Clinical Research in Cardiology最新文献

Background: Mineralocorticoid receptor antagonists (MRA) have proven efficacy in heart failure and post-infarct left ventricular dysfunction, but their broader impact in acute coronary syndrome (ACS) remains uncertain.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing MRA versus placebo in patients following ACS. The primary endpoint was a composite of cardiovascular death, heart failure, or significant arrhythmia. Secondary endpoints included individual cardiovascular outcomes, recurrent myocardial infarction, stroke, all-cause mortality, ventricular remodeling parameters, and adverse events. PROSPERO registry CRD420251149760.

Results: Nine trials with 16,882 patients were included. Treatment with MRA significantly reduced the risk of the composite cardiovascular endpoint (RR 0.89, 95% CI 0.83-0.96; p = 0.001). This effect was primarily driven by reductions in cardiovascular mortality and heart failure events; no significant effect was observed for arrhythmias. Also, MRA lowered all-cause mortality (RR 0.88, 95% CI 0.80-0.97; p = 0.009) and improved left ventricular remodeling indices (increase in LVEF, reductions in LVESV/LVEDV). MRA did not significantly affect recurrent myocardial infarction or stroke. Safety analysis showed an increased risk of hyperkalemia (RR 2.14, 95% CI 1.45-3.16; p < 0.001) but no significant differences in overall or serious adverse events versus placebo.

Conclusions: In patients with ACS, MRA therapy confers a significant reduction in composite cardiovascular events and all-cause mortality, with favorable remodeling effects and a safety profile consistent with known risks (notably hyperkalemia). These results support guideline-aligned use of MRA in post-ACS management, with appropriate monitoring strategies.

Aim: This study evaluated the efficacy and safety of the subcutaneous implantable cardioverter defibrillator (S-ICD) in patients with obesity.

Methods: In this bicentric, retrospective study, S-ICD recipients were divided into two groups based on body mass index (BMI: < 30 kg/m² and ≥ 30 kg/m²). Defibrillation testing (DFT) failure, shock impedance, rates of appropriate and inappropriate shock, long-term complications, survival, and device-related or cardiac rehospitalizations were compared.

Results: Of the 120 patients included, most baseline characteristics were similar between patients with (n = 30) and without obesity (n = 90), except for a higher prevalence of diabetes in the group with obesity. The first shock during DFT was similarly effective (99 vs. 100%), although, shock impedance was significantly higher in patients with obesity (59 vs. 74 Ω; p = 0.011). There was no difference between the groups regarding the incidence of appropriate (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.21-2.34, p = 0.584), and inappropriate shocks (HR 0.92, 95% CI 0.23-3.48, p = 0.902). Non-infectious complications occurred numerically more often in obese patients (16.7% vs. 4.9%, p = 0.058), while device-associated infections were more frequent among non-obese patients (7.4% vs. 0%, p = 0.188). The risk of all-cause mortality (HR 0.32; 95% CI 0.11-0.97; p = 0.141), device-related (HR 0.52; 95% CI 0.14-1.90; p = 0.395) or cardiac rehospitalization (HR 1.06; 95% CI 0.48-2.32; p = 0.890) were similar between the groups.

Conclusion: Despite higher shock impedance during DFT at S-ICD implantation, shock efficacy remained stable during implantation and follow-up in both groups. Fewer infectious but more system-specific complications may manifest in patients with obesity compared to non-obese patients.

Introduction: Early integration of palliative care (EIPC) has been proposed to improve quality of life in heart failure (HF), but evidence is mixed and potential differences by HF subtype remain unclear. This exploratory secondary analysis of the EPCHF trial examined whether patient-reported outcomes differed between patients with and without reduced EF.

Methods: A total of 205 patients with symptomatic HF were randomized 1:1 to EIPC or standard care in the EPCHF trial. For this exploratory analysis, patients were stratified by left ventricular ejection fraction (≤ 40% vs > 40%). Patient-reported outcomes were assessed over 12 months using the Kansas City Cardiomyopathy Questionnaire (KCCQ), Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-PAL), Hospital Anxiety and Depression Scale (HADS), MIDOS, and FACIT-SP12.

