Joint Effects of Plasma Homocysteine Concentration and Traditional Cardiovascular Risk Factors on the Risk of New-Onset Peripheral Arterial Disease

Synergies between diabetes and hyperhomocysteinaemia: New insights to predict and prevent adverse cardiovascular effects

AIM

To explore the association of hyperhomocysteinaemia (HHcy) and diabetes synergies with cardiovascular events in the adult population of northern China.

METHODS

Data were collected from the Asymptomatic Polyvascular Abnomalities Community study for 2010 to 2019. Serum homocysteine (Hcy) levels were determined by enzyme-linked immunosorbent assay. The participants were categorized into four groups based on their Hcy levels and diabetes status: non-diabetes/non-HHcy, non-diabetes/HHcy, diabetes/non-HHcy and diabetes/HHcy. The composite endpoint consisted of the occurrence of first-ever stroke, myocardial infraction (MI) or all-cause mortality. Cox regression analyses were performed to evaluate the associations of diabetes and HHcy with cardiovascular disease (CVD) events.

RESULTS

In total, 5278 participants were eligible (average age 55.1 years, 60% male). Over a follow-up of 9.1 years, 618 events were identified, 202 stroke, 52 MI and 406 all-cause deaths. Compared with the non-diabetes/non-HHcy group, hazard ratios with 95% confidence intervals in the diabetes/HHcy group for stroke, MI, major adverse cardiovascular event (MACE), all-cause death and composite endpoint were 1.85 (1.12-3.04), 1.33 (0.42-4.23), 1.78 (1.13-2.80), 2.24 (1.56-3.23) and 1.97 (1.47-2.65), respectively. Significant interactions between HHcy and diabetes status were found for stroke, MI and MACE (P for interaction = .002, .027 and .044, respectively). In addition, the association of diabetes/HHcy with stroke was modified by age (< 60 and ≥ 60 years; P for interaction = .016).

CONCLUSIONS

The findings highlight the synergistic impact of diabetes and HHcy on CVD. Joint assessments of diabetes and Hcy levels should be emphasized for risk stratification and primary prevention of CVD.

Association between serum folate levels and migraine or severe headaches: A nationwide cross-sectional study

Migraine and severe headaches are common neurological disorders with significant societal impact. Previous research indicates a potential link between serum folate levels and migraine occurrence, yet there is a lack of sufficient relevant studies and more are required. This study aimed to determine the association between a severe headache or migraine and serum folate levels in large populations. Using data from the National Health and Nutrition Examination Survey, we conducted a cross-sectional study. Using multivariable logistic regression models, we investigated the association between serum folate and severe headache or migraine. In a subsequent subgroup analysis, several confounding factors were also explored to investigate the association between migraine and serum folate. A total of 13,351 individuals participated in the study, with 2742 reporting severe headache or migraine in the previous 3 months. Serum folate was negatively associated with severe headache or migraine (odds ratio [OR] = 0.5, 95% confidence interval [CI] = 0.28-0.89, P = .018). The stratified analysis revealed this association persisted among female (OR = 0.38, 95% CI = 0.18-0.82, P < .001), individuals aged 20 to 50 years (OR = 0.53, 95% CI = 0.28-0.99, P < .001), and non-Hispanic White participants (OR = 0.38, 95% CI = 0.17-0.87, P < .001). We found that greater levels of serum folate were significantly related to a decreased likelihood of migraine onset, especially among women, young and middle-aged populations, and non-Hispanic White participants. Further research is required to validate and expand upon our results.

