Skip to main content

Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes

Abstract

Background

Circulating thrombospondin-2 (TSP2) levels were associated with the development of heart failure (HF) in recent studies. However, these studies included only a minority of patients with type 2 diabetes, which is associated with an increased HF risk. As hyperglycemia induces TSP2 expression and its tissue expression increases in type 2 diabetes, we investigated the prospective association of circulating TSP2 with incident HF hospitalization (HHF), and its associations with longitudinal changes of echocardiographic parameters in type 2 diabetes.

Methods

Baseline serum TSP2 levels were measured in 4949 patients with type 2 diabetes to determine its association with incident HHF using multivariable Cox regression analysis. In the echocardiographic study, baseline serum TSP2 levels were measured in another 146 patients with type 2 diabetes but without cardiovascular diseases who underwent detailed transthoracic echocardiography at baseline and after 1 year.

Results

Over a median follow-up of 7.8 years, 330 of 4949 patients (6.7%) developed incident HHF. Baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.31, 95%CI 1.06–1.62, p = 0.014) after adjustments for baseline conventional cardiovascular risk factors, atrial fibrillation, estimated glomerular filtration rate, albuminuria and high-sensitivity C-reactive protein level, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop-diuretics, aspirin, insulin, metformin and sodium-glucose co-transporter 2 inhibitors. Moreover, baseline serum TSP2 levels were independently associated with increase in average E/e’ and left atrial volume index (p = 0.04 and < 0.01, respectively).

Conclusion

Serum TSP2 levels were independently associated with both incident HHF and deterioration in diastolic function in type 2 diabetes.

Trial registration

Not Applicable

Introduction

Thrombospondin-2 (TSP2) is a matricellular protein that interacts with various ligands such as extracellular matrix (ECM) structural proteins and is implicated in the pathogenesis of cardiovascular diseases (CVD)[1, 2]. Circulating TSP2 levels have been associated with adverse cardiovascular outcomes in patients with heart failure (HF) with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively) [3, 4]. Recently, plasma proteomic profiling had demonstrated that circulating TSP2 level was associated with incident HF in a population-based cohort, as well as the presence of acute HF among individuals attending the emergency department, independent of N-terminal pro-hormone BNP (NT-proBNP) and B-type natriuretic peptide (BNP), respectively [5, 6]. In patients with advanced HF, circulating TSP2 levels decreased significantly from baseline following heart transplantation [5, 6]. However, in all these cohorts, patients with type 2 diabetes only constituted a small proportion, and the prognostic significance of circulating TSP2 levels with regard to HF in type 2 diabetes remains undefined. This is a significant knowledge gap because while patients with type 2 diabetes are at high risk of HF and its adverse outcomes [7, 8], the use of several anti-diabetic agents such as glitazones and sodium glucose co-transporter 2 inhibitors (SGLT2i) has been associated with altered risk of hospitalization for heart failure (HHF) [9, 10]. Most importantly, hyperglycemia induces TSP2 expression and increased tissue expression has been observed in patients with type 2 diabetes [11,12,13].

In this study with an exclusively diabetic population, we investigated prospectively the association of circulating TSP2 with incident HHF, an outcome that can be significantly reduced with the use of SGLT2i [14,15,16,17,18,19]. Moreover, the prospective associations between circulating TSP2 and the longitudinal changes of echocardiographic parameters in type 2 diabetes were also evaluated.

Methods

The study comprised two parts. Part 1 was a prospective cohort study that evaluated the association between baseline circulating TSP2 levels and the development of HHF in type 2 diabetes, whereas Part 2 was an echocardiographic study to investigate whether baseline circulating TSP2 levels were associated with the longitudinal changes in left ventricular (LV) systolic and diastolic functions in type 2 diabetes.

Study participants

In Part 1, all participants were recruited from the Hong Kong West Diabetes Registry (HKWDR) which consisted of patients with type 2 diabetes regularly followed up at the medical specialist clinics of the Hong Kong West Cluster since 2008. On enrolment to HKWDR, all Chinese patients were invited to participate in a prospective cohort study that aimed to identify the risk factors, including genetic and serum biomarkers, of diabetic complications [20]. In the current study that evaluated the association between serum TSP2 levels and incident HHF, individuals were excluded if they had history of HF, on renal replacement therapy or had received a kidney transplant at baseline. Moreover, only individuals who had follow-up for more than one year after recruitment to HKWDR were included in the analysis to minimize the possibility of reverse causation.

In Part 2, all participants were recruited from the Chinese Diabetic Heart Study (CDHS), which consisted of Chinese patients who had type 2 diabetes but without CVD or severe structural heart disease and were regularly followed up in the medical specialist clinics of Queen Mary Hospital, Hong Kong between July 2011 and August 2014 [21, 22]. All CDHS participants received blood tests and transthoracic echocardiography (ECHO) at baseline to investigate the cardiovascular manifestations and underlying pathophysiology of Chinese patients with type 2 diabetes. These participants were subsequently invited for one follow-up ECHO after at least 1 year.

In both Parts 1 and 2, the study protocols were approved by the Institutional Review Board of the University of Hong Kong / Hospital Authority Hong Kong West Cluster (Ref: UW 07-378 and UW 11–121, respectively). Written informed consent was obtained from all recruited participants prior to any study related procedures.

