2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC

The addition of alpha-ketoglutarate to NT-proBNP improves the prediction of long-term all-cause mortality in acute heart failure patients

BACKGROUND AND OBJECTIVE

Alpha-ketoglutarate (AKG), is a major intermediate metabolite of the tricarboxylic acid cycle, and is closely associated with cardiometabolic disease prognosis. Previous studies indicated that AKG is related to myocardial energy expenditure levels and reflects adverse short-term outcomes in heart failure (HF) patients. In this prospective cohort study, we examined the long-term prognostic value of AKG levels in acute HF (AHF) patients.

METHODS

Plasma AKG levels were assessed in patients hospitalized with AHF. Hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality were calculated via multiple Cox regression. All-cause mortality was compared between patients with NT-proBNP < 1000 pg/ml and those with NT-proBNP ≥ 1000 pg/ml via subgroup analysis.

RESULTS

Patients with AKG ≥ 9.83 μg/ml had higher heart rates and NT-proBNP and lower left ventricular ejection fraction (LVEF) and systolic blood pressure (SBP). After multiple adjustment, higher AKG was associated with an increased all-cause mortality risk (HR = 1.078, p < 0.001). Compared with AKG < 9.83 μg/ml, AKG ≥ 9.83 μg/ml nearly doubled (HR = 1.929, p < 0.001) and quadrupled (HR = 4.160, p < 0.001) the all-cause mortality risk in patients with NT-proBNP ≥ 1000 pg/ml and those with NT-proBNP < 1000 pg/ml, respectively.

CONCLUSIONS AND RELEVANCE

Plasma AKG was independently associated with greater all-cause mortality risk in patients with AHF. Higher AKG levels retained prognostic value for patients with relatively low NT-proBNP.

Cost-utility analysis of empagliflozin for heart failure in the Philippines

AIMS

Empagliflozin confers cardioprotective benefits among patients with heart failure, across the range of ejection fraction (EF), regardless of type 2 diabetes status. The long-term cost-effectiveness of empagliflozin for the treatment of heart failure (HF) in the Philippines remains unclear. This study aims to determine the economic benefit of adding empagliflozin to the standard of care (SoC) vs the SoC alone for HF in the Philippines.

METHODS

Using a Markov model, we predicted lifetime costs and clinical outcomes associated with treating HF in the Philippine setting. We used estimates of treatment efficacy, event probabilities, and derivations of utilities from the EMPEROR trials. Costs were derived from hospital tariffs and expert consensus. Separate analyses were performed for patients with left ventricular EF > 40%, categorized under mid-range ejection fraction or preserved ejection fraction (HFmrEF/HFpEF), and patients with left EF ≤ 40%, categorized under HF with reduced ejection fraction (HFrEF).

RESULTS

Our model predicted an average of 0.09 quality-adjusted life year (QALY) gains among HFmrEF/HFpEF patients and HFrEF patients when empagliflozin was compared to SoC. The addition of empagliflozin in the treatment results in a discounted incremental lifetime cost of PHP 62,692 (USD 1,129.99) and PHP 17,215 (USD 308.67) for HFmrEF/HFpEF and HFrEF, respectively. The incremental cost-effectiveness ratio (ICER) of empagliflozin is PHP 198,270 (USD 3,570.72)/QALY and PHP 742,604 (USD 13,385.08)/QALY for HFrEF and HFmrEF/HFpEF, respectively.

LIMITATIONS

This study employed parameters derived from short-term clinical trial data, alongside metrics representative of Asian populations, which are not specific to the Philippine cohort.

CONCLUSIONS

Adding empagliflozin to the SoC in comparison to the SoC is associated with improved clinical outcomes and quality-of-life, at additional costs for both HFrEF and HFmrEF/HFpEF.

Characteristics, outcomes and the necessity of continued guideline-directed medical therapy in patients with heart failure with improved ejection fraction

BACKGROUND

Much remains to be learned about patients with heart failure with improved ejection fraction (HFimpEF).

OBJECTIVE

This study sheds light on the characteristics and clinical outcomes of HFimpEF patients, including the consequences of halting guideline-directed medical therapy (GDMT).

METHODS

This retrospective study was conducted on patients diagnosed with heart failure with reduced ejection fraction (HFrEF) who underwent a second echocardiogram at least 6 months apart between January 2009 and February 2023. The primary outcomes were major adverse cardiovascular events (MACEs), including all-cause mortality and heart failure hospitalization. The second outcome was recurrent HFrEF.

RESULTS

Of 4,560 HFrEF patients were included, 3,289 (72.1%) achieved HFimpEF within a median follow-up period of 3.4 years (IQR: 1.8 - 5.9 years). Among these HFimpEF patients, recurrent HFrEF was observed in 941 (28.6%) patients during a median follow-up period of 2.3 years (IQR: 0.8-4.6 years). The proportion of patients who halted GDMT was 70.4%, 53.2%, 59.8% and 63.8% for MRA, beta-blockers, ACEI/ARB/ARNI and SGLT-2 inhibitors. Multivariable Cox analysis revealed ischemic heart disease, chronic kidney disease, coronary heart disease, lower left ventricular ejection fraction, larger left ventricular diastolic dimension and non-use GDMT are associated with recurrent HFrEF. Individuals without GDMT use exhibited lower chances of persistently recovering ejection fraction and high risks of MACEs compared to those who continue use.

CONCLUSIONS

HFimpEF is a common condition across all clinical follow-ups. Prevalent discontinuation of GDMT medications may contribute significantly to recurrent HFrEF, placing patients at a higher risk for poor prognosis.

Atrial fibrillation in cancer patients: Epidemiology, identification and management

Cancer and cardiovascular disease (CVD) are among the leading causes of death globally, and the rate of coexistence of the two diseases has been increasing in recent years, with the elevation of the susceptible population base in aging societies and the improvement of therapeutic approaches. Atrial fibrillation (AF), as a common type of cancer-related cardiovascular toxicity (CTR-CVT) in oncology patients, is a serious threat to patients' health and may lead to other cardiovascular complications. Therefore, early detection, timely recognition, and effective intervention of AF are essential to maintain long-term survival of tumor survivors. However, the causal mechanisms regarding its association are still inconclusive, and there is no consensus in the clinic on the optimal treatment. In this review, we will integrate existing guidelines and studies to summarize the current state of research on atrial fibrillation in oncology patients in terms of epidemiology, pathophysiological mechanisms, predictive diagnostics, and therapeutic measures, and propose some research directions to be improved. We hope to provide a more comprehensive review and provide assistance in clinical response.

Identifying low-risk in patients with worsening heart failure with short hospital stay: A comparison of risk scores in predicting 30-day risk events

INTRODUCTION

Heart failure (HF) is a leading cause of hospitalization worldwide, with high mortality rates and significant economic burden. To address the issue outpatient strategies (day-care diuretics) to avoid unplanned ED visits and reduce HF hospitalizations. However, the identification of low risk patients worsening heart failure (WHF) who could benefit from outpatient treatment remains poorly documented.

OBJECTIVE

We aimed to evaluate the accuracy of multiple scores in predicting the risk of 30-day events in patients WHF who underwent brief hospitalizations.

METHODS

We conducted a retrospective analysis of a prospective and consecutive cohort of WHF patients with hospitalizations of less than 72 h at a tertiary care hospital between 2015 and 2020. The risk of 30-day all-cause mortality was evaluated using the OPTIMIZE-HF, GWTG-HF, and ADHERE risk scores. And the secondary endpoint was the combined unplanned visit or readmission for worsening HF or death at 30 days. The risk of events in low-risk populations was analyzed by tertiles within the most predictive model.

RESULTS

Among the 200 included patients (mean age: 75.5 ± 12 years; 62% male), 95.9% had a 30-day follow-up, with an overall mortality rate of 4% and a secondary composite endpoint of 14%. AUC-ROC for the prediction of 30-day all-cause mortality were 0.76 (95% CI 0.59-0.93), 0.66 (95% CI 0.46-0.86), and 0.64 (95% CI 0.44-0.85) for OPTIMIZE-HF, GWTG-HF, and ADHERE, respectively. For the secondary combined event, the AUC-ROC was 0.70 (95% CI 0.59-0.79) for OPTIMIZE-HF, GWTG-HF 0.67 (0.56-0.77) and ADHERE 0.67 (0.56 -0.77). The three scores had good calibration (Hosmer-Lemeshow goodness-of-fit test >0.05). Among the low-risk patients (n = 76, OPTIMIZE-HF score <32), the incidence of mortality and combined events at 30 days was 1.3% and 5.3%, respectively. Kaplan-Meier survival analysis showed that low risk patients had lower risk of the combined event (log rank p < 0.006).

CONCLUSION

Among WHF patients with short hospital stays, the OPTIMIZE-HF score exhibited superior predictive ability compared to other scores and may serve as a valuable tool for assessing the risk of death or combined events at 30 days. Utilizing the OPTIMIZE-HF risk score could aid in identifying low-risk patients who might benefit from outpatient management of AHF in a day-care diuretic clinic.

Long-term impact of anthracycline in early-stage breast cancer, bridging of MiRNAs profiler for early cardiotoxicity

BACKGROUND

Anthracyclines are essential in early breast cancer chemotherapy but pose long-term cardiotoxicity risks.

OBJECTIVES

This study aims to investigate the long-term incidence of cancer therapy-related cardiac dysfunction (CTRCD), bridging with the miRNAs profiler representing acute cardiac injury.

METHODS

We conducted a prospective cohort including stage I-III breast cancer patients who received anthracycline between 2007 and 2012. Echocardiography was performed before and 12 weeks after anthracycline administration. The miRNAs profiler was conducted by NanoString and RT-PCR. Long-term cardiac magnetic resonance imaging (CMR) was evaluated in 24.2% of asymptomatic participants.

