Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling

BACKGROUND

In recent decades, novel echocardiographic measures have constantly emerged. It is still unclear which echocardiographic measures have the most significant prognostic value in the general population. Accordingly, the aim of this study was to compare the prognostic value of a large panel of echocardiographic measures to identify the most promising measures.

METHODS

A total of 1,497 Framingham study participants (mean age, 65 years; 55.4% women) who underwent echocardiographic measurements of left ventricular ejection fraction, left ventricular mass index, global longitudinal strain, global circumferential strain, mitral annular plane systolic excursion, mitral E/e' ratio, maximum and minimum left atrial (LA) volume index, LA emptying fraction, and left ventricular longitudinal synchrony were evaluated. These measures were related to the incidence of two composite outcomes: cardiovascular disease (CVD) or death and atrial fibrillation (AF) or congestive heart failure (CHF).

RESULTS

On follow-up (mean, 8.3 years), there were 241 CVD events or deaths and 139 AF or CHF events. In multivariate-adjusted Cox models, higher LA emptying fraction was associated with a lower risk (hazard ratios per SD, 0.80 and 0.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) while higher minimum LA volume index (hazard ratios per SD, 1.32 and 1.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) and maximum LA volume index (hazard ratios per SD, 1.26 and 1.54 for CVD or death and AF or CHF, respectively; P ≤ .002 for both) were associated with a higher risk for both composite outcomes.

CONCLUSIONS

In this community-based sample, LA volumes and function were the best echocardiographic predictors of clinical outcomes. Therefore, these values should be considered for inclusion in standard echocardiographic assessments for the purpose of risk stratification.

Risk factor-based subphenotyping of heart failure in the community

Background

Heart failure (HF) is a heterogeneous clinical syndrome with varying prognosis. Subphenotyping of HF is a research priority to advance our understanding of the syndrome. We formulated a subphenotyping schema and compared long-term mortality risk among the HF subphenotypes in the community-based Framingham Study.

Methods and results

In hierarchical order, we grouped participants with new-onset HF (stratified by HF with reduced [HFrEF] vs. preserved ejection fraction [HFpEF]) according to the presence of: (1) coronary heart disease (CHD), (2) metabolic syndrome (MetS), (3) hypertension, and (4) ‘other’ causes. Age at HF onset was lowest in people with the MetS (mean 76 vs. 77 years for HFrEF and HFpEF, respectively) and highest in those with hypertension only (mean 82 and 85 years for HFrEF and HFpEF, respectively). For HFrEF, 10-year cumulative mortality and hazards ratios [HR] were 87% for CHD (n = 219; referent group), 88% for MetS (n = 105; HR 0.95 [95% CI 0.73–1.23]), 82% for hypertension (n = 104; HR 0.71 [0.55–0.91]), and 78% for other (n = 37; HR 0.81 [0.55–1.19]). Corresponding 10-year cumulative mortality and HR data for HFpEF were: 85% for CHD (n = 84; referent), 83% for MetS (n = 118; HR 0.98 [0.72–1.33]), 81% for hypertension (n = 127; HR 0.71 [0.52–0.95]), and 76% for other (n = 43; HR 0.76 [0.50–1.14]). In a sample without overt heart failure (n = 5536), several echocardiographic and vascular indices showed graded worsening of age- and sex adjusted-values among those having CHD, MetS, hypertension, or obesity, compared with individuals not having these risk factors.

Conclusions

HF subphenotypes characterized by the presence of CHD or metabolic syndrome present at a younger age and are marked by greater mortality risk. The clinical utility of the proposed subphenotyping schema warrants further research.

Association of Circulating Ceramides With Cardiac Structure and Function in the Community: The Framingham Heart Study

Background

A higher circulating plasma ceramide ratio (C16:0/C24:0) is associated with an increased risk of heart failure, even after accounting for standard risk factors including lipid markers. However, the pathobiological mechanisms that underlie this association are incompletely understood. We tested the hypothesis that plasma ceramide ratio (C16:0/C24:0) is associated with adverse cardiac remodeling in the community.

Methods and Results

We evaluated 2652 Framingham Offspring Study participants (mean age, 66±9 years; 55% women) who attended their eighth examination cycle and underwent routine echocardiography and liquid chromatography–tandem mass spectrometry–based assays for circulating ceramide concentrations. We used multivariable linear regression models to relate C16:0/C24:0 (independent variable) to the following echocardiographic measures (dependent variables; separate models for each): left ventricular mass, left ventricular ejection fraction, left atrial emptying fraction, left atrial end‐systolic volume, E/e′ (a measure of left ventricular diastolic function), and left ventricular global circumferential and longitudinal strain by speckle‐tracking echocardiography. In multivariable‐adjusted analyses, higher C16:0/C24:0 per standard deviation increment was associated with lower left ventricular ejection fraction (0.991‐fold change in left ventricular ejection fraction; P=0.0004), worse global circumferential strain (β=0.34, P=0.004), higher left atrial end‐systolic volume (β=2.48, p<0.0001), and lower left atrial emptying fraction (0.99‐fold change; P<0.0001). The C16:0/C24:0 ratio was not associated with either E/e′ or global longitudinal strain, and the association with higher left ventricular mass was rendered statistically nonsignificant upon correction for multiple comparisons.

