Abstract P174: The Association Between Infection-Related Hospitalization and Incident Heart Failure: The Atherosclerosis Risk in Communities Study

Introduction: Infections are associated with worse clinical outcomes among patients with heart failure (HF). However, little is known about the influence of infection-related hospitalizations on development of incident HF and its subtype.

Hypothesis: We hypothesize that those with an infection-related hospitalization (hereafter ‘infection’) compared to those without infection, will experience an increased rate of incident HF events (any HF, HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)).

Methods: We examined 14,398 participants enrolled in the Atherosclerosis Risk in Communities Study who were HF free at visit 1 (1987-1989). Hospitalized infections and HF were identified via participant self-report and active surveillance of hospitalizations. Among the hospitalized, infection was further defined using ICD-9/10 codes in the first five positions of hospital records. A subset of HF events was further classified as HFpEF or HFrEF via chart abstraction and adjudication by centrally trained and certified physicians. Infection was treated as a time-varying exposure and the co-occurrence of infection and HF in the same hospital visit were excluded. Multivariable-adjusted Cox proportional hazards models assessed the association between infection and incident HF, HFrEF, and HFpEF.

Results: The overall baseline sample was 54% (7,835 of 14,398) female, 26% (3,688 of 14,398) Black and had a mean(SD) age of 54(5.8). Mean(SD) time to infection was 16.1(8.7) years, and 2.3(7.5) years from infection to incident HF. Average follow-up among the full sample was 23.0(8.5). Overall, 46% (6,603 of 14,398) had an infection and 3,561 developed any HF. Among participants with subtype adjudication, 470 had HFpEF and 450 had HFrEF. Infection-related hospitalization was associated with an increased risk for both HFpEF and HFrEF (Table).

Conclusion: Infection-related hospitalization was associated with both incident HFpEF and HFrEF. A stronger effect is seen among those with HFpEF.

Abstract P433: Predictors of Self-Reported Medication Non-Adherence in Older Adults: The Atherosclerosis Risk in Communities Study

Introduction: Medication non-adherence increases the risk of hospitalization and mortality in older adults. Evidence from previous studies was not conclusive due to small sample size or lack of adjustment for potential confounders. This study aims to investigate the prevalence and predictors of medication non-adherence in older adults, considering both individual-level and neighborhood-level factors.

Methods: We studied participants (aged 66-90 years) who were on at least one medication at visit 5 (2011-2013) of the ARIC Study. Potential predictors included demographic factors, individual-level and neighborhood-level socioeconomic factors, behavioral factors, depressive symptoms, and cognitive function. We estimated the prevalence of self-reported medication adherence using the Morisky Green Levine medication adherence questionnaire and considered intermediate and low as medication non-adherence. We used multivariable logistic regression to identify independent predictors of medication non-adherence, further adjusting for race-center, insurance types, comorbidities, and number of medications.

Results: Among 5304 participants (mean age of 75.5 [SD 5.1] years, 21.6% Black, and 58.2% female), 2.3% and 37.1% reported low and intermediate medication adherence, respectively. After adjustment, age 66-74 (odds ratio [OR]= 1.23 [95% CI, 1.10-1.38]), current drinker (1.31 [1.10-1.55]), lack of physical activity (PA) (1.18 [1.01-1.37] for intermediate PA; 1.38 [1.21-1.58] for low PA), and depressive symptoms (2.30 [1.82-2.91]) were significant predictors of medication non-adherence ( Table ). Education and ADI were not associated with medication non-adherence.

Conclusions: We found that almost 40% of older adults have medication non-adherence. Unhealthy lifestyle factors and depressive symptoms were associated with medication non-adherence. Education and neighborhood-level SES were not. Depression is an important modifiable factor to improve medication adherence in older adults.

Abstract MP01: Midlife Diabetes and Lifetime Risk of Dementia: During 30 Years Follow-Up From the ARIC Study

Introduction: Diabetes is associated with both dementia and death. Ignoring the competing risk of mortality may result in overestimation of the lifetime of dementia.

Hypothesis: The lifetime cumulative incidence of dementia associated with diabetes will be much lower when taking into account the competing risk of mortality, particularly at the oldest ages.

Methods: We conducted a prospective cohort analysis of data from the Atherosclerosis Risk in Communities (ARIC) Study (midlife baseline at visit 2, 1990-1992). Diabetes was defined as a self-reported physician diagnosis, diabetes medication use, or HbA1C of 6.5% or greater. Incident dementia was ascertained via active surveillance involving interviews and adjudication. We conducted survival analysis using age as the time scale with age 50 as the origin and December 31st, 2019 as the administrative censoring date. Dementia risk was analyzed with death treated as a censoring event or as a competing risk.

Results: Among 13,381 participants, 1798 (13.4%) had diabetes at baseline (mean age: 56.8 years). Using a standard Cox model, diabetes was associated with an increased hazard of dementia (HR 1.36; 95% CI 1.21, 1.52) and death (HR 1.87; 95% CI 1.76, 1.99). Censoring mortality (ignoring competing risk), diabetes was associated with a higher cumulative incidence of dementia at all ages ( Figure A ). Competing risk models showed a lower risk of dementia than models censoring death. Furthermore, diabetes was associated with a higher risk of dementia only before age 85 but a lower cumulative risk after age 85 due to the large excess risk of mortality ( Figures B and C ).

Conclusion Standard methods dramatically overestimate the lifetime risk of dementia in persons with and without diabetes. Competing risk models are critical for accurate absolute risk estimates, particularly in the oldest ages. Interventions which increase life expectancy in patients with diabetes may increase the cumulative risk of dementia in old age.

Abstract P500: Age-Specific Population Attributable Fractions for the Impact of Hypertension on Dementia Risk

Introduction: Hypertension in midlife, but not late life, is a robust predictor of subsequent dementia. However, the fraction of dementia attributable to hypertension might vary depending on the age of the population considered, and the age through which dementia onset occurs. Here, we investigated associations of hypertension assessed at various ages with incident dementia by age 80 or 90, then estimated population attributable fractions (PAF) for dementia from hypertension categories at each of these age groups.

