International Journal of Cardiology

ObjectiveTo analyze the experience of the last six years with ECMO in Uncontrolled Donation after Circulatory Death (uDCD), assessing the clinical and logistical factors that determine donation effectiveness and the viability of retrieved organs, with the nurse perfusionist as the central figure in organ perfusion. MethodsRetrospective observational study of uDCD procedures performed at Hospital Clinic de Barcelona between June 2019 and October 2025. ResultsOf 184 out-of-hospital ECMO-CPR activations, 108 (58.7%) underwent perfusion; 72 donor cases (66.7%) were generated, and 109 kidneys (75.7%) and 3 livers (4.15%) were retrieved. The annual number of uDCD donors was heterogeneous. Compared with non-effective donors, effective donors were significantly younger (48.1 {+/-} 12.4 vs 53.0 {+/-} 10.7 years, p=0.03) and had fewer comorbidities such as hypertension (13.8% vs 33.0%, p=0.018) and diabetes (4.1% vs 16.6%, p=0.027). Although effective donors had a shorter cannulation time (25.6 {+/-} 13.9 vs 29.1 {+/-} 11.9 min, p=0.09), the difference was not statistically significant; however, cardiocompressor time did show a significant difference (58.9 {+/-} 17.7 vs 65.8 {+/-} 18.2 min, p=0.03). ConclusionsuDCD was a useful source of transplantable organs, mainly kidneys (two out of every three perfused patients became donors), in the current context of scarcity of brain-dead donors. Shorter warm ischemia times (cardiocompressor and cannulation times) were significantly associated with more effective organ donation. The multidisciplinary transplant team may benefit from perfusion professionals with expertise in extracorporeal oxygenation therapy.

The objective of this systematic review and meta-analysis was to identify the interventions used to manage intolerance in patients receiving statins for primary prevention of CVD and to determine the effectiveness of these interventions. This study was conducted according to the PRISMA checklist. The electronic databases MEDLINE (PubMed), SCOPUS, EMBASE, and CINAHL were searched for studies published until June 2025. Based on the NLA definition of statin intolerance, the outcomes were split into adverse effects caused by statins and statin discontinuation. In total, 1,238 studies were identified and screened. Nine studies were eligible for systematic review, and six studies were eligible for meta-analysis. The identified intervention strategies were adjuvant therapy, statin titration, replacing statins with other lipid-lowering agents and switching to different statin. The meta-analysis showed that the pooled risk ratio (RR) relative to control was 0.97 (95% CI, 0.86-1.08) in randomized controlled trials and 0.94 (95% CI, 0.63-1.42) in overall, with point estimates in favour of intervention arms. Moderate to substantial heterogeneity was observed, with I2 between 27% to 57%. Due to the smaller number of studies, no clear conclusions can be drawn regarding how the implemented interventions may affect statin discontinuation. This study showed no strong evidence that the implemented interventions reduced statin intolerance. PROSPERO registration numberCRD42024587573 HighlightsThis study found that the intervention strategies used to manage intolerance in patients receiving statins for the primary prevention of cardiovascular diseases were adjuvant therapy, statin titration, replacing statins with other lipid-lowering agents and switching to different statin. O_LIThis study showed no strong evidence that the implemented interventions reduced statin intolerance C_LIO_LIDue to the smaller number of studies, no clear conclusions can be drawn regarding how the implemented interventions may affect statin discontinuation C_LI