Conclusions

Our cross‐sectional observations in a large community‐based sample are consistent with a potential detrimental impact of higher ceramide ratio (C16:0/24:0) on cardiac remodeling traits, which may partly explain the associations of these molecular species with clinical heart failure.

Interrelations Between Arterial Stiffness, Target Organ Damage, and Cardiovascular Disease Outcomes

Background Excess transmission of pressure pulsatility caused by increased arterial stiffness may incur microcirculatory damage in end organs (target organ damage [TOD] ) and, in turn, elevate risk for cardiovascular disease ( CVD ) events. Methods and Results We related arterial stiffness measures (carotid-femoral pulse wave velocity, mean arterial pressure, central pulse pressure) to the prevalence and incidence of TOD (defined as albuminuria and/or echocardiographic left ventricular hypertrophy) in up to 6203 Framingham Study participants (mean age 50±15 years, 54% women). We then related presence of TOD to incident CVD in multivariable Cox regression models without and with adjustment for arterial stiffness measures. Cross-sectionally, greater arterial stiffness was associated with a higher prevalence of TOD (adjusted odds ratios ranging from 1.23 to 1.54 per SD increment in arterial stiffness measure, P<0.01). Prospectively, increased carotid-femoral pulse wave velocity was associated with incident albuminuria (odds ratio per SD 1.28, 95% CI, 1.02-1.61; P<0.05), whereas higher mean arterial pressure and central pulse pressure were associated with incident left ventricular hypertrophy (odds ratio per SD 1.37 and 1.45, respectively; P<0.01). On follow-up, 297 of 5803 participants experienced a first CVD event. Presence of TOD was associated with a 33% greater hazard of incident CVD (95% CI , 0-77%; P<0.05), which was attenuated upon adjustment for baseline arterial stiffness measures by 5-21%. Conclusions Elevated arterial stiffness is associated with presence of TOD and may partially mediate the relations of TOD with incident CVD . Our observations in a large community-based sample suggest that mitigating arterial stiffness may lower the burden of TOD and, in turn, clinical CVD .

A Mediterranean Style Diet Is Favorably Associated with Concentrations of Circulating Ceramides and Ceramide Ratios in the Framingham Offspring Cohort (P18-048-19)

Objectives

A Mediterranean style diet may impact cardiometabolic health by modifying concentrations of circulating lipid species. Distinct circulating ceramide species are positively associated with cardiometabolic risk; whereas, ratios of very-long to long-chain ceramides demonstrate an inverse association. We evaluated the relation between consuming a Mediterranean-style diet with concentrations of three circulating ceramides and ceramide ratios.

Methods

Participants of the Framingham Offspring cohort who attended exam cycle 8 (n = 2174, mean age 67 years, 55% women) were categorized according to quartile of a Mediterranean-style diet score (MDS). The MDS consisted of 9 components (vegetables, fruits, nuts, legumes, whole grains, fish, red meat, monounsaturated to saturated fat ratio, and alcohol). For each component, scores in each exam cycle were based on sex-specific consumption quartiles. A higher score represents greater conformity, with a maximum score of 25. We determined the cumulative MDS, reflective of usual intake over 14 years (mean of exam cycles 5 and 8). Plasma ceramide concentrations (ug/mL) were assayed at exam 8 using a validated LC-MS/MS protocol. Multivariable linear regression was used to relate the MDS to circulating ceramide concentrations (C16:0, C22:0, and C24:0), and to ceramide ratios (C22:0/C16:0 and C24:0/C16:0) adjusting for age, sex, smoking status, lipid-lowering medications, total energy intake, physical activity, and BMI.

Results

The median (IQR) MDS within each quartile was Q1: 7.5 (2.0), Q2: 11.0 (1.5), Q3: 13.5 (1), and Q4: 17.0 (3.0). A higher cumulative MDS was inversely associated with concentrations of the C16:0 (LS mean [95% CI] µg/mL; Q1: 0.169 [0.166, 0.172], Q4: 0.158 [0.155, 0.161]) and C22:0 (Q1: 0.628 [0.612, 0.643], Q4: 0.594 [0.579, 0.610]) ceramides (both Ptrend < 0.05, across quartiles). In contrast, a higher cumulative MDS was positively associated with the C24:0/C16:0 ratio (Q1: 13.41 [13.13, 13.70], Q4: 14.60 [14.33, 14.88]; Ptrend < 0.05). Associations between the MDS score and concentrations of the C24:0 ceramide and the C22:0/C16:0 ratio were not statistically significant.

Conclusions

This cross-sectional study provides insight into how a Mediterranean style diet may favorably influence distinct ceramide species and ceramide ratios.

Funding Sources

NIH Multidisciplinary Training Program in Cardiovascular Epidemiology, NIH National Heart Lung and Blood Institute (NHLBI) Framingham Heart Study, and the U.S. Department of Agriculture, Agricultural Research Service.

