Sykes R, Tan D, McKinley G
… +32 more, Carrick D, Ang D, Apps AP, Bradley C, Brogan RA, Carberry J, Collison DG, Eteiba H, Gildea P, Ghattas A, Gohar A, Good RIS, Hanna R, Jamieson L, Joshi FR, Kamdar AL, Lindsay MM, McCartney PJ, McFarlane R, McMenamin M, Morrow AJ, Orchard V, Robertson KE, Rocchiccioli PJ, Shaukat A, Tzolos E, Vicere A, Watkins S, Galbraith M, Reynolds H, McConnachie A, Berry C
BACKGROUND: Myocardial Infarction with No Obstructive Coronary Arteries (MINOCA) or Nonischemic Myocardial Injury affects approximately 1 in 9 patients presenting with acute coronary syndrome, yet evidence-based therapie...BACKGROUND: Myocardial Infarction with No Obstructive Coronary Arteries (MINOCA) or Nonischemic Myocardial Injury affects approximately 1 in 9 patients presenting with acute coronary syndrome, yet evidence-based therapies are lacking. Coronary microvascular dysfunction is implicated in the pathogenesis of suspected MINOCA, but its prevalence, prognostic implications and treatment are uncertain. The objectives are, first, to assess the prevalence of coronary microvascular dysfunction in patients with suspected MINOCA and, second, to implement endotype-informed stratified medicine involving patients with coronary microvascular dysfunction to treatment with eplerenone, a cardio- and vasculo-protective mineralocorticoid receptor antagonist. METHODS: This is a prospective, registry-based, multicenter, diagnostic study and nested, randomized, controlled, open-label, blinded-endpoint (PROBE) basket trial. Up to 400 patients with clinically suspected MINOCA and one or more cardiovascular risk factors will be enrolled into a registry-based diagnostic study. Coronary microvascular function will be assessed during invasive angiography using thermodilution. Patients with an index of coronary microvascular resistance (IMR) ≥25 will be randomized 1:1 to eplerenone (25-50 mg daily for 6 months) or standard care without eplerenone (control group) (n=150 randomized). Final endotypes will be centrally adjudicated by a panel of blinded cardiologists. The primary outcome of the diagnostic study is the proportion of patients with IMR ≥25 during index coronary angiography. Secondary outcomes include coronary flow reserve, cardiovascular MRI parameters, patient-reported outcome measures, biomarkers of myocardial fibrosis and vascular inflammation, health outcomes and health economic assessments. The primary outcome of the randomized trial is the within-individual change in NT-proBNP at baseline, 1 month, and 6 months, based on intention-to-treat. Secondary outcomes include mechanistic blood biomarkers and patient-reported outcome measures. VALUE: This registry-based randomized trial will provide novel evidence on endotype-informed secondary prevention therapy with eplerenone for suspected MINOCA.
BACKGROUND: The 2026 ACC/AHA dyslipidemia guideline introduces PREVENT-based risk assessment, new direct-treatment pathways for comorbid conditions, and long-term risk estimation. The population-level effect of these cha...BACKGROUND: The 2026 ACC/AHA dyslipidemia guideline introduces PREVENT-based risk assessment, new direct-treatment pathways for comorbid conditions, and long-term risk estimation. The population-level effect of these changes on lipid-lowering therapy recommendations is unknown. OBJECTIVES: To compare classification of U.S. adults under the 2018 and 2026 dyslipidemia guidelines for treatment recommendations. METHODS: Cross-sectional study of the National Health and Nutrition Examination Survey (2013-2023) including adults aged 40-75 years with data suitable for guideline classification. Individuals already receiving lipid-lowering therapy were classified separately. Treatment recommendation categories of 'recommended/indicated', 'reasonable/favored/selective-consideration', and 'not-routinely-recommended' were constructed for cross-classification of untreated adults between the two guidelines. RESULTS: The analytic cohort included 6,118 adults representing 118.9 million U.S. adults; 1,984 [weighted, 36.0 million (30.3%)] were already receiving lipid-lowering therapy. Among 4,134 untreated adults [82.9 million], the 2026 guideline classified 1,868 [31.2 million (37.7%)] as recommended/indicated, 1,154 [27.1 million (32.7%)] as reasonable/favored/selectively-considered, and 1,112 [24.6 million (29.7%)] as not-routinely-recommended. Under the 2018 guideline, corresponding counts were 1,289 [21.2 million (25.6%)], 1,107 [21.2 million (25.6%)], and 1,738 [40.5 million (48.9%)]. All adults recommended/indicated under the 2018 framework remained so under the 2026 framework, 45.5% of those in the 2018 reasonable stratum moved to the 2026 recommended/indicated stratum, and 39.9% of the previously not-routinely-recommended moved to a higher-intensity category. PREVENT-based pathways accounted for 33.4% of the 2026 recommended/indicated stratum. CONCLUSIONS: Under the 2026 dyslipidemia guideline, an additional 15.9 million (14.1-17.7) untreated Americans aged 40-75 years would be newly identified for treatment consideration. The updated guideline substantially reallocates untreated adults toward consideration for treatment.
