Cohort Profile: Rationale and design of the fourth visit of the STANISLAS cohort: a familial longitudinal population-based cohort from the Nancy region of France

Population-based cohort studies allow the assessment of exposure-outcome relationships and potential confounders, as well as numerous other variables of potential interest.1 Given their nature and design, population-based cohort studies generally enable evaluation of multiple hypotheses, some defined a priori whereas others are suggested during the course or at the end of the study.1 In particular, having data repeatedly and longitudinally collected on cohort members allows the testing and generation of new hypotheses such as predictors of events and disease/state incidence determination and its trends over time, in addition to the testing of multiple associations (in both cross-sectional and longitudinal manners). Additionally, the estimation of distributions and prevalence rates of relevant variables and the calculation of population-attributable risks can be performed, as well as data confirmation for external validation and reproducibility.2 The STANISLAS cohort was established with the primary objective of investigating gene-gene and gene-environment interactions in the field of cardiovascular diseases, based on the study of interindividual variability and familial segregation analysis of biological and morphological intermediate phenotypes of cardiovascular risk. The longitudinal nature of this study should enable researchers to take into account the evolution of intermediate phenotypes related to genetic factors throughout the follow-up period. The families, consisting of two parents and at least two biological children, were deemed healthy, initially free of declared acute and/or chronic illness, in order to assess the effect of genetics on the variability of intermediate phenotypes studied under physiological conditions without the influence of disease. To the best of our knowledge, the STANISLAS cohort is one of the largest longitudinal familial cohorts to date. The aim of this article is to provide an overview of the fourth visit at 17 years of the STANISLAS cohort (STANISLAS-V4), its included population, the complementary methods used and the main objectives of the study. The STANISLAS (Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux) cohort is a single-centre familial longitudinal cohort comprising 1006 families (4295 participants) from the Nancy region of France, who were recruited during 1993–95 at the Center for Preventive Medicine during a yearly routine examination, under the coverage of the Caisse Nationale d’Assurance Maladie (CNAM).3 The second and third visits were performed ≈5 and 10 years later, respectively. Thereafter, the cohort follow-up was moved to the Plurithematic Clinical Investigation Center at Nancy University Hospital (the latter is now the cohort sponsor) and the fourth visit (held from 2011 to 2016) included 1705 subjects of the original cohort willing to return. Participants were recruited for the initial visit (1993–95) during their routine examination at the Center for Preventive Medicine. During this period, a total of 1197 families was selected to participate in the study; 191 families refused to participate for reasons such as lack of motivation, lack of availability or refusal to give extra blood, and 1006 families gave their informed consent. Among these 1006 recruited families (4295 subjects), 9% of the parents were attending the Center for Preventive Medicine for the first time, 29.5% for the second time, 40% for the third, 17% for the fourth and 4.5% for the fifth time. To be recruited for the STANISLAS cohort, families had to be of French origin, reside in the Lorraine region (north-east of France) and have at least two parents and two biological children aged older than 6 years. Participants would have to be declared free of disease (acute and/or chronic) in order to evaluate gene-gene and gene-environment interactions in the cardiovascular system without the influence of disease and/or its treatments. Regarding children, 74.7% of the families had two children, 23.7% of the families had three children and 1.6% of the families had four children.3 The second visit took place between October1998 and November 2000. For this visit 756 families (2952 subjects) were recruited. During these two visits, serum, plasma and DNA samples were collected. Additionally, a database was created, combining data from the health examination and data specific to the STANISLAS Cohort (clinical, biological and genetic data). In 2002, the STANISLAS Cohort was recognized by INSERM (Institut National de la Santé et de la Recherche Médicale) as a biological resource centre (BRC). The main objectives were to maintain the collections of the first and second check-ups, to extend the collection of biological samples (serum, plasma and DNA) and clinical, biological and genetic data to the third medical check-up (2003–05) and to build up new RNA and peripheral blood mononuclear cell (PBMC) extract banks4. The third visit started in October 2003. For this visit, 399 families (1330 participants) have been recruited. The RNA and PBMCs extract banks have been incorporated in this visit in order to provide a more in-depth understanding of the relation between genetic factors, intermediate phenotypes and cardiovascular disease.4 The implementation of the fourth visit enabled follow-up at 18 to 23 years of this cohort population. The sample collection will be enriched with new biomarkers and clinical phenotyping of the cohort, allowing the generation of novel hypotheses and the testing