Journal: Heart

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<div><h4>Potential mechanisms linking high-volume exercise with coronary artery calcification.</h4><i>Zambrano A, Tintut Y, Demer LL, Hsu JJ</i><br /><AbstractText>Recent studies have found an association between high volumes of physical activity and increased levels of coronary artery calcification (CAC) among older male endurance athletes, yet the underlying mechanisms have remained largely elusive. Potential mechanisms include greater exposure to inflammatory cytokines, reactive oxygen species and oxidised low-density lipoproteins, as acute strenuous physical activity has been found to enhance their systemic release. Other possibilities include post-exercise elevations in circulating parathyroid hormone, which can modify the amount and morphology of calcific plaque, and long-term exposure to non-laminar blood flow within the coronary arteries during vigorous physical activity, particularly in individuals with pre-existing atherosclerosis. Further, although the association has only been identified in men, the role of testosterone in this process remains unclear. This brief review discusses the association between high-volume endurance exercise and CAC in older men, elaborates on the potential mechanisms underlying the increased calcification, and provides clinical implications and recommendations for those at risk.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 26 Jan 2023; epub ahead of print</small></div>
Zambrano A, Tintut Y, Demer LL, Hsu JJ
Heart: 26 Jan 2023; epub ahead of print | PMID: 36702539
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<div><h4>FOXO3A acts as immune response modulator in human virus-negative inflammatory cardiomyopathy.</h4><i>Makrutzki-Zlotek K, Escher F, Karadeniz Z, Aleshcheva G, ... Thevathasan T, Skurk C</i><br /><b>Objective</b><br />Inflammatory cardiomyopathy is characterised by inflammatory infiltrates leading to cardiac injury, left ventricular (LV) dilatation and reduced LV ejection fraction (LVEF). Several viral pathogens and autoimmune phenomena may cause cardiac inflammation.The effects of the gain of function <i>FOXO3A</i> single-nucleotide polymorphism (SNP) rs12212067 on inflammation and outcome were studied in a cohort of patients with inflammatory dilated cardiomyopathy (DCMi) in relation to cardiac viral presence.<br /><b>Methods</b><br />Distribution of the SNP was determined in virus-positive and virus-negative DCMi patients and in control subjects without myocardial pathology. Baseline and outcome data were compared in 221 virus-negative patients with detection of cardiac inflammation and reduced LVEF according to their carrier status of the SNP.<br /><b>Results</b><br />Distribution of SNP rs12212067 did not differ between virus-positive (n=22, 19.3%), virus-negative (n=45, 20.4 %) and control patients (n=18, 23.4 %), indicating the absence of susceptibility for viral infection or inflammation per se (p=0.199). Patients in the virus-negative DCMi group were characterised by reduced LVEF 35.5% (95% CI) 33.5 to 37.4) and increased LVEDD (LV end-diastolic diameter) 59.8 mm (95% CI 58.5 to 61.2). Within the group, SNP and non-SNP carriers had similarly impaired LVEF 39.2% (95% CI 34.3% to 44.0%) vs 34.5% (95% CI 32.4 to 36.5), p=0.083, and increased LVEDD 58.9 mm (95% CI 56.3 to 61.5) vs 60.1 mm<i> </i>(95% CI 58.6 to 61.6), p=0.702, respectively. The number of inflammatory infiltrates was not different in both SNP groups at baseline. Outcome after 6 months showed a significant improvement in LVEF and clinical symptoms in SNP rs12212067 carriers 50.9%<i> </i>(95% CI 45.4 to 56.3) versus non-SNP carriers 41.7%<i> </i>(95% CI 39.2 to 44.2), p≤0.01. The improvement in clinical symptoms and LVEF was associated with a significant reduction in cardiac inflammation (ΔCD45RO<sup>+</sup> p≤0.05; ΔMac-1<sup>+</sup> p≤0.05; ΔLFA-1<sup>+</sup> p≤0.01; ΔCD54<sup>+</sup> p≤0.01) in the SNP cohort versus non-SNP cohort, respectively. Subgroup analyses identified ΔMac-1<sup>+</sup>, ΔLFA-1<sup>+</sup>, ΔCD3<sup>+</sup> and Δperforin<sup>+</sup> as predictors for improvement in cardiac function in SNP-positive patients.<br /><b>Conclusion</b><br />FOXO3A might act as modulator of the cardiac immune response, diminishing cardiac inflammation and injury in pathogen-negative DCMi.<br /><br />© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 26 Jan 2023; epub ahead of print</small></div>
Makrutzki-Zlotek K, Escher F, Karadeniz Z, Aleshcheva G, ... Thevathasan T, Skurk C
Heart: 26 Jan 2023; epub ahead of print | PMID: 36702542
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<div><h4>Cost-effectiveness of rapid assessment of potential ischaemic heart disease with CT coronary angiography.</h4><i>Thokala P, Goodacre S, Oatey K, O\'Brien R, Newby DE, Gray A</i><br /><b>Objectives</b><br />To estimate the cost-effectiveness of early CT coronary angiography (CTCA) for intermediate risk patients with suspected acute coronary syndrome (ACS), compared with standard care <br /><b>Methods:</b><br/>We performed within-trial economic analysis using data from the RAPID-CTCA randomised trial, and long-term modelling of cost-effectiveness using secondary data sources to estimate the cost-effectiveness of early CTCA compared with standard care for patients with suspected ACS attending acute hospitals in the UK. Cost-effectiveness was estimated as the incremental cost per quality-adjusted life year (QALY) gained, and the probability of each strategy being cost-effective at varying willingness-to-pay per QALY gained.<br /><b>Results</b><br />The within-trial analysis showed that there were no demonstrable differences in costs or QALYs between early CTCA and standard care, with point estimates suggesting higher costs (£7414 vs £6845: mean difference £569, 95% CI -£208 to £1335; p=0.1521) and lower QALYs (0.749 vs 0.758, mean difference -0.009, 95% CI -0.026 to 0.010; p=0.377) in the CTCA arm. The long-term economic analysis suggested that, on average, CTCA was slightly less effective than standard care alone with 0.025 quality-adjusted life years lost per patient treated and was more expensive with additional costs of £481 per patient treated. At a threshold of £20 000 per QALY, CTCA has 24% probability of being cost-effective.<br /><b>Conclusions</b><br />There are no demonstrable differences in within-trial costs and QALYs, and long-term cost-effectiveness modelling suggested higher long-term costs with CTCA and uncertain effect on long-term QALYs, making routine use of CTCA for suspected ACS unlikely to be a cost-effective use of NHS resources.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 26 Jan 2023; epub ahead of print</small></div>
Thokala P, Goodacre S, Oatey K, O'Brien R, Newby DE, Gray A
Heart: 26 Jan 2023; epub ahead of print | PMID: 36702543
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<div><h4>Clinical characteristics, evaluation and outcomes of chylopericardium: a systematic review.</h4><i>Verma B, Kumar A, Verma N, Agrawal A, ... Wang TKM, Klein AL</i><br /><b>Objective</b><br />Chylopericardium (CPE) is a rare condition associated with accumulation of triglyceride-rich chylous fluid in the pericardial cavity. Due to minimal information on CPE within the literature, we conducted a systematic review of all published CPE cases to understand its clinical characteristics, management and outcomes.<br /><b>Methods</b><br />We performed a literature search and identified cases of patients with CPE from 1946 until May 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We identified relevant articles for pooled analyses of clinical, diagnostic and outcome data.<br /><b>Results</b><br />A total of 95 articles with 98 patients were identified. Patient demographics demonstrated male predominance (55%), with a mean age of 37±15 years. Time from symptom onset to diagnosis was 5 (Q1 4.5, Q3 14) days, with 74% of patients symptomatic on presentation. Idiopathic CPE (60%) was the most common aetiology. Cardiac tamponade secondary to CPE was seen in 38% of cases. Pericardial fluid analysis was required in 94% of cases. Lymphangiography identified the leakage site in 59% of patients. Medical therapy (total parenteral nutrition, medium-chain triglycerides or octreotide) was undertaken in 63% of cases. In our cohort, 32% progressed towards surgical intervention. During a median follow-up of 180 (Q1 180, Q3 377) days, CPE recurred in 16% of cases. Of the patients with recurrence, 10% were rehospitalised.<br /><b>Conclusion</b><br />CPE tends to develop in younger patients and may cause serious complications. Many patients fail medical therapy, thereby requiring surgical intervention. Although overall mortality is low, associated morbidities warrant close follow-up and possible reintervention and hospitalisations.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 26 Jan 2023; epub ahead of print</small></div>
Verma B, Kumar A, Verma N, Agrawal A, ... Wang TKM, Klein AL
Heart: 26 Jan 2023; epub ahead of print | PMID: 36702544
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<div><h4>Severe aortic stenosis management in heart valve centres compared with primary/secondary care centres.</h4><i>Rudolph TK, Messika-Zeitoun D, Frey N, Lutz M, ... Steeds RP, IMPULSE enhanced investigators</i><br /><b>Objective</b><br />Current guidelines recommend use of heart valve centres (HVCs) to deliver optimal quality of care for patients with valve disease but there is no evidence to support this. The hypothesis of this study is that patient care with severe aortic stenosis (AS) will differ in HVCs compared with satellite centres. We aimed to compare the treatment of patients with AS at HVCs (tertiary care hospitals with full access to AS interventions) to satellites (hospitals without such access).<br /><b>Methods</b><br /><i>IMPULSE enhanced</i> is a European, observational, prospective registry enrolling consecutive patients with newly diagnosed severe AS at four HVCs and 10 satellites. Clinical characteristics, interventions performed and outcomes up to 1 year by site-type were examined.<br /><b>Results</b><br />Among 790 patients, 594 were recruited in HVCs and 196 in satellites. At baseline, patients in HVCs had more severe valve disease (higher peak aortic velocity (4.3 vs 4.1 m/s; p=0.008)) and greater comorbidity (coronary artery disease (CAD) (44% vs 27%; p<0.001) prior myocardial infarction (MI) (11% vs 5.1%; p=0.011) and chronic pulmonary disease (17% vs 8.9%; p=0.007)) than those presenting in satellites. An aortic valve replacement was performed more often by month 3 in HVCs than satellites in the overall population (52.6% of vs 31.3%; p<0.001) and in symptomatic patients (66.7% vs 43.2%, p<0.001). One-year survival rate was higher for patients in HVCs than satellites (HR2.19; 95% CI 1.28 to 3.73 total population and 2.89 (95%CI 1.64 to 5.11) for symptomatic patients.<br /><b>Conclusions</b><br />Our data support the implementation of referral pathways that direct patients to HVCs performing both surgery and transcatheter interventions.<br /><b>Trial registration number</b><br />NCT03112629.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 19 Jan 2023; epub ahead of print</small></div>
Rudolph TK, Messika-Zeitoun D, Frey N, Lutz M, ... Steeds RP, IMPULSE enhanced investigators
