BACKGROUND:Although Sweden and Canada are high-income countries with similar social structures, obesity prevalence is significantly higher in Canada. This study explored country-specific differences in the association between socioeconomic and behavioural risk factors for obesity in Sweden and Canada, using data from the Prospective Urban Rural Epidemiological (PURE) study. METHODS:This cross-sectional study included 9 790 adults aged 34-60 years from Canada (n = 6 652, 55% women) and Sweden (n = 3 138, 54% women). The Boruta algorithm was used to identify relevant factors that were associated with obesity among individual with normal weight (body mass index [BMI]: 18.5-<25 kg/m2) compared to individuals with obesity (BMI > 30 kg/m2). Logistic regression models with 95% confidence intervals (CI) estimated odds ratios (OR) of obesity by country in relation to selected risk factors for obesity. RESULTS:More Canadians than Swedes had obesity (26 vs. 16%, p-value: <0.001). Ultra-processed food (UPF) and the Alternative Healthy Eating Index (AHEI-2010) score were identified as the main drivers of obesity risk. The highest UPF intake group was strongly associated with obesity in both Canada (OR = 2.31 [CI = 1.57-3.37]) and Sweden (OR = 2.83 [CI = 2.30-3.49]). Canadian men had higher UPF intake and were found to have a significantly higher risk of obesity (p for interaction: 0.032 and 0.021 for middle and highest tertiles), compared to Swedish males. Among women, low socioeconomic status (rural residence (OR = 2.30 [CI = 1.66-3.17] vs. OR = 1.42 [CI = 1.19-1.70]), low income (OR = 4.75 [CI = 2.71-8.95] vs. OR = 2.62 [CI = 2.16-3.18]), not working (OR = 2.24 [CI = 1.51-3.29] vs. OR = 1.32 [CI = 1.07-1.63]), and unskilled occupation (OR = 5.08 [CI = 3.05-8.45] vs. OR = 1.78 [CI = 1.38-2.28]) was more strongly associated with obesity in Sweden than in Canada. CONCLUSIONS:This study highlights important differences in obesity-related risk factors between Sweden and Canada. UPF consumption, the AHEI-2010 score and socioeconomic disadvantage emerged as key drivers of obesity, with notable sex- and country-specific patterns. These findings underscore the importance of tailored, context-specific public health strategies to address obesity in different national settings.

AIMS:Pulmonary abnormalities are commonly reported in heart failure (HF) and may have prognostic implications. Current evidence is limited to high-income countries. We examined the relationship between forced expiratory volume in 1 second (FEV1), HF burden, and long-term clinical outcomes in a diverse multi-national HF cohort. METHODS AND RESULTS:In a sub-study within the multinational Global Congestive Heart Failure registry, which collected clinical data including spirometry from HF participants in 28 high-, middle-, and low-income countries, and followed for a median 3.8 (IQR 2.1, 5.0) years. Baseline FEV1 was transformed into z-scores standardized for age, sex, and height. The association between baseline FEV1 with all-cause mortality, cardiovascular (CV) deaths, and all-cause hospitalizations was examined. FINDINGS:The analysis included 3359 HF participants (mean age 61.9 [SD 14.1] years, 66.4% males). Participants with lower FEV1 z-scores, even within the normal range (z-score>-2), showed increasing burden of HF, cardiac structural and functional impairment, and lower health-related quality of life. FEV1 z-score ≤ -2 was independently associated with higher risks of all-cause (HR 2.20 [95%CI 1.61-3.01]), CV mortality (HR 2.45 [1.64-3.66]), and hospitalizations (HR 1.40 [1.12-1.74]). The effect sizes were comparable to those of other major prognostic factors. The association was consistent across populations from diverse socio-economic development, HF aetiology, HF types, and airflow obstruction. CONCLUSION:In a diverse, multi-national HF cohort, reductions in FEV1 were independently associated with higher HF burden and poor health outcomes. The effect of lower FEV1 was generalizable across the HF spectrum and comparable to other major established HF prognostic factors.

