Cohort Study of Repeated Measurements of Serum Urate and Risk of Incident Atrial Fibrillation

Progress of uric acid in cardiovascular disease

Due to the global prevalence of hyperuricemia (HUA), there is growing interest in research on uric acid (UA). HUA is a common condition that has various adverse consequences, including gout and kidney disease. However, recent studies have also implicated UA in the development of cardiovascular diseases (CVD) such as atrial fibrillation (AF) and coronary heart disease (CHD). Experimental and clinical research has extensively demonstrated the detrimental effects of elevated serum UA levels on cardiovascular health. Furthermore, serum UA levels have been identified as predictors of CVD outcomes following percutaneous coronary intervention (PCI) and catheter ablation. Additionally, the use of UA-lowering therapy holds important implications for the management of CVD. This review aims to consolidate the current evidence on the relationship between serum UA and CVD.

Predictive nomogram models for atrial fibrillation in COPD patients: A comprehensive analysis of risk factors and prognosis

The aim of the present study was to identify the independent risk factors and prognostic indicators for atrial fibrillation (AF) in patients with chronic obstructive pulmonary disease (COPD) and to develop predictive nomogram models. This retrospective study included a total of 286 patients with COPD who were admitted to the Second Affiliated Hospital of Guilin Medical College between January 2020 and May 2022. The average age of the patients was 77.11±8.67 years. Based on the presence or absence of AF, the patients were divided into two groups: The AF group (n=87) and the non-AF group (n=199). Logistic regression analysis was conducted to identify variables with significant differences between the two groups. Nomogram models were constructed to predict the occurrence of AF in COPD patients and to assess prognosis. Survival analysis was performed using the Kaplan-Meier method. The follow-up period for the present study extended until April 31, 2023. Survival time was defined as the duration from the date of the interview to the date the participant succumbed or the end of the follow-up period. In the present study, age, uric acid (UA) and left atrial diameter (LAD) were found to be independent risk factors for the development of AF in patients diagnosed with COPD. The stepwise logistic regression analysis revealed that age had an odds ratio (OR) of 1.072 [95% confidence interval (CI): 1.019-1.128; P=0.007], UA had an OR of 1.004 (95% CI: 1.001-1.008; P=0.010) and LAD had an OR of 1.195 (95% CI: 1.098-1.301; P<0.001). Univariate and multivariate Cox regression analysis revealed that LAD and UA were independent prognostic factors for long-term mortality in COPD patients with AF. LAD had a hazard ratio (HR) of 1.104 (95% CI: 1.046-1.165; P<0.001) and UA had an HR of 1.004 (95% CI: 1.000-1.008; P=0.042). Based on these findings, predictive nomogram models were developed for AF in COPD patients, which demonstrated good discrimination ability with an area under the curve of 0.886. The prognostic nomogram for COPD patients with AF also showed good predictive accuracy with a concordance index of 0.886 (95% CI: 0.842-0.930). These models can provide valuable information for risk assessment and prognosis evaluation in clinical practice. Age, UA and LAD are independent risk factors for AF in COPD patients. The developed nomogram models provide a reliable tool for predicting AF in COPD patients and for prognosis assessment.

Association between uric acid and cardiac outcomes mediated by neutrophil-to-lymphocyte ratio in patients with left ventricular diastolic dysfunction and pulmonary hypertension

To evaluate the association of uric acid (UA) with adverse outcomes and its potential mediator in patients with left ventricular diastolic dysfunction (LVDD) and pulmonary hypertension (PH). We retrospectively analyzed 234 patients with LVDD and PH. The baseline characteristics of patients with low UA (≤ 330 µmol/L) group were compared with high UA (> 330 µmol/L) group. Adverse outcomes included all-cause mortality, cardiac death and heart failure (HF) hospitalization. Their association with UA and the mediator were evaluated using Cox regression and mediation analysis. The mediation proportion was further quantified by the R mediation package. During a mean follow-up of 50 ± 18 months, there were 27 all-cause deaths, 18 cardiovascular deaths and 41 incidents of HF hospitalization. Multivariable Cox regression analysis showed UA was an independent risk factor of adverse outcomes in LVDD and PH patients, even after adjusting for age, sex, body mass index, medical histories, systolic blood pressure, fasting blood glucose, total cholesterol, triglyceride, eGFR, BNP and medications. The hazard ratios (HRs) for UA (per 10 µmol/L increase) were as below: for all-cause mortality, HR 1.143, 95% CI 1.069-1.221, P < 0.001; for cardiac death, HR 1.168, 95% CI 1.064-1.282, P = 0.001; for HF hospitalization, HR 1.093, 95% CI 1.035-1.155, P = 0.001. Neutrophil-to-lymphocyte ratio (NLR) played a partial mediation role in the association, and the mediation proportion for NLR on the UA-adverse outcomes were 21%, 19% and 17%, respectively. In patients of LVDD with PH, higher UA level was independently correlated with adverse outcomes. Furthermore, NLR partially mediated the effect of UA on the risk of all-cause mortality, cardiac death and HF hospitalization.

Hip circumference has independent association with the risk of hyperuricemia in middle-aged but not in older male patients with type 2 diabetes mellitus

BACKGROUND

Obesity and type 2 diabetes mellitus (T2DM) are risk factors for hyperuricemia. However, which anthropometric indices can better predict incident hyperuricemia in patients with T2DM remains inconsistent. This study aimed to examine the associations between hyperuricemia and different anthropometric indices in middle-aged and older male patients with T2DM.

METHODS

In this retrospective study, a total of 1447 middle-aged (45-65 years, n = 791) and older (≥ 65 years, n = 656) male patients with T2DM were collected from December 2015 to January 2020 at Shanghai Xinhua Hospital. Hyperuricemia was defined as a serum uric acid level above 7.0 mg/dL. Weight, height, waist circumference (WC) and hip circumference (HC) were measured by trained nurses at visit.

RESULTS

The median uric acid level of subjects was 5.6 (interquartile ranges: 4.7-6.7) mg/dl, and 279 (19.3%) were hyperuricemia, with 146 (18.5%) in the middle-aged group, and 133 (20.3%) in the older group. After adjusting for age, duration of T2DM, fasting plasma glucose and insulin, homeostasis model assessment-β, aspartate aminotransferase, triglycerides, high-density lipoprotein cholesterol and estimated glomerular filtration rate, body mass index (BMI), WC, HC, and waist-to-height ratio (WHtR) were associated with a higher risk of hyperuricemia in both middle-aged and older group (P < 0.05). After further adjusting for BMI and WC, HC still showed a positive relationship with the risk of hyperuricemia (Odds Ratio = 1.51, 95% confidence intervals: 1.06-2.14) in the middle-aged group, but such relationship was not found in the older group. Moreover, according to receiver operating characteristic analysis, the optimal cutoff value was 101.3 cm of HC for hyperuricemia screening in the middle-aged male patients with T2DM.

