Gender differences in the presentation and management of patients with severe aortic stenosis at specialist versus primary/secondary care centres: A sub-analysis of the IMPULSE enhanced registry

BACKGROUND

Management and treatment of severe aortic stenosis (AS) may differ considerably in European countries. To investigate these differences in France, Germany, and the UK, the IMPULSE enhanced registry was established. Previous data revealed differences in how patients were managed in specialist (hub) versus primary/secondary care (satellite) centres.

METHODS

The IMPULSE enhanced registry sub-analysis aimed to determine if there were gender-specific differences for patients with severe AS at centres with and without access to intervention.

RESULTS

Among the 790 patients, 594 and 196 were recruited at hub and satellite centres, respectively; 44 % of patients were female. In both settings, women were older than men (hubs: 78.7 vs. 76.2, p = 0.007; satellites: 79.8 vs. 75.1, p = 0.002). Symptoms at the presentation were comparable. Males had more often undergone previous cardiac surgery. Females had a smaller left ventricular (LV) outflow tract, smaller LV cavities, and, more often, a preserved ejection fraction (>50 %). There was no gender-based difference in time to intervention. At one year, the cumulative incidence of aortic valve replacement in females was higher than in males in hubs (p = 0.012) but not in satellites (p = 0.600); surgical AVR was more common in males in hubs only (p = 0.008), while transcatheter aortic valve implantation was more common in females in both settings (hubs: p < 0.001; satellites: p = 0.022). One-year survival was comparable in both genders, regardless of setting.

CONCLUSIONS

A better understanding of gender-specific differences in patients with severe AS, according to the diagnostic setting, could improve patient stratification and earlier diagnosis.

Atrial arrhythmias following lung transplantation: A state of the art review

Lung transplantation (LT) is now an accepted therapy for end stage lung disease in appropriate patients. Atrial arrhythmias (AA) can occur after LT. Early AA after LT are most often atrial fibrillation, whereas late arrhythmias which occur many months or years after LT are often atrial tachycardia. The causes of AA are multifactorial. The review begins with a brief history of LT and AA. This review further describes the pathophysiology of the AA. The risk factors, incidence, recipient characteristics including intra-operative factors are elaborated on. Since there are no clear and specific guidelines on the management of atrial arrhythmia following LT, the recommended guidelines on the management of AA in general are often extrapolated and used in the setting of post LT arrhythmia. The strategy of rate control vs rhythm control is discussed. The pros and cons of various drug regimen, need for direct current cardioversion and catheter ablation therapies are considered. Possible methods to prevent or reduce the incidence of AA after LT are considered. The impact of AA on the short-term and long-term outcomes following LT is discussed.

Effects of a Cloud-Based Synchronous Telehealth Program on Valvular Regurgitation Regression: Retrospective Study

BACKGROUND

Telemedicine has been associated with better cardiovascular outcomes, but its effects on the regression of mitral regurgitation (MR) and tricuspid regurgitation (TR) remain unknown.

OBJECTIVE

This study aimed to evaluate whether telemedicine could facilitate the regression of MR and TR compared to usual care and whether it was associated with better survival.

METHODS

This retrospective cohort study enrolled consecutive patients with moderate or greater MR or TR from 2010 through 2020, excluding those with concomitant aortic stenosis, aortic regurgitation, or mitral stenosis greater than mild severity. All patients underwent follow-up transthoracic echocardiography (TTE) at least 3 months apart. Patients receiving telehealth services for at least two weeks within 90 days of baseline TTE were categorized as the telehealth group; the remainder constituted the nontelehealth group. Telemedicine participants transmitted daily biometric data-blood pressure, pulse rate, blood glucose, electrocardiogram, and oxygen saturation-to a cloud-based platform for timely monitoring. Experienced case managers regularly contacted patients and initiated immediate action for concerning measurements. The primary endpoint was MR or TR regression from ≥moderate to

RESULTS

The MR cohorts consisted of 264 patients (mean age 67 years), including 97 regressors and 74 telehealth participants. Telehealth participation (hazard ratio 2.20, 95% CI 1.35-3.58; P=.001) was robustly associated with MR regression; MR regressors were linked to reverse cardiac remodeling, indicated by improved left ventricular ejection fraction (LVEF), and reduced left ventricular (LV) and left atrial (LA) dimensions (all P≤.005). Determinants of ACD were age (P<.001), LVEF (P<.001), percutaneous coronary intervention (P<.001), and MR regressors (P=.02). The TR cohort consisted of 245 patients (mean age 68 years), including 87 TR regressors and 61 telehealth participants. Telehealth (P=.05) was one of the univariable determinants of TR regression, while beta-blocker use (P=.048) and baseline TR severity (P=.01) remained strong predictors of TR regression in multivariable analysis.

CONCLUSIONS

Patients in the telehealth group were 2.2 times more likely to experience MR regression. Moreover, MR regressors had better survival and reverse cardiac remodeling compared to nonregressors. These findings may have important implications for future guidelines.

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Key Words

• cardiac remodeling
• mitral regurgitation
• telehealth
• telemedicine
• tricuspid regurgitation

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MESH Headings

• Humans
• Retrospective Studies
• Male
• Telemedicine
• Female
• Aged
• Mitral Valve Insufficiency/therapy
• Mitral Valve Insufficiency/mortality
• Cloud Computing
• Middle Aged
• Tricuspid Valve Insufficiency/therapy
• Tricuspid Valve Insufficiency/mortality
• Echocardiography

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Affiliation(s)

Li-Tan Yang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Han Wu Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Wei-Jyun Wang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Ying-Hsien Chen Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Ching-Chang Huang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Sheng Hung Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Kuang-Chien Chiang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Yi-Lwun Ho Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Hui-Wen Wu Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan

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The use of left ventricular ejection fraction in the diagnosis and management of heart failure. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

Temporal Trends in Etiology of Aortic Valvular Diseases for Patients Undergoing Surgical Valve Replacement: A Report From 40 Years Pathological Experience

Although aortic valvular disease has various etiologies, recently, calcific aortic valve stenosis has been increasing. We analyzed the trends in the pathological characteristics of aortic valvular disease in the past four decades in Japan. The pathology department data for aortic valvular disease operated in our hospital documented 4508 patients from 1978 to 2022. Subsequently, trend analyses were performed over four periods: Period 1, 1978-1989 (618 cases); Period 2, 1990-1999 (903 cases); Period 3, 2000-2010 (1179 cases); and Period 4, 2011-2022 (1808 cases). We reviewed the pathological characterization of the resected aortic valves and categorized them based on the representative etiology of aortic valvular disease as congenital bicuspid, chronic rheumatic change, infective endocarditis, degenerative calcific change, and myxoid change. Our pathologic analysis revealed a significant decrease in the proportion of chronic rheumatic disease from 47% to 14%, an increase in the congenital bicuspid valve from 8% to 24%, and a rise of the degenerative calcific change of the aortic valve from 4% to 27% (p < 0.001), especially significant increases in aortic stenosis. Calcification of the aortic valve may result from an active process similar to atherosclerosis, leading to aortic stenosis with increasing dyslipidemia in Japanese patients in 40 years.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

MANAGEMENT OF ASYMPTOMATIC SEVERE AORTIC STENOSIS: A CRITICAL REVIEW OF GUIDELINES AND CLINICAL OUTCOMES

BACKGROUND

Asymptomatic severe aortic stenosis (AS) poses a clinical challenge with variations in recommendations for management.

OBJECTIVES

We sought to compare contemporary guidelines focusing on asymptomatic AS management and present a summary of contemporary studies on early intervention in these patients.

METHODS

Systematic search of electronic databases was conducted with guidelines analyzed using a comparative matrix. A pooled random-effects meta-analysis of randomized controlled trial (RCT) data comparing intervention versus clinical surveillance in asymptomatic severe AS was also performed.

RESULTS

Four guidelines from ACC/AHA, ESC/EACTS, JCS/JSCS/JATS/JSVS, and NICE were included encompassing 108 recommendations. Consensus was found for intervention thresholds including left ventricular dysfunction and very severe AS while discrepancies existed in the utility of biomarkers, myocardial fibrosis, exercise stress testing and choice of intervention. Despite variation in study inclusion criteria, current RCTs on the management of asymptomatic AS indicated a significant reduction in rates of major adverse cardiovascular events when comparing early intervention to clinical surveillance (hazard ratio [HR] 0.52 [0.42, 0.63]), driven primarily by reductions in unplanned hospitalizations (HR 0.41 [0.32, 0.52]).