BACKGROUND: Cardiometabolic risk factors are major contributors to premature mortality in the United States. Little is known about recent changes in the cardiometabolic health of US adults by income level, particularly a...BACKGROUND: Cardiometabolic risk factors are major contributors to premature mortality in the United States. Little is known about recent changes in the cardiometabolic health of US adults by income level, particularly after the COVID-19 pandemic. OBJECTIVE: To assess changes in the cardiometabolic health of US adults from 2009 to August 2023 by income level, and to evaluate pandemic-related shifts. METHODS: We conducted a serial cross-sectional analysis of National Health and Nutrition Examination Survey participants aged ≥ 18 years (2009-2010 to August 2021-August 2023). Low-income was defined as ≤ 200% of the federal poverty level. We evaluated changes in the age- and sex-adjusted prevalence, treatment, and control of hypertension, diabetes, and high cholesterol, and the prevalence of obesity and smoking, among low- and higher-income adults. Linear regression models estimated pandemic-associated shifts. RESULTS: Among 62,108 adults (mean age 46.3 years; 51.7% female), the prevalence of hypertension or high cholesterol did not change in either income group. Obesity prevalence rose among low-income adults (37.3% to 42.1%; absolute change +4.8 pp [95% CI: 1.1, 8.5]). Diabetes prevalence increased in both groups (low-income: +5.1 pp [1.4, 8.8]; higher-income: +2.5 pp [0.7, 4.3]), but remained higher among low-income adults (17.6% vs. 12.4%; absolute difference +5.2 pp [1.6, 8.8]). While diabetes treatment did not change, an income-related gap in diabetes control emerged: by August 2021-August 2023, 43.0% of low-income adults achieved glycemic control compared to 52.8% of higher-income adults (absolute difference -9.8 pp [-17.5, -2.1]), coinciding with a greater-than-expected decline in diabetes control among low-income adults in the wake of the pandemic (level shift -8.7 pp [-16.7, -0.6]). The income-related gap in hypertension treatment in 2009-2010 had closed by August 2021-August 2023, following a greater-than-expected increase in treatment among low-income adults after the pandemic (level shift +7.8 pp [1.8, 13.8]). High cholesterol treatment and control improved in both groups, with no income-related differences. Smoking declined for both low-income (30.2% to 22.8%, absolute change -7.4 pp [-12.0, -2.8]) and higher-income (15.0% to 10.3%, absolute change -4.7 pp [-7.1, -2.3]) adults, but remained more than two-fold higher in the low-income group. CONCLUSIONS: Between 2009 and August 2023, there was no improvement in the prevalence of hypertension or high cholesterol. Obesity and diabetes prevalence rose among low-income adults and a new income-related gap in diabetes control emerged, coinciding with a greater-than-expected decline in glycemic control among low-income adults after the pandemic. Targeted efforts are needed to improve risk factor prevention, strengthen glycemic control in low-income populations, and address persistent income-related disparities in cardiometabolic health.
