Comparison of ankle-brachial index and upstroke time in association with target organ damage: the Northern Shanghai Study

Effects of acute creatine supplementation on cardiac and vascular responses in older men; a randomized controlled trial

BACKGROUND AND AIMS

In the recent years creatine has been shown promising results in patients with neurodegenerative diseases, myopathies and dystrophies. Cardiovascular diseases could be another pathology that can benefit from creatine supplementation, considering the influence on the risk factors associated with the development of cardiovascular diseases including reduction in chronic inflammation, and improved control of hyperglycemia and dyslipidemia The aim of the present study was to investigate the impact of short-term creatine supplementation on cardiac and vascular health in older adults.

METHODS

Males between the ages of 55-80 were randomly assigned to three groups: creatine, placebo and control. Creatine or placebo was provided for 7-day supplementation, at a dose of 20 g/day. Testing was performed at the same time of the day at baseline and on the eighth day. Vascular responses were assessed using an arterial pulse wave velocity equipment, while cardiac assessment was performed using an impedance cardiography device.

RESULTS

The placebo group was older (71.1 ± 8.2 yr) compared to creatine (61.4 ± 5.2 yr) and control (62.5 ± 7.1 yr). Cardio-ankle vascular index improved just in the creatine group (8.7 ± 0.5 to 8.2 ± 0.5, p = 0.03). While the upstroke time of the placebo and control groups did not change after 7 days, the creatine group had a nonsignificant reduction, 178.9 ± 26.5 ms to 158.4 ± 28.6 ms, p = 0.07. Similar tendency was seen with the systolic blood pressures, while the placebo and control did not change, the creatine group showed nonsignificant improvement, especially on the right, 144.0 ± 12.7 mmHg to 136.1 ± 13.4 mmHg, p = 0.08. All three groups had similar responses in stroke volume (p = 0.61), contractility index (p = 0.64) and ejection fraction (p = 0.72).

CONCLUSIONS

In older adults, acute creatine supplementation can positively affect vascular parameters of arterial stiffness and atherosclerosis. Creatine supplementation has the potential to serve as a potent adjuvant in the management of CVD for older adults.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov; ID: NCT05329480.

Prognostic Value of Arm Circumference for Cardiac Damage and Major Adverse Cardiovascular Events: A Friend or a Foe? A 2-Year Follow-Up in the Northern Shanghai Study

Background

The high prevalence of cardiovascular diseases globally causes a great social burden and much individual suffering. The effective recognition of high-risk subjects is critical for primary prevention in the general population. In the elderly cohort, anthropometric measurements may have different prognostic values. Our study aimed to find convincing anthropometric measures to supplement conventional risk factors for major adverse cardiovascular events (MACEs) in the elderly cohort.

Materials and Methods

A total of 1,576 elderly participants (44.5% male, aged 72.0 ± 6.0 years) recruited into the Northern Shanghai Study (2014–2015) were followed up between 2016 and 2017. Following the standard guideline for cardiovascular risk evaluation, all conventional cardiovascular risk factors were assessed. The body measures were made up of body weight, body height, hip circumference, waist circumference, and middle-upper arm circumference (MUAC). Organ damage (OD) markers for cardiac, vascular, and renal diseases will be evaluated by the standardized methods.

Results

After the average 571 (±135) days of follow-up, a total of 90 MACEs (5.7%) occurred, i.e., 13 non-fatal myocardial infarction, 68 non-fatal stroke, and 9 cardiovascular deaths. Univariable COX survival analysis revealed that only MUAC could validly predict MACEs among anthropometric characters [adjusted hazard ratio (HR) 0.89; 95% confidence interval (CI) 0.82–0.96]. In Kaplan-Meier analysis, the group of high MUAC showed the lowest MACE risk (log-rank p = 0.01). Based on OD analysis, MUAC was independently linked to higher risk of left ventricular hypertrophy (LVH) in women and left ventricular diastolic dysfunction (LVDD) in both men and women. In adjusted COX analysis, only MUAC indicated statistical significance, but all other anthropometric parameters such as BMI, waist circumference, and waist-to-hip ratio (WHR) did not indicate significance. The higher level of MUAC remained a protective factor in fully adjusted models (HR: 0.73; 95% CI: 0.59–0.91), with p-values markedly significant in men (HR: 0.69; 95% CI: 0.49–0.97) and marginally significant in women (HR: 0.0.77; 95% CI: 0.59–1.01). After considering all factors (i.e., cardiovascular risk factors, MUAC, BMI, and WHR), the fully adjusted COX regression analysis demonstrated that the increased MUAC level was linked to decreased MACE risk in both men (HR: 0.57; 95% CI: 0.37–0.88) and women (aHR: 0.64; 95% CI: 0.46–0.93).

