Journal of Cardiovascular Medicine最新文献

Background and aims: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess prognosis and guide treatment. We evaluated current diagnostic practices across European academic centres in its diagnosis and management, to focus on current gaps in clinical practice.

Methods: Between June and October 2023, we distributed an electronic survey to 42 centres selected from a 2023 list of European Association of Percutaneous Cardiovascular Interventions Hosting Academic Centres, obtaining information on demographics of MINOCA, perceived clinical impact, testing and treatments.

Results: The analysis was based on data from 41 centres. According to the survey, MINOCA accounts for approximately 10% of MI cases. Only 38% of the respondents perceived MINOCA as increasing the risk for future major adverse cardiovascular events. Sixty-three percent of centres agreed on the need for further testing after MINOCA diagnosis, and 22% reported proceeding with a comprehensive diagnostic algorithm. Intravascular (51%) and cardiac magnetic resonance imaging (50%) were the most common diagnostic tools used. Coronary plaque disruption was perceived as the most frequent cause based on respondents' opinions. Sixty-nine percent of centres considered 'empiric' therapy acceptable without functional testing.

Conclusions: This survey revealed a significant heterogeneity in the diagnostic approaches to MINOCA in academic European centres, with variable belief of its clinical impact, wide variation in diagnostic algorithms, noteworthy diagnostic inertia, and poor adherence to guideline recommendations. All these point to a pressing need for a unified approach to MINOCA testing and a much closer alignment to guidelines.

Aims: We aimed to develop and comprehensively evaluate our artificial intelligence model for predicting atrial fibrillation based on standard 12-lead sinus rhythm electrocardiogram (ECG) images in a Korean population, and to validate its performance in Brazilian patient cohorts.

Methods: We developed a modified convolutional neural network (CNN) model using a dataset comprising 811 542 ECGs from 121 600 patients at Seoul National University Bundang Hospital (2003-2020). Ninety percent of the patients were allocated to the training dataset, while the remaining 10% were assigned to the internal validation dataset. External validation was performed using the CODE 15% dataset, an open ECG dataset from the Telehealth Network of Minas Gerais, Brazil, by applying a 1 : 4 (atrial fibrillation : non-atrial fibrillation) random sampling strategy.

Results: In the internal validation, our artificial intelligence model achieved an area under the receiver-operating characteristic curve (AUROC) of 0.907 [95% confidence interval (CI): 0.897-0.916] for atrial fibrillation prediction. In the external interethnic validation with the CODE 15% dataset, the artificial intelligence model exhibited an AUROC of 0.884 (95% CI: 0.869-0.900), which increased to 0.906 (95% CI: 0.893-0.919) when adjusted for age and sex. In the subset of patients with 'normal ECG' interpretations, the AUROC was 0.826 (95% CI: 0.769-0.883), increasing to 0.861 (95% CI: 0.814-0.908) after applying the same adjustments.

Conclusion: Our artificial intelligence-powered sinus rhythm ECG interpretation model demonstrated excellent performance in predicting paroxysmal or incident atrial fibrillation, with valid performance in the Brazilian population as well. This suggests that the model has the potential for broad application across different ethnic groups.

Aims: To compare long-term outcomes of repeat percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome, distinguishing between target-vessel revascularization (TVR) and nontarget-vessel revascularization (non-TVR), and to identify predictors of major adverse cardiovascular events (MACE).

Methods: We analyzed consecutive patients with prior PCI undergoing repeat PCI for recurrent ischemia. Patients were classified as TVR or non-TVR. The primary endpoint was MACE (all-cause death, myocardial infarction, or repeat revascularization) at 3, 5, and 10 years. Cox regression identified independent predictors.

Results: Among 299 patients, 51.8% underwent TVR and 48.2% non-TVR. Left anterior descending (LAD) was more often treated in TVR (58.1 vs. 36.5%, P = 0.003). At 3 years, MACE occurred in 37.3% of TVR and 28.8% of non-TVR (hazard ratio 1.51, P = 0.052), with similar trends at 5 and 10 years. Independent predictors of MACE included cardiogenic shock, longer fluoroscopy time, and LAD involvement. Intravascular imaging was used in 5.7% and functional assessment in 2.6%, both below contemporary acute coronary syndrome registry averages. Nearly half of patients had LDL-C more than 55 mg/dL despite prior PCI.

Conclusion: Patients requiring repeat PCI, whether for the same or a different vessel, face high long-term event rates. Adverse prognosis is determined by clinical severity, procedural complexity, and high-risk anatomy. Greater adoption of imaging-guided PCI and intensive secondary prevention may help break the cycle of recurrent events.

Background: Intravascular lithotripsy (IVL) has demonstrated excellent results in treating calcified coronary lesions. However, specific focus on different calcification patterns is still limited. The aim of our study was to evaluate the procedural and clinical outcomes of IVL in treating concentric vs. eccentric calcifications.

Methods: The BENELUX-IVL prospective registry enrolled patients aged ≥18 years who underwent IVL. For this study, patients who underwent both IVL and intravascular ultrasound (IVUS) before and after the procedure were selected. Based on IVUS-derived calcium arc quantification, patients were categorized into two groups: concentric calcification (>180°) and eccentric calcification (≤180°). The primary technical endpoint was technical success, defined as successful IVL catheter crossing of the target lesion with residual stenosis <30%, with final TIMI 3 flow. The primary efficacy endpoint was the incidence of major adverse cardiac events (MACE) at 12-month follow-up.

