Background Revascularization through coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as an add-on therapy to optimal medical therapy (OMT) is routinely used in patients with severe ischemic cardiomyopathy (ICM) with left ventricular ejection fraction (LVEF) ≤ 35% to improve cardiovascular outcomes with limited available data about their relative costs and efficacies. We performed a cost-effectiveness analysis to illustrate the most economically favorable strategy in this population. Methods A Markov model simulated a cohort with severe ICM (EF ≤ 35%) and evaluated strategies of CABG+OMT, PCI+OMT and OMT alone. Model inputs were obtained from STICH and REVIVED clinical trials and their subsequent cost-effectiveness analyses. Cohorts were followed monthly, with mortality and major adverse cardiac events (MACE; a composite of heart failure hospitalization, myocardial infarction, revascularization and arrythmias) modeled as lifetime disutilities, taking the US health system perspective, and discounting 3% per year over lifetime horizon. Outcome measures were lifetime medical costs (2019 US$), quality-adjusted-life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Results OMT alone was the least costly strategy at $107,780 and yielded 5.29 QALYs. PCI+OMT yielded 5.50 QALYs and cost $124,295, while the CABG+OMT strategy resulted in 6.04 QALYs and cost $154,965 with an ICER of $62,786 per QALY gained. Thus, CABG+OMT was preferred at a $100,000/QALY gained threshold, a commonly cited US benchmark. In a probabilistic sensitivity analysis, CABG+OMT was the preferred strategy in 25%, 51% and 58% of the model iterations at $50,000, $100,000, and $150,000 per QALY gained willingness-to-pay (WTP) thresholds respectively. Conclusions CABG+OMT is the most cost-effective strategy in patients with severe ICM as compared with PCI+OMT or OMT only strategies at current benchmarks for value in the United States.

Predicting major bleeding in nonvalvular atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) is crucial for personalized care. Alternatives like left atrial appendage closure devices lower stroke risk with fewer nonprocedural bleeds. This study compares machine learning (ML) models with conventional bleeding risk scores (HAS-BLED, ORBIT, and ATRIA) for predicting bleeding events requiring hospitalization in AF patients on DOACs at their index cardiologist visit. This retrospective cohort study used electronic health records from 2010 to 2022 at the University of Pittsburgh Medical Center. It included 24,468 nonvalvular AF patients (age ≥18) on DOACs, excluding those with prior significant bleeding or warfarin use. The primary outcome was hospitalization for bleeding within one year, with follow-up at one, two, and five years. ML algorithms (logistic regression, classification trees, random forest, XGBoost, k-nearest neighbor, naïve Bayes) were compared for performance. Of 24,468 patients, 553 (2.3%) had bleeding within one year, 829 (3.5%) within two years, and 1,292 (5.8%) within five years. ML models outperformed HAS-BLED, ATRIA, and ORBIT in 1-year predictions. The random forest model achieved an AUC of 0.76 (0.70 to 0.81), G-Mean of 0.67, and net reclassification index of 0.14 compared to HAS-BLED's AUC of 0.57 (p < 0.001). ML models showed superior results across all timepoints and for hemorrhagic stroke. SHAP analysis identified new risk factors, including BMI, cholesterol profile, and insurance type. In conclusion, ML models demonstrated improved performance to conventional bleeding risk scores and uncovered novel risk factors, offering potential for more personalized bleeding risk assessment in AF patients on DOACs.

