Heart

ObjectivesTo examine short-term primary causes of death after percutaneous coronary intervention (PCI) in a national cohort before and during COVID-19. BackgroundPublic reporting of PCI outcomes is a performance metric and a requirement in many healthcare systems. There are inconsistent data on the causes of death after PCI, and what proportion of these are attributable to cardiac causes. MethodsAll patients undergoing PCI in England between 1st January 2017 and 10th May 2020 were retrospectively analysed (n=273,141), according to their outcome from the date of PCI; no death and in-hospital, post-discharge, and 30-day death. ResultsThe overall rates of in-hospital and 30-day death were 1.9% and 2.8%, respectively. The rate of 30-day death declined between 2017 (2.9%) and February 2020 (2.5%), mainly due to lower in-hospital death (2.1% vs. 1.5%), before rising again from 1st March 2020 (3.2%) due to higher rates of post-discharge mortality. Only 59.6% of 30-day deaths were due to cardiac causes, the most common being acute coronary syndrome, cardiogenic shock and heart failure, and this persisted throughout the study period. 10.4% of 30-day deaths after 1st March 2020 were due to confirmed COVID-19. ConclusionsIn this nationwide study, we show that 40% of 30-day deaths are due to non-cardiac causes. Non-cardiac deaths have increased even more from the start of the COVID-19 pandemic, with one in ten deaths from March 2020 being COVID-19 related. These findings raise a question of whether public reporting of PCI outcomes should be cause-specific.

BackgroundThe Covid-19 pandemic has affected human behaviour and burdened health systems and has thus had an impact on other health outcomes. ObjectiveThis paper studies whether there was a decrease in cardiac surgery operations in Greece during the first wave of the Covid-19 pandemic. Data and MethodsWe used data from 7 major hospitals that geographically cover about half the country and more than half the population, including a mix of public, private, military and childrens hospitals. We used a difference-in-differences econometric approach to compare trends in cardiac surgery before and after the pandemic in 2020, to the same months in 2019, controlling for seasonality and unemployment, and using hospital fixed effects. ResultsWe found that during the first wave of the pandemic and the associated lockdown, there were 35-56% fewer cardiac surgery operations compared to what we would have expected in the absence of the pandemic. ConclusionsThere was a steep decline in Cardiac surgery operations in Greece during the first wave of the Covid-19 pandemic. Possible reasons may include people not seeking medical attention to avoid the risk of catching Covid-19; fewer referrals; and working from home, thus not being exposed to a stressful work environment or commute.

BackgroundSocial deprivation markers are associated with worse clinical outcomes after cardiac revascularization procedures. However, the association between social deprivation and cardiac valvular procedural outcomes is less established. We sought to distinguish the relationship between social deprivation and outcomes in the management of severe aortic stenosis, specifically transcatheter aortic valve replacement (TAVR) versus conventional surgical aortic valve replacement (SAVR). MethodsDemographics, patient comorbidities, procedural details, and outcomes for adults undergoing TAVR and SAVR between April 2017 and March 2022 were obtained from clinical and administrative databases and linked to neighbourhood-level measures of social deprivation using the Ontario Marginalization Index (ON-MARG) in Ontario, Canada. The three dimensions of social deprivation assessed were (1) material deprivation, (2) residential instability and (3) ethnic concentration. Our outcomes were 30-day mortality, 30-day readmission, 1-year mortality and 1-year readmission. Separate Cox proportional hazard models for post-procedural mortality and cause-specific hazard models for post-procedural re-admission were used to determine the association between social deprivation and post-procedural outcomes after TAVR versus SAVR. ResultsWe identified a total of 6,218 TAVR procedures and 3,342 isolated SAVR procedures within our study period after exclusion criteria were applied. After multivariable adjustment, we found that TAVR was associated with lower 30-day mortality (HR 0.58; 95% CI [0.37, 0.92]; p = 0.02), lower 30-day readmission rates (HR 0.75; 95% CI [0.63, 0.89]; p-value = 0.001) and a higher 1-year readmission rate (HR 1.14; 95% CI [1.02, 1.27]; p-value = 0.01) when compared to SAVR. When the three ON-MARG domains by treatment interactions were included in the analysis, the associations between TAVR and SAVR and these outcomes were not modified by the degree of neighbourhood social deprivation. ConclusionTAVR is associated with lower 30-day mortality and 30-day re-admission rates and higher 1-year re-admission compared to SAVR. These associations were not modified by social deprivation, including ethnic concentration, material deprivation and residential instability.

