TY - JOUR T1 - Lipoprotein-associated phospholipase A(2) and risk of coronary disease, stroke, and mortality: collaborative analysis of 32 prospective studies. JF - Lancet Y1 - 2010 A1 - Thompson, Alexander A1 - Gao, Pei A1 - Orfei, Lia A1 - Watson, Sarah A1 - Di Angelantonio, Emanuele A1 - Kaptoge, Stephen A1 - Ballantyne, Christie A1 - Cannon, Christopher P A1 - Criqui, Michael A1 - Cushman, Mary A1 - Hofman, Albert A1 - Packard, Chris A1 - Thompson, Simon G A1 - Collins, Rory A1 - Danesh, John KW - 1-Alkyl-2-acetylglycerophosphocholine Esterase KW - Blood Pressure KW - Coronary Disease KW - Female KW - Humans KW - Linear Models KW - Lipids KW - Male KW - Middle Aged KW - Prospective Studies KW - Risk Assessment KW - Risk Factors KW - Stroke KW - Systole AB -

BACKGROUND: Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), an inflammatory enzyme expressed in atherosclerotic plaques, is a therapeutic target being assessed in trials of vascular disease prevention. We investigated associations of circulating Lp-PLA(2) mass and activity with risk of coronary heart disease, stroke, and mortality under different circumstances.

METHODS: With use of individual records from 79 036 participants in 32 prospective studies (yielding 17 722 incident fatal or non-fatal outcomes during 474 976 person-years at risk), we did a meta-analysis of within-study regressions to calculate risk ratios (RRs) per 1 SD higher value of Lp-PLA(2) or other risk factor. The primary outcome was coronary heart disease.

FINDINGS: Lp-PLA(2) activity and mass were associated with each other (r=0.51, 95% CI 0.47-0.56) and proatherogenic lipids. We noted roughly log-linear associations of Lp-PLA(2) activity and mass with risk of coronary heart disease and vascular death. RRs, adjusted for conventional risk factors, were: 1.10 (95% CI 1.05-1.16) with Lp-PLA(2) activity and 1.11 (1.07-1.16) with Lp-PLA(2) mass for coronary heart disease; 1.08 (0.97-1.20) and 1.14 (1.02-1.27) for ischaemic stroke; 1.16 (1.09-1.24) and 1.13 (1.05-1.22) for vascular mortality; and 1.10 (1.04-1.17) and 1.10 (1.03-1.18) for non-vascular mortality, respectively. RRs with Lp-PLA(2) did not differ significantly in people with and without initial stable vascular disease, apart from for vascular death with Lp-PLA(2) mass. Adjusted RRs for coronary heart disease were 1.10 (1.02-1.18) with non-HDL cholesterol and 1.10 (1.00-1.21) with systolic blood pressure.

INTERPRETATION: Lp-PLA(2) activity and mass each show continuous associations with risk of coronary heart disease, similar in magnitude to that with non-HDL cholesterol or systolic blood pressure in this population. Associations of Lp-PLA(2) mass and activity are not exclusive to vascular outcomes, and the vascular associations depend at least partly on lipids.

FUNDING: UK Medical Research Council, GlaxoSmithKline, and British Heart Foundation.

VL - 375 IS - 9725 U1 - https://www.ncbi.nlm.nih.gov/pubmed/20435228?dopt=Abstract ER - TY - JOUR T1 - Diabetes mellitus, fasting glucose, and risk of cause-specific death. JF - N Engl J Med Y1 - 2011 A1 - Rao Kondapally Seshasai, Sreenivasa A1 - Kaptoge, Stephen A1 - Thompson, Alexander A1 - Di Angelantonio, Emanuele A1 - Gao, Pei A1 - Sarwar, Nadeem A1 - Whincup, Peter H A1 - Mukamal, Kenneth J A1 - Gillum, Richard F A1 - Holme, Ingar A1 - Njølstad, Inger A1 - Fletcher, Astrid A1 - Nilsson, Peter A1 - Lewington, Sarah A1 - Collins, Rory A1 - Gudnason, Vilmundur A1 - Thompson, Simon G A1 - Sattar, Naveed A1 - Selvin, Elizabeth A1 - Hu, Frank B A1 - Danesh, John KW - Blood Glucose KW - Cause of Death KW - Diabetes Mellitus KW - Female KW - Humans KW - Hyperglycemia KW - Life Expectancy KW - Male KW - Middle Aged KW - Risk KW - Survival Analysis AB -

BACKGROUND: The extent to which diabetes mellitus or hyperglycemia is related to risk of death from cancer or other nonvascular conditions is uncertain.

