U-shaped Relationship Research Articles

A U-shaped association between composite dietary antioxidant index and migraine in US adults: a nationwide cross-sectional study.

The field of dietary therapies for migraine has grown in popularity. Less research has been conducted to establish the relationship between migraine and the composite dietary antioxidant index (CDAI), a crucial indicator for evaluating the overall combined effects of multiple dietary antioxidants. Therefore, this study addressed this gap based on the National Health and Nutrition Examination Survey (NHANES) database. Multivariate logistic regression equations were used to investigate the relationship between CDAI and migraine, and smoothed-fitted curves were plotted. After a nonlinear relationship was discovered, the recursive algorithm and a two-stage linear regression model were employed to calculate the turning point. Additional stratified analyses were performed to explore differences between populations. This study included a total of 9,190 participants aged 20 years old or older. A U-shaped association was observed between the CDAI and migraine, with an inflection point of 0.2. They were negatively correlated before the inflection point with OR of 0.93 (95% CI = 0.88-0.97) and positively correlated after the inflection point with OR of 1.04 (95% CI = 1.01-1.07). This U-shaped relationship persisted among people aged <60 and ≥60 years, women, and people with BMI <30 and ≥30. We identified a U-shaped association between CDAI and migraine in the U.S. adult population. Further case-control studies and experimental research are needed to explore the underlying mechanisms of action.

Do public-private partnerships (PPPs) promote the sustainable development of infrastructure (SDI)? Evidence from China

PurposeTo address challenges such as inadequate funding and inefficiency in public infrastructure construction, PPPs have gained significant global traction. This study aims to comprehensively assess the impacts and mechanisms of PPPs on the SDI and to provide rational policy recommendations based on the findings.Design/methodology/approachWe collated a dataset from 30 Chinese provinces covering the years 2005–2020 as our research sample. The study’s hypotheses are tested using a double fixed-effects model, a chained mediated-effects model and a multidimensional heterogeneity analysis.FindingsOur findings indicate that PPPs have a facilitating effect on SDI in general. This boost usually lags behind policy implementation and is cyclical in the time dimension. In the spatial dimension, PPPs contribute significantly to SDI in the eastern and western regions, but not in the central region. From the perspective of the dynamics of economic, social and industrial development, PPPs in economically backward areas are difficult to promote SDI, promote it the most in economically medium regions and are slightly less in economically developed regions than in medium regions. This promotion effect has an inverted U-shaped relationship with social development and diminishes with industrial structure upgrading. Finally, due to the negative relationship between PPPs and social development and between social development and SDI, PPPs are shown to contribute to SDI and are identified as critical paths. However, PPPs suppress SDI by inhibiting economic and industrial development.Originality/valueThis study makes three novel contributions to the existing body of knowledge: (1) we innovatively introduce the United Nations Sustainable Development Goals (SDGs) into the field of infrastructure research, offering fresh perspectives on SDI enhancement; (2) revealing the mechanisms by which PPPs affect SDI through the three dimensions of economic, social and industrial development enabling policymakers to better understand and optimize resource allocation and improve planning, design and management of PPP projects for sustainable infrastructure and (3) we assess the spatiotemporal variances of PPPs’ effects on SDI and the diversity across regions at different social, economic and industrial structures developmental stages, offering critical insights to global decision-makers to devise tailored policy measures.

Novel Adiposity Indices Are Associated With Poor Prognosis in Heart Failure With Preserved Ejection Fraction Without the Obesity Paradox.

