Heart最新文献

Cardiopulmonary exercise testing (CPET) allows for the study of the pathophysiology of exercise intolerance through assessment of exercise integrative physiology of the pulmonary, cardiovascular, muscular and cellular oxidative systems. Over the years, key gas exchange variables have shown a role in the interpretative translation of physiology to clinical decision making. CPET is a standard when approaching all forms of exercise intolerance, with a predominant evidence for heart failure and hypertrophic cardiomyopathy. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in patients with cardiac issues, invasive CPET (iCPET) has been gaining popularity, especially in confirming the diagnosis of heart failure with preserved ejection fraction (HFpEF) and exercise-induced pulmonary hypertension. Impactful advancements come from the application of CPET combined with echocardiography, or CPET imaging, which shows less accuracy in the left and right haemodynamic assessment compared with iCPET but adds information on atrial and biventricular cardiac valve functional perturbations. While gas exchange classifications and scores are predominant for heart failure with reduced ejection fraction, algorithms are growing on refining exercise unexplained dyspnoea categorisation in HFpEF. The implementation of wearable systems and artificial intelligence to estimate peak oxygen consumption is part of the novel applications. This review focuses on CPET use and perspectives focusing on the most modern advancements in cardiology.

Cardiac rehabilitation (CR) is a multidisciplinary intervention central to secondary prevention after acute coronary syndromes (ACSs), combining medical management, structured exercise, psychological support and lifestyle modification. CR reduces mortality, recurrent events and hospitalisations, while improving quality of life and functional capacity. Its benefits extend beyond physical recovery to include mitigation of systemic inflammation, attenuation of adverse cardiac remodelling and promotion of long-term behavioural change. Recent advances have expanded the scope of CR. Digital health tools, telemedicine and hybrid delivery models have improved accessibility and adherence, particularly in resource-limited settings. Pharmacological innovations, such as PCSK9 inhibitors, inclisiran and agents targeting lipoprotein(a) and inflammation, contribute to residual risk reduction when integrated into CR. Mind-body interventions, including yoga, tai chi and Qigong Baduanjin, offer additional physiological and psychological benefits, especially in elderly or deconditioned patients. The use of advanced functional assessments, including cardiopulmonary exercise testing and ventilatory thresholds, facilitates personalised risk stratification and training prescription. Despite these developments, access to CR remains limited, with significant variability in implementation and participation across regions. Addressing these gaps requires harmonised referral systems, multidisciplinary coordination and patient-centred strategies. Ongoing research should focus on integrating emerging therapies and technologies to enhance personalisation, promote equity and expand CR applications across broader patient populations.

Objectives: The optimal prosthetic aortic valve replacement (AVR) for long-term outcomes in patients aged 50-70 years remains uncertain. International guidelines differ; contemporary randomised trials are lacking, and use of bioprosthetic valves has increased. This review synthesised evidence comparing efficacy and safety outcomes between valve types in this age group.

Methods: A systematic review and meta-analysis of randomised and observational studies comparing mechanical and bioprosthetic AVR in patients aged 50-70 years was conducted. Medline, Embase and the Cochrane Library were searched. The primary outcome was overall survival; secondary outcomes were major bleeding, reoperation and stroke. Data were pooled using inverse variance random-effects meta-analysis and presented as HRs with 95% CIs.

Results: 30 studies involving 120 844 patients were included, 29 of which were observational. Mechanical valves were associated with better overall survival (HR 0.88; 95% CI 0.81 to 0.94; p=0.001). Stroke rates did not differ significantly (HR 1.07; 95% CI 0.91 to 1.27; p=0.37). Mechanical valves carried a higher risk of major bleeding (HR 1.60; 95% CI 1.43 to 1.78; p<0.001), while bioprosthetic valves had higher reoperation rates (HR 0.44; 95% CI 0.33 to 0.57; p<0.001).

Conclusions: Drawing largely from observational data, mechanical valves were associated with superior overall survival but increased bleeding due to lifelong anticoagulation. Bioprosthetic valves offer lower bleeding risk but higher reoperation rates from structural degeneration. The growing use of bioprosthetic valves in this age group may lead to more reinterventions in older, more comorbid patients. Contemporary randomised trials are needed to evaluate outcomes with modern valve designs.

Prospero registration number: CRD42024540272.

Background: The epidemiology and long-term healthcare utilisation associated with chronic kidney disease (CKD) among those with heart failure (HF) has not been mapped.

Methods: This is a 5-year longitudinal cohort analysis of patients hospitalised for HF and enrolled in the Patient Centered Care Transitions in HF randomised controlled trial. We compared clinical events, healthcare resource utilisation and direct healthcare costs (Canadian dollars, adjusted for inflation) between those with and without a CKD diagnosis at index hospitalisation. Diagnoses and outcomes were determined from linked, administrative databases. Survival was evaluated using Cox-proportional hazards models adjusted for baseline variables.

