Journal of the American Heart Association最新文献

Significant advancements in pediatric heart care models, interventions, and innovations have occurred over the past 20 years since the first American Heart Association scientific statement on preparing children and adolescents for invasive cardiac procedures. Clinical outcomes after invasive procedures have significantly improved, which has increased the frequency and complexity of care for children discharged back to their homes and communities. Specialty-trained pediatric professionals are emerging to support nuanced family-centered preparation and education of children with heart disease and their families. This scientific statement will update previously presented content, highlight emerging topics such as digital modalities for education and preparation for pediatric heart disease procedures and care transitions, and identify knowledge gaps and areas of future research.

Background: Stressor-associated atrial fibrillation (AF) refers to new-onset AF that occurs with a reversible, acute stressor. Identifying individuals at highest risk for AF recurrence is essential to guide management. Although clinical factors have shown limited value, the utility of contemporary artificial intelligence (AI)-enabled models using the 12-lead ECG to estimate recurrence risk remains unknown.

Methods: We retrospectively analyzed consecutive primary care and cardiology patients with stressor-associated AF occurring during hospitalization. We quantified the cumulative incidence of recurrence accounting for death as a competing risk. We investigated the relationship between time-varying recurrence and a composite end point of AF-related adverse events (stroke, heart failure, all-cause death) using Cox models. We then developed and validated a penalized regression model to predict recurrence using clinical factors, stressor type, and AF risk estimates from a previously validated ECG-based AI model.

Results: We analyzed 3371 patients with stressor-associated AF (mean age, 69±12 years; 40% women). Over a median of 3.7 years (interquartile range, 1.8-7.2), the 10-year cumulative incidence of AF recurrence was 41% (95% CI, 39-44). AF recurrence was strongly associated with AF-related adverse events (hazard ratio, 2.24 [95% CI, 1.81-2.76]). A model incorporating clinical factors, stressor type, and ECG-based AI model AF risk estimates (clinical-AI) discriminated AF recurrence (area under the receiver operating characteristic curve, 0.768 [95% CI, 0.707-0.830]) favorably compared with clinical features (area under the receiver operating characteristic curve, 0.707 [95% CI, 0.642-0.772]; P<0.05).

Conclusions: AF recurrence rates following stressor-associated AF are considerable and are associated with substantially higher risk of adverse cardiovascular events. Models incorporating ECG-based AI risk estimates may prioritize individuals for intensive monitoring and preventive interventions.

Background: Group 2 pulmonary hypertension (PH), defined as PH caused due to left heart disease, remains a challenging condition. However, its prognostic impact and implications for emerging therapies are unclear. We aimed to evaluate the real-world relationship between pulmonary vascular resistance (PVR) and prognosis in Group 2 PH and assess the efficacy of emerging therapies.

Methods: Two prospective registries supported by Japanese PH societies were analyzed: a current (2018-2024; n=563) and a previous (2012-2016; n=425) registry. The composite end points were hospitalization for heart failure, all-cause death, ventricular assist device implantation, or cardiac transplantation.

Results: Stratified analyses using propensity score-matched data demonstrated a significant association between PVR >3 Wood units and prognosis in patients with Group 2 PH (6-year event-free rates, PVR >3 Wood units versus PVR ≦3 Wood units, previous registry: 72.9% versus 61.4%; current registry: 75.2% versus 55.4%). Consistent patterns were observed in both heart failure with reduced ejection fraction and heart failure with preserved ejection fraction subgroups. The use of SGLT2 (sodium-glucose cotransporter-2) inhibitors in the current registry was associated with improved outcomes in patients with elevated PVR, showing event-free rates of 73.8% versus 35.5% in those without treatment. Among multivariate analyses including major treatment options, SGLT2 inhibitor treatment exhibited significant associations with improvement of composite end points.

Conclusions: Elevated PVR (>3 Wood units) identified a high-risk subset of patients with Group 2 PH. The association between the use of SGLT2 inhibitors and better outcomes suggests a potential therapeutic role that warrants further investigation through controlled studies.

Background: Despite differences in operative characteristics in patients with mitral valve disease, it remains unclear if sex is an independent risk factor associated with perioperative mortality after mitral valve surgery.

Methods: We performed a retrospective cohort study of 3313 adult patients who underwent mitral valve surgery between 2011 and 2024 at 2 academic institutions. Patients were stratified by sex, and the primary outcome was operative mortality. Multivariable logistic regression was used to identify independent predictors of operative mortality.

