BACKGROUND:Mineralocorticoid receptor antagonists (MRAs) reduce mortality in heart failure, yet whether eplerenone and spironolactone differ in effectiveness remains uncertain owing to the absence of head-to-head trials. OBJECTIVE:To compare all-cause mortality, heart failure hospitalization, major adverse cardiovascular events (MACE), and chronic kidney disease (CKD) progression between new users of eplerenone and spironolactone with heart failure. METHODS:Retrospective, new-user cohort study using the TriNetX Global Collaborative Network (171 healthcare organizations). Adults with heart failure receiving a first MRA prescription were matched 1 : 1 by propensity score. Prespecified subgroup analyses were performed in heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). RESULTS:After matching (38 952 pairs), all standardized mean differences (SMDs) were below 0.10 except serum potassium (SMD 0.18). At 36 months, eplerenone was associated with lower all-cause mortality [11.75 vs. 14.58%; hazard ratio 0.795, 95% confidence interval (CI) 0.765-0.827; P < 0.0001], heart failure hospitalization (hazard ratio 0.917, 95% CI 0.902-0.932), MACE (hazard ratio 0.900, 95% CI 0.886-0.915), and CKD progression (hazard ratio 0.803, 95% CI 0.745-0.867; all P < 0.0001). In HFrEF, eplerenone was associated with significantly lower rates across all outcomes. In HFpEF, mortality did not differ significantly (hazard ratio 0.946, 95% CI 0.876-1.021; P = 0.162), and spironolactone was associated with lower MACE (hazard ratio 1.135, 95% CI 1.087-1.184) and heart failure hospitalization (hazard ratio 1.144, 95% CI 1.108-1.181; both P < 0.0001). CONCLUSION:In this large propensity score-matched cohort, eplerenone was associated with lower mortality, MACE, and CKD progression than spironolactone overall and in HFrEF. In HFpEF, spironolactone was favoured for MACE and heart failure hospitalization, with no significant difference in mortality. These hypothesis-generating findings support prospective head-to-head trials.
INTRODUCTION:Cardiac implantable electronic device (CIED) infections are associated with substantial morbidity and mortality, and early recognition with referral for device extraction is crucial for optimal outcomes. General practitioners (GPs) are essential for long-term follow-up, yet their adherence to international guidelines remains poorly defined. This survey aimed to assess GPs' levels of awareness and clinical management of CIED infections. METHODS:A nationwide survey endorsed by the Electrophysiology and Cardiac Pacing Study Group of the Italian Federation of Cardiology was sent to GPs throughout Italy. The questionnaire explored epidemiology, prognosis, clinical scenarios, preventive strategies, therapeutic pathways, and educational background regarding CIED infections. RESULTS:A total of 183 GPs from 10 Italian regions participated. Most respondents (62.8%) correctly estimated CIED infection incidence at 1-2%. However, two-thirds (122 GPs, 66.6%) considered conservative management to be associated with good outcomes, and only 28.4% recognized CIED infection as a condition with a poor prognosis. While 93.4% identified systemic inflammatory symptoms as warning signs, fewer than one-third would refer febrile CIED carriers to an electrophysiology specialist. Preventive strategies were heterogeneous, with more than half (54.1%) prescribing antibiotic prophylaxis before dental procedures. Only six GPs (3.8%) reported having received adequate training or dedicated education courses on CIED infections during their educational pathway. CONCLUSIONS:Italian GPs demonstrate reasonable epidemiological awareness of CIED infections. However, major gaps exist in prognostic understanding, diagnostic referral, prevention, and therapeutic alignment with guidelines. These findings highlight the need for structured educational programs and shared care pathways between primary care and electrophysiology services.
