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The role of the nurse in the heart failure (HF) multi-disciplinary team (MDT) has become well-established, with clear evidence of improved patient outcomes and recommended by professional guidelines. Recognizing the change in the HF landscape since the publication of the first Heart Failure Association (HFA) of the European Society of Cardiology (ESC) HF nurse curriculum in 2016, and the expanding role of HF nurses of in the HF MDT, the HFA in collaboration with the Association of Cardiovascular Nursing and Allied Professions (ACNAP) of the ESC prioritized this update to the curriculum. Standardized training programmes for HF nurses improve the quality of care provided to patients with HF and their caregivers. Recognizing the variability of education background and clinical autonomy across Europe and beyond, this curriculum is designed in a flexible way to be able to be adapted and adjusted based on individual country regulations and forms. Endorsement of this curriculum from national professional bodies or Nursing Councils would ensure uniformity and enhance the profession's contribution to HF care. The updated specialist HF nurse curriculum provides the basis for the advanced level of knowledge, skills and attitudes required for the appropriate expansion of the role of the HF nurse that can be adapted across Europe and beyond, while complying with professional legislation of different healthcare systems and supporting nurses who move between countries.
Kawasaki disease (KD) is a childhood vasculitis affecting medium-sized arteries, particularly the coronary arteries. Despite treatment with intravenous immunoglobulin (IVIG), coronary artery aneurysm (CAA) rates remain high in Europe and North America. The KD-CAAP trial evaluated whether adjunctive prednisolone reduces CAA in unselected European children with KD. This multicentre, randomised, open-label, blinded endpoint-assessed, superiority trial (ISRCTN71987471) enrolled children aged 30 days to 16 years across 59 centres in 12 European countries. Participants were randomised 1:1 to oral prednisolone (2 mg/kg/day) plus IVIG (2 g/kg) and aspirin (experimental group); or IVIG and aspirin (control group), stratified by age (<1 vs ≥1 year), sex and country. Co-primary outcomes were: CAA within 12 weeks and mean maximum coronary artery z-score across weeks 1-6, analysed using intention-to-treat. Between Jan 2021-July 2024, 103 children (58% male; median age 2 years) were randomised: 50 to experimental and 53 to control groups. All children received IVIG + aspirin; fewer experimental participants received a second IVIG dose [9 (18%) vs 20 (38%) control, p = 0.021] or rescue therapy [8 (16%) vs 17 (32%), respectively, p = 0.044]. CAA occurred in 12/50 (24%) experimental vs 12/53 (23%) control participants (adjusted risk difference +1.1% (95% credibility interval -13.8%-16.1%), with 45% probability of benefit. There was no evidence of difference in mean maximum coronary z-scores over weeks 1-6 (mean 0.6 (95% confidence interval 0.4-0.9) vs 0.7 (0.4-0.9); adjusted difference -0.0; 95% confidence interval -0.2 to +0.2; p = 0.72). CAA developed in 6/12 (50%) infants <1 year. Serious Adverse Events occurred in 7 (14%) experimental vs 3 (6%) control participants (p = 0.19). Costs were significantly lower in the experimental group due to less IVIG use over 12 weeks. Prednisolone reduced treatment escalation, with potential health economic benefits, but did not reduce CAA in unselected European children with KD. CAA rates remained high, particularly in infants. Innovative Medicines Initiative grant 777389.
Asymptomatic severe aortic stenosis (aSAS) is associated with morbidity, with mortality increasing once symptoms develop. Benefits of early aortic valve replacement (AVR) over clinical surveillance (CS) with delayed AVR upon symptom onset have been demonstrated, and it is now recommended from the latest European Guidelines if procedural risk is low (Class IIa, Level A). The aim of this study is to estimate the economic impact of transcatheter aortic valve implantation (TAVI) for the treatment of aSAS. A cost-utility analysis compared TAVI using the SAPIEN 3/SAPIEN 3 Ultra valve vs. CS in patients with aSAS across nine European countries. A lifetime Markov model captured peri-procedural and long-term outcomes across three health states: alive and well, stroke, and death. Inputs were derived from the EARLY TAVR trial (NCT03042104) and literature sources. Clinical event rates were estimated via parametric survival analysis. Transcatheter aortic valve implantation treatment for patients with aSAS was modelled to be the economically dominant strategy for treating aSAS across all nine European healthcare systems, with cost-effectiveness probabilities ranging from 97.3% (UK) to 99.9% (Belgium). Incremental results per person included cost savings from -£1788 (UK) to -CHF15 802 (Switzerland), quality-adjusted life years gains of 0.18 (Germany, UK) to 0.23 (Switzerland), and life-year gains of 0.12 (UK) to 0.17 (Belgium). Annual discounting of upfront TAVI costs vs. delayed AVR costs drove results. For patients with aSAS, early intervention with TAVI is estimated to deliver greater health benefits and reduce costs compared with CS. These findings support policies promoting early detection and timely intervention before symptom onset.
