Long-term blood pressure variability and frailty risk in older adults

INTRODUCTION

In healthy older adults, the relationship between long-term, visit-to-visit variability in blood pressure (BP) and frailty is uncertain.

METHODS

Secondary analysis of blood pressure variability (BPV) and incident frailty in >13 000 participants ≥65-70 years enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) trial and its observational follow-up (ASPREE-XT). Participants were without dementia, physical disability, or cardiovascular disease at baseline. BPV was estimated using standard deviation of mean BP from three annual visits (baseline through the second annual follow-up). Frailty was defined using Fried phenotype and a frailty deficit accumulation index (FDAI). Participants with frailty during the BPV estimation period were excluded from the main analysis. Adjusted Cox proportional hazards regression evaluated the association between BPV and incident frailty, and linear mixed models for change in frailty scores, through a maximum of 9 years of follow-up.

RESULTS

Participants in the highest systolic BPV tertile were at higher risk of frailty compared to those in the lowest (referent) tertile of systolic BPV [Fried hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.04-1.31; FDAI HR 1.18, 95% CI 1.07-1.30]. Findings were consistent when adjusted for multiple covariates and when stratified by antihypertensive use. Linear mixed models showed that higher systolic BPV was associated with increasing frailty score over time. Diastolic BPV was not consistently associated.

CONCLUSIONS

High systolic BPV, independent of mean BP, is associated with increased risk of frailty in healthy older adults. Variability of BP across visits, even in healthy older adults, can convey important risk information beyond mean BP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01038583 and ISRCTN83772183.

Relationship between TV Watching during Childhood and Adolescence, and Artery Function in Adulthood

PURPOSE

Artery dysfunction is an early, integral stage in atherogenesis that predicts future cardiovascular events. Sedentary behavior, such as TV watching, is highly prevalent and associated with increased risk of developing cardiovascular diseases. This study investigated whether patterns of TV watching throughout childhood and adolescence were associated with artery function in adulthood.

METHODS

TV watching data were collected when participants of the Raine Study were aged 5, 8, 10, 14, 17, and 20 yr. Previous latent class analysis indicated three trajectory groups of TV watching: low TV (<14 h·wk -1 ), high TV (>14 h·wk -1 ), and increasing TV (change from low TV to high TV). At age 28 yr, participants were invited to undergo tests of brachial and femoral artery function by flow-mediated dilation (FMD). General linear models examined differences in artery function between TV trajectory groups for men and women.

RESULTS

Five hundred sixty participants (n = 261 women, n = 299 men) were included in the study. In women, the low TV group had significantly greater femoral artery FMD (10.8 ± 1.6%) than both High TV (9.0 ± 1.3%, P = 0.005) and Increasing TV groups (8.5 ± 1.3%, P < 0.001); these results were maintained following mediation analysis, including contemporaneous risk factors. There were no significant differences in femoral artery FMD between TV trajectory groups in men ( P = 0.955).

CONCLUSIONS

This study suggests that TV watching behaviors during childhood and adolescence may have legacy impacts on artery function at age 28 yr, particularly in women. This may increase the risk of atherosclerotic vascular pathologies in later life.

Long-term occupational exposures on disability-free survival and mortality in older adults

BACKGROUND

The impact of long-term occupational exposures on health in older adults is increasingly relevant as populations age. To date, no studies have reported their impact on survival free of disability in older adults.

AIMS

We aimed to investigate the association between long-term occupational exposure and disability-free survival (DFS), all-cause mortality and cause-specific mortality in initially healthy older adults.

METHODS

We analysed data from 12 215 healthy participants in the ASPirin in Reducing Events in the Elderly (ASPREE) study whose mean age was 75 years. Their work history was collated with the 'ALOHA-plus JEM' (Job Exposure Matrix) to assign occupational exposures. The primary endpoint, DFS, was a composite measure of death, dementia or persistent physical disability. The secondary endpoint, mortality, was classified according to the underlying cause. Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals, adjusted for confounders.

RESULTS

A total of 1835 individuals reached the DFS endpoint during the median 4.7 years follow-up period. Both ever-high and cumulative exposure to all dusts and all pesticides during a person's working years were associated with reduced DFS. Compared to no exposure, men with high exposure to dusts and pesticides had a reduced DFS. Neither of these exposures were significantly associated with all-cause mortality. Men with high occupational exposure to solvents and women exposed to dusts experienced higher all-cause and cancer-related mortality.

CONCLUSIONS

Long-term occupational exposure to all dusts and pesticides was associated with a reduced DFS and increased mortality in community-dwelling healthy older adults.

Genome-Wide Interaction Analysis with DASH Diet Score Identified Novel Loci for Systolic Blood Pressure

Objective

We examined interactions between genotype and a Dietary Approaches to Stop Hypertension (DASH) diet score in relation to systolic blood pressure (SBP).

Methods

We analyzed up to 9,420,585 biallelic imputed single nucleotide polymorphisms (SNPs) in up to 127,282 individuals of six population groups (91% of European population) from the Cohorts for Heart and Aging Research in Genomic Epidemiology consortium (CHARGE; n=35,660) and UK Biobank (n=91,622) and performed European population-specific and cross-population meta-analyses.

Results

We identified three loci in European-specific analyses and an additional four loci in cross-population analyses at P for interaction < 5e-8. We observed a consistent interaction between rs117878928 at 15q25.1 (minor allele frequency = 0.03) and the DASH diet score (P for interaction = 4e-8; P for heterogeneity = 0.35) in European population, where the interaction effect size was 0.42±0.09 mm Hg (P for interaction = 9.4e-7) and 0.20±0.06 mm Hg (P for interaction = 0.001) in CHARGE and the UK Biobank, respectively. The 1 Mb region surrounding rs117878928 was enriched with cis-expression quantitative trait loci (eQTL) variants (P = 4e-273) and cis-DNA methylation quantitative trait loci (mQTL) variants (P = 1e-300). While the closest gene for rs117878928 is MTHFS, the highest narrow sense heritability accounted by SNPs potentially interacting with the DASH diet score in this locus was for gene ST20 at 15q25.1.

Conclusion

We demonstrated gene-DASH diet score interaction effects on SBP in several loci. Studies with larger diverse populations are needed to validate our findings.

The relationship between long-term blood pressure variability and cortical thickness in older adults

High blood pressure variability (BPV) is a risk factor for cognitive decline and dementia, but its association with cortical thickness is not well understood. Here we use a topographical approach, to assess links between long-term BPV and cortical thickness in 478 (54% men at baseline) community dwelling older adults (70-88 years) from the ASPirin in Reducing Events in the Elderly NEURO sub-study. BPV was measured as average real variability, based on annual visits across three years. Higher diastolic BPV was significantly associated with reduced cortical thickness in multiple areas, including temporal (banks of the superior temporal sulcus), parietal (supramarginal gyrus, post-central gyrus), and posterior frontal areas (pre-central gyrus, caudal middle frontal gyrus), while controlling for mean BP. Higher diastolic BPV was associated with faster progression of cortical thinning across the three years. Diastolic BPV is an important predictor of cortical thickness, and trajectory of cortical thickness, independent of mean blood pressure. This finding suggests an important biological link in the relationship between BPV and cognitive decline in older age.

Longitudinal association between handgrip strength, gait speed and risk of serious falls in a community-dwelling older population

OBJECTIVE

Both grip strength and gait speed can be used as markers of muscle function, however, no previous study has examined them in the same population with respect to risk of falls.

