Pub Date : 2022-06-16DOI: 10.1136/heartjnl-2022-321350
T. A. Meijs, M. Voskuil
The Authors' reply: We thank Pavšič et al for their remarks regarding our recent article. They raise some important points. First, the definition of a hypertensive response to exercise varies between studies in patients with coarctation of the aorta (CoA), which limits their comparability. We used a cutoff value of 210 mm Hg in men and 190 mm Hg in women for systolic blood pressure (SBP) during peak exercise, since these values correspond to the 90th percentile in both sexes in a healthy population. Although this definition is most widely used, we acknowledge that there are potential drawbacks when extrapolating this definition to a relatively young cohort of patients with CoA. As noted by Pavšič et al, contemporary data indicate that peak exercise SBP increases with age in a pattern similar to resting SBP. Since most patients in our cohort were between 18 and 40 years old, we may have detected an even higher prevalence of a hypertensive response to exercise using ageadjusted cutoff values. However, we believe we should be cautious in comparing patients with CoA with apparently healthy individuals. Patients with CoA represent a very distinct group with a high prevalence of hypertension and signs of a generalised arteriopathy, which are often already present from a young age. At this moment, there is insufficient evidence how this generalised arteriopathy progresses over time. Interestingly, our presented data show a trend towards a lower peak exercise SBP with increasing age, even when corrected for workload (table 2 in original article). This may be partly explained by differences in surgical era. Repair techniques have improved over the last decades, which has most benefited the younger patients in our cohort. Consequently, even the patients with the most severe forms of arteriopathy, who presumably have the highest risk of a hypertensive response to exercise, survive into adulthood in reasonable condition. In contrast, patients >50 years whose exercise tolerance is well enough to undergo exercise stress testing may represent a subgroup with a relatively mild arteriopathy. These era differences are likely to introduce some degree of selection bias, which should be taken into account when interpreting exercise stress testing in patients with CoA. Pavšič et al argue that workloadindexed SBP better reflects an abnormal blood pressure response than SBP alone. Workload may indeed confound the relationship between exercise and SBP, which is why we reported workload in metabolic equivalents (METs) and adjusted for this factor in multivariable analysis. It is plausible to adjust for workload, since there is a nearly linear relationship between workload and cardiac output during exercise. However, it has not yet been demonstrated that workloadindexed SBP is superior to SBP alone in predicting adverse cardiovascular events. The importance of preventing cardiovascular events in adult patients with CoA was emphasised by our recent study, showing a substant
{"title":"Response to: Correspondence on ‘Hypertensive response to exercise in adult patients with repaired aortic coarctation’ by Pavšič et al","authors":"T. A. Meijs, M. Voskuil","doi":"10.1136/heartjnl-2022-321350","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321350","url":null,"abstract":"The Authors' reply: We thank Pavšič et al for their remarks regarding our recent article. They raise some important points. First, the definition of a hypertensive response to exercise varies between studies in patients with coarctation of the aorta (CoA), which limits their comparability. We used a cutoff value of 210 mm Hg in men and 190 mm Hg in women for systolic blood pressure (SBP) during peak exercise, since these values correspond to the 90th percentile in both sexes in a healthy population. Although this definition is most widely used, we acknowledge that there are potential drawbacks when extrapolating this definition to a relatively young cohort of patients with CoA. As noted by Pavšič et al, contemporary data indicate that peak exercise SBP increases with age in a pattern similar to resting SBP. Since most patients in our cohort were between 18 and 40 years old, we may have detected an even higher prevalence of a hypertensive response to exercise using ageadjusted cutoff values. However, we believe we should be cautious in comparing patients with CoA with apparently healthy individuals. Patients with CoA represent a very distinct group with a high prevalence of hypertension and signs of a generalised arteriopathy, which are often already present from a young age. At this moment, there is insufficient evidence how this generalised arteriopathy progresses over time. Interestingly, our presented data show a trend towards a lower peak exercise SBP with increasing age, even when corrected for workload (table 2 in original article). This may be partly explained by differences in surgical era. Repair techniques have improved over the last decades, which has most benefited the younger patients in our cohort. Consequently, even the patients with the most severe forms of arteriopathy, who presumably have the highest risk of a hypertensive response to exercise, survive into adulthood in reasonable condition. In contrast, patients >50 years whose exercise tolerance is well enough to undergo exercise stress testing may represent a subgroup with a relatively mild arteriopathy. These era differences are likely to introduce some degree of selection bias, which should be taken into account when interpreting exercise stress testing in patients with CoA. Pavšič et al argue that workloadindexed SBP better reflects an abnormal blood pressure response than SBP alone. Workload may indeed confound the relationship between exercise and SBP, which is why we reported workload in metabolic equivalents (METs) and adjusted for this factor in multivariable analysis. It is plausible to adjust for workload, since there is a nearly linear relationship between workload and cardiac output during exercise. However, it has not yet been demonstrated that workloadindexed SBP is superior to SBP alone in predicting adverse cardiovascular events. The importance of preventing cardiovascular events in adult patients with CoA was emphasised by our recent study, showing a substant","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1328 - 1329"},"PeriodicalIF":0.0,"publicationDate":"2022-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41898891","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-13DOI: 10.1136/heartjnl-2022-320852
