Overt Cardiovascular Disease Risk Research Articles

A comparison in women with newly diagnosed diabetes between those with and without a history of gestational diabetes: a new perspective

AimsPrevious gestational diabetes mellitus (GDM) entails increased risk of future diabetes. We describe the characteristics of women with previous GDM and compare with no previous GDM from the cohort Diabetes in Kalmar and Kronoberg (DKK) of 1248 adults, 40% women, with new diabetes, and factors affecting age and C-peptide levels at diagnosis of diabetes.MethodsAge-at-diagnosis of diabetes, BMI, hypertension, hyperlipidemia, smoking, physical activity, and pre-existing myocardial infarction, stroke, or peripheral arterial insufficiency were registered at ordinary care visits close to diagnosis of diabetes, for the 43 women (9.4% of 456 from DKK with complete data for this analysis) with self-reported previous GDM (yes/no) and 86 controls without it, matched for date of diagnosis of diabetes. Blood samples were centrally analyzed for GADA and C-peptide for classification of diabetes.ResultsWomen with previous GDM had lower mean age-at-diagnosis of diabetes, 53.4 vs 65.0 years, lower systolic blood pressure (SBP), 131.2 vs 137.5 mmHg, and fewer had pre-existing hypertension than without previous GDM (p < 0.001–0.05). Among antibody negative women with previous GDM, BMI (p = 0.024), hypertension (p = 0.023) and hyperlipidemia (p < 0.001) were associated with higher levels of C-peptide, while physical activity was inversely associated (p = 0.035), and SBP (p = 0.02) and hypertension (p = 0.016) were associated with age-at-diagnosis of diabetes.ConclusionsWomen with previous GDM were a decade younger and had lower prevalence of hypertension at diagnosis of diabetes; C-peptide levels were associated with BMI, hypertension, and hyperlipidemia and showed a tendency to be lower, possibly indicating a phenotype with higher risk of overt cardiovascular disease later in life.

Physical activity and fitness in childhood cancer survivors: a scoping review.

Estimates indicate that nearly eight percent of the over 500,000 survivors of childhood cancer living in the United States are frail in their fourth and fifth decades of life, a phenotype typically seen in geriatric populations. Participation in regular physical activity to improve physical fitness in healthy and diseased populations reduces risk for frail health by increasing physiologic reserve. However, physical activity may not have the same effects on fitness in childhood cancer survivors as it does among their peers with no cancer history. This scoping review seeks to describe associations between physical activity, physical fitness, chronic disease, and mortality in childhood cancer survivors. Relevant literature was identified through a comprehensive search in the PubMed, Web of Science, CINAHL, and Cochrane databases. A narrative synthesis was performed on observational studies that had physical activity or physical fitness clearly defined and compared with chronic disease outcomes. A total of 595 studies were screened, and results from 11 studies are presented. Childhood cancer survivors who participate in regular physical activity have improved markers of cardiovascular health, decreased risk of overt cardiovascular disease, and decreased risk of all-cause mortality compared to survivors who are not physically active. Childhood cancer survivors who are physically fit have increased neurocognition, and decreased risk of all-cause mortality compared to survivor's who are not fit. The differential effects of physical activity on fitness and health among childhood cancer survivors when compared to peers is potentially related to treatment exposures that damage cardiovascular tissue and impact regenerative potential. Research is needed to determine the optimal timing, frequency, intensity, and duration of physical activity necessary to optimize fitness in childhood cancer survivors.

Visual estimate of coronary artery calcium predicts prevalent coronary artery disease in patients with respiratory disease

