Open Heart最新文献

Background: Balloon pulmonary angioplasty (BPA) improves haemodynamics in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Previous studies on BPA have set the treatment objective to achieve a mean pulmonary arterial pressure (mPAP) of <30 mm Hg. However, the clinical impact of mPAP after BPA remains unclear. This study aimed to stratify patients according to their mPAP after BPA and evaluate its association with clinical status and long-term outcomes.

Methods: We retrospectively reviewed 304 patients with inoperable CTEPH (median age, 72 (61 to 79) years) who underwent BPA and follow-up right heart catheterisation. Patients were categorised by mPAP after BPA: ≤20, >20-<30 and ≥30 mm Hg groups.

Results: The WHO functional classification, 6 min walk distance and right ventricular ejection fraction were significantly better in the group with a lower mPAP (trend test p=0.007, p<0.001 and p=0.002, respectively). Additionally, the proportions of patients who required pulmonary vasodilators or oxygen therapy were significantly lower in the group with a lower mPAP (trend test p<0.001 and p<0.001, respectively). Across all multivariable models, the mPAP ≥30 mm Hg group had a significantly poorer prognosis compared with the mPAP ≤20 mm Hg group. In contrast, no significant difference was observed between the mPAP ≤20 mm Hg and >20-<30 mm Hg groups.

Conclusions: In patients with CTEPH after BPA, an mPAP of <30 mm Hg was associated with a favourable prognosis, and patients with an mPAP of ≤20 mm Hg presented with better symptoms, exercise capacity, right ventricular function and more withdrawal from oxygen therapy and pulmonary vasodilators. The BPA treatment goal may require individual adaptation.

Background: The complication risk of procedures may be influenced by operator and institutional characteristics. Our aim was to assess whether supervising consultant seniority and operative volume, and hospital volume were associated with the risk of reintervention following complex device implantation.

Methods: A nationwide population-based study was performed using the National Institute for Cardiovascular Outcomes Research registry including all patients receiving their first transvenous implantable cardioverter defibrillator or cardiac resynchronisation therapy (CRT) implant in England over 5 years (April 2014-March 2019). The primary endpoint was 1-year reintervention. We evaluated the association between reintervention and supervising consultant annualised complex device volume, supervising consultant seniority and hospital annualised complex device volume, using multilevel logistic regression.

Results: 47 630 implants were included. The 1-year reintervention rate was 6.1% (N=2916). There was no difference in reintervention risk with increasing supervising consultant volume (OR 0.89 Q4 vs Q1; 95% CI 0.76 to 1.05, p=0.17). When CRT-pacemakers/defibrillators implants were analysed separately (N=26 108), there was an association between operator volume and 1-year reintervention, but this was of borderline statistical significance and only evident in the highest compared with the lowest volume quartile of operators (adjusted OR 0.79 Q4 vs Q1; 95% CI 0.63 to 0.98, p=0.03). There was a non-linear relationship between reintervention risk and supervising consultant seniority, with the operators in the middle two quartiles of seniority having a lower risk (OR 0.87 Q2 vs Q1, p=0.02; OR 0.81 Q3 vs.Q1; p=0.003) while the most and least senior operators had a similar reintervention risk (OR 0.93 Q4 vs Q1, p=0.31). Hospital volume was not associated with 1-year reintervention.

Conclusions: There is a U-shaped curve between operator seniority and reintervention risk for complex devices. Although there are several potential explanations, these data suggest that while newly qualified consultants may benefit from mentoring, all operators should continuously evaluate their outcomes and share them within their centre and more widely through the national audit.

Background: Valvular surgery for infective endocarditis (IE) can improve survival but carries substantial risk. Limited data exist on long-term outcomes for patients who survive surgery compared with a background population. We aim to compare long-term mortality and morbidity in patients with IE, who survive 90-days following valvular surgery to a matched Danish background population.

Methods: Using Danish registries, we identified patients who survived >90 days post-valvular surgery for first-time IE (2010-2023). Each patient was matched 1:3 with controls from the background population by age, sex and selected comorbidities. All-cause mortality was assessed at 5 and 10 years using the Kaplan-Meier estimator and the multivariate Cox model. Further, we examined the time spent in hospital during the first year following the index date.