BACKGROUND:Observational studies suggest that metabolic/bariatric surgery (MBS) reduces mortality and major adverse cardiovascular events in patients with obesity, but adequately powered randomized trials (RCTs) are lacking. The Bariatric Surgery for the Reduction of Cardiovascular Events (BRAVE) trial was designed to address this evidence gap. METHODS:BRAVE is an investigator-initiated, multi-center, open-label RCT with blinded endpoint adjudication comparing MBS vs guideline-based medical weight management (MWM) in adults with obesity and high-risk cardiovascular disease (CVD). Eligible participants have a body-mass index ≥35 kg/m² or ≥30 kg/m² with type 2 diabetes or age >55 years, and prior myocardial infarction (MI), coronary intervention, heart failure (HF), atrial fibrillation (AF) with elevated CHA₂DS₂-VASc score, cerebrovascular disease, or peripheral arterial disease. Participants are randomized 1:1 to MBS (sleeve gastrectomy, Roux-en-Y gastric bypass, or duodenal switch) or MWM, which includes dietary, behavioral, and pharmacologic therapies. The primary outcome is the composite of all-cause death, MI, stroke, HF events, coronary revascularization, AF hospitalization, and renal events. A vanguard phase of 200 participants was implemented to optimize recruitment and logistics. RESULTS:As of October 2025, 2,514 individuals have been screened from 17 centers in Canada, Brazil, Italy and Spain, with 444 entered MBS work-up, and 200 have been randomized. The randomized cohort (mean age 59.8 years; 37% female; mean BMI 44.0 kg m⁻²) has high burden of hypertension (82%), diabetes (45%), coronary artery disease (44%), HF (39%), and AF (48%). Recruitment barriers were identified and addressed through targeted education and enhanced patient engagement. CONCLUSIONS:BRAVE is the first large RCT evaluating whether MBS safely reduces major cardiovascular events compared with medical therapy in high-risk patients with obesity. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT05531474.

BACKGROUND AND AIMS:Clinical models incompletely capture the molecular pathways driving heart failure (HF) progression. This study evaluated whether molecular risk stratification provides incremental prognostic information beyond established clinical predictors in patients with HF. METHODS:A total of 2432 patients from the Global Congestive Heart Failure (G-CHF) registry with available genotyping, DNA methylation, and proteomic profiling were analysed. Three molecular scores were assessed: a composite cardiovascular polygenic risk score (PRS) from DNA sequence polymorphisms, a methylation risk score (MRS) derived from epigenome-wide associations, and a 23-protein-based score (ProteomicDeath23). Each score was tested individually and in combination with the clinical Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels for mortality prediction. Validation was performed in an HF subset of the UK Biobank (UKB). RESULTS:Over a median follow-up of 3.0 years in G-CHF, 523 patients died from any cause (7.64 per 100 person-years [PY]). In multivariable analyses, ProteomicDeath23 was the strongest independent predictor of all-cause mortality (hazard ratio [HR] per 1 standard deviation, 2.23), outperforming NT-proBNP (HR 2.00), MRSMortality (HR 1.66), PRSmetaCVD (HR 1.10), and the MAGGIC score (HR 1.70). A model combining ProteomicDeath23 with MAGGIC and NT-proBNP achieved the highest discrimination for mortality (C-index, 0.77). Addition of MRSMortality to this proteomic-clinical model resulted in only small improvements in discrimination (ΔC-index, +0.004, P = .0039), while the PRSmetaCVD provided no incremental benefit. Among patients with low NT-proBNP/MAGGIC score, mortality rates increased from 1.71 to 8.12 per 100 PY across ProteomicDeath23 tertiles. Consistent results were observed in the UKB-HF validation cohort. CONCLUSION:A proteomic score was the strongest molecular predictor of mortality in HF. Integrating proteomic signatures with clinical risk factors significantly improved risk prediction.

