Clinical Research in Cardiology最新文献

Background: Current guidelines recommend frailty assessment for risk stratification of candidates for transcatheter mitral and tricuspid valve repair (TMTVR), but it remains unclear which frailty score is most appropriate.

Methods: In a retrospective monocentric analysis of patients who received TMTVR, a modified version of the essential frailty toolset (EFT) was calculated from four categories: gait speed, cognitive impairment, hemoglobin, and serum albumin. Cox proportional hazards models were used to examine the association between EFT frailty and all-cause mortality.

Results: A total of 206 patients were analyzed; median age was 76 [72-82] years, and 55% were male. According to the EFT, 49 patients (24%) were non-frail, 127 patients (62%) were pre-frail, and 30 patients (15%) were frail. Estimated survival at 2 years was 88 ± 5% for non-frail patients, 74 ± 5% for pre-frail patients, and 62 ± 10% for frail patients, with a hazard ratio of 1.54 (95% CI 1.16-2.04; p = 0.003) per standard deviation of EFT score. This association remained virtually unchanged when adjusted for other risk factors and Fried physical frailty, but disappeared when adjusted for the multidimensional prognostic index (MPI), which is based on a comprehensive geriatric assessment. A stepwise approach using EFT in all patients and MPI only in pre-frail EFT patients resulted in two risk categories with a 4.4-fold (95% CI 2.3-9.4) difference in 2-year mortality between categories.

Conclusions: The EFT has prognostic value for patients undergoing TMTVR. Due to its simplicity, the EFT could serve as a first-line frailty assessment tool to guide therapeutic decision-making, potentially in a stepwise approach with MPI.

Cancer-associated venous thromboembolism (VTE) is one of the most frequent and life-threatening complications in oncology, representing the second leading cause of death in patients with malignancy. Its pathogenesis is multifactorial, driven by tumor-specific procoagulant activity, systemic inflammation, and the prothrombotic effects of anticancer therapies. The risk is particularly high in pancreatic, gastric, cerebral, and pulmonary cancers and is further amplified by advanced disease stage, comorbidities, and treatment-related factors. Management of cancer-associated VTE requires a careful balance between the risks of thrombosis and bleeding. Low-molecular-weight heparins (LMWHs) were long considered the standard of care, based on superior efficacy over vitamin K antagonists. More recently, direct oral anticoagulants (DOACs) have emerged as effective alternatives, offering the convenience of oral administration and comparable efficacy. However, increased rates of gastrointestinal and genitourinary bleeding, drug-drug interactions, and challenges in patients with renal dysfunction or thrombocytopenia complicate their use. Current international guidelines recommend both LMWHs and DOACs as first-line options, with agent selection guided by tumor type, bleeding risk, comorbidities, and patient preference. Despite these advances, unmet needs persist, including recurrent thrombosis despite anticoagulation, management in thrombocytopenic patients, and adherence to prolonged LMWH therapy. Novel strategies, particularly inhibition of coagulation factor XI, hold promise for dissociating antithrombotic efficacy from bleeding risk. Ongoing phase 3 trials of abelacimab may provide critical evidence to refine anticoagulation strategies in patients with complex clinical profiles. Cancer-associated VTE remains a major clinical challenge requiring individualized decision-making and continuous reassessment. Emerging therapies may further improve outcomes in this vulnerable population.

Background: T2-mapping of the blood-pool in cardiac magnetic resonance imaging (CMR) provides important information on blood-oxygenation, and differences between right and left ventricular (RV/LV) T2-relaxation times are linked to exercise capacity in heart failure. However, there are no data available on RV/LV T2-ratio after ST-segment elevation myocardial infarction (STEMI). Our aim was to investigate the prognostic value of RV/LV T2-ratio for the development of newly diagnosed congestive heart failure (CHF) post-STEMI.

Methods: Six hundred four patients were enrolled after revascularized first-time STEMI; all patients underwent CMR within four days afterwards (interquartile range (IQR) 2-5). T2 relaxation times were measured in the RV and LV blood pool on short-axis T2-maps; T2-ratio was calculated as T2_RV/T2_LV. Telephonic follow-ups were performed at a median observation interval of 3.0 years. CHF was defined as cardiac decompensation symptoms requiring i.v. diuretics.

