Health benefits of the Mediterranean Diet: an update of research over the last 5 years

The Mediterranean Diet (MedDiet) has been reported to be protective against the occurrence of several diseases. Increasing evidence suggests that the MedDiet could counter diseases associated with chronic inflammation, including metabolic syndrome, atherosclerosis, cancer, diabetes, obesity, pulmonary diseases, and cognition disorders. Adoption of a MedDiet was associated with beneficial effects on the secretion of anti-inflammatory cytokines, antioxidant cellular and circulating biomarkers as well as with regulation of gene polymorphisms involved in the atherosclerotic process. The MedDiet has been considered for the prevention of cardiovascular and other chronic degenerative diseases focusing on the impact of a holistic dietary approach rather than on single nutrients. Epidemiological dietary scores measuring adherence to a MedDiet have been developed. This narrative review considers the results of up-to-date clinical studies (with a focus on the last 5 years) that evaluated the effectiveness of the MedDiet in reducing the prevalence of chronic and degenerative diseases.

Impact of Intima-Media Thickness Progression in the Common Carotid Arteries on the Risk of Incident Cardiovascular Disease in the Suita Study

Background

No prospective study of the relationship between intima–media thickness (IMT) progression and incident cardiovascular disease (CVD) has been performed.

Methods and Results

We studied 4724 participants (mean age: 59.7±11.9 years; without CVD at the baseline) who had carotid ultrasonographic measurement of IMT on both sides of the entire carotid artery area (ie, the entire scanned common carotid artery [CCA], carotid artery bulb, internal carotid artery, and external carotid artery areas for both sides) between April 1994 and August 2001. Carotid ultrasonographic follow‐up was performed every 2 years between April 1994 and March 2005 in 2722 of these participants, newly revealing 193 CCA plaques (maximum IMT in the CCA >1.1 mm). We followed up for incident CVD until December 2013. Statistical analyses were performed using a Cox proportional hazards regression model, evaluated using C statistics, and net reclassification improvement. During the 59 909 person‐years of follow‐up, we observed 221 strokes and 154 coronary heart disease events. CCA plaque and maximum IMT in the whole carotid artery area >1.7 mm were risk factors for CVD. CCA plaque presented an increased risk of CVD based on C statistics and the reclassification improvement of the current risk prediction model. After adding the new incident CCA plaques, during the 23 702 person‐years of follow‐up, 69 strokes and 43 coronary heart disease events occurred. The adjusted hazard ratios for incident CCA plaque were 1.95 (95% confidence interval, 1.14–3.30) in CVD and 2.01 (95% confidence interval, 1.01–3.99) in stroke.

Conclusions

Maximum IMT in the CCA contributed significantly but modestly to the predictive power of incident CVD used in calculating traditional risk factors. This study provides the first demonstration that new progression of incident CCA plaque is a CVD risk.

Evaluation of Metformin on Cognitive Improvement in Patients With Non-dementia Vascular Cognitive Impairment and Abnormal Glucose Metabolism

Objective: Recent studies have suggested that metformin can penetrate the blood–brain barrier, protecting neurons via anti-inflammatory action and improvement of brain energy metabolism. In this study, we aim to investigate the effect of metformin on cognitive function in patients with abnormal glucose metabolism and non-dementia vascular cognitive impairment (NDVCI).

Methods: One hundred patients with NDVCI and abnormal glucose metabolism were randomly allocated into two groups: metformin and donepezil (n = 50) or acarbose and donepezil (n = 50). The neuropsychological status, glucose metabolism, and common carotid arteries intima–media thickness (CCA-IMT) before and after a year of treatment, were measured and compared between the groups.

Results: Ninety four patients completed all the assessment and follow-up. After a year of treatment, there was a decrease in Alzheimer’s disease Assessment Scale-Cognitive Subscale scores and the duration of the Trail Making Test in the metformin-donepezil group. Furthermore, these patients showed a significant increase in World Health Organization–University of California–Los Angeles Auditory Verbal Learning Test scores after treatment (all P < 0.05). However, there was no obvious improvement in cognitive function in the acarbose-donepezil group. We also observed a significant decrease in the level of fasting insulin and insulin resistance (IR) index in the metformin-donepezil group, with a lower CCA-IMT value than that in the acarbose-donepezil group after a year of treatment (P < 0.05).

Conclusion: We conclude that metformin can improve cognitive function in patients with NDVCI and abnormal glucose metabolism, especially in terms of performance function. Improved cognitive function may be related to improvement of IR and the attenuated progression of IMT.

Trial Registration:ChiCTR-IPR-17011855.