Supporting Tables, Images and/or Graphs

Trajectories of Blood Lipid Concentrations Over the Adult Life Course and Risk of Cardiovascular Disease and All-Cause Mortality: Observations From the Framingham Study Over 35 Years

Background

Elevated total cholesterol (TC), low‐density lipoprotein cholesterol (LDL‐C), triglycerides, and non‐high‐density lipoprotein cholesterol (non‐HDL‐C) and low high‐density lipoprotein cholesterol (HDL‐C) concentrations correlate with atherosclerotic cardiovascular disease (ASCVD) and mortality. Therefore, understanding how lipid trajectories throughout adulthood impact ASCVD and mortality risk is essential.

Methods and Results

We investigated 3875 Framingham Offspring participants (54% women, mean age 48 years) attending ≥1 examination between 1979 and 2014. We evaluated longitudinal correlates of each lipid subtype using mixed‐effects models. Next, we clustered individuals into trajectories through group‐based modeling. Thereafter, we assessed the prospective association of lipid trajectories with ASCVD and mortality. Male sex, greater body mass index, and smoking correlated with higher TC, LDL‐C, triglycerides, non‐HDL‐C, and lower HDL‐C concentrations. We identified 5 TC, HDL‐C, and LDL‐C trajectories, and 4 triglycerides and non‐HDL‐C trajectories. Upon follow‐up (median 8.2 years; 199 ASCVD events; 256 deaths), elevated TC (>240 mg/dL), LDL‐C (>155 mg/dL), or non‐HDL‐C (>180 mg/dL) concentrations conferred >2.25‐fold ASCVD and mortality risk compared with concentrations <165 mg/dL, <90 mg/dL, and <115 mg/dL, respectively ([TC hazard ratio (HR)_ASCVD=4.17, 95% CI 1.94–8.99; TC HR_death=2.47, 95% CI 1.28–4.76] [LDL‐C HR_ASCVD=5.09, 95% CI 1.54–16.85; LDL‐C HR_death=4.04, 95% CI 1.84–8.89] [non‐HDL‐C HR_ASCVD=4.60, 95% CI 1.98–10.70; LDL‐C HR_death=3.74, 95% CI 2.03–6.88]). Consistent HDL‐C concentrations <40 mg/dL were associated with greater ASCVD and mortality risk than concentrations >70 mg/dL (HR_ASCVD=3.81, 95% CI 2.04–7.15; HR_death=2.88, 95% CI 1.70–4.89). Triglycerides trajectories were unassociated with outcomes.

Conclusions

Using a longitudinal modeling technique, we demonstrated that unfavorable lipid trajectories over 35 years confer higher ASCVD and mortality risk later in life.

See Editorial Gidding and Allen

Natural History of Obesity Subphenotypes: Dynamic Changes Over Two Decades and Prognosis in the Framingham Heart Study

CONTEXT

The natural histories of obesity subphenotypes are incompletely delineated.

OBJECTIVES

To investigate dynamic changes in obesity subphenotypes and associations with outcomes.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Framingham Offspring Cohort participants (n = 4291) who attended the examination cycles 2 (1979 to 1983) to 7 (1998 to 2001), which included 26,508 participant observations. Obesity subphenotypes [metabolically healthy nonobese (MHNO), metabolically healthy obese (MHO), metabolically unhealthy nonobese (MUNO), and metabolically unhealthy obese (MUO)] were ascertained based on metabolic health (<2 Adult Treatment Panel III criteria). The outcomes were subclinical cardiovascular disease (CVD), incident diseases [diabetes, hypertension, chronic kidney disease (CKD), CVD], and all-cause mortality.

RESULTS

At baseline, 4% and 31% of participants exhibited the MHO and MUNO subphenotypes, respectively. Four-year probability of MHO participants becoming MUO was 43% in women and 46% in men. Compared with MHNO, MHO participants had 1.28-fold (95% CI, 0.85 to 1.93) and 1.92-fold (95% CI, 1.38 to 2.68) higher odds of subclinical CVD and coronary artery calcification, respectively; corresponding values for MUNO were 1.95 (1.54 to 2.47) and 1.92 (1.38 to 2.68). During follow-up (median of 14 years), 231 participants developed diabetes, 784 hypertension, 423 CKD, 639 CVD, and 1296 died. Compared with MHNO, MHO conferred higher risks of diabetes [hazard ratio (HR), 4.69; 95% CI, 2.21 to 9.96] and hypertension (HR, 2.21; 95% CI, 1.66 to 2.94). Compared with MUO, MHO conferred lower risks of diabetes (0.21; 0.12 to 0.39), CVD (0.64; 0.43 to 0.95), and CKD (0.44; 0.27 to 0.73), but similar hypertension, cardiovascular mortality, and overall mortality risks.

CONCLUSION

Over time, most MHO participants developed metabolic abnormalities and clinical disease. The MHO subphenotype is a harbinger of future risk.

Association of Circulating Adipokines With Echocardiographic Measures of Cardiac Structure and Function in a Community-Based Cohort

BACKGROUND

Adipokines mediate cardiometabolic risk associated with obesity but their role in the pathogenesis of obesity-associated heart failure remains uncertain. We investigated the associations between circulating adipokine concentrations and echocardiographic measures in a community-based sample.

