The Results of the URRAH (Uric Acid Right for Heart Health) Project: A Focus on Hyperuricemia in Relation to Cardiovascular and Kidney Disease and its Role in Metabolic Dysregulation

The relationship between Serum Uric Acid (UA) and Cardiovascular (CV) diseases has already been extensively evaluated, and it was found to be an independent predictor of all-cause and cardiovascular mortality but also acute coronary syndrome, stroke and heart failure. Similarly, also many papers have been published on the association between UA and kidney function, while less is known on the role of UA in metabolic derangement and, particularly, in metabolic syndrome. Despite the substantial number of publications on the topic, there are still some elements of doubt: (1) the better cut-off to be used to refine CV risk (also called CV cut-off); (2) the needing for a correction of UA values for kidney function; and (3) the better definition of its role in metabolic syndrome: is UA simply a marker, a bystander or a key pathological element of metabolic dysregulation?. The Uric acid Right for heArt Health (URRAH) project was designed by the Working Group on uric acid and CV risk of the Italian Society of Hypertension to answer the first question. After the first papers that individuates specific cut-off for different CV disease, subsequent articles have been published responding to the other relevant questions. This review will summarise most of the results obtained so far from the URRAH research project.

Serum Uric Acid Predicts All-Cause and Cardiovascular Mortality Independently of Hypertriglyceridemia in Cardiometabolic Patients without Established CV Disease: A Sub-Analysis of the URic acid Right for heArt Health (URRAH) Study

High serum uric acid (SUA) and triglyceride (TG) levels might promote high-cardiovascular risk phenotypes across the cardiometabolic spectrum. However, SUA predictive power in the presence of normal and high TG levels has never been investigated. We included 8124 patients from the URic acid Right for heArt Health (URRAH) study cohort who were followed for over 20 years and had no established cardiovascular disease or uncontrolled metabolic disease. All-cause mortality (ACM) and cardiovascular mortality (CVM) were explored by the Kaplan-Meier estimator and Cox multivariable regression, adopting recently defined SUA cut-offs for ACM (≥4.7 mg/dL) and CVM (≥5.6 mg/dL). Exploratory analysis across cardiometabolic subgroups and a sensitivity analysis using SUA/serum creatinine were performed as validation. SUA predicted ACM (HR 1.25 [1.12-1.40], p < 0.001) and CVM (1.31 [1.11-1.74], p < 0.001) in the whole study population, and according to TG strata: ACM in normotriglyceridemia (HR 1.26 [1.12-1.43], p < 0.001) and hypertriglyceridemia (1.31 [1.02-1.68], p = 0.033), and CVM in normotriglyceridemia (HR 1.46 [1.23-1.73], p < 0.001) and hypertriglyceridemia (HR 1.31 [0.99-1.64], p = 0.060). Exploratory and sensitivity analyses confirmed our findings, suggesting a substantial role of SUA in normotriglyceridemia and hypertriglyceridemia. In conclusion, we report that SUA can predict ACM and CVM in cardiometabolic patients without established cardiovascular disease, independent of TG levels.

Hyperuricemia increases the risk of cardiovascular mortality associated with very high HdL-cholesterol level

BACKGROUND AND AIMS

Whether the association between very high HDL-cholesterol levels and cardiovascular mortality (CVM) is modulated by some facilitating factors is unclear. Aim of the study was to investigate whether the risk of CVM associated with very high HDL-cholesterol is increased in subjects with hyperuricemia.

METHODS AND RESULTS

Multivariable Cox analyses were made in 18,072 participants from the multicentre URRAH study stratified by sex and HDL-cholesterol category. During a median follow-up of 11.4 years there were 1307 cases of CVM. In multivariable Cox models a J-shaped association was found in the whole population, with the highest risk being present in the high HDL-cholesterol group [>80 mg/dL, adjusted hazard ratio (HR), 1.28; 95%CI, 1.02-1.61; p = 0.031)]. However, a sex-specific analysis revealed that this association was present only in women (HR, 1.34; 95%CI, 1.02-1.77; p = 0.034) but not in men. The risk of CVM related to high HDL-cholesterol was much greater in the women with high uric acid (>0.30 mmol/L, HR 1.61; 95%CI, 1.08-2.39) than in those with low uric acid (HR, 1.17; 95%CI, 0.80-1.72, p for interaction = 0.016). In women older than 70 years with hyperuricemia the risk related to high HDL-cholesterol was 1.83 (95%CI, 1.19-2.80, p < 0.005). Inclusion of BMI in the models weakened the strength of the associations.

