Cardio-Ankle Vascular Index as a Surrogate Marker of Early Atherosclerotic Cardiovascular Disease in Koreans 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.

The effects of severe periodontitis on arterial stiffness using cardio-ankle vascular index in patients with type 2 diabetes

BACKGROUND AND OBJECTIVE

Arterial stiffness, which is a measure of the elasticity of the arteries, is also a risk factor for the development of cardiovascular diseases and its measurement is important for evaluating the atherosclerosis process. The purpose of this cross-sectional study to investigate whether severe periodontitis in short-term type 2 diabetes may be associated with increased cardio-ankle vascular index (CAVI) values specified for subclinical atherosclerosis risk.

METHODS

A total of 136 subjects, including 69 subjects with short-term type 2 diabetes (35 with severe periodontitis and 34 with periodontally healthy) and 67 systemically healthy subjects (32 with severe periodontitis and 35 with periodontally healthy) were enrolled to this study. Assessment of all participants included in this study in terms of arterial stiffness was determined by CAVI. Serum fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), triglyceride (TRG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC) and C-reactive protein (CRP) levels were calculated using standard methods. Full mouth periodontal measurements were recorded. Multiple linear regression analysis was performed to evaluate the relationship between periodontal parameters and mean CAVI values of the groups.

RESULTS

Mean CAVI levels were significantly higher in diabetic and periodontitis group compared to the other study groups (p < .05). In diabetes and periodontitis group, CAVI was showed positive correlations with CRP (r = .337, p = .048) and HbA1c (r = .442, p = .008). Also, positive significant correlations were found with probing depth (PD) and clinical attachment level (CAL) in the periodontitis groups. Multiple regression analysis revealed that CAL independently predicted CAVI levels in periodontitis groups (β = .433, p = .019 in diabetes and periodontitis groups and β = .57, p = .001 in systemically healthy and periodontitis group respectively).

CONCLUSION

This is the first study investigating the association between severe periodontitis and CAVI in patients with short-term diabetes. Our findings suggest that severe periodontitis may be an intermediate factor in the pathway between type 2 diabetes and cardiovascular disease by increasing the arterial stiffness.

Impact of Fasting Blood Glucose Levels on Blood Pressure Parameters among Older Adults with Prediabetes

Prediabetes mellitus (pre-DM) is defined as blood glucose levels higher than normal but lower than the threshold for diabetes mellitus (DM) diagnosis. Four-limb blood pressure (BP) differences can help identify a significant risk for cardiovascular diseases (CVDs). The current study aimed to determine the importance of BP and the ankle-brachial index (ABI) between two patient groups and the association between fasting blood glucose (FBG) levels and four-limb BP, ABI, interarm BP difference (IAD), and interleg BP difference (ILD). Moreover, the effect of cardiovascular risk factors on the development of pre-DM among older adults was evaluated. The participants were divided into the normal fasting glucose (NFG) and impaired fasting glucose (IFG) groups. Data on physical characteristics, lipid profiles, four-limb BP, ABI, IAD, ILD, and cardiovascular risk factors were assessed. The IFG group had a significantly higher systolic blood pressure (SBP) and pulse pressure than the NFG group (p  <  0.05). SBP was significantly positively correlated with FBG levels (p  <  0.05). The IFG group had a lower ABI than the NFG group (p  <  0.05). However, there was no significant difference in terms of IAD and ILD between the two groups. Furthermore, hypertension (HT), metabolic syndrome (MetS), and dyslipidemia were significantly correlated with a high prevalence of prediabetes (p  <  0.05). Individuals with prediabetes had a higher BP than those with normoglycemia. Prediabetes was correlated with HT, MetS, and dyslipidemia.

Diastolic Pressure and ACR Are Modifiable Risk Factors of Arterial Stiffness in T2DM Without Cardiovascular Disease

AIM

To evaluate early, before the onset of cardiovascular events and of chronic renal insufficiency, the association between chronic kidney disease (CKD)-mineral bone disorder (MBD) biomarkers and vascular stiffness [Cardio Ankle Vascular Index (CAVI)] in the course of type 2 diabetes (T2DM).

