Cardiovascular morbidity and mortality related to non-alcoholic fatty liver disease: a systematic review and meta-analysis of prospective studies

Background

Whether non-alcoholic fatty liver disease (NAFLD) is a risk factor for cardiovascular (CV) events is still debated. Currently available evidence derives from non-homogeneous studies yielding conflicting results.

Purpose

We set out to assess the relationship between NAFLD and CV morbidity and mortality by pooling results of previous studies.

Methods

We performed a systematic review and meta-analysis of prospective observational studies published from 1966 through 2021 reporting summary-level outcome data in subjects with and without NAFLD. Adjusted risk ratios (RRs) and 95% confidence intervals (CIs) for all-cause mortality, CV mortality, myocardial infarction (MI), stroke, major adverse cerebrocardiovascular events (MACCE) and atrial fibrillation (AF) were pooled through inverse variance random-effect meta-analysis to compute the summary effect size. We performed post-hoc subgroup analysis stratified by geographical region and univariate mixed-effect model meta-regression analysis to address statistical heterogeneity.

Results

We identified a total of 29 studies pooling an overall population of 5,626,573 middle-aged individuals (mean age 56±8; male sex 53%; NAFLD 5.8%, n=326,389). Mean follow-up was 10±6 years. Compared with control population, presence of NAFLD was associated with similar risk of all-cause death (RR 1.17; 95% CI 0.89–1.52) and CV death (RR 0.84; 95% CI 0.64–1.10). When analysed by geographic location, pooled estimates of RR (95% CI) for all-cause death were 1.57 (1.00–2.48) for Western countries, and 0.81 (0.52–1.1.26) for Eastern countries (test for subgroup difference, P=0.04). Meta-regression analysis showed a stronger relationship between NAFLD and all-cause mortality proportional to increasing body mass index (P=0.048). NAFLD was associated with increased risk of myocardial infarction (RR 1.35; 95% CI 1.09–1.68), stroke (RR 1.20; 95% CI 1.06–1.35), MACCE (RR 2.09; 95% CI 1.57–2.78) and atrial fibrillation (RR 1.37; 95% CI 1.05–1.78).

Conclusion

NAFLD portends excess all-cause mortality but only in Western countries. CV mortality was similar in NAFLD and non-NAFLD groups. NAFLD is associated with increased risk of incident MI, stroke, MACCE and AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prevention of contrast-induced nephropathy with urine alkalinization: the TEATE study

Background

Contrast-induced acute kidney injury (CI-AKI) after coronary angiography and percutaneous interventions (PCI) impacts on hospitalization duration and mortality. Pre-procedural hydration is the sole strategy currently recommended for preventing CI-AKI. The role of sodium bicarbonate (SB) although attractive, since urine alkalinization suppresses the production of reactive oxygen species, is still controversial, and the optimal dosing to attain adequate urine alkalinization is still undefined.

Purpose

The PrevenTion of contrast-inducEd nephropathy with urine alkalinization (TEATE) study was a prospective 3-center 3-arm single-blind randomized controlled trial testing the hypothesis that adequate urine alkalinization is associated with CI-AKI prevention. Secondary endpoints were the efficacy of SB vs saline in achieving adequate urine alkalinization and reducing the incidence of CI-AKI compared with saline.

Methods

Patients candidate to coronary angiography and/or PCI with moderate-to-severe chronic kidney disease [eGFR of 15 to 60 mL/min/1.73 m2, by the Modification of Diet in Renal Disease Study equation (MDRD)] were randomly assigned to saline hydration (control), oral SB or i.v. SB. The study protocol was registered. We evaluated urinary pH at the time of hospitalization, immediately before coronary angiography and 24–48 hours after angiography. According to urine pH immediately before the procedure, patients were divided in two groups above or below a pH cut-off of 6.

Results

We enrolled a total of 241 patients: 81 were randomly assigned to the control group, 82 to i.v. SB and 78 to oral SB. Patients achieving a urinary pH >6 before angiography had a lower incidence of CI-AKI (46%) than patients with urinary pH ≤6 (54%) [OR=0.48 (95% CI 0.25–0.9) p=0.023]. The number of patients with urine pH >6 was higher in both the i.v. (71%) and the oral SB (65%) groups compared to the hydration-only group (44%, p=0.004). We found however no difference in the incidence of CI-AKI in the 3 treatment arms (20% in hydration alone, 21% in oral SB group and 22% in iv SB group) (p=0.94). Subgroup analyses according to basal urine pH and eGFR ranges failed to identify statistically significant differences in the development of CI-AKI according to treatment allocation.