Association of plasma homocysteine with peripheral arterial disease in the hypertensive adults: A cross-sectional study

Increased plasma homocysteine (Hcy) has been identified as one of the important risk factors for cardiovascular disease. However, the association between plasma Hcy and peripheral artery disease (PAD) is still controversial. This study aimed to investigate the association between plasma Hcy and PAD and the potential modifier factors in Chinese hypertensive adults. A total of 25 300 hypertensive patients aged 18 years or older were included in the analysis in this cross-sectional study. The outcome was PAD, which defined as an ankle-brachial index ≤0.90 in either limb. Multiple logistic regression was used to analyze the relationship between plasma Hcy and PAD. The median plasma Hcy was 14.00 (interquartile range: 11.60-17.80) μmol/L. There was a significant positive association between plasma Hcy and PAD (per SD increment; OR: 1.13; 95% CI: 1.06-1.19). Patients in the upper plasma Hcy tertile (≥16.16 μmol/L) were associated with a 53% increased risk of PAD compared with patients in the lower tertile (<12.33 μmol/L) after adjustment for multiple potential confounders. Subgroup analyses showed the association between Hcy and PAD was robust among various strata. Among Chinese adults with hypertension, plasma Hcy is an independent risk factor for PAD. This finding may improve the risk stratification of PAD.

Association between geriatric nutritional risk index and depression prevalence in the elderly population in NHANES

BACKGROUND

The prevalence of depression is increasing in the elderly population, and growing evidence suggests that malnutrition impacts mental health. Despites, research on the factors that predict depression is limited.

METHODS

We included 2946 elderly individuals from National Health and Nutrition Examination Survey (NHANES) spanning the years 2011 through 2014. Depressive symptoms were assessed using the PHQ-9 scale. Multinomial logistic regression was performed to evaluate the independent association between Geriatric Nutritional Risk Index (GNRI) and depression prevalence and scores. Subgroup analysis was conducted to explore potential factors influencing the negative correlation between GNRI and depression. Restricted cubic spline graph was employed to examine the presence of a non-linear relationship between GNRI and depression.

RESULTS

The depression group had a significantly lower GNRI than the non-depression group, and multivariate logistic regression showed that GNRI was a significant predictor of depression (P < 0.001). Subgroup analysis revealed that certain demographic characteristics were associated with a lower incidence of depression in individuals affected by GNRIs. These characteristics included being female (P < 0.0001), non-Hispanic black (P = 0.0003), having a moderate BMI (P = 0.0005), having a college or associates (AA) degree (P = 0.0003), being married (P = 0.0001), having a PIR between 1.50 and 3.49 (P = 0.0002), being a former smoker (P = 0.0002), and having no history of cardiovascular disease (P < 0.0001), hypertension (P < 0.0001), and diabetes (P = 0.0027). Additionally, a non-linear negative correlation (non-linear P < 0.01) was found between GNRI and depression prevalence, with a threshold identified at GNRI = 104.17814.

CONCLUSION

The GNRI demonstrates efficacy as a reliable indicator for forecasting depression in the elderly population. It exhibits a negative nonlinear correlation with the prevalence of depression among geriatric individuals.

Additive effect between homocysteine and low-density-lipoprotein cholesterol upon incidence of novel carotid plaque formation: data from a Chinese community-based cohort

OBJECTIVE

Homocysteine (HCY) has been associated with carotid plaque in cross-sectional studies, but the prospective relationship between HCY and incident carotid plaque has not been well established. The purpose of this study was to investigate the association between HCY and incidence of novel carotid plaque in a Chinese community-based population without pre-existing carotid atherosclerosis and to assess the additive effect of HCY and low-density lipoprotein cholesterol (LDL-C) on the incidence of novel plaque.

METHODS

At baseline, we measured HCY and other risk factors in subjects aged ≥ 40 years. All participants underwent carotid ultrasound examinations at baseline and after an average of 6.8 years of follow-up. Incidence of plaque was identified if plaque was absent at baseline, but plaque was detected at the end of follow-up. A total of 474 subjects were included in the analysis.