Results: Median T2-ratio was 73% (IQR 65-80) and significantly lower in patients with newly diagnosed CHF (69% vs. 73%, p = 0.019). Dichotomized at 60% (10th percentile), patients with a reduced T2-ratio experienced CHF significantly more often (19% vs. 6%, p < 0.001) and sooner (55 vs. 485 days, p < 0.001) and were significantly older, had larger infarcts, higher peak troponin T, N-terminal pro-brain natriuretic peptide (NT-proBNP), lower LV-/RV-ejection fraction, and more commonly microvascular injuries (all p < 0.05). In logistic regression, T2-ratio < 60% emerged as an independent prognostic marker in multiparametric models including classic CHF risk factors. Addition of RV/LV T2-ratio to NT-proBNP resulted in a net reclassification improvement of 0.32 (95% CI 0.06-0.57, p = 0.016).

Conclusion: CMR-derived RV/LV T2-ratio is an easily applicable tool bearing prognostic potential for CHF after STEMI.

Background: Hospital length of stay (LOS) in acute decompensated heart failure (ADHF) lacks standardized thresholds. Prior studies using administrative data have reported neutral all-cause outcomes with very short hospital stays (1-2 days) despite higher cardiovascular readmissions, raising concerns about residual confounding from unmeasured clinical severity.

Methods: This is a retrospective cohort study of adults (≥ 18 years) hospitalized with ADHF at a single center in Israel between 2007 and 2017. We excluded in-hospital deaths and coronary artery bypass grafting (CABG) surgery cases. LOS was categorized as short (1-2 days), standard (3-6 days, reference), or prolonged (≥ 7 days).

Primary outcome: 30-day all-cause readmission or mortality. Cox models adjusted for age, sex, ischemic heart disease, atrial fibrillation, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, and anemia. Restricted cubic splines with three knots at approximately the 10th, 50th, and 90th percentiles modeled continuous LOS, using 5 days as reference.

Results: Among 8332 patients with first ADHF hospitalization, 7455 were analyzed after excluding 707 in-hospital deaths and 170 CABG cases. Distribution by LOS: 1072 short (14.4%), 3457 standard (46.4%), 2926 prolonged (39.2%). Patients with a short LOS were younger (median 75 vs. 78 and 79 years), less often female, and had lower CKD (29.9% vs. 33.5% and 35.2%) and anemia (61.9% vs. 65.0% and 70.2%; all p ≤ 0.006), with favorable discharge labs. Unadjusted 30-day composite rates were 19.9% (short), 21.6% (standard), and 28.6% (prolonged; p < 0.001). Adjusted HR for short vs. standard: 0.86 (95% CI 0.73-1.02, p = 0.081); prolonged vs. standard: 1.37 (95% CI 1.23-1.52, p < 0.001). Spline analysis showed a J-shaped curve: protective effect (HR < 1.0) for LOS 2-5 days, risk rising significantly beyond 6 days.

Conclusion: In a clinically detailed ADHF cohort, discharge after 1-2 days was not associated with higher 30-day readmission or mortality among patients selected for early discharge. In contrast, prolonged hospitalization identified a subgroup at substantially higher short-term risk, underscoring hospital length of stay as a marker of clinical complexity rather than a determinant of outcomes.

Aim: The role of drug-coated balloon (DCB)-only strategy in de novo chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains uncertain. We compared DCB with drug-eluting stent (DES) strategies in patients undergoing CTO angioplasty.

Methods: We retrospectively analyzed 170 patients with de novo CTO undergoing PCI between 2013 and 2019. Patients were treated with either DCB-only (n = 85) or DES-only (n = 85) strategies. The primary endpoint was target vessel revascularization (TVR); secondary endpoints included all-cause mortality, cardiovascular death, target vessel-myocardial infarction (TV-MI), any MI, and a composite of all-cause mortality, MI, and TVR. Median follow-up was 3.67 years.

Results: TVR occurred in 11 (12.9%) DCB vs. 5 (5.9%) DES patients (HR 2.33, 95% CI 0.81-6.74, p = 0.118). All-cause mortality (7.1% vs. 12.9%; HR 0.56, p = 0.262) and the composite endpoint (21.2% vs. 20.0%; HR 1.15, p = 0.686) did not differ significantly. After adjustment for creatinine, J-CTO score, and vessel diameter, outcomes remained comparable between groups. Creatinine was independently associated with mortality and the composite endpoint. No acute vessel closure or thrombosis occurred within 30 days. During follow-up, no target lesion thrombosis was observed in the DCB group, while one late stent thrombosis (1.2%) occurred in the DES group.

Conclusion: In this single-center study, a DCB-only strategy for de novo CTO PCI demonstrated long-term efficacy and safety outcomes comparable to DES, supporting DCB as a potential alternative.