Clinical and biochemical assessments

In both Parts 1 and 2, participants attended each study visit after an overnight fast of at least 8 h. At the baseline visit, demographic and anthropometric data including body mass index (BMI), waist circumference (WC), blood pressure (BP) and smoking history were obtained. Fasting blood was collected for baseline evaluation of glycaemic and lipid status, with the remaining blood stored in aliquots at − 70oC for assays of biomarkers of diabetic complications. Baseline estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation as described previously [23]. In Part 1, albuminuria status was also assessed using at least two random urine samples on two separate occasions within six months, and categorized according to their urine to albumin creatinine ratio (UACR): <30 mg/g (A1), 30–300 mg/g (A2) and > 300 mg/g (A3) [24]. Serum high sensitivity C-reactive protein (hsCRP) was measured with a high-sensitivity, particle-enhanced immune-turbidimetric assay (Roche Diagnostics, GmbH, Mannheim, Germany).

Echocardiography assessments

In Part 2 of the study, comprehensive transthoracic ECHO examination was performed using commercially available ECHO machines (Vingmed Vivid E9, General Electric Vingmed Ultrasound, Milwaukee, WI, USA) at baseline and follow-up as described previously [22]. Images were obtained using a 3.5-MHz transducer and digitally stored into three cardiac cycles for analysis by EchoPAC version 112.0 (General Electric Vingmed, Horten, Norway). LV posterior wall thickness and inter-ventricular septal dimension at end-diastole (LVPWd and IVSd, respectively) were measured using a two-dimensional ECHO guided M-mode approach. LV mass was calculated according to the Devereux formula, whereas LV ejection fraction (LVEF) and volumes were assessed using the modified biplane Simpson’s method in both apical two- and four-chamber views. Left atrial volume (LAV) was assessed by single-plane disk summation method in apical four-chamber view. LAV index (LAVi) was determined by LAV divided by the body surface area of the participants. Tissue and pulse-wave Doppler imaging were applied to assess LV diastolic function in apical four-chamber view. Peak trans-mitral flow velocities in early (E-wave) and late diastole (A-wave) were measured to calculate the E/A ratio. The peak velocities of septal and lateral mitral annulus in early diastole (e’) were also determined by tissue Doppler imaging to calculate the average E/e’.

Measurement of serum TSP2 levels

Serum TSP2 levels were measured with an enzyme-linked immunosorbent assay (ELISA) kit for human TSP-2, which utilized a pair of monoclonal antibodies recognizing distinct sites of human TSP2. (ImmunoDiagnostics Limited, Hong Kong) The assay was highly specific to human TSP2 and did not cross-react with human TSP1, TSP3, TSP4 and TSP5. The lowest detection limit was 0.156 ng/ml. The intra- and inter-assay precision were < 4.6% and < 7.2%, respectively.

Definitions of clinical variables and outcomes

In our study, dyslipidemia was defined as fasting triglycerides (TG) ≥150 mg/dL, high-density lipoprotein cholesterol (HDL-C) < 40 mg/dL in men and < 50 mg/dL in women, and low-density lipoprotein cholesterol (LDL-C) ≥100 mg/dL, or on lipid-lowering agents. Hypertension was defined as BP ≥140/90 mmHg or the use of anti-hypertensive medications. Although SGLT2i usage has been shown to decrease the risk of HHF in several landmark randomized controlled studies [10], SGLT2i only became available locally after 2015. Therefore, the use of SGLT2i was included as a time-dependent covariate in our prospective evaluation of the association between serum TSP2 levels and incident HHF. SGLT2i usage was defined by the continuous prescription of canagliflozin, dapagliflozin, empagliflozin and ertugliflozin for at least 90 days during the study period from the initiation of medication to the development of outcome or end of observation, whichever was earlier, and classified based on their cumulative daily defined dose (cDDD) as described by the World Health Organization [25]. cDDD reflects the average daily maintenance dose of a drug prescribed for the main indication in an adult. In this study, cDDD was calculated as the sum of dispensed defined daily doses (DDD) of all prescribed SGLT2i during the study period. One DDD of SGLT2i is equivalent to daily use of dapagliflozin 10 mg, empagliflozin 17.5 mg, canagliflozin 200 mg, or ertugliflozin 10 mg.

All outcomes were recorded and verified from the Hong Kong Hospital Authority database or their private practitioners as of 30 June 2020. HHF, the primary outcome of interest in this study, was defined as the first recorded hospitalization with HF as the principle diagnosis coded by a physician based on the ICD-9. The diagnosis were adjudicated and reviewed by two physicians independently, who took into account a constellation of symptoms (shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea), signs (ankle oedema, basal chest crepitations), chest X-ray or transthoracic ECHO findings if available (pulmonary congestion, suboptimal LVEF) and HF treatment (use of intravenous or increased dose of oral diuretics). Disagreements between the two adjudicating physicians were resolved by a third.