BACKGROUND:Air pollution is a risk factor for dementia, but its role in early cognitive dysfunction is not clear. We aimed to investigate the association of air pollution with cognitive function, and the role of cardiovascular risk factors and greenspace in this association. METHODS:The CAHHM (Canadian Alliance for Healthy Hearts and Minds Cohort Study) is a cohort of Canadian adults recruited between 2014 and 2018, for whom averages of exposures to NO2 and fine particulate matter were estimated for 5 years before recruitment. Outcomes included the Montréal Cognitive Assessment and Digit Symbol Substitution Test for cognitive function, and magnetic resonance imaging-measured covert vascular brain injury. Generalized linear mixed models assessed pollutant associations with outcomes in this cross-sectional analysis. RESULTS:A total of 6878 adults participated in the study, with a mean age of 57.6 years (SD=8.8), and 55.6% were women. Mean (SD; range) 5-year pollutant concentrations preceding enrollment for fine particulate matter were 6.9 μg/m3 (2.0 [1.8-11.2]), and for NO2 were 12.9 parts per billion (5.9 [0.9-33.9]). In adjusted models, a 5 μg/m3 higher fine particulate matter concentration was associated with 0.44 points lower Montréal Cognitive Assessment (95% CI, -0.62 to -0.25) and 1.31 points lower Digit Symbol Substitution Test (95% CI, -2.41 to -0.22) scores. A 5 parts per billion higher NO2 concentration was associated with 0.12 points lower Montréal Cognitive Assessment (95% CI, -0.17 to -0.07) and 0.38 points lower Digit Symbol Substitution Test (95% CI, -0.70 to -0.05) scores. A 5 parts per billion higher NO2 concentration was associated with higher odds of covert vascular brain injury (adjusted odds ratio, 1.08 [95% CI, 1.00-1.17]). Cardiovascular risk factors and greenspace did not change these associations. CONCLUSIONS:Fine particulate matter and NO2 were associated with lower cognitive function scores in middle-aged adults living in Canada, independent of cardiovascular risk factors. Our results warrant longitudinal follow-up to study the impact of air pollution on cognitive decline.

Background Prospective cohort studies documenting long-term dietary trends across multiple world regions are lacking. Objective To evaluate 15-year (2007-2022) changes in food and beverage consumption among adults aged 35 to 70 years living in 626 urban and rural communities across 16 high-income (HIC), middle-income (MIC) and low-income (LIC) countries. Methods In the Prospective Urban Rural Epidemiology (PURE) Study, dietary intake was assessed using an abbreviated food-frequency questionnaire at baseline and approximately every 3 years across four follow-up visits over a 15-year calendar period (2007-2022). Linear mixed-effect models and mixed-effect multinomial logistic regression were used to evaluate changes in food and beverage consumption over time . Dietary changes <0.05 servings/day (s/day) are presented as servings/week (s/week). Changes of <0.2 s/day change over the study period were considered modest. Participant demographics (age, sex, urban/rural residence, and education) closely matched national distributions in each country. Results 120,782 participants provided at least one dietary assessment (median follow-up: 12.1 years).Consumption of animal-based products has generally increased, with clear regional differences. Milk increased in China (+0.21 s/day, +0.15 to +0.26), and in LICs (+0.08 s/day, +0.05 to +0.11); decreased in HICs (-0.10 s/day, -0.12 to -0.07) and in MICs (-0.21 s/week, -0.28 to -0.15). Eggs increased in HICs MICs, and China up to 0.12 eggs/day (+0.11 to +0.14); no change in LICs. All regions increased chicken intake. Only HICs increased cooked fish consumption (0.28 s/week, +0.06 to +0.50). By contrast, plant-based food intake has generally decreased, but these changes were generally small and there was some regional variation. Fruit consumption decreased in HICs (-0.16 s/day, -0.18 to -0.14) and MICs (-0.09 s/day, -0.10 to -0.07); increased in China (+0.13 s/day, +0.11 to +0.14) and LICs (+0.22 s/week, +0.16 to +0.29). Fresh and cooked vegetable consumption decreased in HICs [-0.05 s/day (-0.06, -0.04) and -0.17 s/week (-0.30 to -0.03), respectively], MICs [-0.19 s/week (-0.23 to -0.16) and -0.08 s/day (-0.09 to -0.07), respectively], and in China [-0.07 s/day (-0.08 to -0.06) and -0.31 s/week (-0.40 to -0.23), respectively]. In LICs, fresh vegetable consumption increased (+0.19 s/week, +0.12 to +0.26); cooked vegetable intake was unchanged. All regions decreased rice consumption. Conclusions : In this international prospective study, dietary changes for most foods and beverages during the 15-year (2007-2022) study period were modest in size (most changes less than 0.2 s/day) but varied by region. Animal-source food intake generally increased, particularly in rapidly developing economies, while plant-based food intake decreased. As these shifts remain below the magnitude usually associated with measurable changes in disease risk, their clinical importance is uncertain.

