Di Napoli S, Pacella D, Ordine L
… +10 more, Canciello G, Borrelli F, Moscano L, Martorano R, Polizzi R, Napolitano B, Spinelli A, Lombardi R, Esposito G, Losi MA
BACKGROUND: In Hypertrophic cardiomyopathy (HCM) increasing evidence suggests left atrial (LA) remodelling plays a critical role in disease progression. Traditional static LA size measurements, while established as risk...BACKGROUND: In Hypertrophic cardiomyopathy (HCM) increasing evidence suggests left atrial (LA) remodelling plays a critical role in disease progression. Traditional static LA size measurements, while established as risk markers, do not reflect the dynamic nature of LA changes over time. OBJECTIVES: This study aimed to define long-term LA remodelling trajectories in HCM and assess their prognostic value for predicting atrial fibrillation (AF), sudden cardiac death (SCD), and heart failure (HF) death. METHODS: A cohort of 210 HCM patients with at least 5 LA measurements (36 % women, mean age 45 ± 17 years) was followed over a 35-year period. Group-based trajectory modelling identified distinct longitudinal patterns of LA size. Clinical endpoints included incident AF, SCD, and a composite of heart failure-related death or transplantation. Cox regression analyses compared the predictive value of these trajectories against static baseline LA measurements. RESULTS: Three LA remodelling trajectories were identified. Over a mean follow-up of 21.8 ± 7.8 years, 73 patients developed AF, 25 experienced SCD, and 9 died from HF. Moderate (Cluster B) and severe (Cluster C) remodelling trajectories were associated with significantly increased AF risk (log-rank p < 0.001), with Cluster C showing a markedly elevated adjusted hazard ratio (aHR 9.30 vs. 5.03 for baseline size). Cluster C was also significantly associated with higher risk of SCD (aHR 3.61, p = 0.031) and HF death (p = 0.028). CONCLUSIONS: Longitudinal LA remodelling patterns offer superior prognostic value over static measurements in HCM, enabling improved risk stratification and personalized care.
Pulsed field ablation (PFA) is a novel and minimally thermal energy source that exploits the biophysics of irreversible electroporation (IRE) to cause cell death. Differently from radiofrequency ablation (RFA) where adeq...Pulsed field ablation (PFA) is a novel and minimally thermal energy source that exploits the biophysics of irreversible electroporation (IRE) to cause cell death. Differently from radiofrequency ablation (RFA) where adequate catheter-tissue contact proved paramount in lesion formation, the additional role of contact force (CF) during PFA is under debate due to the inherent myocardial selectivity and the customizable nature of IRE. In fact, it is not clear whether the amount of contact exerted during PFA delivery is as pivotal in achieving optimal lesion size as during RFA. Moreover, the variety of PFA catheters and the myriads of IRE ablation settings available would further potentially limit the role of CF in this scenario. However, beyond CF, specific ablation parameters, such as the PFA dose, number of pulses, catheter tip orientation and specific PFA workflows, proved to act in synergy with CF in achieving wide and deep ablation lesions even during PFA delivery. Therefore, the aim of this systematic review is to provide a better understanding on which ablation parameters - CF included - can help to obtain effective lesion formation during PFA.
Leadless pacemakers offer several advantages over transvenous pacemakers. They mainly reduce lead and pocket related complications which result in a reduction of re-intervention and infection rates (Graphical abstract)....Leadless pacemakers offer several advantages over transvenous pacemakers. They mainly reduce lead and pocket related complications which result in a reduction of re-intervention and infection rates (Graphical abstract). However, leadless pacemakers are not without drawbacks. Implantation of leadless pacemakers present a higher risk of pericardial perforation compared to its transvenous counterpart. Also, the leadless pacing technology is relatively new, and little is known about the best approach to manage these devices at the time of an upgrade or when the battery is at end of life. A modular approach for leadless pacing is emerging as a logical way to minimize the amount of hardware in the heart while preserving the ability to upgrade a single chamber device to a dual chamber (Graphical abstract). This review aims to present an overview of the different leadless pacemakers, indications for implantation, guidance on extraction while highlighting the advances made in the field.
