Carotid Plaque, Intima-Media Thickness, and Incident Aortic Stenosis

Angiotensin II Receptor Blockers Are Associated With Reduced Valvular Fibrosis in Women With Aortic Stenosis

BACKGROUND

Angiotensin receptor blockers (ARBs) may slow down the progression of aortic stenosis (AS) through their antifibrotic effect. Women present more valvular fibrosis than men, so ARBs may have more effect in females. Our aim was to assess the impact of ARBs on the remodelling of the aortic valve in men and women.

METHODS

We included patients who had an aortic valve replacement with or without coronary bypass grafting from 2006 to 2013. Patients with missing echocardiographic or histologic data were excluded. Warren-Yong and fibrosis scores of the explanted valves were performed. Patients were divided into 4 phenotypes according to their Warren-Yong and fibrosis scores: mild calcification/fibrosis, severe calcification/fibrosis group, predominant fibrosis group, predominant calcification group.

RESULTS

Among the 1321 included patients, the vast majority (89%) has severe AS. Patients in the predominant fibrosis group, compared with the predominant calcium group, were more often female (39% vs 31%; P = 0.008) with bicuspid valves (44% vs 34%; P = 0.002), and less often used ARBs (25% vs 30%; P = 0.046). Female sex was independently associated with being in the predominant fibrosis group (odds ratio 1.45, 95% confidence interval 1.08-1.95; P = 0.01), with a significant interaction between female sex and ARBs. Women taking ARBs compared with women not taking ARBs had significantly lower fibrosis scores (P < 0.001). This difference was not seen in men.

CONCLUSIONS

In this large series of patients with moderate-severe AS, among the women there was a negative association between intake of ARBs and valvular fibrosis. Thus, the possible effects of ARBs may be sex specific, with a larger therapeutic role in women.

Leukocyte and Platelet Related Inflammatory Indicators and Risk of Carotid and Femoral Plaques: A Population-Based Cross-Sectional Study in Southeast China

The associations between several blood inflammatory indicators and risk of vascular plaques remain inconclusive. A total of 4596 native rural residents in Southeast China were enrolled from the Fuqing cohort study. Blood cell counts and their composite indexes including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and 2 novel indicators (systemic immune inflammation index (SII) and systemic immune inflammation response index (SIRI)) were considered as inflammatory indicators. Common carotid and femoral intima-media thickness (IMT) and plaques were assessed using B-mode ultrasound. Unconditional or multinomial logistic regression was used to evaluate potential associations. The prevalence of multiple femoral plaques (defined as IMT ≥1.5 mm) was significantly higher among participants with the highest tertile of total leukocyte count (odds ratio, 1.78), neutrophil count (1.88), monocyte count (2.51), platelet count (1.68), NLR (1.93), PLR (1.57), SII (2.10), and SIRI (2.94). Higher levels of neutrophil count, platelet count, NLR, and SII were also found to have significant linear dose-response relationships with the prevalence of stenosis, especially in femoral arteries. In conclusion, several blood inflammatory biomarkers may contribute to, or are associated with, the presence of IMT ≥1.5 mm or stenosis especially in femoral arteries.

Traditional and novel risk factors for incident aortic stenosis in community-dwelling older adults

OBJECTIVES

Calcific aortic stenosis (AS) is the most common valvular disease in older adults, yet its risk factors remain insufficiently studied in this population. Such studies are necessary to enhance understanding of mechanisms, disease management and therapeutics.

METHODS

The Cardiovascular Health Study is a population-based investigation of older adults that completed adjudication of incident AS over long-term follow-up. We evaluated traditional cardiovascular risk factors or disease, as well as novel risk factors from lipid, inflammatory and mineral metabolism pathways, in relation to incident moderate or severe AS (including AS procedures) and clinically significant AS (severe AS, including procedures).

RESULTS

Of 5390 participants (age 72.9±5.6 years, 57.6% female, 12.5% black), 287 developed moderate or severe AS, and 175 clinically significant AS, during median follow-up of 13.1 years. After full adjustment, age (HR=1.66 per SD (95% CI=1.45, 1.91)), male sex (HR=1.41 (1.06, 1.87)), diabetes (HR=1.53 (1.10, 2.13)), coronary heart disease (CHD, HR=1.36 (1.01, 1.84)), lipoprotein-associated phospholipase-A2 (LpPLA2) activity (HR=1.21 per SD (1.07, 1.37)) and sCD14 (HR=1.16 per SD (1.01, 1.34)) were associated with incident moderate/severe AS, while black race demonstrated an inverse association (HR=0.40 (0.24, 0.65)), and creatinine-based estimated glomerular filtration rate (eGFRcr) showed a U-shaped relationship. Findings were similar for clinically significant AS, although CHD and sCD14 fell short of significance, but interleukin-(IL) 6 showed a positive association.

CONCLUSION

This comprehensive evaluation of risk factors for long-term incidence of AS identified associations for diabetes and prevalent CHD, LpPLA2 activity, sCD14 and IL-6, and eGFRcr. These factors may hold clues to biology, preventive efforts and potential therapeutics for those at highest risk.