RESULTS

The incidence of novel carotid plaque was 24.47%. Multivariate regression analyses showed that HCY was independently associated with a 1.05-fold-higher likelihood for incident novel plaque (adjusted odds ratio [OR] = 1.05, 95% confidence interval [CI]: 1.01-1.09, P = 0.008). Using tertile 1 and tertile 2 for reference, the top HCY tertile (T3) showed a 2.28-fold-higher likelihood for incident plaque (adjusted OR = 2.28, 95%CI: 1.33-3.93, P = 0.002). The combination of HCY T3 and LDL-C ≥ 3.4 mmol/L had the highest risk for novel plaque formation (adjusted OR = 3.63, 95%CI: 1.67-7.85, P = 0.001) compared to those without either condition. In the LDL-C ≥ 3.4 mmol/L subgroup, HCY was significantly associated with incidence of plaque (adjusted OR = 1.16, 95%CI: 1.04-1.28, P = 0.005, P-interaction = 0.023).

CONCLUSION

In the Chinese community-based population, HCY was independently associated with the incidence of novel carotid plaque. There were additive effect between HCY and LDL-C on the incidence of plaque, the highest risk was observed in individuals with both high HCY levels and LDL-C ≥ 3.4 mmol/L. Our findings suggest that HCY may be a potential target for preventing the incidence of carotid plaque, particularly in individuals with elevated LDL-C levels.

Circulating level of homocysteine contributes to diabetic retinopathy associated with dysregulated lipid profile and impaired kidney function in patients with type 2 diabetes mellitus

BACKGROUND

To test the hypothesis that elevated plasma levels of homocysteine (Hcy) and lipoprotein (a) (LPA) contribute to diabetic retinopathy (DR) associated with dysregulated lipid profile, dyslipidaemia, and kidney function.

METHODS

A total of 83 patients with type 2 diabetes mellitus (T2DM) were enrolled in this prospective case-control study. Patients were categorized into those with no DR (DM), non-proliferative DR (NPDR), and proliferative DR (PDR). Age and sex-matched individuals with no diabetes were included in the control group. Biochemical tests, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), Hcy, LPA, lipid profile, and urine microalbumin (UMA), were evaluated.

RESULTS

Hcy was negatively correlated with high-density lipoprotein-cholesterol (HDL-C) (p < 0.05), but positively correlated with [total cholesterol (TC)-HDL-C)/HDL-C] (p < 0.05), low-density lipoprotein cholesterol (LDL-C)/HDL-C (p < 0.05), and UMA (p < 0.05). Traditional risk factors, Hcy, arteriosclerosis-associated plasma indices, and UMA, resulted as the independent risk factors for the occurrence of DM and DR. After controlling for age, sex, duration of DM, and FBG, a multiple ordinal logistic regression model showed that LPA [OR = 2.90, 95% confidence interval (95% CI) 1.16-7.23, p = 0.023)], LDL-C (OR = 4.28, 95% CI 1.24-14.79, p = 0.021), and (TC-HDL-C)/HDL-C (OR = 1.92, 95% CI 1.05-3.53, p = 0.035) were risk factors for DM and DR.

CONCLUSIONS

Hcy and LPA contributed to DM and DR. Hcy was positively correlated with kidney dysfunction and the ratios of lipid profiles, and negatively with HDL-C, LPA, LDL-C, and (TC-HDL-C)/HDL-C resulted as predictors of the occurrence of DM and severity of DR.

Association of Blood Heavy Metal Exposure with Atherosclerotic Cardiovascular Disease (ASCVD) Among White Adults: Evidence from NHANES 1999-2018