Heart: 19 Jan 2023; epub ahead of print | PMID: 36657962
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<div><h4>National Institute for Health and Care Excellence (NICE) guidance on heart valve disease.</h4><i>Shah BN</i><br /><AbstractText>The National Institute for Health and Care Excellence (NICE) guidelines are evidence-based recommendations for health and care in England. In late 2021, NICE published its first ever guidance on the investigation and management of adults with heart valve disease. This followed on from recent updates to the international societal practice guidelines on heart valve disease produced by the American College of Cardiology and American Heart Association (in 2020) and the European Society of Cardiology and European Association for Cardiothoracic Surgery (in 2021). The purpose of the NICE guidance has significant differences from societal guidelines, as NICE guidance is designed for implementation within the UK\'s taxpayer-funded National Health Service and thus must account not just for clinical effectiveness of treatments but cost-effectiveness also. This explains some of the differences between recent recommendations from these bodies, most notably in the treatment of patients with symptomatic severe aortic stenosis, in which NICE clearly explains that cost implications influenced their final guidance (which differs from the recently published European and North American guidelines). The aims of this review article are to provide an overview of the scope and recommendations of the NICE guideline and to compare and contrast the guidelines, highlighting reasons for differences between the guidance from professional societies and NICE and discussing the relative strengths and weaknesses of the NICE guideline.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 18 Jan 2023; epub ahead of print</small></div>
Shah BN
Heart: 18 Jan 2023; epub ahead of print | PMID: 36653169
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<div><h4>Matched comparison between external aortic root support and valve-sparing root replacement.</h4><i>Van Hoof L, Lamberigts M, Noé D, El-Hamamsy I, ... Verbrugghe P, Aortic Valve Repair Research Network Investigators from the Heart Valve Society</i><br /><b>Objectives</b><br />Differences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of PEARS and VSRR for syndromic root aneurysm.<br /><b>Methods</b><br />Patients in the PEARS 200 Database and Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (undergoing VSRR) with connective tissue disease operated electively for root aneurysm <60 mm with aortic regurgitation (AR) <1/4 were included. Using a PS analysis, 80 patients in each cohort were matched. Survival, freedom from reintervention and from AR ≥2/4 were estimated using a Kaplan-Meier analysis.<br /><b>Results</b><br />Median follow-up was 25 and 55 months for 159 PEARS and 142 VSRR patients. Seven (4.4%) patients undergoing PEARS required an intervention for coronary injury or impingement, resulting in one death (0.6%). After VSRR, there were no early deaths, 10 (7%) reinterventions for bleeding and 1 coronary intervention. Survival for matched cohorts at 5 years was similar (PEARS 98% vs VSRR 99%, p=0.99). There was no difference in freedom from valve or ascending aortic/arch reintervention between matched groups. Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS vs 92% for VSRR (p=0.55). There were no type A dissections.<br /><b>Conclusions</b><br />VSRR and PEARS offer favourable mid-term survival, freedom from reintervention and preservation of valve function. Both treatments deserve their place in the surgical repertoire, depending on a patient\'s disease stage. This study is limited by its retrospective nature and different follow-ups in both cohorts.<br /><br />© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.<br /><br /><small>Heart: 17 Jan 2023; epub ahead of print</small></div>
Van Hoof L, Lamberigts M, Noé D, El-Hamamsy I, ... Verbrugghe P, Aortic Valve Repair Research Network Investigators from the Heart Valve Society
Heart: 17 Jan 2023; epub ahead of print | PMID: 36650042
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<div><h4>Exercise in patients with repaired tetralogy of Fallot: a systematic review and meta-analysis.</h4><i>Schuermans A, Boerma M, Sansoni GA, Van den Eynde J, ... Van De Bruaene A, Budts W</i><br /><b>Objective</b><br />Children and adults with repaired tetralogy of Fallot (rTOF) have an impaired exercise capacity, a less active lifestyle and an increased long-term risk of adverse outcomes compared with healthy peers. This study aimed to summarise the current evidence for the effectiveness and safety of exercise training interventions in patients with rTOF.<br /><b>Methods</b><br />PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus and reference lists of relevant articles were searched for prospective studies published by November 2021. Random-effects meta-analysis and descriptive synthesis were performed to assess the effectiveness and safety of exercise training in patients with rTOF.<br /><b>Results</b><br />Of the 9677 citations identified, 12 articles were included that reported on 10 unique studies and covered 208 patients with rTOF (range of mean/median age: 7.4-43.3 years). All studies implemented 2 to 7 aerobic or respiratory training sessions per week with durations ranging from 6 to 26 weeks. Meta-analysis of the included randomised controlled trials showed that exercise training was associated with a significant improvement in peak VO<sub>2</sub> (pooled mean difference: +3.1 mL/min/kg; 95% CI: 0.76 to 5.36 mL/min/kg, p=0.019). Cardiac imaging studies revealed no subclinical adverse remodelling after the exercise interventions. No serious adverse events including arrhythmias were reported in these studies.<br /><b>Conclusion</b><br />Current evidence suggests that exercise training can improve exercise capacity in patients with rTOF with a low risk for adverse events. Exercise prescription may be a safe and effective tool to help improving outcomes in patients with rTOF.<br /><b>Prospero registration number</b><br />CRD42021292809.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 13 Jan 2023; epub ahead of print</small></div>
Schuermans A, Boerma M, Sansoni GA, Van den Eynde J, ... Van De Bruaene A, Budts W
Heart: 13 Jan 2023; epub ahead of print | PMID: 36639227
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<div><h4>Coronary low-attenuation plaque and high-sensitivity cardiac troponin.</h4><i>Meah MN, Wereski R, Bularga A, van Beek EJR, ... Williams MC, Lee KK</i><br /><b>Objective</b><br />In patients with acute chest pain who have had myocardial infarction excluded, plasma cardiac troponin I concentrations ≥5 ng/L are associated with risk of future adverse cardiovascular events. We aim to evaluate the association between cardiac troponin and coronary plaque composition in such patients.<br /><b>Methods</b><br />In a prespecified secondary analysis of a prospective cohort study, blinded quantitative plaque analysis was performed on 242 CT coronary angiograms of patients with acute chest pain in whom myocardial infarction was excluded. Patients were stratified by peak plasma cardiac troponin I concentration ≥5 ng/L or <5 ng/L. Associations were assessed using univariable and multivariable logistic regression analyses.<br /><b>Results</b><br />The cohort was predominantly middle-aged (62±12 years) men (69%). Patients with plasma cardiac troponin I concentration ≥5 ng/L (n=161) had a higher total (median 33% (IQR 0-47) vs 0% (IQR 0-33)), non-calcified (27% (IQR 0-37) vs 0% (IQR 0-28)), calcified (2% (IQR 0-8) vs 0% (IQR 0-3)) and low-attenuation (1% (IQR 0-3) vs 0% (IQR 0-1)) coronary plaque burden compared with those with concentrations <5 ng/L (n=81; p≤0.001 for all). Low-attenuation plaque burden was independently associated with plasma cardiac troponin I concentration ≥5 ng/L after adjustment for clinical characteristics (adjusted OR per doubling 1.62 (95% CI 1.17 to 2.32), p=0.005) or presence of any visible coronary artery disease (adjusted OR per doubling 1.57 (95% CI 1.07 to 2.37), p=0.026).<br /><b>Conclusion</b><br />In patients with acute chest pain but without myocardial infarction, plasma cardiac troponin I concentrations ≥5 ng/L are associated with greater burden of low-attenuation coronary plaque.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 11 Jan 2023; epub ahead of print</small></div>
Meah MN, Wereski R, Bularga A, van Beek EJR, ... Williams MC, Lee KK
Heart: 11 Jan 2023; epub ahead of print | PMID: 36631142
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<div><h4>National Institute for Health and Care Excellence guidelines on myocardial revascularisation.</h4><i>Jabbour RJ, Curzen N</i><br /><AbstractText>Cardiologists in the UK predominantly use the National Institute for Health and Care Excellence (NICE) and European Society of Cardiology guidelines to help guide decision-making. This article will appraise the current recommendations from NICE regarding myocardial revascularisation and compare them with other major international guidelines. While there are many similarities, subtle differences exist. These differences arise in part due to the evidence base at time of publication, as well as from the different healthcare systems that they are designed for, and from the cost-effectiveness models that dominate the methodology used by NICE. The clinical implications of the differences between the international guidelines will be analysed.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 11 Jan 2023; epub ahead of print</small></div>
Jabbour RJ, Curzen N
Heart: 11 Jan 2023; epub ahead of print | PMID: 36631143
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<div><h4>Cardiac sarcoidosis.</h4><i>Sohn DW, Park JB</i><br /><AbstractText>The diagnostic yield of endomyocardial biopsy in cardiac sarcoidosis (CS) is quite low because of the patchy involvement, and for the diagnosis of CS, existing guidelines required histological confirmation. Therefore, especially for isolated CS, diagnosis consistent with the guidelines cannot be made in a large number of patients. With recent developments in imaging modalities such as cardiac magnetic resonance and 18-fluorodeoxyglucose positron emission tomography, diagnosing CS has become easier and diagnostic criteria for CS not compulsorily requiring histological confirmation have been suggested. Despite significant advances in diagnostic tools, large-scale studies that can guide treatment plans are still lacking, and treatment has relied on the experience accumulated over the past years and the consensus of experts. However, opinions vary, depending on the situation, which is quite puzzling for the physician treating CS. Moreover, with the advent of new immunosuppressant agents, these new drugs have been applied under the assumption that the effect of immunosuppression is not much different from that of other well-known autoimmune diseases that require immunosuppression. However, we should wait to see the beneficial effects of these new immunosuppressants before we attempt to apply these agents in our clinical practice. This review summarises the widely used diagnostic criteria, current diagnostic modalities and recommended treatments for sarcoidosis. We have added our opinions on selecting or modifying diagnostic and treatment plans from the diverse current recommendations.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 11 Jan 2023; epub ahead of print</small></div>
