Abstract Circulating plasma proteins are key biomarkers and therapeutic targets, now measurable at scale through high-throughput technologies, yet whether expanding proteomics platforms beyond the classical plasma secretome enhances genetic discovery and causal inference remains poorly understood. Here, we use an expanded SomaScan 7k platform to map the genetic architecture of a broader segment of the plasma proteome and to evaluate how proteome expansion affects pQTL discovery, causal inference and therapeutic target prioritisation. After quality control, we analysed 7,144 aptamers targeting 6,267 proteins in the harmonised dataset of two European cohorts: INTERVAL (n = 9,251 participants) and CHRIS (n = 4,194), and conducted genome-wide pQTL association analyses followed by meta-analysis. We identified 7,870 significant pQTLs (P-value < 1.26 × 10 −11 ; 1,784 cis , 6,086 trans ), of which 2,704 (34%) associations were not reported in five prior large-scale pQTL studies. Newly assessed proteins, which accounted for 53% (1,422/2,704) of the novel associations, were less likely to harbour cis -pQTLs associations (∼15%) than those in the previous platform version (∼28%), consistent with their lower expected plasma concentrations and predominantly intracellular localisation. Colocalization analyses revealed widespread sharing of genetic signals across proteins and characterised 22 pleiotropic trans -regulatory hotspots accounting for 68% of all trans -pQTLs. Through two-sample Mendelian randomization analyses on 2,003 phenotypes from the Million Veteran Program, UK Biobank, and FinnGen (combined N > 1.2 million), we identified 6,340 genetically supported protein–trait associations, highlighting disease mechanisms and potential therapeutic opportunities beyond currently drug-targeted circulating proteins. Together, these findings provide a systematic view of the genetic architecture of the expanded plasma proteome and demonstrate that plasma proteome expansion reveals genetically anchored disease biology beyond the classical secretome, while exposing inherent biological and technical constraints of studying low-abundance intracellular proteins in circulation.

Proteomics holds great promise for identifying potentially druggable effectors of common diseases, yet its application at population-scale across diverse ancestries, remains challenging. Here, we developed genetic imputation models for 2,594 plasma proteins using proteomic and genetic data from 54,219 UK Biobank participants, validating their performance across multiple ancestry groups and in an independent cohort. Plasma proteomes were then imputed for over 640,000 participants in the UK Biobank and the All of Us Research Program. To assess its aetiological value at population-scale, a further proteome-wide association study of cardiovascular diseases was performed across six genetic ancestries. We identified ∼9000 protein-disease associations across 89 cardiovascular conditions (PheCodes), the majority of which show consistent effects across ancestries and biobanks, with many comprising known targets of drugs either approved or under development. The associations reveal both shared and distinct proteomic signatures across cardiovascular conditions and defined clusters of distinct pathophysiology with shared underlying molecular pathways. Integration of data on tissue specificity and single-cell transcriptomics prioritised liver-derived proteins in circulation as candidate effectors of coronary artery disease, highlighting inter-alpha-trypsin inhibitor heavy chain H4 (ITIH4) as a putative effector. Using a liver-targeted CRISPR gene-editing platform, we show that in vivo disruption of ITIH4 reduces plasma cholesterol and pro-atherogenic lipid species in a preclinical model, consistent with a causal role in cardiovascular disease. Our study enables study of large-scale proteomics in diverse populations, provides a systematic map of protein associations of cardiovascular diseases, and demonstrates the utility of genetically imputed proteomes for target discovery and experimental validation. To facilitate proteomic analyses for the research community, the resultant models and association results have been made freely available through the OmicsPred platform.

