Open Heart最新文献

Background: Aortogenic stroke is an important subtype of embolic strokes, yet lacks a diagnostic method for proactive identification. Non-obstructive general angioscopy (NOGA) is a catheter-based technique to observe spontaneously ruptured aortic plaques (SRAPs), a potential embolic source of ischaemic stroke.

Objectives: This study aimed to identify the embolic source of ischaemic stroke using NOGA.

Methods: From June 2022 to January 2024, 321 consecutive patients with acute ischaemic stroke were hospitalised. 25 underwent emergent mechanical thrombectomy and NOGA. The aortic arch was screened using NOGA, and atherosclerotic materials from the SRAPs were sampled and pathologically analysed. Transoesophageal echocardiography (TEE) was performed the day after catheterisation to investigate intracardiac thrombus, patent foramen ovale and aortic plaques. The primary outcome was the diagnosis of aortogenic stroke.

Results: NOGA identified seven SRAPs in the aortic arch as potential embolic sources. Of those, one patient with atrial fibrillation and cardiac chamber thrombus was diagnosed as having a cardiogenic stroke. The findings of the six remaining cases included aortic arch plaque (also observed via TEE) (n=2), thrombus in an artificial aortic graft wall (n=1), and cholesterol crystals in sampled materials indicating plaque rupture (n=3). The Brain-Heart team finally diagnosed these 6 cases (24%) as aortogenic stroke. 16 patients were diagnosed with cardiogenic stroke. One was diagnosed with paradoxical embolism. The remaining two cases (8%) with unidentified embolic sources were diagnosed with cryptogenic stroke.

Conclusions: Using a systematic diagnostic protocol for embolic source detection, the Brain-Heart team could proactively diagnose aortogenic stroke and clarify embolic source.

Background: Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, requiring careful revascularisation strategy consideration. While surgical aortic valve replacement (SAVR) plus coronary artery bypass grafting (CABG) is traditional, transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) is increasingly used. The optimal strategy, particularly regarding residual CAD burden, remains unclear.

Objectives: This study investigated the impact of residual SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score (rSS) on outcomes in men and women with AS and CAD undergoing TAVR+PCI versus SAVR+CABG.

Methods: In this retrospective study, propensity score-matched cohorts of men and women undergoing either procedure were analysed. Matching variables included age, left ventricular ejection fraction, EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) and CAD severity.

Results: 398 patients (114 women and 284 men) were included. The rSS was predictive of the primary composite endpoint in the TAVR+PCI group (p=0.006 women and p<0.001 men) but not in the SAVR+CABG group. In patients achieving an rSS<8, TAVR+PCI was associated with a lower combined endpoint rate compared with SAVR+CABG, consistent across genders (p=0.02). Furthermore, TAVR+PCI demonstrated significant safety benefits, including lower rates of major bleeding in men (2.1% vs 10.6%) and stroke in women (1.8% vs 12.3%).

Conclusions: The prognostic importance of the rSS is strategy-dependent. For patients undergoing TAVR+PCI, achieving extensive revascularisation (rSS <8) is a critical procedural goal associated with improved outcomes. For patients undergoing SAVR+CABG, prognosis appears driven more by baseline clinical risk.

Purpose: Sotatercept, an activin signalling inhibitor approved in March 2024 for pulmonary arterial hypertension (PAH), demonstrated efficacy in clinical trials. This pharmacovigilance study evaluated its real-world safety profile using the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) to identify postmarketing risks.

Methods: FAERS reports from 2024 were analysed, focusing on cases where sotatercept was designated as the primary suspect. Duplicate entries were removed using standardised FDA protocols. Adverse events (AEs) were categorised using the Medical Dictionary for Regulatory Activities (MedDRA V.28.0). Disproportionality signals were assessed via reporting ORs (RORs; 95% CI lower limit >1 with ≥3 cases). Severity was classified using the EudraVigilance Important Medical Events (IMEs) list.

Results: Among 1 484 350 deduplicated reports, 613 sotatercept-associated AEs (1717 occurrences, 395 MedDRA terms) were identified. Disproportionality analysis revealed 48 safety signals: 30 aligned with labelled risks (eg, haemoglobin elevation (ROR=272.2), telangiectasia (ROR=334.1)) and 18 novel signals. The most frequent AEs included headache (n=78), epistaxis (n=57) and diarrhoea (n=53). Two unlabelled events-cerebral haemorrhage and ascites-met criteria for critical IMEs. Most reports originated from the USA (98.5%) and involved females (73.6%).

