Background N-terminal-pro–B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (TnT) predict cardiovascular disease (CVD) risk in a variety of populations. Whether their predictive value ...varies by ethnicity is unknown. We sought to determine whether NT-proBNP and TnT improve prediction of incident coronary heart disease (CHD) and CVD, independent of CVD risk factors, in a multiethnic population; whether NT-proBNP improves prediction compared with the Framingham Risk Score or the Pooled Cohort Risk Equation; and whether a second NT-proBNP further improves prediction. Methods Both NT-proBNP and TnT were measured in 5,592 MESA white, black, Hispanic, and Chinese participants (60% nonwhite; mean age 62.3 ± 10.3 years) in 2000 to 2002 and 2004 to 2005. We evaluated adjusted risk of incident CHD and CVD based on baseline and change in biomarker concentration. Results Participants were followed up through 2011 and incurred 370 CVD events (232 CHD). Concentrations of NT-proBNP and TnT varied by ethnicity. Both NT-proBNP and TnT were associated with an increased risk of events (adjusted hazard ratio HR for CHD 95% CI for fifth quintile vs other 4 quintiles of NT-proBNP, 2.03 1.50-2.76; HR for CHD for detectable vs undetectable TnT, 3.95 2.29-6.81). N-terminal-pro–B-type natriuretic peptide improved risk prediction and classification compared with the Framingham Risk Score and the Pooled Cohort Risk Equation. Change in NT-proBNP was independently associated with events (HR for CHD per unit increase in ΔlogNT-proBNP, 1.95 1.16-3.26). None of the observed associations varied by ethnicity. Conclusions Both NT-proBNP and TnT are predictors of incident CHD, independent of established risk factors and ethnicity, in a multiethnic population without known CVD. Change in NT-proBNP may add additional prognostic information.
Most population-based estimates of incident hospitalized heart failure (HF) have not differentiated acute decompensated heart failure (ADHF) from chronic stable HF nor included racially diverse ...populations. The Atherosclerosis Risk in Communities Study conducted surveillance of hospitalized HF events (age ≥55 years) in 4 US communities. We estimated hospitalized ADHF incidence and survival by race and gender. Potential 2005 to 2009 HF hospitalizations were identified by International Classification of Diseases, Ninth Revision, Clinical Modification , codes; 6,168 records were reviewed to validate ADHF cases. Population estimates were derived from US Census data; 50% of eligible hospitalizations were classified as ADHF, of which 63.6% were incident ADHF and 36.4% were recurrent ADHF. The average incidence of hospitalized ADHF was 11.6 per 1,000 persons, aged ≥55 years, per year, and recurrent hospitalized ADHF was 6.6 per 1,000 persons/yr. Age-adjusted annual ADHF incidence was highest for black men (15.7 per 1,000), followed by black women (13.3 per 1,000), white men (12.3 per 1,000), and white women (9.9 per 1,000). Of incident ADHF events with heart function assessment (89%), 53% had reduced the ejection fraction (heart failure with reduced ejection fraction HFrEF) and 47% had preserved ejection fraction (heart failure with preserved ejection fraction HFpEF). Black men had the highest proportion of acute HFrEF events (70%); white women had the highest proportion of acute HFpEF (59%). Age-adjusted 28-day and 1-year case fatality after an incident ADHF was 10.4% and 29.5%, respectively. Survival did not differ by race or gender. In conclusion, ADHF hospitalization and HF type varied by both race and gender, but case fatality rates did not. Further studies are needed to explain why black men are at higher risk of hospitalized ADHF and HFrEF.
