Heart

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.

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.

IntroductionAtrial fibrillation (AF), a common arrhythmia, is associated with impaired quality of life (QoL) and increased stroke risk and mortality. Clinical guidelines recommend leveraging digital technologies to support patient education and AF self-management. Conversational artificial intelligence (AI) technologies may support patient engagement with self-management by enabling human-like conversations. This study aims to evaluate the effectiveness of a conversational AI intervention (Conversational HeAlth supporT in Atrial Fibrillation Self-Management - CHAT-AF-S) in improving QoL in patients with AF. Methods and analysisCHAT-AF-S is a 3-month randomised controlled trial with 1:1 allocation and embedded process evaluation. We will randomise 480 adults (18 years of age and older) with documented AF to the CHAT-AF-S intervention or usual care. Primary outcome is the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) overall score. We will follow intention-to-treat principles and data analysts will be blinded. Intervention participants will be invited to complete a user experience survey and take part in an interview to explore the feasibility, acceptability, perceived utility, and barriers and enablers to implementing the intervention. Qualitative data will be analysed thematically. Ethics and disseminationEthics approval was obtained from the Western Sydney Local Health District Human Ethics Research Committee (2023/ETH00765). Written and informed consent will be obtained from all study participants before commencing any study procedures. Results will be disseminated via peer-reviewed publications and presentations at international conferences. Declaration of InterestsAll investigators report nil conflicts of interest. Data AvailabilityThe data that supports this project are available from the corresponding author upon reasonable request. Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12623000850673 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386249

Structured AbstractO_ST_ABSBackgroundC_ST_ABSGuideline recommendations for infective endocarditis (IE) prophylaxis have narrowed significantly over the past decade. However, these recommendations are derived from adult data and may not adequately account for the unique risk factors for IE in pediatric and congenital heart disease (CHD) patients with cardiac implantable electronic devices (CIEDs). ObjectiveTo characterize contemporary IE cases and prophylaxis practices among members of the Pediatric and Congenital Electrophysiology Society (PACES) and assess how these practices align with or diverge from current international guidelines or practice recommendations. MethodsA cross-sectional, web-based survey was distributed to PACES members worldwide. Questions addressed prophylaxis practices for CIED implantation, reinterventions, and bacteremia-inducing procedures, as well as clinician experience with IE in patients with CIED. Responses were analyzed descriptively. ResultsSubstantial practice heterogeneity was identified across multiple clinical scenarios. Although most clinicians aligned with guideline recommendations for patients with structurally normal hearts, nearly all respondents (92.3%) reported recommending lifelong prophylaxis for patients with complex or repaired CHD. Among 35 reported IE cases, 97% occurred in transvenous systems, 77% occurred >6 months post-implantation, and 90% lacked a clear procedural or infectious trigger. Despite successful device extraction in 77% of cases, significant morbidity and mortality were observed. ConclusionCurrent practice patterns among pediatric and congenital electrophysiologists reflect uncertainty regarding the applicability of adult-derived IE prophylaxis guidelines to younger patients with CIEDs. High observed morbidity, long-term device exposure, and distinct anatomic considerations highlight the need for pediatric-specific risk stratification and updated guidance.

ObjectiveTo validate case number correctness and time interval agreement in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) for out-of-hospital cardiac arrest (OHCA) by linkage to Emergency Medical Dispatch Centre (EMDC) data between 2015 and 2024. MethodsIn this retrospective validation study, OHCA records reported to the SCRC were linked with EMDC-indexed OHCA for validation and correction of EMS case numbers. We quantified the proportion of correct EMS case numbers reported as agreement for fully correct and partially correct EMS case numbers in SRCR. Time interval agreement was assessed by comparing dispatch to arrival (unit response time) and call start to arrival (total response time) between SRCR and EMDC. For each linked case, time differences were calculated as (SRCR - EMDC) in seconds. Median differences were estimated using Bayesian quantile regression. ResultsEMS case number completeness was high, but the proportion of fully correct case numbers was limited. Among 56,969 SRCR records, 1,004 (1.8%) lacked an EMS case number. The proportion of SRCR records with partially correct EMS case numbers was around 90% up to the year 2020 and declined to 85% in 2022-2024. Dispatch-related time intervals showed high agreement between sources, with a median difference of -0.3 seconds (95% CrI -3.9 to 4.0). In contrast, SRCR total response time (from dispatch call answer to arrival at scene) was shorter than EMDC, with a median difference of 80.9 seconds (95% CrI -84.7 to -77.0). ConclusionSRCR unit response time reflects EMDC operational recording. The SRCR total response times were consistently shorter than the interval at the EMDC, indicating a potential underestimation of the total EMS response time in the registry.