CONCLUSION

While there is broad consensus on classic indicators of severity such as left ventricular dysfunction as indication for intervention, guidelines diverge on other high-risk features warranting intervention. Early studies indicate the overall safety of early intervention, although further work is needed to identify whether it can reduce the risk of hard clinical endpoints. This underscores the need for further research and updated guidelines to clarify the optimal thresholds for intervention and harmonize treatment pathways for the growing number of patients with asymptomatic AS.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

The use of Left Ventricular Ejection Fraction in the Diagnosis and Management of Heart Failure. A Clinical Consensus Statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

The value of handheld ultrasound in point-of-care or at home EF prediction

In this paper, AI-enabled handheld ultrasound is used in point-of-care or at home, and evaluate the accuracy of it for left ventricular ejection fraction (LVEF) evaluation. It provides a simple, convenient, and practical tool for the patients with heart disease, especially those with heart failure. The AI model used for this AI-enabled handheld ultrasound is a machine learning model trained with tens of thousands of ultrasound four-chamber cardiograms. The LVEF evaluation accuracy of the AI model was compared by the experts performing ultrasound four-chamber cardiogram detection in 100 patients on high-end ultrasound in the hospital. In the 100 clinical trials, the sensitivity, specificity, and accuracy of the AI model were 91%, 95%, and 98%, respectively. Then 10 cases were used to compare the LVEF results of hospital tests with the predicted results of the AI model. The difference between the two is less than 10%. Finally, over the course of one month, the AI-enabled handheld ultrasound was employed to conduct regular evaluations of left LVEF for point-of-care purposes on a group of 10 patients diagnosed with heart failure. The LVEF evaluation accuracy of AI-enabled handheld ultrasound is more than 96%, which was higher than that of experts in high-end ultrasound in hospitals. The easy-to-use AI-enabled handheld ultrasound can evaluate the LVEF in the point of care or at home and get the same accuracy as the high-end ultrasound equipment in the hospital. It may play an important role in monitoring cardiac function at home for the ambulatory heart failure patients.

Alcohol Septal Ablation for Left Ventricle Outflow Tract Obstruction Prevention Before Transcatheter Mitral Valve Replacement Procedure: Computed Tomography Analysis Series

BACKGROUND

Left ventricle outflow tract obstruction (LVOTO) is the main limitation of transcatheter mitral valve replacement (TMVR) procedure occurring in 7%-9% of cases and responsible of 25% TMVR screen failures.

AIMS

We aim to assess the alcohol septal ablation (ASA) effect on LVOTO risk before TMVR by multistage cardiac computed tomography (CT).

METHODS

Patients indicated for TMVR procedure using Sapiens 3 Prosthesis with high LVOTO risk were enrolled in the study. ASA was the first choice technique to reduce this risk based on multiple and staged cardiac CT screening.

RESULTS

Out of 29 consecutive TMVR procedures conducted in our center between March 2021 and April 2023, nine patients presented high LVOTO risk and were enrolled in our study. The main risk factor retained was a reduced predicted NeoLVOT surface 89 mm2 [66-135] (< 170 mm2). Most procedures were valve in MAC and all patients underwent at least one ASA. CT control showed a significant increase by 95% in the predicted NeoLVOT surface: 174 mm2 [121-240]; p = 0.012 compared to the baseline value. There were no significant paraprosthesis leakage or LVOTO found on TTE according to the MVARC criteria. Cardiac CT showed a larger than predicted final NeoLVOT surface: 215 mm2 [175-317]; p = 0.018. One patient died after ASA, and two others during the first year of follow-up. Survivors had significant symptom relief (p = 0.046) and a decreased PASP (38 mmHg [32-47] vs. 54 mmHg [46-62.5]; p = 0.028).

CONCLUSIONS

Multistage CT analysis shows that ASA is effective in high LVOTO-risk patients undergoing TMVR.

Prevalence and prognostic value of ventricular conduction delay in heart failure with preserved ejection fraction

Background

The pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF) is heterogeneous and incompletely understood. This study evaluated the presence of a ventricular conduction delay (VCD) phenotype in HFpEF through QRS duration and vectorcardiographic QRS area, and their relation to adverse outcomes.

Methods

This study included consecutive ambulatory HFpEF patients. Baseline QRS duration was obtained from an electrocardiogram (ECG). QRS area was derived from vectorcardiographic analyses of the ECG. QRS duration and area were assessed and analysed as categorical (<100 ms, 100-119 ms, ≥120 ms; ≤ 43.1 µVs, >43.1 µVs) and continuous variables to determine the relation to the composite outcome of HF hospitalisation and all-cause mortality.

Results

349 HFpEF patients were included of whom 70 % had a QRS duration < 100 ms compared to 21 % with QRS duration 100-119 ms and 9 % with QRS duration ≥120 ms. 87 (25 %) patients had QRS area >43.1 µVs. Only 4 % had a QRS area ≥69µVs, indicating delayed lateral wall activation. After a median of 3 years follow-up, 30 % of the patients had an adverse outcome. Longer QRS duration but not larger QRS area was associated with more adverse outcomes on both categorical and continuous scales (HR per 5 ms increase = 1.06, P = 0.033). This prognostic association was mainly present in males.

Conclusion

HFpEF patients have a low prevalence of a VCD phenotype(9 % QRS duration ≥120 ms;4 % a QRS area ≥69 µVs). However, QRS duration >100 ms was present in 30 % and was an independent predictor for adverse outcomes. Future efforts are needed to understand the mechanisms underlying the association of QRS duration and adverse outcomes, and to determine its clinical implications.

Impact of Exercise on Atrial Functional Mitral Regurgitation and Its Determinants: An Exercise Echocardiographic Study

Atrial functional mitral regurgitation (AFMR) is a distinct form of mitral regurgitation in patients with atrial fibrillation and heart failure with preserved ejection fraction. Its pathophysiology remains elusive, and data on exercise-related AFMR are scarce. We sought to investigate the impact of acute exercise on AFMR severity and to identify its determinants. In total, 47 patients with heart failure with preserved ejection fraction (n = 39) and/or atrial fibrillation (n = 22) were enrolled. We assessed AFMR severity, mitral annular dimensions, left atrial size, AFMR severity, and parameters of systolic and diastolic function at rest and during maximal exercise by echocardiography. An increase in AFMR severity of ≥1 grade was observed in 20 patients (43%) during exercise and was associated with impaired progression of peak mitral annulus systolic velocity and increased systolic mitral annular diameter during exercise, whereas the systolic annular diameter decreased in patients without AFMR progression. Furthermore, patients with ≥ moderate AFMR during exercise (n = 19, 40%) had lower peak mitral annulus systolic velocity, greater systolic mitral annular diameters, reduced tricuspid annular plane systolic excursion, and more severe tricuspid regurgitation than patients with ≤ mild MR during exercise. In conclusion, AFMR is a dynamic condition which may worsen during exercise. Deterioration of AFMR during exercise was associated with impaired longitudinal left ventricular contractile reserve and greater mitral annular dimensions. Because impaired left ventricular longitudinal function may influence mitral annular dynamics, this attributes to the hypothesis that AFMR results from mitral annulus area/leaflet area imbalance caused by annular dilation and impaired mitral annular dynamics.

Survival Outcomes After Multiple vs Single Arterial Grafting Among Patients With Reduced Ejection Fraction

Importance

Multiarterial coronary bypass procedures offer improved clinical outcomes compared with single arterial grafting with supplementary saphenous vein grafts. However, the survival advantage of multiarterial grafting across varying levels of left ventricular impairment remains uncertain.

Objective

To compare long-term survival outcomes of patients undergoing multiple vs single arterial grafting, stratified by preoperative ejection fraction.

Design, Setting, and Participants

A complete-case retrospective cohort study was conducted using data from a multicenter population-based cardiac registry established by the Australian & New Zealand Society of Cardiac & Thoracic Surgeons with linkage to the National Death Index. Participants were individuals who underwent primary isolated coronary bypass surgery between June 1, 2001, and January 31, 2020. Exclusion criteria were nonadults, reoperations, concomitant or previous cardiac surgical procedures, single-graft procedure, and cases without any arterial grafts. Statistical analyses were conducted in September 2024.

