Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.07.005
Evan J. Wiens MD, MSc, FRCPC , Kristal L. Kawa MN, NP , Silvia J. Leon MD, MSc , Reid Whitlock MSc , Setor Kunutsor BSc, MD, MPhil, PhD , Navdeep Tangri MD, PhD , Ashish H. Shah MBBS, MD, MD-Research, FRCP
Background
Although delays in treatment are known to worsen outcomes in ST-elevation myocardial infarction, their effect in non-ST-elevation myocardial infarction (NSTEMI) is less clear. Care quality and timely revascularization should be comparable across presentation sites to optimize patient outcomes.
Methods
Using the Manitoba Centre for Health Policy data, we retrospectively analyzed adult NSTEMI patients who underwent cardiac catheterization and revascularization from January 2001 to March 2021. Patients were grouped by initial presentation site—rural hospital, urban noncardiac hospital, or specialized cardiac centre. We assessed in-hospital, 1-year, and long-term outcomes.
Results
Of 30,817 NSTEMI patients, 19,482 underwent catheterization, and 12,567 received revascularization. Distribution by site was as follows: 44% at cardiac centres, 28.5% at urban noncardiac hospitals, and 27.5% at rural hospitals. Urban noncardiac hospital patients experienced significantly higher cardiovascular mortality in-hospital (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.09-2.47), at 1 year (HR 1.30; 95% CI 1.11-1.53), and over an average 6.65-year follow-up period (HR 1.15; 95% CI 1.07-1.24). Rural hospital patients showed a lower mortality incidence, potentially due to selection bias if critically ill patients did not survive the transfer. Both rural and urban noncardiac cohorts had elevated rates of major adverse cardiovascular events at all follow-up intervals. Time to catheterization was notably delayed for nonspecialized sites (cardiac centre, 0.83 ± 1.90 vs urban noncardiac 3.20 ± 3.05 vs rural, 3.09 ± 2.56 days; P < 0.001).
Conclusions
NSTEMI patients presenting to rural and urban nonspecialized hospitals experience worse short- and long-term outcomes, including increased incidence of major adverse cardiovascular events and mortality. These findings highlight the need for strategies to reduce disparities in access to specialized cardiac care.
{"title":"Outcomes of Non-ST Elevation Myocardial Infarction Patients by Presentation Site: Rural, Urban Community, or Specialized Cardiac Hospital","authors":"Evan J. Wiens MD, MSc, FRCPC , Kristal L. Kawa MN, NP , Silvia J. Leon MD, MSc , Reid Whitlock MSc , Setor Kunutsor BSc, MD, MPhil, PhD , Navdeep Tangri MD, PhD , Ashish H. Shah MBBS, MD, MD-Research, FRCP","doi":"10.1016/j.cjco.2025.07.005","DOIUrl":"10.1016/j.cjco.2025.07.005","url":null,"abstract":"<div><h3>Background</h3><div>Although delays in treatment are known to worsen outcomes in ST-elevation myocardial infarction, their effect in non-ST-elevation myocardial infarction (NSTEMI) is less clear. Care quality and timely revascularization should be comparable across presentation sites to optimize patient outcomes.</div></div><div><h3>Methods</h3><div>Using the Manitoba Centre for Health Policy data, we retrospectively analyzed adult NSTEMI patients who underwent cardiac catheterization and revascularization from January 2001 to March 2021. Patients were grouped by initial presentation site—rural hospital, urban noncardiac hospital, or specialized cardiac centre. We assessed in-hospital, 1-year, and long-term outcomes.</div></div><div><h3>Results</h3><div>Of 30,817 NSTEMI patients, 19,482 underwent catheterization, and 12,567 received revascularization. Distribution by site was as follows: 44% at cardiac centres, 28.5% at urban noncardiac hospitals, and 27.5% at rural hospitals. Urban noncardiac hospital patients experienced significantly higher cardiovascular mortality in-hospital (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.09-2.47), at 1 year (HR 1.30; 95% CI 1.11-1.53), and over an average 6.65-year follow-up period (HR 1.15; 95% CI 1.07-1.24). Rural hospital patients showed a lower mortality incidence, potentially due to selection bias if critically ill patients did not survive the transfer. Both rural and urban noncardiac cohorts had elevated rates of major adverse cardiovascular events at all follow-up intervals. Time to catheterization was notably delayed for nonspecialized sites (cardiac centre, 0.83 ± 1.90 vs urban noncardiac 3.20 ± 3.05 vs rural, 3.09 ± 2.56 days; <em>P</em> < 0.001).</div></div><div><h3>Conclusions</h3><div>NSTEMI patients presenting to rural and urban nonspecialized hospitals experience worse short- and long-term outcomes, including increased incidence of major adverse cardiovascular events and mortality. These findings highlight the need for strategies to reduce disparities in access to specialized cardiac care.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1466-1473"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555415","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.06.021
Alisha Labinaz BSc , Ren Jie Robert Yao MD , Farshad Hosseini MD , Ricky D. Turgeon BSc (Pharm), ACPR, PharmD , Miles Marchand MD , Liam Brunham MD, PhD, FRCPC, FACP , Nathaniel M. Hawkins MD, MBChB, MPH , Graham Wong MD, MPH, FRCPC, FACC, FCCS, FAHA , G.B. John Mancini MD, FRCPC, FACP, FACC , Christopher B. Fordyce MD, MHS, MSc, FRCPC
Following an acute coronary syndrome (ACS), patients remain at a residual increased risk of adverse cardiovascular events. As such, secondary prevention strategies, including dyslipidemia management, are key in the delivery of post-ACS care. Multiple randomized controlled trials have highlighted the benefit of lipid-lowering therapies in reducing low-density lipoprotein cholesterol levels, an independent predictor of adverse cardiovascular events post-ACS. However, registries have demonstrated that post-ACS, a significant proportion of patients are not achieving guideline-recommended low-density lipoprotein target levels, and intensification of lipid-lowering therapies continues to be underutilized. This review assesses strategies in which post-ACS lipid management can be improved, in particular by standardizing follow-up care through dedicated post-ACS clinics.
