Clinical Research in Cardiology最新文献

Dyslipidaemia, especially elevated low-density lipoprotein cholesterol (LDL-C), is a major modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD). Dyslipidaemia remains underdiagnosed and undertreated. Dyslipidemia is highly prevalent in Germany. Even among patients with high- and very-high cardiovascular risk, LDL-C targets are often not achieved. This paper highlights key lipid parameters beyond LDL-C, such as triglycerides and lipoprotein(a), which contribute to residual cardiovascular risk. Practical guidance to address diagnostic challenges and cardiovascular risk assessment, especially in younger adults and those with risk modifiers, is provided. Lifestyle interventions are the basis of therapy. Statins remain the first-line treatment, with additional options including ezetimibe, bempedoic acid, and PCSK9 inhibitors, alone or in combination. Novel lipid-lowering therapies are currently in development and may offer more individualized treatment options in the future. The most important messages from the 2025 Focused Update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias have been incorporated into the paper. While LDL-C targets remain unchanged, important novel recommendations encompass consideration of cardiovascular risk modifiers such as lipoprotein(a) and CRP/inflammatory diseases. A second important new recommendation is the use of potent early combination therapy after an acute coronary syndrome. Improved awareness, early diagnosis, and evidence-based lipid management are critical for reducing ASCVD burden. This paper is aimed at supporting clinicians in optimizing lipid diagnostics and therapy in daily practice.

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.

Objective: To systematically evaluate the causal effect of lipoproteins to the risk of coronary artery disease (CAD) by systematic review and meta-analysis of the associated Mendelian randomization (MR) studies.

Methods: This systematic review was registered in PROSPERO (ID CRD42023465430). Searches from the databases (e.g., PubMed, Embase, Cochrane, Web of Science) and non-database sources to collect MR studies. The search time frame was from the database inception to August 2023. After data extraction, quality evaluation was performed, and the meta-analysis with bias evaluation was carried out with RevMan software.

Results: A total of 5,828,409 participants from 21 records were included. Quality and bias assessment was performed by evaluating the internal three assumptions of MR studies. Meta-analysis for the causal association between non-HDL lipoproteins and CAD showed a significantly positive association between LDL and CAD (OR 1.37, 95% CI 1.26-1.49; P < 0.001, I² = 95%), apoB and CAD (OR 1.38, 95% CI 1.11-1.71; P = 0.003, I² = 98%), and Lp(a) and CAD (OR 1.21, 95% CI 1.12-1.31; P < 0.001, I² = 99%). Interestingly, although there was no statistical significance in the association between VLDL/apoA1 and CAD (both P > 0.05), the pooled non-HDL lipoproteins showed a significantly positive association with CAD (OR 1.28, 95% CI 1.22-1.34; P < 0.001, I² = 99%). For the HDL lipoproteins, the pooled OR showed a significantly negative association with CAD (OR 0.84, 95% CI 0.72-0.98; P = 0.002, I² = 72%). However, the protective effect of HDL on CAD diminished when analyzed together with apoA1 and/or apoB (both P > 0.05). The funnel plot did not show serious publication bias, and sensitivity analysis performed relatively well robustness of the causal association of LDL, apoB, Lp(a), and total cholesterol with CAD.

Conclusion: The present meta-analysis suggests an overall effect of causal association between lipoproteins and CAD. Most of the non-HDL lipoproteins (LDL, apoB, Lp(a)) promote CAD, while the protective effect of HDL in CAD still needs to be verified in the future.

Background: Intravascular lithotripsy (IVL) emerged for the treatment of coronary artery calcification with encouraging safety and effectiveness rates in previous trials. Knowledge about the in-hospital safety of IVL in comparison to frequently used plaque modification techniques remains limited.

Objectives: The aim of this study was to assess the in-hospital outcomes of IVL in comparison to rotational atherectomy (RA) and cutting/scoring balloons (C/S).

Methods: A total of 51,921 isolated PCI procedures of patients who underwent planned coronary angiography with IVL, RA or C/S between 2019 and 2023 were extracted from a German nationwide registry. Analyses of the average treatment effect were carried out employing a double-robust estimator using machine learning algorithms.

