Intermediate-high-risk (IHR) pulmonary embolism (PE) represents a heterogeneous group in whom guideline-based criteria may insufficiently capture biologic and hemodynamic variability relevant to early deterioration. Data-driven phenotyping may improve risk stratification and support individualized decisions regarding reperfusion therapy. In this retrospective cohort study (2012-2025), 553 guideline-defined IHR PE patients were analyzed using unsupervised machine learning. Thirty-six demographic, clinical, laboratory, echocardiographic, and CT variables were standardized and encoded as appropriate for clustering. Multiple algorithms were compared, and the optimal model was selected using silhouette width and stability metrics. Clinical characteristics, imaging findings, treatment patterns, and outcomes were compared across phenotypes. The primary outcome was in-hospital mortality; secondary outcome was all-cause long-term mortality. Multivariable logistic regression and Cox models assessed associations with outcomes, and pre-post-treatment changes were evaluated. Two phenotypes were identified using the k-prototypes algorithm (silhouette width = 0.697). Cluster 1 (RV-failure phenotype; n = 360) exhibited younger age, lower systolic blood pressure, more severe RV dysfunction, higher thrombotic burden, and lower baseline TAPSE/PASP ratios. Cluster 2 (comorbidity-dominant phenotype; n = 193) comprised older patients with more cardiovascular/metabolic comorbidities but relatively preserved hemodynamics. In-hospital mortality was 6.0% overall and lower in Cluster 2 (3.6% vs. 7.2%); Cluster 2 remained independently associated with reduced early mortality (OR: 0.43; 95% CI: 0.19-0.98). The CDT-cluster interaction term was not statistically significant. Both phenotypes demonstrated significant improvements in RV function after reperfusion, with greater gains-including TAPSE/PASP-in Cluster 1. Over a median follow-up of 73.2 months, long-term mortality did not differ significantly between phenotypes (log-rank p = 0.11). Unsupervised ML revealed two clinically meaningful IHR PE phenotypes with divergent early risk but comparable long-term outcomes. These findings suggest that phenotype-based assessment may refine risk stratification and help guide individualized decisions regarding CDT and other reperfusion strategies in acute PE.

BACKGROUND:This study assessed the efficacy and tolerability of the oral prostacyclin receptor agonist selexipag as part of sequential triple combination therapy in patients with pulmonary arterial hypertension (PAH). METHODS:The study retrospectively analyzed 127 of 1160 PAH patients from a single-center registry who received sequential triple therapy including selexipag. Clinical, echocardiographic, and hemodynamic variables and multiparametric risk scores (MRS) were evaluated to assess changes in risk and outcomes. RESULTS:The mean age was 43.2 ± 16.4 years, and 84.3% were female. Prior to selexipag initiation, Comparative Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension 2.0 risk strata were: 15% first, 31.5% second, 44.1% third, and 9.4% fourth; European Society of Cardiology/European Respiratory Society low-, intermediate-, and high-risk rates were 20.5%, 61.4%, and 18.1%, respectively. Mean REVEAL Lite 2.0 score was 6.3 ± 2.7. Maximal selexipag dosing reached 1600 μg BID in 18.1% of patients, while 64.6% remained at ≤1000 μg BID. Patients were grouped into low-, intermediate-, and high-dose cohorts. Median follow-up was 727.5 days (interquartile range (IQR) 224-985). Selexipag was discontinued in 15% of patients. Across dosing cohorts, initial improvements in functional class, 6-minute walk distance, right ventricular and pulmonary echocardiographic parameters, and MRSs during the first year attenuated thereafter, except for N-terminal pro-brain natriuretic peptide and Tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio. Lower baseline REVEAL Lite 2.0 score predicted low-risk status at final assessment (P = .017). Three-year survival was 72.5%, 85.7%, and 75.1% in low-, medium-, and high-dose cohorts (P > .05). Mortality was independently predicted by baseline Swedish PAH Registry, REVEAL 2.0, REVEAL Lite 2.0, and REVEAL Echo scores. CONCLUSION:Earlier escalation to triple therapy with selexipag may improve outcomes. Baseline risk-but not achieved selexipag dose-was associated with survival. A possible decline in treatment effect after 1 year warrants further investigation.