Although antihypertensive medication is central to hypertension management, substantial residual risks persist. This study evaluated the associations of healthy lifestyle behaviors with all-cause mortality and cardiovascular disease (CVD) among individuals with hypertension, and assessed whether favorable lifestyles provided additional benefits beyond antihypertensive medication. From the perspective of predictive, preventive, and personalized medicine (PPPM/3PM), we assumed that comprehensive lifestyle assessment could refine risk stratification and help identify priority targets. This study included 16,314 participants with hypertension from the Prospective Urban Rural Epidemiology (PURE)-China study. A healthy lifestyle score (0–6, higher scores indicating healthier behaviors) was constructed based on six lifestyle behaviors. Antihypertensive medication use was defined as regular intake at least once per week. Cox frailty models were used to estimate hazard ratios (HRs) and 95

This Viewpoint from the DSMB of the Women’s Health Initiative studies discusses weighing the evidence of benefits and risks of various estrogen products following the FDA’s decision to remove most box warnings from hormone replacement therapy products.

Evidence on the combined effects of extreme temperature events and PM2.5 exposure on mortality remains limited, particularly in populations outside high-income countries. We aimed to evaluate the associations of extreme heat and cold events with all-cause and cardiovascular mortality in China and their joint effects with PM2.5 exposure. We analyzed data from 43,264 participants aged 35–70 years in the Prospective Urban Rural Epidemiology (PURE)-China cohort across 115 communities in 12 provinces. Daily temperature and PM2.5 exposures during 2008–2021 were assigned at the community level using ERA5-Land and CHAP datasets. Heat and cold events were defined using community-specific percentile thresholds and duration criteria. Time-dependent Cox models were used to estimate associations across climate zones, and climate-specific estimates were pooled using random-effects meta-analysis. Heat- and cold-related analyses were restricted to warm and cold seasons, respectively. During a median follow-up of 11.9 years, heat events during the warm season were associated with increased risks of all-cause and cardiovascular mortality. The strongest association was observed for cardiovascular mortality during heat events lasting ≥ 3 days (95th percentile, P95_3d; HR: 2.51, 95

The European Society of Cardiology (ESC) develops and updates clinical practice guidelines (CPGs) based on the latest evidence. However, their implementation remains suboptimal, leading to missed opportunities to improve cardiovascular (CV) outcomes. The success of CPG implementation is influenced by four key factors: (i) patient-related barriers, (ii) health care professionals' engagement, (iii) the clarity and usability of CPGs, and (iv) the health care system and economic context in which care is delivered. To address these challenges, innovative strategies are needed to bridge the gap between CPG recommendations and clinical practice. The ESC has developed several initiatives to improve implementation, including (i) educational programmes, (ii) examinations for cardiologists, (iii) accreditation policies, and (iv) registries. However, persistent gaps indicate that knowledge dissemination alone is insufficient. A more integrated, structured, and equitable approach to quality-of-care improvement is required. Despite the need for evidence-based implementation strategies, only a limited number of high-quality randomized controlled trials have evaluated individual approaches for CV conditions. Strategies such as text messaging, educational interventions, the involvement of non-physician health workers, structured order sheets, and financial incentives have been tested, but their feasibility and effectiveness can vary across health care systems. Future research should explore the potential of artificial intelligence-enhanced technologies to support and scale implementation efforts. This manuscript reviews current evidence on CPG implementation and proposes strategies to enhance the adoption of best practices in CV care.

