The research team, led by Katharina Alina Riedl of the University Medical Center Hamburg-Eppendorf and collaborators at institutions including Charité Berlin and the German Centre of Cardiovascular Research, analyzed data from 2,093 participants who had undergone both advanced magnetic resonance imaging of the heart and aorta and a dedicated ultrasound examination of the abdominal aorta. The participants, drawn from the first 10,000 volunteers enrolled in the Hamburg City Health Study between February 2016 and November 2018, had a median age of 66 years, and roughly 42 percent were women. The Hamburg City Health Study is an ambitious, single-center, prospective epidemiological project aiming to follow more than 20,000 residents of Hamburg aged 45 to 74 over the long term, making it an ideal laboratory for studying how vascular aging manifests in a general population rather than in selected patient groups.

At the heart of the study are two measurements that cardiologists describe as windows into the biological age of the arteries. The first is pulse wave velocity, or PWV, which quantifies how fast the pressure wave generated by each heartbeat travels along the aortic wall. A stiffer artery propagates the wave more quickly, so higher PWV signals greater arterial stiffness, itself both a contributor to and a consequence of atherosclerosis and vascular aging. The second is aortic distensibility, or AD, which captures how much the aortic wall expands with each pulse of blood; a healthy, elastic aorta distends readily, whereas a stiffened vessel barely moves. Both parameters were derived from two-dimensional phase-contrast velocity-encoded CMR sequences acquired on a 3 Tesla scanner, with regions of interest placed manually in the ascending and descending aorta and then automatically propagated through the cardiac cycle.

The technical approach matters, because measuring aortic stiffness is notoriously method-sensitive. The team computed PWV as the distance between two measurement points divided by the transit time of the pulse wave, with the distance determined precisely by tracing an aortic centerline on a parasagittal T2-weighted HASTE image rather than estimating it from surface landmarks. The transit time was determined using the PWV 50 percent algorithm, which identifies the moment flow reaches half of its peak in each aortic segment, a method chosen because prior work showed it delivers the highest reproducibility with the fewest outliers. Distensibility, in turn, was calculated as the relative change in aortic diameter over the cardiac cycle divided by the pulse pressure measured at the brachial artery. This centerline-based CMR approach stands in contrast to the conventional carotid-femoral PWV technique, which relies on approximate surface distances and, the authors argue, may be unreliable in people with enlarged abdominal aortas because it samples a different vascular territory.

The ultrasound side of the investigation focused on the infrarenal aorta, the segment below the renal arteries where the overwhelming majority of abdominal aortic aneurysms arise. Using a convex array transducer, sonographers measured the maximum anteroposterior diameter in systole with the outer-to-outer method, as well as the peak flow velocity of blood moving through the vessel. Following current European clinical practice guidelines, a diameter between 25 and 29 millimeters was classified as ectasia and a diameter of 30 millimeters or more as an aneurysm. The median diameter in the cohort was 18.1 millimeters and the median peak flow velocity was 98.6 centimeters per second. In total, 55 participants had either ectasia or an aneurysm, including 21 with a true aneurysm, a prevalence consistent with earlier reports from the same cohort.

The statistical analysis, performed with linear and logistic regression models adjusted progressively for age, sex, and classical cardiovascular risk factors including hypertension, hyperlipidemia, diabetes, smoking, and body mass index, produced a nuanced picture. After adjustment for age and sex, the maximum infrarenal aortic diameter was significantly associated with the distensibility of the descending thoracic aorta, with a regression coefficient of −0.572 and a p-value of 0.009, meaning that people whose descending aorta distends less also tend to have wider infrarenal segments. Likewise, peak flow velocity in the infrarenal aorta was significantly associated with pulse wave velocity, with a coefficient of −0.399 and a p-value of 0.029, indicating that faster aortic pulse waves travel alongside slower peak flow in the abdominal vessel. Adding these stiffness parameters to models containing only age and sex significantly improved model fit in both cases, as confirmed by likelihood ratio tests.

Perhaps the most striking findings emerged when the researchers compared participants with ectasia or aneurysm against those with normal aortic diameters. The 55 affected individuals had significantly higher median pulse wave velocity, 8.59 versus 7.58 meters per second, alongside significantly lower distensibility in both the ascending and descending aorta and significantly lower peak flow velocity, 84.30 versus 98.70 centimeters per second. They also carried a heavier burden of cardiovascular risk factors, with significantly higher rates of hypertension, hyperlipidemia, smoking, prior myocardial infarction, and elevated body mass index. Yet when the same stiffness parameters were tested as predictors of prevalent ectasia or aneurysm in adjusted logistic regression models, none retained a statistically significant predictive value. The differences were real but modest in absolute terms, and the small number of affected participants, particularly the few women in this subgroup, limited statistical power.