BackgroundPatients undergoing cardiac surgery face an increased risk of infective endocarditis (IE), a risk that may be further exacerbated by implantation of cardiac implantable electronic devices (CIED). This study aimed to assess the risk of IE after CIED implantation within 30 days of cardiac surgery and identify associated risk factors. MethodsAll patients in Sweden, with no previous CIED, who underwent first-time cardiac surgery between 2006 and 2020 were included in this nationwide registry-based study. Cox proportional hazards models adjusted for demographic and clinical covariates were used to estimate the association between CIED implantation and the risk of IE. ResultsOut of 73,367 patients, 2,302 (3.1%) received a CIED within 30 days. Over a median follow-up of 6.5 years (interquartile range, 3.2-10.1 years), 1,556 patients (2.1%) developed IE. CIED implantation was associated with an increased IE risk (adjusted Hazard ratio (aHR) 1.46; 95% confidence interval (CI) 1.20-1.77). Patients with IE had a significantly higher risk of mortality compared to those without IE (aHR 1.80; 95% CI 1.67-1.94; p<0.001). The type of cardiac surgery influenced IE risk, with valvular surgeries showing a higher incidence than coronary artery bypass grafting. Risk factors independently associated with IE included male sex, age at surgery, diabetes mellitus, and peripheral vascular disease. ConclusionsCIED implantation within 30 days after cardiac surgery is associated with an increased long-term risk of IE and subsequent mortality. The type of surgery and patient comorbidities influence the risk. CLINICAL PERSPECTIVE What is new?O_LIIn this large nationwide registry study, cardiac implantable electronic devices (CIEDs) placed within 30 days after cardiac surgery were associated with a substantial and persistent risk of infective endocarditis. C_LIO_LIThe risk of infective endocarditis was influenced by the type of cardiac surgery and patient-specific factors, rather than the timing of device implantation. C_LI What are the clinical implications?O_LIAmong post-cardiac surgery patients at elevated risk for infective endocarditis (e.g., those undergoing valvular procedures) who require a CIED, selecting devices associated with lower infection risk--such as leadless pacemakers or non-transvenous ICDs--may be a preferable strategy when appropriate. C_LIO_LIThe optimal timing of CIED implantation after cardiac surgery remains uncertain. When delaying implantation, the rationale should center on allowing for potential recovery of conduction abnormalities, rather than attempting to mitigate the risk of device-related infection. C_LI

Background: Bailout cardiac surgery during transcatheter aortic valve replacement (TAVR) is uncommon but remains associated with substantial morbidity and mortality. Although registries have described its incidence and major causes, they often provide limited detail regarding device-related failure mechanisms, attempted transcatheter rescue, and the clinical pathway leading to surgical conversion. We aimed at analyzing post-marketing safety reports from the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to characterize the mechanisms, management strategies, and reported outcomes of bailout surgery during or shortly after TAVR. Methods: We retrospectively analyzed FDA MAUDE reports received from July 1, 2016, through June 30, 2026. Eligible reports described unplanned urgent or emergent open cardiac surgery during or immediately after TAVR. Candidate reports were screened, adjudicated, and deduplicated at the clinical-event level. Events were classified by precipitating complication, transcatheter rescue, operative pathway, and reported outcome. Associations were evaluated using permutation tests, Fisher exact tests with Benjamini?Hochberg correction, adjusted regression models, and sensitivity analyses. Results: After screening 43,239 initial reports, we identified 376 bailout-surgery events, with survival status was documented in 254, including 104 deaths and 150 survivors, corresponding to 40.9% reported mortality. Valve embolization, migration, or malposition was the most frequent complication phenotype (32.4%), whereas ventricular perforation or laceration was associated with the highest mortality (74.1%; OR, 4.86; 95% CI, 1.97?11.99). Mortality differed across complication phenotypes (p<0.001) and operative pathways (p<0.001), but not across transcatheter rescue pathways (p=0.355). Valve explantation with SAVR was associated with lower reported mortality (18.9%; OR, 0.29; 95% CI, 0.12?0.69), whereas unspecified surgery or access/support alone was associated with higher mortality (56.9%; OR, 3.04; 95% CI, 1.80?5.12). Ancillary analyses identified potential platform-specific differences in complication and management patterns, while bailout timing was not independently associated with mortality after adjustment. Conclusions: In this MAUDE analysis, bailout cardiac surgery after TAVR was most commonly precipitated by valve embolization, migration, or malposition, whereas ventricular perforation or laceration was associated with the highest reported mortality. Outcomes differed across complication and operative pathways but not across transcatheter rescue strategies or bailout timing after adjustment. These findings identify clinically relevant post-marketing safety signals but should not be interpreted as incidence estimates, comparative device risks, or causal treatment effects.

BackgroundChloroquine (CQ) and Hydroxychloroquine (HCQ) have recently been suggested as treatment for the current Corona Virus Disease 2019 (COVID-19) pandemic. However, despite their long-term use and only few case reports on adverse effects, CQ and HCQ are listed as a known risk of the lethal ventricular arrhythmia Torsade de Pointes and their cardiac safety profile is being questioned. Thus, we aimed to investigate the electrocardiographic and mortality effects of CQ and HCQ in a primary care population. MethodsWe used Danish health care registers and electrocardiograms (ECGs) from primary care to define three studies. 1) A paired study of subjects with ECGs before and during use of CQ/HCQ, 2) a matched ECG study of subjects taking CQ/HCQ compared to controls, and 3) a mortality study on people taking HCQ matched to control. In both matched studies, we adjusted for connective tissue diseases, use of QT-prolonging drugs, and cardiac disease. We used the QTc interval as the marker for electrocardiographic safety. In the mortality study, cases were followed from first claimed prescription until 300 days after estimated completion of the last prescription. 95% confidence intervals follow estimates in parenthesis. ResultsUse of CQ was associated with a 5.5 (0.7;10) ms increase in QTc in the paired study (n=10). In the matched study (n=28, controls=280), QTc was insignificantly increased in subjects taking CQ by 4.7 (-3.4;13) ms. With a {Delta}QTc of 1.0 (-5.6;7.5), use of HCQ was not associated with an increased QTc in the paired study (n=32). In the matched study (n=172, controls=1,720), QTc also was not different between groups (p=0.5). In the mortality study (n=3,368), use of HCQ was associated with a hazard ratio of 0.67 (0.43;1.05). ConclusionsIn subjects free of COVID-19, we found a small increase in QTc associated with use of chloroquine, but not hydroxychloroquine. We found no increased mortality associated with use of hydroxychloroquine.