METHOD

We evaluated 174 T2DM patients [median age 56 years; male/female (M/F) 100/74] with diabetes duration < 10 years and without decreased estimated glomerular filtration rate (eGFR; ≥60 mL/min/1.73 m2) or macrovascular complications. Thirty-four age-matched healthy subjects [M/F 13/21; age 53.5 (50.0-57.7) years; eGFR 107.5 (97.0-119.7) mL/ min1.73 m2] served as local reference control for CAVI (pathological: ≥8) and the novel CKD-MBD biomarkers.

RESULTS

Albumin-to-creatinine ratio (ACR) averaged 8.5 mg/g (5.6-17.2) with 12.6% of the patients showing pathologic values, indicative of incipient diabetic nephropathy. Serum parathyroid hormone, fibroblast growth factor 23, and sclerostin were higher while 1,25-dihydroxyvitamin D and Klotho were lower than a control group. CAVI was normal (<8) in only 54% and correlated positively with age (P < 0.001), hemoglobin 1A1c (P = 0.036), and systolic (P = 0.021) and diastolic blood pressure (DBP) (P = 0.001) and negatively correlated with 25-hydroxyvitamin D (P = 0.046). In multivariate analysis, age, DBP, ACR, and serum Klotho were independent positive predictors of CAVI.

CONCLUSION

In the absence of overt cardiovascular disease and of chronic renal insufficiency, CAVI is frequently pathologic in T2DM. DBP and ACR are modifiable risk factors of vascular stiffness in T2DM, thus warranting optimal assessment.

Risk assessment indicators and brachial-ankle pulse wave velocity to predict atherosclerotic cardiovascular disease

Brachial-ankle pulse wave velocity (baPWV) is used for predicting the severity of vascular damage and prognosis of atherosclerotic cardiovascular disease (ASCVD) in people with hypertension and diabetes mellitus. This correlation study aimed to compare the baPWV with other risk indicators for identification of subclinical vascular disease for primary prevention and to determine the clinical utility of baPWV-guided therapy in improving prognosis in high-risk subjects. We included 4881 subjects who underwent voluntary health examination at Mackay Memorial Hospital, Taiwan between 2014 and 2019. Participants were categorized into the low-risk (<5%), borderline-risk (5%-7.4%), intermediate-risk (7.5%-19.9%), and high-risk (≥20%) groups based on the 10-year risk for ASCVD. The predictive risk criteria, that is, the metabolic syndrome score, Framingham Risk Score, estimated glomerular filtration rate, and baPWV were compared among these groups. The chief cause of induced responses and the relationships between parameters were identified using principal component analysis. The participants' ages, body mass index, systolic, diastolic blood pressure, triglycerides, fasting glucose, hemoglobin A1c, creatinine, neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, metabolic syndrome, Framingham Risk Score, and age-related arterial stiffness (vascular age) increased significantly from the low-risk to high-risk groups (P < .001). The mean estimated glomerular filtration rate decreased significantly from the low- to high-risk groups (P < .001). The predicted vascular age and actual age differed significantly between the intermediate- and high-risk groups (P < .001). High-density lipoprotein levels plummeted significantly among the 4 groups (P < .001). The right and left baPWV and ankle brachial index differed significantly among the 4 groups (all P < .001) and increased from the low-risk to high-risk groups (P < .001). Carotid Doppler ultrasonography revealed a significant increase in plaque formation (23.5%, 35.4%, 46.3%, and 61.5% for the low-, borderline-, intermediate, and high-risk groups, respectively). The total explanatory variation was 61.9% for 2 principal variation factors (baPWV, 36.8% and creatinine, 25.1%). The vascular age predicted using baPWV greatly exceeded the chronological age. Plaque formation was significant even in the low-risk group, and its frequency increased with the predicted ASCVD risk. Risk indicators and baPWV are useful predictors of ASCVD, which in conjunction with conventional pharmacotherapy could be useful for primary prevention of plaque formation in subjects with cardiovascular comorbidities.