METHODS AND RESULTS

We evaluated 3514 Framingham Heart Study participants (mean age 40 years, 53.8% women) who underwent routine echocardiography and had select circulating adipokines measured, ie, leptin, soluble leptin receptor, fatty acid-binding protein 4, retinol-binding protein 4, fetuin-A, and adiponectin. We used multivariable linear regression, adjusting for known correlates (including weight), to relate adipokine concentrations (independent variables) to the following echocardiographic measures (dependent variables): left ventricular mass index, left atrial diameter in end systole, fractional shortening, and E/e'. In multivariable-adjusted analysis, left ventricular mass index was inversely related to circulating leptin and fatty acid-binding protein 4 concentrations but positively related to retinol-binding protein 4 and leptin receptor levels (P≤0.002 for all). Left atrial end-systolic dimension was inversely related to leptin but positively related to retinol-binding protein 4 concentrations (P≤0.0001). E/e' was inversely related to leptin receptor levels (P=0.0002). We observed effect modification by body weight for select associations (leptin receptor and fatty acid-binding protein 4 with left ventricular mass index, and leptin with left atrial diameter in end systole; P<0.05 for interactions). Fractional shortening was not associated with any of the adipokines. No echocardiographic trait was associated with fetuin-A or adiponectin concentrations.

CONCLUSIONS

In our cross-sectional study of a large, young to middle-aged, relatively healthy community-based sample, key indices of subclinical cardiac remodeling were associated with higher or lower circulating concentrations of prohypertrophic and antihypertrophic adipokines in a context-specific manner. These observations may offer insights into the pathogenesis of the cardiomyopathy of obesity.

Left Ventricular Diastolic Dysfunction in the Community: Impact of Diagnostic Criteria on the Burden, Correlates, and Prognosis

BACKGROUND

Left ventricular diastolic dysfunction (DD) is common, particularly in women and older individuals, and it is associated with adverse cardiovascular outcomes. We evaluated the impact of age- and sex-specific diagnostic criteria on the assessment of DD in the community-based Framingham Heart Study.

METHODS AND RESULTS

We estimated age- and sex-specific reference limits for echocardiographic measures of DD in a healthy reference subsample (N=2355, mean age 44 years, 66% women). The prevalence, correlates, and association with future cardiovascular disease were compared for DD using age- and sex-specific versus single cut point reference limits in a broad sample (N=6102, mean age 50 years, 56% women). Using age- and sex-specific criteria, DD was present in ≈25% to 30% of individuals across age groups, and it was directly associated with a number of modifiable risk factors. In contrast, with single cut point criteria, age was the primary determinant of DD. During follow-up (mean 7.9±2.2 years), incident cardiovascular disease occurred in 213 of 5770 individuals. Using age- and sex-specific criteria, mild and moderate-severe DD were associated with 50% (95% confidence interval, 1.09-2.05) and 65% (95% confidence interval, 1.14-2.38) higher incidences of cardiovascular disease, respectively, in age- and sex-adjusted analyses. With single cut point criteria, moderate-severe DD (hazard ratio, 1.66; 95% confidence interval, 1.05-2.61), but not mild DD (hazard ratio, 0.94; 95% confidence interval, 0.63-1.40), was associated with incident cardiovascular disease.

CONCLUSIONS

Age- and sex-specific reference limits may result in DD assessments that are less dependent on age, more robustly related to modifiable risk factors, and are more closely associated with incident cardiovascular disease.

Heritability of Mitral Regurgitation: Observations From the Framingham Heart Study and Swedish Population

BACKGROUND

Familial aggregation has been described for primary mitral regurgitation (MR) caused by mitral valve prolapse. We hypothesized that heritability of MR exists across different MR subtypes including nonprimary MR.

METHODS AND RESULTS

Study participants were FHS (Framingham Heart Study) Generation 3 (Gen 3) and Gen 2 cohort participants and all adult Swedish siblings born after 1932 identified in 1997 and followed through 2010. MR was defined as ≥ mild regurgitation on color Doppler in FHS and from International Classification of Diseases codes in Sweden. We estimated the association of sibling MR with MR in Gen 2/Gen 3/Swedish siblings. We also estimated heritability of MR in 539 FHS pedigrees (7580 individuals). Among 5132 FHS Gen 2/Gen 3 participants with sibling information, 1062 had MR. Of siblings with sibling MR, 28% (500/1797) had MR compared with 17% (562/3335) without sibling MR (multivariable-adjusted odds ratio, 1.20; 95% confidence interval [CI], 1.01-1.43; P=0.04). When we combined parental and sibling data in FHS pedigrees, heritability of MR was estimated at 0.15 (95% CI, 0.07-0.23), 0.12 (95% CI, 0.04-0.20) excluding mitral valve prolapse, and 0.44 (95% CI, 0.15-0.73) for ≥ moderate MR only (all P<0.05). In Sweden, sibling MR was associated with a hazard ratio of 3.57 (95% CI, 2.21-5.76; P<0.001) for development of MR.

CONCLUSIONS

Familial clustering of MR exists in the community, supporting a genetic susceptibility common to primary and nonprimary MR. Further studies are needed to elucidate the common regulatory pathways that may lead to MR irrespective of its cause.

