Insulin resistance, body mass index and venous thromboembolism Results of a population-based cohort study Inge M. van Schouwenburg Division of Hemostasis and Thrombosis, Department of Hematology University Medical Center Groningen The Netherlands

Disclosures for I.M. van Schouwenburg In compliance with AMA requirements, ISTH makes the following disclosures to the session audience: Research Support/P.I. No relevant conflicts of interest to declare Employee Consultant Major Stockholder Speakers Bureau Honoraria Scientific Advisory Board Presentation includes discussion of the following off-label use of a drug or medical device: <N/A>

Background Relation between arterial (ATE) and venous thromboembolism (VTE) has been reported1 Joint underlying pathology or common risk factors? Only obesity consistently shown as risk factor for VTE2-4 Growing evidence shows a relation between arterial and venous thromboembolism. Literature suggest that subjects who develop unprovoked VTE are at a 2-fold increased risk to develop arterial cardiovascular disease. Uptill now, it is unknown what explains this association between arterial and venous thromboembolism. It is possible that a joint underlying pathology increases the risk of both arterial and venous thromboembolism, but it could also be that both diseases have an overlap in risk factors. As for the latter, several studies investigated the relation between cardiovascular risk factors and VTE. And only one cardiovascular risk factor has consitently been shown to be associated with VTE risk, namely, obesity. Becattini et al. J Thromb Haemost 2010 Holst et al. Circulation 2010 (3) Quist-Paulsen et al. Haematologica. 2010 (4) Tsai et al. Arch Intern Med. 2002

Background Insulin resistance, a well-known risk factor for arterial thromboembolism1,2 Insulin Resistance ↑ Total Cholesterol ↑ Triglycerides ↑ CRP ↑ ATE ↑ Blood Pressure ↑ High BMI HDL ↓ In arterial thromboembolism, obesity is thought to increase the risk by a combination of risk factors that influence the risk of cardiovascular disease. Insulin resistance, a well-known risk factor for ATE, plays a central role in this relation between obesity and ATE. A high body mass index is suggested to be related to insulin resistance which in turn is thought to influence several cardiovascular risk factors, like levels of HDL, total cholesterol, c-reactive protein, triglycerides and blood pressure. These factors are known to be associated with a high cardiovascular risk. 3,4 (1) Rexrode et al. JAMA 1997 (2) Kurth et al. Arch Intern Med 2002 (3) DeFronzo et al. Diabetes Care 1991 (4) Reaven. Clin Chem 2008

Aim of the study Is insulin resistance an independent risk factor for venous thromboembolism? The question arises whether insulin resistance also plays a key-role in the association between obesity and venous thromboembolism. Therefore we came to the following research question: Is insulin resistance an independent risk factor for venous thromboembolism?

Methods – Study Population Prevention of REnal and Vascular ENd-stage Disease (PREVEND) Inhabitants city of Groningen 28-75 years 44,656 Non-responders Responders (n=40,856) Selected cohort (n=8592) Excluded Non fasting (n=857) Anti-diabetic medication (n=140) Missing values glucose or insulin (n=202) 7393 subjects insulin dependent DM Pregnant females To answer our research question we used the database of the PREVEND Study. The PREVEND study was originally designed to prospectively investigate the natural course of albuminuria and its relation to renal and cardiovascular disease in a large cohort drawn from the general population. In 1997-1998, all inhabitants of the city of Groningen, aged 28 to 75 years were invited to participate in this prospective cohort study. More then 40.000 subjects responded. Individuals with insulin dependent diabetes were excluded from the PREVEND Study since the link between cardiovascular or renal disease and microalbuminuria in this population is well established. Pregnant females were excluded from the study too, as pregnancy may cause temporary microalbuminuria. After these exclusions around 8500 subjects were randomly selected to be extensively investigated on several cardiovascular and renal aspects. For the present study, subjects with a possible invalid assessment of insulin resistance were excluded. This were subjects who had not explicitly stated to have been fasting for at least 8 h prior to blood sampling and subjects whom were using anti-diabetic medication. After also excluding those with missing values on glucose or insulin measurement more than 7000 subjects were included in the present analysis.

