Use of Cardiovascular Disease Secondary Prevention Medications in Four Middle East Countries in a Community Setting

Background

Evidence-based International clinical practice guidelines, universally recommend secondary prevention medications for those with previous cardiovascular disease (CVD). There is limited data on the community use of these medications in the Middle East (ME).

Objectives

This study assesses the use and predictors of evidence based secondary prevention medications in individuals with a history of CVD [coronary heart disease (CHD) or stroke].

Methods

Between 2005 and 2015, we enrolled 11,228 individuals aged between 35-70 years from 52 urban and 35 rural communities from four ME countries, United Arab Emirates (n = 1499), Kingdom of Saudi Arabia (n = 2046), Occupied Palestinian Territory (n = 1668) and Islamic Republic of Iran (n = 6013). With standardized questionnaires, we report estimates of medication use in those with CVD at national level and the independent predictors of their utilization through a multivariable analysis model. Results: Of the total ME cohort, 614 (5.5%) had CVD, of which 115 (1.0%) had stroke, 523 (4.7%) had CHD and 24 (0.2%) had both. The mean age of those with CVD was 56.6 ± 8.8 years and 269 (43.8%) were female. Overall, only 23.5% of those with CVD reported using three or more proven secondary prevention medications, and a substantial proportion (stroke 27.8%, CHD 25.8%) did not take any of these medications. In a fully adjusted analysis, increasing age, female gender, higher education, higher wealth in individual household, residence in a higher income country as well as being obese, hypertensive or diabetic were independent predictors of medication use.

Conclusion

The use of secondary prevention medication is low in ME and has not reached the modest recommended WHO target of 50% use of 3 or more medications. Independent factors of higher use were, better socioeconomic status (household wealth, country wealth and education) and better contact and accessibility to health care (increasing age, female gender, obesity, diabetes and hypertension).

Exploring the Relationship between Acute Coronary Syndrome, Lower Respiratory Tract Infections, and Atmospheric Pollution

Background: Respiratory infections were found to be connected with the incidence of acute coronary syndrome (ACS). The proposed pathway of this connection includes inflammation, oxidative stress, pro-coagulation, and atherosclerotic plaque destabilization. This can cause rapture and thrombus formation, leading to ACS. Our study aimed to assess the risk factors for coronary artery thrombosis as a manifestation of ACS and for lower respiratory tract infections (LRTIs) in patients with ACS. Methods: The study included 876 patients with ACS from January 2014 to December 2018. Both the clinical data and air pollution data were analyzed. Statistical tests used for analysis included Student's t-test, the Mann-Whitney U-test, the Chi-squared test, and the odds ratio Altman calculation. Results: LRTIs were found in 9.13% patients with ACS. The patients with LRTI had a higher risk of coronary artery thrombosis (OR: 2.4903; CI: 1.3483 to 4.5996). Moreover, they had increased values of inflammatory markers, were older, had a lower BMI, and a higher rate of atrial fibrillation. The average atmospheric aerosols with a maximum diameter of 2.5 μm (PM2.5 concentration) from three consecutive days before hospitalization for ACS were higher in patients with LRTI. Conclusions: The occurrence of coronary artery thrombosis was higher among the patients with LRTI during ACS. PM2.5 exposition was higher in the three consecutive days before hospitalization in patients with LRTI during ACS.

Investigation of the Usefulness of HALP Score in Predicting Short-Term Mortality in Patients with Acute Decompensated Heart Failure in a Coronary Care Unit

Background/Objectives: Acute decompensated heart failure (ADHF) presents a significant clinical challenge characterized by frequent hospitalizations, high mortality rates, and substantial healthcare costs. The united index of hemoglobin, albumin, lymphocytes and platelets (HALP) is a new indicator that reflects systemic inflammation and nutritional status. This study aimed to investigate the prognostic utility of the HALP score and hematological parameters in predicting short-term mortality among ADHF patients admitted to the coronary care unit (CCU). Methods: This investigation adopts a retrospective observational design, encompassing a cohort of patients with ADHF who were followed in the CCU at our medical institution between January 2019 and April 2024. Results: The cohort of 227 individuals was dichotomized into two subsets based on the presence or absence of short-term mortality in the hospital, resulting in 163 (71.8%) and 64 (28.2%) individuals in the survivor and exitus groups, respectively. Age was significantly higher in the exitus group (p-value = 0.004). Hemoglobin, lymphocyte count, platelet count, albumin, and HALP score were significantly higher in the survivor group (all p-values < 0.001). No significant difference was observed between the groups in terms of gender, diabetes mellitus (DM), coronary artery disease (CAD), or ejection fraction (EF), although hypertension (HT) prevalence was significantly higher in the exitus group (p-value = 0.038). ROC analysis demonstrated that hemoglobin, lymphocyte, albumin, and HALP score had significant discriminative power, with albumin showing the highest AUC (0.814). Conclusions: In conclusion, the HALP score and hematological parameters represent valuable prognostic feature for short-term mortality prediction in ADHF patients admitted to the CCU. These findings underscore the importance of early risk stratification and targeted interventions guided by comprehensive biomarker assessments in optimizing patient outcomes.

Decoding Pulmonary Embolism: Pathophysiology, Diagnosis, and Treatment

Pulmonary Embolism (PE) is a life-threatening condition initiated by the presence of blood clots in the pulmonary arteries, leading to severe morbidity and mortality. Underlying mechanisms involve endothelial dysfunction, including impaired blood flow regulation, a pro-thrombotic state, inflammation, heightened oxidative stress, and altered vascular remodeling. These mechanisms contribute to vascular diseases stemming from PE, such as recurrent thromboembolism, chronic thromboembolic pulmonary hypertension, post-thrombotic syndrome, right heart failure, and cardiogenic shock. Detailing key risk factors and utilizing hemodynamic stability-based categorization, the review aims for precise risk stratification by applying established diagnostic tools and scoring systems. This article explores both conventional and emerging biomarkers as potential diagnostic tools. Additionally, by synthesizing existing knowledge, it provides a comprehensive outlook of the current enhanced PE management and preventive strategies. The conclusion underscores the need for future research to improve diagnostic accuracy and therapeutic effectiveness in PE.

Relationship between serum vitamin C and serum uric acid in people with different BMIs: results from the NHANES 2017-2018 and Mendelian randomization study

Objective

To examine the association of overweight/obesity and serum vitamin C (serum VC) with serum uric acid (SUA) and to assess causality using Mendelian randomization (MR).

Methods

4,772 participants from the National Health and Nutrition Examination Survey (NHANES), 2017-2018 were included in this study. Multivariate linear regression, variance inflation factor and quantile regression were used to analyze the relationships between overweight/obesity and serum VC and SUA levels. Secondly, Mendelian randomization (MR) was utilized to mitigate bias and prevent reverse causality in the observational study. Genetic variants associated with obesity (N = 13,848), vitamin C levels (N = 64,979) and serum uric acid levels (N = 343,836) were sourced from the most extensive genome-wide association studies (GWAS). The primary analytical method employed was inverse variance weighted (IVW).

Results

Based on the observational study, BMI was positively associated with SUA (β = 0.06, 95% CI: 0.05 to 0.07, p < 0.001) and serum VC was negatively associated with SUA (β = -0.14, 95% CI: -0.23 to -0.04, p = 0.005). In individuals with overweight/obesity (BMI > =25), the negative effects of serum VC on SUA enhanced with increasing serum VC. High serum VC level (Q4 level, above 1.19 mg/dL) reduced SUA (β = -0.30, 95% CI: -0.47 to -0.14, p < 0.001) in individuals with overweight/obesity compared to low serum VC level (Q1 level, below 0.54 mg/dL). IVW-MR analysis revealed a significant association between SUA levels and genetically elevated levels of VC (β = -0.03, 95% CI: -0.06 to -0.00, p = 0.029) and obesity (β = 0.06, 95% CI: 0.04 to 0.07, p < 0.001).

Conclusion

Cross-sectional observational analysis revealed that BMI exhibited a positive correlation with SUA levels and that serum VC was negatively correlated with SUA levels; moreover, moderate serum VC can reduce SUA, especially in individuals with overweight/obesity. There was evidence indicating a causal effect of VC and obesity on SUA. It highlights the importance of VC in the management of SUA levels, particularly in overweight/obese individuals. The findings might be helpful for the management of high SUA levels.

Medication adherence and associated factors among chronic heart failure patients on follow-up in north Shewa public hospitals, Oromia region, Ethiopia

BACKGROUND

Chronic heart failure affects approximately 26 million people globally. World Health Organization data show that only approximately half of chronically ill patients in developed countries adhere to recommended medication, with even lower rates in developing countries. Medication adherence is critical for managing chronic heart failure symptoms, delaying disease progression, and preventing hospitalizations. However, poor adherence increases rehospitalization, morbidity, mortality, and healthcare costs.

OBJECTIVE

To assess medication adherence and associated factors among chronic heart failure patients on follow-up at North Shewa Public Hospitals, Oromia Region, Ethiopia, in 2023.

METHODS

This institutional-based cross-sectional study was conducted from March 1 to April 30, 2023, G.C. A total of 603 individuals were selected consecutively among those who underwent chronic OPD after being proportionally allocated to five hospitals in the zone. The data were collected using an interviewer-administered questionnaire and a medical chart review. The data were entered into Epi-data version 3.1 and then exported to SPSS version 26 for analysis. The multivariable logistic regression model included variables with a P value < 0.25 in the bivariate analysis. The degree of association was expressed using an adjusted odds ratio (AOR) with a 95% confidence interval (CI) at a P value < 0.05.

