bluuebunny/crossref_metadata_2025_split huggingface dataset:
Echocaridographic assessment of pulmonary hypertension: improving the probability
Authors: Wild C , Gurung A , Willis J , Slegg O , Rossdale J , Suntharalingham J , Mackenzie Ross R , Page J , Charalampopoulous T , Johnson M , Oxborough D , Thompson D , Peacock O , Coghlan G , Augustine D X 
Published: October 2024

Abstract

Introduction
Pulmonary hypertension (PH) is a cardio-pulmonary disorder characterised by raised pulmonary artery pressure (mPAP &gt;20mmHg) leading to right ventricular failure, and death if left untreated. Transthoracic echocardiography (TTE) assessment of PH uses a probability-based approach, combining peak tricuspid regurgitant velocity with other supporting signs. We evaluated the latest ESC TTE PH guidelines in a real-world UK dataset and identified markers that may improve the sensitivity of the existing algorithm.

Method
Retrospective analysis of 447 patients referred for initial PH assessment. This was a select population of patients who underwent both TTE and right heart catheter (RHC) (mean time to RHC = 40±30 days). In addition to current TTE PH probability markers we analysed right ventricular free wall strain (RVFWS). Measurements were made by a single operator using Tomtec Arena 2020. Crosstabulation, ROC curve analysis and T-tests were used to compare variables between PH and no PH.

Results
Mean sample age was 64±15 yrs (61% female). 6.9% (n=4) of the no PH group had pulmonary mid-systolic notching, which may be due to pseudo-notching attributable to incomplete Doppler envelope. Sensitivity and specificity of current ESC TTE probability guidelines were 83%, and 65% respectively (95% C.I.). However, within the low probability group (i.e. those felt to be less likely to have PH) 62% (n=63) had confirmed PH at RHC (mPAP = 28±9). The addition of RVFWS as an additional marker to the existing supporting signs of PH (Table 1) resulted in an improvement of the sensitivity of the algorithm to 92% with a mild reduction in specificity (63%). The number of false negatives were reduced by 51%. Of these, the majority were in the low TTE probability group (n = 32).

Conclusions
Using current PH TTE probability algorithms classifies a significant proportion of those with PH as having a low TTE PH probability. The addition of RVFWS improves the sensitivity of the existing algorithm to 92% and reduces false negatives by 51%.
Biological effects of radiation exposure in patients treated with X-ray guided endovascular aortic repair
Authors: Yeong T T , Abdelhalim M A , Moquet J , Barnard S , O'brien G , Smith A , Badie C , Patel A S , Ainsbury E , Terry S Y A , Modarai B 
Published: October 2024

Abstract

Background
X-ray guided cardiovascular interventions such as endovascular aortic repair (EVAR) expose patients and operators to significant amounts of repeated ionising radiation over a long period of time. The biological effect of such protracted radiation exposure is poorly understood. We have previously demonstrated a higher incidence of dicentric chromosome (DC) aberrations in high-volume endovascular interventionalists and differences in acute DNA damage in lymphocytes between individuals following in vitro irradiation. Studies suggested a higher incidence of cancer in patients who underwent EVAR compared with those who have had open aneurysm repair, but the evidence is inconclusive. Further work is required to evaluate the biological radiation risk of X-ray guided cardiovascular interventions.

Purposes
We aimed to examine radiation-induced genome instability from patients after complex EVAR. We also aimed to investigate the intrinsic response of each patient to radiation using biomarkers of acute DNA damage following in vitro irradiation of their blood and to correlate this response to the expression of radiation-responsive genes.

Methods
Lymphocytes were isolated from patients after complex (branched/fenestrated) EVAR and non-irradiated controls. DC, a type of chromosomal aberration caused by radiation exposure were enumerated. γ-H2AX, a marker of acute DNA damage/repair, was measured by immunofluorescence after in vitro irradiation at 0.2 Gy and 1 Gy, along with the expression of the radiation-responsive genes FDXR, CCNG1, P21 and PHPT1 using qPCR.

