Circulation: Genomic and Precision Medicine

BackgroundPediatric dilated cardiomyopathy (DCM) is a rare, progressive heart disease with variable outcomes that range from recovery to heart transplantation. To date, there are no prognostic biomarkers for children with DCM. Identifying circulating biomarkers that are associated with clinical outcomes is critical for personalized management. MethodsmiRNAs were identified by RNA-seq, whereas proteins were identified by SomaScan(R). Machine learning methodologies were used to explore the predictive ability of circulating factors identified from serum samples collected at the time of presentation with acute heart failure. ResultsThirty patients experienced poor outcomes (cardiac transplantation, mechanical circulatory support, or death) and 19 patients recovered left ventricular function. Distinct miRNA and protein signatures differentiated outcomes groups. Top candidate proteins (COL2A1, CXCL12, and ADGRF5) and miRNAs (miR-874-3p, miR-335-3p, miR-323a-3p) demonstrated strong discriminatory performance within the study cohort (recovered vs poor outcomes; Area Under the Curve of 0.92). Ingenuity Pathway Analysis implicates cardiac remodeling, fibrosis, and inflammatory signaling as central pathways differentiating patient outcomes. ConclusionsCirculating miRNA and protein signatures at presentation identify a circulating molecular signature associated with divergent clinical trajectories in pediatric DCM. These findings support the potential utility of multi-omic biomarkers for early risk stratification and provide insight into mechanisms underlying divergent outcomes. CLINICAL PERSPECTIVEWhat Is New? O_LICirculating miRNA and protein profiles measured at presentation distinguish children with pediatric DCM who recover from those who progress to advanced heart failure. C_LIO_LIA combined multi-omic biomarker demonstrated strong discriminatory performance in this cohort (AUC 0.92). C_LIO_LIPathway analysis implicates extracellular matrix remodeling, fibrosis, and inflammatory signaling in children with adverse clinical trajectories. C_LI What Are the Clinical Implications? O_LISerum-based molecular biomarkers may enable earlier risk stratification in children presenting with dilated cardiomyopathy. C_LIO_LIMulti-omic integration may improve identification of pediatric patients at risk for transplantation, mechanical circulatory support, or death. C_LIO_LIThese findings support further validation of circulating biomarker panels to guide personalized management in this rare disease. C_LI RESEARCH PERSPECTIVEWhat New Question Does This Study Raise? O_LICan integrated circulating miRNA-protein signatures identify biologically distinct trajectories of recovery versus progression in children with dilated cardiomyopathy? C_LIO_LIDo circulating molecular profiles reflect underlying disease mechanisms that determine divergent clinical outcomes in pediatric DCM? C_LI What Question Should Be Addressed Next? O_LIDo the pathways identified by integrated miRNA-protein analysis (fibrosis, remodeling, and inflammation) play causal roles in determining recovery versus progression? C_LIO_LICan multi-omic biomarkers be incorporated into prospective studies to improve early risk stratification and guide clinical management? C_LI

BackgroundA coronary artery calcium (CAC) score of 0 is widely considered to indicate low short- to intermediate-term risk for coronary artery disease (CAD) and is frequently used to defer lipid-lowering therapy. However, a subset of individuals with CAC=0 still experience events, highlighting residual risk not captured by imaging alone. Polygenic risk scores (PRS) quantify lifelong inherited susceptibility, but conventional approaches rely on predefined ancestry labels despite human genetic diversity existing along a continuum. To address this limitation, we developed 8 Billion, a novel, label-free framework that models genetic similarity without pre-labeling individuals by ancestry. We evaluated whether a CAD PRS derived using this approach identifies clinically meaningful residual risk among individuals with baseline CAC=0. MethodsWe analyzed participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with baseline CAC=0. The 8 Billion framework estimates individualized PRS by anchoring each participant to a genetically similar reference neighborhood rather than discrete ancestry groups. Multivariable Cox proportional hazards models assessed associations between PRS-defined risk groups and incident CAD, adjusting for principal components of genetic variation (PC1-PC4), age, sex, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol, diabetes, and antihypertensive medication use. Two classifications were evaluated: (1) a Top 5% group defined by the highest 5% of PRS-derived odds ratios in the cohort; and (2) an individualized high-risk group defined using a personalized threshold derived from the 8 Billion framework. Ten-year absolute risk estimates were derived from adjusted models. ResultsDespite CAC=0 at baseline, polygenic burden was independently associated with incident CAD. Individuals in the Top 5% PRS group had higher risk of CAD events compared with the remainder (hazard ratio [HR], 3.12; 95% CI, 1.05-9.31; P=0.041). The individualized high-risk group defined through 8 Billion was similarly associated with increased CAD risk (HR, 2.52; 95% CI, 1.12-5.66; P=0.025). Estimated 10-year ASCVD risk among high-PRS individuals exceeded the 7.5% threshold commonly used to guide initiation of lipid-lowering therapy, despite CAC=0. In fully adjusted models, conventional risk factors were not statistically significant within this subset. ConclusionsAmong individuals with CAC=0 in a multi-ethnic cohort, a label-free, ancestry-continuum PRS approach identified subgroups at significantly increased risk of incident CAD and at guideline-relevant 10-year treatment thresholds. Integration of polygenic risk with CAC imaging refines preventive decision-making beyond imaging alone. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIAmong individuals with baseline CAC=0, the Allelica Multi-ancestry CAD PRS calculated with the 8 Billion framework identified subgroups at significantly increased risk of incident CAD. C_LIO_LIIn this CAC=0 population, high polygenic risk was associated with 10-year risk estimates above the 7.5% treatment threshold, whereas conventional risk factors were not statistically significant in adjusted models. C_LI What are the clinical implications?O_LIA CAC score of 0 should not be interpreted as uniformly protective, because genetically high-risk individuals may still experience clinically meaningful coronary events. C_LIO_LIIntegrating PRS with CAC assessment may improve preventive decision-making by identifying patients with residual risk despite reassuring baseline imaging. C_LIO_LIIn selected patients with CAC=0, high polygenic risk may support closer follow-up and earlier consideration of lipid-lowering therapy or other preventive strategies and imaging modalities. C_LI