Results: A total of 455 patients were enrolled in the registry, of whom 136 (29.9%) met the inclusion criteria for the study. Concentric calcifications were more prevalent (83.1% vs. 16.9%, P < 0.01). The median SYNTAX score was similar between the two groups [19 (10-29) vs. 20 (12-31), P = 0.64]. Technical success was achieved similarly between the two calcification patterns (93.0% vs. 95.7%, P = 0.98). At 12-month follow-up, MACE (6.2% vs. 4.3%, P = 0.66), cardiac death (1.8% vs. 4.3%, P = 0.44), and target vessel revascularization (4.4% vs. 4.3%, P = 0.99) were similar.

Conclusion: IVUS-guided percutaneous coronary intervention of calcified lesions treated with IVL demonstrates comparable procedural outcomes and low adverse clinical event rates in both concentric and eccentric calcification patterns. However, further studies are warranted to draw definitive conclusions regarding long-term clinical outcomes.

Background: Transthyretin cardiac amyloidosis (ATTR-CA) typically manifests with heart failure. Discontinuing beta-blockers and avoiding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) in patients with ATTR-CA has been recommended.

Methods: We investigated the prescription of neurohormonal therapies and their relationship with all-cause mortality in a multicenter cohort.

Results: Patients (n = 926) had a median age of 79 years (interquartile range 74-83), 90% were men, 17% had a left ventricular ejection fraction (LVEF) 40% or less, and 27% were in New York Heart Association (NYHA) class III/IV. At diagnosis, 60% of patients were on beta-blockers, 58% on ACEi/ARB/ARNI, and 35% on MRA. Patients on beta-blockers had more often NYHA class III/IV, a greater burden of comorbidities, and lower LVEF, and those on ACEi/ARB/ARNI had more comorbidities. Nonetheless, the survival of patients on beta-blockers or ACEi/ARB/ARNI was not significantly shorter over a 2.5-year follow-up (1.6-3.8) (P = 0.577 and P = 0.977, respectively), and patients on both drugs did not have a worse outcome than those not receiving any neurohormonal drug (P = 0.575). During the entire follow-up, the number of neurohormonal drugs remained unchanged in 54%, decreased in 27%, and increased in 19%. Patients with a number of neurohormonal drugs either unchanged or increased had a lower risk of mortality (odds ratio 0.71, 95% confidence interval 0.53-0.95, P = 0.023).

Conclusion: ATTRwt-CA patients on beta-blockers or ACEi/ARB/ARNI at diagnosis did not have a shorter survival. Beta-blockers were discontinued less often than were ACEi/ARB/ARNI. There was no sign of better outcomes in patients discontinuing these therapies, or worse outcomes in those starting them.

Iron deficiency is a highly prevalent and clinically significant comorbidity in patients with heart failure, occurring in up to 80% of acute heart failure and over 50% of chronic heart failure cases. It can occur independently of anemia and contributes to impaired oxygen transport and utilization, mitochondrial dysfunction, ventilatory inefficiency, and reduced exercise capacity, ultimately diminishing quality of life and worsening prognosis. Mechanistically, iron deficiency in heart failure involves systemic and molecular alterations, including dysregulation of iron-related genes, hepcidin-mediated ferroportin inhibition, and inflammatory sequestration of iron. These changes impair hemoglobin synthesis, aerobic enzyme activity, and skeletal and cardiac muscle function. Clinically, iron deficiency is associated with reduced peak oxygen uptake (VO2) and increased ventilation to carbon dioxide production (VE/VCO2) slope, even in the absence of anemia. Intravenous iron supplementation with ferric carboxymaltose might improve ventilatory efficiency (e.g. VE/VCO2 slope) and could be of importance to regain functional capacity. This review aims to explore the impact of iron deficiency, with and without concomitant anemia, on exercise performance in patients with chronic heart failure, linking molecular mechanisms to clinical manifestations and summarizing therapeutic implications.

Aim: Etiological diagnosis is critical in patients with left ventricular dysfunction, as both dilated cardiomyopathy (DCM) and ischemic heart disease (IHD) can present similarly in the early stages. This study aims to evaluate the discriminative power of global longitudinal strain (GLS) and heart rate variability (HRV) parameters using interpretable machine learning models to differentiate between DCM and IHD patients with left ventricular ejection fraction (LVEF) of between 40% and 50%.

Methods: In this retrospective exploratory study, we included consecutive patients with LVEF 40-50% who had a recent (<3 months) 24-h Holter ECG and no history of acute myocardial infarction or heart failure hospitalization. HRV features and GLS were extracted by the processing of Holter ECG and echocardiographic imaging, respectively. Feature selection was performed through the ReliefF method and interpretable predictive models were produced using HRV features, sex, age, and GLS to differentiate between DCM and IHD patients.

Results: The study population included 97 DCM patients (63 males and 34 females, aged 57 ± 15 years) and 91 IHD patients (73 males and 18 females, aged 71 ± 11 years). The logistic regression model achieved a classification accuracy of 76% in distinguishing the populations with an area under the curve of 83%. Sex, age, mean RR, FD, HFn, GLS, pNN50, SD1/SD2, SD1, and LFn were identified as the most important features in distinguishing between IHD and DCM.

Conclusion: This study highlights the added value of a novel approach based on a predictive model that integrates HRV metrics with myocardial deformation parameters to support the differential diagnosis between DCM and IHD in patients with mildly reduced ejection fraction.