{"title":"Implementing Dyslipidemia Guidelines into Clinical Practice Following an Acute Coronary Syndrome: Challenges and Opportunities for Improvement","authors":"Alisha Labinaz BSc , Ren Jie Robert Yao MD , Farshad Hosseini MD , Ricky D. Turgeon BSc (Pharm), ACPR, PharmD , Miles Marchand MD , Liam Brunham MD, PhD, FRCPC, FACP , Nathaniel M. Hawkins MD, MBChB, MPH , Graham Wong MD, MPH, FRCPC, FACC, FCCS, FAHA , G.B. John Mancini MD, FRCPC, FACP, FACC , Christopher B. Fordyce MD, MHS, MSc, FRCPC","doi":"10.1016/j.cjco.2025.06.021","DOIUrl":"10.1016/j.cjco.2025.06.021","url":null,"abstract":"<div><div>Following an acute coronary syndrome (ACS), patients remain at a residual increased risk of adverse cardiovascular events. As such, secondary prevention strategies, including dyslipidemia management, are key in the delivery of post-ACS care. Multiple randomized controlled trials have highlighted the benefit of lipid-lowering therapies in reducing low-density lipoprotein cholesterol levels, an independent predictor of adverse cardiovascular events post-ACS. However, registries have demonstrated that post-ACS, a significant proportion of patients are not achieving guideline-recommended low-density lipoprotein target levels, and intensification of lipid-lowering therapies continues to be underutilized. This review assesses strategies in which post-ACS lipid management can be improved, in particular by standardizing follow-up care through dedicated post-ACS clinics.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1482-1494"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Populations with lower socioeconomic position (SEP) are at increased risk of developing cardiovascular disease (CVD). Movement behaviours, including physical activity, sedentary behaviour, and sleep, contribute to socioeconomic gradients in CVD risk, as low-SEP populations are less likely to meet evidence-informed recommendations for these behaviours. Adolescence represents a sensitive period for establishing lifelong health behaviours, with CVD risk beginning to accumulate before adulthood. This study will model the potential effect of adolescent movement behaviour interventions on socioeconomic inequalities in adult CVD risk. We will conduct a population-based cohort study of adolescents from the Add Health study, recruited in 1994-1995 from the US and followed into adulthood. Unhealthy movement behaviours, including a low level of moderate-to-vigorous physical activity, a high level of recreational screen time, and short sleep duration, will be operationalized based on the 24-hour Movement Guidelines and measured twice during adolescence (ages 12-24 years). Parental educational attainment and family financial hardship will be used to capture SEP in adolescence. The outcome will be the 30-year risk of CVD, assessed in adulthood (ages 33-41 years) using a validated risk score that incorporates objectively measured biomarkers, demographic information, and self-reported health indicators. We will perform causal decompositions to quantify the change of socioeconomic inequalities in adult CVD risk under 2 interventional scenarios: (i) elimination (unhealthy movement behaviours are eliminated in the whole population of adolescents); and (ii) equalization (the distributions of unhealthy movement behaviours for low-SEP adolescents are equalized to those of high-SEP adolescents). This study will provide insights into how modifying adolescent movement behaviours may contribute to reducing socioeconomic inequalities in CVD risk.
