Open Heart

BackgroundChronic conditions such as hypertension can significantly disrupt daily life and emotional well-being. The interaction between patients perceptions, adherence to antihypertensive medication and quality of life (QoL) remains underexplored outside structured clinical settings. ObjectivesTo capture unprompted patient perspectives and assess whether hypertension affects QoL and to investigate if patient reported experiences are associated with self-reported antihypertensive medication adherence. MethodsSocial media listening (SML) study analyzing 86,368 anonymized posts from individuals with hypertension in 12 countries, collected between January 2022 and May 2024. Posts from 11 countries (n=81,368) were analyzed using artificial intelligence-enabled natural language processing. Posts from China (n=5,000) were analyzed separately using a harmonized framework. Quantitative and qualitative methods assessed variations by country, age, and gender, and associations between emotional expression and antihypertensive medication adherence. ResultsAcross the 11-country core sample, 45% of posts mentioned at least one QoL impact, most commonly worry/anxiety (11%). Impacts varied across countries. Among 8,096 posts with age identified, individuals <40 years reported emotional balance impacts in 28% of posts versus 22% among those aged 40+. Work/Education impacts were mentioned in 17% of posts by those <40 years vs 12% in 40+. Among 7968 posts explicitly referencing adherence, expressed worry was associated with stricter adherence (62% association score), as were structured routines (79% score), home monitoring (77%), dietary changes (77%), and exercise (71%). In contrast, sadness/depression was associated with inconsistent adherence (71%), as were forgetfulness (79%), side effects (73%), and cost/insurance concerns (65%). ConclusionsThese results emphasize the importance of the psychological and emotional impact of hypertension, including on adherence to medication regimens, reinforcing the value of a holistic approach to patient care. Plain language summaryMany people have high blood pressure, which increases the risk for stroke and other harmful events. Although there is much medical research on high blood pressure, little is known about the experiences of those people who live with the condition. This study aimed to scope out how people react emotionally and how their high blood pressure affects their daily lives. To do this, we analyzed social media posts from the United States, Canada, Brazil, the United Kingdom, Germany, France, Italy, Spain, Japan, South Korea, China, and Australia. In all countries, patients were affected emotionally by their high blood pressure. People often worried, particularly when they received their diagnosis. High blood pressure also negatively affected everyday life and work/education. This was often due to frequent medical appointments with lengthy wait times and difficulty accessing specialists. Taking medications regularly and sticking to diet and exercise programs was more difficult for individuals who reported being sad or depressed, or who suffered from side effects of their medications. The findings show that efficient management of high blood pressure has to take into account the emotional reactions of those who are affected, and provide support in several areas beyond the prescription of medication.

Background: Improved survival of adolescents with congenital heart disease has shifted the focus to examine health-related quality of life and address challenges in transition to adult care. We aim to describe how congenital heart disease complexity, gender, number of interventions, and Fontan circulation may affect the health-related quality of life and transition readiness of adolescents with congenital heart disease. Methods: We conducted a single-center cross-sectional study involving 536 patients aged 14 to 18 years old who attended a nurse-led, pediatric to adult care cardiac transition clinic, from 2020 to 2024. health-related quality of life was evaluated using the PedsQLTM 4.0 Generic Core Scales and the PedsQLTM 3.0 Cardiac Module. Patients were screened for anxiety and depression using the PHQ-9 and GAD-7. Transition readiness was assessed using the Transition-Q score. Results: The median age of patients was 16 years old and 44% self-identified as female. PedsQLTM 4.0 Generic had a median overall score of 77 (IQR 67?87), with no significant difference according to congenital heart disease severity. Female patients had significantly lower overall PedsQLTM 4.0 score (p=0.028) and lower physical and emotional functioning scores (p=0.005, p<0.001, respectively) when compared to males. Physical functioning scores were lower amongst patients with Fontan circulation compared to non-Fontan patients (p=0.003), although overall PedsQLTM 4.0 score and transition readiness scores were similar to those with complex biventricular congenital heart disease. Number of previous interventions were inversely associated with overall PedsQLTM 4.0 score (p=0.036). Moderate to severe symptoms of depression or anxiety were reported in 30% of screened patients and were associated with 2 significantly lower PedsQLTM 4.0 scores (p<0.001). Transition readiness was significantly lower in patients with moderate and complex compared to those with simple congenital heart disease (p<0.001). Transition readiness improved with repeat transition clinic visits (p=0.004) whereas PedsQLTM 4.0 score did not change significantly. Conclusion: In this large cohort of adolescents with congenital heart disease, health-related quality of life was lower than population norms. Female gender, higher interventional burden, and anxiety or depressive symptoms are associated with lower health-related quality of life scores rather than anatomical severity or Fontan physiology. Transition readiness was lower in complex disease; it has improved with a structured, nurse-led transition clinic, demonstrating modifiability. Consequently, adolescent congenital heart disease care requires a multidisciplinary approach including psychosocial screening, especially for high-risk groups, and structured transition planning to improve long-term outcomes.