Sohn DW, Park JB
Heart: 11 Jan 2023; epub ahead of print | PMID: 36631144
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<div><h4>Diagnosis of cardiac sarcoidosis in patients presenting with cardiac arrest or life-threatening arrhythmias.</h4><i>Hatipoglu S, Gardezi SKM, Azzu A, Baksi J, ... Pennell DJ, Mohiaddin R</i><br /><b>Objective</b><br />Cardiac sarcoidosis (CS) may present with cardiac arrest or life-threatening arrhythmias. There are limited data on this subgroup of patients with CS. Advanced imaging including cardiovascular magnetic resonance (CMR) and cardiac 18-fluorodeoxyglucose (FDG) positron emission tomography (PET) are used for diagnosis. This study aimed to describe advanced imaging patterns suggestive of CS among patients presenting with cardiac arrest or life-threatening arrhythmias.<br /><b>Methods</b><br />An imaging database of a CS referral centre (Royal Brompton Hospital, London) was screened for patients presenting with cardiac arrest or life-threatening arrhythmias and having imaging features of suspected CS. Patients diagnosed with definite or probable/possible CS were included.<br /><b>Results</b><br />Study population included 60 patients (median age 49 years) with male predominance (76.7%). The left ventricle was usually non-dilated with mildly reduced ejection fraction (53.4±14.8%). CMR studies showed extensive late gadolinium enhancement (LGE) with 5 (4-8) myocardial segments per patient affected; the right ventricular (RV) side of the septum (28/45) and basal anteroseptum (28/45) were most frequently involved. Myocardial inflammation by FDG-PET was detected in 45 out of 58 patients vs 11 out of 33 patients with oedema imaging available on CMR. When PET was treated as reference to detect myocardial inflammation, CMR oedema imaging was 33.3% sensitive and 77% specific.<br /><b>Conclusions</b><br />In patients with CS presenting with cardiac arrest or life-threatening arrhythmias, LGE was located in areas where the cardiac conduction system travels (basal anteroseptal wall and RV side of the septum). While CMR was the imaging technique that raised possibility of cardiac scarring, oedema imaging had low sensitivity to detect myocardial inflammation compared with FDG-PET.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 10 Jan 2023; epub ahead of print</small></div>
Hatipoglu S, Gardezi SKM, Azzu A, Baksi J, ... Pennell DJ, Mohiaddin R
Heart: 10 Jan 2023; epub ahead of print | PMID: 36627181
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<div><h4>Impact of policy alterations on elective percutaneous coronary interventions in Japan.</h4><i>Morishita T, Takada D, Shin JH, Kunisawa S, Fushimi K, Imanaka Y</i><br /><b>Objective</b><br />Establishing appropriate percutaneous coronary intervention (PCI) in stable angina pectoris (SAP) has become a distinctive performance measure worldwide. Clinical guidelines call for documenting ischaemia in patients with SAP prior to elective PCI. The Japanese Ministry of Health, Labour and Welfare introduced a new reimbursement policy in April 2018 to promote the appropriate and judicious implementation of PCI. The 2018 reimbursement changes clarified the required proof of ischaemia. Tests to evaluate functional ischaemia and coronary stenosis have been added as a requirement for reimbursement. We examined whether this reimbursement revision had an impact on PCI procedures for SAP in Japan.<br /><b>Methods</b><br />We used administrative claims data in Japan\'s Diagnosis Procedure Combination database from April 2014 through March 2020. We used interrupted time series analyses with a control to ascertain the impacts on elective PCI procedures before and after the Japanese reimbursement revision. The primary outcome was the change in elective PCI procedures per month. Emergent PCI procedures served as a control group.<br /><b>Results</b><br />A total of 773 240 PCI procedures were identified between April 2014 and March 2020: 388 817 and 180 462 elective PCIs before and after the reimbursement revision, respectively. After the 2018 reimbursement revision, significant trend changes were found in elective PCI procedures per month (-106.3, 95% CI -155.8 to -56.8, p<0.01), while the number of emergent PCIs remained stable throughout the study period.<br /><b>Conclusions</b><br />After revising the reimbursement tariff for elective PCIs in 2018, there was a significant reduction in elective PCI procedures per month.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 10 Jan 2023; epub ahead of print</small></div>
Morishita T, Takada D, Shin JH, Kunisawa S, Fushimi K, Imanaka Y
Heart: 10 Jan 2023; epub ahead of print | PMID: 36627183
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<div><h4>Impact of frailty on disease-specific health status in cardiovascular disease.</h4><i>Nguyen DD, Arnold SV</i><br /><AbstractText>Frailty is a syndrome of older age that reflects an impaired physiological reserve and decreased ability to recover from medical stressors. While the impact of frailty on mortality in cardiovascular disease has been well described, its impact on cardiovascular disease-specific health status-cardiac symptoms, physical functioning and quality of life-has been less well studied. In this review, we summarise the impact of frailty on health status outcomes across different cardiovascular conditions. In heart failure, frail patients have markedly impaired disease-specific health status and are at risk for subsequent health status deteriorations. However, frail patients have similar or even greater health status improvements with interventions for heart failure, such as cardiac rehabilitation or guideline-directed medical therapy. In valvular heart disease, the impact of frailty on disease-specific health status is of even greater concern since management involves physiologically taxing procedures that can worsen health status. Frailty increases the risk of poor health status outcomes after transcatheter aortic valve intervention or surgical aortic valve replacement for aortic stenosis, but there is no evidence that frail patients benefit more from one procedure versus another. In both heart failure and valvular heart disease, health status improvements may reverse frailty, highlighting the overlap between cardiovascular disease and frailty and emphasising that treatment should typically not be withheld based on the presence of frailty alone. Meanwhile, data are limited on the impact of frailty on health status outcomes in the treatment of coronary artery disease, peripheral artery disease and atrial fibrillation, and requires further research.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 05 Jan 2023; epub ahead of print</small></div>
Nguyen DD, Arnold SV
Heart: 05 Jan 2023; epub ahead of print | PMID: 36604164
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<div><h4>Trimethylamine-N-oxide is associated with cardiovascular mortality and vascular brain lesions in patients with atrial fibrillation.</h4><i>Luciani M, Müller D, Vanetta C, Diteepeng T, ... Beer JH, SWISS-AF Investigators</i><br /><b>Objective</b><br />Trimethylamine-N-oxide (TMAO) is a metabolite derived from the microbial processing of dietary phosphatidylcholine and carnitine and the subsequent hepatic oxidation. Due to its prothrombotic and inflammatory mechanisms, we aimed to assess its role in the prediction of adverse events in a susceptible population, namely patients with atrial fibrillation.<br /><b>Methods</b><br />Baseline TMAO plasma levels were measured by liquid chromatography-tandem mass spectrometry in 2379 subjects from the ongoing Swiss Atrial Fibrillation cohort. 1722 underwent brain MRI at baseline. Participants were prospectively followed for 4 years (Q1-Q3: 3.0-5.0) and stratified into baseline TMAO tertiles. Cox proportional hazards and linear and logistic mixed effect models were employed adjusting for risk factors.<br /><b>Results</b><br />Subjects in the highest TMAO tertile were older (75.4±8.1 vs 70.6±8.5 years, p<0.01), had poorer renal function (median glomerular filtration rate: 49.0 mL/min/1.73 m<sup>2</sup> (35.6-62.5) vs 67.3 mL/min/1.73 m<sup>2</sup> (57.8-78.9), p<0.01), were more likely to have diabetes (26.9% vs 9.1%, p<0.01) and had a higher prevalence of heart failure (37.9% vs 15.8%, p<0.01) compared with patients in the lowest tertile. Oral anticoagulants were taken by 89.1%, 94.0% and 88.2% of participants, respectively (from high to low tertiles). Cox models, adjusting for baseline covariates, showed increased total mortality (HR 1.65, 95% CI 1.17 to 2.32, p<0.01) as well as cardiovascular mortality (HR 1.86, 95% CI 1.21 to 2.88, p<0.01) in the highest compared with the lowest tertile. When present, subjects in the highest tertile had more voluminous, large, non-cortical and cortical infarcts on MRI (log-transformed volumes; exponentiated estimate 1.89, 95% CI 1.11 to 3.21, p=0.02) and a higher chance of small non-cortical infarcts (OR 1.61, 95% CI 1.16 to 2.22, p<0.01).<br /><b>Conclusions</b><br />High levels of TMAO are associated with increased risk of cardiovascular mortality and cerebral infarction in patients with atrial fibrillation.<br /><b>Trial registration number</b><br />NCT02105844.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 02 Jan 2023; epub ahead of print</small></div>
Luciani M, Müller D, Vanetta C, Diteepeng T, ... Beer JH, SWISS-AF Investigators
Heart: 02 Jan 2023; epub ahead of print | PMID: 36593094
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<div><h4>Prospective study of sleep duration, snoring and risk of heart failure.</h4><i>Zhuang S, Huang S, Huang Z, Zhang S, ... Wu S, Gao X</i><br /><b>Objective</b><br />To investigate whether nighttime sleep duration and snoring status were associated with incident heart failure (HF).<br /><b>Methods</b><br />A prospective study was conducted based on Kailuan cohort including 93 613 adults free of pre-existing cardiovascular diseases. Sleep duration and snoring status were assessed by self-reported questionnaire. Incident HF cases were ascertained by medical records. Cox proportional hazards model was applied to calculate the HR and 95% CI of risk of developing HF. Mediation analysis was used to understand whether hypertension and diabetes mediated the association between sleep duration, snoring and HF. Data analysis was performed from 1 June 2021 to 1 June 2022.<br /><b>Results</b><br />During a median follow-up of 8.8 years, we documented 1343 incident HF cases. Relative to sleep duration of 7.0-7.9 hour/night, short sleep duration was associated with higher risk of developing HF: adjusted HR was 1.24 (95% CI 1.01 to 1.55) for <6 hours/night and 1.29 (95% CI 1.06 to 1.57) for 6.0-6.9 hours/night, after adjustment for potential confounders such as age, sex, smoking, hypertension and diabetes. A similar 20%-30% higher risk of incident HF was found in individuals reporting occasional or frequent snoring relative to never/rare snorers: adjusted HR was 1.32 for occasional snoring (95% CI 1.14 to 1.52) and 1.24 (95% CI 1.06 to 1.46) for frequent snoring. Presence of diabetes significantly mediated the association between both short sleep duration and snoring and HF risk and hypertension significantly mediated the snoring-HF relationship.<br /><b>Conclusion</b><br />Short sleep duration and snoring were associated with high risk of HF.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 02 Jan 2023; epub ahead of print</small></div>
