INTRODUCTION:Pulmonary endarterectomy (PEA) is the first-line treatment for chronic thromboembolic pulmonary hypertension (CTEPH), while balloon pulmonary angioplasty (BPA) is an established alternative for inoperable patients. Although both interventions improve resting pulmonary hemodynamics, the extent of long-term physiological recovery during exercise and the persistence of functional limitations remain incompletely characterized. METHODS:Prospective single-center registry (2017-2023) including 14 patients completing BPA (71 sessions) and 15 undergoing PEA, with median follow-up of 50 months (IQR 36-61). Clinical assessment included resting hemodynamics, invasive exercise right heart catheterization to derive the exercise slope of the mean pulmonary arterial pressure to cardiac output relashionship (mPAP/CO slope), and health-related quality of life (HRQOL) evaluated using the SF-36 questionnaire. Analyses were descriptive and focused on within-pathway changes over time. RESULTS:Both BPA and PEA significantly reduced mPAP (44.8 ± 12.4 → 26.1 ± 9.3 mmHg; 42.1 ± 12.9 → 22.6 ± 5.4 mmHg, both p < 0.001) and pulmonary vascular resistance (9.8 ± 4.6 → 3.0 ± 1.3 WU; 9.0 ± 5.4 → 2.9 ± 1.9 WU, both p < 0.001) at long term follow-up. Despite sustained improvements in resting hemodynamics, abnormal exercise pulmonary vascular responses persisted, with mean mPAP/CO slopes of 7.0 ± 5.6 mmHg/L/min after BPA and 4.0 ± 2.3 mmHg/L/min after PEA. Physical HRQOL remained impaired at long-term follow-up, with Physical Component Summary (PCS) scores below population norms in both pathways (44.4 ± 12.7 after BPA and 44.5 ± 7.3 after PEA). CONCLUSION:BPA and PEA provide durable improvements in resting pulmonary hemodynamics; however, incomplete physiological recovery is common, with persistent exercise abnormalities and reduced physical quality of life at long-term follow-up.

OBJECTIVE:The aim of this study was to characterise thoracic aortic diameters across pre-defined segments in adults undergoing chest computed tomography (CT) during hospitalisation for coronavirus disease 2019 (COVID-19) in Portugal and to estimate the prevalence of thoracic aortic aneurysm (TAA) and ectasia. METHODS:A retrospective cross sectional analysis of a random sample of adults hospitalised for COVID-19 between March 2020 and December 2021 who underwent chest CT as part of routine care was performed. External aortic diameters were measured at pre-defined thoracic segments using multiplanar reconstructions. Sex and age specific means and standard deviations (SD) were calculated. Median and interquartile range values are presented in the tables. TAA was defined as a segmental diameter ≥ 1.5 times the sex specific mean diameter, and ectasia as > mean + 2 SD. Prevalence estimates were calculated, and logistic regression was used to examine the association between age and TAA. Interobserver variability was assessed. RESULTS:A total of 763 patients were included (mean age 65 ± 18.3 years; 44.2% women). Thoracic aortic diameters progressively decreased from the arch (31 - 28 mm) to the descending thoracic aorta (27 - 23 mm). Men had larger diameters than women across all segments (mean difference 1.7 - 2.7 mm), and aortic size steadily increased with age. The overall prevalence of TAA was 1.4% (n = 11), with a similar prevalence in women (1.5%) and men (1.4%). TAA most frequently occurred in patients ≥ 75 years (2.9%). Thoracic ectasia or aneurysm was identified in 8.7% of patients, with the highest segment specific prevalence in the arch and descending thoracic aorta. Interobserver variability was minimal (< 1 mm). CONCLUSION:This study provides the first CT based thoracic aortic morphometric data in a Portuguese cohort and identified age and sex as key correlates of aortic size. Exploratory estimates of TAA and ectasia prevalence are also reported but should be cautiously interpreted given the small number of aneurysm cases.

There are a number of guidelines on how to manage ischemic heart disease (IHD), but inconsistencies in healthcare access, varying infrastructure, resource constraints and diverse local practices restrict their global applicability. This underscores the need for universal recommendations that address the unique challenges faced by patients and healthcare providers worldwide. Our Global Guidelines emphasize the incorporation of novel therapies, while integrating standards of care with the most up-to-date evidence to enable clinicians to optimize IHD management. These Global Guidelines provide evidence-based recommendations that represent a group consensus considering the previously published guidelines that have reviewed many of the issues related to the management of IHD but have also provided recommendations on several issues where resource limitations may put constraints on the evaluation and treatments provided to patients with IHD. Such recommendations aim to guide situations when resources are somewhat limited or when resources are severely limited. Hence, this document presents a comprehensive update to IHD management guidelines, thereby aiming to provide a unified strategy for the management of IHD that is applicable to all cardiovascular care worldwide.