METHODS: We calculated hazard ratios for cause-specific death, according to baseline diabetes status or fasting glucose level, from individual-participant data on 123,205 deaths among 820,900 people in 97 prospective studies.

RESULTS: After adjustment for age, sex, smoking status, and body-mass index, hazard ratios among persons with diabetes as compared with persons without diabetes were as follows: 1.80 (95% confidence interval [CI], 1.71 to 1.90) for death from any cause, 1.25 (95% CI, 1.19 to 1.31) for death from cancer, 2.32 (95% CI, 2.11 to 2.56) for death from vascular causes, and 1.73 (95% CI, 1.62 to 1.85) for death from other causes. Diabetes (vs. no diabetes) was moderately associated with death from cancers of the liver, pancreas, ovary, colorectum, lung, bladder, and breast. Aside from cancer and vascular disease, diabetes (vs. no diabetes) was also associated with death from renal disease, liver disease, pneumonia and other infectious diseases, mental disorders, nonhepatic digestive diseases, external causes, intentional self-harm, nervous-system disorders, and chronic obstructive pulmonary disease. Hazard ratios were appreciably reduced after further adjustment for glycemia measures, but not after adjustment for systolic blood pressure, lipid levels, inflammation or renal markers. Fasting glucose levels exceeding 100 mg per deciliter (5.6 mmol per liter), but not levels of 70 to 100 mg per deciliter (3.9 to 5.6 mmol per liter), were associated with death. A 50-year-old with diabetes died, on average, 6 years earlier than a counterpart without diabetes, with about 40% of the difference in survival attributable to excess nonvascular deaths.

CONCLUSIONS: In addition to vascular disease, diabetes is associated with substantial premature death from several cancers, infectious diseases, external causes, intentional self-harm, and degenerative disorders, independent of several major risk factors. (Funded by the British Heart Foundation and others.).

VL - 364 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21366474?dopt=Abstract ER - TY - JOUR T1 - Lipid-related markers and cardiovascular disease prediction. JF - JAMA Y1 - 2012 A1 - Di Angelantonio, Emanuele A1 - Gao, Pei A1 - Pennells, Lisa A1 - Kaptoge, Stephen A1 - Caslake, Muriel A1 - Thompson, Alexander A1 - Butterworth, Adam S A1 - Sarwar, Nadeem A1 - Wormser, David A1 - Saleheen, Danish A1 - Ballantyne, Christie M A1 - Psaty, Bruce M A1 - Sundström, Johan A1 - Ridker, Paul M A1 - Nagel, Dorothea A1 - Gillum, Richard F A1 - Ford, Ian A1 - Ducimetiere, Pierre A1 - Kiechl, Stefan A1 - Koenig, Wolfgang A1 - Dullaart, Robin P F A1 - Assmann, Gerd A1 - D'Agostino, Ralph B A1 - Dagenais, Gilles R A1 - Cooper, Jackie A A1 - Kromhout, Daan A1 - Onat, Altan A1 - Tipping, Robert W A1 - Gómez-de-la-Cámara, Agustín A1 - Rosengren, Annika A1 - Sutherland, Susan E A1 - Gallacher, John A1 - Fowkes, F Gerry R A1 - Casiglia, Edoardo A1 - Hofman, Albert A1 - Salomaa, Veikko A1 - Barrett-Connor, Elizabeth A1 - Clarke, Robert A1 - Brunner, Eric A1 - Jukema, J Wouter A1 - Simons, Leon A A1 - Sandhu, Manjinder A1 - Wareham, Nicholas J A1 - Khaw, Kay-Tee A1 - Kauhanen, Jussi A1 - Salonen, Jukka T A1 - Howard, William J A1 - Nordestgaard, Børge G A1 - Wood, Angela M A1 - Thompson, Simon G A1 - Boekholdt, S Matthijs A1 - Sattar, Naveed A1 - Packard, Chris A1 - Gudnason, Vilmundur A1 - Danesh, John KW - Aged KW - Biomarkers KW - Cardiovascular Diseases KW - Cholesterol, HDL KW - Cohort Studies KW - Female KW - Humans KW - Lipoproteins KW - Male KW - Middle Aged KW - Risk Assessment AB -

