Causal associations between epigenetic age and thromboembolism: a bi-directional two-sample Mendelian randomization study

Abstract

Background

Thromboembolism is one of the most prevalent cardiovascular conditions affecting the elder population. The associations between epigenetic aging and thromboembolism risks remain incompletely elucidated. Through Mendelian randomization (MR), this research seeks to assess the causal links between genetically determined epigenetic aging factors and thromboembolism.

Results

Genetic variants were extracted from genome-wide association studies (GWAS) under stringent threshold as instrumental variables (IVs). Bi-directional two-sample MR analyses were conducted to determine the direction of causal associations. We employed the inverse variance weighted (IVW), weighted median, weighted mode and MR Egger to estimate the causal effect, with sensitivity analyses such as Cochran’s Q tests, MR-PRESSO and leave-one-out performed to avoid potential heterogeneity and pleiotropy. Our MR analysis revealed a causal association between intrinsic epigenetic age acceleration and deep vein thrombosis of lower extremities (IVW: OR 0.963, 95% CI 0.934–0.992, P = 0.014), and between the genetically determined levels of plasminogen activator inhibitor-1 and other arterial embolism and thrombosis (IVW: OR 1.000, 95% CI 1.000–1.0005, P = 0.029). Causality was also identified between the genetically predicted levels of FGF23 and other arterial embolism and thrombosis (IVW: OR: 1.661, 95% CI 1.051–2.624, P = 0.029) and arterial embolism and thrombosis of lower extremity artery (IVW: OR 1.68, 95% CI 1.031–2.725, P = 0.037). Moreover, bi-directional MR showed reverse effects between portal vein thrombosis and PhenoAge (IVW: OR 0.871, 95% CI 0.765–0.992, P = 0.037) and between venous thromboembolism and GrimAge (IVW: OR 1.186, 95% CI 1.048–1.341, P = 0.007). Sensitivity analysis using Cochran’s Q tests, MR-PRESSO and leave-one-out excluded the influence of heterogeneity, horizontal pleiotropy, and outliers.

Conclusion

Our results identified a causal association between genetically predicted epigenetic aging factors and thromboembolism. The findings highlight the necessity for further exploration into the underlying etiology of thromboembolism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-025-01875-3.

Background

Thromboembolism, a critical cardiovascular condition that is frequently underdiagnosed and undertreated, significantly impacts a large portion of the global population, accounting for approximately one in four deaths worldwide [1]. Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT), pulmonary embolism (PE), thrombophlebitis and portal vein thrombosis (PVT), is a significant health issue affecting approximately 10 million people globally each year [2]. Characterized by abnormal blood clotting in the deep veins, VTE disrupts normal venous return, which can result in severe complications and long-term consequences. Arterial thromboembolism, on the other hand, resulting from clot formation within arteries or embolization from the heart or vessel walls, obstructs blood flow and is a leading cause of ischemic heart disease and stroke [3]. Despite advances in diagnosis and treatment, venous and arterial thromboembolism remain a challenge for clinicians, highlighting the need for primary prevention strategies to reduce the risk of thrombosis. The underlying mechanisms of venous and arterial thromboembolism are complex and multi-factorial, with risk factors including dietary habits, tobacco use, and sedentary behavior and accelerated epigenetic aging [4, 5].

Epigenetic aging, which refers to the biological aging process as indicated by specific epigenetic markers, such as DNA methylation and histone modifications, is a significant area of research in the field of gerontology and epidemiology [6]. Epigenetic age, an indicator of biological age that can differ from chronological age, is a reflection of health status and aging rate. This measure is linked to various health outcomes and can predict longevity [7]. Epigenetic clocks, such as HannumAge, PhenoAge and GrimAge, are tools developed to predict biological age and assess the risk of age-related diseases based on these methylation patterns [8–10]. The relationship between epigenetic aging and thrombosis is an emerging area of research [11]. Recent studies have shown that epigenetic age acceleration is associated with a prothrombotic hemostatic profile, characterized by increased levels of clotting factors such as fibrinogen and PAI1, as well as decreased clotting time, which may contribute to the increased risk of thrombotic events [5]. However, prothrombotic profiles may contribute to accelerated epigenetic aging, as chronic inflammation and oxidative stress commonly seen in diabetes or obesity, both of which are risk factors for thrombosis, can contribute to epigenetic aging acceleration [12]. Therefore, the precise causal links between epigenetic aging and thrombosis are not yet fully understood. This gap in knowledge underscores the need for further research to uncover the underlying host factors that could inform more effective prevention and treatment strategies for thrombotic events.

MR offers an alternative to conduct causality assumptions that cannot be readily obtained from conventional observational studies [13]. Using random genetic variants as IVs, MR explores the causal relationships between two variables, helping to control for confounding factors and address issues of reverse causality [14, 15]. Here, an MR analysis was executed to test whether these SNP alleles affecting epigenetic aging are causally associated with the risk of thromboembolism at the population level.

Methods

Study design

A two-sample MR analysis was conducted to assess the casual connections between genetically predicted epigenetic aging factors and thromboembolism. SNPs were selected as IVs based on three criteria: 1) directly linked to the exposure, 2) not correlated with potential confounders, and 3) an exclusive influence on the outcome through the exposure. [14, 16]. Figure 1 summarizes the overall study design. Our study was reported in line with the “STrengthening the Reporting of OBservational studies in Epidemiology using Mendelian Randomization (STROBE-MR)” checklist [16].

Fig. 1.

Overall study design of the MR analysis. A flowchart depicts how the bi-directional MR analysis was conducted in this study

Data sources

The GWAS summary data of venous and arterial thromboembolism was collected from the FinnGen database, a large public–private partnership in Finland aimed at collecting and analyzing genomic and health data to better understand the genetic basis of diseases, which were categorized into VTE (21,021 cases and 391,160 controls), DVT (6501 cases and 357,111 controls), PE (10,046 cases and 401,128 controls), thrombophlebitis (7683 cases and 357,111 controls), PVT (394 cases and 357,111 controls), and arterial embolism and thrombosis of lower extremity artery (1076 cases and 381,977 controls) and other arterial embolism and thrombosis (869 cases and 381,977 controls) of European ancestry.

The GWAS summary data of PhenoAge, GrimAge, HannumAge and intrinsic epigenetic age acceleration (IEAA) derived from the HorvathAge were obtained from a previous study [17]. In addition, genetically predicted levels of five factors that have been associated with epigenetic aging, including granulocyte proportions, plasminogen activator inhibitor-1 (PAI1), telomere length, circulating plasma α-Klotho and fibroblast growth factor 23 (FGF23) were considered for exposure as well, and the genetic data were acquired from public studies [18–22]. The detailed information for each phenotypic exposure and outcome data is provided in Supplemental Table 1.

Selection of instrumental variables

SNPs for each exposure phenotype were selected as candidate IVs at a threshold of p < 5e-8 [23], with the exception of analyses involving granulocyte proportions, PVT, arterial embolism, and thrombosis of the lower extremity artery and other arterial sites, where a less stringent threshold of p < 5e-6 was applied due to limited number of SNPs at p < 5e-8 [24]. Subsequently, SNPs with MAF (minor allele frequency) no more than 0.01 were discarded. Linked disequilibrium (LD)-clumping was conducted to ensure the independence of each SNPs under a stringent criteria (r² < 0.001, window size = 10,000 kb). For SNPs missing in the outcome, we identified the most highly correlated proxy SNPs within a ± 500 kb window around the original SNP locus, ensuring a high degree of correlation (r² > 0.8) to maintain their validity as IVs. Furthermore, F-statistics for these IVs were calculated using the formula F = R²*(N-2)/(1-R²), of which R² represents the proportion of phenotypic variance explained by a single SNP and N refers to sample sizes [25]. SNPs with an F-statistic below 10 were considered as weak IVs and subsequently discarded [26]. Finally, during the harmonization process of aligning exposure and outcome data, alleles that were non-concordant and those with palindromic sequences were eliminated. These stringently selected SNPs were utilized as eligible IVs for MR analyses.

Mendelian randomization analysis

Bi-directional two-sample MR analysis was executed between genetically determined epigenetic aging factors and thromboembolism by calculating odds ratio (OR) and 95% confidence interval (CI). We applied inverse variance weighted (IVW) [27], weighted median [28], weighted mode [29] and MR Egger [30], with IVW as the main approach and other methods utilized for the robustness of the results.

MR Egger considers the presence of intercept terms and can provide accurate causal effect estimates in the presence of pleiotropic bias. The weighted median analyzed the causality based on the assumption that half of the IVs were valid. We initially computed the causal estimates using the fixed effects IVW methods for each IV. The random effects IVW was utilized in case of significant heterogeneity (p < 0.05). Forest plots, scatter plots and funnel plots were also produced to depict the causality and the influence of each SNP on the outcome. All MR analyses were run in R 4.0.5 along with the package “Two-sample MR.”

Sensitivity analysis

To exclude pleiotropy, MR Egger was utilized. The intercept term in MR Egger regression is crucial as it indicates the presence of horizontal pleiotropy. Specifically, a significant intercept term (p < 0.05) suggests that there is unbalanced horizontal pleiotropy [31]. Conversely, a non-significant intercept term (p ≥ 0.05) suggests that there is no strong evidence of horizontal pleiotropy, thereby supporting the validity of the causal estimates.

Cochran’s Q was utilized for heterogeneity identification among IVs of each phenotypic exposure [32]. A significant Q statistic (P < 0.05) indicates heterogeneity, suggesting inconsistent effect sizes across IVs. Conversely, a non-significant Q statistic (P ≥ 0.05) suggests no significant heterogeneity and indicates that effect sizes are consistent and can be reliably pooled. Furthermore, Mendelian Randomization Pleiotropy RESidual Sum and Outlier (MR-PRESSO) was applied for outlier elimination (p < 0.05) and correcting for horizontal pleiotropy [31]. Leave-one-out analysis, which discarded each SNP prior to MR analysis of remaining SNPs on the risk of thromboembolism, was conducted to obtain the effect of each SNP on the overall causality [33].

Results

Screening of IVs associated with epigenetic aging factors

We selected SNPs from GWAS summary data for each phenotypic exposure, applying a stringent threshold. During the harmonization process, we eliminated alleles that were non-concordant and palindromic. Therefore, we acquired a total of 224 IVs associated with the exposure, with 11 for PhenoAge, 4 for GrimAge, 9 for HannumAge, 24 for IEAA, 19 for granulocyte proportions, 5 for PAI1, 138 for telomere length, 8 for FGF23 and 6 for α-Klotho, which all showed an F-statistics > 10 (Supplemental Table 2). Certain SNPs were not found in the outcome and therefore replaced with appropriate proxy SNPs (Supplemental Table 3).

Causal effects of epigenetic aging factors on thromboembolism

Based on the GWAS summary data for thromboembolism, MR analysis revealed significant causality between IEAA and DVT of lower extremities (IVW: OR 0.963, 95% CI 0.934–0.992, P = 0.014), suggesting that IEAA may serve as a risk factor for this condition (Table 1). In addition, genetically predicted levels of FGF23 and other arterial embolism and thrombosis (IVW: OR 1.661, 95% CI 1.051–2.624, P = 0.029) and arterial embolism and thrombosis of lower extremity artery (IVW: OR 1.68, 95% CI 1.031–2.725, P = 0.037) were found to be causally associated, consistent with the weighted median method (Table 1). This suggested the potential of FGF23 in exacerbating thrombotic events. A weak association was observed between PAI1 and other arterial embolism and thrombosis (IVW: OR 1.000, 95% CI 1.000–1.0005, P = 0.029), suggesting a minimal impact on the risk of these conditions (Table 1). No heterogeneity and pleiotropy were identified among these associations (Table 2). MR-PRESSO revealed outliers among associations between α-Klotho and DVT of lower extremities, thrombophlebitis, VTE and PE, between FGF23 and DVT of lower extremities, thrombophlebitis, PE and VTE, between PhenoAge and arterial embolism and thrombosis of lower extremity artery, between telomere length and thrombophlebitis, PE and VTE, the causal associations of which remained negative after outliers were removed (Table 3). We additionally produced scatter plots and forest plots, visually examining for any potential influence of outliers (Figs. 2A–D, 3A–D). Leave-one-out analysis plots and funnel plots further consolidated the stability of the results (Supplemental Figs. 1A–D, 2A–D).

Table 1.

