Role of Systemic Factors in Improving the Prognosis of Diabetic Retinal Disease and Predicting Response to Diabetic Retinopathy Treatment

Topic

To review clinical evidence on systemic factors that might be relevant to update diabetic retinal disease (DRD) staging systems, including prediction of DRD onset, progression, and response to treatment.

Clinical relevance

Systemic factors may improve new staging systems for DRD to better assess risk of disease worsening and predict response to therapy.

Methods

The Systemic Health Working Group of the Mary Tyler Moore Vision Initiative reviewed systemic factors individually and in multivariate models for prediction of DRD onset or progression (i.e., prognosis) or response to treatments (prediction).

Results

There was consistent evidence for associations of longer diabetes duration, higher glycosylated hemoglobin (HbA1c), and male sex with DRD onset and progression. There is strong trial evidence for the effect of reducing HbA1c and reducing DRD progression. There is strong evidence that higher blood pressure (BP) is a risk factor for DRD incidence and for progression. Pregnancy has been consistently reported to be associated with worsening of DRD but recent studies reflecting modern care standards are lacking. In studies examining multivariate prognostic models of DRD onset, HbA1c and diabetes duration were consistently retained as significant predictors of DRD onset. There was evidence of associations of BP and sex with DRD onset. In multivariate prognostic models examining DRD progression, retinal measures were consistently found to be a significant predictor of DRD with little evidence of any useful marginal increment in prognostic information with the inclusion of systemic risk factor data apart from retinal image data in multivariate models. For predicting the impact of treatment, although there are small studies that quantify prognostic information based on imaging data alone or systemic factors alone, there are currently no large studies that quantify marginal prognostic information within a multivariate model, including both imaging and systemic factors.

Conclusion

With standard imaging techniques and ways of processing images rapidly evolving, an international network of centers is needed to routinely capture systemic health factors simultaneously to retinal images so that gains in prediction increment may be precisely quantified to determine the usefulness of various health factors in the prognosis of DRD and prediction of response to treatment.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Associations between dimensions of the social environment and cardiometabolic risk factors: Systematic review and meta-analysis

Aim

The social environment (SE), including social contacts, norms and support, is an understudied element of the living environment which impacts health. We aim to comprehensively summarize the evidence on the association between the SE and risk factors of cardiometabolic disease (CMD).

Methods

We performed a systematic review and meta-analysis based on studies published in PubMed, Scopus and Web of Science Core Collection from inception to 16 February 2021. Studies that used a risk factor of CMD, e.g., HbA1c or blood pressure, as outcome and social environmental factors such as area-level deprivation or social network size as independent variables were included. Titles and abstracts were screened in duplicate. Study quality was assessed using the Newcastle-Ottawa Scale. Data appraisal and extraction were based on the study protocol published in PROSPERO. Data were synthesized through vote counting and meta-analyses.

Results

From the 7521 records screened, 168 studies reported 1050 associations were included in this review. Four meta-analyses based on 24 associations suggested that an unfavorable social environment was associated with increased risk of cardiometabolic risk factors, with three of them being statistically significant. For example, individuals that experienced more economic and social disadvantage had a higher "CVD risk scores" (OR = 1.54, 95%CI: 1.35 to 1.84). Of the 458 associations included in the vote counting, 323 (71%) pointed towards unfavorable social environments being associated with higher CMD risk.

Conclusion

Higher economic and social disadvantage seem to contribute to unfavorable CMD risk factor profiles, while evidence for other dimensions of the social environment is limited.

Longitudinal association of premature atrial contractions with atrial fibrillation and brain ischemia in people with type 2 diabetes: The Hoorn Diabetes Care System cohort

Background

Premature atrial contractions (PACs) are potential markers for imminent onset of both atrial fibrillation (AF) and brain ischemia (BI; transient ischemic attack [TIA] or ischemic stroke). We investigated the association of PACs with incident AF and BI events separately, and of incident AF with BI events in people with type 2 diabetes (T2D) without pre-existing AF or cerebrovascular disease.

Methods

A prospective longitudinal study of 12,242 people with T2D without known AF or cerebrovascular disease from the Hoorn Diabetes Care System cohort. Annual measurements (1998-2018) included cardiovascular risk factors, over 85,000 ECGs, and self-reported cardiovascular events. We assessed the association of PACs with incident AF and BI events and of incident AF with BI events using time-dependent Cox-regression models, adjusted for time-varying cardiovascular risk factors and medication use (Hazard Ratios with 95%CIs).