Results: We identified 1050 patients (77.5% male, median age 65.8 years) surgically treated for IE and 3150 controls. The most common pathogens were: Viridans group streptococci (44.6%), Staphylococcus aureus (23.1%), Enterococci (17.9%). Patients with IE had higher absolute 5-year (20.1% vs 12.9%, p=0.001) and 10-year (38.5% vs 27.9%, p<0.001) mortality compared with controls. Adjusted 5-year and 10-year mortality rates were also higher in patients with IE (5-year HR=1.49 (95% CI 1.24 to 1.79) and 10-year HR 1.38 (95% CI 1.19 to 1.60)). Patients with IE experienced more frequent and longer hospitalisations within the first year postsurgery, as 36.8% patients with IE were hospitalised within the first year following index compared with 17.5% in the matched controls. 9.3% of patients with IE were hospitalised for >14 days compared with 3.0% in matched controls. 60 patients with IE (5.7%) died within the first year following index compared with 51 (1.6%) in the matched controls.

Conclusion: Patients with IE who underwent valve surgery had a higher crude mortality than their controls from the background population. After adjusting for confounders, 5-year and 10-year mortality rates remained higher in the IE patient population.

Objective: Sex differences play a critical role in the presentation, progression and treatment outcomes of cardiac diseases. However, historical male predominance in clinical studies has led to disparities in evidence supporting care for both sexes. Clinical guidelines are essential for cardiovascular care, shaping practice and influencing patient outcomes. In this study, we reviewed 34 European Society of Cardiology (ESC) guidelines between 2002 and 2024 to evaluate the representation of women and the inclusion of female-specific recommendations.

Methods: We compiled 136 gender-related keywords, validated by six clinicians, and quantified their occurrence across guidelines. While our primary analysis focused on female-specific keywords, we also identified male-specific terms as a comparison point to help quantitatively interpret the representation of female-specific terminology in the guidelines. Each guideline underwent independent review by two auditors who used structured questions to assess its sensitivity to female-specific differences in disease presentation, diagnosis, management and treatment.

Results: The most frequent terms were 'pregnancy', 'women' and 'sex', with 1768 (17.9%), 1573 (15.9%) and 676 (6.8%) overall repetitions, respectively, contrasted against 'cardiac' (6932 occurrences) as a baseline. Results showed inconsistency in addressing female-specific factors and health considerations in ESC guidelines. We were able to assess the relative frequency of female-specific language and highlight in contrast areas where female representation in cardiovascular guidelines may be insufficient. Most guidelines (24/34) mentioned pregnancy and provided related recommendations, with one of the guidelines entirely dedicated to cardiovascular disease (CVD) in pregnancy (2018) and a new one planned for 2025. Only 10/30 guidelines acknowledged menopause as a CVD risk factor and offered recommendations for clinical practice.

Conclusions: These findings highlight the need for systematic integration of female-specific considerations across all guidelines. In the wider context, there is also a need for improved representation of women in clinical trials and for making the available evidence on which the guidelines are based less biased toward men.

Objective: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are guideline-recommended agents for treating heart failure (HF), but the role of metabolomic biomarkers in underlying mechanisms, particularly acylcarnitines, remains unclear. This study examined the associations of acylcarnitines with SGLT2 inhibition and incident HF.

Methods: This subcohort study included 2178 participants from the prospective China Kadoorie Biobank without cardiovascular disease, diabetes or cancer at baseline. Plasma levels of 40 acylcarnitines were quantified using targeted mass spectrometry-based platforms. The impact of genetically predicted random plasma glucose (RPG) via SGLT2 inhibition on acylcarnitines was assessed with Mendelian randomization (MR). The associations of acylcarnitines with HF risk were assessed using Cox proportional hazards models. Acylcarnitines were classified into short-, medium- and long-chain groups and analysed individually or summed as scores.

Results: Of the 2178 participants, the mean (SD) age was 53.2 (9.8) years. 13 incident HF cases occurred during a median follow-up of 10.5 years. SGLT2 inhibition was associated with higher levels of acylcarnitines, while higher levels of acylcarnitines were associated with reduced HF risk. An unweighted acylcarnitines score was associated with SGLT2 inhibition (β, 2.04 (0.29, 3.79) SD increase per 1 mmol/L lower genetic RPG via SGLT2 inhibition) and HF risk (HR, 0.97 (0.93, 0.99) per 1-SD higher of the score). Glucokinase activation, another antidiabetic agent used for comparison, showed weaker associations with acylcarnitines.

