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Publications 2025
- How socioeconomic differences affect the risk of new cardiovascular events and healthy life expectancy in patients with cardiovascular disease
People with cardiovascular disease (CVD), such as a heart attack or stroke, have a high risk of developing another heart or vascular problem. The likelihood of this may be related to socioeconomic status (SES).
This study examined whether patients with a lower SES have a higher risk of developing CVD again and whether this occurs at a younger age compared with patients with a higher SES. The results showed that patients in the lowest SES group:
- Had a 35% higher risk of developing another heart or vascular problem compared with the highest SES group.
- Had on average a 2.4-year shorter life expectancy and a 5.5-year shorter healthy life expectancy (without cardiovascular disease) than patients in the highest SES group.
This study shows that patients with a lower SES have the poorest cardiovascular health. This highlights the need to reduce inequalities in healthcare.
Stella Bijkerk, Frank L. J. Visseren, Manon G. van der Meer, Gert J. de Borst, Ynte M. Ruigrok, Tomas Jernberg, Mark Woodward, Eric P. Moll van Charante, Ilonca Vaartjes, Jannick A. N. Dorresteijn, Steven H. J. Hageman
Read the full article > - High triglyceride levels are linked to a higher risk of cardiovascular disease and death, even when cholesterol is well controlled
In almost 10,000 people with cardiovascular disease, we investigated whether high triglyceride levels (a type of fat in the blood) are associated with a higher risk of new cardiovascular problems and death.
This was indeed the case, even when LDL cholesterol (“bad” cholesterol) had already been well reduced and people were receiving intensive treatment with cholesterol-lowering medication. People with high triglyceride levels therefore remained at increased risk.
For this reason, it is important in clinical practice not only to lower LDL cholesterol, but also to pay attention to triglyceride levels. Lifestyle changes such as weight loss, increased physical activity, and limiting alcohol and fat intake can help reduce triglycerides and may further lower the risk of cardiovascular disease.
Pauline C. E. Schuitema, Frank L J Visseren, Børge G Nordestgaard, Martin Teraa, Manon G van der Meer, Ynte M Ruigrok, N Charlotte Onland Moret, Charlotte Koopal, UCC SMART Study Group
Read the full article > - Arterial stiffness and arterial calcification in people with type 2 diabetes
Arterial stiffness and arterial calcification are important causes of cardiovascular disease and death. Both occur more often in people with type 2 diabetes.
This study shows that arterial calcification explains a larger part of the increased cardiovascular risk in people with type 2 diabetes than arterial stiffness.
This knowledge can help healthcare professionals better determine which medications are most important for people with type 2 diabetes and an increased risk of cardiovascular disease.
Jan F. de Leijer, Frank L. J. Visseren, Birgitta K. Velthuis, Ynte M. Ruigrok, Jaco J.M. Zwanenburg, Manon G. van der Meer, Martin Teraa, Pim A. de Jong, Thomas T. van Sloten, UCC-SMART study group
Read the full article > - Risk of new cardiovascular events within 10 years and the potential health benefits of prevention in people with HIV
People with HIV who have cardiovascular disease have an increased risk of developing another heart or vascular problem. We calculated how large this risk is and how much health benefit can be achieved with treatment.
In this study, we compared more than 1,200 people with HIV with a group of people without HIV in the Netherlands. The results showed that the risk of new cardiovascular problems is somewhat higher in people with HIV. This appears to be mainly due to higher smoking rates in this group. When we look at the potential health benefits, we see that many new conditions could be prevented. Stopping smoking and lowering cholesterol and blood pressure are particularly important, especially for people with a very high risk.
Improving the treatment of cardiovascular disease in people with HIV is therefore very important.
Rosa H. Elias, Joris Holtrop, Colette Smit, Jannick A.N. Dorresteijn, Marc van der Valk, Casper Rokx, Annelies Verbon, Berend J. van Welzen
Read the full article > - Do results from cholesterol-lowering clinical trials apply to today’s patients with cardiovascular disease?
Doctors often choose medications for high cholesterol based on large scientific studies. But do the participants in those studies actually resemble today’s patients?
Using data from 8,537 participants in the UCC-SMART study (2000–2023), we investigated this question. For eight well-known studies, we examined how many UCC-SMART participants would have been eligible to take part. This varied greatly by study and by disease: for coronary heart disease (narrowing of the coronary arteries) about 9–85%, after stroke 7–42%, and for peripheral artery disease in the legs 8–78%.
Participants who did and did not meet the study criteria often differed in age or other medical conditions. However, their risk of new cardiovascular problems and death was usually similar.
This means that the results of these studies are generally applicable to patients in clinical practice. However, more recent studies often focus on smaller and more specific groups. Therefore, it remains important for doctors and patients to decide together which treatment is most appropriate.
Pauline C E Schuitema, Manon C Stam-Slob, Frank L J Visseren, Charlotte Koopal, UCC-SMART Study Group
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View the summary figure > - Which body fat measurements best predict the risk of cardiovascular disease, diabetes, or cancer in patients with cardiovascular disease
People with cardiovascular disease have a higher risk of developing new health problems, such as type 2 diabetes, cancer, or another cardiovascular disease. In this study, we examined which body fat measurement is most strongly related to this risk. For this purpose, data from 6,138 participants with cardiovascular disease from the UCC-SMART study were used.
The results showed that people with a larger waist circumference or more fat around the abdominal organs had a 62% higher risk of developing one of these three diseases. They also developed these diseases on average 4 to 5 years earlier. People with more fat under the skin did not have an increased risk.
This study shows that measuring waist circumference is a simple and reliable way to identify people with a higher risk of developing type 2 diabetes, cancer, or another cardiovascular disease. This can help ensure that they receive appropriate guidance at an earlier stage.