Abstract Background Coronary artery calcification (CAC) measured using ECG-triggered coronary computed tomography correlates strongly with overt cardiovascular disease risk. Evidence is emerging to suggest CAC measured on non-gated thoracic CT scans may also correlate with cardiovascular disease. Herein, we sought to ascertain the utility of Weston scoring (visual score for CAC) in predicting prevalent coronary artery disease (CAD) and incident cardiovascular disease (CVD) for patients undergoing lung cancer screening or follow-up for interstitial lung disease with a non-triggered high-resolution CT (HRCT) thorax. Methods The Computerised Radiology Information Service (CRIS) database was manually searched to determine all HRCT scans performed in a single UK trust from 01/05/2016 to 01/05/2017 for the aforementioned indications. Radiology reports and images of selected studies were reviewed. For patients with evidence of CAC, we calculated the calcium score using the Agatston and Weston methods. Clinical events were determined from the electronic medical record without knowledge of patients' CAC findings. At baseline, significant CAC was defined as Agatston &amp;gt;400 and Weston &amp;gt;7. Results 2152 scans were analysed. Data at follow up was available for 100% of patients, with a median duration of follow up of 3.6 years. A history of CAD was reported by 8% (172) of subjects at baseline, who were subsequently excluded from analysis. Significant CAC was found in 450 (22.5%) and 650 (32.5%) by Weston and Agatston scores respectively, with a significant correlation between the two scores (r-0.71, p&amp;lt;0.01). During follow up 7.4% (160) of patients developed incident CVD. Patients with low Weston scores of ≤7 and Agatston scores of ≤400 had a lower incidence of CVD compared to those with Weston &amp;gt;7 and Agatston &amp;gt;400 (31 [19.3%] vs 129 [80.6%]; P=0.003 for Weston scores; 37 [23.1%] vs 123 [76.9%] for Agatston scores; P&amp;lt;0.001). Conclusion In this retrospective study of patients with respiratory disease attending for HRCT scanning, the Weston visual score for CAC performs well in predicting prevalent CAD and future CVD events. With previous data demonstrating excellent inter- and intra- observer agreement, our study demonstrates Weston scoring is a valid tool in reporting non-gated CT scans, removing the need for dedicated software analysis as required with the Agatston score, and has a high overall positive and negative predictive value for future CVD. Further multi-centre prospective studies of this strategy, should be conducted to clarify the utility of Weston CAC scoring in non-gated CTs as a prediction tool which may be used to modify cardiac risk and reduce the risk of incident cardiovascular events. Funding Acknowledgement Type of funding sources: None.

Left ventricular strain rate is reduced during voluntary apnea in healthy humans.

During an apneic event, sympathetic nerve activity increases resulting in subsequent increases in left ventricular (LV) afterload and myocardial work. It is unknown how cardiac mechanics are acutely impacted by the increased myocardial work during an apneic event. Ten healthy individuals (23 ± 3 yr) performed multiple voluntary end-expiratory apnea (VEEA) maneuvers exposed to room air, while a subset ( n = 7) completed multiple VEEA exposed to hyperoxic air (100% [Formula: see text]). Beat-by-beat blood pressure, heart rate, and stroke volume were measured continuously. Effective arterial elastance (EA) was calculated as an index of cardiac afterload, and myocardial work was calculated as the rate pressure product (RPP). Tissue Doppler echocardiography was used to measure LV tissue velocities, deformation via strain, and strain rate (SR). Systolic blood pressure (Δ18 ± 13 mmHg, P < 0.01), EA (Δ0.13 ± 0.10 mmHg/ml, P < 0.01), and RPP (Δ9 ± 10 beats/min × mmHg 10-2, P < 0.01) significantly increased with room air VEEA. This occurred in parallel with decreases in peak longitudinal systolic (Δ-0.62 ± 0.41 cm/s, P < 0.01) and early LV filling (Δ-2.81 ± 1.99 cm/s, P < 0.01) myocardial velocities. Longitudinal SR (Δ-0.30 ± 0.32 1/s, P = 0.01) was significantly decreased during room air VEEA. VEEA with hyperoxia did not alter ( P > 0.18) EA or RPP and attenuated the systolic blood pressure response compared with room air. Myocardial velocities and LV strain rate response to VEEA were unchanged ( P = 0.30) with hyperoxia. Consistent with our hypotheses, VEEA-induced increases in EA and myocardial work impact LV mechanics, which may depend, in part, on stimulation of peripheral chemoreceptors. NEW & NOTEWORTHY Transient increases in arterial blood pressure and systemic vascular resistance occur during sleep apnea events and may contribute to the associated daytime hypertension and risk of overt cardiovascular disease. To date, the link between this apnea pressor response and acute changes in left ventricular function remains poorly understood. We demonstrate that in parallel to increases in cardiac afterload a depressed left ventricular systolic function occurs at end apnea.

Serum 25-hydroxyvitamin D and the risk of cardiovascular disease: dose-response meta-analysis of prospective studies1–3

