BACKGROUND:Heart failure (HF) is characterized by recurrent clinical deterioration, and multidimensional frailty (i.e., functional status, nutritional status, sarcopenia-related phenotypes, and cognitive impairment) is a key determinant of prognosis. We explored longitudinal changes in these multidimensional domains across recurrent hospitalizations for HF. METHODS AND RESULTS:This single-center retrospective cohort study analyzed 337 patients initially hospitalized for HF between 2016 and 2024 who subsequently experienced ≥1 rehospitalization (total 780 admissions). Longitudinal changes across repeated hospitalizations were evaluated using age- and sex-adjusted linear mixed-effects models. The median age was 83 years, and 47.2% were women. Across repeated hospitalizations, frailty and functional status worsened (Clinical Frailty Scale, β=0.40, P<0.001; Barthel Index, β=-4.21, P<0.001; Short Physical Performance Battery score, β=-0.56, P=0.043). Gait speed also declined, although this trend did not reach statistical significance (β=-0.03, P=0.089). Nutritional status deteriorated (Controlling Nutritional Status score, β=0.56, P<0.001; Geriatric Nutritional Risk Index, β=-2.37, P<0.001). Sarcopenia-related indices deteriorated (appendicular skeletal muscle index, β=-2.79, P=0.006; grip strength, β=-4.64%, P<0.001). Cognitive function assessed by the Mini-Mental State Examination showed no significant longitudinal change (β=0.11, P=0.501). CONCLUSIONS:Many domains of frailty deteriorated across recurrent hospitalizations for HF, suggesting cumulative frailty progression.

BACKGROUND:The 2025 Asian Working Group for Sarcopenia (AWGS) updated diagnostic criteria redefine sarcopenia based on low muscle strength and low skeletal muscle mass, incorporating body mass index (BMI)-adjusted appendicular skeletal muscle mass (ASM) alongside height-adjusted ASM. The clinical relevance of these definitions in heart failure (HF) patients remains unclear. METHODS AND RESULTS:This retrospective study included 594 patients aged ≥65 years hospitalized for HF (2016-2024). Sarcopenia was defined according to AWGS 2025 criteria as H-sarcopenia (height-adjusted ASM) or B-sarcopenia (BMI-adjusted ASM). The primary outcome was all-cause mortality. Physical function was assessed using gait speed. We analyzed associations using Cox proportional hazards and linear regression models. The prevalence of H-sarcopenia and B-sarcopenia was similar (24.2% vs. 25.1%, respectively), but BMI-dependent patterns differed, with the prevalence of H-sarcopenia decreasing and B-sarcopenia increasing as BMI increased. H-sarcopenia was independently associated with higher mortality (adjusted hazard ratio 1.48; 95% confidence interval 1.04-2.12), although its prognostic impact was attenuated at higher BMI. B-sarcopenia was not associated with mortality. Both sarcopenia definitions were associated with slower gait speed (P<0.001), but B-sarcopenia showed superior model performance (P<0.001 for the difference in root mean square error). CONCLUSIONS:In patients hospitalized with HF, H-sarcopenia and B-sarcopenia had distinct prognostic and functional implications: H-sarcopenia was related to mortality, particularly for lower BMI, whereas B-sarcopenia better reflected physical function, supporting outcome-specific sarcopenia definitions.

BACKGROUND:The Asian Working Group for Sarcopenia (AWGS) updated its diagnostic criteria in 2025 by incorporating body mass index (BMI)-adjusted skeletal muscle mass. This revision may influence the prevalence and clinical interpretation of sarcopenic obesity in heart failure (HF). METHODS AND RESULTS:We conducted a single-center retrospective cohort study of 589 patients aged ≥65 years who were hospitalized for HF. Application of the AWGS 2025 criteria significantly altered classification, increasing the prevalence of sarcopenic obesity from 7.8% to 13.6%. Among the 4 groups defined by sarcopenia (AWGS 2025) and obesity, patients with sarcopenia without obesity had the worst prognosis, whereas those with sarcopenic obesity had preserved survival (log-rank P=0.038). Following the transition from the AWGS 2019 to AWGS 2025 criteria, newly classified patients with sarcopenic obesity were more frequently female and had a higher BMI with preserved height-adjusted muscle mass compared with patients with persistent sarcopenic obesity. Mortality and gait speed were comparable between the persistent and newly classified sarcopenic obesity groups (both P>0.05). The AWGS 2025 sarcopenia-obesity phenotype classification showed no improvement in discrimination or the Akaike information criterion for prognosis compared with the AWGS 2019 classification (both P>0.05). CONCLUSIONS:The AWGS 2025 criteria increase the prevalence of sarcopenic obesity by identifying a distinct phenotype in patients with HF. However, this expanded classification does not improve risk stratification.