METHODS

In this prospective cohort study, utilising data from the ASPirin in Reducing Events in the Elderly (ASPREE) trial and ASPREE-Fracture substudy, we analysed the association of grip strength and gait speed and serious falls in healthy older adults. Grip strength was measured using a handheld dynamometer and gait speed from 3-metre timed walks. Serious falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for associations with falls.

RESULTS

Over an average of 4.0±1.3 years, amongst 16,445 participants, 1,533 had at least one serious fall. After adjustment for age, sex, physical activity, body mass index, Short Form 12 (state of health), chronic kidney disease, polypharmacy and aspirin, each standard deviation (SD) lower grip strength was associated with 27% (HR 1.27, 95% CI 1.17-1.38) higher risk of falls. The results remained the same for males and females. There was a dose-response relationship in the association between grip strength and falls risk. The higher risk of falls was observed in males in all body mass index (BMI) categories, but only in obese females. The association between gait speed and falls risk was weaker than the association between grip strength and falls risk.

CONCLUSIONS

All males and only obese females with low grip strength appear to be at the greatest risk of serious falls. These findings may assist in early identification of falls.

Statins for extension of disability-free survival and primary prevention of cardiovascular events among older people: protocol for a randomised controlled trial in primary care (STAREE trial)

INTRODUCTION

The world is undergoing a demographic transition to an older population. Preventive healthcare has reduced the burden of chronic illness at younger ages but there is limited evidence that these advances can improve health at older ages. Statins are one class of drug with the potential to prevent or delay the onset of several causes of incapacity in older age, particularly major cardiovascular disease (CVD). This paper presents the protocol for the STAtins in Reducing Events in the Elderly (STAREE) trial, a randomised double-blind placebo-controlled trial examining the effects of statins in community dwelling older people without CVD, diabetes or dementia.

METHODS AND ANALYSIS

We will conduct a double-blind, randomised placebo-controlled trial among people aged 70 years and over, recruited through Australian general practice and with no history of clinical CVD, diabetes or dementia. Participants will be randomly assigned to oral atorvastatin (40 mg daily) or matching placebo (1:1 ratio). The co-primary endpoints are disability-free survival defined as survival-free of dementia and persistent physical disability, and major cardiovascular events (cardiovascular death or non-fatal myocardial infarction or stroke). Secondary endpoints are all-cause death, dementia and other cognitive decline, persistent physical disability, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, atrial fibrillation, fatal and non-fatal cancer, all-cause hospitalisation, need for permanent residential care and quality of life. Comparisons between assigned treatment arms will be on an intention-to-treat basis with each of the co-primary endpoints analysed separately in time-to-first-event analyses using Cox proportional hazards regression models.

ETHICS AND DISSEMINATION

STAREE will address uncertainties about the preventive effects of statins on a range of clinical outcomes important to older people. Institutional ethics approval has been obtained. All research outputs will be disseminated to general practitioner co-investigators and participants, published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02099123.

The association between frailty and incident cardiovascular disease events in community-dwelling healthy older adults

Study objective

This study examined the association between frailty and incident cardiovascular disease (CVD) events, major adverse cardiovascular events (MACE), and CVD-related mortality.

Design

Longitudinal cohort study.

Setting

The ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial in Australia and the United States.

Participants

19,114 community-dwelling older adults (median age 74.0 years; 56.4 % females).

Interventions

Pre-frailty and frailty were assessed using a modified Fried phenotype and a deficit accumulation Frailty Index (FI) at baseline.

Main outcome measures

CVD was defined as a composite of CVD death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure; MACE included all except heart failure. Cox proportional hazards regression was used to analyze the association between frailty and CVD outcomes over a median follow-up of 4.7 years.

Results

Baseline pre-frail and frail groups had a higher risk of incident CVD events (Hazard Ratio (HR): 1.31; 95 % Confidence Interval (CI): 1.14-1.50 for pre-frail and HR: 1.63; 95 % CI: 1.15-2.32 for frail) and MACE (pre-frail HR: 1.26; 95 % CI: 1.08-1.47 and frail HR: 1.51; 95 % CI: 1.00-2.29) than non-frail participants according to Fried phenotype after adjusting for traditional CVD risk factors. Effect sizes were similar or larger when frailty was assessed with FI; similar results for men and women.

Conclusion

Frailty increases the likelihood of developing CVD, including MACE, in community-dwelling older men and women without prior CVD events. Screening for frailty using Fried or FI method could help identify community-dwelling older adults without prior CVD events who are more likely to develop CVD, including MACE, and may facilitate targeted preventive measures to reduce their risk.

Relationship between TV watching during childhood and adolescence and fitness in adulthood in the Raine Study cohort

To investigate: (1) whether TV watching habits throughout childhood and adolescence, a proxy of sedentary behaviour, impacted cardiorespiratory fitness (CRF) in adulthood, and (2) whether any potential impact of TV watching in childhood and adolescence on CRF in adulthood was changed by adult physical activity (PA) levels. A longitudinal study with questionnaire data available regarding TV watching collected at ages 5, 8, 10, 14, 17 and 20 yrs, allowed trajectories of TV watching to be developed. At age 28 yrs, participants completed a V̇O₂peak test and the International Physical Activity Questionnaire. General linear models tested for differences in CRF (time to exhaustion TTE and V̇O₂peak mL·kg^-1·min^-1) between TV watching trajectories. The secondary analysis tested the potential effect current PA levels has on the relationship between TV trajectory and fitness. In total, 449 participants [male n = 255 (56.8%), 28.3 ± 0.5 yrs; female n = 194 (43.2%), 28.2 ± 0.4 yrs] were included in the study. Three distinct trajectories of TV watching were identified: High TV, Increasing TV and Low TV. CRF was lowest in the High TV watching trajectory and increased progressively from High to Increasing TV and Increasing to Low TV (all P < .05). Within each of the TV trajectories, those engaging in high levels of current PA had greater CRF than those engaging in low and moderate PA. TV watching in childhood and adolescence negatively impacts upon adult fitness at the age of 28 years. However, this negative impact of historical TV watching on CRF can largely be attenuated by engaging in higher levels of PA in adulthood.

The Association between Metabolic Syndrome, Frailty and Disability-Free Survival in Healthy Community-dwelling Older Adults

OBJECTIVES

To examine the association between metabolic syndrome (MetS) and frailty, and determine whether co-existent MetS and frailty affect disability-free survival (DFS), assessed through a composite of death, dementia or physical disability.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

Community-dwelling older adults from Australia and the United States (n=18,264) from "ASPirin in Reducing Events in the Elderly" (ASPREE) study.

MEASUREMENTS

MetS was defined according to American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (2018). A modified Fried phenotype and a deficit accumulation Frailty Index (FI) were used to assess frailty. Association between MetS and frailty was examined using multinomial logistic regression. Cox regression was used to analyze the association between MetS, frailty and DFS over a median follow-up of 4.7 years.

RESULTS

Among 18,264 participants, 49.9% met the criteria for MetS at baseline. Participants with Mets were more likely to be pre-frail [Relative Risk Ratio (RRR): 1.22; 95%Confidence Interval (CI): 1.14, 1.30)] or frail (RRR: 1.66; 95%CI: 1.32, 2.08) than those without MetS. MetS alone did not shorten DFS while pre-frailty or frailty alone did [Hazard Ratio (HR): 1.68; 95%CI: 1.45, 1.94; HR: 2.65; 95%CI:1.92, 3.66, respectively]. Co-existent MetS with pre-frailty/frailty did not change the risk of shortened DFS.