Exploring the significance of epicardial adipose tissue in aortic valve stenosis and left ventricular remodeling: Unveiling novel therapeutic and prognostic markers of disease

Aortic stenosis (AS) is a dynamic degenerative process that shares many pathophysiological features with atherogenesis, from initial proinflammatory calcification and focal thickening of the valve leaflets to obstruction of left ventricular outflow due to superimposed of severe calcification and immobilization of the valve leaflets. As the prevalence increases with age, AS is expected to become one of the most common heart diseases worldwide. In both obese and nonobese patients, persistent thickening of epicardial adipose tissue (EAT) is associated with a shift in its normal metabolic functions toward a dysmetabolic and proatherogenic phenotype that may impair the physiology of adjacent coronary arteries and promote the occurrence of coronary atherosclerosis. In tight analogy with atherosclerosis, recent clinical evidence indicates that EAT may also exert a deleterious role in promoting AS and contributing to myocardial dysfunction, leading to increased health risk for elderly patients with AS and an economic burden on the health care system. This review discusses the clinical and pathologic evidence for the association between EAT and AS and concomitant left ventricular hypertrophy, and provides new insights for the future direction of AS diagnosis and treatment.

The clinical value of carotid plaque score in patients with metabolic syndrome and cardiovascular diseases

OBJECTIVE

To investigate the relationship between carotid plaque load score (CPS) and metabolic syndrome (MS) and cardiovascular diseases (CVD), in order to provide theoretical basis for the precaution and control of MS and CVD.

METHODS

A total of 1962 patients were incorporated into the study and divided into MS group and non-MS group, CVD group and non-CVD group. CPS and CIMT were obtained by carotid artery ultrasound, and the data of each group were statistically analyzed.

RESULTS

Age, BMI, basal metabolic rate, body fat rate, gender, and the incidence of central obesity, hypertension, diabetes and dyslipidemia are statistical different between MS group and non-MS group (P < 0.05). CIMT between CVD group and non-CVD group are statistical different (1.040 ± 0.239 VS 0.972 ± 0.297, P < 0.001). CPS was statistically significant between MS group and non-MS group(2.254 ± 2.728 VS 1.548 ± 2.219, P = 0.003) and between CVD group and non-CVD group (2.322 ± 2.760 VS 1.688 ± 2.347, P = 0.004).

CONCLUSION

Patients in MS group and CVD group have higher carotid plaque burden than those in non-MS group and non-CVD group. The higher the CPS was, the higher the incidence of MS and CVD was, and the distribution of CPS in MS and CVD population was consistent.

Body Mass Index and Mortality from Nonrheumatic Aortic Valve Disease among Japanese Men and Women

AIM

We aimed to examine the impact of overweight and obesity on mortality from nonrheumatic aortic valve disease.

METHODS

In the Japan Collaborative Cohort Study, we analyzed data of 98,378 participants aged 40-79 years, with no history of coronary heart disease, stroke, or cancer at baseline (1988-1990) and who completed a lifestyle questionnaire including height and body weight; they were followed for mortality until the end of 2009. The Cox proportional hazards model was used to calculate the multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) of nonrheumatic aortic valve disease mortality according to body mass index (BMI) after adjusting for potential confounding factors.

RESULTS

During the median 19.2 years follow-up, 60 deaths from nonrheumatic aortic valve disease were reported. BMI was positively associated with the risk of mortality from nonrheumatic aortic valve disease; the multivariable HRs (95% CIs) were 0.90 (0.40-2.06) for persons with BMI ＜21 kg/m², 1.71 (0.81-3.58) for BMI 23-24.9 kg/m², 1.65 (0.69-3.94) for BMI 25-26.9 kg/m², and 2.83 (1.20-6.65) for BMI ≥ 27 kg/m² (p for trend=0.006), compared with persons with BMI 21-22.9 kg/m². Similar associations were observed between men and women (p for interaction=0.56). Excluding those who died during the first ten years of follow-up or a competing risk analysis with other causes of death as competing risk events did not change the association materially.

CONCLUSIONS

Overweight and obesity may be independent risk factors for nonrheumatic aortic valve disease mortality in Asian populations.

A population-based study of precision health assessments using multi-omics network-derived biological functional modules

Recent technological advances in multi-omics and bioinformatics provide an opportunity to develop precision health assessments, which require big data and relevant bioinformatic methods. Here we collect multi-omics data from 4,277 individuals. We calculate the correlations between pairwise features from cross-sectional data and then generate 11 biological functional modules (BFMs) in males and 12 BFMs in females using a community detection algorithm. Using the features in the BFM associated with cardiometabolic health, carotid plaques can be predicted accurately in an independent dataset. We developed a model by comparing individual data with the health baseline in BFMs to assess health status (BFM-ash). Then we apply the model to chronic patients and modify the BFM-ash model to assess the effects of consuming grape seed extract as a dietary supplement. Finally, anomalous BFMs are identified for each subject. Our BFMs and BFM-ash model have huge prospects for application in precision health assessment.