BACKGROUND:Advanced heart failure (HF) remains associated with poor outcomes despite contemporary therapies, with right ventricular dysfunction influenced by afterload. This study evaluated whether combined assessment of the pulmonary artery pulsatility index (PAPi) and capacitance (PAC), and their transitions during acute-phase therapy, provides prognostic stratification in patients with advanced HF. METHODS:This post-hoc analysis of the ESCAPE trial included 146 patients with complete hemodynamic data. A bootstrap-based grid search identified prognostic cutoffs: PAPi at 2.67 and PAC at 2.03 (optimal, PAPi ≥2.67 and PAC ≥2.03; suboptimal, PAPi <2.67 or PAC <2.03). Patients were categorized based on transitions between zones from baseline to final assessment after acute-phase therapy. The primary endpoint was a composite of all-cause mortality, left ventricular assist device implantation, or heart transplantation within 6 months. RESULTS:The mean age was 56.2 years, 39 patients (26.9%) were female, and the median left ventricular ejection fraction was 20.0%. At baseline, 127 patients (87.0%) were suboptimal. Following acute-phase therapy, 33 (22.6%) transitioned to optimal, whereas 94 (64.4%) remained suboptimal. Kaplan-Meier curves demonstrated significant stratification among groups based on transitions (log-rank P = 0.016). In Cox regression models using the suboptimal→suboptimal group as reference, suboptimal→optimal transition was associated with improved prognosis (multivariable hazard ratio 0.300, 95% confidence interval 0.107-0.847, P = 0.023). CONCLUSIONS:Transitions in PAPi and PAC during acute-phase therapy were associated with subsequent outcomes in advanced HF. Combined assessment of PAPi and PAC may provide a therapeutic target for risk stratification and management in this high-risk population.

Background:Postoperative declines in activities of daily living (ADL) are concerning in older adults undergoing cardiovascular surgeries. Sarcopenia represents a determinant of such adverse outcomes. We examined whether preoperative sarcopenia and its components predicted postoperative ADL decline in older patients who underwent elective cardiovascular surgeries. Methods and Results:This retrospective cohort study included 589 patients aged ≥65 years who underwent elective coronary artery bypass grafting, heart valve surgery, or thoracic aortic surgery. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 criteria. ADLs were assessed using the Barthel Index, with in-hospital ADL decline being defined as a ≥10-point reduction. Thirty-three (5.6%) patients had sarcopenia preoperatively. ADL decline was significantly higher in the patients with sarcopenia compared with those without (15.2% vs. 5.0%; P=0.014). Multivariable logistic regression analyses demonstrated that sarcopenia was independently associated with ADL decline (odds ratio 3.094; 95% confidence interval 1.067-8.968; P=0.038). Each sarcopenia component - low muscle mass, low muscle strength, and slow gait speed - was also independently associated with ADL decline (all P<0.050). Age-adjusted receiver operating characteristic analyses showed that sarcopenia demonstrated moderate discrimination for predicting postoperative ADL decline, with an area under the curve of 0.707. Conclusions:Preoperative sarcopenia and its individual components independently predicted in-hospital ADL decline following cardiovascular surgery. Preoperative assessments may help identify high-risk patients.

