JAMA cardiology最新文献

Importance: Efficient approaches to prevent postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) are still needed.

Objective: To investigate whether partial cardiac denervation, achieved by cutting off the ligament of Marshall (LOM) and resecting the fat pad along the Waterston groove, can reduce the risk of POAF following CABG.

Design, setting and participants: This single-center, randomized clinical trial enrolled adult patients scheduled for isolated CABG in China. Enrollment was from August 15, 2022, to December 13, 2023; follow-up visits were 30 days after discharge.

Interventions: Participants were randomized into the intervention group (CABG plus partial cardiac denervation) and the control group (CABG only) in a 1:1 pattern. All participants were continuously monitored for the incidence of POAF until day 6 after the operation.

Main outcome and measures: The primary end point was the incidence of POAF in 6 days, defined as a supraventricular arrhythmia lasting for more than 30 seconds.

Results: The trial enrolled 430 patients (79 [18.4%] female; mean [SD] age, 61.9 [7.8] years). Compared with the control group, the 6-day incidence of POAF was significantly lower in the intervention group (18.1% vs 31.6%; P = .001; risk ratio, 0.57 [95% CI, 0.41-0.81]). To further support these results, a sensitivity analysis performed with Kaplan-Meier survival curves also showed a significant reduction in the occurrence of POAF in the intervention group (hazard ratio, 0.53 [95% CI, 0.36-0.79]; P = .002). Safety assessments showed no difference between the 2 groups, while postoperative medical cost was reduced in the intervention group.

Conclusions and relevance: This randomized clinical trial found that partial cardiac denervation was an effective procedure to reduce the occurrence of POAF after isolated CABG without additional postoperative complications. These results suggest that partial cardiac denervation may be a good option for cardiac surgeons to consider for preventing POAF after CABG.

Trial registration: ClinicalTrials.gov Identifier: NCT05009914.

Importance: Treatment with finerenone, a nonsteroidal mineralocorticoid receptor antagonist (MRA), improved outcomes in patients with heart failure with mildly reduced or preserved ejection fraction in FINEARTS-HF, but was associated with increased levels of serum potassium in follow-up.

Objective: To investigate the frequency and predictors of serum potassium level greater than 5.5 mmol/L and less than 3.5 mmol/L and examine the treatment effect associated with finerenone, relative to placebo, on clinical outcomes based on postrandomization potassium levels.

Design, setting, and participants: Secondary analysis of the FINEARTS-HF multicenter, randomized clinical trial, performed between September 14, 2020, and January 10, 2023, with a median follow-up of 32 months (final date of follow-up: June 14, 2024). Patients with heart failure and left ventricular ejection fraction greater than or equal to 40%, New York Heart Association class II to IV symptoms, and elevated natriuretic peptides were included.

Intervention: Participants received finerenone or placebo.

Main outcomes and measures: The primary outcome was a composite of total worsening heart failure events or cardiovascular death.

Results: A total of 6001 participants were included (3003 randomized to receive finerenone and 2998 randomized to receive placebo). The increase in serum potassium was greater in the finerenone group than the placebo group at 1 month (median [IQR] difference, 0.19 [0.17-0.21] mmol/L) and 3 months (median [IQR] difference, 0.23 [0.21-0.25] mmol/L), which persisted for the remainder of trial follow-up. Finerenone increased the risks of potassium level increasing to greater than 5.5 mmol/L (hazard ratio [HR], 2.16 [95% CI, 1.83-2.56]; P < .001) and decreased the risks for potassium level decreasing to less than 3.5 mmol/L (HR, 0.46 [95% CI, 0.38-0.56]; P < .001). Both low (< 3.5 mmol/L; HR, 2.49 [95% CI, 1.8-3.43]) and high (>5.5 mmol/L; HR, 1.64 [95% CI, 1.04-2.58]) potassium levels were associated with higher subsequent risks of the primary outcome in both treatment groups. Nevertheless, the risk of the primary outcome was generally lower in patients treated with finerenone compared with placebo, even in those whose potassium level increased to greater than 5.5 mmol/L.