Causal estimates of epigenetic aging factors on thromboembolism

Outcome	Exposure	N.SNP	Methods	OR_CI	P value
Arterial embolism and thrombosis of lower extremity artery	PAI1	5	Inverse variance weighted	1.0001 (0.9998–1.0004)	0.5369
Arterial embolism and thrombosis of lower extremity artery	PAI1	5	MR Egger	0.9998 (0.9991–1.0004)	0.5215
Arterial embolism and thrombosis of lower extremity artery	PAI1	5	Weighted median	0.9999 (0.9996–1.0002)	0.706
Arterial embolism and thrombosis of lower extremity artery	PAI1	5	Weighted mode	0.9999 (0.9994–1.0003)	0.6133
Pulmonary embolism	PAI1	5	Inverse variance weighted	1 (0.9999–1)	0.229
Pulmonary embolism	PAI1	5	MR Egger	1.0001 (0.9999–1.0002)	0.5325
Pulmonary embolism	PAI1	5	Weighted median	0.9999 (0.9998–1)	0.1424
Pulmonary embolism	PAI1	5	Weighted mode	1 (0.9999–1.0001)	0.6384
DVT of lower extremities	PAI1	5	Inverse variance weighted	1 (0.9999–1.0001)	0.4935
DVT of lower extremities	PAI1	5	MR Egger	1 (0.9997–1.0002)	0.756
DVT of lower extremities	PAI1	5	Weighted median	1 (0.9999–1.0001)	0.7119
DVT of lower extremities	PAI1	5	Weighted mode	1 (0.9999–1.0001)	0.8901
Other arterial embolism and thrombosis	PAI1	5	Inverse variance weighted	1.0003 (1–1.0005)	0.0294
Other arterial embolism and thrombosis	PAI1	5	MR Egger	0.9999 (0.9993–1.0005)	0.7654
Other arterial embolism and thrombosis	PAI1	5	Weighted median	1.0003 (0.9999–1.0006)	0.0981
Other arterial embolism and thrombosis	PAI1	5	Weighted mode	1.0002 (0.9999–1.0006)	0.2518
Phlebitis and thrombophlebitis	PAI1	5	Inverse variance weighted	0.9999 (0.9998–1.0001)	0.3214
Phlebitis and thrombophlebitis	PAI1	5	MR Egger	0.9998 (0.9995–1)	0.1429
Phlebitis and thrombophlebitis	PAI1	5	Weighted median	1 (0.9999–1.0001)	0.8411
Phlebitis and thrombophlebitis	PAI1	5	Weighted mode	1 (0.9998–1.0001)	0.6743
Venous thromboembolism	PAI1	5	Inverse variance weighted	1 (0.9999–1)	0.3209
Venous thromboembolism	PAI1	5	MR Egger	1 (0.9999–1.0001)	0.8608
Venous thromboembolism	PAI1	5	Weighted median	1 (0.9999–1)	0.3764
Venous thromboembolism	PAI1	5	Weighted mode	1 (0.9999–1)	0.5273
Portal vein thrombosis	PAI1	5	Inverse variance weighted	1.0002 (0.9998–1.0006)	0.3304
Portal vein thrombosis	PAI1	5	MR Egger	1.0001 (0.9991–1.0012)	0.8249
Portal vein thrombosis	PAI1	5	Weighted median	1.0002 (0.9997–1.0007)	0.4344
Portal vein thrombosis	PAI1	5	Weighted mode	1.0003 (0.9996–1.0009)	0.4585
Arterial embolism and thrombosis of lower extremity artery	HannumAge	9	Inverse variance weighted	1.0563 (0.9162–1.2177)	0.4507
Arterial embolism and thrombosis of lower extremity artery	HannumAge	9	MR Egger	0.8537 (0.4949–1.4728)	0.5875
Arterial embolism and thrombosis of lower extremity artery	HannumAge	9	Weighted median	0.9589 (0.7964–1.1546)	0.658
Arterial embolism and thrombosis of lower extremity artery	HannumAge	9	Weighted mode	0.9521 (0.7647–1.1853)	0.6719
Pulmonary embolism	HannumAge	9	Inverse variance weighted	1.0257 (0.9784–1.0753)	0.2929
Pulmonary embolism	HannumAge	9	MR Egger	0.8792 (0.7333–1.0541)	0.2068
Pulmonary embolism	HannumAge	9	Weighted median	1.0314 (0.9699–1.0968)	0.3242
Pulmonary embolism	HannumAge	9	Weighted mode	1.0205 (0.9382–1.11)	0.6487
DVT of lower extremities	HannumAge	9	Inverse variance weighted	0.9857 (0.9297–1.045)	0.628
DVT of lower extremities	HannumAge	9	MR Egger	1.0119 (0.8084–1.2667)	0.9206
DVT of lower extremities	HannumAge	9	Weighted median	0.9899 (0.9217–1.0632)	0.7807
DVT of lower extremities	HannumAge	9	Weighted mode	0.9908 (0.8982–1.0931)	0.8588
Other arterial embolism and thrombosis	HannumAge	9	Inverse variance weighted	1.0611 (0.9059–1.2429)	0.462
Other arterial embolism and thrombosis	HannumAge	9	MR Egger	1.1217 (0.6111–2.0587)	0.7219
Other arterial embolism and thrombosis	HannumAge	9	Weighted median	1.09 (0.8899–1.3351)	0.4049
Other arterial embolism and thrombosis	HannumAge	9	Weighted mode	1.0774 (0.8196–1.4163)	0.6077
Phlebitis and thrombophlebitis	HannumAge	9	Inverse variance weighted	1.0106 (0.9525–1.0721)	0.7274
Phlebitis and thrombophlebitis	HannumAge	9	MR Egger	1.1894 (0.9655–1.4653)	0.1471
Phlebitis and thrombophlebitis	HannumAge	9	Weighted median	0.9963 (0.9293–1.0682)	0.9178
Phlebitis and thrombophlebitis	HannumAge	9	Weighted mode	0.9937 (0.9059–1.0899)	0.8963
Venous thromboembolism	HannumAge	9	Inverse variance weighted	1.0091 (0.9761–1.0432)	0.5921
Venous thromboembolism	HannumAge	9	MR Egger	0.9802 (0.8627–1.1138)	0.7681
Venous thromboembolism	HannumAge	9	Weighted median	0.9935 (0.9529–1.0359)	0.7613
Venous thromboembolism	HannumAge	9	Weighted mode	0.9919 (0.9411–1.0454)	0.7687
Portal vein thrombosis	HannumAge	9	Inverse variance weighted	1.1249 (0.8908–1.4206)	0.3228
Portal vein thrombosis	HannumAge	9	MR Egger	1.0881 (0.4441–2.6656)	0.8588
Portal vein thrombosis	HannumAge	9	Weighted median	1.195 (0.8881–1.6078)	0.2394
Portal vein thrombosis	HannumAge	9	Weighted mode	1.1955 (0.8274–1.7274)	0.3695
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	11	Inverse variance weighted	1.028 (0.9004–1.1737)	0.6825
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	11	MR Egger	0.8759 (0.5801–1.3226)	0.5442
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	11	Weighted median	1.0494 (0.9135–1.2056)	0.4955
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	11	Weighted mode	1.0395 (0.8489–1.2728)	0.7157
Pulmonary embolism	PhenoAge	11	Inverse variance weighted	1.0019 (0.9697–1.0352)	0.9093
Pulmonary embolism	PhenoAge	11	MR Egger	0.9907 (0.8919–1.1005)	0.8661
Pulmonary embolism	PhenoAge	11	Weighted median	0.9975 (0.9563–1.0404)	0.906
Pulmonary embolism	PhenoAge	11	Weighted mode	0.9934 (0.9314–1.0594)	0.8433
DVT of lower extremities	PhenoAge	11	Inverse variance weighted	1.0322 (0.993–1.0729)	0.1084
DVT of lower extremities	PhenoAge	11	MR Egger	0.9951 (0.8842–1.12)	0.9371
DVT of lower extremities	PhenoAge	11	Weighted median	1.0302 (0.9798–1.0832)	0.2454
DVT of lower extremities	PhenoAge	11	Weighted mode	1.0403 (0.9633–1.1234)	0.3377
Other arterial embolism and thrombosis	PhenoAge	11	Inverse variance weighted	1.0622 (0.9532–1.1837)	0.275
Other arterial embolism and thrombosis	PhenoAge	11	MR Egger	1.224 (0.8755–1.7112)	0.2674
Other arterial embolism and thrombosis	PhenoAge	11	Weighted median	1.0374 (0.8921–1.2063)	0.6338
Other arterial embolism and thrombosis	PhenoAge	11	Weighted mode	1.0045 (0.7643–1.3203)	0.9749
Phlebitis and thrombophlebitis	PhenoAge	11	Inverse variance weighted	0.9955 (0.9607–1.0316)	0.8055
Phlebitis and thrombophlebitis	PhenoAge	11	MR Egger	0.9504 (0.8523–1.0598)	0.3842
Phlebitis and thrombophlebitis	PhenoAge	11	Weighted median	0.9721 (0.9269–1.0195)	0.2439
Phlebitis and thrombophlebitis	PhenoAge	11	Weighted mode	0.9647 (0.8999–1.0343)	0.3356
Venous thromboembolism	PhenoAge	11	Inverse variance weighted	1.0106 (0.9886–1.0331)	0.3471
Venous thromboembolism	PhenoAge	11	MR Egger	0.9872 (0.9229–1.0559)	0.7162
Venous thromboembolism	PhenoAge	11	Weighted median	1.0224 (0.9915–1.0542)	0.1569
Venous thromboembolism	PhenoAge	11	Weighted mode	1.0276 (0.9783–1.0795)	0.3029
Portal vein thrombosis	PhenoAge	11	Inverse variance weighted	0.9804 (0.8018–1.1987)	0.847
Portal vein thrombosis	PhenoAge	11	MR Egger	0.8399 (0.4436–1.5903)	0.6052
Portal vein thrombosis	PhenoAge	11	Weighted median	1.044 (0.841–1.2961)	0.6962
Portal vein thrombosis	PhenoAge	11	Weighted mode	1.0397 (0.736–1.4687)	0.8296
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	1.1493 (0.8205–1.6099)	0.4182
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	5	MR Egger	1.1627 (0.4427–3.0536)	0.7796
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	5	Weighted median	1.1047 (0.826–1.4774)	0.502
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	5	Weighted mode	1.4465 (0.9881–2.1175)	0.1305
Pulmonary embolism	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	1.1426 (0.9671–1.35)	0.1173
Pulmonary embolism	Circulating plasma alpha-Klotho levels	5	MR Egger	1.4498 (0.9937–2.1153)	0.1496
Pulmonary embolism	Circulating plasma alpha-Klotho levels	5	Weighted median	1.0134 (0.9147–1.1228)	0.7988
Pulmonary embolism	Circulating plasma alpha-Klotho levels	5	Weighted mode	0.989 (0.8905–1.0983)	0.8457
DVT of lower extremities	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	1.2193 (0.8978–1.6558)	0.2042
DVT of lower extremities	Circulating plasma alpha-Klotho levels	5	MR Egger	2.0177 (1.0882–3.7414)	0.1122
DVT of lower extremities	Circulating plasma alpha-Klotho levels	5	Weighted median	0.9698 (0.8614–1.0919)	0.6123
DVT of lower extremities	Circulating plasma alpha-Klotho levels	5	Weighted mode	0.9295 (0.8266–1.0452)	0.2889
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	0.9483 (0.7654–1.1747)	0.6269
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	5	MR Egger	0.9469 (0.5546–1.6166)	0.8543
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	5	Weighted median	0.9694 (0.7551–1.2447)	0.8076
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	5	Weighted mode	0.9778 (0.7295–1.3107)	0.888
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	1.1942 (0.9454–1.5084)	0.1366
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	5	MR Egger	1.8421 (1.2316–2.7552)	0.0589
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	5	Weighted median	1.0595 (0.9397–1.1945)	0.3451
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	5	Weighted mode	0.9812 (0.8428–1.1424)	0.8192
Venous thromboembolism	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	1.1657 (0.9512–1.4286)	0.1394
Venous thromboembolism	Circulating plasma alpha-Klotho levels	5	MR Egger	1.6063 (1.0464–2.4657)	0.1187
Venous thromboembolism	Circulating plasma alpha-Klotho levels	5	Weighted median	0.9973 (0.9304–1.069)	0.9387
Venous thromboembolism	Circulating plasma alpha-Klotho levels	5	Weighted mode	0.9914 (0.9258–1.0615)	0.8157
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	5	Inverse variance weighted	0.8749 (0.6344–1.2067)	0.4154
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	5	MR Egger	1.1939 (0.5134–2.7766)	0.7083
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	5	Weighted median	0.8835 (0.5773–1.3521)	0.5684
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	5	Weighted mode	1.2336 (0.6922–2.1987)	0.5157
Arterial embolism and thrombosis of lower extremity artery	GrimAge	4	Inverse variance weighted	1.1536 (0.8906–1.4943)	0.279
Arterial embolism and thrombosis of lower extremity artery	GrimAge	4	MR Egger	18.0742 (0.3639–897.6039)	0.2835
Arterial embolism and thrombosis of lower extremity artery	GrimAge	4	Weighted median	1.1728 (0.8793–1.5643)	0.2781
Arterial embolism and thrombosis of lower extremity artery	GrimAge	4	Weighted mode	1.2058 (0.7908–1.8387)	0.4485
Pulmonary embolism	GrimAge	4	Inverse variance weighted	0.9538 (0.8834–1.0298)	0.2266
Pulmonary embolism	GrimAge	4	MR Egger	1.2556 (0.3435–4.5889)	0.7635
Pulmonary embolism	GrimAge	4	Weighted median	0.958 (0.8783–1.045)	0.3337
Pulmonary embolism	GrimAge	4	Weighted mode	0.9639 (0.8607–1.0794)	0.5695
DVT of lower extremities	GrimAge	4	Inverse variance weighted	1.0336 (0.9102–1.1737)	0.6107
DVT of lower extremities	GrimAge	4	MR Egger	0.8912 (0.0646–12.2899)	0.9392
DVT of lower extremities	GrimAge	4	Weighted median	0.9879 (0.8777–1.1121)	0.8408
DVT of lower extremities	GrimAge	4	Weighted mode	0.9631 (0.8321–1.1146)	0.6485
Other arterial embolism and thrombosis	GrimAge	4	Inverse variance weighted	0.9157 (0.7085–1.1834)	0.5007
Other arterial embolism and thrombosis	GrimAge	4	MR Egger	0.6469 (0.0084–49.5764)	0.8622
Other arterial embolism and thrombosis	GrimAge	4	Weighted median	0.9018 (0.6714–1.2113)	0.4924
Other arterial embolism and thrombosis	GrimAge	4	Weighted mode	0.8513 (0.5649–1.2829)	0.4978
Phlebitis and thrombophlebitis	GrimAge	4	Inverse variance weighted	0.9427 (0.8385–1.0598)	0.3229