Conclusions

Urinary pH before the administration of contrast medium is an inverse correlate of CI-AKI incidence, and SB is superior to hydration alone in achieving urinary alkalinization. Since, however, SB did not reduce the incidence of CI-AKI, we conclude that urinary pH is a marker and not a mediator of CI-AKI.

Funding Acknowledgement

Type of funding sources: None.

Clinical outcome with NOACs vs VKAs in patients with atrial fibrillation and severe chronic kidney disease: results of a retrospective, multicenter, real-world study

Background

Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) are at higher risk of both bleeding and thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) are licensed to be used in these patients, although they were excluded from phase III controlled randomized trials comparing NOACs vs warfarin in AF. Thus, current evidence on NOACs use in such setting of patients is not definitive.

Purpose

Aim of our multicenter study was to perform a real-world comparison of clinical outcome with NOACs vs vitamin K antagonist anticoagulants (VKAs) also in AF patients having an estimated glomerular filtration rate (eGFR) 15–29 mL/min.

Methods

We retrospectively included a total of 266 patients receiving NOACs (N=159) or VKAs (N=107). Primary outcome measure was the cumulative incidence of the net composite endpoint including ischemic stroke, systemic thromboembolism or any bleeding. Mean follow-up was 2.6 years.

Results

CHA2DS2-VASc and HAS-BLED scores at baseline were similar in the two groups (3.4±1.3 with NOACs vs 3.4±0.9 with VKAs and 3.1±1.0 vs 3.0±0.7, respectively); eGFR and hemoglobin values were also comparable (31.8±12.3 vs 32±11.9 mL/min and 10.2±2.1 vs 11.0±2.3 g/dL, respectively). NOACs were not inferior to VKAs for the primary net composite endpoint: incidence 20.7% vs 29.9%, p<0.01 for non-inferiority, p=0.11 for superiority. In proportional Cox regression model, hazard ratio for the primary outcome measure with NOACs use was 0.74 (95% CI 0.45–1.21, p=0.22). In the NOAC group there was a trend towards reduction in minor bleeding complications (p=0.08).

Conclusions

Our real-world data indicate that in patients with AF and severe renal failure NOACs are not inferior to VKAs for both safety and efficacy. The use of NOACs was associated with a numerically lower incidence of minor bleeding.

Funding Acknowledgement

Type of funding source: None

Additive predictive power of the CHA2DS2-VASc and HAS-BLED scores for mortality in patients with atrial fibrillation

Background and objectives

In atrial fibrillation (AF), assessment of thromboembolic and bleeding risks are recommended to prescribe anticoagulation for stroke prevention. However, AF also increases mortality, and predictors of death are less characterized than predictors for stroke. We investigated the predictive power for mortality of the CHA2DS2-VASc, the HAS-BLED score and their combination.

Methods

Individual patient data were analyzed from the PREvention oF thromboembolic events-European Registry in Atrial Fibrillation (PREFER AF), a prospective real-world registry with a 12-month follow-up, with a total of 7243 patients enrolled from 461 hospitals and 7 European countries (Austria, France, Germany, Italy, Spain, Switzerland, and United Kingdom). Logistic regression was used to analyze the relationship of the CHA2DS2-VASc and HAS-BLED scores, and their combinations with outcome events, including mortality, at one year. The predictive ability of the scores was analyzed by comparing c-statistics.

Results

The study sample consisted of 5,209 AF patients with complete information on both scores. Mean age was 71.8±10.46 years; 3145 subjects (60.4%) were male. Events rate of stroke/SEE and major bleeding at one-year were 2.3% (122 patients) and 2.9% (149 patients), respectively. At one year, 3.1% of patients died (160 out of 5,209). Both scores had broadly similar c-statistics; for CHA2DS2-VASc: 0.637, 0.656 and 0.616 for models predicting mortality, SSE and major bleeding, respectively; for HAS-BLED: 0.620, 0.647, and 0.627, respectively. When including the individual components of both scores separately, c-statistics increased to 0.715, 0.694 and 0.636 with CHA2DS2-VASc, and to 0.681, 0.697 and 0.680 with HAS-BLED. The predictive power with both scores combined, removing overlapping components, was higher, with a c-statistic of 0.74, 0.73 and 0.70 for mortality (Table), SSE and major bleeding, respectively.