Conclusions and relevance: In patients with heart failure with mildly reduced or preserved ejection fraction, finerenone resulted in more frequent hyperkalemia and less frequent hypokalemia. However, with protocol-directed surveillance and dose adjustment, clinical benefit associated with finerenone relative to placebo was maintained even in those whose potassium level increased to greater than 5.5 mmol/L.

Trial registration: ClinicalTrials.gov Identifier: NCT04435626.

Importance: Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are the first therapy shown to improve clinical outcomes for patients with heart failure (HF) and a left ventricular ejection fraction (LVEF) greater than 40%. Nationwide adoption of SGLT2is in the US since publication of the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved) in August 2021 is unknown.

Objective: To examine trends and hospital-level variation in SGLT2i adoption.

Design, setting, and participants: This cohort study included patients with LVEF greater than 40% who were hospitalized for decompensated HF at 1 of 557 sites in the US between July 1, 2021, and September 30, 2023, from the Get With The Guidelines-Heart Failure registry.

Main outcomes and measures: Patient-level trends and site-level variation in prescription rates of SGLT2i at hospital discharge. Site-level variation was quantified using the median odds ratio, which describes the average odds that a patient being treated at one vs another randomly selected hospital would receive SGLT2i therapy at discharge.

Results: Of 158 849 patients (median [IQR] age, 76 [66-85] years; 89 816 females [56.5%]), 22 126 eligible patients (13.9%) with HF and an LVEF greater than 40% were prescribed an SGLT2i at hospital discharge. Quarterly prescription rates increased from 4.2% in July to September 2021 to 23.5% in July to September 2023 (P for trend < .001). SGLT2i prescription was more likely among patients with HF with mildly reduced LVEF (41%-49%) than in those with preserved LVEF (≥50%; 5127 of 27 712 patients [18.5%] vs 16 999 of 131 137 patients [13.0%]; absolute standardized difference, 16.7%). After adjustment for patient characteristics, there was a high variance between hospitals in the rate of SGLT2i prescription (median odds ratio, 2.12; 95% CI, 2.02-2.25). Among 518 hospitals with 10 or more eligible discharges, 11 hospitals (2.1%) discharged 50% or more of their patients with an SGLT2i prescription, while 232 (44.8%) discharged fewer than 10% of eligible patients with an SGLT2i prescription.

Conclusion and relevance: For patients with HF and an LVEF greater than 40%, discharge prescription of SGLT2is increased from 4.2% to 23.5% during the first 2 years after the EMPEROR-Preserved trial demonstrating treatment benefits; however, these rates varied across US hospitals.

Importance: Women are underrepresented in leadership positions in cardiology. Institutional grand rounds (GR) are platforms through which faculty can gain professional exposure and access to career development opportunities. The gender diversity of invited cardiology GR speakers has not been investigated.

Objective: To examine the representation of women among cardiology GR speakers in the United States.

Design, setting, and participants: This cross-sectional study reviewed all 626 internal medicine residency training program websites in the American Medical Association's FRIEDA directory to identify publicly available records of cardiology GR. Grand rounds from September 1997 through December 2022 were included; GR with more than 1 speaker and trainee-led case conferences were excluded.

Exposures: Grand rounds speaker gender.

Main outcomes and measures: Data on GR topic focus, speaker gender, and academic rank were collected.

Results: A total of 3806 GR lectures at 42 institutions were included; 799 (21%) were delivered by women and 3007 (79%) by men. The proportion of women GR speakers increased by 1% per year and increased for each topic over time with the exception of electrophysiology and basic/translational science. Women were most likely to speak on women's cardiovascular health (80 lectures [10.0%] vs 17 [0.6%] for men; P < .001).