BACKGROUND:The COVID-19 pandemic led to substantial health services disruption in England. Health-care policy makers need reliable national-level information on disease burden to plan services. Whole-population individual-level data, which are routinely collected and linked across multiple sources, provide comprehensive estimates that can be regularly updated at low cost. We aimed to measure the burden of cardiovascular diseases in the whole population of England from 2020 to 2024. METHODS:Using linked National Health Service England hospital, primary care, death, and specialist registers between Jan 1, 2020, and May 31, 2024, we defined 79 common and rare cardiovascular diseases, and estimated incidence, prevalence, 30-day case fatality, and post-diagnosis rates of myocardial infarction and ischaemic stroke, focusing on five common conditions (myocardial infarction, ischaemic stroke, heart failure, atrial fibrillation, and peripheral vascular disease), as well as pulmonary embolism, myocarditis, and intracranial venous thrombosis. We conducted subgroup analyses based on and adjusted for age, sex, ethnicity, long-term conditions, deprivation, and geographical area. FINDINGS:Analysis of data for 57 406 990 people in England between 2020 and 2024 revealed changes in cardiovascular disease burden. Although incidences after the pandemic were generally stable for the five common diagnoses, myocardial infarction (events per 100 000 person-years: 245·2 vs 216·9; -12%, 95% CI -17 to -6; p=0·0003) and peripheral vascular disease (97·9 vs 86·5; -12%, -21 to -1; p=0·032) showed decreases compared with January to February, 2020. Prevalence increased for ischaemic stroke (1·5% vs 1·8%; +16%, 10 to 21; p<0·0001), heart failure (0·9% vs 1·2%; +25%, 17 to 34; p<0·0001), and atrial fibrillation (2·8% vs 2·9%; +3%; 2 to 5; p=0·0001). There was little change in 30-day case fatality for most common diagnoses before and after the pandemic. Post-diagnosis myocardial infarction and stroke rates from 30 days to 1 year increased for myocardial infarction (events per 100 000 person-years: 18 850 vs 21 289; +13%, 5 to 22; p=0·0023), ischaemic stroke (11 849 vs 13 574; +15%, 7 to 23; p=0·0008), and heart failure (5821 vs 6393; +10%, 1 to 19; p=0·031) after the pandemic. Subgroup analyses indicated higher burdens among older adults, males, deprived populations, people with multiple long-term conditions, and Asian or Black ethnicities. There were clear regional variations in the incidence of stroke, myocardial infarction, heart failure, atrial fibrillation, and peripheral vascular disease. INTERPRETATION:Our study offers new insights into recent cardiovascular disease patterns and reveals important health inequalities at a whole-population scale for multiple cardiovascular diseases, during and after the COVID-19 pandemic. These inequalities are targets for the improvement of cardiovascular health. FUNDING:British Heart Foundation Data Science Centre (Health Data Research UK).

PurposeBangladesh has experienced a rapid epidemiological transition from communicable to non-communicable diseases (NCDs) in recent decades. There is, however, limited evidence about multidimensional determinants of NCDs in this population. The BangladEsh Longitudinal Investigation of Emerging Vascular and nonvascular Events (BELIEVE) study is a household-based prospective cohort study established to investigate biological, behavioural, environmental and broader determinants of NCDs.ParticipantsBetween January 2016 and March 2020, 73 883 participants (aged 11 years or older) were recruited from 30 817 households across urban, urban-poor (‘slum’) and rural settings in Bangladesh. A structured questionnaire was administered by trained personnel recording participants’ demographic, socioeconomic, behavioural, medical, environmental and other factors. Anthropometric measurements and blood pressure were recorded for each participant. Biological specimens were collected and aliquoted for long-term storage and analysis.Findings to dateOf the 73 883 study participants (mean [SD] baseline age: 39 [15] years), 43 470 (59%) were females, and 38 848 (52%) had no or only primary-level education. Focusing only on the 65 822 adult participants aged 20–79 years at baseline, 15 411 (23%) reported being diagnosed with hypertension; 10 578 (16%) with type 2 diabetes and 7624 (12%) with hypercholesterolaemia. Age and sex-standardised prevalences of these conditions were much higher in urban than slum and rural settings. Overall, the mean (SD) body mass index (BMI) was 25 (5) kg/m2, with 10 442 (16%) participants aged 20–79, classified as obese (ie, BMI≥30 kg/m2). Mean BMI was also higher in urban than slum and rural areas.Future plansThe collection of information during the baseline visit was completed in 2020. Regular longitudinal follow-up is ongoing for ascertainment and adjudication of a range of fatal and non-fatal health outcomes among participants. This cohort will provide a powerful resource to investigate multidimensional determinants of incident NCDs across diverse settings in Bangladesh, helping to advance scientific discovery and public health action in an archetypal low-middle-income country with pressing public health needs.