BACKGROUND:Life expectancy is increasing globally, but if people are to age healthily, they must do so with fewer limitations in their daily activities. However, information on either the frequency or risk factors for limitations to walking ability or other key activities across different regions of the world is limited. Our aim was to describe the incidence, trajectories, risk factors, and population-attributable fraction of new-onset walking limitations in 25 countries at all socioeconomic levels. METHODS:PURE is an ongoing, prospective cohort study. The current analysis included community-dwelling participants who lived in four high-income countries (HICs), 16 middle-income countries (MICs), and five low-income countries (LICs). Individuals aged 35-70 years at baseline who completed a baseline questionnaire about activity limitations between Jan 12, 2001, and May 6, 2019, were included in our analysis. The activity limitation screen included questions on self-reported difficulty with walking, grasping, bending, seeing close-up, seeing distance, and hearing. The primary outcome was incident walking limitation and our analytic sample comprised those with no walking limitation at baseline. We estimated the incidence rates, adjusted for age and sex, per 100 person-years in the overall PURE population, by country income level (and separately for China) and sex. We used multistate modelling to evaluate trajectories across the life course, analysed across continuous age, through three distinct sequential states: no limitation, walking limitation, and death. We used survival models to evaluate the associations of socioeconomic status, vascular and behavioural factors, community walkability, and incident adverse events, with incident walking limitations. We then calculated the population-attributable fraction of selected modifiable factors and compared the risk factors for walking limitation and mortality. FINDINGS:172 889 people from the PURE cohort answered questions on walking limitations at baseline, 150 221 of whom reported no walking limitation and were included in the multistate model. Of these 150 221 individuals, 122 538 had at least one follow-up assessment with walking limitations data (mean age at baseline 49·7 years [SD 9·5]; 71 424 [58·3%] female and 51 114 [41·7%] male). Mean follow-up was 14·5 years (SD 3·3). Incidence of a new walking limitation per 100 person-years was higher in LICs (3·34 [95% CI 3·27-3·41]), and lowest in China (0·58 [0·56-0·60]), compared with other MICs (1·80 [1·77-1·84]) and HICs (1·31 [1·27-1·37]). The incidence of walking limitation was higher in female participants (1·84 [1·81-1·87]) than in male participants (1·25 [1·22-1·28]). In multistate models, state transitions from no walking limitation to walking limitation and death occurred at a higher rate and earlier in LICs, where the age at which the probability of transitioning to a walking limitation was reached by an estimated one-third of people at 64 years compared with age 76 years in HICs. Female participants had a higher probability of incident walking limitation across the age spectrum compared with male participants. Many socioeconomic, vascular, and behavioural risk factors, community walkability, and incident adverse events, especially incident stroke, were associated with incident walking limitations. The population-level risk factors with the highest population-attributable fractions for walking limitation were low education (11·1% [95% CI 9·9-12·4]), obesity (5·2% [4·7-5·8]), hypertension (3·6% [2·2-5·0]), and low recreational physical activity (4·3% [2·3-6·3]), with obesity being the highest in HICs (12·9% [11·2-14·6]) and low education being the highest elsewhere. Potentially modifiable individual-level risk factors explained approximately 32·9% of the population's risk of walking limitations and approximately 47·4% of mortality, and four of the top five factors were shared for both outcomes (low education, low recreational activity, poor diet, and hypertension). INTERPRETATION:Individuals in LICs had an accelerated transition to walking limitation, which was approximately 12 years earlier than those in HICs. Walking limitation and mortality shared a common set of modifiable risk factors, accounting for almost one-third of the population-level risk of walking limitations and highlighting opportunities for integrated prevention strategies in mid-life that simultaneously target disability and premature mortality across socioeconomic settings. FUNDING:Funding sources are listed at the end of the Article.