RESULTS

At a median follow-up of 11 [IQR 6-12] years, 194 patients who completed follow-up echocardiography after anthracycline were included in the analysis. The median age at diagnosis was 50 [26-72] years. An early LVEF decline of ≥ 10% was found in 32.9% of participants. The cumulative equivalent dose of doxorubicin was 223.2 ± 21.6 mg/m2. At the time of censoring, sixty-four participants (32.9%) died, 70% from breast cancer. Nine participants (4.6%) reported cardiovascular events compatible with the CTRCD definition. Forty-seven participants (24.2%) underwent long-term cardiac evaluation. The miRNAs profiler and RT-PCR at different time points, 3 weeks and 6 weeks, respectively, revealed significantly diverse expressions of miR-1-3p and miR-16-5p in participants with and without an early LVEF decline of ≥ 10%. Despite cardiac injury demonstrated by dynamic miR-1-3p and miR-16-5p, CMR parameters revealed no significant differences.

CONCLUSIONS

Our study demonstrates a very low incidence of long-term symptomatic CTRCD. The diverse expression patterns of miR-16-5p and miR-1-3p at different time points also provide valuable biological insights. Within-normal results of an exact and comprehensive CMR, in asymptomatic and any LVEF change participants, indicate the long-term safety of limited-dose anthracycline-containing use.

Active EBV infection in children: associations between DNA load, infection status, immune status, and disease severity

BACKGROUND

This study investigated active Epstein-Barr virus (EBV) infection in children and examined the associations among EBV deoxyribonucleic acid (DNA) load, infection types, disease severity, and immune characteristics.

METHODS

A total of 35,956 pediatric patients who underwent EBV DNA load testing were included. Patients were categorized based on their EBV DNA levels and infection status.

RESULTS

Spearman's rank correlation analysis revealed a positive association between EBV DNA levels and the mortality rate, as well as the incidence rates of acute kidney injury (AKI), respiratory failure, cardiovascular complications, coagulation abnormalities, and liver injury. Mortality risk significantly increased when EBV DNA exceeded 1 × 105 copies/mL (adjusted odds ratio: 10.53, 95% confidence interval: 2.38-46.59, P < 0.05). As EBV DNA levels increase, the rise in mortality rate during activation- immunoglobulin G (IgG+) was more pronounced than that observed during primary infections. Gaussian mixture model clustering identified two immune clusters. Cluster 0 exhibited elevated pro-inflammatory indicators (IFN-γ, IL-6) and anti-inflammatory indicator (IL-10) levels, along with reduced immune cell counts. This cluster showed higher activation-IgG+ and mortality rates compared with Cluster 1.

CONCLUSIONS

An elevated EBV DNA load (> 1 × 105 copies/mL) in children is associated with increased mortality risk. High pro-inflammatory and anti-inflammatory states, coupled with low immune cell numbers, indicate critical condition. Simultaneous examinations of EBV DNA, antibodies, and immune status are recommended, especially for children with EBV DNA > 1 × 105 copies/mL, emphasizing the need for caution in those with activation-IgG+ and immune dysregulation.

Iron deficiency in patients with cardiogenic shock: protocol for a scoping review

INTRODUCTION

Cardiogenic shock (CS) is a severe condition characterised by low cardiac output and often hypotension, which results in organ hypoperfusion due to cardiac failure. As a form of acute heart failure, this condition seems to share similar underlying pathological mechanisms. It is well established that iron deficiency is correlated with chronic and acute heart failure, causing worsening of the symptoms, reduction of quality of life and survival and simultaneously increasing the rehospitalisation rates for all causes in these patients. It remains unclear whether there is an association between iron deficiency and CS. The objective of this scoping review will be to determine the actual state of the art regarding the significance of iron deficiency in patients affected by CS.

METHODS AND ANALYSIS

We will conduct a systematic review of the literature using MEDLINE and EMBASE via 'Ovid' (Elsevier) and Web of Science (2024 Clarivate). The goal is to analyse the incidence and clinical significance of iron deficiency in patients affected by cardiogenic shock. To gain a deeper insight into the underlying pathophysiological mechanisms, the review will include basic research conducted on both human subjects and on animal models as well as observational, randomised controlled studies and systematic reviews and meta-analysis. To maximise the identification of relevant reports and reduce loss of information, a systematic search of the literature will be performed from inception until January 2025 using the terms "iron deficiency" as well as "iron", "ferritin", "transferrin", "transferrin saturation", "hepcidin" and "soluble transferrin receptor" matching these terms with the keywords "cardiogenic shock", "acute heart failure", "advanced heart failure", "decompensated heart failure", "lvad", "left ventricular assist device", "mechanical circulatory support", "VA-ECMO" and "Extracorporeal Life Support". We will also use the corresponding MeSH and Emtree terms. In order to find grey literature, we will use the OADT.org internet-based database.

ETHICS AND DISSEMINATION

No additional ethics approval is required, as this review is based on existing research without new data collection. Only studies with ethics approval will be included. We plan to publish our findings in a peer-reviewed journal and present them at international conferences on cardiology, intensive and acute cardiovascular care, cardiac surgery and cardioanaesthesiology.

Ca2+ Cycling Alteration in a Porcine Model of Right Ventricular Dysfunction

BACKGROUND

Pulmonary hypertension is a severe disease with high mortality rates due to right ventricular (RV) failure. The molecular and cellular processes involved in RV remodeling, including Ca2+ handling, remain elusive due to the lack of relevant animal models. In this study, we aim to understand better the pathophysiological mechanisms involved in RV failure.

METHODS

We used the chronic thromboembolic pulmonary hypertension (CTEPH) pig model, which leads to progressive RV hypertrophy and dysfunction. Cellular, molecular unbiased global transcriptional profiling and biochemical analyses were performed on RV cardiomyocytes from CTEPH and Sham-operated pigs.

RESULTS

CTEPH pigs replicated the hemodynamics and histological changes of human CTEPH features. Transcriptome analysis in Sham and CTEPH pigs revealed molecular RV remodeling close to human patients with pulmonary arterial hypertension with decompensated RV function and notably identified changes in genes involved in Ca2+ signaling. At the cellular level, CTEPH myocytes presented reduced L-type Ca2+ current in association with reduced mRNA of CACNA1C. Furthermore, CTEPH myocytes showed lower [Ca2+]i transients, decreased sarcoplasmic reticulum Ca2+ content, and decreased cell shortening, related to reduced SERCA2a (Sarco/endoplasmic reticulum Ca2+-ATPase isoform 2a) protein expression. Moreover, CTEPH cardiomyocytes exhibited reduced Ca2+ spark occurrence, which relied on smaller RyR2 (ryanodine receptor 2) clusters and T-tubule disorganization. Finally, these alterations in Ca2+ homeostasis were also associated with an increased store-operated Ca2+ entry and the de novo expression of the Ca2+ sensor protein STIM1L in CTEPH myocytes as well as in RV from human patients with pulmonary arterial hypertension.

CONCLUSIONS

Our data reveal cellular Ca2+ cycling remodeling that participates in the pathogenesis of RV dysfunction and may constitute therapeutic targets to limit the development of RV dysfunction.

Ambient low-level benzene, genetic factors, and heart failure incidence among urban adults

Ambient benzene, a representative volatile organic compound (VOC) primarily resulting from rapid industrialization and urbanization, is also of great concern as an urban air toxic. The global benzene market is experiencing steady growth, driven by its use in industrial manufacturing. Currently, population epidemiological evidence about the effects of ambient benzene on heart failure (HF) incidence is still inadequate, especially at low levels of long-term exposure. Leveraging data from 277,585 urban residents in the UK Biobank, the study utilized Cox regression models adjusted for potential confounders to evaluate the association between low-concentration benzene exposure and HF risk. The investigation also assessed potential interactions between genetic predisposition and ambient benzene by applying relative excess risk due to interaction (RERI) metrics and interaction significance testing. Furthermore, the effect of ambient benzene on cardiac functional parameters was estimated using multiple linear regression models. This study demonstrated that per interquartile range increment of ambient benzene was related to the elevated HF risk (hazard ratios = 1.22, 95 % confidence interval (CI): 1.07-1.39] from the time-dependent Cox model. An additive interaction between ambient benzene and genetic risk was observed (RERI = 0.18, 95 % CI: 0.01-0.36). Ambient benzene exposure demonstrated significant correlations with modifications in cardiac functional parameters, such as ventricular end-diastolic and end-systolic volumes. Prolonged exposure to low-concentration ambient benzene may elevate the likelihood of developing HF, which provides the necessary evidence for the systematic risk assessment of ambient benzene and promotes the formulation and updating of air quality guidelines worldwide.

PINK1-mediated mitophagy attenuates pathological cardiac hypertrophy by suppressing the mtDNA release-activated cGAS-STING pathway

AIMS

Sterile inflammation is implicated in the development of heart failure (HF). Mitochondria play important roles in triggering and maintaining inflammation. Mitophagy is important for regulation of mitochondrial quality and maintenance of cardiac function under pressure overload. The association of mitophagy with inflammation in HF is largely unclear. As PINK1 is a central mediator of mitophagy, our objective was to investigate its involvement in cardiac hypertrophy, and the effect of PINK1-mediated mitophagy on cGAS-STING activation during cardiac hypertrophy.

METHODS AND RESULTS

PINK1 knockout and cardiac-specific PINK1-overexpressing transgenic mice were created and subsequently subjected to transverse aortic constriction (TAC) surgery. In order to explore whether PINK1 regulates STING-mediated inflammation during HF, PINK1/STING (stimulator of interferon genes) double-knockout (DKO) mice were created. Pressure overload was induced by TAC. Our findings indicate a significantly decline in PINK1 expression in TAC-induced hypertrophy. Cardiac hypertrophic stimuli caused the release of mitochondrial DNA (mtDNA) into the cytosol, activating the cGAS-STING signalling, which in turn initiated cardiac inflammation and promoted the progression of cardiac hypertrophy. PINK1 deficiency inhibited mitophagy activity, promoted mtDNA release, and then drove the overactivation of cGAS-STING signalling, exacerbating cardiac hypertrophy. Conversely, cardiac-specific PINK1 overexpression protected against hypertrophy thorough inhibition of the cGAS-STING signalling. DKO mice revealed that the effects of PINK1 on hypertrophy were dependent on STING.