Senman B, Miller PE, Gage A
… +66 more, Dudzinski DM, Alviar C, Araiza-Garaygordobil D, Arias-Mendoza A, Barnes A, Barnett C, Basir MB, Berg DD, Bernard S, Brusca S, Burkart KM, Chacón-Lozsán F, Chaisson NF, Cutrone M, Dahiya G, Dezfulian C, Dupont A, Elliott A, Enstrom C, Farfan L, Fiedler A, Franko A, Fry C, Hall E, Hansra B, Higgins A, Hollenberg SM, Horowitz J, Il'Giovine ZJ, Jumean M, Karpenshif Y, Khalif A, Kochar A, Krishnamoorthy V, Krishnan S, Lawler P, Lee R, Li B, Luk A, McKenzie-Solis J, Methvin L, Moghaddam N, Nagraj S, O'Brien CG, Potarazu D, Rabon A, Rali A, Safiriyu I, Sayood S, Schimmer H, Schrage B, Sinha S, Sridharan L, Tennyson C, Thachil R, Thompson A, Tomey MI, Vallabhajosyula S, van Diepen S, Weickert TT, Wiley B, Zern E, Zhang Y, Sener YZ, Katz JN, Society of Critical Care Cardiology
IMPORTANCE: Since the cardiac intensive care unit (CICU) was first introduced into to the medical landscape, patient complexity, comorbidity, and illness severity have increased substantially over time. This evolution ha...IMPORTANCE: Since the cardiac intensive care unit (CICU) was first introduced into to the medical landscape, patient complexity, comorbidity, and illness severity have increased substantially over time. This evolution has required and informed the cultivation of new tools and an expanding skill set for those who deliver care in these units, and has paved the way for the emergence and growth of a distinct discipline-Critical Care Cardiology. With the genesis of this field and the need to care for comorbid and critically ill patients, numerous questions have been posed, including those related to optimal staffing models, appropriate training pathways, and the development of best practice principles to guide patient management. To address these and other challenges, to foster necessary collaborations, and to galvanize a maturing field, the Society of Critical Care Cardiology (SoCCC) was born. OBSERVATIONS: SoCCC was created to provide an independent, yet complementary home for stakeholders within this rapidly growing discipline. Its mission is to address the unique needs and concerns of Critical Care Cardiology through an inclusive approach that prioritizes the development of early career faculty, actively engaging them to help to shape the field and to strengthen its unique practice environment - the CICU. While collaborations with larger professional societies remain essential, an independent subspecialty society like SoCCC intends to capitalize on the historical precedent and experiences shared by other successful organizations, while leveraging its nimble structure to advocate for and advance the needs of its constituency. CONCLUSIONS/RELEVANCE: While this document primarily details the history and rationale that led to the establishment of SoCCC, it also endeavors to be a practical blueprint to support future leaders who might be considering a new society for their own subspecialty.
BACKGROUND: The DOAC Score is a bleeding risk score that incorporates ten common clinical variables to risk stratify major bleeding in patients with atrial fibrillation and demonstrated improved risk stratification than...BACKGROUND: The DOAC Score is a bleeding risk score that incorporates ten common clinical variables to risk stratify major bleeding in patients with atrial fibrillation and demonstrated improved risk stratification than HAS-BLED in patients receiving direct acting oral anticoagulants (DOACs). This study evaluates the discriminative performance of the DOAC Score among patients taking vitamin K antagonists (VKAs). METHODS: Data was obtained from COMBINE-AF and GARFIELD-AF. COMBINE-AF included patients with atrial fibrillation randomized to warfarin from four clinical trials: RE-LY, ARISTOTLE, ROCKET-AF, and ENGAGE AF-TIMI 48. GARFIELD-AF included patients with atrial fibrillation prescribed VKAs in a registry. The DOAC Score of each patient was determined, based on commonly obtained clinical variables. Patients were then stratified by DOAC Score clinical risk categories (very low [score: 0-3], low [score: 4-5], moderate [score: 6-7], high [score: 8-9], and very high [score: 10]), and the rate of major bleeding at one-year was compared between groups. Discrimination was assessed using C-statistics and compared with HAS-BLED using DeLong's test. RESULTS: A total of 28,818 patients in COMBINE-AF and 20,183 patients in GARFIELD-AF receiving vitamin K antagonists were included. Of these individuals, 994 (3.4%) in COMBINE-AF and 313 (1.6%) in GARFIELD-AF experienced a major bleeding event at one-year. Patients in higher DOAC Score risk categories experienced greater one-year major bleeding rates in COMBINE-AF, including very low (1.8 events per 100 person-years [events/100p-y]), low (3.0 events/100 p-y), moderate (4.6 events/100 p-y), high (5.6 events/100 p-y), and very high (7.9 events/100 p-y). Discrimination in COMBINE-AF was moderate and higher than HAS-BLED at one-year (C-statistic: 0.62 vs 0.59, P<0.001). In GARFIELD-AF, higher risk categories also had higher one-year major bleeding rates: very low (0.8 events per 100 person-years [events/100 p-y]), low (1.5 events/100 p-y), moderate (2.2 events/100 p-y), high (3.2 events/100 p-y), and very high (7.6 events/100 p-y). Discrimination in GARFIELD-AF was moderate and higher than the HAS-BLED score at one-year (C-statistic: 0.65 vs 0.62, P<0.001). CONCLUSION: In patients with atrial fibrillation taking VKAs, the DOAC Score was able to risk stratify patients based on bleeding risk, had moderate discrimination, and out-performed the HAS-BLED score in both a pooled clinical trials cohort and a usual care registry.