Association of cardio-ankle vascular index and future major adverse cardiovascular events in older adults living with HIV

ABSTRACTIncreased arterial stiffness is an indicator of cardiovascular disease (CVD) and death in the general population. The cardio-ankle vascular index (CAVI) is a novel method for measuring arterial stiffness. This study investigated the utility of CAVI as a prognostic indicator of CVD and death in older adults living with HIV(OALHIV). Patients aged ≥50 taking antiretroviral treatment with no history of cardiovascular events enrolled from multiple centers in Chiang Mai, Thailand. Participants (N = 347) who underwent CAVI were followed up for five years. The primary endpoint was major adverse cardiovascular events (MACE): a composite of total deaths and hospitalizations due to myocardial infarction, coronary revascularization, stroke, and heart failure. Cox regression analysis determined between normal (<8) and high (≥8) CAVI against the incidence of MACE. Forty-five participants (13.0%) were diagnosed with MACE. The risk of MACE was more significant in high CAVI than normal CAVI (adjusted HR =  2.11, 95% confidence interval 1.06-4.20, p = 0.033). In OALHIV, CAVI was an independent prognosis of MACE, in addition to conventional CVD risk factors. CAVI-assisted to help identify high-risk patients showed the benefit of further evaluation and more intensive therapy to prevent CVD and death.

Effects of long-term air pollution exposure on ankle-brachial index and cardio-ankle vascular index: A longitudinal cohort study using data from the Electricity Generating Authority of Thailand study

BACKGROUND

Ankle-brachial index (ABI) and cardio-ankle vascular index (CAVI) are surrogate measures of atherosclerosis based on the functional performance of vessels, and are highly related to cardiovascular events. However, only a few longitudinal studies have been conducted on their associations with long-term air pollution exposure.

OBJECTIVE

This study aimed to examine whether long-term air pollution exposure is associated with ABI and CAVI in workers of the Electricity Generating Authority of Thailand (EGAT) in the Bangkok Metropolitan Region (BMR).

METHODS

This longitudinal study included 1261 participants (age range, 57-76 years as of 2007) of the EGAT study (2007-2017). ABI and CAVI were measured in 2007, 2012, and 2017. Annual mean concentrations of particulate matter ≤10 μm in diameter (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), ozone (O₃), and carbon monoxide (CO) were estimated by ordinary kriging using data from 22 background and 7 traffic monitoring stations in BMR between 2002 and 2017. Linear mixed-effects models were used to assess associations between air pollution (expressed as 1-year, 3-year, and 5-year average concentration) and ABI and CAVI (expressed as percent changes per interquartile range (IQR) increase in PM₁₀, O₃, NO₂, SO_2, and CO). We also applied the mixed-effect ordinal logistic models to calculate odds ratios (ORs) of having high or moderate CAVI per an IQR increase in air pollution.

RESULTS

After controlling for potential confounders, 1-year average CO was negatively associated with ABI, but not significantly (-0.48%, 95% CI: -1.03, 0.07). Three-year average NO₂ was positively associated with CAVI (6.67%, 95% CI: 0.21, 13.1). In contrast, 1-year average PM₁₀ was inversely associated with CAVI although the association was not significant. Although not significantly, 1-year average NO₂ and CO were positively associated with prevalence of high or moderate CAVI.

CONCLUSIONS

Although not statistically significant, long-term NO₂ and CO exposure was associated with ABI and CAVI in the participants of the EGAT study.

Cardio-ankle vascular index represents the best surrogate for 10-year ASCVD risk estimation in patients with primary hypertension

Background: Identification of target organ damage and/or risk-enhancing factors help treatment decisions in hypertensive and hyperlipidaemic patients who reside in borderline to an intermediate risk category based on 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates.Aim: In the present study, we aimed to investigate the comparative efficacy of certain hypertension-mediated organ damage markers (HMOD) for the prediction of 10-year ASCVD risk ≥10%, in patients with primary hypertension without established CVD.Methods: One-hundred thirty-seven asymptomatic hypertensive patients ≥40 years of age were enrolled in the present study. Ten-year ASCVD risks were estimated by Pooled Cohort Equations. The following HMOD markers; pulse pressure (PP), left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), ankle-brachial index (ABI), cardio-ankle vascular index (CAVI) and estimated glomerular filtration rate (eGFR) were evaluated with respect to efficacy for predicting ≥10% ASCVD risk with ROC analysis.Results: CAVI gave the greatest Area Under Curve (AUC = 0.736, p < .000), and followed by CIMT (AUC = 0.727, p < .000), LVMI (AUC = O.630, p = .01), and PP (AUC = 0.623, p = .02). ABI and eGFR were not found to be predictive. CAVI correlated best with estimated 10-year ASCVD risk (r = 0.460, p < .000). A CAVI value ≥8 was found 71% sensitive and 72% specific for predicting ≥10% risk in 10-year ASCVD risk scale. CAVI gave the best graded response to increments in 10-year ASCVD risk categories.Conclusion: We suggest that CAVI is the best surrogate for 10-year ASCVD risk, among several HMOD markers.

