Open Heart

Inhibitors of the Renin-Angiotensin-Aldosterone System (RAAS) notably Angiotensin-Converting Enzyme inhibitors (ACEi) or Angiotensin Receptor Blockers (ARB) have been scrutinised in hypertensive patients hospitalised with coronavirus disease 2019 (COVID-19) following some initial data they might adversely affect prognosis. With an increasing number of COVID-19 cases worldwide and the likelihood of a "second wave" of infection it is imperative to better understand the impact RAAS inhibitor use in antihypertensive covid positive hospitalised patients. A systematic review and meta-analysis of ACEi or ARB in patients admitted with COVID-19 was conducted. PubMed and Embase were searched and six studies were included in the meta-analysis. Pooled analysis demonstrated that 18.3% of the patients admitted with COVID-19 were prescribed ACEi/ARBs (0.183, CI 0.129 to 0.238, p<0.001). The use of RAAS inhibitors did not show any association with critical events (Pooled OR 0.833 CI 0.605 to 1.148, p=0.264) or death (Pooled OR 0.650, CI 0.356 to 1.187, p=0.161). In conclusion, our meta-analysis including critical events and mortality data on patients prescribed ACEi/ARB and hospitalised with COVID-19, found no evidence to associate ACEi/ARB with death or adverse events.

Several diseases (cancer, neurological) show geographic clustering, giving insights into possible genetic and environmental causes. The pathogenesis of Congenital Heart Disease (CHD) remains largely unknown and analysis of geographic distribution of CHD cases lacks input from large, national-scale datasets. People with structural CHD were selected from the Australia and New Zealand CHD Registry. Of people known to be still living, from linkage with the National Death Index, addresses were geocoded and aggregated to standardised geographic regions with measures of the Australian population. Areas were described based on measures of their remoteness and driving time to hospitals. The relationship between the distribution of the CHD and Australian populations was compared with bivariate spatial correlation. Of 81,349 people with structural CHD in the Registry, 63,863 were still living and could be geocoded. Overall, most people lived in Major Cities, and within 1-hour drive from a hospital, with the proportion the same across the CHD population, the "complex CHD" population and the Australian population. Across the country, there was a strong positive correlation between the Australian population and the CHD population. There were only a small number of areas (6%) where the Australian and the CHD populations were proportionally different. Overall, there was clear evidence that the geographic distribution of the CHD population proportionally follows the general Australian population. This suggests that there is unlikely to be any spatial clusters that are driven by genetic or environmental causes. Author SummaryPeople living with congenital heart disease have overgone many changes over recent decades. As surgical intervention has improved, people with congenital heart disease are living longer and a greater proportion are now adults. This is success brings new challenges surrounding their healthcare. What kinds of complications will older people with congenital heart disease face, how will our health services cope with the increasing demands, and how should we deploy health services? We aimed to answer some of these question by assessing where people with congenital heart disease lived in Australia, and how that distribution compares with the general Australian population. This research is made possible by the Australia and New Zealand Congenital Heart Disease Registry, which enables this analysis to be conducted at a national scale for the first time. Most of the congenital heart disease population was living in major cities, and within a 1-hour drive of a hospital. Overall, their geographic distribution was very similar to that of the Australia population. These results suggest that there are not any environmental factors that are causing congenital heart disease, or that people with congenital heart disease are choosing to live in different places, compared to the general Australian population.

BackgroundTelemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown. MethodsWe conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at [&ge;]6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials ([&ge;]25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials. ResultsThirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP). ConclusionsTM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIIn this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care. C_LIO_LIThe BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses, C_LIO_LINon-White patient predominant trials achieved lesser BP reductions than White patient predominant trials. C_LI What Are the Clinical Implications?O_LIBefore wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control. C_LIO_LIWithout equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US. C_LI