Hypothesis: Given hypertension prevalence increases with age but its relative risk for dementia tends to decrease, we had no prior expectation of the age at which the PAF’s would be highest. We hypothesized, however, that PAFs for incident dementia would be higher when hypertension is measured in midlife age groups versus late-life age groups.

Methods: We leveraged 32 years of follow-up data from the Atherosclerosis Risk in Communities study (ARIC), a prospective, community-based cohort that enrolled participants aged 45-64 years from four US communities (Washington County, MD; Forsyth County, NC; Jackson, MS; and selected suburbs of Minneapolis, MI) at ARIC visit 1 (1987-1989). Participants were followed through 2018-2019. We used Cox proportional hazards models to estimate hazard ratios, then quantified PAFs, of dementia by age 80 and 90 from hypertension assessed at ages of 45-54 (ARIC visit 1), 55-64 (ARIC visits 1 and 4), 65-74 (ARIC visits 4 and 5), and 75-84 (ARIC visit 5).

Results: Hypertension was assessed among 7,572 participants aged 45-54; 12,033 aged 55-64; and 6,561 aged 65-74. By age 80 the number identified as having incident dementia was 711, 910, and 372, respectively. Relative to normotension, hypertension in each age category was associated with hazard ratios (HRs) greater than 1.0 for dementia from hypertension by age 80. The PAF for dementia by age 80 from hypertension measured at age 45-54 was 15.3% (95% CI = 6.9, 22.3%), 19.1% (95% CI = 9.9, 26.9%) at ages 55-64, and 19.9% (95% CI = -4.4, 38.5%) at ages 65-74. By age 90, the number of incident dementia cases were 958; 2,302; and 1,327, respectively; and, among the 2,086 participants aged 75-84, 400 incident dementia cases. HRs were slightly smaller than those by age 80, while hypertension assessed in the 75-84 age group was not significant. The PAFs for dementia by age 90 from hypertension at age 45-54 was 13.8% (95% CI = 6.6, 20.0%), 12.9% (95% CI = 7.0, 18.2%) at ages 55-64, 10.9% (95% CI = 0.02, 21.0%) at ages 65-74, and non-significant at ages 75-84.

Conclusions: Public health interventions targeting hypertension in midlife through early late-life might reduce a sizeable proportion of dementia cases.

Abstract MP21: Associations Between Plasma Proteome, Leukocyte Telomere Length, and Polygenic Risk Score for Leukocyte Telomere Length: The Atherosclerosis Risk in Communities Study (ARIC)

Introduction: Leukocyte telomere length (LTL) is an important aging biomarker implicated in the pathogenesis of age-related conditions. We conducted a large-scale proteomics study to characterize the proteomic signatures of LTL and its genetic determinants measured by polygenic risk score (PRS).

Hypothesis: We hypothesize that LTL and LTL PRS are associated with blood proteomic signatures linked to aging-related conditions.

Methods: We used TelSeq to estimate LTL based on whole genome sequencing (WGS) data measured in samples collected in ARIC visits 1, 2, and 3 (i.e., the baseline for this study). TelSeq counted reads containing at least 12 TTAGGG repeats. This count was then normalized to the number of reads with GC content between 48% and 52%. Only samples with read lengths of 150 or 151 were included in subsequent analyses, and LTL estimates were inverse normalized within read length group and WGS group before being merged. We derived a PRS for LTL based on previously published genome-wide association study (GWAS) summary statistics for 150 significant autosomal SNPs and ARIC GWAS data. We then analyzed LTL or LTL PRS as a predictor and plasma levels of proteins as outcomes, measured at ARIC visit 2 (for the LTL PRS analysis) and visit 3 (for the LTL analysis) using SOMAscan v4 (~5,000 proteins). Race-specific linear regressions were performed to evaluate the association between LTL or LTL PRS and levels of each protein adjusting for potential confounders at baseline. We used a Bonferroni correction to account for multiple testing. The analysis in Whites served as a discovery (p≤1x10 -5 ) and that in Blacks as a replication.

Results: The final sample sizes were as follows: LTL PRS analysis (n=7,587 Whites and 2,094 Blacks) and LTL analysis (n=5,014 Whites and 884 Blacks). In Whites, LTL PRS was significantly associated with five proteins (p≤1x10 -5 ) that also showed the same direction of association in Blacks: THPO, GP1Bα, PEAR1, KDR, and GP5, with the association for KDR reaching nominal significance in Blacks (p=0.02). For LTL as the predictor, GP1Bα, GDF15 and TXNDC5 were significant in Whites, with consistent direction of associations in Blacks (p>0.05). These proteins are linked to hemostasis (all), endothelial proliferation (KDR), heart disease and cancer (GDF15), and cancer and rheumatoid arthritis (TXNDC5) in the literature.

Conclusion: This large-scale proteomic analysis reveals blood proteomic signatures for LTL PRS and LTL, which will likely improve the understanding of biological pathways and clinical conditions implicated by LTL.

Abstract MP65: Magnesium-Rich Diet Score is Inversely Associated With Incident Cardiovascular Disease: The Atherosclerosis in Communities (ARIC) Study

Background: Numerous studies have shown inverse associations between serum magnesium (Mg) levels and risk of cardiovascular disease (CVD), but studies of dietary Mg have not been consistent.

Aim: The association of a Mg-rich diet score with risks of incident CVD, coronary heart disease (CHD), and ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) study was examined.

Methods: There were 15,022 Black and White adults without prevalent CVD included in this analysis. Diet was assessed at two visits using an interviewer-administered 66-item food frequency questionnaire. A Mg-rich diet score was created including whole grain products, nuts, fruits, vegetables, legumes, coffee, and tea. Cox proportional hazard regression evaluated the associations of incident CVD, CHD and stroke through 2019 across quintiles of Mg-rich diet score adjusted for demographic characteristics, lifestyle factors, and clinical characteristics.