RESULTS

Among the 603 patients, 56% had optimal medication adherence, with a 95% CI of 52.1 to 60. Being able to read and write (AOR: 2.20; 95% CI: 1.34, 3.61), having a secondary education (AOR: 1.97; 95% CI: 1.06, 3.67), having community-based health insurance (AOR: 1.82; 95% CI: 1.22, 2.71), not having comorbidities (AOR: 1.82; 95% CI: 1.18, 2.52), taking several drugs < 2 (AOR: 2.11; 95% CI: 1.20, 2.45), not adding salt when cooking (AOR: 1.72; 95% CI: 1.20, 2.45), and asking a doctor or nurse without fear (AOR: 1.87; 95% CI: 1.03, 3.40) were factors associated with medication adherence among CHF patients.

CONCLUSION

This study revealed that 56% of chronic heart failure patients had optimal medication adherence. Factors associated with higher adherence included higher education, community health insurance, lack of comorbidities, fewer medications, avoiding added salt, and comfortable communication with providers. Health professionals should provide education to strengthen medication adherence.

Association of combined body mass index and central obesity with cardiovascular disease in middle-aged and older adults: a population-based prospective cohort study

BACKGROUND

Cardiovascular diseases (CVDs) pose a significant threat to public health. Evidence indicates that the combination of central obesity and normal body mass index (BMI) is associated with an increased risk of cardiovascular disease and mortality. However, limited evidences exists in middle aged and elderly adults in China.

METHODS

This was a prospective cohort study that utilized a nationally representative sample of 6,494 adults aged 45 years and above. These individuals participated in the China Health and Retirement Longitudinal Study spanning from 2011 to 2018. Height, weight and waist circumference (WC) were measured, and BMI was calculated by height and weight. Other variables were obtained through self-reported questionnaires. Association analysis was conducted using Cox proportional hazard regression models.

RESULTS

A total of 10,186 participants were investigated, with 57,185 person-years of follow-up. During this period, 1,571 CVDs occurred, including 1,173 heart diseases and 527 strokes. After adjusting for various factors including age, gender, education, marital status, smoking status, alcohol intake, social activity, hypertension, dyslipidemia, diabetes, cancer, chronic lung diseases, liver disease, kidney disease, digestive disease, ENP(emotional, nervous, or psychiatric problems), memory related disease, arthritis or rheumatism, asthma, self-rated health and depression, the results revealed that compared to those with normal WC normal body mass index (BMI), individuals with central obesity normal BMI had a 27.9% higher risk of CVD incidence (95% confidence interval [CI]:1.074-1.524), and a 33.4% higher risk of heart disease incidence (95% CI:1.095-1.625), while no significant association was found with stroke. Additionally, those with normal WC high BMI showed a 24.6% higher risk of CVD incidence (95% CI:1.046-1.483), and a 29.1% higher risk of heart disease incidence (95% CI:1.045-1.594), again with no significant association with stroke. Finally, individuals with central obesity high BMI exhibited a 49.3% higher risk of CVD incidence (95% CI:1.273-1.751), a 61% higher risk of heart disease incidence (95% CI:1.342-1.931), and a 34.2% higher risk of stroke incidence (95% CI:1.008-1.786). Age- and sex- specific analyses further revealed varying trends in these associations.

CONCLUSIONS

We discovered that the combined association of body mass index(BMI) and central obesity with CVD incidence exhibited a significantly enhanced predictive value. Specifically, a high BMI with central obesity was notably linked to an increased risk of CVD incidence. Additionally, central obesity with a normal BMI or a normal WC coupled with a high BMI significantly augmented the risk of heart disease incidence, but not stroke. Notably, male and middle-aged adults demonstrated a greater propensity for heart disease incidence. Our study underscores the importance of maintaining an optimal BMI and preventing abdominal obesity in promoting cardiovascular health.

Oxygenator assisted dynamic microphysiological culture elucidates the impact of hypoxia on valvular interstitial cell calcification

INTRODUCTION

Microphysiological systems (MPS) offer simulation of (patho)physiological parameters. Investigation includes items which lead to fibrosis and calcification in development and progress of calcific aortic valve disease, based e.g. on culturing of isolated valvular interstitial cells (VICs). Hypoxia regulated by hypoxia inducible factors impacts pathological differentiation in aortic valve (AV) disease. This is mimicked via an MPS implemented oxygenator in combination with calcification inducing medium supplementation.

METHODS

Human valvular interstitial cells were isolated and dynamically cultured in MPS at hypoxic, normoxic, arterial blood oxygen concentration and cell incubator condition. Expression profile of fibrosis and calcification markers was monitored and calcification was quantified in induction and control media with and without hypoxia and in comparison to statically cultured counterparts.

RESULTS

Hypoxic 24-hour culture of human VICs leads to HIF1α nuclear localization and induction of EGLN1, EGLN3 and LDHA mRNA expression but does not directly impact expression of fibrosis and calcification markers. Dependent on medium formulation, induction medium induces monolayer calcification and elevates RUNX2, ACTA2 and FN1 but reduces SOX9 mRNA expression in dynamic and static MPS culture. But combining hypoxic oxygen concentration leads to higher calcification potential of human VICs in calcification and standard medium formulation dynamically cultured for 96 h.

CONCLUSION

In hypoxic oxygen concentration an increased human VIC calcification in 2D VIC culture in an oxygenator assisted MPS was detected. Oxygen regulation therefore can be combined with calcification induction media to monitor additional effects of pathological marker expression. Validation of oxygenator dependent VIC behavior envisions future advancement and transfer to long term aortic valve tissue culture MPS.

Bicuspid Aortic Valve Disease: From Pathophysiology to Treatment

The Bicuspid Aortic Valve (BAV) is the most common congenital anomaly in adults, with a global incidence of 1.3%. Despite being well documented, BAV presents significant clinical challenges due to its phenotypic heterogeneity, diverse clinical manifestations, and variable outcomes. Pathophysiologically, BAV differs from tricuspid valves in calcification patterns and hemodynamic effects, leading to increased shear stress and aortic root dilatation, while it is influenced by genetic and hemodynamic factors. This is why therapeutically, BAV presents challenges for both surgical and transcatheter interventions, with surgical approaches being traditionally preferred, especially when aortopathy is present. However, transcatheter aortic valve implantation (TAVI) has emerged as a viable option, with studies showing comparable outcomes to surgery in selected patients, while advancements in TAVI and a better understanding of BAV's genetic and pathophysiological nuances are expanding treatment options. The choice between mechanical and bioprosthetic valves also presents considerations, particularly regarding long-term durability and the need for anticoagulation. Future research should focus on long-term registries and genetic studies to refine therapeutic strategies and improve patient outcomes. This review aims to evaluate current approaches in the surgical and interventional management of BAV, focusing on its anatomy, pathogenesis, pathophysiology, and therapeutic strategies.

The COVID-19 thrombus: distinguishing pathological, mechanistic, and phenotypic features and management

A heightened risk for thrombosis is a hallmark of COVID-19. Expansive clinical experience and medical literature have characterized small (micro) and large (macro) vessel involvement of the venous and arterial circulatory systems. Most events occur in patients with serious or critical illness in the hyperacute (first 1-2 weeks) or acute phases (2-4 weeks) of SARS-CoV-2 infection. However, thrombosis involving the venous, arterial, and microcirculatory systems has been reported in the subacute (4-8 weeks), convalescent (> 8-12 weeks) and chronic phases (> 12 weeks) among patients with mild-to-moderate illness. The purpose of the current focused review is to highlight the distinguishing clinical features, pathological components, and potential mechanisms of venous, arterial, and microvascular thrombosis in patients with COVID-19. The overarching objective is to better understand the proclivity for thrombosis, laying a solid foundation for screening and surveillance modalities, preventive strategies, and optimal patient management.

Adverse outcomes with left atrial appendage occlusion device implantation in chronic and end stage kidney disease: A systemic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) and end stage renal disease (ESRD) are associated with increased risk of bleeding events, including hemorrhagic stroke, and periprocedural and gastrointestinal bleeding among patients with atrial fibrillation who are on anticoagulation. Safety of percutaneous left atrial appendage occlusion (LAAO) among this patient population has been uncertain with studies showing contradictory results.

METHODS

PubMed and Google Scholar databases were queried for studies comparing outcomes among patients with and without significant CKD, and with and without ESRD who underwent LAAO device implantation. Data on outcomes from the selected studies were extracted and analyzed using random effects model. Heterogeneity was assessed using I2 test.

RESULTS

Data from eleven studies with 61,724 patients with and without kidney disease were included in the final analyses. There was an increased risk of in-hospital mortality (OR 2.76, 95 % CI [1.15-6.64]; p = 0.02) and peri-procedural bleeding (1.51 [1.33-1.71]; p < 0.01) associated with kidney disease. There was no significant difference in risk of stroke (1.19 [0.70-2.03]; p = 0.53), pericardial effusion (1.22 [0.77-1.92]; p = 0.40), vascular complications (1.18 [0.92-1.52]; p = 0.20), or device related thrombus (1.13 [0.53-2.40]; p = 0.75).

CONCLUSIONS

This study shows an increased risk of complications among patients with kidney disease, who undergo LAAO device implantation. These findings suggest the need for studies with randomized control design specifically designed to compare outcomes with LAAO versus anticoagulation in the CKD and ESRD populations.

Prognosis and treatment strategies for atrial fibrillation in heart failure with mildly reduced ejection fraction

AIMS

The study investigates the prognosis of atrial fibrillation (AF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). Data concerning the prognostic impact of AF in patients with HFmrEF is scarce.

