Distribution and categorization of left ventricular measurements in the general population: results from the population-based Gutenberg Heart Study

Small Left Ventricular Chamber Size and Mortality in a Large General Population

Enlargement of the left ventricle (LV) is an important marker of adverse cardiac remodeling and poor prognosis. Previous studies demonstrated increased cardiovascular risk in small subsets of patients with a small LV chamber size; however, the prognostic implications of small chamber size in the general population remains unclear. This study aimed to examine the prognosis of a small LV chamber in a large general cohort. All consecutive subjects who underwent echocardiography examinations from 2011 to 2023 were retrieved for analysis. Small chamber size was defined as end-diastolic diameter <42 mm for men and 37.8 mm for women as per American Society of Echocardiography guidelines. The primary end point for the study was all-cause mortality. A total of 46,529 subjects (mean age 60 ± 19 years, 56% men) were included, of whom 3,787 had a small LV chamber size. Clinical variables associated with small chamber included increasing age and lower body surface area. Echocardiographic variables included higher relative wall thickness and E/e' ratio. On the multivariable analysis, the presence of a small LV was significantly associated with mortality (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.22 to 1.46, p <0.001). This finding was significant in older (over 65 years) (HR 1.30, 95% CI 1.19 to 1.41, p <0.001) and younger (HR 2.09, 95% CI 1.81 to 2.41, p <0.001) subjects and in men and women. In conclusion, in this retrospective large cohort study, small LV chamber size was significantly associated with mortality in a broad range of patients. Further study is necessary to elucidate mechanisms and design preventive strategies.

Comparison of ante- and postmortem ventricular wall thickness using echocardiography and autopsy findings

In autopsy practice, the thickness of ventricular walls is one of the parameters used to identify cardiac hypertrophy. The presented study aimed to compare ante- and postmortem measurements of ventricular wall thickness, (i) to determine a postmortem standardized localization and dissection method for ventricular wall measurements, and (ii) to determine the ability of postmortem measurements in recognition of antemortem hypertrophy. A single-center prospective study was conducted at the Institute of Legal Medicine in Hamburg, Germany. Sixty hearts were dissected alternating by the inflow-outflow or short-axis method, and the ventricular walls were measured at different locations and compared with the echocardiographic values of the end-diastolic phase during life of these individuals. The results showed measurement differences between the autoptic and echocardiographic values-for the left ventricle between 3.3 and 5.2 mm, for the right ventricle between 0.2 and 1.1 mm, and for the septum between 1.3 and 1.4 mm. Diagnostic performance of recognizing antemortem hypertrophy with postmortem measurement was poor, except for measuring the right ventricle and septum with the short-axis method (area under the ROC curve of 0.72 and 0.82, respectively). According to the results, cardiac changes may occur postmortem and need to be considered when used for diagnosing cardiac pathology. The postmortem diagnosis of left or right ventricular hypertrophy should always be made in conjunction with other, particularly cardiac, autopsy findings. An autoptic diagnosis of hypertrophy solely by a ventricular wall thickness > 15 mm or > 5 mm alone is not sufficient.

Chronic disease outcome metadata from German observational studies - public availability and FAIR principles

Metadata from epidemiological studies, including chronic disease outcome metadata (CDOM), are important to be findable to allow interpretability and reusability. We propose a comprehensive metadata schema and used it to assess public availability and findability of CDOM from German population-based observational studies participating in the consortium National Research Data Infrastructure for Personal Health Data (NFDI4Health). Additionally, principal investigators from the included studies completed a checklist evaluating consistency with FAIR principles (Findability, Accessibility, Interoperability, Reusability) within their studies. Overall, six of sixteen studies had complete publicly available CDOM. The most frequent CDOM source was scientific publications and the most frequently missing metadata were availability of codes of the International Classification of Diseases, Tenth Revision (ICD-10). Principal investigators' main perceived barriers for consistency with FAIR principles were limited human and financial resources. Our results reveal that CDOM from German population-based studies have incomplete availability and limited findability. There is a need to make CDOM publicly available in searchable platforms or metadata catalogues to improve their FAIRness, which requires human and financial resources.

Development and Phenotype of Heart Failure in Long-Term Survivors of Childhood Cancer: The CVSS Study

Background The CVSS (Cardiac and Vascular Late Sequelae in Long-Term Survivors of Childhood Cancer) study aimed to investigate the prevalence of different stages of heart failure (HF) in childhood cancer survivors (CCSs) compared with the general population. Methods and Results A total of 1002 CCSs (age range, 23-48 years) diagnosed with neoplasia before an age of 15 years underwent a comprehensive cardiovascular screening. An age- and sex-matched sample from the population-based GHS (Gutenberg Health Study) served as a comparison group. Although prevalence of HF was significantly higher in CCSs, prevalence of different HF stages varied strongly by specific tumor history. Compared with the population, the prevalence ratio was 2.6 (95% CI, 2.4-2.8) for HF stage A and 4.6 (95% CI, 4.1-5.1) for the composite of HF stage B to D in an age- and sex-adjusted Poisson regression model. Multivariable linear regression, adjusting for tumor entities, age, sex, and cardiovascular risk factors, revealed a lower left ventricular ejection fraction in patients with history of bone tumors (β, -4.30 [95% CI, -5.70 to -2.80]), soft tissue sarcoma (β, -1.60 [95% CI, -2.90 to -0.30]), and renal tumors (β, -1.60 [95% CI, -2.80 to -0.29]) compared with the population. The same model for the diastolic marker, ratio of the peak early diastolic filling velocity/lateral mitral annular early diastolic velocity, showed an association only with cardiovascular risk factors but not with tumor entities. Conclusions The prevalence of HF stage A to D was significantly higher among long-term CCSs compared with the population and varied strongly by tumor entity. Systolic dysfunction was primarily associated with tumor entities, whereas diastolic dysfunction was associated with a higher burden of cardiovascular risk factors in CCSs.

Circulating Soluble EPCR Levels Are Reduced in Patients with Ischemic Peripheral Artery Disease and Associated with Markers of Endothelial and Vascular Function

(1) Background: Endothelial dysfunction initiates cardiovascular pathologies, including peripheral artery disease (PAD). The pathophysiology of impaired new vessel formation in the presence of angiogenic stimuli, such as ischemia and inflammation, is unknown. We have recently shown in mice that reduced endothelial protein C receptor (EPCR) expression results in defective angiogenesis following experimental hindlimb ischemia. (2) Purpose: To determine soluble (s)EPCR levels in the plasma of patients with PAD and to compare them with the protein C activity and biomarkers of endothelial function, inflammation, and angiogenesis. (3) Methods and Results: Clinical tests of vascular function and immunoassays of plasma from patients with PAD stage II were compared to age- and sex-matched individuals with and without cardiovascular risk factors or PAD stage III/IV patients. sEPCR levels were significantly lower in PAD stage II patients compared to subjects with risk factors, but no PAD, and further decreased in PAD stage III/IV patients. Plasma protein C activity or levels of ADAM17, a mediator of EPCR shedding, did not differ. Significant associations between sEPCR and the ankle-brachial index (p = 0.0359), age (p = 0.0488), body mass index (p = 0.0110), and plasma sE-selectin levels (p = 0.0327) were observed. High-sensitive CRP levels and white blood cell counts were significantly elevated in PAD patients and associated with serum glucose levels, but not sEPCR. In contrast, plasma TNFα or IL1β levels did not differ. Circulating levels of VEGF were significantly elevated in PAD stage II patients (p = 0.0198), but not associated with molecular (sE-selectin) or functional (ankle-brachial index) markers of vascular health. (4) Conclusions: Our findings suggest that circulating sEPCR levels may be useful as biomarkers of endothelial dysfunction, including angiogenesis, in persons older than 35 years and that progressive loss of endothelial protein C receptors might be involved in the development and progression of PAD.

