Hyperuricemia and incident heart failure

Mechanism and use strategy of uric acid-lowering drugs on coronary heart disease

Coronary heart disease (CHD) is a serious cardiovascular illness, for which an elevated uric acid (UA) level presents as a considerable risk factor. This can be treated with UA-lowering drugs such as allopurinol and benzbromarone, which can reduce UA levels by the inhibition of UA production or by promoting its excretion. Such drugs can also be beneficial to CHD in other ways, such as reducing the degree of coronary arteriosclerosis, improving myocardial blood supply and alleviating ventricular remodeling. Different UA-lowering drugs are used in different ways: allopurinol is preferred as a single agent in clinical application, but in absence of the desired response, a combination of drugs such as benzbromarone with ACE inhibitors may be used. Patients must be monitored regularly to adjust the medication regimen. Appropriate use of UA-lowering drugs has great significance for the prevention and treatment of CHD. However, the specific mechanisms of the drugs and individualized drug use need further research. This review article expounds the mechanisms of UA-lowering drugs on CHD and their clinical application strategy, thereby providing a reference for further optimization of treatment.

Large-scale cross-ancestry genome-wide meta-analysis of serum urate

Hyperuricemia is an essential causal risk factor for gout and is associated with cardiometabolic diseases. Given the limited contribution of East Asian ancestry to genome-wide association studies of serum urate, the genetic architecture of serum urate requires exploration. A large-scale cross-ancestry genome-wide association meta-analysis of 1,029,323 individuals and ancestry-specific meta-analysis identifies a total of 351 loci, including 17 previously unreported loci. The genetic architecture of serum urate control is similar between European and East Asian populations. A transcriptome-wide association study, enrichment analysis, and colocalization analysis in relevant tissues identify candidate serum urate-associated genes, including CTBP1, SKIV2L, and WWP2. A phenome-wide association study using polygenic risk scores identifies serum urate-correlated diseases including heart failure and hypertension. Mendelian randomization and mediation analyses show that serum urate-associated genes might have a causal relationship with serum urate-correlated diseases via mediation effects. This study elucidates our understanding of the genetic architecture of serum urate control.

A Ten-Year Follow-Up Study of the Association Between Uric Acid and Adverse Cardiovascular Events in Patients With Coronary Artery Disease

The association between uric acid (UA) and long-term mortality in patients with coronary artery disease is poorly investigated. We assessed the association between UA and 10-year mortality after percutaneous coronary intervention (PCI) in 3,998 patients who underwent PCI. Patients were categorized in groups according to UA tertiles: tertile 1 (UA <5.80 mg/100 ml, n = 1,347), tertile 2 (UA 5.80 to 7.04 mg/100 ml, n = 1,340), and tertile 3 (UA >7.94 mg/100 ml, n = 1,311). The primary outcome was 10-year all-cause mortality. All-cause deaths occurred in 1,200 patients: 320 deaths (26.5%) in patients with UA in the first tertile, 325 deaths (26.9%) in patients with UA in the second tertile, and 555 deaths (46.0%) in patients with UA in the third tertile (adjusted hazard ratio 1.22, 95% confidence interval 1.17 to 1.27, p <0.001) for 1 mg/100 ml increment in UA level. Cardiac deaths occurred in 748 patients: 194 deaths (16.5%) in patients with UA in the first tertile, 202 deaths (17.0%) in patients with UA in the second tertile, and 352 deaths (29.7%) in patients with UA in the third tertile (adjusted hazard ratio 1.24 [1.17 to 1.32], p <0.001) for 1 mg/100 ml increment in the UA level. The 10-year rates of target lesion revascularization, target vessel revascularization, or nontarget vessel revascularization did not differ significantly according to the UA level. In conclusion, in patients with coronary artery disease treated with PCI, increased UA level was associated with higher 10-year mortality. Increased UA level was not associated with the progression of atherosclerosis in nontreated coronary vessels or progression of intimal hyperplasia in stented lesions requiring intervention.

Uric acid in health and disease: From physiological functions to pathogenic mechanisms

Owing to renal reabsorption and the loss of uricase activity, uric acid (UA) is strictly maintained at a higher physiological level in humans than in other mammals, which provides a survival advantage during evolution but increases susceptibility to certain diseases such as gout. Although monosodium urate (MSU) crystal precipitation has been detected in different tissues of patients as a trigger for disease, the pathological role of soluble UA remains controversial due to the lack of causality in the clinical setting. Abnormal elevation or reduction of UA levels has been linked to some of pathological status, also known as U-shaped association, implying that the physiological levels of UA regulated by multiple enzymes and transporters are crucial for the maintenance of health. In addition, the protective potential of UA has also been proposed in aging and some diseases. Therefore, the role of UA as a double-edged sword in humans is determined by its physiological or non-physiological levels. In this review, we summarize biosynthesis, membrane transport, and physiological functions of UA. Then, we discuss the pathological involvement of hyperuricemia and hypouricemia as well as the underlying mechanisms by which UA at abnormal levels regulates the onset and progression of diseases. Finally, pharmacological strategies for urate-lowering therapy (ULT) are introduced, and current challenges in UA study and future perspectives are also described.

Uric acid is a biomarker for heart failure, but not therapeutic target: result from a comprehensive meta-analysis

AIMS

This systematic review and meta-analysis aimed to investigate the association between serum uric acid (SUA) levels and the incidence rate and prognosis of heart failure (HF), as well as the impact of uric acid-lowering treatment on HF patients.

METHODS AND RESULTS

PubMed and Embase were searched for original articles reporting on the association between SUA and HF incidence, adverse outcomes, and the effect of uric acid-lowering treatment in HF patients. Data were pooled using random effects or fixed effects models. Univariable meta-regression analysis assessed the influence of study characteristics on research outcomes. Statistical analyses were conducted using RevMan software and STATA software version 15.0. Eleven studies on HF incidence and 24 studies on adverse outcomes in HF patients were included. Higher SUA levels were associated with an increased risk of HF (RR: 1.81, 95% CI: 1.53-2.16), all-cause mortality (RR: 1.44, 95% CI: 1.25-1.66), cardiac death (RR: 1.56, 95% CI: 1.32-1.84), and HF rehospitalization (RR: 2.07, 95% CI: 1.37-3.13) in HF patients. Uric acid-lowering treatment was found to increase all-cause mortality in HF patients (RR: 1.15, 95% CI: 1.05-1.25).

CONCLUSIONS

Uric acid is an independent predictor of heart failure occurrence and adverse prognosis. Targeting uric acid lowering as a therapeutic intervention does not improve the prognosis of patients with heart failure. It may not be advisable to use traditional urate-lowering drugs in young patients with heart failure, and elderly patients should exercise caution when using them.

Hyperuricemia and Its Association With the Severity and Complications of Congestive Heart Failure: A Systematic Review

Several studies have shown that an association exists between hyperuricemia and heart failure. Despite several innovative management strategies, heart failure is a significant cause of mortality worldwide. Hyperuricemia in heart failure patients leads to poorer outcomes. Additionally, hyperuricemia can be a strong surrogate marker for increased oxidative stress in heart failure patients. This oxidative stress leads to vascular endothelial damage and is linked to worsening heart failure and subsequent mortality. Hence, the measurement of serum uric acid levels in these patients can predict the present and future risk of complications of heart failure. Despite this knowledge, serum uric acid levels are not usually followed up in heart failure patients. This systematic review aims to give additional clarity to this association. We used research from the last twenty years (2002 to 2022) obtained from databases such as PubMed, PubMed Central (PMC), Google Scholar, and Science Direct. We used the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 guidelines. We removed duplicates, screened articles on the basis of title and abstract, applied eligibility criteria, and performed quality appraisal. Eventually, 15 articles were selected for review. There were 12 observational studies, two randomized controlled trials, and one meta-analysis. Our review showed that serum uric acid elevation is associated with the severity and complications of congestive heart failure. Serum uric acid can serve as a useful surrogate marker of oxidative stress in congestive heart failure (CHF) patients. The role of xanthine oxidase inhibitors needs to be evaluated further in CHF patients.

Serum uric acid and left ventricular mass index independently predict cardiovascular mortality: The uric acid right for heart health (URRAH) project

A relationship between serum uric acid (SUA) and cardiovascular (CV) events has been documented in the Uric Acid Right for Heart Health (URRAH) study.

AIM

of this study was to investigate the association between SUA and left ventricular mass index (LVMI) and whether SUA and LVMI or their combination may predict the incidence of CV death.

METHODS

Subjects with echocardiographic measurement of LVMI included in the URRAH study (n=10733) were part of this analysis. LV hypertrophy (LVH) was defined as LVMI > 95 g/m2 in women and 115 g/m2 in men.

