Heart最新文献

Background: Current guidelines recommend complete removal of a cardiac implantable electronic device (CIED) in patients with infective endocarditis (IE), although these recommendations are largely based on expert opinion (level of evidence C). We aimed to examine outcomes stratified by CIED removal status in patients with IE.

Methods: Using Danish nationwide registries (2010-2021), we identified patients aged ≥18 years with first-time IE, who were alive at discharge, managed without valve surgery and had a CIED. Patients who underwent CIED removal during IE admission were compared with those without removal. The study outcomes were IE readmission, recurrent bacteraemia (including IE with the same microbial aetiology) and all-cause mortality within 6 months after discharge.

Results: The study population comprised 1040 patients with non-surgically managed IE and a CIED, and among these, 596 (57.3%) underwent CIED removal during admission. Patients who underwent removal were younger and less frail than those without removal. In the removal versus non-removal group, the 6-month cumulative incidences were 2.5% (95% CI 1.4% to 4.1%) vs 7.1% (95% CI 4.9% to 9.9%) for IE readmission (p value <0.001), 2.1% (95% CI 1.1% to 3.5%) vs 5.2% (95% CI 3.4% to 7.6%) for recurrent bacteraemia (p value=0.005) and 11.5% (95% CI 9.1% to 14.3%) vs 20.0% (95% CI 16.4% to 23.9%) for all-cause mortality (p value <0.001). In multivariable Cox regression models, CIED removal was associated with lower 6-month rates of IE readmission (HR 0.39 (95% CI 0.19 to 0.79)) and all-cause mortality (HR 0.70 (95% CI 0.49 to 0.996)), compared with no removal.

Conclusions: In this nationwide study of patients with non-surgically managed IE and a CIED, CIED removal was associated with significantly lower 6-month rates of IE readmission, recurrent bacteraemia and mortality compared with no removal, supporting current guideline recommendations. However, randomised clinical trials are warranted to determine the most effective treatment strategy.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) shares metabolic and inflammatory pathways with heart failure. However, prior studies with small samples and broad cardiometabolic risk factor (CMRF) groupings have left the relationship unclear. We aimed to assess the independent effect of MASLD and the combined impact of specific CMRFs on heart failure incidence.

Methods: We analysed data from 218 605 adults in the Korean National Health Insurance Service screening cohort between 2009 and 2010, excluding those with other liver diseases, excessive alcohol use, cancer, cirrhosis or missing data. MASLD was defined based on a Fatty Liver Index ≥30 with at least one CMRF. Participants were categorised by MASLD and CMRF status, and incident heart failure was identified during follow-up until 2019. Adjusted HRs were estimated using multivariable adjusted Cox proportional hazards models.

Results: Among the 218 605 participants, 32% had MASLD with less favourable cardiometabolic profiles than those without steatotic liver disease. During a median follow-up of 9.6 years, 16 340 incident heart failure cases occurred. Patients with MASLD had a significantly higher risk of heart failure than individuals without steatotic liver disease and CMRFs (adjusted HR 2.62, 95% CI 2.39 to 2.86). Heart failure risk increased progressively with an increasing number of CMRFs (per additional CMRF: adjusted HR 1.24, 95% CI 1.22 to 1.25).

Conclusions: MASLD is independently associated with incident heart failure beyond traditional CMRFs. Therefore, MASLD's role may warrant consideration in future heart failure risk stratification.

Background: The 12-lead ECG is a simple, inexpensive clinical tool with a key role in the assessment of patients with hypertrophic cardiomyopathy (HCM). The aims of this single centre, retrospective cohort study were to characterise ECG findings and to identify potential ECG predictors of major adverse cardiovascular events (MACE-cardiovascular mortality, resuscitated cardiac arrest, ventricular arrhythmias with haemodynamic compromise, appropriate implantable cardioverter defibrillator therapy or heart failure hospitalisation) in children with RASopathy-associated HCM (RAS-HCM).

Methods: The resting 12-lead ECGs of 84 children with RAS-HCM were compared with those from 113 patients with sarcomeric HCM (s-HCM).

Results: A significant proportion of ECGs in RAS-HCM had superior axis deviation (29.8% vs 2.5%, p value<0.001) and voltage criteria for right ventricular hypertrophy (52.4% vs 28.3%, p value<0.001), and a significantly lower prevalence of pathological Q waves (27.4% vs 47.8%, p value<0.001). Over a median follow-up period of 6.8 years (3.1-9.7), 19 patients (22.6%) with RAS-HCM suffered an MACE. Right atrial enlargement and ST segment changes>2 mm correlated with MACE on univariate analysis, with the latter remaining significant after adjustment in a multivariate model (adjusted relative risk (RR) 2.33, 95% CI 1.12 to 4.86, p value 0.024).

Conclusion: These findings suggest that the 12-lead ECG may be a useful screening tool to distinguish RAS-HCM from s-HCM in everyday practice and could have potential implications for prediction of adverse outcomes.

Background: Atrial fibrillation (AF) impacts management decisions in valvular heart disease but its significance in patients with chronic aortic regurgitation (AR) is not well established.

Objectives: To evaluate the prevalence and prognostic role of AF in patients with chronic, haemodynamically significant AR.

Methods: Adults with chronic ≥moderate-to-severe AR, from March 2004 to April 2019, were retrospectively identified. Those with acute AR, moderate or worse other valve disease or prior valve surgery were excluded. Patients with AF were identified based on 12-lead ECGs, 1-lead ECGs (showing AF for ≥30 s), or episodes recorded by implanted cardiac devices. Primary outcome was all-cause mortality. Cox regression models were used to assess associations with mortality: model 1 adjusted for age, symptoms (New York Heart Association class II-IV), Charlson Comorbidity Index, left ventricle (LV) end-systolic volume index and AF; model 2 added left atrial volume index and model 3 further added systolic pulmonary artery pressure.