BackgroundAlthough morbidity and mortality from COVID-19 have been widely reported, the indirect effects of the pandemic beyond 2020 on other major diseases and health service activity have not been well described. MethodsAnalyses used national administrative electronic hospital records in England, Scotland and Wales for 2016-2021. Admissions and procedures during the pandemic (2020-2021) related to six major cardiovascular conditions (acute coronary syndrome, heart failure, stroke/transient ischaemic attack, peripheral arterial disease, aortic aneurysm, and venous thromboembolism) were compared to the annual average in the pre-pandemic period (2016-2019). Differences were assessed by time period and urgency of care. ResultsIn 2020, there were 31,064 (-6%) fewer hospital admissions (14,506 [-4%] fewer emergencies, 16,560 [-23%] fewer elective admissions) compared to 2016-2019 for the six major cardiovascular diseases combined. The proportional reduction in admissions was similar in all three countries. Overall, hospital admissions returned to pre-pandemic levels in 2021. Elective admissions remained substantially below expected levels for almost all conditions in all three countries (-10,996 [-15%] fewer admissions). However, these reductions were offset by higher than expected total emergency admissions (+25,878 [+6%] higher admissions), notably for heart failure and stroke in England, and for venous thromboembolism in all three countries. Analyses for procedures showed similar temporal variations to admissions. ConclusionThis study highlights increasing emergency cardiovascular admissions as a result of the pandemic, in the context of a substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years. Key QuestionWhat is the impact in 2020 and 2021 of the COVID-19 pandemic on hospital admissions and procedures for six major cardiovascular diseases in England, Scotland and Wales? Key FindingIn 2020, there were 6% fewer hospital admissions (emergency: -4%, elective: -23%) compared to 2016-2019 for six major cardiovascular diseases, across three UK countries. Overall, admissions returned to pre-pandemic levels in 2021, but elective admissions remained below expected levels. Take-home MessageThere was increasing emergency cardiovascular admissions as a result of the pandemic, with substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years.

BackgroundPermanent pacemaker implantation (PPI) is required in up to 30% of patients following transcatheter aortic valve replacement (TAVR), mainly due to conduction disturbances. While transvenous pacemakers (TVPM) have traditionally been used, leadless pacemakers (LLPM) could improve outcomes and reduce complications, especially in high-risk populations. MethodsWe conducted a retrospective, observational, propensity-matched cohort study using the TriNetX Global Collaborative Network. Patients who underwent TAVR followed by single chamber PPI within 30 days were identified and divided into two groups: LLPM and TVPM. Those with pre-existing pacemakers or concomitant cardiac surgery were excluded. Propensity score matching (1:1) was performed on demographic, clinical, laboratory, echocardiographic, and medication variables. Clinical outcomes such as all-cause mortality, heart failure, atrial fibrillation, procedural and device-related complications during follow-up were assessed. Kaplan-Meier analyses and Cox proportional hazards models were used. ResultsAmong 1,425 identified patients (469 LLPM, 956 TVPM), 367 matched pairs were analyzed. At 5-year follow-up, there was no significant difference in all-cause mortality (27.2% LLPM vs. 29.4% TVPM; HR 1.07, 95% CI 0.81-1.40; p=0.637). LLPM was associated with a significantly lower incidence of heart failure (16.1% vs. 25.6%; HR 0.61, 95% CI 0.44-0.84; p=0.002). Atrial fibrillation during follow-up was lower in the LLPM group (18.0% vs. 25.6%; HR 0.69, 95% CI 0.50-0.95; p=0.018). Procedure and device-related complication rates were low and similar between groups. ConclusionsIn this large real-world cohort, LLPM was associated with a reduced risk of heart failure and atrial fibrillation compared to TVPM, without differences in overall mortality or safety. These data support considering leadless pacing in selected post-TAVR patients, although prospective randomized studies are required to confirm these findings. Clinical PerspectiveO_ST_ABSWhat Is KnownC_ST_ABSO_LIPermanent pacemaker implantation is frequent after transcatheter aortic valve replacement (TAVR) and may negatively impact outcomes through device related complications, pacing-induced dyssynchrony and tricuspid interference. C_LIO_LILeadless pacemakers eliminate transvenous leads and pockets, reducing the risk of lead-related and infectious complications. C_LI What the Study AddsO_LIIn this large real-world propensity-matched analysis, leadless pacemakers were associated with fewer heart failure and atrial fibrillation events compared with transvenous devices, without differences in mortality or procedural safety. C_LIO_LIThese findings support the use of leadless pacing as a safe and potentially morbidity-sparing option in selected post-TAVR patients. C_LI