CONTEXT: The value of assessing various emerging lipid-related markers for prediction of first cardiovascular events is debated.

OBJECTIVE: To determine whether adding information on apolipoprotein B and apolipoprotein A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 to total cholesterol and high-density lipoprotein cholesterol (HDL-C) improves cardiovascular disease (CVD) risk prediction.

DESIGN, SETTING, AND PARTICIPANTS: Individual records were available for 165,544 participants without baseline CVD in 37 prospective cohorts (calendar years of recruitment: 1968-2007) with up to 15,126 incident fatal or nonfatal CVD outcomes (10,132 CHD and 4994 stroke outcomes) during a median follow-up of 10.4 years (interquartile range, 7.6-14 years).

MAIN OUTCOME MEASURES: Discrimination of CVD outcomes and reclassification of participants across predicted 10-year risk categories of low (<10%), intermediate (10%-<20%), and high (≥20%) risk.

RESULTS: The addition of information on various lipid-related markers to total cholesterol, HDL-C, and other conventional risk factors yielded improvement in the model's discrimination: C-index change, 0.0006 (95% CI, 0.0002-0.0009) for the combination of apolipoprotein B and A-I; 0.0016 (95% CI, 0.0009-0.0023) for lipoprotein(a); and 0.0018 (95% CI, 0.0010-0.0026) for lipoprotein-associated phospholipase A2 mass. Net reclassification improvements were less than 1% with the addition of each of these markers to risk scores containing conventional risk factors. We estimated that for 100,000 adults aged 40 years or older, 15,436 would be initially classified at intermediate risk using conventional risk factors alone. Additional testing with a combination of apolipoprotein B and A-I would reclassify 1.1%; lipoprotein(a), 4.1%; and lipoprotein-associated phospholipase A2 mass, 2.7% of people to a 20% or higher predicted CVD risk category and, therefore, in need of statin treatment under Adult Treatment Panel III guidelines.

CONCLUSION: In a study of individuals without known CVD, the addition of information on the combination of apolipoprotein B and A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 mass to risk scores containing total cholesterol and HDL-C led to slight improvement in CVD prediction.

