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Ravichandran S, Gajjar P, Walker ME, Prescott B, Tsao CW, Jha M, Rao P, Miller P, Larson MG, Vasan RS, Shah RV, Xanthakis V, Lewis GD, Nayor M. Life's Essential 8 Cardiovascular Health Score and Cardiorespiratory Fitness in the Community. J Am Heart Assoc 2024; 13:e032944. [PMID: 38700001 DOI: 10.1161/jaha.123.032944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/14/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND The relation of cardiorespiratory fitness (CRF) to lifestyle behaviors and factors linked with cardiovascular health remains unclear. We aimed to understand how the American Heart Association's Life's Essential 8 (LE8) score (and its changes over time) relate to CRF and complementary exercise measures in community-dwelling adults. METHODS AND RESULTS Framingham Heart Study (FHS) participants underwent maximum effort cardiopulmonary exercise testing for direct quantification of peak oxygen uptake (V̇O2). A 100-point LE8 score was constructed as the average across 8 factors: diet, physical activity, nicotine exposure, sleep, body mass index, lipids, blood glucose, and blood pressure. We related total LE8 score, score components, and change in LE8 score over 8 years with peak V̇O2 (log-transformed) and complementary CRF measures. In age- and sex-adjusted linear models (N=1838, age 54±9 years, 54% women, LE8 score 76±12), a higher LE8 score was associated favorably with peak V̇O2, ventilatory efficiency, resting heart rate, and blood pressure response to exercise (all P<0.0001). A clinically meaningful 5-point higher LE8 score was associated with a 6.0% greater peak V̇O2 (≈1.4 mL/kg per minute at sample mean). All LE8 components were significantly associated with peak V̇O2 in models adjusted for age and sex, but blood lipids, diet, and sleep health were no longer statistically significant after adjustment for all LE8 components. Over an ≈8-year interval, a 5-unit increase in LE8 score was associated with a 3.7% higher peak V̇O2 (P<0.0001). CONCLUSIONS Higher LE8 score and improvement in LE8 over time was associated with greater CRF, highlighting the importance of the LE8 factors in maintaining CRF.
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Affiliation(s)
| | - Priya Gajjar
- Section of Cardiovascular Medicine, Department of Medicine Boston University School of Medicine MA USA
| | - Maura E Walker
- Section of Preventive Medicine and Epidemiology, Department of Medicine Boston University School of Medicine Boston MA USA
- Department of Health Sciences, Sargent College of Health and Rehabilitation Sciences Boston University Boston MA USA
| | - Brenton Prescott
- Section of Preventive Medicine and Epidemiology, Department of Medicine Boston University School of Medicine Boston MA USA
| | - Connie W Tsao
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA
| | - Mawra Jha
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA
| | - Prashant Rao
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA
| | - Patricia Miller
- Department of Biostatistics Boston University School of Public Health Boston MA USA
| | - Martin G Larson
- Department of Biostatistics Boston University School of Public Health Boston MA USA
- Framingham Heart Study Framingham MA USA
| | - Ramachandran S Vasan
- Framingham Heart Study Framingham MA USA
- University of Texas School of Public Health San Antonio TX USA
- Departments of Medicine and Population Health Sciences University of Texas Health Science Center San Antonio TX USA
| | - Ravi V Shah
- Vanderbilt Translational and Clinical Research Center, Cardiology Division Vanderbilt University Medical Center Nashville TN USA
| | - Vanessa Xanthakis
- Section of Preventive Medicine and Epidemiology, Department of Medicine Boston University School of Medicine Boston MA USA
- Framingham Heart Study Framingham MA USA
| | - Gregory D Lewis
- Cardiology Division, Cardiovascular Research Center and Pulmonary Critical Care Unit, Department of Medicine Massachusetts General Hospital Boston MA USA
| | - Matthew Nayor
- Section of Cardiovascular Medicine, Department of Medicine Boston University School of Medicine MA USA
- Section of Preventive Medicine and Epidemiology, Department of Medicine Boston University School of Medicine Boston MA USA
- Framingham Heart Study Framingham MA USA
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Khan SS, Coresh J, Pencina MJ, Ndumele CE, Rangaswami J, Chow SL, Palaniappan LP, Sperling LS, Virani SS, Ho JE, Neeland IJ, Tuttle KR, Rajgopal Singh R, Elkind MSV, Lloyd-Jones DM. Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1982-2004. [PMID: 37947094 DOI: 10.1161/cir.0000000000001191] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
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.
