Netherlands Heart Journal最新文献

Introduction: The left atrial appendage is the dominant source of cardioembolic stroke in patients with atrial fibrillation (AF). Contemporary guidelines recommend considering left atrial appendage occlusion (LAAO) in AF patients contraindicated to oral anticoagulation therapy (OAC), but randomized controlled trial (RCT) data for this subpopulation are lacking.

Methods: COMPARE LAAO was designed as an event-driven, multicenter, prospective, randomized, open, blinded endpoint (PROBE) trial that randomized AF patients with an increased thromboembolic risk and a contraindication to OAC 2:1 to LAAO or standard-of-care (SOC). The co-primary endpoints comprised 1) time to first occurrence of ischemic/hemorrhagic/undetermined stroke and 2) time to first occurrence of all-cause stroke/TIA/SE. The trial aimed to enroll 609 patients.

Results: After randomization of 69 patients, the trial was terminated prematurely by the sponsor due to a slow inclusion rate. Results are discussed briefly without formal statistical testing. All-cause stroke occurred in 7/48 and 2/21 patients randomized to LAAO and SOC, respectively. According to the as-treated principle, all-cause stroke occurred in 5/41 and 4/28 patients treated with LAAO and SOC. The composite of all-cause stroke/TIA/SE occurred in 10/48 and 4/21 patients randomized to and 8/41 and 6/28 patients treated with LAAO and SOC.

Conclusion: Insufficient statistical power of COMPARE LAAO impedes drawing any conclusions. Among other factors, the loss of perceived clinical equipoise among physicians proved problematic for successful trial completion. Conducting an RCT on LAAO vs SOC in OAC-ineligible patients appears infeasible globally, which threatens to preclude reimbursement in the Netherlands for these patients that have no proven alternative.

This review evaluates the 2023 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis (IE) and offers insights into topics particularly relevant to clinical practice in the Netherlands. The multidisciplinary IE Working Group assessed all ESC recommendations and concluded that the majority could be endorsed, albeit with certain modifications. The IE Working Group presents a refined (and simplified) antibiotic prophylactic regimen and an updated table to guide the analysis of suspected blood culture-negative IE. Furthermore, the pivotal role of the Endocarditis Team in the management of patients with suspected and confirmed IE was reaffirmed, along with reinforced recommendations for nearly all cardiac and extracardiac imaging in these cases. Most notable, a preliminary recommendation was issued for switching to oral antibiotic therapy in patients with native valve endocarditis caused by viridans streptococci, while awaiting the revision of the Dutch Working Group on Antibiotic Policy (SWAB) IE guideline. In addition, the surgical recommendations were evaluated and revised, including improved clinical criteria in case of cardiac surgery following neurological complications of IE and an advised disregard of the new class I ESC recommendation for surgery in early prosthetic valve endocarditis (< 6 months). Moreover, an additional device recommendation was proposed for the choice of (alternate) devices in case of device reimplantation after IE.

Cardiovascular disease in women has historically been underrepresented in research. In recent years, several funding bodies, including the Dutch Heart Foundation, have launched numerous research initiatives and consortia in the Netherlands to address knowledge gaps in women. This article provides an overview of the current landscape of cardiovascular disease in women and emphasizes the critical need for continued investment in this field. One area with urgent knowledge gaps is the early detection, diagnosis, therapy, and prognosis of Angina with Non-Obstructive Coronary Arteries (ANOCA) in women with persistent signs and symptoms of ischemia. In the Netherlands, in recent years, we have established a robust clinical infrastructure and a translational framework that enables us to address these challenges. Additionally, we have performed implementation studies to fast-track knowledge on ANOCA in clinical practice, giving us a unique opportunity to transform clinical care for women with signs and symptoms of ischemia. We advocate for a broad perspective that incorporates characteristics such as ethnicity, socio-economic background, and female-specific risk factors. Our goal is to provide solid evidence to ensure the best possible care for all women suffering from persistent signs and symptoms of ischemia.

Background: There is increasing evidence that presentation, progression, and management of atrial arrhythmias, such as atrial fibrillation (AF), differ between women and men. Bachmann's bundle (BB) is the main route for interatrial conduction, and sex-related differences in structural and electrical remodeling of BB may contribute to differences in AF development between women and men.

Objective: Investigate whether sex differences in the electrophysiological properties of BB assessed by high-resolution and density maps exist in patients with AF.

Methods: Sinus rhythm at BB was recorded for 5 s during cardiac surgery. Potential voltage, low-voltage area (LVA), conduction heterogeneity, unipolar potential morphology, and conduction velocity were assessed for both men and women.

