Clinical Significance of Cardio-Ankle Vascular Index as a Cardiovascular Risk Factor in Elderly Patients With Type 2 Diabetes Mellitus

Predictive value of Systematic Coronary Risk Evaluation 2-Diabetes risk model and arterial stiffness for cardiovascular events in the Asian population with type 2 diabetes mellitus

AIMS/INTRODUCTION

Individuals with diabetes are at high risk of developing cardiovascular events. The present study investigated the predictive value of the cardio-ankle vascular index (CAVI) when added to the Systematic Coronary Risk Evaluation 2-Diabetes (SCORE2-Diabetes) risk algorithm to predict cardiovascular events in the Asian population.

MATERIALS AND METHODS

The SCORE2-Diabetes risk was assessed in 1,502 patients with diabetes, aged 40-69 years. Then, we further stratified each 10-year risk category with a CAVI value of 9.0. The primary outcomes (composite of all causes of death, myocardial infarction, stroke and hospitalization for heart failure) were assessed over 5 years.

RESULTS

The mean age of the population was 59.8 ± 6.4 years. The proportion of 10-year risk according to the SCORE2-Diabetes risk of low, moderate, high and very high risk identified at 7.2, 30.0, 27.2 and 35.6%, respectively. The mean CAVI value was 8.4 ± 1.4, and approximately 35.4% of the patients had CAVI ≥9.0. The SCORE2-Diabetes risk algorithm independently predicted the primary outcomes in patients with diabetes (hazard ratio 1.18, 95% confidence interval [CI] 1.13-1.22), whereas CAVI did not (hazard ratio 1.03, 95% CI 0.89-1.18). The C-index for the primary outcomes of the SCORE2-Diabetes risk algorithm alone was 0.72 (95% CI 0.67-0.77). The combination of SCORE2-Diabetes and CAVI, both in the continuous value and risk groups, did not improve discrimination (C-index 0.72, 95% CI 0.67-0.77 and 0.68, 95% CI 0.64-0.74, respectively).

CONCLUSIONS

Adding the CAVI to the SCORE2-Diabetes risk algorithm did not improve individual risk stratification in patients with diabetes.

Model-Based Assessment of the Reference Values of CAVI in Healthy Russian Population and Benchmarking With CAVI0

BACKGROUND

Cardio-ankle vascular index (CAVI) and its modified version (CAVI0) are promising non-invasive markers of arterial stiffness, extensively evaluated primarily in the Japanese population. In this work, we performed a model-based analysis of the association between different population characteristics and CAVI or CAVI0 values in healthy Russian subjects and propose a tool for calculating the range of reference values for both types of indices.

METHODS

The analysis was based on the data from 742 healthy volunteers (mean age 30.4 years; 73.45% men) collected from a multicenter observational study. Basic statistical analysis [analysis of variance, Pearson's correlation (r), significance tests] and multivariable linear regression were performed in R software (version 4.0.2). Tested covariates included age, sex, BMI, blood pressure, and heart rate (HR).

RESULTS

No statistically significant difference between healthy men and women were observed for CAVI and CAVI0. In contrast, both indices were positively associated with age (r = 0.49 and r = 0.43, P < 0.001), however, with no clear distinction between subjects of 20-30 and 30-40 years old. Heart rate and blood pressure were also identified as statistically significant predictors following multiple linear regression modeling, but with marginal clinical significance. Finally, the algorithm for the calculation of the expected ranges of CAVI in healthy population was proposed, for a given age category, HR and pulse pressure (PP) values.

CONCLUSIONS

We have evaluated the quantitative association between various population characteristics, CAVI, and CAVI0 values and established a method for estimating the subject-level reference CAVI and CAVI0 measurements.

Rapid Rise in Cardio-Ankle Vascular Index as a Predictor of Impending Cardiovascular Events -Smooth Muscle Cell Contraction Hypothesis for Plaque Rupture

Predictive factors for vascular events have not been established. The vasculature of the atheroma is supplied by penetration of the vasa vasorum through the smooth muscle cell layer from the adventitia. Smooth muscle cell contraction induces compression of the vasa vasorum, resulting in ischemia in intimal atheromatous lesions. Cardio-ankle vascular index (CAVI) has become known as an index of arterial stiffness of the arterial tree from the origin of the aorta to the ankle. CAVI reflects the progress of arteriosclerosis, and a rapid rise in CAVI indicates arterial smooth muscle cell contraction. We hypothesized that rapidly increased arterial stiffness evaluated by CAVI may be a predictor of impending cardiovascular events.

