Heart最新文献

Background: Iron deficiency (ID) is common in patients with atrial fibrillation/flutter (AF), but its prognostic implications and optimal diagnostic criteria, particularly in those with and without heart failure (HF), remain unclear. This study assessed the associations between different ID definitions and clinical outcomes in patients with AF.

Methods: This Danish nationwide cohort study included 10 834 patients with AF who underwent iron studies between 2008 and 2019, stratified by HF status. ID was defined using four criteria: European Society of Cardiology (ESC) guidelines, ferritin <100 ng/mL, transferrin saturation (TSAT) <20% and serum iron ≤13 µmol/L. Associations between ID definitions and all-cause mortality, cardiovascular mortality and all-cause hospitalisation were evaluated using Cox regression models, adjusted for confounders.

Results: Prevalence of ID varied substantially across definitions, ranging from 36.2% to 62.7%. Over a median follow-up of 31 months, TSAT <20% was associated with increased all-cause and cardiovascular mortality in both HF (HR 1.25, 95% CI 1.14 to 1.37 and HR 1.31, 95% CI 1.14 to 1.49, respectively) and patients without HF (HR 1.39, 95% CI 1.18 to 1.64 and HR 1.54, 95% CI 1.18 to 2.00, respectively). Similarly, serum iron ≤13 µmol/L was associated with higher all-cause and cardiovascular mortality in HF (HR 1.44, 95% CI 1.31 to 1.58 and HR 1.42, 95% CI 1.24 to 1.63, respectively) and patients without HF (HR 1.67, 95% CI 1.41 to 1.97 and HR 1.46, 95% CI 1.13 to 1.89, respectively). ID defined by ESC guidelines or ferritin <100 ng/mL was not associated with mortality in either group but was linked to higher all-cause hospitalisation in patients with HF (HR 1.15, 95% CI 1.08 to 1.23 and HR 1.16, 95% CI 1.09 to 1.23, respectively).

Conclusions: ID defined by TSAT <20% or serum iron ≤13 µmol/L is associated with increased mortality in patients with AF, irrespective of HF status, highlighting these criteria as clinically relevant for risk stratification.

Background: Clinical trials and meta-analyses indicate a reduced reinfarction risk with invasive management in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study investigated whether similar benefits might be observed in frail patients.

Methods: The coMOrbilidades Síndrome Coronario Agudo - FRAIL (MOSCA-FRAIL) trial included 167 adults aged ≥70 years with frailty (Clinical Frailty Scale ≥4 points) and NSTEMI, who were randomised to invasive (n=84) or conservative (n=83) strategy during the index hospitalisation. The primary end point of this subanalysis was reinfarction, considering all-cause mortality as a competing event, at a 3-year median follow-up. The time to first reinfarction and all reinfarctions (first and recurrent) were considered. The substudy was not prespecified.

Results: The total number of deaths (93, 56%) exceeded that of first reinfarctions (32, 19%). Invasive treatment did not influence the reinfarction risk when accounting for death as a competing risk (subdistribution HR=0.87, 95% CI 0.54 to 1.40, p=0.56). An initially increased mortality risk with invasive management (significant between days 131 and 175) shifted to a lower mortality risk over time. A total of 45 reinfarctions (first and recurrent) were observed. The longitudinal trajectories corroborated that the invasive strategy did not reduce the risk of reinfarction over time (p=0.72). However, mortality followed a biphasic pattern, with higher mortality in the invasive group during the first 6 months and a reduction between 9 months and 3 years (p=0.05 for the entire time-dependent trajectory). The win ratio for the invasive strategy versus the conservative strategy was 1.08 (95% CI 0.72 to 1.63, p=0.70).

Conclusions: In older adults with frailty and NSTEMI, routine invasive management did not reduce the reinfarction risk at a 3-year follow-up. The high all-cause mortality associated with frailty may limit the impact of invasive management. Due to the limited sample size and risk for type II error, these findings should be considered hypothesis-generating.

Trial registration number: NCT03208153.

Background: Intercellular adhesion molecule-1 (ICAM-1) is a cell-surface protein that facilitates inflammation through leucocyte adhesion. Approximately 35% of Black individuals carry at least one copy of an ICAM1 missense variant (rs5491; p.K56M), which has been associated with increased risk of heart failure (HF) with preserved ejection fraction (HFpEF). Whether the risk of HFpEF conferred by rs5491 extends to individuals with chronic kidney disease (CKD), a cohort at high risk for HF, is unknown.