D. Lawin, T. Lawrenz, K. Marx, N. B. Danielsmeier, M. Poudel, C. Stellbrink
Objective Alcohol septal ablation (ASA) improves symptoms in hypertrophic obstructive cardiomyopathy (HOCM). We conducted a large retrospective analysis investigating gender effects on outcome after ASA. Methods and results 1367 ASAs between 2002 and 2020 were analysed. Women (47.2%) were older (66.0 years (IQR 55.0–74.0) vs 54.0 years (IQR 45.0–62.0); p<0.0001) with more severe symptoms. The interventricular septal diameter (IVSD) was higher in men (21.0 mm (IQR 19.0–24.0) vs 20.0 mm (IQR 18.0–23.0); p<0.0001) but the IVSD indexed to body surface area was higher in women (10.9 mm/m2 (IQR 9.7–12.7) vs 10.2 mm/m2 (IQR 9.0–11.7); p<0.0001). Women had lower exercise-induced left ventricular outflow tract gradients (LVOTG) 1–4 days after ASA (55.0 mm Hg (IQR 30.0–109.0) vs 71.0 mm Hg (IQR 37.0–115.0); p=0.0006). There was a trend for lower resting LVOTG 1–4 days after ASA (20.0 mm Hg (IQR 12.0–37.5) vs 22.0 mm Hg (IQR 13.0–40.0); p=0.0062) and lower exercise-induced LVOTG after 6 months in women (34.0 mm Hg (IQR 21.0–70.0) vs 43.5 mm Hg (IQR 25.0–74.8); p=0.0072), but this was not statistically significant after Bonferroni correction. More women developed atrioventricular (AV) block (20.3% vs 13.3%; p=0.0005) and required a pacemaker (17.4% vs 10.4%; p=0.0002) but not a cardioverter defibrillator (9.0% vs 11.6% in men; p=n .s.). However, in multivariable regression models, there was no evidence that sex independently influenced LVOTG and the occurrence of AV block. Conclusion Female patients with HOCM were older and had more advanced disease at the time of ASA. Women had superior short-term haemodynamic response to ASA but more often developed AV block after ASA. These results are important to consider for sex-specific counselling before ASA.
{"title":"Gender disparities in alcohol septal ablation for hypertrophic obstructive cardiomyopathy","authors":"D. Lawin, T. Lawrenz, K. Marx, N. B. Danielsmeier, M. Poudel, C. Stellbrink","doi":"10.1136/heartjnl-2022-320852","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-320852","url":null,"abstract":"Objective Alcohol septal ablation (ASA) improves symptoms in hypertrophic obstructive cardiomyopathy (HOCM). We conducted a large retrospective analysis investigating gender effects on outcome after ASA. Methods and results 1367 ASAs between 2002 and 2020 were analysed. Women (47.2%) were older (66.0 years (IQR 55.0–74.0) vs 54.0 years (IQR 45.0–62.0); p<0.0001) with more severe symptoms. The interventricular septal diameter (IVSD) was higher in men (21.0 mm (IQR 19.0–24.0) vs 20.0 mm (IQR 18.0–23.0); p<0.0001) but the IVSD indexed to body surface area was higher in women (10.9 mm/m2 (IQR 9.7–12.7) vs 10.2 mm/m2 (IQR 9.0–11.7); p<0.0001). Women had lower exercise-induced left ventricular outflow tract gradients (LVOTG) 1–4 days after ASA (55.0 mm Hg (IQR 30.0–109.0) vs 71.0 mm Hg (IQR 37.0–115.0); p=0.0006). There was a trend for lower resting LVOTG 1–4 days after ASA (20.0 mm Hg (IQR 12.0–37.5) vs 22.0 mm Hg (IQR 13.0–40.0); p=0.0062) and lower exercise-induced LVOTG after 6 months in women (34.0 mm Hg (IQR 21.0–70.0) vs 43.5 mm Hg (IQR 25.0–74.8); p=0.0072), but this was not statistically significant after Bonferroni correction. More women developed atrioventricular (AV) block (20.3% vs 13.3%; p=0.0005) and required a pacemaker (17.4% vs 10.4%; p=0.0002) but not a cardioverter defibrillator (9.0% vs 11.6% in men; p=n .s.). However, in multivariable regression models, there was no evidence that sex independently influenced LVOTG and the occurrence of AV block. Conclusion Female patients with HOCM were older and had more advanced disease at the time of ASA. Women had superior short-term haemodynamic response to ASA but more often developed AV block after ASA. These results are important to consider for sex-specific counselling before ASA.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1623 - 1628"},"PeriodicalIF":0.0,"publicationDate":"2022-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45340077","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-13DOI: 10.1136/heartjnl-2022-320897
A. Coisne, D. Montaigne, S. Ninni, N. Lamblin, G. Lemesle, P. Delsart, Alexandre Filiot, Paul Andrey, P. Balaye, L. Butruille, R. Decoin, E. Woitrain, J. Granada, B. Staels, C. Bauters
Objective Current data regarding the impact of diabetes mellitus (DM) on cardiovascular mortality in patients with aortic stenosis (AS) are restricted to severe AS or aortic valve replacement (AVR) trials. We aimed to investigate cardiovascular mortality according to DM across the entire spectrum of outpatients with AS. Methods Between May 2016 and December 2017, patients with mild (peak aortic velocity=2.5–2.9 m/s), moderate (3–3.9 m/s) and severe (≥4 m/s) AS graded by echocardiography were included during outpatient cardiology visits in the Nord-Pas-de-Calais region in France and followed-up for modes of death between May 2018 and August 2020. Results Among 2703 patients, 820 (30.3%) had DM, mean age was 76±10.8 years with 46.6% of women and a relatively high prevalence of underlying cardiovascular diseases. There were 200 cardiovascular deaths prior to AVR during the 2.1 years (IQR 1.4–2.7) follow-up period. In adjusted analyses, DM was significantly associated with cardiovascular mortality (HR=1.40, 95% CI 1.04 to 1.89; p=0.029). In mild or moderate AS, the cardiovascular mortality of patients with diabetes was similar to that of patients without diabetes. In severe AS, DM was associated with higher cardiovascular mortality (HR=2.65, 95% CI 1.50 to 4.68; p=0.001). This was almost exclusively related to a higher risk of death from heart failure (HR=2.61, 95% CI 1.15 to 5.92; p=0.022) and sudden death (HR=3.33, 95% CI 1.28 to 8.67; p=0.014). Conclusion The effect of DM on cardiovascular mortality varied across AS severity. Despite no association between DM and outcomes in patients with mild/moderate AS, DM was strongly associated with death from heart failure and sudden death in patients with severe AS.
