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Allopurinol to reduce cardiovascular morbidity and mortality: A systematic review and meta-analysis. PLoS One 2021; 16:e0260844. [PMID: 34855873 PMCID: PMC8638940 DOI: 10.1371/journal.pone.0260844] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
Aims To compare the effectiveness of allopurinol with no treatment or placebo for the prevention of cardiovascular events in hyperuricemic patients. Methods and results Pubmed, Web of Science and Cochrane library were searched from inception until July 2020. Randomized controlled trials (RCT) and observational studies in hyperuricemic patients without significant renal disease and treated with allopurinol, versus placebo or no treatment were included. Outcome measures were cardiovascular mortality, myocardial infarction, stroke, or a combined endpoint (CM/MI/S). For RCT’s a random effects meta-analysis was performed. For observational studies a narrative synthesis was performed. Of the original 1995 references we ultimately included 26 RCT’s and 21 observational studies. We found a significantly reduced risk of combined endpoint (Risk Ratio 0.65 [95% CI] [0.46 to 0.91]; p = 0.012) and myocardial infarction (RR 0.47 [0.27 to 0.80]; p = 0.01) in the allopurinol group compared to controls. We found no significant effect of allopurinol on stroke or cardiovascular mortality. Of the 15 observational studies with sufficient quality, allopurinol was associated with reduced cardiovascular mortality in 1 out of 3 studies that reported this outcome, myocardial infarction in 6 out of 8, stroke in 4 out of 7, and combined end-point in 2 out of 2. Cardiovascular benefit was only observed when allopurinol therapy was prolonged for more than 6 months and when an appropriate allopurinol dose was administered (300 mg or more/day) or sufficient reduction of serum urate concentration was achieved (<0.36 mmol/l). Conclusions Data from RCT’s and observational studies indicate that allopurinol treatment reduces cardiovascular risk in patients with hyperuricemia. However, the quality of evidence from RCTs is low to moderate. To establish whether allopurinol lowers the risk of cardiovascular events a well-designed and adequately powered randomized, placebo-controlled trial is needed in high-risk patients with hyperuricemia. Systematic review registration PROSPERO registration CRD42018089744
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Lukkunaprasit T, Rattanasiri S, Ongphiphadhanakul B, McKay GJ, Attia J, Thakkinstian A. Causal Associations of Urate With Cardiovascular Risk Factors: Two-Sample Mendelian Randomization. Front Genet 2021; 12:687279. [PMID: 34306027 PMCID: PMC8297413 DOI: 10.3389/fgene.2021.687279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background Mendelian Randomization (MR) studies show conflicting causal associations of genetically predicted serum urate with cardiovascular risk factors (i.e., hypertension, diabetes, lipid profile, and kidney function). This study aimed to robustly investigate a causal relationship between urate and cardiovascular risk factors considering single nucleotide polymorphisms (SNPs) as instrumental variables using two-sample MR and various sensitivity analyses. Methods Data on SNP-urate associations were taken from the Global Urate Genetics Consortium and data on SNP-cardiovascular risk factor associations were taken from various consortia/UK Biobank. SNPs were selected by statistically and biologically driven approaches as instrumental variables. Various sensitivity analyses were performed using different MR methods including inverse variance weighted, MR-Egger, weighted median/mode, MR-PRESSO, and the contamination mixture method. Results The statistically driven approach showed significant causal effects of urate on HDL-C and triglycerides using four of the six MR methods, i.e., every 1 mg/dl increase in genetically predicted urate was associated with 0.047 to 0.103 SD decrease in HDL-C and 0.034 to 0.207 SD increase in triglycerides. The biologically driven approach to selection of SNPs from ABCG2, SLC2A9, SLC17A1, SLC22A11, and SLC22A12 showed consistent causal effects of urate on HDL-C from all methods with 0.038 to 0.057 SD decrease in HDL-C per 1 mg/dl increase of urate, and no evidence of horizontal pleiotropy was detected. Conclusion Our study suggests a significant and robust causal effect of genetically predicted urate on HDL-C. This finding may explain a small proportion (7%) of the association between increased urate and cardiovascular disease but points to urate being a novel cardiac risk factor.
