Open Heart最新文献

Background: Hypertension is a major cause of premature death worldwide, controlled by only one in five adults. Two trials (Australia and USA) found a single quadpill containing a quarter dosage of four classes of medication effective in reducing blood pressure (BP) among participants with hypertension. By pooling these trials, we can estimate the overall benefit of the quadpill and its heterogeneity across subgroups and two important barriers for BP control: clinician medication inertia and participant medication adherence.

Methods: In a prespecified pooled individual participant data analysis of two QUARTET randomised, multicentre, double-blinded trials in people with hypertension using ≤1medication, quadpill (irbesartan (37.5 mg) (Australia)/candesartan (2 mg) (USA)), amlodipine (1.25 mg), indapamide (0.625 mg), bisoprolol (2.5 mg) unattended office systolic BP (SBP) at 12 weeks was compared with initial monotherapy (irbesartan (150 mg) (Australia), candesartan (8 mg) (USA)). Heterogeneity was assessed using an interaction term in the mixed cox model. Adherence, ≥80% pill count and treatment inertia were estimated.

Results: In 653 participants (Australia, 591 (91%); USA, 62 (9%)) a significant drop in mean SBP (6.5 mm Hg (95% CI 4.8 to 8.8; p<0·001)) and diastolic BP (5.6 mm Hg (95% CI 4.5 to 6.9; p<0.001)) in favour of the quadpill was found, with less need for uptitration (p<0.001) and less treatment inertia (non-significant: p=0.303). Adherence was high for both treatment arms (over 80%). Compared with monotherapy, the quadpill effect varied by ethnicity (SBP reduced by White (6.9 mm Hg; 95% CI 4.7 to 9.2), Hispanic (3.3 mm Hg; 95% CI 4.0 to 10.6), Asian (12.3 mm Hg; 95% CI 6.2 to 18.5) and Black/other (1.4 mm Hg; 95% CI -9.0 to 6.3), interaction p=0.032).

Conclusion: This prospective individual participant data pooled analysis provides further evidence that the quadpill strategy is superior to initial monotherapy by virtue of improved BP-lowering, less need for uptitration and being associated with less treatment inertia.

Background: Predicting progression to aortic valve replacement (AVR) in moderate aortic stenosis (AS) is challenging. This study explored whether haemodynamic parameters from four-dimensional flow MRI (4D flow MRI) are associated with the potential progression to AVR.

Methods: 15 patients with moderate AS underwent baseline 4D flow MRI and echocardiography, with repeat echocardiography within 2 years. Patients were categorised into AVR (n=8) or no-AVR (n=7) groups based on whether they underwent AVR during follow-up.

Results: AVR occurred a mean of 396±156 days after baseline. The AVR group had higher follow-up peak velocity (p=0.001), mean pressure gradient (p=0.022) and smaller valve area (p=0.004). Baseline peak vortex volume was greater in the AVR group (p=0.009) and was associated with AVR with an area under the curve of 0.88 (95% CI 0.82 to 1.00). Peak vortex volume moderately correlated with baseline (r=0.69) and follow-up (r=0.63) peak velocity and baseline mean pressure gradient (r=0.59) measured by echocardiography.

Conclusion: Abnormal vortex formation may reflect haemodynamic alterations associated with AS progression and eventual AVR. These exploratory results should be validated in larger cohorts to define the potential role of 4D flow MRI-based vortex assessments in AS evaluation.

Objective: Identify predictors for mortality and clinical short-term outcomes in patients with left-sided infective endocarditis (IE).

Methods: This study was a retrospective cohort investigating 376 patients who experienced left-sided IE between 1 January 2013 and 31 December 2022, at the National Cardiovascular Center Harapan Kita Hospital. Bivariate and multivariate statistical analyses were conducted to identify predictors of short-term clinical outcomes.