Cardiovascular diseases (CVD) are risk factors for severe respiratory syncytial virus (RSV) infection, which in turn increases the risk of cardiovascular complications. The burden of RSV disease among adults with CVD is...Cardiovascular diseases (CVD) are risk factors for severe respiratory syncytial virus (RSV) infection, which in turn increases the risk of cardiovascular complications. The burden of RSV disease among adults with CVD is not yet fully understood and evidence remains to be consolidated through a systematic approach. Covering the publication period from January 1, 2000 to November 28, 2023, this systematic literature review documented RSV disease burden among adults ≥18 years with CVD including heart failure (HF), ischemic heart disease (IHD), and non-specified CVD. Relevant publications were retrieved from databases (PubMed, Embase) and gray literature (conference abstracts) to quantify the prevalence of CVD among RSV-infected adults, and RSV-related hospitalizations, complications, and mortality among adults with CVD. Sixty-two studies were selected for data extraction; most were conducted in the United States and among inpatients. The highest pooled estimates of CVD prevalence were observed among inpatients: 27.5 % (95 % confidence interval: 24.0-31.2) for HF, 22.9 % (17.7-29.0) for IHD, and 44.4 % (38.5-50.5) for non-specified CVD. Adults with CVD were at significantly higher risk of hospitalization following RSV infection compared to those without these comorbidities. Various general, respiratory, and cardiovascular complications attributable to RSV were documented among adults with CVD. RSV-related in-hospital case fatality rates of 7.8-14.8 % (HF), 13.7-20.0 % (IHD), and 2.9-12.5 % (non-specified CVD) were reported. This study shows that adults with CVD bear a significant burden of RSV infection, highlighting the need for effective RSV preventive measures and strategies (i.e., vaccination) targeting this high-risk population.
Direct current cardioversion (DCCV) is a cornerstone in the management of atrial fibrillation (AF) and is the quickest way to convert AF to sinus rhythm. Overall, the procedure is effective and safe, but the efficacy of...Direct current cardioversion (DCCV) is a cornerstone in the management of atrial fibrillation (AF) and is the quickest way to convert AF to sinus rhythm. Overall, the procedure is effective and safe, but the efficacy of DCCV can be reduced due to modifiable and non-modifiable patient characteristics, or procedural factors. Additionally, inadequate preparation, such as a lack of QRS-synchronization or omitting preprocedural imaging of the left atrial appendage (LAA), could lead to significant harm. This manuscript discusses a brief history of electrical cardioversion, the currently available cardioverter settings/configuration with the highest success rate, the common barriers to successful cardioversion, strategies to overcome these barriers, and suggested protocols to ensure a high level of patient safety.
The field of cardiac pacing has changed dramatically since the first pacemakers were implanted in the 1950s. Over the ensuing decades, advancements in pacing technology have yielded longer battery life, smaller devices,...The field of cardiac pacing has changed dramatically since the first pacemakers were implanted in the 1950s. Over the ensuing decades, advancements in pacing technology have yielded longer battery life, smaller devices, sturdier leads, and more sophisticated pacemaker programming. Cardiac resynchronization therapy (CRT) represented a significant revolution in pacing approach, with the goal of correcting interventricular dyssynchrony through biventricular pacing. More recently, conduction system pacing (CSP) has emerged as a means to deliver even more physiological activation through direct engagement of the conduction system. The enthusiasm for CSP, driven primarily by investigator-initiated studies, has led to a rapid evolution in our understanding of conduction system physiology and represents a contemporary paradigm shift in our approach to treating patients with bradyarrhythmias and heart failure. The goal of this review is to provide a brief overview of the progression of CSP over time and to highlight key gaps in our understanding that need to be resolved prior to moving forward (Graphical Abstract).
