The higher the serum albumin, the better? Findings from the PRACTICE study

AIMS

The relation between hypoalbuminemia and coronary artery disease (CAD) has been established. However, the association of increased albumin level and outcomes of CAD has not been investigated.

METHODS

There were 14 994 CAD patients from the PRACTICE study, which is a large, single center prospective cohort study based on case records and follow-up registry performed in the First Affiliated Hospital of Xinjiang Medical University from Dec. 2016 to Oct. 2021 in the present study. All the 14 994 patients were divided into five categories according albumin levels: <35 g/L group (n = 1 478), 35-40 g/L group (n = 5 007), 40-45 g/L group (n = 6 076), 45-50 g/L group (n = 1 835), and ≥50 g/L group (n = 598).

RESULTS

A total of 448 all-cause deaths(ACD), 333 cardiac deaths (CD), 1 162 MACEs and 1 276 MACCEs were recorded during up to 60-months follow-up period. After adjusting for confounders, we observed a non-linear relation for either MACE or MACCE with the lowest risk at 45 g/L of albumin levels. A threshold value of albumin ≥50 g/L was associated with an increased risk for either MACE (adjusted HR=1.617, 95%CI:1.130-2.315, P = 0.009) or MACCE (adjusted HR= 1.439, 95%CI: 1.007-2.056, P = 0.045) in multivariable Cox regression model. For mortality, we only found decreased (<35 g/L) but not increased albumin level was associated with either ACD (HR=2.744, 95%CI: 1.631-4.617, P<0.001) or CD (HR=2.736, 95%CI: 1.484-5.045, P = 0.001).

CONCLUSIONS

In the present study, a U-shaped curve relation was identified between albumin levels and MACE and MACCE in CAD patients, with the lowest risk at 45 g/L levels.

Mutated CYP17A1 promotes atherosclerosis and early-onset coronary artery disease

BACKGROUND

Coronary artery disease (CAD) is a multi-factor complex trait and is heritable, especially in early-onset families. However, the genetic factors affecting the susceptibility of early-onset CAD are not fully characterized.

METHODS

In the present study, we identified a rare nonsense variant in the CYP17A1 gene from a Chinese Han family with CAD. To validate the effect of this variation on atherosclerosis and early-onset coronary artery disease, we conducted studies on population, cells, and mice.

RESULTS

The mutation precisely congregated with the clinical syndrome in all the affected family members and was absent in unaffected family members and unrelated controls. Similar to the human phenotype, the CYP17A1-deficient mice present the phenotype of metabolic syndrome with hypertension, increased serum glucose concentration, and presentation of central obesity and fatty liver. Furthermore, CYP17A1 knockout mice or CYP17A1 + ApoE double knockout mice developed more atherosclerotic lesions than wild type (WT) with high fat diary. In cell models, CYP17A1 was found to be involved in glucose metabolism by increasing glucose intake and utilization, through activating IGF1/mTOR/HIF1-α signaling way, which was consistent in CYP17A1 knockout mice with impaired glucose tolerance and insulin resistance.

CONCLUSIONS

Through our study of cells, mice and humans, we identified CYP17A1 as a key protein participating in the pathophysiology of the atherosclerotic process and the possible mechanism of CYP17A1 C987X mutation induced atherosclerosis and early-onset CAD involving glucose homeostasis regulation was revealed. Video Abstract.

Low HDL Cholesterol Associated with Reduced Bleeding Risk in Patients Who Underwent PCI: Findings from the PRACTICE Study

AIMS

We sought to examine the dose-response relationship between high-density lipoprotein cholesterol(HDL-C) and bleeds in coronary artery disease(CAD) patients who underwent percutaneous coronary intervention(PCI) .

METHODS

All the 15 250 participants were from the Personalized Antiplatelet Therapy According to CYP2C19 Genotype in Coronary Artery Disease(PRACTICE) study, which is a large, single centre prospective cohort study based on case records and follow-up registry performed in the First Affiliated Hospital of Xinjiang Medical University from Dec. 2016 to Oct. 2021. We divided all the patients into five groups according HDL-C levels:≤35mg/dL group(n=4732), 35-45 mg/dL group (n=6049), 45-55 mg/dL group (n=2826), 55-65 mg/dL group (n=1117), >65 mg/dL group (n=526). The incidence of bleeds, mortality, ischaemic events and net adverse clinical events among the five groups was compared.