CONCLUSIONS

MetS was associated with pre-frailty or frailty in community-dwelling older individuals. Pre-frailty or frailty increased the risk of reduced DFS but presence of MetS did not change this risk. Assessment of frailty may be more important than MetS in predicting survival free of dementia or physical disability.

EFFECT OF CHANGE IN BODY SIZE ON MORTALITY IN THE INITIALLY HEALTHY COMMUNITY-DWELLING OLDER ADULTS

Utilising data from the ASPirin in Reducing Events in the Elderly trial participants [aged &gt;70-years (Australians), &gt;65-years (US)], we estimated percent change in body size (BMI: body mass index, WC: waist circumference) from baseline and the second annual visits. Both BMI and WC changes were categorised as 1) change within 5% (stable), 2) decrease by 5–10%, 3) decrease by &gt;10%, 4) increase by 5–10%, and 5) increase by &gt;10%. Mortality events were classified according to the underlying cause by adjudicators. Hazard ratios were calculated to compare mortality between body size change categories. Amongst 16,773 participants, 1,269 mortality were observed over an average 4.4±1.7 years. In men compared to stable BMI, a 5–10% decrease in BMI had a 35% higher (HR 1.35, 95% CI 1.08–1.67), and a &gt;10% decrease in BMI had a 3.84-fold higher (HR 2.99, 95% CI 2.44–3.68) risk in all-cause mortality. A decrease in BMI was associated with a higher cause-specific (cancer, cardiovascular disease [CVD], and non-cancer non-CVD) mortality. A decrease in BMI was associated with higher mortality risk in women, however, the magnitude of association was weaker than men. A decrease in WC was predictive of mortality but with a much weaker relationship than a decrease in BMI. Weight gain was not predictive of mortality except for non-cancer non-CVD mortality in women. Physicians should be aware of the ominous consequence of weight loss, especially amongst older men. The risk extends beyond an increased risk of cancer, extending to CVD and a range of other life-limiting conditions.

PLASMA HIGH DENSITY LIPOPROTEIN CHOLESTEROL AND RISK OF FRACTURES IN OLDER ADULTS

The ASPirin in Reducing Events in the Elderly trial participants (ASPREE, aged >70-years Australians), for whom high-density lipoprotein cholesterol (HDL-C) levels were measured were included. Fractures included were confirmed by medical imaging and included both traumatic and pathological fractures. Fractures were confirmed by an expert review panel. Cox proportional hazards regression was used to calculate hazard ratio (HR) and 95% confidence interval (CI) for associations with fractures. Of the 16262 participants who had a plasma HDL-C measurement at baseline 1,659 experienced at least one episode of fracture over a median of 3.98 years (interquartile range, 0.02, 7.0 years). In the fully adjusted model, each mmol/L increment in HDL-C was associated with a 34% (HR 1.34, 95% CI 1.20–1.50) higher risk of fractures. The results remained similar when these analyses were stratified by sex. Sensitivity analyses demonstrated that these associations persisted when the analyses were repeated including only: 1) nontraumatic fractures, 2) participants not on osteoporotic medications, 3) participants who were never-smokers and reported that they did not drink alcohol, and 4) participants who walked outside less than 30 minutes and reported no participation in moderate/vigorous physical activity. No association was observed between non-HDL-C and fractures. This prospective observational study suggests that higher levels of HDL-C are associated with higher fracture risk. This association was independent of the common risk factors of fractures.

Aspirin for Primary Prevention of Cardiovascular Events in Relation to Lipoprotein(a) Genotypes

BACKGROUND

The role of aspirin in reducing lipoprotein(a)-mediated atherothrombotic events in primary prevention is not established.

OBJECTIVES

This study sought to assess whether low-dose aspirin benefits individuals with elevated plasma lipoprotein(a)-associated genotypes in the setting of primary prevention.

METHODS

The study analyzed 12,815 genotyped individuals ≥70 years of age of European ancestry and without prior cardiovascular disease events enrolled in the ASPREE (ASPirin in Reducing Events in the Elderly) randomized controlled trial of 100 mg/d aspirin. We defined lipoprotein(a)-associated genotypes using rs3798220-C carrier status and quintiles of a lipoprotein(a) genomic risk score (LPA-GRS). We tested for interaction between genotypes and aspirin allocation in Cox proportional hazards models for incidence of major adverse cardiovascular events (MACE) and clinically significant bleeding. We also examined associations in the aspirin and placebo arms of the trial separately.

RESULTS

During a median 4.7 years (IQR: 3.6-5.7 years) of follow-up, 435 MACE occurred, with an interaction observed between rs3798220-C and aspirin allocation (P = 0.049). rs3798220-C carrier status was associated with increased MACE risk in the placebo group (HR: 1.90; 95% CI: 1.11-3.24) but not in the aspirin group (HR: 0.54; 95% CI: 0.17-1.70). High LPA-GRS (vs low) was associated with increased MACE risk in the placebo group (HR: 1.70; 95% CI: 1.14-2.55), with risk attenuated in the aspirin group (HR: 1.41; 95% CI: 0.90-2.23), but the interaction was not statistically significant. In all participants, aspirin reduced MACE by 1.7 events per 1,000 person-years and increased clinically significant bleeding by 1.7 events per 1,000 person-years. However, in the rs3798220-C and high LPA-GRS subgroups, aspirin reduced MACE by 11.4 and 3.3 events per 1,000 person-years respectively, without significantly increased bleeding risk.

CONCLUSIONS

Aspirin may benefit older individuals with elevated lipoprotein(a) genotypes in primary prevention.

Comparison of the cardiometabolic profiles of adolescents conceived through ART with those of a non-ART cohort

STUDY QUESTION

Is the cardiometabolic health of adolescents conceived through ART worse than that of their counterparts conceived without ART?

SUMMARY ANSWER

The majority of cardiometabolic and vascular health parameters of adolescents conceived through ART are similar or more favourable, than those of their counterparts of similar age and conceived without ART.

WHAT IS KNOWN ALREADY

It has been proposed that the cardiometabolic health of offspring conceived with ART may be unfavourable compared to that of their counterparts conceived without ART. The literature pertaining to cardiometabolic health of offspring conceived after ART is contradictory, but generally suggests unfavourable cardiometabolic health parameters, such as an increase in blood pressure (BP), vascular dysfunction and adiposity, as well as unfavourable glucose and lipid profiles. With over 8 million children and adults born through ART worldwide, it is important to investigate whether these early signs of adverse cardiometabolic differences persist into adolescence and beyond.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective cohort study that recruited 303 adolescents and young adults conceived after ART (aged 13-21 years) and born between 1991 and 2001 in Western Australia. Their health parameters, including cardiometabolic factors, were assessed and compared with counterparts from the Raine Study Generation 2 (Gen2). The 2868 Gen2 participants were born 1989-1992 and are representative of the Western Australian adolescent population. At ∼17 years of age (2013-2017), 163 GUHS participants replicated assessments previously completed by Gen2 at a similar age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cardiometabolic parameters were compared between a total of 163 GUHS and 1457 Gen2 adolescents. Separate male (GUHS n = 81, Gen2 n = 735) and female (GUHS n = 82, Gen2 n = 722) analyses were conducted. Assessments consisted of a detailed questionnaire including health, lifestyle and demographic parameters, anthropometric assessments (height, weight, BMI, waist circumference and skinfold thickness), fasting serum biochemistry, arterial stiffness and BP (assessed using applanation tonometry). Abdominal ultrasonography was used to assess the presence and severity of hepatic steatosis, and thickness of abdominal fat compartments. Non-alcoholic fatty liver disease (NAFLD) was diagnosed if there was sonographic fatty liver in the absence of significant alcohol consumption. Chi2, Fisher's exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences and generalized estimating equations adjusted for the following covariates: singleton vs non-singleton pregnancy, birthweight (z-score), gestational age, BMI, smoking, alcohol consumption in the past 6 months and parent cardiovascular status. Arterial stiffness measures and waist circumference were additionally adjusted for height, and female analyses were additionally adjusted for use of oral contraceptives in the preceding 6 months.

