ESC Heart Failure最新文献

Aims: Left ventricular outflow tract obstruction (LVOTO) drives symptoms and functional limitation in obstructive hypertrophic cardiomyopathy (oHCM). Some patients may only show treatment-qualifying obstruction during exercise echocardiography, yet their clinical profile and response to cardiac myosin inhibition are not well defined. This study compared the characteristics and therapeutic response of patients requiring exercise echocardiography to establish eligibility for mavacamten versus those meeting criteria at rest or during Valsalva.

Methods and results: A single-centre retrospective cohort of 56 symptomatic oHCM patients treated with mavacamten was evaluated. LVOTO was assessed at rest, with Valsalva, and during exercise; patients were classified as 'exercise' or 'non-exercise' LVOTO based on the provocation manoeuvre eliciting a qualifying gradient (≥50 mmHg). Haemodynamic (Valsalva LVOT gradient) and symptomatic (NYHA class) response were assessed at 12 and 24 weeks. A total of 42.9% qualified for mavacamten exclusively during exercise echocardiography. Although resting and Valsalva gradients were lower by definition, these patients showed similar baseline functional limitation and exercise capacity (pVO2; 17.9 ± 7.4 vs. 16.8 ± 5.5 mL/kg/min, P = .550). By 24 weeks, most patients in both groups achieved non-obstructive gradients (<30 mmHg; 93.3% vs. 96.4%, P = .646) and NYHA class improvement (75.0% vs. 93.3%, P = .266), without significant between-group differences.

Conclusion: Patients requiring exercise echocardiography to document treatment-qualifying LVOTO do not exhibit a milder disease phenotype and derive similar treatment benefits from mavacamten compared to those with resting or Valsalva-provoked obstruction. Exercise echocardiography identifies a substantial proportion of symptomatic HCM patients with significant LVOTO missed by resting assessment and is essential for guiding treatment eligibility.

Implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) in non-ischaemic cardiomyopathy (NICM), but most evidence predates comprehensive guideline-directed medical therapy (GDMT). We quantified the relative and absolute survival benefit of primary-prevention ICDs in NICM across therapeutic eras and explored how contemporary GDMT modifies absolute benefit. We searched MEDLINE, Embase, and CENTRAL through March 2025 and included randomized controlled trials comparing prophylactic ICD implantation vs control in NICM with left ventricular ejection fraction ≤35%. Three trials (DEFINITE, SCD-HeFT NICM subgroup, and DANISH) contributed to the quantitative synthesis. ICD therapy reduced all-cause mortality (pooled hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.66-0.95) and SCD (HR 0.44, 95% CI 0.28-0.70). Five-year absolute risk reduction (ARR) was 5.9% (NNT 17) in SCD-HeFT NICM and 4.4% (NNT 23) in DANISH. Under a full-GDMT scenario parameterized from pharmacological randomized controlled trials, projected baseline risk was ∼11%, yielding ARR 2.31% (NNT 43). All contemporary 'GDMT-era' absolute benefit estimates are scenario-based modelling outputs. No randomized trial has evaluated ICDs on top of full modern GDMT in NICM; therefore, these results represent illustrative ranges rather than empirical estimates.

Introduction: Residual mitral regurgitation (MR) after mitral transcatheter edge-to-edge repair (M-TEER) is associated with adverse prognosis. However, the long-term clinical impact of MR persistence or progression has not been well stratified. We aimed to evaluate the proportion, clinical benefits, and prognostic value of maintaining mild MR 1 year after M-TEER.

Methods and results: This multi-centre registry-based analysis included 1865 patients who achieved mild MR at discharge following M-TEER. At 1 year, patients were classified as having stable MR (≤ mild) or worsening MR (≥ moderate). The frequency of left atrial (LA) and left ventricular (LV) reverse remodelling and tricuspid regurgitation (TR) improvement were assessed from baseline to 1 year. Clinical endpoints-including all-cause mortality and heart failure hospitalization-were evaluated beyond 1 year after M-TEER up to 2 years. Worsening MR occurred in 28.4% of patients. Compared with the worsening MR group, the stable MR group demonstrated significantly more frequent LA and LV reverse remodelling (38.4% vs 28.1%, and 44.7% vs 31.1%, respectively; both P < .001). Improvement in TR (≥ Grade 1) was also more prevalent in the stable MR group (32.4% vs 20.6%, P < .001). Worsening MR was independently associated with increased risk of adverse clinical outcomes (hazard ratio: 2.02; 95% confidence interval: 1.26-3.23; P = .003).

