Nontraditional Cardiovascular Risk Factors

Helicobacter pylori infection and rheumatoid arthritis as risk enhancers' factors for atherosclerotic cardiovascular diseases

BACKGROUND

In addition to established risk factors for atherosclerotic cardiovascular diseases (aCVDs), infections and autoimmune diseases, such as Helicobacter pylori (H. pylori) and rheumatoid arthritis (RA), have been reported as risk-enhancer factors. In this retrospective single-center, case-control study, the relative weight of RA and H. pylori infection on aCVD was evaluated in a cohort of patients from Northern Sardinia, Italy, where both conditions are frequent.

MATERIALS AND METHODS

Data were retrieved from records of subjects undergoing upper endoscopy and screened for H. pylori infection by at least four biopsies. The presence of H. pylori and chronic-active gastritis were labeled as a current infection or a long-lasting infection (LLHp) when atrophy and/or metaplasia and/or dysplasia were detected in at least one gastric specimen. Diagnosis of aCVD and RA was made by the cardiologist and the rheumatologist, respectively, according to guidelines. Odd ratios (ORs) for aCVD were evaluated, adjusting for age, sex, excess weight, cigarette smoking, blood hypertension, dyslipidemia, diabetes, H. pylori status, and RA.

RESULTS

Among 4821 records (mean age 52.1 ± 16.7 years; 66.0% female), H. pylori infection was detected in 2262 patients, and more specifically, a LLHp infection was present in 1043 (21.6%). Three-hundred-three (6.3%) patients were diagnosed with aCVD, and 208 (4.3%) with RA. In patients with aCVD (cases), the LLHp infection (33.3% vs. 20.8%, p < 0.0001) and RA (12.2% vs. 3.8%, p < 0.0001) were more frequent in cases compared with controls (patients without aCVD). After adjusting for traditional aCVD risk factors, ORs significantly increased for LLHp infection (1.57; 95% CI 1.20-2.06) and RA (2.63; 95% CI 1.72-4.02). Interestingly, the LLHp infection in patients with RA showed an overall addictive effect on the risk for aCVD (7.89; 95% CI 4.29-14.53).

CONCLUSIONS

According to our findings, patients with RA should benefit from being screened and eventually treated for H. pylori infection.

Effect of Bariatric Surgery on Flow-Mediated Vasodilation as a Measure of Endothelial Function: A Systematic Review and Meta-Analysis

Objectives. Flow mediated vasodilation (FMD) is a marker of endothelial function and its decline is related to increased cardiovascular risk. This systematic review and meta-analysis evaluated the impact of bariatric surgery on FMD. Materials and methods. A systematic literature search in PubMed, Scopus, Embase, and Web of Science was performed to 1 May 2021. Meta-analysis was performed using Comprehensive Meta-Analysis (CMA) V2 software. All types of bariatric surgery were considered, with the inclusion that FMD had to have been tested before and after the surgical procedure. Meta-analysis was carried out using a random-effects model and the generic inverse variance approach. The leave-one-out approach was used for sensitivity analysis. To assess metabolic parameter confounders, a weighted random-effects meta-regression was used. Results. A meta-analysis and a systematic review of 23 studies (n = 891 individuals) demonstrated improvement in FMD following bariatric surgery (weighted mean difference (WMD): 5.867, 95% CI: 4.481, 7.252, p < 0.001; I2: 96.70). Iteratively removing each item in the meta-analysis did not result in a significant alteration in the pooled estimate of effect size. There was an improvement in FMD for up to 6 months following bariatric surgery in a meta-analysis from 7 trials that included 356 subjects (WMD: 5.248, 95% CI: 2.361, 8.135, p < 0.001; I2: 98.18). The meta-analysis from 9 trials (n = 414 subjects) showed an improvement in FMD 6 to 12 months after bariatric surgery (WMD: 5.451, 95% CI: 3.316, 7.587, p < 0.001; I2: 94.18). The meta-analysis from 10 trials (n = 414 subjects) demonstrated an improvement in FMD 12 months after bariatric surgery (WMD: 2.401, 95% CI: 0.944, 3.859, p = 0.001; I2: 88.35). Random-effects meta-regression did not show any association between the alteration in FMD and percent body mass index (BMI) change (slope: 0.0258; 95% CI: −0.323, 0.375; p = 0.884), or changes in blood pressure; however, there was an association between the changes in FMD and the duration of follow-up (slope: −0.106; 95% CI: −0.205, −0.008; p = 0.033) with greater changes in FMD after 12 months. Conclusions. Bariatric surgery significantly improved FMD that increased with time, and the resultant improvement in endothelial function was independent of weight loss or a reduction in blood pressure.

