European heart journal open最新文献

Aims: Left ventricular (LV) thrombus carries a high risk of death and systemic embolism. While warfarin has been the standard treatment, evidence comparing direct oral anticoagulants (DOACs) with warfarin in this setting remains limited. This study aimed to compare real-world, risk-adjusted outcomes of DOAC vs. warfarin use in patients with LV thrombus.

Methods and results: We conducted a retrospective cohort analysis using the TriNetX research network database. Adults (≥18 years) with echocardiographically confirmed LV thrombus from 2016 to 2022 were included. Patients with atrial fibrillation/flutter, venous thromboembolism, end-stage renal disease, mechanical/bioprosthetic valves, or therapy switch during follow-up were excluded. Propensity score matching (1:1) was used to balance covariates. The primary outcome was a composite of all-cause mortality and stroke/transient ischaemic attack at 30 days and 1 year. Secondary outcomes included major bleeding and LV thrombus resolution. Of 2488 eligible patients (DOAC: 950; warfarin: 1538), 945 matched pairs were analysed with all baseline covariates balanced. In the DOAC group, 74% received apixaban and 26% rivaroxaban. At 30 days and 1 year, the composite outcome did not differ significantly between DOAC and warfarin [13.3% vs. 15%; matched hazard ratio (HR): 0.90, P = 0.41, and 23.8% vs. 26.7%; matched HR: 0.93, P = 0.46, respectively]. Major bleeding rates were similar at 30 days and 1 year (1.18% vs. 1.54%; matched HR: 0.77, P = 0.54, and 4.8% vs. 4.7%; matched HR: 1.13, P = 0.58, respectively). Thrombus resolution at 6 months occurred in ∼81% of patients with follow-up imaging, with no difference by treatment group.

Conclusion: In a large propensity-matched cohort, DOACs and warfarin demonstrated comparable effectiveness and safety for LV thrombus management, supporting DOACs as a reasonable alternative.

Aims: Vasorelaxant and anti-inflammatory properties of glucagon-like peptide-1 (GLP-1) agonists support their investigation in aiding the recovery of patients with acute pulmonary embolism (PE) at risk of worse outcomes.

Methods: We undertook a four week non-randomized, controlled open-label study examining proteomic changes, markers of vascular inflammation and exploratory imaging endpoints in response to GLP-1 agonist, semaglutide (0.25 mg weekly) added to standard of care anticoagulation in patients with intermediate high-risk PE.

Results: 44 plasma proteins were downregulated in response to semaglutide that were significantly enriched for glycoproteins (false discovery rate q < 0.01). Glycopeptide analysis of highly abundant glycoproteins between diagnosis and follow-up demonstrated a reduction in glycopeptide abundance suggesting protein deglycosylation as a possible mechanism of glycoprotein down-regulation. Down-regulated proteins included regulators of metabolic stress and complement pathway intermediates, which were at higher abundance in PE patients at diagnosis compared to age and sex-matched controls without PE (all P < 0.001). Exploratory evaluation of radiological markers of right ventricular dysfunction improved from baseline to follow-up only in patients who received semaglutide (P < 0.01).

Conclusions: These findings suggest merit in wider investigation of immunometabolic changes in the plasma proteome during acute PE recovery and their potential relevance to modulation using GLP-1 agonists.

Registration: The study was registered under clinicaltrials.org (NCT06118203).

Aims: The prevalence of adults with congenital heart disease (ACHD) is rising due to improved paediatric care. In parallel, updated data on prognosis in adult life are needed.

Objectives: The aim was to calculate the standardized mortality ratio (SMR) and death rates in ACHD compared to the general population.

Methods and results: Data were obtained from the national register of congenital heart disease. The general Swedish population served as a reference. SMR was calculated as the ratio between observed and expected deaths. 9089 patients (median age 28 years, interquartile range [IQR] 20-45, 47% females) were followed for a median of 8 years (IQR 4-14). 525 deaths occurred during observation. The SMR increased by lesion complexity: atrial septal defect [1.3 (95% CI: 1.1-1.5)]; ventricular septal defect [2.0 (1.4-2.7)]; congenital aortic valve disease [2.2 (1.6-2,9)]; Ebstein's anomaly [3.2 (1.8-5.2)]; tetralogy of Fallot [3.8 (2.6-5.2)]; congenitally corrected transposition of the great arteries [5.6 (2.9-9.6)]; Eisenmenger syndrome [8.7 (5.5-13.1)]; transposition of the great arteries with a previous atrial redirection operation [12.3 (6.8-20.1)]; and Fontan physiology [22.5 (12.5-37.0)]. Calculations were also performed by severity (mild, moderate, and severe) and age by six age groups. SMR was generally higher in younger age, and the difference in mortality from the general population was estimated to be lower for older age groups. The mortality distribution and death rate per 1000 person-years have also been calculated for each lesion.

