American Journal of Cardiology最新文献

In-stent restenosis (ISR) remains a challenging complication following percutaneous coronary intervention (PCI), owing to its complex pathogenesis and multifaceted risk factor profile. We performed a retrospective analysis of all PCI data recorded in the Victorian Cardiac Outcomes Registry (VCOR), from 2013 to 2022, dividing patients into the ISR or de novo-PCI groups based on the intervened lesion. The primary outcome was in hospital mortality, with secondary outcomes including 30-day major adverse cardiovascular events and long-term mortality. Among 104,722 total PCI procedures, 4,935 procedures (4.7%) were for ISR, and 99,787 procedures (95.3%) were for de novo coronary lesions. Patients with ISR were older (mean age 69.0 ± 10.7 years vs. 66.4 ± 11.9 years, p < 0.001) with a higher burden of comorbidities including advanced chronic kidney disease (eGFR less than 31ml/min/1.73m² (4.2% vs. 2.5%, p < 0.001)), peripheral vascular disease (6.3% vs. 3.3%, p < 0.001) and diabetes mellitus (34.8% vs. 22.3%, p < 0.001). Lesion complexity was higher in the ISR group, with more lesions classified as ACC/AHA Type B2 and above (74.8% vs. 59.6%, p < 0.001). Adjunctive imaging devices were more commonly utilized in the ISR group; however, use was generally low (8.4% vs. 2.8%, p < 0.001). In-hospital mortality was lower in the ISR group, whereas 30-day target vessel and lesion revascularization rates were higher (1.3% vs. 0.7%, p < 0.001 and 0.8% vs. 0.4%, p = 0.001 respectively). Long term mortality as assessed over 10 years was higher in the ISR group. In conclusion, compared with de novo PCI, patients undergoing ISR PCI were older with greater comorbidities and lesion complexity. ISR PCI was associated with lower in-hospital mortality but worse long-term survival. These findings provide contemporary, population-based evidence on the evolving clinical profile and outcomes of ISR in routine PCI practice.

Postoperative atrial fibrillation (POAF) occurs in approximately 5-10% of patients undergoing noncardiac surgery, yet its long-term impact compared to patients without POAF (nPOAF) remains uncertain. This study aimed to assess the incidence of cardiovascular outcomes in patients with new-onset POAF. A systematic search of PubMed, EMBASE, and Scopus up to August 2025 identified studies including adults who developed AF within the first postoperative week. Outcomes analyzed were AF recurrence, cardiac-related hospitalization, stroke, and all-cause mortality. Pooled analyses were performed using random-effects models, reconstructed time-to-event data, and Restricted Mean Survival Time (RMST). A total of 14 studies comprising 3,622,824 patients were included, with 61,305 experiencing POAF. Compared to nPOAF patients, POAF was associated with significantly higher risks of stroke at 1 year (HR 2.34, 95% CI, 1.46-3.21), in-hospital mortality (HR 3.29, 95% CI, 2.90-3.67), and 1-year mortality (HR 1.64, 95% CI, 1.56-1.71). The cumulative incidence of hospitalization or stroke was greater in the POAF group (HR 1.75, 95% CI, 1.18-2.61). Time-to-event analysis showed frequent AF recurrence within days of surgery, with risk persisting over 1 year. RMST analysis indicated that POAF patients experienced hospitalization or stroke an average of 14.77 days earlier than nPOAF patients during follow-up. New-onset POAF after noncardiac surgery is strongly associated with increased risks of stroke, mortality, and recurrent hospitalization. These findings underscore the importance of early recognition and management, and highlight the need for further research into preventive and therapeutic strategies, including the role of anticoagulation.

While transcatheter aortic valve replacement (TAVR) is a rapidly expanding minimally invasive alternative to surgical aortic valve replacement (SAVR), its access might be limited due to proximity to a TAVR center. Among Medicare beneficiaries, real-world driving times from residential zip codes to TAVR and SAVR center zip codes were computed using the Google Distance Matrix Application Programming Interface. Zip code-level sociodemographic correlates of driving times more than 1 hour to TAVR and SAVR centers were computed using generalized linear mixed-effects models. Of 29,089 US residential zip codes, 407 (1.4%) had a TAVR center and 639 (2.2%) a SAVR center. The median driving time to the nearest zip code with a TAVR center (59 min [IQR, 30-96]) was longer compared with SAVR center (44 min [IQR, 24-73]), and driving times were longer in Western and Southern regions compared with the Northeast. A higher proportion of beneficiaries drive over 1 hour to nearest TAVR center (24.3%) compared with SAVR center (13.1%). Zip codes with a higher median age, a higher ratio of Hispanic to White individuals, and outside metropolitan areas were more likely to have driving times longer than 1 hour to the nearest TAVR centers. In conclusion, access to TAVR is consistently lower compared with SAVR centers, particularly in the Western and Southern US. The geographic barrier to access care, particularly among socioeconomically disadvantaged rural communities, requires evaluating the selection process for sites that provide care.

