Usefulness of P‐wave peak time as an electrocardiographic parameter in predicting left ventricular diastolic dysfunction in patients with mitral regurgitation

IntroductionConventional Doppler measurements have limitations in predicting left ventricular diastolic dysfunction (LVDD) in patients with mitral regurgitation (MR). Recently, electrocardiographic P‐wave peak time (PWPT) has been proposed as a parameter of detecting LVDD. This study aimed to evaluate the association between PWPT and left ventricular end‐diastolic pressure (LVEDP) in patients with MR.MethodsWe performed echocardiography and cardiac catheterization in 82 patients with moderate or severe MR. We classified patients into two groups: low LVEDP group (L‐LVEDP) (LVEDP <16 mmHg, n = 40) and high LVEDP group (H‐LVEDP) (LVEDP ≥16 mmHg, n = 42). We evaluated LVDD and PWPT based on echocardiographic and electrocardiographic findings in both groups.ResultsThe PWPT in lead II (PWPT_II) was significantly longer in patients in the H‐LVEDP group than in those in the L‐LVEDP group (67 vs. 47 ms, p < .001). Using correlation analysis, LVEDP was positively correlated with PWPT_II (r = .577, p < .001). Using multivariate analysis, PWPT_II was found to be an independent predictor of increased LVEDP (95% CI: 0.1030–0.110; p < .001). Using receiver operating characteristic (ROC) curve analysis, the optimal cutoff value of PWPT_II for predicting elevated LVEDP was 58.9 ms, with a sensitivity of 80.0% and a specificity of 73.8% (area under curve: 0.809, 95% CI: 0.713–0.905).ConclusionTo the best of our knowledge, this is the first study to assess the effect of a significant valvular disease on PWPT in lead II. These findings suggest that prolonged PWPT_II may be an independent predictor of increased LVEDP in patients with moderate or severe MR.     

The effects of aerobic exercise combined with resistance training on inflammatory factors and heart rate variability in middle‐aged and elderly women with type 2 diabetes mellitus

ObjectiveThis study investigated the effects of aerobic exercise combined with resistance training on serum inflammatory factors and heart rate variability (HRV) in women with type 2 diabetes mellitus (T2DM).MethodsA total of 30 patients with diabetic cardiovascular autonomic neuropathy (DCAN) were randomly divided into a control group (n = 15) and an exercise group (n = 15). The control group was treated with routine hypoglycemic drugs, while the exercise group was treated with routine hypoglycemic drugs + resistance training (AE + RT). The levels of fasting plasma glucose (FBG), two‐hour plasma glucose (2hPG), serum inflammatory factors C‐reactive protein (CRP), interleukin‐6 (IL‐6) and tumor necrosis factor alpha (TNF‐α) were measured before and after the intervention. The HRV was evaluated by 24‐h ambulatory electrocardiogram.ResultsAfter the intervention, the levels of FBG, 2hPG, serum inflammatory factors, IL‐6 and TNF‐α in the exercise group were significantly lower than those in the control group (p < .05) with no significant differences in serum CRP (p > .05). After the intervention, the HRV time domain and frequency domain indexes in the two groups were significantly improved compared with those before the exercise experiment (p < .01) and with no significant difference in (lnlf) (p > .05). The time‐domain indexes, i.e., SDNN and RMSSD, as well as the frequency domain index, i.e., (lnhf), were significantly higher in the exercise group than in the control group, whereas lnlf/lnhf were significantly lower than those in the control group (p < .05).ConclusionsCompared with routine hypoglycemic drug therapy, combining aerobic exercise and resistance training helped to reduce the level of blood glucose and serum inflammatory factors in T2DM patients with DCAN, and improved autonomic nerve function.     

Longitudinal association between cognitive depressive symptoms and D‐dimer levels in patients following acute myocardial infarction