CONCLUSION

In middle-aged male patients with T2DM, more attention should be paid to HC with the cutoff value of 101.3 cm in clinical practice for early recognition of individuals with a high risk of hyperuricemia for targeted guidance on disease prevention, such as community screening.

Life's Essential 8 and Risk of Stroke: A Prospective Community-Based Study

BACKGROUND

Data are lacking regarding cardiovascular health (CVH) with Life's Essential 8 approach and future stroke risk. We sought to elucidate whether the CVH score constructed by the Life's Essential 8 metrics predicted stroke risk in 2 Chinese ongoing cohorts.

METHODS

This included 41 043 participants of the Kailuan I study and 27 842 participants of the Kailuan II study who were free of cardiovascular disease or cancer in 2014. CVH score (ranged from 0 to 100) was assessed using the Life's Essential 8 metrics (body mass index, cigarette smoking, diet quality, physical activity, sleep health, lipid, blood glucose, and blood pressure). A composite of incident stroke events (ischemic stroke and hemorrhagic stroke) was identified via review of medical records. The follow-up period was calculated from the finishing date of the 2014 survey to either the date of stroke occurrence, death, loss to follow-up, or the end of follow-up (December 31, 2020). We also examined the longitudinal association between the CVH score and arterial stiffness status, as assessed by brachial-ankle pulse wave velocity, in 25 922 participants free of cardiovascular disease during the follow-up. We performed a meta-analysis to assess the association between CVH, based on the 2010 American Heart Association recommendation, and stroke integrating the results of current study and previous studies.

RESULTS

During a median follow-up of 5.65 years (interquartile range, 5.20-6.09), a total of 1750 incident stroke events were identified in the pooled Kailuan study. The pooled hazard ratios were 0.33 (95% CI, 0.20-0.54) for ideal versus poor health category of CVH (Ptrend<0.0001). Higher CVH scores were also associated with lower brachial-ankle pulse wave velocity values at baseline and slower increments of brachial-ankle pulse wave velocity during follow-up (Ptrend≤0.001 for both). Arterial stiffness mediated 9.07% (95% CI, 5.83%-15.0%) of the total association between CVH and incident stroke. The pooled hazard ratio comparing 2 extreme CVH categories for stroke was 0.45 (95% CI, 0.35-0.59) when including 10 published studies and the current study.

CONCLUSIONS

The CVH score as assessed by the Life's Essential 8 metrics significantly predicted future stroke risk and arterial stiffness status.

Association of proteinuria and risk of incident atrial fibrillation in the general population: A prospective study of Kailuan study participants

BACKGROUND

Proteinuria is a well-known cardiovascular risk factor, but whether it independently increases the risk for atrial fibrillation (AF) in Chinese population is unknown. To address this deficiency, herein, we investigated the association between proteinuria detected using urine dipstick test and the risk of AF.

METHODS

This was a prospective cohort study of Kailuan study participants who underwent the 2006-2007 and 2010-2011 health checkups and was free from AF. Participants were classified into four groups based on the level of proteinuria: [-, trace (±), 1+, ≥2+]. The outcome was incident AF as confirmed by 12-lead electrocardiography.

RESULTS

During a median of 11.90 years of follow-up, we documented 514 incident AF cases among 60,599 participants. Proteinuria was found in 6302 (10.40%) participants. Relative to participants without proteinuria at the baseline, those with proteinuria (≥2+) had an 83.9% higher risk (95% confidence interval [CI], 1.073-3.154, p = .0267) of developing AF, after adjusted for confounding variables. The result was consistent in the sensitivity analysis. Compared to consistently negative proteinuria, the risk of AF significantly increased in the aggravated proteinuria group (hazard ratio [HR] 1.552, 95% CI 1.140-2.114) and the persistent proteinuria group (HR 2.485, 95% CI 1.414-4.366). Among participants with resolved proteinuria (from positive to negative), the risk of incident AF was not significantly increased compared to those with persistently negative proteinuria (HR 1.300, 95% CI 0.743-2.276).

CONCLUSIONS

Proteinuria could be a modifiable risk factor for predicting AF development. Knowing the presence of proteinuria may improve risk stratification for decision-making about AF prevention.

Elevated Uric Acid Is Associated With New-Onset Atrial Fibrillation: Results From the Swedish AMORIS Cohort

Background The role of uric acid is gaining increasing importance in the evaluation of cardiovascular disease, but its relationship with atrial fibrillation (AF) is unclear. This study aims to investigate the association between uric acid levels and risk of new-onset AF. Methods and Results A total of 339 604 individuals 30 to 60 years of age and free from cardiovascular disease at baseline (1985-1996) in the Swedish AMORIS (Apolipoprotein-Mortality Risk) cohort were followed until December 31, 2019 for incident AF. Cox regression models were used to examine the association between uric acid and AF, adjusting for potential confounders and stratifying by incident cardiovascular disease. Over a mean follow-up of 25.9 years, 46 516 incident AF cases occurred. Compared with the lowest uric acid quartile, each of the upper 3 quartiles were associated with an increased risk of AF in a dose-response manner. Adjusted hazard ratios were 1.09 (95% CI, 1.06-1.12) for second quartile, 1.19 (95% CI, 1.16-1.23) for third quartile, and 1.45 (95% CI, 1.41-1.49) for fourth quartile. The association was similar among individuals with and without incident hypertension, diabetes, heart failure, or coronary heart disease. The dose-response pattern was further supported in a subsample of individuals with repeated measurements of uric acid. Conclusions Elevated uric acid was associated with an increased risk of AF, not only among people with cardiovascular disease and cardiovascular risk factors but also among those without. Future investigations are needed to examine whether lowering uric acid is relevant for AF prevention.

Serum uric acid: A risk factor for right ventricular dysfunction and prognosis in heart failure with preserved ejection fraction

BACKGROUND

Hyperuricemia and right ventricular dysfunction (RVD) are both widespread in heart failure with preserved ejection fraction (HFpEF) patients. RVD is associated with a poor prognosis in HFpEF. The correlation between serum uric acid (UA) levels and right ventricular function is unclear. The prognostic performance of UA in patients with HFpEF needs further validation.