G Protein-Coupled Receptor 15 Expression Is Associated with Myocardial Infarction

Beyond the influence of lifestyle-related risk factors for myocardial infarction (MI), the mechanisms of genetic predispositions for MI remain unclear. We sought to identify and characterize differentially expressed genes in early-onset MI in a translational approach. In an observational case−control study, transcriptomes from 112 early-onset MI individuals showed upregulated G protein-coupled receptor 15 (GPR15) expression in peripheral blood mononuclear cells compared to controls (fold change = 1.4, p = 1.87 × 10−7). GPR15 expression correlated with intima-media thickness (β = 0.8498, p = 0.111), C-reactive protein (β = 0.2238, p = 0.0052), ejection fraction (β = −0.9991, p = 0.0281) and smoking (β = 0.7259, p = 2.79 × 10−10). The relation between smoking and MI was diminished after the inclusion of GPR15 expression as mediator in mediation analysis (from 1.27 (p = 1.9 × 10−5) to 0.46 (p = 0.21)). The DNA methylation of two GPR15 sites was 1%/5% lower in early-onset MI individuals versus controls (p = 2.37 × 10−6/p = 0.0123), with site CpG3.98251219 significantly predicting risk for incident MI (hazard ratio = 0.992, p = 0.0177). The nucleotide polymorphism rs2230344 (C/T) within GPR15 was associated with early-onset MI (odds ratio = 3.61, p = 0.044). Experimental validation showed 6.3-fold increased Gpr15 expression in an ischemic mouse model (p < 0.05) and 4-fold increased Gpr15 expression in cardiomyocytes under ischemic stress (p < 0.001). After the induction of MI, Gpr15gfp/gfp mice showed lower survival (p = 0.042) and deregulated gene expression for response to hypoxia and signaling pathways. Using a translational approach, our data provide evidence that GPR15 is linked to cardiovascular diseases, mediating the adverse effects of smoking.

Relationships between coagulation factors and thrombin generation in a general population with arterial and venous disease background

Background

The current study aims to identify the relationships between coagulation factors and plasma thrombin generation in a large population-based study by comparing individuals with a history of arterial or venous thrombosis to cardiovascular healthy individuals.

Methods

This study comprised 502 individuals with a history of arterial disease, 195 with history of venous thrombosis and 1402 cardiovascular healthy individuals (reference group) from the population-based Gutenberg Health Study (GHS). Calibrated Automated Thrombography was assessed and coagulation factors were measured by means of BCS XP Systems. To assess the biochemical determinants of TG variables, a multiple linear regression analysis, adjusted for age, sex and antithrombotic therapy, was conducted.

Results

The lag time, the time to form the first thrombin, was mainly positively associated with the natural coagulant and anti-coagulant factors in the reference group, i.e. higher factors result in a longer lag time. The same determinants were negative for individuals with a history of arterial or venous thrombosis, with a 10 times higher effect size. Endogenous thrombin potential, or area under the curve, was predominantly positively determined by factor II, VIII, X and IX in all groups. However, the effect sizes of the reported associations were 4 times higher for the arterial and venous disease groups in comparison to the reference group.

Conclusion

This large-scale analysis demonstrated a stronger effect of the coagulant and natural anti-coagulant factors on the thrombin potential in individuals with a history of arterial or venous thrombosis as compared to healthy individuals, which implicates sustained alterations in the plasma coagulome in subjects with a history of thrombotic vascular disease, despite intake of antithrombotic therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00392-0.

Right atrium size in the general population

Echocardiography is the most common routine cardiac imaging method. Nevertheless, only few data about sex-specific reference limits for right atrium (RA) dimensions are available. Transthoracic echocardiographic RA measurements were studied in 9511 participants of the Gutenberg-Health-Study. A reference sample of 1942 cardiovascular healthy subjects without chronic obstructive pulmonary disease was defined. We assessed RA dimensions and sex-specific reference limits were defined using the 95th percentile of the reference sample. Results showed sex-specific differences with larger RA dimensions in men that were attenuated by standardization for body-height. RA-volume was 20.2 ml/m in women (5th–95th: 12.7–30.4 ml/m) and 26.1 ml/m in men (5th–95th: 16.0–40.5 ml/m). Multivariable regressions identified body-mass-index (BMI), coronary artery disease (CAD), chronic heart failure (CHF) and atrial fibrillation (AF) as independent key correlates of RA-volume in both sexes. All-cause mortality after median follow-up-period of 10.7 (9.81/11.6) years was higher in individuals who had RA volume/height outside the 95% reference limit (HR 1.70 [95%CI 1.29–2.23], P = 0.00014)). Based on a large community-based sample, we present sex-specific reference-values for RA dimensions normalized for height. RA-volume varies with BMI, CHF, CAD and AF in both sexes. Individuals with RA-volume outside the reference limit had a 1.7-fold higher mortality than those within reference limits.

Determinants of left ventricular structure, filling and long axis function in systemic sclerosis

Background

Abnormalities of left ventricular (LV) structure, filling and long-axis function have all been reported in subjects with systemic sclerosis (SSc) and a normal LV ejection fraction (EF), but previous study findings have not been consistent. The aim of this study was to identify factors which could have confounded the analyses in previous studies of SSc, and in particular to consider the variables of body surface area (BSA), sex, age, heart rate, blood pressure (BP), disease duration (DD), disease type (limited versus diffuse) and interstitial lung disease (ILD).

Methods

Echocardiography was performed on 100 subjects with SSc (79 women; age 56±15 years) with a LVEF ≥50% and free of pulmonary arterial hypertension, coronary artery disease, more than mild valvular heart disease and atrial fibrillation. Measurements were performed of the LV end-diastolic dimension (LVEDD) and septal wall thickness (SWT), the transmitral Doppler E, A and deceleration time (DT), and the peak systolic (s’) and early diastolic (e’) LV long-axis velocities. Multivariate analyses were performed to investigate correlations of the above LV variables with BSA, sex, age, heart rate, BP, DD, disease type, and the presence of ILD.

Results

DD varied between 0.1 and 41.2 years, 25% had diffuse and 75% had limited disease, and 37% had ILD. SWT and LVEDD were positively correlated with BSA, SWT was also positively correlated with age and larger in males, and LVEDD was larger in diffuse disease. Age was positively correlated with A and DT, and inversely correlated with E and E/A, and heart rate was inversely correlated with E and E/A. None of E, A, E/A, or DT were independently associated with DD or disease type. Septal and lateral LV wall s’ and e’ were all inversely correlated with age, and there was a small independent contribution to the prediction of lateral s’ from DD, but no association of either s’ or e’ with disease type. The presence of ILD was not a predictor of any of the LV variables.

Conclusion

In SSc there are associations of sex, body size, age and disease type with LV structural variables, of age and heart rate with E/A, and of age with both systolic and early diastolic LV long-axis velocities. Appropriate adjustment for these variables could help to resolve current uncertainties regarding SSc effects on the left ventricle.

Distribution of estimated glomerular filtration rate and determinants of its age dependent loss in a German population-based study

Glomerular filtration rate (GFR) declines with age by approx. 1 ml/min/m2 per year beginning in the third decade of life. At 70 years of age > 40 ml/min/m2 of GFR will be lost. Thus, factors affecting loss of GFR have significant public health implications. Furthermore, the definition of chronic kidney disease based on GFR may not be appropriate for the elderly. We analyzed factors affecting absolute and relative change of eGFR over a 5 year period in 12,381 participants of the Gutenberg Health Study. We estimated GFR at baseline and after 5 years of follow-up by two different equations. Association with the decline of estimated GFR (eGFR) was assessed by multivariable regression analysis. We confirmed a median loss of eGFR per year of approx. 1 ml/min/m2. Aside from albuminuria systolic blood pressure was most strongly associated with faster decline of eGFR followed by echocardiographic evidence of left ventricular diastolic dysfunction and reduced ejection fraction. White blood cell count showed a moderate association with eGFR loss. Diastolic blood pressure, serum uric acid and serum albumin were associated with slower GFR decline in multivariable analysis. Sensitivity analysis with exclusion of individuals taking diuretics, antihypertensive, antidiabetic, or lipid lowering drugs confirmed these associations.

Arterial hypertension and morphologic abnormalities of cardiac chambers: results from the Copenhagen General Population Study

OBJECTIVES

In patients with arterial hypertension (AH), hypertension-mediated organ damage may be manifested by cardiac chamber enlargement and/or remodeling. Cardiac computed tomography imaging has emerged as an important method for morphological assessment of cardiac chambers. We tested the hypothesis that prevalence of cardiac chamber abnormalities is specifically related to clinical categories of AH in the general population.

