Background: Inhibition of IL-4/IL-13-driven inflammation by dupilumab has shown significant clinical benefits in treatment of Objective: Our aim was to assess longitudinal protein and metabolite composition in AD skin during dupilumab treatment. Methods: Skin tape strips (STSs) were collected from lesional/ nonlesional skin of 20 patients with AD during a 16-week dupilumab treatment course and from 20 healthy volunteers (HVs) followed for 16 weeks. STS extracts were examined by liquid chromatography-mass spectrometry proteomic analysis and targeted metabolomics. Results: Approximately 2500 individual proteins were identified in the STS extracts. Of those proteins, 490 were present in at least 80% of the AD and HV skin samples and differentially expressed in the AD skin; the levels of 249 proteins were significantly reduced (cluster 1), and the levels of 136 were significantly increased (cluster 2) in the AD skin versus in the HV skin (both P < .0001). Functionally, cluster 1 included proteins involved in epidermal barrier formation, lysosomal enzymes required for lamellae assembly, and oxidative response. Cluster 2 was enriched for markers of epidermal hyperplasia, glycolytic enzymes, and actin filament proteins. A significant increase in cluster 1 and a significant inhibition of cluster 2 proteins expression were achieved in AD skin by 16 weeks of dupilumab treatment (P <.0001 for both vs baseline), approaching the levels in HV skin. These improvements were also revealed in differential metabolite changes in the STS extracts, including amino acids, nucleotide breakdown products, and antioxidants. Conclusion: Longitudinal integrated assessment of the skin proteome and metabolome in patients with AD who were treated with dupilumab established significant inhibition of epidermal hyperplasia and improvement in epidermal differentiation. The identified changes were linked to improvements in clinical AD skin assessments, including improvements in transepidermal water loss and disease severity.

Background: We analyzed the impact of dupilumab treatment on skin barrier function and stratum corneum (SC) lipid components in children with moderate-to-severe atopic dermatitis (AD).

The effect of the inhibition of type 2 inflammation by dupilumab on stratum corneum (SC) lipids responsible for skin barrier function in children with atopic dermatitis (AD) has not been evaluated. In the PELISTAD open-label study (NCT04718870), pediatric (6-11 years old, n=23) patients with moderate to severe AD were treated with dupilumab for 16 weeks then followed up for three months. Matched healthy children (HC, n=18) were followed for 28 weeks. SC was collected using skin tape stripping (STS) and STS samples were serially evaluated for changes in lipid profile by mass spectrometry. At baseline, lesional SC of AD children, in comparison to HC, had increased level of N(C18S)-Ceramides (mean Fold Change (mFC) 3.314, p=0.00224), decreased levels of esterified omega-hydroxy fatty acid containing ceramides (EO(C18S)S-Ceramides, mFC 0.48, p=0.00424), and increased ratio of N(C18S)-Ceramides-to-EO(C18S)-Ceramides (mFC 6.35, p<0.0001). Treatment with dupilumab significantly improved lipid components (N(C18)S-Ceramides, within 4 weeks, p=0.00125; EO(C18S)-Ceramides, within 8 weeks, p=0.00233; and N(C18S)-Ceramide-to-EO(C18S)-Ceramide ratio, within 2 weeks, p=0.0074). Normalized levels of SC lipids in lesional skin were sustained for up to three months after the end of treatment. Dysregulation of SC barrier lipids in non-lesional skin was less pronounced than that of lesional skin but their normalization followed similar pattern as lesional skin dynamics. Dupilumab normalized the levels of SC lipids in pediatric AD patients within one-two months after the beginning of treatment. These beneficial changes persisted for at least three months after the end of treatment.