Cardiovascular diseases (CVD) are main public health concerns highly prevalent in industrialized societies where human health is threatened by a series of environmental pollutants, particularly heavy metal contaminants. We aimed to find out if blood heavy metals are associated with the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) in a nationally representative sample of US adults. We analyzed the cross-sectional data on blood heavy metals of 3268 non-Hispanic white participants aged 40-79 years from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. We introduced a risk estimation algorithm, namely the 2013 Pooled Cohort Equations (PCE), to assess the risk for ASCVD over a 10-year period. The 10-year risk for ASCVD was categorized as either reduced risk (< 7.5% risk) or elevated risk (≥ 7.5% risk). Blood lead, cadmium, and mercury were distributed into four quartiles. We used weighted multivariate logistic regression models and restricted cubic spline (RCS) regression to detect the association of blood heavy metal exposure with 10-year ASCVD risk. Following the adjustment of covariates, the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for elevated 10-year ASCVD risk for participants from the highest quartiles were 4.50 (2.88-7.02), 2.59 (1.68-4.00), and 1.06 (0.66-1.71) for blood cadmium, lead, and mercury compared to the lowest quartiles, respectively. The RCS plot demonstrated that blood cadmium was linearly and positively associated with 10-year ASCVD risk (P for nonlinearity = 0.112). According to our findings, non-Hispanic whites aged 40-79 years had a greater 10-year ASCVD risk as their blood lead and cadmium levels increased. Consequently, when establishing approaches for ASCVD prevention, blood heavy metals should be considered.

Association between migraine and cardiovascular disease: A cross-sectional study

Background

Cardiovascular disease (CVD) poses a tremendous threat to global health, giving rise to exceedingly high morbidity and mortality among patients. A migraine is a common neurological disorder characterized by recurrent attacks of severe headache, while its cardiovascular burden remains unclear. Therefore, this study aims to investigate whether migraine is associated with CVD.

Methods

The cross-sectional data of 5,692 subjects aged 20 or above was obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. To determine whether migraine is associated with CVD, weighted logistic regression models were used. In a subsequent subgroup analysis, several confounding factors were also explored to investigate the association between migraine and CVD.

Results

In total, 5,692 subjects were enrolled in this study, with the prevalence of CVD being 13.3%. Participants with CVD tended to be older, male, non-Hispanic whites, more educated, former smokers, and alcohol drinkers, and had a higher waist circumference, less physical activity, a higher level of triglyceride and creatinine as well as a lower level of high-density lipoprotein cholesterol (HDL-C) and estimated glomerular filtration rate (eGFR) (all P < 0.05). Considering all potential confounders, migraine was associated with a higher risk of CVD [odds ratios (ORs) 2.77; 95% confidence intervals (CIs): 1.56-4.90]. Subgroup analysis showed a higher risk of CVD in females, those older than 60 years, with a lower body mass index (BMI) level (≤ 30 kg/m²), a higher level of eGFR (> 90 mL/min/1.73 m²), hypertension and hyperlipidemia and without diabetes.

Conclusion

In summary, our study revealed a positive association between migraine with CVD in a nationally representative US adult population. Our findings highlighted that migraine should be considered an important risk factor for CVD.

Relationship between serum homocysteine, fibrinogen, lipoprotein-a level, and peripheral arterial disease: a dose-response meta-analysis

AIM

At present, the relationship between serum homocysteine (Hcy), fibrinogen (FIB), lipoprotein-a (LPa), and PAD is uncertain, and there has been no meta-analysis to establish the dose-response relationship between their exposure levels and PAD.

METHODS AND RESULTS

Relevant literature published in PubMed, Embase, and Web of Science was retrieved. The robust error meta-regression method was used to assess the linear and non-linear dose-response relationship between exposure level and PAD risk. A total of 68 articles, involving 565,209 participants, were included. Combined with continuous variables, the serum Hcy, FIB, and LPa levels of PAD patients were significantly higher than those of healthy individuals. The odds ratios (ORs) of PAD for individuals with high Hcy, FIB, and LPa levels compared with those with low levels were 1.47, 1.14, and 1.76, respectively. The study also showed that circulating Hcy, FIB, and LPa were significantly elevated in patients with PAD compared with controls. The level of Hcy and the risk of PAD presented a U-shaped distribution. The nonlinear dose-response model showed that each 1 μmol/L increase in serum Hcy increased the risk of PAD by 7%. Similarly, for each 10 mg/dL FIB and 10 mg/dL LPa increases, the risk of PAD increased by 3% and 6%, respectively.