{"title":"Reducing Socioeconomic Inequalities in Adult Cardiovascular Disease Risk by Targeting Unhealthy Movement Behaviours During Adolescence: A Protocol","authors":"Nicholas Grubic MSc , Katerina Maximova PhD , Arnaud Chiolero MD, PhD , Arjumand Siddiqi ScD , Sarah Carsley PhD , Brice Batomen PhD , Kathleen Mullan Harris PhD , Cristian Carmeli PhD","doi":"10.1016/j.cjco.2025.08.002","DOIUrl":"10.1016/j.cjco.2025.08.002","url":null,"abstract":"<div><div>Populations with lower socioeconomic position (SEP) are at increased risk of developing cardiovascular disease (CVD). Movement behaviours, including physical activity, sedentary behaviour, and sleep, contribute to socioeconomic gradients in CVD risk, as low-SEP populations are less likely to meet evidence-informed recommendations for these behaviours. Adolescence represents a sensitive period for establishing lifelong health behaviours, with CVD risk beginning to accumulate before adulthood. This study will model the potential effect of adolescent movement behaviour interventions on socioeconomic inequalities in adult CVD risk. We will conduct a population-based cohort study of adolescents from the Add Health study, recruited in 1994-1995 from the US and followed into adulthood. Unhealthy movement behaviours, including a low level of moderate-to-vigorous physical activity, a high level of recreational screen time, and short sleep duration, will be operationalized based on the 24-hour Movement Guidelines and measured twice during adolescence (ages 12-24 years). Parental educational attainment and family financial hardship will be used to capture SEP in adolescence. The outcome will be the 30-year risk of CVD, assessed in adulthood (ages 33-41 years) using a validated risk score that incorporates objectively measured biomarkers, demographic information, and self-reported health indicators. We will perform causal decompositions to quantify the change of socioeconomic inequalities in adult CVD risk under 2 interventional scenarios: (i) elimination (unhealthy movement behaviours are eliminated in the whole population of adolescents); and (ii) equalization (the distributions of unhealthy movement behaviours for low-SEP adolescents are equalized to those of high-SEP adolescents). This study will provide insights into how modifying adolescent movement behaviours may contribute to reducing socioeconomic inequalities in CVD risk.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1495-1506"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.07.015
Sophia Wolfermann , Timo Schmitz MD , Philip Raake MD , Bernhard Kuch MD , Jakob Linseisen PhD , Christa Meisinger MD, MPH
Background
Our aim in this study was to identify the frequencies of typical and atypical acute myocardial infarction (AMI) symptoms over the past 35 years as well as age and sex differences.
Methods
In this study we used data from the population-based Augsburg Myocardial Infarction Registry. All patients (N = 23,905) 25-74 years of age and hospitalized with AMIs occurring between 1985 and 2019 were included in this analysis. During their hospital stay, patients were interviewed about their symptoms at the acute event and information from patient records was used. Multivariable adjusted logistic regression analyses were conducted to investigate the trends of AMI symptoms over time.
Results
On comparing the time interval 1985-1995 vs 2006-2019, there was a decrease in frequencies (P < 0.001 for all) for symptoms of typical chest pain (83.5% vs 80.0%), pain in the left shoulder/arm/hand (52.1% vs 44.9%), pain between the shoulder blades (23.8% vs 19.5%), nausea/vomiting (36.0% vs 30.1%), and fear of death/feeling of annihilation (30.7% vs 14.7%), whereas shortness of breath increased significantly over time (43.8% vs 48.4%, P < 0.001). Multivariable logistic regression analysis confirmed the decrease of frequency of AMI symptoms over the past decades. The only exception was occurrence of shortness of breath, where a significantly independent increase was observed when comparing 1985-1995 and 2006-2019 (odds ratio 1.22, 95% confidence interval 1.13-1.32). Atypical symptoms occurred more frequently in older patients and women.
Conclusions
Although there has been a decrease in the frequency of most AMI symptoms over almost 4 decades, AMIs are still commonly accompanied by typical chest pain. In particular, AMI must be considered if shortness of breath is present.
