Importance:Cardiovascular-kidney-metabolic (CKM) syndrome represents a syndromic continuum encompassing overlapping cardiovascular, kidney, and metabolic dysfunction. Hypertension is a central driver in the pathogenesis of CKM syndrome, promoting both kidney and metabolic deterioration, but little is known about the benefits of intensive blood pressure (BP) control across CKM syndrome stages. Objective:To evaluate CKM syndrome stage-specific outcomes, safety, and net clinical benefits associated with a comprehensive intensive BP intervention. Design, Setting, and Participants:This is a post hoc, secondary analysis of a cluster randomized clinical trial, the China Rural Hypertension Control Project (CRHCP), which was conducted between May 2018 and March 2023. Participants were adults aged 40 years or older with hypertension and CKM syndrome stages 2 to 4, which were defined using standard criteria. Stage 2 indicates that the patient has a metabolic risk factor; stage 3, subclinical cardiovascular disease or predicted 10-year risk of 20% or greater; and stage 4, clinical cardiovascular disease. In this analysis, participants had a median (IQR) follow-up of 3.02 (2.97-3.06) years. Data analysis was conducted from November 2024 to June 2025. Intervention:The comprehensive BP control strategy targeted a systolic BP less than 130 mm Hg and a diastolic BP less than 80 mm Hg. The intervention was delivered by trained nonphysician practitioners. Main Outcomes and Measures:The primary clinical outcome was a composite of major adverse cardiovascular events (stroke, myocardial infarction, heart failure, or cardiovascular death). Safety outcomes included hypotension, syncope, injurious falls, and kidney adverse events. A quantitative benefit-harm analysis was conducted to estimate net benefit associated with the intervention. Results:Among 33 736 participants (mean [SD] age, 63.0 [9.2] years; 20 677 [61.3%] women), 18 662 (55.3%) had stage 2 CKM syndrome (of whom 9526 [51.0%] received the intervention), 7984 (23.7%) had stage 3 (of whom 4032 [50.5%] received the intervention), and 7090 (21.0%) had stage 4 (of whom 3713 [52.4%] received the intervention). Treatment outcomes were generally consistent across CKM syndrome stages. Intensive BP control was associated with reduced cardiovascular events across all stages: in stage 2, the hazard ratio (HR) was 0.61 (95% CI, 0.50-0.73); in stage 3, the HR was 0.71 (95% CI, 0.58-0.84); and in stage 4, the HR was 0.67 (95% CI, 0.58-0.76). The risk of all-cause mortality was also lower in stage 2 (HR, 0.73; 95% CI, 0.57-0.90) and stage 3 (HR, 0.82; 95% CI, 0.68-0.96) but not in stage 4 (HR, 1.02; 95% CI, 0.84-1.20). Risk of hypotension increased across all stages (relative risk range, 1.79-2.34), while other adverse events, including kidney events, were similar between groups, despite some numerical variation across stages. Net benefits were favorable: stage 2, 1.58 (95% CI, 1.53-1.62); stage 3, 2.53 (95% CI, 2.42-2.64); and stage 4, 2.15 (95% CI, 2.04-2.26). Conclusions and Relevance:In this post hoc analysis of a cluster randomized clinical trial, a comprehensive intervention targeting BP less than 130/80 mm Hg demonstrated a favorable benefit-to-harm profile across CKM syndrome stages, with no clear heterogeneity across CKM syndrome stages. These findings provide the first trial-based evidence to guide CKM syndrome management and support scalable strategies for this high-risk, multimorbid population. Trial Registration:ClinicalTrials.gov Identifier: NCT03527719.