BackgroundAcute type A aortic dissection (AAAD) complicated by cardiopulmonary arrest is characterized by high mortality rates, rendering the selection of surgical candidates a subject of intense debate. Despite the necessity for cardiopulmonary resuscitation (CPR) prior to the completion of a definitive intervention, the prognostic impact of CPR duration on postoperative survival and neurological outcomes remains insufficiently elucidated. This study sought to evaluate the association between pre- and intra-operative CPR duration and the incidence of early mortality and central nervous system (CNS) complications in patients undergoing emergent surgical repair for AAAD. MethodsThis retrospective, cohort study was conducted at two tertiary community hospitals in Japan. All the patients who underwent emergency surgery for AAAD between January 2014 and December 2024 were enrolled. A multilevel Cox proportional hazards model, with each patient as level 1 and institutions as level 2, was used to evaluate the association between pre-or intra-operative CPR events and early postoperative mortality and CNS complications. ResultsOf the 880 patients enrolled, 785 (89.2%), 13 (1.5%), and 82 (9.3%) were without CPR, with CPR <15 min, and with CPR [&ge;]15 min, respectively. Among them, death within 30 days post-surgery occurred in 76/785 (9.7%), 3/13 (23.1%), and 47/82 (57.3%), respectively. CNS complications within 30 days post-surgery occurred in 141/785 (18.0%), 5/13 (38.5%), and 38/82 (46.3%) without CPR, CPR <15 min, and [&ge;]15 min, respectively. In multivariable analysis, CPR lasting [&ge;]15 min was associated with mortality within 30 days post-surgery (adjusted hazard ratio, 7.66; 95% confidence interval [CI], 3.56-16.5; P<0.001). Both CPR <15 min and [&ge;]15 min were associated with an increase in the sub-hazard ratio of CNS complications within 30 days post-surgery (adjusted sub-hazard ratios, 4.49; 95% CI, 3.92-5.11; P<0.001, and 3.62; 95% CI, 2.73-4.81; P<0.001, respectively). ConclusionA preoperative CPR duration of [&ge;]15 min prior to the initiation of cardiopulmonary bypass or extracorporeal membrane oxygenation was associated with a substantial escalation in 30-day mortality compared with patients without CPR. These findings suggest that CPR duration might serve as a pivotal prognostic indicator, necessitating careful consideration for surgical indication in patients with AAAD complicated by CPR. CLINICAL PERSPECTIVEO_ST_ABSWhat is new?C_ST_ABSO_LIPre- or intra-operative cardiopulmonary resuscitation lasting [&ge;]15 min in patients with acute type A dissection is associated with a nearly seven-fold increase in 30-day postoperative mortality. C_LIO_LIBoth short (<15 min) and prolonged ([&ge;]15 min) cardiopulmonary resuscitation are associated with a higher risk of early postoperative complications in the central nervous system. C_LI What are the clinical implications?O_LIPatients with acute type A dissection who require pre- or intra-operative cardiopulmonary resuscitation [&ge;]15 min should undergo careful multidisciplinary evaluation, as the risk of early mortality is substantially elevated. C_LIO_LIEven brief cardiopulmonary resuscitation is associated with increased neurological complications, highlighting the need for early neurological monitoring and supportive care postoperatively. 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.

BackgroundCardiac surgery significantly improves clinical endpoints but imposes challenges in postoperative recovery. Assessing patient-reported outcome is crucial for optimal care. However, no cardiac surgery-specific tools currently exist to adequately capture postoperative recovery experience. ObjectivesTo develop and validate a recovery scale after cardiac surgery (Fuwai-CRS). MethodsThis study was conducted from May 2023 to December 2024, comprising: (1) a qualitative study (Cohort 1) enrolling postoperative patients of cardiac surgery and medical staffs to develop the draft scale through literature review, semi-structured interview and Delphi consensus; and (2) a single-center prospective validation study (Cohort 2) to finalize the scale and evaluate psychometric properties. ResultsIn Cohort 1, a 17-item draft Fuwai-CRS was generated based on literature review, semi-structured interview (40 patients and medical staffs) and a Delphi study (15 experts). In Cohort 2 (n=500), a 9-item Fuwai-CRS was finalized by data distribution assessment, hierarchical cluster and factor analysis, and its understandability, reliability, validity and responsiveness were found acceptable. ConclusionsThe Fuwai-CRS is a concise and valid tool for recovery assessment after cardiac surgery.

