Heart最新文献

Heart failure with preserved ejection fraction (HFpEF) is a syndrome characterised by cardiac and non-cardiac physiologic disturbances, commonly underpinned by cardiometabolic abnormalities, which culminate in elevated left ventricular filling pressures and progressive symptoms of exercise intolerance. Arrhythmias, particularly atrial fibrillation (AF), are common in HFpEF and have important clinical implications. AF complicates the diagnosis and management of HFpEF. In this review, we synthesise the impact of AF on disease detection, symptom burden and prognosis and HFpEF treatment. Furthermore, we review pharmacological and interventional therapies that may mitigate the risk of AF and improve how patients with HFpEF feel, function and survive.

Heritable thoracic disease (HTAD) represents a heterogeneous group of genetic conditions predisposing to thoracic aortic aneurysm and dissection, with important implications for patients and families. Accurate diagnosis requires integration of clinical assessment-including subtle syndromic features-and molecular genetic testing, supported by family screening. While aortic root pathology is a hallmark, extra-aortic manifestations such as myocardial dysfunction, arrhythmias, premature atherosclerosis and aneurysms in distal or branch vessels are increasingly recognised, with gene-specific associations informing risk stratification.Imaging plays a central role in diagnosis and longitudinal monitoring. Transthoracic echocardiography remains the first-line tool, but cross-sectional imaging (cardiovascular magnetic resonance or cardiovascular CT) is essential for complete aortic assessment and detection of extra-aortic involvement. Surveillance intervals and imaging techniques must be standardised and tailored to genotype and clinical features.Medical therapy aims to control blood pressure and reduce aortic growth. Beta-blockers and angiotensin receptor blockers are first-line in Marfan syndrome; evidence for other HTAD subtypes is emerging. Surgical thresholds differ by genotype, emphasising the importance of personalised care. Paediatric management follows similar principles but requires adapted imaging techniques, growth-adjusted interpretation and careful timing of intervention.Pregnancy in women with HTAD demands multidisciplinary planning, individualised risk assessment and close follow-up to minimise maternal and fetal complications. Finally, recent data support moderate aerobic activity while avoiding isometric and contact sports; exercise prescriptions should be individualised.Overall, HTAD care requires lifelong, multidisciplinary, gene-informed management, integrating imaging, genetics and lifestyle considerations to optimise outcomes across the lifespan.

Background: The Fontan procedure is associated with long-term cardiac and non-cardiac complications and early mortality. Recent data suggest that some fibrosis scores may offer prognostic insight for individuals with Fontan circulation. This study aimed to investigate whether biomarkers of liver fibrosis can predict transplant-free survival in Fontan circulation.

Methods: This was a retrospective observational cohort study of 334 adults with Fontan circulation who had FibroSURE testing between 2008 and 2022 at a large-volume adult congenital heart disease centre. FibroSURE score, Aminotransferase-to-Platelet Ratio Index (APRI), fibrosis-4 (FIB-4) and Model for End-stage Liver Disease eXcluding INR (international normalised ratio) (MELD-XI) were recorded and analysed against clinical outcomes.

Results: There were 664 FibroSURE results during the study period with 83 (13%) above the nominal cut-off predicting cirrhosis (>0.74). There were 37 deaths (11%) and four transplants (1%) over a median follow-up of 5.6 years (IQR 2.7-9.9). After adjusting for age at FibroSURE and history of hepatitis C, each 0.1 increase in FibroSURE score remained associated with a 1.19-fold increased hazard of death or transplant (95% CI 1.02 to 1.40, p=0.032), and FibroSURE >0.74 remained associated with a 3.26-fold increased hazard of death or transplant (95% CI 1.62 to 6.59, p=0.001). In 314 patients where FibroSURE, APRI, FIB-4 and MELD-XI were all available, FibroSURE >0.74 (HR 5.11, 95% CI 2.66 to 9.83, p<0.001), APRI >0.5 (HR 2.56, 95% CI 1.36 to 4.81, p=0.004), FIB-4 >1.45 (HR 5.07, 95% CI 2.67 to 9.64, p<0.001) and MELD-XI >18 (HR 24.1, 95% CI 5.51 to 106, p<0.001) were all associated with increased hazard of death or transplant.

Conclusions: Higher FibroSURE, APRI, FIB-4 and MELD-XI are associated with increased hazard of death or transplant in Fontan circulation.