of laboratory and experimental findings with translational applications and potential mechanistic relevance. The STANISLAS-V4 also allows the long-term evaluation of clinical, biological and morphological data. In particular, by analysing the influence of ageing (average age of parents in 1993: 45 years and in 2011–16: 64 years), the incidence and changes in prevalence of cardiovascular risk factors (such as ‘metabolic syndrome’) and their familial segregation can be assessed. For example, as early as the second visit, at least one family member presented ‘metabolic syndrome’ according the definition of the NCEP-ATPIII guidelines. Moreover, approximately 20% of adults had blood pressure ≥ 140/90 mmHg and 50% had a body mass index ≥ 25 kg/m2. In short, this cohort permits the study of genetic and environmental determinants of disease, through a multifaceted approach including familial segregation and candidate genes, as well as the progression of cardiovascular risk and the incidence of cardiovascular diseases. The composition of the participating families throughout the four visits is depicted in Table 1, the information gathered at each visit is shown in Table 2 and the characteristics of the population at each visit is described in Table 2. Composition of the STANISLAS population from visit 1 (baseline) to visit 4, with a follow-up of ∼20 years Parents = father, mother; children = son, daughter; other relatives = mother-in-law, son second wedding, daughter second wedding, son-in-law, daughter-in-law, grandson, granddaughter, grandson second wedding, granddaughter second wedding. aFamily composition defined at subject’s first recruitment regardless of subsequent changes (e.g. son becoming a father). Composition of the STANISLAS population from visit 1 (baseline) to visit 4, with a follow-up of ∼20 years Parents = father, mother; children = son, daughter; other relatives = mother-in-law, son second wedding, daughter second wedding, son-in-law, daughter-in-law, grandson, granddaughter, grandson second wedding, granddaughter second wedding. aFamily composition defined at subject’s first recruitment regardless of subsequent changes (e.g. son becoming a father). Data collected at each study visit aPhone questionnaire at visit 4; if alive: smoking and alcohol habit, physical activity, concomitant treatment, medical history; if dead: date and cause of death, medical history, smoking habit. bData for 387 subjects. cData for 1034 subjects. dData for 3582 subjects. eData for 590 subjects. Data collected at each study visit aPhone questionnaire at visit 4; if alive: smoking and alcohol habit, physical activity, concomitant treatment, medical history; if dead: date and cause of death, medical history, smoking habit. bData for 387 subjects. cData for 1034 subjects. dData for 3582 subjects. eData for 590 subjects. All cohort members were contacted to participate in the fourth visit. The collected data included those also stored during the previous visits (see below for details), the latter of which were enhanced with new phenotyping analyses including morphological investigations (12-lead electrocardiogram, echocardiography, carotid echo-tracking for intima-media thickness evaluation, arterial stiffness as assessed by pulse wave velocity, ankle brachial index and thorax and abdominal aortic ultrasound) as well as magnetic resonance imaging in a subset of patients. The research protocol was approved by local ethics committee (Comité de Protection des Personnes Est III—Nancy—France) and all study participants gave written informed consent to participate. The informed written consent was previously approved by the local ethics committee. The tests carried out on all four STANISLAS Cohort visits include: (i) biological data [complete blood count, albumin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), bilirubin, gamma-glutamyl transferase, alkaline phosphatase, total proteins, creatinine, glucose, uric acid, C-reactive protein, total cholesterol, high-density lipoprotein (HDL)-cholesterol, triglycerides, apolipoproteins A1, B and E, lipoproteins CIIIB, CIII and BE and urinalysis with proteins, glucose and search for haematuria]; (ii) clinical data (blood pressure, heart rate, electrocardiogram, body mass index, waist-to-hip ratio, weight and height at birth, subscapular skinfolds, supra-iliac skinfolds, pubertal maturation); (iii) life habits (leisure time, physical activity, profession, studies, residence, familial situation, alcohol, drugs and tobacco consumption, perceived health, family history,nutrition status).5 In addition, numerous genetic studies have been performed and data on 161 polymorphic sites located on 83 candidate genes of cardiovascular disease are available. The biological banks that are available for each subject are total blood, serum, plasma, white blood cells and DNA for all four visits; and PAXGENE mRNA, PBMC mRNA and PBMC extracts only for the third and fourth visits. These data and information have been previously described.4 In addition to the data common to all four visits, all participants attending the fourth visit (and a subgroup of patients attending the first visit) had vascular exploration (carotid intima-media thickness, pulse wave velocity, atheroma plaques) and echocardiography with particular focus on diastolic function. Additionally, 24-h ambulatory blood pressure measurement was performed only in the fourth visit (Tables 2 and 3). Description of the STANISLAS population from visit 1 (baseline) to visit 4, with a follow-up of ∼20 years BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; LVM, left ventricular mass; eGFR, estimated