METHODS

We studied 4747 individuals, mean age was 60 years (range: 40-93), 46% were men, undergoing 320-detector computed tomography in the Copenhagen General Population Study. Clinical categories of AH were: normotensive (n = 2484), untreated hypertensive (n = 1301), treated controlled hypertensive (n = 412) and treated uncontrolled hypertensive (n = 550). Chamber abnormalities in the form of left ventricular (LV) concentric remodeling, LV eccentric hypertrophy, LV concentric hypertrophy or left atrial enlargement were assessed, in addition to LV or right ventricular enlargement.

RESULTS

Chamber abnormalities were present in 23% of all individuals. Combined LV and left atrial abnormalities were rare (<2%). LV concentric remodeling (10%) was the most prevalent abnormality, and most commonly found in individuals with treated hypertension. LV and right ventricular enlargements were unrelated to hypertension. The highest frequencies of chamber abnormalities were found in individuals of elevated blood pressure (BP) with (40%) or without (32%) treatment, as opposed to individuals of normal BP with (27%) or without (14%) treatment, P less than 0.0001.

CONCLUSION

In a general population cohort, untreated or inadequately treated AH was associated with the highest prevalence of cardiac chamber enlargement and remodeling. These observations suggest a strong link between elevated BPs and development of hypertension-mediated organ damage.

Relation between Tissue Factor Pathway Inhibitor Activity and Cardiovascular Risk Factors and Diseases in a Large Population Sample

OBJECTIVE

 Tissue factor pathway inhibitor (TFPI) is a potent anticoagulant protein in the extrinsic coagulation pathway. In the present study, we aim to identify the cardiovascular determinants for total TFPI activity and its association with cardiovascular disease (CVD) and total mortality.

METHODS

 Total TFPI activity was assessed in a selection of the population-based Gutenberg Health Study (n = 5,000). Statistical analysis was performed to identify the determinants for total TFPI activity as well as the associations with CVD and mortality.

RESULTS

 Multivariable linear regression analysis identified smoking (β 0.095 [0.054-0.136]) as a positive determinant for total TFPI activity, while diabetes (β -0.072 [-0.134 to -0.009]), obesity (β -0.063 [-0.101 to -0.024]), and history of coronary artery disease (CAD) were negatively associated with total TFPI activity, independent of age, sex, and the remaining cardiovascular risk factors. After adjustment for lipoprotein levels, the association between total TFPI activity levels and obesity and CAD was lost. The analysis additionally revealed a strong positive association between total TFPI activity levels and low-density lipoprotein (β 0.221 [0.204-0.237]). The Cox regression models revealed that a higher total TFPI activity, above 97.5th percentile of the reference group, was associated with an increased mortality risk (hazard ratio = 2.58 [95% confidence interval: 1.49-4.47]), independent of age, sex, and cardiovascular risk profile.

CONCLUSION

 In the Gutenberg Health Study population-based cohort, the highest percentage of total TFPI correlated with an increased mortality risk. While elevated TFPI may reflect endothelial cell activation, the associations between total TFPI activity and obesity and CAD, points to additional mechanistic interactions.

Thrombin generation in cardiovascular disease and mortality - results from the Gutenberg Health Study

Thrombin generation may be a potential tool to improve risk stratification for cardiovascular diseases. This study aims to explore the relation between thrombin generation and cardiovascular risk factors, cardiovascular diseases, and total mortality. For this study, N=5000 subjects from the population-based Gutenberg Health Study were analysed in a highly standardized setting. Thrombin generation was assessed by the Calibrated Automated Thrombogram method at 1 and 5 pM tissue factors trigger in platelet poor plasma. Lag time, endogenous thrombin potential, and peak height were derived from the thrombin generation curve. Sex-specific multivariable linear regression analysis adjusted for age, cardiovascular risk factors, cardiovascular diseases and therapy, was used to assess clinical determinants of thrombin generation. Cox regression models adjusted for age, sex, cardiovascular risk factors and vitamin K antagonists investigated the association between thrombin generation parameters and total mortality. Lag time was positively associated with obesity and dyslipidaemia for both sexes (p<0.0001). Obesity was also positively associated with endogenous thrombin potential in both sexes (p<0.0001) and peak height in males (1 pM tissue factor, p=0.0048) and females (p<0.0001). Cox regression models showed an increased mortality in individuals with lag time (1 pM tissue factor, hazard ratio=1.46, [95% CI: 1.07; 2.00], p=0.018) and endogenous thrombin potential (5 pM tissue factor, hazard ratio = 1.50, [1.06; 2.13], p=0.023) above the 95th percentile of the reference group, independent of the cardiovascular risk profile. This large-scale study demonstrates traditional cardiovascular risk factors, particularly obesity, as relevant determinants of thrombin generation. Lag time and endogenous thrombin potential were found as potentially relevant predictors of increased total mortality, which deserves further investigation.

Cardiovascular health outcomes of mobbing at work: results of the population-based, five-year follow-up of the Gutenberg health study

Background

The aim of this study was to determine if there is an increased risk of incident cardiovascular disease (CVD) resulting from workplace mobbing measured with two mobbing instruments in the Gutenberg Health Study.

Methods

In this prospective study, we examined working persons younger than 65 years for the presence of mobbing at baseline and at a 5-year follow-up using a single-item and a 5-item instrument. We used multivariate models to investigate the association between mobbing and incident CVD, hypertension, and change in arterial stiffness and further stratified the models by sex.

Results

After adjustment for confounders, mobbed workers appeared to have a higher risk of incident CVD than those not mobbed (single-item HR = 1.28, 95% CI 0.73–2.24; 5-item HR = 1.57, 95% CI 0.96–2.54). With the 5-item instrument, men who reported mobbing had a higher risk of incident CVD (HR = 1.77, 95% CI 1.01–3.09), while no association was observed for women (HR = 1.05, 95% CI 0.38–2.91). There was no difference in risks between men and women with the single-item instrument. No association between mobbing and incident hypertension and arterial stiffness was seen.

Conclusions

Our results show an indication of an increased risk of incident CVD for those mobbed at baseline when using the whole study population. Differences in risks between men and women when using the five-item instrument may be due to the instrument itself. Still, it is essential to detect or prevent workplace mobbing, and if present, to apply an intervention to halt it in order to minimize its adverse effects on CVD.

Oblique views of chest radiography from a designed rotation angle recommendation increase the contrast ratio between obscured lesions and surrounding structures

Background

Chest radiography (CXR) is the main tool used to detect pulmonary nodules. Lateral views of CXR are less effective and the aim of our study was to develop a rotation angle recommendation model to obtain the best oblique CXR with significantly increased contrast between lesions and surrounding normal structures in order to enhance the detection rate for potential obscured lesions on traditional posterior and anterior (PA) CXR.

Methods

A total of 140 subjects receiving low‐dose lung computed tomography (CT) screening were enrolled from the health check‐up database. An additional 14 cases with lung lesions on chest CT were included. Demography was also reviewed. Gross, left and right cardiothoracic ratios (CTR) were measured. All CT images were transformed to CXR to detect the best rotation angles and produce different views of CXR. Contrast ratio was calculated in the transformed CXR from CT with lesions. Comparison of contrast ratio among oblique, posterior‐anterior and lateral views was performed.

Results

CXR shows smaller gross CTR and left CTR but larger heart width and thoracic width in men than in women. Correlation evaluation displays gross CTR, heart width and left CTR are positively correlated with age only for the women group. The most important factor for the best rotation angle is right CTR for left rotation angle and left CTR for right rotation angle. The contrast ratio of the lesion to surrounding structures is significantly better on the oblique views in the designed angles than that on the traditional views.

Conclusion

CXR oblique views in the assigned angle from the 10‐degree rotation angle recommendation are able to enhance contrast ratio between the possible obscured lesions and surrounding structures on CXR.