Conclusion: Maintaining MR within mild at 1-year post-M-TEER is associated with favourable cardiac reverse remodelling and improved clinical prognosis. These findings underscore the importance of long-term MR surveillance and its implications for outcome optimization following M-TEER.

Introduction: The aim of this analysis was to evaluate the prognostic features of the cardiogenic shock 4 proteins (CS4P) biomarker-based risk score in patients with cardiogenic shock (CS), presenting with ST-segment elevation myocardial infarction (STEMI) vs non-ST-segment elevation myocardial infarction (NSTEMI), with and without cardiopulmonary resuscitation (CPR).The CS4P risk score, validated in cohorts of CS patients with both acute coronary syndrome (ACS) and non-ACS aetiologies, showed advanced predictive metrics compared with other contemporary risk prediction scores for CS. However, there is lack of data concerning the prognostic performance of the CS4P score among CS patients with different forms of ACS.

Methods: The present analysis is a post-hoc analysis of the randomized CULPRIT-SHOCK trial. The primary outcome was a composite of mortality or necessity for renal replacement therapy at 30-day follow-up. Cardiogenic shock 4 proteins markers were determined in serum using ELISA assays.

Results: Of the 412 patients with CS included in this study, 240 (58.3%) patients had STEMI and 172 (41.7%) patients had NSTEMI. In CS patients presenting with STEMI, CS4P score exhibited better prognostication of the primary outcome compared with patients with NSTEMI [area under the curve (AUC) 0.74, 95% confidence interval (CI) 0.67-0.80 vs AUC 0.69, 95% CI 0.61-0.77; P = .05). Further, CS4P score displayed a higher prognostic performance in STEMI patients who had not undergone CPR prior to enrolment as compared with STEMI patients with preceding CPR (AUC 0.78; 95% CI 0.65-0.84 vs AUC 0.70, 95% CI 0.62-0.79; P < .001). Cardiogenic shock patients in the highest tertile of the CS4P risk score showed higher mortality rates within 30 days compared to those in the lowest tertile (hazard ratio 1.42, 95% CI 1.11-1.82; P = .005).

Conclusion: The CS4P score provides acceptable short-term mortality risk stratification among patients with CS due to acute myocardial infarction. The CS4P prediction model exhibits superior prognostication among CS patients with STEMI as compared to NSTEMI and in STEMI patients without CPR prior to hospital presentation.

Introduction: Left ventricular (LV) longitudinal function is a prognostic marker of hospitalization and mortality in LV dysfunction. Recently, left atrial (LA) reservoir and conduit strain have also been presented as independent prognostic markers. However, the atria and ventricles are coupled in the fibrous atrioventricular plane (LA-LV coupling). The degree to which the LA strain is affected, or even determined, by the LV longitudinal function in LV dysfunction has been explored by echocardiography, but not by cardiac magnetic resonance imaging (CMR). Therefore, we aimed to quantify the association between LV longitudinal ventricular function and LA strain using CMR feature-tracking.

Methods: Three hundred and forty-two patients with LV dysfunction (including heart failure with reduced ejection fraction (HFrEF), candidates for cardiac resynchronization therapy (CRT) implantation, and ischaemic heart disease (IHD)), and 19 healthy controls (HC) who had undergone CMR were retrospectively included. LV global longitudinal strain (LV-GLS), LV atrioventricular plane displacement (AVPD), and LA-GLS (i.e. reservoir strain) were analysed in long-axis views using CMR feature-tracking.

Results: LA-GLS was lower in the LV dysfunction group when compared to HC (12 ± 8% vs 19 ± 7, P < .001), mirroring reductions in LV-GLS (-10 ± 5% vs -19 ± 3, P < .001), and LV-AVPD (9 ± 3 vs 15 ± 2 mm, P < .001). The coefficient of determination (r2) between LV-GLS and LA-GLS was .40 (95% CI 0.32-0.48) for the whole cohort, and 0.39 (95% CI 0.31-0.47) between LV-AVPD and LA-GLS.

Conclusion: In a large cohort comprising both patients with LV dysfunction and HC, LA reservoir function quantified as LA-GLS was to a large extent determined by LV longitudinal function. LA function may not be an independent marker of global cardiac function for certain patient groups where diminished LA function can be a reflection of LV dysfunction.

