Genetic Complexities of Cerebral Small Vessel Disease, Blood Pressure, and Dementia
Authors: Sargurupremraj Muralidharan , Soumaré Aicha , Bis Joshua C. , Surakka Ida , Jürgenson Tuuli , Joly Pierre , Knol Maria J. , Wang Ruiqi , Yang Qiong , Satizabal Claudia L. , Gudjonsson Alexander , Mishra Aniket , Bouteloup Vincent , Phuah Chia-Ling , van Duijn Cornelia M. , Cruchaga Carlos , Dufouil Carole , Chêne Geneviève , Lopez Oscar L. , Psaty Bruce M. , Tzourio Christophe , Amouyel Philippe , Adams Hieab H. , Jacqmin-Gadda Hélène , Ikram Mohammad Arfan , Gudnason Vilmundur , Milani Lili , Winsvold Bendik S. , Hveem Kristian , Matthews Paul M. , Longstreth W. T. , Seshadri Sudha , Launer Lenore J. , Debette Stéphanie 
Published: May 2024

ImportanceVascular disease is a treatable contributor to dementia risk, but the role of specific markers remains unclear, making prevention strategies uncertain.ObjectiveTo investigate the causal association between white matter hyperintensity (WMH) burden, clinical stroke, blood pressure (BP), and dementia risk, while accounting for potential epidemiologic biases.Design, Setting, and ParticipantsThis study first examined the association of genetically determined WMH burden, stroke, and BP levels with Alzheimer disease (AD) in a 2-sample mendelian randomization (2SMR) framework. Second, using population-based studies (1979-2018) with prospective dementia surveillance, the genetic association of WMH, stroke, and BP with incident all-cause dementia was examined. Data analysis was performed from July 26, 2020, through July 24, 2022.ExposuresGenetically determined WMH burden and BP levels, as well as genetic liability to stroke derived from genome-wide association studies (GWASs) in European ancestry populations.Main Outcomes and MeasuresThe association of genetic instruments for WMH, stroke, and BP with dementia was studied using GWASs of AD (defined clinically and additionally meta-analyzed including both clinically diagnosed AD and AD defined based on parental history [AD-meta]) for 2SMR and incident all-cause dementia for longitudinal analyses.ResultsIn 2SMR (summary statistics–based) analyses using AD GWASs with up to 75 024 AD cases (mean [SD] age at AD onset, 75.5 [4.4] years; 56.9% women), larger WMH burden showed evidence for a causal association with increased risk of AD (odds ratio [OR], 1.43; 95% CI, 1.10-1.86; P = .007, per unit increase in WMH risk alleles) and AD-meta (OR, 1.19; 95% CI, 1.06-1.34; P = .008), after accounting for pulse pressure for the former. Blood pressure traits showed evidence for a protective association with AD, with evidence for confounding by shared genetic instruments. In the longitudinal (individual-level data) analyses involving 10 699 incident all-cause dementia cases (mean [SD] age at dementia diagnosis, 74.4 [9.1] years; 55.4% women), no significant association was observed between larger WMH burden and incident all-cause dementia (hazard ratio [HR], 1.02; 95% CI, 1.00-1.04; P = .07). Although all exposures were associated with mortality, with the strongest association observed for systolic BP (HR, 1.04; 95% CI, 1.03-1.06; P = 1.9 × 10−14), there was no evidence for selective survival bias during follow-up using illness-death models. In secondary analyses using polygenic scores, the association of genetic liability to stroke, but not genetically determined WMH, with dementia outcomes was attenuated after adjusting for interim stroke.ConclusionsThese findings suggest that WMH is a primary vascular factor associated with dementia risk, emphasizing its significance in preventive strategies for dementia. Future studies are warranted to examine whether this finding can be generalized to non-European populations.