METHODS AND RESULTS

A total of 210 patients with HFpEF were included in the study and divided into two groups according to UA level: the normal UA group (≤7 mg/dl) and the high UA group (>7 mg/dl). The variables examined included clinical characteristics, echocardiography, and serum biochemical parameters. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (TAPSV). Baseline characteristics were compared between the two groups, and the correlation between baseline UA and RVD was assessed using multifactorial binary logistic regression. Kaplan-Meier curves were used to describe all-cause mortality and heart failure readmission. Results showed that right ventricular function parameters were worse in the high UA group. After adjusting for UA, left ventricular posterior wall thickness (LVPWT), N-terminal B-type natriuretic peptide (NT-proBNP), atrial fibrillation (AF), and low-density lipoprotein cholesterol (LDL-C), UA (odds ratio = 2.028; p < 0.001) was independently associated with RVD, and UA >7 mg/dl (HR = 2.98; p < 0.001) was associated with heart failure readmission in patients with HFpEF.

CONCLUSION

Elevated serum UA is closely associated with RVD and significantly associated with the heart failure readmission rate in patients with HFpEF.

Uric acid in metabolic syndrome: Does uric acid have a definitive role?

Increased serum uric acid (SUA) levels are commonly seen in patients with metabolic syndrome and are widely accepted as risk factors for hypertension, gout, non-alcoholic fatty liver disease, chronic kidney disease (CKD), and cardiovascular diseases. Although some ambiguity for the exact role of uric acid (UA) in these diseases is still present, several pathophysiological mechanisms have been identified such as increased oxidative stress, inflammation, and apoptosis. Accumulating evidence in genomics enlightens genetic variabilities and some epigenetic changes that can contribute to hyperuricemia. Here we discuss the role of UA within metabolism and the consequences of asymptomatic hyperuricemia while providing newfound evidence for the associations between UA and gut microbiota and vitamin D. Increased SUA levels and beneficial effects of lowering SUA levels need to be elucidated more to understand its complicated function within different metabolic pathways and set optimal target levels for SUA for reducing risks for metabolic and cardiovascular diseases.

Declines in serum uric acid level after catheter ablation of atrial fibrillation

BACKGROUND

Few studies have examined whether catheter ablation for AF patients improves biomarkers other than serum levels of brain natriuretic peptide (BNP) and renal function. This study was to explore whether catheter ablation for atrial fibrillation (AF) patients affects uric acid (UA), glucose and lipid metabolism.

METHODS AND RESULTS

A total of 206 patients (66.6 ± 10.4 years; 132 men) who underwent initial AF ablation without changes to oral medications were included. Baseline BNP and UA levels significantly decreased at 1 year after ablation (p < 0.05 each). Changes in UA level correlated significantly with pre-procedural UA level (r = 0.57). In multivariable logistic regression modeling, pre-procedural UA level, persistent AF, and hemoglobin A1c (p < 0.05 each) were independent predictors of post-procedural UA level decline. Significant improvements in both persistent and paroxysmal AF patients were identified, and the magnitude of post-procedural serum UA level decline after ablation (ΔUA) was significantly greater in patients with persistent AF (0.8 ± 1.0 mg/dl) than in those with paroxysmal AF (0.2 ± 0.8 mg/dl, p < 0.001). Of the 48 patients with high UA level before procedure, 28 patients showed improvement in UA level to normal range.

CONCLUSIONS

Catheter ablation for AF patients significantly improved serum UA levels without obvious influences of heart failure, renal function, or inflammation, suggesting that AF ablation may be effective for AF patients with hyperuricemia. Trial registration The study was approved by the Research Ethics Committee of University of Fukui (no. 20210132) and clinical trial registration (UMIN000044669).

A case-control study to investigate association between serum uric acid levels and paroxysmal atrial fibrillation

The relationship between serum uric acid (SUA) levels and paroxysmal atrial fibrillation (AF) remains controversial. The objective of this case–control study was to investigate the association between serum SUA levels and paroxysmal AF by gender in 328 patients. This study included 328 hospitalized patients with newly diagnosed paroxysmal AF in China between January 2019 and September 2021. Controls with sinus rhythm were matched (2:1) to cases by age and gender. Baseline data were analyzed using ANOVA, T-test, and Chi-square test. Pearson correlation analyses were used to confirm the correlation between variables, and multivariate regression analyses were used to adjust for covariates. Elevated SUA levels in female patients were significantly associated with paroxysmal AF after adjusting for confounding factors (OR = 1.229, 95% CI 1.058–1.427, P = 0.007). Further results showed SUA levels were negatively correlated with high-density lipoprotein cholesterol (HDL-C) (r = − 0.182, p = 0.001) and apolipoprotein A1 (APOA1) (r = − 0.109, p = 0.049), were positively correlated with low-density lipoprotein cholesterol (LDL-C) (r = 0.169, p = 0.002) and prealbumin (PAB) (r = 0.161, p = 0.004) . Nevertheless, there was no significant complication difference between SUA levels and paroxysmal AF (P > 0.05). Increased SUA in female patients was significantly associated with paroxysmal AF in a Chinese population. This finding implies that it would be interesting to monitor and interfere with hyperuricemia in paroxysmal AF patients.

Hyperuricemia Is Associated With the Risk of Atrial Fibrillation Independent of Sex: A Dose-Response Meta-Analysis

Background:

Conflicting findings of the association between serum uric acid (SUA) and atrial fibrillation (AF) have been reported in both men and women. The sex-specific associations between SUA and the risk of AF are unclear, although hyperuricemia is independently associated with the risk of AF. We performed this meta-analysis to assess the sex-specific effect of SUA on the risk of AF.

Methods

The PubMed, EMBASE, and Cochrane Library databases were searched up to October 3, 2021, for studies that reported sex-specific associations of SUA levels with AF. Linear relationships were assessed by the generalized least squares trend estimation. This study was registered with PROSPERO (42020193013).