Conclusion: MR analysis indicated SGLT2 inhibition showed associations with acylcarnitines, which are also associated with HF risk. Our findings highlighted the potential involvement of acylcarnitines in the mechanisms between SGLT2 inhibitors and HF.

Background: Despite standardised approaches, subjective assessment and inconsistent diagnostic testing for chest pain in the emergency department (ED) drive costs, disparities and adverse outcomes. Artificial intelligence offers potential to automate and improve risk stratification.

Methods and results: Using a retrospective cohort of 15 048 patients presenting to the ED of a tertiary care hospital, we trained a neural network classifier ('Chest Pain-AI' or 'CP-AI') to predict a 7-day composite endpoint of major cardiovascular diagnoses including myocardial infarction, pulmonary embolism, aortic dissection and all-cause mortality. Inputs to CP-AI included age, sex, cardiac biomarkers (D-dimer or troponin I or T positivity) and numerical representations of presenting 12-lead ECGs. ECG representations were derived using a publicly available deep learning model known as patient contrastive learning of representations. In an external validation set of 14 476 patients, we evaluated CP-AI against comparator models, including a 'Biomarker Model' incorporating clinical data (age, sex, biomarker positivity), based on both the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). CP-AI outperformed the Biomarker Model in prediction of the 7-day composite endpoint with an AUROC of 0.82 (95% CI 0.81 to 0.83) vs 0.79 (95% CI 0.78 to 0.81) and an AUPRC of 0.46 (95% CI 0.44 to 0.49) vs 0.35 (95% CI 0.33 to 0.37) (p<0.05 for both comparisons).

Conclusions: CP-AI, a fully automated neural network classifier, demonstrated superior performance in the prediction of 7-day major cardiovascular diagnoses for patients presenting with acute chest pain compared with conventional models trained on demographics and cardiac biomarkers. CP-AI may standardise and expedite risk stratification of patients presenting to the ED with chest pain.

Background: Machine learning based on clinical characteristics has the potential to predict coronary CT angiography (CCTA) findings and help guide resource utilisation.

Methods: From the SCOT-HEART (Scottish Computed Tomography of the HEART) trial, data from 1769 patients was used to train and to test machine learning models (XGBoost, 10-fold cross validation, grid search hyperparameter selection). Two models were separately generated to predict the presence of coronary artery disease (CAD) and an increased burden of low-attenuation coronary artery plaque (LAP) using symptoms, demographic and clinical characteristics, electrocardiography and exercise tolerance testing (ETT).

Results: Machine learning predicted the presence of CAD on CCTA (area under the curve (AUC) 0.80, 95% CI 0.74 to 0.85) better than the 10-year cardiovascular risk score alone (AUC 0.75, 95% CI 0.70, 0.81, p=0.004). The most important features in this model were the 10-year cardiovascular risk score, age, sex, total cholesterol and an abnormal ETT. In contrast, the second model used to predict an increased LAP burden performed similarly to the 10-year cardiovascular risk score (AUC 0.75, 95% CI 0.70 to 0.80 vs AUC 0.72, 95% CI 0.66 to 0.77, p=0.08) with the most important features being the 10-year cardiovascular risk score, age, body mass index and total and high-density lipoprotein cholesterol concentrations.

Conclusion: Machine learning models can improve prediction of the presence of CAD on CCTA, over the standard cardiovascular risk score. However, it was not possible to improve the prediction of an increased LAP burden based on clinical factors alone.

Background: Optimal antithrombotic therapy and its duration, whether triple therapy with dual antiplatelets plus oral anticoagulant (OAC), or dual antithrombotic therapy with an antiplatelet plus OAC, is uncertain for patients with myocardial infarction (MI) and atrial fibrillation (AF).

Methods: Patients registered in SWEDEHEART (Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies) for their first MI between 2011 and 2021 with a history or new-onset AF were included (n=26 574). Linkage between SWEDEHEART and Swedish administrative health databases was performed, and pseudonymised data analysed.

Results: Over time, OAC use at discharge after MI tripled from 27% in 2011 to 77% in 2021, with direct OACs (DOACs) largely replacing warfarin, predominantly in combination with a single antiplatelet. The strongest factors for initiating OAC therapy were the performance of coronary angiography (OR 1.53 (1.40-1.68)), and percutaneous coronary intervention (OR 1.49 (1.39-1.61)). However, the year of the MI was the most predictive variable associated with OAC initiation, with an OR of 9.31 (7.92-10.95) in 2021 compared with 2011. The clinical factors associated with lower likelihood of OAC initiation were dementia, liver disease, cancer and ST-elevation MI (STEMI) versus non-STEMI.