BACKGROUND:The Micra leadless pacemaker (LPM) should ideally be implanted in the septal location to enhance safety. However, the probability of accurate septal implantation and its predictive factors have not been fully elucidated. METHODS:Eighty-three consecutive patients who underwent computed tomography (CT) following LPM implantation were included. The ventricular septum was targeted using a standard fluoroscopic-guided transfemoral approach. The LPM implantation site was classified as septal or non-septal based on CT findings. The septal-inferior vena cava (IVC) angle was evaluated as a patient-specific anatomical parameter representing the relationship between IVC inflow and the ventricular septum. RESULTS:Accurate septal implantation was achieved in 44 patients (53.0%). The septal-IVC angle was significantly larger in the septal group than in the non-septal group (13.1 ± 11.6° vs. 2.7 ± 10.6°, p < 0.001). Multivariate logistic regression analysis indicated that the septal-IVC angle (odds ratio, 1.09; 95% confidence interval, 1.03-1.14; p = 0.002) was independently associated with the incidence of septal implantation. The optimal cutoff value for the septal-IVC angle was 6°, with a sensitivity of 77.3% and a specificity of 66.7% for predicting septal implantation. There were no cases of cardiac tamponade or pericardial effusion. No significant differences in long-term outcomes, including all-cause mortality, cardiac mortality, and heart failure hospitalization, were observed between the two groups. CONCLUSIONS:Accurate septal implantation was observed in 53.0% of patients who had undergone LPM implantation with the standard femoral approach. A larger septal-IVC angle was associated with accurate septal implantation.

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) improve clinical outcomes in patients with heart failure (HF) with a broad range of body mass indices (BMIs); however, concerns remain regarding their tolerability, safety, and clinical outcomes in patients with extremely low BMI.Patients hospitalized for acute HF at a single center between 2021 and 2023 were retrospectively evaluated. Low BMI was defined as < 18.5 kg/m2 for patients < 70 years and < 20 kg/m2 for those ≥ 70 years. We assessed the clinical characteristics, SGLT2i prescription at discharge, discontinuation within 1 year, and clinical outcomes, including cardiovascular death, HF readmission, and all-cause mortality, were assessed. Time-to-event analyses and inverse probability of treatment weighting (IPTW) were performed.Of 621 patients (median age: 81 years), 29.0% had a low BMI and 35.6% received a SGLT2i at discharge. SGLT2is were prescribed significantly less frequently in patients with low BMI (22.1% versus 41.5%, P < 0.001). Kaplan-Meier analysis showed that the overall 1-year discontinuation-free rate was 0.880, with no significant difference between the BMI groups. In crude analyses, SGLT2i use was associated with lower cardiovascular event rates in the non-low BMI group and lower all-cause mortality in the low BMI group; however, after IPTW adjustment, the latter association was attenuated.SGLT2is were underutilized in patients with HF and low BMI, yet discontinuation and adverse outcomes were not increased. These findings suggest that low BMI alone should not be a reason to avoid or discontinue SGLT2is in patients with acute HF.

BACKGROUND:Atrial fibrillation (AF) is frequently observed in patients with heart failure (HF), and the efficacy of catheter ablation for AF treatment has been established; however, recurrence of atrial arrhythmia is possible. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been reported to suppress AF recurrence in patients with diabetes; however, the efficacy of SGLT2i after AF ablation in patients with HF has not been fully elucidated. METHODS:A total of 141 consecutive patients with HF aged ≤75 years who underwent AF ablation were analyzed. Patients with follow-up shorter than six months were excluded. The primary endpoint was atrial arrhythmia recurrence after a 3-month blanking period. The type of recurrence, incidence of hospitalization for HF, and mortality rates were also evaluated. RESULTS:Forty-five patients used SGLT2i, and the median follow-up period was 372 days. The incidence of atrial arrhythmia recurrence was significantly lower in patients taking SGLT2i than in those that were not taking SGLT2i (20.0 % vs. 38.5 %, p = 0.029; log-rank test, p = 0.034). In the multivariate analysis, intake of SGLT2i was associated with a low risk of atrial arrhythmia recurrence (hazard ratio: 0.38, 95 % confidence interval: 0.18-0.80, p = 0.010). The rate of AF recurrence was significantly lower than the rate of atrial tachycardia/flutter recurrence in the SGLT2i group (44.4 % vs. 83.8 %; p = 0.013). The incidence of hospitalization for HF and/or death was low in both groups (0 % in the SGLT2i group and 1.0 % in the non-SGLT2i group). In 24 propensity score-matched pairs, the SGLT2i group had a lower recurrence rate (16.7 % vs. 45.8 %, p = 0.029, log-rank test, p = 0.047) than the non-SGLT2i group. CONCLUSIONS:SGLT2i use in patients with HF was associated with a lower atrial arrhythmia recurrence after AF ablation; hence, SGLT2i administration for patients with HF who will undergo AF ablation may be beneficial.