BACKGROUND:There exists clinical equipoise regarding whether and when an invasive approach should be preferred over conservative treatment in the management of stable late ST-elevation myocardial infarction (STEMI) presenting within 12 to 72 h of symptom onset. OBJECTIVE:To perform a systematic review to identify the most effective treatment strategy between percutaneous coronary intervention (PCI) and medical therapy in stable late STEMI presenters by comparing their respective outcomes as well as determine the optimal timing of PCI by evaluating the outcomes of urgent versus non-urgent PCI approach in this patient population. METHODS:PubMed, Embase, and Cochrane databases were queried from inception until March 2024 for studies comparing the outcomes of PCI versus medical therapy, as well as urgent versus non-urgent PCI, in stable late STEMI patients presenting with symptom onset within 12-72 h. Quality of the studies and risk of bias were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and the Cochrane Risk of Bias (ROBINS-I 2016) tool, respectively. RESULTS:A total of 8 studies were included in this systematic review that met the inclusion criteria. Among these, 5 studies (1 randomized controlled trial (RCT), 1 post-hoc analysis, and 3 observational studies) with an aggregate of 3820 participants compared PCI and medical therapy in stable late STEMI presenters. They found that PCI was associated with statistically significant better short- and long-term outcomes by lowering all-cause mortality, recurrent myocardial infarction (MI), and infarct size, and by improving myocardial salvage index (P < 0.001). Similarly, a non-statistically significant improvement was seen in the events of cardiac death, heart failure, and revascularization as well as ejection fraction percentage with PCI (P > 0.05). The other 3 studies, involving 1270 participants, were observational and compared urgent versus non-urgent PCI and did not find any statistically significant difference in clinical outcomes between the two approaches (P > 0.05). The included studies were significantly heterogeneous in methodologies, follow-up intervals, and reporting of outcomes. Most of the studies provided moderate quality of evidence and had moderate to serious risk of bias. CONCLUSIONS AND RELEVANCE:Revascularization through PCI is associated with superior short- and long-term outcomes compared to medical therapy in stable late STEMI patients presenting within 12-72 h of symptom onset. However, the optimal timing of PCI needs further investigation.

Abstract Chemotherapeutic agents can cause a variety of cardiovascular toxicities that are unique to the specific drug that is being used to treat a cancer. The field of cardio-oncology focuses on recognizing those toxicities and utilizing noninvasive imaging as well as biomarkers to predict the risk of cardiotoxicity and to prevent or mitigate that toxicity. Nuclear cardiac imaging plays an important role in the prevention and detection of cardiotoxicity, during, immediately after, and years after cancer treatment, not only for well-characterized agents such as anthracyclines and trastuzumab but also for the newer molecularly targeted chemotherapeutic agents. This chapter reviews the important role of nuclear cardiac imaging in the management of patients with cancer.

Valvular heart diseases (VHDs) significantly impact morbidity and mortality rates worldwide. Early diagnosis improves patient outcomes. Artificial intelligence (AI) applied to electrocardiogram (ECG) interpretation presents a promising approach for early VHD detection. We conducted a meta-analysis on the efficacy of AI models in this context. We reviewed databases including PubMed, MEDLINE, Embase, Scopus, and Cochrane until August 20, 2023, focusing on AI for ECG-based VHD detection. The outcomes included pooled accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value. The pooled proportions were derived using a random-effects model with 95% confidence intervals (CIs). Study heterogeneity was evaluated with the I-squared statistic. Our analysis included 10 studies, involving ECG data from 713,537 patients. The AI algorithms mainly screened for aortic stenosis (n = 6), mitral regurgitation (n = 4), aortic regurgitation (n = 3), mitral stenosis (n = 1), mitral valve prolapse (n = 2), and tricuspid regurgitation (n = 1). A total of 9 studies used convolution neural network models, whereas 1 study combined the strengths of support vector machine logistic regression and multilayer perceptron for ECG interpretation. The collective AI models demonstrated a pooled accuracy of 81% (95% CI 73 to 89, I2 = 92%), sensitivity was 83% (95% CI 77 to 88, I2 = 86%), specificity was 72% (95% CI 68 to 75, I2 = 52%), PPV was 13% (95% CI 7 to 19, I2 = 90%), and negative predictive value was 99% (95% CI 97 to 99, I2 = 50%). The subgroup analyses for aortic stenosis and mitral regurgitation detection yielded analogous outcomes. In conclusion, AI-driven ECG offers high accuracy in VHD screening. However, its low PPV indicates the need for a combined approach with clinical judgment, especially in primary care settings.

The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.

Right ventricular (RV) function is an important factor in patients presenting with ST-elevation myocardial infarction (STEMI) that has prognostic value for major adverse cardiovascular events (MACE).1 Compromised RV function often indicates a more severe myocardial infarction (MI) and can be a harbinger of worse short- and long-term outcomes. Although impaired RV function is most commonly associated with inferior STEMI, RV function is believed to be a predictor for increased in-hospital MACE in patients with STEMI, regardless of the culprit lesion.

