BACKGROUND:Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. METHODS:Between 2020 and 2023, adults hospitalised in the previous 6-24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120-129/70-79 mm Hg) or below target (<120/70 mm Hg); according to both 2023 ESH and 2024 ESC guidelines. RESULTS:Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76-1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120-129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate <60 mL/min/1.73 m² (18.9% vs 10.7%, p<0.001), when compared with those at target. They were also statistically more likely to be severely frail (p=0.030). The median number of BP-lowering medications did not differ significantly between the 3 BP target groups. Cumulative dosing of BP-lowering medications in the below-target group was also not more intensive than that in the at-target group. CONCLUSIONS:More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

BACKGROUND:Chronic kidney disease (CKD) is an important risk factor for the progression of coronary artery disease (CAD). OBJECTIVES:The purposes of this study were to quantify the prevalence of CKD in CAD patients from 14 countries from all World Health Organization regions and to evaluate the prognostic value of estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio (UACR). METHODS:A total of 4,548 patients with CAD were included (79.6% were males; age range: 18-80 years). They were assessed for eGFR and UACR 6 to 24 months after the CAD diagnosis. Complete information on kidney function and cardio-renal protective therapy was available for 3,865 patients and follow-up data after a median of 1 year were available for 3,577 (92.5%). RESULTS:CKD according to the Kidney Disease Improving Global Outcomes classification was present in 32% of whom 19.7% were classified as low-moderate, 6.9% as high, and 5.6% as very high risk. Without UACR, 51.3% of them would have been undetected. The primary event, first of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure, was observed in 7.9%, with the highest incidence in the Kidney Disease Improving Global Outcomes high-risk group (men: 13.0%; women: 11.8%). This relationship was independent of other risk factors and evident soon after the index examination. Only a minority of the patients received adequate cardio-renal protective therapy. CONCLUSIONS:Early screening for CKD in patients with CAD is important and should preferably include both eGFR and UACR to provide a complete diagnosis. Without UACR, half of those with CKD would remain undetected. Treatment with cardio-renal protective therapy was low, providing great potential for improvement.

An ageing population means more people are living longer with cardiovascular disease. As a result, health systems face sustained pressures to provide effective long-term care. Cardiac rehabilitation has evolved from group-based exercise-based programs to comprehensive secondary prevention, with a growing focus on supporting lifelong cardiovascular health. The World Heart Federation (WHF) recently published a Roadmap that advances this shift by reframing cardiovascular rehabilitation around person-centred, future-focused care, and identifying five key recommendations: prioritise lifelong health, strengthen patient and clinician engagement, adopt new models of care, build workforce capacity, and advance advocacy and policy. This paper outlines practical implementation strategies to support adoption of the WHF Roadmap on Cardiac Rehabilitation (a pathway to improve lifelong cardiovascular health) in diverse real-world settings. We present adaptable approaches at the patient, clinician, and system levels, focusing on how cardiovascular rehabilitation can be embedded across the continuum of care with modernised concepts and terminology. Key strategies include integrating rehabilitation earlier and more consistently into care pathways, leveraging data for continuous quality improvement, and aligning funding mechanisms and policy frameworks to enable sustainable delivery. Importantly, implementation must remain responsive to local contexts, including variations in resources, workforce capacity, and population needs. Robust research strategies are also outlined that evaluate approaches to translate global priorities into routine practice and support the concept of being the lifelong cardiovascular health program for all.

Background As procedural volumes for left atrial appendage occlusion (LAAO) continue to rise, optimizing catheterization laboratory efficiency while maintaining safety has become paramount. We evaluated an ultra-efficient, standardized protocol designed to minimize procedural duration and hospital resource utilization. Methods This prospective series included 13 patients undergoing Watchman FLX Pro implantation at Vancouver General Hospital. The protocol integrated three core pillars: (1) pre-procedural 3D-CT imaging; (2) intra-procedural mini-TEE guidance; and (3) minimal conscious sedation (MCS) with low-dose midazolam and fentanyl. The endpoint was procedural and workflow efficiency, assessed by total case time, operative procedural time, mini-TEE indwelling time, hospitalization duration, technical success, procedural safety, sedation metrics, and the rate of same-day discharge. Results Our protocol produced highly efficient workflow metrics. Technical success was 100%, with no peri-procedural complications (0%). The mean total case time (room entry-to-exit) was 49.8 ± 9.5mins. The mean operative procedural time (venous puncture to hemostasis) was 24.2 ± 6.1mins. The mean mini-TEE indwelling time was 39.5 ± 20.2mins. Same-day discharge was achieved in 92.3% (12/13) of patients; the remainder patient met criteria for same-day discharge but preferred overnight stay. Mean sedation doses were 0.85 ± 0.80mg for midazolam and 73.0 ± 21.6μg for fentanyl; one patient had propofol due to patient preference. Conclusions A streamlined LAAO workflow is safe and feasible. This protocol significantly optimizes procedural efficiency and hospital resource utilization, achieving 100% technical success and high rates of same-day discharge. It offers a scalable minimalist framework for contemporary structural heart programs.

