Open Heart最新文献

Background: Pocket haematoma is a common complication of cardiac implantable electronic device (CIED) procedures and may lead to pain, delayed healing, surgical evacuation or infection. Although pressure dressings with adhesive tapes are widely used for haematoma prevention, they can cause skin erosion. Therefore, this study evaluated the efficacy of the Heart band, a novel compression tool, in preventing device implantation-related complications in patients who underwent CIED procedures.

Methods: Among 663 consecutive patients who underwent CIED procedures, we retrospectively analysed 532 (compression tool use, n=283; adhesive tape use, n=249) who underwent CIED implantation or generator replacement between April 2019 and March 2021. Either adhesive tape (2019-2020) or the compression tool (2020-2021) was used in the patients. Compression was applied for 2 days postoperatively, and recompression was performed at the physician's discretion if haematoma-related swelling was noted. The primary endpoints were postoperative complications including recompression, haematoma and skin erosion. Intervention-requiring haematoma (IRH) was defined as haematomas for which transfusion or surgical evacuation was necessary.

Results: Skin erosion occurred significantly less often in the compression tool group (0.4% vs 9.6%, p<0.01), whereas there were no significant intergroup differences in the rates of recompression (19.4% (compression tool group) vs 16.1% (adhesive tape group), p=0.36) and IRH (0.7% (compression tool group) vs 0% (adhesive tape group), p=0.50). These trends were consistent in high-risk subgroups, including patients receiving antithrombotic therapy, with diabetes or with implantable cardioverter-defibrillator/cardiac resynchronisation therapy-defibrillator. Multivariate analysis identified the compression tool as an independent negative predictor of skin erosion (OR 0.03, 95% CI <0.01 to 0.26, p<0.01).

Conclusion: The compression tool had efficacy comparable to that of conventional pressure dressing with adhesive tape in preventing IRH. Compression tools are also associated with a lower incidence of skin erosion.

Background: We aimed to estimate mental disorder disparities in cardiovascular disease (CVD) incidence and determine whether these disparities were worsened by the COVID-19 pandemic.

Methods: For each outcome (myocardial infarction (MI), heart failure and stroke), we created a population-based cohort of people without a prior diagnosis of the outcome using linked electronic health records, with follow-up from November 2019 until December 2023. We ascertained pre-existing schizophrenia, bipolar disorder and depression, and each CVD outcome from primary care and hospital admission records and (for CVD outcomes) mortality records. We calculated sex-stratified age-standardised incidence rates by mental disorder diagnosis and used quasi-Poisson modelling to obtain rate ratios (RRs) of CVD among people with each of schizophrenia, bipolar disorder or depression versus those without any of these disorders, adjusting for sociodemographic factors and time period. We investigated whether mental disorder disparities changed as a consequence of the COVID-19 pandemic by including an interaction term between mental disorder and time.

Results: During follow-up, 383 365 people had incident MI, 868 590 had incident heart failure and 455 300 had incident stroke. Age-standardised incidence of each CVD outcome decreased markedly between February and April 2020, with incidence levels returning to, but not exceeding, prepandemic levels in subsequent years. Mental disorder was associated with a higher incidence of each CVD outcome, with RRs ranging from 1.31 (95% CI 1.25 to 1.38) to 2.15 (95% CI 2.05 to 2.24). There was generally no evidence of interaction between mental disorder and time, with mental disorder disparities in CVD incidence stable over time.

Conclusion: We found no clear evidence that the mental disorder disparities in CVD incidence widened during the acute period of the pandemic or during the subsequent years. Continued monitoring of the CVD burden in the general population and among marginalised groups is critical to identifying longer-term impacts on CVD and worsening disparities.

Background: The minimally important difference (MID) for frailty variation associated with adverse outcomes remains unknown in patients with heart failure and preserved ejection fraction (HFpEF), and whether spironolactone can ameliorate frailty progression in this population remains unclear.

Methods: We analysed data from 1767 participants in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial. The MID for frailty was calculated using an anchor-based approach, with the EuroQol-Visual Analogue Scale (EQ-VAS) as the anchor. Frailty index (FI), defined as a 35-item cumulative deficit score, and EQ-VAS were assessed at baseline and 1-year follow-up. The primary composite outcome (cardiovascular death, aborted cardiac arrest or heart failure hospitalisation) was assessed from the 1-year follow-up visit. Adjusted Cox proportional hazards models evaluated the link between FI changes (ΔFI≥MID) and the primary outcome. Longitudinal FI changes were analysed using linear mixed-effects models to evaluate spironolactone's effect.