Atrial Fibrillation Manifestations Risk Factors and Sex Differences in a Population-Based Cohort (From the Gutenberg Health Study)

Sex differences in cardiovascular risk factors, cardiac structure and function, and disease and symptom burden in the common arrhythmia atrial fibrillation (AF) have not been investigated systematically at the population level. Cross-sectional data of 14,796 subjects (age range 35 to 74 years, 50.5% men) from the population-based Gutenberg Health Study were examined to show the distribution of cardiovascular risk factors by AF status and sex, and to determine sex-specific predictors for AF. The prevalence of AF was higher in men (4.3%) than in women (1.9%). Men had a worse cardiovascular risk factor profile, a higher prevalence of cardiovascular disease, but fewer symptoms than women. Age-adjusted Cox regressions showed sex interactions in the association of high-density lipoprotein-cholesterol, triglycerides, diabetes mellitus, coronary artery disease, myocardial infarction, generalized anxiety disorder, and heart rate with AF. After multivariable adjustment, sex interactions were seen for thickness of interventricular end-diastolic septum, odds ratio (OR) per standard deviation (SD), 95% confidence interval women: 0.9 (0.8, 1.1), men: 1.2 (1.1, 1.4), interaction p value = 0.02; left atrial diameter index, OR per SD women: 1.5 (1.3, 1.8), men: 1.9 (1.7, 2.1), interaction p value = 0.03; and myocardial infarction, OR women: 2.7 (1.3, 5.6), men: 0.7 (0.5, 1.1), interaction p value = 0.002. In conclusion, in our large cohort, we observed substantial sex differences in AF distribution and clinical characteristics including comorbidities, symptom burden, and structural cardiac changes.

Transcriptome-Wide Analysis Identifies Novel Associations With Blood Pressure

Hypertension represents a major cardiovascular risk factor. The pathophysiology of increased blood pressure (BP) is not yet completely understood. Transcriptome profiling offers possibilities to uncover genetics effects on BP. Based on 2 populations including 2549 individuals, a meta-analyses of monocytic transcriptome-wide profiles were performed to identify transcripts associated with BP. Replication was performed in 2 independent studies of whole-blood transcriptome data including 1990 individuals. For identified candidate genes, a direct link between long-term changes in BP and gene expression over time and by treatment with BP-lowering therapy was assessed. The predictive value of protein levels encoded by candidate genes for subsequent cardiovascular disease was investigated. Eight transcripts (CRIP1, MYADM, TIPARP, TSC22D3, CEBPA, F12, LMNA, and TPPP3) were identified jointly accounting for up to 13% (95% confidence interval, 8.7-16.2) of BP variability. Changes in CRIP1, MYADM, TIPARP, LMNA, TSC22D3, CEBPA, and TPPP3 expression associated with BP changes-among these, CRIP1 gene expression was additionally correlated to measures of cardiac hypertrophy. Assessment of circulating CRIP1 (cystein-rich protein 1) levels as biomarkers showed a strong association with increased risk for incident stroke (hazard ratio, 1.06; 95% confidence interval, 1.03-1.09; P=5.0×10-5). Our comprehensive analysis of global gene expression highlights 8 novel transcripts significantly associated with BP, providing a link between gene expression and BP. Translational approaches further established evidence for the potential use of CRIP1 as emerging disease-related biomarker.

Simulation of complex data structures for planning of studies with focus on biomarker comparison

BACKGROUND

There are a growing number of observational studies that do not only focus on single biomarkers for predicting an outcome event, but address questions in a multivariable setting. For example, when quantifying the added value of new biomarkers in addition to established risk factors, the aim might be to rank several new markers with respect to their prediction performance. This makes it important to consider the marker correlation structure for planning such a study. Because of the complexity, a simulation approach may be required to adequately assess sample size or other aspects, such as the choice of a performance measure.

METHODS

In a simulation study based on real data, we investigated how to generate covariates with realistic distributions and what generating model should be used for the outcome, aiming to determine the least amount of information and complexity needed to obtain realistic results. As a basis for the simulation a large epidemiological cohort study, the Gutenberg Health Study was used. The added value of markers was quantified and ranked in subsampling data sets of this population data, and simulation approaches were judged by the quality of the ranking. One of the evaluated approaches, the random forest, requires original data at the individual level. Therefore, also the effect of the size of a pilot study for random forest based simulation was investigated.

RESULTS

We found that simple logistic regression models failed to adequately generate realistic data, even with extensions such as interaction terms or non-linear effects. The random forest approach was seen to be more appropriate for simulation of complex data structures. Pilot studies starting at about 250 observations were seen to provide a reasonable level of information for this approach.

CONCLUSIONS

We advise to avoid oversimplified regression models for simulation, in particular when focusing on multivariable research questions. More generally, a simulation should be based on real data for adequately reflecting complex observational data structures, such as found in epidemiological cohort studies.

Unlocking echocardiogram measurements for heart disease research through natural language processing

BACKGROUND

In order to investigate the mechanisms of cardiovascular disease in HIV infected and uninfected patients, an analysis of echocardiogram reports is required for a large longitudinal multi-center study.

IMPLEMENTATION

A natural language processing system using a dictionary lookup, rules, and patterns was developed to extract heart function measurements that are typically recorded in echocardiogram reports as measurement-value pairs. Curated semantic bootstrapping was used to create a custom dictionary that extends existing terminologies based on terms that actually appear in the medical record. A novel disambiguation method based on semantic constraints was created to identify and discard erroneous alternative definitions of the measurement terms. The system was built utilizing a scalable framework, making it available for processing large datasets.

RESULTS

The system was developed for and validated on notes from three sources: general clinic notes, echocardiogram reports, and radiology reports. The system achieved F-scores of 0.872, 0.844, and 0.877 with precision of 0.936, 0.982, and 0.969 for each dataset respectively averaged across all extracted values. Left ventricular ejection fraction (LVEF) is the most frequently extracted measurement. The precision of extraction of the LVEF measure ranged from 0.968 to 1.0 across different document types.

CONCLUSIONS

This system illustrates the feasibility and effectiveness of a large-scale information extraction on clinical data. New clinical questions can be addressed in the domain of heart failure using retrospective clinical data analysis because key heart function measurements can be successfully extracted using natural language processing.

Distribution of antiphospholipid antibodies in a large population-based German cohort

BACKGROUND

Antiphospholipid syndrome (APS) is the most common acquired thrombophilia. Diagnosis is based on clinical criteria and the presence of antiphospholipid antibodies (aPLs) above the 99th percentile of a reference group. Data on the distribution of aPL in the population are limited. The distribution of aPL including diagnostic cutoffs should be determined in a population-based cohort.

METHODS

The Gutenberg Health Study (GHS) is a population-based cohort aged 35-74 years. We determined the presence of antibodies against cardiolipin (aCL, IgG, and IgM), β2-glycoprotein I (anti-β2GPI, IgG, and IgM), and domain 1 of β2-glycoprotein I (anti-domain 1, IgG) in a sample of 4979 participants.

RESULTS

aPL titers were similar in the whole sample and in an apparently healthy subgroup of 1049 individuals. There was a strong age-dependent increase of both aCL and anti-β2GPI IgM, while aPL IgG titers were stable or tended to decrease with age. A relevant decrease was observed for aCL IgG in women and anti-domain 1 IgG in both sexes. There was no association of aPL titers with a history of venous thromboembolism (VTE).

CONCLUSIONS

Our data show that for IgM aPL, age-dependent reference ranges should be used. In fact, the controversy regarding the clinical utility of IgM aPL might be related to the use of inappropriate reference ranges among other causes. In our population, aPLs were not associated with a history of VTE.

FEV1 and FVC predict all-cause mortality independent of cardiac function - Results from the population-based Gutenberg Health Study

BACKGROUND

Lung function has previously been related to increased mortality. Whether pulmonary impairment is associated with an increased mortality independent of cardiac dysfunction remains unclear.

METHODS

In 15010 individuals from the general population (age range 35-74years, 51% men) in the Gutenberg Health Study we performed spirometry and transthoracic echocardiography. N-terminal pro-B-type natriuretic peptide (Nt-proBNP) and high-sensitive troponin I (hsTnI) were measured in all individuals. 1819 individuals with pulmonary diseases were excluded from further analysis.

