Open Heart最新文献

Background: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) carries high mortality. Early revascularisation improves survival, but the effect of structured multidisciplinary care on outcomes remains underexplored.

Methods and results: ACT-SHOCK is a service evaluation at a UK tertiary cardiac centre. Between May 2023 and May 2024, 82 patients with AMI-related CS requiring emergent percutaneous coronary intervention (PCI) were identified using protocolised physiological criteria and managed by an Advanced Cardiogenic-Shock Team (ACT). The ACT comprised interventional cardiologists, intensivists, anaesthetists, critical care staff and cardiac physiologists, coordinating PCI and ongoing care. Outcomes were compared with 83 historical controls from the year preceding ACT roll-out, who received standard care without ACT activation. Primary endpoints were 30-day and 1-year all-cause mortality; secondary outcomes included predictors of 30-day mortality.Within the ACT cohort, elevated lactate, critical care admission, invasive ventilation, out-of-hospital cardiac arrest and Society for Cardiovascular Angiography and Interventions (SCAI) Shock Stage E at first medical contact predicted 1-year mortality. Adjusted analyses showed ACT management was associated with lower 1-year mortality compared with standard care (HR 0.53, 95% CI 0.30 to 0.92; p=0.026). Although 30-day mortality was lower in the ACT group, this did not reach statistical significance (HR 0.71, 95% CI 0.39 to 1.29; p=0.26). Escalation from coronary care to critical care during the recovery phase occurred more promptly in the ACT group (9.7% vs 2.4%, p=0.09). At 24 hours, a smaller proportion of ACT patients remained in SCAI stages D/E compared with standard care (42% vs 48%; p=0.003).

Conclusions: Implementation of physiological criteria to identify CS and activation of a multidisciplinary ACT in a UK tertiary centre was associated with earlier detection and improved 1-year survival in AMI-related CS. These pilot data support further study across multiple UK centres to inform national policy and standardise care pathways.

Background: Aortic dimensions are critical for assessing the risk of acute aortic complications and guiding surgical interventions. Current guidelines define absolute diameter thresholds based largely on Western cohorts, while data on Indian patients remain limited. To address this gap, our study provides a direct, large-scale comparison of aortic diameters between Indian and Dutch individuals to determine whether existing geometry-based surgical guidelines are equally applicable across populations.

Methods: In this retrospective cohort study, we analysed all consecutive patients who underwent CT imaging between January and December 2022 at SIMS Hospital (India) and Amsterdam University Medical Center (Netherlands). Aortic diameters were measured at five predefined anatomical locations: aortic root, ascending aorta, aortic arch, descending aorta and abdominal aorta. Multivariable linear regression models were used, adjusting for age, sex, height and comorbidities.

Results: A total of 3692 patients were included (2000 Indian and 1692 Dutch). Indian patients had a larger aortic root (33.9 ± 4.6 mm vs 31.5 ± 5.4 mm; p<0.001), whereas Dutch patients had significantly larger diameters of the ascending aorta (33.1 ± 5.4 mm vs 30.5 ± 4.3 mm; p<0.001), aortic arch (29.8 ± 4.5 mm vs 26.4 ± 3.7 mm; p<0.001), descending aorta (26.7 ± 4.2 mm vs 23.0 ± 3.9 mm; p<0.001) and abdominal aorta (23.1 ± 5.0 mm vs 21.3 ± 3.4 mm; p<0.001). These differences persisted after adjustment for age, sex, height and comorbidities.

Conclusions: In this first global comparison of ascending aortic dimensions between Indian and Dutch patients, we demonstrate substantial geographic heterogeneity. These findings highlight concerns about applying current surgical thresholds to Indian patients with aortopathy and emphasise the need for individualised risk assessment and treatment strategies in this population. Future guidelines should consider population-specific differences in India and incorporate indexed measurements to optimise personalised surgical decision-making.