METHODS AND RESULTS

Consecutive patients with HFmrEF [i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of heart failure (HF)] were retrospectively included at one institution from 2016 to 2022. Patients with AF were compared with patients without with regard to the primary composite endpoint of all-cause mortality and HF-related rehospitalization at 30 months (median follow-up). Statistical analyses included Kaplan-Meier, multivariable Cox proportional regression analyses, and propensity score matching. A total of 2148 patients with HFmrEF were included with an overall prevalence of AF of 43%. The presence of AF was associated with a higher risk of the primary composite endpoint all-cause mortality and HF-related rehospitalization at 30 months [hazard ratio (HR) = 2.068; 95% confidence interval (CI) 1.802-2.375; P = 0.01], which was confirmed after propensity score matching (HR = 1.494; 95% CI 1.216-1.835; P = 0.01). AF was an independent predictor of both all-cause mortality (HR = 1.340; 95% CI 1.066-1.685; P = 0.01) and HF-related rehospitalization (HR = 2.061; 95% CI 1.538-2.696; P = 0.01). Finally, rhythm control may be associated with lower risk of all-cause mortality compared with rate control for AF (HR = 0.342; 95% CI 0.199-0.587; P = 0.01).

CONCLUSION

Atrial fibrillation affects 43% of patients with HFmrEF and represents an independent predictor of adverse long-term prognosis.

Socioeconomic Gender Variables Impact the Association between Hypertension and Chronic Health Issues: Cross-Sectional Study

Our aim is to investigate if sex and gender influence the association of hypertension and their comorbidities. We investigated how gender differences in five socioeconomic factors impact the relation between hypertension and ten comorbidities including diabetes mellitus, renal disease, and chronic pulmonary disease in European countries grouped by their gender inequality index using representative survey data from the European Health Interview Survey. Using logistic regressions, we compute the ratio of odds ratios in females versus males. Therefore, an ORR > 1 is associated with a higher odds ratio for females than for males while an ORR < 1 means the opposite. To account for multiple hypothesis testing, we applied the Bonferroni correction. Hypertension in both sexes was associated with lower educational level, being unemployed, and lower income. In males, being divorced/widowed (OR1.12, p < 0.001) had an association to hypertension, whereas in females, being common-law/married (OR1.30, p < 0.001) and being divorced/widowed (OR1.17, p < 0.001) was associated with a higher risk for hypertension. Moreover, in hypertension, females who worked had an association with myocardial infarction (OR1.39, p < 0.001) and having post-secondary education had an association with arthrosis (OR 1.35, p < 0.001) compared to males. Our findings show that gender variables influence the association of hypertension and comorbidities, especially in females. These results can be used to inform targeted prevention measures taking gender-specific contextual factors into account.

Neutrophil-to-lymphocyte ratio as a predictor of all-cause and cardiovascular mortality in coronary heart disease and hypertensive patients: a retrospective cohort study

Background

To date, no studies have investigated the correlation between the neutrophil-to-lymphocyte ratio (NLR) and the long-term risk of mortality in individuals with both coronary heart disease (CHD) and hypertension. This study aims to evaluate the association between NLR and all-cause and cardiovascular mortality among this patient population.

Methods

National Death Index (NDI) and National Health and Nutrition Examination Survey (NHANES 2001-2018) were the data sources. A nonlinear association between the NLR and mortality risk was shown by restricted cubic spline (RCS) analysis. Using a weighted Cox proportional hazards model, we quantitatively evaluated the effect of NLR on mortality risk.The capacity of NLR to forecast survival was assessed by evaluating time-dependent receiver operating characteristic (ROC) curves. A mediating influence analysis was conducted to assess the influence of NLR on mortality through eGFR as a mediator.

Results

The study involved a total of 2136 individuals. During the median follow-up interval of 76.0 months, 801 deaths were recorded. The RCS analysis showed NLR and mortality risk to have a nonlinear relationship. Two groups were established based on the participants' NLR levels: a group with high NLR (NLR > 2.65) and a group with low NLR (NLR < 2.65). After adjusting for potential confounding factors, the Cox proportional hazards model revealed that participants with an increased NLR faced a significantly higher risk of cardiovascular mortality. (HR 1.58, 95% CI 1.33-1.82, p < 0.0001) and all-cause mortality (HR 1.46, 95% CI 1.30-1.62, p < 0.0001). An analysis of interactions and data stratification corroborated the validity of our findings. eGFR was identified as a partial mediator in the association between NLR and mortality rates, contributing 12.17% and 9.66% of the variance in all-cause and cardiovascular mortality, respectively. The predictive performance for cardiovascular mortality was quantified using ROC curves, with respective AUC values of 0.67, 0.65, and 0.64 for predictions over 3, 5, and 10 years. The AUC values for all-cause mortality were 0.66, 0.64, and 0.63 for the same time frames.

Conclusion

For patients with CHD and hypertension, an elevated NLR serves as an independent prognostic indicator for both all-cause and cardiovascular mortality.

Percutaneous Extraction of Transvenous Permanent Pacemaker/Defibrillator Leads-A Single-Center Experience

Background and Objectives: The number of cardiac pacemakers being used has increased in recent decades, and this increase has led to a rise in device-related complications, requiring percutaneous device extraction. Our aim was to present our single-center clinical experience in percutaneous lead extractions. Materials and Methods: We analyzed an observational retrospective cohort study of 93 patients for the transvenous removal of a total of 163 endocardial leads. We evaluated the device details, indications, lead characteristics, extraction methods, complications, reimplantation procedure, follow-up data, effectiveness, and safety. Results: Patients' mean age was 68.6 ± 11.6 years. Lead extraction indications were pocket infection in 33 (35.5%), lead dysfunction in 33 (35.5%), and system upgrade in 21 (23%) cases, and lead endocarditis in 6 (6%) cases. The duration from implantation to extraction time was a detected median of 43 (24-87) months. The most common retracted lead type was the RV defibrillator lead (62%), and the lead fixation type was active for one hundred (61%) patients. A new device was inserted in 74 (80%) patients, and the device type was most commonly a CRT-D (61%). Patients were followed up at a median of 17 (8-36) months, and 18 patients (19%) died at follow-up. Complete procedural success was obtained in 78 (84%) patients, and clinical procedural success was obtained in 83 (89%) patients. Procedural failure was detected in 15 (16%) patients. Major and minor complications were detected in 10 (11%) and 6 (6.5%) patients, respectively. The most common minor complication was pocket hematoma. Conclusions: Our experience suggests that transvenous lead extraction has a high success rate with an acceptable risk of procedural complications. The simple manual traction method has a high rate of procedural success, despite a high dwell time of the lead.

Liver stiffness as a prognostic parameter and tool for risk stratification in advanced cardiac transthyretin amyloidosis

BACKGROUND

In light of increasing therapeutic options, risk stratification of advanced cardiac transthyretin amyloidosis (ATTR-CA) is gaining clinical importance to avoid ineffective treatments. Liver stiffness as a marker of hypervolemia and hepatic congestion might predict mortality in advanced ATTR-CA and allow to identify patients at highest risk.

METHODS

Proven ATTR-CA patients underwent repeated vibration-controlled transient elastography (VTCE) and standardized serial workup within the local amyloidosis cohort study AmyKoS. Spearman correlation analyses and Cox regressions were performed to evaluate the prognostic value.

RESULTS

41 patients with ATTR-CA were included with median age of 76.6 (55.1-89.1) years, of which 90.2% were male and > 92% wild-type ATTR-CA. In total, 85 VCTE examinations were performed. Median follow-up was 43.7 (2.4-75.6) months; 26.8% of the patients died. At the first clinical evaluation, median left ventricular (LV) absolute global longitudinal strain (GLS) was 11.4 (5.2-19.0) % and median liver stiffness was 6.3 (2.4-22.9) kPa, both significantly correlated with mortality. NT-proBNP possessed statistically significant predictive power in ATTR-CA with more preserved LV function (absolute GLS ≥ 10), whereas stiffness seemed to be more discriminative for ATTR-CA with absolute GLS < 10. The use of alternative congestion surrogates such as liver vein dilation and tricuspid regurgitation peak velocity (tr-vmax) showed congruent results.

CONCLUSION

Liver stiffness shows prognostic value regarding all-cause mortality and allows risk stratification in advanced ATTR-CA, particularly in those with markedly impaired longitudinal LV function. These results are transferable to other congestion surrogates.

Generative Large Language Models in Electronic Health Records for Patient Care Since 2023: A Systematic Review

BACKGROUND

Generative Large language models (LLMs) represent a significant advancement in natural language processing, achieving state-of-the-art performance across various tasks. However, their application in clinical settings using real electronic health records (EHRs) is still rare and presents numerous challenges.

OBJECTIVE

This study aims to systematically review the use of generative LLMs, and the effectiveness of relevant techniques in patient care-related topics involving EHRs, summarize the challenges faced, and suggest future directions.

METHODS

A Boolean search for peer-reviewed articles was conducted on May 19th, 2024 using PubMed and Web of Science to include research articles published since 2023, which was one month after the release of ChatGPT. The search results were deduplicated. Multiple reviewers, including biomedical informaticians, computer scientists, and a physician, screened the publications for eligibility and conducted data extraction. Only studies utilizing generative LLMs to analyze real EHR data were included. We summarized the use of prompt engineering, fine-tuning, multimodal EHR data, and evaluation matrices. Additionally, we identified current challenges in applying LLMs in clinical settings as reported by the included studies and proposed future directions.

