acute exercise on Hcy plasma levels, and the exercise-induced changes in Hcy liver metabolism.

METHOD

First, thirty-two Wistar rats were randomly submitted to an acute bout of swimming exercise carrying a load of 2% (n=8), 4% (n=8) and 6% (n=8) of their total body weight attached in their tail. Control rats remained rested (n=8). Blood samples were taken from tail vein for plasma S-containing amino acids determination before (Rest) and post, 1, 2, 3, 4, 6, and 10h after acute swimming exercise. Second, 56 exercised rats (4% loads) were euthanized before (Rest) and1, 2, 3, 4, 6, and 10h after acute swimming exercise. Blood and liver samples were collected for amino acids and keys genes involved in the Hcy metabolism assay.

RESULTS

Acute exercise increases (P<0.05) plasma Hcy concentration in an intensity-dependent manner (rest 7.7±0.8; 6% load 13.8±3.6; 4% load 12.2±2.9±and 2% load 10.1±2.6, μmol/L); this increase is transient and does not promote hyperhomocysteinemia (<15μmol/L).Exercise-induced increased plasma Hcywas accompanied by the decreased liver S-adenosylmethionine/S-adenosylhomocysteine ratio and elevated MAT1a mRNA content. Acute exercise also caused elevated mRNA of key enzymes of transsulfuration (CBS) and remethylation (BHMT and the MTRR).

CONCLUSION

Our data provided evidence that acute exercise increases plasma Hcy concentration due to the augmented requirement for methylated compounds that increases liver SAM consumption. Also, Hcy remethylation and transsulfuration are coordinately regulated to maintain methyl balance.

Association between platelet distribution width and poor outcome of acute ischemic stroke after intravenous thrombolysis

PURPOSE

The platelet distribution width (PDW) reflects the status of platelet activity and may be useful for early predictions of the clinical outcome of stroke patients. The purpose of the study was to determine the associations between PDW and clinical outcomes after intravenous thrombolysis in stroke patients.

PATIENTS AND METHODS

Acute ischemic stroke patients who received intravenous treatment with recombinant tissue-type plasminogen activator were selected for inclusion in the retrospective cohort of this study. The relations between PDW at admission and clinical outcomes were analyzed, including a poor outcome as assessed using the modified Rankin Scale at 3 months, early neurological improvement, and any hemorrhage. The effect of PDW at admission on a poor outcome at 3 months was analyzed using a multivariable logistic regression model with adjustment for potential confounders. The optimal PDW cutoff for predicting poor outcome at 3 months was determined by analyzing the receiver operating characteristics curve.

RESULTS

PDW was significantly higher for a good outcome than a poor outcome (p=0.005), with median (interquartile range) values of 16.2 (13.2-17.2) and 13.6 (12.5-15.9), respectively. PDW was also higher in patients with early neurological improvement than in patients without improvement (p=0.020) and did not differ between hemorrhage and nonhemorrhage patients. The association between PDW <16.05% and poor outcome remained in a multivariable logistic regression analysis, with an OR of 6.68 and a 95% CI of 1.69-26.49 (p=0.007).

CONCLUSION

Results suggest a novel hypothesis that a lower PDW may be related with a poor outcome at 3 months after intravenous thrombolysis in acute ischemic stroke patients.

Elevated plasma homocysteine upon ischemic stroke is associated with increased long-term mortality in women

BACKGROUND

Ischemic stroke is a leading cause of death worldwide, despite preventive and therapeutic advances during the last twenty years. Blood-borne biomarkers have been studied in association to short- and long-term outcome, in order to investigate possible modifiable predictors of disability and death. Increased homocysteine has been associated with increased vascular risk and unfavorable outcome, but homocysteine lowering treatment has not consistently been successful in risk reduction. The aim of this study was to investigate homocysteine levels upon acute ischemic stroke in association to long-term mortality.

METHODS

Of 622 patients included in our hospital-based registry, 331 survived the first month after admission, and had a diagnosis of ischemic stroke and available homocysteine values. All-cause and vascular mortality were investigated based on the national patient- and cause of death-registries. Survival analysis and Cox proportional hazard models were used to investigate time to death and predictors of outcome.

RESULTS

Of 331 patients, 148 (45%) had low homocysteine (<13 micromol/L) and 183 (55%) had high homocysteine (> = 13 micromol/L). During 10 years of follow-up (median 5.5 years), 47 patients (32%) with low homocysteine and 94 (51%) with high homocysteine died (p<0.0001). Estimated median survival was not reached for the low homocysteine group, and was 80 months in the high homocysteine group (p with log-rank test 0.002). High homocysteine was not independently associated with increased risk for death after adjustment for age, sex, comorbidities, and eGFR (HR 1.29, 95% CI 0.86-1.93; p = 0.2). Subgroup analysis by sex showed that high homocysteine was an independent predictor of mortality in women after adjustment for age and vascular comorbidities (HR 1.85; 95% CI 1.03-3.31; p = 0.04), but not in men (HR 0.87; 95% CI 0.52-1.43; p = 0.6).