Zhuang S, Huang S, Huang Z, Zhang S, ... Wu S, Gao X
Heart: 02 Jan 2023; epub ahead of print | PMID: 36593101
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<div><h4>Anatomy of the mitral valve relative to controversies concerning the so-called annular disjunction.</h4><i>Anderson RH, Garbi M, Zugwitz D, Petersen SE, Nijveldt R</i><br /><AbstractText>It is now accepted that the mitral valve functions on the basis of a complex made up of the annulus, the leaflets, the tendinous cords and the papillary muscles. So as to work properly, these components must combine together in harmonious fashion. Despite the features of the arrangement of each component having been the focus of anatomical investigation for centuries, controversies still exist in their inter-relations and how best to describe them. To a large extent, the ongoing problems reflect the fact that, again for centuries, morphologists when describing the heart have ignored the rule that its components should be described as seen in the body during life. Failure to use attitudinally appropriate descriptions underscores a particular current issue, namely the influence of the so-called disjunction within the atrioventricular junction as a potential substrate for leaflet prolapse or malignant arrhythmias. With these difficulties in mind, we have reviewed how the components of the valvar complex can best be described when comparing direct images with those obtained using three-dimensional techniques now used for clinical imaging. We submit that these show that the skirt of leaflet tissue is best described as having aortic and mural components. When the hinge of the mural leaflet is assessed within the overall atrioventricular junction, the so-called disjunction is ubiquitous, but not always in the same place. We further suggest that its significance will best be determined when clinicians describe its presence using attitudinally appropriate terms.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 30 Dec 2022; epub ahead of print</small></div>
Anderson RH, Garbi M, Zugwitz D, Petersen SE, Nijveldt R
Heart: 30 Dec 2022; epub ahead of print | PMID: 36585240
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<div><h4>Haemodynamic and prognostic associations of liver fibrosis scores in Fontan-associated liver disease.</h4><i>Martin de Miguel I, Kamath PS, Egbe AC, Jain CC, ... Connolly HM, Miranda WR</i><br /><b>Objectives</b><br />Fontan-associated liver disease (FALD) is universal post-Fontan palliation; however, its impact on survival remains controversial and current diagnostic tools have limitations. We aimed to assess the prognostic role of liver fibrosis scores (aminotransferase to platelet ratio [APRI] and fibrosis-4 [FIB-4]) and their association with haemodynamics and other markers of liver disease.<br /><b>Methods</b><br />159 adults (age ≥18 years) post-Fontan undergoing catheterisation at Mayo Clinic, Minnesota, between 1999 and 2017 were included. Invasive haemodynamics and FALD-related laboratory, imaging and pathology data were documented.<br /><b>Results</b><br />Mean age was 31.5±9.3 years, while median age at Fontan procedure was 7.5 years (4-14). Median APRI score (n=159) was 0.49 (0.33-0.61) and median FIB-4 score (n=94) was 1.12 (0.71-1.65). Correlations between APRI and FIB-4 scores and Fontan pressures (r=0.30, p=0.0002; r=0.34, p=0.0008, respectively) and pulmonary arterial wedge pressure (r=0.25, p=0.002; r=0.30, p=0.005, respectively) were weak. Median average hepatic stiffness by magnetic resonance elastography was 4.9 kPa (4.3-6.0; n=26) and 24 (77.4%) showed stage 3 or 4 liver fibrosis on biopsy; these variables were not associated with APRI/FIB-4 scores. On multivariable analyses, APRI and FIB-4 scores were independently associated with overall mortality (HR 1.31 [1.07-1.55] per unit increase, p=0.003; HR 2.15 [1.31-3.54] per unit increase, p=0.003, respectively).<br /><b>Conclusions</b><br />APRI and FIB-4 scores were associated with long-term all-cause mortality in Fontan patients independent of other prognostic markers. Correlations between haemodynamic status and liver scores were weak; furthermore, most markers of liver fibrosis failed to correlate with non-invasive indices, underscoring the complexity of FALD.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 29 Dec 2022; epub ahead of print</small></div>
Martin de Miguel I, Kamath PS, Egbe AC, Jain CC, ... Connolly HM, Miranda WR
Heart: 29 Dec 2022; epub ahead of print | PMID: 36581444
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<div><h4>Prognosis of patients with hypertrophic cardiomyopathy and low-normal left ventricular ejection fraction.</h4><i>Choi YJ, Kim HK, Hwang IC, Park CS, ... Cho GY, Kim YJ</i><br /><b>Objective</b><br />To investigate whether low-normal left ventricular ejection fraction (LVEF) is associated with adverse outcomes in hypertrophic cardiomyopathy (HCM) and evaluate the incremental value of predictive power of LVEF in the conventional HCM sudden cardiac death (SCD)-risk model.<br /><b>Methods</b><br />This retrospective study included 1858 patients with HCM from two tertiary hospitals between 2008 and 2019. We classified LVEF into three categories: preserved (<b>≥</b>60%), low normal (50%-60%) and reduced (<50%); there were 1399, 415, and 44 patients with preserved, low-normal, and reduced LVEF, respectively. The primary outcome was a composite of SCD, ventricular tachycardia/fibrillation and appropriate implantable cardioverter-defibrillator shocks. Secondary outcomes were hospitalisation for heart failure (HHF), cardiovascular death and all-cause death.<br /><b>Results</b><br />During the median follow-up of 4.09 years, the primary outcomes occurred in 1.9%. HHF, cardiovascular death, and all-cause death occurred in 3.3%, 1.9%, and 5.3%, respectively. Reduced LVEF was an independent predictor of SCD/equivalent events (adjusted HR (aHR) 5.214, 95% CI 1.574 to 17.274, p=0.007), adding predictive value to the HCM risk-SCD model (net reclassification improvement 0.625). Compared with patients with HCM with preserved LVEF, those with low-normal and reduced LVEF had a higher risk of HHF (LVEF 50%-60%, aHR 2.457, 95% CI 1.423 to 4.241, p=0.001; LVEF <50%, aHR 7.937, 95% CI 3.315 to 19.002, p<0.001) and cardiovascular death (LVEF 50%-60%, aHR 2.641, 95% CI 1.314 to 5.309, p=0.006; LVEF <50%, aHR 5.405, 95% CI 1.530 to 19.092, p=0.009), whereas there was no significant association with all-cause death.<br /><b>Conclusions</b><br />Low-normal LVEF was an independent predictor of HHF and cardiovascular death in patients with HCM.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 29 Dec 2022; epub ahead of print</small></div>
Choi YJ, Kim HK, Hwang IC, Park CS, ... Cho GY, Kim YJ
Heart: 29 Dec 2022; epub ahead of print | PMID: 36581445
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<div><h4>Imaging of intracoronary thrombus.</h4><i>Whittington B, Tzolos E, Williams MC, Dweck MR, Newby DE</i><br /><AbstractText>The identification of intracoronary thrombus and atherothrombosis is central to the diagnosis of acute myocardial infarction, with the differentiation between type 1 and type 2 myocardial infarction being crucial for immediate patient management. Invasive coronary angiography has remained the principal imaging modality used in the investigation of patients with myocardial infarction. More recently developed invasive intravascular imaging approaches, such as angioscopy, intravascular ultrasound and optical coherence tomography, can be used as adjunctive imaging modalities to provide more direct visualisation of coronary atheroma and the causes of myocardial infarction as well as to improve the sensitivity of thrombus detection. However, these invasive approaches have practical and logistic constraints that limit their widespread and routine application. Non-invasive angiographic techniques, such as CT and MRI, have become more widely available and have improved the non-invasive visualisation of coronary artery disease. Although they also have a limited ability to reliably identify intracoronary thrombus, this can be overcome by combining their anatomical and structural characterisation of coronary anatomy with positron emission tomography. Specific radiotracers which bind with high specificity and sensitivity to components of thrombus, such as activated platelets, fibrin and factor XIIIa, hold promise for the non-invasive detection of intracoronary thrombus. The development of these novel non-invasive approaches has the potential to inform clinical decision making and patient management as well as to provide a non-invasive technique to assess the efficacy of novel antithrombotic therapies or interventional strategies. However, these have yet to be realised in routine clinical practice.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 22 Dec 2022; epub ahead of print</small></div>
Whittington B, Tzolos E, Williams MC, Dweck MR, Newby DE
Heart: 22 Dec 2022; epub ahead of print | PMID: 36549679
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<div><h4>Right ventricular-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension.</h4><i>Bartnik A, Pepke-Zaba J, Hoole SP, White P, ... Tsui S, Weir-McCall J</i><br /><AbstractText>Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular-pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 22 Dec 2022; epub ahead of print</small></div>
Bartnik A, Pepke-Zaba J, Hoole SP, White P, ... Tsui S, Weir-McCall J
Heart: 22 Dec 2022; epub ahead of print | PMID: 36549680
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<div><h4>Dysregulated carbohydrate and lipid metabolism and risk of atrial fibrillation in advanced old age.</h4><i>Pellegrini CN, Buzkova P, Oesterle A, Heckbert SR, ... Djoussé L, Kizer JR</i><br /><b>Objective</b><br />Obesity and dysmetabolism are major risk factors for atrial fibrillation (AF). Fasting and postload levels of glucose and non-esterified fatty acids (NEFAs) reflect different facets of metabolic regulation. We sought to study their respective contributions to AF risk concurrently.<br /><b>Methods</b><br />We assessed levels of fasting and postload glucose and NEFA in the Cardiovascular Health Study to identify associations with AF incidence and, secondarily, with ECG parameters of AF risk available at baseline. Linear and Cox regressions were performed.<br /><b>Results</b><br />The study included 1876 participants (age 77.7±4.4). During the median follow-up of 11.4 years, 717 cases of incident AF occurred. After adjustment for potential confounders, postload glucose showed an association with incident AF (HR per SD increment of postload glucose=1.11, 95% CI 1.02 to 1.21, p=0.017). Both glucose measures, but not NEFA, were positively associated with higher P wave terminal force in V1 (PTFV1); the association remained significant only for postload glucose when the two measures were entered together (β per SD increment=138 μV·ms, 95% CI 15 to 260, p=0.028). Exploratory analyses showed significant interaction by sex for fasting NEFA (p<sub>interaction</sub>=0.044) and postload glucose (p<sub>interaction</sub>=0.015) relative to AF, with relationships stronger in women. For postload glucose, the association with incident AF was observed among women but not among men.<br /><b>Conclusions</b><br />Among older adults, postload glucose was positively associated with incident AF, with consistent findings for PTFV1. In exploratory analyses, the relationship with AF appeared specific to women. These findings require further study but suggest that interventions to address postprandial dysglycaemia late in life might reduce AF.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 22 Dec 2022; epub ahead of print</small></div>