Results: In our cohort, 44.5% were women. Women were older (63.9 versus 62.2 years, P<0.0001), more likely to have New York Heart Association class III (15.9% versus 7.6%) and IV (1.4 versus 1.1%) heart failure (P<0.05 for both), and less likely to undergo mitral valve repair (63.5% versus 80.0%, P<0.0001). Women had shorter cross-clamp times (101.1 versus 105.0 min, P<0.01). Although postoperative intensive care unit stay was longer for women (3.0 versus 2.3 days, P<0.0001), operative mortality did not differ significantly by sex (1.42% versus 0.92%, P=0.32). In multivariable regression, female sex was not significantly associated with mortality after adjusting for covariates (odds ratio [OR], 1.03 [95% CI, 0.39-2.77], P=0.66). Prolonged cardiopulmonary bypass time was significantly associated with an increased odds of postoperative mortality (OR, 1.01 per 10 minutes [95% CI, 1.01-1.02], P=0.002).

Conclusions: Despite differences in baseline characteristics and surgical approach, operative mortality did not differ significantly by sex. Female sex was not significantly associated with operative mortality after adjustment for clinical and operative factors in patients undergoing elective mitral valve surgery.

Background: The SAXOPHONE (Safety of Apixaban on Pediatric Heart Disease on the Prevention of Embolism) trial demonstrated the safety of apixaban for thromboprophylaxis in children with heart disease. Included a priori in the trial design was an exploratory biomarker substudy to evaluate the effects of apixaban on surrogate biomarkers of efficacy, thrombin generation capacity, and hemostatic proteins. The study assessed changes in d-dimer, thrombin generation assay parameters, factor VIII, fibrinogen, protein C, and protein S in children receiving apixaban compared with standard-of-care vitamin K antagonists (VKAs) or low-molecular-weight heparin.

Methods: SAXOPHONE participants aged >1 year (n=182) had blood samples for biomarkers collected at baseline, week 2, or month 6. Participants were randomized to apixaban (n=123) or standard of care (VKA or low-molecular-weight heparin; n=59). Subgroup analyses accounted for prior VKA exposure.

Results: d-dimer levels decreased at month 6 in all treatment groups and remained stable during VKA-to-apixaban bridging. Apixaban significantly prolonged thrombin generation assay lag time and time to peak compared with VKAs and decreased peak thrombin similarly to VKAs in anticoagulant-naïve participants. Apixaban was associated with decreased fibrinogen and factor VIII at month 6, with no effect on protein C or S. Prior VKA exposure produced carryover effects, suppressing baseline d-dimer, thrombin generation assay parameters, and proteins C and S.

Conclusions: Apixaban reduced hypercoagulability, as shown by decreased d-dimer levels and prolonged lag time, and preserved endogenous thrombin potential in thrombin generation assay, changes consistent with adult data. These findings align with SAXOPHONE's primary outcomes, supporting apixaban's favorable risk-benefit profile as a thromboprophylaxis option in children with heart disease.

Background: The impact of prior antiplatelet exposure on outcomes of acute myocardial infarction remains unclear, particularly in East Asian populations with distinct antithrombotic response profiles.

Methods: This retrospective cohort study analyzed 29 281 patients with acute myocardial infarction from 2 nationwide Korean registries. After excluding patients with atrial fibrillation, prior coronary artery disease, heart failure, cerebrovascular accident, or thrombolysis and those discharged on oral anticoagulants, 21 304 patients were categorized into previous-user and nonuser groups. Propensity score matching was performed to adjust for baseline differences. The primary outcome was 3-year major adverse cardiac and cerebrovascular events.

Results: Previous users were older and had more comorbidities and angiographic complexity. Unadjusted analysis showed higher major adverse cardiac and cerebrovascular event rates in previous users, but the difference attenuated after propensity score matching in both the overall matched (adjusted hazard ratio [HR], 0.967 [95% CI, 0.850-1.100]) and selected population (adjusted HR, 1.036 [95% CI, 0.847-1.267]). All-cause death remained slightly elevated in the overall matched cohort (HR, 1.204 [95% CI, 1.004-1.443]) but not in the selected population. In-hospital outcomes and platelet reactivity findings supported the high-risk profile of prior users.

Conclusions: Prior antiplatelet exposure was associated with a higher-risk clinical phenotype among patients with acute myocardial infarction, but this relationship was not independent after adjustment for baseline differences. These findings should be interpreted as hypothesis generating and underscore the importance of individualized antithrombotic strategies tailored to risk profiles, particularly in East Asian populations.

Background: Exposure to metals in the external environment and system circulation has been linked to cerebrovascular health. However, population-based epidemiological evidence on the association between multiple metals and cerebral microbleeds (CMBs) is lacking.