Results: Among 4441 patients hospitalised for HF, 929 (20.9%) had an established CKD diagnosis at index hospitalisation. Patients with CKD at index HF hospitalisation faced a higher adjusted risk of death (adjusted HR 1.55, 95% CI 1.42 to 1.69), poorer survival (mean [SD] 2.2 [1.8] vs 3.0 [1.9] years), more rehospitalisations (mean [SD] 4.5 [12.2] vs 2.5 [6.6] per patient) and more in-hospital days (mean [SD] 43.8 [61.8] vs 22.7 [42.3] per patient) than those without a diagnosis of CKD. Patients with a CKD diagnosis at index hospitalisation received more ambulatory and diagnostic services and were less likely to be dispensed an ACE inhibitor or mineralocorticoid receptor antagonist after adjusting for relevant baseline characteristics. Annual healthcare costs were nearly two times as high in patients with CKD at index hospitalisation than those without (mean [SD] $C128 840 [137 611] vs $C67 937 [104 149] $C/year), largely due to rehospitalisations. Among those without CKD at baseline, at least 83.4% received a CKD diagnosis during the follow-up period.

Conclusions: CKD is common at index hospitalisation for HF and is associated with a higher risk of death, shorter lifespan, more rehospitalisations and nearly twice the direct healthcare costs than no CKD. A vast majority of patients without CKD at index hospitalisation for HF are diagnosed with it subsequently.

Aim: Surgical aortic valve replacement (SAVR) improves survival in severe, symptomatic aortic stenosis (AS), but whether it fully restores life expectancy is uncertain. This study aimed to evaluate long-term relative survival following SAVR compared with the general population and identify predictors of any residual survival discrepancies.

Method: A total of 1287 patients (median age 71 (63-77) years, 32% female) undergoing SAVR for ≥moderate AS were identified from the Western Australian Heart Valves Study database. Flexible parametric models were used to estimate relative survival.

Results: Over a median follow-up of 47 (23-81) months, 247 (19%) patients died. All-cause 30-day, 1-year, 5-year and 10-year relative survivals were 97.3%, 97.2%, 93.0% and 83.3%, respectively, compared with an age-matched, sex-matched and year-matched general population. Flexible multivariable modelling indicated impaired left ventricular ejection fraction (LVEF) (45%-60%, excess HR 1.97, 95% CI 1.11 to 3.51, p=0.02; 30%-45%, excess HR 2.40, 95% CI 1.24 to 4.64, p=0.01; <30%, excess HR 2.96, 95% CI 1.18 to 7.39, p=0.02), significant mitral regurgitation (MR) (excess HR 2.28, 95% CI 1.29 to 4.03, p=0.005), Indigenous status (excess HR 4.53, 95% CI 2.03 to 10.12, p<0.001), diabetes mellitus (excess HR 2.30, 95% CI 1.44 to 3.68, p<0.001), estimated glomerular filtration rate (eGFR) 30-59 mL/kg/1.73 m² (excess HR 2.74, 95% CI 1.33 to 5.65, p=0.006) and eGFR 0-29 mL/kg/1.73 m² (excess HR 5.75, 95% CI 2.36 to 13.99, p<0.001) were independently associated with long-term excess mortality relative to that of the national comparator, whereas age, sex, year of surgery, concomitant coronary artery bypass graft surgery and symptom status were not.

Conclusion: In a contemporary population, relative survival following SAVR for significant AS was reduced compared with an age-matched, sex-matched and year-matched general population. Impaired LVEF, significant MR, Indigenous status, renal impairment and diabetes mellitus were independent predictors of long-term excess mortality. Timely intervention and optimised postoperative follow-up may be crucial for the restoration of normal life expectancy following SAVR.

Background: Platypnoea-orthodeoxia syndrome (POS) is a rare but underdiagnosed cause of positional dyspnoea and hypoxaemia. It results from right-to-left interatrial shunting through a patent foramen ovale (PFO) or atrial septal defect (ASD), often precipitated by anatomical or functional distortions.

Objectives: We systematically characterised the clinical spectrum, anatomical correlates and procedural outcomes associated with percutaneous closure in patients diagnosed with intracardiac POS.

Methods: A systematic search of PubMed, Embase and MEDLINE databases was conducted. Case reports, case series and observational studies were included if they involved patients with POS with percutaneous closure of PFO/ASD.

