Histone deacetylase 9 (HDAC9) exacerbates atherosclerosis through inflammatory pathways, yet its specific role in cholesterol metabolism remains to be fully elucidated. Here, we investigated whether HDAC9 promotes atherosclerosis by impairing hepatic cholesterol excretion via bile acid synthesis. Using ApoE-/- and ApoE-/-PSRC1-/- mice fed a high-fat diet (HFD), we observed that PSRC1 deficiency or HFD feeding up-regulated hepatic HDAC9 expression, concomitant with suppression of the rate-limiting bile acid enzyme CYP7A1. Pharmacological inhibition of HDAC9 (TMP195) or liver-targeted AAV8-shHdac9 knockdown restored CYP7A1 expression, reduced plasma LDL-C, and attenuated aortic plaque burden in HFD-fed ApoE-/- mice. In vitro assays in Hep1-6 and HepG2 hepatocytes confirmed that Hdac9 knockdown attenuated free fatty acid-induced cholesterol accumulation, while overexpression exacerbated it. Mechanistically, HDAC9 transcriptionally represses Cyp7a1, as the cholesterol-lowering effect of Hdac9 knockdown was abolished by concomitant Cyp7a1 silencing. Collectively, our findings indicate that HDAC9 promotes atherosclerosis by transcriptionally repressing Cyp7a1 and impairing bile acid synthesis, independent of its inflammatory roles. These results highlight hepatic HDAC9 as a promising therapeutic target for hypercholesterolemia and advocate for the development of liver-directed HDAC9 inhibitors.

BACKGROUND AND PURPOSE:Surgical ventricular reconstruction (SVR) partially reverses left ventricular remodelling in postinfarction heart failure, yet residual cardiac dysfunction persists through unknown mechanisms. We investigated ferroptosis involvement in post-SVR pathology and explored pharmacological interventions. EXPERIMENTAL APPROACH:Myocardial infarction (MI) was induced in C57BL/6 mice followed by SVR at 4 weeks. Cardiac function was assessed by echocardiography and pressure-volume catheterization. Ferroptosis biomarkers were quantified. Connectivity Map analysis identified candidate compounds validated in Erastin-challenged AC16 cardiomyocytes and SVR mouse models. KEY RESULTS:Compared with MI group, SVR improved the left ventricular end-diastolic volume index by 36.8% but showed persistent iron overload, glutathione depletion and elevated malondialdehyde. Transcriptomic analysis identified 90 ferroptosis-related differentially expressed genes following SVR. Connectivity Map prioritized three ferroptosis inhibitors, and chenodeoxycholic acid (CDCA) exhibited superior efficacy. Farnesoid X receptor (FXR) knockdown in AC16 cardiomyocytes exacerbated erastin-induced ferroptosis, while CDCA co-treatment significantly reduced erastin-induced ROS production, upregulated glutathione peroxidase 4 (GPX4) expression, and restored superoxide dismutase activity, rescued the ferroptotic phenotype and reversed associated molecular changes in FXR-knockdown cells. In SVR-treated mice, 3-week CDCA administration (50 mg·kg-1·day-1) reduced myocardial iron deposition by 14.8%, improved left ventricular ejection fraction from 23.73% to 31.61% and restored GSH/GSSG ratio from 1.645 to 1.988. CDCA up-regulated GPX4 expression by 1.573-fold compared with the vehicle group. CONCLUSION AND IMPLICATIONS:SVR paradoxically exacerbates ferroptosis in residual myocardium through iron dysregulation and antioxidant depletion. CDCA, a primary bile acid activating FXR signalling, is a novel pharmacological strategy to mitigate post-SVR ferroptosis and improve cardiac outcomes.

Human placental mesenchymal stem cell-derived extracellular vesicles (hPMSC-EVs) have demonstrated anti-senescence effects across various diseases. However, their role in abdominal aortic aneurysm (AAA), a degenerative aortic pathology, remains unexplored. Our findings demonstrated that hPMSC-EVs effectively delay vascular smooth muscle cell (VSMC) senescence. In vivo, modification of hPMSC-EVs with an osteopontin(OPN)-targeted peptide facilitated precise homing to aneurysmal sites and improved local retention. Additionally, administration of OPN-targeted hPMSC-EVs significantly reduced AAA formation in both AngII and elastase-induced murine models, by inhibiting VSMC senescence. Mechanistic studies further demonstrated that hPMSC-EVs suppressed VSMC senescence and lowered AAA incidence through downregulation of Nat10 expression. MiRNA sequencing identified miR-149-5p encapsulated in hPMSC-EVs as the key mediator of Nat10 suppression. These results position OPN-targeted hPMSC-EVs as a promising targeted therapy for AAA, exerting protective effects via the miR-149-5p/Nat10/senescence axis.