BackgroundEvidence of the diverse genetic architecture of dilated cardiomyopathy (DCM) continues to emerge and requires reassessment of the clinical relevance of implicated disease genes. Building on the 2019-2020 Clinical Genome Resource (ClinGen) evaluation, the DCM Gene Curation Expert Panel (GCEP) reconvened in 2024-2025 to conduct a reassessment of genes in DCM. MethodsThe ClinGen semi-quantitative clinical validity classification framework was applied with specifications to DCM to classify genes into categories based upon strength of published evidence for a DCM phenotype. Previously curated genes were reassessed and newly reported gene-disease-mode of inheritance (MOI) relationships, termed "curations," were evaluated. ResultsSixty-eight genes were evaluated, inclusive of 72 unique gene-disease-MOI relationships across 51 previously evaluated and 17 newly assessed genes. Thirty-five curations were classified as high evidence (16 Definitive, 10 Strong, 9 Moderate), increasing by 16 from the prior assessment. Nine newly assessed genes were classified as high evidence, including BAG5, FLII, LMOD2, MYLK3, MYZAP, NRAP, PPA2, PPP1R13L, and RPL3L. Twelve genes (11 newly appraised) were rated as high evidence with an autosomal recessive (AR) MOI. Five re-evaluated genes from 2019-2020 had clinically significant changes in classification. Except for JPH2, for which curation was modified to separate autosomal dominant (-AD) and -AR MOI curations, clinically significant changes involved upgrades from low to high evidence categories (PLEKHM2, PRDM16, TBX20, TNNI3K), demonstrating the robustness of the ClinGen gene curation process over time. An additional 29 gene-disease-MOI curations were classified as Limited, including six newly evaluated genes and one new MOI for a previously evaluated gene, MYBPC3-AR; four were classified as No Known Disease Relationship, and four remained Disputed. Four previously evaluated genes were curated for both AD and AR MOIs, including JPH2 (AD-Strong, AR-Limited), LDB3 (AD-Limited, AR-Strong), MYBPC3 (AD-Limited, AR-Limited), and TNNI3 (AD- and AR- Strong). ConclusionsWith substantial new evidence, the genetic architecture of DCM has rapidly expanded. This updated assessment of genes reported in DCM yielded 35 high evidence curations, an increase from 19 only five years ago. The results of this evidence-based evaluation process informs clinical interpretation of genetic information in the care of DCM patients and families. CLINICAL PERSPECTIVEO_ST_ABSWhats new?C_ST_ABSO_LIThe Clinical Genome Resource (ClinGen) Dilated Cardiomyopathy (DCM) Gene Curation Expert Panel reconvened to update the evidence for genes in DCM using the ClinGen clinical validity framework. C_LIO_LIA total of 35 genes were classified into clinically actionable, high evidence categories of Definitive, Strong, or Moderate evidence, an increase of 16 from the 2019-2020 curation. C_LIO_LIOf the 16 newly classified high evidence curations, 11 (69%) had an autosomal recessive mode of inheritance and were observed primarily in pediatric DCM. C_LI What are the clinical implications?O_LIThis update has substantially expanded the complex and diverse genetic architecture of DCM spanning 18 gene ontologies (8 new) identified in both adult and pediatric patients. C_LIO_LIThe 19 genes classified as high evidence in the 2019-2020 curations were adopted by the clinical genetics community as the key genes for clinical genetic testing and care for DCM patients and families. The 35 high evidence curations from the current assessment are recommended to be used as an updated list for clinical genetics care for DCM. C_LIO_LIDCM gene curation will require ongoing reassessments due to the continuing expansion of high-quality research data. C_LI

Background: Non-ischemic cardiomyopathy (NICM) represents a major cause of heart failure with limited tools for early risk stratification. Atrial fibrillation (AF) is a well-established contributor to cardiomyopathy but is often clinically silent in its early stages. The atrial fibrillation polygenic risk score (AF-PRS) reflects genetic susceptibility to AF and may identify individuals at risk for AF-related cardiomyopathy. We hypothesized that higher AF-PRS is associated with greater risk of NICM. Methods: This was a retrospective cohort study of 16,801 individuals of European ancestry from the Sanford Biobank and Imagenetics program with genetic sequencing and longitudinal electronic health record data. AF-PRS was calculated using 315 genome-wide significant single-nucleotide polymorphisms with standard quality control. NICM was defined by International Classification of Diseases, 10th Revision, Clinical Modification codes, excluding ischemic etiologies. Cox regression models evaluated the association between AF-PRS and incident NICM, adjusting for age, sex, smoking status, body mass index (BMI), hypertension, and diabetes. AF-PRS was analyzed both as a quasi-continuous variable (15% quartile increments) and dichotomized at the 85th percentile. Sensitivity analyses assessed associations with all-cause cardiomyopathy and ischemic cardiomyopathy. Survival analysis was used to model time-to-event outcomes. Results: Among all participants, 418 (2.5%) had NICM. 99% were Caucasian. NICM cases were older and more often male (both p<0.001) than those without a diagnosis. After multivariable adjustment for sex, smoking status, BMI, and hypertension, a linear AF-PRS (15% increments) was specifically predictive of increased hazard risk of NICM (HR = 1.09 [1.03, 1.15], p < 0.001). Conclusion: These findings complement recent evidence of bidirectional genetic relationships between cardiomyopathy and AF, supporting comprehensive genetic risk assessment in cardiovascular disease prevention. Clinical implementation requires validation in diverse populations and prospective evaluation. Future research should investigate the mechanistic pathways linking AF-associated genetic variants to cardiomyopathy development and evaluate whether AF-PRS-guided screening improves clinical outcomes.