CONCLUSION

Our findings suggest that PINK1-mediated mitophagy plays a protective role in pressure overload-induced cardiac hypertrophy via inhibiting the mtDNA-cGAS-STING pathway.

Characteristics of comparatively young heart failure with preserved ejection fraction: PurSuit-HFpEF registry

Because heart failure (HF) with preserved ejection fraction (HFpEF) is mainly a disease of elderly, there are a few reports focusing young patients. This study aims to elucidate characteristics of comparatively young HFpEF patients. We divided HFpEF patients in PURSUIT-HFpEF registry into younger HFpEF group (age ≤ 65 years) and older HFpEF group and compared the all-cause mortality and HF readmission (HFR) between the two groups and identified discharge factors correlated with HFR among younger HFpEF patients. The younger HFpEF group comprised 51 patients (4.1%). In this group, body mass index and smoking were significantly higher, while hypertension was significantly lower compared to older HFpEF group. Kaplan-Meier analysis indicated no significant difference in HFR between the groups, although all-cause mortality was significantly lower in younger HFpEF group (p < 0.001). Multivariable Cox proportional hazards analysis indicated that angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) were inversely correlated with HFR, whereas mineralocorticoid receptor antagonists (MRA) were positively correlated with HFR in younger HFpEF patients (p = 0.004 and p = 0.007, respectively). In conclusion, younger HFpEF is rare (approximately 4%), with obesity and smoking being significant modifiable factors. HFR was similar between younger and older HFpEF patients. Administration of ACEI/ARB and unnecessity of MRA at discharge may be associated with reducing HFR in younger HFpEF patients.

Remote dielectric sensing to detect pulmonary congestion in acute dyspnoeic patients: Reproducibility and the effect of pulmonary comorbidities

BACKGROUND

Remote Dielectric Sensing (ReDS) is a fast and non-invasive method that estimates lung fluid. We previously described moderate accuracies for ReDS to detect acute heart failure in consecutive patients. We hypothesise that unprecise ReDS values may stem from concomitant pulmonary diseases.

PURPOSE

To examine the ReDS reproducibility and the effect of pulmonary comorbidities on ReDS values in acute dyspnoeic patients.

METHODS

This prospective observational study included 97 consecutive patients ≥50 years with acute dyspnoea. Upon admission, patients underwent low-dose chest computed tomography (CT), echocardiography and ReDS examination. ReDS is by default performed on the right hemithorax in sitting position. For reproducibility comparisons, we conducted additional ReDS measurements two centimetres above and below the default placement, and in sitting and supine position. Two blinded radiologists evaluated the CT scans for pulmonary congestion and pulmonary diseases.

RESULTS

Comparing three ReDS measurements on the right hemithorax revealed coefficients of variations of 9.6 %, 8.2 %, and 8.3 %. For sitting versus supine comparison, the coefficient of variation was 9.5 % for the default ReDS placement. Patients with CT-verified pulmonary congestion had a coefficient of variation of 5.9 % in sitting versus supine comparison, while those without had 10.3 %. In multivariable regression, lower ReDS values were observed in patients with pneumonia (-1.81, p = 0.215, N = 51), emphysema (-5.44, p = 0.001, N = 26), and higher in fibrosis (5.58, p = 0.032, N = 8) and congestion (5.79, p = 0.002, N = 17), compared to those without.

CONCLUSION

ReDS values of lung fluid content and reproducibility were affected by pulmonary diseases. ReDS showed consistent reproducibility for patients with CT-verified pulmonary congestion.

Artificial Intelligence in Diagnosis of Heart Failure

Heart failure (HF) is a complex and varied condition that affects over 50 million people worldwide. Although there have been significant strides in understanding the underlying mechanisms of HF, several challenges persist, particularly in the accurate diagnosis of HF. These challenges include issues related to its classification, the identification of specific phenotypes, and the assessment of disease severity. Artificial intelligence (AI) algorithms have the potential to transform HF care by enhancing clinical decision-making processes, enabling the early detection of patients at risk for subclinical or worsening HF. By integrating and analyzing vast amounts of data with intricate multidimensional interactions, AI algorithms can provide critical insights that help physicians make more timely and informed decisions. In this review, we explore the challenges in current diagnosis of HF, basic AI concepts and common AI algorithms, and latest AI research in HF diagnosis.

Effects of palliative care consultation service on decedents experiencing end-stage heart failure: a 4-year observational study

BACKGROUND

Patients experiencing end-stage heart failure are a particularly important population who carry with them a heavy disease burden. However, evidence related to palliative care for patients with end-stage heart failure remains scarce, particularly when it comes to the issue of palliative care consultation service (PCCS). This 4-year observational study aimed to evaluate the effects of PCCS on opioid use and aggressive treatment during end of life (EOL) among patients diagnosed with end-stage heart failure.

METHODS

This observational study used the hospice palliative care database of a tertiary medical center in Taiwan. We enrolled all decedents who were diagnosed with end-stage heart failure from the period January 1, 2018 to December 31, 2021. PCCS prior to death was documented with the relationship between PCCS and opioid use and treatment aggressiveness during EOL then analyzed through use of multivariable logistic regression.

RESULTS

A total of 120 patients were enrolled, which included 60 (50.0%) patients with end-stage heart failure who received PCCS prior to death. Compared with patients who did not receive PCCS, patients with PCCS during EOL were found to have had significantly more opioids use (odds ratio and 95% confidence interval: 3.192, 1.311-7.768) as well as a greater likelihood of their hospitalization extending for more than 14 days (odds ratio and 95% confidence interval: 4.454, 1.863-10.651) during EOL. Even though patients who received PCCS did not experience significantly different combined treatment aggressiveness during EOL, they received less CPR and had more DNR consent orders. Moreover, the promotion of PCCS increased disease awareness in both patients and their families.

CONCLUSION

PCCS in patients diagnosed with end-stage heart failure during EOL could significantly increase their opioid use and reduce some forms of aggressive treatments during EOL.

Targeting Viperin prevents coxsackievirus B3-induced acute heart failure

Coxsackievirus B3 (CVB3)-induced acute heart failure (AHF) is a common cause of cardiogenic death in young- and middle-aged people. However, the key molecular events linking CVB3 to AHF remain largely unknown, resulting in a lack of targeted therapy strategies thus far. Here, we unexpectedly found that Viperin deficiency does not promote CVB3 infection but protects mice from CVB3-induced AHF. Importantly, cardiac-specific expression of Viperin can induce cardiac dysfunction. Mechanistically, CVB3-encoded 3C protease rescues Viperin protein expression in cardiomyocytes by lowering UBE4A. Viperin in turn interacts with and reduces STAT1 to activate SGK1-KCNQ1 signaling, and eventually leads to cardiac electrical dysfunction and subsequent AHF. Furthermore, we designed an interfering peptide VS-IP1, which blocked Viperin-mediated STAT1 degradation and therefore prevented CVB3-induced AHF. This study established the first signaling link between CVB3 and cardiac electrical dysfunction, and revealed the potential of interfering peptides targeting Viperin for the treatment of CVB3-induced AHF.

Metabolomic profiling in heart failure as a new tool for diagnosis and phenotyping

Classifying heart failure (HF) by stages and ejection fraction (EF) remains a debated topic in cardiology. Metabolomic profiling (MP) offers a means to identify unique pathophysiological changes across different phenotypes, presenting a promising approach for the diagnosis and prognosis of HF, as well as for the development of targeted therapies. In our study, MP was performed on 408 HF patients (54.9% male). The mean ages of patients were 62 [53;68], 67 [65;74], 68 [61;72], and 69 [65;73] years for stages A, B, C, and D, respectively. This study demonstrates high accuracy in HF stage classification, distinguishing Stage A from Stage B with an AUC ROC of 0.91 and Stage B from Stage C with an AUC ROC of 0.97, by integrating chromatography-mass spectrometry data through multiparametric machine learning models. The observed metabolic similarities between HF with mildly reduced EF and HF with reduced EF phenotypes (AUC ROC 0.96) once again highlight the fundamental differences at the cellular and molecular levels between HF with preserved EF and HF with EF < 50%. Hierarchical clustering based on MP identified four distinct HF phenotypes and 26 key metabolites, including metabolites of tryptophan catabolism, glutamine, riboflavin, norepinephrine, serine, and long- and medium-chain acylcarnitines. The average follow-up period was 542.37 [16;1271] days. A downward change in the trajectory of EF [HR 3,008, 95% CI 1,035 to 8,743, p = 0,043] and metabolomic cluster 3 [HR 2,880; 95% CI 1,062 to 7,810, p = 0,0376] were associated with increased risk of all-cause mortality. MP can refine HF phenotyping and deepen the understanding of its underlying mechanisms. Metabolomic analysis illuminates the biochemical landscape of HF, aiding in its classification and suggesting new therapeutic pathways.