BACKGROUND AND AIMS:Clinical biomarkers, nuclear magnetic resonance (NMR) metabolomics biomarker scores, and polygenic risk scores (PRS) have shown promise for improving cardiovascular disease (CVD) prediction but have not yet been evaluated in the context of current prediction models (SCORE2) and ESC recommendations for 10-year prediction of fatal and non-fatal CVD. METHODS:NMR metabolomic biomarker scores were constructed and compared to clinical biomarkers, PRS and SCORE2 in 297 463 UK Biobank participants (8919 incident CVD cases) aged 40-69 without previous CVD, diabetes, or lipid-lowering treatment. Improvement in risk discrimination when added to SCORE2 was assessed using Harrel's C-index. Improvement in risk stratification following ESC guideline risk thresholds was assessed using categorical net reclassification. Population modelling was subsequently applied to estimate the impact on CVD prevention if applied at scale. RESULTS:Risk discrimination provided by SCORE2 (C-index: 0.719) improved when 11 clinical biomarkers (ΔC-index: 0.014 [0.012-0.015]), NMR metabolomic biomarker scores (ΔC-index: 0.010 [0.009-0.012]) and PRSs (ΔC-index 0.009; [0.008-0.011]) were added individually. The combination of 11 clinical biomarkers, NMR metabolomic biomarker scores, and PRSs yielded the largest improvement risk discrimination, with ΔC-index 0.024 (0.022-0.027). Concomitant improvements in risk stratification were observed in categorical net reclassification index, with net case reclassification of 16.66% (15.50%-17.81%). Modelling suggested that addition of these biomarkers to SCORE2 for targeted risk reclassification would increase the number of CVD events prevented per 100 000 screened from 229 to 413 (ΔCVDprevented: 184 [174-194]) while essentially maintaining the number of statins prescribed per CVD event prevented. CONCLUSIONS:Combining NMR metabolomic, polygenic, and clinical biomarkers with SCORE2 enhanced prediction of first-onset CVD and could have substantial population health benefit if applied at scale.

Background Deterioration of the cardiac conduction system is an important manifestation of cardiac ageing. Cellular ageing is accompanied by telomere shortening and telomere length (TL) is often regarded as a marker of biological ageing, potentially adding information regarding conduction disease over and above chronological age. We therefore sought to evaluate the association between leucocyte telomere length (LTL) on two related, but distinct aspects of the cardiac conduction system: ECG measures of conduction (PR interval and QRS duration) and incident pacemaker implantation in a large population-based cohort.Methods In the UK Biobank, we measured PR interval and QRS duration from signal-averaged ECG waveforms in 59 868 and 62 266 participants, respectively. Incident pacemaker implantation was ascertained using hospital episode data from 420 071 participants. Associations with LTL were evaluated in (Cox) multivariable regression analyses adjusted for potential confounders. Putative causal effects of LTL were investigated by mendelian randomisation (MR).Results Mean PR interval and QRS duration were 144.2 ms (+/- 20.4) and 92.3 ms (+/- 7.8), respectively, and there were 7169 (1.7%) incident pacemaker implantations, during a median follow-up period of 13.6 (IQR 1.5) years. LTL was significantly associated with PR interval (0.19 ms (95% CI: 0.03 to 0.35), per 1 SD shorter LTL, p=0.021), but not QRS duration. After adjusting for age, sex and cardiovascular risk factors, shorter LTL remained associated with an increased risk for incident pacemaker implantation (HR per SD decrease in LTL: 1.03 (95% CI: 1.01 to 1.06), p=0.012). MR analysis showed a trend towards an association of shorter LTL with longer PR interval and higher risk of pacemaker implantation but was likely to be underpowered.Conclusions Shorter LTL was significantly, and possibly causally, associated with prolongation of atrioventricular conduction and pacemaker implantation, independent of traditional cardiovascular risk factors. Our findings support further research to explore the role of ageing on cardiac conduction beyond chronological age.

AIMS:Associations of saturated and unsaturated fatty acids (FAs) with cardiovascular disease (CVD) remain controversial. We therefore aimed to investigate the prospective associations of objectively measured FAs with CVD, including incident coronary heart disease (CHD) and stroke, as well as CVD mortality. METHODS AND RESULTS:Circulating FA concentrations expressed as the percentage of total FAs were assayed in 172 891 participants without prior vascular disease at baseline from the European Prospective Investigation into Cancer and Nutrition-CVD (EPIC-CVD) (7343 CHD; 6499 stroke), UK Biobank (1825; 1474), and INTERVAL (285; 209) cohort studies. Hazard ratio (HR) per 1-standard deviation (SD) higher FA concentrations was estimated using Cox regression models and pooled by random-effects meta-analysis. Systematic reviews with meta-analysis published by 6 May 2023 on associations between FAs and CVDs were systematically searched and updated meta-analyses using random-effects model were conducted. Evidence from randomized controlled trials (RCTs) was also summarized. Higher concentrations of total saturated FAs (SFAs) were associated with higher cardiovascular risks in the combined analysis, with differential findings noted for SFA sub-types in further analysis restricted to EPIC-CVD: positive associations for even-chain SFA [HR for CHD 1.24 (95% CI: 1.18-1.32); stroke 1.23 (1.10-1.38)] and negative associations for odd-chain [0.82 (0.76-0.87); 0.73 (0.67-0.78)] and longer-chain [0.95 (0.80-1.12); 0.84 (0.72-0.99)] SFA. In the combined analysis, total n-3 polyunsaturated FA (PUFA) [0.91 (0.85-0.97)], including docosahexaenoic acid (DHA) [0.91 (0.84-0.98)], was negatively associated with incident CHD risk. Similarly, total n-6 PUFA [0.94 (0.91-0.98)], including linoleic acid (LA) [0.89 (0.83-0.95)], was negatively associated with incident stroke risk. In contrast, more detailed analyses in EPIC-CVD revealed that several downstream n-6 PUFAs of LA were positively associated with CHD risk. Updated meta-analyses of 37 FAs including 49 non-overlapping studies, involving between 7787 and 22 802 CHD cases and between 6499 and 14 221 stroke cases, showed broadly similar results as our combined empirical analysis and further suggested significant inverse associations of individual long-chain n-3 PUFAs and LA on both CHD and stroke. The findings of long-chain n-3 PUFAs were consistent with those from published RCTs on CHD despite insufficient evidence in monotherapy, while RCT evidence remained unclear for the rest of the explored FAs. CONCLUSION:Our study provides an overview of the most recent evidence on the associations between objectively measured FAs and CVD outcomes. Collectively, the data reveal notable differences in associations by SFA sub-types and call for further studies, especially RCTs, to explore these links.