Aim: To identify factors associated with late atrial fibrillation (AF) recurrence after radiofrequency catheter ablation and to develop a nomogram for individualized risk prediction, followed by external validation in an independent cohort. Methods: We conducted a retrospective cohort study of patients with AF who underwent catheter ablation at Tongji Hospital (training cohort, January 2020-December 2022) and the Second Hospital of Lanzhou University (validation cohort, June 2020-June 2023). Follow-up visits were scheduled at 1, 3, 6, 12, and 18 months after the procedure. Candidate predictors were identified using the Boruta algorithm and the least absolute shrinkage and selection operator. Selected variables were then entered into multivariable Cox proportional hazards models. Model performance was evaluated using Harrell’s C-index, time-dependent area under the receiver operating characteristic curve, calibration plots, and decision curve analysis. Results: A total of 256 patients in the training cohort and 203 in the validation cohort were included, with a median follow-up of 12 months. Late AF recurrence occurred in 21.9% and 21.2% of patients, respectively. Six variables were included in the final model: early recurrence (HR = 7.616), left atrial diameter (HR = 1.684), intraoperative electrical cardioversion (HR = 1.423), serum creatinine (HR = 1.018), use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI) (HR = 0.426), and AF duration (HR = 1.003). The nomogram showed good discrimination, calibration, and clinical usefulness in both cohorts. Conclusion: We developed and externally validated a six-variable nomogram for predicting late AF recurrence after catheter ablation. This model may support individualized risk stratification and guide post-ablation management.

QuestionIs intensive blood pressure management associated with consistent net clinical benefits across cardiovascular-kidney-metabolic (CKM) syndrome stages?FindingsIn a secondary analysis of a large cluster randomized trial involving more than 33 000 adults, a comprehensive intensive blood pressure intervention was associated with significantly reduced risk of cardiovascular events across CKM syndrome stages 2 to 4. Net benefit analyses demonstrated favorable benefit-to-harm profiles at all stages.MeaningThis study offers the first trial-based evidence to guide stage-specific CKM syndrome care and supports scalable strategies for high-risk, multimorbid populations, particularly in resource-limited settings, such as rural China. This secondary analysis of a randomized clinical trial evaluates whether there are any differences in the outcomes, safety, and net clinical benefits associated with an intensive blood pressure control intervention by cardiovascular-kidney-metabolic (CKM) syndrome stages. ImportanceCardiovascular-kidney-metabolic (CKM) syndrome represents a syndromic continuum encompassing overlapping cardiovascular, kidney, and metabolic dysfunction. Hypertension is a central driver in the pathogenesis of CKM syndrome, promoting both kidney and metabolic deterioration, but little is known about the benefits of intensive blood pressure (BP) control across CKM syndrome stages.ObjectiveTo evaluate CKM syndrome stage-specific outcomes, safety, and net clinical benefits associated with a comprehensive intensive BP intervention.Design, Setting, and ParticipantsThis is a post hoc, secondary analysis of a cluster randomized clinical trial, the China Rural Hypertension Control Project (CRHCP), which was conducted between May 2018 and March 2023. Participants were adults aged 40 years or older with hypertension and CKM syndrome stages 2 to 4, which were defined using standard criteria. Stage 2 indicates that the patient has a metabolic risk factor; stage 3, subclinical cardiovascular disease or predicted 10-year risk of 20% or greater; and stage 4, clinical cardiovascular disease. In this analysis, participants had a median (IQR) follow-up of 3.02 (2.97-3.06) years. Data analysis was conducted from November 2024 to June 2025.InterventionThe comprehensive BP control strategy targeted a systolic BP less than 130 mm Hg and a diastolic BP less than 80 mm Hg. The intervention was delivered by trained nonphysician practitioners.Main Outcomes and MeasuresThe primary clinical outcome was a composite of major adverse cardiovascular events (stroke, myocardial infarction, heart failure, or cardiovascular death). Safety outcomes included hypotension, syncope, injurious falls, and kidney adverse events. A quantitative benefit-harm analysis was conducted to estimate net benefit associated with the intervention.ResultsAmong 33 736 participants (mean [SD] age, 63.0 [9.2] years; 20 677 [61.3%] women), 18 662 (55.3%) had stage 2 CKM syndrome (of whom 9526 [51.0%] received the intervention), 7984 (23.7%) had stage 3 (of whom 4032 [50.5%] received the intervention), and 7090 (21.0%) had stage 4 (of whom 3713 [52.4%] received the intervention). Treatment outcomes were generally consistent across CKM syndrome stages. Intensive BP control was associated with reduced cardiovascular events across all stages: in stage 2, the hazard ratio (HR) was 0.61 (95% CI, 0.50-0.73); in stage 3, the HR was 0.71 (95% CI, 0.58-0.84); and in stage 4, the HR was 0.67 (95% CI, 0.58-0.76). The risk of all-cause mortality was also lower in stage 2 (HR, 0.73; 95% CI, 0.57-0.90) and stage 3 (HR, 0.82; 95% CI, 0.68-0.96) but not in stage 4 (HR, 1.02; 95% CI, 0.84-1.20). Risk of hypotension increased across all stages (relative risk range, 1.79-2.34), while other adverse events, including kidney events, were similar between groups, despite some numerical variation across stages. Net benefits were favorable: stage 2, 1.58 (95% CI, 1.53-1.62); stage 3, 2.53 (95% CI, 2.42-2.64); and stage 4, 2.15 (95% CI, 2.04-2.26).Conclusions and RelevanceIn this post hoc analysis of a cluster randomized clinical trial, a comprehensive intervention targeting BP less than 130/80 mm Hg demonstrated a favorable benefit-to-harm profile across CKM syndrome stages, with no clear heterogeneity across CKM syndrome stages. These findings provide the first trial-based evidence to guide CKM syndrome management and support scalable strategies for this high-risk, multimorbid population.Trial RegistrationClinicalTrials.gov Identifier: NCT03527719

