2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Cutaneous Wound-Healing Activity of Quercetin-Functionalized Bimetallic Nanoparticles

Quercetin, a natural flavonol, is reported to have significant antioxidant and anti-inflammatory activity, which further aids in its good wound-healing properties via acting on acute as well as chronic inflammatory phases. The current study is focused on understanding the potential of the green-synthesized iron and zinc oxide bimetallic (i.e., zinc ferrite) nanoparticles of quercetin (ZFQNP) on wound healing by an in vivo study model. Bimetallic quercetin nanoparticles were prepared by the co-precipitation method and characterized by UV-visible spectroscopy, scanning electron microscopy (SEM), and dynamic light scattering (DLS) analyses. Synthesized ZFQNP was utilized to prepare the ointment for topical application, and wound-healing activity was evaluated by using the excisional wound method in Wistar rats. The binding affinity of quercetin was ascertained against various wound-healing protein targets by molecular docking. Characterization data confirmed the synthesis of bimetallic ZFQNP of an irregular shape. Molecular docking studies showed satisfactory binding potential of quercetin with selected molecular targets. The study results of various parameters corroborated the significant wound-healing properties of ZFQNP, possibly attributed to the promising binding potential of quercetin with vital wound-healing targets. The study demonstrated that the quercetin bimetallic nanoparticles could provide a promising wound-healing effect.

Patent Foramen Ovale Closure in Patients With and Without Nickel Hypersensitivity: A Randomized Trial

BACKGROUND

Nickel-containing devices, such as the Amplatzer PFO Occluder and Gore Cardioform Septal Occluder, are used for transcatheter patent foramen ovale closure. However, the impact of nickel hypersensitivity on postprocedural outcomes remains poorly understood. This study aimed to evaluate the risk of adverse events in patients with nickel hypersensitivity undergoing patent foramen ovale closure.

METHODS

This was a prospective, double-blinded, randomized study enrolling patients with cryptogenic stroke and patent foramen ovale-related ischemic stroke to receive either the Amplatzer or Gore Cardioform Septal Occluder device. Nickel hypersensitivity was assessed using skin patch testing. The primary end point was the incidence of device syndrome, a composite of patient-reported symptoms (chest pain, palpitations, migraines, dyspnea, and rash).

RESULTS

Of the 96 patients, 28 (29.2%) had nickel hypersensitivity. The incidence of device syndrome was significantly higher in patients with nickel hypersensitivity compared with those without (71.4% versus 20.6%, P<0.001). Specifically, new-onset or worsening migraines and palpitations were more frequent in nickel-hypersensitive patients. No significant differences were observed in documented arrhythmias, bleeding, or stroke. Multivariable analysis showed that nickel hypersensitivity was associated with a 10.5-fold increase in the odds of device syndrome (adjusted odds ratio, 10.53 [95% CI, 3.17-35.00]; P<0.001). The incidence of device syndrome was similar for both devices.

CONCLUSIONS

Patients with nickel hypersensitivity are at significantly higher risk of developing device syndrome after patent foramen ovale closure. Both the Amplatzer and Gore Cardioform Septal Occluder devices demonstrated comparable safety and efficacy in this population. These findings highlight the need for further research to optimize device selection and improve outcomes in nickel-hypersensitive patients.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04713683.

Risk factors for cardiovascular diseases: the focus on primary prevention

Views on the etiopathogenesis of atherosclerosis are subject to evolution. In addition to the classic well-known risk factors, new ones related to mental state, social life and environment are being discovered. Both acute and chronic stress stimulate inflammatory processes. Due to the change in lifestyle and eating habits, the accumulation of risk factors in childhood is an increasing problem. Knowledge of risk factors allows for effective primary prevention of cardiovascular diseases. The effectiveness of prevention increases when the activities cover the largest possible part of the society, and access to a doctor is easy. Therefore, government programs are being implemented offering patients easier access to diagnostics of cardiovascular diseases at the level of primary health care, which enables faster identification of people at the greatest cardiovascular risk. Easier access to primary care and a good doctor-patient relationship improve patient compliance. In this situation, the importance of the family doctor as a key link in the diagnosis, prevention and treatment of cardiovascular diseases is increasing.

Systemic aging fuels heart failure: Molecular mechanisms and therapeutic avenues

Systemic aging influences various physiological processes and contributes to structural and functional decline in cardiac tissue. These alterations include an increased incidence of left ventricular hypertrophy, a decline in left ventricular diastolic function, left atrial dilation, atrial fibrillation, myocardial fibrosis and cardiac amyloidosis, elevating susceptibility to chronic heart failure (HF) in the elderly. Age-related cardiac dysfunction stems from prolonged exposure to genomic, epigenetic, oxidative, autophagic, inflammatory and regenerative stresses, along with the accumulation of senescent cells. Concurrently, age-related structural and functional changes in the vascular system, attributed to endothelial dysfunction, arterial stiffness, impaired angiogenesis, oxidative stress and inflammation, impose additional strain on the heart. Dysregulated mechanosignalling and impaired nitric oxide signalling play critical roles in the age-related vascular dysfunction associated with HF. Metabolic aging drives intricate shifts in glucose and lipid metabolism, leading to insulin resistance, mitochondrial dysfunction and lipid accumulation within cardiomyocytes. These alterations contribute to cardiac hypertrophy, fibrosis and impaired contractility, ultimately propelling HF. Systemic low-grade chronic inflammation, in conjunction with the senescence-associated secretory phenotype, aggravates cardiac dysfunction with age by promoting immune cell infiltration into the myocardium, fostering HF. This is further exacerbated by age-related comorbidities like coronary artery disease (CAD), atherosclerosis, hypertension, obesity, diabetes and chronic kidney disease (CKD). CAD and atherosclerosis induce myocardial ischaemia and adverse remodelling, while hypertension contributes to cardiac hypertrophy and fibrosis. Obesity-associated insulin resistance, inflammation and dyslipidaemia create a profibrotic cardiac environment, whereas diabetes-related metabolic disturbances further impair cardiac function. CKD-related fluid overload, electrolyte imbalances and uraemic toxins exacerbate HF through systemic inflammation and neurohormonal renin-angiotensin-aldosterone system (RAAS) activation. Recognizing aging as a modifiable process has opened avenues to target systemic aging in HF through both lifestyle interventions and therapeutics. Exercise, known for its antioxidant effects, can partly reverse pathological cardiac remodelling in the elderly by countering processes linked to age-related chronic HF, such as mitochondrial dysfunction, inflammation, senescence and declining cardiomyocyte regeneration. Dietary interventions such as plant-based and ketogenic diets, caloric restriction and macronutrient supplementation are instrumental in maintaining energy balance, reducing adiposity and addressing micronutrient and macronutrient imbalances associated with age-related HF. Therapeutic advancements targeting systemic aging in HF are underway. Key approaches include senomorphics and senolytics to limit senescence, antioxidants targeting mitochondrial stress, anti-inflammatory drugs like interleukin (IL)-1β inhibitors, metabolic rejuvenators such as nicotinamide riboside, resveratrol and sirtuin (SIRT) activators and autophagy enhancers like metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors, all of which offer potential for preserving cardiac function and alleviating the age-related HF burden.

Sex-related outcomes after percutaneous coronary intervention of in-stent restenosis

Limited data are available for sex-related long-term outcomes of patients treated for coronary drug-eluting stent (DES) restenosis. The aim of this observational, retrospective analysis was to close this lack of evidence. Between January 2007 and February 2021, a total of 3511 patients with 5497 in-stent restenosis (ISR) lesions were treated at two large-volume centers in Munich, Germany, of which 763 (21.7%) were female. Endpoints of interest were all-cause mortality and rates of repeat revascularization. Outcomes are presented as Kaplan-Meier event rates. Univariate and multivariate analyses were performed. Female patients were older (72.1 ± 10.4 versus 68.4 ± 10.4 years, p < 0.001) and suffered more often from diabetes (38.8% versus 34.4%, p = 0.029). There was no statistical difference regarding the clinical presentation and interventional treatment strategy. After 10 years, the risk of all-cause mortality was higher in female patients [hazard ratio (HR) 1.18 (1.02-1.35); p = 0.022]; however, after adjustment for age, the risk did not differ significantly between both sexes [adjusted HR 0.96 (0.83-1.11); p = 0.6]. Regarding target vessel revascularization (TVR) and non-target vessel revascularization (NTVR), the risk was lower in female patients [HR 0.73 (0.61-0.87); p < 0.001 and HR 0.74 (0.64-0.86); p < 0.001] even after age adjustment. No statistical differences were found regarding the risk of target lesion revascularization, target vessel myocardial infarction and stent thrombosis. In the long term, all-cause mortality after percutaneous coronary intervention of DES-ISR did not differ between both sexes after age adjustment. The risk of TVR and NTVR was lower in female patients even after age adjustment.