Conclusion

Both the CHA2DS2-VASc and the HAS-BLED score predict mortality similarly in AF, and a combination of the score components increases prediction significantly. Such combination may thus be clinically useful.

Funding Acknowledgement

Type of funding source: None

P6223Relationship between platelet indices and future cardiovascular events: results from a population-based cohort study

Background

Studies evaluating the relationship between platelet indices and cardiovascular outcome yielded conflicting results. In particular, the evidence from large, population-based, prospective studies with extended follow-up duration is scarce.

Purpose

We investigated the incidence of major adverse events in relation to baseline values of platelet count, mean platelet volume (MPV) and platelet distribution width (PDW) in the prospective cohort of the Malmö Diet and Cancer Study.

Methods

A total of 30,314 middle-aged individuals (mean age 57±8 years; 40% men) were overall included and followed up for a median of 16 years (in total, 468,490 person-years). The following outcome measures were considered: all-cause death, myocardial infarction (MI) and ischemic stroke.

Results

There was no relationship between increase in MPV or PDW values and adverse events during follow-up. In particular, the incidence of all-cause death, MI and stroke in patients in the 4thquartile of MPV was 19.8% (vs. 20.7% in the 1stquartile; p=0.08), 8.5% (vs. 8.2%; p=0.78) and 7.9% (vs. 7.1%; p=0.09), respectively. The rates of all-cause death, MI and stroke in patients in the 4thquartile of PDW were 20.1% (vs. 20.7% in the 1stquartile; p=0.16), 8.7% (vs. 8.1%; p=0.30) and 8.1% (vs. 7.2%; p=0.09), respectively. There was a significant rise in mortality by platelet count increase (log-rank p<0.001). In multivariable analysis, patients in the 4thquartile of platelet count (>264 x 109/L) showed a significantly higher incidence of all-cause death (HR 1.17, 95% CI 1.07–1.28; p=0.001), MI (HR 1.24, 95% CI 1.08–1.43; p=0.003) and stroke (HR 1.20, 95% CI 1.04–1.39; p=0.014) vs the 1stquartile. The higher mortality in the 4thquartile of platelet count was independent of the history of previous stroke, was significant in patients without prior MI (HR 1.18, 95% CI 1.08–1.29; p<0.001) and non-significant in those with prior MI (HR 0.86, 95% CI 0.56–1.33; p=0.51). The risk of MI in the 4thquartile of platelet count was higher regardless of the history of previous MI (p for interaction=0.11). The risk of stroke in the 4thquartile of platelet count was higher regardless of the history of previous stroke (p for interaction=0.15).

Conclusions

In this population-based, prospective, cohort study there was no difference in the incidence of adverse events across various strata of baseline platelet morphology. However, patients with highest platelet count at baseline showed a significantly higher risk of all-cause death, MI and stroke. Whether or not these individuals should be targeted by more aggressive primary prophylactic measures including antiplatelet treatment, remains to be proven.

P2555Efficacy and safety of oral anticoagulant versus antiplatelet therapy for secondary prevention of cardiovascular disease in patients without atrial fibrillation

Background

Anticoagulation is the mainstay of prevention of arterial thromboembolism in patients with atrial fibrillation, but it could be effective also in secondary prevention of patients who are in sinus rhythm.

Purpose

We performed this meta-analysis to determine relative efficacy and safety of oral anticoagulant therapy (OAC) as compared with antiplatelet therapy (APT) in patients with prevalent cerebro-cardiovascular disease without atrial fibrillation.

Methods

Our systematic review of the literature published through January 31st, 2019 sought all phase III randomized controlled trials which compare OAC with APT in patients with sinus rhythm and report at least one of the following outcomes: ischemic stroke, death, myocardial infarction, and major bleeding, assessed at the longest available follow-up. We used random-effects models to estimate summary relative risk reduction (RRR) and 95% confidence intervals (95% CI).