Results: Participants in the highest quintile of Mg-rich diet score compared to the lowest quintile consumed more servings of Mg-rich foods and fiber and less refined grains, red and processed meat, total fat and saturated fat. Over 30 years of follow up, a Mg-rich diet score was inversely associated with incident CVD (HR Q5 vs Q1 =0.88, 95% CI 0.78-0.99, p trend =0.03) and CHD (HR=0.83, 95% CI 0.72-0.96, p trend =0.01); however the diet-stroke association was null (HR=1.08, 95% CI 1.07-1.09, p trend =0.93) (Table).

Conclusions: Consuming a diet rich in whole grains, nuts, fruits and vegetables, legumes, coffee and tea is consistent with a lower long-term risk of CVD and CHD.

Abstract P256: Psychosocial Risk Factors Are Associated With Lower Cardiovascular Health, Measured by Life’s Essential 8, in the Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Psychosocial factors (social isolation, social support, trait anger, and depressive symptoms) are associated with cardiovascular disease risk factors and incidence; few studies investigate whether they are associated with cardiovascular health (CVH), and none with a new definition of CVH, Life’s Essential 8 (LE8) published by the American Heart Association (AHA).

Hypothesis: Cross-sectional associations of psychosocial factors and CVH will be inverse, and will be modified by sex and race.

Methods: We included 11,674 ARIC cohort participants (58% women; 23% Black; mean age 57 (standard deviation (SD): 6) years) who attended Visit 2 (1990-1992) and had complete data. All psychosocial factors and the following LE8 components were measured at Visit 2: nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure. Physical activity and diet were measured at Visit 1 (1987-1989). Psychosocial factors were categorized per standard convention or by tertiles. LE8 was scored per the AHA definition (0-100 range). Associations of each psychosocial factor with continuous LE8 score were assessed using multivariable linear regressions.

Results: Mean LE8 score was 61 (SD: 15). Poorer scores on psychosocial factor assessments were associated with lower LE8 scores, with the largest magnitude of association for depressive symptoms (Figure). Participants with high levels of depressive symptoms had an LE8 score 8 points lower than those with low levels of depressive symptoms. Stratum-specific estimates and p-values for interaction terms suggested no modification by sex; however psychosocial factors were associated with approximately a 1 point lower LE8 score in White participants than in Black participants.

Conclusion: Poorer psychosocial health factors were associated with lower CVH among middle-aged men and women in ARIC. Future work could investigate whether psychosocial factors modify the relationship between CVH and incident cardiovascular disease.

Abstract P467: Left Atrial Appendage Occlusion and Risk of Stroke in Medicare Beneficiaries

Background: Atrial fibrillation (AF) is a significant risk factor for stroke, with oral anticoagulants (OACs) recommended for stroke prevention. However, a nonpharmacologic option is needed for patients with contraindications for OACs. Recently, percutaneous left atrial appendage occlusion (LAAO) has emerged as an alternative treatment option. Although clinical trials have shown that percutaneous LAAO is non-inferior to warfarin and direct OACs, few studies using real-world data have been done.

Methods: Using data from the Medicare 20% sample databases (2015-18), we assessed the association between percutaneous LAAO vs. OAC use and risk of all stroke among patients with AF who had an elevated CHA 2 DS 2 -VASc score. Secondary outcomes included death and hospitalized bleeding. Patients undergoing percutaneous LAAO were matched with up to 5 other patients who were taking OACs by sex, age, date of enrollment, index date, and CHA 2 DS 2 -VASc score. A total of 17,514 patients with AF were matched (average [SD] 78 [6] years, 44% female). Cox proportional hazards model was used.

Results: Over a median follow-up of 10.3 months, 293 stroke events, 1,925 deaths and 618 major bleeding events occurred. After multivariable adjustments, no significant difference for risk of stroke or death was noted when patients with percutaneous LAAO was compared to those taking OACs (HRs [95% CIs]: 1.25 [0.95, 1.67] and 0.94 [0.83, 1.06], respectively). However, there was a 3.24-fold (95% CI: 2.75, 3.81) increased risk for hospitalized bleeding after percutaneous LAAO compared to OAC.

Conclusion: Using data from the Medicare 20% sample databases, no significant difference in risk of stroke or death were noted when percutaneous LAAO was compared to OAC users. However, there was an increased risk for bleeding. Our results confirm the results of randomized trials that among older patients with AF and a high-risk for stroke, percutaneous LAAO may be an alternative to OAC use; however, patients should be aware of potential risks associated with the implantation.

Abstract P198: Associations Between Plasma Proteome and Leukocyte Mitochondrial DNA Copy Number: The Atherosclerosis Risk in Communities Study (ARIC)

Introduction: The number of copies of the mitochondrial genome, termed mitochondrial DNA copy number (MTCN), is a proxy for mitochondrial function and varies by cell. Critically, lower MTCN has been associated with aging and chronic diseases such as dementia and cancer. We conducted a large-scale proteomics analysis of leukocyte MTCN (L-MTCN) to elucidate pathways modulated by L-MTCN that may be involved in diseases of aging.

Hypothesis: We hypothesize that L-MTCN is significantly associated to plasma proteins that have been implicated in biological pathways of L-MTCN and related diseases.

Methods: Based on whole genome sequencing (WGS) data measured in samples collected in ARIC visits 1, 2, and 3 (i.e., baseline for the current study), L-MTCN was calculated as (2 * coverage of the mitochondrial genome) / coverage of the autosome, using the median coverage of 1000 base pair bins overlapping the mitochondrial genome (16 total) and the median coverage of ~142,000 higher quality autosomal bins. Only samples with read lengths of 150 or 151 were included in subsequent analyses, and L-MTCN estimates were inverse normalized within read length group and WGS group before being merged together. This normalized L-MTCN was then analyzed as a predictor for an association with 4,870 plasma proteins measured by SOMAscan v4 in ARIC visit 3 in race-specific generalized linear models, adjusting for the following covariates at baseline: WGS sample visit, age, gender, field center, smoking status, and a measure of kidney function. Bonferroni correction was applied to account for the number of proteins tested in 5,007 White participants (p≤1x10 -5 ). Associations were tested for replication in 1,178 Black participants and considered significant if protein estimates had the same direction of association as Whites at p-value ≤ 2.2x10 -4 .

