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A multi-marker risk score may improve risk stratification of incident HF in the community. The authors aim to develop a risk score using N-terminal proB-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin (hs-cTnT) and a unique systemic biomarker of KB to predict HF among participants without cardiovascular disease.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>A multi-marker score was developed incorporating NT-proBNP \u2265 125\u2005pg\/mL, hs-cTnT \u2265 14\u2005ng\/L, and total KB \u2265 75th percentile (316\u2005\u03bcmol\/L), with one point allocated for each abnormal marker among Multi-Ethnic Study of Atherosclerosis participants. Multivariable Cox model was used to assess the association between multi-marker risk score and the risk of incident HF. Among 6748 participants, there were 383 incident HF events over a median follow-up of 15.7 years. The three biomarkers exhibited poor correlation with one another (r &amp;lt; 0.06 for all). The addition of KB to NT-proBNP and hs-cTnT to identify incident HF improved 5- and 10-year risk prediction (C-statistic 0.74 vs. 0.77, P = 0.02 and 0.70 vs. 0.73, P = 0.02, respectively). There was no evidence of miscalibration using the multi-marker score for predicting 5- and 10-year HF risk (P &amp;gt; 0.05). A graded association was observed between the multi-marker score and risk of HF independent of established clinical factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The addition of plasma KB to a clinical risk score using biomarkers of cardiac injury and stress may further improve the prediction of incident HF.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/eurjpc\/zwaf168","type":"journal-article","created":{"date-parts":[[2025,3,22]],"date-time":"2025-03-22T20:34:09Z","timestamp":1742675649000},"page":"189-198","source":"Crossref","is-referenced-by-count":8,"title":["Integrating ketone bodies in multi-marker risk prediction of incident heart failure in the multi-ethnic study of atherosclerosis"],"prefix":"10.1093","volume":"33","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4084-8175","authenticated-orcid":false,"given":"Parag Anilkumar","family":"Chevli","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University School of Medicine , Winston-Salem, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Senthil","family":"Selvaraj","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Duke University School of Medicine, Duke Molecular Physiology Institute , Durham, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Byron C","family":"Jaeger","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Data Science, Wake Forest University School of Medicine , Winston-Salem, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9563-7060","authenticated-orcid":false,"given":"Aziz","family":"Hammoud","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University School of Medicine , Winston-Salem, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3917-592X","authenticated-orcid":false,"given":"Margery A","family":"Connelly","sequence":"additional","affiliation":[{"name":"Labcorp , Morrisville, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0660-4943","authenticated-orcid":false,"given":"Christopher","family":"deFilippi","sequence":"additional","affiliation":[{"name":"Inova Heart and Vascular Institute , Falls Church, VA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joao A C","family":"Lima","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Departments of Medicine, Johns Hopkins University , Baltimore, MD ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sadiya S","family":"Khan","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine , Chicago, IL ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David M","family":"Herrington","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University School of Medicine , Winston-Salem, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9071-3287","authenticated-orcid":false,"given":"Michael D","family":"Shapiro","sequence":"additional","affiliation":[{"name":"Center for the Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Medical Center Boulevard , Winston-Salem, NC 27157 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0885-1953","authenticated-orcid":false,"given":"Muthiah","family":"Vaduganathan","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,3,21]]},"reference":[{"key":"2026020218524412900_zwaf168-B1","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1016\/j.jchf.2018.03.006","article-title":"Temporal trends in the incidence of and mortality associated with heart failure with preserved and reduced ejection fraction","volume":"6","author":"Tsao","year":"2018","journal-title":"JACC Heart 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