Associations between Hysterectomy and Metabolic Syndrome: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Metabolic syndrome is linked to an increased risk of incident cardiovascular disease (CVD) and all-cause mortality. Notable associations exist between hysterectomy with bilateral salpingo-oophorectomy and metabolic syndrome. However, there is emerging evidence that even with ovarian conservation, hysterectomy may be independently associated with long-term CVD risk.

OBJECTIVE

To examine the associations between hysterectomy with ovarian preservation and metabolic syndrome risk in a multi-ethnic cohort.

METHODS

We studied 3,367 female participants in the Multi-Ethnic Study of Atherosclerosis who had data on self-reported history of hysterectomy, oophorectomy, hystero-oophorectomy and metabolic syndrome at baseline (2000-2002). We used adjusted logistic regression to assess the cross-sectional associations between hysterectomy/oophorectomy subgroups and prevalent metabolic syndrome at baseline. Furthermore, we investigated 1,355 participants free of baseline metabolic syndrome and used adjusted Cox regression models to evaluate incident metabolic syndrome from exams 2 (2002-2004) to 6 (2016-2018).

RESULTS

The mean±SD age was 59.0±9.5 years, with 42% White, 27% Black, 19% Hispanic, and 13% Chinese American participants. 29% and 22% had a history of hysterectomy and oophorectomy, respectively. Over a median follow-up period of 10.5 (3.01-17.62) years, there were 750 metabolic syndrome events. Hysterectomy [HR, 1.32 (95%CI, 1.01-1.73)] and hystero-oophorectomy [1.40 (1.13-1.74)] were both strongly associated with incident metabolic syndrome compared to having neither hysterectomy or oophorectomy.

CONCLUSION

Hysterectomy, even with ovarian preservation, may be independently associated with a higher risk of metabolic syndrome. If other studies confirm these findings, screening and preventive strategies focused on females with ovary-sparing hysterectomy and the mechanisms underpinning these associations may be explored.

Galectin-3, Metabolic Risk, and Incident Heart Failure: The ARIC Study

BACKGROUND

It is unclear how metabolic syndrome (MetS) and diabetes affect Gal-3 (galectin 3) levels and the resulting implications for heart failure (HF) risk. We assessed relationships of MetS and diabetes with Gal-3, and their joint associations with incident HF.

METHODS AND RESULTS

We included 8445 participants without HF (mean age, 63 years; 59% men; 16% Black race) at ARIC (Atherosclerosis Risk in Communities) study visit 4 (1996-1999). We categorized participants as having MetS only, MetS with diabetes, or neither, and by quartiles of MetS severity Z score. We assessed cross-sectional associations of metabolic risk categories with high Gal-3 level (≥75th percentile) using logistic regression. We used Cox regression to evaluate combined associations of metabolic risk categories and Gal-3 quartiles with HF. In cross-sectional analyses, compared with no MetS and no diabetes, MetS only (odds ratio [OR], 1.24 [95% CI, 1.10-1.41]) and MetS with diabetes (OR, 1.59 [95% CI, 1.32-1.92]) were associated with elevated Gal-3. Over a median follow-up of 20.5 years, there were 1749 HF events. Compared with individuals with neither diabetes nor MetS and with Gal-3 in the lowest quartile, the combination of MetS with diabetes and Gal-3 ≥75th percentile was associated with a 4-fold higher HF risk (hazard ratio, 4.35 [95% CI, 3.30-5.73]). Gal-3 provided HF prognostic information above and beyond MetS, NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity cardiac troponin T, and CRP (C-reactive protein) (ΔC statistic for models with versus without Gal-3: 0.003; P=0.004).

CONCLUSIONS

MetS and diabetes are associated with elevated Gal-3. The HF risk significantly increased with the combination of greater metabolic risk and higher Gal-3.

Four high sensitivity troponin assays and mortality in US adults with cardiovascular disease: The national health and nutrition examination survey, 1999-2004

Objective

High sensitivity cardiac troponin (hs-cTn) may be useful to monitor residual risk in secondary prevention. Our objective was to study the correlations and comparative associations with mortality of four hs-cTn assays in US adults with known cardiovascular disease (CVD).

Methods

We studied 1,211 adults with a history of CVD who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Using stored samples, we measured hs-cTnT (Roche) and three hs-cTnI assays (Abbott, Siemens, and Ortho). Outcomes were all-cause and CVD mortality, with follow-up through December 31, 2019.

Results

Mean age was 64 years, 48 % were female, and 80 % identified as non-Hispanic White. Pearson's correlation coefficients between hs-cTn assays ranged from 0.67 to 0.85. There were 848 deaths (365 from CVD). Among adults with a history of prior non-fatal CVD, each hs-cTn assay (log-transformed, per 1-SD) was independently associated with CVD death (HRs ranging from 1.55 to 2.16 per 1-SD, all p-values <0.05) and with all-cause death (HRs ranging from 1.31 to 1.62 per 1-SD, all p-values <0.05). Associations of hs-cTnT and all-cause and CVD death remained significant after adjusting for hs-cTnI (and vice versa). Associations between hs-cTnI and CVD death remained significant after mutually adjusting for other individual hs-cTnI assays: e.g., HR 2.21 (95 % CI 1.60, 3.05) for Ortho (hs-cTnI) after adjustment for Siemens (hs-cTnI) and HR 1.81 (95 % CI 1.35, 2.43) for Ortho (hs-cTnI) after adjustment for Abbott (hs-cTnI).

Conclusion

In US adults with a history of CVD, we found modest correlations between 4 hs-cTn assays. All assays were associated with all-cause and CVD mortality. The hs-cTnT assay was associated with mortality independent of the hs-cTnI assays. Hs-cTnI assays also appeared to be independent of each other. Thus, hs-cTn assays may provide distinct information for residual risk in secondary prevention adults.

Plasma Ferritin Levels, Incident Heart Failure, and Cardiac Structure and Function: The ARIC Study

BACKGROUND

Whether iron deficiency contributes to incident heart failure (HF) and cardiac dysfunction has important implications given the prevalence of iron deficiency and the availability of several therapeutics for iron repletion.

OBJECTIVES

The aim of this study was to estimate the associations of plasma ferritin level with incident HF overall, HF phenotypes, and cardiac structure and function measures in older adults.

METHODS

Participants in the ongoing, longitudinal ARIC (Atherosclerosis Risk In Communities) study who were free of prevalent HF and anemia were studied. The associations of plasma ferritin levels with incident HF overall and heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) were estimated using Cox proportional hazards regression models. Linear regression models estimated the cross-sectional associations of plasma ferritin with echocardiographic measures of cardiac structure and function.

RESULTS

The cohort included 3,472 individuals with a mean age of 75 ± 5 years (56% women, 14% Black individuals). In fully adjusted models, lower ferritin was associated with higher risk for incident HF overall (HR: 1.20 [95% CI: 1.08-1.34] per 50% lower ferritin level) and higher risk for incident HFpEF (HR: 1.28 [95% CI: 1.09-1.50]). Associations with incident HFrEF were not statistically significant. Lower ferritin levels were associated with higher E/e' ratio and higher pulmonary artery systolic pressure after adjustment for demographics and HF risk factors but not with measures of left ventricular structure or systolic function.

CONCLUSIONS

Among older adults without prevalent HF or anemia, lower plasma ferritin level is associated with a higher risk for incident HF, HFpEF, and higher measures of left ventricular filling pressure.

Development and Validation of the American Heart Association's PREVENT Equations

BACKGROUND

Multivariable equations are recommended by primary prevention guidelines to assess absolute risk of cardiovascular disease (CVD). However, current equations have several limitations. Therefore, we developed and validated the American Heart Association Predicting Risk of CVD EVENTs (PREVENT) equations among US adults 30 to 79 years of age without known CVD.

METHODS

The derivation sample included individual-level participant data from 25 data sets (N=3 281 919) between 1992 and 2017. The primary outcome was CVD (atherosclerotic CVD and heart failure). Predictors included traditional risk factors (smoking status, systolic blood pressure, cholesterol, antihypertensive or statin use, and diabetes) and estimated glomerular filtration rate. Models were sex-specific, race-free, developed on the age scale, and adjusted for competing risk of non-CVD death. Analyses were conducted in each data set and meta-analyzed. Discrimination was assessed using the Harrell C-statistic. Calibration was calculated as the slope of the observed versus predicted risk by decile. Additional equations to predict each CVD subtype (atherosclerotic CVD and heart failure) and include optional predictors (urine albumin-to-creatinine ratio and hemoglobin A1c), and social deprivation index were also developed. External validation was performed in 3 330 085 participants from 21 additional data sets.

RESULTS

Among 6 612 004 adults included, mean±SD age was 53±12 years, and 56% were women. Over a mean±SD follow-up of 4.8±3.1 years, there were 211 515 incident total CVD events. The median C-statistics in external validation for CVD were 0.794 (interquartile interval, 0.763-0.809) in female and 0.757 (0.727-0.778) in male participants. The calibration slopes were 1.03 (interquartile interval, 0.81-1.16) and 0.94 (0.81-1.13) among female and male participants, respectively. Similar estimates for discrimination and calibration were observed for atherosclerotic CVD- and heart failure-specific models. The improvement in discrimination was small but statistically significant when urine albumin-to-creatinine ratio, hemoglobin A1c, and social deprivation index were added together to the base model to total CVD (ΔC-statistic [interquartile interval] 0.004 [0.004-0.005] and 0.005 [0.004-0.007] among female and male participants, respectively). Calibration improved significantly when the urine albumin-to-creatinine ratio was added to the base model among those with marked albuminuria (>300 mg/g; 1.05 [0.84-1.20] versus 1.39 [1.14-1.65]; P=0.01).