MAIN RESULTS AND THE ROLE OF CHANCE

In adjusted analyses, GUHS females had a lower BMI (22.1 vs 23.3 kg/m2, P = 0.014), and thinner skinfolds (triceps, subscapular, mid-abdominal; 16.9 vs 18.7 mm, P = 0.021, 13.4 vs 15.0 mm, P = 0.027, 19.7 vs 23.2 mm, P < 0.001, respectively), whereas males were not significantly different. Waist circumference was lower in GUHS adolescents (males: 78.1 vs 81.3 cm, P = 0.008, females: 76.7 vs 83.3 cm, P = 0.007). There were no significant differences between the two groups in glucose, insulin, homeostatic model assessment for insulin resistance, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C), total cholesterol (TC), alanine aminotransferase and high-sensitivity C-reactive protein in both sexes. In females, serum triglycerides were lower in GUHS adolescents (1.0 vs 1.2 mmol/l, P = 0.029). GUHS males had higher serum HDL-C (1.1 vs 1.0 mmol/l, P = 0.004) and a lower TC/HDL-C ratio (3.2 vs 3.6, P = 0.036). There were no significant differences in the prevalence of NAFLD or steatosis severity scores between the cohorts in males and females. GUHS females had less subcutaneous adipose tissue (9.4 vs 17.9 mm, P < 0.001), whereas GUHS males had greater visceral adipose thickness (44.7 vs 36.3 mm, P < 0.001). There was no significant difference in pre-peritoneal adipose thickness. Pulse wave velocity was lower in GUHS males (5.8 vs 6.3 m/s, P < 0.001) and heart rate corrected augmentation index was lower in GUHS females (-8.4 vs -2.7%, P = 0.048). There were no significant differences in BP or heart rate in males or females between the two groups.

LIMITATIONS, REASONS FOR CAUTION

Despite the substantial study size and the unique study design of the ART cohort, we were unable to differentiate between different types of ART, due to the low number of ICSI cycles (e.g. IVF vs ICSI), draw definite conclusions, or relate the outcomes to the cause of infertility. Considering the differences in time points when both cohorts were studied, external factors could have changed, which could not be accounted for. Given the observational nature of this study, causation cannot be proven.

WIDER IMPLICATIONS OF THE FINDINGS

Contrary to our hypothesis and previous findings focussing mainly on childhood, this study reports mostly similar or favourable cardiometabolic markers in adolescents conceived with ART compared to those conceived without ART. The greater visceral adipose thickness, particularly present in males, requires further investigation. While these findings are generally reassuring, future well-designed and appropriately powered studies are required to definitively address the issue of cardiometabolic health in ART adults.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by NHMRC project grant number 1042269 and R.J.H. received education grant funding support from Ferring Pharmaceuticals. R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director of PIVET Medical Centre, Perth, Western Australia.

TRIAL REGISTRATION NUMBER

N/A.

Long-Term Blood Pressure Variability and Kidney Function in Participants of the ASPREE Trial

BACKGROUND

Whether long-term blood pressure variability (BPV) predicts kidney function decline in generally healthy older adults is unknown. We investigated this association in ASPirin in Reducing Events in the Elderly (ASPREE) trial participants.

METHODS

Between 2010 and 2014, Australian and US individuals aged ≥70 years (≥65 if US minority) were recruited and followed with annual study visits for a median of 4.7 years. Time-to-event analyses and linear mixed effects models were used to examine associations between incident chronic kidney disease (CKD), and trajectories of estimated glomerular filtration rate (eGFR) and log albumin-creatinine ratio (log ACR) with systolic BPV as a continuous measure, and, by tertile of SD of systolic blood pressure (BP). BPV was estimated using systolic BP measures from baseline through the second annual visit, and kidney outcomes were assessed following this period.

RESULTS

Incident CKD occurred in 1,829 of 6,759 participants (27.2%), and more commonly in BPV tertiles 2 (27.4%) and 3 (28.3%) than tertile 1 (25.5%); however, the risk was not significantly increased after covariate adjustment (tertile 3 hazard ratio = 1.02; 95% confidence interval: 0.91-1.14). Analysis of eGFR (n = 16,193) and log ACR trajectories (n = 15,213) showed individuals in the highest BPV tertile having the lowest eGFR and highest log ACR, cross-sectionally. However, the trajectories of eGFR and log ACR did not differ across BPV tertiles.

CONCLUSIONS

CKD and markers of reduced kidney function occur more commonly in individuals with higher BPV; however, BPV does not influence trajectory of decline in kidney function over time in older adults who are in generally good health.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01038583 and ISRCTN83772183.

The Association Between Metabolic Syndrome and Frailty in Healthy Community-Dwelling Older Adults

This study examined the association between metabolic syndrome (MetS) and frailty status in relatively healthy community-dwelling older adults. Participants included 19,114 individuals from the “ASPirin in Reducing Events in the Elderly” (ASPREE) trial. The diagnostic criteria for MetS were according to the International Diabetes Federation Task Force on Epidemiology and Prevention and the American Heart Association/National Heart, Lung, and Blood Institute (2009); and comprised any three of five parameters: waist circumference, triglycerides, fasting blood glucose, high-density lipoprotein cholesterol or hypertension. Frailty and prefrailty were defined using a modified Fried phenotype (FP) comprising exhaustion, body mass index, grip strength, gait speed and physical activity and a deficit accumulation frailty index (FI) of 66 items. The association between MetS and frailty was examined using multinomial logistic regression. At baseline, 51.1% of participants met the criteria of MetS; of those, 41.8% and 2.5 % were prefrail and frail, respectively, according to Fried phenotype, while 49.6% and 11.8 % were prefrail and frail, respectively, according to FI. MetS at baseline was associated with an increased likelihood of prefrailty (RRR: 1.25; 95% CI: 1.17, 1.33) and frailty (RRR: 1.60; 95% CI: 1.28, 2.01) compared to no frailty after adjustment for potential confounders according to Fried phenotype, while the association was stronger for prefrailty (RRR: 2.74; 95% CI: 2.55, 2.94) and frailty (RRR: 5.30; 95% CI: 4.60, 6.11) according to FI. Overall, at baseline, more than half of the participants had MetS, and the presence of MetS was significantly associated with pre-frailty and frailty.

O-072 Markers of cardiometabolic health of adolescents conceived through assisted reproductive technologies (ART) appear reassuring

Study question

Is the cardiometabolic health of adolescents conceived through ART worse than that of their spontaneously-conceived counterparts?

Summary answer

The majority of cardiometabolic and vascular health parameters of ART-conceived adolescents are more favourable than those of their spontaneously-conceived counterparts of similar age.