RESULTS

A significant association between SUA and LVMI was observed in multiple regression analysis in men: beta 0,095, F 5.47, P< 0.001 and women: beta 0,069, F 4.36, P<0.001. During follow-up 319 CV deaths occurred. Kaplan-Meier curves showed a significantly poorer survival rate in subjects with higher SUA (> 5.6 mg/dl in men and 5.1 mg/dl in women) and LVH (log-rank chi-square 298.105; P<0.0001). At multivariate Cox regression analysis in women LVH alone and the combination of higher SUA and LVH but not hyperuricemia alone, were associated with a higher risk of CV death, while in men hyperuricemia without LVH, LVH without hyperuricemia and their combination were all associated with a higher incidence of CV death.

CONCLUSIONS

Our findings demonstrate that SUA is independently associated with LVMI and suggest that the combination of hyperuricemia with LVH is an independent and powerful predictor for CV death both in men and women.

Hyperuricemia and gout increased the risk of long-term mortality in patients with heart failure: insights from the National Health and Nutrition Examination Survey

BACKGROUND

The prevalence of hyperuricemia, gout, and heart failure (HF) is on the rise, and these conditions often share similar risk factors. The present study aimed to evaluate the relationship among hyperuricemia, gout, HF, and all-cause mortality.

METHODS

The data on nonpregnant participants aged ≥ 20 years with or without hyperuricemia, gout, and HF from the National Health and Nutrition Examination Survey 2001-2018 and 2007-2018 were included in this study. The binary logistic regression, Kaplan-Meier curve, Cox proportional-hazards model, and restricted cubic spline analysis were employed to evaluate the relationship among hyperuricemia, gout, HF, and all-cause mortality.

RESULTS

Of 204,179,060 and 223,702,171 weighted eligible participants, 40,044,228 (19.6%) and 9,158,600 (4.1%) had hyperuricemia and gout, respectively. Older age, diabetes, stroke, and coronary artery disease were the risk factors for HF among patients with hyperuricemia and gout. The median survival time was 7.00 years and 6.25 years and the 5-year survival rate was 59.9% and 55.9% for patients with HF and hyperuricemia and those with HF and gout, respectively. Patients with hyperuricemia or gout were 2.46 and 2.35 times more likely to have HF and 1.37 and 1.45 times more likely to experience all-cause mortality compared with those who did not exhibit these conditions. The restricted cubic spline showed a nonlinear correlation between uric acid levels and HF and a J-shaped correlation between uric acid levels and all-cause mortality.

CONCLUSIONS

Ambulatory patients with hyperuricemia or gout were more likely to have HF compared with those without hyperuricemia or gout. Patients with HF with hyperuricemia or gout were more likely to experience all-cause mortality in the long-term follow-up.

Update in uric acid, hypertension, and cardiovascular diseases

A direct relationship between serum uric acid levels and hypertension, cardiovascular, renal and metabolic diseases has been reported in many basic and epidemiological studies. Among these, high blood pression is one of the most common features associated with hyperuricemia. In this regard, several small-scale interventional studies have demonstrated a significant reduction in blood pressure in hypertensive or prehypertensive patients on uric acid-lowering drugs. These observation or intervention studies have led to affirm that there is a causal relationship between uric acid and hypertension. While the clinical association between uric acid and high blood pressure is notable, no clear conclusion has yet been reached as to whether lowering uric acid is beneficial to prevent cardiovascular and renal metabolic diseases. Recently, several prospective randomized controlled intervention trials using allopurinol and other uric acid-lowering drugs have been reported, and the results from these trials were almost negative, suggesting that the correlation between hyperuricemia and cardiovascular disease has no causality. However, it is important to note that in some of these recent studies there were high dropout rates and an important fraction of participants were not hyperuricemic. Therefore, we should carry caution in interpreting the results of these studies. This review article presents the results of recent clinical trials using uric acid-lowering drugs, focusing on hypertension and cardiovascular and renal metabolic diseases, and discusses the future of uric acid therapy.

Comparative Safety of Gout Treatment Strategies on Cardiovascular Outcomes Using Observational Data: Clone-censor-weight Target Trial Emulation Approach

BACKGROUND

We sought to examine the cardiovascular safety of intensive treat-to-target serum urate strategies for gout using Medicare claims data linked to electronic health record laboratory data.

METHODS

We selected patients with gout who initiated urate-lowering therapy. We emulated a hypothetical trial comparing the rate of major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death) among seven different strategies over 24 months. Three aspects were considered in defining increasingly intensive strategies: (1) continuation of urate-lowering therapy, (2) serum urate monitoring, and (3) modification of urate-lowering therapy when serum urate >6 mg/dl. We applied the "clone-censor-weight" method to account for baseline and time-varying confounding.

RESULTS

We identified 4402 patients with gout who initiated urate-lowering therapy (mean age 77; male 60%). During a total of 6611 person-years (PY) of follow-up under usual care, the rate of major cardiovascular events (first and recurrent) was 4.5/100 PY (95% CI = 4.0, 5.1). The rate ratios (RRs) suggested reductions (RR point estimates 0.88-0.84) compared with usual care. All 95% CIs were imprecise, but their upper bounds excluded substantial increase in RRs. RRs were closer to 1.0 for the analysis focusing on the first major adverse cardiovascular event during follow-up and on comparison to the strategy requiring continuation of urate-lowering therapy (but not necessarily titration).

CONCLUSIONS

Our treatment strategy trial emulation did not find increased risk of major adverse cardiovascular events with intensive urate-lowering strategies. Results may provide reassurance of the cardiovascular safety of intensive treat-to-target serum urate strategies recommended by rheumatology societies.

Novel Oxidative Stress Biomarkers with Risk Prognosis Values in Heart Failure

Oxidative stress (OS) is mediated by reactive oxygen species (ROS), which in cardiovascular and other disease states, damage DNA, lipids, proteins, other cellular and extra-cellular components. OS is both initiated by, and triggers inflammation, cardiomyocyte apoptosis, matrix remodeling, myocardial fibrosis, and neurohumoral activation. These have been linked to the development of heart failure (HF). Circulating biomarkers generated by OS offer potential utility in patient management and therapeutic targeting. Novel OS-related biomarkers such as NADPH oxidases (sNox2-dp, Nrf2), advanced glycation end-products (AGE), and myeloperoxidase (MPO), are signaling molecules reflecting pathobiological changes in HF. This review aims to evaluate current OS-related biomarkers and their associations with clinical outcomes and to highlight those with greatest promise in diagnosis, risk stratification and therapeutic targeting in HF.

Association between serum uric acid levels and the prevalence of heart failure due to acute coronary syndrome in Chinese hospitalized patients: A cross-sectional study

BACKGROUND AND AIMS

Serum uric acid (SUA) may play a role in heart failure (HF). Our study was to find relationships between SUA and the prevalence of HF due to acute coronary syndrome (ACS), and the ethnic-specific relationship between them in an inpatient population.

METHODS AND RESULTS

We analyzed 1075 Chinese ACS patients. SUA levels were cut to four groups as Q1 to Q4, according to quartiles. Binary logistic regression models were used to assess associations of SUA with HF due to ACS. Subgroup analysis was performed to find ethnic-specific association between SUA and HF due to ACS. We also performed univariate and multivariate logistic regression analyses taking into account an Italian's cut-off for SUA for HF prognosis stratification. After adjustment for all potential confounders, compared to the lowest quartile, quartiles 2, 3 and 4 had a prevalence OR of 0.69 (0.44-1.08), 1.06 (0.67-1.67) and 2.19 (1.35-3.56), respectively, for the HF due to ACS (p for trend <0.001). Subgroup analyses didn't reveal an ethnic-specific differences between SUA and HF due to ACS. In Han, the highest SUA level was significantly associated with the risk of HF due to ACS. OR with 95%CI for Q4 was 1.85 (1.02-3.37), Q1 as a reference. For Mongolians, the OR with 95%CI for Q4 was 6.82 (1.90-24.50), Q1 as a reference.

CONCLUSION

We found positive associations between SUA and the prevalence of HF due to ACS among Chinese patients. No differences exist regarding ethnicity.

Global status and trends in gout research from 2012 to 2021: a bibliometric and visual analysis

BACKGROUND

Gout is the most common inflammatory arthritis with an increasing prevalence and incidence across the globe. We aimed to provide a comprehensive and systematic knowledge map of gout research to determine its current status and trends over the past decade.

METHODS

Publications on gout research were obtained from the Web of Science Core Collection (WOSCC) database. Bibliometric R, VOSviewer, and Citespace were employed to analyze the eligible literature.

