European heart journal open最新文献

Aims: Over recent decades, numerous measures have been implemented to improve treatment and timely intervention for ST-elevation myocardial infarction (STEMI). For deeper insights into the current state of care, this study investigates whether patient outcomes differ based on the timing of presentation (on-hours vs. off-hours) for primary percutaneous coronary intervention (PCI) for STEMI.

Methods and results: Data from STEMI PCIs performed from 2017 to October 2020, as registered within the Netherlands Heart Registration (NHR), were analysed. Off-hours presentation was defined as arrival at the catheterization laboratory (cath lab) on weekends, during working days between 17.00 and 08.00, or Monday between midnight and 08.00. Short-term outcomes included 30-day all-cause mortality and acute MI within 30 days. Long-term outcomes included all-cause mortality rates up till 5 years after PCI, target vessel revascularization within 1 year, and repeat revascularization with elective or non-STEMI PCI. The study included 19 090 STEMI patients from 17 centres, with 11 719 (61.4%) PCIs performed on-hours. No significant difference in 30-day mortality was observed between on-hours and off-hours patients (5.7% vs. 5.8%). On-hours patients had a longer time from symptom onset to cath lab arrival (≤6 h: 80.2% vs. 84.4%, P < 0.001) and were less likely to present with out-of-hospital cardiac arrest (7.6% vs. 9.5%, P < 0.001). No statistically significant differences in long-term outcomes were observed after adjusting for confounders.

Conclusion: Outcomes after primary PCI for STEMI are comparable between on-hours and off-hours presentations. The quality of care appears to be independent of time of arrival at the cath lab.

Aims: The number of patients undergoing percutaneous coronary interventions (PCI) after transcatheter aortic valve replacement (TAVR) is expected to increase, but their prognosis remains poorly understood.

Methods and results: Consecutive PCI patients with prior TAVR were compared to patients without prior TAVR between 2008 and 2023. The Kaplan-Meier method was used to estimate the 1-year incidence of major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death or myocardial infarction. An entropy balance approach was implemented to adjust for imbalances in patient and procedural characteristics. Adjusted hazard ratios (HRs) were estimated using weighted Cox regression models. Comparing 420 PCI patients with prior TAVR (mean age 80.8 years, 37.1% women) to 1197 without (mean age 70.4 years, 24.6% women), 1-year MACE was higher in the prior TAVR group (8.7 vs. 3.7%; unadjusted HR 2.35, 95% CI 1.49-3.69; P < 0.001). After adjustment for clinical and procedural characteristics, prior TAVR remained associated with an increased risk of MACE (adjusted HR 2.36, 95% CI 1.08-5.16; P = 0.032). This was primarily driven by higher cardiovascular death (adjusted HR 3.12, 95% CI 1.10-8.79, P = 0.032), while the association with myocardial infarction was attenuated post-adjustment and no longer statistically significant.

Conclusion: Patients undergoing PCI after TAVR experience a higher incidence of MACE compared to those undergoing PCI without prior TAVR, underscoring the importance of accurate patient selection before performing PCI in patients with chronic coronary syndrome and history of TAVR.

Aims: Approximately two-thirds of obesity-related mortality is attributable to cardiovascular disease (CVD). The aim of this analysis is to examine predicted CVD risk reduction following weight loss in persons with obesity for primary prevention between tirzepatide and semaglutide, and projected CVD events that could be potentially prevented in the USA.

Methods and results: SURMOUNT-5 was a Phase 3b, open-label, randomized trial conducted in participants with obesity and without Type-2 diabetes, comparing tirzepatide (10 or 15 mg) with semaglutide (1.7 or 2.4 mg) and administered via weekly subcutaneous injection. Predicted 10-year CVD risks were compared between treatments at baseline and up to 72 weeks post-treatment among participants without prior CVD. The impact of cardiovascular risk reduction was estimated as the projected preventable CVD events over 10 years for tirzepatide and semaglutide in the USA. The average predicted 10-year CVD risk score before treatment was 9.3%. Treatment with tirzepatide was associated with significantly greater reduction in predicted 10-year CVD risk compared with semaglutide (absolute reduction from baseline of 2.4% and 1.4%, respectively, P < 0.001). Translating risk reduction to the US population who met treatment eligibility criteria and without prior CVD (∼85 million), an estimated 2 million CVD events could be potentially prevented over 10 years after 72 weeks of tirzepatide treatment, vs. 1.15 million with semaglutide.