Multiethnic Exome-Wide Association Study of Subclinical Atherosclerosis

BACKGROUND

The burden of subclinical atherosclerosis in asymptomatic individuals is heritable and associated with elevated risk of developing clinical coronary heart disease. We sought to identify genetic variants in protein-coding regions associated with subclinical atherosclerosis and the risk of subsequent coronary heart disease.

METHODS AND RESULTS

We studied a total of 25 109 European ancestry and African ancestry participants with coronary artery calcification (CAC) measured by cardiac computed tomography and 52 869 participants with common carotid intima-media thickness measured by ultrasonography within the CHARGE Consortium (Cohorts for Heart and Aging Research in Genomic Epidemiology). Participants were genotyped for 247 870 DNA sequence variants (231 539 in exons) across the genome. A meta-analysis of exome-wide association studies was performed across cohorts for CAC and carotid intima-media thickness. APOB p.Arg3527Gln was associated with 4-fold excess CAC (P=3×10^-10). The APOE ε2 allele (p.Arg176Cys) was associated with both 22.3% reduced CAC (P=1×10^-12) and 1.4% reduced carotid intima-media thickness (P=4×10^-14) in carriers compared with noncarriers. In secondary analyses conditioning on low-density lipoprotein cholesterol concentration, the ε2 protective association with CAC, although attenuated, remained strongly significant. Additionally, the presence of ε2 was associated with reduced risk for coronary heart disease (odds ratio 0.77; P=1×10^-11).

CONCLUSIONS

Exome-wide association meta-analysis demonstrates that protein-coding variants in APOB and APOE associate with subclinical atherosclerosis. APOE ε2 represents the first significant association for multiple subclinical atherosclerosis traits across multiple ethnicities, as well as clinical coronary heart disease.

Obese adolescents with polycystic ovarian syndrome have elevated cardiovascular disease risk markers

Women with polycystic ovarian syndrome (PCOS) have evidence of subclinical cardiovascular disease (CVD). However, insulin resistance, an important factor in the development of CVD in adults, is common in adolescents with PCOS, yet data in adolescents are limited. Therefore, we sought to measure insulin resistance and CVD markers in obese youth with and without PCOS. Thirty-six PCOS and 17 non-PCOS adolescent girls who were obese, sedentary, and non-hypertensive were recruited from clinics located within the Children's Hospital Colorado. Following 3 days of controlled diet and restricted exercise, fasting plasma samples were obtained prior to a hyperinsulinemic euglycemic clamp. PCOS girls were more insulin resistant than controls (glucose infusion rate 5.24±1.86 mg/kg/min vs 9.10±2.69; p<0.001). Girls with PCOS had blood pressure in the normal range, but had greater carotid intima-media thickness (cIMT) (0.49±0.07 mm vs 0.44±0.06; p=0.038), beta stiffness index (5.1±1.3 U vs 4.4±0.9; p=0.037), and reduced arterial compliance (1.95±0.47 mm²/mmHg × 10^-1 vs 2.13±0.43; p=0.047). PCOS girls had a normal mean lipid profile, yet had a more atherogenic lipoprotein cholesterol distribution and had persistent elevations of free fatty acids despite hyperinsulinemia (68±28 μmol/mL vs 41±10; p=0.001), both potential contributors to CVD. Free fatty acid concentrations correlated best with all CVD markers. In summary, adolescent girls with PCOS have greater cIMT and stiffer arteries than girls without PCOS, perhaps related to altered lipid metabolism, even when clinical measures of blood pressure and cholesterol profiles are 'normal'. Therefore, management of adolescent PCOS should include assessment of CVD risk factor development.

Carotid Atherosclerosis and Cerebral Microbleeds: The Framingham Heart Study

BACKGROUND

Carotid atherosclerosis is associated with subclinical ischemic cerebrovascular disease, but its role in hemorrhage-prone small vessel disease-represented by cerebral microbleed (CMB)-is unclear, although vascular risk factors underlie both conditions. We hypothesized that persons with carotid atherosclerosis would have higher risk of CMB, particularly in deep regions.

METHODS AND RESULTS

We studied 1243 participants in the Framingham Offspring Study (aged 56.9±8.8 years; 53% women) with carotid ultrasound available on 2 occasions (1995-1998 and 2005-2008) prior to brain magnetic resonance imaging. Using multivariable logistic regression, we related baseline carotid stenosis, baseline intima-media thickness, and site-specific carotid intima-media thickness progression (at internal and common carotid locations) to the prevalence and location (lobar or deep plus mixed) of CMB. In addition, we assessed effect modification by lipid levels and use of statin and antithrombotic medications. Carotid stenosis ≥25% (a marker of cerebrovascular atherosclerosis) was associated with presence of CMB overall (Odds Ratio 2.20, 95% CI 1.10-4.40) and at deep and mixed locations (odds ratio 3.60, 95% CI 1.23-10.5). Baseline carotid intima-media thickness was not associated with CMB. Progression of common carotid artery intima-media thickness among persons on hypertension treatment was associated with lower risk of deep and mixed CMB (odds ratio per SD 0.41, 95% CI 0.18-0.96).

