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1.  Hemostasis, inflammation and fatal and non-fatal coronary heart disease; long-term follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort 
This study examines the hypothesis that chronic inflammation is associated with a higher risk of cardiac death compared to the risk of non-fatal myocardial infarction.
Cardiac death and non-fatal MI events were identified in the ARIC cohort during follow-up from 1987 through 2001. Markers of inflammation and hemostasis were determined at baseline using standardized procedures. Cox proportional hazard regression and polytomous logistic regression were used to estimate associations.
We observed a positive gradient in incidence of sudden cardiac death, non-sudden cardiac death and non-fatal MI in association with decreasing levels of albumin and increasing levels of white blood cell count and of markers of hemostasis (fibrinogen, von Willebrand factor, factor VIIIc). Associations for von Willebrand factor (vWF) and factor VIIIc were stronger for fatal relative to non-fatal events (3rd versus 1st tertile hazard ratios: vWF: SCD 2.67 (95% CI 1.80, 3.96), NSCD 2.11 (95% CI 1.40, 3.19), non-fatal MI 1.40 (95% CI 1.17, 1.67); factor VIIIc: SCD 2.58 (95% CI 1.77, 3.78), NSCD 2.01 (95% CI 1.38, 2.93), non-fatal MI 1.48 (95% CI 1.24, 1.78). Gradients of association for fibrinogen and white blood cell count, examined over tertiles of distribution and per one SD increase, were similar for the three endpoints. All associations were independent of smoking status.
Von Willebrand factor and factor VIIIc are associated with an increased risk of cardiac death as compared to the risk of non-fatal MI.
PMCID: PMC3057473  PMID: 19797708
hemostasis; inflammation; von Willebrand factor; sudden cardiac death; non-fatal myocardial infarction
2.  Coagulation factors II, V, IX, X, XI, XII, plasminogen, and α-2 antiplasmin and risk of coronary heart disease 
Since few studies have examined the associations of plasma levels of coagulation factors II, V, IX, X, XI, XII, plasminogen, or α-2 antiplasmin with coronary heart disease (CHD), we sought to examine the associations of these factors with incident CHD in a prospective case-cohort study.
This case-cohort sample consisted of 368 African-American or white incident CHD cases that occurred between 1990–92 and 1998 in the Atherosclerosis Risk in Communities (ARIC) study, and a cohort random sample of n=412. Hemostatic factors were measured in the case-cohort sample using plasma stored at −70°C since 1990–92.
After adjustment for age, sex and race, coagulation factors IX and XI, and α-2 antiplasmin were associated positively with risk of CHD: The hazard ratio [95% confidence interval] for the highest vs lowest quartiles was 1.52 [1.01–2.27] for factor IX; 2.26 [1.47–3.48] for factor XI; and 1.64 [1.05–2.57] for α-2 antiplasmin. However, these hemostatic factors were correlated with classical risk factors, so that after multivariable adjustment their associations with CHD were attenuated and no longer statistically significant. No associations were observed between CHD and factors II, V, X, XII, or plasminogen.
Positive associations of factors IX and XI, and α-2 antiplasmin with incident CHD were not strong and were accounted for by classical coronary risk factors. (213 words/250 limits)
PMCID: PMC2866762  PMID: 20379055
epidemiology; cardiovascular disease; ischemic disease; fibrinolytic factors; blood clotting
3.  Factors Associated with Presence and Extent of Coronary Calcium in Individuals Predicted to be at Low Risk Based on Framingham Risk Score (From The Multi-Ethnic Study of Atherosclerosis) 
The American journal of cardiology  2011;107(6):879-885.
Even among asymptomatic people at low risk (<10%) by Framingham Risk Score (FRS), high coronary artery calcium (CAC) scores signify higher predicted risk of coronary heart disease (CHD) events. We sought to determine non-invasive factors (without radiation exposure) significantly associated with CAC in low-risk, asymptomatic persons. In a cross-sectional analysis, we studied 3046 participants from MESA at low 10-year predicted risk (FRS <10%) for CHD events. Multivariable logistic regression was used to assess the association of novel markers with presence of any CAC (CAC >0) and advanced CAC (CAC ≥ 300). CAC >0 and CAC ≥ 300 were present in 30% and 3.5% of participants, respectively. Factor VIIIc, fibrinogen and sICAM were each associated with CAC presence (P ≤ 0.02); and C-reactive protein, D-dimer and carotid intima-media thickness (CIMT) with advanced CAC (P ≤ 0.03). The base model combining traditional risk factors had excellent discrimination for advanced CAC (C-statistic, 0.808). Addition of the 2 best-fit models combining biomarkers plus/minus CIMT improved the c-statistics to 0.822 and 0.820, respectively. All 3 models calibrated well, but were similar in estimating individual risk probabilities for advanced CAC (prevalence = 9.97%, 10.63% and 10.10% in the highest quartiles of predicted probabilities versus 0.26%, 0.26% and 0.26% in the lowest quartiles, respectively). In conclusion, in low risk individuals, traditional risk factors alone predicted advanced CAC with high discrimination and calibration. Biomarker combinations +/− CIMT were also significantly associated with advanced CAC, but improvement in prediction and estimation of clinical risk were modest compared to traditional risk factors alone.
PMCID: PMC3182475  PMID: 21376929
coronary calcium; biomarkers; novel markers; low-risk; risk factors
4.  Hemostatic markers are associated with the risk and prognosis of atrial fibrillation: the ARIC study 
International Journal of Cardiology  2010;155(2):217-222.