Conclusion: In SURMOUNT-5, treatment with tirzepatide was associated with greater predicted 10-year CVD risk reduction compared with semaglutide. This post hoc analysis suggests tirzepatide treatment may provide greater benefit in primary prevention of CVD than semaglutide in people with obesity and overweight.

Registration: ClinicalTrials.gov: NCT05822830.

Aims: Abdominal aortic calcification (AAC) is a marker of systemic atherosclerosis associated with adverse cardiovascular (CV) outcomes in the general population. This study aimed to evaluate the association of AAC with all-cause and CV mortality in cancer survivors.

Methods and results: Using 7 years of data from the National Health and Nutrition Examination Survey (NHANES, 2013-2019), we analysed a nationally representative cohort of US cancer survivors. AAC burden was quantified using the Kauppila AAC-24 scores on dual-energy X-ray absorptiometry (DXA) scans. Kaplan-Meier curves and multivariable Cox models were used to assess the associations between AAC and all-cause mortality, while Fine and Gray models assessed associations between AAC and CV mortality, accounting for non-CV mortality as a competing risk. A total of 23 126 424 cancer survivors (aged ≥40 years) were analysed, recording 4 199 131 (114 unweighted) all-cause deaths and 1 160 618 (34 unweighted) CV deaths over a 69-month median follow-up. AAC was present in 46%, with 19.5% of the cohort showing severe AAC (AAC-24 > 6). Each one-unit increase in AAC-24 score was associated with higher risks of all-cause mortality and CV mortality [adjusted hazard ratio, 95% confidence interval of 1.04 (1.00-1.09) and subdistribution hazard ratio 1.07 (1.02-1.12); P = 0.047 and P = 0.002, respectively] after adjustment for demographic, socioeconomic, traditional CV risk factors, baseline comorbidities, and cancer-specific characteristics.

Conclusion: AAC detected on DXA scans is independently associated with increased all-cause and CV mortality in cancer survivors aged 40 years and older. DXA-based AAC assessment may serve as a valuable tool for risk stratification in cardio-oncology.

Aims: Patients with bicuspid aortic valve (BAV) stenosis were excluded from major TAVR trials, and data comparing TAVR and SAVR in this population remain limited. To compare real-world, risk-adjusted outcomes of TAVR vs. SAVR in patients with BAV stenosis.

Methods and results: We conducted a retrospective cohort analysis using the TriNetX research network database. Adults (≥18 years) with echocardiographically confirmed BAV stenosis undergoing isolated TAVR or SAVR from 2012 to 2022 were included. Patients with prior cardiac procedures or concomitant cardiac interventions were excluded. Propensity score matching (PSM) (1:1) was used to balance covariates. Primary outcomes were 2-year all-cause mortality, stroke, and valve re-intervention. Secondary outcomes included new pacemaker implantation (PPM), 30-day AKI, and bleeding. 5547 patients (TAVR: 1444; SAVR: 4103) were included. In unadjusted analysis, TAVR patients were sicker and older at baseline and had a higher risk of death and/or stroke compared with those who underwent SAVR (10.9% vs. 5.37%, P < 0.0001). Following PSM, 663 matched pairs were analyzed with all covariates balanced. At 2 years, all-cause mortality (TAVR: 4.8% vs. SAVR: 5.3%; OR: 0.91, P = 0.71) and stroke (TAVR: 7.3% vs. SAVR: 4.5%; OR: 1.67, P = 0.058) were similar between the two groups. Re-intervention rates were low and comparable. TAVR was associated with higher PPM rates but lower AKI and bleeding rates.

Conclusion: In propensity-matched BAV patients, TAVR and SAVR demonstrated comparable 2-year mortality, stroke, and re-intervention rates. These findings support TAVR as a viable option in appropriately selected BAV patients, warranting further prospective validation.

Aims: Cancer survivors are at increased cardiovascular risk due to shared risk factors and treatment-related toxicity. The recently proposed cardiovascular-kidney-metabolic (CKM) syndrome framework provides a novel approach for cardiometabolic risk stratification, but its prognostic value in cancer patients remains unclear. In this study, we aimed to evaluate the association between CKM stages and cardiovascular outcomes in cancer patients using a large-scale nationwide dataset.

Methods and results: We conducted a retrospective cohort study of 76 111 cancer patients without prior CVD from the DeSC database (2014-2023). Participants were classified into CKM stages (0-3) at baseline, with Stage 4 defined as the composite outcome of myocardial infarction, heart failure, atrial fibrillation, stroke, or peripheral artery disease. Multivariable Cox proportional hazards models were used to assess the risk of progression to Stage 4. Over a median follow-up of 2.6 years, advancing CKM stages were associated with a graded increase in cardiovascular disease (CVD) risk. Compared to Stage 0-1 (reference), adjusted hazard ratios for Stage 4 were 1.23 (95% confidence interval: 1.13-1.33) for Stage 2 and 1.47 (1.36-1.60) for Stage 3. Sensitivity analyses confirmed consistent associations across different groups stratified by age, sex, chemotherapy history, and cancer types. Furthermore, sensitivity analyses using alternative risk prediction models or expanded CVD definitions yielded similar results.