There is limited study that illuminates the relationship between obesity indices and prognosis in patients with heart failure with preserved ejection fraction, nor has it been examined whether the obesity paradox persists when using these metrics. This study is a post hoc analysis of data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. A total of 3114 individuals were included in our final analysis, and a total of 481 (15.4%) all-cause deaths, and 389 (12.5%) heart failure hospitalizations were recorded. In a multivariable Cox regression model, compared with patients with a body mass index (BMI) <24.9 kg/m2, those with a BMI of 25.0-29.9, 30.0-34.9, and 35-39.9 kg/m2 were associated with a decreased risk of all-cause death, with hazard ratio (95% CI) of 0.59 (0.45-0.78), 0.61 (0.46-0.82), and 0.66 (0.47-0.92), respectively. Conversely, patients with a BMI ≥40 kg/m2 showed an increased risk of heart failure hospitalization, compared with BMI <24.9 kg/m2. Furthermore, patients in the highest quintile of obesity indices exhibited a significantly elevated hazard ratio for both all-cause death and heart failure hospitalization, compared with the lowest quintile. An elevated BMI over a certain range was associated with a reduced risk of all-cause death in heart failure with preserved ejection fraction, displaying a U-shaped relationship, with no mortality reduction observed in cases of extreme obesity. In contrast, higher values of novel obesity indices were positively correlated with all-cause death and heart failure hospitalization without the obesity paradox.

Association between stress hyperglycemia ratio and postoperative major adverse cardiovascular and cerebrovascular events in noncardiac surgeries: a large perioperative cohort study

BackgroundThere has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS.MethodsThere were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed.ResultsA total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08–1.66) in the T3 group and by 1.35 times (95% CI 1.08–1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21–2.12) in the T3 group and by 1.61 times (95% CI 1.21–2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008).ConclusionIn this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS.

Unveiling the Forces driving expert Activity: The impact of information environment and peer behavior on expert reviewer engagement behavior

Online platform engagement with customers, especially those with high expertise, is crucial for companies. As these expert customer reviews directly impact a company’s brand image and sales volume, an understanding of expert reviewer engagement behavior (EREB) is critical for companies’ marketplace success. This study explores the factors that influence EREB from two key situational cues: those from the company’s information environment and from peer expert behavior. Data from 144,634 Yelp reviewers and 5,080 restaurants were analyzed. The results reveal that companies with higher aggregate ratings are more likely to encourage EREB. The impact of overall and peer expert rating inconsistency on EREB varies: Overall rating inconsistency has a positive effect, while inconsistency among expert peers has a negative effect. Additionally, EREB exhibits herding and differentiation patterns in response to changes in peer expert engagement density. This results in a U-shaped relationship between EREB and peer expert engagement density, moderated by aggregate rating, overall rating inconsistency, and peer expert rating inconsistency. This study provides practical insights for marketers looking to engage expert customers and expands on the literature on expert customer engagement behavior.

Nonlinear impact of economic policy uncertainty on corporate ESG performance: Regional, industrial and managerial perspectives

The relationship between Economic Policy Uncertainty (EPU) and corporate Environmental, Social, and Governance (ESG) practices has garnered significant attention, yet the nature of this relationship remains unclear. While previous studies have explored linear associations, the potential for nonlinear dynamics and the role of contextual factors have been largely overlooked. This study addresses this gap by investigating the nonlinear relationship between EPU and ESG performance, considering the moderating effects of regional marketization, industry competition, and managerial green perception. Using a comprehensive dataset of Chinese listed companies from 2011 to 2022, we employ quantitative methods including baseline regression analysis, robustness tests, and heterogeneity analysis across different stages of the firm lifecycle. Our findings reveal an inverted U-shaped relationship between EPU and ESG performance, indicating that moderate levels of EPU encourage ESG engagement, while excessive uncertainty leads to declined practices. Furthermore, we find that regional marketization, industry competition, and managerial green perception significantly moderate this relationship, with regional factors exerting the strongest influence. These results contribute to the advancement of theoretical frameworks in sustainable finance and offer valuable insights for managers and policymakers navigating the complex interplay between economic uncertainty and corporate sustainability in diverse contexts.

Association Between Urinary Rare Earth Element Levels and Metabolic Syndrome: A Cross-sectional Study in the Minority Population of Guangxi in China.

