Journal of the American Heart Association最新文献

Background: Markers of renal function have been added to the Predicting Risk of Cardiovascular Disease Events and Systematic Coronary Risk Evaluation cardiovascular risk calculators to enhance risk prediction. Here we examine the role of estimated glomerular filtration (eGFR) and urine albumin creatinine ratio (UACR)-and related dichotomous cut points (eGFR <60 mL/minute per 1.73 m² and albuminuria ≥30 mg albumin/gram creatinine)-for prediction of coronary heart disease, cardiovascular disease (CVD) outcomes (CVD mortality, heart failure, stroke, total CVD), and total mortality, using the MESA (Multi-Ethnic Study of Athersclerosis) calculator, which includes coronary artery calcium scores as a predictor in addition to traditional CVD risk factors.

Methods: The study included 6707 participants without clinical CVD with coronary artery calcium scoring. Cox proportional hazards models, adjusted for covariates including coronary artery calcium, were used to gauge the association of UACR, eGFR, albuminuria, and eGFR<60 with outcomes and change in disease prediction by area under the curve compared with models not including renal variables. Prespecified subgroups-age, sex, race or ethnicity, diabetes-were examined.

Results: UACR and albuminuria were significantly associated with most study outcomes; eGFR and eGFR<60 were less consistently related. Albuminuria significantly increased disease prediction for heart failure and for total mortality (P<0.001) but not for other outcomes. When prespecified subgroups were examined, UACR and albuminuria significantly improved prediction for many outcomes in participants >65 years of age, and for all outcomes in participants with diabetes.

Conclusions: When coronary artery calcium is known, albuminuria improves heart failure prediction. Albuminuria and UACR each improve total mortality prediction as well. UACR and albuminuria improve prediction for all outcomes in people with diabetes.

Background: Beta blockers represent an important class of antihypertensive agents, but comparative data on different beta blockers in the treatment of hypertension remain limited. Nebivolol, a third-generation beta blocker, possesses unique pharmacological properties. This study aimed to evaluate its real-world effectiveness in blood pressure and heart rate control, as well as the associated clinical outcomes in patients with hypertension.

Methods: We conducted a retrospective review of the Chang Gung Research Database to identify patients with hypertension who were newly prescribed beta blockers-primarily nebivolol, carvedilol, and bisoprolol-between 2018 and 2023. Inverse probability of treatment weighting was applied to balance the baseline characteristics across groups. Outcomes included changes in blood pressure and heart rate, as well as the incidence of major adverse cardiovascular events.

Results: We identified 99 942 patients with hypertension. After inverse probability of treatment weighting, the patients treated with nebivolol had significantly greater reductions in systolic blood pressure (-11.0 mm Hg [95% CI, -11.6 to -10.4]), diastolic blood pressure (-8.1 mm Hg [95% CI, -8.5 to -7.6]), and heart rate (-7.3 bpm [95% CI, -7.8 to -6.9]) compared with carvedilol and other beta blockers. During a mean follow-up of 4.5 years, nebivolol use was associated with a significantly lower risk of all-cause mortality (hazard ratio [HR], 0.73 [95% CI, 0.63-0.86]) and major adverse cardiovascular events (HR, 0.81 [95% CI, 0.74-0.90]).

Conclusions: In this retrospective cohort study of patients with hypertension without heart failure, nebivolol was associated with greater reductions in blood pressure and heart rate, as well as a lower risk of all-cause mortality and major adverse cardiovascular events, compared with carvedilol and other beta blockers. Although these findings suggest potential benefits of nebivolol in this population, prospective studies are needed to validate these observations.

Background: ANGPTL8 (angiopoietin-like protein 8) regulates lipid metabolism, but its role in atherosclerosis among patients with type 2 diabetes, particularly through lipid-independent mechanisms, remains unclear.

Methods: This matched case-control study included 202 patients with type 2 diabetes (101 with atherosclerosis, and 101 without) matched for age, body mass index, and sex. Atherosclerosis was assessed via carotid intima-media thickness and plaque scores. Circulating ANGPTL8 levels were measured by ELISA. Associations were evaluated using multivariate logistic regression, restricted cubic splines, and mediation analyses.

Results: Patients with atherosclerosis had significantly higher circulating ANGPTL8 levels (529.96 [350.58-816.78] versus 470.62 [265.54-717.47] pg/mL; P=0.027). After adjusting for confounders, the highest ANGPTL8 quartile showed 3.71-fold increased atherosclerosis risk (95% CI, 1.52-9.06; P=0.004) versus the lowest quartile. Each SD increase in ANGPTL8 was associated with 56% higher risk (odds ratio, 1.56 [95% CI, 1.18-2.05]). A significant linear dose-response relationship was observed (P=0.036). Adding ANGPTL8 to traditional risk factors significantly improved discrimination (area under the curve, 0.62 [95% CI, 0.54-0.70]) and reclassification (net reclassification improvement, 0.40 [95% CI, 0.13-0.66]; P<0.001) for atherosclerosis prediction. Mediation analysis revealed that cystatin C partially mediated (8.22%) the effect of ANGPTL8 on atherosclerosis, whereas triglycerides showed negligible mediation.

