Frontiers in Cardiovascular Medicine最新文献

A recent multi-site randomized controlled trial, PEERLESS, demonstrated superiority of FlowTriever mechanical thrombectomy (FTMT) to catheter-directed thrombolysis (CDT) in the treatment of intermediate-risk pulmonary embolism using a 5-point composite outcome. The purpose of our study is to review clinical outcomes between these two procedures in actual clinical practice without the use of a composite endpoint using a large sample size. This is a retrospective, single-center analysis of 461 patients who presented with submassive or massive PE and underwent treatment with either FTMT or CDT. No significant difference was observed in 7-day (RR 0.495; p = 0.25) or 30-day mortality (RR 1.347; p = 0.67). There was significantly less risk of procedure-related decompensations within the FTMT group (RR 0.221; p = 0.01). Non-procedure-related decompensations were similar between treatment options (RR 1.091; p = 0.51). ICU LOS was significantly lower for FTMT (mean 1.87 vs. 3.07; p < 0.001) however total LOS was longer within the FTMT (mean 6.85 vs. 5.68; p = 0.008). Similar to PEERLESS, we observed decreased ICU utilization with FTMT in our real-world retrospective data, likely reflecting our practice of ICU admission during thrombolytic administration. We observed slightly lower risk of procedure-related decompensations within the FTMT group, suggesting lower periprocedural morbidity; however, overall mortality between groups was not different.

Objectives: Inappropriate dosing of direct oral anticoagulants (DOACs) may increase the risk of thromboembolism or bleeding in patients with atrial fibrillation (AF). The inappropriate use of these medications presents a significant clinical challenge. Our study aimed to analyze the current utilization of rivaroxaban and edoxaban among Chinese patients with AF, as well as the factors influencing the use of nonstandard doses.

Methods: This study evaluated patients diagnosed with AF between January 2017 and December 2023. Descriptive analyses were performed to summarize the characteristics of the study population. Inappropriate dosing was identified based on the guidelines. Multivariate analysis was performed to identify factors associated with inappropriate dosing in these patients.

Results: A total of 1,066 patients diagnosed with AF, comprising 852 individuals treated with rivaroxaban and 214 individuals treated with edoxaban, were included. Their median age was 69 years, and 58.7% of them were males. Among them, 573 patients (53.8%) received inappropriate dosages. Among the patients prescribed rivaroxaban, 503 (59.0%) were underdosed and eight (0.9%) were overdosed. Among the patients prescribed edoxaban, 49 patients (22.9%) were underdosed and 13 patients (6.1%) were overdosed. Multivariate analysis identified independent factors associated with inappropriate medication dosing, including advanced age [adjusted odds ratio (OR) 1.031, 95% confidence interval (CI) 1.010-1.052], combined use of antiplatelet drugs (adjusted OR 1.649, 95% CI 1.111-2.447), and reduced use of dronedarone (adjusted OR 0.332, 95% CI 0.126-0.877).

Conclusions: The incidence of inappropriate DOAC dosing in Chinese patients with AF was high. Advanced age, the concurrent use of antiplatelet medications, and the nonuse of dronedarone have been identified as independent factors associated with inappropriate dosing.

Background: Acute myocarditis is one of the common causes of sudden cardiac death among young adults. While melatonin has been recognized for its cardioprotective properties, the specific relationship between melatonin and acute myocarditis in humans is not well established.

Methods: We collected morning urine samples from 21 patients diagnosed with acute myocarditis and 21 healthy controls to measure the levels of 6-sulfatoxymelatonin (aMT6s), a biomarker of nocturnal melatonin secretion, using an ELISA assay.