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.

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

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

BackgroundHypertension is the leading modifiable risk factor for ischemic stroke, yet the adequacy of preventative hypertension care in routine clinical practice remains suboptimal. Whether gaps in hypertension management represent missed opportunities for stroke prevention remains unclear. ObjectiveTo evaluate the association between hypertension care delivery and the risk of incident ischemic stroke. MethodsWe conducted a retrospective, matched, nested case-control study among adults with hypertension using electronic health record data from a large regional health system (2010-2024). Patients with a first-ever ischemic stroke were matched 1:2 to controls on age, sex, race and ethnicity, and calendar time. Three care metrics were assessed during follow-up: (1) outpatient visits with blood pressure (BP) measurement per year; (2) number of antihypertensive medication ingredients; and (3) medication intensification score. Conditional logistic regression estimated adjusted odds ratios (aORs). ResultsThe study included 13,476 cases and 26,952 matched controls (N = 40,428). Mean (SD) age was 64.8 (12.2) years, 54.1% were female, and mean follow-up was 2,497 (1,308) days. Cases had fewer BP visits per year (median, 2.50 vs. 3.01; p < 0.001), similar number of medication ingredients (2.00 vs 2.00), and lower treatment intensification scores (-0.211 vs -0.125). In adjusted models, >5 BP visits per year was associated with lower stroke odds (aOR, 0.55; 95% CI, 0.51-0.59) compared with [&le;]1 visit. Use of 2-3 medication ingredients (vs 0) was also associated with reduced stroke odds (aOR, 0.80; 95% CI, 0.75-0.86), whereas >3 ingredients was not significant. The highest quartile of treatment intensification showed the strongest association (aOR, 0.47; 95% CI, 0.44-0.51). Findings were consistent across subgroup and sensitivity analyses, including strata defined by baseline SBP and follow-up SBP. ConclusionsGreater engagement in hypertension care was associated with lower odds of ischemic stroke, suggesting that gaps in routine management may represent missed opportunities for prevention. Novelty and RelevanceO_ST_ABSWhat Is New?C_ST_ABSO_LIIn this nested case-control study, differences in hypertension care over time--including follow-up frequency, medication use, and treatment adjustments--were associated with incident ischemic stroke. C_LI What Is Relevant?O_LIVariations in hypertension care delivery over time may represent missed opportunities for stroke prevention regardless of baseline or average SBP levels during follow-up. C_LIO_LIImproving follow-up and timely treatment adjustments may offer actionable targets for primary prevention. C_LI Clinical/Pathophysiological ImplicationsO_LILongitudinal gaps in hypertension management may contribute to stroke risk beyond BP control, highlighting opportunities to improve prevention through more consistent care delivery. C_LI