Background: During the past decade, an increasing number of prospective studies have focused on the association between vitamin D and cardiovascular disease (CVD). However, the evidence on the relation between serum 25-hydroxyvitamin D [25(OH)D] and the risk of overt CVD is inconclusive.Objective: We performed a dose-response meta-analysis to summarize and prospectively quantify the RR of low serum 25(OH)D concentration and total CVD (events and mortality).Design: We identified relevant studies by searching PubMed and EMBASE up to December 2015 and by hand-searching reference lists. Prospective studies based on the general population and reported RRs and 95% CIs were included. A random-effects model was used to calculate the pooled RRs. Nonlinear association was assessed by using restricted cubic spline analyses.Results: A total of 34 publications with 180,667 participants were eligible for the meta-analysis. We included 32 publications (27 independent studies) for total CVD events and 17 publications (17 independent studies) for CVD mortality. We observed an inverse association between serum 25(OH)D and total CVD events and CVD mortality, and the pooled RRs per 10-ng/mL increment were 0.90 (95% CI: 0.86, 0.94) for total CVD events and 0.88 (95% CI: 0.80, 0.96) for CVD mortality. A nonlinear association was detected for total CVD events (P-nonlinear < 0.001) and CVD mortality (P-nonlinear = 0.022).Conclusion: Serum 25(OH)D concentration was inversely associated with total CVD events and CVD mortality from the observed studies.

OntoDiabetic: An Ontology-Based Clinical Decision Support System for Diabetic Patients

Clinical decision support systems (CDSS) assist medical practitioners in their daily work, thereby enhancing the quality of care given to a patient. It supports them in the decision-making process and suggests appropriate treatments. The use of the ontology to build knowledge-driven decision support systems is widely adopted. Ontology is best suited to encapsulate the concepts and relationships of terms associated with the medical domain. It is suitable for capturing medical knowledge in a formal way, allowing sharing and reusing it whenever necessary. All concepts and relationships detailed in clinical guidelines can be implemented using Web Ontology Language (OWL). The reasoning mechanism is vital in any knowledge-based system. Ontology can be reasoned to recommend the suitable treatment for a patient by considering the current medical status of the patient. OntoDiabetic, an ontology-based decision support system is developed to assess the risk factors and provide appropriate treatment suggestions for diabetic patients. This paper focuses on the modeling and implementation of clinical guidelines using OWL2 rules and the reasoning process of the OntoDiabetic system. The case study is conducted for patients having the risk of overt cardiovascular disease, diabetic nephropathy and hypertension in primary health centers of Oman.

The benefits of weight loss, even if regained, in reducing cardiovascular disease: welcoming evidence!

The relation between obesity and risk of cardiovascular disease (CVD) is complex and – despite extensive research – still not fully understood. Whereas research has conclusively demonstrated that several obesity-related factors such as insulin resistance/diabetes, dyslipidaemia and hypertension are strong and independent risk factors for CVD, less is known about whether obesity increases the CVD risk independent of these risk factors. Some (1,2), but not all (3,4), of the recent observational studies have suggested that obesity is only associated with increased atherosclerotic CVD risk through metabolic disturbances, which has casted doubts as to whether being overweight or obese is always bad. A particular challenge when interpreting the results of such studies is that time of follow-up often is limited and that there is no sensitive and specific method for distinguishing between those who will and will not develop metabolic disturbances. Also, it takes time to develop overt CVD, especially in the absence of a larger burden of risk factors. Thus, from a CVD point of view, it is obviously not valid to state that metabolic healthy overweight or obese individuals do not need to lose weight. The opposite postulation, i.e. that weight loss among overweight or obese individuals will translate into a reduction in future CVD events is, however, also not supported by an overwhelming amount of evidence (5,6). In selected cohorts, those who are overweight may even have better prognosis than normal or underweight individuals (7). The amount of studies showing such an obesity paradox is so overwhelming that we sometimes have doubted whether weight loss is beneficial and may, perhaps, even be detrimental for selected people. The recent study by Charakida et al., published in Lancet Diabetes and Endocrinology, contributed important insights on the long-term relation of body mass index (BMI) and CVD risk (8). The authors studied participants of a cohort derived from a nationally representative sample of singleton births occurring in 1946 in England, Scotland and Wales who attended a clinical assessment at age 60–64 year. The participants had previously been examined at ages 2, 4, 6, 7, 11, 36, 43 and 53 years. Authors looked at the cross-sectional association of BMI category (divided into normal weight, overweight and obese) and carotid intima media thickness (cIMT); a measure of subclinical atherosclerosis that relates to the future risk of overt CVD (9). They observed a direct association of higher cIMT with higher BMI groups after adjustment for several confounding variables including systolic blood pressure and lowdensity lipoprotein cholesterol levels. Authors also showed that those who had been overweight or obese at any of the prior examinations, but had moved ‘downward’ to a lower BMI category had cIMT levels nearly comparable with those who had never been overweight or obese. This clinical obesity doi: 10.1111/cob.12073

Microvascular function in younger adults with obesity and metabolic syndrome: role of oxidative stress