BACKGROUND:The interplay between frailty dynamics and the newly defined Cardiovascular-Kidney-Metabolic (CKM) syndrome remains poorly understood. We aimed to quantify the association between frailty transitions and the risk of incident advanced CKM syndrome and identify modifiable drivers of frailty progression. METHODS:Using data from the China Health and Retirement Longitudinal Study (CHARLS), we analyzed 8159 participants cross-sectionally and 3506 longitudinally over four years. Frailty was assessed using a deficit-accumulation index. The primary outcome was prevalent and incident advanced CKM syndrome (Stages 3-4). We employed multivariable regression models to evaluate associations and a machine learning pipeline to identify key predictors of frailty progression. RESULTS:Baseline frailty showed a robust dose-response relationship with prevalent advanced CKM (OR 1.44 per 0.1-unit FI increase; 95% CI 1.38-1.51). Longitudinally, individuals progressing to a frail state had a 40% increased risk of incident advanced CKM compared to stable non-frail peers (OR 1.40; 95% CI 1.01-1.94). Notably, this risk was sex-specific, observing a significant association in men (OR 2.20; 95% CI 1.33-3.64) but not in women. Machine learning identified life satisfaction, smoking status, and sleep duration as the top predictors of frailty progression. CONCLUSIONS:Frailty progression acts as a potent, sex-specific risk amplifier for advanced CKM syndrome. Integrating frailty screening into CKM care and targeting psychosocial well-being-specifically life satisfaction-alongside lifestyle factors may be important strategies to preempt frailty and potentially mitigate cardiovascular-renal-metabolic risks.

Aim: Reliable prognostic tools remain limited for patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) more than 48 h after symptom onset. This study aimed to develop and externally validate a nomogram based on routinely available in-hospital clinical variables to predict post-discharge adverse outcomes in this population. Methods: We retrospectively analyzed data from Tongji Hospital between June 2019 and August 2022 and identified 198 STEMI patients who underwent delayed PCI as the training cohort. Independent predictors of composite adverse events, defined as all-cause mortality, nonfatal myocardial infarction, and New York Heart Association class IV heart failure, were identified using multivariate Cox proportional hazards regression. A nomogram was subsequently constructed and internally validated using bootstrap resampling. External validation was performed in an independent cohort of 599 patients treated at the Second Hospital of Lanzhou University, with a median follow-up duration of 20 months. Results: Four variables were identified as independent predictors of adverse outcomes and incorporated into the nomogram: (1) heart rate > 83 beats per minute (hazard ratio [HR] 2.786, 95% confidence interval [CI]: 1.226-6.32, P = 0.014); (2) absence of statin therapy (HR 0.213, 95%CI: 0.064-0.71, P = 0.012); (3) intraoperative slow-flow/no-reflow phenomenon (HR 2.889, 95%CI: 1.247-6.69, P = 0.013); and (4) requirement for mechanical ventilation (HR 7.469, 95%CI: 2.57-21.70, P < 0.001). The nomogram demonstrated good discrimination and calibration in the training cohort, with a concordance index of 0.782. External validation confirmed its robust predictive performance. Patients classified as high risk exhibited significantly lower event-free survival compared with those at low risk (P < 0.0001). Conclusion: This validated nomogram, derived from routinely collected clinical variables, provides reliable prediction of adverse outcomes in STEMI patients undergoing delayed PCI and may facilitate individualized risk stratification and optimized post-discharge management.