RESULTS

The initial search identified 6,328 unique studies, with 76 studies included after eligibility screening. Of these, 67 studies (88.2%) employed zero-shot prompting, five of them reported 100% accuracy on five specific clinical tasks. Nine studies used advanced prompting strategies; four tested these strategies experimentally, finding that prompt engineering improved performance, with one study noting a non-linear relationship between the number of examples in a prompt and performance improvement. Eight studies explored fine-tuning generative LLMs, all reported performance improvements on specific tasks, but three of them noted potential performance degradation after fine-tuning on certain tasks. Only two studies utilized multimodal data, which improved LLM-based decision-making and enabled accurate rare disease diagnosis and prognosis. The studies employed 55 different evaluation metrics for 22 purposes, such as correctness, completeness, and conciseness. Two studies investigated LLM bias, with one detecting no bias and the other finding that male patients received more appropriate clinical decision-making suggestions. Six studies identified hallucinations, such as fabricating patient names in structured thyroid ultrasound reports. Additional challenges included but were not limited to the impersonal tone of LLM consultations, which made patients uncomfortable, and the difficulty patients had in understanding LLM responses.

CONCLUSION

Our review indicates that few studies have employed advanced computational techniques to enhance LLM performance. The diverse evaluation metrics used highlight the need for standardization. LLMs currently cannot replace physicians due to challenges such as bias, hallucinations, and impersonal responses.

Phosphodiesterase-5 Expression in Buccal Mucosa of Patients with Erectile Dysfunction One Year after Radical Prostatectomy

(1) Background: Radical prostatectomy has a high incidence of erectile dysfunction (ED). The aim was to determine if the expression of the nitric oxide synthase-3/soluble guanylate cyclase/phosphodiesterase 5 axis could be detected in buccal mucosa and if it could be differently expressed in patients with and without ED; (2) Methods: Erectile function from 38 subjects subjected to prostatectomy was evaluated using the International Index of Erectile Function-Erectile Function Domain before and one year after surgery. Nitric oxide synthase (NOS3), β1-subunit of soluble guanylate cyclase (sGC), phosphodiesterase-5 (PDE-5) expressions, and interleukin-6 and interleukin-10 content were measured in the buccal mucosa. PDE5A rs3806808 gene polymorphism was genotyped; (3) Results: One year after prostatectomy, 15 patients had recovered functional erection, and 23 showed ED. NOS3, β1-sGC, interleukin-6, and interleukin-10 expressions were not different between patients with and without ED after radical prostatectomy. Buccal mucosa levels of PDE-5 were higher in patients with ED compared to those who recovered erectile functionality. There were no differences found in the genotype of PDE5A polymorphism; (4) Conclusions: One year after prostatectomy, patients with ED had higher PDE5 levels in their buccal mucosa than patients who had recovered erectile function. Rs3806808 PDE5A gene polymorphism was not associated with increased PDE5 expression in buccal mucosa.

The Current Molecular and Cellular Landscape of Chronic Obstructive Pulmonary Disease (COPD): A Review of Therapies and Efforts towards Personalized Treatment

Chronic obstructive pulmonary disease (COPD) ranks as the third leading cause of global illness and mortality. It is commonly triggered by exposure to respiratory irritants like cigarette smoke or biofuel pollutants. This multifaceted condition manifests through an array of symptoms and lung irregularities, characterized by chronic inflammation and reduced lung function. Present therapies primarily rely on maintenance medications to alleviate symptoms, but fall short in impeding disease advancement. COPD's diverse nature, influenced by various phenotypes, complicates diagnosis, necessitating precise molecular characterization. Omics-driven methodologies, including biomarker identification and therapeutic target exploration, offer a promising avenue for addressing COPD's complexity. This analysis underscores the critical necessity of improving molecular profiling to deepen our comprehension of COPD and identify potential therapeutic targets. Moreover, it advocates for tailoring treatment strategies to individual phenotypes. Through comprehensive exploration-based molecular characterization and the adoption of personalized methodologies, innovative treatments may emerge that are capable of altering the trajectory of COPD, instilling optimism for efficacious disease-modifying interventions.

Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner: a rand-modified Delphi method

BACKGROUND

Hypertension, a chronic medical condition affecting millions of people worldwide, is a leading cause of cardiovascular diseases. A multidisciplinary approach is needed to reduce the burden of the disease, with general practitioners playing a vital role. Therefore, it is crucial that GPs provide high-quality care that is standardized and based on the most recent European guidelines. Quality indicators (QIs) can be used to assess the performance, outcomes, or processes of healthcare delivery and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes. However, QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. The aim of our study is to define quality indicators for hypertension in general practice that are extractable from the electronic health record (EHR) and can be used to evaluate and improve the quality of care for hypertensive patients in the general practice setting.

METHODS

We used a Rand-modified Delphi procedure. We extracted recommendations from European guidelines and assembled them into an online questionnaire. An initial scoring based on the SMART principle and extractability from the EHR was performed by panel members, these results were analyzed using a Median Likert score, prioritization and degree of consensus. A consensus meeting was set up in which all the recommendations were discussed, followed by a final validation round.

RESULTS

Our study extracted 115 recommendations. After analysis of the online questionnaire round and a consensus meeting round, 37 recommendations were accepted and 75 were excluded. Of these 37 recommendations, 9 were slightly modified and 4 were combined into 2 recommendations, resulting in a list of 35 recommendations. All recommendations of the final set were translated to QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up.

CONCLUSIONS

Our study resulted in a set of 35 QIs for hypertension in general practice. These QIs, tailored to the Belgian EHR, provide a robust foundation for automated audit and feedback and could substantially benefit other countries if adapted to their systems.

Episode Care Costs Following Catheter-Directed Reperfusion Therapies for Pulmonary Embolism: A Literature-Based Comparative Cohort Analysis

This analysis aimed to estimate 30-day episode care costs associated with 3 contemporary endovascular therapies indicated for treatment of pulmonary embolism (PE). Systematic literature review was used to identify clinical research reporting costs associated with invasive PE care and outcomes for ultrasound-accelerated thrombolysis (USAT), continuous-aspiration mechanical thrombectomy (CAMT), and volume-controlled-aspiration mechanical thrombectomy (VAMT). Total episode variable care costs were defined as the sum of device costs, variable acute care costs, and contingent costs. Variable acute care costs were estimated using methodology sensitive to periprocedural and postprocedural resource allocation unique to the 3 therapies. Contingent costs included expenses for thrombolytics, postprocedure bleeding events, and readmissions through 30 days. Through February 28, 2023, 70 sources were identified and used to inform estimates of 30-day total episode variable costs. Device costs for USAT, CAMT, and VAMT were the most expensive single component of total episode variable costs, estimated at $5,965, $10,279, and $11,901, respectively. Costs associated with catheterization suite utilization, intensive care, and hospital length of stay, along with contingent costs, were important drivers of total episode costs. Total episode variable care costs through 30 days were $19,146, $20,938, and $17,290 for USAT, CAMT, and VAMT, respectively. In conclusion, estimated total episode care costs after invasive treatment for PE are heavily influenced by device expense, in-hospital care, and postacute care complications. Regardless of device cost, strategies that avoid thrombolytics, reduce the need for intensive care unit care, shorten length of stay, and reduce postprocedure bleeding and 30-day readmissions contributed to the lowest episode costs.

Methylome analysis of endothelial cells suggests new insights on sporadic brain arteriovenous malformation

Arteriovenous malformation of the brain (bAVM) is a vascular phenotype related to brain defective angiogenesis. Involved vessels show impaired expression of vascular differentiation markers resulting in the arteriolar to venule direct shunt. In order to clarify aberrant gene expression occurring in bAVM, here we describe results obtained by methylome analysis performed on endothelial cells (ECs) isolated from bAVM specimens, compared to human cerebral microvascular ECs. Results were validated by quantitative methylation-specific PCR and quantitative realtime-PCR. Differential methylation events occur in genes already linked to bAVM onset, as RBPJ and KRAS. However, among differentially methylated genes, we identified EPHB1 and several other loci involved in EC adhesion as well as in EC/vascular smooth muscle cell (VSMC) crosstalk, suggesting that only endothelial dysfunction might not be sufficient to trigger the bAVM phenotype. Moreover, aberrant methylation pattern was reported for many lncRNA genes targeting transcription factors expressed during neurovascular development. Among these, the YBX1 that was recently shown to target the arteridin coding gene. Finally, in addition to the conventional CpG methylation, we further considered the role of impaired CHG methylation, mainly occurring in brain at embryo stage. We showed as differentially CHG methylated genes are clustered in pathways related to EC homeostasis, as well as to VSMC-EC crosstalk, suggesting as impairment of this interaction plays a prominent role in loss of vascular differentiation, in bAVM phenotype.

Characteristics and outcomes associated with sarcomere mutations in patients with hypertrophic cardiomyopathy: A systematic review and meta-analysis

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is an inherited heart disease that can lead to sudden cardiac death. Impact of genetic testing for the prognosis and treatment of patients with HCM needs to be improved. We conducted a systematic review and meta-analysis to investigate the characteristics and outcomes associated with sarcomere genotypes in index patients with HCM.

METHODS

A systematic search was conducted in Medline, Embase, and Cochrane Library up to Dec 31, 2023. Data on clinical characteristics, morphological and imaging features, outcomes and interventions were collected from published studies and pooled using a random-effects meta-analysis.

RESULTS

A total of 30 studies with 10,825 HCM index patients were included in the pooled analyses. The frequency of sarcomere genes in HCM patients was 41%. Sarcomere mutations were more frequent in women (p < 0.00001), and were associated with lower body mass index (26.1 ± 4.7 versus 27.5 ± 4.3; p = 0.003) and left ventricular ejection fraction (65.7% ± 10.1% vs. 67.1% ± 8.6%; p = 0.03), less apical hypertrophy (6.5% vs. 20.1%; p < 0.0001) and left ventricular outflow tract obstruction (29.1% vs. 33.2%; p = 0.03), greater left atrial volume index (43.6 ± 21.1 ml/m2 vs. 37.3 ± 13.0 ml/m2; p = 0.02). Higher risks of ventricular tachycardia (23.4% vs. 14.1%; p < 0.0001), syncope (18.3% vs. 10.9%; p = 0.01) and heart failure (17.3% vs. 14.6%; p = 0.002) were also associated with sarcomere mutations.

