Open Heart最新文献

Introduction: Atrial fibrosis identified on cardiac magnetic resonance (CMR) imaging has been proposed as a preprocedural imaging biomarker for patient selection for rhythm control interventions in patients with atrial fibrillation (AF). Whether atrial fibrosis is present in patients considered as 'pre-AF' is unknown.

Methods and results: We prospectively recruited 12 participants with pre-AF as defined by the Future Innovations in Novel Detection for Atrial Fibrillation (FIND-AF machine learning algorithm, without AF diagnosed during AF screening, and compared them to 25 participants with confirmed AF. All participants underwent CMR using a 3T system with left atrial fibrosis quantification and ADAS-3D left atrial image postprocessing software. Participants with pre-AF had smaller left atrial end-systolic (33.6±9.8 vs 43.0±17.0, p=0.003) and end-diastolic (16.5±8.7 vs 28.2±14.4, p=0.007) volumes, and higher left atrial ejection fraction (59.6±14.6 vs 40.7±17.5, p=0.005) than participants with AF. The extent of atrial fibrosis was not different between those with pre-AF and AF (borderzone (%) 5.2±5.0 vs 2.9±6.9, p=0.772; borderzone fibrosis (cm) 6.2±5.8 vs 6.8±10.7, p=0.927).

Conclusion: CMR identifies atrial fibrosis before manifest AF in patients with pre-AF as defined by a machine learning algorithm.

Background: Mitral regurgitation (MR) is the most common valvular heart disease and the most common comorbidities of atrial fibrillation (AF), which is prevalent with age. Nonetheless, the prognosis of MR in elderly patients with AF has not been fully elucidated.

Aim: This study is a post hoc analysis of the CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial.

Methods: Patients were classified into two groups: those with moderate or severe MR (msMR) and those with no or mild MR (nmMR). The primary endpoint was a composite of death, disabling stroke, serious bleeding or cardiac arrest. The secondary endpoints included all-cause mortality and the composite of all-cause mortality and heart failure hospitalisation. Quality of life was assessed at baseline, 3 and 12 months, and annually up to 60 months.

Results: Overall, 1368 participants were included in the final analysis (mean age: 65.6±8.2; female 61.3%), including 135 patients with msMR and 1233 with nmMR. The primary endpoint occurred in 7.2% of patients with nmMR versus 14.1% with msMR (HR 1.97, 95% CI 1.20 to 3.25; p=0.008). The secondary endpoint rates for nmMR versus msMR, respectively, were 4.7% vs 8.8% for all-cause mortality (HR 1.73, 95% CI 0.92 to 3.25; p=0.089) and 10.8% vs 15.5% for the composite of death and heart failure hospitalisation (HR 1.25, 95% CI 0.78 to 1.99; p=0.357).

Conclusions: Among elderly patients with AF, msMR is associated with an increased risk of the primary composite endpoint of death, disabling stroke, serious bleeding or cardiac arrest.

Trial registration number: NCT00911508.

Heart failure (HF) is of worldwide public health concern, yet with higher morbidity and mortality in low- and middle-income countries compared with high-income nations, posing a significant burden to the already overstrained and unprepared health systems in many countries.In sub-Saharan Africa (SSA), while community level data is sparse, a number of hospital-based HF studies have been conducted, highlighting the distinct presentation of HF when compared with data from other regions of the world. It is imperative that more data on the precise nature of HF in Africa are obtained, but multiple barriers exist to obtaining reliable data. In the present commentary, we discuss characteristics of HF in Africa, their potential impact on conducting screening studies at the community level and describe the strategies that we have incorporated in the MAPUTO-HF (The Maputo Antecedents, Prevalence and Urban Transition Of Heart Failure Project: feasibility of a population-based study in a low-resource African setting) study, a feasibility study that was designed to overcome these barriers and facilitate HF research in SSA in both a rural and urban setting.

Background: Left ventricular (LV) thrombus is a complication of myocardial infarction and dilated cardiomyopathy and is associated with a high thromboembolic risk. Although warfarin has traditionally been used, direct oral anticoagulants (DOACs) offer a more convenient alternative. With the addition of the RIVAWAR trial, we conducted an updated systematic review and meta-analysis to assess the efficacy and safety of DOACs compared with warfarin in patients with LV thrombus.

Methods: A systematic search of electronic databases (PubMed, EMBASE, Cochrane and clinicaltrials.gov) from inception to April 2025 identified randomised clinical trials (RCTs) comparing DOACs with warfarin for the treatment of LV thrombus. The main outcome of interest was thrombus resolution at 3 months. Risk ratios (RRs) with 95% CIs were calculated using random-effects models.

