Heart

Background: Atrial high-rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with increased thromboembolic risk, yet their clinical significance and optimal anticoagulation strategy remain uncertain, particularly in the absence of electrocardiogram (ECG)-confirmed atrial fibrillation. Methods: We conducted a nationwide cross-sectional survey of UK clinicians involved in CIED follow-up. The survey assessed anticoagulation decision-making in AHRE, including episode-duration thresholds, cumulative burden, CHA2DS2-VA use, additional ECG monitoring, and anticoagulant choice. Only responses from UK-based consultant clinicians were included and analysed descriptively. Results: A total of 51 responses were received; 38 met the inclusion criteria and were analysed. Most respondents (86.8%) reported having reviewed AHRE alerts within the preceding six months, indicating that AHRE are commonly encountered in clinical practice. A [≥]24-hour episode was the most common threshold for anticoagulation (44.7%), although many clinicians reported lower thresholds or individualised approaches. Nearly half (44.7%) did not consider cumulative AHRE burden in decision-making. CHA2DS2-VA thresholds also varied, most commonly [≥]2 or [≥]1. Additional ECG monitoring was infrequently performed. Direct oral anticoagulants were universally preferred, with apixaban the most commonly selected agent (73.7%). Conclusion: There is substantial variation in UK clinical practice regarding anticoagulation for AHRE, reflecting ongoing uncertainty and lack of clear guidance. These findings highlight the need for evidence-based thresholds to support consistent and informed clinical decision-making.

BackgroundThere is no consensus on a risk threshold for sudden cardiac death (SCD) that could be used in practical design and evaluation of prediction models and decisions regarding implantable cardioverter-defibrillator (ICD) therapy. MethodsBaseline assumptions for a simulation framework were derived from previous randomized controlled trials (n=18) to identify minimal SCD risk threshold that would translate to mortality benefit by ICD therapy also considering the effect of competing non-sudden mortality. ICD efficacy to prevent SCDs and other data for simulations were estimated using inverse-variance weighted meta-analysis of included trials. Number needed to treat (NNT) was evaluated over a five-year horizon ([&le;]21 defined as clinically relevant). ResultsCorrelation analysis confirmed annual SCD incidence in trial populations as the key factor associating with ICD therapy effectiveness to reduce mortality (Pearsons r=0.653, p<0.01). In a simulation assuming 5% annual non-sudden mortality (pooled estimate of included RCTs) and a 56% (48-62%) efficacy for ICDs to reduce SCDs or similar events, 3% annual SCD risk ({approx}12% over five years) emerged as the lowest practical threshold even after controlling for excess (overlapping) mortality among those saved successfully from SCD by ICD therapy. The theoretical minimum threshold for annual SCD risk is 2.0%, 2.5% and 3.5% for populations with the annual incidence of non-sudden deaths 2%, 5% and 10% (assuming no overlapping mortality). ConclusionsEven under substantial competing risk, a 3% annual SCD threshold appears an optimal minimum threshold for identifying patients most likely to benefit from ICD therapy if severe mortality overlap is not observed. Key QuestionsWhat is the minimal risk threshold after which ICD therapy will likely lead to meaningful reduction in overall mortality. This information is needed in practical design of clinical trials and evaluation and development of prediction models Key FindingAnalysis of the data extracted from previous randomized controlled trials revealed that annual SCD risk should be at least 3% in most scenarios (with the annual incidence of non-sudden mortality [&le;]5%) for ICD therapy to be effective. Take-home MessagePrimary prevention SCD and risk models targeted to identify high-risk individual should aim for identifying patients with 3% or higher annual risk for SCD.

