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Background: There are limited data on acute pericarditis according to different age groups. The aim of this study is to investigate the role of age-related features in clinical characteristics, management, and outcomes of acute pericarditis, with a focus on the geriatric population.

Methods: Patients with a first episode of acute pericarditis were consecutively enrolled between January 2014 and June 2022, and divided into four groups according to age (G1: 18-35 years; G2: 35-55 years; G3: 55-75 years; G4: >75 years). Clinical characteristics and medical therapy were recorded at baseline, and during follow-up.

Results: A total of 471 patients (median age 56.3 (IQR 33-73) years, 32.3% women) were included. Younger age (G1-G2-G3) was associated with a higher frequency of chest pain, pericardial rubs (p<0001), ECG changes (p=0.002) and were more commonly treated with colchicine (p<0.001), and non-steroidal anti-inflammatory drugs (p=0.006). Older patients (G4) depicted more commonly dyspnoea, pericardial/pleural effusion (p=0.007) and were more often treated with corticosteroids (p=0.037). A secondary cause of pericarditis was detected in 128/471 (27.2%) patients. Older patients were more commonly hospitalised and had a complicated course with new-onset atrial fibrillation (p<0.001) and cardiac tamponade (p=0.005), compared with younger patients, who presented more recurrences (respectively G1: 43.0%, G2: 34.7%, G3: 28.2% and G4: 16.2%; p<0.001). After multivariable analysis, younger age remained the strongest independent predictor for recurrences (HR 3.23, 95% CI 1.81 to 5.58, p<0.001).

Conclusion: Older age is associated with less recurrences of pericarditis, but more severe complications with need for hospitalisation.

Background: Cardiac magnetic resonance (CMR) allows comprehensive myocardial tissue characterisation, revealing areas of myocardial inflammation or fibrosis that may predispose to ventricular arrhythmias (VAs). With this study, we aimed to estimate the prevalence of structural heart disease (SHD) and decipher the prognostic implications of CMR in selected patients presenting with significant VAs.

Methods: Electronic databases were searched for studies enrolling adult patients that underwent CMR for diagnostic or prognostic purposes in the setting of significant VAs. A random effects model meta-analysis of proportions was performed to estimate the prevalence of SHD. HRs were pooled together in order to evaluate the prognostic value of CMR.

Results: The prevalence of SHD was reported in 18 studies. In all-comers with significant VAs, the pooled rate of SHD post-CMR evaluation was 39% (24% in the subgroup of premature ventricular contractions and/or non-sustained ventricular tachycardia vs 63% in the subgroup of more complex VAs). A change in diagnosis after use of CMR ranged from 21% to 66% with a pooled average of 35% (29%-41%). A non-ischaemic cardiomyopathy was the most frequently identified SHD (56%), followed by ischaemic heart disease (21%) and hypertrophic cardiomyopathy (5%). After pooling together data from six studies, we found that the presence of late gadolinium enhancement was associated with increased risk of major adverse outcomes in patients with significant VAs (pooled HR: 1.79; 95% CI 1.33 to 2.42).

Conclusion: CMR is a valuable tool in the diagnostic and prognostic evaluation of patients with VAs. CMR should be considered early after initial evaluation in the diagnostic algorithm for VAs of unclear aetiology as this strategy may also define prognosis and improve risk stratification.

Background: Decreased diffusing capacity of the lungs for carbon monoxide (DLco) is associated with microvascular damage in chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) is an effective treatment for CTEPH, but the efficacy of BPA in patients with CTEPH with low DLco remains unclear because BPA does not directly address microvascular damage. This study investigates the influence of microvasculopathy on BPA in CTEPH according to DLco.

Methods: We retrospectively analysed data from patients with inoperable CTEPH who underwent BPA at the University of Tokyo Hospital from July 2011 to August 2023. The patients were classified into two groups based on their preprocedural DLco (normal DLco (ND) and low DLco (LD) groups), with a DLco cut-off value of 80%. We compared the patient characteristics and effectiveness of BPA between the groups.