CONCLUSIONS

PREVENT equations accurately and precisely predicted risk for incident CVD and CVD subtypes in a large, diverse, and contemporary sample of US adults by using routinely available clinical variables.

Identification of Fatigue Subtypes and Their Correlates in Prevalent Heart Failure: A Secondary Analysis of the Atherosclerosis Risk in Communities Study

BACKGROUND

Among patients with heart failure (HF), fatigue is common and linked to quality of life and functional status. Fatigue is hypothesized to manifest as multiple types, with general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve outcomes. We conducted this study to identify fatigue subtypes in persons with prevalent HF in the ARIC study (Atherosclerosis Risk in Communities) and describe the distribution of characteristics across subtypes.

METHODS

We performed a cross-sectional analysis of 1065 participants with prevalent HF at ARIC visit 5 (2011-2013). We measured exertional fatigue using the Modified Medical Research Council Breathlessness scale and general fatigue using the Patient Reported Outcomes Measurement Information System fatigue scale. We used latent class analysis to identify subtypes of fatigue. Number of classes was determined using model fit statistics, and classes were interpreted and assigned fatigue severity rating based on the conditional probability of endorsing survey items given class. We compared characteristics across classes using multinomial regression.

RESULTS

Overall, participants were 54% female and 38% Black with a mean age of 77. We identified 4 latent classes (fatigue subtypes): (1) high general/high exertional fatigue (18%), (2) high general/low exertional fatigue (27%), (3) moderate general/moderate exertional fatigue (20%), and (4) low/no general and exertional fatigue (35%). Female sex, Black race, lower education level, higher body mass index, increased depressive symptoms, and higher prevalence of diabetes were associated with higher levels of general and exertional fatigue.

CONCLUSIONS

We identified unique subtypes of fatigue in patients with HF who have not been previously described. Within subtype, general and exertional fatigue were mostly concordant in severity, and exertional fatigue only occurred in conjunction with general fatigue, not alone. Further understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication and secondary prevention efforts for persons with HF.

A historical, evidence-based, and narrative review on commonly used dietary supplements in lipid-lowering

Dietary supplements augment the nutritional value of everyday food intake and originate from the historical practices of ancient Egyptian (Ebers papyrus), Chinese (Pen Ts'ao by Shen Nung), Indian (Ayurveda), Greek (Hippocrates), and Arabic herbalists. In modern-day medicine, the use of dietary supplements continues to increase in popularity with greater than 50% of the US population reporting taking supplements. To further compound this trend, many patients believe that dietary supplements are equally or more effective than evidence-based therapies for lipoprotein and lipid-lowering. Supplements such as red yeast rice, omega-3 fatty acids, garlic, cinnamon, plant sterols, and turmeric are marketed to and believed by consumers to promote "cholesterol health." However, these supplements are not subjected to the same manufacturing scrutiny by the Food and Drug Administration as pharmaceutical drugs and as such, the exact contents and level of ingredients in each of these may vary. Furthermore, supplements do not have to demonstrate efficacy or safety before being marketed. The holistic approach to lowering atherosclerotic cardiovascular disease risk makes dietary supplements an attractive option to many patients; however, their use should not come at the expense of established therapies with proven benefits. In this narrative review, we provide a historical and evidence-based approach to the use of some dietary supplements in lipoprotein and lipid-lowering and provide a framework for managing patient expectations.

Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association

Cardiovascular-kidney-metabolic (CKM) syndrome is a novel construct recently defined by the American Heart Association in response to the high prevalence of metabolic and kidney disease. Epidemiological data demonstrate higher absolute risk of both atherosclerotic cardiovascular disease (CVD) and heart failure as an individual progresses from CKM stage 0 to stage 3, but optimal strategies for risk assessment need to be refined. Absolute risk assessment with the goal to match type and intensity of interventions with predicted risk and expected treatment benefit remains the cornerstone of primary prevention. Given the growing number of therapies in our armamentarium that simultaneously address all 3 CKM axes, novel risk prediction equations are needed that incorporate predictors and outcomes relevant to the CKM context. This should also include social determinants of health, which are key upstream drivers of CVD, to more equitably estimate and address risk. This scientific statement summarizes the background, rationale, and clinical implications for the newly developed sex-specific, race-free risk equations: PREVENT (AHA Predicting Risk of CVD Events). The PREVENT equations enable 10- and 30-year risk estimates for total CVD (composite of atherosclerotic CVD and heart failure), include estimated glomerular filtration rate as a predictor, and adjust for competing risk of non-CVD death among adults 30 to 79 years of age. Additional models accommodate enhanced predictive utility with the addition of CKM factors when clinically indicated for measurement (urine albumin-to-creatinine ratio and hemoglobin A1c) or social determinants of health (social deprivation index) when available. Approaches to implement risk-based prevention using PREVENT across various settings are discussed.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.

Insulin Resistance and N-Terminal Pro-B-Type Natriuretic Peptide Among Healthy Adults

Importance

It is unclear to what extent insulin resistance is associated with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the general population after accounting for body composition.

Objective

To characterize the association of insulin resistance with NT-proBNP independently of measures of body composition in US adults.

Design, Setting, and Participants

In a cross-sectional design, data on participants aged 20 years or older were obtained from the 1999-2004 National Health and Nutrition Examination Survey with measures of NT-pro-BNP, body mass index (BMI), and dual energy x-ray absorptiometry (DEXA)-derived measures of body composition (fat and lean masses). Linear and logistic regression was used to characterize the associations of measures of body mass and composition (BMI, waist circumference, fat mass, and lean mass) with NT-proBNP, adjusting for cardiovascular risk factors. Linear regression was used to characterize the associations of homeostasis model assessment of insulin resistance [HOMA-IR] and NT-proBNP after adjusting for cardiovascular risk factors and body composition measures. The quantitative insulin sensitivity check index [QUICKI], triglyceride-glucose index [TyG index], insulin to glucose ratio [IGR], fasting insulin, and homeostasis model assessment of β-cell function (HOMA-β) were also examined. Data for this study were analyzed from August 10, 2022, to June 30, 2023.

Main Outcomes and Measures

Adjusted changes in NT-proBNP by insulin resistance levels.

Results

A total of 4038 adults without diabetes or cardiovascular disease were included (mean [SD] age, 44 years; 51.2% female; and 74.3% White). In sex-specific analyses, insulin resistance measures were inversely associated with NT-pro-BNP. After adjustment including cardiovascular risk factors, BMI, waist circumference, and DEXA-derived fat mass and lean mass, the percent change in NT-proBNP associated with an SD increase in HOMA-IR was -16.84% (95% CI, -21.23% to -12.21%) in women and -19.04% (95% CI, -24.14 to -13.59) in men. Similar associations were observed for other indices of insulin resistance, including QUICKI (women: 17.27; 95% CI, 10.92-23.99 vs men: 22.17; 95% CI, 15.27 to 29.48), TyG index women: -11.47; 95% CI, -16.12 to -6.57 vs men: -15.81; 95% CI, -20.40 to -10.95), IGR women: -15.15; 95% CI, -19.35 to -10.74 vs men: -16.61; 95% CI, -21.63 to -11.26), and fasting insulin (women: -16.32; 95% CI, -20.63 to -11.78 vs men: -18.22; 95% CI, -23.30 to -12.79), as well as HOMA-β (women: -10.71; 95% CI, -14.71 to -6.52 vs men: -11.72; 95% CI, -16.35 to -6.85).

Conclusions and Relevance

In a national sample of US adults, insulin resistance was inversely associated with NT-proBNP, even after rigorously accounting for multiple measures of fat mass and lean mass. These results suggest that the mechanisms linking NT-proBNP to insulin resistance are partially independent of excess adiposity and may be associated with hyperinsulinemia.

Associations of N-terminal pro-B-type natriuretic peptide, estimated glomerular filtration rate, and mortality in US adults

BACKGROUND

NT-proBNP is an important predictor of mortality but is inversely related to estimated glomerular filtration rate (eGFR). Whether the prognostic value of NT-proBNP is similar at different levels of kidney function is unknown.

AIMS

We evaluated the association of NT-proBNP with eGFR and its implications for all-cause and cardiovascular mortality risk in the general population.

METHODS

We included adults without prior cardiovascular disease from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004. We used linear regression to characterize the cross-sectional associations of NT-proBNP with eGFR. We used Cox regression to assess the prospective associations of NT-proBNP with mortality across categories of eGFR.