Abstract Context Accurate assessment of excess body fat and its cardiometabolic risk is essential in clinical and epidemiologic research. Body mass index (BMI), although widely used, does not capture visceral or ectopic fat. Objective To evaluate how anthropometric measures—BMI, percent body fat, waist circumference (WC), and waist-to-hip ratio (WHR)—relate to MRI-measured visceral adipose tissue (VAT) and hepatic fat fraction (HFF), overall and by sex. Design Cross-sectional analysis within the Canadian Alliance for Healthy Heart and Minds (CAHHM) cohort. Setting Community-based, pan-Canadian prospective study. Patients or Other Participants 6,683 apparently healthy adults (mean age 57±9 years; 3,665 females) with baseline anthropometric and MRI measures; analyses adjusted for study center. Intervention(s) Not applicable. Main Outcome Measure(s) MRI-derived VAT and HFF. Associations were estimated using linear regression and mixed models, stratified by sex, ethnicity, age, and BMI category. Results . Mean BMI was 26.7 kg/m2, WC 88.3 cm, VAT 71 mL, and HFF 5.7%. Females had lower VAT and HFF than males. Correlations with VAT ranged from 0.35–0.77 and with HFF from 0.26–0.47. Each 10-cm higher WC was associated with 21.0 mL higher VAT and 2.1% higher HFF; each 5-kg/m2 higher BMI predicted 24.7 mL and 2.8% higher values. When modeled jointly, WC remained strongly predictive, while BMI contributed modestly. Associations were smaller in females. VAT and HFF increased across WC tertiles within BMI categories. Conclusions . WC is a robust surrogate for visceral and hepatic fat across BMI categories, supporting its use when MRI is not feasible.

The European Society of Cardiology (ESC) develops and updates clinical practice guidelines (CPGs) based on the latest evidence. However, their implementation remains suboptimal, leading to missed opportunities to improve cardiovascular (CV) outcomes. The success of CPG implementation is influenced by four key factors: (i) patient-related barriers, (ii) health care professionals’ engagement, (iii) the clarity and usability of CPGs, and (iv) the health care system and economic context in which care is delivered. To address these challenges, innovative strategies are needed to bridge the gap between CPG recommendations and clinical practice. The ESC has developed several initiatives to improve implementation, including (i) educational programmes, (ii) examinations for cardiologists, (iii) accreditation policies, and (iv) registries. However, persistent gaps indicate that knowledge dissemination alone is insufficient. A more integrated, structured, and equitable approach to quality-of-care improvement is required. Despite the need for evidence-based implementation strategies, only a limited number of high-quality randomized controlled trials have evaluated individual approaches for CV conditions. Strategies such as text messaging, educational interventions, the involvement of non-physician health workers, structured order sheets, and financial incentives have been tested, but their feasibility and effectiveness can vary across health care systems. Future research should explore the potential of artificial intelligence-enhanced technologies to support and scale implementation efforts. This manuscript reviews current evidence on CPG implementation and proposes strategies to enhance the adoption of best practices in CV care.

Background:Although vascular aging and insulin resistance (IR) are recognized contributors to cardiovascular disease (CVD) pathophysiology, their independent and joint associations with CVD outcomes have not been fully clarified in large population-based cohorts. Evidence regarding their complementary rather than mediating roles remains limited. Methods:We used data from the Prospective Urban Rural Epidemiology (PURE) China study, a large prospective cohort comprising 47 931 individuals from 12 provinces across China. Vascular aging was assessed using estimated pulse wave velocity and categorized into supernormal (SVA), healthy (HVA), and early vascular aging (EVA) based on cohort percentiles. IR was evaluated using the triglyceride-glucose (TyG) index. The primary outcome was major CVD events (myocardial infarction, stroke, and heart failure). Cox frailty models with center-level random effects were used to estimate adjusted hazard ratios (aHRs). Results:A total of 40 513 participants with complete information were included in the current study. Over a median follow-up of 11.9 years (interquartile ranges 9.5-12.5), 3615 major CVD events, 829 CVD deaths, and 2344 all-cause deaths occurred. Compared with HVA, EVA was associated with substantially higher risks of major CVD events [aHR = 2.17, 95% confidence interval (CI): 1.99-2.35], CVD mortality (aHR = 4.07, 95% CI: 3.47-4.76), and all-cause mortality (aHR = 2.93, 95% CI: 2.65-3.23), while SVA showed consistently lower risks. Furthermore, higher TyG index levels were independently associated with major CVD event risk in a dose-response manner. Exploratory analyses revealed no significant mediation by the TyG index or interaction between vascular aging and TyG levels. Joint analysis revealed that individuals with both EVA and high TyG had the greatest major CVD risk (aHR = 2.20, 95% CI: 1.75-2.77). Conclusions:EVA and IR were independently associated with higher CVD risk, highlighting the need for integrated vascular-metabolic risk assessment in clinical practice, although further validation is warranted.

