Open Heart最新文献

Objective: Heart failure (HF) is common with high associated morbidity and mortality. UK National Institute for Health and Clinical Excellence (NICE) Guidelines suggest prioritising assessment by natriuretic peptide (NP) level, with patients with high NP levels assessed within 2 weeks. We evaluated adherence to NICE guidelines in the post-COVID-19 era.

Methods: We conducted a retrospective audit of consecutive referrals to a HF diagnostic pathway across seven hospitals in the West of Scotland (between 5 January and 2 June 2022). Patients were categorised by NP level according to NICE Guidelines: NT-proBNP 400-2000 ng/L (echocardiogram within 6 weeks) or >2000 ng/L (echocardiogram within 2 weeks). Time-to-echocardiogram was recorded, and 1-year outcomes (HF hospitalisation, death) were obtained from electronic records.

Results: Of the 899 patients (median age 79 years, 56% female) referred for echocardiography on the HF diagnostic pathway, 264 (29%) and 635 (71%) had an NT-proBNP >2000 ng/L and 400-2000 ng/L, respectively. Only 20 (8%) patients with NT-proBNP >2000 ng/L and 51 (8%) patients with NT-proBNP 400-2000 ng/L received an echocardiogram within the recommended timeframe. 252 (28%) patients were diagnosed with HF, 110 (42%) and 142 (22%) in the NT-proBNP >2000 ng/L and 400-2000 ng/L groups, respectively, p<0.001. One-year mortality was 12% and was higher in the >2000 ng/L NT-proBNP group at 21% compared with 9% in the 400-2000 ng/L group.

Conclusion: High NP levels identified a high-risk group who are more likely to have HF and a higher risk of mortality. Few patients received echocardiography within the NICE Guideline-recommended timeframe. Patients with high NP levels should be investigated with the same urgency as suspected cancer.

Background: The epidemiology of native valve infective endocarditis (IE) has shifted toward older adults with substantial comorbidity burdens, yet contemporary nationwide data on outcomes and surgical impact remain limited.

Methods: We conducted an 18-year nationwide cohort study of adults hospitalised with native valve IE in Korea (2006-2023). Outcomes included in-hospital and 5-year all-cause mortality, IE relapse and a composite of death or relapse. Temporal trends, mortality predictors and surgical associations across age strata were evaluated using multivariable Cox models and stratified survival analyses.

Results: Among 18 402 patients (mean age 63.7 years), incidence declined in individuals <45 years but increased in those ≥65 years. In-hospital mortality was 25.5%, and 5-year mortality exceeded 50% overall. Advanced age, dialysis dependence, cancer and major complications predicted mortality. Valve surgery, performed in 29.1% of patients, was consistently associated with lower short- and long-term mortality across age groups, with no evidence of age-by-treatment interaction. Both early (≤7 days) and late (>7 days) surgery showed reduced mortality versus medical therapy. IE relapse was more frequent in older adults, and surgery was associated with a lower relapse risk. In the composite outcome of death or relapse, older adults had a higher event burden, whereas surgery remained associated with fewer composite events.

Conclusions: Native valve IE in Korea has shifted toward an elderly, multimorbid population with persistently high mortality. Despite declining utilisation, the survival benefit of surgery was preserved across the age spectrum, supporting operative consideration in appropriately selected older adults.

Objective: To evaluate the potential mediating role of left ventricular ejection fraction (LVEF) in the relationship between replacement fibrosis (assessed by late gadolinium enhancement (LGE)) and sudden cardiac death (SCD) post-myocardial infarction (MI) and also to assess this mediation effect in subgroups based on LVEF ≤ 35% and > 35% according to implantable cardioverter-defibrillator (ICD) selection criterion.

Methods: A retrospective analysis was conducted on 917 post-MI patients (mean age: 56.3±11.0 years, 88.8% male) who underwent cardiac MR from January 2017 to August 2021. The endpoint for SCDs included SCD, aborted SCD and appropriate ICD discharges. The association of LGE with LVEF was quantified using linear regression models. The associations of LGE and LVEF with SCDs were evaluated using competing risk models. Mediation analysis was then used to decompose the total effect of LGE on SCDs into direct and indirect (mediated through LVEF) effects using accelerated failure time models.

