French perspectives on the 2025 ESC/EACTS guidelines for valvular heart disease.

Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement

The goal of this American Heart Association Guide for Improving Cardiovascular Health at the Community Level (AHA Community Guide) is to provide a comprehensive inventory of evidence-based goals, strategies, and recommendations for cardiovascular disease (CVD) and stroke prevention that can be implemented on a community level. This guide advances the 2003 AHA Community Guide1 and the 2005 AHA statement on guidance for implementation2 by incorporating new evidence for community interventions gained over the past decade, expanding the target audience to include a broader range of community advocates, aligning with the concepts and terminology of the AHA 2020 Impact Goals, and recognizing the contributions of new public and private sector programs involving community interventions. In recent years, expanding arrays of programs and policies have been implemented in increasingly diverse communities to provide tools, strategies, and other best practices to potentially reduce the incidence of initial and recurrent cardiovascular events. The AHA Community Guide complements the AHA statement entitled “Population Approaches to Improve Diet, Physical Activity, and Smoking Habits”3 and supports the AHA 2020 goal4 to “improve the cardiovascular health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.” The present AHA Community Guide supports the AHA 2020 goal by identifying exemplary regional or national programs that encourage cardiovascular health behaviors and health factors (formerly addressing risk behaviors and risk factors) from which communities might acquire proven strategies, expertise, and technical assistance for improving cardiovascular health. The AHA Community Guide seeks to prevent the onset of disease (primary prevention) and to maintain optimal cardiovascular health (primordial prevention) among broader segments of the population. Prior research indicates that using public health strategies such as sodium reduction in processed foods to lower blood pressure,5–8 tobacco laws to promote smoking cessation,9–11 and modification of …

Transcatheter edge-to-edge repair (TEER) is becoming the standard invasive treatment for ventricular functional mitral regurgitation (MR). It is necessary to determine the severity of MR before treatment with MitraClip; however, the severity of secondary MR is usually underestimated compared with that of primary MR and varies temporally. Therefore, to accurately determine the severity of MR, it is important to correctly use the algorithm of the guidelines for valvular heart disease and aggressively perform stress echocardiography. Before performing TEER, the difficulty of the procedure should be evaluated. First, morphological features that make TEER unsuitable, such as cleft of the mitral leaflet, mitral stenosis (MS), or perforation of the mitral leaflet, should be checked. The mitral valve orifice area, transmitral valve pressure gradient, coaptation depth, coaptation length, and posterior leaflet length should be measured to determine the difficulty of the procedure based on the inclusion criteria of Endovascular Valve Edge-to-Edge Repair Study II and the German consensus. After MitraClip implantation, in addition to assessing the severity of MS and residual MR, the pulmonary venous flow pattern and stroke volume should be evaluated to comprehensively assess whether TEER improves the hemodynamics. MitraClip has also been used to treat atrial functional MR, another type of secondary MR. Several reports suggest that MitraClip is effective for atrial functional MR; however, evidence is still being accumulated.

Antianginal medications are a class I recommendation by the American College of Cardiology/American Heart Association guidelines for stable ischemic heart disease. We sought to better understand guidance in drug selection and real-life outcomes of antianginal medication use. In patients with stable ischemic heart disease, antianginal medications lower mortality. We evaluated 5608 patients with obstructive coronary artery disease (CAD) on elective cardiac catheterization with follow-up through self-administered questionnaires. Patients were classified as being prescribed a particular medication if they received that medication at index catheterization, or within 3 months postcatheterization. The association between antianginal medication use and outcomes was evaluated using Cox proportional hazards models. Compared with the 11% not prescribed any antianginal medication, patients prescribed antianginal medication were more likely to be older and female; have a history of hypertension, diabetes mellitus, peripheral vascular disease, or 3-vessel CAD; have lower adjusted mortality (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.63-0.89); and experience mortality or myocardial infarction (HR: 0.83, 95% CI: 0.71-0.98). Compared with patients not taking β-blockers (17%), those taking β-blockers had a lower risk of mortality (HR: 0.76, 95% CI: 0.66-0.88). Patients prescribed calcium channel blockers or long-acting nitrates had a higher risk of mortality compared with nonusers (HR: 1.16, 95% CI: 1.04-1.29; HR: 1.20, 95% CI: 1.08-1.34; respectively). Antianginal medications are not universally prescribed among obstructive CAD patients; nonuse was associated with higher mortality. For CAD patients with or without prior myocardial infarction, β-blockers were associated with improved long-term survival.