Conclusions and relevance: Women compose about 1 in 5 cardiology GR speakers with modest growth in representation over time but remain underrepresented as GR speakers for procedural cardiology and basic/translational science topics.

Importance: Drug-coated balloon (DCB) angioplasty has emerged as an alternative to drug-eluting stent (DES) implantation for percutaneous coronary intervention (PCI) in patients with coronary in-stent restenosis (ISR) as well as de novo coronary artery disease.

Observations: DCBs are balloons coated with antiproliferative agents and excipients, whose aim is to foster favorable vessel healing after appropriate lesion preparation. By providing homogeneous antiproliferative drug delivery in the absence of permanent foreign body implantation, DCBs offer multiple advantages over DES, including preservation of vessel anatomy and function and positive vessel remodeling. As such, DCBs have become appealing for treatment of ISR, small-vessel disease, long lesions, simplification of bifurcation procedures, and treatment of diffuse distal disease after recanalization of chronic total occlusions. In addition, patients with high bleeding risk, diabetes, and acute coronary syndrome might also stand to benefit from DCB angioplasty.

Conclusions and relevance: Although commercially available in numerous countries now for more than a decade, DCB only recently obtained US Food and Drug Administration approval for the treatment of coronary ISR. Moreover, preliminary results from newer generation devices tested in different clinical scenarios have raised the interest of the international community. Accordingly, an up-to-date review is timely particularly with the anticipated wave of research on the matter. Herein, this review encompasses DCB technologies, their worldwide usage, details on relevant indications, and key procedural aspects of DCB angioplasty.

Importance: Infrequent intraprocedural premature ventricular complexes (PVCs) limit the efficacy of catheter ablation. Intravascular stimulation of sympathetic nerves via vertebral veins (VVs) has been used to activate cardiac sympathetic tone and may promote PVCs.

Objective: To characterize the ability of direct electrical sympathetic stimulation via VVs to induce PVCs at the time of catheter ablation.

Design, setting, and participants: This prospective case series involved adult patients undergoing catheter ablation of PVCs, with rare or absent PVCs despite standard provocation, at the Hospital of the University of Pennsylvania between 2022 and 2024. Stimulation was performed via the left VV (20 Hz, up to 25 mA).

Main outcomes and measures: The primary outcome was PVC frequency, assessed before, during, and after stimulation. A multilevel mixed-effects Poisson regression was used to compare the rate of PVCs during the procedure.

Results: Fifteen patients (mean [SD] age, 60 [17] years; 10 male [71%]) had a mean (SD) preprocedure PVC burden of 16.3% (8.6%) (median [IQR], 17.0% [11.5%-21.5%]), and 7 of 15 had undergone at least 1 prior unsuccessful ablation. Provocation of PVCs was attempted with isoproterenol, atrial and ventricular burst pacing, and minimal sedation in all patients before VV stimulation. Throughout the 10-minute period before VV stimulation, patients had a mean (SD) of 1.3 (1.4) PVCs (median [IQR], 1.0 [0.0-2.5] PVCs). During VV stimulation, PVCs were noted in all patients (mean [SD], 8.2 [5.7] PVCs per minute; median [IQR], 6.0 [4.5-13.0] PVCs per minute). In the 10-minute period after VV stimulation, patients had a mean (SD) of 5.1 (6.6) PVCs per minute (median [IQR], 3.0 [0.5-6.5] PVCs per minute). After VV stimulation, ablation was guided by activation mapping in 7 patients and by pace mapping alone in the remaining patients. Postablation monitoring demonstrated a mean (SD) 1.3% (2.3%) burden of PVCs (median [IQR], 0.0% [0.0%-2.5%]), with 9 of 15 patients having less than 1% burden of PVCs. There were no adverse events related to VV stimulation.

Conclusions and relevance: These findings suggest that intravascular sympathetic stimulation via the VV can be used to safely provoke PVCs during catheter ablation.