BACKGROUND:Tricuspid regurgitation (TR) is a common but historically under-recognized valvular heart disease. Although mild to moderate TR was long considered benign, accumulating evidence indicates that clinically significant TR is associated with right ventricular failure, hepatic congestion, recurrent hospitalization, and increased mortality. AIMS:This review aims to provide a comprehensive overview of contemporary evaluation and management strategies for TR across its clinically relevant spectrum, with particular emphasis on severe disease and secondary mechanisms when discussing intervention. METHODS:Current literature was synthesized with a focus on TR classification, underlying mechanisms, imaging and hemodynamic assessment, risk stratification, device-related TR, and evolving therapeutic strategies, including both surgical and transcatheter approaches. RESULTS:Management paradigms have shifted toward earlier recognition and intervention, with echocardiography remaining central to diagnosis and procedural planning. While medical therapy is primarily supportive, advances in transcatheter edge-to-edge repair, annuloplasty systems, and transcatheter valve replacement have significantly expanded treatment options, particularly for patients at high surgical risk. Key determinants of therapeutic decision-making include pulmonary artery pressure, right ventricle-pulmonary artery coupling, right-sided chamber remodeling, surgical risk, and anatomic suitability. CONCLUSION:TR represents a complex and rapidly evolving area of cardiology that requires individualized assessment based on anatomy, hemodynamics, comorbidities, and the quality of available evidence. Ongoing clinical trials and emerging therapies are expected to further refine treatment algorithms and future guideline recommendations.
This study aimed to determine whether angiography-based physiological assessment yields clinical outcomes comparable to those of conventional wire-based pressure measurements in patients with coronary artery disease (CAD) undergoing evaluation of intermediate coronary stenoses. A systematic literature search was conducted in PubMed, Embase, and the Cochrane Central Register of Controlled Trials through April 12, 2026. Randomized controlled trials comparing angiography-derived indices (such as QFR, vFFR, and angiography-based FFR) with standard wire-based methods (FFR/iFR) were included. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model, and heterogeneity was evaluated using the I² statistic. A total of three randomized trials involving 6,141 participants were included, with 3,089 patients assigned to angiography-derived assessment. At 12 months, no statistically significant difference was observed in major adverse cardiovascular events between the two strategies (RR 1.14; 95% CI 0.58-2.25; P =.48). Additionally, outcomes including all-cause mortality, myocardial infarction, target vessel failure, repeat revascularization, stent thrombosis, stroke, and cardiac mortality were comparable across groups (all P >.05). Angiography-derived physiological assessment provides similar short-term clinical outcomes to traditional wire-based techniques, supporting its use as a less invasive alternative for assessing intermediate coronary lesions. Larger studies with extended follow-up are needed to confirm these findings.
BACKGROUND:Despite the use of atrial fibrillation (AF) cutoff of 30s as the standard for success in most AF clinical trials, patients consider an AF Severity Scale (AFSS) of ≤ 5 or AF duration ≤ 1 hour as treatment success. Prevalence and factors associated with these patient-defined endpoints are unknown. METHODS:We performed a cross-sectional analysis using a single-site cohort of AF patients. We report rates of patient-defined treatment success (AFSS ≤ 5 or AF burden ≤ 1 hour) and multivariable analyses to identify factors associated with either successful outcome. RESULTS:From 2019 to 2023, 2087 patients had available AFSS symptom scores and 2305 had ambulatory ECG monitoring. Of these, 862 (41%) had AFSS scores ≤5 and 1130 (49%) had AF burden ≤1 hour. After adjusted analysis, older age (OR 1.03, 95% CI 1.02-1.04, p <0.001) was associated with AFSS ≤5. Whereas female sex (OR 0.43, 95% CI 0.35-0.52, p <0.001), CKD, COPD, depression, and CHF were less likely to meet AFSS threshold. Among the AF burden cohort, age (OR 0.98, 95% CI 0.97-0.99, p <0.001), and female sex (OR 1.24, 95% CI 1.03-1.50, p=0.025) were associated with AF burden ≤ 1 hour. Unlike the AFSS cohort, medical comorbidities such as COPD and CHF, were not significantly different for meeting AF burden goal. CONCLUSION:Less than half of AF patients had AF-symptom scores or arrhythmia burdens reflecting patient-defined treatment success. Factors associated with reaching patient reported outcome goals were distinct from those associated with arrhythmia burden goals.
