Critical Pathways in Cardiology最新文献

Radiofrequency catheter ablation (CA) has emerged as a therapeutic strategy for Brugada syndrome (BrS), particularly for patients with recurrent ventricular fibrillation (VF) and implantable cardioverter-defibrillator (ICD) shocks. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of CA compared with standard management. PubMed, Embase, and Scopus were searched from inception to August 2025 for randomized controlled trials and adjusted observational studies enrolling BrS patients undergoing CA versus ICD-only therapy, pharmacotherapy, or observation. Five studies (2 RCTs, 3 cohorts) comprising 510 patients (296 ablation; 214 control) were included. The primary outcome was ventricular arrhythmia recurrence; secondary outcomes were procedural complications and ICD-related complications. Pooled analysis demonstrated that CA significantly reduced ventricular arrhythmia recurrence (RR 0.20; 95% CI 0.05-0.75; P=0.02), with consistent benefit in randomized trials. No significant differences were observed in procedural complications (RR 0.81; 95% CI 0.32-2.01; P=0.65) or ICD-related complications (RR 1.16; 95% CI 0.49-2.78; P=0.73). Certainty of evidence ranged from moderate to very low based on GRADE. In conclusion, CA is an effective intervention for reducing recurrent ventricular arrhythmias in BrS without an increase in procedural or device-related adverse events. These findings support the expanding role of substrate-based ablation as a disease-modifying therapy in appropriately selected BrS patients.

Background: During the COVID-19 pandemic, a temporary policy change required Emergency Medical Services (EMS)-identified ST-elevation myocardial infarction (STEMI) patients to undergo COVID testing in the emergency department (ED) prior to percutaneous coronary intervention (PCI), suspending the standard ED bypass to the catheterization lab. We compared system performance metrics during this COVID-era routing to pre- and post-pandemic periods in a large rural health system.

Methods: This was a retrospective single-center cohort study of consecutive EMS-identified STEMI activations across three periods: pre-COVID (5/27/2018-3/26/2020), COVID-era ED routing (3/27/2020-1/25/2022), and post-COVID with resumed ED bypass (1/26/2022-11/26/2023). Primary outcomes were standard STEMI system performance metrics; the secondary outcome was in-hospital mortality.

Results: A total of 373 patients were included (pre-COVID: 132; COVID: 104; post-COVID: 137). Compared to pre-COVID, the median time from EMS first medical contact to device time increased by 13 minutes (p = 0.017). The median time from symptom onset to device time increased by 30 minutes (p = 0.0013). The median time of first EMS ECG to device placement was increased by 14 minutes (p=0.013). The median door to device time was increased by 6 minutes (p = 0.0007). There was a non-significant trend toward higher in-hospital mortality during the COVID era.

Conclusion: In a rural STEMI system, pandemic-era routing of EMS-identified patients through the ED was associated with significant delays in key reperfusion metrics. While in-hospital mortality did not differ significantly, likely due to limited statistical power, these findings underscore the importance of preserving streamlined STEMI pathways. Larger multicenter studies to assess outcomes are warranted.

Cardiac myosin inhibitors (CMIs) are novel, disease-modifying therapies for hypertrophic cardiomyopathy (HCM). This meta-analysis evaluates the efficacy of CMIs versus placebo in patients with HCM. A systematic review and meta-analysis of randomized controlled trials (RCTs) involving adults with obstructive and non-obstructive HCM was performed following the PRISMA 2020 guidelines and registered on PROSPERO. Database including PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through September 2025. Random-effects models were performed using SMDs for biomarker and WMDs for echocardiographic parameters. RRs were calculated for dichotomous outcomes, with 95% confidence intervals. Seven RCTs, comprising 1,406 patients (732 CMI; 674 placebo) were included. CMIs significantly improved resting (WMD: -57.27 mmHg [-63.05, -51.49]; p < 0.001) and post-Valsalva LVOT gradient (WMD: -55.87 mmHg [-63.05, -51.49]; p < 0.001). LVEF decreased modestly (WMD: -4.74% [-7.22, -2.26]; p = 0.0002). CMIs increased the likelihood of ≥1 NYHA class improvement (RR: 1.94 [1.37, 2.74]; p < 0.001) and KCCQ-CSS (WMD: +6.60 points [3.84, 9.35]; p < 0.001). NT-proBNP (WMD: -13.35 [-18.04, -8.67]; p < 0.001) and cardiac troponin I (WMD: -11.90 [-15.07, -8.73]; p < 0.001) declined. Peak oxygen uptake showed no overall change (WMD: +0.64 mL/kg/min [-0.18, 1.47]; p = 0.12). CMIs increased adverse events (RR: 1.07 [1.02, 1.13]; p = 0.008), particularly hypertension (RR: 2.19 [1.06, 4.53]; p = 0.03). CMIs improve hemodynamics, functional status, and biomarkers in HCM with an acceptable safety profile and hold promise as disease-modifying therapy, though long-term outcomes require confirmation.