BACKGROUND:Aortic dimensions vary according to age, sex, and population characteristics. This study aimed to establish computed tomography (CT)-based reference diameters for the abdominal aorta in a Portuguese hospital population, providing reference data that may support the assessment of aortic dilatation and future population-specific studies of aneurysm diagnosis and surveillance. METHODS:A single-center cross-sectional study was conducted using CT examinations performed at a tertiary referral hospital in Portugal during 2018. CT scans were randomly selected using a stratified sampling strategy according to month and time of day. Patients with known aortic disease or CT examinations requested in the context of vascular or cardiac surgery consultations were excluded. Aortic diameters were measured on multiplanar reconstructions using outer-to-outer wall measurements at standardized anatomical locations. Analyses were performed overall and stratified by sex and age group (<50, 50-75, and >75 years). Comparisons were performed using Student's t-test and linear regression models, including age-adjusted analyses for sex comparisons. RESULTS:A total of 479 patients were included, of whom 266 (55.5%) were males. The mean age was 64.5 years (standard deviation [SD] 17.3). The mean abdominal aortic diameters were 23.71 mm (SD 4.32) at the celiac level, 22.07 mm (SD 4.08) at the superior mesenteric artery level, and 20.95 mm (SD 4.14) at the renal level. Infrarenal diameters ranged from 18.95 mm (SD 4.05) proximally to 17.72 mm (SD 3.89) distally. Men had significantly larger diameters than women at all anatomical locations (all P < 0.001). Aortic diameter increased significantly with age across all segments (all P < 0.001), with consistent and additive effects of age and sex. CONCLUSION:This study provides CT-based reference values for abdominal aortic diameters in a Portuguese population. Aortic size is strongly influenced by age and sex, supporting the need for population-specific and demographically stratified reference values.

AIMS:To assess the relationship between coffee consumption and all-cause mortality in heart failure (HF) patients, using data from the National Health and Nutrition Examination Survey (NHANES). METHODS AND RESULTS:We analyzed data from NHANES (2003-2018), including 915 participants with HF who reported daily caffeine intake. Participants were categorized into coffee consumption levels: zero, one, two, three, and ≥4 cups/day. Multivariate logistic regression evaluated the relationship between coffee intake and mortality, adjusted for age, sex, and income. The mean participant age was 67, with 401 (44%) women. While one to three cups/day showed no significant association with mortality, consuming ≥4 cups/day increased mortality risk (OR: 1.58; 95% CI: 1.16-2.16; p=0.004). Age was the strongest predictor of mortality, while income and sex showed marginal associations. CONCLUSIONS:Consuming up to three cups of coffee per day may be safe for patients with HF, while intake of four or more cups warrants caution due to the association with increased mortality. These findings underscore the need for further research to provide reliable recommendations.

Elevated lipoprotein(a) (Lp(a)) and Lp(a)-raising genetic variants (e.g. rs3798220) are independent cardiovascular risk factors lacking preventive strategies. Given the prothrombotic properties attributed to high Lp(a), aspirin was hypothesized to confer benefit in primary prevention. We performed a systematic review and meta-analysis to evaluate the impact of aspirin on cardiovascular and bleeding outcomes in this population. MEDLINE, Web of Science and CENTRAL were searched (November 2025) for randomized and observational studies assessing aspirin use in primary prevention among individuals with Lp(a) ≥ 50 mg/dL or Lp(a)-associated genetic variants. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), coronary artery disease (CAD), cardiovascular mortality, and bleeding. Random-effects meta-analyses pooled the Hazard ratios (HR) with 95

AIM:The primary objective of this study was to assess the impact of attending a phase 3 cardiac rehabilitation (CR) program on all-cause mortality. METHODS:We conducted a systematic review using database searches (MEDLINE and Cochrane Central Register of Controlled Trials) up to December 2022 to identify studies that compared adult patients undergoing phase 3 of CR with those receiving usual care. RESULTS:Out of a total of 1867 identified articles, eight met the eligibility criteria (two randomized controlled trials (RCT) and six non-RCT) and were included (n=60939 patients; 82% male, average age of 62±11 years). Phase 3 of a CR program showed a significant association with reduced mortality rates, with a hazard ratio (HR) of 0.56 (95% CI 0.49-0.65), with minimal evidence of statistical heterogeneity. The studies presented a range of differently structured CR programs. They varied in duration, training methods, and components. CONCLUSION:This systematic review demonstrates that attending a phase 3 CR program has the beneficial effect of reducing mortality among patients with cardiovascular disease, in particular those with coronary artery disease. These findings highlight the importance of CR participation on a long-term basis and reinforce the value of increasing the number of specialized worldwide and optimizing patient referrals to participate in a long-term phase 3 CR program.

