GDF15 linked to maternal risk of nausea and vomiting during pregnancy

GDF15, a hormone acting on the brainstem, has been implicated in the nausea and vomiting of pregnancy, including its most severe form, hyperemesis gravidarum (HG), but a full mechanistic understanding is lacking1-4. Here we report that fetal production of GDF15 and maternal sensitivity to it both contribute substantially to the risk of HG. We confirmed that higher GDF15 levels in maternal blood are associated with vomiting in pregnancy and HG. Using mass spectrometry to detect a naturally labelled GDF15 variant, we demonstrate that the vast majority of GDF15 in the maternal plasma is derived from the feto-placental unit. By studying carriers of rare and common genetic variants, we found that low levels of GDF15 in the non-pregnant state increase the risk of developing HG. Conversely, women with β-thalassaemia, a condition in which GDF15 levels are chronically high5, report very low levels of nausea and vomiting of pregnancy. In mice, the acute food intake response to a bolus of GDF15 is influenced bi-directionally by prior levels of circulating GDF15 in a manner suggesting that this system is susceptible to desensitization. Our findings support a putative causal role for fetally derived GDF15 in the nausea and vomiting of human pregnancy, with maternal sensitivity, at least partly determined by prepregnancy exposure to the hormone, being a major influence on its severity. They also suggest mechanism-based approaches to the treatment and prevention of HG.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Fetally-encoded GDF15 and maternal GDF15 sensitivity are major determinants of nausea and vomiting in human pregnancy

Human pregnancy is frequently accompanied by nausea and vomiting that may become severe and life-threatening, as in hyperemesis gravidarum (HG), the cause of which is unknown. Growth Differentiation Factor-15 (GDF15), a hormone known to act on the hindbrain to cause emesis, is highly expressed in the placenta and its levels in maternal blood rise rapidly in pregnancy. Variants in the maternal GDF15 gene are associated with HG. Here we report that fetal production of GDF15, and maternal sensitivity to it, both contribute substantially to the risk of HG. We found that the great majority of GDF15 in maternal circulation is derived from the feto-placental unit and that higher GDF15 levels in maternal blood are associated with vomiting and are further elevated in patients with HG. Conversely, we found that lower levels of GDF15 in the non-pregnant state predispose women to HG. A rare C211G variant in GDF15 which strongly predisposes mothers to HG, particularly when the fetus is wild-type, was found to markedly impair cellular secretion of GDF15 and associate with low circulating levels of GDF15 in the non-pregnant state. Consistent with this, two common GDF15 haplotypes which predispose to HG were associated with lower circulating levels outside pregnancy. The administration of a long-acting form of GDF15 to wild-type mice markedly reduced subsequent responses to an acute dose, establishing that desensitisation is a feature of this system. GDF15 levels are known to be highly and chronically elevated in patients with beta thalassemia. In women with this disorder, reports of symptoms of nausea or vomiting in pregnancy were strikingly diminished. Our findings support a causal role for fetal derived GDF15 in the nausea and vomiting of human pregnancy, with maternal sensitivity, at least partly determined by pre-pregnancy exposure to GDF15, being a major influence on its severity. They also suggest mechanism-based approaches to the treatment and prevention of HG.

The burden of coronary revascularization associated with lipoprotein(a) in patients with atherosclerotic cardiovascular disease: data from the UK Biobank

Background/Introduction

Elevated lipoprotein(a) [Lp(a)] is an inherited, independent, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). In a previous analysis of 30,510 ASCVD patients from UK Biobank, adjusted models showed a 100 nmol/L (≈50 mg/dL) difference in Lp(a) was associated with a 19% (95% CI 14–23%) higher risk of coronary revascularization (Welsh P, 2022).

Purpose

To determine the absolute risk for coronary revascularization in an ASCVD population with elevated versus normal Lp(a) levels.

Methods

This was an observational, retrospective study including 32,537 patients from UK Biobank with an ASCVD diagnosis (CHD, cerebrovascular or peripheral arterial disease). Absolute risk (AR) of coronary revascularization (number of coronary revascularizations per 100-person-years) was reported in patients with normal (&lt;65 nmol/L ≈ 30 mg/dL; n=22,257) and elevated (≥150 nmol/L ≈ 70 mg/dL; n=5,204) Lp(a) levels across two time periods: within the first year of ASCVD diagnosis, and using all available follow-up data (median 4.7 years). Lp(a) was measured in an accredited single laboratory using a method standardized to WHO/IFCC reference material. The AR was also calculated for various subgroups within the ASCVD population.

Results

Within the first year after ASCVD diagnosis, 628 (12.07%) of the population with elevated Lp(a) underwent coronary revascularization compared to 1,787 (8.03%) with normal Lp(a). Those with elevated Lp(a) had a higher AR (14.00 per 100-person-years, 95% CI 13.02–14.99; p&lt;0.001) than those with normal Lp(a) (9.34; 95% CI 8.92–9.76). This also held in a subgroup with myocardial infarction (MI; n=9,588), AR of 18.98 (95% CI 16.95–21.01) in those with elevated Lp(a) (n=1,571) vs. AR of 13.02 (95% CI 12.16–13.89) in those with normal Lp(a) (n=6,441) (p&lt;0.001). AR of coronary revascularization within the first year of ASCVD diagnosis was also greater in participants with family history of CV disease (p&lt;0.001) and premature CV disease (&lt;60 years of age) (p&lt;0.001). When using all available follow-up, AR of coronary revascularization was higher in participants with elevated versus normal Lp(a) in the ASCVD population (3.79 vs 2.55; p&lt;0.001) and across all subgroups.

Conclusion

Elevated Lp(a) in patients with ASCVD was associated with increased risk of coronary revascularization in the first year (and subsequently), including those with a prior MI, premature CV disease, or family history of CV disease. Lp(a) testing in ASCVD patients can therefore aid estimations for the risk of revascularization, and thus the targeting of additional therapies to lower such risks.

Funding Acknowledgement

Type of funding sources: None.

Relationship between endothelin-1, heart failure with reduced ejection fraction and dapagliflozin: findings from DAPA-HF

Background

Circulating Endothelin-1 (ET-1) is associated with heart failure (HF) severity and has also been widely implicated in the pathophysiology of renal disease. However, its prognostic importance and relationship with kidney function in patients with HFrEF receiving contemporary treatment is uncertain.

Purpose

To investigate the association of ET-1 with heart failure outcomes, as well as change in kidney function; and the efficacy of dapagliflozin according to baseline serum ET-1 in the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure trial (DAPA-HF).

Methods

Serum ET-1 was measured at randomization and at 12 months and analysed using a Microfluidics immunoassay. We investigated the incidence of the primary outcome (cardiovascular death or worsening HF), and analysed change in kidney function according to tertile of baseline ET-1 concentration. Additionally, we assessed whether baseline ET-1 modified the treatment effect of dapagliflozin.

Results

Of 4744 randomized participants, 3048 (64.2%) had a baseline ET-1 measurement: tertile 1 (≤3.28 pg/mL, n=1016), tertile 2 (&gt;3.28 to 4.41 pg/mL, n=1022), and tertile 3 (&gt;4.41 pg/mL, n=1010). Patients with higher baseline ET-1 concentrations were more likely male, obese and to have lower LVEF, lower eGFR, worse functional status, and elevated NT-proBNP and high-sensitivity troponin-T.

Adjusting for other predictive variables including NT-proBNP, higher baseline ET-1 was independently associated with worse outcomes and steeper decline in kidney function: adjusted hazard ratio (aHR) for the primary outcome of 1.95 (1.53–2.50) for tertile 3 and 1.36 (95% CI 1.06–1.75) for tertile 2; aHR for worsening HF of 2.54 (1.82–3.53) for tertile 3 and 1.54 (1.10–2.18) for tertile 2; aHR for cardiovascular death of 1.39 (1.01–1.92) for tertile 3 and 1.13 (0.82–1.57) for tertile 2; and eGFR slope −3.19 (95% CI −3.66 to −2.72) mL/min/1.73 m2 per year in tertile 3 versus −2.06 (−2.51 to −1.62) in tertile 2 and −2.35 (−2.79 to −1.91) in tertile 1, p for difference (eGFR slope)=0.002.

The benefit of dapagliflozin was consistent regardless of baseline ET-1, whether analysed according to tertiles or as a continuous variable, with p-interaction for primary outcome 0.47 and 0.10 respectively. Compared to placebo, there was a trend to reduction in ET-1 level at 12 months with dapagliflozin (difference −0.12 pg/mL, p-value=0.07).

Conclusions

Baseline ET-1 concentration was independently associated with clinical outcomes and with more rapid decline in kidney function. The benefit of dapagliflozin was consistent across the range of ET-1 concentrations measured.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The DAPA-HF trial was funded by AstraZeneca. Professor John McMurray is supported by a British Heart Foundation Centre of Research Excellence Grant RE/18/6/34217.