Results

We identified a total of 9 randomized controlled trials including a total of 34,912 patients (ASA, n=17,726; adjusted-dose warfarin, n=4,460; rivaroxaban, n=12726), with a mean follow-up of 2.2 years. When compared with antiplatelet therapy, OAC was associated with reduced risk of ischemic stroke (RRR 38%, 95% CI: 1; 47; P=0.04; I2=72%) and myocardial infarction (RRR 13%, 95% CI: 0,23; P=0.05, I2=0%), but increased risk of major bleeding (RRR −52%, 95% CI: −129; −1; P=0.04; I2=76%). Compared to antiplatelet treatment, OAC did not significantly affect the risk of all-cause death (RRR 1%, 95% CI: −9; 10; P=0.86; I2=12%).

Conclusions

In sinus rhythm patients with prevalent cardiovascular disease, OAC reduces risk of ischemic stroke and myocardial infarction, but significantly increases risk of major bleeding. The choice of antithrombotic treatment does not appear to influence all-cause mortality.

Malakoplakia: A Pseudoneoplastic Disease of the Rectum

A review of the literature on extraurinary malakoplakia is followed by the description of a typical case, located in the rectum, whose clinical and rectoscopic features suggested the existence of neoplastic disease. This condition should therefore be borne in mind in the course of differential diagnosis of anorectal tumors.

Increased left atrial size in obese children and its association with insulin resistance: a pilot study

Subclinical cardiac abnormalities represent predisposing factors for cardiovascular disease (CVD) in obese subjects. The aim of this study was to evaluate early cardiac abnormalities in obese youth and the potential association with insulin resistance (IR). Thirty obese (12 males (M)/18 females (F); age = 11.5 ± 2.4 years; body mass index (BMI)-standard deviation score (SDS) = +2.1 ± 0.5) and 15 normal weight (10 M/5 F; age = 12.8 ± 3.1 years; BMI-SDS = +0.3 ± 0.9) children and adolescents underwent Doppler two-dimensional echocardiographic assessments of left atrial (LA) and ventricular (LV) geometry and LV diastolic function (peak early [E] and late waves, E wave deceleration time, myocardial flow velocities). Homeostasis model assessment of IR (HOMA-IR) was used as an IR index. LA size was increased in obese children, as indicated by higher LA diameter (4.9 ± 0.5 vs 4.1 ± 0.4 cm, p < 0.001), area (14.3 ± 2.5 vs 10.7 ± 2.0 cm(2), p < 0.001), and volume (33.8 ± 10.6 vs 23.7 ± 6.4 ml, p = 0.003). LV mass was also increased in obese children (87.0 ± 16.6 vs 68.8 ± 13.2 g, p = 0.003), who also showed subtle diastolic dysfunctions, as indicated by higher values of E (97.1 ± 14.3 vs 86.2 ± 11.9 cm/s, p = 0.02). All the above parameters were significantly associated with BMI-SDS (p < 0.05). In addition, HOMA-IR was independently associated with LA diameter, area, and volume (β = 0.314, p = 0.040; β = 0.415, p = 0.008; β = 0.535, p = 0.001).

CONCLUSION

Obese children feature increased LA size, which emerged to be mainly correlated to, and possibly driven by IR, suggesting an increased CVD risk.

WHAT IS KNOWN

Left atrial and ventricular alterations have been reported in obese adults, and they represent predisposing factors for cardiovascular disease. There is some evidence suggesting that obese children show increased left ventricular mass and also increased atrial size, although with conflicting results.

WHAT IS NEW

Obese normotensive children showed a moderately increased atrial size, subtle alterations in left cardiac diastolic function, and ventricular mass. An association between insulin resistance and left cardiac changes was found, although its mechanism remains to be determined.