CONCLUSIONS

This meta-analysis provided evidence that elevated Hcy, PIB, and LPa levels may increase the risk of PAD, and the risk of PAD increases with the increase in serum exposure within a certain range. By controlling Hcy level, the incidence of PAD may be reduced to control the PAD growing epidemic.

TRIAL REGISTRATION NUMBER

PROSPERO (CRD42021250501), https://www.crd.york.ac.uk/prospero/.

Association of Plasma Bilirubin Levels With Peripheral Arterial Disease in Chinese Hypertensive Patients: New Insight on Sex Differences

Background and aims: Previous studies have indicated that Plasma total bilirubin (TBiL) might play an essential role in peripheral arterial disease (PAD). However, the effects of different levels of TBiL on PAD development remain uncertain. We aimed to examine the TBiL and the prevalence of PAD among Chinese adults with hypertension, with particular attention paid to sex differences.

Methods: A total of 10,900 hypertensive subjects were included in the current study. The mean age of our study participants was 63.86 ± 9.25 years, and there were 5,129 males and 5,771 females. The outcome was peripheral arterial disease (PAD), defined as present when the ankle-brachial index (ABI) of either side was ≤0.90. The association between TBiL and PAD was examined using multivariate logistic regression analysis and the restricted cubic spline.

Results: Of 10,900 hypertensive participants, 350 (3.21%) had PAD, and the mean plasma total bilirubin was 14.66 (6.86) μmol/L. The mean TBiL was 15.67 μmol/L in men and 13.76 μmol/L in women. The smoothing curve showed that a U-shaped curve association existed between TBiL and the prevalence of PAD in Chinese adults with hypertension. When stratified by sex, TBiL was significantly U-shaped associated with PAD among men but not women. Among males, the inflection point was 11.48 μmol/L; to the left inflection point, the effect size and 95% CI were 0.08, 0.01, 0.66, respectively; to the right inflection point, OR, 5.16; 95% CI,1.64, 16.25.

Conclusions: We found an independent U-shaped association between TBiL and the prevalence of PAD among hypertensive subjects and a differential association between men and women. We further revealed a turning point by threshold effect analysis.

Effects of individualized administration of folic acid on prothrombotic state and vascular endothelial function with H-type hypertension: A double-blinded, randomized clinical cohort study

BACKGROUND

Hypertension and hyperhomocysteinemia (HHcy) have long been associated with adverse cardiovascular and cerebrovascular health outcomes. This study evaluated the effect of individualized administration of folic acid (FA) on homocysteine (Hcy) levels, prothrombotic state, and blood pressure (BP) in patients with H-type hypertension (combination of HHcy and hypertension).

METHODS

In this double-blinded, randomized clinical cohort study, 126 patients with H-type hypertension who were treated at our hospital were randomly divided into treatment and control groups (n = 55 each). The control group was treated with oral levamlodipine besylate tablets 2.5 mg and placebo, once a day (in the morning). The treatment group was first treated with oral levamlodipine besylate 2.5 mg and FA tablets 0.8 mg, once a day (in the morning), for 12 weeks. Then, in a second 12-week phase, the FA dose was adjusted using the methylene tetrahydrofolate reductase C677 polymorphism genotype. The levels of Hcy and coagulation factors, prothrombotic state parameters, BP, and adverse drug reactions were compared between the 2 groups.

RESULTS

Pretreatment general patient characteristics, including Hcy levels, were similar between the 2 groups (P > .05). BP and prothrombotic status did not differ before and after the first phase of treatment (P > .05). However, Hcy and endothelin-1 (ET-1) levels decreased, while nitric oxide levels increased significantly in the intervention group (P < .05). In the second phase, after 3 months' treatment with an FA dose adjusted according to methylene tetrahydrofolate reductase C677T genotype, the Hcy and ET-1/NO levels were significantly decreased in the intervention group and were lower than those after the first treatment phase and lower than in the control group (P < .01). BP, D-dimer levels, and fibrinogen scores were significantly lower after the second treatment phase (P < .01). There was no significant difference in the incidence of adverse drug reactions between the 2 groups (P > .05).