Conclusion: This study confirms sotatercept's labelled risks (haematological and vascular effects) and identifies novel safety concerns, including cerebral haemorrhage and ascites, highlighting the need for vigilant monitoring in PAH management. Real-world data underscore the value of postmarketing surveillance for detecting rare or unanticipated AEs. Clinicians should prioritise monitoring for haematological abnormalities and bleeding risks. Longitudinal studies are warranted to clarify long-term safety outcomes.

Background: Routine invasive management by coronary angiography and revascularisation as appropriate reduces recurrent ischaemic events in non-ST-segment myocardial infarction (NSTEMI), but its mortality benefit is uncertain.

Methods: Within this state-wide retrospective cohort study, patients with a primary diagnosis of NSTEMI were identified from the New South Wales (NSW) Admitted Patient Data Collection database between 2003 and 2020 and linked to the NSW death registry. Primary outcomes were cardiovascular (CV) and all-cause mortality among NSTEMI patients stratified by in-hospital invasive management.

Results: Among 121 089 patients with NSTEMI (median age 71.4 years; 62.7% men), invasive management increased from 48.8% to 66.8% while all-cause in-hospital mortality decreased from 4.8% to 2.9% between triennial periods of 2003-2005 and 2018-2020, respectively. During the follow-up period (median 8.47 years), 47 304 (39.1%) patients died. CV mortality fell between 2003 and 2020 for those who were and were not invasively managed with greater magnitude in the former (subdistribution HR (sHR)=0.32, 95% CI 0.29 to 0.36; sHR=0.58, 95% CI 0.54 to 0.63, respectively, p_interaction<0.001). For all-cause mortality, the fall was significant for the invasively managed patients, with no plateau evident, but not in patients managed conservatively (adjusted HR (aHR)=0.56, 95% CI 0.52 to 0.61; aHR=1.00, 95% CI 0.95 to 1.06, respectively, p_interaction<0.001).

Conclusions: In patients presenting to NSW hospitals with NSTEMI between 2003 and 2020, we observed improvements in CV mortality in both invasively and conservatively managed patients while all-cause mortality improved in invasively but not conservatively managed patients. Wider implementation of routine invasive management may further improve long-term mortality among NSTEMI patients in NSW.

Background: Biochemical markers of inflammation, coagulation and myocardial stress have been associated with both prevalent and incident atrial fibrillation (AF), but little is known about the relationship between biomarker expression and AF burden.

Aims: Our aim was to investigate the association between cardiovascular biomarkers and AF burden and AF episode duration ≥24 hours.

Methods and results: In this multicentre observational cohort study, we included 404 patients with paroxysmal AF from the Reappraisal of Atrial Fibrillation: Interaction between Hypercoagulability, Electrical Remodelling and Vascular Destabilisation in the Progression of AF study and evaluated a total of 92 potential cardiovascular blood biomarkers. All patients completed 1 year of follow-up with continuous rhythm monitoring using an implanted loop recorder or a dual-chamber pacemaker. The relationship between biomarker expression and AF was investigated using multiple regression including nine preselected covariates: age, sex, prior heart failure, hypertension, renal insufficiency, prior stroke, coronary artery disease, body mass index and treatment with antiarrhythmic drugs. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with higher AF burden (incidence rate ratio 1.75, 95% CI 1.75 to 2.06) and AF episode duration ≥24 hours (OR 1.78, 95% CI 1.39 to 2.27). Increased levels of matrix metalloproteinase 2, neurogenic locus notch homologue protein 3 and tumour necrosis factor receptor 2 were additionally associated with AF episode durations ≥24 hours.

Conclusions: Higher circulating levels of NT-proBNP are associated with increased AF burden and AF episode duration ≥24 hours in patients with paroxysmal AF.

Trial registration number: NCT02726698.

Background: Hospitalisation with acute heart failure (AHF) carries a high risk of death, and those surviving to discharge remain at high risk of death or rehospitalisation with AHF. The impact of outpatient heart failure (HF) specialist care after discharge from AHF hospitalisation on longer-term outcomes is unclear in contemporary UK practice.