VL - 307 IS - 23 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22797450?dopt=Abstract ER - TY - JOUR T1 - Glycated hemoglobin measurement and prediction of cardiovascular disease. JF - JAMA Y1 - 2014 A1 - Di Angelantonio, Emanuele A1 - Gao, Pei A1 - Khan, Hassan A1 - Butterworth, Adam S A1 - Wormser, David A1 - Kaptoge, Stephen A1 - Kondapally Seshasai, Sreenivasa Rao A1 - Thompson, Alex A1 - Sarwar, Nadeem A1 - Willeit, Peter A1 - Ridker, Paul M A1 - Barr, Elizabeth L M A1 - Khaw, Kay-Tee A1 - Psaty, Bruce M A1 - Brenner, Hermann A1 - Balkau, Beverley A1 - Dekker, Jacqueline M A1 - Lawlor, Debbie A A1 - Daimon, Makoto A1 - Willeit, Johann A1 - Njølstad, Inger A1 - Nissinen, Aulikki A1 - Brunner, Eric J A1 - Kuller, Lewis H A1 - Price, Jackie F A1 - Sundström, Johan A1 - Knuiman, Matthew W A1 - Feskens, Edith J M A1 - Verschuren, W M M A1 - Wald, Nicholas A1 - Bakker, Stephan J L A1 - Whincup, Peter H A1 - Ford, Ian A1 - Goldbourt, Uri A1 - Gómez-de-la-Cámara, Agustín A1 - Gallacher, John A1 - Simons, Leon A A1 - Rosengren, Annika A1 - Sutherland, Susan E A1 - Björkelund, Cecilia A1 - Blazer, Dan G A1 - Wassertheil-Smoller, Sylvia A1 - Onat, Altan A1 - Marín Ibañez, Alejandro A1 - Casiglia, Edoardo A1 - Jukema, J Wouter A1 - Simpson, Lara M A1 - Giampaoli, Simona A1 - Nordestgaard, Børge G A1 - Selmer, Randi A1 - Wennberg, Patrik A1 - Kauhanen, Jussi A1 - Salonen, Jukka T A1 - Dankner, Rachel A1 - Barrett-Connor, Elizabeth A1 - Kavousi, Maryam A1 - Gudnason, Vilmundur A1 - Evans, Denis A1 - Wallace, Robert B A1 - Cushman, Mary A1 - D'Agostino, Ralph B A1 - Umans, Jason G A1 - Kiyohara, Yutaka A1 - Nakagawa, Hidaeki A1 - Sato, Shinichi A1 - Gillum, Richard F A1 - Folsom, Aaron R A1 - van der Schouw, Yvonne T A1 - Moons, Karel G A1 - Griffin, Simon J A1 - Sattar, Naveed A1 - Wareham, Nicholas J A1 - Selvin, Elizabeth A1 - Thompson, Simon G A1 - Danesh, John KW - Aged KW - C-Reactive Protein KW - Cholesterol, HDL KW - Coronary Disease KW - Diabetes Mellitus KW - Female KW - Glycated Hemoglobin A KW - Humans KW - Male KW - Middle Aged KW - Predictive Value of Tests KW - Prospective Studies KW - Risk Assessment KW - Stroke AB -

IMPORTANCE: The value of measuring levels of glycated hemoglobin (HbA1c) for the prediction of first cardiovascular events is uncertain.

OBJECTIVE: To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease (CVD) risk.

DESIGN, SETTING, AND PARTICIPANTS: Analysis of individual-participant data available from 73 prospective studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment.

MAIN OUTCOMES AND MEASURES: Measures of risk discrimination for CVD outcomes (eg, C-index) and reclassification (eg, net reclassification improvement) of participants across predicted 10-year risk categories of low (<5%), intermediate (5% to <7.5%), and high (≥ 7.5%) risk.

RESULTS: During a median follow-up of 9.9 (interquartile range, 7.6-13.2) years, 20,840 incident fatal and nonfatal CVD outcomes (13,237 coronary heart disease and 7603 stroke outcomes) were recorded. In analyses adjusted for several conventional cardiovascular risk factors, there was an approximately J-shaped association between HbA1c values and CVD risk. The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate, but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein. The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 (95% CI, 0.7350 to 0.7517). The addition of information on HbA1c was associated with a C-index change of 0.0018 (0.0003 to 0.0033) and a net reclassification improvement of 0.42 (-0.63 to 1.48) for the categories of predicted 10-year CVD risk. The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting, random, or postload plasma glucose levels.

CONCLUSIONS AND RELEVANCE: In a study of individuals without known CVD or diabetes, additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk.