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Nayor M, Gajjar P, Miller P, Murthy VL, Shah RV, Houstis NE, Velagaleti RS, Larson MG, Vasan RS, Lewis GD, Mitchell GF. Arterial Stiffness and Cardiorespiratory Fitness Impairment in the Community. J Am Heart Assoc 2023; 12:e029619. [PMID: 37850464 PMCID: PMC10727403 DOI: 10.1161/jaha.123.029619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/13/2023] [Indexed: 10/19/2023]
Abstract
Background During exercise, a healthy arterial system facilitates increased blood flow and distributes it effectively to essential organs. Accordingly, we sought to understand how arterial stiffening might impair cardiorespiratory fitness in community-dwelling individuals. Methods and Results Arterial tonometry and maximum effort cardiopulmonary exercise testing were performed on Framingham Heart Study participants (N=2898, age 54±9 years, 53% women, body mass index 28.1±5.3 kg/m2). We related 5 arterial stiffness measures (carotid-femoral pulse wave velocity [CFPWV]: a measure of aortic wall stiffness; central pulse pressure, forward wave amplitude, characteristic impedance: measures of pressure pulsatility; and augmentation index: a measure of relative wave reflection) to multidimensional exercise responses using linear models adjusted for age, sex, resting heart rate, habitual physical activity, and clinical risk factors. Greater CFPWV, augmentation index, and characteristic impedance were associated with lower peak oxygen uptake (VO2; all P<0.0001). We observed consistency of associations of CFPWV with peak oxygen uptake across age, sex, and cardiovascular risk profile (interaction P>0.05). However, the CFPWV-peak oxygen uptake relation was attenuated in individuals with obesity (P=0.002 for obesity*CFPWV interaction). Higher CPFWV, augmentation index, and characteristic impedance were also related to cardiopulmonary exercise testing measures reflecting adverse O2 kinetics and lower stroke volume and peripheral O2 extraction but not to ventilatory efficiency, a prognostic measure of right ventricular-pulmonary vascular performance. Conclusions Our findings delineate relations of arterial stiffness and cardiorespiratory fitness in community-dwelling individuals. Future studies are warranted to evaluate whether the physiological measures implicated here may represent potential targets for improving cardiorespiratory fitness in the general population.