What is known already

It has been proposed that ART induces epigenetic alterations during embryonic development which could lead to cardiometabolic disease later in life. However, individuals requiring ART may themselves be metabolically less healthy than the general population, which could lead to a genetically increased risk of cardiometabolic disorders in the offspring, rather than the ART procedure. The literature pertaining to cardiometabolic health of ART-conceived offspring is contradictory, but generally suggests unfavourable cardiometabolic health parameters. With over 8 million children and adults born through ART worldwide, it is imperative to investigate whether early signs of adverse cardiometabolic differences persist into adolescence and beyond.

Study design, size, duration

The Growing Up Healthy Study (GUHS) is a prospective study that recruited 303 ART-conceived adolescents, born 1991-2001 in Western Australia. Their health parameters, including cardiometabolic factors, were assessed and compared with spontaneously conceived counterparts of similar socioeconomic background and age from the Raine Study Generation 2 (Gen2). The 2868 Gen2 participants were born 1989-1992 and are representative of the Western Australian adolescent population. At age 16-17 (2013-2017), GUHS participants replicated assessments previously completed by Gen2.

Participants/materials, setting, methods

Cardiometabolic parameters were compared between 165 GUHS (male = 50.9%) and 1690 Gen2 (male = 49.8%) adolescents. Assessments consisted of a detailed questionnaire; health and demographic parameters, anthropometric assessments; height, weight, body-mass index (BMI), waist circumference and skinfold thickness, fasting serum biochemistry, arterial stiffness and blood pressure assessment using applanation tonometry, assessment of non-alcoholic fatty liver (NAFLD) and thickness of abdominal fat compartments using ultrasonography. Chi2, Fisher’s Exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences.

Main results and the role of chance

GUHS adolescents appeared to be healthier from a cardiometabolic perspective than their Gen2 counterparts. They were leaner, with lower BMI (median: 21.23 vs. 22.06, P = 0.004), lower waist circumference (median: 74.10 vs. 76.75 cm, P = 0.031), and thinner skinfolds (triceps median: 12.1 vs. 14.0 mm, P = 0.019, subscapular median: 10.6 vs. 11.9 mm, P &lt; .001, mid-abdominal median: 16.0 vs. 19.9 mm, P &lt; 0.001, supraspinal median: 10.7 vs. 13.5 mm, P &lt; 0.001). No significant differences were detected in the following serum fasting parameters: glucose, insulin, HOMA-IR, LDL cholesterol, total cholesterol, cholesterol/HDL-ratio, triglycerides, CRP and ALT. HDL cholesterol levels were more favourable in GUHS (P &lt; 0.001). NAFLD was present in 10.9% of GUHS vs. 15.2% of Gen2 adolescents (P = 0.174), with no difference in steatosis severity score (P = 0.309). ART offspring had less subcutaneous adipose tissue (median: 8.0 vs. 14.0 mm, P &lt; .001), more visceral adipose tissue (median: 40.0 vs. 32.0 mm, P &lt; 0.001), with no difference in pre-peritoneal adipose tissue (P = 0.087). Measures of arterial stiffness were lower in GUHS. Pulse wave velocity: median 6.1 vs. 6.4 m/s, P &lt; 0.001 and heart rate corrected augmentation index: median -10.25 vs. -8.00, P = 0.006. No significant differences in blood pressure or heart rate were detected. Stratification by sex did not greatly alter the results.

Limitations, reasons for caution

Despite the substantial study size and the unique study design, we were unable to differentiate between different types of ART (e.g. IVF vs. ICSI), draw definite conclusions or relate outcomes to cause of infertility. Given the observational character of this study, causation cannot be proven.

Wider implications of the findings

In this study we did not detect any adverse effect of ART on cardiometabolic health at adolescence, in contrast to some studies. Given the lack of consensus, future well-designed and appropriately-powered studies are necessary to investigate cardiometabolic health in ART adults.

Trial registration number

not applicable

The interactions between genetics and early childhood nutrition influence adult cardiometabolic risk factors

It is well established that genetics, environment, and interplay between them play a crucial role in adult disease. We aimed to evaluate the role of genetics, early life nutrition, and the interaction between them, on optimal adult health. As part of a large international consortium (n ~ 154,000), we identified 60 SNPs associated with both birthweight and adult disease. Utilising the Raine Study, we developed a birthweight polygenic score (BW-PGS) based on the 60 SNPs and examined relationships between BW-PGS and adulthood cardiovascular risk factors, specifically evaluating interactions with early life nutrition. Healthy nutrition was beneficial for all individuals; longer duration of any breastfeeding was particularly associated with lower BMI and lower Systolic Blood Pressure in those with higher BW-PGS. Optimal breastfeeding offers the greatest benefit to reduce adult obesity and hypertension in those genetically predisposed to high birthweight. This provides an example of how precision medicine in early life can improve adult health.

Participation in sport in childhood and adolescence: Implications for adult fitness

OBJECTIVES

To investigate whether participation in sport during the developmental stages of life is associated with cardiorespiratory fitness (CRF) in adulthood.

DESIGN

Observational longitudinal study.

METHODS

Participants were Generation 2 of the Raine Study. Questionnaires related to participation in sport were administered at ages 5, 8, 10, 14 and 17 years. These data were used to develop sex-specific trajectories of sports participation: (for males) Consistent Participators, Drop-Outs and Joiners; and (females) Consistent Participators, Non-Participators and Drop-Outs. At age 28.3 ± 0.6 years, participants completed a graded maximal exercise test (i.e. V̇O₂peak test). A General Linear Model assessed differences in CRF between trajectories.

RESULTS

402 participants n = 231 (57.5%) male, n = 171 (42.5%) female were included in the study. In males, Consistent Participators (all p < 0.001) and Joiners (p < 0.050) had greater fitness than Drop-Outs. In females, Consistent Participators had greater fitness than Non-Participators (p < 0.050), but there were no significant differences in fitness between Consistent Participators and Drop-Outs (p > 0.050) or Non-Participators and Drop-Outs (p > 0.050).

CONCLUSION

Participation in sport during childhood and adolescence is associated with greater fitness in adulthood, compared to individuals who never participate or those that cease participation in adolescence. A simple dichotomous question regarding sports participation over the childhood and adolescent period can be implemented to predict better fitness outcomes in young adulthood. Childhood and adolescence could be an opportune stage in life for parents, schools and governments to facilitate participation in sport and prevent drop out, as it may have an impact on long term risk reduction, with associated health and economic benefits.

Energy drink intake and metabolic syndrome: A prospective investigation in young adults

BACKGROUND AND AIMS

There are concerns that energy drinks (EDs) are contributing to upward trends in overweight, obesity, and cardiometabolic conditions in young people. We investigated cross-sectional and prospective associations between frequency of ED-intake in young-adults and (i) body mass index (BMI) and (ii) Metabolic Syndrome (MetS) and its components.

METHODS AND RESULTS

Participants from the Raine Study at 20-years (n = 1236) and 22 years (n = 1117) self-reported ED-intake, dietary intake, and physical activity, and had blood and anthropometric measures taken. Regression modelling examined associations between ED-intake and BMI, MetS and its components. There was a positive, but not significant, cross-sectional association with BMI and likelihood of MetS with frequent ED use at 20-years (BMI: β = 0.19; MetS: OR = 1.11) and 22-years (BMI: β = 0.51; MetS: OR = 1.28). There were no associations in the prospective analysis. After adjustment, significant associations existed between occasional ED-intake and lower HDL-cholesterol (β = -0.07) and higher fasting triglycerides (β = 0.16) at 20-years, and lower fasting triglycerides at 22-years (β = -0.10), but no significant associations in the prospective analyses.