Exposures

Patients underwent either multiple or single arterial grafting, stratified by their preoperative left ventricular ejection fraction.

Main Outcomes and Measures

Long-term all-cause mortality.

Results

The study included 59 641 patients (mean [SD] age at the time of surgery, 65.8 [10.2] years; 48 321 men [81.0%]). The median follow-up duration was 5.0 years (IQR, 2.3-8.6 years). Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared with single arterial grafting among patients with a normal left ventricular ejection fraction (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87; P < .001). Similar survival benefits were observed among patients with mild (HR, 0.83; 95% CI, 0.77-0.90; P < .001), moderate (HR, 0.82; 95% CI, 0.74-0.90; P < .001), and severe left ventricular impairment (HR, 0.82; 95% CI, 0.71-0.96; P = .01). A multivariable Cox proportional hazards regression interaction-term analysis indicated no significant differences in the multiarterial survival benefit by ejection fraction stratification (P = .75). Multiarterial grafting with exclusively arterial conduits was associated with enhanced survival benefits compared with other multiarterial procedures with saphenous vein grafts, except when the left ventricular ejection fraction was below 30% (HR, 0.87; 95% CI, 0.67-1.13; P = .30).

Conclusions and Relevance

In this retrospective cohort study using data from a binational database, multiarterial procedures were associated with reduced long-term mortality risk compared with single arterial grafting across the spectrum of preoperative left ventricular ejection fractions. Total arterial revascularization was associated with incrementally improved survival, particularly among patients with preserved ejection fraction. Because most coronary surgery practice continues to use single arterial grafting, consideration to alter grafting strategy to multiarterial procedures may be indicated.

Demographic Factors and Aortic Stenosis-Related Death Locations: A Cross-Sectional Analysis

Background: Aortic stenosis (AS) imposes a significant mortality burden. Understanding demographic influences on the location of AS-related death is crucial for advancing equitable end-of-life care. Therefore, we investigated how demographic factors influence the location of death among AS patients in the United States. Methods: We completed a cross-sectional study utilizing US mortality data from the CDC's WONDER database for 2019. All files related to decedents with AS identified as the primary cause of death were obtained, including demographic information and death locations (i.e., inpatient facilities, outpatient/ER facilities, home, or hospice/nursing facilities). Associations between demographic factors (age, sex, race/ethnicity, marital status, and education) and place of death were assessed using multivariable logistic regression models, yielding odds ratios (ORs). Results: In 2019, most AS-related deaths occurred in inpatient facilities (38.3%, n = 5062), home (29.2%, n = 3859), or hospice/nursing facilities (28.6%, n = 3775). Higher odds of inpatient death were observed among Black (OR 1.67, p < 0.001) and Hispanic individuals (OR 1.91, p < 0.001) compared to White decedents. Those aged >85 years were more likely to die at home (OR 1.76, p < 0.001) or in hospice/nursing facilities (OR 7.80, p < 0.001). Males had increased odds of inpatient death (OR 1.09, p = 0.044) but decreased odds of hospice/nursing facility death (OR 0.87, p = 0.003). Higher education levels were associated with increased odds of home death (OR 1.33, p = 0.023) and decreased odds of hospice/nursing facility death (OR 0.71, p = 0.015). Conclusions: Demographic factors significantly influence the location of death among AS patients, emphasizing the need for culturally and socioeconomically tailored interventions to promote equitable end-of-life care.

Natural history of initially asymptomatic severe aortic stenosis: a one-stage meta-analysis

BACKGROUND

Current guidelines on the management strategy for patients with asymptomatic severe aortic stenosis (AS) remain unclear. This uncertainty stems from the lack of data regarding the natural history of these patients. To address this gap, we performed a systematic review and meta-analysis examining the natural history of asymptomatic severe AS patients receiving conservative treatment.

METHODS

The PubMed, Cochrane, and Embase databases were searched from inception to 24 January 2024 using the keywords "asymptomatic" AND "aortic" AND "stenosis". We included studies examining patients with asymptomatic severe AS. In interventional trials, only data from conservatively managed arms were collected. A one-stage meta-analysis was conducted using individual patient data reconstructed from published Kaplan-Meier curves. Sensitivity analysis was performed for major adverse cardiovascular outcomes in patients who remained asymptomatic throughout follow-up.

RESULTS

A total of 46 studies were included (n = 9545). The median time to the development of symptoms was 1.11 years (95% CI 0.90-1.53). 49.36% (40.85-58.59) of patients who were asymptomatic had suffered a major adverse cardiovascular event by 5 years. The median event-free time for heart failure hospitalization (HFH) was 5.50 years (95% CI 5.14-5.91) with 36.34% (95% CI 33.34-39.41) of patients experiencing an HFH by year 5. By 5 years, 79.81% (95% CI 69.26-88.58) of patients developed symptoms (angina, dyspnoea, syncope and others) and 12.36% (95% CI 10.01-15.22) of patients died of cardiovascular causes. For all-cause mortality, the median survival time was 9.15 years (95% CI 8.50-9.96) with 39.43% (CI 33.41-36.40) of patients dying by 5 years. The median time to AVR was 4.77 years (95% CI 4.39-5.17), with 52.64% (95% CI 49.85-55.48) of patients requiring an AVR by 5 years.

CONCLUSION

Our results reveal poor cardiovascular outcomes for patients with asymptomatic severe AS on conservative treatment. A significant proportion eventually requires an AVR. Further research is needed to determine if early intervention with AVR is more effective than conservative treatment.

Valve cells are crucial for efficient cardiac performance in Drosophila

Blood flow in metazoans is regulated by the activity of the heart. The open circulatory system of insects consists of relatively few structural elements that determine cardiac performance via their coordinated interplay. One of these elements is the intracardiac valve between the aorta and the ventricle. In Drosophila, it is built by only two cells, whose unique histology represents an evolutionary novelty. While the development and differentiation of these highly specialised cells have been elucidated previously, their physiological impact on heart performance is still unsolved. The present study investigated the physiological consequences of cardiac valve malformation in Drosophila. We show that cardiac performance is reduced if valves are malformed or damaged. Less blood is transported through the heart proper, resulting in a decreased overall transport capacity. A reduced luminal opening was identified as a main reason for the decreased heart performance in the absence of functional valves. Intracardiac hemolymph flow was visualised at the valve region by microparticle injection and revealed characteristic similarities to valve blood flow in vertebrates. Based on our data, we propose a model on how the Drosophila intracardiac valves support proper hemolymph flow and distribution, thereby optimising general heart performance.

Sacubitril-Valsartan Lowers Atrial Fibrillation Recurrence and Left Atrial Volume Post-catheter Ablation: Systematic Review and Meta-Analysis

INTRODUCTION

In patients with atrial fibrillation (AF) who have undergone catheter ablation, the comparative effectiveness of sacubitril-valsartan (SV) versus ACE inhibitors (ACEi) or angiotensin-receptor blockers (ARB) in preventing AF recurrence remains unclear. The purpose of the present systematic review and meta-analysis is to determine whether SV offers superior outcomes in this clinical setting.

METHODS

This study systematically reviewed PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating SV's efficacy in preventing AF recurrence after catheter ablation. Outcomes included AF recurrence and structural remodeling assessed via left ventricular ejection fraction (LVEF) and left atrial volume index (LAVi), with statistical analyses performed using Review Manager 5.1.7 and heterogeneity assessed via I2 statistics.

RESULTS

The analysis comprised 642 patients from three RCTs and one PMC (319 SV-treated). SV significantly reduced AF recurrence [risk ratios (RR) 0.54; 95% confidence intervals (CI) 0.41-0.70; p < 0.00001; I2 = 0%), a trend also observed when considering RCTs exclusively (RR 0.58; 95% CI 0.41-0.84; p = 0.004; I2 = 0%). Moreover, SV demonstrated a notable reduction in LAVi [mean deviation (MD) -5.34 mL/m2; 95% CI -8.77 to -1.91; p = 0.002; I2 = 57%] compared with ARB, alongside a significant improvement in LVEF (MD 1.83%; 95% CI 1.35-2.32; p < 0.00001; I2 = 0%). Subgroup analyses among patients with hypertension and LVEF < 50% also indicated lower AF recurrence with SV.