AIMS:Right ventricular to pulmonary artery (RV-PA) coupling has emerged as an important determinant of prognosis in heart failure and pulmonary hypertension. However, its role in patients undergoing catheter ablation of atrial fibrillation remains uncertain. This study investigated changes in RV-PA coupling after ablation and its association with atrial fibrillation recurrence. METHODS AND RESULTS:In this multicenter prospective study, 118 patients undergoing ablation of atrial fibrillation were evaluated at baseline and after 3 months using comprehensive clinical and echocardiographic assessment. Atrial fibrillation recurrence was assessed at 1-year follow-up.After 3 months, tricuspid annular plane systolic excursion (TAPSE) increased (22.4 ± 4.1 to 24 ± 3.8, P < 0.001), pulmonary artery systolic pressure (PASP) decreased (29.5 ± 6.6 to 27.9 ± 7.7, P = 0.030), and TAPSE/PASP increased (0.81 ± 0.27 to 0.93 ± 0.29, P < 0.001). At 1 year, atrial fibrillation recurrence occurred in 50/118 patients (42%). Restricted cubic spline analysis demonstrated a significant nonlinear association between TAPSE/PASP and AF recurrence (P for nonlinearity = 0.041). Patients in the lowest TAPSE/PASP tertile (<0.67 mm/mmHg) had a higher risk of atrial fibrillation recurrence at 1 year compared with those in the highest (hazard ratio 2.66, 95% confidence interval 1.31-5.45, P = 0.007). Kaplan-Meier analysis confirmed a higher recurrence rate in the lowest tertile (log-rank P = 0.012). CONCLUSION:In patients undergoing catheter ablation for atrial fibrillation, RV-PA coupling significantly improved after the procedure. Lower baseline TAPSE/PASP was independently associated with atrial fibrillation recurrence, supporting the role of RV-PA uncoupling as a potential marker for postablation risk stratification.
AIMS:Fragmented QRS (fQRS) is an electrocardiographic marker of myocardial injury associated with adverse outcomes in acute coronary syndromes. This study aimed to examine its prognostic value within the acute coronary occlusion myocardial infarction (ACOMI) classification framework. METHODS:We retrospectively analyzed 996 patients with Type 1a or Type 1b ACOMI-compatible ECGs. The primary endpoint was all-cause mortality. A prespecified multivariable Cox regression model with 10 covariates was used. Model discrimination was assessed using the area under the ROC curve (AUC). RESULTS:fQRS was present in 237 patients (23.7%). During a median follow-up of 618 days (IQR: 398-725 days), 127 deaths occurred (12.6%). Kaplan-Meier analysis showed significantly lower survival in fQRS-positive patients (79.3% vs. 89.7%; P < 0.001). On multivariable Cox regression, fQRS was an independent predictor of mortality [hazard ratio (HR): 1.702; 95% confidence interval (CI) 1.050-2.760; P = 0.032], alongside the GRACE risk score (HR: 1.021; P < 0.001) and left ventricular ejection fraction (HR: 0.955; P < 0.001). fQRS improved model discrimination (AUC: 0.784-0.800; ΔAUC = +0.016). In the Type 1a subgroup, a signal toward increased fQRS-associated mortality was observed (HR: 1.662; P = 0.056), though this did not reach statistical significance. The fQRS × ECG type interaction was nonsignificant (P-interaction = 0.733); subgroup findings should be regarded as hypothesis-generating. CONCLUSION:fQRS on admission ECG is independently associated with all-cause mortality in ACOMI patients and may serve as a simple adjunctive marker for risk stratification, though prospective validation is needed.
BACKGROUND:We evaluated the effects of a 24-h istaroxime infusion on changes in self-reported dyspnea among patients with acute heart failure (AHF). METHODS:Patients hospitalized for AHF with ejection fraction ≤40 were randomized to receive a 24-h infusion of placebo or istaroxime at doses of 0.5 (Ista-0.5) or 1.0 μg/kg/min (Ista-1.0). Self-reported dyspnea was assessed by means of a visual analogue scale (VAS). Dyspnea VAS area under the curve (AUC) and changes in VAS dyspnea from baseline through 24 and 48 h were compared between istaroxime- and placebo-treated patients. RESULTS:Among 113 AHF patients (n = 39 placebo, n = 39 Ista-0.5, n = 35 Ista-1.0), a statistically significant difference in dyspnea VAS AUC from baseline through 24 h was observed in the pooled istaroxime arm vs. the placebo arm [win odds 1.44, 95% confidence interval (CI) 1.00 to 2.07; P = 0.048], with similar findings for Ista-0.5 vs. placebo (win odds 1.48, 95% CI 1.01 to 2.18; P = 0.047). Win odds consistently favored istaroxime through 48 h, though significance was not maintained. Results were numerically more pronounced among patients with baseline dyspnea VAS < 80, particularly for Ista-0.5 vs. placebo (win odds 1.71, 95% CI 0.76 to 3.83; P = 0.172). Consistent findings were observed changes in dyspnea VAS through 24 h, with a least square mean difference of 2.6 points (95% CI -1.8 to 7.0) between Ista-1.0 and placebo. CONCLUSIONS:Among patients with AHF, 24-h istaroxime infusion was associated with a significantly higher probability of dyspnea improvement compared with placebo through 24 h, with results being numerically more pronounced among patients with worse dyspnea at baseline.