VL - 311 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24668104?dopt=Abstract ER - TY - JOUR T1 - Association of Cardiometabolic Multimorbidity With Mortality. JF - JAMA Y1 - 2015 A1 - Di Angelantonio, Emanuele A1 - Kaptoge, Stephen A1 - Wormser, David A1 - Willeit, Peter A1 - Butterworth, Adam S A1 - Bansal, Narinder A1 - O'Keeffe, Linda M A1 - Gao, Pei A1 - Wood, Angela M A1 - Burgess, Stephen A1 - Freitag, Daniel F A1 - Pennells, Lisa A1 - Peters, Sanne A A1 - Hart, Carole L A1 - Håheim, Lise Lund A1 - Gillum, Richard F A1 - Nordestgaard, Børge G A1 - Psaty, Bruce M A1 - Yeap, Bu B A1 - Knuiman, Matthew W A1 - Nietert, Paul J A1 - Kauhanen, Jussi A1 - Salonen, Jukka T A1 - Kuller, Lewis H A1 - Simons, Leon A A1 - van der Schouw, Yvonne T A1 - Barrett-Connor, Elizabeth A1 - Selmer, Randi A1 - Crespo, Carlos J A1 - Rodriguez, Beatriz A1 - Verschuren, W M Monique A1 - Salomaa, Veikko A1 - Svärdsudd, Kurt A1 - van der Harst, Pim A1 - Björkelund, Cecilia A1 - Wilhelmsen, Lars A1 - Wallace, Robert B A1 - Brenner, Hermann A1 - Amouyel, Philippe A1 - Barr, Elizabeth L M A1 - Iso, Hiroyasu A1 - Onat, Altan A1 - Trevisan, Maurizio A1 - D'Agostino, Ralph B A1 - Cooper, Cyrus A1 - Kavousi, Maryam A1 - Welin, Lennart A1 - Roussel, Ronan A1 - Hu, Frank B A1 - Sato, Shinichi A1 - Davidson, Karina W A1 - Howard, Barbara V A1 - Leening, Maarten J G A1 - Leening, Maarten A1 - Rosengren, Annika A1 - Dörr, Marcus A1 - Deeg, Dorly J H A1 - Kiechl, Stefan A1 - Stehouwer, Coen D A A1 - Nissinen, Aulikki A1 - Giampaoli, Simona A1 - Donfrancesco, Chiara A1 - Kromhout, Daan A1 - Price, Jackie F A1 - Peters, Annette A1 - Meade, Tom W A1 - Casiglia, Edoardo A1 - Lawlor, Debbie A A1 - Gallacher, John A1 - Nagel, Dorothea A1 - Franco, Oscar H A1 - Assmann, Gerd A1 - Dagenais, Gilles R A1 - Jukema, J Wouter A1 - Sundström, Johan A1 - Woodward, Mark A1 - Brunner, Eric J A1 - Khaw, Kay-Tee A1 - Wareham, Nicholas J A1 - Whitsel, Eric A A1 - Njølstad, Inger A1 - Hedblad, Bo A1 - Wassertheil-Smoller, Sylvia A1 - Engström, Gunnar A1 - Rosamond, Wayne D A1 - Selvin, Elizabeth A1 - Sattar, Naveed A1 - Thompson, Simon G A1 - Danesh, John KW - Adult KW - Aged KW - Comorbidity KW - Diabetes Mellitus KW - Female KW - Humans KW - Life Expectancy KW - Male KW - Middle Aged KW - Mortality KW - Myocardial Infarction KW - Risk Factors KW - Stroke AB -

IMPORTANCE: The prevalence of cardiometabolic multimorbidity is increasing.

OBJECTIVE: To estimate reductions in life expectancy associated with cardiometabolic multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS: Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates.

EXPOSURES: A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI).

MAIN OUTCOMES AND MEASURES: All-cause mortality and estimated reductions in life expectancy.

RESULTS: In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy.