Statistical analysis

All data were analysed with IBM SPSS Statistics 26.0 (http://www.IBM.com/SPSS) and R version 3.2.3 (http://www.r-project.org). Kolmogorov-Smirnov test was used to test for normality of data. Data that were skewed were either analysed by non-parametric tests, or logarithmically transformed to obtain near normality before analysis. Values were reported as means ± standard deviation (SD), or medians with 25th and 75th percentiles for variables with skewed data, or percentages, as appropriate. Comparisons between groups were analysed by Chi-square test for categorical variables, whereas continuous variables were compared using independent t or Mann-Whitney U test as appropriate. Paired t-test was performed to compare changes in ECHO parameters between baseline and follow-up. Pearson correlation analysis was conducted to determine the relationship between serum TSP2 levels and other clinical variables. Multivariable Cox regression analysis was performed to evaluate the associations of baseline circulating TSP2 levels with incident HHF. The Cox regression analysis was repeated with use of SGLT2i included as a time-dependent covariate. The variables included in the Cox regression models were those that were statistically or biologically significant in the univariate analysis. The proportional hazards assumption was checked and verified using a global goodness-of fit test proposed by Schoenfeld [26]. The hazard ratio (HR) for circulating TSP2 levels referred to the risk of developing HHF per unit difference in the log-transformed serum TSP2 levels measured in ng/ml. The performance of the clinical model to predict incident HHF, with and without serum TSP2 levels, was examined using time-dependent c-statistics, net reclassification index (NRI) and integrated discrimination index (IDI). Linear regression analysis was performed to evaluate the associations of baseline serum TSP2 levels at baseline with longitudinal changes in ECHO parameters. A two-sided P-value of < 0.05 was considered significant in all statistical tests.

Results

Baseline serum TSP2 levels were higher in patients with type 2 diabetes who developed HHF

In Part 1, a total of 4949 patients with type 2 diabetes were included in the study. At baseline, serum TSP2 levels positively correlated with age, BMI, WC, systolic BP and serum hsCRP levels, and negatively correlated with eGFR levels of the study participants (all p < 0.001). (Supplemental Table S1) Moreover, serum TSP levels were significantly higher in men (p < 0.001), and among participants who had hypertension (p < 0.001), atrial fibrillation (p < 0.001), CVD (p = 0.004) and albuminuria (p < 0.001) than those who did not. (Supplemental Table S2)

Over a median follow-up of 7.8 years, 330 (6.7%) of them developed incident HHF, with a rate of 8.7 per 1000 person-years. Those who developed HHF had significantly longer duration of diabetes (p < 0.001), higher BMI (p = 0.002), WC (p < 0.001), systolic BP (p < 0.001), prevalence of dyslipidemia (p = 0.007), atrial fibrillation (p < 0.001), CVD (p < 0.001) and albuminuria (p < 0.001) at baseline than those who did not. Participants with incident HHF also had significantly higher glycated hemoglobin (HbA1c) and hsCRP, but lower eGFR levels (all p < 0.001) at baseline than those without. Moreover, there were significantly more users of insulin, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), beta-blockers, loop-diuretics, statin and aspirin (all p < 0.001) but less users of metformin (p = 0.021) among participants who had incident HHF than those who did not. Importantly, baseline serum TSP2 levels were significantly higher in participants with incident HHF than those without (Men: 3.70 ng/ml vs. 3.32 ng/ml; women: 4.51 ng/ml vs. 3.71 ng/ml; p < 0.001) (Table 1).

Table 1 Baseline characteristics of the participants by incident HHF in Part 1 of the study (N = 4949)

Baseline serum TSP2 levels were independently associated with incident HHF in type 2 diabetes

In multivariable Cox regression analysis, baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.27, 95%CI 1.03–1.58, p = 0.028), together with age (HR 1.04, 95%CI 1.03–1.06, p < 0.001), duration of diabetes (HR 1.01, 95%CI 1.00–1.03, p = 0.034), BMI (HR 1.04, 95%CI 1.02–1.07, p = 0.003), systolic BP (HR 1.008, 95%CI 1.003–1.010, p = 0.009), HbA1c (HR 1.14, 95%CI 1.05–1.23, p < 0.001), eGFR (HR 0.98, 95%CI 0.98–0.99, p < 0.001), presence of atrial fibrillation (HR 1.96, 95%CI 1.44–2.67, p < 0.001) and albuminuria (HR 2.18, 95%CI 1.65–2.88, p < 0.001), in a model also consisting of sex, smoking status, dyslipidemia, CVD and serum hsCRP levels at baseline (Table 2).

Table 2 Multivariable Cox regression analysis showing the associations of serum TSP2 level and other clinical variables with incident HHF (N = 4949)

The association between baseline serum TSP2 levels and incident HHF remained significant after adjustments for the use of insulin, metformin, ACEI/ARB, beta-blockers, loop-diuretics and aspirin (HR 1.29, 95%CI 1.04–1.60, p = 0.02), as well as the time-dependent cDDD of SGLT2i (HR 1.31, 95%CI 1.06–1.62, p = 0.014) (Table 3). When study participants were stratified by the presence of CVD at baseline, serum TSP2 levels were significantly associated with incident HHF among those with baseline CVD (p = 0.029) but not in those without. Notably, 9.4% and 5.3% of participants with and without CVD at baseline developed HHF, respectively (Table 3).