Observational and Genetic Associations of Modifiable Risk Factors with Aortic Valve Stenosis: A Prospective Cohort Study of 0.5 Million Participants

Background: Observational studies have shown that modifiable risk factors are associated with aortic valve stenosis (AVS). However, the causality behind these associations remains largely unknown. Objectives: To explore the associations of modifiable risk factors, including metabolic factors, biochemical measures, education, and lifestyles with AVS and their potential causal associations. Methods: We enrolled 361,930 British white people with genetic data in the UK biobank. Cox proportional risk regression models were used to estimate the hazard ratios between 28 modifiable risk factors and AVS. We used genetic instruments for modifiable risk factors to determine the potential causal relationships using a one-sample Mendelian randomization (MR) approach. Results: A total of 1602 participants developed AVS during an 8.4-year follow-up. Observational analyses showed higher adiposity, blood pressure, heart rate, low-density lipoprotein, urate, C-reactive protein, creatinine, albumin, and glycated hemoglobin, but lower serum vitamin D, and education, unhealthy lifestyle, and poor sleep quality were related to a higher risk of AVS after adjusting for the Bonferroni correction (p < 0.0013). Genetically predicted 1-SD higher levels of body mass index [HR: 1.09, 95% CI: 1.03 to 1.16], body fat percentage (1.17, 1.03 to 1.33), triglyceride (TG) [1.08, 1.00 to 1.16], low-density lipoprotein (LDL) (1.15, 1.08 to 1.21) and serum total cholesterol (TC) (1.13, 1.02 to 1.25) were associated with a higher risk of AVS, respectively. Genetically determined per category higher insomnia (1.32, 1.13 to 1.55) was also associated with AVS. The abovementioned genetic associations with the incident AVS showed an increasing relationship pattern. Conclusions: This study provides strong evidence for the potential causal roles of cardiometabolic factors in developing AVS, highlighting that an idea of metabolic status through a healthy lifestyle may help prevent AVS.

Prediction of Aortic Stenosis Progression by 18F-FDG and 18F-NaF PET/CT in Different Aortic Valve Phenotypes

Background: Different imaging techniques, such as echocardiography (ECHO) and CT, allow to assess aortic stenosis (AS) severity and could be used to study its progression. But only PET/CT open opportunities to assess activity of valvular inflammation and calcification in vivo. The aim of this study was to assess prognostic value of valvular inflammation and calcification measured by 18F-FDG and 18F-NaF PET/CT in patients with tricuspid (TAV) and bicuspid aortic valve (BAV). Methods: The study included 71 patients aged 40-70 years with mild, moderate and severe asymptomatic calcific AS. Patients were divided into two groups according to valve morphology: with BAV and TAV. All patients underwent standard ECHO, CT calcium scoring PET/CT with 18F-NaF and 18F-FDG. All patients were evaluated during a follow-up visit with evaluation of ECHO parameters. (16.8 ± 4.2 months). Results: TAV and BAV groups were comparable in AS severity by ECHO (peak aortic jet velocity (Vmax): 2.90 [2.60; 3.50] vs. 2.96 [2.55; 3.31] m/s, p = 0.83). TBR max 18F-FDG did not vary in TAV and BAV patients (1.15 [1.06; 1.23] vs. 1.11 [1.03; 1.20], p = 0.39). Both groups did not differ in valvular calcification degree (Agatston score 1,058 [440; 1798] vs. 1,128 [533; 2,360], p = 0.55) and calcification activity assessed by 18F-NaF uptake level (TBR max 1.50 [1.30; 1.78] vs. 1.48 [1.27; 1.83], p = 0.97). 18F-NaF TBR max was associated with AS severity measured by Vmax in men and women with TAV (r = 0.54; p = 0.04 vs. r = 0.53; p = 0.03). In BAV group this relationship was true only in female patients (r = 0.1; p = 0.67 vs. r = 0.7; p = 0.0004). There was no association between Vmax and TBR max 18F-FDG was revealed in TAV and BAV groups. During follow-up period, the most important positive predictors of AS progression in TAV obtained by multinomial logistic regression analysis were Vmax, and 18F-NaF TBR. Whereas in BAV the highest predictive value showed model included age and Vmax. Conclusion: 18F-NaF PET/CT may be considered as the valuable predictor for hemodynamic progression of calcific AS in case of TAV. 18F-FDG PET/CT does not play a significant role to predict the AS progression.

Association of Carotid Intima-Media Thickness with Brain MRI Markers in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS)

OBJECTIVE

Elevated carotid intima-media thickness (cIMT) and carotid plaque are markers of arterial injury and may be linked to structural brain injury. We hypothesized cIMT or presence of carotid plaque at midlife are associated with presence of infarcts and cerebral microbleeds, greater white matter hyperintensity (WMH) volume, and smaller regional brain volumes in late-life.

METHODS

We included 1,795 Atherosclerosis Risk in Communities (ARIC) Study participants (aged 57±6 years, 57% female, 23% Black) with carotid ultrasounds in 1990-1992 and brain MRI scans in 2011-2013. Weighted linear regression was used for brain volume outcomes, while logistic regression was used for infarcts and cerebral microbleeds.

RESULTS

After multivariable adjustments, the highest cIMT quintile was associated with smaller deep gray matter (β [95% CI]: -0.11 [-0.22, -0.01]) and cortical volume in a temporal-parietal meta region of interest (ROI) (β [95% CI]: -0.10 [-0.20, -0.01]) in late-life. Similarly, those with carotid plaque had smaller regional brain volumes than those without (βs [95% CIs]: -0.05 [-0.12, 0.03] and -0.06 [-0.13, 0.01] for deep gray matter and temporal-parietal meta ROI). No significant relations were observed with WMH volume, infarcts, or cerebral microbleeds.

CONCLUSION

Over a median follow-up of 21 years, greater midlife cIMT and presence of carotid plaque were associated with smaller deep gray matter volume and cortical volume in a meta ROI involving temporal and parietal lobe regions typically involved in neurodegeneration, including Alzheimer's disease, in later life. Contrary to our hypothesis, associations between measures of arterial injury and markers of vascular brain injury were null.