Guidelines recommend fasting before catheterization laboratory (cath lab) procedures. However, recent studies question the necessity of fasting, suggesting that fasting may not provide significant clinical benefits. This study aims to evaluate the existing evidence between outcomes for patients with fasting and non-fasting regimens. We conducted a comprehensive search for randomized controlled trials (RCTs) comparing fasting and non-fasting protocols before cath lab procedures. Outcomes included hypoglycemia, aspiration pneumonia, contrast nephropathy, all-cause mortality, and cardiovascular mortality. A random effects meta-analysis was performed to derive odds ratios (ORs) and 95% confidence intervals (CIs). The meta-analysis included 8 RCTs with a total of 3,068 participants: 1,544 in the fasting group and 1,524 in the non-fasting group. Compared with fasting, non-fasting was not associated with significant differences in hypoglycemia (OR = 0.77, 95% CI: 0.44 to 1.34), aspiration pneumonia (OR = 1.33, 95% CI: 0.38 to 4.72), contrast nephropathy (OR = 1.82, 95% CI: 0.88 to 3.75), all-cause mortality (OR = 1.29, 95% CI: 0.51 to 3.28), or cardiovascular mortality (OR = 0.94, 95% CI: 0.22 to 4.05). Non-fasting regimens show no significant differences in safety outcomes compared to fasting, suggesting it may be implemented to improve patient experience without compromising safety. Larger trials are needed to confirm the safety of non-fasting regimens.

Despite technological advancements, mortality remains high in patients with myocardial infarction complicated by cardiogenic shock. Impella is increasingly used as an adjunct to standard treatment due to its hemodynamic benefits, though mixed study results limit its adoption. This meta-analysis aims to clarify Impella's efficacy by focusing on high-quality data from RCTs and cohort studies. A comprehensive literature search was conducted for randomized controlled trials and cohort studies comparing Impella with intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO). Assessed metrics included mortality, clinical events, and hematologic markers. Data was analyzed using the Mantel-Haenszel random-effects model. Of 787 articles, 12 studies (4918 patients) met the inclusion criteria. Impella groups showed significant increases in thrombosis risk (RR: 4.94) and had a higher bleeding risk compared to IABP (RR: 1.98) but a lower risk compared to ECMO (RR: 0.66). All other comparisons did not reach statistical significance. Despite updated data and a stringent quality threshold, the hemodynamic benefits of Impella and the device's risk of thrombosis and bleeding were high. Future trials should emphasize patient selection, timing of placement, and operator proficiency to evaluate Impella's efficacy and safety better.

Background: Patients with potential transient ischemic attacks (TIA) are often evaluated with transthoracic echocardiography (TTE) to identify cardioembolic sources. The diagnostic yield of TTE among patients in an Emergency Department Observation Unit (EDOU) with suspected TIA is unknown. We aimed to determine the diagnostic yield of TTE in a U.S. EDOU TIA cohort.