RESULTS

The median for forced expiratory volume in 1s (FEV1) was 94.2% and for forced vital capacity (FVC) 94.2% as a percentage of their predicted values. The median FEV1/FVC ratio was 79.1%. In 13191 subjects, 335 deaths were verified from death certificate over a median follow-up of 5.5years. Multivariable-adjusted Cox regression analyses for common cardiovascular risk factors and heart failure revealed that an increase of one standard deviation (SD) of percent predicted (%pred.) FEV1 was associated with a 22% risk reduction (hazard ratio [HR] per SD 0.78 [95% confidence interval (CI): 0.70, 0.86]). The association remained statistically significant after additional adjustment for diastolic dysfunction, Nt-proBNP or hsTnI. Comparable results were seen for %pred. FVC. After adjustment, no association of FEV1/FVC ratio with mortality could be shown. No significant interaction by heart failure was observed.

CONCLUSIONS

The lung function parameters FEV1 and FVC, but not FEV1/FVC ratio, were related to all-cause mortality in individuals from the general population independent of cardiac function.

Biomarkers for characterization of heart failure - Distinction of heart failure with preserved and reduced ejection fraction

BACKGROUND

Heart failure (HF) incidence is rising worldwide and HF with preserved ejection fraction (HFpEF) represents nearly half of all cases. Treatment options are still limited in HFpEF in comparison to HF with reduced ejection fraction (HFrEF).

METHODS

We analyzed biomarkers in the general population to characterize HFpEF and HFrEF and defined a biomarker index to differentiate HFpEF from HFrEF. Growth differentiation factor-15 (GDF-15), soluble source of tumorigenicity 2 (sST2), C-reactive protein (CRP) and NT-proBNP were measured in 5000 individuals of the population-based Gutenberg Health Study (GHS). The median follow-up time for all-cause mortality was 7.3years with 213 events.

RESULTS

Identification of subjects with HF was improved by GDF-15 (p<0.001) in addition to NT-proBNP with an odds ratio (OR) of 1.4 (95% confidence interval [CI]:1.1-1.7). Discrimination of subjects with and without HF was slightly higher for GDF-15 (area under the ROC curve [AUC]:0.79 [95%CI:0.75-0.83]) compared to NT-proBNP (AUC:0.77 [95% CI:0.72-0.82]). For subjects with HF, differentiating HFpEF from HFrEF was feasible with the index ((CRP+GDF-15+sST2)/NT-proBNP) with an OR of 3.7 (95% CI:1.9-8.5) (p<0.001). The best biomarkers predicting all-cause mortality were NT-proBNP and GDF-15 with a hazard ratio (HR) of 1.9 (95% CI:1.6-2.2) and 1.7 (95%CI:1.6-1.9) (both p<0.001), respectively.

CONCLUSION

GDF-15 was useful to detect prevalent HF in addition to NT-proBNP and was elevated in HFrEF and HFpEF, whereas NT-proBNP was higher in HFrEF than in HFpEF. All biomarkers were useful to predict mortality in the general population. The index of ((CRP+GDF-15s+sST2)/NT-proBNP) was able to discriminate HFpEF from HFrEF.

Subclinical impairment of lung function is related to mild cardiac dysfunction and manifest heart failure in the general population

BACKGROUND

Lung function impairment has previously been related to heart failure, although no overt cardiovascular or structural heart disease is present. The extent to which pulmonary function is related to subclinical left ventricular impairment in the general population remains to be investigated.

METHODS

15010 individuals from the general population (mean age 55±11years, 50.5% men) in the Gutenberg Health Study underwent spirometry, transthoracic echocardiography and biomarker measurement. Forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) in percent of the predicted value and FEV1/FVC ratio were associated with echocardiographic measures of cardiac structure, systolic and diastolic function, biomarkers of cardiac necrosis (high-sensitive troponin I, hsTnI) and stress (N-terminal pro-B-type natriuretic peptide, Nt-proBNP) and heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF).

RESULTS

Percent predicted FEV1 and FVC were significantly associated with hsTnI (P<0.001) and Nt-proBNP (P<0.001). Additionally, FEV1/FVC ratio was significantly related to hsTnI (P=0.0043) and Nt-proBNP (P<0.001). In the multivariable-adjusted linear regression analyses strongest associations were observed for percent predicted FEV1 and FVC with LVESD, E/e', SV and EF. FEV1/FVC ratio was significantly related with SV and EF. The three lung function parameters were significantly (P<0.001) associated with HFpEF and HFrEF. Associations remained statistically significant after exclusion of individuals with COPD.

CONCLUSIONS

FEV1, FVC and FEV1/FVC ratio were associated with systolic and diastolic function and manifest heart failure. Our observations could show, that subclinical lung function impairment is related to a measurable reduction of left ventricular filling and cardiac output in the general population.

Prognostic value of left ventricular mass normalized to different body size indexes: findings from the PAMELA population

AIM

We estimated the risk of cardiovascular and all-cause mortality associated with left ventricular hypertrophy (LVH) as assessed by left ventricular mass (LVM), normalized by various indexation methods in 1716 representatives of the general population of Monza, enrolled in the Pressioni Arteriose Monitorate E Loro Associazioni study.

METHODS

LVH was defined according to four sex-specific criteria derived from the upper limits of normality for LVM index in the healthy normotensive fraction of the Pressioni Arteriose Monitorate E Loro Associazioni population. Death certificates were collected over an average 211 months of follow-up.

RESULTS

During follow-up, 89 fatal cardiovascular events and 264 all-cause deaths were observed. LVH prevalence rates in the whole population ranged from 14.2% [LVM/body surface area (BSA)] to 18.0% (LVM/height). Adjusted risk (for baseline covariates, including ambulatory blood pressure) of cardiovascular mortality was increased in patients with LVH, regardless of the indexation type: LVH/BSA [hazard ratio 3.19, 95% confidence interval (CI) 2.02-5.06, P < 0.0001], LVH/height (hazard ratio 2.39, 95% CI 1.51-3.78, P = 0.0002), LVH/height (hazard ratio 2.38, 95% CI 1.50-3.76, P = 0.0002), LVH/height (hazard ratio 2.28, 95% CI 1.44-3.60 P = 0.0004). Similar findings were observed for all-cause mortality and when LVM was assessed as a continuous variable. The fraction of patients (5%) classified into the LVH group by height, but not by BSA, had a mild increased LVM index and showed no increased risk.

CONCLUSIONS

LVH, irrespective of indexation methods for LVM, confers an increased risk of cardiovascular and all-cause mortality in the general population. LVH, detected by height-based indexes, but not by BSA-based criteria, was not associated with increased mortality; this finding, however, was based on a small group of patients and will deserve further investigations.

The Gutenberg health study: associations between occupational and private stress factors and work-privacy conflict

Background

Work-privacy conflict (WPC) is no longer a rarity but constitutes a societal problem. The objectives of the present study were (1) to investigate the distribution and prevalence of WPC among the employed participants in the Gutenberg Health Study at baseline and (2) to study the dependence of WPC on a broad range of private life and occupational characteristics as well as on psychosocial working conditions.

Methods

This analysis is based on a representative, population-based sample of 3,709 employees participating in the Gutenberg Health Study. Descriptive and bivariable analyses were carried out separately for women and men. Distribution and prevalence of WPC were examined according to socio-demographic and occupational characteristics as well as psychosocial working conditions. Further, stepwise selection of Poisson log-linear regression models were performed to determine which socio-demographic and occupational characteristics were most associated with the outcome variable WPC and to obtain adjusted prevalence ratios from the final model. The multivariable analyses were conducted both separately for women and men and with all subjects together in one analysis.

Results

There was a high prevalence of WPC in the present study (27.4 % of the men and 23.0 % of the women reported a high or very high WPC). A variety of factors was associated with WPC, e.g. full-time employment, depression and many of the psychosocial risk factors at work. Also, the multivariable results showed that women were of higher risk for a WPC.

Conclusions

By affecting the individual work life, home life, and the general well-being and health, WPC may lead to detrimental effects in employees, their families, employers, and society as a whole. Therefore, the high prevalence of WPC in our sample should be of concern. Among women, the risk for suffering from WPC was even higher, most likely due to multiple burdens.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2881-8) contains supplementary material, which is available to authorized users.

Inflammatory bowel disease (IBD) locus 12: is glutathione peroxidase-1 (GPX1) the relevant gene?