Conclusion

Despite being associated with a higher rate of cardiac damage, higher MUAC independently and significantly conferred protection against the MACE, in the elderly cohort.

Assessment of the systolic rise time by photoplethysmography in peripheral arterial diseases: a comparative study with ultrasound Doppler

Aims

Peripheral arterial disease (PAD) is a major public health burden requiring more intensive population screening. Ankle brachial index (ABI) using arm and ankle cuffs is considered as the reference method for the detection of PAD. Although it requires a rigorous methodology by trained operators, it remains time-consuming and more technically difficult in patients with diabetes due to mediacalcosis. Techniques based on the study of hemodynamic, such as the systolic rise time (SRT), appear promising but need to be validated. We retrospectively compared the reliability and accuracy of SRT using a photoplethysmography (PPG) technique to the SRT measured by ultrasound doppler (UD) in PAD patients diagnosed with the ABI (137 patients, 200 lower limbs).

Methods and results

There was a significant correlation between SRT measured with UD (SRTud) compared with that with PPG (SRTppg, r = 0.25; P = 0.001). Best correlation was found in patients without diabetes (r = 0.40; P = 0.001). Bland and Altman analysis showed a good agreement between the SRTud and SRTppg. In contrast, there was no significant correlation between UD and PPG in diabetes patients. Furthermore, patients with diabetes exhibited a significant increase of SRTppg (P = 0.02) compared with patients without diabates but not with the SRTud (P = 0.18). The SRTppg was significantly linked to the arterial velocity waveforms, the type of arterial lesion but not vascular surgery revascularization technique.

Conclusion

This monocentric pilot study shows that SRT measured with the PPG signal reliably correlates with SRT recorded with UD. The PPG is an easy to use technique in the hand of non-expert with a potential interest for general screening of PAD, especially in diabetes patients, due to its ease to use.

Usefulness of Upstroke Time per Cardiac Cycle for Cardiovascular and All-Cause Mortality Prediction in Patients with Normal Ankle-Brachial Index

AIM

Abnormal ankle-brachial index (ABI) is regarded as peripheral artery disease and can be used to predict cardiovascular (CV) outcomes. However, the usefulness of ABI for the prediction of CV outcome in patients with normal ABI is limited. Upstroke time per cardiac cycle (UTCC) is recently reported to be associated with mortality in patients with acute myocardial infarction and the elderly. Therefore, we aimed to evaluate UTCC, left ventricular ejection fraction (LVEF), brachial-ankle pulse wave velocity (baPWV), and ABI for the prediction of mortality in patients with normal ABI.

METHODS

Patients arranged for echocardiographic examinations were enrolled, and 1076 patients with normal ABI were included. ABI, baPWV, and UTCC were measured by an ABI-form device.

RESULTS

The median follow-up to mortality was 95 months. There were 88 CV and 244 all-cause deaths. After multivariate analysis, UTCC was associated with increased CV and all-cause mortality (P ≤ 0.004). Age, diabetes, heart failure, left ventricular hypertrophy, baPWV, and LVEF were also independent predictors of CV and all-cause mortality, but ABI was not. Furthermore, UTCC had a better additive predictive value than ABI, baPWV, and LVEF for CV mortality ( P ≤ 0.012). It also had a better additive predictive value than ABI and LVEF for all-cause mortality (P ≤ 0.013).

CONCLUSIONS

UTCC is an independent predictor for CV and all-cause mortality in patients with normal ABI. It also has a better additive predictive value of CV and all-cause mortality than ABI and LVEF. Therefore, UTCC is a simple, novel, and useful parameter for identifying high-risk patients with normal ABI.

Hypertension-Mediated Organ Damage Correlates With Serum Homocysteine Level in Community-Dwelling Elderly Chinese: The North Shanghai Study

Introduction: Serum homocysteine (Hcy) level is associated with cardiocerebrovascular disease. However, the relationship between Hcy and hypertension-mediated organ damage (HMOD) in non-hospitalized residents has not been elucidated. We aimed to investigate the association of HMOD with Hcy in elderly Chinese.