Congenital heart disease (CHD) occurs in over half of individuals with 22q11.2 deletion syndrome (22q11.2DS) and the types of lesions range from mild to severe. To determine the basis of variation in cardiac phenotypes we analyzed demographic data from 3,016 unrelated individuals with 22q11.2DS from centers in the Northeast US, Canada, Europe, South America, Israel and Australia. Most individuals in this cohort had a 3 million base pair hemizygous deletion between low copy repeat, LCR22 A-D (87.2%), while some had nested deletions. We performed multivariable mixed-effects logistic regression and uncovered significant differences between CHD phenotypes and basic demographic features. Individuals with the A-D deletion had a lower risk of persistent truncus arteriosus (OR = 0.37, 95% CI 0.18-0.75) but a higher risk of septal defects (OR = 4.7, 95% CI 1.7-12.8) compared to those with the smaller A-B deletion, suggesting distinct developmental pathways sensitive to 22q11.2 gene dosage. In addition, genome-wide genetic principal components (PCs) were associated with specific CHD subtypes, including reduced risk of pulmonary stenosis or atresia with other heart lesions (PC2; OR = 0.73, 95% CI 0.61-0.87) and increased risk of abnormal origin of the subclavian arteries (PC4; OR = 2.6, 95% CI 1.4-4.9), indicating that background genetic variation modifies heart lesion-specific susceptibility. Together, these results suggest that both deletion size and background genetic variation shape the highly variable cardiac phenotypes in 22q11.2DS.

Background. Hypertrophic cardiomyopathy (HCM) is a clinically variable disease in terms of onset and progression. Pathogenic MYBPC3 variants account for a substantial proportion of HCM diagnoses. This study sought to identify protein biomarkers associated with HCM severity. Methods. Olink-assayed plasma proteins of 144 MYBPC3 pathogenic variant carriers were tested for associations with HCM severity based on HCM diagnostic criteria (unaffected, mildly, or severely affected). The UK Biobank was used to replicate the identified proteins through considering time to onset of HCM (67 cases), cardiomyopathy (156 cases),and associations with cardiac MRI derived left ventricular maximum wall thickness (6,492 participants). Replicated proteins were further prioritised based on cardiac tissue expression and druggability, and annotated using pathway enrichment and association with onset of: heart failure (HF), dilated cardiomyopathy (DCM), sudden cardiac arrest (SCA), and ventricular arrhythmias (VA). Results. Among pathogenic MYBPC3 variant carriers, we identified 27 proteins associated with HCM severity. We independently replicated 21 proteins in the UK Biobank. Of the five prioritised proteins (NT-proBNP, GDF-15, FGF-23, ADM, and NCAM1), all but NT-proBNP were targeted by drugs with repurposing potential. The replicated proteins additionally associated with the incidence of HF (n=5), DCM (n=4), SCA (n=4), and VA (n=4). Conclusion. This study replicated 21 and prioritised five proteins associated with HCM severity in pathogenic MYBPC3 variant carriers. Replication in unselected HCM suggests the prioritised proteins are associated with HCM independent of genotype, providing important leads for plasma-based markers for diagnoses, disease monitoring, and drug targets.

Background and aimsSpontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute myocardial infarction (MI) that predominantly affects young women. As an under-recognized cause of MI, large genome-wide association studies (GWAS) remain challenging. We aimed to leverage SCAD shared genetic basis with related vascular diseases to uncover genetically determined biological mechanisms. MethodsSummary statistics for SCAD GWAS (1,917 cases, 9,293 controls) was harmonised with seven related vascular traits: fibromuscular dysplasia, intracranial aneurysm, cervical artery dissection, migraine, coronary artery disease, abdominal aortic aneurysm, and thoracic aortic aneurysm/dissection. We applied Multi-Trait Analysis of GWAS (MTAG). We integrated coronary-artery regulatory annotations, cis-eQTL mapping, and colocalization to prioritize candidate genes. Gene-based testing (LDAK-GBAT) was applied to SCAD dataset. ResultsMTAG identified 40 independent SCAD loci, including 24 that were novel. Candidate variants were enriched in open chromatin from coronary smooth muscle cells and fibroblasts and in vascular regulatory regions. LDAK-GBAT identified 46 significant genes, including 12 outside MTAG loci. Integrated functional annotation prioritized 56 genes linked to arterial integrity, vasoactive tone, haemostasis, and coagulation. Extracellular matrix organization was confirmed as a key pathway, with additional enrichment in bone mineralization and TGF-{beta} related terms. ConclusionsIntegrating multi-trait GWAS, gene-based testing, epigenetic and transcriptomic data substantially expanded the SCAD genetic landscape. Our findings implicate key arterial-wall pathways beyond extracellular matrix organization, and point at relevant biological mechanisms in non-atherosclerotic dissection. These findings nominate tractable targets for experimental follow-up and support future efforts toward SCAD risk stratification in women.