Conclusions: Elevated ANGPTL8 levels are independently associated with increased atherosclerosis risk in patients with type 2 diabetes. This relationship is partially mediated through cystatin C but not lipid parameters. ANGPTL8 significantly improves cardiovascular risk prediction beyond traditional risk factors, suggesting its potential as a novel biomarker for cardiovascular risk stratification and a therapeutic target addressing residual cardiovascular risk through lipid-independent inflammatory pathways in type 2 diabetes.

Background: A recent randomized prospective controlled trial demonstrated that atorvastatin for up to 2 years was safe but did not significantly alter rebleeding in cerebral cavernous malformations. However, any consequences of discontinuing atorvastatin remain unknown. We hypothesized that symptomatic hemorrhage (SH) recurs more frequently in cerebral cavernous malformations after discontinuation of atorvastatin than placebo.

Methods: We conducted a 12-month posttreatment follow-up of patients enrolled in the Atorvastatin Therapy in Cavernous Angiomas with Symptomatic Hemorrhage Exploratory Proof of Concept (AT CASH EPOC) trial (41 randomized to atorvastatin, 39 to placebo) to identify potential recurrent SH after trial drug discontinuation. Every SH was adjudicated by review of imaging and corresponding symptoms. Patients were excluded from follow-up for <90% compliance with study drug, for its discontinuation <3 months after trial enrollment, for statin reinitiation <3 months after discontinuation, or for lack of follow-up. Cases were censored during follow-up upon cerebral cavernous malformation resection/radiation or later statin reinitiation.

Results: Follow-up included 33 patients who had been randomized to placebo and 32 who had taken atorvastatin. Four SH events occurred at 3, 49, 84, and 225 days after atorvastatin discontinuation, and 1 SH at 395 days after discontinuing placebo. There was significantly lower symptomatic hemorrhage-free survival in the atorvastatin-discontinuation group (log-rank χ²=4.136, P=0.042). The hazard ratio was 0.162 (95% CI, 0.027-0.977) for placebo versus atorvastatin discontinuation.

Conclusions: Discontinuation of atorvastatin was associated with a higher risk of recurrent SH compared with placebo discontinuation. Additional studies are warranted to confirm this hypothesis-generating observation, examine potential mechanisms, and how best to mitigate this risk.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02603328.

Background: Transcatheter edge-to-edge mitral valve repair is a key therapeutic option for patients with severe symptomatic mitral regurgitation at high surgical risk. This prospective study aimed to develop a novel end-to-end deep learning model for preoperative artificial intelligence assessment in transcatheter edge-to-edge mitral valve repair (TEERAI-pre) candidates using multiview, multimodal echocardiography.

Methods: TEERAI-pre, a video vision transformer-based classification model, predicts morphological suitability for transcatheter edge-to-edge mitral valve repair from multiview, multimodal echocardiography. A transformer-based feature-level fusion module was designed in TEERAI-pre to integrate multiview, multimodal features for final prediction. An internal data set of 633 patients (7997 transthoracic echocardiographic videos; 766 pulsed-wave Doppler images) was split for 5-fold cross-validation. An external data set of 150 patients (1735 transthoracic echocardiographic videos; 169 pulsed-wave Doppler images) across 2 hospitals evaluated generalizability. Reference standards were provided by 2 experienced valvular cardiologists per international guidelines.

Results: On the internal data set, TEERAI-pre achieved 75.0% accuracy (95% CI, 71.7%-78.4%) for classifying red (unsuitable), yellow (challenging), and green (ideal) zones, with 77.1% precision, 75.5% recall, and 76.2% F1 score. External validation yielded 73.3% accuracy, 74.0% precision, and 74.0% recall. Multiview multimodal integration improved performance. Binary classification (red versus green) showed TEERAI-pre matched senior experts and outperformed intermediate/junior echocardiologists. Feature-level fusion outperformed output-level fusion and single-view model. Backbone selection and calibration analysis confirmed robust performance.

Conclusions: TEERAI-pre demonstrates strong performance in transcatheter edge-to-edge mitral valve repair preoperative assessment using transthoracic echocardiographic videos and images, supporting more accurate patient selection and enhancing clinical workflow efficiency.

Registration: URL: clinicaltrials.gov; Unique Identifier: NCT05508438.

Background: The synergistic effects of multiple environmental factors on stroke remain unknown. The aim of this study was to explore the relationship between multiple living environment factors and stroke in middle-aged and older Chinese adults.