Methods: One thousand seven hundred and forty-four community-dwelling elderly Chinese (age ≥65 years) participated in the Northern Shanghai Study from Jun. 2014 to Aug. 2015. Hyperhomocysteinemia (HHcy) was defined as serum Hcy ≥15 mmol/L, and HMOD was estimated as arterial stiffness [carotid-femoral pulse wave velocity (CF-PWV) and ankle-brachial index (ABI)], cardiac impairment [left ventricular (LV) hypertrophy and LV diastolic dysfunction], and renal dysfunction [estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio]. Linear and logistic regression models were built to explore the associations of HMOD with Hcy.

Results: Among 1,744 participants, 632 (36.2%) were diagnosed as HHcy. HHcy group had more men (61.2 vs. 35.3%), with higher age (73.7 ± 6.7 vs. 70.4 ± 5.3 years) and BMI (24.2 ± 3.4 vs. 23.7 ± 3.5 kg/m²). Linear regression analysis showed that serum Hcy level was positively associated CF-PWV and negatively associated with ABI and eGFR. By logistic regression, HHcy was significantly associated with abnormal CF-PWV [odds ratio (OR) = 1.53, 95% confidence interval (CI) 1.08–2.16] and ABI (OR = 1.55, 95% CI 1.17–2.04), and decreased eGFR (OR = 7.09, 95% CI 4.03–12.47) after adjustment for covariates. Moreover, similar associations of serum Hcy level with CF-PWV and eGFR were observed in subgroups by gender and hypertensive state.

Conclusion: HMOD, particularly renal dysfunction and arterial stiffening, was significantly and independently associated with increased serum Hcy level in the elderly Chinese.

Clinical Trial Registration: [ClinicalTrial.gov], identifier [NCT02368938].

Upstroke Time as a Novel Predictor of Mortality in Patients with Chronic Kidney Disease

Upstroke time (UT), measured from the foot-to-peak peripheral pulse wave, is a merged parameter used to assess arterial stiffness and target vascular injuries. In this study, we aimed to investigate UT for the prediction of cardiovascular and all-cause mortality in patients with chronic kidney disease (CKD). This longitudinal study enrolled 472 patients with CKD. Blood pressure, brachial pulse wave velocity (baPWV), and UT were automatically measured by a Colin VP-1000 instrument. During a median follow-up of 91 months, 73 cardiovascular and 183 all-cause mortality instances were recorded. Multivariable Cox analyses indicated that UT was significantly associated with cardiovascular mortality (hazard ratio (HR) = 1.010, p = 0.007) and all-cause mortality (HR = 1.009, p < 0.001). The addition of UT into the clinical models including traditional risk factors and baPWV further increased the value in predicting cardiovascular and all-cause mortality (both p < 0.001). In the Kaplan–Meier analyses, UT ≥ 180 ms could predict cardiovascular and all-cause mortality (both log-rank p < 0.001). Our study found that UT was a useful parameter in predicting cardiovascular and all-cause mortality in CKD patients. Additional consideration of the UT might provide an extra benefit in predicting cardiovascular and all-cause mortality beyond the traditional risk factors and baPWV.

Upstroke Time Per Cardiac Cycle as A Novel Parameter for Mortality Prediction in Patients with Acute Myocardial Infarction

Background: Acute myocardial infarction (AMI) is one of the leading causes of death in the world. How to simply predict mortality for AMI patients is important because the appropriate treatment should be done for the patients with higher risk. Recently, a novel parameter of upstroke time per cardiac cycle (UTCC) in lower extremities was reported to be a good predictor of peripheral artery disease and mortality in elderly. However, there was no literature discussing the usefulness of UTCC for prediction of cardiovascular (CV) and overall mortality in AMI patients. Methods: 184 AMI patients admitted to the cardiac care unit were enrolled. Ankle-brachial index (ABI) and UTCC were measured by an ABI-form device in the same day of admission. Results: The median follow-up to mortality was 71 months. There were 36 CV and 124 overall mortality. Higher UTCC was associated with increased CV and overall mortality after multivariable analysis (P = 0.033 and P < 0.001, respectively). However, ABI was only associated with CV mortality and overall mortality in the univariable analysis but became insignificant after the multivariable analysis. In addition, after adding UTCC into a basic model including important clinical parameters, left ventricular ejection fraction, Charlson comorbidity index, and ABI, we found the basic model + UTCC had a better predictive value for overall mortality than the basic model itself (P < 0.001). Conclusions: Our study is the first one to evaluate the usefulness of UTCC in AMI patients for prediction of long-term mortality. Our study showed UTCC was an independent predictor of long-term CV and overall mortality and had an additive predictive value for overall mortality beyond conventional parameters. Therefore, screening AMI patients by UTCC might help physicians to identify the high-risk group with increased mortality.

