Open Heart

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

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.

BackgroundHypertension is a major modifiable risk factor for cardiovascular disease, yet blood pressure (BP) control remain suboptimal, particularly in socially disadvantaged communities. Guidelines recommend initiating single-pill combination (SPC) therapy to improve adherence and BP control, but uptake in primary care is limited. ObjectivesTo evaluate the SOLO care improvement project, promoting SPC initiation among general practitioners (GPs) in Amsterdam Zuidoost, a disadvantaged, multi-ethnic community in The Netherlands with a high hypertension burden. MethodsIn a cluster quasi-randomized cluster design, adult hypertensive patients from nine general practices within one health facility were allocated to intervention (IC; n=5) or usual care (UC; n=4). Intervention practices received case-specific guidance on SPC therapy. Outcomes were SPC uptake, changes in systolic and diastolic BP (SBP and DBP), target BP achievement and cardiovascular events. Analyses used intention-to-treat adjusted regression and Cox models, with additional as-treated analysis among SPC users. ResultsAmong 438 patients (mean age 64.5{+/-}12.2 years; median follow-up of 367 days [213-467]), SPC initiation was higher in the IC than US (25.1% vs. 9.6%, p<0.001). SBP/DBP decreased by -15.7/-6.9 mmHg in the IC and -10.4/-4.6 mmHg in the UC. Target BP was more often achieved in the IC (57.3% vs. 48.1%; OR: 1.4, 95%CI:1.0-2.1). Among SPC users, SBP/DBP decreased by -22.4/-10.5 mmHg. ConclusionPromoting SPC therapy improved blood pressure control, supporting local, targeted implementation as a pragmatic strategy to enhance hypertension management. Summary box, bullet points- In the SOLO care improvement project, SPC initiation was increased and improved blood pressure control in routine primary care. - The real-world implementation and cluster-based comparison enhanced practical relevance and reduced contamination between practices. - Although conducted in a large community health center, generalizability cannot be assumed; the non-blinded, non-randomized design allows residual confounding.

Background: Chronic conditions such as hypertension can significantly disrupt daily life and emotional wellbeing. The interaction between patients' perceptions, adherence to antihypertensive medication and quality of life (QoL) remains underexplored outside structured clinical settings. Objectives: To 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. Methods: Social 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. Results: Across 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%). Conclusions: These 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.

BackgroundAngiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are commonly prescribed alongside exercise to manage hypertension in individuals with metabolic syndrome (MetS). However, their potential to interfere with exercise-induced physiological adaptations remains unclear. MethodsIn this prospective, parallel-group study, 62 sedentary obese adults with MetS completed a 16-week supervised high-intensity interval training (HIIT) program. Participants were either chronically medicated with ACEi or ARBs (antihypertensive medication group, AHM, n=27) or a non-medicated control group (CONTROL, n=35). Primary outcomes included changes in resting and graded exercise blood pressure, MetS components, and cardiorespiratory fitness (CRF). ResultsBoth groups exhibited significant comparable improvements (all p time x group > 0.05) in cardiometabolic health (MetS Z-score; AHM -0.22{+/-}0.42; CONTROL - 0.30{+/-}0.33; p time < 0.001) and CRF (VO2MAX: AHM 3.9{+/-}2.1; CONTROL 5.0{+/-}3.1 mL{middle dot}kg-{superscript 1}{middle dot}min-{superscript 1}; p time = 0.003). Resting blood pressure decreased similarly in both groups (Mean Arterial Pressure: AHM -4.2{+/-}8.7; CONTROL -6.5{+/-}6.3 mmHg; both p time = 0.005; p time x group > 0.05). Additionally, antihypertensive medication did not interfere with the maximal (MAP; p time = 0.008) and submaximal (DBP; p time = 0.047) blood pressure exercise responses following training with no significant time x group interaction (both p > 0.05) ConclusionsChronic treatment with angiotensin antagonist medication to treat hypertension does not restrain the effects of supervised HIIT program on improving cardiovascular function, cardiorespiratory fitness, or reducing the components of MetS. Our findings support aerobic exercise training as an effective nonpharmacological co-therapy for hypertensive patients treated with angiotensin antagonists.

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

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.