Ritobrata Bhattacharya, Frank L. J. Visseren, Manon G. van der Meer, Martin Teraa, Jannick A. N. Dorresteijn, Ynte M. Ruigrok, Thomas T. van Sloten
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Publications 2024
- The percentage of patients with cardiovascular disease reporting certain dietary habits changes over the years.
From 1996 to 2019, patients with cardiovascular disease were less likely to report a low-fat diet (from 22.4% to 3.8%) . This is consistent with guidelines, which no longer recommend the low-fat diet for this patient group.
A small percentage of patients report a vegetarian diet and this gradually increases over the years (from 1.1% to 2.3%). This increase corresponds to a broader societal interest in this diet. Also, in recent years, from guidelines, more emphasis has been placed on the importance of more plant/vegetarian food for patients with cardiovascular disease.
The number of patients reporting eating a low salt diet was low and declined over the years. Less salt intake reduces blood pressure and the risk of cardiovascular disease. Given the great health benefits of a low-salt diet, renewed action is needed to ensure that more patients with cardiovascular disease adopt a low-salt diet.
L L F Hoes, J M Geleijnse, N E Bonekamp, J A N Dorresteijn, M G van der Meer, Yvonne T van der Schouw, Frank L J Visseren, Charlotte Koopal; UCC-SMART study group
Read the full article > - Impact of the European Prevention Directive in patients with established cardiovascular disease.
Patients with established cardiovascular disease (CVD) are at high risk for new CVD. The European Society of Cardiology guideline for the prevention of HVZ introduced a stepwise treatment approach. Step 1 in this approach are treatments that apply to all patients, and Step 2 consists of intensive treatments that can be prescribed to patients who are still at high risk of HVZ after Step 1. This study looks at the effect of Step 1 and Step 2 on HVZ within 27,094 patients across Europe. It shows that after Step 1, 80-99% of patients still have more than a 10% risk of new HVZ. Intensive treatment options could prevent 198-245 new HVZ per 1,000 people treated. 198-245 new cardiovascular events could be prevented for every 1000 and 63% of patients could achieve <10% risk of HVZ.
Joris Holtrop, Deepak L Bhatt, Kausik K Ray, François Mach, Yvo M Smulders, David Carballo, Philippe Gabriel Steg, Frank L J Visseren, Jannick A N Dorresteijn, on behalf of the SMART study group.
Read the full article > - Exercise, sports participation, insulin sensitivity and non-alcoholic fatty liver disease (NAFLD) in people with type 1 diabetes.
In this study, we examined whether there is a relationship between exercise, insulin sensitivity and non-alcoholic fatty liver disease (NAFLD) in people with type 1 diabetes. 254 people participated in the study. All participants completed a questionnaire, blood samples were taken from everyone and some received a FibroScan (type of ultrasound of the liver). The questionnaire was about type of exercise, amount of exercise and participation in sports. We saw that people who exercised regularly (sports participation) had better insulin sensitivity and were less likely to have NAFLD. We think this is the group of people who also have a healthier lifestyle. In our study, the amount of exercise did not affect insulin sensitivity or the risk of having NAFLD (no dose-response relationship). This study shows that even in people with type 1 diabetes it is important to pay attention to lifestyle treatment.
Marieke de Vries, Jan Westerink, Karin Kaasjager, Harold de Valk
Read the full article > - HbA1c and FPG are similar in their relationship with cardiovascular disease risk in a high-risk population.
Type 2 diabetes is known to increase the risk of cardiovascular disease. Therefore, people with cardiovascular disease and those at high risk for it are also tested for diabetes. There are two tests for this, namely the amount of sugar in the blood when you are sober (FPG; fasting plasma glucose), and HbA1c, a value that reflects the average blood sugar over the past 2-3 months. We examined which of these two methods has a stronger association with the development and worsening of cardiovascular disease, to see if one of them could be used better than the other. Our conclusion is that this is not the case, and that both tests can be used. This allows the choice of test to be made based on other criteria, such as what is more convenient for the patient or the price of the test.
Been, Riemer A., Noordstar, Ellen, Helmink, Marga A.G., van Sloten, Thomas T., de Ranitz-Greven, Wendela L., van Beek, André P., Houweling, Sebastiaan T., van Dijk, Peter R., Westerink, Jan and on behalf of the UCC-SMART Study Group.
Read the full article > - Predicting type 2 diabetes in people with cardiovascular disease.
People who have previously experienced cardiovascular disease are at increased risk of developing type 2 diabetes. Using the CVD2DM model, both the 10-year and lifetime risk of developing type 2 diabetes can be predicted for people with a history of cardiovascular disease. With this model, it is possible to assess the possible benefit of preventive interventions (e.g., a lifestyle program) for individual patients. When patients gain insight into their risk of developing type 2 diabetes, it may motivate them to adopt a healthier lifestyle. In addition, the model has a potential role in early detection of type 2 diabetes in people with previous cardiovascular disease. Although current guidelines already recommend screening for type 2 diabetes after recent cardiovascular disease, this model could help in determining the timing of any follow-up screenings if patients do not initially have diabetes.
Helmink MAG, Peters SAE, Westerink J, Harris K, Tillmann T, Woodward M, van Sloten TT, van der Meer MG, Teraa M, Dorresteijn JAN, Ruigrok YM, Visseren FLJ, Hageman SHJ; UCC-SMART study group.
Read the full article > - The neutrophil/lymphocyte ratio and CRP in the blood of people with type 2.
This study shows that in patients with type 2 diabetes (T2D), the ratio of neutrophils to lymphocytes (NLR) in the blood is related to a higher risk of cardiovascular disease and all-cause mortality, independent of C-reactive protein (CRP). This means that NLR is an additional marker of cardiovascular disease risk even when CRP is low. Both NLR and CRP are independently related to all-cause mortality in T2D patients.