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Affiliation(s)
- Matthew Nayor
- Cardiovascular Medicine Section, Department of MedicineBoston University School of MedicineBostonMAUSA
- Preventive Medicine and Epidemiology Section, Department of MedicineBoston University School of MedicineBostonMAUSA
- Boston University’s and NHLBI’s Framingham Heart StudyFraminghamMAUSA
| | - Priya Gajjar
- Cardiovascular Medicine Section, Department of MedicineBoston University School of MedicineBostonMAUSA
| | - Patricia Miller
- Department of BiostatisticsBoston University School of Public HealthBostonMAUSA
| | - Venkatesh L. Murthy
- Division of Cardiovascular Medicine and Frankel Cardiovascular Center, Department of MedicineUniversity of MichiganAnn ArborMIUSA
| | - Ravi V. Shah
- Vanderbilt Translational and Clinical Research Center, Cardiology DivisionVanderbilt University Medical CenterNashvilleTNUSA
| | - Nicholas E. Houstis
- Cardiology Division, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | - Raghava S. Velagaleti
- Boston University’s and NHLBI’s Framingham Heart StudyFraminghamMAUSA
- Cardiology Section, Department of MedicineBoston VA Healthcare SystemWest RoxburyMAUSA
| | - Martin G. Larson
- Boston University’s and NHLBI’s Framingham Heart StudyFraminghamMAUSA
- Department of BiostatisticsBoston University School of Public HealthBostonMAUSA
| | - Ramachandran S. Vasan
- Boston University’s and NHLBI’s Framingham Heart StudyFraminghamMAUSA
- University of Texas School of Public Health San AntonioUniversity of Texas Health Science CenterSan AntonioTXUSA
- Departments of Medicine and Population Health SciencesUniversity of Texas Health Science CenterSan AntonioTXUSA
| | - Gregory D. Lewis
- Cardiology Division, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
- Pulmonary Critical Care Unit, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
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Sietsema KE, Rossiter HB. Exercise Physiology and Cardiopulmonary Exercise Testing. Semin Respir Crit Care Med 2023; 44:661-680. [PMID: 37429332 DOI: 10.1055/s-0043-1770362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Aerobic, or endurance, exercise is an energy requiring process supported primarily by energy from oxidative adenosine triphosphate synthesis. The consumption of oxygen and production of carbon dioxide in muscle cells are dynamically linked to oxygen uptake (V̇O2) and carbon dioxide output (V̇CO2) at the lung by integrated functions of cardiovascular, pulmonary, hematologic, and neurohumoral systems. Maximum oxygen uptake (V̇O2max) is the standard expression of aerobic capacity and a predictor of outcomes in diverse populations. While commonly limited in young fit individuals by the capacity to deliver oxygen to exercising muscle, (V̇O2max) may become limited by impairment within any of the multiple systems supporting cellular or atmospheric gas exchange. In the range of available power outputs, endurance exercise can be partitioned into different intensity domains representing distinct metabolic profiles and tolerances for sustained activity. Estimates of both V̇O2max and the lactate threshold, which marks the upper limit of moderate-intensity exercise, can be determined from measures of gas exchange from respired breath during whole-body exercise. Cardiopulmonary exercise testing (CPET) includes measurement of V̇O2 and V̇CO2 along with heart rate and other variables reflecting cardiac and pulmonary responses to exercise. Clinical CPET is conducted for persons with known medical conditions to quantify impairment, contribute to prognostic assessments, and help discriminate among proximal causes of symptoms or limitations for an individual. CPET is also conducted in persons without known disease as part of the diagnostic evaluation of unexplained symptoms. Although CPET quantifies a limited sample of the complex functions and interactions underlying exercise performance, both its specific and global findings are uniquely valuable. Some specific findings can aid in individualized diagnosis and treatment decisions. At the same time, CPET provides a holistic summary of an individual's exercise function, including effects not only of the primary diagnosis, but also of secondary and coexisting conditions.
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Affiliation(s)
- Kathy E Sietsema
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
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Triantafyllidi H, Benas D, Iliodromitis E. Cardiopulmonary exercise testing: Is it time to be included in a routine checkup for a relatively healthy population? Int J Cardiol 2023; 373:81-82. [PMID: 36423690 DOI: 10.1016/j.ijcard.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Helen Triantafyllidi
- 2(nd) Department of Cardiology, Medical School, National and Kapodistrian University of Athens, ATTIKON Hospital, Athens, Greece.