BACKGROUND:Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to improve outcomes across all heart failure (HF) phenotypes, but their role in patients undergoing transcatheter aortic valve replacement (TAVR) remains limited. METHODS:Using the TriNetX Global Collaborative Network, we identified all adults undergoing TAVR (2019-2025). Patients were divided into 2 groups - those receiving SGLT2i within 1-year post-TAVR and matched controls not receiving SGLT2i. Propensity-score matching was applied across demographics, comorbidities, medications, and labs. The primary endpoint was a composite of all-cause mortality and HF exacerbation. Secondary outcomes included major adverse cardiac and cerebrovascular events, ischemic stroke, acute myocardial infarction, and all-cause rehospitalization at 1 and 5 years. RESULTS:Among 55,147 TAVR patients, 2,478 (4.5%) received SGLT2i. After 1:1 matching, 2,020 well-balanced patients per group were analyzed. At 1 year, SGLT2i use was associated with lower incidence of primary composite endpoint (hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.69-0.80), HF exacerbation (HR 0.44, 95% CI 0.31-0.62), and all-cause rehospitalization (HR 0.41, 95% CI 0.38-0.44). Benefits persisted at 5 years with additional reduction in all-cause mortality (HR 0.84, 95% CI 0.73-0.97). Acute pancreatitis (falsification outcome) showed no association at both follow-ups. CONCLUSIONS:In a large multinational database, SGLT2i therapy after TAVR resulted in a significantly lower incidence of all-cause mortality or HF exacerbation.
BACKGROUND:Immune checkpoint inhibitors (ICIs) are widely used in cancer therapy but may cause cardiovascular immune-related adverse events (irAEs) with substantial morbidity and mortality. The impact of biological sex on ICI-associated cardiotoxicity remains incompletely defined in real-world populations. OBJECTIVES:To evaluate sex-based differences in cardiovascular immune-related adverse events following immune checkpoint inhibitor therapy. METHODS:We conducted a retrospective, propensity score-matched cohort study using the TriNetX global research network. Adults initiating ICI therapy were stratified by biological sex and matched 1:1 on demographics, cardiovascular comorbidities, and baseline cardiotoxic therapies. The primary outcome was incident myocarditis at 6 months, 1 year, and 2 years. Secondary outcomes included arrhythmias, conduction abnormalities, and cardiomyopathies. Relative risks (RRs) with 95% confidence intervals (CIs) were reported. RESULTS:The matched cohort included 60,116 pairs of female and male patients with good overall covariate balance. Females had a lower risk of myocarditis at 6 months (RR 0.76; 95% CI 0.63-0.91; P=0.004), 1 year (RR 0.81; 95% CI 0.68-0.95; P=0.011), and 2 years (RR 0.81; 95% CI 0.69-0.94; P=0.008), along with lower risks of atrial fibrillation, ventricular arrhythmias, high-degree atrioventricular block, ischemic cardiomyopathy, and dilated cardiomyopathy. In contrast, females had a higher risk of Takotsubo cardiomyopathy across all time points. CONCLUSIONS:ICI-associated cardiotoxicity is associated with sex-related differences, with higher rates of myocarditis and arrhythmic events in males and increased occurrence of Takotsubo cardiomyopathy in females. These findings suggest differences in cardiovascular risk patterns and highlight the need for further study to better understand their clinical relevance.