This study aimed to investigate the association between rare earth elements (REEs) and metabolic syndrome (MetS). We used a cross-sectional design based on the baseline data of the Prospective Cohort Study of Chronic Diseases in Ethnic Minority Natural Population in Guangxi in China. Logistic regression and BKMR models were employed to evaluate the association between REEs and risk of MetS. Although REEs were not significantly associated with MetS, certain elements such as La, Pr, and Nd were negatively associated with abdominal obesity, whereas Ce, Pr, Nd, and Dy were positively associated with hypertension. BKMR models suggested a U-shaped relationship between mixed REEs and MetS, with varying effects on abdominal obesity and high blood pressure. This study suggests that exposure to REEs may be associated with a reduced risk of abdominal obesity and an increased risk of high blood pressure.

Scrutinizing the load capacity curve for a global perspective: The role of Fintech, government effectiveness and renewable energy

With the evolving world order, countries are using financial technologies (Fintech) to access financial resources more effectively, and Fintech can have an impact on the environment. This study aims to investigate the influence of Fintech on ecological sustainability, focusing on the contribution of renewable energy (RE) and government effectiveness (GE) under the Load Capacity Curve (LCC). This research analyzes data from 69 middle-income economies between 2006 and 2022 using the dynamic panel threshold model (DPTR). The outcomes document that GDP reduces the LCF below a certain threshold, but a positive impact above this threshold. Specifically, the model yielded a threshold value of $US 5222.234, which is higher than the average GDP of $US 4276.802. This finding suggests a U-shaped relationship between GDP and LCF, which supports the LCC hypothesis. The outcome also reports that Fintech plays a crucial role in improving ecological sustainability, while government effectiveness has a negative effect. The study emphasizes that middle-income countries should support Fintech and renewable energy along development with economic progress to improve ecological quality.

The dietary inflammatory index (DII®) and human papillomavirus infection: a cross-sectional study of US women

BackgroundDiet may influence susceptibility of human papillomavirus (HPV) infection by affecting inflammation and immunity. However, the association between HPV infection and the inflammatory potential of diet has not been investigated. The research aimed to examine the correlation between HPV status and the dietary inflammatory index (DII®).MethodsWe utilized data from the National Health and Nutrition Examination Survey (NHANES) 2003–2016 to investigate the correlation between DII and HPV status among 9,256 women aged 18–59 years. DII scores were calculated based on 24-hour dietary recall interviews. The association between HPV status and DII was analyzed using weighted logistic regression and restricted cubic spline (RCS).ResultsWomen with HPV infection exhibited higher DII scores than those without HPV infection. An increased likelihood of HPV infection was found to be significantly associated with higher DII scores (OR = 1.05, 95% CI: 1.01–1.09, P = 0.021), after full multivariate adjustment. Compared with the lowest tertile of DII scores, the ORs (95% CIs) for HPV infection were 1.20 (1.01, 1.42) and 1.27 (1.07, 1.51) for the second and third tertiles, respectively (P for trend = 0.006). RCS analysis showed a U-shaped relationship between DII and HPV infection, with a breakpoint identified at 0.13.ConclusionsOur findings suggest that a pro-inflammatory diet is associated with an increased likelihood of HPV infection among women in the United States. Dietary interventions to reduce inflammation may help prevent HPV infection and related diseases.

An inverted U-shaped relationship between work-family conflict and job burnout among village clinic doctors: the moderating effect of information and communication technology use