Methods – Measurements Insulin resistance: HOMA product Glucose x insulin / 22.5 BMI Blood pressure hs C-reactive protein Total cholesterol High-density lipoprotein Triglyceriden As measure for insulin resistance we used the HOMA product, which takes both the insulin and glucose levels in to account. The HOMA product is calculated as fasting glucose level multiplied by fasting insulin level, divided by 22.5 Length and weight were measured to calculate body mass index. Furtheremore, several cardiovascular risk factors associated with insulin resistance were measured. This were …

Methods – Adjudication of events Anticoagulation clinics and national registry of hospital discharge diagnoses, confirmed in patients medical records VTE 1997-2009: DVT, PE Provoked: surgery, trauma, immobilization for more than 7 days, pregnancy, puerperium, the use of oral contraceptives or hormonal replacement therapy, or malignancy The database of the prevend study was coupled with databases of the regional anticoagulation clinic and with the databases of the national registry of hospital discharge diagnoses to identify subjects with venous thromboembolism between study entry and January 1, 2009. Data on subjects with venous thromboembolism according to one of these databases was confirmed by patients’ medical records. VTE was defined as deep vein thrombosis, which had to be confirmed by compression ultrasound or as pulmonary embolism which had to be confirmed by ventilation/perfusion lung scanning, spiral computed tomography, or at autopsy. When venous thromboembolism had occurred at or within 3 months after exposure to an exogenous risk factor this event was classified as being provoked. When no such risk factor occurred venous thromboembolism was classified as unprovoked.

Results – Baseline Characteristics VTE No VTE P-valuea TOTAL 120 7273 Male 65 (54) 3565 (49) 0.26 Age at enrolment, y 59 (47-66) 48 (38-59) <0.001 Glucose level, mmol/l 5.0 (4.6-5.3) 4.7 (4.4-5.1) Insulin level, pmol/l 65 (47-106) 54 (38-81) HOMA 2.10 (1.44-3.22) 1.63 (1.10-2.56) Systolic BP, mmHg 135 (118-147) 125 (113-140) 0.002 Total cholesterol, mmol/l 5.8 (5.1-6.5) 5.6 (4.9-6.3) 0.013 HDL, mmol/l 1.3 (1.0-1.5) 1.3 (1.0-1.6) 0.14 Triglycerides, mmol/l 1.27 (0.95-1.80) 1.15 (0.84-1.66) 0.010 C-reactive protein, mg/L 1.82 (1.08-3.91) 1.25 (0.55-2.89) BMI-index, kg/m2 27.9 (25.3-31.2) 25.5 (23.1-28.3) In this table, you see the baseline characteristics of our cohort. During a median follow-up of almost 11 years, 120 subjects developed venous thromboembolism. When comparing these subjects with those who did not develop VTE, we see that subjects with VTE have significantly higher levels on all measured cardiovascular risk factors … except for HDL level which is not significantly different between those with and without VTE. P=pico-mol

Results – Univariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.51 (1.27-1.78) <0.001 Age (per SD) 1.88 (1.56-2.27) Sex (per SD) 0.89 (0.75-1.07) 0.21 SBP (per SD) 1.31 (1.12-1.54) 0.001 Total cholesterol (per SD) 1.22 (1.04-1.44) 0.02 HDL (per SD) 0.83 (0.69-1.01) 0.06 Triglycerides (per SD) 1.08 (0.95-1.23) 0.26 hsCRP (per SD) 1.18 (1.08-1.29) BMI (per SD) 1.59 (1.40-1.80) Decreased risk of VTE Increased risk of VTE When we performed an univariate analyses of overall VTE, meaning we made no distinction between provoked and unprovoked VTE, we see that insulin resistance, or HOMA product, increases the risk of VTE significantly. An increase of 1 SD in HOMA product increases the risk of VTE with 50%. As you can also see age, high systolic blood pressure, high total cholosterol, high crp and high body mass index increase the risk of venous thromboembolism, in an univariate analysis. Niet first VTE, want van de niet VTE-ers wisten we history niet!!! 0.5 1 5

Results – Univariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.51 (1.27-1.78) <0.001 Age (per SD) 1.88 (1.56-2.27) Sex (per SD) 0.89 (0.75-1.07) 0.21 SBP (per SD) 1.31 (1.12-1.54) 0.001 Total cholesterol (per SD) 1.22 (1.04-1.44) 0.02 HDL (per SD) 0.83 (0.69-1.01) 0.06 Triglycerides (per SD) 1.08 (0.95-1.23) 0.26 hsCRP (per SD) 1.18 (1.08-1.29) BMI (per SD) 1.59 (1.40-1.80) Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Univariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.51 (1.27-1.78) <0.001 Age (per SD) 1.88 (1.56-2.27) Sex (per SD) 0.89 (0.75-1.07) 0.21 SBP (per SD) 1.31 (1.12-1.54) 0.001 Total cholesterol (per SD) 1.22 (1.04-1.44) 0.02 HDL (per SD) 0.83 (0.69-1.01) 0.06 Triglycerides (per SD) 1.08 (0.95-1.23) 0.26 hsCRP (per SD) 1.18 (1.08-1.29) BMI (per SD) 1.59 (1.40-1.80) Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.41 (1.15-1.75) 0.001 Age (per SD) 1.85 (1.48-2.13) <0.001 Sex (per SD) 0.96 (0.78-1.18) 0.67 SBP (per SD) 0.92 (0.75-1.14) 0.45 Total cholesterol (per SD) 1.01 (0.81-1.25) 0.96 HDL (per SD) 0.93 (0.72-1.20) 0.58 Triglycerides (per SD) 0.78 (0.58-1.06) 0.11 hsCRP (per SD) 1.12 (1.00-1.24) 0.04 BMI (per SD) - Decreased risk of VTE Increased risk of VTE On this sheet you see the risk of overall VTE in a multivariate models in which adjustements were made for all cardiovascular risk factors, except BMI. You see, that besides high crp and age, the HOMA-product still significantly increases the risk of VTE, after correction for all these cardiovascular risk factors. 0.5 1 5