OBJECTIVE:Accurate estimation of left ventricular ejection fraction (LVEF) after ST-segment elevation myocardial infarction (STEMI) is essential for optimizing long-term management and cardiovascular risk stratification. This study aimed to identify predictors of LVEF at six months after STEMI and to develop a clinically applicable nomogram for individualized prognostic assessment. METHOD:This prospective, single-center cohort study included consecutive patients admitted with STEMI between July 2018 and October 2018. Baseline clinical, laboratory, and angiographic variables were collected. LVEF was assessed by transthoracic echocardiography during the index hospitalization and at six-month follow-up. Patients were categorized into four groups according to follow-up LVEF. Predictors of six-month LVEF were identified using proportional odds logistic regression, and a nomogram was constructed based on the final multivariable model. RESULTS:A total of 231 patients were analyzed (median age: 57 years; 83% male). At baseline, 119 patients (51%) had an LVEF < 50%, whereas at six months 115 patients (49%) had an LVEF < 50%. Multivariable analysis identified baseline LVEF, peak creatine kinase-myocardial band (CKMB) level, age, hypertension, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade as independent predictors of follow-up LVEF (all P < 0.05). CONCLUSION:Baseline LVEF and peak CK-MB level were the strongest independent predictors of six-month LVEF following STEMI. Age, hypertension, and final TIMI flow grade were identified as additional predictors. The proposed nomogram provides a practical tool for individualized follow-up planning and risk assessment in STEMI survivors.

BACKGROUND:Hypertrophic cardiomyopathy (HCM) is a complex myocardial disorder with heterogeneous clinical presentations and structural manifestations. This study aimed to assess the distribution, clinical characteristics, and diagnostic approaches in a regional cohort of patients with HCM. METHODS:Patients diagnosed with HCM at a tertiary cardiomyopathy clinic between October 2021 and November 2024 were retrospectively analyzed. Patients were classified into obstructive, latent obstructive, non-obstructive, or apical phenotypes based on clinical and imaging findings. Comprehensive demographic, clinical, and imaging data were collected for detailed analysis, providing valuable insights into the phenotypic diversity of HCM. RESULTS:The cohort included 701 patients with a median age of 53 years of whom 68% were male. The phenotypic distribution comprised 9.3% apical, 38.1% non-obstructive, 32.5% resting obstructive, and 20.1% latent obstructive HCM. Implantable cardioverter-defibrillator implantation was more common in obstructive phenotypes, particularly in the latent obstructive group. Although late gadolinium enhancement (LGE) was more frequently observed in apical HCM, post-hoc analysis showed no significant difference in prevalence across subgroups. In contrast, LGE extent was significantly greater in the apical group. Genetic testing, performed in 32% of patients, revealed a 44% positivity rate, with MYBPC3 and MYH7 being the most commonly detected mutations. The overall mortality rate was 2.8%, with heart failure identified as the leading cause of death. CONCLUSION:In this large regional cohort of HCM patients, obstructive and non-obstructive phenotypes were predominant, with a notable burden of genetic mutations and a low overall mortality rate primarily driven by heart failure. These findings emphasize the clinical heterogeneity of HCM and highlight the importance of comprehensive diagnostic evaluation.