BackgroundA prothrombotic tendency could partially explain the poor prognosis of patients with coronary heart disease and depression. We hypothesized that cognitive depressive symptoms are positively associated with the coagulation activation marker D‐dimer throughout the first year after myocardial infarction (MI).MethodsPatients with acute MI (mean age 60 years, 85% men) were investigated at hospital admission (n = 190), 3 months (n = 154) and 12 months (n = 106). Random linear mixed regression models were used to evaluate the relation between cognitive depressive symptoms, assessed with the Beck depression inventory (BDI), and changes in plasma D‐dimer levels. Demographics, cardiac disease severity, medical comorbidity, depression history, medication, health behaviors, and stress hormones were considered for analyses.ResultsThe prevalence of clinical depressive symptoms (13‐item BDI score ≥ 6) was 13.2% at admission and stable across time. Both continuous (p < .05) and categorical (p < .010) cognitive depressive symptoms were related to higher D‐dimer levels over time, independent of covariates. Indicating clinical relevance, D‐dimer was 73 ng/ml higher in patients with a BDI score ≥ 6 versus those with a score < 6. There was a cognitive depressive symptom‐by‐cortisol interaction (p < .05) with a positive association between cognitive depressive symptoms and D‐dimer when cortisol levels were high (p < .010), but not when cortisol levels were low (p > .05). Fluctuations (up and down) of cognitive depressive symptoms and D‐dimer from one investigation to the next showed also significant associations (p < .05).ConclusionsCognitive depressive symptoms were independently associated with hypercoagulability in patients up to 1 year after MI. Hypothalamic–pituitary–adrenal axis could potentially modify this effect.     

Tuberculin skin test and interferon‐γ release assays: Can they agree?

IntroductionThe diagnosis of latent tuberculosis infection (LTBI) relies largely on the tuberculin skin test (TST) or, more recently, on interferon‐gamma release assays (IGRA). Knowledge regarding these tests is essential to improve their usefulness in combating the tuberculosis epidemic.ObjectivesTo characterize the agreement between the IGRA and TST tests by determining the kappa coefficient (K) and agreement rate between these two tests in patients with active tuberculosis (TB).MethodsRetrospective cohort study conducted with data from active TB patients notified in the Portuguese Tuberculosis Surveillance System (SVIG‐TB), from 2008 to 2015. TST results were interpreted using a 5 mm (TST‐5 mm) and 10 mm (TST‐10 mm) cutoff. Kappa coefficient and agreement rate were calculated in order to evaluate the agreement between IGRA and TST (both cutoffs) test results.ResultsA total of 727 patients with results for both tests were included in the study, of which 3.4% (n = 25) had HIV infection, 5.6% (n = 41) diabetes, 5.0% (n = 36) oncological diseases and 4.4% (n = 32) inflammatory diseases.Of the 727 patients, 16.5% (n = 120) presented different outcomes between IGRA and TST‐5 mm, and 20.5% (n = 149) presented different outcomes between IGRA and TST‐10 mm. Kappa coefficient between IGRA and TST‐5 mm was 0.402 (p < 0.001) with an agreement rate of 83.5%. Between IGRA and TST‐10 mm, the kappa coefficient was 0.351 (p < 0.001), with an agreement rate of 79.5%. Patients with HIV infection, diabetes, oncologic diseases and inflammatory diseases presented a substantial agreement between IGRA and TST‐5 mm, while inflammatory diseases was the only variable that presented a substantial agreement between IGRA and TST‐10 mm.ConclusionAs both tests can present false‐negative results, the low level of agreement between the tests can potentially help identify more cases of LTBI if the two tests are used in parallel, with infections not detected by IGRA possibly being detected by the TST and vice versa.     

Assessment of left ventricular myocardial work done by noninvasive pressure–strain loop technique in patients with essential hypertension

ObjectiveTo investigate the value of the noninvasive pressure–strain loop (PSL) technique for assessing left ventricular myocardial work done in patients with essential hypertension.MethodsProspectively, 60 patients with hypertension visiting the hospital from August 2020 to July 2021 were collected and divided into the mild hypertension group (SBP 140–159 mmHg, 35 cases) and the moderate‐to‐severe hypertension group (SBP ≥160 mmHg, 25 cases). Another 40 cases of healthy adults were collected as the control group. The differences in the global long‐axis strain (GLS) and peak strain dispersion (PSD) of the left ventricle, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were compared among the three groups. The receiver operating characteristic curve was used to evaluate the PSD, GWI, GCW, and GWW. The myocardial work index (MWI) and MWI percentages in the apical, middle, and basal segments of the heart were also compared among the groups.Results(1) The PSD, GWI, GCW, and GWW were significantly different among the groups (Χ ² = 57.605, 79.203, 76.973, and 17.429, respectively, p < .05), while the GLS and GWE were not (Χ ² = 1.559 and 5.849, respectively, p > .05). (2) The GWI had the highest specificity (97.5%) and the GCW the highest sensitivity (95%) in predicting hypertension. The percentage of apical MWI gradually increased (F = 11.230, p < .05) and the percentage of basal MWI gradually decreased (F = 10.665, p < .05) from the control group to the mild hypertension group to the moderate‐to‐severe hypertension group; there was no significant difference in the percentage of mid‐MWI (F = 0.593, p > .05).ConclusionsThe noninvasive PSL technique could be used to assess myocardial work done in patients with essential hypertension.     