Socioeconomic deprivation: an important largely unrecognized risk factor in primary prevention of cardiovascular disease

Background

Socioeconomic deprivation is associated with higher cardiovascular morbidity and mortality. Whether deprivation status should be incorporated in more cardiovascular risk estimation scores remains unclear.

Purpose

This study evaluates how socioeconomic deprivation status affects the performance of three primary prevention cardiovascular risk scores.

Methods

The Generation Scotland Scottish Family Health Study was used to evaluate the performance of three cardiovascular risk scores with (ASSIGN) and without (SCORE2, PCE) socioeconomic deprivation as a covariate in the risk prediction model. Deprivation was defined by Scottish Index of Multiple Deprivation score. The predicted 10-year risk was evaluated against the observed event rate for the cardiovascular outcome of each risk score. The comparison was made across three groups defined by the deprivation index score consisting of group 1 defined as most deprived, group 3 defined as least deprived and group 2 which consisted of individuals in the middle deprivation categories.

Results

The study population consisted of 15,506 individuals (60.0% female, median age of 51). Across the population 1,808 (12%) individuals were assigned to group 1 (most deprived), 8,119 (55%) to group 2, and 4,708 (32%) to group 3 (least deprived). Risk scores based on models that did not include deprivation status significantly under predicted risk in the most deprived (6.4% observed versus 4.6% predicted for SCORE2 and 6.7% observed versus 4.7% predicted for PCE, p&lt;0.001 for both). Both risk scores also significantly overpredicted the risk in the least deprived group (4.0% observed versus 4.7% predicted for SCORE2, p=0.007 and 4.2% observed versus 4.9% predicted for PCE, p=0.028). In contrast, no significant difference was demonstrated in the observed versus predicted risk when using the ASSIGN risk score, which included socioeconomic deprivation status in the risk model.

Conclusions

Socioeconomic status is a largely unrecognized risk factor in primary prevention of cardiovascular disease. Risk scores that exclude socioeconomic deprivation as a covariate under- and overestimate the risk in the most and least deprived individuals, respectively. This study highlights the importance of incorporating socioeconomic deprivation status in risk estimation systems to ultimately reduce inequalities in health care provision for cardiovascular disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation.Health Data Research UK which receives its funding from HDR UK Ltd (HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation and the Wellcome Trust.

Outcomes related to IGFBP-7 in patients with heart failure and reduced ejection fraction and effects of dapagliflozin: findings from DAPA-HF

Introduction

Insulin-like growth factor binding protein 7 (IGFBP-7) has been proposed as a novel prognostic biomarker in heart failure, but the association between IGFBP-7 and cardiovascular outcomes has not been examined in a large cohort of patients with heart failure and reduced ejection fraction (HFrEF).

Purpose

In this post-hoc analysis of the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure trial (DAPA-HF) we examined the relationship between plasma IGFBP-7 level and outcomes in patients with HFrEF, the effect of dapagliflozin according to IGFBP-7 level and change in IGFBP-7 at 12 months.

Methods

Patients in NYHA class II–IV with LVEF ≤40% and elevated NT-proBNP were included in DAPA-HF. Participants were randomly allocated to dapagliflozin 10mg or matching placebo. In this analysis, patients were categorized by IGFBP-7 tertile. The primary outcome was a composite of cardiovascular death or worsening HF event; secondary outcomes were components of the primary outcome and all-cause mortality. The risk of each outcome was compared across thirds of IGFBP-7 using Cox regression models with adjustment for NT-proBNP and high-sensitivity troponin T as well as: randomised treatment, age, sex, race, region, systolic blood pressure, heart rate, ejection fraction, estimated glomerular filtration rate, NYHA class, history of HF hospitalisation, ischaemic aetiology of HF, hypertension, stroke, atrial fibrillation, prior MI and stratified by diabetes status. The efficacy of dapagliflozin was assessed according to baseline IGFBP-7 level. Change in IGFBP-7 at 12 months was assessed using the ratio of geometric means.

Results

3158 patients had measurement of IGFBP-7 at baseline. The median value of IGFBP-7 was 192 ng/mL (interquartile range 158–246). Patients in the highest third of IGFBP-7 levels had more advanced HF, with higher NYHA class and NT-proBNP, had worse renal function and more type 2 diabetes. Patients in the highest third had the highest rate of the primary outcome (Figure 1). The adjusted hazard ratio (aHR) for the primary endpoint (with lowest third of IGFBP-7 as reference) was 0.94 (95% CI 0.74–1.20) for middle third and 1.49 (95% CI 1.17–1.89) for top third. The corresponding aHRs for worsening HF event were 0.99 (95% CI 0.72–1.36) for middle third and 1.84 (95% CI 1.35–2.50) for top third. Cardiovascular and all-cause mortality did not vary by IGFBP-7 tertile. The benefit of dapagliflozin was consistent regardless of baseline IGFBP-7 (p for interaction for primary endpoint = 0.34). The change in IGFBP-7 from baseline to 12 months did not differ between placebo and dapagliflozin.

Conclusions

Elevation of IGFBP-7 in patients with HFrEF was associated with more adverse HF outcomes, even after adjustment for both NT-proBNP and hsTnT. The treatment benefit of dapagliflozin did not vary by baseline IGFBP-7.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The DAPA-HF trial was funded by AstraZeneca.CA and JJVM are supported by a British Heart Foundation Centre of Research Excellence Grant.

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21

Background

Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection.

Methods

A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID.

Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea.

Discussion

Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals.

Trial registration

ClinicialTrials.gov NCT04900961. Prospectively registered on 25 May 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06632-y.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Association of statin use in older people primary prevention group with risk of cardiovascular events and mortality: a systematic review and meta-analysis of observational studies

Background

Current evidence from randomized controlled trials on statins for primary prevention of cardiovascular disease (CVD) in older people, especially those aged &gt;75 years, is still lacking.

Purpose

We conducted a systematic review and meta-analysis of observational studies to extend the current evidence about association of statin use in older people primary prevention group with risk of CVD and mortality.

Methods

PubMed, Scopus, and Embase were searched from inception until March 18, 2021. We included observational studies (cohort or nested case-control) that compared statin use vs non-use for primary prevention of CVD in older people aged ≥65 years; provided that each of them reported the risk estimate on at least one of the following primary outcomes: all cause-mortality, CVD death, myocardial infarction (MI), and stroke. Risk estimates of each relevant outcome were pooled as a hazard ratio (HR) with a 95% confidence interval (CI) using the random-effects meta-analysis model.

Results

Ten observational studies (9 cohort and one case-control study; n=872,845) fulfilled our criteria. The overall combined estimate suggested that statin therapy was associated with a significantly lower risk of all-cause mortality (HR: 0.86 [95% CI: 0.79 to 0.93]), CVD death (HR: 0.80 [95% CI: 0.78 to 0.81]), and stroke (HR: 0.85 [95% CI: 0.76 to 0.94]) and a non-significant association with risk of MI (HR: 0.74 [95% CI: 0.53 to 1.02]). The beneficial association of statins with the risk of all-cause mortality remained significant even at higher ages (&gt;75 years old; HR: 0.88 [95% CI: 0.81 to 0.96]) and in both men (HR: 0.75 [95% CI: 0.74 to 0.76]) and women (HR: 0.85 [95% CI: 0.72 to 0.99]). However, this association with the risk of all-cause mortality remained significant only in those with DM (HR: 0.82 [95% CI: 0.68 to 0.98]) but not in those without DM.

Conclusions

Statin therapy in older people (aged ≥65 years) without CVD was associated with a 14%, 20% and 15% lower risk of all-cause mortality, CVD death and stroke, respectively. The beneficial association with the risk of all-cause mortality remained significant even at higher ages (&gt;75 years old), in both men and women, and in individuals with DM, but not in those without DM. These observational findings support the need for trials to test benefits of statins in those above 75 years of age.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Results of the meta-analysis

Diverging trends for onset of acute myocardial infarction, heart failure, stroke and mortality in young males: role of changes in obesity and fitness

BACKGROUND

As opposed to the decreasing overall rates of coronary heart disease (CHD) incidence and overall cardiovascular disease (CVD) mortality, heart failure (HF) and stroke incidence are increasing in young people, potentially due to rising rates of obesity and reduced cardiorespiratory fitness (CRF).

OBJECTIVES

We investigated trends in early major CVD outcomes in a large cohort of young men.

METHODS

Successive cohorts of Swedish military conscripts from 1971 to 1995 (N = 1,258,432; mean age, 18.3 years) were followed, using data from the National Inpatient and Cause of Death registries. Cox proportional hazard models were used to analyse changes in 21-year CVD event rates.

RESULTS

21-year CVD and all-cause mortality and incidence of acute myocardial infarction (AMI) decreased progressively. Compared with the cohort conscripted in 1971-1975 (reference), the hazard ratios (HRs) for the last 1991-1995 cohort were 0.50 [95% confidence interval (CI) 0.42-0.59] for CVD mortality; 0.57 (95% CI 0.54-0.60) for all-cause mortality; and 0.63 (95% CI 0.53-0.75) for AMI. In contrast, the incidence of ischaemic stroke, intracerebral haemorrhage and HF increased with HRs of 1.43 (95% CI 1.17-1.75), 1.30 (95% CI 1.01-1.68) and 1.84 (95% CI 1.47-2.30), respectively. During the period, rates of obesity increased from 1.04% to 2.61%, whilst CRF scores decreased slightly. Adjustment for these factors influenced these secular trends only moderately.