Genome-wide association studies have identified thousands of variants associated with disease risk but the mechanism by which such variants contribute to disease remains largely unknown. Indeed, a major challenge is that variants do not act in isolation but rather in the framework of highly complex biological networks, such as the human metabolic network, which can amplify or buffer the effect of specific risk alleles on disease susceptibility. Here we use genetically predicted reaction fluxes to perform a systematic search for metabolic fluxes acting as buffers or amplifiers of coronary artery disease (CAD) risk alleles. Our analysis identifies 30 risk locus-reaction flux pairs with significant interaction on CAD susceptibility involving 18 individual reaction fluxes and 8 independent risk loci. Notably, many of these reactions are linked to processes with putative roles in the disease such as the metabolism of inflammatory mediators. In summary, this work establishes proof of concept that biochemical reaction fluxes can have non-additive effects with risk alleles and provides novel insights into the interplay between metabolism and genetic variation on disease susceptibility.

The biological mechanisms through which most nonprotein-coding genetic variants affect disease risk are unknown. To investigate gene-regulatory mechanisms, we mapped blood gene expression and splicing quantitative trait loci (QTLs) through bulk RNA sequencing in 4,732 participants and integrated protein, metabolite and lipid data from the same individuals. We identified cis-QTLs for the expression of 17,233 genes and 29,514 splicing events (in 6,853 genes). Colocalization analyses revealed 3,430 proteomic and metabolomic traits with a shared association signal with either gene expression or splicing. We quantified the relative contribution of the genetic effects at loci with shared etiology, observing 222 molecular phenotypes significantly mediated by gene expression or splicing. We uncovered gene-regulatory mechanisms at disease loci with therapeutic implications, such as WARS1 in hypertension, IL7R in dermatitis and IFNAR2 in COVID-19. Our study provides an open-access resource on the shared genetic etiology across transcriptional phenotypes, molecular traits and health outcomes in humans ( https://IntervalRNA.org.uk ).

BACKGROUND:Epidemiological evidence suggests that a potential association between dietary protein intake and cardiovascular disease (CVD) may depend on the protein source, that is, plant- or animal-derived, but past research was limited and inconclusive. OBJECTIVES:To evaluate the association of dietary plant- or animal-derived protein consumption with risk of CVD, and its components ischemic heart disease (IHD) and stroke. METHODS:This analysis in the European Prospective Investigation into Cancer and Nutrition (EPIC)-CVD case-cohort study included 16,244 incident CVD cases (10,784 IHD and 6423 stroke cases) and 15,141 subcohort members from 7 European countries. We investigated the association of estimated dietary protein intake with CVD, IHD, and stroke (total, fatal, and nonfatal) using multivariable-adjusted Prentice-weighted Cox regression. We estimated isocaloric substitutions of replacing fats and carbohydrates with plant- or animal-derived protein and replacing food-specific animal protein with plant protein. Multiplicative interactions between dietary protein and prespecified variables were tested. RESULTS:Neither plant- nor animal-derived protein intake was associated with incident CVD, IHD, or stroke in adjusted analyses without or with macronutrient-specified substitution analyses. Higher plant-derived protein intake was associated with 22% lower total stroke incidence among never smokers [HR 0.78, 95% confidence intervals (CI): 0.62, 0.99], but not among current smokers (HR 1.08, 95% CI: 0.83, 1.40, P-interaction = 0.004). Moreover, higher plant-derived protein (per 3% total energy) when replacing red meat protein (HR 0.52, 95% CI: 0.31, 0.88), processed meat protein (HR 0.39, 95% CI: 0.17, 0.90), and dairy protein (HR 0.54, 95% CI: 0.30, 0.98) was associated with lower incidence of fatal stroke. CONCLUSION:Plant- or animal-derived protein intake was not associated with overall CVD. However, the association of plant-derived protein consumption with lower total stroke incidence among nonsmokers, and with lower incidence of fatal stroke highlights the importance of investigating CVD subtypes and potential interactions. These observations warrant further investigation in diverse populations with varying macronutrient intakes and dietary patterns.

