Eliseo Guallar
Eliseo Guallar
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Chair and Professor of the Department of Epidemiology
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Professional overview
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Dr. Guallar is an epidemiologist whose research is focused on the study of cardiovascular disease epidemiology and prevention, with an emphasis on evaluating the role of environmental and nutritional exposures in the development of cardiovascular disease. This research has made critically important and novel contributions to our understanding of risk factors for chronic disease both in the US and globally. He has published seminal articles and is a leading figure in an emerging field highlighting the risks of exposure to levels of metals previously considered safe for cardiovascular health. In addition to his work in toxic metals, Dr. Guallar has made important contributions to understanding the effects of certain micronutrients and vitamin supplements on cardiovascular disease risk and outcomes. Publications in this area were influential in changing consumer habits and attitudes towards these products. Much of this research has been funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, the American Heart Association, the CDC, and other funders.
Dr. Guallar was the founding director of the Center for Clinical Epidemiology at the Samsung Medical Center and a lead investigator of the Kangbuk Samsung Cohort Study at the Kangbuk Samsung Hospital since its inception in 2010. Dr. Guallar has published over 500 research papers in peer-reviewed journals. He is also a Deputy Editor for Methods at the Annals of Internal Medicine and a past member and Chair of the Cancer, Heart, and Sleep Study Section at the National Institutes of Health.
Prior to teaching at NYU, Dr. Guallar was a Professor of Epidemiology and Medicine at the Johns Hopkins University Bloomberg School of Public Health and a core faculty member of the Welch Center for Prevention, Epidemiology, and Clinical Research at Johns Hopkins. In the Department of Epidemiology, Dr. Guallar was the Director of the Environmental and Occupational Area of Concentration and the Co-Director of the PhD Program. Dr. Guallar was also an adjunct Professor at the Department of Clinical Research Design and Evaluation of the Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, in Seoul, Korea.
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Education
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Diploma of English, Spanish Official School of Languages at Zaragoza (Escuela Oficial de Idiomas de Zaragoza), Zaragoza, SpainMD, University of Zaragoza, Zaragoza, SpainMPH, University of Minnesota, Minneapolis, MNDrPH, Harvard University, Boston, MA
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Honors and awards
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Six Honor Calls in the MD Program, University of Zaragoza School of Medicine (1981)Fellow of Spain’s Program of Training of Graduate Research of the Ministry of Education and Science, University of Zaragoza (1988)Fulbright Scholar, sponsored by Spain’s Ministry of Health and Consumer Affairs (1989)Faculty Innovation Award, Johns Hopkins University Bloomberg School of Public Health (2001)Scientist Development Award, American Heart Association (2002)Fellow of the American Heart Association, Council on Epidemiology and Prevention (2013)Advising, Mentoring, and Teaching Recognition Award 2014 – 2015, Johns Hopkins University Bloomberg School of Public Health (2015)High Impact Research Icon, University of Malaya (2015)
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Publications
Publications
Modern prevalence of dysbetalipoproteinemia (fredrickson-levy-lees type III hyperlipoproteinemia)
AbstractPallazola, V. A., Sathiyakumar, V., Park, J., Vakil, R. M., Toth, P. P., Lazo-Elizondo, M., Brown, E., Quispe, R., Guallar, E., Banach, M., Blumenthal, R. S., Jones, S. R., Marais, D., Soffer, D., Sniderman, A. D., & Martin, S. S. (n.d.).Publication year
2019Journal title
Archives of Medical ScienceVolume
16Issue
5Page(s)
993-1003AbstractIntroduction: Dysbetalipoproteinaemia (HLP3) is a disorder characterized by excess cholesterol-enriched, triglyceride-rich lipoprotein remnants in genetically predisposed individuals that powerfully promote premature cardiovascular disease if untreated. The current prevalence of HLP3 is largely unknown. Material and methods: We performed cross-sectional analysis of 128,485 U.S. adults from the Very Large Database of Lipids (VLDbL), using four algorithms to diagnose HLP3 employing three Vertical Auto Profile ultracentrifugation (UC) criteria and a previously described apolipoprotein B (apoB) method. We evaluated 4,926 participants from the 2011–2014 National Health and Nutrition Examination Survey (NHANES) with the apoB method. We examined demographic and lipid characteristics stratified by presence of HLP3 and evaluated lipid characteristics in those with HLP3 phenotype discordance and concordance as determined by apoB and originally defined UC criteria 1. Results: In U.S. adults in VLDbL and NHANES, a 1.7–2.0% prevalence is observed for HLP3 with the novel apoB method as compared to 0.2–0.8% prevalence in VLDbL via UC criteria 1–3. Participants who were both apoB and UC criteria HLP3 positive had higher remnant particles as well as more elevated triglyceride/apoB and total cholesterol/apoB ratios (all p < 0.001) than those who were apoB method positive and UC criteria 1 negative. Conclusions: HLP3 may be more prevalent than historically and clinically appreciated. The apoB method increases HLP3 identification via inclusion of milder phenotypes. Further work should evaluate the clinical implications of HLP3 diagnosis at various lipid algorithm cut-points to evaluate the ideal standard in the modern era.Non-alcoholic fatty liver disease and cerebral small vessel disease in Korean cognitively normal individuals
AbstractJang, H., Kang, D., Chang, Y., Kim, Y., Lee, J. S., Kim, K. W., Jang, Y. K., Kim, H. J., Na, D. L., Shin, H. Y., Kang, M., Guallar, E., Cho, J., & Seo, S. W. (n.d.).Publication year
2019Journal title
Scientific reportsVolume
9Issue