Results
17 patients (82% male, median age 73[59 – 85years]) and 16 controls (56% male, median age 68[53 – 83years]) were recruited. The mean incidence of DC was 3.782 (95% CI 3.13 - 4.43) and 0.898 (95% CI 0.48 -1.32) per 1000 cells for patients and controls, respectively (P&lt;0.0001). Patients had higher background of γ-H2AX foci than unexposed controls, (0.7056, 95% CI 0.316 - 1.10) vs (0.241 95% CI 0.077 - 0.405) per cell, P&lt;0.05. FDXR expression was most increased following irradiation (P&lt;0.0001), reaching a mean 13.1-fold and 11.4-fold increase at 4-hour and 24-hour time-point, respectively, but this upregulation was not significantly different between the two groups.

Conclusion
We have shown an increased frequency of chromosomal aberrations in patients after complex EVAR, a biological finding that may support a propensity to developing malignancies. Patients also have higher basal DNA damage/repair (γ-H2AX) activity. Expression of ferredoxin reductase, FDXR gene could be a potential radio-responsive biomarker to provide personalised biological dosimetry information for clinical monitoring. Our study further underlines the long-term radiation risk of X-ray guided cardiovascular interventions and the potential of biological assays that may guide personalised care.
High ABCD2-score after transient ischemic attack is associated with a two-fold higher stroke-rate during long-term follow-up
Authors: Al-Chaer K , Alhakak A , Vinding N , Butt J H , Johnsen S P , Kruuse C R , Schou M , Torp-Pedersen C , Koeber L , Fosboel E 
Published: October 2024

Abstract

Background
The ABCD2-score is a validated risk score used to estimate the short-term risk of stroke after transient ischemic attack (TIA). However, "real-world" contemporary data on the long-term risk of stroke after TIA according to ABCD2-score are needed in order to guide preventive strategies.

Purpose
To determine the long-term risk of stroke after TIA according to modified ABCD2-score (high-risk (≥4 points) versus low-risk (&lt;4 points)).

Methods
Patients aged ≥18 years with first-time TIA were included from the Danish Stroke Registry (2014-2020). The study population was stratified in high-risk (≥4 points) and low-risk (&lt;4 points) ABCD2-score group. We utilized a modified ABCD2-score consisting of the following parameters: age ≥60 years, hypertension, clinical features, and diabetes. The 3-year risk of ischemic stroke and all-cause mortality was compared between the high-risk and low-risk group using the Aalen-Johansen and Kaplan-Meier estimator. A cox regression model was also conducted.

Results
In total, 21,433 patients with first-time TIA were included; 1,281 (6.0%) in the high-risk and 20,152 (94.0%) in the low-risk group. Patients in the high-risk group were older (77.5 years [interquartile range [IQR] 70.8-84.1] versus 70.3 years [IQR 60.1-78.2]), more often females (52.2% versus 46.6%) (p &lt;0.001), more comorbid and received more medication compared with the low-risk group at baseline. The 3-year cumulative incidence of stroke was 6.0% [95% CI: 4.6-7.5] in the high-risk group and 4.2% [95% CI: 3.9-4.5] in the low-risk group, and the unadjusted hazard ratio (HR) was 1.6 (95% CI 1.2 – 2.0) (Figure 1). The cumulative incidence of all-cause mortality within three-years after TIA was 28.9% [95% CI: 26.1-31.7] in the high-risk group and 10.3% [95% CI: 9.9-10.8] in the low-risk group. The unadjusted HR was 3.2 (95% CI 2.8 – 3.6).