[This corrects the article DOI: 10.1016/j.isci.2026.114872.][This corrects the article DOI: 10.1016/j.isci.2024.111340.].

Heart failure with preserved ejection fraction (HFpEF) is characterized by diastolic dysfunction despite a preserved left ventricular ejection fraction, and visceral adipose tissue is implicated in its pathogenesis. We hypothesize that VAT-derived small extracellular vesicles (sEVs) impair coronary microcirculation in HFpEF, and that the SGLT2 inhibitor canagliflozin can mitigate this effect. Using a mouse model of HFpEF established by a high-fat diet and L-NAME, we found that these mice exhibited significant coronary microcirculation dysfunction. Isolated VAT-sEVs from HFpEF mice were shown to exacerbate cardiac microvascular endothelial cell (CMEC) apoptosis and impair coronary flow reserve. Mechanistically, miRNA sequencing identified mmu-miR-582-3p as a key mediator enriched in these sEVs, which promotes CMEC apoptosis and mitochondrial dysfunction by directly targeting and downregulating Rap1b. Treatment with canagliflozin improved cardiac function, reduced CMEC apoptosis, and was associated with the downregulation of mmu-miR-582-3p in VAT-sEVs and the subsequent upregulation of Rap1b in CMECs. Our findings demonstrate that VAT-sEVs contribute to coronary microcirculation dysfunction in HFpEF via the mmu-miR-582-3p/Rap1b signaling pathway. Furthermore, the therapeutic benefit of SGLT2 inhibition is associated with modulation of this pathway; however, this association may be secondary to overall disease improvement, and a direct causal link requires future validation.

BACKGROUND:Pathological cardiac hypertrophy remains a major contributor to heart failure, with impaired glucose metabolism playing a central role. Although exercise is known to enhance myocardial glucose utilization, the long-term metabolic reprogramming effects of exercise and their role in preventing pathological hypertrophy are poorly understood. This study elucidates the mechanisms underlying the sustained metabolic memory induced by exercise-induced hypertrophic preconditioning (EHP) and its cardioprotective effects, with a focus on RNA methylation and arachidonic acid metabolism. METHODS:We used positron emission tomography/computed tomography to assess cardiac glucose uptake and bulk RNA sequencing to profile myocardial gene expression in sedentary and EHP mice. Genetic manipulation of Pdk4 (pyruvate dehydrogenase kinase 4) was achieved via adeno-associated virus-mediated overexpression and tamoxifen-inducible, cardiac-specific Pdk4 knockout. Pressure overload was induced by transverse aortic constriction in cardiac-specific Pdk4 knockout and control (MCM [Myh6-MerCreMer]) mice. Epigenetic regulation of Pdk4 by EHP was investigated using pyrosequencing, single-base elongation- and ligation-based quantitative polymerase chain reaction and dual-luciferase assays. Untargeted metabolomics and molecular docking, molecular dynamics simulation, and cellular thermal shift assay were performed on heart tissues and neonatal rat cardiomyocytes/fibroblasts to identify key metabolites and their mechanisms of action. RESULTS:EHP conferred sustained myocardial glucose preference even after regression of physiological hypertrophy, mediated through METTL3 (methyltransferase-like 3)-dependent m6A RNA methylation that suppressed Pdk4 expression. Pdk4 overexpression abolished EHP-mediated cardioprotection, whereas Pdk4 deletion enhanced cardiac function and attenuated fibrosis under pressure overload. Metabolomic profiling identified arachidonic acid-derived metabolites 5-KETE (5-oxo-6E,8Z,11Z,14Z-eicosatetraenoic acid), 12-keto-leukotriene B4, and 20-hydroxy-leukotriene B4 as novel inhibitors of hypertrophy and fibrosis. These metabolites attenuated cardiomyocyte hypertrophy and fibroblast transdifferentiation through inhibition of the ERK2 (extracellular signal-regulated kinase 2)/MAPK1 (mitogen-activated protein kinase 1) pathway. CONCLUSIONS:This study establishes a unified mechanism by which EHP induces metabolic memory through RNA methylation-dependent suppression of Pdk4, leading to altered arachidonic acid metabolism and the accumulation of protective lipid mediators. These findings highlight the therapeutic potential of targeting the PDK4-arachidonic acid metabolites axis to mitigate pathological cardiac remodeling.