Abstract Introduction/Background Type 2 inflammatory cytokines interleukin 4 (IL-4) and IL-13 play an important role in skin barrier disruption in atopic dermatitis (AD). Filaggrin and ceramides play a crucial role in skin barrier integrity. Loss of function mutations in the FLG gene are associated with the impaired skin barrier function and more severe AD.1,2 FLG mutations only affect a minority of AD patients; however, increased IL-4 and IL-13 cytokines are a common cause of reduced filaggrin expression in patients with AD, independent of FLG genotype. Objectives To explore whether dupilumab treatment improves skin barrier function in patients with or without FLG mutations. Methods In the BArrier function and LIpidomics STudy in Atopic Dermatitis (BALISTAD; NCT04447417), a 16-week study in patients with AD aged 12 to 65 years, adult patients with AD received dupilumab 300 mg every 2 weeks; adolescent patients with AD received dupilumab 200 mg every 2 weeks if their baseline weight was <60 kg and 300 mg if ≥60 kg. FLG mutations were evaluated in DNA from blood samples of consenting patients with AD and healthy volunteers. Transepidermal water loss (TEWL) was assessed longitudinally after 5 skin tape strippings (STS) from AD lesions (n = 26) and from the skin of healthy participants (n =26) (age: 12 to 63 years) over a 16-week course of dupilumab treatment. Quantitative N(C18)S-ceramide analysis of STS samples collected on Days 1, 15, 29, 57, and 85, and at Week 16 from AD lesions and from the skin of healthy participants was performed using liquid chromatography tandem mass spectrometry. Results At baseline, mean TEWL after 5 STS (TEWL5) was significantly higher in AD lesional skin than healthy skin (p<0.0001). The mean TEWL5 in AD lesions in subjects with FLG mutations (n = 6/19) was significantly higher at baseline than in AD subjects without mutations (P < 0.0001). Dupilumab treatment significantly reduced TEWL5 in AD lesional skin as early as Week 2 with a progressive decrease through Week 16 (P < 0.0001). Reduction in mean TEWL5 was similar from Week 2 to Week 16 in AD patients with and without FLG mutations. At Week 16, TEWL5 was comparable to healthy skin in the lesional skin of AD patients with and without FLG mutations (P > 0.05). AD skin lesions had increased levels of N(C18)S-ceramides at baseline (P < 0.0001); but no differences were noted in subjects with or without FLG mutations (P > 0.05). Dupilumab treatment significantly reduced levels of N(C18)S-ceramides in AD lesional skin as early as Week 2 with a progressive decrease through Week 16 (P < 0.0001). Dupilumab treatment decreased levels of N(C18)S-ceramides in STS samples similarly in subjects with and without FLG mutations from Week 2 to Week 16. Conclusions Dupilumab treatment normalizes TEWL5 and decreases levels of N(C18)S-ceramides in AD lesional skin of subjects with and without FLG mutations.

Background Diet is a key modifiable risk factor of coronary artery disease (CAD). However, the causal effects of specific dietary traits on CAD risk remain unclear. With the expansion of dietary data in population biobanks, Mendelian randomization (MR) could help enable the efficient estimation of causality in diet-disease associations. Objectives The primary goal was to test causality for 13 common dietary traits on CAD risk using a systematic two-sample MR framework. A secondary goal was to identify plasma metabolites mediating diet-CAD associations suspected to be causal. Methods Cross-sectional genetic and dietary data on up to 420,531 UK Biobank and 184,305 CARDIoGRAMplusC4D individuals of European ancestry were used in two-sample MR. The primary analysis used fixed effect inverse-variance weighted regression, while sensitivity analyses used weighted median estimation, MR-Egger regression, and MR-Pleiotropy Residual Sum and Outlier. Results Genetic variants serving as proxies for muesli intake were negatively associated with CAD risk (OR: 0.74; 95% CI: 0.65-0.84; P = 5.385 × 10−4). Sensitivity analyses using weighted median estimation supported this with a significant association in the same direction. Additionally, we identified higher plasma acetate levels as a potential mediator (OR: 0.03; 95% CI: 0.01-0.12; P = 1.15 × 10−4). Conclusions Muesli, a mixture of oats, seeds, nuts, dried fruit, and milk, may causally reduce CAD risk. Circulating levels of acetate, a gut microbiota-derived short-chain fatty acid, could be mediating its cardioprotective effects. These findings highlight the role of gut flora in cardiovascular health and help prioritize randomized trials on dietary interventions for CAD.