CONCLUSION

Secular trends of young-onset CVD events demonstrated a marked shift from AMI and CVD mortality to HF and stroke incidence. Trends were significantly, though moderately, influenced by changing baseline BMI and CRF.

Predictors of type 2 diabetes remission in the Diabetes Remission Clinical Trial (DiRECT)

AIM

To identify predictors of type 2 diabetes remission in the intervention arm of DiRECT (Diabetes Remission Clinical Trial).

METHODS

Participants were aged 20-65 years, with type 2 diabetes duration of <6 years and BMI 27-45 kg/m² , and were not receiving insulin. Weight loss was initiated by total diet replacement (825-853 kcal/day, 3-5 months, shakes/soups), and weight loss maintenance support was provided for 2 years. Remissions (HbA_1c <48 mmol/mol [<6.5%], without antidiabetes medications) in the intervention group (n = 149, mean age 53 years, BMI 35 kg/m² ) were achieved by 68/149 participants (46%) at 12 months and by 53/149 participants (36%) at 24 months. Potential predictors were examined by logistic regression analyses, with adjustments for weight loss and effects independent of weight loss.

RESULTS

Baseline predictors of remission at 12 and 24 months included being prescribed fewer antidiabetes medications, having lower triglyceride and gamma-glutamyl transferase levels, and reporting better quality of life with less anxiety/depression. Lower baseline HbA_1c was a predictor at 12 months, and older age and male sex were predictors at 24 months. Being prescribed antidepressants predicted non-remission. Some, but not all effects were explained by weight loss. Weight loss was the strongest predictor of remission at 12 months (adjusted odds ratio per kg weight loss 1.24, 95% CI 1.14, 1.34; P < 0.0001) and 24 months (adjusted odds ratio 1.23, 95% CI 1.13, 1.35; P <0.0001). Weight loss in kilograms and percentage weight loss were equally good predictors. Early weight loss and higher programme attendance predicted more remissions. Baseline BMI, fasting insulin, fasting C-peptide and diabetes duration did not predict remission.

CONCLUSIONS

Other than weight loss, most predictors were modest, and not sufficient to identify subgroups for which remission was not a worthwhile target.

POS1068 Cardiac biomarkers are associated with the development of cardiovascular events in patients with psoriatic arthritis and psoriasis

Background:

N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and troponin I (TnI) are established cardiac biomarkers that predict cardiovascular events (CVEs) in the general population. While patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk of developing CVEs, the use of these cardiac biomarkers to predict CV risk has not been investigated in this population.

Objectives:

We aimed to evaluate the association between these cardiac biomarkers and incident CVEs, and assess their predictive value beyond the Framingham Risk Score (FRS).

Methods:

A longitudinal cohort study was conducted in patients with PsD without prior history of CVEs. NT-proBNP and TnI concentrations were measured using automated clinical assays in the first available serum sample. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, transient ischemic attack, stroke, revascularization and CV death. Associations with incident CVEs were analyzed separately for each biomarker using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for the FRS. The added value of cardiac biomarkers to improve predictive performance beyond the FRS was assessed using the area under the receiver operator characteristic curve (AUC), net reclassification index (NRI) and integrated discrimination index (IDI).

Results:

A total of 1000 patients with PsD were assessed between 2002 and 2019 (mean age 49 ± 12.8 years, 44.6% female) (Table 1). During a mean follow-up of 7.1 years, 64 patients developed incident CVEs. Both TnI (Hazard Ratio (HR) 3.02, 95% Confidence Interval (CI) 1.12, 8.16) and NT-proBNP (HR 2.02; 95% CI 1.28, 3.18) predicted CVEs independently of the FRS (Figure 1). The association was stronger in males than females. Including all cardiac biomarkers and the FRS in a single model, NT-proBNP retained statistical significance (HR 1.91, 95% CI 1.23, 2.97), while TnI did not (HR 2.60, 95% CI 0.98, 6.87). When comparing the predictive performance of the base model (FRS alone, AUC 75.4) to the expanded models, there was no significant improvement in any of the predictive indices with the addition of TnI (AUC 73.5, p = 0.21; NRI 0.08, p = 0.67; IDI 0.005, p = 0.37), NT-proBNP (AUC 71.0, p = 0.35; NRI 0.20, p = 0.06; IDI 0.017, p = 0.10), or both TnI and NT-proBNP (AUC 70.0, p = 0.23; NRI 0.27, p = 0.05; IDI 0.021, p =0.05).

Conclusion:

In patients with PsD, elevated NT-proBNP and TnI predict incident CVEs independent of the FRS. We did not observe a significant improvement in the performance of the predictive model when combining these cardiac biomarkers with the FRS.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Table 1.

Baseline characteristics of the study population (n=1000)

VariableMean ± SD / Frequency (%)PsA, no. (%)648 (64.8)PsC, no. (%)352 (35.2)Age (years)49 ± 12.8Male sex, no. (%)554 (55.4)Disease duration (years)20.2 ± 14.1Ethnicity, Caucasian (%)834 (83.4)Current smoker (%)164 (16.4)FRS (%)8.2 ± 8.6Diabetes77 (7.7)Hypertension274 (27.4)BMI (kg/m2)28.7 ± 5.9PASI4.1 ± 6.3Use of lipid-lowering medications (%)100 (10)Current use of DMARDs362 (36.2)Current use of Biologics214 (21.4)Current use of NSAIDs (daily use)265 (26.5)

1 Applicable only to patients with PsA CVE, cardiovascular events; DMARD, disease-modifying antirheumatic drug; FRS, Framingham Risk Score; NSAID, non-steroidal anti-inflammatory drug; PASI, Psoriasis Area Severity Index; PsA, psoriatic arthritis; PsC, psoriasis without arthritis

Figure 1.

Hazard ratios of cardiac biomarker measures for incident cardiovascular events (n = 1000, 64 events). Error bars denote 95% confidence intervals. CI indicates confidence interval; CVEs, cardiovascular events; FRS, Framingham Risk Score; NT-proBNP, N-terminal pro-brain-type natriuretic peptide; TnI, troponin I.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared.

OP0221 TARGETED METABOLOMIC PROFILING AND PREDICTION OF CARDIOVASCULAR EVENTS: A PROSPECTIVE STUDY OF PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background:

Psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), are associated with increased cardiovascular (CV) risk. Metabolites comprise biomarkers that may add predictive value over traditional CV risk factors.

Objectives:

We aimed to identify metabolites associated with CV events (CVEs) and to determine whether they could improve CV risk prediction beyond traditional CV risk factors.

Methods:

Patients from a longitudinal PsD cohort without a prior history of CVEs were included. In the first available serum sample, a targeted nuclear magnetic resonance (NMR) metabolomics platform was used to quantify 64 metabolite measures comprised of lipoprotein subclasses, fatty acids, glycolysis precursors, ketone bodies and amino acids. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. The association of each metabolite with incident CVEs were analyzed separately using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for traditional CV risk factors. Variable selection was performed using penalization with boosting after adjusting for age and sex. The added predictive value of the selected metabolites to improve risk prediction beyond traditional CV risk factors was assessed using the area under the receiver operator characteristic curve (AUC).

Results:

A total of 977 patients with PsD, followed between 2002 and 2019, were analyzed (mean age 49.1 ± 12.6 years, 45.1% female). During a mean follow-up of 7.1 years, 70 (7.2%) patients developed incident CVEs. In Cox regression models adjusted for CV risk factors, alanine, tyrosine, total high-density lipoprotein (HDL) cholesterol, medium and large HDL particles, and the degree of unsaturation of fatty acids were significantly associated with decreased CV risk. Glycoprotein acetyls, apolipoprotein B, remnant cholesterol, very low-density lipoprotein (VLDL) cholesterol, and very small VLDL particles were associated with an increased CV risk. In proportional sub-distribution hazards regression models adjusted for age and sex, 13 metabolites were selected (Table 1). The age- and sex-adjusted expanded model (base model + 13 metabolites) significantly improved prediction of CVEs beyond the base model (only age and sex) with an AUC of 79.9 vs. 72.6, respectively (p=0.019) (Figure 1).

Table 1.

Regression coefficients of the selected metabolites in a model adjusted for age and sex.

CategoryMetaboliteModel adjusted for Age and SexAmino AcidsAlanine-0.1179Glycine-0.0339Tyrosine-0.1010Fatty acid ratios, relative to total fatty acidsDocosahexaenoic acid-0.0862Unsaturation degree, double bonds per fatty acid-0.1265Fluid BalanceAlbumin+0.0685GlyceridesTriglycerides in IDL cholesterol+0.1546Glycolysis precursorsGlucose+0.1391InflammationGlycoprotein acetyls+0.1478Ketone bodiesAcetoacetate+0.0464Lipoprotein subclassesHDL3 Cholesterol-0.0211Medium HDL-0.0296Large HDL-0.0309Figure 1.