This apparent paradox, significant group differences but no individual-level predictive power, carries an important message for the field. The authors conclude that CMR-based aortic stiffness parameters are associated with infrarenal aortic geometry and flow, but that their diagnostic, screening, and prognostic value remains to be established. Screening for abdominal aortic aneurysm currently rests on simple ultrasound diameter thresholds, and the new data suggest that thoracic stiffness measurements are unlikely to replace that approach. However, the findings leave open the possibility that pulse wave velocity and distensibility could help identify individuals at risk of future aneurysm development or rupture vulnerability, questions that the ongoing follow-up of the Hamburg cohort is designed to address. The biology reinforces this caution: the infrarenal aorta has a lower elastin-to-collagen ratio than the thoracic aorta, so stiffness in one segment does not simply mirror stiffness in the other.

The study is not without limitations, which the authors acknowledge candidly. It was conducted at a single center, the cohort contained far more men than women, and only 21 participants had a true aneurysm, an expected figure given the population-based design and the known prevalence of roughly 0.8 percent in this cohort. Peak flow velocity may also be confounded by the cross-sectional area of the vessel, since a larger lumen mechanically reduces peak velocity regardless of wall stiffness. The team used two-dimensional flow CMR rather than the more information-rich four-dimensional technique, a deliberate trade-off favoring fast acquisition and feasibility in large population studies, and brachial blood pressure served as a surrogate for central aortic pressure in the distensibility calculation. Nonetheless, by combining magnetic resonance and ultrasound data in the same large, unselected sample, the study represents the largest investigation to date linking CMR-derived aortic stiffness with ultrasound-based infrarenal parameters, and it sets the stage for longitudinal analyses that may finally determine whether the stiffness of the great vessels can foretell the vessels’ most dangerous failure mode.

Subject of Research: Associations between CMR-based aortic stiffness parameters and ultrasound-based infrarenal aortic parameters in a population-based cohort

Article Title: Associations of CMR-based pulse wave velocity and aortic distensibility with infrarenal ultrasound-based aortic parameters in the Hamburg City Health Study

Article References: Riedl, K. A., Di Carluccio, E., Lund, G., Huellebrand, M., Hennemuth, A., Braren, R., Kirchhof, P., Blankenberg, S., Tilemann, L., Ziegler, A., Behrendt, C. A., Muellerleile, K., & Kölbel, T. (2026). Associations of CMR-based pulse wave velocity and aortic distensibility with infrarenal ultrasound-based aortic parameters in the Hamburg City Health Study. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03029-8

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03029-8

Keywords: pulse wave velocity, aortic distensibility, aortic stiffness, abdominal aortic aneurysm, cardiovascular magnetic resonance, infrarenal aorta, ultrasound, Hamburg City Health Study, arterial stiffening, vascular aging, aneurysm screening, cardiovascular risk factors

The study’s technical approach is what sets it apart from the questionnaire-based surveys that have dominated Indonesian national health surveillance. Rather than relying primarily on interviews, the researchers put every willing participant through a battery of objective measurements. Anthropometric assessments captured body mass index and waist circumference, blood pressure was measured with calibrated devices, and each subject received a single-lead electrocardiogram to probe for silent rhythm abnormalities. Crucially, blood was drawn for biochemical analysis, including glycated hemoglobin, or HbA1c, which reflects average blood glucose over roughly three months, and a full lipid panel measuring cholesterol fractions including low-density lipoprotein. This laboratory anchoring matters because prior nationwide efforts, such as the Indonesian Health Survey of 2023, largely depended on self-reported history and tested only a limited subset of respondents with oral glucose tolerance tests and biochemical lipid profiling, leaving substantial blind spots in prevalence estimates.

The metabolic findings were perhaps the most dramatic. Sixty-nine percent of participants met criteria for obesity, a further 15 percent were overweight, and 83 percent had elevated waist circumference, a marker of central adiposity that is increasingly recognized as an independent predictor of cardiometabolic risk. Central obesity, in which fat accumulates around the abdominal organs, is metabolically active tissue that promotes insulin resistance, raises blood pressure and dysregulates lipid metabolism. That more than eight in ten screened adults carried excess abdominal fat, in a population where 80 percent of participants were women, points to a profound nutritional and lifestyle transition in this semi-urban setting. Indonesia, like much of Southeast Asia, has seen rapid shifts in diet and physical activity patterns over recent decades, and these data offer one of the clearest snapshots yet of what that transition means for the cardiovascular health of a working-age and older population outside the major megacities.