Background: Up to half of patients with infective endocarditis (IE) require cardiac surgery. Although anaemia is common, its precise prevalence, transfusion practices and impact on outcomes in surgically treated IE patients remain unclear. Therefore, our aim was to determine the incidence and severity of preoperative anaemia, describe transfusion and coagulation management and evaluate associations of anaemia and red blood cell (RBC) transfusion with mortality, including sex-based differences.

Methods: This retrospective multicentre cohort study used data from the Netherlands Heart Registration, including all adult patients who underwent valve surgery for active IE between 1 January 2016 and 31 December 2023. Anaemia was defined by WHO criteria. Kaplan-Meier and Cox proportional hazards models were used to evaluate associations between anaemia severity, RBC transfusion and 30-day and 1-year mortality. Multivariable analyses were adjusted for age, sex, prior valve surgery, renal dysfunction, surgery urgency, cardiopulmonary bypass and aortic cross-clamp times, surgical re-exploration, preoperative critical illness, surgical re-exploration and year of surgery.

Results: Of 2480 patients, 84.9% had preoperative anaemia (50.7% moderate, 2.8% severe). RBC transfusion occurred in 78.7% of patients. 30-day and 1-year mortality were 10.6% and 16.6%, respectively. Moderate and severe anaemia were associated with higher mortality in univariable, but not in multivariable analysis. RBC transfusion remained independently associated with mortality at both time points (adjusted HR for mortality at 30 days 3.58, 95% CI 2.07 to 6.19). Female patients had higher transfusion rates and mortality.

Conclusions: Anaemia and transfusion are highly prevalent in IE surgery and associated with increased mortality. RBC transfusion is an independent predictor of adverse outcomes, underscoring the need for improved anaemia management and individualised transfusion strategies.

Background: Aortic valve calcification (AVC) is a disease process driven by inflammation and lipid infiltration, serving as a precursor to aortic stenosis. While male sex has been implicated as a risk factor for AVC, sex-specific differences, particularly among younger individuals in the general population, are not well characterised.

Methods: The Swedish CArdioPulmonary BioImage Study was used, comprising 30 154 individuals between 50 and 64 years, randomly selected from the general population. Study participants were part of a prospective cohort and underwent laboratory tests, clinical examinations, comprehensive questionnaires and cardiac CT. Cardiac CT was used for determining presence of AVC. Logistic regression analysis was performed to assess associations between traditional cardiovascular risk factors and AVC.

Results: In total, 29 160 participants were included and AVC was found in 1291 men (9%) and 730 women (5%). Male sex was an independent predictor of AVC (OR 1.91; 95% CI 1.71 to 2.13). Characteristics associated with AVC were similar between the sexes. In the adjusted analyses, lipoprotein(a), hyperlipidaemia, hypertension and smoking were strongly associated with AVC, whereas low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, diabetes, glycated haemoglobin and estimated glomerular filtration rate showed no significant associations with AVC. Higher body mass index (BMI) was associated with AVC in men but not women.

Conclusions: Male sex was independently associated with AVC, and the prevalence of AVC was nearly twice as high in men as in women. Traditional cardiovascular risk factors, including lipoprotein(a), hyperlipidaemia, hypertension and smoking, were associated with AVC, with similar associations between sexes, except for BMI, which was associated with AVC in men but not in women.

Background: Socioeconomic disparities are associated with sudden cardiac arrest (SCA) in older populations, but evidence in young adults is limited. We investigated the association between income status, geographical region and SCA risk among young adults in South Korea.

Methods: Using the Korean National Health Insurance Service database, we identified 6 307 644 adults aged 20-39 years who underwent health screening between 2009 and 2012. Income status was defined by insurance premium quartiles and medical aid status. The primary outcome was incident SCA through December 2020. Multivariable Cox regression models were used to estimate adjusted HRs with 95% CIs.

Results: Over a mean follow-up of 9.4 years, 5340 individuals (0.08%) experienced SCA. Crude incidence rates were similar across income quartiles (0.09 per 1000 person-years) but highest among medical aid beneficiaries (0.28 per 1000 person-years; 95% CI 0.21 to 0.39). After multivariable adjustment, higher income was associated with lower SCA risk (adjusted HR for highest vs lowest quartile 0.67; 95% CI 0.61 to 0.73), while medical aid beneficiaries had substantially higher risk (adjusted HR 3.44; 95% CI 2.49 to 4.74). Geographical variation in SCA incidence was modest, and no significant interaction between income status and region was observed. Mediation analysis showed that modifiable risk factors explained only a small proportion of the income-SCA association.