RESULTS

Among 11,456 participants (mean age 43 years, 48% female, 71% White, 11% Black), there was an inverse association between NT-proBNP and eGFR, which was stronger in those with more impaired kidney function. Per 15-unit decrease in eGFR, NT-proBNP was 4.3-fold higher for eGFR<30; 1.7-fold higher for eGFR 30 to 60, 1.4-fold higher for eGFR 61 to 90, 1.1-fold higher for eGFR 91 to 120 mL/min/1.73 m2. Over a median 17.6 years of follow-up, 2,275 deaths (622 cardiovascular) occurred. Higher NT-proBNP was associated with higher all-cause (HR per doubling of NT-proBNP: 1.20, 95% CI: 1.16-1.25) and cardiovascular mortality (HR: 1.34, 95% CI 1.25-1.44). Associations were similar across eGFR categories (P-interaction >.10). Adults with NT-proBNP≥450 pg/mL and eGFR<60 mL/min/1.73m2 had 3.4-fold higher all-cause mortality and 5.5-fold higher cardiovascular mortality risk, compared to those with NT-proBNP<125 pg/mL and eGFR>90 mL/min/1.73m2.

CONCLUSION

Despite its strong inverse association with eGFR, NT-proBNP has robust associations with mortality across the full range of kidney function in the general US adult population.

Racial and ethnic differences in circulating N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in US adults

BACKGROUND

The presence and interpretation of racial and ethnic differences in circulating N-terminal pro-brain-type natriuretic peptide (NT-proBNP), a diagnostic biomarker for heart failure, are controversial.

OBJECTIVE

To examine racial and ethnic differences in NT-proBNP levels among the general US adult population.

METHODS

We performed a cross-sectional analysis of data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). We included 4717 non-Hispanic White, 1675 non-Hispanic Black, and 2148 Mexican American adults aged 20 years or older without a history of cardiovascular disease. We examined the associations of race and ethnicity with NT-proBNP using linear and logistic regression models in the overall population and in a younger, 'healthy' subsample.

RESULTS

The mean age was 45 years. Median NT-proBNP levels were significantly lower among Black (29.3 pg/mL) and Mexican American adults (28.3.4 pg/mL) compared to White adults (49.1pg/mL, P-values<0.001). After adjusting for sociodemographic factors and cardiovascular risk factors, NT-proBNP was 34.4% lower (95%CI -39.2 to -29.3%) in Black adults and 22.8% lower (95%CI -29.4 to -15.5) in Mexican American adults compared to White adults. Our findings were consistent in a young, healthy subsample, suggesting non-cardiometabolic determinants of these differences.

CONCLUSIONS

NT-proBNP levels are significantly lower among Black and Mexican American adults compared with White adults, independent of cardiometabolic risk. Although race/ethnicity is a poor proxy for genetic differences, our findings may have clinical implications for the management of HF. However, studies in diverse populations are needed to characterize the biological basis of NT-proBNP variation.

The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention

The prevalence of heart failure (HF) in the United States (U.S.) is estimated at over 6 million adults, with the incidence continuing to increase. A large proportion of the U.S. population is also at risk of HF due to the high prevalence of established HF risk factors, such as hypertension, diabetes, and obesity. Many individuals have multiple risk factors, placing them at even higher risk. In addition, these risk factors disproportionately impact various racial and ethnic groups. Recognizing the rising health and economic burden of HF in the U.S., the 2022 American Heart Association / American College of Cardiology / Heart Failure Society of America (AHA/ACC/HFSA) Heart Failure Guideline placed a strong emphasis on prevention of HF. The purpose of this review is to highlight the role of both primary and secondary prevention in HF, as outlined by the recent guideline, and address the role of the preventive cardiology community in reducing the prevalence of HF in at-risk individuals.

Body Composition Measures and N-terminal pro-B-type Natriuretic Peptide (NT-pro-BNP) in US Adults

BACKGROUND

The associations of N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) with dual energy x-ray absorptiometry (DEXA)-derived measures of body mass and composition are largely unknown.

METHODS

We included participants aged ≥20 years from the 1999-2004 National Health and Nutrition Examination Survey with NT-pro-BNP and DEXA-derived body composition (fat and lean mass) measures. We used linear and logistic regression to characterize the associations of measures of body mass and composition (body mass index [BMI], waist circumference [WC], fat mass, and lean mass) with NT-pro-BNP, adjusting for cardiovascular risk factors.

RESULTS

We conducted sex-specific analyses among 9134 adults without cardiovascular disease (mean age 44.4 years, 50.8% women, and 72% White adults). The adjusted mean NT-proBNP values were lowest in the highest quartiles of BMI, WC, fat mass, and lean mass. There were large adjusted absolute differences in NT-pro-BNP between the highest and lowest quartiles of DEXA-derived lean mass, -6.26 pg/mL (95% confidence interval [CI], -8.99 to -3.52) among men and -22.96 pg/mL (95% CI, -26.83 to -19.09) among women. Lean mass exhibited a strong inverse association with elevated NT-pro-BNP ≥ 81.4 pg/mL (highest quartile) - odds ratio (OR) 0.58 (95% CI, 0.39-0.86) in men and OR 0.59 (95% CI, 0.47-0.73) in women for highest lean mass quartile vs. lowest quartile. Further adjustment for fat mass, BMI, or WC did not appreciably alter the inverse association of lean mass with NT-pro-BNP.

CONCLUSIONS

In a national sample of US adults, lean mass was inversely associated with NT-pro-BNP.

High-sensitivity troponins and mortality in the general population

AIMS

Cardiac troponin T and I can be measured using a number of high-sensitivity (hs) assays. This study aimed to characterize correlations between four such assays and test their comparative associations with mortality.

METHODS AND RESULTS

Among adults without cardiovascular disease in the 1999-2004 National Health and Nutrition Examination Survey, hs-troponin T was measured using one assay (Roche) and hs-troponin I using three assays (Abbott, Siemens, and Ortho). Cox regression was used to estimate associations with all-cause and cardiovascular mortality. Pearson's correlation coefficients comparing concentrations from each assay ranged from 0.53 to 0.77. There were 2188 deaths (488 cardiovascular) among 9810 participants. Each hs-troponin assay [log-transformed, per 1 standard deviation (SD)] was independently associated with all-cause mortality: hazard ratio (HR) 1.20 [95% confidence interval (CI) 1.13-1.28] for Abbott hs-troponin I; HR 1.10 (95% CI 1.02-1.18) for Siemens hs-troponin I; HR 1.23 (95% CI 1.14-1.33) for Ortho hs-troponin I; and HR 1.31 (95% CI 1.21-1.42) for Roche hs-troponin T. Each hs-troponin assay was also independently associated with cardiovascular mortality (HR 1.44 to 1.65 per 1 SD). Associations of hs-troponin T and all-cause and cardiovascular mortality remained significant after adjusting for hs-troponin I. Furthermore, associations of hs-troponin I remained significant after mutually adjusting for hs-troponin I from the other individual assays: e.g. cardiovascular mortality HR 1.46 (95% CI 1.19-1.79) for Abbott after adjustment for the Siemens assay and HR 1.29 (95% CI 1.09-1.53) for Abbott after adjustment for the Ortho assay.

CONCLUSION

This study demonstrates only modest correlations between hs-troponin T and three hs-troponin I assays and that hs-troponin I assays can provide distinct risk information for mortality in the general population.

NT-proBNP and All-Cause and Cardiovascular Mortality in US Adults: A Prospective Cohort Study

Background NT-proBNP (N-terminal pro-B-type natriuretic peptide) is strongly associated with mortality in patients with heart failure. Prior studies, primarily in middle-aged and older populations, have suggested that NT-proBNP has prognostic value in ambulatory adults. Methods and Results We conducted a prospective cohort analysis of adults, aged ≥20 years, in the nationally representative 1999 to 2004 National Health and Nutrition Examination Survey, to characterize the association of NT-proBNP with mortality in the general US adult population overall and by age, race and ethnicity, and body mass index. We used Cox regression to characterize associations of NT-proBNP with all-cause and cardiovascular disease (CVD) mortality through 2019, adjusting for demographics and cardiovascular risk factors. We included 10 645 individuals (mean age, 45.7 years; 50.8% women; 72.8% White adults; 8.5% with a self-reported history of CVD). There were 3155 deaths (1009 CVD-related) over a median 17.3 years of follow-up. Among individuals without prior CVD, elevated NT-proBNP (≥75th percentile [81.5 pg/mL] versus <25th percentile [20.5 pg/mL]) was associated with a significantly higher risk of all-cause (hazard ratio [HR], 1.67 [95% CI, 1.39-2.00]) and CVD mortality (HR, 2.87 [95% CI, 1.61-5.11]). Associations of NT-proBNP with all-cause and CVD mortality were generally similar across subgroups defined by age, sex, race and ethnicity, or body mass index (all P interaction >0.05). Conclusions In a representative sample of the US adult population, NT-proBNP was an important independent risk factor for all-cause and CVD mortality. NT-proBNP may be useful for monitoring risk in the general adult population.

NT-proBNP Reference Intervals in Healthy U.S. Children, Adolescents, and Adults

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a cardiac biomarker used in the clinical management of heart failure. We sought to create updated reference intervals for NT-proBNP for healthy US children, adolescents, and adults.

METHODS

We identified a population of healthy individuals using the 1999 to 2004 cycles of the National Health and Nutrition Examination Survey (NHANES). We measured serum NT-proBNP in 12 346 adults and 15 752 children and adolescents with the Elecsys NT-proBNP assay on the Roche e601 autoanalyzer. We compared 4 methods for reference interval calculation, and presented the final reference intervals using the robust method partitioned by age and sex categories.