BackgroundCongenital Heart Disease (CHD) research must focus on outcomes that affect the whole-of-life course. To achieve this, datasets with long term follow up and patient-relevant outcomes are required. This paper reports on the linkage of The Australian and New Zealand Congenital Heart Disease Registry (ANZCHD Registry) (>80 000 unique individuals) with Australian National Administrative Health records and describes the final dataset. MethodsLinkage on two cohorts was conducted by accredited linkage agencies, after all appropriate Ethics and Governance approvals. Cohort 1 included people who were identified from the ANZCHD Registry and Cohort 2 included people with an inpatient admission with a CHD diagnosis who had not been identified in Cohort 1. Healthcare events linked from 2010 to 2024 included outpatient encounters and medications, hospital admissions and emergency department presentations. Linked data was cleaned and curated to minimize the impacts of errors from the probabilistic linkage process. ResultsThe final dataset included 94,383 subjects with structural CHD (58,523 from Cohort 1 and 35,860 from Cohort 2). There were over 35 million linked healthcare events recorded for this population, from 2010 to 2025. Cohort 1 was younger by an average of 14 years (95% CI: 13.2 - 13.9, p<0.001) and had a higher proportion of severe CHD lesions (20%) compared to Cohort 2 (6%) ({chi}2 = 7433.1, p<0.001). ConclusionsThe linkage described here represent a significant enrichment of the large and comprehensive Australian National CHD Registry. This will provide important research infrastructure that will enable better quality research in CHD. Key MessagesO_LIWe sought to link the Australia and New Zealand Congenital Heart Disease Registry with comprehensive, national Australian administrative healthcare records. C_LIO_LIThe final dataset included a total of 95,383 individuals with over 35 million healthcare events from 2010 to 2025. C_LIO_LICongenital Heart Disease is a whole-of-life condition with a growing and ageing population and comprehensive datasets such as these need to be made available to improve healthcare for people with Congenital Heart Disease. C_LI