Results: Among White participants, 230 proteins were significantly associated with L-MTCN. Of these proteins S100A9, GP1Bα, EGFR, THBS2, and FCGR3B were significantly replicated among Black participants. Strongest associations with L-MTCN were seen with GP1Bα (Estimate: 0.121) and S100A9 (Estimate: -0.191). Biologically S100A9 is a calgranulin and together with S100A8 forms calprotectin, which have roles mediating inflammatory processes. GP1Bα helps mediate platelet activation and forms the glycoprotein Ib-IX-V complex which acts as a platelet surface receptor for von Willebrand factor facilitating platelet adhesion.

Conclusion: This large proteomics analysis identified 230 plasma proteins significantly associated with L-MTCN. Some of the proteins have been connected to inflammatory diseases, cardiovascular disease, and cancer in the literature. These results provide insight into proteins involved in biological pathways related to L-MTCN.

Circulating Magnesium and Risk of Major Adverse Cardiac Events among Patients with Atrial Fibrillation in the ARIC Cohort

Background: Serum magnesium (Mg) has been reported to be inversely associated with the risk of atrial fibrillation (AF), coronary artery disease (CAD), and major adverse cardiovascular events (MACE). The association between serum Mg and the risk of MACE, heart failure (HF), stroke, and all-cause mortality among patients with AF has not been evaluated. Objective: We aim to examine whether higher serum Mg is associated with a lower risk of MACE, heart failure (HF), stroke, and all-cause mortality among patients with AF. Methods: We evaluated prospectively 413 participants of the Atherosclerosis Risk in Communities (ARIC) Study with a diagnosis of AF at the time of Mg measurement participating in visit 5 (2011-2013). Serum Mg was modeled in tertiles and as a continuous variable in standard deviation units. Endpoints (HF, MI, stroke, cardiovascular (CV) death, all-cause mortality, and MACE) were identified and modeled separately using Cox proportional hazard regression adjusting for potential confounders. Results: During a mean follow-up of 5.8 years, there were 79 HFs, 34 MIs, 24 strokes, 80 CV deaths, 110 MACEs, and 198 total deaths. After adjustment for demographic and clinical variables, participants in the second and third tertiles of serum Mg had lower rates of most endpoints, with the strongest inverse association for the incidence of MI (HR 0.20, 95% CI 0.07, 0.61) comparing top to bottom tertile. Serum Mg modeled linearly as a continuous variable did not show clear associations with endpoints except MI (HR 0.50, 95% CI 0.31, 0.80). Due to the limited number of events, the precision of most estimates of association was relatively low. Conclusions: Among patients with AF, higher serum Mg was associated with a lower risk of developing incident MI and, to a lesser extent, other CV endpoints. Further studies in larger patients with AF cohorts are needed to evaluate the role of serum Mg in preventing adverse CV outcomes in these patients.

Abstract P625: Differences in Urban/Rural Oral Anticoagulation and Mortality Among People With Incident Venous Thromboembolism: Medicare 20% Sample 2016-2018

Introduction: Oral anticoagulants (OAC) are a standard and highly efficacious treatment for venous thromboembolism (VTE), with newer direct oral anticoagulants (DOACs; rivaroxaban and apixaban) equivalent or preferred over warfarin for many patients. Rural residents often lack easy access to medical care, which may cause differences in OAC use and outcomes in people with incident VTE.

Hypothesis: People enrolled in Medicare who reside in rural locations will be less likely to be prescribed DOACs for primary treatment of incident VTE and will experience higher 6-month mortality compared to patients residing in urban areas.

Methods: We used the Medicare 20% sample to identify a cohort of individuals aged ≥65 years with incident VTE and prescribed an OAC from 2016-2018. Risk factors, demographics, and ZIP codes to create urban/rural categories based on rural-urban commuting area codes were defined at time of VTE diagnosis. All-cause mortality and death date were ascertained via Medicare linkage to the Social Security Administration. Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association of urban/rural status and 6-month mortality rates, adjusting for demographics, comorbidities and medications. Urban/rural status and OAC choice were tested for multiplicative interaction.

Results: Among 37,954 beneficiaries with VTE (mean age 76.7, SD 8.1), 82% were urban and 18% were rural. There were 3,778 deaths within 6 months of VTE diagnosis; 3,130 among urban residents while 649 among rural residents (83% vs. 17%). Overall, warfarin was prescribed more often in rural areas than urban areas (34% vs. 27%), rivaroxaban prescriptions were less common in rural versus urban areas (32% vs. 36%), and apixaban did not differ by rural versus urban status (35% vs. 37%). In multivariable-adjusted analyses, risk of mortality was not significantly different in rural versus urban areas (HR: 1.08 (0.99-1.17)). The HRs for mortality with rivaroxaban versus warfarin was 0.85 (95% CI: 0.79, 0.93), for apixaban versus warfarin it was 0.96 (95% CI: 0.89, 1.04), while for apixaban versus rivaroxaban it was 1.14 (95% CI: 1.05, 1.23). There was no interaction between OAC prescribed and urban/rural status for all comparisons of OACs (p-interaction rivaroxaban vs. warfarin: 0.50; apixaban vs. warfarin: 0.54; apixaban vs. rivaroxaban: 0.27).

Conclusions: Rural versus urban residence resulted in less prescription of DOACs versus warfarin or oral anticoagulation treatment of VTE, but not a significant difference in 6-month mortality. The reasons for different prescribing patterns are unclear, whether due to comorbid conditions or provider knowledge. Greater attention to understanding rural-urban treatment differences is needed to ensure high quality care for everyone.

Abstract P623: Long-Term Mortality and Causes of Death After Venous Thromboembolism: The Atherosclerosis Risk in Communities Study

Background: Each year in the U.S, 60,000-100,000 people die of venous thromboembolism (VTE), but little is known about mortality and causes of death over the long-term after VTE.

Hypotheses: VTE, especially cancer-related VTE, is associated with poor long-term survival. Cancer and circulatory diseases are the main causes of death after VTE.