Results: KCCQ scores, HADS-anxiety, and MIDOS symptom intensity improved significantly over 12 months in both EIPC and control groups, with no significant between-group differences in either EF subgroup. Reductions in HADS-depression occurred only in patients with HFrEF, with similar improvements in both EIPC (-1.37; 95% CI: -2.31 to -0.44; p = 0.004) and control (-1.99; 95% CI: -2.89 to -1.09; p < 0.001). Among patients with LVEF > 40%, EIPC produced a significant improvement in spiritual well-being compared with standard care (mean difference 3.47; 95% CI: 0.32 to 6.62; p = 0.031), whereas the control group showed no improvement. Mortality and hospitalization rates did not differ between groups.

Conclusion: In this exploratory EF-stratified analysis of EPCHF trial, EIPC did not improve overall HRQOL, mood, or symptom burden compared with standard care. A significant effect was observed only for spiritual well-being in patients with LVEF > 40%, suggesting that this subgroup may have distinct supportive-care needs warranting further investigation.

Background: Rheumatoid arthritis (RA) increases heart failure (HF) risk. Left atrial strain (LAs) may allow early detection of cardiac disease but has been seldom studied in RA. This study evaluated associations between LAs, clinical, laboratory, and echocardiographic parameters, and outcomes in RA patients without known cardiac disease.

Methods: In this prospective observational study, RA patients underwent LAs analysis and were stratified into two groups by the median left atrium reservoir strain (LARs). The primary endpoint was a composite of myocardial infarction, stroke, atrial fibrillation, HF hospitalization, or cardiovascular death; secondary endpoints were its individual components and all-cause mortality. Median follow-up was 6.2 years.

Results: Of 364 patients enrolled, 260 underwent LAs analysis and comprised the final cohort (median LARs 37.4%). LARs ≤ median (n = 131, 50.4%) was associated with older age, shorter 6-min walk distance, higher troponin-T and NT-proBNP, higher E/e', and lower left-ventricular global longitudinal strain. Primary endpoint incidence was numerically higher in patients with LARs ≤ median, but did not differ significantly between groups (15.5 vs 10.3 events/1000 patient-years; HR 0.64 [0.26-1.57]; p = 0.33). A trend toward higher all-cause mortality was observed in the lower LARs group (12.5 vs 3.75 events/1000 patient-years; HR 0.29 [0.078-1.04]; p = 0.06), with no significant differences in other secondary endpoints.

Conclusion: In RA patients, LARs ≤ 37.4% was associated with shorter walked distances, more pronounced cardiac structural, functional and biomarker alterations. While not significantly associated with adverse cardiovascular outcomes, the findings underscore the need for larger prospective studies to further explore this potential relationship.

Aims: Lipoprotein(a) [Lp(a)] is a novel biomarker for Atherosclerotic cardiovascular disease prediction. Yet, given the scarcity in high-quality evidence, its use in routine primary prevention screening is lacking. For this reason, we aimed to assess Lp(a) prognostic utility during routine screening.

Methods: A retrospective cohort of adults with available Lp(a) measurement, taken during a screening program (2008-2024) in a tertiary care center. Major adverse cardiovascular events (MACE) was the study primary outcome. The optimal Lp(a) threshold was evaluated using spline curve analysis and validated by Cox regression models adjusted for clinical and laboratory covariates. Subgroup analyses were performed in patients with SCORE2 and PCE data.

Results: 3052 people were included with a median (IQR) follow-up of 6.4 (3.5-12) years. Lp(a) threshold of 50 mg/dL was identified as a risk inflection point. High Lp(a) (> 50 mg/dL) was associated with increased MACE risk, independent of clinical data (HR 1.55, 95% CI 1.10-2.17, p = 0.011) or different laboratory variables (HR 1.62, 95% CI 1.07-2.46). High Lp(a) remained a predictor for MACE in models incorporating the SCORE2 and PCE scores, and its incorporation into these scores improved their performance in high-risk patients. In people with cardiovascular comorbidities, the optimal Lp(a) threshold for MACE prediction was 61 mg/dL, while it was 48.4 mg/dL in those without (n = 2778).