CONCLUSIONS

Individualized administration of FA tablets can effectively reduce BP, and Hcy and coagulation factor levels, and significantly improve prothrombotic status in patients with H-type hypertension.

Iron Metabolism Markers and Lower Extremity Arterial Disease in People with Type 2 Diabetes

OBJECTIVE

To determine the levels of serum iron, ferritin, total iron-binding capacity, and hepcidin in patients with type 2 diabetes mellitus (T2DM), and to elucidate the relationship of these biomarkers with lower extremity arterial disease (LEAD).

METHODS

Three hundred fifteen patients with T2DM were selected for the study and divided into non-LEAD (n = 119) and LEAD groups (n=196) based on the ankle-brachial index (ABI) results. Demographic data and clinical test results were collected from all patients. Serum iron, ferritin, total iron-binding capacity, and hepcidin levels were measured, and the transferrin saturation was calculated.

RESULTS

Hepcidin levels were substantially higher in the LEAD group (19.17 ± 8.66 ng/mL) than the non-LEAD group (15.44±7.55 ng/mL, P < 0.001), and there was a negative correlation between the ABI and serum lecithin level (r = -0.349, P < 0.001). There were no other correlations with the other iron metabolism indicators. The results of dichotomous logistic regression with LEAD as the dependent variable revealed that smoking history (OR = 4.442, P = 0.008), hypertension history (OR = 3.721, P = 0.006), cardiovascular disease history (OR = 11.126, P < 0.001), diabetes duration (OR = 1.305, P < 0.001), age (OR = 1.056, P = 0.021), hs-CRP level (OR = 1.376, P = 0.002), HbA1c concentration (OR = 1.394, P = 0.001), and hepcidin level (OR = 1.097, P = 0.003) were independent risk factors for LEAD in T2DM patients.

CONCLUSION

Serum hepcidin levels were elevated in the LEAD group compared with the non-LEAD group, and elevated hepcidin levels were associated with the development of LEAD in T2DM patients, suggesting that hepcidin may be involved in the occurrence and development of LEAD in T2DM patients.

Association between serum Klotho levels and the prevalence of diabetes among adults in the United States

BACKGROUND

Diabetes is a critical contributor to the pathogenesis of cardiovascular diseases. Klotho is an anti-aging protein with cardiovascular-renal protective effects. However, the relationship between serum Klotho levels and diabetes remains poorly understood.

OBJECTIVES

This study aimed to investigate the relationship between serum Klotho levels and diabetes in US adults.

METHODS

We analyzed the cross-sectional data obtained from 13751 subjects aged 40-79 years in the National Health and Nutrition Examination Survey (NHANES) (2007-2016). Serum Klotho concentration was measured using an enzyme-linked immunosorbent assay (ELISA) and categorized into four quartiles (Q1-Q4). Multivariate logistic regression and restricted cubic spline (RCS) regression were conducted to explore the association between serum Klotho levels and the prevalence of diabetes.

RESULTS

As compared with quartile 1, serum Klotho levels in quartiles 2-4 yielded odds ratios (OR) (95% CI) of diabetes of 0.96 (0.80-1.15), 0.98 (0.82-1.18), and 1.25 (1.04-1.50), respectively, after covariate adjustment (P for trend = 0.018). The results implied an increased risk of diabetes. The RCS plot showed a U-shaped relationship linking serum Klotho levels with diabetes (P for nonlinearity = 0.003).

CONCLUSIONS

In summary, a nonlinear and positive association was found between serum Klotho levels and the prevalence of diabetes. Further study is needed to verify the causality of this association and elucidate the underlying mechanisms.