Background and Purpose: The timing of anticoagulation resumption in patients who experience ischemic stroke despite ongoing anticoagulation and develop hemorrhagic transformation (HT) remains uncertain. We aimed to describe the characteristics and outcomes of patients with HT after a breakthrough ischemic stroke and to explore the association between anticoagulation resumption timing and the model-predicted balance of recurrent ischemic and bleeding risks in this high-risk population. Methods: We analyzed data from patients with breakthrough ischemic stroke receiving anticoagulation therapy from the multicenter ASPERA-R registry. Analyses focused on patients with HT. HT was defined according to the Heidelberg Bleeding Classification based on brain imaging within 24 h and categorized as hemorrhagic infarction or parenchymal hematoma. Anticoagulation resumption and its timing were determined by treating clinicians and were not randomized. Landmark Cox regression models were used to evaluate recurrent ischemic events and moderate-to-severe bleeding after anticoagulation resumption. Restricted cubic spline models and exploratory net clinical benefit analyses integrating ischemic and bleeding risks were used to assess the relationship between anticoagulation resumption timing and model-predicted combined risk, overall and across clinically relevant subgroups. Results: Among 1555 patients with breakthrough ischemic stroke, 269 (17.3%) developed HT, of whom 170 (63.2%) resumed anticoagulation and contributed to the restart-timing analyses. At 90 days, patients with HT had higher crude rates of recurrent ischemic events (27.1% vs. 13.8%), moderate-to-severe bleeding (7.4% vs. 2.8%), and mortality (34.2% vs. 17.7%) compared with patients without HT. In landmark analyses, HT was not associated with recurrent ischemic events (hazard ratio (HR) = 1.42, 95% confidence interval (CI) = 0.85–2.37) but remained strongly associated with moderate-to-severe bleeding (HR = 3.39, 95% CI = 1.61–7.13). Exploratory net clinical benefit analyses showed that the model-predicted combined risk reached its nadir at approximately 10 days after stroke in the overall HT population, with substantial uncertainty around this estimate. Conclusions: HT is a marker of poor prognosis in patients with breakthrough ischemic stroke, with an increased risk of bleeding after anticoagulation resumption. Among selected patients who resumed anticoagulation, exploratory modeling suggested that the combined predicted ischemic and bleeding risk reached its nadir at approximately 10 days after stroke. Given the non-randomized treatment timing and potential for treatment-selection bias, this estimate is hypothesis-generating and requires prospective validation.
Background and Aims In SELECT, subcutaneous semaglutide (target dose 2.4 mg) weekly in adults with pre-existing cardiovascular disease and body mass index >= 27 kg/m(2) without diabetes significantly reduced major adverse cardiovascular events (MACE) by 20% vs placebo. This analysis explored potential mediators of this cardiovascular benefit. Methods Changes from randomization to 24 months in body weight, waist circumference, plasma high-sensitivity C-reactive protein (hsCRP), glycated haemoglobin (HbA(1c)), lipids, blood pressure, estimated glomerular filtration rate, and urinary albumin-to-creatinine ratio were examined individually, and in combination, as potential mediators of MACE risk reduction, using the Vansteelandt repeated regression method (a counterfactual approach). Results Semaglutide significantly (P < .05) improved all potential mediators investigated. Point estimates for % mediation were largest for waist circumference (64.0% [95% confidence interval (CI) 27.5, 179.6]), hsCRP (42.1% [17.9, 110.5]), HbA(1c) (29.0% [-20.7, 120.5]), and body weight (19.5% [-33.0, 110.7]), examined separately, but all had wide CIs. Supplementary analyses suggested unreliability of estimates for body weight and waist circumference, potentially due to differing relationship of body weight and waist change to MACE between treatment arms. Multivariable analysis estimated joint mediation for all potential mediators combined to be 31.4% (95% CI -30.1, 143.6). When variables other than body weight and waist circumference were considered, % mediation was 46.0% (95% CI -6.0, 161.0). Conclusions Mediation analyses could not fully ascribe the effects of semaglutide on MACE to known risk factors in SELECT with any certainty. Further investigation of potential additional biomarkers and mediators of semaglutide's cardiovascular protective effect are of interest. [GRAPHICS] .