Cardiohepatic syndrome (CHS) is a parameter used to define liver dysfunction in heart failure patients and has been shown to be associated with poor prognosis. In this study, we investigated the relationship between the presence of preoperative CHS and postoperative mortality in heart failure patients with reduced ejection fraction (HFrEF) undergoing coronary artery bypass grafting (CABG). We retrospectively included patients who were evaluated in anesthesia outpatient clinic of our hospital before first-time elective isolated CABG and had HFrEF (left ventricular ejection fraction [LVEF] ≤ 40

Aims: Artificial intelligence (AI)-based electrocardiogram (ECG) analysis tools have shown promise in detecting various cardiac conditions. However, their performance in specific patient populations, such as those with hypertrophic cardiomyopathy (HCM), remains incompletely characterized. To evaluate the performance of three AI-based ECG analysis tools in patients with confirmed HCM: (1) a tool calculating HCM probability, (2) a tool calculating structural heart disease (SHD) probability, and (3) a tool providing ECG-based diagnoses across multiple categories. Methods and results: We analysed digitized 12-lead ECGs from patients with confirmed HCM (n = 681) using three AI tools. We assessed the distribution of AI-calculated probabilities and their associations with clinical parameters and evaluated agreement between AI-based and manually assigned ECG diagnoses using Cohen's kappa. Despite all patients having confirmed HCM, the AI-calculated HCM probabilities showed a relatively uniform distribution [median 38.8% (IQR: 12.8-63.4%)], with only 41.2% and 12.5% of patients receiving a probability score >50% and >75%. HCM probabilities were significantly higher in patients with abnormal vs. normal ECGs (P < 0.001) and correlated with markers of disease severity. SHD probabilities were generally higher [median 51.4% (IQR: 28.7-74.5%)], with 51.2% and 25% of patients receiving scores >50% and >75%. Conclusion: AI-based ECG analysis tools demonstrated modest performance in our HCM cohort. These findings highlight the challenges of applying AI tools developed in general populations to specific disease cohorts and underscore the need for disease-specific validation before clinical implementation.

BACKGROUND:Comparative data on ultrasound-assisted catheter-directed thromboly-sis (USAT) and systemic low-dose tissue-type plasminogen activator (tPA) for intermediate-high-risk (IHR) pulmonary embolism (PE) remain limited. The efficacy and safety outcomes of USAT vs. intravenous (IV) low-dose tPA were evaluated in this population. METHODS:This study enrolled 329 IHR PE patients treated with USAT (n = 205) or IV low-dose tPA (n = 124). Post-treatment changes in clot burden (Qanadli score), right ventricular (RV) strain, and long-term mortality (median follow-up 95.8 months) were assessed. Propensity score analysis with inverse probability weighting (IPW) was employed to adjust for confounders. RESULTS:Ultrasound-assisted catheter-directed thrombolysis was predominantly bilateral (82.9%), with a mean tPA dose of 38.5 ± 13.6 mg. In the IV tPA cohort, 58.9% required a second infusion to achieve stabilization. While IV tPA was associated with more pronounced early reductions in heart rate and RV/LV (left ventricle) ratio, USAT provided significantly greater thrombus resolution (all P < .005). After IPW adjustment, USAT demonstrated clear superiority over IV tPA in reducing residual clot burden (P < .001). However, improvements in oxygen saturation, tricuspid annular plane systolic excursion , and pulmonary artery systolic pressure (PASP) were comparable. No significant differences were observed in in-hospital mortality, PE recurrence, or long-term survival between cohorts. Higher PE severity indexes scores independently predicted in-hospital adverse events, whereas older age, male sex, and higher discharge PASP were predictors of shortened long-term survival. CONCLUSIONS:In IHR PE, IV low-dose tPA relates to more pronounced early hemodynamic and RV diameter improvements, whereas USAT achieves superior thrombus resolution. Despite these divergent surrogate responses, both strategies yield comparable early and long-term clinical outcomes, supporting their roles as viable reperfusion options.