Left ventricular pseudoaneurysm (LVPA) is a rare mechanical complication of acute myocardial infarction (MI) associated with significant mortality. Given the paucity of available data in the literature, we sought to pool existing evidence to better understand the current management strategies and outcomes. Electronic search was performed in February 2025 to identify all studies reporting management of post-MI LVPA. A total of 158 reports, with a total of 159 patients, were included. Patient-level data were extracted for analysis. A total of 159 patients were included in the analysis. The median age was 65 years [Interquartile range (IQR), 57-75], and 70% (106/159) of patients were male. The most frequent site of MI was the inferior wall (31.4%, 49/156), and the most common method of MI management was thrombolysis (49%, 64/131). The median time from MI to presentation signs/symptoms of LVPA was 21 days (IQR, 0-152). The most common LVPA location was the anterior/apical wall (27.7%, 44/159). Sixty-six percent of patients (105/159) underwent surgical repair, while 22% of patients (35/159) were managed medically, and 5.7% (9/159) of patients underwent transcatheter repair. In-hospital/30-day mortality was 10% (16/159), with operative mortality after surgical repair of 4.8% (5/105). Mortality from reoperative surgery was 18.8% (3/16) as opposed to 2.2% (2/89) in patients without redo sternotomy ( P = 0.004). Periprocedural mortality among patients treated with transcatheter intervention occurred in a single case (11.1%), involving a patient with prior coronary artery bypass grafting. At a median follow-up of 6 months (IQR, 1-12), overall survival was 86.1% (137/159). Surgery remains the standard therapy of LVPA, with acceptable operative risk; however, reoperative sternotomy carries a higher surgical risk. In carefully selected patients, percutaneous repair may serve as a viable alternative to surgery.
BACKGROUND:Accurate estimation of atherosclerotic cardiovascular disease (ASCVD) risk underpins primary prevention strategies. The pooled cohort equations (PCE), long used in US guidelines, face criticism for risk overestimation and reliance on race-based coefficients. In 2023, the American Heart Association introduced the race-neutral Predicting Risk of Cardiovascular Disease Events (PREVENT) equations, which integrate metabolic, renal, and socioeconomic factors to improve calibration and clinical relevance. However, comparative evidence has not been systematically synthesized. METHODS:PubMed, EMBASE, Scopus, and Google Scholar were searched (January 2010-September 2025) for studies directly comparing PREVENT and PCE within the same adult cohorts. Eligible studies reported discrimination (area under the curve/C-statistic), calibration, or reclassification metrics. Random-effects models using restricted maximum-likelihood pooled standardized mean differences. Heterogeneity, influence, and publication bias were assessed using I 2 , leave-one-out analyses, and Egger's test. RESULTS:Eight studies, including 2,296,156 adults without baseline CVD and 5-15 years of follow-up, were analyzed. No significant difference in discrimination was observed between PREVENT and PCE (pooled standardized mean difference 0.93; 95% confidence interval, -1.56 to 3.41; P = 0.465). Heterogeneity was substantial (I 2 = 100%), though leave-one-out analyses confirmed robustness. Subgroup analyses by ASCVD versus broader CVD outcomes showed consistent findings. Egger test revealed no small-study effects ( P = 0.352). Across individual studies, several studies reported differences in calibration and risk reclassification between PREVENT and PCE. CONCLUSIONS:PREVENT and PCE exhibit similar discrimination for 10-year ASCVD risk despite marked heterogeneity. PREVENT may offer differences in calibration and risk reclassification across populations. Ongoing validation across diverse populations is warranted to confirm generalizability and long-term clinical utility across healthcare systems.
