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Background: Cardiac magnetic resonance (CMR) may radiologically identify or confirm underlying pathophysiologies in myocardial infarction with non-obstructive coronary arteries (MINOCA), however, there are scant prospective data evaluating the impact on routine clinical care.

Methods: In a multicentre international cohort study of MINOCA, clinical diagnosis, diagnostic certainty and intended clinical management were prospectively determined before and again after CMR. The primary outcome was a composite of change in clinical diagnosis and/or management. Secondary outcomes were individual components of the primary outcome, change in diagnostic certainty and number-needed-to-test for deprescription of dual antiplatelet therapy (DAPT). Predictors of the primary outcome were evaluated by multivariable logistic regression analysis.

Results: In 320 patients, CMR was associated with change in diagnosis and/or management in 63% (95% CI 57% to 68%, p<0.001) and significantly increased diagnostic certainty (8/10 post-CMR (5-9) vs 6/10 pre-CMR (4-7), p<0.0001). Relevant predictors of the primary outcome on multivariable analysis were early CMR (≤14 days), absence of atheroma on coronary angiography and significant pre-CMR diagnostic uncertainty (≤5/10); CMR changed diagnosis and/or management in 80% of individuals with all three predictors versus 40% in those with none. In individuals where treating physicians initially chose to prescribe DAPT despite no obstructive culprit lesion, number-needed-to-test by CMR for DAPT deprescription was 3.

Conclusions: CMR in MINOCA is associated with significant changes in clinical diagnosis, diagnostic certainty and management. The impact on deprescription of unnecessary DAPT could have important implications for patient safety and costs and warrants further evaluation. Early CMR should be considered to augment diagnosis and management in MINOCA.

Trial registration number: ISRCTN75233845.

Background: Elevation in serum troponin following elective percutaneous coronary intervention (PCI) is indicative of post-PCI troponin increase (pTI) and is associated with higher mortality rates. In this analysis, we sought to identify clinical and angiographic risk factors for pTI.

Methods: Consecutive patients undergoing elective PCI with drug-eluting stent implantation at Mount Sinai Hospital, New York, USA, between 2012 and 2022 were retrospectively analysed. Patients with elevated baseline troponin (>1× upper reference limit (URL)) and missing baseline or post-PCI troponin values were excluded. pTI was defined according to the cut-offs established by the Fourth Universal Definition of Myocardial Infarction (UDMI, ≥5× URL) and the Academic Research Consortium 2 (ARC-2) definition (≥35× URL). Predictors of pTI were evaluated through multivariable logistic regression with stepwise selection of candidate covariates.

Results: Of the 10 592 included patients, 16.3% had pTI by UDMI criteria and 4.4% by ARC-2 criteria. Predictors of pTI for both definitions included low-density lipoprotein cholesterol, lesion length and maximum stent diameter, while higher left ventricular ejection fraction, prior PCI and intravascular imaging use had a protective effect. Female sex, anaemia and P2Y12 inhibitor loading (as opposed to chronic therapy) predicted UDMI-defined pTI but not ARC-2-defined pTI, whereas chronic kidney disease predicted only ARC-2-defined pTI.

Conclusions: In conclusion, there are patient-specific angiographic and clinical risk factors that can predict pTI. These risk factors should be considered in formulating more individualised risk assessment for those undergoing elective PCI.

Background: The cross-sectional association between cerebral tissue oxygen saturation (SctO₂) and heart failure (HF) has been previously studied, but the prognostic significance of SctO₂ in HF remains uncertain. This study aimed to assess the role of SctO₂ as a risk factor for all-cause mortality and rehospitalisation, as well as to explore the cross-sectional association between physical activity and SctO₂ in a Swedish HF cohort.

Methods: In 102 patients with HF (mean age 70.2 years (±12.4); 21.6% women), near-infrared spectroscopy was used to assess SctO₂. Adjusted Cox regression analyses were conducted to examine the associations between resting SctO₂ levels and all-cause mortality and the initial occurrence of postdischarge rehospitalisations. The associations between self-reported physical inactivity and SctO₂ were explored by using multivariable linear and logistic regression analyses.

Results: The median follow-up time to death of any cause and first-of-any rehospitalisation was 830 (IQR: 519-1283) and 208 (72-584) days, respectively. During follow-up, 31 (30.4%) patients died and 63 (61.8%) were rehospitalised. Higher SctO₂ was associated with lower risk of mortality (HR 0.86; 95% CI 0.77 to 0.95; p=0.002) but not with rehospitalisation risk (HR 0.96; 95% CI 0.90 to 1.02; p=0.162). Physical inactivity (≤1 hour per week of strenuous activity) was associated with lower SctO₂ (β-1.56; 95% CI -3.07 to -0.05, p=0.043).