Hypogonadism and hormone replacement therapy on bone mass of adult women with thalassemia major

We studied bone mass and metabolism in 30 adult women (age 28.5 +/- 1.3) with thalassemia major (TM) and evaluated whether prolonged hormone replacement therapy (HRT) was able to optimize bone accrual. TM patients had reduced bone mass, increased bone turnover and lower serum gonadotropin and estradiol levels compared with 10 normal women of similar age. A significant correlation was found between bone mass and sex hormone levels. Six TM patients with normal ovarian function had normal bone turnover markers and modestly low bone mass (lumbar spine -1.29 +/- 0.31; femoral neck -0.60+/-0.21; Z-score). The other 24 TM women were hypogonadic and had significantly lower bone mass for age (lumbar spine -2.35 +/- 0.2, femoral neck -1.83 +/- 0.2) and increased bone turnover relative to eugonadal women. Of the hypogonadal patients, 13 had taken HRT since age 15 +/- 1 years, but their bone mass and turnover markers were not different than untreated hypogonadal patients. In conclusion, while hypogonadism negatively affects bone mass acquisition in adult TM women, HRT at the standard replacement doses is not sufficient to secure optimal bone accrual.

Transient microvascular vasoconstriction: a possible cause of unstable angina

We report the case of a 65-year-old woman who developed unstable angina 2 months after successful coronary angioplasty of the left anterior descending coronary artery. Coronary angiography failed to show angiographic restenosis, but intracoronary ergonovine caused ST segment elevation and her habitual chest pain in the absence of epicardial coronary spasm and important pressure changes in the distal left anterior descending coronary artery assessed by a pressure wire, thus suggesting that distal vessel constriction was responsible for unstable angina.

Circadianicity of hemostatic function and coronary vasomotion

Acute myocardial infarction, sudden cardiac death and ischemic stroke show a circadian periodicity, occurring more frequently in the morning. Because arterial thrombosis is common to these disorders, a circadianicity of prothrombotic and antithrombotic processes may contribute to explain the 24 h rhythms of these acute events. Available data indeed indicate that coronary vasomotor tone, platelet aggregability, plasma inhibition of fibrinolysis, coagulant activity and blood viscosity are all greater in the morning than at other times of day, producting a relative prothrombotic state in the early morning.

Dose-dependent inhibition of platelet cyclooxygenase-1 and monocyte cyclooxygenase-2 by meloxicam in healthy subjects

We evaluated whether therapeutic blood levels of meloxicam are associated with selective inhibition of monocyte cyclooxygenase (COX)-2 in vitro and ex vivo. Concentration-response curves for the inhibition of monocyte COX-2 and platelet COX-1 were obtained in vitro after the incubation of meloxicam with whole blood samples. Moreover, 11 healthy volunteers received placebo or 7.5 or 15 mg/day meloxicam, each treatment for 7 consecutive days, according to a randomized, double-blind, crossover design. Before dosing and 24 h after the seventh dose of each regimen, heparinized whole blood samples were incubated with lipopolysaccharide (10 microgram/ml) for 24 h at 37 degrees C, and prostaglandin E2 was measured in plasma as an index of monocyte COX-2 activity. The production of thromboxane B2 in whole blood allowed to clot at 37 degrees C for 60 min was assessed as an index of platelet COX-1 activity. The administration of placebo did not significantly affect plasma prostaglandin E2 (21. 3 +/- 7.5 versus 19.1 +/- 4 ng/ml, mean +/- S.D., n = 11) or serum thromboxane B2 (426 +/- 167 versus 425 +/- 150 ng/ml) levels. In contrast, the administration of 7.5 and 15 mg of meloxicam caused dose-dependent reductions in monocyte COX-2 activity by 51% and 70%, respectively, and in platelet COX-1 activity by 25% and 35%, respectively. Although the IC50 value of meloxicam for inhibition of COX-1 was 10-fold higher than the IC50 value of COX-2 in vitro, this biochemical selectivity was inadequate to clearly separate the effects of meloxicam on the two isozymes after oral dosing as a function of the daily dose and interindividual variation in steady-state plasma levels.

Effects of nimesulide on constitutive and inducible prostanoid biosynthesis in human beings

BACKGROUND

The aim of this study was to test the hypothesis that nimesulide, a nonsteroidal antiinflammatory drug, or its principal metabolite 4-hydroxynimesulide, is a selective inhibitor of prostaglandin H synthase-2 in human beings.