Introduction: Inherited cardiac conditions, including dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM), may have a monogenic cause identified through genetic testing (GT). Confirmation of pathogenic gene variants can have important implications for the patient and their relatives. The UK National Genomic Test Directory (NGTD) provides strict criteria on the indications for GT; however, the European Society of Cardiology (ESC) recommends wider GT. We reviewed the prevalence of pathogenic genotypes in patients undergoing GT who did not meet the NGTD criteria.

Methods: We conducted a retrospective analysis of patients who underwent GT with a confirmed diagnosis of HCM or DCM attending the Essex Inherited Cardiac Conditions Clinic between January 2023 and January 2025.

Results: 257 patients were included in the analysis, with 136 patients with DCM (52.9%) and 121 patients with HCM (47.1%). The diagnostic yield of GT was 19.9% in DCM and 17.4% in HCM.14.8% of gene-positive patients with DCM and 14.3% of gene-positive patients with HCM did not meet current UK testing criteria, predominantly due to age of onset. All gene-positive patients in the DCM subgroup not meeting current NGTD criteria for testing had evidence of myocardial fibrosis.

Conclusion: A significant minority of patients (1 in 7) with cardiomyopathy and a pathogenic genotype did not meet current UK testing criteria; each patient has an average of 4 first-degree relatives at risk who will benefit from predictive GT. We propose the adoption of the wider ESC guidance, removing the strict age-related cut-offs and being guided more by the severity of the phenotype, particularly involving myocardial scarring.

Background: Biomarkers could improve risk stratification in patients with acute ST-segment elevation myocardial infarction (STEMI), beyond left ventricular ejection fraction (LVEF). Our study evaluated the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP), C reactive protein (CRP) and mortality in a cohort of patients with acute STEMI.

Methods: This prospective, observational cohort study included patients with reperfused acute STEMI admitted to a tertiary cardiovascular disease centre between July 2020 and October 2023. All patients underwent NT-proBNP and CRP testing. The association between NT-proBNP, CRP and all-cause mortality was evaluated in relation to predischarge LVEF.

Results: The cohort included 566 patients with a mean age of 63 years. After a median follow-up of 39 months, postdischarge all-cause mortality reached 13.4%. NT-proBNP was associated with mortality irrespective of LVEF (HR 2.34 per SD increment in log NT-proBNP; p<0.001 at LVEF <50% and HR 2.36; p=0.004 at LVEF ≥50%), but the association between CRP and mortality was significant only in patients with LVEF <50% (HR 1.55, p=0.003). Across the cohort, NT-proBNP remained associated with death after adjustment for age, sex, diabetes, baseline high-sensitivity cardiac troponin T (hs-cTnT), CRP, final Thrombolysis in myocardial infarction (TIMI) flow grade and reduced LVEF (HR 1.45, p=0.03). In patients with preserved LVEF, routine NT-proBNP testing (area under the curve (AUC) 0.753 (0.642-0.863), p<0.001) improved risk stratification compared with isolated LVEF assessment (AUC 0.592 (0.453-0.730), p=0.18).

Conclusions: In a cohort of stabilised acute STEMI survivors, NT-proBNP was associated with all-cause mid-term mortality independent of hs-cTnT and LVEF. The association between CRP and mortality was significant only in patients with LVEF <50%.

Background: Fibrocalcific aortic valve sclerosis (AVSc), the earliest manifestation of aortic stenosis (AS), is increasingly recognised as a marker of systemic vascular damage and adverse cardiovascular outcomes. While a subset of AVSc patients progresses to AS, reported rates vary widely. We conducted a systematic review and meta-analysis to better define the natural history of AVSc progression.

Methods: Following Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we searched PubMed, Scopus and Web of Science through July 2025 for observational studies reporting AS development in AVSc patients. Primary outcomes were progression to any degree of AS and to severe AS. Pooled event rates were calculated using a random-effects model. Heterogeneity and publication bias were assessed using standard statistical methods. Meta-regression explored associations with clinical and demographic variables.