Hyperlipidemia, and high low-density lipoprotein cholesterol (LDL-c) in particular, is a risk factor for cardiovascular disease, including atherosclerosis, myocardial infarction, and stroke. Nearly 200 million people worldwide take HMG-CoA reductase inhibitors, commonly known as statins, to lower their LDL-c. If statins interfere with the genetic pathways that endogenously increase the risk for hyperlipidemia, gene-statin interactions may identify genomic variants, and thereby individuals with those genotypes, that are particularly sensitive to these medications. We performed a series of genome-wide gene-statin interaction analyses in the UK Biobank for LDL-c and two related lipids: high-density lipoprotein cholesterol (HDL-c) and triglycerides (TG). We identified five genome-wide significant gene-statin interactions for LDL-c, two interactions for HDL-c, and four interactions for TG. Importantly, only the SNP-based heritability of LDL-c was reduced by statin use. Using data from All of Us, we replicated all five significant gene-statin interaction loci for LDL-c in the European-like ancestry sample, two loci in the Americas-like ancestry sample, and one locus in the African-like ancestry sample. We also identified fifteen loci that remained associated with LDL-c despite statin treatment, highlighting potential additional genetic targets for drug development, enhancement, and repurposing. These loci include gene-targets for the recently developed hyperlipidemia drug class (PCSK9 inhibitors) validating our approach to finding new treatments. These results are an important step towards personalized medicine for patients with hyperlipidemia. Author SummaryHigh cholesterol raises the risk of heart attacks and strokes and nearly 200 million people worldwide take statins to lower it. While statins work for nearly everyone, they work better for some people than others. We examined how genetic differences enhance the effectiveness of statin medication as a step toward enhancing personalized medicine for those with high cholesterol. By analyzing genetic and health data from about 390,000 people, we found that statins primarily disrupt the link between genes and LDL or "bad" cholesterol levels. Across the genome, statins reduce the impact of genes on LDL-c levels, but not other blood lipids like HDL-c or triglycerides. For LDL-c specifically, we found five regions where genetic differences increase the effectiveness of statins. People with the protective genetic variants are expected to see greater cholesterol reduction with statin use. We confirmed four of the five findings in European-like ancestry samples, with partial replication in Americas-like and African-like ancestry samples (two variants and one variant, respectively). We also found 15 genomic regions where cholesterol stays high despite statin treatment. These genomic regions could be targets for new or enhanced cholesterol medications. In fact, a newer drug class targets one of these regions supporting our approach to finding new treatments.

Abstract Background Spontaneous coronary artery dissection (SCAD) is a well-recognised cause of acute coronary syndrome particularly among women without conventional cardiovascular risk factors. Increasing evidence indicates a genetic contribution; however, the underlying genetic architecture of SCAD remains insufficiently understood. Objective The aim of this study was to assess the prevalence of rare variants in previously reported SCAD associated genes and to explore the potential presence of novel genetic alterations in well-characterised Swedish patients with SCAD. Methods The study comprised 201 patients enrolled in SweSCAD, a national project examining the clinical characteristics, aetiology, and outcomes of SCAD. All individuals had a confirmed diagnosis based on invasive coronary angiography. Comprehensive exome sequencing was performed to identify rare variants contributing to disease susceptibility. Results Genetic variants that have been associated with SCAD according to current clinical genetics practice for variant reporting were identified in approximately 4 % of patients. In addition, rare potentially relevant variants were detected in almost 60 % of patients in genes associated with vascular integrity and vascular remodelling. Conclusion This study supports SCAD as a genetically complex arteriopathy, driven by rare high?impact variants together with broader polygenic susceptibility. Variants in collagen, vascular extracellular matrix, and oestrogen?responsive pathways provide biologically plausible links to female?predominant disease. Although the diagnostic yield of clearly actionable variants is modest, these findings support broader genomic evaluation beyond overt syndromic presentations and highlight the need for larger integrative genomic and functional studies to refine risk stratification and management.

Background and Aims Despite treatment, patients with established atherosclerotic cardiovascular disease (ASCVD) are at high risk of recurrent events. Existing clinical risk scores for recurrence provide only moderate predictive performance and rely largely on the same conventional risk factors used to predict disease onset. Proteomics is a promising source of new biomarkers but the technologies need focused use cases in order to achieve utility and implementation. We aimed to determine whether plasma proteomics improves prediction of recurrent cardiovascular events beyond established clinical risk models in secondary prevention in a population-scale cohort. Methods Plasma proteomic profiles from ~9,300 participants in the UK Biobank with established ASCVD at baseline were analysed using machine learning methods to derive and evaluate proteomic predictors of recurrent cardiovascular events. The top performing model comprised proteins with non-zero weights (full protein score). Predictive performance of the proteomic predictors, an established clinical risk score (SMART2), and their combination was evaluated across six pre-defined testing datasets representing multiple ethnic and geographic groups. A parsimonious set of proteins with existing clinical-grade enzyme-linked immunosorbent assays (ELISAs) available was then derived. Results The full protein score achieved higher performance for recurrent ASCVD than the SMART2 risk score across all ethnic and geographic subgroups (mean C-index 0.743 vs 0.653). Adding the full protein score to SMART2 improved discrimination, with the largest increase in White Irish participants ({Delta}C-index, 0.140; 95% CI, 0.074-0.205; P<0.001). However, adding SMART2 to the protein score provided minimal additional value. The parsimonious score preserved most of the discrimination of the full protein model with C-indices of the recurrent ASCVD risk model comprising age, sex and the parsimonious protein score being nearly identical to the full protein model in the largest testing set (0.723 vs 0.728 for White British in England and Wales). The parsimonious protein score showed a marked gradient of risk with the top, middle and bottom quintiles showing 10-year recurrent ASCVD rates of ~27.4%, ~9.6% and ~2.4%, respectively. Conclusions In patients with established ASCVD, plasma protein measurements substantially improved prediction of recurrent events beyond conventional clinical risk factors, supporting their potential as a complementary tool to guide secondary prevention of cardiovascular disease.