Background Despite the high prevalence and significant mortality associated with aortic stenosis (AS), data demonstrate low rates of referral to specialized heart valve teams. The objectives of this study were therefore to highlight contemporary referral patterns in patients with significant AS and identify potential barriers to referral. Methods Patients undergoing transthoracic echocardiography (TTE) in a large public health catchment had automatically generated text inserted into their TTE report and electronic medical record if the TTE met the American Society of Echocardiography criteria for moderate or severe AS. Text recommended referral to a heart valve team for further assessment or treatment. Patients were prospectively identified and followed. Structured telehealth was performed to clarify symptom status and perceived barriers to referral. Results Over 6 months, 343 patients with severe (n = 142) or moderate (n = 201) AS were identified. Despite significant AS alongside a referral prompt, only 86 (61%) patients with severe and 44 (22%) with moderate AS were referred for assessment. Patient and echocardiographic characteristics were similar between referred and nonreferred. Mortality was significantly higher in nonreferred patients with severe AS (19.6 vs. 2.3% referred, p < 0.001). Of the nonreferred patients who died, 5/11 (45%) had no compelling reason for lack of referral. Most nonreferred patients with severe AS reported progressive symptoms (75% New York Heart Association class II/III). Over half (51.2%) reported being managed with a “watchful waiting” strategy despite meeting a class I indication for aortic valve replacement, and nearly one-third (27.5%) were unaware of their diagnosis. Conclusions Despite automatically generated referral prompts in patients with severe AS, many patients without a compelling reason for lack of referral were not appropriately assessed and died.

Observational studies and intervention trials provide the evidence base for developing strategies for primary and secondary prevention of cardiovascular disease (CVD). The Joint European Society of Cardiology recommendations on prevention of coronary heart disease published in 1994 was the first European guideline to summarize this evidence and propose prevention strategies for clinical practice with regular updates since. The implementation of these recommendations, and subsequent guidelines, was evaluated from 1996 onwards through the EUROASPIRE programme of surveys, which have evolved over a 30-year period, involving thousands of coronary and high-risk patients from hundreds of medical centres across 30 countries. This cycle of surveys over six iterations is described in this historical review, informing the need for quality improvements in real-life practice, both to prevent the development of atherosclerotic disease in high-risk individuals (primary prevention) and in those with established CVD (secondary prevention).

BACKGROUND:Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact transcatheter aortic valve replacement (TAVR) procedural and long-term outcomes. CT coronary angiography (CTA) and CT-derived fractional flow reserve (FFRCT) are tools used to assess CAD. However, adoption in the TAVR population is hindered by safety concerns with nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTA and FFRCT optimised with these medications for TAVR have not been established. METHODS:This international, multi-center, prospective registry included severe AS patients referred for TAVR, assessed for CAD with CTA and FFRCT. Patients all received nitroglycerin and beta-blockers as needed to optimise image quality. Severe ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTA stenosis ≥50 ​% and FFRCT≤0.75. Primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Secondary endpoints included specificity and positive predictive value (PPV) of CTA and FFRCT, safety, feasibility (non-evaluable rate), and the modelled potential of CTA ​+ ​FFRCT to reduce pre-TAVR ICA. RESULTS:327 patients (75.9 ​± ​9.7 years, 53 ​% male) underwent CTA. CTA was safe and well tolerated in nearly all patients, with transient hypotension in 4 (1.2 ​%). CTA was evaluable in 326 patients (99.7 ​%), with 9 (2.8 ​%) having a non-evaluable vessel. FFRCT and ICA were performed in 110 (33.6 ​%) and 133 (40.7 ​%) patients, respectively. Per-patient sensitivity, specificity, NPV, and PPV of CTA were 100 ​%, 71.4 ​%, 100 ​%, and 75.9 ​% and per-vessel 82.7 ​%, 78.9 ​%, 92.3 ​%, and 59.9 ​%. FFRCT improved specificity and PPV to 88.9 ​% and 88.0 ​% for per-patient and 95.1 ​% and 81.8 ​% for per-vessel analysis. Using a simulated triage model deferring ICA in patients with CTA <50 ​% or ≥50 ​% stenosis with FFRCT >0.75, 267 patients (81.7 ​%) could potentially have avoided ICA. CONCLUSION:Coronary CTA performed with nitroglycerin and selective use of beta-blockers is safe and effective for assessing CAD in stable severe AS patients. Combining CTA and FFRCT enhances diagnostic accuracy, potentially reducing the need for invasive angiography and streamlining TAVR workup.

