Heart最新文献

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.

Background: Current evidence supports the role of circulating carbohydrate antigen 125 (CA125) in risk assessment, disease monitoring and therapeutic guidance in heart failure (HF). However, there is limited data on its diagnostic applicability. This study aimed to assess the diagnostic performance of CA125 in identifying HF with preserved ejection fraction (HFpEF) in an outpatient population.

Methods: This was a prospective, multicentre study involving 246 consecutive patients with clinically suspected HF. Patients with a left ventricular ejection fraction <50% (n=8) and those with a history of malignancy (n=22) were excluded. The final study cohort comprised 210 patients. The diagnosis of HFpEF was confirmed by a trained cardiologist blinded to the biomarker levels.

Results: The mean age of the study cohort was 69.7±15 years, and 69% were women. Median levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and CA125 were 125 pg/mL (IQR: 51-332) and 11 U/mL (IQR: 8-17), respectively. HFpEF was diagnosed in 65 (31%) patients. For HFpEF diagnosis, NT-proBNP and CA125 levels demonstrated comparable areas under the receiver operating characteristic curves 0.765 (95% CI: 0.686 to 0.843) vs 0.715 (95% CI: 0.636 to 0.793), respectively (p=0.323). Optimal cut points were identified as 12.2 U/mL for CA125 (sensitivity: 0.69; specificity: 0.68) and 243 pg/mL for NT-proBNP (sensitivity: 0.65; specificity: 0.83). Elevated CA125 levels (>23 U/mL, 12.4% of the sample) exhibited high specificity (0.97), a positive predictive value of 80.8% and correctly classified 77.1% of cases as HFpEF. Conversely, CA125 levels<9 U/mL were associated with a high negative predictive value (85.7%).

Conclusion: In an ambulatory setting, CA125 exhibits acceptable diagnostic performance for identifying HFpEF and may complement NT-proBNP in clinical practice.

Intravenous thrombolytics remain the mainstay of treatment for ischaemic stroke and retain importance for selected patients with ST-elevation myocardial infarction and pulmonary embolism. Pharmacological and practical advantages of the fibrinolytic tenecteplase have recently led to a widespread shift in ischaemic stroke management. Meta-analysis of randomised trials demonstrated superiority of tenecteplase over alteplase in achieving excellent functional outcome after stroke (no disability). Trials have also extended the time window for thrombolytics in stroke to 24 hours, provided imaging demonstrates salvageable brain tissue. Although endovascular therapy is the most effective treatment for large vessel occlusion stroke, access remains limited to major metropolitan centres in developed nations. Trials suggest that thrombolytics add value, even in patients receiving endovascular therapy, and for many patients globally, intravenous thrombolytics are the only accessible reperfusion treatment. Tenecteplase is established as the preferred thrombolytic for selected patients with ST-elevation myocardial infarction, generally reserved for patients who cannot rapidly access percutaneous intervention following first medical contact. Notably, the dose used is twice that for stroke. Pre-hospital delivery of tenecteplase by paramedics is an important strategy in rural and remote areas. While patients with high-risk pulmonary embolism benefit from systemic thrombolysis, adjunctive tenecteplase in intermediate-risk pulmonary embolism has been associated with increased risk of major bleeding and haemorrhagic stroke. The practical advantages of bolus administration and having a single thrombolytic on formulary for all relevant indications have positioned tenecteplase as the leading thrombolytic agent in current practice. This review discusses the current evidence and treatment guidelines in this rapidly evolving field.

Background: Heart failure (HF) imposes a major health burden on women. While traditional (well-established) risk factors are well studied, less attention has been given to psychosocial, environmental and female-specific reproductive risk factors. This study quantifies the contribution of these risk domains to incident HF in women.

Methods: We included 233 125 women from the UK Biobank with a median follow-up of 13.7 years. 22 risk factors were grouped as well-established (eg, hypertension), under-recognised (eg, depression, socioeconomic deprivation) or female-specific (eg, early age at menopause, parity). Cox regression models and population attributable fractions (PAFs) were used to estimate HF risk and burden. Analyses were stratified by age and obesity.

Results: A total of 6077 women developed HF. The overall PAF for all risk factors was 66.0%. Hypertension had the largest individual contribution (PAF 25.3%). Well-established, under-recognised and female-specific risk factors accounted for 46.0%, 25.5% and 15.5% of HF cases, respectively. Chronic inflammatory diseases, early age at menopause and early age at first birth were key reproductive drivers. Age-stratified analyses showed the highest HF burden in women aged 55-59 years (PAF 70.0%).

Conclusion: A combination of modifiable, psychosocial, environmental and reproductive risk factors accounts for two-thirds of HF cases in women. Tailored, life course-oriented prevention strategies are essential to reduce this burden.

Background: Chronic kidney disease is common in patients with coronary artery disease (CAD) and can significantly affect drug excretion and efficacy. This study focuses on the effects of modification of renal function on platelet aggregation.