BackgroundBlood pressure (BP) is routinely measured during healthcare visits. A standardized measurement is essential to ensure accurate values, particularly in outpatient settings, where patient preparation, environment, and technique can significantly influence results. MethodsA quasi-experimental study was conducted in adult outpatients. Demographic, anthropometric, and clinical data were collected through interviews and physical examination. BP was measured using a validated automated oscillometric device under four non-randomized predefined sequences. The standardized method followed international guideline recommendations, whereas the other three incorporated common errors observed in clinical practice (unsupported body position on the examination table, patient speaking, or legs crossed). Systolic and diastolic BP values were compared using the Friedman test and paired Wilcoxon tests with Holm adjustment. Effect sizes were expressed as median paired differences with interquartile ranges. Analyses were performed using R and Stata. ResultsA total of 295 participants were included (61% women; median age 56 years), with hypertension as the most frequent comorbidity (33%). Significant differences were observed across the four measurement models (p < 0.001). Compared with the standardized method, systolic BP was higher by +8 mmHg (M2), +2.5 mmHg (M3), and +4 mmHg (M4), while diastolic BP increased by +7 mmHg, +2 mmHg, and +2 mmHg, respectively. Clinically relevant differences (|{Delta}| [&ge;] 5 mmHg) occurred in up to 81% of systolic and 79% of diastolic measurements with M2. ConclusionsNon-adherence to guideline-recommended BP measurement protocols leads to BP overestimation and misclassification of hypertension status, which may affect therapeutic decision-making and the use of pharmacological treatments.

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)

ObjectivesVisit-to-visit blood pressure variability (VVV BPV) is an underutilised risk factor for cardiovascular disease (CVD). This study aims to determine the minimum number of BP measurements needed and to identify cut-off values for the standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of systolic and diastolic VVV BPV to predict CVD risk in primary care. MethodsWe analysed data from the electronic practice-based research network (ePBRN) in Southwestern Sydney, including patients aged 18-55 with at least eight BP readings. Patients with incomplete data or no follow-up beyond age 55 were excluded. The agreement between SD calculated from 3-5 measurements and 8 measurements (reference) was evaluated using Pearsons correlation coefficient and the intraclass correlation coefficient. Then, after identifying that a minimum of five BP measurements is needed, another cohort with at least five BP measurements was developed. Percentile-based cut-offs (10th - 90 th, 5-percentile increments) were derived for systolic and diastolic BPV (SD, CV, ARV). Predictive accuracy was assessed using the C-statistic. The outcome was the first CVD occurrence. ResultsA total of 1,549 patients were included in the first study. Five BP measurements showed good agreement with eight measurements (ICC: 0.79; correlation: 0.80). A total of 3,022 patients were included (55.2% women). Higher VVV BPV (SD, CV. ARV) was associated with increased CVD risk. Optimal cut-off values for systolic BP were 19 mmHg (SD), 14% (CV), and 15 mmHg (ARV), and for diastolic BP were 11 mmHg (SD), 12% (CV), and 11 mmHg (ARV). Predictive performance was consistent across time frames. ConclusionsThese BPV cut-offs provide clinically relevant thresholds for CVD risk prediction. At least five BP measurements are sufficient to estimate BPV for this purpose.

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

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.

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

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

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.

BackgroundThe prevalence of severe symptomatic aortic stenosis (sSAS) continues to rise, yet women remain significantly less likely to receive timely intervention. Evidence indicates a 36% lower likelihood of diagnosis and a 20% lower likelihood of undergoing aortic valve replacement (AVR) compared with men. The purpose of this study was to examine the perspectives of interventional cardiologists and cardiothoracic surgeons who treat AS about late diagnosis and undertreatment of women with sSAS. MethodsA cross-sectional, web-based survey was distributed to interventional cardiologists and cardiothoracic surgeons across the United States. Participants completed a 10-item open-ended questionnaire developed from published literature. Responses were analyzed using descriptive statistics and qualitative content analysis to identify key issues related to diagnostic practices, referral patterns, and provider perceptions. ResultsNineteen physicians completed the survey (15% response rate). While most participants believed women receive timely AVR consistent with guidelines, they acknowledged delays due to multifactorial causes, including under-recognition of symptoms, diagnostic variability in community echocardiography practices, limited awareness of sex-specific guideline gaps, and socioeconomic barriers such as financial constraints, caregiver burden, and access to care. Although some respondents denied overt gender bias, others described subtle or unconscious bias influencing referral timing and symptom interpretation. ConclusionsSurvey respondents recognized complex clinical and systemic factors contributing to delayed diagnosis and undertreatment of women with sSAS. Enhanced provider education, improved access to diagnostic testing, and revision of sex-specific clinical guidelines are needed to promote equitable care and timely intervention for female patients.