目前关于糖尿病(DM)对主动脉瓣狭窄(AS)患者心血管死亡率影响的数据仅限于严重AS或主动脉瓣置换术(AVR)试验。我们的目的是调查心血管死亡率根据糖尿病在整个频谱门诊AS患者。方法在2016年5月至2017年12月期间，在法国北加来pas -de- calais地区的门诊心脏病学就诊中纳入超声心动图分级的轻度(主动脉峰值速度= 2.5-2.9 m/s)、中度(3-3.9 m/s)和重度(≥4 m/s) AS患者，并于2018年5月至2020年8月随访死亡方式。结果2703例患者中，糖尿病820例(30.3%)，平均年龄76±10.8岁，女性占46.6%，基础心血管疾病患病率较高。在2.1年(IQR 1.4-2.7)随访期间，AVR发生前有200例心血管死亡。在校正分析中，糖尿病与心血管死亡率显著相关(HR=1.40, 95% CI 1.04 ~ 1.89;p = 0.029)。在轻度或中度AS中，糖尿病患者的心血管死亡率与非糖尿病患者相似。在严重AS患者中，糖尿病与较高的心血管死亡率相关(HR=2.65, 95% CI 1.50 ~ 4.68;p = 0.001)。这几乎完全与心力衰竭死亡的高风险相关(HR=2.61, 95% CI 1.15 ~ 5.92;p=0.022)和猝死(HR=3.33, 95% CI 1.28 ~ 8.67;p = 0.014)。结论糖尿病对心血管病死率的影响随AS严重程度的不同而不同。尽管在轻度/中度AS患者中，DM与预后没有关联，但在重度AS患者中，DM与心力衰竭和猝死的死亡密切相关。
{"title":"Diabetes mellitus and cardiovascular mortality across the spectrum of aortic stenosis","authors":"A. Coisne, D. Montaigne, S. Ninni, N. Lamblin, G. Lemesle, P. Delsart, Alexandre Filiot, Paul Andrey, P. Balaye, L. Butruille, R. Decoin, E. Woitrain, J. Granada, B. Staels, C. Bauters","doi":"10.1136/heartjnl-2022-320897","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-320897","url":null,"abstract":"Objective Current data regarding the impact of diabetes mellitus (DM) on cardiovascular mortality in patients with aortic stenosis (AS) are restricted to severe AS or aortic valve replacement (AVR) trials. We aimed to investigate cardiovascular mortality according to DM across the entire spectrum of outpatients with AS. Methods Between May 2016 and December 2017, patients with mild (peak aortic velocity=2.5–2.9 m/s), moderate (3–3.9 m/s) and severe (≥4 m/s) AS graded by echocardiography were included during outpatient cardiology visits in the Nord-Pas-de-Calais region in France and followed-up for modes of death between May 2018 and August 2020. Results Among 2703 patients, 820 (30.3%) had DM, mean age was 76±10.8 years with 46.6% of women and a relatively high prevalence of underlying cardiovascular diseases. There were 200 cardiovascular deaths prior to AVR during the 2.1 years (IQR 1.4–2.7) follow-up period. In adjusted analyses, DM was significantly associated with cardiovascular mortality (HR=1.40, 95% CI 1.04 to 1.89; p=0.029). In mild or moderate AS, the cardiovascular mortality of patients with diabetes was similar to that of patients without diabetes. In severe AS, DM was associated with higher cardiovascular mortality (HR=2.65, 95% CI 1.50 to 4.68; p=0.001). This was almost exclusively related to a higher risk of death from heart failure (HR=2.61, 95% CI 1.15 to 5.92; p=0.022) and sudden death (HR=3.33, 95% CI 1.28 to 8.67; p=0.014). Conclusion The effect of DM on cardiovascular mortality varied across AS severity. Despite no association between DM and outcomes in patients with mild/moderate AS, DM was strongly associated with death from heart failure and sudden death in patients with severe AS.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1815 - 1821"},"PeriodicalIF":0.0,"publicationDate":"2022-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47977894","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-13DOI: 10.1136/heartjnl-2022-321251
S. Nagueh
Hypertrophic obstructive cardiomyopathy (HOCM) is currently treated with septal reduction therapy in severely symptomatic patients who are not responsive to medical treatment. Since its introduction by Dr Ulrich Sigwart in 1995, alcohol septal ablation (ASA) has been increasingly performed across the globe. In fact, after discussion of risks, benefits and alternatives, many patients elect to undergo ASA. There have been several attempts to identify ASA outcome predictors in this patient population and there are concerns about worse outcomes in female patients. This important question is tackled in this issue of the journal by Lawin et al. The authors report on procedural outcomes at 1–4 days and at 6 months after ASA in 1367 patients with HOCM, stratified by sex. In comparison with men, women were older but had similar prevalence of coronary artery disease. Overall, symptomatic status was worse in women with more frequent syncope, and more severe dyspnoea and angina. Despite these differences, there were no apparent differences in medical therapy prior to ASA. Symptoms were corroborated by a significantly shorter 6minute walking distance (6MWD) in women prior to ASA. However, we are not told whether there was a difference in the doses of the drugs used or the combination of medications (eg, betablockers and disopyramide). Importantly, both resting gradients and exerciseinduced gradients (supine bicycle exercise to workload of 75 W for 5 min) were similar between men and women. While the basal septum was slightly thicker in men (on average for the study sample a difference of 1 mm), when indexed to body surface area (BSA), septum thickness was more in women (average difference: 0.7 mm/ m). This occurred because of the smaller BSA in women. Interestingly, despite the similar