BACKGROUND:Lipid-lowering reduces cardiovascular events (CVEs) in patients with coronary artery disease. We sought to understand lipid-lowering therapy (LLT), low-density lipoprotein cholesterol (LDL-C) levels, and CVEs after coronary revascularization (CR). METHODS:We identified adults who underwent CR from 2014 to 2019 in linked datasets (IQVIA PharMetrics Plus health plan claims, IQVIA longitudinal prescription claims, and Prognos LDL-C database) using established methodology for extraction of deidentified claims data. RESULTS:A total of 184,271 patients were identified, 73,619 (40.0%) of whom were hospitalized for myocardial infarction (MI) in the 30 days before the index revascularization. Utilization of LLT increased from 46.0% at 3 months prerevascularization to 92.7% 12 months postrevascularization. Only 56.4% of patients were prescribed high-intensity statins. In a subset of patients with LDL-C values (n = 5496), the mean (SD) LDL-C decreased from 108 (41) mg/dL at 6 months prerevascularization to 82 (33) mg/dL at 12 months postrevascularization ( P < 0.0001). At 12 months after revascularization, LDL-C was ≥70 mg/dL in 55.7% of patients with prior MI and 62.1% of patients without recent MI. CVEs rates (per 100 patient-years) at 12 months postrevascularization were 5.2 (95% confidence interval [CI], 5.1-5.3) for MI, 2.0 (95% CI, 1.9-2.0) for stroke, and 6.6 (95% CI, 6.5-6.7) for unstable angina. CONCLUSIONS:Although LLT utilization increased after revascularization, high-intensity statins were underutilized. LDL-C levels remained above 70 mg/dL in more than half of the patients. Systematic efforts are needed after CR to improve lipid control and prevent recurrent CV events.
Pericardial disease represents a diverse clinical spectrum, including acute pericarditis, pericardial effusion, cardiac tamponade, effusive-constrictive pericarditis (CP), and CP, which vary significantly in presentation, urgency, and management. Recent consensus guidelines from the European Society of Cardiology and the American College of Cardiology have enhanced clinical phenotyping, multimodal imaging techniques, and targeted immunomodulatory therapies; however, their implementation in clinical practice remains variable. We introduce our updated pathway-based framework that structures diagnosis and treatment around 5 key clinical scenarios: chest pain, hemodynamic collapse, dyspnea, incidental pericardial effusion, and right-sided heart failure. Each scenario guides a systematic process of risk stratification, tiered diagnostic evaluation, and phenotype-specific therapy. In cases of acute pericarditis, management employs a 3-tier escalation approach, with interleukin-1 inhibitors (rilonacept, anakinra) as the preferred escalation for inflammatory phenotypes unresponsive to nonsteroidal anti-inflammatory drugs and colchicine. Cardiac magnetic resonance imaging is integral to phenotyping, utilizing late gadolinium enhancement and T2-STIR sequences to inform treatment escalation. Management of pericardial effusion is standardized through a validated drainage scoring system that considers etiology, size, and echocardiographic hemodynamics. CP is classified into 3 subtypes: transient/inflammatory, effusive-constrictive, and chronic/fixed, each with a distinct management pathway, reserving surgical pericardiectomy at specialized centers for fibrotic or medically refractory cases. This pathway consolidates current evidence into a reproducible clinical framework designed to standardize care, enhance diagnostic precision, and facilitate shared decision-making among multidisciplinary pericardial disease teams.
Complete revascularization improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD); however, the optimal timing of noninfarct-related artery intervention during the index procedure, immediate revascularization (IR) versus a staged approach (SR), remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials comparing SR and IR in patients with STEMI and MVD. The primary outcome was major adverse cardiovascular events. Secondary outcomes included all-cause and cardiovascular mortality, recurrent myocardial infarction, unplanned ischemia-driven revascularization, stent thrombosis, stroke, major bleeding, acute kidney injury, and heart failure hospitalization. Random-effects models with Hartung-Knapp adjustment were used. Trial sequential analysis assessed evidence conclusiveness, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation. Eight randomized trials, including 5077 patients (2556 SR; 2521 IR), were analyzed. No significant differences were observed between SR and IR for major adverse cardiovascular events [odds ratios (ORs), 1.07; 95% confidence intervals (CI), 0.76-1.49], recurrent myocardial infarction (OR, 1.30; 95% CI, 0.80-2.14), cardiovascular mortality (OR, 0.76; 95% CI, 0.51-1.13), or all-cause mortality (OR, 0.75; 95% CI, 0.54-1.06). Rates of stent thrombosis, stroke, unplanned ischemia-driven revascularization, major bleeding, acute kidney injury, and heart failure hospitalization were also comparable. Trial sequential analysis indicated insufficient information size to draw definitive conclusions, and the certainty of evidence ranged from very low to low. In patients with STEMI and MVD, staged and immediate complete revascularization provide comparable ischemic, safety, and mortality outcomes. Current evidence supports clinical equipoise, and revascularization timing should be individualized pending results from adequately powered trials.