CONCLUSION

SV therapy exhibited superior efficacy in reducing AF recurrence compared with ACEi or ARB and demonstrated superior outcomes in attenuating atrial structural remodeling after catheter ablation. These findings underscore the potential of SV as a therapeutic option for patients with AF undergoing catheter ablation, highlighting its efficacy in mitigating AF recurrence and structural remodeling.

REGISTRATION

PROSPERO identifier number CRD42024497958.

A Case of Immediate Reduction of Severe Mitral Regurgitation After the Ablation of Atrial Flutter

Mitral regurgitation (MR) is a common valvular dysfunction often classified as primary or secondary, with the latter typically associated with left ventricular dysfunction or mitral annular dilation. A subset of MR is termed atrial functional MR, related to atrial fibrillation, but the relationship between atrial flutter and MR remains underexplored. This report describes the case of a 71-year-old man with severe MR and atrial flutter who experienced rapid improvement in MR severity following successful atrial flutter ablation and restoration of sinus rhythm. Initial echocardiography revealed severe left atrial dilation, moderate to severe eccentric MR, and moderate tricuspid regurgitation. Following ablation, MR severity significantly improved despite persistent left atrial dilation, with sustained improvement observed over two years alongside reverse remodeling of the left atrium. This case highlights the independent effect of atrial flutter on MR severity, separate from structural remodeling, and emphasizes the potential for rhythm control strategies to improve MR and avoid invasive valve interventions. It also raises important questions about the interplay between atrial arrhythmias and MR, underscoring the need for further studies to better understand atrial functional MR and its management.

The HbA1c/C-Peptide Ratio is Associated With the No-Reflow Phenomenon in Patients With ST-Elevation Myocardial Infarction

Currently, the gold standard treatment for ST-elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (pPCI), but even after successful pPCI, a perfusion disorder in the epicardial coronary arteries, termed no-reflow phenomenon (NR), can develop, resulting in short- and long-term adverse events. The present study assessed the relationship between NR and HbA1c/C-peptide ratio (HCR) in 1834 consecutive patients who underwent pPCI due to STEMI. Participants were divided into two groups according to NR status and the demographic, clinical and periprocedural characteristics of the groups were compared. NR developed in 352 (19.1%) of the patients in the study. While C-peptide levels were significantly lower in the NR group, HbA1c and HCR were significantly higher (P < .001, for all). In multivariable analysis, C-peptide, HbA1c, and HCR, were determined as independent predictors for NR (P < .05, for all). In Receiver Operating Characteristic (ROC) analysis, HCR predicted the NR with 80% specificity and 77% sensitivity. In STEMI patients, combining HbA1c and C-peptide in a single fraction has a predictive value for NR independent of diabetes. This ratio may contribute to risk stratification of STEMI patients.

AI-echocardiography: Current status and future direction

Echocardiography, which provides detailed evaluations of cardiac structure and pathology, is central to cardiac imaging. Traditionally, the assessment of disease severity, treatment effectiveness, and prognosis prediction relied on detailed parameters obtained by trained sonographers and the expertise of specialists, which can limit access and availability. Recent advancements in deep learning and large-scale computing have enabled the automatic acquisition of parameters in a short time using vast amounts of historical training data. These technologies have been shown to predict the presence of diseases and future cardiovascular events with or without relying on quantitative parameters. Additionally, with the advent of large-scale language models, zero-shot prediction that does not require human labeling and automatic echocardiography report generation are also expected. The field of AI-enhanced echocardiography is poised for further development, with the potential for more widespread use in routine clinical practice. This review discusses the capabilities of deep learning models developed using echocardiography, their limitations, current applications, and research utilizing generative artificial intelligence technologies.

Multimodality Imaging in the Diagnosis of Coronary Microvascular Disease: An Update

Coronary microvascular dysfunction (CMD) is characterized by structural and functional abnormalities in the coronary microvasculature which can lead to ischaemia and angina and is increasingly recognized as a major contributor to adverse cardiovascular outcomes. Despite its clinical importance, the diagnosis of CMD remains limited compared with traditional atherosclerotic coronary artery disease. Furthermore, the historical lack of non-invasive methods for detecting and quantifying CMD has hindered progress in understanding its pathophysiology and clinical implications. This review explores advancements in non-invasive cardiac imaging that have enabled the detection and quantification of CMD. It evaluates the clinical utility, strengths and limitation of these imaging modalities in diagnosing and managing CMD. Having improved our understanding of CMD pathophysiology, cardiac imaging can provide insights into its prognosis and enhance diagnostic accuracy. Continued innovation in imaging technologies is essential for advancing knowledge about CMD, leading to improved cardiovascular outcomes and patient care.

Assessing the Vulnerability of Splenectomized Patients to Severe COVID-19 Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Splenectomized/asplenic individuals are at a heightened risk for severe infections due to compromised immune function. However, the impact of splenectomy/asplenia on COVID-19 outcomes remains underexplored. This study aims to systematically review and meta-analyze the association between splenectomy/asplenia and severe COVID-19 outcomes.

METHODS

Following the PRISMA guidelines, databases including Scopus, MEDLINE/PubMed, and Web of Knowledge were searched for relevant articles published between January 2020 and June 2024. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for severe COVID-19 outcomes, with a random-effects model being used to account for heterogeneity. Out of 749 identified studies, 4 met the inclusion criteria.

RESULTS

The meta-analysis revealed a significant association between splenectomy/asplenia and overall severe COVID-19 outcomes (OR = 1.92; 95% CI = 1.06-3.47). Specifically, splenectomy/asplenia was significantly associated with increased COVID-19-related hospitalization (OR = 2.06; 95% CI = 1.21-3.49), while the association with COVID-19-related death was not statistically significant (OR = 1.52; 95% CI = 0.78-2.99). COVID-19 vaccination is strongly recommended for these patients.

CONCLUSIONS

Splenectomy/asplenia significantly increases the risk of severe COVID-19 outcomes, particularly hospitalization. The findings underscore the need for vigilant clinical management and targeted interventions for this vulnerable population. Further research is warranted to fully understand the risks and to develop effective guidelines for the protection of splenectomized individuals against COVID-19.

Evaluation of Hematological and Biochemical Parameters that Predict the No-reflow Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

Acute coronary syndromes (ACS) are one of the most common causes of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the main treatment strategy to restore myocardial perfusion. However, the no-reflow phenomenon (NRP) may block coronary flow. The present study focused on assessing and contrasting predictive parameters for NRP in ACS patients. Our research is a retrospective analysis. We assessed the parameters significantly associated with NRP using Cox regression and Receiver operating characteristic (ROC) Curve analysis. The study included 5122 patients who met the criteria. The average age of the patients was 63.9 + 13.2, and 74.4% were male. It was observed that NRP developed in 1.8% of all patients. Age, hemoglobin (Hb), white blood cell (WBC), glucose and low density lipoprotein cholesterol (LDL-C) were determined to be independent predictors of NRP. The power of these parameters to predict NRP was similar, and WBC was the most predictive (Area Under Curve (AUC): 0.605 95% CI: 0.539-0.671, P = .001). We believe that the use of these simple, practical, and routinely used hematological and biochemical parameters will help us predict the risk of developing NRP before pPCI. This information should improve management.

Sex-related differences in outcomes and prognosis of severe calcific mitral stenosis due to mitral annular calcification: A propensity-score matched cohort study

BACKGROUND

The prevalence of severe calcific mitral stenosis (MS) is higher in female patients. The aim of the study was to assess the sex-related differences in clinical characteristics and prognosis in patients with severe calcific MS.

METHODS

Among 7154 adult patients with MS due to mitral annular calcification who underwent echocardiography between October 2010 and August 2020, 287 patients with severe MS were retrospectively analyzed. The endpoint was all-cause mortality. We calculated a propensity score matched analysis with 22 potential confounding covariates including clinical characteristics and medication usage.

RESULTS

In the entire cohort, there was a predominance of female patients (66 %), and the mean age was 72 ± 11 years. While 97 patients (34 %) underwent MV intervention, 190 patients (66 %) were conservatively managed. During a median follow-up of 12 months (25th -75th percentile: 3-29 months), 102 patients (36 %) died. The cumulative survival rate of female patients was lower compared with male patients in conservative treatment group (p = 0.012), while the cumulative survival rate was comparable between the sexes in MV intervention group (p = 0.63). Even after propensity score matching in 170 patients (85 females and 85 males), similar results were obtained (p = 0.012 for conservative treatment group, p = 0.61 for MV intervention group).