Translating guidelines into clinical practice has proved to be quite difficult, even when the guidelines are well accepted and noncontroversial. Both computerized reminders and academic detailing have been effective in changing physician prescribing behavior. In this study, we sought to use these methods, mediated by clinical pharmacists, to improve adherence to the secondary prevention guidelines in hospitalized patients with myocardial infarction. A randomized, prospective study was performed in which computerized alerts identifying hospitalized patients with elevated troponin I levels were routed to clinical pharmacists. The pharmacists then conducted academic detailing for physicians caring for patients with acute myocardial infarction who were randomized to the intervention group. Patients in the control group received standard care. The main outcome measure was the proportion of patients discharged on a regimen of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins. The intervention had a significant impact on the proportion of patients discharged on a regimen of angiotensin-converting enzyme inhibitors (328/365 [89.9%] vs 409/488 [83.8%], intervention vs control, respectively, P = .02), and statins (344/365 [94.2%] vs 436/488 [89.3%], P = .02). There was no statistical impact on beta-blocker (350/365 [95.9%] vs 448/488 [91.8%], P = .10) or aspirin use (352/365 [96.4%] vs 471/488 [96.5%], P = .87). When all 4 classes were considered together, 305 (83.6%) of 365 patients vs 343 (70.3%) of 488 patients were discharged on a regimen of all secondary prevention medications to which they did not have a contraindication (P<.001). A computerized alert with pharmacist-mediated academic detailing is an effective means to increase adherence to secondary prevention guidelines for coronary heart disease.

Objective. A case report of a patient with acute coronary syndrome with occlusion of the left main coronary artery with a typical clinical picture and a negative exercise stres test result.Case report. A 44-year-old patient is presented to our service as STEMI with elevation in the inferior leads and ST depression in the precordial leads. After intrahospital cardiac arrest and resuscitation, primary PCI of left main coronary artery is performed, after which hemodynamic stabilization occurs. Retrospective review of medical history reveals that he was evaluated three years before the acute event due to occasional chest pain. The pretest probability for coronary heart disease was 38%, so in accordance with the then valid ESC guidelines for stable coronary heart disease, a stress ECG test was performed, which was assessed as negative for significant coronary heart disease. All analyzed test parameters indicated a low risk of adverse cardiovascular events: functional capacity, ST segment denivelation, chronotropic competence, blood pressure variations, Duke treadmill score. With a postest probability of 9%, the patient was not further evaluated for coronary heart disease and was asymptomatic for the next three years and did not respond to follow-up examinations. If he presented himself after 2019 according to the newer ESC guidelines for chronic coronary syndromes, the patient would be indicated to perform a functional imaging test or CT coronary angiography at the time of the initial clinical evaluation.Conclusion. The diagnostic algorithm for patients with chest pain is based on a pretest probability that determines further diagnostic workup. Patients with a negative exercise test and a typical clinical presentation should be referred for further diagnostic imaging test because of the risk that a small number of them may have significant and even critical coronary stenosis.