Diet is a key modifiable risk factor of coronary artery disease (CAD). However, the causal effects of specific dietary traits on CAD risk remain unclear. With the expansion of dietary data in population biobanks, Mendelian randomization (MR) could help enable the efficient estimation of causality in diet-disease associations. The primary goal was to test causality for 13 common dietary traits on CAD risk using a systematic two-sample MR framework. A secondary goal was to identify plasma metabolites mediating diet-CAD associations suspected to be causal. Cross-sectional genetic and dietary data on up to 420,531 UK Biobank and 184,305 CARDIoGRAMplusC4D individuals of European ancestry were used in two-sample MR. The primary analysis used fixed effect inverse-variance weighted regression, while sensitivity analyses used weighted median estimation, MR-Egger regression, and MR-Pleiotropy Residual Sum and Outlier. Genetic variants serving as proxies for muesli intake were negatively associated with CAD risk (OR: 0.74; 95% CI: 0.65-0.84; P = 5.385 × 10−4). Sensitivity analyses using weighted median estimation supported this with a significant association in the same direction. Additionally, we identified higher plasma acetate levels as a potential mediator (OR: 0.03; 95% CI: 0.01-0.12; P = 1.15 × 10−4). Muesli, a mixture of oats, seeds, nuts, dried fruit, and milk, may causally reduce CAD risk. Circulating levels of acetate, a gut microbiota-derived short-chain fatty acid, could be mediating its cardioprotective effects. These findings highlight the role of gut flora in cardiovascular health and help prioritize randomized trials on dietary interventions for CAD.

Highly cross-linked insoluble proteins and the extracellular lipids form skin cornified envelop (CE). Keratins (KRTs) are anchored to the CE through conjugation with desmosomal proteins. Type 2-driven inflammation in atopic dermatitis (AD) inhibits CE formation. The role of dupilumab, a humanized monoclonal antibody against IL-4 receptor, in the regulation of CE assembly in AD has not been established. Skin tape strips (STS) were collected from 20 AD patients over the 16-week course of dupilumab treatment and 20 healthy volunteers followed for 16 weeks. Lesional and non-lesional STS extracts were examined at baseline, weeks 8 and 16 of treatment by liquid chromatography mass spectrometry for proteomic analysis. Desmoglein 1 (DSG1) and desmocollin 1 (DSC1) were decreased in AD lesional skin (p<0.01) at baseline and were normalized with dupilumab treatment (p<0.01). Other desmosomal structures, including plakophillins, envoplakin and periplakin, were increased in AD skin (p<0.0001), and were inhibited by dupilumab treatment (p<0.001). KRT1 and KRT10 form bundles with filaggrin in differentiated epidermis, were significantly inhibited in AD lesional skin (p<0.0001) at baseline and were normalized with dupilumab treatment (p<0.0001). KRT16, KRT6A and KRT6B that compete with the assembly of KRT1 andKRT10 filaments were significantly elevated in AD skin at baseline(p<0.0001), and were significantly reduced in AD skin after dupilumab treatment (p<0.0001). The study revealed abnormal expression of KRT filaments required for the CE formation in AD skin. As a result, to compensate for the mechanical stress, the expression of desmosomal proteins was altered in AD skin. Dupilumab-mediated IL-4/IL-13 inhibition resulted in redistribution of KRTs and desmosomal components required for proper CE assembly, suggesting an underlying mechanism of action of Dupilumab in improving skin barrier function in AD. These data provide supportive evidence for the restoration of the appropriate equilibrium of KRTs and desmosomal components in CE following treatment with dupilumab.