2024 EACTS/EACTAIC/EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery

Clinical practice guidelines consolidate and evaluate all pertinent evidence on a specific topic available at the time of their formulation. The goal is to assist physicians in determining the most effective management strategies for patients with a particular condition. These guidelines assess the impact on patient outcomes and weigh the risk-benefit ratio of various diagnostic or therapeutic approaches. While not a replacement for textbooks, they provide supplementary information on topics relevant to current clinical practice and become an essential tool to support the decisions made by specialists in daily practice. Nonetheless, it is crucial to understand that these recommendations are intended to guide, not dictate, clinical practice, and should be adapted to each patient's unique needs. Clinical situations vary, presenting a diverse array of variables and circumstances. Thus, the guidelines are meant to inform, not replace, the clinical judgement of healthcare professionals, grounded in their professional knowledge, experience and comprehension of each patient's specific context. Moreover, these guidelines are not considered legally binding; the legal duties of healthcare professionals are defined by prevailing laws and regulations, and adherence to these guidelines does not modify such responsibilities. The European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) and the European Board of Cardiovascular Perfusion (EBCP) constituted a task force of professionals specializing in cardiopulmonary bypass (CPB) management. To ensure transparency and integrity, all task force members involved in the development and review of these guidelines submitted conflict of interest declarations, which were compiled into a single document available on the EACTS website (https://www.eacts.org/resources/clinical-guidelines). Any alterations to these declarations during the development process were promptly reported to the EACTS, EACTAIC and EBCP. Funding for this task force was provided exclusively by the EACTS, EACTAIC and EBCP, without involvement from the healthcare industry or other entities. Following this collaborative endeavour, the governing bodies of EACTS, EACTAIC and EBCP oversaw the formulation, refinement, and endorsement of these extensively revised guidelines. An external panel of experts thoroughly reviewed the initial draft, and their input guided subsequent amendments. After this detailed revision process, the final document was ratified by all task force experts and the leadership of the EACTS, EACTAIC and EBCP, enabling its publication in the European Journal of Cardio-Thoracic Surgery, the British Journal of Anaesthesia and Interdisciplinary CardioVascular and Thoracic Surgery. Endorsed by the EACTS, EACTAIC and EBCP, these guidelines represent the official standpoint on this subject. They demonstrate a dedication to continual enhancement, with routine updates planned to ensure that the guidelines remain current and valuable in the ever-progressing arena of clinical practice.

Does organized atrial tachycardia after a pulmonary vein isolation-only procedure portend better outcome of repeat ablation compared to recurrent atrial fibrillation?

Background

Better outcome has been suggested for repeat procedures after atrial fibrillation (AF) ablation, when recurrence presented as organized atrial tachycardia (OAT) compared to recurrent AF. However, this contradicts the finding of more advanced atrial remodeling in patients with OAT recurrence and may be related to iatrogenesis by substrate modification during the index procedure. Therefore, we examined the prognostic significance of the type of recurrent arrhythmia after pulmonary vein isolation (PVI) without additional substrate modification.

Methods

We included 185 patients (88 female, 64 ± 9 years) undergoing repeat ablation after index PVI for recurrent OAT (24%) or AF (76%). The recurrence rate, arrhythmia-free survival time, and the type of further recurrences were recorded.

Results

There was no difference in the rate and mean time of arrhythmia-free survival between patients with OAT versus AF recurrence after the first (49% vs. 52%, p = .72 and 51.08 ± 6.66 vs. 53.37 ± 4.75 months, p = .54, respectively) and last (60% vs. 58%, p = .80 and 63.2 ± 7.04 vs. 61.2 ± 5.32 months, p = .23, respectively) redo procedure. AF occurred in the majority of subsequently recurring patients in both groups. No significant difference was found in the outcome of redo procedures between patients with typical flutter and atypical OAT, but a higher rate of successful rhythm control was observed in those with paroxysmal, as compared to persistent AF recurrence.

Conclusion

After a PVI-only index procedure, recurrent OAT is not associated with a better outcome of redo procedures compared to recurrent AF. After repeat ablations, both groups experience AF as the dominant further recurrence.

Effects of Nicorandil, Isosorbide Mononitrate, or Diltiazem on Radial Artery Grafts After CABG: The Randomized ASRAB-Pilot Trial

BACKGROUND

The optimal antispastic treatment after coronary artery bypass grafting using radial artery (RA) grafts is controversial. This clinical trial aimed to generate pilot comparative data on the effects of nicorandil, isosorbide mononitrate, or diltiazem on RA grafts.

METHODS

This was a single-center, randomized, open-label, parallel-group pilot trial. Eligible patients who underwent coronary artery bypass grafting using RA grafts were randomized in a 1:1:1 ratio to receive oral nicorandil (15 mg daily), isosorbide mononitrate (50 mg daily), or diltiazem (180 mg daily) for 24 weeks post-coronary artery bypass grafting. The primary outcome was RA graft failure (modified Fitzgibbon grade B, S, or O) at 1 and 24 weeks, assessed by coronary computed tomography angiography.

RESULTS

Among 150 randomized participants, 149 (mean age, 56.8 years; 13.4% women) with 177 RA grafts were assessed at least once by coronary computed tomography angiography, including 50 participants with 64 RA grafts in the nicorandil group, 50 participants with 57 RA grafts in the isosorbide mononitrate group, and 49 participants with 56 RA grafts in the diltiazem group, respectively. At 1 week post-coronary artery bypass grafting, the RA graft failure rates were lower with nicorandil versus diltiazem (19.4% versus 25.0%; difference, -5.6% [95% CI, -20.6% to 9.3%]) and isosorbide mononitrate versus diltiazem (18.2% versus 25.0%; difference, -6.8% [95% CI, -21.8% to 8.6%]). The RA graft failure rates were slightly higher with nicorandil versus isosorbide mononitrate (19.4% versus 18.2%; difference, 1.2% [95% CI, -13.3% to 15.2%]). At 24 weeks, RA graft failure rates were lower with nicorandil versus diltiazem (16.1% versus 27.8%; difference, -11.7% [95% CI, -26.6% to 3.4%]), and isosorbide mononitrate versus diltiazem (12.5% versus 27.8%; difference, -15.3% [95% CI, -29.8% to -0.2%]), and slightly higher with nicorandil versus isosorbide mononitrate (16.1% versus 12.5%; difference, 3.6% [95% CI, -9.6% to 16.4%]).

CONCLUSIONS

In this pilot trial, treatment with nicorandil or isosorbide mononitrate was associated with a lower RA graft failure rate compared with diltiazem. Larger hypothesis-testing trials are warranted.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04310995.

Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS)

IntroductionThe trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest.MethodsThis is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis.ResultsThe trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250).ConclusionsMiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.

Do antithrombotic drugs have a role in migraine prevention? A systematic review

OBJECTIVES

To explore the available evidence on the role of antithrombotics as migraine preventive medication.

BACKGROUND

In clinical practice, the use of antithrombotic drugs in individuals with migraine is sometimes considered, especially in the case of frequent auras, association with patent foramen ovale, or prothrombotic states. This paper systematically reviews evidence on antithrombotic agents' efficacy for migraine prevention.

METHODS

We performed a systematic literature search on PubMed and Scopus including observational and interventional studies focused on antiplatelets or anticoagulants as preventive treatments for migraine. The search included studies published until June 30th, 2024. Ongoing trials on Clinicaltrials.org were also explored. Quality assessment used the Cochrane Risk of Bias 2 (RoB-2) tool for randomized controlled trials (RCTs) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) for observational studies. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO identifier CRD42024501531).

RESULTS

Out of 1854 records, we found 12 RCTs and 8 observational studies investigating the impact of antithrombotic drugs in migraine prevention. Due to heterogeneity of data, a meta-analysis was not feasible. RCTs tested acetylsalicylic acid (ASA) alone (seven), ASA in combination with other preventive treatments (two), clopidogrel (one), dual antiplatelet treatment (one), and vitamin K antagonists (one). Observational studies tested ASA (three), vitamin K antagonists (three), and clopidogrel (two). No clear evidence of efficacy was found for the overall population of individuals with migraine. Limited evidence from old RCTs-not specifically addressing the role of antithrombotic drugs for migraine prevention-and observational studies showed a potential improvement of migraine with the use of antiplatelet agents, mostly ASA, in special populations, including males, individuals with migraine with aura, and those with patent foramen ovale.

CONCLUSIONS

Evidence supporting the effectiveness of antithrombotic drugs as a preventive treatment for patients with migraine is insufficient. As preliminary data show potential improvements in special populations in whom those agents act indirectly by ameliorating vascular function, RCTs are worth conducting.

Blockade of YAP Mechanoactivation Prevents Neointima Formation and Adverse Remodeling in Arterialized Vein Grafts

BACKGROUND

Bypass surgery using saphenous vein (SV) grafts is commonly performed to revascularize the ischemic heart and lower limbs. These interventions have limited success due to adverse remodeling caused by overproliferation of smooth muscle cells in the intima layer, leading to progressive bypass stenosis. We previously showed that cyclic strain deriving from exposure to coronary flow induces the expression of the matricellular protein thrombospondin-1 in the human SV, promoting activation of progenitor cells normally residing in the adventitia.

METHODS

We analyzed the data of an RNA-sequencing profiling of human SV progenitors subjected to uniaxial strain we previously performed by. Experiments in cell culture, ex vivo, and in vivo vein arterialization models were performed to substantiate findings with particular reference to the role of mechanically activated transcription factors. Validation was performed in vitro and in ex vivo/in vivo models of vein graft disease.

RESULTS

Results of bioinformatic assessment of the RNA-sequencing data indicated Yes-associated protein (YAP) as a possible mechanically regulated effector in pathologic evolution of SV progenitors. Inhibition of YAP by verteprofin-a drug that abolishes the interaction of YAP with Tea Domain DNA-binding proteins-reduced the expression of pathologic markers in vitro and reduced intima hyperplasia in vivo.

CONCLUSIONS

Our results reveal that desensitizing the SV-resident cells to mechanoactivation of YAP is feasible to reduce the graft disease progression.

