European Heart Journal - Quality of Care and Clinical Outcomes最新文献

Aims: To investigate the prevalence of familial hypercholesterolaemia (FH) and compare the performance of clinical criteria and genetic testing in patients undergoing coronary angiography.

Methods and results: The prevalence of FH was determined with the Dutch Lipid Clinical Network (DLCN), US 'Make Early Diagnosis to Prevent Early Death' (US-MEDPED), Simon Broome (SB) criteria, the 'familial hypercholesterolaemia case ascertainment tool' (FAMCAT), and a clinical algorithm. Genetic screening was conducted with a custom array from Affymetrix (CARRENAL array) harbouring 944 FH mutations.The study cohort consisted of 3267 patients [78.6% with coronary artery disease (CAD)]. FH was diagnosed in 2.8%, 2.2%, 3.9%, and 7.9% using the DLCN, US-MEDPED, SB criteria, and the FAMCAT. The clinical algorithm identified the same patients as the SB criteria. Pathogenic FH mutations were found in 1.2% (1.2% in patients with CAD, 1.0% in patients without CAD). FH was more frequently diagnosed in younger patients. With genetic testing as reference, the clinical criteria achieved areas under the ROC curve [area under the curves (AUCs)] in the range of 0.56-0.68. Using only low-density lipoprotein cholesterol (LDL-C) corrected for statin intake, an AUC of 0.68 was achieved.

Conclusion: FH is up to four-fold more prevalent in patients undergoing coronary angiography than in contemporary cohorts representing the general population. Different clinical criteria yield substantially different diagnosis rates, overestimating the prevalence of FH compared with genetic testing. LDL-C testing alone may be sufficient to raise the suspicion of FH, which then needs to be corroborated by genetic testing.

Lay summary: In this study, we investigated the frequency of familial hypercholesterolaemia-a common genetic condition leading to markedly elevated low-density lipoprotein (LDL) cholesterol and increased risk of atherosclerosis-in 3267 patients undergoing coronary angiography according to commonly used diagnostic scoring systems and genetic testing.

Background: Brugada Syndrome (BrS) is a life-threatening cardiac arrhythmia disorder associated with an increased risk of ventricular arrhythmias (VAs) and sudden cardiac death. Current management primarily relies on implantable cardioverter-defibrillators (ICDs), but patients may experience ICD shocks. Catheter ablation (CA) has emerged as a potential intervention to target the arrhythmogenic substrate. This systematic review aims to evaluate the safety and efficacy of CA in BrS patients.

Methods and results: Studies with BrS patients undergoing CA for VAs were included. Fourteen studies that involved a total population of 709 BrS patients, with CA performed in 528 of them, were included. CA resulted in the non-inducibility of VAs in 91% (95% CI: 83-99, I2 = 76%) and resolution of type 1 ECG Brugada pattern in 88% (95% CI: 81-96.2, I2 = 91%) of the patients. After a mean follow-up of 30.7 months, 87% (95% CI: 80-94, I2 = 82%) of patients remained free from VAs. The incidence of VAs during follow-up was significantly lower in the ablation cohort in comparison to the group receiving only ICD therapy (OR = 0.03, 95% CI: 0.01-0.12, I2 = 0%).

Conclusion: CA shows potential as a therapeutic approach to reduce VAs and improve outcomes in BrS patients. While further research with a long follow-up period is required to confirm these findings, it represents a valuable tool as an add-on intervention to ICD implantation in BrS patients with a high burden of VAs.

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the 10 guidelines and recommendations retrieved, 7 showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced diseases. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

Aims: Aspirin is considered mandatory after myocardial infarction (MI). However, its long-term efficacy has been questioned. This study investigated the effectiveness of long-term aspirin after MI.

Methods and results: Patients ≥40 years with MI from 2004 to 2017 who were adherent to aspirin 1 year after MI were included from Danish nationwide registries. At 2, 4, 6, and 8 years after MI, continued adherence to aspirin was evaluated. Absolute and relative risks of MI, stroke, or death at 2 years from each time point were calculated using multivariable logistic regression analysis with average treatment effect modelling standardized for age, sex, and comorbidities. Subgroup analyses were stratified by sex and age > and ≤65 years. Among 40 116 individuals included, the risk of the composite endpoint was significantly higher for non-adherent patients at all time points. The absolute risk was highest at 2-4 years after MI for both adherent [8.34%, 95% confidence interval (CI): 8.05-8.64%] and non-adherent patients (10.72%, 95% CI: 9.78-11.66%). The relative risk associated with non-adherence decreased from 4 years after index-MI and onwards: 1.41 (95% CI: 1.27-1.55) at 4-6 years and 1.21 (95% CI: 1.06-1.36) at 8-10 years (Ptrend = 0.056). Aspirin non-adherence in women and individuals >65 years was not associated with increased risk. Pinteraction at each of the time points: Age - <0.001, <0.001, 0.002, 0.51; Sex - 0.25, 0.02, 0.02, 0.82.

