European heart journal open最新文献

Aims: To assess for the first time the impact of socio-demographic variables on prescription of guideline-directed medical therapy (GDMT) after an episode of heart failure (HF) decompensation in the Italian healthcare system.

Methods and results: Utilizing 'GENERATOR-HF DataMart', a cross-sectional analysis was performed. We included patients with HF and reduced ejection fraction discharged between January 2019 and July 2024. The degree of GDMT implementation across the different socio-demographic variables (i.e. patient's age, sex, marital status, nationality, place of residence, and educational level) was evaluated through the modified optimal medical therapy (mOMT) score (i.e. a ratio between the number of pillars actually prescribed and the number of pillars that could be prescribed on the basis of each specific contraindication). A multivariable logistic regression model was also fitted to assess the association between the socio-demographic variables and the prescription of each pillar and loop diuretics. 1730 patients (median age: 72 years; 24% females) were included. The mOMT score was significantly lower in elderly patients, but comparable across other pre-specified socio-demographic categories. In multivariable regression analysis, older age was the only independent socio-demographic predictor of under-prescription both overall and for ACEi/ARB/ARNI (OR0.70; 95% CI 0.55-0.89), beta-blockers (OR0.59; 95% CI 0.41-0.84) and SGLT2i (OR0.66, 95% CI 0.47-0.93), while also associated with a loop diuretics use (OR1.56; 95% CI 1.13-2.17). A higher mOMT score was significantly associated with a reduced incidence of early adverse events (i.e. 30-day all-cause death and urgent re-admissions) (4.1% vs. 8.5%; P = 0.001).

Conclusion: Older age was the only independent predictor of under-prescription of GDMT and enhanced use of loop diuretics, whereas no discrepancies were found across the other socio-demographic subgroups.

Aims: Transthyretin cardiac amyloidosis (ATTR-CA) is an important cause of heart failure (HF). Several therapies demonstrated an efficacy in reducing hard and surrogate endpoints. We compared the relative efficacy of therapies evaluated in completed phase III trials.

Methods and results: We conducted a network meta-analysis using data from ATTR-ACT, ATTRIBUTE-CM, APOLLO-B, and HELIOS-B. The primary endpoint was a composite of all-cause mortality and cardiovascular hospitalizations. Secondary endpoints were changes in the 6-minute walk distance (6MWD) and Kansas City Cardiomyopathy Questionnaire-Overall Summary (KCCQ-OS) scores. For the primary endpoint, tafamidis and vutrisiran demonstrated a significant survival benefit over placebo; acoramidis approached significance. In indirect comparisons, there was no clear evidence of a larger absolute risk reduction for any drug. Tafamidis was associated with the lowest risk for the primary endpoint (surface under the cumulative ranking, SUCRA 82%), followed by vutrisiran monotherapy (70%). Regarding changes in 6MWD, tafamidis and acoramidis had the highest SUCRA curve values (97% and 69%, respectively). For KCCQ-OS changes, tafamidis also had the highest SUCRA (87%), followed by acoramidis (79%) and vutrisiran monotherapy (67%). When the ATTR-ACT trial was excluded from the analysis, vutrisiran monotherapy consistently showed the highest probability of being ranked better than other treatments in terms of primary end-point.

Conclusion: Although differences in trial design and study populations complicate direct efficacy comparisons, tafamidis demonstrated the highest efficacy in improving survival, reducing cardiovascular hospitalizations, and enhancing functional capacity and quality of life in patients with ATTR-CA, but also vutrisiran and acoramidis emerged as viable options.

Aims: Oesophageal fistulas (OF) and injuries (OI) are rare, but life-threatening complications following catheter ablation for atrial fibrillation (AF). Data about their incidence, management, and outcome are scarce. This study investigates the clinical characteristics and outcomes of OF and OI following AF ablation.

Methods and results: All OF and OI reported between August 2009 and August 2019 in the Manufacturer and User Facility Device Experience (MAUDE) database of the Food and Drug Administration were analysed. A total of 1274 device adverse events following AF/atrial flutter (AFL) ablation were reported in the MAUDE database. Of them, 60 (4.7%) represented patients with OF or OI. A total of 47 patients exhibited OF, while 13 OI without perforation. A total of 35 (58.3%) patients underwent radiofrequency (RF)-based ablation, 20 (33.3%) cryoballoon (CB)-based PVI, and 5 (8.3%) a laser-based PVI. The mortality was 63.3%, but significantly higher in the OF group as compared to the OI group (76.6% vs. 15.4%; P < 0.001). When analysing only the patients exhibiting OF, the mortality was 71.0% among the RF patients, 86.7% among the CB patients, and 100% among those receiving laser ablations (P = 0.427). Among patients exhibiting OF only, the mortality was 80% for those treated surgically, 80% for those treated exclusively endoscopically, and 100% for those treated conservatively.

Conclusion: Almost one-third of the patients developing OF underwent CB-based ablation. More than three-fourths of the patients died, without significant difference between the ablation energy used. All patients with OF treated conservatively died. OF may occur despite oesophageal temperature monitoring.