BACKGROUND:Despite successful transcatheter aortic valve interventions (TAVIs), a residual risk of heart failure (HF) hospitalization persists. RESULTS:A total of 37 490 patients from Optum's de-identified Clinformatics Data Mart were included. HF diagnosis was recorded in 21 283 (56.9%) patients during a year before TAVI. One-/two-year risks for a composite of HF hospitalization and mortality were 15.6% [95% confidence interval (CI), 15.2-16.0]/25.4% (95% CI, 24.8-25.9). Post-TAVI, HF medication prescriptions remained low. MAJOR FINDINGS:HF burden among TAVI recipients is high and HF therapies are underused. Persistent residual risks highlight the need for future clinical trials investigating a role of more aggressive medical management after TAVI.
INTRODUCTION:Patients undergoing durable ventricular assist device (VAD) implantation after acute myocardial infarction (AMI) present critical surgical and clinical challenges. Data on outcomes in this high-risk population remain limited. The aim of this study was to describe the clinical profile and identify predictors of long-term outcomes in AMI patients receiving durable VAD support. METHODS:Retrospective analysis of patients included in the EUROMACS registry (1995-2024) was conducted. RESULTS:Three hundred and thirty-five patients (4.8% of EUROMACS records) underwent VAD implantation post-AMI. Most patients presented with severe cardiogenic shock (82% INTERMACS class 1-2), and the median time from AMI hospitalization to VAD implantation was 9 (IQR 8-14) days. Surgical revision for bleeding was required in 20% of patients. Mortality risk was 31% at 1 year, 46% at 5 years and 56% at 10 years. At multivariable analysis, female sex [subdistribution hazard ratio (SHR): 2.70, 95% confidence interval (95% CI): 1.62-4.49, P = 0.016], mechanical ventilation (SHR: 2.16, 95% CI: 1.44-3.26, P < 0.001) and VAD implantation as destination therapy (SHR: 2.48, 95% CI: 1.69-3.64, P < 0.001) were independent predictors of mortality, while a recent year of implant (SHR: 0.84, 95% CI: 0.73-0.97, P = 0.016) increasing BMI (SHR: 0.96, 95% CI: 0.94-0.99, P = 0.014), no previous history of heart failure (SHR: 0.61, 95% CI: 0.42-0.91, P = 0.014) and the presence of sinus rhythm (SHR: 0.63, 95% CI: 0.43-0.92, P = 0.017) were protective factors against mortality. CONCLUSION:AMI patients accounted for a small subset of durable VAD recipients in an all-comers international registry, with high cardiogenic shock severity and substantial mortality risk. These findings provide a rationale for future prospective studies aimed at optimizing management and outcomes in this vulnerable population.