Conclusions: In a large ambulatory and mostly healthy cohort, Lp(a) showed a strong predictive utility for cardiovascular events. These findings support the integration of Lp(a) into primary cardiovascular risk assessment and role in guiding emerging targeted therapies.

Background: Clonal hematopoiesis of indeterminate potential (CHIP), commonly involving TET2 and DNMT3A mutations, is increasingly recognized as a cardiovascular risk factor, but its prognostic role in severe aortic valve stenosis (AVS) remains unclear. This study aimed to systematically evaluate the impact of CHIP on survival in AVS patients undergoing valve replacement.

Methods: A systematic search of PubMed, Embase, Web of Science, and Scopus through May 2025 identified observational studies of CHIP in AVS patients undergoing valve replacement. Eligible studies used validated genomic sequencing methods to identify CHIP and reported mortality outcomes. Two reviewers independently extracted study characteristics, outcomes, and related variables. Pooled hazard ratios (HRs) were calculated, with subgroup analyses by mutation type and geographic region, and meta-regression to assess effect modifiers. Risk of bias was assessed using the Newcastle-Ottawa Scale, and sensitivity and publication bias analyses were also assessed.

Results: Five studies with 1,175 patients were included. CHIP showed a non-significant trend toward increased all-cause mortality (HR = 1.58; 95% CI: 0.97-2.57; P = 0.0687; I² = 64.8%). When defined by TET2 mutations, CHIP was significantly associated with worse survival (HR = 1.91; 95% CI: 1.43-2.56; P < 0.001, I² = 0%), whereas DNMT3A mutations were not. In Western cohorts, CHIP was significantly associated with increased mortality (HR = 1.65; 95% CI: 1.28-2.12; P < 0.0001; I² = 38.7%). Meta-regression identified body mass index (BMI) as a significant modifier of the CHIP-mortality association (P = 0.0069).

Conclusions: CHIP, particularly TET2-related mutations, is associated with poorer survival in patients with severe AVS undergoing valve replacement. In Western populations, CHIP was significantly associated with increased mortality. Higher BMI further strengthened this association across all patients. These findings indicate that CHIP may be a potential marker for risk stratification and preventive strategies, but confirmation in larger and more diverse cohorts is required.

Background: Primary PCI is the standard of care for STEMI, but whether interhospital transfer (IHT) to a PCI-capable center worsens outcomes versus direct admission (DA) is uncertain.

Methods: We systematically searched PubMed, EMBASE, Scopus, and Web of Science for comparative studies of IHT vs DA among STEMI patients undergoing primary PCI. The primary outcome was in-hospital mortality; secondary outcomes included 30-day, 6-month, and 12-month mortality, major adverse cardiovascular events (MACE), stroke, bleeding, target-vessel revascularization (TVR), heart-failure hospitalization, left-ventricular ejection fraction (LVEF), and reperfusion time metrics. A random effects model was used when heterogeneity was significant (I² > 50%).

Results: Sixteen cohort studies (n = 183,422; 10 retrospective, 6 prospective) were included. In-hospital mortality was lower with IHT (RR 0.82, 95% CI 0.71-0.94), whereas 6-month mortality favored DA (RR 1.34, 95% CI 1.25-1.43). MACE, stroke, bleeding, TVR, heart-failure hospitalization, and 30-day/12-month mortality did not differ significantly. LVEF was modestly lower with IHT (MD - 1.79%, 95% CI - 3.33 to - 0.24). DA shortened symptom-to-admission (MD ≈103 min), symptom-to-PCI (MD ≈94 min), and total ischemic time (MD ≈70 min). Although transferred patients achieved a shorter in-hospital D2B (MD ≈ - 8.4 min) and were more likely to meet the < 90-min benchmark (RR 1.08), these gains were outweighed by longer pre-PCI delays. After weighting on covariates, in-hospital mortality was essentially identical between groups. Time-dependent Cox regression similarly showed that LVEF differences were driven by clinical severity (Killip class) rather than transfer itself.