Predictors of Plasma Selenium Levels and Association with Prognosis in Outpatients with Heart Failure: a 36-Month Prospective Cohort Study

Selenium plays a role in the context of heart failure (HF), but still, there are gaps regarding the factors associated with selenium status, as well as its association with the prognosis of HF. We aimed to investigate predictors of plasma selenium and its association with hospitalization and all-cause mortality. This prospective cohort study included 80 outpatients with HF. Non-elective hospitalization and all-cause mortality were assessed during 36 months of follow-up. The associations between plasma selenium, dietary selenium intake, and sociodemographic, clinical, and biochemical parameters were evaluated by a multiple linear regression model. The risk of these clinical outcomes was assessed with multivariate Cox regression and cubic splines analysis. Albumin (β = 0.113, p < 0.001; R2 = 0.291) and triacylglycerol levels (β = 0.0002, p < 0.021, R2 = 0.376) were predictors of plasma selenium levels. No significant associations were found between dietary selenium intake and plasma selenium tertiles with hospitalization and all-cause mortality (all p > 0.05). The cubic splines analysis revealed that both low and high selenium concentrations influence these outcomes. The predictors of plasma selenium were related to the clinical conditions of HF. Selenium in plasma should be interpreted cautiously, considering that low and high levels may be associated with risks of adverse outcomes in HF.

Clinical applications of artificial intelligence and machine learning in neurocardiology: a comprehensive review

Neurocardiology is an evolving field focusing on the interplay between the nervous system and cardiovascular system that can be used to describe and understand many pathologies. Acute ischemic stroke can be understood through this framework of an interconnected, reciprocal relationship such that ischemic stroke occurs secondary to cardiac pathology (the Heart-Brain axis), and cardiac injury secondary to various neurological disease processes (the Brain-Heart axis). The timely assessment, diagnosis, and subsequent management of cerebrovascular and cardiac diseases is an essential part of bettering patient outcomes and the progression of medicine. Artificial intelligence (AI) and machine learning (ML) are robust areas of research that can aid diagnostic accuracy and clinical decision making to better understand and manage the disease of neurocardiology. In this review, we identify some of the widely utilized and upcoming AI/ML algorithms for some of the most common cardiac sources of stroke, strokes of undetermined etiology, and cardiac disease secondary to stroke. We found numerous highly accurate and efficient AI/ML products that, when integrated, provided improved efficacy for disease prediction, identification, prognosis, and management within the sphere of stroke and neurocardiology. In the focus of cryptogenic strokes, there is promising research elucidating likely underlying cardiac causes and thus, improved treatment options and secondary stroke prevention. While many algorithms still require a larger knowledge base or manual algorithmic training, AI/ML in neurocardiology has the potential to provide more comprehensive healthcare treatment, increase access to equitable healthcare, and improve patient outcomes. Our review shows an evident interest and exciting new frontier for neurocardiology with artificial intelligence and machine learning.

Association of microRNA-210-3p with NT-proBNP, sST2, and Galectin-3 in heart failure patients with preserved and reduced ejection fraction: A cross-sectional study

BACKGROUND

Heart failure (HF) is a growing health problem and around two percent are affected in the general population. Accurate diagnostic markers that have the potential for early diagnosis of HF are lacking. This study aimed to compare the expression levels of microRNA-210-3p with biomarkers NT-proBNP, sST2, and galectin-3, in heart failure patients with preserved and reduced ejection fractions.

MATERIALS AND METHODS

The cross-sectional study was conducted on 270 hypertensive heart failure patients in the age group of 30 to 75 years of both genders. The participants with evidence of HF were recruited from the Department of Cardiology in a tertiary care hospital in Chennai, India. MicroRNA-210-3p was analyzed by qRT-PCR in a stratified sample of 80 HF patients and 20 apparently healthy individuals. Biomarkers were analyzed by ELISA. Institutional ethics committee approval and written informed consent were obtained. Statistical analysis was performed using R software (4.2.1). Based on the type of distribution of data, appropriate statistical tools were used. p-value ≤  0.05 was considered to be statistically significant.

RESULTS

All the biomarkers including microRNA-210-3p were significantly higher in HFrEF than in HFpEF. MAGGIC score showed a positive correlation with all the biomarkers. The cut-off of microRNA-210-3p was 5.03.

CONCLUSION

All the biomarkers were significantly elevated in HFrEF compared to HFpEF. However, microRNA-210-3p could be an early marker in the diagnosis of heart failure. The strategy of employing a multi-marker approach could help in the early diagnosis as well as in stratifying the HF patients.

Y4 RNA fragment alleviates myocardial injury in heart transplantation via SNRNP200 to enhance IL-10 mRNA splicing

Myocardial ischemia-reperfusion injury (MIRI) inevitably occurs during heart transplantation, highlighting the imperative for effective therapeutic interventions. A Y4 RNA fragment (YF1) was applied to treat a syngeneic mouse model of heart transplantation, with the heart subjected to cold ischemia-reperfusion (CIR). Cardiomyocytes and macrophages were treated with YF1, and a cellular cold hypoxia-reoxygenation (CHR) model was established. We found that YF1 alleviated CIR-induced inflammatory macrophage infiltration and cardiomyocytes injury in the graft heart. YF1 had no direct effects on cardiomyocytes in vitro, while YF1 inhibited macrophage polarization to the pro-inflammatory phenotype with increased expression of anti-inflammatory factors. Moreover, YF1 attenuated CHR-induced cardiomyocyte injury by regulating the interleukin-10 (IL-10) expression in macrophages. Mechanistically, YF1 increased the mRNA expression ratio of IL-10/pre-IL-10 by binding to SNRNP200, a spliceosome-specific protein for pre-mRNA splicing, with reduced SNRNP200 ubiquitination. It was reversed by Brr2-IN-3, a specific SNRNP200 inhibitor. Collectively, we hold that YF1 might alleviate MIRI in heart transplantation via binding to SNRNP200 and regulating its ubiquitination to enhance IL-10 pre-mRNA splicing. These findings further clarify the effects and mechanism of YF1 on MIRI and suggest a potential cardioprotective therapy in heart transplantation.

Gated myocardial perfusion SPECT for evaluating left ventricular dyssynchrony in cardiac resynchronization therapy candidates: a systematic review

OBJECTIVES

Cardiac resynchronization therapy (CRT) is an intervention for heart failure patients with reduced ejection fraction who exhibit specific electrocardiographic indicators of electrical dyssynchrony. However, electrical dyssynchrony does not universally correspond to left ventricular mechanical dyssynchrony (LVMD). Gated single-photon emission computed tomography (SPECT) myocardial perfusion allows for the assessment of LVMD, yet its role in the CRT selection process remains debated.

METHODS

We conducted a systematic literature review to critically evaluate the evidence for the prediction and prognostic utility of SPECT for LVMD in assessing LVMD among CRT candidates. The review adhered to PRISMA 2020 Statement criteria and included articles from PubMed, Embase, and Cochrane databases. The quality of evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation framework.

RESULTS

From an initial pool of 1055 records, 33 met the inclusion criteria and provided original data on the predictive value of myocardial perfusion SPECT for LVMD. Most of them measured LVMD according to established recommendations, focusing on phase histogram bandwidth (HBW) and phase histogram standard deviation (PSD). Out of 2066 patients from 27 studies, 62% ( n  = 1214) were qualified as CRT responders. Five studies reported SPECT-based cutoffs for predicting CRT response (HBW ranging 55°-152° and for PSD 20°-54°). Only five studies assessed the prognostic implications of baseline SPECT-measured LVMD, indicating that elevated baseline HBW and PSD values are associated with poorer outcomes.

CONCLUSION

The objective and reproducible measurement of LVMD provided by SPECT underscores its potential as a valuable tool. Such assessment seems to be emerging as a promising adjunctive technique with potential to enhance CRT outcomes.

Prevalence and prognostic value of ventricular conduction delay in heart failure with preserved ejection fraction

Background

The pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF) is heterogeneous and incompletely understood. This study evaluated the presence of a ventricular conduction delay (VCD) phenotype in HFpEF through QRS duration and vectorcardiographic QRS area, and their relation to adverse outcomes.

Methods

This study included consecutive ambulatory HFpEF patients. Baseline QRS duration was obtained from an electrocardiogram (ECG). QRS area was derived from vectorcardiographic analyses of the ECG. QRS duration and area were assessed and analysed as categorical (<100 ms, 100-119 ms, ≥120 ms; ≤ 43.1 µVs, >43.1 µVs) and continuous variables to determine the relation to the composite outcome of HF hospitalisation and all-cause mortality.

Results

349 HFpEF patients were included of whom 70 % had a QRS duration < 100 ms compared to 21 % with QRS duration 100-119 ms and 9 % with QRS duration ≥120 ms. 87 (25 %) patients had QRS area >43.1 µVs. Only 4 % had a QRS area ≥69µVs, indicating delayed lateral wall activation. After a median of 3 years follow-up, 30 % of the patients had an adverse outcome. Longer QRS duration but not larger QRS area was associated with more adverse outcomes on both categorical and continuous scales (HR per 5 ms increase = 1.06, P = 0.033). This prognostic association was mainly present in males.

Conclusion

HFpEF patients have a low prevalence of a VCD phenotype(9 % QRS duration ≥120 ms;4 % a QRS area ≥69 µVs). However, QRS duration >100 ms was present in 30 % and was an independent predictor for adverse outcomes. Future efforts are needed to understand the mechanisms underlying the association of QRS duration and adverse outcomes, and to determine its clinical implications.

Usefulness of tissue tracking to differentiate tachycardia-induced cardiomyopathy from dilated cardiomyopathy in patients admitted for heart failure

INTRODUCTION

Differentiation of tachycardia-induced cardiomyopathy (TIC) from dilated cardiomyopathy (DCM) in patients admitted for heart failure (HF) with left ventricular dysfunction and supraventricular tachyarrhythmia (SVT) remains challenging. The role of tissue tracking (TT) in this setting remains unknown.

METHODS

Forty-three consecutive patients admitted for HF due to SVT with left ventricular ejection fraction (LVEF) < 50% undergoing CMR were retrospectively included. Those eventually evolving to LVEF > 50% at follow-up were classified as TIC and those maintaining a LVEF < 50% were classified as DCM. Clinical, echocardiography, and CMR findings, including TT, were analyzed to predict LVEF recovery.