CONCLUSION

Our data indicate that very high HDL-cholesterol levels in women are associated with CVM in a J-shaped fashion. The risk of CVM is increased by concomitant hyperuricemia suggesting that a proinflammatory/oxidative state can enhance the detrimental cardiovascular effects associated with high HDL-cholesterol.

Serum uric acid / serum creatinine ratio as a predictor of cardiovascular events. Detection of prognostic cardiovascular cut-off values

OBJECTIVE

In the frame of the Uric Acid Right for Heart Health (URRAH) study, a nationwide multicenter study involving adult participants recruited on a regional community basis from all the territory of Italy under the patronage of the Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension, we searched for the cut-off values of the ratio between serum uric acid (SUA) and serum creatinine (sCr) able to predict cardiovascular (CV) events.

METHODS

Among 20 724 participants followed-up for 126 ± 64 months, after detecting cut-off by the receiver operating characteristic curves, we calculated by Cox models adjusted for confounders having CV events as dependent variable the hazard ratio (HR) of SUA/sCr > cut-off. We also verified if the role of cut-off varied with increasing SUA/sCr.

RESULTS

A plausible prognostic cut-off of SUA/sCr was found and was the same in the whole database, in men and in women (>5.35). The HR of SUA/sCr > cut-off was 1.159 (95% confidence interval [CI] 1.092-1.131, P < 0.03) in all, 1.161 (95% CI 1.021-1.335, P < 0.02) in men, and 1.444 (95% CI 1.012-1.113, P < 0.03) in women. In increasing quintiles of SUA/sCr the cut-offs were >3.08, >4.87, >5.35, >6.22 and >7.58, respectively. The HRs significantly increased from the 3rd to the 5th quintile (1.21, 95% CI 1.032-1.467, P = 0.018; 1.294, 95% CI 1.101-1.521, P = 0.002; and 1.642, 95% CI 1.405-1.919, P < 0.0001; respectively), that is, over 5.35, whereas the 2nd quintile was not significantly different from the 1st (reference).

CONCLUSION

Having SUA/sCr >5.35 is an independent CV risk indicator both in men and women. The cut-off is dynamic and significantly increases with increasing SUA/sCr.

Serum uric acid levels threshold for mortality in diabetic individuals: The URic acid Right for heArt Health (URRAH) project

BACKGROUND AND AIM

The URRAH (URic acid Right for heArt Health) Study has identified cut-off values of serum uric acid (SUA) predictive of total mortality at 4.7 mg/dl, and cardiovascular (CV) mortality at 5.6 mg/dl. Our aim was to validate these SUA thresholds in people with diabetes.

METHODS AND RESULTS

The URRAH subpopulation of people with diabetes was studied. All-cause and CV deaths were evaluated at the end of follow-up. A total of 2570 diabetic subjects were studied. During a median follow-up of 107 months, 744 deaths occurred. In the multivariate Cox regression analyses adjusted for several confounders, subjects with SUA ≥5.6 mg/dl had higher risk of total (HR: 1.23, 95%CI: 1.04-1.47) and CV mortality (HR:1.31, 95%CI:1.03-1.66), than those with SUA <5.6 mg/dl. Increased all-cause mortality risk was shown in participants with SUA ≥4.7 mg/dl vs SUA below 4.7 mg/dl, but not statistically significant after adjustment for all confounders.

CONCLUSIONS

SUA thresholds previously proposed by the URRAH study group are predictive of total and CV mortality also in people with diabetes. The threshold of 5.6 mg/dl can predict both total and CV mortality, and so is candidate to be a clinical cut-off for the definition of hyperuricemia in patients with diabetes.