Conclusions
Patients with high-risk ABCD2-scores had an almost two-fold higher associated long-term stroke-rate compared to those with low-risk scores. Trials focusing on preventive measures, including evidence-based antithrombotic strategies, especially for the high-risk group are warranted.
Machine learning identification of risk factors for ischaemic stroke in patients with heart failure with reduced ejection fraction but without atrial fibrillation: A report from WARCEF trial
Authors: Ishiguchi H , Chen Y , Huang B , Gue Y , Correa E , Homma S , Thompson J L P , Lip G Y H , Abdul-Rahim A H 
Published: October 2024

Abstract

Background
The prediction of ischaemic stroke in patients with heart failure with reduced ejection fraction (HFrEF) but without atrial fibrillation (AF) remains challenging and risk stratification based clinical factors alone has limited discrimination. Our aim was to evaluate the performance of machine learning (ML) to identify risk factors for ischaemic stroke in such HFrEF patients.

Methods
We performed a post-hoc analysis of the WARCEF trial, only including patients without prior history of AF, and censoring those who developed incident AF during follow-up. We evaluated the performance of 9 ML models to identify risk factors for incident stroke, using metrics including area under the curve (AUC), precision, specificity, and decision curve analysis. The importance of each feature in constructing the model was quantified using SHapley Additive exPlanations (SHAP) values.

Results
We included 2,213 patients with HFrEF but without AF (mean age 59±12 years; 79% male). Of these, 74 (3.3%) had an ischaemic stroke during mean follow-up of 3.5±1.8 years. Out of the 29 patient-demographics variables, 12 were selected for the ML training.
All ML models demonstrated high AUC values, outperforming the CHA2DS2-VASc score (Figure 1). The logistic regression model exhibited a slight deviation from this trend. The XGBoost model achieved an AUC of 0.86 (95% confidence interval [CI]: 0.72-0.99), while the Random Forest model showed an AUC of 0.85 (95% CI: 0.74-0.96). Similarly, the Support Vector Machine and Light Gradient Boosting Machine models recorded AUCs of 0.85 (95% CI: 0.72-0.97) and 0.83 (95% CI: 0.70-0.96), respectively. Each of these models attained precision and specificity scores of 1.0, indicating high performance. These models consistently provided significant net clinical benefits. Key risk factors for stroke identified across these models were creatinine clearance and blood urea nitrogen. The use of warfarin appears to be protective.

Conclusions
Machine-learning models can identify risk factors for ischaemic stroke in patients with HFrEF but without AF. Worsening renal failure was predictive of an incident stroke, while warfarin use was protective against stroke (Figure 2).Figure 1Figure 2
Efficacy and safety of P2Y12 inhibitors plus aspirin versus aspirin alone in ischemic stroke or high-risk transient ischemic attack: a meta-analysis of randomized controlled trials
Authors: Ahmed M , Ahsan A , Fatima L , Basit J , Nashwan A J , Ali S , Hamza M , Karalis I , Ahmed R , Ijioma N N , Alraies M C 
Published: October 2024

Abstract

Background
Patients with mild ischemic stroke or transient ischemic attack (TIA) have an increased risk of recurrent stroke within 90 days after the onset of the initial thrombotic event. Antiplatelet therapy plays an essential role in reducing the risk of stroke recurrence. However, data regarding the efficacy and safety of dual antiplatelet therapy (DAPT) with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy is limited.

Purpose
We performed an updated systematic review and meta-analysis to evaluate the effectiveness of DAPT versus aspirin monotherapy in patients with mild ischemic stroke or TIA in the light of new published evidence. Moreover, we investigated whether antiplatelet therapy started within 72 hours is effective in reducing recurrent stroke as compared to the conventionally used 24-hour time window for initiating DAPT.

Methods
PubMed/MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared DAPT with aspirin plus clopidogrel to aspirin alone started within 24 hours or 72 hours in patients with acute mild ischemic stroke or high-risk TIA from inception to December 31st, 2023. A random-effects model was used to pool risk ratios (RRs) and 95% confidence intervals (CIs) for clinical endpoints.