Results: A total of 469 patients from 196 studies (183 case reports/series, 13 observational studies) were identified (mean age 68.3±14.1 years; 51% female). Common symptoms included orthodeoxia (95%), exertional dyspnoea (42%) and platypnoea (35%) with a median time from symptoms to diagnosis of 13 (IQR 4-26) weeks. Anatomical contributors included aortic dilation (33%), thoracic structural abnormalities/surgery (33%) and right heart disorders (15%). A mean PFO/ASD diameter of 11.5±5.2 mm and a pulmonary blood flow/systemic blood flow ratio of 0.89±0.34 was noted. Amplatzer occluders were the most used device (60% of closures). Postclosure oxygen saturation improved significantly (pre: 79.5±8.7% vs post: 94.5±5.0%). Symptomatic improvement was reported in 82% of cases, with a low procedural complication rate of 5%.

Conclusions: POS remains an underdiagnosed clinical entity, where systematic evaluation for POS should be considered in patients with positional desaturation and unexplained hypoxaemia. Percutaneous closure of the interatrial shunt offers significant symptomatic and physiological benefit with a favourable safety profile.

Prospero registration number: CRD420250652717.

Sports cardiology has emerged as a distinct subspecialty at the intersection of preventive cardiology and athlete care. While regular exercise confers substantial cardiovascular benefits, vigorous exertion can unmask latent disease and precipitate sudden cardiac death (SCD), particularly in predisposed individuals. Although uncommon, such events carry profound societal impact and underscore the importance of early detection, risk stratification and tailored management.This primer reviews the epidemiology of SCD in athletes, noting the demographic variations in risk and the spectrum of conditions implicated. The role of preparticipation cardiac screening is examined, with emphasis on the utility and limitations of the 12-lead ECG.Physiological, electrical, structural and functional adaptations of the 'athlete's heart' are outlined, along with practical guidance for distinguishing these benign changes from cardiomyopathy. Secondary diagnostic strategies, including echocardiography, cardiovascular MRI, stress testing and genetic evaluation, are discussed in the context of differentiating adaptation from disease.Management principles focus on evidence-based risk stratification, safe exercise prescription and shared decision-making. Specific recommendations are provided for structural heart disease, electrical disorders, myocarditis, congenital anomalies and survivors of cardiac arrest. Emerging data on master athletes, atrial fibrillation, coronary calcification and myocardial fibrosis are highlighted.

Prehabilitation aims to improve postoperative outcomes by enhancing patients' physical and psychological resilience prior to surgery. It comprises three 'pillars'-exercise, nutritional and psychological components. Although well established in major non-cardiac surgery, prehabilitation has not been widely implemented in cardiac surgery.Candidates for cardiac surgery present unique challenges, including reduced cardiorespiratory fitness and high prevalence of frailty. Additionally, the dual care pathway differs markedly between elective outpatients and acutely admitted inpatients, with implications for timing, feasibility of the prehabilitation, as well as the components within it. Effective implementation is also dependent on behavioural considerations-wrapping the three pillars in a behavioural framework offers the best chance of an effective intervention.Despite biological plausibility and supportive signals from individual components, few high-quality, sufficiently powered trials have evaluated multimodal prehabilitation strategies in cardiac surgery. Large-scale pragmatic trials are beginning to be designed that will determine the clinical effectiveness and cost-effectiveness of prehabilitation in cardiac surgery. The outcomes of these will determine whether the potentially costly intervention of prehabilitation should be rolled out by healthcare providers.

Background: Although cardiac amyloidosis (CA) is often considered to be a cause of heart failure with preserved ejection fraction (HFpEF), many patients present with mildly reduced (HFmrEF) or reduced ejection fraction (HFrEF). Recognising CA across this spectrum is essential for diagnosis and risk stratification.

Methods: We studied 2244 patients with CA (557 light chain amyloidosis, 392 hereditary transthyretin amyloidosis, 1137 wild-type transthyretin amyloidosis) at the French national reference centre. Left ventricular ejection fraction (LVEF) was classified according to European Society of Cardiology guidelines. We evaluated the prognostic relevance of LVEF and its interaction with global longitudinal strain (GLS) and cardiac index (CIx). Survival was assessed with a Kaplan-Meier analysis, and a decision tree combined LVEF, GLS and CIx. Our findings were confirmed externally in an independent, French validation cohort.

Results: Although HFpEF was the most common phenotype, 39% of patients presented with HFmrEF or HFrEF. The survival time varied with the phenotype; the median was 30 months in HFrEF, 40 months in HFmrEF and was not reached in HFpEF. LVEF correlated moderately with GLS and weakly with CIx. A decision tree integrating LVEF, GLS and CIx identified four prognostic groups with HRs for 4-year mortality ranging from 1.6 to 3.7.

Conclusions: CA affects the full spectrum of LVEF phenotypes. The integration of LVEF, GLS and CIx improves prognostic stratification and argues in favour of a multimodal imaging approach for early diagnosis and individualised management.