BACKGROUND:Both atrial fibrillation (AF) and right ventricular dysfunction (RVD) are prognostic factors in patients with heart failure (HF). However, the association between AF and RVD in patients with HF is not fully understood. The pulmonary artery pulsatility index (PAPi), obtained via right heart catheterisation, is a hemodynamic index of the right ventricular function. We investigated the clinical impact of PAPi in patients with HF and concomitant AF. METHODS:This was a single-center, retrospective cohort study involving consecutive patients who underwent right heart catheterisation for HF between January 2016 and December 2018. Patients with acute decompensated phase of HF were excluded. The primary endpoint was a composite of all-cause death or hospitalisation due to HF. RESULTS:A total of 347 patients with compensated HF were enrolled. The median follow-up duration was 3.2 years. Patients with AF had lower PAPi levels compared to those without AF. Multiple regression analysis revealed that AF was independently associated with reduced PAPi levels (partial regression coefficient -0.116, 95% confidence intervals [CIs] - 0.174 to -0.058; p < 0.001). Multivariate Cox regression analysis further revealed that low PAPi was an independent predictor of the incidence of the primary endpoint in patients with HF and AF (HR 1.861, 95% CIs 1.076-3.219, p = 0.026). CONCLUSION:AF was associated with reduced PAPi levels in patients with HF. Low PAPi independently predicted the prognosis of patients with AF and HF. Measuring PAPi provides useful information for the management of patients with HF and concomitant AF.

The Global Leadership Initiative on Malnutrition (GLIM) suggested a two-step framework for the assessment of malnutrition based on screening and diagnosis. Malnutrition, as defined by the GLIM criteria, and the risk of malnutrition determined through nutritional screening are associated with adverse outcomes in patients with heart failure (HF). This study investigated the prognostic impact of malnutrition, as defined by the GLIM criteria, compared with the risk of malnutrition determined by the Mini Nutritional Assessment-Short Form (MNA-SF) screening tool among patients hospitalized for acute HF. A total of 446 patients with acute HF who underwent nutritional screening using the MNA-SF and were diagnosed with malnutrition based on the GLIM criteria were include in this study. The primary outcome was the incidence of all-cause death or HF-related readmission after discharge. Patients diagnosed with malnutrition based on both indices had a higher incidence of adverse events within one year post-discharge than patients diagnosed without malnutrition. However, a landmark analysis of years one to three post-discharge found that the incidence of the primary outcome was comparable between patients diagnosed with malnutrition and those that here not. Furthermore, although malnutrition as defined by the GLIM criteria was found to be an independent predictor of the 1 year incidence of all-cause death or rehospitalization for HF even after adjusting for other prognostic indicators (hazard ratio, 1.593; 95

The aging population has led to an increase in nonagenarians undergoing percutaneous coronary intervention (PCI). Nonagenarian patients are at risk for geriatric complications, including delirium, which can worsen clinical outcomes. However, research on delirium and its clinical implications in nonagenarians with acute coronary syndrome (ACS) following PCI is limited.This retrospective observational cohort study analyzed data from 307 nonagenarians with ACS who underwent PCI. Delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders-5 criteria. Prevalence and prognostic impact of delirium during hospitalization were investigated.Delirium occurred in 85 patients (27.7%) during hospitalization. Patients with delirium had longer hospital stays and lower discharge rates to home or the same location as prior to hospitalization compared to patients without delirium. However, in-hospital mortality rates were comparable between the groups. Over a median follow-up of 480 days, no significant differences were found in all-cause mortality between the two groups.Delirium was common among nonagenarians with ACS following PCI. While delirium was associated with length of hospital stays and discharge destination, it was not linked to survival rates. Prevention, early detection, and effective management of delirium are important for optimizing care in super-aged patients following PCI.