Results: The MID for the FI was 0.03 points. An FI reduction ≥MID was associated with a lower risk of the primary composite outcome (aHR, 0.63; 95% CI 0.48 to 0.82), all-cause mortality (aHR, 0.57; 95% CI 0.42 to 0.76) and heart failure hospitalisation (aHR, 0.55; 95% CI 0.40 to 0.75) after adjusting for baseline FI, age, sex, New York Heart Association class, smoking status and treatment assignment. No between-group difference in FI change was observed with spironolactone versus placebo (aOR, 0.85; 95% CI 0.67 to 1.09).

Conclusions: Frailty improvement exceeding the 0.03 FI threshold predicts better prognosis in HFpEF, underscoring the value of routine assessment. Spironolactone use was associated with neutral effects on frailty progression in our analysis, suggesting potential safety in this vulnerable population.

Trial registration number: NCT00094302.

Background: Many observational studies highlight clonal haematopoiesis (CH) as a novel determinant of cardiovascular disease (CVD). However, disentangling cause and effect from important confounders, such as age and smoking, is challenging.

Objectives: Mendelian randomisation (MR) was used to assess the causal relationships of CH with (1) major CVD outcomes associated with adverse remodelling, and (2) cardiovascular magnetic resonance (CMR) phenotypes which have not been examined previously.

Methods: Uncorrelated (r²<0.001), genome-wide significant (p<5×10^-6) single nucleotide polymorphisms were extracted from Genome-Wide Association Study summary statistics for CH (any subtype), gene-specific CH subtypes (DNMT3A and TET2), and CH clonal size subtypes (small clone and large clone). Mendelian Randomisation using a Robust Adjusted Profile Score (MR-RAPS) was used for analyses on outcomes of atrial fibrillation (AF), heart failure and 13 CMR phenotypes. Multiple comparisons in the discovery analyses were accounted for by Benjamini-Hochberg correction.

Results: Both DNMT3A-CH and small-clone-CH were associated with increased AF risk. Overall-CH was associated with larger left ventricular end-diastolic volume. DNMT3A-CH was associated with larger right atrial size, and left and right ventricular end-diastolic volumes. TET2-CH was associated with higher myocardial native T1 time. Small-clone-CH was associated with larger left atrial size and lower aortic distensibility.

Conclusions: Common forms of CH are associated with higher AF risk and adverse remodelling patterns comprising larger atrial and ventricular sizes, myocardial fibrosis, and reduced aortic compliance. Using MR methods, this study triangulates previous observational studies and provides new evidence to support likely causal links between CH and CVD. This study, for the first time, describes associations of CH with adverse CMR phenotypes suggesting early remodelling patterns; these changes may indicate a window of opportunity for intervention such as by risk stratification and early preventative strategies to improve patient outcomes; however, further examination of the utility of such interventions is warranted.

Background: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment for aortic regurgitation (AR) in patients at high surgical risk. However, evidence comparing outcomes of different new-generation devices remains limited.

Objectives: To compare clinical outcomes of on-label, off-label self-expanding (SE) and off-label balloon-expandable (BE) TAVR devices in AR patients.

Methods: A systematic review and meta-analysis were conducted, including studies reporting clinical outcomes of new-generation TAVR devices in AR. The primary outcome was 1-year all-cause mortality. Secondary outcomes included procedural success, moderate or severe AR and perioperative complications. Subgroup and meta-regression analyses assessed the impact of valve type and clinical variables.

Results: 32 studies involving 2682 patients were included. 1-year mortality was 10.4% (95% CI: 7.2% to 14.7%) with no significant difference among valve types. Technical success was highest with on-label devices (97%), followed by off-label:BE (92%) and off-label:SE (85%) (p<0.001). Valve migration occurred in 2% of on-label, 7% of off-label:BE and 10% of off-label:SE cases (p=0.004). Moderate or severe AR was observed in 2% of on-label, 4% of off-label:BE and 8% of off-label:SE recipients (p<0.001). Meta-regression identified coronary heart disease as an independent predictor of 1 year mortality (p=0.026), while other factors showed no significant association.

Conclusions: On-label devices were associated with improved procedural outcomes, including lower rates of valve migration and residual AR, although 1-year mortality did not differ significantly between device groups. Further prospective studies with longer follow-up are needed to assess valve durability and long-term clinical outcomes.

Prospero registration number: CRD 42024611296.

Introduction: Resistant hypertension remains a clinical challenge, often linked to elevated aldosterone levels not fully controlled by mineralocorticoid receptor antagonists. Aldosterone synthase inhibitors (ASIs) directly suppress aldosterone production. We evaluated the efficacy and safety of ASIs for blood pressure (BP) control.