Atopic dermatitis (AD) is characterized by epidermal dysfunction and interleukin (IL)-4/IL-13-predominant inflammation. Dupilumab, a monoclonal antibody that targets IL-4Rα, has demonstrated clinical efficacy/safety in AD. The skin barrier proteomic changes in AD patients with dupilumab treatment are not established. Longitudinal lesional and non-lesional skin tape stripping (STS) was performed for 20 healthy volunteers and 20 AD patients treated with dupilumab for 16 weeks. STS protein extracts were examined by liquid chromatography tandem mass spectrometry. Skin proteomic profiles were correlated with AD clinical parameters (SCORAD, EASI) and transepidermal water loss (TEWL AUC10). 490 proteins were detected in ≥80% of AD and healthy STS. 139 proteins were differentially expressed between AD and healthy individuals, 90 of which were significantly increased (cluster 1) (p<0.0001) and 49 were significantly reduced (cluster 2) (p<0.0001) in AD as compared to healthy skin in unsupervised cluster analysis at baseline. Functionally, cluster 1 proteins were enriched for markers of epidermal hyperplasia—intermediate keratin filaments (KRT6, KRT16, KRT17, KRT14, KRT5, DSP), glycolytic proteins (PKM, ALDOA, LDHA), proteins involved in actin filament organization (ACTB, ACT, TPM2), and protein translation (ribosomal subunits). Expression of these proteins significantly decreased in AD lesional skin with dupilumab treatment (p=0.0001) and approached levels seen in healthy skin at week 16. The decrease in expression of cluster 1 proteins in response to treatment significantly correlated with TEWL AUC10 decrease in AD lesional skin (r=0.73, p<0.001). Longitudinal proteomic assessment of dupilumab-treated AD skin established significant inhibition of epidermal hyperplasia markers, which correlated with significant improvements in TEWL.

BACKGROUND: Atopic dermatitis (AD) skin lesions are associated with oozing, bleeding, and erythema. This suggests that AD is associated with vascular changes. Dupilumab is an antibody to the alpha subunit of IL-4 receptor that demonstrates strong efficacy in the treatment of AD. IL-4 is known to reduce the permeability barrier function of vascular endothelium.OBJECTIVE: To examine the effects of dupilumab on vascular barrier function in AD skin.METHODS: Using proteomic analysis, we evaluated the plasma protein composition in skin tapes of lesional and nonlesional skin of adults and adolescents with moderate to severe AD over the course of a 16-week treatment with dupilumab and compared those with matched healthy subjects.RESULTS: At baseline, 115 plasma proteins were detected in AD skin and globally increased (1.5-fold or greater) compared with healthy skin. Functionally, these proteins included immunoglobulins, proteins involved in the coagulation process, enzymes, protease inhibitors, transport proteins, acute-phase proteins, complement proteins, and other pleiotropic proteins. Noteworthy, fibrinogens, fibronectin, and heme-binding proteins haptoglobin and hemopexin were among the top proteins originating from plasma and were increased in AD lesional versus healthy skin at baseline (P < .0001). Dupilumab treatment resulted in significantly reduced levels of plasma proteins in AD skin (P < .0001), with most dropping to levels seen in healthy skin or no longer detectable at week 16.CONCLUSIONS: Inhibition of IL-4/IL-13 action by dupilumab significantly reduces the efflux of plasma proteins into AD skin. Several of these proteins, such as fibrinogens and fibronectin, are known to enhance Staphylococcus aureus colonization and are associated with AD skin severity. (c) 2023 American Academy of Allergy, Asthma & Immunology (J Allergy Clin Immunol Pract 2023;11:1421-8)