1AbstractWe aimed to investigate the association between nonalcoholic fatty liver disease (NAFLD) and cerebral small vessel disease (CSVD) burden, especially according to the NAFLD severity. A total of 1,260 participants were included. The CSVD burden was assessed with white matter hyperintensities (WMH), lacunes, and microbleeds (MBs) on brain MRI. An ultrasound diagnosis of fatty liver was made based on standard criteria, and the Fibrosis-4 (FIB-4) index was used to classify participants with NAFLD with having a high-intermediate (FIB-4 ≥1.45) or low (FIB-4 < 1.45) probability of advanced fibrosis. A multivariable logistic regression analysis was used to assess the association between NAFLD and the presence of moderate to severe WMH, lacunes, and MBs. NAFLD had a significant association only with moderate to severe WMH (OR: 1.64, 95% CI: 1.10–2.42), even after controlling for cardiometabolic risk factors. A linear trend test showed a significant association between the severity of NAFLD fibrosis and the presence of moderate to severe WMH (p for trend <0.001). Our findings suggest that NAFLD, especially NAFLD with fibrosis, has a significant association with the presence of moderate to severe WMH in cognitively normal individuals, and NAFLD severity predicted more frequent moderate to severe WMH.Permanent Chemotherapy-Induced Alopecia in Patients with Breast Cancer: A 3-Year Prospective Cohort Study
AbstractKang, D., Kim, I. R., Choi, E. K., Im, Y. H., Park, Y. H., Ahn, J. S., Lee, J. E., Nam, S. J., Lee, H. K., Park, J. H., Lee, D. Y., Lacouture, M. E., Guallar, E., & Cho, J. (n.d.).Publication year
2019Journal title
OncologistVolume
24Issue
3Page(s)
414-420AbstractBackground: Although chemotherapy-induced alopecia (CIA) is considered temporary, some patients report persistent alopecia several years after chemotherapy. There is, however, a paucity of long-term prospective data on the incidence and impact of permanent CIA (PCIA). The objective of our study was to estimate the long-term incidence of PCIA in a cohort of patients with breast cancer whose hair volume and density were measured prior to chemotherapy and who were followed for 3 years after chemotherapy. Materials and Methods: Prospective cohort study of consecutive patients ≥18 years of age with postoperative diagnosis of stage I–III breast cancer expected to receive adjuvant chemotherapy at the outpatient breast cancer clinic at the Samsung Medical Center in Seoul, Korea, from February 2012 to July 2013 (n = 61). Objective hair density and thickness were measured using a noninvasive bioengineering device. Results: The proportion of participants who had PCIA at 6 months and 3 years was 39.5% and 42.3%, respectively. PCIA was characterized in most patients by incomplete hair regrowth. Patients who received a taxane-based regimen were more likely to experience PCIA compared with patients with other types of chemotherapy. At a 3-year follow-up, hair thinning was the most common problem reported by study participants (75.0%), followed by reduced hair volume (53.9%), hair loss (34.6%), and gray hair (34.6%). Conclusion: PCIA is a common adverse event of breast cancer adjuvant cytotoxic chemotherapy. Clinicians should be aware of this distressing adverse event and develop supportive care strategies to counsel patients and minimize its impact on quality of life. Implications for Practice: Knowledge of permanent chemotherapy-induced alopecia, an under-reported adverse event, should lead to optimized pretherapy counseling, anticipatory coping techniques, and potential therapeutic strategies for this sequela of treatment.Racial Differences in Sudden Cardiac Death: Atherosclerosis Risk in Communities Study (ARIC)
AbstractZhao, D., Post, W. S., Blasco-Colmenares, E., Cheng, A., Zhang, Y., Deo, R., Pastor-Barriuso, R., Michos, E. D., Sotoodehnia, N., & Guallar, E. (n.d.).Publication year
2019Journal title
CirculationVolume
139Issue
14Page(s)
1688-1697AbstractBackground: Blacks have a higher incidence of out-of-hospital sudden cardiac death (SCD) in comparison with whites. However, the racial differences in the cumulative risk of SCD and the reasons for these differences have not been assessed in large-scale community-based cohorts. The objective of this study is to compare the lifetime cumulative risk of SCD among blacks and whites, and to evaluate the risk factors that may explain racial differences in SCD risk in the general population. Methods: This is a cohort study of 3832 blacks and 11 237 whites participating in the Atherosclerosis Risk in Communities Study (ARIC). Race was self-reported. SCD was defined as a sudden pulseless condition from a cardiac cause in a previously stable individual, and SCD cases were adjudicated by an expert committee. Cumulative incidence was computed using competing risk models. Potential mediators included demographic and socioeconomic factors, cardiovascular risk factors, presence of coronary heart disease, and electrocardiographic parameters as time-varying factors. Results: The mean (SD) age was 53.6 (5.8) years for blacks and 54.4 (5.7) years for whites. During 27.4 years of follow-up, 215 blacks and 332 whites experienced SCD. The lifetime cumulative incidence of SCD at age 85 years was 9.6, 6.6, 6.5, and 2.3% for black men, black women, white men, and white women, respectively. The sex-adjusted hazard ratio for SCD comparing blacks with whites was 2.12 (95% CI, 1.79-2.51). The association was attenuated but still statistically significant in fully adjusted models (hazard ratio, 1.38; 95% CI, 1.11-1.71). In mediation analysis, known factors explained 65.3% (95% CI 37.9-92.8%) of the excess risk of SCD in blacks in comparison with whites. The single most important factor explaining this difference was income (50.5%), followed by education (19.1%), hypertension (22.1%), and diabetes mellitus (19.6%). Racial differences were evident in both genders but stronger in women than in men. Conclusions: Blacks had a much higher risk for SCD in comparison with whites, particularly among women. Income, education, and traditional risk factors explained ≈65% of the race difference in SCD. The high burden of SCD and the racial-gender disparities observed in our study represent a major public health and clinical problem.Relation of Elevated Resting Heart Rate in Mid-Life to Cognitive Decline Over 20 Years (from the Atherosclerosis Risk in Communities [ARIC] Study)
AbstractWang, S., Fashanu, O. E., Zhao, D., Guallar, E., Gottesman, R. F., Schneider, A. L., McEvoy, J. W., Norby, F. L., Aladin, A. I., Alonso, A., & Michos, E. D. (n.d.).Publication year
2019Journal title
American Journal of CardiologyVolume
123Issue
2Page(s)
