Myocardial Injury, Obesity, and the Obesity Paradox

To examine whether pre-heart failure (HF) myocardial injury explains the differential mortality after HF across weight categories

High-Sensitivity Troponin T and Cardiovascular Events in Systolic Blood Pressure CategoriesNovelty and Significance: Atherosclerosis Risk in Communities Study

Based on observational studies there is a linear increase in cardiovascular risk with higher systolic blood pressure, yet clinical trials have not shown benefit across all systolic blood pressure categories. We assessed if troponin-T measured using high-sensitivity assay was associated with cardiovascular disease within systolic blood pressure categories in 11191 Atherosclerosis Risk in Communities study participants. Rested sitting systolic blood pressure by 10-mmHg increments and troponin categories were identified. Incident heart failure hospitalization, coronary heart disease and stroke were ascertained over a median of 12 years after excluding individuals with corresponding disease. Approximately 53% of each type of cardiovascular event occurred in individuals with systolic blood pressure<140 mmHg and troponin-T≥3ng/L. Higher troponin-T was associated with increasing cardiovascular events across most systolic blood pressure categories. The association was strongest for heart failure and least strong for stroke. There was no similar association of systolic blood pressure with cardiovascular events across troponin-T categories. Individuals with troponin-T≥3ng/L and systolic blood pressure<140mmHg had higher cardiovascular risk compared to those with troponin-T<3ng/L and systolic blood pressure 140-159 mmHg

The CardioMetabolic Health Alliance Working Toward a New Care Model for the Metabolic Syndrome

AbstractThe Cardiometabolic Think Tank was convened on June 20, 2014, in Washington, DC, as a “call to action” activity focused on defining new patient care models and approaches to address contemporary issues of cardiometabolic risk and disease. Individual experts representing >20 professional organizations participated in this roundtable discussion. The Think Tank consensus was that the metabolic syndrome (MetS) is a complex pathophysiological state comprised of a cluster of clinically measured and typically unmeasured risk factors, is progressive in its course, and is associated with serious and extensive comorbidity, but tends to be clinically under-recognized. The ideal patient care model for MetS must accurately identify those at risk before MetS develops and must recognize subtypes and stages of MetS to more effectively direct prevention and therapies. This new MetS care model introduces both affirmed and emerging concepts that will require consensus development, validation, and optimization in the future

EPIDEMIOLOGIC CHARACTERIZATION OF THE RELATIONSHIP OF OBESITY WITH SUBCLINICAL MYOCARDIAL INJURY AND HEART FAILURE

Obesity is a potent risk factor for heart failure (HF), a cardiovascular condition associated with high morbidity and mortality. However, the relationship between obesity and HF has not been fully characterized. Prior data suggest that obesity may be independently linked to HF. However, there are limited comparisons of the relationship of obesity to various forms of cardiovascular disease (CVD), including HF, coronary heart disease (CHD) and stroke, including the extent to which they are unexplained by traditional mediators of CVD, such as hypertension, dyslipidemia and diabetes. Furthermore, the pathways linking obesity to HF are incompletely understood, with a growing body of laboratory and clinical data suggesting direct toxic effects of obesity on heart muscle. Additionally, the prognostic impact of weight history on HF risk is presently unknown. Therefore, in the following epidemiologic analyses, we compared the associations of obesity with incident HF, CHD and stroke before and after adjusting for traditional CVD mediators (Aim 1); evaluated the cross-sectional association between obesity and a novel biomarker of subclinical myocardial injury, a high sensitivity assay for troponin T (hs-cTnT), and to assess the combined prospective associations of obesity and elevated hs-cTnT with incident HF (Aim 2); assessed the prognostic impact of several weight history metrics on the risk of incident HF (Aim 3); and evaluated the relationship between weight history and myocardial injury, as assessed by hs-cTnT (Aim 4). We demonstrated that: obesity has the strongest association with incident HF among CVD subtypes, and that among CVD subtypes, the association of obesity with HF is uniquely unexplained by traditional risk factors; obesity is independently associated with elevated hs-cTnT and the combination of severe obesity and elevated hs-cTnT is associated with a greater than 9-fold higher risk of incident HF compared to those with normal weight and undetectable hs-cTnT; and that past excess weight and increasing weight over time are significantly associated with incident HF and elevated hs-cTnT, with perhaps the most useful prognostic information provided by cumulative weight. This work has advanced knowledge regarding the epidemiologic association between obesity and HF and potential pathways underlying this relationship

The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention

The prevalence of heart failure (HF) in the United States (U.S.) is estimated at over 6 million adults, with the incidence continuing to increase. A large proportion of the U.S. population is also at risk of HF due to the high prevalence of established HF risk factors, such as hypertension, diabetes, and obesity. Many individuals have multiple risk factors, placing them at even higher risk. In addition, these risk factors disproportionately impact various racial and ethnic groups. Recognizing the rising health and economic burden of HF in the U.S., the 2022 American Heart Association / American College of Cardiology / Heart Failure Society of America (AHA/ACC/HFSA) Heart Failure Guideline placed a strong emphasis on prevention of HF. The purpose of this review is to highlight the role of both primary and secondary prevention in HF, as outlined by the recent guideline, and address the role of the preventive cardiology community in reducing the prevalence of HF in at-risk individuals

Four high sensitivity troponin assays and mortality in US adults with cardiovascular disease: The national health and nutrition examination survey, 1999–2004