BackgroundIncidence and recurrence of atrial fibrillation (AF) is associated with several lifestyle risk factors. Lifestyle and risk factor modification (LRFM) clinics could have a role in comprehensively addressing AF from a holistic patient-centred approach to improve clinical outcomes. MethodsWe performed a systematic review and meta-analysis of randomised controlled trials (RCTs) evaluating the role of LRFM clinics compared with usual care (UC) in patients with AF. The primary endpoint was atrial arrhythmia recurrence. Secondary endpoints were AF and heart failure (HF) related hospitalisation, cardiovascular death, stroke or transient ischaemic attack (TIA), and quality-of-life (QOL). ResultsA total of eleven RCTs with a total of 3364 patients were included (five RCTs performed in the context of AF ablation). Mean age was 58-73 years, 30% were female and 18% had persistent AF. Duration of follow-up ranged from 3-24 months. LRFM clinics significantly reduced the primary endpoint of arrhythmia recurrence compared with UC after catheter ablation (OR 0.34, 95% CI 0.23-0.51, p<0.001, I2=0%). LRFM clinics also reduced AF-related hospitalisation (OR 0.70, 95%CI 0.51-0.98, p=0.04, I2=21%) and improved QOL (mean improvement on Short Form 36 Questionnaire 8.90, 95% CI 7.6.91-10.90, p<0.001). There was no difference between LRFM clinics and UC for HF-related hospitalisation (p=0.16), cardiovascular deaths (p=0.79) or stroke/TIA (p=0.83). ConclusionIn this meta-analysis of RCTs, LRFM clinics reduced AF recurrence after ablation, reduced AF-related hospitalisation and improved QOL. This study supports a comprehensive multidisciplinary lifestyle risk modification model of care to improve clinical outcomes in patients with AF.

BackgroundLeft atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) have emerged as alternatives to warfarin for stroke prevention in atrial fibrillation (AF). However, recent trials have shown variable results igniting the debate on this topic. MethodsWe performed a systematic review and network meta-analysis (NMA) of RCTs comparing LAAC, DOACs, and warfarin in patients with AF. The primary efficacy outcome was ischemic stroke or systemic embolism (IS/SE) and the primary bleeding outcome was hemorrhagic stroke (HS). Secondary outcomes included net adverse clinical events (NACE) and major or clinically relevant bleeding (MCRB). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using a random-effects model. ResultsTen RCTs (LAAC: 6 trials; DOAC: 8 trials; warfarin: 6 trials) enrolling 78,594 patients fulfilled the inclusion criteria. There were no significant differences for the primary efficacy outcome of IS/SE among the 3 strategies. However, when compared with warfarin, both DOACs (OR 0{middle dot}43, 95% CI 0{middle dot}34-0{middle dot}54) and LAAC (OR 0{middle dot}34, 95% CI 0{middle dot}18-0{middle dot}63) reduced the primary safety outcome of HS, with no significant difference between them (OR 0{middle dot}79, 95% CI 0{middle dot}44-1{middle dot}3). For NACE, both DOACs (OR 0{middle dot}87, 95% CI 0{middle dot}83-0{middle dot}91) and LAAC (OR 0{middle dot}85, 95% CI 0{middle dot}73-0{middle dot}99) were superior to warfarin, with similar performance between them (OR 0{middle dot}98, 95% CI 0{middle dot}84-1{middle dot}13). For MCRB, DOACs were superior to warfarin (OR 0{middle dot}79, 95% CI 0{middle dot}63-0{middle dot}99), while LAAC showed a non-significant trend towards benefit. ConclusionIn this meta-analysis of RCTs with data from over 78,000 patients, LAAC and DOACs significantly reduced NACE driven by lower hemorrhagic stroke and provided equivalent IS/SE protection compared with warfarin, making LAAC a potential viable alternative to oral anticoagulation in appropriately selected AF patients. FundingNone.

Background Non-vitamin K antagonist oral anticoagulants (NOACs) are the guideline-recommended standard for stroke prevention in atrial fibrillation (AF), yet bleeding risks limit real-world adherence. Percutaneous left atrial appendage closure (LAAC) offers a mechanical alternative without definitive comparative synthesis. Objectives To evaluate percutaneous LAAC versus NOAC therapy by synthesizing all contemporary NOAC-era randomized controlled trials (RCTs). Methods Five databases and registries (PubMed, MEDLINE, Embase, Cochrane CENTRAL, ClinicalTrials.gov) were searched from inception to 8 May 2026 for RCTs comparing percutaneous LAAC against NOACs in adults with non-valvular AF. Risk of bias was assessed using Cochrane RoB 2. Ischemic stroke was pooled using a random-effects DerSimonian-Laird model; primary efficacy composite and non-procedural bleeding were evaluated via pre-specified narrative synthesis. Results Four RCTs (CHAMPION-AF, OPTION, PRAGUE-17, CLOSURE-AF) comprising 5,890 patients were included. LAAC achieved noninferiority for the primary efficacy composite in three trials and demonstrated a statistically significant 45-56% reduction in non-procedural bleeding across the three moderate-risk trials. CLOSURE-AF did not meet noninferiority but retained a directionally consistent bleeding reduction. Pooled ischemic stroke analysis (HR 1.31; 95% CI 0.96-1.80; I^2=0%) showed no statistically significant increase in stroke risk, though a consistent directional trend toward more ischemic events was observed. Conclusions LAAC significantly reduces non-procedural bleeding in moderate-risk AF patients, though this benefit attenuates in very high-risk populations. A consistent, statistically nonsignificant ischemic stroke trend and population-dependent efficacy establish LAAC as a shared decision-making alternative to NOACs rather than a universal replacement, pending 5-year CHAMPION-AF data.