CONCLUSIONS

Female sex predominated in patients with severe calcific MS. Female patients with severe calcific MS had worse prognosis than male patients when treated conservatively, while in patients undergoing MV intervention, prognosis was similar between the sexes.

Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making.

METHODS

We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR).

RESULTS

Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98-1.11; HR: 1.10, 95% CI: 0.94-1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85-1.12; HR: 0.94, 95% CI: 0.73-1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27-0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57-0.99, p = 0.04; HR: 0.64, 95% CI: 0.49-0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02-2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04-3.56, p = 0.04).

CONCLUSION

In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors.

Use of signal detection methods to identify associations between prenatal medication exposure and subsequent childhood cancers: a Nordic hypothesis-generating registry-based study

BACKGROUND

Childhood cancer is an important contributor to childhood mortality in high-income countries. Information on associations between childhood cancer and in-utero exposure is absent or limited for most medications. Signal detection methods identify medications where research should be focused but have not been applied to datasets containing prenatal medication exposures and childhood cancers.

RESEARCH DESIGN AND METHODS

The aim of this study was to apply and evaluate four signal detection methods - odds ratios (OR), the information component (IC), sequential probability ratio testing (SPRT), and Bayesian hierarchical models (BHM) - for identification of associations between medications dispensed during pregnancy and subsequent, incident diagnosis of childhood cancer <10 years, using linked Nordic registry data. Signal detection results were compared to propensity score adjusted odds ratios from generalized linear models.

RESULTS

Analysis was performed for 117 medication-cancer pairs with 5 or more observations. The OR had the greatest sensitivity (0.75). The IC had a greater specificity (0.98) than the OR (0.95).

CONCLUSIONS

The IC may be the most appropriate method for identifying signals within this type of data. Reported signals should not be considered sufficient evidence of causal association and must be followed-up by tailored investigations that consider confounding by indication.

Echocardiographic Findings in Jordanian Atrial Fibrillation Patients: Analysis from Jo-Fib Study

Background and Objectives: Atrial fibrillation (AF) carries a huge socioeconomic burden as it is the most encountered cardiac arrhythmia with a significant morbidity. Echocardiographic (Echo) imaging is of monumental value in providing insight into assessing the cardiac function and anatomy, etiology, and risk stratification of AF patients, which will ultimately lead to the best management plan. Materials and Methods: A total of 2160 adult patients diagnosed with AF in 18 hospitals and 30 out-patient cardiology clinics in Jordan and 1 hospital in the Palestinian Territories were enrolled in this study from May 2019 to January 2021. Ultimately, 1776 patients were included in the analysis after going through the exclusion criteria. Results: The majority of our participants were found to have normal EF at the time of enrollment, with only 31.6% exhibiting a decreased EF. Only 40% of overall patients had Echo evidence of left ventricular hypertrophy (LVH). These patients were older (70.27 ± 10.1 vs. 66.0 ± 14.3, p < 0.001), more obese (45.2% vs. 37.3%, p-value < 0.001), and had a more frequent occurrence of HTN (89.0% vs. 65.6%, p < 0.001) and DM (49.2% vs. 40.1%, p < 0.001) when compared to patients without LVH. A proportion of 84.2% of female patients had abnormal left atrial (LA) size (>3.8 cm), in contrast to only 53.4% of males (LA > 4.2 cm). Pulmonary hypertension (PH) was only observed in 27.9% of our patients, and when comparing patients with PH vs. patients without PH, decreased EF (<50%) (36.9% vs. 20.6%, p = 0.001), a higher prevalence of OSA (6.7% vs. 3.8%, p = 0.009), female predominance (60.3% vs. 39.7%, p < 0.001), and older age (70.2 ± 10.7 vs. 66.7 ± 13.6, p < 0.001) were observed in patients with PH. Conclusion: This study provides the first reported insights on the atrial fibrillation-related echocardiographic findings in a Middle Eastern population. Notably, our study demonstrates that the majority of the studied population have no evidence of LVH and have preserved EF on baseline. However, LA enlargement was extremely frequent among females but not in males, warranting further evaluation to determine the factors contributing to such a difference.

Supersaturated Oxygen Therapy as a Treatment for No Reflow

No reflow, an interruption in epicardial and microvascular blood flow, during percutaneous coronary intervention (PCI) is associated with adverse outcomes but continues to have limited therapeutic options. We present a case of a patient with multiple comorbidities, multivessel disease and reduced left ventricular function with calcified left anterior descending stenosis who was treated with rotational atherectomy, complicated by slow flow after balloon dilatation. Infusion of supersaturated oxygen (SSO2) into the left main was instituted as an adjunct to PCI, along with pharmacologic vasodilators. Subsequently, there was resolution of the patient's symptoms and improvement in ejection fraction postprocedurally. The potential role of SSO2 in treating patients with intraoperative no reflow is intriguing, given no reflow's current limited treatment options and known increased risk of adverse events (major adverse cardiovascular events, cardiogenic shock, and so on). SSO2 may be a promising therapy for PCI complicated by no reflow.

Valvular Heart Disease-A New Evolving Paradigm

Valvular heart disease is one of the most common cardiovascular diseases today and may result in severe limiting symptoms, a shortened lifespan, and, in some cases, sudden death. It is important to identify significant valve disease because intervention can restore quality of life and in many instances increase longevity. In most patients, the diagnosis of significant valvular heart disease can be made on the basis of a physical examination, yet nearly half of the patients who could benefit from interventions are not being recognized or referred. There have been major improvements in both the diagnosis and treatment of patients with valvular heart disease, with noninvasive echocardiography available to confirm the presence and severity of valve disease, better and more durable surgical procedures, and the advent of catheter-based therapies. There are now national guidelines to aid clinicians in the optimal timing of the intervention, which are presented. However, it is now recognized that the long-standing volume or pressure overload from valve disease can result in incipient ventricular dysfunction even before the onset of symptoms or a drop in ejection fraction; therefore, there is an impetus to recognize and to treat these patients earlier and earlier in the disease natural history. A shared decision-making process should play a key role in the final decision for therapy, outlining the goals and risks of possible intervention coupled with the patient's own needs and expectations.

Impact of Baseline Left Ventricular Ejection Fraction on Midterm Outcomes in Women Undergoing Transcatheter Aortic Valve Implantation: Insight from the WIN-TAVI Registry

Limited evidence exists concerning the prognostic impact of baseline left ventricular ejection fraction (LVEF) on outcomes among women undergoing transcatheter aortic valve implantation (TAVI), which we aimed to investigate in the present analysis. Patients from the Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized according to baseline LVEF into 3 groups: reduced (LVEF ≤40%), mildly reduced (LVEF between 41% and 49%), and preserved (LVEF ≥50%) LVEF. The primary (Valve Academic Research Consortium 2 [VARC-2]) efficacy point was defined as a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure, or valve-related dysfunction at 1 year. The primary (VARC-2) safety end point included all-cause mortality, stroke, major vascular complication, life-threatening bleeding, stage 2 to 3 acute kidney injury, coronary artery obstruction requiring intervention, or valve-related dysfunction requiring repeated procedures. A Cox regression model was performed using the preserved LVEF group as the reference. Among the 944 patients included, 764 (80.9%) exhibited preserved, 80 (8.5%) had mildly reduced, and 100 (10.6%) had reduced LVEF. The 1-year incidence of VARC-2 efficacy end point was numerically higher in patients with reduced LVEF, albeit not resulting in a significant risk difference. Notably, reduced LVEF was associated with a higher risk of the 1-year VARC-2 safety end point, still significant after adjustment (28.0% vs 19.6%, Hazard Ratio 1.78, 95% Confidence Interval 1.12- 2.82, p = 0.014). These differences were primarily driven by trends toward increased rates of all-cause mortality, cardiovascular mortality, and major vascular complications. Clinical outcomes were similar between patients with mildly reduced and preserved LVEF. In conclusion, when performed in women with reduced LVEF, TAVI was associated with a worse (VARC-2) safety profile at 1-year follow-up. In contrast, patients with mildly reduced LVEF appeared to align more closely with outcomes observed in the preserved LVEF group than with the reduced LVEF group.