Conclusion: The mortality in ACHD remains increased compared to the general population and reflects the severity of the lesion. In higher ages, the observed mortality is more in line with the general population, probably because of survival of the least affected patients, and that few persons with severe lesions have reached advanced age.

Aims: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a recognized marker of myocardial wall stress, but its prognostic role in patients undergoing transcatheter aortic valve implantation (TAVI) remains incompletely defined. This study assessed whether NT-proBNP levels at admission and discharge - interpreted using age-specific guideline thresholds - are associated with long-term clinical outcomes post-TAVI.

Methods and results: We retrospectively analysed 683 consecutive patients who underwent successful TAVI at Magna Graecia University between 2009 and 2023. NT-proBNP was measured at both admission and discharge. Patients were stratified into low or high NT-proBNP groups based on age-adjusted cutoffs. Among 468 patients with paired measurements, four NT-proBNP trajectory groups were identified: Low-Low, Low-High, High-Low, and High-High. The primary endpoint was a composite of all-cause mortality or heart failure (HF) rehospitalization at 2 years. Multivariable Cox models were used to adjust for confounders. At admission, 41.6% of patients had elevated NT-proBNP, associated with worse echocardiographic parameters and more comorbidities. Elevated baseline NT-proBNP predicted a higher risk of the primary outcome (26.1% vs. 13.7%; HR 2.23; 95% CI, 1.51-3.28) and all-cause mortality (21.3% vs. 9.6%; HR 2.40; 95% CI, 1.52-3.79). Among patients with serial values, 34.6% had persistently elevated NT-proBNP, while only 10.7% improved. High-High and Low-High groups showed worse outcomes compared to Low-Low; High-Low patients had comparable risk to Low-Low.

Conclusion: NT-proBNP, interpreted with age-specific thresholds, is a strong independent predictor of adverse outcomes after TAVI. Serial assessment adds prognostic value and may help guide postprocedural management.

Aims: Little is known regarding strategies to improve influenza vaccination uptake among individuals with atrial fibrillation (AF). We assessed the effect of electronically delivered behavioural nudges on influenza vaccination uptake and clinical outcomes according to AF status.

Methods and results: This is a prespecified analysis of the nationwide randomized NUDGE-FLU-CHRONIC trial in which citizens aged 18-64 years with a chronic disease were randomized to usual care or six different electronic nudge letters aiming to increase influenza vaccination uptake during the 2023-2024 influenza season. The primary endpoint was receipt of an influenza vaccine on or before 1 January 2024. We reported absolute differences and relative risks (RRs) of each intervention letter vs. usual care on influenza vaccination uptake and assessed effect modification by AF status using binomial regression. Among 299 881 randomized participants, 19 481 (6.5%) had a history of AF (median age 58.5 years, 27.8% female). During follow-up, 41.5% of participants with a history of AF received influenza vaccination compared with 35.8% of those without (P < 0.001). In the overall population, influenza vaccination uptake was higher among those receiving any electronic nudge letter compared with usual care. AF status modified the absolute effect of any electronic letter on influenza vaccination uptake (P interaction < 0.001): the effect of any electronic letter was higher among those who had a history of AF [45.9 vs. 31.1%; difference: +14.8% points; 99.29% confidence interval (CI) (12.8-16.8), RR: 1.48, 99.29% CI (1.39-1.56)] compared with those without AF [39.1 vs. 27.7%; difference: +11.4% points; 99.29% CI (10.9-12.0), RR: 1.41, 99.29% CI (1.39-1.44)]. Similar results were observed for the individual electronic letter-based nudges.

Conclusion: In this prespecified, secondary analysis, electronic nudge letters highlighting the importance of influenza vaccination were especially effective in increasing influenza vaccination uptake among young and middle-aged adults with AF, supporting simple electronic letters as an efficient public health strategy to improve vaccination coverage in high-risk groups.