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

Abstract Background: Heart Failure is a complex clinical syndrome of growing public health concern in sub-Saharan Africa, yet the data from Sierra Leone are absent. The aim of the study is to characterise the clinical profile, etiological and temporal trends of hospitalised HF patients at Choithrams Memorial Hospital (CMH), Freetown, Sierra Leone, to confirm specific management strategies. Methods: This single-center, retrospective observational cohort study analysed data on HF patients (>18years) admitted at the CMH between January 2021 to 31 December 2025. The clinical definition of HF was based on the Framingham criteria and the European Society of Cardiology (ESC) guidelines , including standard echocardiographic parameters. All variables, including patients demographics, HF. phenotype, aetiology, medical history and hospital outcomes were extracted from the digital record. Non-parameteric tests, multivariable logistic regression to identify variables associated with etiology, Wilcoxon rank-sum test to compare groups and Kruskal-Wallis test to analyse trends over time were utilised. Result: A total of 765 patients were included in the study, with a median age of 53 years (IQR 42-61) and male predominance of 55.3%. Patients with recurrent HF (60.9%) were more common than those with de novo HF (39.1%), were older (54 years vs 53 years), had a higher comorbidity burden (34% vs 4%, p < 0.001), and presented with a cold-wet hemodynamic profile (18.4% vs 8.4%, p < 0.001). HFrEF (61.3%) was the most predominant phenotype, though HFpEF increased with age. Dilated Cardiomyopathy (37.0%), Hypertensive Heart Disease (31.2%) and Valvular Heart Failure (17.1%) were the leading etiologies, while ischemic heart disease (6.3%) was relatively uncommon. A majority of the patients were referred (77.9%), and 50.8% presented with NYHA IV. The strongest independent predictor for HF was hypertensive heart disease [AOR = 17.81; C.I 95%: (3.13-48.76), p <0.001]. An analysis of the trends in etiologies and demographics over the five-year period demonstrated no significant changes (all p-values > 0.05 for age, sex, aetiology, and most comorbidities). Conclusion: HF affects the younger adult population in Sierra Leone and is mainly caused by DCM and HHD. The late case presentations, the high prevalence of recurrent HF, and the associated high burden of comorbidities emphasize an urgent need to develop and implement improved strategies for the prevention, early detection, and long-term management of HF within Sierra Leone's healthcare system.

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

RationaleUp to 90% of strokes are preventable through the modification and control of lifestyle risk factors. Health and Wellness (HWC) coaching is an established psychological intervention that may address multiple risk factors, including high blood pressure to reduce the risk of stroke. AimsTo determine the effectiveness of HWC in the management of blood pressure and stroke-related modifiable risk factors in reducing the risk of stroke. MethodsThis Phase III, open-label, single-blinded, two-arm randomised controlled trial recruited adults with first-ever or recurrent minor stroke or transient ischaemic attack from hospitals in Auckland and Hamilton, New Zealand. Eligible participants were [&ge;]18 years, independent in activities of daily living, had at least two modifiable cardiovascular risk factors, elevated or treated systolic blood pressure, were English-speaking, and had no history of major stroke, myocardial infarction, significant cognitive or mood disorders, or terminal illness. Longitudinal outcomes will be analysed using linear mixed-effects models under an intention-to-treat framework, with time-to-event outcomes analysed using competing-risk methods and missing data handled using multiple imputation with pooling based on Rubins rules. Study outcomesThe primary outcome is difference in the mean change from baseline systolic blood pressure (SBP) to 6-months post-randomisation between control (Usual Care, UC) and HWC groups. The study (n=360) is powered 85% (two sided =0.05) to detect a mean difference in change of SBP 6 mm Hg (SD {+/-} 20 mm Hg) between HWC and UC groups at 6-months post-randomisation, accounting for a 20% attrition rate. A revised sample size calculation due to a lower attrition rate (9%) provided a required sample size of 320. Secondary outcomes include cardiovascular health score using the Lifes Simple 7; stroke awareness; quality of life; satisfaction with life: cognition; mood; medication adherence; adverse cardiovascular events; health and service costs and productivity status. DiscussionHWC has the potential to modify lifestyle risk factors for stroke. This trial will be the first to test the effectiveness of HWC to modify lifestyle risk factors for secondary stroke prevention. Ethical approvalThe trial was approved by the New Zealand Health and Disability Ethics Committee (#2022 EXP 124562022), and The Auckland University of Technology Ethics Committee (#22/206). Trial registrationACTRN12622000939796 (registered 01/07/2022)