Various hemostatic markers are associated with the risk of cardiovascular disease; however, limited information exists on their relationship with the occurrence and prognosis of atrial fibrillation (AF).
To assess whether hemostatic markers are associated with the incidence and prognosis of AF.
We studied 14,858 men and women in the Atherosclerosis Risk in Communities cohort, aged 45–64 and free of AF at baseline (1987–1989). Fibrinogen, von Willebrand factor (vWf), factor VII activity (VIIc), factor VIII activity (VIIIc), protein C, antithrombin III (ATIII), and activated partial thromboplastin time (aPTT) were measured in blood samples at baseline. AF and other cardiovascular outcomes through 2005 were determined following standardized protocols.
During a median follow-up of 16.8 years, 1209 cases of AF were identified. In multivariable Cox models, the hazard ratios (HR) and 95% confidence intervals (CI) of incident AF associated with a 1-standard deviation (SD) increase in each marker were 1.13 (1.07–1.20) for fibrinogen, 1.17 (1.11–1.23) for vWf, 1.17 (1.11–1.24) for factor VIIIc, 0.93 (0.88–1.00) for factor VIIc, 0.98 (0.92–1.04) for protein C, 1.00 (0.94–1.06) for aPTT and 1.00 (0.95–1.06) for ATIII. Greater factor VIIIc, fibrinogen and vWf were consistently associated with a higher risk of cardiovascular outcomes and mortality in those with and without incident AF, while greater protein C was associated with a lower risk of ischemic stroke.
Several hemostatic markers are associated with the incidence of AF independently of other cardiovascular risk factors. Their role in the risk stratification of AF patients should be further studied.
PMCID: PMC3025309  PMID: 20965585
atrial fibrillation; epidemiology; prognosis; fibrinogen; von Willebrand factor
5.  The association of optimism and pessimism with inflammation and hemostasis in the Multi-Ethnic Study of Atherosclerosis (MESA) 
Psychosomatic medicine  2010;72(2):134-140.
Optimism and pessimism are associated with cardiovascular disease mortality and progression, however the biological mechanism remains unclear. This study investigates the association between optimism/pessimism and concentrations of seven inflammation and hemostasis markers.
This cross-sectional study used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a study of 6814 persons aged 45–84 with no history of clinical cardiovascular disease. The Life-Orientation Test—Revised (LOT-R) was used to measure dispositional optimism and pessimism. Regression analyses were used to estimate associations of optimism and pessimism with interleukin-6 (IL-6), C-reactive protein (CRP), fibrinogen, homocysteine, factor VIII, D-dimer, and plasmin-antiplasmin, before and after adjustment for sociodemographics, depression, cynicism, health behaviors, BMI, hypertension, and diabetes.
Higher scores on the LOT-R (positive disposition) were related to lower concentrations of IL-6 (p=0.001), fibrinogen (p<0.001) and homocysteine (p=0.031). Associations were stronger for the pessimism subscale. After adjustment for demographics, the percentage differences in inflammatory markers corresponding to a 2-standard deviation increase in pessimism were 6.01% (p=0.001) for IL-6; 10.31% (p=0.001) for CRP; 2.47% (p<0.0001) for fibrinogen, and 1.36% (p=0.07) for homocysteine. Associations were attenuated but significant after adjustment for sociodemographics, depression, cynical distrust, and behaviors. Further adjustment for hypertension, BMI and diabetes reduced associations for CRP and IL-6. Pessimism remained associated with a 1.36% (p=0.02) increase in fibrinogen in the fully adjusted model. Factor VIII, D-dimer and plasmin-antiplasmin were not associated with the LOT-R or subscales.
Pessimism is related to higher levels of inflammation. Health behaviors, BMI, hypertension and diabetes appear to play a mediating role.
PMCID: PMC2842951  PMID: 20100888
Psychosocial factors; inflammation; coagulation; epidemiology; risk factors
6.  Incidence and risk factors for cardiovascular disease in African Americans with diabetes: the Atherosclerosis Risk in Communities (ARIC) study. 
To determine the incidence rate of cardiovascular disease (CVD) and its association with conventional and less well-established risk factors in African Americans with diabetes, we studied 741 African Americans aged 45 to 64 years with diabetes, in the Atherosclerosis Risk in Communities (ARIC) study. Risk factors were measured from 1987 to 1989, and incident CVD (n = 143 coronary heart disease (CHD) or stroke events) was ascertained through 1998. The crude incidence rate (per 1000 person-years) of CVD was 22.5 (11.9 for CHD and 12.0 for stroke). After multivariate adjustments, total cholesterol, prevalent hypertension and current smoking were significantly and positively associated with incident CVD among these African Americans with diabetes. Among the non-conventional risk factors, serum creatinine, factor VIII, von Willebrand factor, and white blood cell count were positively and serum albumin negatively and independently associated with CVD incidence. Adjusted relative risks for highest versus lowest tertiles of these risk factors ranged from 1.77 to 2.13. This study confirms that the major risk factors (hypercholesterolemia, hypertension and smoking) are important determinants of CVD in African Americans with diabetes. In addition, several blood markers of hemostasis or inflammatory response and elevated serum creatinine also proved to be CVD risk factors in African Americans with diabetes.