Methods: Atherosclerosis Risk in Communities (ARIC) cohort participants, free of VTE at baseline (n=15,516), were followed (1986-2019) to identify first-time VTE (classified as unprovoked, cancer-provoked, or other-provoked, e.g., after surgery) and deaths. ICD10 codes were used to define cause of death. The proportion who died for each cause of death after first VTE, by type of VTE, was tabulated. Hazard ratios (HRs) of death by type of VTE were estimated with Cox proportional hazards models adjusted for age, race, gender, and pre-baseline cancer. Survival rates were visualized by adjusted survival curves.

Results: Over a maximum follow-up of 33 years, 1,076 participants had first-time VTE; 441 were unprovoked, 271 were cancer-provoked, 364 were other-provoked. Mean age at first VTE was 74. After unprovoked VTE, 37% died of circulatory diseases (excluding VTE) and 13% of cancer. Those values were 35% and 13% for other-provoked VTE. By contrast, for cancer-provoked VTE, 80% died of cancer and 10% of circulatory diseases (excluding VTE). In the Figure , those with VTE had poorer long-term survival than 14,400 participants without VTE, and cancer-provoked VTE had the highest mortality. Overall, the HR of death was 2.75 (95% CI: 2.49-3.05) for those with vs without VTE. Those with cancer-provoked VTE had the highest HR, 10.02 (95% CI 8.81-11.40), but those with unprovoked and other-provoked VTE also had higher mortality than those without VTE.

Conclusions: In this study, long-term survival after VTE was poor. Apart from cancer-provoked VTE, circulatory diseases were the primary causes of death after VTE. Optimizing cardiovascular prevention could improve long-term survival of patients with VTE.

Abstract MP45: Nocturnal Hypoxemia, Obstructive Sleep Apnea and the Risk of Cardiovascular Diseases and Mortality: Insights From the Atherosclerosis Risk in Communities Participants of the Sleep Heart Health Study

Background: Nocturnal hypoxemia may better capture disease burden than obstructive sleep apnea (OSA). Using a subset of participants from the Atherosclerosis Risk in Communities (ARIC) study who participated in the Sleep Heart Health Study (SHHS), we examined the association of nocturnal hypoxemia and OSA with cardiovascular diseases (CVD) and mortality in a white, older cohort in the US.

Methods: A total of 1,455 participants free of CVD had an in-home, overnight polysomnogram; nocturnal hypoxemia (% of total sleep time with oxygen saturation <90%) and OSA (apnea-hypopnea index - # of apneas/hypopneas per hour of sleep) were derived from these readings. Incident CVD events and mortality were identified through the end of 2019 using annual telephone calls, hospital discharge lists and death certificates and were adjudicated by physician review. Included in this analysis were coronary heart disease (CHD), heart failure (HF), stroke, any CVD event (CHD, HF, or stroke), atrial fibrillation (AF), and all-cause mortality. We used Cox proportional hazards models to assess the association of nocturnal hypoxemia (categories: <1%, 1-<5%, ≥5%) and OSA (categories: <5, 5-<15, 15-<30, ≥30) with each outcome.

Results: At the sleep assessment, participants had a mean (SD) age of 62 (6) years, 53% were female, and 14% had a nocturnal hypoxemia ≥5%. Over a mean follow-up of 17.8 years, a total of 408 participants had any CVD event, and 602 died. Nocturnal hypoxemia ≥5% was associated with incident HF and all-cause mortality in the fully adjusted model (Table). Nocturnal hypoxemia ≥5% was also associated with incident CVD and AF in Model 1; however, adjustment for body mass index attenuated these associations (Table, Model 2). OSA was not associated with the outcomes in any model (data not shown).

Conclusion: Further research is needed to understand the distinction between nocturnal hypoxemia and OSA and how they relate to the risk of CVD and mortality. It is possible that reducing nocturnal hypoxemia should be targeted over OSA for CVD prevention.

Sleep Irregularity and Subclinical Markers of Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

Background Sleep irregularity has been linked to incident cardiovascular disease. Less is known about associations of sleep regularity with atherosclerosis. We examined cross-sectional associations of actigraphy-assessed sleep duration and sleep timing regularity with subclinical atherosclerosis in the community-based MESA (Multi-Ethnic Study of Atherosclerosis). Methods and Results MESA Sleep Ancillary Study participants (N=2032; mean age, 68.6±9.2 years; 37.9% White) completed 7-day wrist actigraphy. Participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and the ankle-brachial index. Sleep regularity was quantified by the 7-day with-in person SD of sleep duration and sleep onset timing. Relative risk regression models were used to calculate prevalence ratios and 95% CIs. Models are adjusted for demographics, cardiovascular disease risk factors, and other objectively assessed sleep characteristics including obstructive sleep apnea, sleep duration, and sleep fragmentation. After adjustment, compared with participants with more regular sleep durations (SD ≤60 minutes), participants with greater sleep duration irregularity (SD >120 minutes) were more likely to have high coronary artery calcium burden (>300; prevalence ratio, 1.33 [95% CI, 1.03-1.71]) and abnormal ankle-brachial index (<0.9; prevalence ratio, 1.75 [95% CI, 1.03-2.95]). Compared with participants with more regular sleep timing (SD ≤30 minutes), participants with irregular sleep timing (SD >90 minutes) were more likely to have high coronary artery calcium burden (prevalence ratio, 1.39 [95% CI, 1.07-1.82]). Associations persisted after adjustment for cardiovascular disease risk factors and average sleep duration, obstructive sleep apnea, and sleep fragmentation. Conclusions Sleep irregularity, particularly sleep duration irregularity, was associated with several measures of subclinical atherosclerosis. Sleep regularity may be a modifiable target for reducing atherosclerosis risk. Future investigation into cardiovascular risk reduction interventions targeting sleep irregularity may be warranted.

A proteomic approach for investigating the pleiotropic effects of statins in the atherosclerosis risk in communities (ARIC) study

BACKGROUND

Statins are prescribed to reduce LDL-c and risk of CVD. Statins have pleiotropic effects, affecting pathophysiological functions beyond LDL-c reduction. We compared the proteome of statin users and nonusers (controls). We hypothesized that statin use is associated with proteins unrelated to lipid metabolism.