Predictive performance of a model with age and sex alone is compared to a model with age and sex plus selected metabolites.

Conclusion:

Using NMR metabolomics profiling, we identified a variety of metabolites associated with a lower and higher risk of developing CVEs in patients with PsD. Further study of their underlying association with CVEs is needed to clarify the clinical utility of these biomarkers to guide CV risk assessment in this population.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

[2]Soininen P, Kangas AJ, Wurtz P, et al. Quantitative serum nuclear magnetic resonance metabolomics in cardiovascular epidemiology and genetics. Circ Cardiovasc Genet 2015;8(1):192-206.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared

Socio-economic status and mortality in people with type 1 diabetes in Scotland 2006-2015: a retrospective cohort study

AIMS

To describe the association between socio-economic status and mortality in a nation-wide cohort of people with type 1 diabetes in Scotland and to compare patterns over time and with the general population.

METHODS

A retrospective cohort study was performed using data for people with type 1 diabetes from a population-based register linked to mortality records. Socio-economic status was derived from quintiles of an area-based measure: the Scottish Index of Multiple Deprivation. Sex-specific directly age-standardized mortality rates for each Scottish Index of Multiple Deprivation quintile and rate ratios comparing the most vs least deprived quintile were calculated for two time periods: 2006-2010 and 2011-2015. Data for the population without type 1 diabetes between 2011 and 2015 were available for comparison.

RESULTS

Data for 3802 deaths among 33 547 people with type 1 diabetes were available. The age-standardized mortality rate per 1000 person-years decreased over time (from 2006-2010 to 2011-2015) for men and women with type 1 diabetes: 24.8 to 20.2 and 22.5 to 17.6, respectively. Mortality in populations with and without type 1 diabetes was generally higher for men than women and was inversely associated with socio-economic status. Rate ratios for the most vs least deprived groups increased over time among people with type 1 diabetes (men: 2.49 to 2.81; women: 1.92 to 2.86) and were higher than among populations without type 1 diabetes in 2011-2015 (men: 2.06; women: 1.66).

CONCLUSIONS

Socio-economic deprivation was associated with a steeper mortality gradient in people with type 1 diabetes than in the population without type 1 diabetes in Scotland. Age-standardized mortality has decreased over time but socio-economic inequalities may be increasing.

Lipoprotein(a) and cardiovascular disease: prediction, attributable risk fraction and estimating benefits from novel interventions

Background

Lipoprotein (a) (Lp(a)) measurement may help guide CVD risk prediction, is thought to be causal in several CVD outcomes, and phase 3 intervention trials of Lp(a) lowering agents are underway. We aimed to investigate the population attributable fraction due to elevated Lp(a) and its utility in CVD risk prediction.

Methods

In 413,724 participants from UK Biobank, associations of serum Lp(a) with composite fatal/nonfatal CVD (n=10,065 events), fatal CVD (n=3247), coronary heart disease (n=16,649), ischaemic stroke (n=3191), and peripheral vascular disease (n=2716) were compared using Cox models. Predictive utility was determined by C-index changes. The population attributable fraction was estimated.

Results

Median Lp(a) was 19.7nmol/L (interquartile interval 7.6–75.3nmol/L). 20.8% had Lp(a) values &gt;100nmol/L; 9.2% had values &gt;175nmol/L. After adjustment for classical risk factors, in participants with no baseline CVD and not taking a statin, 1 standard deviation increment in log Lp(a) was associated with a HR for fatal/nonfatal CVD of 1.09 (95% CI 1.07–1.11). Associations were similar for fatal CVD, coronary heart disease, and peripheral vascular disease. Adding Lp(a) to a prediction model containing traditional CVD risk factors improved the C-index by +0.0017 (95% CI 0.0009, 0.0026). We estimated that having Lp(a) values &gt;100nmol/L accounts for 5.7% of CVD events in the whole cohort. We modelled that an ongoing trial to lower Lp(a) in patients with CVD and Lp(a) above ∼175nmol/L may be expected to reduce CVD risk by 20.3%, assuming causality, and an achieved Lp(a) reduction of 80%.

Conclusions

Population screening for elevated Lp(a) may help to predict CVD and target Lp(a) lowering drugs to those with markedly elevated levels, if such drugs prove efficacious.

Population attributable fractions: Lp(a)

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Chest, Heart, and Stroke Association Scotland and British Heart Foundation

Estimating cardiovascular disease-free life-years with the addition of semaglutide in people with type 2 diabetes using pooled data from SUSTAIN 6 and PIONEER 6

Introduction

Cardiovascular disease (CVD) is the leading cause of disability and death in people with type 2 diabetes (T2D). In a post hoc analysis of pooled data (POOLED cohort) from two phase 3, randomized CV outcomes trials, SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716), the addition of the glucagon-like peptide-1 analogue semaglutide to standard of care (SoC) in people with T2D at high risk of CVD significantly reduced the risk of major adverse CVD events (3-point MACE: CV death, non-fatal stroke and non-fatal myocardial infarction).

Purpose

To estimate the effect of adding semaglutide to SoC on CVD-free life-years and 10-year CVD risk in patients with T2D by predicting individual patient-level risk of CVD events in the POOLED cohort using the DIAL CVD risk model.

Methods

The 3-point MACE hazard ratio from the POOLED cohort (N=6480; HR = 0.76 [95% confidence interval [CI]: 0.62–0.92]) was applied to the patient-level lifetime risk of CVD events derived from the DIAL model. CVD-free life-years and 10-year CVD risk were then calculated based on the age-specific risks of CVD events and non-vascular mortality, using standard actuarial methods. Both new and recurrent CVD events were considered. The DIAL model was validated by comparing the predicted and observed number of CVD events after 1 year. The DIAL model was previously developed using data from people with T2D in the Swedish National Diabetes Registry and validated across geographical regions.

Results

The DIAL model was considered valid for use in the POOLED cohort because the predicted number of CVD events at 1 year was within 5% of the number observed. Adding semaglutide to SoC was associated with a mean reduction in 10-year CVD risk of 20.0% (95% CI: 6.4–32.6%) and a mean increase of 1.72 (95% CI: 0.52–2.96) CVD-free life-years. The number of mean CVD-free life-years gained ranged from 0.62–2.91 years between age groups (Table). For a 60-year-old male with baseline characteristics matched to the average male from the POOLED cohort, adding semaglutide to SoC reduced 10-year CVD risk by 20.8% and provided 2.53 additional CVD-free life-years. The number of CVD-free life-years decreased when baseline age was increased (Figure).

Conclusions

The addition of semaglutide to SoC was associated with a gain in CVD-free life-years. This analysis helps contextualize the results of CV outcomes trials and may help to inform clinical decision-making.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novo Nordisk A/S

Socio-economic differences in cardiovascular disease risk factor prevalence in people with type 2 diabetes in Scotland: a cross-sectional study

AIM

To describe the association between socio-economic status and prevalence of key cardiovascular risk factors in people with type 2 diabetes in Scotland.

METHODS

A cross-sectional study of 264 011 people with type 2 diabetes in Scotland in 2016 identified from the population-based diabetes register. Socio-economic status was defined using quintiles of the area-based Scottish Index of Multiple Deprivation (SIMD) with quintile (Q)1 and Q5 used to identify the most- and least-deprived fifths of the population, respectively. Logistic regression models adjusted for age, sex, health board, history of cardiovascular disease and duration of diabetes were used to estimate odds ratios (ORs) for Q1 compared with Q5 for each risk factor.

RESULTS

The mean (sd) age of the study population was 66.7 (12.8) years, 56% were men, 24% were in Q1 and 15% were in Q5. Crude prevalence in Q1/Q5 was 24%/8.8% for smoking, 62%/49% for BMI ≥ 30 kg/m² , 44%/40% for HbA_1c ≥ 58 mmol/mol (7.5%), 31%/31% for systolic blood pressure (SBP) ≥ 140 mmHg, and 24%/25% for total cholesterol ≥ 5 mmol/l, respectively. ORs [95% confidence intervals (CI)] were 3.08 (2.95-3.21) for current smoking, 1.48 (1.44-1.52) for BMI ≥ 30 kg/m² , 1.11 (1.08-1.15) for HbA_1c ≥ 58 mmol/mol (7.5%), 1.03 (1.00-1.06) for SBP ≥ 140 mmHg and 0.87 (0.84-0.90) for total cholesterol ≥ 5 mmol/l.

CONCLUSIONS

Socio-economic deprivation is associated with higher prevalence of smoking, BMI ≥ 30 kg/m² and HbA_1c ≥ 58 mmol/mol (7.5%), and lower prevalence of total cholesterol ≥ 5 mmol/l among people with type 2 diabetes in Scotland. Effective approaches to reducing inequalities are required as well as reducing risk factor prevalence across the whole population.