Immunotherapy has significantly altered the treatment paradigm of non-small cell lung cancer (NSCLC), but not all patients experience durable benefits. Predictive biomarkers are needed to identify patients who may benefit from immunotherapy. We retrospectively collected tumor tissues from 65 patients with advanced NSCLC before treatment, and performed transcriptomic and genomic analysis. By performing single-sample gene set enrichment analysis, we constructed a predictor named IKCscore based on the tumor microenvironment characteristics. IKCscore is a robust biomarker predicting response to immunotherapy, and its predictive capacity was confirmed from public datasets across different cancer types (N = 892), including OAK, POPLAR, IMvigor210, GSE135222, GSE126044, and Kim cohorts. High IKCscore was characterized by inflammatory tumor microenvironment phenotype and higher T cell receptor diversity. The IKCscore exhibits promise as a bioindicator that can predict the efficacy of both immunotherapy and immunotherapy-based combination therapies, while providing guidance for personalized therapeutic strategies for advanced NSCLC patients.

Background: The switch to endothelial-to-mesenchymal transition (EndMT) in endothelial cells (ECs) induced by disturbed flow (d-flow) has been identified as the critical driver of the pathogenesis of inflammatory vascular disorders. We aimed to investigate the role of EndMT in abdominal aortic aneurysms (AAA) and the underlying mechanism. Methods: Immunoblotting, immunofluorescence and transmission electron microscope were used to assess d-flow-induced EndMT in human and mouse AAA models (Ang II/PPE). An Ibidi pump system was used to produce d-flow on human aortic endothelial cells (HAECs), and the expression of galectin-7 was enhanced and weakened using an adeno-associated virus. Furthermore, single-cell RNA sequencing was performed to explore the underlying mechanism of galectin-7-mediated EndMT. Results: EndMT induced by d-flow, which suppressed galectin-7 expression, was positively correlated with AAA. Enhanced galectin-7 expression inhibited d-flow-induced EndMT and AAA progression, whereas reduced galectin-7 expression resulted in the opposite effect. Mechanistically, we found a EndMT-related cluster in HAECs by single-cell RNA sequencing, and the SRGN gene in this cluster was considered the core gene. Galectin-7 bound competitively to the transcription factor CREB, resulting in the inhibition of SRGN transcription, which in turn prevented TGFβ/smad pathway activation, thereby restoring EndMT progression. Conclusions: EndMT transformation in ECs exposed to d-flow was the critical driver of AAA development. Furthermore, endothelium-enriched galectin-7 suppressed the EndMT process induced by d-flow and prevent AAA progression by transcriptionally inhibiting SRGN via competitive binding with CREB to restrict TGFβ/smad pathway.