Table 3 Multivariable Cox regression analysis showing the associations of serum TSP2 level with incident HHF stratified by presence of CVD at baseline (N = 4949)

Since SGLT2i was not locally available until 2015, a sensitivity analysis was further conducted involving only participants who had survived and remained free of HHF in 2015. Among these 4812 participants, 296 developed HHF after 2015. In multivariable Cox regression analysis, baseline serum TSP2 levels remained significantly associated with incident HHF (HR 1.32, 95%CI 1.06–1.64, p = 0.014), together with the use of SGLT2i with cDDD ≥ 180 (HR 0.42, 95%CI 0.20–0.90, p = 0.025) (Supplementary Table S3).

Discrimination and reclassification performance of the addition of baseline serum TSP2 levels in predicting HHF in type 2 diabetes

The addition of serum TSP2 levels into a clinical model, which consisted of age, sex, duration of diabetes, smoking status, BMI, hypertension, dyslipidemia, atrial fibrillation, CVD, HbA1c, CKD, albuminuria and serum hsCRP level at baseline, led to a significant improvement of c-statistics in predicting HHF from 0.79 (95%CI 0.78–0.81) to 0.81 (95%CI 0.79–0.83) (p = 0.003). This was accompanied by improvement in both NRI (0.33, 95%CI 0.26–0.41; p < 0.001) and IDI (0.02, 95%CI 0.01–0.03; p < 0.001) (Table 4),

Table 4 Discrimination and reclassification performance of the addition of circulating TSP2 level in predicting HHF in diabetes

Baseline serum TSP2 levels were associated with deterioration in average E/e’ and LAVi in patients with type 2 diabetes but without CVD

In Part 1, the association between baseline serum TSP2 levels and incident HHF seemed to be more readily observed among patients who had type 2 diabetes and CVD. To evaluate whether serum TSP2 levels were still associated with changes in ventricular function in patients with type 2 diabetes but without CVD, a longitudinal echocardiographic analysis was conducted as Part 2 of the study in 146 participants with type 2 diabetes who did not have CVD at baseline. Among them, participants who were in the highest serum TSP2 tertile had significantly higher baseline BMI than those in the lower tertiles (p < 0.01). Otherwise, their baseline clinical characteristics were comparable between the two groups (Supplemental Table S4).

Table 5 summarizes the echocardiographic parameters of these 146 participants at baseline and follow-up after a median interval of 27 months (Range 12–46 months). Compared to participants in the lower baseline serum TSP2 tertiles, those in the highest serum TSP2 tertile had significantly higher LVPWd and LV mass at baseline (both p < 0.05), as well as lower LVEF (p < 0.05), higher average E/e’ (p < 0.01) and LAVi (p < 0.01) at follow-up. Importantly, the increase in average E/e’ and LAVi from baseline were both significantly greater among participants in the highest serum TSP2 tertile than those in the lower tertiles (Both p < 0.05).

Table 5 Echocardiographic parameters of the study participants in Part 2 stratified by baseline serum TSP2 tertiles (N = 146)

In multivariable linear regression analysis, baseline serum TSP2 levels were positively and independently associated with both changes in average E/e’ (beta 0.75, 95%CI 0.02–1.49, p = 0.04) and LAVi (beta 4.12, 95%CI 1.48–6.77, p < 0.01) (Table 6).

Table 6 Univariate and multivariable linear regression analyses showing the associations between baseline characteristics and change in echocardiographic parameters (N = 146)

Discussion

To our knowledge, the current study is the first demonstration of a clinically significant association between circulating TSP2 levels and incident HHF in an exclusively diabetic population, known to be at increased HF risk, and was independent of the use of SGLT2i during the study period. Moreover, using an echocardiographic study, we found that baseline serum TSP2 levels were significantly associated with left ventricular remodeling and the subsequent deterioration of diastolic function in patients with type 2 diabetes but without CVD, highlighting the potential of circulating TSP2 level as a novel biomarker of HF in type 2 diabetes, regardless of the presence of CVD.

Although the association between circulating TSP2 and HF has been demonstrated previously in studies involving community-dwelling individuals and patients across the various stages of HF, only a minority of the participants had type 2 diabetes in all these studies [3,4,5,6, 27]. Notably, type 2 diabetes significantly elevates HF risk and is also associated with increased TSP2 tissue expression [7, 11,12,13]. Therefore, the current study has substantially expanded our understanding of the prognostic importance of circulating TSP2 levels in HF, especially in a study population of high clinical relevance. The use of circulating TSP2 levels, in combination with BNP, was shown to improve the identification of acute HF among individuals attending the emergency department [6]. Here we further demonstrated that the addition of circulating TSP2 levels to conventional clinical variables also significantly improved the prediction of HHF over years in type 2 diabetes, potentially allowing early HF risk stratification and treatment prioritization.