Twenty-Year Trends in the American Heart Association Cardiovascular Health Score and Impact on Subclinical and Clinical Cardiovascular Disease: The Framingham Offspring Study

BACKGROUND

Data on the temporal trends in ideal cardiovascular health (CVH) as well as on their association with subclinical/overt cardiovascular disease (CVD) and death are limited.

METHODS AND RESULTS

This study included 3460 participants attending ≥1 of 4 consecutive exams of the Framingham Heart Study (1991-2008, mean age 55.4 years, CVH score ranged 0-14). We created 4 groups describing changes in CVH score between examination cycles 5 and 8, using first and last exams attended (high-high: starting CVH score ≥8, last score of ≥8, referent; high-low: ≥8 start and ≤7 last; low-high: ≤7 start and ≥8 last; and low-low: ≤7 start and ≤7 last) and related them to subclinical CVD cross-sectionally, and incident CVD and death. Fewer people have ideal CVH scores over the past 20 years (8.5% for 1991-1995, 5.9% for 2005-2008, P=0.002), because of decreases in those with ideal status of body mass index, blood glucose, and serum cholesterol levels (P<0.05 for all). The odds of subclinical disease and risk of CVD and death were higher for all compared with the high-high group (428 CVD and 367 death events, median follow-up 5.1 years, hazard ratios for CVD: 1.39, 1.73, 1.9 and death: 1.12, 1.57, 1.4 and odds ratios for subclinical disease: 1.61, 1.98, 2.86 for high-low, low-high, and low-low, respectively).

CONCLUSIONS

The decreased presence of ideal CVH scores over the past 20 years resulted in increasing odds of subclinical disease and risk of CVD and death, emphasizing the importance of maintaining ideal CVH over the life course.

Ceramide Remodeling and Risk of Cardiovascular Events and Mortality

BACKGROUND

Recent studies suggest that circulating concentrations of specific ceramide species may be associated with coronary risk and mortality. We sought to determine the relations between the most abundant plasma ceramide species of differing acyl chain lengths and the risk of coronary heart disease (CHD) and mortality in community-based samples.

METHODS AND RESULTS

We developed a liquid chromatography/mass spectrometry assay to quantify plasma C24:0, C22:0, and C16:0 ceramides and ratios of these very-long-chain/long-chain ceramides in 2642 FHS (Framingham Heart Study) participants and in 3134 SHIP (Study of Health in Pomerania) participants. Over a mean follow-up of 6 years in FHS, there were 88 CHD and 90 heart failure (HF) events and 239 deaths. Over a median follow-up time in SHIP of 5.75 years for CHD and HF and 8.24 years for mortality, there were 209 CHD and 146 HF events and 377 deaths. In meta-analysis of the 2 cohorts and adjusting for standard CHD risk factors, C24:0/C16:0 ceramide ratios were inversely associated with incident CHD (hazard ratio per average SD increment, 0.79; 95% confidence interval, 0.71-0.89; P<0.0001) and inversely associated with incident HF (hazard ratio, 0.78; 95% confidence interval, 0.61-1.00; P=0.046). Moreover, the C24:0/C16:0 and C22:0/C16:0 ceramide ratios were inversely associated with all-cause mortality (C24:0/C16:0: hazard ratio, 0.60; 95% confidence interval, 0.56-0.65; P<0.0001; C22:0/C16:0: hazard ratio, 0.65; 95% confidence interval, 0.60-0.70; P<0.0001).

CONCLUSIONS

The ratio of C24:0/C16:0 ceramides in blood may be a valuable new biomarker of CHD risk, HF risk, and all-cause mortality in the community.

Development and Validation of Risk Prediction Models for Cardiovascular Events in Black Adults: The Jackson Heart Study Cohort

IMPORTANCE

Cardiovascular risk assessment is a fundamental component of prevention of cardiovascular disease (CVD). However, commonly used prediction models have been formulated in primarily or exclusively white populations. Whether risk assessment in black adults is dissimilar to that in white adults is uncertain.

OBJECTIVES

To develop and validate risk prediction models for CVD incidence in black adults, incorporating standard risk factors, biomarkers, and subclinical disease.

DESIGN, SETTING, AND PARTICIPANTS

The Jackson Heart Study (JHS), a longitudinal community-based study of 5301 black adults in Jackson, Mississippi. Inclusive study dates were the date of a participant's first visit (September 2000 to March 2004) to December 31, 2011. The median (75th percentile) follow-up was 9.1 (9.7) years. The dates of the analysis were August 2013 to May 2015. Measurements included standard risk factors, including age, sex, body mass index, systolic and diastolic blood pressure, ratio of fasting total cholesterol to high-density lipoprotein cholesterol, estimated glomerular filtration rate, antihypertensive therapy, diabetes mellitus, and smoking; blood biomarkers; and subclinical disease measures, including ankle-brachial index, carotid intimal-medial thickness, and echocardiographic left ventricular hypertrophy and systolic dysfunction.

MAIN OUTCOMES AND MEASURES

Incident CVD event was defined as the first occurrence of myocardial infarction, coronary heart disease death, congestive heart failure, stroke, incident angina, or intermittent claudication. Model performance was compared with the American College of Cardiology/American Heart Association (ACC/AHA) CVD risk algorithm and the Framingham Risk Score (FHS) refitted to the JHS data and evaluated in the Atherosclerosis Risk in Communities (ARIC) and Multi-Ethnic Study of Atherosclerosis cohorts.

