Assessing the Role of Rare Genetic Variation in Patients With Heart Failure

Key Points

Question  What is the contribution of rare genetic variants to all-cause heart failure with and without reduced left ventricular ejection fraction?

Findings  In this gene-based collapsing analysis of 5942 patients with heart failure and 13 156 controls using whole-exome sequencing, a significant enrichment of rare protein-truncating variants in the TTN gene and in general an increased burden of mendelian cardiomyopathy variants was demonstrated in patients with heart failure of mostly presumed ischemic etiology compared with controls.

Meaning  Mendelian genetic conditions may represent an important subset of complex late-onset diseases such as heart failure, irrespective of the clinical presentation.

Importance  Sequencing studies have identified causal genetic variants for distinct subtypes of heart failure (HF) such as hypertrophic or dilated cardiomyopathy. However, the role of rare, high-impact variants in HF, for which ischemic heart disease is the leading cause, has not been systematically investigated.

Objective  To assess the contribution of rare variants to all-cause HF with and without reduced left ventricular ejection fraction.

Design, Setting, and Participants  This was a retrospective analysis of clinical trials and a prospective epidemiological resource (UK Biobank). Whole-exome sequencing of patients with HF was conducted from the Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity (CHARM) and Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA) clinical trials. Data were collected from March 1999 to May 2003 for the CHARM studies and September 2003 to July 2007 for the CORONA study. Using a gene-based collapsing approach, the proportion of patients with HF and controls carrying rare and presumed deleterious variants was compared. The burden of pathogenic variants in known cardiomyopathy genes was also investigated to assess the diagnostic yield. Exome sequencing data were generated between January 2018 and October 2018, and analysis began October 2018 and ended April 2020.

Main Outcomes and Measures  Odds ratios and P values for genes enriched for rare and presumed deleterious variants in either patients with HF or controls and diagnostic yield of pathogenic variants in known cardiomyopathy genes.

Results  This study included 5942 patients with HF and 13 156 controls. The mean (SD) age was 68.9 (9.9) years and 4213 (70.9%) were male. A significant enrichment of protein-truncating variants in the TTN gene (P = 3.35 × 10⁻¹³; odds ratio, 2.54; 95% CI, 1.96-3.31) that was further increased after restriction to variants in exons constitutively expressed in the heart (odds ratio, 4.52; 95% CI, 3.10-6.68). Validation using UK Biobank data showed a similar enrichment (odds ratio, 4.97; 95% CI, 3.94-6.19 after restriction). In the clinical trials, 201 of 5916 patients with HF (3.4%) had a pathogenic or likely pathogenic cardiomyopathy variant implicating 21 different genes. Notably, 121 of 201 individuals (60.2%) had ischemic heart disease as the clinically identified etiology for the HF. Individuals with HF and preserved ejection fraction had only a slightly lower yield than individuals with midrange or reduced ejection fraction (20 of 767 [2.6%] vs 15 of 392 [3.8%] vs 166 of 4757 [3.5%]).

Conclusions and Relevance  An increased burden of diagnostic mendelian cardiomyopathy variants in a broad group of patients with HF of mostly ischemic etiology compared with controls was observed. This work provides further evidence that mendelian genetic conditions may represent an important subset of complex late-onset diseases such as HF, irrespective of the clinical presentation.

Heart failure (HF) is a complex clinical syndrome affecting approximately 40 million people worldwide.¹ Heart failure risk increases with age, leads to a high number of hospitalizations, and creates a major burden for the health care system.² Although survival after diagnosis has improved, death rates remain high, with a 5-year survival averaging 50%.³

Heart failure is often classified into 3 main subtypes based on the left ventricular ejection fraction (EF). An EF of 50% or more is defined as HF with preserved EF (HFpEF), an EF between 40% and 49% is referred to as HF with midrange EF (HFmrEF), and an EF of 40% or less is called HF with reduced EF (HFrEF).⁴ All 3 subtypes have overlapping risk factors, but their pathophysiology and response to treatment are distinct.⁵

The majority of HF cases are attributed to ischemic heart disease, hypertension, or primary/secondary cardiomyopathies.⁶ Primary cardiomyopathies such as hypertrophic, dilated, or arrhythmogenic cardiomyopathies are often inherited but show variable expressivity with incomplete penetrance.⁷ They are typically caused by rare variants in genes encoding sarcomere or cytoskeletal proteins, membrane ion channels, or desmosomes. Studies have revealed a significant heritability of HF, estimated at 26%.⁸ While large-scale genome-wide association studies have highlighted the contribution of common variants to the cause of HF,^9,10 the role of rare genetic variants in all-cause HF has not been systematically assessed, to our knowledge. The absence of such studies does not mean that rare, high-impact variants do not also play a role in HF due to ischemic disease, the leading cause of HF, but rather reflects the scarcity of large HF cohorts with sequencing data.