Results

Ten eligible studies with 814,804 participants (415,779 men and 399,025 women) were identified. In the category analysis, high SUA was associated with an increased risk of AF in both men (OR: 1.42; 95% CI, 1.18–1.71, I² = 34%) and women (OR: 2.02; 95% CI, 1.29–3.16, I² = 70%). In the dose-response analysis, for each 60 μmol/L (1 mg/dL) increase in the SUA level, the risk of AF increased by 15% (OR: 1.15; 95% CI, 1.07–1.25, I² = 74%) in men and 35% (OR: 1.35; 95% CI, 1.18–1.53, I² = 73%) in women. There was a borderline difference in the impact of SUA on the risk of AF between men and women (P for interaction = 0.05). A significant linear relationship between SUA and the risk of AF was observed in men (P for non-linearity = 0.91) and women (P for non-linearity = 0.92).

Conclusions

This study suggested that there was a significant linear relationship between SUA and the risk of AF among men and women, with a higher risk estimate for women. Additional trials are required to assess the effect of reduced SUA therapy on AF incidence.

Systematic Review Registration

https:www.crd.york.ac.uk/PROSPERO/, identifier: CRD 42020193013.

Adherence to the dietary approaches to stop hypertension diet and non-alcoholic fatty liver disease

BACKGROUND AND AIMS

The evidence of the relationship between dietary approaches to stop hypertension (DASH) and non-alcoholic fatty liver disease (NAFLD) is limited. Thus, we conducted a cohort-based case-control study to examine whether adherence to the DASH diet was associated with lower NAFLD risk in China.

METHODS

We included 11 888 participants (2529 incident NAFLD and 9359 non-NAFLD) from the Kailuan cohort with no history of hepatitis B/C infection and alcohol drinking. DASH score was calculated based on the energy-adjusted consumption of vegetables, fruits, dairy, beans, grains, meats, fat, sodium and beverage, collected by a validated food frequency questionnaire. We used Logistic regression analysis to determine the NAFLD's risk according to the DASH score.

RESULTS

Higher DASH score was associated with lower risk of NAFLD. Compared with the lowest quintile of DASH score, the highest DASH quintile had a lower risk of occurring NAFLD, with odds ratio (OR) of 0.82 (95% confidence interval [CI]: 0.70-0.96) in the multivariate model. Stratified analysis showed that the inverse association was only observed in women (OR = 0.67, 95% CI: 0.48-0.94), and participants with overweight/obesity (OR = 0.79, 95% CI: 0.66-0.94), fasting blood glucose <6.1 mmol/L (OR = 0.80, 95%: 0.67-0.96), low density lipoprotein ≥3.4 mmol/L (OR = 0.71, 95% CI: 0.53-0.96), high density lipoprotein ≥1.0 mmol/L (OR = 0.81, 95% CI: 0.69-0.96), ALT < 40 U/L (OR = 0.79, 95% CI:0.67-0.93) and C-reactive protein ≥2.0 mg/L (OR = 0.56, 95% CI: 0.40-0.78).

CONCLUSIONS

Adherence to the DASH diet was inversely associated with a lower risk of NAFLD in the Chinese population. DASH diet should be highly recommended, especially for women and people with overweight/obesity and a high CRP level.

The Relationship between Uric Acid and the Development, Complication, and Prognosis of Atrial Fibrillation: The Views from a Clinical Study

A large number of studies suggest that uric acid (UA) is related to the occurrence, complications, and prognosis of atrial fibrillation (AF). However, the guidelines did not clearly elaborate on this issue. The current research results need to be summarized to analyze the association between UA and AF. This study found that in the current clinical research on the relationship between UA and AF, studies mainly focus on the development or complications of AF. A lot of repetitive work does not deepen awareness of this question. In contrast, studies investigating the effects of UA-lowering therapy on the management of AF are limited. The only reports deny the protective effect of UA-lowering therapy. For now, we suggest that UA is close to the occurrence and progression of AF; therefore, it may have important significance as a clinical marker. The role of UA-lowering therapy in the management of AF is one of the next key issues to be explored. It will be a meaningful topic to focus on the latest research on AF ablation and to conduct a secondary analysis to explore the prognostic impact of UA on the latest treatment methods for AF. Multiomics techniques may allow us to have a deeper understanding of the role of UA in AF management in the future.

Relationship between serum uric acid levels and different types of atrial fibrillation: An updated meta-analysis

AIM

Increasing evidence supports the hypothesis that high serum uric acid (SUA) levels are related to atrial fibrillation (AF). However, the incidence of AF in patients with hyperuricemia and SUA levels in different types of AF is not entirely clear. This meta-analysis was designed to evaluate the relationship between SUA and incidence of AF, and the variation in SUA levels in different types of AF.

DATA SYNTHESIS

Relevant reports were searched for in Embase, PubMed and the Cochrane Library. A fixed-effects model combining relative risk (RR) and the corresponding 95% confidence interval (95% CI) was used to evaluate the correlation between SUA and AF. The standardized mean differences (SMDs) of SUA values were calculated using a random-effects model to evaluate the differences in SUA levels among different types of AF. A total of 31 studies with 504,958 participants were included in this research. The results from 8 cohort studies showed that high SUA levels significantly increased the incidence of AF [RR (95% CI): 1.92 (1.68-2.20); P < 0.01]. The results from 29 studies revealed that SUA levels elevated in patients with AF [SMD (95% CI): 0.55 (0.43-0.66); P < 0.001]. Meanwhile, SUA levels in new-onset AF [SMD (95%CI): 0.24 (0.10-0.38); P = 0.001], paroxysmal AF [SMD (95%CI): 0.52 (0.33-0.72); P < 0.001] and persistent AF [SMD (95%CI): 1.23 (0.98-1.48); P < 0.001] were significantly higher than that in patients without AF.

CONCLUSIONS

High SUA levels had an obvious correlation with the occurrence rate of AF. In addition, SUA levels were significantly different among patients with new-onset, paroxysmal and persistent AF.