CONCLUSIONS AND RELEVANCE: Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

VL - 314 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26151266?dopt=Abstract ER - TY - JOUR T1 - Natriuretic peptides and integrated risk assessment for cardiovascular disease: an individual-participant-data meta-analysis. JF - Lancet Diabetes Endocrinol Y1 - 2016 A1 - Willeit, Peter A1 - Kaptoge, Stephen A1 - Welsh, Paul A1 - Butterworth, Adam A1 - Chowdhury, Rajiv A1 - Spackman, Sarah A1 - Pennells, Lisa A1 - Gao, Pei A1 - Burgess, Stephen A1 - Freitag, Daniel A1 - Sweeting, Michael A1 - Wood, Angela A1 - Cook, Nancy A1 - Judd, Suzanne A1 - Trompet, Stella A1 - Nambi, Vijay A1 - Olsen, Michael A1 - Everett, Brendan A1 - Kee, Frank A1 - Arnlöv, Johan A1 - Salomaa, Veikko A1 - Levy, Daniel A1 - Kauhanen, Jussi A1 - Laukkanen, Jari A1 - Kavousi, Maryam A1 - Ninomiya, Toshiharu A1 - Casas, Juan-Pablo A1 - Daniels, Lori A1 - Lind, Lars A1 - Kistorp, Caroline A1 - Rosenberg, Jens A1 - Mueller, Thomas A1 - Rubattu, Speranza A1 - Panagiotakos, Demosthenes A1 - Franco, Oscar A1 - de Lemos, James A1 - Luchner, Andreas A1 - Kizer, Jorge A1 - Kiechl, Stefan A1 - Salonen, Jukka A1 - Goya Wannamethee, S A1 - de Boer, Rudolf A1 - Nordestgaard, Børge A1 - Andersson, Jonas A1 - Jørgensen, Torben A1 - Melander, Olle A1 - Ballantyne, Christie A1 - DeFilippi, Christopher A1 - Ridker, Paul A1 - Cushman, Mary A1 - Rosamond, Wayne A1 - Thompson, Simon A1 - Gudnason, Vilmundur A1 - Sattar, Naveed A1 - Danesh, John A1 - Di Angelantonio, Emanuele KW - Aged KW - Biomarkers KW - Cardiovascular Diseases KW - Female KW - Humans KW - Male KW - Middle Aged KW - Natriuretic Peptide, Brain KW - Peptide Fragments KW - Prospective Studies KW - Risk Assessment AB -

BACKGROUND: Guidelines for primary prevention of cardiovascular diseases focus on prediction of coronary heart disease and stroke. We assessed whether or not measurement of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) concentration could enable a more integrated approach than at present by predicting heart failure and enhancing coronary heart disease and stroke risk assessment.

METHODS: In this individual-participant-data meta-analysis, we generated and harmonised individual-participant data from relevant prospective studies via both de-novo NT-proBNP concentration measurement of stored samples and collection of data from studies identified through a systematic search of the literature (PubMed, Scientific Citation Index Expanded, and Embase) for articles published up to Sept 4, 2014, using search terms related to natriuretic peptide family members and the primary outcomes, with no language restrictions. We calculated risk ratios and measures of risk discrimination and reclassification across predicted 10 year risk categories (ie, <5%, 5% to <7·5%, and ≥7·5%), adding assessment of NT-proBNP concentration to that of conventional risk factors (ie, age, sex, smoking status, systolic blood pressure, history of diabetes, and total and HDL cholesterol concentrations). Primary outcomes were the combination of coronary heart disease and stroke, and the combination of coronary heart disease, stroke, and heart failure.

FINDINGS: We recorded 5500 coronary heart disease, 4002 stroke, and 2212 heart failure outcomes among 95 617 participants without a history of cardiovascular disease in 40 prospective studies. Risk ratios (for a comparison of the top third vs bottom third of NT-proBNP concentrations, adjusted for conventional risk factors) were 1·76 (95% CI 1·56-1·98) for the combination of coronary heart disease and stroke and 2·00 (1·77-2·26) for the combination of coronary heart disease, stroke, and heart failure. Addition of information about NT-proBNP concentration to a model containing conventional risk factors was associated with a C-index increase of 0·012 (0·010-0·014) and a net reclassification improvement of 0·027 (0·019-0·036) for the combination of coronary heart disease and stroke and a C-index increase of 0·019 (0·016-0·022) and a net reclassification improvement of 0·028 (0·019-0·038) for the combination of coronary heart disease, stroke, and heart failure.

INTERPRETATION: In people without baseline cardiovascular disease, NT-proBNP concentration assessment strongly predicted first-onset heart failure and augmented coronary heart disease and stroke prediction, suggesting that NT-proBNP concentration assessment could be used to integrate heart failure into cardiovascular disease primary prevention.

FUNDING: British Heart Foundation, Austrian Science Fund, UK Medical Research Council, National Institute for Health Research, European Research Council, and European Commission Framework Programme 7.

VL - 4 IS - 10 ER -