PMCID: PMC2568397  PMID: 12510702
7.  Kidney Function and Risk of Cardiovascular Disease and Mortality in Kidney Transplant Recipients: the FAVORIT Trial 
In kidney transplant recipients, cardiovascular disease (CVD) is the leading cause of death. The relationship of kidney function with CVD outcomes in transplant recipients remains uncertain. We performed a post-hoc analysis of the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) Trial to assess risk factors for CVD and mortality in kidney transplant recipients. Following adjustment for demographic, clinical and transplant characteristics, and traditional CVD risk factors, proportional hazards models were used to explore the association of estimated GFR with incident CVD and all-cause mortality. In 4016 participants, mean age was 52 years and 20% had prior CVD. Mean eGFR was 49±18 mL/min/1.73m2. In 3,676 participants with complete data, there were 527 CVD events over a median of 3.8 years. Following adjustment, each 5 mL/min/1.73m2 higher eGFR at levels below 45 mL/min/1.73m2 was associated with a 15% lower risk of both CVD [HR = 0.85 (0.80, 0.90)] and death [HR = 0.85 (0.79, 0.90)], while there was no association between eGFR and outcomes at levels above 45 mL/min/1.73m2. In conclusion, in stable kidney transplant recipients, lower eGFR is independently associated with adverse events, suggesting that reduced kidney function itself rather than pre-existing comorbidity may lead to CVD.
PMCID: PMC3424309  PMID: 22594581
Kidney Transplant; Glomerular Filtration Rate; Cardiovascular Disease; Chronic Kidney Disease; Epidemiology; Mortality
8.  Alcohol Consumption and Risk of Cardiovascular Disease and Mortality in Women: Potential Mediating Mechanisms 
Circulation  2009;120(3):237-244.
Although an association between moderate alcohol consumption and decreased cardiovascular disease (CVD) and mortality has been reported, limited data are available on potential mediating mechanisms. We examined the association between alcohol and CVD and mortality in 26,399 women and estimated the proportion of reduced risk of CVD/mortality explained by a series of intermediate factors.
Methods and Results:
Alcohol consumption was self-reported at baseline and CVD events and deaths were ascertained via follow-up questionnaires and medical records. Baseline levels of hemoglobin A1c, inflammatory markers, hemostatic factors, and lipids were measured. Blood pressure and hypercholesterolemia; and treatment for lipids were self-reported. During a mean follow up of 12.2 years, 1039 CVD events, 785 deaths (153 CVD deaths) occurred. There was a J-shaped relation between alcohol consumption and incident CVD, total and CVD mortality in a multivariable model. Compared with abstainers, alcohol intake of 5-14.9 g/d was associated with 26%, 35%, and 51% lower risk of CVD, total and CVD mortality, respectively, in a multivariable model. For CVD risk reduction, lipids made the largest contribution to the lower risk of CVD (28.7%), followed by hemoglobin A1c/diabetes (25.3%), inflammatory/hemostatic factors (5%), and blood pressure factors (4.6%). All these mediating factors together explained 86.3%, 18.7%, and 21.8% of the observed lower risk of CVD, total and CVD mortality, respectively.
These data suggest that alcohol effects on lipids and insulin sensitivity may account for a large proportion of the lower risk of CVD/mortality observed with moderate drinking under the assumption that the alcohol-CVD association is causal.
PMCID: PMC2745640  PMID: 19597054
Alcohol drinking; epidemiology; cardiovascular disease
9.  Age-Related Macular Degeneration and Incident Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis 
Ophthalmology  2011;119(4):765-770.
To determine whether age-related macular degeneration (AMD) is a risk indicator for coronary heart disease (CHD) and cardiovascular disease (CVD) events independent of other known risk factors in a multi-ethnic cohort.
Population-based prospective cohort study.
A diverse population sample of 6233 men and women aged 45–84 without known CVD from the Multi-Ethnic Study of Atherosclerosis (MESA).
Participants in the MESA had retinal photographs taken between 2002 and 2003. Photographs were evaluated for AMD. Incident CHD/CVD events were ascertained during clinical follow-up visits for up to 8 years after the retinal images were taken.
Main Outcome Measures
Incident CHD/CVD events.
Of the 6814 persons at risk of CHD, there were 893 participants with early AMD (13.1%) and 27 (0.5%) at baseline. Over a mean follow-up period of 5.4 years, there was no statistically significant difference in incident CHD or CVD between the AMD and non-AMD groups (5.0%vs. 3.9%, p=0.13 for CHD and 6.6 vs. 5.5%, p=0.19 for CVD, respectively). In Cox regression models adjusting for CVD risk factors, there was no significant relationship between presence of any AMD and any CHD/CVD events (HR=0.99, 95% CI 0.74–1.33, p=0.97). No significant association was found between subgroups of early AMD or late AMD and incident CHD/CVD events.
In persons without a history of cardiovascular disease, AMD was not associated with an increased risk of CHD or CVD.
PMCID: PMC3314126  PMID: 22197438
10.  Lack of association between haemostatic variables and the presence or the extent of coronary atherosclerosis. 
British Heart Journal  1988;59(3):287-291.
Blood samples were taken for haemostatic analysis from 225 patients with angina pectoris who were admitted to hospital for coronary angiography. beta thromboglobulin, platelet factor 3, platelet factor 4, factor VII:C, factor VIII:C, von Willebrand factor antigen, activated partial thromboplastin time, fibrinogen, antithrombin III, protein C:Ag, plasminogen, and antiplasmin were measured before angiography. Patients who had had a myocardial infarction in the two months before the investigation were excluded from the study. Multiple linear regression analysis showed that none of the haemostatic variables contributed independently to the prediction of an angiographic score that indicated the extent of coronary atherosclerosis. History of myocardial infarction, male sex, worsening of angina pectoris, serum triglycerides, and ejection fraction were independently associated with the angiographic score. There were some significant correlations between haemostatic variables and conventional risk factors for coronary heart disease. Thus data obtained from haemostatic analyses of peripheral venous blood do not permit the presence or the extent of atherosclerosis in coronary arteries to be predicted.