BACKGROUND:Patients with a history of malignancy are at elevated risk for acute coronary syndrome (ACS). This study evaluates in-hospital cardiovascular outcomes in ACS patients with and without a cancer history. METHODS:A systematic search of PubMed, Scopus, Embase, and ClinicalTrials.gov (2000-2025) identified studies comparing in-hospital outcomes for ACS in patients with vs. without malignancy. Data were pooled and analyzed using RevMan 5.4, calculating risk ratios (RRs) under a random-effects model. RESULTS:Fifteen studies were included. Among ACS patients, a history of cancer was associated with significantly worse in-hospital outcomes. Cancer history increased all-cause mortality by 44% [RR: 1.44; 95% confidence interval (CI): 1.21-1.71; P < 0.001], bleeding by 72% (RR: 1.72; 95% CI: 1.33-2.22; P < 0.001), major adverse cardiac events (MACE) by 18% (RR: 1.18; 95% CI: 1.17-1.19; P < 0.001), and stroke by 48% (RR: 1.48; 95% CI: 1.35-1.63; P < 0.001). No significant associations were observed for heart failure (RR: 1.24; 95% CI: 0.96-1.59; P = 0.10), re-infarction (RR: 1.17; 95% CI: 0.83-1.65; P = 0.36), or cardiogenic shock (RR: 1.22; 95% CI: 0.97-1.55; P = 0.09). CONCLUSION:Patients with a history of malignancy presenting with ACS face significantly higher in-hospital risks of mortality, bleeding, MACE, and stroke, while risks of heart failure, re-infarction, and shock show nonsignificant trends. These findings underscore the vulnerability of this population and highlight the need for multidisciplinary, individualized management strategies to improve outcomes.
AIMS:In asymptomatic severe degenerative mitral regurgitation (MR), indications for surgery mainly rely on 2D echocardiographic criteria. Preoperative peak atrial longitudinal strain (PALS) has prognostic value for predicting clinical outcome after surgery for MR while Bernard demonstrated the prognostic value of an echocardiographic staging assessment of extra-valvular cardiac damage in patients with at least moderate MR.The primary aim was to assess the additive prognostic value of PALS to Bernard's staging classification in patients undergoing surgery for degenerative MR. METHODS:Ambispective multicenter cohort study of patients with severe degenerative MR undergoing surgery. Patients were assigned to Bernard's stages based on pre-operative echocardiographic data, from which PALS values were obtained. Follow-up assessed the composite primary endpoint: all-cause mortality, hospitalization for heart failure, acute myocardial infarction, stroke, life-threatening bleeding or wound infections requiring re-intervention, failure requiring re-intervention. RESULTS:Three hundred patients (mean age 63 ± 13 years; 65% men) were enrolled with a median follow-up of 24 months. Bernard's staging predicted outcomes in our population, as demonstrated by survival analysis with Kaplan-Meier curves (log-rank 13.3; P = 0.01) and Cox model (hazard ratio of 1.51; P < 0.001). Adding PALS improved prognostic performance (χ2 = 20.96 vs. 16.15), with an area under the curve of 0.70 vs. 0.64 at 24 months, a net reclassification improvement of 0.18 (P = 0.031), an integrated discrimination improvement of 0.02 (P = 0.020). We identified an optimal PALS cutoff of 18% associated with the primary endpoint. CONCLUSIONS:PALS has a potential additive role in estimating the prognosis of patients undergoing surgery for severe degenerative MR.
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly in young women. A high-risk subset of these patients presents with cardiac arrest (CA), creating a profound clinical management dilemma. Current guidelines for secondary prevention with an implantable cardioverter-defibrillator (ICD) offer limited guidance for life-threatening ventricular arrhythmias (VA) secondary to putatively 'reversible' causes such as SCAD. This review critically analyzes the evidence for and against ICD implantation. While the observed rate of appropriate ICD therapy in SCAD survivors is low, the risk of recurrent SCAD is significant (10-30%). Although the acute dissection may heal, the underlying systemic arteriopathy represents a persistent, nonreversible substrate. Therefore, for a selected, high-risk cohort of SCAD patients presenting with CA, the event might be considered a marker for a durable arrhythmic substrate. In these cases, an ICD implantation for secondary prevention should be considered after a comprehensive risk assessment and shared decision-making.
The cases reported in this study have the following characteristics: ① no J waves were observed in sinus beats, while transient J waves (Cases 1 and 3) or J point/ST-segment elevation (Case 2) appeared in atrial premature beats (APB), indicating that the occurrence of significant J waves/ST-segment elevation was dependent on short cycles (Cases 1 and 2) or long-short-cycle sequences (Case 3); ② the degree of J waves/ST-segment elevation was significant in all cases. Analysis suggests that short-cycle-dependent or long-short-cycle sequence-dependent J waves/ST-segment elevation is an ECG manifestation that can be caused by different underlying mechanisms, namely repolarization abnormalities and/or depolarization abnormalities.