Atrial fibrillation (AF) care has shifted dramatically, with a focus on early rhythm control to reduce AF-related morbidity and mortality and improve quality of life. However, clinical trials for AF rely on historical de...Atrial fibrillation (AF) care has shifted dramatically, with a focus on early rhythm control to reduce AF-related morbidity and mortality and improve quality of life. However, clinical trials for AF rely on historical definitions of treatment failure, including freedom from recurrence of ≥ 30 seconds of atrial fibrillation/flutter/tachycardia, which is a poor predictor of AF severity, or traditional clinical endpoints (i.e., stroke, heart failure, death) which have low incidence in contemporary AF populations. Therefore, a directly measurable and clinically meaningful measure for these clinical endpoints has the potential to accelerate clinical trials of rhythm control in AF while reducing overall trial overhead. The Cardiovascular Sciences Research Consortium hosted a Think Tank comprising scientists, clinicians, regulators, and industry representatives to develop a roadmap to establish AF burden as a valid surrogate clinical endpoint. This document reviews currently available data to support the use of AF burden as a surrogate endpoint, provides standards for measuring AF burden across measurement modalities and devices, and establishes a practical roadmap for a collaborative approach to validating the use of AF burden. Moving beyond historical definitions of AF treatment success and failure, AF burden has the potential to be a patient-centric endpoint that can leverage contemporary monitoring technologies while serving as an early signifier of AF-related risk.
Muro FMD, Raona V, Sartori S
… +12 more, Smith K, Oliva A, Cohen RM, Gitto M, Bay B, Krishnan P, Sweeny J, Moreno P, Dangas G, Kini A, Sharma S, Mehran R
BACKGROUND AND AIM: Inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) and the neutrophil-to-lymphocyte ratio (NLR) have been individually associated with cardiovascular risk in patients undergoing...BACKGROUND AND AIM: Inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) and the neutrophil-to-lymphocyte ratio (NLR) have been individually associated with cardiovascular risk in patients undergoing percutaneous coronary intervention (PCI). However, their combined prognostic value remains incompletely defined. METHODS: Consecutive patients undergoing PCI between 2012 and 2022 were included and stratified according to baseline hs-CRP (≥2 mg/L vs <2 mg/L) and NLR (≥75th vs <75th percentile). The primary endpoint was 1-year major adverse cardiovascular events (MACE). Multivariable Cox proportional hazards models were used to assess associations after adjustment for confounders. RESULTS: Among 7,303 included patients, those with concomitantly elevated NLR and hs-CRP exhibited the highest incidence of overall MACE, followed by patients with only one elevated inflammatory marker, while the lowest event rates were observed in those with both markers below threshold. No significant interaction between NLR and hs-CRP was observed (p=0.451). Elevated NLR was associated with a higher risk of MACE in both hs-CRP strata (hs-CRP ≥2 mg/L: HR 1.83, 95% CI 1.42-2.35, p<0.001; hs-CRP <2 mg/L: HR 1.55, 95% CI 1.10-2.17, p=0.012). After multivariable adjustment, this association remained significant only in patients with hs-CRP ≥2 mg/L, driven primarily by all-cause mortality and myocardial infarction. CONCLUSION: In patients undergoing PCI, elevated NLR identifies a gradient of increasing risk, particularly when combined with hs-CRP ≥2 mg/L. A dual-marker inflammatory approach may improve post-PCI risk stratification beyond either biomarker alone.