| | - Dimitrios Benas
- 2(nd) Department of Cardiology, Medical School, National and Kapodistrian University of Athens, ATTIKON Hospital, Athens, Greece
| | - Efstathios Iliodromitis
- 2(nd) Department of Cardiology, Medical School, National and Kapodistrian University of Athens, ATTIKON Hospital, Athens, Greece
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Nayor M, Gajjar P, Murthy VL, Miller P, Velagaleti RS, Larson MG, Vasan RS, Lewis GD, Mitchell GF, Shah RV. Blood Pressure Responses During Exercise: Physiological Correlates and Clinical Implications. Arterioscler Thromb Vasc Biol 2023; 43:163-173. [PMID: 36384270 PMCID: PMC9780190 DOI: 10.1161/atvbaha.122.318512] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Abnormal blood pressure (BP) responses to exercise can predict adverse cardiovascular outcomes, but their optimal measurement and definitions are poorly understood. We combined frequently sampled BP during cardiopulmonary exercise testing with vascular stiffness assessment to parse cardiac and vascular components of exercise BP. METHODS Cardiopulmonary exercise testing with BP measured every two minutes and resting vascular tonometry were performed in 2858 Framingham Heart Study participants. Linear regression was used to analyze sex-specific exercise BP patterns as a function of arterial stiffness (carotid-femoral pulse wave velocity) and cardiac-peripheral performance (defined by peak O2 pulse). RESULTS Our sample was balanced by sex (52% women) with mean age 54±9 years and 47% with hypertension. We observed variability in carotid-femoral pulse wave velocity and peak O2 pulse across individuals with clinically defined exercise hypertension (peak systolic BP [SBP] in men ≥210 mm Hg; in women ≥190 mm Hg). Despite similar resting SBP and cardiometabolic profiles, individuals with higher peak O2 pulse displayed higher peak SBP (P≤0.017) alongside higher fitness levels (P<0.001), suggesting that high peak exercise SBP in the context of high peak O2 pulse may in fact be favorable. Although both higher (favorable) O2 pulse and higher (adverse) arterial stiffness were associated with greater peak SBP (P<0.0001 for both), the magnitude of association of carotid-femoral pulse wave velocity with peak SBP was higher in women (sex-carotid-femoral pulse wave velocity interaction P<0.0001). In sex-specific models, exercise SBP measures accounting for workload (eg, SBP during unloaded exercise, SBP at 75 watts, and SBP/workload slope) were directly associated with the adverse features of greater arterial stiffness and lower peak O2 pulse. CONCLUSIONS Higher peak exercise SBP reflects a complex trade-off between arterial stiffness and cardiac-peripheral performance that differs by sex. Studies of BP responses to exercise accounting for vascular and cardiac physiology may illuminate mechanisms of hypertension and clarify clinical interpretation of exercise BP.
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Affiliation(s)
- Matthew Nayor
- Cardiovascular Medicine Section, Department of Medicine, Boston University School of Medicine, Boston, MA
- Preventive Medicine and Epidemiology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, MA
| | - Priya Gajjar
- Cardiovascular Medicine Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Venkatesh L. Murthy
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor
| | - Patricia Miller
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Raghava S. Velagaleti
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, MA
- Cardiology Section, Department of Medicine, Boston VA Healthcare System, West Roxbury, Massachusetts
| | - Martin G. Larson
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Ramachandran S. Vasan
- Cardiovascular Medicine Section, Department of Medicine, Boston University School of Medicine, Boston, MA
- Preventive Medicine and Epidemiology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, MA
- University of Texas School of Public Health San Antonio, and Departments of Medicine and Population Health Sciences, University of Texas Health Science Center, San Antonio, TX
- Department of Epidemiology, Boston University School of Public Health, and the Center for Computing and Data Sciences, Boston University, Boston, MA
| | - Gregory D. Lewis
- Cardiology Division and Pulmonary Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Ravi V. Shah
- Vanderbilt Translational and Clinical Research Center, Cardiology Division, Vanderbilt University Medical Center, Nashville, TN
