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Cardiology training in the UK is facing significant challenges due to a range of factors. Recent curriculum changes have further compounded this issue and significantly risk the ability to produce adequately trained consultants capable of managing patients with increasingly complex cardiovascular disease. The introduction of mandatory dual accreditation in general internal medicine (GIM) alongside cardiology, by design, results in significantly reduced training opportunities, including procedural and subspecialty exposure. Despite prolongation in training duration to mitigate these effects, most trainees now report needing post-certificate of completion of training fellowships to gain the standard competencies required for consultant roles, undermining the curriculum's aim of fostering independent practice. Furthermore, the current training model is misaligned with patient needs, lacking provisions for training in key and expanding services, such as complex structural interventions and inherited cardiac conditions. The increasing complexity of expectations placed on trainees also has the potential to significantly hinder academic training, discouraging research and innovation, thereby risking the future of UK clinical academia. Urgent curriculum reform is not only desirable but also essential and should include limiting GIM training time, improving subspecialty accreditation pathways and revising academic training provisions. If current bodies overseeing cardiology training fail to implement these essential changes, additional options, including an independent regulatory framework for cardiology training, should be considered. Without immediate action, UK cardiology training risks facing a generational crisis of inadequately skilled consultants, which could compromise future patient care.

A significant proportion of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) have concomitant coronary artery disease (CAD). The best way to treat these patients is contentious. Conventional assessments of ischaemia such as fractional flow reserve (FFR) and instantaneous wave-free ratio are not validated in the context of severe AS despite having a Class I European Society of Cardiology indication in patients with isolated coronary disease. A better understanding of how we assess and interpret coronary physiology in these patients is required to optimise treatment pathways. Only one prospective, randomised trial has investigated the routine use of FFR to guide revascularisation in patients undergoing TAVI and several observational cohort studies have measured changes in hyperaemic and resting indices in patients with severe AS as well as before and after TAVI. The purpose of this review article is to provide a summary of the current data regarding the functional assessment of CAD in patients with severe AS and highlight the current best practice in this evolving area.

Background: Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults, often leading to complications such as thoracic aortic aneurysms and aortic stenosis. While BAV is frequently associated with 22q11.2 deletion syndrome (22q11.2DS), the contribution of rare copy number variants (CNVs) in this region to non-syndromic BAV is less clear. This study is aimed to assess the role of rare 22q11.2 CNVs in patients with early-onset BAV (EBAV) and to determine whether these variants are linked to an increased risk of complications.

Methods: Whole genome microarray genotyping was conducted on 272 patients with BAV with early onset valve or aortic disease (EBAV) and 272 biological relatives. CNVs were detected using three independent algorithms, focusing on the 22q11.2 region (18-24 Mb). CNV burden in the EBAV cohort was compared with unselected European ancestry controls.

Results: Rare duplications and deletions within the 22q11.2 region, particularly involving genes associated with cardiac development, were identified in 7.4% of EBAV probands. These CNVs were significantly enriched compared with the general population and segregated with BAV in families. Individuals carrying rare 22q11.2 CNVs had a higher prevalence of psychiatric diagnoses and learning difficulties, although they did not exhibit the typical features of 22q11.2DS. Importantly, these CNVs were associated with early onset or complex BAV cases, underscoring their potential clinical relevance.

Conclusions: Rare 22q11.2 CNVs play a role in non-syndromic BAV, particularly in cases with early onset or complex presentations. CNV screening could be considered as part of risk stratification for patients with BAV, helping to predict complications and guide management.

Trial registration number: NCT01823432.

Background: Cardiovascular disease (CVD) remains a significant public health challenge in China. This study aimed to project the burden of CVD from 2020 to 2030 using a nationwide cohort and to simulate the potential impact of various control measures on morbidity and mortality.

Methods: An agent-based model was employed to simulate annual CVD incidence and mortality from 2021 to 2030. The effects of different prevention and treatment interventions, modelled on international strategies, were also explored.

Results: The study included 106 259 participants. The annual CVD incidence rate is projected to increase from 0.74% in 2021 to 0.97% by 2030, with age-standardised and sex-standardised rates rising from 0.71% to 0.96%. CVD mortality is expected to rise from 0.39% in 2021 to 0.46% in 2024, after which it will stabilise at 0.44% by 2030. Community-based interventions and improved access to inpatient care are predicted to reduce the projected burden of CVD significantly.

Conclusions: The incidence of CVD in China is projected to increase steadily over the next decade, while mortality will plateau after 2024. Comprehensive interventions, including community-based screenings and enhanced healthcare access, could significantly mitigate the CVD burden.

Trial registration number: NCT02536456.

Background: Health inequalities in cardiovascular care have been identified in the UK. The sociodemographic characteristics of patients undergoing intervention for aortic stenosis (AS) in England, and the impact of COVID-19, is unknown.

Methods: National linked data sets identified all surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) for AS, and post-intervention cardiovascular mortality, between 2000 and 2023.

Results: Of 179 645 procedures, there were 139 990 SAVR (mean age 71±10.8 years, 64% male, 96.0% white) and 39 655 TAVI (mean age 81±7.7 years, 57% male, 95.7% white). Rates of SAVR declined during COVID-19 for all groups, but TAVI rates increased steadily. Women were older; ethnic minority groups and those from most deprived areas were younger, with greater comorbidities. Women and more deprived groups had lower rates of SAVR (age-standardised rates per 100 000 in 2020-2023: 17.07 vs 6.65 for men vs women; 9.82 vs 10.10 for Index of Multiple Deprivation (IMD)-1 vs IMD-5) and TAVI (20.20 vs 9.79 for men vs women; 9.55 vs 13.36 for IMD-1 vs IMD-5). These discrepancies widened over time. Ethnic differences were observed for SAVR, with the lowest rates in black patients. Cardiovascular mortality post-intervention was lower in female patients and with decreasing deprivation, with no ethnicity-based differences.