Dupilumab, a monoclonal antibody that targets IL-4Ra, has shown significant clinical benefits in modulation of type 2(T2) inflammation in atopic dermatitis(AD). To date, there are no detailed proteomic studies of longitudinal changes in AD skin proteins in patients treated with dupilumab. Assessments of lesional and non-lesional skin of 20 AD patients during 16 weeks of dupilumab treatment were done by skin tape stripping(STS) and compared to STS of 20 healthy volunteers (HV). STS protein extracts were examined at baseline, weeks 8 and 16 of treatment by liquid chromatography mass spectrometry proteomic analysis. 490 proteins were detected in ≥80% of AD and HV skin samples. 139 proteins were differentially expressed between AD and HV at baseline and significantly changed during dupilumab treatment (p<0.05). At baseline, expression of 49 proteins, including proteins involved in epidermal barrier formation (KRT2, KRT77, TGM3, CDSN, DSC3, KLK7, BLMH), lysosomal enzymes required for lamellae assembly (ASAH1, GLB1, HEXA, HEXB, GAA, FUCA1, ALOXE3), oxidative response enzymes (CAT, GSS, GGCT) and proteasome subunits, was significantly lower in AD skin compared to HV (p<0.0001). Expression of these proteins in AD skin significantly increased at weeks 8 and 16 of dupilumab treatment (both p<001) and approached levels observed in HV. Longitudinal assessment of the skin proteome in AD patients treated with dupilumab demonstrated significant improvement in the expression of proteins involved in epidermal differentiation, normalization of lamellae assembly and antioxidant defense by 16 weeks of treatment, suggesting that these proteins are under control of T2 cytokines in AD skin.

Background: Dupilumab inhibits signaling of IL-4 and IL-13 and has demonstrated efficacy for treatment of atopic dermatitis (AD). IL-4 and IL-13 are known to play roles in skin barrier function. This study explores the effects of dupilumab on skin barrier function in patients with AD.

Background: Causality between plasma triglyceride (TG) levels and atherosclerotic cardiovascular disease (ASCVD) risk remains controversial despite more than four decades of study and two recent landmark trials, STRENGTH, and REDUCE-IT. Further unclear is the association between TG levels and non-atherosclerotic diseases across organ systems. Methods: Here, we conducted a phenome-wide, two-sample Mendelian randomization (MR) analysis using inverse-variance weighted (IVW) regression to systematically infer the causal effects of plasma TG levels on 2600 disease traits in the European ancestry population of UK Biobank. For replication, we externally tested 221 nominally significant associations (p<0.05) in an independent cohort from FinnGen. To account for potential horizontal pleiotropy and the influence of invalid instrumental variables, we performed sensitivity analyses using MR-Egger regression, weighted median estimator, and MR-PRESSO. Finally, we used multivariable MR (MVMR) controlling for correlated lipid fractions to distinguish the independent effect of plasma TG levels. Results: Our results identified seven disease traits reaching Bonferroni-corrected significance in both the discovery (p<1.92 × 10-5) and replication analyses (p<2.26 × 10-4), suggesting a causal relationship between plasma TG levels and ASCVDs, including coronary artery disease (OR 1.33, 95% CI 1.24–1.43, p=2.47 × 10-13). We also identified 12 disease traits that were Bonferroni-significant in the discovery or replication analysis and at least nominally significant in the other analysis (p<0.05), identifying plasma TG levels as a novel potential risk factor for nine non-ASCVD diseases, including uterine leiomyoma (OR 1.19, 95% CI 1.10–1.29, p=1.17 × 10-5). Conclusions: Taking a phenome-wide, two-sample MR approach, we identified causal associations between plasma TG levels and 19 disease traits across organ systems. Our findings suggest unrealized drug repurposing opportunities or adverse effects related to approved and emerging TG-lowering agents, as well as mechanistic insights for future studies.Funding: RD is supported by the National Institute of General Medical Sciences of the National Institutes of Health (NIH) (R35-GM124836) and the National Heart, Lung, and Blood Institute of the NIH (R01-HL139865 and R01-HL155915).

Phenome-wide association studies identified numerous loci associated with traits and diseases. To help interpret these associations, we constructed a phenome-wide network map of colocalized genes and phenotypes. We generated colocalized signals using the Genotype-Tissue Expression data and genome-wide association results in UK Biobank. We identified 9151 colocalized genes for 1411 phenotypes across 48 tissues. Then, we constructed bipartite networks using the colocalized signals in each tissue, and showed that the majority of links were observed in a single tissue. We applied the biLouvain clustering algorithm in each tissue-specific network to identify co-clusters of genes and phenotypes. We observed significant enrichments of these co-clusters with known biological and functional gene classes. Overall, the phenome-wide map provides links between genes, phenotypes and tissues, and can yield biological and clinical discoveries.