RESULTS

The study cohort comprised 3689 participants with mean (SD) age at baseline was 53 (11) years, and 64.8% (n = 2390) were female. Over a median of 9.1 years, 270 participants (166 women) experienced a first CVD event. A simple combination of standard CVD risk factors, B-type natriuretic peptide, and ankle-brachial index (model 6) yielded modest improvement over a model without B-type natriuretic peptide and ankle-brachial index (C statistic, 0.79; 95% CI, 0.75-0.83 [relative integrated discrimination improvement, 0.22; 95% CI, 0.15-0.30]). However, the reclassification improvement was not substantially different between model 6 and the ACC/AHA CVD Pooled Cohort risk equations or between model 6 and the FHS. The models discriminated reasonably well in the ARIC and Multi-Ethnic Study of Atherosclerosis data (C statistic range, 0.70-0.77).

CONCLUSIONS AND RELEVANCE

Our findings using the JHS data in the present study are valuable because they confirm that current FHS and ACC/AHA risk algorithms work well in black individuals and are not easily improved on. A unique risk calculator for black adults may not be necessary.

Comorbidities and Cardiometabolic Disease: Relationship With Longitudinal Changes in Diastolic Function

OBJECTIVES

This study sought to evaluate the course, correlates, and prognosis of longitudinal changes in left ventricular (LV) diastolic dysfunction (DD) in the community-based Framingham Heart Study.

BACKGROUND

Relationships of clinical risk factors to longitudinal progression of DD are incompletely understood.

METHODS

Diastolic function was assessed by echocardiography performed at consecutive examinations (visits 1 and 2, mean interval 5.6 years) in 1,740 participants (64 ± 8 years of age at visit 1, 59% women) with normal LV systolic function and no atrial fibrillation.

RESULTS

Of 1,615 individuals with normal-to-mild DD at visit 1, 198 (12%) progressed to ≥ moderate DD at visit 2. Progression was more likely in women and with advancing age (p < 0.0001). Of 125 individuals with ≥ moderate DD at visit 1, 25 (20%) regressed to normal-to-mild DD by visit 2. Regression of DD was associated with younger age (p < 0.03). In stepwise regression models, age, female sex, baseline and changes in systolic blood pressure, diastolic blood pressure, body mass index, serum triglycerides, and diabetes were positively associated with worsening diastolic function (all p < 0.05). Noncardiac comorbidity tracked with progressive DD. Cardiovascular disease (CVD) or death events occurred in 44 of 1,509 participants free of CVD at visit 2, during 2.7 ± 0.6 years of post-visit 2 follow-up. Presence of ≥ moderate DD was associated with higher risk (age- and sex-adjusted hazard ratio for CVD or death: 2.14; 95% confidence interval: 1.06 to 4.32; p = 0.03).

CONCLUSIONS

In a community-based cohort of middle-aged to older adults, cardiometabolic risk factors and noncardiac comorbidities were associated with DD progression. Moderate or worse DD was associated with higher risk of CVD or death.

Incidence of cardiovascular disease in individuals affected by recent changes to US blood pressure treatment guidelines

OBJECTIVE

We evaluated the incidence of cardiovascular disease (CVD) in individuals whose blood pressure (BP) management strategy would change with adoption of recent US hypertension guidelines in two large, community-based cohorts with different racial and geographic compositions: the Framingham and Jackson Heart Studies (FHS and JHS).

METHODS

We assigned 11 237 FHS (mean age 46, 53% women) and 2948 JHS (mean age 55, 69% women) participants free of CVD and chronic kidney disease to one of five categories representing different treatment recommendations between 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee and The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines. Absolute incidence rates (incidence rate; per 1000 person-years) and multivariable-adjusted hazard ratios were calculated for each group; cohort-specific results were combined using fixed effect meta-analysis.

RESULTS

CVD events occurred in 1047 FHS and 230 JHS participants during mean follow-up times of 11 and 8.9 years, respectively. Compared with individuals without hypertension, those with BP 140-149/<90 mmHg had increased risk for CVD regardless of treatment status [hazard ratio for untreated BP 140-149/<90 mmHg 1.96, 95% confidence interval (CI) 1.40-2.75; hazard ratio for treated BP 140-149/<90 mmHg 3.37, 95% CI 2.37-4.78]. The risk for those with treated BP 140-149/<90 mmHg was consistent in those aged at least 60 years (hazard ratio: 2.61, 95% CI 1.75-3.90). Statistical power was limited to evaluate the effect of diabetes.

CONCLUSION

Individuals with treated BP 140-149/<90 mmHg have increased risk of CVD compared with those without hypertension including in participants at least 60 years. The 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee recommendations to treat BP levels less aggressively may be associated with substantial residual CVD risk.

Plasma Nitrate and Incidence of Cardiovascular Disease and All-Cause Mortality in the Community: The Framingham Offspring Study

BACKGROUND

Nitrate is a dietary component as well as an endogenously formed metabolite and source of the signaling molecule nitric oxide. Harmful as well as beneficial effects of nitrate have been advocated. Data regarding the prognostic relevance of plasma nitrate are limited. The aim of this study was to evaluate the prospective association of plasma nitrate with cardiovascular disease (CVD) and all-cause mortality.