RESULTS

Twenty-five (58%) patients were classified as TIC. Late gadolinium enhancement (LGE) was more frequent in DCM group (61% vs 16%, p = 0.004). Left ventricle (LV) peak systolic radial velocity and peak diastolic radial strain rate were lower in DCM group (7.24 ± 4.44 mm/s vs 10.8 ± 4.5 mm/s; p = 0.015 and -0.12 ± 0.33 1/s vs -0.48 ± 0.51 1/s; p = 0.016, respectively). Right ventricle (RV) peak circumferential displacement was lower in patients with TIC (0.2 ± 1.3 vs 1.3 ± 0.9°; p = 0.009). In the multivariate analysis, diabetes (p = 0.046), presence of LGE (p = 0.028), LV peak systolic radial velocity < 7.5 mm/s (p = 0.034), and RV peak circumferential displacement > 0.5° (p = 0.028) were independent predictors of lack of LVEF recovery.

CONCLUSION

In the setting of acute HF with LV dysfunction related to SVT, diabetes, LGE, LV peak systolic velocity, and RV peak circumferential displacement are independent predictors of lack of LVEF recovery and, therefore, represent clinically useful parameters to differentiate TIC from DCM.

Prevalence of transthyretin cardiac amyloidosis in patients with heart failure with preserved ejection fraction: the PRACTICA study

INTRODUCTION AND OBJECTIVES

Transthyretin cardiac amyloidosis (ATTR-CA) is a frequent cause of heart failure with preserved ejection fraction (HFpEF). This study sought to determine the prevalence of ATTR-CA among HFpEF patients in a multicenter nationwide study.

METHODS

Consecutive ambulatory or hospitalized patients aged ≥ 50 years with HFpEF and left ventricle hypertrophy ≥ 12mm were studied at 20 Spanish hospitals. Screening for cardiac amyloidosis was initiated according to the usual clinical practice of each center. Positive scintigraphs were centrally analyzed.

RESULTS

422 patients were included, of whom 387 underwent further screening for cardiac amyloidosis. A total of 65 patients (16.8%) were diagnosed with ATTR-CA, none below 75 years. There was an increase of prevalence with age. Of them, 60% were male, with a mean age of 85.3±5.2 years, mean left ventricle ejection fraction of 60.3±7.6% and a mean maximum left ventricle wall thickness of 17.2 [12-25] mm. Most of the patients were New York Heart Association class II (48.4%) or III (46.8%). Besides being older than non-ATTR-CA patients, ATTR-CA patients had higher median NT-proBNP levels (3801 [2266-7132] vs 2391 [1141-4796] pg/mL; P=.003). There was no statistical difference in the prevalence of ATTR-CA by sex (19.7% for men and 13.8% for women, P=.085). A ∼7% (4/56) of the patients exhibited a genetic variant (ATTRv).

CONCLUSIONS

This multicenter nationwide study found a prevalence of 16.8%, confirming that ATTR-CA is a significant contributor to HFpEF in male and female patients with left ventricle hypertrophy and more than 75 years.

Association of nighttime very short-term blood pressure variability determined by pulse transit time with adverse prognosis in patients with heart failure

Long-term blood pressure (BP) variability (BPV) is associated with adverse prognosis in patients with heart failure. However, the clinical significance of very short-term (beat-to-beat) BPV is unclear. We collected data on nighttime pulse transit time-based continuous beat-to-beat BP measurement in patients with heart failure (n = 366, median age 72.0, male sex 53.3%). Coefficient of variation (CoV) of pulse transit time-based BP was considered as very short-term BPV. The primary outcome was a composite of heart failure hospitalization or cardiac death. Median values (25th and 75th percentiles) of systolic and diastolic BP CoV were 3.6% (2.8%, 4.5%) and 5.1% (3.8%, 6.5%), respectively. During a median follow-up period of 1084 days after BPV evaluation, 71 patients experienced the primary outcome. When the patients were divided into tertiles based on the systolic and diastolic BPV, the primary outcome occurred most frequently in the highest tertile of BPV. Multivariable Cox proportional hazard analysis revealed that systolic and diastolic BPV, as continuous variables, were independently associated with the primary outcome (hazard ratio 1.199 and 1.101, respectively). In conclusion, high nighttime very short-term BPV was associated with adverse prognosis in patients with heart failure.

Cardiogenic shock mortality according to Aetiology in a Mediterranean cohort: Results from the Shock-CAT study

AIMS

Mortality in cardiogenic shock (CS) remains elevated, with the potential for CS causes to impact prognosis and risk stratification. The aim was to investigate in-hospital prognosis and mortality in CS patients according to aetiology. We also assessed the prognostic accuracy of CardShock and IABP-SHOCK II scores.

METHODS

Shock-CAT study was a multicentre, prospective, observational study conducted from December 2018 to November 2019 in eight university hospitals in Catalonia, including non-selected consecutive CS patients. Data on clinical presentation, management, including mechanical circulatory support (MCS) were analysed comparing acute myocardial infarction (AMI) related CS and non-AMI-CS. The accuracy of CardShock and IABP-SHOCK II scores to assess 90 day mortality risk were also compared.

RESULTS

A total of 382 CS patients were included, age 65.3 (SD 13.9) years, 75.1% men. Patients were classified as AMI-CS (n = 232, 60.7%) and non-AMI-CS (n = 150, 39.3%). In the AMI-CS group, 77.6% were STEMI. Main aetiologies for non-AMI-CS were heart failure (36.2%), arrhythmias (22.1%) and valve disease (8.0%). AMI-CS patients required more MCS than non-AMI-CS (43.1% vs. 16.7%, P < 0.001). In-hospital mortality was higher in AMI-CS (37.1 vs. 26.7%, P = 0.035), with a two-fold increased risk after multivariate adjustment (odds ratio 2.24, P = 0.019). The IABP-SHOCK II had superior discrimination for predicting 90 day mortality when compared with CardShock in AMI-CS patients [area under the curve (AUC) 0.74 vs. 0.66, P = 0.047] although both scores performed similarly in non-AMI-CS (AUC 0.64 vs. 0.62, P = 0.693).

CONCLUSIONS

In our cohort, AMI-CS mortality was increased by two-fold when compared with non-AMI-CS. IABP-SHOCK II score provides better 90 day mortality risk prediction than CardShock score in AMI-CS, but both scores performed similar in non-AMI-CS patients.

Novel predictors of infection-related rehospitalization in older patients with heart failure in Japan

AIM

Rehospitalization of patients with heart failure (HF) incurs high health care costs and increased mortality. Infection-related rehospitalizations in patients with HF occur frequently, and the risk increases with age. This study aimed to identify the factors associated with infection-related rehospitalizations in older patients with HF.

METHODS

Demographic, clinical, and pharmacological data from 1061 patients with acute HF who were enrolled in the Kochi Registry of Subjects With Acute Decompensated Heart Failure (Kochi YOSACOI study) were analyzed. Additionally, a machine learning approach was applied in addition to the traditional statistical analysis model. Of the patients hospitalized for HF, 729 were ultimately analyzed.

RESULTS

During the 2-year postdischarge follow-up period, 121 (17%) patients were readmitted for infections. Logistic regression analysis identified a Japanese Cardiovascular Health Study (J-CHS) score of ≥3 (odds ratio, 1.83 [95% confidence interval, 1.18-2.83]; P = 0.007) at discharge as a key factor for infection-related rehospitalizations. Machine learning models confirmed that a higher J-CHS score and lower estimated glomerular filtration rate (eGFR) increased the risk of infection-related rehospitalizations. Decision tree analysis classified the risk into high (J-CHS score ≥3), medium (J-CHS score <3; eGFR ≤35.0) and low (J-CHS score <3; eGFR >35.0) groups.

CONCLUSIONS

Infection-related rehospitalizations occur in older patients with HF and are associated with frailty and eGFR. These findings provide valuable insights for health care providers to better manage the risk of infection-related rehospitalizations in older patients with HF, potentially improving patient outcomes. Geriatr Gerontol Int 2025; 25: 543-552.

Medical Care as Flea Market Bargaining? An International Interdisciplinary Study of Varieties of Shared Decision Making in Physician-Patient Interactions

Phenomenon: Shared decision making (SDM) is a core ideal in the interaction between healthcare providers and patients, but the implementation of the SDM ideal in clinical routines has been a relatively slow process. Approach: In a sociological study, 71 interactions between physicians and simulated patients enacting chronic heart failure were video-recorded in China, Germany, the Netherlands, and Turkey as part of a quasi-experimental research design. Participating physicians varied in specialty and level of experience. The secondary analysis presented in this article used content analysis to study core components of SDM in all of the 71 interactions and a grounded theory approach to observe how physicians responded actively to patients even though they did not actively employ the SDM ideal. Findings: Full realization of the SDM ideal remains an exception, but various aspects of SDM in physician-patient interaction were observed in all four locations. Analyses of longer interactions show dynamic processes of interaction that sometimes surprised both patient and physician. We observed varieties of SDM that differ from the SDM ideal but arguably achieve what the SDM ideal is intended to achieve. Our analysis suggests a need to revisit the SDM ideal-to consider whether varieties of SDM may be acceptable, even valuable, in their own right. Insights: The gap between the SDM ideal and SDM as implemented in clinical practice may in part be explained by the tendency of medicine to define and teach SDM through a narrow lens of checklist evaluations. The authors support the argument that SDM defies a checklist approach. SDM is not uniform, but nuanced, dependent on circumstances and setting. As SDM is co-produced by patients and physicians in a dynamic process of interaction, medical researchers should consider and medical learners should be exposed to varieties of SDM-related practice rather than a single idealized model. Observing and discussing worked examples contributes to the physician's development of realistic expectations and personal professional growth.