Exploring receptors for pro-resolving and non-pro-resolving mediators as therapeutic targets for sarcopenia

Sarcopenia is defined by a reduction in both muscle strength and mass. Sarcopenia may be an inevitable component of the aging process, but it may also be accelerated by comorbidities and metabolic derangements. The underlying mechanisms contributing to these pathological changes remain poorly understood. We propose that chronic inflammation-mediated networks and metabolic defects that exacerbate muscle dysfunction are critical factors in sarcopenia and related diseases. Consequently, utilizing specialized pro-resolving mediators (SPMs) that function through specific G-protein coupled receptors (GPCRs) may offer effective therapeutic options for these disorders. However, challenges such as a limited understanding of SPM/receptor signaling pathways, rapid inactivation of SPMs, and the complexities of SPM synthesis impede their practical application. In this context, stable small-molecule SPM mimetics and receptor agonists present promising alternatives. Moreover, the aged adipose-skeletal axis may contribute to this process. Activating non-SPM GPCRs on adipocytes, immune cells, and muscle cells under conditions of systemic, chronic, low-grade inflammation (SCLGI) could help alleviate inflammation and metabolic dysfunction. Recent preclinical studies indicate that both SPM GPCRs and non-SPM GPCRs can mitigate symptoms of aging-related diseases such as obesity and diabetes, which are driven by chronic inflammation and metabolic disturbances. These findings suggest that targeting these receptors could provide a novel strategy for addressing various chronic inflammatory conditions, including sarcopenia.

Role of the Transient Receptor Potential Ankyrin-1 in the Pulmonary, Vascular, and Systemic Effects of Short-Term Acrolein Inhalation in Mice: Implications for the Toxicity of Electronic Nicotine Delivery Systems

The cardiovascular and pulmonary disease risks of the use of electronic nicotine delivery systems (ENDS) are uncertain. We recently showed that ENDS solvent-derived aerosol (propylene glycol and vegetable glycerin, PG:VG) exposure induced a transient receptor potential ankyrin-1 (TRPA1)-dependent endothelial dysfunction (ED) in healthy female mice. As thermal degradation of PG:VG generates aldehydes, we hypothesized that acrolein (AC), a constituent of ENDS-derived aerosol and a known TRPA1 agonist, was responsible, in part, for the observed TRPA1-dependent pulmonary and vascular effects of PG:VG. To test this, female wild-type (WT) and TRPA1 null mice were exposed by inhalation to either filtered air or AC alone, and biomarkers of exposure and of harm were measured. Compared with their genotype-matched air control group, JUUL Virginia Tobacco (VT), PG:VG, and AC alone exposures (6 h) significantly increased urinary levels of the AC metabolite, 3-hydroxypropyl mercapturic acid (3HPMA), in both female WT and TRPA1 null mice. AC exposures at 1 and 3 ppm led to the rapid onset and reversal (upon cessation) of 'respiratory braking' in female WT but not in TRPA1 null mice indicating a TRPA1 dependence. As AC stimulated TRPA1-dependent respiratory braking, we measured urinary monoamines and their metabolites after exposure as a proxy of nervous system activation. In WT mice, AC exposure suppressed levels of dopamine, metanephrine, serotonin (5HT), and 5HT metabolite (5HIAA), whereas in TRPA1 null mice only 5HT was equally suppressed by AC. To assess vascular effects, mice were exposed for 4 days to Air or AC (6 h/day, 1 ppm), and aortic function was measured ex vivo. Although endothelial-dependent relaxation was similar in air control and AC-exposed mice, aortic sensitivity to an NO donor was enhanced significantly and equally by AC in both WT and TRPA1 null mice reflective of a TRPA1-independent and compensatory effect. Collectively, AC exposure at a level present in ENDS aerosols stimulated both TRPA1-dependent and -independent pulmonary, vascular, and systemic effects. These data suggest that ENDS use may increase cardiovascular and pulmonary disease risk, in part, via AC present in ENDS-derived aerosols yet independent of either nicotine or flavorants. The level of AC present in ENDS aerosols should be lowered to an amount where it does not induce biomarkers of vascular, pulmonary, and systemic harm to mitigate potential long-term disease risk.

Dapagliflozin alleviates high-fat-induced obesity cardiomyopathy by inhibiting ferroptosis

AIM

Dapagliflozin (Dapa) is a novel hypoglycaemic agent with multiple cardiovascular protective effects, and it is widely used in treatment of heart failure patients, but whether it can improve obese phenotype of heart failure and its mechanism is still unclear. Ferroptosis is an iron dependent form of cell death and has been proved to be an important role in heart failure. The aim of this study is to determine whether Dapa improves obesity-related heart failure by regulating ferroptosis in high-fat diet rats.

METHODS AND RESULTS

Male SD rats were fed a high-fat diet for 12 weeks and confirmed of obese heart failure by metabolic parameters and cardiac ultrasound. Being overweight by 20% compared with the normal group, with elevated systolic blood pressure and abnormal levels of insulin and blood lipid (TG and LDL-c), is recognized as obesity. The obese rats with reduced EF, FS, and E/A shown on ultrasound are defined as the obese heart failure (OHF) group. Histological tests confirmed the more pronounced cardiac fibrosis, mitochondrial volume and collagen deposition in OHF group. Dapa treatment effectively reduced body weight, INS, ISI/IRI index, TG and HDL-C levels (P < 0.05). Also, Dapa administration can slightly decrease the SBP and DBP levels; however, there was no statistical difference among those four groups. Furthermore, Dapa treatment can significantly improve high-fat induced systolic and diastolic dysfunction via regulating cardiac histological abnormalities, including less obvious mitochondrial swelling, muscle fibre dissolution and collagen deposition. Additionally, genes from the OHF group were used by GO enrichment analysis, and it shows that ferroptosis metabolic pathway participated in the development of obese phenotype of heart failure. More importantly, Dapa significantly inhibited Fe2+ and MDA levels (P < 0.05), but augmented GSH content (P < 0.05). In addition, the mRNAs and protein expression of some important regulators of ferroptosis, like GPX4, SLC7A11, FTH1 and FPN1, were all decreased after Dapa intervention.

CONCLUSION

Dapa improved high-fat induced obese cardiac dysfunction via regulating ferroptosis pathway.

Long-Term Evaluation of Revascularization Strategies for Medina 0.1.0 Left Main Bifurcation Lesions: The LM-CROSSOVER Registry

The present study aimed to compare long-term outcomes of patients with Medina 0.1.0 left main (LM) bifurcation lesions treated by crossover stenting (COS) versus accurate ostial stenting (AOS). A total of 229 consecutive eligible patients with Medina 0.1.0 LM bifurcation lesions were enrolled and were stratified according to the stenting techniques. The primary end-point was major cardiovascular and cerebral events (MACCE), defined as the combination of all-cause death, target vessel related-myocardial infarction (MI), clinically driven target lesion revascularization (TLR), stroke, or stent thrombosis. COS and AOS were applied to 78 (34%) and 151 (66%) patients, respectively. During a mean of 40.6 ± 21.1 months of follow-up, the rate of MACCE (27.8 vs 12.8%; P=.007) was higher in patients treated with AOS than those treated with the COS technique, mainly driven by more frequent all-cause death (13.9 vs 3.8%, P = .013) and TLR (6.4 vs 15.9%; P = .029). In multivariable Cox regression analysis, AOS strategy was one of the independent predictors of MACCE (odds ratio: 2.166; 95% confidence interval, 1.080-4.340; P = .029). The current study suggests that COS was associated with a better long-term MACCE rate and lower all-cause mortality rate than AOS in patients with Medina 0.1.0 LM bifurcation disease.

Inflammation in atherosclerosis: a Big Idea that has underperformed so far

PURPOSE OF REVIEW

For many years, inflammation has been a major concept in basic research on atherosclerosis and in the development of potential diagnostic tools and treatments. The purpose of this review is to assess the performance of this concept with an emphasis on recent clinical trials. In addition, contemporary literature may help identify new therapeutic targets, particularly in the context of the treatment of early, rather than end-stage, arterial disease.

RECENT FINDINGS

Newly reported clinical trials cast doubt on the efficacy of colchicine, the sole anti-inflammatory agent currently approved for use in patients with atherosclerotic cardiovascular disease (ASCVD). New analyses also challenge the hypothesis that residual ASCVD event risk after optimal management of lipids, blood pressure, and smoking arises primarily from residual inflammatory risk. Current clinical practice to initiate interventions so late in the course of atherosclerotic arterial disease may be a better explanation. Lipid-lowering therapy in early atherosclerosis, possibly combined with novel add-on agents to specifically accelerate resolution of maladaptive inflammation, may be more fruitful than the conventional approach of testing immunosuppressive strategies in end-stage arterial disease. Also discussed is the ongoing revolution in noninvasive technologies to image the arterial wall. These technologies are changing screening, diagnosis, and treatment of atherosclerosis, including early and possibly reversable disease.

SUMMARY

The burden of proof that the Big Idea of inflammation in atherosclerosis has clinical value remains the responsibility of its advocates. This responsibility requires convincing trial data but still seems largely unmet. Unfortunately, the focus on inflammation as the source of residual ASCVD event risk has distracted us from the need to screen and treat earlier.

Viability and Congestive Heart Failure

Management of ischemic cardiomyopathy is challenging, especially when treatment benefits do not clearly exceed the estimated risk of procedures. Myocardial viability assessment provides additional data in this setting to anticipate potential functional recovery and possibly prognostic improvement following revascularization. This evidence comes from the positive signals received from posthoc analyses of some clinical trials. There are multiple clinically available modalities to evaluate myocardial viability among which more sensitive ones such as cardiac magnetic resonance and PET are more preferrable. Yet, there are emerging tools that may further escalate the utility of these modalities.