CONCLUSIONS

Cumulative vascular risk factor exposure may increase the risk of CMB, especially in deep regions. The apparent paradoxical association of carotid intima-media thickness progression with lower risk of CMB may reflect benefits of intensive vascular risk factor treatment among persons with higher cardiovascular risk and deserves further investigation. If replicated, the results may have potential implications for assessment of preventive and therapeutic interventions for subclinical cerebral hemorrhage.

The Circulating GRP78/BiP Is a Marker of Metabolic Diseases and Atherosclerosis: Bringing Endoplasmic Reticulum Stress into the Clinical Scenario

BACKGROUND

Glucose-regulated protein 78/Binding immunoglobulin protein (GRP78/BiP) is a protein associated with endoplasmic reticulum stress and is upregulated by metabolic alterations at the tissue-level, such as hypoxia or glucose deprivation, and it is hyper-expressed in fat tissue of obese individuals.

OBJECTIVE

To investigate the role of the GRP78/BiP level as a metabolic and vascular disease biomarker in patients with type 2 diabetes (DM), obesity and metabolic syndrome (MS).

METHODS

Four hundred and five patients were recruited, of whom 52.5% were obese, 72.8% had DM, and 78.6% had MS. The intimae media thickness (cIMT) was assessed by ultrasonography. The plasma GRP78/BiP concentration was determined, and its association with metabolic and vascular parameters was assessed. Circulating GRP78/BiP was also prospectively measured in 30 DM patients before and after fenofibrate/niacin treatment and 30 healthy controls.

RESULTS

In the cross-sectional study, the GRP78/BiP level was significantly higher in the patients with obesity, DM, and MS. Age-, gender- and BMI-adjusted GRP78/BiP was directly associated with LDL-cholesterol, non-HDL-cholesterol, triglycerides, apoB, and cIMT. GRP78/BiP was positively associated to carotid plaque presence in the adjusted model, irrespective of obesity, DM and MS. In the prospective study, nicotinic acid treatment produced a significant reduction in the GRP78/BiP levels that was not observed with fenofibrate.

CONCLUSIONS

GRP78/BiP plasma concentrations are increased in patients with both metabolic derangements and subclinical atherosclerosis. GRP78/BiP could be a useful marker of metabolic and cardiovascular risk.

Ultrasound Markers of Carotid Atherosclerosis and Cognition: The Northern Manhattan Study

BACKGROUND AND PURPOSE

Ultrasound markers of carotid atherosclerosis may be related to cognitive status. We hypothesized that individuals with greater carotid intima-media thickness (cIMT) and carotid plaque burden would exhibit worse cognition.

METHODS

One thousand one hundred sixty-six stroke-free participants from the NOMAS (Northern Manhattan Study) underwent carotid ultrasound and neuropsychological examination. Among them, 826 underwent a second neuropsychological examination an average of 5 years later. cIMT and plaque were assessed by a standardized B-mode ultrasound imaging and reading protocol. We used multivariable linear regression to examine cIMT, carotid plaque presence, and carotid plaque area as correlates of domain-specific neuropsychological Z scores cross-sectionally and over time. We also investigated possible effect modification by APOE ε4 allele, age, and race/ethnicity.

RESULTS

Participants had a mean (SD) age of 70 (9) years and were 60% women, 66% Hispanic, 15% white, and 18% black. Those with greater cIMT exhibited worse episodic memory after adjustment for demographics and vascular risk factors (β=-0.60; P=0.04). APOE ε4 carriers with greater cIMT exhibited worse episodic memory (β=-1.31; P=0.04), semantic memory (β=-1.45; P=0.01), and processing speed (β=-1.21; P=0.03). Participants with greater cIMT at baseline did not exhibit significantly greater cognitive decline after adjustment. APOE ε4noncarriers with greater cIMT exhibited greater declines in executive function (β=-0.98; P=0.06). Carotid plaque burden was not significantly associated with cognition at baseline or over time.

CONCLUSIONS

Subclinical carotid atherosclerosis was associated with worse cognition among those at higher risk for Alzheimer disease. Interventions targeting early stages of atherosclerosis may modify cognitive aging.