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

BACKGROUNDThe increased survival rate among individuals with congenital heart disease (CHD) has sparked interest in their transition to adult healthcare. Although there is a general agreement on the importance of transition interventions, the empirical evidence supporting them is insufficient. Therefore, this study aimed to conduct a systematic review and meta-analysis of transition interventions for adult healthcare in adolescents and young adults. METHODS AND RESULTSA literature search was conducted for studies comparing the quantitative effects of transition interventions with control groups, published up to March 15, 2023, in major databases (CENTRAL, Embase, PubMed, Web of Science, CINAHL, KISS, and KMbase), major clinical trial registers, academic journal sites related to the topic, and grey literature databases. Ten studies involving a total of 1,297 participants were identified. Transition interventions proved effective in enhancing disease-related knowledge (Hedges g=0.89, 95% CI=0.29-1.48) and self-management (Hedges g=0.67, 95% CI=0.38-0.95), as well as reducing loss to follow-up (OR=0.41, 95% CI=0.22-0.77). The certainty of evidence for the estimated values of each major outcome was low or very low. CONCLUSIONSThis study supports the implementation of transition interventions by demonstrating that they can improve patients disease knowledge and self-management, while also promoting treatment continuity. However, since the available data on transition interventions for adolescents and young adults with CHD remain limited, the widespread adoption of structured transition interventions in the future may alter the conclusions of this study. REGISTRATIONURL: https://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42023399026. CLINICAL PERSPECTIVEO_ST_ABSWhat Is New?C_ST_ABSO_LIThis systematic review of transition programs for individuals of transitional age with congenital heart disease identified 10 relevant studies. C_LIO_LITransition programs for adolescents and young adults with congenital heart disease were primarily designed to provide individual education, supplement roles related to anatomical and hemodynamic considerations, manage medications and medical appointments and facilitate communication with healthcare providers. C_LIO_LIThe transition programs demonstrated efficacy in enhancing disease-related knowledge and self-management, as well as in reducing instances of loss to follow-up. However, they did not significantly improve disease-related quality of life. C_LI What Are the Clinical Implications?O_LIGiven the ethical and practical considerations that arise from country-specific conditions and environments, research on congenital heart disease transition programs should utilize a feasible study design that incorporates a control group. C_LIO_LITransition programs should address lifestyle factors that can enhance heart function and alleviate clinical symptoms. After promoting long-term commitment to these programs, it is necessary to assess the effects on disease-related quality of life. C_LIO_LIAn execution of a transition program that takes into account the developmental characteristics of the target age group, as well as a transition program involving parents, is necessary. Subsequently, an analysis of the effects of these programs is also required. C_LIO_LIAs a result of the transition program, it is necessary to measure and analyze not only process indicators but also outcome indicators that directly reflect an individuals health (e.g. emergency room visits, hospital admissions, and the status of disease or complications). C_LI

Captopril, an ACE inhibitor, is widely used for acute hypertensive episodes, while hydroxyzine, an antihistamine with sedative and anxiolytic effects, is also employed in Poland despite limited research on its efficacy for this purpose. To our knowledge, no prior studies have specifically investigated the direct impact of hydroxyzine on hypertension, despite its common use in Polish medical practice. A retrospective cohort analysis of 2144 patients who required emergency intervention for hypertension or had high blood pressure during other interventions. Effectiveness was based on blood pressure improvement post-intervention. 84.28% of interventions were performed by basic emergency teams, and 15.72% by specialist teams. Captopril and hydroxyzine were the most commonly used medications. Blood pressure improved in 36.61% of patients, with no improvement in 41.47%. Hydroxyzine was more frequently administered by paramedic teams, while captopril was favoured by specialist teams. There were no statistically significant differences in captopril use across age groups, with approximately 80% receiving it. Hydroxyzine use did not vary significantly by age, though its overall use was low. Hydroxyzine showed a non-significant trend towards greater blood pressure reduction compared to captopril. Captopril is the primary treatment for acute hypertension in emergency settings, but hydroxyzine may have potential benefits, especially in patients with anxiety-related hypertension. However, due to the lack of significant evidence and current guidelines advising against hydroxyzine in elderly patients, further research is needed to establish protocols and optimize hypertension treatment strategies. Additionally, incorporating anxiolytics into guidelines and an official statement on their use would aid clinical practice.

BackgroundResistant hypertension is quite prevalent and a risk factor for cardiovascular events. Patients with suspected resistant hypertension undergo more screening intensity for secondary hypertension, despite some of them being non-adherent to prescribed pharmacotherapy. The prevalence of non-adherence in this setting varies from about 5 to 80% in the published literature. Apart from the wide range, the relation between method of assessment and prevalence is not well established. Our objective was to establish the overall prevalence of non-adherence in the apparent treatment resistant hypertension population, explore causes of heterogeneity, and evaluate the effect of the method of assessment on the estimate of non-adherence. MethodsWe performed a systematic review and meta-analysis. MEDLINE, EMBASE Classic+EMBASE, Cochrane, CINAHL, and Web of Science were searched for relevant articles. Details about the method of adherence assessment were extracted from each included article and grouped into direct and indirect. Pooled analysis was performed using the random effects model and heterogeneity was explored with metaregression and subgroup analyses. ResultsThe literature search yielded 1428 studies, of which 36 were included. The pooled prevalence of non-adherence was 35% (95% confidence interval 25 - 46 %). For indirect methods of adherence assessment, it was 25% (95% CI 15 - 39 %), whereas for direct methods of assessment, it was 44% (95% CI 32 - 57 %). Metaregression suggested gender, age, and time of publication as potential factors contributing to the heterogeneity. ConclusionsNon-adherence to pharmacotherapy is quite common in resistant hypertension, with the prevalence varying with the methods of assessment. Brief SummaryResistant hypertension is known to be a risk factor for cardiovascular events. These patients also undergo higher screening intensity for secondary hypertension. However, not all patients with apparent treatment resistant hypertension have true resistant hypertension, with some of them being non-adherent to prescribed pharmacotherapy. This systematic review aims to establish the overall prevalence of non-adherence in the apparent treatment resistant hypertension population and assess the relative contributions of non-adherence assessed with direct and indirect measures.