Older adults with cardiovascular disease exhibit microvascular dysfunction and increased levels of reactive oxygen species (ROS). We hypothesized that microvascular impairments begin early in the disease process and can be improved by scavenging ROS. Forearm blood flow (Doppler ultrasound) was measured in 45 young (32 ± 2 yr old) adults (n = 15/group) classified as lean, obese, and metabolic syndrome (MetSyn). Vasodilation in response to endothelial (ACh) and vascular smooth muscle [nitroprusside (NTP) and epoprostenol (Epo)] agonists was tested before and after intra-arterial infusion of ascorbic acid to scavenge ROS. Vasodilation was assessed as a rise in relative vascular conductance (ml·min(-1)·dl(-1)·100 mmHg(-1)). ACh and NTP responses were preserved (P = 0.825 and P = 0.924, respectively), whereas Epo responses were lower in obese and MetSyn adults (P < 0.05) than in lean controls. Scavenging of ROS via infusion of ascorbic acid resulted in an increase in ACh-mediated (P < 0.001) and NTP-mediated (P < 0.001) relative vascular conductance across all groups, suggesting that oxidative stress influences vascular responsiveness in adults with and without overt cardiovascular disease risk. Ascorbic acid had no effect on Epo-mediated vasodilation (P = 0.267). These results suggest that obese and MetSyn adults exhibit preserved endothelium-dependent vasodilation with reduced dependence on prostacyclin and are consistent with an upregulation of compensatory vascular control mechanisms.

Psoriatic arthritis and risk of overt cardiovascular disease: review of the evidence

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis. Emerging evidence suggests that the systemic inflammation of PsA may lead to an increased likelihood of developing overt cardiovascular disease (CVD). It has been hypothesized that this systematic inflammation leads to insulin resistance, in turn triggering endothelial dysfunction and providing the basis for accelerated atherosclerosis. Ultimately, this results in major cardiovascular events such as myocardial infarction and stroke. However, there are a limited number of studies that have investigated the association between the onset of PsA and subsequent risk of overt CVD. Therefore, questions remain about the role of inflammation in the development of overt CVD. The purpose of this report is to review the literature on PsA and overt CVD, weigh the strength of existing evidence and discuss methodological challenges for future research.

Relations of circulating vitamin D concentrations with left ventricular geometry and function

Vitamin D deficiency has been associated with risk of overt cardiovascular disease (CVD), but associations with subclinical disease are not well characterized. Hence, we examined associations of circulating vitamin D concentrations and left ventricular (LV) geometry and function by echocardiography at baseline and after 5 years in a community-based study. In the PIVUS study, we measured serum 25-dihydroxyvitamin-D (25-OH D) at age 70 and performed echocardiography including LV mass, wall thickness, end-diastolic diameter, end-systolic diameter (LVESD), left atrial diameter, fractional shortening, ejection fraction, isovolumic relaxation time, and E/A ratio at both age 70 and 75. We included 870 participants (52% women) without prior myocardial infarctions, heart failure, or prevalent valvular disease. After adjusting for potential confounders, 25-OH D at baseline was found to be significantly associated with LVESD, fractional shortening, and ejection fraction (β, -0.42 mm, P = 0.03; β, 0.70%, P = 0.03; and β, 0.91% P = 0.01, respectively), per 1 SD increase in 25-OH D (SD = 20 nmol/L) at baseline. In longitudinal analyses, vitamin D levels at baseline were not significantly associated with change in LV geometry and function after 5 years. In our community-based study among the elderly, we found higher circulating vitamin D concentrations to be associated cross-sectionally with better LV systolic function and smaller LVESD at baseline. The association persisted after adjusting for several potential confounders, including cardiovascular risk factors and calcium, phosphate, and parathyroid hormone levels. Randomized clinical trials are needed to establish firmly or refute a causal relationship between vitamin D levels and changes in LV geometry and function.

Microalbuminuria as a marker of silent myocardial ischaemia in IDDM patients.

Insulin-dependent diabetic (IDDM) subjects with microalbuminuria have an increased long-term risk of overt cardiovascular disease; however, the early exposure to cardiovascular risk factors may increase their predisposition to current silent myocardial ischaemia. The frequency of silent myocardial ischaemia detected by stress echocardiography and electrocardiography was significantly greater in 32 asymptomatic IDDM patients with microalbuminuria compared to 32 normoalbuminuric IDDM patients (25% [n = 8] vs 6.3% [n = 2]; p = 0.03, odds ratio [95% CI] 6.3 [1.2, 37.8]). Elective coronary artery bypass grafting was required in 1 patient with microalbuminuria and silent myocardial disease. Microalbuminuria and poorer autonomic function were independently associated with silent myocardial ischaemia in multivariate analysis (p = 0.03 and p = 0.02, respectively). Screening for silent myocardial ischaemia using these non-invasive tests may be warranted in microalbuminuric IDDM which patients could be of considerable clinical importance.

