BACKGROUND AND AIMS: The prognostic significance of global calcium burden-including coronary artery (CAC), mitral annular (MAC), aortic valve (AVC), and thoracic aortic calcification (TAC)-as assessed by cardiac computed...BACKGROUND AND AIMS: The prognostic significance of global calcium burden-including coronary artery (CAC), mitral annular (MAC), aortic valve (AVC), and thoracic aortic calcification (TAC)-as assessed by cardiac computed tomography (CCT), remains incompletely understood in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). This study aimed to evaluate the prognostic impact of overall calcification burden in patients with severe AS undergoing AVR. METHODS: A retrospective analysis of 313 patients with severe AS undergoing CCT before AVR between 2016 and 2019 was conducted. MAC, CAC, AVC were quantified using established scoring methods. For TAC, a total thoracic aortic (TTA) score was developed by evaluating calcifications in the ascending, descending and aortic arch. MAC, CAC, AVC, and TTA were integrated into a comprehensive scoring system, the New Total Calcium (NTC) score, using Random Forest models. Outcomes considered included MACE, all-cause mortality, and non-cardiovascular mortality over a 60-month follow-up. RESULTS: Among 313 patients (mean age 81 years), 93% underwent transcatheter AVR. Severe CAC and MAC were observed in 11% and 7.7% of patients, respectively. During follow-up, 48% of patients died, with non-cardiovascular deaths accounting for 34% and MACE occurring in 43%. In this predominantly TAVR population, the TTA score predicted MACE (p = 0.01), all-cause mortality (p = 0.01), and non-cardiovascular mortality (p = 0.005). The NTC score demonstrated high prognostic accuracy for MACE at 1-, 2-, and 3-years, with AUC values of 0.91, 0.80, and 0.81, respectively. Validation in an external cohort of 100 patients confirmed its robustness. CONCLUSIONS: In this predominantly transcatheter AVR cohort, the NTC score is a promising tool for risk stratification in patients with severe AS. These findings are primarily applicable to transcatheter AVR patients, and further validation in SAVR populations is warranted.
BACKGROUND: Mitral annular calcification (MAC) can be complicated by mitral regurgitation (MR). However, data on outcomes of severe MR caused by MAC are limited. This study evaluated outcomes of severe MR due to MAC and...BACKGROUND: Mitral annular calcification (MAC) can be complicated by mitral regurgitation (MR). However, data on outcomes of severe MR caused by MAC are limited. This study evaluated outcomes of severe MR due to MAC and the prognostic significance of frailty and comorbidities in guiding management. METHODS: In this single-center, retrospective cohort study, we reviewed our echocardiographic database to identify patients with isolated severe MR due to severe MAC. The primary endpoint was all-cause mortality. The Society of Thoracic Surgeons (STS) risk score, Charlson Comorbidity Index (CCI), and a 3-point frailty index (hemoglobin, albumin, inactivity) were calculated. Echocardiographic parameters were recorded. RESULTS: Between January 2010 and August 2023, out of 10,061 patients with severe MAC on echocardiography, 128 patients with severe MR due to severe MAC were identified, and followed for a median of 134 days (IQR: 33-1812). Median age was 81 years; 72.7% were female. Forty-five patients (35.2%) underwent mitral valve (MV) intervention, and 83 (64.8%) received conservative management. During follow-up, 63 patients (49.2%) died. MV intervention improved survival, even after propensity score matching (p < 0.001). Higher frailty scores predicted poorer outcomes in the entire cohort (p = 0.004) and the conservative subgroup (p = 0.014) but not the surgical group (p = 0.406). CCI did not influence mortality when stratified by treatment. CONCLUSION: Patients with severe MR due to MAC were frail with multiple comorbidities and often managed conservatively. Frailty is associated with all-cause mortality, and MV intervention improves survival regardless of frailty status.