Results: The study comprised 376 patients with left-sided IE who received standardised antibiotic therapy, with 56.6% of them undergoing surgical intervention. The observed short-term mortality rate was 18.6%. Furthermore, the morbidity profile during the treatment phase revealed the following incidences: sepsis in 27.1% of cases, intensive care unit stay exceeding 10 days in 18.6% of cases, mechanical ventilation for more than 7 days in 11.4% of cases, stroke in 28.5% of cases and acute renal failure in 57.7% of cases.

Conclusion: Predictors of short-term mortality outcomes in patients with left-sided IE included New York Heart Association functional class III-IV, aortic valve vegetation involvement, vegetation size ≥10 mm, incomplete antibiotic administration, sepsis and the requirement for renal replacement therapy.

Background: Previous epidemiological studies demonstrated that premature atrial contractions (PACs) and premature ventricular contractions (PVCs) detected by single 12-lead ECGs can predict incident cardiovascular disease and death. The determinants of cardiac ectopy remain unknown, with some evidence that hypertension may contribute.

Objective: To determine if intensive blood pressure (BP) control reduces the incidence of cardiac ectopy.

Methods: We performed a post-hoc analysis of the Systolic Blood Pressure Intervention trial, which randomised hypertensive participants to standard treatment (BP target <140 mm Hg) or intensive treatment (<120 mm Hg) with ECGs obtained at baseline, 2 years, 4 years and 5 years. The primary outcomes were incidence of ectopy (PACs or PVCs) as coded by Minnesota ECG classification, censoring for pacing, atrioventricular block, pre-excitation or atrial fibrillation/flutter. We performed Cox proportional hazards regression to determine the association of treatment group with outcomes.

Results: The analysis cohort comprised 3910 participants randomised to standard treatment and 3911 to intensive treatment, of whom 452 had ectopy on baseline ECG. After excluding those with baseline ectopy, there was no significant difference in the incidence of ectopy (incidence rate ratio 0.93 (95% CI 0.81 to 1.05)). There was no significant association between treatment group and ectopy incidence, with an unadjusted Cox HR of 0.93 (95% CI 0.82 to 1.07), and HR of 1 (95% CI 0.81 to 1.25) after adjusting for covariates.

Conclusion: Intensive BP control did not reduce the incidence of cardiac ectopy in patients with hypertension. Given the variable nature of PAC and PVC burden, further studies with continuous monitoring or more frequent sampling in larger populations are warranted.

Aims: To evaluate the effect of combining real-time deep learning (DL)-based guiding and automated measurements of left ventricular (LV) volumetric measurements and strain.

Methods and results: Patients (n=47) with mixed cardiac pathology were examined by two sonographers and one reference cardiologist. A real-time DL guiding tool to avoid LV foreshortening was used by one sonographer only per patient. Automated DL-based measurements from the sonographer using the guiding tool were paired with automated measurements from the reference cardiologist (artificial intelligence (AI)-assisted echocardiography), while manual measurements from the sonographer not using the guiding tool were paired with manual measurements from the reference cardiologist (standard echocardiography). The variability of LV EDV, LV ESV, ejection fraction (LV EF) and global longitudinal strain (LV GLS) was compared for standard echocardiography versus AI-assisted echocardiography. Coefficients of variation were lower for AI-assisted echocardiography compared with standard echocardiography (6% vs 15% for LV EDV (p<0.001), 10% vs 19% for ESV (p<0.001) and 7% vs 11% for GLS (p=0.047), respectively). For LV EF, the coefficients of variation were similar across groups (8% vs 9%, p=0.503, respectively). In exploratory analyses, automated measurements alone (all p≤0.002) but not the guiding tool (all ≥0.199) explained the improved variability for LV EDV, ESV and GLS.

Conclusions: AI-assisted echocardiography combining DL-based real-time guiding and automated measurements significantly reduced the variability of LV EDV, ESV and GLS when compared to standard echocardiography. Among experienced operators, automated measurements were more beneficial than real-time guiding.

Trial registration number: ClinicalTrials.gov, ID: NCT04580095.

Aim: To systematically evaluate whether relationships between cardiac rehabilitation participation and clinical outcomes, return to work, or knowledge about cardiovascular disease vary across socioeconomic indicators.