BACKGROUND:Right ventricular dysfunction (RVD), driven by right ventricular (RV) afterload, is prognostic in patients with heart failure with preserved ejection fraction (HFpEF). Hemodynamic phenotyping based on RVD and RV afterload may provide useful information for the management of HFpEF. This study investigated the prognostic impacts of the pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC) in patients with HFpEF. METHODS AND RESULTS:A retrospective cohort of 246 HFpEF patients who underwent right heart catheterization was analyzed. Patients were divided into 4 groups according to the median PAPi and PAC values. The primary endpoint was a composite of all-cause death or heart failure-related hospitalization over a median follow-up of 4.1 years. Kaplan-Meier analysis showed significant stratification of event-free survival among the groups (log-rank P=0.003). Multivariate Cox proportional analysis revealed that patients with low PAPi and PAC exhibited worse outcomes than those with the high PAPi and PAC (hazard ratio 3.205; 95% confidence interval [CI] 1.401-7.330; P=0.006). Incorporating PAPi and PAC values into the MAGGIC risk score improved the C-index from 0.671 to 0.720 (∆C-index 0.050; 95% CI 0.004-0.095; P=0.032). CONCLUSIONS:A combination of PAPi and PAC improved prognostic ability in patients with HFpEF. Future investigations into treatments for these new hemodynamic phenotypes may improve clinical outcomes of patients with HFpEF.

The nine 3-mm electrodes, 3.75-mm fixed interelectrode space, and soft and slightly tilted shape of the PulseSelect catheter enables creating high-quality 3D electroanatomical mapping. Combined with an Ensite NavX 3D mapping system, it may be a superior option for managing atrial tachycardia after pulmonary vein isolation with pulsed field ablation.

Background: In advanced heart failure (HF), dynamic interplays between right ventricular (RV) dysfunction and afterload complicate prognostic assessments. The pulmonary artery pulsatility index (PAPi) reflects RV function, while pulmonary arterial capacitance (PAC) represents the pulsatile component of afterload. We investigated whether a combined PAPi-PAC assessment improves risk stratification in patients with decompensated advanced HF. Methods: This retrospective analysis included 187 patients with advanced HF and complete baseline PAPi and PAC data from the ESCAPE trial. The composite endpoint included all-cause death, left ventricular assist device implantation, or orthotopic heart transplantation within 6 months. A grid search approach identified optimal cutoffs for PAPi (2.00) and PAC (1.64), stratifying patients into four groups. Results: In Cox models adjusted for the Get With The Guidelines-Heart Failure (GWTG-HF) score, the low PAPi/low PAC group had the highest risk of the composite endpoint compared with the high PAPi/high PAC group (hazard ratio [HR] 3.167, 95% confidence interval [CI] 1.387?7.230), followed by the high PAPi/low PAC (HR 2.388, 95%CI 1.075?5.305) and the low PAPi/high PAC groups (HR 2.266, 95%CI 0.962?5.334). Model discrimination?assessed using C-indices?was improved by the addition of both PAPi and PAC to the GWTG-HF score (C-index 0.688 vs. 0.652; ?C-index +0.047, 95%CI 0.002?0.100, P=0.038). Conversely, models incorporating PAPi or PAC alone did not significantly enhance discrimination. Conclusions: In patients with decompensated advanced HF, early invasive hemodynamic phenotyping using combined PAPi-PAC enhances risk stratification beyond established clinical scores and may aid timely consideration of advanced therapies in high-risk individuals. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement None. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was waived by the institutional review board of the Anjo Kosei Hospital ethic committee on April 22, 2025 (Waiver No. R24-031), due to the retrospective nature of the study using de-identified data. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available from the National Heart, Lung, and Blood Institute's Biologic Specimen and Data Repository Information Coordinating Center but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission from the National Heart, Lung, and Blood Institute's Biologic Specimen and Data Repository Information Coordinating Center.

