Cardiovascular diagnosis and therapy最新文献

Background: Carbohydrate antigen 125 (CA125) has been associated with a higher risk of mortality and readmission after an acute heart failure (HF) episode. However, the utility of CA125 in evaluating prognosis in chronic and stable HF is not yet established. The aim of this prospective study was to assess whether there is prognostic value of plasma CA125 in chronic HF population with reduced ejection fraction (HFrEF) after a long period of clinical stability.

Methods: Prospective cohort study that included consecutive patients with stable HFrEF who were followed in the outpatient HF clinic of the General University Hospital of Elche (Alicante, Spain) between July 2018 and January 2019. Stability was defined as the absence of hospital admissions due to HF symptoms or use of intravenous diuretics for at least six months before the inclusion date. The primary outcome was all-cause mortality related to CA125. The secondary endpoints were HF admissions and total cardiovascular (CV) admissions. The association between CA125 and recurrent hospitalizations was evaluated by the Famoye bivariate Poisson regression model.

Results: The study included 116 patients [69±12 years, 71.6% males, left ventricular ejection fraction 33.4%±7.1%; 52.6% in New York Heart Association class I (indicating long-term stability)]. The median CA125 value was 9.15 U/mL [interquartile range (IQR), 6.15-14.08 U/mL]. During a median follow-up of 18 months (IQR, 13-19 months), there were 13 deaths, 47 HF admissions, and 60 CV admissions. After multivariate adjustment, patients with CA125 >9.15 U/mL had higher rates of HF admissions [incidence rate ratio (IRR) 2.49; 95% confidence interval (CI): 1.14-5.44; P=0.02] and CV admissions (IRR 1.88; 95% CI: 1.01-3.52; P=0.04) compared with those with lower levels. Higher CA125 values were also associated with an increased risk of mortality in a non-linear fashion (P=0.02). Additionally, CA125 levels correlated with serum sodium (P<0.001), inferior vena cava diameter (P=0.03), and inflammatory status (P=0.01).

Conclusions: In patients with stable chronic HFrEF, higher plasma CA125 was associated with an increase in the burden of mid-term morbidity and mortality. CA125 could be a surrogate marker of residual congestion and inflammatory activity in this particular scenario.

Background: Artificial intelligence-assisted quantitative coronary angiography (AI-QCA) has been developed to enable the automated, objective assessment of coronary artery stenosis without human intervention. Previous studies have shown its accuracy compared with manual QCA and intravascular ultrasound. In this study, we aimed to evaluate cardiologists' experience of analyzing coronary lesions with AI-QCA.

Methods: Ten board-certified cardiologists from multiple centers specializing in coronary intervention, with varying periods of experience, participated in this study. They analyzed angiograms from 180 patients with marked coronary stenosis requiring coronary revascularization. Correlations between manual QCA and AI-QCA were measured by using Pearson's or Spearman's correlation coefficients.

Results: The average System Usability Scale (SUS) score was 66.7, indicating marginal high acceptability. The angiographic frame selected by the cardiologists with AI-QCA assistance was within five frames of that elected by the QCA analyst in 64.2% of cases. Furthermore, the time taken by cardiologists to analyze angiograms with AI-QCA assistance was 1.5±0.9 s, significantly lower than that required by an expert analyst to perform manual QCA (88.1±35.5 s, P<0.001). Key angiographic variables, such as reference vessel diameter (RD), minimal lumen diameter (MLD), diameter stenosis (DS), and lesional length (LL), showed moderate-to-strong correlations between AI-QCA and manual QCA (e.g., distal reference diameter, R=0.74).

Conclusions: This prospective study showed that automated analysis with AI-QCA can be performed with an acceptable user experience as well as minimal human intervention and little additional time. Therefore, the application of AI-QCA in the Cath lab is feasible and potentially helpful during coronary angiography (CAG) and intervention.