The screening also caught a quieter danger. Using the single-lead electrocardiogram, the team identified atrial fibrillation in 1.3 percent of subjects. Atrial fibrillation is an irregular heart rhythm that dramatically increases the risk of ischemic stroke, often presenting with no symptoms at all until a clot-related catastrophe occurs. Detecting it in a community cohort of adults without known cardiovascular disease underscores the value of including simple, inexpensive rhythm screening in population health programs. A single-lead ECG takes minutes and requires modest equipment, yet it can flag individuals who would benefit from anticoagulation therapy and closer follow-up, potentially preventing disabling strokes before they happen.

To understand who was most at risk, the researchers turned to multivariable logistic regression, a statistical technique that estimates the independent association between each candidate factor and an outcome while holding the others constant. The analysis showed that the presence of cardiovascular risk factors was significantly associated with older age, obesity and elevated waist circumference. These associations align with the established pathophysiology of atherosclerosis and metabolic disease, in which adiposity drives hypertension, insulin resistance and dyslipidemia over decades of exposure. But the regression results also carry a public health message: the risk factor burden in this population concentrates in identifiable, measurable subgroups, meaning targeted screening and intervention programs could plausibly reach the people who need them most without screening everyone identically.

Beyond physiology, the study probed the psychology of prevention. A subset of participants completed a 14-point questionnaire assessing knowledge, attitudes and practices, commonly abbreviated KAP in global health research. The median knowledge score was just 5 out of 10, and the median combined KAP score was 9 out of 14, revealing substantial gaps in what these adults understood about cardiovascular risk factors and how to control them. Further regression analysis suggested that KAP scores rose with education level but were unrelated to occupation, hinting that formal schooling, rather than workplace environment, shapes cardiovascular health literacy in this setting. Strikingly, the researchers found no significant relationship between KAP scores and the actual presence of cardiovascular risk factors. Knowing what is unhealthy, in other words, did not translate into measurably healthier risk profiles among those screened.

That disconnect between knowledge and behavior is a familiar puzzle in chronic disease prevention, but its scale here is notable. Health communication campaigns that simply inform people about the dangers of salt, sugar, tobacco and inactivity may be necessary but insufficient when the environments in which people eat, work and age make healthy choices difficult. In semi-urban North Sumatera, where community health infrastructure includes PUSKESMAS, the government community health centers, and POSBINDU, the integrated development posts designed for noncommunicable disease monitoring, the study’s findings suggest these channels exist but are not yet detecting or managing risk at the scale required. With more than half of screened adults hypertensive and most of those cases newly identified, the gap between the population’s need and the system’s reach is wide.

The study’s design deserves scrutiny as well as praise. Recruitment was opportunistic rather than a random population sample, meaning participants were people who came forward at screening sites, and four-fifths of them were women. Prevalence estimates drawn from such a cohort may not perfectly mirror the general adult population of North Sumatera, and the researchers are careful to frame the work as community-based screening rather than definitive epidemiology. Even so, the objective biochemical and instrumental measurements give the numbers a solidity that interview-based surveys cannot match, and the sheer proportion of newly diagnosed hypertension, diabetes and dyslipidemia among ostensibly healthy adults is unlikely to be an artifact. If anything, self-selection into a screening program would be expected to attract more health-conscious individuals, suggesting the true population burden could be still higher.

The ECARDIA-NS partnership between Universitas Sumatera Utara and the SingHealth Duke-National University of Singapore Global Health Institute, funded through pilot grants from both institutions, offers a model for how regional collaboration can generate locally actionable data. The authors conclude that the high burden of cardiometabolic disease, combined with the knowledge gaps the KAP survey exposed, indicates that considerably more work remains to be done in the region to address cardiovascular risk. Their findings arrive at a moment when low- and middle-income countries across Asia are confronting the collision of aging populations with rising obesity and diabetes, and when global health agencies are pressing for primary prevention strategies that identify risk before the first heart attack or stroke. In Medan and its surrounding districts, the message from this study is unambiguous: the risk factors are there, they are common, they are largely silent, and they are waiting to be found by anyone willing to measure a blood pressure, draw a blood sample and look.