Background:Glycoprotein IIb/IIIa inhibitors are generally reserved for selected high-thrombotic-risk or bailout percutaneous coronary intervention (PCI) scenarios, but their routine value in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with anatomically complex coronary lesions remains uncertain. We evaluated adjunctive tirofiban in patients with left main, chronic total occlusion, bifurcation, ostial, long, or severely calcified lesions, while excluding confirmed intracoronary thrombus, no-reflow, or slow-flow. Methods:This retrospective observational study included 1462 NSTE-ACS patients undergoing PCI with stent implantation. Patients receiving dual antiplatelet therapy (DAPT) with or without tirofiban were compared. The efficacy endpoint was 30-day composite ischemic events, and the safety endpoint was any bleeding. Multivariable adjustment and 1:1 propensity score matching (PSM) were performed. Results:In the overall cohort, tirofiban was not associated with lower ischemic risk (9.35% vs 9.42%; unadjusted OR 0.99, 95% CI 0.68-1.45; adjusted OR 1.02, 95% CI 0.68-1.52). Bleeding was numerically higher but not significant (3.94% vs 3.59%; adjusted OR 1.08, 95% CI 0.58-2.01). After matching, 431 patients per group were retained. Ischemic events (10.21% vs 9.51%; OR 1.08, 95% CI 0.69-1.69) and bleeding events (5.10% vs 3.71%; OR 1.40, 95% CI 0.72-2.69) remained non-significantly higher with tirofiban. No significant subgroup interactions were observed. Conclusion:In this selected non-thrombotic complex-lesion NSTE-ACS cohort, routine adjunctive tirofiban was not associated with improved 30-day ischemic outcomes. Anatomical complexity alone may be insufficient to justify routine "add-on" tirofiban in the absence of thrombotic or bailout indications.

Background Acute kidney injury (AKI) constitutes a critical complication in patients with acute coronary syndrome (ACS) following percutaneous coronary intervention (PCI), substantially elevating morbidity and mortality risks. Traditional biomarkers like serum creatinine present considerable limitations for timely detection of renal impairment. This investigation evaluated the predictive capacity of novel biomarkers in identifying post-PCI renal dysfunction. Methods We conducted a retrospective cohort analysis utilizing the MIMIC-IV database, encompassing 350 ACS patients who underwent PCI procedures. Blood samples were systematically collected at baseline and multiple time points (2, 6, 12, and 24 hours) post-PCI. Novel biomarkers including Neutrophil Gelatinase-Associated Lipocalin (NGAL), Kidney Injury Molecule-1 (KIM-1), and Interleukin-18 (IL-18) were quantified alongside conventional markers. The primary outcome measure was AKI occurrence within 48 hours post-PCI, determined according to KDIGO diagnostic criteria. Results Among 350 patients, AKI developed in 94 individuals (26.9%). AKI patients demonstrated significantly elevated baseline creatinine (2.51±2.30 vs 1.18±0.96 mg/dL, p<0.001), higher prevalence of diabetes mellitus (61.7% vs 37.5%, p<0.001), chronic kidney disease (62.8% vs 24.2%, p<0.001), and heart failure (72.3% vs 37.1%, p<0.001). Clinical outcomes revealed substantially elevated in-hospital mortality (16.0% vs 1.6%, p<0.001), overall mortality (54.3% vs 27.3%, p<0.001), and prolonged hospital stay (10.91±8.90 vs 5.43±7.00 days, p<0.001). AKI severity stratification showed 16.0% Stage 1, 1.4% Stage 2, and 10.3% Stage 3, with progressive mortality escalation across stages (48.2%, 60.0%, and 63.9%, respectively). Conclusion Post-PCI AKI represents a frequent and severe complication with profound prognostic implications. Novel biomarkers, particularly NGAL, KIM-1, and IL-18, demonstrate substantial promise for early detection. The combination of multiple biomarkers provides superior predictive accuracy compared to traditional markers. Early identification of high-risk patients through comprehensive risk stratification may facilitate timely preventive interventions, potentially improving clinical outcomes.

