European heart journal open最新文献

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.

Aims: Atrial fibrillation (AF) may be associated with adverse influenza-related outcomes. We assessed the relative vaccine effectiveness (rVE) of high-dose (HD-IIV) vs. standard-dose (SD-IIV) inactivated influenza vaccination against cardiovascular and all-cause hospitalizations and all-cause mortality according to history of AF.

Methods and results: This was a prespecified analysis of DANFLU-1, a pragmatic, open-label, feasibility trial randomizing adults aged 65-79 years 1:1 to HD-IIV or SD-IIV during the 2021-2022 influenza season in Denmark. Baseline and endpoint data were obtained from the nationwide administrative health registries. Prespecified endpoints included cardiovascular hospitalizations and all-cause mortality occurring 14 days after vaccination until 31 May 2022. Among 12 477 randomized participants, 878 (7.0%) had AF at baseline. Participants with AF were older (73.0 ± 3.8 vs. 71.7 ± 3.9 years, P < 0.001), more likely to be male (70.7% vs. 51.5%, P < 0.001) and have concomitant comorbidities. The incidence rate of hospitalization for AF was 75.5 vs. 5.1 per 1000 person-years for individuals with vs. without AF (P < 0.001). HD-IIV vs. SD-IIV was associated with a lower all-cause mortality rate irrespective of AF status (AF: 9 events, rVE 54.1%, 95% CI -114.7 to 92.6% vs. no AF: 53 events, rVE 48.3%, 95% CI 6.3-72.5%, pinteraction = 0.87). HD-IIV was not associated with a lower incidence of AF hospitalization regardless of AF status (overall rVE: 29.7%, 95% CI -13.9 to 57.1, pinteraction = 0.51).

Conclusion: Although DANFLU-1 was not powered for clinical endpoints, HD-IIV vs. SD-IIV was associated with lower all-cause mortality irrespective of AF status. HD-IIV compared with SD-IIV was not associated with a significantly lower incidence of AF hospitalizations regardless of AF status.

Aims: Deformation imaging remains underused for cardiovascular risk assessment. As tissue characterization has now been recognized as an additional assessment tool, we sought to investigate the significance of native T1 and extracellular volume (ECV) in an unselected clinical routine population.

Methods and results: The single-centre, prospective cardiovascular magnetic resonance (CMR) registry included patients referred for clinical CMR. Left ventricle global longitudinal strain (GLS) was evaluated in long-axis views. Native T1 and ECV were assessed on septal, basal, or midventricular short-axis positions. Follow-up was conducted for primary (all-cause mortality and heart failure hospitalization) and secondary (all-cause mortality, hospitalized angina, and myocardial infarction) endpoints. The final population consisted of n = 1633 patients who met primary (n = 68) and secondary (n = 90) endpoints during the median follow-up of 395 days. A 10-ms T1 increase was associated with a hazard ratio (HR) of 1.11 [95% confidence interval (CI) 1.07-1.15, P < 0.001] for the primary endpoint independent of ECV (P = 0.738). T1 (HR 1.07, 95% CI 1.03-1.11, P = 0.001) but not ECV (P = 0.674) was an independent predictor for the primary endpoint after correction for common risk factors including age, New York Heart Association class, biomarker NT-proBNP/glomerular filtration rate, and GLS. After dichotomization at the median of 1126 ms, T1 added incremental value for primary endpoint prediction on Kaplan-Meier plots in patients with left ventricular ejection fraction above/below (P = 0.019/0.017) the median of 55% and GLS above/below (P = 0.019/0.041) the median of -16.4%.

Conclusion: Native T1 was found to be an independent risk predictor beyond GLS as well as common clinical risk factors. This may justify the use of non-contrast CMR protocols in selected patients if contrast application is contraindicated.

Aims: Myocardial infarction size is associated with mortality in ST-elevation myocardial infarction (STEMI). With advances in primary percutaneous coronary intervention (PPCI) and medical therapy, whether this relationship has changed over time is unclear.