In this study, we performed whole-exome sequencing of patients with HF, representing all broad clinical subtypes, from the Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity (CHARM)¹¹ and Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA)¹² clinical trials. We applied gene-based collapsing analyses to discover genes with an excess of rare, presumably deleterious variants among patients with HF compared with controls. We also performed a diagnostic analysis in known cardiomyopathy genes to investigate the overall burden of pathogenic cardiomyopathy variants. Finally, we used UK Biobank data to validate the main collapsing results.

Sites participating in all studies received approval from local ethics committees for their conduct.^11,12 Only patients who gave written informed consent for genetic analysis and for whom a DNA sample was available were included in the present study. This study was performed in accordance with the policy on bioethics and human biologic samples of AstraZeneca. Data were collected from March 1999 to May 2003 for the CHARM study and September 2003 to July 2007 for the CORONA study. Exome sequencing data were generated between January 2018 and October 2018.

A total of 5011 patients 60 years and older with chronic HF of investigator-reported ischemic cause and a left ventricular EF of 40% and less were enrolled for the study (NCT00206310) and randomly assigned to receive rosuvastatin or placebo.¹¹

Eligible patients, 18 years or older with symptomatic HF, were enrolled into 1 of 3 concurrent studies, according to their left ventricular EF: more than 40% (CHARM Preserved; NCT00634712), 40% or less and treated with angiotensin-converting enzyme inhibitor (CHARM Added; NCT00634309), or 40% or less and not treated with angiotensin-converting enzyme inhibitor due to intolerance (CHARM Alternative; NCT00634400).¹² A total of 7601 patients were enrolled in these studies and randomly assigned candesartan or placebo. For the subgroup analysis, CHARM Preserved samples were split according to their EF into HFmrEF (EF, 40%-49%) and HFpEF (EF, ≥50%).^13,14

The control cohort consisted of unrelated individuals from the Institute for Genomic Medicine database collected as part of unrelated studies (eMethods and eTable 2 in the Supplement). Protocols were approved by Columbia University’s institutional review board and participants provided informed consent for the use of DNA in genetic research.

UK Biobank is a large prospective cohort study with more than 500 000 participants aged 40 to 69 years recruited from the general population in the United Kingdom.¹⁵ UK Biobank Field ID 41270 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes based on hospital in-patient diagnoses) was interrogated for the following codes: I20-I25 ischemic heart diseases, I42 cardiomyopathy, I50 HF, and I70 atherosclerosis. Individuals with a primary or secondary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code in those categories were considered cases.

Whole-exome sequencing of all patients with HF and controls was performed at the Institute for Genomic Medicine. All samples were processed with the same bioinformatic pipeline for variant calling and underwent basic quality control (eMethods in the Supplement).

Principal component analysis for dimensionality reduction was performed on a set of predefined variants (previously described by Cameron-Christie et al¹⁶) to capture population structure. We applied the Louvain method of community detection¹⁷ to the first 6 principal components to identify clusters that reflect ancestry. Louvain and other graph-based clustering methods have advantages compared with other techniques because they do not assume clusters of a particular size, density, or shape.¹⁸ To check the quality of the clusters, we performed further dimensionality reduction using the Uniform Manifold Approximation and Projection¹⁹ on the first 6 principal components (eFigure 1 in the Supplement). We performed coverage harmonization and gene-based collapsing as detailed in the eMethods in the Supplement and below for each cluster with at least 30 patients with HF and 30 controls.

We performed gene-based collapsing to test for a significant difference in the proportion of patients with HF carrying at least 1 qualifying variant (QV) in a gene compared with controls. A QV is defined as a variant that passes certain filter criteria. While the quality control filters mentioned in the eMethods in the Supplement are the same in all models, other filters such as variant effect, pathogenicity predictors, and internal and external minor allele frequency are specific to a certain model. eTable 3 in the Supplement depicts the core models used for all analyses on the full data set with all patients with HF combined and 6 different subgroups (eTable 4 in the Supplement). The synonymous model was used as a negative control (eFigure 2 in the Supplement). We did not analyze individuals with HFmrEF and HFpEF who were 50 years and younger separately because of small sample sizes. Including models with regional intolerance described in the eMethods in the Supplement, we analyzed 7 synonymous and 119 nonsynonymous models.