Pellegrini CN, Buzkova P, Oesterle A, Heckbert SR, ... Djoussé L, Kizer JR
Heart: 22 Dec 2022; epub ahead of print | PMID: 36549682
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<div><h4>Coronary calcium score in the initial evaluation of suspected coronary artery disease.</h4><i>Pedersen ER, Hovland S, Karaji I, Berge C, ... Rotevatn S, Larsen TH</i><br /><b>Objective</b><br />We evaluated coronary artery calcium (CAC) scoring as an initial diagnostic tool in outpatients and in patients presenting at the emergency department due to suspected coronary artery disease (CAD).<br /><b>Methods</b><br />10 857 patients underwent CAC scoring and coronary CT angiography (CCTA) at Haukeland University Hospital in Norway during 2013-2020. Based on CCTA, obstructive CAD was defined as at least one coronary stenosis ≥50%. High-risk CAD included obstructive stenoses of the left main stem, the proximal left ascending artery or affecting all three major vascular territories with at least one proximal segment involved.<br /><b>Results</b><br />Median age was 58 years and 49.5% were women. The overall prevalence of CAC=0 was 45.0%. Among those with CAC=0, 1.8% had obstructive CAD and 0.6% had high-risk CAD on CCTA. Overall, the sensitivity, specificity, positive predictive value and negative predictive value (NPV) of CAC=0 for obstructive CAD were 95.3%, 53.4%, 30.0% and 98.2%, respectively. However, among patients <45 years of age, although the NPV was high at 98.9%, the sensitivity of CAC=0 for obstructive CAD was only 82.3%.<br /><b>Conclusions</b><br />In symptomatic patients, CAC=0 correctly ruled out obstructive CAD and high-risk CAD in 98.2% and 99.4% of cases. This large registry-based cross-sectional study supports the incorporation of CAC testing in the early triage of patients with chest pain and as a gatekeeper to further cardiac testing. However, a full CCTA may be needed for safely ruling out obstructive CAD in the youngest patients (<45 years of age).<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 22 Dec 2022; epub ahead of print</small></div>
Pedersen ER, Hovland S, Karaji I, Berge C, ... Rotevatn S, Larsen TH
Heart: 22 Dec 2022; epub ahead of print | PMID: 36549683
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<div><h4>Pulmonary hypertension with a precapillary component in heart failure with preserved ejection fraction.</h4><i>Sera F, Ohtani T, Tamaki S, Yano M, ... Sakata Y, Osaka Cardiovascular Conference (OCVC)-Heart Failure Investigators</i><br /><b>Objectives</b><br />Heart failure with preserved ejection fraction (HFpEF) is often complicated by pulmonary hypertension (PH), which is mainly characterised by postcapillary PH and occasionally accompanied by a precapillary component of PH. Haemodynamic changes in worsening heart failure (HF) can modify the characteristics of PH. However, the clinical features of PH after HF treatment in HFpEF remain unclear. We investigated the prevalence and clinical significance of the precapillary component of PH after HF treatment in HFpEF, using data from the Prospective Multicentre Observational Study of Patients with HFpEF (PURSUIT-HFpEF).<br /><b>Methods</b><br />From the PURSUIT-HFpEF registry, 219 patients hospitalised with acute HF who underwent right heart catheterisation after initial HF treatment were divided into four groups according to the 2015 and 2018 PH definitions: non-PH, isolated postcapillary pulmonary hypertension (Ipc-PH), precapillary PH and combined postcapillary and precapillary pulmonary hypertension (Cpc-PH). The latter two were combined as PH with the precapillary component.<br /><b>Results</b><br />Using the 2015 definition, we found that the prevalence of PH after HF treatment was 27% (Ipc-PH: 20%, precapillary PH: 3%, Cpc-PH: 4%). Applying the 2018 definition resulted in a doubled frequency of precapillary PH (6%). PH with a precapillary component according to the 2015 definition was associated with poor clinical outcomes and characterised by small left ventricular dimension and high early diastolic mitral inflow velocity/early diastolic mitral annular tissue velocity.<br /><b>Conclusion</b><br />After initial HF treatment, 7% of hospitalised patients with HFpEF had precapillary component of PH according to the 2015 definition. Echocardiographic parameters of the left ventricle can contribute to the risk stratification of patients with HFpEF with a precapillary component of PH.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 21 Dec 2022; epub ahead of print</small></div>
Sera F, Ohtani T, Tamaki S, Yano M, ... Sakata Y, Osaka Cardiovascular Conference (OCVC)-Heart Failure Investigators
Heart: 21 Dec 2022; epub ahead of print | PMID: 36543519
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<div><h4>Impact of cardiovascular health and genetic risk on coronary artery disease in Chinese adults.</h4><i>Cui Q, Liu Z, Li J, Liu F, ... Lu X, Gu D</i><br /><b>Objective</b><br />To examine whether adherence to ideal cardiovascular health (CVH) can mitigate the genetic risk of coronary artery disease (CAD) in non-European populations.<br /><b>Methods</b><br />Fine and Grey\'s models were used to calculate HRs and their corresponding 95% CIs, as well as the lifetime risk of CVH metrics across Polygenic Risk Score (PRS) categories.<br /><b>Results</b><br />We included 39 755 individuals aged 30-75 years in Chinese prospective cohorts. 1275 CAD cases were recorded over a mean follow-up of 12.9 years. Compared with unfavourable CVH profile (zero to three ideal CVH metrics), favourable CVH profile (six to seven ideal CVH metrics) demonstrated similar relative effects across PRS categories, with the HRs of 0.40 (95% CI 0.24 to 0.67), 0.41 (95% CI 0.32 to 0.52) and 0.36 (95% CI 0.26 to 0.52) in low (bottom quintile of PRS), intermediate (two to four quintiles of PRS) and high (top quintile of PRS) PRS categories, respectively. For the absolute risk reduction (ARR), individuals with high PRS achieved the greatest benefit from favourable CVH, mitigating the risk to the average level of population (from 21.1% to 8.7%), and the gradient was strengthened in individuals at the top 5% of PRS. Moreover, compared with individuals at low PRS, those at high PRS obtained longer CAD-free years (2.6 vs 1.1) from favourable CVH at the index age of 35 years.<br /><b>Conclusion</b><br />Favourable CVH profile reduced the CAD relative risk by similar magnitude across PRS categories, while the ARR from favourable CVH was most pronounced in high PRS category. Attaining favourable CVH should be encouraged for all individuals, especially in individuals with high genetic susceptibility.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 20 Dec 2022; epub ahead of print</small></div>
Cui Q, Liu Z, Li J, Liu F, ... Lu X, Gu D
Heart: 20 Dec 2022; epub ahead of print | PMID: 36539268
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<div><h4>Double outlet ventricles: review of anatomic and imaging characteristics.</h4><i>Xu Z, Semple T, Gu H, McCarthy KP, Yen Ho S, Li W</i><br /><AbstractText>Hearts with double outlet ventricles and concordant atrioventricular connections account for about 1%-3% of all cases of congenital heart disease. We review hearts with two ventricles and concordant atrioventricular connections with double outlet right ventricle (DORV), double outlet left ventricle (DOLV) and double outlet both ventricles (DOBV) from the morphological and clinical imaging perspectives. These hearts are a heterogeneous group of congenital cardiac malformations with a wide range of pathophysiologies that require an individualised surgical approach based on a precise understanding of the complex cardiovascular anatomy. Owing to their differing temporal, spatial and contrast resolutions, we propose that multimodality imaging provides optimal characterisation of various intracardiac morphological features of double outlet hearts. This approach aids clinical diagnosis for optimising treatment options across these malformations.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 20 Dec 2022; epub ahead of print</small></div>
Xu Z, Semple T, Gu H, McCarthy KP, Yen Ho S, Li W
Heart: 20 Dec 2022; epub ahead of print | PMID: 36539269
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<div><h4>Management of coronary artery disease in patients with aortic stenosis.</h4><i>Androshchuk V, Patterson T, Redwood SR</i><br /><AbstractText>Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 16 Dec 2022; epub ahead of print</small></div>
Androshchuk V, Patterson T, Redwood SR
Heart: 16 Dec 2022; epub ahead of print | PMID: 36526337
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<div><h4>Efficacy of implantable haemodynamic monitoring in heart failure across ranges of ejection fraction: a systematic review and meta-analysis.</h4><i>Curtain JP, Lee MMY, McMurray JJ, Gardner RS, Petrie MC, Jhund PS</i><br /><b>Aims</b><br />We conducted a meta-analysis of randomised controlled trials (RCTs) of implantable haemodynamic monitoring (IHM)-guided care.<br /><b>Methods</b><br />PubMed and Ovid MEDLINE were searched for RCTs of IHM in patients with heart failure (HF). Outcomes were examined in total (first and recurrent) event analyses.<br /><b>Results</b><br />Five trials comparing IHM-guided care with standard care alone were identified and included 2710 patients across ejection fraction (EF) ranges. Data were available for 628 patients (23.2%) with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%) and 2023 patients (74.6%) with heart failure with a reduced ejection fraction (HFrEF) (EF <50%). Chronicle, CardioMEMS and HeartPOD IHMs were used. In all patients, regardless of EF, IHM-guided care reduced total HF hospitalisations (HR 0.74, 95% CI 0.66 to 0.82) and total worsening HF events (HR 0.74, 95% CI 0.66 to 0.84). In patients with HFrEF, IHM-guided care reduced total worsening HF events (HR 0.75, 95% CI 0.66 to 0.86). The effect of IHM-guided care on total worsening HF events in patients with HFpEF was uncertain (fixed-effect model: HR 0.72, 95% CI 0.59 to 0.88; random-effects model: HR 0.60, 95% CI 0.32 to 1.14). IHM-guided care did not reduce mortality (HR 0.92, 95% CI 0.71 to 1.20). IHM-guided care reduced all-cause mortality and total worsening HF events (HR 0.80, 95% CI 0.72 to 0.88).<br /><b>Conclusions</b><br />In patients with HF across all EFs, IHM-guided care reduced total HF hospitalisations and worsening HF events. This benefit was consistent in patients with HFrEF but not consistent in HFpEF. Further trials with pre-specified analyses of patients with an EF of ≥50% are required.<br /><b>Prospero registration number</b><br />CRD42021253905.<br /><br />© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 15 Dec 2022; epub ahead of print</small></div>