Frequency of Visit-to-Visit Variability of Resting Heart Rate and the Risk of New-Onset Atrial Fibrillation in the General Population

Resting heart rate (RHR) has been an established predictor for atrial fibrillation (AF). However, the association of visit-to-visit heart rate variability (VVHRV) with new-onset AF risk over long term remains unclear. Our study investigates the relation of VVHRV to new-onset AF in general population in the prospective study of the Kailuan cohort. A total of 46,126 individuals without arrhythmia were included. They underwent 3 health examinations from 2006 to 2010 and performed follow up. VVHRV was measured by coefficient of variation (CV), variability independent of the mean (VIM), and standard deviation (SD). Participants were separately divided into 5 categories by quintiles of visit-to-visit RHR-CV, RHR-VIM and RHR-SD. Multivariate Cox regression and restricted cubic spline models were performed to establish the association between VVHRV and new-onset AF. 241 new-onset AF occurred during a median follow-up of 7.54 years. The incidence of new-onset AF in the group of the lowest (Q1) and highest quintiles (Q5) of RHR-CV were higher than that in other groups. The HRs for the new-onset AF were 2.07 (95% CI, 1.34-3.21, p < 0.01), in the highest quintile group(Q5) compared with group Q2, and 1.89(95% CI, 1.20-2.97, p < 0.01) in the lowest quintile group(Q1) compared with group Q2. The risk for new-onset AF showed a similar trend using RHR-VIM (p < 0.01) and RHR-SD (p < 0.05) parameters. Further sensitivity analyses indicated the consistent results in subjects without prior cardiovascular disease and without taking beta blockers or CCB. To match the covariates, analyses were also performed by propensity score matching, and prominent trends were also found in RHR-SD and RHR-VIM. In conclusion, the study indicated that higher and lower VVHRV were associated with the increasing risk of new-onset AF, which supporting a U-shaped curve existence.

Could Sodium/Glucose Co-Transporter-2 Inhibitors Have Antiarrhythmic Potential in Atrial Fibrillation? Literature Review and Future Considerations

The global burden of atrial fibrillation (AF) is constantly increasing, necessitating novel and effective therapeutic options. Sodium glucose co-transporter 2 (SGLT2) inhibitors have been introduced in clinical practice as glucose-lowering medications. However, they have recently gained prominence for their potential to exert substantial cardiorenal protection and are being evaluated in large clinical trials including patients with type 2 diabetes and normoglycemic adults. In this review we present up-to-date available evidence in a pathophysiology-directed manner from cell to bedside. Preclinical and clinical data regarding a conceivable antiarrhythmic effect of SGLT2 inhibitors are beginning to accumulate. Herein we comprehensively present data that explore the potential pathophysiological link between SGLT2 inhibitors and AF. With regard to clinical data, no randomized controlled trials evaluating SGLT2 inhibitors effects on AF as a pre-specified endpoint are available. However, data from randomized controlled trial post-hoc analysis as well as observational studies point to a possible beneficial effect of SGLT2 inhibitors on AF. Meta-analyses addressing this question report inconsistent results and the real magnitude of AF prevention by SGLT2 inhibition remains unclear. Still, while (i) pathophysiologic mechanisms involved in AF might be favorably affected by SGLT2 inhibitors and (ii) emerging, yet inconsistent, clinical data imply that SGLT2 inhibitor-mediated cardiorenal protection could also exert antiarrhythmic effects, the argument of whether these novel drugs will reduce AF burden is unsettled and mandates appropriately designed and adequately sized randomized controlled studies.

Habitually skipping breakfast is associated with chronic inflammation: a cross-sectional study

OBJECTIVE

We examined whether breakfast frequency was associated with chronic inflammatory, as assessed by high-sensitivity C-reactive protein (CRP) concentration.

DESIGN

Cross-sectional study.

SETTING

Kailuan community, China.

PARTICIPANTS

Included were 70 092 Chinese adults without CVD and cancer in 2014 with CRP concentrations <10 mg/l, when breakfast frequency was assessed via a questionnaire, and plasma CRP concentration was measured.

RESULTS

Breakfast frequency was associated with CRP concentration (P-trend < 0·001). The adjusted mean CRP was 1·33 mg/l (95 % CI 1·23, 1·44) for the 'no breakfast' group and 1·07 mg/l (95 % CI 1·0, 1·14) for the 'breakfast everyday' group (P-difference < 0·001), adjusting for age, sex, diet quality, total energy, obesity, education, occupation, marital status, smoking, alcohol consumption, blood pressure, sleep parameters, fasting blood glucose and lipid profiles. Consistently, the adjusted OR for CRP ≥ 1·0 mg/l and CRP ≥ 3·0 mg/l were 1·86 (95 % CI 1·73, 2·00) and 1·27 (95 % CI 1·15, 1·40), respectively, when comparing these two breakfast consumption groups (P-trend < 0·001 for both). The associations were more pronounced among older adults, relative to those who were younger (P-interaction < 0·001). Significant association between breakfast skipping and elevated CRP concentration was observed in those with poor diet quality, but not those with good diet quality.

CONCLUSIONS

Habitually skipping breakfast is associated with elevated concentrations of CRP. Future prospective studies including repeated assessment of inflammatory biomarkers and a collection of detailed information on type and amount of breakfast foods are warranted.

The risk of ischemic stroke and hemorrhagic stroke in Chinese adults with low-density lipoprotein cholesterol concentrations < 70 mg/dL

BACKGROUND

The risk of stroke in individuals with very low low-density lipoprotein cholesterol (LDL-C) concentrations remains high. We sought to prioritize predictive risk factors for stroke in Chinese participants with LDL-C concentrations < 70 mg/dL using a survival conditional inference tree, a machine learning method.

METHODS

The training dataset included 9327 individuals with LDL-C concentrations < 70 mg/dL who were free of cardiovascular diseases and did not use lipid-modifying drugs from the Kailuan I study (N = 101,510). We examined the validity of this algorithm in a second Chinese cohort of 1753 participants with LDL-C concentrations < 70 mg/dL from the Kailuan II study (N = 35,856).

RESULTS

During a mean 8.5-9.0-year follow-up period, we identified 388 ischemic stroke cases and 145 hemorrhagic stroke cases in the training dataset and 20 ischemic stroke cases and 8 hemorrhagic stroke cases in the validation dataset. Of 15 examined predictors, poorly controlled blood pressure and very low LDL-C concentrations (≤ 40 mg/dL) were the top hierarchical predictors of both ischemic stroke risk and hemorrhagic stroke risk. The groups, characterized by the presence of 2-3 of aforementioned risk factors, were associated with a higher risk of ischemic stroke (hazard ratio (HR) 7.03; 95% confidence interval (CI) 5.01-9.85 in the training dataset; HR 4.68, 95%CI 1.58-13.9 in the validation dataset) and hemorrhagic stroke (HR 3.94, 95%CI 2.54-6.11 in the training dataset; HR 4.73, 95%CI 0.81-27.6 in the validation dataset), relative to the lowest risk groups (presence of 0-1 of these factors). There was a linear association between cumulative average LDL-C concentrations and stroke risk. LDL-C concentrations ≤ 40 mg/dL was significantly associated with increased risk of ischemic stroke (HR 2.07, 95%CI 1.53, 2.80) and hemorrhagic stroke (HR 2.70, 95%CI 1.70, 4.30) compared to LDL-C concentrations of 55-70 mg/dL, after adjustment for age, hypertension status, and other covariates.