Background: Heart failure (HF) remains a major early complication following myocardial infarction (MI), contributing significantly to morbidity and adverse clinical outcomes. Reliable early risk stratification is essential for optimizing post-MI management. This study aimed to evaluate the prognostic performance and incremental value of the HALP (Hemoglobin-Albumin-Lymphocyte-Platelet) score and the AHEAD score in predicting 1-month HF after MI. Methods: This retrospective cohort study included 3205 consecutive patients with MI. The primary endpoint was the development of HF within one month. Three multivariable logistic regression models were constructed: a baseline clinical model (Model 1), a HALP-integrated model (Model 2), and an AHEAD-integrated model (Model 3), with component variables excluded to avoid collinearity. Model performance was assessed using odds ratios (ORs), 95% confidence intervals (CIs), and discrimination metrics (AUC). Incremental predictive value was further evaluated using net reclassification improvement (NRI). Internal validation was performed using bootstrapping and 5-fold cross-validation. A predefined subgroup analysis was conducted in patients with preserved ejection fraction (EF ≥ 40%), excluding EF from the models. Results: In the full cohort, all models demonstrated high discriminative ability for 1-month HF (AUC range: 0.950-0.954), with minimal differences between models. The AHEAD-based model showed the highest point estimate (AUC = 0.954, 95% CI: 0.944-0.963), but ROC curves were largely overlapping. Despite limited changes in AUC, the AHEAD score provided moderate improvement in risk reclassification (NRI = 0.287), whereas the HALP score showed minimal incremental value (NRI = 0.152) and was not independently associated with HF in multivariable analysis. In the EF ≥ 40 subgroup, HF incidence was lower (1.9%), and model performance was attenuated but remained robust (AUC range: 0.839-0.882), with the AHEAD score retaining strong independent predictive value. Peak CKMB and creatinine were consistently associated with increased HF risk. Although the odds ratio for CKMB appeared close to unity, this reflects unit scaling, and clinically meaningful increases corresponded to substantial risk increments. A clear dose-response relationship between AHEAD score and HF probability was observed. Conclusions: While both HALP and AHEAD scores are associated with post-MI HF risk, only the AHEAD score provides consistent independent and incremental prognostic value beyond established clinical predictors. Its simplicity and ability to capture comorbidity burden make it a practical adjunct for early risk stratification, particularly in patients with preserved EF. However, given the minimal differences in discrimination metrics and lack of external validation, these findings should be interpreted cautiously and considered hypothesis-generating.

BACKGROUND:The incorporation of side branches in vessel geometry influences wall shear stress (WSS) distribution. However, complete vessel reconstruction is time-consuming, and there is no evidence that its WSS estimations better predict atherosclerotic disease progression compared with the output of the conventional single-vessel reconstruction (SVR). METHODS:Patients who had baseline and 1-year follow-up intravascular ultrasound imaging (n=40 vessels), and patients with neoatherosclerotic lesions (n=13 vessels) on optical coherence tomography were included. All the studied vessels had at least one side branch with a diameter >1 mm; 3-dimensional complete vessel reconstruction and SVR were performed, and the time-averaged WSS and multidirectional WSS were computed. The performance of both methods in predicting disease progression in intravascular ultrasound and optical coherence tomography models was assessed. RESULTS:The incorporation of side branches in 3-dimensional geometry resulted in lower minimum predominant time-averaged WSS in the intravascular ultrasound (1.09 versus 1.58 Pa, P<0.001) and optical coherence tomography-based reconstructions (0.68 versus 1.33 Pa, P<0.001) and influenced the multidirectional WSS distribution. In native segments, complete vessel reconstruction-derived WSS metrics demonstrated superior predictive performance for disease progression-defined as lumen area reduction and plaque burden increase-compared with SVR, as evidenced by improved out-of-sample accuracy (leave-one-out information criterion: 429 versus 551), discrimination (C statistic: 0.725 versus 0.651), calibration (Brier score: 0.172 versus 0.226), and explained variance (27.8% versus 20.7%). Consistent findings were observed in stented segments, where complete vessel reconstruction-derived WSS metrics more accurately predicted neointimal proliferation than SVR-derived metrics. CONCLUSIONS:Incorporating side branches into vessel reconstruction influences WSS distribution and enables more accurate prediction of atherosclerotic disease progression in native and stented segments than SVR.