Objectives To assess agreement between Cardio-HART (CHART) and echocardiography for left ventricular ejection fraction (LVEF) estimation and heart failure (HF) classification in a real-world predominantly ischaemic cohort, while examining whether a point-of-care structural and functional assessment tool could reveal a broader workflow gap between the nominal availability of echocardiography and timely cardiac assessment in routine care. Design Prospective single-centre cohort study. Setting Secondary-care cardiology service at Cascais Hospital, Lisbon, Portugal. Participants Forty-seven adults referred for cardiology evaluation with suspected HF or followed in a hospital HF clinic. Primary and secondary outcome measures Agreement between CHART-derived and echocardiographic LVEF by Bland-Altman analysis; diagnostic performance for HF phenotypes; comparison with the Teichholz method. Results Mean age was 65.6+-15.9 years; 78.7% of participants had HF and 43.2% of HF cases were ischaemic. CHART showed a mean LVEF bias of +1.92% versus echocardiography, with 95% limits of agreement from -14.6% to +18.4% and a mean absolute error of 6.09%. Agreement was strongest in HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF), and lower in HF with preserved ejection fraction (HFpEF). Diagnostic area under the curve for HFrEF classification was 0.89. Compared with the Teichholz method, CHART showed a lower root mean square error relative to Simpson's biplane LVEF. Conclusions CHART showed clinically credible performance for LVEF estimation and HF stratification, particularly in reduced-EF phenotypes. However, the most important finding of this study was not agreement alone. By performing credibly in a cardiology-based real-world setting, CHART exposed a previously under-recognised workflow gap between the nominal availability of echocardiography and timely access to structural cardiac assessment in routine care. The study therefore suggests that the value of CHART lies not only in diagnostic performance, but in making visible, and potentially narrowing, a hidden but consequential gap in cardiac assessment pathways. Larger studies are warranted, particularly for HFpEF and across broader clinical workflows.

BackgroundThe incidence of sudden cardiac arrest (SCA) manifesting as pulseless electrical activity (PEA) has increased, and survival remains extremely low. Methods for early identification and management of high-risk individuals are needed, but no clinical risk scores currently exist to predict PEA-SCA. Our objective was to develop and validate a clinical prediction model for PEA-SCA. MethodsFrom an ongoing prospective, population-based study of SCA in Portland, Oregon (catchment pop. {approx}1 M, 2002-2020), we identified PEA-SCA adults. Lifetime clinical records were compared with those of a control group with >50% prevalence of significant coronary disease. Prediction models were constructed using backwards stepwise logistic regression in a training dataset (67%) and evaluated in a validation dataset (33%). Model discrimination was assessed using receiver operating characteristic curves (C statistic). External validation was performed in a geographically distinct population in Ventura County, California (population {approx}850,000, 2015-2022). ResultsThe final clinical algorithm (PEA-Risk) incorporating 12 clinical, electrocardiogram and medication variables demonstrated strong discrimination in the training dataset (C statistic = 0.860 [95% CI: 0.838-0.881]) and remained robust in internal (C statistic = 0.832 [95% CI: 0.800-0.865]) and external validation datasets (C statistic = 0.704 [95% CI: 0.665-0.743]). ConclusionsWe developed and externally validated a clinical algorithm for predicting PEA-SCA. Given the low rates of successful resuscitation after PEA arrest, this risk prediction tool may enable earlier identification and prevention of PEA-SCA. Clinical PerspectiveO_ST_ABSWhat is knownC_ST_ABSO_LIThe proportion of SCA presenting as pulseless electrical activity (PEA) is increasing, and survival from these events remains extremely low. C_LIO_LIThe are no available methods for clinical risk prediction of these events. C_LI What the study addsO_LIThe present study constructs and replicates a risk score for prediction of SCA manifesting with PEA using widely available clinical and noninvasive markers. C_LIO_LIThese findings have implications for developing prevention and management strategies for individuals at high risk of PEA-SCA. C_LI