The global incidence of atrial fibrillation is on the rise. Atrial fibrillation, a complex disease, heightens the likelihood of heart failure, stroke, and mortality, necessitating careful attention. Controlling heart rate and rhythm, addressing risk factors, and preventing strokes are fundamental in treating atrial fibrillation. Catheter ablation stands out as the primary approach for atrial fibrillation rhythm control. Nevertheless, the limited success rates pose a significant challenge to catheter ablation, particularly for persistent atrial fibrillation. Various adjunctive ablation techniques are currently under investigation to enhance the effectiveness of catheter ablation. This review provides an overview of the current state of the art and the latest optimized treatments for persistent atrial fibrillation in the areas of rhythm control, heart rate control, and risk factor management.

Hypertension management strategies have evolved from solely controlling office blood pressure (BP) to comprehensive 24-h BP regulation. This review synthesizes current evidence on the timing of antihypertensive medication, with a focus on circadian BP rhythms and patients with specific BP patterns or comorbidities. Bedtime dosing may benefit individuals with nocturnal hypertension and nondipper BP patterns, but large trials, such as the TIME study, have shown no significant cardiovascular outcome differences between morning and bedtime dosing. However, the optimal timing of antihypertensive medication for patients with distinct BP rhythms or comorbidities remains uncertain. Future research should investigate the potential benefits of personalized medication timing tailored to BP patterns and clinical conditions. Additionally, treatment strategies should consider BP rhythms, comorbidities, and adherence to optimize outcomes, paving the way for more effective management of hypertensive patients with complex clinical profiles.

Accurate risk prediction in heart failure remains challenging due to its complex pathophysiology. We aimed to develop and validate a comprehensive prognostic model integrating demographic, electrocardiographic, echocardiographic, and biochemical parameters. We conducted a retrospective cohort study of 445 heart failure patients. The cohort was randomly divided into training (n = 312) and validation (n = 133) sets. Feature selection was performed using LASSO regression followed by backward stepwise Cox regression. A nomogram was constructed based on independent predictors. Model performance was assessed through discrimination, calibration, and decision curve analyses. Random survival forest analysis was conducted to validate variable importance. During a median follow-up of 4.14 years, 142 deaths (31.91

Background Preventing ischemic events is a critical concern for patients undergoing percutaneous coronary intervention (PCI). Glycoprotein IIb/IIIa inhibitors can significantly reduce short-term ischemic risk in ST-segment elevation myocardial infarction patients after PCI. However, their effectiveness in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with complex lesions remains unclear. Methods This retrospective study included 1240 NSTE-ACS patients with complex coronary lesions. Patients receiving dual antiplatelet therapy (DAPT) after PCI, with or without tirofiban, were compared. The efficacy endpoint was a composite of 30-day ischemic events, while the safety endpoint was any occurrence of bleeding. Results The addition of tirofiban did not improve the 30-day ischemic outcomes among NSTE-ACS patients with complex lesions, and no significant enhancement was observed in these outcomes following multivariate adjustment (9.1% vs. 8.6%, P = 0.745; adjusted HR: 1.219, P = 0.342). The subgroup analyses showed consistent results. Although additional tirofiban treatment did not increase bleeding risk (3.8% vs. 3.4%, P = 0.742), the medicine costs in the tirofiban group were significantly higher than those in the control group (¥2121 vs. ¥1579, P < 0.001). Conclusions NSTE-ACS patients with complex lesions undergoing PCI may not benefit from additional tirofiban. However, the use of tirofiban significantly increased the medicine costs. The use of DAPT provides adequate antithrombotic protection in NSTE-ACS patients with complex lesions after PCI.

Objectives: To identify predictors of intraoperative electrical cardioversion and develop a predictive model for patients undergoing radiofrequency ablation for atrial fibrillation (AF). Methods: We retrospectively analyzed data from 1,348 patients with AF who underwent radiofrequency catheter ablation at Tongji Hospital between January 2018 and December 2023. Clinical, echocardiographic, and CT imaging data were collected. The Boruta algorithm and multivariable logistic regression were used to identify predictors and construct a nomogram. Model performance was assessed using the area under the ROC curve (AUC), calibration plots, and decision curve analysis (DCA). External validation was performed on 121 patients treated at Hubei No. 3 People’s Hospital of Jianghan University from June 2023 to February 2025. Results: Patients were divided into training and validation sets (7:3 ratio). Five independent predictors were identified: AF type (OR = 13.63), valvular regurgitation (OR = 3.25), BMI (OR = 1.06), left atrial diameter (OR = 1.74), and systolic blood pressure (OR = 0.96). The nomogram showed excellent discriminative ability with AUCs of 0.881 (training), 0.879 (internal validation), and 0.866 (external validation). Calibration curves demonstrated good agreement between predicted and actual outcomes. DCA confirmed the model’s clinical utility. Conclusions: The proposed nomogram accurately predicts the need for intraoperative electrical cardioversion during AF ablation and may aid in individualized procedural planning.