Methods: In total, 164 patients with stable CAD undergoing dual antiplatelet therapy were enrolled and randomised to receive either 75 mg clopidogrel or 3.75 mg prasugrel daily. Patients were stratified based on estimated glomerular filtration rate (eGFR) into two groups: eGFR <45 (eGFR <45 group) or ≥45 mL/min/1.73 m² (eGFR ≥45 group). The primary endpoint was the inhibition of platelet aggregation on day 5 and day 30. Analysis of covariance was performed to compare the P2Y₁₂ reaction units (PRU) on days 5 and 30 after randomisation.

Results: In the eGFR <45 group, prasugrel induced a more rapid decrease in platelet aggregation than clopidogrel. Mean PRU value for clopidogrel and prasugrel at baseline, day 5 and day 30 was 198.2 vs 177.2, 214.2 vs 157.9 and 200.0 vs 141.7, respectively. The differences were statistically significant on day 5 (p=0.036), but not on day 30 (p=0.105). The p for interaction between treatment effect and eGFR was 0.498 at baseline, 0.028 at day 5 and 0.212 at day 30, emphasising that the drug effect was significantly different by kidney function, but only in the early phase of drug initiation.

Conclusion: In patients with impaired renal function, prasugrel provided a more rapid reduction in platelet aggregation compared with clopidogrel, particularly during the early phase of antiplatelet treatment. Further research is needed to confirm these findings in larger and more diverse populations.

Trial registration number: URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000027055; Unique identifier: UMIN000023489.

Background: Acute coronary syndrome (ACS) is a global leading cause of morbidity, with residual inflammation contributing to recurrent events. Colchicine has been proposed as an adjunct therapy, but its efficacy remains uncertain.

Methods: We performed a systematic review and meta-analysis. PubMed, Embase and Cochrane databases were searched for randomised controlled trials (RCTs) data comparing colchicine versus placebo in ACS. Risk ratio (RR) and mean difference with 95% CIs were computed for binary and continuous outcomes, respectively. Primary outcomes were adverse cardiovascular events (ACEs), mortality and safety. Random-effects models were used for pooled estimates.

Results: Seventeen RCTs comprising 14 794 patients were included, of whom 7390 (50%) were randomised to colchicine. The mean patient age across the studies ranged from 54 to 63 years, in a follow-up period ranging from 5 days to 12 months. Colchicine reduced the incidence of recurrent ACS (RR 0.41, 95% CI 0.19 to 0.92; p=0.03; I²=55%) and unstable angina (RR 0.27, 95% CI 0.11 to 0.63; p<0.01; I²=0%). No meaningful differences were observed in all-cause mortality (RR 0.95, 95% CI 0.79 to 1.14; I²=12%), cardiovascular death (RR 1.03, 95% CI 0.82 to 1.30; I²=0%) or ACE (RR 0.77, 95% CI 0.59 to 1.01; p=0.05; I²=58%). Subgroup analyses suggested a dose-dependent effect, with 0.5 mg/day potentially reducing ACE (RR 0.63, 95% CI 0.45 to 0.88; I²=41%), but higher doses increasing gastrointestinal symptoms.

Conclusion: Low-dose colchicine may reduce recurrent ischaemic events in ACS, but evidence remains uncertain due to heterogeneity and limited long-term data. Safety and efficacy in women and optimal dosing require further investigation.

Trial registration number: CRD42024627348.

Background: Aortic stenosis (AS) frequently coexists with heart failure (HF), but its prevalence, prognostic impact and management across the full HF spectrum remain incompletely characterised.

Methods: In this retrospective cohort study, we analysed 22 906 patients with HF undergoing echocardiography between 2010 and 2020. AS was classified as mild, moderate, low-gradient (LG) or severe according to guideline criteria. Outcomes were assessed using Cox regression, stratified by HF subtype and adjusted for clinical confounders. The primary endpoint was event-free survival, defined as all-cause mortality or aortic valve replacement (AVR).

Results: Moderate AS was present in 5.5%, LG AS in 2.5% and severe AS in 6.5% of HF patients, with HF with preserved ejection fraction (HFpEF) being the most common HF subtype across all AS grades. Increasing AS severity was associated with a stepwise increase in adverse outcomes compared with HF patients without AS (adjusted HR 2.20 (95% CI 2.00 to 2.41) for moderate AS; 3.32 (95% CI 2.97 to 3.72) for LG AS and 6.20 (95% CI 5.74 to 6.69) for severe AS). These associations were consistent across HFpEF, HF with mildly reduced EF and HF with reduced EF. Despite established guideline indications, only 59.5% (95% CI 57% to 62%) of HF patients with severe AS underwent AVR within 2 years.

Conclusions: AS is common in HF and is associated with substantially worse long-term outcomes across all HF subtypes, even at non-severe stages. The high mortality risk and frequent lack of intervention highlight major treatment gaps and underscore the need for prospective trials evaluating earlier intervention strategies.