Do coping strategies really affect cardiovascular events? The Isfahan cohort study of adults in Eastern Mediterranean Regional Office

AIMS

Psychological factors are among the most suspected indicators which may cause atherosclerosis. Coping strategies modifying psychological stress may be significantly associated with health outcomes. However, little is known about the influence of adaptive and maladaptive coping strategies on major adverse cardiovascular disease (CVD) events. The purpose of this study is to examine this idea among a sample of adults. Design: cohort study.

METHODS AND RESULTS

The Isfahan cohort study (ICS) is a longitudinal population-based, prospective study. Participants (N=6323 individuals aged 35 years or greater at baseline) were selected by multistage random sampling with 6-year intervals (i.e. 2001: 6323 individuals, 2007: 3296 individuals, and 2013: 1706 individuals). Adaptive and maladaptive coping strategies were evaluated by a multicomponent self-administered stress management paper-based questionnaire. All CVD events were confirmed by a blinded panel of experts and a marginal cox regression model was used to model the survival data. Adaptive coping strategies could be protective against CVD events with hazard ratios (95% confidence interval) [0.97 (0.95-0.99)] and maladaptive coping strategies seem to be a risk factor, 1.02 (1.01-1.04) in the whole population. Individuals younger than 60 showed similar results, with 0.96 (0.93-0.98) and 1.04 (1.01-1.07) for adaptive and maladaptive coping strategies, respectively. However, these findings were not replicated among seniors older than age 60.

CONCLUSION

Based on our results, coping strategies have an important role in cardiovascular events, particularly among young adults. According to the results, informing patients about adaptive stress management may promote primary prevention of CVD events.

Amlodipine and atorvastatin in atherosclerosis: a review of the potential of combination therapy

Hypertension and hyperlipidaemia are major risk factors for the development of atherosclerosis. Calcium channel blockers (CCBs) have been used for decades and have established antihypertensive effects. Statins have been extensively used because of their potent lipid lowering properties. Amongst other factors, inflammation and oxidation are involved in enhanced progression of atherosclerosis and new lesion development. Therefore, research has been initiated focusing on the antioxidant and anti-inflammatory properties of CCBs and statins, beyond their primary effect, in order to evaluate the possible additive effects of combined treatment of CCBs with statins as antiatherosclerotic therapy. Clinical studies (e.g., the International Nifedipine Trial on Antiatherosclerotic Therapy [INTACT]) have demonstrated that the antiatherosclerotic action of CCBs is limited to the attenuation of the first stage of atherosclerogenesis (fatty streak formation or new lesion growth). The lesions that pre-existed at the start of CCB therapy did not demonstrate progression or regression on angiography. However, because the mechanisms of action of lipid-lowering drugs and CCBs, and their role in preventing the progression of atherosclerosis differ, it is conceivable to conclude that these two classes may have an additive or synergic effect, not only on new lesion formation but also on inhibiting the progression of established coronary atherosclerosis. Indeed, this combined effect of lipid-lowering therapy and CCBs on human coronary atherosclerosis has been reported in the Regression Growth Evaluation Statin Study (REGRESS) trial. This beneficial effect of combining CCBs with statins has now been replicated in transgenic atherosclerotic mice, where the combination of amlodipine and atorvastatin produced an additional 60% reduction of atherosclerosis compared with that observed with the statin alone. Serum markers of atherosclerosis and vascular integrity also improved most in the combination group. Synergistic effects of the combination of atorvastatin and amlodipine on acute nitric oxide release/endothelial function, and additive effects of the combination of amlodipine and atorvastatin in the improvement of arterial compliance in hypertensive hyperlipidaemic patients has been demonstrated. Collectively, these studies support the clinical antiatherosclerotic advantages of combination of CCBs and statins and in particular, of atorvastatin with amlodipine beyond their established antihyperlipidaemic and antihypertensive modes of action.

Implications of oxidative stress and homocysteine in the pathophysiology of essential hypertension

The present review examines the clinical and experimental data to support the view that homocysteine and oxidative stress, two alternative risk factors of vascular disease, may play a role in the pathogenesis of primary or essential hypertension. Although the precise mechanism of this disease has not been elucidated, it may be related to impairment of vascular endothelial and smooth muscle cell function. Thus, the occurrence of endothelial dysfunction could contribute to alterations of the endothelium-dependent vasomotor regulation. Hyperhomocysteinemia limits the bioavailability of nitric oxide, increases oxidative stress, stimulates the proliferation of vascular smooth muscle cells, and alters the elastic properties of the vascular wall. The link between oxidative stress and hyperhomocysteinemia is also biologically plausible, because homocysteine promotes oxidant injury to the endothelium. Cumulated evidence suggests that the diminution of oxidative stress with antioxidants or the correction of hyperhomocysteinemia with vitamins-B plus folic acid, could be useful as an adjuvant therapy for essential hypertension. Further studies involving long-term trials could help to assess the tolerability and efficacy of the use of these therapeutic agents.