IntroductionThe Top End of Australia has a high proportion of Indigenous people with a high burden of chronic cardiac and pulmonary diseases likely to contribute to pulmonary hypertension (PH). The epidemiology of PH has not been previously studied in this region. MethodsPatients with PH were identified from the Northern Territory echocardiography database from January 2010 to December 2015 and followed to the end of 2019 or death. PH was defined as a tricuspid regurgitation velocity [&ge;]2.75 m/s measured by Doppler echocardiography. The etiology of PH, as categorized by published guidelines, was determined by reviewing electronic health records. Results1764 patients were identified comprising 49% males and 45% Indigenous people. The prevalence of PH was 955 per 100,000 population (with corresponding prevalence of 1587 for Indigenous people). Hypertension, atrial fibrillation, diabetes and respiratory disease were present in 85%, 45%, 41% and 39%, respectively. Left heart disease was the leading cause for PH (58%), the majority suffering from valvular disease (predominantly rheumatic). Pulmonary arterial hypertension (PAH), respiratory disease related PH, chronic thromboembolic PH (CTEPH) and unclear multifactorial PH represented 4%, 16%, 2% and 3%, respectively. Underlying causes were not identifiable in 17% of the patients. Only 31% of potentially eligible patients were on PAH-specific therapy. At census, there was 40% mortality, with major predictors being age, ePASP and Indigenous ethnicity. ConclusionPH is prevalent in Northern Australia, with a high frequency of modifiable risk factors and other treatable conditions. Whether earlier diagnosis, interpretation and intervention improves outcomes merits further assessment.

Sudden cardiac death (SCD) in the young (<35years) can be due to an inherited cardiovascular condition. The impact of SCD on the surviving family is significant, with high rates of symptoms of posttraumatic stress and prolonged grief. Using stakeholder codesign we developed COPE-SCD: an online community supporting families after SCD. The intervention includes a website and four online support sessions (general information on SCD, navigating uncertainty, coping with grief and loss both individually and as a family). Here we aim to develop content and assess the acceptability of the COPE-SCD intervention. Participants were recruited from the Genetic Heart Disease Clinic, Royal Prince Alfred Hospital, Sydney, Australia and EndUCD.org, a patient organisation. Demographic and psychological measures were collected at baseline. Think aloud interviews were conducted to assess the website. Online sessions were assessed with post session questionnaires and qualitative interviews. Both interview schedules and questionnaires were mapped to seven constructs of the Theoretical Framework of Acceptability. Website and online session content were developed. Six think aloud interviews were conducted to assess the website, including feedback on content and layout. Twelve participants, in two groups, completed the four online sessions. Overall, participants liked both parts of the COPE-SCD intervention, particularly the opportunity for peer support. They found the intervention acceptable when considering the seven constructs of the theoretical framework of acceptability. Further work is needed to assess the effectiveness of the intervention as its implemented into clinical practice. What is known about this topicSudden cardiac death due to an inherited cardiovascular condition has a devastating impact on the surviving family, with high rates of psychological distress. Previous research has shown more psychosocial support for family members is needed. What this paper adds to the topicWe describe the development and acceptability of a support intervention for families after sudden cardiac death in the young. The intervention combined information and peer support and was found acceptable to individuals with a family history of sudden cardiac death.

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

BackgroundIn the past 50 years, therapeutic options for treating both children and adults with native aortic coarctation have significantly improved. In contrast to surgery, In 1982, balloon angioplasty (BA) was suggested as a potential alternative for the Primary treatment of CoA. Here, Surgery vs Angioplasty is compared to understand the rates of their compilations like aneurysm and recoarctation. MethodA total of 13 RCTs with a total of 877 patients (Surgery-537, Angioplasty-340) of total patients were identified following PRISMA guidelines till November 2019 and were matched for inclusion and exclusion criteria. The following search strings and MESH terms were used: coarctation of aorta, surgery, balloon angioplasty, and aneurysm. Following this, Surgery and Angioplasty were evaluated for complications and recoarctation. RevMan 5.3 was used for appropriate statistical tests. Fixed and Random Effect Model tests were used and p<0.05 was considered statistically significant. ResultAngioplasty seems to be a Statistically better alternative with lesser complications (OR=1.993, CI95=1.126 to 3.527, p=0.018). It can be seen that Surgery is statistically far better in preventing the formation of an aneurysm (OR=0.291, CI95=0.141 to 0.602, p=0.001). Surgery as a treatment is statistically better than angioplasty to prevent a recoarctation (OR=0.375, CI95=0.268 to 0.524, p=<0.001). ConclusionSurgery is found to be a better treatment option for preventing complications whereas angioplasty is better in preventing the formation of aneurysms and recoarctation.