Background Albuminuria has been associated with cardiovascular risk, but the relationship of high-normal albuminuria to subsequent heart failure has not been well established. Study Design ...Prospective observational study, the Atherosclerosis Risk in Communities (ARIC) Study. Setting & Participants 10,975 individuals free from heart failure were followed up from the fourth ARIC Study visit (1996-1998) through January 2006. Predictor Urinary albumin-creatinine ratio (UACR), analyzed continuously and categorically as optimal (<5 mg/g), intermediate-normal (5-9 mg/g), high-normal (10-29 mg/g), microalbuminuria (30-299 mg/g), and macroalbuminuria (≥300 mg/g). Outcomes & Measurements Incident heart failure was defined as a heart failure–related hospitalization or death. Cox proportional hazard models were used to calculate the HR of heart failure after adjustment for age, race, sex, estimated glomerular filtration rate (eGFR), and other cardiovascular risk factors. Results Individuals were followed up for a median of 8.3 years and experienced 344 heart failure events. Compared with normal UACR, albuminuria was associated with a progressively increased risk of heart failure from intermediate-normal (adjusted HR, 1.54; 95% CI, 1.12-2.11) and high-normal UACR (adjusted HR, 1.91; 95% CI, 1.38-2.66) to microalbuminuria (adjusted HR, 2.49; 95% CI, 1.77-3.50) and macroalbuminuria (adjusted HR, 3.47; 95% CI, 2.10-5.72). Results were similar in secondary analyses of participants censored at the time of coronary heart disease event and along a range of eGFRs. Limitations UACR was measured as a single random sample. Conclusions Albuminuria is associated with subsequent heart failure, even in individuals with few cardiovascular risk factors and UACR within the normal range. Our results suggest that the association between albuminuria and heart failure may not be mediated fully by ischemic heart disease or kidney disease, measured using eGFR.
Novel Metabolic Risk Factors for Incident Heart Failure and Their Relationship With Obesity: The MESA (Multi-Ethnic Study of Atherosclerosis) Trial Hossein Bahrami, David A. Bluemke, Richard Kronmal, ...Alain G. Bertoni, Donald M. Lloyd-Jones, Eyal Shahar, Moyses Szklo, João A. C. Lima The objectives of this study were to determine the associations of the metabolic syndrome, inflammatory markers, and insulin resistance with incident congestive heart failure (CHF), beyond established risk factors, and to examine whether these risk factors may provide the link between obesity and CHF. The study population was 6,814 participants of the MESA (Multi-Ethnic Study of Atherosclerosis) study. Serum interleukin-6 or C-reactive protein and macroalbuminuria were predictors of CHF, independent of obesity and the other established risk factors. Although obesity was significantly associated with incident CHF, this association was no longer significant after adding inflammatory markers to the model.
Background Left ventricular (LV) hypertrophy (LVH) is associated with chronic kidney disease, but the association of LVH with a mild decrease in kidney function is not known. We hypothesized that ...mild and moderate decreases in kidney function, reflected in greater serum cystatin C concentrations, would be linearly associated with a greater prevalence of LVH. Study Design Cross-sectional observational study. Settings & Participants Participants in baseline examinations in the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based study with several sites in the United States. Predictors Cystatin C–based estimated glomerular filtration rate (eGFRcysC ) and creatinine-based eGFR. Outcomes LVH and LV mass index. Measurements Serum cystatin C and creatinine, LV mass obtained by using magnetic resonance imaging. LVH cutoff values for men and women were defined by the upper 95th percentile of LV mass index of all MESA participants without hypertension. Results Of the 4,971 participants analyzed, mean creatinine-based eGFR was 81 ± 17 (SD) mL/min/1.73 m2 and mean eGFRcysC was 94 ± 32 mL/min/1.73 m2 . LVH was distinctly more prevalent (>12%) in only the lowest 2 deciles of eGFRcysC (<75 mL/min/1.73 m2 ). When 435 participants (9%) with stage 3 or higher chronic kidney disease (creatinine-based eGFR < 60 mL/min/1.73 m2 ) were excluded, the odds for LVH increased for each lower category of eGFRcysC less than 75 mL/min/1.73 m2 : odds ratio 1.6 for LVH with eGFRcysC of 60 to 75 mL/min/1.73 m2 (95% confidence interval, 1.20 to 2.07; P = 0.001), and odds ratio 2.0 for eGFRcysC less than 60 mL/min/1.73 m2 (95% confidence interval, 1.03 to 3.75; P = 0.04) after adjustment for demographic factors, study site, diabetes, and smoking. The association of lower eGFRcysC with LVH was attenuated after further adjustment for hypertension. Limitations Cross-sectional rather than longitudinal design, lack of participants with more advanced kidney disease, lack of a direct measurement of glomerular filtration rate. Conclusions In participants without chronic kidney disease, eGFRcysC of 75 mL/min/1.73 m2 or less was associated with a greater odds of LVH.