AIMS:Hypertension is a highly common cardiovascular risk factor, and a large proportion of patients with coronary heart disease (CHD) have uncontrolled hypertension. We report on the distribution and determinants of hypertension awareness, treatment, and control in CHD hypertensive patients. METHODS:The EUROASPIRE V survey included 8261 CHD patients from 27 countries. Awareness was defined as patients reporting being told by a health professional to have raised blood pressure (BP), being aware of their BP target and latest measurement. Patients using antihypertensive medication to lower BP were considered treated. Controlled hypertension was defined as BP <140/90mmHg (<140/85mmHg in patients with diabetes). Factors associated with hypertension awareness, treatment and control were identified with logistic regression. RESULTS:A total of 6496 EUROASPIRE V patients were considered hypertensive, from which 60.4% were aware, 91.7% were on treatment, and 46.8% were controlled. Number of antihypertensive drugs and adherence were independently associated with awareness (OR 1.23, 95%CI 1.16-1.31, and 2.18, 1.74-2.74 respectively) and control (1.11, 1.05-1.17 and 1.93, 1.57-2.37 respectively). Secondary (1.32, 1.03-1.68) and tertiary (1.70, 1.32-2.17) education and undertaking lifestyle changes (1.60, 1.37-1.87) were associated with awareness. Controlled patients were more often aware (1.43, 1.23-1.65) and had a healthier risk factor profile (BMI >25kg/m2 0.73, 0.61-0.87, diabetes 0.67, 0.59-0.76, LDL ≥1.8mmol/L 0.75, 0.65-0.86) than uncontrolled patients. CONCLUSION:Hypertension control remains poor in hypertensive CHD patients, despite high treatment and reasonable awareness levels. Communication with CHD hypertensive patients, especially those from vulnerable groups, needs to improve to facilitate change of health behaviours.

With an ageing population and the persistence of unhealthy lifestyle behaviours, health-care systems are challenged by a growing number of individuals living longer with cardiovascular disease and its sequelae. The evolution of cardiac rehabilitation, from a group exercise-based programme to encompassing all aspects of secondary prevention, has led to the ultimate objective of achieving lifelong cardiovascular health for all. In this World Heart Federation Roadmap, we present a united and forward-looking vision to consolidate global and collaborative efforts that enhance equitable access, improve patient outcomes and ensure value-based health care. The Roadmap outlines a reframing of terminology and interconnected solutions founded on unity, person-centredness and being future-focused. The five key roadblocks and widely applicable solutions are interlinked and include having a greater emphasis on lifelong cardiovascular health, better engagement among patients and clinicians, a greater emphasis on new models of care, workforce strengthening and support for strong advocacy and policy. We present a series of practical solutions and successful international case studies. The next steps are to facilitate local and regional implementation and evaluation strategies. A shift to systems, policy and advocacy thinking is crucial for the sector, with a view to long-term investment to meet growing demands. This World Heart Federation Roadmap is endorsed by the International Council of Cardiovascular Prevention and Rehabilitation.

Dysglycaemia, defined as type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT), increases the cardiovascular risk and prognosis. INTERASPIRE performed in 14 countries across 6 WHO regions evaluated guideline adherence and management of patients with coronary artery disease (CAD) and dysglycaemia. A total of 4,548 CAD patients (18–80 years) were interviewed 6 months–2 years after hospital admission. All without diabetes were eligible for an oral glucose test (OGTT). Overall, 1990 (44