Results: The mean age of the control group was 31.05 ± 9.75 years, and the acute myocarditis group had a mean age of 30.71 ± 10.11 years. Both groups were evenly divided by gender, with 15 males and 6 females in each. Acute myocarditis patients exhibited significantly lower aMT6s levels (50.57 ± 36.39 ng/mL) compared with healthy volunteers (80.36 ± 48.92 ng/mL; P = 0.031). Similarly, the aMT6s-to-creatinine ratio was reduced in patients (106.95 ± 73.45 ng/mg cr) vs. controls (159.73 ± 92.96 ng/mg cr; P = 0.048).

Conclusion: Lower melatonin levels, measured via urinary aMT6s concentrations in acute myocarditis patients, suggest a link to the disease process.

Background: Ascending aortic pseudoaneurysm is a rare but potentially fatal complication after aortic surgery, particularly challenging in elderly high-risk patients.

Case presentation: We report an 80-year-old man with a history of surgical repair for acute type A aortic dissection who presented with a two-month history of chest pain. Transthoracic echocardiography and computed tomography angiography revealed a large posterior ascending aortic pseudoaneurysm measuring 6.5 × 5.4 cm with a narrow neck. Because of his advanced age, previous sternotomy, and overall frailty, the patient was considered unsuitable for redo surgery after heart team discussion.

Management and outcome: After obtaining written informed consent, the patient underwent successful percutaneous closure using a 10-mm Cocoon Septal Occluder device via transfemoral access. The procedure was uncomplicated, and immediate angiography confirmed minimal residual flow. Six-month follow-up computed tomography angiography demonstrated complete thrombosis of the aneurysm sac, and the patient remained asymptomatic with no residual shunt at two-year follow-up.

Conclusion: This case illustrates that transcatheter closure of a posterior ascending aortic pseudoaneurysm using a septal occluder device can be a safe and durable alternative to high-risk reoperation, provided that careful pre-procedural imaging and catheter selection are performed.

Background: Patients who have diabetes mellitus experience significantly higher rates of in-stent restenosis following percutaneous coronary intervention compared to the general population. The underlying pathophysiology of restenosis is exacerbated by diabetes-specific mechanisms including endothelial dysfunction, enhanced inflammatory response, and accelerated smooth muscle cell proliferation. While both intravascular brachytherapy (IVB) and drug-coated balloons (DCB) have been used to treat this condition, their comparative effectiveness in this high-risk population has never been evaluated in a long-term study.

Objectives: To compare the efficacy and safety of IVB vs. DCB for the treatment of in-stent restenosis specifically in patients with diabetes.

Methods: This dual-center study compared 2-year outcomes between patients with diabetes treated with IVB at Houston Methodist Hospital (USA) and DCB at Kaplan Medical Center (Israel). Propensity score matching was performed for age, sex, vessel size, and ejection fraction. Primary outcomes included all-cause mortality and target lesion failure (TLF).

Results: DCB treatment was associated with shorter procedure times (58.2 ± 26.1 vs. 83.4 ± 37.2 min, p < 0.01) and reduced contrast use (121.5 ± 53.2 vs. 158.7 ± 73.5 mL, p = 0.03). In the propensity-matched cohort, MACE rates were similar (46.8% vs. 50.2%, p = 0.62). DCB treatment demonstrated significantly lower TLF rates compared to IVB (5.2% vs. 21.3%, p < 0.01) and reduced target vessel myocardial infarctions (3.9% vs. 15.6%, p = 0.01). Cardiac death rates were similar between groups (7.8% vs. 5.2%, p = 0.48). The mortality signal was particularly pronounced among patients with diabetes aged ≥65 years (HR 4.82, 95% CI: 1.05-22.17) and those with reduced ejection fraction (HR 3.15, 95% CI: 1.03-9.64), while the TLF benefit was consistent across most subgroups within the diabetic population.

Conclusions: In this first-ever comparison with 2-year follow-up in patients with diabetes, DCB was associated with similar MACE rates and cardiac mortality rates compared to IVB but demonstrated significantly lower target lesion failure. These findings suggest that while DCB offers superior efficacy for ISR treatment in patients with diabetes, careful patient selection is crucial, particularly considering diabetes-related comorbidities that strongly influence overall survival.