AimsEarly discharge after electrophysiological procedures has gained increasing attention. However, definition of patient- and procedure-related prerequisites for successful and safe discharge strategies after atrial tachycardia (AT) ablation remains unknown. We therefore evaluated patient characteristics, procedural features, and outcomes according to index length of stay (LOS) following AT ablation. Methods and resultsThe multicenter observational SATELLITE registry enrolled consecutive patients undergoing AT rhythm control. Patients were stratified by LOS ([&le;]1, 2 and >2 nights) after catheter ablation. Among 670 patients (67 [IQR 56-75] years, 54.9% male), LOS was [&le;]1 night in 13.9%, 2 nights in 41.9% and >2 nights in 44.2%. LOS was only modestly predictable from clinical characteristics including age, sex, atrial fibrillation and prior atrial ablation (AUC 0.73). Discrimination improved after inclusion of procedural variables and early post-procedural events (AUC 0.77; P=0.0300), consistent with an increase in left atrial procedures (26.5% vs. 76.0% vs. 80.8%; P<0.0001), acute minor complications (3.2% vs. 2.5% vs. 14.5%; P<0.0001) and early recurrences of atrial arrhythmia (2.2% vs. 6.8% vs. 21.3%; P<0.0001). During 2.8{+/-}3.0 years of follow-up, LOS did not predict long-term outcomes including subsequent cardiovascular hospitalization (HR 1.19, 95% CI 0.78-1.81; P=0.4175). ConclusionDespite multiple comorbidities, most patients undergoing AT ablation need up to 2 nights of hospitalization. However, prolonged hospital stays before successful and safe discharge are common and associated with acute minor complications and early recurrences of atrial arrhythmia rather than comorbidities. Accordingly, discharge timing largely reflects the immediate peri-procedural clinical course, therefore challenging purely logistics-driven planning. Key Learning PointsO_ST_ABSWhat is already knownC_ST_ABSO_LIEarly discharge after electrophysiological procedures has gained increasing attention. C_LIO_LIDefinition of patient- and procedure-related prerequisites for successful and safe discharge strategies after atrial tachycardia (AT) ablation remains unknown. C_LI What this study addsO_LIDespite multiple comorbidities, most patients undergoing AT ablation need up to 2 nights of hospitalization. C_LIO_LIProlonged hospital stays before successful and safe discharge are common and associated with acute minor complications and early recurrences of atrial arrhythmia rather than comorbidities. C_LIO_LIDischarge timing largely reflects the immediate peri-procedural clinical course, therefore challenging purely logistics-driven planning C_LI Structured Graphical AbstractO_LIDespite multiple comorbidities, most patients undergoing AT ablation need up to 2 nights of hospitalization. However, prolonged hospital stays before successful and safe discharge are common and associated with acute minor complications and early recurrences of atrial arrhythmia rather than comorbidities. Accordingly, discharge timing largely reflects the immediate peri-procedural clinical course, therefore challenging purely logistics-driven planning. C_LI O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=130 SRC="FIGDIR/small/26345799v1_ufig1.gif" ALT="Figure 1"> View larger version (31K): org.highwire.dtl.DTLVardef@200309org.highwire.dtl.DTLVardef@1a745fcorg.highwire.dtl.DTLVardef@e3cd45org.highwire.dtl.DTLVardef@1b98c3e_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundIn patients with atrial fibrillation (AF) and stable coronary artery disease beyond 1 year after percutaneous coronary intervention (PCI), oral anticoagulant monotherapy is guideline-recommended; however, its efficacy and safety in patients with complex PCI remain uncertain. MethodsWe conducted a post-hoc analysis of the randomized ADAPT AF-DES trial comparing NOAC monotherapy versus NOAC plus clopidogrel in AF patients [&ge;]12 months after second- or third-generation drug-eluting stent implantation. Complex PCI was defined by one of the following characteristics: [&ge;]3 stents, [&ge;]3 lesions, bifurcation with 2 stents, total stent length [&ge;]60 mm, left main PCI, or chronic total occlusion PCI. Net adverse clinical events (NACE), ischemic composite outcomes, and bleeding composite outcomes were evaluated according to PCI complexity. ResultsAmong 960 patients, 247 (25.7%) underwent complex PCI and 713 (74.3%) underwent noncomplex PCI. NOAC monotherapy was associated with a lower risk of NACE compared with combination therapy in both the complex PCI group (9.5% vs 21.5%; hazard ratio 0.42, 95% confidence interval 0.21-0.83; P=0.01) and the noncomplex PCI group (9.6% vs 15.7%; hazard ratio 0.59, 95% confidence interval 0.39-0.90; P=0.02), with no significant interaction. Ischemic outcomes did not differ significantly between treatment strategies regardless of PCI complexity, whereas bleeding outcomes were consistently lower with NOAC monotherapy in both complex and noncomplex PCI groups. ConclusionsIn this post hoc analysis of the randomized ADAPT AF-DES trial, the clinical benefits of NOAC monotherapy beyond 12 months after PCI--characterized by reduced bleeding without a significant increase in ischemic events--were consistent regardless of PCI complexity. While hypothesis-generating, these findings support a long-term antithrombotic strategy prioritizing bleeding reduction in patients with AF, irrespective of prior PCI complexity. Trial registrationURL: http://www.clinicaltrials.gov; Unique identifier: NCT04250116. Clinical perspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIIn a randomized population of patients with AF and prior drug-eluting stent implantation, the efficacy and safety of NOAC monotherapy versus NOAC plus clopidogrel were evaluated according to anatomic PCI complexity. C_LIO_LIAmong patients with prior complex PCI, NOAC monotherapy was not associated with an increased risk of ischemic events and was associated with a substantial reduction in bleeding. C_LI What are the clinical implications?O_LINOAC monotherapy beyond 1 year after PCI was supported in patients with AF, including those with prior complex PCI. C_LIO_LILong-term antithrombotic decisions may place greater emphasis on bleeding risk than PCI complexity. C_LIO_LIThe optimal duration of combination antithrombotic therapy after complex PCI in patients with AF remains to be determined. 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.