Genome-wide association studies have identified and repeatedly confirmed the association of rs3197999 in MST1 with inflammatory bowel disease (IBD). However, the underlying pathophysiology remains unclear. rs3197999 is a non-synonymous single-nucleotide polymorphism which modifies the function of macrophage stimulating protein-1 (MST1). We show by haplotyping that rs3197999 is in linkage disequilibrium with rs1050450 in GPX1, with almost complete cosegregation of the minor alleles. As shown by immunoassay, rs3197999 influences the MST-1 level in serum. But also rs1050450 causes an amino acid exchange in glutathione peroxidase 1 (GPx-1) and reduced activity of this antioxidant enzyme. The association of GPx deficiency and IBD in mice was already shown. We propose that GPx-1 is a better candidate than MST1 for the pathophysiologic link between IBD locus 12 and IBD.

Reference Values for Echocardiography in Middle-Aged Population: The Cardiovascular Risk in Young Finns Study

BACKGROUND

Population and sex-specific reference limits produced with modern ultrasound equipment are needed for accurate clinical echocardiography diagnostics. We report a comprehensive set of reference limits of cardiac function and dimensions in a group of young and middle-aged Finnish men and women produced by the recommendations of European Society of Echocardiography and American Society of Cardiology.

METHODS AND RESULTS

Cardiac structure and function was studied in a standardized comprehensive echocardiographic examination in 1,079 healthy volunteers without cardiovascular diseases or major known risk factors participating in the population-based Young Finns study (444 men and 635 women, age range 34 and 49 years). We present sex-specific reference values for echocardiographic parameters reflecting cardiac structure (ventricular and atrial dimensions and volumes, left ventricular wall thickness and mass, aortic root) and function. From the 86 measured parameters, only 7 were not statistically significantly different between sexes.

CONCLUSION

The Young Finns study provides echocardiographic reference ranges for cardiac structure and function quantification that can be utilized to enhance the accuracy or echocardiography diagnostics. The results emphasize the need for sex-specific assessment for most echocardiographic parameters.

Development of a mobbing short scale in the Gutenberg Health Study

PURPOSE

Despite its highly detrimental potential, most standard questionnaires assessing psychosocial stress at work do not include mobbing as a risk factor. In the German standard version of COPSOQ, mobbing is assessed with a single item. In the Gutenberg Health Study, this version was used together with a newly developed short scale based on the Leymann Inventory of Psychological Terror. The purpose of the present study was to evaluate the psychometric properties of these two measures, to compare them and to test their differential impact on relevant outcome parameters.

METHODS

This analysis is based on a population-based sample of 1441 employees participating in the Gutenberg Health Study. Exploratory and confirmatory factor analyses and reliability analyses were used to assess the mobbing scale. To determine their predictive validities, multiple linear regression analyses with six outcome parameters and log-binomial regression models for two of the outcome aspects were run.

RESULTS

Factor analyses of the five-item scale confirmed a one-factor solution, reliability was α = 0.65. Both the single-item and the five-item scales were associated with all six outcome scales. Effect sizes were similar for both mobbing measures.

CONCLUSION

Mobbing is an important risk factor for health-related outcomes. For the purpose of psychosocial risk assessment in the workplace, both the single-item and the five-item constructs were psychometrically appropriate. Associations with outcomes were about equivalent. However, the single item has the advantage of parsimony, whereas the five-item construct depicts several distinct forms of mobbing.

Sex Differences in Correlates of Intermediate Phenotypes and Prevalent Cardiovascular Disease in the General Population

Background

There are marked sex differences in cardiovascular disease (CVD) manifestation. It is largely unknown how the distribution of CVD risk factors or intermediate phenotypes explain sex-specific differences.

Methods and Results

In 5000 individuals of the population-based Gutenberg Health Study, mean age 55 ± 11 years, 51% males, we examined sex-specific associations of classical CVD risk factors with intima-media thickness, ankle-brachial index, flow-mediated dilation, peripheral arterial tonometry, echocardiographic, and electrocardiographic variables. Intermediate cardiovascular phenotypes were related to prevalent CVD [coronary artery disease, heart failure, stroke, myocardial infarction, lower extremity artery disease (LEAD) N = 561].

We observed differential distributions of CVD risk factors with a higher risk factor burden in men. Manifest coronary artery disease, stroke, myocardial infarction, and LEAD were more frequent in men; the proportion of heart failure was higher in women. Intermediate phenotypes showed clear sex differences with more beneficial values in women. Fairly linear changes toward less beneficial values with age were observed in both sexes. In multivariable-adjusted regression analyses, age, systolic blood pressure, and body mass index were consistently associated with intermediate phenotypes in both sexes with different ranking according to random forests, maximum model R² 0.43. Risk factor-adjusted associations with prevalent CVD showed some differences by sex. No interactions by menopausal status were observed.

Conclusion

In a population-based cohort, we observed sex differences in risk factors and a broad range of intermediate phenotypes of non-invasive cardiovascular structure and function. Their relation to prevalent CVD differed markedly. Our results indicate the need of future investigations to understand sex differences in CVD manifestation.

Distribution, genetic and cardiovascular determinants of FVIII:c - Data from the population-based Gutenberg Health Study

BACKGROUND

Elevated levels of

FVIII

c are associated with risk for both venous and arterial thromboembolism. However, no population-based study on the sex-specific distribution and reference ranges of plasma

FVIII

c and its cardiovascular determinants is available.

METHODS

FVIII

c was analyzed in a randomly selected sample of 2533 males and 2440 females from the Gutenberg Health Study in Germany. Multivariable regression analyses for

FVIII

c were performed under adjustment for genetic determinants, cardiovascular risk factors and cardiovascular disease.

RESULTS AND CONCLUSIONS

Females (126.6% (95% CI: 125.2/128)) showed higher

FVIII

c levels than males (121.2% (119.8/122.7)).

FVIII

c levels increased with age in both sexes (ß per decade: 5.67% (4.22/7.13) male, 6.15% (4.72/7.57) female; p<0.001). Sex-specific reference limits and categories indicating the grade of deviation from the reference were calculated, and nomograms for

FVIII

c were created.

FVIII

c was approximately 25% higher in individuals with non-O blood type. Adjusted for sex and age, ABO-blood group accounted for 18.3% of

FVIII

c variation. In multivariable analysis,

FVIII

c was notably positively associated with diabetes mellitus, obesity, hypertension and dyslipidemia and negatively with current smoking. In a fully adjusted multivariable model, the strongest associations observed were of elevated

FVIII

c with diabetes and peripheral artery disease in both sexes and with obesity in males. Effects of SNPs in the vWF, STAB2 and SCARA5 gene were stronger in females than in males. The use of nomograms for valuation of

FVIII

c might be useful to identify high-risk cohorts for thromboembolism. Additionally, the prospective evaluation of

FVIII

c as a risk predictor becomes feasible.

Interleukin 17 drives vascular inflammation, endothelial dysfunction, and arterial hypertension in psoriasis-like skin disease

OBJECTIVE

Interleukin (IL)-17A is regarded as an important cytokine to drive psoriasis, an inflammatory skin disease marked by increased cardiovascular mortality. We aimed to test the hypothesis that overproduction of IL-17A in the skin leading to dermal inflammation may systemically cause vascular dysfunction in psoriasis-like skin disease.

APPROACH AND RESULTS

Conditional overexpression of IL-17A in keratinocytes caused severe psoriasis-like skin inflammation in mice (K14-IL-17A(ind/+) mice), associated with increased reactive oxygen species formation and circulating CD11b(+) inflammatory leukocytes in blood, with endothelial dysfunction, increased systolic blood pressure, left ventricular hypertrophy, and reduced survival compared with controls. In K14-IL-17A(ind/+) mice, immunohistochemistry and flow cytometry revealed increased vascular production of the nitric oxide/superoxide reaction product peroxynitrite and infiltration of the vasculature with myeloperoxidase(+)CD11b(+)GR1(+)F4/80(-) cells accompanied by increased expression of the inducible nitric oxide synthase and the nicotinamide dinucleotide phosphate (NADPH) oxidase, nox2. Neutrophil depletion by anti-GR-1 antibody injections reduced oxidative stress in blood and vessels. Neutralization of tumor necrosis factor-α and IL-6 (both downstream of IL-17A) reduced skin lesions, attenuated oxidative stress in heart and blood, and partially improved endothelial dysfunction in K14-IL-17A(ind/+) mice.