Methods: A systematic review was conducted using CENTRAL, CINAHL, Embase and Medline up to 1 November 2024. Studies were included if they compared outcomes between participants who received cardiac rehabilitation and those who did not or received an exercise programme. Outcomes included all-cause death, all-cause and cardiovascular-related rehospitalisation, return to work and cardiovascular knowledge, stratified by socioeconomic indicators. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies-of Interventions-I tool.

Results: Six studies involving 555 731 participants were included. Compared with non-participants, cardiac rehabilitation participants had lower rates of all-cause death (12.3%-16.9%) and all-cause rehospitalisation (15.2%-16.1%), with incidence rate differences in cardiovascular-related rehospitalisation reaching up to 27.8 fewer events/100 person-years. Some of the greatest differences were among participants residing in more disadvantaged areas, although this was not consistent across studies. No significant differences were observed in the combined outcome of all-cause death and cardiovascular-related rehospitalisation when stratified by educational attainment levels. Return to work and knowledge outcomes showed greater variation across education and income subgroups, with higher values consistently observed among cardiac rehabilitation participants from less disadvantaged backgrounds. All studies were observational and had moderate risk of bias.

Conclusions: Cardiac rehabilitation improves clinical and functional outcomes across socioeconomic subgroups, although disparities in participation and outcomes persist. Tailoring programme delivery to be more flexible and responsive to literacy needs may help ensure its benefits are equitably achieved across patient subgroups.

Prospero registration number: CRD42022332355.

Background: Hypertension is a significant risk factor for cardiovascular disease, dementia and chronic kidney disease (CKD). Older adults bear the brunt of these conditions, and managing hypertension can be especially challenging in this cohort. In this study, we apply the European Society of Cardiology (ESC) hypertension guidelines to adults ≥50 years participating in a nationally-representative longitudinal study on ageing, providing crucial context for guideline implementation among older adults.

Methods: Data from waves 1 (2009-2010), 3 (2014-2015) and 6 (2021-2023) of The Irish Longitudinal Study on Ageing were analysed. Hypertension (blood pressure (BP) ≥140/90 mm Hg) prevalence, awareness, treatment, control (on-treatment BP <130/80 mm Hg) and adherence to ESC recommendations were assessed. Subgroup analyses included people aged ≥85 years, adults with frailty, with CKD and with home BP measurements. Data were analysed using Stata V.15.1 applying inverse probability weighting.

Results: From wave 3 (n=5329), weighted hypertension prevalence was 64.0% (62.4-65.6%). Of these, 55.5% were aware and 70.3% were on antihypertensive treatment. 32.2% on treatment had controlled BP, 20.9% were on dual therapy and 55.2% were taking one ESC-recommended agent. 87.8%, 77.1% and 76.7% of those with hypertension at waves 1, 3 and 6 were undiagnosed, untreated or uncontrolled. Hypertension prevalence was 91.1% (84.7-95.0%) in people ≥85 years and 75.9% (69.3-81.5%) in moderate-severe frailty.

Conclusions: In a nationally-representative sample of older Irish adults, there is a high prevalence of hypertension, with low awareness, control and adherence to ESC guidelines.

Objective: To develop and validate a 10-year predictive model for cardiovascular and metabolic disease (CVMD) risk using comprehensive health examination data from nearly 37 701 individuals.

Methods: This retrospective cohort study used health examination data, including demographic information, clinical measurements, laboratory tests and lifestyle factors. Potential predictors were selected based on a literature review and exploratory analysis. Machine learning techniques (including random forest and gradient boosting) were employed to develop the predictive model. The model's performance was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Model validation was conducted on separate test and validation sets.