OBJECTIVE: Aortic dissection presents significant variations in incidence, treatment, and outcomes based on demographic and clinical factors. This study leverages official databases to elucidate the epidemiological trend...OBJECTIVE: Aortic dissection presents significant variations in incidence, treatment, and outcomes based on demographic and clinical factors. This study leverages official databases to elucidate the epidemiological trends of aortic dissection and related syndromes in Spain while examining demographic, clinical, and economic variables. METHODS: A Python-based workflow refined and classified data from the Spanish hospital database (2016-2021) of patients with aortic dissection, crosslinking age, sex, management, and resource use. The study examined sex- and age-specific differences, quantified treatment modalities in relation to outcomes such as procedure choice and in-hospital case fatality, and assessed hospitalization and intervention costs to evaluate the economic burden. RESULTS: Findings from 9587 cases reveal persistently high case-fatality (∼20 %) despite advancements in diagnosis and highlight disparities in care. Case-fatality was significantly higher in females (29.3 %) than in males (22.4 %), with diagnoses occurring at an older age in females compared to males (70.4 vs. 65.5 years). Open surgery remains as the predominant strategy across all analyzed aortic locations despite the medical and economic advantages of percutaneous intervention, although the database's limitation in recording cases according to the Stanford classification hinders the ability to criticize the treatment selection. CONCLUSION: Clinical data highlight the need for innovative medical and technological solutions. Moreover, transitioning to a new data system could enhance epidemiological reliability and improve patient management.
OBJECTIVE: To evaluate the independent and joint associations of social determinants of health (SDOH) and healthy lifestyle factors with life expectancy among adults with cardiovascular-kidney-metabolic (CKM) syndrome. R...OBJECTIVE: To evaluate the independent and joint associations of social determinants of health (SDOH) and healthy lifestyle factors with life expectancy among adults with cardiovascular-kidney-metabolic (CKM) syndrome. RESEARCH DESIGN AND METHODS: We analyzed two prospective population-based cohorts: the UK Biobank (2006-2010) and the US National Health and Nutrition Examination Survey (NHANES, 1999-2018). Adults with CKM at baseline and complete data on SDOH and lifestyle indicators were included. Cox proportional hazards models were used to estimate mortality risk by CKM stage, SDOH, and lifestyle adherence. Life expectancy at age 50 was calculated using life table methods, stratified by CKM stage and levels of SDOH and lifestyle. RESULTS: A total of 213,738 UK Biobank participants (6.69 % deaths) and 10,345 NHANES participants (9.48 % deaths) were included. Advanced CKM stages were associated with significantly higher mortality risk and shorter life expectancy in both cohorts. Individuals with higher SDOH weighted scores or lower healthy lifestyle scores had elevated mortality risks. The joint effects of poor CKM status, adverse SDOH, and unhealthy lifestyle were additive. In NHANES, life expectancy at age 50 ranged from 33.9 years (CKM stage 0 with healthy lifestyle) to 13.2 years (CKM stage 4 with unhealthy lifestyle). In the UK Biobank, the corresponding figures were 34.2 and 21.7 years. CONCLUSIONS: In two large cohorts, poorer CKM health, greater social disadvantage, and unhealthy lifestyles were each independently and jointly associated with lower life expectancy. These findings support the need for integrated strategies targeting both social and behavioral factors to improve outcomes in CKM populations.
The implantable cardioverter-defibrillator (ICD) is a cornerstone therapy for the prevention of sudden cardiac death (SCD). However, with the global population aging, the application of ICD therapy to elderly patients pr...The implantable cardioverter-defibrillator (ICD) is a cornerstone therapy for the prevention of sudden cardiac death (SCD). However, with the global population aging, the application of ICD therapy to elderly patients presents a significant clinical and ethical challenge. The main clinical trials that established the efficacy of ICDs largely excluded or underrepresented individuals over the age of 75, as well as those with significant frailty and comorbidities. We critically examine the evidence for primary and secondary prevention, highlighting the concept of competing risks of non-arrhythmic death, which attenuates the potential benefit of ICDs with advancing age. The risk-benefit ratio is further complicated by a heightened risk of procedural and long-term complications, including device-related infections and pocket integrity issues such as skin erosion. The decision to perform a generator replacement at the time of battery depletion is a crucial opportunity for a new goals-of-care discussion rather than a routine procedure, as evidence shows high mortality rates and a low likelihood of appropriate therapy post-exchange in the very elderly. Finally, we address the management of the ICD at the end of life, summarizing the ethical and legal consensus supporting device deactivation as a critical component of palliative care to prevent suffering from futile shocks. This review calls for a paradigm shift away from criteria based solely on left ventricular ejection fraction and chronological age towards a holistic, individualized approach integrating comprehensive geriatric assessment, comorbidity burden, and structured shared decision-making.