The prospective echocardiographic analysis is another strength of this study. In a recent proteomics study consisting of 999 obese individuals with HFpEF, circulating TSP2 levels were significantly elevated compared with controls and was associated with greater left atrial dilatation, higher LV mass index and E/e’ [27]. Similarly, another recent study demonstrated that circulating TSP2 levels were inversely correlated with LVEF measured at 4 months post-myocardial infarction [28]. Therefore, our findings that circulating TSP2 levels were also associated with indices of LV hypertrophy and subsequent development of diastolic dysfunction in patients without pre-existing CVD or HF at baseline provided further clinical support that TSP2 could possibly be implicated in adverse left ventricular remodeling earlier on, even before the development of clinical HF.

TSP2 is a pro-fibrotic and anti-angiogenic protein that plays a major role in matrix assembly during tissue injury and remodelling processes [29, 30]. In preclinical studies, lack of TSP2 expression in mice after fetal murine cardiomyocyte grafting was shown to promote graft integration, vascularization leading to better graft survival [30]. On the other hand, mice with genetic ablation of TSP2 had difficulty to cope with increased cardiac loading, with augmented matrix metalloproteinase (MMP)-2 and MMP-9 activities which disrupted myocardial matrix integrity, resulting in cardiomyopathy and fatal cardiac rupture [31]. Subsequent studies also demonstrated that the absence of TSP2 predisposed mice to age-related dilated cardiomyopathy, doxorubicin-induced cardiomyopathy and heightened cardiac inflammation in viral myocarditis [24,25,26,27,28,29,30,31,32, 34]. Interestingly, TSP2 expression in the heart was paradoxically elevated during cardiac injury in both rodents and humans, especially among those that would further progress to HF with worse outcomes [31, 34]. Moreover, TSP2 expression was significantly higher in human hypertrophied hearts that were accompanied by LV systolic dysfunction than those with preserved LVEF [31]. Consistently, in our echocardiographic study, participants in the highest serum TSP2 tertile had significantly greater LV mass and LVPWd at baseline indicating LV hypertrophy. Furthermore, they also experienced significantly more deterioration in average E/e’ and LAVi which were two indices of diastolic dysfunction. Taken together, it is likely that TSP2 activation forms part of an important early-stage molecular program that precedes the development of HF. In other words, the resultant high cardiac TSP2 expression, and possibly its circulating levels in HF, may represent a futile adaptive response that was initially a bodily attempt to overcome HF development. Indeed, recent in-vitro studies demonstrated that pro-inflammatory and pro-fibrotic stimuli could increase THBS2 gene expression, which encodes TSP2, in cardiac fibroblasts [28]. Therefore, in patients with established CVD, this compensatory protective mechanism against cardiac dysfunction might even be more pronounced leading to their higher circulating TSP2 levels. Furthermore, this could also explain the significant reduction in circulating TSP2 levels from baseline following heart transplantation, as demonstrated in recent studies [5, 6], and the observation in the current study that a significant association of serum TSP2 levels with incident HHF was found only amongst those with CVD at baseline.

Our study has a few limitations. First, the observational study design in both parts of our study precludes any inferred causal relationship between high circulating TSP2 levels and incident HF. Secondly, echocardiographic data is not available in Part 1 of our study, and hence rendering it difficult to evaluate the relationship between baseline serum TSP2 levels and longitudinal changes in ECHO parameters in patients who had type 2 diabetes and CVD. Thirdly, serum TSP2 levels were measured only once in all participants and it was therefore impossible to investigate if changes in serum TSP2 levels would also contribute to the development of HHF. Furthermore, external validation of our findings using an independent cohort was not performed. Lastly, neither BNP nor NT-proBNP level was measured in our study. Interestingly, in a preclinical study of hypertensive renin-overexpressing rats, although the cardiac expression of BNP and TSP2 were both up-regulated with pressure overload, it was found that TSP2, but not BNP, more reliably identified those that were prone to develop HF progression [31]. Nonetheless, as ELISA kits for measuring serum TSP2 levels are now commercially available from various sources, further studies, preferably together with the measurements of these established HF markers, are clearly required to validate our current findings, as well as to assess the cost-effectiveness of using this novel biomarker for early HF risk stratification in type 2 diabetes.

Conclusion

Over the years, reductions in cardiovascular mortality due to coronary heart disease and stroke have been reported especially among older individuals with type 2 diabetes [35]. However, mortality related to HF did not change significantly and remained high. On the other hand, the advent of SGLT2i has introduced a paradigm shift in the management of type 2 diabetes and HF, with several landmark randomized controlled trials showing consistent benefits in reducing the rates of HHF regardless of the presence of CVD and the status of LV function [14,15,16,17,18, 36,37,38,39,40] While we recently demonstrated that circulating TSP2 had the potential to become a novel prognostic marker of liver fibrosis in type 2 diabetes [41], our current findings further proposed that it might also be usefully employed for HF risk stratification in patients with type 2 diabetes.