Lukas L.F. Hoes, Niels P. Riksen, Johanna M. Geleijnse, Mark C.H. de Groot, Yvonne T. van der Schouw, Frank L.J. Visseren, Charlotte Koopal, on behalf of the UCC-SMART study group.
Read the full article > - Estimating uncertainty in individual cardiovascular disease risk prediction: How Bayesian methods can help.
For personalized treatment, physicians use so-called risk scores to see who will benefit most from preventive treatment. Traditionally, risk scores provide only an estimate of risk without indicating how certain that estimate is. Therefore, in this study, researchers looked at how to calculate uncertainty as well.
The study used a new statistical method to not only calculate the risk, but also to provide an estimate of the uncertainty surrounding that risk estimate. This means that in addition to a risk estimate, the researchers also give a range of possible values within which the true risk lies.
In their study, they looked at data from more than 8,000 people with cardiovascular disease from the UCC-SMART cohort. They found that their new method could properly calculate risk estimates and associated uncertainties. This can help physicians better understand how reliable their risk estimates are in order to make more informed decisions.
Steven H.J. Hageman, Richard A.J. Post , Frank L.J. Visseren, J. William McEvoyc , J. Wouter Jukema, Yvo Smulders, Maarten van Smeden, Jannick A.N. Dorresteijn
Read the full article > - Cost-effectiveness of the Mediterranean diet and physical activity in secondary prevention of cardiovascular disease.
Lifestyle optimization, including physical activity and a healthy diet, is a central recommendation for preventing recurrent cardiovascular disease. This study examined whether improving physical activity and adhering to a heart-healthy Mediterranean diet would also be a cost-effective option. The results were remarkable: following the Mediterranean diet and participating in physical activity were expected to lead to an increase of 2.0 quality-adjusted life years (QALYs, equivalent to one life year in perfect health) and cost savings. This means that lifestyle optimization in secondary prevention of cardiovascular disease improves population health while reducing overall healthcare costs. These findings highlight the importance of implementing lifestyle changes in care for all individuals with cardiovascular disease. A healthy lifestyle is not only effective in improving health, but also a wise financial decision.
Bonekamp NE, Visseren FLJ, van der Schouw YT, van der Meer MG, Teraa M, Ruigrok YM, Geleijnse JM, Koopal C
Read the full article > - Long-term lifestyle changes and risk of mortality and type 2 diabetes in patients with cardiovascular disease.
In this study, we examined whether lifestyle changes are associated with improved health outcomes in people with cardiovascular disease (CVD). We assessed self-reported lifestyle factors (smoking, waist circumference, alcohol consumption and physical activity) both at the start of the study and approximately 10 years later. The results highlight the importance of healthy lifestyle choices, even for people already diagnosed with HVD, and suggest that it is never too late to improve your lifestyle.
Nadia E. Bonekamp , Frank L.J. Visseren, Maarten J. Cramer, Jannick A.N. Dorresteijn , Manon G. van der Meer , Ynte M. Ruigrok, Thomas T. van Sloten , Martin Teraa , Johanna M. Geleijnse, and Charlotte Koopal
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Publications 2023
- The power of exercise: By what mechanism does physical activity lower the risk of death and cardiovascular events.
Regular physical activity reduces the risk of death and recurrent vascular events in patients with cardiovascular disease. In an analysis of over 8,500 participants from the UCC-SMART cohort, we showed that the type and intensity of physical activity do not matter much but that the volume of exercise is most important. People who regularly performed moderate to vigorous exercise had a significantly lower risk of death and vascular events. The beneficial effect of exercise was largely explained by improvements in factors such as insulin sensitivity and systemic inflammation. These findings highlight the importance of exercise as an effective strategy to improve the health of people with cardiovascular disease.
Nadia E Bonekamp, Anne M May, Martin Halle, Jannick A N Dorresteijn, Manon G van der Meer, Ynte M Ruigrok, Gert J de Borst, Johanna M Geleijnse, Frank L J Visseren, Charlotte Koopal on behalf of the UCC-SMART study group.
Read the full article > - Screening for brain aneurysms in hypertensive smokers.
Brain aneurysms are bulges of the arteries in the brain, they occur in 3% of the population. Most will never cause symptoms, but some can burst and cause a brain hemorrhage (called an aneurysmal subarachnoid hemorrhage). Still unruptured aneurysms can be detected with a scan of the blood vessels in the head, this is called screening. The aneurysms with a high chance of bursting are treated to prevent bleeding in the future. The purpose of our study was to assess the yield of screening in people over 35 years of age with symptomatic vascular disease, high blood pressure and who smoke or have smoked. Scans of the blood vessels in the head were viewed from 500 patients. In these, 25 aneurysms were found (25/500=5%). These aneurysms were small with a low probability of bursting. Since only one of the 25 aneurysms found required treatment over a five-year period, we do not recommend screening this entire group at this time. We saw that increasing age, female gender and smoking conferred the highest risk of an aneurysm. Whether screening makes sense for any of these high-risk groups will need further investigation in future studies.
Liselore A Mensing, Rick J van Tuijl, Gerard A de Kort, Irene C van der Schaaf, Frank L Visseren, Gabriel JE Rinkel, Birgitta K Velthuis, Ynte M Ruigrok, on behalf of the UCC-SMART study group
Read the full article > - Dysregulated metabolism and heart failure.
The metabolic syndrome is a collective term for disorders related to dysregulated metabolism. The purpose of the article is to investigate whether there is a relationship between metabolic syndrome and heart failure, in which the heart works less well. This was examined specifically in patients with cardiovascular disease without diabetes. The study concluded that in this group of patients, there was an association between the metabolic syndrome and an increased risk of heart failure. This effect was not influenced by other factors that may play a role in the development of heart failure.
Pascal M. Burger, Stefan Koudstaal, Jannick A.N. Dorresteijn, Gianluigi Savarese, Manon G. van der Meer, Gert J. de Borst, Arend Mosterd, Frank L.J. Visseren.