Background and aimsEvidence of the impact of frailty on oral anticoagulant (OAC) prescription in older people with atrial fibrillation (AF) is conflicting. This study aimed to examine the prevalence of frailty in hospitalised older patients with AF and its relationship with OAC prescription during admission. The secondary aim was to examine the association between frailty and rate/rhythm control medication prescriptions. MethodsThis retrospective observational study included adults aged [&ge;]65 with AF admitted to six hospitals in Australia in 2022. Frailty was defined by a Frailty Index [&ge;]0.25. Logistic regression models were applied to examine the association between frailty and the prescriptions of OAC, rate-control and rhythm-control drugs during hospitalisation. Results are presented as odds ratios and 95% confidence intervals (CI). ResultsThere were 685 patients, with a mean age of 82.6(SD 8.3), 49.8% female and 42.8% identified as frail. Overall, 75.6% were prescribed OAC (67.9% in the frail versus 81.4% in the non-frail, p<0.001), 37.7% received rate-control drugs (42.0% in the frail versus 34.4% in the non-frail, p=0.044), 27.3% received rhythm-control drugs (22.9% in the frail versus 30.6% in the non-frail, p=0.024). The adjusted odds ratios of frailty on prescriptions were 0.58 (95% CI 0.39-0.86) for OAC, 1.75 (95%CI 1.22-2.52) for rate-control drugs, and 0.83 (95%CI 0.55-1.24) for rhythm-control drugs. ConclusionsThe study revealed a high prevalence of frailty in older inpatients with AF. Frailty was associated with reduced likelihood of prescription of OAC during admission and increased likelihood of prescribing rate-control medications, with no independent impact on rhythm-control therapy. Further studies are needed to understand these prescribing patterns.

BackgroundFrailty is common in older adults with hypertension and can affect blood pressure (BP) control. Sex differences related to frailty and cardiovascular physiology may contribute to the effective treatment of hypertension. Aimto examine the prevalence of frailty in older adults with hypertension and its association with uncontrolled BP, with a particular focus on differences by sex. MethodsThis study was conducted at the outpatient clinics of two major hospitals in Vietnam from June 2023 to June 2024. Frailty was defined by a Clinical Frailty Scale of [&ge;]4. Uncontrolled BP was defined as systolic BP [&ge;]140 mmHg or diastolic BP [&ge;]90 mmHg, averaged over recordings in the last 6 months. Multivariable logistic regression was applied to identify the association between frailty and uncontrolled BP. The odds ratios (ORs) for uncontrolled BP of each risk factor were estimated by sex, with interaction terms fitted between each risk factor and sex to obtain the women-to-men ratio of ORs (ROR). ResultsThere were 1038 participants (326 women, 712 men). They had a mean age of 73.3 (SD7.4). The prevalence of frailty was 28.6% in all participants, higher in women (35.3%) than men (25.6%), p=0.001. The overall rate of uncontrolled BP was 26.7%. In women, the frail had a significantly higher rate of uncontrolled BP (33.9%) compared to the non-frail (20.9%), but no significant differences among men (26.4% in the frail vs. 27.5% in the non-frail). The adjusted ORs of frailty on uncontrolled BP were 1.70 (1.00-2.90) in women, 0.84 (0.57-1.25) in men; women-to-men ROR 2.02 (1.04-3.92). ConclusionIn older adults with hypertension, frailty was more common in women and was associated with an increased risk of having uncontrolled BP in women only. These findings highlight the need for sex-specific approaches in managing hypertension in older populations.