Background: Revascularization through coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as an add-on therapy to optimal medical therapy (OMT) is routinely used in patients with severe ischemic cardiomyopathy (ICM) with ejection fraction (EF) ≤ 35% to improve cardiovascular outcomes with limited available data about their relative costs and efficacies. We performed a cost-effectiveness analysis to illustrate the most economically favorable strategy in this population. Methods: A Markov model simulated a cohort with severe ICM (EF ≤ 35%) and evaluated strategies of CABG+OMT, PCI+OMT and OMT alone. Model inputs were obtained from STICHES and REVIVED clinical trials and their subsequent cost-effectiveness analyses. Cohorts were followed monthly, with mortality and major adverse cardiac events (MACE; a composite of heart failure hospitalization, myocardial infarction, revascularization and arrythmias) modeled as lifetime disutilities, taking the US health system perspective, and discounting 3%/year over lifetime horizon. Outcome measures were lifetime medical costs (2019 US$), quality-adjusted-life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Results: OMT alone was the least costly strategy at $107,780 and yielded 5.29 QALYs. PCI+OMT yielded 4.87 QALYs and cost $121,368, while the CABG+OMT strategy resulted in 7.01 QALYs and cost $160,124 or $38,755 per QALY gained compared to PCI+OMT with an ICER of $18,130 per QALY gained over lifetime horizon. Thus, CABG+OMT was preferred at a $100,000/QALY gained threshold, a commonly cited US benchmark. In a probabilistic sensitivity analysis, CABG+OMT was the preferred strategy in 69%, 82% and 85%% of the model iterations at $50,000, $100,000, and $150,000 per QALY gained willingness-to-pay (WTP) thresholds respectively. Conclusions: CABG+OMT is the most cost-effective strategy in patients with severe ICM as compared with PCI+OMT or OMT only strategies at current benchmarks for value in the United States.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThe study did not receive any funding.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:UPMC IRBI 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.YesI 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).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesThe corresponding and senior authors have full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Early identification and implementation of a therapeutic plan is key to optimizing outcomes for patients with pulmonary hypertension (PH). In 1981, the National Institutes of Health began a registry to collect data from 32 centers to study primary PH, defined as a progressive pulmonary vascular disorder characterized by pulmonary vascular aberrations, which can lead to right ventricular dysfunction, failure, and death. 1 Thenappan T Shah SJ Rich S Tian L Archer SL Gomberg-Maitland M. Survival in pulmonary arterial hypertension: a reappraisal of the NIH risk stratification equation. Eur Respir J. 2010; 35: 1079-1087 Crossref PubMed Scopus (389) Google Scholar ,2 Noordegraaf AV Galiè N. The role of the right ventricle in pulmonary arterial hypertension. Eur Respir Rev. 2011; 20: 243-253 Crossref PubMed Scopus (189) Google Scholar The study reported a time-to-diagnosis of 2 years, primarily due to the presence of nonspecific symptoms including dyspnea, fatigue, or syncope with the requirement of a right heart catheterization to confirm the diagnosis. 3 Rich S Dantzker DR Ayres SM Bergofsky EH Brundage BH Detre KM Fishman AP Goldring RM Groves BM Koerner SK. Primary pulmonary hypertension. A national prospective study. Ann Intern Med. 1987; 107: 216-223 Crossref PubMed Scopus (1781) Google Scholar After three decades, consequent to a significant improvement in the surveillance, education, management, and therapeutic advances in pulmonary arterial hypertension (PAH), or Group I PH, the Registry to Evaluate Early and Long-term PAH Disease (REVEAL) reported a time-to-diagnosis of 1 year of which 21% of patients were diagnosed >2 years from initial presentation. 4 Brown LM Chen H Halpern S Taichman D McGoon MD Farber HW Frost AE Liou TG Turner M Feldkircher K Miller DP Elliott CG. Delay in recognition of pulmonary arterial hypertension: factors identified from the REVEAL Registry. Chest. 