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Atrial fibrillation (AF) has traditionally been classified by episode duration, whereas rhythm control outcomes-via antiarrhythmic drugs or catheter ablation (CA)-have typically been evaluated using a binary approach, with any arrhythmic recurrence lasting over 30 s deemed a failure. Both definitions have notable limitations. Clinical classification often fails to accurately represent the actual time spent in arrhythmia, and AF recurrence following CA does not always correlate well with relevant clinical outcomes. This has driven increasing interest in the concept of AF burden which, although not consistently defined in literature, generally refers to the total percentage of time spent in arrhythmia during the monitoring period. Emerging evidence suggests that AF burden more accurately reflects the impact of CA on symptoms and serves as a valuable prognostic marker, particularly in specific patient subgroups.This review aims to summarise current knowledge on the impact and prognostic value of AF burden, highlighting unsolved issues, such as the absence of a standardised definition and the need for consensus on its use. Additionally, the review underscores the significance of monitoring strategies, highlighting the potential role that wearable devices and artificial intelligence could play in enhancing continuous monitoring in the near future.

Background: Atrial fibrillation(AF) may be linked to increased sudden cardiac death (SCD) risk, but patients with AF are often neglected in studies on ECG risk factors for SCD. We aimed to clarify the long-term SCD incidence in AF among patients undergoing coronary angiography.

Methods: SCD incidence was retrospectively assessed between 2007 and 2018 in patients with suspected or known coronary artery disease referred for elective angiography and in patients with acute coronary syndrome (ACS). Follow-up extended until 31 December 2022. SCD (defined per American Heart Association/American College of Cardiology/Heart Rhythm Society/European Society of Cardiology guidelines) and SCD-equivalent events occurring during follow-up were identified through in-depth review of medical records, including accounts of circumstances leading to deaths. History of AF was identified through review of medical records, while AF at baseline and during follow-up was detected using the GE HealthCare Marquette 12SL algorithm.

Results: 9622 ACS and 11 799 elective patients were included, with 955 SCD events during follow-up. The 10-year SCD incidence among patients with AF was 7.7% in ACS and 6.4% in elective patients, compared with 4.5% and 3.2% in those without AF. In competing risk models adjusted for baseline risk factors including left ventricular ejection fraction, AF was associated with SCD (ACS: subdistribution hazard 1.33 (95% CI 1.05 to 1.67); elective: 1.37 (95% CI 1.10 to 1.71)), but this was no longer evident in the elective cohort after adjusting for incident heart failure hospitalisations, which AF preceded in 57.5% by an average of 1.4 years. Overall, 33% of SCD cases occurred in patients with known AF (paroxysmal, persistent or permanent), and 21% of SCD victims had AF on their last ECG.

Conclusions: A significant proportion of SCDs occur in patients with AF, but the risk appears mediated by heart failure hospitalisations rather than AF itself.

Objective: Comprehensive data and analyses on cardiovascular research could clarify recent research trends for the academic community and facilitate policy development. We examined publications and reference data to identify research topics, trends and interdisciplinarity for cardiovascular disease (CVD).

Methods: We extracted and clustered text fragments from the titles and abstracts of 2 512 445 publications using artificial intelligence techniques, including natural language processing (NLP) for semantic analysis. Cardiovascular experts identified topics and document clusters based on the output of those semiautomatic methods. We also applied machine learning algorithms to predict the trends over the next 5 years in each field. We examined the crossover between the two cluster groups using citation relationships in the documents.

Results: Research in clinical studies showed the most notable increase; that was followed by research in population and basic studies. The research hotspots were minimally invasive treatments for valve disease, circulatory haemodynamics, and prevention and control of hypertension. The fastest-growing topics were health monitoring, evidence-based medicine and immunotherapy. We found extensive crossover relationships among document clusters for the periods of 2017-2018 and 2020-2021.

Conclusions: This study provides valuable insights into the research hotspots for cardiovascular research, including an increasing emphasis on early disease detection and prevention, exploration of minimally invasive treatments and assessment of risk factors. The research landscape demonstrates signs of interdisciplinarity and integration as reflected in citation relationships. These findings suggest practical implications for optimising resource allocation in healthcare systems, guiding clinical guideline updates and informing policy-making to prioritise high-impact research areas aligned with evolving CVD challenges. Given the evolving global burden of CVD, continuous research and innovation are imperative, with interdisciplinary collaboration assuming a pivotal role in advancing scientific knowledge.

Objective: The impact of off-label underdosing of direct oral anticoagulants (DOACs) on clinical outcomes in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) remains unclear.

Methods: The EPIC-CAD trial (Edoxaban vs Edoxaban with antiPlatelet agent In patients with atrial fibrillation and Chronic stable Coronary Artery Disease) randomised patients with AF and stable CAD to receive either edoxaban monotherapy or dual antithrombotic therapy (edoxaban plus single antiplatelet agent). Off-label underdosing was defined as low-dose edoxaban (30 mg once daily) without standard criteria for dose reduction. The primary outcome was a composite of death, myocardial infarction, stroke, systemic embolism, unplanned revascularisation and major or clinically relevant non-major bleeding at 12 months.