Data availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

A wave:

Peak trans-mitral flow velocities in late diastole

ACEI:

Angiotensin converting enzyme inhibitors

ARB:

Angiotensin II receptor blockers

BMI:

Body mass index

BNP:

B-type natriuretic peptide

BP:

Blood pressure

BW:

Body weight

cDDD:

Cumulative daily defined dose

CDHS:

Chinese Diabetic Heart Study

CI:

Confidence interval

CKD-EPI:

Chronic kidney disease epidemiology collaboration

CVD:

Cardiovascular diseases

DDD:

Daily defined dose

E’ Peak:

velocities of septal and lateral mitral annulus in early diastole

ECHO:

Echocardiography

ECM:

Extracellular matrix

eGFR:

Estimated glomerular filtration rate

E-wave:

Peak trans-mitral flow velocities in early diastole

HbA1c:

Glycated haemoglobin

HDL-C:

High-density lipoprotein cholesterol

HF:

Heart failure

HFpEF:

Heart failure with preserved ejection fraction

HHF:

Hospitalization for heart failure

HKWDR:

Hong Kong West Diabetes Registry

HR:

Hazard ratio

hsCRP:

High sensitivity C-reactive protein

IDI:

Integrated discrimination index

IVSd:

Inter-ventricular septal dimension at end-diastole

LAV:

Left atrial volume

LAVi:

Left atrial volume index

LDL-C:

Low-density lipoprotein cholesterol

LV:

Left ventricular

LVEF:

Left ventricular ejection fraction

LVPWd:

Left ventricular posterior wall thickness at end-diastole

MMP:

Matrix metalloproteinase

NRI:

Net reclassification index

NTproBNP:

N-terminal pro-hormone BNP

SD:

Standard deviation

SGLT2i:

Sodium glucose co-transporter 2 inhibitors

TG:

Triglyceride

TSP2:

Thrombospondin-2

UACR:

Urine to albumin creatinine ratio

WC:

Waist circumference

References

  1. Bornstein P, Agah A, Kyriakides TR. The role of thrombospondins 1 and 2 in the regulation of cell-matrix interactions, collagen fibril formation, and the response to injury. Int J Biochem Cell Biol. 2004;36(6):1115–25.

    Article  CAS  PubMed  Google Scholar 

  2. Zhang K, Li M, Yin L, Fu G, Liu Z. Role of thrombospondin1 and thrombospondin2 in cardiovascular diseases (Review). Int J Mol Med. 2020;45(5):1275–93.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Hanatani S, Izumiya Y, Takashio S, Kimura Y, Araki S, Rokutanda T, Tsujita K, Yamamoto E, Tanaka T, Yamamuro M, et al. Circulating thrombospondin-2 reflects disease severity and predicts outcome of heart failure with reduced ejection fraction. Circ J. 2014;78(4):903–10.

    Article  CAS  PubMed  Google Scholar 

  4. Kimura Y, Izumiya Y, Hanatani S, Yamamoto E, Kusaka H, Tokitsu T, Takashio S, Sakamoto K, Tsujita K, Tanaka T, et al. High serum levels of thrombospondin-2 correlate with poor prognosis of patients with heart failure with preserved ejection fraction. Heart Vessels. 2016;31(1):52–9.

    Article  PubMed  Google Scholar 

  5. Egerstedt A, Berntsson J, Smith ML, Gidlof O, Nilsson R, Benson M, Wells QS, Celik S, Lejonberg C, Farrell L, et al. Profiling of the plasma proteome across different stages of human heart failure. Nat Commun. 2019;10(1):5830.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Wells QS, Gupta DK, Smith JG, Collins SP, Storrow AB, Ferguson J, Smith ML, Pulley JM, Collier S, Wang X, et al. Accelerating biomarker discovery through electronic health records, automated biobanking, and proteomics. J Am Coll Cardiol. 2019;73(17):2195–205.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, et al. Type 2 diabetes mellitus and heart failure, a scientific statement from the American heart association and heart failure society of America. J Card Fail. 2019;25(8):584–619.

    Article  PubMed  Google Scholar 

  8. Kristensen SL, Preiss D, Jhund PS, Squire I, Cardoso JS, Merkely B, Martinez F, Starling RC, Desai AS, Lefkowitz MP, et al. Risk related to pre-diabetes mellitus and diabetes mellitus in heart failure with reduced ejection fraction: insights from prospective comparison of ARNI With ACEI to determine impact on global mortality and morbidity in heart failure trial. Circ Heart Fail 2016, 9(1).

  9. Erdmann E, Charbonnel B, Wilcox RG, Skene AM, Massi-Benedetti M, Yates J, Tan M, Spanheimer R, Standl E, Dormandy JA, et al. Pioglitazone use and heart failure in patients with type 2 diabetes and preexisting cardiovascular disease: data from the PROactive study (PROactive 08). Diabetes Care. 2007;30(11):2773–8.

    Article  CAS  PubMed  Google Scholar 

  10. Giugliano D, Longo M, Scappaticcio L, Bellastella G, Maiorino MI, Esposito K. SGLT-2 inhibitors and cardiorenal outcomes in patients with or without type 2 diabetes: a meta-analysis of 11 CVOTs. Cardiovasc Diabetol. 2021;20(1):236.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Raman P, Harry C, Weber M, Krukovets I, Stenina OI. A novel transcriptional mechanism of cell type-specific regulation of vascular gene expression by glucose. Arterioscler Thromb Vasc Biol. 2011;31(3):634–42.