Background: Administering antithrombotic therapy (ATT) in patients with infective endocarditis (IE) involves a complex balance of bleeding and thromboembolic risks. Data on outcomes beyond the acute phase remain limited. This retrospective single-center cohort study had two aims: first, to describe the use of anticoagulation during the acute phase of left-sided IE; and second, to examine, without inferring causality, how anticoagulation, as used in routine care, correlated with in-hospital and long-term clinical outcomes, including mortality and neurological events.

Methods: ATT in patients with left-sided IE was assessed retrospectively and categorized into two groups: any therapy that included anticoagulation (AC) and therapy without anticoagulation (No-AC). Two observational periods were analyzed: the in-hospital phase and the period beginning 3 months after discharge, when 30% of patients had their ATT modified. Vital and neurological status were obtained by standardized telephone follow-up (mean follow-up time 4.2 ± 3.1 years). Log-rank tests, Kaplan-Meier estimates, Cox regression analyses, and matched analyses were used to explore correlations between ATT and these outcomes.

Results: A total of 504 hospitalized patients (mean age 65 ± 13 years, 25% female) with left-sided IE were included. During inpatient treatment, 83 patients (16%) died, with no relevant difference between AC and No-AC groups. During follow-up, patients in the AC group showed a more favorable value for the combined endpoint of mortality and unfavorable neurological function (P = 0.029) that was driven primarily by higher survival rates (P < 0.001). In Cox regression analyses, higher age, CHA₂DS₂-VA score, EuroSCORE II, Staphylococcus aureus bacteremia, and atrial fibrillation were each linked to a higher hazard of the combined endpoint, whereas AC showed an inverse correlation. Consecutive matched analyses yielded similar results.

Conclusion: In this retrospective cohort, anticoagulated patients did not show a higher rate of adverse events during hospitalization and had a lower long-term event rate. These findings represent correlations observed in a non-randomized, single-center setting and may partly reflect differences in underlying risk profiles and treatment selection (confounding by indication and residual confounding). Prospective studies are needed to confirm any causal effects and to define more precisely the role of ATT in patients with IE and elevated cardiovascular risk.

Background: The role of cardiovascular magnetic resonance (CMR)-imaging-based pulse wave velocity (PWV) and aortic distensibility (AD) in population-based cohorts as a risk stratification tool remains unclear. The purpose of this study was the CMR-based quantification of PWV and AD in the context of cardiovascular risk factors (CVRF) and/or diseases (CVD) in the Hamburg City Health Study (HCHS).

Methods: The HCHS is a prospective, population-based cohort study. 2D-phase-contrast-flow CMR measurements were performed to quantify PWV and AD in the ascending (AD AoAsc) and descending aorta (AD AoDesc).

Results: The CMR cohort consisted of 2270 participants (41.5% females, median age 66.5 years). PWV was 5.80 [4.91, 7.19] m/s, AD AoAsc 0.54 [0.34, 0.78] [1/(10^3*kPa)], and AD AoDesc 0.61 [0.39, 0.84] [1/(10^3*kPa)] in participants without any CVRF and/or CVD. In participants with at least one CVRF and/or CVD PWV was significantly higher, AD AoAsc and AD AoDesc significantly lower. After adjustment for age and sex, PWV was significantly associated with smoking (OR 1.05), CAD (OR 0.932), and hypertension (OR 1.118); AD AoAsc with hypertension (OR 0.448); and AD AoDesc with hypertension (OR 0.343), BMI > 30 kg/m² (OR 0.575), CAD (OR 2.17), and history of myocardial infarction (OR 2.413).

Conclusions: The presence of CVRF and/or CVD is related to significantly higher PWV and lower AD values. However, hypertension is the only CVRF/CVD consistently associated with higher PWV and lower AD after adjustment for age and sex. Our findings do not indicate a predictive value of abnormal PWV and AD values for prevalent CAD and MI.

Background: Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) remains an incompletely characterized cause of acute coronary syndrome during pregnancy and postpartum period. We aimed to compare clinical presentation, comorbidities and outcomes of P-SCAD with non-pregnancy associated spontaneous coronary artery dissection (NP-SCAD).

Methods: We studied 83 women with prior SCAD and at least one pregnancy (aged 44.8 ± 9.7y at SCAD event, 36% with hypertension), including 11 P-SCAD and 72 NP-SCAD cases in SCAD-POL Registry. P-SCAD was defined as SCAD occurring during pregnancy or within 12 months postpartum.