BACKGROUND:Door-to-electrocardiogram (D2E) time is a critical quality metric in evaluating patients with suspected acute coronary syndromes (ACS), yet adherence to the ≤10-minute benchmark remains suboptimal. This study aimed to quantify D2E performance, identify predictors of delayed electrocardiogram (EKG) acquisition, and evaluate associations between D2E delays, in-hospital mortality, and length of stay (LOS). OBJECTIVE:To quantify D2E performance, identify patient- and system-level predictors of delayed EKG acquisition, and evaluate associations between D2E delays, in-hospital mortality, and LOS. METHODS:This retrospective cohort study included adults presenting to a single community hospital emergency department in 2024 with symptoms suggestive of ACS. The primary outcome was receipt of a 12-lead EKG within 10 minutes of arrival. Secondary outcomes included D2E distribution, in-hospital mortality, and hospital LOS. Multivariable logistic regression examined predictors of D2E >10 minutes. RESULTS:Among 3435 patients (median age 62 years; 52.3% female), 49.7% achieved D2E ≤10 minutes (median 10.0 minutes). In ACS subgroup analysis, female sex, atypical presentation, lower triage acuity, and afternoon shift were independently associated with D2E >10 minutes. Delayed EKG acquisition correlated with longer LOS, including a higher proportion of stays >4 days and a higher median LOS (3.0 vs. 2.0 days, P < 0.01). Overall, in-hospital mortality was 6.5%. CONCLUSIONS:Fewer than 5 in 10 patients met the 10-minute D2E target. Delays were more frequent among women, patients with atypical presentations, lower triage acuity, and those arriving during afternoon shifts. Delayed EKG acquisition was associated with prolonged hospitalization, underscoring D2E time as a modifiable process measure.
BACKGROUND:Type 2 myocardial infarction (Type 2 MI) is increasingly recognized among older adults and individuals with multiple comorbidities. We evaluated the association between maximum troponin levels and 30- and 90-day all-cause mortality using both continuous values and clinically meaningful thresholds. METHODS:We conducted a retrospective cohort study using the Medical Information Mart for Intensive Care IV database. Our analysis focused on patients with Type 2 MI, with maximum troponin level being the primary exposure of interest. We examined troponin's association with both 30-day and 90-day mortality, treating it as a continuous variable and categorizing it into thresholds: 10×, 100×, and 1000× the upper limit of normal (ULN), using 0.04 ng/mL (99th percentile of ULN) as the reference group. 1398 patients met our inclusion criteria. RESULTS:Maximum troponin was an independent predictor of 30-day mortality and 90-day mortality after adjusting for confounders ( P = 0.018, P = 0.016, respectively). Compared with the reference group (<0.04 ng/mL), the relative risks of 30-day mortality were 1.39 [95% confidence intervals (CI), 0.89-2.17] for 10× ULN, 1.72 (95% CI, 1.10-2.71) for 10-100× ULN, 1.85 (95% CI, 1.16-2.95) for 100-1000× ULN, and 2.45 (95% CI, 1.31-4.57) for >1000× ULN. A similar pattern was seen for 90-day mortality, with relative risks of 1.28 (95% CI, 0.89-1.96), 1.76 (95% CI, 1.22-2.69), 1.63 (95% CI, 1.09-2.54), and 2.07 (95% CI, 1.05-3.35), respectively. CONCLUSIONS:Higher troponin levels are independently associated with increased short- and intermediate-term mortality in Type 2 MI, supporting the potential use of troponin thresholds for risk stratification in this high-risk population.
