Clinical Research in Cardiology最新文献

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.

Background: High-sensitivity cardiac troponin (hs-cTn) assays are the gold standard for the early diagnosis and risk stratification of acute myocardial infarction (AMI). PERFORM-TSIX (clinicaltrials.gov identifier: NCT06734117) is a prospective, international, observational, longitudinal cohort study to evaluate the clinical performance of the next-generation Elecsys® Troponin T hs Gen 6 assay; the study design is presented here.

Objectives: The primary objective is to determine the sensitivity of the Troponin T hs Gen 6 assay for the detection of centrally adjudicated AMI diagnosis at 3 h post-emergency department (ED) presentation. Secondary objectives include evaluation of clinical performance at 0, 1-, 5-, and 6-h post-ED presentation and validation of thresholds for a 0/1-h algorithm to rule out AMI. Exploratory objectives include validation of thresholds for a 0/1-h algorithm to rule in AMI and a 0/2-h algorithm to rule in/out AMI and evaluation of prognostic performance at 30 and 180 days.

Methods: PERFORM-TSIX enrolled 5631 participants across 50 sites from the USA, Europe, China, and Japan. Patients aged ≥ 20 years presenting to the ED with symptoms/signs of acute coronary syndrome were enrolled. All patients were required to have cTn measured as part of their routine care; AMI diagnosis was adjudicated by an independent clinical events committee in accordance with the Fourth Universal Definition of MI, blinded to the results of the Troponin T hs Gen 6 assay.

Conclusion: PERFORM-TSIX will determine the clinical performance of the Troponin T hs Gen 6 assay for the diagnosis of AMI in a large, diverse global population.

Background: The prognostic benefit of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in stable coronary artery disease (CAD) remains uncertain.

Objectives: To evaluate long-term survival following CTO PCI compared with medical therapy (MT) using target trial emulation and a nationwide real-world registry.

Methods: We included 7813 patients with stable CAD and a documented CTO from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) between 2015 and 2024. CTO PCI was modeled as a time-dependent exposure. The primary outcome was all-cause mortality. We used inverse probability of treatment weighting (IPTW), time-dependent Cox regression, and instrumental variable (IV) analysis to adjust for confounding.

Results: Over a median follow-up of 5.08 years, 1253 deaths occurred. While unadjusted survival favored CTO PCI (HR 0.74; 95% CI, 0.64-0.86; p < 0.001), IPTW and IV adjustment showed no significant reduction in mortality compared with MT (IPTW HR 0.94; 95% CI, 0.80-1.10; p = 0.41; IV HR 1.00; 95% CI, 0.71-1.40; p = 0.999). Successful CTO PCI was associated with improved survival (HR 0.74; 95% CI, 0.62-0.87), whereas unsuccessful procedures were not (HR 1.08; 95% CI, 0.79-1.47). Subgroup analyses showed no consistent benefit, although a modest survival advantage was observed in non-diabetic patients.

Conclusions: In this large nationwide study using target trial emulation, CTO PCI was not associated with improved overall survival compared with MT. Only successful procedures conferred a benefit, highlighting the importance of procedural success and patient selection in CTO revascularization strategies.

Background and objective: Related to ongoing demographic, the number of patients with cardiac and non-cardiac comorbidities increases. Heart failure with mildly reduced ejection fraction (HFmrEF) represents a heterogeneous population with diverse clinical profiles. The study investigates the prevalence and prognostic impact of multimorbidity in patients hospitalized with HFmrEF.

Methods: Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022 and divided into four groups based on the number of concomitant comorbidities taking into account 12 comorbidities (i.e., 0-1, 2-3, 4-5, ≥ 6 comorbidities). The prognostic impact of the number of comorbidities was investigated with regard to the primary endpoint all-cause mortality at 30 months.

Results: From 2,184 patients hospitalized with HFmrEF, 37% presented with 4-5 comorbidities, 17% with ≥ 6 comorbidities. Compared to patients with 4-5, 2-3, 0-1 comorbidities, patients with ≥ 6 comorbidities were more frequently discharged with beta-blockers (83.6% vs. 78.7% vs. 77.6% vs. 64.7%; p = 0.001) and mineralocorticoid receptor antagonists (MRA) (17.2% vs. 15.7% vs. 12.8% vs. 7.9%; p = 0.004). The risk of all-cause mortality at 30 months was higher in patients with ≥ 6 comorbidities compared to patients with less comorbidities (i.e., 4-5, 2-3, 0-1) (59.5% vs. 38.6% vs. 17.0% vs. 7.9%, p = 0.001). Both cardiovascular (HR = 1.106; 95% CI 1.030 - 1.188; p = 0.006) and non-cardiovascular (HR = 1.564; 95% CI 1.470 - 1.664; p = 0.001) comorbidities predicted the risk of long-term all-cause mortality.

Conclusion: In patients hospitalized with HFmrEF, more than 50% had at least 4 comorbidities. Both cardiovascular and non-cardiovascular comorbidities predicted the risk of long-term all-cause mortality in HFmrEF.

Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) and cardiometabolic multimorbidity (CMM) are growing public health concerns. However, the impact of MASLD on single cardiometabolic disease (CMD), CMM, and mortality remains unclear.

Methods: This prospective analysis used data from the UK Biobank, involving 376,087 participants aged 37-73 years. CMM was defined as the coexistence of at least two CMDs, including stroke, ischemic heart disease (IHD), and type 2 diabetes (T2D). MASLD severity was evaluated using liver fibrosis scores. Multivariable Cox proportional hazards model was used to investigate the associations. Structural equation modeling was employed to determine the extent to which CMD or CMM mediated the relationship between MASLD and death.

Results: Over a median follow-up of 11.7 years, MASLD was linked to significantly higher risks of single CMD (HR 1.94, 95% CI 1.92-1.96), CMM (HR 3.40, 95% CI 3.31-3.49), and all-cause mortality (HR 1.21, 95% CI 1.20-1.23) in CMD-free participants. Additionally, MASLD increased the risk of progression from single CMD to CMM (HR 1.95, 95% CI 1.81-2.10) and to all-cause mortality (HR 1.11, 95% CI 1.03-1.20). However, MASLD was not independently associated with transitions from CMM to mortality (HR 1.06, 95% CI 0.89-1.28). Furthermore, these risks escalated with increasing MASLD severity. CMD mediated 44.5% of the indirect effect of MASLD on mortality, and CMM mediated 32.5% of this effect.

Conclusion: MASLD is associated with the increased risk of CMD, CMM, and mortality. Preventing and managing MASLD may reduce the incidence of CMD, CMM, and associated mortality.