Aims: We investigated the association between rs5491 and the incidence of HF in CKD.

Methods: We estimated associations of rs5491 with incident HF and HF subtypes among Black individuals who were free from HF at baseline in the Chronic Renal Insufficiency Cohort (CRIC). The CRIC study recruited individuals who were 21-74 years old with estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m² at baseline.

Results: Among 1267 Black participants (mean age 57±11 years, 51% female, mean eGFR 45±15 mL/min/1.73 m²), 464 (37%) had at least one copy of rs5491. During a median follow-up of 10.3 years (IQR: 4.7-15.0 years), there were 309 incident overall HF hospitalisations (160 HFpEF, 111 HF with reduced ejection fraction (HFrEF) and 38 HF with unknown ejection fraction). Each additional rs5491 allele was significantly associated with incident HFpEF (HR 1.35, 95% CI 1.03 to 1.76, p=0.029). The rs5491 variant was not associated with incident overall HF (HR 1.14, 95% CI 0.93 to 1.39, p=0.20) or incident HFrEF (HR 0.76, 95% CI 0.53 to 1.10, p=0.15).

Conclusion: The ICAM1 p.K56M variant is specifically associated with increased risk of incident HFpEF among individuals with CKD.

Background: Aortic stenosis is a degenerative condition with high mortality in its severe stages and no preventive treatment. While diabetes is a known risk factor, the role of elevated glucose levels below the diabetic threshold in the development of aortic stenosis remains unclear. This study investigated the association between dysglycaemia, including impaired fasting glucose, and the incidence of aortic stenosis.

Methods: This study included 324 449 participants from the Swedish Apolipoprotein Mortality Risk cohort (1985-1996) who were free of aortic valve disease at baseline and had fasting glucose and lipid levels recorded. Participants were followed for incident aortic stenosis through the National Patient and Cause of Death Registers until 31 December 2020. Fasting glucose was categorised into low (<3.9 mmol/L), normal (3.9-6.0 mmol/L), impaired fasting glucose (6.1-6.9 mmol/L), high glucose (≥7.0 mmol/L) and diabetes. HRs were calculated using Cox proportional hazards models, with adjustments for age, sex, lipids, socioeconomic status, hypertension and kidney disease.

Results: Over a mean follow-up of 25.9 years, 8523 participants developed aortic stenosis. Compared with normal glucose levels, adjusted HRs were 0.96 (95% CI 0.82 to 1.13) for low glucose, 1.36 (95% CI 1.24 to 1.50) for impaired fasting glucose, 1.79 (95% CI 1.60 to 1.99) for high glucose and 2.21 (95% CI 1.80 to 2.73) for diabetes. Spline analysis indicated a continuous increase in risk with rising glucose levels, even below the impaired fasting glucose threshold.

Conclusions: Dysglycaemia, including glucose levels below the diabetic range, is associated with a higher risk of aortic stenosis.

Background: Patients with cryptogenic stroke or embolic stroke of undetermined source (ESUS) face a high risk of recurrent ischaemic stroke, but the optimal antithrombotic strategy remains unclear. This systematic review and meta-analysis compared the effectiveness and safety of oral anticoagulants (OACs) versus antiplatelets in these populations, with a focus on subgroup effects by key clinical characteristics.

Methods: Six databases were searched through March 2024 to identify randomised controlled trials (RCTs) comparing OACs and antiplatelets in patients with cryptogenic stroke or ESUS. The primary outcome was recurrent ischaemic stroke. Subgroup analyses evaluated treatment effects based on supracardiac atherosclerosis risk, presence of patent foramen ovale (PFO) and signs or risk factors for atrial cardiopathy. Meta-regression with interaction p values was employed to assess differences in treatment effects between subgroups.

