Value of blood pressure measurement earlier versus later in life to predict cardiovascular mortality

 

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality.

The purpose of this study was to compare the value of systolic blood pressure earlier versus later in life to predict cardiovascular mortality.

In a cardiovascular observation study (OS) we prospectively recorded fatal cardiovascular events over up to 19 years in 1282 patients of whom 570 had the Metabolic Syndrome (MetS) at baseline. These patients had participated in a health survey (HS) 15 years prior to the OS baseline. BP was measured both at the HS and at the baseline of the OS.

We found that the increase in cardiovascular mortality matched the increase of BP in the HS in a linear way but this is not the case for BP assessed at the OS (figure). A cox regression analysis revealed that each millimeter of mercury (mm Hg) increased the risk for cardiovascular death by 2% (HR = 1.02 [1.01–1.03], p<0.001). Applying a stratification for the presence of MetS, we found that in both groups BP was a significant predictor of cardiovascular mortality (HRMetS = 1.02 [1.01–1.02], p<0.001 and HRnoMetS = 1.02 [1.01–1.03], p<0.001). In contrast, BP as measured at the baseline of the OS was not significantly associated with cardiovascular death during follow-up neither in the total population nor in any subgroup (HR = 1.00 [0.99–1.01], p=0.652; HRMetS = 1.00 [0.99–1.01], p=0.468 and HRnoMetS = 1.00 [0.99–1.01], p=4.66).

We thus conclude that BP assessed earlier in life is a better predictor of cardiovascular mortality than BP assessed later in life.

Funding Acknowledgement

Type of funding sources: None.

Ceramide-based lipid profiles and the prevalence of type 2 diabetes differ between patients with coronary artery disease and those with peripheral artery disease

Introduction

Serum lipids and metabolic diseases, in particular type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD), predict the atherosclerotic diseases coronary artery disease (CAD) and peripheral arterial disease (PAD).

Purpose

The purpose of this study was to investigate in how far a more detailed characterization including serum lipids improves discrimination of PAD from CAD.

Method

A cohort of 274 statin-naïve patients with either PAD (n=89) or stable CAD (n=185) were referred to metabolic screening and were characterized using nuclear magnetic resonance- and liquid chromatography-tandem mass spectrometry based advanced lipid and lipoprotein analysis. Results were validated in an independent cohort of 1239 patients with PAD or CAD.

Results

We found a significant difference in T2D prevalence and in the ceramide-based lipid profile between PAD and CAD patients. However, neither cholesterol-based markers (including LDL-C, HDL-C) and detailed lipoprotein profiles nor the LD status differed significantly between PAD and CAD patients (figure). The difference between ceramide-based lipid profiles of CAD and PAD remained significant also after adjusting for body composition, smoking, inflammatory parameters, and T2D.

Conclusion

We conclude that PAD and CAD differ in ceramide-based lipid profiles and T2D status, but not in other lipid characteristics or metabolic diseases.

Funding Acknowledgement

Type of funding sources: None.

The ceramide- and phosphatidylcholine- based Coronary Event Risk Test2 (CERT2) and cardiovascular mortality in men and women with type 2 diabetes

 

The recently introduced Coronary Event Risk Test version 2 (CERT2) is a validated cardiovascular risk predictor score that uses circulating ceramide and phosphatidylcholine concentrations.

The purpose of this study was to investigate the power of CERT2 to predict cardiovascular mortality in 280 male and 121 female patients with type 2 diabetes (T2DM).

Prospectively, we recorded 55 cardiovascular deaths in men and 19 in women during a mean follow-up time of 7.6±3.6 and 8.1±3.4 years respectively.

Overall, cardiovascular survival decreased with increasing CERT2 risk categories (figure 1). In Cox regression models, CERT2 significantly predicted the incidence of cardiovascular mortality in male patients with T2DM (unadj. HR 1.82 [1.39–2.37] per standard deviation; p<0.001), the unadj. HR in women was 1.36 [0.83–2.22]; p=0.228). After adjustment for age, BMI, current smoking, LDL cholesterol, HDL cholesterol, hypertension, and statin use the HR in men was 1.73 [1.31–2.29]; p<0.001) and 1.40 [083–2.36]; p=0.210 in women. Interaction terms CERT2 x gender were non-significant both in univariate analysis (p=0.354) and after multivariate adjustment (p=0.359).