Conclusions: In current STEMI networks, IHT was not associated with consistently worse clinical outcomes than DA despite longer pre-PCI delays. Apparent early survival advantages for IHT and small LVEF decrements likely reflect timing patterns and selection/survivor bias. Minimizing prehospital delays remains essential.

Background: Skin autofluorescence (SAF) is a biomarker of tissue accumulation of advanced glycation end-products, which increase the risk of cardiovascular disease (CVD) and mortality, particularly among individuals with chronic kidney disease (CKD) or diabetes mellitus (DM).

Objective: The aim was to summarise existing evidence and estimate the association between SAF and all-cause mortality, cardiovascular mortality and CVD.

Methods: A search of Medline, Scopus, Web of Science and the Cochrane Library was conducted from inception to June 2025. Observational studies estimating the association between SAF and all-cause mortality, cardiovascular mortality and CVD were included. Meta-analyses of these associations were performed by categorising SAF (high vs. low) and by 1 arbitrary unit (AU) increment of SAF, expressed as hazard ratio (HR) or odds ratio (OR) and their 95% confidence intervals.

Results: Thirty-two studies were included in the systematic review. Elevated SAF was associated with an increased risk of all-cause mortality, cardiovascular mortality and CVD. Per 1 AU increase, an HR of 1.51 (1.35, 1.69) was obtained for all-cause mortality, an HR of 1.48 (1.16, 1.90) for cardiovascular mortality and an HR of 1.25 (1.13, 1.38) for CVD. However, estimates with OR tended to be higher. Finally, the results were similar in CKD and DM.

Conclusions: SAF is a strong predictor of CVD and mortality in general, and in CKD and DM in particular. Integrating SAF measurement into clinical practice could help clinicians implement early and intensive interventions to prevent associated morbidity and mortality, although clinical trials are needed to evaluate its effectiveness.

Background: Catheter-directed thrombolysis using the EkoSonic™ Endovascular System (EKOS) is an established therapy for intermediate-high risk (IHR) pulmonary embolism (PE). However, whether the timing of intervention, during regular working hours (RW) versus (vs.) on duty hours (OD), impacts safety and efficacy outcomes remains unclear.

Methods: We retrospectively analyzed consecutive patients with IHR-PE treated with EKOS-lysis at three German centers between 08/2020 and 12/2023. Patients were grouped by timing into RW and OD group, based on institutional definitions of working hours. The primary endpoint was procedural safety, including in-hospital mortality of any cause and bleeding/non-bleedings complications. Secondary outcome compromised echocardiographic efficacy parameters, including reduction in right ventricular to left ventricular (RV/LV) ratio, systolic pulmonary artery pressure (sPAP), and improvement in tricuspid annular plane systolic excursion (TAPSE).

Results: Of 154 patients, 99 procedures were performed during RW hours, while 55 were done during OD hours. Baseline characteristics were comparable in both groups. Door-to-EKOS time (20.6 (4.8; 44) h vs. 7.2 (4,1; 19) h; p = 0.012) and CT-EKOS time (6.4 (1.3; 20) h vs. 2.3 (1.4; 3.5) h; p = 0.002) were significantly shorter during OD. Overall complication rates were lower OD (20 (20.2%) vs. 4 (7.3%); p = 0.038), with fewer bleeding events (18 (18.2%) vs. 3 (5.5%); p = 0.029). In-hospital mortality was similar (RW 8 (8.1%) vs. OD 2 (3.6%); p = 0.496). Both groups showed significant improvement in echocardiographic parameters with no significant intergroup differences in treatment efficacy.

Conclusion: EKOS-lysis performed during OD hours is safe and effective, with even fewer complications than during RW hours. These findings support the feasibility and safety of continuous PE-care by an experienced Pulmonary Embolism Response Team irrespective of procedural timing.