The cross-sectional study design is unable to establish a causal relationship between inflammatory indices and LVH

The gap

Evidence profile

Sourced from the limitations section and limitations of the source papers, classified as general, drawn from work published between 2024 and 2026, spanning 3 journals. Those papers have been cited 21 times in total.

Supporting evidence — 3 representative gaps

• Comparison of Novel Systemic Inflammatory Indices for Identification of Left Ventricular Hypertrophy in Hypertensive Patients: A Large-Scale Cross-Sectional Study in China (2026) · Journal of Cardiovascular Development and Disease · doi

  The cross-sectional study design is unable to establish a causal relationship between inflammatory indices and LVH. The study population consisted primarily of Chinese patients diagnosed with hypertension; given that it was based on a single-center cohort of hypertensive patients, selection bias may be present, and the findings still need to be validated in other populations. Certain elements (such as physical activity, lifestyle, and genetics) were not thoroughly incorporated and may have impacted the results.

  generallimitations section
  Keywords: cross-sectional study design unable establish causal relationship between
• Association between METS-VF and hypertension in U.S.: a cross-sectional analysis of NHANES data (2026) · Scientific Reports · doi

  This research possesses several key strengths. First, the primary analysis was based on NHANES, a large nationally representative survey of the US population, and all analyses accounted for the complex multistage sampling design. Second, the study comprehensively adjusted for demographic, socioeconomic, clinical, lifestyle, PA, and dietary covariates, thereby reducing potential confounding as much as possible. Third, subgroup, threshold effect, and ROC analyses were performed to assess the robustness and discriminatory performance of METS-VF. Importantly, we further conducted an independent external validation analysis using the CHARLS cohort. In 18 ARTICLE IN PRESS ARTICLE IN PRESS this external validation cohort, METS-VF retained the highest discriminatory ability for hypertension among the evaluated indices, and logistic regression analyses showed a directionally consistent positive association between METS-VF and hypertension. These findings strengthen the robustness and external validity of the association between METS-VF and hypertension. Several limitations should be acknowledged. First,Although we added an independent external validation analysis using the CHARLS cohort, several limitations should be acknowledged. CHARLS mainly includes middle-aged and older Chinese adults, whereas NHANES represents a broader US adult population. Therefore, differences in age structure, ethnicity, lifestyle, and healthcare context may influence the absolute AUC estimates. Second, the sample data are cross-sectional, and the results are not causally related. Third, the METS-VF is an indirect formula to estimate visceral fat load and is not a direct imaging measurement, which is susceptible to measurement error and could influence the accuracy of the findings. Fourthly, the data on physical activity and related past medical history are evaluated through self-reported questionnaire data, which may be affected by recall bias and incorrect classification. Antihypertensive medication use was not included as a separate diagnostic criterion in the primary definition of hypertension. Fifth, although self-reported physician-diagnosed hypertension may capture most clinically diagnosed cases, some participants with medication-controlled blood pressure may have been misclassified. Therefore, potential outcome misclassification cannot be fully excluded. Meanwhile, because the final analytical cohort was restricted to participants with complete fasting 19 ARTICLE IN PRESS ARTICLE IN PRESS laboratory data and complete covariate information, potential selection bias cannot be fully excluded. Participants included in the fasting subsample or complete-case analysis may differ from excluded participants in demographic characteristics, metabolic status, health behaviors, or comorbidity profiles. Therefore, although NHANES sampling weights were applied to improve national representativeness, the findings should be interpreted as representative of the eligible fasting analytical population rather than the entire original NHANES population. Finally, although we have made additional adjustments to the physical activity situation, residual confounding factors related to cardiopulmonary function and muscle strength still cannot be completely excluded.

  generallimitationsevidence 5/5
  Keywords: mets hypertension nhanes population external cohort article press participants excluded several analyses potential validation charls
• Association of the metabolic score for insulin resistance with cardiovascular diseases, cardiovascular and all-cause mortality in Chinese hypertensive population (2024) · Frontiers in Endocrinology · cited 21× · doi

  This was a substudy of the H-type hypertension. The METS-IR and CVD function of the study participants was only assessed at baseline and the exit visit. Although there is some evidences to suggest that METS-IR can serve as an alternative biomarker for evaluating IR, we did not compare the effects of other IR biomarkers on mortality in the same population. Even if we adjust for the most important known risk factors for CVD, there may still be residual confounding factors such as lifestyle factors, genetic factors, environmental factors, etc. The participants included in this study were Chinese hypertensive adults; thus, the applicability of our findings to people from other countries remains to be verified.

  generallimitations sectionevidence 5/5
  Keywords: was substudy h-type hypertension mets-ir cvd function study

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