Methods: We conducted a cross-sectional study using data from the META-KLS (Multi-modality Medical Imaging Study Based on Kailuan Study) to investigate the association between plasma metals and CMBs. CMBs were determined through brain magnetic resonance imaging as having ≥1 CMB lesion. Fasting plasma concentrations of 14 metals were measured. A total of 1206 adults were included in this study, with a median (interquartile range) age of 54.4 (19.2) years; 630 (52.2%) were female, and 291 (24.1%) were identified as CMBs cases. Binary logistic regression models and the quartile g-computation model were used to assess single-metal and multi-metal associations with CMBs, respectively.

Results: After fully covariate adjustment, each interquartile range increment in plasma calcium, magnesium, lead, and vanadium was associated with higher CMBs risk. The odds ratios (ORs) and 95% CIs were 1.36 (1.12-1.64) for calcium, 1.34 (1.10-1.63) for magnesium, 1.38 (1.13-1.69) for lead, and 1.25 (1.06-1.47) for V. In the quartile g-computation model, lead, magnesium, and calcium exhibited significant positive effects with weights of 28.6%, 8.0%, and 3.6%, respectively.

Conclusions: Elevated levels of plasma calcium, magnesium, lead, and vanadium in the body may increase the risk of CMBs. Thus, limiting exposure and timely monitoring of these metals may help prevent CMBs.

Background: Preclinical evidence suggests that time-restricted eating (TRE) exerts beneficial metabolic and cardiovascular effects by ameliorating inflammation and modulating immune cell function. However, the effect in patients with established coronary artery disease remains unknown.

Methods: In this prospective, randomized, open-label, blinded end point crossover study, we explored the effect of a 2-week TRE intervention (eating allowed between 8 am and 2 pm) on metabolomic parameters, innate immune cell function, and systemic inflammation in patients with a history of myocardial infarction. Patients were randomized to a 2-week TRE intervention or a 2-week control period with their regular diet, followed by a ≥6-week washout and crossover to the other group. Blood samples were collected in a fasted state before and after each period.

Results: In total, 19 patients (mean age, 65.3 years [SD 8.1], 2 [11%] female), of whom 10 were randomized to start with the control diet, and 9 randomized to start with the TRE diet, were included in the current analysis. All visits were conducted between November 2022 and January 2024. Compared with the control diet, the TRE diet led to reduced neutrophil counts, lower neutrophil-to-lymphocyte ratio, decreased neutrophil CD11b expression, and anti-inflammatory changes in the monocyte transcriptome. Furthermore, a reduction in low-grade systemic inflammation was found. The TRE diet was associated with widespread metabolic changes. No significant effects on monocyte subsets, monocyte inflammatory surface marker expression, or cytokine production capacity were observed.

Conclusions: Our findings highlight the capability of TRE in the modulation of inflammation, suggesting a potential role in reducing cardiovascular risk in patients with established cardiovascular disease.

Background: It is unclear whether patients with heart failure with preserved ejection fraction respond to spironolactone based on cardiac structure or function.

Methods: A post hoc analysis was performed among participants with left ventricular (LV) ejection fraction ≥50% and evidence of abnormal LV diastolic function or filling pressures in TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial). Log-rank tests and Cox regression models were used for comparison between groups.

Results: Totally, 757 subjects were qualified and stratified by parameters on cardiac structure or function. In patients with increased left atrial volume index, spironolactone reduced cardiovascular mortality (adjusted hazard ratio [HR], 0.48 [95% CI, 0.24-0.98]; P=0.042, log-rank; interaction P=0.045). Meanwhile, in patients with increased LV mass index, spironolactone decreased heart failure hospitalization (adjusted HR, 0.51 [95% CI, 0.32-0.80]; P=0.009, log-rank; interaction P=0.041) and the composite outcome of cardiovascular mortality, heart failure hospitalization, and aborted sudden death (adjusted HR, 0.63 [95% CI, 0.43-0.93]; P=0.045, log-rank; interaction P=0.029). Then, in participants with increased left atrial volume index and LV mass index, who matched at 1:1 ration by propensity score matching, spironolactone reduced cardiovascular mortality (adjusted HR, 0.31 [95% CI, 0.11-0.92]; P=0.039, log-rank), heart failure hospitalization (adjusted HR, 0.26 [95% CI, 0.10-0.68]; P=0.005, log-rank), and the composite outcome (adjusted HR, 0.33 [95% CI, 0.15-0.72]; P=0.006, log-rank).

Conclusions: Spironolactone reduced cardiovascular mortality, heart failure hospitalization, or the composite outcome of cardiovascular mortality, heart failure hospitalization, and aborted sudden death in patients with heart failure with preserved ejection fraction with increased left atrial volume index or LV mass index.