We performed a diagnostic analysis in known cardiomyopathy genes and classified variants based on the American College of Medical Genetics and Genomics (ACMG) guidelines²⁰ to investigate the overall burden of pathogenic cardiomyopathy variants in our cohort. We selected 41 known cardiomyopathy genes based on the ACMG’s 2016 recommendations for reporting of secondary findings in clinical exome and genome sequencing²¹ and gene lists obtained from the curated Genomics England PanelApp²² (eMethods and eTable 5 in the Supplement) and extracted all variants with a minor allele frequency 1% or less. While all protein-truncating variants (PTVs) passing the minor allele frequency filter were evaluated, all other variants were only included if they were classified as pathogenic or likely pathogenic in ClinVar^23,24 or disease Mutation in the Human Gene Mutation Database.²⁵ All variants that passed above filters were assessed according to ACMG guidelines,²⁰ and variants classified as pathogenic or likely pathogenic were deemed diagnostic variants.

From the collapsing results of the individual clusters, we extracted the number of patients with HF and controls with and without a QV per gene and used the exact 2-sided Cochran-Mantel-Haenszel test^26,27 to test for an association between disease status and QV status while controlling for cluster membership (using the stats package in R version 3.6; R Foundation). We created quantile-quantile plots and estimated the genomic inflation factor λ using a permutation-based expected distribution of P values (eMethods in the Supplement). We defined a studywide Bonferroni multiplicity-adjusted significance threshold of P < 2.25 × 10⁻⁸ (0.05 / [18 650 genes × 119 nonsynonymous models]). Considering the high degree of correlation among the various models and subgroups, this is a very conservative threshold. Analysis of the sequencing data began in October 2018 and ended April 2020.

In total, we performed whole-exome sequencing of 5942 patients with HF. After removal of related individuals, we performed gene-based collapsing analyses stratified by clusters in 5916 individuals with HF and 13 156 unrelated controls without reported heart disease. In the CORONA trial, 2869 of 2870 unrelated patients (99.97%) had HFrEF due to an ischemic event. The CHARM studies included 3046 patients, of whom 1887 (62.0%) and 767 (25.2%) had HFrEF and HFpEF, respectively, overall comprising 1836 patients (60.3%) with ischemic HF (Table 1; eTable 1 in the Supplement). The mean (SD) age for all patients was 68.9 (9.9) years. Of all patients, 4213 (70.9%) were male. Of unrelated samples, 4199 (71.0%) were male.

We removed 3 of 11 clusters because they did not contain enough cases, and only 5860 patients with HF and 10 578 controls were included in the final test (eTable 6 in the Supplement reports cluster sizes). In an analysis comprising all HF subtypes, 1 gene, TTN (encoding Titin), reached studywide significance in several models. We detected the strongest association in the dominant PTV model (P = 3.35 × 10⁻¹³; odds ratio [OR], 2.54; 95% CI, 1.96-3.31; Figure 1), for which QVs were defined as PTVs with an internal and external minor allele frequency below 0.1%.

PTVs in TTN (TTN–truncating variants; TTNtvs) are a known cause of cardiomyopathies, especially dilated cardiomyopathy (DCM). Not all TTNtvs are considered causal, as the background prevalence of TTNtvs of uncertain significance in the general population is relatively high.^28,29 Roberts et al²⁹ showed that TTNtvs in healthy controls are enriched in exons that are usually not expressed in the main cardiac isoforms of TTN, whereas the majority of variants in cardiomyopathy patients cluster in the constitutively expressed distal exons. The proportion spliced-in (PSI) metric is an estimate of the percentage of TTN transcripts that incorporate an exon based on RNA sequencing data and can be used to identify variants with a higher probability of pathogenicity.^29,30 Filtering QVs in TTN for a PSI more than 0.9 removes the majority of control variants while retaining most of the case variants increasing the odds ratio from 2.54 to 4.52 and decreasing the P value further to 5.21 × 10⁻¹⁸. The collapsing signal for TTNtvs is detectable in all subgroups (Figure 2A), although it does not reach significance in some of them.

Overall, 71 of 127 patients with HF (55.9%) with TTNtvs in exons with a high PSI had ischemic heart disease as the identified primary etiology, 43 (33.9%) had known idiopathic DCM, 7 (5.5%) were classified as having hypertensive HF, and the remaining 6 (4.7%) had various other HF etiologies. While the distribution shows the expected enrichment in known DCM, a surprisingly high number of patients with ischemic etiology harbor potentially diagnostic TTN variants. These results highlight that although TTNtvs are only known to cause nonischemic cardiomyopathies, also patients with a clinical diagnosis of ischemic HF are enriched for this type of variant.