With the demonstration that AF is highly hereditable and strongly associated with over 100 genetic loci, one step towards personalized treatment of AF is the potential use of genetic testing to predict response to therap...With the demonstration that AF is highly hereditable and strongly associated with over 100 genetic loci, one step towards personalized treatment of AF is the potential use of genetic testing to predict response to therapy. Although various clinical models have been developed to predict recurrence, none have shown a consistent ability to predict treatment outcomes. This highlights a need for additional patient information to increase predictive value. Here, we review the use of genetic data for prediction of AF recurrence after interventions such as ablation, cardioversion, or drug therapy. We explore the use of other downstream predictors, such as mRNA and protein, as other possible predictive tools. Finally, we assess how this genetic data can further our mechanistc understanding of AF pathogenesis and recurrence.
BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality, affecting more than 500 million individuals globally. National guidelines recommend lipid-lowering therapies (LLTs) as first lin...BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality, affecting more than 500 million individuals globally. National guidelines recommend lipid-lowering therapies (LLTs) as first line agents for both primary and secondary prevention of ASCVD. However, under-prescribing of pharmacologic LLTs and sub-optimal medication adherence remain common problems. AIM: This mixed-methods study aimed to identify patient and prescriber factors influencing adherence to LLTs. METHODS: Patients with an ASCVD diagnosis and treatment plan that included LLT were sampled from a large community health system serving seven states. A stratified random sample of 2500 patients was surveyed by mail, capturing barriers and facilitators to medication adherence using an adapted version of the Adherence Starts with Knowledge-12 (ASK-12) scale, achieving a 16.2 % response rate (406 patients). Twenty-three semi-structured interviews were conducted with a sample of patient survey respondents to further explore drivers of non-adherence. Eligible prescribers with experience treating patients with ASCVD were surveyed by email, resulting in a 3.3 % response rate (122 respondents). Survey data were analyzed descriptively and using regression models; interview data were analyzed thematically. RESULTS: While cohort patients were identified as having an ASCVD diagnosis and taking a LLT from their medical chart, only 16.8 % of respondents reported having an ASCVD diagnosis and 84.2 % reported taking LLTs. Patients taking medication reported a higher average number of health condition diagnoses compared to those not taking a medication (2.63 and 1.50, respectively). Of those taking medication, 55.7 % were identified as adherent. Non-adherent patients were more likely to report poor healthcare experiences and social determinants of health needs. Multivariable regression analysis revealed that patients were more likely to be adherent when they felt their healthcare provider always spent enough time with them and treated them with respect. Interview findings further emphasized the importance of healthcare experiences, convenience, and belief the treatment works as important factors to adherence. In contrast, prescribers perceived higher non-adherence rates, citing forgetfulness and medication inconvenience as the main barriers. However, only 10.0 % of responding prescribers reported using a tool to assess patients' medication adherence and only 42.6 % reported asking patients about changes to their medication regimens. CONCLUSION: A substantial proportion of patients reported adherence to their medications, with adherence being associated with positive healthcare experiences, self-reported health conditions, perceived effectiveness of the medication, and social determinants of health needs. Prescribers perceived relatively low adherence among their patients, however only a small percent reported using tools to assess medication adherence. Comprehensive assessment tools and open communication could optimize patient care and enhance medication adherence and treatment outcomes.