Background: Socioeconomic factors impact cardiovascular health. We investigated the association between patient education level and incident heart failure (HF), acute myocardial infarction (AMI), and stroke following a first hospitalization with atrial fibrillation (AF). Methods: In this nationwide retrospective cohort study using linked Swedish national registers, we included all patients receiving a diagnosis of AF while hospitalized in Sweden from 1995 through 2008; categorized education level as primary, secondary, or academic; and followed patients for up to five years. Outcomes were first hospitalization for HF, AMI, or stroke. Associations were assessed using sex-stratified Cox proportional hazards models adjusted for age, calendar year of AF diagnosis, and measures of comorbidity burden (Charlson Comorbidity Index) and thromboembolic risk (CHA2DS2VA score). Results: The cohort comprised 263,172 patients (mean age 72.5 {+/-} 10.4 years; 56.2% male). Compared with primary education, secondary and academic education attainment were associated with lower adjusted risk of HF and AMI in both females and males. For HF, adjusted hazard ratios (HR) were 0.96 (95% CI 0.93 - 1.00) for secondary and 0.82 (95% CI 0.77 - 0.87) for academic education for females and 0.93 (95% CI 0.90 - 0.96) and 0.76 (95% CI 0.72 - 0.80), respectively, for males. For AMI, adjusted HRs were 0.89 (95% CI 0.85 - 0.93) and 0.71 (95% CI 0.65 - 0.78) for females and 0.91 (95% CI 0.87 - 0.94) and 0.75 (95% CI 0.71 - 0.80) for males. For stroke, lower adjusted risk was observed only in the academic education group. Baseline comorbidity burden and thromboembolic risk were higher in lower education groups. Conclusions: Education level was inversely associated with risk of incident HF and AMI over five years, while the association with stroke risk was weaker. Documenting education level may help identify patients at increased risk who could benefit from careful monitoring and optimized preventive care.

Background Disparities between sexes in mortality and morbidity after coronary artery bypass grafting remain incompletely understood. Multi-arterial grafting demonstrates superior outcome compared to single arterial grafting, although the optimal type of a second arterial graft and possible sex-dependent differences in grafting strategy have not been elucidated. We aim to determine whether the right internal thoracic artery or the radial artery is the optimal second arterial graft. Methods We analyzed data from 14,196 patients undergoing primary isolated coronary artery bypass grafting with the left internal thoracic artery and either right internal thoracic artery or radial artery between 2013 and 2022 from the Netherlands Heart Registration. Patients were stratified by sex and type of second arterial graft. Inverse probability treatment weighting was used to balance baseline characteristics. The primary outcome was long-term mortality. Secondary outcomes included short-term complications and repeat revascularization. Results In both sexes, the choice of second arterial graft did not significantly impact long-term survival. Postoperative arrhythmias were more prevalent in both sexes following right internal thoracic artery use (p<0.001). The radial artery was associated with higher rate of repeat revascularization in men (p=0.044 at 5 years follow-up) and more cerebrovascular accidents in women (0.9% vs 0.2%, p=0.028). Conclusion The choice of second arterial graft did not affect long-term survival in either sex. The radial artery was associated with an increased risk of repeat revascularization in men and more cerebrovascular accidents in women. These results underscore the need for further research in the field of sex-specific considerations in operative strategy.

Background: A growing burden of cardiovascular risk factors has raised cardiovascular disease-related mortality in Sub-Saharan Africa (SSA), driving higher prevalence of heart failure with reduced ejection fraction (HFrEF) and its complication with atrial fibrillation (AF). No prospective study has examined AF's clinical impact on HFrEF in SSA. Aim: To determine AF prevalence in HFrEF, describe HFrEF-AF clinical characteristics, and determine AF's impact on mortality. Methods: In this prospective observational study at a tertiary hospital in Johannesburg, 136 HFrEF patients were enrolled and categorised as HFrEF- SR (sinus rhythm) or HFrEF-AF. Baseline clinical characteristics and biochemistry were recorded. Comprehensive echocardiography including left atrial strain by 2D speckle-tracking was performed. Median follow-up was 30.6 months. Results: AF was present in 28 patients (21%). The mean age was 58.7 {+/-} 14.9 years (52.9% male) and differed between groups (p < 0.001). Hypertensive heart disease was the leading cause of HFrEF (36%). Compared with SR, HFrEF-AF patients had poorer health status (KCCQ 27 [16-43] vs 45 [32-60], p < 0.001) and lower left atrial strain (26.2 {+/-} 11.3%, p < 0.001). Guideline-directed medical therapy was suboptimal in the AF group: anticoagulation use was higher than SR (60% vs 9.5%, p < 0.001) but overall inadequate; HFrEF-AF patients received lower median doses of carvedilol (15.6 mg vs 25 mg, p = 0.002) and enalapril (10 mg vs 20 mg, p = 0.004), and fewer received spironolactone (50% vs 75.3%, p = 0.013). Survival was significantly lower in HFrEF-AF (0.41 [0.22-0.61]) versus SR (0.73 [0.61-0.82], p < 0.001). Independent predictors of mortality included prior stroke, lower TAPSE and KCCQ, and higher E/e' and heart rate. Conclusion: AF is common among HFrEF patients in this SSA cohort (though lower than in high-income countries) and associates with worse clinical status, suboptimal therapy, and higher mortality.