    Article  CAS  PubMed  Google Scholar 

  12. Bae ON, Wang JM, Baek SH, Wang Q, Yuan H, Chen AF. Oxidative stress-mediated thrombospondin-2 upregulation impairs bone marrow-derived angiogenic cell function in diabetes mellitus. Arterioscler Thromb Vasc Biol. 2013;33(8):1920–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Kunkemoeller B, Bancroft T, Xing H, Morris AH, Luciano AK, Wu J, Fernandez-Hernando C, Kyriakides TR: Elevated Thrombospondin-2 contributes to delayed wound healing in diabetes. Diabetes 2019.

  14. Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, Mattheus M, Devins T, Johansen OE, Woerle HJ, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117–28.

    Article  CAS  PubMed  Google Scholar 

  15. Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, Shaw W, Law G, Desai M, Matthews DR, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377(7):644–57.

    Article  CAS  PubMed  Google Scholar 

  16. Wiviott SD, Raz I, Bonaca MP, Mosenzon O, Kato ET, Cahn A, Silverman MG, Zelniker TA, Kuder JF, Murphy SA, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2019;380(4):347–57.

    Article  CAS  PubMed  Google Scholar 

  17. McMurray JJV, Solomon SD, Inzucchi SE, Kober L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Belohlavek J, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381(21):1995–2008.

    Article  CAS  PubMed  Google Scholar 

  18. Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, Januzzi J, Verma S, Tsutsui H, Brueckmann M, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413–24.

    Article  CAS  PubMed  Google Scholar 

  19. Anker SD, Butler J, Filippatos G, Ferreira JP, Bocchi E, Bohm M, Brunner-La Rocca HP, Choi DJ, Chopra V, Chuquiure-Valenzuela E, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med 2021.

  20. Lee CH, Cheung CYY, Woo YC, Lui DTW, Yuen MMA, Fong CHY, Chow WS, Xu A, Lam KSL. Prospective associations of circulating adipocyte fatty acid-binding protein levels with risks of renal outcomes and mortality in type 2 diabetes. Diabetologia. 2019;62(1):169–77.

    Article  CAS  PubMed  Google Scholar 

  21. Chen Y, Zhao CT, Zhen Z, Wong A, Tse HF, Yiu KH. Association of myocardial dysfunction with vitamin D deficiency in patients with type 2 diabetes mellitus. J Diabetes Complicat. 2014;28(3):286–90.

    Article  Google Scholar 

  22. Wu MZ, Lee CH, Chen Y, Yu SY, Yu YJ, Ren QW, Fong HC, Wong PF, Tse HF, Lam SK, et al. Association between adipocyte fatty acid-binding protein with left ventricular remodelling and diastolic function in type 2 diabetes: a prospective echocardiography study. Cardiovasc Diabetol. 2020;19(1):197.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604–12.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Chapter 2. Definition, identification, and prediction of CKD progression. Kidney International Supplements 2013(3):63–72.

  25. Methodology WCCfDS: Anatomical Therapeutic Chemical (ATC) / Defined Daily Dose (DDD) index on sodium-glucose co-transporter 2 inhibitors. 2019.

  26. D. S: Chi-squared goodness-of-fit tests for the proportional hazards regression model. Biometrika 1980, 67(1):145–153.

  27. Kresoja KP, Rommel KP, Wachter R, Henger S, Besler C, Kloting N, Schnelle M, Hoffmann A, Buttner P, Ceglarek U, et al. Proteomics to improve phenotyping in obese patients with heart failure with preserved ejection fraction. Eur J Heart Fail. 2021;23(10):1633–44.

    Article  CAS  PubMed  Google Scholar 

  28. Chan MY, Efthymios M, Tan SH, Pickering JW, Troughton R, Pemberton C, Ho HH, Prabath JF, Drum CL, Ling LH, et al. Prioritizing candidates of post-myocardial infarction heart failure using plasma proteomics and single-cell transcriptomics. Circulation. 2020;142(15):1408–21.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Agah A, Kyriakides TR, Lawler J, Bornstein P. The lack of thrombospondin-1 (TSP1) dictates the course of wound healing in double-TSP1/TSP2-null mice. Am J Pathol. 2002;161(3):831–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Reinecke H, Robey TE, Mignone JL, Muskheli V, Bornstein P, Murry CE. Lack of thrombospondin-2 reduces fibrosis and increases vascularity around cardiac cell grafts. Cardiovasc Pathol. 2013;22(1):91–5.

    Article  CAS  PubMed  Google Scholar 

  31. Schroen B, Heymans S, Sharma U, Blankesteijn WM, Pokharel S, Cleutjens JP, Porter JG, Evelo CT, Duisters R, van Leeuwen RE, et al. Thrombospondin-2 is essential for myocardial matrix integrity: increased expression identifies failure-prone cardiac hypertrophy. Circ Res. 2004;95(5):515–22.

    Article  CAS  PubMed  Google Scholar 

  32. Swinnen M, Vanhoutte D, Van Almen GC, Hamdani N, Schellings MW, D’Hooge J, Van der Velden J, Weaver MS, Sage EH, Bornstein P, et al. Absence of thrombospondin-2 causes age-related dilated cardiomyopathy. Circulation. 2009;120(16):1585–97.