Expert consensus statement for quantitative measurement and morphologic assessment of optical coherence tomography: update 2025

In this updated expert consensus document, the methods for the quantitative measurement and morphologic assessment of optical coherence tomography (OCT) / optical frequency domain imaging images (OFDI) are briefly summarized. The focus is on the clinical application and the clinical evidence of OCT / OFDI to guide percutaneous coronary interventions.

Systematic Review of Randomized Controlled Trials Evaluating the Use of Platelet-Rich Plasma for Knee Osteoarthritis: Adherence to Minimum Information for Studies Evaluating Biologics in Orthopaedics

BACKGROUND

The Minimum Information for Studies Evaluating Biologics in Orthopedics (MIBO) guidelines were developed in May 2017 to encourage improved reporting standards, promote increased transparency and reproducibility, and enhance clinical evaluation capabilities. The MIBO guidelines consist of 23 checklist items considered necessary to critically appraise clinical studies evaluating platelet-rich plasma (PRP).

PURPOSE

To assess randomized controlled trials that evaluated PRP for the treatment of knee osteoarthritis in order to systematically review their adherence to the MIBO guidelines.

STUDY DESIGN

Systematic review. Level 1a.

METHODS

A search was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were randomized controlled trials reporting on knee osteoarthritis treated with intra-articular PRP. The studies were categorized into pre-, peri-, and post-MIBO groups based on the start date of data collection. The overall MIBO scores, defined as percentage of checklist items out of the 23 checklist items reported in 1 study, individual item scores, defined as percentage of studies reporting the checklist item within a specified group, and overall item score defined as the average of the individual item scores from all the included studies were calculated.

RESULTS

The review included 87 studies (7925 patients; 8118 knees). Of these, 51 studies were assigned to the pre-MIBO group, 19 studies to the peri-MIBO group, and 17 studies to the post-MIBO group. The overall MIBO score was 72%. No statistically significant differences in MIBO scores were found among the 3 MIBO groups (P = .345). The majority of the studies (62 studies; 71%) had MIBO scores <80%. MIBO items with particularly low item scores included reporting of whole-blood characteristics (20%), platelet recovery rate (22%), PRP analysis (30%), and PRP activation (47%). No significant difference among the 3 MIBO groups was found for the item scores except for the reporting of the recipient details (P = .012).

CONCLUSION

This study highlights the deficiencies in adherence to the MIBO guidelines, particularly in reporting key variables such as whole-blood characteristics, platelet recovery rate, PRP analysis, and PRP activation. These findings suggest that the publication of the MIBO guidelines has not resulted in improved reporting practices in studies investigating intra-articular PRP for the treatment of knee osteoarthritis.

Achieved levels of apolipoprotein B and plaque composition after acute coronary syndromes: Insights from HUYGENS

BACKGROUND AND AIMS

Addition of the PCSK9 inhibitor, evolocumab, to statin therapy promoted coronary plaque stabilization after an acute coronary syndrome. While apolipoprotein B (ApoB) has been proposed as a goal for lipid-lowering therapy in the prevention of cardiovascular disease, its association with plaque stability has not been studied.

METHODS

The High-Resolution Assessment of Coronary Plaques in a Global Evolocumab Randomized Study (HUYGENS) used serial optical coherence tomography to assess coronary plaque phenotypes in patients with non-ST elevation myocardial infarction treated with evolocumab plus statin or placebo plus statin for 52 weeks. Changes in plaque composition were studied in patients according to achievement of a goal ApoB level <65 mg/dL.

RESULTS

Of 112 patients, 67 (59.8 %) achieved the ApoB goal and had lower ApoB values at follow-up compared with those not at goal (37.1 ± 15.0 vs 92.7 ± 19.4 mg/dL, P < 0.001). Patients achieving the ApoB goal demonstrated a greater increase in minimum fibrous cap thickness (+44.6 ± 36.0 vs +24.9 ± 38.1 μm, P = 0.007) and a more pronounced decrease in lipid arc (-57.8 ± 52.8 vs -27.0 ± 59.2°, P = 0.005) at follow-up, compared with those who did not achieve the ApoB goal. At follow-up, thin-cap fibroatheroma (TCFA) was less prevalent among patients achieving the ApoB goal compared with those not at goal (9.0 vs. 40.0 %, P < 0.001). Multivariate analysis demonstrated that achieving an ApoB <65 mg/dL at follow-up independently associated with the absence of TCFA at follow-up (P = 0.004).

CONCLUSIONS

Lower achieved ApoB levels associated with evidence of greater plaque stabilization even after controlling for low-density lipoprotein cholesterol levels. This highlights the importance of optimizing ApoB levels for the reduction of cardiovascular risk.

CLINICALTRIALSGOV IDENTIFIER

NCT03570697.

Stroke recurrence after transcatheter PFO closure in patients with cryptogenic stroke

BACKGROUND

Patent foramen ovale (PFO) closure is recommended for secondary prevention of cryptogenic stroke. However, data on long-term results are limited. We aimed to evaluate safety and efficacy of transcatheter PFO closure and predict neurologic recurrence.

METHODS

Data from patients undergoing PFO closure between 2010 and 2015 were collected to assess the combined endpoint of transient ischemic attack (TIA), stroke, or death from stroke at short- and long-term follow-up.

RESULTS

330 patients were included, mean age was 49 (±12) years, and 55.5% were male. Before PFO closure, 86% experienced a stroke and 19% multiple neurological events. Procedure-related complications occurred in 2.4% of patients. Over a median follow-up of 10 years, the combined endpoint occurred in 3.6%, with a recurrence rate of 0.38 per 100 patient-years. Freedom from the combined endpoint at 5 and 10 years was 97.5% and 96.2%, respectively. New-onset atrial fibrillation was detected in 3%. The Risk of Paradoxical Embolism (RoPE) score (adjHR: 0.68; p = 0.032), the PFO-Associated Stroke Causal Likelihood (PASCAL) classification system (adjHR: 0.37; p = 0.042), and a history of prior neurological events (adjHR: 9.94; p < 0.001) were independent predictors of future recurrent neurologic events. Age, sex, and cardiovascular risk factors did not influence outcomes.

CONCLUSION

In this real-world cohort, transcatheter PFO closure was associated with low long-term recurrence of neurologic events, especially cryptogenic strokes. The RoPE score, the PASCAL score, and history of previous neurological events were predictive of recurrent events. This study supports the safety and efficacy of PFO closure for secondary prevention of cryptogenic strokes, and underscores the importance of patient selection.

Associations Between Social Determinants of Health, Allostatic Load, and Anthracycline Cardiotoxicity in a Diverse Patient Population

BACKGROUND

Allostatic load (AL) is a measurement of physiological burden of chronic stress, operationalized using a composite score derived from biomarkers from multiple physiologic systems. The relationship between AL and anthracycline cardiotoxicity is unclear.

METHODS AND RESULTS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. Patients with preexisting heart failure and lack of AL score measures were excluded from the analysis. A composite AL score was calculated using 9 biomarkers tested before initiating chemotherapy. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction≥10% to <50%). A total of 718 patients were included in the analysis (29% Non-Hispanic White, 31% Non-Hispanic Black, 40% Hispanic). The mean AL score was 2.4±1.4 and it was significantly higher in Non-Hispanic Black and Hispanic patients compared with Non-Hispanic White patients (2.5±1.3 in Non-Hispanic Black versus 2.4±1.3 in Hispanic versus 2.1±1.5 in Non-Hispanic White, P=0.031). In patients who developed cardiotoxicity, AL score was significantly higher than patients without cardiotoxicity (2.7±1.4 versus 2.3±1.3, P=0.006). AL score was independently associated with incident anthracycline cardiotoxicity after adjusting for race and ethnicity, age, sex, cardiovascular risk factors, anthracycline dose, baseline left ventricular ejection fraction, cancer type, and cancer metastasis (hazard ratio 1.20 per 1 AL score increase [95% CI, 1.02-1.43], P=0.033). AL score remained significantly associated with anthracycline cardiotoxicity after additional adjustment of social determinants of health.

CONCLUSIONS

AL score can be a potential important prognostic marker in the prediction of cardiotoxicity in patients with cancer undergoing cardiotoxic treatment independent of social determinants of health.

Perioperative Antithrombotic Strategies in Vascular Surgery: A Survey in Germany

Background and Aims

The variety of modern antithrombotic medications complicates the choice of individual perioperative therapy in vascular surgery, especially when more than one antithrombotic option is possible. The aim of this study was to determine the perioperative and periinterventional setting concerning antithrombotics in vascular surgery in Germany.

Methods

This article is based on a survey from year 2018 of heads of German vascular surgical departments or units regarding their experience with different anticoagulants. The survey asked for the frequency and time of preoperative pausing of the antithrombotics before various vascular operations or interventions.

Results

The evaluable response rate was 52% (169/324). Acetylsalicylic acid was discontinued before open aortic surgery in 9% (15/169) of respondents. Clopidogrel was paused in 65% (107/169) before open aortic surgery, in 25% (41/169) before vascular surgery (like carotid endarterectomy, endovascular aortic repair, or operations on peripheral arteries), and in 11% (18/169) before peripheral percutaneous interventions. Discontinuation of vitamin K antagonists or direct oral anticoagulants (took place before conventional operations in 99.4%; oral anticoagulation was continued for peripheral percutaneous interventions in only 6% (8/169). Management was heterogeneous with regard to the timing of the perioperative medication pause. Clopidogrel was not discontinued according to time specifications in 8%; ticagrelor in 75%; rivaroxaban in 23%; and dabigatran in 29%, compared to the recommendations of the industrial information sheets.

