Progress in cardiovascular diseases最新文献

The management of symptomatic obstructive hypertrophic cardiomyopathy remains a therapeutic clinical challenge. Surgical septal myectomy has long been established as the gold-standard intervention for patients with persistent symptoms despite optimal medical therapy, offering durable symptom relief with low perioperative risk in experienced centers. Recently, the introduction of cardiac myosin inhibitors, such as mavacamten and aficamten, has reshaped the treatment paradigm for obstructive hypertrophic cardiomyopathy. By selectively inhibiting cardiac myosin ATPase activity, these agents reduce hypercontractility and improve myocardial energetic efficiency. Randomized, placebo-controlled trials such as EXPLORER-HCM and SEQUOIA-HCM have demonstrated the efficacy of cardiac myosin inhibitors in reducing left ventricular outflow tract gradients, alleviating symptoms, and enhancing functional capacity in patients with obstructive hypertrophic cardiomyopathy. The growing clinical use of cardiac myosin inhibitors raises critical questions regarding their role relative to surgical intervention. While cardiac myosin inhibitors offer an effective and less invasive alternative for many patients, they do not fully replace surgical myectomy across all clinical settings. This review articles explores the evolving therapeutic landscape of obstructive hypertrophic cardiomyopathy, focusing on the comparative advantages and limitations of cardiac myosin inhibitors and surgical myectomy.

Objective: LIFECARD is a community-based longitudinal cohort in Pakistan investigating how anthropometric, environmental, and mental health factors (anxiety and depression) and lifestyle behaviors in low middle income country settings influence cardiovascular -kidney-metabolic (CKM) syndrome risk trajectories in individuals aged 10 to 45 years old.

Methods and analysis: This 10-year longitudinal study will enroll approximately 4000 participants: 2000 adolescents (10-20 years) and 2000 young adults (21-45 years) from Karachi (peri-urban) and Matiari (rural) districts of Sindh. A multistage sampling design will be employed. Clusters of 200 households will be selected first in each area, followed by random selection of 75 households per cluster. One eligible participant per household will be enrolled to minimize clustering. Baseline assessments include sociodemographic data, clinical and family history, obstetric history (married women aged 15-45), tobacco/alcohol consumption, anxiety and depression screening, dietary intake, physical activity, and air quality measurements (personal, indoor, and outdoor). Anthropometric measurements and laboratory investigations (HbA1c, lipid profile) will be performed. These baseline variables will be captured every 2 years. Blood specimens will be bio-banked for future biomarkers and genomic analyses. Carotid intima-media thickness (cIMT) and plaque assessment via ultrasound will be conducted at baseline and every 5 years.

Conclusion: LIFECARD will be Pakistan's first cohort investigating contextual risk factors for premature CKM from early adolescence (10 years) through adulthood (45 years). These insights will identify critical windows for early interventions to prevent disease initiation and progression.

Background and aims: The prognostic significance of global calcium burden-including coronary artery (CAC), mitral annular (MAC), aortic valve (AVC), and thoracic aortic calcification (TAC)-as assessed by cardiac computed tomography (CCT), remains incompletely understood in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). This study aimed to evaluate the prognostic impact of overall calcification burden in patients with severe AS undergoing AVR.

Methods: A retrospective analysis of 313 patients with severe AS undergoing CCT before AVR between 2016 and 2019 was conducted. MAC, CAC, AVC were quantified using established scoring methods. For TAC, a total thoracic aortic (TTA) score was developed by evaluating calcifications in the ascending, descending and aortic arch. MAC, CAC, AVC, and TTA were integrated into a comprehensive scoring system, the New Total Calcium (NTC) score, using Random Forest models. Outcomes considered included MACE, all-cause mortality, and non-cardiovascular mortality over a 60-month follow-up.

Results: Among 313 patients (mean age 81 years), 93% underwent transcatheter AVR. Severe CAC and MAC were observed in 11% and 7.7% of patients, respectively. During follow-up, 48% of patients died, with non-cardiovascular deaths accounting for 34% and MACE occurring in 43%. In this predominantly TAVR population, the TTA score predicted MACE (p = 0.01), all-cause mortality (p = 0.01), and non-cardiovascular mortality (p = 0.005). The NTC score demonstrated high prognostic accuracy for MACE at 1-, 2-, and 3-years, with AUC values of 0.91, 0.80, and 0.81, respectively. Validation in an external cohort of 100 patients confirmed its robustness.

Conclusions: In this predominantly transcatheter AVR cohort, the NTC score is a promising tool for risk stratification in patients with severe AS. These findings are primarily applicable to transcatheter AVR patients, and further validation in SAVR populations is warranted.

Background: Mitral annular calcification (MAC) can be complicated by mitral regurgitation (MR). However, data on outcomes of severe MR caused by MAC are limited. This study evaluated outcomes of severe MR due to MAC and the prognostic significance of frailty and comorbidities in guiding management.

Methods: In this single-center, retrospective cohort study, we reviewed our echocardiographic database to identify patients with isolated severe MR due to severe MAC. The primary endpoint was all-cause mortality. The Society of Thoracic Surgeons (STS) risk score, Charlson Comorbidity Index (CCI), and a 3-point frailty index (hemoglobin, albumin, inactivity) were calculated. Echocardiographic parameters were recorded.

