European heart journal open最新文献

Aims: Patients with pulmonary arterial hypertension (PAH) after congenital heart disease (CHD) correction (PAH-CHDcor) are becoming the most prevalent and rapidly expanding group within PAH associated with CHD (PAH-CHD), yet data on its presentation, long-term outcomes and prognostic variables are lacking. We report on a large paediatric and adult population with PAH-CHDcor, focusing on clinical presentation and long-term survival.

Methods and results: We studied 127 PAH-CHDcor patients (mean age 21.5 ± 10.5 years; 74.8% female) diagnosed via cardiac catheterization from 2006 to 2022. The majority had post-tricuspid shunts (73.2%), with combined pre- and post-tricuspid (11.8%) and complex shunts (6.3%) less frequent. Pulmonary vascular resistance (PVR) at diagnosis averaged 13.2 ± 8.9 WU. Diagnosis occurred late (>5 years post-repair) in 43.3% of patients. Median follow-up was 4.0 (IQR 2.0-6.4) years. Kaplan-Meier estimates for survival at 3 and 5 years were 93.3% and 89.6%, respectively. Higher baseline PVR predicted mortality (HR 1.10, 95% CI 1.03-1.16, P = 0.003) and was the strongest multivariable predictor of a composite endpoint (death, heart failure hospitalization, or parenteral prostacyclin initiation; HR 1.11, 95% CI 1.05-1.18, P < 0.001). An exploratory application of a paediatric prognostic score (GOSH) showed excellent discriminative power for mortality (AUC 0.867) and the composite endpoint (AUC 0.856) at 5 years in this independent cohort.

Conclusion: Mortality and morbidity are considerable in patients with PAH-CHDcor despite modern management. Regular, careful screening of all patients with repaired CHD is essential to ensure early diagnosis and risk stratification, with proactive evidence-based treatment to improve outcomes in this expanding population.

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.

Aims: Bioprosthetic valves are increasingly used for surgical aortic valve replacement (SAVR) in patients ≤ 70 years though the relative benefits compared to mechanical valve replacement remain uncertain. This study aims to compare mortality and other outcomes by prosthesis type for patients aged 50-70 years who received SAVR in a well-characterized Australian cohort.

Methods and results: Data were prospectively collected at the time of heart valve surgery and linked administrative outcome data. This analysis includes all patients aged 50-70 years who had SAVR in Western Australian public hospitals between 2010 and 2020. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular mortality, separately and combined with admission for either non-fatal myocardial infarction or for non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes, categorized by prosthesis type (mechanical or bioprosthetic), were compared using propensity matching. Within the initial cohort of 706 patients undergoing SAVR (mean age 62.5 years, SD 6), propensity score matching identified 149 patients each with mechanical or bioprosthetic valves. After adjustment, patients who received mechanical valves had lower all-cause mortality [adjusted hazard ratio (aHR) 0.51; 95% confidence interval (CI) 0.27-0.98; P = 0.04] and MACE (aHR 0.53; 95% CI 0.30-0.95; P = 0.03) during median follow-up of 3.6 years. Mechanical valves were associated with increased risk of major bleeding (aHR3.40; 95% CI 1.32-8.77; P = 0.01). There was no difference in risk of cardiovascular mortality, admissions for non-fatal MI, non-fatal stroke, or DAOH by prosthesis type.

Conclusion: Patients aged 50-70 years who underwent mechanical valve SAVR had lower risk of all-cause mortality and MACE compared with those who received a bioprosthesis, despite higher bleeding risk. Randomized comparisons are necessary to confirm these findings.

Electronic consultation (econsultation) has proven effective in optimizing communication between primary care and cardiology, reducing waiting times and unnecessary face-to-face referrals. This study assessed the impact of incorporating tele-echocardiography and event-based electrocardiographic monitoring (EEM) into an advanced e-consultation model. A prospective observational cohort of 1200 consecutive e-consultations was analysed; in 354 cases, the advanced pathway was activated, including 300 tele-echocardiograms and 54 EEM studies. Remote resolution increased from 38.0% in the traditional model to 54.3% in the advanced model (P < 0.01). Diagnostic agreement was high (κ=0.85 for tele-echo vs. standard echo; κ =0.75 for primary care vs. cardiologist interpretation), with only 6.7% non-interpretable studies and no major adverse events during a mean follow-up of 19 months. This structured implementation of tele-echocardiography and EEM suggests a feasible, scalable, and safe innovation aligned with digital transformation goals in cardiology.

Aims: The long-term cardiovascular (CV) risks after percutaneous coronary intervention (PCI) in cancer patients are unclear. We assessed the risks of adverse events after PCI related to active or inactive cancer and the duration of dual antiplatelet therapy (DAPT).

Methods and results: This is a retrospective cohort of all patients having PCI with second-generation drug-eluting stents in the national Veterans Affairs Healthcare System between 2008 and 2016. We compared patients with active cancer (cancer and chemotherapy/radiotherapy), inactive cancer (cancer without chemotherapy/radiotherapy), or no cancer using Cox proportional hazards regression models adjusted by the propensity for cancer. Models estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for myocardial infarction (MI), major bleeding, and death and the relationship to duration of DAPT after PCI. Of 40 677 patients, 791 (2%) had active cancer, 7633 (19%) had inactive cancer, and 32 253 (79%) had no cancer. Over a mean 5.4 (SD 2.8) years, the risks of MI and major bleeding were higher in patients with active cancer (MI: HR = 1.18, 95% CI = 1.00, 1.40; major bleed: HR = 1.73, 95% CI = 1.43, 2.10) and inactive cancer (MI: HR = 1.13 95% CI = 1.07, 1.20; major bleed: HR = 1.30, 95% CI = 1.21, 1.41). Discontinuing DAPT more than 9 months after PCI associated with lower risks of MI (active cancer: HR = 0.91, 95% CI = 0.70, 1.19; inactive cancer: HR = 0.78, 95% CI = 0.70, 0.88) and major bleeding (active cancer: HR = 0.68, 95% CI = 0.49, 0.97; inactive cancer: HR = 0.87, 95% CI = 0.76, 0.99).

Conclusion: Patients with cancer have higher risks of ischaemic and bleeding outcomes after PCI. However, we found no evidence that DAPT duration should differ from current guidelines in patients with cancer after PCI.