Conclusions: There are differences in intervention rates for AS in England, with lower rates in female patients and to a lesser extent, those from the most deprived areas and ethnic minority groups. These variations have widened over time. Post-intervention cardiovascular mortality is lower in women and with decreasing deprivation. Public health measures and research are needed to identify the true prevalence of AS in different populations, and the reasons for potential inequalities.

Background: Participation in regular exercise activities is recommended for patients with chronic heart failure. However, less is known about the effect of exercise in patients with genetic dilated cardiomyopathy (DCM). We sought to examine the effect of vigorousintensity training on physical capacity in patients with DCM caused by truncating titin variants (TTNtv).

Trial design: Non-randomised clinical pre-post trial of exercise training.

Methods: Individuals with DCM-TTNtv were included from outpatient clinics for inherited cardiac diseases. The trial consisted of 8 weeks of usual care followed by 8 weeks of regular vigorous-intensity cycling exercise, enclosed by three test days. The primary outcome was change in peak oxygen uptake (VO₂). Secondary outcomes included change in blood volume, total haemoglobin mass, measures of systolic function and cardiac output/stroke volume during exercise.

Results: Thirteen out of 14 included participants (43% women, age 48±11 years, body mass index: 30±6 kg/m²) completed the trial. In the exercise training period, peak VO₂ increased by +1.9 mL/kg^/min (95% CI +0.9 to +2.9, p=0.002). Compared with usual care, exercise training improved peak VO₂ by +2.9 mL/kg/min (95% CI +1.2 to +4.5, p=0.002), corresponding to a 10% increase. Adaptations to exercise training included an increase in resting cardiac output (+0.8 L/min, p=0.042), total blood volume (+713 mL, p<0.001), total haemoglobin mass (+73 g, p<0.001), and improved left ventricular (LV) systolic function (LV ejection fraction: +3.2% (p=0.053) and global longitudinal strain: -2.0% (p=0.044)). No exercise-related adverse events or change in plasma biomarkers of cardiac or skeletal muscle damage were observed.

Conclusions: Our study shows that vigorous intensity exercise training improved peak VO₂ in patients with DCM-TTNtv. Exercise training was associated with improved LV systolic function and increased blood volume and oxygen carrying capacity. Future research should investigate the effect of long-term exercise in this group.

Trial registration number: NCT05180188.

Background: Limited empirical evidence informs driving restrictions after implantable cardioverter-defibrillator (ICD) implantation. We sought to evaluate real-world motor vehicle crash risks after ICD implantation.

Methods: We performed a retrospective cohort study using 22 years of population-based health and driving data from British Columbia, Canada (2019 population: 5 million). Individuals with a first ICD implantation between 1997 and 2019 were age and sex matched to three controls. The primary outcome was involvement as a driver in a crash that was attended by police or that resulted in an insurance claim. We used survival analysis to compare crash risk in the first 6 months after ICD implantation to crash risk during a corresponding 6-month interval among controls.

Results: A crash occurred prior to a censoring event for 296 of 9373 individuals with ICDs and for 1077 of 28 119 controls, suggesting ICD implantation was associated with a reduced risk of subsequent crash (crude incidence rate, 8.5 vs 10.5 crashes per 100 person-years; adjusted HR (aHR), 0.71; 95% CI 0.61 to 0.83; p<0.001). Results were similar after stratification by primary versus secondary prevention ICD. Relative to controls, ICD patients had more traffic contraventions in the 3 years prior to ICD implantation but fewer contraventions in the 6 months after implantation, suggesting individuals reduced their road exposure (hours or miles driven per week) or drove more conservatively after ICD implantation.

Conclusions: Crash risk is lower in the 6 months after ICD implantation than among matched controls, likely because individuals reduced their road exposure in order to comply with contemporary postimplantation driving restrictions. Policymakers might consider liberalisation of postimplantation driving restrictions while monitoring crash rates.

Background: Rapid Access Chest Pain Clinics (RACPC) are widely used for the outpatient assessment of chest pain, but there appears to be limited high-quality evidence justifying this model of care. This study aimed to review the literature to determine the effectiveness of RACPCs.

Methods: A systematic review of studies evaluating the effectiveness of RACPCs was conducted to assess the quality of the evidence supporting this model. Outcomes related to effectiveness included major adverse cardiovascular events, emergency department reattendance, cost-effectiveness and patient satisfaction. Study quality was assessed using the RoB 2 tool, Newcastle-Ottawa quality assessment tool or the Consolidated Criteria for Reporting Qualitative Studies checklist, as appropriate.

Results: Thirty-two studies were eligible for inclusion, including one randomised trial. Five analytical cohort studies were included, with three comparing outcomes against non-RACPC controls. Three qualitative studies were included. Most reports were descriptive. Findings were consistent with RACPCs being associated with favourable clinical outcomes, reduced emergency department reattendance, cost-effectiveness and high patient satisfaction. However, there was significant heterogeneity in care models, and overall literature quality was low, with a high risk of publication bias.

Conclusion: While the literature suggests RACPCs are safe and efficient, the quality of the available evidence is limited. Further high-quality data from adequately controlled clinical trials or large scare registries are needed to inform healthcare resource allocation decisions.

Prospero registration number: CRD42023417110.