number of septal vessels occluded and volume of ethanol used in men and women, infarct size as assessed by peak creatine kinase was significantly higher in men. The magnitude of change at 6 months in basal septal thickness, rest and exerciseinduced gradients, and 6MWD was similar between men and women. Likewise, symptomatic improvement was comparable. Complications were similar, with the exception of highgrade atrioventricular (AV) block, the need for permanent pacemakers and vascular complications which occured more frequently in women, and pulmonary embolism which was more common in men. The study has the strengths of a large data set and coming from an experienced referral centre for ASA. It has several limitations acknowledged by the authors including followup being available in only 65% of women and 74% of men, the absence of baseline ECG findings and the short duration of followup. The absence of ECG findings is particularly relevant to understanding the reasons behind the higher incidence of advanced AV block in women. While the results of 6MWD at followup were included, data on exercise tolerance were not available. In general, the findings are similar to other studies
{"title":"Sex and outcomes after alcohol septal ablation for patients with hypertrophic obstructive cardiomyopathy","authors":"S. Nagueh","doi":"10.1136/heartjnl-2022-321251","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321251","url":null,"abstract":"Hypertrophic obstructive cardiomyopathy (HOCM) is currently treated with septal reduction therapy in severely symptomatic patients who are not responsive to medical treatment. Since its introduction by Dr Ulrich Sigwart in 1995, alcohol septal ablation (ASA) has been increasingly performed across the globe. In fact, after discussion of risks, benefits and alternatives, many patients elect to undergo ASA. There have been several attempts to identify ASA outcome predictors in this patient population and there are concerns about worse outcomes in female patients. This important question is tackled in this issue of the journal by Lawin et al. The authors report on procedural outcomes at 1–4 days and at 6 months after ASA in 1367 patients with HOCM, stratified by sex. In comparison with men, women were older but had similar prevalence of coronary artery disease. Overall, symptomatic status was worse in women with more frequent syncope, and more severe dyspnoea and angina. Despite these differences, there were no apparent differences in medical therapy prior to ASA. Symptoms were corroborated by a significantly shorter 6minute walking distance (6MWD) in women prior to ASA. However, we are not told whether there was a difference in the doses of the drugs used or the combination of medications (eg, betablockers and disopyramide). Importantly, both resting gradients and exerciseinduced gradients (supine bicycle exercise to workload of 75 W for 5 min) were similar between men and women. While the basal septum was slightly thicker in men (on average for the study sample a difference of 1 mm), when indexed to body surface area (BSA), septum thickness was more in women (average difference: 0.7 mm/ m). This occurred because of the smaller BSA in women. Interestingly, despite the similar number of septal vessels occluded and volume of ethanol used in men and women, infarct size as assessed by peak creatine kinase was significantly higher in men. The magnitude of change at 6 months in basal septal thickness, rest and exerciseinduced gradients, and 6MWD was similar between men and women. Likewise, symptomatic improvement was comparable. Complications were similar, with the exception of highgrade atrioventricular (AV) block, the need for permanent pacemakers and vascular complications which occured more frequently in women, and pulmonary embolism which was more common in men. The study has the strengths of a large data set and coming from an experienced referral centre for ASA. It has several limitations acknowledged by the authors including followup being available in only 65% of women and 74% of men, the absence of baseline ECG findings and the short duration of followup. The absence of ECG findings is particularly relevant to understanding the reasons behind the higher incidence of advanced AV block in women. While the results of 6MWD at followup were included, data on exercise tolerance were not available. In general, the findings are similar to other studies ","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1588 - 1589"},"PeriodicalIF":0.0,"publicationDate":"2022-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44254332","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-10DOI: 10.1136/heartjnl-2022-321137
K. Kusunose