BackgroundVaping among adolescents and young adults (AYA) could affect cardiovascular health. While pulmonary outcomes of vaping are well-documented, the link between vaping and abnormalities of heart rhythm remains unclear. We conducted a retrospective cohort study to test the hypothesis that the risk of heart rhythm abnormalities is increased in AYA who vape. MethodsWe used data from the TriNetX network to identify two cohorts of AYA (11 to 24 years old). The first cohort included individuals who vaped, and the second cohort was a comparison of individuals who did not report vaping. Individuals in the vaping cohort were matched 1:1 with those in the comparison cohort using propensity scores. The primary outcome was the association between vaping and diagnoses of heart rhythm abnormalities. The study analyzed data from 114,404 patients (57,202 in each cohort) with no significant differences in baseline characteristics. ResultsPatients who vaped had 82% higher odds of being diagnosed with heart rhythm abnormalities compared to those who did not vape (OR: 1.82, 95% CI: 1.74-1.91, p < 0.001). Furthermore, the hazard of developing heart rhythm abnormalities was approximately twice as high among vapers compared to those who did not (HR: 1.97, 95% CI: 1.88-2.06, p < 0.001). ConclusionThis study shows a significant association between e-cigarette use and an increased risk of heart rhythm abnormalities in AYA. These findings highlight the potentially harmful cardiac electrophysiological outcomes of vaping in this population and underscore the importance of health interventions and surveillance.

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.

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.

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

ObjectiveCerebral Embolic Protection Devices (CEPs) have been designed to minimize the risk of periprocedural stroke. The clinical significance of these devices, however, is still under debate. AimsWe aimed to compare periprocedural neurological outcomes and mortality in patients undergoing transfemoral transcatheter aortic valve replacement (TF-TAVR) with versus without CEP. MethodsA single-center retrospective analysis of 1101 patients undergoing transfemoral TAVR from August 2017 to May 2025 was performed. CEPs were used routinely at our institution whenever feasible beginning with October 2019. The primary outcome was defined as the incidence of ischemic stroke occurring within 3 days postoperatively. Secondary endpoints included overall neurological outcomes defined as a combined endpoint of stroke, transient ischemic attack (TIA) and delirium within 3 days and short-term all-cause mortality. ResultsOverall, 809 underwent TF-TAVR with CEP, while 292 were treated without. The primary endpoint of clinical ischemic stroke occurred less frequently in the CEP group (1.4% vs. 4.1%), and the group difference revealed a significant result in a univariable Cox regression analysis (p = 0.007). No clinically relevant differences were observed in the incidence of TIA (0.5% vs. 0.7%, p = 0.71) and postprocedural delirium (1.6% vs. 2.4%, p = 0.39). Although the 30-day mortality rate in the control group was higher, the difference did not reach statistical significance (3.9% vs. 1.9%, p = 0.06). ConclusionsThe use of neuroprotection during TAVR was associated with a reduced early periprocedural ischemic stroke.