RESULTS

A total of 713 major bleeds, 1180 ischemic events, 456 deaths and 1893 net adverse clinical events were recorded during up to 60-months follow-up period. After adjusting for confounders, we observed a non-linear relation for major bleeds, with the highest risk at intermediate HDL-C levels(45-55mg/dL). We also identified a dose-response relationship for ischaemic events. A threshold value of HDL-C≤35 mg/dL(adjusted HR=0.627, 95%CI: 0.494-0.798, P<0.001) was associated with a decreased risk for major bleeds in multivariable Cox regression model. The results were consistent in multiple sensitivity analyses and propensity matching(PSM) anslysis.

CONCLUSIONS

In the present study, a non-linear association was identified between HDL-C levels and major bleeds in CAD patients who underwent PCI, with the higher risk at intermediate levels. However, further multicenter studies are warranted.

ALB-dNLR Score Predicts Mortality in Coronary Artery Disease Patients After Percutaneous Coronary Intervention

Background

The influence of the albumin/derived neutrophil and lymphocyte ratio (ALB-dNLR) on the outcomes of patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI) is not known. Here, we aimed to determine the association between the ALB-dNLR score and post-PCI CAD patient outcomes.

Methods

A total of 6,050 patients from the First Affiliated Hospital of Xinjiang Medical University were enrolled between January 2008 and December 2016. These patients were divided into three groups according to their ALB-dNLR scores (0 points, n = 1,121; 1 point, n = 3,119; 2 points, n = 1,810). Mortality after PCI [all-cause (ACM) and cardiac (CM)] was taken as the primary endpoint. The prognostic value of the ALB-dNLR score was determined with the Cox proportional hazard model after adjustment for covariates.

Results

The ACM and CM rates differed among participants in the three groups (P = 0.007 and P = 0.034, respectively). Multivariate Cox analysis showed that the ALB-dNLR score independently predicted both ACM [1 point vs. 0 points, HR = 1.249 (95% CI: 0.79–1.774), P = 0.215; 2 points vs. 0 points, HR = 1.777 (95% CI: 1.239–2.549), P = 0.002] and CM [1 point vs. 0 points, HR = 1.294 (95% CI: 0.871–1.922), P = 0.202; 2 points vs. 0 points, HR = 1.782 (95% CI: 1.185–1.782), P = 0.027]. We also found that among male patients in the three groups, both ACM and CM rates differed (P = 0.006 and P = 0.017, respectively). Multivariate Cox analysis showed that the ALB-dNLR score independently predicted both ACM [1 point vs. 0 points, HR = 1.237 (95% CI: 0.806–0.330), P = 0.330; 2 points vs. 0 points, HR = 1.790 (95% CI: 1.159–2.764), P = 0.009] and CM [1 point vs. 0 points HR = 1.472 (95% CI: 0.892–2.430), P = 0.130; 2 points vs. 0 points, HR = 1.792 (95% CI: 1.182–3.289), P = 0.009].

Conclusion

The ALB-dNLR score is a credible predictor for mortality in patients with CAD who have undergone PCI.

Hemoglobin-to-Red-Cell Distribution Width Ratio Is a Novel Predictor of Long-Term Patient Outcomes After Percutaneous Coronary Intervention: A Retrospective Cohort Study

Background

The hemoglobin level and red cell distribution width (RDW) have been linked to the prognosis of coronary atherosclerotic heart disease (CAHD). However, the relationship between the ratio of hemoglobin to the RDW (HRR) and clinical outcomes after percutaneous coronary intervention (PCI) is not known. Here, we explored the impact of the HRR on clinical outcomes after PCI.

Methods

In our study, we selected 6,046 CAHD patients with PCI hospitalized in the First Affiliated Hospital of Xinjiang Medical University from 2008 to 2016. The patients were grouped according to their HRR ratio: group A (HRR < 10.25, n = 2,344) and group B (HRR ≥ 10.25, n = 3,702). The difference in clinical outcomes between the two groups was compared. Patients were followed up for 35.9 ± 22.6 months.

Results

Three hundred nine patients died during follow-up. These included 166 patients (7.1%) in the HRR < 10.25 group and 143 patients (3.9%) in the HRR ≥ 10.25 group (P < 0.001). The incidences of cardiogenic death (5.7 vs. 3.2%) and major cardiovascular adverse events (16.5 vs. 12.9%) also differed significantly between the groups (both Ps < 0.001). Analysis using the multivariate Cox proportional hazard model found a significant association between a decreased HRR and post-PCI mortality (all-cause death, adjusted HR: 1.479, 95% CI: 1.156–1.893, p = 0.002; cardiac death, adjusted HR: 1.470, 95% CI: 1.116–1.936, p = 0.006).

