Journal of the American Heart Association最新文献

Background: The competing risk of nonstroke mortality may limit the potential benefit of stroke prophylaxis therapy in patients with atrial fibrillation or atrial flutter AF.

Methods: Using a Medicare 20% sample, we identified a cohort of beneficiaries diagnosed with atrial fibrillation or atrial flutter from 2006 to 2019 using International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. Fine and Gray regression analysis determined the hazard of stroke with a competing risk of nonstroke mortality, and Cox proportional hazard analysis determined risk of nonstroke mortality. A scoring tool stratified patients into low or high potential benefit for thromboembolic prophylaxis.

Results: Among a total of 1 883 759 Medicare beneficiaries, 330 136 patients were included with median age of 79.7 years. 54% of patients had prior bleeding episodes. The median CHA₂DS₂-VASc score was 5. Of these patients, 211 791 (64%) died and 77 717 (24%) experienced an embolic stroke over median follow-up of 7.3 years. In the high potential benefit group (26.1%), the risk of stroke was much higher than the risk of nonstroke mortality at 1 year (12.2% versus 7.1%); 3 years (22.7% versus 16.9%); 5 years (31.9% versus 26.1%). In the low potential benefit group (73.9%), the risk of stroke was much lower than the risk of nonstroke mortality at 1 year (11.5% versus 39.2%); 3 years (23.2 versus 57.2%); and 5 years (34.3% versus 69.4%).

Conclusions: We propose a scoring tool to identify the potential benefit of thromboembolic prophylaxis therapy in older patients diagnosed with atrial fibrillation or atrial flutter. This tool can be used in shared decision-making settings. Further studies to improve and validate this scoring tool are warranted.

Background: Cardiac troponin T is associated with mortality in heart transplantation recipients, but the association between its longitudinal measurements and clinical outcomes has not been evaluated. This study aimed to determine whether 3 parameterizations of serial hs-cTnT (high-sensitivity cardiac troponin T)-instantaneous concentration, temporal trend, and cumulative exposure-are associated with clinical outcomes in this population.

Methods: In a retrospective analysis, 222 heart transplantation recipients (median age 50 years, 86% men) who survived >30 days post transplant were included. Joint models were used to analyze the association between longitudinal hs-cTnT and the primary outcome of all-cause mortality and the secondary outcome of major adverse cardiac events.

Results: Over a median follow-up of 2.3 years, 32 deaths and 41 major adverse cardiac events occurred. Both instantaneous hs-cTnT concentration (hazard ratio [HR], 1.85 [95% CI, 1.48-2.31]; P<0.001) and cumulative hs-cTnT exposure (HR, 1.80 [95% CI, 1.38-2.37]; P<0.001) were strongly associated with mortality. The temporal trend of hs-cTnT was significantly associated with mortality after adjustment for donor and recipient factors. Similarly, instantaneous concentration and cumulative exposure were associated with major adverse cardiac events incidence (both P<0.05). In contrast, baseline hs-cTnT lost its significant association with outcomes after multivariable adjustment.

Conclusions: Longitudinally measured hs-cTnT is independently associated with mortality and major adverse cardiac events in heart transplant recipients.

Despite advances in drug and device technology, health care delivery, and research infrastructure, cardiogenic shock (CS) continues to have nearly 50% in-hospital mortality. In patients with CS, both the initial severity of Society for Cardiovascular Angiography and Intervention CS and its subsequent trajectory predicts the clinical outcomes. Accordingly, delayed initial recognition and failure to escalate or deescalate treatment can significantly affect the outcomes of CS. Traditional assessment methods, with the exception of blood pressure measurement, require a high index of suspicion and frequent reassessment by the clinical team. Electronic medical record-based detection has been successfully implemented in acute and critical care patients with septic shock and acute kidney injury. In CS, electronic medical record-based studies have largely focused on using models to predict outcomes in patients with CS, with limited data on electronic medical record-based tools to assist with either predicting CS or providing real time alerts when escalation or de-escalation might be indicated. Early detection of CS may be associated with detection of earlier Society for Cardiovascular Angiography and Intervention stages of CS and potentially prevent deterioration to higher stages. In this review, we seek to highlight a blueprint for electronic medical record-based detection of CS that focuses on reproducibility, convenience, clinical decision support, and research aspects.

Background: Catheter ablation of atrial fibrillation (AF) is an effective treatment to achieve left atrial (LA) and left ventricular (LV) reverse remodeling in patients with systolic dysfunction. However, the relationship between LA and LV reverse remodeling (LARR and LVRR) and their clinical implications remains unclear.

Methods: Among 5287 consecutive patients undergoing first-time AF ablation, 620 with baseline LV ejection fraction <50% were evaluated. They underwent multidetector computed tomography at baseline and 3 months after ablation. LARR and LVRR were defined as ≥15% reductions in the LA and LV end-systolic volume, respectively. The relationship between LARR and LVRR and their impact on clinical outcomes was investigated.