RESULTS

A total of 5535 publications concerning gout research between 2012 and 2021 were included. Most publications and citations both numerically came from China. The strongest international cooperation belonged to the USA. The University of Auckland was the most productive institution with a leading place in research collaboration. The prime funding agency was the National Natural Science Foundation of China. Most papers were published in Clinical Rheumatology. Annals of the Rheumatic Diseases achieved the highest number of citations, H-index and IF, which showed the most excellent comprehensive strength. The individual author with the most paper authorship was Dalbeth Nicola with 241 publications and 46 H-index. Keywords and co-citation analysis discovered that pathological mechanism remains the future hotspot in gout research. It may involve gout connection with gut microbiota, NLRP3 inflammasome, xanthine oxidase, and urate-transporter ABCG2. In addition, besides metabolic diseases, the relationship between gout and heart failure may need more attention.

CONCLUSION

This study clarified the current status and research frontier in gout over the past decade, which would provide valuable research references for later researchers. Key Points •We disclosed the current status and frontier directions of gout over the past 10 years worldwide. •We identified future hotspots of gout research, including gout connection with gut microbiota, NLRP3 inflammasome, xanthine oxidase, and urate-transporter ABCG2. •We discovered that the relationship between gout and heart status would be the research frontier.

Serum uric acid: A risk factor for right ventricular dysfunction and prognosis in heart failure with preserved ejection fraction

BACKGROUND

Hyperuricemia and right ventricular dysfunction (RVD) are both widespread in heart failure with preserved ejection fraction (HFpEF) patients. RVD is associated with a poor prognosis in HFpEF. The correlation between serum uric acid (UA) levels and right ventricular function is unclear. The prognostic performance of UA in patients with HFpEF needs further validation.

METHODS AND RESULTS

A total of 210 patients with HFpEF were included in the study and divided into two groups according to UA level: the normal UA group (≤7 mg/dl) and the high UA group (>7 mg/dl). The variables examined included clinical characteristics, echocardiography, and serum biochemical parameters. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (TAPSV). Baseline characteristics were compared between the two groups, and the correlation between baseline UA and RVD was assessed using multifactorial binary logistic regression. Kaplan-Meier curves were used to describe all-cause mortality and heart failure readmission. Results showed that right ventricular function parameters were worse in the high UA group. After adjusting for UA, left ventricular posterior wall thickness (LVPWT), N-terminal B-type natriuretic peptide (NT-proBNP), atrial fibrillation (AF), and low-density lipoprotein cholesterol (LDL-C), UA (odds ratio = 2.028; p < 0.001) was independently associated with RVD, and UA >7 mg/dl (HR = 2.98; p < 0.001) was associated with heart failure readmission in patients with HFpEF.

CONCLUSION

Elevated serum UA is closely associated with RVD and significantly associated with the heart failure readmission rate in patients with HFpEF.

Impaired sensitivity to thyroid hormones is associated with hyperuricemia in a Chinese euthyroid population

Objective

Impaired sensitivity to thyroid hormones has been reported as a common metabolic disorder, and it remains poorly understood whether it interplays with uric acid (UA) metabolism as an established risk factor for cardiovascular diseases (CVDs). We aimed to investigate the relationship between thyroid hormone sensitivity and elevated UA in a Chinese euthyroid population.

Methods

A total of 15,955 euthyroid subjects were included in this study. Thyroid hormone sensitivity indices were calculated, including the thyroid feedback quantile-based index (TFQI), the Chinese-referenced parametric TFQI (PTFQI), the TSH index (TSHI), and the thyrotropin thyroxine resistance index (TT4RI), and the FT3/FT4 ratio. Linear and logistic regression analyses were performed to detect the association between thyroid hormone sensitivity and elevated UA.

Results

Subjects with reduced sensitivity to thyroid hormones had increased UA levels in both genders (p for trend < 0.001). Logistic and linear regression analyses showed that higher TFQI, PTFQI, TSHI, and TT4RI were positively associated with elevated UA levels, but negatively associated with the FT3/FT4 ratio. The odds ratio (OR) of the highest versus the first quartile of TFQI was 1.20 (1.05, 1.38) in men and 1.80 (1.46, 2.23) in women (p < 0.001). PTHQI, TSHI, and TT4RI obtained similar results in both genders. Conversely, the highest quartile of the FT3/FT4 ratio was negatively correlated with elevated UA levels [men: OR 0.78 (0.68,0.89), women: OR 0.66 (0.53,0.81)].

Conclusion

Impaired sensitivity to thyroid hormones was associated with elevated UA levels in euthyroid subjects. Our findings shed light on the role of thyroid hormone sensitivity in UA metabolism.

The effect of allopurinol on cardiovascular outcomes in patients with type 2 diabetes: a systematic review

BACKGROUND

Cardiovascular disease (CVD) remains the main cause of death in patients with type 2 diabetes (T2D). Although hyperuricemia has been associated with multiple CV complications, it is not officially recognized as a target parameter for CVD risk reduction.

AIM

To systematically review the literature in order to determine whether treating hyperuricemia with allopurinol in patients with T2D reduces CVD risk.

METHODS

A thorough literature search in the PubMed, CENTRAL, and EMBASE databases from inception to August 2022 was performed. After application of selection criteria, 6 appropriate studies were identified.

RESULTS

Detailed analysis of the data derived indicated that there is an association between allopurinol treatment and CV benefits, resulting in a reduced risk of CVD events and mortality rates. This association can be attributed mainly to the reduction of inflammation and oxidative burden, as well as to the improvement of glycemic and lipid profiles.

CONCLUSIONS

This systematic review provides evidence that allopurinol may reduce CVD risk in patients with T2D. Randomized, placebo-controlled trials should be performed in order to confirm these findings and identify specific subgroups of patients who will benefit most.

Uric Acid and Hypertension: a Review of Evidence and Future Perspectives for the Management of Cardiovascular Risk

Uric acid is the final product of purine metabolism, and its increased serum levels have been directly involved in the pathogenesis and natural history of hypertension. The relationship between elevated uric acid and hypertension has been proven in both animals and humans, and its relevance is already evident in childhood and adolescent population. The mechanism responsible for blood pressure increase in hyperuricemic subjects is implicating both oxidative stress and intracellular urate activity with a primary involvement of XOR (xanthine-oxidoreductase activity). An increase in the relative risk of hypertension has been confirmed by genetic data and by large meta-analyses of epidemiological data. The effects of urate-lowering treatment on blood pressure control in patients with elevated serum uric acid has been investigated in a small number of reliable studies with a large heterogeneity of patient populations and study designs. However, 2 large meta-analyses suggest a significant effect of urate-lowering treatment on blood pressure, thus confirming the significant relationship between high serum urate and blood pressure. The future research should be focused on a more appropriate identification of patients with cardiovascular hyperuricemia by considering the correct cardiovascular threshold of serum urate, the time-course of uricemia fluctuations, and the identification of reliable markers of urate overproduction that could significantly clarify the clinical and therapeutic implications of the interaction between serum uric acid and hypertension.

Serum urate and heart failure: a bidirectional Mendelian randomization study

AIMS

Observational studies indicate that serum urate level is associated with heart failure (HF). However, whether this association is causal remains controversial, due to confounding factors and reverse causality. We aim to evaluate the causal relationship of genetically predicted serum urate level with HF.

METHODS AND RESULTS

A bidirectional Mendelian randomization (MR) study was performed. Instrumental variables were obtained from the largest genome-wide association studies of serum urate (457 690 individuals) to date. We obtained summary statistics of HF from HERMES consortium (47 309 cases; 930 014 controls), the FinnGen study (13 087 cases; 195 091 controls), and the UK Biobank study (1088 cases; 360 106 controls). Inverse-variance-weighted method was applied to obtain MR estimates and other statistical methods were conducted in the sensitivity analyses. The reverse MR analysis was performed to evaluate the effect of HF on serum urate levels. Genetically determined serum urate level was associated with HF [odds ratio (OR), 1.07; 95% confidence interval (CI), 1.03-1.10; P = 8.6×10-5]. The main results kept robust in the most sensitivity analyses. The association pattern remained for the HF in FinnGen (OR, 1.10; 95% CI, 1.03-1.19; P = 0.008) and the combined results of three data sources (OR, 1.08; 95% CI, 1.04-1.13; P < 0.001). No consistent evidence was found for the causal effect of HF on serum urate levels.

CONCLUSION

We provide consistent evidence for the causal effect of genetically predicted serum urate level on HF, but not the reverse effect of HF. Urate-lowering therapy may be of cardiovascular benefit in the prevention of HF.

Synthetic heterocyclic derivatives as promising xanthine oxidase inhibitors: An overview

Inhibition of xanthine oxidase is an effective and most prominent therapeutic approach for the management of gout. Discovery of its association in the pathophysiology of diabetes, cardiovascular disorders, etc., widened its therapeutic horizons. Limited drug candidates in clinical practice along with side effects forced researchers to develop more efficacious and safer xanthine oxidase inhibitors for the management of gout and other disorders associated with xanthine oxidase hyperactivity. In this regard, this review focus on: (a) Various drug candidates in clinical practice and under clinical trials, (b) Development of various heterocyclic motifs as xanthine oxidase inhibitors in last two decades and (c) Various patented synthetic xanthine oxidase inhibitors.