Curtain JP, Lee MMY, McMurray JJ, Gardner RS, Petrie MC, Jhund PS
Heart: 15 Dec 2022; epub ahead of print | PMID: 36522146
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<div><h4>Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis.</h4><i>Scarsini R, Pighi M, Mainardi A, Portolan L, ... Pesarini G, Ribichini FL</i><br /><b>Objectives</b><br />We hypothesised that low flow low gradient aortic stenosis (LFLGAS) is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac performance.<br /><b>Methods</b><br />Invasive CMD assessment was performed in 41 consecutive patients with isolated severe aortic stenosis with unobstructed coronary arteries undergoing transcatheter aortic valve implantation (TAVI). The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were measured in the left anterior descending artery before and after TAVI. Speckle tracking echocardiography was performed to assess cardiac function at baseline and repeated at 6 months.<br /><b>Results</b><br />IMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 (14.6 to 39.1) vs 12.8 (8.6 to 19.2), p=0.002), while RRR was significantly lower (1.4 (1.1 to 2.1) vs 2.6 (1.5 to 3.3), p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index, low cardiac output and reduced peak atrial longitudinal strain (PALS). TAVI determined no significant variation in microvascular function (IMR: 16.0 (10.4 to 26.1) vs 16.6 (10.2 to 25.6), p=0.403) and in PALS (15.9 (9.9 to 26.5) vs 20.1 (12.3 to 26.7), p=0.222). Conversely, left ventricular (LV) global longitudinal strain increased after TAVI (-13.2 (8.4 to 16.6) vs -15.1 (9.4 to 17.8), p=0.047). In LFLGAS, LV systolic function recovered after TAVI in patients with preserved microvascular function but not in patients with CMD.<br /><b>Conclusions</b><br />CMD is more severe in patients with LFLGAS compared with NFHGAS and is associated with low-flow state, left atrial dysfunction and reduced cardiac performance.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 13 Dec 2022; epub ahead of print</small></div>
Scarsini R, Pighi M, Mainardi A, Portolan L, ... Pesarini G, Ribichini FL
Heart: 13 Dec 2022; epub ahead of print | PMID: 36598066
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<div><h4>COVID-19 international experience in paediatric patients with congenital heart disease.</h4><i>Yeh MJ, Bergersen L, Gauvreau K, Barry OM, ... Travessa MAF, Jenkins KJ</i><br /><b>Objective</b><br />As COVID-19 continues to affect the global population, it is crucial to study the impact of the disease in vulnerable populations. This study of a diverse, international cohort aims to provide timely, experiential data on the course of disease in paediatric patients with congenital heart disease (CHD).<br /><b>Methods</b><br />Data were collected by capitalising on two pre-existing CHD registries, the International Quality Improvement Collaborative for Congenital Heart Disease: <i>Improving Care in Low- and Middle-Income Countries</i> and the Congenital Cardiac Catheterization Project on Outcomes. 35 participating sites reported data for all patients under 18 years of age with diagnosed CHD and known COVID-19 illness during 2020 identified at their institution. Patients were classified as low, moderate or high risk for moderate or severe COVID-19 illness based on patient anatomy, physiology and genetic syndrome using current published guidelines. Association of risk factors with hospitalisation and intensive care unit (ICU) level care were assessed.<br /><b>Results</b><br />The study included 339 COVID-19 cases in paediatric patients with CHD from 35 sites worldwide. Of these cases, 84 patients (25%) required hospitalisation, and 40 (12%) required ICU care. Age <1 year, recent cardiac intervention, anatomical complexity, clinical cardiac status and overall risk were all significantly associated with need for hospitalisation and ICU admission. A multivariable model for ICU admission including clinical cardiac status and recent cardiac intervention produced a c-statistic of 0.86.<br /><b>Conclusions</b><br />These observational data suggest risk factors for hospitalisation related to COVID-19 in paediatric CHD include age, lower functional cardiac status and recent cardiac interventions. There is a need for further data to identify factors relevant to the care of patients with CHD who contract COVID-19 illness.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 12 Dec 2022; epub ahead of print</small></div>
Yeh MJ, Bergersen L, Gauvreau K, Barry OM, ... Travessa MAF, Jenkins KJ
Heart: 12 Dec 2022; epub ahead of print | PMID: 36598072
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<div><h4>Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics.</h4><i>Paolisso P, Beles M, Belmonte M, Gallinoro E, ... Bartunek J, Van Camp G</i><br /><b>Background</b><br />Heart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team.<br /><b>Objective</b><br />To determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS).<br /><b>Methods</b><br />Single-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations.<br /><b>Results</b><br />2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007).<br /><b>Conclusions</b><br />In patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 12 Dec 2022; epub ahead of print</small></div>
Paolisso P, Beles M, Belmonte M, Gallinoro E, ... Bartunek J, Van Camp G
Heart: 12 Dec 2022; epub ahead of print | PMID: 36598073
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<div><h4>Pre-arrest comorbidity burden and the future risk of out-of-hospital cardiac arrest in Korean adults.</h4><i>Hong SI, Kim YJ, Kim YJ, Kim WY</i><br /><b>Objective</b><br />To investigate the impact of pre-arrest comorbidities on future out-of-hospital cardiac arrest (OHCA) development using a nationwide dataset.<br /><b>Methods</b><br />This population-based, matched case-control study used the national health insurance claims data relevant to OHCA in South Korea from January 2009 to December 2018. Case patients were randomly matched to controls by age, sex and date of cardiac arrest. Controls were defined as patients who did not experience OHCA based on claim codes in national health screening data. The comorbidity burden was assessed using the Charlson Comorbidity Index (CCI).<br /><b>Results</b><br />A total of 191 370 OHCA patients were matched to 347 568 controls. The mean CCI in the case group was 3.76, which was significantly higher than that in the control group (1.75, p<0.001). Overall, OHCA was 1.35 (95% CI 1.34 to 1.35) times more likely to occur with every 1 point increase in the CCI. All other comorbidities constituting the CCI were associated with the OHCA risk (p<0.001). Patients with CCI ≥3 presented an OR of 3.71 (95% CI 3.67 to 3.76) for the risk of OHCA occurrence. This association was more pronounced in patients aged <70 years than in those aged ≥70 years (OR (95% CI) 16.07 (15.48 to 16.68) vs 6.50 (6.33 to 6.68)).<br /><b>Conclusion</b><br />A high burden of pre-arrest comorbidity was associated with a higher risk of OHCA development, which was more pronounced in patients with less advanced age.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 06 Dec 2022; epub ahead of print</small></div>
Hong SI, Kim YJ, Kim YJ, Kim WY
Heart: 06 Dec 2022; epub ahead of print | PMID: 36598057
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<div><h4>Changes in aortic valve replacement procedures in Denmark from 2008 to 2020.</h4><i>Graversen PL, Butt JH, Østergaard L, Jensen AD, ... Køber L, Fosbøl EL</i><br /><b>Introduction</b><br />Since 2007, transcatheter aortic valve implantation (TAVI) has emerged as another treatment strategy for severe symptomatic aortic stenosis (AS) compared with surgical aortic valve replacement (SAVR). The objectives were to compare annual rates of aortic valve replacement (AVR) procedures performed in Denmark in the era of TAVI and to assess proportion of AVRs stratified by age with use of age recommendations presented in current guidelines.<br /><b>Methods</b><br />Using Danish nationwide registries, we identified first-time AVRs between 2008 and 2020. Patients who were not diagnosed with AS prior to AVR were excluded <br /><b>Results:</b><br/>The rate of AVRs increased by 39% per million inhabitants from 2008 to 2020. TAVI has steadily increased since 2008, accounting for 64.2% of all AVRs and 72.5% of isolated AVRs by 2020. Number of isolated SAVRs decreased from 2014 and onwards. The proportion of TAVI increased significantly across age groups (<75 and ≥75 years of age, p<sub>trend</sub><0.001), and TAVI accounted for 91.5% of isolated AVR procedures in elderly patients (aged ≥75 years). Length of hospital stay were significantly reduced for all AVRs during the study period (p<sub>trend</sub> all<0.001).<br /><b>Conclusions</b><br />The number of AVRs increased from 2008 to 2020 due to adaptation of TAVI, which represented 2/3 of AVRs and more than 70% of isolated AVRs. In elderly patients, the increased use of AVR procedures was driven by TAVI, in agreement with the age recommendations in current guidelines; however, TAVI was used more frequently in patients aged <75 years, accompanied by a flattening use of SAVR.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 05 Dec 2022; epub ahead of print</small></div>
Graversen PL, Butt JH, Østergaard L, Jensen AD, ... Køber L, Fosbøl EL
Heart: 05 Dec 2022; epub ahead of print | PMID: 36598047
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<div><h4>Methamphetamine-associated heart failure: a systematic review of observational studies.</h4><i>Manja V, Nrusimha A, Gao Y, Sheikh A, ... Sandhu ATS, Asch S</i><br /><b>Objective</b><br />To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .<br /><b>Methods</b><br />Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.<br /><b>Results</b><br />Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.<br /><b>Conclusions</b><br />The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 01 Dec 2022; epub ahead of print</small></div>
Manja V, Nrusimha A, Gao Y, Sheikh A, ... Sandhu ATS, Asch S
Heart: 01 Dec 2022; epub ahead of print | PMID: 36456204
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<div><h4>Multimodality imaging of large-vessel vasculitis.</h4><i>Tarkin JM, Gopalan D</i><br /><AbstractText>Multimodality cardiovascular imaging is an essential component of the clinical management of patients with large-vessel vasculitis (LVV), a chronic, relapsing and remitting inflammatory disease of the aorta and its major branches. Imaging is needed to confirm the initial diagnosis, to survey the extent and severity of arterial involvement, to screen for cardiovascular complications and for subsequent long-term disease monitoring. Indeed, diagnosing LVV can be challenging due to the non-specific nature of the presenting symptoms, which often evoke a broad differential. Identification of disease flares and persistent residual arteritis following conventional treatments for LVV present additional clinical challenges. However, by identifying and tracking arterial inflammation and injury, multimodality imaging can help direct the use of disease-modifying treatments that suppress inflammation and prevent or slow disease progression. Each of the non-invasive imaging modalities can provide unique and complementary information, contributing to different aspects of the overall clinical assessment. This article provides a focused review of the many roles of multimodality imaging in LVV.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 29 Nov 2022; epub ahead of print</small></div>