Background: The measurement of Fractional Exhaled Nitric Oxide(FENO) is non-invasive, quick and easy to do. The current ERS(Gaillard:ERJ:2021)and NICE guidelines(2017) recommend measurement of FENO to support a diagnosis of asthma in children ≥ 5 years with cut off values of >25 and >35 parts per billion(ppb)respectively as significant. We undertook this study as the measurement of FENO is influenced by several factors including ethnicity(Kovesi:Chest:2008)and there is limited data available from India Aims: We aimed to establish normal FENO values in healthy school-aged Indian children. The objective was to assess whether cut-offs proposed by ERS and NICE were applicable to our population Methods: Prospective cross-sectional study conducted at the out-patient division of a tertiary paediatric centre in western India between July-October 2021. Children with asthma, history of wheezing and allergic rhinitis were excluded. FENO was measured by a single breath technique as per the manufacturers’ recommendation Results: 141 children were recruited. There were 63 girls(44.6%) and 78 boys(55.4%). Median age of the population was 8 years(range-5-12 years). Median FENO value was 9 ppb(range- 3.5 -53 ppb). Median FENO in boys was 8 ppb(range- 3.5- 53) and girls was 8 ppb(range- 3.5 - 42), the difference was not statistically significant(p value 0.516). 98.5% of patients had a value of less than 35ppb and 94.3% had a value of less than 25ppb Conclusion: Our study, for the first time provides normal FENO levels in healthy school age children from India. Cut off values recommended by the ERS and NICE asthma guidelines can be applied to school aged children from India for management of asthma.

Background Causality between plasma triglyceride (TG) levels and atherosclerotic cardiovascular disease (ASCVD) risk remains controversial despite more than four decades of study and two recent landmark trials, STRENGTH and REDUCE-IT. Further unclear is the association between TG levels and non-atherosclerotic diseases across organ systems. Methods Here, we conducted a phenome-wide, two-sample Mendelian randomization (MR) analysis using inverse-variance weighted (IVW) regression to systematically infer the causal effects of plasma TG levels on 2,600 disease traits in the European ancestry population of UK Biobank. For replication, we externally tested 221 nominally significant associations ( p < 0.05) in an independent cohort from FinnGen. To account for potential horizontal pleiotropy and the influence of invalid instrumental variables, we performed sensitivity analyses using MR-Egger regression, weighted median estimator, and MR-PRESSO. Finally, we used multivariable MR controlling for correlated lipid fractions to distinguish the independent effect of plasma TG levels. Results Our results identified 7 disease traits reaching Bonferroni-corrected significance in both the discovery ( p < 1.92 × 10-5) and replication analyses ( p < 2.26 × 10-4), supporting a causal relationship between plasma TG levels and ASCVDs, including coronary artery disease (OR 1.33, 95% CI 1.24-1.43, p = 2.47 × 10-13). We also identified 12 disease traits that were Bonferroni-significant in the discovery or replication analysis and at least nominally significant in the other analysis ( p < 0.05), identifying plasma TG levels as a novel risk factor for 9 non-ASCVD diseases, including uterine leiomyoma (OR 1.19, 95% CI 1.10-1.29, p = 1.17 × 10-5). Conclusions Taking a phenome-wide, two-sample MR approach, we identified causal associations between plasma TG levels and 19 disease traits across organ systems. Our findings suggest unrealized drug repurposing opportunities or adverse effects related to approved and emerging TG-lowering agents as well as mechanistic insights for future study. ### Competing Interest Statement RD reports receiving grants from AstraZeneca; grants and non-financial support from Goldfinch Bio; being a scientific co-founder, consultant, and equity holder (pending) for Pensieve Health; and a consultant for Variant Bio, all unrelated to this work. RSR reports receiving grants from Amgen, Arrowhead, Lilly, Novartis and Regeneron; consulting fees from Amgen, Arrowhead, Lilly, Novartis and Regeneron; honoraria for non-promotional lectures from Amgen, Kowa and Regeneron, royalties from Wolters Kluwer (UpToDate); and stock holdings in MediMergent, LLC. ### Funding Statement RD is supported by the National Institute of General Medical Sciences of the National Institutes of Health (NIH) (R35-GM124836) and the National Heart, Lung, and Blood Institute of the NIH (R01-HL139865 and R01-HL155915). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: UK Biobank has approval from the North West Multi Centre Research Ethics Committee (MREC) as a Research Tissue Bank (RTB) (11/NW/0382), and all participants of UKB provided written informed consent. More information is available at (https://www.ukbiobank.ac.uk/learn-more-about-uk-biobank/about-us/ethics). The work described in this study was approved by UKB under application number 16218. All participants of FinnGen provided written informed consent for biobank research, based on the Finnish Biobank Act. The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa (HUS) approved the FinnGen study protocol Nr HUS/990/2017. More information is available at (https://www.finngen.fi/en/code\_of\_conduct). 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. Not Applicable 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). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable All analyses used publicly available data (UKB, FinnGen), including previously published GWAS (GLGC) ([Willer et al., 2013][1]). Obtaining access to UKB (Pan-UKB\_Team, 2020) and FinnGen (FinnGen, 2020) GWAS summary statistics is detailed here (https://www.finngen.fi/en/access\_results) and here (https://pan.ukbb.broadinstitute.org/downloads). Please note the summary statistics for FinnGen and Pan-UKB are made publicly available. [1]: #ref-78