The association of uric acid with mortality modifies at old age: data from the uric acid right for heart health (URRAH) study

OBJECTIVES

In older individuals, the role of serum uric acid (SUA) as risk factor for mortality is debated. This study investigated the association of SUA with all-cause and cardiovascular (CV) mortality in older adults participating in the large multicentre observational uric acid right for heart health (URRAH) study.

METHODS

Eight thousand URRAH participants aged 65+ were included in the analysis. The predictive role of SUA was assessed using Cox regression models stratified according to the cut-off age of 75. SUA was tested as continuous and categorical variable (age-specific quartiles). The prognostic threshold of SUA for mortality was analysed using receiver operating characteristic curves.

RESULTS

Among participants aged 65-74, multivariate Cox regression analysis adjusted for CV risk factors and comorbidities identified an independent association of SUA with both all-cause mortality (hazard ratio [HR] 1.169, 95% confidence interval [CI] 1.107-1.235) and CV mortality (HR 1.146, 95% CI 1.064-1.235). The cut-off value of 4.8 mg/dl discriminated mortality status. In participants aged 75+, we observed a J-shaped relationship of SUA with all-cause and CV mortality, with risk increasing at extreme SUA levels.

CONCLUSIONS

These results confirmed the predictive role of SUA for all-cause and CV mortality in older adults, while revealing considerable age-related differences. Mortality risk increased at higher SUA levels in participants aged 65-74, with a prognostic threshold of 4.8 mg/dl. The relationship between SUA and mortality was J-shaped in oldest participants. Large interventional studies are needed to clarify the benefits and possible risks of urate-lowering treatments in older adults.

The importance of including uric acid in the definition of metabolic syndrome when assessing the mortality risk

Introduction

Serum uric acid (SUA) has been depicted as a contributory causal factor in metabolic syndrome (MS), which in turn, portends unfavourable prognosis.

Aim

We assessed the prognostic role of SUA in patients with and without MS.

Methods

We used data from the multicentre Uric Acid Right for Heart Health study and considered cardiovascular mortality (CVM) as death due to fatal myocardial infarction, stroke, sudden cardiac death, or heart failure.

Results

A total of 9589 subjects (median age 58.5 years, 45% males) were included in the analysis, and 5100 (53%) patients had a final diagnosis of MS. After a median follow-up of 142 months, we observed 558 events. Using a previously validated cardiovascular SUA cut-off to predict CVM (> 5.1 mg/dL in women and 5.6 mg/dL in men), elevated SUA levels were significantly associated to a worse outcome in patients with and without MS (all p < 0.0001) and provided a significant net reclassification improvement of 7.1% over the diagnosis of MS for CVM (p = 0.004). Cox regression analyses identified an independent association between SUA and CVM (Hazard Ratio: 1.79 [95% CI, 1.15–2.79]; p < 0.0001) after the adjustment for MS, its single components and renal function. Three specific combinations of the MS components were associated with higher CVM when increasing SUA levels were reported, and systemic hypertension was the only individual component ever-present (all p < 0.0001).

Conclusion

Increasing SUA levels are associated with a higher CVM risk irrespective of the presence of MS: a cardiovascular SUA threshold may improve risk stratification.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01815-0.

High heart rate amplifies the risk of cardiovascular mortality associated with elevated uric acid

AIMS

Whether the association between uric acid (UA) and cardiovascular disease is influenced by some facilitating factors is unclear. The aim of this study was to investigate whether the risk of cardiovascular mortality (CVM) associated with elevated UA was modulated by the level of resting heart rate (HR).

METHODS AND RESULTS

Multivariable Cox analyses were made in 19 128 participants from the multicentre Uric acid Right for heArt Health study. During a median follow-up of 11.2 years, there were 1381 cases of CVM. In multivariable Cox models both UA and HR, either considered as continuous or categorical variables were independent predictors of CVM both improving risk discrimination (P ≤ 0.003) and reclassification (P < 0.0001) over a multivariable model. However, the risk of CVM related to high UA (≥5.5 mg/dL, top tertile) was much lower in the subjects with HR

CONCLUSION

This data suggest that the contribution of UA to determining CVM is modulated by the level of HR supporting the hypothesis that activation of the sympathetic nervous system facilitates the action of UA as a cardiovascular risk factor.