Background and aims: Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is now increasingly identified as a cause of heart failure in older adults. This study aimed to clarify the morphological and functional alterations of the left ventricle (LV) that define the early stage of this condition.

Methods: We prospectively evaluated 81 patients diagnosed with wild-type ATTR (ATTRwt) amyloidosis (mean age 77 ± 6 years; 88% male), categorized into three groups based on myocardial uptake on radioactive pyrophosphate scintigraphy and histological confirmation: (i) carpal ATTR without cardiac involvement (Group 1, n = 13), (ii) asymptomatic cardiac involvement (Group 2, n = 10) and (iii) overt heart failure (Group 3, n = 58).

Results: Compared with Group 3, Group 1 showed higher absolute global longitudinal strain (GLS) (median 19.0 [13.2-23.8]%, P < .001), a lower apical-sparing ratio (median 0.66 [0.55-1.04], P < .001) and lower brain natriuretic peptide (BNP) (median 13.5 [6-49] pg/mL, P < .001) and troponin-T concentrations (0.012 [0.006-0.022] ng/mL, P < .001), while the estimated glomerular filtration rate remained preserved (64 ± 9 mL/mL/1.73 m², P = .022). Segmental longitudinal strain (LS) differentiated Group 1 from Group 2, with basal inferoseptal LS significantly lower in patients with elevated troponin-T (> 0.014 ng/mL) than in those with lower values (13.9 ± 5.6% vs. 7.4 ± 1.8%, P = .046) in Group 1. A basal inferoseptal LS cutoff of 9.1% identified high troponin-T with an area under the curve (AUC) of 0.833 (P = .005), outperforming GLS (AUC 0.306, P = .217), BNP (AUC 0.667, P = .292), and LV ejection fraction (AUC 0.556, P = .743).

Conclusions: Basal inferoseptal LS impairment may indicate early cardiac involvement in individuals with carpal tunnel syndrome carrying ATTRwt deposits.

A decline in mortality due to heart failure (HF) with reduced ejection fraction (HFrEF) has been attributed to effective guideline-directed medical therapies. But few effective therapies are available for HF with preserved ejection fraction (HFpEF), despite a high burden of HF events, or for HF with mildly reduced ejection fraction (HFmrEF). Novel therapies are needed for these HF subtypes. Clinical trials have demonstrated the efficacy of sodium-glucose cotransporter 2 inhibitors for improving outcomes in HFpEF and HFmrEF. While renin-angiotensin system inhibitors, angiotensin receptor/neprilysin inhibitors, and steroidal mineralocorticoid receptor antagonists for HFpEF or HFmrEF have not demonstrated effects on primary trial outcomes, sub-analyses from large HF trials suggest they may reduce the risk of hospitalization for HF or mortality. Beta blockers may be beneficial for HFmrEF. Finerenone, a non-steroidal mineralocorticoid receptor antagonist, reduced HF events and cardiovascular deaths in participants with HF and ejection fraction ≥40% in the FINEARTS-HF trial, and is under evaluation for HFpEF and HFmrEF in the REDEFINE-HF and CONFIRMATION-HF trials. As treatment for HFpEF and HFmrEF may be impacted by comorbidities, novel treatments could be tailored to specific phenotypes such as obesity and chronic kidney disease. Trials of glucagon-like peptide-1 receptor agonist (GLP-1 RA), semaglutide, and dual glucose-dependent insulinotropic polypeptide receptor agonist/GLP-1 RA, tirzepatide, for HFpEF with obesity, observed an impact on HF hospitalization events and quality of life. Trials of selective mineralocorticoid modulator, balcinrenone, and aldosterone synthase inhibitor, vicadrostat, will address key evidence gaps and help improve outcomes for patients with HFpEF and HFmrEF.

Introduction: The BRING-UP 3 Heart Failure (HF) study was designed to evaluate the real-world implementation of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), given the limited evidence on the uptake of the contemporary four-pillar treatment strategy.

Methods: BRING-UP 3 HF study is an observational, prospective, nationwide investigation encompassing 179 sites. This analysis includes HFrEF patients enrolled in the ambulatory and hospitalized cohorts with complete pharmacological data at 6-month follow-up. The objective was to describe the use of the four GDMT pillars after 6 months.