BackgroundVillage clinic doctors are an integral part of the rural healthcare workforce. With the advancement of science and technology and the coronavirus disease 2019 (COVID-19) pandemic, the prevalence of remote work and the use of information and communication technologies (ICT) have increased significantly. However, these developments have also had an impact on the work family balance and mental well-being of village clinic doctors. The study aimed to explore how work-family conflict affected job burnout and what the role of ICT use was in this relationship.MethodsThis was a cross-sectional study. Data were collected collected through an anonymous self-administered questionnaire survey conducted in December 2021 in Shandong Province, China. A total of 1,093 village clinic doctors participated in the survey. The data were analyzed using multiple linear regression and the PROCESS macro in SPSS.ResultsThe results showed that an inverted U-shaped relationship between work-family conflict and job burnout among village clinic doctors. Specifically, the squared term of work-family conflict had a negative coefficient (-0.324). The slope was positive (SL=2.291) at the low end of the X-range and negative (SH=-0.379) at the high end. The turning point occurred at X = 1.227(-2.309 ≤ X ≤ 1.812). Additionally, ICT use positively moderated between work-family conflict and job burnout (β1β4-β2β3 = 0.217, β4 > 0).ConclusionsThe work-family conflict has an inverted U-shaped effect on job burnout, while the use of ICT positively moderates this relationship between work-family conflict and job burnout. Policymakers should pay attention to the effects of ICT use and work-family conflict on job burnout among village clinic doctors.

U-shaped Relationship between Cash Conversion Cycle and Financial Distress: Evidence from Unlisted Companies in Korea

U-shaped Relationship between Cash Conversion Cycle and Financial Distress: Evidence from Unlisted Companies in Korea

Cardiovascular disease modifies the relationship between systolic blood pressure and outcomes in people with diabetes

ObjectiveWe aimed to evaluate the influences of cardiovascular disease (CVD) on the relationship between baseline systolic blood pressure (SBP) and outcomes in community populations with diabetes. MethodsThis is an observational study of 16,431 community adults with diabetes. The relationship between SBP with major adverse cardiovascular event (MACE) and all-cause death were evaluated using multivariable-adjusted Cox proportional hazard models and restricted cubic spline. ResultsAfter a median follow-up of 3.4 (IQR 2.6, 4.3) years, 2145 (13.1 %) MACE and 1025 (6.2 %) all-cause death occurred. In participants free of CVD, in reference to SBP < 120 mmHg group, the risks for MACE increased as SBP category (120–129, 130–139, and ≥ 140 mmHg) advanced (P-trend < 0.001), and there was a linear relationship (P-nonlinear = 0.75). The risks for all-cause death were lower in SBP of 120–139 mmHg and 140–159 mmHg groups but higher in SBP ≥ 160 mmHg group, and there was a U-shaped relationship (P-nonlinear < 0.001). In participants with existing CVD the relationship between baseline SBP with MACE and all-cause death did not show any specific pattern. ConclusionResults of the current study suggest that the relationship between baseline SBP with MACE and all-cause death varied significantly by baseline CVD status.

Initial blood pressure and adverse cardiac events following acute ischaemic stroke: An individual patient data pooled analysis from the VISTA database.

Adverse cardiac events following ischaemic stroke (stroke-heart syndrome, SHS) pose a clinical challenge. We investigated the association between initial blood pressure at stroke presentation and the risk of SHS. We utilised data from the Virtual International Stroke Trials Archive (VISTA). We defined SHS as the incidence of cardiac complications within 30 days post-ischaemic stroke. These presentations included acute coronary syndrome encompassing myocardial injury, heart failure/left ventricular dysfunction, atrial fibrillation/flutter, other arrhythmia/electrocardiogram abnormalities, and cardiorespiratory arrest. Using Cox proportional hazards models, we assessed the risk trajectories for developing SHS and its presentations associated with initial blood pressure. We also explored the risk trajectories for 90-day mortality related to initial blood pressure. From 16,095 patients with acute ischaemic stroke, 14,965 (mean age 69 ± 12 years; 55% male) were analysed. Of these, 1774 (11.8%) developed SHS. The risk of SHS and initial blood pressure showed a U-shaped relationship. The lowest blood pressures (⩽130 mmHg systolic and ⩽55 mmHg diastolic) were associated with the highest risks (adjusted hazard ratio [95%confidence interval]: 1.40 [1.21-1.63]; p < 0.001, 1.71 [1.39-2.10]; p < 0.001, respectively, compared to referential blood pressure range).Cardiorespiratory arrest posed the greatest risk at higher blood pressure levels (2.34 [1.16-4.73]; p = 0.017 for systolic blood pressure >190 mmHg), whereas other presentations exhibited the highest risk at lower pressures. The 90-day mortality risk also followed a U-shaped distribution, with greater risks observed at high blood pressure thresholds. There is a U-shaped relationship between initial blood pressure at ischaemic stroke presentation and the risk of subsequent SHS.