Conclusion

The HRR is predictive of post-PCI mortality among CAHD patients.

Characteristics of the Intestinal Microorganisms in Middle-Aged and Elderly Patients: Effects of Smoking

Introduction: Smoking affects the occurrence and development of many diseases. We attempt to study the structure of intestinal flora in the middle-aged and elderly population as well as how smoking affects the intestinal flora. Methods: We collected population information, biochemical indicators, and patient feces from 188 middle-aged and elderly male patients, and their feces were tested for the 16S rRNA gene of intestinal flora. Results: We performed a cluster analysis on the intestinal structure of the included population and found that there was a significant difference in the number of smokers between each group (p = 0.011). Subsequently, the microbiological diversity analysis of current smokers and nonsmokers was carried out. The results indicated that there was a significant difference in species composition between the two groups (p = 0.029). Through the analysis on LEfSe differential bacteria, it was found that in current smoking patients, the abundances of the genus Bifidobacterium and the genus Coprobacillus were less, while the abundances of the genera Shigella, Paraprevotella, Burkholderia, Sutterella, Megamonas, and p-75-a5 under the family level of Erysipelotrichaceae were slightly high. We analyzed the correlation between the abundances of these eight different bacteria and clinical indicators. The results revealed the following: the abundance of the genus Bifidobacterium was negatively correlated with fasting blood glucose (r = -0.198, p = 0.006) and positively correlated with uric acid (r = 0.207, p = 0.004) and total bilirubin (r = 0.175, p = 0.017); Shigella bacteria were positively correlated with fasting blood glucose (r = 0.160, p = 0.028) and uric acid (r = 0.153, p = 0.036) levels; the genus Paraprevotella and BMI (r = -0.172, p = 0.018) are negatively correlated; the abundance of the genus Burkholderia was positively correlated with γ-glutamyltransferase (r = 0.146, p = 0.045) levels; Sutterella was correlated with fasting blood glucose (r = 0.143, p = 0.05) and creatinine level (r = -0.16, p = 0.027), which was positively correlated with fasting blood glucose and negatively correlated with creatinine. Conclusions: In middle-aged and elderly patients with cardiovascular disease, smoking can reduce the abundance of Bifidobacterium, while the abundances of some negative bacteria such as Burkholderia, Sutterella, and Megamonas increase.

Gut Microbiome-Based Diagnostic Model to Predict Diabetes Mellitus

The aim of this study was to determine the diversity of intestinal microflora and its correlation with clinical parameters in diabetic patients and healthy subjects and to assess the importance of intestinal flora in patients with diabetes. Forty-four patients with diabetes were included. The control group included 47 healthy people. Their data, biochemical indicators and results from 16S rRNA sequencing of their fecal samples were collected. Compared with the healthy population, the intestinal flora of the diabetic patients was obviously abnormal. Within the diabetes group, the abundances of the genera Faecalibacterium, Prevotella, and Roseburia were higher, and the abundances of the genera Shigella and Bifidobacterium were lower. In the correlation analysis between bacteria and clinical indicators, it was found that the genera Veillonella and unclassified_Enterobacteriaceae were negatively related to blood glucose, while the genera Phascolarctobacterium, unidentified_Bacteroidales and Prevotella were significantly positively correlated with fasting blood glucose. Twelve microbial markers were detected in the random forest model, and the area under the curve (AUC) was 84.1%. This index was greater than the diagnostic effect of fasting blood glucose. This was also supported by the joint diagnostic model of microorganisms and clinical indicators. In addition, the intestinal flora significantly improved the diagnosis of diabetes. In conclusion, it can be concluded from these results that intestinal flora is essential for the occurrence and development of diabetes, which seems to be as important as blood glucose itself.