BackgroundWe evaluated whether development efficiency, the component of the Human Development Index independent of GDP per capita and income inequality, is associated with in-hospital mortality after coronary artery bypass grafting (CABG) in Brazil, and whether this association is mediated by access to elective surgery. MethodsWe conducted a retrospective ecological panel study using administrative data on CABG hospitalizations within the Brazilian Unified Health System from 2008-2024. State-year observations were linked to socioeconomic indicators. Development efficiency was defined as the residual of HDI after regression on GDP per capita and the Gini coefficient. Associations with in-hospital mortality were examined using volume-weighted multilevel models. Absolute causal effects and mediation through urgency status were estimated using g-computation and parametric causal mediation analysis. ResultsThe final analytic panel included 379 state-year observations. A 1-standard deviation increase in development efficiency was associated with a reduction in predicted in-hospital mortality from 6.8% to 5.7% (absolute risk reduction -1.1 percentage points; p<0.001), corresponding to one death prevented for every 91 procedures. Mediation analysis indicated that 95.5% of the total effect was attributable to the natural direct effect, while only 4.5% was mediated through urgency status, with no significant indirect effect. ConclusionsDevelopment efficiency is an independent and clinically meaningful determinant of survival after CABG in Brazil. Higher income-independent HDI performance is associated with substantial absolute mortality reductions, driven predominantly by direct system-level pathways rather than changes in urgency profile. Strengthening health-system efficiency and perioperative capacity may therefore yield meaningful gains in cardiac surgical outcomes.

Transcatheter aortic valve replacement (TAVR) use in young patients has recently increased following FDA approval for use in low-risk patients. How TAVR use among young patients may have accelerated in the interval between the FDA approval and the guideline publication remain unknown. We sought to characterize the national trends in aortic valve replacement (AVR) among young patients before and after the low-risk indication approval. Using the National Inpatient Sample data, we conducted a cross-sectional study of patients younger than 65 years of age who underwent TAVR, SAVR, or Ross operations between January 1, 2016, and February 29, 2020. We compared in-hospital mortality before and after the low-risk indication approval to infer whether the expansion occurred among lower-risk strata within the TAVR group in relation to SAVR. We identified 106,340 AVRs, including 13,095 TAVR (12.3%), 63,620 bioprosthetic SAVR (59.8%), 28,370 mechanical SAVR (26.7%), and 1,255 Ross (1.2%). The mean age was 54 (10.9), including 32,775 (30.8%) women. Before and after the low-risk approval, the TAVR share increased at 0.25 (0.03%) and 0.60 (0.09%) per month, respectively (interaction term p-value <0.001). Expansion of TAVR use among young patients around the time of FDA approval in low surgical risk patients serves as a case study to highlight the potential importance of specifying the indicated age group in future FDA approvals of transcatheter valve intervention devices.

BackgroundAtrial Fibrillation (AF) detection tools have rapidly developed over the last decade alongside the evolution of mobile health (mHealth) monitoring. mHealth wearable technologies have been hypothesised to be a potential non-invasive and near continuous modality for long term detection and monitoring of atrial arrhythmias. We conducted a proof-of-concept study to evaluate changes in heart rate obtained from a consumer wearable device and compare against implanted loop recorder (ILR)-detected recurrence of AF and atrial tachycardia (AT) after AF ablation. MethodsREMOTE-AF (Remote Monitoring of AF Recurrence Using mHealth Technology; NCT05037136) was a prospectively designed sub study of the CASA-AF randomised controlled trial (NCT04280042). Participants without a permanent pacemaker had an ILR implanted at their index ablation procedure (catheter vs thoracoscopic) for longstanding persistent AF. Heart rate (HR) and step count were continuously monitored using a wrist-worn wearable device connected to a smartphone. Photoplethysmography (PPG) recorded HR data was pre-processed with noise filtration and episodes at 1 -minute intervals over 30 minutes of HR elevations (Z-score = 2) were compared to corresponding ILR data. Arrhythmias detected by ILR were validated by an independent cardiac physiologist. The AF Effect on Quality of Life (AFEQT) questionnaire was completed by participants at baseline and at the conclusion of the study. ResultsThirty-five patients were enrolled, with mean age 70.3 +/- 6.8 yrs, 12 (34%) women, and median follow-up 10 months (IQR 8-12 months). ILR analysis revealed 17 out of 35 patients (49%) had recurrence of AF/AT. Compared with ILR recurrence, wearable-derived elevations in HR [&ge;] 110 beats per minute had a sensitivity of 95.3%, specificity 54.1%, positive predictive value (PPV) 15.8%, negative predictive value (NPV) 99.2% and overall accuracy 57.4%. With PPG recorded HR elevation spikes (non-exercise related), the sensitivity was 87.5%, specificity 62.2%, PPV 39.2%, NPV 92.3% and overall accuracy 64.0% in the entire patient cohort. In the AF/AT recurrence only group, sensitivity was 87.6%, specificity 68.3%, PPV 53.6%, NPV 93.0% and overall accuracy 75.0%. ConclusionConsumer wearable devices have the potential to contribute to arrhythmia detection after AF ablation, but further work is needed to improve and validate new composite detection algorithms. Clinical PerspectivesO_ST_ABSWhat is New?C_ST_ABSO_LIWe have utilised a new composite of data obtained from wearable devices in a predominantly older cohort of patients > 65 years old to detect AF/AT recurrence in a long-standing persistent AF (LSPAF) patient population who have undergone AF ablation. C_LIO_LIWe introduce a novel concept of the spike score, defined as the rate of change in HR over a consecutive two-minute period to detect AF/AT recurrence. C_LIO_LIThis is the first study to have achieved this in a post AF ablation cohort of LSPAF compared to the gold standard ILR. C_LI Clinical ImplicationsO_LIThe use of wearable devices to look for recurrence of atrial arrythmias in post ablation cohorts may enable a more rapid time to detection for more timely interventions. C_LIO_LIData composites recorded from wearables may be used alongside the PPG waveform to further improve accuracy in detecting atrial arrythmias. C_LIO_LIAF/AT recurrence detected via wearable devices and associated smart mobile applications can encourage risk factor modification through lifestyle interventions and improve health literacy. C_LI