CONCLUSION

No significant associations existed between frequency of ED-intake, and BMI, MetS or its individual components over two years (ages 20-22 years). Future studies should include volume of EDs consumed and longer follow-up.

Antihypertensive medication use and blood pressure control among treated older adults

The association of different antihypertensive regimens with blood pressure (BP) control is not well-described among community-dwelling older adults with low comorbidity. We examined antihypertensive use and BP control in 10 062 treated hypertensives from Australia and the United States (US) using baseline data from the ASPirin in Reducing Events in the Elderly (ASPREE) trial. Renin-angiotensin system (RAS) drugs were the most prevalently used antihypertensive in both countries (Australia: 81.7% of all regimens; US: 62.9% of all regimens; P < .001). Diuretics were the next most commonly used antihypertensive in both countries, but were more often included in regimens of US participants (48.9%, vs 33.3% of regimens in Australia; P < .001). Among all antihypertensive classes and possible combinations, monotherapy with a RAS drug was the most common regimen in both countries, but with higher prevalence in Australian than US participants (35.9% vs 20.9%; P < .001). For both monotherapy and combination users, BP control rates across age, ethnicity, and sex were consistently lower in Australian than US participants. After adjustment for age, sex, ethnicity, and BMI, significantly lower BP control rates remained in Australian compared to US participants for the most commonly used classes and regimens (RAS blocker monotherapy: BP control = 45.5% vs 54.2%; P = .002; diuretic monotherapy: BP control = 45.2% vs 64.5%; P = .001; and RAS blocker/diuretic combo: BP control = 50.2% vs 65.6%; P = .001). Our findings highlight variation in antihypertensive use in older adults treated for hypertension, with implications for BP control. Differences in BP control that were observed may be influenced, in part, by reasons other than choice of specific regimens.

The effects of alcohol on plasma lipid mediators of inflammation resolution in patients with Type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus is characterized by peripheral insulin resistance and low-grade systemic inflammation. Inflammation resolution is recognised as an important process driven by specialised pro-resolving mediators of inflammation (SPMs) and has the potential to moderate chronic inflammation. Alcohol has the potential to affect synthesis of SPMs by altering key enzymes involved in SPM synthesis and may influence ongoing inflammation associated with Type 2 diabetes mellitus.

AIMS

(i) To examine the effects of alcohol consumed as red wine on plasma SPM in men and women with Type 2 diabetes in a randomised controlled trial and (ii) compare baseline plasma SPM levels in the same patients with those of healthy volunteers.

METHODS

Twenty-four patients with Type 2 diabetes mellitus were randomized to a three-period crossover study with men drinking red wine 300 ml/day (∼31 g alcohol/day) and women drinking red wine 230 ml/day (∼24 g alcohol/day), or equivalent volumes of dealcoholized red wine (DRW) or water, each for 4 weeks. The SPM 18-hydroxyeicosapentaenoic acid (18-HEPE), E-series resolvins (Rv) (RvE1-RvE3), 17-hydroxydocosahexaenoic acid (17-HDHA), and D-series resolvins (RvD1, 17R-RvD1, RvD2, RvD5), 14-hydroxydocosahexaenoic acid (14-HDHA) and Maresin 1 were measured at the end of each period. A baseline comparison of plasma SPM, hs CRP, lipids and glucose was made with healthy volunteers.

RESULTS

Red wine did not differentially affect any of the SPM measured when compared with DRW or water. Baseline levels of the hs-CRP and the SPM 18-HEPE, 17-HDHA, RvD1 and 17R-RvD1 in patients with Type 2 diabetes mellitus were all significantly elevated compared with healthy controls and remained so after adjusting for age and gender.

CONCLUSION

Moderate alcohol consumption as red wine does not alter plasma SPM in patients with Type 2 diabetes mellitus. The elevation of SPM levels compared with healthy volunteers may be a homeostatic response to counter ongoing inflammation.

Dietary intake in population-based adolescents: support for a relationship between eating disorder symptoms, low fatty acid intake and depressive symptoms

BACKGROUND

Relatively little is known about the dietary intake and nutritional status of community-based individuals with eating disorders. This research aimed to: (i) describe the dietary intake of population-based adolescents with an eating disorder and (ii) examine associations between eating disorder symptoms, fatty acid intake and depressive symptoms in adolescents with and without an eating disorder.

METHODS

Data were drawn from the Western Australian Pregnancy Cohort (Raine) Study, a population-based cohort study that has followed participants from birth to young adulthood. This research utilised self-report data from the 17-year Raine Study assessment. Participants comprised 429 female adolescents who completed comprehensive questionnaire measures on dietary intake, eating disorder symptoms and depressive symptoms.

RESULTS

Adolescents with an eating disorder (n = 66) reported a significantly lower intake of total fat, saturated fat, omega-6 fatty acid, starch, vitamin A and vitamin E compared to adolescents without an eating disorder (n = 363). Adolescents with an eating disorder and pronounced depressive symptoms (n = 23) also reported a significantly lower intake of polyunsaturated fat and omega-3 and omega-6 fatty acid than adolescents with an eating disorder but no marked depression (n = 43). In the eating disorder sample but not the control sample, omega-3 and omega-6 fatty acid correlated significantly and negatively with eating disorder symptoms and with depressive symptoms.

CONCLUSIONS

Support is provided for a relationship between low omega-3 and omega-6 fatty acid intake and depressive symptoms in adolescents with eating disorders. Research is needed to examine the feasibility and effectiveness of fatty acid supplementation in this high-risk group.

OS049. Exome sequencing identifies likely functional variantsinfluencing preeclampsia and CVD risk

INTRODUCTION

Next-generation sequencing (NGS) in family-based study designs will be pivotal in unlocking the missing heritability of common complex diseases. Whilst our prior linkage- and association-based positional cloning studies in family- and population-based Australian cohorts, respectively, have discovered novel preeclampsia candidate genes (INHBB,ACVR2A,LCT,LRP1B,RND3,GCA,ERAP2,TNFSF13B), the full complement of causal genetic variation remains largely unknown. We have now sequenced the exomes of two Australian preeclampsia families in another step forward to unlocking preeclampsia's complex allelic architecture.

OBJECTIVES

Identify family-specific exon-centric loci segregating in preeclamptic women only.

METHODS

The exomes of 18 women (7 preeclamptics,11 controls) from two Australian families contributing to our chromosome 5q (Family 1) and 13q (Family 2) susceptibility loci, respectively, were sequenced using Illumina's TruSeq Exome Enrichment assay and NGS technology. Sequence alignments, quality control assessment and variant calling were conducted on our 8000 parallel processor compute server, MEDUSA. As a first pass, we prioritized exome sequence data to non-synonymous variants within the 1-LOD drop intervals of our 5q and 13q loci. Prioritized exonic variants were also genotyped in the Western Australian Pregnancy (Raine) Cohort to assess their significance against a plethora of cardiovascular disease (CVD) related traits.