CONCLUSIONS

Sarcomere mutations are more frequent in women, and are associated with worse clinical characteristics and poor outcomes.

Non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) and hypertension in American adults: a NHANES cross-sectional study

Objectives

The relationship between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) and hypertension remains uncertain, warranting further investigation. This study aims to elucidate the association between NHHR and hypertension.

Methods

A comprehensive cross-sectional stratified survey involving 30,602 participants aged 20 years and older was conducted using the National Health and Nutrition Examination Survey (NHANES) dataset from 2001 to 2018. NHHR was calculated as [total cholesterol (TC) - high-density lipoprotein cholesterol (HDL-C)]/HDL-C. The relationship between NHHR and hypertension was examined using weighted multiple linear regression, smooth curve fitting, hierarchical analysis, and interaction testing.

Results

The mean age of participants was 49.82 ± 17.64 years, with 15,266 women included. The average NHHR was 2.94 ± 0.56. A positive correlation between NHHR and hypertension was observed. Stratification of NHHR into quartiles, in the fully adjusted Model 3, revealed that individuals in the highest NHHR quartile had a 60% increased risk of hypertension for each unit increase in NHHR compared to those in the lowest quartile. Interaction tests indicated that the relationship between NHHR and hypertension remained consistent across subgroups, except for gender, age, education, and smoking status, which influenced this association.

Conclusion

Analysis of NHANES data from 2001 to 2018 demonstrated a consistent positive association between NHHR and hypertension. NHHR may provide potential assistance in hypertension prevention and diagnosis.

Prognostic Role of Tissue Iron Deficiency Measured by sTfR Levels in Heart Failure Patients without Systemic Iron Deficiency or Anemia

Background. Iron deficiency (ID) is a significant, high-prevalence comorbidity in chronic heart failure (HF) that represents an independent predictor of a worse prognosis. However, a clear-cut diagnosis of ID in HF patients is not assured. The soluble transferrin receptor (sTfR) is a marker that reflects tissue-level iron demand and may be an early marker of ID. However, the impact of sTfR levels on clinical outcomes in non-anemic HF patients with a normal systemic iron status has never been evaluated. Methods. This is a post hoc analysis of an observational, prospective cohort study of 1236 patients with chronic HF of which only those with normal hemoglobin levels and a normal systemic iron status were studied. The final cohort consisted of 215 patients. Tissue ID was defined as levels of sTfR > 75th percentile (1.65 mg/L). Our aim was to describe the association between sTfR and clinical outcomes (all-cause death and HF hospitalization) and to explore its association with a wide array of serum biomarkers. Results. The sTfR level (HR 1.48, 95% CI 1.13-1.96, p = 0.005) and tissue ID (HR 2.14, 95% CI 1.22-3.75, p = 0.008) was associated with all-cause death. However, we found no association between sTfR levels and the risk of HF hospitalization. Furthermore, high sTfR levels were associated with a worse biomarker profile indicating myocardial damage (troponin and NT-proBNP), systemic inflammation (CRP and albumin), and impaired erythropoiesis (erythropoietin). Conclusions. In this cohort, the presence of tissue ID defined by sTfR levels is an independent factor for all-cause death in patients with normal systemic iron parameters.

Swift Onset, Swift Recovery: Unusual Nonrheumatic Myocarditis in a Young Adult Post Group A Streptococcal Pharyngitis

This case report highlights the unusual presentation and management of nonrheumatic myocarditis in a 24-year-old male, an age demographic not commonly associated with myocardial complications following Group A streptococcal pharyngitis. The patient, devoid of any prior medical history, manifested symptoms one day after being diagnosed with Group A streptococcal pharyngitis, a stark contrast to the typical progression of myocardial complications. The swift onset of symptoms and the patient's subsequent clinical presentation necessitated a comprehensive diagnostic approach. The patient's symptoms were successfully alleviated with amoxicillin and anti-inflammatory therapy, underscoring its potential efficacy in managing nonrheumatic myocarditis. This case serves as a poignant reminder of the importance of maintaining a broad differential diagnosis, especially in atypical presentations, and the pivotal role of timely clinical intervention. The insights from this report contribute to the broader understanding of nonrheumatic myocarditis, emphasizing the significance of tailored diagnostic and therapeutic strategies to ensure optimal patient outcomes.

Unraveling phenotypic heterogeneity in stanford type B aortic dissection patients through machine learning clustering analysis of cardiovascular CT imaging

OBJECTIVE

Aortic dissection remains a life-threatening condition necessitating accurate diagnosis and timely intervention. This study aimed to investigate phenotypic heterogeneity in patients with Stanford type B aortic dissection (TBAD) through machine learning clustering analysis of cardiovascular computed tomography (CT) imaging.

METHODS

Electronic medical records were collected to extract demographic and clinical features of patients with TBAD. Exclusion criteria ensured homogeneity and clinical relevance of the TBAD cohort. Controls were selected on the basis of age, comorbidity status, and imaging availability. Aortic morphological parameters were extracted from CT angiography and subjected to K-means clustering analysis to identify distinct phenotypes.

RESULTS

Clustering analysis revealed three phenotypes of patients with TBAD with significant correlations with population characteristics and dissection rates. This pioneering study used CT-based three-dimensional reconstruction to classify high-risk individuals, demonstrating the potential of machine learning in enhancing diagnostic accuracy and personalized treatment strategies. Recent advancements in machine learning have garnered attention in cardiovascular imaging, particularly in aortic dissection research. These studies leverage various imaging modalities to extract valuable features and information from cardiovascular images, paving the way for more personalized interventions.

CONCLUSION

This study provides insights into the phenotypic heterogeneity of patients with TBAD using machine learning clustering analysis of cardiovascular CT imaging. The identified phenotypes exhibit correlations with population characteristics and dissection rates, highlighting the potential of machine learning in risk stratification and personalized management of aortic dissection. Further research in this field holds promise for improving diagnostic accuracy and treatment outcomes in patients with aortic dissection.

Blood Pressure/Heart Rate-Derived Ratios as Indices of Health and Cardiovascular Pathology

This communication, based on a review of the relevant literature on ratios deriving from blood pressure and heart rate measurements, and their conformance/nonconformance to the mathematical golden rule (ie, 1.681), proposes that such ratios, particularly emanating from large numbers of home blood pressure and heart rate measurements obtained by the patients themselves or their caretakers, may constitute new risk markers, useful in the assessment of health and cardiovascular pathologies, prognosis of morbidity and mortality, and implementation to clinical practice and research.

Management of cardiac sarcoidosis

Cardiac sarcoidosis (CS) is a form of inflammatory cardiomyopathy associated with significant clinical complications such as high-degree atrioventricular block, ventricular tachycardia, and heart failure as well as sudden cardiac death. It is therefore important to provide an expert consensus statement summarizing the role of different available diagnostic tools and emphasizing the importance of a multidisciplinary approach. By integrating clinical information and the results of diagnostic tests, an accurate, validated, and timely diagnosis can be made, while alternative diagnoses can be reasonably excluded. This clinical expert consensus statement reviews the evidence on the management of different CS manifestations and provides advice to practicing clinicians in the field on the role of immunosuppression and the treatment of cardiac complications based on limited published data and the experience of international CS experts. The monitoring and risk stratification of patients with CS is also covered, while controversies and future research needs are explored.

Characterization of Liquid Dosage Forms of Atenolol and Enalapril Maleate for Oral and Enteral Feeding Administration

The limited availability of pharmaceutical formulations tailored for cardiovascular diseases in both pediatric and geriatric populations generates the need for compounded dosage forms to guarantee precise dosing and medication adherence. This study aimed to analyze the physicochemical properties and stability of formulations of atenolol and enalapril maleate prepared with a proprietary oral vehicle, SuspendIt®. To this end, palatability, injectability, pH, rheological behavior, and physical, microbiological, and chemical stability over a 180-day storage period at 25 °C and 5 °C were evaluated. Injectability tests confirmed the suitable use of both formulations for administration through enteral feeding tubes. By using a potentiometric electronic tongue, it was confirmed that the SuspendIt® vehicle effectively served as a bitter-blocking strategy for atenolol and enalapril maleate. Adequate stability throughout the storage period was confirmed in terms of the mechanical properties, pH, and effectiveness of the preservative system. The atenolol concentration remained above 90% of the initial amount, while the concentration of enalapril maleate decreased to 88% after 90 days of storage at 25 °C. In summary, the atenolol formulation maintained suitable chemical, physical, and microbiological stability after 180 days at both storage temperatures, while the enalapril maleate formulation remained stable up to 60 days at 25 °C and for 180 days at 5 °C.

Systematic review and meta-analysis to predict mortality in heart failure with preserved ejection fraction: Development and validation of the HF-DANAS score

AIMS

The morbidity and mortality of heart failure with preserved ejection fraction (HFpEF) continue to increase with the accelerating global aging process. During the past decade, the pathophysiology, diagnostic methods, and prognostic prediction of HFpEF have been revolutionized, resulting in new and effective management strategies. Dynamic prognostic assessment facilitates systematic clinical management of patients, and the aim of this study was to investigate the risk factors for mortality in patients with HFpEF and to develop a risk prediction assessment model.

