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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.

Background: Primary percutaneous coronary intervention (PCI) has significantly improved outcomes for ST-segment elevation myocardial infarction (STEMI) patients. However, the long-term durability of PCI in terms of target lesion failure (TLF) remains unknown.

Objectives: This study investigates the long-term incidence, predictors and clinical impact of TLF over a 10-year follow-up in STEMI patients treated with primary PCI.

Methods: From the DANAMI-3 trial, we analysed STEMI patients treated with primary PCI. TLF was defined as a composite of cardiovascular death, target lesion myocardial infarction or target lesion revascularisation. Independent predictors of TLF were identified by Cox regression. Outcomes in high-risk and low-risk groups were evaluated using cumulative incidence functions with competing risk analysis.

Results: Of 2217 patients (median follow-up of 10.7 years), 443 (20.0%) experienced TLF. TLF occurred in 5.6% within the first year after PCI and continued at a constant annual rate of 1.6% thereafter. All-cause mortality, any MI or any revascularisation occurred in 961 (43%) patients, and TLF constitutes 46% of the total patient-oriented events. Multivariable Cox regression identified age, hypertension, previous AMI and Killip class II-IV as independent predictors of an increased risk of TLF, whereas PCI with drug-eluting stents was associated with a reduced risk of TLF. Patients with ≥1 high-risk feature had a twofold greater risk of TLF compared with those without (HR 2.05, 95% CI 1.65 to 2.55, p<0.001).

Conclusions: One in five STEMI patients treated with primary PCI experiences TLF within 10 years, accounting for a significant proportion of any mortality, any MI or any revascularisation, with sustained occurrence rates beyond the first year.

Trial registration number: NCT01960933.

Introduction: European valvular heart disease guidelines define women as a 'special group'. To explore what factors have led us to consider more than 50% of the global population special, we assessed access to transcatheter aortic valve implantation (TAVI) by sex on national and local levels and studied post-TAVI outcomes by sex within our centre.

Methods: Population statistics from census data were compared against British Cardiovascular Intervention Society (BCIS) audit and local data.Using the National Institute for Cardiovascular Outcomes Research TAVI database, a retrospective analysis of 1049 consecutive patients from 2013 to 2023 was conducted at our UK tertiary centre.Primary outcomes were all-cause death, a three-point composite of major adverse cardiac events (MACE) comprising death, non-fatal myocardial infarction and non-fatal stroke during TAVI admission, and post-TAVI survival.

Results: Nationally, females comprise 60% of over 75-year-olds; however, TAVI was performed more frequently in males: nationally (55.2% vs 44.8%, p<0.01) and locally (53.2% vs 46.8%, p<0.01). Males were 1.82 times more likely to undergo TAVI.Locally, females undergoing TAVI were older and had worse renal function, higher frailty and greater transvalvular gradients. Males had more cardiovascular comorbidity.In-hospital mortality and MACE did not differ by sex. Median survival was longer in females (1350 days vs 1728 days, p=0.02). Regression analysis demonstrated female sex as a predictor of increased survival (HR 0.73, 95% CI 0.61 to 0.88, p<0.01). Chronic obstructive pulmonary disease, atrial fibrillation, frailty and poor mobility were identified as predictors of reduced survival.

Conclusion: In this retrospective, observational study, we have demonstrated an under-representation of females undergoing TAVI. This observation is likely of multifactorial cause, including different disease recognition, referral, investigation and treatment practices.We observed no difference in procedural death or MACE, but longer female survival, despite higher baseline age, frailty and renal impairment.

Background: Guidelines strongly recommend reperfusion therapy, including thrombolysis and percutaneous coronary intervention, for ST-elevation myocardial infarction but contraindicate its use in most non-ST-elevation acute coronary syndromes (ACS). This practice largely stems from the landmark fibrinolytic therapy trialists (FTT) meta-analysis, which reported no benefit in patients without ST elevation (STE). However, the FTT included a subgroup from the ISIS-3 trial with substantial methodological issues, potentially obscuring a genuine treatment effect.

Methods: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing thrombolysis vs placebo or no thrombolysis in ACS. Patients were grouped by ECG findings: STE, ST depression (STD) or absence of STE. All-cause mortality was extracted from each trial's short-term follow-up (typically 21-35 days). We reassessed outcomes with and without inclusion of the ISIS-3 'uncertain diagnosis' subgroup.

Results: Nine RCTs (40 226 patients) were analysed. Thrombolysis significantly reduced mortality in patients without STE (excluding isolated STD) (risk ratio (RR): 0.799; 95% CI 0.668 to 0.956; I²=0%). Including the ISIS-3 'uncertain diagnosis' subgroup (representing 42% of the non-STE population) would have eliminated the statistical significance in non-STE patients (RR: 0.928; 95% CI 0.694 to 1.242) and markedly increased heterogeneity (I²=71%).

Conclusion: In historical RCTs, thrombolysis was associated with lower short-term mortality in non-STE presentations excluding isolated ST-segment depression, while isolated STD showed no benefit. Legacy conclusions hinge on outdated methods, delayed treatment and heterogeneous ECG definitions (and are sensitive to ISIS-3). This study exposes a material evidence gap in the foundation of current guidelines. Contemporary randomised trials with prespecified ECG criteria, rapid treatment windows and rigorous safety adjudication are needed.

Prospero registration number: CRD42024573681.

Background: Acute kidney injury (AKI) often complicates percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). However, evidence on the incidence and prognostic impact of AKI after revascularisation for left main coronary artery disease (LMCAD) is scant, especially in terms of subsequent risk of persistent renal dysfunction (RD).

Methods: All consecutive patients undergoing PCI or CABG for LMCAD in two European institutions from 2015 to 2022 were enrolled. The coprimary endpoints were AKI, defined as an increase in serum creatinine (sCr) levels ≥0.3 mg/dL or increase by >50% as compared with baseline levels, and persistent RD, defined as a persistent increase of sCr at 1 year. The secondary endpoint was all-cause mortality. The risk of AKI with PCI versus CABG was assessed with multivariable logistic regression and inverse probability of treatment weighting (IPTW). The prognostic impact of transient and persistent RD at 1 year was evaluated with Cox regression analysis.

Results: 1047 patients were included (PCI: 617, CABG: 430). Patients undergoing PCI were older, more often male and affected by chronic kidney disease. AKI occurred in 17% and 28% of patients after PCI and CABG, respectively (adjusted OR 2.82; 95% CI 1.89 to 4.21). Consistent findings were observed after IPTW. AKI was associated with increased 1-year risk of all-cause death, irrespective of revascularisation strategy, but only persistent RD (HR 9.56; 95% CI 4.06 to 22.53) worsened patients' prognosis, unlike AKI with only transient RD (HR 0.65; 95% CI 0.08 to 5.04).

Conclusions: AKI is common after LMCAD revascularisation and occurred more frequently following CABG than PCI. AKI has a substantial prognostic impact irrespective of revascularisation modality, but only when resulting in persistent RD.