BACKGROUND: Among individuals with single ventricle (SV) congenital heart disease (CHD), systemic right ventricle morphology is associated with decreased survival compared to systemic left ventricle morphology. We aimed...BACKGROUND: Among individuals with single ventricle (SV) congenital heart disease (CHD), systemic right ventricle morphology is associated with decreased survival compared to systemic left ventricle morphology. We aimed to determine the association of ventricular morphology with quality of life and medical, neurocognitive, socioeconomic outcomes and compare these between SV CHD patients and siblings. METHODS: We performed a cross-sectional cohort study using data from CHD PULSE (Congenital Heart Disease Project to Understand Lifelong Survivor Experience), a survey conducted from 2021-2023 among adults with CHD interventions and siblings across 11 US Pediatric Cardiac Care Consortium centers. Quality of life was assessed by PROMIS (Patient-Reported Outcomes Measurement Information System) surveys. RESULTS: We included 226 SV patients (146 left and 80 right ventricular) and 40 siblings. No outcome differences were found between left and right ventricular groups. Compared to siblings, SV patients reported more medical comorbidities (p<0.001), future health concerns (0.008), disability benefits (p<0.001), and work affected by health (p<0.001). Siblings had higher rates of college/graduate degrees (p=0.002) and employment (p=0.044). However, 95.6% of SV patients completed high school, 45.6% had college/graduate degrees, and 73.9% were employed. SV patients had lower PROMIS scores for global mental health and physical function but similar scores for global physical health, cognitive function, anxiety, depression, and ability to participate in social roles. CONCLUSIONS: Ventricular morphology was not associated with differences in long-term outcomes. Adults with SV CHD have medical, neurocognitive, and socioeconomic differences compared to siblings, but similar PROMIS scores compared to the general population.
The REvascularization CHoices Among Under-Represented Groups Evaluation (RECHARGE) program is enrolling 1200 women, Black, and Hispanic patients in two parallel randomized trials of percutaneous coronary intervention (PC...The REvascularization CHoices Among Under-Represented Groups Evaluation (RECHARGE) program is enrolling 1200 women, Black, and Hispanic patients in two parallel randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). Funded by a phased Patient-Centered Outcomes Research Institute award, the pilot phase was designed to assess the feasibility of enrolling groups historically under-represented and challenging to enroll in prior revascularization trials, evaluate willingness of patients to accept randomization, refine patient and stakeholder engagement, and scale site infrastructure and data collection across diverse centers. We report key insights from the pilot phase. Physician and patient treatment preferences, often shaped by prior experience and evidence not directly applicable to these cohorts, were the main reasons eligible patients were not randomized. Many sites also lacked consistent multidisciplinary Heart Team processes for coronary disease, requiring new workflows to establish equipoise between PCI and CABG. Successful recruitment required intentional trust-building and tailored patient-facing materials, while engagement of non-academic centers demanded added financial, educational, and start-up support. During the 2-year pilot phase, 91 U.S. and 17 Canadian sites were selected, and 65 were activated. Median activation time was 10.8 months (IQR 9.1-13.6). The pilot enrollment goal of 60 participants was exceeded, with 141 patients randomized within 13 months at a mean rate of 0.27 patients/site/month, prompting expansion to up to 150 sites for the full program. The lessons learned from the pilot phase of the RECHARGE program can inform the design and implementation of future randomized trials seeking to enroll traditionally under-represented populations.
de Barros E Silva PGM, Damiani L, Arantes PE
… +24 more, Ianof JN, Yoshida LAF, Barbosa LM, Gomez JE, Bahit MC, Padilla FG, Dall'Orto FTC, de Los Ríos Ibarra MO, Antunes M, Sánchez AO, Cartasegna L, Tramujas L, Dos Reis Saraiva Falcão SN, Hominal M, Gamba MAA, de Lima CEB, Venancio AC, Montenegro E, Muntaner JA, Almagro SM, Troiani do Nascimento C, Carneiro RM, Montaña OR, Lopes RD
The LACROSS study followed 2,012 patients with atrial fibrillation in Latin America and found that nearly 30% were not receiving oral anticoagulation. Clinical outcomes included notable rates of death, stroke, hospitaliz...The LACROSS study followed 2,012 patients with atrial fibrillation in Latin America and found that nearly 30% were not receiving oral anticoagulation. Clinical outcomes included notable rates of death, stroke, hospitalization, and bleeding, with higher risk linked to age, diabetes, and renal disease. These findings highlight persistent gaps in anticoagulation use and the need to improve care in the region.