Srivats S, Zghyer F, Shahrori Z
… +13 more, Albert C, Al-Khatib SM, Chugh S, Etheridge SP, Goldberger ZD, Gopinathannair R, Lakkireddy D, Morin DP, Perez MV, Rottmann M, Sunshine JE, Wang PJ, Chung MK
Prog Cardiovasc Dis
· 2025 · PMID 40553720
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Full text
Sudden cardiac death (SCD) remains a pervasive public health challenge, accounting for a significant proportion of cardiac and all-cause mortality worldwide. Despite notable advancements in cardiovascular therapies and r...Sudden cardiac death (SCD) remains a pervasive public health challenge, accounting for a significant proportion of cardiac and all-cause mortality worldwide. Despite notable advancements in cardiovascular therapies and reductions in overall cardiac mortality, survival following sudden cardiac arrest (SCA) remains dismally low, and prediction strategies remain inadequate. This comprehensive review examines the current landscape of SCD etiologies and the latest guidelines for primary and secondary prevention of SCD with implantable cardioverter defibrillators (ICDs). Particular attention is given to the limitations of left ventricular ejection fraction (LVEF) as the primary tool for risk stratification, given its low sensitivity, specificity, and limited applicability to the broader population in which most SCDs occur. Emerging risk scores and machine learning (ML) driven prediction models have begun to efficiently integrate clinical, electrical, imaging, genetic and laboratory parameters to improve SCD risk stratification. This review highlights examples of such artificial intelligence (AI) prediction models and discusses their potential role in the near-term and long-term prediction of SCD in both in-hospital and out-of-hospital settings, while emphasizing the need for external validation of such models. The review also discusses critical system-level gaps in the chain of survival from cardiac arrest, particularly the need for automated emergency medical services (EMS) activation, community responder engagement, high-quality cardiopulmonary resuscitation (CPR) and improved access to defibrillation. It explores the role of digital technologies such as wearable sensors, smartwatches, smartphone applications and implantable devices in improving real-time SCA detection and enhancing early aspects of the chain of survival from cardiac arrest. Finally, the review calls for a multidisciplinary, multi-sectoral approach including regulatory, technological, and public health stakeholders to bridge gaps in SCD prevention, detection, and response.
Heart rate variability (HRV) has been reported to predict overall mortality and the risk of cardiovascular disease events in patients, including those with heart failure. However, inconsistent methods of recording and an...Heart rate variability (HRV) has been reported to predict overall mortality and the risk of cardiovascular disease events in patients, including those with heart failure. However, inconsistent methods of recording and analyzing HRV parameters, along with a lack of randomized data substantiating its clinical efficacy and potential to guide treatment decisions for improved patient outcomes, have limited its use in clinical settings. With the advancements in technologies such as artificial intelligence and machine learning, and emergence of ablation procedures that can alter autonomic function, this article re-explores HRV assessment methods, their potential for clinical application, the issues encountered in using them in clinical research, and potential approaches to studying HRV in the future (Graphical Abstract).
The inherited arrhythmia (IA) syndromes are a group of rare and complex conditions that may predispose individuals to ventricular arrhythmias and sudden cardiac death. Our understanding of the genetic architecture underl...The inherited arrhythmia (IA) syndromes are a group of rare and complex conditions that may predispose individuals to ventricular arrhythmias and sudden cardiac death. Our understanding of the genetic architecture underlying these syndromes has evolved, with recent reappraisals of variant pathogenicity and quantification of polygenic influences. The IA population includes an increasing proportion of low-risk patients, often identified via familial screening; avoiding over-treatment in these patients is an important consideration. Conversely, high-risk patients have an expanding armamentarium of targeted therapeutic interventions available beyond the ICD, with many emerging novel therapies. Refined risk stratification in the intermediate risk group is critical, utilising novel risk factors, genotype and multiparametric risk scores. Artificial intelligence will almost certainly play a role in diagnosis and risk stratification moving forward. Durable phenotype correction with gene therapy (or precision ablation) is an ultimate goal. This review will focus on updates in pathophysiology, diagnosis, risk stratification and management of Brugada syndrome, long QT syndrome, catecholaminergic polymorphic ventricular tachycardia and arrhythmogenic right ventricular cardiomyopathy.
Class 1C antiarrhythmic drugs (AADs) are a key treatment option for effective rhythm control in several common arrhythmias. Here, we review the relevant background on Class 1C AADs, these drugs' indications and contraind...Class 1C antiarrhythmic drugs (AADs) are a key treatment option for effective rhythm control in several common arrhythmias. Here, we review the relevant background on Class 1C AADs, these drugs' indications and contraindications, and potential safe ways to use them. The safety profile of 1C AADs, and related restrictions on their use, has been largely based on the decades-old CAST trial, but more recent evidence may favor re-evaluating previously excluded populations. This review examines opportunities to reconsider certain patient populations that have previously been excluded from the use of 1C AADs. This reconsideration is made feasible due to advances in cardiac reperfusion, medical therapies for heart failure, and cardiac imaging.
