Open Heart最新文献

The optimal timing for initiating direct oral anticoagulants (DOACs) for secondary stroke prevention in patients with atrial fibrillation and acute ischaemic stroke remains controversial due to concerns about haemorrhagic transformation. This study aimed to analyse the efficacy and safety of early versus late DOAC initiation. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was conducted, searching major databases (PubMed, Embase, Cochrane Library and ClinicalTrials.gov) up to May 2024. A total of 11 studies were identified, comprising nine cohort studies (75.5% weight) and two randomised controlled trials (RCTs) (24.5% weight), involving 13 020 participants. The early DOAC group (mean initiation 3.5±1.29 days) included 6250 participants, while the late group (5.7±1.25 days) had 6770 participants. Outcome measures included recurrent ischaemic stroke (RIS), intracranial haemorrhage (ICH), systemic embolism, major haemorrhage (MH), non-major haemorrhage (NMH) and all-cause mortality. Statistical analysis using the Cochrane Review Manager calculated ORs and 95% CIs via the Mantel-Haenszel random effects model. This pooled meta-analysis revealed that the early DOAC group had lower rates of RIS (2.2% vs 2.9%, OR 0.72, 95% CI 0.52 to 0.98, p=0.04, I²=40%) and ICH (0.51% vs 0.93%, OR 0.45, 95% CI 0.29 to 0.70, p<0.05, I²=0%) compared with the late DOAC group. Subgroup analysis of RCTs and cohort studies showed reduced RIS and ICH risks in the early DOAC group, with moderate heterogeneity. In the sensitivity analysis, the early group (<4 days) had a lower risk of RIS compared with the late group (>4 days) without a statistically significant impact on ICH. No significant differences in MH, NMH, systemic embolism or all-cause mortality were observed between either group; however, a limited number of RCTs and moderate heterogeneity weakened the conclusions. Additional RCTs are needed to provide more definitive insights.

Introduction: Atrial fibrillation (AF)-induced cardiomyopathy (AIC) is retrospectively defined after normalisation of left ventricular ejection fraction (LVEF) in sinus rhythm. It is unclear why some patients develop AIC.

Hypothesis: Patients with AIC have a subtle cardiomyopathic process that precedes their AF-mediated LVEF reduction. Detailed assessment of cardiac function after successful catheter ablation will reveal this.

Objective: To evaluate the utility of measures to identify cardiomyopathic features that persist after LVEF normalisation in AIC.

Methods: Patients with rate-controlled persistent AF and LVEF<50% undergoing catheter ablation (CA) were prospectively evaluated using echocardiography, cardio-pulmonary exercise testing and serum N-terminal pro b-type natriuretic peptide (NT-proBNP) at baseline and 6 months after CA. Participants with AIC, (LVEF recovery (≥50%) and no other cause for cardiac dysfunction) were evaluated using left ventricular (LV) longitudinal strain and left atrial (LA) reservoir strain (LARS). Changes in peak oxygen consumption and the minute ventilation/carbon dioxide production slope were measured as markers of functional capacity and ventilatory inefficiency. A control group of patients with persistent AF with preserved LVEF were also enrolled.

Results: 34/41 (82.9%) participants recovered LVEF in sinus rhythm; defined as AIC. NT-proBNP levels were elevated in 18 (52.9%), and 16 reported ongoing heart failure (HF) symptoms. 10 (29.4%) had no improvement in functional capacity, and seven (20.6%) showed persistent ventilatory inefficiency. 20 (58.8%) had impaired global LV longitudinal strain with a relative apical sparing pattern. Nine (26.5%) had impaired LARS. There was an overlap of these abnormalities. 32 (94.1%) demonstrated at least one, 17 (50.0%) having no cardiovascular risk factors. Patients with preserved LVEF during persistent AF had similar demographics but a lower burden of short R-R intervals (<660 ms) on Holter monitoring.