METHODS AND REULTS

Data for the derivation cohort were obtained from three databases, PubMed, Embase, and Cochrane. The validation cohort was obtained from the Chinese Heart Failure Center database. The β-coefficient was calculated based on the risk ratio (RR) and 95% confidence intervals (CI) corresponding to each risk factor to construct a mortality risk assessment model. A total of 30 studies were included in the meta-analysis: 22 prospective cohort studies and 8 retrospective cohort studies, including 34 196 HFpEF patients. Seven predictors of all-cause mortality in HFpEF patients were derived. Considering the need for feasibility in clinical practice, we performed subgroup and sensitivity analyses and determined the following cutoff values: age > 75 years (RR: 2.07, 95% CI: 1.83-2.35; P < 0.001), male sex (RR: 1.36, 95% CI: 1.17-1.59; P < 0.001), DM (RR: 1.23, 95% CI: 1.11-1.36; P < 0.001), anaemia (RR: 1.53, 95% CI: 1.41-1.67; P < 0.001), albumin concentration < 3.2 g/dL (RR: 1.29, 95% CI: 1.14-1.47; P < 0.001), AF (RR: 1.27, 95% CI: 1.12-1.43; P < 0.001), and NYHA class III/IV (RR: 1.63, 95% CI: 1.43-1.87; P < 0.001). The area under the receiver operating characteristic (ROC) curve (AUC) for this model was 71.3% (95% CI: 0.696-0.736), with an optimal cut-off value of 10.75. The sensitivity and specificity were 0.778 and 0.566, respectively. According to this risk score, we divided patients into three risk classes (low, moderate, and high risk), the numbers of patients who died by the end of the 1-year follow-up were 23 (1.87%), 82 (5.62%), and 382 (15.52%) in these three groups, and the 5-year mortality rates were 9.82%, 20.68%, and 43.28%, respectively.

CONCLUSIONS

This study developed an HF-DANAS scoring system for the HFpEF mortality risk containing seven predictors, providing clinicians with a simple assessment tool that can help improve clinical management.

Association of central arterial stiffness with atrial myopathy: the Atherosclerosis Risk in Communities (ARIC) study

Atrial myopathy-defined as abnormal left atrial (LA) size and function-is associated with an increased risk of atrial fibrillation, heart failure, and dementia. Central arterial stiffness is associated with increased atrial afterload and fibrosis and may be a risk factor for atrial myopathy. We examined the association of carotid-femoral pulse wave velocity (cfPWV) with LA function and assessed potential causal relationships. We included 2825 Atherosclerosis Risk in Communities (ARIC) study participants from Visit 5 (2011-2013). cfPWV was related to echocardiographic LA function continuously per 1-SD and categorically in quartiles. Mendelian randomization (MR) analysis was performed using U.K. Biobank-derived genetic variants associated with arterial stiffness index and cardiac magnetic resonance measures of LA function. When analyzed per SD increment (297.6 cm/s), higher cfPWV was significantly associated with lower LA reservoir and conduit strain (β = -0.53%, 95% CI [-0.81, -0.25] and β = -0.46%, 95% CI [-0.68, -0.25], respectively) after adjusting for demographics, clinical characteristics, systolic blood pressure, and left ventricular (LV) morphology and function. In MR analyses there was a non-significant inverse association of arterial stiffness index with LA total, passive, and active emptying fractions. Higher cfPWV is associated with lower LA reservoir and conduit strain, independent of systolic blood pressure and LV morphology and function. No evidence for a causal relationship between arterial stiffness index and alterations in LA function was found. Future studies should examine the prospective association of central arterial stiffness with LA function alterations.

Brain natriuretic peptide as a predictive marker of mortality in sepsis: an updated systematic review and meta-analysis

INTRODUCTION

Early identification of patients with sepsis at high risk of death remains a challenge, and whether brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) has a prognostic effect on patients with sepsis is controversial. Here, we clarified the prognostic value of BNP and NT-proBNP and sought to establish suitable cutoff values and intervals.

METHODS

We searched five databases to identify studies that met the inclusion criteria. The primary outcomes were the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the curve (AUC), and corresponding 95% credible interval (95% CI) of BNP and NT-proBNP. The secondary outcomes were the sensitivity and specificity of BNP or NT-proBNP in subgroup analyses.

RESULTS

Forty-seven studies were included in our meta-analysis. The pooled sensitivity of NT-proBNP (0.77 [0.68, 0.84]) was weaker than that of BNP (0.82 [0.76, 0.87]), the pooled specificity of NT-proBNP (0.70 [0.60, 0.77]) was less than that of BNP (0.77 [0.71, 0.82]), and the AUC of BNP (0.87 [0.83-0.89]) was greater than that of NT-proBNP (0.80 (0.76-0.83]). The results of the subgroup analysis showed that the cutoff range of 400-800 pg/mL for BNP had high sensitivity (0.86 [0.74-0.98]) and specificity (0.87 [0.81-0.93]) and was probably the most appropriate cutoff range.

CONCLUSIONS

Elevated levels of BNP and NT-proBNP were significantly related to the mortality of patients with sepsis and had a moderate prognostic value in predicting the mortality of patients with sepsis. In addition, our meta-analysis preliminarily established appropriate cutoff values for BNP and NT-proBNP.

Accuracy of routine laboratory tests to predict mortality and deterioration to severe or critical COVID-19 in people with SARS-CoV-2

BACKGROUND

Identifying patients with COVID-19 disease who will deteriorate can be useful to assess whether they should receive intensive care, or whether they can be treated in a less intensive way or through outpatient care. In clinical care, routine laboratory markers, such as C-reactive protein, are used to assess a person's health status.

OBJECTIVES

To assess the accuracy of routine blood-based laboratory tests to predict mortality and deterioration to severe or critical (from mild or moderate) COVID-19 in people with SARS-CoV-2.

SEARCH METHODS

On 25 August 2022, we searched the Cochrane COVID-19 Study Register, encompassing searches of various databases such as MEDLINE via PubMed, CENTRAL, Embase, medRxiv, and ClinicalTrials.gov. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs that produced estimates of prognostic accuracy in participants who presented to outpatient services, or were admitted to general hospital wards with confirmed SARS-CoV-2 infection, and studies that were based on serum banks of samples from people. All routine blood-based laboratory tests performed during the first encounter were included. We included any reference standard used to define deterioration to severe or critical disease that was provided by the authors.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each included study, and independently assessed the methodological quality using the Quality Assessment of Prognostic Accuracy Studies tool. As studies reported different thresholds for the same test, we used the Hierarchical Summary Receiver Operator Curve model for meta-analyses to estimate summary curves in SAS 9.4. We estimated the sensitivity at points on the SROC curves that corresponded to the median and interquartile range boundaries of specificities in the included studies. Direct and indirect comparisons were exclusively conducted for biomarkers with an estimated sensitivity and 95% CI of ≥ 50% at a specificity of ≥ 50%. The relative diagnostic odds ratio was calculated as a summary of the relative accuracy of these biomarkers.

MAIN RESULTS

We identified a total of 64 studies, including 71,170 participants, of which 8169 participants died, and 4031 participants deteriorated to severe/critical condition. The studies assessed 53 different laboratory tests. For some tests, both increases and decreases relative to the normal range were included. There was important heterogeneity between tests and their cut-off values. None of the included studies had a low risk of bias or low concern for applicability for all domains. None of the tests included in this review demonstrated high sensitivity or specificity, or both. The five tests with summary sensitivity and specificity above 50% were: C-reactive protein increase, neutrophil-to-lymphocyte ratio increase, lymphocyte count decrease, d-dimer increase, and lactate dehydrogenase increase. Inflammation For mortality, summary sensitivity of a C-reactive protein increase was 76% (95% CI 73% to 79%) at median specificity, 59% (low-certainty evidence). For deterioration, summary sensitivity was 78% (95% CI 67% to 86%) at median specificity, 72% (very low-certainty evidence). For the combined outcome of mortality or deterioration, or both, summary sensitivity was 70% (95% CI 49% to 85%) at median specificity, 60% (very low-certainty evidence). For mortality, summary sensitivity of an increase in neutrophil-to-lymphocyte ratio was 69% (95% CI 66% to 72%) at median specificity, 63% (very low-certainty evidence). For deterioration, summary sensitivity was 75% (95% CI 59% to 87%) at median specificity, 71% (very low-certainty evidence). For mortality, summary sensitivity of a decrease in lymphocyte count was 67% (95% CI 56% to 77%) at median specificity, 61% (very low-certainty evidence). For deterioration, summary sensitivity of a decrease in lymphocyte count was 69% (95% CI 60% to 76%) at median specificity, 67% (very low-certainty evidence). For the combined outcome, summary sensitivity was 83% (95% CI 67% to 92%) at median specificity, 29% (very low-certainty evidence). For mortality, summary sensitivity of a lactate dehydrogenase increase was 82% (95% CI 66% to 91%) at median specificity, 60% (very low-certainty evidence). For deterioration, summary sensitivity of a lactate dehydrogenase increase was 79% (95% CI 76% to 82%) at median specificity, 66% (low-certainty evidence). For the combined outcome, summary sensitivity was 69% (95% CI 51% to 82%) at median specificity, 62% (very low-certainty evidence). Hypercoagulability For mortality, summary sensitivity of a d-dimer increase was 70% (95% CI 64% to 76%) at median specificity of 56% (very low-certainty evidence). For deterioration, summary sensitivity was 65% (95% CI 56% to 74%) at median specificity of 63% (very low-certainty evidence). For the combined outcome, summary sensitivity was 65% (95% CI 52% to 76%) at median specificity of 54% (very low-certainty evidence). To predict mortality, neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR (diagnostic Odds Ratio) 2.05, 95% CI 1.30 to 3.24), C-reactive protein increase (RDOR 2.64, 95% CI 2.09 to 3.33), and lymphocyte count decrease (RDOR 2.63, 95% CI 1.55 to 4.46). D-dimer increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.49, 95% CI 1.23 to 1.80), C-reactive protein increase (RDOR 1.31, 95% CI 1.03 to 1.65), and lactate dehydrogenase increase (RDOR 1.42, 95% CI 1.05 to 1.90). Additionally, lactate dehydrogenase increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.30, 95% CI 1.13 to 1.49). To predict deterioration to severe disease, C-reactive protein increase had higher accuracy compared to d-dimer increase (RDOR 1.76, 95% CI 1.25 to 2.50). The neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR 2.77, 95% CI 1.58 to 4.84). Lastly, lymphocyte count decrease had higher accuracy compared to d-dimer increase (RDOR 2.10, 95% CI 1.44 to 3.07) and lactate dehydrogenase increase (RDOR 2.22, 95% CI 1.52 to 3.26).