METHODS

Heparinized whole blood samples obtained from healthy subjects were incubated with lipopolysaccharide (10 micrograms/ml) for 24 hours at 37 degrees C and prostaglandin E2 was measured in plasma as an index of monocyte prostaglandin H synthase-2 activity. The production of thromboxane B2 in whole blood allowed to clot at 37 degrees C for 60 minutes was assessed as an index of platelet prostaglandin H synthase-1 activity. We also measured the urinary excretion of 11-dehydrothromboxane B2, prostaglandin E2, 6-ketoprostaglandin F1 alpha, and thromboxane B2 as in vivo indexes of cyclooxygenase activity. All prostanoids were measured by previously validated radioimmunoassay techniques.

RESULTS

In the whole blood assays in vitro, nimesulide was twentyfold more potent than 4-hydroxynimesulide toward the two isozymes and both compounds displayed a twentyfold preference for prostaglandin H synthase-2 versus prostaglandin H synthase-1. The administration of a single oral dose of 100 mg nimesulide to six healthy subjects significantly (p < 0.01) reduced monocyte prostaglandin H synthase-2 and prostaglandin H synthase-1 activity ex vivo by more than 90% and 50%, respectively, up to 6 hours. At 24 hours, prostaglandin H synthase-2 but not prostaglandin H synthase-1 activity was significantly reduced by 49% (p < 0.05). Nimesulide significantly (p < 0.05) reduced the urinary excretion of 11-dehydrothromboxane B2 and 6-ketoprostaglandin F1 alpha by approximately 30% and 25%, respectively, while not affecting that of prostaglandin E2 and thromboxane B2.

CONCLUSIONS

Nimesulide is a potent inhibitor of human monocyte prostaglandin H synthase-2. However, despite a twentyfold selectivity ratio, therapeutic plasma levels of nimesulide are sufficiently high to cause detectable inhibition of platelet prostaglandin H synthase-1.

Differential inhibition of human prostaglandin endoperoxide synthase-1 and -2 by nonsteroidal anti-inflammatory drugs

We have evaluated the selectivity in vitro of various conventional nonsteroidal anti-inflammatory drugs (NSAIDs) and new anti-inflammatory compounds (NS-398, L-745,337 and SC58125) in inhibiting the cyclooxygenase activity of platelet prostaglandin endoperoxide synthase (PGHS)-1 and monocyte PGHS-2 in a human whole blood assay. The effects of the compounds towards the cyclooxygenase activity of monocyte PGHS-2 induced in response to lipopolysaccharide (LPS) was evaluated by measuring the levels of PGE2 produced in plasma. The effects of the same inhibitors on platelet PGHS-1 activity were assessed by allowing 1-ml whole blood samples to clot at 37 degrees C for 1 h in the presence of the compounds and measuring immunoreactive TXB2 levels in serum. Under these experimental conditions, most compounds resulted equipotent towards the two isozymes. Differently, meloxicam, nimesulide and diclofenac were approximately 10- to 20-fold more potent in inhibiting the cyclooxygenase activity of monocyte PGHS-2 than platelet PGHS-1. L-745,337, NS-398 and SC58125 achieved selective inhibition of monocyte PGHS-2 (IC50, PGHS-1/IC50, PGHS-2: < 100) and may provide adequate tools to test the contribution of this novel pathway of arachidonate metabolism to human inflammatory disease and to verify the hypothesis that the common side-effects of NSAIDs are due primarily to their ability to affect the activity of PGHS-1.

Platelet activation and inhibition in unstable coronary syndromes

Platelet activation occurs episodically in unstable angina, as reflected by enhanced thromboxane metabolite excretion, and most episodes can be suppressed by low-dose aspirin. Biochemical evidence of platelet activation and electrocardiographic evidence of myocardial ischemia are often temporally dissociated, thus suggesting the likely involvement of different triggers. Aspirin is effective in reducing the short-term and long-term risks of myocardial infarction and death by 40-60%, in a dose-independent fashion consistent with the saturability of platelet cyclo-oxygenase inhibition at low doses. Suppression of platelet thromboxane synthesis by aspirin and the blockade of platelet adenosine diphosphate receptors by ticlopidine or clopidogrel appear to have a similar impact on limiting the risk of a thrombotic outcome of plaque fissuring, thereby suggesting combined strategies for future studies.