European Journal of Cardiovascular Medicine

Beta-thalassemia major (B-TM) is a severe hereditary hemoglobinopathy characterized by chronic hemolytic anemia, requiring lifelong red blood cell transfusions.¹ While transfusion therapy extends survival, it also predisposes patients to iron overload and metabolic disturbances. Emerging evidence suggests that B-TM patients are at an increased risk of early vascular dysfunction, including atherosclerosis and coronary artery disease.² Atherosclerosis, traditionally considered an age-related condition, may begin in childhood with a prolonged subclinical phase.³ Lipid metabolism alterations and changes in atherogenic indices may serve as early indicators of cardiovascular risk in these patients.⁴

Advancements in the management of B-TM have significantly improved survival rates, shifting the focus toward long-term complications, particularly cardiovascular disease.^5,6 Studies have reported altered lipid profiles in transfusion-dependent B-TM patients, often characterized by reduced total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels.⁷ The role of atherogenic indices, such as the atherogenic index of plasma (AIP) and lipid ratios, in predicting cardiovascular risk in this population remains underexplored.

Despite growing recognition of cardiovascular risk in B-TM, comprehensive studies on lipid profile alterations and atherogenic indices in pediatric populations remain limited. The impact of chronic anemia, iron overload, and oxidative stress on lipid metabolism in these patients is not well understood. Comparative studies with healthy age-matched controls are scarce, limiting the ability to establish clear risk stratification. This study aims to assess lipid profile abnormalities and atherogenic indices in children with transfusion-dependent B-TM and compare them with healthy controls. Identifying lipid alterations and cardiovascular risk markers at an early stage could help implement targeted interventions to reduce long-term atherosclerotic complications in this vulnerable population.

Our prospective observational study was undertaken among 70 pediatric participants, comprising 35 individuals diagnosed with beta-thalassemia major and 35 healthy controls. The investigation was conducted within the Department of Pediatrics at Hassan Institute of Medical Sciences (HIMS), Hassan, spanning a five-month duration from May 2023 to September 2023.

Approval from the Institutional Ethical Committee was obtained before initiation, and written informed consent was secured from the guardians of all enrolled children. The eligibility criteria included children aged 2 to 18 years with a confirmed diagnosis of transfusion-dependent beta-thalassemia major, having received a minimum of eight transfusions annually or being transfusion-dependent for at least six months. Individuals with familial hypercholesterolemia or congenital heart disease were not included in the study.

Comprehensive demographic and clinical details were collected for each participant, encompassing age, gender, height, weight, body mass index (BMI), and prior history of iron chelation therapy. Hematological and biochemical evaluations were performed upon enrollment, including complete blood counts (CBC), lipid profile, serum ferritin, C-reactive protein (CRP), liver enzymes, and blood glucose levels. These parameters were analyzed to assess the clinical and metabolic characteristics of children with beta-thalassemia major compared to the control group.

Data entry was performed using Microsoft Excel, and statistical analysis was conducted with SPSS version 22. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test when assumptions were unmet, with Yates’ correction applied as needed. Normality of continuous data was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests. The Independent t-test compared means, while the Mann-Whitney U test analyzed skewed data.

The majority of the participants in both groups were either below five years (39.5% in controls, 36.8% in beta-thalassemia) or above ten years (36.8% in controls, 39.5% in beta-thalassemia), with an almost equal distribution across age groups. Gender distribution was similar, with a slightly higher proportion of females in both groups (63.2% in controls and 60.5% in beta-thalassemia). These similarities indicate demographic comparability between the groups. (Table 1)

Table 1: Comparison of demographics of the study subjects between the groups

# Chi-square test

Statistically significant

Among beta-thalassemia patients, the mean duration since the first transfusion was 7.37 years, with a standard deviation of 4.28 years, ranging from 1 to 16 years. The median duration was 6.5 years, indicating that most participants had received transfusions for several years. This reflects the chronic nature of transfusion dependency in these children. (Table 2)

Table 2: Duration since first transfusion among the subjects with beta thalassemia

A significant majority (86.8%) of beta-thalassemia patients were on regular iron-chelating agents, while 13.2% were not. This suggests that most patients adhered to iron chelation therapy, which is essential for managing transfusion-related iron overload. (Figure 1)

Figure 1: Proportion of subjects with beta thalassemia who were on regular chelating agents