{"title":"Frequencies and Trends of Myocardial Infarction Symptoms From the Years 1985-2019: A Register-based, Real-world Analysis","authors":"Sophia Wolfermann , Timo Schmitz MD , Philip Raake MD , Bernhard Kuch MD , Jakob Linseisen PhD , Christa Meisinger MD, MPH","doi":"10.1016/j.cjco.2025.07.015","DOIUrl":"10.1016/j.cjco.2025.07.015","url":null,"abstract":"<div><h3>Background</h3><div>Our aim in this study was to identify the frequencies of typical and atypical acute myocardial infarction (AMI) symptoms over the past 35 years as well as age and sex differences.</div></div><div><h3>Methods</h3><div>In this study we used data from the population-based Augsburg Myocardial Infarction Registry. All patients (N = 23,905) 25-74 years of age and hospitalized with AMIs occurring between 1985 and 2019 were included in this analysis. During their hospital stay, patients were interviewed about their symptoms at the acute event and information from patient records was used. Multivariable adjusted logistic regression analyses were conducted to investigate the trends of AMI symptoms over time.</div></div><div><h3>Results</h3><div>On comparing the time interval 1985-1995 vs 2006-2019, there was a decrease in frequencies (<em>P</em> < 0.001 for all) for symptoms of typical chest pain (83.5% vs 80.0%), pain in the left shoulder/arm/hand (52.1% vs 44.9%), pain between the shoulder blades (23.8% vs 19.5%), nausea/vomiting (36.0% vs 30.1%), and fear of death/feeling of annihilation (30.7% vs 14.7%), whereas shortness of breath increased significantly over time (43.8% vs 48.4%, <em>P</em> < 0.001). Multivariable logistic regression analysis confirmed the decrease of frequency of AMI symptoms over the past decades. The only exception was occurrence of shortness of breath, where a significantly independent increase was observed when comparing 1985-1995 and 2006-2019 (odds ratio 1.22, 95% confidence interval 1.13-1.32). Atypical symptoms occurred more frequently in older patients and women.</div></div><div><h3>Conclusions</h3><div>Although there has been a decrease in the frequency of most AMI symptoms over almost 4 decades, AMIs are still commonly accompanied by typical chest pain. In particular, AMI must be considered if shortness of breath is present.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1474-1481"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.cjco.2025.06.014
Peng Jin MD , Lan Su MD , Tiantian Chen MD , Shenglong Zheng MD , Zhongping Yang PhD , Hao Zhou MD , Xiao Chen MD , Shengjie Wu MD , Lu Lin MD , Xi Zhou MD , Xue Xia MD , Weijian Huang MD
Background
Right atrial appendage pacing (RAAp) may increase the risk of atrial fibrillation (AF), compared to right atrial septal pacing (RASp). However, the implantation of atrial septal stylet-driven leads (SDLs) for RASp can present procedural challenges and limit its clinical application. We evaluated the long-term safety and feasibility of using lumenless leads (LLLs) with the delivery sheath for RASp and SDLs for RAAp, and compared AF events between the RASp and RAAp in patients with sick sinus syndrome.
Methods
A total of 329 patients with sick sinus syndrome who underwent pacemaker implantation were divided into 2 groups, based on the site of atrial lead placement: the RASp group (n = 162) with LLLs, and the RAAp group (n = 167) with SDLs. Implantation success rate, procedural time, P-wave characteristics, pacing parameters, complications, and AF episodes were compared between the 2 groups.
Results
The success rates were similar for the RASp and RAAp groups (98.8% vs 97.6%, P > 0.05). The lead implantation time was significantly shorter in the RASp group (2.5 ± 1.9 minutes vs 10.3 ± 2.9 minutes, P < 0.05). During a mean follow-up of 36.4 ± 20.5 months, the pacing parameters remained stable without serious complications. Additionally, the RASp group had a significantly reduced incidence of AF episodes (6.7% vs 14.0%, P < 0.05) and new-onset AF (1.8% vs 4.6%, P < 0.05).
Conclusions
The long-term safety and feasibility of RASp with LLLs were comparable to those of RAAp patients with SDLs. The RASp reduced the incidence of postoperative AF episodes and new-onset AF. The RASp by delivery sheath implantation is a safe and effective method.