Conclusions: Use of OAC has increased over the years in patients with MI and concurrent AF, primarily driven by the increased adoption of DOACs. Additionally, there has been a shift in antithrombotic combinations, with most patients in recent years receiving DOAC in combination with a single antiplatelet, reflecting the nationwide implementation of recent evidence and guidelines. However, significant variation in antithrombotic therapy strategies remains.

Objective: Guidelines worldwide recommend specialist outpatient clinics staffed by a multidisciplinary team for management of patients with heart failure (HF). However, there is limited information on how best to select these patients for efficient use of resources. This study aimed to determine the effectiveness of team-based care for patients with HF after discharge from hospital according to duration of intervention and stratification of patients according to risk.

Methods: We retrospectively identified 185 eligible patients who were hospitalised with acute decompensated HF at our institution between January 2021 and June 2023. Multidisciplinary team care was defined as outpatient follow-up by both cardiologists and nurses postdischarge. The primary outcome was a composite of cardiovascular-related death and readmission with HF within 1 year, which was compared between patients receiving HF team care and those receiving standard follow-up.

Results: HF team care was provided for 53.0% of patients, who were younger than those receiving standard follow-up and required more oral inotropes, tolvaptan and amiodarone. Among those receiving HF team care, the majority (58.2%) had an intervention duration of 30 days or less after discharge. After adjusting for background differences by inverse probability of treatment weighting, HF team care was associated with favourable 180-day outcomes, but there was no significant between-group difference in the 1-year primary outcomes. In subgroup analysis, patients with a higher Meta-Analysis Global Group in Chronic Heart Failure score (≥28), indicating a higher risk of exacerbation of HF, had significantly lower 1-year event rates with HF team care (p value for interaction <0.05).

Conclusions: Multidisciplinary HF team care is most effective for patients at higher risk of exacerbation of HF. A risk score model may optimise patient selection for specialised care.

Background: The relationship between left ventricular wall stress (LVWS) and cardiac remodelling post structural intervention has not previously been examined. We examined the relationship between LVWS and cardiac remodelling 6 months post transcatheter aortic valve replacement (TAVR) and MitraClip (MC).

Methods: LVWS was calculated in 40 patients with severe aortic stenosis (AS) and 11 patients with severe mitral regurgitation (MR) immediately preintervention and postintervention with TAVR or MC. LVWS was calculated by integrating invasive haemodynamic data with cardiac MR (CMR)-derived measures of left ventricular (LV) volume and mass. Patients underwent a 6 min walk test (6MWT), transthoracic echocardiogram and CMR preprocedure and 6 months postprocedure.

Results: Both TAVR and MC resulted in significant improvements in functional capacity and cardiac remodelling with no significant difference in the degree of LV mass or volume reduction between the two groups.Linear regression analysis showed that baseline diastolic LVWS (D-LVWS) in the MC cohort and baseline systolic LVWS (S-LVWS) in the TAVR cohort were predictors of larger LV end-diastolic volumes (EDV) and lower ejection fractions (EF) at follow-up (in the MC cohort: B=7.86, p=0.015 for EDV, B=-1.4, p=0.02 for EF; in the TAVR cohort: B=1.53, p=0.04 for EDV and B=-0.702, p<0.001 for EF).

Conclusions: Higher baseline D-LVWS in patients undergoing MC, and higher baseline S-LVWS in patients undergoing TAVR, were predictors of poorer EF and larger LV volumes at follow-up. These findings suggest that LVWS may be used to predict the degree of LV recovery postprocedure and suggest that intervening below a certain LVWS threshold may lead to better outcomes with regards to cardiac remodelling.

Condensed abstract: LVWS was calculated in patients with AS and mitral regurgitation (MR) pre and immediately post valve intervention with TAVR or MC. The patients were followed up at 6 months with 6MWT, echocardiography and CMR imaging Both cohorts demonstrated significant functional improvements and cardiac remodelling postprocedure. Baseline D-LVWS in MC and baseline S-LVWS in TAVR were predictors of poorer EF and larger LV volumes at follow-up. This suggests that in patients with severe AS or MR, baseline LVWS may be useful to predict degree of recovery postintervention or determine need for early intervention.