We conclude that sex does not significantly impact the association of CERT2 with cardiovascular mortality in patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Remnant cholesterol in patients with established cardiovascular disease predicts cardiovascular events both among patients with type 2 diabetes and among non-diabetic subjects

 

Remnant cholesterol, which is calculated as total cholesterol minus LDL cholesterol minus HDL cholesterol has attracted interest as a marker of cardiovascular event risk.

The purpose of this study was to investiage whether remnant cholesterol has the power to predict cardiovascular events in patients with established cardiovascular disease.

We enrolled 1822 consecutive patients with established cardiovascular disease, including 1472 with angiographically proven stable CAD, 350 with sonographically proven peripheral artery disease. Prospectively, cardiovascular events were recorded over a mean follow-up period of 6.2±3.2 years.

At baseline, remnant cholesterol was significantly higher in patients with T2DM (n=608) than in non-diabetic subjects (27±25 vs. 21±21 mg/dl; p<0.001). During follow-up, 584 of our patients suffered cardiovascular events; the event rate was significantly higher in patients with T2DM than in non-diabetic subjects (45.4 vs. 32.2%; p<0.001). Remnant cholesterol in Cox regression models adjusting for age, sex, hypertension, smoking, body mass index and LDL cholesterol independently predicted cardiovascular events in the total study population (standardized adjusted HR 1.15 [1.07–1.23]; p<0.001), and in patients with T2DM as well as in non-diabetic subjects (standardized adjusted HRs 1.17 [1.03–1.34]; p=0.013 and 1.12 [1.01–1.23]; p=0.028, respectively).

From our data we conclude that remnant cholesterol in patients with established cardiovascular disease predicts cardiovascular events both among patients with T2DM and among non-diabetic subjects.

Funding Acknowledgement

Type of funding sources: None.

The new myokine myonectin is significantly associated with type 2 diabetes in elderly patients

 

The novel myokine myonectin is predominantly expressed in skeletal muscle and is involved in the regulation of metabolic homeostasis. A putative association between myonectin and type 2 diabetes mellitus (T2DM) has been discussed controversially in current literature.

The purpose of this study was to investigate the association between myonectin and T2DM at different ages.

We measured myonectin in 410 vascular risk patients with a mean age of 66 years.

Myonectin did not correlate with age (r=−0.19; p=0.697). From our patients 219 (53%) were >65 years, with a mean age of 74 years and 191 ≤65 years, with a mean age of 57 years. The prevalence of T2DM was 40.6% vs. 42.4% in the older as compared to the younger age group. Myonectin concentrations were significantly decreased in elderly patients with T2DM compared to non-diabetic subjects (1.8 vs. 4.2 ng/ml; p=0.002), whereas no significant difference was observed in younger patients (2.6 vs. 2.3 ng/ml; p=0.183). Concordantly, regression analysis revealed an unadjusted odds ratio (OR) of 0.24 [0.07–0.81] (p=0.021) for the association between myonectin and T2DM in elderly patients but not in younger patients (OR=1.08 [0.80–1.45]; p=0.609). The association between myonectin and T2D; remained significant after adjusting for sex, body mass index, LDL cholesterol, HDL cholesterol, current smoking, as well as statin intake in elderly but remained non-significant in younger patients (OR=0.23 [0.07–0.81]; p=0.021 vs. OR=1.05 [0.76–1.46]; p=0.769).

We conclude that plasma myonectin levels are significantly associated with T2DM, particularly in elderly vascular risk patients.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes, chronic kidney disease and major cardiovascular events in patients with established coronary artery disease

 

Both type 2 diabetes (T2DM) and chronic kidney disease (CKD) confer a high risk of cardiovascular disease (CVD), and these conditions frequently coincide.

The purpose of this study was to investigate the single and joint effects of T2DM and CKD on major cardiovascular events (MACE) in a high-risk population of patients with established coronary artery disease (CAD).

We prospectively investigated 1460 patients with angiographically proven CAD over 10.4±4.8 years, of whom 454 (30.8%) had T2DM and 251 (17.1%) had CKD.