Results: The study population consisted of 108 patients (73 men, 35 women). Women had significantly lower potential voltages (5th percentile: 0.7 mV [0.6-1.0] vs 1.1 mV [0.6-1.4], p = 0.028), more LVAs (10.8% [4.6-19.7] vs 4.3% [2.2-11.7], p = 0.012) and more long double potentials (11.1% [3.6-13.5] vs 5.0% [1.0-10.3], p = 0.015) compared to men.

Conclusions: We observed sex-related differences in the electrical remodeling of BB in AF patients. Women have a higher proportion of low voltage potentials, and more abnormal potential morphologies compared to men. These findings may reflect sex-specific differences in the underlying substrate of AF at BB.

Background: Prior studies showed underrepresentation of females in cardiovascular disease (CVD) clinical trials, potentially hindering accurate treatment effect estimates. We assessed the female contribution to treatment effect estimates in selected CVD trials and explored sex differences in efficacy outcomes.

Methods: We analyzed completed (1997-2024) randomized controlled CVD trials performed via the Dutch WCN Investigator Network. Female participation was quantified using the Participation to Prevalence (in the population) Ratio (PPR_F). In trials with a cardiovascular event as the primary efficacy endpoint, a meta-analysis was conducted to evaluate differences in treatment effect on the study-specific primary endpoint between females and males using a random-effects model.

Results: In 115 trials investigating various treatments across different cardiovascular domains (801 k participants, 29.1% females), the median PPR_F was 0.75 (interquartile range: 0.64-0.83), while 58% of trials had a PPR_F below 0.8 (underrepresentation). Based on 46 trials, female contribution to primary endpoints was lower than their sample size contribution (mean 26.2% versus 28.5%). Similarly, based on 66 trials, female contribution to sex-stratified efficacy estimates was lower than their sample size contribution (27.4% versus 29.2%). Regarding the primary endpoint, the relative treatment effect was similar in females and males: pooled difference of the relative effect measure on the natural log scale of -0.02, 95% CI -0.05 to 0.01, p = 0.23, I² = 11%.

Conclusion: Despite underrepresentation, female participation in the selected WCN-CVD trials was sufficient to exclude major sex differences in efficacy. Given the limited and heterogeneous trial sample, further disease-specific studies are needed, and greater female inclusion remains essential for equity and safety insights.

Background: Diagnosing heart failure with preserved ejection fraction (HFpEF) remains challenging. While diagnostic algorithms support clinical evaluation, their performance across sexes is understudied, despite HFpEF being more prevalent in females, which may result in sex-specific underdiagnosis.

Purpose: To assess the diagnostic accuracy of three HFpEF algorithms-HFA-PEFF, H₂FPEF, and the ESC HF 2016 criteria-and to evaluate sex-related differences in performance.

Methods: Two prospective cohorts with unexplained dyspnoea were analysed. The Amsterdam cohort (2014-2020; n = 135) had HFpEF confirmed or excluded via (exercise) right heart catheterization (RHC). The Maastricht cohort (2015-2021; n = 659) had HFpEF confirmed or excluded based on expert consensus with utilisation of HFpEF scores, and RHC when needed. Sex-specific diagnostic performance of three HFpEF algorithms was assessed using ROC curves, AUC, and a panel of metrics with cut-offs determined by the rule-in/rule-out strategies.

Results: HFpEF prevalence was high in both cohorts (84.4% and 82.5%), with a female majority (69.6% and 66.5%). Across all algorithms, males consistently showed lower AUC values than females, although differences were not statistically significant. The highest diagnostic performance within the Amsterdam cohort was observed with H₂FPEF (AUC 0.86 and 0.82 for females and males), while HFA-PEFF performed best within Maastricht cohort (AUC 0.85 and 0.83, respectively). Performance for ruling-in and ruling-out HFpEF was numerically lower in males than females; Amsterdam cohort HFA-PEFF and ESC 2016 specificity were 83% versus 93% and 50% versus 73%, Maastricht cohort H₂FPEF specificity was 81% versus 89%.

Conclusions: HFpEF diagnostic algorithms may perform better in females than males in referral outpatient settings. Inconsistent performance of diagnostic algorithms between different sexes warrants further optimisation to diagnose HFpEF.

Background: Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide, affecting both women and men. However, its evaluation and treatment have historically been influenced by gender, resulting in significant disparities for women.

Objective: This review aims to comprehensively examine the literature on gender disparities in the care of patients with CAD.

Results: Evidence highlights several key inequalities, including the relatively greater impact of shared risk factors in women, the presence of female-specific risk factors, differences in CAD symptom presentation, and reduced screening sensitivity and management quality in women compared with men.

Conclusions: Addressing these disparities requires updated screening strategies that recognize the unique clinical manifestations of CAD in women, increasing awareness among both women and healthcare providers, greater inclusion of women in CAD research studies, revisiting the role of hormonal replacement therapy, and integrating emerging tools such as genetic research and artificial intelligence. These steps have the potential to improve the equity and effectiveness of CAD management across genders.