Association of Pulse Volume Recording at Ankle with Total and Cardiovascular Mortality in Hemodialysis Patients

Pulse volume recording is an accurate modality for detecting arterial occlusion in the lower extremities. There are two indexes of pulse volume recording measured at ankle, percentage of mean arterial pressure (%MAP) and upstroke time (UT). The aim of the study was to examine the ability of %MAP and UT for the prediction of overall and cardiovascular mortality in hemodialysis (HD) patients. In 197 routine HD patients, ankle %MAP, ankle UT, and ankle-brachial index (ABI) were automatically measured by Colin VP-1000 instrument. Fourteen cardiovascular mortality and 29 overall mortalities were documented during 2.7 ± 0.6 years follow-up. In the univariate analysis, in addition to co-morbidities and traditional clinical parameters, increased total mortality was associated with decreased ABI, ABI < 0.9, increased %MAP and UT, %MAP > 50%, and UT > 169 ms (p < 0.041) and increased cardiovascular mortality was associated with increased UT and %MAP > 50% (p < 0.022). After multivariate analysis, increased %MAP and %MAP > 50% (p < 0.047) were still the predictors of total mortality and %MAP > 50% (p = 0.024) was still the predictor of cardiovascular mortality. In HD patients, we found that ankle %MAP and %MAP > 50% could predict total mortality and ankle %MAP > 50% could predict cardiovascular mortality in the multivariate analysis. Hence, assessment of %MAP from pulse volume recording at ankle might be helpful in identifying the high-risk group for poor prognosis in HD patients.

UPSTROKE TIME PER CARDIAC CYCLE IS ASSOCIATED WITH CARDIOVASCULAR PROGNOSIS IN TYPE 2 DIABETES

Objective: Upstroke time per cardiac cycle (UTCC) in the lower extremities has been found to be predictive of cardiovascular mortality in the general population. Therefore, the purpose of the study was to test the associations between increasing UTCC and outcomes in patients with type 2 diabetes. Methods: A total of 452 patients with type 2 diabetes (age, 67.5 ± 8.6 years; male, 54%) registered in a share-care program participated in the study at an outpatient clinic in Taipei Veterans General Hospital across a mean of 5.8 years. Primary outcomes were all-cause mortality hospitalization for coronary artery disease, stroke, revascularization, amputation, and diabetic foot syndrome. Secondary end-point outcome was all-cause mortality. Results: Increment of UTCC associations with primary and secondary outcomes were undertaken prior to baseline characteristic adjustments. A UTCC of 20.1% exhibited the greatest area under curve (AUC), sensitivity, and specificity balance to predict composite events in receiver operating curves (AUC, 0.63 [P = .001]; sensitivity, 67.7%; specificity, 54.9%). Sixty-four composite events and 17 deaths were identified from medical records. UTCC ≥20.1% was associated with the occurrence of composite events and an increased risk of mortality. For composite events, an adjusted hazard ratio (HR) of 2.45 and 95% confidence interval (CI) of 1.38 to 4.35 (P = .002) were calculated. For all-cause mortality, an adjusted HR of 1.91 and 95% CI of 0.33 to 10.99 (P = .467) were calculated. Conclusion: Increasing UTCC was associated with cardiovascular outcomes in patients with type 2 diabetes. Therefore, UTCC is advocated as a noninvasive screening tool for ambulatory patients with type 2 diabetes. Abbreviations: CAD = coronary artery disease; CI = confidence interval; eGFR = estimated glomerular filtration rate; HR = hazard ratio; PAD = peripheral artery disease; UTCC = upstroke time per cardiac cycle.