BACKGROUND: Although more than 90% of adults with repaired coarctation of aorta (COA) have preserved left ventricular ejection fraction (LVEF), heart failure (HF) and cardiovascular mortality are relatively common in thi...BACKGROUND: Although more than 90% of adults with repaired coarctation of aorta (COA) have preserved left ventricular ejection fraction (LVEF), heart failure (HF) and cardiovascular mortality are relatively common in this population. The purpose of this study was to assess the relationship between LV contractility and clinical outcomes in adults with repaired COA and preserved LVEF. METHOD: Retrospective cohort study of adults with repaired COA and preserved LVEF (LVEF ≥50%) (2003-2024). LV contractility index (LVCi) was assessed as the ratio of brachial systolic blood pressure and LV end-systolic volume index. Based on LVEF and LVCi obtained from the baseline echocardiogram, patients were dichotomized using the median value of LVEF (LVEF_ versus LVEF_) and LVCi (LVCi_ versus LVCi_). Study outcomes were peak VO, NT-proBNP, and all-cause mortality. RESULTS: Of 821 patients, median LVEF was 63% (56,70), and median LVCi was 5.8 (4.8,7.1) mmHg/ml/m. Compared to LVCi_ group, the LVCi_ group had lower predicted peak VO, higher NT-proBNP levels and higher incidence of mortality. In contrast, there was no difference in peak VO, NT-proBNP levels, and mortality between the LVEF_ versus LVEF_ groups. LVCi was independently associated with all-cause mortality and had superior prognostic performance compared to LVEF and LV global longitudinal strain. CONCLUSIONS: Further studies are required to determine the optimal cutoff point of LVCi that defines reduced LV contractility, and whether patients with reduced LV contractility (in the setting of preserved LVEF) would benefit from medical therapy considering the higher risk of mortality in this subgroup of patients.
BACKGROUND: Among individuals with ST-segment elevation myocardial infarction (STEMI), a single subcutaneous injection of the short-acting glycoprotein IIb/IIIa receptor blocker antagonist zalunfiban at first medical con...BACKGROUND: Among individuals with ST-segment elevation myocardial infarction (STEMI), a single subcutaneous injection of the short-acting glycoprotein IIb/IIIa receptor blocker antagonist zalunfiban at first medical contact significantly improved the primary outcome including clinical endpoints. The impact of zalunfiban on MI size and association with downstream outcomes remains unclear. METHODS: In a prespecified analysis, we studied results among study participants treated with two doses of zalunfiban who had core laboratory measurements concentrations of hs-cTnT. RESULTS: More elevated hs-cTnT concentrations at presentation were associated with less resolution of ST deviation (P =0.006) and more frequent Q wave development (P <0.001). At coronary angiography more elevated hs-cTnT at presentation was associated with higher thrombus grade and worse epicardial and myocardial perfusion (all P <0.05). In multivariable analyses, higher hs-cTnT concentrations at 24 hours were associated with greater adjusted risk for all-cause death (odds ratio [OR] 1.83 per log unit increase; P=0.03), cardiovascular death (OR 1.83 per log unit increase; P=0.03), heart failure (OR 2.74 per log unit increase; P <0.001) or the composite of death and heart failure (P<0.001) by 30 days. At 24 hours, those treated with zalunfiban had lower hs-cTnT compared to placebo (P =0.04) and across multiples ≥10 to ≥1000 times elevation, treatment with zalunfiban resulted in smaller hs-cTnT determined MI size. CONCLUSION: Among patients with STEMI, more elevated concentrations of hs-cTnT are associated with worse measures of reperfusion and higher risk for short-term death or heart failure. A single dose of zalunfiban at first medical contact reduced MI size. STUDY REGISTRATION: A Phase 3 Study of Zalunfiban in Subjects With ST-elevation MI (CELEBRATE); NCT04825743.