PMCID: PMC1216461  PMID: 3258521
11.  Burden of Cardiovascular Risk Factors, Subclinical Atherosclerosis, and Incident Cardiovascular Events Across Dimensions of Religiosity: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Circulation  2010;121(5):659-666.
Religious involvement has been associated with improved health practices and outcomes; however, no ethnically-diverse community-based study has examined differences in cardiac risk factors, subclinical cardiovascular disease, and cardiovascular disease (CVD) events across levels of religiosity.
Methods and Results
We included 5474 White, Black, Hispanic, and Chinese participants who attended Exam 2 of the NHLBI’s MESA study. We compared cross-sectional differences in cardiac risk factors and subclinical CVD, and longitudinal CVD event rates across self-reported levels of religious participation, prayer/meditation, and spirituality. Multivariable-adjusted regression models were fitted to assess associations of measures of religiosity with risk factors, subclinical CVD, and CVD events. MESA participants (52.4% female, mean age 63) with greater levels of religious participation were more likely to be female and black. After adjustment for demographic covariates, participants who attended services daily, compared with never, were significantly more likely to be obese (adjusted odds ratio 1.57, 95% confidence interval [CI] 1.12 – 1.72), but less likely to smoke (adjusted odds ratio 0.39, 95% CI 0.26 – 0.58). Results were similar for those with frequent prayer/meditation or high levels of spirituality. There were no consistent patterns of association observed between measures of religiosity and presence/extent of subclinical CVD at baseline or incident CVD events during longitudinal follow up over 4 years.
Our results do not confirm those of previous studies associating greater religiosity with overall better health risks and status, at least with regard to CVD. There was no reduction in risk for CVD events associated with greater religiosity.
PMCID: PMC2871276  PMID: 20100975
Religion; Cardiovascular diseases; Obesity
12.  Inflammatory, Hemostatic, and Other Novel Biomarkers for Diabetic Retinopathy 
Diabetes Care  2009;32(9):1704-1709.
There are conflicting data regarding relationships of systemic biomarkers of inflammation, hemostasis, and homocysteine with diabetic retinopathy. We examined these relationships in the Multi-Ethnic Study of Atherosclerosis.
A total of 921 participants with diabetes were included. Diabetic retinopathy was graded from retinal photographs. We defined two outcomes: any diabetic retinopathy and vision-threatening diabetic retinopathy (severe nonproliferative diabetic retinopathy or worse). Systemic markers analyzed were C-reactive protein, homocysteine, fibrinogen, plasmin-α2-antiplasmin complex (PAP), interleukin-6, d-dimer, factor VIII, serum creatinine, and urinary albumin-to-creatinine (UAC) ratio.
Prevalence of diabetic retinopathy was 33.2% and vision-threatening diabetic retinopathy 7.1%. After adjusting for established risk factors (diabetes duration, A1C, systolic blood pressure, waist-to-hip ratio, and use of diabetes medications), fibrinogen (odds ratio 1.14 [95% CI 1.01–1.32], P = 0.05) and PAP (1.25 [1.05–1.50], P = 0.01) were associated with any diabetic retinopathy, while PAP (1.54 [1.13–2.11], P = 0.007) and homocysteine (1.57 [1.16–2.11], P = 0.003) were associated with vision-threatening diabetic retinopathy. Only PAP remained significant after additional adjustment for serum creatinine and UAC ratio. Area under receiver-operator characteristic curve (AUROC) for diabetic retinopathy was constructed for established and novel risk factors. Established risk factors accounted for a 39.2% increase of the AUROC, whereas novel markers (fibrinogen, PAP, homocysteine, serum creatinine, and UAC ratio) only accounted for an additional 2.2%.
There were few associations of novel markers of inflammation, hemostasis, and homocysteine with diabetic retinopathy after controlling for established risk factors. These data suggest that there is limited clinical use of these biomarkers for prediction of diabetic retinopathy.
PMCID: PMC2732144  PMID: 19549733
Annals of the rheumatic diseases  2011;70(3):482-487.
To examine the impact of systemic inflammation and serum lipids on cardiovascular disease (CVD) in rheumatoid arthritis (RA).
In a population-based RA incident cohort (1987 ACR criteria first met between 1988 and 2007), we collected serum lipid measures, erythrocyte sedimentation rates (ESR), C-reactive protein (CRP) measures and cardiovascular events including ischemic heart disease, and heart failure. Cox models were used to examine the association of lipids and inflammation with the risk of CVD and mortality adjusting for age, sex and year of RA incidence.
The study included 651 RA patients (mean age 55.8 years, 69% female); 67% were rheumatoid factor positive. ESR was associated with the risk of CVD (hazard ratio [HR] 1.2 per 10 mm/hr increase, 95% confidence interval [CI] 1.1, 1.3). Similar findings, although not statistically significant, were seen with CRP (p=0.07). We found a significant nonlinear association for total cholesterol (TCh) on risk of CVD, with 3.3-fold increased risk for TCh<4 mmol/L (95%CI 1.5, 7.2) and no increased risk of CVD for TCh≥4 mmol/L (p=0.57). Low low-density cholesterol (LDL<2 mmol/L) was associated with marginally increased risk of CVD (p=0.10); there was no increased risk for LDL≥2 mmol/L (p=0.76).
Inflammatory measures (particularly, ESR) are significantly associated with the risk of CVD in RA. Lipids may have paradoxical associations with the risk of CVD in RA, whereby lower TCh and LDL levels are associated with increased cardiovascular risk.