Multidimensional Approach of Heart Failure Diagnosis and Prognostication Utilizing Cardiac Imaging with Biomarkers

Heart failure (HF) is a clinical syndrome caused by various etiologies that results in systolic and diastolic cardiac dysfunction with congestion. While evaluating HF and planning for treatment, physicians utilize various laboratory tests, including electrocardiography, diverse imaging tests, exercise testing, invasive hemodynamic evaluation, or endomyocardial biopsy. Among these, cardiac imaging modalities and biomarkers are the mainstays during HF diagnosis and treatment. Recent developments in non-invasive imaging modalities, such as echocardiography, computed tomography, magnetic resonance imaging, and nuclear imaging, have helped us understand the etiology, pathophysiology, and hemodynamics of HF, and determine treatment options and predict the outcomes. Due to the convenience of their use and potential impact on HF management, biomarkers are increasingly adopted in our clinical practice as well as research purpose. Natriuretic peptide is the most widely used biomarker for the diagnosis of HF, evaluation of treatment response, and prediction of future outcomes. Other cardiac biomarkers to evaluate the pathophysiological mechanisms of HF include myocardial injury, oxidative stress, inflammation, fibrosis, hypertrophy, and neurohormonal activation. Because HF results from complex cardiac disorders, it is essential to assess the disease status multidimensionally. The proper utilization of multimodality imaging and cardiac biomarkers can improve the quality of patient management and predict clinical outcomes in HF in the era of personalized medicine.

Serum Uric Acid Levels and Cardiometabolic Profile in Middle-Aged, Treatment-Naïve Hypertensive Patients

INTRODUCTION

Uric acid (UA) is a risk factor associated with cardiometabolic diseases. However, the appropriate threshold of UA remains a matter of controversy.

AIM

To assess whether slightly increased UA levels have any significance in middle-aged, treatment-naïve persons with new-onset hypertension.

METHODS

In this cross-sectional study we recruited middle-aged participants with new-onset hypertension who were treatment-naïve. Subjects below (Group 1) and above the median UA levels (Group 2) were compared regarding clinical and laboratory characteristics that are implicated in cardiovascular and renal risk. The study population consisted of 369 persons (mean age 48.4±10 years) with median UA of 4.8 mg/dl. Group 2 individuals were predominantly male and had higher levels of blood pressure, increased body mass index, waist circumference, and a greater degree of insulin resistance. Additionally, greater lipid profile abnormalities were detected. This group also exhibited a significantly decreased fractional excretion of UA. Multivariate analysis demonstrated that serum UA levels were correlated with male sex, waist circumference, estimated glomerular filtration rate (eGFR), serum calcium and insulin levels, as well as with fractional excretion of UA. A positive association between serum UA levels and the number diagnostic criteria of the metabolic syndrome (MtS) was also noticed. After reclassification of subjects according to UA quartiles, individuals with UA levels ≥ 3.8 mg/dl had significantly higher odds (2.5-fold to 9.8-fold) of having MtS after adjustment of age, sex, and eGFR.

CONCLUSIONS

Uric acid levels in middle-aged, treatment-naïve hypertensive patients are correlated with risk factors for cardiovascular and renal disease.

Impact of serum uric acid levels on cardiovascular events and quality of life in patients with chronic coronary syndromes: Insights from a contemporary, prospective, nationwide registry

BACKGROUND AND AIMS

Hyperuricemia is a metabolic disorder that has been associated with adverse cardiovascular (CV) events. Using the data from a nationwide, prospective registry on patients with chronic coronary syndromes (CCS), we assessed the impact of serum uric acid (SUA) levels on quality of life (QoL) and major adverse CV events (MACE), a composite of CV death and hospitalization for myocardial infarction, heart failure (HF), angina or revascularization at 1-year.

METHODS AND RESULTS

Among the 5070 consecutive CCS patients enrolled in the registry, levels of SUA were available for 2394 (47.2%). Patients with SUA levels available at baseline were grouped as low tertile (n = 860; 4.3 [3.7-4.7] mg/dL), middle tertile (n = 739; 5.6 [5.3-5.9] mg/dL) and high tertile (n = 795; 7.1 [6.7-7.9] mg/dL). At 1 year, the incidence of MACE was 3.7%, 4.1% and 6.8% for low, middle and high tertiles, respectively (p = 0.005 for low vs high tertile). Patients in the high tertile of SUA had a significantly higher rate of CV mortality (1.4% vs 0.4%; p = 0.05) and hospital admission for HF (2.8% vs 1.6%; p = 0.03) compared to the low tertile. However, hyperuricemia did not result as an independent predictor of MACE at multivariable analysis [hazard ratio: 1.27; 95% confidence intervals: 0.81-2.00; p = 0.3].

CONCLUSIONS

In this contemporary, large cohort of CCS, those in the high tertile of SUA had a greater burden of CV disease and worse QoL. However, SUA did not significantly influence the higher rate of CV mortality, hospitalization for HF and MACE observed in these patients during 1-year follow-up.

A New Predictor of Mortality in ST-Elevation Myocardial Infarction: The Uric Acid Albumin Ratio

Several studies have shown that high uric acid (UA) and low serum albumin (SA) values increase the risk of cardiovascular disease and mortality in ST-elevation myocardial infarction (STEMI). We determined whether the uric acid/albumin ratio (UAR) is a predictor of mortality in STEMI patients. All patients who presented at our center with a diagnosis of STEMI and underwent percutaneous intervention from 2015 to 2020 were screened consecutively; 4599 patients were included. A Cox proportional hazards model was used to evaluate UAR, and adjusted predictors obtained from laboratory findings and clinical characteristics contributed to mortality. Also, a regression model was presented with a directed acyclic graph (DAG). The median age of the patients was 58 years (IQR [interquartile range]: 50–67); 3581 patients (77.9%) were male. The incidence of mortality in the entire patient group was 11.9%. Median follow-up duration of all groups was 42 months. Multivariate Cox proportional regression (model-1) analysis showed age (increase 50 to 67 years; HR [hazard ratio]: 1.34, 95% CI 1.18–1.52) and UAR (increase 1.15–1.73; HR: 1.33, 95% CI 1.16–1.52) were associated with mortality. UAR may be a prognostic factor for mortality in STEMI patients and an easily accessible parameter to identify high-risk patients.

Serum Uric Acid and Risk of Chronic Heart Failure: A Systematic Review and Meta-Analysis

Objectives: A systematic review and meta-analysis was performed to evaluate the potential prognostic role of serum uric acid (SUA) in patients with chronic heart failure (CHF).

Methods: The Embase, PubMed, Web of Science and Cochrane Library databases were searched up to 5 April 2021 for relevant publications. Random effects model was used to pool data. STATA15.0 software was used to perform meta-analysis. Heterogeneity was assessed using the Cochran Q statistic (significance level of P < 0.10) and I² statistics (significance level of 50%).

Results: Ultimately, 18 publications reporting adverse events in CHF patients were included. The results indicate reveal associations between a high level of SUA and the risk of all-cause mortality (HR 2.24, 95% CI 1.49–3.37), cardiovascular mortality (HR 1.14, 95% CI 1.06–1.23), and the composite of death or cardiac events (HR 1.26, 95% CI 1.01–1.56) in CHF patients. A 1 mg/dL increase in serum uric acid led to 4% (HR 1.04, 95% CI 1.02–1.05) and 9% (HR 1.09, 95% CI 1.03–1.17) increases in the risk of all-cause mortality and the composite endpoint of death or cardiac events in CHF patients, respectively.

Conclusion: Serum uric acid is positively associated with the risk of adverse events in CHF patients. This study protocol has been registered at PROSPERO as CRD42021247084 (https://www.crd.york.ac.uk/PROSPERO).

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO.