Subject of Research: Prevalence and detection of cardiovascular risk factors among semi-urban adults in North Sumatera, Indonesia

Article Title: Prevalence of cardiovascular risk factors in a semi-urban population in Indonesia [Early detection of cardiovascular risk factors as primary prevention amongst North Sumatera adults (ECARDIA-NS) study]

Article References: Siregar, Y. F., Tern, P. J. W., Lei, J., Ilyas, K. K., Raynaldo, A. H., Sarastri, Y., Haykal, T. B., Andra, C. A., Habib, F., Hasan, R., Siregar, D. I. S., Koh, S. J. Q., Koh, A. S.-M., Tan, J. W. C., & Lubis, A. C. (2026). Prevalence of cardiovascular risk factors in a semi-urban population in Indonesia [Early detection of cardiovascular risk factors as primary prevention amongst North Sumatera adults (ECARDIA-NS) study]. BMC Public Health. https://doi.org/10.1186/s12889-026-29179-y

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29179-y

Keywords: cardiovascular risk factors, hypertension, diabetes, dyslipidemia, obesity, Indonesia, North Sumatera, population screening, primary prevention, atrial fibrillation, public health, Prevalence

About the Study: What is the global disease burden attributable to elevated low-density lipoprotein cholesterol (LDL-C)? In 2023, high LDL-C caused 3.6 million deaths (6.0% of all deaths) and 90.7 million disability-adjusted life years (DALYs) (3.2% of total DALYs). Despite declines of 45.6% in age-standardized mortality rates and 39.5% in DALY rates, the absolute LDL-C–related burden increased by 38.5% from 1990 to 2023, driven by population growth and aging, with notable regional disparities shifting toward middle-sociodemographic settings. Strategic approaches to prevent, diagnose, and treat elevated LDL-C across populations globally are needed.

Corresponding Author: Christian Razo, PhD, Department of Health Metrics Sciences, School of Medicine, Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave NE, Seattle, WA 98195. For interviews, contact the communications team at Institute of Health Metrics and Evaluation at University of Washington School of Medicine (ihmemedia@uw.edu).

10.1001/jama.2026.8628

To access the embargoed study: Visit our JAMA Network Media Center website at this link

Link to the article in your story
We encourage you to link out to this article in your story using the link below. It includes an access token that will give free access to the article for your readers up to one year after publication. (The link will be live after the article publishes and embargo is lifted.)

Editor’s Note: Please see the article for additional information, including full author list, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

Journal

JAMA

Mitral annular disjunction is a structural abnormality characterized by a separation or “sliding” of the mitral valve’s annulus from the underlying ventricular myocardium. Under normal physiology, the mitral valve annulus serves as a firm attachment point tethering the leaflets to the left ventricle, thus ensuring efficient valve closure during systole. However, in MAD, this anchoring relationship is disrupted, compromising the mechanical stability of the mitral apparatus. This anatomical derangement has been increasingly associated with electrical instability of the ventricular myocardium, leading to potentially fatal arrhythmogenic events, most notably ventricular tachycardia and sudden cardiac arrest.

Mitral valve prolapse, an often coexisting condition with MAD, affects approximately 2.5% of the global population and involves the abnormal displacement of one or both mitral valve leaflets into the left atrium during ventricular contraction. This aberrant leaflet movement causes mitral regurgitation, whereby blood flows retrograde into the left atrium, imposing volume overload and precipitating progressive cardiac remodeling. The clinical manifestations frequently include fatigue, palpitations, and exertional dyspnea. Historically, surgical correction via mitral valve repair or replacement has been the cornerstone for alleviating symptoms and preventing progression to heart failure in severe cases.

The critical question addressed by the current large-scale observational study was whether the presence of MAD continues to portend a significant arrhythmogenic risk after valve surgery aimed at correcting related anatomical abnormalities. Investigators meticulously followed 599 patients diagnosed with mitral valve prolapse who underwent surgical intervention at Karolinska University Hospital from 2010 to 2022. Notably, 16% of these patients exhibited preoperative evidence of MAD. This longitudinal cohort study thus offers a unique window into long-term postoperative outcomes regarding cardiac rhythm disturbances.

Intriguingly, patients harboring MAD were disproportionately younger—by an average of eight years—and predominantly female compared to their MAD-negative counterparts. This demographic skew raises compelling questions about sex-specific cardiac structural vulnerability and age-related myocardial plasticity in the context of valvular pathology. Furthermore, these individuals presented with more advanced mitral disease, which potentially signals an intrinsic link between structural severity and electrical instability.