PMCID: PMC3058921  PMID: 21216812
rheumatoid arthritis; inflammation; lipid paradox; cardiovascular outcomes; ESR; CRP; lipids
14.  Novel Hemostatic Factor Levels and Risk of Ischemic Stroke: The Atherosclerosis Risk in Communities (ARIC) Study 
Background and Objective
The role of hemostatic factor levels in cerebral infarction remains uncertain. We studied the association of levels of several under-studied hemostatic factors with ischemic stroke in a population-based cohort.
The Atherosclerosis Risk in Communities (ARIC) study includes 15,792 individuals aged 45–54 years at intake. Hemostatic factors II, V, IX, X, XI, XII, plasminogen and α2-antiplasmin were measured on frozen citrate plasma samples from 1990 to 1992. A case-cohort design was used, including all incident ischemic strokes (n = 89) over a median of 7.5 years and a stratified cohort random sample (n = 412). To determine the association of hemostatic factors with incident ischemic stroke, we computed hazard ratios (HRs) using multivariate proportional hazard regression analyses adjusted for demographic and other cardiovascular risk factors.
The cohort random sample had a mean age (SD) of 56.9 (5.4) years and 42% were men. The age-, sex- and race-adjusted HRs for highest versus lowest quartiles were: factor XI (2.74, 95% CI 1.42–5.29), factor IX (1.92, 95% CI 0.99–3.73), and α2-antiplasmin (2.24, 95% CI 1.16–4.33). Correspondingly, the HRs of ischemic stroke per SD increment of factors XI, IX, and α2-antiplasmin were 1.64, 1.46 and 1.52, respectively (all p < 0.05). After multivariate adjustment including other clinical variables, the standardized HR remained significant for factor XI (1.50, 95% CI 1.10–2.05), but no other factor.
A greater level of factor XI was associated with an increased risk of ischemic stroke. Higher factor XI levels might help identify patients at elevated ischemic stroke risk.
PMCID: PMC2865476  PMID: 20299790
Stroke; Coagulation; Risk factors
15.  Multiple Risk Factor Intervention Trial Revisited: A New Perspective Based on Nonfatal and Fatal Composite Endpoints, Coronary and Cardiovascular, During the Trial 
The Multiple Risk Factor Intervention Trial evaluated a multifactor intervention on coronary heart disease (CHD) in 12 866 men. A priori defined endpoints (CHD death, CHD death or nonfatal myocardial infarction, cardiovascular disease [CVD] death, and all-cause death) did not differ significantly between the special intervention (SI) and usual care (UC) groups over an average follow-up period of 7 years. Event rates were lower than anticipated, reducing power. Other nonfatal CVD outcomes were prespecified but not considered in composite outcomes comparing SI with UC.
Methods and Results
Post-trial CVD mortality risks associated with nonfatal CVD events occurring during the trial were determined with Cox regression. Nonfatal outcomes associated with >2-fold risk of CVD death over the subsequent 20 years were combined with during-trial deaths to create 2 new composite outcomes. SI/UC hazard ratios and 95% confidence intervals were estimated for each composite outcome. Of 10 during-trial nonfatal events, 6 were associated (P<0.001) with >2-fold risk of CVD death. A CHD composite outcome (CHD death, myocardial infarction [clinical or serial ECG change], CHF, or coronary artery surgery) was experienced by 520 SI and 602 UC men (SI/UC hazard ratio = 0.86; 95% confidence interval, 0.76–0.97; P=0.01). A CVD composite outcome (CHD [as above], other CVD deaths, stroke, or renal impairment) was experienced by 581 SI and 652 UC men (hazard ratio = 0.89; 95% confidence interval, 0.79–0.99; P=0.04).
In post hoc analyses, composite fatal/nonfatal CHD and CVD rates over 7 years were significantly lower for SI than for UC. These findings reinforce recommendations for improved dietary/lifestyle practices, with pharmacological therapy as needed, to prevent and control major CVD risk factors.
PMCID: PMC3541632  PMID: 23316301
clinical trials; primary prevention; risk factors
16.  Relevance of hemostatic risk factors on coronary morphology in patients with diabetes mellitus type 2 
The influence hemostatitc parameters on the morphological extent and severity of coronary artery disease were studied in patients with and without DM type 2.
It is known that patients with diabetes (DM) have abnormal metabolic and hemostatic parameters
Of 150 consecutive patients with angiographically proven coronary artery disease 29 presented with DM. Additionally to parameters of lipid-metabolism fibrinogen, tissue-plasminogenactivator (t-PA), plasminogen-activator-inhibitor (PAI), plasmin-a-antiplasmin (PAP), prothrombin-fragment 1+2 (F1+2), thrombin-antithrombin (TAT), von-willebrand-factor (vWF), platelet factor 4 (PF4), glykomembranproteine 140 (GMP140) and the rheologic parameters plasma viscosity and red blood cell aggregation were evaluated. The extent and severity of CAD was evaluated according to the criteria of the American Heart Association.
Patients with DM presented with a higher number of conventional risk factors as compared to non-diabetic patients. Additionally there were significant differences for F1+2, red blood cell aggregation and PAI. Diabetic patients showed a more severe extent of coronary arteriosclerosis, which also could be found more distally. A significant relationship between blood-glucose, thrombocyte-activation (vWF), endogenous fibrinolysis (PAI) and the severity of CAD and a more distal location of stenoses could be found (r = 0.6, p < 0.001).