Beta-thalassemia patients exhibited significantly lower hemoglobin levels (mean: 8.06 g/dL vs. 11.37 g/dL, p <0.001) and markedly elevated serum ferritin (2080.70 ng/mL vs. 128.03 ng/mL, p <0.001), reflecting anemia and iron overload. Total bilirubin and SGPT levels were significantly higher in beta-thalassemia patients, indicating potential liver dysfunction. Despite higher mean TLC and MCV values in beta-thalassemia patients, these differences were not statistically significant. The findings emphasize hematologic and metabolic alterations associated with chronic transfusion therapy. (Table 3)

Beta-thalassemia patients had significantly higher serum cholesterol (194.39 mg/dL vs. 156.63 mg/dL, p <0.001), LDL (131.97 mg/dL vs. 93.95 mg/dL, p <0.001), triglycerides (261.87 mg/dL vs. 127.32 mg/dL, p = 0.001), and VLDL (56.45 mg/dL vs. 25.76 mg/dL, p <0.001). HDL levels were significantly lower in beta-thalassemia patients (27.08 mg/dL vs. 40.42 mg/dL, p <0.001), contributing to a higher TG/HDL ratio and atherogenic index of plasma. These alterations suggest an increased cardiovascular risk profile in transfusion-dependent children. (Table 4)

Table 3: Comparison of investigation findings among the study subjects between the groups

# Independent t-test

* Statistically significant

Table 4: Comparison of lipid profile among the study subjects between the groups

# Independent t-test

* Statistically significant

Atherogenic indices, including Castellis Risk Index 1 (4.727 vs. 3.517, p <0.001) and the atherogenic coefficient (3.727 vs. 2.517, p <0.001), were significantly higher in beta-thalassemia patients. AIP values were also significantly elevated (0.87 vs. 0.48, p <0.001), reflecting a greater propensity for atherogenic lipid alterations. These findings reinforce the notion that beta-thalassemia patients are at an increased risk for premature cardiovascular complications. (Table 5)

Table 5: Comparison of atherogenic indices among the study subjects between the groups

# Independent t-test

* Statistically significant

All lipid indexes showed weak and statistically non-significant correlations with anthropometric and hematological parameters among children with β-Thalassemia. Serum ferritin exhibited the strongest positive correlation across indexes—highest with Castelli’s Risk Index I and Atherogenic Coefficient (r = 0.305; p = 0.062)—suggesting a possible link between iron overload and lipid abnormalities. Most other variables, including weight, height, BMI, and hemoglobin, showed minimal associations, highlighting a generally weak overall relationship between lipid indexes and the studied parameters. (Table 6)

Table 6: Association of lipid indices with various parameters among the children with β-Thalassemia

In recent years, advancements in medical care have significantly enhanced both the life expectancy and quality of life of children with transfusion-dependent thalassemia (TDT). Despite these improvements, non-hematological complications, particularly atherosclerosis, remain a major cause of long-term morbidity and mortality.⁸ The pathogenesis of dyslipidemia in TDT patients is multifactorial, with oxidative stress, iron overload, and impaired lipolytic activity being proposed as key contributing mechanisms. These factors collectively place TDT children at heightened atherogenic risk.^9,10

Iron overload, which is commonly observed in β-thalassemia major (β-TM) patients due to repeated blood transfusions, may lead to structural and functional alterations in the vascular system, promoting premature atherosclerosis characterized by increased arterial stiffness and endothelial dysfunction.¹¹ Traditionally, the diagnosis of atherosclerosis relied on invasive procedures such as angiography and stress testing. However, recent clinical practice favors the use of non-invasive, reliable methods like carotid intima-media thickness (CIMT) measurement as a surrogate marker for early atherosclerotic changes.¹²

Demographics & Transfusion History

The present study aligns with previous research by Dogan M et al.¹⁰, demonstrating comparable mean ages between β-thalassemia major patients and control groups, with Dogan M et al.¹⁰ reporting a median age of 8 years. Similar findings by Kumaravel KS et al.¹³ and Sherief LM et al.⁷ emphasize the early onset and chronic nature of transfusion dependency in these patients. The mean transfusion duration in this study was 7.37 years, closely matching Dogan M et al.¹⁰ (6.5 years) and Sherief LM et al.⁷ (8.5 years), reflecting prolonged exposure to iron overload. Chelation therapy was widely utilized, with an adherence rate of 86.8%, paralleling Dogan M et al.¹⁰ and Kumaravel KS et al.¹³, where all patients received Deferasirox. Sherief LM et al.⁷ reported a more diverse chelation approach, incorporating Deferiprone and Desferrioxamine, highlighting variability in treatment strategies. The consistently prolonged transfusion dependency observed across studies underscores the heightened risk of iron overload-related complications, necessitating optimized chelation therapy for long-term disease management.