背景：与右房间隔起搏（RASp）相比，右心房附件起搏（RAAp）可能增加心房颤动（AF）的风险。然而，房间隔样式驱动导联（SDLs）的植入对RASp的治疗存在操作上的挑战，并限制了其临床应用。我们评估了RASp和RAAp使用无腔导联（LLLs）和SDLs的长期安全性和可行性，并比较了RASp和RAAp在病窦综合征患者中的AF事件。方法将329例病窦综合征患者行心脏起搏器植入术，根据心房导联放置位置分为两组：RASp组（n = 162）合并lll， RAAp组（n = 167）合并sdl。比较两组植入率、手术时间、p波特征、起搏参数、并发症及房颤发作情况。结果RASp组和RAAp组的成功率相似（98.8% vs 97.6%, P > 0.05）。RASp组导联种植时间明显缩短（2.5±1.9 min vs 10.3±2.9 min, P < 0.05）。在平均36.4±20.5个月的随访中，起搏参数保持稳定，无严重并发症。此外，RASp组AF发作发生率（6.7% vs 14.0%, P < 0.05）和新发AF发生率（1.8% vs 4.6%, P < 0.05）均显著降低。结论RAAp合并LLLs的长期安全性和可行性与RAAp合并SDLs的长期安全性和可行性相当。RASp可降低房颤术后发作和新发房颤的发生率，通过分娩鞘植入RASp是一种安全有效的方法。
{"title":"Long-Term Safety and Feasibility of Right Atrial Septal Pacing with Lumenless Leads in Patients with Sick Sinus Syndrome","authors":"Peng Jin MD , Lan Su MD , Tiantian Chen MD , Shenglong Zheng MD , Zhongping Yang PhD , Hao Zhou MD , Xiao Chen MD , Shengjie Wu MD , Lu Lin MD , Xi Zhou MD , Xue Xia MD , Weijian Huang MD","doi":"10.1016/j.cjco.2025.06.014","DOIUrl":"10.1016/j.cjco.2025.06.014","url":null,"abstract":"<div><h3>Background</h3><div>Right atrial appendage pacing (RAAp) may increase the risk of atrial fibrillation (AF), compared to right atrial septal pacing (RASp). However, the implantation of atrial septal stylet-driven leads (SDLs) for RASp can present procedural challenges and limit its clinical application. We evaluated the long-term safety and feasibility of using lumenless leads (LLLs) with the delivery sheath for RASp and SDLs for RAAp, and compared AF events between the RASp and RAAp in patients with sick sinus syndrome.</div></div><div><h3>Methods</h3><div>A total of 329 patients with sick sinus syndrome who underwent pacemaker implantation were divided into 2 groups, based on the site of atrial lead placement: the RASp group (n = 162) with LLLs, and the RAAp group (n = 167) with SDLs. Implantation success rate, procedural time, P-wave characteristics, pacing parameters, complications, and AF episodes were compared between the 2 groups.</div></div><div><h3>Results</h3><div>The success rates were similar for the RASp and RAAp groups (98.8% vs 97.6%, <em>P</em> > 0.05). The lead implantation time was significantly shorter in the RASp group (2.5 ± 1.9 minutes vs 10.3 ± 2.9 minutes, <em>P</em> < 0.05). During a mean follow-up of 36.4 ± 20.5 months, the pacing parameters remained stable without serious complications. Additionally, the RASp group had a significantly reduced incidence of AF episodes (6.7% vs 14.0%, <em>P</em> < 0.05) and new-onset AF (1.8% vs 4.6%, <em>P</em> < 0.05).</div></div><div><h3>Conclusions</h3><div>The long-term safety and feasibility of RASp with LLLs were comparable to those of RAAp patients with SDLs. The RASp reduced the incidence of postoperative AF episodes and new-onset AF. The RASp by delivery sheath implantation is a safe and effective method.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 10","pages":"Pages 1345-1353"},"PeriodicalIF":2.5,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145334550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aortic valve replacement (AVR) for chronic aortic regurgitation (AR) in the presence of reduced left ventricular ejection fraction (LVEF) is associated with greater surgical risk. Long-term outcomes remain poorly described in contemporary cohorts.
Methods
Between 2004 and 2019, 122 patients underwent AVR for chronic severe AR with LVEF < 50%. Patients with severely reduced LVEF (< 35%; n = 37) were compared with those with mild to moderately reduced LVEF (35%-50%; n = 85).
Results
Preoperative and intraoperative characteristics were similar in both groups. Operative mortality for the entire cohort was 1.6% (n = 2) and similar across the LVEF spectrum. Postoperatively, optimal medical therapy was achieved in most patients and > 25% of patients with LVEF < 35% benefited from cardiac resynchronization therapy. At latest follow-up, mean LVEF was 42 ± 12% in the severely reduced LVEF group (vs baseline 28 ± 5%; P < 0.001) and 51 ± 9% in the mild to moderately reduced LVEF group (vs baseline 46 ± 4%; P < 0.001). Freedom from cardiovascular death at 10 years was 87.2% in the severe group and 94.7% in the mild to moderate group (P = 0.10). Freedom from heart failure hospitalization at 10 years was higher in the mild to moderate group (96.3%) than in the severe group (88.3%; P = 0.009).
Conclusions
In this contemporary cohort of patients who underwent AVR for chronic severe AR, patients with severely reduced LVEF treated with optimal medical therapy had operative mortality and freedom from cardiovascular death similar to patients with mild to moderately reduced LVEF. Favourable left ventricular remodelling was observed in both groups. Hospitalization for heart failure was < 15% in both groups at 10-year follow-up.