Methods: A retrospective analysis of a cohort of 2104 patients admitted to hospital due to AHF between 2014-2022 in a single UK county was performed. Patient characteristics, left ventricular ejection fraction (EF) (LVEF) category (HF with reduced EF (LVEF ≤40%; HFrEF), HF with mildy reduced EF (LVEF 41%-49%; HFmrEF) and HF with preserved EF (LVEF ≥50%; HFpEF)) and survival free from a composite end point of AHF rehospitalisation or death are described. Cox regression survival analysis was performed to explore the impact of baseline patient characteristics and HF specialist care on long-term outcomes.

Results: The median age of the cohort was 83 years. HFrEF was present in 36%, HFmrEF in 9% and HFpEF in 55%. 13% died during index AHF hospitalisation. Median follow-up for those surviving to discharge was 618 (IQR 264-1275) days. 21% were rehospitalised due to AHF, and 63% died during follow-up. On adjusted survival analysis of 1511 patients with echocardiogram data available, HF specialist care after discharge from hospital was independently associated with a significant reduction in the composite end point across all LVEF categories (HFrEF: HR 0.577, 95% CI 0.429 to 0.775, p<0.001; HFmrEF: HR 0.485, 0.281-0.834, p=0.009; HFpEF HR 0.762, 0.623-0.931, p=0.008).

Conclusions: HF specialist care after discharge for patients hospitalised with AHF is associated with a significant reduction in the long-term risk of rehospitalisation and all-cause death. This association was present across the three LVEF categories (HFrEF, HFmrEF and HFpEF) and was independent of age and important comorbidities.

Background: In patients with acute ischaemic stroke (AIS) and concomitant non-ST-elevation acute coronary syndrome (NSTE-ACS), the role of intravenous thrombolysis (IVT) before percutaneous coronary intervention (PCI) is unclear.

Methods: We performed a subanalysis of the PRAISE (PRediction of Acute coronary syndrome in acute Ischemic StrokE) study, a multicentre, prospective observational study in 247 patients with AIS and elevated high-sensitivity cardiac troponin who underwent coronary angiography based on European Society of Cardiology guidelines. The impact of IVT prior to PCI on coronary artery flow (Thrombolysis in Myocardial Infarction (TIMI) score) and myocardial perfusion (TIMI myocardial perfusion score) was compared using Fisher's exact test and logistic regression analysis, adjusting for time from stroke onset to PCI.

Results: Among 71 patients with AIS undergoing PCI, those who received IVT prior to PCI for NSTE-ACS (33 women; median age 77 (66-82 IQR)) achieved a TIMI grade 3 flow more frequently than those undergoing direct PCI (97% vs 79%; p=0.04). Regression analysis indicated a trend toward improved coronary artery flow with IVT (adjusted OR 8.5, 95% CI 0.9 to 75.3; p=0.05). Myocardial perfusion did not differ between groups (p=0.06).

Conclusions: This subanalysis suggests that IVT before PCI may enhance coronary artery flow in selected patients with NSTE-ACS with AIS. The results of this exploratory subanalysis warrant further investigation, particularly in patients with delayed access to PCI.

Background: Mavacamten has revolutionised the treatment of hypertrophic obstructive cardiomyopathy (HOCM) but requires frequent follow-up. Routine ECG may offer an accessible tool to indicate response to therapy. This study evaluates ECG-based indices of left ventricular hypertrophy (LVH) in patients with HOCM receiving mavacamten therapy.

Methods: In this retrospective study, after screening of 62 consecutive patients with HOCM treated at a German tertiary referral centre from August 2023 to February 2025, 31 patients (42% female, mean age 61±12 years) were included. During the first 12 weeks of myosin inhibitor treatment, echocardiographic parameters, laboratory values, symptoms and ECG LVH indices were assessed.