Unveiling the Systemic Impact of Congestion in Heart Failure: A Narrative Review of Multisystem Pathophysiology and Clinical Implications

Congestion is a key clinical feature of heart failure (HF), contributing to hospitalizations, disease progression, and poor outcomes. While traditionally considered a hemodynamic issue, congestion is now recognized as a systemic process affecting multiple organs. Renal dysfunction arises from impaired perfusion and sodium retention, leading to maladaptive left ventricular remodeling. Hepatic congestion contributes to cholestatic liver injury, while metabolic disturbances drive anemia, muscle wasting, and systemic inflammation. Additionally, congestion disrupts the intestinal barrier and immune function, exacerbating HF progression. Given its widespread impact, effective congestion management requires a shift from a cardiovascular-centered approach to a comprehensive, multidisciplinary strategy. Targeted decongestive therapy, metabolic and nutritional optimization, and immune modulation are crucial in mitigating congestion-related organ dysfunction. Early recognition and intervention are essential to slow disease progression, preserve functional capacity, and improve survival. Addressing HF congestion through personalized, evidence-based strategies is vital for optimizing long-term care and advancing treatment paradigms.

Dilated cardiomyopathy: from genes and molecules to potential treatments

Dilated cardiomyopathy is a myocardial condition marked by the enlargement of the heart's ventricular chambers and the gradual decline in systolic function, frequently resulting in congestive heart failure. Dilated cardiomyopathy has obvious familial characteristics, and mutations in related pathogenic genes can account for about 50% of patients with dilated cardiomyopathy. The most common genes related to dilated cardiomyopathy include TTN, LMNA, MYH7, etc. With more and more research on these genes, it will undoubtedly provide more potential targets and therapeutic pathways for the treatment of dilated cardiomyopathy. In addition, myocardial inflammation, myocardial metabolism abnormalities and cardiomyocyte apoptosis all have an important impact on the pathogenesis of dilated cardiomyopathy. Approximately half of sudden deaths among children and adolescents, along with the majority of patients undergoing heart transplantation, stem from cardiomyopathy. Therefore, precise and prompt clinical diagnosis holds paramount importance. Currently, diagnosis primarily hinges on the patient's medical background and imaging tests, with the significance of genetic testing steadily gaining prominence. The primary treatment for dilated cardiomyopathy remains heart transplantation. However, the scarcity of donors and the risk of severe immune rejection underscore the pressing need for novel therapies. Presently, research is actively exploring preclinical treatments like stem cell therapy as potential solutions.

Global Longitudinal Strain: A Potential Non-invasive Tool for Early Detection of Radiation-Induced Cardiac Dysfunction in Lung Cancer Patients Receiving Thoracic Radiation Therapy

PURPOSE

Radiation-induced cardiac dysfunction (RICD) is a competing cause of morbidity and death in patients receiving thoracic radiation therapy (RT). Currently, there are no clinically validated approaches for early detection of RICD at a time point that affords the potential for mitigation. The goal of this study is to evaluate the potential of global longitudinal strain (GLS) derived from standard-of-care echocardiography (ECHO) for the early detection of RICD, and to assess the association between adverse GLS changes and survival in patients receiving thoracic RT.

METHODS

A retrospective review of changes in GLS was carried out in patients with primary or secondary lung cancer who received standard-of-care thoracic RT with a mean heart dose of ≥5 Gy and had measurable GLS on ECHOs performed before and after RT. Changes in two-chamber (2C), 3-chamber (3C), and 4-chamber (4C) GLS, and peak average GLS after RT (relative to pre-RT baseline) were quantified. Survival probabilities were estimated in patients with normal versus abnormal GLS.

RESULTS

Thirty-eight patients had measurable GLS before and after RT. Abnormal GLS (defined as less than 18%, or more than 15% relative decline in GLS after RT from a normal baseline value) was present in 31.6% of patients before RT and in 57.9% of patients after RT (p = 0.012). On paired comparisons, the absolute median reduction (IQR) in 2C, 3C, 4C, and average GLS after RT relative to pre-RT baseline was 1.90 (4.43), 3.00 (3.83), 2.50 (3.63), and 2.25 (3.53) respectively, all p < 0.001. No statistically significant change in LVEF was noted after RT. Patients with abnormal GLS after RT had significantly worse survival than those with normal GLS on univariable analysis (p = 0.049). Despite small sample size of the study, the survival detriment in patient with abnormal GLS after RT strongly trended towards significance on multivariable analysis (p = 0.063).

CONCLUSIONS

Adverse changes in GLS are detectable on standard-of-care ECHOs, and precede significant changes in LVEF in this cohort of high-risk patients with primary and secondary lung cancer receiving thoracic RT. Thus, ECHO-derived GLS has the potential to serve as an early and non-invasive marker of RICD in this patient population and may enable early adoption of GLS-guided cardioprotective therapy, which has been shown to mitigate cardiac dysfunction in cancer patients receiving cardiotoxic treatments.

The prognostic value of global longitudinal strain in patients with myocardial infarction and preserved ejection fraction: a prespecified substudy of the REDUCE-AMI trial

AIMS

The REDUCE-AMI trial showed that beta-blockers in patients with preserved left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI) had no effect on mortality or cardiovascular outcomes. The aim of this substudy was to evaluate whether global longitudinal strain (GLS) is a better prognostic marker than LVEF, and if beta-blockers have a beneficial effect in patients with decreased GLS.

METHODS AND RESULTS

REDUCE-AMI was a registry-based randomized clinical trial. Conventional echocardiographic parameters and GLS were obtained and a likelihood ratio test between models adjusted for age, sex, hypertension, smoking, diabetes, previous AMI, and multi-vessel disease was used to compare LVEF and GLS as prognostic methods. A Cox regression model evaluated the impact of beta-blocker treatment on the composite endpoint of death from any cause or new AMI. A total of 1436 patients (28.6% of the total population) were included in this substudy. Due to poor image quality or incompatible equipment, 324 (22.6%) patients were excluded from the analysis of GLS. The median GLS was 17.3%. The likelihood ratio test resulted in no difference (P = 0.56) when comparing the combination of GLS to LVEF. The results were robust when adding beta-blocker randomization status as an independent variable.

CONCLUSION

In patients after AMI with preserved LVEF, GLS did not add prognostic value regarding death from any cause or new AMI. In addition, beta-blocker treatment did not alter the prognostic information obtained from GLS. Consequently, this study does not support an additive value of GLS compared with standard echocardiographic measurement in this patient population.

Effect of family management styles on the outcomes of children with complex congenital heart disease after palliative surgery

Background

This study aimed to explore family management style (FMS) after palliative surgery in children with complex congenital heart disease (CCHD) and evaluate its influence on their outcomes.

Methods

A cross-sectional survey was conducted among 252 families of children with CCHD who underwent palliative surgery at our center. The Family Management Measure was used to investigate their FMS, and the outcomes with different FMSs were analyzed. Cluster analysis was employed to classify the FMSs into distinct groups.

Results

The cluster analysis identified four FMSs, namely, the Active and Collaborative (Cluster 1, 29.37%), the Chaotic and Nervous (Cluster 2, 10.71%), the Confident and Caring (Cluster 3, 22.22%), and the Laissez-Faire style (Cluster 4, 37.70%). Children in Cluster 1 demonstrated the highest quality of life, while those in Cluster 2 had the lowest (73.93 ± 12.71 and 59.03 ± 18.70, P < 0.01). The unplanned readmission rates were significantly higher in Clusters 2 and 4 (18.52% and 22.11%) compared to Clusters 1 and 3 (4.05% and 3.57%, P < 0.01).

Conclusion

The findings highlight the significant influence of FMS on the outcomes of children with CCHD following palliative surgery. The children in Cluster 1 exhibited the most favorable quality of life, whereas those in Cluster 2 had the worst. Health professionals should implement interventions to optimize FMS.

Phenotype-Based Classification of Obstructive Hypertrophic Cardiomyopathy Undergoing Myectomy

This study partitioned variables derived from clinical and pathological information in patients who received septal reduction therapy to identify obstructive hypertrophic cardiomyopathy subtypes. Subtype 1 was characterized by a high percentage of sarcomere mutation carriers and the highest interventricular septal thickness. Subtype 2 was featured by left atrial enlargement and a high percentage of patients with atrial fibrillation. Subtype 3 was characterized by a high left ventricular outflow tract gradient, serious inflammatory cell infiltration, and a high incidence of postoperative adverse events. This finding has been well replicated in 2 validation cohorts with short- and long-term follow-up.

Epidemiology and prognosis of pediatric acute myocarditis: a 5-year retrospective study in Shiraz, South of Iran running title: pediatric acute myocarditis in Iran

BACKGROUND

Early diagnosis, appropriate management, and vigilant follow-up can lead to the recovery and improved quality of life in many pediatric myocarditis cases. Due to the rarity of this condition, a comprehensive understanding of its epidemiology and outcomes is essential.

AIM

This study aims to provide a thorough epidemiological analysis of pediatric clinically suspected myocarditis and introduce a potential prognostic tool for identifying high-risk patients.

METHOD

A retrospective cross-sectional study was conducted on patients admitted to Namazi Hospital with clinically suspected myocarditis. Demographic, clinical, laboratory, imaging data, and vasoactive inotrope scores were collected from the beginning of hospitalization and throughout the patients' stay. Critical hospital events such as cardioversion, intensive care unit (ICU) care, and mechanical ventilation were documented.

RESULTS

A total of 117 children, including 103 (88%) males, were included in the final evaluation. Patients who required intubation had significantly higher inotrope scores (p-value < 0.0001). Moreover, statistically significant differences were observed in the outcomes of patients presenting with hepatomegaly and decreased left ventricular ejection fraction (P = 0.022).