Phlebitis and thrombophlebitis	GrimAge	4	MR Egger	0.3423 (0.0475–2.4668)	0.3988
Phlebitis and thrombophlebitis	GrimAge	4	Weighted median	0.9756 (0.8756–1.087)	0.6545
Phlebitis and thrombophlebitis	GrimAge	4	Weighted mode	1.0024 (0.8523–1.1789)	0.979
Venous thromboembolism	GrimAge	4	Inverse variance weighted	0.9769 (0.919–1.0385)	0.4545
Venous thromboembolism	GrimAge	4	MR Egger	1.1206 (0.3206–3.917)	0.8749
Venous thromboembolism	GrimAge	4	Weighted median	0.9681 (0.9045–1.0362)	0.3501
Venous thromboembolism	GrimAge	4	Weighted mode	0.9634 (0.879–1.0559)	0.4835
Portal vein thrombosis	GrimAge	4	Inverse variance weighted	0.9253 (0.5139–1.6661)	0.7958
Portal vein thrombosis	GrimAge	4	MR Egger	235.0712 (0.0188–2,932,589.7984)	0.3742
Portal vein thrombosis	GrimAge	4	Weighted median	1.1034 (0.683–1.7828)	0.6876
Portal vein thrombosis	GrimAge	4	Weighted mode	1.1461 (0.6524–2.0134)	0.6675
Arterial embolism and thrombosis of lower extremity artery	IEAA	24	Inverse variance weighted	1.0144 (0.9426–1.0916)	0.7027
Arterial embolism and thrombosis of lower extremity artery	IEAA	24	MR Egger	1.0593 (0.8883–1.2632)	0.5278
Arterial embolism and thrombosis of lower extremity artery	IEAA	24	Weighted median	0.98 (0.8722–1.1012)	0.7344
Arterial embolism and thrombosis of lower extremity artery	IEAA	24	Weighted mode	0.978 (0.8353–1.1452)	0.7851
Pulmonary embolism	IEAA	24	Inverse variance weighted	0.9759 (0.9488–1.0038)	0.0902
Pulmonary embolism	IEAA	24	MR Egger	0.9579 (0.8952–1.0249)	0.2253
Pulmonary embolism	IEAA	24	Weighted median	0.9682 (0.9336–1.004)	0.081
Pulmonary embolism	IEAA	24	Weighted mode	0.9701 (0.9249–1.0175)	0.2245
DVT of lower extremities	IEAA	24	Inverse variance weighted	0.963 (0.9344–0.9924)	0.0141
DVT of lower extremities	IEAA	24	MR Egger	0.9668 (0.9005–1.0379)	0.3609
DVT of lower extremities	IEAA	24	Weighted median	0.9722 (0.9304–1.016)	0.2102
DVT of lower extremities	IEAA	24	Weighted mode	0.9647 (0.9115–1.0211)	0.2277
Other arterial embolism and thrombosis	IEAA	24	Inverse variance weighted	0.9885 (0.9048–1.0801)	0.7985
Other arterial embolism and thrombosis	IEAA	24	MR Egger	1.0082 (0.8149–1.2473)	0.9409
Other arterial embolism and thrombosis	IEAA	24	Weighted median	1.0294 (0.9161–1.1567)	0.6264
Other arterial embolism and thrombosis	IEAA	24	Weighted mode	1.0266 (0.8882–1.1866)	0.7257
Phlebitis and thrombophlebitis	IEAA	24	Inverse variance weighted	1.0061 (0.9694–1.0441)	0.7489
Phlebitis and thrombophlebitis	IEAA	24	MR Egger	1.0136 (0.9265–1.1088)	0.7715
Phlebitis and thrombophlebitis	IEAA	24	Weighted median	0.9871 (0.9453–1.0308)	0.5581
Phlebitis and thrombophlebitis	IEAA	24	Weighted mode	0.9821 (0.9132–1.0561)	0.6305
Venous thromboembolism	IEAA	24	Inverse variance weighted	0.9865 (0.966–1.0074)	0.2029
Venous thromboembolism	IEAA	24	MR Egger	0.9772 (0.9291–1.0278)	0.3812
Venous thromboembolism	IEAA	24	Weighted median	0.991 (0.9659–1.0169)	0.4925
Venous thromboembolism	IEAA	24	Weighted mode	0.986 (0.9538–1.0193)	0.4143
Portal vein thrombosis	IEAA	24	Inverse variance weighted	1.0204 (0.9042–1.1515)	0.743
Portal vein thrombosis	IEAA	24	MR Egger	0.9233 (0.6929–1.2303)	0.5912
Portal vein thrombosis	IEAA	24	Weighted median	1.0723 (0.8951–1.2846)	0.449
Portal vein thrombosis	IEAA	24	Weighted mode	1.1051 (0.823–1.4839)	0.5128
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.6766 (1.0314–2.7255)	0.0371
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	8	MR Egger	1.1593 (0.1739–7.7295)	0.8836
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	8	Weighted median	1.8414 (1.0253–3.307)	0.041
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	8	Weighted mode	2.3152 (0.8674–6.1796)	0.1376
Pulmonary embolism	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.6756 (0.873–3.2162)	0.1208
Pulmonary embolism	Fibroblast growth factor 23 levels	8	MR Egger	0.9083 (0.0731–11.2882)	0.9428
Pulmonary embolism	Fibroblast growth factor 23 levels	8	Weighted median	1.1584 (0.9495–1.4131)	0.1472
Pulmonary embolism	Fibroblast growth factor 23 levels	8	Weighted mode	1.1087 (0.8718–1.4099)	0.4281
DVT of lower extremities	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.838 (0.6461–5.2292)	0.2538
DVT of lower extremities	Fibroblast growth factor 23 levels	8	MR Egger	0.9454 (0.0159–56.2531)	0.9794
DVT of lower extremities	Fibroblast growth factor 23 levels	8	Weighted median	1.051 (0.8374–1.319)	0.6679
DVT of lower extremities	Fibroblast growth factor 23 levels	8	Weighted mode	1.0404 (0.7963–1.3592)	0.7801
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.661 (1.0515–2.6237)	0.0296
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	8	MR Egger	1.5355 (0.2888–8.1645)	0.6329
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	8	Weighted median	1.535 (0.8227–2.8641)	0.1781
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	8	Weighted mode	1.0397 (0.3378–3.1997)	0.9478
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.6514 (0.6913–3.945)	0.2589
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	8	MR Egger	0.6945 (0.0241–19.9755)	0.8386
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	8	Weighted median	1.0437 (0.8467–1.2865)	0.6888
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	8	Weighted mode	1.0552 (0.8176–1.3619)	0.6919
Venous thromboembolism	Fibroblast growth factor 23 levels	8	Inverse variance weighted	1.6847 (0.7696–3.6879)	0.192
Venous thromboembolism	Fibroblast growth factor 23 levels	8	MR Egger	0.8861 (0.0423–18.5408)	0.9404
Venous thromboembolism	Fibroblast growth factor 23 levels	8	Weighted median	1.0404 (0.9027–1.1991)	0.5843
Venous thromboembolism	Fibroblast growth factor 23 levels	8	Weighted mode	1.0073 (0.8367–1.2128)	0.9406
Portal vein thrombosis	Fibroblast growth factor 23 levels	8	Inverse variance weighted	0.9412 (0.4792–1.8486)	0.8604
Portal vein thrombosis	Fibroblast growth factor 23 levels	8	MR Egger	2.6005 (0.2243–30.1527)	0.4736
Portal vein thrombosis	Fibroblast growth factor 23 levels	8	Weighted median	0.8242 (0.3372–2.0145)	0.6716
Portal vein thrombosis	Fibroblast growth factor 23 levels	8	Weighted mode	0.7664 (0.1948–3.0149)	0.7147
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	17	Inverse variance weighted	0.445 (6e-04–330.4622)	0.8103
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	17	MR Egger	20.56 (0–3,348,467,402.5206)	0.7583
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	17	Weighted median	0.0144 (0–30.5736)	0.2781
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	17	Weighted mode	5e-04 (0–13.3953)	0.1634
Pulmonary embolism	Granulocyte proportions	17	Inverse variance weighted	0.6016 (0.0992–3.6488)	0.5806
Pulmonary embolism	Granulocyte proportions	17	MR Egger	1.3205 (0.009–193.2275)	0.9144
Pulmonary embolism	Granulocyte proportions	17	Weighted median	0.6808 (0.0584–7.941)	0.759
Pulmonary embolism	Granulocyte proportions	17	Weighted mode	0.5273 (0.0114–24.402)	0.7478
DVT of lower extremities	Granulocyte proportions	17	Inverse variance weighted	1.2366 (0.124–12.3367)	0.8564
DVT of lower extremities	Granulocyte proportions	17	MR Egger	0.3527 (5e-04–243.765)	0.759
DVT of lower extremities	Granulocyte proportions	17	Weighted median	4.0782 (0.1457–114.1372)	0.4083
DVT of lower extremities	Granulocyte proportions	17	Weighted mode	18.1044 (0.0116–28,202.9539)	0.4513
Other arterial embolism and thrombosis	Granulocyte proportions	17	Inverse variance weighted	0.0084 (0–14.3396)	0.2083
Other arterial embolism and thrombosis	Granulocyte proportions	17	MR Egger	6404.8057 (0–2,728,161,929,173.31)	0.4009
Other arterial embolism and thrombosis	Granulocyte proportions	17	Weighted median	0.8313 (1e-04–6261.454)	0.9676
Other arterial embolism and thrombosis	Granulocyte proportions	17	Weighted mode	0.6123 (0–94,765.3308)	0.9369
Phlebitis and thrombophlebitis	Granulocyte proportions	17	Inverse variance weighted	0.4733 (0.0462–4.8464)	0.5285
Phlebitis and thrombophlebitis	Granulocyte proportions	17	MR Egger	79.5555 (0.1914–33,072.3351)	0.1753
Phlebitis and thrombophlebitis	Granulocyte proportions	17	Weighted median	0.2253 (0.0144–3.5196)	0.2879
Phlebitis and thrombophlebitis	Granulocyte proportions	17	Weighted mode	0.2386 (0.0047–12.0739)	0.4845
Venous thromboembolism	Granulocyte proportions	17	Inverse variance weighted	0.6193 (0.1459–2.628)	0.5158
Venous thromboembolism	Granulocyte proportions	17	MR Egger	1.6196 (0.027–97.3142)	0.8206
Venous thromboembolism	Granulocyte proportions	17	Weighted median	0.987 (0.1371–7.1068)	0.9897
Venous thromboembolism	Granulocyte proportions	17	Weighted mode	3.4619 (0.0538–222.7793)	0.5671
Portal vein thrombosis	Granulocyte proportions	17	Inverse variance weighted	0.9453 (0–189,361.1019)	0.9928
Portal vein thrombosis	Granulocyte proportions	17	MR Egger	144,137,284.7907 (0–4.55585213355333e + 22)	0.2875
Portal vein thrombosis	Granulocyte proportions	17	Weighted median	1.8643 (0–4,086,034.95)	0.9334
Portal vein thrombosis	Granulocyte proportions	17	Weighted mode	16.8321 (0–67,786,189,361,647,096)	0.8795
Arterial embolism and thrombosis of lower extremity artery	Telomere length	130	Inverse variance weighted	1.155 (0.795–1.6781)	0.4496
Arterial embolism and thrombosis of lower extremity artery	Telomere length	130	MR Egger	0.9434 (0.4874–1.8261)	0.8631
Arterial embolism and thrombosis of lower extremity artery	Telomere length	130	Weighted median	1.1652 (0.6754–2.0102)	0.5827
Arterial embolism and thrombosis of lower extremity artery	Telomere length	130	Weighted mode	1.1461 (0.6302–2.0844)	0.6558
Pulmonary embolism	Telomere length	130	Inverse variance weighted	0.924 (0.8055–1.06)	0.2592
Pulmonary embolism	Telomere length	130	MR Egger	0.9166 (0.7188–1.1688)	0.4837
Pulmonary embolism	Telomere length	130	Weighted median	1.0155 (0.8218–1.255)	0.8864
Pulmonary embolism	Telomere length	130	Weighted mode	1.0736 (0.8581–1.3432)	0.5354
DVT of lower extremities	Telomere length	130	Inverse variance weighted	0.9092 (0.7871–1.0501)	0.1953
DVT of lower extremities	Telomere length	130	MR Egger	0.8291 (0.6428–1.0694)	0.1514
DVT of lower extremities	Telomere length	130	Weighted median	0.9131 (0.7318–1.1394)	0.4211
DVT of lower extremities	Telomere length	130	Weighted mode	0.8892 (0.6934–1.1403)	0.3565
Other arterial embolism and thrombosis	Telomere length	130	Inverse variance weighted	0.948 (0.6324–1.4211)	0.7959
Other arterial embolism and thrombosis	Telomere length	130	MR Egger	0.8661 (0.4229–1.7736)	0.6948
Other arterial embolism and thrombosis	Telomere length	130	Weighted median	0.9232 (0.4879–1.7466)	0.8058
Other arterial embolism and thrombosis	Telomere length	130	Weighted mode	0.8868 (0.4321–1.8201)	0.7438
Phlebitis and thrombophlebitis	Telomere length	130	Inverse variance weighted	1.1297 (0.9856–1.2949)	0.0798
Phlebitis and thrombophlebitis	Telomere length	130	MR Egger	1.0097 (0.794–1.2839)	0.9376
Phlebitis and thrombophlebitis	Telomere length	130	Weighted median	1.1047 (0.8867–1.3763)	0.3746
Phlebitis and thrombophlebitis	Telomere length	130	Weighted mode	1.0662 (0.8058–1.4107)	0.6546
Venous thromboembolism	Telomere length	130	Inverse variance weighted	0.9487 (0.8523–1.0561)	0.3359
Venous thromboembolism	Telomere length	130	MR Egger	0.9388 (0.7766–1.1349)	0.5155
Venous thromboembolism	Telomere length	130	Weighted median	0.8973 (0.7847–1.0261)	0.1134
Venous thromboembolism	Telomere length	130	Weighted mode	0.8787 (0.74–1.0433)	0.1423
Portal vein thrombosis	Telomere length	130	Inverse variance weighted	1.279 (0.7408–2.2082)	0.3771
Portal vein thrombosis	Telomere length	130	MR Egger	1.4762 (0.5635–3.8674)	0.4294
Portal vein thrombosis	Telomere length	130	Weighted median	1.2242 (0.5061–2.961)	0.6535
Portal vein thrombosis	Telomere length	130	Weighted mode	0.9886 (0.3491–2.7995)	0.9828