Background: Acute coronary syndrome (ACS) remains one of the leading causes of mortality worldwide. This study investigates the diagnostic and prognostic value of circulating exosomal miR-20b-5p and miR-1273g-3p in ACS.

Methods: This retrospective study randomly included 138 patients diagnosed with ACS according to the 2020 European Society of Cardiology (ESC) Guidelines for managing ACSs and 129 controls with normal coronary arteries (NCA) between October 2020 and November 2023 in Meizhou People's Hospital. Plasma-derived exosomes were isolated from patients with ACS and NCA controls. The expression of miR-20b-5p and miR-1273g-3p was measured using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Major adverse cardiovascular events (MACEs) within 1 year after percutaneous coronary intervention (PCI) were recorded. Receiver operating characteristic (ROC) curve analysis was carried out to assess diagnostic performance, and Kaplan-Meier survival analysis with Cox regression was applied to examine association of exosomal miR-20b-5p with MACEs.

Results: Both exosomal miR-20b-5p and miR-1273g-3p were markedly elevated in patients compared with NCA controls. The ROC analysis yielded an area under the curve (AUC) of 0.705 [95% confidence interval (CI): 0.639-0.771] for miR-20b-5p and 0.720 (95% CI: 0.657-0.783) for miR-1273g-3p, both slightly lower than that of cardiac troponin I (cTnI) (AUC =0.761; 95% CI: 0.693-0.829). Combined detection of cTnI with miR-20b-5p and miR-1273g-3p achieved AUCs of 0.818 (95% CI: 0.764-0.871) and 0.794 (95% CI: 0.737-0.850), respectively. During follow-up, patients with elevated miR-20b-5p levels exhibited a significantly higher incidence of MACEs. Multivariable Cox regression confirmed an independent association between miR-20b-5p expression and MACEs, with a hazard ratio of 3.107 (95% CI: 1.157-8.340, P=0.02).

Conclusions: Exosomal miR-20b-5p and miR-1273g-3p represent potential diagnostic biomarkers for ACS, and miR-20b-5p also provides prognostic value for predicting MACEs.

[This corrects the article DOI: 10.21037/cdt-2024-692.].

Background: Stroke is the second-leading cause of death and the third-leading cause of disability, with acute ischemic stroke (AIS) being the most serious subtype. Systematic reviews of randomized controlled trials (RCTs) for AIS play a crucial role in formulating clinical guidelines and health policies. However, potential outcome reporting bias (ORB) in RCTs may skew the analytical results of systematic reviews and ultimately lead to suboptimal medical decisions. This study was conducted to investigate the prevalence and possible influencing factors of ORB in RCTs included in systematic reviews of AIS and to correct ORB at the level of systematic reviews.

Methods: A systematic literature search was conducted across three databases to retrieve subject headings and text terms related to AIS, RCTs, and systematic reviews, with the aim of identifying AIS-related systematic reviews published in 2022. ORB in trials was employed to assess the risk of ORB in RCTs, and multivariate logistic regression was used to identify the possible ORB-related factors, including registration, country, quality of journal, funding, sample size, and type of control. The correcting for ORB model was used to correct ORB evidence synthesis results.

Results: A total of 33 systematic reviews and 287 nonduplicate RCTs were included in this study. ORB was suspected in 138 (48.08%) of these RCTs. Statistically significant outcomes were more likely to be reported than were nonsignificant ones [relative risk (RR) =3.18; 95% confidence interval (CI): 2.77-3.64]. The potential factors associated with ORB were unregistered status [odds ratio (OR) =4.87; 95% CI: 1.93-12.28] and sample sizes smaller than 100 (OR =2.57; 95% CI: 1.30-5.10). The corrected results indicated that 31.58% of the therapeutic effects were overestimated due to reversal and that 16.67% of adverse reactions were underestimated due to reversal. Among outcomes without reversal, 56.52% of the effect sizes and 60.87% of the P values exceeded the clinically acceptable range.