The TET2 gene achieved a significant P value in the dominant PTV model (P = 8.30 × 10⁻¹⁰; OR, 33.73; 95% CI, 7.56-311.77) for the HFrEF CORONA subgroup and suggestive signal in the full cohort (P = 1.22 × 10⁻⁶; OR, 5.11; 95% CI, 2.50-10.80). Quiz Ref IDSomatic mutations in TET2 are associated with age-related clonal hematopoiesis.^31-33 Previous studies have shown an association between age-related clonal hematopoiesis and the risk of coronary heart disease in humans and with accelerated atherosclerosis in mice.^31,32,34 The frequency of somatic mutations increases with age and a considerable clonal expansion is needed to increase the alternate allele fraction so that the variant is detected and passes our quality control filters. Hence, a higher age at sample collection increases the chance of detecting an age-related somatic mutation via germline calling and inclusion in the collapsing analysis. Because the patients in this study are notably older than the controls, we cannot disentangle the age-related effect from the true effect that might be responsible for our phenotype of interest. Further analyses with age-matched controls are needed to investigate the role of somatic TET2 mutations in HF.

Restricting the analysis to clusters that reflect European ancestry did not lead to changes in the significant genes because it still included 93.8% of the patients with HF (5494 of 5860). eTables 7 and 8 in the Supplement list the top genes across models and subgroups.

In the CHARM and CORONA trials, we performed a diagnostic analysis in 41 known cardiomyopathy genes and classified variants according to ACMG criteria. Overall, we detected 204 diagnostic variants in 201 of 5916 patients with HF (3.4%) affecting 21 different genes (Table 2; eResults in the Supplement). Consistent with the findings from the collapsing analysis, a large proportion of the diagnostic variants (125 of 204 [61.3%]) were TTNtvs. There was a substantial overlap (124 of 127 [97.6%]) between TTNtvs that passed PSI filtering and diagnostic TTN variants showing that the collapsing model with additional PSI filtering truly captures diagnostic variants. Quiz Ref IDOther genes containing multiple diagnostic variants include MYBPC3, known to primarily cause hypertrophic cardiomyopathy; MYH7, a gene in which variants can cause either DCM or hypertrophic cardiomyopathy; DSP, DSC2, DSG2, and SCN5A, genes known to be implicated in dilated and arrhythmogenic cardiomyopathies; and FLNC, in which variants can cause all types of cardiomyopathies.

While almost all of the diagnostic variants in individuals with idiopathic DCM as the primary etiology affected known DCM genes, 2 individuals had diagnostic variants in MYBPC3, a gene primarily associated with hypertrophic cardiomyopathy. In individuals with ischemic heart disease, diagnostic variants were also primarily found in DCM genes such as TTN, DSG2, and BAG3 or genes known for several types of cardiomyopathy such as FLNC or TNNT2. Diagnostic variants in individuals with a primarily hypertensive etiology were mostly TTNtvs or missense variants in MYBPC3. While there was 1 gene uniquely affected by diagnostic variants in HFmrEF and 11 genes in HFrEF, all genes implicated in HFpEF were a subgroup of HFrEF genes and the small overlap of genes (1 of 23) that were affected in all groups was probably due to the small sample size for HFmrEF and HFpEF, because unique genes also harbored a smaller number of diagnostic variants in general (Figure 3; eTable 9 in the Supplement).

Quiz Ref IDPatients with HFpEF had a slightly lower diagnostic yield than those with HFmrEF or HFrEF (20 of 767 [2.6%] vs 15 of 392 [3.8%] vs 166 of 4757 [3.5%]). The difference does not seem to be caused by primary etiology or sex as it is present in almost all of the subgroups but could be due to different rates of TTNtvs, since after removal of TTN and individuals with a diagnostic TTNtv, the yields were comparable (10 of 757 [1.3%] for HFpEF, 3 of 380 [0.8%] for HFmrEF, and 66 of 4654 [1.4%] for HFrEF; eTables 10 and 11 in the Supplement).