Background COPD is associated with reduced physical capacity. However, it is unclear whether pulmonary emphysema, which can occur without COPD, is associated with reduced physical activity in daily ...life, particularly among people without COPD and never smokers. We hypothesized that greater percentage of emphysema-like lung on CT scan is associated with reduced physical activity assessed by actigraphy and self-report. Methods The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants free of clinical cardiovascular disease from the general population. Percent emphysema was defined as percentage of voxels < −950 Hounsfield units on full-lung CT scans. Physical activity was measured by wrist actigraphy over 7 days and a questionnaire. Multivariable linear regression was used to adjust for age, sex, race/ethnicity, height, weight, education, smoking, pack-years, and lung function. Results Among 1,435 participants with actigraphy and lung measures, 47% had never smoked, and 8% had COPD. Percent emphysema was associated with lower activity levels on actigraphy ( P = .001), corresponding to 1.5 hour less per week of moderately paced walking for the average participant in quintile 2 vs 4 of percent emphysema. This association was significant among participants without COPD ( P = .004) and among ever ( P = .01) and never smokers ( P = .03). It was also independent of coronary artery calcium and left ventricular ejection fraction. There was no evidence that percent emphysema was associated with self-reported activity levels. Conclusions Percent emphysema was associated with decreased physical activity in daily life objectively assessed by actigraphy in the general population, among participants without COPD, and nonsmokers.
To determine the relation between aortic wall thickness (WT) and aortic distensibility (AD) with traditional cardiovascular risk factors in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort, ...1,053 participants in MESA who underwent cardiac magnetic resonance imaging were consecutively selected for the measurement of aortic WT and AD. Double inversion-recovery fast spin-echo images of the thoracic aorta were obtained to measure average and maximum WT. AD was measured at the same level using a gradient-echo cine sequence. Average and maximum WT were positively correlated with increasing age, and AD was inversely related to age (p <0.01). Compared with normotensive participants, those with hypertension had significantly greater mean average WT (2.45 vs 2.23 mm, p <0.01) and maximum WT (3.61 vs 3.41 mm, p <0.01) and lower AD (0.15 vs 0.2 mm Hg−1 , p <0.01). In multiple regression analysis, older age and hypertension were significantly associated with higher mean average WT, while older age, male gender, and higher blood pressure were associated with higher mean maximum WT. AD was inversely related to older age, hypertension, current smoking, African American ethnicity, and lower high-density lipoprotein cholesterol level. In conclusion, in the MESA cohort, older age and higher blood pressure were associated with higher aortic WT and lower AD. Decreased AD was further associated with current smoking, African American ethnicity, and higher high-density lipoprotein cholesterol level.
Previous studies have raised the question of whether an association exists between physical activity and atrial fibrillation (AF). We used the Multi-Ethnic Study of Atherosclerosis (MESA) database to ...examine the association between physical activity and AF in a diverse population without clinically recognized cardiovascular disease (CVD). MESA participants (n = 5,793) with complete baseline physical activity and covariate data were included. Cox proportional hazards models were used to calculate hazard ratios (HRs) for incident AF by levels of total intentional exercise and vigorous physical activity, independently and in combination. Multivariate models were adjusted for demographics and CVD risk factors. During a mean follow-up of 7.7 ± 1.9 years, 199 AF cases occurred. In the overall MESA population, neither vigorous physical activity nor total intentional exercise was independently associated with incident AF after adjusting for covariates. However, within the group that reported any vigorous physical activity, there was a statistically significant inverse association between total intentional exercise (modeled as a continuous variable) and incident AF. In those who reported any vigorous physical activity, the top tertile of total intentional exercise was associated with a significantly lower risk of incident AF compared with the group with no total intentional exercise in the fully adjusted model (HR 0.46, 95% confidence interval 0.22 to 0.98). In conclusion, neither total intentional exercise nor vigorous physical activity alone was associated with incident AF, but greater total intentional exercise was associated with a lower risk of incident AF in those who participated in any vigorous physical activity. As importantly, no subgroup of participants demonstrated an increased risk of incident AF with greater physical activity. The results re-emphasize the beneficial role of physical activity for cardiovascular health.
