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

Aims: This study aimed to assess the educational inequalities in cardiovascular disease (CVD), coronary heart disease (CHD), and stroke among four generations, and to analyse the mediating role of healthy lifestyles and metabolic factors.

Methods and results: This prospective cohort study included 447 227 participants from UK Biobank, with a mean age of 56.10 (8.08) years, divided into four generations born in 1930s, 1940s, 1950s, and 1960s. Cox regression models and the relative index of inequality (RII) were employed to estimate educational inequality on CVD, CHD, and stroke. Counterfactual mediation analysis was utilized to estimate the mediating effects of healthy lifestyles and metabolic factors. After a median of 13.39 years follow-up, 81 470 cases of CVD were documented. In the fully adjusted model, compared to participants with college education, participants with primary school or below had hazard ratios [95% confidence interval (CI)] for CVD of 1.03 (0.96, 1.11), 1.05 (1.03, 1.08), 1.15 (1.10, 1.20), and 1.37 (1.25, 1.51) in 1930s, 1940s, 1950s, and 1960s, respectively. RII (95% Cl) in CVD increased from 1.04 (0.94,1.14) in the 1930s to 1.35(1.22,1.49) in the 1960s. Across all generations, the proportion mediated by healthy lifestyles and metabolic factors on CVD was 13.36-21.72% and 30.65-40.70%, respectively. Similar results were observed for CHD and stroke.

Conclusion: Educational inequalities in CVD incidence persisted across generations, with potentially greater disparities in 1960s. Implementing effective interventions for healthy lifestyle and metabolic factors that target the less educated population may help reduce these health disparities.

Background: A significant proportion of patients requiring mitral valve (MV) intervention have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk.

Aims: To evaluate the utilization and outcomes of transcatheter vs. surgical MV interventions in patients with prior CABG.

Methods: We queried the Nationwide Readmission Database (2016-21) to identify adults with prior CABG hospitalized for transcatheter or surgical MV intervention. In-hospital outcomes were compared using multivariable regression and propensity-matching analyses. Readmissions were compared using Cox proportional hazards regression model.

Results: Of 305 625 weighted hospitalizations for MV intervention, 23 506 (7.7%) occurred in patients with prior CABG. From 2016Q1-2021Q4, the use of transcatheter MV interventions increased among patients with prior CABG (72 to 191 for repair and 6 to 45 for replacement per 100 000 hospitalizations, both ptrend < 0.001). Compared with surgical MV repair and replacement, transcatheter MV repair and replacement were associated with similar in-hospital mortality (adjusted odds ratio [aOR] 0.44, 95% confidence interval [CI] 0.20-1.03 for repair; aOR 0.61, 95% CI 0.38-1.02 for replacement) and 180-day heart failure (HF) readmissions (adjusted hazard ratio [aHR] 1.56, 95% CI 0.85-2.87 for repair; aHR 1.15, 95% CI 0.63-2.09 for replacement) and lower stroke, acute kidney injury, permanent pacemaker placement, length of stay, and non-home discharges, respectively. Vascular complications were higher with transcatheter vs. surgical MV replacement.

Conclusion: Transcatheter MV interventions are increasingly used as the preferred modality of MV intervention in patients with prior CABG and are associated with similar in-hospital mortality and 180-day HF readmissions compared with surgical MV interventions.

Aims: The prevalence of mitral valve prolapse (MVP) varies across populations and age groups; its natural history and clinical outcomes remain unclear. This meta-analysis established the prevalence of MVP in the general population, in associated syndromes and at different ages. It also determined the rate of progression and the incidence of adverse outcomes.

Methods and results: A systematic search identified original reports on the prevalence of MVP and related outcomes. A total of 83 studies met inclusion: 47 (n = 992 944) non-syndrome associated; 31 (n = 3067) syndrome associated; and 5 (n = 1287) described mitral regurgitation (MR) progression or adverse outcomes. In the general population, the prevalence was 1.35% but higher in hospital cohorts (8.7%). Age-stratified prevalence was 0.5, 1.8, 2.7, and 2.0% in neonates, children, adolescents and adults, respectively. Meta-regression and subgroup analysis found no significant difference (P = 0.81) across ages but revealed a significantly higher prevalence in older compared to young adults (2.87% vs. 0.67%, P = 0.01). Prevalence rates were markedly higher in patients with genetic syndromes. MR progressed at 5.5 per 100 person-years, overall. Event rates for all-cause mortality, development of heart failure, and need for mitral valve intervention were 1.7, 1.0, and 1.2 per 100 person-years, respectively.

Conclusion: MVP is common, with greater prevalence in syndromes. Although more common with age, MVP is observed in infants. MVP related MR is progressive, especially in moderate MR, and there is a signal of excess mortality for unclear reasons. Valve services must manage the whole life journey and the potential risks associated with MVP.