Results: AF ablation reduced the LA and LV end-systolic volumes, with reduction rates of 24%±16% and 39%±24%, respectively (r=0.54, P<0.001). During a follow-up of 50.4 months, patients with LARR-/LVRR- (n=86) showed the highest incidence of AF recurrence (50.0%) and composite of heart failure hospitalization or cardiovascular death (25.6%). Patients with LARR+/LVRR- (n=43) exhibited similar AF recurrence but the second highest incidence of the composite outcomes (16.3%) compared with those with LARR-/LVRR+ (n=95) and LARR+/LVRR+ (n=396). Age- and sex-adjusted Cox regression analysis revealed that LARR-/LVRR- alone was associated with AF recurrence (hazard ratio [HR], 2.01 [95% CI, 1.42-2.85], P<0.001), whereas LARR-/LVRR- (HR, 6.73 [95% CI, 3.48-13.0]) and LARR+/LVRR- (HR, 4.58 [95% CI, 1.86-11.3]) were associated with the composite end point.

Conclusions: LARR and LVRR were moderately correlated after AF ablation in patients with systolic dysfunction. Their combined assessment delineated distinct postablation trajectories and may improve individual risk stratification.

Background: Patients with atrial fibrillation (AF) often complain of dyspnea, raising the question that symptoms could be related to unrecognized heart failure (HF) with preserved ejection fraction (HFpEF).

Methods: We used the HFpEF-age, body mass index and history of AF algorithm to estimate the probability of undiagnosed HFpEF in CABANA (Catheter Ablation vs. Antiarrhythmic Drug Therapy), and its interaction with catheter ablation on quality of life (QOL). Probable HFpEF was defined as patient-reported dyspnea with HFpEF-age, body mass index and history of AF probability≥75%. Absence of dyspnea or HFpEF-age, body mass index and history of AF probability<75% was considered to reflect patients without HFpEF. The effect of randomization to catheter ablation on QOL (Mayo Atrial Fibrillation-Specific Symptom Inventory questionnaire and EuroQol-5 Dimension-3 Level score) was assessed using mixed models.

Results: Of participants without known HF, 70% (n=1225) had probable HFpEF and the remaining 30% (n=522) did not. Those with probable HFpEF had worse New York Heart Association class, EuroQol-5 Dimension-3 Level score, Mayo Atrial Fibrillation-Specific Symptom Inventory severity, and Mayo Atrial Fibrillation-Specific Symptom Inventory frequency scores (P<0.0001 for all), with higher risk of HF hospitalization (hazard ratio [HR], 2.19 [95% CI, 1.11-4.31], P=0.01). Ablation resulted in greater improvement in EuroQol-5 Dimension-3 Level and Mayo Atrial Fibrillation-Specific Symptom Inventory severity/frequency scores in probable HFpEF (interactions P=0.005, P=0.05, and P=0.04 respectively). In probable HFpEF, catheter ablation was associated with lower risk of cardiovascular hospitalization (HR, 0.78 [95% CI, 0.66-0.92], P=0.003, interaction P=0.03) but not HF hospitalization (HR, 0.94 [95% CI, 0.55-1.64], P=0.84).

Conclusions: Nearly three quarters of CABANA participants had potentially undiagnosed HFpEF, with worse QOL and risk of HF hospitalization. Catheter ablation in probable HFpEF resulted in greater improvement in QOL, but residual QOL impairment and HF risk remained elevated despite ablation. These data reinforce the importance of diligent consideration of HFpEF among patients with symptomatic AF to ensure optimal use of foundational treatments for HF.

Background: Secondary mitral regurgitation is associated with adverse clinical outcomes and cardiac remodeling. While transcatheter edge-to-edge repair (TEER) improves symptoms and prognosis in selected patients, its effects on cardiac remodeling remain debated. This systematic review and meta-analysis aimed to evaluate the impact of TEER on echocardiographic indices of cardiac remodeling.

Methods: PubMed, Scopus, and Cochrane Library were used to identify relevant studies assessing echocardiographic changes before and after TEER. Outcomes of interest were left ventricular (LV) ejection fraction, global longitudinal strain, LV end-diastolic and end-systolic volumes and LV end-diastolic and end-systolic diameter, tricuspid annular plane systolic excursion, pulmonary artery systolic pressure, and left atrial end-systolic volume.

Results: Forty-two studies (3987 patients) were included. TEER was associated with a significant increase in LV ejection fraction (mean difference [MD], 1.51% [95% CI, 0.47-2.55]), without significant improvement in global longitudinal strain. Significant LV remodeling was observed, with reductions in LV end-diastolic volume (standardized MD, -0.26 [95% CI, -0.37 to -0.14]), LV end-systolic volume (standardized MD, -0.21 [95% CI, -0.30 to -0.12]), LV end-diastolic diameter (MD, -2.35 mm [95% CI, -3.66 to -1.04]) and left ventricular end-systolic diameter (MD, -2.30 mm [95% CI, -3.86 to -0.74). TEER also improved right ventricular function (tricuspid annular plane systolic excursion [MD, 1.29 mm [95% CI, 0.60-1.97]) and reduced pulmonary artery systolic pressure (MD, -6.75 mm Hg [95% CI, -8.53 to -4.97). No significant improvement in left atrial end-systolic volume was detected.