Carotid Artery Plaques, Carotid Intima-Media Thickness, and Risk of Cardiovascular Events and All-Cause Death in Older Adults: A 5-Year Prospective, Community-Based Study

We assessed the effect of asymptomatic carotid atherosclerosis (CAS) on the development of cardiovascular diseases (CVDs) in a community-based population aged ≥55 years in China. A total of 1376 residents underwent CAS assessment by ultrasonography in July 2009. New CVD events, including stroke and coronary heart events, were collected at the follow-up survey at the end of 2014. After adjusting for baseline demographic characteristics and traditional CVD risk factors, the risk of CVD in patients with minimal CAS (mean common carotid artery intima-media thickness [CCA-IMT] ≥1 mm and no plaques), nonstenotic plaques (carotid stenosis <50%), and stenotic plaques (carotid stenosis ≥50%) was 0.8 (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.33-1.69), 2.0 (HR: 2.01, 95% CI: 1.24-3.25), and 3.1 (HR: 3.05, 95% CI: 1.62-5.74) times greater, respectively, than that of patients without CAS (CCA-IMT <1 mm and no plaques). Our findings provide direct evidence of the independent predictive value of the severity of asymptomatic CAS for the development of CVD in older Chinese adults.

Immune-Mediated Inflammation Promotes Subclinical Atherosclerosis in Recent-Onset Psoriatic Arthritis Patients without Conventional Cardiovascular Risk Factors

Studies on the inflammatory burden in recent-onset psoriatic arthritis (PsA) patients without conventional cardiovascular risk factors (CVRFs) are not available. This preliminary study focuses on cardiovascular risk in cutaneous psoriasis (CPs) and recent-onset PsA patients. Blood biochemistry (glucose, cholesterol, uric acid, lipid profile and apolipoprotein B) was analyzed using standard kits. Proatherogenic inflammation markers, C-reactive protein (CRP) and interleukin-6 (IL-6), and endothelial activators monocyte chemoattractant protein-1 (MCP-1) and soluble intercellular adhesion molecule-1 (sICAM-1), were determined by enzyme-linked immunosorbent assay. Ultrasound images allowed measuring carotid intima-media thickness (cIMT). Our study first shows an increase in cIMT, and in serum levels of sICAM-1 and CRP in recent-onset PsA patients not presenting conventional CVRFs over the non-medicated time-period, from disease diagnosis to the beginning of pharmacological treatment, compared with healthy subjects. The outcome highlights the importance of monitoring serum level of sICAM1, CRP, and cIMT, and the value of primary prevention in psoriatic patients even with no history of cardiovascular events.

The Relationship Between Atherogenic Index and Carotid Artery Atherosclerosis in Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is a disease characterized by chronic inflammation. Atherogenic index of plasma (AIP) is a logarithmic value of the triglyceride to high-density lipoprotein cholesterol ratio and it is a good marker for atherosclerotic heart disease and cardiac risk. In this study, we investigated subclinical atherosclerosis and cardiac risks in patients with FMF. Patients with FMF (78 men and 84 women) and healthy controls (74 men and 82 women) were included in this study. The AIP values of the patients were calculated and carotid intima-media thicknesses (cIMTs) were measured. The cIMT ( P < .001) and AIP ( P < .001) values of patients with FMF were higher than the values of the control group. There was a positive correlation between cIMT and AIP values ( r = .304, P < .001). In regression analysis, we detected an independent relationship between cIMT and AIP (β = .248, P = .001). Atherogenic index of plasma may be highly correlated with the subclinical atherosclerosis. Particularly, male patients with FMF may have a high cardiac risk.

Ideal Cardiovascular Health and Subclinical Markers of Carotid Structure and Function: The Paris Prospective Study III

OBJECTIVE

We hypothesized that subclinical markers of vascular structure and function, which are independent predictors of cardiovascular disease, would be less frequent in subjects with ideal than poor cardiovascular health (CVH) as defined by the American Heart Association (AHA).

APPROACH AND RESULTS

Carotid parameters were measured using high-precision echotracking device in 9155 nonreferred participants attending a health checkup in a large health center in Paris (France) between 2008 and 2012. According to the AHA, participants with 0 to 2, 3 to 4, and 5 to 7 metrics (smoking, physical activity, body mass index, diet, blood glucose and total cholesterol, blood pressure) at the ideal level were categorized as having poor, intermediate, and ideal CVH. Carotid parameters were dichotomized according to their median value, and multivariable logistic regression analysis was performed. Mean age was 59.5 (SD 6.3) years; 39% were females, and ideal CVH was present in 10.11% of the study participants. After adjustment for age, sex, education, and living alone and compared with a poor CVH, an ideal CVH was associated with lower common carotid artery intima-media thickness (odds ratio=1.64; 95% confidence interval 1.40, 1.93), absence of carotid plaques (odds ratio=2.14; 95% confidence interval 1.60, 2.87), lower Young's elastic modulus (odds ratio=2.43; 95% confidence interval 2.07, 2.84), and higher carotid distensibility coefficient (odds ratio=2.90; 95% confidence interval 2.47, 3.41).