Background: Familial hypercholesterolemia (FH) is most frequently caused by pathogenic variants in LDLR, but phenotypic variability suggests the influence of genetic modifiers. Methods: We investigated a large multigenerational family with FH, combining clinical data, lipid profiles, and genetic analysis with functional studies. LDLR and PCSK9 variants were characterized according to ACMG/ClinGen guidelines. Functional assays in CHO-ldlA7 cells assessed LDLR activity, while plasma PCSK9 levels were quantified by ELISA. Results: LDLR c.2479G>A variant was associated with FH in the family. The presence of loss of function c.137G>T and c.2023del variants at PCSK9 appears to mitigate the effect of the LDLR variant. Conclusions: This study provides evidence that PCSK9 variants can counteract the deletereous effect of a LDLR variant associated with FH. These findings highlight the importance of gene/gene interactions in the clinical variability of FH and their potential implications for precision medicine.

Rationale: Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with substantial unmet diagnostic and therapeutic needs. Circulating lipid metabolism is increasingly implicated in HFpEF pathophysiology but has not been systematically leveraged for molecular stratification. Objective: To determine whether plasma lipidomics can identify molecular phenogroups of HFpEF associated with distinct clinical characteristics and outcomes. Methods and Results: Untargeted plasma lipidomics was performed in non-HF subjects and HFpEF patients from a primary Belgian cohort and an independent Canadian cohort (n=177 in each cohort). In the Belgian cohort, 235 unique lipids spanning 19 subclasses were annotated, including 96 significantly associated with HFpEF (q<0.02). Unsupervised analyses revealed marked lipidomic heterogeneity, with a distinct HFpEF subgroup separable from non-HF subjects. Hierarchical clustering identified three phenogroups with divergent lipid profiles and clinical features. One phenogroup exhibited severe atrial dysfunction, congestion-related biomarkers, elevated indices of cardiac and liver fibrosis, and markedly reduced survival, a second was characterized by prominent metabolic syndrome features, and a third by preserved renal function. Cross-cohort comparison using a supervised classifier trained on 158 shared lipids confirmed analogous lower-risk phenogroups in the Canadian cohort, while the high-risk phenotype was underrepresented. A signature of 10 lipids across six subclasses, including long-chain acylcarnitines, ether phosphatidylcholines, and oxidized sphingomyelins, discriminated the high-risk group and correlated with markers of disease severity. Conclusion: Our findings demonstrate that HFpEF comprises metabolically distinct patient subgroups across cohorts, revealing specific lipidomic dysfunctions that deepen our understanding of HFpEF heterogeneity and underlying pathophysiology.

Background: The clinical significance of sarcomere variants of uncertain significance (VUS) in hypertrophic cardiomyopathy (HCM) remains unclear, and VUS are currently regarded as clinically non-actionable despite their increasing prevalence. This study aimed to evaluate genotype?phenotype and genotype?outcome associations according to variant pathogenicity in patients with HCM, with a particular focus on the clinical relevance of sarcomere VUS. Methods: This multicenter retrospective cohort study included 438 patients with HCM who underwent next-generation sequencing-based genetic testing at two tertiary hospitals. Patients were classified into three groups: pathogenic or likely pathogenic (P/LP) variants, VUS, and no sarcomere mutations. Clinical characteristics, imaging phenotypes, and outcomes were compared across groups. The primary endpoint was a composite of cardiovascular death, aborted sudden cardiac death, appropriate implantable cardioverter-defibrillator therapy, and heart transplantation. Time-to-event analyses were performed using Kaplan-Meier methods and Cox proportional hazards models with Firth's penalized partial likelihood approach. Results: P/LP variants were identified in 171 patients (39.0%) and sarcomere VUS in 159 patients (36.3%). Patients with VUS demonstrated intermediate clinical and phenotypic features between P/LP carriers and genotype-negative patients. Kaplan?Meier analysis showed a graded difference in event-free survival across variant classifications. While VUS were not independently associated with adverse outcomes when modeled as a categorical variable, increasing pathogenicity from genotype-negative to VUS and P/LP variants was associated with a stepwise increase in risk of the primary endpoint (hazard ratio 2.05, 95% confidence interval 1.11?4.16 p=0.019). Identified VUS were preferentially enriched in Z-disc and giant sarcomere scaffolding proteins. Conclusion: Sarcomere VUS represent intermediate characteristics along a continuum of sarcomere dysfunction, associated with distinct phenotypic features and clinical outcomes compared with both P/LP variants and the absence of sarcomere mutations. These findings suggest that sarcomere VUS may not be entirely clinically neutral and should be interpreted within a broader genetic and structural context in patients with HCM.