Tarkin JM, Gopalan D
Heart: 29 Nov 2022; epub ahead of print | PMID: 36446545
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<div><h4>Electrocardiographic findings and prognostic values in patients hospitalised with COVID-19 in the World Heart Federation Global Study.</h4><i>Pinto-Filho MM, Paixão GM, Gomes PR, Soares CPM, ... Sliwa K, Ribeiro ALP</i><br /><b>Background</b><br />COVID-19 affects the cardiovascular system and ECG abnormalities may be associated with worse prognosis. We evaluated the prognostic value of ECG abnormalities in individuals with COVID-19.<br /><b>Methods</b><br />Multicentre cohort study with adults hospitalised with COVID-19 from 40 hospitals across 23 countries. Patients were followed-up from admission until 30 days. ECG were obtained at each participating site and coded according to the Minnesota coding criteria. The primary outcome was defined as death from any cause. Secondary outcomes were admission to the intensive care unit (ICU) and major adverse cardiovascular events (MACE). Multiple logistic regression was used to evaluate the association of ECG abnormalities with the outcomes.<br /><b>Results</b><br />Among 5313 participants, 2451 had at least one ECG and were included in this analysis. The mean age (SD) was 58.0 (16.1) years, 60.7% were male and 61.1% from lower-income to middle-income countries. The prevalence of major ECG abnormalities was 21.3% (n=521), 447 (18.2%) patients died, 196 (8.0%) had MACE and 1115 (45.5%) were admitted to an ICU. After adjustment, the presence of any major ECG abnormality was associated with a higher risk of death (OR 1.39; 95% CI 1.09 to 1.78) and cardiovascular events (OR 1.81; 95% CI 1.30 to 2.51). Sinus tachycardia (>120 bpm) with an increased risk of death (OR 3.86; 95% CI 1.97 to 7.48), MACE (OR 2.68; 95% CI 1.10 to 5.85) and ICU admission OR 1.99; 95% CI 1.03 to 4.00). Atrial fibrillation, bundle branch block, ischaemic abnormalities and prolonged QT interval did not relate to the outcomes.<br /><b>Conclusion</b><br />Major ECG abnormalities and a heart rate >120 bpm were prognostic markers in adults hospitalised with COVID-19.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 25 Nov 2022; epub ahead of print</small></div>
Pinto-Filho MM, Paixão GM, Gomes PR, Soares CPM, ... Sliwa K, Ribeiro ALP
Heart: 25 Nov 2022; epub ahead of print | PMID: 36428092
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<div><h4>Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter.</h4><i>Gupta D, Ding WY, Calvert P, Williams E, ... Mahida S, Sticherling C</i><br /><b>Objective</b><br />We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL).<br /><b>Methods</b><br />Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy.<br /><b>Results</b><br />Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000).<br /><b>Conclusion</b><br />Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF.<br /><b>Trial registration number</b><br />NCT03401099.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 17 Nov 2022; epub ahead of print</small></div>
Gupta D, Ding WY, Calvert P, Williams E, ... Mahida S, Sticherling C
Heart: 17 Nov 2022; epub ahead of print | PMID: 36396438
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<div><h4>Emergent readmission and long-term mortality risk after incident atrial fibrillation hospitalisation.</h4><i>Weber C, Hung J, Hickling S, Li I, Murray K, Briffa T</i><br /><b>Objective</b><br />To assess the frequency and predictors of unplanned readmissions after hospitalisation for incident atrial fibrillation (AF) and the association of readmissions with mortality over 2 years.<br /><b>Methods</b><br />We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived incident (first-ever) hospitalisation for AF (principal diagnosis), between 2001 and 2015. Ordinal logistic models determined the covariates independently associated with unplanned readmission(s), and Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over 2 years after incident AF.<br /><b>Results</b><br />Of 22 956 patients, 57.7% male, mean age 67.9 (SD 13.8) years, 44.0% experienced 22 053 unplanned readmissions within 2 years, 50.6% being cardiovascular-related. All-cause death occurred in 8.0% of the cohort, and the multivariable-adjusted mortality HR of 1 (vs 0) readmission was 2.9 (95% CI 2.6 to 3.3), increasing to 5.6 (95% CI 5.0 to 6.5) for 3+ readmissions. First emergent readmission for AF, stroke, heart failure or myocardial infarction was independently associated with an increased hazard for mortality. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk, whereas AF ablation was associated with reduced risk.<br /><b>Conclusion</b><br />This study highlights the large burden of unplanned all-cause and cardiovascular-specific readmissions within 2 years after being hospitalised for incident AF and their associated adverse impact on mortality. Concomitant comorbidities are independently associated with unplanned hospitalisations and mortality, which supports integrated multidisciplinary management of comorbidities, along with AF-targeted treatments, to improve long-term outcomes in patients with AF.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 16 Nov 2022; epub ahead of print</small></div>
Weber C, Hung J, Hickling S, Li I, Murray K, Briffa T
Heart: 16 Nov 2022; epub ahead of print | PMID: 36384748
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<div><h4>Lower birth weight is linked to poorer cardiovascular health in middle-aged population-based adults.</h4><i>Raisi-Estabragh Z, Cooper J, Bethell MS, McCracken C, ... Harvey NC, Petersen SE</i><br /><b>Objective</b><br />To examine associations of birth weight with clinical and imaging indicators of cardiovascular health and evaluate mechanistic pathways in the UK Biobank.<br /><b>Methods</b><br />Competing risk regression was used to estimate associations of birth weight with incident myocardial infarction (MI) and mortality (all-cause, cardiovascular disease, ischaemic heart disease, MI), over 7-12 years of longitudinal follow-up, adjusting for age, sex, deprivation, maternal smoking/hypertension and maternal/paternal diabetes. Mediation analysis was used to evaluate the role of childhood growth, adulthood obesity, cardiometabolic diseases and blood biomarkers in mediating the birth weight-MI relationship. Linear regression was used to estimate associations of birth weight with left ventricular (LV) mass-to-volume ratio, LV stroke volume, global longitudinal strain, LV global function index and left atrial ejection fraction.<br /><b>Results</b><br />258 787 participants from white ethnicities (61% women, median age 56 (49, 62) years) were studied. Birth weight had a non-linear relationship with incident MI, with a significant inverse association below an optimal threshold of 3.2 kg (subdistribution HR: 1.15 (1.08 to 1.22), p=6.0×10<sup>-5</sup>) and attenuation to the null above this threshold. The birth weight-MI effect was mediated through hypertension (8.4%), glycated haemoglobin (7.0%), C reactive protein (6.4%), high-density lipoprotein (5.2%) and high cholesterol (4.1%). Birth weight-mortality associations were statistically non-significant after Bonferroni correction. In participants with cardiovascular magnetic resonance (n=19 314), lower birth weight was associated with adverse LV remodelling (greater concentricity, poorer function).<br /><b>Conclusions</b><br />Lower birth weight was associated with greater risk of incident MI and unhealthy LV phenotypes; effects were partially mediated through cardiometabolic disease and systemic inflammation. These findings support consideration of birth weight in risk prediction and highlight actionable areas for disease prevention.<br /><br />© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.<br /><br /><small>Heart: 16 Nov 2022; epub ahead of print</small></div>
Raisi-Estabragh Z, Cooper J, Bethell MS, McCracken C, ... Harvey NC, Petersen SE
Heart: 16 Nov 2022; epub ahead of print | PMID: 36384749
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<div><h4>National Institute for Health and Care Excellence guidelines for lipid management.</h4><i>Cegla J</i><br /><AbstractText>This article provides a summary of the available lipid-lowering therapies in the UK and how they fit into national guidelines. In addition, comparison is made between the current National Institute for Health and Care Excellence lipid modification guidelines and international guidance such as those published by the European Society of Cardiology/European Atherosclerosis Society and American Heart Association/American College of Cardiology.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 15 Nov 2022; epub ahead of print</small></div>
Cegla J
Heart: 15 Nov 2022; epub ahead of print | PMID: 36379696
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<div><h4>Prognostic implications of atrial fibrillation in adults with Ebstein anomaly.</h4><i>Martin de Miguel I, Madhavan M, Miranda WR, Connolly HM, Egbe AC</i><br /><b>Objective</b><br />Supraventricular arrhythmias are common in adults with Ebstein anomaly (EA). However, there are limited data about prognostic implications of atrial fibrillation (AF) in this population. Accordingly, our aim was to assess the clinical profile and burden of AF in adults with EA, and the relationship between AF and outcomes.<br /><b>Methods and results</b><br />Six hundred eighty-two consecutive adults with a median age of 36 (24-49) years from Mayo Clinic, Minnesota, USA, between 2003 and 2020 were included. Sustained episodes of AF, clinical, echocardiographic, rhythm and surgical data were collected. Prevalence of AF at baseline was 18% (126 patients); the first episode occurred at a mean age of 43±17 years. Patients with AF were older, were more likely men, and had hypertension, renal dysfunction, cardiac devices, and more advanced right-sided and left-sided remodelling. During a median follow-up of 156 (81-240) months, 62 patients (11%) developed incident AF. At the last encounter, prevalence of AF was 28% (188 patients); of those, 63 (34%) had recurrent AF. Hospitalisation for heart failure (HF) occurred in 51 patients (7%). AF (HR 2.32, 95% CI 1.18 to 4.47; p=0.01) was independently associated with hospitalisation for HF. All-cause death occurred in 53 patients (8%); it was more frequent in those with AF in the univariable analysis, although it did not remain significant in the multivariable analysis.<br /><b>Conclusions</b><br />AF in EA develops at relatively young ages with one-third of the cohort exhibiting a recurrent pattern. Patients with AF had a higher prevalence of comorbidities and worse right-sided and left-sided cardiac remodelling. AF was independently associated with HF hospitalisation.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 11 Nov 2022; epub ahead of print</small></div>
Martin de Miguel I, Madhavan M, Miranda WR, Connolly HM, Egbe AC