BACKGROUND: Visceral adipose tissue (VAT) is a metabolically active fat depot strongly associated with cardiometabolic diseases. Current cardiovascular risk models, including the PREVENT equation, do not incorporate dire...BACKGROUND: Visceral adipose tissue (VAT) is a metabolically active fat depot strongly associated with cardiometabolic diseases. Current cardiovascular risk models, including the PREVENT equation, do not incorporate direct measures of visceral fat. This study evaluates whether MRI-derived VAT enhances the discrimination and calibration of the PREVENT model for atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and total cardiovascular disease (CVD) in a large, population-based cohort. METHODS: We included 38,373 UK Biobank participants who underwent abdominal MRI and had no known CVD at baseline. VAT volume was quantified using standardized MRI protocols. We assessed whether adding VAT to the PREVENT model improved model performance for incident ASCVD, HF, and total CVD, using C-statistics and net reclassification improvement (NRI). RESULTS: The mean age was 54.86 years (SD 7.49), and 52 % of participants were female. The median VAT volume was 3.58 L (IQR:2.14-5.33). Using the overall median VAT value as the threshold, higher visceral adiposity (>3.58 L) was associated with significantly increased risk of ASCVD (HR: 1.32, 95 % CI: 1.15-1.51), heart failure (HR: 1.55, 95 % CI: 1.27-1.89), and total CVD (HR: 1.38, 95 % CI: 1.23-1.55) adjusting for age and sex. Adding VAT to the PREVENT model did not significantly improve discrimination for ASCVD (C-statistic 0.731 vs. 0.729, p = 0.85), nor for HF or total CVD. However, VAT significantly improved reclassification: NRI for ASCVD was 0.37 (95 % CI: 0.30-0.33), for HF was 0.48 (95 % CI: 0.35-0.61), and for total CVD was 0.37 (95 % CI: 0.28-0.46). The association between VAT and all outcomes remained robust after adjustment for age and sex. CONCLUSIONS: MRI-derived visceral adiposity is associated with increased risk of ASCVD, HF, and total CVD. While VAT did not improve overall discrimination of the PREVENT model, it significantly enhanced reclassification, particularly for HF risk. This suggests that VAT may improve individualized cardiovascular risk stratification and inform targeted preventive strategies.
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly utilized for severe aortic stenosis (AS), yet optimal risk stratification remains challenging, particularly in patients with preserved ejection fr...BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly utilized for severe aortic stenosis (AS), yet optimal risk stratification remains challenging, particularly in patients with preserved ejection fraction (EF). Diastolic dysfunction (DD) has been reported in up to 54.4 % of TAVR patients (predominantly grade 1) and severe (grade 3) DD in ∼13.4 % in prior cohorts and predicts poor outcomes. N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), a marker of ventricular stress, shows promise in enhancing risk assessment. This study evaluates NT-pro-BNP's utility in detecting DD and predicting outcomes in severe AS patients with preserved EF undergoing TAVR. METHODS: This retrospective study included 1594 patients with severe AS (aortic valve area < 1 cm) and EF ≥50 % undergoing TAVR at Cleveland Clinic (2016-2020). Of these, 784 had complete echocardiographic DD data. Pre- and post-TAVR NT-pro-BNP levels, clinical, and echocardiographic parameters were analyzed. DD was classified using Mitral valve (MV) E/e', tricuspid regurgitation (TR) velocity, and left atrial volume index (LAVi). The Youden Index determined the optimal NT-pro-BNP cut-off, with outcomes assessed via Kaplan-Meier and Cox regression analyses. RESULTS: NT-pro-BNP correlated with DD severity, with a cut-off of 802 pg/ml (sensitivity 62.3 %, specificity 54.1 %) identified. Higher NT-pro-BNP tertiles were linked to worse baseline characteristics (e.g., NYHA III/IV 65.7 %-82.5 %, p = 0.02) and echocardiographic DD markers (e.g., LAVi 37.61-50.14 ml/m, p < 0.001). Post-TAVR, NT-pro-BNP >802 pg/ml predicted increased mortality, heart failure hospitalizations, and prolonged length of stay (p < 0.001), with Cox regression confirming NT-pro-BNP as an independent predictor (OR 1.645, 95 % CI: 1.244-2.174). CONCLUSION: NT-proBNP should be considered a complementary biomarker of DD and predicts adverse outcomes in severe AS patients with preserved EF undergoing TAVR, supporting its integration into pre-procedural risk stratification to optimize management.