Results: Among the 1040 randomised patients, 694 patients (66.7%) without dose-reduction criteria were included; of whom, 121 patients (17.4%) received edoxaban underdosing. At 12 months, the incidence of primary outcome was similar between standard-dose and under-dose edoxaban groups (10.5% vs 9.2%, adjusted HR 0.77, 95% CI 0.39 to 1.54). There was no significant difference in major ischaemic events (1.4% vs 1.7%, HR 1.14, 95% CI 0.22 to 5.91) and major or clinically relevant non-major bleeding (9.0% vs 8.4%, HR 0.87, 95% CI 0.42 to 1.78). Regardless of edoxaban underdosing, edoxaban monotherapy was associated with lower risk of primary net-clinical outcomes and bleeding compared with dual antithrombotic therapy.

Conclusions: In patients with AF and stable CAD, there was no significant difference in the rate of primary outcome between off-label underdose and standard-dose edoxaban. The benefit of edoxaban monotherapy over dual antithrombotic therapy was consistent regardless of edoxaban underdosing. However, given the analyses were underpowered and the CI was wide, the results cannot be considered clinically directive.

Trial registration number: URL: https://www.

Clinicaltrials: gov; unique identifiers: NCT03718559.

Background: Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive treatment for therapy-refractory ventricular tachycardia (VT). In STAR, a high dose of radiation is used to non-invasively target and treat the VT substrate. Initial studies indicate promising VT burden reduction, but comprehensive efficacy and safety evaluations remain limited.

Methods: A systematic review (Preferred Reporting Items for Systematic Reviews and Meta-Analyses/Meta-analysis Of Observational Studies in Epidemiology guidelines) included studies on STAR for monomorphic VT identified up to 30 June 2024 via MEDLINE and EMBASE. Outcomes assessed were freedom of VT, percentage reduction in VT episodes and implantable cardioverter-defibrillator (ICD) shocks per month, survival and adverse events (AEs). Meta-analyses included prospective and retrospective studies only, using random-effects models with double arcsine transformation. Subgroup analyses by study design and planning target volume (PTV) were performed. AEs were qualitatively analysed and classified by organ system, severity and causality.

Results: The meta-analysis included 215 patients from 22 studies (age 66.0±4.4 years, 85.9% men, left ventricular ejection fraction 29.8±5.0%, 52.2% ischaemic cardiomyopathy, mean follow-up of 11.9±6.6 months). The overall survival was 69.6% (95% CI 62.6% to 76.2%). VT episodes and ICD shocks/month reduced by 81.5% (95% CI 64.2% to 94.8%) and 84.7% (95% CI 65.1% to 98.1%), respectively. However, only 23.1% (95% CI 10.7% to 37.7%) were VT-free at the end of follow-up. There were no significant differences in clinical outcomes between prospective and retrospective studies, nor between studies with high PTV and low PTV. A total of 352 AEs were reported in 280 patients, with a mean of 1.26 AE per patient. Of these AEs, 50.6% were classified as severe, though only 9.7% were likely STAR-related.

Conclusions: STAR significantly reduces VT episodes and ICD shocks, offering symptomatic relief. However, high recurrence rates and severe AEs underscore the need for protocol optimisation and multidisciplinary collaboration to improve STAR's safety and efficacy in VT management.

Renal nerves are critical modulators of kidney function and blood pressure (BP) control. Their influence on sodium and fluid retention, renin release and vasoconstriction rendered them a therapeutic target more than a century ago when surgical splanchnicectomy emerged as one of the first effective antihypertensive therapies. Revisiting the concept using catheter-based approaches to ablate renal afferent and efferent nerves more selectively with various energy sources demonstrated the efficacy of renal denervation in reducing sympathetic nerve activity. A series of sham-controlled randomised clinical trials in patients with uncontrolled or resistant hypertension either on or off concomitant antihypertensive drugs demonstrated procedural safety and clinically meaningful BP reduction. Durability of the BP lowering efficacy has been demonstrated out to 10 years in observational studies. Major international guidelines now recommend renal denervation as an adjunct therapy in patients with uncontrolled or resistant hypertension where other means have failed or resulted in insufficient BP control. Patient selection and patient preference are relevant aspects to be considered in a shared decision-making process leading up to the denervation procedure, which should be performed in experienced centres. While approved in the USA, most countries in Europe, Asia-Pacific and many other regions lack adequate reimbursement currently, which remains a barrier for more widespread implementation into clinical practice despite favourable cost-effectiveness analyses. While now established in the context of hypertension management, ongoing research explores its potential utility in other conditions characterised by increased sympathetic drive, with most promising results in patients with chronic kidney disease, atrial fibrillation, heart failure and others. Further refinement of procedural aspects may reduce procedure time and augment the BP lowering efficacy. Clinicians should embrace the additional options that device-based therapies offer to improve BP management, mostly in combination with pharmacologic therapies. After all, it is just another means of bringing the pressure down.