Results
Five RCTs with 27,563 patients were included in this study. DAPT significantly reduced the risk of recurrent stroke by 23% (RR: 0.77; 95% CI: 0.70-0.83; p&lt;0.00001), ischemic stroke by 26% (RR: 0.74; 95% CI: 0.68-0.81; p&lt;0.00001), and major adverse cardiovascular events (MACE) by 23% (RR: 0.77; 95% CI: 0.71-0.84; p&lt;0.00001). However, DAPT was associated with a significantly increased risk of moderate or severe bleeding (RR: 2.19; 95% CI: 1.38-3.48; p=0.0009) and hemorrhagic stroke (RR: 2.08; 95% CI: 1.13-3.82; p=0.02). No significant differences were observed for all-cause death (RR: 1.28; 95% CI: 0.95-1.71; p=0.10), cardiovascular death (RR: 1.38; 95% CI: 0.81-2.33; p=0.23), and myocardial infarction (RR: 1.63; 95% CI: 0.77-3.46; p=0.20). We performed sensitivity analysis based on the hazard ratio reported by RCTs which showed comparable results. Subgroup analysis based on treatment onset time (therapy initiation within 24 hours of thrombotic event vs therapy initiation within 72 hours of thrombotic event) showed that both strategies were effective in reducing the risk of recurrent stroke. Subgroup analysis based on the duration of DAPT (21 days vs. 90 days) showed that DAPT for 90 days was associated with an increased risk of moderate or severe bleeding as compared to therapy lasting for 21 days.

Conclusion
DAPT with P2Y12 inhibitors and aspirin reduces the risk of recurrent stroke and MACE but is associated with an increased risk of moderate or severe bleeding.
Investigation of age-related in-hospital outcomes of left atrial appendage occlusion in germany
Authors: Voran J , Seoudy H , Leye M , Kreidel F , Frank D 
Published: October 2024

Abstract

Background
The aim of this study was to assess demographics, in-hospital mortality and baseline characteristics of hospital cases with a left atrial appendage occlusion (LAAO) procedure in relation to patient age.

Methods
This is a retrospective observational analysis of all German in-hospital cases from 2016 to 2022 with a coded LAAO procedure using the Diagnose Related Groups (DRG) statistics database of the Research Data Center of the Federal Statistical Office.

Results
In total 40435 cases were observed in the investigated time period. Over the 5 years studied we found a significant shift towards an older patient collective. Compared to 28,3% in 2016, in 2022 40,1% of all patients were over 80 years of age (a rise of 152 %). Cases of patients with over 85 years of age increased from 7.7 % to 11.4 % during the same time period. We observed an in-hospital death rate for patients &lt;70, 70-75, 80-85 and &gt;85 years of age in 0.8, 1.0, 1.4 and 2.2 % respectively. Further we saw significant higher rates of intensified care treatment, pericardial effusion, acute kidney injury and red blood cell transfusion for patients &gt;80 years of age. In unadjusted and adjusted logistic regression models age was significantly associated with a higher rate of in-hospital death.

Conclusions
In this study we present real world data from a health-care-system level. Our main findings were an increasing age in patients undergoing LAAO procedures and an independent association of age with in-house mortality and complications. This data provides a further basis to balance risks and benefits of LAAO procedure as a preventive treatment.
Pulmonary artery pulsatility index evaluation in intermediate-to-high and high-risk pulmonary embolism patients underwent transcatheter intervention
Authors: Iannaccone M , Gamardella M , Fumarola F , Mangione R , Botti G , Russo F , Boccuzzi G 
Published: October 2024

Abstract

Background
The clinical impact of pulmonary embolism (PE) transcatheter intervention on the right ventricular function and its potential role as procedural outcomes has to be defined.

Methods
Consecutive patients who underwent pulmonary transcatheter intervention between 2021 and 2023 were included in an observational fashion. Data about clinical characteristics, PE risk stratification, pre and post-interventional pulmonary artery pressure (PAP) and Pulmonary Artery Pulsatility Index (PAPi) were collected. The primary endpoint was a composite of in-hospital death or repeated intervention.