Results: Over a median follow-up of 63.3 (IQR, 43.6 to 76.6) months, 65 patients (7.1%) experienced SCDs. In all patients, LGE was significantly associated with lower LVEF (β=-0.35, p<0.001). Both LGE and LVEF independently predicted SCDs (subdistribution hazard ratio (sHR)=1.06, p<0.001; sHR=0.95, p=0.03, respectively). Mediation analysis showed that LVEF accounted for 19.7% of the total effect of LGE on SCDs (p<0.001). This mediation effect was 40.4% in patients with LVEF > 35% (p = 0.02), while no mediation was observed in patients with LVEF ≤ 35% (p = 0.08).

Conclusion: LVEF partially mediated the effect of LGE on the SCD, accounting for less than one-fifth of the total effect. LVEF alone inadequately captured the whole SCD risk, irrespective of whether LVEF is greater than 35% or 35% or less.

Background: Annually, 4% of the global population undergoes non-cardiac surgery, with 30% of those patients having at least one cardiovascular risk factor. It is estimated that the 30-day mortality is between 0.5% and 2%.The main objective of this study is to develop a traditional machine learning (ML) model that provides a cardiovascular risk score for patients older than 50 years undergoing non-cardiac surgery, calculating the risk from the date of surgery until 30 days post surgery, with specific emphasis on interpretability and explainability of the model's decision-making process.

Methods: The NSQIP 2022 dataset was used to build the model. It consisted of a total of 4 97 011 patients after data cleaning. The primary clinical endpoint was death, myocardial infarction, cardiac arrest or stroke at 30 days postoperatively, which occurred in 1.44% of the patients. Different preprocessing techniques were performed for data cleaning and feature selection. The cleaned data were then used to model the selected learning algorithms, including Logistic Regression, Naive Bayes, Random Forest and boosting Decision Tree algorithms (CatBoost, AdaBoost, Light Gradient Boosting Machine (LightGBM, XGBoost, Gradient Boosting). These models were evaluated in terms of the area under the receiver operating characteristic curve (AUROC) and their corresponding 95% CI.

Results: For classification, the trained models were evaluated using AUROC on the test set. LightGBM achieved the highest AUROC of 0.9009 with a 95% CI of 0.8889 to 0.9126. The model consisted of six data elements: type of surgery, American Society of Anesthesiology classification, Blood Urea Nitrogen (BUN), sepsis, emergent surgery and mechanical ventilation.

Conclusion: In our study, LightGBM classifier proved to be the best model for cardiovascular risk scoring, demonstrating a strong balance between prediction accuracy and generalisation.

Background: Ruling out myocardial infarction (MI) in patients with an initial indeterminate (detectable to mildly elevated) troponin measure is challenging. Myocardial-Ischaemic-Injury Index (MI³) is a machine-learning algorithm designed to diagnose MI, but its utility in patients with indeterminate troponins is unclear. This study seeks to evaluate its diagnostic performance in patients with an initial indeterminate troponin.

Methods: We conducted a secondary analysis of a cohort (Cardiovascular Magnetic Resonance-Invasive-based Strategies in Patients with Chest Pain and Detectable to Mildly Elevated Serum Troponin) of adult patients with symptoms suggestive of acute coronary syndrome and an initial clinical contemporary troponin of 0.006-1.0 ng/mL across four US hospitals. Patients with initial and 3-hour high-sensitivity cardiac troponin I (Abbott Laboratories) measures were classified by MI³ into low-risk, intermediate-risk and high-risk groups. The primary outcome was adjudicated MI at 30 days. The sensitivity, specificity and negative likelihood ratio (-LR) of MI³ for MI at 30 days were calculated and reported with 95% CIs. A receiver operator characteristics curve for MI at 30 days was created and area under the curve (AUC) for MI³ was calculated.

Results: Among 207 patients, 34.3% (71/207) were female with a mean age of 61±11 years. MI at 30 days occurred in 43.5% (90/207). The AUC for MI³ for the detection of MI at 30 days was 0.882 (95% CI 0.833 to 0.932). MI³ classified 34.8% (72/207) of patients as low-risk, of which 8.3% (6/72) had MI at 30 days, yielding a sensitivity of 93.3% (95% CI 86.1 to 97.5%) and -LR of 0.12 (95% CI 0.05 to 0.26). Among the 47.3% (98/207) classified as intermediate-risk, MI at 30 days occurred in 48.0% (47/98). MI³ classified 17.9% (37/207) as high-risk, among which 100% (37/37) had MI at 30 days, yielding a specificity of 100% (95% CI 96.9% to 100%).

Conclusions: Among emergency department patients with an initial indeterminate troponin measure, the MI³ machine-learning algorithm had high AUC and specificity for 30-day MI.

