Journal of Cardiovascular Medicine最新文献

Background: De-escalation of dual antiplatelet therapy (DAPT) by early discontinuation of one antiplatelet agent has been proposed as an alternative to 12-month DAPT to balance ischemic and bleeding risks in patients with acute coronary syndrome (ACS). However, the efficacy and safety of abbreviated DAPT regimens in ST-elevation myocardial infarction (STEMI) - a subset of ACS with distinct clinical and risk profiles - remain uncertain.

Methods: Randomized trials and sub-analyses of randomized trials comparing DAPT de-escalation by early discontinuation versus 12-month DAPT in patients with STEMI treated with primary angioplasty were included. Co-primary endpoints were major bleeding and major adverse cardiovascular events (MACE). Secondary endpoints included net adverse clinical events (NACE), individual ischemic outcomes, and clinically relevant bleeding. Trial sequential analysis (TSA) and sensitivity analyses were prespecified (CRD42024608709).

Results: Eight randomized trials encompassing 10,216 patients were included. Short DAPT regimens significantly reduced major bleeding [hazard ratio, 0.50; 95% confidence interval (CI), 0.30-0.85; P  = 0.011] compared with standard DAPT. No significant differences were observed in MACE (hazard ratio, 1.21; 95% CI, 0.91-1.64; P  = 0.193) or NACE (hazard ratio, 0.94; 95% CI, 0.80-1.10; P  = 0.427). The results of TSA reinforced these findings. Other secondary outcomes showed no significant differences, but interpretation was limited by the small number of studies reporting these events.

Conclusion: Abbreviated DAPT significantly reduces major bleeding risk in patients with STEMI compared with standard 12-month DAPT, without apparently compromising ischemic protection. However, further research is needed to clarify net clinical outcomes in this high-risk ACS subset.

Protocol registration identifier: CRD42024608709.

Introduction: Approximately two-thirds of patients suffering from hypertrophic cardiomyopathy present with an obstructive (HOCM) physiology. For years, medical therapy has been limited to beta blockers, verapamil and/or disopyramide. Recently, a novel class of drugs, the allosteric inhibitors of the cardiac-specific myosin head adenosine triphosphatase (ATPase), have been demonstrated to be effective in relieving the dynamic obstruction and related clinical condition. In July 2024 the Cardiomyopathies and Pericardial Diseases WG of the Italian Society of Cardiology started with a nationwide multicentre registry aimed at investigating the pathophysiology of dynamic obstruction in real-world patients with HOCM. Based on the medical records, this brief report deals with the proportion of patients who were eligible for Mavacamten based on the Explorer-HCM entry criteria, and then admitted for compassionate use by the end of 2024.

Methods and results: The Hypertrophic Obstructive Physiology Study (HOPS) was designed as a registry on consecutive adult patients admitted to 19 tertiary Cardiac Centres in Italy until June 2024. A total of 424 patients, 53% males, aged 64 ± 13 years, were included. We retrospectively recognized 200 Mavacamten-eligible patients (47.2%) on 5 Explorer-HCM requirements. Forty out of this latter group, along with 15 more patients on 4 criteria, were admitted to the compassionate use programme ( n  = 55, 13% of the whole population). Forty-three showed subaortic obstruction and 12 a mid-ventricular variant. Ethical committee approval items varied among centres and regions.

Discussion: This study confirmed our recent demonstration that approximately half of real-world HOCM patients are suitable for Mavacamten therapy based on the full Explorer-HCM trial entry criteria. Due to the current limitation of compassionate use programmes in Italy, only one in four patients was admitted for treatment.

Aims: Age, estimated glomerular filtration rate and ejection fraction (AGEF) score correlates with mortality in patients with ST-elevation myocardial infarction, yet its relationship with cardiogenic shock mortality remains unknown.

Objectives: This research aims to explore the correlation between AGEF and the probability of all-cause 90-day mortality in patients with cardiogenic shock.

Methods: Our study included 168 cardiogenic shock patients from a multicenter, prospective, observational study. The Cox regression model, subgroup analyses, Kaplan-Meier survival curves, and restricted cubic spline analysis were applied to assess the relationship between AGEF and 90-day mortality. Receiver-operating characteristic curve analysis was performed to evaluate the predictive accuracy of AGEF for 90-day mortality.

Results: High AGEF scores correlated with significantly higher mortality (56.1 vs. 19.7%, P < 0.05). AGEF was significantly associated with 90-day mortality [hazard ratio: 1.33, per 1-point increase, 95% confidence interval (95% CI) 1.03-1.70, P < 0.001; hazard ratio: 1.65, per 1 standard deviation increase, 95% CI 1.27-2.14, P < 0.001]. The high AGEF group had a two-fold higher risk of 90-day mortality (hazard ratio: 3.08, 95% CI 1.48-6.41, P < 0.001). Kaplan-Meier curve analysis revealed a higher probability of 90-day death in the group with higher AGEF scores. The restricted cubic spline analysis also suggested a linear relationship between AGEF and 90-day mortality. The area under the receiver-operating characteristic curve for the AGEF was 0.71 (95% CI 0.633-0.787), indicating moderate discrimination ability.

Conclusion: AGEF is significantly associated with all-cause 90-day mortality in patients experiencing cardiogenic shock, indicating its potential as a prognostic indicator in this patient population.

Introduction: Arrhythmia-induced cardiomyopathy (AIC) due to atrial fibrillation is probably related to high ventricular rates and irregular rhythm caused by atrial fibrillation. We sought to investigate the efficacy of pulmonary vein isolation (PVI) using radiofrequency catheter ablation (RFCA) compared to conventional medical therapy in terms of rate of hospitalizations and atrial fibrillation recurrence.

Methods: All patients diagnosed with atrial fibrillation associated with heart failure and left ventricular ejection fraction (LVEF) less than 50%, with no other identifiable cause of heart failure aside from the tachyarrhythmia, were included. A 1 : 1 propensity score matching was carried out including age, sex, diabetes, LVEF and BMI in the logistic regression model. The primary endpoint was to assess recurrences of hospitalizations for heart failure; secondary endpoints included hospitalizations for all causes and recurrence of atrial fibrillation during the follow-up.

Results: Seventeen patients who had undergone RFCA were matched and compared with 17 patients under conventional medical therapy. Over a median follow-up of 26 months [interquartile range (IQR) 13.4-32], the RFCA group exhibited a significantly lower rate of heart failure-related hospitalization compared with the control group (23.5 versus 58.8%, P = 0.04). The rates of all-cause hospitalizations and atrial fibrillation recurrence were also significantly lower in the RFCA group. The RFCA group also showed a significant increase in LVEF and a significant reduction in left atrial volume compared with medical therapy alone.

Conclusion: In patients with AIC due to atrial fibrillation, catheter ablation seems to favor the reverse remodeling and to be effective in reducing atrial recurrence and the rate of all-cause and heart failure-related hospitalizations.

Background: In recent years, there has been a significant increase in the use of mechanical circulatory support devices, including the Impella device (Abiomed, Danvers, MA, USA), as hemodynamic support during high-risk percutaneous coronary intervention (PCI) and in acute management of cardiogenic shock.

Results: In this case series, we present two patients with non-ST-elevation myocardial infarction complicated by cardiogenic shock treated with Impella CP-protected PCI. After the revascularization, for both patients, a clinically relevant, access-site bleeding occurred, challenging the Impella CP maintenance. However, hemostasis was successfully achieved with a mechanical external compression device, allowing Impella hemodynamic support to continue.

Major findings: In this case series we propose a novel and easy approach to manage access-site bleeding while using the Impella catheter.