Journal of the American Heart Association最新文献

Background: The role of transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve stenosis requires further evaluation, particularly as its use has become comparable to surgical aortic valve replacement. We sought to compare midterm outcomes of TAVI and surgical aortic valve replacement in patients with bicuspid aortic valve stenosis.

Methods: Systematic searches of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials identified studies reporting TAVI and surgical aortic valve replacement outcomes in patients aged ≥60 years with bicuspid aortic valve stenosis. The primary analysis included only comparative studies with interpretable Kaplan-Meier curves. Individual patient data were reconstructed for time-to-event analysis. Sensitivity analyses incorporated noncomparative single-arm studies. Baseline differences and heterogeneity were addressed using landmark analysis, time-varying hazard ratios (HRs), frailty Cox models, and covariate-adjusted restricted mean survival time. The primary outcome was death with or without unplanned rehospitalization and stroke.

Results: Five comparative, risk-adjusted studies (TAVI, 5901; surgical aortic valve replacement, 12 427) were included. At 48-month follow-up, TAVI was associated with a higher hazard for adverse events (HR, 1.62 [95% CI, 1.46-1.79]; P<0.0001 for the composite end point of death, stroke, or rehospitalization at 48 months); landmark analysis showed an initial benefit with TAVI, followed by a reversal at 6 months that was maintained beyond 12 months (12-48 months; P<0.0001). Time-varying HRs confirmed this trend. Sensitivity analyses, including frailty Cox models on the full cohort and restricted mean survival time analysis, supported the robustness of the findings.

Conclusions: This meta-analysis found limited midterm benefits (ie, 48 months) of TAVI in bicuspid aortic valve stenosis. These findings should be interpreted considering patient selection, as younger patients with bicuspid aortic valve stenosis are increasingly referred for TAVI.

Background: This study compared the predictive capacity of traditional and novel obesity indices for stroke subtype risks across sexes and glucose metabolic statuses, addressing limitations of current anthropometric tools.

Methods: A retrospective cohort of 398 270 UK Biobank participants who were stroke free was analyzed. Eight novel indices-weight-adjusted waist index, a body shape index, body roundness index, visceral adiposity index, conicity index, lipid accumulation product, waist-to-hip ratio, and waist-to-height ratio-were compared with traditional measures (body mass index, waist circumference). Cox proportional hazards and Fine-Gray competing risk models generated hazard ratios (HRs) with 95% CIs, stratified by sex and glucose status. Predictive discrimination was assessed via Harrell's C-statistic.

Results: Novel indices outperformed traditional metrics for total and ischemic stroke. Weight-adjusted waist index showed the strongest associations: men in the highest quartile had a 25% increased ischemic stroke risk (HR, 1.25 [95% CI, 1.11-1.36]); women had a 36% increased risk (HR, 1.36 [95% CI, 1.20-1.57]). For ischemic stroke prediction, weight-adjusted waist index significantly surpassed body mass index in both sexes (C-statistics: men, 0.712 [95% CI, 0.705-0.720] versus body mass index, 0.688 [95% CI, 0.680-0.696], P<0.0001; women, 0.748 [95% CI, 0.739-0.757] versus body mass index, 0.726 [95% CI, 0.717-0.735], P=0.0007). No significant associations were observed for hemorrhagic stroke.

Conclusions: Weight-adjusted waist index exceeds conventional obesity metrics in predicting cerebrovascular events, with robust performance across sexes and glucose-regulated populations. Findings support sex-specific adiposity assessment in stroke prevention, particularly for ischemic subtypes in normoglycemic individuals.

Background: Elevated troponin levels are a frequent finding in patients presenting with atrial fibrillation or atrial flutter (AF) to the emergency department but are seldom caused by myocardial infarction (MI). The current high-sensitivity cTnT (cardiac troponin T) assay measures both the intact and highly fragmented cTnT forms (total cTnT) and detects cTnT elevations in conditions causing myocardial injury or MI without distinction between the 2.