BackgroundPost-Ross procedure antihypertensive treatment strategies differ substantially, with no clear consensus and limited evidence to inform decision-making. We evaluated the association between discharge oral antihypertensive medications and post-discharge outcomes in pediatric Ross procedure patients. MethodsChildren (<18 years) undergoing the Ross procedure in the Pediatric Health Information Systems database (2004-2024) were included. Patients were divided into two groups based on discharge antihypertensives defined as the receipt of oral antihypertensive medication during the final two days of hospitalization: Anti-hypertensive (Anti-HTN) versus no-Anti-HTN groups. Primary outcomes were composite of left-sided (neo aortic valve/root/arch) reintervention or mortality at up to five years post-procedure. Trends in oral-antihypertensive therapy use post-Ross were examined. Results2,097 children were included, of which 1,234 (59%) were discharged with an oral anti-hypertensive regimen. Of these, 253 (21%) were discharged on >1 oral anti-hypertensive drug class. Anti-HTN patients had lower rates of the composite of left-sided interventions or mortality at one (2.8% vs 6.1%), three (6.3% vs 9.8%) and five years (8.9% vs 13.9%), log-rank=0.0025). On stratification by age categories, statistically significant results were only observed in age category 1-12 years (log-rank=0.0127). Lowest reintervention/mortality rates were observed in patients receiving beta-blockers (log-rank=0.0112). Between 2006 and 2022, there was an increase in discharge prescription rates of beta-blockers and >1 anti-hypertensive drug class. ConclusionsFollowing pediatric Ross procedure, discharge antihypertensive therapy was associated with a reduced composite risk particularly in the 1-12 year age group. These findings support prospective studies to define optimal antihypertensive strategies in Ross procedure patients.

ImportanceUsing aggregated data, two recent meta-analyses have concluded that early aortic valve replacement (AVR) was associated with reduced adverse events compared to clinical surveillance in severe but asymptomatic aortic stenosis. However, individual patient data was not used and the possibility and extent of bias due to the unblinding trial design were not considered. ObjectiveUsing reconstructed individual patient level data, the possiblity of early bias was investigated and a meta-analysis of longer term benefits was performed using one year landmark data. Evidence ReviewFour randomized trials, as identified from previous systematic reviews, showed important clinical and statistical heterogeneity in year one AVR crossovers to cardiovascular hospitalizations. To minimize any early bias from unblinding, one year landmark analyses were performed separately for each trial and combined in a Bayesian (hierarchical) meta-analysis. FindingsThe largest trial with a TAVR intervention arm was the only trial to show improved outcomes in the first year, driven almost completely by an approximate two fold increase in the crossover rate compared to previous SAVR intervention trials. A one year landmark meta-analysis showed no long term benefit for AVR compared to CS for the primary outcome of mortality and cardiovascular hospitalizations for any individual study or for the pooled result (RR 0.70, 95% CI 0.34 - 1.08). Conclusions and RelevanceThe early benefit with TAVR in asymptomatic patients with severe aortic stenosis appears more driven by bias than by efficacy. Landmark analysis accounting for this potential bias show no longer term advantage for early AVR compared to clinical surveillance in this population. Key PointsO_ST_ABSQuestionC_ST_ABSDoes early intervention for severe asymptomatic aortic stenosis improve patient outcomes compared to clinical surveillance.? FindingsA systematic review suggested early benefits were likely attributable not to interventional efficacy but rather bias due to an unblinded design for a subjective outcome. A one-year landmark meta-analysis showed no long term benefit for early intervention compared to clinical surveillance for the primary composite outcome of mortality and cardiovascular hospitalizations (RR 0.70, 95% CI 0.34 - 1.08). MeaningAfter accounting for possible early bias, landmark meta-analysis shows no longer term advantage for early intervention compared to clinical surveillance in this population.

BackgroundOver one billion adults have hypertension globally, of whom approximately 70% cannot achieve blood pressure control goal with monotherapy alone. Data are lacking on patterns of dual combination therapies prescribed to patients who escalate from monotherapy in routine practice. MethodsUsing eleven electronic health record databases that cover 118 million patients across eight countries/regions, we characterized the initiation of antihypertensive dual combination therapies for patients with hypertension. In each database, we first constructed twelve exposure cohorts of patients who newly initiate dual combination therapy with one of the four most commonly used antihypertensive drug classes (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin receptor blocker [ARB]; calcium channel blocker [CCB]; beta-blocker; and thiazide or thiazide-like diuretic) after escalating from monotherapy with one of the three alternative classes. Using these cohorts, we then described dual combination therapy utilization, stratified by age, gender, history of cardiovascular diseases (CVD), and country. ResultsAcross data sources, we identified 980,648 patients with hypertension initiating dual combination therapy with antihypertensive agents after escalating from monotherapy: 12,541 from Australia, 6,980 from South Korea, 2,096 from Singapore, 7,008 from China, 16,663 from Taiwan, 103,994 from France, 76,082 from Italy, and 754,137 from the United States (US). Significant variations in treatment utilization existed across countries and patient subgroups. In Australia and Singapore, starting an ACEi/ARB monotherapy followed by a CCB was most common while in South Korea, China and Taiwan, starting a CCB monotherapy followed by an ACEi/ARB was most common. In Italy, France, and the US, sequential use of an ACEi/ARB monotherapy followed by a diuretic was most common. Younger patients were more likely to be prescribed ACEi/ARB followed by either a CCB or a diuretic compared with older patients. Women were more likely to be prescribed diuretics then an ACEi/ARB or a CCB compared with men. Among patients with history of CVD, ACEi/ARB followed by beta-blocker, and beta-blocker followed by ACEi/ARB were more commonly prescribed. ConclusionThis is the largest and most comprehensive study characterizing the real-world utilization of dual combination therapies in treating hypertension. Large variation in the transition between monotherapy and dual combination therapy for hypertension was observed across countries. These results highlight the need for future research to identify which second-line dual combination therapy is most effective in practice.