Discussion: Abnormal structural, metabolic and HF biomarkers are seen in patients with AIC in sinus rhythm. These features may represent a precedent subtle cardiomyopathic process predisposing them to left ventricular systolic dysfunction in AF.

Trial registration number: NCT04987723.

Introduction: Cardiac implantable electronic devices (CIED) can transfer data to the healthcare team, remotely. National and international cardiac organisations recommend all patients use this technology, however patient engagement is suboptimal. Previously, in cardiovascular patients, SMS messaging services have shown improvements in patient engagement and subsequent health outcomes. This paper describes the protocol and intervention of a randomised controlled trial (RCT) to assess the feasibility of a novel CIED remote monitoring SMS patient support programme on self-efficacy in managing CIED and cardiovascular health following CIED implantation.

Methods/analysis: A two-arm RCT will be conducted of 100 participants with 1:1 allocation to intervention or control. Participants awaiting-CIED or immediately post-CIED implantation from sites throughout Australia will be invited to partake. The intervention group will receive regular SMS communication with a range of educational and self-efficacy resources, in conjunction with engagement initiatives following CIED clinical issue detection. The control group will receive CIED remote monitoring education and clinical issue management as per standard practice at their respective sites. The primary outcome will assess the patient's capacity to manage their CIED as measured by the 'Self-Efficacy Expectations After Implantable Cardioverter Defibrillator Implantation Scale'. Secondary outcomes will assess participant's ability to manage their cardiovascular condition, CIED remote monitoring, quality of life, impact on health service utilisation, cardiovascular behavioural risk factor change and motivation to improve cardiovascular health. A sample size of 100 will have a 90% power to detect a minimum difference of 1.07 in the 'Self-Efficacy Expectations After Implantable Cardioverter Defibrillator Implantation Scale' between the intervention and control group with an alpha value of 0.05.

Ethics and dissemination: Ethics approval for this study has been obtained from the Western Sydney Local Health District Human Research Ethics Committee. The project results will be published in peer-reviewed journals, at scientific meetings and in the media.

Trial registration number: ACTRN12623000702617.

Background: Valvular heart disease (VHD) represents a significant burden on healthcare systems worldwide, necessitating specialised care through multidisciplinary valve clinics. However, there is a lack of a standardised training and certification framework for clinical scientists and specialist physiologists (CSSPs) working within specialist valve clinics (SVCs). This study aimed to design, implement and validate a competency framework dedicated to training and certifying valve CSSPs to enhance patient outcomes and establish standardised care.

Methods: A comprehensive competency framework was developed and implemented, consisting of two levels: Enhanced Valve Clinic Training (EVCT) and Advanced Valve Clinic Training (AVCT). The programme was trialled at Guy's Valve Clinic, London, over a 12-month period. Validation was undertaken through trainee and patient feedback, including multiple-choice questions, clinical skills assessments, and patient satisfaction surveys.

Results: Nine CSSPs completed the EVCT and four the AVCT. All participants passed their certification examinations with scores ranging from 80% to 95%. The time to complete each programme averaged 6 months. After certification, clinical queries raised by EVCT trainees averaged 1.2 per session but dropped by 75% to 0.3 per session in the AVCT group, indicating greater confidence and independence in managing cases. Physician review of trainee-led cases led to additional tests or treatment changes in 23% of cases and referrals to physician clinics in 11%. Patient feedback was positive: 95% felt confident in the clinical scientists' knowledge, and 100% were satisfied with the clarity of their care plans and follow-up.

Conclusions: The implementation of this training and certification framework demonstrated enhanced clinical outcomes and care delivery in SVCs. By advocating for formal recognition and accreditation of valve clinic training, this framework could serve as a model for national and international standardisation in valve care and clinical training.

Background: Hypertrophic cardiomyopathy (HCM) is an inherited disorder whose causal variants involve sarcomeric protein genes. One of these is myosin-binding protein C (MYBPC3), being previously associated with a favourable prognosis. Our objective is to describe the clinical characteristics and events of a molecularly homogeneous HCM cohort associated with truncating MYBPC3 variants.