Results: Among the 75 patients, 36 were in the LD group. The LD group had a shorter 6-minute walking distance (324±91 vs 427±114 m) than the ND group but the mean pulmonary artery pressure (mPAP) was similar (38.9±7.3 vs 41.1±9.2 mm Hg) before BPA. BPA improved the haemodynamic status and exercise tolerance in both groups. The LD group exhibited a higher mPAP (25.1±7.4 vs 21.5±5.6 mm Hg) and required more sessions of BPA (median 6 vs 4). Based on the analysis of covariance adjusted for baseline values, low DLco significantly correlated with mPAP (sβ=-0.304, 95% CI -7.015 to -1.132, p=0.007) and pulmonary vascular resistance (sβ=-0.324, 95% CI -141.0 to -29.81, p=0.003).

Conclusions: BPA was associated with an improvement in the haemodynamic status and exercise tolerance in patients with CTEPH even with low DLco. However, low DLco may attenuate the effect of BPA on mPAP and pulmonary vascular resistance and require more treatment sessions.

Background: Long-term outcome of contemporary stress echocardiography has not been systematically assessed.

Objective: To evaluate the association between results of stress echocardiography and patients' outcomes with suspected coronary artery disease using randomised controlled trials.

Methods: Multiple electronic databases were searched for studies evaluating long-term outcome (>12 months) of stress echocardiography in patients suspected of coronary artery disease since year 2000. A common-effect model was used to derive pooled estimates. The primary outcome was a composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction, depending on the definition applied in individual trials, termed as major adverse cardiovascular event (MACE). Secondary outcome was all-cause mortality. Positive stress echocardiography result was defined as inducible ischaemia in at least one of the 17 left ventricular segments and negative stress echocardiography with no inducible ischaemia.

Results: Among a total of six trials, 16 581 subjects underwent either pharmacological or treadmill stress echocardiography, a median follow-up of 31 months (range 21-101). The annual event rate was 1.76% for the composite MACE and 1.35% for all-cause mortality. Compared with negative stress echocardiography, positive stress echocardiography was associated with an increased risk of the MACE and all-cause mortality with an annual event rate of 1.99% vs 1.54% (OR 2.04, 95% CI 1.79 to 2.33) and 1.68% vs 1.02% (OR 2.06, 95% CI 1.80 to 2.35), respectively.

Conclusion: Positive stress echocardiography results were associated with poorer long-term MACE and all-cause mortality. Stress echocardiography results may provide a useful long-term guidance in intensifying preventative treatment in patients with suspected coronary artery disease.

Prospero registration number: CRD42023416766.

Background: The diagnostic performance of non-invasive imaging techniques for detecting obstructive coronary artery disease (CAD) in patients with a history of myocardial infarction or percutaneous coronary intervention has not been comprehensively evaluated. This meta-analysis assesses the diagnostic value of coronary CT angiography (CCTA), CCTA combined with CT perfusion (CCTA+CTP), cardiac MRI (CMR) and single-photon emission CT (SPECT) compared with invasive reference standards.

Methods: We systematically searched PubMed, Embase, Web of Science and the Cochrane Library from 2005 to September 2022 for prospective, blinded studies including populations with ≥50% prior CAD.

Results: We identified 18 studies encompassing 3265 patients, with obstructive CAD present in 64%. The per-patient sensitivity of CCTA (0.95; 95% CI 0.92 to 0.98), CCTA+CTP (0.93; 95% CI 0.84 to 0.98) and CMR (0.91; 95% CI 0.86 to 0.94) was high, while SPECT showed lower sensitivity (0.63; 95% CI 0.52 to 0.73). SPECT had higher specificity compared with CCTA (0.66; 95% CI 0.56 to 0.76 vs 0.37; 95% CI 0.29 to 0.46), but was comparable to CCTA+CTP (0.59; 95% CI 0.49 to 0.69) and CMR (0.69; 95% CI 0.53 to 0.81). The area under the curve for SPECT was the lowest (0.70; 95% CI 0.58 to 0.87), while CCTA (0.91; 95% CI 0.86 to 0.98), CCTA+CTP (0.89; 95% CI 0.73 to 1.00) and CMR (0.91; 95% CI 0.80 to 1.00) showed similar high values.