Results – Multivariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.41 (1.15-1.75) 0.001 Age (per SD) 1.85 (1.48-2.13) <0.001 Sex (per SD) 0.96 (0.78-1.18) 0.67 SBP (per SD) 0.92 (0.75-1.14) 0.45 Total cholesterol (per SD) 1.01 (0.81-1.25) 0.96 HDL (per SD) 0.93 (0.72-1.20) 0.58 Triglycerides (per SD) 0.78 (0.58-1.06) 0.11 hsCRP (per SD) 1.12 (1.00-1.24) 0.04 BMI (per SD) - Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.07 (0.84-1.35) 0.60 Age (per SD) 1.82 (1.45-2.27) <0.001 Sex (per SD) 0.89 (0.72-1.11) 0.30 SBP (per SD) 0.90 (0.73-1.11) 0.33 Total cholesterol (per SD) 0.98 (0.78-1.22) 0.83 HDL (per SD) 0.97 (0.75-1.25) 0.78 Triglycerides (per SD) 0.80 (0.59-1.09) 0.80 hsCRP (per SD) 1.10 (0.98-1.25) 0.11 BMI (per SD) 1.57 (1.29-1.90) Decreased risk of VTE Increased risk of VTE On this sheet you see the same multivariate model, with an additional adjustment for BMI. And you see that after BMI was added to the model, the HR of Homa product decreases, and becomes insignificant. 0.5 1 5

Results – Multivariate, overall VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.07 (0.84-1.35) 0.60 Age (per SD) 1.82 (1.45-2.27) <0.001 Sex (per SD) 0.89 (0.72-1.11) 0.30 SBP (per SD) 0.90 (0.73-1.11) 0.33 Total cholesterol (per SD) 0.98 (0.78-1.22) 0.83 HDL (per SD) 0.97 (0.75-1.25) 0.78 Triglycerides (per SD) 0.80 (0.59-1.09) 0.80 hsCRP (per SD) 1.10 (0.98-1.25) 0.11 BMI (per SD) 1.57 (1.29-1.90) Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, unprovoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.62 (1.17-2.23) 0.003 Age (per SD) 2.01 (1.43-2.84) <0.001 Sex (per SD) 0.90 (0.65-1.24) 0.53 SBP (per SD) 0.89 (0.65-1.22) 0.47 Total cholesterol (per SD) 1.04 (0.75-1.45) 0.81 HDL (per SD) 0.79 (0.53-1.20) 0.27 Triglycerides (per SD) 0.64 (0.39-1.07) 0.09 hsCRP (per SD) 0.95 (0.68-1.31) 0.74 BMI (per SD) - Decreased risk of VTE Increased risk of VTE I’ll also show you the same multivariate models for unprovoked and provoked VTE seperately. In this model of unprovoked VTE, where adjustments were made for all card vasc rf, except for BMI, we see that IR increases the risk of VTE significantly. 0.5 1 5

Results – Multivariate, unprovoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.62 (1.17-2.23) 0.003 Age (per SD) 2.01 (1.43-2.84) <0.001 Sex (per SD) 0.90 (0.65-1.24) 0.53 SBP (per SD) 0.89 (0.65-1.22) 0.47 Total cholesterol (per SD) 1.04 (0.75-1.45) 0.81 HDL (per SD) 0.79 (0.53-1.20) 0.27 Triglycerides (per SD) 0.64 (0.39-1.07) 0.09 hsCRP (per SD) 0.95 (0.68-1.31) 0.74 BMI (per SD) - Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, unprovoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.14 (0.79-1.63) 0.49 Age (per SD) 2.05 (1.45-2.90) <0.001 Sex (per SD) 0.79 (0.56-1.11) 0.17 SBP (per SD) 0.87 (0.63-1.20) 0.39 Total cholesterol (per SD) 0.99 (0.71-1.39) 0.96 HDL (per SD) 0.82 (0.54-1.25) 0.36 Triglycerides (per SD) 0.64 (0.38-1.08) 0.09 hsCRP (per SD) 0.83 (0.55-1.27) 0.40 BMI (per SD) 1.91 (1.43-2.55) Decreased risk of VTE Increased risk of VTE When BMI was added to this model, the relation between IR and VTE disappears. 0.5 1 5