The prognostic impact of stress hyperglycemia ratio for all-cause mortality in patients with Psoriasis.

Aims The stress hyperglycemia ratio (SHR) is a valuable biomarker of acute hyperglycemia, significantly correlated with unfavorable prognosis in various conditions. However, its impact on Psoriasis has not been studied. We explored the association between SHR and long-term mortality in psoriasis patients. Methods We conducted a prospective cohort study with 288 psoriasis patients from the 2003-2006 and 2009-2014 NHANES. Participants were divided into three groups based on SHR tertiles: T1 (SHR ≤ 0.870), T2 (SHR 0.870-0.958), and T3 (SHR ≥ 0.958). Cox regression and Kaplan-Meier analyses assessed the correlation between SHR and mortality, while restricted cubic splines explored non-linear correlations. ROC analyses determined the optimal SHR cut-off value for predicting clinical outcomes. Results Out of 288 Psoriasis patients, 38 all-cause deaths occurred during an average follow-up of 112.13 ± 45.154 months. Kaplan-Meier analysis indicated that higher SHR values were linked to an increased risk of all-cause mortality (log-rank P = 0.049). A U-shaped relationship was observed between SHR and all-cause mortality (P for non-linear = 0.028). Spearman correlation revealed significant associations between SHR and WC, BMI, neutrophil, monocyte, lymphocyte counts, SCr, uric acid, DM and MetS (all P < 0.05). After adjusting for confounders, multivariate Cox regression showed that SHR was associated with a 10.937-fold risk of all-cause mortality. ROC curve analysis identified an optimal SHR cut-off value of 1.045 for predicting long-term all-cause mortality in psoriasis patients. Conclusions Elevated SHR value independently correlates with all-cause mortality in Psoriasis patients, displaying a U-shaped relationship with clinical endpoints. An optimal SHR cut-off value of 1.045 has been determined for predicting clinical outcomes.

U-shaped association of serum vitamin A concentrations with all-cause mortality in patients with NAFLD: results from the NHANES database prospective cohort study.

Previous studies have demonstrated a significant association between serum vitamin A concentration and non-alcoholic fatty liver disease (NAFLD) development. However, the long-term prognostic implications of serum vitamin A in patients with NAFLD remain underexplored. This study aims to investigate whether there exists a correlation between serum vitamin A concentrations and overall mortality among subjects diagnosed with NAFLD. To investigate the association between serum vitamin A concentrations and NAFLD outcomes, we conducted prospective cohort studies using data from the 1999-2006 and 2017-2018 National Health and Nutrition Examination Survey (NHANES). We utilized a multivariate Cox regression model to explore the relationship between serum vitamin A levels and all-cause mortality. Survival curves related to serum vitamin A were constructed using the Kaplan-Meier method. Additionally, the restricted cubic splines (RCS) method was applied to examine potential nonlinear relationships between serum vitamin A concentrations and all-cause mortality of NAFLD. Over a median follow-up period of 10.3 years, a total of 1,399 all-cause deaths were recorded. The weighted average concentration of serum vitamin A was 61.48 ± 0.37 μg/dL. After adjusting for potential confounders, a significant U-shaped relationship was identified between serum vitamin A concentrations and the risk of all-cause mortality in NAFLD patients. This relationship was particularly pronounced in men and elderly individuals aged 60 to 85. Our study reveals a significant non-linear relationship between serum vitamin A concentrations and the risk of all-cause mortality in patients with NAFLD. These findings underscore the importance of monitoring and maintaining optimal serum vitamin A levels to potentially improve survival outcomes in NAFLD patients.