Objective: High sensitivity cardiac troponin (hs-cTn) may be useful to monitor residual risk in secondary prevention. Our objective was to study the correlations and comparative associations with mortality of four hs-cTn assays in US adults with known cardiovascular disease (CVD). Methods: We studied 1,211 adults with a history of CVD who participated in the National Health and Nutrition Examination Survey (NHANES) 1999–2004. Using stored samples, we measured hs-cTnT (Roche) and three hs-cTnI assays (Abbott, Siemens, and Ortho). Outcomes were all-cause and CVD mortality, with follow-up through December 31, 2019. Results: Mean age was 64 years, 48 % were female, and 80 % identified as non-Hispanic White. Pearson's correlation coefficients between hs-cTn assays ranged from 0.67 to 0.85. There were 848 deaths (365 from CVD). Among adults with a history of prior non-fatal CVD, each hs-cTn assay (log-transformed, per 1-SD) was independently associated with CVD death (HRs ranging from 1.55 to 2.16 per 1-SD, all p-values <0.05) and with all-cause death (HRs ranging from 1.31 to 1.62 per 1-SD, all p-values <0.05). Associations of hs-cTnT and all-cause and CVD death remained significant after adjusting for hs-cTnI (and vice versa). Associations between hs-cTnI and CVD death remained significant after mutually adjusting for other individual hs-cTnI assays: e.g., HR 2.21 (95 % CI 1.60, 3.05) for Ortho (hs-cTnI) after adjustment for Siemens (hs-cTnI) and HR 1.81 (95 % CI 1.35, 2.43) for Ortho (hs-cTnI) after adjustment for Abbott (hs-cTnI). Conclusion: In US adults with a history of CVD, we found modest correlations between 4 hs-cTn assays. All assays were associated with all-cause and CVD mortality. The hs-cTnT assay was associated with mortality independent of the hs-cTnI assays. Hs-cTnI assays also appeared to be independent of each other. Thus, hs-cTn assays may provide distinct information for residual risk in secondary prevention adults

Abstract MP57: Objectively-Assessed Sleep Duration And Incident Heart Failure: The Atherosclerosis Risk In Communities Study-Sleep Heart Health Study

Introduction: Evidence is mixed on short sleep duration and heart failure (HF) risk. Notably, no studies have investigated objectively-assessed sleep duration or controlled for comorbid sleep apnea in this context. Objective: To examine the independent associations of objective short sleep duration with incident HF, accounting for sleep apnea. Methods: We studied ARIC-SHHS study participants free of HF at visit 4 (1996-98). Sleep duration was measured by at-home polysomnography (PSG) and defined as: 7 to <9 hours (reference), 6 to <7 hours, 5 to <6 hours, and <5 hours. The apnea-hypopnea index (AHI; defined as: <5, 5 to <15, 15 to <30, and ≥30), a measure of sleep apnea, was also measured by at-home PSG. Cox proportional hazards models, with progressive adjustment for comorbidities and AHI, were used to evaluate the association of sleep duration with incident HF (hospitalizations or deaths with HF diagnosis). Results: We included 1,056 participants (mean age 62 years, 50% female, 99% White). During a median follow-up of 22 years, there were 211 HF events. Participants with sleep duration <5 hours had a higher risk of incident HF in unadjusted and age-sex-adjusted models, with corresponding hazard ratios of 2.44 (95% CI : 1.40-4.26) and 1.88 (95% CI : 1.07-3.29) ( Table ). However, further adjustment for clinical factors attenuated the results. The associations for sleep duration appeared more evident when we restricted our analysis to participants without prevalent cardiovascular disease ( Table ). The AHI was not a significant predictor of incident HF in the presence of sleep duration. Conclusions: Objectively-assessed short sleep duration <5 hours was modestly associated with HF risk. Our study suggests the need and value of larger studies exploring objectively-assessed sleep duration in terms of HF risk. Importantly, sleep duration may be objectively measured without PSG, using wearable devices

Associations between endogenous sex hormone levels and adipokine levels in the Multi-Ethnic Study of Atherosclerosis

BackgroundDifferences in sex hormone levels contribute to differences in cardiovascular disease (CVD) risk. Adipokines play a role in cardiometabolic pathways and have differing associations with CVD. Adipokine levels differ by sex; however, the association between sex hormone profiles and adipokines is not well established. We hypothesized that a more androgenic sex hormone profile would be associated with higher leptin and resistin and lower adiponectin levels among postmenopausal women, with the opposite associations in men.MethodsWe performed an analysis of 1,811 adults in the Multi-Ethnic Study of Atherosclerosis who had both sex hormones and adipokines measured an average of 2.6 years apart. Sex hormones [Testosterone (T), estradiol (E2), sex hormone binding globulin (SHBG), and dehydroepiandrosterone (DHEA)] were measured at exam 1; free T was estimated. Serum adipokines (leptin, resistin, adiponectin) were measured at exams 2 or 3. We used multivariable linear regression to examine the cross-sectional associations between sex hormones and adipokines.ResultsThe mean (SD) age was 63 (10) years, 48% were women; 59% non-White participants. For leptin, after adjusting for demographics only, higher free T and lower SHBG, were associated with higher leptin in women; this association was attenuated after further covariate adjustment. However in men, higher free T and lower SHBG were associated with greater leptin levels in fully adjusted models. For adiponectin, lower free T and higher SHBG were associated with greater adiponectin in both women and men after adjustment for CVD risk factors. For resistin, no significant association was found women, but an inverse association with total T and bioT was seen in men.ConclusionOverall, these results further suggest a more androgenic sex profile (higher free T and lower SHBG) is associated with a less favorable adipokine pattern. These findings may provide mechanistic insight into the interplay between sex hormones, adipokines, and CVD risk