Results: Of the 1006 included patients (age 59±18 years; 822 (82%) men), 446 (46%) had hypertension and 364 (36%) had a bicuspid aortic valve. AF was present in 161 (16%) patients at the time of ≥moderate-to-severe AR diagnosis. During a median follow-up of 1.6 years (IQR 0.2-6.2), AF was associated with an increased mortality risk in univariate and in all three multivariable models (HR 1.61 (95% CI 1.07 to 2.43), HR 2.21 (95% CI 1.31 to 3.72) and HR 2.06 (95% CI 1.21 to 3.52), respectively), including after propensity matching (HR 1.58 (95% CI 1.01 to 2.48)).

Conclusions: AF is present in one in six patients with chronic≥moderate-to-severe AR and is associated with an increased risk of mortality even after adjusting for measures of LV systolic and diastolic function. There is a need for future prospective studies to validate these findings and evaluate AF as a potential trigger for early surgery.

Background: Patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension (PAH/CTEPH) may experience physiological stress at high altitude. We investigated pulmonary haemodynamics and right heart function during incremental (IET) and constant work-rate exercise tests (CWRET) at high (2500 m) vs low altitude (470 m).

Methods: In this randomised crossover trial, patients with stable PAH/CTEPH without resting hypoxaemia performed IET and CWRET at both altitudes. Systolic pulmonary arterial pressure (sPAP) and right ventricular (RV) arterial coupling (tricuspid annular plane systolic excursion/sPAP) were assessed by echocardiography.

Results: Among 27 patients (44% women, 61±14 years), sPAP was higher at rest at 2500 m vs 470 m (mean difference: 14 mm Hg, 95% CI 7 to 23), but increased linearly during exercise with similar slopes at each altitude (7.9 vs 9.7 mm Hg/min, respectively). RV arterial coupling was lower at high altitude at rest (difference: -0.13 mm/mm Hg, 95% CI -0.26 to -0.04) but decreased comparably during exercise. During CWRET, sPAP rose steeply in the first 3 min, plateauing thereafter, with no altitude-dependent differences in pressure-flow slope. Oxygen delivery was reduced at high altitude.

Conclusion: Despite higher baseline sPAP and reduced RV coupling at rest, exercise-induced haemodynamic changes were similar at both high and low altitudes, suggesting short-term altitude exposure does not exacerbate cardiopulmonary stress during exercise in stable PAH/CTEPH. The exercise protocol (IET vs CWRET) alters haemodynamic trajectories more than altitude.

Trial registration number: NCT05107700.

Background: Radiation exposure of the heart secondary to radiotherapy can lead to potential cardiac injury. However, the hazard ratio (HR) for cardiac morbidity and mortality associated with undergoing breast cancer radiotherapy remains unknown.

Objectives: To pool the HRs for cardiovascular risk in patients with breast cancer treated with or without radiotherapy, compare the cardiac risk among irradiated patients divided by the laterality of radiotherapy and further assess the association between the cardiac radiation dose and cardiac morbidity.

Methods: A literature search was conducted using MEDLINE, EMBASE and the Cochrane Library from inception to 1 December 2024. Studies that reported HRs with 95% CIs for the associations of interest were included. Pooled effect estimates were obtained using random-effects meta-analysis. Subgroup analyses were carried out to investigate the influence of the treatment period on cardiovascular outcomes. Publication bias was evaluated using the Egger and Begger's tests.

Results: Thirty-one studies involving 610 690 participants were ultimately included. Compared with patients who did not receive radiotherapy, patients who underwent radiotherapy experienced increased risks for developing heart failure (HR: 1.37; 95% CI 1.20 to 1.57). Among patients treated with radiotherapy, left-sided radiotherapy increased the risk of subsequent coronary artery disease (HR: 1.11; 95% CI 1.05 to 1.16). There was a linear correlation between the mean heart exposure dose and cardiac morbidity development (HR: 1.12; 95% CI 1.05 to 1.19). When patients were grouped by treatment period, the risk of cardiac mortality in patients treated with left-sided radiotherapy decreased after 1989 (HR: 1.30 vs 1.02, p<0.01*). No evidence of significant publication bias was identified.

Conclusions: Radiotherapy for breast cancer was associated with an increased risk of experiencing adverse cardiovascular events, which was highly dependent on the cardiac irradiation dose. With advances in radiation techniques, cardiovascular prognosis is expected to improve further.

Despite advances in its understanding and treatment, coronary heart disease remains the leading cause of death worldwide. Acute coronary syndromes most commonly result as a consequence of the rupture of non-flow-limiting, high-risk coronary artery plaques. Advances in multimodality imaging have allowed the detailed assessment of the high-risk plaque including the assessment of plaque burden, high-risk plaque features, plaque activity and thrombosis. This in turn may help identify those patients at greatest risk, and thus benefit from intensification of pharmacotherapies or from local preventative strategies including coronary revascularisation. However, the optimal management of high-risk plaques and the prevention of consequent adverse coronary events have yet to be established. Further development and observational studies are required to determine how best to apply high-risk plaque metrics into clinical practice. Nevertheless, a new era of precision medicine is upon us, with advanced plaque imaging allowing enhanced risk stratification and targeting of the growing armamentarium of atherosclerotic therapies to the highest risk patients.