RESULTS

In Family 1 we identified two missense SNPs and in Family 2 we identified one missense SNP to segregate in the preeclamptic women but not in the unaffected women. The first SNP in Family 1 (rs62375061) resides within the LYSMD3 gene, is predicted to "possibly" damage the focal protein and the only public record of this SNP is within the Watson genome. The second SNP in Family 1 (rs111033530) resides within the GPR98 gene, is predicted to "probably" damage the focal protein and is rare (1.7% population prevalence). The SNP in Family 2 (rs1805388) resides within the LIG4 gene, is predicted to be highly deleterious (F-SNP FSS=0.849) and is common (⩾17% population prevalence). In the Raine cohort the LIG4 SNP was also significantly associated with weight (p=0.0085), total cholesterol (p=0.0007), HDL cholesterol (p=0.0067) and LDL cholesterol (p=0.0324).

CONCLUSION

Our preliminary exome data documents the substantial potential to rapidly identify likely functional variants that influence preeclampsia risk. The GPR98 finding is of major interest to us as a recent genome-wide association study reported a significant association with diastolic blood pressure for a SNP at this same gene locus. Furthermore, our findings implicate LIG4 as a novel candidate susceptibility gene for CVD and add weight to the hypothesis of shared genetic risk factors for preeclampsia and CVD.

The associations between physical activity, screen time and weight from 6 to 14 yrs: the Raine Study

To examine the strength and direction of the relationship between physical activity level, screen use and BMI in a cohort at ages 6, 8, 10 and 14 yrs as part of a prospective longitudinal cohort study. The sample comprised 1403 males and females who participated in the follow-up survey at 14 yrs of age between 2003 and 2005. Exploratory structural equation modelling was used to examine the interrelationships between physical activity level, BMI and screen time at 6, 8, 10 and 14 yrs. Predictors of BMI at 6, 8, 10 and 14 yrs explained 1.3, 76.1, 80.1 and 73.1 percent of the variances, respectively, with previous BMI the largest predictor [χ(2)=43.082, df=36, p=194]. Increased screen time predicted higher BMI and lower physical activity at 8 and 10 yrs but not 14 yrs. At 14 yrs, physical activity predicted BMI. Sedentary patterns of behaviour in early childhood were predictive of later and concurrent obesity, whereas physical activity was predictive of obesity in adolescence. Different intervention targets are required for children and adolescents.

Longitudinal modelling of body mass index from birth to 14 years

BACKGROUND

To examine the tracking of BMI from birth to age 14 years.

PARTICIPANTS AND METHODS

Linear mixed model (LMM) analysis was used to model the trajectories of BMI (n = 1,403). Adiposity rebound was investigated for a subset of individuals (n = 173).

RESULTS

Adolescents who were overweight or obese at 14 years followed a different BMI trajectory from birth compared to those of normal weight. There was a difference between weight status groups for the timing of adiposity rebound (p < 0.001) and BMI at nadir (p < 0.001). The LMM depicted a significant difference in rate of change of BMI over time for males and females (p < 0.001), with female BMI increasing at a faster rate, and for weight status groups (p < 0.005), with the obese cohort having the faster increase in BMI over time. BMI at birth was significantly lower for the normal weight cohort compared to the overweight (p = 0.029) and obese (p = 0.019) cohorts.

CONCLUSION

This study introduces a powerful analytic tool, LMM, to model BMI and shows that weight status at 14 years is the result of a distinct path in earlier years. Compared to their normal weight peers, overweight and obese adolescents experience an earlier adiposity rebound, with a higher BMI at rebound.

Childhood obesity, hypertension, the metabolic syndrome and adult cardiovascular disease

1. The worldwide epidemic of obesity in adults has been mirrored in children in developed and developing countries. 2. Central obesity appears to be driving a cluster of abnormalities often referred to as the metabolic syndrome. 3. The definition of the metabolic syndrome in children is not suited to arbitrary cut-offs and a definition using the significant clustering of risk factors that is already evident in childhood and adolescent populations may be preferable. 4. An Australian population study showed that 25% of 8-year-olds and 29% of 14-year-olds could be described by the high risk cluster with features similar to adult metabolic syndrome. 5. The high risk cluster was significantly linked to high and low birthweight, shorter duration of breast-feeding, larger postnatal weight gains after 12 months of age and raised C-reactive protein, gamma glutamyl transferase and alanine transaminase levels. At-risk young adults have also been shown to have macroscopic atherosclerosis in post-mortem studies. 6. Identification of at-risk children has obvious benefits for the individual and as well, for prevention of a future cohort with raised cardiovascular morbidity and mortality; however, complexities and controversies exist in doing so. Familial, genetic and lifestyle risk factors aggregate and labelling children with predisease may be problematic. Committed political and societal changes are necessary to reduce childhood obesity and subsequent adult cardiovascular disease.

Rationale for a trial of low-dose aspirin for the primary prevention of major adverse cardiovascular events and vascular dementia in the elderly: Aspirin in Reducing Events in the Elderly (ASPREE)

Low-dose aspirin (acetylsalicylic acid) therapy has been shown to reduce the risk of vascular events and there is increasing evidence of its potential to reduce the rate of cognitive decline in the elderly. Adverse effects including gastrointestinal and intracranial haemorrhage may offset these benefits. The balance of risks versus benefits of aspirin for the primary prevention of cardiovascular disease and vascular dementia has not been established in the elderly. There is clearly a need to conduct a study in family practice to investigate whether routine use of low-dose aspirin for the primary prevention of cardiovascular disease and vascular dementia in the elderly is beneficial or harmful. Aspirin in reducing events in the elderly (ASPREE) is a placebo-controlled trial of low-dose aspirin for the primary prevention of major adverse cardiovascular events and vascular dementia. It will follow 15,000 subjects aged 70 years or more for an average of 5 years. This sample size has a power of 87% to detect a 15% reduction in primary events in the aspirin group, with an anticipated combined primary event rate of 20 per 1000 patient years.

Angiotensin-converting enzyme activity and the ACE Alu polymorphism in autosomal dominant polycystic kidney disease

BACKGROUND

Previous studies concerning Alu I/D polymorphism in the ACE gene and ADPKD severity have used the Alu genotypes as a representative of the true biological variable, namely ACE activity. However, wide individual and ethnic differences in the proportion of variance in ACE activity explained by the I/D genotype may have confounded these studies. This investigation examines the association between ADPKD severity and ACE in terms of plasma enzyme activity and I/D genotypes in individuals from three different countries.

METHODS

Blood samples were collected from 307 ADPKD patients (116 Australian, 124 Bulgarian and 67 Polish) for determination of ACE activity levels and I/D genotypes. Chronic renal failure (CRF) was present in 117 patients and end-stage renal failure (ESRF) in 68 patients.

RESULTS

ACE activity was related to the I/D genotype, showing a dosage effect of the D allele (P=0.006). The proportion of variance due to the Alu polymorphism was 14%. No difference in ACE activity and I/D genotype distribution was found between patients with CRF versus normal renal function (P=0.494; P=0.576) or between those with ESRF versus those without ESRF (P=0.872; P=0.825). No effect of the I/D genotype on age at development and progression to renal failure (CRF; ESRF) was detected in the overall group, and in subgroups based on ethnic origin, linkage status and sex.

CONCLUSION

ACE is not likely to play a role as a determinant of ADPKD phenotype severity.