334-340AbstractResting heart rate (RHR) is independently associated with cardiovascular disease (CVD) risk. We determined whether RHR, measured in mid-life, is also associated with cognitive decline. We studied 13,720 middle-aged white and black ARIC participants without a history of stroke or atrial fibrillation. RHR was obtained from a 12-lead resting electrocardiogram at the baseline visit (1990 to 1992) and categorized into groups as <60 (reference), 60 to 69, 70 to 79 and ≥80 beats/min. Cognitive scores were obtained at baseline and at up to 2 additional visits (1996 to 1998 and 2011 to 2013). The primary outcome was a global composite cognitive score (Z-score) derived from 3 tests: delayed word recall, digit symbol substitution, and word fluency. The associations of RHR with cognitive decline and incident dementia were examined using linear mixed-effects and Cox hazard models, respectively, adjusting for sociodemographics, CVD risk factors, and AV-nodal blockade use. Multiple imputation methods were used to account for attrition over follow-up. Participants had mean ± SD age of 58 ± 6 years; 56% were women, 24% black. Average RHR was 66 ± 10 beats/min. Over a mean follow-up of 20 years, those with RHR ≥80 beats/min had greater global cognitive decline (average adjusted Z-score difference −0.12 [95% confidence interval −0.21, −0.03]) and increased risk for incident dementia (hazard ratio 1.28 (1.04, 1.57), compared with those with RHR <60 beats/min. In conclusion, elevated RHR is independently associated with greater cognitive decline and incident dementia over 20 years. Further studies are needed to determine whether the associations are causal or secondary to another underlying process, and whether modification of RHR can affect cognitive decline.Relationship of the Blood Pressure Categories, as Defined by the ACC/AHA 2017 Blood Pressure Guidelines, and the Risk of Development of Cardiovascular Disease in Low-Risk Young Adults: Insights From a Retrospective Cohort of Young Adults
AbstractKim, S., Chang, Y., Kang, J., Cho, A., Cho, J., Hong, Y. S., Zhao, D., Ahn, J., Shin, H., Guallar, E., Ryu, S., & Sung, K. C. (n.d.).Publication year
2019Journal title
Journal of the American Heart AssociationVolume
8Issue
11AbstractBackground: There are limited outcome studies of hypertension among young adults, especially using the new blood pressure (BP) categories from the American College of Cardiology and the American Heart Association. We examined associations between the new BP categories and the risk of incident cardiovascular disease (CVD) in low-risk and young adults. Methods and Results: A cohort study was performed in 244 837 Korean adults (mean age, 39.0 years; SD, 8.9 years) who underwent a comprehensive health examination at Kangbuk Samsung Hospital from January 1, 2011, to December 31, 2016; they were followed up for incident CVD via linkage to the Health Insurance and Review Agency database until the end of 2016, with a median follow-up of 4.3 years. BP was categorized according to the new American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines. During 924 420.7 person-years, 1435 participants developed new-onset CVD (incidence rate of 16.0 per 104 person-years). The multivariable-adjusted hazard ratios (95% CIs) for CVD comparing elevated BP, stage 1 hypertension, stage 2 hypertension, treated and strictly controlled (systolic BP/diastolic BP <130/80 mm Hg with antihypertensive use), treated and controlled (systolic BP 130–139 and diastolic BP 80 to 89 mm Hg with antihypertensive use), treated uncontrolled, and untreated hypertension to normal BP were 1.37 (1.11–1.68), 1.45 (1.26–1.68), 2.12 (1.74–2.58), 1.41 (1.12–1.78), 1.97 (1.52–2.56), 2.29 (1.56–3.37) and 1.93 (1.53–2.45), respectively. Conclusions: In this large cohort of low-risk and young adults, all categories of higher BP were independently associated with an increased risk of CVD compared with normal BP, underscoring the importance of BP management even in these low-risk populations.Resting Heart Rate, Short-Term Heart Rate Variability and Incident Atrial Fibrillation (from the Multi-Ethnic Study of Atherosclerosis (MESA))
AbstractHabibi, M., Chahal, H., Greenland, P., Guallar, E., Lima, J. A., Soliman, E. Z., Alonso, A., Heckbert, S. R., & Nazarian, S. (n.d.).Publication year
2019Journal title
American Journal of CardiologyVolume
124Issue
11Page(s)
1684-1689AbstractEvidence suggests an association between autonomical nervous system (ANS) function and atrial fibrillation (AF) development. We sought to examine the association of baseline resting heart rate (RHR) and short-term heart rate variability (HRV) as surrogates of (ANS) with incident AF in individuals without previous cardiovascular disease. A total of 6,261 participants of the Multi-Ethnic Study of Atherosclerosis who were free of AF and diagnosed cardiovascular disease were enrolled. Three standard 10-second, 12-lead electrocardiograms (ECG) were used to measure RHR, the standard deviation of normal-to-normal intervals (SDNN) and the root mean square of successive differences in RR intervals (RMSSD). Cox proportional hazards models adjusted for demographics, atrioventricular nodal agents, and known cardiovascular risk factors were used to examine the association of baseline RHR, and log transformed SDNN and RMSDD with incident AF. Over a mean follow-up of 11.3 ± 3.7 years, 754 (12%) participants developed AF. Spline curve analysis revealed a nonlinear association between RHR, HRV, and incident AF. In fully adjusted models higher (but not lower) baseline RHR (RHR >76 beats/min) was associated with incident AF (hazard ratio 1.48 95% confidence interval 1.18 to 1.86). Additionally, lower values of RMSDD and SDNN and higher values of RMSDD were independently associated with incident AF. In conclusion, cardiac ANS dysregulation indicated as higher RHR and lower HRV is associated with incident AF independent of known cardiovascular risk factors.Risk of chronic obstructive pulmonary disease in healthy individuals with high C-reactive protein levels by smoking status: A population-based cohort study in Korea
AbstractLim, S. Y., Zhao, D., Guallar, E., Chang, Y., Ryu, S., Cho, J., & Shim, J. Y. (n.d.).Publication year
2019Journal title
International Journal of COPDVolume
14Page(s)
2037-2046AbstractPurpose: Chronic obstructive pulmonary disease (COPD) is associated with systemic inflammation. We investigated whether elevated baseline serum C-reactive protein (CRP) levels in healthy individuals are associated with the risk of incident COPD by smoking status. Patients and methods: This was a cohort study of 63,260 adult men and women who were older than 40 years, free of COPD at baseline, and underwent health screening from 2002 to 2016 with at least one follow-up visit through December 2016. We investigated the association between baseline high-sensitivity CRP (hsCRP) levels and incident COPD by smoking status, using flexible parametric proportional hazards models and pooled logistic regression analyses. Results: The multivariable-adjusted hazard ratio (95% confidence interval) comparing participants in the 90th to those in the 10th percentile of hsCRP was 1.19 (1.08, 1.31). The corresponding hazard ratio in never, former, and current smokers were 1.07 (0.89, 1.29), 1.22 (1.05, 1.42), and 1.22 (1.05, 1.41), respectively. The association between hsCRP levels and incident COPD had a similar dose–response pattern in former and current smokers, but not in never smokers. Conclusion: Higher baseline hsCRP is associated with an increased risk to develop COPD in ever smokers but not in never smokers.Serum metabolites and cardiac death in patients on hemodialysis