Results: A total of 37 701 electric power employees were included in this study after applying rigorous inclusion and exclusion criteria. The dataset was divided into training, validation and testing sets in a 70:15:15 ratio, with no significant differences observed in baseline characteristics, ensuring robust analysis. Feature selection using the random forest classifier identified the top predictors of CVMD. Machine learning models, particularly random forest and gradient boosting, demonstrated superior predictive performance compared with traditional Cox regression methods. These results significantly outperformed traditional Cox models, which yielded an AUC of approximately 0.60. Correlation analysis revealed strong associations between key variables, such as systolic and diastolic blood pressure, low-density lipoprotein and total cholesterol, and creatinine and blood urea nitrogen, highlighting the complex interactions among CVMD risk factors.

Conclusion: The developed 10-year predictive model for CVMD risk, based on health examination data, shows promising potential for early identification and targeted intervention in individuals at high risk for CVMDs. This approach could contribute to the reduction of CVMD incidence and related morbidity and mortality.

Background: Patients with single-ventricle physiology are often palliated with the Fontan operation, which may involve the creation of a fenestration. We aimed to evaluate differences in cardiopulmonary exercise test (CPET) performance between patients with fenestrated and non-fenestrated Fontan circulation.

Methods: Patients with a Fontan circulation referred to CPET between 2006 and 2024 were included and were categorised based on their fenestration status at the time of CPET. Logistic regression analyses were performed to assess the impact of fenestration on peak oxygen consumption (VO₂), and Cox proportional hazard to evaluate the impact of fenestration on cardiovascular outcomes (death, heart transplant and Fontan-related hospitalisation).

Results: Of the 184 patients, 141 were classified as non-fenestrated and 43 as fenestrated. The minute ventilation-carbon dioxide production (V_E/VCO₂ slope) was higher in the fenestrated (36.9±7.9) versus (33.2±6.2; p=0.009) in the non-fenestrated group. There was no significant difference in predicted VO₂ between groups (non-fenestrated 51.9%±14.4 vs 51.3%±15.6; p=0.7). Resting oxygen saturation was higher in the non-fenestrated group (93%±4.7 compared with fenestrated group 90.1%±5; p<0.001). Fontan fenestration was not significantly associated with the composite outcome; older patient age at the time of the CPET, cirrhosis and ventricular ejection fraction <40% were significantly associated with higher risk, while higher resting systolic blood pressure, left ventricular morphology and higher predicted peak VO₂ were protective.

Conclusions: The increased hypoxia and reduced ventilatory efficiency associated with Fontan fenestration offset any potential benefits, resulting in similar exercise performance between the groups. Fontan fenestration was not significantly associated with cardiovascular outcomes.

Background: Left ventricular mass (LVM) is suggested to be a sensitive predictor of adverse cardiovascular outcomes, such as heart failure. In recent years, genome-wide association studies have discovered loci that associate with outcomes related to LVM, providing an opportunity for the development of genetic risk scores. However, the relevance of these genetic variants to non-European ancestry groups requires additional testing. Here, we examined if variants that have been associated with heart failure and LVM in multi-ancestry populations are associated with LVM among African American individuals in the Jackson Heart Study (JHS).

Methods: Heart failure and LVM associated variants were identified from two published multi-ancestry studies. Two polygenic risk scores (PRSs) were computed for 2175 African American participants (mean age 53, 63% female). We assessed the linear association of both PRSs with LVM indexed to height (LVM_h) and indexed to body surface area (LVM_bsa) and fit a multivariate general linear model to LVM containing both PRS and covariates (age, sex, body mass index (BMI), diabetes and hypertension). Type III MANOVA Pillai tests were run to assess the effects of the PRS on the log LVM values.

Results: Linear correlation analysis showed positive associations between age and LVM_h (r=0.278) and LVM_bsa (r=0.296) as well as BMI with LVM_h (r=0.320). A strong linear correlation was observed between LVM_h and LVM_bsa (r=0.894). Elevated LVM among individuals with diabetes and hypertension was observed. When accounting for age, sex, BMI, diabetes and hypertension, we found insufficient evidence to suggest that the heart failure PRS affected either measure of LVM; the same can be said for the LVM PRS.

Conclusion: We find insufficient evidence to suggest that heart failure and LVM genetic variants derived from predominantly European multi-ancestry populations are linearly associated with log LVM among African American participants in the JHS.