BackgroundRate and rhythm control medications remain central to atrial fibrillation (AF) management, even as catheter ablation becomes increasingly preferred for select patients. However, national spending patterns and cost disparities between these medication classes under Medicare Part D remain poorly defined. ObjectivesTo evaluate Medicare Part D spending trends and cost differences between rate and rhythm control agents from 2013 to 2022. MethodsA retrospective analysis of Medicare Part D Prescription Drug Event data (2013-2022) was performed, including 13 commonly prescribed monotherapy agents categorized as rate or rhythm control. For each drug, total annual spending, cost per claim, and cost per beneficiary were calculated. Linear regression assessed temporal cost trends, and independent t-tests compared rate versus rhythm classes. Statistical significance was defined as p < 0.05. ResultsRate control agents showed a significant decline in cost per claim (p = 0.003), driven by metoprolol succinate (-53.9%, p < 0.001). Rhythm control agents demonstrated significant increases in both cost per claim (p < 0.001) and cost per beneficiary (p = 0.026). Dronedarone rose from $2,166 to $5,374 per beneficiary (p < 0.001), while flecainide increased to $71 per claim and $276 per beneficiary (p = 0.001, p = 0.036). Despite generic availability, amiodarone, verapamil, and diltiazem also trended upward. Across all years, rhythm agents remained more expensive than rate agents (p < 0.001). ConclusionFrom 2013-2022, Medicare costs decreased for rate control medications but rose sharply for rhythm agents. Addressing these disparities through transparent pricing and formulary reform is essential to preserve equitable access to rhythm control therapy.

BackgroundThis study aimed to evaluate the differences in stroke risk and the impact of atrial fibrillation (AF) among racial groups by conducting a patient-level comparative analysis using two nationwide datasets. Methods and ResultsThis study utilized data from the Korean National Health Insurance Service-Health Screening and UK Biobank, which included participants who underwent health examinations between 2005 and 2012. The primary outcome was a composite of ischemic and hemorrhagic stroke. A total of 446,986 East Asians in Korea, 3904 East Asians in the UK, and 403,240 Caucasians in the UK were analyzed. East Asians in Korea had a higher comorbidity burden compared to both UK groups (p<0.001). During the follow-up period, the incidence of AF showed no significant difference between East Asians in Korea and the UK (Log-rank p=0.21), while Caucasians had a higher rate (Log-rank p<0.001). Incidence rates of the primary outcome per 1000 person-years were 3.78 (95% CI 3.72-3.85) for East Asians in Korea, 0.92 (95% CI 0.64-1.20) for East Asians in the UK, and 1.13 (95% CI 1.10-1.16) Caucasians in the UK. Although there was no difference between the two UK groups (p=0.13), the rate was significantly higher among East Asians in Korea (p<0.001). This trend consistently observed regardless of AF status or oral anticoagulant use. ConclusionsBased on this patient-level analysis, East Asians in Korea, unlike East Asians in the UK, were more susceptible to stroke compared to Caucasians. This increased vulnerability was partly attributed to their higher comorbidity burden. Key messagesO_ST_ABSWhat is new?C_ST_ABSO_LIThis large-scale study utilizes patient-level data from approximately one million individuals to evaluate stroke risk differences and the impact of atrial fibrillation (AF). C_LIO_LIWhile East Asians in the UK demonstrated a similar stroke incidence to Caucasians in the UK, East Asians in Korea, who had the greatest burden of underlying cardiovascular disease such as hypertension, dyslipidemia, and heart failure, showed a stroke incidence rate more than three times that of the two UK race groups. C_LIO_LIThe impact of AF on stroke was not significantly difference between the East Asians in Korea and Caucasians in the UK. C_LI What are the clinical implications?O_LIIn contrast to East Asians in Korea, East Asians in the UK demonstrated a stroke risk similar to that of Caucasians, underscoring the imperative need for rigorous management of cardiovascular risk factors and lifestyle modification in order to prevent stroke. C_LIO_LIFuture studies should investigate how other risk factors, such as extreme weather, dietary habits, and genetic factors, contribute to the differences in long-term prognosis between East Asians and other racial groups. C_LI