Background: Diastolic dysfunction (DD) represents an early indicator of cardiac impairment and is strongly linked to adverse cardiovascular outcomes. While obesity-related indices have been associated with DD, the role of Body Roundness Index (BRI)-a novel adiposity measure reflecting body shape-remains unclear. This study aimed to evaluate the association between BRI and diastolic function in a community-based cohort.

Methods: This cross-sectional analysis included 1,466 participants from the Longitudinal Investigation of Osteoarthritis and Cardiovascular Health Status cohort. BRI was calculated using a validated formula, and DD was assessed via echocardiographic parameters. BRI's optimal cutoff was derived via 1000-iteration bootstrap ROC analysis. Multivariable regression models were used to evaluate associations, adjusting for age, sex, blood pressure, lipid profile, and cardiovascular comorbidities.

Results: Higher BRI was significantly associated with increased odds of DD. In fully adjusted logistic regression, each 1-unit increase in BRI was associated with 14.4% higher odds of DD (OR = 1.144, 95% CI: 1.046-1.251, P = 0.003). High BRI (≥4.2) was linked to 41.7% higher odds of DD (OR = 1.417, 95% CI: 1.114-1.804, P = 0.004). Robust regression confirmed BRI was inversely associated with septal e' (β = -0.164, P = 8.10 × 10^-4) and lateral e' velocities (β=-0.167, P = 5.59 × 10^-3), and marginally positively associated with E/e' ratio (β=0.121, P = 0.053). Restricted cubic spline models showed a nonlinear association between BRI and DD probability (P < 0.001 for overall association, P = 0.006 for linearity). Interaction analyses indicated BRI's effect on DD was not modulated by blood pressure and lipid profiles. Subgroup analyses indicated a consistent trend of association between BRI and DD.

Conclusions: BRI is nonlinearly and independently associated with impaired diastolic function in middle-aged and older adults, with modest diagnostic performance. These findings provided evidence on the link between body shape metrics and DD.

Introduction: Although low-dose aspirin effectively reduces atherothrombosis occurrence in individuals diagnosed with cardiovascular disease (CVD) or in those with high-risk factors, it is significantly associated with increased bleeding. No evidence has been established for a lower dose of aspirin.

Methods: The Lower-dose Aspirin for Primary and Secondary Prevention of Cardiovascular Disease in the Elderly (LAPIS) is a multicenter, prospective, observational cohort study, which compared the benefits and risks in adults aged 60 years and older taking aspirin 50 or 100 mg/day for primary and secondary CVD prevention in a propensity score-matched population. The efficacy outcome was a composite of the first occurrence of major adverse cardiovascular events (MACE). The safety outcome was the first occurrence of any hemorrhagic events.

Results: In this interim analysis of LAPIS, 7,021 participants were followed up for a median of 183 (95% CI 169-197) days (primary prevention cohort, 2,070; secondary prevention cohort, 4,951). After adjusting for baseline characteristics using propensity score matching, the MACE incidence did not differ significantly between the two dosage groups in either cohort. However, in the primary prevention cohort, the incidence of any bleeding [8.89 vs. 3.45 events/100 patient-years, hazard ratio (HR) 2.917, 95% confidence interval (CI) 1.719-4.952, P < 0.001] and gastrointestinal events (8.30 vs. 5.04 events/100 patient-years, HR 1.745, 95% CI 1.047-2.907, P = 0.037) was higher in the 100 mg/day group. In the secondary prevention cohort, the 100 mg/day group showed higher rates of any bleeding (9.19 vs. 6.37 events/100 patient-years, HR 1.473, 95% CI 1.087-1.998, P = 0.015), minor bleeding (9.10 vs. 6.06 events/100 patient-years, HR 1.541, 95% CI 1.116-2.127, P = 0.009), and gastrointestinal adverse events (7.10 vs. 3.53 events/100 patient-years, HR 1.943, 95% CI 1.291-2.925, P = 0.002).