Long-term outcomes of women compared to men after off-pump coronary artery bypass grafting-a propensity-matched analysis

Background

Literature is not clear whether women experience increased mortality and adverse events after coronary artery bypass grafting (CABG). Studies have shown that women had comparative outcomes to men in off-pump CABG (OPCAB). Hence, we undertook this study to understand the short- and long-term outcomes of women compared to men after OPCAB.

Methods

Two thousand two hundred patients who underwent OPCAB from November 2014 to December 2021 were included in the study. Median follow-up period was 4.8 years. We performed propensity matching to match 404 women to 404 men.

Results

In the unmatched cohort, women had increased cardiovascular mortality and inferior major adverse cardiovascular and cerebral event (MACCE)-free survival. In the matched cohorts, there was no difference in the 30-day mortality, long-term survival, MACCE-free survival, and cardiovascular mortality between the sexes. Cox proportional hazard showed post-operative renal failure (p-value < 0.001; hazard ratio (HR) 11.469) (confidence interval (CI) 2.911-45.180), post-operative stroke (p-value 0.023, HR 6.473) (CI 1.295-32.356), EuroSCORE II > 6 (p-value 0.022, HR 3.561) (1.204-10.531), emergency surgery (p-value 0.022, HR 3.498) (CI 1.202-10.177), and ventilation hours (p-value 0.004, HR 3.327) (CI 1.455-7.607) were the risk factors associated with long-term mortality in women.

Conclusion

Our study showed that the increased risk profile of women was the reason for inferior MACCE-free survival and increased cardiovascular mortality in women in the long term after OPCAB. When the risk factors were matched, women had comparable outcomes to men.

Graphical Abstract

Prognostic Value of Multiple Complete Blood Count-Derived Indices in Intermediate Coronary Lesions

Complete blood count (CBC)-derived indices have been proposed as reliable inflammatory biomarkers to predict outcomes in the context of coronary artery disease. These indices have yet to be thoroughly validated in patients with intermediate coronary stenosis. Our study included 1527 patients only with intermediate coronary stenosis. The examined variables were neutrophil-lymphocyte ratio (NLR), derived NLR, monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), system inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI). The primary endpoint was the composite of major adverse cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, and unplanned revascularization. Over a follow-up of 6.11 (5.73-6.55) years, MACEs occurred in 189 patients. Receiver operator characteristic curve analysis showed that SIRI outperformed other indices with the most significant area under the curve. In the multivariable analysis, SIRI (hazard ratio [HR] 1.588, 95% confidence interval [CI] 1.138-2.212) and AISI (HR 1.673, 95% CI 1.217-2.300) were the most important prognostic factors among all the indices. The discrimination ability of each index was strengthened in patients with less burden of modifiable cardiovascular risk factors. SIRI also exhibited the best incremental value beyond the traditional cardiovascular risk model.

Pregnancy-Associated Myocardial Infarction in Alberta: A Population-Based Study

Background

Cardiac disease is the leading cause of maternal mortality in developed countries, and myocardial infarction (MI) is an important cause of pregnancy-associated morbidity and mortality. These infrequent, but very serious, events are not optimally described in the medical literature.

Objectives

This study describes a 15-year consecutive, retrospective cohort of confirmed pregnancy-associated MIs (PAMIs) identified in Alberta, Canada (2003-2017).

Methods

Utilizing a provincial administrative database, a cohort of women with PAMI were identified using a validated algorithm. Additional cases were identified by reviewing provincial maternal mortality records. Medical record review was conducted on each case with further details obtained via linkage with a provincial coronary heart disease registry. Available angiographic images were also reviewed.

Results

Forty-three cases of PAMI were identified in Alberta between 2003 and 2017, providing a crude incidence of ∼5.64/100,000 births. Rates of PAMI increased over the study period. Of the identified MIs, 16.3% occurred antepartum (mean gestational age of 18 weeks), while 30.2% were peripartum and 53.4% occurred within 6 months postpartum (at a mean of 7.8 weeks after delivery). The most common mechanism of PAMI was spontaneous coronary artery dissection (44.2%) and this mechanism predominated postpartum. Coronary artery disease was a frequent antepartum cause of MI, whereas demand ischemia was the leading cause of peripartum MI. Maternal mortality was approximately 9%.

Conclusions

PAMI is an increasing cause of maternal morbidity and mortality in Alberta. Clinicians should have a high index of suspicion for PAMI and ensure optimal management of this dangerous complication of pregnancy.

Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis

BACKGROUND

For patients with asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction, current guidelines recommend routine clinical surveillance every 6 to 12 months. Data from randomized trials examining whether early intervention with transcatheter aortic-valve replacement (TAVR) will improve outcomes in these patients are lacking.

METHODS

At 75 centers in the United States and Canada, we randomly assigned, in a 1:1 ratio, patients with asymptomatic severe aortic stenosis to undergo early TAVR with transfemoral placement of a balloon-expandable valve or clinical surveillance. The primary end point was a composite of death, stroke, or unplanned hospitalization for cardiovascular causes. Superiority testing was performed in the intention-to-treat population.

RESULTS

A total of 901 patients underwent randomization; 455 patients were assigned to TAVR and 446 to clinical surveillance. The mean age of the patients was 75.8 years, the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 1.8% (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after surgery), and 83.6% of patients were at low surgical risk. A primary end-point event occurred in 122 patients (26.8%) in the TAVR group and in 202 patients (45.3%) in the clinical surveillance group (hazard ratio, 0.50; 95% confidence interval, 0.40 to 0.63; P<0.001). Death occurred in 8.4% of the patients assigned to TAVR and in 9.2% of the patients assigned to clinical surveillance, stroke occurred in 4.2% and 6.7%, respectively, and unplanned hospitalization for cardiovascular causes occurred in 20.9% and 41.7%. During a median follow-up of 3.8 years, 87.0% of patients in the clinical surveillance group underwent aortic-valve replacement. There were no apparent differences in procedure-related adverse events between patients in the TAVR group and those in the clinical surveillance group who underwent aortic-valve replacement.

CONCLUSIONS

Among patients with asymptomatic severe aortic stenosis, a strategy of early TAVR was superior to clinical surveillance in reducing the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes. (Funded by Edwards Lifesciences; EARLY TAVR ClinicalTrials.gov number, NCT03042104.).

Accuracy of Three-Dimensional Neo Left Ventricular Outflow Tract Simulations With Transcatheter Mitral Valve Replacement in Different Mitral Phenotypes

BACKGROUND

Transcatheter mitral valve replacement (TMVR) is emerging in the context of annular calcification (valve-in-MAC; ViMAC), failing surgical mitral annuloplasty (mitral-valve-in-ring; MViR) and failing mitral bioprosthesis (mitral-valve-in-valve; MViV). A notorious risk of TMVR is neo left ventricular outflow tract (neo-LVOT) obstruction. Three-dimensional computational models (3DCM) are derived from multi-slice computed tomography (MSCT) and aim to predict neo-LVOT area after TMVR. Little is known about the accuracy of these neo-LVOT predictions for various mitral phenotypes.

METHODS

Preprocedural 3DCMs were created for ViMAC, MViR and MViV cases. Throughout the cardiac cycle, neo-LVOT dimensions were semi-automatically calculated on the 3DCMs. We compared the predicted neo-LVOT area on the preprocedural 3DCM with the actual neo-LVOT as measured on the post-procedural MSCT.

RESULTS

Across 12 TMVR cases and examining 20%-70% of the cardiac phase, the mean difference between predicted and post-TMVR neo-LVOT area was -23 ± 28 mm2 for MViR, -21 ± 34 mm2 for MViV and -73 ± 61 mm2 for ViMAC. The mean intra-class correlation coefficient for absolute agreement between predicted and post-procedural neo-LVOT area (throughout the whole cardiac cycle) was 0.89 (95% CI 0.82-0.94, p < 0.001) for MViR, 0.81 (95% CI 0.62-0.89, p < 0.001) for MViV, and 0.41 (95% CI 0.12-0.58, p = 0.002) for ViMAC.