Results: P-SCAD occurred between 2 and 32 weeks after delivery. Compared with NP-SCAD, women with P-SCAD were younger (33.1 ± 4.9 vs 46.4 ± 9.1y, p < 0.001), had higher parity (3.6 ± 1.2 vs 2.5 ± 1.1 pregnancies, p < 0.01) and more often reported ≥ 1 miscarriage (63.5% vs 27.8%, p < 0.05). Pregnancies in the P-SCAD were more frequently complicated with hypertension (45.5% vs 6.9%, p < 0.005) and pre-eclampsia (27.3% vs 1.4%, p < 0.01). All P-SCAD patients had at least one caesarean section versus 35.8% in the NP-SCAD group (p < 0.001). P-SCAD patients more often required coronary bypass grafting (18.2% vs 1.6%, p < 0.05). Frequency of fibromuscular dysplasia was non-significantly higher in P-SCAD (45.5% vs 29.2%).

Conclusions: Pregnancies in women with P-SCAD were more often complicated by hypertension, pre-eclampsia and miscarriage than in NP-SCAD. P-SCAD events occurred mainly in the early postpartum period and more often required surgical revascularization. Given the small sample, these findings are exploratory and hypothesis-generating.

Purpose: Our hypothesis was that computed tomography angiography (CTA)-derived Hounsfield units (HU) can differentiate between thrombosis and leaflet fibrosis (defined by a lack of response to oral anticoagulation) in patients with bioprosthetic heart valve dysfunction.

Materials and methods: Valvular leaflet HU were retrospectively assessed in 95 patients (derivation cohort) undergoing CTA 35 days after bioprosthetic heart valve (BHV) implantation showing signs of subclinical leaflet thrombosis (hypoattenuated leaflet thickening, HALT). A second (validation) cohort included 46 patients undergoing CTA for suspected BHV dysfunction 2 years [interquartile range IQR 1.5-5.0] after valve replacement. This study included CTA between May 2012 and December 2017.

Results: In the derivation cohort, the median HU (95 patients) was 87 (IQR 77; 96). In the validation cohort, patients with resolution of findings in a follow-up CTA after newly initiated anticoagulation ("thrombosis" subgroup, 19 patients) similarly demonstrated HU of 87 (IQR 74; 100) (p = 0.816). In contrast, patients without improvement under oral anticoagulation ("fibrosis" subgroup, 27 patients) exhibited a median of 137 HU (IQR 116, 164; p < 0.001 vs. thrombosis subgroup). In multivariable Cox regression analysis, lower HU were an independent predictor of thrombosis. C-statistics demonstrated an area under the receiver operating characteristic curve of 0.94 ± 0.02 (CI 0.897-0.983, p < 0.001) with a value of 105 HU resulting in a sensitivity of 84% and a specificity of 91% for the differentiation between thrombosis and fibrosis.

Conclusion: A value of 105 HU on CTA provides good discriminatory power to distinguish between leaflet fibrosis (as defined by a lack of response to oral anticoagulation) and thrombosis after bioprosthetic valve replacement and may help in choosing optimal treatment.

Background: Severe symptomatic aortic stenosis is associated with increased morbidity and mortality. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are established treatment options. Neurological complications such as subclinical cerebral ischemia, delirium, and postoperative cognitive decline can occur during either treatment; however, precise data on neurological impairment remain scarce.

Objectives: The aim of this study was to compare neurological outcomes of patients undergoing TAVI or SAVR.

Methods: COSTA (Cognitive Outcome after Surgical and Transcatheter Aortic valve replacement) is a single-center sub-study of the randomized DEDICATE trial (clinicaltrials.gov ID: NCT04535076). Neurocognitive tests (memory, attention, language, executive functions), questionnaires on neuropsychology (cognitive failures questionnaire [CFQ], hospital anxiety, and depression scale [HADS]), and health-related quality of life (SF-36) were used before intervention and 3 months thereafter. Cranial magnetic resonance imaging (MRI) was carried out post-intervention. In addition, there was a systematic assessment of delirium during the hospital stay.

Results: The study cohort (mean age 71.8 years, 32% female) consisted of SAVR (n = 13) and TAVI (n = 18) patients. In the SAVR group, subsyndromal delirium was more common (54 vs. 11%, p = 0.017; OR = 8.58), visual recognition ability was worse (mean difference (MD) =  - 0.6 vs. + 0.3, p = 0.036, η² = 0.14), and emotional impairment was numerically more declined (MD =  - 36.8 vs. - 4.7, p = 0.058, η² = 0.12) when compared to the TAVI group.

Conclusion: In this small, exploratory sample, SAVR showed a trend toward less favorable neuropsychological outcomes compared with TAVI in patients with low-to-intermediate surgical risk.

Trial registration: ClinicalTrials.gov Identifier: NCT04535076. 27 August 2020 (retrospectively registered).