Aims: The IVUS-ACS trial demonstrated that intravascular ultrasound (IVUS) guidance reduces target-vessel failure (TVF) in patients with acute coronary syndromes (ACSs) undergoing percutaneous coronary intervention (PCI). Whether this benefit applies to all ACS patients across the spectrum of risk is unknown. We sought to develop a new risk score for 1-year TVF after PCI in ACS and determine whether IVUS guidance compared with angiography guidance improves outcomes in both high- and low-risk patients.

Methods and results: From the angiography-guided group of the IVUS-ACS trial (n = 1743), the TVF-ACS risk score was developed using the least absolute shrinkage and selection operator method in a derivation group (n = 1288), and its robustness was assessed in an internal validation group (n = 455). External validation was then performed separately in the IVUS-XPL and ULTIMATE trials. Outcomes in high- and low-risk patients randomized to IVUS guidance vs. angiography guidance were then examined. Ten readily available clinical, laboratory, and angiographic variables were selected for inclusion in the TVF-ACS risk score. A cut-off value of 15.64 discriminated angiography-guided PCI patients at high-risk vs. low risk [area under the curve (AUC) 0.715, 95% confidence interval (CI) 0.653-0.777]. The AUC was similar in the validation group [0.709 (95% CI 0.630-0.788)]. High-risk patients exhibited a higher 1-year rate of TVF compared with low-risk patients [19.8 vs. 5.7%, hazard ratio (HR) 3.81, 95% CI 2.06-7.02, P = 0.00002]. Among 3486 randomized patients, IVUS guidance compared with angiography guidance reduced 1-year TVF in high-risk patients (6.9 vs. 17.6%; HR 0.38, 95% CI 0.24-0.59) with a lesser effect in low-risk patients (3.2 vs. 4.3%; HR 0.75, 95% CI 0.51-1.11; P _interaction = 0.02). External validation in the IVUS-XPL and ULTIMATE trials confirmed these benefits but with consistent effects in high- and low-risk patients (P _interactions = 0.49 and 0.92, respectively).

Conclusion: The TVF-ACS risk score reliably stratifies ACS patients undergoing PCI into high- and low-risk groups. The benefits of IVUS guidance during PCI are most pronounced in high-risk ACS patients, although all ACS patients are likely to benefit.

Aims: Older patients with AF (≥65 years) have on average four additional comorbidities. Comorbidity management requires a systematic approach for identification, and interdisciplinary care, often lacking in clinical practice. The EHRA-PATHS project's overall aim is to create an approach to systematically address multimorbidity in older patients with AF.

Methods and results: This project involves a consortium of 14 partners from 11 European countries. The comorbidity care pathways were developed using a stepwise approach. (i) A literature study. (ii) Online meetings/discussions to create structured care pathways. (iii) A two-round Delphi study for consensus on the final pathways (agreement ≥80%) and to rank the comorbidities for priority. (iv) Selection of comorbidities for evaluation in the planned randomized controlled trial (RCT). Development of care pathways for 23 comorbidities or special clinical settings was obtained and agreed upon. The Delphi surveys were sent to 37 consortium experts. After round 1 (28 responses), 13 pathways reached an agreement ≥80%. Twelve adjusted pathways were presented in round 2 (27 responses), of which 8 received an agreement ≥80%. The last four pathways were finalized after expert consensus. Hypertension, heart failure, and overweight were ranked as the most important comorbidities.

Conclusion: A structured process of expert meetings and two Delphi rounds led to the development and ranking of 23 concise care pathways to identify and manage comorbidities in patients with AF. All pathways will be combined into a software tool, providing clinicians with a systematic approach to comorbidity management, which will be tested in the RCT of EHRA-PATHS.

Aims: To compare outcomes of patients with severe mitral regurgitation (MR) after m-TEER and surgery.

Methods and results: PubMed, Scopus, and Google Scholar databases were searched for randomized controlled trials and propensity score matching studies comparing mid-term outcomes of m-TEER vs. surgical valve repair. All-cause of death, rehospitalization for heart failure, mitral reintervention, NYHA class at clinical follow-up and grade ≥ 3 at echocardiographic follow-up were the outcomes of interest. Additional sensitivity analyses were performed to account for heterogeneity. Nine studies (2 RCT and 7 propensity score matching studies) with a total of 23 825 patients (m-TEER group = 11 970; surgery group = 11 855) were included. Surgery and m-TEER were associated with comparable rates of all-cause mortality at a median follow-up of 18 months (RR 1.02, 95%CI 0.77-1.37, P-value 0.87). Surgical repair was associated with a reduced risk of rehospitalization for heart failure (RR 1.70, 95%CI 1.47-1.98, P value < 0.01) and mitral reintervention (RR 3.27, 95%CI 2.49-4.30, P value < 0.01), due to a reduced at least moderate residual MR (RR 6.35, 95%CI 1.43-28.22, P value 0.02).