Methods and results: A cohort of patients and relatives with HCM diagnosis and carrying a truncating MYBPC3 variant were retrospectively recruited. Subjects had an average follow-up of 7.77 years, with an incident HCM phenotype of 10%. They were middle-aged adult patients (47±16.8 years) without significant comorbidities or symptoms. Hypertrophy was discrete with a significative difference between probands and relatives (17.5±4 mm vs 14.6±5 mm; p<0.0001). Ejection fraction was predominantly preserved (65%±10%). Despite it being the most common clinical event, relevant heart failure (observed in 8.1% of patients) was infrequent and commonly found in the presence of a second environmental precipitating agent. ESC-HCM risk calculator and modifier factors did not correlate with the risk of major events predicting events, which were low (1.51 per 100 patients/year) and associated with the severity of HCM, abnormal QRS in the ECG and age. Genetic factors and sex were not associated with major events.

Conclusions: This is the first molecularly homogeneous, contemporary cohort, including HCM patients secondary to MYBPC3 truncating variants. Patients showed a good prognosis with a low event rate. In our cohort, major arrhythmic events were not related to measured environmental or genetic factors.

Background: Ventricular arrhythmias (VAs) frequently occur in the acute phase of myocarditis. Possible arrhythmic recurrences and the risk of sudden cardiac death (SCD) in this setting are reasons for concern, and limited data have been published to guide clinical management of these patients. The aim of the present paper is to report the incidence of major arrhythmic events, defined as sustained VA, SCD and appropriate implantable cardiac-defibrillator (ICD) treatment, in patients with acute myocarditis and ventricular arrhythmic phenotype.

Methods: We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate studies reporting long-term outcomes in patients with acute myocarditis and arrhythmic presentation. We systematically searched PubMed, EMBASE and Scopus databases for relevant studies up to 2 August 2024. Study quality was assessed by the Newcastle-Ottawa Scale. The primary outcome was a composite of SCD, VA recurrence and appropriate ICD therapy. Random-effect models were used to calculate pooled ORs and CIs.

Results: Five observational studies enrolling 322 patients were identified. The pooled proportion of patients who experienced VA recurrence was 0.41 (95% CI 0.30 to 0.53, p=0.13). An increased risk of adverse outcomes during follow-up was observed in patients presenting with monomorphic ventricular tachycardia (OR 3.77, 95% CI 1.23 to 11.53) and left ventricular ejection fraction (LVEF) <50% (OR 2.74, 95% CI 0.78 to 9.63). Gender and anteroseptal late gadolinium enhancement were not found as potential risk factors in this analysis.

Conclusions: Patients with myocarditis with arrhythmic ventricular presentation have a high recurrence rate of VA, underscoring the importance of careful monitoring and management in this patient population. Risk stratification for SCD during follow-up should be individualised, and monomorphic VA at presentation or a reduced LVEF may be markers of poor prognosis. In these cases, an ICD implantation may be cautious pending further dedicated studies.

Objectives: Elevations of cardiac troponin T (cTnT) levels are common after strenuous exercise. We assessed whether the composition of cTnT release after marathon race differs from that of acute myocardial infarction (MI).

Methods: Troponin composition was analysed in plasma samples taken from 45 runners after marathon race and from 84 patients with type 1 MI. The concentration of long cTnT (intact and mildly fragmented cTnT) was measured with a novel upconversion luminescence immunoassay, total cTnT with a commercial high-sensitivity cTnT assay, and the ratio of long to total cTnT (troponin ratio) was determined as a measure of troponin fragmentation.