Read the full article > - Coronary Heart Disease and Colchicine.
In coronary heart disease, there are problems with blood flow to the heart muscle as a result of arterial calcification. Research has shown that the anti-inflammatory effects of the drug Colchicine reduces the risk of new cardiovascular disease in patients with coronary artery disease. The article compared the long-term benefits of low-dose Colchicine with the effects of lipid- and blood pressure-lowering medications. On average, low-dose Colchicine would lower the risk of cardiovascular disease from 17.8% to 13.2% (a 4.6% decrease) over a 10-year period and provide an average of 2 additional years of life without cardiovascular disease. Low dose Colchicine was estimated to be the most effective treatment in 49% of patients, intensive blood pressure lowering therapy in 28% and intensive lipid lowering therapy in 23% of patients.
Pascal M Burger, Jannick A N Dorresteijn, Aernoud T L Fiolet, Stefan Koudstaal, John W Eikelboom, Stefan M Nidorf, Peter L Thompson, Jan H Cornel, Charley A Budgeon, Iris C D Westendorp, Driek P W Beelen, Fabrice M A C Martens, Philippe Gabriel Steg, Folkert W Asselbergs, Maarten J Cramer, Martin Teraa, Deepak L Bhatt, Frank L J Visseren, Arend Mosterd, for the LoDoCo2 Trial Investigators , UCC-SMART Study Group , REACH Registry Investigators.
Read the full article > - The relationship between cardiovascular disease, inflammation and heart failure.
Patients with cardiovascular disease are at higher risk for heart failure, in which the heart works less well. This may be due to an increase in overall inflammatory levels in these patients. CRP stands for C-reactive protein, which is a protein in the blood that indicates the level of inflammation in the body. In this article, the presence of this protein has been shown to increase the risk of heart failure. The study thus provides rationale for other studies investigating whether anti-inflammatory drugs may play a role in preventing new cardiovascular diseases in patients whose risk is insufficiently reduced with regular treatment.
Pascal M. Burger, Stefan Koudstaal, Arend Mosterd, Aernoud T.L. Fiolet, Martin Teraa, Manon G. van der Meer, Maarten J. Cramer, Frank L.J. Visseren, Paul M. Ridker, Jannick A.N. Dorresteijn, M.J. Cramer, M.G. van der Meer, H.M. Nathoe, G.J. de Borst, M.L. Bots, M.H. Emmelot-Vonk, P.A. de Jong, A.T. Lely, N.P. van der Kaaij, L.J. Kappelle, Y.M. Ruigrok, M.C. Verhaar, F.L.J. Visseren, J.A.N. Dorresteijn.
Read the full article > - UCC-SMART in a nutshell.
SMART stands for Second Manifestations of ARTerial diseases, which is part of the Utrecht Cardiovascular Cohorts. This article provides a comprehensive overview of the program's design, including rationale and development over the years. Since the start of the program in September 1996, a total of 14,830 patients have participated. Participation is possible if one is between 18 and 90 years old and referred to the University Medical Center Utrecht because of (an increased risk of) cardiovascular disease. During a one-time research program, several measurements are taken after which participants are followed up annually via a questionnaire. Through this data collection, the UCC-SMART cohort has contributed to more than 350 articles including models used to predict cardiovascular disease risk. Due to the ongoing inclusion of patients, the cohort is a good reflection of daily clinical practice.
Maria C. Castelijns, Marga A. G. Helmink, Steven H. J. Hageman, Folkert W. Asselbergs, Gert J. de Borst, Michiel L. Bots, Maarten J Cramer, Jannick A. N. Dorresteijn, Marielle H. Emmelot-Vonk, Mirjam I. Geerlings, Pim A. de Jong, Niels P. van der Kaaij, L. Jaap Kappelle, A. Titia Lely, Manon G. van der Meer, Barend M. Mol, Hendrik M. Nathoe, N. Charlotte Onland-Moret, Rutger B. van Petersen, Ynte M. Ruigrok, Maarten van Smeden, Martin Teraa, Angela Vandersteen, Marianne C. Verhaar, Jan Westerink, Frank L. J. Visseren.
Read the full article > - Waist circumference and metabolic fatty tissue dysfunction: its link to cancer development.
We investigated in people with and without type 2 diabetes the relationship between the amount of adipose tissue and adipose tissue dysfunction on the one hand and the risk of cancer on the other. In people without type 2 diabetes, both a greater amount of adipose tissue (measured by waist circumference) and the presence of adipose tissue dysfunction (assessed by a modified definition of metabolic syndrome) were associated with a higher risk of several types of cancer. No statistically significant association was found in people with type 2 diabetes. This may be explained by the fact that their metabolism is already so disturbed that the degree of dysregulation no longer makes a difference in cancer risk. Another possible explanation is that the group studied with type 2 diabetes was relatively small. The findings of this study underscore the importance of obesity prevention, since even in people without type 2 diabetes, a higher waist circumference is associated with a higher risk of cancer.
Marga A.G. Helmink, Jan Westerink, Steven H.J. Hageman, Miriam Koopman, Manon G. van der Meer, Martin Teraa, Ynte M. Ruigrok, Frank L.J. Visseren.
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Publications 2022
- Exercise is important, but are all types of exercise equally good for you?
For this project we looked at the relationship between the risk of cardiovascular disease on the one hand and exercise in leisure time and exercise at work on the other in people who already have cardiovascular disease. Leisure time exercise is very good. It provides a 30-40% relative risk reduction of new cardiovascular disease, of mortality and of developing diabetes. Exercise at work provides less benefit. We found that people doing physically demanding work did not have a lower risk of these diseases. Exercise is important to improve your health. In this regard, exercise at work is not enough. Everyone should try to exercise in leisure time, even if they are already moving at work.
Nadia E Bonekamp, Frank L J Visseren, Ynte Ruigrok, Maarten J M Cramer, Gert Jan de Borst, Anne M May, Charlotte Koopal.