Background Nutri-Score is a scientifically validated 5-color front-of-pack nutrition label reflecting the nutrient profile of foods. It has been implemented in several European countries on a voluntary basis, pending the revision of the European labeling regulation. Hence, scientific evidence is needed regarding the ability of the nutrient profile underlying the Nutri-Score (uNS-NPS, 2023-updated version) to characterize healthier foods. Our objective was therefore to study the prospective association between the nutritional quality of diet characterized by the uNS-NPS and the risk of cardiovascular diseases in a large European population. Methods Our analyses included 345,533 participants from the European Prospective Investigation into Cancer and Nutrition study (EPIC, 1992-2010, 7 European countries). Food intakes were assessed at baseline using country-specific dietary questionnaires. The uNS-NPS was calculated as a continuous scale for each food, based on its 100 g content of energy, sugars, saturated fatty acids, salt, fibre, and protein and percentage content of fruit, vegetables, and pulses. A dietary index was derived at the individual level (uNS-NPS DI: energy-weighted mean of uNS-NPS scores of all foods consumed by a participant). Cardiovascular events during follow-up were retrieved using country-specific methods (self-report, registry data). Multi-adjusted Cox models were computed. Findings Overall, 16,214 first cardiovascular events were reported (median follow-up: 12.3 years; 4,103,133 person-years). The consumption of foods with a higher uNS-NPS score (reflecting a lower overall nutritional quality of diet) was associated with higher risks of total cardiovascular events (Hazards Ratio (HR) for an increment of 1 standard deviation: 1.03 (95% Confidence Interval 1.01-1.05)), especially myocardial infarction (HR = 1.03 (1.01-1.07)), and stroke (HR = 1.04 (1.01-1.07)). Interpretation In this large prospective study among European adults, a higher risk of cardiovascular diseases (total and several subtypes) was observed in individuals consuming a diet with a lower nutritional value, as graded by the uNS-NPS score. This brings new evidence on the relevance of the updated nutrient profile underlying the Nutri-Score to characterize foods with a healthier nutrient profile. Copyright (c) 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

BACKGROUND:Heart failure is common, complex, and often associated with coexisting chronic medical conditions and a high mortality. We aimed to assess the epidemiology of people admitted to hospital with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), including the period covering the COVID-19 pandemic, which was previously not well characterised. METHODS:In this retrospective, cohort study, we used whole-population electronic health records with 57 million individuals in England to identify patients hospitalised with heart failure as the primary diagnosis in any consultant episode of an in-patient admission to a National Health Service (NHS) hospital. We excluded individuals with less than 1 year of medical history records in primary or secondary care; admissions to NHS hospitals for which less than 10% of heart failure cases were linkable to the National Heart Failure Audit (NHFA); individuals younger than 18 years at the time of the heart failure hospitalisation; and patients who died in hospital during the index heart failure admission. For patients with new onset heart failure, we assessed incidence rates of 30-day and 1-year all-cause and cause-specific (cardiovascular, non-cardiovascular, and heart failure-related) emergency rehospitalisation and mortality after discharge, and dispensed guideline-recommended medical therapy (GRMT). Follow-up occurred from the index admission to the earliest occurrence of the event of interest, death, or end of data coverage. We estimated adjusted hazard ratios (HRs) to compare HFrEF with HFpEF. We computed population-attributable fractions to quantify the percentage of outcomes attributable to coexisting chronic medical conditions. FINDINGS:Among 233 320 patients identified who survived the index heart failure admission across 335 NHS hospitals between Jan 1, 2019, and Dec 31, 2022, 101 320 (43·4%) had HFrEF, 71 910 (30·8%) had HFpEF, and 60 090 (25·8%) had an unknown classification. In patients with new onset heart failure, there were reductions in all-cause 30-day (-5·2% [95% CI -7·7 to -2·6] in 2019-22) and 1-year rehospitalisation rates (-3·9% [-6·6 to -1·2]). Declining 30-day rehospitalisation rates affected patients with HFpEF (-4·8% [-9·2 to -0·2]) and HFrEF (-6·2% [-10·5 to -1·6]), although 1-year rates were not statistically significant for patients with HFpEF (-2·2% [-6·6 to 2·3] vs -5·7% [-10·6 to -0·5] for HFrEF). There were no temporal trends in incidence rates of 30-day or 1-year mortality after discharge. The rates of all-cause (HR 1·20 [1·18-1·22]) and cause-specific rehospitalisation were uniformly higher in those with HFpEF than those with HFrEF. Patients with HFpEF also had higher rates of 1-year all-cause mortality after discharge (HR 1·07 [1·05-1·09]), driven by excess risk of non-cardiovascular death (HR 1·25 [1·21-1·29]). Rates of rehospitalisation and mortality were highest in patients with coexisting chronic kidney disease, chronic obstructive pulmonary disease, dementia, and liver disease. Chronic kidney disease contributed to 6·5% (5·6-7·4) of rehospitalisations within 1 year for HFrEF and 5·0% (4·1-5·9) of rehospitalisations for HFpEF, double that of any other coexisting condition. There was swift implementation of newer GRMT, but markedly lower dispensing of these medications in patients with coexisting chronic kidney disease. INTERPRETATION:Rates of rehospitalisation in patients with heart failure in England have decreased during 2019-22. Further population health improvements could be reached through enhanced implementation of GRMT, particularly in patients with coexisting chronic kidney disease, who, despite being at high risk, remain undertreated. FUNDING:Wellcome Trust, Health Data Research UK, British Heart Foundation Data Science Centre.