Accurate quantification of aortic valve area (AVA) is essential in the evaluation of aortic stenosis (AS) severity. While two-dimensional (2D) Transesophageal echocardiography (TEE) is widely used for AVA planimetry, three-dimensional (3D) TEE may offer superior accuracy due to improved anatomical visualization. We aimed to compare AVA measurements by 2D versus 3D TEE in patients with AS. We conducted a systematic review and meta-analysis of studies reporting AVA measurements using both 2D and 3D TEE in adult patients with AS. Paired measurements, means and standard deviations, or correlations between techniques were extracted. The primary outcome was the mean difference in AVA (cm²) between modalities. Secondary outcomes included pooled correlation coefficients and assessment of heterogeneity. Analyses were performed using random-effects models. Eight studies comprising 381 patients were included. The pooled mean absolute difference between 2D and 3D TEE was 0.16 cm² (95

INTRODUCTION:To compare the effect of smoking cessation in abdominal aortic aneurysm growth compared to active smokers and non-smokers. EVIDENCE ACQUISITION:A systematic review and Network Meta-Analysis was performed following the PRISMA guidelines using a registered protocol (CRD42021295315). We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey databases from inception to January 2022 for comparative studies reporting on abdominal aortic aneurysm growth according to smoking habits. AAA was defined as an infra-renal aortic diameter >3 cm. The main outcome was to estimate the mean difference of abdominal aortic aneurysms growth between smokers, former smokers, and nonsmokers. The estimates were pooled through a random-effects model network meta-analysis and heterogeneity assessed through the I2 statistic. EVIDENCE SYNTHESIS:After 567 abstracts reviewed and 17 full text studies, six studies were included in the review and meta-analysis. Studies reported data from 1987-2017, encompassing a population of 2960 people with diagnosis of AAA, which 972 were active smokers, 1254 were former smokers and 679 were nonsmokers. Based on the network estimates, we did not find a statistically significant difference between AAA growth rate differences between former smokers and non-smokers (MD 0.05, 95% CI: -0.36 to 0.47). However, we found statistically significant differences between former smokers and active smokers (MD -0.45, 95% CI: -0.83 to -0.06) and active smokers versus non-smokers (MD 0.50, 95% CI: 0.16 to 0.85). CONCLUSIONS:Smoking cessation seems to reduce the growth rate of AAA to rates similar to non-smokers, being a potential therapeutic target. These findings should lead to a higher awareness of the importance of smoking eviction in AAA patients and to future studies on this matter.

Background:Sudden cardiac death (SCD) remains a major concern in hypertrophic cardiomyopathy (HCM). Over recent years, European Society of Cardiology (ESC) guidelines have broadened recommendations for implantable cardioverter defibrillator (ICD) implantation in primary prevention. We aimed to evaluate clinical outcomes and event detection in an HCM primary prevention cohort, while assessing how these evolving criteria translate into real-world ICD eligibility and event detection. Methods:We conducted a single-centre retrospective study including 52 consecutive HCM patients who received an ICD for primary prevention between 2014 and 2024. Baseline clinical, imaging, and follow-up data were collected. The primary endpoint was appropriate ICD therapy for ventricular tachycardia or fibrillation. Patients were classified according to the 2014, 2022, and 2023 ESC guidelines. Time-to-event analyses using univariate Cox regression were performed to identify predictors of ICD activation. Results:Over a median follow-up of 2.2 years, 6 patients (12%) experienced appropriate ICD therapy. According to ESC classifications, the 2022/2023 guidelines would have increased ICD eligibility by about 50% compared with the 2014 guideline, mainly due to the inclusion of extensive late gadolinium enhancement on CMR and reduced LVEF (<50%) as risk enhancers. However, no guideline set identified all patients who developed ventricular arrhythmias, and a subset of patients with events would not have been eligible for ICD implantation under any ESC recommendation. Lower LVEF was associated with higher risk of ICD activation. Conclusions:Successive ESC guidelines have lowered the threshold for ICD implantation in HCM, increasing eligibility but also implantations in event-free patients. Persistent event occurrence in ineligible individuals highlights the need for refined prediction models and individualized clinical judgment, including complementary tools such as ILR monitoring.