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Key Words

• Cardiovascular
• Heart rate
• Longitudinal study
• Mortality
• Sympathetic activity
• Uric acid

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Affiliation(s)

Paolo Palatini Department of Medicine, Studium Patavinum, University of Padova, Via S. Fris 121, 31029 Vittorio Veneto, Italy
Gianfranco Parati S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy
Agostino Virdis Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Gianpaolo Reboldi Department of Medical and Surgical Science, University of Perugia, Perugia, Italy
Stefano Masi Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Alessandro Mengozzi Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Edoardo Casiglia Department of Medicine, University of Padua, Padua, Italy
Valerie Tikhonoff Department of Medicine, University of Padua, Padua, Italy
Arrigo F G Cicero Alma Mater Studiorum University of Bologna, Bologna, Italy
Andrea Ungar Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
Giulia Rivasi Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
Massimo Salvetti Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
Carlo M Barbagallo Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo, Italy
Michele Bombelli Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Monza, Italy Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Raffaella Dell'Oro Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Monza, Italy Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Berardino Bruno Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
Luciano Lippa Italian Society of General, Medicine (SIMG), Avezzano, L'Aquila, Italy
Lanfranco D'Elia Department of Clinical Medicine and Surgery, "Federico II" University of Naples Medical School, Naples, Italy
Paolo Verdecchia Hospital S. Maria della Misericordia, Perugia, Italy
Fabio Angeli Department of Medicine and Surgery, University of Insubria, Varese, Italy Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, Varese, Italy
Francesca Mallamaci CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
Massimo Cirillo Department of Public Health, "Federico II" University of Naples, Napoli, Italy
Marcello Rattazzi Department of Medicine-DIMED, University of Padova, Medicina, Interna 1°, Ca' Foncello University Hospital, Treviso, Italy
Pietro Cirillo Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
Loreto Gesualdo Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
Alberto Mazza Department of Internal Medicine, Hypertension Unit, General Hospital, Rovigo, Italy
Cristina Giannattasio Cardiology IV, 'A. De Gasperis' Department, Niguarda Ca' Granda Hospital, Milano, Italy Health Science Department, Milano-Bicocca University, Milano, Italy
Alessandro Maloberti Cardiology IV, 'A. De Gasperis' Department, Niguarda Ca' Granda Hospital, Milano, Italy Health Science Department, Milano-Bicocca University, Milano, Italy
Massimo Volpe Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy IRCCS Neuromed, Pozzilli (IS), Italy
Giuliano Tocci Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy IRCCS Neuromed, Pozzilli (IS), Italy
Georgios Georgiopoulos First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
Guido Iaccarino Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Napoli, Italy
Pietro Nazzaro Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari, Italy
Ferruccio Galletti Department of Clinical Medicine and Surgery, "Federico II" University of Naples Medical School, Naples, Italy
Claudio Ferri Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
Giovambattista Desideri Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
Francesca Viazzi Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
Roberto Pontremoli Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
Maria Lorenza Muiesan Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
Guido Grassi Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Monza, Italy Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Claudio Borghi Alma Mater Studiorum University of Bologna, Bologna, Italy

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Hyperuricemia and Risk of Cardiovascular Outcomes: The Experience of the URRAH (Uric Acid Right for Heart Health) Project

The latest European Guidelines of Arterial Hypertension have officially introduced uric acid evaluation among the cardiovascular risk factors that should be evaluated in order to stratify patient's risk. In fact, it has been extensively evaluated and demonstrated to be an independent predictor not only of all-cause and cardiovascular mortality, but also of myocardial infraction, stroke and heart failure. Despite the large number of studies on this topic, an important open question that still need to be answered is the identification of a cardiovascular uric acid cut-off value. The actual hyperuricemia cut-off (> 6 mg/dL in women and 7 mg/dL in men) is principally based on the saturation point of uric acid but previous evidence suggests that the negative impact of cardiovascular system could occur also at lower levels. In this context, the Working Group on uric acid and CV risk of the Italian Society of Hypertension has designed the Uric acid Right for heArt Health project. The primary objective of this project is to define the level of uricemia above which the independent risk of CV disease may increase in a significantly manner. In this review we will summarize the first results obtained and describe the further planned analysis.