Results: Among 3201 HFrEF patients enrolled, 142 (4.4%) had died by 6 months, and treatment data were available for 2950 patients. Mean age was 69 ± 11 years (26.6% > 75 years), 18.0% were female. Prescription rates of GDMT were high at baseline and remained stable over 6-months, with a shift from ACE-I/ARBs to ARNIs, and a modest increase in SGLT2i use. A significant reduction in diuretic prescription was also observed. Quadruple therapy was prescribed in 64.3% of patients at 6 months versus 63.9% at baseline/discharge (P = NS), while quadruple therapy including ARNI went from 52.9% to 55.9%, P < .0001. Dose up-titration of GDMT remained suboptimal, with most agents prescribed at <50% of target doses. Discontinuation rates at follow-up were very low.

Conclusion: In this large nationwide cohort, guideline-directed therapies for HFrEF were widely implemented and maintained over 6 months with excellent treatment persistence. However, dose optimization remains a key unmet need in routine clinical practice.

Aims: Patients with first-degree atrioventricular (AV) block and mechanical AV dyssynchrony can present with heart failure (HF)-like symptoms. AV-optimized conduction system pacing (CSP) can improve haemodynamics and symptoms, but selection criteria remain uncertain. We aimed to identify electrocardiographic and echocardiographic predictors of an acute haemodynamic response to AV-optimized CSP in symptomatic first-degree AV block.

Methods and results: Nineteen patients (mean age 60.5 ± 21.1 years; 37% female) with symptomatic first-degree AV block underwent baseline electrocardiography and echocardiography followed by AV-optimized conduction system pacing and repeat echocardiographic assessment. Electrocardiographic parameters (PR interval, P wave duration/PR interval ratio) and echocardiographic indices (E/A wave confluence, A-Q interval, and DFT/RR ratio) were tested for association with change in left ventricular stroke volume (LVSV).The mean PR interval was 395 ± 61 ms, the mean A-Q interval 155 ± 65 ms, and the mean DFT/RR ratio 0.34 ± 0.1. E/A wave confluence was present in 15 patients (79%). AV-optimized pacing increased LVSV by 7.8 ± 3.9 ml, corresponding to an 11.8 ± 5.7% relative increase (P < .01). Echocardiographic parameters were associated with LVSV response, including A-Q interval (r = 0.63, P = .004), DFT/RR ratio (r = -0.59, P = .008), and E/A wave confluence (r = 0.57, P = .01). Electrocardiographic parameters were not associated with LVSV change.

Conclusions: Echocardiographically assessed mechanical AV dyssynchrony, rather than electrocardiographic parameters, is associated with an acute haemodynamic response to pacing. Echocardiographic evaluation may help identify patients with prolonged PR interval who could benefit from AV-optimized CSP.

Introduction: To compare long-term outcomes of patients with Takotsubo syndrome (TTS) and heart failure (HF).

Methods: This retrospective observational study used the TriNetX global federated research network. Adult patients (≥18 years) discharged with a diagnosis of TTS (ICD-10-CM I51.81) or HF (I50.x) between 2018 and 2022 were identified. Primary outcomes were 3-year risk of all-cause death, major adverse cardiovascular events (MACE; myocardial infarction or ischaemic stroke), and acute HF. Secondary outcomes included myocardial infarction, ischaemic stroke, ventricular arrhythmias (ventricular tachycardia), malignant arrhythmias (ventricular fibrillation or cardiac arrest), and new-onset atrial fibrillation (AF). Cox proportional hazards models estimated hazard ratios (HRs) with 95% confidence intervals (CIs) before and after 1:1 propensity score matching (PSM). Subgroup analyses were performed by HF phenotype, age (≥65 vs <65 years), and mental health status.

Results: The study included 2240 patients with TTS (mean age 62.6 ± 17.3 years; 73.7% female) and 265 564 patients with HF (69.3 ± 14.7 years; 45.8% female). After PSM, TTS was associated with a lower risk of acute HF (HR 0.622, 95% CI 0.539-0.717), ventricular arrhythmias (HR 0.637, 95% CI 0.441-0.919), malignant arrhythmias (HR 0.656, 95% CI 0.571-0.754), new-onset AF (HR 0.672, 95% CI 0.517-0.875), and myocardial infarction (HR 0.818, 95% CI 0.687-0.974), with no significant differences in the remaining outcomes. Differences were greater when TTS was compared with heart failure with reduced ejection fraction.

Conclusions: TTS is associated with lower risk of adverse events than HF. Further research is needed on mental health in its pathogenesis and prognosis.