Conclusion: In patients with severe MR, m-TEER resulted in comparable outcomes for all-cause deaths compared to surgery, although the latter was associated with reductions in heart failure rehospitalization, reintervention and MR residual rates at a median 18-month follow-up.

Aims: Individuals with a previous stroke face an increased risk of Non-ST-segment myocardial infarction (NSTEMI) and may have a higher associated mortality. However, the impact of inpatient care quality during the NSTEMI admission on long-term outcomes remains unclear. To assess whether there were disparities in care and NSTEMI clinical outcomes between individuals with and without a previous stroke.

Methods and results: We analysed 425 274 adults hospitalized between January 2005 and March 2019, with NSTEMI from the UK Myocardial Ischaemia National Audit Project (MINAP) registry, linked with Office for National Statistics mortality reporting. We examined long-term outcomes by previous stroke status and inpatient care quality for patients that survived to discharge using the opportunity-based quality-indicator score (OBQI) score, categorized as 'poor', 'fair', 'good' or 'excellent'. Individuals with previous stroke were older (median age 79 vs. 72 years) and underwent revascularization by PCI (22% vs. 37%) less frequently than those without a previous stroke. The adjusted mortality risk for those with a previous stroke was higher at 30 days (aHR 1.14, 95% CI 1.10, 1.18), 1 year (aHR 1.20, 95% CI 1.17, 1.22) and 10 years (aHR 1.27, 95% CI 1.26 1.29) with higher quality inpatient care associated with lower mortality rates compared with poor care (good: HR 0.86, 95% CI 0.80, 0.92; excellent: HR 0.76, 95% CI 0.71, 0.81).

Conclusion: Individuals with a previous stroke, experience disparities during inpatient care following NSTEMI and have a higher risk of long-term mortality. Higher quality inpatient care may lead to better long-term survival.

Introduction: There is a growing population with cardiac devices (pacemakers, implantable cardioverter defibrillators and cardiac resynchronization therapy), but whether this influences quality of care and long-term mortality after ST-elevation myocardial infarction (STEMI) is unknown.

Methods and results: Patients in England and Wales between January 2005 and March 2019 with a diagnosis of STEMI were included from the Myocardial Ischaemia National Audit Project, Hospital Episode Statistics and mortality linkage to July 2021. Primary outcomes were all-cause mortality over the study period, secondary outcomes were odds of undergoing reperfusion within guideline mandated timeframes. Multivariate cox-models compared all-cause mortality over specified time-periods and logistic regression models illustrated odds of undergoing reperfusion. 322 890 patients with STEMI were included, 2118 (0.7%) had a cardiac device at STEMI admission. Patients with cardiac devices were older (78 years old vs. 66 years old) and more often female (32% vs. 29%) (P < 0.001). After multivariate adjustment, patients with cardiac devices were less likely to have a 'door-to-balloon time' of under 60 min (aOR 0.61 95% CI 0.54-0.70) (P < 0.001). Patients with cardiac devices had an increased risk of all-cause mortality at 5-years (aHR 1.12 95% CI 1.05-1.20) (P < 0.001). Excluding patients dying within 30 days of admission, patients with cardiac devices still had a higher risk of death at 5-years (aHR 1.23 95% CI 1.13-1.33) (all P < 0.001).

Conclusion: Patients with cardiac devices were less likely to undergo revascularization for STEMI within guideline mandated timeframes. They remain at elevated risk of all-cause mortality up to 5-years compared with STEMI patients without cardiac devices.

Aims: The number of patients undergoing catheter ablation is continuously growing, and techniques are improving. However, studies reporting contemporary data on catheter ablations from large real-world populations are scarce. This study aims to report characteristics and outcomes of catheter ablation from 2006 to 2020, using a nationwide registry with virtually complete coverage.

Methods and results: From the Swedish Catheter Ablation Registry, patients >18 years of age undergoing catheter ablation from 2006 to 2020 were included. Periprocedural data and baseline characteristics were recorded retrospectively. A total of 61 243 procedures were included. There was an overall increase in the number of catheter ablations performed. From 2006, the number of atrial fibrillation (AF) ablations performed increased from 352 procedures in 2006 to 2609 procedures in 2020. Decreased procedural times were seen in catheter ablation of accessory pathway/Wolff-Parkinson-White syndrome, atrial tachycardia (AT), atrioventricular nodal reentry tachycardia, cavotricuspid isthmus (CTI), AF, and atrioventricular junction. Between the time periods 2006-15 and 2016-20, median procedural time in AF ablations decreased from 180 to 140 min (P < 0.001). There was a decreased trend in fluoroscopy time and median dose area product for all ablation procedures (P < 0.001). For AT, CTI, and AF, the cumulative probability of requiring a repeat ablation was significantly lower for procedures performed after January 2016 (P < 0.001).

Conclusion: With a yearly increase in the number of ablations performed, there was a reduction in the need for repeat ablations for AF, AT, and CTI, along with reduced procedural times and lower fluoroscopy levels.