BackgroundCongenital heart defects (CHDs) contribute to approximately 220,000 childhood deaths globally each year, with most occurring in low- and middle-income countries. Despite advances in diagnosis and management, survival remains poor in sub-Saharan Africa due to delayed diagnosis and limited access to specialized care. In Uganda, an estimated 16,000 children are born with CHDs annually, many requiring urgent intervention. Despite this burden, evidence on survival and its determinants in Uganda remains limited. This study aimed to investigate socio-demographic and clinical factors associated with survival among children born with CHDs at the Uganda Heart Institute. MethodsA retrospective cohort study was conducted using electronic patient records of children diagnosed with congenital heart defects at the Uganda Heart Institute between January 2014 and December 2018. Survival analysis was performed using the log-rank test to assess differences across groups, and the Cox proportional hazards regression model was used to identify independent predictors of mortality. ResultsChildren residing in rural areas had a significantly higher hazard of death compared to those in urban areas (HR = 1.33; 95% CI: 1.06-1.66; p = 0.013). Underweight children had more than twice the hazard of death compared to those with normal BMI (HR = 2.07; 95% CI: 1.60-2.69; p < 0.001). Defect severity was significantly associated with survival, with moderate defects showing increased hazard relative to critical defects (HR = 1.98; 95% CI: 1.25-3.13; p = 0.004), while non-critical defects were not statistically significant. Timing of diagnosis was a strong predictor of mortality (HR = 1.67; 95% CI: 1.30-2.14; p < 0.001), indicating that delayed diagnosis increases the risk of death. Oxygen level was not significantly associated with survival. ConclusionSurvival among children with congenital heart defects is significantly influenced by nutritional status, place of residence, defect severity, and timing of diagnosis. Underweight children, those from rural areas, and those diagnosed later have a higher risk of mortality. Early detection and improved nutritional support are essential to enhance survival outcomes. Strengthening early screening programs and improving access to timely diagnosis and specialized care, particularly in rural settings, are critical to reducing mortality.

Abstract Introduction: Cardiovascular disease is a leading cause of maternal and neonatal morbidity and mortality in the UK. Its prevalence in pregnancy continues to rise, driven by both improved survival of women with congenital and inherited heart disease into reproductive age and an increasing burden of acquired cardiovascular risk factors. However, its natural history and optimal management remain poorly defined. Current research is limited by small sample sizes, drawn from highly selected patient cohorts from individual units. The aim of the PREGnancy, HEART Health, and Cardiovascular Disease (PREG-HEART) study is to develop a patient driven, clinically relevant, digital platform to understand the epidemiology of cardiovascular disease in pregnancy and support clinical trials of management strategies. This paper provides the protocol for PREG-HEART, which will start with a 6-month pilot study. Methods and analysis: PREG-HEART will utilise an online, direct-to-patient platform to enrol patients with cardiovascular disease in pregnancy alongside healthy pregnant controls. Enrolled women will be invited to provide self-reported demographic and clinical data and consent to linkage with national health records for long-term follow up. We will also seek consent for storage and analysis of leftover clinical biosamples and to re-contact participants, enabling recruitment into sub-studies and clinical trials. Planned analysis for the pilot study at 6 months will assess feasibility, including recruitment rates, case-mix of cardiovascular diagnoses, and participant geographical, socio-economic, and ethnic background compared to the UK general pregnant population. Findings from the pilot study will inform subsequent phases of PREG-HEART, which will explore associations between different cardiovascular diagnoses and adverse cardiovascular, obstetric, and neonatal events. We will work closely with patients and clinicians to define priority research questions and use the PREG-HEART platform to support a range of observational and interventional studies to address these. Ethics: This study was approved by the West Midlands Solihull Research Ethics Committee. Registration details: PREG-HEART has been registered prospectively on the ISRCTN registry (ISRCTN11700499)