CONCLUSIONS

Dermal overexpression of IL-17A induces systemic endothelial dysfunction, vascular oxidative stress, arterial hypertension, and increases mortality mainly driven by myeloperoxidase(+)CD11b(+)GR1(+)F4/80(-) inflammatory cells. Depletion of the GR-1(+) immune cells or neutralization of IL-17A downstream cytokines by biologicals attenuates the vascular phenotype in K14-IL-17A(ind/+) mice.

Genome-wide association study of L-arginine and dimethylarginines reveals novel metabolic pathway for symmetric dimethylarginine

BACKGROUND

Dimethylarginines (DMA) interfere with nitric oxide formation by inhibiting nitric oxide synthase (asymmetrical DMA [ADMA]) and l-arginine uptake into the cell (ADMA and symmetrical DMA [SDMA]). In prospective clinical studies, ADMA has been characterized as a cardiovascular risk marker, whereas SDMA is a novel marker for renal function and associated with all-cause mortality after ischemic stroke. The aim of the current study was to characterize the environmental and genetic contributions to interindividual variability of these biomarkers.

METHODS AND RESULTS

This study comprised a genome-wide association analysis of 3 well-characterized population-based cohorts (Framingham Heart Study [FHS; n=2992], Gutenberg Health Study [GHS; n=4354], and Multinational Monitoring of Trends and Determinants in Cardiovascular Disease Study [MONICA]/Cooperative Health Research in the Augsburg Area, Augsburg, Bavaria, Germany [KORA] F3 [n=581]) and identified replicated loci (DDAH1, MED23, Arg1, and AGXT2) associated with the interindividual variability in ADMA, l-arginine, and SDMA. Experimental in silico and in vitro studies confirmed functional significance of the identified AGXT2 variants. Clinical outcome analysis in 384 patients of the Leeds stroke study demonstrated an association between increased plasma levels of SDMA, AGXT2 variants, and various cardiometabolic risk factors. AGXT2 variants were not associated with poststroke survival in the Leeds study or were they associated with incident stroke in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium.

CONCLUSIONS

These genome-wide association study support the importance of DDAH1 and MED23/Arg1 in regulating ADMA and l-arginine metabolism, respectively, and identify a novel regulatory renal pathway for SDMA by AGXT2. AGXT2 variants might explain part of the pathogenic link between SDMA, renal function, and outcome. An association between AGXT2 variants and stroke is unclear and warrants further investigation.

Assessment of microRNAs in patients with unstable angina pectoris

AIMS

While cardiac troponin measurements have significantly improved the early diagnosis of myocardial infarction, the timely biomarker-based diagnosis of unstable angina pectoris (UAP) remains a major unmet clinical challenge. The aim of this study was to assess levels of circulating microRNAs (miRNAs) as possible novel biomarkers in patients with UAP.

METHODS AND RESULTS

A three-phase approach was conducted, comprising (i) profiling of miRNAs in patients with UAP and controls groups; (ii) replication of significant miRNAs in an independent patient cohort, (iii) validation of a multi-miRNAs panel in a third cohort. Out of 25 miRNAs selected for replication, 8 miRNAs remained significantly associated with UAP. In a validation phase, a miRNA panel including miR-132, miR-150, and miR-186 showed the highest discriminatory power [area under the receiver-operating-characteristic curve (AUC): 0.91; CI: 0.84-0.98].

CONCLUSION

Using a profiling-replication-validation model, we identified eight miRNAs, which may facilitate the diagnosis of UAP.

The Pamela study: main findings and perspectives

PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) is an epidemiological study, originally designed to determine the normality of home and ambulatory blood pressure values. The study was performed on 3,200 subjects, aged 25 to 74 years, randomly selected from the general population of Monza (Milan, Italy). In the study context we performed clinical, home and ambulatory blood pressure measurements, echocardiographic assessment of cardiac structure and function as well as laboratory examinations (glucose and lipids). Personal and family histories were collected. The same procedures were repeated 10 years later. During a 12-year follow-up, the incident cardiovascular events were validated. Cardiovascular and all-cause fatal events were collected for a 16-year follow-up. This article will review the main results of the PAMELA study, with particular emphasis on (1) the prognostic value of the different blood pressure measurements, (2) the relationships between metabolic variables and blood pressure and (3) the clinical relevance and prognostic importance of left ventricular mass values and alterations.

Association of high-sensitivity assayed troponin I with cardiovascular phenotypes in the general population: the population-based Gutenberg health study

BACKGROUND

Aim of the study was to analyze the correlation of high-sensitivity assayed troponin I with cardiac and vascular structure and function in a large population-based cohort.

METHODS

In a sample of 4,139 subjects (2,099 men, 2,040 women, age 35-74 years) from the population-based Gutenberg Health Study, troponin I was measured with a high-sensitivity assay that had a limit of detection of 1.9 pg/mL.

RESULTS

In the study cohort, 3,405 subjects had detectable troponin I concentrations [82.3% overall, 89.9% men (N = 1,888), 74.4% women (N = 1,517)]. All analyses were adjusted for age. The strongest correlate between detectable troponin I and measures of cardiac phenotypes was observed for left ventricular mass (p < 0.001) and left ventricular end-diastolic diameter (p < 0.001) for both, women and men. Left ventricular ejection fraction was inversely correlated with troponin I (p value <0.001 in men and 0.0013 in women), also measures of diastolic dysfunction as represented by Tei index and E/E' correlated with detectable troponin I concentrations (p < 0.001 for both gender). With respect to vascular structure and function, troponin I correlated with mean intima-media thickness of the carotid artery (p < 0.001 in men and p = 0.013 in women) but showed only borderline correlation with measures of vascular function represented by flow-mediated dilation (p = 0.05 in women and p = 0.018 in men) and arterial stiffness.

CONCLUSIONS

Troponin I assessed by a high-sensitivity assay correlated with measures of left ventricular hypertrophy and systolic and diastolic function, whereas its correlation with vascular phenotypes was only of weak magnitude.

Rationale and design of a multicenter echocardiographic study to assess the relationship between cardiac structure and function and heart failure risk in a biracial cohort of community-dwelling elderly persons: the Atherosclerosis Risk in Communities study

BACKGROUND

Heart failure is an important public health concern, particularly among persons>65 years of age. Women and blacks are critically understudied populations that carry a sizeable portion of the heart failure burden. Limited normative and prognostic data exist on measures of cardiac structure, diastolic function, and novel measures of systolic deformation in older adults living in the community.

METHODS AND RESULTS

The Atherosclerosis Risk in Communities (ARIC) study is a large, predominantly biracial, National Heart, Lung, and Blood Institute-sponsored epidemiological cohort study. Between 2011 and 2013, ≈6000 surviving participants, now in their seventh to ninth decade of life, are expected to return for a fifth study visit during which comprehensive 2-dimensional, Doppler, tissue Doppler, and speckle-tracking echocardiography will be performed uniformly in all cohort clinic visit participants. The following objectives will be addressed: (1) to characterize cardiac structural and functional abnormalities among the elderly and to determine how they differ by sex and race/ethnicity, (2) to determine the relationship between ventricular and vascular abnormalities, and (3) to prospectively examine the extent to which these noninvasive measures associate with incident heart failure.

CONCLUSIONS

We describe the design, imaging acquisition and analysis methods, and quality assurance metrics for echocardiography in visit 5 of the ARIC cohort. A better understanding of the differences in cardiac structure and function through the spectrum of heart failure stages in elderly persons generally, and between sexes and racial/ethnic groups specifically, will deepen our understanding of the pathophysiology driving heart failure progression in these at-risk populations and may inform novel prevention or therapeutic strategies.

High population prevalence of cardiac troponin I measured by a high-sensitivity assay and cardiovascular risk estimation: the MORGAM Biomarker Project Scottish Cohort

AIMS

Our aim was to test the prediction and clinical applicability of high-sensitivity assayed troponin I for incident cardiovascular events in a general middle-aged European population.