Methods: We conducted an observational cohort study using the Wake Forest Emergency Medicine TIA Registry. We included patients ≥18 years old evaluated in the EDOU TIA Protocol at a large academic tertiary care center between 7/1/2021-12/1/2023. TTE results were reviewed for high-risk cardioembolic features, which we included as patent foramen ovale (PFO), left ventricular ejection fraction (LVEF) ≤ 40%, focal wall motion abnormalities (FWMA), and ventricular thrombus. The diagnostic yield, defined as the proportion of patients who were found to have a high-risk cardioembolic feature on TTE, was calculated and reported with an exact 95% confidence interval (95%CI) and used to determine the number needed to test (NNT).

Results: Among 686 patients included our cohort, 67.1% (460/686) underwent TTE. The diagnostic yield of TTE was 19.4% (95%CI 15.7-23.0%), which corresponds to a NNT of 6 (95%CI 5-7). In our cohort, TTE identified 63 PFOs, 26 instances of LVEF ≤ 40%, 6 FWMAs, and 0 ventricular thrombi.

Conclusions: Among patients with suspected TIA in the EDOU, TTE was useful in the detection of high-risk cardioembolic features, especially PFOs and reduced LVEF. These findings support the continued use of TTE for those evaluated for TIA in the EDOU.

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a major cardiovascular condition associated with substantial morbidity, mortality, and risk of recurrence. Extended anticoagulation is frequently required beyond the initial treatment phase, yet the optimal strategy remains uncertain. Direct oral anticoagulants (DOACs) provide practical advantages over vitamin K antagonists, but their role in long-term secondary prevention warrants clarification.We performed a systematic review and meta-analysis of placebo-controlled randomized controlled trials (RCTs) evaluating extended DOAC therapy in VTE. A comprehensive literature search identified five eligible trials with a total of 13,802 patients. Data were pooled using random-effects models to calculate risk ratios (RR) and 95% confidence intervals (CI). Outcomes included recurrent VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), mortality, stroke, cancer incidence, and bleeding events. Compared with placebo, extended DOAC therapy significantly reduced symptomatic recurrent VTE (RR 0.26; 95% CI 0.16-0.41), with consistent findings across sensitivity analyses. DOACs demonstrated strong protection against recurrent DVT, while results for recurrent PE were less consistent. No significant differences were observed in all-cause mortality, ischemic stroke, or cancer incidence. Safety analyses showed no increase in major bleeding. Extended DOAC therapy is highly effective in preventing recurrent VTE, particularly DVT, and maintains an acceptable safety profile. Despite the absence of mortality or stroke benefit, the favorable efficacy-safety balance supports DOACs as a convenient and effective option for prolonged secondary prevention in patients at ongoing risk of recurrence.

Aims: Early detection of cardiovascular disease and implementation of evidence-based treatments can reduce cardiovascular morbidity and mortality. Medical algorithms and decision-making tools provide a compelling option for screening, risk prediction and treatment management. Such digital tools have the potential to aid both healthcare professionals (HCPs) and patients, providing support to decrease unwarranted diagnostic and treatment variability while guiding personalized care, with the overall objective of improving clinical outcomes. However, incorporating digital tools in healthcare settings is challenging, and evidence the required to support their adoption and understand the limitations can be lacking.

Methods and results: A multi-national panel of expert cardiologists and emergency physicians across North America, Europe, and Oceania gathered to deliberate on the current landscape of digital tools and medical algorithms, drawing on prior clinical experiences and knowledge of country-specific regulations. In this viewpoint, the evidence to support and guide the adoption of digital tools in cardiovascular clinical practice and the necessary components for successful integration into clinical workflows were discussed.

Conclusions: Digital tools must be developed with the needs of the HCPs, other relevant stakeholders (e.g., administration personnel), and patients in mind to give them the best chance of widespread adoption. Academia, industry, and regulatory bodies should work together to cultivate and accelerate the implementation of digital tools in healthcare. The considerations discussed here may help decision makers to determine if a digital tool has the components necessary to integrate into the clinical workflow successfully.

Background: Limited data exist on the impact of body mass index (BMI) on the outcomes of admissions with acute pulmonary embolism (PE).