AimsLow-dose aspirin is no longer routinely recommended for primary prevention in older adults because bleeding risks outweigh cardiovascular benefits. We aimed to investigate whether polygenic scores (PGSs) could modify the effects of aspirin on major bleeding and major adverse cardiovascular events (MACE) in a trial of older individuals. MethodsWe conducted post-hoc genetic analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, placebo-controlled trial in Australia and the United States. Participants aged [&ge;]70 years ([&ge;]65 years for U.S. minorities) without cardiovascular disease, dementia, or physical disability were randomized to 100 mg daily aspirin or placebo. Among those with high-quality genotyping data (n=13,571; median follow-up 4.6 years), we tested 572 cardiovascular- and hematologic-related PGSs for interaction with aspirin using Cox proportional hazards models, applying Bonferroni correction. ResultsA triglyceride-related PGS (PGS003144) modified aspirins effect on major bleeding (interaction P=5.9x10-5; Bonferroni-adjusted P=0.034). In the lowest PGS quintile, aspirin increased major bleeding compared with placebo (hazard ratio [HR] 2.28; 95% CI 1.45-3.58) without reducing MACE (HR 1.04; 95% CI 0.67-1.62). In contrast, in the highest quintile, aspirin was associated with lower risks of major bleeding (HR 0.62; 95% CI 0.38-0.97) and MACE (HR 0.66; 95% CI 0.44-0.99). Baseline measured triglyceride levels demonstrated a similar pattern of effect modification. ConclusionA triglyceride-related PGS identifies older adults with divergent bleeding and cardiovascular responses to aspirin, supporting the potential role of genetically-informed strategies for primary cardiovascular prevention. Lay summaryThis study shows that genetic differences related to triglyceride levels may help identify older adults who are more likely to be harmed or to benefit from taking aspirin to prevent heart disease. O_LIIn older adults with certain genetic profiles linked to triglycerides, aspirin increased the risk of serious bleeding without reducing heart attacks or strokes, while in others it was associated with lower risks of both bleeding and cardiovascular events. C_LIO_LIUsing genetic information alongside traditional risk factors could help tailor aspirin use for primary prevention, avoiding unnecessary harm while identifying those most likely to benefit. C_LI Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=140 SRC="FIGDIR/small/26346656v1_ufig1.gif" ALT="Figure 1"> View larger version (60K): org.highwire.dtl.DTLVardef@7ac690org.highwire.dtl.DTLVardef@8256c2org.highwire.dtl.DTLVardef@10de40corg.highwire.dtl.DTLVardef@f6e5e9_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOFigure, Graphical Abstract:C_FLOATNO Genetic stratification of aspirin benefit and harm using a triglyceride polygenic score. Screening of 572 polygenic scores in the ASPREE trial identified a triglyceride-related PGS that modified aspirin-associated bleeding and cardiovascular risk. Aspirin increased bleeding risk in the lowest PGS quintile but reduced major bleeding and MACE in the highest quintile. Abbreviations: PGS, polygenic score; GI, gastrointestinal; IC, intracranial; MACE, major adverse cardiovascular events. C_FIG

Background: Insulin resistance (IR) and obesity are key drivers of atrial fibrillation (AF). However, the comparative predictive value of the Triglyceride-Glucose (TyG) index versus composite indices combining IR and anthropometric measures such as TyG-BMI, TyG-Waist Circumference (TyG-WC), and Waist-to-Height Ratio (WHtR) remains undefined. We aimed to evaluate these associations and the modifying effect of genetic susceptibility. Methods: We analyzed 293,318 UK Biobank participants free of AF at baseline. Hazard ratios (HRs) were estimated using Cox proportional hazards models, and non-linearity was assessed using restricted cubic splines. Incremental predictive value was evaluated via Net Reclassification Improvement (NRI). Interactions with AF Polygenic Risk Scores (PRS) were examined. Results: During follow-up, 22,707 incident AF cases occurred. While the TyG index was associated with AF in unadjusted models, this association was nullified after full adjustment. In contrast, composite indices (TyG-BMI, TyG-WC) and WHtR showed robust, positive associations (WHtR HR per SD: 1.30, 95% CI 1.28-1.32). Spline analysis identified non-linear threshold effects (e.g., WHtR inflection at 0.556). Adding WHtR or TyG-BMI to baseline models significantly improved risk reclassification (NRI ~10.3-11.8%, P<0.001), whereas TyG alone did not (P=0.73). Elevated metabolic risk increased AF incidence across all genetic categories, with significant interactions suggesting greater relative impact in low-genetic risk groups. Conclusions: Composite indices integrating central obesity and insulin resistance are superior to the TyG index alone in predicting incident AF. The identification of specific risk thresholds and genetic interactions highlights "metabolic health" as a crucial, modifiable target for AF prevention.