As expected, individuals with DCM as the primary etiology had a very high diagnostic yield (55 of 563 [9.8%]), especially if they had HFmrEF (7 of 55 [12.7%]) or were male and had HFrEF (34 of 283 [12.0%]). Notably, the diagnostic rate for female individuals with HFrEF and an idiopathic DCM was substantially lower (9 of 152 [5.9%]). Male patients with HFrEF and ischemic heart disease, by far the largest subgroup, had a diagnostic yield of almost 3% (90 of 3166). The diagnostic yield for a hypertensive etiology or other cause was greater than 3% (15 of 416 [3.6%] and 10 of 232 [4.3%]).

Restricting the analysis to patients with HF 50 years or younger increased the diagnostic yield in individuals with DCM to 12.9% (15 of 116) but decreased the yield for all other etiologies, which might be due to the small sample size (eTable 12 in the Supplement). Most of the diagnostic variants found in younger individuals (15 of 18 [83.3%]) were TTNtvs.

Results restricted to only individuals of mostly European ancestry were almost identical to those of the full cohort (eTable 13 in the Supplement) because this group encompasses 5481 of 5916 patients with HF (92.7%). Sample sizes for other ancestries were too low, but we did detect diagnostic TTNtvs in all groups.

To assess the clinical significance of the diagnostic results, we performed the same analysis for all 13 156 controls and observed a 3-fold overall increase in diagnostic yield for patients with HF (201 of 5916 [3.4%] vs 146 of 13 156 [1.1%] for controls) and up to 5-fold increase in TTN alone (eTable 14 in the Supplement).

The enrichment observed with PSI filtering in the UK Biobank Europeans for HF (I50) was very similar to the enrichment in the CORONA and CHARM trials (Figure 2). After filtering, the genetic risk was increased from 2.95 (95% CI, 2.42-3.57) to 4.97 (95% CI, 3.94-6.19) compared with 2.54 (95% CI, 1.96-3.31) to 4.52 (95% CI, 3.10-6.68) in the clinical studies. Furthermore, similar enrichment is observed for cardiomyopathy (I42) from 7.32 (95% CI, 5.65-9.50) to 15.15 (95% CI, 11.57-19.84). A smaller enrichment could also be observed in the ischemic heart disease group (I20-25) (1.31 [95% CI, 1.15-1.49] to 1.53 [95% CI, 1.28-1.83]). No association with atherosclerosis (I70) could be observed with or without PSI filtering (eTable 15 in the Supplement). A more detailed analysis of the ischemic heart disease group (I20-25) showed that there is no enrichment in patients with an I20-25 diagnosis that do not have cardiomyopathy (I42) or HF (I50), but there is an enrichment in those with an I20-25 code and an HF diagnosis but no cardiomyopathy (eTable 16 in the Supplement).

We performed the first large-scale whole-exome sequencing study of a broad population of patients with HF. Although our criteria for determining diagnostic variants were very stringent, our results demonstrate a surprisingly high diagnostic yield within known cardiomyopathy genes (3.4%) for a cohort clinically classified as mostly ischemic. This is particularly relevant in context of the significantly lower diagnostic yield in controls and highlights the enrichment of deleterious cardiomyopathy variants in patients with HF. Individuals with idiopathic DCM had the highest diagnostic yield (9.8%). However, even within the largest subgroup of ischemic HF, almost 3% of patients with HF had a diagnostic variant. The yield was only slightly lower in HFpEF compared with HFrEF or HFmrEF and the genes implicated largely overlap, suggesting more commonality in the genetic architecture than would be expected from the clinically identified mechanisms involved in these different subgroups. This finding was unexpected because the pathophysiology of the different subtypes is distinct. HFpEF in particular is thought to be more affected by comorbidities and environmental triggers with little genetic contribution.³⁵ Given the complexity of the syndrome of HF, these findings suggest that genetic variants could add to the clinical phenotype and prognosis as this may not completely reflect the underlying causes of the HF.

We also show that after filtering based on expression in the heart, the TTNtvs from our collapsing model were almost all diagnostic variants based on ACMG criteria. Quiz Ref IDTherefore, the almost 5-times increased rate of QVs in TTN found in patients with HF compared with controls reflects the increased diagnostic yield of the patients with HF. The TTN signal is present in HFpEF, HFmrEF, and HFrEF, again underlining the genetic overlap of the subtypes irrespective of the EF and of the underlying clinical diagnosis.

Currently, there is strong interest in linking genetic information to electronic health record data. While many reproducible association results have been reported,^36,37 there are also concerns about the quality of the records and suitability for genetic analyses.³⁸ In our analyses, it is reassuring that we observed similar enrichment values of TTNtvs in patients with HF compared with controls between the clinical studies, with stringent inclusion and exclusion criteria, and UK Biobank, a population cohort. Quiz Ref IDFurthermore, the more detailed analysis of the ischemic heart disease group might indicate that TTNtvs are not associated with increased risk of ischemic heart disease in general, but increased risk of developing HF after an ischemic event.