Results – Multivariate, unprovoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.14 (0.79-1.63) 0.49 Age (per SD) 2.05 (1.45-2.90) <0.001 Sex (per SD) 0.79 (0.56-1.11) 0.17 SBP (per SD) 0.87 (0.63-1.20) 0.39 Total cholesterol (per SD) 0.99 (0.71-1.39) 0.96 HDL (per SD) 0.82 (0.54-1.25) 0.36 Triglycerides (per SD) 0.64 (0.38-1.08) 0.09 hsCRP (per SD) 0.83 (0.55-1.27) 0.40 BMI (per SD) 1.91 (1.43-2.55) Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, provoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.24 (0.93-1.66) 0.14 Age (per SD) 1.71 (1.26-2.31) 0.001 Sex (per SD) 1.02 (0.77-1.36) 0.87 SBP (per SD) 0.92 (0.69-1.22) 0.56 Total cholesterol (per SD) 0.95 (0.71-1.27) 0.71 HDL (per SD) 1.06 (0.77-1.45) 0.74 Triglycerides (per SD) 0.95 (0.66-1.36) 0.77 hsCRP (per SD) 1.19 (1.06-1.33) 0.002 BMI (per SD) - Decreased risk of VTE Increased risk of VTE In subjects who develop provoked VTE we see the same trend, however IR is not significantly associated with VTE in the first multivariate model either. 0.5 1 5

Results – Multivariate, provoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.24 (0.93-1.66) 0.14 Age (per SD) 1.71 (1.26-2.31) 0.001 Sex (per SD) 1.02 (0.77-1.36) 0.87 SBP (per SD) 0.92 (0.69-1.22) 0.56 Total cholesterol (per SD) 0.95 (0.71-1.27) 0.71 HDL (per SD) 1.06 (0.77-1.45) 0.74 Triglycerides (per SD) 0.95 (0.66-1.36) 0.77 hsCRP (per SD) 1.19 (1.06-1.33) 0.002 BMI (per SD) - Decreased risk of VTE Increased risk of VTE 0.5 1 5

Results – Multivariate, provoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.03 (0.74-1.43) 0.86 Age (per SD) 1.66 (1.23-2.25) 0.001 Sex (per SD) 1.00 (0.75-1.33) 0.98 SBP (per SD) 0.90 (0.67-1.20) 0.46 Total cholesterol (per SD) 0.93 (0.69-1.25) 0.61 HDL (per SD) 1.09 (0.79-1.51) 0.62 Triglycerides (per SD) 0.97 (0.68-1.38) 0.85 hsCRP (per SD) 1.19 (1.06-1.33) 0.004 BMI (per SD) 1.36 (1.03-1.78) 0.028 Decreased risk of VTE Increased risk of VTE But we do see that the HR decreases even more when BMI was added to the model. 0.5 1 5

Results – Multivariate, provoked VTE Hazard ratio (95%CI) P-value HOMA (per SD) 1.03 (0.74-1.43) 0.86 Age (per SD) 1.66 (1.23-2.25) 0.001 Sex (per SD) 1.00 (0.75-1.33) 0.98 SBP (per SD) 0.90 (0.67-1.20) 0.46 Total cholesterol (per SD) 0.93 (0.69-1.25) 0.61 HDL (per SD) 1.09 (0.79-1.51) 0.62 Triglycerides (per SD) 0.97 (0.68-1.38) 0.85 hsCRP (per SD) 1.19 (1.06-1.33) 0.004 BMI (per SD) 1.36 (1.03-1.78) 0.028 Decreased risk of VTE Increased risk of VTE 0.5 1 5

Conclusion Insulin resistance increases the risk of (unprovoked) VTE, but not independent of BMI. The relation between obesity and VTE is not explained by insulin resistance. With these results we came to the following conclusions…

Authors Inge M. van Schouwenburg Bakhtawar K. Mahmoodi Nic J.G.M. Veeger Stephan J.L. Bakker Hanneke C. Kluin-Nelemans K. Meijer Ron T. Gansevoort