Background: Ebstein's anomaly (EA) exhibits significant anatomical and clinical heterogeneity, warranting a systematic approach to risk stratification. While the Carpentier classification (CC) is commonly employed for qualitative disease assessment, there is increasing interest in quantitative imaging parameters to personalise monitoring strategies and therapeutic interventions. We sought to evaluate the association between cardiovascular magnetic resonance (CMR) parameters, CC and symptoms of heart failure (HF). Also, we investigated whether CMR-derived markers may predict the need for bidirectional cavopulmonary anastomosis (BCPA) and the occurrence of haemodynamic complications or significant right ventricular (RV) dysfunction in the postoperative stay.

Methods: This retrospective study evaluated consecutive patients diagnosed with EA undergoing 1.5T CMR acquisition at a tertiary care centre. CC and quantitative indices were extracted from steady-state free precession sequences.

Results: In a total population of 60 patients (53% male, median age 22 years), CMR parameters most strongly associated (p<0.001) with CC included indexed displacement of the septal (SLDi) and inferior (ILDi) leaflets, Ebstein valve rotation angle, functional RV ejection fraction, indexed atrialised RV end-diastolic volume and the ratio of either atrialised or functional RV to anatomical RV. Decreasing left ventricular ejection fraction (OR 0.85, 95% CI 0.75 to 0.97, p=0.01) and increasing ILDi (OR 1.05, 95% CI 1.00 to 1.10, p=0.04) emerged as the most prominent variables associated with HF symptoms. Additionally, ILDi was significantly linked to the need for BCPA (OR 1.15, 95% CI 1.03 to 1.28), the occurrence of haemodynamic complications (OR 1.09, 95% CI 1.01 to 1.18) and significant RV dysfunction in the postoperative stay (OR 1.08, 95% CI 1.01 to 1.17).

Conclusions: Quantitative CMR indices proved to be effective in distinguishing between Carpentier classes and they may be valuable in an integrated CMR-based approach to assess EA severity. Among these, ILDi reflects both the extent of tricuspid valve abnormality and RV atrialisation and may serve as a useful metric in guiding personalised therapeutic strategies.

Background: Differentiating type 1 myocardial infarctions (T1MI) from type 2 myocardial infarctions (T2MI) can be challenging based on clinical variables alone. This review aimed to explore the utility of novel and traditional biomarkers to discriminate between these entities and potentially provide additional prognostic information.

Methods: A systematic review of observational studies and randomised controlled trials that examined the discriminatory or prognostic roles of either traditional cardiac biomarkers (troponin, creatine kinase or b-type natriuretic peptide) or non-traditional biomarkers. Data sources included PubMed, SCOPUS, Web of Science, EMBASE and clinicaltrials.gov and were last searched on 15 November 2024. The diagnostic accuracy of biomarkers and prognostic utility of identified biomarkers are narratively reported.

Results: 31 studies with 16 111 individuals with a T2MI were included. Most studies (97%) demonstrated moderate or severe risk of bias. Of studies that examined traditional cardiac biomarkers (n=13), the ability to discriminate between T2MI and T1MI ranged from an area under the curve (AUC) of 0.61-0.71. Studies that added traditional cardiac biomarkers to clinical variables (n=4) demonstrated a diagnostic accuracy AUC 0.71-0.82. Studies exploring non-traditional biomarkers, metabolic and proteomic profiles (n=14) demonstrated a wide range of diagnostic accuracy (AUC 0.50-0.77). Traditional cardiac biomarkers inconsistently demonstrated a correlation with subsequent cardiovascular events. The prognostic utility of non-traditional biomarkers was infrequently assessed.

Conclusion: The role of biomarkers, metabolic and proteomic profiles in the diagnosis and prognostication of T2MI remains unclear. Higher quality studies and refining the classification of T2MI may improve this further.

Prospero registration number: CRD42023418095.

Background: Constrictive pericarditis (CP) is a rare but significant pericardial disease resulting in impaired ventricular filling and heart failure symptoms, often following cardiac surgery. Its clinical presentation complicates diagnosis, mimicking other causes of heart failure. Recent technological advances, including artificial intelligence (AI)-based non-invasive pulse wave analysis (AI-PWA), have the potential for improved haemodynamic assessment and clinical decision-making.

Objectives: This study evaluates the clinical utility of AI-PWA in assessing central aortic blood pressure (CABP), arterial stiffness and cardiac function in CP.

Methods: This prospective case-control study enrolled 12 adult CP patients and 12 age- and sex-matched healthy controls. CABP and peripheral blood pressure (PBP) were measured using the VascAssist2. Haemodynamic parameters, including pulse wave velocity (PWV), augmentation index@75 (AIx@75), cardiac index, stroke volume and dP/dtmax, were assessed and compared between groups.