BackgroundBystander cardiopulmonary resuscitation (CPR) plays a significant role in survival from out-of-hospital cardiac arrest (OHCA). This study aimed to assess whether bystander CPR differed by patient sex among bystander-witnessed arrests. MethodsData on all OHCAs attended by New South Wales (NSW) paramedics between January 2017 and December 2019 was obtained from the NSW Public Health Risks and Outcomes Registry (PHROR). This observational study was restricted to bystander-witnessed cases with presumed medical aetiology. OHCA from arrests in aged care, medical facilities, and cases with an advance care directive (do-not-resuscitate) were excluded. Multivariate logistic regression was used to examine the association of patient sex with bystander CPR. Secondary outcomes were OHCA recognition, bystander AED applied, initial shockable rhythm, and survival outcomes. ResultsAmong the 4,491 bystander-witnessed cases, females were less likely to receive bystander CPR in both private residential (Adjusted Odds ratio [AOR]: 0.82, 95%CI: 0.70-0.95) and public locations (AOR: 0.58, 95%CI:0.39-0.88). Recognition of OHCA in the emergency call was lower for females, particularly in those who arrested in public locations (84.6% vs 91.6%-males, p=0.002) and it partially explained the association of sex with bystander CPR ([~]44%). There was no significant difference in OHCA recognition by sex for arrests in private residential locations (p=0.2). Females had lower rates of bystander AED use (4.8% vs 9.6%, p<0.001) however, after adjustment for arrest location and other covariates, this relationship was attenuated and no longer significant (AOR: 0.83, 95%CI: 0.60-1.12). Females were significantly less likely to record an initial shockable rhythm (AOR: 0.52, 95%CI: 0.44-0.61). Although females had greater odds of event survival (AOR: 1.34, 95%CI: 1.15 - 1.56), there was no sex difference in survival to hospital discharge (AOR: 0.96, 95%CI: 0.77-1.19). ConclusionOHCA recognition and bystander CPR provision differs by patient sex in NSW. Given their importance to patient outcomes, research is needed to understand why this difference occurs and to raise awareness of this issue to the public. CLINICAL PERSPECTIVEO_ST_ABSWhat is new?C_ST_ABSO_LIFemale OHCA patients in New South Wales, Australia were less likely to receive bystander CPR, irrespective of arrest location. C_LIO_LIIn public locations, recognition of OHCA during the emergency call was lower in women and this partly explained the observed sex difference in bystander CPR provision. C_LI What are the clinical implications?O_LIPublic education campaigns and training programs that address bystander response should consider sex differences as a potential barrier to bystander CPR in OHCA C_LIO_LIFuture research that examines reasons for lower rates of bystander response in women and ways of addressing this barrier could help address sex disparities in the future. C_LI

BackgroundOver 1 billion people worldwide suffer from the common chronic medical condition of hypertension. A hypertensive crisis occurs when blood pressure exceeds 180/110 mmHg. Depending on whether the target organ is harmed, the situation may be presented as a hypertensive emergency or urgency. ObjectiveTo assess the prevalence and risk factors of patients with hypertensive crises who visited the Emergency Outpatient Department (EOPD) at Adama Hospital Medical College in Adama, Oromia, Ethiopia, between January 01 and August 31, 2021 G.C. MethodologyA cross sectional, prospective study on hypertensive crisis was conducted at Adama Hospital Medical College from January 01 to August 31, 2021 G.C. The data was collected using a standardized questionnaire, validated for completeness, and analyzed using SPSS. The findings were tabulated, and conclusions and recommendations were conveyed. ResultA total of 444 individuals with hypertension in crisis were identified. Of these, 56.8% were men, resulting in a M:F ratio of 1.31:1. Those between the ages of 66 and 75 were the most affected. At presentation, 91.0% of the study participants were known hypertensive patients. Of the known hypertensive patients, the majority (34.9%) were known to have been hypertensive for 5 to 10 years. Of the known hypertensive patients, 48.6% were found to be adherent. Hypertensive urgency was discovered to be far more common than hypertensive emergencies (63.5% vs. 36.5%). Headache was the most common presenting symptom, and most of the patients (36.5%) presented to the health setup in less than 24 hours. The main risk variables identified were drug discontinuation, family history of hypertension, salt consumption, and alcohol usage. The main excuse for lack of adherence was the cost of the medications. More than half of the patients do not have any additional comorbidities, and of those who do, diabetes mellitus is the most prevalent. A stroke was identified as a major complication. Conclusions and recommendationsHypertensive crises are one of the most prevalent reasons for EOPD admission and are linked to significant consequences. At presentation, most of the study subjects were known hypertension patients. Diabetes mellitus was discovered to be a comorbid condition in one quarter of them. Although more than half of the patients have improved, the death rate remains high. Infrastructure and capacity building to provide hospitals with the requisite baseline investigations are among the governments recommendations. Health practitioners are expected to make improvements, such as educating the public about the need for lifestyle changes and evaluating and managing any hypertension problems.