Read the full article > - The SMART-2 risk model for predicting the 10-year risk of cardiovascular disease, in people who have had previous vascular disease.
Currently, the risk of vascular disease in people with previous vascular disease can be estimated with the SMART risk score. In this article, we have revamped this risk score, making several methodological improvements and using more data to make even more precise estimates. One of the improvements is the proper inclusion of geographical differences within Europe. The updated SMART2 risk score uses 8355 patients with previous vascular diseases who were included from the UMC Utrecht, these people were followed for a long time. This long-term data was used for the update, and the score was then further validated in 369,044 people from various regions within Europe and beyond.
Steven H J Hageman, Ailsa J McKay, Peter Ueda, Laura H Gunn, Tomas Jernberg, Emil Hagström, Deepak L Bhatt, Ph. Gabriel Steg, Kristi Läll, Reedik Mägi, Mari Nordbø Gynnild, Hanne Ellekjær, Ingvild Saltvedt, José Tuñón, Ignacio Mahíllo, Álvaro Aceña, Karol Kaminski, Malgorzata Chlabicz, Emilia Sawicka, Taavi Tillman, John W McEvoy, Emanuele Di Angelantonio, Ian Graham, Dirk De Bacquer, Kausik K Ray, Jannick A N Dorresteijn, Frank L J Visseren
Read the full article > - Lifetime risk prediction is an effective and cost-effective way to decide which people we should treat most intensively.
For people with vascular disease, cardiovascular risk can also be predicted with a lifetime perspective, this can be done with the previously published SMART-REACH model. This article examined whether treatment decisions made on the basis of these predictions are effective and cost-effective. Through a simulation, such treatment decisions are compared with following current guidelines. The results show that using the increase in vascular disease-free survival is an effective measure to use for treatment decisions, this can lead to more vascular disease-free life years and prevention of cardiovascular events.
Steven H J Hageman, Jannick A N Dorresteijn, Michiel L Bots, Folkert W Asselbergs, Jan Westerink, Miriam P van der Meulen, Arend Mosterd, Frank L J Visseren, the UCC-SMART Study Group , F W Asselbergs, H M Nathoe, G J de Borst, M L Bots, M I Geerlings, M H Emmelot, P A de Jong, T Leiner, A T Lely, N P van der Kaaij, L J Kappelle, Y M Ruigrok, M C Verhaar, F L J Visseren, J Westerink.
Read the full article > - Changes in lifestyle and kidney function: A 10-year follow-up study in patients with cardiovascular disease.
Patients with cardiovascular disease are at higher risk for decline in kidney function. In patients with cardiovascular disease, continued smoking, recent smoking cessation and an increase in obesity markers were related to a greater decline in kidney function. The results support the importance of encouraging weight loss and smoking cessation in high-risk patients as a means of slowing the decline of kidney function.
Helena Bleken Østergaard, Imre Demirhan, Jan Westerink, Marianne C Verhaar, Folkert W Asselbergs, Gert J de Borst, L Jaap Kappelle, Frank LJ Visseren, Joep van der Leeuw, on behalf of the UCC-SMART study group.
Read the full article > - Microinfarcts in the brain on 7 tesla MRI
Microinfarcts are very small infarcts that can be detected by an MRI scan with a strong magnet (7 tesla MRI). This article looked for microinfarcts in deep areas of the brain on the 7 tesla MRI. Microinfarcts were detected in about 13% of subjects, and these abnormalities were seen more often in subjects who scored worse on cognitive tests.
Rashid Ghaznawi, Maarten H.T. Zwartbol, Jeroen de Bresser, Hugo J. Kuijf, Koen L. Vincken, Ina Rissanen, Mirjam I. Geerlings, Jeroen Hendrikse.
Read the full article > - Mild arteriosclerosis of the carotid artery and brain shrinkage
Severe arteriosclerosis of the carotid artery may be a risk factor for increased brain shrinkage. Whether this is also the case for mild arteriosclerosis is as yet unknown. In this study, mild arteriosclerosis in the carotid artery was found to be a risk factor for more brain shrinkage over time (measured by an MRI scan of the brain).
Rashid Ghaznawi, Jet M.J. Vonk, Maarten H.T. Zwartbol, Jeroen de Bresser, Ina Rissanen, Jeroen Hendrikse, Mirjam I. Geerlings.
Read the full article > - Carotid artery calcification and brain shrinkage
This study investigated whether different degrees of vascular calcification of the carotid artery lead to more brain shrinkage of the hemisphere on the same side of the vascular calcification. It was found that only severe vascular calcification is a risk factor for more shrinkage of the brain hemisphere on the side of the vascular calcification.
Rashid Ghaznawi, Ina Rissanen, Jeroen de Bresser, Hugo J. Kuijf, Nicolaas P.A. Zuithoff, Jeroen Hendrikse, Mirjam I. Geerlings.
Read the full article > - The association between the amount of visceral fat and disturbed action of adipose tissue in the abdomen on the occurrence of severe bleeding in patients with cardiovascular disease.
Fat that lies between organs in the abdomen increases the risk of cardiovascular disease. Patients with a lot of this fat are therefore helped by proper treatment to prevent new cardiovascular diseases, for example with blood thinners. The risk of blood thinners is the development of bleeding. This study looked at whether there is also a relationship between abdominal fat and the occurrence of severe bleeding. It looked at both the amount and derangement of fat because fat also affects things like blood pressure, sugar levels, fat levels and inflammation levels in the blood.
A total of 6927 patients with cardiovascular disease were followed for about 9 years, and 237 patients (3%) experienced severe bleeding. No relationship was seen between abdominal fat (amount and impaired function) and the occurrence of severe bleeding.
This knowledge is important when patients decide on blood thinners with their doctor.