Abbreviations: PCoA: principal coordinate analysis; NMDS: non econometric multidimensional scaling analysis; LEfSe: linear discriminant analysis effect size; LDA: linear discriminant analysis; POD: probability of disease; BMI: body mass index; DCA: decision curve analysis

Gut Microbiota Characterization in Patients with Asymptomatic Hyperuricemia: probiotics increased

Asymptomatic hyperuricemia (AH) is an early stage of gout. Emerging evidence shows that the intestinal microbiota is related to gout. However, the relationship between AH and the intestinal microbiota is poorly understood. Therefore, the aim of the current study was to explore the possible correlation between AH and intestinal flora. We compared the intestinal microbial communities of AH (45 cases) and healthy subjects (45 cases) by 16S rRNA gene sequencing and clustering analysis on the incorporated population. Intestinal-type clustering can be divided into two groups, and significant differences in the proportion of AH are found among different bowel types. Alpha diversity indices were higher in the AH group than in the control group, and beta diversity indices also showed significant differences. A total of 19 genera were found different between the AH group and the control group. Compared with the control group, some probiotics are increased in the AH population. Two groups were ranked by importance of bacteria. We found the different bacteria partially coincided with the important bacteria, and the joint diagnosis level of the important bacteria was good. Conclusion: There were significant differences in the composition of intestinal biota between AH patients and healthy subjects. Some probiotics increased in AH.

White Blood Cell Counts to High-Density Lipoprotein Cholesterol Ratio, as a Novel Predictor of Long-Term Adverse Outcomes in Patients After Percutaneous Coronary Intervention: A Retrospective Cohort Study

Background: White blood cell (WBC) counts and high-density lipoprotein cholesterol (HDL-C) are widely available in clinical practice. However, the predictive value for cardiovascular disease (CVD) is uncertain. In the present study, we firstly assessed the prognostic value of WBC to HDL-C ratio (WHR) in patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI).

Methods: Six thousand and fifty patients with CAD after PCI from a retrospective cohort study (identifier: ChiCTR-INR-16010153) were evaluated initially. Three hundred and seventy-one patients were excluded due to HDL cholesterol data not available, malignancy, dementia, psoriasis or eczema, systemic connective tissue disorders, multiple sclerosis, chronic liver disease, and chronic obstructive pulmonary disorder. Finally, 5,679 patients were included in the study. The primary outcome was long-term mortality. Secondary endpoints were mainly major adverse cardiovascular and cerebrovascular events (MACCEs), defined as a combination of stroke, cardiac death, stent thrombosis, recurrent myocardial infarction, and target vessel revascularization. The mean follow-up time of this study was 35.9 ± 22.5 months. We defined the best cutoff value of MHR according to the receiver operating curve (ROC), and then patients were divided into high and low WHR groups according to the cutoff value. We analyzed the data in both an acute coronary syndrome group (ACS) and a stable CAD subgroup, respectively.

Results: Overall, there were 293 cases of long-term mortality during the follow-up period. According to the cutoff value (WHR = 8.25), 1,901 ACS patients were divided into high WHR group (n = 724) and low WHR group (n = 1,177). Compared to low WHR group, the incidence of all-cause mortality (ACM, 5.5 vs. 3.6%, p = 0.048) and cardiac death (4.7vs. 2.9%, p = 0.042) were significantly higher in the high WHR group. In stable CAD group, we also found the incidence of ACM and cardiac death were significantly higher in the high group compared to that in the low group. We did not find significant difference between the high and the low WHR group in the incidence of MACCEs. The multivariate Cox proportional hazards model showed that increased WHR level was independently correlated with the mortality. In the high WHR group, the risk of ACM increased two times in ACS [adjusted HR = 2.036 (1.258–3.296), p = 0.004] and 1.5 times in stable CAD [adjusted HR = 1.586 (1.178–2.136), p = 0.002].

Conclusion: The present study indicated that an increased WBC count to HDL-C ratio was independently associated with long-term mortality in CAD patients who underwent PCI.

Cardiac Shock Wave Therapy for Coronary Heart Disease: an Updated Meta-analysis

Introduction

The aim of this article is to study the efficacy and safety of cardiac shock wave therapy (CSWT) in the treatment of coronary heart disease (CAD).

Methods

A comprehensive search of electronic databases and a manual search of conference papers and abstracts were performed until September 30, 2018. The studies using RevMan 5.3 and STATA 14.0 softwares were reviewed, and meta-analyses were performed on 13 indicators, such as a six-min walking distance test (6MWT), New York Heart Association (NYHA) functional class, Seattle Angina Questionnaire (SAQ) score, angina class (Canadian Cardiology Society [CCS]), etc.