With rapidly ageing population, aortic stenosis (AS) has become one of the most common valvular heart diseases. Severe AS is clearly associated with increased mortality, and the current American College of Cardiology/American Heart Association guidelines designate a class I or IIa indication for aortic valve surgery in severe patients with AS with symptoms or with low left ventricular (LV) function. Historically, based on the lower risk of sudden death in moderate AS compared with severe AS, watchful observation was recommended to patients with moderate AS. In the last decade, prognostic findings on moderate AS have been gathered (table 1). A large echocardiographic national database study, including 3315 moderate AS with various LV systolic functions, suggested a poor survival rate (5year mortality: 56%). Recently, two academic institutional databases, including 1245 moderate AS, also showed poor prognosis during followup (median followup: 4.3 years; mortality: 45.3%). From a physiological viewpoint, narrowing of the aortic valve area leads to LV systolic/diastolic dysfunction due to LV pressure overloading. In patients with severe AS who particularly underwent transcatheter aortic valve replacement (TAVR), diastolic dysfunction (DD) has been described as an early marker of myocardial damage and an important prognostic information. Thaden et al reported an association between echocardiographic data and outcomes from a retrospective singlecentre study. Over a mean followup period of 7.3 years, increased left atrial pressure based on the American Society of Echocardiography/ European Association of Cardiovascular Imaging criteria remained an independent predictor of mortality after successful aortic valve replacement (AVR) (HR: 1.45; 95% CI 1.16 to 1.81). More recently, Ong et al clearly showed an association between DD grading at baseline and combined cardiovascular death/rehospitalisation at 1 year from the Placement of Aortic Transcatheter Valves (PARTNER) 2 and SAPIEN 3 registry analysed by core laboratories (n=1253). These previous studies described a consistent message of an increased risk of event with worsening grade and stage of DD in severe AS. What about the association of moderate AS with DD? In their Heart article, Stassen et al presented data from a large registry of patients with moderate AS and preserved LV systolic function from three academic institutions between October 2001 and December 2019. Moderate AS was defined as an aortic valve area of between 1.0 cm and 1.5 cm. Finally, 1247 patients with moderate AS were retrospectively included and divided into three groups (normal diastolic function, indeterminate diastolic function and DD) based on the guidelines. The aims of the study were (1) to evaluate the prevalence of DD and (2) to examine the prognostic implications of DD in moderate AS with preserved LV systolic function. The primary outcome was allcause mortality. The secondary outcome was a composite of allcause mortality
随着人口老龄化的加速，主动脉瓣狭窄已成为最常见的心脏瓣膜病之一。严重的AS明显与死亡率增加相关，目前美国心脏病学会/美国心脏协会指南为有症状或左心室功能低下的严重AS患者的主动脉瓣手术指定了I级或IIa级适应症。历史上，鉴于中度AS患者猝死风险较重度AS患者低，建议对中度AS患者进行观察。在过去十年中，已经收集了中度AS的预后发现(表1)。一项大型超声心动图国家数据库研究，包括3315例具有各种左室收缩功能的中度AS，表明其生存率较低(5年死亡率:56%)。最近，包括1245名中度AS在内的两个学术机构数据库在随访期间也显示预后不良(中位随访:4.3年;死亡率:45.3%)。从生理学的角度来看，主动脉瓣面积变窄导致左室压力超载导致左室收缩/舒张功能障碍。重度AS患者特别是经导管主动脉瓣置换术(TAVR)的患者，舒张功能障碍(DD)被认为是心肌损伤的早期标志和重要的预后信息。Thaden等人报道了超声心动图数据与回顾性单中心研究结果之间的关联。在平均7.3年的随访期间，根据美国超声心动图学会/欧洲心血管成像协会的标准，左房压升高仍然是主动脉瓣置换术(AVR)成功后死亡率的独立预测因子(HR: 1.45;95% CI 1.16 - 1.81)。最近，Ong等人通过核心实验室(n=1253)对经主动脉瓣置入术(PARTNER) 2和SAPIEN 3登记进行分析，清楚地表明基线DD分级与1年后心血管死亡/再住院之间存在关联。这些先前的研究描述了一个一致的信息，即随着严重AS的DD等级和阶段的恶化，事件的风险增加。中度AS与DD的关系如何?在他们的心脏文章中，Stassen等人介绍了2001年10月至2019年12月期间来自三个学术机构的中度AS和左室收缩功能保留患者的大量注册数据。中度AS被定义为主动脉瓣面积在1.0 cm至1.5 cm之间。最后，回顾性纳入1247例中度AS患者，并根据指南分为舒张功能正常、不确定舒张功能和DD三组。该研究的目的是(1)评估DD的患病率，(2)检查DD对中度AS左室收缩功能保留的预后影响。主要结局为全因死亡率。次要结局是全因死亡率和手术或经导管AVR的综合结果。结果显示，中度AS患者经常出现DD(舒张功能正常:32%;舒张功能不确定:25%;弟弟:43%)。在中位53个月的随访中，39%的患者死亡。1年生存率为91%，5年生存率为65%。DD的存在与全因死亡率独立相关(HR: 1.37;95% CI 1.09 ~ 1.73)和全因死亡率和AVR的复合终点(HR: 1.24;95% CI 1.04 - 1.49)，对几个临床变量进行校正(图1)。该研究的优势在于样本量大，数据收集设计良好。该研究的主要局限性包括分析的回顾性性质和缺乏验证队列。此外，在DD评估中的一个主要限制是使用指南算法有许多不确定的情况。与舒张功能正常的患者相比，不确定DD患者与更高的无事件生存率无关。此外，评估左室舒张功能的个体变量(E/ E′、左房容积指数和三尖瓣反流速度)与结果的相关性不高。由于指南算法存在一定的局限性，我们需要补充方法来确定DD的存在与否。在引入应变成像后，很明显左室射血分数正常的患者可能通过整体纵向应变轻度降低左室收缩功能。因此，左室应变成像是一种补充测试，当超声心动图舒张功能指标不确定时是有用的。Tastet等人表明，新的分期系统使用几个参数来表征AS的主动脉瓣外心脏损伤，包括全局纵向应变。 应变成像可为中度AS左室收缩功能保留的DD分级系统提供附加价值。缺乏心脏磁共振数据是另一个限制，因为在这个队列中没有排除心脏淀粉样变性。约30%的患者有利尿剂，约40%的患者属于纽约心脏协会II-IV级。该队列中约有一半的患者似乎是症状高发的中度AS患者。心房颤动(AF)在该队列中相对普遍(25%)，尚不清楚AF患者是如何评估的。三个研究所对房颤患者超声心动图检查结果的差异可能会影响结果。在中位53个月的随访期间，初始诊断为中度AS的患者可以预期AS严重程度的进展。虽然这是一项评估不同类型的DD在诊断为中度AS时的预后意义的横断面研究，但尚不清楚进展为重度AS是否会导致随访期间的死亡率。AS进展对死亡率的影响需要在未来的研究中进一步明确。