BACKGROUND:To perform a systematic review and meta-analysis of studies reporting the incidence of post-dissection aneurysms and need for secondary interventions after surgery for acute type A aortic dissections (ATAAD). METHODS:Following PRISMA guidelines, MEDLINE and CENTRAL databases were searched from inception to June 2023 for longitudinal studies reporting post-dissection aneurysmal formation and secondary interventions after surgery for ATAAD. The main outcome was the incidence of post-dissection aneurysms. Secondary outcomes included the incidence of post-dissection suture-line complications and secondary interventions related to aneurysmal complications. Additionally, the overall and aortic-related mortality during follow-up were pooled. RESULTS:One hundred and twenty-eight studies were included. The pooled calculated incidence of post-dissection aneurysmal formation after surgery for ATAAD was 10.24% (95% CI: 8.03-12.66). On sensitivity analysis considering only studies assessed having low risk of bias, incidence of post-dissection aneurysms increased to 24.9% (95% CI: 17.9-33.3). The incidence of suture line complications was 1.59% (95% CI: 0.98-22.30) and the incidence of late secondary interventions related to aortic aneurysmal complications was 12.00% (95% CI 10.12-14.00). Lastly, the calculated overall mortality was 17.53% (95% CI 14.71-20.53) and the aortic-related mortality was 1.59% (95% CI 1.08-2.18). CONCLUSIONS:The incidence of post-dissection aneurysmal formation in patients after previous surgery for acute type A aortic dissection in primarily untreated segments remains frequent. The reporting of this long-term issue has been broadly adopted in the aortic literature. Further studies are needed to assess the initial surgical strategy and its extent as well as a stringent follow-up protocol on early detection and intervention in these patients.

BACKGROUND:Push-dose pressors (PDP) were mainly studied in operating room (OR) patients. Critically ill patients outside the OR present with different characteristics and logistical challenges. Available evidence in this population is limited, and the safety risk makes it a controversial therapy. OBJECTIVES:We performed a systematic review to evaluate the benefits and risks of using PDP in this population. METHODS:We included studies performed outside the OR, evaluating efficacy, safety and prognostic outcomes, as well as comparing different vasopressor strategies. We searched Pubmed for eligible studies. A random-effects meta-analysis (proportional for single-arm studies), reporting the mean, mean difference or risk ratio with 95% confidence intervals (CI) was performed. Risk of bias was assessed with the Newcastle-Ottawa Scale (NOS) scale. RESULTS:Nineteen observational studies evaluating 5034 patients were included. 77.9% (95% CI [71.9-83.4]) of patients corrected hypotension after PDP, with a mean systolic blood pressure increase of 30 mm Hg (95%CI [24.7-35.9]). Adverse effects occurred in 14.4% (95% CI [7.8-22.5]) and serious adverse effects in 1.36% (95% CI [0.16-3.30]). Protocol use was associated with a non-significant tendency for lower risk of adverse effects, that became significant when considering only epinephrine. 69.5% (95% CI [59.3-78.9]) of PDP-treated patients needed a vasopressor infusion. Starting with PDP followed by infusion instead of infusion alone was associated with a non-significant lower survival at discharge (RR: 0.85, 95% CI [0.7-1.02]), that became significant after removing one influential study. CONCLUSIONS:PDP is effective for transient hypotension correction in critical patients outside the OR, with a safety risk that could be reduced with protocol use. Clinical trials are needed to inform current practice.