Although we sequenced 5942 patients with HF, sample sizes for several subgroups were small, as were the numbers of cases carrying a diagnostic variant. Therefore, especially for small differences in yield, we cannot distinguish true differences from random effects. Furthermore, the stringent criteria used to classify variants as pathogenic may lead to an underdiagnosis of patients with mendelian conditions.

Our results show that rare genetic variants provide complementary information to the clinical phenotypes in patients with HF. For the holistic assessment of patients and understanding of differences in prognosis or treatment response, it is unclear whether grouping patients with HF based on their EF or primary etiology alone is sufficient because a proportion of patients with HF have genetic causes that may influence outcomes and response.

Corresponding Author: David B. Goldstein, PhD, Institute for Genomic Medicine, Columbia University Medical Center, Hammer Health Sciences, 701 W 168th St, New York, NY 10032 (dg2875@cumc.columbia.edu); Carolina Haefliger, MD, Discovery Sciences, Biopharma R&D, AstraZeneca, da Vinci Building, Melbourn Science Park, Cambridge Road, Melbourn SG8 6HB, United Kingdom (carolina.haefliger@astrazeneca.com).

Accepted for Publication: October 27, 2020.

Published Online: December 16, 2020. doi:10.1001/jamacardio.2020.6500

Author Contributions: Dr Haefliger had full access to the clinical data and the UK Biobank data used in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Goldstein had full access to the genetic data of the clinical studies and takes responsibility for the integrity of the data and the accuracy of the data analysis. A representative of AstraZeneca was authorized to transfer copyright on behalf of Drs Chazara, Carss, Deevi, Armisen, Paul, and Haefliger and Mr Wang.

Concept and design: Carss, Granger, Haefliger, Goldstein.

Acquisition, analysis, or interpretation of data: Povysil, Chazara, Deevi, Wang, Armisen, Paul, Granger, Kjekshus, Aggarwal, Haefliger, Goldstein.

Drafting of the manuscript: Povysil, Chazara, Haefliger, Goldstein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Povysil, Chazara, Wang, Goldstein.

Obtained funding: Haefliger, Goldstein.

Administrative, technical, or material support: Armisen, Goldstein.

Supervision: Carss, Paul, Haefliger, Goldstein.

Conflict of Interest Disclosures: Drs Chazara, Carss, Deevi, and Paul report personal fees from AstraZeneca during the conduct of the study and outside the submitted work. Mr Wang reports personal fees from AstraZeneca and is a stockholder of AstraZeneca outside the submitted work. Dr Armisen reports personal fees from AstraZeneca during the conduct of the study and outside the submitted work and is a stockholder of AstraZeneca. Dr Granger reports personal fees from AbbVie, Bayer, Boston Scientific, CeleCor, Correvio, Espero BioPharma, Medscape, Medtronic, Merck, National Institutes of Health, Novo Nordisk, Rhoshan, and Roche; grants from Akros, Apple, AstraZeneca, Daiichi Sankyo, US Food and Drug Administration, GlaxoSmithKline, and Medtronic Foundation; grants and personal fees from Boehringer Ingelheim, Bristol Myers Squibb, Janssen, Novartis, and Pfizer; and other support from Duke Clinical Research Institute outside the submitted work. Dr Haefliger reports personal fees from AstraZeneca during the conduct of the study and outside the submitted work and is a stockholder of AstraZeneca. Dr Goldstein reports holding equity in the publicly traded precision medicine company Praxis Precision Medicine, Apostle Inc, and Q-State Biosciences and has in the past been a paid advisor to AstraZeneca, Gilead Sciences, GoldFinch Bio, and Johnson & Johnson. No other disclosures were reported.

Funding/Support: This work was supported by the Columbia University Institute for Genomic Medicine and AstraZeneca. Funding for the exome sequencing in the CHARM, CORONA, and UK Biobank cohort was provided fully or partially by AstraZeneca.

Role of the Funder/Sponsor: AstraZeneca was involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We are grateful to Slavé Petrovski, PhD (Centre for Genomics Research, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK), for helping with the UK Biobank analysis and interpretation of data. Compensation was not received. This research has been conducted using the UK Biobank Resource under Application Number 26041. We thank all the study participants for contributing to this effort and the CHARM and CORONA coinvestigators.