{"title":"Is diastolic dysfunction a red flag sign in moderate aortic stenosis?","authors":"K. Kusunose","doi":"10.1136/heartjnl-2022-321137","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321137","url":null,"abstract":"With rapidly ageing population, aortic stenosis (AS) has become one of the most common valvular heart diseases. Severe AS is clearly associated with increased mortality, and the current American College of Cardiology/American Heart Association guidelines designate a class I or IIa indication for aortic valve surgery in severe patients with AS with symptoms or with low left ventricular (LV) function. Historically, based on the lower risk of sudden death in moderate AS compared with severe AS, watchful observation was recommended to patients with moderate AS. In the last decade, prognostic findings on moderate AS have been gathered (table 1). A large echocardiographic national database study, including 3315 moderate AS with various LV systolic functions, suggested a poor survival rate (5year mortality: 56%). Recently, two academic institutional databases, including 1245 moderate AS, also showed poor prognosis during followup (median followup: 4.3 years; mortality: 45.3%). From a physiological viewpoint, narrowing of the aortic valve area leads to LV systolic/diastolic dysfunction due to LV pressure overloading. In patients with severe AS who particularly underwent transcatheter aortic valve replacement (TAVR), diastolic dysfunction (DD) has been described as an early marker of myocardial damage and an important prognostic information. Thaden et al reported an association between echocardiographic data and outcomes from a retrospective singlecentre study. Over a mean followup period of 7.3 years, increased left atrial pressure based on the American Society of Echocardiography/ European Association of Cardiovascular Imaging criteria remained an independent predictor of mortality after successful aortic valve replacement (AVR) (HR: 1.45; 95% CI 1.16 to 1.81). More recently, Ong et al clearly showed an association between DD grading at baseline and combined cardiovascular death/rehospitalisation at 1 year from the Placement of Aortic Transcatheter Valves (PARTNER) 2 and SAPIEN 3 registry analysed by core laboratories (n=1253). These previous studies described a consistent message of an increased risk of event with worsening grade and stage of DD in severe AS. What about the association of moderate AS with DD? In their Heart article, Stassen et al presented data from a large registry of patients with moderate AS and preserved LV systolic function from three academic institutions between October 2001 and December 2019. Moderate AS was defined as an aortic valve area of between 1.0 cm and 1.5 cm. Finally, 1247 patients with moderate AS were retrospectively included and divided into three groups (normal diastolic function, indeterminate diastolic function and DD) based on the guidelines. The aims of the study were (1) to evaluate the prevalence of DD and (2) to examine the prognostic implications of DD in moderate AS with preserved LV systolic function. The primary outcome was allcause mortality. The secondary outcome was a composite of allcause mortality ","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1340 - 1341"},"PeriodicalIF":0.0,"publicationDate":"2022-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48473981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-10DOI: 10.1136/heartjnl-2022-320886
J. Stassen, S. Ewe, S. Butcher, MR Ammanullah, K. Hirasawa, G. Singh, Z. Ding, SM Pio, N. Chew, C. Sia, W. Kong, K. Poh, N. Marsan, V. Delgado, Jeroen J. Bax
Objective To investigate the prognostic impact of left ventricular (LV) diastolic dysfunction in patients with moderate aortic stenosis (AS) and preserved LV systolic function. Methods Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) and preserved LV systolic function (LV ejection fraction ≥50%) were identified. LV diastolic function was evaluated using echocardiographic criteria according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). Results Of 1247 patients (age 74±10 years, 47% men), 535 (43%) had LV diastolic dysfunction at baseline. Patients with LV diastolic dysfunction showed significantly higher mortality rates at 1-year, 3-year and 5-year follow-up (13%, 30% and 41%, respectively) when compared with patients with normal LV diastolic function (6%, 17% and 29%, respectively) (p<0.001). On multivariable analysis, LV diastolic dysfunction was independently associated with all-cause mortality (HR 1.368; 95% CI 1.085 to 1.725; p=0.008) and the composite endpoint of all-cause mortality and AVR (HR 1.241; 95% CI 1.035 to 1.488; p=0.020). Conclusions LV diastolic dysfunction is independently associated with all-cause mortality and the composite endpoint of all-cause mortality and AVR in patients with moderate AS and preserved LV systolic function. Assessment of LV diastolic function therefore contributes significantly to the risk stratification of patients with moderate AS. Future clinical trials are needed to investigate whether patients with moderate AS and LV diastolic dysfunction may benefit from earlier valve intervention.
