High visit-to-visit cholesterol variability predicts heart failure and adverse cardiovascular events: a population-based cohort study

Clustering of Cardiovascular Risk Factors and Heart Failure in Older Adults from the Brazilian Far North

Given the aging global population, identifying heart failure (HF) phenotypes has become crucial, as distinct disease characteristics can influence treatment and prognosis in older adults. This study aimed to analyze the association between clustering of cardiovascular risk factors and HF in older adults. A cross-sectional epidemiological study was conducted with 1322 older adults (55% women, mean age 70.4) seen in primary health care. Diagnosis of HF was performed by a cardiologist based on diagnostic tests and medical history. Cardiovascular risk factors included hypertension, diabetes, hypercholesterolemia, and smoking. Using logistic regression, potential associations were tested. Individual risk factor analysis showed that older adults with hypertension, diabetes, or hypercholesterolemia had up to 7.6 times higher odds to have HF. The cluster where older adults had only one risk factor instead of none increased the odds of HF by 53.0%. Additionally, the odds of older patients having HF ranged from 3.59 times for the two-risk factor cluster to 20.61 times for the simultaneous presence of all four factors. The analysis of clusters substantially increasing HF risk in older adults revealed the importance of individualizing subgroups with distinct HF pathophysiologies. The clinical significance of these clusters can be beneficial in guiding a more personalized therapeutic approach.

New-onset syncope in diabetic patients treated with sodium-glucose cotransporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors: a Chinese population-based cohort study

BACKGROUND AND AIMS

Syncope is a symptom that poses an important diagnostic and therapeutic challenge, and generates significant cost for the healthcare system. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated beneficial cardiovascular effects, but their possible effects on incident syncope have not been fully investigated. This study compared the effects of SGLT2i and dipeptidyl peptidase-4 inhibitors (DPP4i) on new-onset syncope.

METHODS AND RESULTS

This was a retrospective, territory-wide cohort study enrolling type 2 diabetes mellitus (T2DM) patients treated with SGLT2i or DPP4i between 1 January 2015 and 31 December 2020, in Hong Kong, China. The outcomes were hospitalization of new-onset syncope, cardiovascular mortality, and all-cause mortality. Multivariable Cox regression and different approaches using the propensity score were applied to evaluate the association between SGLT2i and DPP4i with incident syncope and mortality. After matching, a total of 37 502 patients with T2DM were included (18 751 SGLT2i users vs. 18 751 DPP4i users). During a median follow-up of 5.56 years, 907 patients were hospitalized for new-onset syncope (2.41%), and 2346 patients died from any cause (6.26%), among which 471 deaths (1.26%) were associated with cardiovascular causes. Compared with DPP4i users, SGLT2i therapy was associated with a 51% lower risk of new-onset syncope [HR 0.49; 95% confidence interval (CI) 0.41-0.57; P < 0.001], 65% lower risk of cardiovascular mortality (HR 0.35; 95% CI 0.26-0.46; P < 0.001), and a 70% lower risk of all-cause mortality (HR 0.30; 95% CI 0.26-0.34; P < 0.001) in the fully adjusted model. Similar associations with syncope were observed for dapagliflozin (HR 0.70; 95% CI 0.58-0.85; P < 0.001), canagliflozin (HR 0.48; 95% CI 0.36-0.63; P < 0.001), and ertugliflozin (HR 0.45; 95% CI 0.30-0.68; P < 0.001), but were attenuated for empagliflozin (HR 0.79; 95% CI 0.59-1.05; P = 0.100) after adjusting for potential confounders. The subgroup analyses suggested that, compared with DPP4i, SGLT2i was associated with a significantly decreased risk of incident syncope among T2DM patients, regardless of gender, age, glucose control status, Charlson comorbidity index, and the association remained constant amongst those with common cardiovascular drugs and most antidiabetic drugs at baseline.