AUTHORS' CONCLUSIONS

Laboratory tests, associated with hypercoagulability and hyperinflammatory response, were better at predicting severe disease and mortality in patients with SARS-CoV-2 compared to other laboratory tests. However, to safely rule out severe disease, tests should have high sensitivity (> 90%), and none of the identified laboratory tests met this criterion. In clinical practice, a more comprehensive assessment of a patient's health status is usually required by, for example, incorporating these laboratory tests into clinical prediction rules together with clinical symptoms, radiological findings, and patient's characteristics.

Relationships between biatrial substrate and recurrence after radiofrequency ablation in patients with persistent atrial fibrillation

BACKGROUND

Global longitudinal strain (GLS) and atrial voltage are acknowledged markers for worse rhythm outcome after ablation of persistent atrial fibrillation (PeAF). The majority of research efforts have been directed towards the left atrium (LA), with relatively fewer studies focusing on the right atrium (RA). The aim of this study was to investigate the effect of the biatrial substrate on the outcome following radiofrequency catheter ablation (RFCA).

METHODS

All patients underwent two-dimensional speckle tracking echocardiography (2D-STE) and high-density mapping (HDM) on LA and RA in preoperative and postoperative stages of RFCA. Atrial substrate was assessed by GLS, average voltage, and low voltage zone (LVZ).

RESULTS

This retrospective study enrolled 48 patients. With a follow-up of 385.98 ± 161.78 days, 22.92% (11/48) of all patients had AF recurrence and 63.64% in low strain group. Left atrial-low voltage zone (LA-LVZ) prior to RFCA was 67.52 ± 15.27% and 54.21 ± 20.07%, respectively, in the recurrence group and non-recurrence group. Multivariate regression analysis showed that preoperative LA-GLS (OR 0.047, 95%CI 0.002-0.941, p = .046) was independent predictors of AF recurrence. Biatrial average voltage in preoperative and postoperative stages were positively correlated (preoperative: r = 0.563 p < .001; postoperative: r = 0.464 p = .002). There was no significant difference in the proportion of RA in the recurrence group except the septum in preoperative and postoperative stages.

CONCLUSIONS

Low LA-GLS and high LA-LVZ may be predictors of RFCA recurrence in PeAF patients. Biatrial average voltage were positively correlated in preoperative and postoperative stages.

Survival benefit of IABP in pre- versus post-primary percutaneous coronary intervention in patients with cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) remains a major cause of in-hospital mortality in the setting of acute myocardial infarction (AMI). However, little evidence is available regarding the optimal order of intra-aortic balloon counter-pulsation (IABP) insertion and primary percutaneous coronary intervention (PPCI). The aim of this study was to assess the hospital and short-term survival benefits of two different IABP insertion approaches, before versus after PPCI in patients with acute myocardial infarction and cardiogenic shock.

RESULTS

Total mortality was 80 patients representing 48.4% of the total 165 studied patients; 60 patients died during the hospital admission period, while the remaining 20 patients died post-discharge. In-hospital mortality was significantly higher in Post-PPCI-IABP group 40 (49.4%) versus Pre-PPCI-IABP group 20 (23.8%) (P = 0.001). Moreover, the mortality difference between the two groups was sustained over six-month follow-up period, where 15 patients (18.5%) died in the Post-PPCI-IABP group, while only 5 patients 6.0% died in the Pre-PPCI-IABP (P = 0.001).

CONCLUSIONS

Early IABP insertion before PPCI is associated with improved in-hospital and long-term survival when used for patients presenting with AMI complicated by hemodynamic instability.

Does the management of patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) changes with advanced diagnostic workup beyond coronary angiography? Results from the "Evaluation of the clinical Profile, Investigations and Cardiac Imaging of the Patients with MINOCA (EPIC-MINOCA Study)"

BACKGROUND

Evaluation of the patients with MINOCA and identifying the underlying aetiology remains challenging. However, investigation in most patients remains limited to coronary angiography (CAG). The study aimed to assess the clinical profile, investigations and cardiac imaging of the patients with MINOCA and its outcomes.

RESULTS

Out of 55 patients with MINOCA, CAG was normal in 16 (29.1%), while 39 (69.9%) had nonobstructive coronary artery disease. Of 55 patients, 34 had limited workup (Group 1) and only 21 had advanced workup (Group 2). In comparison to Group 1, Group 2 had a significantly higher association with the identification of possible underlying aetiology (16 vs. 4, p < 0.001) and a change in the management (10 vs. 3, p = 0.002).

CONCLUSION

Diagnostic workup in patients with MINOCA was limited to CAG in 61.8% of patients in this study. However, patients with advanced workup had a significantly higher association with the change in the treatment and identifying possible underlying aetiology in such patients.

Metabolic dysfunction-associated steatotic liver disease: A pathophysiology and clinical framework to face the present and the future

AIMS

This review aims to provide a straightforward conceptual framework for the knowledge and understanding of Metabolic dysfunction-associated steatotic liver disease (MASLD) in the broad spectrum of steatotic liver disease and to point out the need to consider metabolic dysfunction and comorbidities as interrelated factors for a holistic approach to fatty liver disease.

DATA SYNTHESIS

MASLD is the new proposed term for steatotic liver disease that replaces the old terminology of non-alcoholic fatty liver disease. This term focused on the relationship between metabolic alteration and hepatic steatosis, reflecting a growing comprehension of the association between metabolic dysfunction and hepatic steatosis. Numerous factors and conditions contribute to the underlying mechanisms, including central obesity, insulin resistance, adiponectin, lipid metabolism, liver function, dietary influences, the composition of intestinal microbiota, and genetic factors. The development of the condition, however, involves a more intricate network of components, such as neurotensin and Advanced Glycation End Products, highlighting the complexity of its pathogenesis.

CONCLUSIONS

MASLD must be regarded as a complex clinical problem in which only a holistic approach can win through the coordination of multi-professional and multi-speciality interventions.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions.

DATA SOURCES

MEDLINE and Embase.

REVIEW METHODS

MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of lower extremity, carotid, and visceral artery vascular interventions via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedure time, fluoroscopy time, and contrast volume.

RESULTS

Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedure time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes.

CONCLUSION

The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Global and regional cardiac magnetic resonance feature tracking left ventricular strain analysis in assessing early myocardial disease in β thalassemia major patients

BACKGROUND

Cardiac magnetic resonance imaging (CMR) is the modality of choice for quantification of myocardial iron overload in β-thalassemia major patients using the T2* sequence. CMR feature tracking (FT) is a recent magnetic resonance imaging tool that gives an idea about myocardial fibers deformation; thus, it can detect early impairment in myocardial function even before the reduction in ejection fraction.

METHODS

This study aims to assess the ability of left ventricular CMR-FT in the early detection of systolic dysfunction in β thalassemia major patients and to correlate it with the degree of myocardial iron overload measured by CMR T2*. This prospective study enrolled 57 β thalassemia major patients who received long-term blood transfusion and 20 healthy controls. CMR was used to evaluate left ventricular volumes, ejection fraction, and the amount of myocardial T2*. A two-dimensional left ventricular FT analysis was performed. Both global and segmental left ventricular strain values were obtained.

RESULTS

The mean global circumferential strain (GCS) and global radial strain (GRS) values were significantly lower in patients compared to control (P = 0.002 and P = 0.006, respectively). No correlation was found between T2* values and ejection fraction; however, there was a significant correlation between T2* values and GCS and GRS (P = 0.012 and P = 0.025, respectively) in thalassemia patients. Regional strain revealed significantly lower values of GCS and GRS in basal regions compared to apical ones (P = 0.000).

CONCLUSIONS

Our study revealed that CMR-FT can play a role in the early detection of systolic impairment in thalassemia patients.

The effectiveness of HALP score in predicting mortality in non-ST-elevation myocardial infarction patients

BACKGROUND

The HALP score, measured based on hemoglobin, albumin, lymphocyte, and platelet levels, is regarded as a novel scoring system that indicates the status of systemic inflammation and nutritional health. Our study aimed to evaluate the relationship between HALP score and prognosis in non-ST-elevation myocardial infarction (NSTEMI) patients.

METHODS

Between 1 January 2020 and 1 January 2022, 568 consecutive patients diagnosed with NSTEMI from a single center were included in the study retrospectively. The patients were divided into two equal groups according to the median HALP cutoff value of 44.05. Patients were followed for at least 1 year from the date of admission.