glomerular filtration rate; NA, not available. aUrine albumin/creatinine is presented as median (interquatile range) due to its skewed distribution. Description of the STANISLAS population from visit 1 (baseline) to visit 4, with a follow-up of ∼20 years BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; LVM, left ventricular mass; eGFR, estimated glomerular filtration rate; NA, not available. aUrine albumin/creatinine is presented as median (interquatile range) due to its skewed distribution. Blood was drawn for assays by the Clinical Investigation Center of Nancy. Certain measurements were performed on blood from all participants, whereas others were performed only on frozen blood from a sample of ‘cases’ and matched controls. A minimally traumatic venepuncture was required. Standardized sample handling procedures enabled the collection of serum and plasma (EDTA, heparin) as well as buffy coat fraction. For a subset of patients (n = 584), peripheral blood mononuclear cells (PBMCs) were also isolated. The use of DNA and RNA Paxgene tubes additionally allowed access to DNA and total RNA (micro-, long non-coding and messenger RNAs) from each patient. All blood-derived bio samples are stored in the central biobank facility at between −80°C and −196°C. Spot urine samples were collected at the beginning of the fourth visit from all fasted participants. Once aliquoted, samples were stored at −80°C. Echocardiographic examinations were performed by an experienced echocardiographer, in the left lateral decubitus position with a commercially available standard ultrasound scanner (Vivid 9, General Electric Medical Systems, Horten, Norway) using a 2.5 MHz phased-array transducer (M5S). The echo/Doppler examination included exhaustive examination in parasternal long- and short-axis views and in the standard apical views. For each view, 2-D Doppler and Tissue Doppler Imaging (TDI) acquisitions with and without colour were recorded. Longitudinal left ventricular deformation parameters (strain) were also obtained using speckle tracking echocardiography. All acquired images and media were stored on a secured network server as digital clips, using a unique identification number and analysed on a dedicated workstation (EchoPAC PC, version 110.1.0, GE Healthcare). The image acquisition in STANISLAS-V4 has shown to be highly reproducible.6 A systematic search for atherosclerosis lesions and plaque was also performed with a 10-Mhz probe (9 L-D) on both carotid arteries. Carotid plaques were defined according to the Mannheim consensus7 as a focal increase of at least 0.5 mm or 50% compared with the surrounding IMT value or a focal structure with an intima-media thickness > 1.5 mm. Abdominal aorta diameters (i.e. anterior-posterior diameter measured from outer-to-outer edge) were also assessed by ultrasound using an echocardiography probe with the patient in the supine position and the image perpendicular to the aorta longitudinal axis.8 Carotid intima-media thickness (cIMT) measurements were routinely performed by high-resolution echo-tracking in STANISLAS-V4.9 The non-invasive investigations were performed in a controlled environment at 22 ± 1°C after 10 min of rest in the supine position.10 Carotid diameter, distension and intima -media thickness were measured on the right common carotid artery. measurements were obtained patient. were performed with the system The and the The in For each a was the diameter, and distension measured at each The variability of diameter, distension and was compared between all The and of the measurements were wave measurement was performed with France) and blood pressure was measured after at least 10 min of rest in supine in a Carotid to was assessed with using the of the for Investigation of were on the carotid and on the of the artery. measurements were performed, with as the of the two the two first acquisitions by more than 0.5 a third measurement was performed and the was as the median of the three The based on the second was used for the determination of the time. The carotid to carotid to and to carotid were measured with a The used for calculation was the wave was measured with the after of three on the for The probe was on the carotid and the in at the as the The protocol with to the number of measurements was The was used to the time. were performed by four blood pressure and carotid local blood pressure were assessed by using the 10 min of rest in the supine systolic and diastolic blood were measured with an and used to the and carotid pressure were in by a and carotid pulse were analysed and central blood pressure was with an on the In addition to the of biomarkers in the STANISLAS cohort and other biomarkers including studies will also be measured in the STANISLAS The is an that be to and novel the examination, a or the with the findings and for or and of were for all the study participants, using the National de of subjects of the initial participants had of or of or The STANISLAS-V4 database was and is at the of the A data has been based on common and analyses will be to each with generation of analysis according to the standard These familial segregation and gene-gene and gene-environment using as and network The characteristics of the STANISLAS cohort population from visit 1 to visit are in Table Participants with at and For example, a subject was at if or had a blood pressure 140/90 and/or had at least one whereas the was as at if or had a of based on medical and/or had blood pressure mmHg 24-h ambulatory blood pressure and/or had at least one The evolution of the prevalence of four disease parameters in patients who at