Table 2.

Heterogeneity and pleiotropy for each exposure factor on thromboembolism

Outcome	Exposure	Heterogeneity		Pleiotropy
		Q statistic (IVW)	P value	MR Egger Intercept	P value
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	12.791	0.012	− 0.003	0.981
DVT of lower extremities	Circulating plasma alpha-Klotho levels	62.882	0	− 0.137	0.179
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	2.39	0.665	0	0.996
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	42.713	0	− 0.117	0.105
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	4.109	0.392	− 0.083	0.488
Pulmonary embolism	Circulating plasma alpha-Klotho levels	27.934	0	− 0.064	0.27
Venous thromboembolism	Circulating plasma alpha-Klotho levels	84.111	0	− 0.086	0.208
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	9.812	0.199	0.032	0.706
DVT of lower extremities	Fibroblast growth factor 23 levels	270.753	0	0.057	0.751
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	5.353	0.617	0.007	0.927
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	221.154	0	0.074	0.618
Portal vein thrombosis	Fibroblast growth factor 23 levels	6.077	0.531	− 0.087	0.43
Pulmonary embolism	Fibroblast growth factor 23 levels	160.509	0	0.053	0.638
Venous thromboembolism	Fibroblast growth factor 23 levels	467.86	0	0.055	0.682
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	23.46	0.102	− 0.021	0.676
DVT of lower extremities	Granulocyte proportions	17.037	0.383	0.007	0.692
Other arterial embolism and thrombosis	Granulocyte proportions	24.411	0.081	− 0.076	0.172
Phlebitis and thrombophlebitis	Granulocyte proportions	20.557	0.196	− 0.029	0.094
Portal vein thrombosis	Granulocyte proportions	29.996	0.018	− 0.105	0.254
Pulmonary embolism	Granulocyte proportions	10.628	0.832	− 0.004	0.745
Venous thromboembolism	Granulocyte proportions	20.761	0.188	− 0.005	0.629
Arterial embolism and thrombosis of lower extremity artery	GrimAge	3.764	0.288	− 0.512	0.301
DVT of lower extremities	GrimAge	5.394	0.145	0.028	0.922
Other arterial embolism and thrombosis	GrimAge	0.808	0.848	0.065	0.889
Phlebitis and thrombophlebitis	GrimAge	5.399	0.145	0.188	0.42
portal vein thrombosis	GrimAge	7.183	0.066	− 1.03	0.368
Pulmonary embolism	GrimAge	0.82	0.845	− 0.051	0.718
Venous thromboembolism	GrimAge	3.85	0.278	− 0.026	0.85
Arterial embolism and thrombosis of lower extremity artery	HannumAge	6.343	0.609	0.055	0.454
DVT of lower extremities	HannumAge	2.047	0.98	− 0.007	0.819
Other arterial embolism and thrombosis	HannumAge	6.71	0.568	− 0.014	0.858
Phlebitis and thrombophlebitis	HannumAge	9.683	0.288	− 0.042	0.157
portal vein thrombosis	HannumAge	4.321	0.827	0.009	0.942
Pulmonary embolism	HannumAge	6.844	0.554	0.04	0.128
Venous thromboembolism	HannumAge	2.248	0.972	0.008	0.658
Arterial embolism and thrombosis of lower extremity artery	IEAA	22.951	0.464	− 0.014	0.6
DVT of lower extremities	IEAA	16.678	0.825	− 0.001	0.906
Other arterial embolism and thrombosis	IEAA	27.255	0.245	− 0.006	0.843
Phlebitis and thrombophlebitis	IEAA	41.12	0.011	− 0.002	0.86
portal vein thrombosis	IEAA	22.665	0.48	0.031	0.459
Pulmonary embolism	IEAA	30.899	0.125	0.006	0.557
Venous thromboembolism	IEAA	34.529	0.058	0.003	0.691
Arterial embolism and thrombosis of lower extremity artery	PAI1	5.515	0.238	0.24	0.351
DVT of lower extremities	PAI1	2.157	0.707	0.004	0.96
Other arterial embolism and thrombosis	PAI1	3.731	0.444	0.296	0.256
Phlebitis and thrombophlebitis	PAI1	6.954	0.138	0.131	0.202
Portal vein thrombosis	PAI1	4.28	0.369	0.049	0.904
Pulmonary embolism	PAI1	2.432	0.657	− 0.086	0.27
Venous thromboembolism	PAI1	0.176	0.996	− 0.012	0.812
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	20.1	0.028	0.061	0.441
DVT of lower extremities	PhenoAge	6.61	0.762	0.014	0.537
Other arterial embolism and thrombosis	PhenoAge	10.764	0.376	− 0.054	0.403
Phlebitis and thrombophlebitis	PhenoAge	7.619	0.666	0.018	0.4
Portal vein thrombosis	PhenoAge	16.774	0.08	0.059	0.627
Pulmonary embolism	PhenoAge	10.925	0.363	0.004	0.83
Venous thromboembolism	PhenoAge	7.614	0.667	0.009	0.489
Arterial embolism and thrombosis of lower extremity artery	Telomere length	163.435	0.022	0.007	0.467
DVT of lower extremities	Telomere length	144.202	0.17	0.003	0.391
Other arterial embolism and thrombosis	Telomere length	155.466	0.056	0.003	0.765
Phlebitis and thrombophlebitis	Telomere length	152.703	0.076	0.004	0.268
Portal vein thrombosis	Telomere length	101.641	0.964	− 0.005	0.724
Pulmonary embolism	Telomere length	200.123	0	0	0.937
Venous thromboembolism	Telomere length	246.465	0	0	0.896

Table 3.

MR-PRESSO results of the MR analysis

Outcome	Exposure	Raw		Outlier corrected		Global p	outliers	Distortion p
		OR_CI	P	OR_CI	P
Arterial embolism and thrombosis of lower extremity artery	Circulating plasma alpha-Klotho levels	1.1493 (0.8205–1.6099)	0.4636	NA (NA–NA)	NA	0.075	NA	NA
Arterial embolism and thrombosis of lower extremity artery	Fibroblast growth factor 23 levels	1.6766 (1.0314–2.7255)	0.0756	NA (NA–NA)	NA	0.251	NA	NA
Arterial embolism and thrombosis of lower extremity artery	Granulocyte proportions	0.441 (8e-04–232.0941)	0.8009	NA (NA–NA)	NA	0.142	NA	NA
Arterial embolism and thrombosis of lower extremity artery	GrimAge	1.1536 (0.8906–1.4943)	0.3582	NA (NA–NA)	NA	0.354	NA	NA
Arterial embolism and thrombosis of lower extremity artery	HannumAge	1.0563 (0.9306–1.1989)	0.4215	NA (NA–NA)	NA	0.639	NA	NA
Arterial embolism and thrombosis of lower extremity artery	IEAA	1.0144 (0.9427–1.0915)	0.7059	NA (NA–NA)	NA	0.466	NA	NA
Arterial embolism and thrombosis of lower extremity artery	PAI1	1.0001 (0.9998–1.0004)	0.5703	NA (NA–NA)	NA	0.334	NA	NA
Arterial embolism and thrombosis of lower extremity artery	PhenoAge	1.028 (0.9004–1.1737)	0.6912	1.0798 (0.9684–1.2041)	0.2005	0.034	1	0.56
Arterial embolism and thrombosis of lower extremity artery	Telomere length	1.1093 (0.7665–1.6054)	0.5831	NA (NA–NA)	NA	0.022	NA	NA
DVT of lower extremities	Circulating plasma alpha-Klotho levels	1.2193 (0.8978–1.6558)	0.2731	0.9674 (0.8727–1.0724)	0.6422	< 0.001	3	< 0.001
DVT of lower extremities	Fibroblast growth factor 23 levels	1.838 (0.6461–5.2292)	0.2914	1.1056 (0.9653–1.2663)	0.2429	< 0.001	4	< 0.001
DVT of lower extremities	Granulocyte proportions	0.8852 (0.0887–8.8367)	0.9185	NA (NA–NA)	NA	0.259	NA	NA
DVT of lower extremities	GrimAge	1.0336 (0.9102–1.1737)	0.6458	NA (NA–NA)	NA	0.226	NA	NA
DVT of lower extremities	HannumAge	0.9857 (0.957–1.0152)	0.3661	NA (NA–NA)	NA	0.975	NA	NA
DVT of lower extremities	IEAA	0.963 (0.9386–0.988)	0.0084	NA (NA–NA)	NA	0.829	NA	NA
DVT of lower extremities	PAI1	1 (0.9999–1)	0.4038	NA (NA–NA)	NA	0.754	NA	NA
DVT of lower extremities	PhenoAge	1.0322 (1.0002–1.0651)	0.0765	NA (NA–NA)	NA	0.76	NA	NA
DVT of lower extremities	Telomere length	0.9147 (0.7941–1.0537)	0.219	NA (NA–NA)	NA	0.197	NA	NA
Other arterial embolism and thrombosis	Circulating plasma alpha-Klotho levels	0.9483 (0.8036–1.119)	0.5635	NA (NA–NA)	NA	0.733	NA	NA
Other arterial embolism and thrombosis	Fibroblast growth factor 23 levels	1.661 (1.1137–2.4774)	0.0417	NA (NA–NA)	NA	0.573	NA	NA
Other arterial embolism and thrombosis	Granulocyte proportions	0.0132 (0–16.2968)	0.2497	NA (NA–NA)	NA	0.105	NA	NA
Other arterial embolism and thrombosis	GrimAge	0.9157 (0.8015–1.046)	0.2852	NA (NA–NA)	NA	0.849	NA	NA
Other arterial embolism and thrombosis	HannumAge	1.0611 (0.9181–1.2265)	0.4451	NA (NA–NA)	NA	0.607	NA	NA
Other arterial embolism and thrombosis	IEAA	0.9885 (0.9048–1.0801)	0.8008	NA (NA–NA)	NA	0.279	NA	NA
Other arterial embolism and thrombosis	PAI1	1.0003 (1–1.0005)	0.0871	NA (NA–NA)	NA	0.492	NA	NA
Other arterial embolism and thrombosis	PhenoAge	1.0622 (0.9532–1.1837)	0.3006	NA (NA–NA)	NA	0.358	NA	NA
Other arterial embolism and thrombosis	telomere length	0.9246 (0.6187–1.3817)	0.7025	NA (NA–NA)	NA	0.053	NA	NA
Phlebitis and thrombophlebitis	Circulating plasma alpha-Klotho levels	1.1942 (0.9454–1.5084)	0.2108	1.0406 (0.8516–1.2715)	0.7639	0.002	3	1
Phlebitis and thrombophlebitis	Fibroblast growth factor 23 levels	1.6514 (0.6913–3.945)	0.2961	1.0933 (0.9438–1.2664)	0.3001	< 0.001	3	< 0.001
Phlebitis and thrombophlebitis	Granulocyte proportions	0.3401 (0.0334–3.4668)	0.3753	NA (NA–NA)	NA	0.196	NA	NA
Phlebitis and thrombophlebitis	GrimAge	0.9427 (0.8385–1.0598)	0.3958	NA (NA–NA)	NA	0.227	NA	NA
Phlebitis and thrombophlebitis	HannumAge	1.0106 (0.9525–1.0721)	0.7363	NA (NA–NA)	NA	0.356	NA	NA
Phlebitis and thrombophlebitis	IEAA	1.0061 (0.9694–1.0441)	0.7517	NA (NA–NA)	NA	0.007	NA	NA
Phlebitis and thrombophlebitis	PAI1	0.9999 (0.9998–1.0001)	0.3776	NA (NA–NA)	NA	0.25	NA	NA
Phlebitis and thrombophlebitis	PhenoAge	0.9955 (0.9651–1.027)	0.7836	NA (NA–NA)	NA	0.689	NA	NA
Phlebitis and thrombophlebitis	Telomere length	1.1098 (0.9665–1.2742)	0.1421	1.1228 (0.982–1.2839)	0.0927	0.033	1	0.895
Portal vein thrombosis	Circulating plasma alpha-Klotho levels	0.8749 (0.6344–1.2067)	0.4611	NA (NA–NA)	NA	0.39	NA	NA
Portal vein thrombosis	Fibroblast growth factor 23 levels	0.9412 (0.5018–1.7654)	0.8557	NA (NA–NA)	NA	0.542	NA	NA
Portal vein thrombosis	Granulocyte proportions	0.3368 (0–44,735.1727)	0.8586	NA (NA–NA)	NA	0.016	NA	NA
Portal vein thrombosis	GrimAge	0.9253 (0.5139–1.6661)	0.8125	NA (NA–NA)	NA	0.132	NA	NA
Portal vein thrombosis	HannumAge	1.1249 (0.9476–1.3354)	0.2154	NA (NA–NA)	NA	0.86	NA	NA
Portal vein thrombosis	IEAA	1.0204 (0.905–1.1505)	0.7442	NA (NA–NA)	NA	0.46	NA	NA
Portal vein thrombosis	PAI1	1.0002 (0.9998–1.0006)	0.3855	NA (NA–NA)	NA	0.435	NA	NA
Portal vein thrombosis	PhenoAge	0.9804 (0.8018–1.1987)	0.8509	NA (NA–NA)	NA	0.098	NA	NA
Portal vein thrombosis	Telomere length	1.2326 (0.7546–2.0134)	0.4049	NA (NA–NA)	NA	0.932	NA	NA
Pulmonary embolism	Circulating plasma alpha-Klotho levels	1.1426 (0.9671–1.35)	0.1923	1.0012 (0.9636–1.0403)	0.9559	0.014	2	< 0.001
Pulmonary embolism	Fibroblast growth factor 23 levels	1.6756 (0.873–3.2162)	0.1647	1.2381 (1.1013–1.392)	0.016	< 0.001	2	< 0.001
Pulmonary embolism	Granulocyte proportions	0.588 (0.1459–2.3696)	0.4654	NA (NA–NA)	NA	0.849	NA	NA
Pulmonary embolism	GrimAge	0.9538 (0.9163–0.9928)	0.1038	NA (NA–NA)	NA	0.86	NA	NA
Pulmonary embolism	HannumAge	1.0257 (0.9818–1.0715)	0.2883	NA (NA–NA)	NA	0.57	NA	NA
Pulmonary embolism	IEAA	0.9759 (0.9488–1.0038)	0.1037	NA (NA–NA)	NA	0.134	NA	NA
Pulmonary embolism	PAI1	1 (0.9999–1)	0.1978	NA (NA–NA)	NA	0.644	NA	NA
Pulmonary embolism	PhenoAge	1.0019 (0.9697–1.0352)	0.9116	NA (NA–NA)	NA	0.399	NA	NA
Pulmonary embolism	Telomere length	0.9247 (0.8079–1.0583)	0.2577	0.9198 (0.8085–1.0463)	0.2058	< 0.001	2	0.952
Venous thromboembolism	Circulating plasma alpha-Klotho levels	1.1657 (0.9512–1.4286)	0.2134	0.9661 (NaN–NaN)	NA	< 0.001	4	< 0.001
Venous thromboembolism	Fibroblast growth factor 23 levels	1.6847 (0.7696–3.6879)	0.2332	1.2722 (1.2147–1.3325)	0.0095	< 0.001	5	1
Venous thromboembolism	Granulocyte proportions	0.5238 (0.1268–2.1643)	0.3842	NA (NA–NA)	NA	0.144	NA	NA
Venous thromboembolism	GrimAge	0.9769 (0.919–1.0385)	0.5088	NA (NA–NA)	NA	0.397	NA	NA
Venous thromboembolism	HannumAge	1.0091 (0.9915–1.0271)	0.3417	NA (NA–NA)	NA	0.969	NA	NA
Venous thromboembolism	IEAA	0.9865 (0.966–1.0074)	0.2156	NA (NA–NA)	NA	0.063	NA	NA
Venous thromboembolism	PAI1	1 (1–1)	0.0091	NA (NA–NA)	NA	0.994	NA	NA
Venous thromboembolism	PhenoAge	1.0106 (0.9914–1.0302)	0.3066	NA (NA–NA)	NA	0.67	NA	NA
Venous thromboembolism	Telomere length	0.9443 (0.8494–1.0498)	0.2909	0.9419 (0.8524–1.0408)	0.2423	< 0.001	2	0.968