Identification of the Uric Acid Thresholds Predicting an Increased Total and Cardiovascular Mortality Over 20 Years

Serum uric acid (SUA) levels discriminating across the different strata of cardiovascular risk is still unknown. By utilizing a large population-based database, we assessed the threshold of SUA that increases the risk of total mortality and cardiovascular mortality (CVM). The URRAH study (Uric Acid Right for Heart Health) is a multicentre retrospective, observational study, which collected data from several large population-based longitudinal studies in Italy and subjects recruited in the hypertension clinics of the Italian Society of Hypertension. Total mortality was defined as mortality for any cause, CVM as death due to fatal myocardial infarction, stroke, sudden cardiac death, or heart failure. A total of 22 714 subjects were included in the analysis. Multivariate Cox regression analyses identified an independent association between SUA and total mortality (hazard ratio, 1.53 [95% CI, 1.21-1.93]) or CVM (hazard ratio, 2.08 [95% CI, 1.146-2.97]; P<0.001). Cutoff values of SUA able to discriminate total mortality (4.7 mg/dL [95% CI, 4.3-5.1 mg/dL]) and CVM status (5.6 mg/dL [95% CI, 4.99-6.21 mg/dL]) were identified. The information on SUA levels provided a significant net reclassification improvement of 0.26 and of 0.27 over the Heart Score risk chart for total mortality and CVM, respectively (P<0.001). Sex-specific cutoff values for total mortality and CVM were also identified and validated. In conclusion, SUA levels increasing the risk of total mortality and CVM are significantly lower than those used for the definition of hyperuricemia in clinical practice. Our data provide evidence of a cardiovascular SUA threshold that might contribute in clinical practice to improve identification of patients at higher risk of CVM.

Reduction of intratumoral brain perfusion by noninvasive transcranial electrical stimulation

Malignant brain neoplasms have a poor prognosis despite aggressive treatments. Animal models and evidence from human bodily tumors reveal that sustained reduction in tumor perfusion via electrical stimulation promotes tumor necrosis, therefore possibly representing a therapeutic option for patients with brain tumors. Here, we demonstrate that transcranial electrical stimulation (tES) allows to safely and noninvasively reduce intratumoral perfusion in humans. Selected patients with glioblastoma or metastasis underwent tES, while perfusion was assessed using magnetic resonance imaging. Multichannel tES was applied according to personalized biophysical modeling, to maximize the induced electrical field over the solid tumor mass. All patients completed the study and tolerated the procedure without adverse effects, with tES selectively reducing the perfusion of the solid tumor. Results potentially open the door to noninvasive therapeutic interventions in brain tumors based on stand-alone tES or its combination with other available therapies.

Loss of cervical lordosis: What is the prognosis?

Neck pain is a diffuse problem with a high incidence and often leads to the more or less appropriate prescription of imaging studies of the cervical spine. In general, this is represented by a magnetic resonance imaging (MRI) scan. Frequently such studies reveal no other significant findings apart from a loss of cervical lordosis either under the form of a simple straightening of the spine or even an inversion of the normal curvature into a kyphosis. Faced with this entity, the clinician is put in front of a series of questions: to which extent such a finding plays a role in the patient's symptoms? If it does what is the role of conservative or even invasive treatment? What are the implications for surgery either for decompressive procedures or corrective procedures? To shed some light on these questions, the authors present a narrative review of the most relevant literature on the topic. Papers examined span from the initial epidemiologic reports out of the pre-MRI and computerized tomography era up to the most recent discussions on cervical sagittal alignment and its implications both for the surgical and nonsurgical patient. In this process, it becomes increasingly clear that we are still far from making any definite statements.