Outcome of alcohol septal ablation in mildly symptomatic patients with hypertrophic obstructive cardiomyopathy: A comparison with medical therapy

ObjectiveThe aim of this study was primarily to determine efficacy after alcohol septal ablation (ASA) in mildly symptomatic patients (NYHA class II) with hypertrophic obstructive cardiomyopathy (HOCM), as compared to medical therapy.MethodsThis retrospective study included 163 mildly symptomatic patients with HOCM evaluated in Beijing Anzhen Hospital between March 2001 and August 2019, consisting of the medical group (n = 105) and the ASA group (n = 58). All‐cause mortality and HCM‐related death were mainly observed.ResultsFollow‐up was completed in 161 patients and the median follow‐up was 6.0 years. Compared to medically treated patients, patients post‐ASA had comparable survival free of all‐cause mortality (98.3% and 95.1% vs. 93.0% and 83.1% at 5 and 10 years, respectively; p = 0.374). Survival free of HCM‐related death was also similar between ASA and medical groups (98.3% and 95.1% vs. 94.3% and 86.2% at 5 and 10 years, respectively; p = 0.608). However, compared to medical therapy, ASA had advantages on the improvement of NYHA class (1.4 ± 0.6 vs. 2.1 ± 0.5, p = .000) and lower occurrence of new‐onset atrial fibrillation (AF) (7.8% vs. 20.4%, p = .048). Multivariate analysis demonstrated that resting LVOT gradient at the last clinical check‐up was an independent predictor of all‐cause mortality (HR = 1.021, 95%CI 1.002–1.040, p = .027).ConclusionThis registry suggests that mildly symptomatic patients with HOCM treated with ASA have comparable survival to that of medically treated patients, with the improvement of NYHA class and lower occurrence of new‐onset AF. All‐cause mortality is independently associated with resting LVOT gradient at the last clinical check‐up.     

Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation

IntroductionThere are no consistently confirmed predictors of atrial fibrillation (AF) recurrence after catheter ablation. Therefore, we aimed to study whether left atrial appendage volume (LAAV) and function influence the long‐term recurrence of AF after catheter ablation, depending on AF type.MethodsAF patients who underwent point‐by‐point radiofrequency catheter ablation after cardiac computed tomography (CT) were included in this analysis. LAAV and LAA orifice area were measured by CT. Uni‐ and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence.ResultsIn total, 561 AF patients (61.9 ± 10.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence‐free time of 22.7 (9.3–43.1) months. Patients with persistent AF had significantly higher body surface area‐indexed LAV, LAAV, and LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment left ventricular ejection fraction (LVEF) <50% (HR = 2.17; 95% CI = 1.38–3.43; p < .001) and LAAV (HR = 1.06; 95% CI = 1.01–1.12; p = .029) were independently associated with AF recurrence in persistent AF, while no independent predictors could be identified in paroxysmal AF.ConclusionThe current study demonstrates that beyond left ventricular systolic dysfunction, LAA enlargement is associated with higher rate of AF recurrence after catheter ablation in persistent AF, but not in patients with paroxysmal AF.     

Predictors and 3‐year outcomes of compromised left circumflex coronary artery after left main crossover stenting