The most dangerous error in clinical trial interpretation is equating p > 0.05 with no effect. This review provides a practical, algorithm-based framework for classifying randomized controlled trial (RCT) results into six distinct categories positive, imprecise (+), neutral, inconclusive, negative, and harmful using confidence interval (CI) position relative to the minimal clinically important difference (MCID) as the primary tool, augmented by Bayesian posterior probabilities. We demonstrate that the same p > 0.05 result can represent three fundamentally different conclusions (inconclusive, negative, or neutral), show how Bayesian reanalysis can rescue benefit signals missed by frequentist thresholds, and illustrate the framework with real-world examples from critical care and cardiology trials. The framework synthesizes guidance from Altman, Harrell, Pocock, Zampieri, the ASA, and ICH E9 into a single coherent decision algorithm.

BACKGROUND:The optimal treatment strategy for isolated side branch (SB) lesions remains uncertain. In this study, the aim was to evaluate the safety and efficacy of drug-coated balloon (DCB) angioplasty for the treatment of de novo isolated SB stenosis. METHODS:This single-center, retrospective study included patients with symptomatic isolated SB occlusion who underwent percutaneous coronary intervention using DCB. The primary endpoint was procedural success, and the secondary endpoint was the occurrence of major adverse cardiac events, defined as death from all causes, myocardial infarction, target vessel revascularization, or revascularization of target lesions. RESULTS:Forty-eight patients were included between April 2022 and June 2025. The mean age was 62.8 ± 13.9 years, and the majority were male (n = 35, 72.9%). The cohort exhibited a high cardiovascular risk profile. Procedural success was achieved in 97.9% (n = 47). Thrombolysis in myocardial infarction grade 3 flow was obtained in all patients, with a mean residual stenosis of 26% ± 14.9. One patient (2.1%) required bailout stenting, and no cases of acute thrombosis were observed. During a mean follow-up of 423 days, 8 patients (16.7%) underwent repeat coronary angiography for angina, 6 patients (12.5%) required additional medical therapy, and 1 patient (2.1%) experienced myocardial infarction. CONCLUSION:These findings suggest that, with appropriate lesion preparation and patient selection, DCB angioplasty represents a safe and feasible revascularization strategy for isolated SB occlusions. However, larger, controlled, and long-term studies are needed to confirm these results.

Random-effects meta-analysis summarizes heterogeneous trials by estimating an average effect over the observed evidence base, which may not represent the clinically relevant target population. In cardiovascular medicine, treatment effects vary systematically across era, endpoint definitions, background therapy, and case-mix, making the historical average often misaligned with current decision-making. We propose stable transport meta-analysis (AMT-MA), a nuisance-anchor estimator that models anchor-aligned variation but does not transport it to the target population. The method combines a weighted-average loss with a scale-normalized softmax regime loss, and incorporates a precision-weighted sign-stability diagnostic with a two-condition abstention rule to avoid reporting a single pooled estimate when stability is not supported. AMT-MA is not intended to minimize RMSE relative to random-effects models, but to redefine the estimand as a stable target-population effect. In a pre-specified ADEMP simulation across six scenarios, AMT-MA (rho = 0.2) showed reduced bias relative to unadjusted pooling and improved coverage in adversarial settings where classical Wald intervals fail (dominant trial: 0.85 vs 0.01; confounded anchor: 0.86 vs 0.34; anchor shift: 0.91 vs 0.60). WLS meta-regression remained competitive when correctly specified. Under sign-flip heterogeneity, the abstention rule triggered in 84