RESULTS

NT-proBNP values were available for 1949 healthy adults and 5250 healthy children and adolescents. NT-proBNP concentrations in males and females varied according to age, being higher in early childhood, relatively lower in late adolescence, and highest through middle age and older age. Females tended to have higher NT-proBNP concentrations compared to men from late adolescence until middle age. The upper reference limit, or 97.5th percentile, for 50 to 59 year-old men was 225 ng/L (90% CI: 158 to 236), and for 50 to 59 year-old women, 292 ng/L (90% CI: 242 to 348).

CONCLUSIONS

Among healthy individuals, NT-proBNP concentrations varied greatly according age and sex. The reference intervals presented here should inform future clinical decision limits and suggest that age- and sex-specific intervals may be necessary to more precisely characterize risk.

Heart failure and obesity: The latest pandemic

The marked rise in rates of obesity, which is most prominent among individuals from socio-economically disadvantaged circumstances, has been a powerful contributor to the rising prevalence of heart failure (HF). Obesity has indirect effects on HF through the development of several metabolic risk factors, but also direct adverse effects on the myocardium. Obesity contributes to myocardial dysfunction and HF risk through multiple mechanisms, including hemodynamic changes, neurohormonal activation, endocrine and paracrine effects of adipose tissue, ectopic fat deposition and lipotoxicity. These processes principally result in concentric left ventricular (LV) remodeling and predominant increase in the risk for HF with preserved LV ejection fraction (HFpEF). Despite the excess risk for HF associated with obesity, there is a well described obesity paradox in which individuals with overweight and grade I obesity have better survival than those with normal weight and overweight. Despite the obesity paradox among individuals with prevalent HF, intentional weight loss is associated with improvements in metabolic risk factors, myocardial dysfunction and quality of life, in a dose-response fashion. In matched observational studies of bariatric surgery patients, marked weight loss is associated with decreased risk for developing HF, as well as improved cardiovascular disease (CVD) outcomes in those with existing HF. Ongoing clinical trials using powerful new obesity pharmacotherapies in individuals in with obesity and CVD may provide definitive information regarding the cardiovascular impact of weight loss. Given the powerful contribution of rising obesity prevalence to rates of HF, addressing these intertwined epidemics is a clinical and public health priority.

Myocardial Injury Thresholds for 4 High-Sensitivity Troponin Assays in U.S. Adults

BACKGROUND

Myocardial injury is currently defined as a cardiac troponin above the sex-specific 99th percentile of a healthy reference population (upper reference limit [URL]).

OBJECTIVES

The purpose of this study was to estimate high-sensitivity (hs) troponin URLs in a representative sample of the U.S. adult population; overall and by sex, race/ethnicity, and age group.

METHODS

Among adults participating in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), we measured hs-troponin T using 1 assay (Roche) and hs-troponin I using 3 assays (Abbott, Siemens, and Ortho). In a strictly defined healthy reference subgroup, we estimated 99th percentile URLs for each assay using the recommended nonparametric method.

RESULTS

Of 12,545 participants, 2,746 met criteria for the healthy subgroup (mean age 37 years, 50% men). The NHANES 99th percentile URL for hs-troponin T (19 ng/L) matched the manufacturer-reported URL (19 ng/L). NHANES URLs were 13 ng/L (95% CI: 10-15 ng/L) for Abbott hs-troponin I (manufacturer: 28 ng/L), 5 ng/L (95% CI: 4-7 ng/L) for Ortho hs-troponin I (manufacturer: 11 ng/L), and 37 ng/L (95% CI: 27-66 ng/L) for Siemens hs-troponin I (manufacturer: 46.5 ng/L). There were significant differences in URLs by sex, but none by race/ethnicity. Furthermore, the 99th percentile URLs for all 4 hs-troponin assays were statistically significantly lower in healthy adults aged <40 years compared with healthy adults ≥60 years (all P < 0.001 by rank sum testing).

CONCLUSIONS

We found URLs for hs-troponin I assays that were substantially lower than currently listed 99th percentile URLs. There were significant differences in hs-troponin T and I URLs by sex and by age group in healthy U.S. adults but none by race/ethnicity.

Associations of Adipokine Levels with Levels of Remnant Cholesterol: the Multi-Ethnic Study of Atherosclerosis (MESA)

Background

The metabolic syndrome phenotype of individuals with obesity is characterized by elevated levels of triglyceride (TG)-rich lipoproteins and remnant particles, which have been shown to be significantly atherogenic. Understanding the association between adipokines, endogenous hormones produced by adipose tissue, and remnant cholesterol (RC) would give insight into the link between obesity and atherosclerotic cardiovascular disease.

Methods

We studied 1,791 MESA participants of an ancillary study on body composition who had adipokine levels measured (leptin, adiponectin, resistin) at either visit 2 or 3. RC was calculated as non-high density lipoprotein cholesterol minus low-density lipoprotein cholesterol (LDL-C), measured at the same visit as the adipokines, as well as subsequent visits 4 through 6. Multivariable-adjusted linear mixed effects models were used to assess the cross-sectional and longitudinal associations between adipokines and levels of RC.

Results

Mean (SD) age was 64.5±9.6 years and for body mass index (BMI) was 29.9±5.0 kg/m2; 52.0% were women. In fully adjusted models that included BMI, LDL-C and lipid-lowering therapy, for each 1-unit increment in adiponectin, there was 14.4% (12.0, 16.8) lower RC. With each 1-unit increment in leptin and resistin, there was 4.5% (2.3, 6.6) and 5.1% (1.2, 9.2) higher RC, respectively. Lower adiponectin and higher leptin were also associated with longitudinal increases in RC levels over median follow-up of 5(4-8) years.

Conclusions

Lower adiponectin and higher leptin levels were independently associated with higher levels of RC at baseline and longitudinal RC increase, even after accounting for BMI and LDL-C.

CLINICAL PERSPECTIVE

What is new?: - Among individuals without history of cardiovascular disease, adiponectin is inversely associated with cross-sectional levels of remnant cholesterol, whereas leptin and resistin are directly associated.- Adiponectin had an inverse association with progression of remnant cholesterol levels over time.What are the clinical implications?: - Adiponectin levels were not associated with LDL-C levels but with levels of triglyceride-rich lipoproteins, particularly remnant cholesterol.-Incrementing adiponectin via lifestyle modification and/or pharmacological therapies (i.e. GLP-1 agonists) could be a mechanism to reduce remnant cholesterol levels and ultimately cardiovascular risk.

High-Sensitivity Troponin T and I Among Pregnant Women in the US-The National Health and Nutrition Examination Survey, 1999-2004

This cross-sectional study investigates the expected physiologic concentrations of high-sensitivity cardiac troponin in normal pregnancy.

Ideal Cardiovascular Health and Adipokine Levels: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE

Adipokines are hormones implicated in obesity and its cardiometabolic consequences. The concept of ideal cardiovascular health (CVH) was introduced to promote 7 key health factors and behaviors in the general population. Prior studies have found strong associations between obesity and ideal CVH. We now sought to evaluate the association between CVH and adipokines.

METHODS

We studied 1,842 MESA participants free of cardiovascular disease (CVD), who had 7 CVH metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood pressure and fasting blood glucose) measured at baseline and serum adipokine levels measured at a median of 2.4 years later. Each CVH metric was assigned a score of 0(poor), 1(intermediate) and 2(ideal), and summed for a total CVH score (0-14). Total CVH scores of 0-8 were considered inadequate, 9-10 average, and 11-14 optimal. We used multivariable linear regression models to assess the non-concurrent associations between CVH score and log-transformed adipokine levels.

RESULTS

The mean age was 62.1±9.8 years; 50.2% of participants were men. After adjusting for sociodemographic factors, a 1-unit higher CVH score was significantly associated with 4% higher adiponectin and 15% and 1% lower leptin and resistin levels. Individuals with optimal CVH scores had 27% higher adiponectin and 56% lower leptin levels compared to those with inadequate CVH scores. Similar trends were observed for those with average versus inadequate CVH scores.

CONCLUSION

In a multi-ethnic cohort free of CVD at baseline, individuals with average and optimal CVH scores had a more favorable adipokine profile than those with inadequate CVH.

Proteomic Predictors of Incident Diabetes: Results From the Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

The plasma proteome preceding diabetes can improve our understanding of diabetes pathogenesis.

RESEARCH DESIGN AND METHODS

In 8,923 Atherosclerosis Risk in Communities (ARIC) Study participants (aged 47-70 years, 57% women, 19% Black), we conducted discovery and internal validation for associations of 4,955 plasma proteins with incident diabetes. We externally validated results in the Singapore Multi-Ethnic Cohort (MEC) nested case-control (624 case subjects, 1,214 control subjects). We used Cox regression to discover and validate protein associations and risk-prediction models (elastic net regression with cardiometabolic risk factors and proteins) for incident diabetes. We conducted a pathway analysis and examined causality using genetic instruments.