Hu, J. R., Grams, M. E., Coresh, J., Hwang, S., Kovesdy, C. P., Guallar, E., Rhee, E. P., & Shafi, T. (n.d.).Publication year
2019Journal title
Clinical Journal of the American Society of NephrologyVolume
14Issue
5Page(s)
747-749Trace Minerals, Heavy Metals, and Preeclampsia: Findings from the Boston Birth Cohort
AbstractLiu, T., Zhang, M., Guallar, E., Wang, G., Hong, X., Wang, X., & Mueller, N. T. (n.d.).Publication year
2019Journal title
Journal of the American Heart AssociationVolume
8Issue
16AbstractBackground: Preeclampsia is a leading contributor to maternal and perinatal morbidity and mortality. In mice experiments, manganese (Mn) and selenium (Se) are protective whereas cadmium (Cd) is promotive for preeclampsia. Epidemiologic findings on these chemical elements have been inconsistent. To confirm experimental findings in mice, we examined associations of trace minerals (Mn and Se) and heavy metals (Cd, lead [Pb], and mercury [Hg]) with preeclampsia in a birth cohort. Methods and Results: A total of 1274 women from the Boston Birth Cohort (enrolled since 1998) had complete data on the exposures and outcome. We measured Mn, Se, Cd, Pb, and Hg from red blood cells collected within 24 to 72 hours after delivery. We ascertained preeclampsia diagnosis from medical records. We used Poisson regression with robust variance models to estimate prevalence ratios (PRs) and 95% CIs. A total of 115 (9.0%) women developed preeclampsia. We observed evidence of a dose–response trend for Mn (P for trend<0.001) and to some extent for Cd (P for trend=0.009) quintiles. After multivariable adjustment, a 1 SD increment in Mn was associated with 32% lower risk of developing preeclampsia (PR=0.68; 95% CI, 0.54–0.86), whereas a 1 SD increment in Cd was associated with 15% higher risk of preeclampsia (PR=1.15; 95% CI, 0.98–1.36). Null associations were observed for Se, Pb, and Hg. Conclusions: Findings from our cohort, consistent with evidence from mice experiments and human studies, indicate that women with lower blood concentration of Mn or higher Cd are more likely to develop preeclampsia.Use of proton pump inhibitors and the risk of cholangitis: a nationwide cohort study
AbstractMin, Y. W., Kang, D., Shin, J. Y., Kang, M., Park, J. K., Lee, K. H., Lee, J. K., Lee, K. T., Rhee, P. L., Kim, J. J., Guallar, E., Cho, J., & Lee, H. (n.d.).Publication year
2019Journal title
Alimentary Pharmacology and TherapeuticsVolume
50Issue
7Page(s)
760-768AbstractBackground: Proton pump inhibitor (PPI) use may alter the gut microbiome and increase the risk of cholangitis. However, the association of PPI use with the risk of incident cholangitis has not been evaluated. Aim: To evaluate whether PPI use was associated with a higher risk of cholangitis. Methods: This cohort study included a nationwide representative sample of the Korean general population followed up for 10 years (1 January 2003 to 31 December 2013). PPI use was identified from treatment claims and considered as a time-varying variable. Incident cholangitis was identified from hospitalisation and out-patient visit claims. Results: During 4 212 003 person-years of follow-up, 58,863 participants had at least one PPI prescription and 1 834 participants developed cholangitis. The age-, sex-, residential area- and income-adjusted hazard ratio (HR) for incident cholangitis comparing PPI use with non-use was 6.06 (95% CI, 4.64-7.91). The association was essentially unchanged in fully adjusted models (HR 5.75; 95% CI, 4.39-7.54). The risk was highest during PPI treatment and decreased gradually after PPI discontinuation (Ptrend <.001). Conclusions: In this large cohort, PPI use was associated with an increased risk of cholangitis. Physicians prescribing PPIs should consider cholangitis as a potential complication of PPI use.A nationwide analysis of intensive care unit admissions, 2009–2014 – The Korean ICU National Data (KIND) study
AbstractPark, J., Jeon, K., Chung, C. R., Yang, J. H., Cho, Y. H., Cho, J., Park, C. M., Park, H., Cho, J., Guallar, E., & Suh, G. Y. (n.d.).Publication year
2018Journal title
Journal of Critical CareVolume
44Page(s)
24-30AbstractPurpose: To evaluate unbiased information on the characteristics, procedures, and outcomes of intensive care unit (ICU) admissions in a long-term nationwide study. Materials and methods: Cohort study of all ICU admissions in patients > 18 years of age in Korea between August 1, 2009 and September 30, 2014 (1,553,673 ICU admissions in 1,265,509 patients). Results: From August 2009 to September 2014, the age-standardized ICU admission rate was 744.6 per 100,000 person-years (869.5 per 100,000 person-years in men and 622.0 per 100,000 person-years in women). The overall in-hospital mortality was 13.8% (14.1% in men and 13.5% in women). Among all Koreans, the ICU mortality rate was 102.9 per 100,000 person-years (122.5 per 100,000 person years in men and 83.8 per 100,000 person years in women). The median ICU and hospital length of stay were 4 and 13 days, respectively. The median cost per ICU admission was $5051, which increased steadily over the study period. There were marked differences by gender in ICU admission rates, aggressive support, and outcomes. Conclusions: Our study identified increasing trends in ICU admissions and utilization of advance life support systems that add to the burden of care in a developed society.Adiposity and Incident Heart Failure and its Subtypes: MESA (Multi-Ethnic Study of Atherosclerosis)
AbstractRao, V. N., Zhao, D., Allison, M. A., Guallar, E., Sharma, K., Criqui, M. H., Cushman, M., Blumenthal, R. S., & Michos, E. D. (n.d.).Publication year
2018Journal title
JACC: Heart FailureVolume
6Issue
12Page(s)