BackgroundThere are few predictors of decreased fractional flow reserve (FFR) in the left circumflex coronary artery (LCx) after left main (LM) crossover stenting.ObjectivesWe aimed to determine the predictors for low FFR at LCx and possible treatment strategies for compromised LCx, together with their long‐term outcomes.MethodsAltogether, 563 patients who met the inclusion criteria were admitted to our hospital from February 2015 to November 2020 with significant distal LM bifurcation lesions. They underwent single‐stent crossover percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS) guidance with further LCx intervention based on the measured FFR.ResultsThe patients showed significant angiographic LCx ostial affection post‐LM stenting, but only 116 (20.6%) patients had FFR < 0.8. The three‐year composite major adverse cardiac events (MACE) rates were comparable between the high and low FFR groups (16.8% vs. 15.5; p = 0.744). In a multivariate analysis, low FFR at the LCx was associated with post‐stenting minimal luminal area (MLA) of LCx (odds ratio [OR]: 0.032, p < .001), post‐stenting LCx plaque burden (OR: 1.166, p < .001), poststenting LM MLA (OR: 0.821, p = .038), and prestenting LCx MLA (OR: 0.371, p = .044). In the low FFR group, those with compromised LCx managed with drug‐eluting balloon had the lowest three‐year MACE rate (8.1%), as compared to either those undergoing kissing balloon inflation (KBI) (17.5%) or stenting (20.5%) (p = 0.299).ConclusionUnnecessary LCx interventions can be avoided with FFR‐guided LCx intervention. Poststenting MLA and plaque burden of the LCx, and main vessel stent length are poststenting predictors of low FFR.     

Impact of chronic kidney disease on clinical outcomes in patients with Stage B progressive aortic regurgitation (mild to moderate and moderate grades)

BackgroundChronic kidney disease (CKD) is a significant comorbidity in patients with heart failure and valvular heart disease. Renal impairment is not well evaluated in the patients with Stage B progressive aortic regurgitation (AR) (mild to moderate and moderate grades in this study), for estimating outcome.HypothesisWe sought to investigate the prognostic factor, especially CKD, in the patients with progressive AR.MethodsWe enrolled 262 patients with Stage B progressive AR and preserved left ventricular systolic function (ejection fraction ≥ 50%). Based on the presence of CKD, the patients were divided into CKD (n = 70) and non‐CKD (n = 192) groups, which CKD was defined as estimated glomerular filtration rate < 60 ml/min/1.73 m². The primary outcome was major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, hospitalization for heart failure, and aortic valve replacement.ResultsThe median follow‐up duration was 41.5 (interquartile range: 16.2–71.7) months. Between groups, the CKD patients were older; they had a higher pulse pressure and higher incidence of hypertension, diabetes mellitus, dyslipidemia, cerebrovascular accident, and atrial fibrillation. Compared to the non‐CKD group, the CKD group had lower eʹ velocity (4.36 ± 2.21 vs. 5.20 ± 2.30 cm/s, p = .009), higher right ventricular systolic pressure (38.02 ± 15.79 vs. 33.86 ± 11.77 mmHg, p = .047). The CKD group was associated with increased risk of MACEs (41.4% vs. 22.4%; unadjusted hazard ratio [HR]: 1.78, 95% confidence interval [CI]: 1.11–2.85, p = .017). In multivariate Cox regression analyses, the risk of MACEs was significantly different between groups (adjusted HR: 1.71, 95% CI: 1.11–2.62, p = .015); furthermore, the risk of hospitalization for heart failure (10.0% vs. 2.6%; adjusted HR: 2.30, 95% CI: 1.16–4.55, p = .017) was significantly higher in the CKD group than in the non‐CKD group.ConclusionsIn patients with Stage B progressive AR, CKD is an independent prognostic factor for clinical outcomes (composite clinical outcome, hospitalization for heart failure).     

Comparison of prognosis and outcomes of catheter ablation versus drug therapy in patients with atrial fibrillation and stable coronary artery disease: A prospective propensity‐score matched cohort study

BackgroundAtrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist.HypothesisTo investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD.MethodsIn total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all‐cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence.ResultsOver a median follow‐up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence‐free rate (53.50% vs. 18.41%, p < .01). In multivariate analysis, there was no significant difference between the strategy of catheter ablation and drug therapy in primary composite end point (adjusted HR 074, 95%CI 0.54–1.002, p = .0519). However, catheter ablation was associated with fewer all‐cause death independently (adjusted HR 0.36, 95%CI 0.22–0.59, p < .01). In subgroup analysis, catheter ablation was an independent risk factor for all‐cause death in the high‐stroke risk group (adjusted HR 0.39, 95%CI 0.23–0.64, p < .01), not in the low‐medium risk group (adjusted HR 0.17, 95%CI 0.01–2.04, p = .17).ConclusionsIn the patients with AF and SCAD, catheter ablation was not independently associated with the primary composite endpoint compared with drug therapy. However, catheter ablation was an independent protective factor of all‐cause death     