Patients with coronary artery disease and DM type 2 showed marked alterations of metabolic, hemostatic, fibrinolytic and rheologic parameters, which can produce a prothrombogenic state. A direct association of thrombogenic factors on coronary morphology could be shown. This can be the pathophysiologic mechanism of more severe and distal pronounced coronary atherosclerosis in these patients.
PMCID: PMC2688504  PMID: 19419582
17.  A Genetic Risk Score is Associated with Incident Cardiovascular Disease and Coronary Artery Calcium - The Framingham Heart Study 
Limited data exist regarding the use of a genetic risk score for predicting risk of incident cardiovascular disease (CVD) in US based samples.
Methods and Results
Using findings from recent GWAS, we constructed genetic risk scores (GRS) comprised of 13 genetic variants associated with myocardial infarction (MI) or other manifestations of CHD and 102 genetic variants associated with CHD or its major risk factors. We also updated the 13 SNP GRS with 16 SNPs recently discovered by GWAS. We estimated the association, discrimination and risk reclassification of each GRS for incident cardiovascular events and for prevalent coronary artery calcium (CAC).
In analyses adjusted for age, sex, CVD risk factors and parental history of CVD, the 13 SNP GRS was significantly associated with incident hard CHD (HR 1.07, 95% CI 1.00-1.15, p=0.04), CVD (hazard ratio [HR] per-allele 1.05, 95% confidence interval [CI] 1.01-1.09; p=0.03), and high CAC (defined as >75th age and sex-specific percentile; odds ratio [OR] per-allele 1.18, 95% CI 1.11-1.26, p=3.4 × 10-7). The GRS did not improve discrimination for incident CHD or CVD but led to modest improvements in risk reclassification. However, significant improvements in discrimination and risk reclassification were observed for the prediction of high CAC. The addition of 16 newly discovered SNPs to the 13 SNP GRS did not significantly modify these results.
A GRS comprised of 13 SNPs associated with coronary disease is an independent predictor of cardiovascular events and of high CAC, modestly improves risk reclassification for incident CHD and significant improves discrimination for high CAC. The addition of recently discovered SNPs did not significantly improve the performance of this GRS.
PMCID: PMC3292865  PMID: 22235037
Genetics; single nucleotide polymorphisms; cardiovascular disease; coronary heart disease; risk prediction; reclassification
18.  Traditional risk factors and D-dimer predict incident cardiovascular disease events in chronic HIV infection 
AIDS (London, England)  2010;24(10):1509-1517.
Cardiovascular disease (CVD) contributes significantly to HIV-related morbidity and mortality. Chronic immune activation and inflammation are thought to augment the progression of atherosclerotic disease. In this retrospective, case-control study of HIV-infected subjects, we investigated the association of traditional cardiac risk factors, HIV-related disease and inflammation with CVD events.
HIV-infected subjects who experienced an incident CVD event while enrolled in National Institutes of Health clinical protocols from 1995-2009 were matched 2:1 to HIV-infected subjects without known CVD. Markers of inflammation and cell activation were measured in serum or plasma using ELISA-based assays and peripheral mononuclear cells by four-color flow cytometry.
Fifty-two patients experienced an incident CVD event. Events were related to smoking, dyslipidemia, hyperglycemia and family history as well as D-dimer, sVCAM-1, TIMP-1, and soluble tissue factor but not hsCRP. No significant differences in antiviral therapy, CD4+ T-cell count or CD38 and HLA-DR expression were identified between cases and controls. In multivariable analysis, smoking, family history, D-dimer, and glucose were independently related to CVD risk.
In this cohort, CVD risk was related to traditional CVD risk factors and markers of thrombosis and endothelial damage but not to hsCRP or markers of T-cell activation such as CD38+/HLA-DR coexpression. D-dimer may help identify HIV-infected patients at elevated CVD risk.
PMCID: PMC2884071  PMID: 20505494
HIV; cardiovascular disease; myocardial infarction; smoking; D-dimer; tissue factor; VCAM-1
19.  Paternal and Maternal History of Myocardial Infarction and Cardiovascular Diseases Incidence in a Dutch Cohort of Middle-Aged Persons 
PLoS ONE  2011;6(12):e28697.
A positive parental history of myocardial infarction (MI) is an independent risk factor for cardiovascular diseases (CVD). However, different definitions of parental history have been used. We evaluated the impact of parental gender and age of onset of MI on CVD incidence.
Baseline data were collected between 1993 and 1997 in 10 524 respondents aged 40–65 years. CVD events were obtained from the National Hospital Discharge Register and Statistics Netherlands. We used proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for CVD incidence and adjusted for lifestyle and biological risk factors.
At baseline, 36% had a parental history of MI. During 10-year follow-up, 914 CVD events occurred. The age and gender adjusted HR was 1.3 (95% CI 1.1–1.5) for those with a paternal MI, 1.5 (1.2–1.8) for those with a maternal MI and 1.6 (1.2–2.2) for those with both parents with an MI. With decreasing parental age of MI, HR increased from 1.2 (1.0–1.6) for age ≥70 years to 1.5 (1.2–1.8) for age <60 years for a paternal MI and from 1.1 (0.9–1.5) to 2.2 (1.6–3.0) for a maternal MI. The impact of having a mother with MI before age 60 significantly differed in women [(2.9 (1.8–4.6)] and men [1.5 (0.9–2.6)]. Adjustment only slightly influenced HRs for maternal MI.
Respondents with a parental history of MI have an increased CVD incidence, in particular with parental onset of MI before age 70. A maternal history of MI before age 60 was the strongest predictor of CVD incidence.