BACKGROUND:Cardiomyocytes exhibit marked susceptibility to ferroptosis after myocardial infarction (MI), rendering ferroptosis inhibition a promising therapeutic strategy to mitigate ischemic myocardial injury. Although mitochondrial dysfunction is recognized as a core driver of ferroptosis, the potential role of mitochondrial DNA transcription in regulating cardiomyocyte ferroptosis remains unexplored. METHODS:To clarify the temporal role of the various modes of cell death in MI progression, we performed time-course echocardiography in MI models treated with various cell death inhibitors. To characterize the crucial process and molecular regulator in cardiomyocyte ferroptosis, we integrated RNA sequencing and single-nucleus RNA sequencing data from murine post-MI hearts and performed functional rescue experiments using mitochondrial protective agents. To determine the role of ABHD11 (αβ-hydrolase domain-containing protein 11) in cardiomyocyte ferroptosis and cardiac repair after MI, we used loss- and gain-of-function approaches. To elucidate the underlying mechanisms, we conducted transcriptomics, nontargeted lipidomics, site-specific mutagenesis, molecular docking, coimmunoprecipitation, native gel electrophoresis, proximity ligation assay, methylation-specific polymerase chain reaction, and chromatin immunoprecipitation assay. RESULTS:We found that cardiac ferroptosis peaked at day 7 after MI and was enriched in peri-infarct cardiomyocytes. Mitochondrial dysfunction was a key driver of cardiomyocyte ferroptosis after MI, and the lipid enzyme ABHD11 was identified as a potential regulator of both processes. ABHD11 expression was consistently reduced in mouse and human MI hearts, and its transcription was repressed by DNMT1 (DNA methyltransferase 1)-mediated promoter hypermethylation. Functionally, cardiac-specific overexpression of ABHD11 markedly alleviated cardiomyocyte ferroptosis and improved cardiac function after MI. Conversely, loss of ABHD11 in adult mice exacerbated pathological cardiac remodeling and heart failure. Mechanistically, independent of its canonical enzymatic activities, ABHD11 acted as a mitochondrial DNA transcription coactivator by enhancing the TEFM (mitochondrial transcription elongation factor)-POLRMT (mitochondrial RNA polymerase) interaction. This promoted mitochondrial DNA transcription, restored mitochondrial function, and reduced reactive oxygen species/PUFA-PLs (polyunsaturated fatty acid-containing glycerophospholipids)-driven lipid peroxidation and 4-hydroxynonenal generation. The reduction in 4-hydroxynonenal stabilized YY1 (Yin Yang 1), which subsequently regulated key ferroptosis-driving genes governing iron deposition, reactive oxygen species production, and polyunsaturated fatty acid lipids accumulation, further inhibiting lipid peroxidation and ferroptosis, and ultimately promoting cardiac recovery after MI. CONCLUSIONS:This study revealed that ABHD11-mediated mitochondrial DNA transcription attenuated cardiomyocyte ferroptosis after MI by orchestrating a mitochondrial-nuclear crosstalk, offering a novel therapeutic strategy for ischemic myocardial injury.

Background Physical exercise is known to induce trained immunity and improve function of macrophages, and we recently reported that exercise-induced hypertrophic preconditioning (EHP) could protect pathological hypertrophic heart, but it remains unclear whether EHP can mitigate myocardial ischemic injury. Here we hypothesized that EHP would alleviate acute myocardial ischemic injury through trained immunity of macrophages. Methods Swimming or treadmill running training was used to induce EHP in C57 mice. After 1-week of exercise termination, mice were subjected to myocardial ischemia/reperfusion (IR). IR injury and inflammatory response and cell energy metabolism reprogramming of bone marrow-derived macrophages (BMDMs) were analysed. Moreover, the effects of exercise on myocardial ischemic injury or long-term survival in patients with acute myocardial infarction (AMI) or history of MI were retrospectively analysed. Results EHP mice had a significantly smaller infarct size and less apoptotic cardiomyocytes than IR mice without EHP. At 4 weeks after IR, EHP mice had better cardiac function and less myocardial fibrosis. We noted less infiltration and polarization of myocardial M1 macrophages, higher expression of M2 signature anti-inflammatory factors in BMDMs of EHP mice. EHP promoted tricarboxylic acid cycle, mitochondrial oxidative phosphorylation (OXPHOS) and adenosine 5’-monophosphate activated protein kinase (AMPK) phosphorylation, decreased glycolysis and phosphorylation of AKT and mTOR in BMDMs. Importantly, AMPK inhibitor treatment abrogated the cardioprotective effects of EHP, abolishing the improvement in infarct size and apoptosis and reversing the metabolic reprogramming of macrophages. In mice received treadmill running training for 6 weeks, no physiological hypertrophy occurred but myocardial infarct size after IR was significantly reduced. Similarly, in response to AMI, patients with exercise habit had higher left ventricular ejection fraction and lower plasma levels of cardiac troponin T than those sedentary AMI patients. In 2457 patients with self-reported history of MI, patients with regular exercise habit had significantly lower post-MI mortality. Conclusions EHP protects heart against myocardial ischemic injury through trained immunity of macrophage mediated by energy metabolism reprogramming.

The tumor microenvironment (TME) significantly influences cancer prognosis and therapeutic outcomes, yet its composition remains highly heterogeneous, and currently, no highly accessible, high-throughput method exists to define it. To address this complexity, the TMEclassifier, a machine-learning tool that classifies cancers into three distinct subtypes: immune Exclusive (IE), immune Suppressive (IS), and immune Activated (IA), is developed. Bulk RNA sequencing categorizes patient samples by TME subtype, and in vivo mouse model validates TME subtype differences and differential responses to immunotherapy. The IE subtype is marked by high stromal cell abundance, associated with aggressive cancer phenotypes. The IS subtype features myeloid-derived suppressor cell infiltration, intensifying immunosuppression. In contrast, the IA subtype, often linked to EBV/MSI, exhibits robust T-cell presence and improved immunotherapy response. Single-cell RNA sequencing is applied to explore TME cellular heterogeneity, and in vivo experiments demonstrate that targeting IL-1 counteracts immunosuppression of IS subtype and markedly improves its responsiveness to immunotherapy. TMEclassifier predictions are validated in this prospective gastric cancer cohort (TIMES-001) and other diverse cohorts. This classifier could effectively stratify patients, guiding personalized immunotherapeutic strategies to enhance precision and overcome resistance.