Long‐term safety and efficacy of left atrial appendage closure in patients with small appendage orifices measured with transesophageal echocardiography

BackgroundThe Watchman device is the most widely used occluder but is indicated in atrial fibrillation (AF) patients with a maximal left atrial appendage (LAA) orifice diameter between 17 and 31 mm. We aimed to compare the long‐term safety and efficacy of left atrial appendage closure (LAAC) between patients with a small LAA (<17 mm) and those with an indicated LAA (17–31 mm) measured by transesophageal echocardiography (TEE).MethodsA total of 369 AF patients treated with LAAC between March 2015 and February 2019 were included and divided into two groups based on the maximal LAA orifice diameter measured by TEE: small LAA group (n = 22) and indicated LAA group (n = 347). Periprocedural complications and long‐term clinical outcomes were compared.ResultsThe Watchman device was successfully implanted in all patients. Mean device compression was higher in the small LAA group. Four patients (1.2%) in the indicated LAA group experienced pericardial effusion, and none experienced pericardial effusion in the small LAA group. Device‐related thrombus was detected in one (4.5%) patient in the small LAA group and five (1.4%) in the indicated LAA group (p = .310). After a mean follow‐up period of 4.1 ± 1.6 years, one patient in the small LAA group (4.5%; 1.1/100 person‐years) and four in the indicated LAA group (1.2%; 0.3/100 person‐years) suffered an ischemic stroke (p = .266).ConclusionsThe safety and efficacy of LAAC with the Watchman device were comparable between patients with small and indicated LAA orifice diameters measured by TEE.     

Distinguishing exercise intolerance in early‐stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E/VCO2 and ETCO2 identify pulmonary vascular disease

BackgroundAmong subjects with exercise intolerance and suspected early‐stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management.HypothesisRest gas exchange parameters (minute ventilation to carbon dioxide production ratio: V _E/VCO₂ and end‐tidal carbon dioxide: ETCO₂) can identify PVD in early‐stage PH.MethodsWe conducted a retrospective review of 55 subjects with early‐stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant.ResultsThe mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest V _E/VCO₂ and lower rest ETCO₂ (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5–0.6*). On receiver‐operating characteristic analysis to predict PVD (vs. non‐PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest V _E/VCO₂ = 0.70* and ETCO₂ = 0.73*. Based on this, optimal thresholds of rest V _E/VCO₂ > 40 mm Hg and rest ETCO₂ < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group.ConclusionsIn a broad cohort of subjects with suspected early‐stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (V _E/VCO₂ > 40 mm Hg and ETCO₂ < 30 mm Hg) identify PVD.     

The duration of beta‐blocker therapy and outcomes in patients without heart failure or left ventricular systolic dysfunction after acute myocardial infarction: A multicenter prospective cohort study

BackgroundThe duration of beta‐blocker therapy in patients without heart failure (HF) or left ventricular systolic dysfunction after acute myocardial infarction (AMI) is unclear.HypothesisContinuous beta‐blocker therapy is associated with an improved prognosis.MethodsThis is a prospective, multicenter, cohort study. One thousand four hundred and eighty‐three patients eventually met the inclusion criteria. The study groups included the continuous beta‐blocker therapy group (lasted ≥6 months) and the discontinuous beta‐blocker therapy group (consisting of the no‐beta‐blocker therapy group and the beta‐blocker therapy <6 months group). The inverse probability treatment weighting was used to control confounding factors. The study tried to learn the role of continuous beta‐blocker therapy on outcomes. The median duration of follow‐up was 13.0 months. The primary outcomes were cardiac death and major adverse cardiovascular events (MACE). The secondary outcomes were all‐cause death, stroke, unstable angina, rehospitalization for HF, and recurrent myocardial infarction (MI).ResultsCompared with discontinuous beta‐blocker therapy, continuous beta‐blocker therapy was associated with a reduced risk of unstable angina, recurrent MI, and MACE (hazard ratio [HR]: 0.51; 95% CI: 0.32–0.82; p = 0.006); but this association was not available for cardiac death (HR: 0.57; 95% CI: 0.24–1.36; p = 0.206). When compared to the subgroups of no‐beta‐blocker therapy and beta‐blocker therapy <6 months, respectively, continuous beta‐blocker therapy was still observed to be associated with a reduced risk of unstable angina, recurrent MI, and MACE.ConclusionsContinuous beta‐blocker therapy was associated with a reduced risk of unstable angina or recurrent MI or MACE in patients without HF or left ventricular systolic dysfunction after AMI.     