Conclusions: Lower income status, particularly receipt of medical aid, was independently associated with higher SCA risk among young adults. Socioeconomic disparities in SCA risk were not fully explained by lifestyle or metabolic factors.

Background: Patients with prior coronary artery bypass grafting (CABG) account for around 10% of non-ST-elevation acute coronary syndromes (NSTE-ACS), but the optimal diagnostic and management strategy remains uncertain. Invasive coronary angiography (ICA) in this group is technically challenging, carries increased risk and often does not lead to percutaneous coronary intervention (PCI). CT coronary angiography (CTCA) may help identify which patients benefit from ICA and reduce unnecessary invasive procedures.

Methods: In the BYPASS-CTCA (Randomised Controlled Trial to Assess Whether Computed Tomography Cardiac Angiography Can Improve Invasive Coronary Angiography in Bypass Surgery Patients) study, patients with prior CABG undergoing ICA were randomised to CTCA plus ICA or ICA alone. For this analysis, anonymised case vignettes and CTCA reports from 150 patients with NSTE-ACS were independently reviewed by 50 experienced interventional cardiologists (median 17 years post-qualification; 5103 total case reviews). Agreement on management strategy before and after CTCA was assessed using Fleiss' κ statistic.

Results: Based on clinical information alone, respondents chose medical therapy in 13.2% of cases, with poor agreement on management strategy (κ=0.14, 95% CI 0.11 to 0.17). After reviewing CTCA, agreement improved to moderate (κ=0.53, 95% CI 0.48 to 0.58; p<0.001), and medical management was selected in 39.3% (p<0.001). When invasive management was selected post-CTCA, PCI was required in 85% of cases, and a selective angiographic approach was planned in 79%.

Conclusions: Management decisions for post-CABG NSTE-ACS vary widely among experienced cardiologists. Incorporating CTCA into the diagnostic pathway substantially improves consensus, reduces unnecessary invasive angiography and enables targeted, lower-risk procedures. These findings support evaluation of a CTCA-guided strategy in a prospective randomised trial.

Background: Coarctation of the aorta (CoA) has good modern results, but large multicentre longitudinal data on outcomes, especially hospital resource utilisation through childhood and adolescence, are not available.

Methods: All patients with CoA treated between 2000 and 2017 in England and Wales were linked to hospital and outpatient records through the Linking AUdit and National datasets in Congenital HEart Services (LAUNCHES) project. Mortality, reintervention and hospital stay were described, and associated risk factors were explored using multivariable regression models for each of these three outcomes (Cox regression, Fine-Gray subdistribution hazard model and quantile regression at median, respectively).

Results: A total of 3321 patients were included: n=669 (20.1%) had CoA with ventricular septal defect (VSD), n=331 (10.0%) had CoA with small VSD and n=2321 (69.9%) had isolated CoA. Mortality and cardiac reintervention at 10 years (from birth and CoA repair, respectively) were 3.7% (95% CI 3.0%; 4.4%) and 13.3% (12.1%; 14.5%), respectively. Compared with isolated surgical repair, isolated catheter repair (HR 3.7, (95% CI 2.2; 6)) and concomitant VSD closure (HR 1.34, (1; 1.9)) or pulmonary artery banding (HR 3.5, (2.4; 5.1)) had higher risk of reintervention. During the first year of life, the median time in hospital was 26 days (IQR 17; 44), decreasing to 1 (0; 2) day beyond 8 years. CoA with large VSD (-12, (-16; -8)), premature birth (-50, (-60; -40)), congenital comorbidity (-31, (-37; -25)), low weight (-23/kg, (-37; -11)) and younger age at first procedure (-6/year (-7; -5)) were associated with fewer days spent at home.

Conclusions: Subgroups of patients with CoA are still at risk of unfavourable outcomes during childhood and adolescence follow-up, especially cardiac reintervention at a distance from initial repair. Hospital resource utilisation remains low beyond the first year of life in the majority of patients. Identified factors, while non-modifiable, remain useful in risk stratification and counselling.