BackgroundEvolocumab promotes coronary plaque regression in patients with coronary artery disease, but little is known regarding carotid plaques (CP). This study aimed to evaluate the impact of evolocumab on top of lipid-lowering therapy (ELLT) on carotid morphological stabilization (MS) and plaque regression (PR) compared to lipid-lowering therapy (LLT) alone. MethodsAsymptomatic patients with internal carotid stenosis[&ge;]50% and LDL-C[&ge;]100 mg/dL were randomized to ELLT or LLT and monitored by serial duplex ultrasound. The primary endpoint was a composite of 6-month-MS (i.e., switch from morphologic types I-II to III-IV) and/or 12-month-PR (i.e., reduction of carotid stenosis by at least 5% compared to baseline). The secondary endpoint was LDL-C change at 12 months. Major adverse vascular events (MAVE, i.e., cardiac death, stroke, myocardial infarction, carotid or coronary or peripheral revascularization) were recorded. ResultsA total of 170 patients were randomized. Mean carotid stenosis was 57%. At 6 months, MS occurred in the ELLT group (10.3%) only (p=0.29). At 12 months, PR was numerically more frequent in the ELLT group, without reaching statistical significance (43% versus 35.1%, p=0.42). The primary endpoint was met in 44.3% versus 35.1% (p=0.26). As compared to baseline, 6 and 12-month shifts from low to high-risk types were significantly higher in the LLT group (p=0.03). The 12-month LDL-C percentage reduction was -73.5% with ELLT, and -48.3% with LLT (p=0.0001). At 1 year, MAVE were significantly more frequent with LLT (14.6% versus 2.4%, p=0.005), and the absence of evolocumab was the only predictor (OR 7, p=0.014). ConclusionsIn patients with CP[&ge;]50% and LDL-C[&ge;]100 mg/dL, ELLT compared to LLT was associated with numerically but not statistically higher 6-month MS and/or 12-month PR. In the LLT group, 6- and 12-month changes from low to high-risk types, LDL-C, and MAVE were significantly higher. According to these results, evolocumab should be considered standard treatment for patients with CP[&ge;]50%. The study was registered at www.clinicaltrials.gov (NCT04730973) and Eudract (2020-005663-31). SHORT ABSTRACTPatients with carotid stenosis[&ge;]50% and LDL-C[&ge;]100 mg/dL were randomized to evolocumab on top of optimal lipid-lowering therapy (ELLT) or optimal lipid-lowering therapy (LLT) alone to assess the impact of ELLT on carotid plaque morphological stabilization (MS) and plaque regression (PR). At 6 and 12 months, MS and PR occurred in both groups, but were numerically higher in the ELLT group, without reaching statistical significance. In the LLT group, 6- and 12-month changes from low to high-risk types were significantly higher, and the rate of adverse vascular events was sevenfold higher. Evolocumab might become the standard treatment for patients with carotid artery stenosis [&ge;]50%. CLINICAL PERSPECTIVEO_ST_ABSWhat is new?C_ST_ABSO_LIThe CARUSO is the largest randomized trial evaluating the impact of evolocumab on top of lipid-lowering therapy (ELLT) on carotid morphological stabilization (MS) and plaque regression (PR) monitored by serial duplex ultrasound. C_LIO_LIThe primary endpoint was a composite of 6-month-MS (i.e., switch from morphologic types I-II to III-IV) and/or 12-month-PR (i.e., reduction of carotid stenosis by at least 5% compared to baseline) and was numerically higher in the ELLT group compared to lipid-lowering therapy (LLT) alone, without reaching statistical significance. C_LIO_LIThe 1-year rate of major adverse vascular events (MAVE) was sevenfold higher in the LLT group. C_LI What are the clinical implications?O_LICarotid plaque morphology is a dynamic event, and 6 and 12-month shifts from low to high-risk morphological types were significantly higher in the LLT group, thus suggesting that evolocumab added to LLT may prevent morphological deterioration. C_LIO_LIThe absence of evolocumab was the only independent predictor of MAVE; according to our results, ELLT might become the standard treatment for patients with carotid plaques [&ge;]50% and LDL-C not at target. C_LIO_LIFuture larger studies are warranted to validate our findings, assess long-term adherence to therapy, and identify subgroups with higher probability of achieving MS and PR. C_LI

BackgroundIron metabolism disorder is highly prevalent before and after heart transplantation (HTx). The impact of pretransplant and posttransplant iron disorder on posttransplant outcomes is unclear. ObjectivePretransplant serum levels of key regulator proteins of iron metabolism (hepcidin, interleukin-6, erythroferrone) were tested for prediction of the composite outcome 1-year posttransplant all-cause mortality (ACM) or [&ge;]moderate acute cellular rejection (ACR). Furthermore, serum levels of these proteins were measured at 1-year posttransplant to explore their posttransplant course and association with ACR. ResultsIn a multicenter cohort including 276 consecutive HTx recipients, patients with or without outcome (n=118/158, respectively) did not differ for pretransplant demographics, mismatch of donor/recipient sex, mismatch of HLA epitopes, and hepcidin or interleukin-6 levels. However, pretransplant erythroferrone levels were higher (1.40 vs. 1.19 ng/mL; p=0.013) and hemoglobin levels were lower (124.5 vs. 127 g/L; p=0.004) among patients with the composite outcome. Pretransplant erythroferrone levels >2.25 ng/ml (4th-quartile) were significantly associated with the composite outcome in multivariable analysis (OR 2.17; 95% CI 1.19-3.94, p=0.011; reference: 1st-3rd quartiles). In adjusted predicted proportions analysis, the incidence of the composite outcome was higher in 4th-quartile patients when compared to 1-3rd -quartiles patients (58.0 vs. 37.7%; p=0.003). At 1-year posttransplant, 80.4% of patients with pretransplant erythroferrone levels >2.25 ng/ml remained high; 88.4% of patients with pretransplant erythroferrone levels [&le;]2.25 ng/ml had high levels posttransplant. In 1-year survivors with high erythroferrone levels and [&ge;]moderate ACR during the first postoperative year, the ratio of the opponent regulators of hepcidin gene expression, erythroferrone to interleukin-6, was higher when compared to those without ACR (1.18 vs. 0.41; p=0.016). Hepcidin levels were not different between these two subgroups indicating disproportionate ERFE increase. ConclusionHigh pretransplant erythroferrone levels predict the composite posttransplant outcome 1-year ACM and ACR. Disproportionately high posttransplant erythroferrone levels are related with [&ge;]moderate acute cellular rejection.