CONCLUSIONS

Three-dimensional computational models accurately predict neo-LVOT dimensions post TMVR in MViR and MViV but not in ViMAC. Further research should incorporate device host interactions and the effect of changing hemodynamics in these simulations to enhance accuracy in all mitral phenotypes.

CardiacField: computational echocardiography for automated heart function estimation using two-dimensional echocardiography probes

Aims

Accurate heart function estimation is vital for detecting and monitoring cardiovascular diseases. While two-dimensional echocardiography (2DE) is widely accessible and used, it requires specialized training, is prone to inter-observer variability, and lacks comprehensive three-dimensional (3D) information. We introduce CardiacField, a computational echocardiography system using a 2DE probe for precise, automated left ventricular (LV) and right ventricular (RV) ejection fraction (EF) estimations, which is especially easy to use for non-cardiovascular healthcare practitioners. We assess the system's usability among novice users and evaluate its performance against expert interpretations and advanced deep learning (DL) tools.

Methods and results

We developed an implicit neural representation network to reconstruct a 3D cardiac volume from sequential multi-view 2DE images, followed by automatic segmentation of LV and RV areas to calculate volume sizes and EF values. Our study involved 127 patients to assess EF estimation accuracy against expert readings and two-dimensional (2D) video-based DL models. A subset of 56 patients was utilized to evaluate image quality and 3D accuracy and another 50 to test usability by novice users and across various ultrasound machines. CardiacField generated a 3D heart from 2D echocardiograms with <2 min processing time. The LVEF predicted by our method had a mean absolute error (MAE) of 2.48 % , while the RVEF had an MAE of 2.65 % .

Conclusion

Employing a straightforward apical ring scan with a cost-effective 2DE probe, our method achieves a level of EF accuracy for assessing LV and RV function that is comparable to that of three-dimensional echocardiography probes.

Use of artificial intelligence to predict outcomes in mild aortic valve stenosis

Aims

Aortic stenosis (AS) is a common and progressive disease, which, if left untreated, results in increased morbidity and mortality. Monitoring and follow-up care can be challenging due to significant variability in disease progression. This study aimed to develop machine learning models to predict the risks of disease progression and mortality in patients with mild AS.

Methods and results

A comprehensive database including 9611 patients with serial transthoracic echocardiograms was collected from a single institution across three clinical sites. The data set included parameters from echocardiograms, electrocardiograms, laboratory values, and diagnosis codes. Data from a single clinical site were preserved as an independent test group. Machine learning models were trained to identify progression to severe stenosis and all-cause mortality and tested in their performance for endpoints at 2 and 5 years. In the independent test group, the AS progression model differentiated those with progression to severe AS within 2 and 5 years with an area under the curve (AUC) of 0.86 for both. The feature of greatest importance was aortic valve mean gradient, followed by other valve haemodynamic measurements including valve area and dimensionless index. The mortality model identified those with mortality within 2 and 5 years with an AUC of 0.84 and 0.87, respectively. Smaller reduced-input validation models had similarly robust findings.

Conclusion

Machine learning models can be used in patients with mild AS to identify those at high risk of disease progression and mortality. Implementation of such models may facilitate real-time, patient-specific follow-up recommendations.

Latest evidence on assessment and invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in the older population

INTRODUCTION

Invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) should be considered regardless of age, but a key challenge is deciding which patients are most likely to benefit from an invasive approach in the older population. In addition to assessment of the clinical signs and symptoms, a holistic assessment of geriatric syndromes such as frailty, multimorbidity and cognitive impairment is of increasing importance. Recent trials have validated the roles of physiological assessment and intracoronary imaging to guide revascularisation.

AREAS COVERED

This review focuses on the comparison between invasive and conservative management in the older population with NSTE-ACS, the clinical characteristics of the older population with NSTE-ACS, and the role of physiological assessment and intracoronary imaging to guide revascularisation in this cohort.

EXPERT OPINION

Invasive management in the older population with NSTE-ACS may not improve mortality but reduces the risk of non-fatal myocardial infarction and repeat revascularisation. Decisions surrounding invasive versus conservative management should be individualized to each patient, depending on patient preference, clinical features, comorbidities and frailty. In patients where invasive management is indicated, a combination of physiological assessment and intracoronary imaging is likely to improve revascularisation outcomes, especially in the context of complex anatomical characteristics like multivessel disease.

Clot lysis time and thrombin generation in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Aortic valve stenosis (AS) is the most prevalent valvular heart disease and is associated with a significant increase in mortality. AS has been shown to be linked with numerous coagulation system abnormalities, including increased fibrin deposition on the stenotic aortic valves. Transcatheter aortic valve implantation (TAVI) is the primary treatment method for patients at high surgical risk.

OBJECTIVES

The aim of the study was to assess the impact of treating severe AS with TAVI on thrombin generation and clot lysis time (CLT).

METHODS

We studied 135 symptomatic AS patients recommended for TAVI by the local Heart Team. All measurements were performed before and 5-7 days after TAVI. Alongside clinical assessment and echocardiographic analysis, we assessed clot lysis time (CLT) and thrombin generation parameters, including lag time, peak thrombin generation, time to peak thrombin generation (ttPeak), and endogenous thrombin potential (ETP).

RESULTS

70 patients were included in the final analysis. After TAVI, there was a significant 9% reduction in CLT despite a 12% increase in fibrinogen concentration. We observed significant increase in lag time and ttPeak (20% and 12%, respectively), and 13% decrease in peak thrombin concentration compared to pre-procedural levels. Multivariable linear regression analysis demonstrated that baseline CLT and C-reactive protein (CRP) levels were independent predictors of significant reduction in mean aortic gradient, defined as TAVI procedure success.

CONCLUSIONS

CLT and peak thrombin concentration decreased, while Lag time and ttPeak increased significantly after TAVI. Multivariable linear regression analysis demonstrated CLT and CRP levels as independent predictors of achieving a reduction in mean aortic gradient, defining TAVI procedure success.

Impact of pulmonary hypertension on short-term outcomes in patients undergoing surgical aortic valve replacement for severe aortic valve stenosis

OBJECTIVES

In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center.

METHODS

In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data.

RESULTS

Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR.

CONCLUSION

In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.

Degenerative mitral stenosis by echocardiography: presentation and outcome

AIMS

Degenerative mitral stenosis (DMS) is due to degenerative mitral annular calcification (MAC) and valvular calcification. However, DMS impacts on the outcome, and therefore, potential treatment needs are poorly known. We aimed at evaluating survival after DMS diagnosis by Doppler echocardiography in routine practice.

METHODS AND RESULTS

A cohort of 2937 (75 ± 12 years, 67% women) consecutive patients were diagnosed between 2003 and 2014 with DMS (diastolic mean gradient ≥ 5 mmHg), with analysis of short- and long-term survival. All patients had overt mitral annular/valvular degenerative calcification without rheumatic involvement. Mean gradient was 6.5 ± 2.4 mmHg, and DMS was considered mild in 50%, moderate in 44%, and severe in 6%. DMS was associated with left atrial enlargement (52 ± 23 mL/m2) and elevated pulmonary pressure (49 ± 16 mmHg) despite generally normal ejection fraction (61 ± 13%). DMS was associated with frequent comorbid conditions (74% hypertension, 58% coronary disease, and 52% heart failure) and humoural alterations (haemoglobin 11.3 ± 1.8 g/dL and creatinine 1.5 ± 1.4 mg/dL). One-year mortality was 22%, most strongly related to older age, higher comorbidity, and abnormal haemoglobin/creatinine but only weakly to DMS severity (with anaemia 42% irrespective of DMS severity, P = 0.99; without anaemia 18, 23, and 28% with mild, moderate, and severe DMS, respectively, P < 0.0004). Long-term mortality was high (56% at 5 years) also mostly linked to aging and weakly to DMS severity [with anaemia P = 0.90; without anaemia: adjusted-hazard ratio: 1.30 (1.19-1.42), P < 0.0001, for moderate vs. mild DMS and 1.63 (1.34-1.98), P < 0.0001, for severe vs. mild DMS].

CONCLUSION

DMS is a condition of the elderly potentially resulting in severe mitral obstruction and haemodynamic alterations. However, DMS is frequently associated with severe comorbidities imparting considerable mortality following diagnosis, whereas DMS severity is a weak (albeit independent) determinant of mortality. Hence, patients with DMS should be carefully evaluated and interventional/surgical treatment prudently considered in those with limited comorbidity burden, particularly without anaemia. Keywords: Degenerative Mitral Stenosis; Outcome; Natural history; Ecocardiography; Mitral Stenosis.