Results: Eight studies (n=12 388 patients) reported on the progression of AVSc patients to any AS stage, and nine studies (n=19 486 patients) on the progression to severe AS. Over a median follow-up of 4.0 years, 14.1% of AVSc patients progressed to any AS stage (effect size: 0.14; 95% CI 0.02 to 0.53), and 2.0% to severe AS (effect size: 0.02; 95% CI 0.003 to 0.094). Heterogeneity was high, but no publication bias was detected. Meta-regression found no significant predictors of progression.

Conclusions: Approximately one in six AVSc patients progresses to AS within 4 years, and 2% develop a severe disease. These findings underscore the importance of structured echocardiographic surveillance and support AVSc as a clinically relevant marker of systemic cardiovascular risk.

Background: While female sex has historically been associated with worse outcomes following surgical aortic valve replacement, the evidence regarding sex-related differences after transcatheter aortic valve implantation (TAVI) remains inconclusive. Given that women are more frequently referred for TAVI, clarifying the role of sex in procedural outcomes is clinically relevant.

Objectives: To systematically evaluate and summarise randomised clinical trial (RCT) evidence comparing TAVI outcomes between women and men.

Methods: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO (CRD42024510202). PubMed, EMBASE and Web of Science were searched for English-language RCTs up to 1 July 2024. Studies comparing TAVI outcomes by sex were included. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular mortality, stroke or transient ischaemic attack (TIA), major bleeding and permanent pacemaker implantation (PPI). Pooled ORs were calculated using Mantel-Haenszel random-effects models.

Results: 14 RCTs with a total of 15 225 participants were included. No overall difference in all-cause mortality was observed between sexes (OR: 0.83; 95% CI 0.65 to 1.06), though a significant protective effect for female sex was found among intermediate-risk patients (OR: 0.64; 95% CI 0.49 to 0.84; I²=0%). Women had a significantly higher risk of major bleeding (OR: 1.35; 95% CI 1.21 to 1.52; I²=15%). No significant sex-based differences were identified in cardiovascular mortality (OR: 0.98), stroke/TIA (OR: 0.96) or PPI (OR: 1.05).

Conclusion: Female sex was associated with a lower all-cause mortality among intermediate-risk patients undergoing TAVI, but also with a higher overall risk of major bleeding. These findings suggest the need for further investigation into sex-related anatomical and procedural factors.

Prospero registration number: CRD42024510202.

Background: Patients with severe aortic stenosis (AS) are at high risk of mortality, regardless of symptom status. Despite this, aortic valve replacement rates remain low for patients with severe AS due to challenges in identifying clinically significant AS in time. This has prompted the need to develop and investigate novel diagnostic modalities. The objective of this study was to develop and validate novel, non-invasive diagnostic algorithm leveraging seismocardiography (SCG) data to detect severe AS.

Method: A device capable of collecting a single-lead ECG and a three-dimensional SCG signal using a microelectromechanical-based accelerometer was used to collect sensor data. Phase 1 data were collected for training and validation of an algorithm for AS detection. Phase 2 data were collected as a blinded independent test set with age-matched and sex-matched patients as controls.

Results: In phase 1 of the study, 115 subjects (n=56 AS patients and n=59 controls; mean age 73.8±10.4 years) were collected for training and validation of an algorithm for AS detection. Once model development was complete, the frozen model was then evaluated in a fully independent, single blinded phase 2 cohort of 99 subjects (n=50 AS patients and n=49 controls; mean age 76.8±6.4 years) for final analysis. The algorithm accurately classified 89 out of 99 patients, with four true AS cases misclassified as controls and six true control cases misclassified as AS. The sensitivity, specificity and area under the curve of the model were 92% (95% CI 84.5% to 99.5%), 87.8% (95% CI 78.6% to 96.9%), and 96% (95% CI 91.9% to 99.9%), respectively.

Conclusions: This SCG-based algorithm to detect severe AS demonstrated high sensitivity and specificity when tested in a blinded, age-matched and sex-matched cohort. These findings suggest that this technology may hold potential as a low-cost diagnostic tool for the detection of AS.

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.