Maria C Castelijns, Steven H J Hageman, Ynte M Ruigrok, Manon G van der Meer, Martin Teraa, Jan Westerink, Frank L J Visseren
Read the full article > - Screening for dilation of the large abdominal artery (AAA) in patients with cardiovascular disease
The aim of this study was to investigate how the prevalence of dilation of the large abdominal artery (AAA = aneurysm of the abdominal aorta) found by screening has changed over time in patients previously diagnosed with cardiovascular disease. For this, we used data collected in the UCC-SMART study. We found that AAA is found more often in men than in women. We see that since 1997 the prevalence in men over 60 years of age has decreased, but is higher than if you screened men without cardiovascular disease. This means that screening for AAA in patients with cardiovascular disease could potentially be cost-effective.
de Boer AR, Vaartjes I, van Dis I, van Herwaarden JA, Nathoe HM, Ruigrok YM, Bots ML, Visseren FLJ; UCC-SMART study group.
Read the full article > - Patients with fused spine at greater risk of stroke
Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of the spine characterized by the formation of new bone and fusion of vertebrae. Patients with DISH suffer greatly from cardiovascular disease, high blood pressure, high BMI and the presence of diabetes. Previous research has shown that patients with DISH have more calcifications in the brain and experience more heart attacks. With this study, we wanted to see what the relationship was between having DISH and developing cardiovascular disease. We found that patients with DISH had an increased risk for developing strokes in which blood clots in the brain cause the cutoff of oxygen and blood supply to the brain. No association was found between DISH and heart attacks, or other causes of death. We provide further evidence for DISH as a marker for cardiovascular disease and emphasize the importance of prevention.
Netanja I. Harlianto, Nadine Oosterhof, Wouter Foppen, Marjolein E. Hol, Rianne Wittenberg, Pieternella H. van der Veen, Bram van Ginneken, Firdaus A.A. Mohamed Hoesein, Jorrit-Jan Verlaan, Pim A. de Jong, Jan Westerink, UCC-SMART-Study Group.
Read the full article > - Patients with fused spine have more vascular calcification in the great arteries
Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of the spine characterized by the formation of new bone and fusion of vertebrae. Patients with DISH suffer greatly from cardiovascular disease, high blood pressure, high BMI and the presence of diabetes. Recently, a large study found that patients with DISH have an increased risk of strokes, due to occluded men's vessels. These strokes usually occur when blood clots form as a result of clogged arteries. The blood clots then prevent the supply of oxygen and blood to the brain. We examined the severity of vascular calcification in the aorta, the large artery. Vascular calcifications are mineral deposits in blood vessels that increase the risk of stroke. We found that DISH is associated with more severe vascular calcification in the aorta, which may explain its relationship with stroke.
Netanja I. Harlianto, Jan Westerink, Marjolein E. Hol, Rianne Wittenberg, Wouter Foppen, Pieternella H. van der Veen, Bram van Ginneken, Jorrit-Jan Verlaan, Pim A. de Jong, Firdaus A.A. Mohamed Hoesein, UCC-SMART-Study Group.
Read the full article > - Different forms of stress have specific effects on the brain
The brain region that plays an important role in memory formation is the hippocampus. Certain regions of the hippocampus can be particularly vulnerable to stress, and we wanted to see if different forms of stress would have different effects on these regions. To do this, we looked at the following psychosocial factors: depressive symptoms, anxiety symptoms, child abuse, social support and recent stressful events. We used data from the "Memory Depression and Aging (Medea)-7T" study, in which the hippocampus had been measured in great detail in a 7 Tesla MRI scanner.
We found no association between hippocampal volume and depressive or anxiety symptoms. We did find that childhood abuse was associated with lower volumes of all regions, while the experience of recent stressful events was associated with higher volumes. Low social support was specifically associated with lower volumes in the 'CA3' region. The CA3 region is particularly vulnerable to stress. These results suggest that different forms of stress have different relationships with hippocampal region volume.
Emma L Twait, Kim Blom, Huiberdina L Koek, Maarten H T Zwartbol, Rashid Ghaznawi, Jeroen Hendrikse, Lotte Gerritsen, Mirjam I Geerlings; UCC SMART Study Group.
Read the full article > - Exercise is important, but are all types of exercise equally good for you?
For this project we looked at the relationship between the risk of cardiovascular disease on the one hand and exercise in leisure time and exercise at work on the other hand in people who already have cardiovascular disease.
Leisure time exercise is very good. It provides a 30-40% relative risk reduction of new cardiovascular disease, of mortality and of developing diabetes. Exercise at work provides less benefit. We found that people doing physically demanding work did not have a lower risk of these diseases.
Exercise is important to improve your health. In this regard, exercise at work is not enough. Everyone should try to exercise in leisure time, even if they are already moving at work.
Nadia E Bonekamp, Frank L J Visseren, Ynte Ruigrok, Maarten J M Cramer, Gert Jan de Borst, Anne M May, Charlotte Koopal.
Read the full article > - The importance of 'competing' risks in predicting cardiovascular disease
This study examined the effect of taking into account 'competing risks' (such as other diseases or accidents) in predicting cardiovascular disease (CVD) in high-risk groups. In 8,355 patients from the UCC-SMART cohort, 10-year CVD risk was estimated with two models: one model took competing risks into account (Fine and Gray), the other (Cox) did not. The Cox model gave higher risk predictions and tended to overestimate, especially in older people or those at highest risk. If these predictions were used to decide on treatment, more people would be treated according to the Cox model. The study concludes that considering competing risks is important for accurate predictions, especially in high-risk groups.
Steven H J Hageman, Jannick A N Dorresteijn, Lisa Pennells, Maarten van Smeden, Michiel L Bots, Emanuele Di Angelantonio, Frank L J Visseren.
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Publications 2021
- How does vascular calcification occur in the posterior part of the brain?