Background: Sex-related disparities in acute coronary syndrome (ACS) recognition and management remain a global health concern. We examined sex-based differences in clinical presentation, management, and outcomes among patients with chest pain attended by emergency medical services (EMS) across Brazil. Methods: We conducted a retrospective study using a registry from 14 Brazilian states between January 2020 and June 2024 within a private hospital network. Patients with chest pain were classified by cardiologists as unstable angina (UA), ST-elevation myocardial infarction (STEMI), or non-ST-elevation myocardial infarction (NSTEMI). Multivariable regression evaluated sex differences in diagnosis, treatment, and outcomes. Sensitivity analyses included state-clustered standard errors and E-values for unmeasured confounding. Results: Among 7,171 patients with confirmed ACS (68.2% male), median age was 63.0 years [IQR 20.0]; women were older than men (67.0 [20.0] vs 61.0 [19.0] years). Diagnoses were UA in 46.7%, STEMI in 18.8%, and NSTEMI in 34.6%. Overall, 91.7% received aspirin and 89.6% at least one additional antiplatelet agent. After adjustment, women had higher odds of chest pain classified as probably or possibly ischemic versus definitely ischemic (adjusted OR 1.51 [95% CI 1.33-1.72] and 1.60 [1.37-1.86], respectively) and lower odds of STEMI and NSTEMI relative to UA (adjusted OR 0.59 [0.51-0.68] and 0.74 [0.66-0.83], respectively). Door-to-ECG time was longer in women unadjusted ({beta}=1.53 minutes [0.24-2.82]) but not after adjustment ({beta}=1.04 [-0.27 to 2.36]). In-hospital mortality did not differ between sexes, with no evidence of excess short-term mortality in women. Conclusions: Within a private hospital network in Brazil, women with confirmed ACS were more often classified with less definitely ischemic chest pain and less frequently with STEMI or NSTEMI than men. Door-to-ECG differences did not persist after adjustment, and mortality did not differ by sex. These findings support sex-sensitive triage and diagnostic protocols to reduce inequities in ACS recognition and treatment.

Background: Postoperative atrial fibrillation (POAF) is a frequent complication following coronary artery bypass grafting (CABG) and is associated with increased acute morbidity and resource utilization. However, its independent role in driving post-discharge adverse events in contemporary practice remains debated. Objective: To evaluate the association between POAF and short-term outcomes after CABG, and to utilize empirical Bayesian risk updating to stratify 90-day post-discharge vulnerabilities. Methods: A retrospective cohort analysis of 4,684 adult patients who underwent isolated CABG in Florida between January 1, 2021, and June 30, 2024, was conducted, excluding those with documented preoperative AFib. We employed multivariable negative binomial and logistic regression models to assess length of stay (LOS), discharge disposition, 90-day readmission, and 90-day composite complications. Additionally, a Bayesian Beta-Binomial conjugate model with an objective Jeffreys Prior was utilized to estimate the posterior probabilities of adverse outcomes across key clinical phenotypes. Results: POAF occurred in 355 patients (7.58%). Multivariable analysis demonstrated a 30% relative increase in expected LOS (IRR 1.30, 95% CI [1.23 - 1.36], P < .001) and 33% higher odds of facility discharge (OR 1.33, 95% CI [1.03 - 1.72], P = .030) for patients with POAF. However, POAF was not independently associated with 90-day readmission (OR 1.25, P = .063) or composite complications (OR 1.20, P = .118). Chronic heart failure (CHF) emerged as the dominant predictor. Bayesian risk updating revealed that while the baseline posterior probability for a 90-day complication was 27.2%, the synergistic presence of both POAF and CHF radically shifted this posterior risk to 42.6% (Probability of Direction > 0.999 vs. baseline). Conclusions: POAF prolongs hospitalization and drives non-home discharges, but it does not independently dictate 90-day morbidity. Bayesian stratification demonstrates that post-discharge outcomes are predominantly driven by underlying chronic conditions. Effective reduction of readmissions requires robust transition-of-care frameworks, empowering primary care clinicians to aggressively optimize heart failure and metabolic disease rather than focusing solely on the acute surgical arrhythmic event.