PMCID: PMC3241680  PMID: 22194890
20.  Higher plasma high-mobility group box 1 levels are associated with incident cardiovascular disease and all-cause mortality in type 1 diabetes: a 12 year follow-up study 
Diabetologia  2012;55(9):2489-2493.
This study aimed to investigate the associations of plasma levels of the pro-inflammatory cytokine high-mobility group box 1 (HMGB1) with incident cardiovascular disease (CVD) and all-cause mortality in patients with type 1 diabetes.
We prospectively followed 165 individuals with diabetic nephropathy and 168 individuals with persistent normoalbuminuria who were free of CVD at study entry and in whom levels of HMGB1 and other cardiovascular risk factors were measured at baseline.
During the course of follow-up (median, 12.3 years [interquartile range, 7.8–12.5]), 80 patients died, 82 suffered a fatal (n = 46) and/or non-fatal (n = 53) CVD event. After adjustment for age, sex, case–control status and other risk factors, patients with higher levels of loge HMGB1 had a higher incidence of fatal and non-fatal CVD and all-cause mortality: HR 1.55 (95% CI 0.94, 2.48) and HR 1.86 (95% CI 1.18, 2.93), respectively. Further adjustments for differences in markers of low-grade inflammation, endothelial and renal dysfunction and arterial stiffness did not attenuate these associations because plasma levels of HMGB1 were not independently associated with these variables.
In patients with type 1 diabetes, higher levels of plasma HMGB1 are independently associated with a higher risk of all-cause mortality and, to a lesser extent, with a higher incidence of CVD. Larger studies are needed to ascertain more definitely the role of HMGB1 in the development of vascular complications in diabetes.
Electronic supplementary material
The online version of this article (doi:10.1007/s00125-012-2622-1) contains peer-reviewed but unedited supplementary material, which is available to authorised users.
PMCID: PMC3411294  PMID: 22752054
All-cause mortality; Cardiovascular disease; High-mobility group box 1; Type 1 diabetes mellitus
21.  Coronary Artery Calcification Compared with Carotid Intima-Media Thickness in Prediction of Cardiovascular Disease Incidence: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Archives of internal medicine  2008;168(12):1333-1339.
Coronary artery calcium (CAC) and carotid intima-media thickness (IMT) are noninvasive measures of atherosclerosis that consensus panels have recommended as possible additions to risk factor assessment for predicting the probability of cardiovascular disease (CVD) occurrence.
To assess whether maximum carotid IMT or CAC (Agatston Score) is the better predictor of incident CVD.
Design, Setting, Patients
Prospective cohort study of 45–84 year-olds initially free of CVD (n = 6,698) in four ethnic groups, with standardized carotid IMT and CAC measures at baseline, in six field centers of the Multi-Ethnic Study of Atherosclerosis (MESA).
Main Outcome Measure(s)
Incident CVD events (coronary heart disease, stroke, and fatal CVD) over a maximum of 5.3 years of follow-up.
There were 222 CVD events during follow-up. CAC was associated more strongly than carotid IMT with risk of incident CVD. After adjustment for each other and traditional CVD risk factors, the hazard of CVD increased 2.1-fold (95% CI 1.8–2.5) for each standard deviation greater level of log-transformed CAC, versus 1.3-fold (95% CI 1.1–1.4) for each standard deviation greater maximum IMT. For coronary heart disease, the hazard ratios per standard deviation increment were 2.5-fold (95% CI 2.1–3.1) for CAC and 1.2-fold (95% CI 1.0–1.4) for IMT. An ROC analysis also suggested that CAC predicted incident CVD better than IMT did.
Although whether and how to clinically use bio-imaging tests of subclinical atherosclerosis remains a topic of debate, this study found that CAC predicts subsequent CVD events better than does carotid IMT.
PMCID: PMC2555989  PMID: 18574091
22.  Cysteamine enhances the procoagulant activity of Factor VIII-East Hartford, a dysfunctional protein due to a light chain thrombin cleavage site mutation (arginine-1689 to cysteine). 
Journal of Clinical Investigation  1992;89(5):1375-1381.
We have recently identified the molecular defect responsible for cross-reacting material-positive hemophilia A in two unrelated patients in which the substitution of cysteine for arginine-1689 (Factor VIII-East Hartford[FVIII-EH]) abolishes a critical Factor VIII light chain thrombin cleavage site. As other mutant proteins with a cysteine for arginine substitution have been modified in the presence of cysteamine, we have determined the effect of this and other reducing agents on FVIII-EH function. Cysteamine concentrations between 0.1 and 10 mM caused dose- and time-dependent increases in FVIII-EH VIII:C activity, as much as 14-fold (to 35 and 62 U/dl for the two patients tested). Comparable data were obtained in a standard one-stage VIII:C coagulation assay and in a chromogenic substrate assay measuring Factor Xa generation. Thrombin cleavage of the FVIII-EH light chain in the presence of cysteamine was documented by immunoadsorption and analysis. Cystamine and cysteamine-S-phosphate, similar compounds that do not possess a free thiol group, had no effect. Cysteamine augmentation of FVIII-EH VIII:C was abolished by the simultaneous addition of N-ethyl maleimide or iodoacetamide, but these sulfhydryl blocking agents did not prevent the VIII:C increase and light chain cleavage by thrombin if the plasma samples were dialyzed to remove the inhibitors before adding the cysteamine. However, incubation with DTT before iodoacetamide prevented the cysteamine effect after dialysis. These data suggest that when isolated from patient plasma, FVIII-EH cysteine-1689 is present in a disulfide bond. This bond is cleaved by cysteamine to form a new mixed disulfide, a pseudolysine that restores a thrombin cleavage site that is essential for procoagulant function.