{"title":"Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis","authors":"J. Stassen, S. Ewe, S. Butcher, MR Ammanullah, K. Hirasawa, G. Singh, Z. Ding, SM Pio, N. Chew, C. Sia, W. Kong, K. Poh, N. Marsan, V. Delgado, Jeroen J. Bax","doi":"10.1136/heartjnl-2022-320886","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-320886","url":null,"abstract":"Objective To investigate the prognostic impact of left ventricular (LV) diastolic dysfunction in patients with moderate aortic stenosis (AS) and preserved LV systolic function. Methods Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) and preserved LV systolic function (LV ejection fraction ≥50%) were identified. LV diastolic function was evaluated using echocardiographic criteria according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). Results Of 1247 patients (age 74±10 years, 47% men), 535 (43%) had LV diastolic dysfunction at baseline. Patients with LV diastolic dysfunction showed significantly higher mortality rates at 1-year, 3-year and 5-year follow-up (13%, 30% and 41%, respectively) when compared with patients with normal LV diastolic function (6%, 17% and 29%, respectively) (p<0.001). On multivariable analysis, LV diastolic dysfunction was independently associated with all-cause mortality (HR 1.368; 95% CI 1.085 to 1.725; p=0.008) and the composite endpoint of all-cause mortality and AVR (HR 1.241; 95% CI 1.035 to 1.488; p=0.020). Conclusions LV diastolic dysfunction is independently associated with all-cause mortality and the composite endpoint of all-cause mortality and AVR in patients with moderate AS and preserved LV systolic function. Assessment of LV diastolic function therefore contributes significantly to the risk stratification of patients with moderate AS. Future clinical trials are needed to investigate whether patients with moderate AS and LV diastolic dysfunction may benefit from earlier valve intervention.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1401 - 1407"},"PeriodicalIF":0.0,"publicationDate":"2022-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44451136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-08DOI: 10.1136/heartjnl-2022-321212
Chaowu Yan, L. Wan, Hua Li, Cheng Wang, Tingting Guo, Hanxu Niu, Shiguo Li, Pingcuo Yundan, Lei Wang, Wei Fang
Objective Preclinical research suggests that the combined use of radiofrequency ablation and balloon dilation (CURB) could create stable interatrial communications without device implantation. This study examined the first in-human use of CURB for modified atrial septostomy in patients with severe pulmonary arterial hypertension (PAH). Methods Between July 2018 and October 2021, CURB was performed in 19 patients with severe PAH (age: 31.5±9.1 years; mean pulmonary artery pressure: 73 mm Hg (IQR: 66–92); pulmonary vascular resistance: 18.7 Wood units (IQR: 17.8–23.3)). Under guidance of intracardiac echocardiography and three-dimensional location system, (1) fossae ovalis was reconstructed and ablated point-by-point with radiofrequency; (2) then graded balloon dilation was performed after transseptal puncture and the optimal size was determined according to the level of arterial oxygen saturation (SatO2); (3) radiofrequency ablation was repeated around the rims of the created fenestration. The interatrial fenestrations were followed-up serially. Results After CURB, the immediate fenestration size was 4.4 mm (IQR: 4.1–5.1) with intracardiac echocardiography, systolic aortic pressure increased by 10.2±6.9 mm Hg, cardiac index increased by 0.7±0.3 L/min/m2 and room-air resting SatO2 decreased by 6.2±1.9% (p<0.001). One patient experienced increased pericardiac effusion postoperatively; the others had no complications. On follow-up (median: 15.5 months), all interatrial communications were patent with stable size (intraclass correlation coefficient=0.96, 95%CI:0.89 to 0.99). The WHO functional class increased by 1 (IQR: 1–2) (p<0.001) with improvement of exercise capacity (+159.5 m, P<0.001). Conclusion The interatrial communications created with CURB in patients with severe PAH were stable and the mid-term outcomes were satisfactory. Trial registration number NCT03554330.
目的临床前研究表明，射频消融术和球囊扩张术（CURB）的联合使用可以在不植入设备的情况下建立稳定的室间通信。本研究首次在严重肺动脉高压（PAH）患者中使用CURB进行改良心房间隔造口术。方法在2018年7月至2021年10月期间，对19名严重PAH患者（年龄：31.5±9.1岁；平均肺动脉压：73 mm Hg（IQR:66-92）；肺血管阻力18.7 Wood单位（IQR:17.8~23.3）。在心内超声心动图和三维定位系统的指导下，（1）用射频逐点重建和消融卵窝；（2） 然后在经中隔穿刺后进行分级球囊扩张，并根据动脉血氧饱和度（SatO2）水平确定最佳尺寸；（3） 射频消融术在开窗边缘重复进行。对术后开窗术进行了连续随访。结果CURB术后，心内超声心动图显示即刻开窗尺寸为4.4mm（IQR:4.1-5.1），主动脉收缩压增加10.2±6.9 mm Hg，心脏指数增加0.7±0.3 L/min/m2，室内静息血氧饱和度下降6.2±1.9%（p<0.001）；其他人没有并发症。在随访中（中位数：15.5个月），所有的试验间交流都是稳定的（组内相关系数=0.96，95%CI:0.89~0.99）。世界卫生组织功能组增加1（IQR:1-2）（p＜0.001），运动能力提高（+159.5 m，p＜0.001）。试验注册号NCT03554330。
{"title":"First in-human modified atrial septostomy combining radiofrequency ablation and balloon dilation","authors":"Chaowu Yan, L. Wan, Hua Li, Cheng Wang, Tingting Guo, Hanxu Niu, Shiguo Li, Pingcuo Yundan, Lei Wang, Wei Fang","doi":"10.1136/heartjnl-2022-321212","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321212","url":null,"abstract":"Objective Preclinical research suggests that the combined use of radiofrequency ablation and balloon dilation (CURB) could create stable interatrial communications without device implantation. This study examined the first in-human use of CURB for modified atrial septostomy in patients with severe pulmonary arterial hypertension (PAH). Methods Between July 2018 and October 2021, CURB was performed in 19 patients with severe PAH (age: 31.5±9.1 years; mean pulmonary artery pressure: 73 mm Hg (IQR: 66–92); pulmonary vascular resistance: 18.7 