Conclusion

The perioperative antithrombotic therapy in German vascular surgery clinics is not uniform and does not correspond to the current specialist recommendations in a notable proportion of clinics.

Thoracoabdominal normothermic regional perfusion in donors with neurological determination of death extends organ donors pool

BackgroundHeart transplantation team of the Heart Institute of the Ministry of Health of Ukraine performs thoracoabdominal normothermic regional perfusion (TA-NRP) procedure for organ preconditioning in marginal donors. Martial law in Ukraine worsens preexisting shortage of donor organs since February 2022. The use of TA-NRP has been shown to be effective in rescucitating organs in donors with circulatory determination of death (CDD), and we hypothesize that TA-NRP can be used to perform in situ organ perfusion in donors with neurological determination of death (NDD) as well, thereby improve organ quality.MethodsA single centre, retrospective analysis of outcomes after heart transplantation using organs from donors with NDD who underwent TA-NRP for preconditioning from 2022 to 2024 year at the Heart Institute Ministry of Health of Ukraine. The indications for TA-NRP were hemodynamic instability of donors with NDD, characterized by the need for norepinephrine >1.0 μg/kg/h to maintain mean blood pressure >50 mm Hg.ResultsTA-NRP for donor preconditioning was performed in 12 cases (11.3%) of 106 heart transplantations between 2019 and 2023. The average duration of TA-NRP was 124.5 ± 10.1 minutes. Prior to TA-NRP initiation, all donors exhibited metabolic acidosis, hyperkalemia, and hyperlactatemia. The implementation of TA-NRP normalized the acid-base balance, demonstrated by a significant increase in pH (p < .001), correction of base excess (BE) (p < .001), and an increase in bicarbonate levels (HCO3-) (p < .001). TA-NRP also significantly reduced baseline lactate levels from 10.4 ± 2.91 mmol/L to 1.57 ± 0.33 mmol/L (p < .001) and decreased potassium levels (p = .003). Additionally, it led to a significant reduction in donor heart rate (p = .001) and an increase in mean arterial pressure (p = .012), accompanied by a 6.6-fold reduction in donor norepinephrine requirements (p = .003).ConclusionThe use of TA-NRP in donors with NDD improved organ quality which resulted in 30 days survival rate of 83% and 1-year survival rate of 75% in organ recipients.

Racial and Ethnic Disparities in Cardiotoxicity in Patients With Cancer Treated With Anthracyclines

BACKGROUND

Cardiotoxicity in patients with cancer treated with anthracyclines is associated with increased morbidity and mortality. We aimed to examine the incidence of and risk factors for cardiotoxicity in a racially and ethnically diverse cohort with cancer treated with anthracyclines.

METHODS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction ≥10% to ≤50%).

RESULTS

A total of 743 individuals were included (28.0% Non-Hispanic [NH] White, 30.5% NH Black, 38.5% Hispanic, 3.0% Asian). Hypertension, diabetes, hyperlipidemia, obesity, and low socioeconomic status were more common in NH Black and Hispanic individuals. During a median follow-up of 21 months, 98 individuals (13.2%) developed cardiotoxicity. The incidence of cardiotoxicity was significantly higher in NH Black (16.3%), Hispanic (14.7%) and Asian (18.2%) individuals than in NH White (7.2%) individuals (P=0.024). After adjusting for cardiovascular risk factors, socioeconomic status score, anthracycline dose, baseline left ventricular ejection fraction, and cancer type, being NH Black (hazard ratio [HR], 2.62 [95% CI, 1.23-5.56]) or Hispanic (HR, 2.37 [95% CI, 1.11-5.07]) was independently associated with a higher risk of cardiotoxicity. NH Black and Hispanic individuals had a greater decline in left ventricular ejection fraction compared with NH White and Asian counterparts. The associations between baseline characteristics and incident cardiotoxicity were similar across different racial and ethnic groups.

CONCLUSIONS

In a large retrospective multiracial and ethnic cohort treated with anthracyclines, NH Black, Hispanic, and Asian individuals had an increased risk of cardiotoxicity compared with their NH White counterparts.

Clinical characteristics and outcomes in takotsubo syndrome -Review of insights from the InterTAK Registry

Takotsubo syndrome (TTS) is a complex cardiovascular condition characterized by transient left and/or right ventricular dysfunction in the absence of a coronary artery culprit lesion. The InterTAK registry, a large international collaborative registry, has significantly advanced our understanding of TTS. This review summarizes key findings from the InterTAK registry, including epidemiology, clinical presentation, comorbidities, outcomes, and treatment. The registry has revealed the diverse clinical spectrum of TTS, including atypical presentations, and identified various risk factors associated with adverse outcomes. The InterTAK registry has been instrumental in shaping the current understanding of TTS and will continue to guide future research and clinical practice.

Therapeutic novelties in acute heart failure and practical perspectives

Acute Heart Failure (AHF) is a leading cause of death and represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Since the past decade, several randomized clinical trials have highlighted the importance and pivotal role of certain therapeutics, including decongestion by the combination of loop diuretics, the need for rapid goal-directed medical therapies implementation before discharge, risk stratification, and early follow-up after discharge therapies. Cardiogenic shock, defined as sustained hypotension with tissue hypoperfusion due to low cardiac output and congestion, is the most severe form of AHF and mainly occurs after acute myocardial infarction, which can progress to multiple organ failure. Although its prevalence is relatively low, cardiogenic shock complicates 12% of acute myocardial infarction. After a brief summary of the epidemiology of AHF and cardiogenic shock, followed by key pathophysiological points, we detailed current treatments in AHF and cardiogenic shock what every anaesthesiologist and intensivist needs to know, based on the latest guidelines and randomized clinical trials published in recent years.

Operator Radiation Exposure Comparing the Left Radial Artery Approach and a Uniform Hyper-Adducted Right Radial Artery Approach: The HARRA Study

BACKGROUND

Radiation exposure is one of the most adverse occupational hazards faced by interventional cardiologists. Various arterial access sites have shown to yield different operator radiation exposure during diagnostic cardiac catheterization.

METHODS

This single-center randomized controlled trial assessed the cumulative radiation exposure and normalized radiation exposure at 4 different anatomic locations (thorax, abdomen, left eye, and right eye) of the primary operator when using the left radial artery (LRA) approach compared with a uniform hyper-adducted right radial artery (HARRA) approach. Patients (n=534) were randomized to LRA (n=269) or HARRA (n=265). During diagnostic catheterization, real-time radiation dosimeters were placed on the thorax, abdomen, left eye, and right eye of each operator.

RESULTS

Cumulative radiation measurements were as follows: thorax (LRA, 9.66±8.57 microsieverts [μSv] versus HARRA, 12.27±7.09 μSv; P<0.001); abdomen (LRA, 27.46±21.20 μSv versus HARRA, 36.56±23.72 μSv; P<0.001); left eye (LRA, 2.65±2.59 μSv versus HARRA, 3.77±2.67 μSv; P<0.001); and right eye (LRA, 1.13±1.69 μSv versus HARRA, 1.44±1.62 μSv; P=0.01). Normalized radiation measurements were: thorax (LRA, 0.38±0.35 versus HARRA, 0.49±0.24; P<0.001); abdomen (LRA, 1.06±0.72 versus HARRA, 1.38±0.69; P<0.001); left eye (LRA, 0.10±0.09 versus HARRA, 0.15±0.10; P<0.001); and right eye: (LRA, 0.04±0.06 versus HARRA, 0.05±0.06; P=0.02). LRA had lower subclavian tortuosity than HARRA (15.6% versus 32.5%, P<0.001).

CONCLUSIONS

The LRA was associated with significantly less cumulative and normalized radiation exposure to the thorax, abdomen, left eye, and right eye of the primary operator compared with HARRA during diagnostic cardiac catheterization. Operators should consider using LRA more frequently than HARRA for diagnostic cardiac catheterization as this approach can reduce occupational radiation exposure.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05833516.

Feasibility and Safety of Transradial Access for Renal Artery Embolization: A Single Center Prospective Study

OBJECTIVE

The objective of this study is to evaluate the feasibility and safety of renal artery embolization (RAE) via transradial access (TRA) in patients with renal angiomyolipoma (AML) or renal hemorrhage.

MATERIALS AND METHODS

Data were collected for this prospective single-center study from 50 patients (51 ± 12 years; male:female, 11:39) who underwent RAE for renal AML (n = 46) or renal hemorrhage (n = 4) between November 2020 and January 2024. Patients with a Barbeau D waveform or a radial artery diameter of <1.5 mm were excluded. Technical success in patients with renal AML and renal hemorrhage was defined as achieving selective catheterization of the culprit artery with embolization, leading to flow stasis and the absence of bleeding evidence, respectively. Clinical success was indicated by a reduction in AML size on follow-up CT scans and the absence of bleeding signs without necessitating additional RAE. The EuroQol 5-Dimension 5-level (EQ-5D-5L) questionnaire was utilized to assess health-related quality of life (HRQoL).

RESULTS

In one patient with AML, embolization could not be performed following selective catheterization and angiography due to the lack of visible tumor vascularity, resulting in a technical success rate of 98% (49/50). The clinical success rate was 96% (48/50 patients). No instances of TRA failure, conversion to transfemoral access (TFA), or hemostasis failure were noted. During the follow-up period, no major adverse events associated with the RAE occurred. Two patients exhibited asymptomatic radial artery occlusion, and one patient displayed asymptomatic partial thrombosis of the renal artery at the first follow-up visit. The EQ-5D-5L scores were 0.90 (95% confidence interval [CI]: 0.86-0.95) within 24 hours post-procedure and 0.89 (95% CI: 0.85-0.92) at the first follow-up (P = 0.332).