Results

The baseline mean age was 62.2 ± 11.9 years. During a median follow-up of 7.0 (IQR 3.4-11.0) years, 1031 (8.4 %) participants had PACs, and 566 (4.6 %) had incident AF at any of the median 6 (IQR 3-10) annual ECG recordings. BI events occurred in 517 (4.2 %) people (304 TIAs, 213 ischemic strokes). After adjustment, PACs were associated with incident AF (Hazard Ratio, 1.96 (95%CI, 1.53-2.50)), but not with overall BI events (1.09 (0.76-1.56)), or with TIA (0.91 (0.57-1.46)) or ischemic stroke (1.50 (0.88-2.54)) separately. AF was not associated with BI events (0.95 (0.55-1.63)).

Conclusions

In people with T2D without a history of AF or BI events, PACs are associated with a two-fold increased risk of incident AF.

The HFA-PEFF score identifies 'early-HFpEF' phenogroups associated with distinct biomarker profiles

AIMS

The HFA-PEFF score was developed to optimize diagnosis and to aid in early recognition of heart failure (HF) with preserved ejection fraction (HFpEF) in patients who present with HF-like symptoms. Recognizing early-HFpEF phenogroups is essential to better understand progression towards overt HFpEF and pave the way for early intervention and treatment. Whether the HFA-PEFF domain scores can identify 'early-HFpEF' phenogroups remains unknown. The aims of this pilot study are to (i) identify distinct phenogroups by cluster analysis of HFA-PEFF domain scores in subjects that present with HF-like symptoms and (ii) study whether these phenogroups may be associated with distinct blood proteome profiles.

METHODS AND RESULTS

Subjects referred to the Cardiology Centers of the Netherlands, location Utrecht, with non-acute possibly cardiac-related symptoms (such as dyspnoea or fatigue) were prospectively enrolled in the HELPFul cohort (N = 507) and were included in the current analysis. Inclusion criteria for this study were (i) age ≥ 45 years and (ii) a left ventricular ejection fraction (LVEF) ≥ 50%, in the absence of a history of HF, coronary artery disease, congenital heart disease, or any previous cardiac interventions. Multinominal-based clustering with latent class model using the HFA-PEFF domain scores (functional, structural, and biomarker scores) as input was used to detect distinct phenotypic clusters. For each bootstrapping run, the 92 Olink proteins were analysed for their association with the identified phenogroups. Four distinct phenogroups were identified in the current analysis (validated by bootstrapping 1000×): (i) no left ventricular diastolic dysfunction (no LVDD, N = 102); (ii) LVDD with functional left ventricular (LV) abnormalities (N = 204); (iii) LVDD with functional and structural LV abnormalities (N = 204); and (iv) LVDD with functional and structural LV abnormalities and elevated BNP (N = 107). The HFA-PEFF total score risk categories significantly differed between the phenogroups (P < 0.001), with an increase of the HFA-PEFF score from Phenogroup 1 to 4 (low/intermediate/high HFA-PEFF risk score: Phenogroup 1: 88%/12%/0%; Phenogroup 2: 9%/91%/0%; Phenogroup 3: 0%/92%/8%; Phenogroup 4: 5%/83%/12%). Thirty-two out of the 92 Olink protein biomarkers significantly differed among the phenogroups. The top eight biomarkers-N-terminal prohormone brain natriuretic peptide, growth differentiation factor-15, matrix metalloproteinase-2, osteoprotegerin, tissue inhibitor of metalloproteinase-4, chitinase-3-like protein 1, insulin-like growth factor-binding protein 2, and insulin-like growth factor-binding protein 7-are mainly involved in inflammation and extracellular matrix remodelling, which are currently proposed key processes in HFpEF pathophysiology.

CONCLUSIONS

This study identified distinct phenogroups by using the HFA-PEFF domain scores in ambulant subjects referred for HF-like symptoms. The newly identified phenogroups accompanied by their circulating biomarkers profile might aid in a better understanding of the pathophysiological processes involved during the early stages of the HFpEF syndrome.

Association of Cardiovascular Risk Factors and Lifestyle Behaviors With Hypertension

Hypertension is a major risk factor for cardiovascular disease and mortality. To identify targets for the prevention of hypertension and its associated disease burden, we used the 2-sample Mendelian randomization method to investigate the causal associations of 18 cardiovascular risk factors and lifestyle behaviors with hypertension. From European-descent genome-wide association studies, we selected genetic variants (P<5×10−8) for type 2 diabetes, fasting glucose, lipids, body mass index, smoking, alcohol and coffee consumption, physical activity, sleep duration, insomnia, and educational level. We extracted the genetic associations with hypertension from 2 European cohorts: the FinnGen Study (15 870 cases and 74 345 controls) and UK Biobank (54 358 cases and 408 652 controls). The inverse-variance weighted method was used as main analysis method. Genetically predicted triglycerides (pooled odds ratio [OR] per 1 SD, 1.17 [1.10–1.25]), body mass index (OR per 1 SD, 1.42 [1.37–1.48]), alcohol dependence (OR, 1.10 [1.06–1.13]), and insomnia (OR, 1.17 [1.13–1.20]) were associated with a higher odds of hypertension. Higher genetically predicted high-density lipoprotein cholesterol (OR per 1 SD, 0.88 [0.83–0.94]) and educational level (OR per 1 SD, 0.56 [0.54–0.59]) were associated with a lower odds of hypertension. Suggestive evidence was obtained for type 2 diabetes, smoking initiation and alcohol consumption with a higher hypertension odds, and longer sleep duration with a lower hypertension odds. This Mendelian randomization study identified high-density lipoprotein cholesterol, triglycerides, body mass index, alcohol dependence, insomnia, and educational level as causal risk factors for hypertension. This implicates that these modifiable risk factors are important targets in the prevention of hypertension.