{"title":"Effect of Contemporary Optimal Medical Therapy on Patients With Reduced Ejection Fraction Who Have Undergone Surgery for Severe Chronic Aortic Regurgitation","authors":"Marie-Christine Blais MD , Alexandre Cinq-Mars MD , Émile Voisine MD , Roxanne St-Louis MD , Charline Pujos MD , Montse Massot MD , Jean-Benoît Veillette MD , Florence Bernier MD , David Belzile MD , Pierre Yves Turgeon MD , Alexander Beaulieu-Shearer MD , Mathieu Bernier MD , Francois Dagenais MD , Mario Sénéchal MD","doi":"10.1016/j.cjco.2025.06.017","DOIUrl":"10.1016/j.cjco.2025.06.017","url":null,"abstract":"<div><h3>Background</h3><div>Aortic valve replacement (AVR) for chronic aortic regurgitation (AR) in the presence of reduced left ventricular ejection fraction (LVEF) is associated with greater surgical risk. Long-term outcomes remain poorly described in contemporary cohorts.</div></div><div><h3>Methods</h3><div>Between 2004 and 2019, 122 patients underwent AVR for chronic severe AR with LVEF < 50%. Patients with severely reduced LVEF (< 35%; n = 37) were compared with those with mild to moderately reduced LVEF (35%-50%; n = 85).</div></div><div><h3>Results</h3><div>Preoperative and intraoperative characteristics were similar in both groups. Operative mortality for the entire cohort was 1.6% (n = 2) and similar across the LVEF spectrum. Postoperatively, optimal medical therapy was achieved in most patients and > 25% of patients with LVEF < 35% benefited from cardiac resynchronization therapy. At latest follow-up, mean LVEF was 42 ± 12% in the severely reduced LVEF group (vs baseline 28 ± 5%; <em>P</em> < 0.001) and 51 ± 9% in the mild to moderately reduced LVEF group (vs baseline 46 ± 4%; <em>P</em> < 0.001). Freedom from cardiovascular death at 10 years was 87.2% in the severe group and 94.7% in the mild to moderate group (<em>P</em> = 0.10). Freedom from heart failure hospitalization at 10 years was higher in the mild to moderate group (96.3%) than in the severe group (88.3%; <em>P</em> = 0.009).</div></div><div><h3>Conclusions</h3><div>In this contemporary cohort of patients who underwent AVR for chronic severe AR, patients with severely reduced LVEF treated with optimal medical therapy had operative mortality and freedom from cardiovascular death similar to patients with mild to moderately reduced LVEF. Favourable left ventricular remodelling was observed in both groups. Hospitalization for heart failure was < 15% in both groups at 10-year follow-up.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 10","pages":"Pages 1413-1422"},"PeriodicalIF":2.5,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145334590","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Low-extremity peripheral artery disease (LE-PAD) is often associated with coronary artery disease (CAD). Development of biomarkers is needed to identify those among LE-PAD patients who have associated CAD. The pharmacologic profile of adenosine A2A receptors (A2AR; expression, cyclic adenosine monophosphate [cAMP] production, half maximal effective concentration [EC50]) evaluated on peripheral blood mononuclear cells is useful because these parameters are modified during myocardial ischemia. A total of 127 patients were included; 75 with CAD had a positive flow-fraction-reserve (FFR) but no intermittent claudication. Among those with LE-PAD, 27 had a positive FFR, and 25 had a negative FFR. The A2AR expression and EC50 were lower in patients with a positive FFR vs a negative FFR. Obstructive CAD might be detected by measuring the adenosine A2AR profile.
{"title":"Pharmacologic Profile of A2A Adenosine Receptors: Identifying Patients with Intermittent Claudication and Associated Myocardial Ischemia","authors":"Pierre Deharo MD, PhD , Julien Fromonot MD, PhD , Soumeya Aliouane PhD , Marion Marlinge MD, PhD , Bouchra Talbi MD , Nathalie Kipson BHsc , Tristan Werquin PhD , Julia Dodivers MD , Thomas Cuisset MD, PhD , Marine Gaudry MD, PhD , Régis Guieu MD, PhD , Franck Paganelli MD, PhD","doi":"10.1016/j.cjco.2025.06.024","DOIUrl":"10.1016/j.cjco.2025.06.024","url":null,"abstract":"<div><div>Low-extremity peripheral artery disease (LE-PAD) is often associated with coronary artery disease (CAD). Development of biomarkers is needed to identify those among LE-PAD patients who have associated CAD. The pharmacologic profile of adenosine A<sub>2A</sub> receptors (A<sub>2A</sub>R; expression, cyclic adenosine monophosphate [cAMP] production, half maximal effective concentration [EC<sub>50</sub>]) evaluated on peripheral blood mononuclear cells is useful because these parameters are modified during myocardial ischemia. A total of 127 patients were included; 75 with CAD had a positive flow-fraction-reserve (FFR) but no intermittent claudication. Among those with LE-PAD, 27 had a positive FFR, and 25 had a negative FFR. The A<sub>2A</sub>R expression and EC<sub>50</sub> were lower in patients with a positive FFR vs a negative FFR. Obstructive CAD might be detected by measuring the adenosine A<sub>2A</sub>R profile.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 10","pages":"Pages 1410-1412"},"PeriodicalIF":2.5,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145334553","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.cjco.2025.05.021
Christopher De Luca MHSc , Hardik Bhatt MD , Arnav Gupta MD , Ashkan Yahyavi MD , Behrooz Banivaheb MD , Daniel Rayner MSc , Kim Anderson MD , Shelley Zieroth MD , Sean A. Virani MD , Farid Foroutan PhD , Natasha Aleksova MD, MSc
Background
The recommendations for mineralocorticoid receptor antagonists (MRAs) in patients with heart failure with nonreduced ejection fraction (HFnrEF), defined as heart failure with left ventricular ejection fraction > 40%, are not clear. This systematic review and meta-analysis aims to evaluate the effect of MRAs on patient-important outcomes in HFnrEF.
