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J Am Heart Assoc. 2019 Apr 2;8(7):e010868. doi: 10.1161/JAHA.118.010868.

NT -pro BNP as a Mediator of the Racial Difference in Incident Atrial Fibrillation and Heart Failure.

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1 Section of Cardiac Electrophysiology Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA.
2 Department of Epidemiology and Biostatistics University of California, San Francisco San Francisco California USA.
3 Division of Cardiology University of Maryland Baltimore Maryland USA.
4 Department of Epidemiology Rollins School of Public Health Emory University Atlanta Georgia USA.
5 Cardiovascular Health Research Unit Departments of Medicine, Epidemiology, and Health Services University of Washington Seattle Washington USA.
6 Kaiser Permanente Washington Health Research Institute Seattle Washington USA.
7 Department of Epidemiology University of Washington, School of Public Health Seattle Washington USA.
8 Division of Atherosclerosis and Vascular Medicine Baylor College of Medicine Houston Texas USA.
9 McKusick-Nathans Institute of Genetic Medicine Johns Hopkins University Baltimore Maryland USA.
10 Division of Cardiovascular and Clinical Epidemiology Johns Hopkins University Baltimore Maryland USA.
11 Cardiovascular Division University of Minnesota Minneapolis and Saint Paul, Minnesota USA.
12 Knight Cardiovascular Institute Oregon Health & Science University Portland Oregon USA.
13 Division of Cardiac Electrophysiology University of California, San Francisco San Francisco California USA.


Background Blacks harbor more cardiovascular risk factors than whites, but experience less atrial fibrillation ( AF ). Conversely, whites may have a lower risk of heart failure ( CHF ). N-terminal pro-B-type natriuretic peptide ( NT -pro BNP) levels are higher in whites, predict incident AF , and have diuretic effects in the setting of increased ventricular diastolic pressures, potentially providing a unifying explanation for these racial differences. Methods and Results We used data from the CHS (Cardiovascular Health Study) to determine the degree to which baseline NT -pro BNP levels mediate the relationships between race and incident AF and CHF by comparing beta estimates between models with and without NT -pro BNP . The ARIC (Atherosclerosis Risk in Communities) study was used to assess reproducibility. Among 4731 CHS (770 black) and 12 418 ARIC (3091 black) participants, there were 1277 and 1253 incident AF events, respectively. Whites had higher baseline NT -pro BNP ( CHS : 40% higher than blacks; 95% CI , 29-53; ARIC : 39% higher; 95% CI , 33-46) and had a greater risk of incident AF compared with blacks ( CHS : adjusted hazard ratio, 1.60; 95% CI , 1.31-1.93; ARIC : hazard ratio, 1.93; 95% CI , 1.57-2.27). NT -pro BNP levels explained a significant proportion of the racial difference in AF risk ( CHS : 36.2%; 95% CI , 23.2-69.2%; ARIC : 24.6%; 95% CI , 14.8-39.6%). Contrary to our hypothesis, given an increased risk of CHF among whites in CHS (adjusted hazard ratio, 1.20; 95% CI , 1.05-1.47) and the absence of a significant association between race and CHF in ARIC (adjusted hazard ratio, 1.07; 95% CI , 0.94-1.23), CHF -related mediation analyses were not performed. Conclusions A substantial portion of the relationship between race and AF was statistically explained by baseline NT -pro BNP levels. No consistent relationship between race and CHF was observed.


NT‐proBNP; atrial fibrillation arrhythmia; congestive heart failure; mechanisms; mediation; natriuretic peptide

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