AimsThis study aimed to examine the prevalence of malnutrition and its associations with functional capacity and quality of life (QoL) in AL and ATTR cardiac amyloidosis patients. Methods and ResultsThis cross-sectional pilot study included 29 patients with confirmed CA (14 AL, 15 ATTR). Data were collected between January 2020 and September 2021. Nutritional status was assessed using body mass index (BMI), anthropometric measures, and the Subjective Global Assessment (SGA). Functional capacity was evaluated via handgrip strength and the 6-minute walk test, while QoL was assessed using the SF-36 and Kansas City Cardiomyopathy Questionnaire. Malnutrition, as determined by SGA, was present in 62% of patients, with no significant difference between AL and ATTR subtypes. In contrast, BMI according to WHO criteria failed to identify any cases of malnutrition, highlighting its limited utility in this population. These results suggest that conventional indicators may underestimate nutritional impairment in CA. Although overall QoL and functional capacity did not differ significantly between nutritional groups, malnourished AL patients showed notably lower QoL scores compared with well-nourished peers. ConclusionMalnutrition is highly prevalent in cardiac amyloidosis and seems to particularly affect the AL subtype. These findings underscore the importance of routine nutritional screening and targeted interventions, as early identification and management of malnutrition may improve patients quality of life and long-term outcomes.

ObjectiveThe objective of this study was to explore the predictors of statin intolerance in the primary and secondary prevention of CVD among patients in the first two years after the date of first prescription using real-world data. MethodsThis study used the Electronic Practice Based Research Network Linked Dataset. An algorithm, which considered the muscle symptoms and creatinine kinase of patients, was used to identify statin intolerant patients. The R software was used for all analyses. Descriptive and multivariate logistic regression analyses were performed along with sensitivity analysis which was done using the Akaike Information Criterion model selection method. ResultsOverall, 4,016 patients accounting for 60,873 visits met the selection criteria. About 3.5% of the patients were statin intolerant. After adjusting for all other variables, statin intolerance was positively associated with gender (AOR 1.5, 95% CI 1.0 - 2.2), SEIFA index (AOR 3.8, 95% CI 2.3 - 6.7), employment status (AOR 2.4, 95% CI 1.1 - 5.7), and comorbidities (AOR 7.0, 95% CI 2.2 - 19.0). A similar direction of associations was seen for the exposures of the model from the sensitivity analysis and the regression model. However, since the unrecorded employment status showed a positive association, the sensitivity analysis suggests that the relationship may be influenced by residual confounding or information bias, indicating that this finding should be interpreted with caution. ConclusionStatin intolerance within the diverse community represented in the dataset is driven by gender, employment status, area-based social advantage and disadvantage index, and comorbidities.

BackgroundKetone bodies have shown potential to improve cardiac metabolism and function in patients with heart failure (HF). ObjectiveTo evaluate the effects of exogenous ketone-based interventions on cardiac function in patients with HF or related cardiometabolic risk factors. MethodsWe conducted a systematic review based on a search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus from inception to January 2025. Eligible studies included randomized controlled trials evaluating exogenous ketones (oral ketones or ketone infusions) compared to placebo in adults with HF or patients with risk factors for HF including type 2 diabetes mellitus, hypertension, or coronary artery disease. Paired reviewers independently screened and identified hits at title-and-abstract and full-text levels to determine eligibility and extracted data from eligible studies. Random-effects meta-analysis was performed. Effects of interventions were summarized as mean differences (MD). Risk of bias was assessed using Cochrane RoB 2.0 tool. Certainty of evidence was evaluated using the GRADE (grading of recommendations assessment, development and evaluation) approach. ResultsOut of 565 unique records, 22 full-text articles were reviewed, and 8 studies met inclusion criteria. Exogenous ketone administration increased left ventricular ejection fraction (LVEF) (MD = 3.94, 95% CI 2.18-5.70, p = 0.001), cardiac output (CO) (MD = 1.11 L/min, 95% CI 0.55-1.67, p = 0.002), heart rate (4.85 bpm, 95% CI 2.24-7.46, p = 0.003), and stroke volume (SV) (MD = 10.21 mL, 95% CI 4.06-16.35, p = 0.005). Pulmonary capillary wedge pressure (PCWP) decreased (MD = -0.93 mmHg, 95% CI -1.44 to -0.43, p = 0.003), while mean arterial pressure showed no change (MD = -1.37 mmHg, 95% CI -3.53 to 0.79, p = 0.18). ConclusionsExogenous ketone-based therapies are associated with improvements in hemodynamic markers of cardiac function, including increases in LVEF, CO, and SV, along with a reduction in PCWP. These findings suggest that ketone supplementation may offer clinical benefits for patients with HF or vascular disease.