A Machine Learning Model for the Prediction of No-Reflow Phenomenon in Acute Myocardial Infarction Using the CALLY Index

BACKGROUND

Acute myocardial infarction (AMI) constitutes a major health problem with high mortality rates worldwide. In patients with ST-segment elevation myocardial infarction (STEMI), no-reflow phenomenon is a condition that adversely affects response to therapy. Previous studies have demonstrated that the CALLY index, calculated using C-reactive protein (CRP), albumin, and lymphocytes, is a reliable indicator of mortality in patients with non-cardiac diseases. The objective of this study is to investigate the potential utility of the CALLY index in detecting no-reflow patients and to determine the predictability of this phenomenon using machine learning (ML) methods.

METHODS

This study included 1785 STEMI patients admitted to the clinic between January 2020 and June 2024 who underwent percutaneous coronary intervention (PCI). Patients were in no-reflow status, and other clinical data were analyzed. The CALLY index was calculated using data on patients' inflammatory status. The Extreme Gradient Boosting (XGBoost) ML algorithm was used for no-reflow prediction.

RESULTS

No-reflow was detected in a proportion of patients participating in this study. The model obtained with the XGBoost algorithm showed high accuracy rates in predicting no-reflow status. The role of the CALLY index in predicting no-reflow status was clearly demonstrated.

CONCLUSIONS

The CALLY index has emerged as a valuable tool for predicting no-reflow status in STEMI patients. This study demonstrates how machine learning methods can be effective in clinical applications and paves the way for innovative approaches for the management of no-reflow phenomenon. Future research needs to confirm and extend these findings with larger sample sizes.

The emerging challenge of Enterococcus faecalis endocarditis after transcatheter aortic valve implantation: time for innovative treatment approaches

SUMMARYInfective endocarditis (IE) is a life-threatening infection that has nearly doubled in prevalence over the last two decades due to the increase in implantable cardiac devices. Transcatheter aortic valve implantation (TAVI) is currently one of the most common cardiac procedures. TAVI usage continues to exponentially rise, inevitability increasing TAVI-IE. Patients with TAVI are frequently nonsurgical candidates, and TAVI-IE 1-year mortality rates can be as high as 74% without valve or bacterial biofilm removal. Enterococcus faecalis, a historically less common IE pathogen, is the primary cause of TAVI-IE. Treatment options are limited due to enterococcal intrinsic resistance and biofilm formation. Novel approaches are warranted to tackle current therapeutic gaps. We describe the existing challenges in treating TAVI-IE and how available treatment discovery approaches can be combined with an in silico "Living Heart" model to create solutions for the future.

Comprehensive Analysis of Cardiovascular Diseases: Symptoms, Diagnosis, and AI Innovations

Cardiovascular diseases are some of the underlying reasons contributing to the relentless rise in mortality rates across the globe. In this regard, there is a genuine need to integrate advanced technologies into the medical realm to detect such diseases accurately. Moreover, numerous academic studies have been published using AI-based methodologies because of their enhanced accuracy in detecting heart conditions. This research extensively delineates the different heart conditions, e.g., coronary artery disease, arrhythmia, atherosclerosis, mitral valve prolapse/mitral regurgitation, and myocardial infarction, and their underlying reasons and symptoms and subsequently introduces AI-based detection methodologies for precisely classifying such diseases. The review shows that the incorporation of artificial intelligence in detecting heart diseases exhibits enhanced accuracies along with a plethora of other benefits, like improved diagnostic accuracy, early detection and prevention, reduction in diagnostic errors, faster diagnosis, personalized treatment schedules, optimized monitoring and predictive analysis, improved efficiency, and scalability. Furthermore, the review also indicates the conspicuous disparities between the results generated by previous algorithms and the latest ones, paving the way for medical researchers to ascertain the accuracy of these results through comparative analysis with the practical conditions of patients. In conclusion, AI in heart disease detection holds paramount significance and transformative potential to greatly enhance patient outcomes, mitigate healthcare expenditure, and amplify the speed of diagnosis.

The Impact of the Coexistence of Frailty Syndrome and Cognitive Impairment on Early and Midterm Complications in Older Patients with Acute Coronary Syndromes

Background/Objectives: The ageing population has heightened interest in the prognostic role of geriatric conditions, notably frailty syndrome (FS) and cognitive impairment (CI). Evidence indicates a significant link between cardiovascular disease, FS, and CI. However, limited research has explored the impact of impaired functional and cognitive performance on outcomes in acute coronary syndrome (ACS) patients. This study aimed to evaluate the effect of coexisting FS and CI (FSxCI) on early and 6-month complications in older adults with ACS. Methods: This study included 196 ACS patients (119 men) aged 65 and over (mean = 74.7 years), with 90.8% undergoing invasive treatment (PCI in 81.6%, CABG in 9.2%). FS and CI were assessed on the third hospital day using the Tilburg Frailty Indicator (TFI) and Mini Mental State Examination (MMSE). Early (in-hospital) complications included major bleeding, ventricular arrhythmia (VT), conduction disturbances, cardiac arrest, stent thrombosis, acute heart failure (Killip-Kimball class III/IV), stroke, prolonged stay, and in-hospital death. Six-month follow-up recorded major adverse cardiovascular and cerebrovascular events (MACCEs). Results: Patients with FSxCI (n = 107, 54.6%) were older and had higher hypertension prevalence and lower nicotine dependence. FSxCI patients faced over twice the risk of prolonged hospital stays (OR 2.39; p = 0.01) and nearly three times the risk of early complications (OR 2.73; p < 0.001). At 6 months, FSxCI tripled the risk of MACCEs (OR 2.8; p = 0.007). Kaplan-Meier analysis confirmed a worse 6-month prognosis for FSxCI patients. Conclusions: Elderly patients with ACS and concomitant FSxCI had significantly higher rates of early (in-hospital) and 6-month complications. FSxCI was associated with a worse 6-month prognosis. This highlights its significance for clinical decision-making, as identifying FSxCI in ACS patients can help prioritize high-risk individuals for tailored interventions, optimize resource allocation, and improve outcomes.

Sex differences in long-term heart failure prognosis: a comprehensive meta-analysis

AIMS

Sex differences in the long-term prognosis of heart failure (HF) remain controversial, and there is a lack of comprehensive pooling of the sex differences in outcomes of HF. This study aims to characterize the sex differences in the long-term prognosis of HF and explore whether these differences vary by age, HF course, left ventricular ejection fraction, region, period of study, study design, and follow-up duration.

METHODS AND RESULTS

A systematic review was conducted using Medline, Embase, Web of Science, and the Cochrane Library, from 1 January 1990 to 31 March 2024. The primary outcome was all-cause mortality (ACM), and the secondary outcomes included cardiovascular mortality (CVM), hospitalization for HF (HHF), all-cause hospitalization, a composite of ACM and HHF, and a composite of CVM and HHF. Pooled hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Ninety-four studies (comprising 96 cohorts) were included in the meta-analysis, representing 706,247 participants (56.5% were men; the mean age was 71.0 years). Female HF patients had a lower risk of ACM (HR 0.83; 95% CI 0.80, 0.85; I2 = 84.9%), CVM (HR 0.84; 95% CI 0.79, 0.89; I2 = 70.7%), HHF (HR 0.94; 95% CI 0.89, 0.98; I2 = 84.0%), and composite endpoints (ACM + HHF: HR 0.89; 95% CI 0.83, 0.95; I2 = 80.0%; CVM + HHF: HR 0.85; 95% CI 0.77, 0.93; I2 = 87.9%) compared with males. Subgroup analysis revealed that the lower risk of mortality observed in women was more pronounced among individuals with long-course HF (i.e. chronic HF, follow-up duration > 2 years) or recruited in the randomized controlled trials (P for interaction < 0.05).

CONCLUSION

Female HF patients had a better prognosis compared with males, with lower risks of ACM, CVM, HHF, and composite endpoints. Despite the underrepresentation of female populations in HF clinical trials, their mortality benefits tended to be lower than in real-world settings.

REGISTRATION

PROSPERO: CRD42024526100.