RESULTS

There were 2,147 new diabetes cases over a median of 19 years. In the discovery sample (n = 6,010), 140 proteins were associated with incident diabetes after adjustment for 11 risk factors (P < 10-5). Internal validation (n = 2,913) showed 64 of the 140 proteins remained significant (P < 0.05/140). Of the 63 available proteins, 47 (75%) were validated in MEC. Novel associations with diabetes were found for 22 the 47 proteins. Prediction models (27 proteins selected by elastic net) developed in discovery had a C statistic of 0.731 in internal validation, with ΔC statistic of 0.011 (P = 0.04) beyond 13 risk factors, including fasting glucose and HbA1c. Inflammation and lipid metabolism pathways were overrepresented among the diabetes-associated proteins. Genetic instrument analyses suggested plasma SHBG, ATP1B2, and GSTA1 play causal roles in diabetes risk.

CONCLUSIONS

We identified 47 plasma proteins predictive of incident diabetes, established causal effects for 3 proteins, and identified diabetes-associated inflammation and lipid pathways with potential implications for diagnosis and therapy.

Reclassification of Pre-Heart Failure Stages Using Cardiac Biomarkers: The ARIC Study

BACKGROUND

The recent heart failure (HF) guideline recommends the inclusion of cardiac biomarkers in defining Stage B HF.

OBJECTIVES

The authors evaluated the impact of incorporating cardiac biomarkers to reclassify HF in 5,324 participants (mean age: 75.8 years) without prevalent HF enrolled in the ARIC (Atherosclerosis Risk In Communities) study and assessed prognosis of Stage B using cardiac biomarkers.

METHODS

Using N-terminal pro-B-type natriuretic peptide (<125 pg/mL or ≥125 pg/mL), high-sensitivity troponin T (<14 ng/L or ≥14 ng/L), and abnormal cardiac structure/function by echocardiography, individuals were classified as Stage Anew and Stage Bnew HF, respectively. Stage Bnew was further evaluated as elevated biomarker only, abnormal echocardiogram only, and abnormalities in both (echo + biomarker). The authors assessed risk for incident HF and all-cause death using Cox regression.

RESULTS

Overall, 4,326 (81.3%) individuals were classified as Stage Bnew with 1,123 (21.1%) meeting criteria for elevated biomarkers only. Compared with Stage Anew, Stage Bnew was associated with increased risk for incident HF (HR: 3.70 [95% CI: 2.58-5.30]) and death (HR: 1.94 [95% CI: 1.53-2.46]). Stage Bbiomarkers only and Stage Becho only were associated with increased HF risk, whereas Stage Bbiomarkers only was also associated with increased death. Stage Becho+biomarker had the highest risk for HF (HR: 6.34 [95% CI: 4.37-9.19]) and death (HR: 2.53 [95% CI: 1.98-3.23]).

CONCLUSIONS

Incorporating biomarkers based on the new HF guideline reclassified approximately 1 in 5 older adults without prevalent HF to Stage B. The routine measurement of biomarkers can help to identify individuals at higher HF risk who may benefit most from HF prevention efforts.

Prevalence and Correlates of Elevated NT-proBNP in Pregnant Women in the General U.S. Population

BACKGROUND

Physiologic changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) across trimesters of pregnancy have not been well studied.

OBJECTIVES

The authors aimed to measure NT-proBNP in adult women, by pregnancy status and trimester, in a nationally representative sample from the National Health and Nutrition Examination Survey 1999 to 2004.

METHODS

We conducted a cross-sectional analysis of 2,134 women (546 pregnant) aged 20 to 40 years without a history of cardiovascular disease.

RESULTS

Among pregnant women in the first trimester, the prevalence of elevated NT-proBNP (>125 pg/mL) was 20.0% (SE, 6.6%) compared to 2.4% (SE, 0.8%) among women in the third trimester and 8.0% among nonpregnant women. After adjustment for demographics and cardiovascular risk factors, NT-proBNP was 44% higher (absolute difference 26.4 [95% CI: 11.2-41.6] pg/mL) in the first trimester of pregnancy compared to nonpregnant women. Among pregnant women only, adjusted NT-proBNP was 46% lower (absolute difference -22.2 [95% CI: -36.9 to -7.5] pg/mL) in women in the third trimester compared to women in the first trimester. NT-proBNP was inversely associated with body mass index and with systolic blood pressure.

CONCLUSIONS

Women in the first trimester of pregnancy had significantly higher NT-proBNP than those in the third trimester and compared to similarly aged nonpregnant women. The dynamic nature of NT-proBNP should be taken into consideration when ordering NT-proBNP lab tests in pregnant women.

Association of Long-term Change in N-Terminal Pro-B-Type Natriuretic Peptide With Incident Heart Failure and Death

Importance

Most studies, especially in primary prevention patients, have evaluated N-terminal B-type natriuretic peptide (NT-proBNP) at one time point. Evaluation of change in NT-proBNP may improve risk stratification for incident cardiovascular events.

Objective

To assess the association between change in NT-proBNP and risk for incident heart failure (HF) and death.

Design, Setting, and Participants

Participants were recruited from 4 US communities enrolled in the Atherosclerosis Risk in Community (ARIC) study. Individuals who attended ARIC visits 2 and 4 (approximately 6 years apart) with measurements of NT-proBNP and without prevalent HF were included. Assays of NT-proBNP were conducted between 2011 and 2013, and analysis took place between July 2021 and October 2022.

Exposures

The primary exposure variable was NT-proBNP change between visits 2 and 4, modeled as change categories (<125 pg/mL or ≥125 pg/mL) and as percent change.

Main Outcomes and Measures

The primary outcome measures were incident HF hospitalization and all-cause death. The association between changes in cardiovascular risk factors with change in NT-proBNP was further assessed.

Results

A total of 9776 individuals (mean [SD] age, 57.1 [5.7] years at visit 2; 5523 [56.5%] women) were included in the study. Compared with participants with NT-proBNP level less than 125 pg/mL at both visits, participants with NT-proBNP level of 125 pg/mL or higher at both visits had an increase in incident HF (adjusted hazard ratio [HR], 2.40 [95% CI, 2.00-2.88]) and mortality risk (HR, 1.68 [95% CI, 1.47-1.91). Participants with NT-proBNP levels of 125 pg/mL or higher at visit 2 and less than 125 pg/mL at visit 4 had similar risk for HF and death (HR, 1.01 [95% CI, 0.71-1.43]; HR, 0.79 [95% CI, 0.61-1.01]) compared with the group with NT-proBNP levels of less than 125 pg/mL at both visits. The percent change in NT-proBNP was positively associated with HF and death (HR, 1.06 [95% CI, 1.02-1.10]; HR, 1.05 [95% CI, 1.03-1.08] per 1-SD increase, respectively). Change in systolic blood pressure, low-density lipoprotein cholesterol, triglyceride level, body mass index, and estimated glomerular filtration rate were significantly associated with change in NT-proBNP.

Conclusions and Relevance

In this study, 6-year change in NT-proBNP reflected dynamic change in risk for HF events and death among community-dwelling adults without prevalent clinical HF. These results support the utility of serial NT-proBNP measurements to improve risk stratification of patients with pre-HF.

Abstract 28: Proteomic Signatures of Adiposity in Middle-Aged Adults: The Atherosclerosis Risk in Communities (ARIC) Study

Background: Excess adiposity is linked to adverse cardiovascular outcomes via direct and indirect effects on metabolic pathways. There is limited large-scale data assessing proteomic signatures of adiposity.

Methods: We quantified 4,955 plasma proteins using SomaLogic v4.0 in stored plasma samples of 9,940 ARIC Visit 2 participants (1990-92, mean age: 57±6 years, 55% women, 22% Black adults, 28% with obesity). We used linear regression and Bonferroni-corrected p-values to identify proteins associated with body mass index (BMI) in 2/3 discovery and 1/3 validation samples. We performed additional analyses to assess key pathways associated with obesity.

Results: In the discovery sample (28% with obesity), after adjusting for age, sex, race-center, eGFR, 1,312 proteins were significantly associated with BMI. After further adjustments for clinical and lifestyle risk factors (Figure), 975 proteins were significantly associated with BMI (p<10 -5 ). There were 713 proteins confirmed in the validation sample (p<0.05/975). Among the confirmed proteins, there were >500 proteins that did not have previously described BMI associations in population studies (including serine protease HTRA1, seizure 6-like protein) as well as proteins with known BMI associations (including leptin, fatty acid binding proteins, insulin-like growth factor-binding proteins). Acute phase response, atherosclerosis signaling, hepatic fibrosis, pancreatic cancer and lipid metabolism were among the top biological pathways overrepresented by the proteins associated with BMI (Figure). The upstream regulators of these proteins included interleukins (IL-17A, IL-13, IL-4), as well as tumor necrosis factor (TNF), which was activated.

Conclusion: We discovered several novel proteins associated with adiposity and confirmed previously identified proteins. Alteration in the plasma proteome related to adiposity is linked to differential regulation of inflammatory and metabolic pathways independent of cardiovascular risk mediators.

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 P323: Three Year Changes in Adipokine Levels and Metabolic Risk Status: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Adipokine levels are strongly linked to diabetes and metabolic syndrome, with higher adiponectin having protective associations and higher leptin having harmful associations. Little is known about how past changes in adipokine levels relate to current metabolic risk.