Conclusion: Higher SctO2 at rest is associated with lower risk of all-cause mortality but it was not possible to show significant association with first-of-any rehospitalisation risk in patients with HF. Physical inactivity is associated with lower cerebral oxygen saturation at rest. These findings could suggest SctO2 as a potential marker associated with long-term outcomes in HF, warranting larger confirmatory studies.

Background: Elevated high-sensitivity cardiac troponin (hs-cTn) levels are linked with cardiovascular disease and cognitive impairment, both of which are strong risk factors for late-life dementia (LLD). This study examined the association between hs-cTnI levels below the sex-specific 99th percentile for myocardial injury and the incidence of LLD in older women.

Methods: 986 community-dwelling women aged ≥70 years without prior LLD and with hs-cTnI <15.6 ng/L (stratified into quartiles) were included from the Perth Longitudinal Study of Ageing Women. The primary outcome was incident LLD events, including LLD hospitalisation or death, over 14.5 years obtained from linked health records. Associations between hs-cTnI and LLD outcomes were explored using multivariable-adjusted Cox models, as part of restricted cubic splines.

Results: At baseline, participants' mean (±SD) age was 75.2±2.7 years. Over 14.5 years of follow-up, LLD events (n=174, 17.7%), hospitalisations (n=155, 15.7%) and deaths (n=68, 6.9%) were recorded. Compared with those in the lowest quartile (Q1, median 3.1 ng/L), women in the highest quartile of hs-cTnI (Q4, median 7.3 ng/L) had a greater risk of developing LLD-related events (adjusted HR: 1.88, 95% CI: 1.22 to 2.91), hospitalisation (adjusted HR: 1.65, 95% CI: 1.04 to 2.64) and death (adjusted HR: 2.27, 95% CI: 1.13 to 4.59), after adjusting for established cardiovascular and dementia risk factors, including apolipoprotein E (APOE) genotype.

Conclusion: Among older women, hs-cTnI levels below the sex-specific 99th percentile for myocardial injury were associated with an increased risk of LLD events over 14.5 years. These findings suggest that hs-cTnI may identify older women at higher risk of LLD, capturing both cardiovascular and brain health vulnerability in older age.

Trial registration number: ACTRN12617000640303.

The use of left-sided Impella microaxial flow pumps has expanded rapidly for the management of cardiogenic shock, left ventricular unloading and as a bridge to heart transplantation. However, standard life support and resuscitation algorithms are not directly applicable to patients receiving this therapy due to fundamental alterations in circulatory physiology. To address this gap, eleven UK Impella centres and eight national professional societies collaborated to develop a unified national consensus statement on the emergency management of patients with left-sided Impella support. Using a systematic review of the literature and a modified Delphi process guided by the European Society of Cardiology framework for grading recommendations, expert representatives achieved agreement on key priorities and structured actions to be undertaken in the first few minutes of resuscitation.The consensus outlines early recognition of circulatory inadequacy (mean arterial pressure <30 mm Hg or end-tidal CO₂ <2 kPa), prompt activation of multidisciplinary responders, reduction of Impella power to P2 before initiating cardiopulmonary resuscitation and structured division of patient-focused and device-focused teams. Device-specific troubleshooting algorithms are presented for suction, malposition, purge-system failure and mechanical malfunction. This multisociety consensus represents the first national standard for emergency management and resuscitation of patients supported by a left-sided Impella device and is intended to inform structured clinical training and improve patient outcomes through rapid, coordinated and physiologically tailored interventions.

Background: In 2024, the UK National Institute of Health and Care Excellence (NICE) recommended TriageHF alerts as an option for remote monitoring of patients with heart failure (HF) and a compatible cardiac implantable electronic device (CIED). Data on the cost-effectiveness of this approach has not been published. This research evaluates the cost-effectiveness of TriageHF Plus in public hospital settings, using data from the TriageHF Plus multicentre study (758 participants, NCT04177199).

Methods: An economic model was developed to capture the lifetime cost and benefits of TriageHF Plus versus usual care, based on a site of 300 eligible patients. Analysis on individual patient-level data informed model efficacy and resource use parameters. EuroQol five-dimensional questionnaire data and unit costs were obtained from published, peer-reviewed literature and national databases respectively. Costs and benefits were discounted at 3.5% per annum to adjust future costs and benefits to present value.

Results: In a site size of 300, TriageHF Plus was predicted to prevent 384 (363-405) hospitalisations over 5 years. In total, TriageHF Plus saved £3989 (£1812-£5563) per person-lifetime versus usual care and was more effective and cost-saving in 99.4% of simulations. Results were robust to changes in key input parameters. Modelling showed that to avoid one hospitalisation, 1.7 people would need lifetime access to TriageHF Plus.

Conclusion: The TriageHF Plus pathway is cost-effective for the remote monitoring of HF in patients with CIEDs.

Trial registration number: NCT04177199.

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.