European Heart Journal最新文献

Background and aims: Cardiac resynchronization therapy (CRT) produces long-term reverse remodelling which requires greater adenosine triphosphate delivery to the contractile machinery. Whilst the heart retains some metabolic flexibility in non-ischaemic cardiomyopathy, whether this correlates with reverse remodelling is unknown. This study investigated whether CRT acutely changes cardiac substrate uptake, and whether this translates to favourable reverse remodelling.

Methods: The effect of CRT on cardiac substrate uptake was assessed via direct coronary flow and arteriovenous measurements, with metabolomic/lipidomic analysis on infusions of insulin/glucose and intralipid. Cardiac function was assessed with left ventricular pressure-volume loops during implantation, and cardiac magnetic resonance before and 6 months following CRT, with and without biventricular pacing.

Results: Regardless of substrate infusion, CRT acutely improved stroke work without increasing O2 uptake on both insulin/glucose (by 34%, P = .05) and intralipid (by 36%, P = .03). This was followed by increased fatty acid (FA) uptake on insulin/glucose (R = 0.89, P = .03) and increased β-hydroxybutyrate uptake (R = 0.81, P = .05) during intralipid infusion. After 6 months, there was a 48% (P < .001) reduction in left ventricular end diastolic volume, beyond that achievable by acutely shortening or lengthening QRS duration. Reverse remodelling significantly correlated with increased FA uptake with CRT on insulin/glucose (R = 0.71, P = .05) driven by long and medium chain uptake, and increased ketone uptake with CRT on intralipid (R = 0.79, P = .05).

Conclusions: CRT acutely alters the metabolic phenotype of non-ischaemic cardiomyopathy towards a more physiological picture of FA uptake which correlates with reverse remodelling. Retained metabolic flexibility may therefore be critical for subsequent reverse remodelling.

Background and aims: Emerging evidence supports artificial intelligence-enhanced electrocardiogram (AI-ECG) for detecting acute myocardial infarction (AMI), but real-world validation is needed. The aim of this study was to evaluate the performance of AI-ECG in detecting AMI in the emergency department (ED).

Methods: The Rule-Out acute Myocardial Infarction using Artificial intelligence Electrocardiogram analysis (ROMIAE) study is a prospective cohort study conducted in the Republic of Korea from March 2022 to October 2023, involving 18 university-level teaching hospitals. Adult patients presenting to the ED within 24 h of symptom onset concerning for AMI were assessed. Exposure included AI-ECG score, HEART score, GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. The primary outcome was diagnosis of AMI during index admission, and the secondary outcome was 30 day major adverse cardiovascular event (MACE).

Results: The study population comprised 8493 adults, of whom 1586 (18.6%) were diagnosed with AMI. The area under the receiver operating characteristic curve for AI-ECG was 0.878 (95% CI, 0.868-0.888), comparable with the HEART score (0.877; 95% CI, 0.869-0.886) and superior to the GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. For predicting 30 day MACE, AI-ECG (area under the receiver operating characteristic, 0.866; 95% CI, 0.856-0.877) performed comparably with the HEART score (0.858; 95% CI, 0.848-0.868). The integration of the AI-ECG improved risk stratification and AMI discrimination, with a net reclassification improvement of 19.6% (95% CI, 17.38-21.89) and a C-index of 0.926 (95% CI, 0.919-0.933), compared with the HEART score alone.

Conclusions: In this multicentre prospective study, the AI-ECG demonstrated diagnostic accuracy and predictive power for AMI and 30 day MACE, which was similar to or better than that of traditional risk stratification methods and ED physicians.

Background and aims: In randomized clinical trials of patients undergoing percutaneous coronary intervention (PCI) for de novo small-vessel coronary artery disease (SV-CAD), paclitaxel-coated balloon (PCB) angioplasty showed mid-term angiographic or clinical non-inferiority to drug-eluting stent (DES) implantation. Nevertheless, these trials have sample size limitations, and the relative safety and efficacy beyond the first year remain uncertain.

Methods: The ANDROMEDA study was a collaborative, investigator-initiated, individual patient data meta-analysis comparing 3 year clinical outcomes between PCB angioplasty and DES implantation for the treatment of de novo SV-CAD. Multiple electronic databases (PubMed, Scopus, ScienceDirect, and Web of Science) were searched from May 2010 to June 2024 to identify eligible trials. All the following eligibility criteria were required: (i) random allocations of treatments; (ii) patients with SV-CAD; (iii) treatment with PCB or DES; and (iv) clinical follow-up of at least 36 months. The primary and co-primary endpoints were major adverse cardiac events (MACE) and target lesion failure (TLF), respectively. The protocol was registered with PROSPERO (CRD42023479035).

Results: Individual patient data from three randomized trials, including a total of 1154 patients and 1360 lesions, were combined. At 3 years, PCB was associated with a lower risk of MACE compared with DES [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.47-0.96], due to a lower risk of myocardial infarction and target vessel revascularization. This benefit persisted after multivariable adjustment (HR 0.75, 95% CI 0.58-0.96), but did not reach statistical significance in the two-stage analysis (HR 0.67, 95% CI 0.43-1.04). At the landmark analysis, the risk of MACE between groups was consistent over time. At 3 years, TLF was not significantly different between PCB and DES groups. Reconstructed time-to-event information from a fourth trial was included in a sensitivity analysis (1384 patients and 1590 lesions), showing consistent results in terms of TLF (HR 0.87, 95% CI 0.63-1.20). The comparison between PCB and second-generation DES did not reveal significant differences in 3 year TLF (HR 1.03, 95% CI 0.70-1.50).

Conclusions: In patients undergoing PCI for de novo SV-CAD, PCB angioplasty is associated with a reduction in MACE and a non-significant difference in TLF at 3 year follow-up compared with DES implantation. The restriction of the comparator group to second-generation DES does not alter the main conclusions. Larger trials comparing contemporary devices at a more prolonged follow-up are warranted to confirm these findings.