2011; 140: 19-26 Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar Delays in time-to-diagnosis and referral to expert PH centers limits the efficacy of therapeutic interventions, which are favorable at the earlier stages of PAH, and impact quality of life, morbidity, and survival. PAH is one of five classifications of PH, which are pathophysiologically similar entities that share common clinical and hemodynamic presentations, that requires echocardiography to detect and stratify probability of PAH. 5 Humbert M Kovacs G Hoeper MM Badagliacca R Berger RMF Brida M Carlsen J Coats AJS Escribano-Subias P Ferrari P Ferreira DS Ghofrani HA Giannakoulas G Kiely DG Mayer E Meszaros G Nagavci B Olsson KM Pepke-Zaba J Quint JK Rådegran G Simonneau G Sitbon O Tonia T Toshner M Vachiery JL Vonk Noordegraaf A Delcroix M Rosenkranz S ESC/ERS Scientific Document Group2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). Eur Heart J. 2022; 43: 3618-3731 Crossref PubMed Scopus (555) Google Scholar Despite noted limitations, the use of echocardiography in addition to risk calculators require information not readily available to the non-expert clinician limiting early recognition and referral, therefore delaying diagnosis and treatment, and impacting prognosis. 5 Humbert M Kovacs G Hoeper MM Badagliacca R Berger RMF Brida M Carlsen J Coats AJS Escribano-Subias P Ferrari P Ferreira DS Ghofrani HA Giannakoulas G Kiely DG Mayer E Meszaros G Nagavci B Olsson KM Pepke-Zaba J Quint JK Rådegran G Simonneau G Sitbon O Tonia T Toshner M Vachiery JL Vonk Noordegraaf A Delcroix M Rosenkranz S ESC/ERS Scientific Document Group2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). Eur Heart J. 2022; 43: 3618-3731 Crossref PubMed Scopus (555) Google Scholar , 6 Gall H Yogeswaran A Fuge J Sommer N Grimminger F Seeger W Olsson KM Hoeper MM Richter MJ Tello K Ghofrani HA. Validity of echocardiographic tricuspid regurgitation gradient to screen for new definition of pulmonary hypertension. EClinicalmedicine. 2021; 34100822 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar , 7 Janda S Shahidi N Gin K Swiston J. Diagnostic accuracy of echocardiography for pulmonary hypertension: a systematic review and meta-analysis. Heart. 2011; 97: 612-622 Crossref PubMed Scopus (271) Google Scholar , 8 Greiner S Jud A Aurich M Hess A Hilbel T Hardt S Katus HA Mereles D Reliability of noninvasive assessment of systolic pulmonary artery pressure by Doppler echocardiography compared to right heart catheterization: analysis in a large patient population. J Am Heart Assoc. 2014; 3e001103 Crossref PubMed Scopus (148) Google Scholar , 9 Fisher MR Forfia PR Chamera E Housten-Harris T Champion HC Girgis RE Corretti MC Hassoun PM. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med. 2009; 179: 615-621 Crossref PubMed Scopus (777) Google Scholar

The intricacies of intracardiac fluid dynamics hold the key to understanding various cardiovascular pathologies and their management. Echocardiography-derived hemodynamic forces (HDF) have emerged as a noninvasive technique to measure intracardiac hemodynamics characterizing the relation between wall mechanics and fluid dynamics of the left ventricle (LV), thus providing insight into mechanical synchrony in the context of ventricular remodeling. 1 Vallelonga F Airale L Tonti G Argulian E Milan A Narula J Pedrizzetti G Introduction to hemodynamic forces analysis: moving into the new frontier of cardiac deformation analysis. J Am Heart Assoc. 2021; 10e023417 Crossref PubMed Scopus (20) Google Scholar This technique builds on existing modalities of cardiac deformation analysis (i.e., strain and LV ejection fraction [LVEF]) by its ability to temporally quantify the interplay between blood flow and the endocardium of the LV. The noninvasive nature of this technique offers several advantages: (1) minimizing patient discomfort and risk, (2) repeated measurements with limited cumulative harm, (3) is cost-effective, and (4) providing a readily accessible means of monitoring cardiac performance. The significance of this technique lies in the changes in HDF which become apparent before pathologic alterations in myocardial deformation. In recent years, computational advancements have facilitated the calculation of HDF in the LV by drawing correlations with established imaging modalities such as 4-dimensional flow cardiac magnetic resonance imaging. 