Results: Seven RCTs comprising 554 patients were included. Non-contrast transthoracic echocardiography was used for LV thrombus assessment in all RCTs. There was no difference between DOACs and warfarin in thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09), major adverse cardiovascular events (RR 0.50; 95% CI 0.16 to 1.54), all-cause mortality (RR 0.92; 95% CI 0.36 to 2.31), stroke/systemic embolism (RR 0.76; 95% CI 0.12 to 4.68), rehospitalisation (RR 1.36; 95% CI 0.47 to 3.94) or major bleeding (RR 0.54; 95% CI 0.20 to 1.48). Subgroup and sensitivity analyses confirmed the robustness of these results.

Conclusions: DOACs demonstrated similar efficacy and safety to warfarin for LV thrombus management in this meta-analysis, supporting their use for the treatment of LV thrombus. However, large-scale RCTs with longer follow-up periods and using diagnostic modalities with higher sensitivity and specificity for detecting LV thrombus resolution are warranted to confirm these findings and clarify long-term outcomes.

Prospero registration number: CRD420251023513.

Background: Eisenmenger syndrome (ES) is a severe and fatal complication of uncorrected congenital heart disease characterised by the development of pulmonary arterial hypertension (PAH) due to chronic left-to-right shunting. Despite the increasing use of PAH-targeted therapies, evidence of their long-term effects on the survival of patients with ES remains limited.

Methods: We reviewed 101 consecutive adult patients with ES (69% female; mean age, 34±18 years) who were referred to our centre between December 1972 and December 2023. We investigated the clinical, haemodynamic and treatment data from medical records. The primary outcome measure was transplantation-free survival. The effect of PAH-targeted therapy on transplantation-free survival was analysed using a time-dependent Cox proportional hazards model.

Results: Among the 101 patients, 57 (56%) received PAH-targeted therapy (PAH therapy group), while 44 (44%) did not (treatment-naïve group). In the PAH therapy group, 75% received combination therapy (25%, monotherapy; 56%, dual-combination therapy; and 19%, triple-combination therapy). The median follow-up time since diagnosis of ES was 8.8 (IQR: 4.1-22.3) years. The median follow-up transplantation-free survival rates were significantly higher in the PAH therapy group than in the treatment-naïve group (100%, 100% and 89% vs 95%, 66% and 53% at 1, 5 and 10 years, respectively; p<0.001). In the multivariate analysis adjusting for age, sex, WHO functional class (III/IV vs I/II) and PAH-targeted therapy, PAH-targeted therapy was independently associated with improved transplantation-free survival (adjusted HR=0.275, 95% CI 0.132 to 0.572).

Conclusions: The long-term survival of patients with ES who received PAH-targeted therapy was better than that of those who did not. These results support the benefits of PAH-targeted therapies in this population while underscoring the need for large-scale studies to better define optimal treatment strategies.

Background: Nonagenarians and centenarians admitted to intensive care units (ICUs) following in-hospital cardiac arrest (IHCA) represent a growing yet understudied population. Clinicians require accurate prognostic tools to inform early goals of care discussions and resource allocation. This study evaluated the predictive performance of commonly used clinical scores in this unique cohort.

Methods: We conducted a retrospective binational cohort study of nonagenarian and centenarian patients admitted to ICUs in Australia and New Zealand between 2010 and 2024 after IHCA, using data from the ANZICS Adult Patient Database. We assessed the prognostic accuracy of four clinical scores: Acute Physiology and Chronic Health Evaluation III (APACHE III), Sequential Organ Failure Assessment (SOFA), Clinical Frailty Scale (CFS) and Glasgow Coma Scale, in predicting ICU and hospital mortality. Discrimination was measured using area under the receiver operating characteristic curve (AUROC). Multivariable Cox regression and Fine-Gray competing risk models were used to examine associations with mortality and discharge outcomes.

Results: A total of 219 patients (median age 91.6 years; 44% female) were included. ICU and hospital mortality were 45.2% and 55.7%, respectively. The APACHE III score showed the highest discriminatory ability (ICU mortality AUROC=0.850; hospital mortality AUROC=0.842), followed by the SOFA score (AUROCs=0.758 and 0.761, respectively). The CFS showed poor prognostic performance (AUROCs close to 0.5). In adjusted Cox models, both APACHE III and SOFA scores were independently associated with mortality. SOFA scores were associated with longer ICU length of stay, while higher APACHE III scores were associated with shorter hospital stay, likely reflecting early mortality.

Conclusions: In the oldest critically ill patients following IHCA, physiologic severity scores, particularly APACHE III and SOFA, outperform frailty in predicting short-term mortality and resource use. These findings support the integration of validated scoring systems into early clinical decision-making to improve care precision and guide resource allocation in ageing ICU populations.

Background: Heart failure (HF) is a major cause of morbidity and mortality worldwide. Despite significant improvements in the management of HF, the overall outcome remains poor. In addition to pharmacotherapy and device therapy, non-pharmacological interventions are needed to mitigate the effects of this illness. The aim of this study was to evaluate the impact of the HF outreach programme on the rate of mortality, HF hospitalisations and guideline-directed medical therapy (GDMT) for HF in South-Western Sydney Local Health District (SWSLHD).