CONCLUSION

Compared with DPP4i, SGLT2i was associated with a significantly lower risk of new-onset syncope in patients with T2DM, regardless of gender, age, degree of glycaemic control, and comorbidity burden.

Association between visit-to-visit lipid variability and risk of ischemic heart disease: a cohort study in China

AIMS

To explore the associations between visit-to-visit lipid variability and risk of ischemic heart disease (IHD) in a population-based cohort in China.

METHODS

We evaluated lipid variability in 30,217 individuals from the Yinzhou Health Information System who had ≥3 recorded lipid measurements during 2010-2014. We used various indicators including standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV) to quantify the variability in triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C). We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Overall, a total of 1305 participants with IHD were identified during the follow-up of 194,421 person-years. Subjects in Q4 had a 21% elevated risk of IHD (HR = 1.21, 95% CI: 1.03-1.41) for LDL-C variability (CV) compared with the reference (Q1). The HRs for Q4 vs Q1 were 1.21 (95% CI: 1.04-1.42) for HDL-C variability, and 1.28 (95% CI: 1.10-1.50) for TC variability. However, no association was observed between triglycerides variability and risk of IHD.

CONCLUSIONS

Higher variability in LDL-C, HDL-C, and TC levels was associated with an elevated risk of IHD, suggesting that lipid variability could be considered as an independent risk factor of IHD.

Major adverse cardiovascular events of enzalutamide versus abiraterone in prostate cancer: a retrospective cohort study

BACKGROUND

While the cardiovascular risks of androgen receptor pathway inhibitors have been studied, they were seldom compared directly. This study compares the risks of major adverse cardiovascular events (MACE) between enzalutamide and abiraterone among prostate cancer (PCa) patients.

METHODS

Adult PCa patients receiving either enzalutamide or abiraterone in addition to androgen deprivation therapy in Hong Kong between 1 December 1999 and 31 March 2021 were identified in this retrospective cohort study. Patients who switched between enzalutamide and abiraterone, initiated abiraterone used without steroids, or experienced prior cardiac events were excluded. Patients were followed-up until 30 September 2021. The primary outcomes were MACE, a composite of stroke, myocardial infarction (MI), Heart failure (HF), or all-cause mortality and a composite of adverse cardiovascular events (CACE) not including all-cause mortality. The secondary outcomes were individual components of MACE. Inverse probability treatment weighting was used to balance covariates between treatment groups.

RESULTS

In total, 1015 patients were analyzed (456 enzalutamide users and 559 abiraterone users; mean age 70.6 ± 8.8 years old) over a median follow-up duration of 11.3 (IQR: 5.3-21.3) months. Enzalutamide users had significantly lower risks of 4P-MACE (weighted hazard ratio (wHR) 0.71 [95% confidence interval (CI) 0.59-0.86], p < 0.001) and CACE (wHR 0.63 [95% CI: 0.42-0.96], p = 0.031), which remained consistent in multivariable analysis. Such an association may be stronger in patients aged ≥65 years or without diabetes mellitus and was independent of bilateral orchidectomy. Enzalutamide users also had significantly lower risks of MI (wHR 0.57 [95% CI: 0.33-0.97], p = 0.040) and all-cause mortality (wHR 0.71 [95% CI: 0.59-0.85], p < 0.001).

CONCLUSION

Enzalutamide was associated with lower cardiovascular risks than abiraterone in PCa patients.

Visit-to-Visit Variability in Fasting Blood Glucose Predicts the New-Onset Heart Failure: Results From Two Large Chinese Cohorts