CONCLUSIONS

In community subjects aged 50 to 75 years, ideal CVH was associated with substantially less arterial stiffness and thickness. These associations might contribute to the lower risk of cardiovascular diseases in subjects with ideal CVH.

Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study

AIMS

According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima-media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk.

METHODS AND RESULTS

In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10-20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination.

CONCLUSIONS

Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.

Associations of antiretroviral drug use and HIV-specific risk factors with carotid intima-media thickness

BACKGROUND

Previous research has demonstrated an increase in carotid intima-media thickness (cIMT) in HIV-infected individuals compared to controls. However, the reason for this increased level of subclinical vascular disease is unknown.

OBJECTIVE

To identify HIV-related risk factors for increased cIMT.

METHODS

We evaluated the relationship between HIV-related characteristics (including markers of HIV disease severity and use of antiretroviral therapy) and cIMT measurements in the internal/bulb and common carotid regions among 538 HIV-infected participants from the Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM). We used Bayesian model averaging to estimate the posterior probability of candidate HIV and non-HIV-related risk factors being true predictors of increased cIMT. Variables with a posterior probability of more than 50% were used to develop a selected regression model for each of the anatomic regions.

RESULTS

For common cIMT, the Bayesian model selection process identified age, African-American race, and systolic and diastolic blood pressure with probability more than 95%, HDL cholesterol with probability 85% and Hispanic ethnicity with probability 51%. Among the HIV-related factors included in the analysis, only tenofovir use was selected (51% probability). In the selected model, duration of tenofovir use was associated with lower common cIMT (-0.0094 mm/year of use; 95% confidence interval: -0.0177 to -0.0010). For internal cIMT, no HIV-related risk factors were above the 50% posterior probability threshold.

CONCLUSION

We observed an inverse association between duration of tenofovir use and common carotid cIMT. Whether this association is causal or due to confounding by indication needs further investigation.

Non-compressible arterial disease and the risk of coronary calcification in type-2 diabetes

OBJECTIVE

Ankle-brachial index (ABI) screening is recommended for the detection of asymptomatic peripheral arterial disease (PAD) in at-risk populations, including diabetics. A low ABI identifies obstructive lower extremity vascular disease and predicts CVD events and increased mortality. A high ABI represents non-compressible arterial disease (NCAD), and is also associated with increased mortality and vascular events. Our objective is to investigate whether low and high ABI have distinct patterns of association with cardiovascular disease (CVD) risk factors and subclinical atherosclerosis in individuals with type-II diabetes mellitus.

METHODS

The Penn Diabetes Heart Study (PDHS) is a prospective observational cohort of diabetic individuals without clinically evident CVD. Multivariate logistic and Tobit linear regression were used to compare CVD risk factors and coronary artery (CAC) among 1863 subjects with PAD (ABI ≤ 0.9), NCAD (ABI ≥ 1.4 or non-compressible) or normal ABI (0.91-1.39).

RESULTS

Compared to those with normal ABI, PAD was associated with smoking, obesity, and lower HDL-c; while diabetes duration and reduced renal function were associated with NCAD. Both PAD and NCAD were independently associated with increased CAC compared to those with normal ABI, and these relationships were not attenuated in multiply adjusted models.

CONCLUSION

NCAD bears a distinct relationship to traditional CVD risk factors among diabetics, though like PAD is independently associated with increased CAC. These findings support the recognition of NCAD as a high-risk phenotype and provide additional relevance to ABI screening in diabetics.

Serum and Urinary Orosomucoid in Young Patients With Type 1 Diabetes: A Link Between Inflammation, Microvascular Complications, and Subclinical Atherosclerosis

Orosomucoid is an acute-phase serum protein that is upregulated in urine samples of patients with diabetic nephropathy. We assessed serum and urinary orosomucoid levels in children and adolescents with type 1 diabetes and their relation to microvascular complications and carotid intima-media thickness (CIMT). Sixty patients with type 1 diabetes were divided into 2 groups according to the presence of microvascular complications and compared with 60 healthy controls. High-sensitivity C-reactive protein (hs-CRP), hemoglobin A1c (HbA1c), urinary albumin-creatinine ratio (UACR), serum and urinary orosomucoid, and CIMT were assessed. Both serum and urinary orosomucoid levels were significantly increased in patients with and without microvascular complications compared with controls, and the highest levels were in patients with complications (P < .001). Serum and urinary orosomucoid were higher in patients with microalbuminuria than normoalbuminuric group (P < .001). The cutoff value of urinary orosomucoid at 2825 ng/mL could differentiate patients with and without microvascular complications. Serum and urinary orosomucoid were positively correlated. Multiple regression analysis showed that HbA1c, UACR, hs-CRP, and CIMT were independently related to orosomucoid. We suggest that orosomucoid is a significant independent factor for diabetic microvascular complications and can be considered as an early marker of renal injury. High orosomucoid levels in type 1 diabetes reflect endothelial dysfunction and subclinical atherosclerosis.