2 Pedrizzetti G Arvidsson PM Töger J Borgquist R Domenichini F Arheden H Heiberg E On estimating intraventricular hemodynamic forces from endocardial dynamics: a comparative study with 4D flow MRI. J Biomech. 2017; 60: 203-210 Crossref PubMed Scopus (39) Google Scholar Evolution of Echocardiography-Derived Hemodynamic Force Parameters After Cardiac Resynchronization TherapyAmerican Journal of CardiologyVol. 209PreviewEchocardiography-derived hemodynamic forces (HDF) allow calculation of intraventricular pressure gradients from routine transthoracic echocardiographic images. The evolution of HDF after cardiac resynchronization therapy (CRT) has not been investigated in large cohorts. The aim was to assess HDF in patients with heart failure implanted with CRT versus healthy controls. HDF were assessed before and 6 months after CRT. The following HDF parameters were calculated: (1) apical-basal strength, (2) lateral-septal strength, (3) the ratio of lateral-septal to apical-basal strength ratio, and (4) the force vector angle (1 and 2 representing the magnitude of HDF, 3 and 4 representing the orientation of HDF). Full-Text PDF Open Access

Cardiac sarcoidosis (CS) is a clinically challenging manifestation of systemic sarcoidosis, which is an idiopathic inflammatory disorder pathologically distinguished by non–caseating granulomas. Advanced cardiac imaging estimates approximately 30% of patients diagnosed with systemic sarcoidosis have cardiac involvement, with a primary presentation of heart failure, complete heart block, or ventricular arrhythmias. 1 Patel MR Cawley PJ Heitner JF Klem I Parker MA Jaroudi WA Meine TJ White JB Elliott MD Kim HW Judd RM Kim RJ. Detection of myocardial damage in patients with sarcoidosis. Circulation. 2009; 120: 1969-1977 Crossref PubMed Scopus (532) Google Scholar ,2 Terasaki F Azuma A Anzai T Ishizaka N Ishida Y Isobe M Inomata T Ishibashi-Ueda H Eishi Y Kitakaze M Kusano K Sakata Y Shijubo N Tsuchida A Tsutsui H Nakajima T Nakatani S Horii T Yazaki Y Yamaguchi E Yamaguchi T Ide T Okamura H Kato Y Goya M Sakakibara M Soejima K Nagai T Nakamura H Noda T Hasegawa T Morita H Ohe T Kihara Y Saito Y Sugiyama Y Morimoto SI Yamashina A Japanese Circulation Society Joint Working GroupJCS 2016 guideline on diagnosis and treatment of cardiac sarcoidosis - digest version. Circ J. 2019; 83: 2329-2388 Crossref PubMed Scopus (168) Google Scholar The past decades have seen a >20-fold increase in CS detection, emphasizing its escalating clinical significance. 2 Terasaki F Azuma A Anzai T Ishizaka N Ishida Y Isobe M Inomata T Ishibashi-Ueda H Eishi Y Kitakaze M Kusano K Sakata Y Shijubo N Tsuchida A Tsutsui H Nakajima T Nakatani S Horii T Yazaki Y Yamaguchi E Yamaguchi T Ide T Okamura H Kato Y Goya M Sakakibara M Soejima K Nagai T Nakamura H Noda T Hasegawa T Morita H Ohe T Kihara Y Saito Y Sugiyama Y Morimoto SI Yamashina A Japanese Circulation Society Joint Working GroupJCS 2016 guideline on diagnosis and treatment of cardiac sarcoidosis - digest version. Circ J. 2019; 83: 2329-2388 Crossref PubMed Scopus (168) Google Scholar

In recent decades, the field of medical diagnostics, particularly, in relation to atrial fibrillation (AF), has undergone a transformative shift. This evolution is characterized by unparalleled advancements in precision, accuracy, and clinical relevance. Concurrently, these advancements have been accompanied by a significant influx of data. Notably, individual cardiac evaluations are now generating expansive data sets. 1 Telenti A Jiang X. Author Correction: treating medical data as a durable asset. Nat Genet. 2020; 52: 1433 Crossref PubMed Scopus (1) Google Scholar This proliferation of data not only underscores the complexity of conditions such as AF but also challenges the capacities of traditional analytical approaches, highlighting the opportunity for novel, more sophisticated tools to elicit meaningful interpretations.