Previous studies have hypothesized an association between higher fasting blood glucose (FBG) and heart failure (HF). However, FBG values fluctuate continuously over time, the association between FBG variability and the risk of HF is uncertain. We investigated the relationship between visit-to-visit variability in FBG and the risk of new-onset HF. This cohort study used data from a prospective Kailuan cohort (recruited during 2006-2007) and a retrospective cohort of family medicine patients from Hong Kong (recruited during 2000-2003) were followed up until December 31st, 2016, and December 31st, 2019, respectively, for the outcome of incident HF. Four indexes of variability were used, including standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV). Cox regression was used to identify HF. In total, 98,554 and 22,217 subjects without preexisting HF from the Kailuan and Hong Kong cohorts were analyzed, respectively, with 1218 cases of incident HF in the former and 4,041 in the latter. Subjects in the highest quartile of FBG-CV had the highest risk of incident HF in both cohorts (Kailuan: HR 1.245, 95% CI 1.055-1.470); Hong Kong: HR 1.362, 95%CI 1.145-1.620; compared with the lowest quartile). Similar results were observed when using FBG-ARV, FBG-VIM, and FBG-SD. Meta-analysis showed similar results (highest versus lowest quartile: HR 1.30, 95%CI 1.15-1.47, P < 0.0001). As observed from 2 large, geographically distinct Chinese cohorts, a higher FBG variability was independently associated with higher risk of incident HF.

P-wave durations from automated electrocardiogram analysis to predict atrial fibrillation and mortality in heart failure

BACKGROUND

P-wave indices have been used to predict incident atrial fibrillation (AF), stroke, and mortality. However, such indices derived from automated ECG measurements have not been explored for their predictive values in heart failure (HF). We investigated whether automated P-wave indices can predict adverse outcomes in HF.

METHODS

This study included consecutive Chinese patients admitted to a single tertiary centre, presenting with HF but without prior AF, and with at least one baseline ECG, between 1 January 2010 and 31 December 2016, with last follow-up of 31 December 2019.

RESULTS

A total of 2718 patients were included [median age: 77.4, interquartile range (IQR): (66.9-84.3) years; 47.9 males]. After a median follow-up of 4.8 years (IQR: 1.9-9.0 years), 1150 patients developed AF (8.8/year), 339 developed stroke (2.6/year), 563 developed cardiovascular mortality (4.3/year), and 1972 had all-cause mortality (15.1/year). Compared with 101-120 ms as a reference, maximum P-wave durations predicted new-onset AF at ≤90 ms [HR: 1.17(1.11, 1.50), P < 0.01], 131-140 ms [HR: 1.29(1.09, 1.54), P < 0.001], and ≥141 ms [HR: 1.52(1.32, 1.75), P < 0.001]. Similarly, they predicted cardiovascular mortality at ≤90 ms [HR: 1.50(1.08, 2.06), P < 0.001] or ≥141 ms [HR: 1.18(1.15, 1.45), P < 0.001], and all-cause mortality at ≤90 ms [HR: 1.26(1.04, 1.51), P < 0.001], 131-140 ms [HR: 1.15(1.01, 1.32), P < 0.01], and ≥141 ms [HR: 1.31(1.18, 1.46), P < 0.001]. These remained significant after adjusting for significant demographics, past co-morbidities, P-wave dispersion, and maximum P-wave amplitude.

CONCLUSIONS

Extreme values of maximum P-wave durations (≤90 ms and ≥141 ms) were significant predictors of new-onset AF, cardiovascular mortality, and all-cause mortality.

Metformin use and mortality in Asian, diabetic patients with prostate cancer on androgen deprivation therapy: A population-based study

BACKGROUND

This study aims to examine the associations between metformin use concurrent with androgen deprivation therapy (ADT) and mortality risks in Asian, diabetic patients with prostate cancer (PCa).

METHODS

This study identified diabetic adults with PCa receiving any ADT attending public hospitals in Hong Kong between December 1999 and March 2021 retrospectively, with follow-up until September 2021. Patients with <6 months of medical castration without subsequent bilateral orchidectomy, <6 months of concurrent metformin use and ADT, or missing baseline HbA1c were excluded. Metformin users had ≥180 days of concurrent metformin use and ADT, while non-users had no concurrent metformin use and ADT or never used metformin. The primary outcome was PCa-related mortality. The secondary outcome was all-cause mortality. The study used inverse probability treatment weighting to balance covariates.