BACKGROUND:Takotsubo cardiomyopathy (TTC) is an acute heart condition in which physical or emotional stress causes left ventricular dysfunction. Psychiatric comorbidities have been linked to the precipitation of this condition, but large-scale data are limited. The goal of this study was to analyze the associations between TTC and various psychiatric conditions using nationally representative data. METHODS:A retrospective observational cohort study was conducted using the Nationwide Inpatient Sample database from 2016 to 2022. International Classification of Diseases, Tenth Revision code I51.81 was used to identify hospitalized patients ≥18 years with a primary diagnosis of TTC. In addition, International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with various psychiatric comorbidities. RESULTS:A total of 291,600 patients had a primary diagnosis of TTC. The mean age was 67.1 ± 14.26 years, and 82.04% of the population was female. The following 4 psychiatric comorbidities were found to have significant associations with TTC: nicotine dependence [17.48% of patients; P < 0.001; odds ratio (OR), 1.08; 95% confidence intervals (CI), 1.06-1.11], depressive disorders (19.20% of patients; P < 0.001; OR, 1.46; 95% CI, 1.43-1.49), anxiety (24.25% of patients; P < 0.001; OR, 1.83; 95% CI, 1.80-1.87), and post traumatic stress disorder (2.91% of patients; P < 0.001; OR, 1.25; 95% CI, 1.18-1.31). No significant associations were found for dementia, alcohol related disorders, substance use other than tobacco and alcohol, manic disorders, or schizophrenia. CONCLUSIONS:In this large, nationally representative sample, nicotine dependence, anxiety, depression, and post traumatic stress disorder were significantly associated with TTC. These findings highlight the importance of incorporating psychiatric health practices into the field of cardiology.
Radiofrequency catheter ablation (CA) has emerged as a therapeutic strategy for Brugada syndrome (BrS), particularly for patients with recurrent ventricular fibrillation (VF) and implantable cardioverter-defibrillator (ICD) shocks. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of CA compared with standard management. PubMed, Embase, and Scopus were searched from inception to August 2025 for randomized controlled trials and adjusted observational studies enrolling BrS patients undergoing CA versus ICD-only therapy, pharmacotherapy, or observation. Five studies (2 RCTs, 3 cohorts) comprising 510 patients (296 ablation; 214 control) were included. The primary outcome was ventricular arrhythmia recurrence; secondary outcomes were procedural complications and ICD-related complications. Pooled analysis demonstrated that CA significantly reduced ventricular arrhythmia recurrence (RR 0.20; 95% CI 0.05-0.75; P=0.02), with consistent benefit in randomized trials. No significant differences were observed in procedural complications (RR 0.81; 95% CI 0.32-2.01; P=0.65) or ICD-related complications (RR 1.16; 95% CI 0.49-2.78; P=0.73). Certainty of evidence ranged from moderate to very low based on GRADE. In conclusion, CA is an effective intervention for reducing recurrent ventricular arrhythmias in BrS without an increase in procedural or device-related adverse events. These findings support the expanding role of substrate-based ablation as a disease-modifying therapy in appropriately selected BrS patients.
Cardiac myosin inhibitors (CMIs) are novel, disease-modifying therapies for hypertrophic cardiomyopathy (HCM). This meta-analysis evaluates the efficacy of CMIs versus placebo in patients with HCM. A systematic review and meta-analysis of randomized controlled trials involving adults with obstructive and nonobstructive HCM was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered on PROSPERO. Databases including PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through September 2025. Random-effects models were performed using standardized mean differences for biomarker and WMDs for echocardiographic parameters. Risk ratios (RRs) were calculated for dichotomous outcomes, with 95% confidence intervals. Seven randomized controlled trials, comprising 1406 patients (732 CMI; 674 placebo), were included. CMIs significantly improved resting [WMD: -57.27 mm Hg (-63.05, -51.49); P < 0.001] and post-Valsalva left ventricular outflow tract gradient [WMD: -55.87 mm Hg (-63.05, -51.49); P < 0.001]. Left ventricular ejection fraction decreased modestly [WMD: -4.74% (-7.22, -2.26); P = 0.0002]. CMIs increased the likelihood of ≥1 New York Heart Association class improvement [RR: 1.94 (1.37, 2.74); P < 0.001] and Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score [WMD: +6.60 points (3.84, 9.35); P < 0.001]. N-terminal pro B-type natriuretic peptide [WMD: -13.35 (-18.04, -8.67); P < 0.001] and cardiac troponin I [WMD: -11.90 (-15.07, -8.73); P < 0.001] declined. Peak oxygen uptake showed no overall change [WMD: +0.64 mL/kg/min (-0.18, 1.47); P = 0.12]. CMIs increased adverse events [RR: 1.07 (1.02, 1.13); P = 0.008], particularly hypertension [RR: 2.19 (1.06, 4.53); P = 0.03]. CMIs improve hemodynamics, functional status, and biomarkers in HCM with an acceptable safety profile and hold promise as disease-modifying therapy, though long-term outcomes require confirmation.