Methods: The SuperTROPO (Better Diagnostics of Myocardial Infarction With a Test for Special Forms of Troponin) study included 521 consecutive patients with AF only and 188 patients with MI only (139 Type 1 MI), all with a total cTnT value ≥14 ng/L at emergency department admission. Intact and long forms of cTnT (long cTnT) were analyzed from the first plasma samples using a novel immunoassay. The diagnostic performance of long cTnT and total cTnT assays was compared in these cases with elevated total cTnT.

Results: Long cTnT was superior to total cTnT in discriminating troponin elevations in patients with MI from those in patients with AF (area under the curve for type 1 MI: 0.879 versus 0.783; for any MI: 0.864 versus 0.779; both P<0.001) when measured from the first blood sample without a significant effect of sex, age, estimated glomerular filtration rate, or total cTnT <200 ng/L. The difference in long cTnT levels was most notable in patients presenting within 12 hours of symptom onset.

Conclusions: The long cTnT immunoassay shows that the troponin release in AF is composed mainly of smaller troponin fragments. This novel test holds promise that measuring long cTnT forms could help to separate troponin elevations caused by AF from those of acute Type 1 MI from a single sample with better accuracy than the commercial high-sensitivity cTnT test.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05858112.

Background: Native American (NA) people are at an increased risk for stroke and are disproportionally affected by stroke risk factors such as hypertension and diabetes. The objective of this study is to characterize stroke risk factors in Wisconsin Native American people compared with an age- and sex-matched population in the SHOW (Survey of the Health of Wisconsin) study to direct future therapeutic efforts.

Methods: Stroke risk factor information was collected from an NA and an age- and sex-matched general Wisconsin population. Stroke risk factor data collected included age, sex, height, weight, body mass index, systolic and diastolic blood pressure, history of transient ischemic attack/stroke, history of coronary artery disease, history of hypertension, history of diabetes, current smoking status, and laboratory bloodwork (lipid panel, hemoglobin A_1c, and average glucose). In addition, all Oneida NA participants had a comprehensive carotid ultrasound examination performed to evaluate for the presence of atherosclerotic plaque and examine hemodynamics.

Results: The NA population had significantly higher systolic and diastolic blood pressure, were taller, and had higher body mass indices and higher rates of diabetes compared with the Wisconsin general population (all P<0.05). Significant differences were also noted in total cholesterol, high-density lipoprotein cholesterol, triglycerides, hemoglobin A_1c, and average glucose (all P<0.05). In addition, 81.5% of the Oneida NA population had atherosclerotic plaque present in their carotid arteries.

Conclusions: This study demonstrates several statistically significant differences in stroke risk factors between the NA population and a general Wisconsin sample population. These results indicate a strong relationship between obesity, diabetes, hypertension, and atherosclerosis in the NA group. Thus, there is an opportunity to work with NA communities to identify and modify stroke risk factors. Future work will examine the impact of exercise, diet, and nutrition on these risk factors.

Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04382963.

Background: A study was conducted to estimate the impact of hypertension screening on blood pressure measured 1, 2, and 3 years after baseline, as well as how its impact varies across socioeconomic statuses.

Methods: Embedded within a subcohort of the ChinaHEART (China Health Evaluation and Risk Reduction Through Nationwide Teamwork) project, blood pressure was measured both at baseline and follow-up visits. Information about socioeconomic factors, including education, annual household income, occupational status, and urbanity, was also collected. A sharp regression discontinuity design was used to estimate the impact of hypertension screening on blood pressure measured 1, 2, and 3 years later. We also explored the role of baseline socioeconomic status by adding the interaction term.