Background:Coronary Heart Disease (CHD) with renal insufficiency is a significant global health issue. This study aimed to develop and validate a predictive model for in-hospital mortality to enable early risk identification in these patients. Methods:We analyzed data from 11,830 CHD patients with renal insufficiency treated at Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China (1994-2023). Among 113 clinical variables, five key features-age, high-sensitivity C-reactive protein (hs-CRP), estimated glomerular filtration rate (eGFR), creatine kinase (CK), and blood urea-were selected using Recursive Feature Elimination. Six machine learning models (Random Forest, XGBoost, Decision Tree, Neural Network, Logistic Regression, and Support Vector Machine) were developed and assessed for discrimination, calibration, and clinical utility. Temporal validation was performed using data from May 16, 2023 to October 31, 2024. SHapley Additive exPlanations (SHAP) were used for model interpretation. Results:Of the 11,830 patients, 694 (5.9 %) died during hospitalization. Among the six models, XGBoost showed the best overall performance in the test set, achieving the highest AUC (0.926), lowest Brier score (0.034), highest accuracy (0.957), and balanced sensitivity (0.381) and F1 score (0.512). Decision curve analysis confirmed its superior clinical utility. In a temporally independent validation cohort of 5983 patients, XGBoost maintained strong predictive performance (AUC = 0.901), demonstrating excellent robustness and generalizability. Conclusions:The XGBoost-based model accurately predicts in-hospital mortality in CHD patients with renal insufficiency, supporting early risk stratification and clinical decision-making.

Background: Acute kidney injury (AKI) substantially worsens outcomes in patients hospitalized with heart failure, yet effective early prediction tools remain limited. This study aimed to develop and validate a machine learning-based model for AKI prediction in heart failure patients. Methods: We retrospectively analyzed 870 patients hospitalized for heart failure between October 2017 and June 2024. Missing values (<30%) were imputed, and feature selection was performed using LASSO and backward stepwise logistic regression. Five machine learning models (XGBoost, LightGBM, Logistic Regression, Support Vector Machine, and Decision Tree) were developed and evaluated using ROC curves, precision-recall curves, calibration plots, and decision curve analysis. Results: AKI occurred in 271 patients (31.2%). Baseline comparisons showed significant differences in renal function and electrolyte levels between AKI and non-AKI groups (all P<0.05). Ten potential predictors were identified by LASSO, and seven remained significant after logistic regression. Among all models, XGBoost achieved the best discrimination with AUC of 0.927 (95% CI: 0.902-0.951) in the validation set. It showed excellent sensitivity (0.761), specificity (0.967), and positive predictive value (0.911). Calibration and decision curve analyses confirmed strong agreement and net clinical benefit. SHAP analysis indicated chronic kidney disease (OR=2.805, 95% CI: 1.461-5.383) and electrolyte disturbances as key predictors. Conclusions: The proposed machine learning-based model accurately predicts AKI risk in heart failure patients, outperforming conventional methods. Its interpretability and robust performance suggest promising utility as a clinical decision support tool, warranting external validation.