BACKGROUND:During the COVID-19 pandemic, a temporary policy change required emergency medical services (EMS)-identified ST-segment elevation myocardial infarction (STEMI) patients to undergo COVID testing in the emergency department (ED) before percutaneous coronary intervention, suspending the standard ED bypass to the catheterization lab. We compared system performance metrics during this COVID-era routing to pre- and postpandemic periods in a large rural health system. METHODS:This was a retrospective single-center cohort study of consecutive EMS-identified STEMI activations across 3 periods: pre-COVID (May 27, 2018-March 26, 2020), COVID-era ED routing (March 27, 2020-January 25, 2022), and post-COVID with resumed ED bypass (January 26, 2022-November 26, 2023). Primary outcomes were standard STEMI system performance metrics; the secondary outcome was in-hospital mortality. RESULTS:A total of 373 patients were included (pre-COVID: 132; COVID: 104; post-COVID: 137). Compared to pre-COVID, the median time from EMS first medical contact to device time increased by 13 minutes ( P = 0.017). The median time from symptom onset to device time increased by 30 minutes ( P = 0.0013). The median time of first EMS electrocardiogram to device placement was increased by 14 minutes ( P = 0.013). The median door-to-device time was increased by 6 minutes ( P = 0.0007). There was a nonsignificant trend toward higher in-hospital mortality during the COVID era. CONCLUSIONS:In a rural STEMI system, pandemic-era routing of EMS-identified patients through the ED was associated with significant delays in key reperfusion metrics. While in-hospital mortality did not differ significantly, likely due to limited statistical power, these findings underscore the importance of preserving streamlined STEMI pathways. Larger multicenter studies to assess outcomes are warranted.
BACKGROUND:Patients with potential transient ischemic attacks (TIA) are often evaluated with transthoracic echocardiography (TTE) to identify cardioembolic sources. The diagnostic yield of TTE among patients in an emergency department observation unit (EDOU) with suspected TIA is unknown. We aimed to determine the diagnostic yield of TTE in a US EDOU TIA cohort. METHODS:We conducted an observational cohort study using the Wake Forest Emergency Medicine TIA Registry. We included patients ≥18 years old evaluated in the EDOU TIA protocol at a large academic tertiary care center between July 1, 2021 and December 1, 2023. TTE results were reviewed for high-risk cardioembolic features, which we included as patent foramen ovale (PFO), left ventricular ejection fraction (LVEF) ≤40%, focal wall motion abnormalities, and ventricular thrombus. The diagnostic yield, defined as the proportion of patients who were found to have a high-risk cardioembolic feature on TTE, was calculated and reported with an exact 95% confidence interval (95% CI) and used to determine the number needed to test. RESULTS:Among the 686 patients included in our cohort, 67.1% (460/686) underwent TTE. The diagnostic yield of TTE was 19.4% (95% CI, 15.7-23.0%), which corresponds to a number needed to test of 6 (95% CI, 5-7). In our cohort, TTE identified 63 PFOs, 26 instances of LVEF ≤ 40%, 6 focal wall motion abnormalities, and 0 ventricular thrombi. CONCLUSIONS:Among patients with suspected TIA in the EDOU, TTE was useful in the detection of high-risk cardioembolic features, especially PFOs and reduced LVEF. These findings support the continued use of TTE for those evaluated for TIA in the EDOU.
