Resistin, Adiponectin, and Risk of Heart Failure the Framingham Offspring Study
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Journal of the American College of Cardiology Vol. 53, No. 9, 2009 © 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2008.07.073 Resistin, Adiponectin, and Risk of Heart Failure The Framingham Offspring Study David S. Frankel, MD,* Ramachandran S. Vasan, MD,†‡ Ralph B. D’Agostino, SR,PHD,† Emelia J. Benjamin, MD, SCM,†‡§ Daniel Levy, MD,†ʈ Thomas J. Wang, MD,†¶ James B. Meigs, MD, MPH†# Boston and Framingham, Massachusetts; and Bethesda, Maryland Objectives We tested the association of the adipokines resistin and adiponectin with incident heart failure. Background Abnormal concentrations of adipokines may partially explain the association between obesity and heart failure. Methods We related circulating adipokine concentrations to the incidence of heart failure in 2,739 participants in the Fra- mingham Offspring Study. Results During 6 years of follow-up, 58 participants developed new-onset heart failure. In proportional hazards models (adjusting for age, sex, blood pressure, antihypertensive treatment, diabetes, smoking, total/high-density lipopro- tein cholesterol ratio, prevalent coronary heart disease, valvular heart disease, left ventricular hypertrophy, and estimated glomerular filtration rate) using the lowest third of the resistin distribution as the referent, the hazard ratios for heart failure in the middle and top thirds were 2.89 (95% confidence interval [CI]: 1.05 to 7.92) and 4.01 (95% CI: 1.52 to 10.57), respectively (p ϭ 0.004 for trend). Additional adjustment for body mass index, insulin resistance (measured with the homeostasis model), C-reactive protein, and B-type natriuretic peptide did not substantively weaken this association (multivariable hazard ratios [HRs]: 2.62 and 3.74, p ϭ 0.007). In the maximally adjusted model, each SD increment in resistin (7.45 ng/ml) was associated with a 26% increase in heart failure risk (95% CI: 1% to 60%). Concentrations of adiponectin were not associated with heart failure (multivariable HRs: 0.87 and 0.97, p ϭ 0.9). Conclusions Increased circulating concentrations of resistin were associated with incident heart failure, even after accounting for prevalent coronary heart disease, obesity, and measures of insulin resistance and inflammation. The findings suggest a role for resistin in human disease and a novel pathway to heart failure. (J Am Coll Cardiol 2009;53: 754–62) © 2009 by the American College of Cardiology Foundation Heart failure is a common health problem that is increasing development of prevention strategies. Numerous risk factors in prevalence (1). Despite improvements in treatment, heart have been well established, including age, coronary heart failure remains a highly lethal disease (2). Identification of disease (CHD), hypertension, valvular heart disease, left risk factors for the development of heart failure could aid ventricular hypertrophy, diabetes, and obesity (3). Recent investigations have highlighted the association of over- weight and lesser degrees of obesity with increased inci- From the *Department of Medicine, Massachusetts General Hospital, Boston, dence of heart failure (4). Insulin resistance is likely to Massachusetts; †Framingham Heart Study, Framingham, Massachusetts; ‡Depart- ment of Medicine, School of Medicine, and §Department of Epidemiology, School account for some, but not all of this association (5). of Public Health, Boston University, Boston, Massachusetts; ʈNational Heart, Lung, and Blood Institute, Bethesda, Maryland; and the ¶Division of Cardiology and See page 763 #General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Supported by the National Heart, Lung, and Blood Institute’s Framingham Heart Study (contract no. The mechanisms by which insulin resistance and obesity N01-HC-25195), 2K24HL404334 (Dr. Vasan), RO1 HL076784 (Dr. Benjamin), 1R01 AG028321 (Dr. Benjamin), and an American Diabetes Association Career promote heart failure risk remain uncertain. Proposed Development Award (Dr. Meigs). Dr. D’Agostino has received honoraria from mechanisms include a systemic inflammatory state with Sanofi-Aventis and serves on advisory boards for Pfizer and Bayer. Dr. Meigs increased concentrations of circulating inflammatory medi- currently has research grants from GlaxoSmithKline and serves on safety boards for GlaxoSmithKline and Lilly. The funding agencies had no influence over the content ators such as C-reactive protein, plasminogen activator or conduct of the analysis or the decision to publish the findings. Dr. Frankel had full inhibitor-1, tumor necrosis factor-alpha, interleukin-6, an- access to all of the data in the study and takes responsibility for the integrity of the