Methods: Among ARIC Visit 3 (1993-1995) participants, we examined the association of past changes in adiponectin and leptin levels over the 3-year period from ARIC Visit 2 (1990-1992) to Visit 3 with prevalent diabetes and metabolic syndrome at Visit 3. Adipokines were measured using aptamer technology (correlated 0.9x with immunoassay) and analyzed categorically as >50% increase, >50% decrease and <50% change (stable). Multivariable logistic regression was performed to assess associations with stratification by obesity (BMI ≥ 30 kg/m 2 ) status.

Results: Among 9,287 Visit 3 participants, the mean age was 61 years with 56% female and 19% Black adults. Relative to stable levels, a >50% increase in adiponectin over the past 3 years was associated with higher odds of prevalent diabetes (OR 1.62; 95% CI: 1.29-2.03) and metabolic syndrome (OR 1.45; 95% CI: 1.22-1.72). Past increases in leptin were associated with lower odds of diabetes (OR 0.64; 95% CI: 0.53-0.77) and metabolic syndrome (OR 0.70; 95% CI: 0.62-0.77) (Table). Compared to stable levels, >50% decrease in adiponectin over time was associated with lower likelihood of diabetes and metabolic syndrome. Decreasing leptin had nonsignificant associations. Patterns were largely consistent in obesity stratified analyses, with the principal difference being that adiponectin increase was only associated with increased metabolic risk in those without obesity.

Conclusion: Recent changes in adipokine levels are linked to current metabolic status. A past increase in adiponectin has direct associations, while increasing leptin has inverse associations. The underlying mechanisms and implications for metabolic risk in older age should be further studied.

Abstract MP68: Adipokines as Mediators in the Association of Changes in Physical Activity With Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study

Background: Physical activity (PA) patterns over time influence diabetes risk through incompletely understood mechanisms. Adipokines secreted by adipose tissue have myriad endocrine effects and are affected by PA. It is unknown the extent to which adipokines mediate the association between changes in PA and diabetes.

Methods: We conducted a cross-sectional study of 10,908 ARIC participants (mean age 54; 55% female; 21% Black adults) who attended Visits 1 (V1; 1987-1989) and 3 (V3; 1993-1995) of the ARIC Study. We used mediation analyses to determine the extent to which the association of changes in PA from V1 to V3 and diabetes status at V3 was explained by adipokines. Analyses were stratified by obesity status. PA was defined using American Heart Association guidelines as inactive, intermediate, and recommended (150 minutes of moderate-vigorous activity/week); the intermediate group was further divided into low and moderate (below or above the median activity level). Participants were categorized by PA at V1 and V3 - (1) stable low: inactive or low at both visits; (2) increasing: higher category at V3 than V1; (3) decreasing: lower category at V3 than V1; and (4) stable high: moderate or high at both visits.

Results: Increasing PA was associated with higher adiponectin and lower leptin at V3 compared to stable low PA, while decreasing PA was associated with lower adiponectin and higher leptin compared to stable high PA (p<0.01 for all comparisons). Decreasing PA was associated with 28% higher odds of diabetes compared to stable high PA (Table). Conversely, increasing PA was associated with 12% lower odds of diabetes compared to stable low PA. In mediation analyses, adjustment for leptin/adiponectin ratio explained 45% of the effect of increasing PA and 35% of the effect of decreasing PA. The directionality of associations was similar in obesity stratified analyses, but results were not statistically significant.

Conclusions: The associations between changes in PA and diabetes may be mediated in part by adipokines.

Abstract P117: Weight Loss is Associated With Increases in Mitochondrial DNA Copy Number

Background: Mitochondrial DNA copy number (mtDNA-CN) is a surrogate measure of mitochondrial function that is independently associated with increased cardiovascular disease risk. Individuals with obesity and cardiometabolic risk factors have lower mtDNA-CN levels. However, the modifiability of mtDNA-CN following a weight loss intervention has remained largely unexplored.

Hypothesis: Bariatric surgery-induced weight loss is associated with longitudinal increases in circulating mtDNA-CN levels.

Methods: In the BARI-Heart prospective cohort of bariatric surgery patients, we quantified mtDNA-CN from whole blood samples collected at three visits: 3 to 6 months prior to surgery, 2-4 weeks prior to surgery, and 6 months post-surgery. We used linear mixed models with random effects to assess changes in mtDNA-CN after bariatric surgery, with the pre-surgery visits while awaiting bariatric surgery serving as the control period. We used multivariable linear regression to evaluate the dose-response association between weight loss and change in mtDNA-CN.

Results: We included 71 participants (mean age 45 years, 74% female, 88% White). While mtDNA-CN levels did not change significantly during the pre-surgery period (V1 to V2), mtDNA-CN significantly increased after bariatric surgery (V2 to V3) (Figure). In linear mixed models adjusting for age, sex, and smoking, mtDNA-CN was higher after bariatric surgery than immediately prior to bariatric surgery (Table: ß=0.141, p < 0.001). This increase in mtDNA-CN remained significant following further adjustment for changes in cardiometabolic risk factors (ß=0.116, p < 0.01). In linear regression, each 10% greater weight loss was associated with a 1.6% increase in mtDNA-CN.

Conclusions: Weight loss via bariatric surgery is associated with significant increases in mtDNA-CN, independent of cardiometabolic risk factors. Improvements in mitochondrial function may mediate some of the cardiovascular benefits of significant weight loss.

Abstract P591: Prevalence and Prognosis Comparing the New vs. Old ACC/AHA/HFSA HF Stage Classification: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: New guidelines for the management of heart failure (HF) have now incorporated cardiac biomarkers in the definition of those in pre-clinical HF (Stage B). We sought to compare the prevalence and prognosis according to the new vs. old ACC/AHA/HFSA HF Stage classification using data from the ARIC study visit 5 (2011-2013).

Methods: The “old” classification included Stage 0 (no HF risk factors), Stage A (at risk for HF; without structural heart disease or symptoms), Stage B (structural heart disease; without HF signs and symptoms), Stage C1 (current or previous HF symptoms without HF hospitalization); Stage C2 (current or previous HF symptoms with HF hospitalization); Stage D (marked HF symptoms interfering with daily life). The “new” HF Stage classification included elevated NT-proBNP and cardiac troponin as evidence of Stage B. We examined all-cause mortality over five years, using tKaplan Meier method and multivariable Cox models.

Results: Among 5,004 participants (mean age 75.3 (SD 5.1) years, 57% women, 22% Black), 28% had diabetes, 74% had hypertension, and 15% had coronary artery disease. With the new HF Stage classification, the prevalence of Stage 0/A decreased from 58% (n=2,887) to 27% (n=1,334), and Stage B increased from 29% (n=1,468) to 60% (n=3,021). The prevalence of Stage C2 and C1 were 7.3% and 5.7%, respectively, regardless of the new or old classification (no individuals had Stage D), with corresponding 5-year cumulative mortality of 33% and 21%. The new classification using cardiac biomarkers newly identified individuals as Stage B with mortality risk similar to those who were originally in Stage B (5-y cumulative mortality 10% and 12%, respectively). This “reclassification” left individuals with lower mortality risk as Stage 0/A (5-year cumulative mortality 5% vs. 8% in the new vs. old classification). When we adjusted for potential confounders, individuals newly classified as Stage B had an elevated mortality compared to those with Stage 0/A (HR 1.32 [0.98-1.77]) but not as high as those in original Stage B (1.83 [1.36-2.45]).

Conclusions: The new HF classification newly identified a large number of older adults as Stage B, and they indeed had elevated mortality than those who stayed in Stage 0/A. However, after accounting for potential confounders, individuals newly classified as Stage B had slightly lower mortality than those originally in Stage B. Our findings will guide clinicians as to how to interpret new HF classification in terms of prognosis.

Abstract 37: Proteomic Signatures of Obesity-Related Heart Failure in the Atherosclerosis Risk in Communities (ARIC) Study

Background: Obesity is a strong risk factor for cardiovascular disease. The excess heart failure (HF) risk associated with obesity is uniquely unexplained by traditional risk mediators. We sought to identify proteomic signatures that reflect mechanistic pathways associated with obesity-related HF.

Methods: We quantified 4955 plasma proteins in stored plasma samples of ARIC Visit 2 (1990-1992) participants without HF using an aptamer-based platform (SOMAScan v4.0). We used Cox regression to identify the proteins associated with incident HF, stratified by obesity (BMI≥30 kg/m 2 ). We used Bonferroni-corrected p-values to assess statistical significance in 2/3 discovery and 1/3 validation subsets. We assessed the biological pathways overexpressed by these proteins using a canonical pathway analysis.

Results: We included 9940 participants (28% with obesity, mean age 57 years, 55% female, 22% Black adults). Over a median 21-year follow-up, 2,345 HF events (886 in obesity) occurred. In the discovery subset with obesity, we identified 110 proteins associated with incident HF after demographic adjustment, 19 proteins (7 specific to obesity, Figure B) had robust HF associations after additional adjustment for lifestyle and cardiometabolic risk factors (p<10 -5 ) (Figure A). Of 19 proteins, 12 were also linked to prevalent obesity status. Angiopoietin-2 was associated with higher risk of HF and higher odds of obesity. Conversely, ephrin type-A receptor 4 and seizure 6-like protein were linked to lower HF risk and lower odds of obesity. Lipid and bile acid metabolism (inhibited), cytokine signaling and wound healing pathways (activated) were overexpressed by HF-associated proteins in those with obesity.