Towards Personalized Therapy of Aortic Stenosis

Calcific aortic stenosis (CAS) is the most common cause of acquired valvular heart disease in adults with no available pharmacological treatment to inhibit the disease progression to date. This review provides an up-to-date overview of current knowledge of molecular mechanisms underlying CAS pathobiology and the related treatment pathways. Particular attention is paid to current randomized trials investigating medical treatment of CAS, including strategies based on lipid-lowering and antihypertensive therapies, phosphate and calcium metabolism, and novel therapeutic targets such as valvular oxidative stress, coagulation proteins, matrix metalloproteinases, and accumulation of advanced glycation end products.

Association of Carotid Intima-Media Thickness and Other Carotid Ultrasound Features With Incident Dementia in the ARIC-NCS

Background

Increased carotid intima‐media thickness, interadventitial diameter, presence of carotid plaque, and lower distensibility are predictors for cardiovascular disease. These indices likely relate to cerebrovascular disease, and thus may constitute a form of vascular contributions to dementia and Alzheimer disease–related dementia. Therefore, we assessed the relationship of carotid measurements and arterial stiffness with incident dementia in the ARIC (Atherosclerosis Risk in Communities) study.

Methods and Results

A total of 12 459 ARIC participants with carotid arterial ultrasounds in 1990 to 1992 were followed through 2017 for dementia. Dementia cases were identified using in‐person and phone cognitive status assessments, hospitalization discharge codes, and death certificate codes. Cox proportional hazards models were used to estimate the hazard ratios (HRs) for incident dementia. Participants were aged 57±6 at baseline, 57% were women, and 23% were Black individuals. Over a median follow‐up time of 24 years, 2224 dementia events were ascertained. After multivariable adjustments, the highest quintile of carotid intima‐media thickness and interadventitial diameter in midlife was associated with increased risk of dementia (HR [95% CIs], 1.25 [1.08–1.45]; and 1.22 [1.04–1.43], respectively) compared with its respective lowest quintile. Presence of carotid plaque did not have a significant association with dementia (HR [95% CI], 1.06 [0.97–1.15]). Higher distensibility was associated with lower risk of dementia (HR [95% CI] highest versus lowest quintile, 0.76 [0.63–0.91]).

Conclusions

Greater carotid intima‐media thickness, interadventitial diameter, and lower carotid distensibility are associated with an increased risk of incident dementia. These findings suggest that both atherosclerosis and carotid stiffness may be implicated in dementia risk.

Carotid Occlusion Accentuates Aortic Stenosis and Cardiac Remodeling With Preserved Systolic Function in LDL Receptor-Deficient Mice

Background: Carotid atherosclerotic disease is associated with aortic stenosis and reduced cardiac function. The causality between carotid and cardiac pathologies is unknown. We aim to explore the effects of carotid stenosis or occlusion on cardiac pathology and function.

Methods and Results: We produced carotid obstruction or stenosis in 36 atherogenic mice with 150- or 300-μm tandem surgery or sham surgery. The structure and function of the heart were assessed by histology and animal ultrasound. The 150-μm group had larger plaque burden and thicker valve leaflets in the aortic root than did the control group. Also, the two surgery groups had a thicker left ventricular posterior wall and smaller internal diameter compared with controls. Increased myocardial fibrosis was also found in the 150-μm group compared with controls, although the surgery groups had preserved systolic function compared with that of controls.

Conclusions: In a mouse model, carotid occlusion accentuated the formation of aortic stenosis and promoted ventricular remodeling without impairing systolic function. Carotid atherosclerotic plaque may be a pathogenic factor for aortic stenosis and ventricular remodeling.

Association between dietary fiber intake and risk of incident aortic stenosis

BACKGROUND AND AIMS

Although aortic stenosis is the most common valvular heart disease requiring intervention in Europe, the role that diet plays in development of the disease is largely unknown. The pathophysiology of aortic stenosis is however similar to other cardiovascular diseases that fiber intake has been associated with. The aim of this study was consequently to investigate the association between dietary fiber intake as well as the main food sources of fiber, i.e. fruit and vegetables and whole grains, and risk of incident aortic stenosis.

METHODS AND RESULTS

The Malmö Diet and Cancer Study is a Swedish prospective population-based cohort study with baseline data collection performed between year 1991-1996. Dietary habits were recorded through seven-day food diaries, 168-item diet questionnaires, and interviews, and data on incident aortic stenosis was collected through national registers. Among the 26,063 participants, 672 cases were ascertained during a mean follow-up period of 20 years. Cox regression was used to estimate the association between dietary intakes and incident aortic stenosis. No associations were found between incident aortic stenosis and intake of dietary fiber (HR for the highest vs lowest quintile: 0.93; 95% CI: 0.72-1.24), fruit and vegetables (HR: 0.98; 95% CI: 0.76-1.28), or whole grains (HR: 1.00; 95% CI: 0.79-1.26) in the main model.

CONCLUSION

The findings of this study do not indicate that consumption of dietary fiber or fiber rich foods are associated with incident aortic stenosis.

The relationship between famine exposure during early life and carotid plaque in adulthood

BACKGROUND

Famine exposure is a potential risk factor for adverse cardiometabolic health. However, the relationship between famine exposure during early life and carotid plaque in adulthood remains unclear. Therefore, the aim was to investigate the relationship between famine exposure during early life and the risks for carotid plaque in adulthood.