Prognostic value of the dynamic hepatorenal function on intermediate‐term mortality in TAVI patients with survival to discharge

BackgroundRenal and liver dysfunctions are risk factors for mortality in patients with severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has the potential to break the vicious cycle between AS and hepatorenal dysfunction by relieving aortic valve obstruction.HypothesisA part of patients can derive hepatorenal function improvement from TAVI, and this noncardiac benefit improves the intermediate‐term outcomes.MethodsWe developed this retrospective cohort study in 439 consecutive patients undergoing TAVI and described the dynamic hepatorenal function assessed by model for end‐stage liver disease model for end‐stage liver disease (MELD)‐XI score in subgroups. The endpoint was 2‐year all‐cause mortality.ResultsReceiver‐operating characteristic analysis showed that the baseline MELD‐XI score of 10.71 was the cutoff point. A high MELD‐XI score (>10.71) at baseline was an independent predictor of the 2‐year mortality hazard ratio (HR: 2.65 [1.29–5.47], p = .008). After TAVI, patients with irreversible high MELD‐XI scores had a higher risk of 2‐year mortality than patients who improved from high to low MELD‐XI scores (HR: 2.50 [1.06–5.91], p = .03). Factors associated with reversible MELD‐XI scores improvement were low baseline MELD‐XI scores (≤12.00, odds ratio [OR]: 2.02 [1.04–3.94], p = .04), high aortic valve peak velocity (≥5 m/s, OR: 2.17 [1.11–4.24], p = .02), and low body mass index (≤25 kg/m², OR: 2.73 [1.25–5.98], p = .01).ConclusionHigh MELD‐XI score at baseline is an independent predictor for 2‐year mortality. Patients with hepatorenal function improvement after TAVI have better outcomes. For patients with irreversible hepatorenal dysfunction after TAVI, further optimization of the subsequent treatment after TAVI is needed to improve the outcomes.     

Adherence with cardiovascular medications and the outcomes in patients with coronary arterial disease: “Real‐world” evidence

BackgroundCardiovascular medications are vital for the secondary prevention of coronary arterial disease (CAD). However, the effect of cardiovascular medication may depend on the optimal adherence of the patients. This meta‐analysis aims to determine the magnitude of adherence to vascular medications that influences the absolute and relative risks (RRs) of mortality in patients with CAD in real‐world settings.MethodsThe Cochrane Library, PubMed, and EMBASE databases were searched through March 1, 2022. Prospective studies reporting association as RR and 95% confidence interval between cardiovascular medication adherence and any cardiovascular events and/or all‐cause mortality in patients with CAD were included. A one‐stage robust error meta‐regression method was used to summarize the dose‐specific relationships.ResultsA total of 18 studies were included. There is a significant inverse linear association between cardiovascular medication adherence and cardiovascular events (p _nonlinearity = .68) or mortality (p _nonlinearity = .82). The exposure‐effect analysis showed that an improvement of 20% cardiovascular medication adherence was associated with 8% or 12% lower risk of any cardiovascular events or mortality, respectively. In subgroup analysis, the benefit was observed in adherence of stain (RR: 0.90, for cardiovascular events, RR: 0.85, for mortality), angiotensin‐converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB)(RR: 0.90, for mortality), and antiplatelet agent (RR: 0.89 for mortality) but not in beta‐blocker (RR: 0.90, p = .14, for cardiovascular events, RR: 0.97, p = .32 for mortality). Estimated absolute differences per 1 million individuals per year for mortality associated with 20% improvement were 175 cases for statin, 129 cases for antiplatelet, and 117 cases for ACEI/ARB.ConclusionEvidence from the real word showed poor adherence to vascular medications contributes to a considerable proportion of all cardiovascular disease events and mortality in patients with CAD.     