999-1007AbstractObjectives: This study sought to compare various measures of adiposity with risk for incident hospitalized heart failure (HF) with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF). Background: Obesity is a risk factor for HF, particularly HFpEF. It is unknown which measures of adiposity, including anthropometrics and computed tomography (CT)-measured fat area, are most predictive of HF subtypes. Methods: The authors studied 1,806 participants of the MESA (Multi-Ethnic Study of Atherosclerosis) study without baseline cardiovascular disease who underwent anthropometrics (body mass index [BMI] and waist circumference) and an abdominal CT. Subcutaneous and visceral adipose tissue (VAT) were measured from a single CT slice at L2-L3. Cox hazard models were used to examine associations of adiposity with incident hospitalized HFpEF and HFrEF events. Fully adjusted models included demographics, HF risk factors, and N-terminal pro-B-type natriuretic peptide. Results: Over a mean follow-up of 11 years, there were 34 HFpEF and 36 HFrEF events. The fully adjusted hazard ratio (95% confidence interval [CI]) per 1-SD higher of each anthropometric and CT-measured adiposity measures for incident HFpEF were as follows: BMI HR: 1.66; 95% CI: 1.12 to 2.45; waist circumference HR: 1.59; 95% CI: 1.05 to 2.40; and VAT HR: 2.24; 95% CI: 1.44 to 3.49. None of these adiposity measures were associated with HFrEF. Even among overweight/obese adults (BMI ≥25 kg/m 2 ), assessment of VAT (per 1-SD) was strongly associated with HFpEF (HR: 2.78; 95% CI: 1.62 to 4.76). Subcutaneous adipose tissue was neither associated with HFpEF nor HFrEF. Conclusions: In a multiethnic cohort free of cardiovascular disease, CT-measured VAT was independently associated with incident hospitalized HFpEF but not HFrEF. Measuring visceral fat at the time of CT imaging for other indications may offer additional prognostication of HF risk.Arsenic exposure in relation to ischemic stroke the reasons for geographic and racial differences in stroke study
AbstractTsinovoi, C. L., Xun, P., McClure, L. A., Carioni, V. M., Brockman, J. D., Cai, J., Guallar, E., Cushman, M., Unverzagt, F. W., Howard, V. J., & He, K. (n.d.).Publication year
2018Journal title
StrokeVolume
49Issue
1Page(s)
19-26AbstractBackground and Purpose-The purpose of this case-cohort study was to examine urinary arsenic levels in relation to incident ischemic stroke in the United States. Methods-We performed a case-cohort study nested within the REGARDS (REasons for Geographic and Racial Differences in Stroke) cohort. A subcohort (n=2486) of controls was randomly sampled within region-race-sex strata while all incident ischemic stroke cases from the full REGARDS cohort (n=671) were included. Baseline urinary arsenic was measured by inductively coupled plasma-mass spectrometry. Arsenic species, including urinary inorganic arsenic and its metabolites monomethylarsonic acid and dimethylarsinic acid, were measured in a random subset (n=199). Weighted Cox's proportional hazards models were used to calculate hazard ratios and 95% confidence intervals of ischemic stroke by arsenic and its species. Results-The average follow-up was 6.7 years. Although incident ischemic stroke showed no association with total arsenic or total inorganic arsenic, for each unit higher level of urinary monomethylarsonic acid on a log-scale, after adjustment for potential confounders, ischemic stroke risk increased ∼2-fold (hazard ratio=1.98; 95% confidence interval: 1.12- 3.50). Effect modification by age, race, sex, or geographic region was not evident. Conclusions-A metabolite of arsenic was positively associated with incident ischemic stroke in this case-cohort study of the US general population, a low-to-moderate exposure area. Overall, these findings suggest a potential role for arsenic methylation in the pathogenesis of stroke, having important implications for future cerebrovascular research.Association of Liver Fibrosis with Cardiovascular Diseases in the General Population: The Multi-Ethnic Study of Atherosclerosis (MESA)
AbstractOstovaneh, M. R., Ambale-Venkatesh, B., Fuji, T., Bakhshi, H., Shah, R., Murthy, V. L., Tracy, R. P., Guallar, E., Wu, C. O., Bluemke, D. A., & Lima, J. A. (n.d.).Publication year
2018Journal title
Circulation: Cardiovascular ImagingVolume
11Issue
3AbstractBackground - The association of cardiovascular diseases (CVD) with liver fibrosis is poorly understood. We aim to assess the association of liver fibrosis by T1-mapping magnetic resonance imaging and CVD in MESA (Multi-Ethnic Study of Atherosclerosis). Methods and Results - MESA enrolled 6814 participants free of clinical CVD at baseline (2000-2002). A subsample of participants underwent T1-mapping magnetic resonance imaging 10 years after the baseline (Y10 MESA exam, 2010-2012). Liver T1 maps were generated avoiding vessels and biliary ducts from which native T1 (n=2087) and extracellular volume fraction (ECV, n=1234) were determined. Higher ECV and native T1 were indicators of liver fibrosis. Linear regression analysis evaluated the cross-sectional relationship between liver native T1 and ECV at Y10 MESA exam with a history of CVD events (atrial fibrillation, heart failure, and coronary heart disease [CHD]). Of the 2087 participants (68.7±9.1 years; 46% females), 153 had prior CVD events (78 atrial fibrillation, 25 heart failure, and 78 CHD). History of CVD events was associated with 18.5 ms higher liver native T1 (P<0.001) and 1.4% greater ECV (P=0.06). Prior atrial fibrillation was related to higher liver native T1 (β=21.1; P=0.001) and greater ECV (β=2.2; P=0.02), whereas previous heart failure was associated with greater liver ECV (β=4.1; P=0.02). There was also a relationship of prior CHD with liver native T1 (β=13; P=0.05) and ECV (β=1.9; P=0.05), which was attenuated by adjustment for coronary artery calcium score (β=7.1 and 1.6; P=0.37 and 0.13, respectively). Conclusions - Liver fibrosis by T1-mapping magnetic resonance imaging is associated with history of heart failure, atrial fibrillation, and CHD in a multiethnic cohort. The association of liver fibrosis and CHD is at least in part mediated by atherosclerosis.Association of low-moderate urine arsenic and QT interval: Cross-sectional and longitudinal evidence from the Strong Heart Study
AbstractMoon, K. A., Zhang, Y., Guallar, E., Francesconi, K. A., Goessler, W., Umans, J. G., Best, L. G., Howard, B. V., Devereux, R. B., Okin, P. M., & Navas-Acien, A. (n.d.).Publication year
2018Journal title
Environmental PollutionVolume
240Page(s)