BackgroundPathogenic desmin (DES) variants have been implicated in early-onset atrial disease, yet the mechanisms by which desmin dysfunction alters atrial structure and function remain unclear. Desmin anchors the cytoskeleton to the nuclear envelope (NE) through the linker of nucleoskeleton and cytoskeleton (LINC) complex, suggesting that defects in this network may drive atrial cardiomyopathy. MethodsHuman desmin wild-type (WT) and the pathogenic variants p.S13F, p.N342D, and p.R454W were stably expressed in HL-1 atrial cardiomyocytes. Desmin organization, nuclear morphology, LINC-complex integrity (nesprin-3, lamin A/C), and DNA leakage, assessed by cyclic GMP-AMP synthase (cGAS), were analyzed by confocal microscopy. Action potential duration (APD) and calcium transients (CaT) were measured optically. Human myocardium samples from DES variant carriers were analyzed for validation. Data-independent acquisition (DIA) mass spectrometry profiled atrial proteomes from desmin-network (DN) and titin variant carriers and controls. The heat-shock proteins (HSPs) inducer geranylgeranylacetone (GGA) was evaluated for rescue effects. Resultsp.N342D caused severe filament-assembly defects with prominent perinuclear aggregates, whereas p.S13F showed mixed phenotypes with frequent perinuclear aggregates, and p.R454W largely preserved filamentous networks. p.N342D and p.S13F induced nuclear deformation with disrupted nesprin-3 and lamin A/C distribution. In p.N342D and p.S13F, desmin aggregates drove focal lamin A/C accumulation, nuclear envelope (NE) rupture, DNA leakage, and increased cGAS activation. DES variants significantly shortened APD20/90 and reduced CaT amplitude, indicating pro-arrhythmic electrical remodeling. Atrial proteomics revealed a DN-specific signature enriched for cytoskeletal, NE, intermediate filament, and chaperone pathways, consistent with the structural injury observed in vitro. GGA prevented desmin aggregation and nuclear morphology changes, and mitigated APD shortening in p.N342D-expressing cardiomyocytes. Human myocardium from DES variant carriers showed concordant desmin aggregation and polarized lamin A/C distribution. ConclusionsDES variants induce a desmin-dependent atrial cardiomyopathy characterized by cytoskeletal disorganization, disruption of LINC-complex, NE rupture with DNA leakage, and pro-arrhythmic electrophysiological remodeling. These findings provide mechanistic insight into how DN variants promote atrial disease. HSPs induction by GGA partially restores structural and functional integrity, identifying a potential therapeutic approach for desmin-related atrial cardiomyopathy. Clinical perspectiveWhat is new? O_LIPathogenic DES variants induce a previously unrecognized atrial cardiomyopathy characterized by desmin aggregation, and desmin-network (DN) collapse, disruption of the linker of nucleoskeleton and cytoskeleton (LINC) complex, and nuclear envelope rupture with DNA leakage. C_LIO_LIVariants that lead to desmin aggregation (e.g., p.N342D) cause focal lamin A/C polarization, cyclic GMP-AMP synthase (cGAS) activation, and structural injury at the nuclear envelope. C_LIO_LIDES variants produce pro-arrhythmic electrical remodeling, including action potential duration shortening and impaired Ca{superscript 2} handling in HL-1 atrial cardiomyocytes. C_LIO_LIAtrial proteomics from DN variant carriers reveals enrichment of pathways related to cytoskeletal, nuclear envelope, intermediate filament, and chaperone, supporting a desmin-dependent remodeling program. C_LIO_LIThe heat-shock protein inducer geranylgeranylacetone (GGA) prevents desmin aggregation, restores nuclear morphology, and mitigates electrical and Ca{superscript 2} handling remodeling. C_LI What are the clinical implications? O_LIThese findings establish DN dysfunction as a distinct cause of atrial cardiomyopathy, providing a mechanistic basis for the association between pathogenic DES variants and atrial arrhythmias, including atrial fibrillation. C_LIO_LINuclear envelope rupture and cytosolic DNA leakage represent new mechanistic evidence which links cytoskeletal injury and atrial arrhythmogenesis. C_LIO_LIIdentifying structural vulnerability in DES variant carriers fosters awareness of genetic counseling for atrial disease, enabling early detection and risk stratification. C_LIO_LIThe protective effects of GGA suggest that restoring proteostasis may be a therapeutic strategy for desmin-related atrial cardiomyopathy and potentially other genetic atrial diseases. C_LI Novelty and significance statementO_ST_ABSNoveltyC_ST_ABSThis study identifies a desmin-dependent atrial cardiomyopathy driven by cytoskeletal aggregation, LINC-complex disruption, and nuclear envelope rupture with DNA leakage. We show that pathogenic DES variants are associated with pro-arrhythmic molecular remodeling and that human atrial proteomics confirm nuclear envelope and cytoskeletal injury as core features. Importantly, the heat-shock protein-inducer GGA rescues structural, molecular, and electrophysiological defects, revealing a modifiable pathway in desmin-mediated atrial disease. SignificanceThese findings provide the first integrated mechanistic explanation linking DN variants to atrial cardiomyopathy. By uncovering nuclear envelope rupture and cGAS activation as key drivers of atrial cardiomyopathy, this work expands the molecular framework for inherited atrial disease and highlights proteostasis enhancement as a potential therapeutic strategy for patients carrying DES and related cytoskeletal variants. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=166 HEIGHT=200 SRC="FIGDIR/small/26348559v1_ufig1.gif" ALT="Figure 1"> View larger version (51K): org.highwire.dtl.DTLVardef@1fb0bfborg.highwire.dtl.DTLVardef@cfc00borg.highwire.dtl.DTLVardef@1493578org.highwire.dtl.DTLVardef@1556b61_HPS_FORMAT_FIGEXP M_FIG C_FIG

ObjectiveDiabetes mellitus (DM) approximately doubles the risk of atherosclerotic cardiovascular disease (ASCVD) events, but the molecular basis is poorly understood. We aimed to define arterial differentially expressed genes (DEGs) associated with DM, validate hits as plasma proteins, and ascertain whether these complement ASCVD risk prediction tools. Research design and methodsRNA-sequencing data from the Genotype-Tissue Expression (GTEx) cohort was used to define DEGs associated with DM in two arterial sites in >90 people with DM and >330 controls. UK Biobank (UKB) was used to corroborate that DEGs in their plasma protein form were differentially abundant in people with DM and associated with ASCVD events. Finally, we assessed if including these plasma proteins improved performance of the SCORE2 and SCORE2-Diabetes ASCVD risk models. Results619 and 356 DEGs were associated with DM in the thoracic aorta and tibial artery, respectively. Of these, 22 were common to both arteries, all of which were directionally concordant. Of these, 5 were included in the UKB plasma proteomics dataset and we corroborated 4 (ACP5, LEFTY2, LILRA5 and PSME2) as showing concordant differential abundance in people with DM; all demonstrated associations with a range of incident ASCVD events. Addition of the 4 proteins to SCORE2 and SCORE2-Diabetes (for people without and with DM, respectively) improved the population-level discrimination, classification and calibration of these models. ConclusionsDM is associated with a distinct arterial gene expression profile, hits from which are associated with ASCVD events and add value to risk prediction. Visual abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=139 SRC="FIGDIR/small/26345847v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): org.highwire.dtl.DTLVardef@19e0228org.highwire.dtl.DTLVardef@9fd086org.highwire.dtl.DTLVardef@3315f0org.highwire.dtl.DTLVardef@1e5770f_HPS_FORMAT_FIGEXP M_FIG C_FIG