Introduction: Data are lacking about the risk for death and major adverse cardiovascular events (MACE) after transcatheter aortic valve implantation (TAVI), compared to the general population. Therefore, we assessed the risk for all-cause death and MACE after TAVI in patients aged 65 years and older, in comparison to an age- and sex-matched control population.

Methods and results: In total, 5924 TAVI patients and 10 928 matched controls [mean age 82.1, standard deviation (SD) 6.0, and 81.9, SD 6.1, respectively] were included from 2014 to 2020. The SWEDEHEART registry and four mandatory national registers were used to collect data. Cox regression models were used to assess the association with all-cause mortality and MACE risk. In total, 1410 (23.8%) of the TAVI patients and 2115 (19.4%) controls died during the follow-up period. Median follow-up was 1.9 years (inter quartile range 0.9-3.3) respectively. The crude mortality and MACE risks were higher in TAVI patients than in controls {hazard ratios 1.27 [95% Confidence interval (CI): 1.19-1.36] and HR 1.44 (95% CI: 1.35-1.53), respectively}. After adjustment, there was a lower risk for both mortality and MACE in TAVI patients [adjusted hazard ratio (aHR) 0.77 (95% CI: 0.71-0.84) and aHR 0.90 (95% CI: 0.83-0.98), respectively].

Conclusion: After adjustments for comorbidities, the mortality risk was lower in TAVI patients, compared with an age- and sex-matched control population. These findings suggest that the high burden of comorbidities in TAVI patients has a strong impact on the risk for mortality and MACE after TAVI.

Introduction: The expanding indications for transcatheter aortic valve implantation (TAVI) to younger, lower-risk patients, entails assessing not only the short-term clinical outcomes but also the long-term considerations for future interventions. The prevalence of coronary artery disease in TAVI patients is relevant, and the optimal timing of percutaneous coronary intervention remains a question.

Methods and results: We conducted a systematic literature review and meta-analysis including 20 eligible studies involving 1660 patients who underwent coronary angiography after TAVI. The primary endpoint was the incidence of successful selective coronary re-access. Secondary endpoints included semi-selective and non-selective access rates. The analysis was stratified by balloon-expandable (BEVs) and self-expandable valve (SEVs) types. Successful coronary access after TAVI was feasible in the majority of patients, with a higher success rate observed for the left main (LM) compared to the right coronary artery (RCA). BEVs demonstrated the highest success rates in coronary ostia cannulation, achieving nearly 100% success for both LM and RCA. Among SEVs, the Acurate Neo and Evolut R/PRO showed superior success rates in selective coronary access (68 and 77% for LM; 57 and 72% for RCA, respectively) compared to the CoreValve (46% for LM and 49% for RCA). Notably, the majority of coronary angiograms were performed due to acute coronary syndrome, primarily non-ST-segment elevation myocardial infarction, and unstable angina.

Conclusion: Selective coronary engagement after TAVI is generally achievable, with BEVs demonstrating superior success rates compared to SEVs. Among SEVs, the Acurate NEO showed better outcomes than the other types.

Aims: Mechanical aortic valve replacement (AVR) remains the primary treatment for younger patients with severe aortic valve disease. However, limited information is available regarding the quality of the required lifelong vitamin K antagonist (VKA) therapy, atrial fibrillation (AF), and their relationship with adverse events after AVR. This study assessed the quality of VKA therapy prior to bleeding and ischaemic events following mechanical AVR in patients with AF.

Methods and results: The registry-based Finnish AntiCoagulation in Atrial Fibrillation study combining data from several Finnish healthcare registers covers all patients diagnosed with AF during 2007-18 in Finland. This analysis included patients undergoing mechanical AVR before or after the AF diagnosis. A total of 1086 patients with mechanical AVR and AF either before (41.2%) or after (58.8%) the operation were identified. Cumulative incidence estimates at 10 years after AVR were 27.9% for significant bleeding, 5.8% for intracranial haemorrhage, 12.8% for ischaemic stroke, and 7.2% for myocardial infarction. Time in therapeutic range (TTR) < 80% with international normalized ratio (INR) target 2.0-3.5 was associated with higher bleeding occurrence [adjusted hazard ratio (aHR) 1.97, 1.39-2.79, P < 0.001]. Time in therapeutic range with INR target ≥2.0 was associated with higher stroke occurrence (aHR/standard deviation 1.22, 1.01-1.46, P = 0.035). Mortality was high (28.9%/10 years), and TTR <80% was associated with higher mortality (aHR 2.74, 2.00-3.76, P < 0.001).

Conclusion: Adverse events, particularly major bleeding, are common in patients with AF following mechanical AVR, and mortality is high. Suboptimal TTR appears to predict bleeding episodes, ischaemic stroke, and death, and it could be useful in high-risk patient identification and targeting of preventive strategies.