giotensinogen, vascular endothelial growth factor, and se- data and the accuracy of the data analysis. Manuscript received April 9, 2008; revised June 11, 2008, accepted July 1, 2008. rum amyloid A3 (6). Increased circulating concentrations of JACC Vol. 53, No. 9, 2009 Frankel et al. 755 March 3, 2009:754–62 Inflammatory Adipokines and HF ␣ tumor necrosis factor- , interleukin-6, and C-reactive pro- 2,739 individuals for analysis. Abbreviations tein have been associated with increased incidence of heart Participants not included in the and Acronyms failure (7,8). analysis were older with slightly body mass index ؍ BMI Several novel proteins secreted by adipocytes (adipo- greater levels of CHD risk factors coronary heart ؍ CHD kines), including resistin and adiponectin, have pro- and than those included. The study disease anti-inflammatory properties and are correlated with con- protocol was approved by the In- confidence interval ؍ CI centrations of plasma cytokines (9,10). Like other inflam- stitutional Review Board of the high-density ؍ HDL matory markers, greater concentrations of resistin have been Boston University School of Med- lipoprotein associated with CHD in some (9,11–13) but not in other icine, and all participants provided insulin ؍ HOMA-IR studies (14,15). A single, cross-sectional analysis of patients written informed consent. resistance measured with with established heart failure found that greater concentrations Covariate definitions and labo- the homeostasis model hazard ratio ؍ of resistin correlated with increased disease severity and also ratory methods. We measured HR /urine albumin ؍ predicted adverse cardiac outcomes (16). However, resistin has height, weight, and waist cir- UACR yet to be examined as a predictor of new-onset heart failure in cumference by using a standard- creatinine ratio the community. ized protocol. Body mass index Concentrations of adiponectin are decreased in insulin (BMI) was calculated as the resistance and obesity, an inverse association that suggests weight in kilograms divided by the square of the height in adiponectin may mitigate the adverse effects of circulating meters (kg/m2). The examination blood pressure was taken inflammatory mediators, as has been demonstrated in as the mean of 2 physician-obtained measurements after the experimental models (17,18). Low concentrations of participant had been seated for at least 5 min. We defined adiponectin have been associated with increased risk of diabetes as a fasting plasma glucose Ͼ125 mg/dl or treat- CHD (19) and inconsistently related to heart failure ment with blood glucose-lowering medications. Coronary incidence (20,21). In patients with established heart heart disease was defined by standard Framingham Heart failure, low adiponectin has paradoxically been associated Study criteria as any of new-onset angina, coronary insuf- with decreased mortality (21,22). Thus, the role of ficiency, or fatal or nonfatal myocardial infarction. We adiponectin in the development of heart failure remains defined valvular heart disease by the presence of a systolic uncertain as well. murmur of grade 3/6 or greater or any diastolic murmur With this background in mind, we examined the associ- (24). We used a continuously distributed electrocardio- ation of circulating resistin and adiponectin concentrations graphic metric of left ventricular hypertrophy by summing with the development of heart failure in a community-based the voltages of the R-wave in lead aVL and the S-wave in sample. We hypothesized that greater concentrations of lead V3 (25). Those who reported smoking cigarettes resistin and lower concentrations of adiponectin would be regularly during the year before the examination were associated with an increased risk of heart failure. Addition- considered current smokers. ally, we postulated that this association would be attenuated Participants fasted overnight to provide blood specimens. by adjustment for associated variations in obesity, insulin Samples were frozen at Ϫ80°C until assay. Laboratory resistance, and inflammation that constitute potential me- methods for creatinine, glucose, insulin, and lipid assays diatory mechanisms. have been published previously (26,27). Assay coefficients of variation were Ͻ3% for glucose and Ͻ10% for insulin. We calculated insulin resistance with the homeostasis model Methods using the following validated formula: HOMA-IR ϭ (fast- Study participants. The Framingham Offspring Study is a ing glucose [mmol/l] ϫ fasting insulin [U/ml])/22.5 community-based, prospective, observational study of car- (28,29). C-reactive protein was measured with an immuno- diovascular disease and its risk factors. The study began in precipitation assay (IncStar, Stillwater, Minnesota). We 1971 with the enrollment