Patients with large or extra-large aortic annuli pose a particular challenge for Transcatheter aortic valve replacement (TAVR), as clinical outcomes are less favorable than in patients with smaller annuli. This study aimed to evaluate periprocedural and clinical outcomes in patients with large and extra-large annuli undergoing TAVR and to compare results between balloon-expandable (BEVs) and self-expanding valves (SEVs). This study included patients with severe aortic stenosis (AS) and extra-large annuli who underwent TAVR with either BEVs or SEVs. The primary endpoints were periprocedural and clinical outcomes, including device success, rates of moderate or greater paravalvular leak (PVL), permanent pacemaker (PPM) implantation, new Left bundle branch block (LBBB), stroke, and in-hospital and 1-year mortality. Secondary endpoints included safety outcomes and subgroup analyses comparing outcomes between patients with large (annular perimeter >90 mm and an area >660 mm²) and extra-large annuli (perimeter >96 mm and an area >730 mm²). A total of 237 patients underwent TAVR, including 160 with BEVs and 77 with SEVs. The mean annular area and perimeter were 737 ± 76 mm² and 96.1 ± 4.1 mm, respectively, with no significant differences between groups. Overall device success was high, though slightly lower in the SEV group (84% vs. 93%, p = 0.034), a difference that was no longer statistically significant after multivariate analysis (p = 0.234). Moderate or greater PVL occurred more frequently with SEVs (13% vs. 4%, p = 0.016), particularly in patients with extra-large annuli (26% vs. 4%, p = 0.012). One-year mortality was similar between groups (SEV 13% vs. BEV 12%, p = 0.807), and no significant differences were observed in PPM implantation, new LBBB, stroke, or major vascular and bleeding complications. TAVR is feasible and safe in patients with large and extra-large annuli, with higher rates of moderate or greater paravalvular leak observed in SEV patients with extra-large annuli.

Atherosclerotic renal artery stenosis (RAS) affects nearly 7% of adults over age 65 and is associated with increased cardiovascular and renal morbidity. Although early observational studies suggested benefit from renal artery stenting, subsequent randomized trials failed to show improvement in major clinical endpoints, contributing to substantial declines in procedural use. To characterize contemporary practice, we conducted a retrospective cohort study of Medicare beneficiaries older than 65 years who underwent renal artery stenting for atherosclerotic RAS between 2016 and 2020. Using Medicare claims data, we evaluated baseline characteristics, temporal utilization, and postprocedural outcomes, stratified by race, geographic region, and dual Medicare-Medicaid enrollment status. Among 19,130 patients, the mean age was 76.0 years (±6.4), 59.2% were female, and 90.3% were White; 84.2% had chronic kidney disease and 48.7% had heart failure. Procedural rates declined by 41.1% over the study period. Compared with White patients, Black patients had higher adjusted risks of hypertensive crisis hospitalization (aHR 1.45, 95% CI, 1.24-1.70) and dialysis initiation (aHR 1.78, 95% CI, 1.39-2.27); patients of Other races also had greater risk of dialysis initiation (aHR 1.98, 95% CI, 1.50-2.63). Patients in the South experienced higher unadjusted cardiovascular event rates (50.0%) but similar adjusted mortality compared with those in the Northeast (aHR 1.09, 95% CI, 0.98-1.21). Dual enrollment was associated with increased all-cause mortality (aHR 1.31, 95% CI, 1.20-1.43). In conclusion, renal artery stenting rates continued to decline in recent years, and contemporary recipients constitute an older, comorbid population with substantial cardiovascular risk. Outcomes differed markedly by race, socioeconomic status, and geography, highlighting the need for improved risk stratification and prospective evaluation of stenting in high-risk cohorts.