RESULTS

The analyzed cohort consisted of 1971 patients (1284 metformin users and 687 non-users; mean age 76.2 ± 7.8 years). Over a mean follow-up of 4.1 ± 3.2 years, metformin users had significantly lower risks of PCa-related mortality (weighted hazard ratio [wHR]: 0.49 [95% confidence interval, CI:  0.39-0.61], p < 0.001) and all-cause mortality (wHR 0.53 [0.46-0.61], p < 0.001), independent of diabetic control or status of chronic kidney disease. Such effects appeared stronger in patients with less advanced PCa, which is reflected by the absence of androgen receptor antagonist or chemotherapy use (p value for interaction: 0.017 for PCa-related mortality; 0.048 for all-cause mortality).

CONCLUSIONS

Metformin use concurrent with ADT was associated with lower risks of mortality in Asian, diabetic patients with PCa.

Association between duration of gonadotrophin-releasing hormone agonist use and cardiovascular risks: A population-based competing-risk analysis

BACKGROUND

Although androgen deprivation therapy has known cardiovascular risks, it is unclear if its duration is related to cardiovascular risks. This study thus aimed to investigate the associations between gonadotrophin-releasing hormone (GnRH) agonist use duration and cardiovascular risks.

METHODS

This retrospective cohort study included adult patients with prostate cancer receiving GnRH agonists in Hong Kong during 1999-2021. Patients who switched to GnRH antagonists, underwent bilateral orchidectomy, had <6 months of GnRH agonist, prior myocardial infarction (MI), or prior stroke was excluded. All patients were followed up until September 2021 for a composite endpoint of MI and stroke. Multivariable competing-risk regression using the Fine-Gray subdistribution model was used, with mortality from any cause as the competing event.

RESULTS

In total, 4038 patients were analyzed (median age 74.9 years old, interquartile range (IQR) 68.7-80.8 years old). Over a median follow-up of 4.1 years (IQR 2.1-7.5 years), longer GnRH agonists use was associated with higher risk of the endpoint (sub-hazard ratio per year 1.04 [1.01-1.06], p = 0.001), with those using GnRH agonists for ≥2 years having an estimated 23% increase in the sub-hazard of the endpoint (sub-hazard ratio 1.23 [1.04-1.46], p = 0.017).

CONCLUSION

Longer GnRH agonist use may be associated with greater cardiovascular risks.

Association between visit-to-visit lipid variability and incident cancer: a population-based cohort study

Dyslipidaemia is associated with increased cancer risk. However, the prognostic value of visit-to-visit lipid variability (VVLV) is unexplored in this regard. To investigate the associations between VVLV and the risk of incident cancer, we conducted a retrospective cohort study on adult patients attending a family medicine clinic in Hong Kong during 2000-2003, excluding those with <3 tests for low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and total cholesterol (TC) each, those with prior cancer diagnosis, and those with <1 year of follow-up. Visit-to-visit LDL-C, HDL-C, TC, and triglycerides variabilities were measured by the coefficient of variation (CV). Patients were followed up until 31^st December 2019 for the primary outcome of incident cancer. Altogether, 69,186 patients were included (26,679 males (38.6%); mean age 60±13 years; mean follow-up 16±3 years); 7958 patients (11.5%) had incident cancer. Higher variability of LDL-C, HDL-C, TC, and TG was associated with higher risk of incident cancer. Patients in the third tercile of the CV of LDL-C (adjusted hazard ratio (aHR) against first tercile 1.06 [1.00, 1.12], p=0.049), HDL-C (aHR 1.37 [1.29, 1.44], p<0.001), TC (aHR 1.10 [1.04, 1.17], p=0.001), and TG (aHR 1.11 [1.06, 1.18], p<0.001) had the highest risks of incident cancer. Among these, only HDL-C variability remained associated with the risk of incident cancer in users of statins/fibrates. To conclude, higher VVLV was associated with significantly higher long-term risks of incident cancer. VVLV may be a clinically useful tool for cancer risk stratification.