MACE occurred more frequently in T2DM patients than in non-diabetic subjects (40.4% vs 28.7%, p<0.001) and in patients with CKD (eGFR <60ml/min/1.73m2) than in those with an eGRF ≥60ml/min/1.73m2 (51.6% vs 28.3%, p<0.001). When both, T2DM and CKD were considered, 863 subjects had neither T2DM nor CKD, 346 had T2DM but not CKD, 148 did not have diabetes but had CKD, and 103 had both T2DM and CKD. When compared with the incidence of MACE among patients with neither T2DM nor CKD (25.3%), MACE occurred more frequently in patients with T2DM who did not have CKD (35.8%; p<0.001) as well as in non-diabetic patients with CKD (47.6%; p<0.001) and occurred most freuently in patients with both, T2DM and CKD (57.4%; p<0.001), in whom the incidence of MACE was higher than in those with T2DM but not CKD (p<0.001) or those without T2DM but with CKD (p=0.025); the incidence of MACE was higher in non-diabetic CKD patients than in T2DM patients who did not have CKD (p=0.041). In Cox regression analysis, T2DM (HR=1.46 [1.20–1.78]; p<0.001) and CKD (HR=1.81 [1.45–2.27]; p<0.001) were mutually independent predictors of MACE after multivariate adjustment.

We conclude that T2DM and CKD are mutually independent risk factors for MACE in patients with established CAD. CAD patients with both CKD and T2DM are an extremely high risk for MACE.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes significantly modulates the power of lipoprotein(a) to predict cardiovascular events and mortality in young coronary artery disease patients

 

Lipoprotein(a) [Lp(a)] is an important cardiovascular risk factor especially in young individuals.

The purpose of this study was to investigate whether Lp(a) has the power to predict cardiovascular events in young coronary artery disease (CAD) patients with type 2 diabetes (T2DM).

Lp(a) was measured in a cohort of 731 patients with angiographically proven CAD who were aged <65 years. Vascular events were recorded over a mean follow-up of 6.6±3.2 years.

At baseline, 216 patients had T2DM, and 515 did not have diabetes. During follow-up, 30.2% of our patients suffered cardiovascular events. Lp(a) proved to be a strong and independent predictor of vascular events in the total study cohort (standardized adjusted HR=1.30 [1.07–1.56]; p=0.007). In subgroup analyses by diabetes status, Lp(a) significantly predicted vascular events in non-diabetic patients (standardized adjusted HR= 1.39 [1.12–1.74]; p=0.003) but not in diabetic patients (standardized adjusted HR=0.93 [0.63–1.38]; p=0.731). An interaction term Lp(a) x T2DM was significant (p=0.002), indicating that T2DM significantly modulated the power of Lp(a) to predict cardiovascular events.

We conclude that Lp(a) significantly modulates the power of Lp(a) to predict cardiovascular events in CAD patients <65 years.

Funding Acknowledgement

Type of funding sources: None.

Type 2 diabetes and risk of major cardiovascular events in peripheral artery disease versus coronary artery disease patients

 

The prevalence of type 2 diabetes (T2DM) is higher in peripheral artery disease (PAD) than in coronary artery disease (CAD) patients, and PAD overall confers higher cardiovascular risk than CAD.

The purpose of this study was to investigate how the incidence of major cardiovascular events compares between PAD and CAD patients when analyses are stratified by the presence of type 2 diabetes (T2DM).

We prospectively recorded major cardiovascular events and death over 10.0±4.7 years in 923 patients with stable CAD, of whom 26.7% had T2DM and in 292 patients with PAD, of whom 42.1% had T2DM. Four groups were analyzed: CAD patients without diabetes (CAD/T2DM-; n=677), CAD patients with T2DM (CAD/T2DM+; n=246), PAD patients without diabetes (PAD/T2DM-; n=169) and PAD patients with T2DM (PAD/T2DM+; n=123).