CONCLUSION

Individuals with extremely low LDL-C concentrations without previous lipid-modifying treatment could still be at high stroke risk.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR-TNRC-11001489 . Registered on 24-08-2011.

Restless legs syndrome and perceived olfactory and taste dysfunction: A community-based study

BACKGROUND AND PURPOSE

Restless legs syndrome (RLS) has been suggested as a prodromal symptom of Parkinson disease (PD). Olfactory or taste dysfunction can also occur preceding PD diagnosis. However, whether RLS is associated with chemosensory dysfunction remains unknown. We thus aim to investigate the association between RLS and perceived olfactory and taste dysfunction.

METHODS

We performed a cross-sectional analysis including 90,337 Chinese adults free of neurodegenerative diseases in the Kailuan study in 2016. Presence of RLS was defined using revised RLS diagnostic criteria or the Cambridge-Hopkins questionnaire for RLS. Perceived olfactory and taste dysfunction was collected via a questionnaire. The association between RLS and perceived olfactory and taste dysfunction was assessed using logistic regression model, adjusting for potential cofounders such as age, sex, and medical history.

RESULTS

RLS was associated with high odds of having perceived olfactory and/or taste dysfunction (adjusted odds ratio = 5.92, 95% confidence interval = 3.11-11.3). The significant association persisted when using the Cambridge-Hopkins questionnaire (adjusted odds ratio = 5.55, 95% confidence interval = 2.37-13.0) or when excluding participants with major chronic diseases.

CONCLUSIONS

RLS was associated with increased odds of perceived olfactory and taste dysfunction.

Incidence and Risk Factors of Hyperuricemia among 2.5 Million Chinese Adults during the Years 2017-2018

Objective: To assess the incidence and risk factors of hyperuricemia among Chinese adults in 2017-2018. Methods: A total of 2,015,847 adults (mean age 41.2 ± 12.7, 53.1% men) with serum uric acid concentrations assayed on at least two separate days in routine health examinations during 2017-2018 were analyzed. Hyperuricemia was defined as fasting serum urate concentration >420 μmol/L in men and >360 μmol/L in women. The overall and sex-specific incidence rate were stratified according to age, urban population size, geographical region, annual average temperature and certain diseases. Logistic regression analyses were performed to explore risk factors associated with hyperuricemia. Results: 225,240 adults were newly diagnosed with hyperuricemia. The age- and sex-standardized incidence rate per 100 person-years was 11.1 (95%CI: 11.0-11.1) (15.2 for men and 6.80 for women). The risk of hyperuricemia was positively associated with younger age, being male, larger urban population size, higher annual temperature, higher body mass index, lower estimate glomerular filtration rate, hypertension, dyslipidemia and fat liver. Conclusions: The incidence of hyperuricemia was substantial and exhibited a rising trend among younger adults, especially among men. Socioeconomic and geographic variation in incidence were observed. The risk of hyperuricemia was associated with estimate glomerular filtration rate, fat liver and metabolic factors.

The Key Role of Uric Acid in Oxidative Stress, Inflammation, Fibrosis, Apoptosis, and Immunity in the Pathogenesis of Atrial Fibrillation

Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia that leads to numerous adverse outcomes including stroke, heart failure, and death. Hyperuricemia is an important risk factor that contributes to atrium injury and AF, but the underlying molecular mechanism remains to be elucidated. In this review, we discussed the scientific evidence for clarifying the role of hyperuricemia in the pathogenesis of AF. Experimental and Clinical evidence endorse hyperuricemia as an independent risk factor for the incidence of AF. Various in vivo and in vitro investigations showed that hyperuricemia might play a critical role in the pathogenesis of AF at different UA concentrations through the activation of oxidative stress, inflammation, fibrosis, apoptosis, and immunity.

Risk stratification for mortality in cardiovascular disease survivors: A survival conditional inference tree analysis

BACKGROUND AND AIMS

Efficient analysis strategies for complex network with cardiovascular disease (CVD) risk stratification remain lacking. We sought to identify an optimized model to study CVD prognosis using survival conditional inference tree (SCTREE), a machine-learning method.

METHODS AND RESULTS

We identified 5379 new onset CVD from 2006 (baseline) to May, 2017 in the Kailuan I study including 101,510 participants (the training dataset). The second cohort composing 1,287 CVD survivors was used to validate the algorithm (the Kailuan II study, n = 57,511). All variables (e.g., age, sex, family history of CVD, metabolic risk factors, renal function indexes, heart rate, atrial fibrillation, and high sensitivity C-reactive protein) were measured at baseline and biennially during the follow-up period. Up to December 2017, we documented 1,104 deaths after CVD in the Kailuan I study and 170 deaths in the Kailuan II study. Older age, hyperglycemia and proteinuria were identified by the SCTREE as main predictors of post-CVD mortality. CVD survivors in the high risk group (presence of 2-3 of these top risk factors), had higher mortality risk in the training dataset (hazard ratio (HR): 5.41; 95% confidence Interval (CI): 4.49-6.52) and in the validation dataset (HR: 6.04; 95%CI: 3.59-10.2), than those in the lowest risk group (presence of 0-1 of these factors).

CONCLUSION

Older age, hyperglycemia and proteinuria were the main predictors of post-CVD mortality.

TRIAL REGISTRATION

ChiCTR-TNRC-11001489.

Alcohol consumption and risk of cardiovascular disease, cancer and mortality: a prospective cohort study

Background

Studies regarding whether light to moderate alcohol consumption is associated with a lower risk of cardiovascular diseases (CVD) have generated mixed results. Further, few studies have examined the potential impact of alcohol consumption on diverse disease outcomes simultaneously. We aimed to prospectively study the dose-response association between alcohol consumption and risk of CVD, cancer, and mortality.

Methods

This study included 83,732 adult Chinese participants, free of CVD and cancer at baseline. Participants were categorized into 6 groups based on self-report alcohol consumption: 0, 1–25, 26–150, 151–350, 351–750, and > 750 g alcohol/wk. Incident cases of CVD, cancers, and mortality were confirmed by medical records. Hazard ratios (HRs) for the composite risk of these three outcomes, and each individual outcome, were calculated using Cox proportional hazard model.