Calcification in the blood vessels that supply the brain with blood can have health consequences. For example, it can lead to cerebral hemorrhage or cerebral infarction. Because very little is still known about this, we looked at which people (e.g., older people or mostly men?) have the most vascular calcification in the blood vessels that supply blood to the back part of the brain. This is important because, for example, bleeding in this part of the brain can have serious consequences.
We measured vascular calcification by CT scan in 471 patients in the UCC-SMART study. We saw that especially older patients, patients with diabetes, and overweight patients had high levels of vascular calcification. These results provide more insight into why and in whom vascular calcification develops in the posterior part of the brain. We hope that in the future these data can contribute to the prevention of vascular calcification, for example by preventing obesity, so that serious brain hemorrhages occur less often.
Tim C. van den Beukel, Carlo Lucci, Jeroen Hendrikse, Wilko Spiering, Huiberdina L. Koek, Mirjam I. Geerlings, Pim A. de Jong.
Read the full article > - Insulin resistance is a risk factor for cardiovascular disease in people with type 1 diabetes
People with type 1 diabetes (DM1) have an increased risk of cardiovascular disease (CVD). Even if their blood sugar, cholesterol levels and blood pressure are treated, these people have an increased risk of HVZ. Insulin resistance, best known from type 2 diabetes, seems to play a role. In insulin resistance, the body's cells become less sensitive to insulin (a hormone that causes sugars from food to be absorbed from the blood). Overweight people have an increased risk of insulin resistance. In recent years, more and more people are overweight, including people with DM1. Although DM1 is actually characterized by no insulin production at all, we see that even these people are increasingly insensitive to the insulin they inject. In UCC-SMART, we looked at the relationship between insulin resistance and the risk of HVZ in people with DM1. We see that people who are more insulin resistant indeed have a higher risk of HVZ.
Marga Helmink, Marieke de Vries, Frank Visseren, Wendela de Ranitz, Harold de Valk and Jan Westerink.
Read the full article > - End-stage renal failure in patients with vascular disease; prevalence and risk factors: results from the UCC-SMART cohort study.
Patients with cardiovascular disease are at increased risk for end-stage renal failure. Understanding how frequently renal failure occurs and the role of modifiable risk factors may offer opportunities for prevention in patients with cardiovascular disease. This study concludes that how often end-stage renal failure occurs in patients with cardiovascular disease varies depending on the location of the vascular disease. Several modifiable risk factors for end-stage renal failure were found in patients with cardiovascular disease (smoking, elevated blood pressure, lower kidney function and type 2 diabetes). These findings emphasize the importance of risk factor treatment in patients with cardiovascular disease.
Helena Bleken Østergaard, Jan Westerink, Marianne C Verhaar, Michiel L Bots, Folkert W Asselbergs, Gert J de Borst, L Jaap Kappelle, Frank LJ Visseren, Joep van der Leeuw, on behalf of the UCC-SMART study group.
Read the full article > - White matter abnormalities on MRI and the risk of mortality
White matter abnormalities are often seen on MRI imaging of the brain and may be a manifestation of capillary abnormalities. This study examined the relationship between white matter abnormalities and risk of mortality. Multiple features of white matter abnormalities on MRI such as shape and volume were found to predict the risk of mortality.
Rashid Ghaznawi, Mirjam I. Geerlings, Myriam G. Jaarsma-Coes, JeroenHendrikse, Jeroen de Bresser
Read the full article > - Blood supply to the brain and brain shrinkage
This study investigated whether reduced blood supply to the brain (measured on a brain MRI scan) is a risk factor for increased brain shrinkage. Brain shrinkage is a risk for the development of dementia and complaints with memory. It was found that decreased blood supply to the brain is related to more brain shrinkage over time.
Rashid Ghaznawi, Maarten H.T. Zwartbol, Nicolaas P.A. Zuithoff, Jeroen de Bresser, Jeroen Hendrikse, Mirjam I. Geerlings.
Read the full article > - The association between ischemic imaging phenotype with progression of brain tissue loss and cerebrovascular damage on MRI: the SMART-MR study
The SMART-MR study classified stroke status based on the presence of clinical and MRI findings. Changes in brain volume and white matter hyperintensity from 12 years of follow-up were studied in four groups: no stroke, symptomatic stroke, vascular damage without symptoms and imaging-negative ischemia. This study shows that there is difference in progression and location between decrease in brain volume and cerebrovascular damage depending on the clinical and radiological display of stroke. This finding emphasizes that cerebrovascular disease cannot be viewed as a single entity. Different manifestations should be considered as separate groups in research and in clinical practice.
Ina Rissanen, Carlo Lucci, Rashid Ghaznawi, Jeroen Hendrikse, L. Jaap Kappelle, Mirjam I. Geerlings.
Read the full article > - Patients with Forestier's disease have more obesity, overweight and abdominal fat
Forestier's disease, also called DISH; Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of the spine characterized by the formation of new bone and fusion of vertebrae. Patients with DISH suffer greatly from cardiovascular disease, high blood pressure, high BMI and the presence of diabetes. The cause of a fused spine is still unknown. We examined several markers of obesity in this patient population, in both men and women, because a strong association with abdominal fat supports the role of inflammation in the development of DISH. We found that patients with DISH had more abdominal fat, which may possibly explain why these patients develop DISH.
Netanja I. Harlianto, Jan Westerink, Wouter Foppen, Marjolein E. Hol, Rianne Wittenberg, Pieternella H. van der Veen, Bram van Ginneken, Jonneke S. Kuperus, Jorrit-Jan Verlaan, Pim A. de Jong, Firdaus A.A. Mohamed Hoesein, UCC-SMART-Study Group.