Results: Compared to IVL, adjusted procedural relative risk of in-hospital mortality was significantly higher for RA (RR 1.72; 95% CI: 1.24 - 2.38, p = 0.001) and C/S (RR 1.50; 95% CI: 1.08 - 2.08, p = 0.015), while safety parameters such as stroke, severe bleeding and acute kidney injury were comparable. The adjusted risk of shock (RR 1.57; 95% CI: 1.20 - 2.04, p = 0.001) and pericardial drainage (RR 1.95; 95% CI: 1.23 - 3.07, p = 0.004) was lower for IVL compared to RA but not to C/S. Further, IVL use was associated with a shorter adjusted length of hospitalization compared to RA (- 0.75 days, p < 0.001) and C/S (- 0.22 days, p = 0.047).

Conclusion: IVL is associated with a favorable safety profile compared to RA and C/S and a more timely discharge of patients.

Background: As minimalist transcatheter aortic valve implantation (TAVI) programs continue to expand globally, significant practice variation persists in anesthetic strategy. This meta-analysis directly compares the safety and efficacy of local anesthesia alone (LA) versus local anesthesia with sedation (LAS) for TAVI.

Methods: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception through September 2025. Primary outcomes included all-cause mortality, stroke, acute kidney injury (AKI), and ≥ moderate paravalvular regurgitation (PVR). Secondary outcomes encompassed procedural complications and efficiency metrics. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated using random- or fixed-effects models.

Results: Seven studies (one randomized controlled trial, six observational) with 2,990 patients (LA: n = 1,229; LAS: n = 1,761) were included. We found no significant differences between LA and LAS in all-cause mortality (RR 0.67, 95% CI 0.35-1.29, p = 0.23), stroke (RR 0.77, 95% CI 0.37-1.62, p = 0.49), AKI (RR 0.67, 95% CI 0.26-1.73, p = 0.41), or PVR (RR 1.03, 95% CI 0.63-1.69, p = 0.91). Rates of vascular complications, pacemaker implantation, and major bleeding were also comparable. Procedural efficiency metrics, including procedure time (MD 2.76 min, 95% CI -2.70-8.21, p = 0.32) and hospital length of stay (MD -0.48 days, 95% CI -1.16-0.19, p = 0.16), did not differ significantly between groups.

Conclusions: In patients undergoing transfemoral TAVI, a minimalist approach using LA alone is non-inferior to LAS regarding short-term safety, efficacy, and procedural efficiency. These findings suggest that anesthetic strategy may be individualized based on patient-specific factors and operator experience while maintaining comparable clinical outcomes.

Registration: PROSPERO CRD420251146705.

Background: Electrical storm (ES) is associated with high mortality and may lead to worsening of heart failure or repeat ICD therapy deliveries. Catheter ablation of ventricular tachycardia (VT) in ischemic heart disease has proven to be successful in reducing ventricular arrhythmia recurrences. The prognostic impact of ablation on patients with ES needs to be further elucidated.

Objective: To analyse the impact of catheter ablation on prognostic outcomes in patients with electrical storm.

Methods: A composite study endpoint consisting of all-cause death, implantation of a left ventricular assist device or heart transplantation was in consecutive patients who were admitted for ES therapy to our intensive-care unit from 2016 to 2022. Patients who underwent ablation were compared with propensity score-matched patients who underwent conservative treatment.

Results: Propensity-score matching of 155 patients with ES resulted in 51 patients undergoing catheter ablation and 51 patients with conservative therapy only with comparable baseline characteristics. A study endpoint event occurred in 18 patients (35%) in the ablation group and 34 patients (67%) in the conservative group (P = 0.015, Hazard ratio 2.06, 95%-CI 1.14-3.72) after a mean follow-up of 867 ± 697 days. Ablation performed within 10 days after ES onset (P = 0.04) and an increased ejection fraction (LVEF, P = 0.024) were associated with a negative prediction of the occurrence of a primary endpoint by bivariate logistic regression.

Conclusion: Catheter ablation of ES was associated with a lower likelihood of death from any cause, LVAD implantation or heart transplantation as compared to conservative therapy alone, especially when performed timely after ES onset.

Background: The efficacy of transthyretin stabilisation in cardiac transthyretin amyloidosis (ATTR-CM) has been demonstrated in a clinical trial setting, but little is known about treatment decision-making in the real world. Particularly, initiating or discontinuing specific therapy is challenging in early and advanced disease. We evaluated current decision pathways for tafamidis in ATTR-CM.

Methods: This multicentre retrospective study included consecutive patients from 15 tertiary centres in Germany in whom ATTR-CM was newly diagnosed between January and June 2024, as well as patients, in whom tafamidis treatment was discontinued during this period.