CONCLUSION

TRA is a feasible and safe approach for performing RAE in patients with renal AML or hemorrhage. RAE performed using TRA demonstrated high HRQoL outcomes and may serve as a viable alternative to TFA for performing RAE.

The role of the systemic inflammatory response index in predicting postoperative atrial fibrillation

OBJECTIVE

The aim of the present study was to determine the effect of systemic inflammatory response index in predicting the development of postoperative atrial fibrillation after isolated coronary artery bypass grafting (CABG).

METHODS

The study was conducted at Nevşehir State Hospital, a secondary healthcare center. Patients who underwent elective isolated CABG between October 2018, when the first open-heart surgery was performed at our center, and December 2022 were included. The patients' data were retrospectively reviewed and recorded.

RESULTS

A total of 66 patients were included in the study (mean age: 64.14±8.59 years). Of these patients, 44 (66.7%) were male and 22 (33.3%) were female. Postoperative atrial fibrillation was present in 22 (33.3%) patients. Although the systemic inflammatory response index and systemic immune-inflammatory index values were higher in the patient group that developed postoperative atrial fibrillation, no significant difference was noted (p>0.050). Additionally, age and a family history of coronary artery disease were identified as important factors that significantly affected the development of postoperative atrial fibrillation (p=0.048 and p=0.01, respectively).

CONCLUSION

To the best of our knowledge, no study has investigated the relationship between postoperative atrial fibrillation and the systemic inflammatory response index. Although the present study did not find a statistically significant difference, our findings support the role of inflammation in predicting postoperative atrial fibrillation.

Same-day discharge after elective percutaneous closure of patent foramen ovale

Percutaneous closure of the patent foramen ovale (PFO) is increasingly performed in specific patients with cryptogenic stroke or clinical evidence of a paradoxical embolism. This study was performed to determine the safety of same-day discharge (SDD) following such procedures. This is a prospective, observational study of patients undergoing elective percutaneous PFO closure in a single tertiary center in Portugal between January 2020 and July 2023. AmplatzerTM devices (St. Jude Medical, St. Paul, MN, USA) and NobblestichTM EL (HeartStitch, Inc., Fountain Valley, CA, USA) were used. After 6 months, the following events were looked at: post-procedural paroxysmal atrial fibrillation, stroke, unplanned cardiac re-hospitalization, urgent cardiac surgery, major vascular complications, pericardial effusions, device embolization, and death. We studied 122 consecutive patients (52% female, 68; 48±12 years old) who had elective percutaneous closure with success and no complications. A total of 49 (40%) patients had SDD. AmplatzerTM devices were used more frequently in the SDD group, while NobblestichTM EL was more common in the overnight group. During the overnight group's follow-up period, there was one non-cardiovascular death; there were no further events. SDD after elective percutaneous closure of PFO was shown to be a safe and successful patient management method, including NobblestichTM, which we describe for the first time. Our results prove the safety of this SDD strategy. We hypothesize that in the near future, in selected cases, PFO closure might become an ambulatory procedure.

Percutaneous coronary intervention versus coronary artery bypass in treatment of non-ST-segment elevation acute syndromes: a systematic review and meta-analysis study

The objective of this study is to compare the effectiveness and safety of Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG) in the treatment of Non-ST-Segment Elevation Acute Coronary Syndromes (NSTE-ACS). A literature search was conducted across PubMed, Scopus, and Web of Science, covering studies up to June 2024. Studies comparing PCI and CABG in patients with NSTE-ACS were included, focusing on clinical outcomes such as mortality, myocardial infarction, cerebrovascular accidents, and the need for repeat revascularization. Data extraction and quality assessment were performed. Statistical analysis was conducted using R software, with the Mantel-Haenszel method and random-effects model employed to pool effect sizes and assess heterogeneity. A total of 15 studies met the eligibility criteria, including 48,891 patients. The pooled risk ratio (RR) for mortality showed no significant difference between PCI and CABG (RR=1.09, 95% CI: 0.90-1.19, p=0.28). CABG was associated with a significantly lower risk of subsequent MI (RR=0.56, 95% CI: 0.38-0.61, p <0.01) and the need for repeat revascularization (RR=2.94, 95% CI: 2.30-3.76, p <0.01). Conversely, PCI had a lower associated risk of CVA (RR=0.58, 95% CI: 0.42-0.79, p <0.01). High heterogeneity was observed in mortality outcomes, indicating variability among studies. The findings suggest that while PCI and CABG have comparable mortality risks in NSTE-ACS patients, CABG offers superior protection against myocardial infarction and the need for repeat revascularization, whereas PCI is associated with a lower risk of cerebrovascular accidents. These results underscore the importance of individualized patient assessment in choosing the optimal revascularization strategy, considering patient-specific risk factors and clinical profiles.

Effects of residual inflammatory and cholesterol risks on cardiovascular events with evolocumab in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Evolocumab has shown significant reductions in low-density lipoprotein cholesterol (LDL-C) levels and incident cardiovascular events among acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Nonetheless, the potential modification of evolocumab's effectiveness by baseline inflammatory risk remains unclear. We aimed to assess evolocumab's effectiveness based on baseline neutrophil-to-lymphocyte ratio (NLR) and evaluate residual inflammatory and cholesterol-related risks across varying on-treatment NLR and LDL-C levels.

METHODS

This multicentric, retrospective analysis enrolled consecutive patients with ACS undergoing PCI and exhibiting elevated LDL-C at the First Affiliated Hospital of Zhengzhou University and Zhongda Hospital Southeast University between March 2019 and August 2021. Patients were categorized into evolocumab and standard-of-care treatment groups based on evolocumab administration. Hazard ratios for the primary composite outcome-including myocardial infarction, ischemic stroke, cardiac death, unplanned coronary revascularization, and hospitalization due to unstable angina-comparing baseline NLR quartiles were computed using multivariable Cox regression. We assessed evolocumab's impact on the primary outcome across median-based NLR dichotomization and evaluated the outcome across 1-month NLR and LDL-C levels.

RESULTS

The median baseline NLR was 2.99 (IQR: 2.14-4.69), remaining stable following evolocumab therapy. Each NLR quartile increase heightened the risk of primary outcome by 29% (95% CI, 17-42%; P < 0.01). The relative risk reductions with evolocumab were consistent across NLR categories (P-interaction > 0.05), but absolute risk reductions were higher in high-NLR patients (2.9% vs. 6.2%). Residual inflammatory and cholesterol risks, indicated by on-treatment NLR and LDL-C, independently correlated with the primary outcome (P < 0.001).

CONCLUSIONS

Higher baseline NLR is associated with increased cardiovascular risk in ACS/PCI patients. Relative risk reductions with evolocumab were consistent across NLR categories, while absolute risk reductions were more significant in high-NLR patients. Minimized risk is observed in patients with the lowest on-treatment NLR and LDL-C levels.

LA Epicardial Adipose Tissue Assessed by CTA Associated With Silent Cerebral Infarcts in Patients With AF Catheter Ablation

INTRODUCTION

Left atrium epicardial adipose tissue (LA-EAT) is an atrial cardiomyopathy marker associated with ischemic stroke. However, the relationship between EAT and silent cerebral infarcts (SCI) is unclear. This study investigated the effect of EAT on the risk of SCI after atrial fibrillation catheter ablation (AFCA).

METHODS

This was a single-center prospective study. We consecutively enrolled patients who underwent AFCA from October 2019 to February 2024. All patients completed brain magnetic resonance imaging (MRI) within 24-48 h after AFCA. SCI was defined as new single or multiple brain injuries detectable on MRI without clinical manifestations or neurolocalization signs.

RESULTS

A total of 341 patients were enrolled, including 56 (16.4%) with SCI. Pearson correlation analysis showed that LA-EAT volume index moderately correlated with left atrial volume index (r = 0.391, p < 0.001). After adjusting for potential confounding factors, multivariate analysis showed that LA-EAT volume index (OR = 1.10; 95% CI: 1.03-1.16, p = 0.002) and LA-EAT attenuation (OR = 1.08; 95% CI: 1.03-1.14, p = 0.003) were independent factors for SCI after AFCA. Integrating LA-EAT volume index and LA-EAT attenuation could statistically improve the ability of the model to predict SCI after AFCA (NRI 0.763, 95% CI: 0.5054-1.0196, p < 0.001; IDI 0.043, 95% CI: 0.0133-0.0733, p = 0.005).

CONCLUSION

LA-EAT is associated with SCI after AFCA and larger LA-EAT volume is an independent risk factor for SCI. Integrating LA-EAT can statistically improve the risk assessment model for SCI after AFCA.

Estimating lung cancer risk from e-cigarettes and heated tobacco products: applications of a tool based on biomarkers of exposure and of potential harm

BACKGROUND

Reliable epidemiological data are limited on the lung cancer risk of groups using e-cigarettes (ECIGs) and groups using heated tobacco products (HTPs).

AIM

We describe a methodology to estimate the lung cancer risk of these groups according to their levels of biomarkers of exposure (BOEs) and of potential harm (BOPHs).