CONCLUSION

Increased plasma homocysteine (> = 13 micromol/L) upon acute ischemic stroke was not independently associated with mortality in our study. In the subgroup of women, high homocysteine was associated with increased five-year risk of death. Our study's retrospective design and the exploratory nature of subgroup analysis, prevent robust conclusions based on that observation. Future studies on homocysteine levels before as well as upon stroke will shed further light on a possible causal association.

Effect of Hypokalemia on Functional Outcome at 3 Months Post-Stroke Among First-Ever Acute Ischemic Stroke Patients

Background

Hypokalemia has been confirmed to be a predictor of adverse cardiovascular and renal outcomes. There is a paucity of studies focusing on the potential connection between the serum K⁺ level and the outcome after acute ischemic stroke (AIS). This study investigated whether hypokalemia in the acute stroke stage contributes to worse functional outcome in AIS patients.

Material/Methods

This retrospective cohort study included consecutive patients with first-ever AIS admitted between June 2015 and March 2016. Patients were divided into 2 groups: hypokalemia (K⁺ <3.5 mmol/L) and normokalemia (3.5 mmol/L ≤K⁺ ≤5.5 mmol/L). Primary outcome measure was poor outcome at 3 months (modified Rankin scale >2). Univariate and multivariate logistic regression analyses were used to assess the association between hypokalemia and poor outcome. Receiver operating curve (ROC) analysis was performed to determine the optimal cutoff point of serum K⁺ level for predicting poor outcome.

Results

The percent of patients with poor outcome at 3 months was higher in the hypokalemic group (62.9%) than in the normokalemic group (45.5%). Hypokalemic patients tended to have lower fasting glucose at admission, lower Glasgow coma scale score, and longer time from symptom onset to treatment compared with normokalemic patients. Hypokalemia was associated with poor outcome at 3 months after adjusting for potential confounders (odds ratio=2.42, 95% confidence interval=1.21–4.86, P=0.013). ROC analysis showed that the optimal threshold for serum K⁺ level was 3.7 mmol/L.

Conclusions

Hypokalemia at the initial admission is associated with poor prognosis at 3 months in first-ever AIS patients.

No Association between Elevated Total Homocysteine Levels and Functional Outcome in Elderly Patients with Acute Cerebral Infarction

Background: An elevated plasma total homocysteine (tHcy) level is an independent risk factor for vascular events. The aim of the present study was to investigate the association between tHcy levels in the acute phase of cerebral infarction and functional outcome among elderly patients.

Methods: Between October 2009 and December 2012, we recruited 594 elderly patients (age > 75) with first-onset acute cerebral infarction who were consecutively admitted to the Department of Neurology of Tianjin Huanhu Hospital, China. Levels of tHcy and other biochemical values were measured within 24 h after admission. tHcy values were classified according to quartiles (<9.94; 9.94 to <12.7; 12.7 to <16.8; and ≥16.8 μmol/L). We examined the relationship between tHcy levels at admission and modified Rankin Scale scores (mRS) using univariate and multivariate analyses. Patients were followed up at 3 months and 1 year after stroke.

Results: Within 3 months after stroke, 64 patients died, 37 had recurrent ischemic stroke, and 22 were lost to follow-up; thus, 471 patients were reviewed and analyzed. By the time of the 1-year follow-up, an additional 48 patients had died, 44 had recurrent ischemic stroke, and 40 had been lost to follow-up; the remaining 339 patients were thus reviewed and analyzed. Elevated tHcy levels were not associated with functional outcome among elderly patients with acute cerebral infarction (p > 0.05). Only the National Institutes of Health Stroke Scale score was associated with a poor outcome after adjusting for confounders at 3 months and 1 year (adjusted odds ratio, 1.38; 95% CI, 1.28–1.49; p < 0.01; adjusted odds ratio, 1.34; 95% CI, 1.25–1.44; p < 0.01, respectively).

Conclusion: Among elderly patients with acute cerebral infarction, elevated tHcy at admission was not a predictive factor of outcome at 3 months and 1 year after stroke onset.