894-902AbstractEpidemiologic studies suggest that chronic exposure to arsenic is related to cardiovascular disease (CVD), but the pathophysiological link remains uncertain. We evaluated the association of chronic low-moderate arsenic exposure and arsenic metabolism with baseline difference and annual change in ECG measures (QT interval, JT interval, PR interval, QRS duration, and QT dispersion) using linear mixed models in the Strong Heart Study main cohort (N = 1174, median age 55 years) and family study (N = 1695 diabetes-free, median age 36 years). At baseline, arsenic exposure was measured as the sum of inorganic and methylated species in urine (ΣAs) and arsenic metabolism was measured as the relative percentage of arsenic species. Median ΣAs and Bazett heart rate-corrected QT interval (QTc) were 8.6 μg/g creatinine and 424 ms in the main cohort and 4.3 μg/g and 414 ms in the family study, respectively. In the main cohort, a comparison of the highest to lowest ΣAs quartile (>14.4 vs. <5.2 μg/g creatinine) was associated with a 5.3 (95% CI: 1.2, 9.5) ms higher mean baseline QTc interval but no difference in annual change in QTc interval. In the family study, a comparison of the highest to lowest quartile (>7.1 vs. <2.9 μg/g creatinine) was associated with a 3.2 (95% CI: 0.6, 5.7) ms higher baseline QTc interval and a 0.6 (95% CI: 0.04, 1.2) ms larger annual increase in QTc interval. Associations with JTc interval were similar but stronger in magnitude compared to QTc interval. Arsenic exposure was largely not associated with PR interval, QRS duration or QT dispersion. Similar to arsenic exposure, a pattern of lower %MMA and higher %DMA was associated with longer baseline QTc interval in both cohorts and with a larger annual change in QTc interval in the family study. Chronic low-moderate arsenic exposure and arsenic metabolism were associated with prolonged ventricular repolarization. Chronic low-moderate arsenic exposure and arsenic metabolism were associated with prolonged ventricular repolarization.Association of multivitamin and mineral supplementation and risk of cardiovascular disease: A systematic review and meta-analysis
AbstractKim, J., Choi, J., Kwon, S. Y., McEvoy, J. W., Blaha, M. J., Blumenthal, R. S., Guallar, E., Zhao, D., & Michos, E. D. (n.d.).Publication year
2018Journal title
Circulation: Cardiovascular Quality and OutcomesVolume
11Issue
7AbstractBackground: Multiple studies have attempted to identify the association between multivitamin/mineral (MVM) supplementation and cardiovascular disease (CVD) outcomes, but the benefits remain controversial. We performed a systematic review and meta-analysis of the associations between MVM supplementation and various CVD outcomes, including coronary heart disease (CHD) and stroke. Methods and Results: We conducted a comprehensive search of Medline, Embase, and the Cochrane Library for studies published between January 1970 and August 2016. We included clinical trials and prospective cohort studies in the general population evaluating associations between MVM supplementation and CVD outcomes. Data extraction and quality assessment were independently conducted by 2 authors, and a third author resolved discrepancies. Eighteen studies with 2 019 862 participants and 18 363 326 person-years of follow-up were included in the analysis. Five studies specified the dose/type of MVM supplement and the rest did not. Overall, there was no association between MVM supplementation and CVD mortality (relative risk [RR], 1.00; 95% confidence interval [CI], 0.97-1.04), CHD mortality (RR, 1.02; 95% CI, 0.92-1.13), stroke mortality (RR, 0.95; 95% CI, 0.82-1.09), or stroke incidence (RR, 0.98; 95% CI, 0.91-1.05). There was no association between MVM supplements and CVD or CHD mortality in prespecified subgroups categorized by mean follow-up period, mean age, period of MVM use, sex, type of population, exclusion of patients with history of CHD, and adjustment for diet, adjustment for smoking, adjustment for physical activity, and study site. In contrast, MVM use did seem to be associated with a lower risk of CHD incidence (RR, 0.88; 95% CI, 0.79-0.97). However, this association did not remain significant in the pooled subgroup analysis of randomized controlled trials (RR, 0.97; 95% CI, 0.80-1.19). Conclusions: Our meta-analysis of clinical trials and prospective cohort studies demonstrates that MVM supplementation does not improve cardiovascular outcomes in the general population.Autorefraction-Based Prescription and Mailed Delivery of Eyeglasses
Gajwani, P., Varadaraj, V., Plum, W., Zhao, D., Johnson, E., Dosto, N., Thompson, S., Guallar, E., Kanwar, N., Friedman, D. S., & Mudie, L. I. (n.d.).Publication year
2018Journal title
OphthalmologyVolume
125Issue
1Page(s)
137-138Body mass index from Early‐, Mid‐, and Older‐adulthood and risk of heart failure and atherosclerotic cardiovascular disease: MESA
AbstractFliotsos, M., Zhao, D., Rao, V. N., Ndumele, C. E., Guallar, E., Burke, G. L., Vaidya, D., Delaney, J. C. A., & Michos, E. D. (n.d.).Publication year
2018Journal title
Journal of the American Heart AssociationVolume
7Issue
22AbstractBackground-Obesity contributes significantly to risk of atherosclerotic cardiovascular disease (ASCVD) and especially for heart failure (HF). An elevated body mass index (BMI) in older adults might not carry the same risk as in younger adults, but measured weights at other lifetime points are often not available. We determined the associations of self‐reported weights from early‐ and mid‐adulthood, after accounting for measured weight at older age, with incident HF/ASCVD risk. Methods and Results-We studied 6437 MESA (Multi‐Ethnic Study of Atherosclerosis) participants (aged 45-84, free of baseline HF/ASCVD) with self‐reported weights at ages 20 and 40 years (by questionnaire), measured weights at up to 5 in‐person examinations (2000-2012), and follow‐up for adjudicated HF/ASCVD events. Participant mean±SD age at the baseline examination was 62.2±10.2 years. Over median follow‐up of 13 years, 290 HF and 828 ASCVD events occurred. After adjustment for cardiovascular risk factors and baseline BMI, higher self‐reported weights at ages 20 and 40 years were independently associated with increased risk of incident HF with hazard ratios (95% confidence interval) of 1.27 (1.07-1.50) and 1.36 (1.18-1.57), respectively, per 5‐kg/m2 higher BMI. For incident ASCVD, only higher BMI at age 20 years was associated after accounting for current BMI (1.13 [1.01-1.26] per 5 kg/m2). Obesity during follow‐up examinations was also associated with incident HF (1.72 [1.21-2.45]) but not ASCVD. Conclusions-Self‐reported lifetime weight is a low‐tech tool easily utilized in any clinical encounter. Although subject to recall bias, self‐reported weights may provide prognostic information about future HF risk, incremental to current BMI, in a multiethnic cohort of middle‐aged to older adults. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005487.Carotid artery wall thickness and incident cardiovascular events: A comparison between US and MRI in the multi-ethnic study of atherosclerosis (MESA)