METHODS AND RESULTS

High-sensitivity assayed troponin I was measured in the Scottish Heart Health Extended Cohort (n = 15 340) with 2171 cardiovascular events (including acute coronary heart disease and probable ischaemic strokes), 714 coronary deaths (25% of all deaths), 1980 myocardial infarctions, and 797 strokes of all kinds during an average of 20 years follow-up. Detection rate above the limit of detection (LoD) was 74.8% in the overall population and 82.6% in men and 67.0% in women. Troponin I assayed by the high-sensitivity method was associated with future cardiovascular risk after full adjustment such as that individuals in the fourth category had 2.5 times the risk compared with those without detectable troponin I (P < 0.0001). These associations remained significant even for those individuals in whom levels of contemporary-sensitivity troponin I measures were not detectable. Addition of troponin I levels to clinical variables led to significant increases in risk prediction with significant improvement of the c-statistic (P < 0.0001) and net reclassification (P < 0.0001). A threshold of 4.7 pg/mL in women and 7.0 pg/mL in men is suggested to detect individuals at high risk for future cardiovascular events.

CONCLUSION

Troponin I, measured with a high-sensitivity assay, is an independent predictor of cardiovascular events and might support selection of at risk individuals.

Association of MR-proadrenomedullin with cardiovascular risk factors and subclinical cardiovascular disease

AIMS AND BACKGROUND

Midregional proadrenomedullin (MR-proADM) is a protein, which exerts various effects on the cardiovascular system. Recent studies underscored its prognostic implications in patients with acute dyspnea and cardiovascular diseases. Therefore, we aimed to determine the distribution of MR-proADM in the general population and to reveal potential associations of MR-proADM with cardiovascular risk factors and measures of subclinical cardiovascular disease.

METHODS AND RESULTS

MR-proADM plasma concentrations were determined in individuals of the population-based cohort of the Gutenberg Health Study (N = 5000) using a commercially available fluoroimmunoassay. Individuals were enrolled between April 2007 and October 2008. Subclinical cardiovascular disease was assessed using echocardiographic and functional measures of myocardial and vascular function. The mean age of the study population was 55.5 ± 10.9 years. In the overall population we determined a median MR-proADM plasma concentration of 0.44 nmol/L in men and women. MR-proADM concentrations were elevated in individuals with hypertension, diabetes, dyslipidemia, known cardiovascular disease, heart failure, peripheral artery disease, atrial fibrillation, and history of myocardial infarction and stroke. In men, we observed a positive association of MR-proADM with reduced ejection fraction, intraventricular septal diameter, wall thickness, and echocardiographic measures of diastolic dysfunction.

CONCLUSIONS

In this study, we present age-dependent reference values for MR-proADM in a representative population sample. Elevated MR-proADM plasma concentrations were strongly associated with classical cardiovascular risk factors and manifest cardiovascular diseases. Furthermore, we revealed a gender-specific association with echocardiographic measures of hypertension. MR-proADM seems to be a promising prognostic biomarker for subclinical and manifest cardiovascular disease.

[The Gutenberg Health Study]

The Gutenberg Health Study is a population-based, prospective, single-center cohort study that started in 2007 at the University Medical Center Mainz. The project focuses on cardiovascular diseases, cancer, eye diseases, metabolic diseases, diseases of the immune system and mental diseases. The study aims at improving the individual risk prediction for diseases. Therefore, lifestyle, psychosocial factors, environment, laboratory parameters as well as the extent of the subclinical disease are investigated. A comprehensive biobank enables biomolecular examinations including a systems biological approach. During the baseline visit 15,000 individuals aged 35-74 years were invited to a 5 h examination program in the study center. This will be followed by a computer-assisted telephone interview with a standardized interview and assessment of endpoints after 2.5 years. After 5 years a detailed follow-up examination comparable to the visit at study inclusion will be performed in the study center. Further follow-up visits of the cohort are envisaged.

Analyzing illumina gene expression microarray data from different tissues: methodological aspects of data analysis in the metaxpress consortium

Microarray profiling of gene expression is widely applied in molecular biology and functional genomics. Experimental and technical variations make meta-analysis of different studies challenging. In a total of 3358 samples, all from German population-based cohorts, we investigated the effect of data preprocessing and the variability due to sample processing in whole blood cell and blood monocyte gene expression data, measured on the Illumina HumanHT-12 v3 BeadChip array.

Gene expression signal intensities were similar after applying the log₂ or the variance-stabilizing transformation. In all cohorts, the first principal component (PC) explained more than 95% of the total variation. Technical factors substantially influenced signal intensity values, especially the Illumina chip assignment (33–48% of the variance), the RNA amplification batch (12–24%), the RNA isolation batch (16%), and the sample storage time, in particular the time between blood donation and RNA isolation for the whole blood cell samples (2–3%), and the time between RNA isolation and amplification for the monocyte samples (2%). White blood cell composition parameters were the strongest biological factors influencing the expression signal intensities in the whole blood cell samples (3%), followed by sex (1–2%) in both sample types. Known single nucleotide polymorphisms (SNPs) were located in 38% of the analyzed probe sequences and 4% of them included common SNPs (minor allele frequency >5%). Out of the tested SNPs, 1.4% significantly modified the probe-specific expression signals (Bonferroni corrected p-value<0.05), but in almost half of these events the signal intensities were even increased despite the occurrence of the mismatch. Thus, the vast majority of SNPs within probes had no significant effect on hybridization efficiency.

In summary, adjustment for a few selected technical factors greatly improved reliability of gene expression analyses. Such adjustments are particularly required for meta-analyses.

Age related prevalence of severe left ventricular hypertrophy in essential hypertension: echocardiographic findings from the ETODH study

AIM

We sought to investigate the prevalence and correlates of severe left ventricular hypertrophy (LVH) in relation to age in a large cohort of essential hypertensives referred to a single outpatient hypertension clinic.

METHODS

A total of 3752 (mean age 53±13 years, 53% men) untreated (29.5%) and treated hypertensive patients categorized in three age groups (I: 18-40 years; II: 41-64 years; III: ≥65 years) were considered for this analysis. All patients underwent extensive investigations searching for target organ damage. LVH, defined as LV mass ≥49/45 g/m(2.7) in men/women, respectively, was graded as mild, moderate and severe according to Lang's report.

RESULTS

LVH prevalence was 29.4% in group I, 48.2% in group II and 63.6% in group III. Overall, more than one fourth of patients with LVH had a severely increased LV mass index; the likelihood of having severe LVH was two- and four-fold higher in elderly hypertensives than in their middle-aged and young counterparts, respectively. Increasing age and LVH degree were both associated with a greater prevalence of concentric LV geometry as well as of extra-cardiac organ damage (i.e. carotid intima-media thickness).

CONCLUSIONS

LVH is a highly prevalent organ damage in essential hypertensives, particularly in the elderly, who exhibited a more severe increase of LV mass index, higher relative wall thickness and extra-cardiac organ damage compared with young and middle-aged sub-groups. Our findings suggest that the assessment of cardiovascular risk by grading LVH rather than simply defining the presence/absence of this cardiac phenotype could improve therapeutic strategies in the hypertensive population, particularly in the elderly.

Monozygotic twins discordant for constitutive BRCA1 promoter methylation, childhood cancer and secondary cancer

We describe monozygotic twins discordant for childhood leukemia and secondary thyroid carcinoma. We used bisulfite pyrosequencing to compare the constitutive promoter methylation of BRCA1 and several other tumor suppressor genes in primary fibroblasts. The affected twin displayed an increased BRCA1 methylation (12%), compared with her sister (3%). Subsequent bisulfite plasmid sequencing demonstrated that 13% (6 of 47) BRCA1 alleles were fully methylated in the affected twin, whereas her sister displayed only single CpG errors without functional implications. This between-twin methylation difference was also found in irradiated fibroblasts and untreated saliva cells. The BRCA1 epimutation may have originated by an early somatic event in the affected twin: approximately 25% of her body cells derived from different embryonic cell lineages carry one epigenetically inactivated BRCA1 allele. This epimutation was associated with reduced basal protein levels and a higher induction of BRCA1 after DNA damage. In addition, we performed a genome-wide microarray analysis of both sisters and found several copy number variations, i.e., heterozygous deletion and reduced expression of the RSPO3 gene in the affected twin. This monozygotic twin pair represents an impressive example of epigenetic somatic mosaicism, suggesting a role for constitutive epimutations, maybe along with de novo genetic alterations in recurrent tumor development.