Methylene Tetrahydrofolate Reductase (MTHFR) rs868014 Polymorphism Regulated by miR-1203 Associates with Risk and Short Term Outcome of Ischemic Stroke

Background/Aims: Genetic polymorphisms of methylene tetrahydrofolate reductase (MTHFR) were associated with ischemic stroke risk. This study analyzed MTHFR polymorphisms at the 3'-untranslated region for association with risk and outcome of ischemic stroke in a Chinese Han population. Methods: 500 patients and 600 healthy volunteers were enrolled for MTHFR rs868014 genotyping identified bioinformatically. The binding of miR-1203 to MTHFR rs868014 was determined by luciferase assay, MTHFR expression was assessed using qRT-PCR, and plasma homocysteine levels were assayed by ELISA. Results: Cigarette smoking, alcohol consumption, diabetes, hypertension (all P <0.001), low levels of serum high-density lipoprotein-C (P = 0.01), and high levels of serum low-density lipoprotein-C (P = 0.005) were associated with an increased risk of developing ischemic stroke. BMI and total serum cholesterol concentration was not associated with ischemic stroke. MTHFR rs868014 TC and CC genotypes were significantly associated with increased risk of ischemic stroke compared with the TT genotype (OR: 1.52; 95% CI: 1.01-3.39 for TC genotype, while OR: 1.99; 95% CI: 1.29-3.88 for CC genotype). Furthermore, the MTHFR rs868014 SNP was associated with a poor short-term ischemic stroke outcome. qRT-PCR confirmed that MTHFR rs868014 TC or CC genotypes could facilitate miR-1203 binding leading to low MTHFR levels in cells. In addition, patients carrying the MTHFR rs868014 TC or CC genotypes were associated with accumulation of serum tHcy and a poor ischemic stroke outcome. Linkage disequilibrium analysis indicated that the newly identified SNP rs868014 was strongly linked with the MTHFR A1298C polymorphism. Conclusion: This study demonstrates that the MTHFR rs868014 SNP is associated with increased risk in developing ischemic stroke, miR-1203 binding, low MTHFR levels in cells, and poor shot term outcome of patients.

De Ritis ratio (AST/ALT) as an independent predictor of poor outcome in patients with acute ischemic stroke

PURPOSE

The aspartate transaminase/alanine transaminase ratio (De Ritis ratio, AAR) was reported to be associated with patients' prognosis in certain diseases recently. The objective of the current study was to determine the association between the AAR at admission and poor outcome at 3 months in acute ischemic stroke (AIS) patients.

PATIENTS AND METHODS

This retrospective cohort study included patients who experienced their first-ever AIS between June 2015 and March 2016. The primary outcome measure was a poor outcome at 3 months (modified Rankin Scale score >2). Multivariate logistic regression models were used to assess the relationship between AAR quartiles and clinical outcomes among the AIS patients. Receiver operating characteristic curve analysis was applied to identify the optimal cutoff for AAR in predicting the prognosis of AIS.

RESULTS

In terms of the relationship between poor outcome and AAR, the adjusted odds ratio comparing the highest and lowest AAR quartiles was 2.15 (95% confidence interval =1.14-4.05). An AAR of 1.53 was identified as the optimal cutoff. In a prespecified subgroup analysis according to the time from symptom onset to treatment (>24 vs ≤24 hours), there was no significant difference in the effect of AAR >1.53 between the two groups.

CONCLUSION

An increased AAR at admission is significantly associated with a poor outcome at 3 months in AIS patients.

Association between homocysteine and non-alcoholic fatty liver disease in Chinese adults: a cross-sectional study

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide, and its prevalence is likely to rise even further. To help understand the pathogenesis and early prevention of progressive NAFLD, this large-scale study was designed to explore the potential association between homocysteine and the prevalence of NAFLD.

Methods

A total of 7203 subjects aged 18 years or older were enrolled in this cross-sectional study. The association of homocysteine with the prevalence of NAFLD, in the total sample and stratified by subgroups, was examined using multiple logistic regression analyses.

Results

Subjects in the higher quartiles of homocysteine had a higher prevalence of NAFLD. After multivariate adjustment, the odds ratio (OR) for NAFLD in the highest compared with the lowest quartile of homocysteine was 2.08 (95% confidence interval [CI] 1.61, 2.67). Moreover, in the subgroup analyses, we found an effect modification by gender, body mass index (BMI) and smoking status on the association between homocysteine and the prevalence of NAFLD (P for interaction: 0.001, 0.002 and <0.001, respectively). A stronger association was observed in female, obese and non-smoking adults than in male, normal weight and smoking subjects.

Conclusion

Homocysteine was significantly associated with the prevalence of NAFLD, particularly in female, obese or non-smoking adults.