BACKGROUND: Residual congestion (RC) at discharge is associated with poor outcomes in acute heart failure, yet actionable decongestion targets beyond the first 48 hours are poorly defined. Our objective is to integrate d...BACKGROUND: Residual congestion (RC) at discharge is associated with poor outcomes in acute heart failure, yet actionable decongestion targets beyond the first 48 hours are poorly defined. Our objective is to integrate diuretic resistance (DR) with RC at 72 hours to profile risk and guide decongestion. METHODS: Post hoc pooled analysis of DOSE-AHF and ROSE-AHF with serial congestion assessment and NT-proBNP at baseline and 72 hours. RC was defined using clinical (Orthodema Score [OES]), biomarker-based (NT-proBNP reduction ≤30% and absolute levels), and combined criteria (OES>0 with ≤30% reduction). DR was defined as BAN-ADHF >12. Four 72-hour profiles were prespecified: RC-/low DR, RC-/high DR, RC+/low DR, and RC+/high DR. The primary outcome was a 90-day composite of death, rehospitalization, or Emergency Department visit. RESULTS: Among 636 patients (median age 69 [IQR: 60-79] years; 73% male), the primary outcome occurred in 36% over a median follow-up of 56 (34-62) days. Congestion was common at admission (OES>0 in 93%) but decreased to 57% at 72 hours, whereas DR remained stable. OES alone showed limited risk discrimination (OES>0: HR 1.19, 95% CI 0.90-1.59), whereas NT-proBNP-based definitions identified higher-risk patients (≤30% reduction associated with a 1.7-fold higher risk). Using RC-/low DR as reference, risk increased stepwise: RC+/low DR (1.5-fold), RC-/high DR (1.8-fold), and RC+/high DR (1.9-fold higher risk). CONCLUSIONS: Integrating DR with RC at 72 hours identified four clinical profiles associated with 90-day risk. In the absence of a universally accepted decongestion target, these findings may help contextualize early treatment response and should be prospectively validated before guiding therapy. CONDENSED ABSTRACT: Residual congestion (RC) in acute heart failure (AHF) is linked to poor outcomes, yet optimal decongestion targets beyond 48 hours remain unclear. In a post-hoc pooled analysis of DOSE-AHF and ROSE-AHF (n=636), we evaluated 72-hour RC using clinical (Orthodema Score [OES]), biomarker-based (NT-proBNP reduction ≤30% and absolute levels), and combined definitions (OES>0 with ≤30% reduction), alongside diuretic resistance (DR; BAN-ADHF >12). The primary outcome (90-day death, rehospitalization, or ED visit) occurred in 34%. Clinical congestion alone showed limited discrimination (OES>0: HR 1.19), whereas NT-proBNP-based definitions identified higher risk (≤30% reduction: 1.7-fold higher risk). Compared with RC-/low DR, risk increased stepwise across profiles: RC+/low DR (1.5-fold), RC-/high DR (1.8-fold), and RC+/high DR (1.9-fold). Integrating DR with RC at 72 hours identifies actionable profiles that improve risk stratification and may guide decongestion.
Sheashaa H, Farina JM, Awad K
… +15 more, Abbas MT, Pereyra M, Scalia IG, Abdelfattah F, Ahmed S, Razaghi M, Hafez A, Ibrahim R, Lester SJ, Alsidawi S, Fohtung B, Mital R, Sell-Dottin K, Ayoub C, Arsanjani R
BACKGROUND: Data on clinical outcomes in patients with discordant high-gradient aortic stenosis (DHG-AS), defined by elevated gradients despite an aortic valve area (AVA) > 1 cm², remain conflicting. Limited information...BACKGROUND: Data on clinical outcomes in patients with discordant high-gradient aortic stenosis (DHG-AS), defined by elevated gradients despite an aortic valve area (AVA) > 1 cm², remain conflicting. Limited information exists regarding the impact of aortic valve replacement (AVR) in DHG-AS. METHODS: We analyzed patients with high-gradient aortic stenosis (mean gradient ≥ 40 mm Hg), categorized as concordant (AVA indexed to body surface area [AVAi] ≤ 0.6 cm²/m²) or discordant (AVAi > 0.6 cm²/m²). Propensity score matching (PSM) (1:1) adjusted for demographics and comorbidities. Kaplan-Meier curves and Cox proportional hazards models compared mortality and AVR rates between concordant high-gradient aortic stenosis (CHG-AS) and DHG-AS. For AVR, competing-risk methods used death as a competing event. In a subgroup of DHG-AS patients after PSM, Cox regression with AVR as a time-dependent covariate evaluated its association with mortality. RESULTS: A total of 14,640 patients were included (13,678 CHG-AS; 962 DHG-AS). After PSM, 958 patients were in each group. DHG-AS had lower AVR rates (subdistribution HR [SHR] 0.56; 95% CI 0.50-0.63; Gray P < .001). Ten-year mortality was higher in DHG-AS in univariable analysis (HR 1.24; 95% CI 1.07-1.44; P = .005), but not after adjusting for AVR (HR 1.07; 95% CI 0.92-1.25). In DHG-AS patients after PSM (n = 360 per group), AVR reduced 10-year mortality (HR 0.538; 95% CI 0.418-0.692). CONCLUSIONS: After accounting for AVR, survival did not differ significantly between DHG-AS and CHG-AS. AVR was associated with improved survival in DHG-AS, supporting timely intervention.