Method: We performed a Bayesian network meta-analysis of randomised controlled trials (RCTs) assessing systolic (SBP) and diastolic BP (DBP) in adults with hypertension. Major databases were searched to 2025. Treatment effects were summarised as mean differences (MDs) with 95% credible intervals (CrIs), and treatment rankings were determined using the surface under the cumulative ranking curve (SUCRA). Risk of bias was assessed using the Cochrane RoB V.2.0 tool.

Results: Six RCTs including 2149 patients were analysed. Risk of bias assessment using RoB2 showed that four studies were at low risk of bias, and two studies had some concerns. Compared with placebo, Baxdrostat 2 mg once a day significantly reduced SBP (MD -11.0 mm Hg; 95% CrI -21.0 to -0.30), while Osilodrostat 1 mg once a day significantly reduced both SBP (MD -7.6 mm Hg; 95% CrI -14.0 to -0.73) and DBP (MD -5.4 mm Hg; 95% CrI -10.0 to -0.69). Lorundrostat 50 mg once a day also reduced SBP significantly (MD -9.1 mm Hg; 95% CrI -17.0 to -1.7). SUCRA rankings confirmed these findings, with Baxdrostat 2 mg once a day ranking highest for SBP reduction (77%) and Osilodrostat 1 mg two times per day ranking highest for DBP reduction (84%). Most adverse events were mild, serious events were infrequent and no drug-related deaths were reported.

Conclusion: ASIs significantly reduce BP with generally favourable tolerability. Osilodrostat and Baxdrostat demonstrated the most consistent efficacy across outcomes, while Lorundrostat also showed potential benefit. This analysis supports the use of ASIs as effective alternatives for BP reduction. Further large-scale and long-term RCTs are needed to validate these findings and guide clinical decision-making.

Prospero registration number: PROSPERO CRD420251024035.

Background: Atrial fibrillation (AF)-induced cardiomyopathy (AIC) is characterised by reversible left ventricular (LV) dysfunction after restoration of sinus rhythm (SR). The need for continued guideline-directed medical therapy (GDMT) for heart failure after LV ejection fraction (LVEF) recovery in AIC after catheter ablation (CA) is unclear.

Methods: This multicentre cohort study across 12 UK centres included adults undergoing index AF ablation (June 2019-June 2024) with LVEF <50% preablation and recovery to ≥50% at three timepoints: preablation; early postablation (≥4 weeks) and late postablation (≥3 months or ≥3 months post-GDMT withdrawal). Patients were stratified post recovery of LVEF after CA. The primary outcome was mean LVEF at late follow-up; secondary outcomes included absolute change in LVEF, LV end-diastolic diameter (LVEDD) and SR maintenance.

Results: 88 patients met inclusion enrolment criteria (61.7±10.6 years old; 91% male), of which 50 (56.8%) continued full-dose GDMT and 38 (43.2%) withdrew ≥50% of GDMT. In the GDMT-withdrawn group, mean GDMT classes decreased from 2.97±0.88 to 1.03±0.79 (p<0.001). At late follow-up, mean LVEF was comparable (56.3%±3.8% GDMT-continued vs 56.8%±5.5% GDMT-withdrawn; p=0.59), as was LVEF change (1.2% vs 0.4%; p=0.48). One relapse occurred in each group secondary to an acute coronary syndrome (2.0% vs 2.6%; p=1). LVEDD remained stable (p>0.8). SR was maintained in 82.0% vs 92.1% of patients; p=0.17.

Conclusions: Selective GDMT withdrawal after sustained LVEF recovery and rhythm control did not compromise LV systolic function, remodelling or rhythm maintenance. This supports the study of personalised de-escalation strategies in AIC in prospective trials.

Background: Revised haemodynamic criteria for pulmonary hypertension (PH)-mean pulmonary artery pressure (mPAP) >20 mm Hg and pulmonary vascular resistance (PVR) >2 Wood Units (WU)-have defined new subsets of patients with mild PH. We aimed to characterise their clinical profile and prognosis.

Methods: We included consecutive incident, treatment-naïve patients undergoing right heart catheterisation at a PH referral centre. Patients with mPAP 21-24 mm Hg and pulmonary artery wedge pressure (PAWP) ≤15 mm Hg were stratified by PVR values to identify those with unclassified PH (PVR≤2 WU) and mild precapillary PH (PVR>2 WU). Patients with mild precapillary PH were compared with matched controls with normal haemodynamics and with patients meeting previous pulmonary arterial hypertension (PAH) haemodynamic criteria (mPAP≥25 mm Hg, PAWP≤15 mm Hg, PVR>3 WU).