METHODS AND RESULTS

We assayed plasma nitrate in 2855 Framingham Offspring Study participants (mean age 59 years, 54% women) by gas chromatography-mass spectrometry and evaluated its association with all-cause mortality and incident CVD. On follow-up (median 17.3 years), 775 participants died and 522 developed new-onset CVD (of 2546 participants free of CVD at baseline). In multivariable models adjusting for standard risk factors, plasma nitrate was associated with an increased risk of death in participants (hazard ratio per unit increase in log-nitrate 1.21; 95% confidence interval, 1.04-1.40 [P=0.015]). The strength of the association was attenuated by additional adjustment for estimated glomerular filtration rate (hazard ratio, 1.16; 95% confidence interval, 1.00-1.35 [P=0.057]). In contrast, no evidence was found for an association of plasma nitrate with incident CVD (multivariable-adjusted hazard ratio per unit increase log-nitrate 1.08; 95% confidence interval, 0.89-1.31 [P=0.42]).

CONCLUSIONS

In our prospective community-based investigation, a higher plasma nitrate concentration was associated with all-cause mortality but not with incident CVD. The association of nitrate with mortality may at least in part be attributable to its association with renal function.

Epidemiology of Left Ventricular Systolic Dysfunction and Heart Failure in the Framingham Study: An Echocardiographic Study Over 3 Decades

OBJECTIVES

The purpose of this study was to describe the temporal trends in prevalence of left ventricular systolic dysfunction (LVSD) in individuals without and with heart failure (HF) in the community over a 3-decade period of observation.

BACKGROUND

Temporal trends in the prevalence and management of major risk factors may affect the epidemiology of HF.

METHODS

We compared the frequency, correlates, and prognosis of LVSD (left ventricular ejection fraction [LVEF] <50%) among Framingham Study participants without and with clinical HF in 3 decades (1985 to 1994, 1995 to 2004, and 2005 to 2014).

RESULTS

Among participants without HF (12,857 person-observations, mean age 53 years, 56% women), the prevalence of LVSD on echocardiography decreased (3.38% in 1985 to 1994 vs. 2.2% in 2005 to 2014; p < 0.0001), whereas mean LVEF increased (65% vs. 68%; p < 0.001). The elevated risk associated with LVSD (∼2- to 4-fold risk of HF or death) remained unchanged over time. Among participants with new-onset HF (n = 894, mean age 75 years, 52% women), the frequency of heart failure with preserved ejection fraction (HFpEF) increased (preserved LVEF ≥50%: 41.0% in 1985 to 1994 vs. 56.17% in 2005 to 2014; p < 0.001) and heart failure with reduced ejection fraction (HFrEF) decreased (reduced LVEF <40%: 44.10% vs. 31.06%; p = 0.002), whereas heart failure with midrange LVEF remained unchanged (LVEF 40% to <50%: 14.90% vs. 12.77%; p = 0.66). Cardiovascular mortality associated with HFrEF declined across decades (hazard ratio: 0.61; 95% confidence interval: 0.39 to 0.97), but remained unchanged for heart failure with midrange LVEF and HFpEF. Approximately 47% of the observed increase in LVEF among those without HF and 75% of the rising proportion of HFpEF across decades was attributable to trends in risk factors, especially a decline in the prevalence of coronary heart disease among those with HF.

CONCLUSIONS

The profile of HF in the community has changed in recent decades, with a lower prevalence of LVSD and an increased frequency of HFpEF, presumably due to concomitant risk factor trends.

Associations of objective physical activity with insulin sensitivity and circulating adipokine profile: the Framingham Heart Study

The purpose of this study was to explore the relation of physical activity (PA) and sedentary time (SED) to insulin sensitivity and adipokines. We assessed PA and SED using Actical accelerometers and insulin resistance (HOMA-IR) in 2109 participants (free of type 1 and 2 diabetes mellitus) from Framingham Generation 3 and Omni 2 cohorts (mean age 46 years, 54% women). Systemic inflammation (C-reactive protein [CRP]) and circulating adipokines were measured 6 years earlier. Steps per day, moderate-to-vigorous PA (MVPA) and SED per wear time (%SED) were predictor variables in multivariable regression analyses, with HOMA-IR, CRP and circulating adipokines as outcome measures. We reported that higher MVPA and more steps per day were associated with lower HOMA-IR, adjusting for %SED (β = -0.036, P = 0.002; β = -0.041, P = 0.005). Steps were inversely associated with CRP, but were directly associated with insulin-like growth factor (IGF)-1 levels (β = -0.111, P = 0.002; β = 3.293, P = 0.007). %SED was positively associated with HOMA-IR (β = 0.033, P < 0.0001), but non-significant after adjusting for MVPA (P = 0.13). %SED was associated with higher ratio of leptin/leptin receptor (sOB-R) and higher adipocyte fatty acid-binding protein (FABP)4 (β = 0.096, P < 0.0001; β = 0.593, P = 0.002). Our findings suggest differential influences of PA vs. SED on metabolic pathways, with PA modulating insulin resistance and inflammation, whereas SED influences FABPs.