METHODS

Among 10,902 participants attending ARIC visit 3 (1993-95), plasma concentrations of 4955 proteins were determined using SOMAlogic's DNA aptamer-based capture array. 379 participants initiated statins within the 2 years prior. Propensity scores (PS) were calculated based on visit 2 (1990-92) LDL-c levels and visit 3 demographic/clinical characteristics. 360 statin users were PS matched to controls. Log2-transformed and standardized protein levels were compared using t-tests, with false discovery rate (FDR) adjustment for multiple comparisons. Analyses were replicated in visit 2.

RESULTS

Covariates were balanced after PS matching, except for higher visit 3 LDL-c levels among controls (125.70 vs 147.65 mg/dL; p < 0.0001). Statin users had 11 enriched and 11 depleted protein levels after FDR adjustment (q < 0.05). Proteins related and unrelated to lipid metabolism differed between groups. Results were largely replicated in visit 2.

CONCLUSION

Proteins unrelated to lipid metabolism differed by statin use. Pending external validation, exploring their biological functions could elucidate pleiotropic effects of statins.

SIGNIFICANCE

Statins are the primary pharmacotherapy for lowering low-density lipoprotein (LDL) cholesterol and preventing cardiovascular disease. Their primary mechanism of action is through inhibiting the protein 3hydroxy-3-methylglutaryl CoA reductase (HMGCR) in the mevalonate pathway of LDL cholesterol synthesis. However, statins have pleiotropic effects and may affect other biological processes directly or indirectly, with hypothesized negative and positive effects. The present study contributes to identifying these pathways by comparing the proteome of stain users and nonusers with propensity score matching. Our findings highlight potential biological mechanisms underlying statin pleiotropy, informing future efforts to identify statin users at risk of rare nonatherosclerotic outcomes and identify health benefits of statin use independent of LDL-C reduction.

Comparative Risk of Hospitalized Bleeding of P2Y12 Inhibitors for Secondary Prophylaxis in Acute Coronary Syndrome After Percutaneous Coronary Intervention

In closely monitored randomized controlled trials (RCTs), newer P2Y12 agents (ticagrelor and prasugrel) reduced cardiovascular outcomes compared with clopidogrel following percutaneous coronary intervention (PCI) in acute coronary syndrome. However, these RCTs indicated a higher bleeding risk with these newer agents. This study evaluated the comparative safety of each P2Y12 inhibitor on hospitalizations due to major bleeding in a real-world population. This retrospective, propensity score-matched (PSM) cohort study utilized the IBM MarketScan database over 6 years (2013-2018) to identify incident users of P2Y12 inhibitors with age ≥18 years. The primary safety outcome was hospitalization due to any major bleeding event including gastrointestinal, intracranial, and other serious forms of bleeding. In pairwise comparisons using Cox-proportional hazards models, ticagrelor, prasugrel, and clopidogrel users were compared for the primary safety outcome at 30, 90, and 180 days following the first prescription of P2Y12 inhibitor after PCI. There were 21,719 (ticagrelor vs. clopidogrel), 11,513 (prasugrel vs. clopidogrel), and 11,065 (prasugrel vs. ticagrelor) PSM pairs. Overall, the risk of major bleeding was similar for all P2Y12 inhibitors. Hospitalization for major bleeding was generally lower among ticagrelor users vs. clopidogrel and higher among prasugrel users compared with clopidogrel. Importantly, a 66% higher risk of major bleeding at 90 days is suggested with prasugrel compared with clopidogrel (hazard ratio 1.66; 95% confidence interval, 1.11-2.48). This study indicated a higher short-term bleeding risk with prasugrel compared with clopidogrel, which concurs with the results of RCTs.

Proteomics Analysis of Genetic Liability of Abdominal Aortic Aneurysm Identifies Plasma Neogenin and Kit Ligand: The ARIC Study

BACKGROUND

Genome-wide association studies have reported 23 gene loci related to abdominal aortic aneurysm (AAA)-a potentially lethal condition characterized by a weakened dilated vessel wall. This study aimed to identify proteomic signatures and pathways related to these risk loci to better characterize AAA genetic susceptibility.

METHODS

Plasma concentrations of 4870 proteins were determined using a DNA aptamer-based array. Linear regression analysis estimated the associations between the 23 risk alleles and plasma protein levels with adjustments for potential confounders in a race-stratified analysis of 1671 Black and 7241 White participants. Significant proteins were then evaluated for their prediction of clinical AAA (454 AAA events in 11 064 individuals), and those significantly associated with AAA were further interrogated using Mendelian randomization analysis.

RESULTS

Risk variants proximal to PSRC1-CELSR2-SORT1, PCIF1-ZNF335-MMP9, RP11-136O12.2/TRIB1, ZNF259/APOA5, IL6R, PCSK9, LPA, and APOE were associated with 118 plasma proteins in Whites and 59 were replicated in Black participants. Novel associations with clinical AAA incidence were observed for kit ligand (HR, 0.59 [95% CI, 0.42-0.82] for top versus first quintiles) and neogenin (HR, 0.64 [95% CI, 0.46-0.88]) over a median 21.2-year follow-up; neogenin was also associated with ultrasound-detected asymptomatic AAA (N=4295; 57 asymptomatic AAA cases). Mendelian randomization inverse variance weighted estimates suggested that AAA risk is promoted by lower levels of kit ligand (OR per SD=0.67; P=1.4×10-5) and neogenin (OR per SD=0.50; P=0.03).

CONCLUSIONS

Low levels of neogenin and kit ligand may be novel risk factors for AAA development in potentially causal pathways. These findings provide insights and potential targets to reduce AAA susceptibility.

Adipokines and incident venous thromboembolism: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Obesity leads to adipocyte hypertrophy and adipokine dysregulation and is an independent risk factor for venous thromboembolism (VTE). However, the association between adipokines and VTE is not well established.

OBJECTIVES

To examine whether adipokines are associated with increased risk of incident VTE.