BackgroundBoth acute myocardial infarction (AMI) and acute myocarditis are characterised by cardiac troponin release as a marker of cardiomyocyte injury. While peak troponin is widely accepted as a surrogate marker for infarct size in AMI, its relationship with myocardial injury in acute myocarditis is unclear. This study aimed to quantify and compare the association between peak high-sensitivity cardiac troponin and cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) extent in patients with AMI versus acute myocarditis. MethodsPatients undergoing CMR imaging and measurement of high-sensitivity cardiac troponin I during hospital admission were retrospectively included. LGE extent was quantified in grams using the semi-automated expectation-maximization weighted intensity algorithm (EWA). ResultsCompared to patients with acute myocarditis (n=47), patients with AMI (n=49) had higher peak troponin levels (median [interquartile range] 32,470 [3,109-104,699] vs 7,295 [1,857-22,550] ng/L, p=0.002), larger LGE extent (25 [13-56] vs 10 [6-17] g, p<0.001), and lower left ventricular ejection fraction (45 [36- 52] vs 55 [49-58] %, p<0.001). Peak troponin was moderately positively correlated with LGE extent in both AMI (rho=0.56, p<0.001) and acute myocarditis (rho=0.58, p<0.001). However, the ratio of peak troponin to LGE mass was higher in AMI compared to acute myocarditis (1,299 [419-3233] vs 909 [310-1446] ng/L/g, p=0.02). ConclusionsPeak cardiac troponin correlates positively with LGE extent in both AMI and acute myocarditis, but the magnitude of LGE and LV systolic dysfunction is greater in AMI. Also, AMI typically has an approximately 40% greater amount of troponin release per unit LGE mass compared to acute myocarditis. This suggest that troponin-based estimates of myocardial injury size estimated by LGE are not directly interchangeable between ischaemic and inflammatory myocardial diseases.

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

BackgroundScreening for atherosclerosis focuses on identifying Standard Modifiable Risk Factors (SMuRFs), including diabetes, hypertension, hyperlipidaemia, and smoking. PurposeTo compare the extracardiac thoracoabdominal atherosclerotic plaque burden, as measured by computed tomography angiography (CTA), among heart transplant candidates with ischemic or non-ischemic cardiomyopathy (ICM, NICM), and evaluate potential associations between plaque burden and SMuRFs. MethodsThis retrospective study identified heart transplant candidates with ICM or NICM matched for age and sex, undergoing thoracoabdominal CTA. Patients were classified as with SMuRFs or SMuRF-less. Extracardiac thoracoabdominal non-calcified and calcified atherosclerotic plaque was classified as present or absent across 78 arterial segments per patient. ResultsAmong included patients (n=167, median [interquartile range] age 58 [53-63] years, 16% female, 51% NICM), 40 patients (24%) were SMuRF-less (ICM: 16/82 (20%), NICM: 24/85 (28%), age 56 [50-67] years). Overall, out of 13,026 arterial segments analysed, 1,746 (13%) were affected by atherosclerotic plaque (9 [4-15] segments per patient). ICM had a higher total plaque burden than NICM (11 [7-18] vs 6 [3-11] segments per patient, p<0.001). SMuRF-less patients showed no difference in non-calcified, calcified, or total plaque burden compared to patients with SMuRFs, among all patients (ICM+NICM, p>0.17) and within the ICM and NICM groups, respectively (p>0.30). ConclusionsThe burden of extracardiac thoracoabdominal atherosclerotic plaque is higher among heart transplant candidates with ICM. However, it does not differ between SMuRF-less or those with SMuRFs, regardless of underlying ICM or NICM. The prevalence of SMuRFs is not an effective marker to determine the need to screen for extracardiac atherosclerotic plaque among heart transplant candidates. GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=134 SRC="FIGDIR/small/26347056v1_ufig1.gif" ALT="Figure 1"> View larger version (51K): org.highwire.dtl.DTLVardef@1aff6b1org.highwire.dtl.DTLVardef@16cfb07org.highwire.dtl.DTLVardef@1d4894corg.highwire.dtl.DTLVardef@81e9d3_HPS_FORMAT_FIGEXP M_FIG C_FIG

We performed a systematic review and meta-analysis of randomized controlled trials evaluating glucagon-like peptide-1 receptor agonists (GLP-1 RAs) versus placebo in adults with heart failure (HF), searching PubMed, Cochrane CENTRAL, and ClinicalTrials.gov through February 2026. The primary outcome was the composite of cardiovascular death and first HF hospitalization. Random-effects meta-analysis used restricted maximum likelihood estimation with Hartung-Knapp-Sidik-Jonkman adjustment. We included 14 studies (6 dedicated HF trials and 8 cardiovascular outcomes trial HF subgroup analyses) encompassing 18,558 patients, of whom 2,499 were randomized in dedicated HF trials. The primary composite did not reach statistical significance (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.73-1.01; P=0.067; I2=47%). GLP-1 RAs significantly reduced all-cause mortality (HR 0.87, 95% CI 0.81-0.93; P<0.001; I2=0%), major adverse cardiovascular events (HR 0.83, 95% CI 0.73-0.95; P=0.019), and improved Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (+7.4 points, 95% CI 6.3-8.5) and 6-minute walk distance (+17.6 m, 95% CI 13.4-21.7). Excluding the FIGHT trial (acute HFrEF) yielded a significant primary composite (HR 0.83, P=0.011). The mortality signal was driven primarily by CVOT subgroups; the largest dedicated HFpEF trial (SUMMIT) showed numerically higher mortality (HR 1.25). The strongest evidence supports GLP-1 RAs in HFpEF with obesity. HighlightsO_LIPrimary composite of CV death + HHF was not significant (HR 0.86, P=0.067) C_LIO_LIGLP-1 RAs reduced all-cause mortality (HR 0.87) with no heterogeneity C_LIO_LIKCCQ-CSS improved by 7.4 points and 6MWD by 17.6 m in HFpEF trials C_LIO_LIMortality benefit driven by CVOT subgroups, not dedicated HF trials C_LIO_LIStrongest evidence supports GLP-1 RAs in HFpEF with obesity C_LI