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

BACKGROUNDChronic thromboembolic pulmonary hypertension (CTEPH) is a severe and progressive condition characterized by dyspnea and fatigue. Our previous study reported cognitive impairment in pulmonary hypertension (PH) patients. However, balloon pulmonary angioplasty (BPA) capable of alleviating cognitive impairment in patients with CTEPH is largely unknown. METHODSThis was a prospective study involving a total of 131 patients with CTEPH who underwent BPA at the Shanghai Pulmonary Hospital. We collected Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) questionnaires and examined plasma A{beta} and phosphorylated-tau217 (p-tau217) levels to assess the cognitive function of patients with CTEPH between the pre-BPA and post-BPA stages. RESULTSFollowing BPA, patients exhibited improved cognitive performance, accompanied by reduced plasma levels of A{beta}1-42 and p-tau217. After the third BPA session, patients with a mean pulmonary arterial pressure (mPAP) of[&ge;]25 mmHg had significantly lower MMSE and MoCA scores compared to those with an mPAP of <25 mmHg. Linear regression analyses revealed that baseline and post-intervention MMSE or MoCA total scores were significant predictors of cardiac output (CO) levels measured after the last BPA procedure. Logistic regression analyses incorporating pre- and post-BPA clinical parameters identified three independent predictors of baseline cognitive dysfunction: lower educational attainment, higher baseline A{beta}1-42 levels, and elevated baseline p-tau217 concentrations. CONCLUSIONSOur findings suggest promising therapeutic effects of BPA, associated with improvements in cognitive dysfunction and reductions in plasma A{beta}1-42 and p-tau217 levels in patients with CTEPH. NOVELTY AND RELEVANCEO_ST_ABSWhat Is New?C_ST_ABSThis is the first study to demonstrate that balloon pulmonary angioplasty (BPA) improves cognitive function (MMSE/MoCA scores) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). And the first report that BPA reduces plasma levels of A{beta}1-42 and p-tau217-- key Alzheimers disease-related proteins--in CTEPH patients, establishing a peripheral biomarker for CTEPH-associated cognitive impairment. What Is Relevance?Cognitive impairment is common but underrecognized in CTEPH, BPA now addresses both cardiopulmonary and cognitive dysfunction, improving quality of life beyond hemodynamic recovery. Findings support the cardiopulmonary-brain axis in CTEPH: improved pulmonary hemodynamics and oxygenation reduce systemic pathological protein release, benefiting brain function. Clinical/Pathophysiological Implications?Our findings suggest promising therapeutic effects of BPA, associated with improvements in cognitive dysfunction and reductions in plasma A{beta}1-42 and p-tau217 levels in patients with CTEPH.

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

Congenital heart disease contributes substantially to chronic morbidity, growth impairment, and repeated healthcare utilization among children. Evidence regarding nutritional burden and outpatient healthcare patterns among pediatric patients with congenital heart disease in Indonesia remains limited. This study aimed to evaluate clinical characteristics, nutritional status, healthcare utilization, and factors associated with malnutrition among pediatric outpatients with congenital heart disease at Adam Malik General Hospital, Indonesia. A retrospective observational study was conducted using medical records of pediatric outpatients treated between January and December 2024. Demographic characteristics, cardiac diagnoses, nutritional status, complications, and outpatient visit history were analyzed. Logistic regression analysis was performed to identify factors associated with malnutrition. A total of 606 pediatric outpatients were included. Non cyanotic congenital heart disease predominated the cohort, with ventricular septal defect representing the most common diagnosis followed by patent ductus arteriosus and atrial septal defect. Nearly half of all patients demonstrated underweight or severe underweight nutritional status, while pulmonary hypertension emerged as the most frequent complication. Younger pediatric age groups and higher cumulative clinical burden independently increased the odds of malnutrition. Children with congenital heart disease at this tertiary referral center carried a substantial nutritional and clinical burden. Early nutritional surveillance and integrated long term outpatient management may improve growth outcomes and reduce chronic disease burden in resource limited settings.

Background: Primary aldosteronism (PA) testing is recommended for patients with resistant hypertension but remains underused, and evidence linking aldosterone-targeted therapy to improved cardiovascular and renal outcomes is limited. Methods: In a nationwide cohort of patients with resistant hypertension between 2001 and 2022, we assessed PA testing and subsequent mineralocorticoid receptor antagonist (MRA) use and adrenalectomy. Among tested patients, time-dependent Cox models were used to assess associations between treatment exposure and mortality, major adverse cardiovascular events (MACE) and renal outcomes. Results: Among 254,338 patients, only 2.0% were tested for PA. Tested patients had a higher prevalence of hypokalemia and cardiometabolic comorbidities. In the overall tested population, MRA use was not associated with lower risks of cardiovascular or renal outcomes. However, when testing resulted in an established PA diagnosis, the use of both MRA (hazard ratio [HR] 0.60, 95% CI 0.42-0.86) and adrenalectomy (HR 0.33, 95% CI 0.20-0.54) were associated with a reduced risk of MACE compared with no aldosterone-targeted therapy. Similar results were observed regarding mortality. Adrenalectomy was associated with lower risk of MACE (HR 0.55, 95% CI 0.30-0.99), all-cause mortality (HR 0.52, 95% CI 0.29-0.93) and renal outcomes (HR 0.37, 95% CI 0.17-0.80) compared with MRA in patients with a diagnosis of PA. Conclusions: PA remains markedly underrecognized in resistant hypertension. Among patients with resistant hypertension who did undergo PA testing with establishment of a PA diagnosis, aldosterone-targeted therapy resulted in lower risk of adverse cardiorenal outcomes and death when compared to conventional antihypertensive therapy.