Modifiable lifestyle factors and heart failure: A Mendelian randomization study

BACKGROUND

Lifestyle factors may be important targets in the prevention of heart failure. The current knowledge on the relationship between lifestyle factors and heart failure originates mostly from observational studies. The objective of this study was to investigate causal associations of multiple lifestyle factors with heart failure risk by using Mendelian randomization.

METHODS

We obtained summary statistics data for single nucleotide polymorphisms associated with the following 5 lifestyle factors at genome-wide significance in genome-wide association studies of European-descent individuals: smoking, alcohol consumption, coffee consumption, physical activity, and sleep duration. The corresponding data for heart failure were acquired from a genome-wide association study comprising 47,309 cases and 930,014 controls of European ancestry. For the primary analyses, we used the inverse-variance weighted method.

RESULTS

Genetic predisposition to smoking initiation (ever smoked regularly) was robustly associated with a higher odds of heart failure (odds ratio: 1.28; 99% CI: 1.21-1.35). Genetically predicted longer sleep duration was associated with a lower odds of heart failure (odds ratio per hour/day: 0.73; 99% CI: 0.60-0.89). We found no associations of alcohol consumption, coffee consumption, and physical activity with heart failure.

CONCLUSIONS

This Mendelian randomization study showed that smoking initiation increases heart failure risk, whereas longer sleep duration decreases the risk of heart failure. Sleep duration should be regarded as novel risk factor in heart failure prevention guidelines. The potential causal role of alcohol and coffee consumption and physical activity for heart failure warrants further investigation in future larger Mendelian randomization analyses.

Individual and partner's level of occupation and the association with HbA1c levels in people with Type 2 diabetes mellitus: the Dutch Diabetes Pearl cohort

AIMS

Individual indicators of socio-economic status have been associated with glycaemic control in people with Type 2 diabetes, but little is known about the association between partner's socio-economic status and HbA_1c levels. We therefore examined the cross-sectional association between individual and partner's level of occupation on HbA_1c levels in people with Type 2 diabetes in the Netherlands.

METHODS

We included people with Type 2 diabetes with a partner who were treated in primary, secondary and tertiary care in the Diabetes Pearl cohort. Occupational level was classified according to International Standard Classification of Occupations (ISCO)-08 skill levels. Linear regression analyses were performed stratified for sex, and corrected for age, recruitment centre and diabetes medication.

RESULTS

In total, 3257 participants (59.8% men, mean 62.2±9.4 years) were included. For men, having a partner with an intermediate level of occupation was associated with lower HbA_1c levels [e.g. ISCO level 3: -2 mmol/mol (95% CI -4;-1) or -0.2% (95% CI -0.4;-0.1)], compared with having a partner of the highest occupational level (ISCO level 4). In women, having an unemployed partner was associated with higher HbA_1c levels [14 mmol/mol (95% CI 6; 22) or 1.3% (95% CI 0.6; 2.0)], compared with having a partner of the highest occupational level.

CONCLUSIONS

Partner's occupational status provided additional information on the association between socio-economic status and HbA_1c levels in people with Type 2 diabetes. Women seemed to benefit from a partner with a higher occupational status, while men seemed to benefit from a partner with a lower status. Because of the cross-sectional nature of the present study, more research is necessary to explore this association.

The Role of Vitamin K Status in Cardiovascular Health: Evidence from Observational and Clinical Studies

PURPOSE OF REVIEW

Vitamin K is a fat-soluble vitamin required for the activation of several vitamin K-dependent proteins to confer functioning. A growing body of evidence supports that vitamin K has beneficial effects on bone and cardiovascular health. This review summarizes key evidence on vitamin K status as measured by circulating measures and cardiovascular outcomes.

RECENT FINDINGS

Overall, observational studies indicate that low vitamin K status as measured by high dephosphorylated uncarboxylated matrix gla protein concentrations plays a potential role in cardiovascular disease development, particularly in high-risk and chronic kidney disease populations. Very few vitamin K intervention trials have been conducted with cardiovascular-related outcomes. A couple of intervention trials studied the effect of the combination of vitamin D + K supplementation, which might have synergistic effects compared to vitamin K supplementation alone.