PurposeThe objective of this study was to identify predictors of statin adherence in the primary and secondary prevention of CVD among patients in the first two years after the date of first prescription using real-world data. MethodsThe Electronic Practice Based Research Network Linked Dataset was used in this study. Statin adherence was calculated using a modified proportion of days covered (PDC) formula. Individuals with PDC [&ge;] 80% during the two years of observation period were considered as adherent. All analyses were performed with R software. Descriptive and multivariate logistic regression analyses were performed. Sensitivity analysis was performed using the Akaike Information Criterion model selection method. ResultsOverall, 3,432 patients accounting for 57,227 visits met the selection criteria. The mean PDC was 91.6% ({+/-}22.2%), and 72.0% of the patients were adherent to statins (PDC [&ge;] 80%) in the first two years after the date of first prescription. After adjusting for all other variables, statin adherence was positively associated with age (AOR 1.7, 95% CI 1.4 - 2.0), SEIFA index (AOR 1.8, 95% CI 1.2 - 2.6), polypharmacy (AOR 1.8, 95% CI 1.3 - 2.5) and comorbidities (AOR 1.4, 95% CI 1.1 - 1.7), and negatively associated with the number of statin types (AOR 0.6, 95% CI 0.5 - 0.9) and smoking status (AOR 0.7, 95% CI 0.6 - 0.9). The sensitivity analysis showed similar results as the regression model. ConclusionsStatin adherence is influenced by an aging, multimorbid population, who are exposed to polypharmacy, multiple statin options and socioeconomic diversity. Key pointsO_LIAdherence in the first two years after the first date of statin prescription was measured as proportion of days covered (PDC) C_LIO_LIThe mean PDC was 91.6% ({+/-}22.2%) C_LIO_LI72.0% of the patients were adherent to statins, with PDC [&ge;] 80% C_LIO_LIStatin adherence was positively associated with age, area-based social advantage and disadvantage index, polypharmacy and comorbidities C_LIO_LIStatin adherence was negatively associated with the number of statin types prescribed to the patients and the smoking status of patients C_LI Plain Language SummaryThe objective of this study was to identify predictors of statin adherence among patients in the first two years after the date of first prescription using real-world data. The dataset used was the Electronic Practice Based Research Network Linked Dataset. Statin adherence was calculated using proportion of days covered (PDC). A PDC [&ge;] 80% during the two years of observation period were considered as adherent. Overall, 3,432 patients were eligible for this study, and 72.0% of them were adherent to statins in the first two years after the date of first prescription. Statin adherence was positively associated with age, area-based social advantage and disadvantage index, number of medicines taken by the patient and number of chronic conditions that the patient suffered. Moreover, statin adherence was negatively associated with the number of statin types prescribed to the patients and smoking status of patients.

PurposeDespite strong evidence, real-world adoption of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains suboptimal. The Get With The Guidelines-Heart Failure (GWTG-HF) program was designed to close gaps in care. We evaluated whether hospital participation in GWTG-HF is associated with greater GDMT intensity and improved outcomes. MethodsWe conducted a retrospective analysis (2013-2021) of Medicare beneficiaries with Part A and Part D hospitalized with HFrEF. Using a multiple baseline time series design, we compared changes in GDMT prescribing and outcomes at hospitals before and after GWTG-HF enrollment with hospitals that never participated. The primary outcome was a 90-day post-discharge prescription-fill GDMT score summarizing use and dose of beta blockers, renin-angiotensin system inhibitors (RASI; ACE inhibitor/ARB/ARNI), and mineralocorticoid receptor antagonists (MRA). Secondary outcomes included class-specific medication fills, achievement of [&ge;]50% target doses, and 30-day, 90-day, and 1-year all-cause and HF readmission and mortality. We adjusted for baseline hospital performance, patient characteristics, and temporal trends. ResultsAmong 1,274,863 Medicare beneficiaries hospitalized for HFrEF, 53.5% were treated at hospitals that never participated in GWTG-HF and 9.6% at hospitals that joined GWTG-HF before hospitalization. Unadjusted median GDMT scores increased from 3.0 in both groups to 4.0 in non-participating hospitals and 4.5 in GWTG-HF hospitals at 90 days (p<0.001). Hospital enrollment was associated with a higher 90-day GDMT score (+0.15 points; 95% CI 0.12-0.18; p<0.001), and greater use of beta blockers, RASI, and MRA, but not ARNI. HF readmission did not differ significantly; however, GWTG-HF participation was associated with lower all-cause mortality at 30 days (OR 0.95; 95% CI:0.92-0.98), 90 days (OR: 0.97; 95% CI: 0.95-0.99), and 1 year (0.97; 95% CI: 0.95-.0.99; all p<0.05). ConclusionHospital participation in GWTG-HF was associated with higher GDMT intensity and lower mortality, supporting structured quality programs to improve HFrEF care.