AbstractZhang, Y., Guallar, E., Malhotra, S., Astor, B. C., Polak, J. F., Qiao, Y., Gomes, A. S., Herrington, D. M., Sharrett, A. R., Bluemke, D. A., & Wasserman, B. A. (n.d.).Publication year
2018Journal title
RadiologyVolume
289Issue
3Page(s)
649-657AbstractPurpose: To compare common carotid artery (CCA) wall thickness measured manually by using US and semiautomatically by using MRI, and to examine their associations with incident coronary heart disease and stroke. Materials and Methods: This prospective study enrolled 698 participants without a history of clinical cardiovascular disease (CVD) from the Multi-Ethnic Study of Atherosclerosis (MESA) from July 2000 to December 2013 (mean age, 63 years; range, 45 to 84 years; same for men and women). All participants provided written informed consent. CCA wall thickness was measured with US as well as both noncontrast proton-density–weighted and intravenous gadolinium-enhanced MRI. Cox proportional hazards models were used to assess the associations between wall thickness measurements by using US and MRI with CVD outcomes. Results: The adjusted hazard ratios for coronary heart disease, stroke, and CVD associated with per standard deviation increase in intima-media thickness were 1.10, 1.08, and 1.14, respectively. The corresponding associations for mean wall thickness measured with proton-density–weighted MRI were 1.32, 1.48, and 1.37, and for mean wall thickness measured with gadolinium-enhanced MRI were 1.27, 1.58, and 1.38. When included simultaneously in the same model, MRI wall thickness, but not intima-media thickness, remained associated with outcomes. Conclusion: For individuals without known cardiovascular disease at baseline, wall thickness measurements by using MRI were more consistently associated with incident cardiovascular disease, particularly stroke, than were intima-media thickness by using US.Coexistence of Colorectal Adenomas and Coronary Calcification in Asymptomatic Men and Women
AbstractYun, K. E., Chang, Y., Rampal, S., Zhang, Y., Cho, J., Jung, H. S., Kim, C. W., Jeong, C., Cainzos-Achirica, M., Zhao, D., Pastor-Barriuso, R., Shin, H., Guallar, E., & Ryu, S. (n.d.).Publication year
2018Journal title
Journal of Clinical GastroenterologyVolume
52Issue
6Page(s)
508-514AbstractGoals: Because of shared risk factors between clinically manifest cardiovascular disease and colorectal cancer, we hypothesized the coexistence of subclinical atherosclerosis measured by coronary artery calcium (CAC) and colorectal adenoma (CRA) and that these 2 processes would also share common risk factors. Background: No study has directly compared the risk factors associated with subclinical coronary atherosclerosis and CRA. Study: This was a cross-sectional study using multinomial logistic regression analysis of 4859 adults who participated in a health screening examination (2010 to 2011; analysis 2014 to 2015). CAC scores were categorized as 0, 1 to 100, or >100. Colonoscopy results were categorized as absent, low-risk, or high-risk CRA. Results: The prevalence of CAC>0, CAC 1 to 100 and >100 was 13.0%, 11.0%, and 2.0%, respectively. The prevalence of any CRA, low-risk CRA, and high-risk CRA was 15.1%, 13.0%, and 2.1%, respectively. The adjusted odds ratios (95% confidence interval) for CAC>0 comparing participants with low-risk and high-risk CRA with those without any CRA were 1.35 (1.06-1.71) and 2.09 (1.29-3.39), respectively. Similarly, the adjusted odds ratios (95% confidence interval) for any CRA comparing participants with CAC 1 to 100 and CAC>100 with those with no CAC were 1.26 (1.00-1.6) and 2.07 (1.31-3.26), respectively. Age, smoking, diabetes, and family history of CRC were significantly associated with both conditions. Conclusions: We observed a graded association between CAC and CRA in apparently healthy individuals. The coexistence of both conditions further emphasizes the need for more evidence of comprehensive approaches to screening and the need to consider the impact of the high risk of coexisting disease in individuals with CAC or CRA, instead of piecemeal approaches restricted to the detection of each disease independently.Differential prognosis of vasospastic angina according to presentation with sudden cardiac arrest or not: Analysis of the Korean Health Insurance Review and Assessment Service
AbstractPark, T. K., Gwag, H. B., Park, S. J., Park, H., Kang, D., Park, J., Cho, J., Chung, C. R., Jeon, K., Suh, G. Y., Guallar, E., Cho, J., & Yang, J. H. (n.d.).Publication year
2018Journal title
International Journal of CardiologyVolume
273Page(s)
39-43AbstractBackground: The long-term prognosis of vasospastic angina (VSA) patients presenting with aborted sudden cardiac death (ASCD) is still unknown. We sought to compare the long-term clinical outcomes between VSA patients presenting with and without ASCD by retrospective analysis of a nationwide population-based database. Methods: A total of 6972 patients in the Health Insurance Review and Assessment database who were hospitalized in the intensive care unit with VSA between July 1, 2007 and May 31, 2015 were enrolled. Primary outcome was the composite of cardiac arrest and acute myocardial infarction after discharge. Results: Five hundred ninety-eight (8.6%) VSA patients presented with ASCD. On inverse probability of treatment weighting, ASCD patients had a significantly increased risk of the composite of cardiac arrest and acute myocardial infarction (adjusted hazard ratio, 2.52; 95% confidence interval, 1.72–3.67; p < 0.001) during the median follow-up duration of 4 years. The association of ASCD presentation with a worse outcome in terms of primary outcome was consistent across various subgroups, including comorbidity type and use of vasodilators (all p-values for interaction: non-significant). ASCD patients treated with an implantable cardioverter defibrillator (ICD) had a lower incidence of the composite of cardiac arrest and acute myocardial infarction during follow-up than those without an ICD (p = 0.009). Conclusions: VSA patients that present with ASCD are at increased risk of cardiac arrest or myocardial infarction during long-term follow-up despite adequate vasodilator therapy. An ICD is a potential therapeutic option for secondary prevention.Discordance between 10-year cardiovascular risk estimates using the ACC/AHA 2013 estimator and coronary artery calcium in individuals from 5 racial/ethnic groups: Comparing MASALA and MESA