Issue Highlights

HomeCirculationVol. 116, No. 4Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published24 Jul 2007https://doi.org/10.1161/CIRCULATIONAHA.107.183537Circulation. 2007;116:359BURDEN AND PROGNOSTIC IMPORTANCE OF SUBCLINICAL CARDIOVASCULAR DISEASE IN OVERWEIGHT AND OBESE INDIVIDUALS, by Ingelsson et al.Subclinical cardiovascular disease can be assessed using several routinely available tests that can measure atherosclerotic burden and target organ damage. The extent of subclinical disease in obesity and its prognostic importance has not been investigated systematically. In this issue of Circulation, Ingelsson and colleagues used data from 5 tests (electrocardiography, echocardiography, carotid ultrasound, ankle-brachial pressure, urinary albumin excretion) performed in the community-based Framingham Heart Study sample. The authors report a higher cross-sectional prevalence of subclinical disease in overweight and obese individuals (compared with those with a normal body mass index), and in those with increased waist circumference compared with those with a normal waist circumference. On prospective follow-up, the risk of overt cardiovascular disease was higher in overweight and obese individuals with evidence of subclinical disease, as compared with individuals without subclinical disease. These data suggest that overweight and obesity are associated with a high prevalence of subclinical disease, which in part contributes to the increased risk of overt cardiovascular disease in individuals with excess adiposity. See p 375.PREDICTION OF MODE OF DEATH IN HEART FAILURE: THE SEATTLE HEART FAILURE MODEL, by Mozaffarian et al.Therapeutic strategies to treat symptomatic heart failure are directed toward improving prognosis. Clinicians are very aware that the risk of death and other complications of heart failure vary considerably The Seattle Heart Failure Model incorporates commonly available clinical features, laboratory measurements, and medications used to provide some quantization of this nonhomogeneous risk. In this issue of Circulation, Mozaffarian and colleagues use information from several clinical trials and registries to evaluate the Seattle Heart Failure Model score to assess mode of death in over 10 000 ambulatory patients with symptomatic heart failure. With over 2000 deaths at an annualized rate of approximately 12%, there was a relatively greater increase in the proportion of deaths attributed to progressive pump failure versus sudden, unanticipated heart failure in those with higher scores. The authors appropriately conclude that such information warrants further study and may facilitate decision making regarding improvements in recommendations for implantable cardioverter-defibrillators. See p 392 (editorial p 360).MAST CELL STABILIZATION REDUCES HEMORRHAGE FORMATION AND MORTALITY AFTER ADMINISTRATION OF THROMBOLYTICS IN EXPERIMENTAL ISCHEMIC STROKE, by Strbian et al.Although thrombolysis is an established effective treatment of ischemic stroke, hemorrhagic complications and reperfusion injury limit the outcome of patients after this intervention. Mast cells are known to increase ischemic and hemorrhagic brain edema, possibly because of the release of vasoactive, proteolytic, and fibrinolytic mediators upon degranulation. In a mouse model of cerebral ischemia and reperfusion, the authors investigated this question and found that application of a tissue plasminogen activator, a commonly used treatment strategy in these patients, induces strong mast cell degranulation. Similarly, postischemic administration of a tissue plasminogen activator markedly increased hemorrhagic edema formation, an effect that was significantly reduced by pretreatment of the animals with the mast cell stabilizor, cromoglycate. These results were confirmed in genetically modified mast cell–deficient mice, suggesting that degranulation of these cells is involved in this major complication, as well as in stroke. Further, the potential clinical relevance of these results is interesting, as neurological outcome was improved and mortality reduced in this experimental animal model. Overall, these results point to new treatment modalities in acute stroke using mast cell stabilizers, such as cromoglycate or other molecules, in a relevant clinical setting. See p 411 (editorial p 363).Visit http://circ.ahajournals.org:Images in Cardiovascular MedicineApicoaortic Valve–Containing Conduit in a Patient With Relapsing Prosthetic Endocarditis. See p e88. Download figureDownload PowerPointIsolated Left Ventricular Noncompaction Enhanced by Echocontrast Agent. See p e90.CorrespondenceSee p e92. Previous Back to top Next FiguresReferencesRelatedDetails July 24, 2007Vol 116, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.183537 Originally publishedJuly 24, 2007 PDF download Advertisement