The Prognostic Value of Derivatives-Reactive Oxygen Metabolites (d-ROMs) for Cardiovascular Disease Events and Mortality: A Review

Oxidative stress participates in the development and exacerbation of cardiovascular diseases (CVD). The ability to promptly quantify an imbalance in an individual reductive-oxidative (RedOx) state could improve cardiovascular risk assessment and management. Derivatives-reactive oxygen metabolites (d-ROMs) are an emerging biomarker of oxidative stress quantifiable in minutes through standard biochemical analysers or by a bedside point-of-care test. The current review evaluates available data on the prognostic value of d-ROMs for CVD events and mortality in individuals with known and unknown CVD. Outcome studies involving small and large cohorts were analysed and hazard ratio, risk ratio, odds ratio, and mean differences were used as measures of effect. High d-ROM plasma levels were found to be an independent predictor of CVD events and mortality. Risk begins increasing at d-ROM levels higher than 340 UCARR and rises considerably above 400 UCARR. Conversely, low d-ROM plasma levels are a good negative predictor for CVD events in patients with coronary artery disease and heart failure. Moreover, combining d-ROMs with other relevant biomarkers routinely used in clinical practice might support a more precise cardiovascular risk assessment. We conclude that d-ROMs represent an emerging oxidative-stress-related biomarker with the potential for better risk stratification both in primary and secondary cardiovascular prevention.

Relationships Between Skin Autofluorescence and Cardio-Ankle Vascular Index in Japanese Male Patients With Metabolic Syndrome

Background

An autofluorescence (AF) reader can be used to noninvasively measure tissues that accumulated advanced glycation end-products to diagnose skin AF. This study aimed to clarify the clinical significance of skin AF as a risk factor for cardiovascular disease in Japanese male patients with metabolic syndrome using the cardio-ankle vascular index (CAVI) as a marker of arterial function.

Methods

This cross-sectional study enrolled 261 Japanese male patients with metabolic syndrome without history of cardiovascular disease (mean age, 58 ± 7 years (mean ± standard deviation)). Associations between skin AF and various clinical parameters including CAVI were examined.

Results

Skin AF was significantly positively correlated with CAVI (r = 0.40, P < 0.001). Furthermore, multiple regression analyses revealed that skin AF (β = 0.18, P = 0.002) was selected as an independent subordinate factor for CAVI. Meanwhile, homeostatic model assessment of insulin resistance (HOMA-IR) as a marker of insulin resistance, smoking habits and high-sensitivity C-reactive protein as an inflammation marker were independent variables for either CAVI or skin AF as a subordinate factor. According to the receiver-operating characteristic curve analysis and results of previous reports that determined CAVI of ≥ 9.0 as a diagnostic criterion for vascular failure, skin AF of > 2.7 arbitrary unit is the optimal cut-off point for discriminating high CAVI (area under the curve = 0.718, P < 0.001).

Conclusion

Findings in this study indicate that skin AF may be an important risk factor of cardiovascular disease in Japanese male patients with metabolic syndrome. In addition, the risk value of skin AF was considered as higher than 2.7 arbitrary unit. Further investigations in a large number of prospective studies, including intervention therapies, are required to validate the results in this study.

Clinical Impact of Blood Testosterone Concentration on Cardio-Ankle Vascular Index in Female Patients With Type 2 Diabetes Mellitus

Background

Information regarding testosterone as a significant risk factor of cardiovascular disease (CVD) in female patients with type 2 diabetes mellitus (DM) is limited. However, some clinical studies reported the importance of cardio-ankle vascular index (CAVI) as a novel physiological marker of arterial function in type 2 DM. This cross-sectional study aimed to elucidate the clinical effects of blood testosterone concentration on CAVI in female patients with type 2 DM.