Background: Current risk assessment tools for guiding direct oral anticoagulant (DOAC) therapy for patients with atrial fibrillation (AF) based on clinical risk factors demonstrate modest predictive performance limiting clinical impact. Additionally, while guidelines recommend periodic reassessment of risk over time, there remains an absence of modelling solutions for capturing evolving risk in AF patients. Methods: Using UK electronic health records, we developed and validated the Transformer-based Risk assessment survival model (TRisk), an artificial intelligence model that predicts 12-month thromboembolic and bleeding events in AF patients by leveraging temporal patient journeys up to baseline. A cohort of 411,850 prevalent non-valvular AF patients aged [&ge;]18 years between 2010 and 2020 was identified from 1,442 English general practices. Practices were randomly allocated to derivation (n=1,079) and external validation (n=363) cohorts. TRisk was compared with CHA2DS2-VASc and CHA2DS2-VA for thromboembolic event prediction, and HAS-BLED and ORBIT for bleeding prediction, with subgroup analyses by sex, age, and baseline characteristics. A second validation of TRisk was also performed on 16,218 US AF patients between 2010 and 2023. A decision model compared outcomes and healthcare costs for TRisk versus standard care. Findings: TRisk achieved higher discrimination for thromboembolic event prediction (C-index: 0.82; 95% confidence interval [CI]: [0.81, 0.83]) as compared to CHA2DS2-VASc (0.71 [0.70, 0.73]) in UK validation. Application of TRisk to US data yielded similar C-index: 0.82 (0.80, 0.84). For bleeding prediction, TRisk (C-index: 0.70 [0.69-0.71]) outperformed both HAS-BLED (0.63; [0.61, 0.64]) and ORBIT (0.64; [0.63, 0.65]), with comparable US results (0.71; [0.69, 0.74]). The model remained well-calibrated across both populations and performed equitably across subgroups, including by race and during the COVID-19 pandemic. Impact analyses showed TRisk could reduce DOAC prescriptions by 8% in the UK and 7% in the US relative to guideline-recommended approaches, while preventing at least as many thromboembolic events. This refined approach would generate annual healthcare savings of GBP 5.5 million and USD 456.2 million in the UK and US respectively among patients initiating DOACs, rising to GBP 48.6 million and USD 1.8 billion when extended to all AF patients on DOACs. Interpretation: TRisk enabled more precise prediction for both thromboembolic and bleeding events across AF populations in UK and US compared to established clinical scoring systems. Incorporating TRisk into routine AF care would result in substantial cost savings without compromising the identification of true high-risk patients. Funding: None

Background: Higher METS-IR has been shown to be associated with a higher risk of major adverse cardiovascular events, but data are lacking regarding cardiac arrhythmias. Objectives: The aim of this study was to assess the association between METS-IR and atrial fibrillation/flutter, ventricular arrhythmia and bradyarrhythmia. Methods: Data from the Atherosclerosis Risk in Communities study spanning 1987 to 2013 was utilized for this analysis. METS-IR scores were assessed at baseline (1987-1989) and arrhythmia episodes were identified using ICD-9 codes. Multivariate-adjusted Cox proportional hazard models were constructed to evaluate the relationship between METS-IR and arrhythmia risk, with dose-response analyses conducted. In addition, we analyzed the predictive value of METS-IR for arrhythmias. Results: Over a mean follow-up of 21.9 years, 2493 cases of AF, 688 cases of bradyarrhythmia, and 1315 cases of ventricular arrhythmia were recorded. Each interquartile range increase in METS-IR was associated with a 49% higher risk of atrial fibrillation(P<0.001), 29% higher risk of bradyarrhythmia(P<0.001), and 42% higher risk of ventricular arrhythmia(P<0.001). After correction for relevant confounders, the METS-IR index was significantly and positively associated with the risk of new-onset atrial fibrillation, bradyarrhythmia, and ventricular arrhythmia (P overall<0.05, P for non-linearity>0.05). Most of the results of the subgroup analyses were not significantly different. The inclusion of METS-IR in the base model improves the predictive value of the risk of arrhythmogenesis. Conclusions: There is a significant association between METS-IR and increased risk of arrhythmias.