CONCLUSION

The identification of hepatomegaly and reduced ejection fraction as potential prognostic indicators represents a significant contribution to the field. These findings may assist clinicians in recognizing high-risk patients who require more aggressive treatment and closer monitoring. Patients with elevated inotrope scores are more likely to necessitate mechanical ventilation and cardioversion.

Serum uric acid fluctuations and cardiovascular outcomes in hospitalized acute heart failure patients

BACKGROUND AND AIMS

This study examined the association between serum uric acid (SUA) fluctuation patterns during hospitalization in acute heart failure (HF) patients and clinical outcomes, a relationship not fully understood.

METHODS AND RESULTS

A cohort of 1403 acute HF patients was enrolled with a median follow-up of 20.5 months. Outcomes assessed included cardiovascular (CV) death and/or heart failure hospitalization (CV death & HHP), CV death alone, and all-cause mortality (ACM). Restricted cubic splines analyzed the relationship between admission SUA levels and outcomes. Patients were categorized based on admission and discharge SUA levels into four groups: 1) Normal SUA at both points (N&N), 2) Elevated SUA at admission, normalized at discharge (H&N), 3) Normal SUA at admission, elevated at discharge (N&H), and 4) Elevated SUA at both points (H&H). Associations between SUA categories and outcomes were assessed using COX multivariate regression analysis. Results showed elevated SUA at admission predicted poor outcomes. However, neither N&H nor H&N groups displayed significant increases in CV death & HHP, CV death, or ACM compared to N&N. The H&H group had the highest risks for CV death (adjusted HR 1.79, 95 % CI 1.10-2.93) and ACM (adjusted HR 1.64, 95 % CI 1.08-2.49), with a non-significant trend towards increased risk of CV death & HHP (adjusted HR 1.79, 95 % CI 0.99-2.93).

CONCLUSION

Persistently elevated SUA levels during hospitalization were independently associated with adverse cardiovascular outcomes and ACM in patients with acute HF, whereas fluctuations in SUA levels did not exhibit a similar association.

The Impact of Cold Spray Use on Thirst Distress, Dry Mouth, and Fluid Intake in Heart Failure Patients: A Randomized Controlled Study

BACKGROUND

People with heart failure frequently experience dry mouth and thirst. More information is currently needed on the effectiveness of practical interventions in reducing these symptoms.

OBJECTIVE

This study was conducted to determine the effect of cold-water spray on thirst distress, dry mouth, and fluid intake in patients with heart failure.

METHODS

A randomized controlled trial was conducted involving 72 patients with a confirmed diagnosis of heart failure. The patients were randomly assigned to either an intervention group that received a cold-water spray-based program or a control group that received routine department care. The program of spraying cold water was implemented for 3 days. The level of thirst distress, dry mouth, and fluid intake was measured at the beginning and end of the 3-day intervention, and the data were analyzed using SPSS software version 21.

RESULTS

Before the intervention, the 2 groups showed no significant differences in demographic characteristics, such as age and gender (P > .05). The average scores for thirst and dry mouth distress were also identical. However, after the intervention, the group that received the intervention had significantly lower average scores for thirst distress (20.2 ± 6.9 vs 27.1 ± 8.5, P < .001) and dry mouth distress (3.5 ± 1 vs 5.2 ± 1.2, P < .001) compared with the control group. It is worth noting that there was no significant difference in the average fluid intake between the 2 groups.

CONCLUSION

The study concluded that cold-water spray effectively reduces thirst distress and dry mouth in patients with heart failure.

History of Heart Failure Definition

The concept of heart failure (HF) has undergone significant transformation from ancient times to the present, evolving from rudimentary understandings to a complex clinical syndrome. Early descriptions by Egyptian, Greek and Roman physicians laid the groundwork for understanding cardiac dysfunction. The Renaissance period brought crucial insights with Harvey's discovery of blood circulation. In the 20th century, the Framingham Heart Study provided a pivotal shift, formally defining HF as a clinical syndrome with diagnostic criteria. Over the decades, definitions of HF have evolved, integrating advancements in pathophysiology, biomarkers and imaging techniques. Initially focused on symptomatic and clinical presentations, modern definitions emphasise underlying structural and functional cardiac abnormalities. This evolution reflects the growing complexity and precision of diagnosing and managing HF. A historical perspective underscores the progressive refinement in HF definitions, which enhances diagnostic precision and therapeutic strategies, ultimately improving patient outcomes. Understanding this evolution is crucial for appreciating contemporary HF management and anticipating future advances.

Early experience with a novel transapical transcatheter aortic valve system in patients with severe aortic stenosis: a prospective, multicenter study

Objectives

Registered, prospective, multicenter study of the short-term clinical outcomes of a novel transcatheter aortic valve system (Xcor system, Saint Medical Technology, Inc., Nanjing) to evaluate its safety and efficacy.

Methods

130 high risk patients with symptomatic severe AS from 11 institutions were treated with the novel Xcor system. All patients were pre-TAVR assessed by transthoracic echocardiography and computed tomography of the aortic valve (AV) and relevant left cardiac and vascular anatomy. Procedural, in-hospital, and follow-up clinical outcomes were evaluated after procedures.

Results

The average age of the 130 patients was 71.2 ± 4.4 years old, 55.4% were male, and the STS score was 8.0 ± 3.9%. Device and procedural success were achieved in 98.5% and 97.7% of the patients, respectively. At 30-day follow-up, all-cause mortality, the incidence of major adverse cardiovascular events, major vascular complications, and new permanent pacemaker implantation were 3.8%, 4.6%, 0.8%, and 0.8%, respectively. 7.7% of patients showed ≥ mild paravalvular leakage, and all 125 (100%) patients were in New York Heart Association Class ≤ II. The procedural and clinical outcomes of bicuspid AV patients were similar to those of tricuspid AV patients.

Conclusions

Overall, the 30-day follow-up shows that the procedural outcomes with the novel Xcor system with self-centering support arms are comparable or superior to other contemporary TAVI devices, with a low all-cause mortality, low major adverse cardiovascular events, low PVL and similar clinical outcomes for BAV and TAV patients.

Differences in clinical features and 1-year outcomes of patients with heart failure and reduced, mildly reduced, and preserved ejection fraction in a contemporary cohort: is the clinical profile changing?

AIMS

To analyze in a contemporary registry of heart failure (HF) patients followed in specialized HF units in Spain, the differences in clinical features, treatment, and 1-year outcomes in HF with reduced, mildly reduced, and preserved left ventricular ejection fraction.

METHODS AND RESULTS

We analyzed data from the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology, with 1716 patients with HF included between 2019 and 2021 by 45 specialized HF units accredited by the SEC. Treatment and 1-year mortality, HF hospitalizations and decompensations of HF used were compared according to the type of HF. Of the 1,716 patients, 55.5% had HFrEF, 11.9% had HFmrEF, and 32.6% had HFpEF. HFpEF patients were older and had a higher proportion of women, atrial fibrillation, and hypertension. Sacubitril-valsartan and mineral receptor antagonists were used in greater proportion in HFrEF (56.5% and 73%, respectively, p < 0.001), but also in 10.3 and 33% in HFpEF. One-year mortality (17.3 vs 20.9 vs 15.6/100 persons-year; p = 0.321), 1-year HF hospitalizations (34.4 vs 29.5 vs 26.7/100 persons-year; p = 0.330), and 1-year decompensations of HF without hospitalization (13.1 vs 10.4 vs 11.1; p = 0.393) were similar for the 3 types of HF.

CONCLUSION

In our contemporary cohort of real-life HF patients, slight differences were observed in clinical features and treatment between the 3 types of HF, but the prevalence of most of the major comorbidities and 1-year outcomes (mortality, hospitalizations and decompensations of HF) were similar in the 3 groups.

The clinical classification of patients with acute heart failure at emergency department and its relation with management and outcome: a cross sectional study from Syria

INTRODUCTION

To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to the 2016 European Society of Cardiology (ESC) guidelines taking into account isolated right HF (RHF) with left HF (LHF) phenotypes. Volume status was assessed by the clinical manifestations and lung ultrasound (LUS). The secondary aim was to study the role of echocardiography in congestion based on LUS and their relations with outcomes.

METHODS

This study included AHF patients, who referred to the emergency department (ED) at AL-Mouwasat and AL-Assad University Hospitals in Syria between May and August 2024. The same cardiologist reviewed medical reports, signs/ symptoms of decompensation, echocardiographic assessment, diagnosis, and treatment therapies.

RESULTS

Of 100 patients, 10 patients (10%) had isolated RHF and 90 patients (90%) had LHF, including warm-wet (n = 65, 65%), followed by cold-wet (n = 13, 13%), warm-dry (n = 10, 10%), and cold-dry (n = 2, 2%). Most discharged patients without admission were Warm-dry, meanwhile most of patients with cold-wet (76.9%) were admitted to intensive care unit (ICU). The longest in-hospital stays were in cold-wet (11.9 days) followed by isolated RHF (7.5 days). While in-hospital mortality was mainly in cold-wet (38.5%) followed by isolated RHF (20%). Diuretics dose was highest in cold-wet followed by isolated RHF, while hydration was predominantly in cold-wet. Using vasopressors and inotropes were predominantly in cold-wet. Systolic blood pressure (SBP), hemoglobin (Hb), sodium (Na), proximal right ventricular outflow tract (RVOT1), left ventricular end-diastolic internal diameter (LVIDd), Tricuspid annular systolic plane excursion (TAPSE), and systolic pulmonary atrial pressure (SPAP) correlated with hospital stays, while only SBP and Cr correlated with in-hospital mortality. The cut-off values of E/e' ratio, isovolumic relaxation time (IVRT), and deceleration time (DT) were (12.5, 55ms, and 131.5 ms; respectively) and could predict congestion (guided by LUS) with sensitivities of (96%, 74%, and 62%; respectively) and specificities of (53%, 92%, and 84%; respectively).