Relation between fragmented QRS complex and cardio-ankle vascular index in asymptomatic subjects

OBJECTIVES

Stiffness of large arteries has been related to cardiovascular mortality. Cardio-ankle vascular index (CAVI) is a novel marker of arterial stiffness. Herein, we aimed to study the relationship between fragmented QRS (fQRS) in electrocardiogram and CAVI.

METHODS

Asymptomatic patients with fQRS and without fQRS were enrolled in the study consecutively. The fQRS complexes were analyzed in the 12-lead electrocardiogram. Arterial stiffness was assessed by using cardio ankle vascular index (CAVI). It was measured by a VaSera VS-1000 CAVI instrument.

RESULTS

CAVI values of the patients with fQRS was significantly higher compared to those without fQRS (8.625 (7.9-9.2) versus 6.65 (6.7-8.4) p < .001). In a univariate analysis, it was revealed that there was a significant correlation between increased CAVI and fQRS, age, and epicardial fat thickness. Multiple binary logistic regression analysis revealed that age [95% confidence interval (CI): 1,068-1.214, p < .001] and fQRS [95% (CI): 1.766-23.117, p: 0.005] were the independent determinants of increased CAVI values.

CONCLUSIONS

ECG is a widely and readily available, inexpensive, reproducible technique that can be examined by almost every physician. fQRS values in electrocardiogram may provide a significant predictive value for arterial stiffness in asymptomatic subjects.

Progress of Clinical Evaluation for Vascular Aging in Humans

Human society is experiencing a serious aging process. Age-related arteriosclerotic cardiovascular diseases (ASCVD) are the most common cause of deaths around the world and bring a huge burden on the whole society. Vascular aging-related pathological alterations of the vasculature play an important role in the pathogenesis of ASCVD and morbidity and mortality of older adults. In this review, we describe the progress of clinical evaluation of vascular aging in humans, including functional evaluation, structural assessment, and cellular molecular markers. The significance of detection for vascular aging is highlighted, and we call for close attention to the evaluation for a better quality of life in the elderly population.

The Relationship Between Glycemic Control and Concomitant Hypertension on Arterial Stiffness in Type II Diabetes

Purpose

The impact of glycemic control on macrovascular complications and arterial stiffness in type II diabetes (T2D), as well as the extent of additive effect of hypertension, is unclear. The aims of this study were to investigate the impact of glycemic control on the cardio-ankle vascular index (CAVI), an indicator of arterial stiffness, and to determine the relative risk of concomitant diabetes and hypertension with arterial stiffness.

Methods

One hundred and nine participants were enrolled and classified as non-diabetes (n= 37) and diabetes (n=72); the diabetic group was further identified as controllable and uncontrollable T2D depending on their hemoglobin A1c (HbA1c) levels. Univariate and multiple regression analyses were used to assess the association between CAVI and glycemic control status and hypertension. Relative risk analysis for abnormal CAVI with exposure to diabetes and hypertension was investigated.

Results

In all participants, age, systolic blood pressure, body mass index, and fasting blood sugar were independent predictors of CAVI. In diabetic participants, glycemic control status or HbA1c levels did not significantly correlate with CAVI. Systolic blood pressure was an independent predictor for CAVI with β = 0.26. In addition, the coexistence of diabetes together with hypertension was significantly associated with a 2.4-fold increase in the risk of abnormal CAVI (95% CI, 1.410-4.184; p <0.001).

Conclusion

This study demonstrates that HbA1c as well as fasting blood sugar levels in diabetic participants do not correlate with arterial stiffness. Concomitant diabetes and hypertension significantly increase the risk of arterial stiffness.