Background and AimsPeople with a mental disorder have poorer myocardial infarction (MI) outcomes, with differences in cardiac care thought to be partly responsible. We compared receipt of guideline-informed acute MI care by mental disorder and assessed how the COVID-19 pandemic affected associations. MethodsWe identified people with MI in England (November 2019 - February 2023) from the Myocardial Ischaemia National Audit Project (MINAP), ascertaining prior mental disorder from linked hospitalisation and primary care records and extracting care standards from MINAP. We used logistic regression to compare care standards for ST-elevation MI (STEMI) and non-STEMI (NSTEMI) between people with each of schizophrenia, bipolar disorder or depression versus those without any of these disorders, adjusting for confounders and investigating differences over time. ResultsWe included 131,075 NSTEMI and 79,045 STEMI cases. For NSTEMI, people with prior mental disorder had lower odds of angiography eligibility and receipt, cardiac ward admission and cardiac rehabilitation referral. Odds ratios (95% CIs) ranged from 0.25 (0.20, 0.31) for angiography receipt for schizophrenia to 0.92 (0.89, 0.96) for cardiac ward admission for depression. For STEMI, there was no evidence of care differences for depression; however, people with bipolar disorder were less likely to meet call-to-balloon targets and people with schizophrenia were less likely to be referred for cardiac rehabilitation and receive indicated secondary prevention medication. Disparities were generally unaffected by the COVID-19 pandemic. ConclusionsPeople with a mental disorder are less likely to receive guideline-informed MI care, with variation by MI type, care standard and mental disorder. SummaryWe used linked electronic health records from over 200 000 NSTEMI and STEMI patients in England to compare receipt of guideline-informed care for myocardial infarction by mental disorder status and assess how the COVID-19 pandemic affected associations. We identified disparities in a range of care standards for both NSTEMI and STEMI, which were greatest for people with schizophrenia, but also evident for bipolar disorder and depression. Disparities were generally unaffected by the COVID-19 pandemic.

BackgroundCardiac resynchronization therapy (CRT) has demonstrated survival and symptom benefits in patients with heart failure with reduced ejection fraction (HFrEF). However, the comparative effectiveness of CRT with a defibrillator (CRT-D) versus pacemaker-only (CRT-P) remains uncertain in octogenarians, who are underrepresented in clinical trials. ObjectiveTo assess long-term mortality and hospitalization outcomes associated with CRT-D versus CRT-P in octogenarians with HFrEF and left bundle branch block (LBBB), using real-world propensity-matched data. MethodsWe identified 1,240 patients aged [&ge;]80 years with HFrEF (LVEF [&le;]35%) and LBBB who underwent device implantation. After 1:1 propensity score matching across 65 clinical variables, 772 patients (386 CRT-D, 386 CRT-P) were included in the primary analysis. The primary endpoint was all-cause mortality over 3 years. Secondary endpoints included timepoint-specific mortality and all-cause hospitalization burden. Prespecified subgroup analyses were performed by ejection fraction (EF [&le;]25%, 26-35%) and by sex within each CRT modality. ResultsThree-year mortality did not differ significantly between CRT-D and CRT-P (37.2% vs 39.1%; HR 1.026, 95% CI 0.814-1.293; p = 0.829). Mortality at 30 days, 90 days, and 1 year was numerically lower in CRT-D but not statistically significant. CRT-D recipients experienced fewer hospitalizations (mean 4.05 vs 5.36; p = 0.032). In EF-stratified subgroups, mortality was modestly lower with CRT-D (risk difference -3.8% in EF [&le;]25%; -2.1% in EF 26-35%), though not significant. Among CRT-D recipients, females had lower mortality than males (20.0% vs 29.5%; HR 0.637, 95% CI 0.353-1.149). ConclusionsIn this real-world cohort of octogenarians with HFrEF, CRT-D did not improve survival over CRT-P but was associated with reduced hospitalization burden. These findings highlight the importance of phenotype-guided device selection, informed by arrhythmic risk, comorbid burden, and patient-centered goals of care.

BackgroundThe Veterans Health Administration (VA) healthcare system cares for almost 200,000 Veterans with heart failure with reduced ejection fraction (HFrEF). It is not known how this population fared regarding continuity of care quality measures and access over the past 6 years, including the COVID-19 pandemic and its aftermath. This study aimed to evaluate temporal trends in heart failure care delivery and identify prognostic factors for clinical outcomes for Veterans with HFrEF from 1/1/2019-12/31/2024. MethodsAn interrupted time series analysis examined care patterns across pre-pandemic, early COVID, and late COVID periods using linear regression models with monthly fixed effects. Survival analysis of Veterans with HFrEF identified prognostic factors for mortality and hospitalization. ResultsThe study included 210,535 individuals (mean age 73.1; 2.2% women; mean ejection fraction 32.5%). HFrEF medication prescriptions were maintained or improved, with upward trends for most medications in the early COVID period and all medications in the late COVID period (range: 0.1-0.9 percentage point increase per 6-week period, compared to pre-COVID baseline), yet with significant treatment gaps for all medication classes by study end. The onset of COVID led to a 2-4-fold increase in telehealth utilization (primary care: 18.2 percentage points, 95% CI: 14.7 to 21.6; cardiology: 8.6 percentage points, 95% CI: 7.4 to 9.8). There was a sustained 45% relative decrease in all-cause hospitalization and 40% relative decrease in heart failure hospitalization, but a sustained 20% increase in mortality. Cumulative survival was 56.1% at 6 years. ConclusionsHFrEF medication rates were generally sustained or improved but well below optimal levels for Veterans with HFrEF. Telehealth replaced some in-person care early in the pandemic. Despite these changes, this high-risk population experienced a sustained decrease in hospitalizations and increase in mortality. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSVeterans with heart failure with reduced ejection fraction increasingly used guideline directed medical therapy over the past 6 years with significant gaps remaining. There was an increased use of telehealth, sustained decrease in hospitalizations, and sustained increase in all-cause mortality for this patient population, compared to pre-COVID trends. What are the clinical implications?The sustained increase in mortality despite maintained medication access and successful telehealth implementation suggests that traditional care quality measures may not fully capture patient care associated with outcomes during major healthcare disruptions, warranting further investigation and validation in other health systems.