CONCLUSION

Classifying AHF patients into these five groups, based on clinical examination supporting by echocardiography and LUS evaluation can give better assessment of the AHF phenotypes and gives more details for management. The bedside diagnostic assessment by LUS and echocardiography is an easy tool and seems to be of great benefit in detecting congestion that enhances the treatment protocols.

Myocardial Proteome in Human Heart Failure With Preserved Ejection Fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) constitutes more than half of all HF but has few effective therapies. Recent human myocardial transcriptomics and metabolomics have identified major differences between HFpEF and controls. How this translates at the protein level is unknown.

METHODS AND RESULTS

Myocardial tissue from patients with HFpEF and nonfailing donor controls was analyzed by data-dependent acquisition (n=10 HFpEF, n=10 controls) and data-independent acquisition (n=44 HFpEF, n=5 controls) mass spectrometry-based proteomics. Differential protein expression analysis, pathway overrepresentation, weighted coexpression network analysis, and machine learning were integrated with clinical characteristics and previously reported transcriptomics. Principal component analysis (data-dependent acquisition-mass spectrometry) found HFpEF separated into 2 subgroups: one similar to controls and the other disparate. Downregulated proteins in HFpEF versus controls were enriched in mitochondrial transport/organization, translation, and metabolism including oxidative phosphorylation. Proteins upregulated in HFpEF were related to immune activation, reactive oxygen species, and inflammatory response. Ingenuity pathway analysis predicted downregulation of protein translation, mitochondrial function, and glucose and fat metabolism in HFpEF. Expression of oxidative phosphorylation and metabolism genes (higher) versus proteins (lower) was discordant in HFpEF versus controls. Data-independent acquisition-mass spectrometry proteomics also yielded 2 HFpEF subgroups; the one most different from controls had a higher proportion of patients with severe obesity and exhibited lower proteins related to fuel metabolism, oxidative phosphorylation, and protein translation. Three modules of correlated proteins in HFpEF that correlated with left ventricular hypertrophy and right ventricular load related to (1) proteasome; (2) fuel metabolism; and (3) protein translation, oxidative phosphorylation, and sarcomere organization.

CONCLUSIONS

Integrative proteomics, transcriptomics, and pathway analysis supports a defect in both metabolism and translation in HFpEF. Patients with HFpEF with more distinct proteomic signatures from control more often had severe obesity, supporting therapeutic efforts targeting metabolism and translation, particularly in this subgroup.

Transition to Advanced Heart Failure: From Identification to Improving Prognosis

Advanced heart failure (AHF) represents the terminal stage of heart failure (HF), characterized by persistent symptoms and functional limitations despite optimal guideline-directed medical therapy (GDMT). This review explores the clinical definition, pathophysiology, and therapeutic approaches for AHF. Characterized by severe symptoms, New York Heart Association (NYHA) class III-IV, significant cardiac dysfunction, and frequent hospitalizations, AHF presents substantial challenges in prognosis and management. Pathophysiological mechanisms include neurohormonal activation, ventricular remodeling, and systemic inflammation, leading to reduced cardiac output and organ dysfunction. Therapeutic strategies for AHF involve a multidisciplinary approach, including pharmacological treatments, device-based interventions like ventricular assisted devices, and advanced options such as heart transplantation. Despite progress, AHF management faces limitations, including disparities in access to care and the need for personalized approaches. Novel therapies, artificial intelligence, and remote monitoring technologies offer future opportunities to improve outcomes. Palliative care, which focuses on symptom relief and quality of life, remains crucial for patients ineligible for invasive interventions. Early identification and timely intervention are pivotal for enhancing survival and functional outcomes in this vulnerable population. This review underscores the necessity of integrating innovative technologies, personalized medicine, and robust palliative strategies into AHF management to address its high morbidity and mortality.

How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC

The multiplicity of coexisting comorbidities affecting patients with heart failure (HF), together with the availability of multiple treatments improving prognosis in HF with reduced ejection fraction, has led to an increase in the number of prescribed medications to each patient. Polypharmacy is defined as the regular use of multiple medications, and over the last years has become an emerging aspect of HF care, particularly in older and frailer patients who are more frequently on multiple treatments, and are therefore more likely exposed to tolerability issues, drug-drug interactions and practical difficulties in management. Polypharmacy negatively affects adherence to treatment, and is associated with a higher risk of adverse drug reactions, impaired quality of life, more hospitalizations and worse prognosis. It is important to adopt and implement strategies for the management of polypharmacy from other medical disciplines, including medication reconciliation, therapeutic revision and treatment prioritization. It is also essential to develop new HF-specific strategies, with the primary goal of avoiding the use of redundant treatments, minimizing adverse drug reactions and interactions, and finally improving adherence. This clinical consensus statement document from the Heart Failure Association of the European Society of Cardiology proposes a rationale, pragmatic and multidisciplinary approach to drug prescription in the current era of multimorbidity and 'multi-medication' in HF.

Prognostic Markers of Adverse Outcomes in Acute Heart Failure: Use of Machine Learning and Network Analysis with Real Clinical Data

Background: Acute heart failure (AHF) is one of the leading causes of admissions to the emergency department (ED). There is a need to develop an easy-to-use score that can be used in the ED to risk-stratify patients with AHF and in hospitalization decisions regarding cardiac wards or intensive care units (ICUs). Methods: A retrospective observational study was conducted at a city hospital. The data from the presentation of AHF patients at the ED were collected. The combined primary endpoint included death from any cause during hospitalization or transfer to an intensive care unit (ICU) for using inotropes/vasopressors. Feature selection was performed using artificial intelligence. Results: From August 2020 to August 2021, 908 patients were enrolled (mean age: 71.6 ± 13 years; 500 (55.1%) men). We found significant predictors of in-hospital mortality and ICU transfers for inotrope/vasopressor use and built two models to assess the need for ICU admission of patients from the ED. The first model included SpO2 < 90%, QTc duration, prior diabetes mellitus and HF diagnosis, serum chloride concentration, respiratory rate and atrial fibrillation on admission, blood urea nitrogen (BUN) levels, and any implanted devices. The second model included left ventricular end-diastolic size, systolic blood pressure, pulse blood pressure, BUN levels, right atrium size, serum chloride, sodium and uric acid concentrations, prior loop diuretic use, and pulmonary artery systolic blood pressure. Conclusions: We developed two models that demonstrated a high negative predictive value, which allowed us to distinguish patients with low risk and determine patients who can be hospitalized and sent from the ED to the floor. These easy-to-use models can be used at the ED.

RNA Therapies in Cardio-Kidney-Metabolic Syndrome: Advancing Disease Management

Cardio-Kidney-Metabolic (CKM) Syndrome involves metabolic, kidney, and cardiovascular dysfunction, disproportionately affecting disadvantaged groups. Its staging (0-4) highlights the importance of early intervention. While current management targets hypertension, heart failure, dyslipidemia, and diabetes, RNA-based therapies offer innovative solutions by addressing molecular mechanisms of CKM Syndrome. Emerging RNA treatments, including antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs), show promise in slowing disease progression across CKM stages. For example, ASOs and siRNAs targeting ApoC-III and ANGPTL3 reduce triglycerides and LDL cholesterol, while siRNAs improve blood pressure control by targeting the renin-angiotensin-aldosterone system. Obesity treatments leveraging miRNAs and circRNAs tackle a key CKM risk factor. In heart failure and diabetes, RNA-based therapies improve cardiac function and glucose control, while early kidney disease trials show potential for RNAi in acute injury. Further research is essential to refine these therapies and ensure equitable access.

Status of Cardiac Magnetic Resonance in Clinical Application and Scientific Research: A National Survey in China

BACKGROUND

Cardiovascular magnetic resonance (CMR) is rapidly expanding in China, yet comprehensive national data on its clinical application and research status are limited. This study aims to evaluate the current landscape of CMR across the country.

METHODS

An electronic survey was conducted targeting two groups: physicians trained at the Fuwai Fellowship Program and members of the Chinese Society of Radiology. The survey encompassed details on CMR equipment, clinical practices, and research activities.

RESULTS

Of 248 hospitals responded to the survey, 98.0% were tertiary centers. The number of scanners distributed unevenly across geographic regions, with Central South China leading with 5.89/center. Siemens, Philips and GE were top three scanner vendors. Most centers initiated CMR program post-2015. Coronary artery disease was the primary indication for CMR. The median annual volume was 120/center. High-volume centers unevenly concentrated most CMR cases. The weighted average waiting period was 14.2 days, while scan durations ranged from 40 to 60minutes. Two thirds of hospitals used post-processing software to analyze imaging. Half of responding centers included T1 and T2 mapping in clinical routine, but stress perfusion was underutilized in both clinic and research. Approximately one-third of centers had published CMR-related research. The majority of physicians were confident about the development of CMR. Major barriers to CMR development included long scan times, high costs, insufficient equipment, and limited training.

CONCLUSIONS

CMR is experiencing rapid growth in China but faces significant regional disparities in access to technology and expertise. Efforts to reduce costs, improve training, and expand access to advanced techniques are crucial for balanced development.

The role of estrogen in the sex difference for the risk factors of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a major subtype of heart failure, primarily characterized by a normal or mildly reduced left ventricular ejection fraction along with left ventricular diastolic dysfunction. Recent studies have shown that the prevalence of HFpEF is higher in women than that in men, particularly in postmenopausal women. Concurrently, it has been observed that the incidence of risk factors contributing to HFpEF (such as obesity, hypertension, diabetes, and atrial fibrillation) also notably increases post-menopause, affecting the incidence of HFpEF. This review aimed to examine the relationship between estrogen and risk factors associated with HFpEF, clarifying the underlying mechanisms through which estrogen affects these risk factors from epidemiological and pathophysiological perspectives. This review also provides a comprehensive understanding of the association between estrogen and the risk factors for HFpEF, thus helping explore potential targets for HFpEF treatment.