Aims: There is limited evidence regarding the association between chronic liver disease (CLD) and the risk of readmission in patients with heart failure (HF).

Methods and results: We utilized data from the 2019 Nationwide Readmissions Database (NRD). An index hospitalization was defined as a hospitalization for HF among patients aged ≥18 years with an alive discharge. We categorized patients into two groups, with and without CLD, and compared 30-day and 90-day all-cause and HF-specific readmission. Multiple logistic regression analyses were used to estimate the association between CLD and readmissions in HF patients, adjusting for demographic and clinical characteristics. We also evaluated the association between specific CLD subtypes [i.e. hepatitis B (HBV), hepatitis C (HCV), alcoholic liver disease (ALD), and metabolic dysfunction-associated steatotic liver disease (MASLD)] and the risk of readmission. The study included 2 370 469 index HF hospitalizations for the 30-day analysis and 2 090 370 for the 90-day analysis. CLD patients had higher 30-day all-cause [adjusted odds ratio (aOR) 1.20 (1.18-1.23)] and HF-specific [aOR 1.16 (1.14-1.19)] readmission rates compared with those without CLD. Similar findings were observed for 90-day all-cause [aOR 1.19 (1.17-1.21)] and HF-specific [aOR 1.13 (1.11-1.16)] readmissions. Results were consistent when comparing patients with and without HBV, HCV, and ALD, with no meaningful differences observed between those with and without MASLD.

Conclusion: Compared with HF patients without CLD, those with CLD had a higher risk of 30- and 90-day readmissions, underscoring the importance of accounting for CLD in the risk assessment and clinical decision-making for HF patients.

Aims: Associations of individual comorbidities with incident atrial fibrillation (AF) are well-studied. However, the impact of multimorbidity and potentially clustering of comorbidities on incident AF remains unclear. This study investigated the number and clustering of (non-)cardiovascular comorbidities with incident AF.

Methods and results: We studied 25 (non-)cardiovascular comorbidities in 76 648 participants from the Lifelines cohort. Logistic regression was used to study the association between the number of comorbidities and incident AF. Latent class analysis was used to identify comorbidity clusters. Mean age was 46.4 ± 2.6 years and 59.3% were women. In this population, 56 034 (73.1%) participants had ≥2 comorbidities, 42 575 (55.5%) ≥ 2 cardiovascular comorbidities, and 14 612 (19.1%) ≥ 2 non-cardiovascular comorbidities. After a mean follow-up of 3.70 ± 0.95 years, 188 (0.2%) participants developed incident AF. After adjusting for age and sex, the total number of comorbidities (OR 1.10 [1.01-1.19], P = 0.022) and number of cardiovascular comorbidities (OR 1.18 [1.06-1.31], P = 0.002) were associated with incident AF, but not the number of non-cardiovascular comorbidities. We identified 12 comorbidity clusters carrying different risks of incident AF (AF incidence rate range 0.00 to 0.58 per 100 person-years, P < 0.001) with the median number of comorbidities ranging from one to seven. However, the clusters did not demonstrate specific combinations of comorbidities.

Conclusion: There was a dose-dependent relationship between the number of total comorbidities and cardiovascular comorbidities and risk of incident AF, but not for non-cardiovascular comorbidities. We identified 12 comorbidity clusters with different risks of incident AF; however, these clusters were determined by the number of comorbidities rather than specific combinations.

Aims: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with structural heart disease is usually reserved for those with recurrent implantable cardioverter defibrillator (ICD) shocks or intolerant to anti-arrhythmic drugs. This meta-analysis synthesizes available trial evidence on CA for VT to clarify the role of this approach.