Conclusion: We identified established and novel proteins associated with HF risk in obesity. Many proteins linked to incident HF in obesity are also strongly associated with prevalent obesity. Formal mediation analysis can help elucidate the potential role of these proteins in the development of obesity-related HF.

Abstract P332: Duration of Diabetes and Risk of Multiple Cardiovascular Disease Outcomes

Introduction: Diabetes is strongly linked to cardiovascular disease (CVD). However, there is scarce data on the extent of the association of diabetes duration with multiple CVD outcomes (coronary heart disease [CHD], heart failure [HF], and stroke), considered individually and in combination.

Hypothesis: A longer duration of diabetes is associated with CVD outcomes or death, independent of age, blood glucose control, and other cardiovascular risk factors.

Methods: We included 9,296 participants (mean age 63 years, 58.2% women, 22% Black adults, 19% with diabetes) at ARIC Visit 4 (1996-1998) without CVD at baseline. We calculated diabetes duration at Visit 4 (baseline), utilizing diabetes status at the first four ARIC visits spaced 3 years apart, and self-reported diagnosis date for those with diabetes diagnosed before Visit 1. We used Cox regression to estimate associations of diabetes duration with incident CHD, HF, stroke, a composite of CVD outcomes, and all-cause mortality, adjusted for risk factors. We performed analyses stratified by age (<65 or ≥65 years), race, sex and glycemic control (HbA 1C consistently <7%, vs. HbA 1C ≥7%), with tests for interaction.

Results: Over a maximum of 24 years of follow-up, there were 3109 CVD events and 4095 deaths. Compared to adults without diabetes, the risk of each CVD outcome or death rose progressively with longer diabetes duration, except for stroke (Figure). Participants with a diabetes duration ≥ 15 years were at highest risk of CHD (HR: 2.65, 95%CI: 2.00, 3.51), HF (HR 2.65, 95% CI: 2.00, 3.51), composite CVD (HR: 2.47, 95% CI 2.00, 3.05), and death (HR: 1.95, 95% CI: 1.60, 2.37). Except for stroke, the link of diabetes duration with CVD outcomes was stronger among those <65 years, with HbA 1C ≥7%, women, and Black adults (all P interactions <0.05).

Conclusions: Longer diabetes duration is associated with multiple CVD outcomes and death. Delaying diabetes onset should be a focus of global CVD prevention, and therapies to improve CVD outcomes might target those with long diabetes duration.

Figure: Associations of diabetes duration with cardiovascular outcomes.

Legend: HRs were adjusted for age, sex, race-center, smoking, alcohol, body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, triglycerides and estimated glomerular filtration rate. Diabetes duration (in years) was modeled as a restricted cubic spline with knots located at 0, 2.6, 7.0, and 19.8 years. Dark shaded area along the curve represents the 95% CI. Bar graph reflects the histogram of distribution. No diabetes served as the reference group. Prediabetes was defined as glycosylated hemoglobin of 5.7% to 6.4%. HF: heart failure, CHD: coronary heart disease, CVD: cardiovascular disease (composite of heart failure, coronary heart disease and stroke)

Abstract P176: The Association of Blood Urea Nitrogen With Incident Heart Failure in the Community: The Atherosclerosis Risk in Communities (ARIC) Study

Background: Blood urea nitrogen (BUN) has been shown as a potent predictor of morbidity and mortality in patients with heart failure (HF). Whether BUN levels are associated with incident HF in the general population is unknown.

Methods: Among 14,263 ARIC participants without a history of HF at baseline (1987-1989) (mean age 54 [SD 5.7] years, Female 54.4%, Black 25.4%), we assessed the association of BUN with incident HF. BUN levels (mg/dL) were divided by quartiles in the primary analysis, and the highest quartile was further divided into tertiles in the secondary analysis (Q1<13, Q2 13-15, Q3 15-17, Q4a 17-19, Q4b 19-21, Q4c >21). We defined HF as hospitalization or death with HF diagnosis and estimated hazard ratios (HRs) using multivariable Cox regression models.

Results: During a median follow-up of 26.2 years, 3,506 participants developed incident HF (incidence rate 10.7 per 1,000 person-year). When we adjusted for demographic variables, using the lowest quartile (Q1) as the reference, the top quartile (Q4) showed an HR of 1.18 (95% CI 1.08, 1.10) (Model 1 in Table ). When we subdivided Q4, Q4c showed the highest HR (1.40 [95% CI 1.21, 1.61]). The association was similar after further adjusting for lifestyle and other clinical factors (Model 2 in Table ). Further adjustment for estimated glomerular filtration rate modestly attenuated the association (Model 3 in Table ), but HRs remained significant for Q4 as a whole (1.11 [1.01, 1.22]) and Q4c (1.27 [1.09, 1.47]). In subgroup analysis, the association was stronger in Black participants than in White participants (p-for-interaction <0.05).

Conclusion: In this community-based cohort, higher BUN levels were significantly associated with incident HF. BUN levels are often measured as part of routine clinical care and thus may inform clinicians to identify individuals at risk of HF, particularly in resource-constrained settings with limited availability of measuring HF-specific markers such as natriuretic peptides.

Abstract P416: Higher Quality Diet is Associated With Lower Serum Levels of NT-proBNP

Introduction: N-terminal pro-brain-type natriuretic peptide (NT-proBNP) is widely used as a diagnostic biomarker for heart failure. Higher diet quality is associated with lower risk of cardiovascular disease. However, the association between diet and subclinical cardiovascular disease, as assessed by biomarker concentrations, is less well-studied.

Hypothesis: We hypothesized that higher diet quality, assessed by the Healthy Eating Index-2015 (HEI-2015), would be associated with lower serum levels of NT-proBNP.

Methods: We included 9,782 adults from the National Health and Nutrition Examination Survey (NHANES), 1999-2004. The HEI-2015 ranges from 0 to 100, with higher scores indicating better diet quality, and was categorized into sex-specific quintiles. Weighted multivariable linear regression models were used to estimate associations between the overall HEI-2015 score as well as its 13 components and log-transformed NT-proBNP.

Results: Among 9,782 participants, mean age was 45 years, 48% were men, and 72% were non-Hispanic White adults. After adjusting for sociodemographic characteristics, lifestyle factors, and medical history, persons in the highest HEI-2015 quintile had a 10.0% lower NT-proBNP level compared to those in the lowest HEI-2015 quintile (95% CI: -17.7% to -2.6%). There was a dose-response relationship between HEI-2015 and NT-proBNP ( Figure ). For each 1-unit higher sodium and added sugars score, NT-proBNP was lower by 7.7% and 6.8% respectively (95% CI: -13.8 % to -2.2%, and 95% CI: -13.1% to -0.9% respectively).

Conclusion: Higher diet quality, especially lower intakes of sodium and added sugars, was associated with lower serum levels of NT-proBNP.

Abstract P260: The Association of Changes in Area Deprivation Index With Cardiometabolic Risk Factors: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Higher Area Deprivation Index (ADI) is associated with greater cardiometabolic risk. The impact of changes in ADI on the likelihood of cardiometabolic risk factors is currently unknown.

Methods: Among 12,044 White and Black participants at ARIC Visit 1 (1987-89), we examined the association of cross-categories of ADI quartiles at Visit 1 and at the last visit attended up to Visit 4 (1996-98) with cardiometabolic risk factors at the time of the second ADI measurement. Cross-categories were grouped as stable low ADI (remaining in ADI quartile 1 or 2), increasing ADI (moving from ADI quartile 1 or 2 at Visit 1 to quartile 3 or 4 at follow-up), decreasing ADI (moving from ADI quartile 3 or 4 at Visit 1 to quartile 1 or 2 at follow-up) or stable high ADI (remaining in ADI quartile 3 or 4).We assessed the prevalence of hypertension, diabetes, and obesity in each group at the follow-up time point and used logistic regression to evaluate associations of changes in ADI over the 9-year period with the odds of cardiometabolic risk factors.

Results: The study population had a mean age of 63 years, with 55% female and 22% Black adults. Persons with decreasing ADI had a lower prevalence of hypertension, diabetes and obesity at follow-up than those with stable high ADI, while those with increasing ADI had a higher prevalence of hypertension and obesity at follow-up than those with stable low ADI (Figure). In regression models adjusted for age and sex, decreasing ADI was linked to lower odds of hypertension, diabetes and obesity compared to stable high ADI (Table), with stronger associations for hypertension among Black adults (p interaction = 0.03). Increasing ADI was linked to modestly increased odds of obesity compared to stable low ADI. Associations were attenuated after adjustment for lifestyle measures, comorbidities and other social determinants.

Conclusion: ADI changes are associated with the prevalence of cardiometabolic risk factors. Interventional studies should assess the cardiometabolic impact of targeting the built environment.

Abstract P202: Proteomic Markers Associated With the Risk of Incident Hypertension in the Community: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Proteins are involved in the pathophysiology of hypertension (HTN), but there are no large scale prospective proteomic analyses of incident HTN.