METHODS

Using 28 search terms for BOEs and 82 for BOPHs we sought publications reporting biomarker-specific data from North America and Europe comparing individuals who smoke cigarettes and individuals who use other established products (ETPs; cigars, pipes, smokeless tobacco (ST) and/or snuff/snus). Publications were selected using defined inclusion/exclusion criteria. Additionally using lung cancer relative risk (RR) estimates for users of specific ETPs derived from recent meta-analyses of epidemiological studies in these regions, we derived a regression model predicting the lung cancer RR by level of each specific biomarker. Separately for groups using ECIGs and using HTPs the lung cancer risk was then estimated by combining RR estimates for selected biomarkers. Our primary estimates only considered biomarkers statistically significantly (p < 0.01) related to lung cancer risk which showed no significant (p < 0.01) misfit to the RR of 1.0 for non-users-those with no use of ETPs, ECIGs or HTPs.

RESULTS

Based on 38 available publications, we extracted biomarker-specific data for ETPs for 56 BOEs within 21 of the 28 search terms considered and for 54 BOPHs within 29 of the 82. The regression slope fitted to the lung cancer risk was significant (p < 0.01) for 22 BOEs and six BOPHs. However, the predicted RR for non-users significantly (p < 0.01) differed from 1.0 for 16 of these biomarkers. We estimated the lung cancer RR for using ECIGs, derived from 30 estimates for 10 biomarkers, as 1.88 (95% CI 1.60-2.22), the excess risk (ER = RR - 1) being 6.8% of that for smokers of cigarettes. The RR estimate varied little in most sensitivity analyses conducted, but increased markedly after removing the restriction to significant model fit. We estimated the lung cancer RR for using HTPs, combining estimates for four BOEs, as 1.44 (0.41-5.08), the ER being 3.4% of that for smokers of cigarettes.

CONCLUSIONS

Despite some methodological limitations, our approach estimates risk when reliable epidemiological data are unavailable. Using the biomarkers considered here, the model indicates that the lung cancer risk for individuals using ECIGs is much lower than for smokers of cigarettes, and suggests that the risk for those using HTPs is also low. Research using additional data could add precision to these findings.

Predictive power of ALBI score-based nomogram for 30-day mortality following transcatheter aortic valve implantation

AIM

This retrospective, multi-center study evaluates the relationships between novel liver function scoring systems - Albumin-Bilirubin (ALBI) score, EZ-ALBI, PALBI, and MELD-XI - and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Feature importance was assessed with SHAP-values via the XGBoost-algorithm.

RESULTS

The ALBI score exhibited the strongest association with 30-day mortality after TAVI (AUC = 0.723, p < 0.001), outperforming other scores in this regard and consistently demonstrating predictive power across various subgroup populations. Higher 30-day mortality rates were observed in the higher tertiles of the ALBI score compared to the lower tertiles (log-rank p-value = 0.004). The ALBI-based nomogram (C-index = 0.81, 95% CI:0.73-0.86, p = 0 < 001) demonstrated superior predictive power for 30-day mortality post-TAVI compared to the STS (C-index = 0.71, 95% CI :0.64-0.77, p = 0 < 001). In addition, the nomogram showed a significant improvement in reclassification (69.3%, p < 0.001) and a stronger discrimination 15.2%, p < 0.001) compared to the STS. It integrates nine variables, first ALBI score (SHAP:1.165), including NYHA class (0.594), body mass index (0.510), glomerular filtration rate, creatinine, hemoglobin, gender, predilatation requirement, presence of chronic kidney disease, and providing a comprehensive risk assessment tool.

CONCLUSION

This study exhibits the significance of liver dysfunction with AS patients and suggests incorporating liver function parameters in pre-operative risk assessments for better clinical outcomes in TAVI procedures.

Gender disparities in delayed angina diagnosis: insights from 2001-2020 NHANES data

BACKGROUND

Women with coronary artery disease (CAD) are more likely than men to experience a delay in diagnosis, which is attributed to differences in clinical presentation. The objective of this study is to examine any persistent disparities in timely CAD diagnosis in the United States (U.S.) among women who present with clinically similar symptoms and demographic characteristics to their male counterparts.

METHODS

From the 2001 - 2020 National Health and Nutrition Examination Survey (NHANES) data, participants were categorized as having missed angina if they experienced angina and did not self-report a prior diagnosis of angina pectoris or CAD. We assessed the association between gender and missed angina using weighted multivariate logistic regression models representative of the U.S.

POPULATION

Mortality follow-up data were available for participants up to December 31, 2018.

RESULTS

Of 874 participants with missed angina, 551 (63%) were women and 323 (37.0%) were men. Baseline characteristics showed that women and men with missed angina were more likely than their diagnosed counterparts to be younger, of ethnic minorities, uninsured, and smokers. Women with missed angina were more likely to be in a relationship than diagnosed women, while the opposite pattern was observed in men. The odds ratio of missed angina in women compared to men was 2.61 (95% CI: 1.73, 3.94) after adjusting for age, race, education, body mass index, smoking, alcohol use, income, insurance, and comorbidities. Among participants who had a cardiac cause of death, the odds of missed angina in women compared to men was 3.02 (95% CI: 1.18, 7.75) in the adjusted model.

CONCLUSION

Women with similar CAD symptoms to their male counterparts still have higher odds of going undiagnosed. This relationship extends to individuals who ultimately die of cardiac causes. Potential solutions to this disparity include addressing overgeneralized perceptions of differences in the prevalence and presentation of CAD between genders and exploring targeted screening programs for women with risk factors. Further research accounting for healthcare access and proximity to care is needed to support our findings. Timely recognition of CAD in women is essential to decreasing preventable mortality.

Incidence of stroke in patients with atrial fibrillation undergoing surgical treatment: a meta-analysis

INTRODUCTION

Atrial fibrillation (AF) is self-limiting condition, but it may also increase the risk of stroke and death. The association between AF and surgery with stroke was assessed both subjectively and statistically using systematic review and meta-analysis.

METHODS

For data collection, a thorough search was made in PubMed, EMBASE, Science Direct, Google Scholar, and Cochrane Library using searching keywords "postoperative ischemic stroke, atrial fibrillation, stroke, cardiac surgery, brain ischemia, and heart surgery". Direct and indirect comparisons were made using random-effect network meta-analysis.

RESULTS

16-studies were identified comprising of 132,208 patient, 64% male, median age > 63 years and follow-up > 1.5 years. Pooling the results from the random-effects model showed odds ratios associated with the risk of stroke of surgical processes (CABG) in patients with AF. The odds ratio OR = 1.1 (0.65-1.54, P < 0.001) and heterogeneity (I2 = 17%, P = 0.13) exposing higher risk of the stroke. Odds ratio (HR 1.5, 0.9-1.71) without heterogeneity showed greater risk of stroke after heart valve surgery in patients with AF. Study 8 didn't show any risk of the stroke after left atrial appendage (LAA) clipping intervention, but the outcomes were biased. A pooled analysis showed odd ratio OR, 2 (1.7-2.1, P < 0.0001), without heterogeneity indicating higher stroke risk in general cardiac surgery. The patients undergone cardiac surgery from three studies with pooled analysis study-5 OR 2 (1.7-2.1, P > 0.001), study-6 OR 1.8 (1.7-1.9, P > 0.001), and study-14 OR 7.8 (6.2-8.1, P > 0.0001).

CONCLUSION

The study clearly defines stroke outcomes when they are quantified, however, further research is required.

Beyond Cholesterol: Emerging Risk Factors in Atherosclerosis

Atherosclerosis remains a leading cause of cardiovascular morbidity and mortality worldwide, traditionally linked to elevated cholesterol levels, particularly low-density lipoprotein cholesterol (LDL-C). However, despite aggressive lipid-lowering strategies, residual cardiovascular risk persists, underscoring the need to explore additional contributing factors. This review examines emerging risk factors beyond cholesterol, including chronic inflammation, gut microbiota composition, oxidative stress, and environmental exposures. Inflammation plays a pivotal role in atherogenesis, with markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) serving as indicators of disease activity. The gut microbiome, particularly metabolites like trimethylamine N-oxide (TMAO), has been implicated in vascular inflammation and plaque development, while beneficial short-chain fatty acids (SCFAs) demonstrate protective effects. Oxidative stress further exacerbates endothelial dysfunction and plaque instability, driven by reactive oxygen species (ROS) and lipid peroxidation. Additionally, environmental factors, including air pollution, heavy metal exposure, endocrine disruptors, and chronic psychological stress, have emerged as significant contributors to cardiovascular disease. Understanding these novel risk factors offers a broader perspective on atherosclerosis pathogenesis and provides new avenues for targeted prevention and therapeutic interventions.

Left vs. Right Bundle Branch Block in COVID-19 Patients: Distinct Clinical Presentations and Prognostic Implications

Background/Objectives: COVID-19 is associated with multiple systemic effects, including cardiovascular complications. However, its interplay with cardiac conduction abnormalities remains underexplored. We compared the clinical profile of COVID-19 patients with pre-existing left bundle branch block (LBBB) or right bundle branch block (RBBB) at hospital admission. Methods: This study included 100 COVID-19 patients with antecedent BBB (50 LBBB, 50 RBBB). Critical cardiometabolic, renal, hematological, and inflammatory markers were measured. Logistic regression was used to identify key predictors differentiating COVID-19 patients with LBBB and RBBB. Spearman's correlations were applied to assess intra-strata associations for these variables. Results: COVID-19 patients with LBBB patients were significantly more likely to display lower systolic blood pressure (p = 0.012) but greater left atrial size (p = 0.008), left ventricular diameter (p = 0.001), and interventricular septal thickness (p = 0.023). Hematological and inflammatory markers differed, with LBBB patients being prone to exhibit higher red cell distribution width (p = 0.005), lymphocyte count (p < 0.001), neutrophil count (p = 0.045), and C-reactive protein (p < 0.001). This group also tended to show lower erythrocyte sedimentation rate (p = 0.013) and glycated hemoglobin (p = 0.045) but higher random glucose (p = 0.014). Absolute lymphocyte count, C-reactive protein, and left ventricular diameter were the most robust predictors distinguishing LBBB from RBBB. Significant associations were found exclusively for LBBB, all of them being weak. These predominantly negative relationships indicated an inflammatory origin, and most of them occurred for lymphocyte count. Conclusions: COVID-19 patients with LBBB and RBBB present distinct clinical profiles at hospital admission. The former group demonstrates a more adverse baseline clinical profile, particularly in terms of cardiac and inflammatory markers. These findings suggest that pre-existing BBB type may influence disease progression, potentially helping in risk stratification for COVID-19 patients.