PMCID: PMC443005  PMID: 1569180
23.  The Relationship of Left Ventricular Mass and Geometry to Incident Cardiovascular Events: The MESA Study 
The purpose of this study was to evaluate the relationship of left ventricular mass and geometry measured with cardiac MRI to incident cardiovascular events in the Multi-Ethnic Study of Atherosclerosis (MESA) study.
MRI is highly accurate for evaluation of heart size and structure and has not previously been used in a large epidemiologic study to predict cardiovascular events.
5098 participants in the MESA study underwent cardiac MRI at the baseline examination and were followed for a median of 4 years. Cox proportional hazard models were constructed to predict the endpoints of coronary heart disease (CHD), stroke and heart failure (HF) after adjustment for cardiovascular risk factors.
216 incident events were observed during the follow-up period. In adjusted models, the endpoints of incident CHD and stroke were positively associated with increased left ventricular mass to volume ratio (coronary heart disease, hazard ratio 2.1 per g/ml, p = 0.02; stroke, hazard ratio 4.2 per g/ml, p =0.005). In contrast, left ventricular mass showed the strongest association with incident HF events (hazard ratio 1.4 per 10% increment, p < 0.0001). HF events occurred primarily in participants with left ventricular hypertrophy, i.e.,≥ 95th percentile of left ventricular mass (hazard ratio 8.6, confidence interval, 3.7 – 19.9, reference group <50th percentile of LV mass).
Left ventricular size was related to incident HF, stroke and CHD in this multi-ethnic cohort. While body-size adjusted left ventricular mass alone predicted incident HF, concentric ventricular remodeling predicted incident stroke and CHD.
PMCID: PMC2706368  PMID: 19095132
Heart failure; stroke; coronary heart disease; epidemiology; magnetic resonance imaging; left ventricular hypertrophy
24.  Plasma Leptin Levels and Incidence of Heart Failure, Cardiovascular Disease, and Total Mortality in Elderly Individuals 
Diabetes Care  2008;32(4):612-616.
Obesity predisposes individuals to congestive heart failure (CHF) and cardiovascular disease (CVD). Leptin regulates energy homeostasis, is elevated in obesity, and influences ventricular and vascular remodeling. We tested the hypothesis that leptin levels are associated with greater risk of CHF, CVD, and mortality in elderly individuals.
We evaluated 818 elderly (mean age 79 years, 62% women) Framingham Study participants attending a routine examination at which plasma leptin was assayed.
Leptin levels were higher in women and strongly correlated with BMI (P < 0.0001). On follow-up (mean 8.0 years), 129 (of 775 free of CHF) participants developed CHF, 187 (of 532 free of CVD) experienced a first CVD event, and 391 individuals died. In multivariable Cox regression models adjusting for established risk factors, log-leptin was positively associated with incidence of CHF and CVD (hazard ratio [HR] per SD increment 1.26 [95% CI 1.03–1.55] and 1.28 [1.09–1.50], respectively). Additional adjustment for BMI nullified the association with CHF (0.97 [0.75–1.24]) but only modestly attenuated the relation to CVD incidence (1.23 [1.00–1.51], P = 0.052). We observed a nonlinear, U-shaped relation between log-leptin and mortality (P = 0.005 for quadratic term) with greater risk of death evident at both low and high leptin levels.
In our moderate-sized community-based elderly sample, higher circulating leptin levels were associated with a greater risk of CHF and CVD, but leptin did not provide incremental prognostic information beyond BMI. Additional investigations are warranted to elucidate the U-shaped relation of leptin to mortality.
PMCID: PMC2660448  PMID: 19114611
25.  Inflammation, Coagulation and Cardiovascular Disease in HIV-Infected Individuals 
PLoS ONE  2012;7(9):e44454.
The SMART study was a trial of intermittent use of antiretroviral therapy (ART) (drug conservation [DC]) versus continuous use of ART (viral suppression [VS]) as a strategy to reduce toxicities, including cardiovascular disease (CVD) risk. We studied the predictive value of high sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6) and D-dimer with CVD morbidity and mortality in HIV-infected patients who were enrolled in SMART beyond other measured CVD risk factors.
A blood sample was available in 5098 participants who were enrolled in the SMART study for the measurement of IL-6, hsCRP and D-dimer. Hazard ratios (HR) with 95% CI for CVD events were estimated for each quartile (Q) for each biomarker vs the 1st quartile and for 1 SD higher levels. For both treatment groups combined, unadjusted and adjusted HRs were determined using Cox regression models.
There were 252 participants who had a CVD event over a median follow-up of 29 months. Adjusted HRs (95% CI) for CVD for Q4 vs Q1 were 4.65 (2.61, 8.29), 2.10 (1.40, 3.16), and 2.14 (1.38, 3.33) for IL-6, hsCRP and D-dimer, respectively. Associations were similar for the DC and VS treatment groups (interaction p-values were >0.30). The addition of the three biomarkers to a model that included baseline covariates significantly improved model fit (p<0.001). Area under the curve (AUC) estimates improved with inclusion of the three biomarkers in a model that included baseline covariates corresponding to other CVD risk factors and HIV factors (0.741 to 0.771; p<0.001 for difference).
In HIV-infected individuals, IL-6, hsCRP and D-dimer are associated with an increased risk of CVD independent of other CVD risk factors. Further research is needed to determine whether these biomarkers can be used to improve CVD risk prediction among HIV positive individuals.
PMCID: PMC3438173  PMID: 22970224

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