OP0192 PSORIATIC ARTHRITIS IS ASSOCIATED WITH A METABOLICALLY ADVERSE BODY COMPOSITION PROFILE PREDICTIVE OF GREATER CHD AND TYPE 2 DIABETES RISK – MRI FINDINGS FROM THE IMAPA AND UK BIOBANK STUDIES

Background:

Increased Body Mass Index (BMI) is associated with Psoriatic Arthritis (PsA) but with uncertain pathophysiological significance. BMI does not reflect body fat distribution, but fat storage site is important as increased ectopic fat including visceral adipose tissue (VAT), liver fat, and muscle fat infiltration (MFI), are associated with increased type 2 diabetes and coronary heart disease (CHD) risk1. To date no study has compared detailed body composition in PsA with the general population and other metabolic diseases.

Objectives:

1. To characterize the body composition profile of PsA compared to age, sex, and BMI-matched metabolic disease free (MDF) individuals, and type 2 diabetes. 2. To relate body composition to risk of type 2 diabetes and CHD in PsA versus MDF controls.

Methods:

MRI body composition profiles were available for 29 PsA participants in the IMAPA study2. After excluding 3 participants with concomitant type 2 diabetes, body composition was compared in 26 PsA participants with 130 age, sex, and BMI-matched healthy MDF controls (matched 1:5) and 454 individuals with type 2 diabetes from UK Biobank, using Wilcoxon signed-rank test. Analyses were repeated adjusted for age, sex, and BMI. The propensity of PsA patients to develop CHD or type 2 diabetes based on their body composition profile was compared to that of matched MDF controls.

Results:

PsA participants had significantly more ectopic fat including greater visceral adipose tissue (VAT) volume and liver fat percentage compared to MDF controls (table 1, figure 1A). This difference persisted after adjustment for age, sex, and BMI. Individuals with PsA shared a similar body composition to type 2 diabetes (table 1, figure 1B). Body composition-predicted propensity for CHD or type 2 diabetes was 1.3 and 1.8 times higher, respectively, for PsA compared to matched MDF controls.

Table 1.

Comparison of body composition parameters in PsA, MDF controls, and type 2 diabetes

VariablePsAMDF controlsp-value*Adj. p value**Type 2 diabetesp-value†Adj. p value‡Age (years)56.0 (9.0)57.4 (6.5)0.766-65.4 (6.9)< 0.001-BMI (kg/m2)31.2 (6.4)30.5 (5.3)0.799-29.9 (5.2)0.397-VAT (L)5.89 (2.10)4.34 (1.83)<0.001<0.0015.93 (2.56)0.6620.301Visceral fat index (L/m2)2.06 (0.73)1.52 (0.64)<0.001<0.0012.03 (0.84)0.3370.175Abdominal subcutaneous adipose tissue (L)10.48 (4.90)9.42 (4.86)0.2880.0718.58 (3.93)0.1090.339Abdominal fat index (L/m2)5.87 (2.39)4.93 (2.29)0.084<0.0015.04 (1.92)0.0520.024Liver fat (%)8.88 (4.42-13.18)3.29 (1.98-7.25)0.0020.0026.13 (2.77-11.63)0.3920.656MFI (%)7.74 (2.57)7.43 (1.95)0.7480.2928.61 (2.29)0.7360.191

Values are mean (SD) (liver fat, median (IQR)). *PsA vs. MDF controls. **PsA vs. MDF controls adjusted for age, sex, and BMI. †PsA vs. Type 2 diabetes. ‡ PsA vs. Type 2 diabetes adjusted for age, sex, and BMI.

Figure 1.

Body Composition Profiles of IMAPA PsA participants (pink) versus A. UK Biobank matched MDF controls (green), and B. type 2 diabetes (T2D) (green).

Conclusion:

This is the first study to report that individuals with PsA have a body composition profile associated with an adverse metabolic phenotype, with greater VAT and ectopic liver fat than the general population and more similar to that of type 2 diabetes, in line with their greater cardiometabolic risk. These data mandate a revision of the management approach to PsA that includes attention to weight loss interventions.

References:

[1]Linge et al. Body Composition Profiling in the UK Biobank Imaging Study. Obesity. 2018;26(11):1785

[2]Ferguson et al. Effect of PDE4 Inhibition with Apremilast on Cardiometabolic Outcomes in Psoriatic Arthritis – Initial Results from Immune Metabolic Associations in Psoriatic Arthritis (IMAPA) Study. Arthritis Rheumatol. 2019; 71(suppl 10).

Acknowledgments:

Celgene; BHF (RE/13/5/30177)

Disclosure of Interests:

Lyn D. Ferguson: None declared, Jennifer Linge Shareholder of: AMRA Medical AB, Employee of: AMRA Medical AB, Olof D. Leinhard Shareholder of: AMRA Medical AB, Employee of: AMRA Medical AB, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Stefan Siebert Grant/research support from: BMS, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Celgene, Janssen, Novartis, Naveed Sattar Grant/research support from: Boehringer Ingelheim, Consultant of: Amgen, Boehringer Ingelheim, AstraZeneca, Eli Lilly, Novo Nordisk, Sanofi, and Janssen, Speakers bureau: Amgen, Boehringer Ingelheim, AstraZeneca, Eli Lilly, Novo Nordisk, Sanofi, and Janssen

Metabolomics Profile in Depression: A Pooled Analysis of 230 Metabolic Markers in 5283 Cases With Depression and 10,145 Controls

BACKGROUND

Depression has been associated with metabolic alterations, which adversely impact cardiometabolic health. Here, a comprehensive set of metabolic markers, predominantly lipids, was compared between depressed and nondepressed persons.

METHODS

Nine Dutch cohorts were included, comprising 10,145 control subjects and 5283 persons with depression, established with diagnostic interviews or questionnaires. A proton nuclear magnetic resonance metabolomics platform provided 230 metabolite measures: 51 lipids, fatty acids, and low-molecular-weight metabolites; 98 lipid composition and particle concentration measures of lipoprotein subclasses; and 81 lipid and fatty acids ratios. For each metabolite measure, logistic regression analyses adjusted for gender, age, smoking, fasting status, and lipid-modifying medication were performed within cohort, followed by random-effects meta-analyses.

RESULTS

Of the 51 lipids, fatty acids, and low-molecular-weight metabolites, 21 were significantly related to depression (false discovery rate q < .05). Higher levels of apolipoprotein B, very-low-density lipoprotein cholesterol, triglycerides, diglycerides, total and monounsaturated fatty acids, fatty acid chain length, glycoprotein acetyls, tyrosine, and isoleucine and lower levels of high-density lipoprotein cholesterol, acetate, and apolipoprotein A1 were associated with increased odds of depression. Analyses of lipid composition indicators confirmed a shift toward less high-density lipoprotein and more very-low-density lipoprotein and triglyceride particles in depression. Associations appeared generally consistent across gender, age, and body mass index strata and across cohorts with depressive diagnoses versus symptoms.

CONCLUSIONS

This large-scale meta-analysis indicates a clear distinctive profile of circulating lipid metabolites associated with depression, potentially opening new prevention or treatment avenues for depression and its associated cardiometabolic comorbidity.

P6517Three-year clinical outcome of patients with abnormal glucose metabolism treated with contemporary drug-eluting stents

Background/Introduction

Patients with coronary artery disease that have an abnormal glucose metabolism are known to have more extensive and complex atherosclerotic coronary disease. In patients without previously known diabetes, abnormal glucose metabolism was shown to be independently associated with an up to four-fold higher event risk during the first year after percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Purpose

To examine the 3-year clinical outcome after stenting with contemporary DES in patients with abnormal glucose metabolism, either detected by oral glucose tolerance testing (OGTT) or by glycated haemoglobin A1c (HbA1c) and fasting plasma glucose.

Methods

The present analysis is a local substudy of the BIO-RESORT randomised trial. OGTT and HbA1c with fasting plasma glucose were prospectively assessed in 988 trial participants without previously known diabetes. The main clinical endpoint was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction or target vessel revascularisation at 3-years.

Results

In one out of three study participants (330/988), abnormal glucose metabolism was detected by either OGTT or HbA1c and fasting plasma glucose. Three-year follow up was available in 99.8% of these patients. The rate of target vessel failure was significantly higher in patients with abnormal glucose metabolism versus normoglycaemic patients (8.8% vs. 5.5%, p=0.044; Figure). This difference was driven by the incidence of periprocedural myocardial infarction that was higher in patients with abnormal glucose metabolism than in patients with normoglycaemia (4.5% vs. 1.4%, p=0.002).

Target vessel failure at 3-years

Conclusion

Abnormal glucose metabolism was associated with a significantly higher risk of target vessel failure at 3-years; this difference was driven by higher rates of periprocedural myocardial infarction.

Acknowledgement/Funding

The present substudy received no additional funding. The BIO-RESORT trial was equally funded by Biotronik, Boston Scientific, and Medtronic.