Despite surgical correction deemed successful in anatomical terms, the group with preoperative MAD demonstrated over threefold increased incidence of ventricular arrhythmias over a five-year follow-up period. Ventricular arrhythmias, characterized by rapid and irregular beating of the lower heart chambers, are known to compromise hemodynamic stability and can culminate in cardiac arrest if left unmanaged. These findings reveal that MAD confers a persistent pro-arrhythmic substrate independent of mechanical correction, emphasizing that valvular repair alone may not suffice as a comprehensive therapeutic endpoint.

The study’s senior author, cardiologist and associate professor Bahira Shahim, underscores the clinical imperative to implement vigilant long-term monitoring protocols for patients exhibiting MAD, regardless of ostensibly successful surgical outcomes. This paradigm shift advocates for integrating advanced cardiac imaging and electrophysiological assessments into postoperative care strategies for affected individuals, aiming to preempt catastrophic arrhythmogenic events.

To unravel the pathophysiological underpinnings behind these persistent arrhythmic risks, the research team is currently probing several hypotheses. One proposed mechanism is that MAD induces chronic mechanical stress on the adjacent myocardium, incrementally driving fibrotic remodeling and scar formation that serve as foci for arrhythmic circuits. Alternatively, MAD itself may be a phenotypic marker of a broader, intrinsic cardiomyopathic process that predisposes patients to electrical instability. Advanced cardiac magnetic resonance imaging (MRI) modalities are being deployed to detect myocardial fibrosis and tissue characterization in this regard.

In parallel, the team is analyzing myocardial tissue biopsies obtained during surgery to discern cellular and molecular alterations characteristic of fibrotic and inflammatory pathways within the ventricular myocardium. Decoding these mechanisms holds the potential to identify novel biomarkers predictive of arrhythmic risk and targets for therapeutic intervention aimed at myocardial stabilisation.

This study represents a paradigm-shifting advance in the understanding of valvular heart disease and its intersection with cardiac electrophysiology. It teaches that structural valve repair, while essential, does not invariably translate into resolution of electrical dysregulation caused by underlying myocardial abnormalities. At a time when sudden cardiac arrest remains a leading cause of mortality worldwide, identifying higher-risk subsets and tailoring follow-up care accordingly can fundamentally improve patient survival and quality of life.

The collaborative research efforts led by Bahira Shahim alongside Magnus Dalén and Klara Lodin at Karolinska Institutet underscore the power of integrating surgical, cardiologic, and research expertise to confront complex cardiovascular challenges. Funded by multiple Swedish research foundations and institutional grants, this study exemplifies the crucial role of well-supported clinical research in transforming patient care paradigms.

For clinicians, the critical takeaway is clear: patients with mitral valve prolapse complicated by mitral annular disjunction require not only surgery but also comprehensive longitudinal arrhythmia surveillance and possibly adjunctive therapies. For patients and families, awareness of this persistent risk is vital to ensure early symptom recognition and timely medical intervention. For the broader research community, these findings open new avenues for investigating the molecular substrates of arrhythmogenesis associated with mitral apparatus abnormalities.

As research progresses, the hope is that advanced imaging, genetic profiling, and novel pharmacological agents can synergistically mitigate arrhythmia risk in this vulnerable population, heralding a new era of precision cardiovascular medicine tailored to individual structural and electrophysiologic phenotypes. Until then, this pivotal study serves as a clarion call to both clinicians and patients to remain vigilant long after the operating room lights dim.

—

Subject of Research: People

Article Title: Mitral annular disjunction and mitral valve prolapse: long-term risk of ventricular arrhythmias after surgery

News Publication Date: 15-Apr-2025

Web References:
https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehaf195
http://dx.doi.org/10.1093/eurheartj/ehaf195

References:
Lodin K, Da Silva C, Wang Gottlieb A, Bulatovic I, Rück A, George I, Cohen DJ, Braunschweig F, Svenarud P, Eriksson MJ, Haugaa KH, Dalén M, Shahim B. “Mitral annular disjunction and mitral valve prolapse: long-term risk of ventricular arrhythmias after surgery.” European Heart Journal. 2025 Apr 15. doi: 10.1093/eurheartj/ehaf195.

Keywords:
Health and medicine, Surgery, Heart disease, Cardiac arrest, Heart muscle, Cardiac arrhythmias, Cardiology, Heart failure