METHODS

This was a cross-sectional study. Data were collected between 2017 and 2018 in Guangdong, China. Subjects who were born between 1 October 1952 and 30 September 1964, and had the carotid ultrasound measurement were enrolled. All included participants were divided into five groups: no exposure, fetal exposure, early-childhood exposure, mid-childhood exposure, and late-childhood exposure. Carotid plaque was assessed by carotid ultrasound examination. Multivariate logistic regression was used to estimate the odds ratio (OR) and confidence interval (CI) between famine exposure and carotid plaque.

RESULTS

There were 2652 subjects enrolled, 973 (36.7%) of them were males, and the mean age was 59.1 ± 3.6 years. The prevalence of carotid plaque in unexposed, fetal-exposed, early-childhood, mid-childhood, and late-childhood exposed groups were 40.2%, 40.8%, 55.3%, 56.8%, and 62.1%, respectively. When compared with the unexposed group, the fully adjusted ORs for carotid plaque from fetal-exposed, early-childhood, mid-childhood to late-childhood exposed were 1.023 (95% CI: 0.771, 1.357, P = 0.872), 1.755 (95% CI: 1.356, 2.275, P < 0.001), 1.780 (95% CI: 1.391, 2.280, P < 0.001), and 2.119 (95% CI: 1.643, 2.739, P < 0.001), respectively. Subgroup analyses showed that the famine effect on carotid plaque did not interact with body mass index, gender, smoking status, hypertension, and diabetes history (all P for interaction > 0.500).

CONCLUSIONS

Famine exposure during early life was significantly associated with an increased risk of carotid plaque in adulthood.

Genetic predisposition to smoking in relation to 14 cardiovascular diseases

AIMS

The aim of this study was to use Mendelian randomization (MR) to determine the causality of the association between smoking and 14 different cardiovascular diseases (CVDs).

METHODS AND RESULTS

Our primary genetic instrument comprised 361 single-nucleotide polymorphisms (SNPs) associated with smoking initiation (ever smoked regularly) at genome-wide significance. Data on the associations between the SNPs and 14 CVDs were obtained from the UK Biobank study (N = 367 643 individuals), CARDIoGRAMplusC4D consortium (N = 184 305 individuals), Atrial Fibrillation Consortium (2017 dataset; N = 154 432 individuals), and Million Veteran Program (MVP; N = 190 266 individuals). The main analyses were conducted using the random-effects inverse-variance weighted method and complemented with multivariable MR analyses and the weighted median and MR-Egger approaches. Genetic predisposition to smoking initiation was most strongly and consistently associated with higher odds of coronary artery disease, heart failure, abdominal aortic aneurysm, ischaemic stroke, transient ischaemic attack, peripheral arterial disease, and arterial hypertension. Genetic predisposition to smoking initiation was additionally associated with higher odds of deep vein thrombosis and pulmonary embolism in the UK Biobank but not with venous thromboembolism in the MVP. There was limited evidence of causal associations of smoking initiation with atrial fibrillation, aortic valve stenosis, thoracic aortic aneurysm, and intracerebral and subarachnoid haemorrhage.

CONCLUSION

This MR study supports a causal association between smoking and a broad range of CVDs, in particular, coronary artery disease, heart failure, abdominal aortic aneurysm, ischaemic stroke, transient ischaemic attack, peripheral arterial disease, and arterial hypertension.

Body mass index and body composition in relation to 14 cardiovascular conditions in UK Biobank: a Mendelian randomization study

AIMS

The causal role of adiposity for several cardiovascular diseases (CVDs) is unclear. Our primary aim was to apply the Mendelian randomization design to investigate the associations of body mass index (BMI) with 13 CVDs and arterial hypertension. We also assessed the roles of fat mass and fat-free mass on the same outcomes.

METHODS AND RESULTS

Single-nucleotide polymorphisms associated with BMI and fat mass and fat-free mass indices were used as instrumental variables to estimate the associations with the cardiovascular conditions among 367 703 UK Biobank participants. After correcting for multiple testing, genetically predicted BMI was significantly positively associated with eight outcomes, including and with decreasing magnitude of association: aortic valve stenosis, heart failure, deep vein thrombosis, arterial hypertension, peripheral artery disease, coronary artery disease, atrial fibrillation, and pulmonary embolism. The odds ratio (OR) per 1 kg/m2 increase in BMI ranged from 1.06 [95% confidence interval (CI) 1.02-1.11; P = 2.6 × 10-3] for pulmonary embolism to 1.13 (95% CI 1.05-1.21; P = 1.2 × 10-3) for aortic valve stenosis. There was suggestive evidence of positive associations of genetically predicted fat mass index with nine outcomes (P < 0.05). The strongest magnitude of association was with aortic valve stenosis (OR per 1 kg/m2 increase in fat mass index 1.46, 95% CI 1.13-1.88; P = 3.9 × 10-3). There was suggestive evidence of inverse associations of fat-free mass index with atrial fibrillation, ischaemic stroke, and abdominal aortic aneurysm.

CONCLUSION

This study provides evidence that higher BMI and particularly fat mass index are associated with increased risk of aortic valve stenosis and most other cardiovascular conditions.