Results: Among 259 patients with mPAP 21-24 mm Hg and PAWP≤15 mm Hg, 76% had left heart or lung disease. In unclassified PH, mPAP elevation was mainly due to high stroke volume index (SVI) or backward transmission from borderline PAWP. In mild precapillary PH, SVI was the only independent haemodynamic predictor of survival. Survival was similar between mild precapillary PH and PAH patients. A limited number of patients with PAH risk factors progressed to overt PAH and, in the absence of comorbidities, appeared to benefit from PAH therapies.

Conclusions: Unclassified PH is mainly related to pulmonary overflow or backward transmission from borderline PAWP. Mild precapillary PH is typically associated with comorbidities and not necessarily an early PAH stage. SVI is a key prognostic marker. Careful clinical phenotyping is essential to identify the small subset who may benefit from targeted therapies.

Objective: To clarify whether atherogenic index of plasma (AIP), a comprehensive indicator reflecting both the protective and atherogenic effects of lipoproteins on cardiometabolic health, is associated with increased risk of aortic disease.

Design: Large-scale, population-based, observational, prospective cohort study.

Data sources: Health dataset from UK Biobank.

Participants: A total of 17 530 participants, aged 40-70 years, were enrolled and completed the initial assessment visit before 2010. Participants with a history of aortic dissection (AD) or aortic aneurysm (AA), baseline connective tissue disease, missing triglyceride and high-density lipoprotein cholesterol values, fasting time less than 8 hours or those lost to follow-up were excluded.

Main outcome measures: Aortic disease, a composite outcome comprising AD and AA.

Results: During a median follow-up period of 15.1 years, 164 aortic disease cases, including 14 AD and 155 AA cases, were documented. A linear trend between AIP and the risk of incident aortic disease was confirmed (p for non-linear=0.134). The multivariable-adjusted incident risk of aortic disease gradually increased with elevated AIP tertiles (adjusted HR (aHR) 1.0 (reference) in tertile 1, aHR 1.48 (95% CI 0.91 to 2.41) in tertile 2, aHR 2.04 (95% CI 1.26 to 3.29) in tertile 3), following an adjustment for age, sex, smoking status, drinking status, body mass index, hypertension, low-density lipoprotein cholesterol and glycated haemoglobin. Specifically, participants in the highest AIP tertile had the highest incident risk of AA, with an aHR of 2.47 (95% CI 1.47 to 4.16).

Conclusions: AIP is significantly associated with a higher risk of incident aortic disease, indicating that AIP is an effective risk assessment method for aortic disease, especially for AA.

Background: Circulating proprotein convertase subtilisin/kexin type 9 (PCSK9) is a crucial regulator of cholesterol metabolism. Loss-of-function variants in PCSK9 are associated with lower levels of circulating low-density lipoprotein cholesterol (LDL-C) and reduced cardiovascular disease (CVD) risk, while gain-of-function variants correlate with elevated LDL-C concentrations and increased CVD risk. This study investigated whether genetically determined LDL-C levels, proxied by four PCSK9 genetic variants, influence common carotid artery atherosclerosis.

Methods: The analysis included 3040 European participants (mean age 64.2±5.4 years; 45.8% men) at high cardiovascular risk from the IMPROVE Study, alongside 49 088 individuals of white British ancestry (mean age 55.2±7.6 years; 47.9% men) from the UK Biobank (UKB). Ultrasonographic measurements of common carotid intima-media thickness (CC-IMTmean, CC-IMTmax, CC-IMTmean-max) were obtained. Four lipid-level affecting genetic variants in the PCSK9 locus were selected for analysis, both individually and in a standardised Lipid-Lowering Allelic Score (LLAS), to assess their effects on LDL-C and PCSK9 levels in the IMPROVE cohort and on ultrasonographic measures in both IMPROVE and UKB.

Results: In the IMPROVE cohort, PCSK9 variants (rs11206510, rs2479409, rs11591147, rs11583680) exhibited expected effect directions, although not all statistically significant, on LDL-C and PCSK9 levels. The LLAS was negatively correlated with CC-IMTmean, CC-IMTmax and CC-IMTmean-max among women in IMPROVE, and among men and overall in UKB (all p<0.05). Effect sizes were comparable between cohorts.

Conclusions: Genetic variants in the PCSK9 locus influence LDL-C levels and CC-IMT, in keeping with proven benefits of PCSK9 inhibitors on atherosclerotic cardiovascular events.