Green governance and the EKC hypothesis: Evidence from Vietnamese provinces

The Environmental Kuznets Curve (EKC) posits an inverted U-shaped relationship between environmental degradation and economic development, suggesting that while economic growth may initially harm the environment, it can ultimately lead to both economic and environmental benefits in the long run. Empirical evidence of this hypothesis strongly supports the Sustainable Development Goals (SDGs) such as SDG 1 (No Poverty), SDG 8 (Good Jobs and Economic Growth), and SDG 11 (Sustainable Cities and Communities). While the EKC literature focused more on national or cross-country analyses, limited studies examined this hypothesis at the regional or provincial level and often used data from the U.S. and China. This study revisits the EKC hypothesis in Vietnamese provinces by examining municipal solid waste (MSW), which is important to the SDGs but has attracted less attention compared to other pollutants. The role of green governance, measured via the provincial green index (PGI), is also examined. Findings indicate that the EKC exists at the provincial level in Vietnam, with the PGI reducing the GDP requirement for the EKC turning point, thereby accelerating environmental improvements. Consequently, promoting green governance is important for emerging countries such as Vietnam to achieve sustainable development and the SDGs.

Measuring How AI Innovations and Financial Accessibility Influence Environmental Sustainability in the G-7: The Role of Globalization with Panel ARDL and Quantile Regression Analysis

This study investigates the impact of AI innovation on environmental sustainability in the G-7 region from 2010 to 2022. Additionally, it tests the Load Capacity Curve (LCC) hypothesis in relation to financial accessibility, globalization, and urbanization. Cross-sectional dependence and slope homogeneity tests reveal the presence of cross-sectional dependence and heterogeneity issues. Panel unit root and panel cointegration tests confirm that the variables are free from unit root problems and are cointegrated in the long run. To identify significant factors influencing environmental sustainability, this study employs Panel ARDL and Quantile Regression methods. Both methods confirm the LCC hypothesis in the G-7 region, demonstrating a U-shaped relationship between income and the load capacity factor. The results indicate that AI innovation and financial accessibility are significantly positively correlated with the load capacity factor, while globalization and urbanization are negatively correlated, leading to lower environmental sustainability. To validate the robustness of the Panel ARDL and Quantile Regression results, Driscoll-Kraay standard errors, Augmented Mean Group, and Common Correlated Effects Mean Group estimation approaches are applied, all of which support the initial findings. Furthermore, the D-H causality test reveals unidirectional causality from economic growth, financial accessibility, globalization, and urbanization to the load capacity factor, and bidirectional causality between AI innovation and the load capacity factor.

Unveiling the Nexus: Foreign Ownership, Innovation Dynamics, and Firm Performance through a Resource-Based Lens in Vietnam

This study investigates the complex relationships between firm resources, innovation, foreign ownership, and firm performance in the context of Vietnam's emerging market. Using a comprehensive dataset of 17,430 firm-year observations from 1,245 manufacturing firms across Vietnam for the period 2010 to 2023, we employ system GMM estimation to address potential endogeneity concerns. Our findings reveal non-linear effects of firm resources and foreign ownership on performance, measured by both ROA and Tobin's Q. Specifically, we observe inverted U-shape relationships for human capital and foreign ownership, diminishing returns for physical capital, and a positive squared term for R&amp;D intensity. Moreover, we find that foreign ownership positively moderates the effects of firm resources on performance. These results are robust to alternative measures and subgroup analyses. Our study contributes to the literature by providing a nuanced understanding of firm performance drivers in Vietnam's unique institutional context, extending the applicability of resource-based and knowledge-based views to this emerging market. The findings offer valuable insights for managers and policymakers in Vietnam, highlighting the importance of balanced resource allocation, strategic innovation investments, and the potential benefits of foreign ownership in enhancing firm performance.