BackgroundInternational guidelines recommend regular, hospital-based risk stratification to aid assessment and management of patients with pulmonary arterial hypertension. Technological advances enable daily, remote measurement of cardiopulmonary physiology and physical activity that have the potential to provide early evaluation of therapeutic efficacy and facilitate early intervention based on the physiological changes that precede clinical events. We sought to investigate the relationship between remote-monitored parameters and the COMPERA 2.0 4-strata risk score and evaluate physiological changes following therapeutic escalation and prior to clinical worsening events. MethodsEighty-seven patients with pulmonary arterial hypertension were implanted with insertable cardiac monitors including a nested set of twenty-eight patients also implanted with a pulmonary artery pressure monitor. Hospital measured and remote monitored physiological parameters were evaluated by 4-strata COMPERA 2.0 risk score. A time stratified bidirectional case-crossover study was undertaken to evaluate physiological changes at the time of therapy escalation and clinical worsening events in the nested group with insertable cardiac and pulmonary artery pressure monitors. A summary measure of remote physiological risk was calculated as the sum of the z-score of physical activity, heart rate reserve and total pulmonary resistance and applied to remote monitoring data. ResultsInsertable cardiac monitor-measured physical activity, heart rate variability and heart rate reserve were decreased and night heart rate increased in patients with increasing COMPERA 2.0 score (p<0.0001). Daily physical activity was related to incremental shuttle walk distance (p<0.0001) but not six-minute walk distance. Following therapeutic escalation mean pulmonary artery pressure and total pulmonary resistance were reduced and cardiac output, and physical activity increased at 7, 4, 22, and 42 days, respectively (p<0.05). Clinical worsening events were preceded by increased mean pulmonary artery pressure and total pulmonary resistance, reduced cardiac output and physical activity (p<0.05). Applying a remote physiological risk score to remote-monitored data demonstrated that following a clinically indicated increase in therapy, a reduction in physiological risk was identifiable at day three, and preceding a clinical worsening event, an increase in adverse physiology was observable at day - 16. ConclusionApproved devices accurately identify change in physiology in patients with pulmonary arterial hypertension following therapeutic intensification and before clinical worsening. A remote assessment of haemodynamic and cardiac monitoring may facilitate personalised, proactive medicine and innovative clinical study designs. Condensed AbstractTechnological advances provide the capacity to remotely measure cardiopulmonary physiology. In 87 patients with insertable cardiac monitors and a nested group 28 patients with pulmonary arterial hypertension implanted with pulmonary artery pressure monitors, significant improvements in cardiopulmonary function and physical activity were observed following therapeutic escalation and preceding clinical worsening events. The study highlights the potential of remote monitoring for personalised management, early therapeutic evaluation, and innovative clinical trial designs in patients with pulmonary hypertension. Twitter (X) post#PHPEEPS Remote monitoring shows improved cardiopulmonary function just 7 days after therapy adjustments, and adverse changes 12 days before a worsening event. The future of personalised care? Learning pointsPulmonary artery pressure monitor and insertable cardiac monitors offer safe and reliable data capture of physiological risk markers that change in response to therapy and preceding clinical worsening events. Remote monitored measures of physiology differ between patients with low, int-low, int-high and high risk of one-year mortality stratified by COMPERA 2.0 4-strata risk model. Remote risk evaluation may facilitate personalised medicine and proactive management for early evaluation of therapeutic efficacy and detection of clinical worsening. Plain Language SummaryThis study was undertaken in 87 patients diagnosed with pulmonary arterial hypertension (PAH). Treatments in PAH are based on a risk classification system with the aim of achieving a low-risk group. The usual in-hospital method uses the COMPERA 2.0 risk model which combines a field walk test, NT-proBNP (blood test) and World Health Organisation Functional Classification (WHO FC) which categorises level of breathlessness during everyday activity. The evidence for this is linked to risk of death, classified into four groups: low, intermediate-low, intermediate-high, and high risk. The aim of this study was to see whether newer medical technologies could grade risk in a remote setting. The two technologies used in this study are safe and approved for use. The first is a pulmonary artery pressure monitor (CardioMEMS) that measures the pressure in the lungs. It is implanted during right heart catheterisation (RHC). Measurements can be taken at home and sent securely to a medical database for the healthcare team to view. Please see the plain graphical summary figure for more information on the CardioMEMS device. The second technology is an insertable cardiac monitor (ICM), which is implanted under the skin using local anaesthetic, and sends remote readings such as physical activity and heart rate. Both technologies were implanted into a subgroup of patients to investigate whether these technologies could help classify risk from home, and whether they could detect response to new treatments, or signs that a condition may be getting worse. 28 patients with both these devices took part in the study and a further 59 had an ICM only. A remote risk score was calculated using 3 things: physical activity, heart rate reserve (HRR: difference between maximum heart rate for age and resting heart rate) from the ICM and total pulmonary resistance (TPR: a measure of the pressure and flow through the lungs) from the CardioMEMS. The results showed that these measures could classify risk as well as the in-hospital COMPERA 2.0 model. The remote risk score detected response to treatment as early as 6 days and clinical worsening as early as 12 days before an event (e.g. hospitalisation) in the group observed. Patient and Public Involvement and Engagement (PPIE)The study was developed following the 2017 Pulmonary Hypertension Association UK (PHA UK) survey in which 39% of patients reported difficulties attending hospital for appointments.1 A subsequent remote monitoring survey (2021) was positively received, with key themes highlighting benefits of improving [disease] understanding, personalising treatment, and reducing interruptions or unnecessary visits.2 Patients from the study and volunteers from PHA UK provided feedback on the results of the research. Amendments were made to the lay summary and a graphical summary was introduced following this feedback. There was universal agreement that participation in the study was beneficial to patients and future research. Participants involved in the study agreed the devices offer enhanced accessibility to non-invasive risk stratification and improvements in home-based care with minimal personal effort. Furthermore, the minimally invasive devices offered empowerment, confidence, and reassurance, with "opportunity to play an active role in [their] health and personal wellbeing" and "greater confidence with day-to-day living". No incentives were offered for the PPIE in this study. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=140 SRC="FIGDIR/small/23289153v2_ufig1.gif" ALT="Figure 1"> View larger version (79K): org.highwire.dtl.DTLVardef@842d87org.highwire.dtl.DTLVardef@1c90abeorg.highwire.dtl.DTLVardef@1e063bdorg.highwire.dtl.DTLVardef@b41676_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOPlain Graphical Summary:C_FLOATNO CardioMEMS implantation covering frequently asked questions (FAQ). Created with BioRender.com C_FIG