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Affiliation(s)
- Thitiya Lukkunaprasit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Pharmacology, College of Pharmacy, Rangsit University, Pathum Thani, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Gareth J McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Alem MM, Aldosari SR, Alkahmous AA, Obad AS, Fagir NM, Al-Ghamdi BS. Effect of Long-Term Allopurinol Therapy on Left Ventricular Mass Index in Patients with Ischemic Heart Disease; A Cross-Sectional Study. Vasc Health Risk Manag 2019; 15:539-550. [PMID: 31827327 PMCID: PMC6903809 DOI: 10.2147/vhrm.s226009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
Background Left ventricular hypertrophy (LVH), as assessed by measurement of left ventricular mass (LVM), is one of the most important cardiovascular risk factors. It is commonly present in patients with ischemic heart disease (IHD), irrespective of the level of blood pressure; recently, oxidative stress has been shown to be an important factor in its development. The question then arises: can this risk factor be modified by antioxidant treatment (e.g., with allopurinol, a xanthine oxidase inhibitor)? Methods This is an observational study with a cross-sectional design which explored the association between long-term (>12 months) allopurinol therapy and LV mass index (LVMI) as well as geometry in patients generally receiving standard treatments for IHD. The primary endpoint was LVMI measurement (by 2D-echocardiography) and secondary endpoints included the association of allopurinol use with LV function (ejection fraction), blood pressure, glycemic control, and lipid profile. Results Ninety-six patients on standard anti-ischemic drug treatment (control group) and 96 patients who were additionally taking allopurinol (minimum dose 100 mg/day) were enrolled. Both groups were matched for age, sex, height, and co-morbidities, but poorer kidney function in the allopurinol group required further sub-group analysis based on renal function. Allopurinol treatment was associated with the lowest LVMI in the patients with normal serum creatinine (median LVMI; 70.5 g/m2): corresponding values were 76.0 and 87.0 in the control group with, respectively, normal and elevated serum creatinine, and 89.5 in the allopurinol group with elevated serum creatinine (P=0.027). In addition, allopurinol was associated with better glycemic control (HbA1c) with a difference of 0.8% (95% CI; 1.3, 0.2) (P=0.004) as compared with control patients. Conclusion In our population, treatment with allopurinol (presumably because of its anti-oxidant properties) has shown a tendency to be associated with smaller LVM in IHD patients with normal serum creatinine, along with better glycemic control.
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Affiliation(s)
- Manal M Alem
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | | | - Adam S Obad
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nagy M Fagir
- Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Bandar S Al-Ghamdi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Chen XJ, Eirin A, Kane GC, Misra S, Textor SC, Lerman A, Lerman LO. Impact of Serum Uric Acid Levels on Outcomes following Renal Artery Revascularization in Patients with Renovascular Disease. Int J Hypertens 2019; 2019:3872065. [PMID: 30838132 PMCID: PMC6374789 DOI: 10.1155/2019/3872065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/30/2018] [Accepted: 01/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Percutaneous transluminal renal angioplasty (PTRA) improves blood pressure (BP) and renal function only in selected patients with atherosclerotic renovascular disease (ARVD). Hyperuricemia is associated with elevated risk for hypertension and chronic renal disease, but its role in renovascular hypertension is unclear. We hypothesized that hyperuricemia negatively impacts renal and BP outcomes among patients with ARVD undergoing PTRA. METHODS This retrospective, observational cohort study included 94 patients with ARVD and preserved systolic cardiac function, who underwent PTRA at Mayo Clinic, Rochester, Minnesota. Renal, BP, and mortality outcomes were compared among patients according to their serum uric acid (SUA) levels. Multivariate analysis was used to determine significant predictors of renal, BP, and mortality outcomes after PTRA. RESULTS Compared to patients with normal basal SUA levels (≤5.7 mg/dl), patients with very high SUA (≥8.7 mg/dl) had lower baseline estimated glomerular filtration rate (eGFR), more extensive use of antihypertensive and diuretic drugs, increased baseline systolic blood pressure (SBP), and elevated left ventricular mass index. After PTRA, multiple logistic regression analysis showed that, compared to normal SUA, very high SUA was associated with decreased odds ratio (OR) of change in eGFR (adjusted OR=0.90; 95% confidence interval [CI], 0.86-0.95), but not of change in SBP. In multivariate linear analysis SUA independently predicted delta urine protein/creatinine ratio (β: 26.0; 95% confidence interval, 13.9 to 38.1). CONCLUSION Severe hyperuricemia in patients with AVRD may have a negative impact on outcomes of renal revascularization.
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Affiliation(s)
- Xiao-jun Chen
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Garvan C. Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sanjay Misra
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Stephen C. Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Femoral Intima-media Thickness, Risk Factors, and Markers of Inflammation in Cardiovascular Disease. JOURNAL OF INTERDISCIPLINARY MEDICINE 2018. [DOI: 10.2478/jim-2018-0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: The burden of coronary artery disease (CAD) and peripheral vascular pathologies caused by atherosclerosis is constantly increasing. There is continuous research aiming to develop new methods that can evaluate the extent of atherosclerotic disease in different vascular beds, thus estimating global risk. Similar to carotid artery thickness, which is an established marker for increased cardiovascular risk and cerebrovascular disease, femoral intima-media thickness (f-IMT) may have the same role in case of peripheral arterial involvement. The aim of the study was determine whether f-IMT, determined at the level of the superficial femoral artery, is related to traditional risk factors, markers of peripheral vascular atherosclerosis and inflammation.