Conclusion: The CKM staging system effectively stratifies cardiovascular risk in cancer patients, with higher stages predicting significantly worse outcomes. These findings advocate for integrating CKM assessment into onco-cardiologic practice to guide early intervention and improve patient outcomes.

Aims: Intravenous tolvaptan sodium phosphate (IV-tolvaptan) is a novel aquaretic agent for acute decompensated heart failure (ADHF). This study evaluated its short-term effects and prognostic implications in clinical practice.

Methods and results: In this retrospective cohort of 169 consecutive ADHF patients receiving IV-tolvaptan for the first time (mean age 76.0 ± 12.7 years; 50.9% female), we measured hourly urine output over 6 h and assessed clinical and biochemical parameters at baseline and 24 h post-dose. The primary endpoint was a composite of all-cause mortality and heart failure rehospitalization. At 24 h, IV-tolvaptan significantly reduced body weight (mean difference: -1.1 ± 2.3 kg, P < 0.001), NT-proBNP (median change: -1704 pg/mL; P < 0.001), and urinary osmolality (mean change: -71.4 ± 169.4 mOsm/kg; P = 0.015), while raising serum sodium (mean change: 1.7 ± 2.9 mEq/L; P < 0.001). Six-hour urine output correlated with baseline estimated glomerular filtration rate (eGFR) (r = 0.34; P < 0.001), urinary osmolality (r = 0.28; P = 0.003), and the change in serum sodium (r = 0.21; P = 0.005). In multivariable logistic regression, renal impairment (eGFR < 60 mL/min/1.73m²) [odds ratio (OR) 0.2; 95% confidence interval (CI) 0.1-0.4; P < 0.001] and higher furosemide doses (>20 mg) (OR 0.3; 95% CI 0.2-0.6; P = 0.01) predicted reduced responsiveness, whereas first hospitalization (OR 2.2; 95% CI 1.1-4.5; P = 0.04) and high urinary osmolality (OR 2.3; 95% CI 1.0-5.4; P = 0.05) predicted favourable response. Kaplan-Meier analysis demonstrated a lower incidence of the primary endpoint in patients achieving ≥ 1000 mL urine output (log-rank P = 0.032).

Conclusion: Intravenous tolvaptan sodium phosphate enhances decongestion and short-term outcomes in ADHF without worsening renal function. Early diuretic responsiveness is a robust prognostic marker.

Aims: The role of echocardiography in amyloidosis prognostication remains undefined in international guidelines. This meta-analysis aims to evaluate associations between echocardiography-derived measurements and clinical outcomes in light chain (AL) and transthyretin (ATTR) amyloidosis.

Methods and results: MEDLINE, Embase, Cochrane Library, and Google Scholar were systematically searched through July 2024 for studies reporting associations between echocardiographic variables [left ventricular global longitudinal strain (LV-GLS), LV ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), interventricular septum diameter (IVSd), LV mass index (LVMi) and E/e' ratios] and adverse events in AL or ATTR amyloidosis. Prespecified demographic items and clinical outcomes were extracted by two blinded, independent reviewers. The prespecified primary outcome was all-cause mortality. Random-effect models were applied to pool hazard ratios (HR). 94 studies comprising 16158 patients (n = 4788 AL, n = 8241 ATTR, n = 3129 mixed aetiologies) were included. Median follow-up was 22.3 (IQR, 16.9-31.4) months. Higher all-cause mortality risk (HR, 1.10: 95%CI, 1.08-1.12; P < 0.001) was observed per 1% LV-GLS decrement, consistent across AL and ATTR subgroups. Lower all-cause mortality risk was seen with increasing LVEF (per 1%) and TAPSE (per 1 mm) in the overall population (HR_LVEF, 0.98; 95%CI, 0.98-0.98; P < 0.001; and HR_TAPSE, 0.94; 95%CI, 0.93-0.95; P < 0.001) and in AL and ATTR subgroups. Higher E/e' ratios (per 1 unit) were associated with all-cause mortality (HR, 1.02; 95%CI, 1.02-1.03; P < 0.001), consistent across AL and ATTR subtypes. No reliable associations between structural parameters (IVSd, LVMi) and clinical outcomes were found.