Aortic regurgitation (AR) is the third most common valvular heart disease and its prevalence increases with age. Surgical aortic valve replacement remains the standard treatment but is often deferred due to perceived high surgical risk and frailty, leaving nearly one‑third of patients with severe AR untreated. Transcatheter aortic valve replacement (TAVR) offers a less invasive alternative, but off-label use of transcatheter valves designed for aortic stenosis has been limited by anchoring difficulties, valve embolization, and residual regurgitation. Dedicated devices have addressed these challenges with tailored anchoring mechanisms and demonstrated improved procedural success. This case-based review explores the evolving role of TAVR for AR through 3 patient vignettes that highlight practical considerations for device selection, anchoring strategies, and complication management. While outcomes with dedicated systems are encouraging, further research should establish TAVR in AR treatment. In parallel, device iterations are required to curtail procedure-induced conduction disturbances and broaden anatomical eligibility.

Cardiovascular disease is the leading cause of global morbidity and mortality, with coronary artery disease representing the primary driver of premature death. Cardiac rehabilitation (CR) is a cornerstone of secondary prevention that integrates exercise, risk factor modification, and education. CR reduces all-cause mortality, recurrent ischemic events, and improves quality of life. Yet, participation remains suboptimal, and CR is underutilized by women, older adults, minorities, and socioeconomically disadvantaged groups. We examine the modalities of CR including traditional center-based CR (CBCR), home-based CR and hybrid models. By leveraging telemedicine, mobile health, and wearable biosensors remote delivery of CR has shown comparable efficacy to traditional CBCR. The integration of artificial intelligence offers opportunities to personalize CR through continuous physiological monitoring and exercise prescriptions. In conclusion, CR remains cost-effective from a health-system perspective, but patient-level affordability and equitable access require targeted policy, financial, and culturally adapted interventions to ensure personalized and equitable delivery of secondary prevention.

Right ventricular (RV) - pulmonary arterial (PA) uncoupling is an important predictor of outcomes in heart failure (HF), yet it may change substantially during hospitalization for acute HF. This study sought to investigate the dynamic changes in RV-PA uncoupling during acute HF hospitalization and their prognostic significance. Tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio was measured in consecutive hospitalized acute HF patients using echocardiography on admission and at discharge. TAPSE/PASP <0.36 mm/mmHg was considered as RV-PA uncoupling. Patients were divided into 3 groups; RV-PA coupling on admission and discharge, RV-PA uncoupling on admission that normalized to RV-PA coupling at discharge (normalized RV-PA uncoupling), and RV-PA uncoupling on admission that persisted at discharge (persistent RV-PA uncoupling). The primary endpoint was all-cause mortality and HF rehospitalization. Out of 490 patients (73.4 ± 11.9 years old), 216 (44.1%) had RV-PA coupling, 123 (25.1%) normalized RV-PA uncoupling, and 151 (30.8%) persistent RV-PA uncoupling. After a mean follow-up of 12.0 ± 2.6 months, 186 (38.0%) patients reached the primary endpoint. Significantly worse event-free survival rate was observed for the persistent RV-PA uncoupling patients (RV-PA coupling: 74.1%, normalized RV-PA uncoupling: 71.5%, persistent RV-PA uncoupling: 37.1%, Log-rank p < 0.001). Persistent RV-PA uncoupling status was independently associated with the primary endpoint (hazard ratio 2.78 [95% CI 1.73-4.44]; p < 0.001), and provided incremental prognostic information over a baseline model and RV-PA uncoupling on admission. In conclusion, in hospitalized acute HF patients, persistence of RV-PA uncoupling at discharge is associated with worse 1-year event-free survival. Clinical Trial Registration: https://www.clinicaltrials.gov/study/NCT05573997.

Peripheral artery disease (PAD) remains one of the leading causes of atherosclerotic cardiovascular diseases affecting millions of people worldwide. Clinical presentation ranges from asymptomatic disease to chronic limb-threatening ischemia, and patients are not only at a higher risk of amputation and limb loss but also at increased risk of cardiovascular events and mortality. Nowadays, many physicians from various specialties are involved in the care of patients with PAD and provide a wide range of vascular interventions and procedures, but to date, there is still a huge discrepancy as to how these patients are managed and followed up after their interventions. This review aims to provide a comprehensive road map for physicians to help them administer a more standardized care covering all aspects of management of patients with PAD in the postintervention phase based on our institution's best-practice approach.