Results: Out of 516 patients with newly established ATTR-CM included in the present analysis, tafamidis was initiated in 414 (80%). The 99 patients without recommendation for tafamidis were older (p = 0.002), had a higher amyloidosis disease stage (NAC score), worse NYHA class (both p < 0.001), and higher NT-proBNP levels (p = 0.002) compared to those with tafamidis initiation. During the same observation period, tafamidis therapy was discontinued in 28 ATTR-CM patients. Treatment decisions were mainly taken by an interdisciplinary board (73% of centres). The most frequent reasons for not starting or stopping tafamidis were 'frailty' (47%/61%) and 'life expectancy or comorbidity' (38%/43%), respectively.

Conclusions: In this multicentre analysis, treatment with tafamidis was initiated in about 80% of patients with newly diagnosed ATTR-CM. In most centres, treatment decisions were made by an interdisciplinary board, and the reasons for treatment decisions were similar across centres. Due to the lack of consensus criteria, our data may help to standardise decision pathways for ATTR-CM.

Background: Beyond global left ventricular function, identification of regional wall motion abnormalities (RWMA) is an essential component of emergency echocardiography in patients with non-ST-elevation myocardial infarction (NSTEMI). This study investigated the prognostic significance and diagnostic value of RWMA.

Methods: Echocardiographies of 1110 consecutive NSTEMI patients undergoing coronary angiography were analyzed. Patients were classified as type 1 NSTEMI if an atherosclerotic culprit lesion was identified, otherwise as type 2. Adverse in-hospital events were a composite of in-hospital death, cardiogenic shock, and mechanical ventilation.

Results: Among 895 patients with type 1 NSTEMI and 215 with type 2, RWMA were present in 68.2% overall. Adverse in-hospital events occurred in 18.1% of patients with RWMA versus 10.5% without (OR 1.89, 95% CI 1.29-2.81). Mediation analysis showed this excess risk was largely attributable to reduced ejection fraction. RWMA occurred more frequently in type 1 compared with type 2 NSTEMI (70.3% vs. 59.5%, p = 0.003) and remained an independent predictor of type 1 NSTEMI (OR 1.69, p = 0.002). However, the diagnostic accuracy of RWMA alone was modest (AUC 0.554), improving to fair performance (AUC 0.727) when combined with clinical factors. Among type 1 NSTEMI patients, RWMA corresponded to the culprit lesion territory in 90.1% when present.

Conclusions: RWMA identify NSTEMI patients at higher risk of adverse outcomes. Although insufficient alone to differentiate type 1 from type 2 NSTEMI, RWMA augment diagnostic accuracy when combined with clinical factors. Routine RWMA assessment during emergency evaluation may help guide the urgency of invasive management and anticipate the culprit lesion location.

Background: To examine national trends and forecast future mortality involving hypertension and substance use among United States (US) adults from 1999 to 2035. Hypertension contributes substantially to mortality in the US, particularly among populations with substance use. The interplay between hypertension and substance use varies by gender, race, age, and geography. Hypertension contributes substantially to mortality across the US, particularly among populations with substance use. The interplay between hypertension and SU varies by gender, race, age, and geography.

Methods: Using the CDC WONDER Multiple Cause-of-Death database, we conducted a retrospective analysis of hypertension with substance use mortality from 1999-2024 among adults aged ≥ 25 years. Age-Adjusted Mortality Rates (AAMRs) were calculated, and Joinpoint regression estimated annual and average annual percentage changes (APC, AAPC) with 95% confidence intervals. Auto-ARIMA and Prophet time-series models in R (v4.5.0) projected AAMRs through 2035, evaluated by root mean squared error (RMSE).

Results: From 1999 to 2024, a total of 405,692 deaths involving hypertension and substance use occurred in the US. AAMR increased from 1.32 to 13.9 (AAPC 9.38; p < 0.001). Men had higher AAMRs than women (10.38 vs 3.06). NH American Indian/Alaska Native adults had the highest mean AAMR (17.89), followed by NH Black (11.59), White (6.37), and Hispanic (4.94) adults. Middle-aged adults (45-64) had the greatest burden (10.95). AAMRs ranged from 2.91 in Alabama to 15.03 in the District of Columbia, highest in the West (8.05) and South (6.76). Urban areas slightly exceeded rural (5.31 vs 5.10). Alcohol accounted for 49.3% of deaths, followed by intentional overdose (16.4%) and cocaine (12.7%). Projections to 2035 indicate continued rises, particularly among men, NH American Indian/Alaska Native individuals, middle-aged adults, and in the West and South.

Conclusion: Hypertension with substance use-related mortality has risen sharply, with persistent demographic and regional disparities warranting targeted prevention strategies.