METHODS

We studied 1888 participants of the Multi-Ethnic Study of Atherosclerosis cohort who were initially free of VTE and had adipokine (adiponectin, leptin, and resistin) levels measured at either examination 2 or 3 (2002-2004 or 2004-2005, respectively). During follow-ups, VTE was ascertained through hospitalization records and death certificates by using ICD-9 and 10 codes. We used multivariable Cox proportional hazards regression to assess the association between 1 standard deviation (SD) log-transformed increments in adipokines and incident VTE.

RESULTS

The mean ± SD age was 64.7 ± 9.6 years, and 49.8% of participants were women. Medians (interquartile range) of adiponectin, leptin, and resistin were 17.3 (11.8-26.2) mcg/mL, 13.5 (5.6-28.2) ng/mL, and 15.0 (11.9-19.0) ng/mL, respectively. There were 78 incident cases of VTE after a median of 9.7 (5.0-12.4) years of follow-up. After adjusting for sociodemographics, smoking, and physical activity, the hazard ratios (95% CIs) per 1 SD increment of adiponectin, leptin, and resistin were 1.14 (0.90-1.44), 1.29 (1.00-1.66), and 1.38 (1.09-1.74), respectively. The association for resistin persisted after further adjustments for body mass index and computed tomography-derived total visceral adipose tissue area.

CONCLUSION

Higher resistin levels were independently associated with greater risk of incident VTE. Larger prospective cohort studies are warranted to confirm this association.

Autoimmune disease and risk of postpartum venous thromboembolism

Background

The risk of pregnancy-related mortality in the United States has nearly doubled since 1990, with venous thromboembolism (VTE) accounting for approximately 10% of these deaths.

Objectives

The objective of this study was to assess whether preexisting autoimmune disease is a risk factor for postpartum VTE.

Methods

Using the MarketScan Commercial and Medicare Supplemental administrative databases, a retrospective cohort study analyzed whether postpartum persons with autoimmune disease had a higher risk of postpartum VTE incidence than postpartum persons without autoimmune disease. Using International Classification of Diseases codes, we identified 757,303 individuals of childbearing age who had a valid delivery date with at least 12 weeks of follow-up.

Results

Individuals were, on average, 30.7 years old (SD, 5.4), and 3.7% (N = 27,997 of 757,303) of them had evidence of preexisting autoimmune disease. In covariate-adjusted models, postpartum persons with preexisting autoimmune disease had higher rates of postpartum VTE than postpartum persons without autoimmune disease (hazard ratio [HR], 1.33; 95% CI, 1.07-1.64). When analyzed by individual autoimmune disease, those with systemic lupus erythematosus (HR, 2.49; 95% CI, 1.47-4.21) and Crohn's disease (HR, 2.49; 95% CI, 1.34-4.64) were at an elevated risk of postpartum VTE compared with those without autoimmune disease.

Conclusion

Autoimmune disease was associated with a higher rate of postpartum VTE, with evidence that the association was most pronounced among individuals with systemic lupus erythematosus and Crohn's disease. These findings suggest that postpartum persons of childbearing age with autoimmune disease may require more monitoring and prophylactic care after delivery to prevent potentially fatal VTE events.

Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study

Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.

Case-control studies: Increasing scientific rigor in control selection

The case-control design is an observational study design in which the investigative team identifies individuals with disease (ie, cases) and individuals without disease (ie, controls) and then compares the prevalence of an exposure between the 2 groups. Forethought is needed while designing case-control studies. This is particularly true when selecting controls. This tutorial briefly reviews the case-control design, discusses scenarios of poor case-control study design with an emphasis on control selection, and provides tips for proper control selection. Optimizing control selection to maximize causal inference will increase the scientific rigor of hematologic case-control studies.

Incidence of Dementia Following Hospitalization With Infection Among Adults in the Atherosclerosis Risk in Communities (ARIC) Study Cohort

Importance

Factors associated with the risk of dementia remain to be fully understood. Systemic infections are hypothesized to be such factors and may be targets for prevention and screening.

Objective

To investigate the association between hospitalization with infection and incident dementia.

Design, Setting, and Participants

Data from the community-based Atherosclerosis Risk in Communities (ARIC) study, a prospective cohort study, were used. Enrollment occurred at 4 research centers in the US, initiated in 1987 to 1989. The present study includes data up to 2019, for 32 years of follow-up. Data analysis was performed from April 2021 to June 2022.

Exposures

Hospitalizations with infections were identified via medical record review for selected International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, from baseline until administrative censoring or dementia diagnosis. Participants were considered unexposed until first hospitalization with infection and exposed thereafter. Selected infection subtypes were also considered.

Main Outcomes and Measures

Incident dementia and time-to-event data were identified through surveillance of ICD-9 and ICD-10 hospitalization and death certificate codes, in-person assessments, and telephone interviews. A sensitivity analysis was conducted excluding cases occurring within 3 years or beyond 20 years from exposure. Data were collected before study hypothesis formulation.

Results

Of the 15 792 ARIC study participants, an analytical cohort of 15 688 participants who were dementia free at baseline and of Black or White race were selected (8658 female [55.2%]; 4210 Black [26.8%]; mean [SD] baseline age, 54.7 [5.8] years). Hospitalization with infection occurred among 5999 participants (38.2%). Dementia was ascertained in 2975 participants (19.0%), at a median (IQR) of 25.1 (22.2-29.1) years after baseline. Dementia rates were 23.6 events per 1000 person-years (95% CI, 22.3-25.0 events per 1000 person-years) among the exposed and 5.7 events per 1000 person-years (95% CI, 5.4-6.0 events per 1000 person-years) among the unexposed. Patients hospitalized with infection were 2.02 (95% CI, 1.88-2.18; P < .001) and 1.70 (95% CI, 1.55-1.86; P < .001) times more likely to experience incident dementia according to unadjusted and fully adjusted Cox proportional hazards models compared with individuals who were unexposed. When excluding individuals who developed dementia less than 3 years or more than 20 years from baseline or the infection event, the adjusted hazard ratio was 5.77 (95% CI, 4.92-6.76; P < .001). Rates of dementia were significantly higher among those hospitalized with respiratory, urinary tract, skin, blood and circulatory system, or hospital acquired infections. Multiplicative and additive interactions were observed by age and APOE-ε genotype.