BackgroundAdvances in wearable devices and machine-learning-based ECG analysis enable highly accurate detection of atrial fibrillation (AF) outside traditional clinical settings, leading to increasing identification of asymptomatic AF. However, the prognostic significance of AI-detected asymptomatic AF and its implications for downstream cardiovascular risk remain unclear. In contrast to clinically diagnosed AF, evidence guiding risk stratification and further evaluation in this population is limited. We therefore investigated the association between AI-detected asymptomatic AF and incident cardiovascular outcomes in a large population-based cohort. MethodsWe applied a validated open-source ECG-based deep learning model for atrial fibrillation detection (AI-AF) to 12-lead ECG recordings from participants in the UK Biobank. Participants with AI-detected AF on ECG and no prior clinical AF diagnosis were classified as asymptomatic AF (c). Kaplan-Meier curves and log-rank tests were used to compare the incidence of ischemic stroke and major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, or cardiovascular death) across AF subgroups. Cox proportional hazards models were used to evaluate the association between AI-AF risk and incident MACE, adjusting for age, sex, current smoking, systolic blood pressure, total and HDL cholesterol, and prevalent type 2 diabetes. Follow-up was administratively censored at 6 years. ResultsThe study included 96,531 participants with mean [SD] age of 65 [8] years; 52% female; median follow-up [IQR] of 4.7 [1.6-7.2] years. ECG data were available for 64,029 participants and an additional 32,502 participants with clinically diagnosed atrial fibrillation (AF) without ECG recordings were included. Among participants without prior clinical AF and with available ECGs, 2,399 were classified as asympAF based on AI detection, while 58,879 were AF-free. Over 6 years of follow-up, the incidence of ischemic stroke was significantly higher in participants with asympAF compared with AF-free individuals (1.5% vs 0.52%, p = 7x10-7) and significantly lower than in participants with clinically diagnosed AF (1.5% vs 3.4%, p = 2x10-5). Similar patterns were observed for myocardial infarction and cardiovascular death. Using a more liberal AI-AF threshold corresponding to a 15% false-positive rate (asympAF15) yielded consistent findings: participants classified as asympAF15 had a 62% higher risk of incident MACE in adjusted Cox PH models (hazard ratio 1.6, 95% CI 1.2-2.2) over six years. ConclusionAI-detected asymptomatic AF identified individuals at elevated risk of ischemic stroke and major adverse cardiovascular events. As ischemic stroke is a hallmark complication of atrial fibrillation, these findings support the hypothesis that AI-ECG models may capture subclinical AF-related risk not detected by conventional clinical assessment. This approach may help extend the window for preventive interventions in populations without clinically diagnosed AF.

Abstract Background Premature, or early-onset, coronary artery disease (CAD) carries lifelong consequences. Ethnic inequalities in CAD are established in the UK, but risk estimates mostly derive from events after middle age, while ethnicity is aggregated for South Asian and Black populations. Disaggregated, sex-specific risk estimates would permit better recognition and more targeted prevention. Methods We used Clinical Practice Research Datalink (CPRD) Aurum, an English primary care database linked to hospital, mortality, and deprivation data. We included adults aged 18-45 of White European, South Asian (Indian, Pakistani, Bangladeshi), or Black (African, Caribbean) ethnicity, followed for up to 20 years. Incident premature CAD (onset [&le;]45) was a first myocardial infarction or coronary revascularisation. We estimated age-adjusted and fully adjusted incidence rate ratios (IRRs) versus White Europeans by Poisson regression, testing an ethnicity-sex interaction. Findings Among 14.8 million adults contributing 80.9 million person-years, 16,001 premature CAD events occurred (77.6% in men). In men, the combined South Asian age-adjusted IRR was 1.87 [95% CI 1.77, 1.99], ranging from 1.39 [1.28, 1.50] in Indian to 2.79 [2.52, 3.07] in Bangladeshi men, persisting after full adjustment and already evident at ages 18-26. The combined Black IRR was 0.64 [0.57, 0.71], lowest in African (0.57[0.50, 0.65]) and highest in Caribbean men (0.82 [0.68, 0.98]). In women, the combined South Asian IRR showed no overall excess (1.10 [0.95, 1.26]), concealing a clear excess in Pakistani women (1.56 [1.29, 1.89]). The ethnicity-sex interaction was significant (p<0.001); the male-to-female ratio was highest in Bangladeshi individuals (8.4:1 versus 3.3:1 in White Europeans). Interpretation Aggregated ethnic categories conceal sex-specific subgroups at high risk of premature CAD, a risk already present in early adulthood. Current screening and health check programmes beginning at age 40, start too late to reach these higher-risk, underserved groups. Funding: Kusuma Trust and NIHR UCLH BRC.