Introduction Patients hospitalized with heart failure who do not speak English as their primary language face communication barriers, however the impact on documented History of Present Illness (HPI) and Review of Systems (ROS) has not been reported. Methods This retrospective cohort study was based on MIMIC-IV, an anonymized clinical database. Adult patients admitted to general medicine or cardiology services with heart failure (by DRG) were identified. Multivariable linear regression was used to assess for an association between language (English vs. non-English) and word counts for HPI+ROS and HPI word counts. Qualitative differences in texts were also analyzed using Claude Opus 4.6. Results In a cohort of 552 patients, non-English language (N = 81) was associated with a shorter HPI+ROS (coef. -33.387, 95% CI [-62.076, -4.697], p = 0.023) controlling for age (coef. -1.023, 95% CI [-1.817, -0.230], p = 0.012) and Elixhauser score (coef. 10.391, 95% CI [7.078, 13.705], p<0.001). Similar associations were found for HPI alone. Qualitative differences included less discussion of symptoms and timing of onset. Discussion HPI+ROS and HPI were more abbreviated when the primary documented language was not English. This has important implications for equitable care and the development of emerging translation and documentation technologies.

IntroductionWith improved life expectancy, mitral annular calcification and calcific mitral stenosis (CMS) are increasing in prevalence. Echocardiographic evaluation of CMS is challenging due to acoustic shadowing and lack of CMS specific data on assessment of severity and outcomes. MethodsWe retrospectively identified patients with isolated CMS between the years 1/1/2010 and 4/5/2022. Severe CMS was defined as MVAcont [&le;]1.5 cm2. The primary outcome was a composite of all-cause mortality, mitral valve replacement (MVR) and ischemic stroke. Outcomes were collected through electronic health records with follow up through 8/15/2025. ResultsOur cohort included a total of n=717 patients with CMS of which n=140 had severe CMS. The mean age was 74{+/-}13 years and cohort was predominantly female. We found that MVAPHT consistently overestimates the MVA and is a poor predictor of severe CMS. Mean gradient >5 mm Hg had 81% specificity and 57% sensitivity for severe CMS. Over a median follow up of 36 (IQR 10.5-49.7) months, a total of n=331 (46.2%) patients died, and the primary composite outcome occurred in n=370 (51.6%). Although MVAcont [&le;]1.5 cm2 [aHR 1.3 (95% CI 0.9-1.8),p=0.29] was not an independent predictor of the primary outcome we found that mTMG was a significant independent predictor primary outcome [aHR 1.5 (95% CI 1.1-2), p<0.01]. Patients with MVAcont [&le;]1.5 cm2 and mean gradient [&ge;] 5 mmHg had the highest risk for the primary outcome [aHR 2 (95% CI 1.1-3.7),p=.02]. ConclusionPatients with severe CMS are older, female with a high burden of comorbidities and carry an overall poor prognosis. mTMG is an independent prognostic marker in these patients. Patients with MVA [&le;]1.5 cm2 and mTMG [&ge;]5 mmHg have the worst prognosis.