AbstractAl Rifai, M., Cainzos-Achirica, M., Kanaya, A. M., Kandula, N. R., Dardardi, Z., Joshi, P. H., Patel, J., Budoff, M., Yeboah, J., Guallar, E., Blumenthal, R. S., & Blaha, M. J. (n.d.).Publication year
2018Journal title
AtherosclerosisVolume
279Page(s)
122-129AbstractBackground and aims: South Asian (SA) individuals are thought to represent a group that is at high-risk for atherosclerotic cardiovascular disease (ASCVD). However, the performance of the Pooled Cohort Equations (PCE) remains uncertain in SAs living in the US. We aimed to study the interplay between predicted 10-year ASCVD risk and coronary artery calcium (CAC) in SAs compared to other racial/ethnic groups. Methods: We studied 536 SAs from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, and 2073 Non-Hispanic Whites (NHWs), 1514 African Americans (AAs), 1254 Hispanics, and 671 Chinese Americans (CAs) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were not currently on statins. We used logistic regression models to assess the association between race/ethnicity and CAC within each ASCVD risk stratum. Results: SAs at low and at intermediate estimated ASCVD risk were more likely to have CAC = 0 compared to NHWs, while SAs at high risk had a similar CAC burden to NHWs. For example, intermediate-risk SAs had a 73% higher odds of CAC = 0 compared to NHWs (95% 1.00–2.99), while high-risk SAs were equally likely to have CAC = 0 (OR 0.95, 95% CI 0.65–1.38) and CAC >100 (OR 0.86, 95% CI 0.61–1.22). Conclusions: Our results suggest that the extent of ASCVD risk overestimation using the PCEs may be even greater among SAs considered at low and intermediate risk than among NHWs. Studies with incident ASCVD events are required to validate and/or recalibrate current ASCVD risk prediction tools in this group.Effect of long-term selenium supplementation on mortality: Results from a multiple-dose, randomised controlled trial
AbstractRayman, M. P., Winther, K. H., Pastor-Barriuso, R., Cold, F., Thvilum, M., Stranges, S., Guallar, E., & Cold, S. (n.d.).Publication year
2018Journal title
Free Radical Biology and MedicineVolume
127Page(s)
46-54AbstractBackground: Selenium, an essential trace element, is incorporated into selenoproteins with a wide range of health effects. Selenoproteins may reach repletion at a plasma selenium concentration of ~ 125 µg/L, at which point the concentration of selenoprotein P reaches a plateau; whether sustained concentrations higher than this are beneficial, or indeed detrimental, is unknown. Objective: In a population of relatively low selenium status, we aimed to determine the effect on mortality of long-term selenium supplementation at different dose levels. Design: The Denmark PRECISE study was a single-centre, randomised, double-blinded, placebo-controlled, multi-arm, parallel clinical trial with four groups. Participants were 491 male and female volunteers aged 60–74 years, recruited at Odense University Hospital, Denmark. The trial was initially designed as a 6-month pilot study, but supplemental funding allowed for extension of the study and mortality assessment. Participants were randomly assigned to treatment with 100, 200, or 300 µg selenium/d as selenium-enriched-yeast or placebo-yeast for 5 years from randomization in 1998–1999 and were followed up for mortality for a further 10 years (through March 31, 2015). Results: During 6871 person-years of follow-up, 158 deaths occurred. In an intention-to-treat analysis, the hazard ratio (95% confidence interval) for all-cause mortality comparing 300 µg selenium/d to placebo was 1.62 (0.66, 3.96) after 5 years of treatment and 1.59 (1.02, 2.46) over the entire follow-up period. The 100 and 200 µg/d doses showed non-significant decreases in mortality during the intervention period that disappeared after treatment cessation. Although we lacked power for endpoints other than all-cause mortality, the effects on cancer and cardiovascular mortality appeared similar. Conclusions: A 300 µg/d dose of selenium taken for 5 years in a country with moderately-low selenium status increased all-cause mortality 10 years later. While our study was not initially designed to evaluate mortality and the sample size was limited, our findings indicate that total selenium intake over 300 µg/d and high-dose selenium supplements should be avoided.Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women
AbstractZhao, D., Guallar, E., Ouyang, P., Subramanya, V., Vaidya, D., Ndumele, C. E., Lima, J. A., Allison, M. A., Shah, S. J., Bertoni, A. G., Budoff, M. J., Post, W. S., & Michos, E. D. (n.d.).Publication year
2018Journal title
Journal of the American College of CardiologyVolume
71Issue
22Page(s)
2555-2566AbstractBackground: Higher androgen and lower estrogen levels are associated with cardiovascular disease (CVD) risk factors in women. However, studies on sex hormones and incident CVD events in women have yielded conflicting results. Objectives: The authors assessed the associations of sex hormone levels with incident CVD, coronary heart disease (CHD), and heart failure (HF) events among women without CVD at baseline. Methods: The authors studied 2,834 post-menopausal women participating in the MESA (Multi-Ethnic Study of Atherosclerosis) with testosterone, estradiol, dehydroepiandrosterone, and sex hormone binding globulin (SHBG) levels measured at baseline (2000 to 2002). They used Cox hazard models to evaluate associations of sex hormones with each outcome, adjusting for demographics, CVD risk factors, and hormone therapy use. Results: The mean age was 64.9 ± 8.9 years. During 12.1 years of follow-up, 283 CVD, 171 CHD, and 103 HF incident events occurred. In multivariable-adjusted models, the hazard ratio (95% confidence interval [CI]) associated with 1 SD greater log-transformed sex hormone level for the respective outcomes of CVD, CHD, and HF were as follows: total testosterone: 1.14 (95% CI: 1.01 to 1.29), 1.20 (95% CI: 1.03 to 1.40), 1.09 (95% CI: 0.90 to 1.34); estradiol: 0.94 (95% CI: 0.80 to 1.11), 0.77 (95% CI: 0.63 to 0.95), 0.78 (95% CI: 0.60 to 1.02); and testosterone/estradiol ratio: 1.19 (95% CI: 1.02 to 1.40), 1.45 (95% CI: 1.19 to 1.78), 1.31 (95% CI: 1.01 to 1.70). Dehydroepiandrosterone and SHBG levels were not associated with these outcomes. Conclusions: Among post-menopausal women, a higher testosterone/estradiol ratio was associated with an elevated risk for incident CVD, CHD, and HF events, higher levels of testosterone associated with increased CVD and CHD, whereas higher estradiol levels were associated with a lower CHD risk. Sex hormone levels after menopause are associated with women's increased CVD risk later in life.