As the heritability of abdominal aortic aneurysm (AAA) is high and AAA partially shares genetic architecture with other cardiovascular diseases, genetic information could help inform AAA screening strategies. Exploiting pleiotropy and meta-analysing summary data from large studies, we construct a polygenic risk score (PRS) for AAA. Leveraging related traits improves PRS performance (R2) by 22.7%, relative to using AAA alone. Compared with the low PRS tertile, intermediate and high tertiles have hazard ratios for AAA of 2.13 (95%CI 1.61, 2.82) and 3.70 (95%CI 2.86, 4.80) respectively, adjusted for clinical risk factors. Using simulation modelling, we compare PRS- and smoking-stratified screening with inviting men at age 65 and not inviting women (current UK strategy). In a futuristic scenario where genomic information is available, our modelling suggests inviting male current smokers with high PRS earlier than 65 and screening female smokers with high/intermediate PRS at 65 and 70 respectively, may improve cost-effectiveness.

The genetic factors of stroke in South Asians are largely unexplored. Exome-wide sequencing and association analysis (ExWAS) in 75K Pakistanis identified NM_000435.3(NOTCH3):c.3691C>T, encoding the missense amino acid substitution p.Arg1231Cys, enriched in South Asians (alternate allele frequency = 0.58% compared to 0.019% in Western Europeans), and associated with subcortical hemorrhagic stroke [odds ratio (OR)=3.39, 95% confidence interval (CI)=[2.26, 5.10], p=3.87x10(-9)), and all strokes (OR [CI]=2.30 [1.77, 3.01], p=7.79x10(-10)). NOTCH3 p.Arg231Cys was strongly associated with white matter hyperintensity on MRI in United Kingdom Biobank (UKB) participants (effect [95% CI] in SD units=1.1 [0.61, 1.5], p=3.0x10(-6)). The variant is attributable for approximately 2.0% of hemorrhagic strokes and 1.1% of all strokes in South Asians. These findings highlight the value of diversity in genetic studies and have major implications for genomic medicine and therapeutic development in South Asian populations.