Bosco G, Di Giacomo Barbagallo F, Di Marco M
… +12 more, Scilletta S, Miano N, Esposto S, Pennisi G, Prezzavento S, Gallo A, De Francesco EM, Malaguarnera R, Di Pino A, Purrello F, Piro S, Scicali R
BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is characterized by elevated LDL-C and an increased risk of premature cardiovascular events. Inclisiran is a small interfering RNA that inhibits hepatic PCSK9 synth...BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is characterized by elevated LDL-C and an increased risk of premature cardiovascular events. Inclisiran is a small interfering RNA that inhibits hepatic PCSK9 synthesis and promotes LDL-C clearance by enhancing LDLR expression on hepatocytes. This study aimed to evaluate the efficacy of six-months add-on inclisiran on lipid profile and PWV in FH; furthermore, we investigated the association between LDL-C reduction and PWV variation. METHODS: This prospective observational study involved 78 genetically confirmed FH subjects with an LDL-C off-target despite high-intensity statins plus ezetimibe. All subjects obtained biochemical analysis and PWV evaluation at baseline and after six months add-on inclisiran. RESULTS: After six months add-on inclisiran, 41 % of subjects achieved LDL-C targets. Significant reductions of LDL-C (-41.5 %, p < 0.001), ApoB (-33.7 %, p < 0.01), Non-HDL-C (-35.9 %, p < 0.001), and Lp(a) (-18 %, p < 0.01) were observed, while PWV improved by 14.4 % (p < 0.001). In a secondary analysis, the Primary prevention group showed a higher prevalence of subjects on LDL-C target than the Secondary prevention group (59 % vs 23.1 %, p < 0.001). Both groups exhibited significant improvements of lipid profile and PWV (Δ - 14.1 %, p < 0.01 and Δ - 14.6 %, p < 0.001, respectively). Linear regression showed a significant association between ΔPWV and ΔLDL-C in the whole study population as well as in the Primary and Secondary prevention groups (p for all <0.001). CONCLUSION: Inclisiran significantly improved lipid profile and PWV in FH subjects. ΔPWV was significantly associated with ΔLDL-C.
Pulsed field ablation (PFA) represents an innovative energy delivery approach for cardiac arrhythmia treatment, characterized by a favorable safety profile and effective myocardial lesion formation. It has demonstrated h...Pulsed field ablation (PFA) represents an innovative energy delivery approach for cardiac arrhythmia treatment, characterized by a favorable safety profile and effective myocardial lesion formation. It has demonstrated high acute pulmonary vein isolation rates with a reduced incidence of injury to adjacent anatomical structures. Nonetheless, procedure-specific complications such as haemolysis, intravascular gas formation, and coronary vasospasm have been observed and warrant further evaluation. Clinical evidence supports efficacy comparable to conventional thermal ablation in terms of arrhythmia recurrence. Ongoing advancements in catheter engineering, pulse modulation, and multimodal energy strategies aim to enhance lesion durability and transmurality. These developments position PFA as a promising technology in the field of cardiac ablation.
BACKGROUND: Atherogenic dyslipidemia (AD), characterized by low high-density lipoprotein cholesterol (HDL-C) and elevated triglycerides (TG), is associated with increased cardiovascular disease (CVD) risk. This study eva...BACKGROUND: Atherogenic dyslipidemia (AD), characterized by low high-density lipoprotein cholesterol (HDL-C) and elevated triglycerides (TG), is associated with increased cardiovascular disease (CVD) risk. This study evaluates the association between AD and CVD in hypertension treated to systolic blood pressure (SBP) targets of <120 mmHg (intensive) or < 140 mmHg (standard). METHODS: We included 9361 participants from the Systolic Blood Pressure Intervention Trial (SPRINT). Based on baseline lipid profiles, low HDL-C was defined as <40 mg/dL in men or < 50 mg/dL in women, and high TG as ≥150 mg/dL. Participants were classified into four lipid categories according to these cutoffs. AD was defined as the combination of low HDL-C and high TG. We used multivariable Cox regression to evaluate the association between lipid categories and the primary SPRINT outcome, a composite of major CVD events. RESULTS: Over a median 3.8-year follow-up, 726 primary outcome events occurred. The incidence of the primary outcome was 9.5% (n = 104) in those with AD and 7.4% (n = 434) with normal HDL-C and TG. Compared to the reference group (normal HDL-C with normal TG), the hazard ratios (HRs) for primary outcome were 1.07 (95 % CI: 0.85-1.35) for high TG alone, 1.20 (95 % CI: 0.95-1.52) for low HDL-C alone, and 1.41 (95 % CI: 1.12-1.77) for AD. Similarly, HRs for the primary outcome associated with AD were 1.38 (95 % CI: 1.02-1.87) and 1.44 (95 % CI: 1.01-2.05) in the standard and intensive SBP-lowering arms, respectively. CONCLUSION: Among SPRINT participants, AD was associated with a higher CVD risk. Early detection of AD in hypertensive patients, even without diabetes, may prompt greater therapeutic effort to reduce long-term CVD risk.