Methods: In this observational, registry-based study, adult patients diagnosed with HF with reduced ejection fraction (HFrEF) in SWSLHD were invited to participate in the HF outreach service between March 2011 and January 2016. The primary outcome was all-cause mortality. The secondary outcomes were the rate of optimal GDMT and HF hospitalisations.

Results: There were 818 patients included in the study; 470 (57.5%) patients were enrolled and 348 (42.5%) not enrolled into the programme. At the end of the follow-up period (median 978 days, IQR 720-1237), the primary outcome of mortality was observed less in the enrolled group (122 (26%) vs 133 (38.2%), p<0.001) independently of other variables. In addition, fewer enrolled patients had >3 hospital admissions for HF (16.2% vs 35.6%, p<0.001) and reduced median admission days (14.5 days (IQR 8-25) vs 22 days (IQR 12-37), p<0.001). Patients enrolled into the programme were more likely to be on optimal GDMT (76.6% vs 56.6%, p<0.001).

Conclusions: Enrolment in the HF outreach programme was associated with a significant reduction in mortality and the frequency and length of hospital HF admissions. In addition, the rate of optimal GDMT was significantly higher in the enrolled group. With the high prevalence of HF, these programmes should be considered in the routine management of patients with HFrEF.

Background: Hypothyroidism has been suggested as a predisposing and prognostic factor in patients with spontaneous coronary artery dissection (SCAD), but evidence in this regard is very limited.

Methods: This study sought to compare differences in clinical presentation, angiographic findings, management and outcomes between SCAD patients with (H-SCAD) and without (NH-SCAD) a history of hypothyroidism from the prospective nation-wide Spanish SCAD Registry.

Results: Overall, 47 H-SCAD (12%) and 342 NH-SCAD patients were included. H-SCAD patients when compared with NH-SCAD patients were significantly older (57±10 vs 54±12 years, p=0.045), had more frequent dyslipidaemia (49% vs 31%, p=0.013) and a non-significant trend to more associated fibromuscular dysplasia (47% vs 30%, p=0.191). Clinical presentation did not differ between groups, with non-ST-segment elevation myocardial infarction being the more frequent diagnosis at admission (62% vs 53%, p=0.273). H-SCAD patients showed more frequent multivessel involvement (19% vs 9%, p=0.044), angiographic type 2b lesions (36% vs 23%, p=0.037), lesions at segments with side-branches (68% vs 52%, p=0.026) and tighter lesions (88±13% vs 77±21% diameter stenosis, p=0.001), but less involvement of proximal segments (5% vs 15%, p=0.044). Revascularisation was more commonly needed in H-SCAD patients (34% vs 20%, p<0.05). At late clinical follow-up (median 29 months), the H-SCAD group had a higher adverse event rate (27% vs 11%, p=0.033), mainly driven by myocardial infarction (16% vs 6%, p=0.031) and SCAD recurrence (9% vs 1%, p<0.001). On multivariable analysis, the presence of hypothyroidism remained independently associated with adverse clinical events.

Conclusions: H-SCAD patients were older and had a more diffuse and aggressive angiographic phenotype, including type 2b lesions, tighter lesions and more frequent multivessel involvement. Revascularisation was more frequently needed in H-SCAD patients. Long-term outcomes were poorer in this group, mainly driven by myocardial infarction and SCAD recurrence.

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, and CT imaging plays a crucial role in its diagnosis and management. However, the clinical use of CT is limited by factors, such as suboptimal image quality, diagnostic complexity and the labour-intensive nature of parameter evaluation. Artificial intelligence (AI) is increasingly transforming many areas of medicine. Its integration into CAD CT imaging can enhance image postprocessing, streamline anatomical and functional analyses, support treatment planning and improve risk prediction. This review summarises recent advances in these AI applications, aiming to promote their practical adoption and further development.

Objective: To evaluate the association between β-blocker use and all-cause mortality in a real-world cohort of patients with myocardial infarction (MI).

Methods: This study included 2308 patients with MI from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The primary outcome was all-cause mortality. Multiple approaches were employed to control for confounding, including multivariable Cox regression, propensity score matching and inverse probability of treatment weighting.

Results: Based on data from 2308 patients with MI in the NHANES 1999-2018, with a mean follow-up of 84.6 months, this study evaluated the association between β-blocker use and all-cause mortality. The unadjusted analysis showed a significant protective effect (HR 0.81, 95% CI 0.68 to 0.96, p=0.0178). However, after multivariable adjustment for demographic, clinical and socioeconomic factors, as well as propensity score-based methods and inverse probability of treatment weighting, no significant association was observed (e.g., adjusted HR 1.04, 95% CI 0.87 to 1.25, p=0.6733). Stratified analyses did not reveal significant effect modification by any covariate (all p interaction value >0.05).

Conclusion: After adjustment for measured confounders, this analysis found no significant association between β-blocker use and all-cause mortality in this real-world MI cohort.