Aortic stenosis and diabetes mellitus: An ominous combination

Aortic stenosis and diabetes mellitus are both progressive diseases which, if left untreated, result in significant morbidity and mortality. There is evidence that the prevalence of diabetes is substantially increased in patients with aortic stenosis and those with diabetes have increased rates of progression from mild to severe aortic stenosis. There are good data supporting the hypothesis that aortic stenosis and diabetes mellitus are associated with diabetes mellitus being detrimental towards the quality of life and survival of patients. Thus, a thorough understanding of the pathogenesis of both of these disease processes and the relationship between them aids in designing appropriate preventive and therapeutic approaches. This review aims to give a comprehensive and up-to-date insight into the influence of diabetes mellitus on patients with degenerative aortic stenosis, as well as the prognosis and therapeutic approach to these patients.

Coffee consumption and risk of aortic valve stenosis: A prospective study

BACKGROUND AND AIMS

Coffee contains many biologically active compounds with potential adverse or beneficial effects on the cardiovascular system. Whether coffee consumption is associated with the risk of aortic valve stenosis (AVS) is unknown. The purpose of this study was therefore to examine the association between coffee consumption and AVS incidence.

METHODS AND RESULTS

This prospective study included 71 178 men and women who provided information on their coffee consumption through a questionnaire at baseline. Incident cases of AVS were identified through linkage with the Swedish National Patient and Cause of Death Registers. During a mean follow-up of 15.2 years, 1295 participants (777 men and 518 women) were diagnosed with AVS. Coffee consumption was positively associated with risk of AVS in a dose-response manner after adjustment for age, sex, smoking, and other risk factors (P-trend = 0.005). The multivariable hazard ratios were was 1.11 (95% confidence interval 1.04-1.19) per 2 cups/day increase of coffee consumption and 1.65 (95% confidence interval 1.10-2.48) when comparing the highest (≥6 cups/day) with the lowest (<0.5 cup/day) category of coffee consumption. The association was not modified by other risk factors.

CONCLUSIONS

This study provides novel evidence that high coffee consumption is associated with an increased risk of AVS.

Familial Aggregation of Aortic Valvular Stenosis: A Nationwide Study of Sibling Risk

BACKGROUND

Aortic valvular stenosis (AS) is the most common cause of cardiac valvular replacement surgery. During the last century, the pathogenesis of AS has undergone transitions in developed countries, from rheumatic heart disease to a degenerative calcific pathogenesis. Although a familial component has been described for a subset of cases with a bicuspid valve, data are limited on the overall familial aggregation of this disease.

METHODS AND RESULTS

Contemporary information on 6 117 263 Swedish siblings, of which 13 442 had a clinical diagnosis of AS, was collected from the nationwide Swedish Multi-Generation Register and the National Patient Register. A total of 4.8% of AS cases had a sibling history of AS. Having at least 1 sibling with AS was associated with a hazard ratio of 3.41 (95% confidence interval, 2.23-5.21) to be diagnosed with AS in an adjusted model. Individuals with >1 sibling with AS had an exceptionally high risk (hazard ratio, 32.84) but were uncommon (34 siblings from 11 sibships). In contrast, spouses of subjects with AS were only slightly more likely to be diagnosed with AS compared with subjects without spousal AS (hazard ratio 1.16 for husbands and 1.18 for wives).

CONCLUSIONS

A sibling history of clinically diagnosed AS was associated with increased risk of AS. Spouses of patients with AS only had a modest risk increase, suggesting that shared adult environmental factors contribute less to the development of AS than genetic factors.

Overall and abdominal obesity and incident aortic valve stenosis: two prospective cohort studies

Aims

The aim of this study was to examine the association of overall and abdominal obesity with aortic valve stenosis (AVS) incidence in two prospective cohorts.

Methods and results

We used data from the Cohort of Swedish Men and the Swedish Mammography Cohort, involving 71 817 men and women who were free of cardiovascular disease and had reported their anthropometric measures in 1997. Aortic valve stenosis cases were ascertained through linkage with nationwide registers on hospitalization and causes of death. Data were analysed using Cox proportional hazards regression. During a mean follow-up of 15.3 years, 1297 incident AVS cases (771 in men; 526 in women) were ascertained. Both overall and abdominal obesity, measured as body mass index (BMI) and waist circumference, respectively, was associated with AVS incidence, with similar associations in men and women. Compared with BMI 18.5–22.5 kg/m², the multivariable hazard ratios were 1.24 (95% confidence interval [CI] 1.05–1.48) for overweight (BMI 25.0–29.9 kg/m²) and 1.81 (95% CI 1.47–2.23) for obesity (BMI ≥30 kg/m²). The hazard ratio for substantially increased waist circumference (men: ≥102 cm; women: ≥88 cm) compared with normal waist circumference (men: <94 cm; women: <80 cm) was 1.30 (95% CI 1.12–1.51). The proportion of AVS cases estimated to be attributed to overweight and obesity combined (BMI ≥25 kg/m²) was 10.8% (95% CI 5.2–16.4%).

Conclusion

These findings indicate that obesity is associated with an increased risk of AVS and that a large proportion of the cases may be prevented if the population maintained a healthy BMI.

Type 1 and type 2 diabetes mellitus and incidence of seven cardiovascular diseases

BACKGROUND

The association between type 1 diabetes mellitus (T1DM) and specific cardiovascular diseases (CVD) is uncertain. Furthermore, data on type 2 diabetes mellitus (T2DM) in relation to risk of aortic valve stenosis, atrial fibrillation, abdominal aortic aneurysm, and intracerebral hemorrhage are scarce and inconclusive. We examined the associations of T1DM and T2DM with incidence of seven CVD outcomes.