AIMS:To quantify international variations in lipid-lowering therapies (LLT) use among patients with coronary heart disease (CHD) and attainment of European guideline-recommended lipid goals. METHODS AND RESULTS:INTERASPIRE is an observational study (2020-23) covering 14 countries from all WHO regions. Patients (18-79 years) hospitalized in the preceding 6-36 months with CHD were invited for standardized interviews and examination, with central laboratory analyses for low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and apolipoprotein B (apoB). Valid lipid data meeting quality control standards were available from 13 countries. Lipid goals followed the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology: LDL-C < 1.4 mmol/L, non-HDL-C < 2.2 mmol/L, and apoB <65 mg/dL.Among 4061 patients (78.8% male, mean age 60.3 years), between index event and interview, 66.3% had no change in treatment intensity. LLT use at interview was largely statin monotherapy: 49.6% high-intensity (inter-country range 5.3%-77.3%) and 24.1% low/moderate-intensity (inter-country range 5.1%-70.1%). Otherwise, 12.2% (inter-country range 0.2%-41.1%) were on combination therapy, and 12.7% on no LLT (inter-country range 3.5%-36.7%). Goal attainment for LDL-C was 17.5%. Corresponding non-HDL-C and apoB goals were achieved by 29.9% and 29.2%, respectively. Higher-income countries (defined by the World Bank's 2024-25 classification of income levels) did better in goal attainment than lower-middle-income countries. CONCLUSION:In this international study, contemporary lipid goals were not achieved in most CHD patients, with lower-middle-income countries having the worst goal attainment. Contributory factors include absence of any LLT use, low use of combinations and a failure to up-titrate LLT to achieve guideline targets.

Background:INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods:Patients 18-80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results:Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76-1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions:INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.

BACKGROUND AND AIMS:Hypertriglyceridemia (HTG) is independently associated with risk of atherosclerotic events, even when LDL-cholesterol levels appear controlled. This INTERASPIRE study determined the frequency of HTG and residual combined dyslipidemia and their related factors in patients with coronary heart disease (CHD) from 13 countries across six World Health Organization (WHO) regions. METHODS:Participants with CHD underwent a standardized study interview and examination, including a centralized analysis of fasting blood samples. Elevated triglyceride (TG) and LDL-cholesterol were defined as ≥ 1.7 mmol/L and 1.8 mmol/L, respectively. Elevation in both was considered combined dyslipidemia. RESULTS:Lipid profiles were available for 4069 patients. The mean age was 60.1 years (21.1 % women, 12.6 % smokers, 24 % obesity by body mass index [BMI], 61 % hypertension, and 44 % self-reported diabetes). Participants were evaluated 1.05 (0.76-1.45) years after their index CHD hospitalization. Overall, 12.7 % used no lipid-lowering therapies (LLT), 50.0 % used high-dose statins, and 11.8 % used combination therapies. Specific TG-lowering therapies were used by 2.3 %. One-third of patients had HTG, and 24.6 % had combined dyslipidemia. HTG was seen in all countries, but median TG values varied, with higher values among those not using LLT. HTG was independently associated with female sex, smoking, BMI, blood pressure, and LDL-cholesterol. HTG was inversely associated with HDL-cholesterol. CONCLUSIONS:HTG and residual combined dyslipidemia are common, although with wide variability between countries. A healthier lifestyle, weight reduction, greater use of combination therapy, and evidence-based TG-lowering treatments are necessary to reduce the risks of HTG and combined dyslipidemia.

BACKGROUND: Transcatheter heart valve (THV) underexpansion after transcatheter aortic valve replacement may be associated with worse outcomes. THV expansion can be assessed fluoroscopically using a pigtail for calibration; however, the accuracy of this technique specific to transcatheter aortic valve replacement is unknown. We assessed the accuracy and reproducibility of a novel fluoroscopic method to assess THV expansion using the THV commissural post for calibration. METHODS: Patients who underwent transcatheter aortic valve replacement with a SAPIEN 3 (S3) THV had documented 3 cusp and cusp overlap views, and post-implant computed tomography was identified. THV expansion was fluoroscopically assessed in the 3 cusp and cusp overlap views using the S3 commissural post height and the pigtail as a reference for calibration. The correlation between the 2 methods and computed tomography was evaluated. RESULTS: Forty patients were included. On the bench, the commissural post height measured 3.3, 3.5, 4.0, and 4.5 mm for the 20 mm S3, 23 mm S3, 26 mm S3, and 29 mm S3, respectively. The Pearson correlation coefficient (r) with computed tomography for measuring the inflow, mid-portion, and outflow THV diameter was 0.98, 0.97, and 0.98 for the commissural post height method and 0.82, 0.81, and 0.78 for the pigtail method, respectively. Unlike the pigtail method, the correlation between the commissural post height method and computed tomography remained strong across all THV sizes and in both the 3 cusp and cusp overlap views. CONCLUSIONS: The commissural post height method is a novel real-time fluoroscopic tool that has the potential to assess THV expansion and guide further optimization after balloon-expandable transcatheter aortic valve replacement.