BACKGROUND:Acute total or subtotal occlusion of the unprotected left main coronary artery (ULMCA) is a rare but severe condition with high short-term mortality. However, the long-term prognosis of patients who survive to discharge after emergent percutaneous coronary intervention (PCI) remains unclear. This study aimed to evaluate long-term clinical outcomes in this population. METHODS:This multicenter retrospective study analyzed 61 patients who survived to discharge after emergent PCI for acute total/subtotal ULMCA occlusion. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), including all-cause mortality, target vessel revascularization, heart failure hospitalization, and stroke. Predictors of MACCE were assessed using Cox proportional hazards regression. RESULTS:The median age of the study cohort was 73 (63-77) years, and 72.1% were male. During a median follow-up of 5.4 (1.0-9.2) years from the date of discharge, MACCE occurred in 38 patients (62.3%). The MACCE rates at 5 and 10 years were 58.6% and 74.6%, respectively. The corresponding all-cause mortality rates were 33.5% and 47.4%. Cardiac death was observed in eight patients (13.1%), while 14 patients (23.0%) died from noncardiac causes. Among the clinical and procedural factors assessed, only intratracheal intubation at presentation was identified as an independent predictor of MACCE (adjusted hazard ratio: 2.15, 95% confidence interval: 1.10-4.24, p = 0.03). CONCLUSIONS:These findings suggest the importance of post-discharge management strategies for patients who underwent emergent PCI for acute total/subtotal ULMCA occlusion due to the persistent risk of cardiac or cerebrovascular events.

BACKGROUND:Right ventricular (RV) dysfunction and elevated RV afterload frequently coexist in heart failure (HF) and are associated with adverse outcomes. Pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC) reflect RV function and afterload, respectively; however, their combined prognostic value and optimal cutoff values remain unestablished. We aimed to define clinically relevant cutoff values and assess their prognostic performance. METHODS:We retrospectively analyzed the data from 464 patients with compensated HF who underwent right heart catheterization between 2016 and 2019. Optimal prognostic cutoff values of PAPi and PAC were derived using a grid search with bootstrap resampling. The primary endpoint was a composite of cardiovascular death or HF hospitalization. Prognostic performance was compared with established hemodynamic classifications. RESULTS:During a median follow-up of 3.4 years, 132 patients (28.4 %) experienced the primary endpoint. The optimal cutoff values were 1.67 and 3.08 for PAPi and PAC, respectively. Compared with PAPi ≥1.67/PAC ≥3.08, the adjusted hazard ratios (95 % confidence interval [CI]) were 2.292 (1.280-4.103) for PAPi <1.67/PAC ≥3.08, 2.644 (1.541-4.537) for PAPi ≥1.67/PAC <3.08, and 4.622 (2.500-8.547) for PAPi <1.67/PAC <3.08. The PAPi-PAC model showed the highest concordance index (C-index, 0.723, 95 % CI: 0.672-0.774) and largest improvement over the basic model (ΔC-index, 0.052, P = 0.002), outperforming conventional hemodynamic models. CONCLUSIONS:A classification based on PAPi and PAC cutoff values provided robust risk stratification in HF and showed improved prognostic performance compared with conventional hemodynamic models.

Background:For patients with heart failure (HF) and preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF), there is no treatment that improves survival, but some will reduce HF hospitalizations. Recurrent HF admissions may impair activities of daily living (ADL) and increase the societal burden. Methods and Results:We analyzed 130 patients with HFpEF or HFmrEF who had recurrent HF hospitalizations. The multivariate linear mixed-effects model revealed that HF hospitalization frequency remained an independent predictor of ADL decline, as evaluated by the Barthel index. Conclusions:Recurrent hospitalization for HF contributes to ADL decline. Preventing rehospitalization due to HF is crucial.

