Another major strength is the objective and virtually complete case ascertainment accomplished by record linkage with the unique personal identity number used in all the registries. In conclusion, results from this large prospective study suggest that nut consumption or factors associated with this nutritional behaviour may play a role in reducing the risk of atrial fibrillation and possibly heart failure. Regression dilution bias due to measurement error in the assessment of nut consumption at baseline and changes in nut consumption during follow-up may have attenuated the results. Aortic stenosis shares several traditional cardiovascular risk factors with coronary and cerebrovascular disease but the association of dietary factors with this valvular heart disease has remained unexplored. We conducted a sensitivity analysis restricted to the first 10 years of follow-up and observed somewhat stronger associations HRs further away from the null but with less precision in the estimates because of fewer incident cases.
Nuts may also beneficially influence cardiovascular health through anti-inflammatory and antioxidant effects, 1 improvement of endothelial function 3 and reduction of total and low-density lipoprotein cholesterol levels. Participants who frequently consumed nuts were more likely to adhere to healthy lifestyle behaviours and had fewer other risk factors for CVD compared with non-consumers of nuts. Likewise, omitting the first 2 years of follow-up did not change the results appreciably online supplementary table S3. Discussion In this large prospective study, we observed a previously unrecognised inverse association between nut consumption and incident atrial fibrillation, which remained after adjustment for multiple risk factors. To the best of our knowledge, no previous study has investigated the possible association between nut consumption and risk of aortic valve stenosis, which could not be verified in the present study. In conclusion, results from this large prospective study suggest that nut consumption or factors associated with this nutritional behaviour may play a role in reducing the risk of atrial fibrillation and possibly heart failure. Another major strength is the objective and virtually complete case ascertainment accomplished by record linkage with the unique personal identity number used in all the registries. If anything, a positive association has been reported. We conducted a sensitivity analysis restricted to the first 10 years of follow-up and observed somewhat stronger associations HRs further away from the null but with less precision in the estimates because of fewer incident cases. Key messages What is already known on this subject? These findings suggest that nut consumption may play a role in reducing the risk of atrial fibrillation and possibly heart failure. Strengths of this study include the large sample size, the large number of incident cases for most CVD endpoints and the assessment of nut consumption at baseline in relation to risk of multiple CVD endpoints in the same population. What might this study add? Finally, as this study population comprised Swedish middle-aged and older adults only, our findings might not be generalisable to other populations with potentially other proportions and types of nuts consumed. The overall evidence from this study along with previous cohort studies indicates that nut consumption is not associated with a reduced risk of ischaemic 21—25 or haemorrhagic 21 22 24 25 stroke in European and US adults. How might this impact on clinical practice? In the prospective observational studies, however, nut consumption was lower and likely a mixture of unsalted and salted nuts. However, adjustment for other risk factors attenuated these associations and only a non-linear association with heart failure persisted. We cannot rule out residual confounding by income and occupation because we could not adjust for these potential confounders. Since multiple CVD outcomes were analysed, we cannot exclude the possibility of chance findings. Atrial fibrosis has been identified as a fundamental structural change responsible for the perpetuation of atrial fibrillation. Results were similar in this sensitivity analysis. The observed inverse associations of nut consumption with risk of atrial fibrillation linear dose—response association and heart failure non-linear association might in part be mediated by weight changes as previous prospective studies have shown that high nut consumption is associated with significantly less weight gain during follow-up. Previous studies have found that nut consumption is inversely associated with cardiovascular disease mortality. In analyses stratified by sex, nut consumption was inversely associated with risk of atrial fibrillation in both men and women but results did not attain statistical significance online supplementary figure S2.
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