METHODS

This study comprised 71,483 Swedish adults from two population-based prospective cohorts. T1DM and T2DM diagnosis and incident CVD cases were ascertained through linkage with the population-based registers.

RESULTS

T1DM was associated with myocardial infarction (hazard ratio [HR] 3.26; 95% confidence interval [CI] 2.47-4.30), heart failure (HR 2.68; 95% CI 1.76-4.09), and ischemic stroke (HR 2.61; 95% CI 1.80-3.79). Increased risk of myocardial infarction, ischemic stroke, and heart failure was also observed in T2DM patients and the magnitude of the associations increased with longer T2DM duration. T2DM was also associated with an increased risk of aortic valve stenosis (HR 1.34; 95% CI 1.05-1.71) and with lower risk of abdominal aortic aneurysm (HR 0.57; 95% CI 0.40-0.82) and intracerebral hemorrhage (HR 0.51; 95% CI 0.30-0.88). Only long-term T2DM (≥20 years) was associated with an increased risk of atrial fibrillation (HR 1.44; 95% CI 1.02-2.04).

CONCLUSION

T1DM and T2DM are associated with increased risk of major CVD outcomes.

TRIAL REGISTRATION

The Cohort of Swedish Men and the Swedish Mammography Cohort are registered at clinicaltrials.gov as NCT01127711 and NCT01127698, respectively.

Subclinical Atherosclerosis Among Young and Middle-Aged Adults Using Carotid Intima-Media Thickness Measurements

OBJECTIVES

The presence of atherosclerotic plaque in the carotid arteries is a strong predictor of cardiovascular disease (CVD). Research and data on CVD risk have been derived primarily from individuals aged 55 years or older, and assessment of CVD risk among young and middle-aged adults seldom has been studied. The use of ultrasonography to measure carotid intima-media thickness (IMT) and carotid plaque appears to have utility to detect subclinical atherosclerosis in asymptomatic adults. This study evaluated the presence of carotid plaque using ultrasonography among healthy young and middle-aged adults.

METHODS

Participants were men and women recruited in Miami, Florida, and were 18 to 50 years old with no history of CVD. Participants underwent a general physical examination and carotid artery ultrasonography to evaluate carotid IMT and carotid plaque.

RESULTS

From a total of 173 participants with a mean age of 34 years (standard deviation 8.9), 21.0% (95% confidence interval [CI] 15.0-27.2) were identified as having carotid plaque. IMT values ranged from 0.49 to 1.03 mm, with a mean value of 0.70 mm (standard deviation 0.09). In multivariable logistic regression older age (adjusted odds ratio [AOR] 1.08, 95% CI 1.01-1.16, P = 0.024) and cigarette smoking (AOR 2.67, 95% CI 1.02-7.00, P = 0.045) were associated with plaque, after controlling for IMT (AOR 2.55, 95% CI 1.40-4.65, P = 0.002).

CONCLUSIONS

Traditional CVD risk factors such as those evaluated in this study may fail to provide adequate predictive value of carotid atherosclerosis in younger populations with no history of CVD, because the majority of traditional risk factors identified in previous research were not associated with carotid plaque in this young sample. Further research assessing nontraditional risk factors among asymptomatic individuals is required, and the evaluation of IMT as an intervention tool to detect CVD risk in these asymptomatic populations is warranted.

Alcohol consumption, cigarette smoking and incidence of aortic valve stenosis

BACKGROUND

Alcohol consumption and cigarette smoking are modifiable lifestyle factors with important impact on public health. It is unclear whether these factors influence the risk of aortic valve stenosis (AVS).

OBJECTIVE

To investigate the associations of alcohol consumption and smoking, including smoking intensity and time since cessation, with AVS incidence in two prospective cohorts.

METHODS

This analysis was based on data from the Swedish Mammography Cohort and the Cohort of Swedish Men, comprising 69 365 adults without cardiovascular disease at baseline. Participants were followed for AVS incidence and death by linkage to the Swedish National Patient and Causes of Death Registers. Hazard ratios (HR) with 95% confidence intervals (CI) were estimated by Cox proportional hazards regression.

RESULTS

Over a mean follow-up of 15.3 years, 1249 cases of AVS (494 in women and 755 in men) were recorded. Compared with never drinkers of alcohol (lifelong abstainers), the risk of AVS was significantly lower in current light drinkers (1-6 drinks per week [1 drink = 12 g alcohol]; multivariable HR 0.82; 95% CI: 0.68-0.99). The risk of AVS increased with increasing smoking intensity. Compared with never smokers, the HR was 1.46 (95% CI: 1.16-1.85) in current smokers of ≥30 pack-years. Former smokers who had quit smoking 10 or more years previously had similar risk for AVS as never smokers.

CONCLUSIONS

This study suggests that current light alcohol consumption is associated with a lower risk of AVS, and indicates that the association between smoking and AVS risk is reversible.