RESULTS

The average age of the patients was 62.3 ± 10.6 years and 43.7% were female. In-hospital and 1-year mortality were found to be significantly higher in the group with low HALP scores (6.0 vs. 2.1%, P = 0.019 and 22.5 vs. 9.9%, P < 0.001, respectively). In receiver operating characteristic curve analysis, a cutoff level of 34.6 of the HALP score predicted 1-year mortality with 71% sensitivity and 65% specificity (area under the curve: 0.707, 95% confidence interval: 0.651-0.762, P < 0.001). In Kaplan-Meier analysis, higher mortality rates were observed over time in the group with lower HALP scores (log-rank test=16.767, P < 0.001). In Cox regression analysis, the HALP score was found to be an independent predictor of 1-year mortality (odds ratio: 0.969, 95% confidence interval: 0.958-0.981, P < 0.001).

CONCLUSION

We found that a low HALP score could predict in-hospital and 1-year mortality in patients admitted to the hospital with a diagnosis of NSTEMI.

Effect of dapagliflozin on readmission and loop diuretics use in patients with acute heart failure: a retrospective propensity score-matched cohort study

BACKGROUND

The efficacy of dapagliflozin in patients with acute heart failure remains unclear.

OBJECTIVE

To investigate the impact of dapagliflozin (DAPA) on loop diuretics use and 90-day readmission in patients with acute heart failure.

METHODS

In a retrospective cohort study, patients diagnosed with acute heart failure or chronic heart failure with acute exacerbation admitted to Fuyang People's Hospital from January 2021 to April 2023, this study used DAPA (at a dose of 10 mg once daily) in combination with standard treatment. The patients were divided into DAPA group and DAPA-Free group based on whether they used DAPA in acute heart failure. To minimize the influence of confounding factors and ensure comparability between groups, we used propensity score matching (PSM).

RESULTS

A total of 399 patients were included, with 206 patients (51.63%) in the DAPA group and 193 patients (48.37%) in the DAPA-Free group. PSM produced 160 pairs. After PSM, there were no statistically significant differences between the DAPA and DAPA-Free groups in terms of readmission of all causes (16.88% vs. 18.12%, OR 0.9141, 95% CI 0.5385-1.552, log rank P = 0.739) or readmission for heart failure (11.88% vs. 15.0%, OR 0.9077, 95% CI 0.4441-1.469, log rank P = 0.484) after 90-day follow-up. Patients in the DAPA group had a lower mean daily dose of intravenous loop diuretics compared to the DAPA-Free group (20 mg/d vs. 30.00 mg/d, P<0.001), lower total loop diuretic dose during hospitalization (106.06 ± 31.23 mg vs. 144.50 ± 45.39 mg, P = 0.038) and a decreased number of diuretic types used (11.88% vs. 23.12%, P = 0.008).

CONCLUSIONS

DAPA reduced the dose of intravenous loop diuretics. However, it did not improve all-cause readmission for 90 days or readmission for heart failure after discharge.

Increased adrenocortical activity in patients with vasovagal syncope

OBJECTIVE

Syncope is a transient loss of consciousness resulting from cerebral hypoperfusion. Vasovagal syncope (VVS) is a form of orthostatic intolerance (OI). Its clinical signs such as dizziness and hypotension may mimic symptoms of adrenal insufficiency. The objective of this study was to evaluate the adrenal gland function in patients with vasovagal syncope after stimulation with synthetic adrenocorticotropic hormone (ACTH).

DESIGN

Case-control study on patients with VVS and healthy controls.

METHODS

The study involved 42 participants, including 27 patients diagnosed with VVS using the head-up tilt test and 15 healthy individuals with no history of syncope or any orthostatic symptoms. Serum cortisol and aldosterone concentrations were measured under basal conditions and at 30 and 60 min after intramuscular ACTH stimulation.

RESULTS

Patients with VVS had significantly higher cortisol levels at baseline (441 ± 143 vs. 331 ± 84.7 nmol/L, p = 0.01), at 30 min (802 ± 143 vs. 686 ± 105 nmol/L, p = 0.01) and at 60 min (931 ± 141 nmol/L vs. 793 ± 147 nmol/L, p = 0.001) after ACTH administration (Synacthen 250 μg). Plasma aldosterone increased after ACTH stimulation, but did not show significant differences among groups. Furthermore, there was also no significant correlation between cortisol levels and blood pressure or heart rate.

CONCLUSION

Patients diagnosed with VVS have higher cortisol levels both at baseline and after ACTH stimulation. This finding indicates that individuals with VVS have higher adrenocortical activity potentially as a response to the orthostatic stress induced by syncope, which acts as a stressful stimulus on the autonomic nervous system.

A systematic review about the importance of neuropsychological features in heart failure: is at heart the only failure?

Heart failure can lead to cognitive impairment that is estimated to be present in over a quarter of patients. It is important to intervene at a cognitive level to promote brain plasticity through cognitive training programs. Interventions transformed by technology offer the promise of improved cognitive health for heart failure patients. This review was conducted on studies evaluating the role of cognitive rehabilitation in patients with heart failure. We examined clinical trials involving patients with heart failure. Our search was performed on Pubmed, Web of Science and Cochrane library databases. Of the initial 256 studies, 10 studies met the inclusion criteria. Cognitive rehabilitation training has important implications for the treatment and prevention of cognitive decline in heart failure patients with significant recovery for delayed recall memory and a significant time effect for total recall memory and delayed, psychomotor speed and IADL performance. It is important to include the assessment of cognitive functioning in the routine clinical examinations of patients with heart failure, discover the relationship between cognitive function and heart failure, and target cognitive rehabilitation programs that promote brain plasticity.

Soluble ST2: A Novel Biomarker for Diagnosis and Prognosis of Cardiovascular Disease

The increasing incidence of cardiovascular disease (CVD) is a significant global health concern, affecting millions of individuals each year. Accurate diagnosis of acute CVD poses a formidable challenge, as misdiagnosis can significantly decrease patient survival rates. Traditional biomarkers have played a vital role in the diagnosis and prognosis of CVDs, but they can be influenced by various factors, such as age, sex, and renal function. Soluble ST2 (sST2) is a novel biomarker that is closely associated with different CVDs. Its low reference change value makes it suitable for continuous measurement, unaffected by age, kidney function, and other confounding factors, facilitating risk stratification of CVDs. Furthermore, the combination of sST2 with other biomarkers can enhance diagnostic accuracy and prognostic value. This review aims to provide a comprehensive overview of sST2, focusing on its diagnostic and prognostic value as a myocardial marker for different types of CVDs and discussing the current limitations of sST2.

Comparative Analysis of Clinical Outcomes of High-power, Short-duration Ablation versus Low-power, Long-duration Ablation Strategy in Patients with Atrial Fibrillation: A Comprehensive Umbrella Review of Meta-analyses

Atrial fibrillation (AF) affects around 33 million people worldwide, rendering it a common cardiac arrhythmia. Catheter ablation (CA) has evolved as a leading therapeutic intervention for symptomatic AF. This umbrella review systematically evaluates existing systematic reviews and meta-analyses to assess the safety, efficacy, and potential of high-power, short-duration (HPSD) ablation as an alternative therapy option for AF. A thorough exploration was undertaken across PubMed, the Cochrane Library, and Embase to identify pertinent studies for inclusion in this umbrella review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was employed to assess the overall certainty of the evidence comprehensively, and the quality of the incorporated reviews was meticulously evaluated through use of the AMSTAR 2 tool, the Cochrane Collaboration tool, and the Newcastle-Ottawa scale. In this study, we initially identified 35 systematic reviews and meta-analyses, narrowing them down to a final selection of 11 studies, which collectively integrated data from 6 randomized controlled trials and 26 observational studies. For primary efficacy outcomes, the HPSD approach led to a non-significant decrease in the risk of atrial tachyarrhythmia recurrence (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.70-1.12; I 2 = 90%; P = .31) and a significantly reduced risk of AF recurrence (RR, 0.53; 95% CI, 0.42-0.67; I 2 = 0%; P < .00001) compared to the low-power, long-duration (LPLD) approach. In terms of primary safety outcomes, the HPSD approach significantly reduced the risk of esophageal thermal injury (ETI) (RR, 0.71; 95% CI, 0.61-0.83; I 2 = 0%; P < .00001) and facilitated a non-significant decrease in the risk of other major complications (RR, 0.87; 95% CI, 0.73-1.03; I 2 = 0%; P = .10). In conclusion, HPSD therapy is safer and more effective than LPLD therapy, facilitating decreased AF recurrence rates along with reductions in ETI, total procedure duration, ablation number, ablation time, fluoroscopy time, and acute pulmonary vein reconnection.

Effects of bacterial extracellular vesicles derived from oral and gastrointestinal pathogens on systemic diseases

Oral microbiota and gastrointestinal microbiota, the two largest microbiomes in the human body, are closely correlated and frequently interact through the oral-gut axis. Recent research has focused on the roles of these microbiomes in human health and diseases. Under normal conditions, probiotics and commensal bacteria can positively impact health. However, altered physiological states may induce dysbiosis, increasing the risk of pathogen colonization. Studies suggest that oral and gastrointestinal pathogens contribute not only to localized diseases at their respective colonized sites but also to the progression of systemic diseases. However, the mechanisms by which bacteria at these local sites are involved in systemic diseases remain elusive. In response to this gap, the focus has shifted to bacterial extracellular vesicles (BEVs), which act as mediators of communication between the microbiota and the host. Numerous studies have reported the targeted delivery of bacterial pathogenic substances from the oral cavity and the gastrointestinal tract to distant organs via BEVs. These pathogenic components subsequently elicit specific cellular responses in target organs, thereby mediating the progression of systemic diseases. This review aims to elucidate the extensive microbial communication via the oral-gut axis, summarize the types and biogenesis mechanisms of BEVs, and highlight the translocation pathways of oral and gastrointestinal BEVs in vivo, as well as the impacts of pathogens-derived BEVs on systemic diseases.