Background and Aims A major component of long QT syndrome (LQTS) is LQT2 due to pathogenic variants in KCNH2, which frequently cause trafficking defects. Despite progress in therapeutic management, there is an unmet clinical need for mechanism-targeted therapies. It has been previously shown, using patient-specific human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs), that lumacaftor (LUM), currently used for cystic fibrosis, can partially correct hERG trafficking. A single-arm phase 2 study was conducted to determine whether LUM could shorten QTc in LQT2 patients with trafficking defects. Methods Sixteen adult patients with genetically confirmed trafficking-defective KCNH2 variants were enrolled. Participants were admitted to hospital and received LUM for 7 days under continuous telemetry. QTc was quantified on serial electrocardiograms and 12-lead Holter recordings. For mechanistic correlation, hiPSC-CMs were generated from the first five participants with distinct genetic variants and assessed for hERG maturation and trafficking. Results Overall, lumacaftor produced a significant QTc shortening (P < .001). The per-patient change averaged 31 +/- 21 ms. Patients with baseline QTc >= 500 ms exhibited the most substantial effect, with 75% achieving reductions >= 40 ms. No ventricular arrhythmias occurred, and adverse effects were primarily gastrointestinal and self-limited. In hiPSC-CMs, LUM restored hERG trafficking in three out of five variants, mirroring the clinical observations. Conclusions Short-term LUM therapy is safe and yields a significant QTc shortening in LQT2 patients with a trafficking defect. Concordance between cellular and clinical findings reinforces the value of a mechanism-based, variant-informed approach and supports the feasibility of trafficking-correction strategies within a precision-medicine framework for inherited arrhythmia syndromes.
Background and Aims A simple diagnostic method able to reliably exclude left main (LM) coronary artery disease (CAD) or LMCAD-equivalent would expand implementation of an initial non-invasive strategy in patients with chronic coronary syndrome (CCS). This study assessed the diagnostic utility of an approach using clinical and ECG stress testing (EST) variables in excluding LMCAD/LMCAD-equivalent in CCS patients.Methods In a multicentre case-control study, CCS patients undergoing invasive coronary angiography (CAG) after a maximal EST were evaluated. Cases were patients with angiographic >= 50% LM stenosis or >= 70% stenosis of both proximal left anterior descending and proximal circumflex arteries, matched with similar patients without them (controls) in a 1:3 ratio. A risk model developed through logistic regression was internally and externally validated.Results Three hundred and thirty-five cases were matched with 797 controls. The model area under the curve (AUC) was .78. Assuming LMCAD prevalence of 5% and a misclassification cost ratio of 1:100 (ratio of cost of performing CAG in a control to cost of not performing CAG in a case), negative predictive value was 98.2%. Thus, CAG could be safely avoided in 41% of patients, missing one LMCAD/LMCAD-equivalent diagnosis for every 58 CAGs safely spared in patients without them.Conclusions Among CCS patients, LMCAD/LMCAD-equivalent can be excluded with high negative predictive value through a model based on clinical and EST parameters, allowing initial non-invasive management of most patients able to exercise. This approach is potentially useful particularly in communities where access to computed tomography coronary angiography is limited.
Background and Aims We investigated whether patients with coronary heart disease (CHD) in Europe are achieving the standards set by prevention and rehabilitation guidelines. Variability in achieved standards was also studied: (i) between countries, (ii) between geographical risk regions, and (iii) according to attendance at cardiac rehabilitation (CR). Methods EUROASPIRE VI is an observational study conducted between September 2024 and February 2026 in 160 hospitals across 27 countries. Geographical risk regions were defined as high, moderate, or low based on World Health Organization cardiovascular mortality data. Results were standardized by age and sex. Results Among 8590 patients with CHD (23.7% female), 17.1% were current smokers, 32.0% were obese, and 33.5% reported low physical activity. 59.8% were above blood pressure target (systolic >= 130 and/or diastolic >= 80 mmHg), 82.7% were above LDL-cholesterol target (>= 1.4 mmol/L), 32.8% had known diabetes of whom 42.2% had HbA1c >= 7%, and 30.6% had chronic kidney disease. Prevalences of these risk factors were all highest in countries from high-risk regions. 29.1% of patients attended at least one CR session, with country variability ranging from 0% to 79% and differing by risk region (55.9% low risk, 29.7% moderate risk and 10.2% high risk; P < .001). Attendance at CR programmes was associated with significantly better lifestyles, risk factor control, and use of cardioprotective drugs. Conclusions Most European patients are not achieving targets set by prevention guidelines. Despite better outcomes for those attending CR, there is marked variability in CR attendance and evidence of inverse care, with lowest attendance in highest risk regions. These results provide a baseline to inform the challenges for future implementation of the first European Society of Cardiology guideline on CR.