Trial registration: Finnish AntiCoagulation in Atrial Fibrillation study, ClinicalTrials Identifier: NCT04645537, https://clinicaltrials.gov/ct2/show/NCT04645537.

Background and aims: In patients undergoing heart valve surgery, subsequent bacteraemia and infective endocarditis (IE) are feared events. Data on the incidence and bacterial microbiological etiology following left-sided heart valve surgery are sparse.

Methods and results: Between 2010 and 2021, all patients undergoing left-sided valve surgery were identified using Danish nationwide registries. Incidence and type bacteraemia within 1-year post-surgery was analysed. Secondary outcome of interest was IE. Cumulative incidence curves were stratified for bacterial species and for subgroups of interest: type of valve surgery, age, and sex. A total of 14 935 patients were included, of which 69% were male and the median age was 70.4 years (25th-75th percentile 62.4-76.2 years). The 1-year cumulative incidence of bacteraemia was 6.1% (95% CI 5.7-6.5%), and the most frequent bacteraemia was coagulase-negative staphylococci (CoNS) (27%). More than half of the bacteraemia with CoNS occurred within 30 days of follow-up. Patients developing bacteraemia had a significantly higher Charlson comorbidity score at baseline, more often underwent coronary artery bypass grafting concomitant to valve surgery, and more often had surgery on both valves. The 1-year cumulative incidence of IE was 1.5% (95% CI 1.3-1.7), of which 23% were caused by Enterococci, and 22% were blood culture negative. The median time from surgery to IE was 109 days.

Conclusion: Bacteraemia and infective endocarditis following left-sided heart valve surgery occurred in 6.1% and 1.5% of patients, respectively. The most frequent bacteraemia was coagulase-negative staphylococci, and more than half of these occurred within 30 days of surgery. Optimization of prophylactic strategies are warranted.

Background: Patients undergoing aortic valve replacement (AVR) have high readmission rates. Several risk factors have been proposed as potential modifiable targets, including anaemia. We examined the association between anaemia at discharge and subsequent outcomes in these patients.

Methods and results: Using Danish nationwide registries, we identified all patients who underwent AVR between 2015 and 2021, were alive at discharge (index date), and had an available haemoglobin (Hb) measurement taken between the procedure and discharge. Patients were categorized as having (i) moderate/severe anaemia (Hb <6.2 mmol/L) or (ii) no/mild anaemia (Hb ≥6.2 mmol). The 1-year rates of all-cause mortality, all-cause hospital admission, heart failure (HF) admission, and atrial fibrillation (AF) admission were compared using multivariable Cox regression models. A total of 8614 patients were identified; 2847 (33.1%) had moderate/severe anaemia (60.2% male, median age 74) and 5767 (66.9%) had no/mild anaemia (68.0% male, median age 76). For these two groups, respectively, the cumulative 1-year incidences of the outcomes were: (i) all-cause mortality: 5.1% vs. 4.3%; (ii) all-cause admission: 53.8% vs. 47.5%; (iii) AF admission: 14.0% vs. 11.6%; and (iv) HF admission: 6.8% vs. 6.2%. In adjusted analysis, moderate/severe anaemia, compared with no/mild anaemia, was associated with higher rates of all-cause mortality (hazard ratio (HR) 1.27 [95% confidence interval CI 1.02-1.58]), all-cause admission (HR 1.22 [95% CI 1.14-1.30]), and AF admission (HR 1.23 [95% CI 1.08-1.40]), but not HF admission (HR 1.09 [95% CI 0.91-1.31]).

Conclusions: In patients undergoing AVR, moderate/severe anaemia at discharge, compared with no/mild anaemia, was associated with increased all-cause mortality, all-cause hospital admission, and AF admission, but not HF admission, at 1-year post-discharge.

European Society of Cardiology (ESC) Guidelines provide best practice, evidence-based recommendations for diagnosing and treating patients with cardiovascular diseases. It is not always possible for best practices to be followed, however, particularly in low-resource settings. To address this issue, a set of guideline-related documents were created to identify key priorities for users in these settings. The documents highlight the related recommendations and describe key strategies for clinicians to approach implementation of these recommendations or discuss alternatives which are in line with the intention of the recommendations, if not having all of the same advantages. The suggestions cannot be used as exact substitutes for the original recommendations in the guidelines, which have not been altered and continue to reflect best practice. This document on key priorities for low-resource settings was developed by the task force chairs and other members of the task force who produced the 2023 ESC Guidelines for the management of endocarditis, which are freely available on the ESC website (https://www.escardio.org/Guidelines). This document also underwent external review including international experts from within and beyond Europe and ESC partner organizations, including the Interamerican Society of Cardiology (IASC), The Pan-African Society of Cardiology (PASCAR), the Asian Pacific Society of Cardiology and the ASEAN Federation of Cardiology.