Results

During a median follow-up of 10.0 years, there were 6411 incident cases of CVD, 2947 cancers and 6646 deaths. We observed a J-shaped relation between alcohol intake and risk of CVD, cancer, and mortality, with the lowest risk at 25 g/wk., which is equivalent to ~ 2 servings/wk. Compared to consuming 1–25 g/wk., the adjusted HR for composite outcomes was 1.38 (95% confidence interval (CI):1.29–1.49) for non-drinker, 1.15 (95% CI: 1.04–1.27) for 26–150 g/wk., 1.22 (95% CI: 1.10–1.34) for 151–350 g/wk., 1.33 (95% CI: 1.21–1.46) for 351–750 g/wk., and 1.57 (95% CI: 1.30–1.90) for > 750 g/wk., after adjusting for age, sex, lifestyle, social economic status, and medication use.

Conclusions

Light alcohol consumption at ~ 25 g/wk was associated with lower risk of CVD, cancer, and mortality than none or higher consumption in Chinese adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00671-y.

Hyperuricemia as a Risk Factor for Cardiovascular Diseases

Serum uric acid level above 7 mg/dl is defined as hyperuricemia, which gives rise to the monosodium urate (MSU), causing gout and urolithiasis. Hyperuricemia is an independent risk factor as well as a marker for hypertension, heart failure, atherosclerosis, atrial fibrillation, and chronic kidney disease. MSU crystals, soluble uric acid (UA), or oxidative stress derived from xanthine oxidoreductase (XOR) might be plausible explanations for the association of cardio-renovascular diseases with hyperuricemia. In macrophages, MSU activates the Nod-like receptor family, pyrin　domain containing 3(NLRP3) inflammasome, and proteolytic processing mediated by caspase-1 with enhanced interleukin (IL)-1β and IL-18 secretion. Soluble UA accumulates intracellularly through UA transporters (UAT) in vascular and atrial myocytes, causing endothelial dysfunction ad atrial electrical remodeling. XOR generates reactive oxygen species (ROS) that lead to cardiovascular diseases. Since it remains unclear whether asymptomatic hyperuricemia could be a risk factor for cardiovascular and kidney diseases, European and American guidelines do not recommend pharmacological treatment for asymptomatic patients with cardio-renovascular diseases. The Japanese guideline, on the contrary, recommends pharmacological treatment for hyperuricemia with CKD to protect renal function, and it attaches importance of the cardio-renal interaction for the treatment of asymptomatic hyperuricemia patients with hypertension and heart failure.

Does Serum Uric Acid Status Influence the Association Between Left Atrium Diameter and Atrial Fibrillation in Hypertension Patients?

Objective: Both serum uric acid (SUA) levels and left atrium diameter (LAD) associate with AF. However, the influence of SUA status for the associated risk of AF related to LAD in hypertension patients is currently unknown.

Methods: We retrospectively analyzed a hospital-based sample of 9,618 hypertension patients. Standard electrocardiograms were performed on all patients and were interpreted by expert electro-physiologists.

Results: Overall 1,028 (10.69%) patients had AF out of 9,618 patients. In men >65 years of age, the prevalence of AF in the1st, 2nd, and 3rd tertiles of SUA among those grouped in the third tertile of LAD were 9, 12.3, and 21.7%, respectively. In the hyperuricemia group, the OR (95% CI) of AF for the highest tertile of LAD in men ≤ 65 years of age was 3.150 (1.756, 5.651; P < 0.001). Similarly, the hyperuricemic men in the 3rd LAD tertile had a higher likelihood of AF than those belonging to the 1st tertile. The ORs and (95% CIs) were 3.150 (1.756, 5.651; P < 0.001) and 5.522 (2.932, 10.400; P ≤ 0.001) for patients ≤ 65 and >65 years of age. An increase in SUA values was significantly associated with an increased likelihood of AF among women at the top tertiles of LAD, with the OR (95% CI) = 4.593 (1.857, 11.358; P = 0.001). Also, men> 65 years of age with large LAD, present at the third tertile of SUA, had a higher likelihood of AF, with the OR (95% CI) = 2.427 (1.039, 5.667; P < 0.05).

Conclusion: SUA levels and LAD are associated with AF in patients with hypertension and the risk of AF associated with LAD increases among those with hyperuricemia.

A mendelian randomization analysis: The causal association between serum uric acid and atrial fibrillation

BACKGROUND

Observational studies have shown that high levels of serum uric acid (UA) were associated with atrial fibrillation (AF). However, the causal effect of urate on the risk of AF is still unknown. To clarify the potential causal association between UA and AF, we performed a Mendelian randomization (MR) analysis using genetic instrumental variables (IVs).

MATERIALS AND METHODS

From the Korean GWAS dataset of 633 patients with AF (mean age 50.6 ± 7.8 years, 80.9% male, Yonsei AF Ablation cohort) who underwent radiofrequency catheter ablation and the data from 3533 controls (from the Korea Genome Epidemiology Study), we selected 9 SNPs, with a P value less than .05, associated with an increased UA serum level. Additionally, we calculated the weighted genetic risk score (wGRS) using the selected 9 SNPs, to use it as an instrumental variable. A Mendelian randomization analysis was calculated by a 2-stage estimator method.

RESULTS

The conventional association between the serum UA and AF was significant (P = .001) after adjusting for potential confounding factors. The SNP rs1165196 on SLC17A1 (F-statistics = 208.34, 0.18 mg/mL per allele change, P < .001) and wGRS (F-statistics = 222.26, 0.20 mg/mL per 1SD change, P < .001) were significantly associated with an increase in the UA level. The MR analysis was causally associated with rs1165196 (estimated odds ratio (OR), 0.21, 95% confidence interval (CI), 0.06-0.75, P = .017), but not wGRS (estimated OR, 1.07, 95% CI, 0.57-2.01, P = .832).

CONCLUSION

The serum UA level was independently associated with the AF risk.

Habitual Night Eating Was Positively Associated With Progress of Arterial Stiffness in Chinese Adults

Background

Night eating has been associated with an elevated risk of obesity, dyslipidemia, and cardiovascular disease. However, there is no longitudinal study on whether habitual night eating, regardless of diet quality and energy intake, is associated with arterial stiffness, a major etiological factor in the development of cardiovascular disease.