Heart: 11 Nov 2022; epub ahead of print | PMID: 36368881
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<div><h4>Sequencing of medical therapy in heart failure with a reduced ejection fraction.</h4><i>Savage HO, Dimarco AD, Li B, Langley S, ... Barbagallo R, Dungu JN</i><br /><AbstractText>The management of heart failure with a reduced ejection fraction is a true success story of modern medicine. Evidence from randomised clinical trials provides the basis for an extensive catalogue of disease-modifying drug treatments that improve both symptoms and survival. These treatments have undergone rigorous scrutiny by licensing and guideline development bodies to make them eligible for clinical use. With an increasing number of drug therapies however, it has become a complex management challenge to ensure patients receive these treatments in a timely fashion and at recommended doses. The tragedy is that, for a condition with many life-prolonging drug therapies, there remains a potentially avoidable mortality risk associated with delayed treatment. Heart failure therapeutic agents have conventionally been administered to patients in the chronological order they were tested in clinical trials, in line with the aggregate benefit observed when added to existing background treatment. We review the evidence for simultaneous expedited initiation of these disease-modifying drug therapies and how these strategies may focus the heart failure clinician on a time-defined smart goal of drug titration, while catering for patient individuality. We highlight the need for adequate staffing levels, especially heart failure nurse specialists and pharmacists, in a structure to provide the capacity to deliver this care. Finally, we propose a heart failure clinic titration schedule and novel practical treatment score which, if applied at each heart failure patient contact, could tackle treatment inertia by a constant assessment of attainment of optimal medical therapy.</AbstractText><br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 11 Nov 2022; epub ahead of print</small></div>
Savage HO, Dimarco AD, Li B, Langley S, ... Barbagallo R, Dungu JN
Heart: 11 Nov 2022; epub ahead of print | PMID: 36368882
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<div><h4>Pressure-flow responses to exercise in aortic stenosis, mitral regurgitation and diastolic dysfunction.</h4><i>Andersen MJ, Wolsk E, Bakkestrøm R, Christensen N, ... Hassager C, Moller JE</i><br /><b>Background</b><br />Haemodynamic exercise testing is important for evaluating patients with dyspnoea on exertion and preserved ejection fraction. Despite very different pathologies, patients with pressure (aortic stenosis (AS)) and volume (mitral regurgitation (MR)) overload and diastolic dysfunction after recent acute myocardial infarction (AMI) reach similar filling pressure levels with exercise. The pressure-flow relationships (the association between change in cardiac output (∆CO) and change in pulmonary arterial wedge pressure (∆PAWP) may provide insight into haemodynamic adaptation to exercise in these groups.<br /><b>Methods and results</b><br />One hundred sixty-eight subjects aged >50 years with a left ventricular ejection fraction of ≥50% underwent invasive exercise testing. They were enrolled in four different studies: AS (40 patients), AMI (52 patients), MR (43 patients) and 33 healthy subjects. Haemodynamic data were measured at rest, at 25 W, 75 W and at peak exercise. In all groups, PAWP increased with exercise. The greatest increase was observed in patients with AMI (from 12.7±3.9 mm Hg to 33.1±8.2 mm Hg, p<0.0001) and patients with AS (from 11.8±3.9 mm Hg to 31.4±6.1 mm Hg, p<0.0001), and the smallest was observed in healthy subjects (from 8.3±2.4 mm Hg to 21.1±7.5 mm Hg, p<0.0001). In all groups, the relative pressure increase was greatest at the beginning of the exercise. CO increased most in healthy patients (from 5.3±1.1 to 16.0±3.0 L/min, p<0.0001) and least in patients with AS (from 5.3±1.2 L/min to 12.4±2.6 L/min, p<0.0001). The pressure-flow relationships (∆PAWP/∆CO) and differed among groups (p<i>=</i>0.02). In all groups, the pressure-flow relationship was steepest in the initial phase of the exercise test. The AMI and AS groups (2.3±1.2 mm Hg/L/min and 3.0±1.3 mm Hg/L/min, AMI and AS, respectively) had the largest overall pressure-flow relationship; the healthy group had the smallest initially and at peak exercise (1.3±1.1 mm Hg/L/min) followed by MR group (1.9±1.4 mm Hg/L/min).<br /><b>Conclusion</b><br />The pressure-flow relationship was steepest in the initial phase of the exercise test in all groups. The pressure-flow relationship differs between groups.<br /><b>Trial registration numbers</b><br />NCT01974557, NCT01046838, NCT02961647 and NCT02395107.<br /><br />© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 10 Nov 2022; 108:1895-1903</small></div>
Andersen MJ, Wolsk E, Bakkestrøm R, Christensen N, ... Hassager C, Moller JE
Heart: 10 Nov 2022; 108:1895-1903 | PMID: 36356959
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<div><h4>Impact of sodium-glucose cotransporter-2 inhibitors on heart failure and mortality in patients with cancer.</h4><i>Chiang CH, Chiang CH, Chiang CH, Ma KS, ... Shiah HS, Neilan TG</i><br /><b>Objectives</b><br />Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce heart failure (HF) in at-risk patients and may possess antitumour effects. We examined the effect of SGLT2i on HF and mortality among patients with cancer and diabetes.<br /><b>Methods</b><br />This was a retrospective propensity score-matched cohort study involving adult patients with type 2 diabetes mellitus diagnosed with cancer between January 2010 and December 2021. The primary outcomes were hospitalisation for incident HF and all-cause mortality. The secondary outcomes were serious adverse events associated with SGLT2i.<br /><b>Results</b><br />From a total of 8640 patients, 878 SGLT2i recipients were matched to non-recipients. During a median follow-up of 18.8 months, SGLT2i recipients had a threefold lower rate of hospitalisation for incident HF compared with non-SGLT2i recipients (2.92 vs 8.95 per 1000 patient-years, p=0.018). In Cox regression and competing regression models, SGLT2i were associated with a 72% reduction in the risk of hospitalisation for HF (HR 0.28 (95% CI: 0.11 to 0.77), p=0.013; subdistribution HR 0.32 (95% CI: 0.12 to 0.84), p=0.021). The use of SGLT2i was also associated with a higher overall survival (85.3% vs 63.0% at 2 years, p<0.001). The risk of serious adverse events such as hypoglycaemia and sepsis was similar between the two groups.<br /><b>Conclusions</b><br />The use of SGLT2i was associated with a lower rate of incident HF and prolonged overall survival in patients with cancer with diabetes mellitus.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 09 Nov 2022; epub ahead of print</small></div>
Chiang CH, Chiang CH, Chiang CH, Ma KS, ... Shiah HS, Neilan TG
Heart: 09 Nov 2022; epub ahead of print | PMID: 36351793
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<div><h4>Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes.</h4><i>Ratcovich H, Sadjadieh G, Linde JJ, Joshi FR, ... Engstrøm T, Holmvang L</i><br /><b>Background</b><br />The ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid cCTA analysis may be limited by extensive coronary artery calcification. In addition, the effect of very early invasive coronary angiography (ICA) with possible revascularisation is debated.<br /><b>Methods</b><br />This is a posthoc analysis of patients ≥75 years included in the Very Early vs Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial. cCTA was performed prior to the ICA. The diagnostic accuracy of cCTA was investigated. Presence of a coronary artery stenosis ≥50% by subsequent ICA was used as reference. Patients were randomised to a very early (within 12 hours of diagnosis) or a standard ICA (within 48-72 hours of diagnosis). The primary composite endpoint was 5-year all-cause mortality, non-fatal recurrent myocardial infarction or hospital admission for refractory myocardial ischaemia or heart failure.<br /><b>Results</b><br />Of 452 (21%) patients ≥75 years, 161 (35.6%) underwent cCTA. 19% of cCTAs excluded significant CAD. The negative predictive value (NPV) of cCTA was 94% (95% CI 79 to 99) and the sensitivity 98% (95% CI 94 to 100). No significant differences in the frequency of primary endpoints were seen in patients randomised to very early ICA (at 5-year follow-up, n=100 (46.9%) vs 122 (51.0%), log-rank p=0.357).<br /><b>Conclusion</b><br />In patients ≥75 years with NSTEACS, cCTA before ICA showed a high NPV. A very early ICA <12 hours of diagnosis did not significantly improve long-term clinical outcomes.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 09 Nov 2022; epub ahead of print</small></div>
Ratcovich H, Sadjadieh G, Linde JJ, Joshi FR, ... Engstrøm T, Holmvang L
Heart: 09 Nov 2022; epub ahead of print | PMID: 36351794
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<div><h4>Trends in myocardial infarction and coronary revascularisation procedures in Australia, 1993-2017.</h4><i>Lin RZ, Gallagher C, Tu SJ, Pitman BM, ... Sanders P, Wong CX</i><br /><b>Objective</b><br />Prior data have shown rising acute myocardial infarction (MI) trends in Australia; whether these increases have continued in recent years is not known. This study thus sought to characterise contemporary nationwide trends in MI hospitalisations and coronary procedures in Australia and their associated economic burden.<br /><b>Methods</b><br />The primary outcome measure was the incidence and time trends of total MI, ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) hospitalisations from 1993 to 2017. The incidence and time trends of coronary procedures were additionally collected, alongside MI hospitalisation costs.<br /><b>Results</b><br />Adjusted for population changes, annual MI incidence increased from 216.2 cases per 100 000 to a peak of 270.4 in 2007 with subsequent decline to 218.7 in 2017. Similarly, NSTEMI incidence increased from 68.0 cases per 100 000 in 1993 to a peak of 192.6 in 2007 with subsequent decline to 162.6 in 2017. STEMI incidence decreased from 148.3 cases per 100 000 in 1993 to 56.2 in 2017. Across the study period, there were annual increases in MI hospitalisations of 0.7% and NSTEMI hospitalisations of 5.6%, and an annual decrease in STEMI hospitalisations of 4.8%. Angiography and percutaneous coronary intervention increased by 3.4% and 3.3% annually, respectively, while coronary artery bypass graft surgery declined by 2.2% annually. MI hospitalisation costs increased by 100% over the study period, despite a decreased average length of stay by 45%.<br /><b>Conclusions</b><br />The rising incidence of MI hospitalisations appear to have stabilised in Australia. Despite this, associated healthcare expenditure remains significant, suggesting a need for continual implementation of public health policies and preventative strategies.<br /><br />© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 07 Nov 2022; epub ahead of print</small></div>
Lin RZ, Gallagher C, Tu SJ, Pitman BM, ... Sanders P, Wong CX
Heart: 07 Nov 2022; epub ahead of print | PMID: 36344268
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This program is still in alpha version.