Methods and results: Patients with STEMI in the UK from 2005 to 2019 were included from the national AMI MINAP registry, with mortality linkage to 2021. Primary outcomes were all-cause mortality at 30 days and 1 year according to infarct size, using Cox regression models. Infarct size was stratified by Tertiles (T1-3) of peak troponin level (T1, smallest; T3, largest), across the early (2005-09), middle (2010-14), and late (2015-19) periods. Subgroup analyses assessed the relationship according to infarct location (anterior vs. non-anterior). A total of 177 214 STEMI patients were included. Adjusted 30-day mortality risk according to infarct size was highest in the early period (aHR: 1.32, 1.21-1.45, P < 0.001), compared to middle (1.12, 1.04-1.20, P = 0.002) and late study periods (1.05, 0.96-1.14, P = 0.299). The relationship between infarct size and 30-day mortality was significant for patients with anterior STEMI in early (1.39, 1.22-1.57, P < 0.001) but not middle or late periods, while remained significant for non-anterior infarction until the late period (early, 1.28, 1.13-1.45, P < 0.001; middle, 1.17, 1.06-1.29, P = 0.002; late, 1.09, 0.96-1.24, P = 0.180).

Conclusion: We observed an independent relationship between infarct size and STEMI mortality, strongest between 2005 and 2009, which reduced over time, becoming non-significant in the 2015-19 period. This association diminished more rapidly for patients with anterior STEMIs. These findings underscore the potential role of contemporary revascularization, systems of care, and guideline-directed medical therapy in reducing STEMI-related mortality.

Aims: Pre-clinical studies point towards an administration time-dependency of anthracycline-induced cancer therapy-related cardiac dysfunction (CTRCD). This retrospective study aimed to investigate the association between time-of-day of AC administration and CTRCD.

Methods and results: Patients from two cardio-oncology outpatient clinics, treated with ACs for any malignancy, were included. Percentage of afternoon AC administration was calculated: cumulative dose administered in the afternoon (12 p.m.-11:59 p.m.)/total cumulative dose. Three groups were defined: morning group ≥ 50% of ACs in the morning (12 a.m.-11:59 a.m.), afternoon group ≥ 50% of ACs in the afternoon, and intermediate group = exactly 50% of ACs in the morning and afternoon. Associations between AC timing and occurrence of CTRCD and heart failure (HF) were assessed using survival analyses. Of 270 included patients, 66 developed CTRCD and 17 developed HF. Compared with the morning group, the afternoon group had a higher risk of developing CTRCD: hazard ratio (HR) 2.88 (95% CI: 1.52-5.44). When considering percentage of ACs administered in the afternoon as a continuous variable, the HR for developing CTRCD was 1.14 (95% CI: 1.04-1.24) for each subsequent 10% of afternoon administration. Results were consistent across sensitivity analyses of age, sex, body mass index, malignancy type, cumulative AC dose, and HFA-ICOS risk score. Congruently, the continuous variable of afternoon AC administration was associated with higher risk of HF: HR = 1.19 (95% CI: 1.01-1.41).

Conclusion: Afternoon administration of ACs is associated with an increased risk of developing CTRCD and HF, suggesting that morning administration may be preferred. Before widespread implementation, these findings should be confirmed in an RCT.

Aims: Chronic myeloid leukemia (CML) patients are at high risk for developing cardiovascular (CV) diseases due to adverse effects of BCR-ABL tyrosine kinase inhibitors.

Objectives: The purpose of this study was to compare patient characteristics and in-hospital mortality between CML patients and non-CML patients, who were hospitalized for ischemic heart disease (IHD).

Methods and results: This study was based on the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination (JROAD-DPC) database. All patients who were first hospitalized for IHD and received percutaneous coronary intervention from April 2012 to March 2021 were extracted. Propensity score matching was used to reduce confounding effects related to differences in patient background. A total of 766 385 patients, in which 371 CML patients were included, were analyzed. CML patients were more likely to be male and less likely to have obesity, hypertension, and dyslipidemia. The number of modifiable CV risk factors (obesity, smoking, hypertension, dyslipidemia, and diabetes mellitus) in CML patients was smaller than in non-CML patients. There was no difference in in-hospital mortality, whether considering all cases or only acute myocardial infarction cases. This was also statistically non-significant after propensity score matching.

Conclusion: CML patients were hospitalized for IHD with fewer CV risk factors than non-CML patients, and in-hospital mortality was comparable between CML and non-CML patients. These findings emphasize the need for more stringent management of modifiable CV risk factors for CML patients.