Background. Peripheral artery disease (PAD) may amplify procedural risk during atrial fibrillation (AF) catheter ablation, but dedicated evidence is lacking. We aimed to evaluate the association between PAD and in-hospital outcomes among adults undergoing AF ablation in the National Inpatient Sample (NIS). Methods. We identified inpatient AF ablation hospitalizations in the 2016 through 2020 National Inpatient Sample using ICD-10-PCS procedure codes and a concurrent AF diagnosis. PAD was identified from ICD-10-CM diagnosis codes used in prior claims-based PAD studies. Stabilized inverse probability of treatment weighting based on the propensity score was used to balance baseline differences. The primary outcome was in-hospital mortality. Fourteen secondary outcomes and 2 composite end points were prespecified. Results. Among 22,166 AF ablation hospitalizations, 899 (4.06%) involved patients with PAD. Compared with patients without PAD, those with PAD were older and had a substantially greater cardiovascular, renal, and smoking/tobacco comorbidity burden. In-hospital mortality did not differ significantly (1.39% vs 1.06%; aOR, 1.32; 95% CI, 0.66 - 2.64; P= 0.44). PAD was associated with higher odds of major bleeding (aOR, 1.62; 95% CI, 1.17 - 2.24; P = 0.004), vascular or access-site complications (aOR, 1.80; 95% CI, 1.04 - 3.12; P = 0.04), acute kidney injury (aOR, 1.31; 95% CI, 1.05 - 1.64; P = 0.02), and composite major adverse hospital events (aOR, 1.29; 95% CI, 1.05 - 1.59; P = 0.02). Total hospital charges were 13% higher (charge ratio, 1.13; 95% CI, 1.04 - 1.22; P = 0.003). Major bleeding, vascular/access-site complications, cardiac arrest, and composite major adverse in-hospital events remained elevated in sensitivity analysis. Conclusion. PAD was independently associated with higher bleeding risk, vascular or access-site complications, acute kidney injury, and composite major adverse hospital event during AF ablation, identifying a clinically relevant subgroup with elevated periprocedural risk.

Background: Two-thirds of Dutch cardiovascular risk management (CVRM) for patients at risk of cardiovascular disease is delivered in primary care practices. While individual risk scores are increasingly used during consultation, a population-level structure for risk-based patient outreach is not currently available. We therefore developed the PROSPERA programme, a multilevel intervention comprising population-level risk stratification and individual-level support tools. Aim: To assess anticipated and experienced barriers and facilitators among healthcare professionals (HCPs) to inform implementation in primary care. Methods: We conducted four focus groups and six interviews with nine primary care HCPs to explore anticipated and experienced barriers and facilitators. Inductive codes were thematically analysed and assigned to corresponding domains of the Theoretical Domains Framework (TDF) and the related Capability, Opportunity, Motivation model of Behaviour. Results: Barriers and facilitators were identified in 11 TDF domains. Population-level barriers included altered professional roles and limitations in technological infrastructure. Individual-level barriers were limited skills in interpreting risk calculations and difficulty integrating tools into clinical routine. Facilitators were related to beliefs on the importance of providing proactive care (population level), the use of U-Prevent for risk communication (individual level) and positive patient responses to the Lifestylecheck questionnaire (individual level). Conclusion: Addressing barriers and facilitators identified at both the population and individual levels can support implementation of the PROSPERA programme. Opportunities exist in education and training of HCPs in risk communication, as well as support in restructuring the physical and digital environment.

ObjectiveTo explore the interpretation of unexpected results from a randomized controlled trial (RCT). Study Design and SettingAdjunctive frequentist (power and type{square}M error) and Bayesian analyses were performed on a recently published RCT reporting a statistically significant relative risk reduction (p <0.01) for caffeinated coffee drinkers compared with abstinence on atrial fibrillation (AF) recurrence. Individual patient data for the Bayesian survival models were reconstructed from the RCT published material and priors informed by the RCT power calculations. ResultsThe original RCT design had limited power for realistic effect sizes, increasing susceptibility to type{square}M (magnitude) error. Bayesian analyses also tempered the benefit for caffeinated coffee implied by standard statistical analysis resulting in only modest probabilities of clinically meaningful risk reductions (e.g., hazard ratio < 0.9 of 88% or a risk difference > 2% of 82%). ConclusionsSupplemental frequentist and Bayesian approaches can provide robustness checks for unexpected RCT findings, providing contextualization, clarifying distinctions between statistical and clinical significance, and guiding replication needs. HighlightsO_LIRandomized controlled trial (RCT) results may be unexpected and challenge prior beliefs C_LIO_LISupplemental frequentist and Bayesian analyses can clarify interpretation of surprising findings C_LIO_LIPower and type{square}M error assessments help evaluate design adequacy for realistic effects C_LIO_LIBayesian posterior probabilities provide additional nuanced insights into contextulaization and clinical significance C_LI