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Shah RV, Miller P, Colangelo LA, Chernofsky A, Houstis NE, Malhotra R, Velagaleti RS, Jacobs DR, Gabriel KP, Reis JP, Lloyd‐Jones DM, Clish CB, Larson MG, Vasan RS, Murthy VL, Lewis GD, Nayor M. Blood-Based Fingerprint of Cardiorespiratory Fitness and Long-Term Health Outcomes in Young Adulthood. J Am Heart Assoc 2022; 11:e026670. [PMID: 36073631 PMCID: PMC9683648 DOI: 10.1161/jaha.122.026670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022]
Abstract
Background Cardiorespiratory fitness is a powerful predictor of health outcomes that is currently underused in primary prevention, especially in young adults. We sought to develop a blood-based biomarker of cardiorespiratory fitness that is easily translatable across populations. Methods and Results Maximal effort cardiopulmonary exercise testing for quantification of cardiorespiratory fitness (by peak oxygen uptake) and profiling of >200 metabolites at rest were performed in the FHS (Framingham Heart Study; 2016-2019). A metabolomic fitness score was derived/validated in the FHS and was associated with long-term outcomes in the younger CARDIA (Coronary Artery Risk Development in Young Adults) study. In the FHS (derivation, N=451; validation, N=914; age 54±8 years, 53% women, body mass index 27.7±5.3 kg/m2), we used LASSO (least absolute shrinkage and selection operator) regression to develop a multimetabolite score to predict peak oxygen uptake (correlation with peak oxygen uptake r=0.77 in derivation, 0.61 in validation; both P<0.0001). In a linear model including clinical risk factors, a ≈1-SD higher metabolomic fitness score had equivalent magnitude of association with peak oxygen uptake as a 9.2-year age increment. In the CARDIA study (N=2300, median follow-up 26.9 years, age 32±4 years, 44% women, 44% Black individuals), a 1-SD higher metabolomic fitness score was associated with a 44% lower risk for mortality (hazard ratio [HR], 0.56 [95% CI, 0.47-0.68]; P<0.0001) and 32% lower risk for cardiovascular disease (HR, 0.68 [95% CI, 0.55-0.84]; P=0.0003) in models adjusted for age, sex, and race, which remained robust with adjustment for clinical risk factors. Conclusions A blood-based biomarker of cardiorespiratory fitness largely independent of traditional risk factors is associated with long-term risk of cardiovascular disease and mortality in young adults.
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Affiliation(s)
- Ravi V. Shah
- Vanderbilt Translational and Clinical Research CenterCardiology DivisionVanderbilt University Medical CenterNashvilleTN
| | - Patricia Miller
- Department of BiostatisticsBoston University School of Public HealthBostonMA
| | - Laura A. Colangelo
- Department of Preventive MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Ariel Chernofsky
- Department of BiostatisticsBoston University School of Public HealthBostonMA
| | - Nicholas E. Houstis
- Cardiology DivisionDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Rajeev Malhotra
- Cardiology DivisionDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | | | - David R. Jacobs
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMN
| | | | - Jared P. Reis
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood InstituteBethesdaMD
| | - Donald M. Lloyd‐Jones
- Department of Preventive MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
- Division of CardiologyDepartment of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | | | - Martin G. Larson
- Department of BiostatisticsBoston University School of Public HealthBostonMA
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart StudyFraminghamMA
| | - Ramachandran S. Vasan
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart StudyFraminghamMA
- Sections of Cardiovascular Medicine and Preventive Medicine and EpidemiologyDepartment of MedicineBoston University School of MedicineBostonMA
- Department of EpidemiologyBoston University School of Public Health, and the Center for Computing and Data SciencesBoston UniversityBostonMA
| | - Venkatesh L. Murthy
- Department of EpidemiologyBoston University School of Public Health, and the Center for Computing and Data SciencesBoston UniversityBostonMA
- Division of Cardiovascular MedicineDepartment of Medicine, and Frankel Cardiovascular Center University of MichiganAnn ArborMI
| | - Gregory D. Lewis
- Cardiology DivisionDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
- Pulmonary Critical Care UnitMassachusetts General HospitalBostonMA
| | - Matthew Nayor
- Sections of Cardiovascular Medicine and Preventive Medicine and EpidemiologyDepartment of MedicineBoston University School of MedicineBostonMA
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