Mast cells have emerged as pivotal regulators of cardiovascular physiology and pathology, influencing key processes including fibrosis, angiogenesis, tissue regeneration, and atherosclerosis. This review synthesizes find...Mast cells have emerged as pivotal regulators of cardiovascular physiology and pathology, influencing key processes including fibrosis, angiogenesis, tissue regeneration, and atherosclerosis. This review synthesizes findings from 110 studies to delineate the multifaceted roles of mast cells across these domains. Historically associated with allergic responses, growing evidence now underscores their substantial contribution to the progression of cardiovascular diseases. In fibrotic remodeling, mast cells facilitate extracellular matrix deposition and fibroblast activation through the release of pro-fibrotic mediators such as tryptase and chymase. In the context of angiogenesis, mast cells enhance endothelial proliferation and vascular permeability, predominantly through VEGF-driven signaling pathways. Although the role of mast cells in cardiac regeneration remains underexplored, current evidence suggests a context-dependent function in modulating stem cell dynamics and inflammatory microenvironments. Additionally, mast cells can participate in the pathogenesis of atherosclerosis by promoting lipid accumulation, vascular inflammation, and plaque destabilization. Collectively, these findings highlight mast cells as integral components of cardiovascular disease mechanisms. Therapeutic targeting of mast cell-derived mediators and signaling pathways, through stabilizers, enzyme inhibitors, or selective modulators, represents an avenue worthy of investigation for clinical intervention. Future studies should refine these strategies, aiming to mitigate mast cell-driven pathogenesis while preserving their physiological roles in tissue homeostasis and immune defense.
BACKGROUND: Cardiomyopathies encompass a heterogeneous group of myocardial diseases with variable clinical manifestations and prognoses. Despite their complexity and association with high-risk outcomes, malpractice claim...BACKGROUND: Cardiomyopathies encompass a heterogeneous group of myocardial diseases with variable clinical manifestations and prognoses. Despite their complexity and association with high-risk outcomes, malpractice claims related to cardiomyopathies have not been well-characterized. OBJECTIVE: To characterize medicolegal claims associated with non-ischemic cardiomyopathies in the United States and identify common clinical and systemic contributors to liability. METHODS: A retrospective review of U.S. malpractice and negligence claims from inception to 2025 was conducted using Westlaw, vLex, and a sports cardiology litigation database. Included cases involved a diagnosis or clinical suspicion of cardiomyopathy directly linked to a legal claim. Case frequency, location, demographics, allegations, defendant profiles, and outcomes/awards were identified for all eligible cases. RESULTS: Of 421 cases reviewed, 63 (15 %) met inclusion criteria, spanning 1990-2025 with 1.8 cases/year. Hypertrophic (38 %) and dilated (31 %) cardiomyopathies were the most frequently litigated subtypes. Sudden cardiac arrest/death occurred in 79 % of cases. Leading allegations were failure to diagnose cardiomyopathy (37 %), inappropriate treatment (27 %) and communication failures (19 %). Non-cardiology providers, particularly primary care, were the most frequently named defendants (83 %), while cardiologists were implicated in 29 % of cases. Incarcerated individuals accounted for 16 % of cases. Most outcomes favored defendants (54 %), while 13 % resulted in plaintiff-favorable verdicts or settlements, with awards ranging from $100,000-$21,568,710 ($200,999 - $28,039,323 adjusted for inflation). CONCLUSION: While rare, malpractice claims related to cardiomyopathies are often associated with preventable failures in diagnosis, treatment and communication. These findings underscore the need for improved provider education, standardized diagnostic pathways, and clinical decision support tools to mitigate liability and enhance patient safety.