The aging population has led to an increase in nonagenarians undergoing percutaneous coronary intervention (PCI). Nonagenarian patients are at risk for geriatric complications, including delirium, which can worsen clinical outcomes. However, research on delirium and its clinical implications in nonagenarians with acute coronary syndrome (ACS) following PCI is limited. This retrospective observational cohort study analyzed data from 307 nonagenarians with ACS who underwent PCI. Delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders-5 criteria. Prevalence and prognostic impact of delirium during hospitalization were investigated. Delirium occurred in 85 patients (27.7%) during hospitalization. Patients with delirium had longer hospital stays and lower discharge rates to home or the same location as prior to hospitalization compared to patients without delirium. However, in-hospital mortality rates were comparable between the groups. Over a median follow-up of 480 days, no significant differences were found in all-cause mortality between the two groups. Delirium was common among nonagenarians with ACS following PCI. While delirium was associated with length of hospital stays and discharge destination, it was not linked to survival rates. Prevention, early detection, and effective management of delirium are important for optimizing care in super-aged patients following PCI.

Advanced heart failure (HF) remains associated with poor outcomes despite contemporary therapies. Right ventricular (RV) dysfunction, a hallmark of advanced HF, is strongly influenced by afterload. We aimed to evaluate whether the combined assessment of the pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC)-and their transitions during acute-phase therapy-provides prognostic stratification in patients with advanced HF. We conducted a post-hoc analysis of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial, including 146 patients with complete hemodynamic data. A bootstrap-based grid search identified prognostic cutoffs: PAPi at 2.67 and PAC at 2.03. The optimal zone was defined as PAPi ≥2.67 and PAC ≥2.03; the suboptimal zone as PAPi <2.67 or PAC <2.03. Patients were categorized into four groups based on transitions between zones from baseline to the final assessment after acute-phase therapy. The primary endpoint was a composite of all-cause mortality, left ventricular assist device implantation, or heart transplantation within 6 months. At baseline, 127 patients were in the suboptimal zone. Following acute-phase therapy, 33 transitioned to the optimal zone, while 94 remained suboptimal . Kaplan–Meier curves demonstrated significant stratification among groups. In Cox regression models using the suboptimal→suboptimal as reference, transition to the suboptimal→optimal was associated with improved prognosis (multivariable hazard ratio 0.300, 95% confidence interval 0.107–0.847, P=0.023). Transitions in PAPi and PAC during acute-phase therapy were associated with subsequent outcomes in advanced HF. Combined assessment of PAPi and PAC may provide a novel therapeutic target for risk stratification and management in this high-risk population.

BACKGROUND: Bleeding and thromboembolic complications are significant challenges in the treatment of patients with cardiogenic shock (CS) who require venoarterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation strategies that target higher activated partial thromboplastin time (aPTT) may exacerbate bleeding and lead to poor outcomes. However, there is a lack of sufficient randomized trials to determine the optimal aPTT target for this patient population. RESEARCH QUESTION: Does anticoagulation management with a lower aPTT target range improve outcomes compared with a higher aPTT target range in patients with CS who are treated with VA-ECMO? STUDY DESIGN AND METHODS: The Target for Anticoagulation in the Management of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock (TARGET-ECMO) trial is a multicenter, randomized controlled trial designed to evaluate the impact of different aPTT target ranges on outcomes in patients with CS who are treated with VA-ECMO. Patients are randomized into 1 of 2 groups: a lower aPTT target group (aPTT, 1.5 to1.8 times) or a higher aPTT target group (aPTT, 2.2 to 2.5 times). RESULTS: The primary end point is a hierarchic composite outcome assessed at 7 days that consists of (1) death from any cause, (2) major bleeding, (3) thromboembolic events, and (4) total transfusion of RBC concentrates, which are evaluated with the use of a win ratio. INTERPRETATION: Anticoagulation targets in VA-ECMO management typically are determined at the discretion of individual centers and clinicians. The Target for Anticoagulation in the Management of Venoarterial Extracorporeal Membrane Oxygenation for CS trial aims to improve the prognosis of patients with CS who are treated with VA-ECMO by exploring optimal aPTT target range for anticoagulation management. CLINICAL TRIAL REGISTRATION: Certified Review Board of Nagoya University Hospital (approval number: 2024-0166) and the Japan Registry of Clinical Trials (jRCT1041240069). CHEST Critical Care 2025; 3(4):100198