Background Most population studies examining heart failure (HF) have been conducted in Western high-income countries (HICs), with limited comparable data from lower-income settings. Objectives The aims of this study were to describe differences in HF incidence and 30-day, 1-year, and 5-year case fatality rates among HF patients from countries at different income levels and in different global regions and to examine the impact of common and potentially modifiable risk factors for incident HF. Methods This analysis of the PURE (Prospective Urban Rural Epidemiology) study included 172,653 individuals from 25 HICs, upper middle-income countries (UMICs), lower middle-income countries (LMICs), and low-income countries (LICs) and 8 geographic regions of the world, followed for a median of 15 years. Age- and sex-standardized HF incidence, as well as 30-day, 1-year, and 5-year HF case fatality, were compared by income group and by geographic region. The population attributable fractions (PAFs) for incident HF related to 13 cardiometabolic, lifestyle, socioeconomic, environmental, and psychosocial risk factors were also estimated. Results The standardized rate of incident HF was 0.39 (95% CI: 0.36-0.41) per 1,000 person-years overall; the rate was highest in UMICs (0.58; 95% CI: 0.52-0.64), followed by HICs (0.36; 95% CI: 0.30-0.43), then LMICs (0.34; 95% CI: 0.30-0.38), and then LICs (0.26; 95% CI: 0.22-0.30). Among regions, the highest HF incidence was in sub-Saharan Africa (1.18; 95% CI: 0.95- 1.41) and Europe and Central Asia (0.86; 95% CI: 0.72-1.00) and lowest in South Asia (0.19; 95% CI: 0.15-0.22). Thirty-day case fatality was highest in LICs (59%) and lowest in HICs (11%); it was highest in South Asia (63%) and sub-Saharan Africa (63%) and lowest in North America (12%). Five-year case fatality after HF diagnosis was highest in LICs (77%) and lowest in HICs (28%); it was highest in South Asia (81%) and sub-Saharan Africa (75%) and lowest in North America (25%). More than 71% of the PAF for HF was attributable to the 13 modifiable risk factors studied, the largest being hypertension (PAF = 25%). Conclusions HF incidence and associated mortality vary substantially across countries at different levels of economic development and by geographic region. Hypertension is the largest population-level risk factor for HF globally. Preventive measures, early diagnosis, and access to guideline-directed medical therapy should be prioritized to reduce global disparities in HF incidence and mortality.

Background: The factors driving Coronavirus disease 2019 (COVID-19) severity and its long-term respiratory sequelae remain poorly understood. This study evaluates whether baseline lung function (LF) influences COVID-related clinical outcomes, mortality, and post-infection LF decline. Methods: Data from 602 participants in the Prospective Urban Rural Epidemiology (PURE)-Colombia study were analyzed. Among these, 200 with confirmed SARS-CoV-2 infection and 402 controls (65% women; 68% aged ≥60 years). All underwent baseline spirometry prior to 2010 and follow-up testing 1-40 months post-recovery. Among infected individuals, 51 (26%) died. Spirometric parameters Forced Expiratory Volume in 1 Second (FEV1), Forced Vital Capacity (FVC), and Peak Expiratory Flow (PEF) were compared using paired t-tests and Cohen's d. Non-parametric data were compared using Wilcoxon s (z statistic). Results: Compared to baseline LF, hospitalized COVID-19 patients showed significant declines in follow-up LF: FEV1 (2.84 vs. 2.34 L; p = 0.002), FVC (3.01 vs. 2.53 L; p = 0.006), and PEF (399 vs. 328 L; p = 0.001). Non-hospitalized COVID-19 cases showed a non-significant downward trend, while controls maintained stable LF. Risk factors for post-COVID FEV1 < 80% predicted included hospitalization, elevated waist-to-hip ratio, and incomplete or absent COVID-19 vaccination. Moderate-to-high physical activity was protective. Post-COVID PEF < 80% predicted was associated with female sex, diabetes mellitus, and subsidized healthcare enrollment. Mortality risk was elevated among individuals with low baseline LF, age > 65, male sex, hypertension, obesity, low physical activity, and reduced handgrip strength. Conclusions: Significant LF decline was observed in hospitalized COVID-19 patients, with minimal changes in outpatients and controls. Identifying clinical and demographic predictors of post-COVID LF impairment may inform targeted interventions to mitigate long-term pulmonary complications.