Methods
We searched MEDLINE, Embase, Cochrane Database/Register from inception to September 6, 2024, for all randomized controlled trials comparing MRAs to placebo/standard of care in HFnrEF. Fixed and random effects models pooled estimates for mortality (all-cause and cardiovascular), HF hospitalization (HFH), functional capacity, health-related quality of life, and adverse outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty-of-evidence assessments.
Results
Eight RCTs reported on 10,313 patients with HFnrEF. Compared to placebo or standard of care, MRAs result in a reduction in HFH (risk ratio [RR] 0.83, 95% confidence interval [CI] 0.76-0.91; risk difference [RD] 29 fewer per 1000, 95% CI 31 fewer to 15 fewer; high certainty). Moderate-certainty evidence suggests that MRAs probably result in a slight reduction in all-cause mortality (RR 0.93, 95% CI 0.85-1.02; RD 11 fewer per 1000, 95% CI 23 fewer to 3 more) and cardiovascular mortality (RR 0.92, 95% CI 0.81-1.05; RD 7 fewer per 1000, 95% CI 16 fewer to 5 more). MRA use is associated with more hyperkalemia and worsening renal function, with no difference in withdrawal of the drug due to adverse events. compared to placebo.
Conclusions
Among patients with HFnrEF, MRAs reduce HFH. Although MRAs increase the risk of hyperkalemia and worsening renal function, this does not lead to higher rates of drug discontinuation.
背景：矿质皮质激素受体拮抗剂（MRAs）用于非降低射血分数（HFnrEF）心衰患者（定义为左心室射血分数为40%的心衰）的推荐使用尚不明确。本系统综述和荟萃分析旨在评估mra对HFnrEF患者重要结局的影响。方法：我们检索MEDLINE、Embase、Cochrane数据库/Register，从成立到2024年9月6日，检索所有比较mra与安慰剂/标准治疗在HFnrEF中的随机对照试验。固定效应和随机效应模型汇总了死亡率（全因和心血管）、心衰住院（HFH）、功能能力、健康相关生活质量和不良结局的估计。建议分级评估、发展和评价（GRADE）方法为证据确定性评估提供了依据。结果8项随机对照试验共报道10313例HFnrEF患者。与安慰剂或标准护理相比，MRAs导致HFH降低（风险比[RR] 0.83, 95%置信区间[CI] 0.76-0.91；风险差[RD]每1000人减少29,95% CI减少31至15；高确定性）。中等确定性证据表明，MRAs可能导致全因死亡率（RR 0.93, 95% CI 0.85-1.02； RD减少11 / 1000,95% CI 23减少至3 / 1000）和心血管死亡率（RR 0.92, 95% CI 0.81-1.05； RD减少7 / 1000,95% CI 16减少至5 / 1000）略有降低。MRA的使用与更多的高钾血症和肾功能恶化有关，由于不良事件而停药的情况没有差异。与安慰剂相比。结论在HFnrEF患者中，MRAs降低HFH。尽管mra增加了高钾血症和肾功能恶化的风险，但这并不会导致更高的停药率。
{"title":"The Effect of Mineralocorticoid Receptor Antagonists on Heart Failure with Nonreduced Ejection Fraction: A Systematic Review and Meta-Analysis","authors":"Christopher De Luca MHSc , Hardik Bhatt MD , Arnav Gupta MD , Ashkan Yahyavi MD , Behrooz Banivaheb MD , Daniel Rayner MSc , Kim Anderson MD , Shelley Zieroth MD , Sean A. Virani MD , Farid Foroutan PhD , Natasha Aleksova MD, MSc","doi":"10.1016/j.cjco.2025.05.021","DOIUrl":"10.1016/j.cjco.2025.05.021","url":null,"abstract":"<div><h3>Background</h3><div>The recommendations for mineralocorticoid receptor antagonists (MRAs) in patients with heart failure with nonreduced ejection fraction (HFnrEF), defined as heart failure with left ventricular ejection fraction > 40%, are not clear. This systematic review and meta-analysis aims to evaluate the effect of MRAs on patient-important outcomes in HFnrEF.</div></div><div><h3>Methods</h3><div>We searched MEDLINE, Embase, Cochrane Database/Register from inception to September 6, 2024, for all randomized controlled trials comparing MRAs to placebo/standard of care in HFnrEF. Fixed and random effects models pooled estimates for mortality (all-cause and cardiovascular), HF hospitalization (HFH), functional capacity, health-related quality of life, and adverse outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty-of-evidence assessments.</div></div><div><h3>Results</h3><div>Eight RCTs reported on 10,313 patients with HFnrEF. Compared to placebo or standard of care, MRAs result in a reduction in HFH (risk ratio [RR] 0.83, 95% confidence interval [CI] 0.76-0.91; risk difference [RD] 29 fewer per 1000, 95% CI 31 fewer to 15 fewer; high certainty). Moderate-certainty evidence suggests that MRAs probably result in a slight reduction in all-cause mortality (RR 0.93, 95% CI 0.85-1.02; RD 11 fewer per 1000, 95% CI 23 fewer to 3 more) and cardiovascular mortality (RR 0.92, 95% CI 0.81-1.05; RD 7 fewer per 1000, 95% CI 16 fewer to 5 more). MRA use is associated with more hyperkalemia and worsening renal function, with no difference in withdrawal of the drug due to adverse events. compared to placebo.</div></div><div><h3>Conclusions</h3><div>Among patients with HFnrEF, MRAs reduce HFH. Although MRAs increase the risk of hyperkalemia and worsening renal function, this does not lead to higher rates of drug discontinuation.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 10","pages":"Pages 1332-1344"},"PeriodicalIF":2.5,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145334591","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.cjco.2025.07.013