Total Bilirubin Levels Predict Subclinical Atherosclerosis in Patients With Prediabetes

Bilirubin may have important antiatherosclerotic effects. Prediabetes (PD), the intermediate stage before diabetes mellitus, is associated with increased cardiovascular morbidity and mortality. We evaluated the relationship between serum bilirubin levels and carotid intima-media thickness (cIMT), as a surrogate marker of subclinical atherosclerosis, in patients with PD. We enrolled 170 consecutive patients with PD. The patients underwent ultrasonography to evaluate cIMT. The patients were divided into groups according to cIMT values (<0.9 vs ≥0.9 mm). The patients with cIMT ≥ 0.9 mm had significantly higher diastolic blood pressure, neutrophil-lymphocyte ratio (NLR), and glycated hemoglobin values compared with patients having cIMT < 0.9 mm, whereas total and direct bilirubin values were significantly lower in this group. Multivariate regression analyses revealed NLR and total bilirubin as the independent predictors of subclinical atherosclerosis. The present study demonstrated that NLR and lower total bilirubin levels were independent predictors of subclinical atherosclerosis in patients with PD. Simple measures such as NRL and total bilirubin may provide predictive information regarding the risk of cardiovascular disease in patients with PD.

Admixture Mapping of Subclinical Atherosclerosis and Subsequent Clinical Events Among African Americans in 2 Large Cohort Studies

BACKGROUND

Local ancestry may contribute to the disproportionate burden of subclinical and clinical cardiovascular disease among admixed African Americans compared with other populations, suggesting a rationale for admixture mapping.

METHODS AND RESULTS

We estimated local European ancestry (LEA) using Local Ancestry inference in adMixed Populations using Linkage Disequilibrium method (LAMP-LD) and evaluated the association with common carotid artery intima-media thickness (cCIMT) using multivariable linear regression analysis among 1554 African Americans from MESA (Multi-Ethnic Study of Atherosclerosis). We conducted secondary analysis to examine the significant cCIMT-LEA associations with clinical cardiovascular disease events. We observed genome-wide significance in relation to cCIMT association with the SERGEF gene (secretion-regulating guanine nucleotide exchange factor; β=0.0137; P=2.98×10-4), also associated with higher odds of stroke (odds ratio=1.71; P=0.02). Several regions, in particular CADPS gene (Ca2+-dependent secretion activator 1) region identified in MESA, were also replicated in the ARIC cohort (Atherosclerosis Risk in Communities). We observed other cCIMT-LEA regions associated with other clinical events, most notably the regions harboring CKMT2 gene (creatine kinase, mitochondrial 2) and RASGRF2 gene (Ras protein-specific guanine nucleotide-releasing factor 2) with all clinical events except stroke, the LRRC3B gene (leucine-rich repeat containing 3B) with myocardial infarction, the PRMT3 gene (protein arginine methyltransferase 3) with stroke, and the LHFPL2 gene (lipoma high mobility group protein I-C fusion partner-like 2) with hard and all coronary heart disease.

CONCLUSIONS

We identified several novel LEA regions, in addition to previously identified genetic variations, associated with cCIMT and cardiovascular disease events among African Americans.

Androgenetic alopecia as an indicator of metabolic syndrome and cardiovascular risk

Numerous studies have investigated a probable association between androgenetic alopecia (AGA) and cardiovascular disease (CVD) by researching limited and dispersed parameters. We aimed to evaluate both traditional and non-traditional cardiovascular risk factors in male patients with early-onset AGA. This case-control study included 68 participants: 51 male patients with early-onset AGA and 17 healthy male controls. Patients with AGA were classified into three groups according to the Hamilton-Norwood scale and the presence of vertex hair loss. Traditional and non-traditional cardiovascular risk factors were examined in all study subjects. Metabolic syndrome was diagnosed in 25 patients with AGA and in two control subjects (p < 0.05). The carotid intima-media thickness values were found to be significantly higher in patients with vertex pattern AGA than in patients without vertex baldness and controls (p < 0.05). The pulse-wave velocity values were also found to be significantly higher in patients (p < 0.001). A limitation of this study was the small study population. In conclusion, vertex pattern AGA appears to be a marker for early atherosclerosis. This finding supports the hypothesis that early-onset AGA alone could be an independent risk factor for CVD and metabolic syndrome.