AIM: To evaluate the first presentation of atherosclerotic cardiovascular disease (ASCVD) in individuals without known ASCVD. METHODS: Distribution of first ASCVD events (angina, stroke, myocardial infarction [MI], or de...AIM: To evaluate the first presentation of atherosclerotic cardiovascular disease (ASCVD) in individuals without known ASCVD. METHODS: Distribution of first ASCVD events (angina, stroke, myocardial infarction [MI], or death/resuscitated cardiac arrest [RCA]), and the association between traditional risk factors, coronary artery calcium (CAC) and lipoprotein(a) [Lp(a)] with these events in Cox proportional hazards models were evaluated in 6779 participants in the Multi-Ethnic Study of Atherosclerosis. Risk prediction improvement with addition of CAC to the pooled cohort equations (PCE) was evaluated using net reclassification improvement (NRI). RESULTS: The mean age was 62.1 ± 10.2 years and 1037 participants (15.3 %) experienced an ASCVD event over a median of 15.8 years. The most common first presentation was cardiovascular death/RCA (n = 287;27.7 %). Among those with events, Black (35.6 %, p = 0.001)) individuals more often presented with death/RCA, Hispanic (29.3 %, p = 0.037) individuals more often presented with stroke compared to White individuals (24.8 % and 21.7 %, respectively). Compared to men, women more frequently presented with stroke (29.5 vs. 20.7 %, p = 0.002) and death/RCA (29.8 vs 26.3 %, p = 0.243) though this did not meet statistical significance. CAC score was significantly associated with first presentation of all events, including death/RCA (HR 1.13, 95 % CI 1.07-1.19) and improved risk prediction when added to the PCE (continuous NRI 0.6081, 95 % CI 0.4971-0.7141). Lp(a) was significantly associated with MI only (HR 1.15 per SD, 95 % CI 1.02-1.29). CONCLUSIONS: In previously asymptomatic individuals, the most common initial presentation of ASCVD was death/resuscitated cardiac arrest, particularly among women, minority groups, and those with CAC. CAC scoring may identify individuals at risk for death/resuscitated cardiac arrest as a first presentation of ASCVD.
Pediatric patients and children and adults with congenital heart disease often will require implantation of cardiac implantable electronic devices (CIEDs) for management of a variety of cardiac rhythm pathologies. The sa...Pediatric patients and children and adults with congenital heart disease often will require implantation of cardiac implantable electronic devices (CIEDs) for management of a variety of cardiac rhythm pathologies. The safe and effective use of CIEDs in these patients requires an awareness of important differences between this special population and the adult populations for whom these devices were primarily developed and in whom they have been most thoroughly studied. These include issues of body size and growth, anticipated lifespan, anatomical issues related to implantation and the epidemiology of underlying rhythm issues. In this paper, we discuss these issues in the context of the current state of the art in pediatric and congenital heart disease patients with respect to implant and lead extraction strategies, physiological cardiac pacing and resynchronization, ICD indications and use of transvenous and subcutaneous devices, and the use of implantable monitoring devices.