P3823Body mass index or waist and hip circumference as predictors of outcome in the UK biobank

Background

Controversies exist about the relationship between body habitus and mortality, especially for patients with cardiovascular disease.

Purpose

We evaluated the relations between different anthropometric indices and mortality amongst participants with and without cardiovascular (CV) risk factors, or established CV disease (stroke, myocardial infarction and/or heart failure), enrolled in the UK Biobank.

Methods

The UK Biobank is a large prospective study which, between 2006 and 2010, enrolled 502,620 participants aged 38–73 years. Participants filled questionnaires and had a medical history recorded, physical measurements done and biological samples taken. The UK Biobank is routinely linked to national death registries and updated on a quarterly basis. Data on death were coded according to the International Classification of Diseases, 10th Revision (ICD-10). The primary end-point was all-cause mortality (ACM) across three subgroups of men and women: those with, or without, one or more CV risk factors (smoking, diabetes and/or hypertension), and those with CV disease (history of stroke, myocardial infarction and/or heart failure) at recruitment. Presence, or absence, of CV risk factors and diagnoses of CV disease were self-reported by participants at enrolment. Associations between anthropometric indices (body mass index (BMI), waist circumference (WC), waist to hip ratio (WHiR), and waist to height ratio (WHeR)) and the risk of all-cause mortality were analysed using Cox regression models.

Results

After excluding those with history of cancer at baseline (n=45,222), 453,046 participants were included (median age: 58 (interquartile range: 50 - 63) years; 53% women), of whom 150,732 had at least one CV risk factor, and 17,884 established CV disease.

During a median follow-up of 5 years, 6,319 participants died. Baseline BMI had a U-shaped relationship with ACM, with higher nadir-values for those with CV risk factors or CV disease, for both sexes (figure). WC, WHiR and WHeR (measures of central distribution of body fat) had more linear associations with ACM, regardless of CV risk factors, CV disease and sex.

Conclusions

For adults with or without CV risk factors or established CV disease, measures of central distribution of body fat are more strongly and more linearly associated with ACM than BMI. WC, or WHiR, rather than BMI, appear to be more appropriate variables for risk stratification.

P5313The association between coffee and caffeine consumption and renal function: insight from individual-level data, Mendelian randomization, and meta-analysis

Background

The reported relationship between coffee intake and renal function is poorly understood.

Purpose

By applying on two-sample Mendelian randomization (MR) and systematic review and meta-analysis we investigated the association between caffeine and coffee intake with prevalent CKD and markers of renal function.

Methods

For the individual data analysis we analysed the NHANES data on renal function markers and caffeine intake. MR was implemented by using summary-level data from genome-wide association studies conducted on coffee intake (N=91,462) and kidney function (N=133,413). Inverse variance weighted method (IVW), weighted median-based method, MR-Egger, MR-RAPS, MR-PRESSO were applied. Random effects models and generic inverse variance methods were used for the meta-analysis.

Results

Finally, we included the data of 18,436 participants, 6.9% had prevalent CKD (based on eGFR). Caffeine intake for general population was 131.1±1.1 mg. The % of pts. with CKD, by caffeine quartile was 16.6% in Q1 (lowest), 13.9% in Q2, 12.2% in Q3 and 11.0% in Q4 (p<0.001). After adjustment, for increasing quartiles for caffeine consumption, mean urine albumin, albumin-creatinine ratio and eGFR did not change significantly (p>0.234). In fully adjusted logistic regression models, there was no significant difference in chances of CKD prevalence (p-trend=0.745) (Table). In the same line, results of MR showed no impact of coffee intake on CKD (IVW=β: −0.0191, SE: 0.069, p=0.781) (Figure), on eGFR (overall= IVW= β: −0.0005, SE: 0.005, p=0.926) both in diabetic (IVW= β: −0.006, SE: 0.009, p=0.478), and non-diabetic patients (IVW= β: −6.772, SE: 0.006, p=0.991). Results from the meta-analysis indicted that coffee consumption was not significantly associated with CKD (OR: 0.85, 95% CI 0.71–1.02, p=0.090, n=6 studies, I2=0.32). These findings were robust in sensitivity analyses.

Levels of CKD markers across caffeine Qs Characteristics Quartiles of Caffeine p-value First Second Third Fourth Number of participants (n) 4609 4611 4608 4608 Log Urine Albumin (mg/L) 2.20±0.02 2.16±0.02 2.19±0.02 2.17±0.02 0.239 Serum Creatinine (mg/dL) 0.89±0.003 0.90±0.004 0.91±0.002 0.88±0.003 0.234 Log ACR (mg/g) 2.14±0.02 2.10±0.02 2.11±0.02 2.16±0.02 0.352 eGFR (ml/min/1.73m2) 91.2±0.7 92.8±0.4 90.2±0.5 89.6±0.3 0.415

MR on the impact of coffee intake on CKD

Conclusions

By implementing on different strategies we have highlighted no significant association between coffee consumption with renal function and chance of CKD.

Acknowledgement/Funding

None

45Association of types of dietary fats and all-cause and cause-specific mortality: a prospective cohort study and meta-analysis of prospective studies with 1,148,117 participants

Background

The associations between dietary fats with mortality are poorly delineated.

Purpose

Using a large prospective cohort we evaluated the link between total fat, mono-unsaturated (MUFA), polyunsaturated (PUFA) and saturated fatty acid (SFA) consumption and all-cause, coronary heart disease (CHD), stroke, and diabetes (T2D)-associated mortality in a representative sample of US adults. We then added our results to a systematic review and meta-analysis.

Methods

We evaluated 35,080 participants from the National Health and Nutrition Examination Surveys (NHANES) 1988–1999 (19.2 years follow-up) and 1999–2010 (12 years follow-up), with vital status available through December 31, 2011. Cox proportional hazard regression models were used to evaluate the association between baseline quartiles of fat consumption (g/day, 24h recall) and all-cause or cause-specific mortality. For the systematic review, selected databases were searched up to November 2018 and 29 prospective cohorts (n=1,148,117) met inclusion criteria. The DerSimonian-Laird method and generic inverse variance methods were used for random effects meta-analyses.

Results

In fully adjusted models from our prospective study, there was a negative association between total fat (hazard ratio [HR]:0.90, 95% confidence interval [CI]: 0.82, 0.99, Q4 vs. Q1) and PUFA (0.81,95% CI: 0.78–0.84) consumption and all-cause mortality (Figure), whereas SFA were positively associated with mortality (1.08, 95% CI: 1.04–1.11). In the meta-analysis we found a significant negative association between total fat (HR: 0.89, 95% CI: 0.82–0.97, I2:27%), MUFA (0.93, 95% CI: 0.87–0.99, I2:56%) and PUFA (0.86, 95% CI: 0.80–0.93, I2:63%) consumption and all-cause mortality. No significant association was observed between total fat and both CVD and CHD mortality (0.92, 95% CI: 0.79–1.08, I2:46%, and 1.03, 95% CI: 0.99–1.09, I2:42%, respectively), while a positive association between SFA intake and CHD mortality (1.10, 95% CI: 1.01–1.20, I2:52.6%) was observed. Neither MUFA nor PUFA were associated with CVD and CHD mortality. Inverse associations were observed between MUFA (0.80, 95% CI: 0.67–0.96, I2:0%) and PUFA (0.84, 95% CI: 0.80–0.90, I2:0%) intakes and stroke mortality.

All-cause death and total fat intake.

Conclusions

Our results highlight differential associations of total fat, MUFA and PUFA intake with all-cause mortality, but no association of them with CVD and CHD mortalities. SFA intake was significantly associated with higher all-cause mortality inNHANES and with CHD mortality in our meta-analysis. The type of fat intake appears to be associated with important health outcomes.

Acknowledgement/Funding

None

The association between driving time and unhealthy lifestyles: a cross-sectional, general population study of 386 493 UK Biobank participants

BACKGROUND

Driving is a common type of sedentary behaviour; an independent risk factor for poor health. The study explores whether driving is also associated with other unhealthy lifestyle factors.

METHODS

In a cross-sectional study of UK Biobank participants, driving time was treated as an ordinal variable and other lifestyle factors dichotomized into low/high risk based on guidelines. The associations were explored using chi-square tests for trend and binary logistic regression.

RESULTS

Of the 386 493 participants who drove, 153 717 (39.8%) drove <1 h/day; 140 140 (36.3%) 1 h/day; 60 973 (15.8%) 2 h/day; and 31 663 (8.2%) ≥3 h/day. Following adjustment for potential confounders, driving ≥3 h/day was associated with being overweight/obese (OR = 1.74, 95% CI: 1.64-1.85), smoking (OR = 1.48, 95% CI: 1.37-1.63), insufficient sleep (1.70, 95% CI: 1.61-1.80), low fruit/vegetable intake (OR = 1.26, 95% CI: 1.18-1.35) and low physical activity (OR = 1.05, 95% CI: 1.00-1.11), with dose relationships for the first three, but was not associated with higher alcohol consumption (OR = 0.94, 95% CI: 0.87-1.02).