Stress influence on genesis, onset and maintenance of cardiovascular diseases: literature review

BACKGROUND

Recent mortality profiles in Brazil show that circulatory diseases are the leading cause of death in Brazil. These disorders contribute to 34% of deaths, with 50% of those deaths occurring in people under 50 years of age, that is, in people who are still active in the workforce. We assume that the growing incidence of cardiovascular diseases has occurred as the globalization of Brazil continues and brings with it the associated health risk factors of modern lifestyles, including stress.

AIM

This paper reports the evidence on the influence of stress in the development, onset and progress of cardiovascular diseases. We aim to define the concept of stress and to point systematically to the interrelationships between its emotional and bodily manifestations through a discussion of the history and study of stress. We then suggest that factors leading to the experience of stress in Brazil are no different than in any other modern nation. We further offer a perspective on nursing interventions currently undertaken in Brazil in both hospital and community settings, with their more recent emphasis on health promotion and prevention.

METHODS

An extensive literature review was undertaken. The data presented here were selected from reviews and clinical studies described in MEDLINE, LILACS, SciELO databases, as well as in the classical literature. We also refer to the current Brazilian literature on the prevalence of cardiovascular diseases and their associated risk factors.

CONCLUSIONS

The incidence of cardiovascular diseases in Brazil is rising. Because of the globalization of Brazilian society, with its consequent competitiveness and accelerated modern lifestyles, Brazilians are no less immune to the usual health risk factors associated with cardiovascular diseases. Stresses associated with a modern lifestyle, however, are emerging as a new and major risk for developing cardiovascular diseases in Brazil.

Red and black rice decrease atherosclerotic plaque formation and increase antioxidant status in rabbits

The influence of white, red and black rice consumption on atherosclerotic plaque formation induced by hypercholesterolemia was investigated in rabbits. Male rabbits (n = 36) were divided into five groups. They were fed a normal laboratory purified diet (normal group, n = 6), a high cholesterol (0.5 g/100 g) diet (HC group, n = 6), a high cholesterol diet with 30 g/100 g white rice (WR group, n = 8), 30 g/100 g red rice (RR group, n = 8), or 30 g/100 g black rice (BR group, n = 8) for 10 wk. Blood samples were collected for lipid measurements and aorta were removed for assessment of atherosclerotic plaques at the end of the protocol. The oxidant and antioxidant status of blood, erythrocytes, liver and aorta was evaluated. The area of atherosclerotic plaque was 50% lower in rabbits fed the red or black rice diets than in those fed the white rice diet. Compared with the HC and WR groups, serum HDL cholesterol and apolipoprotein (apo) A-I concentration were greater (P < 0.05) in the RR and BR groups. Liver reactive oxygen species (ROS) and aortic malondialdehyde (MDA) were significantly lower, and the liver total antioxidative capacity (TAC) and erythrocyte superoxide dismutase (SOD) activity were significantly higher in the RR and BR groups compared with the HC and WR groups. Red or black rice consumption reduced or retarded the progression of atherosclerotic plaque development induced by dietary cholesterol. The enhanced serum HDL cholesterol and apo A-I concentrations, and the increased antioxidant and decreased oxidative status may be mechanisms of the antiatherogenic effect of red or black rice.

C-reactive protein, oxidative stress, homocysteine, and troponin as inflammatory and metabolic predictors of atherosclerosis in ESRD

Mortality in patients with end-stage renal disease remains high, with cardiovascular disease accounting for half of these deaths. Novel risk factors such as inflammation, oxidative stress, hyperhomocysteinemia, and high troponin levels are associated with cardiovascular risk in the general population. While there are substantial epidemiologic data confirming that these novel risk factors are associated with cardiovascular risk in end-stage renal disease patients, a causal relationship has not been established. Inflammation is readily identified by the presence of high levels of C-reactive protein, while studies of oxidative stress are hampered by the lack of a standardized test. The cause of both is unknown. Hyperhomocysteinemia results from decreased remethylation to methionine, although vitamin supplementation only partially corrects the defect, suggesting that uremic inhibition of the enzymatic process may be important. The most promising strategies for correcting oxidative stress and hyperhomocysteinemia are vitamin E and folinic acid therapy, respectively. Troponin I appears to be a more specific marker of myocardial injury than Troponin T, but troponin T retains its ability to predict cardiovascular mortality as well as all-cause mortality. Sorting out the role of each of these risk factors may be difficult since the factors may influence each other, may increase oxidative stress, and may mediate atherosclerosis through oxidative modification of lipids.