Guidelines for pulmonary hypertension (PH) continue to evolve to reflect a focus on early disease detection and treatment. This is driven by contemporary data that suggest PH morbidity and mortality exist at smaller hemodynamic parameters than was previously believed. 1 Maron BA Brittain EL Hess E Waldo SW Barón AE Huang S Goldstein RH Assad T Wertheim BM Alba GA Leopold JA Olschewski H Galiè N Simonneau G Kovacs G Tedford RJ Humbert M Choudhary G Pulmonary vascular resistance and clinical outcomes in patients with pulmonary hypertension: a retrospective cohort study. Lancet Respir Med. 2020; 8: 873-884 Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar In 2019, the European Society of Cardiology guidelines reduced the threshold for mean pulmonary artery pressure (mPAP) from 25 to 20 mm Hg, and subsequently, in 2022, the threshold for pulmonary vascular resistance (PVR) to qualify for precapillary PH was reduced from 3 to 2 Woods units. 2 Simonneau G Montani D Celermajer DS Denton CP Gatzoulis MA Krowka M Williams PG Souza R Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019; 531801913 Crossref Scopus (2279) Google Scholar ,3 Humbert M Kovacs G Hoeper MM Badagliacca R Berger RMF Brida M Carlsen J Coats AJS Escribano-Subias P Ferrari P Ferreira DS Ghofrani HA Giannakoulas G Kiely DG Mayer E Meszaros G Nagavci B Olsson KM Pepke-Zaba J Quint JK Radegran G Simonneau G Sitbon O Tonia T Toshner M Vachiery JL Vonk Noordegraaf A Delcroix M Rosenkranz S ESC/ERS Scientific Document Group2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2023; 612200879 Crossref Scopus (255) Google Scholar With these changes, the definition of precapillary PH, or pulmonary arterial hypertension (PAH), is mPAP >20 mm Hg, PVR >2 Woods units, and pulmonary arterial wedge pressure (PAWP) ≤15 mm Hg whereas postcapillary PH, or PH left-sided cardiac disease (PH-LCD ), is defined as mPAP ≥20 mm Hg, PVR ≤2 Woods units, and PAWP >15 mm Hg. 3 Humbert M Kovacs G Hoeper MM Badagliacca R Berger RMF Brida M Carlsen J Coats AJS Escribano-Subias P Ferrari P Ferreira DS Ghofrani HA Giannakoulas G Kiely DG Mayer E Meszaros G Nagavci B Olsson KM Pepke-Zaba J Quint JK Radegran G Simonneau G Sitbon O Tonia T Toshner M Vachiery JL Vonk Noordegraaf A Delcroix M Rosenkranz S ESC/ERS Scientific Document Group2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2023; 612200879 Crossref Scopus (255) Google Scholar As these diagnostic criteria capture a larger population with PH, there is also an increasing number of patients who are qualifying for combined precapillary and postcapillary PH (CpcPH), with mPAP >20 mm Hg, PVR >2 Woods units, and PAWP >15 mm Hg. The pathophysiology of CpcPH is heterogeneous; its genetics likely vary from isolated postcapillary PH, and patients exhibit a broad range of phenotypes between group 1 PAH and group 2 PH-LCD . 4 Miller WL Grill DE Borlaug BA Clinical features, hemodynamics, and outcomes of pulmonary hypertension due to chronic heart failure with reduced ejection fraction: pulmonary hypertension and heart failure. JACC Heart Fail. 2013; 1: 290-299 Crossref PubMed Scopus (237) Google Scholar ,5 Vachiéry JL Tedford RJ Rosenkranz S Palazzini M Lang I Guazzi M Coghlan G Chazova I De Marco T Pulmonary hypertension due to left heart disease. Eur Respir J. 2019; 531801897 Crossref PubMed Scopus (371) Google Scholar It has been shown that CpcPH, carries a greater risk of death than does PH-LCD. This has been driving increased conversation and investigation surrounding the role of diagnostic procedures such as inhaled nitric oxide (iNO) for assessment of vasoreactivity and management of CpcPH with therapies that have only been indicated to be efficacious in PAH. There is a paucity of drug trials that include patients with CpcPH, the most significant of which is the Macitentan in pulmonary hypertension due to left ventricular dysfunction (MELODY-1) study in which the investigators explored the use of macitentan compared with placebo and showed increased fluid retention without improved hemodynamics. 