Background: South Asians may be particularly susceptible to premature myocardial infarction (MI) owing both to classic cardiovascular risk factors and distinctive practices more common in South Asian populations. Hypothesis: Identifying modifiable risk factors for MI in South Asian populations should inform prevention strategies. Goal: To study conventional risk factors and several distinctive South Asian characteristics and practices in relation to the likelihood of first-ever MI in Bangladesh. Methods: In a case-control study involving 8,133 first MI cases and 8,122 controls, we calculated odds ratios (ORs) for MI (adjusted, when appropriate, for age, sex, smoking status, history of diabetes, history of hypertension, family history of MI, and LDL-cholesterol) and assessed their potential public health impact using population attributable fractions (PAFs). Results: The mean (SD) age of first MI was 53 (11) years. Adjusted ORs (95% CIs) were 2.75 (2.53-2.99) for cigarette smoking, 2.33 (2.08-2.60) for parental history of MI, 2.26 (2.07-2.48) for history of hypertension, 1.79 (1.61-1.98) for history of diabetes, and 1.61 (1.55-1.67) per 1-SD higher LDL-cholesterol. The highest PAFs (95% CIs) were for current cigarette smoking (48.9% [46.1%-51.6%]), higher LDL-cholesterol (32.4% [30.2%-34.4%]) and history of hypertension (14.7% [13.2%-16.1%]). As for regionally distinctive practices, ORs were 4.05 (3.15-5.21) with biri smoking, 2.04 (1.48-2.81) with chewing tobacco, and 1.26 (1.05-1.51) with parental history of first cousin marriage. Conclusion: In a large case-control study, we confirmed the relevance of several conventional risk factors to risk of first-onset MI in the Bangladesh population. We also identified significant associations with MI of practices distinctive to South Asian populations, including indigenous modes of tobacco consumption and parental first-cousin marriage, apparently independent of conventional risk factors. These findings should help identify opportunities for cardiovascular disease prevention in South Asia that embrace both conventional and regionally distinctive risk factors.

Restless legs syndrome (RLS) affects up to 10% of older adults. Their healthcare is impeded by delayed diagnosis and insufficient treatment. To advance disease prediction and find new entry points for therapy, we performed meta-analyses of genome-wide association studies in 116,647 individuals with RLS (cases) and 1,546,466 controls of European ancestry. The pooled analysis increased the number of risk loci eightfold to 164, including three on chromosome X. Sex-specific meta-analyses revealed largely overlapping genetic predispositions of the sexes (rg = 0.96). Locus annotation prioritized druggable genes such as glutamate receptors 1 and 4, and Mendelian randomization indicated RLS as a causal risk factor for diabetes. Machine learning approaches combining genetic and nongenetic information performed best in risk prediction (area under the curve (AUC) = 0.82-0.91). In summary, we identified targets for drug development and repurposing, prioritized potential causal relationships between RLS and relevant comorbidities and risk factors for follow-up and provided evidence that nonlinear interactions are likely relevant to RLS risk prediction.

AIMS:The 2021 European Society of Cardiology prevention guidelines recommend the use of (lifetime) risk prediction models to aid decisions regarding initiation of prevention. We aimed to update and systematically recalibrate the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model to four European risk regions for the estimation of lifetime CVD risk for apparently healthy individuals. METHODS AND RESULTS:The updated LIFE-CVD (i.e. LIFE-CVD2) models were derived using individual participant data from 44 cohorts in 13 countries (687 135 individuals without established CVD, 30 939 CVD events in median 10.7 years of follow-up). LIFE-CVD2 uses sex-specific functions to estimate the lifetime risk of fatal and non-fatal CVD events with adjustment for the competing risk of non-CVD death and is systematically recalibrated to four distinct European risk regions. The updated models showed good discrimination in external validation among 1 657 707 individuals (61 311 CVD events) from eight additional European cohorts in seven countries, with a pooled C-index of 0.795 (95% confidence interval 0.767-0.822). Predicted and observed CVD event risks were well calibrated in population-wide electronic health records data in the UK (Clinical Practice Research Datalink) and the Netherlands (Extramural LUMC Academic Network). When using LIFE-CVD2 to estimate potential gain in CVD-free life expectancy from preventive therapy, projections varied by risk region reflecting important regional differences in absolute lifetime risk. For example, a 50-year-old smoking woman with a systolic blood pressure (SBP) of 140 mmHg was estimated to gain 0.9 years in the low-risk region vs. 1.6 years in the very high-risk region from lifelong 10 mmHg SBP reduction. The benefit of smoking cessation for this individual ranged from 3.6 years in the low-risk region to 4.8 years in the very high-risk region. CONCLUSION:By taking into account geographical differences in CVD incidence using contemporary representative data sources, the recalibrated LIFE-CVD2 model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making for cardiovascular prevention as recommended by 2021 European guidelines.