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

BackgroundArtificial intelligence (AI) has emerged as a promising tool for interpreting 12-lead electrocardiograms (ECGs), with the potential to enhance diagnostic accuracy for arrhythmia detection. However, published studies vary widely in methodology and validation strategy, warranting a quantitative synthesis of diagnostic performance. MethodsA systematic review and meta-analysis was conducted according to the PRISMA-DTA 2018 guidelines and registered in PROSPERO (CRD420251027264). Searches were performed in MEDLINE, Embase, and Cochrane Library through September 2025 without language restrictions. Studies evaluating AI algorithms for arrhythmia detection using 12-lead ECGs were included. Data on sensitivity, specificity, and area under the curve (AUC) were extracted. Pooled estimates were generated using a bivariate random-effects model. Risk of bias was assessed with QUADAS-2, and the certainty of evidence was quantified using GRADE. Results20 studies were included in the meta-analysis, encompassing over 5.5 million ECGs. The pooled sensitivity, specificity, and AUC for AI-based arrhythmia detection were 94.0% (95% CI 90.8-96.2; I{superscript 2} = 96.9%), 98.7% (95% CI 97.3-99.3; I{superscript 2} = 98.3%), and 0.982 (95% CI 0.965-0.986), respectively. Detection of atrial fibrillation (AF) yielded a sensitivity of 92.6% (95% CI 86.4-96), a specificity of 99.1% (95% CI 98.4-99.5), and an AUC of 0.988. Convolutional neural networks (CNN) specifically demonstrated a sensitivity of 97.6%, specificity of 98.7%, and an AUC of 0.982 for overall arrhythmia detection. When limited to external validation (n=6), the sensitivity was 96.9% (95% CI 89.2-99.1), specificity was 95.6% (95% CI 77.6-99.3), and AUC was 0.983. No significant publication bias was detected, and the overall certainty of evidence was rated as high. ConclusionsAI models applied to 12-lead ECGs demonstrate excellent diagnostic performance for arrhythmia detection. Findings support potential integration into clinical workflows, particularly in settings with limited cardiology expertise. Given substantial heterogeneity, standardized datasets and multicenter prospective validation are essential to ensure effective and equitable implementation. What is KnownO_LIArtificial intelligence has been increasingly applied to 12-lead electrocardiograms for arrhythmia detection, with multiple studies reporting high diagnostic accuracy. C_LI What the Study AddsO_LIThis meta-analysis demonstrates consistently high diagnostic performance of artificial intelligence for arrhythmia detection on 12-lead ECGs, including atrial fibrillation and externally validated models. C_LIO_LIThe substantial heterogeneity observed underscores the need for standardized datasets and multicenter prospective validation before widespread clinical implementation. C_LI

BackgroundSocial determinants of health (SDOH) affect access to transcatheter aortic valve replacement (TAVR), yet their impact on post-procedural mortality remains incompletely defined. We investigated the association between neighborhood-level social deprivation and post-TAVR mortality, readmission, cardiovascular events, and procedural outcomes. MethodsWe performed a retrospective cohort study of 727 consecutive TAVR patients (2023-2024) with 1-year follow-up data at a central New Jersey tertiary care academic medical center, stratified into quartiles based on the composite Social Deprivation Index (SDI) and its seven constituent domains (Q1 = least deprived; Q4 = most deprived). Kaplan-Meier survival analysis with log-rank testing and Cox proportional hazards regression adjusted for STS-PROM score were used to evaluate mortality across quartiles. ResultsThe cohort (mean age 80.4 years; 46% female; 87% White; mean STS-PROM 5.5%) was skewed toward lower-deprivation neighborhoods (85% in Q1-Q2). Survival differed significantly across SDI quartiles at 30 days (log-rank p=0.037) and 90 days (p=0.049), but not at 1 year (p=0.164). In Cox regression, composite SDI was not a significant predictor of one-year mortality. Domain-specific analysis identified single-parent household density as the only significant mortality predictor, with patients in Q4 having higher 1-year mortality than those in Q1 (aHR 2.65, 95% CI 1.15-6.14, p=0.023). Procedural events, overall 30-day readmissions, and 30-day composite cardiovascular events did not differ significantly across SDI quartiles (all p>0.05). ConclusionNeighborhood-level social deprivation was not independently associated with post-TAVR all-cause mortality, though underrepresentation of patients from highly deprived neighborhoods highlights ongoing access disparities. Single-parent household density, a marker of social fragmentation, demonstrated a hypothesis-generating association with increased mortality risk, suggesting a potential role for neighborhood social fragmentation in post-TAVR outcomes that warrants prospective validation. These findings support equitable TAVR access while highlighting social support as an area for future investigation.