Is the use of renin-angiotensin system inhibitors in patients with aortic valve stenosis safe and of prognostic benefit? A systematic review and meta-analysis

Aortic valve stenosis (AVS) is associated with significant morbidity and mortality, especially in the presence of symptoms and echocardiographic signs of left ventricular remodelling (i.e. increase in left ventricular mass, left ventricular dilation, and systolic dysfunction). Renin-angiotensin system inhibitors (RASi) attenuate cardiac remodelling in various conditions, but the safety and efficacy of RASi in AVS is unsure. We performed a systematic review and meta-analysis to address these issues. We identified three smaller randomized clinical trials and five observational studies eligible for inclusion (PubMed, EMBASE, and Cochrane library search criteria: aortic stenosis, aortic valve, angiotensin-converting enzyme inhibitor in different combinations, published in English at any time up to 1 April 2016). Our analyses suggested that use of RASi was safe, with no observed increase in mortality risk [576/3389 patients receiving RASi vs. 1118/4384 controls died; relative risk 0.93 (95% confidence interval 0.78-1.11), P = 0.44]. Use of RASi was also observed to lower the risk of aortic valve replacement (AVR) surgery [67/2913 patients with RASi vs. 154/3666 controls underwent AVR; relative risk 0.68 (95% confidence interval 0.51-0.91), P = 0.01]. In current clinical practice (based on published literature; mainly observational studies), use of RASi appears to be safe in patients with AVS and may reduce the need for AVR, but the evidence is overall weak. Large-scale randomized clinical trials are warranted to address whether prescription of RASi to treatment-naïve patients may prevent disease progression, delay AVR surgery need, and lower the risk of mortality.

Relationship of Vascular Factors on Electrophysiologic Severity of Diabetic Neuropathy

OBJECTIVE

To investigate the impact of vascular factors on the electrophysiologic severity of diabetic neuropathy (DPN).

METHODS

Total 530 patients with type 2 diabetes were enrolled retrospectively. We rated severity of DPN from 1 (normal) to 4 (severe) based on electrophysiologic findings. We collected the data concerning vascular factors (including brachial-ankle pulse wave velocity [PWV], ankle brachial index, ultrasound of carotid artery, lipid profile from the blood test, and microalbuminuria [MU] within 24 hours urine), and metabolic factors of diabetes (such as glycated hemoglobin [HbA1c]). We analyzed the differences among the four subgroups using χ(2) test and ANOVA, and ordinal logistic regression analysis was performed to investigate the relationship between significant variables and severity of DPN.

RESULTS

The severity of DPN was significantly associated with duration of diabetes, HbA1c, existence of diabetic retinopathy and nephropathy, PWV, presence of plaque, low density lipoprotein-cholesterol and MU (p<0.05). Among these variables, HbA1c and presence of plaque were more significantly related with severity of DPN in logistic regression analysis (p<0.001), and presence of plaque showed the highest odds ratio (OR=2.52).

CONCLUSION

Our results suggest that markers for vascular wall properties, such as PWV and presence of plaque, are significantly associated with the severity of DPN. The presence of plaque was more strongly associated with the severity of DPN than other variables.

Genome-wide association studies of late-onset cardiovascular disease

Human genetics is a powerful tool for discovering causal mediators of human disease and physiology. Cardiovascular diseases with late onset in the lifecourse have historically not been considered genetic diseases, but in recent years the contribution of a heritable factor has been established. More importantly, over the last decade genome-wide association studies (GWASs) have identified many loci associated with late-onset cardiovascular diseases including coronary artery disease, carotid artery disease, ischemic stroke, aortic aneurysm, peripheral vascular disease, atrial fibrillation, valvular disease and correlates of vascular and myocardial function. Here we review findings from GWASs considered statistically robust with regard to multiple testing (p<5×10(-8)) for late-onset cardiovascular diseases and traits. Although for only a handful of the 92 genetic loci described here have the mechanisms underlying disease association been established, new and previously unsuspected pathways have been implicated for several conditions. Examples include a role for NO signaling in myocardial repolarization and sudden cardiac death and a role for the protein sortilin in lipid metabolism and coronary artery disease. Genetic loci with multiple trait associations have also provided novel biological insights. For example, of the 46 genetic loci associated with coronary artery disease, only 16 are also associated with conventional risk factors for cardiovascular disease whereas the remaining two thirds may reflect novel pathways. Much work remains to functionally characterize genetic loci and for clinical utility, but accruing insights into the biological basis of cardiovascular aging in human populations promise to point to novel therapeutic and preventive strategies. This article is part of a Special Issue entitled 'SI:CV Aging'.

Blood coagulation and fibrinolysis in aortic valve stenosis: links with inflammation and calcification

Aortic valve stenosis (AS) increasingly afflicts our aging population. However, the pathobiology of the disease is still poorly understood and there is no effective pharmacotherapy for treating those at risk for clinical progression. The progression of AS involves complex inflammatory and fibroproliferative processes that resemble to some extent atherosclerosis. Accumulating evidence indicates that several coagulation proteins and its inhibitors, including tissue factor, tissue factor pathway inhibitor, prothrombin, factor XIII, von Willebrand factor, display increased expression within aortic stenotic valves, predominantly on macrophages and myofibroblasts around calcified areas. Systemic impaired fibrinolysis, along with increased plasma and valvular expression of plasminogen activator inhibitor-1, has also been observed in patients with AS in association with the severity of the disease. There is an extensive cross-talk between inflammation and coagulation in stenotic valve tissue which contributes to the calcification and mineralisation of the aortic valve leaflets. This review summarises the available data on blood coagulation and fibrinolysis in AS with the emphasis on their interactions with inflammation and calcification.

Raman microspectroscopy of human aortic valves: investigation of the local and global biochemical changes associated with calcification in aortic stenosis

Raman microspectroscopy was applied to characterize the local and global biochemical changes associated with calcification in human stenotic aortic valves.