OBJECTIVE:The aim of this study was to compare aortic size index (ASI) (aortic diameter/body surface area) with aortic diameter (AD) in patients with infrarenal abdominal aortic aneurysms (AAAs) for screening, diagnosis, and outcomes, focusing on women. DATA SOURCES:Cochrane, MEDLINE, and Web of Science Core Collection databases. REVIEW METHODS:Databases were searched (last update 14 May 2024) for reports on ASI in patients with AAA reporting sex disaggregated data. A systematic review and meta-analysis was performed following the PRISMA guidelines. RESULTS:Eleven studies with 150 028 cases (19.8% women) were included. The reported outcomes exhibited considerable heterogeneity. Three studies evaluated incidence and or prevalence rates, seven reported on AD and ASI at the time of repair, three considered rupture risk, and five evaluated peri-operative outcomes. In one study, AAA prevalence was 5.7% in men and 4.5% in women with a cutoff ASI ≥ 1.5 cm/m2 (corresponding to a 30 mm AD in men and 26 mm AD in women), compared with 5.7% in men vs. 2.4% in women using an AD ≥ 30 mm cutoff. ASI ≥ 2.7 cm/m2 was found to be associated with a distribution of ruptured repairs of 12% in both sexes, corresponding to 55 mm AD in men and 49 mm AD in women. A meta-analysis of aneurysm size at the time of surgical repair found that women were operated on at an estimated 3.05 mm smaller diameter but 0.32 cm/m2 higher ASI. Higher ASI was associated with worse clinical outcomes in women, but not consistently so in men. CONCLUSION:Women undergo AAA repair at lower AD but higher ASI than men. Use of ASI suggests that women undergo diagnosis and treatment at a later stage of disease. This warrants reconsideration of current AD threshold recommendations and further in depth studies assessing the impact of ASI standardisation.

Background Hypertrophic cardiomyopathy (HCM) is caused by mutations in sarcomere-related genes, with MYBPC3 being the most common. Documenting potential genotype-phenotype associations may allow for more personalized genetic counselling. Methods and Results Observational case-control, cohort, and cross-sectional studies reporting genotype-phenotype associations and the occurrence of predefined events were selected from Cochrane and Medline databases. A random- effects meta-analysis was conducted. Twenty-four studies were included, with 3869 patients enrolled. The mean age at diagnosis of HCM associated with mutations in the MYBPC3 gene was 39.8 years (95 % CI 32.96 to 46.55), and the mean maximum left ventricular thickness was 20.4 mm (95 % CI 19.72 to 21.06). Proportion rates were 12.6 % (95 % CI 5.7 to 21.5 %) for septal reduction therapy, 20.4 % (95 % CI 11.9 to 30.2 %) for the development of heart failure New York Heart Association (NYHA) III/IV functional class, 16.1 % (95 % CI 10.3 to 22.6 %) for the occurrence of atrial fibrillation, and 26 % (95 % CI 17.0 to 36.1 %) for ventricular tachycardia. Cardioverter-defibrillators were implanted in 31.4 % (95 % CI 18.6 to 45.6 %) for secondary prevention, and sudden cardiac arrest occurred in 14.7 % (95 % CI 7.8 to 23.0 %) of patients. Cardiovascular death occurred in 8.6 % of patients over a median of 73 months of follow-up. Conclusion This is the largest meta-analysis of MYBPC3 HCM patients to date. We were able to obtain data on the proportion rates of events in this population, which allows to answer some questions about the clinical course of HCM disease associated with mutations in the MYBPC3 gene more clearly. We found not only a late disease onset and low mortality risk, but importantly, a non-negligible risk of developing severe heart failure throughout life.

Background: Aspirin is part of the therapeutic antithrombotic armamentarium for the management of patients with established clinically relevant atherosclerosis or thrombotic cardiovascular disease. Personalized medicine identifies those who benefit most or face fewer risks from aspirin. The role of aspirin in primary prevention is still debatable. We aimed to assess the risks and benefits of aspirin in this setting, using the data of the prospective VITAL (VITamins and Lifestyle) study. Methods: We conducted a retrospective evaluation of the VITAL cohort. In this analysis, participants were split according to aspirin usage. Aspirin use was evaluated regarding all-cause mortality, CV mortality, major cardiovascular event (MACE), myocardial infarction, coronary heart disease, total stroke, and hemorrhagic stroke. The hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated to explore the association between cardiovascular events and aspirin usage. The estimates were adjusted for demographic and clinical variables. Results: The aspirin users (n = 11,570) were older, more frequently men, the body mass index was higher, and the proportion of smokers was smaller compared with non-users (n = 13,927). After adjusting for demographic and clinical variables, aspirin was not identified as a predictor of cardiovascular death (HR 1.17, 95%CI 0.89 to 1.55), major cardiovascular events (HR 1.04, 95%CI 0.89 to 1.22), coronary heart disease (HR 1.16, 95%CI 0.98 to 1.37), nor stroke (HR 1.01, 95%CI 0.77 to 1.31). Conclusion: In this retrospective analysis of the VITAL cohort, aspirin was not associated with a reduced risk of cardiovascular mortality or events.