Fig. 2.

MR analyses of the causal relationships between epigenetic aging factors and thromboembolism. Scatter plots of causal association between A PAI1 and other arterial embolism and thrombosis; B IEAA and DVT of lower extremities; C FGF23 and arterial embolism and thrombosis of lower extremity artery; D FGF23 and other arterial embolism and thrombosis. The slopes depicted the causal associations, with each line representing a different methodology

Fig. 3.

Forest plots for MR analyses of the causal relationships between epigenetic aging factors and thromboembolism. The causal effect of A PAI1 on other arterial embolism and thrombosis; B IEAA on DVT of lower extremities; C FGF23 on arterial embolism and thrombosis of lower extremity artery; D FGF23 on other arterial embolism and thrombosis. The MR estimate derived from the MR Egger and IVW methods was shown for comparison

Screening of IVs associated with thromboembolism

We extracted SNPs from GWAS summary statistics of each thromboembolism subtype. In total, we acquired 92 IVs associated with the exposure, with 33 for VTE, 16 for PE, 4 for PVT, 11 for thrombophlebitis, 13 for DVT of lower extremities, nine for arterial embolism and thrombosis of lower extremity artery and six for other arterial embolism and thrombosis, which all showed an F-statistics > 10 (Supplemental Table 2). Some SNPs missing in the outcome data were replaced with suitable proxy SNPs, as detailed in Supplemental Table 3.

Causal effects of thromboembolism on epigenetic aging factors

To assess any reverse causality between genetically determined levels of epigenetic aging factors and thromboembolism, we considered each thromboembolism subtype as the exposure and epigenetic aging factors as the outcome. In the context of PVT, the causal association with PhenoAge (IVW: OR 0.871, 95% CI 0.765–0.992, P = 0.037) was identified, suggesting that PVT might decelerate epigenetic aging (Table 4). In addition, VTE was found to be causally associated with GrimAge (IVW: OR 1.186, 95% CI 1.048–1.341, P = 0.007), indicating VTE as a potential contributor to epigenetic aging (Table 4). Sensitivity analysis identified no heterogeneity and pleiotropy among these associations (Table 5). Additionally, MR-PRESSO revealed outliers among associations between DVT of lower extremities and FGF23, HannumAge, IEAA and telomere length, and between other arterial embolism and thrombosis and telomere length, between thrombophlebitis and FGF23 and HannumAge, between PE and FGF23, and between VTE and FGF23 and telomere length (Table 6). Finally, the robustness of our findings was confirmed and visualized via leave-one-out analysis plots and funnel plots (Supplemental Figs. 3A, B, 4A, B).

Table 4.