Hematological & Biochemical Parameters

Multiple studies, including the present one, consistently report significantly lower hemoglobin levels in β-thalassemia major patients compared to controls. In this study, the mean hemoglobin level was 8.06 g/dL versus 11.37 g/dL in controls, closely aligning with Dogan M et al.¹⁰ (8.1 g/dL vs. 12.0 g/dL). Sherief LM et al.⁷ documented an even lower mean hemoglobin of 6.8 g/dL, suggesting possible differences in transfusion thresholds across study populations. Serum ferritin levels were markedly elevated in all studies, underscoring chronic iron overload. The present study reported a mean ferritin level of 2080.70 ng/mL, while Dogan M et al.¹⁰ observed a higher median (2860 ng/mL), and Kumaravel KS et al.¹³ documented an even greater elevation (4316.8 ng/mL). Sherief LM et al.⁷ (2490 ± 1579 ng/mL) also found significantly increased ferritin, along with elevated CRP, suggesting inflammatory stress. Liver enzyme elevations (SGPT, SGOT) were consistent across this study, Kumaravel KS et al.¹³, and Sherief LM et al.⁷, reinforcing hepatic involvement. The consistent findings across studies highlight the interplay between severe anemia, iron overload, and vascular dysfunction in β-thalassemia major.

Lipid Profile

The present study identified significant dyslipidemia in β-thalassemia major patients, characterized by increased LDL, total cholesterol, and triglycerides, along with a marked reduction in HDL. In contrast, findings from Kumaravel KS et al.¹³ and Sherief LM et al.⁷ reported lower LDL and total cholesterol but elevated triglycerides, suggesting potential population-based variations in lipid metabolism. Sherief LM et al.⁷ documented significantly reduced LDL (44 mg/dL vs. 73 mg/dL, p<0.001) and total cholesterol (116 mg/dL vs. 143 mg/dL, p<0.001), with triglycerides showing a notable increase (128 mg/dL vs. 101 mg/dL, p=0.009). Both the present study and Sherief LM et al.⁷ observed an elevated atherogenic index, reinforcing the presence of a pro-atherogenic lipid profile in β-thalassemia patients. Finn AV et al.¹² highlighted that lipid accumulation and plaque formation, rather than absolute lipid levels, are more predictive of cardiovascular risk. These findings collectively indicate that dyslipidemia in β-thalassemia contributes to early atherosclerotic changes, underscoring the need for routine lipid monitoring and preventive strategies.

Atherogenic Indices

The present study highlights significantly higher atherogenic indices in children with transfusion-dependent beta-thalassemia (TDT), indicating an elevated cardiovascular risk due to dyslipidemia. Dogan M et al.¹⁰ support this by demonstrating increased carotid intima-media thickness (CIMT) in TDT patients, correlating positively with serum ferritin and disease duration, reinforcing the role of iron overload in vascular dysfunction. Finn AV et al.¹² critique CIMT as a sole predictor of atherosclerosis, emphasizing that plaque morphology and necrotic core size are stronger indicators of cardiovascular events, suggesting that lipid-based risk markers should be complemented with structural and compositional assessments. Kumaravel KS et al.¹³ further validate the findings by showing significantly increased CIMT in TDT patients, directly correlating with ferritin levels, and confirming a dyslipidemic pattern similar to the present study, with elevated triglycerides and reduced HDL-C. Sherief LM et al.⁷ add to the discussion by demonstrating a significantly increased atherogenic index of plasma (AIP) in TDT patients and introducing osteoprotegerin (OPG) as a novel biomarker positively associated with CIMT and lipid abnormalities. Together, these previous studies suggest that integrating atherogenic indices, CIMT, and emerging biomarkers like OPG provides a more comprehensive cardiovascular risk assessment, highlighting the need for early monitoring and targeted interventions in TDT patients

This study highlights significant lipid profile abnormalities and elevated atherogenic indices in children with transfusion-dependent beta-thalassemia major (B-TM) compared to healthy controls. Beta-thalassemia patients exhibited lower HDL, higher LDL, triglycerides, and total cholesterol, contributing to an increased cardiovascular risk. Elevated AIP, Castelli’s Risk Indices, and atherogenic coefficient further emphasize their predisposition to premature atherosclerosis. Lipid indexes showed weak, nonsignificant correlations with all parameters; serum ferritin had the strongest positive trend across indices. These findings justify the need for regular lipid monitoring and early interventions to mitigate long-term cardiovascular complications in children with B-TM.

Acknowledgement: We sincerely thank the faculty of the institute for helping us in each aspect of the study.

Declarations

Funding: None

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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