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Publications 2020
- Applicability of large studies on blood pressure-lowering drugs in Dutch patients with cardiovascular disease
It is often said that drug efficacy studies are conducted in selected patient groups. As a result, they might not be applicable to "real" patients. In this study, we sought to see to what extent the results of five large studies on blood pressure-lowering drugs are applicable to patients with cardiovascular disease from the SMART cohort. The majority of SMART participants, could participate in the five large studies. Up to 84% of participants met the selection criteria. For two studies, in people with coronary artery disease, it was found that those who did not meet the selection criteria had a higher risk of developing cardiovascular disease again. For the three other studies, no difference was found in that probability. This research shows that the results of studies on blood pressure lowering drugs can be translated well to a group of Dutch patients in daily clinical practice.
Nadia E Bonekamp, Wilko Spiering, Hendrik M Nathoe, L Jaap Kappelle, Gert J de Borst, Frank L J Visseren, Jan Westerink, on behalf of the UCC-SMART study group.
Read the full article > - The influence of classical risk factors on amputations and leg surgery
Amputations and other vascular procedures on the leg can lead to high dependency and disease burden. These problems are particularly well known in patients with peripheral arterial disease ("venous ulcers"), but can also occur in people with vascular disease in other locations. Using data from 8139 patients from the UCC-SMART cohort, we investigated exactly how often these procedures occur in patients with different types of vascular disease and what the effect of cholesterol, blood pressure and smoking is on this. Cholesterol seems to play a lesser role in the occurrence of amputations and vascular interventions. Higher blood pressure gives a significantly higher risk of this. The biggest effect, however, is from smoking - people who used to smoke have a three times higher risk than those who never smoked. People who still smoke are even zever times more likely to have amputations and vascular interventions. This study shows that it is also very important for amputations and vascular interventions on the legs not to smoke and to treat hypertension.
Steven H J Hageman 1, Gert Jan de Borst 2, Johannes A N Dorresteijn 1, Michiel L Bots 3, Jan Westerink 1, Folkert W Asselbergs 4 5 6, Frank L J Visseren 7, UCC-SMART Study Group.
Read the full article > - Use of kidney injury markers improves prediction of cardiovascular risk.
Chronic kidney injury is a common condition in the Netherlands. Impaired kidney function or protein loss in the urine also leads to increased cardiovascular disease (CVD) risk. Current prediction models for HVZ do not yet use these markers of kidney damage.
In this large international study with nearly 9 million participants (including those from the UCC-SMART study), we show that adding kidney injury markers to HVZ scores allows you to make much better risk estimates.
In individuals with impaired kidney function or high protein loss in urine, the risk of death from HVZ was found to be between 37 and 164% higher than when using the old scores.
The conclusion of this study is that measuring and using renal function and protein in urine can improve risk estimation of HVZ and thus targeted treatment.
Matsushita K, Jassal SK, Sang Y, Ballew SH, Grams ME, Surapaneni A, Arnlov J, Bansal N, Bozic M, Brenner H, Brunskill NJ, Chang AR, Chinnadurai R, Cirillo M, Correa A, Ebert N, Eckardt KU, Gansevoort RT, Gutierrez O, Hadaegh F, He J, Hwang SJ, Jafar TH, Kayama T, Kovesdy CP, Landman GW, Levey AS, Lloyd-Jones DM, Major RW, Miura K, Muntner P, Nadkarni GN, Naimark DM, Nowak C, Ohkubo T, Pena MJ, Polkinghorne KR, Sabanayagam C, Sairenchi T, Schneider MP, Shalev V, Shlipak M, Solbu MD, Stempniewicz N, Tollitt J, Valdivielso JM, van der Leeuw J, Wang AY, Wen CP, Woodward M, Yamagishi K, Yatsuya H, Zhang L, Schaeffner E, Coresh J.
Read the full article > - Hard-to-treat high blood pressure as a risk factor for the development of diabetes
This may be because factors that cause difficult-to-treat high blood pressure, such as obesity, also play a role in the development of other conditions that put people at higher risk for cardiovascular disease, such as diabetes. This study looked at the risk of developing diabetes for people with high blood pressure compared with those without high blood pressure. It found that patients with high blood pressure have an approximately 1.5 times higher risk of diabetes and that it does not matter how well the blood pressure is treated and how much medication is needed for it.
Joris Holtrop, Wilko Spiering, Hendrik M Nathoe, Gert J De Borst, Laurens J Kappelle, Harold W De Valk, Frank L J Visseren, Jan Westerink.
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Publications 2017-2018
- Small infarcts in caudate nucleus on MRI imaging
Small infarcts can only be detected using an MRI with a strong magnet. This study looked for small infarcts in the nucleus caudatus, a part of the brain, by using a 7 tesla MRI (an MRI scanner with a very strong magnet). It was found that the 7 tesla MRI can reliably detect more small infarcts than the more common 1.5 tesla MRI.
Rashid Ghaznawi, Jeroen de Bresser, Yolanda van der Graaf, Maarten HT Zwartbol, Theo D Witkamp, Mirjam I. Geerlings, Jeroen Hendrikse
Read the full article > - Lacunae and white matter abnormalities
Lacunes and white matter abnormalities are both manifestations of brain damage on MRI due to abnormalities of the smallest blood vessels in the brain. This article examined the relationship between lacunes and white matter abnormalities. It was found that lacunes are associated with multiple characteristics of white matter abnormalities such as type, volume and shape.
Rashid Ghaznawi, Mirjam I. Geerlings, Myriam G. Jaarsma-Coes, Maarten H.T. Zwartbol, Hugo J. Kuijf, Yolanda van der Graaf, Theo D. Witkamp, Jeroen Hendrikse, Jeroen de Bresser
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25 years of SMART patient day
2021 marked the 25th anniversary of the UCC-SMART study; 2022 saw more than 15,000 participants in the program. By updating these people with (risk of) cardiovascular disease on what's happening with their research data, the researchers want to show how patients' participation in the program actually helps improve the care of current and future generations. The special UCC-SMART patient day at UMC Utrecht was therefore well-attended.