Despite technological advancements, mortality remains high in patients with myocardial infarction complicated by cardiogenic shock. Impella is increasingly used as an adjunct to standard treatment due to its hemodynamic benefits, though mixed study results limit its adoption. This meta-analysis aims to clarify Impella's efficacy by focusing on high-quality data from RCTs and cohort studies. A comprehensive literature search was conducted for randomized controlled trials and cohort studies comparing Impella with intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO). Assessed metrics included mortality, clinical events, and hematologic markers. Data was analyzed using the Mantel-Haenszel random-effects model. Of 787 articles, 12 studies (4918 patients) met the inclusion criteria. Impella groups showed significant increases in thrombosis risk (RR: 4.94) and had a higher bleeding risk compared to IABP (RR: 1.98) but a lower risk compared to ECMO (RR: 0.66). All other comparisons did not reach statistical significance. Despite updated data and a stringent quality threshold, the hemodynamic benefits of Impella and the device's risk of thrombosis and bleeding were high. Future trials should emphasize patient selection, timing of placement, and operator proficiency to evaluate Impella's efficacy and safety better.
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism, is a major cardiovascular condition associated with substantial morbidity, mortality, and risk of recurrence. Extended anticoagulation is frequently required beyond the initial treatment phase, yet the optimal strategy remains uncertain. Direct oral anticoagulants (DOACs) provide practical advantages over vitamin K antagonists, but their role in long-term secondary prevention warrants clarification. We performed a systematic review and meta-analysis of placebo-controlled randomized controlled trials evaluating extended DOAC therapy in VTE. A comprehensive literature search identified 5 eligible trials with a total of 13,802 patients. Data were pooled using random-effects models to calculate risk ratios (RR) and 95% confidence intervals (CI). Outcomes included recurrent VTE, DVT, pulmonary embolism, mortality, stroke, cancer incidence, and bleeding events. Compared with placebo, extended DOAC therapy significantly reduced symptomatic recurrent VTE (RR, 0.26; 95% CI, 0.16-0.41), with consistent findings across sensitivity analyses. DOACs demonstrated strong protection against recurrent DVT, while results for recurrent pulmonary embolism were less consistent. No significant differences were observed in all-cause mortality, ischemic stroke, or cancer incidence. Safety analyses showed no increase in major bleeding. Extended DOAC therapy is highly effective in preventing recurrent VTE, particularly DVT, and maintains an acceptable safety profile. Despite the absence of mortality or stroke benefit, the favorable efficacy-safety balance supports DOACs as a convenient and effective option for prolonged secondary prevention in patients at ongoing risk of recurrence.
Early detection of cardiovascular disease and implementation of evidence-based treatments can reduce cardiovascular morbidity and mortality. Medical algorithms and decision-making tools provide a compelling option for screening, risk prediction, and treatment management. Such digital tools have the potential to aid both healthcare professionals and patients, providing support to decrease unwarranted diagnostic and treatment variability while guiding personalized care, with the overall objective of improving clinical outcomes. However, incorporating digital tools in healthcare settings is challenging, and evidence the required to support their adoption and understand the limitations can be lacking. A multinational panel of expert cardiologists and emergency physicians across North America, Europe, and Oceania gathered to deliberate on the current landscape of digital tools and medical algorithms, drawing on prior clinical experiences and knowledge of country-specific regulations. In this viewpoint, the evidence to support and guide the adoption of digital tools in cardiovascular clinical practice and the necessary components for successful integration into clinical workflows were discussed. Digital tools must be developed with the needs of the healthcare professionals, other relevant stakeholders (eg, administration personnel), and patients in mind to give them the best chance of widespread adoption. Academia, industry, and regulatory bodies should work together to cultivate and accelerate the implementation of digital tools in healthcare. The considerations discussed here may help decision makers to determine if a digital tool has the components necessary to integrate into the clinical workflow successfully.