Causal estimates of thromboembolism on epigenetic aging factors

Outcome	Exposure	N.SNP	Methods	OR_CI
PAI1	Pulmonary embolism	14	Inverse variance weighted	1.2662 (0.9027–1.7762)
PAI1	Pulmonary embolism	14	MR Egger	0.4456 (0.1887–1.0524)
PAI1	Pulmonary embolism	14	Weighted median	0.9775 (0.6505–1.4689)
PAI1	Pulmonary embolism	14	Weighted mode	1.0126 (0.4517–2.2704)
HannumAge	Pulmonary embolism	12	Inverse variance weighted	0.945 (0.7931–1.1259)
HannumAge	Pulmonary embolism	12	MR Egger	0.9222 (0.5792–1.4683)
HannumAge	Pulmonary embolism	12	Weighted median	0.838 (0.6793–1.0338)
HannumAge	Pulmonary embolism	12	Weighted mode	0.8368 (0.6184–1.1324)
GrimAge	Pulmonary embolism	14	Inverse variance weighted	1.0548 (0.9294–1.1972)
GrimAge	Pulmonary embolism	14	MR Egger	0.9213 (0.6706–1.2658)
GrimAge	Pulmonary embolism	14	Weighted median	1.063 (0.8954–1.2621)
GrimAge	Pulmonary embolism	14	Weighted mode	1.0874 (0.9029–1.3097)
IEAA	Pulmonary embolism	14	Inverse variance weighted	0.9058 (0.7861–1.0437)
IEAA	Pulmonary embolism	14	MR Egger	1.1736 (0.8391–1.6416)
IEAA	Pulmonary embolism	14	Weighted median	0.9451 (0.7856–1.1368)
IEAA	Pulmonary embolism	14	Weighted mode	0.9941 (0.8158–1.2112)
Telomere length	Pulmonary embolism	15	Inverse variance weighted	1.006 (0.9959–1.0161)
Telomere length	Pulmonary embolism	15	MR Egger	0.9986 (0.9717–1.0261)
Telomere length	Pulmonary embolism	15	Weighted median	1.0012 (0.9897–1.0129)
Telomere length	Pulmonary embolism	15	Weighted mode	1.0033 (0.9907–1.016)
Circulating plasma alpha-Klotho levels	Pulmonary embolism	13	Inverse variance weighted	1.079 (0.9822–1.1853)
Circulating plasma alpha-Klotho levels	Pulmonary embolism	13	MR Egger	0.9952 (0.7956–1.2449)
Circulating plasma alpha-Klotho levels	Pulmonary embolism	13	Weighted median	1.0588 (0.9426–1.1894)
Circulating plasma alpha-Klotho levels	Pulmonary embolism	13	Weighted mode	1.0871 (0.9358–1.2628)
PhenoAge	Pulmonary embolism	14	Inverse variance weighted	0.9269 (0.7903–1.087)
PhenoAge	Pulmonary embolism	14	MR Egger	0.9201 (0.6072–1.3941)
PhenoAge	Pulmonary embolism	14	Weighted median	1.0189 (0.8226–1.2621)
PhenoAge	Pulmonary embolism	14	Weighted mode	1.0534 (0.8389–1.3227)
Granulocyte proportions	Pulmonary embolism	12	Inverse variance weighted	1.0025 (0.9993–1.0057)
Granulocyte proportions	Pulmonary embolism	12	MR Egger	0.9969 (0.9889–1.0049)
Granulocyte proportions	Pulmonary embolism	12	Weighted median	1.0015 (0.9971–1.006)
Granulocyte proportions	Pulmonary embolism	12	Weighted mode	1.001 (0.9966–1.0055)
Fibroblast growth factor 23 levels	Pulmonary embolism	16	Inverse variance weighted	1.0353 (0.9614–1.115)
Fibroblast growth factor 23 levels	Pulmonary embolism	16	MR Egger	1.0516 (0.8788–1.2582)
Fibroblast growth factor 23 levels	Pulmonary embolism	16	Weighted median	1.0013 (0.9387–1.0681)
Fibroblast growth factor 23 levels	Pulmonary embolism	16	Weighted mode	0.9848 (0.9236–1.0501)
PAI1	DVT of lower extremities	13	Inverse variance weighted	1.1308 (0.7927–1.6131)
PAI1	DVT of lower extremities	13	MR Egger	1.9279 (0.6671–5.5718)
PAI1	DVT of lower extremities	13	Weighted median	1.0735 (0.7465–1.5437)
PAI1	DVT of lower extremities	13	Weighted mode	0.7285 (0.3659–1.4505)
HannumAge	DVT of lower extremities	11	Inverse variance weighted	0.928 (0.7738–1.1128)
HannumAge	DVT of lower extremities	11	MR Egger	0.7619 (0.5517–1.0522)
HannumAge	DVT of lower extremities	11	Weighted median	0.8212 (0.6966–0.9682)
HannumAge	DVT of lower extremities	11	Weighted mode	0.8044 (0.6757–0.9575)
GrimAge	DVT of lower extremities	13	Inverse variance weighted	1.0275 (0.9194–1.1482)
GrimAge	DVT of lower extremities	13	MR Egger	0.8591 (0.7053–1.0465)
GrimAge	DVT of lower extremities	13	Weighted median	1.0638 (0.9234–1.2255)
GrimAge	DVT of lower extremities	13	Weighted mode	1.1101 (0.8915–1.3822)
IEAA	DVT of lower extremities	13	Inverse variance weighted	0.9658 (0.8312–1.1221)
IEAA	DVT of lower extremities	13	MR Egger	0.9656 (0.7093–1.3147)
IEAA	DVT of lower extremities	13	Weighted median	0.9591 (0.8231–1.1175)
IEAA	DVT of lower extremities	13	Weighted mode	0.973 (0.8075–1.1725)
Telomere length	DVT of lower extremities	13	Inverse variance weighted	1.0059 (0.9965–1.0154)
Telomere length	DVT of lower extremities	13	MR Egger	1.0021 (0.9848–1.0197)
Telomere length	DVT of lower extremities	13	Weighted median	1.0039 (0.9954–1.0124)
Telomere length	DVT of lower extremities	13	Weighted mode	1.0019 (0.9931–1.0107)
Circulating plasma alpha-Klotho levels	DVT of lower extremities	12	Inverse variance weighted	1.0393 (0.9754–1.1074)
Circulating plasma alpha-Klotho levels	DVT of lower extremities	12	MR Egger	0.965 (0.8631–1.0788)
Circulating plasma alpha-Klotho levels	DVT of lower extremities	12	Weighted median	1.0235 (0.9345–1.121)
Circulating plasma alpha-Klotho levels	DVT of lower extremities	12	Weighted mode	1.0089 (0.917–1.11)
PhenoAge	DVT of lower extremities	13	Inverse variance weighted	0.9509 (0.8331–1.0854)
PhenoAge	DVT of lower extremities	13	MR Egger	0.8203 (0.6309–1.0666)
PhenoAge	DVT of lower extremities	13	Weighted median	1.0542 (0.8843–1.2569)
PhenoAge	DVT of lower extremities	13	Weighted mode	1.0822 (0.8468–1.3829)
Granulocyte proportions	DVT of lower extremities	11	Inverse variance weighted	1.0007 (0.9982–1.0033)
Granulocyte proportions	DVT of lower extremities	11	MR Egger	1.001 (0.9964–1.0057)
Granulocyte proportions	DVT of lower extremities	11	Weighted median	1.0005 (0.997–1.0039)
Granulocyte proportions	DVT of lower extremities	11	Weighted mode	1.0004 (0.9968–1.0041)
Fibroblast growth factor 23 levels	DVT of lower extremities	13	Inverse variance weighted	1.0283 (0.9748–1.0846)
Fibroblast growth factor 23 levels	DVT of lower extremities	13	MR Egger	1.0413 (0.9488–1.1427)
Fibroblast growth factor 23 levels	DVT of lower extremities	13	Weighted median	1.0085 (0.9657–1.0531)
Fibroblast growth factor 23 levels	DVT of lower extremities	13	Weighted mode	1.0087 (0.9605–1.0594)
PAI1	Venous thromboembolism	30	Inverse variance weighted	1.1239 (0.7846–1.6098)
PAI1	Venous thromboembolism	30	MR Egger	1.7942 (0.8482–3.7951)
PAI1	Venous thromboembolism	30	Weighted median	1.2186 (0.7813–1.9009)
PAI1	Venous thromboembolism	30	Weighted mode	0.6605 (0.1353–3.2241)
HannumAge	Venous thromboembolism	29	Inverse variance weighted	0.9202 (0.7757–1.0917)
HannumAge	Venous thromboembolism	29	MR Egger	0.7747 (0.5669–1.0586)
HannumAge	Venous thromboembolism	29	Weighted median	0.7982 (0.6528–0.976)
HannumAge	Venous thromboembolism	29	Weighted mode	0.7674 (0.6186–0.9522)
GrimAge	Venous thromboembolism	29	Inverse variance weighted	1.1856 (1.0481–1.341)
GrimAge	Venous thromboembolism	29	MR Egger	1.0919 (0.8443–1.412)
GrimAge	Venous thromboembolism	29	Weighted median	1.1158 (0.9444–1.3182)
GrimAge	Venous thromboembolism	29	Weighted mode	1.1282 (0.9372–1.358)
IEAA	Venous thromboembolism	30	Inverse variance weighted	1.001 (0.8822–1.1358)
IEAA	Venous thromboembolism	30	MR Egger	0.9191 (0.7323–1.1536)
IEAA	Venous thromboembolism	30	Weighted median	0.9778 (0.8189–1.1676)
IEAA	Venous thromboembolism	30	Weighted mode	0.9564 (0.7841–1.1666)
Telomere length	Venous thromboembolism	30	Inverse variance weighted	1.0054 (0.9963–1.0147)
Telomere length	Venous thromboembolism	30	MR Egger	1.0088 (0.993–1.0248)
Telomere length	Venous thromboembolism	30	Weighted median	1.003 (0.9924–1.0138)
Telomere length	Venous thromboembolism	30	Weighted mode	1.0012 (0.9906–1.0119)
Circulating plasma alpha-Klotho levels	Venous thromboembolism	29	Inverse variance weighted	1.0624 (0.9725–1.1607)
Circulating plasma alpha-Klotho levels	Venous thromboembolism	29	MR Egger	1.0102 (0.8688–1.1747)
Circulating plasma alpha-Klotho levels	Venous thromboembolism	29	Weighted median	1.0414 (0.9278–1.1688)
Circulating plasma alpha-Klotho levels	Venous thromboembolism	29	Weighted mode	1.0281 (0.9219–1.1465)
PhenoAge	Venous thromboembolism	30	Inverse variance weighted	1.0485 (0.9039–1.2163)
PhenoAge	Venous thromboembolism	30	MR Egger	0.7565 (0.5812–0.9845)
PhenoAge	Venous thromboembolism	30	Weighted median	1.0683 (0.8572–1.3313)
PhenoAge	Venous thromboembolism	30	Weighted mode	1.0723 (0.8193–1.4034)
Granulocyte proportions	Venous thromboembolism	29	Inverse variance weighted	1.0008 (0.9974–1.0042)
Granulocyte proportions	Venous thromboembolism	29	MR Egger	1.0035 (0.9974–1.0097)
Granulocyte proportions	Venous thromboembolism	29	Weighted median	1.0009 (0.9969–1.0048)
Granulocyte proportions	Venous thromboembolism	29	Weighted mode	1.001 (0.9969–1.005)
Fibroblast growth factor 23 levels	Venous thromboembolism	33	Inverse variance weighted	1.02 (0.974–1.0681)
Fibroblast growth factor 23 levels	Venous thromboembolism	33	MR Egger	1.0561 (0.98–1.138)
Fibroblast growth factor 23 levels	Venous thromboembolism	33	Weighted median	1.0067 (0.9474–1.0699)
Fibroblast growth factor 23 levels	Venous thromboembolism	33	Weighted mode	1.005 (0.9455–1.0682)
PAI1	Phlebitis and thrombophlebitis	10	Inverse variance weighted	1.0973 (0.6707–1.7953)
PAI1	Phlebitis and thrombophlebitis	10	MR Egger	2.7286 (0.6518–11.4216)
PAI1	Phlebitis and thrombophlebitis	10	Weighted median	1.3096 (0.8129–2.1099)
PAI1	Phlebitis and thrombophlebitis	10	Weighted mode	0.9355 (0.4452–1.9658)
HannumAge	Phlebitis and thrombophlebitis	8	Inverse variance weighted	0.8979 (0.6818–1.1825)
HannumAge	Phlebitis and thrombophlebitis	8	MR Egger	0.7348 (0.4687–1.1518)
HannumAge	Phlebitis and thrombophlebitis	8	Weighted median	0.8444 (0.6767–1.0537)
HannumAge	Phlebitis and thrombophlebitis	8	Weighted mode	0.7453 (0.5885–0.944)
GrimAge	Phlebitis and thrombophlebitis	10	Inverse variance weighted	0.9713 (0.82–1.1506)
GrimAge	Phlebitis and thrombophlebitis	10	MR Egger	0.9384 (0.6749–1.3046)
GrimAge	Phlebitis and thrombophlebitis	10	Weighted median	1.0739 (0.8812–1.3088)
GrimAge	Phlebitis and thrombophlebitis	10	Weighted mode	1.1268 (0.8394–1.5126)
IEAA	Phlebitis and thrombophlebitis	10	Inverse variance weighted	0.9937 (0.8038–1.2285)
IEAA	Phlebitis and thrombophlebitis	10	MR Egger	0.8626 (0.5809–1.2809)
IEAA	Phlebitis and thrombophlebitis	10	Weighted median	1.0126 (0.8246–1.2435)
IEAA	Phlebitis and thrombophlebitis	10	Weighted mode	0.988 (0.792–1.2326)
Telomere length	Phlebitis and thrombophlebitis	10	Inverse variance weighted	1.0082 (0.9985–1.018)
Telomere length	Phlebitis and thrombophlebitis	10	MR Egger	1.001 (0.985–1.0173)
Telomere length	Phlebitis and thrombophlebitis	10	Weighted median	1.0052 (0.9945–1.016)
Telomere length	Phlebitis and thrombophlebitis	10	Weighted mode	1.0037 (0.9919–1.0157)
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	9	Inverse variance weighted	1.0013 (0.9247–1.0842)
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	9	MR Egger	0.9735 (0.8543–1.1094)
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	9	Weighted median	1.0059 (0.9081–1.1143)
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	9	Weighted mode	0.9932 (0.8875–1.1114)
PhenoAge	Phlebitis and thrombophlebitis	10	Inverse variance weighted	0.9202 (0.7718–1.097)
PhenoAge	Phlebitis and thrombophlebitis	10	MR Egger	0.7899 (0.5678–1.0988)
PhenoAge	Phlebitis and thrombophlebitis	10	Weighted median	1.0734 (0.8592–1.341)
PhenoAge	Phlebitis and thrombophlebitis	10	Weighted mode	1.0918 (0.7821–1.5243)
Granulocyte proportions	Phlebitis and thrombophlebitis	8	Inverse variance weighted	0.9989 (0.9956–1.0023)
Granulocyte proportions	Phlebitis and thrombophlebitis	8	MR Egger	1.0015 (0.996–1.0069)
Granulocyte proportions	Phlebitis and thrombophlebitis	8	Weighted median	0.9999 (0.9957–1.0042)
Granulocyte proportions	Phlebitis and thrombophlebitis	8	Weighted mode	0.9998 (0.995–1.0046)
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	10	Inverse variance weighted	1.0512 (0.9793–1.1283)
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	10	MR Egger	1.0253 (0.9116–1.1532)
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	10	Weighted median	1.0116 (0.9574–1.0688)
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	10	Weighted mode	1.0048 (0.9539–1.0584)
PAI1	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	1.0438 (0.8346–1.3054)
PAI1	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.7379 (0.4833–1.1265)
PAI1	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	1.0921 (0.809–1.4743)
PAI1	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.9546 (0.6426–1.418)
HannumAge	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9907 (0.9118–1.0764)
HannumAge	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.985 (0.8487–1.1432)
HannumAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	0.9716 (0.8726–1.0818)
HannumAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.9448 (0.82–1.0885)
GrimAge	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9643 (0.8565–1.0858)
GrimAge	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.9439 (0.7518–1.1852)
GrimAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	0.8947 (0.7851–1.0196)
GrimAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.8878 (0.7506–1.05)
IEAA	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	1.0111 (0.9284–1.1013)
IEAA	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	1.0796 (0.9262–1.2585)
IEAA	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	1.0089 (0.9055–1.124)
IEAA	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.9949 (0.8442–1.1723)
Telomere length	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9996 (0.9919–1.0073)
Telomere length	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	1.0059 (0.9928–1.0193)
Telomere length	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	1.0006 (0.9928–1.0084)
Telomere length	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	1.0069 (0.9955–1.0184)
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	7	Inverse variance weighted	0.9719 (0.9064–1.0422)
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	7	MR Egger	1.0011 (0.882–1.1362)
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	7	Weighted median	0.9894 (0.9007–1.0869)
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	7	Weighted mode	0.9747 (0.8739–1.0871)
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9265 (0.8319–1.0318)
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.9671 (0.7884–1.1862)
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	0.9851 (0.8494–1.1424)
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.9849 (0.8284–1.1709)
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9989 (0.9967–1.0012)
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.9985 (0.9944–1.0026)
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	0.9994 (0.9966–1.0022)
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	0.9966 (0.9919–1.0013)
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	9	Inverse variance weighted	0.9879 (0.9578–1.019)
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	9	MR Egger	0.9961 (0.9428–1.0525)
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	9	Weighted median	0.9987 (0.9599–1.039)
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	9	Weighted mode	1.0019 (0.9468–1.0601)
PAI1	Portal vein thrombosis	4	Inverse variance weighted	1.2439 (0.8924–1.7339)
PAI1	Portal vein thrombosis	4	MR Egger	1.9244 (0.4849–7.6371)
PAI1	Portal vein thrombosis	4	Weighted median	1.2395 (0.8483–1.8111)
PAI1	Portal vein thrombosis	4	Weighted mode	1.4027 (0.8552–2.3008)
HannumAge	Portal vein thrombosis	4	Inverse variance weighted	0.967 (0.8764–1.0669)
HannumAge	Portal vein thrombosis	4	MR Egger	0.8073 (0.5866–1.1109)
HannumAge	Portal vein thrombosis	4	Weighted median	0.9757 (0.8666–1.0985)
HannumAge	Portal vein thrombosis	4	Weighted mode	0.9901 (0.8499–1.1534)
GrimAge	Portal vein thrombosis	4	Inverse variance weighted	1.015 (0.9182–1.1221)
GrimAge	Portal vein thrombosis	4	MR Egger	1.1409 (0.8232–1.5813)
GrimAge	Portal vein thrombosis	4	Weighted median	1.0617 (0.9325–1.2089)
GrimAge	Portal vein thrombosis	4	Weighted mode	1.0713 (0.9014–1.2733)
IEAA	Portal vein thrombosis	4	Inverse variance weighted	0.9914 (0.8956–1.0974)
IEAA	Portal vein thrombosis	4	MR Egger	1.0457 (0.7526–1.4531)
IEAA	Portal vein thrombosis	4	Weighted median	0.9993 (0.8888–1.1236)
IEAA	Portal vein thrombosis	4	Weighted mode	1.0108 (0.8775–1.1643)
Telomere length	Portal vein thrombosis	3	Inverse variance weighted	1.0009 (0.9932–1.0086)
Telomere length	Portal vein thrombosis	3	MR Egger	1.0013 (0.9695–1.034)
Telomere length	Portal vein thrombosis	3	Weighted median	1.0024 (0.993–1.0119)
Telomere length	Portal vein thrombosis	3	Weighted mode	1.0036 (0.9934–1.0138)
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	3	Inverse variance weighted	1.036 (0.9582–1.12)
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	3	MR Egger	1.1623 (0.9175–1.4723)
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	3	Weighted median	1.0269 (0.9304–1.1335)
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	3	Weighted mode	1.0111 (0.9061–1.1283)
PhenoAge	Portal vein thrombosis	4	Inverse variance weighted	0.871 (0.7648–0.9918)
PhenoAge	Portal vein thrombosis	4	MR Egger	0.7425 (0.4851–1.1366)
PhenoAge	Portal vein thrombosis	4	Weighted median	0.8598 (0.7316–1.0105)
PhenoAge	Portal vein thrombosis	4	Weighted mode	0.8541 (0.6968–1.0469)
Granulocyte proportions	Portal vein thrombosis	4	Inverse variance weighted	1.0009 (0.9987–1.0031)
Granulocyte proportions	Portal vein thrombosis	4	MR Egger	0.9956 (0.9884–1.0029)
Granulocyte proportions	Portal vein thrombosis	4	Weighted median	1.001 (0.9984–1.0037)
Granulocyte proportions	Portal vein thrombosis	4	Weighted mode	1.002 (0.9984–1.0057)
Fibroblast growth factor 23 levels	Portal vein thrombosis	4	Inverse variance weighted	1.0334 (0.9977–1.0704)
Fibroblast growth factor 23 levels	Portal vein thrombosis	4	MR Egger	1.0306 (0.9244–1.1491)
Fibroblast growth factor 23 levels	Portal vein thrombosis	4	Weighted median	1.0253 (0.9812–1.0713)
Fibroblast growth factor 23 levels	Portal vein thrombosis	4	Weighted mode	1.0166 (0.9631–1.0731)
PAI1	Other arterial embolism and thrombosis	6	Inverse variance weighted	1.0536 (0.7827–1.4184)
PAI1	Other arterial embolism and thrombosis	6	MR Egger	1.4704 (0.3121–6.9267)
PAI1	Other arterial embolism and thrombosis	6	Weighted median	1.2258 (0.824–1.8234)
PAI1	Other arterial embolism and thrombosis	6	Weighted mode	1.3217 (0.861–2.0289)
HannumAge	Other arterial embolism and thrombosis	6	Inverse variance weighted	0.9308 (0.8054–1.0757)
HannumAge	Other arterial embolism and thrombosis	6	MR Egger	0.9807 (0.5933–1.6211)
HannumAge	Other arterial embolism and thrombosis	6	Weighted median	1.0021 (0.8642–1.162)
HannumAge	Other arterial embolism and thrombosis	6	Weighted mode	1.0524 (0.8501–1.303)
GrimAge	Other arterial embolism and thrombosis	6	Inverse variance weighted	1.0128 (0.8887–1.1542)
GrimAge	Other arterial embolism and thrombosis	6	MR Egger	1.2073 (0.7927–1.8389)
GrimAge	Other arterial embolism and thrombosis	6	Weighted median	1.0298 (0.8918–1.1891)
GrimAge	Other arterial embolism and thrombosis	6	Weighted mode	1.056 (0.8615–1.2943)
IEAA	Other arterial embolism and thrombosis	6	Inverse variance weighted	0.9293 (0.8087–1.0679)
IEAA	Other arterial embolism and thrombosis	6	MR Egger	1.012 (0.6275–1.6323)
IEAA	Other arterial embolism and thrombosis	6	Weighted median	0.9954 (0.8532–1.1614)
IEAA	Other arterial embolism and thrombosis	6	Weighted mode	1.0712 (0.8458–1.3566)
Telomere length	Other arterial embolism and thrombosis	6	Inverse variance weighted	1.0003 (0.9888–1.0119)
Telomere length	Other arterial embolism and thrombosis	6	MR Egger	0.9987 (0.9617–1.0372)
Telomere length	Other arterial embolism and thrombosis	6	Weighted median	1 (0.99–1.0102)
Telomere length	Other arterial embolism and thrombosis	6	Weighted mode	0.9988 (0.9848–1.013)
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	5	Inverse variance weighted	0.9667 (0.8886–1.0517)
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	5	MR Egger	1.2492 (0.7945–1.964)
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	5	Weighted median	0.9833 (0.8801–1.0985)
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	5	Weighted mode	1.0053 (0.8582–1.1777)
PhenoAge	Other arterial embolism and thrombosis	6	Inverse variance weighted	1.0475 (0.9124–1.2025)
PhenoAge	Other arterial embolism and thrombosis	6	MR Egger	1.1163 (0.714–1.7453)
PhenoAge	Other arterial embolism and thrombosis	6	Weighted median	1.0409 (0.8748–1.2386)
PhenoAge	Other arterial embolism and thrombosis	6	Weighted mode	1.0048 (0.7819–1.2912)
Granulocyte proportions	Other arterial embolism and thrombosis	6	Inverse variance weighted	0.9984 (0.9952–1.0015)
Granulocyte proportions	Other arterial embolism and thrombosis	6	MR Egger	1 (0.9897–1.0104)
Granulocyte proportions	Other arterial embolism and thrombosis	6	Weighted median	0.9987 (0.9954–1.002)
Granulocyte proportions	Other arterial embolism and thrombosis	6	Weighted mode	0.9987 (0.9948–1.0026)
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	6	Inverse variance weighted	0.9888 (0.9464–1.0331)
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	6	MR Egger	0.9975 (0.8672–1.1474)
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	6	Weighted median	0.9575 (0.9124–1.0049)
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	6	Weighted mode	0.9561 (0.891–1.026)