Methods and results: MEDLINE, PubMed, EMBASE and Cochrane were searched for randomized controlled trials (RCTs) of patients with structural heart disease allocated to receive either CA or standard treatment. Outcomes of interest were: all-cause and cardiovascular (CV) mortality, VT recurrence, incidence of appropriate ICD therapy, CV hospitalizations and VT storm. Evidence was appraised using the risk of bias tool and the grading of recommendations assessment, development and evaluation (GRADE) approach. Trial-level pairwise meta-analyses were conducted for all outcomes. Reconstructed time-to-event data meta-analysis was also performed for all-cause mortality 13 RCTs (n = 1735 patients) were included in the meta-analysis with a follow-up duration of 6-52 months. No significant reduction in all-cause mortality was observed at trial level meta-analysis (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.70-1.08, heterogeneity [I²] = 0%), or reconstructed individual patient data meta-analysis [hazard ratio (HR) 0.79, 95%CI 0.57-1.11 at 3 years]. However, our pooled estimates, observed effect size and GRADE assessments suggest a potential mortality reduction in the ablation group. Patients who underwent CA experienced a significant reduction in CV hospitalizations (RR 0.78, 95%CI 0.65-0.94, I² = 41%), VT storm (RR 0.78, 95%CI 0.63-0.97; I² = 5%), VT recurrence (RR 0.83, 95%CI 0.72-0.95, I² = 21%), and appropriate ICD therapy (RR 0.74, 95%CI 0.61-0.89, I² = 32.5%) compared to control groups.

Conclusion: A potential all-cause mortality reduction by catheter ablation requires further confirmation in a properly powered RCT. No reduction in cardiovascular mortality was found. VT recurrence, CV hospitalizations, VT storm and ICD therapy were all significantly reduced by catheter ablation in patients with structural heart disease.

Lay summary: We examined the effectiveness of catheter ablation (CA) for treating ventricular tachycardia (VT) in patients with structural heart disease, particularly those facing recurrent implantable cardioverter defibrillator shocks or unable to tolerate medications by analysing several randomized controlled trials. The findings suggest that while CA may not significantly reduce overall mortality, it can lead to fewer recurrences of VT and hospitalizations related to cardiovascular problems.

Aims: In patients with diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD), or without ASCVD (primary prevention), the prescribing of lipid lowering therapy (LLT) is an established treatment strategy endorsed by clinical guidelines. This study aimed to document (i) trends in presentation of DM, (ii) treatment, monitoring and achievement of target low-density lipoprotein cholesterol (LDL-C) in DM with ASCVD, and (iii) ASCVD risk assessment and lipid treatment according to risk in the DM primary prevention setting.

Methods and results: A retrospective observational population study including 282 581 DM patients using linked health-care data (2010-23) in Wales. The prevalence of DM (documented DM diagnosis in record prior to the beginning of the year) increased from 133 439 in 2010 to 183 948 in 2023 (6504 to 8200 per 100 000), along with increasing incidence (new diagnosis of DM documented in record during specific year) with 11 074 cases in 2010 (540 per 100 000 per year), increasing to 14 539 in 2023 (648 per 100 000 per year). The proportion of prevalent patients with established ASCVD prescribed LLT decreased from 87.5% to 81.8% (2010-23), testing of LDL-C decreased from 70.3% to 67.1%, and of those with documented lipids 41.0% achieved an LDL-C <1.8 mmol/L in 2010 increasing to 52.2% in 2023. Amongst DM without ASCVD, the proportion prescribed LLT decreased from 78.9% to 54.9% in those with chronic kidney disease (CKD) and from 70.7% to 55.6% in those without CKD. Considering DM without ASCVD or CKD (LLT is recommended according to 10-year CVD risk), only 44.2% of incident DM had a documented QRISK score in 2022 and of those with a 10-year risk >20%, only half were prescribed LLT.

Conclusion: Increasing incidence and prevalence of DM, together with decreasing quality of risk factor management has the potential to lead to poorer health outcomes in the population if not addressed more effectively.

Aims: Although age-related immune deterioration has been implicated as a mechanistic contributor to cardiovascular disease (CVD), evidence for an impairment of adaptive immune function in individuals with clinically verified presence of atherosclerosis is lacking.

Methods and results: To test the association between atherosclerosis and immune function, we evaluated SARS-CoV-2 vaccine responsiveness in 65- to 71-year-old individuals (n = 644) derived from a population-based cohort, characterized for subclinical atherosclerosis by coronary computed tomography angiography and carotid ultrasound. Vaccine-specific T cells were quantified by activation-induced marker assays and antibody responses by ELISA. We did not find any significant associations between the degree of subclinical atherosclerosis or history of cardiovascular disease and vaccine-specific IgG or T cells. Vaccine immunity was not associated with lipid levels but was inversely correlated with several plasma cytokines.

Conclusions: Our study demonstrates that subclinical atherosclerosis or prevalent CVD is not associated with impaired responsiveness to vaccination.