Hyperuricemia Predicts Adverse Outcomes After Myocardial Infarction With Non-obstructive Coronary Arteries

Background: Serum uric acid (SUA) is a well-known predictor of adverse outcomes in patients with various clinical conditions. However, the impact of SUA on patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) remains unclear. Here, we aimed at investigating the potential association between hyperuricemia and the adverse outcomes in MINOCA patients. Methods: Overall, 249 MINOCA patients were enrolled in the present study. Clinical characteristics and laboratory data, were measured in all patients. Based on SUA levels, patients were classified into two groups; the hyperuricemia group [SUA level > 6 mg/dL (360 μmol/L) in women and > 7 mg/dL (420 μmol/L) in men], and the normuricemia group. The primary endpoint of our study was major adverse cardiac events (MACE), defined as cardiovascular death, stroke, heart failure, non-fatal MI, and angina rehospitalization. Results: Seventy-two patients were in hyperuricemia group and 177 in normuricemia group. Fifty-two MACE events were recorded after 30 months of follow-up period. The incidence of MACE was higher in hyperuricemia group compared with normuricemia group (31.9 vs. 16.3%, P = 0.006). Kaplan-Meier survival curves illustrated a significantly increased risk of MACE in hyperuricemia group (log-rank P = 0.006). The multivariable logistic analysis demonstrated that hyperuricemia was independently associated with a high risk of MACE after 30 months of follow-up (OR, 2.234; 95% CI, 1.054-4.737, P = 0.036). Conclusion: Hyperuricemia is associated with adverse outcomes and appears to be an independent predictor of MACE in MINOCA patients. This finding suggests that the SUA levels may serve as a surrogate biomarker related to risk prediction and adverse outcomes of MINOCA patients.

Association between serum urate, gout and comorbidities: a case-control study using data from the UK Biobank

OBJECTIVES

To examine the association between comorbidities and serum urate (SU), gout and comorbidities, and to determine whether the association between gout and comorbidities is independent of SU.

METHODS

We performed a case-control study using UK Biobank data. Two separate analyses were conducted: one excluding participants with gout to investigate the association between comorbidities and SU and the other with participants with gout as the index condition to examine the association between gout and comorbidities. SU was measured at the baseline visit. Self-reported physician-diagnosed illnesses were used to define gout and comorbidities, except for chronic kidney disease (CKD), which was defined using an estimated glomerular filtration rate cut-off. Participants prescribed urate-lowering treatment were also classified as gout. Logistic regression was used to examine associations. Odds ratios (ORs) and 95% CIs were calculated and adjusted for covariates including comorbidities and SU.

RESULTS

Data for 458 781 UK Biobank participants were used to examine the association between comorbidities and SU. There was an association between hypertension, ischaemic heart disease (IHD), congestive cardiac failure (CCF), hyperlipidaemia, CKD and SU with and adjusted OR (aOR) of 1.10-3.14 for each 1 mg/dl SU increase. A total of 10 265 gout cases and 458 781 controls were included in the analysis of association between gout and comorbidities. Gout associated independently with hypertension, IHD, CCF, hyperlipidaemia and diabetes, with aORs of 1.21-4.15 after adjusting for covariates including SU.

CONCLUSION

Comorbidities associate with increasing SU. The association between gout and cardiometabolic comorbidities was independent of SU, suggesting separate SU-independent mechanisms such as inflammation driven by crystal deposition, pro-inflammatory genotype or non-purine dietary factors.

Impact of SGLT2 Inhibitors on Heart Failure: From Pathophysiology to Clinical Effects

Heart failure (HF) affects up to over 20% of patients with type 2 diabetes (T2DM), even more in the elderly. Although, in T2DM, both hyperglycemia and the proinflammatory status induced by insulin resistance are crucial in cardiac function impairment, SGLT2i cardioprotective mechanisms against HF are several. In particular, these beneficial effects seem attributable to the significant reduction of intracellular sodium levels, well-known to exert a cardioprotective role in the prevention of oxidative stress and consequent cardiomyocyte death. From a molecular perspective, patients’ exposure to gliflozins’ treatment mimics nutrient and oxygen deprivation, with consequent autophagy stimulation. This allows to maintain the cellular homeostasis through different degradative pathways. Thus, since their introduction in the clinical practice, the hypotheses on SGLT2i mechanisms of action have changed: from simple glycosuric drugs, with consequent glucose lowering, erythropoiesis enhancing and ketogenesis stimulating, to intracellular sodium-lowering molecules. This provides their consequent cardioprotective effect, which justifies its significant reduction in CV events, especially in populations at higher risk. Finally, the updated clinical evidence of SGLT2i benefits on HF was summarized. Thus, this review aimed to analyze the cardioprotective mechanisms of sodium glucose transporter 2 inhibitors (SGLT2i) in patients with HF, as well as their clinical impact on cardiovascular events.

Mediation of Arterial Stiffness for Hyperuricemia-Related Decline of Cardiac Systolic Function in Healthy Men

Background: This prospective observational study examined whether hyperuricemia may be associated with impaired left ventricular (LV) systolic function and increased cardiac load resulting from increased arterial stiffness.

Methods and Results: In 1,880 middle-aged (mean [±SD] age 45±9 years) healthy men, serum uric acid (UA) levels, pre-ejection period/ejection time (PEP/ET) ratio, serum N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and brachial-ankle pulse wave velocity (baPWV) were measured at the start and end of the 3-year study period. Linear regression analysis revealed that serum UA levels measured at baseline were significantly associated with the PEP/ET ratio, but not with serum NT-proBNP levels, measured at baseline (β=0.73×10⁻¹, P<0.01) and at the end of the study period (β=0.68×10⁻¹, P<0.01). The change in the PEP/ET ratio during the study period was significantly greater in the High-UA (UA >7 mg/dL in 2009 and 2012) than Low-UA (UA ≤7 mg/dL in 2009 and 2012) group. Mediation analysis demonstrated both direct and indirect (via increases in baPWV) associations between serum UA measured at baseline and the PEP/ET ratio measured at the end of the study period.

Conclusions: In healthy middle-aged Japanese men, hyperuricemia may be associated with an accelerated decline in ventricular systolic function, both directly and indirectly, via increases in arterial stiffness.

SGLT2 inhibitors: a focus on cardiac benefits and potential mechanisms

This paper highlights the cardioprotective potential of sodium-glucose cotransporter 2 inhibitors (SLGT2i), as well as several most discussed mechanisms responsible for their cardioprotection. Cardiovascular diseases are considered a primary cause of death in nearly 80% of type 2 diabetes mellitus (T2DM) patients, with a 2-4-fold greater incidence of heart failure (HF) among diabetics. As novel hypoglycemics, SGLT2i showed exceptional cardiovascular benefits, reflected through robust reductions of cardiovascular mortality and hospitalization for HF in T2DM patients. Recently, those effects have been reported even in patients with HF and reduced ejection fraction irrespectively of diabetic status, suggesting that cardioprotective effects of SGLT2i are driven independently of their hypoglycemic actions. SGLT2i exerted hemodynamic and metabolic effects, partially driven by natriuresis and osmotic diuresis. However, those systemic effects are modest, and therefore cannot be completely related to the cardiac benefits of these agents in T2DM patients. Hence, increased circulating ketone levels during SGLT2i administration have brought out another hypothesis of a cardiac metabolic switch. Moreover, SGLT2i influence ion homeostasis and exert anti-inflammatory and antifibrotic effects. Their enviable influence on oxidative stress markers, as well as anti- and pro-apoptotic factors, have also been reported. However, since the main mechanistical contributor of their cardioprotection has not been elucidated yet, a joint action of systemic and molecular mechanisms has been suggested. In the light of ongoing trials evaluating the effects of SGLT2i in patients with HF and preserved ejection fraction, a new chapter of beneficial SGLT2i mechanisms is expected, which might resolve their main underlying action.

Clinical Implications of Uric Acid in Heart Failure: A Comprehensive Review

Affecting more than 26 million people worldwide and with rising prevalence, heart failure (HF) represents a major global health problem. Hence, further research is needed in order to abate poor HF outcomes and mitigate significant expenses that burden health care systems. Based on available data, experts agree that there is an urgent need for a cost-effective prognostic biomarker in HF. Although a significant number of biomarkers have already been investigated in this setting, the clinical utility of adding biomarker evaluation to routine HF care still remains ambiguous. Specifically, in this review we focused on uric acid (UA), a purine metabolism detriment whose role as cardiovascular risk factor has been exhaustingly debated for decades. Multiple large population studies indicate that UA is an independent predictor of mortality in acute and chronic HF, making it a significant prognostic factor in both settings. High serum levels have been also associated with an increased incidence of HF, thus expanding the clinical utility of UA. Importantly, emerging data suggests that UA is also implicated in the pathogenesis of HF, which sheds light on UA as a feasible therapeutic target. Although to date clinical studies have not been able to prove the benefits of xanthine oxidase in HF patients, we discuss the putative role of UA and xanthine oxidase in the pathophysiology of HF as a therapeutic target.

Uric acid and cardiovascular disease: A clinical review

Uric acid, the end-product of purine metabolism in humans, is not only a cause of gout, but also may play roles in developing cardiovascular diseases such as hypertension, atrial fibrillation, chronic kidney disease, heart failure, coronary artery disease, and cardiovascular death. Several clinical investigations have reported serum uric acid as a predictive marker for cardiovascular outcomes. Although the causal relationship of hyperuricemia to cardiovascular diseases remains controversial, there has been a growing interest in uric acid because of the increased prevalence of hyperuricemia worldwide. This review article summarizes current evidence concerning the relation between hyperuricemia and cardiovascular diseases.