Hypothesis: To identify and validate plasma proteins associated with incident HTN among a bi-racial cohort in the US.

Methods: We quantified the associations of 4,955 plasma proteins (measured by SomaScan version 4 assay) with incident HTN over median follow-up of 11 years among 5,080 participants without baseline hypertension at ARIC visit 3 (1993-95). We then validated significant proteins from the primary analysis with incident HTN between visit 2 (n=6,810 during 1990-92) and visit 3 (median follow-up of 3.1y), to avoid including the same incident HTN cases in both analyses. Incident HTN was defined as systolic blood pressure (BP) ≥140, diastolic BP ≥90 mmHg, or HTN medication use. We ran multivariable Cox models and applied Benjamin-Hochberg procedure, with false discovery rate of 0.05, to account for multiple comparisons.

Results: In the primary analysis with visit 3 as baseline (mean age 59y, 54% women, 13% Black), 3,828 participants (75%) developed HTN, and we found 55 proteins significantly associated with incident HTN. Among them, 14 proteins were validated using visit 2 data (Figure). Of those, 11 showed positive associations with HTN, and they are involved in glycoprotein degradation (e.g., MMP7, HTRA1, ASGR1, GUSB, CPM), cell adhesion (e.g., LGALS3BP and RET), and inflammation (e.g., CRP). In contrast, 3 proteins, renin ([REN]), netrin receptor ([UNC5D] apoptosis) and secretogranin-3([SCG3] endothelial cell growth), had inverse relationships with incident HTN. Further exploration showed a U-shaped association between renin and incident HTN.

Conclusion: We identified several proteins associated with incident HTN, with plausible functions contributing to the development of HTN. These findings have implications on understanding mechanisms of HTN and potential targets for prevention and treatment.

Abstract P517: Ideal Cardiovascular Health and Adipokine Levels: The Multi-Ethnic Study of Atherosclerosis (MESA)

Introduction: Adipokines are hormones implicated in obesity and its cardiometabolic consequences. The concept of ideal cardiovascular health (CVH) was introduced to monitor and promote 7 (now 8) key health factors and behaviors in the general population. Although prior studies have found strong associations between obesity and ideal CVH, the link between CVH and adipokines has not been elucidated. We examined the associations between CVH and adipokine levels in MESA.

Methods: We studied 1,842 MESA participants who were free of cardiovascular disease at baseline, had 7 CVH metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood pressure and fasting blood glucose) measured at exam 1 (2000-2002) and adipokine levels measured at either exam 2 or 3 (2002-2004 or 2004-2005). Each metric was assigned a score of 0(poor), 1(intermediate) and 2(ideal), and summed to obtain a total CVH score (0 -14). We used multivariable linear regression models to assess the non-concurrent cross-sectional associations between CVH score and log-transformed serum adipokine levels, adjusting for sociodemographic factors.

Results: The mean ± SD age was 62.1 ± 9.8 years and 50.2% of participants were men. Median (IQR) adiponectin, leptin and resistin levels were 17.4 (11.8 - 26.3) mcg/mL,13.3 (5.6 - 28.2) ng/mL and 15.0 (11.9 - 19.0) ng/mL, respectively. A 1 unit higher CVH score was significantly associated with 4% higher adiponectin, 15% and 1% lower leptin and resistin levels respectively, after adjusting for sociodemographic factors. Individuals with optimal CVH scores had 27% higher adiponectin and 56% lower leptin levels compared to those with inadequate CVH scores. Similar results were obtained for those with average scores (Table).

Conclusion: In a multi-ethnic cohort free of cardiovascular disease at baseline, individuals with average and optimal CVH scores had higher adiponectin and lower leptin and resistin levels compared to those with inadequate CVH scores.

Abstract P618: Visceral and Subcutaneous Adipokine Expression and Serum Adipokine Levels Are Differentially Associated With Metabolic Risk

Background: Adipokines mediate many metabolic effects of adipose tissue. While regional body composition is associated with metabolic risk, it is unclear if metabolic risk associations differ for adipokine expression in visceral and subcutaneous tissue and adipokine concentrations in the circulation.

Methods: We obtained visceral and subcutaneous fat samples, and pre-surgical serum samples from Geisinger Obesity Registry patients undergoing bariatric surgery. We used real-time PCR to quantify mRNA expression of adipokines (adiponectin, leptin, leptin/adiponectin ratio) in fat samples, and targeted assays (ELISA) to measure serum adipokines. Using multivariable linear regression, we evaluated the individual and combined associations of visceral, subcutaneous and serum adipokines (per-1-SD and tertiles) with a metabolic syndrome (MetS) severity Z-score.

Results: 181 participants (mean age 45 years, mean BMI 47 kg/m 2 , 85% female) with available fat and serum samples were included. Visceral, subcutaneous and serum adipokines were all weakly correlated (all ρ<0.15). Each 1-SD higher visceral adipokine expression and serum adipokine concentrations were significantly associated with MetS z-score, whereas no associations with MetS z-score were seen for subcutaneous adipokine expression (Table). Individuals in the top tertile of leptin/adiponectin ratio in serum only (ß=0.29, 95%CI: 0.01, 0.57) or in visceral fat only (ß=0.37, 95%CI: 0.08, 0.66) had higher metabolic risk than those in the top tertile in neither visceral fat nor serum (Figure). However, those in the top leptin/adiponectin tertile in both in visceral fat and serum had the greatest metabolic risk (ß=0.78, 95%CI: 0.46, 1.11).

Conclusion: Visceral, but not subcutaneous, adipokine expression provides complementary information to serum adipokines on metabolic risk. This indicates significant differences in the physiologic impact of regional adipose tissue and highlights adipokines as a potential target for modifying cardiometabolic risk.

Oxidative Stress and Cardiovascular Risk Factors: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Introduction—Oxidative stress is linked to cardiovascular diseases (CVD) and is suggested to vary by sex. However, few population-level studies have explored these associations and the majority comprise populations with advanced CVD. We assessed urinary isoprostane concentrations, a standard measure of oxidative stress, in a relatively young and healthy cohort, hypothesizing that higher oxidative stress is associated with an adverse cardiometabolic profile and female sex. Methods—Oxidative stress was measured in 475 women and 266 men, aged 48–55 years, from the Coronary Artery Risk Development in Young Adults (CARDIA) study using urinary 8-isoprostane (IsoP) and 2,3-dinor-8-isoprostane (IsoP-M). Multivariable-adjusted regression was used to evaluate cross-sectional associations. As secondary analysis, previously measured plasma F2-isoprostanes (plasma IsoP) from another CARDIA subset was similarly analyzed. Results—Mean (SD) ages for men and women were 52.1(2.3) and 52.2(2.2) years, respectively (p = 0.46), and 39% of the participants self-identified as Black (vs. White). Before adjustments, female sex was associated with higher median urinary IsoP (880 vs. 704 ng/g creatinine in men; p < 0.01) and IsoP m (1675 vs. 1284 ng/g creatinine in men; p < 0.01). Higher body mass index (BMI), high-density cholesterol (HDL-C), and triglycerides, current smoking, and less physical activity were associated with higher oxidative stress. Diabetes was not associated with urinary IsoP but was associated with lower IsoP m and plasma IsoP. Higher serum creatinine showed diverging associations with higher plasma and lower urinary isoprostane concentrations. Conclusions—Different isoprostane entities exhibit varying association patterns with CVD risk factors, and therefore are complementary, rather than interchangeable, in assessment of oxidative stress. Still, consistently higher isoprostanes among women, smokers, less active persons, and those with higher BMI and plasma triglycerides could reflect higher oxidative stress among these groups. While urinary isoprostanes are indexed to urinary creatinine due to variations in concentration, caution should be exercised when comparing groups with differing serum creatinine.

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.

Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study

BACKGROUND

Racial disparities in guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) have not been fully documented in a community setting.

METHODS

In the ARIC Surveillance Study (2005-2014), we examined racial differences in GDMT at discharge, its temporal trends, and the prognostic impact among individuals with hospitalized HFrEF, using weighted regression models to account for sampling design. Optimal GDMT was defined as beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Acceptable GDMT included either one of BB, MRA, ACEI/ARB or hydralazine plus nitrates (H-N).

RESULTS

Of 16,455 (unweighted n = 3,669) HFrEF cases, 47% were Black. Only ~ 10% were discharged with optimal GDMT with higher proportion in Black than White individuals (11.1% vs. 8.6%, p < 0.001). BB use was > 80% in both racial groups while Black individuals were more likely to receive ACEI/ARB (62.0% vs. 54.6%) and MRA (18.0% vs. 13.8%) than Whites, with a similar pattern for H-N (21.8% vs. 10.1%). There was a trend of decreasing use of optimal GDMT in both groups, with significant decline of ACEI/ARB use in Whites (- 2.8% p < 0.01) but increasing H-N use in both groups (+ 6.5% and + 9.2%, p < 0.01). Only ACEI/ARB and BB were associated with lower 1-year mortality.

CONCLUSIONS

Optimal GDMT was prescribed in only ~ 10% of HFrEF patients at discharge but was more so in Black than White individuals. ACEI/ARB use declined in Whites while H-N use increased in both races. GDMT utilization, particularly ACEI/ARB, should be improved in Black and Whites individuals with HFrEF.