Plasma Fibroblast Growth Factor 23: Clinical Correlates and Association With Cardiovascular Disease and Mortality in the Framingham Heart Study

Background

Fibroblast growth factor 23 (FGF23) is emerging as a novel biomarker of bone metabolism, chronic kidney disease, and cardiovascular disease (CVD). However, its clinical correlates and potential predictive role in a community‐based setting are incompletely understood.

Methods and Results

We evaluated participants of the Framingham Heart Study (seventh examination cycle of the Offspring cohort plus second examination cycle of the multiethnic Omni cohort) to identify clinical correlates of plasma FGF23 (N=3236) and examine its cross‐sectional association with vascular function (N=2209), and longitudinal association with 10‐year incidence of CVD (N=2823), and all‐cause mortality (N=3223).

Circulating FGF23 concentrations were positively related to African‐American and Asian ethnicity, waist circumference, current smoking, serum glucose, history of CVD, and antihypertensive medication use; and negatively related to male sex, hormone replacement therapy, and estimated glomerular filtration rate. Multivariable‐adjusted cross‐sectional analyses showed no consistent association of FGF23 with vascular function measures. During a median follow‐up time of 10.8 years, 347 incident CVD events and 412 deaths occurred. Multivariable‐adjusted Cox regression models revealed a positive association of FGF23 with all‐cause mortality (hazard ratio [HR] per SD increase, 1.31; 95% CI, 1.20–1.42), but not with incident CVD (HR per SD increase, 1.05; 95% CI, 0.94–1.17).

Conclusions

In our large, community‐based sample, FGF23 was associated with mortality risk, but not with vascular function or incident CVD.

Association of Ideal Cardiovascular Health With Vascular Brain Injury and Incident Dementia

BACKGROUND AND PURPOSE

The American Heart Association developed the ideal cardiovascular health (CVH) index as a simple tool to promote CVH; yet, its association with brain atrophy and dementia remains unexamined.

METHODS

Our aim was to investigate the prospective association of ideal CVH with vascular brain injury, including the 10-year risks of incident stroke and dementia, as well as cognitive decline and brain atrophy on magnetic resonance imaging, measured for ≈7 years. We studied 2750 stroke- and dementia-free Framingham Heart Study Offspring cohort participants (mean age, 62±9 years; 45% men). Ideal CVH was quantified on a 7-point scale with 1 point awarded for each of the following: nonsmoking status, ideal body mass index, regular physical activity, healthy diet, as well as optimum blood pressure, cholesterol, and fasting blood glucose. Both recent (baseline) and remote (6.9 years earlier) ideal CVH scores were examined.

RESULTS

Recent ideal CVH was associated with stroke (hazard ratio, 0.80; 95% confidence interval, 0.67-0.95), vascular dementia (hazard ratio, 0.49; 95% confidence interval, 0.30-0.81), frontal brain atrophy (P=0.003), and cognitive decline on tasks measuring visual memory and reasoning (P<0.05). In addition to predicting stroke, vascular dementia, whole-brain atrophy, and cognitive decline, remote ideal CVH was associated with the incidence of all-cause dementia (hazard ratio, 0.80; 95% confidence interval, 0.67-0.97) and Alzheimer disease (hazard ratio, 0.79; 95% confidence interval, 0.64-0.98).

CONCLUSIONS

Adherence to the American Heart Association's ideal CVH factors and behaviors, particularly in midlife, may protect against cerebrovascular disease and dementia.

Cardiovascular Health Status and Incidence of Heart Failure in the Framingham Offspring Study

BACKGROUND

The American Heart Association Cardiovascular Health (CVH) score is inversely associated with cardiovascular disease, but its relations to cardiac remodeling traits and heart failure (HF) incidence have not been examined.

METHODS AND RESULTS

A 14-point score was constructed for each participant based on the presence of poor, intermediate, or ideal status on each of the 7 CVH metrics (ideal score=14). We related the CVH score to echocardiographic traits cross-sectionally and to HF incidence prospectively in the Framingham Offspring Study. In age- and sex-adjusted models, a higher CVH score was associated with lower left ventricular (LV) mass, LV wall thickness, LV diastolic dimension, and left atrial dimension (P<0.01 for all; n=2392; mean age, 58 years; 56% women), and with a 12% to 15% lower odds of prevalent LV concentric remodeling and concentric hypertrophy, respectively (P<0.0001 for both). On follow-up (mean, 12.3 years), 188 incident HF events were observed in 3201 participants (mean age, 59 years; 53% women). In age- and sex-adjusted Cox proportional hazard models, the CVH score was inversely associated with HF incidence (hazard ratio per 1-point higher CVH score, 0.77; 95% confidence interval, 0.72-0.83). This association was partially attenuated upon adjustment for LV mass and interim myocardial infarction (hazard ratio, 0.84; 95% confidence interval, 0.76-0.93), and it was consistent for HF with preserved and reduced ejection fractions.

CONCLUSIONS

In our community-based sample, comprised predominantly of middle-aged white individuals of European descent, better CVH was associated with lower HF incidence, in part due to a lower prevalence of adverse cardiac remodeling.