Cardiorespiratory Fitness and Carotid Intima-Media Thickness in Physically Active Young Adults: CHIEF Atherosclerosis Study

Background: The relationship of cardiorespiratory fitness (CRF) with subclinical atherosclerosis affected by the body adiposity has been observed in children, whereas this relationship remains unclear in young adults. Methods and Results: A total of 1520 military recruits, aged 18−40 years, were included in Taiwan in 2018−2020. All subjects underwent detailed physical and blood laboratory examinations. CRF was evaluated by time for a 3000 m run, and subclinical atherosclerosis was evaluated by intima−media thickness of the bulb of the left common carotid artery (cIMT) utilizing high-resolution ultrasonography. Multivariable linear regression analysis with adjustments for age, sex, cigarette smoking, alcohol intake, systolic and diastolic blood pressure, high- and low-density lipoprotein cholesterols, fasting glucose, waist circumference, serum uric acid and serum triglycerides were utilized to determine the correlation between CRF and cIMT. CRF was independently correlated with cIMT (standardized β: 0.11, p < 0.001). Of the cardiometabolic risk markers, serum triglycerides were the only independent risk marker of cIMT (standardized β: 0.063, p = 0.03). In addition, the association of CRF with cIMT did not differ between those with a body mass index (BMI) ≥ 25 kg/m2 and those with BMI < 25 kg/m2 (standardized β: 0.103 and 0.117; p = 0.01 and 0.005, respectively). Conclusions: In physically active young men and women, there was an inverse association of cIMT with CRF, which was observed in both overweight/mild obesity and normal-weight individuals, highlighting the importance of endurance capacity on reducing risk of early atherosclerosis and implying that the moderation effect of body adiposity might not be present in this population.

Plasma Galectin-3 and Sonographic Measures of Carotid Atherosclerosis in the Atherosclerosis Risk in Communities Study

Galectin-3 is a β-galactoside-binding lectin that plays a role in the regulation of several conditions that are associated with atherosclerosis. The goal of this cross-sectional study was to assess the association of plasma galectin-3 concentrations with sonographic measures of carotid atherosclerosis in the Atherosclerosis Risk in Communities study. Linear regression was used to determine the difference and 95% confidence intervals (CIs) for carotid intima-media thickness (cIMT) by categorical and continuous representations of galectin-3. Logistic regression was used to determine the odds ratio and 95% CI, separately, for dichotomized cIMT (75th percentile = 0.9 mm) and carotid plaque and/or shadowing. Compared to those in the first quintile of galectin-3, those in the fifth quintile of galectin-3 level had higher cIMT (mean difference: 0.020 mm after multivariable adjustment; P trend = .04). Moreover, compared to those in the lowest galectin-3 quintile, those in the highest galectin-3 quintile had higher odds of carotid plaque/and or shadowing (odds ratio 1.13 after multivariable adjustment; P trend = .014). Higher levels of galectin-3 are associated with greater carotid atherosclerosis. Our findings provide support for the role of inflammatory biomarkers in the pathogenesis of atherosclerosis and suggest galectin-3 as a possible target for intervention in the prevention or management of atherosclerotic disease.

Assessment of Subclinical Atherosclerosis by Carotid Intima-Media Thickness and Epicardial Adipose Tissue Thickness in Prediabetes

Impaired fasting glucose (IFG) and impaired glucose intolerance (IGT) are predictors of cardiovascular disease (CVD). We tested the hypothesis that epicardial fat thickness (EFT) and carotid intima-media thickness (cIMT), as markers of early atherosclerosis, are increased in patients with prediabetes. We prospectively enrolled 246 patients (162 with prediabetes and 84 controls). Prediabetes was defined according to American Diabetes Association criteria, and patients were divided into 3 groups: group 1-IFG, group 2-IGT, and group 3-IFG + IGT. Both cIMT and EFT were significantly greater in patients with prediabetes compared with controls (0.81 ± 0.20 mm vs 0.68 ± 0.16 mm, P < .001 and 7.0 ± 2.0 mm vs 5.6 ± 1.6 mm, P < .001, respectively). This difference was mainly attributed to patients with IGT. Age, waist circumference, and 2-hour glucose independently predicted cIMT, while 2-hour glucose was the only independent predictor of EFT in multivariate analysis among other relevant parameters for cIMT and EFT. The cIMT and EFT (measured noninvasively) could be useful indicators of CVD risk in these patients. In order to prove this hypothesis, long-term prospective studies with greater patient numbers are required.