Short-term impact of aged garlic extract on endothelial function in diabetes: A randomized, double-blind, placebo-controlled trial

Impaired endothelial function portends an increased risk of cardiovascular disease. Vascular oxidative stress and systemic inflammation play a critical role in the pathogenesis and progression of vascular disease. Aged garlic extract (AGE) may improve impaired vascular endothelial function, while decreasing the progression of atherosclerotic plaque. We hypothesized that AGE may improve endothelial function, and in this study, we examined this hypothesis to determine whether this can be achieved over a period of 3 months, measured by the cardio-ankle vascular index (CAVI), by reducing intracellular oxidant stress and stimulating nitric oxide generation in endothelial cells. We conducted a double-blinded placebo controlled, randomized clinical trial to investigate the effects of AGE on CAVI in subjects with type 2 diabetes mellitus. A total of 65 individuals (38 men and 27 women) with a mean age of 58.8±11.1 years were enrolled and randomized to the AGE or placebo group in a double-blind placebo controlled trial. An ANOVA model with treatment as the main effect was used to compare changes in CAVI from baseline to follow-up between groups. The primary objective of this study was reduction in CAVI over a 3-month period. In the AGE group, CAVI was reduced on average by 0.71±1.27 vs. a mean reduction of 0.13±0.94 in the placebo group (P=0.04). On the whole, this study demonstrates that AGE has a positive impact on endothelial function in patients with T2DM and may play a role in the primary prevention of cardiovascular disease.

Association of Kidney Function Tests with a Cardio-Ankle Vascular Index in Community-Dwelling Individuals with a Normal or Mildly Decreased Estimated Glomerular Filtration Rate

Background and objectives: Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease (CVD). Previous studies reported controversial results about the independence of CKD as a risk factor for atherosclerosis. In this study, we tried to determine whether the estimated glomerular filtration rate (eGFR) and other renal function tests are independent factors associated with arterial stiffness in community-dwelling individuals with a normal (≥90) or slightly decreased eGFR (60-90). Materials and Methods: Data of 164 community individuals were analyzed, and demographic information, related disease history, atherosclerosis risk factors, certain laboratory tests, the estimated eGFR, and urine albumin creatinine ratio (UACR) were recorded for each individual. Results: The age, systolic blood pressure (SBP), hypertension (HTN), and cardio-ankle vascular index (CAVI) significantly differed between individuals with a normal and those with a slightly decreased eGFR. Blood urea nitrogen (BUN), glycated hemoglobin (HBA1c), and the eGFR significantly differed between the high- and low-CAVI groups and were also significantly correlated with the CAVI. The relationship between the eGFR and CAVI was shown to be independent of other atherosclerosis risk factors in a multiple linear regression model. Conclusions: We concluded that evaluations of the eGFR, HTN, body-mass index, and SBP can be used in a model for arterial stiffness risk assessments for community-dwelling individuals with a normal or slightly decreased eGFR.

Association between Breakfast Frequency and Atherosclerotic Cardiovascular Disease Risk: A Cross-Sectional Study of KNHANES Data, 2014-2016

The burden of cardiovascular disease (CVD) is increasing worldwide and one related lifestyle choice is breakfast consumption. This study examined the association between breakfast frequency and the 10-year risk of atherosclerotic CVD (ASCVD). The 10-year risk of ASCVD was defined as the risk of the first event of nonfatal myocardial infarction, coronary heart disease death, and nonfatal or fatal stroke within 10 years. Data from the Korean National Health and Nutrition Examination Survey, 2014–2016 were analyzed, and 7212 participants aged 40–79 years with no history of CVD were included. ASCVD risk was calculated according to the pooled cohort ASCVD equation, and participants with a score >7.5% were considered at high risk of ASCVD. The association between breakfast frequency and high ASCVD risk was confirmed by logistic regression analysis. Participants who never ate breakfast were more likely to be in the high-risk group compared to participants who ate breakfast >5 times per week (OR (adjusted odds ratio) = 1.46; 95% CI (confidence interval) = 1.12–1.89), and the risk was especially higher in female participants and those with a family history of CVD. Our study confirms that breakfast consumption even once per week may prevent CVD.