Comparison among random forest,logistic regression,and existing clinical risk scores for predicting outcomes in patients with atrial fibrillation: A report from the J‐RHYTHM registry

BackgroundMachine learning (ML) has emerged as a promising tool for risk stratification. However, few studies have applied ML to risk assessment of patients with atrial fibrillation (AF).HypothesisWe aimed to compare the performance of random forest (RF), logistic regression (LR), and conventional risk schemes in predicting the outcomes of AF.MethodsWe analyzed data from 7406 nonvalvular AF patients (median age 71 years, female 29.2%) enrolled in a nationwide AF registry (J‐RHYTHM Registry) and who were followed for 2 years. The endpoints were thromboembolisms, major bleeding, and all‐cause mortality. Models were generated from potential predictors using an RF model, stepwise LR model, and the thromboembolism (CHADS₂ and CHA₂DS₂‐VASc) and major bleeding (HAS‐BLED, ORBIT, and ATRIA) scores.ResultsFor thromboembolisms, the C‐statistic of the RF model was significantly higher than that of the LR model (0.66 vs. 0.59, p = .03) or CHA₂DS₂‐VASc score (0.61, p < .01). For major bleeding, the C‐statistic of RF was comparable to the LR (0.69 vs. 0.66, p = .07) and outperformed the HAS‐BLED (0.61, p < .01) and ATRIA (0.62, p < .01) but not the ORBIT (0.67, p = .07). The C‐statistic of RF for all‐cause mortality was comparable to the LR (0.78 vs. 0.79, p = .21). The calibration plot for the RF model was more aligned with the observed events for major bleeding and all‐cause mortality.ConclusionsThe RF model performed as well as or better than the LR model or existing clinical risk scores for predicting clinical outcomes of AF.     

Biatrial volume ratio predicts low voltage areas in atrial fibrillation

BackgroundLeft atrial volume (LAV) and low voltage areas (LVAs) are acknowledged markers for worse rhythm outcome after ablation of atrial fibrillation (AF). Some studies reported the importance of increased right atrial volume (RAV) as a predictor for arrhythmia recurrences in AF patients.ObjectiveTo investigate association between the LAV/RAV ratio and LVAs presence.MethodsPatients undergoing first AF ablation were included. LVAs were assessed peri‐procedurally using high‐density 3D maps and defined as <0.5 mV. All patients underwent pre‐procedural cardiovascular magnetic resonance imaging. LAV (biplane) and RAV (monoplane 4‐chamber) were assessed prior to ablation, and the LAV/RAV ratio was calculated.ResultsThe study population included 189 patients (age mean 63 ± 10 years, 33% women, 57% persistent AF, 22% LVAs). There were 149 (79%) patients with LAV > RAV. In univariable analysis LAV > RAV was associated with LVAs (OR 6.803, 95%CI 1.395–26.514, p = .016). The association remained robust in multivariable model after adjustment for persistent AF, CHA₂DS₂‐VASc score, and heart rate (OR 5.981, 95%CI 1.256–28.484, p = .025). Using receiver operator curve analysis, LAV > RAV (AUC 0.668, 95%CI 0.585–0.751, p = .001) was significant predictor for LVAs. In multivariable analysis, after adjustment for age, persistent AF, and renal function, RAV≥LAV was threefold higher in males (OR 3.040, 95%CI 1.050–8.802, p = .04).ConclusionsLAV > RAV is useful for the prediction of electro‐anatomical substrate in AF. LAV > RAV was associated with LVAs presence, while male sex remained associated with RAV≥LAV and less LVAs.     

Effect of early metoprolol before PCI in ST‐segment elevation myocardial infarction on infarct size and left ventricular ejection fraction. A systematic review and meta‐analysis of clinical trials

AimThis meta‐analysis aims to look at the impact of early intravenous Metoprolol in ST‐segment elevation myocardial infarction (STEMI) before percutaneous coronary intervention (PCI) on infarct size, as measured by cardio magnetic resonance (CMR) and left ventricular ejection fraction.MethodsWe searched the following databases: PubMed, Scopus, Cochrane library, and Web of Science. We included only randomized control trials that reported the use of early intravenous Metoprolol in STEMI before PCI on infarct size, as measured by CMR and left ventricular ejection fraction. RevMan software 5.4 was used for performing the analysis.ResultsFollowing a literature search, 340 publications were found. Finally, 18 studies were included for the systematic review, and 8 clinical trials were included in the meta‐analysis after the full‐text screening. At 6 months, the pooled effect revealed a statistically significant association between Metoprolol and increased left ventricular ejection fraction (LVEF) (%) compared to controls (mean difference [MD] = 3.57, [95% confidence interval [CI] = 2.22–4.92], p < .00001), as well as decreased infarcted myocardium(g) compared to controls (MD = −3.84, [95% [CI] = −5.75 to −1.93], p < .0001). At 1 week, the pooled effect revealed a statistically significant association between Metoprolol and increased LVEF (%) compared to controls (MD = 2.98, [95% CI = 1.26−4.69], p = .0007), as well as decreased infarcted myocardium(%) compared to controls (MD = −3.21, [95% CI = −5.24 to −1.18], p = .002).ConclusionA significant decrease in myocardial infarction and increase in LVEF (%) was linked to receiving Metoprolol at 1 week and 6‐month follow‐up.     