Results: Mavacamten reduced the mean left ventricular outflow tract obstruction (LVOTO) during Valsalva from 103 mm Hg (73-145) to 32 mm Hg (19-60), (p<0.001). All ECG LVH indices significantly decreased with treatment (Sokolow-Lyon Index: 2.56±0.97 mm vs 2.04±0.75 mm, p<0.001; Cornell criteria: 1.23 mm (0.92-2.21) vs 0.92 mm (0.75-1.75), p=0.001; Peguero-Lo Presti criteria: 2.39 mm (1.62-3.22) vs 1.61 mm (1.12-2.01), p<0.001; all pre vs post mavacamten). Notably, an increase in the Sokolow-Lyon Index and Peguero-Lo Presti criteria correlated with worsening LVOTO (area under the curve 0.72 and 0.88, respectively). Sensitivity and specificity of ECG LVH indices for detecting LVOTO progression during therapy were 100% and 88.6%, respectively.

Conclusion: A combinatory ECG-based approach using the Sokolow-Lyon Index and Peguero-Lo Presti criteria may serve as an accessible tool for monitoring LVOTO progression in patients with HOCM on mavacamten. Prospective validation is warranted.

Background: The long-term effects of myocarditis following COVID-19 vaccination on cardiac function and symptoms remain unclear.

Purpose: To assess the long-term effects of myocarditis following COVID-19 vaccination on cardiac function, inflammatory biomarkers and symptoms.

Methods: Patients with myocarditis within 50 days of receiving COVID-19 vaccination (2021-2022) were invited to follow-up approximately 2 years after initial hospitalisation. Follow-up assessment included echocardiography, biomarkers, ECG, lung ultrasound (LUS) and symptom questionnaires. Patients with myocarditis following COVID-19 vaccination (V-myocarditis) were compared with non-vaccine-related myocarditis (NV-myocarditis) controls admitted during the same period.

Results: 17 patients with V-myocarditis (median age 47 (27-59) years, 53% women) were included. Median time from vaccination to admission was 6 days, with 88% admitted within 30 days. At follow-up (28±6 months), patients with V-myocarditis showed mildly impaired left ventricular (LV) function (median global longitudinal strain (GLS) 16.0% (13.2%-18.2%)) and diastolic dysfunction in 71%. Right ventricular (RV) and LUS findings were preserved. Biomarkers normalised from admission to follow-up with significant reductions in troponin-I (p<0.001) and C-reactive protein (p=0.001), while 35% showed persistent low-grade inflammation. Symptoms were common at follow-up, including fatigue (35%) and chest pain (41%). Compared with NV-myocarditis, patients with V-myocarditis had similar symptoms and biomarker recovery, but lower GLS at follow-up (NV-myocarditis: 18.5% (15.4%-20.3%), p=0.04).

Conclusion: In one of the longest reported follow-up studies of myocarditis following COVID-19 vaccination, patients exhibited mild LV and diastolic dysfunction, preserved RV function and overall normalised biomarkers. A notable proportion continued reporting symptoms, highlighting the need for long-term follow-up.

Background: The aim of the study was to estimate the sex-specific prevalence and incidence of atrial fibrillation or flutter (AF) in the German population-based Heinz Nixdorf Recall study.

Methods: We analysed data from 4814 participants at baseline 2000-2003 (T0, 50.2% women, 45-75 years), first and second follow-up examination (T1: n=4157, 2005-2008; T2: n=3087, 2010-2015) and yearly postal questionnaires for the AF occurrence until 29 November 2023. We determined the AF prevalence at T0, if participants were aware of having AF at T0, if participants with ECG-proven AF at T0 were anticoagulated, the cumulative incidence and the incidence rate per 1000 person-years over two decades of follow-up.

Results: Overall, 152 (3.2%) participants were identified with AF at or before T0. Of those, only n=89 (58.6%) participants were able to name an existing AF diagnosis. n=80 (1.7%) participants had ECG-confirmed AF and 13 (0.3%) participants were not aware of having AF at T0. Of 4662 participants without AF at T0, 640 (13.7%) developed AF during a median follow-up time of 16.7 (Q1; Q3: 10.5-18.9) years. The overall incidence rate was 9.4 (95% CI: 8.7 to 10.1) per 1000 person-years.

Conclusions: The results of our study show that AF is an epidemic disease in the middle-aged and elderly population. The proportion of patients who do not know that they have AF should be reduced in the future. Patients also need to be better informed about their disease and anticoagulation. This is important in order to prevent avoidable adverse events.