AimsIndividuals with supranormal left ventricular ejection fraction (snLVEF; LVEF >70%) have increased mortality. However, the genetic and phenotypic profile of snLVEF remains unknown. This study aimed to determine the relationship of both snLVEF genetic risk and phenotype with survival and underdiagnosed heart failure (HF).Methods and resultsA snLVEF genetic risk score (GRS) was applied and cases of snLVEF were identified in 486 754 individuals across two population‐based cohorts (BioMe Biobank and UK Biobank). The snLVEF GRS and phenotype were evaluated for association with survival, as well as HF diagnosis, markers, symptoms, and medications. Of 486 754 participants, the median age was 58 years, 20 069 (4.1%) died, and 10 088 (2.1%) had diagnosed HF. Both snLVEF GRS (hazard ratio [HR] 1.1 for top 10% vs. bottom 10% GRS; p = 0.002) and phenotype (HR 1.4; p = 0.003) were associated with increased all‐cause mortality. Both snLVEF GRS and phenotype were associated with reduced HF diagnosis (odds ratio [OR] 0.97 and OR 0.63, respectively; both p ≤0.002). However, the snLVEF GRS and phenotype were both associated with elevated brain natriuretic peptide (BNP) levels (146 and 185 pg/ml increase, respectively; p <0.001), including 268 out of 455 (59%) individuals with snLVEF phenotype who had BNP >100 pg/ml. Among 476 666 participants without HF diagnoses, snLVEF GRS and phenotype were associated with increased HF symptoms (e.g. exertional dyspnoea OR 1.4 and OR 1.3; p <0.003) and HF medications (e.g. loop diuretic OR 1.2 and OR 1.03; p <0.02). Associations were consistent in hypertensive individuals without cardiac comorbidities.ConclusionsGenetic predisposition to and presence of snLVEF are associated with decreased survival and underdiagnosed HF.