Methods: All adult (≥18 years) admissions with a primary diagnosis of PE were identified using the National Inpatient Sample (2016-2020) and categorized using BMI into underweight (<19.9 kg/m 2), normal (19.9-24.9 kg/m 2), and overweight/obese (>24.9 kg/m 2). Outcomes included in-hospital mortality, utilization of PE therapies, and resource utilization.

Results: Of 904,260 admissions, 1.8%, 70.4%, and 27.7% were underweight, normal and overweight/obese, respectively. Underweight admissions were on average older (70.8±0.2, 64.6±0.05, 58.2±0.07 years), male (56.7%, 49%, 58.3%) with higher comorbidity (Elixhauser Index 5.8±0.03, 4±0.06, 5.1±0.09), from a lower socioeconomic status, and with Medicare insurance compared to normal and overweight/obese categories (p<0.001). The underweight cohort had higher rates of acute organ failure, bleeding complications, strokes, shock, and higher mechanical ventilation and hemodialysis use. In contrast to the underweight group, normal and overweight/obese groups had higher rates of mechanical thrombectomy (0.3%, 1.1%, 1.9%), systemic thrombolysis (1.5%, 2.6%, 4.2%), catheter directed therapy (0.9%, 3%, 5.8%), and surgical thrombectomy (0.0%, 0.1%, 0.2%) (p<0.001). Compared to the normal cohort (3.3%), underweight cohort had higher (7.8%; odds ratio [OR] 1.85 [95% confidence interval {CI} 1.54-2.21]), whereas the overweight/obese cohort had lower (2.2%; OR 0.47 [95% CI 0.42-0.52]) in-hospital mortality (both p<0.001). The underweight cohort had longer hospitalization stays, higher hospitalization costs, and were discharged home less frequently.

Conclusion: Compared to those with normal BMI, underweight status was associated with worse outcomes in those hospitalization with acute PE.

Background: Left bundle branch area pacing (LBBAP) has emerged as a physiologically targeted alternative to biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT). We conducted a systematic review and meta-analysis to compare the impact of LBBAP versus BiVP on clinical and procedural outcomes in patients undergoing CRT.

Methods: A systematic search of PubMed, Cochrane Central, and Embase was conducted in August 2025 to identify studies comparing LBBAP and BiVP in patients undergoing CRT. Eligible studies included randomized and observational designs. Primary outcomes were all-cause mortality and heart failure-related hospitalization. Secondary outcomes included changes in QRS duration, LVEF, NYHA class, procedural time, and fluoroscopy time. Meta-analyses were performed using inverse-variance random-effects models. Heterogeneity was assessed using I² and sensitivity was evaluated with leave-one-out analysis. Effect sizes were reported as relative risks (RR) or mean differences (MD) with corresponding 95% confidence intervals (CI).

Results: Eighteen studies (17 observational and 1 randomized controlled trial) encompassing 5605 patients (LBBAP= 2428 and BIVP= 3177) were included in this meta-analysis. Compared to BiVP, LBBAP was associated with a significantly lower risk of all-cause mortality (9.9% vs. 13.9%; RR = 0.68, 95% CI: 0.59, 0.79; p < 0.00001; I² = 0%) and HF-related hospitalization (RR = 0.51, 95% CI: 0.42, 0.62; p < 0.00001; I² = 42%). LBBAP was also associated with a marked improvement in mean LVEF (MD = 4.71%, 95% CI: 3.80, 5.61; p < 0.00001; I² = 35%) and substantial narrowing of mean QRS duration (MD = -24.60 ms, 95% CI: -29.49, -19.70; p < 0.00001; I² = 94%). Functional status (mean NYHA class) was significantly improved within the LBBAP group (MD = -0.31, 95% CI: -0.52, -0.09; p = 0.005; I² = 94%). LBBAP was also associated with significantly shorter procedural and fluoroscopy times (MD = -29.77 mins and -8.62 mins, respectively) compared to BiVP.

Conclusion: This meta-analysis demonstrates that LBBAP is associated with significantly lower all-cause mortality and HF-related hospitalizations compared to BiVP in patients undergoing CRT. LBBAP also offers procedural advantages and greater improvements in electrical and functional cardiac parameters. Further large-scale randomized trials are warranted to confirm these findings.