Objective: The shortage of general practitioners (GPs) in Australia has intensified interest in team-based care for hypertension, involving pharmacists and nurses. This study explored primary care provider experiences, barriers, and facilitators related to implementing team-based care in Australia. Design: Qualitative study using semi-structured interviews with primary care providers. Methods: We conducted 51 interviews with GPs (n=24), nurses (n=12), and pharmacists (n=15), purposively selected from diverse primary care settings. Analysis combined deductive coding, informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research, with inductive thematic analysis to identify emergent themes. Results: Interviews demonstrated a predominantly GP-centred care model, with nurse and pharmacist involvement largely confined to supporting roles, including blood pressure measurement, prescription refills, patient follow-up and counselling. Their contributions were constrained by barriers at both practice (e.g., limited GP support, fragmented communication across providers) and health system levels (e.g., limited financial incentives and restricted reimbursement pathways). Despite their critical role in care planning, nurses described being hamstrung by workload and limited direct funding for hypertension-related services. Pharmacists reported unreimbursed blood pressure checks and restricted funding for medication reviews that constrained the sustainability of their hypertension services. Role ambiguity and the absence of standardised protocols on task sharing further limited collaboration, with nurses and pharmacists describing concerns about overstepping professional boundaries. Attitudes towards team-based care ranged from active disregard (outright rejection) to conditional acceptance and occasional active uptake (strong endorsement). Conclusion: Despite clear willingness among nurses and pharmacists to alleviate GP burden, team-based care is rarely implemented in routine practice. Addressing system-level barriers (funding models that incentivise team-based care and standardised treatment protocols that clarify shared workflows), alongside provider-level barriers (stronger awareness and training that normalises task sharing), is critical to support genuine team-based hypertension care in Australia.

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

Background: Atrial Fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide, representing the primary cardiac etiology of stroke. In recent years, direct oral anticoagulants (DOACs) have shown favorable results in terms of efficacy and safety in the prevention of thromboembolism in patients with AF. TROMBIX-DZ study investigated the safety and efficacy of rivaroxaban in routine clinical settings in response to the need for real-world evidence on the use of DOACs. Methods: We carried a national, multicenter, prospective, observational cohort study to evaluate the safety and efficacy of rivaroxaban in Algerian patients with atrial fibrillation. Patients were followed-up at 3 months intervals for 1 year. The primary outcome of this study was to evaluate the safety of rivaroxaban, reported as the frequency of treatment-emergent serious adverse events (SAEs); Secondary outcomes assessed the frequency of thromboembolic events, adverse events (AEs), and treatment persistence. Results: TROMBIX-DZ enrolled 398 eligible patients with AF from 19 specialized public and private cardiology centers across different regions in Algeria. The mean age was 70.5 {+/-} 11.94. 71.9% of patients received once daily rivaroxaban 20mg, and 28.1% received the 15mg dose. The most common comorbidities included, hypertension (77.1%), diabetes (28.6%) and heart failure (25.4%), prior strokes and TIA (8.8%), and prior major bleeding (3.1%). The mean CHA2DS2-VASc score was 3.147 {+/-} 1.3, and the mean HAS-BLED score was 1.682 {+/-} 1.198; 14.06% of patients had Creatinine clearance < 50 ml/min. A total of 5.77% had treatment-emergent AE, and 1.76% had treatment-emergent SAE. The incidence rate (events per 100 patient-years) of treatment-emergent major bleeding events, treatment-emergent thromboembolic events and all-cause death during the study period were 2.1, 0.9, and 4.18, respectively. Treatment persistence was 75.88% at the end of the study. Conclusion: TROMBIX-DZ study, the first cohort in the Maghreb region, provides important insights into the safety and efficacy of rivaroxaban in Algerian population with atrial fibrillation receiving standard medical care. Rates of major bleeding and stroke were low and broadly consistent with previous international real-world registries. Trial registration number: Clinicaltrial.gov: (NCT06184204). Keywords: Direct oral anticoagulants, Rivaroxaban, Atrial fibrillation, Major bleeding, Stroke, Thromboembolism, The Maghreb region, Real-world.