When compared to the incidence of MACE in CAD+/T2DM- patients (25.1%), it was significantly higher in CAD+/T2DM+ patients (35.4%; p<0.001), in PAD+/T2DM- patients (30.2%; p=0.022) and in PAD+/T2DM+ patients (47.2%; p<0.001). Patients with both PAD and T2DM in turn were at a higher risk than CAD+/T2DM+ or PAD+/T2DM- patients (p=0.001 and p<0.001, respectively). The incidence of MACE did not differ significantly between PAD+/T2DM- and CAD+/T2DM+ patients (p=0.413). Compared to patients with CAD, Cox regression analyses after multivariate adjustment showed an adjusted hazard ratio of 1.46 [1.14–1.87], p=0.002 for the presence of PAD. Conversely, T2DM increased the risk of MACE after multivariate adjustment in CAD and PAD patients (adjusted HR 1.58 [1.27–1.98], p<0.001).

In conclusion, our data show that T2DM and the presence of PAD are mutually independent predictors of MACE. Patients with both PAD and T2DM are at an exceedingly high risk of MACE.

Funding Acknowledgement

Type of funding sources: None.

Reduced recombination and paternal age effect in Klinefelter syndrome

The parental origin of the additional sex chromosome was studied in 47 cases with an XXY sex chromosome constitution. In 23 cases (49%), the error occurred during the first paternal meiotic division. Maternal origin of the additional chromosome was found in the remaining 24 cases (51%). Centromeric homo- versus heterozygosity could be determined in 18 out of the 24 maternally derived cases. According to the centromeric status and recombination rate, the nondisjunction was attributable in 9 cases (50%) to an error at the first maternal meiotic division, in 7 cases (39%) to an error at the second maternal meiotic division and in 2 cases (11%) to a nullo-chiasmata nondisjunction at meiosis II or to postzygotic mitotic error. No recombination, and in particular none in the pericentromeric region, was found in any of the 9 cases due to nondisjunction at the first maternal meiotic division. Significantly increased paternal age was found in the paternally derived cases. Maternal age was significantly higher in the maternally derived cases due to a meiotic I error compared with those due to a meiotic II error. There were no significant clinical differences between patients with respect to the origin of the additional X chromosome.

Molecular study of 45,X conceptuses: correlation with clinical findings

The parental origin of the single X in 45 cases (40 liveborns and 5 fetuses) with a 45,X karyotype was studied using polymorphic DNA probes. The single X was paternal in origin (Xp) in 10 cases (22.2%) and maternal (Xm) in 35 cases (77.8%). Y chromosome material was detected in 1 out of the 35 cases with a 45,Xm constitution. Analysis of parental ages and clinical data of the patients with respect to the origin of the single X revealed no significant differences between the origins.

Uniparental origin of sex chromosome polysomies

The parental origin of the additional sex chromosomes in 8 cases with high-order sex chromosome polysomies was determined using DNA polymorphisms. The additional sex chromosomes were paternally derived in 3 48,XXYY cases, and maternal in origin in 1 48,XXXY case and 4 49,XXXXY cases. Thus, all extra chromosomes, within a particular patient, were always derived from only one parent. Their most likely origin was successive nondisjunction at the first and second meiotic division in one germ cell. The mechanism involved remains unclear, but appears to be independent of parental ages.

A molecular study of X isochromosomes: parental origin, centromeric structure, and mechanisms of formation

Fourteen individuals with an i(Xq) or idic(Xq) were studied using RFLP analysis in order to determine both parental origin and extent of heterozygosity of the isochromosome and to search for the presence of short-arm material. In five cases the isochromosome was paternally derived, while nine patients had a maternal i(Xq). The analysis of heterozygosity of the nine maternally derived isochromosomes by using Xq markers showed heterozygosity in two cases, suggesting an origin from two homologous X chromosomes. Homozygosity was found at all informative loci in seven cases, which therefore are probably the product of either centromere misdivision or sister-chromatid exchange. Presence of Xp markers was seen both in the three i(Xq) chromosomes which appeared dicentric by cytogenetic analysis and in three additional cytogenetically monocentric cases. Mean parental ages were greater for the maternally derived cases as compared with the paternally derived cases.