Metabolomic platforms using nuclear magnetic resonance (NMR) spectroscopy can now rapidly quantify many circulating metabolites which are potential biomarkers of cardiovascular disease (CVD). Here, we analyse ∼170,000 UK Biobank participants (5,096 incident CVD cases) without a history of CVD and not on lipid-lowering treatments to evaluate the potential for improving 10-year CVD risk prediction using NMR biomarkers in addition to conventional risk factors and polygenic risk scores (PRSs). Using machine learning, we developed sex-specific NMR scores for coronary heart disease (CHD) and ischaemic stroke, then estimated their incremental improvement of 10-year CVD risk prediction when added to guideline-recommended risk prediction models (i.e., SCORE2) with and without PRSs. The risk discrimination provided by SCORE2 (Harrell’s C-index = 0.718) was similarly improved by addition of NMR scores (ΔC-index 0.011; 0.009, 0.014) and PRSs (ΔC-index 0.009; 95% CI: 0.007, 0.012), which offered largely orthogonal information. Addition of both NMR scores and PRSs yielded the largest improvement in C-index over SCORE2, from 0.718 to 0.737 (ΔC-index 0.019; 95% CI: 0.016, 0.022). Concomitant improvements in risk stratification were observed in categorical net reclassification index when using guidelines-recommended risk categorisation, with net case reclassification of 13.04% (95% CI: 11.67%, 14.41%) when adding both NMR scores and PRSs to SCORE2. Using population modelling, we estimated that targeted risk-reclassification with NMR scores and PRSs together could increase the number of CVD events prevented per 100,000 screened from 201 to 370 (ΔCVDprevented: 170; 95% CI: 158, 182) while essentially maintaining the number of statins prescribed per CVD event prevented. Overall, we show combining NMR scores and PRSs with SCORE2 moderately enhances prediction of first-onset CVD, and could have substantial population health benefit if applied at scale. ### Competing Interest Statement During the course of this project P.S. became a full-time employee of GSK Plc. All significant contributions to this study were made prior to this role and GSK Plc had no input to the study. J.D. serves on scientific advisory boards for AstraZeneca, Novartis, and UK Biobank, and has received multiple grants from academic, charitable and industry sources outside of the submitted work. A.S.B. reports institutional grants from AstraZeneca, Bayer, Biogen, BioMarin, Bioverativ, Novartis, Regeneron and Sanofi. The remaining authors declare no competing interests. ### Funding Statement This work was performed using resources provided by the Cambridge Service for Data Driven Discovery (CSD3) operated by the University of Cambridge Research Computing Service ([www.csd3.cam.ac.uk][1]), provided by Dell EMC and Intel using Tier-2 funding from the Engineering and Physical Sciences Research Council (capital grant EP/P020259/1), and DiRAC funding from the Science and Technology Facilities Council ([www.dirac.ac.uk][2]). This work was supported by core funding from the: Cambridge BHF Centre of Research Excellence (RE/18/1/34212) and BHF Chair Award (CH/12/2/29428). S.C.R. and S.K. were funded by a British Heart Foundation (BHF) Programme Grant (RG/18/13/33946). S.C.R. was also funded by the National Institute for Health and Care Research (NIHR) Cambridge BRC (BRC-1215-20014; NIHR203312) [*]. X.J. was funded by British Heart Foundation (CH/12/2/29428) and Wellcome Trust (227566/Z/23/Z). L.P. and P.S. were supported by a Rutherford Fund Fellowship from the Medical Research Council grant MR/S003746/1. Y.X. and M.I. were supported by the UK Economic and Social Research Council (ES/T013192/1). S.A.L. was supported by a Canadian Institutes of Health Research postdoctoral fellowship (MFE-171279). E.D.A. holds a NIHR Senior Investigator Award. J.D. holds a BHF Professorship and a NIHR Senior Investigator Award. M.I. is supported by the Munz Chair of Cardiovascular Prediction and Prevention and the NIHR Cambridge Biomedical Research Centre (NIHR203312). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. *The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved under UK Biobank Projects 30418 and ethics approval was obtained from the North West Multi-Center Research Ethics Committee. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data described are available through UK Biobank subject to approval from the UK Biobank access committee. See for further details. [1]: http://www.csd3.cam.ac.uk [2]: http://www.dirac.ac.uk

AbstractDespite widespread use of drugs targeting traditional cardiovascular risk factors such as lipids and blood pressure, a high burden of coronary heart disease (CHD) remains, hence novel therapeutics are needed for people who harbor residual risk. Using transcriptomic and proteomic data to instrument 15,527 genes or proteins, we conducted systematiccis-Mendelian randomization (MR) and conditional colocalization analyses with a genetic meta-analysis involving nearly 300,000 CHD cases. We identified 567 targets with putative causal relevance to CHD, of which 69 were not identified in previous genetic discovery or MR studies and were the sole causal signal in that genomic region. To aid translation of our findings, we annotated results with up-to-date information on drugs acting on these targets. Our results revealed opportunities for drug repurposing and development prioritization. For example, we provide evidence that cilostazol, a drug that targetsPDE3Aand is currently used for claudication, could be repurposed for prevention of CHD.