SUMMARY

Assessing vitamin K status in prospective studies and well-designed randomized trials would provide important insight whether vitamin K is causally related to vascular calcification and cardiovascular disease.

Dietary Saturated Fatty Acids and Coronary Heart Disease Risk in a Dutch Middle-Aged and Elderly Population

Objective—

We assessed whether the association between dietary saturated fatty acids (SFA) and incident coronary heart disease (CHD) depends on the food source, the carbon chain length of SFA, and the substituting macronutrient.

Approach and Results—

From the Rotterdam Study, 4722 men and women (≥55 years) were included. Baseline (1990–1993) SFA intake was assessed using a validated food frequency questionnaire. CHD (nonfatal myocardial infarction and fatal CHD) was ascertained by medical records. Using multivariable Cox regression analysis, we calculated CHD risks for higher intakes of total SFA, SFA from specific food sources, SFA differing in carbon chain length, and substituting other macronutrients instead of SFA. During a median follow-up of 16.3 years, 659 CHD events occurred. Total SFA intake was not associated with CHD risk (hazard ratio [HR] per 5 en%, 1.13; 95% confidence interval, 0.94–1.22), and neither was SFA from specific food sources. A higher CHD risk was observed for palmitic acid (16:0) intake (HR SD , 1.26; 95% confidence interval, 1.05–1.15) but not for SFA with other chain lengths. Except for a higher CHD risk for substitution of SFA with animal protein (HR 5en% , 1.24; 95% confidence interval, 1.01–1.51), substitution with other macronutrients was not associated with CHD.

Conclusions—

In this Dutch population, we observed that a higher intake of palmitic acid, which accounts for ≈50% of the total SFA intake, was associated with a higher CHD risk, as was substitution of total SFA with animal protein. Nevertheless, we found no association between total SFA intake and CHD risk, which did not differ by food source.

Association between alcohol consumption and diabetic retinopathy and visual acuity-the AdRem Study

AIMS

We investigated the association between alcohol consumption and diabetic retinopathy and deterioration of visual acuity in individuals with Type 2 diabetes.

METHODS

We conducted a cohort analysis of 1239 participants with Type 2 diabetes aged 55-81 years enrolled in the AdRem study, a sub-study of the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial. Current and past consumption of wine, spirits and beer was measured by self-report. Moderate and heavy alcohol consumption was defined as 1-14 and >14 drinks/week, respectively. Diabetic retinopathy, measured by mydriatic stereoscopic seven-field retinal photography, was defined by a 2-step progression in the Early Treatment of Diabetic Retinopathy Study (ETDRS) score or the presence of any retinal vascular lesions. Deterioration of visual acuity was defined by a decrease of two lines in best vision in either eye, measured corrected, or through a pinhole using a Snellen chart.

RESULTS

In a mean follow-up of 5.5 years, we identified 182 participants with a 2-step progression in the ETDRS score, 640 participants with the presence of any retinal vascular lesions and 693 participants with a deterioration of visual acuity. Current moderate consumption of alcohol, compared with no current consumption, was not associated with presence or progression of diabetic retinopathy; however, it was associated with higher risk of deterioration of visual acuity (multivariable-adjusted OR 1.83; 95% CI 1.34-2.48; P<0.001).

CONCLUSIONS

Alcohol consumption is associated with increased risk of deterioration of visual acuity, but not with retinopathy in individuals with Type 2 diabetes.

Awareness of hypertension: will it bring about a healthy lifestyle?

Guidelines for cardiovascular disease prevention recommend a non-pharmacological approach to reduce cardiovascular risk in those with elevated blood pressure. We assessed guideline adherence in hypertensives. This study was performed in the European Investigation into Cancer and Nutrition-NL cohort, consisting of 40,011 subjects. From 1993 to 1997, participants completed questionnaires (disease history, lifestyle and diet), a physical examination was performed and blood samples were drawn. Differences in proportions of guideline targets met between aware and unaware hypertensives were studied. Of 8779 hypertensive subjects, 90% was aware of their hypertension. They more often adhered to guidelines than unaware hypertensive subjects with respect to intake of polyunsaturated fat:saturated fat (38.6% vs 33.2%), fibres (40.6% vs 34.2%), body mass index <27 kg m(-2) (53.8% vs 46.5%) and alcohol (79.7% vs 72.6%). Despite statistical significance, the magnitude of these differences was small. Our study suggests that prevalence of a healthy lifestyle according to the recommendations in guidelines is slightly better in subjects aware of hypertension. There seems to be ample room for improvement in implementing the guidelines. Probably, patient tailored interventions and a multisiciplinary and multimodality approach can support this improvement.