Association between haplotypes and specific mutations in Swiss cystic fibrosis families

Cystic fibrosis (CF) is the most common severe autosomal recessive genetic disorder in Caucasian populations, with an incidence of about 1 in 2000 live births, implying a carrier frequency of about 1 in 22. In 1989, the CF gene was isolated and characterized and the major mutation (delta F508), a 3-bp deletion that results in the loss of a phenylalanine residue at position 508, was detected. To determine the frequency of the delta F508 mutation and the predicted number of additional mutations in our population, we have undertaken a collaborative study of 215 CF patients and 175 CF parents in Switzerland. The delta F508 mutation in exon 10 has been found in 70% of the CF chromosomes, and the exon-11 mutation R553X seems to be the second most common CF mutation in our population, with a frequency of 5.3%, whereas the G551D mutation (also in exon 11) has not been detected at all. Haplotype determination of 430 CF and 175 normal chromosomes using XV-2c, KM19, MP6d-9, and J3.11 has been proven to be very helpful in providing additional carrier risk calculations: Haplotypes 1 (1221), 2 (1222), 6 (2111), and 7 (2221) increase the risk of being a carrier from 1 in 55 (haplotype 6) to 1 in 17 (haplotype 1), whereas haplotypes 3 (1122), 4 (1112), 8 (2222) and 10 (1111) lower the risk from 1 in 144 (haplotype 3) to 1 in 1678 (haplotype 10). Moreover, the mutation R553X shows strong correlation with haplotype 3, leading to the suggestion that haplotypes 1, 2, 5, and 6 may account for four additional mutations in Switzerland.(ABSTRACT TRUNCATED AT 250 WORDS)

A 48,XXY,+21 Down syndrome patient with additional paternal X and maternal 21

The origin of meiotic nondisjunction of the extra chromosomes X and 21 was studied in a patient with the karyotype 48,XXY,+21 using DNA polymorphisms. The extra chromosome X was the result of paternal first meiotic nondisjunction of X and Y. The extra chromosome 21 was derived from the mother. The meiotic error in the mother most probably occurred in meiosis II. Thus, this is a combination caused by the chance occurrence of two independent events.

Expression of a cloned adenovirus gene is inhibited by in vitro methylation

In many viral and nonviral eukaryotic systems, an inverse correlation has been observed between the extent of DNA methylation at 5'-C-C-G-G-3' sites and the extent of expression of specific genes as mRNA. The E2a region of adenovirus serotype 2 (Ad2) DNA encodes the Ad2-specific DNA binding protein required for viral DNA replication. In three lines of Ad2 transformed hamster cells (HE1, HE2, and HE3), multiple copies of the major part of the Ad2 genome persist in an integrated state. Cell lines HE2 and HE3 do not express the DNA-binding protein whereas line HE1 does so. It has been shown that, in cell line HE1, all 5'-C-C-G-G-3' (Hpa II/MspI) sites in the E2a region remain unmethylated. Conversely, in lines HE2 and HE3 lacking expression of the E2a region all Hpa II sites are methylated. The cloned E2a region of Ad2 DNA, the HindIII A fragment in pBR322, was methylated in vitro by using Hpa II DNA methyltransferase (5'-C-C*G-G-3') or was left unmethylated. In vitro methylation did not break or nick supercoiled circular DNA. Methylated or unmethylated DNA was then microinjected into the nuclei of Xenopus laevis oocytes, and the subsequent synthesis of Ad2-specific RNA was monitored. In vitro-methylated DNA remained in the methylated state for 24 hr on microinjection into nuclei of xenopus oocytes; unmethylated DNA remained unmethylated. When the injected DNA had been methylated by using Hpa H DNA methyltransferase, Ad2-specific RNA was not synthesized as late as 24 hr after microinjection. Unmethylated DNA was readily expressed into Ad2-specific RNA. As an internal control, unmethylated histone genes (h22 DNA) from sea urchin were microinjected together with methylated E2a DNA from Ad2. Ad2-specific RNA was not found; h22 DNA-specific RNA was readily detected. This finding ruled out nonspecific inhibitory effects in the methylated DNA preparation. Ir was also shown that transcription of the unmethylated HindIII A fragment of Ad2 DNA in Xenopus oocytes was initiated on the late promoter of the E2a region. The same promoter was used in productively infected KB cells. Methylation by BsuRI methylse (5'-G'G-C*C-3') did not inactivate the HindIII A fragment. These results provide evidence for the notion that methylated sequences at highly specific sites are involved in the regulation of gene expression. The actual nature of the regulatory signal is not yet understood.