BackgroundHeart failure (HF) is an increasingly common complication among patients with type 2 diabetes (T2D), yet its early detection remains challenging, especially in those with concomitant chronic kidney disease (CKD). NT-proBNP is a key biomarker for diagnosing and prognosticating HF, but its reference thresholds are influenced by renal function, age, and ethnicity. Current guideline cutoffs, largely derived from Western populations, may not apply to Asian patients. MethodsThis retrospective cohort study included 10,587 adults with T2D who underwent NT-proBNP testing between 2006 and 2021 at the National Taiwan University Hospital. Patients with prior HF were excluded. Generalized additive models identified NT-proBNP thresholds associated with HF hospitalization, and Kaplan-Meier analysis validated outcome separation. Subgroup analyses were stratified by age, sex, body mass index (BMI), and estimated glomerular filtration rate (eGFR). ResultsDuring a mean follow-up of 3.5 years, 1,892 (17.9%) patients were hospitalized for HF. NT-proBNP levels of 179 pg/mL (outpatient) and 728 pg/mL (emergency) marked inflection points for rising event risk (log-rank p < 0.0001). Age-specific analyses showed progressive increases in optimal thresholds: from 85 (<50 years old), 150 (50-74 years old) and 290 pg/mL ([&ge;]75 years old) in outpatients, and from 310, 600 and 1,165 pg/mL, respectively, in emergency settings. In the BMI-stratified analysis, NT-proBNP thresholds demonstrated an inverse relation with BMI. Considering renal function, the optimal cutoffs were 100, 310, and 935 pg/mL for eGFR > 60, 30-60, and < 30 mL/min/1.73 m{superscript 2}, respectively; in the emergency cohort, the corresponding thresholds were 290, 835, and 3,905 pg/mL. ConclusionsThis large Asian cohort defines setting- and renal function-specific NT-proBNP thresholds for predicting HF hospitalization in patients with T2D. The lower optimal cutoffs compared with Western guidelines highlight the need for ethnicity-adjusted diagnostic criteria to improve early identification and risk stratification of HF in clinical practice. What is new?O_LIIn a large real-world Asian cohort of patients with type 2 diabetes, we identified setting-specific NT-proBNP thresholds (179 pg/mL outpatient; 728 pg/mL emergency) associated with heart failure hospitalization risk. C_LIO_LIAge-, BMI-, and kidney function-stratified cutoffs revealed substantial heterogeneity in optimal NT-proBNP thresholds. C_LIO_LICompared with guideline-recommended values, Asian-specific thresholds were consistently lower ([~]30-40%), supporting ethnic differences in natriuretic peptide biology. C_LIO_LIA generalized additive model (GAM) captured nonlinear biomarker-risk relationships, enabling data-driven and clinically interpretable cutoff identification. C_LI What are the clinical implications?O_LIUse of ethnicity- and context-specific NT-proBNP thresholds may improve early detection of heart failure in Asian patients with type 2 diabetes. C_LIO_LIIncorporating kidney function and BMI into NT-proBNP interpretation enhances risk stratification, particularly in patients with CKD. C_LIO_LIReliance on Western guideline cutoffs may underestimate heart failure risk in Asian populations. C_LIO_LIThese findings support a precision medicine approach to biomarker interpretation and highlight the need for population-specific guideline refinement. C_LI

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.