Conclusions and Relevance

Higher rates of dementia were observed among participants who experienced hospitalization with infection. These findings support the hypothesis that infections are factors associated with higher risk of dementias.

Bleeding risk in patients with multiple myeloma treated for venous thromboembolism: a MarketScan analysis

Background

Multiple myeloma (MM) is associated with high risk of venous thromboembolism (VTE). Thromboprophylaxis is thoroughly studied in MM. Contrarily, studies assessing the risk of bleeding in people with MM on anticoagulation are lacking.

Objectives

To determine the rate of serious bleeding in patients with MM receiving anticoagulation for VTE and the clinical factors associated with bleeding risk.

Methods

Using the MarketScan commercial database, we identified 1298 people with MM treated with anticoagulation for incident VTE events between 2011 and 2019. Hospitalized bleeding was identified using the Cunningham algorithm. Rates of bleeding were calculated and Cox regression identified risk factors for bleeding.

Results

Bleeding occurred in 51 (3.9%) cases during median follow-up of 1.13 years. Rate of bleeding among patients with MM on anticoagulation was 24.0 per 1000 person-years. In adjusted regression, factors associated with increased bleeding included age (HR, 1.31 per 10-year increase; 95% CI, 1.03-1.65), Charlson comorbidity index (HR, 1.29 per SD increase; 95% CI, 1.02-1.58), use of antiplatelet agents (HR, 2.4; 95% CI, 1.03-5.68), diabetes (HR, 1.85; 95% CI, 1.06-3.26), and renal disease (HR, 1.80; 95% CI, 1.05-3.16). Cumulative incidence of bleeding was 4.7%, 3.2%, and 3.4% for warfarin, low molecular weight heparin, and direct oral anticoagulants, respectively.

Conclusion

In this real-world analysis, the rate of bleeding in people with MM on anticoagulation was comparable to those in other subsets of cancer-related VTE. Bleeding rate was lower with low molecular weight heparin and direct oral anticoagulants than warfarin. Higher comorbidity index, diabetes, antiplatelet agent use, and renal disease were risk factors for serious bleeding.

Proteomic analysis of diabetes genetic risk scores identifies complement C2 and neuropilin-2 as predictors of type 2 diabetes: the Atherosclerosis Risk in Communities (ARIC) Study

AIMS/HYPOTHESIS

Genetic predisposition to type 2 diabetes is well-established, and genetic risk scores (GRS) have been developed that capture heritable liabilities for type 2 diabetes phenotypes. However, the proteins through which these genetic variants influence risk have not been thoroughly investigated. This study aimed to identify proteins and pathways through which type 2 diabetes risk variants may influence pathophysiology.

METHODS

Using a proteomics data-driven approach in a discovery sample of 7241 White participants in the Atherosclerosis Risk in Communities Study (ARIC) cohort and a replication sample of 1674 Black ARIC participants, we interrogated plasma levels of 4870 proteins and four GRS of specific type 2 diabetes phenotypes related to beta cell function, insulin resistance, lipodystrophy, BMI/blood lipid abnormalities and a composite score of all variants combined.

RESULTS

Twenty-two plasma proteins were identified in White participants after Bonferroni correction. Of the 22 protein-GRS associations that were statistically significant, 10 were replicated in Black participants and all but one were directionally consistent. In a secondary analysis, 18 of the 22 proteins were found to be associated with prevalent type 2 diabetes and ten proteins were associated with incident type 2 diabetes. Two-sample Mendelian randomisation indicated that complement C2 may be causally related to greater type 2 diabetes risk (inverse variance weighted estimate: OR 1.65 per SD; p=7.0 × 10-3), while neuropilin-2 was inversely associated (OR 0.44 per SD; p=8.0 × 10-3).

CONCLUSIONS/INTERPRETATION

Identified proteins may represent viable intervention or pharmacological targets to prevent, reverse or slow type 2 diabetes progression, and further research is needed to pursue these targets.

The Association of Kidney Function with Plasma Amyloid-β Levels and Brain Amyloid Deposition

BACKGROUND

Reduced kidney function is related to brain atrophy and higher risk of dementia. It is not known whether kidney impairment is associated with higher levels of circulating amyloid-β and brain amyloid-β deposition, which could contribute to elevated risk of dementia.

OBJECTIVE

To investigate whether kidney impairment is associated with higher levels of circulating amyloid-β and brain amyloid-β deposition.

METHODS

This cross-sectional study was performed within the community-based Atherosclerosis Risk in Communities (ARIC) Study cohort. We used estimated glomerular filtration rate (eGFR) based on serum creatinine and cystatin C levels and urine albumin-to-creatinine ratio (ACR) to assess kidney function. Amyloid positivity was defined as a standardized uptake value ratios > 1.2 measured with florbetapir positron emission tomography (PET) (n = 340). Plasma amyloid-β1 - 40 and amyloid-β1 - 42 were measured using a fluorimetric bead-based immunoassay (n = 2,569).

RESULTS

Independent of demographic and cardiovascular risk factors, a doubling of ACR was associated with 1.10 (95% CI: 1.01,1.20) higher odds of brain amyloid positivity, but not eGFR (odds ratio per 15 ml/min/1.73 m2 lower eGFR: 1.08; 95% CI: 0.95,1.23). A doubling of ACR was associated with a higher level of plasma amyloid-β1 - 40 (standardized difference: 0.12; 95% CI: 0.09,0.14) and higher plasma amyloid-β1 - 42 (0.08; 95% CI: 0.05,0.10). Lower eGFR was associated with higher plasma amyloid-β1 - 40 (0.36; 95% CI: 0.33,0.39) and higher amyloid-β1 - 42 (0.32; 95% CI: 0.29,0.35).

CONCLUSION

Low clearance of amyloid-β and elevated brain amyloid positivity may link impaired kidney function with elevated risk of dementia. kidney function should be considered in interpreting amyloid biomarker results in clinical and research setting.