Wood units (IQR: 17.8–23.3)). Under guidance of intracardiac echocardiography and three-dimensional location system, (1) fossae ovalis was reconstructed and ablated point-by-point with radiofrequency; (2) then graded balloon dilation was performed after transseptal puncture and the optimal size was determined according to the level of arterial oxygen saturation (SatO2); (3) radiofrequency ablation was repeated around the rims of the created fenestration. The interatrial fenestrations were followed-up serially. Results After CURB, the immediate fenestration size was 4.4 mm (IQR: 4.1–5.1) with intracardiac echocardiography, systolic aortic pressure increased by 10.2±6.9 mm Hg, cardiac index increased by 0.7±0.3 L/min/m2 and room-air resting SatO2 decreased by 6.2±1.9% (p<0.001). One patient experienced increased pericardiac effusion postoperatively; the others had no complications. On follow-up (median: 15.5 months), all interatrial communications were patent with stable size (intraclass correlation coefficient=0.96, 95%CI:0.89 to 0.99). The WHO functional class increased by 1 (IQR: 1–2) (p<0.001) with improvement of exercise capacity (+159.5 m, P<0.001). Conclusion The interatrial communications created with CURB in patients with severe PAH were stable and the mid-term outcomes were satisfactory. Trial registration number NCT03554330.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1690 - 1698"},"PeriodicalIF":0.0,"publicationDate":"2022-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48303908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-08DOI: 10.1136/heartjnl-2022-321135
Abdallah Al-Mohammad
{"title":"Risk of recurrent infective endocarditis: what do we learn from the Euro-ENDO study?","authors":"Abdallah Al-Mohammad","doi":"10.1136/heartjnl-2022-321135","DOIUrl":"10.1136/heartjnl-2022-321135","url":null,"abstract":"","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43028044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-06-08DOI: 10.1136/heartjnl-2022-321429
C. Otto
Sudden cardiac death (SCD) is a major cause of death worldwide, with a higher prevalence in men compared with women. To further understand sex differences in SCD presentation and outcomes, Skjelbred and colleagues looked at data on deaths in Denmark in 2010 and found that SCD accounted for 12.7% of all deaths with a male predominant (56% men, 44% women). The average age at SCD was higher in women (79 years) compared with men (71 years), with the greatest sex difference in SCD incidence rates in the age group from 35 to 50 years (incidence rate ratio 3.7, 95% CI 2.8 to 4.8) (figure 1). Women, compared with men, more often died at home (80.5% vs 69.7%, p<0.01) rather than in the hospital (16.8% vs 22.2%, p<0.01). The cause of SCD was coronary artery disease in about 40% of cases. Other causes (each <5%) included cardiac arrhythmias, heart failure, aortic dissection, valve disease and cardiomyopathy. In the accompanying editorial, Tan and Remme suggest that SCD risk relates not only to biological sex differences but also to societal and environmental factors. In men, the cause of SCD usually is coronary artery disease and the initial rhythm typically is ventricular fibrillation. In contrast, the cause of SCD in women more often is ventricular hypertrophy, aortic dissection or myocarditis and the initial rhythm is likely to be pulseless electrical activity or asystole. Women also are more likely to have an unwitnessed event at home, thus, not receiving prompt resuscitation. Even when witnessed, women are less likely to be resuscitated by bystanders; the combination of a longer delay to resuscitation plus the low frequency of a shockable rhythm results in lower survival rates. The authors urge increased research and action to reduce the risk of SCD in both women and men. ‘Clearly, to reduce the societal burden of SCD, we must focus our efforts on earlier recognition of SCA risk. Given the complex underlying causes of SCA and in view of the observation that our ability at early recognition has been stagnant over the last decades, we must adopt a more comprehensive strategy and reap the benefit of relatively new methods which have so far been poorly used in SCA research, for example, artificial intelligencebased analysis of large data sets, genetic analysis and metabolomic analysis. We must also recognise that we should direct our view to the group in society that has so far received insufficient attention in SCA research, that is, individuals who are in the care of their general practitioner and have not (yet) been referred to a cardiologist.’ (figure 2). Another study in this issue of Heart addresses sex (biological) and gender (sociocultural) differences in cardiovascular disease (CVD) risk factors. Based
心脏性猝死(SCD)是世界范围内的一个主要死亡原因，男性的患病率高于女性。为了进一步了解SCD表现和结果的性别差异，Skjelbred及其同事查看了2010年丹麦的死亡数据，发现SCD占所有死亡人数的12.7%，其中男性占56%，女性占44%。女性患SCD的平均年龄(79岁)高于男性(71岁)，在35岁至50岁年龄组中，SCD发病率的性别差异最大(发病率比3.7,95% CI 2.8至4.8)(图1)。与男性相比，女性更常死于家中(80.5%对69.7%，p<0.01)而不是医院(16.8%对22.2%，p<0.01)。约40%的SCD的病因是冠状动脉疾病。其他原因(均<5%)包括心律失常、心力衰竭、主动脉夹层、瓣膜疾病和心肌病。在随后的社论中，Tan和Remme认为SCD风险不仅与生理性别差异有关，还与社会和环境因素有关。在男性中，SCD的病因通常是冠状动脉疾病，最初的心律通常是心室颤动。相反，女性SCD的病因通常是心室肥大、主动脉夹层或心肌炎，最初的节律可能是无脉性电活动或心脏骤停。女性也更有可能在家中发生无人目击的事件，因此没有得到及时的复苏。即使有目击者在场，妇女也不太可能被旁观者救活;较长的复苏延迟加上较低频率的震荡心律导致较低的存活率。作者敦促增加研究和行动，以降低女性和男性患SCD的风险。“显然，为了减轻SCD的社会负担，我们必须集中精力及早发现SCA风险。”考虑到SCA的复杂潜在原因，并考虑到我们的早期识别能力在过去几十年里一直停滞不前，我们必须采取更全面的策略，并从迄今为止在SCA研究中使用较少的相对较新的方法中获益，例如，基于人工智能的大型数据集分析、遗传分析和代谢组学分析。我们还必须认识到，我们应该把我们的观点指向社会上迄今为止在SCA研究中没有得到足够关注的群体，也就是说，那些由全科医生照顾的个人，还没有被转介给心脏病专家。(图2)本期《心脏》杂志的另一项研究探讨了心血管疾病(CVD)危险因素中的性别(生物学)和性别(社会文化)差异。基于
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