AimsCatheter ablation using radiofrequency (RF) or pulsed field (PF) energy is an effective treatment method for ventricular arrhythmia (VA). PF offers advantages in lesion formation in anatomically challenging regions. However, its acute effects on ventricular contractility during substrate modification require further elucidation. This study aimed to compare real-time hemodynamic changes associated with PF versus radiofrequency ablation in the left ventricle using stroke volume (SV) as a surrogate for myocardial response in regard to the safety of multiple lesion delivery within scarred myocardium. Methods and resultsWe conducted a prospective case series study of eight consecutive patients undergoing VA ablation using a dual-energy lattice-tip catheter (Sphere-9, Medtronic). Lesions were delivered to scarred regions identified via intracardiac echocardiography (ICE) and high-resolution 3D mapping. Hemodynamic monitoring was performed using a minimally invasive arterial waveform system (HemoSphere, Edwards Lifesciences). A total of 317 PFA and 41 RF lesions were delivered. PFA applications were associated with a transient SV reduction of 33.1{+/-}8.3 ml, with normalization post-delivery. RF lesions resulted in a minimal SV change ([&le;]10% from baseline value). SV reduction following PFA was consistent across lesion locations. All patients achieved post-procedural non-inducibility of clinical VT. ConclusionPF causes transient but reversible reductions in LV stroke volume during lesion delivery, likely reflecting acute electroporation-induced myocyte stunning rather than irreversible dysfunction. RF lesions did not produce similar changes. These findings suggest a favorable safety profile for PF in ventricular substrate ablation, including in cases of multiple lesion sets, and support its use in regions of scarring. Further studies are warranted to validate these observations and assess long-term outcomes.

BACKGROUNDPeak oxygen uptake (pVO2) is a strong, independent predictor of adverse cardiovascular outcomes, supporting cardiopulmonary exercise testing as a primary end point assessing efficacy of novel drug therapies in obstructive hypertrophic cardiomyopathy (oHCM) clinical trials. However, characterizing changes in pVO2 that patients perceive as beneficial or meaningful (ie, minimal important difference [MID]) has not been determined. METHODSData from patients with symptomatic oHCM enrolled in SEQUOIA-HCM and MAPLE-HCM were pooled. A total of 282 patients were randomized 1:1 to aficamten (5-20 mg daily) or matching placebo in SEQUOIA-HCM, and 175 patients were randomized 1:1 to aficamten (5-20mg daily) or to metoprolol (50-200 mg) in MAPLE-HCM; follow-up in both trials was 24 weeks. Primary outcome was change from baseline to week 24 ({Delta}) in pVO2 using Patient Global Impression of Change with anchor-based analysis to define MID. RESULTSAt week 24, {Delta}pVO2 (mL/kg/min) that corresponded to no change, one-category improvement, and one-category worsening were -0.05 (95% CI, -0.58 to 0.48), +0.35 (95% CI, -0.22 to 0.91), and -0.61 (95% CI, -1.36 to 0.13), respectively. Similarly, minute ventilation to carbon dioxide production ratio (VE/VCO2) slope that corresponded to no change, one-category improvement, and one-category worsening were 0.16 (95% CI, -0.59 to 0.90), -1.15 (95% CI, - 1.89 to -0.42), and 0.88 (95% CI, -0.42 to 2.19), respectively. In a responder analysis using this new threshold for pVO2, 60% of patients receiving aficamten achieved a {Delta}pVO2 [&ge;]0.35 versus 31% of patients on placebo or metoprolol (odds ratio, 3.4 [95% CI, 2.3-4.9], P<0.001). Consistent findings were seen with VE/VCO2 responder analysis. CONCLUSIONSChanges in pVO2 of +0.35 and -0.61 mL/kg/min were associated with a small but perceptible clinical improvement and worsening, respectively, in patients with oHCM. Applying this newly defined threshold resulted in excellent differentiation of treatment effect in a clinical trial. These novel data provide a measure of clarity to patients and clinicians regarding the interpretation of changes in pVO2 following therapeutic interventions, with potential impact on HCM management strategies and future clinical trials. Clinical Trial RegistrationSEQUOIA-HCM (NCT05186818; https://clinicaltrials.gov/study/NCT05186818?term=sequoia-hcm&rank=1); MAPLE-HCM (NCT05767346; https://clinicaltrials.gov/study/NCT05767346?term=maple-hcm&rank=1) Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIUsing pooled data from over 440 patients with symptomatic obstructive hypertrophic cardiomyopathy enrolled in two phase 3 clinical trials, we define, for the first time, the minimally important difference for peak oxygen uptake (pVO2) and ventilatory efficiency (VE/VCO2) using patient-anchored and distribution-based methodologies. C_LIO_LIA change in pVO2 of +0.35 mL/kg/min and a change in VE/VCO2 of -1.15 represent the minimal thresholds associated with patient-perceived clinical improvement. C_LIO_LIResponder analyses using these thresholds demonstrated robust differentiation between aficamten and placebo/metoprolol, with an odds ratio exceeding 3 for achieving a meaningful improvement in pVO2. C_LI What Are the Clinical Implications?O_LIThese newly defined thresholds bridge the gap between statistically significant changes in cardiopulmonary exercise testing measures and clinically meaningful benefit as perceived by patients with obstructive hypertrophic cardiomyopathy. C_LIO_LIClinicians can use these benchmarks to contextualize individual patient responses to medical therapy, informing shared decision-making regarding treatment continuation or modification. C_LIO_LIThese data provide a standardized, patient-centered framework for designing and interpreting primary end points in future hypertrophic cardiomyopathy clinical trials. C_LI