Study of plasma factors associated with neutrophil activation and lipid peroxidation in preeclampsia

Neutrophil activation occurs in women with preeclampsia and is resolved after delivery. The present study examined whether circulating factors in plasma of women with preeclampsia caused neutrophil activation and lipid peroxidation. Twenty-one women with proteinuric preeclampsia were matched for age and gestational age with 19 normal pregnant women. Plasma was collected from all subjects before delivery and at 6 weeks postpartum and incubated with autologous white-cell buffy coat collected at the postpartum visit. Neutrophil activation was assessed by level of CD11b and CD18 expression after incubation with autologous antepartum or postpartum plasma. Lipid peroxidation was assessed by measurement of F(2)-isoprostanes in plasma, plasma-white cell incubates, and urine. Neutrophil CD11b and CD18 expression was not differentially altered by incubation with plasma from either women with preeclampsia or normal pregnant women and was similar between groups when incubation was performed with plasma collected after delivery. In preeclampsia, plasma F(2)-isoprostanes were significantly increased before and after delivery compared with controls. Plasma F(2)-isoprostanes were increased 2-fold after incubation of plasma with buffy coat, but preeclamptic women had higher levels compared with those of controls when either pregnant or postpartum plasma was used. In pregnant preeclamptics, plasma F(2)-isoprostanes were positively correlated with lymphocyte count. Six weeks after delivery, plasma F(2)-isoprostanes in the preeclamptic women were significantly positively associated with lymphocyte count and cholesterol and negatively associated with albumin. In conclusion, the present study does not suggest that a stable circulating factor causes neutrophil activation in preeclampsia. However, lipid peroxidation is elevated before and after delivery in women with preeclampsia, which suggests that these women may have an underlying predisposition to increased oxidative stress that may be driven by or contribute to a persistent low-grade inflammatory response.

Advanced glycation end-products: a review

Advanced glycation end-products are a complex and heterogeneous group of compounds that have been implicated in diabetes related complications. At present it is not known if they are the cause or the consequence of the complications observed. We discuss the chemistry of advanced glycated end-product formation and their patho-biochemistry particularly in relation to the diabetic microvascular complications of retinopathy, neuropathy and nephropathy as well as their role in the accelerated vasculopathy observed in diabetes. The concept of carbonyl stress as a cause for advanced glycated end-product toxicity is mentioned. We discuss alterations in the concentrations of advanced glycated end-products in the body, particularly in relation to changes occurring with age, diabetes and its complications such as nephropathy. Problems relating to current methods of advanced glycated end-product detection and measurement are highlighted including the lack of a universally established method of detection or unit of measurement. Agents used for the treatment of advanced glycated end-product accumulation are reviewed, with an emphasis on the results of the recent phase III trials using aminoguanidine and diabetes related complications.

Task force IV: Clinical use of ambulatory blood pressure monitoring. Participants of the 1999 Consensus Conference on Ambulatory Blood Pressure Monitoring

OBJECTIVE

To reach a consensus on the clinical use of ambulatory blood pressure monitoring (ABPM).

METHODS

A task force on the clinical use of ABPM wrote this overview in preparation for the Seventh International Consensus Conference (23-25 September 1999, Leuven, Belgium). This article was amended to account for opinions aired at the conference and to reflect the common ground reached in the discussions.

POINTS OF CONSENSUS

The Riva Rocci/Korotkoff technique, although it is prone to error, is easy and cheap to perform and remains worldwide the standard procedure for measuring blood pressure. ABPM should be performed only with properly validated devices as an accessory to conventional measurement of blood pressure. Ambulatory recording of blood pressure requires considerable investment in equipment and training and its use for screening purposes cannot be recommended. ABPM is most useful for identifying patients with white-coat hypertension (WCH), also known as isolated clinic hypertension, which is arbitrarily defined as a clinic blood pressure of more than 140 mmHg systolic or 90 mmHg diastolic in a patient with daytime ambulatory blood pressure below 135 mmHg systolic and 85 mmHg diastolic. Some experts consider a daytime blood pressure below 130 mmHg systolic and 80 mmHg diastolic optimal. Whether WCH predisposes subjects to sustained hypertension remains debated. However, outcome is better correlated to the ambulatory blood pressure than it is to the conventional blood pressure. Antihypertensive drugs lower the clinic blood pressure in patients with WCH but not the ambulatory blood pressure, and also do not improve prognosis. Nevertheless, WCH should not be left unattended. If no previous cardiovascular complications are present, treatment could be limited to follow-up and hygienic measures, which should also account for risk factors other than hypertension. ABPM is superior to conventional measurement of blood pressure not only for selecting patients for antihypertensive drug treatment but also for assessing the effects both of non-pharmacological and of pharmacological therapy. The ambulatory blood pressure should be reduced by treatment to below the thresholds applied for diagnosing sustained hypertension. ABPM makes the diagnosis and treatment of nocturnal hypertension possible and is especially indicated for patients with borderline hypertension, the elderly, pregnant women, patients with treatment-resistant hypertension and patients with symptoms suggestive of hypotension. In centres with sufficient financial resources, ABPM could become part of the routine assessment of patients with clinic hypertension. For patients with WCH, it should be repeated at annual or 6-monthly intervals. Variation of blood pressure throughout the day can be monitored only by ABPM, but several advantages of the latter technique can also be obtained by self-measurement of blood pressure, a less expensive method that is probably better suited to primary practice and use in developing countries.

CONCLUSIONS

ABPM or equivalent methods for tracing the white-coat effect should become part of the routine diagnostic and therapeutic procedures applied to treated and untreated patients with elevated clinic blood pressures. Results of long-term outcome trials should better establish the advantage of further integrating ABPM as an accessory to conventional sphygmomanometry into the routine care of hypertensive patients and should provide more definite information on the long-term cost-effectiveness. Because such trials are not likely to be funded by the pharmaceutical industry, governments and health insurance companies should take responsibility in this regard.

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.

Strategies for prevention of adult hypertension and cardiovascular risk behaviour in childhood. An Australian perspective

This paper addresses approaches to evaluating the importance of different childhood behaviours on subsequent risk of high blood pressure and related cardiovascular risk factors and outlines results of a randomised controlled trial of nutrition and exercise interventions in schoolchildren. Clustering of cardiovascular risk factors was studied in relation to diet, blood pressure, fitness, fatness and blood cholesterol in a representative sample of 555 Perth schoolchildren aged 15 years. Twenty-one percent of males and females had high risk profiles associated with dietary excesses, particularly in fat, cholesterol and sodium intake, and deficiencies of minerals, vitamins and dietary fibre. Socio-economic status was inversely associated with cardiovascular risk and undernutrition in girls. Thus 21% of the school children shared unhealthy lifestyles putting them at substantial risk of subsequent cardiovascular disease. A randomised controlled trial designed to reduce cardiovascular risk was conducted in 1147 children 10-12 years old, assigned to one of six groups for a year. The groups were fitness, fitness and school nutrition, school nutrition, school and home nutrition, home nutrition or controls. On cluster analysis 30% of the children were at higher risk at baseline in terms of blood pressure, blood cholesterol levels, fitness and body fat. With the fitness programmes fitness increased in both high and low risk girls but only in high risk cluster boys. Systolic pressure fell more in the high risk boys in the fitness group than in low risk boys, while diastolic pressure fell in girls regardless of initial risk. Triceps skinfold thickness fell more in higher than lower risk girls in the school and home nutrition group, and more in high risk boys in the home nutrition group. Higher risk girls showed a greater reduction in fat intake and increase in dietary fibre with home nutrition programmes. We concluded that higher risk children do show greater responses to lifestyle intervention programmes in general, with the greatest effects seen with home nutrition or fitness programmes. The results indicate the need for different approaches to prevention of hypertension and cardiovascular risk in higher and lower risk children and for boys and girls.