Conclusions: The presence of ORB within the field of AIS poses a serious threat to the reliability of evidence synthesized in systematic reviews. In the future, healthcare practitioners and decision-makers should adopt a critical perspective when applying seemingly favorable results in clinical practice.

Background: Hypereosinophilic syndrome (HES) is a rare disease characterized by persistent eosinophilia associated with organ damage, and may be complicated by eosinophilic myocarditis (EM). However, the utility of strain imaging in these conditions remains unclear. We aimed to evaluate the value of strain imaging in HES.

Methods: We performed a cross-sectional study of all patients aged >18 years diagnosed with HES at Cleveland Clinic between September 1986 and January 2023. Left ventricular global longitudinal strain (LVGLS), left atrial (LA) strain, and right ventricular (RV) free wall strain were measured. The primary endpoint was a composite of stroke at diagnosis and major adverse cardiovascular events during the follow-up period. Outcomes were compared using chi-square tests.

Results: Of 1,664 patients with eosinophilia, 34 patients with confirmed HES were included in the final cohort. The mean age was 57±16 years, and 58.8% were female. The median follow-up duration was 85 months. Among them, ten patients (29.4%) were diagnosed with EM and twelve patients (35.3%) developed the primary endpoint. EM patients had significantly worse LVGLS (-9.7% vs. -15.5%, P<0.001), LA reservoir strain (21.0% vs. 32.1%, P=0.02) and LA contraction strain (-9.7% vs. -19.2%, P<0.001) compared to non-EM patients, but there was no significant difference in RV free wall strain (-17.5% vs. -23.4%, P=0.08). All EM patients and half of non-EM patients had LVGLS worse than -16%. Patients with worse LVGLS had significantly higher incidence of primary endpoint compared to patients with normal LVGLS (47.6% vs. 9.1%, P=0.03).

Conclusions: LVGLS is frequently impaired in patients with EM, and is associated with increased risk of stroke and major cardiovascular events. These findings suggest its potential as a marker of cardiac involvement and prognosis in HES.

Interval cross-sectional imaging plays an important role in aortopathy surveillance. Often, cardiac magnetic resonance imaging (MRI) is used over computed tomography (CT) due to the lack of radiation in repeated surveillance and the option of additional hemodynamic assessment. Primarily, assessment includes the orthogonal measurement of aortic dimensions in a three-dimensional (3D) structure. Lately, four-dimensional (4D) flow MRI is becoming more widespread as it can be acquired within 1-5 minutes using advanced techniques. In addition to standard flow quantification, 4D flow MRI offers advanced hemodynamic quantification. This review discusses important advanced imaging biomarkers, including helical flow pattern, wall shear stress (WSS), flow displacement and systolic flow reversal ratio (sFRR). It focuses on those parameters that can be analyzed using commercially available post-processing platforms and are accessible for clinical centers without the need for research setup and collaboration. WSS plays a role in the assessment of bicuspid aortic valve disease. Here it is elevated even without the presence of stenosis. Flow displacement is also of value in bicuspid aortic valve disease and is abnormal in heart failure with preserved ejection fraction (HFpEF) as well as chronic aortic dissection. 4D flow MRI is also useful in understanding and assessing flow changes in aortic valve replacement.

[This corrects the article DOI: 10.21037/cdt-2024-691.].

Background and objective: The angiosome concept, introduced by Taylor et al. and further applied by Neville et al., divides the body into three-dimensional blocks of tissue supplied by specific source arteries. This anatomical framework has been instrumental in guiding targeted revascularization strategies, thus enhancing blood flow to ischemic wounds. Building upon this, the woundosome concept was recently introduced, which focuses on individualized perfusion targeting, based on (I) anatomic variations; (II) the presence and extent of collateral circulation; and (III) wound characteristics. The woundosome concept may offer a potentially more tailored approach, paving the way for more thoughtful tissue revascularization. This review aims to investigate the role of angiosome- and woundosome-directed endovascular revascularization for the improvement of outcomes in patients with chronic limb-threatening ischemia (CLTI).