Background With one-quarter of initial myocardial infarctions (MI) being unrecognized MI (UMI), recognition is critical to minimize further cardiovascular risk. Diabetes mellitus is an established ...risk factor for UMI. If impaired fasting glucose (IFG) also increased the risk for UMI, it would represent a significant public health challenge due to the rapid worldwide increase in IFG prevalence. We compared participants with IFG to those with normal fasting glucose (NFG) to determine if IFG was associated with UMIs. Methods We performed cross-sectional analyses from the MESA, a population-based cohort study. There were 6,814 participants recruited during July 2000 to September 2002 from the general community at 6 field sites. After excluding those with diabetes mellitus or missing variables, 5,885 participants were included. At baseline, there were 4,955 participants with NFG and 930 participants with IFG. The main outcome was an UMI defined by the presence of pathological Q waves or minor Q waves with ST-T abnormalities on initial 12-lead electrocardiogram. Logistic regression was used to generate crude ORs and adjust for covariates. Results There was a higher prevalence of UMI in those with IFG compared with those with NFG 3.5% (n = 72) vs 1.4% (n = 30). After adjustment for multiple risk factors, there was a higher odds of an UMI among those with IFG compared with those with NFG OR: 1.60 (95% CI: 1.0-2.5); P = .048. Conclusions Impaired fasting glucose is associated with unrecognized myocardial infarctions in a multi-ethnic population free of baseline cardiovascular disease.
Objectives This study sought to examine and compare the incidence and progression of coronary artery calcium (CAC) among persons with metabolic syndrome (MetS) and diabetes mellitus (DM) versus those ...with neither condition. Background MetS and DM are associated with subclinical atherosclerosis as evidenced by CAC. Methods The MESA (Multiethnic Study of Atherosclerosis) included 6,814 African American, Asian, Caucasian, and Hispanic adults 45 to 84 years of age, who were free of cardiovascular disease at baseline. Of these, 5,662 subjects (51% women, mean age 61.0 ± 10.3 years) received baseline and follow-up (mean 2.4 years) cardiac computed tomography scans. We compared the incidence of CAC in 2,927 subjects without CAC at baseline and progression of CAC in 2,735 subjects with CAC at baseline in those with MetS without DM (25.2%), DM without MetS (3.5%), or both DM and MetS (9.0%) to incidence and progression in subjects with neither MetS nor DM (58%). Progression of CAC was also examined in relation to coronary heart disease events over an additional 4.9 years. Results Relative to those with neither MetS nor DM, adjusted relative risks (95% confidence intervals CI) for incident CAC were 1.7 (95% CI: 1.4 to 2.0), 1.9 (95% CI: 1.4 to 2.4), and 1.8 (95% CI: 1.4 to 2.2) (all p < 0.01), and absolute differences in mean progression (volume score) were 7.8 (95% CI: 4.0 to 11.6; p < 0.01), 11.6 (95% CI: 2.7 to 20.5; p < 0.05), and 22.6 (95% CI: 17.2 to 27.9; p < 0.01) for those with MetS without DM, DM without MetS, and both DM and MetS, respectively. Similar findings were seen in analysis using Agatston calcium score. In addition, progression predicted coronary heart disease events in those with MetS without DM (adjusted hazard ratio: 4.1, 95% CI: 2.0 to 8.5, p < 0.01) and DM (adjusted hazard ratio: 4.9 95% CI: 1.3 to 18.4, p < 0.05) among those in the highest tertile of CAC increase versus no increase. Conclusions Individuals with MetS and DM have a greater incidence and absolute progression of CAC compared with individuals without these conditions, with progression also predicting coronary heart disease events in those with MetS and DM.
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