Methods and Results

The study included 7771 adult participants without cardiovascular disease, cancer, or diabetes mellitus prior to dietary assessment by a validated food frequency questionnaire in 2014 through 2015. Participants were categorized into 3 groups based on self‐reported night‐eating habits: never or rarely, some days (1–5 times per week), or most days (6+ times per week). Arterial stiffness was assessed by brachial‐ankle pulse wave velocity at baseline and repeatedly during follow‐ups. Mean differences and 95% CIs in the yearly change rate of brachial‐ankle pulse wave velocity across the 3 groups were calculated, adjusting for age, sex, socioeconomic status, total energy intake, diet quality, sleep quality, and other cardiovascular disease risk factors. At baseline, 6625 (85.2%), 610 (7.8%), and 536 (6.9%) participants reported night eating as never or rarely, some days, or most days, respectively. During a mean 3.19 years, we observed a positive association between night‐eating frequency and progression of arterial stiffness (P trend=0.01). The adjusted difference in brachial‐ankle pulse wave velocity change rate between the group that ate at night most days and the group that never or rarely ate at night was 14.1 (95% CI, 0.6–27.5) cm/s per year. This association was only significant in women, but not in men (P interaction=0.03).

Conclusions

In an adult population free of major chronic diseases, habitual night eating was positively associated with the progression of arterial stiffness, a hallmark of arteriosclerosis and biological aging.

Registration

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR‐TNRC‐11001489.

Repeated measurements of serum urate and mortality: a prospective cohort study of 152,358 individuals over 8 years of follow-up

BACKGROUND

Longitudinal evidence on change of serum urate level with mortality risk is limited as prior studies have a measurement of serum urate at a single time point. Further, the combined effect of serum urate and systemic inflammation on mortality is unknown.

METHODS

We conducted a prospective cohort study of 152,358 participants (122,045 men and 30,313 women) with repeated measurements of serum urate in 2006, 2008, 2010, and 2012 (107,751 participants had all four measurements of serum urate). We used the Cox proportional hazard model to examine the association between cumulative average and changes in serum urate with mortality. The combined effect of serum urate and systemic inflammation was determined by testing the interaction of serum urate and high-sensitive C-reactive protein (hs-CRP) in relation to mortality risk.

RESULTS

During a median follow-up of 8.7 (interquartile range 6.3-9.2) years, we identified 7564 all-cause deaths, 1763 CVD deaths, 1706 cancer deaths, and 1572 other deaths. We observed U-shaped relationships of cumulative average serum urate with all-cause mortality, cardiovascular mortality, and other mortalities. Compared with participants with stable serum urate, those with greater increases in serum urate had a 1.7-fold elevated mortality (hazard ratio (HR) = 1.66, 95% confidence interval (CI) = 1.49-1.84), and those with decreased serum urate had a 2-fold elevated mortality risk (HR = 2.14, 95% CI 1.93-2.37). Participants with both hyperuricemia and hs-CRP had 1.6 times higher mortality, compared with those with low serum urate and hs-CRP levels (HR = 1.56, 95% CI 1.37-1.76).

CONCLUSIONS

We observed a U-shaped relationship of long-term cumulative average serum urate with all-cause mortality, cardiovascular mortality, and other mortalities. Compared with participants with relatively stable serum urate levels, a greater increase or decrease in serum urate was associated with elevated mortality. Participants with both hyperuricemia and high systemic inflammation had the greatest mortality risk compared with those with low serum urate and low hs-CRP levels.

Hyperuricemia as a Risk Factor for Atrial Fibrillation Due to Soluble and Crystalized Uric Acid

Among the several independent risk factors for atrial fibrillation (AF), hyperuricemia has been widely accepted as associated with the incidence of paroxysmal or persistent AF, as well as with the risk of AF in patients undergoing cardiovascular surgery. The electrophysiological mechanism of AF involves electrical remodeling of the arrhythmogenic substrate and abnormal automaticity as trigger. Both electrical and structural remodeling mediated by oxidative stress derived from either xanthine oxidoreductase (XOR), soluble uric acid (UA) or monosodium urate (MSU) crystals might be plausible explanations for the association of AF with hyperuricemia. XOR generates reactive oxygen species (ROS) that lead to atrial structural remodeling via inflammation. Soluble UA accumulates intracellularly through UA transporters (UAT), shortening the atrial action potential via enhanced expression and activity of Kv1.5 channel proteins. Intracellular accumulation of soluble UA generates ROS in atrial myocytes via nicotinamide adenine dinucleotide phosphate oxidase, which phosphorylates ERK/Akt and heat shock factor 1 (HSF1), thereby increasing transcription and translation of Hsp70, which stabilizes Kv1.5. In macrophages, MSU activates the NLRP3 inflammasome and proteolytic processing mediated by caspase-1 with enhanced interleukin (IL)-1β and IL-18 secretion. Use of an XOR inhibitor, antioxidants, a UAT inhibitor such as a uricosuric agent, and an NLRP3 inflammasome inhibitor, might become a potential strategy to reduce the risk of hyperuricemia-induced AF, and control serum UA level.

Cohort Study of Repeated Measurements of Serum Urate and Risk of Incident Atrial Fibrillation

Background Current evidence on the association between serum urate and risk of atrial fibrillation ( AF ) is limited by cross-sectional designs and 1-time measurement of serum urate. The roles of serum urate, gout-related inflammation, and systemic inflammation in the etiology of AF are currently unknown. This gap is important, given that systemic inflammation is a recognized risk factor for AF . Methods and Results We conducted a prospective cohort study of 123 238 Chinese patients from 2006 to 2014. Serum urate concentrations were measured in 2006, 2008, 2010, and 2012. Incident AF cases were identified via biennial 12-lead ECG assessment. We used a Cox proportional hazards model to examine the sex-specific associations of cumulative average serum urate and changes in serum urate accounting for baseline level with risk of incident AF . We also assessed the joint associations of serum urate and high-sensitivity C-reactive protein levels. Comparing extreme categories, participants with the highest quintile of serum urate had 1.91-fold higher risk of AF (adjusted hazard ratio: 1.91; 95% CI, 1.32-2.76; P=0.001 for trend). Participants with both high serum urate and high-sensitivity C-reactive protein had 2.6-fold elevated risk of incident AF compared with those with normal levels of serum urate and high-sensitivity C-reactive protein (adjusted hazard ratio: 2.63; 95% CI, 1.63-4.23). Conclusions High serum urate levels and increases in serum urate over time were associated with increased risk of incident AF . Patients with high levels of both serum urate and high-sensitivity C-reactive protein had substantially higher risk of AF .