Results: Nine RCTs comprising 15 451 participants were included. In the overall population, there was no significant difference in recurrent ischaemic stroke risk between OACs and antiplatelets (relative risk (RR) 0.90, 95% CI 0.79 to 1.02; I²=0%). Subgroup analyses showed that OACs reduced ischaemic stroke risk in patients with low-risk supracardiac atherosclerosis (RR 0.53, 95% CI 0.35 to 0.80; I²=0%) compared with those with high-risk supracardiac atherosclerosis (RR 0.91, 95% CI 0.78 to 1.06; I²=0%) and evidence of supracardiac atherosclerosis (RR 1.13, 95% CI 0.84 to 1.53; I²=0%) (p interaction=0.0002). Similarly, OACs were more effective in patients with signs or risk factors for atrial cardiopathy (RR 0.84, 95% CI 0.70 to 0.99; I²=0%) than in those without atrial cardiopathy (RR 1.05, 95% CI 0.85 to 1.30; I²=0%) (p interaction=0.02). There was no significant interaction by PFO status (p interaction=0.28). While the risk of major bleeding risk was comparable between groups (RR 1.34, 95% CI 0.73 to 2.44; I²=65%), a significantly higher risk of major bleeding other than intracerebral haemorrhage was observed in patients taking OACs compared with antiplatelets (RR 1.69, 95% CI 1.18 to 2.43; I²=0%).

Conclusions: OACs are more effective than antiplatelets for preventing ischaemic stroke in patients who had a cryptogenic stroke or ESUS with low-risk supracardiac atherosclerosis or atrial cardiopathy. The findings highlight the need for personalised treatment strategies and further trials in these subgroups.

Prospero registration number: CRD42024518903.

Background: Frailty is an independent risk factor for cardiovascular events. It is uncertain whether frailty modifies the efficacy of intensive blood pressure (BP) control among participants with type 2 diabetes mellitus(T2DM).

Methods: The Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial, a two-by-two factorial trial, examined the effects of systolic BP (<120 vs <140 mm Hg) and glycaemic control on cardiovascular events in T2DM. We constructed a frailty index using the Rockwood cumulative deficit approach. Cox proportional hazard models were used to estimate the effectiveness of intensive BP treatment according to frailty status. The primary composite outcome was non-fatal myocardial infarction, non-fatal stroke or death from cardiovascular causes.

Results: There were 4733 participants (mean age: 62.7 years; 39.9% frailty). The mean average number of antihypertensive medications was higher in frail patients compared with non-frail patients in both the standard (2.2 vs 1.7) and intensive (3.1 vs 2.7) treatment groups. In the standard glycaemic arm, intensive BP treatment reduced the risk of the primary outcome (HR 0.75, 95% CI 0.58 to 0.97) regardless of frailty status (p value for interaction=0.86). The benefits of intensive BP intervention were consistent across the spectrum of the frailty index (p value for interaction=0.96) in the standard glycaemic arm. However, no benefits of intensive BP treatment (HR 1.08, 95% CI 0.82 to 1.43) were observed in the intensive glycaemic arm.

Conclusions: In the ACCORD BP study, the benefit of intensive BP treatment was consistent regardless of frailty in the setting of standard glycaemic control. Frailty should not be a barrier to intensive BP control in patients with T2DM treated with guideline-recommended standard glycaemic control.

Background: Atrial functional mitral regurgitation (AFMR) arises from left atrial (LA) dilation, commonly associated with atrial fibrillation, and leads to progressive cardiac damage. This study evaluated the prognostic value of a novel echocardiographic cardiac damage classification system for patients with moderate or severe AFMR.

Methods: In a retrospective multicentre study, 1007 patients with AFMR were stratified into four groups based on echocardiographic findings: group 1, LA damage (dilation); group 2, left ventricular damage (reduced ejection fraction and/or dilation); group 3, right heart damage (tricuspid regurgitation and/or pulmonary hypertension); and group 4, combined left and right heart damage. The primary outcome was a composite of all-cause death, heart failure hospitalisations and mitral valve (MV) interventions over a median follow-up of 3.0 years.

Results: The cohort's mean age was 78±10 years, with 56% female. Event rates for the primary outcome were progressively higher across groups 1-4 (31.0%, 38.0%, 46.3% and 57.2%, respectively; p<0.001). After multivariable adjustment, group 4 was associated with a significantly higher risk of the primary outcome compared with group 1 (HR 1.65, 95% CI 1.29 to 2.11, p<0.001). This classification consistently stratified risks for individual components of the composite endpoint, particularly in patients without MV intervention.

Conclusions: A cardiac damage classification system based on echocardiographic parameters provides prognostic insights in patients with AFMR, identifying subgroups at higher risk of adverse outcomes. Future studies are needed to validate its use in guiding therapeutic decisions.