Methods

A total of 238 postmenopausal patients including 97 with a history of CVD with type 2 DM (age (mean ± standard deviation (SD)), 73 ± 9 years) were enrolled. CAVI was measured according to the standard technique, and serum total testosterone concentration (T-T) was also measured as a testosterone level marker in vivo. The relationship between CAVI and T-T was evaluated.

Results

CAVI is significantly higher (CVD vs. non-CVD: 10.2 ± 1.2 vs. 9.2 ± 1.0, P < 0.001), and log-T-T significantly lower (CVD vs. non-CVD: 1.2 ± 0.2 ng/dL vs. 1.5 ± 0.2 ng/dL, P < 0.001) in patients with CVD than those without CVD. CAVI was significantly negatively correlated with log-T-T (r = -0.41; P < 0.001). Furthermore, multiple regression analysis indicated that CVD (β = 0.23; P < 0.001) and log-T-T (β = -0.18; P < 0.01) were selected as independent subordinate variables for CAVI.

Conclusions

This study showed that T-T was independently inversely associated with CAVI, indicating that low testosterone concentration is a considerable risk factor for the progression of arterial dysfunction in female patients with type 2 DM.

Atherosclerosis as a predictor of transient exacerbation of overactive bladder symptoms after robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

To assess whether atherosclerosis is involved in the development of overactive bladder and the function of lower urinary tract after robot-assisted radical prostatectomy.

METHODS

The present cohort consisted of 80 consecutive participants. The preoperative cardio-ankle vascular index was used to evaluate the presence of atherosclerosis. The present cohort was split into two groups, the atherosclerotic group, whose cardio-ankle vascular index was ≥9.0, and the control group, whose index was <9.0. The overactive bladder symptom score and lower urinary tract function were compared for 12 months after surgery.

RESULTS

The total score of the questionnaire was significantly higher at 6 and 9 months after surgery in the atherosclerosis group (P = 0.04, P = 0.03, respectively). Both the urgency and urgency incontinence subscores of the questionnaire showed a parallel tendency to that of the total score after surgery. At 3 months after surgery, there was a significant increase in the prevalence of de novo overactive bladder in the atherosclerosis group (P = 0.04). At 9 and 12 months after surgery, there was a significant decrease of voided volume in the atherosclerotic group (P < 0.01, P = 0.04, respectively).

CONCLUSIONS

Atherosclerosis delays the improvement in both overactive bladder symptoms and storage function postoperatively, and it is involved in the transient increase in the prevalence of de novo overactive bladder. Atherosclerosis might be a predictor of the development of overactive bladder after robot-assisted radical prostatectomy.

Clinical Usefulness of the Cardio-Ankle Vascular Index as a Predictor of Primary Cardiovascular Events in Patients With Chronic Kidney Disease

Background

The cardio-ankle vascular index (CAVI) is a physiologic marker reflecting arterial function. There have been no prospective studies investigating the relationship between CAVI and cardiovascular events in patients with chronic kidney disease (CKD). The aim of this prospective study was to assess the clinical usefulness of CAVI as a predictor of primary cardiovascular events in patients with CKD.

Methods

The study enrolled 460 outpatients with CKD but no history of cardiovascular disease (152 men and 308 women; mean ± standard deviation age, 74 ± 12 years). Patients were assigned to one of three groups: low (L, CAVI < 9; n = 100), medium (M, CAVI 9 - 10; n = 199), or high (H, CAVI > 10; n = 161). The utility of the CAVI as a predictor of primary cardiovascular events was evaluated.

Results

During the follow-up period (median 60.1 months), major adverse cardiovascular events (MACE) occurred in 91 cases (L, 8 (8.0%); M, 31 (15.6%); H, 52 (32.3%); P < 0.001, log-rank test). On multivariate Cox regression analysis, the risk for a MACE was significantly higher in group H than in non-group H (hazard ratio, 2.04; 95% confidence interval, 1.31 - 3.02; P < 0.01). A CAVI cut-off of 9.7 yielded the largest area under the curve, 0.701 (95% confidence interval: 0.657 - 0.743, P < 0.001), indicating a sensitivity of 74.0% and a specificity of 59.6% for discriminating between those who did and did not experience a MACE during follow-up.

