Heart最新文献

Background: Fluid restriction is a commonly prescribed non-pharmacological intervention in the management of heart failure (HF). However, data on its efficacy and safety are scarce. Recent randomised clinical trial (RCT) data prompt reassessment of the available evidence.

Methods: CINAHL, EMBASE, PubMed and the Cochrane Library were searched up to 1 May 2025. RCTs were included if adults with HF were randomised to fluid restriction in comparison to a liberal or unrestricted intake, less strict restriction or usual care. Outcomes of interest were mortality, HF hospitalisation, quality of life (QoL), thirst distress, New York Heart Association (NYHA) class and N-terminal pro-Brain Natriuretic Peptide (CRD42022292319). No meta-analysis was performed due to high heterogeneity of the included trials.

Results: In total, four RCTs were included, comprising 682 randomised inpatient, recently discharged and stable outpatient patients (ranging from 46 to 504 patients per trial). Only one study had a low risk of bias. None of the four trials found a significant difference in mortality or HF hospitalisations. For QoL, the results are contradictory, but overall, there is no clear benefit for fluid restriction, but it resulted in more thirst distress. No significant differences in NYHA class or (NT-pro)BNP were observed.

Conclusion: Studies on fluid restriction in patients with HF are scarce, and most of the available studies are at high risk of bias. Although power is lacking, there is no evidence indicating that fluid restriction affects mortality or HF hospitalisations, but there is a signal of harm in terms of thirst distress. Taken together, the current evidence does not support the routine use of fluid restriction in patients with HF.

Background: Ethnic inequalities exist in the management of patients with cancer with acute coronary syndrome (ACS). Given their under-representation in trials, ethnic minority patients are often studied using large registries, but the quality of ethnicity coding in these datasets remains unclear.

Methods: Agreement of ethnicity coding and outcomes for patients with cancer with ACS (2000-2018) was examined across four national datasets: National Cancer Registration and Analysis Service (NCRAS), Myocardial Ischaemia National Audit Project (MINAP), British Cardiovascular Intervention Society database (BCIS) and Hospital Episode Statistics (HES). Three linkages were performed: NCRAS-MINAP, NCRAS-MINAP-BCIS, NCRAS-MINAP-HES, with four groups based on ethnicity agreement: Concordant, Discordant, Missing (1 and ≥2 datasets). Multivariable logistic regression and Cox's Proportional Hazards models assessed 1-year and long-term (≤5 years) cardiac and cancer-related death for each agreement group.

Results: Among three linkages, just over half of the ethnicities were concordant (range: 52.4%-53.8%). Discordance was relatively low (range 1.2%-5.5%) while missingness ranged between 28.6% and 43.4% in 1 dataset and 1.6%-12.6% in ≥2 datasets. Ethnicity correlation between individual datasets was poor, lowest between NCRAS and BCIS (r=0.318). We observed higher 1-year and long-term cardiac and cancer deaths in several of the Missing (1 and ≥2 datasets) groups across the three linkages, compared with the Concordant group.

Conclusion: Across four national datasets for patients with cancer with ACS, nearly half of patients had missing ethnicity in at least one dataset, which was associated with higher cardiac or cancer mortality. Inconsistency in ethnicity coding represents a missed opportunity to examine health inequalities in this high-risk and understudied population.

Background: Type A intramural haematoma (TAIMH) and type A aortic dissection (TAAD) are both managed surgically as acute aortic syndromes, but whether their clinical profiles and outcomes differ remains unclear. We performed the first comprehensive meta-analysis to compare patient characteristics, operative findings and complications between TAIMH and TAAD.

Methods: Systematic searches of six databases identified studies comparing TAIMH and TAAD, with data pooled using random-effects models and Hartung-Knapp-Sidik-Jonkman corrections for small samples. Subgroup and meta-regression analyses assessed the influence of treatment strategy, geography and baseline factors. The primary outcome was in-hospital mortality; secondary outcomes were 30-day, operative mortality and perioperative complications.

Results: 16 studies including 6457 patients (1288 TAIMH; 5169 TAAD) were analysed. Compared with TAAD, patients with TAIMH were older, more often female and had more hypertension but less connective-tissue disease, severe aortic regurgitation and malperfusion. TAIMH was associated with shorter aortic cross-clamp and cardiopulmonary bypass times and fewer total arch replacements. Perioperative mortality was significantly lower in TAIMH (in-hospital risk ratio (RR) 0.49, 95% CI 0.35 to 0.68; 30-day RR 0.59, 95% CI 0.40 to 0.88; operative RR 0.31, 95% CI 0.16 to 0.60), with fewer postoperative acute kidney injury (RR 0.57, 95% CI 0.42 to 0.76), consistent across eastern and western populations.