Outcomes after fractional flow reserve-guided percutaneous coronary intervention versus coronary artery bypass grafting (FAME 3): 5-year follow-up of a multicentre, open-label, randomised trial

BACKGROUND

Long-term outcomes following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) might be changing because of improved techniques and better medical therapy. This final prespecified analysis of the Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation (FAME) 3 trial aimed to reassess their comparative effectiveness at 5 years.

METHODS

FAME 3 was a multicentre, randomised trial comparing FFR-guided PCI using current-generation zotarolimus-eluting stents versus CABG in patients with three-vessel coronary artery disease not involving the left main coronary artery. 48 hospitals in Europe, USA and Canada, Australia, and Asia participated in the trial. Patients (aged ≥21 years with no cardiogenic shock, no recent ST segment elevation myocardial infarction, no severe left ventricular dysfunction, and no previous CABG) were randomly assigned to either PCI or CABG using a web-based system. At 1 year, FFR-guided PCI did not meet the prespecified threshold for non-inferiority for the outcome of death, stroke, myocardial infarction, or repeat revascularisation versus CABG. The primary endpoint for this intention-to-treat analysis was the 5-year incidence of the prespecified composite outcome of death, stroke, or myocardial infarction. The trial was registered at ClinicalTrials.gov, NCT02100722, and is completed; this is the final report.

FINDINGS

Between Aug 25, 2014 and Nov 28, 2019, 757 of 1500 participants were assigned to PCI and 743 to CABG. 5-year follow-up was achieved in 724 (96%) patients assigned to PCI and 696 (94%) assigned to CABG. At 5 years, there was no significant difference in the composite of death, stroke, or myocardial infarction between the two groups, with 119 (16%) events in the PCI group and 101 (14%) in the CABG group (hazard ratio 1·16 [95% CI 0·89-1·52]; p=0·27). There were no differences in the rates of death (53 [7%] vs 51 [7%]; 0·99 [0·67-1·46]) or stroke (14 [2%] vs 21 [3%], 0·65 [0·33-1·28]), but myocardial infarction was higher in the PCI group than in the CABG group (60 [8%] vs 38 [5%], 1·57 [1·04-2·36]), as was repeat revascularisation (112 [16%] vs 55 [8%], 2·02 [1·46-2·79]).

INTERPRETATION

At the 5-year follow-up, there was no significant difference in a composite outcome of death, stroke, or myocardial infarction after FFR-guided PCI versus CABG, although myocardial infarction and repeat revascularisation were higher with PCI. These results provide contemporary evidence to allow improved shared decision making between physicians and patients.

FUNDING

Medtronic and Abbott Vascular.

Prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest suspected of acute coronary syndrome

BACKGROUND

There are currently no specific guidelines for prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest (OHCA) associated with acute coronary syndrome (ACS). This study aims to evaluate the efficacy and safety of a prehospital antiplatelet loading dose in patients with OHCA suspected of ACS referred to a cardiac catheterization laboratory (cath lab).

METHODS

We included consecutive patients referred for coronary angiography within 24 h after OHCA from 2012 to 2024. Prehospital antiplatelet treatment was defined as prescribing aspirin alone and/or a P2Y12 inhibitor before admission to the cath lab. Outcomes included: all-cause death at 30 days, in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, myocardial infarction, stent thrombosis, or stroke, and in-hospital major bleeding (BARC ≥ 3). An inverse probability weighting approach was used to compare outcomes between the two groups.

RESULTS

Of the 411 patients admitted to the cath lab within 24 h after OHCA, 217 (52.8%) received prehospital antiplatelet therapy, either aspirin alone (44.5%) or aspirin plus a P2Y12 inhibitor (8.3%). There was no difference in 30-day all-cause death between patients who received a prehospital treatment and those who did not (56.7%[50.0%;63.1%] vs 59.8%[52.8%;66.4%], p = 0.280). Rates of in-hospital MACE and major bleeding were not significantly different between the two strategies. Results appear to be consistent in subgroups of patients with ST-segment elevation or successfully resuscitated patients.

CONCLUSIONS

Prehospital antiplatelet therapy was safe, but showed no apparent improvement in survival or cardiovascular outcomes in patients with OHCA suspected of ACS.

Lack of Vaccination Against COVID-19, Obesity and Coexistence of Cardiovascular Diseases as Independent Predictors of a Higher Number of ECG Changes in Patients with Previous SARS-CoV-2 Infection

Objectives. Many studies have confirmed the existence of a relationship between SARS-CoV-2 virus infection and an increased incidence of arrhythmia in the population of adults, children and adolescents. It is believed that one of the potential side effects of COVID-19 vaccination is arrhythmia. However, large-scale studies confirming the relationship between COVID-19 vaccination and cardiac arrhythmia are currently lacking. The objective of this study was to analyze the occurrence of arrhythmias in 24 h Holter ECG monitoring among patients who had experienced COVID-19, comparing those who were vaccinated against SARS-CoV-2 with those who were unvaccinated. Methods. The study was performed on a study group of 237 patients, who underwent 24 h Holter monitoring. Results. Ventricular extrasystoles (VEs) were distinctively more common in patients, who had COVID-19 infection and were not vaccinated for COVID-19 comparing to the control group. Similarly, research has shown that supraventricular extrasystoles (SVEs) occurred remarkably more frequently in both unvaccinated and vaccinated patients after COVID-19 infection in relation to control groups. Multivariable regression analysis demonstrates that, in the whole study group, obesity, arterial hypertension, previous myocardial infarction and lack of vaccination against COVID-19 are independent risk factors for higher VE rates. Obesity, diabetes type 2 and lack of vaccination against COVID-19 are independent risk factors for higher SVE rates. The use of β-blockers is an independent protective factor against higher VE and SVE rates, and the use of ACE inhibitors against higher SVE rates. Conclusions. In this study, the authors obtained promising results for the future, facilitating further discussion and research on the topic of the antiarrhythmic advantages of COVID-19 vaccination. Moreover, the knowledge acquired in this study serves as a valuable tool for effectively promoting COVID-19 vaccination among patients.

Prognostic Impact of Chronic Kidney Disease After Percutaneous Coronary Intervention with Drug-Coated Balloons

Background: A drug-coated balloon (DCB) is an emerging treatment technology for percutaneous coronary intervention (PCI). However, the prognostic factors of PCI with a DCB remain fully determined. Chronic kidney disease (CKD) is an independent predictor of adverse outcomes in patients with coronary artery disease (CAD) who underwent PCI. The aim of this present study was to clarify the impact of CKD on prognosis in CAD patients who underwent PCI with a DCB. Methods: We enrolled 252 consecutive patients with CAD who underwent PCI with a DCB from 2015 to 2023. The endpoints of this study were composite events including all-cause death, myocardial infarction, target vessel revascularization, stroke, and major bleeding. Results: The prevalence rate of CKD was 48%. Patients with CKD were older and had higher prevalence of hypertension and diabetes mellitus than those without. Kaplan-Meier analysis revealed a significantly higher composite event rate in patients with CKD (log-rank test, p = 0.003). In the multivariate Cox proportional hazards analysis, CKD was independently associated with composite events after adjusting for confounding factors (adjusted hazard ratio 1.985, 95% confidence intervals 1.157-3.406, p = 0.013), mainly driven by all-cause deaths. Conclusions: CKD was associated with unfavorable outcomes in CAD patients who underwent PCI with a DCB.

Cardiac Surgery 2024 Reviewed

For the 11th consecutive time, we systematically reviewed the cardio-surgical literature for the past year (2024), using the PRISMA approach for a results-oriented summary. In 2024, the discussion on the value of randomized and registry evidence increased, triggered by consistent findings in the field of coronary artery disease (CAD) and discrepant results in structural heart disease. The literature in 2024 again confirmed the excellent long-term outcomes of CABG compared with PCI in different scenarios, generating further validation for the CABG advantage reported in randomized studies. This has been reflected in the new guidelines for chronic CAD in 2024. Two studies indicate novel perspectives for CABG, showing that cardiac shockwave therapy in CABG improves myocardial function in ischemic hearts and that CABG guided by computed tomography is safe and feasible. For aortic stenosis, an early advantage for transcatheter (TAVI) compared with surgical (SAVR) treatment has found more support; however, long-term TAVI results keep being challenged, this year by new FDA and registry data in favor of SAVR. For failed aortic valves, redo-SAVR showed superior results compared with valve-in-valve TAVI. In the mitral field, studies showed short-term noninferiority for transcatheter treatment compared with surgery for secondary mitral regurgitation (MR), and significant long-term survival benefit in registries with surgery for primary MR. Finally, surgery was associated with better survival compared with medical therapy for acute type A aortic intramural hematoma. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation but provides up-to-date information for patient-specific decision-making.