Conclusion: Non-adherence to long-term aspirin was associated with increased risk of MI, stroke, or death, but not in women or individuals >65 years. The risk decreased from 4 years after MI with near statistical significance.

Background: Transcatheter aortic valve implantation (TAVI) is an increasingly important treatment option for patients with severe aortic stenosis. Its best implementation is debated, as few centres with high volumes are associated with better outcomes, while centralization might lead to an inferior availability of treatment for patients living far away. The aim of this study was to investigate the implementation of TAVI in Sweden with a focus on regional differences in terms of availability, short-term mortality, and waiting times.

Methods: All patients undergoing TAVI between 2008 and 2020 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. SWENTRY was linked to the National Cause of Death Registry and to publicly available geospatial data from Statistics Sweden.

Results: A total of 7280 patients were included. Over time, TAVI interventions increased markedly, while surgical aortic valve replacement (SAVR) remained constant. There were no statistically significant regional differences in incidence between counties with or without a local TAVI centre (P = 0.7) and no clustering tendencies around regions with a local TAVI centre (P = 0.99). Thirty-day mortality improved over time without evidence of regional differences. No regional differences in waiting time from decision to intervention were found for TAVI centre regions and non-TAVI centre regions (P = 0.7).

Conclusion: This nationwide study indicated no regional differences in terms of availability, short-term mortality, or waiting times. An organization with a few specialized centres was found to be sufficient to provide national coverage of TAVI interventions.

Aim: The Fontan procedure is a palliative surgical treatment for different congenital heart diseases with a univentricular heart, but it has been associated with decreased exercise capacity, cardiovascular morbidity, and premature mortality. The one-and-half ventricle repair (1.5VR) was introduced as an alternative to the Fontan procedure, specifically for selected patients with borderline hypoplastic right ventricle (HRV), aiming for a more physiological circulation. Despite these efforts, the benefit of 1.5VR over Fontan circulation comparison on clinical and functional outcomes remains unclear. The aim of this study was to investigate and compare young patients with HRV after 1.5VR with those with functional single right or left ventricles (FSRV or FSLV) after Fontan palliation over a 10-year follow-up period.

Methods and results: In this retrospective observational study, serial cardiopulmonary exercise tests (CPETs) performed in patients with 1.5VR and Fontan circulation between September 2002 and March 2024 have been analysed. Only patients with at least 10 years of follow-up were considered. A total of 43 patients were included (age at baseline 8.6 ± 2.6 years): 21 with FSLV, 12 with FSRV, and 10 with 1.5VR. No differences in cardiorespiratory fitness and efficiency were shown at the first CPET assessment among the three groups. At 10-year follow-up, 1.5VR had higher cardiorespiratory fitness and efficiency compared to FSLV and FSRV patients.

Conclusion: These findings suggest that the 1.5VR may provide superior long-term functional outcomes than the Fontan procedure in patients with borderline HRV. Further studies are needed to evaluate the impact on hard clinical endpoints.

Background: Most patients undergoing coronary computed tomography angiography (CCTA) to diagnose coronary artery disease (CAD) are referred from general practitioners (GPs). The burden of contacts to GP in relation to investigation of suspected CAD is unknown.

Methods and results: All patients undergoing CCTA in Western Denmark from 2014 to 2022 were included. CCTA stenosis was defined as diameter stenosis of ≥50%. Patients with and without stenosis were matched, in each group, 1:5 to a reference population based on birth year, gender, and municipality using data from national registries. All GP visits were registered up to 5 years preceding and 1 year after the CTA and stratified by gender and age. Charlson comorbidity index (CCI) was calculated in all groups.Of the 62 512 patients included, 12 886 had a stenosis, while 49 626 did not. Patients in both groups had a substantially higher GP visit frequency compared with reference populations. In the year of coronary CTA, the median GP contacts in patients with stenosis were 11 (6-17) vs. 6 (2-11) in the reference population (P < 0.001), and in patients without stenosis, the median GP contacts were 10 (6-17) vs. 5 (2-11) (P < 0.001). These findings were consistent across age and gender. CCI was higher among both patients with and without stenosis compared with reference groups.

Conclusion: In patients undergoing CCTA to diagnose CAD, a substantially increased frequency of contacts to GP was observed in the 5-year period prior to examination compared with the reference populations, regardless of the CCTA findings. Obtaining the CCTA result did not seem to substantially affect the GP visit frequency.