Conclusions: In patients with prior CAD, CCTA, CCTA+CTP and CMR demonstrated high diagnostic performance, whereas SPECT had lower sensitivity. These findings can guide the selection of non-invasive imaging techniques in this high-risk population.

Prospero registration number: CRD42022322348.

Background: Preventing high heart rates in patients with atrial fibrillation (AF) is a key objective of AF management. Data regarding heart rates in patients with paroxysmal AF (PAF) is lacking. This analysis aimed to provide insight into heart rates during PAF episodes measured with continuous implantable loop monitoring.

Methods: In present analysis of the Interaction between hyperCoagulability, Electrical remodeling, and Vascular Destabilization in the Progression of AF study, we included 349 patients with at least one year of continuous rhythm monitoring and an episode of AF. Mean heart rates and duration of AF episodes were used to calculate total AF duration and AF duration above different heart rate cut-offs.

Results: The median age was 64.0 (58.4 to 70.5) years, 152 (44%) were women and CHA₂DS₂-VASc score ≥2 or higher in 255 (73%) patients. During 28.3 (21.3 to 35.0) months of follow-up, the median number of AF episodes was 62 (12 to 293) with a median total AF duration of 4.6 (0.8 to 26.8) days. At baseline, 172 (49%) patients used beta-blockers, 64 (18%) used diltiazem or verapamil and 5 (1%) used digoxin. A total of 133 patients (38%) experienced a heart rate >110 bpm for more than 50% of the time during AF. Fifty-six (16%) patients had a heart rate >130 bpm for more than 50% of the time while in AF. During follow-up, 39 patients (11%) received an increase of rate-controlling medication.

Conclusion: Continuous rhythm monitoring revealed that more than a third of PAF patients had heart rates above 110 bpm for more than half of their time in AF.

Trial registration number: Clinicaltrials.gov identifier NCT02726698.

Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.

Background: The World Health Organization (WHO) promotes the HEARTS technical package for improving hypertension control worldwide, but its effectiveness has not been rigorously evaluated.

Objective: To compare hypertension outcomes in clinics implementing HEARTS versus clinics continuing usual hypertension care in rural Bangladesh.

Methods: A matched-pair cluster quasi-experimental trial in Upazila Health Complexes (UHCs; primary healthcare facilities) was conducted in rural Bangladesh. A total of 3935 patients (mean age 52.3 years, 70.5% female) with uncontrolled hypertension (blood pressure (BP) ≥140/90 mm Hg regardless of treatment history) were enrolled: 1950 patients from 7 HEARTS UHCs and 1985 patients from 7 matched usual care UHCs. The primary outcome was systolic BP at 6 months measured at the patient's home; secondary outcomes were diastolic BP, hypertension control rate (<140/90 mm Hg) and loss to follow-up. Multivariable mixed-effects linear and Poisson models were conducted.

Results: Baseline mean systolic BP was 158.4 mm Hg in the intervention group and 158.8 mm Hg in the usual care group. At 6 months, 95.5% of participants completed follow-up. Compared with usual care, the intervention significantly lowered systolic BP (-23.7 mm Hg vs -20.0 mm Hg; net difference -3.7 mm Hg (95% CI -5.1 to -2.2)) and diastolic BP (-10.2 mm Hg vs -8.3 mm Hg; net difference -1.9 mm Hg (95% CI -2.7 to -1.1)) and improved hypertension control (62.0% vs 49.7%, net difference 12.3% (95% CI 9.0 to 16.8)). Rate of missed clinic visits was lower in the intervention group (8.8% vs 39.3%, p<0.001).

Conclusions: After WHO-HEARTS package implementation in rural Bangladesh, BP was lowered and hypertension control improved significantly compared with usual care.

Trial registration number: NCT04992039.