Introduction: Spontaneous coronary artery dissection (SCAD) is frequently accompanied by persistent symptoms of unknown pathogenesis after the index event. Autonomic dysfunction is a plausible mechanism for these but has not been systematically characterized. We quantified antecedent and contemporary autonomic symptoms in survivors of SCAD and examined their associations with cardiac and extra-cardiac symptoms and health-related quality of life. Methods: This cross-sectional study recruited 227 volunteers from multiple countries with a self-reported history of SCAD. Participants completed validated patient-reported measures, including the Composite Autonomic Symptom Score-31 (COMPASS-31), Anxiety Sensitivity Index-3 (ASI-3), and EuroQol-5 Dimension-5L (EQ-5D-5L). They also completed an internally derived retrospective autonomic predisposition score assessing symptoms during adolescence and early adulthood. Results: Participants were predominantly female (97.8%), median age 53 (47-58) years, and were surveyed a median of 3 (1-5) years after their index SCAD event. 21.6% reported SCAD recurrence. Moderate autonomic symptom burden (COMPASS-31 20) was present in 56.4% and severe burden (40) in 16.3%. History of antecedent autonomic symptoms was the strongest independent predictor of contemporary autonomic symptom burden after adjustment for demographic and clinical covariates (=0.514; P <0.001). Greater autonomic symptom burden independently predicted lower EQ-5D health utility (=0.150; P=0.029) and was associated with the ASI-3 physical concerns (=0.232; P <0.001), but not social concerns domain. Autonomic symptoms were not associated with SCAD recurrence. Conclusion: Symptoms of autonomic dysregulation are common in survivors of SCAD and are associated with reduced quality of life. Their association with antecedent dysautonomic features during adolescence and early adulthood suggests a longstanding predisposition, the significance of which warrants further evaluation.

BackgroundDespite improved cancer outcomes with kinase inhibitors (KIs), their cardiotoxicity remains a significant clinical challenge. Current approaches to predict and prevent KI-induced cardiac adverse events (CAEs) are limited by an incomplete understanding of underlying mechanisms, including the contribution of off-target kinase engagement. ObjectivesTo establish links between kinase inhibition profiles and cardiotoxic phenotypes using empirical proteomic data, and to leverage these profiles in machine learning (ML) models capable of predicting KI cardiotoxicity. MethodsWe curated a database connecting kinome-wide target binding profiles of FDA-approved KIs (n=44) with documented incidence rates of six distinct CAEs. Binding profiles were derived from unbiased chemoproteomics and used to assess associations between KI selectivity, specific kinase targets, and CAEs. Profiles were further used to develop ML models to predict CAE risk, with SHAP-based model interpretation applied to identify cardiotoxicity-associated kinases. ResultsKI promiscuity was not a significant predictor of cardiotoxicity across all six CAEs. Frequency analysis revealed that kinases including RET, PDGFRB, and DDR1 are recurrently inhibited across CAE-linked compounds, with nearly all identified as off-targets not annotated by the FDA. Network and pathway enrichment analyses supported a systems-level model in which cardiotoxicity arises from coordinated disruption of cardiac-relevant signaling networks. ML models achieved 66-84% cross-validated accuracy (ROC-AUC 0.75-0.8) across CAE endpoints, with SHAP analysis identifying PDGFRB, EGFR, and MEK1/2 among the most predictive kinases. ConclusionsProteomic kinome profiling combined with machine learning provides a mechanistically grounded framework for predicting KI cardiotoxicity and supports off-target-aware drug design to minimize cardiovascular risk.

Background: Heart failure (HF) is a major and growing public health problem, and prior studies support a meaningful genetic contribution to HF susceptibility. Clinically, HF is commonly categorized into the major clinical sub-types of HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), which differ in pathophysiology and clinical profiles. However, previous genome-wide association studies have focused on autosomal variation and have routinely excluded the X chromosome, leaving X-linked genetic contributions to HF and its subtypes under-characterized. Methods: We performed X-chromosome wide association study (XWAS) utilizing directly genotyped data from 590,568 Million Veteran Program participants, including 90,694 HF cases across European, African, Hispanic, and Asian Americans. Sex- and ancestry-stratified logistic regression was used with XWAS quality control measures, adjusting for age and population structure, followed by fixed-effects multi-ancestry meta-analysis. Functional annotation, gene-based testing, fine-mapping, and colocalization were performed. We replicated genetic associations with all-cause HF in the UK Biobank. Results: In the multi-ancestry meta-analysis, we identified five X-chromosome-wide significant loci for all-cause HF, five for HFrEF, and one locus for HFpEF in males. No loci reached significance in female-specific analyses. In sex-combined analyses, we identified six loci for all-cause HF and four for HFrEF. The strongest and most emphasized signals mapped to genes were BRWD3, FHL1, and CHRDL1. Ancestry-specific analyses revealed additional loci, including NDP and WDR44 in African ancestry and PHF8 in Hispanic ancestry. One locus, BRWD3, was replicated in UK Biobank HF cohort. Integrated post-GWAS analyses (fine-mapping, colocalization and pleiotropy trait association studies) reinforced the biological plausibility of the X-linked signals. Conclusions: This multi-ancestry, sex-stratified XWAS identifies X-linked genetic contributions to HF and its subtypes and highlights the role of X-chromosome in heart failure pathogenesis.