Results: The regression discontinuity analysis found no effect of baseline hypertension screening on the primary outcomes. When stratified by socioeconomic status, regarding systolic blood pressure measured 1 year later, the impact of screening was 5.52 mm Hg (95% CI, -1.55 to 12.59) for individuals with primary or lower education, 0.80 mm Hg (95% CI, -4.00 to 5.59) for middle education, and -7.39 mm Hg (95% CI, -12.03 to -2.75) for high school or above education, with a significant trend observed (P for interaction=0.002). In addition, among individuals with high school or above education, the impact on systolic blood pressure 1, 2, and 3 years later was -7.39 mm Hg (95% CI, -12.03 to -2.75), -8.30 mm Hg (95% CI, -15.79 to -0.81), and -4.63 mm Hg (95% CI, -12.71 to 3.44), respectively. These patterns, although insignificant, were also found for other socioeconomic factors. The impact on diastolic blood pressure was smaller and insignificant.

Conclusions: The impact of community-based hypertension screening on systolic blood pressure was affected by individual's education level and lasted only in the short term.

Background: Existing risk stratification models are insufficient in identifying patients at high risk for heart failure (HF) hospitalization, particularly among those presenting with symptomatic aortic stenosis and the HF with preserved ejection fraction phenotype.

Methods: This multicenter cohort study enrolled 321 patients diagnosed with severe aortic stenosis and HF with preserved ejection fraction who underwent transcatheter aortic valve replacement between January 2017 and February 2024. Various predictive modeling techniques were used, including random forest, XGBoost, SuperPC, plsRcox, least absolute shrinkage and selection operator-Cox, Gradient Boosting Machine, Coxboost, and Cox regression analysis, at multiple time points.

Results: Patients were divided into a derivation cohort (n=191) and an external validation cohort (n=130) based on institutional affiliation, with a median follow-up of 20 months. Feature selection using the Boruta algorithm and least absolute shrinkage and selection operator regression, combined with variance inflation factor analysis to assess multicollinearity, identified 6 independent predictors. Among 8 prediction models evaluated, the Cox regression-based nomogram demonstrated superior performance in external validation, achieving time-dependent area under the curve values of 0.824 (95% CI, 0.693-0.956) at 12 months and 0.818 (95% CI, 0.715-0.920) at 20 months. The nomogram exhibited excellent calibration and substantial clinical utility across both time points, consistently outperforming the European System for Cardiac Operative Risk Evaluation in discrimination and reclassification analyses. An interactive web-based clinical decision support tool was developed to facilitate point-of-care implementation.

Conclusions: This nomogram, based on machine learning and incorporating metabolic biomarkers, exhibits high predictive accuracy for HF hospitalization in patients with symptomatic aortic stenosis and high-risk HF with preserved ejection fraction phenotype following transcatheter aortic valve replacement.

Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: ChiCTR2400092655.

Background: Coronary arterial calcification predicts coronary events, but although intracranial arterial calcification on CT (CT-IAC) is a frequent finding in older individuals, few longitudinal studies have assessed whether its severity or site predict dementia. We did a population-based study in patients with transient ischemic attack (TIA) or stroke to assess these associations.

Methods: In a matched case-control study of patients with minor stroke/transient ischemic attack nested in the population-based OXVASC (Oxford Vascular Study), severity (qualitatively and semiautomated volume) and location (intimal or internal elastic lamina) of CT-IAC in cases who developed dementia on follow-up was compared with that in age-/sex-matched controls who did not (logistic regression adjusted for other risk factors).

Results: In OXVASC (cases/controls=200/200; mean age=78.0±9.3 years), dementia was independently associated with severity of internal carotid artery CT-IAC on visual assessment (bilateral severe-adjusted OR [aOR], 2.02 [95% CI, 1.26-3.23], P=0.004) and quantitative volume (top versus bottom tertile-aOR, 2.35 [95% CI, 1.33-4.16], P=0.003), driven mainly by individuals with very high calcification volumes (≥600 mm³ versus 0-299 mm³-aOR, 6.23 [95% CI, 1.24-31.24], P=0.026). Similar trends were observed for CT-IAC in the internal carotid artery and vertebrobasilar artery combined (top versus bottom tertile-aOR, 2.59[95% CI, 1.43-4.68], P=0.002), including after exclusion of recurrent stroke (aOR, 2.60 [95% CI, 1.33-5.08], P=0.005) and patients with moderate/severe white matter disease (aOR, 3.19 [95% CI, 1.54-6.62], P=0.002). Internal carotid artery CT-IAC of the internal elastic lamina independently predicted dementia after adjusting for qualitative (aOR, 1.84 [95% CI, 1.11-3.05, P=0.019) or quantitative (aOR, 1.78 [95% CI, 1.06-2.99], P=0.029) CT-IAC severity.