Predicting recurrence after radiofrequency catheter ablation (RFCA) in persistent atrial fibrillation (PeAF) remains challenging. This study evaluated the predictive value of F‐wave amplitude (FWA), F‐wave duration (FWD) in inferior ECG leads (II, III, aVF), and AF duration for post‐ablation recurrence. In this dual‐center retrospective study, 763 persistent atrial fibrillation (PeAF) patients undergoing first RFCA (2017–2022) were analyzed. Pre‐procedural FWA and FWD were measured across 12‐lead ECGs using MATLAB. Clinical data and 12‐month follow‐up outcomes were collected. Independent predictors were identified via binary logistic regression, and a gradient boosting machine (GBM) model was developed. Model performance was assessed using ROC curves, calibration plots, and decision curve analysis (DCA), with internal (random split) and external (between‐center) validation. At 12 months, 198 patients (26%) experienced recurrence. Recurrence patients exhibited significantly lower inferior lead FWA (0.108 [0.076–0.157] vs. 0.126 [0.087–0.173] mV, p = 0.003), narrower FWD (54.96 [40.26–71.31] vs. 61.46 [42.7–76] ms, p = 0.038), and longer AF duration (13.8 [4–38] vs. 6.5 [3–21] months, p < 0.001). Multivariate analysis identified inferior lead FWA (OR = 0.788, 95%CI 0.662–0.937, p = 0.007) and AF duration (OR = 1.014, 95%CI 1.007–1.021, p < 0.001) as independent predictors. The model combining AF duration and FWA achieved an AUC of 0.692 (95%CI 0.648–0.737), improving to 0.746 (0.701–0.787) with FWD inclusion. Validation demonstrated stable discrimination (internal AUC = 0.722, 95%CI 0.680–0.762; external AUC = 0.703, 0.659–0.747). Inferior lead FWA and AF duration are independent predictors of post‐RFCA recurrence in persistent AF. The combined model integrating these parameters with FWD shows robust discriminative ability and clinical utility, supporting personalized treatment strategies.

Figure. S6 Matrix stiffness induces HSC activation.

Abstract Background The mechanisms underlying cardiac remodeling in aortic valvular (AoV) disease remain poorly understood, partially due to the insufficiency of appropriate preclinical animal models. Here, we present a novel murine model of aortic regurgitation (AR) generated by trans‐apical wire destruction of the AoV. Methods Directed by echocardiography, apical puncture of the left ventricle (LV) was performed in adult male C57BL/6 mice, and a metal guidewire was used to induce AoV destruction. Echocardiography, invasive LV hemodynamic and histological examination were conducted to assess the degree of AR, LV function and remodeling. Results AR mice exhibited rapid aortic regurgitation velocity (424 ± 15.22 mm/s) immediately following successful surgery. Four weeks post‐surgery, echocardiography revealed a 54.6% increase in LV diastolic diameter and a 55.1% decrease in LV ejection fraction in AR mice compared to sham mice. Pressure‐volume catheterization indicated that AR mice had significantly larger LV end‐diastolic volumes (66.2 ± 1.5 μL vs. 41.8 ± 3.4 μL), reduced LV contractility (lower dP/dtmax and Ees), and diminished LV compliance (smaller dP/dtmin and longer Tau) compared to sham mice. Histological examination demonstrated that AR mice had significantly larger cardiomyocyte area and more myocardial fibrosis in LV tissue, as well as a 107% and a 122% increase of heart weight/tibial length and lung weight/tibial length, respectively, relative to sham mice. Conclusions The trans‐apex wire‐induced destruction of the AoV establishes a novel and efficient murine model to develop AR, characterized by significant eccentric LV hypertrophy, heart failure, and pulmonary congestion.

Figure. S8 Matrix stiffness induced lipid crosstalk between HSCs and colon cancer cells promote tumor proliferation and angiogenesis.