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 and ObjectiveBlood pressure treatment response is variable in individual patients, and the choice of medical therapy is often dependent on clinician experience. Treatment choices can be personalised by patient empowerment, metabolomic profiles and augmented by machine learning, but robust evaluation is lacking on how these can be combined to enhance clinical effectiveness. The HYPERMARKER trial will evaluate how an individualised choice of medication class can address the avoidable global health and economic burdens of hypertension. Design and InterventionThe HYPERMARKER trial is a proof-of-concept, pragmatic, multicentre, adaptive, open-label strategy trial embedded into routine clinical practice with stratified individual patient randomisation. The trial was co-designed with a patient and public involvement team. The intervention is a digital portal that supports shared decision making on hypertension therapy class using clinical features plus metabolomic profiles determined with liquid chromatography-mass spectrometry. Participants and OutcomesEligible patients are aged [&ge;]18yrs with a systolic blood pressure [&ge;]140mmHg and a clinical indication for antihypertensive therapy. 400 participants will be randomised to usual standard of care for treatment selection, or to the intervention group. Remote follow-up will occur through a patient smartphone application and linked blood pressure monitor to assess the primary outcome of change in home systolic blood pressure during a four-week period after medication changes. Secondary outcomes will include patient-reported adverse effects and quality of life, treatment withdrawal, healthcare utilisation and a health economic analysis. In the second phase of the trial, all participants will receive an updated version of the intervention, regardless of original randomised group. Ethics and DisseminationEthical approval will be obtained for all sites. Approval in England: North West - Greater Manchester West Research Ethics Committee (REC) (25/NW/0296). Trial results will be disseminated via peer-reviewed publications and plain language patient summaries. Trial registrationClinicaltrials.gov: NCT07294794; ISRCTN: ISRCTN29385951. STRENGTH AND LIMITATIONS OF THIS STUDYO_LIHypertension is a major cause of preventable morbidity and mortality, and this study aims to reduce those burdens through machine learning-based integration of metabolomics with clinical factors to enable better personalisation of blood pressure lowering therapy. C_LIO_LIThe HYPERMARKER trial was co-created with patient and public representatives, using digital technology with remote monitoring to facilitate a high level of shared care and patient empowerment. C_LIO_LIHYPERMARKER is a pragmatic proof-of-concept randomised trial designed to evaluate the potential for future pharmacometabolomic strategies to aid clinical decision-making. C_LI

BACKGROUND: Observational studies have suggested an association between obstructive sleep apnea (OSA) and myocardial infarction (MI), but whether this relationship is causal or largely reflects shared risk factors remains unclear. METHODS AND RESULTS: We performed a 2-sample Mendelian randomization (MR) analysis to evaluate the causal effect of OSA on MI. Summary statistics for OSA were obtained from FinnGen, and MI data were obtained from the UK Biobank, with external validation using CARDIoGRAMplusC4D. Mediation MR was used to assess 13 potential mediators, and a 6-step multivariable MR framework was applied to estimate the direct effect of OSA after sequential adjustment for potential confounders. Reverse MR was conducted to test possible reverse causality. Genetically predicted OSA liability was associated with increased MI risk (odds ratio [OR] per log-OR increase, 1.0024 [95% CI, 1.0010-1.0039]; P=0.001). Body mass index (BMI) was the strongest mediator, explaining 35.94% of the association (P=0.030), whereas systolic blood pressure (SBP) showed minimal mediation (0.28%; P=0.678). In stepwise multivariable MR, the OSA-MI association was attenuated after adjustment for BMI and SBP (P=0.156), suggesting partial confounding by shared cardiometabolic risk. In a model including SBP and atrial fibrillation (AF), AF remained independently associated with MI (P=0.004), whereas OSA showed only a marginal direct effect (P=0.050). Reverse MR found no evidence that MI influenced OSA risk. CONCLUSIONS: These findings support a causal association between OSA and MI and suggest that this relationship may be mediated in part through obesity-related and arrhythmia-related pathways. AF may represent an important intermediate component of OSA-related cardiovascular risk beyond traditional hemodynamic factors. Keywords: obstructive sleep apnea; myocardial infarction; Mendelian randomization; mediation analysis; obesity.

AimTo outline the opportunities and barriers when using hairdressing salons as a novel site for enhancing cardiovascular risk factor assessment and management in women. MethodsA process evaluation nested within a cluster-randomised trial, Hairdressers for Health. The trial evaluated a nudge intervention advising women [&ge;]45years attending hairdressing salons to undertake a Heart Health Check with their General Practitioner. The UK Medical Research Council process evaluation framework was used to guide the design, data collection and analysis. Nineteen interviews were conducted with nine hairdressers, nine study participants and a project officer. Thematic analysis assessed recruitment, reach, acceptability, and adoption. Characteristics of the salons and participants were analysed using descriptive statistics. ResultsRecruitment of the planned 88 metropolitan and 28 regional salons for the trial was challenging, requiring resource-intensive face-to-face visits. The nudge intervention was well accepted by participants, and salons were perceived to be an appropriate setting to effectively reach women. Adoption of the study by salons was limited with only 54 of the 116 salons recruiting participants (total recruited 239, range 1-22 participants per salon). Barriers to participant recruitment included technological constraints while using a decentralised online recruitment and data collection platform, client preferences and privacy concerns. Established hairdresser-client relationships in smaller salons facilitated greater client participation and was perceived as a good mechanism for health promotion. ConclusionsCardiovascular health prevention messaging for women in salons was acceptable to hairdressers and clients. Designing the study to make better use of hairdresser-client personal relationships may have improved project implementation. Trial RegistrationACTRN12621001740886