Results

A total of 26 articles were included. The total patient population was 855, of which 781 patients were treated with CSWT. Meta-analyses indicated that 6MWT (mean difference [MD] 75.64, 95% confidence interval [CI] 49.03, 102.25, P<0.00001) and NYHA (MD -0.70, 95% CI -0.92) in the CSWT group were comparable to those in the conventional revascularization group (MD -0.70, 95% CI -0.92, -0.49, P<0.00001). SAQ (MD 10.75, 95% CI 6.66, 14.83, P<0.00001), CCS (MD -0.99, 95% CI -1.13, -0.84, P<0.00001), nitrate dosage (MD -1.84, 95% CI -2.77, -1.12, P<0.00001), LVEF (MD 3.77, 95% CI 2.17, 5.37, P<0.00001), and SSS (MD -4.29, 95% CI -5.61, -2.96, P<0.00001), SRS (MD -2.90, 95% CI -4.85, -0.95, P=0.004), and the exercise test (standard mean difference 0.57, 95% CI 0.12, 1.02, P=0.01) all showed significant differences.

Conclusion

CSWT may offer beneficial effects to patients with CAD, but more large-scale clinical studies are needed to further verify its therapeutic effect.

Drug-Eluting Balloons versus Second-Generation Drug-Eluting Stents for Treating In-Stent Restenosis in Coronary Heart Disease after PCI: A Meta-Analysis

BACKGROUND

In-stent restenosis (ISR) remains a common problem following percutaneous coronary intervention (PCI). However, the best treatment strategy remains uncertain. There is some controversy over the efficacy of drug-eluting balloons (DEBs) and second-generation drug-eluting stents (DESs) for treating ISR.

METHODS

A meta-analysis was used to compare the efficacy of the DEB and second-generation DES in the treatment of ISR. The primary endpoint is the incidence of target lesion revascularization (TLR). The secondary endpoint is the occurrence of target vessel revascularization (TVR), myocardial infarction (MI), all-cause death (ACM), cardiac death (CD), major adverse cardiac events (MACEs), minimum luminal diameter (MLD), late luminal loss (LLL), binary restenosis (BR), and percent diameter stenosis (DS%).

RESULTS

A total of 12 studies (4 randomized controlled trials and 8 observational studies) including 2020 patients with a follow-up of 6-25 months were included in the present study. There was a significant difference in the MLD between the two groups during follow-up (P=0.007, RR = 0.23, and 95% CI: 0.06-0.4 mm). There was no significant difference in LLL, BR, or DS% and the overall incidence of MACEs between the two groups. Subgroup analysis showed no significant difference in the incidence of primary and secondary endpoints when considering RCTs or observational studies only.

CONCLUSIONS

The efficacy of the DEB and second-generation DES in the treatment of ISR is comparable. However, our results need further verification through multicenter randomized controlled trials.

Invasive reperfusion after 12 hours of the symptom onset remains beneficial in patients with ST-segment elevation myocardial infarction: Evidence from a meta-analysis of published data

BACKGROUND

Early myocardial reperfusion therapy (< 12 h) in patients with acute myocardial infarc-tion (AMI) can significantly improve their prognosis. However, the effect of late reperfusion (> 12 h) remains controversial. In this study, the effects of late reperfusion versus standard drug therapy on the outcomes of patients with AMI were evaluated by systematic review and meta-analysis.

METHODS

PubMed, Embase, Medline, Cochrane, Wanfang, and CNKI databases were searched for eligible studies for the present study. Meta-analysis was performed using RevMan 5.3.3 software. Rela-tive risk (RR) and the 95% confidence interval (CI) were used to compare the outcomes between the two groups. The main outcome measures were major adverse cardiac events (MACEs), all-cause mortality, recurrent myocardial infarction (MI), and heart failure.

RESULTS

Eighteen studies were identified including 14,677 patients, of whom 5157 received late reperfusion with percutaneous coronary intervention (PCI) and 9520 received medication therapy (MT). Compared to MT, late PCI was associated with decreased all-cause mortality (RR 0.60, 95% CI 0.44-0.83; p = 0.002), MACEs (RR 0.67; 95% CI 0.50-0.89; p < 0.001), and heart failure (RR 0.76; 95% CI 0.60-0.97; p = 0.03), while there was also a trend toward decreased recurrent MI (RR 0.70; 95% CI 0.47-1.05; p = 0.08). However, subgroup analysis according to time to PCI showed that the clinical benefit was only from PCI after 12 h but not from 2 to 60 days of the onset of symptoms.

CONCLUSIONS

The present meta-analysis suggested that PCI performed > 12 h but not 2-60 days after AMI is associated with significant improvement in clinical outcomes. However, these results need further rigorously designed large sample size clinical trials to be validated.