Results: Total cTnT exceeded the upper reference limit (>14 ng/L) in 37 (82%) runners. Troponin ratio was lower in runners ((IQR) 0.17 (0.11-0.24) vs 0.62 (0.29-0.96), p<0.001). With increasing troponin release the troponin ratio decreased (r=-0.497, p<0.001) in marathon runners and the concentration of long cTnT remained in all runners below 8.4 ng/L. In contrast to marathon runners, troponin ratio increased (r=0.565, p<0.001) with the increase of cTnT release in patients with MI. The median total and long cTnT concentrations were lower in marathon runners than in patients with MI (25 ng/L vs 835 ng/L and 4.1 vs 385 ng/L, p<0.001 for both).

Conclusion: In contrast to type 1 MI, only a small fraction of circulating cTnT exists as intact cTnT or long molecular forms after strenuous exercise and the difference in troponin composition is more pronounced in runners with higher troponin release.

Trial registration number: NCT06000930.

Background: Whether, and how, co-occurring HIV-1 infection (HIV) and tuberculosis (TB) impact cardiovascular status, especially in adolescents with perinatally acquired HIV (APHIV), have not been examined. We hypothesised that APHIV with previous TB disease have worse cardiac efficiency than APHIV without TB, which is mediated by increased inflammation and disordered cardiometabolism.

Methods: APHIV in Cape Town, South Africa, completed 3T cardiovascular magnetic resonance examination and high sensitivity C reactive protein (hsCRP), fasting plasma glucose (FPG), low-density lipoprotein (LDL) and triglyceride measurement. Ventriculoarterial coupling (VAC) was estimated as the ratio of arterial elastance (Ea) to ventricular end-systolic elastance (Ees). Regression models were applied to estimate cross-sectional associations between Ea/Ees ratio and TB status, with decomposition of these associations into direct and mediated effects of hsCRP, FPG and dyslipidaemia, if any, attempted.

Results: We enrolled 43 APHIV with prior TB and 23 without TB of mean (SD) age 15.0 (1.5) and 15.4 (1.7) years, respectively. Prior TB was associated with lower Ea/Ees ratio (0.59 (0.56 to 0.64)) than no TB (0.66 (0.62 to 0.70)), which corresponded to an adjusted mean difference -0.06 (-0.12 to 0.01) (p=0.048). However, previous TB was not associated with increased hsCRP, FPG, LDL or triglycerides nor were hsCRP, FPG, LDL and triglycerides associated with Ea/Ees ruling out their mediated effects in the association between TB and cardiac efficiency.

Conclusions: Previous TB in APHIV is associated with comparatively reduced cardiac efficiency, related to altered VAC. The clinical significance of these findings requires further study, including a wider range of biomarkers of specific immune pathways.

Background: Variant transthyretin amyloidosis (ATTRv) is a hereditary multisystem disorder with clinical spectrum ranging from predominant cardiomyopathy to polyneuropathy. In the Irish population, the T60A mutation has been previously recognised as the most common genotype.

Objectives: The aim of this study is to describe the diagnostic and phenotypic spectrum of patients with T60A ATTRv attending an Irish Expert Amyloidosis Network.

Methods: In this observational study design, the medical, laboratory and radiological records of patients enrolled in our amyloidosis registry with a confirmed genotype diagnosis of T60A ATTRv were reviewed.

Results: A cohort of 24 patients (12 female) met criteria for inclusion. The median age at diagnosis was 65 years (IQR 59.5-66.5) and median follow-up 44 months (IQR 31-58). Carpal tunnel syndrome was the initial manifestation in almost half (46%) of patients. Overall, a mixed cardioneuro phenotype was demonstrated including autonomic (75%), small (58%) and large fibre (46%) neuropathy largely predating a cardiac phenotype consisting of heart failure (63%), atrial arrhythmia (42%) and bradycardia (13%).

Conclusion: The contemporary clinical spectrum of T60A ATTRv in Ireland is one of patients typically presenting in the seventh decade with an already manifest neuropathy phenotype, largely predating a cardiac phenotype dominated by heart failure.