A U-shaped relationship between LVEF and the risk of heart failure hospitalization: a large hospital-based cohort study

Abstract Background Left ventricular ejection fraction (LVEF) is a frequently used metric for quantifying left ventricular function. Previous studies found a U-shaped relationship between LVEF and long-term survival. However, the association between the spectrum of LVEF and heart failure (HF) hospitalization remains unclear. Purpose We aim to investigate the distribution of HF hospitalizations across the spectrum of LVEF using a large hospital-based cohort. Methods Consecutive participants who underwent echocardiography (2002-2021) in a tertiary medical center in Taiwan were included. LVEF was measured by echocardiography using biplane Simpson’s method and was categorized into intervals of 5% from &amp;lt;20% to ≥70%. The study outcome was HF hospitalization by linking to the National Health Insurance Registry Database. Cox proportional hazards regression was used for analyses with adjustment for age, sex, hypertension, diabetes, hyperlipidemia, coronary artery disease, and history of HF. We used restricted cubic splines to demonstrate the distribution of HF hospitalizations across the spectrum of LVEF. Results 94,762 participants (age 59.7 ± 18.1, men 51.4%) were included. Adjusted hazard ratios (HR) for HF hospitalizations showed a U-shaped relationship between LVEF and the risk of incident HF hospitalization with a nadir of risk at LVEF of 60-70%. (Figure) Compared with the reference group (LVEF: 60-65%), subjects with LVEF&amp;gt; 70% had an HR of 1.49 (95% confidence interval [CI]: 1.21-1.84), and those with LVEF of 50-55% had an HR of 1.93 (95% CI: 1.68-2.22). Similar results with a nadir at 60-70% could be observed irrespective of different age groups defined by the World Health Organization (WHO), sex, with or without hypertension or diabetes. Conclusions A U-shaped relationship between LVEF and the risk of incident HF hospitalization can be observed, with a nadir at LVEF of 60-70%. LVEF ≥ 70% may be defined as supranormal LVEF that necessitates further HF treatment.Figure

Influences of cardiovascular disease on the relationship between baseline systolic blood pressure and adverse outcomes in diabetes: insights from large population-based study

Abstract Objective To evaluate the influences of cardiovascular disease (CVD) on the relationship between baseline systolic blood pressure (SBP) and adverse outcomes in diabetes. Methods This is an observational study of 16431 community-dwelling adults with diabetes and 7.8% had CVD. The relationship between SBP (either as a categorical or continuous variable) with major adverse cardiovascular event (MACE) and all-cause death were evaluated by baseline CVD status using multivariable-adjusted Cox proportional hazard models and restricted cubic spline. Results After a median follow-up of 3.4 years, 2145 (13.1%) MACE and 1025 (6.2%) all-cause death occurred. In the overall participants there was a linear relationship between SBP and MACE (P-nonlinear=0.55) and a U-shaped relationship between SBP and all-cause death (P-nonlinear=0.002). In participants free of CVD, in reference to SBP &amp;lt; 120 mmHg group, the risks for MACE increased as SBP category (120-129, 130-139, and ≥ 140 mmHg) advanced (P-trend &amp;lt; 0.001) and there was a linear relationship (P-nonlinear=0.75; Figure 1A); while the risks for all-cause death were lower in SBP of 120-139 mmHg and 140-159 mmHg groups while higher in SBP ≥ 160 mmHg group, and there was a U-shaped relationship (P-nonlinear&amp;lt;0.001; Figure 1B). Notably, in participants with existing CVD the relationship between SBP with MACE and all-cause death did not show any specific pattern. Conclusion The relationship between baseline SBP with MACE and all-cause death varied substantially by baseline CVD status. Future studies to investigate the threshold of initiating BP-lowering treatment and the appropriate BP target in diabetes may consider applying a CVD-based stratification strategy.