Conclusions

The results of this study showed that a high CAVI is a predictor of primary cardiovascular events in patients with CKD.

Usefulness of the Whole Blood Passage Time as a Predictor of Primary Cardiovascular Events in Patients With Traditional Cardiovascular Risk Factors

BACKGROUND

Recent clinical studies have reported that impaired hemorheology is a significant cardiovascular risk factor, but there has been no prospective study of its relationship with cardiovascular events. The aim of this prospective study was to assess the efficacy of whole blood passage time (WBPT), measured by a microchannel array flow analyzer (MC-FAN), as a predictor of primary cardiovascular events in patients with traditional cardiovascular risk factors.

METHODS

The study enrolled 1,134 outpatients with traditional cardiovascular risk factors but no history of cardiovascular events (438 men and 696 women; mean ± standard deviation age, 67 ± 11 years). Based on the value of WBPT, the patients were assigned to one of three groups: L (low, WBPT < 50 s; n = 499), M (medium, WBPT 50 - 70 s; n = 295), or H (high, WBPT > 70 s; n = 340). The utility of the WBPT as a predictor of primary cardiovascular events was evaluated.

RESULTS

During the follow-up period (median 81.9 months), major adverse cardiovascular events (MACE) occurred in 95 cases (L, 21 cases (4.2%); M, 24 cases (8.1%); H, 50 cases (14.7%); P < 0.001, log-rank test). In multivariate Cox regression analyses, the risk for MACE was significantly higher in group H than in group L (hazard ratio, 2.32; 95% confidence interval, 1.31 - 3.20; P < 0.01). A WBPT cut-off of 72.4 s yielded the largest area under the curve of 0.705 (95% confidence interval: 0.678 - 0.732), with a sensitivity of 51.7% and specificity of 85.4% for discriminating between those who did and did not experience MACE during the follow-up period.

CONCLUSION

This study showed that WBPT evaluated by a MC-FAN was a predictor of primary cardiovascular events in patients with traditional cardiovascular risk factors.

Clinical Significance of Skin Autofluorescence in Patients With Type 2 Diabetes Mellitus With Chronic Heart Failure

Background

Recent clinical studies have shown that skin autofluorescence (AF) levels are significantly associated with diabetic complications. In contrast, data regarding the relationships between skin AF and chronic heart failure (CHF) are limited. The aim of this study was to clarify the clinical significance of skin AF in patients with type 2 diabetes mellitus (DM) with CHF.

Methods

This cross-sectional study enrolled 257 outpatients with type 2 DM with CHF who were treated medically (96 men and 161 women; mean age, 79 ± 7 years). Associations between skin AF and various clinical parameters were examined.

Results

Incidence of skin AF in patients with a history of hospitalization due to HF was significantly higher than in those without a history of hospitalization due to HF (3.0 ± 0.5 AU vs. 2.7 ± 0.5 AU, respectively, P < 0.001). Significant positive correlations were found between skin AF and various clinical parameters, such as E/e′ as a maker of left ventricular diastolic function (r = 0.30, P < 0.001), high-sensitivity cardiac troponin T levels as a marker of myocardial injury (r = 0.45, P < 0.001), reactive oxygen metabolite levels as an oxidative stress marker (r = 0.31, P < 0.001), and cardio-ankle vascular index as a marker of arterial function (r = 0.38, P < 0.001). Furthermore, multiple regression analyses showed that these clinical parameters (E/e′ (β = 0.25, P < 0.001)), high-sensitivity cardiac troponin T levels (β = 0.30, P < 0.001), cardio-ankle vascular index (β = 0.21, P < 0.001), reactive oxygen metabolite levels (β = 0.15, P < 0.01), and a history of hospitalization due to HF (β = 0.23, P < 0.001) were independent variables when skin AF was used as a subordinate factor.

Conclusion

The findings of this study showed that skin AF may be a determining factor for prognosis in patients with type 2 DM with CHF. Further investigations in a large prospective study, including intervention therapies, are required to validate the results of this study.