Material and methods: Forty-six patients with known cardiovascular disease were included in the study. Demographical data, cardiovascular history, and risk factors were assessed. We determined metabolic parameters (uric acid, fasting glucose, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides), renal function (creatinine and GFR), and inflammation status for all patients. Each patient underwent ultrasound examination of the superficial femoral artery, by which f-IMT was determined for right and left limbs. Ankle-brachial index was also calculated. Data from the low (f-IMT <0.75 mm) and high (f-IMT >0.75 mm) f-IMT groups were compared and correlation coefficients were determined in each groups for f-IMT in relation to the other parameters.
Results: Mean age was 71.08 ± 9.78 years. 86.95% of the patients suffered from hyper-tension, 56.62% had coronary heart disease, and 21.73% had a history of stroke. More females had history of hypertension and CAD. The most prevalent cardiovascular risk factors were dyslipidemia (68.86%), diabetes (21.73%), and smoking (21.73%). There were significant differences between gender groups for total cholesterol levels (161.36 ± 25.04 mg/dL, 95%CI 150.26–172.47 in males vs. 201.33 ± 52.73 mg/dL, 95%CI 170.07–223.60 in females, p = 0.02), creatinine values (1.04 ± 0.22 mg/dL, 95%CI 0.94–1.14 for males vs. 0.91 ± 0.23 mg/dL, 95%CI 0.81–1.00 for females, p = 0.018), and left f-IMT (0.87 ± 0.18 mm, 95%CI 0.79–0.95 for males vs. 0.75 ± 0.10 mm, 95%CI 0.70–0.79 for females, p = 0.0049). In the group with low f-IMT, a significant, reverse correlation was established between f-IMT, uric acid (r = −0.483, p = 0.042), and right ABI (r = −730, p = 0.0006). In the group with high f-IMT, age (r = 0.408, p = 0.031), fasting glucose (r = 0.407, p = 0.034), total cholesterol (r = 0.429, p = 0.02), HDL-cholesterol (r = −0.56, p = 0.0019), triglycerides (r = 0.45, p = 0.01), hs-CRP (r = 0.45, p = 0.01), and left ABI (r = −0.71, p <0.0001) showed a significant correlation to f-IMT.
Conclusions: Increased femoral intima-media thickness is related to age, cardiovascular risk factors, and markers of peripheral arterial disease. Patients with higher f-IMT have a more augmented inflammatory status. Based on these correlations, in patients with cardiovascular disease, f-IMT could become a marker for increased cardiovascular risk.
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Alem MM, Alshehri AM, Cahusac PMB, Walters MR. Effect of Xanthine Oxidase Inhibition on Arterial Stiffness in Patients With Chronic Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546818779584. [PMID: 29899669 PMCID: PMC5992797 DOI: 10.1177/1179546818779584] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 04/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The xanthine oxidase inhibitor allopurinol improves endothelial function in different populations, including patients with chronic heart failure (CHF). Its effect on arterial stiffness parameters is less clear. We investigated the effect of short-term low-dose allopurinol therapy on arterial stiffness in Saudi patients with stable mild-moderate CHF. METHODS A prospective, randomized, double-blind, placebo-controlled study was performed on 73 patients with mild-moderate CHF. In all, 36 patients were randomized to allopurinol 300 mg daily for 3 months, while 37 patients were randomized to placebo. Arterial stiffness parameters, aortic pulse wave velocity (Ao-PWV) and heart rate corrected augmentation index (c-AIx), were assessed before and after treatment along with serum uric acid. RESULTS A total of 66 patients completed the study. Both groups were matched for age, sex, severity of heart failure, and arterial stiffness. Compared with placebo, allopurinol recipients had a significant fall in uric acid concentration from 6.31 ± 1.4 (SD) mg/dL to 3.81 ± 1.2 (P < .001). Despite that, there was no significant change in arterial stiffness parameters between allopurinol and placebo groups. Post-treatment Ao-PWV was 9.79 ± 2.6 m/s in the allopurinol group and 10.07 ± 3.4 m/s in the placebo group, P = .723. Post-treatment c-AIx was 24.0% ± 9.1% and 22.0% ± 9.9%, respectively, P = .403. CONCLUSIONS We have shown that allopurinol significantly reduced uric acid concentration in Saudi patients with CHF but was not associated with a change in arterial stiffness. Our cohort of patients had worse arterial stiffness values at baseline, which might make them more resistant to change using our study regimen.The study has been registered with the International Standard Randomized Controlled Trial Number registry with an identifier number of ISRCTN58980230.
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Affiliation(s)
- Manal M Alem
- Department of Pharmacology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah M Alshehri
- Internal Medicine Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Peter MB Cahusac
- Department of Pharmacology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Comparative Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Matthew R Walters
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
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