Methods: This study used data of the CHARLS (China Health and Retirement Longitudinal Study). Living environmental factors included ambient fine particulate matter, indoor fuel use, tap water use, room temperature, and residence type. Stroke was ascertained by self-reported physician-diagnosed stroke. Cox proportional hazard regression models were applied to explore the association between living environmental risk factors and stroke events in a cohort analysis. Multiple sensitivity analyses were used to test the robustness of the present finding.

Results: A total of 6483 participants from CHARLS (mean age: 58.17 years; female: 54.17%) were included in the 7-year follow-up. Individuals in the middle-risk (adjusted hazard ratio [HR], 0.73 [95% CI, 0.58-0.90]) and low-risk groups (adjusted HR, 0.56 [95% CI, 0.39-0.80]) demonstrated a 27% and 44% reduction in stroke risk, respectively, compared with the high-risk reference group, when evaluating the synergistic effects of residential environmental exposures. In the fully adjusted continuous model, each 1-unit increment in living environmental quality scores was associated with a 15% lower risk of stroke incidence (adjusted HR, 0.85 [95% CI, 0.78-0.91]). The results of the sensitivity analysis confirmed that our findings are robust.

Conclusions: Living environmental quality is significantly associated with stroke. Poor living quality may increase the risk of stroke. Future studies should focus more on the synergistic effects of exposure to living environmental factors.

Background: Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and increases stroke risk, primarily due to thromboembolism from the left atrial appendage (LAA). Oral anticoagulation (OAC) is recommended, but data on LAA thrombus (LAAT) in HCM and AF are limited. The current study aimed to assess LAAT prevalence in patients with HCM and AF.

Methods: We retrospectively analyzed 170 patients with HCM and AF (mean age, 67.7±12.4 years; 57.1% men) who underwent at least one transesophageal echocardiogram (TEE) during a median follow-up of 41.5 months (interquartile range, 15-77 months).

Results: At the time of TEE, 147 (86.5%) patients were undergoing OAC, with 52 (30.6%) taking vitamin K antagonists and 95 (55.9%) taking non-vitamin K antagonist oral anticoagulants. LAAT was found in 36 patients (21.2%), with prevalence rates of 23.1% (n=12) in vitamin K antagonist users, 16.8% (n=16) in non-vitamin K antagonist oral anticoagulant users, and 34.8% (n=8) in those without OAC. Non-vitamin K antagonist oral anticoagulant use was associated with a significant LAAT risk reduction compared with no OAC (odds ratio, 0.20 [95% CI, 0.05-0.73]; P=0.02). Decreased LAA flow velocity (P<0.001) was independently linked to LAAT.

Conclusions: LAAT is common in patients with HCM and AF, even among those receiving OAC. Reduced LAA flow velocity may increase thrombus risk. TEE should be considered before rhythm-control strategies, even in patients with HCM receiving anticoagulation, to minimize thromboembolic complications.

Background: Transcatheter aortic valve replacement using self-expandable valves requires permanent pacemaker implantation (PPI) more often compared with balloon-expandable systems. The Navitor prosthesis is a novel, tubular-shaped self-expandable valve with increasing use.

Methods: Thirty-day PPI rates were compared between 148 patients treated with the Navitor system and 165 patients treated with the Evolut system. Patients with preexisting PPI, high-risk ECG (right bundle-branch block), and Navitor 35-mm/Evolut 34-mm prostheses were excluded. Multivariable logistic regression was used to adjust for baseline differences.

Results: Patients treated with Navitor were older (83.0 [IQR, 78-86] versus 81.0 [IQR, 76-84] years; P < 0.01) and had higher Society of Thoracic Surgeons mortality risk (5.6% [IQR, 3.0%-9.9%] versus 4.3% [IQR, 2.5%-7.0%]; P = 0.04). Overall, PPI occurred more frequently with Navitor (17.6%) than with Evolut (6.7%; P < 0.01), and this difference persisted after adjustment (adjusted odds ratio, 3.07 [95% CI, 1.10-8.40]; P = 0.03; adjusted probability, 17.7% [95% CI, 15.1%-20.2%] versus 6.7% [95% CI, 5.5%-7.9%]). In patients with small annuli (<430 mm²), unadjusted PPI rate (9.1% versus 6.4%; P = 0.55) and adjusted probabilities were similar (7.8% [95% CI, 5.0%-10.6%] versus 6.4% [95% CI, 4.8%-8.0%]; interaction P = 0.03). Within the Navitor cohort, PPI was more frequent with 27/29 mm than with 23/25 mm prostheses (22.3% versus 6.7%; P=0.02). Implantation depth was greater in Navitor patients requiring PPI (5.3±1.8 versus 4.3±2.2 mm; P=0.04) and lower PPI rates (2.9% versus 30.8%; P<0.01) were observed with high target implantation depth.

Conclusions: Depending on prosthesis size, transcatheter aortic valve replacement with the Navitor system may have PPI rates comparable to other self-expandable valves. High implantation of the Navitor may be attempted to reduce PPI rates.