Results: CP patients showed significantly lower mean CABP than systolic PBP (101.8±23.4 mm Hg vs 112.3±22.9 mm Hg). PWV showed elevated values (>9 m/s) in nnn (42%) of cases, indicating increased arterial stiffness (8.88±1.94 m/s). AIx@75 was higher in CP patients (22.55±8.36%) compared with controls (16.38±6.53%), reflecting increased wave reflection, increased systemic vascular resistance or enhanced aortic compliance. Cardiac performance was notably impaired in the CP group, with reduced stroke volume (64.8±18.8 mL vs 94.9±25.0 mL, p=0.003) and dP/dtmax (724.9±228.2 mm Hg/s vs 1055.3±203.2 mmHg/s, p=0.0011), indicating impaired ventricular function. The heart failure index was significantly higher in CP patients (31.8±18.3% vs . 6.4±6.5%, p<0.001), indicating substantial functional compromise.

Conclusion: AI-PWA provides clinically relevant insights into central haemodynamics and arterial stiffness in CP patients. This non-invasive approach may enhance diagnosis and management of CP and should be considered for integration into routine cardiologic evaluation protocols.

Background: Middle-aged men seem to be particularly susceptible to adverse cardiovascular effects of endurance exercise. The acute impact of training, marathon finishing and recovery on the heart has not been extensively investigated in such at-risk novice marathon runners.

Methods: We prospectively quantified cardiac changes in middle-aged men (41.2±4.5 years; n=17) who participated in their first marathon run at four time points: at baseline, after 16 weeks of training, within 10 hours after completing the 2021 Amsterdam Marathon run and after 4 weeks of recovery. Measurements included comprehensive 3-Tesla MRI examination, echocardiography, ECG and blood sample assays of high-sensitivity troponin-T (hs-TnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP).

Results: Acute effects associated with finishing the marathon run were a <10% reduction in left ventricular end-diastolic volume in absence of other morphological changes, and only minor changes in systolic contractile mechanics and diastolic filling patterns. Neither quantitative myocardial mapping with MRI nor late gadolinium enhancement revealed any signs of post-marathon myocardial injury. ECGs did not reveal any abnormalities. Circulating levels of hs-TnT and NT-proBNP had increased markedly after the marathon, with hs-TnT exceeding the clinical upper reference limit for all participants. All observed marathon running-induced effects were transient.

Conclusions: Extensive phenotyping using state-of-the-art quantitative imaging modalities paired with physical assessments and blood assays in this selected cohort offers no evidence to support the notion that first-time marathon running in healthy middle-aged men has a detrimental impact on the heart.

Background: Severe aortic stenosis (AS) causes a pathophysiological cascade, which impairs myocardial blood flow. This effect is exacerbated in the presence of coronary disease (CAD). Treatment with transcatheter aortic valve implantation (TAVI) may promote reversal of these pathophysiological conditions.

Methods: We performed multimodality assessment of cardiac physiology in patients with AS and concurrent CAD requiring percutaneous coronary intervention, prior to and 6 months after undergoing TAVI. Techniques include: coronary angiography and bolus thermodilution-derived indices of microvascular function (coronary flow reserve (CFR); index of microcirculatory resistance (IMR)); stress perfusion cardiac magnetic resonance (CMR) imaging, which was used to measure changes in global myocardial blood flow (MBF) and left ventricular mass (LVM), and computed resting and hyperaemic vessel specific absolute coronary flow (aCBF) and microvascular resistance (MVR) using a computational model of coronary physiology.

Results: Data were obtained for seven patients (10 vessels). CFR increased from 1.53 (1.2-1.7) to 2.35 (2.0-2.7) (p=0.037) 6 months post-TAVI. There was a 33% reduction in resting aCBF from 218 mL/min to 146 mL/min (p=0.004). On CMR, resting MBF fell 37% from 3.0±0.98 mL/min/g to 1.9±0.7 mL/min/g (p=0.033) and stress MBF fell 25% from 3.6±0.57 mL/min/g to 2.7±0.7 mL/min/g (p=0.004). Indexed LVM regressed from 79±14 g/m² to 71±16 g/m² (p=0.006). MVR remained unchanged.

Conclusions: CFR increased following TAVI. The mechanism for this was a significant reduction in resting coronary blood flow measured with CMR and modelled computationally. The unchanged MVR and IMR suggest that resting blood flow reduces due to reduced myocardial demand and myocardial remodelling, rather than changes in resistance.