Conclusion: Aspirin 50 mg/day was associated with lower hemorrhage and gastrointestinal adverse event risks, with similar cardiovascular benefits, compared with aspirin 100 mg/day, and may be preferred to balance efficacy and safety for older Chinese adults in primary and secondary CVD prevention.

Background: Myocardial bridging (MB), once considered benign, is increasingly recognized for its role in myocardial ischemia, especially when coexisting with proximal left anterior descending (LAD) artery stenosis. Optimal revascularization strategies remain uncertain for such dual pathology. This study assessed whether a fractional flow reserve (FFR)-guided and intravascular ultrasound (IVUS)-optimized percutaneous coronary intervention (PCI) approach improves outcomes in this population.

Methods: In this retrospective single-center study, 238 patients with moderate MB and proximal intermediate LAD stenosis were enrolled. Patients were stratified based on FFR measurements: those with FFR > 0.80 received medical therapy alone (n = 96), while patients with FFR ≤ 0.80 underwent IVUS-guided PCI (n = 142). Baseline characteristics, procedural data, and two-year follow-up outcomes were compared. Major adverse cardiovascular events (MACE) were recorded, and multivariate regression analysis identified predictors of poor outcomes.

Results: Patients undergoing PCI (FFR ≤ 0.80) had significantly lower MACE rates than those managed conservatively (7.7% vs. 18.8%, p = 0.019), mainly due to reduced angina-related rehospitalization. PCI was an independent protective factor (Hazard Ratio = 0.526, p = 0.034). Among PCI patients, stent extension into the MB segment was linked with higher MACE incidence (18.6% vs. 3.0%, p = 0.001). IVUS revealed that stent extension correlated with severe MB compression, shorter distance between lesions, and more frequent dissections. Two anatomical factors-short MB-proximal lesion distance and MB dissection-were predictive of poor outcomes post-MB stenting.

Conclusions: An FFR-guided, IVUS-supported PCI strategy improves clinical outcomes in patients with MB and proximal LAD stenosis, particularly when avoiding stent placement in dynamically compressed MB segments. Procedural planning using IVUS and careful lesion assessment is essential. Functional evaluation alone may underestimate ischemia in MB; integration of anatomical and diastolic functional indices is recommended.

Background: In severe aortic stenosis (AS), relief of afterload excess would be expected to improve left ventricular ejection fraction. However, the response of LVEF to transcatheter aortic valve replacement (TAVR) is variable, with some patients even demonstrating a decline. The mechanisms underlying this phenomenon are incompletely characterized. Accordingly, we investigated changes in systolic function in the near-term postoperative period following TAVR.

Methods: We studied consecutive patients with severe AS referred for TAVR without identifiable perioperative sources of negative inotropy or ventricular dyssynchrony. Preoperative and postoperative day one echocardiograms were compared with respect to hemodynamics, LV geometry, LVEF, and midwall fractional shortening (FSmw). Contractility was assessed by comparing observed FSmw values to those predicted based on the stress-shortening relation of healthy controls.

Results: Thirty-six patients were included (61% women; mean age 77 years; mean Society of Thoracic Surgeons mortality risk score 3.6%). Following TAVR, there was a precipitous decline in circumferential end-systolic wall stress from 122 ± 47 to 74 ± 32 kdyn/cm² (p < 0.001) and a slight increase in LVEF. Surprisingly, however, there was also an increase in the percentage of patients with depressed contractility from 22% (8) to 78% (28) (p < 0.001). Heart rate and ventricular volumes remained unchanged.

Conclusions: Contractility declined in the near-term postoperative period following TAVR. We interpret this finding to suggest that contractility is augmented by high afterload in severe AS and declines in parallel with afterload reduction. We speculate that autoregulatory mechanisms triggered by high valvular resistance support LVEF in severe AS and rapidly abate following TAVR.