BackgroundHeart failure (HF), atrial fibrillation (AF)/atrial flutter (AFL) and sepsis commonly co-occur in hospitalized patients. This study determines temporal mortality trends associated with concurrent HF, AF/AFL, and sepsis among adults across demographic and geographic groups in the United States. MethodsThe CDC Wonder database was utilized to extract age-adjusted mortality rates (AAMR) per 100,000 for deaths listing HF, AF/AFL, and sepsis. Trends were analyzed by age, race/ethnicity, region, and sex. Joinpoint regression calculated the annual percent change (APC) and average annual percent change (AAPC) for AAMR with 95% CI. ResultsFrom 1999 to 2023, there were 1,749,565 deaths involving HF, AF/AFL, and sepsis. AAMR doubled (1999: 11.79 vs 2020: 23.87 per 100,000), with a critical 2012 inflection point accelerating mortality from 1.29% to 6.42% annually. White individuals had steepest post-2012 acceleration (6.67%), surpassing Black individuals by 2020 (24.88 vs 20.80 per 100,000). Males had higher AAMRs than females (28.69 vs 20.19 per 100,000 in 2020). Middle-aged adults (45-64 years) showed highest acceleration (9.98-10.30%), nearly double those aged [&ge;]85 years (5.82%). The Midwest and South had steepest increases (7.07% and 7.11%). During 2018-2023, mortality continued increasing at 6.11% annually without stabilization. ConclusionsMortality involving HF, AF/AFL and sepsis doubled from 1999-2023 with sustained acceleration and no post-pandemic stabilization. Targeted interventions should focus on males, middle-aged adults, and high-risk regions with enhanced post-discharge care. Project OverviewO_LIThis is retrospective cohort study using CDC WONDER data (1999-2023). C_LIO_LIWe analyzed 1,749,565 deaths involving all three conditions, heart failure, atrial fibrillation/flutter, and sepsis. C_LIO_LITo our knowledge, this is the first population-level study examining mortality trends due to the coexistence of heart failure, atrial fibrillation/flutter, and sepsis. C_LI Key FindingsO_LIverall age-adjusted mortality rates doubled from 11.79 to 23.87 per 100,000 (1999-2020). C_LIO_LIwas a critical inflection point in 2012 with marked acceleration thereafter. C_LIO_LIfindings revealed significant demographic disparities regarding age, sex, race/ethnicity, and region. C_LIO_LIacceleration through 2023 was found without post-pandemic. stabilization. C_LI

BackgroundAcute myocarditis is typically self-limiting and resolves spontaneously in most cases. However, ventricular arrhythmias (VA) complications, which may be life-threatening are associated with higher rates of in-hospital complications and mortality. Catheter ablation is occasionally required for acute myocarditis associated ventricular tachycardia (VT), but data on its procedural use and outcomes, in this setting, remain limited. We aimed to determine the prevalence of VA among patients hospitalized for acute myocarditis and to evaluate the subset who underwent in-hospital VT ablation, including their acute outcomes. MethodsRetrospective analyzed data from the National Inpatient Sample (NIS) database for U.S. hospitalizations with a diagnosis of myocarditis between 2016 and 2019. In-hospital outcomes were compared between patients with and without VA. Subgroup analysis examined patients with acute myocarditis associated VT stratified by whether VT ablation was performed. Patient demographics, comorbidities, procedures, and outcomes were identified using ICD-10-CM codes. ResultsAmong an estimated 17,845 hospitalizations for acute myocarditis, 8.4% (n=1,505) had VA (including 7.7% with VT). Patients with VA were more likely to have structural heart disease, renal disease, infectious etiologies, anemia, and atrial arrhythmias, despite lower prevalence of some traditional cardiac risk factors. VA was associated with markedly worse outcomes, including 5.5-fold higher in-hospital mortality (10% vs 1.6%; p<0.001). Multivariate analysis revealed that VA during admission for acute myocarditis was an independent significant risk factor for cardiac complications (aOR=4.8), total complications (aOR=4.2) and in hospital mortality (aOR=5.1) (p<0.001 for each analysis). Among patients with VT, catheter ablation was performed in 13.7% (n=190), more commonly with infectious etiologies. Ablated patients, compared to those without ablation, experienced significantly higher rates of in-hospital complications (73.7% vs 42.3%; p<0.001) and mortality (15.8% vs 6.7%; p<0.001). ConclusionsVA complicating acute myocarditis, portends significantly worse in-hospital outcomes. Although ablation was performed in approximately 1 in 7 patients with VT, those undergoing the procedure had less favorable acute results. Further prospective research is warranted to define optimal criteria for ablation and expected outcomes in this high-risk population.