Methods: We conducted a systematic search in PubMed, Web of Science, and Cochrane Library from 1990 to February 2025 using combinations of the terms "angiosome", "woundosome", "critical limb ischemia", "diabetic foot ulcer", "direct revascularization", and "indirect revascularization". After screening 480 records, 14 studies were included in our analysis. Data were extracted regarding study design, patient population, revascularization strategy, and outcomes (wound healing, limb salvage). Findings were narratively synthesized with respect to study methodology and limitations.

Key content and findings: Most retrospective studies reported improved wound healing and limb salvage rates following angiosome-guided direct revascularization (DR), particularly when inline flow could be restored. However, comparable outcomes were observed with indirect revascularization (IR) in the presence of robust collateral circulation. Evidence for woundosome-guided revascularization remains limited but suggests that a perfusion-oriented, individualized strategy may be especially valuable in anatomically complex cases.

Conclusions: Incorporating angiosome- and woundosome-based strategies in CLTI management may improve limb- and patient-related outcomes. The decision on which particular territory needs primary attention and how many vessels require revascularization largely depends on the patency of feeding arteries in the wound area. In the future, a standardized way to measure the intra- and post-procedural arterial flow to the wound would be necessary, to study the clinical applications of the mentioned strategies. Future studies should therefore prospectively validate woundosome-guided strategies and integrate standardized perfusion assessment tools to guide individualized treatment decisions.

Background and objective: Imaging for peripheral artery disease (PAD) is frequently misallocated: advanced cross-sectional studies are over-ordered for low-risk claudication, while high-risk chronic limb-threatening ischemia (CLTI) patients often receive no timely anatomic study. This narrative review summarizes current guideline pathways, quantifies real-world deviations, and identifies value-based remedies that better align modality and timing with clinical need.

Methods: Data sources were PubMed, professional-society websites [American College of Cardiology/American Heart Association (ACC/AHA), European Society for Vascular Surgery/European Society of Cardiology (ESVS/ESC), American College of Radiology (ACR)], and gray literature in a timeframe of January 2015-February 2025. Eligible items were English-language PAD imaging guidelines/consensus statements, registry/claims analyses, cohort/comparative studies, and cost/equity evaluations; single-case reports and non-vascular imaging were excluded. We extracted guideline-recommended diagnostic pathways, compared them with contemporary utilization and cost data, categorized misallocation and operational drivers.

Key content and findings: Across four contemporary guidelines, the benchmark diagnostic sequence is physiologic testing with the ankle-brachial index or toe-brachial index (ABI/TBI), followed by duplex ultrasonography (DUS); when results would change management, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) should be performed, with catheter-based digital subtraction angiography (DSA) reserved for intervention. Cross-sectional imaging increased three-fold in Medicare from 2011-2021, while first-line physiologic testing declined. Only 54% of CLTI patients receive CTA/MRA within 30 days, and each month of delay raises major amputation risk. Imaging access is poorest among minoritized, socio-economically disadvantaged, and rural groups, whereas supplier-induced demand amplifies scans in affluent settings. Misallocation exposes patients to avoidable radiation and contrast, strains radiology capacity, and contributes >US $4 billion in annual CLTI costs. Evidence shows guideline-aware clinical decision support can cut rarely-appropriate imaging by 10-40%, limb-salvage fast-track pathways reduce major amputations by ~30% and expanding sonographer staffing shifts after-hours demand away from CTA.

Conclusions: PAD imaging is misaligned with value-based medicine: over-applied where benefit is marginal and under-applied where it is limb-saving. Implementing sequencing guardrails, decision-support tools, expedited CLTI workflows, and workforce remedies can rebalance utilization, enhance equity, and improve clinical and economic outcomes.