Table 5.

Heterogeneity and pleiotropy for each exposure factor on epigenetic aging factors

Outcome	Exposure	Heterogeneity		Pleiotropy
		Q statistic (IVW)	P value	MR Egger Intercept	P value
Circulating plasma alpha-Klotho levels	Pulmonary embolism	13.941	0.304	0.017	0.45
Circulating plasma alpha-Klotho levels	DVT of lower extremities	9.583	0.568	0.023	0.144
Circulating plasma alpha-Klotho levels	Venous thromboembolism	39.763	0.069	0.009	0.425
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	6.804	0.558	0.009	0.611
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	4.961	0.549	− 0.013	0.607
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	1.689	0.43	− 0.058	0.497
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	3.025	0.554	− 0.07	0.341
Fibroblast growth factor 23 levels	Pulmonary embolism	42.539	0	− 0.003	0.854
Fibroblast growth factor 23 levels	DVT of lower extremities	33.137	0.001	− 0.004	0.747
Fibroblast growth factor 23 levels	Venous thromboembolism	48.176	0.033	− 0.006	0.257
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	27.716	0.001	0.008	0.608
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	3.829	0.872	− 0.004	0.732
Fibroblast growth factor 23 levels	Portal vein thrombosis	1.568	0.667	0.001	0.964
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	7.245	0.203	− 0.003	0.902
Granulocyte proportions	Pulmonary embolism	9.844	0.545	0.001	0.168
Granulocyte proportions	DVT of lower extremities	8.915	0.54	0	0.887
Granulocyte proportions	Venous thromboembolism	40.334	0.062	0	0.297
Granulocyte proportions	Phlebitis and thrombophlebitis	4.876	0.675	− 0.001	0.289
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	10.2	0.251	0	0.802
Granulocyte proportions	Portal vein thrombosis	2.441	0.486	0.002	0.274
Granulocyte proportions	Other arterial embolism and thrombosis	7.993	0.157	− 0.001	0.755
GrimAge	Pulmonary embolism	12.385	0.496	0.027	0.38
GrimAge	DVT of lower extremities	14.747	0.256	0.048	0.064
GrimAge	Venous thromboembolism	20.183	0.858	0.011	0.481
GrimAge	Phlebitis and thrombophlebitis	15.863	0.07	0.009	0.813
GrimAge	Arterial embolism and thrombosis of lower extremity artery	15.457	0.051	0.01	0.831
GrimAge	Portal vein thrombosis	2.07	0.558	− 0.053	0.538
GrimAge	Other arterial embolism and thrombosis	7.313	0.198	− 0.055	0.437
HannumAge	Pulmonary embolism	17.792	0.087	0.005	0.913
HannumAge	DVT of lower extremities	25.533	0.004	0.051	0.19
HannumAge	Venous thromboembolism	54.387	0.002	0.024	0.21
HannumAge	Phlebitis and thrombophlebitis	23.866	0.001	0.051	0.315
HannumAge	Arterial embolism and thrombosis of lower extremity artery	6.519	0.589	0.003	0.929
HannumAge	Portal vein thrombosis	1.906	0.592	0.081	0.364
HannumAge	Other arterial embolism and thrombosis	9.34	0.096	− 0.016	0.84
IEAA	Pulmonary embolism	16.071	0.245	− 0.051	0.125
IEAA	DVT of lower extremities	26.562	0.009	0	0.999
IEAA	Venous thromboembolism	35.25	0.196	0.013	0.383
IEAA	Phlebitis and thrombophlebitis	24.284	0.004	0.037	0.427
IEAA	Arterial embolism and thrombosis of lower extremity artery	2.808	0.946	− 0.031	0.347
IEAA	Portal vein thrombosis	0.521	0.914	− 0.024	0.77
IEAA	Other arterial embolism and thrombosis	8.088	0.151	− 0.027	0.731
PAI1	Pulmonary embolism	15.118	0.3	0.197	0.025
PAI1	DVT of lower extremities	19.789	0.071	− 0.115	0.318
PAI1	Venous thromboembolism	40.822	0.071	− 0.062	0.176
PAI1	Phlebitis and thrombophlebitis	15.141	0.087	− 0.173	0.223
PAI1	Arterial embolism and thrombosis of lower extremity artery	7.956	0.438	0.149	0.1
PAI1	Portal vein thrombosis	2.546	0.467	− 0.186	0.588
PAI1	Other arterial embolism and thrombosis	3.908	0.563	− 0.093	0.69
PhenoAge	Pulmonary embolism	12.591	0.48	0.001	0.971
PhenoAge	DVT of lower extremities	12.868	0.379	0.039	0.231
PhenoAge	Venous thromboembolism	30.576	0.386	0.05	0.007
PhenoAge	Phlebitis and thrombophlebitis	10.274	0.329	0.038	0.317
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	7.999	0.434	− 0.02	0.636
PhenoAge	Portal vein thrombosis	1.698	0.637	0.072	0.521
PhenoAge	Other arterial embolism and thrombosis	2.229	0.817	− 0.02	0.784
Telomere length	Pulmonary embolism	22.069	0.077	0.002	0.576
Telomere length	DVT of lower extremities	28.926	0.004	0.001	0.618
Telomere length	Venous thromboembolism	49.55	0.01	− 0.001	0.61
Telomere length	Phlebitis and thrombophlebitis	14.474	0.106	0.002	0.311
Telomere length	Arterial embolism and thrombosis of lower extremity artery	16.971	0.03	− 0.003	0.288
Telomere length	Portal vein thrombosis	2.361	0.307	0	0.984
Telomere length	Other arterial embolism and thrombosis	14.713	0.012	0.001	0.935

Table 6.

MR-PRESSO results of the MR analysis

Outcome	Exposure	Raw		Outlier corrected		Global p	Outliers	Distortion p
		OR_CI	P	OR_CI	P
Circulating plasma alpha-Klotho levels	Arterial embolism and thrombosis of lower extremity artery	0.9719 (0.9121–1.0356)	0.4128	NA (NA–NA)	NA	0.61
Fibroblast growth factor 23 levels	Arterial embolism and thrombosis of lower extremity artery	0.9879 (0.967–1.0094)	0.2994	NA (NA–NA)	NA	0.885		NA
Granulocyte proportions	Arterial embolism and thrombosis of lower extremity artery	0.9989 (0.9967–1.0012)	0.3754	NA (NA–NA)	NA	0.275
GrimAge	Arterial embolism and thrombosis of lower extremity artery	0.9643 (0.8565–1.0858)	0.5649	NA (NA–NA)	NA	0.06
HannumAge	Arterial embolism and thrombosis of lower extremity artery	0.9907 (0.9192–1.0678)	0.8132	NA (NA–NA)	NA	0.576		NA
IEAA	Arterial embolism and thrombosis of lower extremity artery	1.0111 (0.9612–1.0636)	0.6798	NA (NA–NA)	NA	0.93		NA
PAI1	Arterial embolism and thrombosis of lower extremity artery	1.0438 (0.8351–1.3046)	0.7161	NA (NA–NA)	NA	0.446
PhenoAge	Arterial embolism and thrombosis of lower extremity artery	0.9265 (0.8319–1.0318)	0.202	NA (NA–NA)	NA	0.484
Telomere length	Arterial embolism and thrombosis of lower extremity artery	0.9996 (0.9919–1.0073)	0.9201	NA (NA–NA)	NA	0.047	NA	NA
Circulating plasma alpha-Klotho levels	DVT of lower extremities	1.0393 (0.9795–1.1027)	0.2284	NA (NA–NA)	NA	0.546
Fibroblast growth factor 23 levels	DVT of lower extremities	1.0283 (0.9748–1.0846)	0.3263	0.9915 (0.9651–1.0187)	0.5492	0.004	rs80136276	0.011
Granulocyte proportions	DVT of lower extremities	1.0022 (0.9997–1.0046)	0.1128	NA (NA–NA)	NA	0.273
GrimAge	DVT of lower extremities	1.0275 (0.9194–1.1482)	0.6413	NA (NA–NA)	NA	0.203
HannumAge	DVT of lower extremities	0.9714 (0.8359–1.129)	0.7121	1.0428 (0.8939–1.2166)	0.6045	0.01	rs80260619	0.217
IEAA	DVT of lower extremities	0.9658 (0.8312–1.1221)	0.6572	0.9375 (0.8222–1.0691)	0.3562	0.016	rs17543805	0.787
PAI1	DVT of lower extremities	1.1308 (0.7927–1.6131)	0.5105	NA (NA–NA)	NA	0.101
PhenoAge	DVT of lower extremities	0.9509 (0.8331–1.0854)	0.4703	NA (NA–NA)	NA	0.359
Telomere length	DVT of lower extremities	1.0059 (0.9968–1.015)	0.2249	1.0038 (0.9971–1.0105)	0.2917	0.017	rs10886430	0.298
Circulating plasma alpha-Klotho levels	Other arterial embolism and thrombosis	0.9667 (0.8984–1.0402)	0.4164	NA (NA–NA)	NA	0.562
Fibroblast growth factor 23 levels	Other arterial embolism and thrombosis	0.9888 (0.9464–1.0331)	0.6372	NA (NA–NA)	NA	0.219		NA
Granulocyte proportions	Other arterial embolism and thrombosis	0.9984 (0.9952–1.0015)	0.3503	NA (NA–NA)	NA	0.208
GrimAge	Other arterial embolism and thrombosis	1.0128 (0.8887–1.1542)	0.8564	NA (NA–NA)	NA	0.235
HannumAge	Other arterial embolism and thrombosis	0.9308 (0.8054–1.0757)	0.3759	NA (NA–NA)	NA	0.109		NA
IEAA	Other arterial embolism and thrombosis	0.9293 (0.8087–1.0679)	0.3487	NA (NA–NA)	NA	0.194		NA
PAI1	Other arterial embolism and thrombosis	1.0536 (0.8101–1.3704)	0.7129	NA (NA–NA)	NA	0.551
PhenoAge	Other arterial embolism and thrombosis	1.0475 (0.9552–1.1486)	0.3694	NA (NA–NA)	NA	0.809
Telomere length	Other arterial embolism and thrombosis	1.0003 (0.9888–1.0119)	0.9631	0.9958 (0.9875–1.0043)	0.3874	0.031	rs12957035	0.353
Circulating plasma alpha-Klotho levels	Phlebitis and thrombophlebitis	1.0169 (0.9452–1.094)	0.664	NA (NA–NA)	NA	0.539
Fibroblast growth factor 23 levels	Phlebitis and thrombophlebitis	1.0376 (0.9677–1.1125)	0.3241	0.9938 (0.9583–1.0305)	0.7436	0.003	rs80136276	0.002
Granulocyte proportions	Phlebitis and thrombophlebitis	1.0016 (0.9985–1.0047)	0.3319	NA (NA–NA)	NA	0.217
GrimAge	Phlebitis and thrombophlebitis	0.9842 (0.8447–1.1467)	0.8422	NA (NA–NA)	NA	0.094
HannumAge	Phlebitis and thrombophlebitis	0.9402 (0.7723–1.1445)	0.5525	0.9111 (0.7628–1.0882)	0.3311	0.004	rs17543805	0.822
IEAA	Phlebitis and thrombophlebitis	0.9902 (0.8193–1.1966)	0.9204	NA (NA–NA)	NA	0.017	NA	NA
PAI1	Phlebitis and thrombophlebitis	1.0786 (0.7051–1.65)	0.7343	NA (NA–NA)	NA	0.212
PhenoAge	Phlebitis and thrombophlebitis	0.9279 (0.7931–1.0855)	0.3719	NA (NA–NA)	NA	0.381
Telomere length	Phlebitis and thrombophlebitis	1.007 (0.998–1.0161)	0.1581	NA (NA–NA)	NA	0.135		NA
Circulating plasma alpha-Klotho levels	Portal vein thrombosis	1.0169 (0.9452–1.094)	0.664	NA (NA–NA)	NA	0.539
Fibroblast growth factor 23 levels	Portal vein thrombosis	1.0334 (1.0074–1.06)	0.0854	NA (NA–NA)	NA	0.69		NA
Granulocyte proportions	Portal vein thrombosis	1.0009 (0.9989–1.0029)	0.4515	NA (NA–NA)	NA	0.496
GrimAge	Portal vein thrombosis	1.015 (0.9339–1.1032)	0.7486	NA (NA–NA)	NA	0.542
HannumAge	Portal vein thrombosis	0.967 (0.894–1.0458)	0.4626	NA (NA–NA)	NA	0.63		NA
IEAA	Portal vein thrombosis	0.9914 (0.9503–1.0342)	0.7146	NA (NA–NA)	NA	0.923		NA
PAI1	Portal vein thrombosis	1.2439 (0.9161–1.6891)	0.2564	NA (NA–NA)	NA	0.594
PhenoAge	Portal vein thrombosis	0.871 (0.7898–0.9604)	0.0696	NA (NA–NA)	NA	0.694
Telomere length	Portal vein thrombosis	1.007 (0.998–1.0161)	0.1581	NA (NA–NA)	NA	0.135		NA
Circulating plasma alpha-Klotho levels	Pulmonary embolism	1.079 (0.9822–1.1853)	0.1388	NA (NA–NA)	NA	0.33
Fibroblast growth factor 23 levels	Pulmonary embolism	1.0353 (0.9614–1.115)	0.3729	0.9902 (0.9423–1.0406)	0.7037	< 0.001	rs74739952	0.051
Granulocyte proportions	Pulmonary embolism	1.0035 (1.0003–1.0067)	0.0485	NA (NA–NA)	NA	0.272
GrimAge	Pulmonary embolism	1.0548 (0.9322–1.1936)	0.4127	NA (NA–NA)	NA	0.523
HannumAge	Pulmonary embolism	1.0049 (0.8433–1.1976)	0.9568	NA (NA–NA)	NA	0.011	NA	NA
IEAA	Pulmonary embolism	0.9058 (0.7861–1.0437)	0.1943	NA (NA–NA)	NA	0.255		NA
PAI1	Pulmonary embolism	1.2662 (0.9027–1.7762)	0.1948	NA (NA–NA)	NA	0.345
PhenoAge	Pulmonary embolism	0.9269 (0.7923–1.0842)	0.3598	NA (NA–NA)	NA	0.441
Telomere length	Pulmonary embolism	1.0059 (0.9961–1.0158)	0.257	NA (NA–NA)	NA	0.138		NA
Circulating plasma alpha-Klotho levels	Venous thromboembolism	1.0624 (0.9725–1.1607)	0.1904	NA (NA–NA)	NA	0.077
Fibroblast growth factor 23 levels	Venous thromboembolism	1.02 (0.974–1.0681)	0.4062	0.9806 (0.9502–1.012)	0.2327	0.007	rs2428493	0.108
Granulocyte proportions	Venous thromboembolism	1.0023 (0.9991–1.0054)	0.1665	NA (NA–NA)	NA	0.051
GrimAge	Venous thromboembolism	1.164 (1.0467–1.2943)	0.0088	NA (NA–NA)	NA	0.822
HannumAge	Venous thromboembolism	0.9604 (0.8277–1.1145)	0.5985	NA (NA–NA)	NA	0.001	NA	NA
IEAA	Venous thromboembolism	1.0043 (0.89–1.1333)	0.9452	NA (NA–NA)	NA	0.235		NA
PAI1	Venous thromboembolism	1.1041 (0.7822–1.5585)	0.5773	NA (NA–NA)	NA	0.122
PhenoAge	Venous thromboembolism	1.0545 (0.9123–1.2189)	0.4781	NA (NA–NA)	NA	0.358
Telomere length	Venous thromboembolism	1.0054 (0.9964–1.0145)	0.2516	1.0037 (0.9956–1.0118)	0.3772	0.015	rs2066865	0.48