    Article  CAS  PubMed  Google Scholar 

  33. van Almen GC, Swinnen M, Carai P, Verhesen W, Cleutjens JP, D’Hooge J, Verheyen FK, Pinto YM, Schroen B, Carmeliet P, et al. Absence of thrombospondin-2 increases cardiomyocyte damage and matrix disruption in doxorubicin-induced cardiomyopathy. J Mol Cell Cardiol. 2011;51(3):318–28.

    Article  PubMed  Google Scholar 

  34. Papageorgiou AP, Swinnen M, Vanhoutte D, VandenDriessche T, Chuah M, Lindner D, Verhesen W, de Vries B, D’Hooge J, Lutgens E, et al. Thrombospondin-2 prevents cardiac injury and dysfunction in viral myocarditis through the activation of regulatory T-cells. Cardiovasc Res. 2012;94(1):115–24.

    Article  CAS  PubMed  Google Scholar 

  35. Gregg EW, Cheng YJ, Srinivasan M, Lin J, Geiss LS, Albright AL, Imperatore G. Trends in cause-specific mortality among adults with and without diagnosed diabetes in the USA: an epidemiological analysis of linked national survey and vital statistics data. Lancet. 2018;391(10138):2430–40.

    Article  PubMed  Google Scholar 

  36. Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, Federici M, Filippatos G, Grobbee DE, Hansen TB, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41(2):255–323.

    Article  PubMed  Google Scholar 

  37. Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM, Edwards R, Agarwal R, Bakris G, Bull S, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295–306.

    Article  CAS  PubMed  Google Scholar 

  38. Bhatt DL, Szarek M, Pitt B, Cannon CP, Leiter LA, McGuire DK, Lewis JB, Riddle MC, Inzucchi SE, Kosiborod MN, et al. Sotagliflozin in patients with diabetes and chronic kidney disease. N Engl J Med. 2021;384(2):129–39.

    Article  CAS  PubMed  Google Scholar 

  39. Bhatt DL, Szarek M, Steg PG, Cannon CP, Leiter LA, McGuire DK, Lewis JB, Riddle MC, Voors AA, Metra M, et al. Sotagliflozin in patients with diabetes and recent worsening heart failure. N Engl J Med. 2021;384(2):117–28.

    Article  CAS  PubMed  Google Scholar 

  40. Anker SD, Butler J, Filippatos G, Ferreira JP, Bocchi E, Bohm M, Brunner-La Rocca HP, Choi DJ, Chopra V, Chuquiure-Valenzuela E, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451–61.

    Article  CAS  PubMed  Google Scholar 

  41. Lee CH, Seto WK, Lui DT, Fong CH, Wan HY, Cheung CY, Chow WS, Woo YC, Yuen MF, Xu A, et al. Circulating Thrombospondin-2 as a novel fibrosis biomarker of nonalcoholic fatty liver disease in type 2 diabetes. Diabetes Care 2021.

Download references

Acknowledgements

We thank Ms. Rachel Wong for her technical assistance in the measurements of serum TSP2 levels.

Funding

This work was supported by Hong Kong Research Grants Council/ Area of Excellence (AoE/M/707-18).

Author information

Authors and Affiliations

Authors

Contributions

C.H.L. and M.Z.W. researched the data and wrote the manuscript. D.T.W.L., Q.W.R., S.Y.Y., M.M.A.Y., W.S.C. and J.Y.H. researched the data. C.H.Y.F. performed statistical analyses. A.X., K.H.Y. and K.S.L.L. critically reviewed and edited the manuscript. K.S.L.L. and K.H.Y. initiated and supervised the study, had full access to all the data and took responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding authors

Correspondence to KH Yiu or KSL Lam.

Ethics declarations

Ethics approval and consent to participate

The study protocols were approved by the Institutional Review Board of the University of Hong Kong / Hospital Authority Hong Kong West Cluster (Ref: UW 07-378 and UW 11–121, respectively). Written informed consent was obtained from all recruited participants prior to any study related procedures.

Consent for publication

All authors have approved the manuscript and agreed with its publication.

Competing interests

K.S.L. is an advisory board member of Merck Sharp and Dohme. C.H.L. received speaker’s fees from AstraZeneca, Bayer and Sanofi Aventis. The remaining authors have no conflict of interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

12933_2022_1646_MOESM1_ESM.pdf

Supplementary Material 1. Supplemental Table S1 Pearson correlation analysis of serum TSP2 level with clinical variables at baseline. Supplemental Table S2 Serum TSP2 level and baseline clinical characteristics at baseline. Supplementary Table S3 Sensitivity analysis showing the association between baseline circulating TSP2 levels and incident HF hospitalization in participants who survived and remained free of outcome events in 2015 (N = 4812). Supplementary Table S4 Baseline characteristics of the participants by serum TSP2 levels in Part 2 of the study (N = 146).

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lee, C., Wu, M., Lui, D. et al. Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes. Cardiovasc Diabetol 21, 231 (2022). https://doi.org/10.1186/s12933-022-01646-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12933-022-01646-x

Keywords (MeSH)

  • Thrombospondin-2
  • Heart failure
  • Hospitalization for heart failure
  • Diastolic dysfunction
  • Diabetes mellitus