Hyperuricaemia and gout in cardiovascular, metabolic and kidney disease

During the last century, there has been an increasing prevalence of hyperuricaemia noted in many populations. While uric acid is usually discussed in the context of gout, hyperuricaemia is also associated with hypertension, chronic kidney disease, hypertriglyceridaemia, obesity, atherosclerotic heart disease, metabolic syndrome, and type 2 diabetes. Here we review the connection between hyperuricaemia and cardiovascular, kidney and metabolic diseases. Contrary to the popular view that uric acid is an inert metabolite of purine metabolism, recent studies suggest serum uric acid may have a variety of pro-inflammatory, pro-oxidative and vasoconstrictive actions that may contribute to cardiometabolic diseases. Hyperuricaemia is a predictive factor for the development of hypertension, metabolic syndrome, type 2 diabetes, coronary artery disease, left ventricular hypertrophy, atrial fibrillation, myocardial infarction, stroke, heart failure and chronic kidney disease. Treatment with uric acid-lowering therapies has also been found to improve outcomes in patients with hypertension and kidney disease, in some but not all studies. In conclusion, uric acid is emerging as a potentially treatable risk factor for cardiometabolic diseases, and more clinical trials investigating the potential benefit of lowering serum uric acid are recommended in individuals with hyperuricaemia with and without deposition and concomitant hypertension, metabolic syndrome or chronic kidney disease.

Insulin resistance and depressed cardiac G6PD activity induced by glucocorticoid exposure during pregnancy are attenuated by maternal estrogen-progestin therapy

This study aimed to investigate the effects of maternal combined oral contraceptive (COC) on dams that were exposed to late gestational glucocorticoids (GC). Twenty-four pregnant female rats were randomly allotted into 4 groups of 6 dams each. Dams received COC (combination of 1.0 μg ethinylestradiol and 5.0 μg levonorgestrel p.o.) between 3rd and 11^th week after delivery with or without prior exposure to GC (dexamethasone; 0.2 mg/kg p.o.) that was administered between gestational days 14-19. Data showed that late-gestational GC exposure led to insulin resistance (IR), increased cardiac adenosine deaminase (ADA), xanthine oxidase (XO), lactate, lactate dehydrogenase (LDH), and disrupted cardiac glucose-6-phosphate dehydrogenase (G6PD)-dependent antioxidant defenses. On the other hand, maternal COC treatment in dams not exposed to gestational GC led to IR, increased cardiac XO, LDH and defective cardiac G6PD-dependent antioxidant defenses. However, maternal COC with prior gestational GC exposure led to attenuated IR, cardiac ADA, UA, LDH, and improved cardiac G6PD-dependent antioxidant defenses but worsened cardiac triglyceride (TG) accumulation when compared with dam with gestational GC exposure without maternal COC. Taken together, the findings of this study provide evidence that maternal COC treatment improves late gestational GC-programmed effects. This is however accompanied with enhanced cardiac TG accumulation.

Associations of serum uric acid level and gout with cardiac structure, function and sex differences from large scale asymptomatic Asians

Hyperuricemia (HU) is a marker for heart failure. There are relatively few data in the Asian population regarding the effects of hyperuricemia and gouty disorders on cardiac remodeling and diastolic dysfunction (DD), an intermediate stage in the development of heart failure. We consecutively recruited asymptomatic Asian individuals to undergo cardiovascular surveys. We categorized them into Non-HU, HU, and Gout groups. We measured cardiac structure and indices for diastolic function, including tissue Doppler (TDI)-derived LV e’ and E/e’. Among 5525 participants, 1568 had HU and 347 had gout. The presence of gout and higher uric acid levels (SUA) (<4, 4–6, 6–8, 8–10, > = 10 mg/dL) were associated with greater LV wall thickness, greater LV mass/volumes, larger LA volume, lower LV e’ and higher E/e’. Higher SUA was associated with greater LV mass index (adjusted coefficient: 0.37), greater mass/volume ratio (adjusted coefficient: 0.01) and larger LA volume index (adjusted coefficient: 0.39, all p<0.05). Both HU and Gout groups were associated with lower LV e’ (coefficient: -0.086, -0.05), higher E/e’ (coefficient: 0.075, 0.35, all p <0.05), larger LA volume, and higher DD risk (adjusted ORs: 1.21 and 1.91 using Non-HU as reference, respectively, both p <0.05). SUA set at 7.0 mg/dL provided the optimal cut-off for identifying DD, with markedly lower e’ (HU: 8.94 vs 8.07, Gout: 7.94 vs 7.26 cm/sec) and higher LV E/e’ in HU/Gout women than in men (HU: 7.84 vs 9.79 cm/sec for men and women, respectively, all p <0.05). Hyperuricemia, even at a relatively low clinical cut-off, was associated with unfavorable remodeling and was tightly linked to diastolic dysfunction. The presence of gout likely aggravated these conditions. Women with hyperuricemia or gout had worse diastolic indices than men despite similar degrees of LV remodeling.

Serum uric acid, predicts heart failure in a large Italian cohort: search for a cut-off value the URic acid Right for heArt Health study

OBJECTIVE

To assess the prognostic cut-off values of serum uric acid (SUA) in predicting fatal and morbid heart failure in a large Italian cohort in the frame of the Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension.

METHODS

The URic acid Right for heArt Health (URRAH) study is a nationwide, multicentre, cohort study involving data on individuals aged 18-95 years, recruited on a community basis from all regions of Italy under the patronage of the Italian Society of Hypertension with a mean follow-up period of 128 ± 65 months. Incident heart failure was defined on the basis of International Classification of Diseases Tenth Revision codes and double-checked with general practitioners and hospital files. Multivariate Cox regression models having fatal and morbid heart failure as dependent variables, adjusted for sex, age, SBP, diabetes, estimated glomerular filtration rate, smoking habit, ethanol intake, BMI, haematocrit, LDL cholesterol, previous diagnosis of heart failure and use of diuretics as possible confounders, were used to search for an association between SUA as a continuous variable and heart failure. By means of receiver operating characteristic curves, two prognostic cut-off values (one for all heart failure and one for fatal heart failure) were identified as able to discriminate between individuals doomed to develop the event. These cut-off values were used as independent predictors to divide individuals according to prognostic cut-off values in a multivariate Cox models, adjusted for confounders.

RESULTS

A total of 21 386 individuals were included in the analysis. In Cox analyses, SUA as a continuous variable was a significant predictor of all [hazard ratio 1.29 (1.23-1.359), P < 0.0001] and fatal [hazard ratio 1.268 (1.121-1.35), P < 0.0001] incident heart failure. Cut-off values of SUA able to discriminate all and fatal heart failure status were identified by mean of receiver operating characteristic curves in the whole database: SUA more than 5.34 mg/dl (confidence interval 4.37-5.6, sensitivity 52.32, specificity 63.96, P < 0.0001) was the univariate prognostic cut-off value for all heart failure, whereas SUA more than 4.89 mg/dl (confidence interval 4.78-5.78, sensitivity 68.29, specificity 49.11, P < 0.0001) for fatal heart failure. The cut-off for all heart failure and the cut-off value for fatal heart failure were accepted as independent predictors in the Cox analysis models, the hazard ratios being 1.645 (1.284-2.109, P < 0.0001) for all heart failure and 1.645 (1.284-2.109, P < 0.0001) for fatal heart failure, respectively.

CONCLUSION

The results of the current study confirm that SUA is an independent risk factor for all heart failure and fatal heart failure, after adjusting for potential confounding variables and demonstrate that a prognostic cut-off value can be identified for all heart failure (>5.34 mg/dl) and for fatal heart failure (>4.89 mg/dl).

Comparison of Characteristics and Outcomes of Patients With Heart Failure With Preserved Ejection Fraction With Versus Without Hyperuricemia or Gout

Hyperuricemia and gout are common in patients with heart failure (HF) and are associated with poor outcomes. Data describing hyperuricemia and gout in patients with HF with preserved ejection fraction (HFpEF) are limited. We used data from the Duke University Health System to describe characteristics of patients with HFpEF and hyperuricemia (serum uric acid >6 mg/dl) or gout (gout diagnosis or gout medication within the previous year) and to explore associations with 5-year outcomes (death and hospitalization). We identified 7,004 patients in the Duke University Health System with a known diagnosis of HFpEF who underwent transthoracic echocardiography between January 1, 2005 and December 31, 2017. A total of 1,136 (16.2%) patients with HFpEF also had hyperuricemia or gout. Patients with HFpEF and hyperuricemia or gout had a greater co-morbidity burden, more echocardiographic findings of cardiac remodeling, and higher unadjusted rates of all-cause death, all-cause hospitalization, and HF hospitalization compared with those with HFpEF without hyperuricemia or gout. After multivariable adjustment, patients with HFpEF and hyperuricemia or gout had a significantly higher rates of first all-cause hospitalization (adjusted hazard ratio 1.10 [95% confidence interval 1.02 to 1.19]; p = 0.020) and recurrent all-cause hospitalization (associated rate ratio 1.13 [95% confidence interval 1.01 to 1.25]; p = 0.026). After adjustment, no significant differences in death or HF hospitalization were observed. In conclusion, patients with HFpEF and hyperuricemia or gout were found to have a higher burden of co-morbidities and a higher rate of all-cause hospitalization, even after multivariable adjustment, compared to patients with HFpEF without hyperuricemia or gout.