Conclusions: Available evidence suggests that TEER promotes significant cardiac remodeling in patients with secondary mitral regurgitation.

Background: The effectiveness and safety of endovascular treatment (EVT) compared with standard medical treatment (SMT) for acute basilar artery occlusion in patients with National Institutes of Health Stroke Scale (NIHSS) scores ≤10 remain unclear. This study aimed to investigate the effectiveness and safety of EVT versus SMT in patients with acute basilar artery occlusion with NIHSS scores ≤10.

Methods: Patients with acute basilar artery occlusion and NIHSS scores ≤10 included in this study were derived from a nationwide prospective registry in China. Patients were divided into the EVT and SMT groups. The primary outcome was the distribution of modified Rankin Scale score at 90 days. Safety outcomes included death at 90 days and symptomatic intracerebral hemorrhage within 48 hours.

Results: Among 106 patients, 78 (73.6%) received EVT. The median age was 64 (interquartile range, 59-71) years, and 23 (21.7%) were women. Compared with SMT, EVT was associated with a favorable shift in the distribution of modified Rankin Scale score at 90 days (adjusted odds ratio, 6.22 [95% CI, 2.31-16.73]) and lower 90-day death (adjusted odds ratio, 0.23 [95% CI, 0.06-0.88]). There was no significant difference in the incidence of symptomatic intracerebral hemorrhage within 48 hours between the 2 groups. At 1-year follow-up, functional outcomes continued to favor EVT over SMT. In both groups, as the baseline NIHSS score increased, the probability of achieving favorable outcomes progressively decreased, while the probability of death increased.

Conclusions: In patients with acute basilar artery occlusion and NIHSS scores of ≤10, EVT was associated with better functional outcomes and lower mortality rate.

Background: The purpose of this study was to estimate the prevalence and number of cerebral microbleeds (CMBs) in a Hispanic and Latino cohort from various self-identified backgrounds and test associations with age, vascular risk factors, APOE (apolipoprotein E), and cognitive function.

Methods: The 3T brain magnetic resonance imaging exams were obtained on SOL-INCA-MRI (Study of Latinos-Investigation of Neurocognitive Aging-MRI) magnetic resonance imaging study participants, a community-based study. CMB number was counted and categorized as: (1) any CMB, (2) lobar only, (3) deep only, (4) mixed, (5) deep+mixed, and (6) lobar+mixed. We examined whether prevalence of CMBs varied by age, sex, education, Hispanic background, cardiovascular risk factors (hypertension, diabetes, Framingham Risk Score), APOE genotype, and cognition.

Results: A total of 2455 participants were included who were 63.0±8.4 years of age, 67.9% women, and 62.2% high school education or higher. CMBs prevalence was 11.7% (8.3% lobar only, 2.0% deep only, 1.4% mixed locations). After adjusting for age, sex, and education, a high Framingham Risk Score was associated with the presence of CMBs of all types, except lobar only. Prevalent stroke/transient ischemic attack was associated with higher likelihood of deep-only CMBs. For participants with cognitive impairment, the adjusted prevalence of mixed CMBs (2.2% versus 1.1%, P=0.023) and deep-only+mixed CMBs (5.2% versus 3.1%, P=0.010) was significantly higher compared with cognitively normal. Cognitive impairment was significantly associated with higher total CMB count (rate ratio, 1.46 [95% CI, 1.14-1.87]; P=0.003). No significant associations were found between diabetes, APOE4, and any CMB type.

Conclusions: High vascular risk scores, self-reported history of stroke/transient ischemic attack, and cognitive status were associated with a higher likelihood of CMBs, especially in deep regions.

Background: People of South Asian background have a high burden of atherosclerotic cardiovascular disease (ASCVD). Few studies have examined if US South Asian individuals develop atherosclerotic cardiovascular disease risk factors at younger ages compared with other racial and ethnic groups.

Methods: Longitudinal data from all eligible participants (ie, those aged between 45 and 55 years at time of the baseline examination) in the MASALA (Mediators of Atherosclerosis in South Asians Living in America) and the MESA (Multi-Ethnic Study of Atherosclerosis) cohort studies were combined. Data from all available examination visits (2010-2018 in MASALA and 2000-2018 in MESA) were used to estimate prevalence and change in prevalence of clinical and behavioral risk factors at ages 45 and 55 years for each racial and ethnic group and by gender.

Results: At age 45 years, South Asian individuals had the highest prevalence of prediabetes and hypertension compared with White, Chinese, and Hispanic individuals. South Asian men had a higher dyslipidemia prevalence than White, Chinese, and Black men, while South Asian women had a higher prevalence than Chinese and Black women. At age 55 years, South Asian adults had the highest estimated hazard probability of diabetes among all racial and ethnic groups. At an increased age, clinical risk factor prevalence increased in all racial and ethnic groups, diet quality improved, and the prevalence of no leisure-time exercise decreased (ie, exercise improved).

Conclusions: Significant differences in risk factor prevalence were observed in South Asian adults compared with other US racial and ethnic groups at age 45 years. Understanding trends in cardiovascular risk and protective factors across the life course can help improve prevention and treatment strategies.