To determine the prevalence, severity, and morphological subtypes of anemia among adults aged 35–70 years in Türkiye and to examine their distribution according to sex, age, educational level, and urban–rural residence. Cross-sectional analysis of baseline data from a nationally representative prospective cohort study. Community-based study conducted in urban and rural areas across eight provinces in Türkiye. A total of 4,050 adults aged 35–70 years enrolled in the Prospective Urban Rural Epidemiology (PURE) Türkiye cohort between 2008 and 2009 with available hemoglobin measurements. Anemia was defined and classified according to World Health Organization criteria. Primary outcomes were the prevalence and severity of anemia. Secondary outcomes included morphological subtypes based on mean corpuscular volume, mean corpuscular hemoglobin concentration, and red cell distribution width, as well as associations with sociodemographic characteristics and estimated dietary iron and vitamin B12 intake. Overall, 13.6% of participants had anemia, with a significantly higher prevalence in women than in men (19.3% vs. 4.8%; p < 0.001). Microcytic anemia was the most common subtype (51.9%), followed by normocytic anemia (48.1%). Among individuals with anemia, approximately 37% had hypochromic microcytic anemia with elevated red cell distribution width, suggestive of iron deficiency. Anemia prevalence showed an inverse association with educational level (p = 0.009) and was slightly higher in urban than in rural areas (14.4% vs. 12.2%; p = 0.049). Estimated dietary iron and vitamin B12 intake did not differ significantly across anemia subtypes or hemoglobin categories, except for lower vitamin B12 intake among anemic men. Anemia affects a substantial proportion of adults aged 35–70 years in Türkiye, particularly women and individuals with lower educational attainment. The predominance of hypochromic microcytic anemia indicates that iron deficiency and non-nutritional factors may play an important role. These findings support the need for targeted public health strategies and routine anemia screening in high-risk adult populations.

Heart failure (HF) remains a global health challenge that imposes significant clinical and economic burden. Treatment adherence to guideline-directed medical therapy (GDMT) remains a major challenge in the management of HF, despite the availability of guideline-directed medical therapy (GDMT). Polypharmacy and regimen complexity contribute to poor adherence, particularly among older adults and in resource-limited settings. The polypill strategy, involving fixed-dose combinations of essential HF medications, has emerged as a potential solution to simplify treatment regimens, enhance adherence, and improve clinical outcomes. This review explores the potential of polypill therapy as a pragmatic strategy to simplify HF treatment and improve adherence. Drawing on its successful application in other cardiovascular diseases, we propose two implementation approaches for HF: early low-dose initiation for newly diagnosed patients or switching to a pre-specified dose polypill for stable, optimized patients. This review discusses formulations tailored to different HF phenotypes and highlights ongoing clinical trials assessing the efficacy and safety of the polypill in the HF setting. While the polypill approach offers promising benefits, i.e., improved adherence, affordability, and streamlined care, critical considerations regarding the selection of optimal drug components, identification and elimination of potential drug-drug interactions, the definition of appropriate flexible dose combinations, and patient-specific factors are crucial. Future research, particularly real-world clinical trials, is essential to comprehensively evaluate the efficacy, safety, and feasibility of polypill therapy in diverse HF patient populations, ensuring its responsible integration into clinical practice across diverse healthcare settings to mitigate the persistent burden of HF.