Conclusions: TAIMH differs pathophysiologically and prognostically from classical TAAD, demonstrating lower perioperative mortality despite affecting an older population. These findings support distinct risk stratification and tailored surgical strategies for TAIMH and should inform updates to future aortic-disease guidelines.

Prospero registration number: CRD42024599964.

Background: Insomnia symptoms are prevalent in older adults and linked to cardiovascular disease (CVD), but the role of long-term symptom trajectories remains unclear. We investigated associations between insomnia symptoms, their trajectories over time and incident CVD in a population-based cohort.

Methods: This longitudinal study included 12 102 participants aged ≥50 years without baseline CVD from the US Health and Retirement Study (2002-2018). Insomnia symptoms (non-restorative sleep, difficulty initiating/maintaining sleep, early awakening) were assessed at baseline; trajectories were modelled over 4 years (2002-2006) using latent class analysis. Cox models estimated HRs for incident CVD (heart disease or stroke), adjusted for sociodemographics, lifestyle and comorbidities.

Results: During a median of 10.2-year follow-up, 3962 incident CVD events occurred. Compared with no symptoms, participants with one, two, or three to four symptoms had higher CVD risk (HR 1.16, 95% CI 1.05 to 1.27; HR 1.16, 95% CI 1.05 to 1.28; HR 1.26, 95% CI 1.15 to 1.38, respectively). Four trajectories were identified: persistent low (56.3%), decreasing (27.1%), increasing (7.2%) and persistent high (9.5%). Compared with persistent low, increasing (HR 1.28, 95% CI 1.10 to 1.50) and persistent high (HR 1.32, 95% CI 1.15 to 1.50) trajectories were associated with elevated CVD risk.

Conclusions: Greater burden of insomnia symptoms at baseline and trajectories over time were associated with higher CVD incidence in older adults.

Transthyretin amyloidosis (ATTR) is a condition caused by TTR protein misfolding and amyloid deposition, particularly in the heart and nervous system, leading to organ dysfunction. Advances in therapeutic strategies have revolutionised the management of ATTR amyloidosis. Treatments available in clinical practice include TTR stabilisers (tafamidis and acoramidis), which prevent the dissociation of TTR tetramer into monomers and oligomers that subsequently form amyloid fibrils, and gene-silencing therapies (patisiran, inotersen and vutrisiran), which suppress the hepatic synthesis of TTR, which is the amyloid precursor protein. Novel treatment strategies that are at various stages of development include Clustered Regularly Interspaced Short Palindromic Repeats-Cas9 gene-editing technology (nexiguran ziclumeran), which, if successful, offers the prospect of a single-dose treatment, and monoclonal (cormitug and ALXN220) and pan-amyloid antibodies (AT-02) that seek to target and remove amyloid fibrils that have deposited in the myocardium. Amyloid removal remains a significant unmet clinical need, and hence, the ability to promote amyloid degradation and clearance through the use of antiamyloid therapies would represent a groundbreaking advancement in the treatment of ATTR amyloidosis. The success of ATTR-specific disease-modifying therapies has already altered the treatment landscape and changed the perception of ATTR amyloidosis from a progressive and fatal disease to one that is treatable through the availability of highly effective disease-modifying therapies. However, important questions remain, including the long-term safety of these drugs, whether combining therapies with different mechanisms of action has an additive prognostic benefit and how best to monitor the treatment response.

Background: Baseline health and driving data might allow clinicians to personalise medical driving restrictions after implantable cardioverter-defibrillator (ICD) implantation.

Methods: Using 22 years of population-based administrative data from British Columbia, Canada, we identified licensed drivers with a first ICD implantation between 1998 and 2018. After stratifying by ICD indication (primary vs secondary prevention of sudden cardiac death), we used baseline health and driving data and logistic regression to estimate each driver's 1-year crash risk. We assessed optimism-corrected discrimination and calibration of the final model using 200 bootstrapped samples.

Results: In the first year after implantation, there were 352 crashes among 3652 primary prevention ICD recipients and 270 crashes among 3408 secondary prevention ICD recipients. Crash prediction models exhibited poor discrimination (c-statistics 0.60 and 0.61, respectively) but good calibration (calibration slopes 1.14 and 1.07). The strongest predictors of crash among primary prevention ICD recipients were male sex, active vehicle insurance in the past year and the number of crashes in the past year. The strongest predictors of crash among secondary prevention ICD recipients were male sex, no history of seizure, an active prescription for opioids and active vehicle insurance in the past year.

Conclusions: Crash prediction models based on health and driving data had a limited ability to distinguish individuals who subsequently crashed from individuals who did not. Observed crash risks are likely to be strongly influenced by unobserved changes in road exposure (the hours or miles of driving per week), limiting the application of these risk scores by clinicians and policy-makers.