In-Hospital Serum Uric Acid Change Predicts Adverse Outcome in Patients With Heart Failure

BACKGROUND

Elevated serum uric acid (UA) is associated with an increased risk of adverse outcome in patients with heart failure (HF), but it remains unknown whether the change of serum UA level during the treatment of acute decompensated HF (ADHF) predicts adverse events.

METHODS AND RESULTS

We retrospectively analyzed consecutive 1562 patients who were hospitalized for ADHF. Serum UA levels both at admission and discharge were available in 1246 patients (78 years of age, range 69-84 years, 40% female). UA values increased or unchanged (group I) in 766 patients and it decreased in the remaining patients (group D). Group I was characterized by older age, higher proportion of females, preserved left ventricular ejection fraction, and the features of less severity of HF such as lower plasma N-terminal pro B-type natriuretic peptide level and lower percentage of catecholamine use. Nevertheless, group I was associated with higher incidence of the primary end point defined as the composite of all-cause death and ADHF rehospitalization (P = .013, log-rank test). UA change, but not UA at discharge, was an independent predictor of the primary end point (hazard ratio 1.30, interquartile range 1.04-1.64, P = .022). Age, estimated glomerular filtration rate, left ventricular ejection fraction, dose of loop diuretics, and thiazide prescription at discharge were independently associated with the UA change.

CONCLUSIONS

In patients with HF, UA change through the treatment of ADHF might predict future adverse outcome.

Uric acid and cardiometabolic diseases

Hyperuricemia, which has been considered as a cause of gout and nephrolithiasis has recently been suggested to be associated with hypertension, coronary heart disease, heart failure, atrial fibrillation, insulin resistance, and nonalcoholic fatty liver disease. Several clinical and experimental studies have supported uric acid (UA) as an independent risk factor for predicting disease development along with the traditional risk factors. The mechanism by which UA causes cardiometabolic disease has not been fully elucidated to date; however, it has been explained by several hypotheses such as oxidative stress, reduced nitric oxide bioavailability, inflammation, endothelial dysfunction, and so on. Although evidence of the preventive and therapeutic effects of UA lowering therapy on cardiometabolic diseases is still insufficient, it is expected to be considered as a new treatment strategy for such diseases through additional, carefully designed, large-scale clinical studies.

Estrogen-progestin oral contraceptive and nicotine exposure synergistically confers cardio-renoprotection in female Wistar rats

Approximately fifty percent of premenopausal women who smoke cigarettes or on nicotine replacement therapy are also on hormonal contraceptives, especially oral estrogen-progestin. Oral estrogen-progestin therapy has been reported to promote insulin resistance (IR) which causes lipid influx into non-adipose tissue and impairs Na⁺/K⁺ -ATPase activity, especially in the heart and kidney. However, the effects of nicotine on excess lipid and altered Na⁺/K⁺ -ATPase activity associated with the use of estrogen-progestin therapy have not been fully elucidated. This study therefore aimed at investigating the effect of nicotine on cardiac and renal lipid influx and Na⁺/K⁺ -ATPase activity during estrogen-progestin therapy. Twenty-four female Wistar rats grouped into 4 (n = 6/group) received (p.o.) vehicle, nicotine (1.0 mg/kg) with or without estrogen-progestin steroids (1.0 μg ethinyl estradiol and 5.0 μg levonorgestrel) and estrogen-progestin only daily for 6 weeks. Data showed that estrogen-progestin treatment or nicotine exposure caused IR, hyperinsulinemia, increased cardiac and renal uric acid, malondialdehyde, triglyceride, glycogen synthase kinase-3, plasminogen activator inhibitor-1, reduced bilirubin and circulating estradiol. Estrogen-progestin treatment led to decreased cardiac Na⁺/K⁺-ATPase activity while nicotine did not alter Na⁺/K⁺-ATPase activity but increased plasma and tissue cotinine. Renal Na⁺/K⁺-ATPase activity was not altered by the treatments. However, all these alterations were reversed following combined administration of oral estrogen-progestin therapy and nicotine. The present study therefore demonstrates that oral estrogen-progestin therapy and nicotine exposure synergistically prevents IR-linked cardio-renotoxicity with corresponding improvement in cardiac and renal lipid accumulation, oxidative stress, inflammation and Na⁺/K⁺-ATPase activity.

Biomarkers in heart failure: the past, current and future

Despite the enhanced knowledge of the pathophysiology of heart failure (HF), it still remains a serious syndrome with substantial morbidity, mortality, and frequent hospitalizations. These are due to the current improvements in other cardiovascular diseases (like myocardial infarction), the aging population, and growing prevalence of comorbidities. Biomarker-guided management has brought a new dimension in prognostication, diagnosis, and therapy options. Following the recommendation of natriuretic peptides (B-type natriuretic peptide and N-terminal-proBNP), many other biomarkers have been thoroughly studied to reflect different pathophysiological processes (such as fibrosis, inflammation, myocardial injury, and remodeling) in HF and some of them (like cardiac troponins, soluble suppression of tumorigenesis-2, and galectin 3) have subsequently been recommended to aid in the diagnosis and prognostication in HF. Consequently, multi-marker approach has also been approved owing to the varied nature of HF syndrome. In this review, we discussed the guidelines available for HF biomarkers, procedures for evaluating novel markers, and the utilities of both emerging and established biomarkers for risk stratification, diagnosis, and management of HF in the clinics. We later looked at how the rapidly emerging field-OMICs, can help transform HF biomarkers discoveries and establishment.

Salivary lactate and 8-isoprostaglandin F2α as potential non-invasive biomarkers for monitoring heart failure: a pilot study

Heart failure (HF) is a cardiovascular disease affecting about 26 million people worldwide costing about $100 billons per year. HF activates several compensatory mechanisms and neurohormonal systems, so we hypothesized that the concomitant monitoring of a panel of potential biomarkers related to such conditions might help predicting HF evolution. Saliva analysis by point-of-care devices is expected to become an innovative and powerful monitoring approach since the chemical composition of saliva mirrors that of blood. The aims of this study were (i) to develop an innovative procedure combining MEPS with UHPLC-MS/MS for the simultaneous determination of 8-isoprostaglandin F2α and cortisol in saliva and (ii) to monitor lactate, uric acid, TNF-α, cortisol, α-amylase and 8-isoprostaglandin F2α concentrations in stimulated saliva samples collected from 44 HF patients during their hospitalisation due to acute HF. Limit of detection of 10 pg/mL, satisfactory recovery (95-110%), and good intra- and inter-day precisions (RSD ≤ 10%) were obtained for 8-isoprostaglandin F2α and cortisol. Salivary lactate and 8-isoprostaglandin F2α were strongly correlated with NT-proBNP. Most patients (about 70%) showed a significant decrease (a factor of 3 at least) of both lactate and 8-isoprostaglandin F2α levels at discharge, suggesting a relationship between salivary levels and improved clinical conditions during hospitalization.

Asymptomatic hyperuricemia and incident congestive heart failure in elderly patients without comorbidities

BACKGROUND AND AIMS

Although hyperuricemia is associated with congestive heart failure (CHF), hyperuricemic patients frequently have other comorbidities. Thus, it is difficult to distinguish the role of hyperuricemia from that of other comorbid conditions in CHF. The aim of this study was to evaluate the association between hyperuricemia and CHF in elderly patients without comorbidities.

METHODS AND RESULTS

Subjects aged ≥65 years were analyzed at enrollment (2009-2012) and during the 4-year follow-up period at the Kangjian Community Health Center of Shanghai. Subjects were excluded if they had hypertension, diabetes mellitus, preexisting cardiovascular disease, hyperlipidemia, overweight or obesity, a history of gout or hyperuricemia and were taking medication for their condition, or chronic kidney disease. The primary outcome of this study was to investigate the impact of asymptomatic hyperuricemia on incident CHF. We used Cox regression to estimate the hazard ratio (HR) for incident CHF events between hyperuricemic (defined as an SUA level >7 mg/dL in men and ≥6 mg/dL in women) and normouricemic subjects. A total of 2749 subjects (70.9 ± 6.0 years) were followed for 47.4 ± 3.6 months. Asymptomatic hyperuricemia was associated with an increased cumulative incidence of incident CHF events (6.5% versus 3.1%, odds ratio [OR] = 2.15, 95% confidence index [CI]: 1.39-3.33, p = 0.001). After adjusting for confounding factors, including baseline eGFR, hyperuricemia independently predicted the risk of incident CHF events (HR = 2.34, 95% CI: 1.50-3.63, p < 0.001).