In clinical practice, the standard of secondary prevention for coronary heart disease (CHD) is quite disappointing in China. The physicians' shortage of knowledge of secondary prevention guidelines is thought to be a key factor contributing to the inadequate and delayed translation of guidelines into clinical practice. The purpose of this study is to investigate the influence of physicians' characteristics, including their education and work experience, on their knowledge of secondary prevention in China. A representative questionnaire survey was made of physicians from cardiology departments in 35 tertiary hospitals in China. The survey contained 19 questions on knowledge of guideline recommendations for the secondary prevention of CHD. We collected basic information about the physicians, including their educational degree, clinical practice duration/work experience and geographic region. In total, 864 physicians participated in the survey. Eight hundred and thirty-seven completed questionnaires were analyzed. For 6 of the 19 questions, physicians with a postgraduate degree were more likely to answer correctly than those without such a degree. For 11 of the 19 questions, physicians with more than three years' clinical experience were more likely to answer correctly than those who had less than three years' experience. For 5 of the 19 questions, physicians from eastern areas were more likely to answer correctly than those from mid/western areas. The mean total score of correct answers to the questionnaire was 11.69 points. Educational degree and clinical practice duration affected total scores significantly while practice location did not (β=0.500, P=0.004; β=0.979, P=0.000; and β=0.228, P=0.162, respectively). Even if a relatively low score of 12 is taken as a threshold level of acceptable knowledge (defined as a pass), the pass rate of all physicians was only 53.9%. Educational degree and clinical practice duration affected pass rate significantly while practice location did not (95% CI: 1.222-2.248, P=0.001; 95% CI: 1.773-3.140, P=0.000; and 95% CI: 0.993-1.758, P=0.056, respectively). Physicians with a clinical practice duration of more than three years knew more about secondary prevention guidelines than those with less experience. Physicians with a postgraduate degree knew more about secondary prevention guidelines than those without a postgraduate degree. However, overall knowledge of secondary prevention guidelines for CHD was poor among this group of physicians from tertiary hospitals.

The implementation of national and international guidelines is beginning to standardise clinical practice. However, since many guidelines have decision limits based on laboratory tests, there is an urgent need to ensure that different laboratories obtain the same analytical result on any sample. A scientifically-based quality control process will be a pre-requisite to provide this level of analytical performance which will support evidence-based guidelines and movement of patients across boundaries while maintaining standardised outcomes. We discuss the finding of a pilot study performed to assess UK clinical laboratories readiness to work to a higher grade quality specifications such as biological variation-based quality specifications. Internal quality control (IQC) data for HbA1c, glucose, creatinine, cholesterol and high density lipoprotein (HDL)-cholesterol were collected from UK laboratories participating in the Bio-Rad Unity QC programme. The median of the coefficient of variation (CV%) of the participating laboratories was evaluated against the CV% based on biological variation. Except creatinine, the other four analytes had a variable degree of compliance with the biological variation-based quality specifications. More than 75% of the laboratories met the biological variation-based quality specifications for glucose, cholesterol and HDL-cholesterol. Slightly over 50% of the laboratories met the analytical goal for HBA1c. Only one analyte (cholesterol) had a performance achieving the higher quality specifications consistent with 5σ. Our data from IQC do not consistently demonstrate that the results from clinical laboratories meet evidence-based quality specifications. Therefore, we propose that a graded scale of quality specifications may be needed at this stage.

Cardiovascular risk of the general population assessed through SCORE and CUORE charts: An extensive survey by the General Practitioners from Abruzzo, Italy

Introduction: Percutaneous coronary intervention (PCI) of coronary artery chronic total occlusions (CTO) has increased over time, despite representing higher procedural risk than traditional PCI. While guidelines for stable ischemic heart disease recommend antianginal therapy prior to attempted revascularization, the frequency with which this occurs for CTO PCI remain unknown. We propose to assess the frequency and variability in upstream use of antianginal therapy prior to CTO PCI attempt over time. Methods: This study identified all patients who underwent a CTO PCI attempt from January 2012 to September 2018 across the Veterans Affairs Healthcare System using the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. Patients were categorized by upstream management: (A) &lt;2 antianginal medications prescribed in year prior to CTO PCI, (B) ≥ 2 antianginals (C) Stress testing within 3 months of CTO PCI attempt and (D) ≥2 antianginals AND stress testing. Antianginal medications included beta blockers, nitrates, calcium channel blockers, and ranolazine. Multivariable logistic regression was used to estimate the propensity for receiving each category of treatment over time. Results: During the study period, 4250 patients underwent CTO PCI, with 1716 (40%) on ≥2 antianginal medications, 2534 (60%) on &lt;2 antianginals, 1023 (24%) with stress testing, and 338 (8%) on ≥2 antianginals with stress testing. Trends in upstream medical management of patients undergoing CTO PCI were unchanged over each fiscal year (Figure 1A) while odds of preprocedural stress testing decreased across fiscal years (Figure 1B). Conclusions: The majority of patients were on low intensity antianginal medical therapy prior to CTO PCI. Utilization of preprocedural stress testing decreased over time while patterns of upstream medical management remained constant, suggesting an opportunity to improve guideline compliance among patients undergoing attempted CTO PCI.

AimsAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Episodes may stop spontaneously (paroxysmal AF); may terminate only via intervention (persistent AF); or may persist indefinitely (permanent AF) (see European and American guidelines, referenced below, for more precise definitions). Recently, there has been renewed interest in an approach to terminate AF acutely referred to as ‘pill-in-the-pocket’ (PITP). The PITP is recognized in both the US and European guidelines as an effective option using an oral antiarrhythmic drug for acute conversion of acute/recent-onset AF. However, how PITP is currently used has not been systematically evaluated.Methods and resultsThe recently published Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey included questions regarding current PITP usage, stratified by US vs. European countries surveyed, by representative countries within Europe, and by cardiologists vs. electrophysiologists. This manuscript presents the data from this planned sub-study. Our survey revealed that clinicians in both the USA and Europe consider PITP in about a quarter of their patients, mostly for recent-onset AF with minimal or no structural heart disease (guideline appropriate). However, significant deviations exist. See the Graphical abstract for a summary of the data.ConclusionOur findings highlight the frequent use of PITP and the need for further physician education about appropriate and optimal use of this strategy.

Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.

ADULTS AND ADOLESCENTS WITH CONGENITAL HEART DISEASE: WHO ARE WE LOSING TO FOLLOW UP?

The 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend offering hydroxyurea to all patients with sickle cell disease SS/Sβ0 (SCD) aged ≥ 9 months. The relationship between early hydroxyurea initiation and the development of cerebrovascular disease (CVD) is unclear. This retrospective study describes trends in HU prescriptions and CVD outcomes in patients with SCD SS/Sβ0 followed at a single center before and after guideline publication. CVD was defined as the first of abnormal transcranial Doppler ultrasound, silent cerebral infarct, steno-occlusive vasculopathy, or arterial ischemic stroke. Among 530 patients with SCD, hydroxyurea prescriptions rose post-guideline, with lower age at initiation. CVD was lower post-guideline (2.2/100py) versus pre-guideline (4.4/100py). However, MRI screening also decreased post-guideline, leading to lower CVD detection. Results suggest decreased CVD, including silent cerebral infarcts, in the era of early hydroxyurea use; further analyses addressing age at hydroxyurea initiation and relevant confounders are needed to confirm whether earlier hydroxyurea initiation improves protection against CVD.

Background/aims. Guidelines from the European Society of Cardiology are important tools for defining and establishing current standards of care for various heart diseases. The aim of the present paper is to describe the process of how these international guidelines may be transformed and implemented at a national level in Sweden. Methods/results. The structure and process behind the national guidelines for heart diseases in Sweden and their relationship to the underlying European guidelines are described and differences between the national and European levels highlighted. We also give examples of how the scientific values of health care measures are weighted against health economic perspectives and integrated in a prioritization process. Compared to the European guidelines, the Swedish national guidelines have a broader economic perspective and aim to ensure that health care is cost effective and provided to all Swedish citizens on equal terms. Discussion. When certain health care measures are implemented, the national process can result in other priorities than could be expected from the European guidelines alone. On the other hand, a forceful implementation may be facilitated by the societal context in which these national guidelines are produced.