Proenkephalin and the risk of new‐onset heart failure: data from prevention of renal and vascular end‐stage disease

BackgroundEnkephalins of the opioid system exert several cardiorenal effects. Proenkephalin (PENK), a stable surrogate, is associated with heart failure (HF) development after myocardial infarction and worse cardiorenal function and prognosis in patients with HF. The association between plasma PENK concentrations and new‐onset HF in the general population remains to be established.HypothesisWe hypothesized that plasma PENK concentrations are associated with new‐onset HF in the general population.MethodsWe included 6677 participants from the prevention of renal and vascular end‐stage disease study and investigated determinants of PENK concentrations and their association with new‐onset HF (both reduced [HFrEF] and preserved ejection fraction [HFpEF]).ResultsMedian PENK concentrations were 52.7 (45.1–61.9) pmol/L. Higher PENK concentrations were associated with poorer renal function and higher NT‐proBNP concentrations. The main determinants of higher PENK concentrations were lower estimated glomerular filtration rate (eGFR), lower urinary creatinine excretion, and lower body mass index (all p < .001). After a median 8.3 (7.8–8.8) years follow‐up, 221 participants developed HF; 127 HFrEF and 94 HFpEF. PENK concentrations were higher in subjects who developed HF compared with those who did not, 56.2 (45.2–67.6) versus 52.7 (45.1–61.6) pmol/L, respectively (p = .003). In competing‐risk analyses, higher PENK concentrations were associated with higher risk of new‐onset HF (hazard ratio [HR] = 2.09[1.47–2.97], p < .001), including both HFrEF (HR = 2.31[1.48–3.61], p < .001) and HFpEF (HR = 1.74[1.02–2.96], p = .042). These associations were, however, lost after adjustment for eGFR.ConclusionsIn the general population, higher PENK concentrations were associated with lower eGFR and higher NT‐proBNP concentrations. Higher PENK concentrations were not independently associated with new‐onset HFrEF and HFpEF and mainly confounded by eGFR.     

Continuous multi‐day tracking of post‐myocardial infarction recovery of cardiac electrical stability and autonomic tone using electrocardiogram patch monitors

BackgroundSudden cardiac death (SCD) risk is elevated following acute myocardial infarction (MI). The time course of SCD susceptibility post‐MI requires further investigation.MethodsIn this observational cohort study, we employed state‐of‐the‐art noninvasive ECG techniques to track the daily time course of cardiac electrical instability and autonomic function following ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI). Preventice BodyGuardian MINI‐EL Holters continuously recorded ECGs for 7 days at hospital discharge and at 40 days for STEMI (N = 5) or at 90 days for NSTEMI patients (N = 5). Cardiac electrical instability was assessed by T‐wave alternans (TWA) and T‐wave heterogeneity (TWH); autonomic tone was determined by rMSSD‐heart rate variability (HRV).ResultsTWA was severely elevated (≥60 μV) in STEMI patients (80 ± 10.3 μV) at discharge and throughout the first recording period but declined by 50% to 40 ± 2.3 μV (p = .03) by Day 40 and remained in the normal range (<47 μV). TWH, a related phenomenon analyzed from 12‐lead ECGs, was reduced by 63% in the five STEMI patients from discharge to normal (<80 μV) at follow‐up (105 ± 27.3 to 39 ± 3.3 μV, p < .04) but increased by 65% in a STEMI case (89 to 147 μV), who received a wearable defibrillator vest and later implantable cardioverter defibrillator. In NSTEMI patients, TWA was borderline abnormal (47 ± 3.3 μV) at discharge and declined by 19% to normal (38 ± 1.2 μV) by Day 90 (p = .05). An overall reciprocal increase in rMSSD‐HRV suggested recovery of vagal tone.ConclusionsThis study provides proof‐of‐principle for tracking post‐MI SCD risk in individual patients with implications for personalized therapy.