CONCLUSION

Asymptomatic hyperuricemia was a valuable biomarker for predicting the development of incident CHF in elderly patients without comorbidities.

Serum uric acid level and subclinical left ventricular dysfunction: a community-based cohort study

AIMS

Although serum uric acid (SUA) level is correlated with oxidative stress and serves as a marker of poor prognosis in heart failure patients, its possible association with subclinical left ventricular (LV) dysfunction has not been evaluated. This study aimed to investigate the association between SUA and subclinical LV dysfunction in a sample of a general population without overt cardiac disease.

METHODS AND RESULTS

We examined 1175 participants who underwent extensive cardiovascular health check-up including laboratory tests and speckle-tracking echocardiography to assess LV global longitudinal strain (GLS). The association of SUA concentration, as a continuous variable and a categorical variable using quartiles, with the presence of abnormal LVGLS was assessed. Mean age was 62 ± 12 years, and 656 (56%) were male participants. Mean SUA was 5.6 ± 1.3 mg/dL (25th-75th percentile, 4.6-6.5 mg/dL). The prevalence of abnormal LVGLS (greater than -18.6%) was greatest in the upper quartile of SUA. In multivariable analysis, SUA as a continuous variable was significantly associated with abnormal LVGLS [adjusted odds ratio (OR), 1.26 per 1 mg/dL; P = 0.008] independent of traditional cardiovascular risk factors, pertinent laboratory parameters and echocardiographic measures, and medications. In the categorical analysis, the upper quartile of SUA was independently associated with abnormal LVGLS in a fully adjusted model (adjusted OR, 2.28 vs. lowest quartile; P = 0.020).

CONCLUSIONS

In a sample of the general population, an elevated SUA was independently associated with subclinical LV dysfunction. Assessment of LVGLS may add important prognostic information in individuals with elevated SUA, even in the absence of overt cardiac disease.

Increased the risk of heart failure and comorbidities in patients with gout treatment: a population-based cohort study

Background

To investigate the association between gout treatment and heart failure (HF).

Methods

Patients with gout between 2000 and 2010 constituted the gout cohort. The main outcome was a new diagnosis of HF. Multivariable Cox proportional hazard regression models were used to measure the effect of gout on the risk of developing HF. The Kaplan-Meier method was used to estimate the cumulative HF incidence curve for the gout and nongout cohorts.

Results

The cohort study included 50,166 patients with gout. The incidence of HF was 1.96 times higher in the gout cohort than the non-gout cohort (7.11 vs. 3.63 per 10,000 person-years). The adjusted HR of developing HF was a 1.06-fold increase (95% CI: 1.06–1.07) with age and a 1.08-fold increase for women compared with men (95% CI: 1.02–1.14). HF incidence was higher in patients with receiving any two or more types of anti-gout drug treatment.

Conclusions

Our study revealed that gout could increase the risk of HF. Gout treatment in Taiwan cannot improve HF and actually increase the risk for HF after combination therapy for gout. The public health burden of gout should be resolved in the future.

Hyperuricemia and Risk of Cardiovascular Outcomes: The Experience of the URRAH (Uric Acid Right for Heart Health) Project

The latest European Guidelines of Arterial Hypertension have officially introduced uric acid evaluation among the cardiovascular risk factors that should be evaluated in order to stratify patient's risk. In fact, it has been extensively evaluated and demonstrated to be an independent predictor not only of all-cause and cardiovascular mortality, but also of myocardial infraction, stroke and heart failure. Despite the large number of studies on this topic, an important open question that still need to be answered is the identification of a cardiovascular uric acid cut-off value. The actual hyperuricemia cut-off (> 6 mg/dL in women and 7 mg/dL in men) is principally based on the saturation point of uric acid but previous evidence suggests that the negative impact of cardiovascular system could occur also at lower levels. In this context, the Working Group on uric acid and CV risk of the Italian Society of Hypertension has designed the Uric acid Right for heArt Health project. The primary objective of this project is to define the level of uricemia above which the independent risk of CV disease may increase in a significantly manner. In this review we will summarize the first results obtained and describe the further planned analysis.

Hyperuricemia and pulse pressure are predictive of incident heart failure in an elderly population

OBJECTIVE

This study investigated the associations between hyperuricemia, pulse pressure (PP) and heart failure (HF) hospitalization among the elders in a community population.

BACKGROUND

Hyperuricemia and PP have been related to the development of HF. Whether PP acts synergistically with hyperuricemia or mediates the causal relationship of HF, especially in the elderly, remains elucidated.

METHODS

This cohort included 1665 adults aged ≥65 years from the National Nutrition and Health Survey in Taiwan Elderly were followed. HF hospitalization (ICD-9-CM:428) was defined by the National Health Insurance Dataset. A Cox proportional hazard model and a Fine and Grays model were adjusted for the conventional cardiovascular risk factors and death as a competing risk to estimate the association between hyperuricemia, PP and HF hospitalization.

RESULTS

A total of 228 elders occurred HF hospitalization, and 692 died during a median of 12 years follow-up period, from 1999 to 2012. The incidence of HF was 14.2 per 1000 person-years. High PP (top quartile) and hyperuricemia (≥6.0 mg/dL [women] and 7.0 mg/dL [Men]) significantly correlated with incident HF (hazard ratio and 95% confidence intervals: 2.131;1.625-2.794 and 1.433;1.071-1.918, respectively). Compared with normal uric acid level and PP, combined hyperuricemia and high PP was additively related to incident HF (4.186:2.874-6.099). The associations remained after accounting for traditional cardiovascular risks, coronary heart disease as a time-dependent covariate, and mortality as a competing risk factor in the study population.

CONCLUSION

Both hyperuricemia and high PP were associated with HF hospitalization in this elderly population. Combine hyperuricemia and high PP would further improve the risk stratification in the prediction of incident HF.

Established and Emerging Roles of Biomarkers in Heart Failure

Heart failure (HF) is a complex syndrome with an enormous societal burden in terms of cost, morbidity, and mortality. Natriuretic peptide testing is now widely used to support diagnosis, prognostication, and management of patients with HF and are incorporated into HF clinical practice guidelines. Beyond the natriuretic peptides, novel biomarkers may supplement traditional clinical and laboratory testing to improve understanding of the complex disease process of HF and possibly to personalize care for those affected through better individual phenotyping. In this review, we will discuss natriuretic peptides and the more novel biomarkers by dividing them into categories based on the major pathophysiologic pathways they represent. Given the complex physiology in HF, it is reasonable to expect that the future of biomarker testing lies in the application of multimarker testing panels, precision medicine to improve HF care delivery, and the use of biomarkers in proteomics and metabolomics to further improve HF care.

Gender differences in association between uric acid and all-cause mortality in patients with chronic heart failure

Background

Elevated serum uric acid (SUA) is associated with poor prognosis in patients with cardiovascular disease, yet it is still not decided whether the role of SUA is causal or only reflects an underlying disease. The purpose of the study was to investigate if SUA was an independent predictor of 5-year all-cause mortality in a propensity score matched cohort of chronic heart failure (HF) outpatients. Furthermore, to assess whether gender or renal function modified the effect of SUA.

Methods

Patients (n = 4684) from the Norwegian Heart Failure Registry with baseline SUA were included in the study. Individuals in the highest gender-specific SUA quartile were propensity score matched 1:1 with patients in the lowest three SUA quartiles. The propensity score matching procedure created 928 pairs of patients (73.4% males, mean age 71.4 ± 11.5 years) with comparable baseline characteristics. Kaplan Meier and Cox regression analyses were used to investigate the independent effect of SUA on all-cause mortality.

Results

SUA in the highest quartile was an independent predictor of all-cause mortality in HF outpatients (hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.03–1.37, p-value 0.021). Gender was found to interact the relationship between SUA and all-cause mortality (p-value for interaction 0.007). High SUA was an independent predictor of all-cause mortality in women (HR 1.65, 95% CI 1.24–2.20, p-value 0.001), but not in men (HR 1.06, 95% CI 0.89–1.25, p-value 0.527). Renal function did not influence the relationship between SUA and all-cause mortality (p-value for interaction 0.539).

Conclusions

High SUA was independently associated with inferior 5-year survival in Norwegian HF outpatients. The finding was modified by gender and high SUA was only an independent predictor of 5-year all-cause mortality in women, not in men.