CONCLUSIONS

Sedentary behaviour, such as driving, is known to have an independent association with adverse health outcomes. It may have additional impact mediated through its effect on other aspects of lifestyle. People with long driving times are at higher risk and might benefit from targeted interventions.

Cardiovascular disease prevalence and risk factor prevalence in Type 2 diabetes: a contemporary analysis

AIMS

To describe the prevalence of major cardiovascular disease (CVD) and risk factor control in a contemporary population with Type 2 diabetes.

METHODS

We used data from the national registry in Scotland, Scottish Care Information-Diabetes, linked to hospital admissions. Using descriptive statistics and logistic regression we described associations of risk factors with CVD. CVD was defined based on diagnostic codes in primary or secondary care data for ischaemic heart disease, cerebrovascular disease peripheral arterial disease, heart failure, cardiac arrhythmia, hypertensive heart disease and revascularization procedures.

RESULTS

Among 248 400 people with Type 2 diabetes with a median age of 67.5 years (IQR 58.2, 76.1) and median diabetes duration of 7.8 years (3.8, 13.0), 32% had prior CVD (35% of men, 29% of women). Median HbA_1c overall was 55 mmol/mol (7.2%), median SBP was 132 mmHg, median total cholesterol was 4.1 mmol/l and mean BMI was 32 kg/m² _. Overall two-thirds (65% of men, 68% of women) have two or more of the following CVD risk factor thresholds: HbA_1c ≥ 53 mmol/mol (7%), SBP > 130 mmHg or DBP > 80 mmHg, total cholesterol ≥ 5 mmol/l or BMI ≥ 30 kg/m² , or were currently smoking. Overall 84% were taking anti-hypertensives and 75% a statin. Use of metformin was common at 58%, but other diabetes drugs that reduce CVD were rarely used.

CONCLUSIONS

There continues to be a high prevalence of CVD among people with Type 2 diabetes and a high level of unmet need for risk factor control. This implies substantial scope for reducing the excess risk of CVD in diabetes through improved management of known risk factors.

Associations of dietary protein intake with bone mineral density: An observational study in 70,215 UK Biobank participants

PURPOSE

Adequate dietary protein intake is important for the maintenance of bone health; however, data in this area is ambiguous with some suggestion that high protein intake can have deleterious effects on bone health. The aim of the current study was to explore the associations of protein intake with bone mineral density (BMD).

METHODS

We used baseline data from the UK Biobank (participants aged 40-69 years) to examine the association of protein intake with BMD (measured by ultrasound). These associations were examined, in women (n = 39,066) and men (n = 31,149), after adjustment for socio-demographic and lifestyle confounders and co-morbidities.

RESULTS

Protein intake was positively and linearly associated with BMD in women (β-coefficient 0.010 [95% CI 0.005; 0.015, p < 0.0001]) and men (β-coefficient 0.008 [95% CI 0.000; 0.015, p = 0.044]); per 1.0 g/kg/day increment in protein intake, independently of socio-demographics, dietary factors and physical activity.

CONCLUSIONS

The current data have demonstrated that higher protein intakes are positively associated with BMD in both men and women. This indicates that higher protein intakes may be beneficial for both men and women.

Dulaglutide decreases plasma aminotransferases in people with Type 2 diabetes in a pattern consistent with liver fat reduction: a post hoc analysis of the AWARD programme

AIMS

To evaluate the effects of dulaglutide vs placebo on liver and glycaemic/metabolic measurements in a population with Type 2 diabetes and in a subgroup with non-alcoholic fatty liver/non-alcoholic steatohepatitis.

METHODS

A total of 1499 participants from AWARD-1, AWARD-5, AWARD-8 and AWARD-9 clinical trials were included in this analysis (dulaglutide 1.5 mg, n=971 and placebo, n=528). Thresholds of alanine aminotransferase levels ≥30 IU/l in men and ≥19 IU/l in women were used to determine the subgroup who had non-alcoholic fatty liver/non-alcoholic steatohepatitis. Objectives included changes from baseline to 6 months in: (1) alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels in the overall population and (2) alanine aminotransferase, aspartate transaminase, gamma-glutamyl transpeptidase and glycaemic/metabolic measurements (e.g. HbA_1c , fasting serum glucose, body weight, lipids and homeostatic model assessment) in the non-alcoholic fatty liver/non-alcoholic steatohepatitis subgroup.

RESULTS

In the overall population at 6 months, dulaglutide significantly reduced alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels vs placebo [least squares mean treatment differences: -1.7 IU/l (95% CI -2.8, -0.6), P=0.003; -1.1 IU/l (95% CI -2.1, -0.1), P=0.037; -6.6 IU/l (95% CI -12.4, -0.8), P=0.025, respectively]. In the subgroup with non-alcoholic fatty liver/non-alcoholic steatohepatitis (alanine aminotransferase levels greater than or equal to the upper limit of normal), mean baseline liver enzyme values were 38.0 IU/l, 27.8 IU/l and 43.9 IU/l for alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase, respectively. In this population, more pronounced reductions from baseline in alanine aminotransferase were observed with dulaglutide vs placebo (-8.8 IU/l vs -6.7 IU/l). In the subgroup of people with alanine aminotransferase levels less than the upper limit of normal, changes from baseline in alanine aminotransferase did not significantly differ between treatment groups (0.0 IU/l vs 0.7 IU/l).

CONCLUSIONS

Once-weekly dulaglutide improved alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels compared with placebo in a pattern consistent with liver fat reductions. Our results add further weight to the notion that glucagon-like peptide-1 receptor agonists may provide benefit in lowering liver fat in addition to their other metabolic actions.

The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease

Background

Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism.

Methods

We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10^− 6, 10^− 5, 10^− 4 mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235).

Results

75 patients were enrolled. Following angiography, 60 patients (mean ± SD age 57.5 ± 8.5 years; 80% male) were eligible and completed the protocol (n = 30 RIPC, n = 30 sham). The mean percentage change in coronary luminal diameter was − 13.3 ± 22.3% and − 2.0 ± 17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2– 21.4, p = 0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01– 21.0, p = 0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function.

Conclusions

RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIPC.

Cannabis use and risk of schizophrenia: a Mendelian randomization study

Cannabis use is observationally associated with an increased risk of schizophrenia, but whether the relationship is causal is not known. Using a genetic approach, we took 10 independent genetic variants previously identified to associate with cannabis use in 32 330 individuals to determine the nature of the association between cannabis use and risk of schizophrenia. Genetic variants were employed as instruments to recapitulate a randomized controlled trial involving two groups (cannabis users vs nonusers) to estimate the causal effect of cannabis use on risk of schizophrenia in 34 241 cases and 45 604 controls from predominantly European descent. Genetically-derived estimates were compared with a meta-analysis of observational studies reporting ever use of cannabis and risk of schizophrenia or related disorders. Based on the genetic approach, use of cannabis was associated with increased risk of schizophrenia (odds ratio (OR) of schizophrenia for users vs nonusers of cannabis: 1.37; 95% confidence interval (CI), 1.09-1.67; P-value=0.007). The corresponding estimate from observational analysis was 1.43 (95% CI, 1.19-1.67; P-value for heterogeneity =0.76). The genetic markers did not show evidence of pleiotropic effects and accounting for tobacco exposure did not alter the association (OR of schizophrenia for users vs nonusers of cannabis, adjusted for ever vs never smoker: 1.41; 95% CI, 1.09-1.83). This adds to the substantial evidence base that has previously identified cannabis use to associate with increased risk of schizophrenia, by suggesting that the relationship is causal. Such robust evidence may inform public health messages about cannabis use, especially regarding its potential mental health consequences.

Adiposity among 132 479 UK Biobank participants; contribution of sugar intake vs other macronutrients

Background

Policy makers are being encouraged to specifically target sugar intake in order to combat obesity. We examined the extent to which sugar, relative to other macronutrients, was associated with adiposity.

Methods

We used baseline data from UK Biobank to examine the associations between energy intake (total and individual macronutrients) and adiposity [body mass index (BMI), percentage body fat and waist circumference]. Linear regression models were conducted univariately and adjusted for age, sex, ethnicity and physical activity.

Results

Among 132 479 participants, 66.3% of men and 51.8% of women were overweight/obese. There was a weak correlation (r = 0.24) between energy from sugar and fat; 13% of those in the highest quintile for sugar were in the lowest for fat, and vice versa. Compared with normal BMI, obese participants had 11.5% higher total energy intake and 14.6%, 13.8%, 9.5% and 4.7% higher intake from fat, protein, starch and sugar, respectively. Hence, the proportion of energy derived from fat was higher (34.3% vs 33.4%, P < 0.001) but from sugar was lower (22.0% vs 23.4%, P < 0.001). BMI was more strongly associated with total energy [coefficient 2.47, 95% confidence interval (CI) 2.36-2.55] and energy from fat (coefficient 1.96, 95% CI 1.91-2.06) than sugar (coefficient 0.48, 95% CI 0.41-0.55). The latter became negative after adjustment for total energy.