6 Vachiéry JL Delcroix M Al-Hiti H Efficace M Hutyra M Lack G Papadakis K Rubin LJ Macitentan in pulmonary hypertension due to left ventricular dysfunction. Eur Respir J. 2018; 511701886 Crossref Scopus (137) Google Scholar There is no multicentered trial that has shown benefit of PAH-specific medication in PH-LCD. 5 Vachiéry JL Tedford RJ Rosenkranz S Palazzini M Lang I Guazzi M Coghlan G Chazova I De Marco T Pulmonary hypertension due to left heart disease. Eur Respir J. 2019; 531801897 Crossref PubMed Scopus (371) Google Scholar Currently, guidelines recommend "an individualized approach to treatment" in CpcPH given this lack of data and varied tolerance of PAH-specific drugs in this population. 3 Humbert M Kovacs G Hoeper MM Badagliacca R Berger RMF Brida M Carlsen J Coats AJS Escribano-Subias P Ferrari P Ferreira DS Ghofrani HA Giannakoulas G Kiely DG Mayer E Meszaros G Nagavci B Olsson KM Pepke-Zaba J Quint JK Radegran G Simonneau G Sitbon O Tonia T Toshner M Vachiery JL Vonk Noordegraaf A Delcroix M Rosenkranz S ESC/ERS Scientific Document Group2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2023; 612200879 Crossref Scopus (255) Google Scholar The ability to predict disease progression and response to medications has been elusive and lives more within the space of the art rather than the science of medicine. Can Inhaled Nitric Oxide Response Predict Tolerance to Therapies and Survival in Patients With Combined Precapillary and Postcapillary Pulmonary Hypertension?American Journal of CardiologyVol. 207PreviewInhaled nitric oxide (iNO) relaxes the pulmonary circulation and variably increases the left ventricular preload and pulmonary artery wedge pressure (PAWP)—hemodynamic information that may help guide treatment decisions and assess prognosis in patients with combined precapillary and postcapillary pulmonary hypertension (PH). We included consecutive patients with combined precapillary and postcapillary PH (mean pulmonary artery pressure >20 mm Hg, PAWP >15 mm Hg, and pulmonary vascular resistance [PVR] >2 Woods unit [WU]) who underwent right-sided cardiac catheterization with iNO at the Cleveland Clinic Pulmonary Vascular Disease program between 2017 and 2022. Full-Text PDF

Cardiac diseases are one of the most common causes of morbidity and mortality following liver transplantation (LT). Prior studies have shown that cardiac diseases affect close to one-third of liver transplant recipients (LTRs) long term and that their incidence has been on the rise. This rise is expected to continue as more patients with advanced age and/or non-alcoholic steatohepatitis undergo LT. In view of the increasing disease burden, a multidisciplinary initiative was developed to critically review the existing literature (between January 1, 1990 and March 17, 2021) surrounding epidemiology, risk assessment, and risk mitigation of coronary heart disease, arrhythmia, heart failure, and valvular heart disease and formulate practice-based recommendations accordingly. In this review, the expert panel emphasizes the importance of optimizing management of metabolic syndrome and its components in LTRs and highlights the cardioprotective potential for the newer diabetes medications (e.g., sodium glucose transporter-2 inhibitors) in this high-risk population. Tailoring the multidisciplinary management of cardiac diseases in LTRs to the cardiometabolic risk profile of the individual patient is critical. The review also outlines numerous knowledge gaps to pave the road for future research in this sphere with the ultimate goal of improving clinical outcomes.