BackgroundChagas cardiomyopathy remains a major cause of heart failure (HF) in endemic regions and is increasingly recognized globally, yet data on in-hospital outcomes are limited. Objective: To assess whether Chagas disease is associated with higher in-hospital mortality among patients hospitalized with HF. MethodsWe analyzed a nationwide administrative database from the Brazilian Unified Health System (DATASUS/SIHSUS), including adults hospitalized with HF between April 2017 and August 2021. HF was identified using ICD-10 code I50.x and Chagas disease using B57.x. The primary outcome was in-hospital mortality, evaluated using multivariable Cox models. Results: Among 910,128 HF hospitalizations, 1,082 (0.12%) were associated with Chagas disease. Patients with Chagas were younger but had a more complex clinical profile and higher resource use. In-hospital mortality was higher in the Chagas group (25% vs 12%; p<0.001). After adjustment, Chagas disease remained independently associated with mortality (HR 1.54; 95% CI 1.35-1.75; p<0.001). ConclusionsIn this large real-world cohort, Chagas disease was associated with higher in-hospital mortality and greater healthcare utilization. These findings reinforce the high-risk nature of Chagas cardiomyopathy and point to the need for more targeted treatment strategies. What is the clinical question being addressed?Chagas cardiomyopathy is a major cause of heart failure in endemic regions and an emerging global health problem, yet real-world data on in-hospital outcomes remain limited. Is Chagas disease associated with higher in-hospital mortality? What is the main finding?Chagas disease was independently associated with a 54% higher risk of in-hospital mortality in a large real-world cohort.

Background: Response to cardiac resynchronization therapy (CRT) is heterogeneous in patients with non-left bundle branch block (non-LBBB) heart failure. Whether pre-implant substrate or procedural characteristics provide the more stable framework for predicting 1-year echocardiographic response remains uncertain. Methods: We retrospectively analyzed 120 non-LBBB patients undergoing CRT. The primary logistic model included left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), left atrial diameter, log-transformed NT-proBNP, baseline QRS duration, fragmented QRS burden across V1?V6 leads, and pulmonary artery pressure. Missing predictor data were handled using multiple imputation with 20 datasets. Model performance was assessed using bootstrap internal validation and recalibration. A prespecified procedural extension added pacing strategy, posterolateral biventricular left ventricular lead location, left ventricular pacing threshold, and right ventricular lead position. Exploratory phenotyping and sensitivity analyses were performed. Results: Echocardiographic response occurred in 51 patients (42.5%). LVEDD (OR, 0.899 [95% CI, 0.826?0.978]; P=0.013) and LVEF (OR, 1.068 [95% CI, 1.000?1.140]; P=0.050) were the most informative predictors. The primary model showed apparent AUC 0.811 and Brier score 0.173, with optimism-corrected AUC 0.766 and calibration slope 0.765. Procedural extension showed no retained incremental value after validation. Exploratory phenotyping identified three response patterns with moderate stability. Conclusions: In non-LBBB CRT, baseline structural, biomarker, and electrocardiographic substrate provided the most stable framework for predicting 1-year echocardiographic response. Procedural variables added limited retained value, suggesting that pacing strategy should be interpreted alongside baseline substrate.

Background: Postoperative atrial fibrillation (POAF) affects up to 50% of cardiac surgery patients and is linked to higher morbidity, longer hospital stays and increased thromboembolic risk. Early identification of at-risk patients remains challenging. Calcitonin (CT), a hormone with anti-fibrotic effects, may serve as a novel biomarker. Methods: In 491 patients undergoing elective cardiac surgery, baseline serum CT was measured preoperatively using CT-specific enzyme-linked immunosorbent assay (ELISA). Patients with pre-existing AF were excluded. Associations between CT levels and POAF incidence and onset were evaluated using logistic regression, Cox proportional hazards models, and Kaplan-Meier analysis. Results: Among 248 patients with detectable CT levels, 88 patients developed POAF. Higher baseline CT was independently associated with lower risk of POAF (OR 0.68 per 5 pg/ml increase; 95% CI 0.51-0.89; P = 0.009) and delayed arrhythmia onset (adjusted HR 0.941; 95% CI 0.898-0.980, P = 0.0026) after adjusting for covariates. Kaplan-Meier analysis demonstrated a graded relationship between increasing CT levels and reduced cumulative incidence of POAF. In this cohort, baseline CT showed greater discriminative ability than CRP and BNP, although overall model performance remained moderate. Conclusion. Higher preoperative circulating CT levels are associated with reduced risk and delayed onset of POAF following cardiac surgery. These findings suggest that calcitonin may have the potential as a biomarker for perioperative risk stratification in POAF. Given the observational design and single-centre setting, further validation in independent cohorts and studies integrating mechanistic insights are warranted.