Conclusions: Severity of CT-IAC independently predicts future dementia after stroke/ transient ischemic attack. The extent of any nonlinearity and calcification- or dementia-subtype differences should be determined in larger studies.

Background: The GRACE (Global Registry of Acute Coronary Events) score is well validated for risk stratification in non-ST-segment-elevation myocardial infarction, but less well established in ST-segment-elevation myocardial infarction (STEMI), particularly relative to coronary disease burden. We therefore assessed its prognostic performance in a STEMI cohort, accounting for baseline coronary disease extent.

Methods: We studied 1099 patients with STEMI from the CardioLines Coronary Biobank (2015-2021) with evaluable GRACE score and follow-up data. Patients were stratified by the number of coronary vessels with significant stenosis. The primary end point was all-cause death at 1 year; the secondary end point was a combined end point, including all-cause death, recurrent acute coronary syndrome, stroke, and revascularization at 1 year.

Results: Mean GRACE scores increased with the number of diseased vessels (P<0.001). In multivariable models, each 10-point increase in GRACE score was associated with a 31% higher risk of all-cause death and a 14% higher risk of the combined end point at 1 year. In single-vessel disease, discrimination for all-cause death was excellent early (30-day area under the curve, 0.874 [95% CI, 0.755-0.991]) and moderate at 1 year (area under the curve, 0.77 [95% CI, 0.613-0.927]), but consistently poor in 3-vessel disease (area under the curve, 0.52-0.57). Discrimination was significantly higher in single- versus multivessel disease at earlier time points, with differences attenuated by 1 year. Stratified regression analyses confirmed stronger associations in single-vessel versus multivessel disease.

Conclusions: In this contemporary STEMI cohort, the GRACE score effectively stratifies event risk in single-vessel but performs poorly in multivessel disease. These findings suggest variable prognostic utility of the GRACE score across anatomic disease burden post-STEMI and caution when applying it across STEMI subgroups.

Background: Cardiorespiratory fitness (CRF) has been investigated as a broad, holistic health indicator for children and adolescents. The adverse effects of particulate matter on lung function and cardiovascular health have been widely reported, whereas the association between particulate matter and CRF and its potential pathways remains unclear. The study aims to estimate the association between particulate matter and CRF in children and adolescents and the mediating effect of adiposity on this association.

Methods: A multistage random cluster sampling method was used to obtain a nationwide sample of 99 995 children and adolescents in China. Daily exposure to particulate matter with aerodynamic diameter ≤2.5 and <10 μm surrounding schools was extracted from the China High Air Pollutants data sets. As surrogates of long-term exposures, we used 3-year average (2013-2015) concentrations before the study for analyses. CRF was estimated by a 20-m shuttle run test.

Results: Per 10-μg/m³ increase in particulate matter with aerodynamic diameter ≤2.5 and <10 μm was associated with -0.12 (95% CI, -0.13 to -0.10) and -0.09 (95% CI, -0.10 to -0.08) mL/kg per min lower CRF levels. Exposure-response curves suggested a nonlinear association of particulate matter with CRF (all P nonlinear <0.001). Waist/height ratio mediated 15.97% (95% CI, 13.99%-18.27%) and 16.15% (95% CI, 13.92%-18.75%) of the association between particulate matter with aerodynamic diameter ≤2.5 and <10 μm, respectively, and CRF among children and adolescents (all P<0.001).

Conclusions: There is a negative and nonlinear association between long-term exposure to particulate matter and CRF among children and adolescents, and this association may be partially explained by adiposity. Cohort studies are needed to further validate the findings.