Pulmonary vein isolation (PVI) using conventional power (30–35 W) radiofrequency ablation (RFA) has been an effective treatment strategy for paroxysmal atrial fibrillation (PAF), but its longer duration may cause collateral damage to peripheral tissue including esophageal and phrenic nerve. High-power (HP) RFA, due to better transmural performance and shorter duration, may reduce the damage to adjacent tissue and is expected to be a safe and efficient ablation strategy. In this retrospective cohort study, we included 259 patients with PAF who underwent lesion size index (LSI)-guided radiofrequency ablation. All patients underwent PVI-based ablation, and some underwent additional ablation, including superior vena cava isolation, tricuspid isthmus block, or left anterior atrial matrix modification. A total of 119 PAF patients underwent 50 W ablation. Complications and twelve-month arrhythmia-free outcomes of the procedure were compared with those of 140 patients who underwent 30–35 W ablation. PVI was successfully achieved in all patients. The procedural duration (140.3 ± 34.4 vs. 151.3 ± 40.6 min, P = 0.022) and overall radiation (112.0 ± 67.2 vs. 188.2 ± 119.2 mGy·cm2, P < 0.001) were significantly lower in the 50 W group. No major complications occurred in the high-power short-duration (HPSD) group, whereas in the conventional power group, five participants developed complications. Among them, three cases were related to venipuncture, one had pericardial tamponade, and one had slight pericardial effusion. The recurrence of arrhythmia at the twelve-month follow-up was not significantly different between the two groups [11 (9.2

Immune checkpoint inhibitors (ICIs) are widely used to treat advanced non-small cell lung cancer (NSCLC). However, it remains crucial to identify patients who are unlikely to benefit from immunotherapy and to explore potential combination treatment strategies. In this study, 1127 advanced NSCLC patients from multicenter randomized clinical trials (OAK, POPLAR, ORIENT-11) and an in-house cohort who received ICIs, ICIs combined with chemotherapy, or chemotherapy alone are analyzed. Using bulk RNA-seq transcriptomic data, an RNA-based model, named the Lung Cancer Immunotherapy Response Assessment (LIRA), is developed, utilizing interaction analysis and a random forest algorithm to predict immunotherapy outcomes. LIRA outperforms PD-L1 expression and tumor mutation burden in predicting responses, particularly in identifying early progression risk during ICI monotherapy (HR: 0.15, 95% CI: 0.11-0.20). Tumor profile analysis reveals that LRP8 and HDAC4 are associated with immunotherapy outcomes. Additionally, scRNA-seq analysis of NSCLC tumors indicates a higher prevalence of T cells and a reduced proportion of epithelial cells in samples with a high LIRA-score. The deep learning model pinpointed critical high-attention regions within whole-slide images that contributed decisively to the LIRA predictions. In summary, these results demonstrate that LIRA enables independent risk stratification of NSCLC patients and provides insights into potential resistance mechanisms.

BACKGROUND:Serum potassium (sK) disorders are associated with worse outcomes in patients with heart failure with preserved ejection fraction (HFpEF). This study introduced a novel metric, time in target range (TTR), for long-term monitoring of sK levels and determined its prognostic value in patients with HFpEF from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. METHODS:The TTR for sK levels was defined as the percentage of time during which the sK was within the target range of 4.3-4.9 mmol/L, and was estimated using linear interpolation based on at least five valid measurements of sK. The association between sK TTR and cardiovascular (CV) events was estimated using adjusted Cox proportional hazards regression models. RESULTS:A total of 3141 TOPCAT participants with HFpEF were evaluated over a median follow-up period of 3.9 years. A greater time within the range of 4.3-4.9 mmol/L for sK was associated with a lower risk of CV events in patients with HFpEF (HR: 0.712; 95% CI: 0.571 to 0.889). The benefits remained when the range of sK was set at 4.3-4.6, or 4.6-4.9, while no benefits or even negative effects were observed at 4.0-4.3, or 4.9-5.2 mmol/L. The association between a higher TTR and lower risk of CV outcomes was consistent across subgroups. The sK TTR predicted a lower risk of CV events, even after adjusting for traditional CV risk factors, mean sK and sK variability. CONCLUSION:Maintaining sK levels within the range of 4.3-4.9 mmol/L most of the time in patients with HFpEF is associated with a lower risk of CV events or all-cause mortality. TRIAL REGISTRATION NUMBER:NCT00094302.

Supplementary Table S4. Primer sequences