Discussion

We conducted a bi-directional two-sample MR analysis using GWAS summary statistics from European ancestry to explore the causal relationships between genetically predicted epigenetic aging factors and thromboembolism. Our results indicated that IEAA may be a potential protective factor for the occurrence of DVT of lower extremities. In addition, the levels of PAI1 and FGF23 were demonstrated as potential risk factors for other arterial embolism and thrombosis and arterial embolism and thrombosis of lower extremity artery. Furthermore, we found evidence for causal associations between VTE and GrimAge, as well as between PVT and PhenoAge. This indicates that VTE is associated with an increase in GrimAge, while PVT is associated with a decrease in PhenoAge.

The relationship between epigenetic aging and thromboembolism is increasingly recognized, particularly concerning how alterations in epigenetic markers can influence hemostatic factors. Elevated epigenetic age has been associated with a pro-coagulation profile, characterized by increased levels of fibrinogen and PAI1, which are critical components in the coagulation cascade [5]. This can lead to a higher risk of clot formation and reduced clotting time, potentially causing thromboembolic events [5]. Moreover, studies indicate that epigenetic modifications, such as DNA methylation changes, play a significant role in the pathogenesis of thromboembolic diseases. For instance, specific epigenetic alterations have been observed in conditions like coronary artery disease and cerebrovascular disease, which are closely linked to thromboembolic events [34]. These findings suggest that understanding the epigenetic mechanisms underlying aging could provide insights into the prevention and management of thromboembolism. Our study provided evidence supporting causal links between epigenetic aging factors and thromboembolism and its subtypes, achieved by inferring causality through genetic prediction using MR, which also effectively addresses confounding variables.

Our results showed that genetically determined levels of FGF23 and PAI1 acted as detrimental factors in arterial thromboembolism. FGF23, a hormone mainly produced by osteocytes, regulates phosphate balance and vitamin D metabolism by enhancing renal phosphate excretion and curbing active vitamin D synthesis [35, 36]. In addition, FGF23-deficient mice exhibited aging phenotypes, such as reduced life span, atherosclerosis, osteoporosis, skin atrophy, infertility, or emphysema [37]. Moreover, clinical studies increasingly link elevated FGF23 levels to cardiovascular risks like arterial stiffness and vascular calcification, which contribute to thromboembolism [36]. Mechanistically, it has been proposed that the effect of FGF23 on mineral metabolism can lead to systemic inflammation and vascular changes that predispose individuals to thromboembolic conditions [35, 38]. On the other hand, PAI1 is a serine protease inhibitor that plays a crucial role in the regulation of fibrinolysis and thrombosis. It primarily inhibits tissue plasminogen activator (t-PA) and urokinase plasminogen activator (u-PA), which are essential for the breakdown of blood clots. Elevated levels of PAI1 can lead to impaired fibrinolysis, contributing to an increased risk of thrombotic events such as VTE and arterial thrombosis [39, 40]. More specifically, genetic polymorphisms, particularly the 4G/5G polymorphism, have been linked to varying levels of PAI1 expression and an individual’s susceptibility to VTE [41]. Furthermore, elevated plasma levels of PAI1 are associated with longer clot lysis times, indicating a higher risk for both venous and arterial thrombosis [40, 41]. In line with existing evidence, our study identified FGF23 and PAI1 as potential detrimental factors for thrombotic events. Given the associations between elevated FGF23 and PAI1 levels and thrombosis risks, targeting them may reduce thromboembolic events. Potential interventions include lowering FGF23 or PAI1 levels or modulating their effects on mineral metabolism and fibrinolysis through pharmacological agents, lifestyle changes, or other approaches.

Our results indicated that IEAA was inversely associated with the incidence of DVT of lower extremities. HorvathAge, developed by Steve Horvath in 2013, is an epigenetic clock that estimates biological age based on DNA methylation patterns [6]. This method utilizes a specific set of CpG sites across the genome to predict an individual’s biological age. Research indicates that accelerated biological aging, as reflected by higher IEAA, may correlate with increased risk factors for thromboembolism. This relationship suggests that individuals who exhibit signs of accelerated aging could be at a heightened risk for developing VTE due to underlying physiological changes associated with aging [42]. However, our results demonstrated the opposite. This discrepancy may arise from the fact that the biological aging processes reflected by epigenetic clocks do not uniformly translate to clinical outcomes across different populations. Additionally, variations in how VTE is diagnosed or reported, as well as the specific epigenetic markers selected for analysis, could lead to conflicting results.

In terms of reverse causation, our results revealed that VTE and PVT were causally linked to increased and reduced GrimAge and PhenoAge, respectively. Unlike HorvathAge, GrimAge is specifically designed to predict mortality risk, lifespan, and healthspan. It incorporates not only more DNA methylation data, but also considers lifestyle factors such as smoking history and levels of specific plasma proteins associated with health outcomes, allowing GrimAge to be a more robust predictor of age-related diseases and overall mortality [43]. Individuals with VTE could experience an increased GrimAge, suggesting that thrombosis and related conditions, such as chronic inflammation or endothelial dysfunction, might exacerbate the biological aging markers and increase the risk of developing age-related diseases [44]. Nonetheless, our results revealed that individuals with PVT may exhibit decelerated epigenetic aging as measured by PhenoAge. PhenoAge is an epigenetic clock that incorporates not only DNA methylation information but also the levels of clinical biomarkers such as creatinine and C-reactive protein. It focuses on integrating clinical biomarkers that reflect physiological aging and disease risk, making it particularly useful for assessing healthspan and age-related diseases. The varying connections between epigenetic clocks and thromboembolism may stem from different focuses of these clocks on biological aging, highlighting the multifaceted nature of the aging process. PhenoAge may reflect a different aspect of health status that is less sensitive to the effects of thromboembolic events. Therefore, for individuals with VTE, the increased GrimAge suggests a heightened risk of age-related diseases and mortality, emphasizing the need for more aggressive preventive measures and monitoring of comorbidities. Conversely, the decelerated epigenetic aging observed in PVT patients, as indicated by PhenoAge, may suggest a unique biological profile that warrants further investigation. Understanding these distinct associations could help in the development of targeted interventions to mitigate the adverse effects of thromboembolism on biological aging and overall health.

This study represents the first evaluation of the associations between epigenetic aging factors and thromboembolism using MR. The main strength of this study lies in its utilization of MR, enabling the assessment of the associations between genetically determined levels of epigenetic aging factors and thromboembolism in independent European populations simultaneously. Genetic associations aid in elucidating the diverse relationships between epigenetic aging factors and thromboembolism by considering shared genetic risk factors. The results were validated through alternative MR methods and sensitivity analyses for pleiotropy. Nonetheless, some limitations have to be addressed for this study. Firstly, the lack of individual-level data restricts our ability to categorize patients into finer subgroups based on disease progression. Future studies can address this limitation by using large-scale datasets or electronic health records to obtain detailed individual-level data, enabling more nuanced analyses of disease subtypes and progression. Secondly, we could not sufficiently account for unmeasured confounders like smoking and alcohol consumption, which are known to influence thromboembolism risk. Further efforts could address this issue by incorporating comprehensive lifestyle assessments. Thirdly, the applicability of this study to populations outside of European ancestry is limited due to its focus on this specific demographic. Thus, caution is advised when extrapolating our findings to populations with different ancestral backgrounds. Future studies should aim to include more diverse samples from various ancestral backgrounds to improve the generalizability of the findings.

Conclusions

Our findings revealed that genetically determined levels of epigenetic aging factors affect thromboembolism risk in European ancestry. Our findings suggested one protective causal association between IEAA and DVT of lower extremities; two detrimental causal associations between PAI1 and FGF23 and other arterial embolism and thrombosis and arterial embolism and thrombosis of lower extremity artery; one protective causal associations between PVT and PhenoAge; one detrimental causal association between VTE and GrimAge. These results suggest that these epigenetic aging factors could serve as potential predictors for thromboembolism, offering avenues for future research to develop targeted prevention strategies. However, further studies are needed to confirm these associations and explore their applicability in diverse populations, particularly those of non-European ancestry, to enhance the external validity of our findings.

Abbreviations

VTE

Venous thromboembolism

DVT

Deep vein thrombosis

PE

Pulmonary embolism

PVT

Portal vein thrombosis

CVD

Cardiovascular diseases

IEAA

Intrinsic epigenetic age acceleration

FGF23

Fibroblast growth factor 23

CI

Confidence interval

Author contributions

Bowen Jin and Yunyan Li carried out the studies, participated in collecting data, and drafted the manuscript. Chi Jing and Qunshan Shen performed the statistical analysis and participated in its design. Dingyang Li and Bowen Jin participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.

Funding

The study was supported by Wuhan Municipal Health Commission guided the project (WX2Z29). The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Availability of data and materials

The GWAS summary statistics for thromboembolism can be accessed via the FinnGen database. The genetic data regarding epigenetic clocks can be accessed from previous studies.

Declarations

Ethics approval and consent to participate

This study utilized summary statistics from public GWAS studies, for which ethical approvement has been obtained. Consequently, no further ethical approval was necessary.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.