Results: Between January 2010 and August 2023, out of 10,061 patients with severe MAC on echocardiography, 128 patients with severe MR due to severe MAC were identified, and followed for a median of 134 days (IQR: 33-1812). Median age was 81 years; 72.7% were female. Forty-five patients (35.2%) underwent mitral valve (MV) intervention, and 83 (64.8%) received conservative management. During follow-up, 63 patients (49.2%) died. MV intervention improved survival, even after propensity score matching (p < 0.001). Higher frailty scores predicted poorer outcomes in the entire cohort (p = 0.004) and the conservative subgroup (p = 0.014) but not the surgical group (p = 0.406). CCI did not influence mortality when stratified by treatment.

Conclusion: Patients with severe MR due to MAC were frail with multiple comorbidities and often managed conservatively. Frailty is associated with all-cause mortality, and MV intervention improves survival regardless of frailty status.

Objective: Aortic dissection presents significant variations in incidence, treatment, and outcomes based on demographic and clinical factors. This study leverages official databases to elucidate the epidemiological trends of aortic dissection and related syndromes in Spain while examining demographic, clinical, and economic variables.

Methods: A Python-based workflow refined and classified data from the Spanish hospital database (2016-2021) of patients with aortic dissection, crosslinking age, sex, management, and resource use. The study examined sex- and age-specific differences, quantified treatment modalities in relation to outcomes such as procedure choice and in-hospital case fatality, and assessed hospitalization and intervention costs to evaluate the economic burden.

Results: Findings from 9587 cases reveal persistently high case-fatality (∼20 %) despite advancements in diagnosis and highlight disparities in care. Case-fatality was significantly higher in females (29.3 %) than in males (22.4 %), with diagnoses occurring at an older age in females compared to males (70.4 vs. 65.5 years). Open surgery remains as the predominant strategy across all analyzed aortic locations despite the medical and economic advantages of percutaneous intervention, although the database's limitation in recording cases according to the Stanford classification hinders the ability to criticize the treatment selection.

Conclusion: Clinical data highlight the need for innovative medical and technological solutions. Moreover, transitioning to a new data system could enhance epidemiological reliability and improve patient management.

Objective: To evaluate the independent and joint associations of social determinants of health (SDOH) and healthy lifestyle factors with life expectancy among adults with cardiovascular-kidney-metabolic (CKM) syndrome.

Research design and methods: We analyzed two prospective population-based cohorts: the UK Biobank (2006-2010) and the US National Health and Nutrition Examination Survey (NHANES, 1999-2018). Adults with CKM at baseline and complete data on SDOH and lifestyle indicators were included. Cox proportional hazards models were used to estimate mortality risk by CKM stage, SDOH, and lifestyle adherence. Life expectancy at age 50 was calculated using life table methods, stratified by CKM stage and levels of SDOH and lifestyle.

Results: A total of 213,738 UK Biobank participants (6.69 % deaths) and 10,345 NHANES participants (9.48 % deaths) were included. Advanced CKM stages were associated with significantly higher mortality risk and shorter life expectancy in both cohorts. Individuals with higher SDOH weighted scores or lower healthy lifestyle scores had elevated mortality risks. The joint effects of poor CKM status, adverse SDOH, and unhealthy lifestyle were additive. In NHANES, life expectancy at age 50 ranged from 33.9 years (CKM stage 0 with healthy lifestyle) to 13.2 years (CKM stage 4 with unhealthy lifestyle). In the UK Biobank, the corresponding figures were 34.2 and 21.7 years.

Conclusions: In two large cohorts, poorer CKM health, greater social disadvantage, and unhealthy lifestyles were each independently and jointly associated with lower life expectancy. These findings support the need for integrated strategies targeting both social and behavioral factors to improve outcomes in CKM populations.

The implantable cardioverter-defibrillator (ICD) is a cornerstone therapy for the prevention of sudden cardiac death (SCD). However, with the global population aging, the application of ICD therapy to elderly patients presents a significant clinical and ethical challenge. The main clinical trials that established the efficacy of ICDs largely excluded or underrepresented individuals over the age of 75, as well as those with significant frailty and comorbidities. We critically examine the evidence for primary and secondary prevention, highlighting the concept of competing risks of non-arrhythmic death, which attenuates the potential benefit of ICDs with advancing age. The risk-benefit ratio is further complicated by a heightened risk of procedural and long-term complications, including device-related infections and pocket integrity issues such as skin erosion. The decision to perform a generator replacement at the time of battery depletion is a crucial opportunity for a new goals-of-care discussion rather than a routine procedure, as evidence shows high mortality rates and a low likelihood of appropriate therapy post-exchange in the very elderly. Finally, we address the management of the ICD at the end of life, summarizing the ethical and legal consensus supporting device deactivation as a critical component of palliative care to prevent suffering from futile shocks. This review calls for a paradigm shift away from criteria based solely on left ventricular ejection fraction and chronological age towards a holistic, individualized approach integrating comprehensive geriatric assessment, comorbidity burden, and structured shared decision-making.