Vitamin D, carotid intima-media thickness and bone structure in patients with type 2 diabetes

Despite aggressive treatment of cardiovascular disease (CVD) risk factors individuals with type 2 diabetes (T2D) still have increased risk of cardiovascular morbidity and mortality. The primary aim of this study was to examine the cross-sectional association between total (25-hydroxy vitamin D (25(OH)D)) and risk of CVD in patients with T2D. Secondary objective was to examine the association between 25(OH)D and bone health. A Danish cohort of patients with T2D participating in a randomised clinical trial were analysed. In total 415 patients (68% men, age 60±9 years (mean±s.d.), duration of diabetes 12±6 years), including 294 patients (71%) treated with insulin. Carotid intima-media thickness (IMT) and arterial stiffness (carotid artery distensibility coefficient (DC) and Young's elastic modulus (YEM)) were measured by ultrasound scan as indicators of CVD. Bone health was assessed by bone mineral density and trabecular bone score measured by dual energy X-ray absorptiometry. In this cohort, 214 patients (52%) were vitamin D deficient (25(OH)D <50 nmol/l). Carotid IMT was 0.793±0.137 mm, DC was 0.0030±0.001 mmHg, YEM was 2354±1038 mmHg and 13 (3%) of the patients were diagnosed with osteoporosis. A 25(OH)D level was not associated with carotid IMT or arterial stiffness (P>0.3) or bone health (P>0.6) after adjustment for CVD risk factors. In conclusion, 25(OH)D status was not associated with carotid IMT, arterial stiffness or bone health in this cohort of patients with T2D. To explore these associations and the association with other biomarkers further, multicentre studies with large numbers of patients are required.

Classical Pathway of Complement Activation: Longitudinal Associations of C1q and C1-INH With Cardiovascular Outcomes: The CODAM Study (Cohort on Diabetes and Atherosclerosis Maastricht)-Brief Report

OBJECTIVE

The classical complement pathway has been assigned both protective and pathological effects in cardiovascular disease (CVD), but human data are lacking. We determined the associations of the pattern recognition factor C1q and the regulator C1-INH (C1-inhibitor) with incident CVD, carotid intima-media thickness, endothelial dysfunction, and low-grade inflammation.

APPROACH AND RESULTS

Baseline concentrations of C1q and C1-INH were measured in the CODAM study (Cohort on Diabetes and Atherosclerosis Maastricht; n=574; 61% men; age, 60±7 years). The 7-year incidence of CVD in participants free of CVD at baseline was evaluated using logistic regression analyses (n=342; 73 cases). The lowest incidence of CVD was observed in the middle tertile of C1q (T_low compared with T_middle: odds ratio, 2.38 [95% confidence interval, 1.14-4.95]; T_high compared with T_middle: odds ratio, 1.96 [95% confidence interval, 0.94-4.07]). C1-INH was not associated with CVD. During the 7-year follow-up period, C1q and C1-INH were not, or inconsistently, associated with carotid intima-media thickness or with biomarker scores reflecting endothelial dysfunction and low-grade inflammation.

CONCLUSIONS

Our results suggest a nonlinear association between C1q and incident CVD. This supports the concept that early steps in classical pathway activation may have both protective and pathological effects on human CVD.

Echocardiographic association of epicardial fat with carotid intima-media thickness in patients with type 2 diabetes

BACKGROUND

Epicardial fat is recognized as active endocrine organ and as emerging risk factor for cardio-metabolic diseases. The aim of this study was to explore the relationship between epicardial fat and carotid intima-media thickness in type 2 diabetes patients.

METHODS

Epicardial fat thickness was measured in 76 type 2 diabetes patients without clinical atherosclerotic cardiovascular disease and 30 age- and sex-matched controls. In addition to laboratory tests, all patients underwent transthoracic echocardiography for epicardial fat thickness and ultrasonographic examination of carotid intima-media thickness.

RESULTS

Patients with diabetes had higher epicardial fat thickness and carotid intima-media thickness than those of the controls (6.23 ± 1.27 mm vs 4.6 ± 1.03 mm, p < 0.001 and 0.77 ± 0.150 mm vs 0.58 ± 0.08 mm, p < 0.001, respectively). Epicardial fat thickness was correlated significantly with age, duration of type 2 diabetes, body mass index, waist circumference, HbA1c, carotid intima-media thickness, Homeostasis Model Assessment Index for insulin resistance and lipid profile in the type 2 diabetic patients. Stepwise regression analysis showed that carotid intima-media thickness, duration of diabetes, triglyceride and body mass index were the independent predictors of epicardial fat thickness, with carotid intima-media thickness the most important predictor (β = 3.078, t = 4.058, p < 0.001). Receiver operating characteristic curve analysis was done and cut-off high-risk epicardial fat thickness value of 6.1 mm was determined with a sensitivity and specificity of 71.4% and 72%, respectively.

CONCLUSION

Patients with type 2 diabetes have higher carotid intima-media thickness and epicardial fat thickness. Epicardial fat thickness was found to be a strong predictor of subclinical atherosclerosis.