Background Fulminant myocarditis (FM) is the most severe form of myocarditis, characterized by rapid clinical progression and circulatory instability. However, its pathological features and their relationship to clinical presentation are not well understood. Objectives This study aims to provide an overview of the clinicopathologic features of FM. Methods A total of 80 patients with FM were enrolled between January 2021 and September 2022 in Wuhan, China. Endomyocardial biopsies and subsequent histochemical staining were performed on all patients who were followed up for 3 months. The pathological features of the myocardium were described. The relationship between myocardial inflammatory cell infiltration and clinical presentation was analyzed. Results According to hematoxylin and eosin staining, 76 out of 80 patients with FM were diagnosed with lymphocytic myocarditis, while 4 were diagnosed with eosinophilic myocarditis. Microscopically, various forms of cell degeneration were observed, especially myocardial edema and cardiomyocyte necrosis. Histochemical analysis indicated that innate immune cells (primarily macrophages and neutrophils) predominated in the acute stage of FM. Proper treatment with immunomodulatory agents, such as glucocorticoids and immunoglobulin, promoted macrophage polarization into the M2 subtype. A high density of total inflammatory cell infiltration was associated with elevated levels of inflammatory biomarkers (hs-CRP and ESR) and more severe circulatory deterioration, which necessitated more frequent use of IABP, ECMO, and pacemakers. Conclusions To date, this largest cohort of histochemical analyses of FM, based on endomyocardial biopsy samples, has revealed dominant infiltration of innate immune cells in the early stage, followed by lymphocytes. This finding suggests that the activation of innate immunity is the initial mechanism triggering the cytokine storm in FM. The results also support the beneficial effects of immunomodulatory therapy using glucocorticoids and immunoglobulins rather than immunosuppression by promoting M2 macrophage polarization. This study was registered at https://clinicaltrials.gov/study/NCT03268642.

Background Traditionally, amiodarone or electrical cardioversion was used if radiofrequency catheter ablation (RFCA) could not terminate atrial fibrillation during the procedure in patients with persistent atrial fibrillation (PeAF). Objective To investigate whether the nifekalant instead of amiodarone during RFCA improve procedure outcomes in patients with PeAF. Methods This study enrolled patients with PeAF who failed to achieve cardioversion after initial ablation at our center between January 2020 and December 2022. These patients were classified into the nifekalant (N) group and the amiodarone (A) group. And patients were followed for 1 year to evaluate long-term success rates. Subgroup analyses and the logistic regression analyses were performed. Results The study comprised 300 participants and included N (n = 121) and A (n = 179) groups. Following propensity score matching (PSM), 101 participants were in each group. Within the N and A groups, 57(56.44 %) and 19(18.81 %) cases successfully terminated AF, 45 (44.56 %) and 15(14.85 %) cases achieved conversion to atrial tachycardia (P < 0.001), respectively. The ventricular tachycardia was observed in only one case in the N group (P > 0.05). The follow-up results demonstrated that one-year success rates were 63.37 % and 49.50 % for the N and A groups (P < 0.05). Conclusion For patients with PeAF that persists after initial catheter ablation, compared to amiodarone, administration of nifekalant could convert atrial fibrillation into atrial tachycardia, following by target ablation, has the potential to improve the procedure outcomes.

Dementia is a leading cause of death and disability worldwide. Here we tested the effectiveness of blood pressure (BP) reduction on the risk of all-cause dementia among 33,995 individuals aged ≥40 years with uncontrolled hypertension in rural China. We randomly assigned 163 villages to a non-physician community healthcare provider-led intervention and 163 villages to usual care. In the intervention group, trained non-physician community healthcare providers initiated and titrated antihypertensive medications according to a simple stepped-care protocol to achieve a systolic BP goal of <130 mm Hg and a diastolic BP goal of <80 mm Hg, with supervision from primary care physicians. Over 48 months, the net reduction in systolic BP was 22.0 mm Hg (95% confidence interval (CI) 20.6 to 23.4; P < 0.0001) and that in diastolic BP was 9.3 mm Hg (95% CI 8.7 to 10.0; P < 0.0001) in the intervention group compared to usual care. The primary outcome of all-cause dementia was significantly lower in the intervention group than in the usual care group (risk ratio: 0.85; 95% CI 0.76 to 0.95; P = 0.0035). Additionally, serious adverse events occurred less frequently in the intervention group (risk ratio: 0.94; 95% CI 0.91 to 0.98; P = 0.0006). This cluster-randomized trial indicates that intensive BP reduction is effective in lowering the risk of all-cause dementia in patients with hypertension. ClinicalTrials.gov: NCT03527719 .

There has been a significant increase in the prevalence of atrial fibrillation (AF) over the past 30 years. Pulmonary vein isolation (PVI) is an effective treatment for AF, but research investigations have shown that AF recurrence still occurs in a significant number of patients after ablation. Heart rhythm outcomes following catheter ablation are correlated with numerous clinical factors, and researchers developed predictive models by integrating risk factors to predict the risk of recurrence of atrial fibrillation. The purpose of this article is to outline the risk scores for predicting cardiac rhythm outcomes after PVI and to discuss the modifiable factors that increase the risk of recurrence of AF, with the hope of further improving catheter ablation efficacy through preoperative identification of high-risk populations and postoperative management of modifiable risk factors.