Results
49 patients were included, mostly female gender (61.2%), with a mean age of 67±12,9 years old, 79.6% with &gt; 1 PE risk factor, and 55% of them stratified as high-risk (HR) PE. 34.6% of the patients were treated with transcatheter thrombolysis (all in the intermediate-to-high-risk cohort), 20% with FlowTriever device, 53.4% with Indigo Cath8 or Lightning 12 device, 8.1% of the procedure was performed under ECMO support. All patients classified in intermediate-to-high risk (IHR) survived, and the mean PAP was reduced (33.4±10.9 to 24.3±7.1 mmHg p&lt;0.01), as well as PAPi (2,3±0.35 to 1.68±0.26 p&lt;0.01). 22% of the patients In IHR experienced the primary endpoint, in these populations, the mean PAP (pre 33±4.1 vs post 30.5±4.6 p=0.58) and PAPi (pre 1.35±.0.6 vs post 1.4±0.6 p=0.39) did not change significantly. On the other side, those who survived without events had a slight significative reduction in mean PAP (pre 32±6.7 vs post 24.6±4.3 p&lt;0.02) while the PAPi significantly increased (1.2±0.6 vs 1.8±0.2 p&lt;0.01). In the HR population, a delta PAPi &gt; 0.45 demonstrated a 65.7% sensitivity and 75% Specificity for the primary outcome AUC 0.83 at ROC curve analysis.

Conclusion
Pulmonary Thrombus aspiration significantly changes the PAP and PAPi in patients with acute PE. While in IHR patients the overperforming PAPi seems to normalize, in HR patients it increases and may be a marker of procedural success and right ventricle recovery.
Myocardial parametric mapping in patients with suspected acute myocarditis: a prognosis study
Authors: Wang Y , Duan X , Sirajuddin A , Arai A E , Zhao S , Wang H , Md M 
Published: October 2024

Abstract

Background
T1 mapping and T2 mapping have become essential components of the 2018 Lake Louise criteria and obtained excellent results in diagnosing myocarditis. However, their prognostic value in acute myocarditis has not yet been well recognized or established.

Purpose
Our study aims to investigate the prognostic value of T1 mapping, T2 mapping, and extracellular volume fraction (ECV) in a large cohort of patients with suspected acute myocarditis.

Materials
Patients meeting the recommended clinical criteria for suspected acute myocarditis were consecutively enrolled. The primary endpoint is the composite of cardiac death, heart failure hospitalization, heart transplantation, sustained ventricular arrhythmia, and recurrent myocarditis, defined as major adverse cardiovascular events (MACE). All patients underwent CMR at 3.0 T scanner using a standardized, routine imaging protocol, and the three short-axis view slices (basal, mid-ventricular, and apical) were divided into 16 segments according to the American Heart Association 17-segment model (apex excluded). We also averaged the native T1 values, ECV, and T2 values of all 16 segments to get global T1 and ECV fraction values, respectively. Statistically significant parameters from univariate Cox analyses were put into multivariate Cox analysis.

Results
A total of 235 patients (150 men; 32±13 years) were enrolled in this study. During a mean follow-up of 43.0±3.6 months, MACE occurred in 37 patients (15.7%) and was univariably associated with heart failure presentation, left ventricular ejection fraction, left ventricular end-systolic volume index, left ventricular end-diastolic volume index, native T1 and ECV. Patients with MACE showed higher global native T1, ECV, and T2 values (1348±59 vs 1266±51, p=&lt;0.001; 40.0±8.7 vs 32.8±5.9, p&lt;0.001; 63.4±12.1 vs. 55.5±9.1, p=0.011), and were more likely to have tissue changes in the interventricular septum and anterior wall (Figure 1). In a series of nesting multivariable Cox regression models, the addition of native T1 (per 10-ms increase: HR, 1.128; 95% CI: 1.043, 1.220; p = 0.003; Harrell’s C-index = 0.833) or ECV (per 5% increase: HR, 1.382; 95% CI: 1.060, 1.802; p = 0.017; Harrell’s C-index = 0.847) improved prognostication compared with the model based on clinical variables, left ventricular ejection fraction, and septal late gadolinium enhancement (Harrell’s C-index = 0.762) (Figure 2). T2 in multivariate Cox regression analysis didn’t show predictive value, but his inclusion increased the C-index of the model to 0.814.