both visit 1 and visit (n = is depicted in was an increase in conditions during the follow-up The definition of at visit 1 was based on of blood glucose for blood glucose, > 2 and/or the of at least one visit 4, the based on medical was an available to the two variables for and are described in Table 1 and in 2 1 and visit 4, for of in participants who at both 1 and The tests a between and for the four conditions of families and participants family in the STANISLAS cohort study. subjects of the family at visit 1 at visit The STANISLAS cohort, to its familial structure and cardiovascular phenotyping at visit 4, the unique of the and familial associations of relevant with the early changes to cardiovascular and ageing in initially all in a population-based research has a in the of potential and allows the testing of novel hypotheses in or that will be in in order to the The STANISLAS cohort allows study of family participants, with characteristics to those by the this cohort and biological data with medical events in a permits assessment of family the health of the In the population, the progression from risk to disease a in which genetic and factors with each The STANISLAS participants having phenotyping during a longitudinal follow-up cardiovascular phenotyping available from visit analysis of the data will a in and factors and their interactions from the specific of the STANISLAS research are to (e.g. genetic and external (e.g. of ageing and their approach should allow the of an early consisting of specific of biomarkers in order to to each risk in the of ageing is to clinical measurements and of the health of an over time. on the between clinical and experimental and clinical studies have a of biomarkers suggested to enable the identification and definition of of at risks of cardiovascular of these biomarkers have been in and for their of the of or the lack of long from over years of data and the STANISLAS cohort allows through of disease progression using clinical, imaging and biological data (e.g. conditions not at at The STANISLAS cohort also permits the of findings in other as well as data in cohort studies such as the in and for in the assessment of biomarkers in disease The STANISLAS cohort unique to these candidate biomarkers in order to and their use as biomarkers an disease The early of cardiovascular risk factors and at in the population allows the assessment of disease predictors and potential over time, novel the of the of for the STANISLAS participants were using (blood and a of as 10 the use of the collected in the and previous visits. the of novel biomarkers and related that will validation in other and validation are both highly as biomarkers are in clinical to to and for the of cardiovascular and disease as well as to of patients more to from a the STANISLAS analyses should in the value of biomarkers over the clinical Among also clinical and in disease and risk which such as chronic disease, heart disease and heart the from health common a in the standard in the and of chronic diseases, is recognized that common that or The long follow-up of the health of STANISLAS participants should in the specific and over of the research potential of this cohort have been by network analysis the of the research clinical and in-depth phenotyping will be with a of determinants that influence the and progression of health in which of the or which of the latter the more and more of health will now be in STANISLAS participants. (blood and and data with clinical phenotyping of the STANISLAS participants should be to the identification of with cardiovascular disease and our translational and clinical research aim at not only from their also based on clinical and In the STANISLAS cohort access to phenotypes in over as to the of the of disease. cohort to the exploration of novel and mechanistic biomarkers and allowing understanding of the from health to disease and of disease and also the of according to All data the STANISLAS cohort are researchers are to for by the primary and will be to have access to the data through a secured server with analysis Data can be not and analysis can be performed for the data In order to be to access the and the a written to the and of the Nancy The the data or to access and the of the which a The will a by the of the under be to a third in a The STANISLAS cohort is a longitudinal study with the primary objective of investigating gene-gene and gene-environment interactions in the field of cardiovascular diseases, based on the study of interindividual variability and familial segregation analysis of biological and morphological intermediate phenotypes of cardiovascular risk. The cohort 1006 families (4295 participants) from the Nancy region of France, who were recruited during The second and third visits were performed ≈5 and 10 years later, respectively. The fourth visit (held from 2011 to 2016) included 1705 subjects of the original cohort willing to return. The implementation of the fourth visit enabled follow-up at 18 to 23 years. The a of and environmental biological genetic and information and to health and STANISLAS is a access The STANISLAS study is by the de is by the French of de Recherche by the de and by a by the French National as of the second is also by the in the and la de Recherche are highly to the Nancy de and to who the STANISLAS Cohort for the first three visits. The the of the Clinical Investigation Center and other in the Cohort E, E, Data Imaging and E, E, Hospital E, E, E, E, E, E, E, and all not who to the and analysis of the fourth visit of the STANISLAS also the of the Nancy for of the for the of the of