Daniel Boctor MD , Samuel B. Brusca MD , Gurpreet Dhaliwal MD , Matthew D. Ponzini MS, MPH , Noelle Boctor MD , Connor G. O’Brien MD
Background
Heart failure is one of the leading causes of hospital admissions in North America. Although guidelines support the continuation of beta blockers on admission, hemodynamic considerations and mechanistic reasoning may prompt beta blocker discontinuation even in the absence of contraindications. Resident physicians often face this dilemma and are an important group in which to evaluate this decision-making.
Methods
Internal medicine residents at two institutions were presented with two scenarios: 1) whether to continue outpatient metoprolol succinate for a patient without evidence of shock admitted with acute decompensated heart failure (ADHF) and 2) beta blocker selection during a patient’s index presentation with heart failure.
Results
142 of 287 (49.5%) residents responded to the survey. In scenario 1, 61% of residents discontinued metoprolol succinate on admission. The top three concerns about continuing metoprolol were precipitating cardiogenic shock, discomfort with the vital signs range, and attending physician disagreement. In scenario 2, 74% of participants initiated metoprolol succinate, 25% chose carvedilol, and only 1 participant chose bisoprolol.
Conclusions
Drivers of inpatient beta blocker discontinuation should be considered by internal medicine training programs and heart failure guideline writers when opportunities arise to enact practice changes that align with evidence.
{"title":"Factors Influencing Internal Medicine Resident Beta-Blocker Discontinuation in Acute Decompensated Heart Failure","authors":"Daniel Boctor MD , Samuel B. Brusca MD , Gurpreet Dhaliwal MD , Matthew D. Ponzini MS, MPH , Noelle Boctor MD , Connor G. O’Brien MD","doi":"10.1016/j.cjco.2025.07.013","DOIUrl":"10.1016/j.cjco.2025.07.013","url":null,"abstract":"<div><h3>Background</h3><div>Heart failure is one of the leading causes of hospital admissions in North America. Although guidelines support the continuation of beta blockers on admission, hemodynamic considerations and mechanistic reasoning may prompt beta blocker discontinuation even in the absence of contraindications. Resident physicians often face this dilemma and are an important group in which to evaluate this decision-making.</div></div><div><h3>Methods</h3><div>Internal medicine residents at two institutions were presented with two scenarios: 1) whether to continue outpatient metoprolol succinate for a patient without evidence of shock admitted with acute decompensated heart failure (ADHF) and 2) beta blocker selection during a patient’s index presentation with heart failure.</div></div><div><h3>Results</h3><div>142 of 287 (49.5%) residents responded to the survey. In scenario 1, 61% of residents discontinued metoprolol succinate on admission. The top three concerns about continuing metoprolol were precipitating cardiogenic shock, discomfort with the vital signs range, and attending physician disagreement. In scenario 2, 74% of participants initiated metoprolol succinate, 25% chose carvedilol, and only 1 participant chose bisoprolol.</div></div><div><h3>Conclusions</h3><div>Drivers of inpatient beta blocker discontinuation should be considered by internal medicine training programs and heart failure guideline writers when opportunities arise to enact practice changes that align with evidence.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 10","pages":"Pages 1314-1323"},"PeriodicalIF":2.5,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145335043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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