Conclusion: Echocardiographic measures of biventricular deformation, systolic and diastolic function, were consistently associated with mortality in amyloidosis, while structural parameters were not. Echocardiography may have an important role in the initial risk stratification of cardiac amyloidosis.

Aims: Aortic valve-sparing root replacement is recommended over composite root replacement for aortic root aneurysms, especially in younger patients, but long-term outcomes in low-volume nationwide settings remain unclear. The objectives are to compare long-term survival, stroke, and reoperation rates between the two procedures in a low-volume national setting.

Methods and results: Patients were identified from the Western Danish Heart Registry and the Danish Heart Registry. Cases were validated by review of operative descriptions. The primary outcome was long-term survival from all-cause mortality; secondary outcomes included stroke, reoperation, recurrent aortic regurgitation, and aortic stenosis. Groups were balanced using propensity score matching. Echocardiographic data were provided for the matched cohort. We identified 760 patients treated with composite root replacement and 179 patients with aortic valve-sparing root replacement between January 2010 and April 2022. Mean follow-up was 6.5 years. Composite root replacement patients were younger [50.7 years (SD 14.1) vs. 55.2 (SD 13.5), P < 0.001], but more comorbid with a median EuroSCOREII of 5.5 [interquartile range (IQR): 3.3-11.7] vs. 3.4 (IQR: 2.6-5.0) (P < 0.001). After matching 157 patients per group, aortic valve-sparing root replacement showed improved 10-year survival [91.2%, 95% confidence interval (CI) 82.3-95.8 vs. 80.4%, 95% CI 70.0-87.5, log-rank P = 0.026], with lower 10-year stroke risk (4.9%, 95% CI 1.8-13.0 vs. 18.9%, 95% CI 11.7-29.9, log-rank P = 0.007). Risk of reoperation was nonsignificant (log-rank P = 0.12), which was consistent in the crude population when accounting for competing risk of death (log-rank P = 0.09).

Conclusion: In this nationwide study, aortic valve-sparing root replacement was associated with better long-term survival and lower stroke risk, supporting its role as a durable surgical option for selected patients.

Aims: Cardiogenic shock remains a significant cause of mortality despite multiple advancements in medical interventions. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides crucial circulatory support but also increases left ventricular (LV) after-load, potentially worsening outcomes. Effective LV unloading strategies can enhance patient survival during VA-ECMO treatment. Our aim was to evaluate the impact of LV unloading strategies, including intra-aortic balloon pump (IABP) and Impella, on outcomes such as mortality and adverse effects in patients with cardiogenic shock treated with VA-ECMO.

Methods and results: A systematic search of EMBASE and Medline was conducted from inception up to 20 August 2024. Additional sources included forward citation searches of primary references. Inclusion criteria were studies reporting mortality rates in patients undergoing VA-ECMO with and without LV unloading. Exclusion criteria included case studies, editorials, commentaries, literature reviews, studies without a control group, those not examining LV unloading, studies on non-cardiogenic shock patients, and paediatric populations. From 943 identified studies, 26 met the inclusion criteria after abstract and full text screening by two authors. Data extraction followed PRISMA guidelines with independent reviewers abstracting data and assessing study quality using the Cochrane Risk of Bias in non-randomized studies (ROBINS-I) tool. A random-effects model was used to pool data, accounting for study heterogeneity. The primary outcome was all-cause mortality, assessed at three time points: intra-hospital mortality, 30-day mortality and mortality at longest available follow-up. Secondary outcomes included adverse effects such as bleeding, infection, cardiovascular events, limb ischaemia, and renal replacement therapy (RRT). The meta-analysis included 26 studies with a total of 22 625 patients. LV unloading strategies significantly reduced mortality compared to no unloading (RR: 0.80; 95% CI: 0.73 to 0.96). IABP (RR: 0.78; 95% CI: 0.69 to 0.89) was associated with a significant reduction of mortality compared to no unloading. All adverse effects were comparable across groups apart from significantly increased infection rates and need for RRT in Impella patients (RR: 1.37; 95% CI: 1.07 to 1.75, and RR: 2.02; 95% CI: 1.37 to 3.00, respectively).

Conclusion: LV unloading strategies associated with reduced mortality in patients with cardiogenic shock treated with VA-ECMO. Whilst adverse effects are similar across all strategies, Impella specifically is linked to higher infection rates and need for RRT. These findings could be used to support the use of LV unloading devices in clinical practice and highlight the need for further randomized controlled trials to establish optimal device-options and management protocols.