Banach M, Toth PP, Ahn HJ
… +23 more, Bielecka-Dabrowa A, Cicero AFG, Covic A, Dalakoti M, Escobar C, Fogacci F, Gaita D, Gaita L, Jóźwiak J, Latkovskis G, Lewek J, Ntaios G, Okopień B, Pećin I, Pella D, Penson PE, Proietti M, Sadowski J, Solnica B, Sosnowska B, Viigimaa M, Lip GYH, International Lipid Expert Panel and in collaboration with the European Society of Cardiology Council on Stroke
Ischemic stroke is a significant global health challenge, accounting for approximately 66 % of all strokes worldwide. Recent data indicates that stroke was the third leading cause of death (10.7 % of all deaths), followi...Ischemic stroke is a significant global health challenge, accounting for approximately 66 % of all strokes worldwide. Recent data indicates that stroke was the third leading cause of death (10.7 % of all deaths), following ischemic heart disease and COVID-19. In 2021, nearly 94 million people were living with the consequences of a stroke, and about 12 million new cases were reported. Major risk factors for stroke include high systolic blood pressure, exposure to ambient particulate matter, smoking, and elevated levels of low-density lipoprotein cholesterol (LDL-C), with LDL-C contributing to nearly one-third of all ischemic strokes. In primary prevention, many at-risk individuals have undiagnosed or poorly managed lipid disorders, including elevated lipoprotein(a). The challenge persists in secondary prevention, where up to 40 % of individuals at risk of recurrent ischemic stroke experience a recurrence within five years. A key reason for this is the inadequate diagnosis and management of lipid disorders, underscoring the necessity for early and intensive (upfront) combination lipid-lowering therapy (LLT) to meet treatment goals promptly after an event. Unfortunately, data indicates that up to 40 % of post-stroke patients receive no LLT, and many more receive inadequate treatment. Additionally, existing guidelines for LLT in both primary and secondary stroke prevention are often inconsistent and outdated. Similarly, the understanding of the effects of LDL-C and LLT on the risks of haemorrhagic stroke and dementia remains limited, emphasizing the need for clear and practical guidance. Thus, within this Consensus Paper we aimed to provide consistent, easy-to-follow, and practical guidance on lipid targets, along with clear pathways for effectively treating patients with lipid disorders who are at risk for stroke and those who have experienced one. This approach is intended to help reduce the risk of recurrent ischemic strokes and their associated complications.
Chedid El Helou M, Finet JE, Kassab J
… +11 more, El Dahdah J, Carmona Rubio A, Kanta A, Rizzo J, Martyn T, Kwon D, Jaber W, Klein A, Popović Z, Collier P, Hanna M
BACKGROUND: Left ventricular wall thickness (LVWT) is a key echocardiographic parameter in the diagnosis of cardiac amyloidosis (CA), yet its measurement is prone to variability, and traditional thresholds may miss early...BACKGROUND: Left ventricular wall thickness (LVWT) is a key echocardiographic parameter in the diagnosis of cardiac amyloidosis (CA), yet its measurement is prone to variability, and traditional thresholds may miss early disease. We aimed to characterize the spectrum of LVWT and derived parameters in patients with transthyretin (ATTR-CA) and light chain (AL-CA) cardiac amyloidosis. METHODS: In this retrospective study, we included 1845 patients treated for CA at a tertiary amyloidosis center from 2006 to 2024. Echocardiographic data were analyzed to assess LVWT, relative wall thickness (RWT), and left ventricular mass index (LVMi). Sex differences and inter-/intra-observer variability were also examined. RESULTS: A significant subset of patients presented with normal or mildly increased LVWT ({less than or equal to}1.2 cm), including 13 % of AL-CA and 6.5 % of ATTR-CA patients. Conversely, 12.2 % of AL-CA patients exhibited markedly elevated LVWT (>2.0 cm). Women had significantly lower LVWT. Despite low LVWT, 68 % of patients with IVST and PWT {less than or equal to}1.2 cm had RWT >0.42. RWT was more sensitive than LVMi in identifying CA and showed no sex difference. Measurement variability was substantial, with a standard error of ∼1.5 mm. CONCLUSIONS: CA presents across a wide range of LVWT values, including within normal limits, especially in women. RWT offers greater sensitivity and may enhance early disease detection. Significant observer variability underscores the need for standardization and incorporation of derived metrics in echocardiographic interpretation. These findings highlight the limitations of echocardiography and support the use of complementary parameters for improved diagnostic accuracy.