BackgroundHypertension (HTN) is a key risk-factor for cardiovascular diseases (CVDs). Blood-pressure (BP) categorizations between systolic blood pressure (SBP) of 120 and 140 remain debatable. In the current study we aim to evaluate if individuals with a baseline SBP between 130-140 mm Hg (hypertension as per AHA 2017 guidelines) have a significantly higher proportion of incident hypertension on follow-up, as compared to those with SBP between 120-130 mm Hg. MethodsSecondary data analysis was performed in a community-based cohort, instituted, and followed since 2017. Participants were aged [&ge;]30 years, residents of urban slums in Bhopal. BP was measured at or near home by Community Health Workers (CHWs). Two-year follow up was completed in 2019. We excluded participants who were on BP reduction therapy, had fewer than two out-of-office BP measurements and who could not be followed. Eligible participants were re-classified based on baseline BP in four categories: Normal (Category-A), Elevated-BP (Category-B), Variable-BP (Category-C) and reclassified HTN based on AHA-2017 (Category-D). Proportion of individuals who developed incident hypertension on follow up was primary outcome. ResultOut of 2649 records, 768 (28.9%), 647 (24.4%), 586 (22.1%), 648 (24.4%) belonged to Categories A, B, C and D respectively. Incident HTN with cut-off of 140/90 mm Hg was, 1.6%, 2.6%, 6.7%, 12% in categories A, B, C and D respectively. Incidence of incident hypertension in individuals with a baseline SBP between 130-140 mm Hg (Category D) was significantly higher as compared to those with SBP between 120-130 mm Hg (Category B). ConclusionWe conclude that biological basis for AHA-2017 definition of hypertension is relatively robust also for low income and resource-limited settings. Evidence from our longitudinal study will be useful for policy makers for harmonizing national guidelines with AHA-2017.