Conclusions
Myocardial parametric mapping not only holds substantial diagnostic value but also plays a critical role in the prognostic assessment and risk prediction of myocarditis. Their utilization in these contexts enhances the accuracy and effectiveness of clinical evaluations and decision-making processes.
Absolute coronary flow and microvascular resistance before and after TAVR
Authors: Gallinoro E , Paolisso P , Belmonte M , Bertolone D , Esposito G , Leone A , Viscusi M , Shumkova M , Penicka M , Bartunek J , Collet C , Casselman F , De Bruyne B , Vanderheyden M , Barbato E 
Published: October 2024

Abstract

Purpose
This study aims to investigate microcirculatory changes, both at rest and during hyperemia, using continuous intracoronary thermodilution, before TAVR, immediately post-TAVR, and at 6-month follow-up.

Methods
We included consecutive patients with high-gradient AS undergoing TAVR with non-obstructive coronary artery disease in the left anterior descending artery (LAD). Absolute coronary flow (Q) and microvascular resistance (R) were measured in the LAD using continuous intracoronary thermodilution at rest (Qrest) and during hyperemia (Qhyper) before and after TAVR, as well as at 6-month follow-up. Echocardiography and cardiac computed tomography (CCT) were used to quantify total myocardial mass and LAD-specific mass. Regional myocardial perfusion (QN) was calculated by dividing absolute coronary flow by the subtended myocardial mass.

Results
In 51 patients, absolute flow and microvascular resistance were assessed at rest and during hyperemia before and after TAVR. The mean age was 84.1 ± 5.0 years, and 35 participants were male (68.6%). Measurements were also obtained 6 months after TAVR in 20 (39%) patients. Overall, there were no significant changes in resting and hyperemic flow and resistance before and after TAVR (Qrest 68 [55-88] mL/min vs 69 [54 – 92] mL/min, p=0.776; Qhyper 158 [129 – 200] mL/min vs 172 [132, 216] mL/min, p=0.449, before and after TAVR, respectively). Consequently, coronary flow reserve (CFR) and microvascular resistance reserve (MRR) remained unchanged. At 6 months, there were no significant changes in flow and resistance both at rest and during hyperemia compared to baseline (Qrest: 72 [63-84] vs 83 [59-108] mL/min, p=0.658; Qhyper: 181 [158-200] vs 194 [167-222] mL/min, p=0.492; pre-TAVR and at 6 months follow-up, respectively), resulting in unchanged CFR and MRR. However, at follow-up, there was a noteworthy reduction in left ventricular mass of approximately 13% (from 201.9 ± 37.9g to 175.1 ± 46.6 g, p&lt;0.001), leading to an increase in hyperemic perfusion (QN,hyper: 0.86 [0.69-1.06] vs 1.20 [0.99-1.32] mL/min/g, p=0.008; pre-TAVR and follow-up, respectively), but not in resting perfusion (QN, rest: 0.34 [0.30-0.48] vs 0.47 [0.36-0.67] mL/min/g, p=0.06).

Conclusion
Immediately after TAVR, there are no changes in absolute coronary flow and coronary flow reserve. Over time, LV remodeling is associated with increased hyperemic perfusion, indicating that, in the context of the observed pathophysiological changes in coronary microcirculation in AS patients after TAVR, the reverse LV remodeling has a more significant impact than the acute LV unloading achieved by valve replacement itself.