Villaschi A, Pini D, Stolfo D
… +22 more, Baldetti L, Lombardi CM, Adamo M, Loiacono F, Mazzoni A, Facchetti G, Tomasoni D, Inciardi RM, Maccallini M, Gasparini G, Contessi S, Cocianni D, Perotto M, Barone G, Cappelletti AM, Condorelli G, Merlo M, Scandroglio AM, Sinagra G, Metra M, Pagnesi M, Chiarito M
BACKGROUND: Cardiovascular, kidney, and metabolic (CKM) conditions frequently coexist in patients with heart failure (HF), potentially compounding their risk. However, their prevalence and prognostic impact in patients w...BACKGROUND: Cardiovascular, kidney, and metabolic (CKM) conditions frequently coexist in patients with heart failure (HF), potentially compounding their risk. However, their prevalence and prognostic impact in patients with severe HF remain underexplored. OBJECTIVES: To evaluate the impact of CKM overlap in patients with severe HF. METHODS: We analysed data from 1,149 patients enrolled in the multicenter HELP-HF registry, which includes individuals with severe HF identified by the "I NEED HELP" markers. CKM conditions were assessed across 3 domains: atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD) (eGFR < 60 mL/min/1.73 m²), and metabolic disorders (obesity or type 2 diabetes). Patients were grouped by number of CKM conditions (0-3). The primary endpoint was a composite of 1-year all-cause death or HF hospitalization. Secondary endpoints included all-cause death, cardiovascular death, and first HF hospitalization. RESULTS: CKM conditions were highly prevalent: 85.5% of patients had at least 1 condition, and 22.3% had all 3 conditions. ASCVD was the most common (58.7%), followed by CKD (56.5%) and metabolic disorders (48.9%). An increasing number of CKM conditions was associated with worse outcomes, even after multivariable adjustment. The risk of the primary endpoint increased progressively with each additional CKM condition (1: HR 1.92, 95% CI, 1.33-2.78; 2: HR 2.11, 95% CI, 1.47-3.02; 3: HR 2.52, 95% CI, 1.74-3.65; all P < .001 vs 0 conditions). Similar trends were observed for mortality and HF hospitalization alone. CONCLUSIONS: CKM overlap is highly prevalent among patients with severe HF and is independently associated with worse clinical outcomes. These findings underscore the importance of CKM profiling in HF risk stratification.
BACKGROUND: Patient-reported outcome measures (PROM) are used routinely in adult heart failure (HF) practice but not in pediatric (PHF) practice. Adult PROMs are often not applicable to pediatrics whose manifestations an...BACKGROUND: Patient-reported outcome measures (PROM) are used routinely in adult heart failure (HF) practice but not in pediatric (PHF) practice. Adult PROMs are often not applicable to pediatrics whose manifestations and experience of living with HF differ from adults. We sought to understand the experience of adolescents living with HF to facilitate development of a PROM for PHF. METHODS AND RESULTS: Between 2019 and 2020, patients aged 12-21 years with recent HF and their caregivers were recruited at two children's hospitals for qualitative interviews or focus groups about their HF symptoms, physical functioning, and quality of life. Transcripts were analyzed using methods of directed content analysis. Twenty-one patients and 12 caregivers participated. Primary themes spanned 4 domains: (1) functional impairment (e.g., inability to participate in activities of daily living); (2) social impairment (e.g., feeling different or isolated from others); (3) emotional effects (e.g., anxiety, depression, frustration); (4) illness burden (e.g., taking multiple medications, time burden of clinic visits and procedures). CONCLUSION: The health and social experiences of adolescents with HF differ from adults with HF and warrant development of an adolescent-specific PROM. Such a PROM would be useful to clinicians managing adolescents with HF and to regulators evaluating emerging medical products.