BACKGROUND:Hypertrophic cardiomyopathy (HCM) is a genetic heart disease characterized by left ventricular hypertrophy (LVH) in the absence of other causes. More than 90% of patients exhibit abnormalities such as T wave inversion, Q waves, or LVH voltage criteria. However, a small subgroup with milder disease may present with a normal electrocardiogram (ECG), which can delay diagnosis. This study aimed to determine the prevalence and clinical characteristics of HCM patients with a normal ECG and their relationship with indicators of disease severity. METHODS:Patients diagnosed with HCM according to European Society of Cardiology (ESC) guideline criteria were retrospectively evaluated. Those with alternative causes of LVH or infiltrative/storage cardiomyopathies were excluded. Abnormal ECG was defined by the presence of atrial fibrillation, conduction block, pathological Q waves, repolarization changes, LVH voltage, low voltage, QTc >460 ms, or QRS >120 ms. RESULTS:Among 682 patients, 11 (1.6%) had completely normal ECGs. The most frequent abnormalities were repolarization changes (82.6%) and LVH voltage criteria (70.2%). Normal ECGs were associated with lower NT-proBNP, lower pulmonary artery pressudre, better right ventricular function, and less frequent late gadolinium enhancement on cardiac magnetic resonance imaging (CMR). The number of ECG abnormalities correlated positively with wall thickness, NT-proBNP, left atrial diameter, pulmonary pressures, and sudden cardiac death (SCD) risk score, but negatively with right ventricular functionand left ventricular ejection fraction. CONCLUSION:A completely normal ECG was observed in only 1.6% of patients with hypertrophic cardiomyopathy. While a normal ECG substantially lowers the likelihood of HCM, it does not exclude the diagnosis. Despite advances in imaging, the ECG remains a simple, accessible, and indispensable screening tool for early detection.

Background: This study compared changes in percentage atheroma volume (PAV) using an end-diastolic (ED) intravascular ultrasound (IVUS) segmentation approach vs. the conventional 1-mm interval analysis in serial IVUS data from the PACMAN-AMI trial. Methods and results: IVUS data from the PACMAN-AMI study were analyzed by 2 core laboratories: one with 1-mm segmentation and the other with an ED-based approach. The same arterial segments were assessed at baseline and at the 52-week follow-up in patients receiving alirocumab or placebo. Changes in segment length, lumen, vessel, total atheroma volume (TAV), and PAV between baseline and follow-up were compared between methods. Biomarkers associated with atherosclerotic progression were measured and correlated with TAV and PAV changes. In all, 387 segments were analyzed. Agreement between conventional and ED volumetric analysis was excellent (intraclass coefficient >0.891, P<0.001). TAV and PAV were larger in both groups in the ED analysis than with the conventional approach; however, changes between treatment arms were similar for the conventional and ED analyses (TAV: 14.34 vs. 14.64 mm(3), respectively [P=0.823]; PAV: 1.29% vs. 1.25%, respectively [P=0.911]). Biomarker correlations with TAV and PAV changes did not differ between approaches. Conclusions: ED- and 1-mm-based analyses demonstrated comparable treatment effects of alirocumab on plaque regression in PACMAN-AMI. These findings support the use of the less time-consuming 1-mm segmentation method in serial IVUS studies.

Background: Cardiovascular diseases remain a major global health concern, and coronary care units (CCUs) provide specialized care for patients with acute cardiovascular conditions. Aim: This multicenter cohort study aimed to investigate mortality rates in Turkish CCUs and identify predictors of in-hospital mortality. Study Design: Multicenter, observational cohort study. Methods: Patients admitted to CCUs across Türkiye with cardiovascular diagnoses were included. Demographic, clinical, laboratory, and outcome data were collected. Regression analyses were performed to identify predictors of in-hospital mortality. Results: A total of 3,157 patients were included, and the overall CCU mortality rate was 4.3% (n=137). The median age was 65 years (interquartile range, 56-73), and 66.1% of the patients were male. Hypertension (59.8%) and diabetes mellitus (37.5%) were the most common comorbidities. Non-survivors had significantly higher rates of heart failure and chronic kidney disease and lower ejection fractions than survivors. Age, female sex, lower mean blood pressure (BP), elevated serum creatinine, C-reactive protein, and white blood cell count were independent predictors of in-hospital mortality. Mean BP and serum creatinine were the strongest contributors to mortality prediction. Conclusion: CCU mortality in Türkiye was relatively low. Hemodynamic impairment and renal dysfunction were the primary determinants of in-hospital mortality, highlighting the value of simple clinical parameters for early risk stratification.