Conclusions

Fat is the largest contributor to overall energy. The proportion of energy from fat in the diet, but not sugar, is higher among overweight/obese individuals. Focusing public health messages on sugar may mislead on the need to reduce fat and overall energy consumption.

Men across a range of ethnicities have a higher prevalence of diabetes: findings from a cross-sectional study of 500 000 UK Biobank participants

AIMS

Studies show that white men have a higher prevalence of Type 2 diabetes mellitus than women at a given age and BMI, but equivalent standardized data for other ethnic groups in the UK are sparse.

METHODS

This cross-sectional study analysed UK Biobank data from 489 079 participants to compare the prevalence of diabetes mellitus across four major ethnic groups including: 471 700 (96.4%) white, 7871 (1.6%) South Asian, 7974 (1.6%) black and 1534 (0.3%) Chinese participants, before and after standardizing for age, socio-economic status (SES), BMI and lifestyle factors including physical activity, TV viewing, fruit and vegetable intake, processed meat, red meat, oily fish, alcohol intake and smoking. A subgroup analysis of South Asians was also undertaken.

RESULTS

Crude diabetes prevalence was higher in men across all four ethnicities. After standardizing for age, SES, BMI and lifestyle factors, a significant sex difference in diabetes prevalence persisted in white (men 6.0% vs. women 3.6%), South Asian (21.0% vs. 13.8%) and black individuals (13.3% vs. 9.7%) (P < 0.0001); there was a non-significant difference between Chinese men and women (7.1% vs. 5.5%) (P = 0.211). Sex differences persisted across South Asian subgroups.

CONCLUSIONS

Men across a range of major ethnic groups including white, South Asian and black, have a higher prevalence of diabetes compared with women of similar age, BMI, SES and lifestyle in the UK.

Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013

AIM

To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013.

METHODS

Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes.

RESULTS

During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)].

CONCLUSIONS

Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.

Association between grip strength and diabetes prevalence in black, South-Asian, and white European ethnic groups: a cross-sectional analysis of 418 656 participants in the UK Biobank study

AIMS

To quantify the extent to which ethnic differences in muscular strength might account for the substantially higher prevalence of diabetes in black and South-Asian compared with white European adults.

METHODS

This cross-sectional study used baseline data from the UK Biobank study on 418 656 white European, black and South-Asian participants, aged 40-69 years, who had complete data on diabetes status and hand-grip strength. Associations between hand-grip strength and diabetes were assessed using logistic regression and were adjusted for potential confounding factors.

RESULTS

Lower grip strength was associated with higher prevalence of diabetes, independent of confounding factors, across all ethnicities in both men and women. Diabetes prevalence was approximately three- to fourfold higher in South-Asian and two- to threefold higher in black participants compared with white European participants across all levels of grip strength, but grip strength in South-Asian men and women was ~ 5-6 kg lower than in the other ethnic groups. Thus, the attributable risk for diabetes associated with low grip strength was substantially higher in South-Asian participants (3.9 and 4.2 cases per 100 men and women, respectively) than in white participants (2.0 and 0.6 cases per 100 men and women, respectively). Attributable risk associated with low grip strength was also high in black men (4.3 cases) but not in black women (0.4 cases).

CONCLUSIONS

Low strength is associated with a disproportionately large number of diabetes cases in South-Asian men and women and in black men. Trials are needed to determine whether interventions to improve strength in these groups could help reduce ethnic inequalities in diabetes prevalence.

Dietary fat and total energy intake modifies the association of genetic profile risk score on obesity: evidence from 48 170 UK Biobank participants

BACKGROUND

Obesity is a multifactorial condition influenced by both genetics and lifestyle. The aim of this study was to investigate whether the association between a validated genetic profile risk score for obesity (GPRS-obesity) and body mass index (BMI) or waist circumference (WC) was modified by macronutrient intake in a large general population study.

METHODS

This study included cross-sectional data from 48 170 white European adults, aged 37-73 years, participating in the UK Biobank. Interactions between GPRS-obesity and macronutrient intake (including total energy, protein, fat, carbohydrate and dietary fibre intake) and its effects on BMI and WC were investigated.

RESULTS

The 93-single-nucleotide polymorphism (SNP) GPRS was associated with a higher BMI (β: 0.57 kg m^-2 per s.d. increase in GPRS (95% confidence interval: 0.53-0.60); P=1.9 × 10^-183) independent of major confounding factors. There was a significant interaction between GPRS and total fat intake (P_{(interaction)}=0.007). Among high-fat-intake individuals, BMI was higher by 0.60 (0.52, 0.67) kg m^-2 per s.d. increase in GPRS-obesity; the change in BMI with GPRS was lower among low-fat-intake individuals (β: 0.50 (0.44, 0.57) kg m^-2). Significant interactions with similar patterns were observed for saturated fat intake (high β: 0.66 (0.59, 0.73) versus low β: 0.49 (0.42, 0.55) kg m^-2, P_{(interaction)}=2 × 10^-4) and for total energy intake (high β: 0.58 (0.51, 0.64) versus low β: 0.49 (0.42, 0.56) kg m^-2, P_{(interaction)}=0.019), but not for protein intake, carbohydrate intake and fibre intake (P_{(interaction)} >0.05). The findings were broadly similar using WC as the outcome.

CONCLUSIONS

These data suggest that the benefits of reducing the intake of fats and total energy intake may be more important in individuals with high genetic risk for obesity.

Effect of metformin therapy on circulating amino acids in a randomized trial: the CAMERA study

AIMS

To investigate whether metformin therapy alters circulating aromatic and branched-chain amino acid concentrations, increased levels amino acid concentrations, increased levels of which have been found to predict Type 2 diabetes.

METHODS

In the Carotid Atherosclerosis: Metformin for Insulin Resistance (CAMERA) study (NCT00723307), 173 individuals without Type 2 diabetes, but with coronary disease, were randomized to metformin (n=86) or placebo (n=87) for 18 months. Plasma samples, taken every 6 months, were analysed using quantitative nuclear magnetic resonance spectroscopy. Ten metabolites consisting of eight amino acids [three branched-chain (isoleucine, leucine, valine), three aromatic (tyrosine, phenylalanine, histidine) and two other amino acids (alanine, glutamine)], lactate and pyruvate were quantified and analysed using repeated-measures models. On-treatment analyses were conducted to investigate whether amino acid changes were dependent on changes in weight, fat mass or insulin resistance estimated using homeostasis model assessment (HOMA-IR).

RESULTS

Tyrosine decreased [-6.1 μmol/l (95% CI -8.5, -3.7); P<0.0001], while alanine [42 umol/l (95% CI 25, 59); P<0.0001] increased in the metformin-treated group compared with the placebo-treated group. Decreases in phenylalanine [-2.0 μmol/l (95% CI -3.6, -0.3); P=0.018] and increases in histidine [2.3 μmol/l (95% CI 0.1, 4.6); P=0.045] were also observed in the metformin group, although these changes were less statistically robust. Changes in these four amino acids were not accounted for by changes in weight, fat mass or HOMA-IR values. Levels of branched-chain amino acids, glutamine, pyruvate and lactate were not altered by metformin therapy.

CONCLUSIONS

Metformin therapy results in a sustained and specific pattern of changes in aromatic amino acid and alanine concentrations. These changes are independent of any effects on weight and insulin sensitivity. Any causal link to metformin's unexplained cardiometabolic benefit requires further study.

EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update

Patients with rheumatoid arthritis (RA) and other inflammatory joint disorders (IJD) have increased cardiovascular disease (CVD) risk compared with the general population. In 2009, the European League Against Rheumatism (EULAR) taskforce recommended screening, identification of CVD risk factors and CVD risk management largely based on expert opinion. In view of substantial new evidence, an update was conducted with the aim of producing CVD risk management recommendations for patients with IJD that now incorporates an increasing evidence base. A multidisciplinary steering committee (representing 13 European countries) comprised 26 members including patient representatives, rheumatologists, cardiologists, internists, epidemiologists, a health professional and fellows. Systematic literature searches were performed and evidence was categorised according to standard guidelines. The evidence was discussed and summarised by the experts in the course of a consensus finding and voting process. Three overarching principles were defined. First, there is a higher risk for CVD in patients with RA, and this may also apply to ankylosing spondylitis and psoriatic arthritis. Second, the rheumatologist is responsible for CVD risk management in patients with IJD. Third, the use of non-steroidal anti-inflammatory drugs and corticosteroids should be in accordance with treatment-specific recommendations from EULAR and Assessment of Spondyloarthritis International Society. Ten recommendations were defined, of which one is new and six were changed compared with the 2009 recommendations. Each designated an appropriate evidence support level. The present update extends on the evidence that CVD risk in the whole spectrum of IJD is increased. This underscores the need for CVD risk management in these patients. These recommendations are defined to provide assistance in CVD risk management in IJD, based on expert opinion and scientific evidence.