Objective To compare the long-term prognosis of patients who experienced acute ST-segment elevation myocardial infarction and underwent either late percutaneous coronary intervention (PCI) within a period of 2 days to less than 1 week or more advanced PCI within 1 week to less than 1 month. Methods We enrolled 198 patients from Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, between June 2019 and August 2022. These patients had experienced acute ST-segment elevation myocardial infarction and underwent either late PCI or more advanced PCI. Long-term follow-up was conducted through outpatient clinic visits or telephone interviews. The study endpoints included all-cause death, nonfatal myocardial infarction, and New York Heart Association class IV heart failure. We utilized the Kaplan-Meier method to illustrate the cumulative incidence of endpoint events in both patient groups. Statistical significance in survival differences was assessed using the log-rank test. Additionally, the Cox proportional risk model was employed to analyze whether the timing of late revascularization procedures had an impact on the long-term prognosis of the patients. Results Among the 198 patients included in the study, 108 underwent late PCI, while 90 underwent more advanced PCI. The majority were male (73.74%), with an average age of 62 ± 13 years. The follow-up period averaged 20 (15, 28) months, and all patients successfully completed the follow-up process. Analysis based on the Kaplan-Meier method revealed that the incidence of all-cause death [11.1% vs. 5.6%, P=0.165], nonfatal myocardial infarction [7.4% vs. 7.8%, P=0.922], New York Heart Association class IV heart failure [2.8% vs. 3.3%, P>0.999], and the composite endpoint [18.5% vs. 14.4%, P=0.444] were not statistically significant between the late PCI and more advanced PCI groups. After adjusting for factors like left ventricular ejection fraction, renin-angiotensin system inhibitors, β-blockers, and statins, the results still indicated no statistically significant differences between the two groups in terms of rates for all-cause death, recurrent myocardial infarction, New York Heart Association class IV heart failure, and composite endpoints (P=0.05). Conclusion This study’s 20 (15, 28) months follow-up suggests that patients experiencing acute ST-segment elevation myocardial infarction have a comparable prognosis regardless of whether they underwent late or more advanced PCI. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial The study procedures were approved by the Medical Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology(TJ-IRB202401016). ### Funding Statement No external funding was received. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Our study adhered to the principles of the Declaration of Helsinki. Prior to participation, each individual provided signed informed consent. The study procedures were approved by the Medical Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology(TJ-IRB202401016). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Comprehensive aggregate data will be shared from the corresponding author upon request.

Fulminant myocarditis (FM) is an acute and severe form of myocarditis with rapid progression and poor clinical outcomes in the absence of acute or chronic coronary artery disease. Electrocardiogram (ECG) abnormalities can provide preliminary clues for diagnosis; however, there is a lack of systemic descriptions on ECG changes in FM populations. Thus, a retrospective analysis of 150 consecutive FM patients and 300 healthy controls was performed to determine the characteristic ECG findings in FM. All patients included had markedly abnormal ECG findings. Specifically, 83 (55.33%) patients had significantly lower voltage with remarkably decreased QRS amplitudes in all leads compared with healthy controls (p < 0.01), and 77 (51.33%) patients had a variety of arrhythmias with lethality ventricular tachycardia/ventricular fibrillation in 21 (14.00%) patients and third-degree atrioventricular block in 21 (14.00%) patients, whereas sinus tachycardia was only found in 43 (28.67%) patients with the median heart rate (HR; 88.00 bpm, IQR: 76.00–113.50) higher than that of controls (73.00 bpm, IQR: 68.00–80.00) (p = 0.000). Conduction and repolarization abnormalities were common in patients. A longer QTc interval (452.00 ms, IQR: 419.00–489.50) and QRS duration (94.00 ms, IQR: 84.00–119.00) were observed in patients compared to controls (QTc interval = 399.00 ms, IQR: 386.00–414.00; QRS duration = 90.00 ms, IQR: 86.00–98.00) (p < 0.05). Additionally, HR > 86.50 bpm, QTc > 431.50 ms, and RV5 + SV1 < 1.715 mV can be used to predict FM. Thus, marked and severe ECG abnormalities provide preliminary clues for the diagnosis of FM.