Background: Causality between plasma triglyceride (TG) levels and atherosclerotic cardiovascular disease (ASCVD) risk remains controversial despite more than four decades of study and two recent landmark trials, STRENGTH and REDUCE-IT. Further unclear is the association between TG levels and non-atherosclerotic diseases across organ systems.Methods: Here, we conducted a phenome-wide, two-sample Mendelian randomization (MR) analysis using an inverse-variance weighted (IVW) estimator to systematically infer the causal effects of plasma TG levels on 2,600 disease traits in the European ancestry population of UK Biobank. For replication, we externally tested 221 nominally significant associations (p < 0.05) in an independent cohort from FinnGen. To account for potential horizontal pleiotropy and the influence of invalid instrumental variables, we performed sensitivity analyses using MR-Egger regression, weighted median estimator, and MR-PRESSO methods. Finally, we used multivariable MR controlling for correlated lipid fractions to distinguish the independent effect of plasma TG levels.Results: Our results identified 7 disease traits reaching Bonferroni-corrected significance in both the discovery (p < 1.92 x 10-5) and replication analyses (p < 2.26 x 10-4), supporting a causal relationship between plasma TG levels and ASCVDs, including coronary artery disease (OR 1.33, 95% CI 1.24-1.43, p = 2.47 x 10-13). We also identified 12 disease traits that were Bonferroni-significant in either the discovery or replication analysis and at least nominally significant in the other analysis (p < 0.05), identifying plasma TG levels as a novel risk factor for 9 non-ASCVD disease traits, including uterine leiomyoma (OR 1.19, 61 95% CI 1.10-1.29, p = 1.17 x 10-5).Conclusions: Using a phenome-wide Mendelian randomization approach, we identified causal relationships between plasma TG levels and 19 disease traits across organ systems. Our findings suggest unrealized drug repurposing opportunities or adverse effects related to approved and emerging TG-lowering agents as well as mechanistic insights for future study.Funding: RD is supported by the National Institute of General Medical Sciences of the National Institutes of Health (NIH) (R35-GM124836) and the National Heart, Lung, and Blood Institute of the NIH (R01-HL139865 and R01-HL155915).

Importance Population-based assessment of disease risk associated with gene variants informs clinical decisions and risk stratification approaches. Objective To evaluate the population-based disease risk of clinical variants in known disease predisposition genes. Design, Setting, and Participants This cohort study included 72 434 individuals with 37 780 clinical variants who were enrolled in the BioMe Biobank from 2007 onwards with follow-up until December 2020 and the UK Biobank from 2006 to 2010 with follow-up until June 2020. Participants had linked exome and electronic health record data, were older than 20 years, and were of diverse ancestral backgrounds. Exposures Variants previously reported as pathogenic or predicted to cause a loss of protein function by bioinformatic algorithms (pathogenic/loss-of-function variants). Main Outcomes and Measures The primary outcome was the disease risk associated with clinical variants. The risk difference (RD) between the prevalence of disease in individuals with a variant allele (penetrance) vs in individuals with a normal allele was measured. Results Among 72 434 study participants, 43 395 were from the UK Biobank (mean [SD] age, 57 [8.0] years; 24 065 [55%] women; 2948 [7%] non-European) and 29 039 were from the BioMe Biobank (mean [SD] age, 56 [16] years; 17 355 [60%] women; 19 663 [68%] non-European). Of 5360 pathogenic/loss-of-function variants, 4795 (89%) were associated with an RD less than or equal to 0.05. Mean penetrance was 6.9% (95% CI, 6.0%-7.8%) for pathogenic variants and 0.85% (95% CI, 0.76%-0.95%) for benign variants reported in ClinVar (difference, 6.0 [95% CI, 5.6-6.4] percentage points), with a median of 0% for both groups due to large numbers of nonpenetrant variants. Penetrance of pathogenic/loss-of-function variants for late-onset diseases was modified by age: mean penetrance was 10.3% (95% CI, 9.0%-11.6%) in individuals 70 years or older and 8.5% (95% CI, 7.9%-9.1%) in individuals 20 years or older (difference, 1.8 [95% CI, 0.40-3.3] percentage points). Penetrance of pathogenic/loss-of-function variants was heterogeneous even in known disease predisposition genes, including BRCA1 (mean [range], 38% [0%-100%]), BRCA2 (mean [range], 38% [0%-100%]), and PALB2 (mean [range], 26% [0%-100%]). Conclusions and Relevance In 2 large biobank cohorts, the estimated penetrance of pathogenic/loss-of-function variants was variable but generally low. Further research of population-based penetrance is needed to refine variant interpretation and clinical evaluation of individuals with these variant alleles.