Idiopathic pulmonary fibrosis (IPF) and other progressive forms of pulmonary fibrosis (PPF) place a heavy burden on patients' lives. While research on clinical aspects of IPF and PPF progresses, evidence on patients' subjective experiences is still emerging. This qualitative study investigated how patients with IPF/PPF and caregivers define "good health", key health outcomes of the care they receive and unmet care needs. This work is part of the COCOS-IPF project, which aims to develop a Core Outcome Set for IPF and PPF. Together with the European Lung Foundation and the European Pulmonary Fibrosis Federation, focus groups were conducted by trained patient representatives, supported by allied health professionals, across five European countries. Discussions followed a semi-structured topic guide. An inductive thematic analysis was performed, following Braun and Clarke's framework for extraction of qualitative data, with findings refined through consensus meetings. Our analyses revealed 10 major themes reflecting participants' perspectives on health, reflecting four broader areas: social connectedness, adaptive strategies and activity, physical and emotional wellbeing, and overarching perceptions of quality of life and normality. One additional major theme summarises participants' unfulfilled care needs, including access to clear information, holistic and person-centred care, and attention to psychological and social needs. Patients and caregivers define good health in a multidimensional way, linking physical, emotional and social aspects. Including these perspectives in developing the IPF/PPF Core Outcome Set could better align care with patients' real-life needs and priorities.
To assess the impact of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) on all-cause and cardiovascular (CV) mortality, as well as CV, cerebrovascular, and renal outcomes in patients at high/very-high CV risk without heart failure by a systematic review and meta-analysis of placebo-controlled, double-blind, randomized trials. The CENTRAL, ClinicalTrials.gov, Ovid-MEDLINE, Ovid-Embase, Science Citation Index-Expanded, and WHO-ICTRP databases were searched between August and September 2023. Heart failure trials were excluded. The hypothesis of a homogeneous treatment effect between ACE-Is and ARBs was tested with a Cochran's Q statistic. The protocol for the systematic review was registered on PROSPERO (CRD42023452406) and the study reported as per PRISMA guidelines.17 trials (9 ACE-Is and 8 ARBs, total of 87 908 participants) were included. The event rates for all-cause mortality, CV mortality, and major CV events (MACEs) did not differ in the parallel placebo arms of ACE-I and ARB trials; however, compared to placebo, ACE-Is reduced the rate of CV mortality [hazard ratio (HR) 0.88; 95% confidence interval (CI) 0.78-0.99], all-cause mortality (HR 0.92; 95% CI 0.85-0.99) and myocardial infarction (HR 0.83; 95% CI 0.73-0.94), while ARBs did not. The rates of HF, stroke, and MACEs were significantly reduced by both drug classes. Angiotensin-converting enzyme inhibitors induced a greater reduction of CV mortality than ARBs (Q = 4.59; P-value = 0.03). In patients at high/very-high CV risk, ACE-Is were more protective against CV mortality than ARBs, supporting their preferential use for CV protection.
Black individuals have a lower incidence of atrial fibrillation (AF) than White individuals, despite a higher burden of traditional risk factors. Prior studies have suggested that European genetic ancestry may contribute to this paradox, but findings have been inconsistent. We examined the association between European genetic ancestry and incident AF among 6920 UK Biobank (UKB) participants who self-identified as Black and were free of AF at baseline. European ancestry proportions were estimated by comparing participants to HapMap populations and were analysed both continuously and categorically using Cox proportional hazards models. Non-linear associations were evaluated using flexible spline curves. We then conducted a meta-analysis combining these results with those from the Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study and the Women's Health Initiative. During a median follow-up of 13.7 years, 205 (3%) participants developed incident AF. Each 10% increase in European ancestry was non-significantly associated with increased AF risk (HR 1.07 (95% CI 0.95 to 1.20)), and individuals in the highest European ancestry category had a higher AF incidence rate compared with all other categories. Random-effects meta-analysis of all four cohorts yielded a pooled relative risk (RR) of 1.09 (95% CI 0.99 to 1.21), with substantial heterogeneity largely driven by the Women's Health Initiative (WHI) study. Excluding WHI resulted in a pooled estimate (RR 1.14 (95% CI 1.05 to 1.23)) without heterogeneity. In UKB, European ancestry proportion was not significantly linked to incident AF, and pooled cross-cohort results were heterogeneous. Excluding WHI in sensitivity analyses produced a modest positive pooled association with no heterogeneity.
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A paradigm shift has emerged regarding exercise participation in patients with hypertrophic cardiomyopathy (HCM), with recent studies suggesting that structured training may improve functional capacity and cardiopulmonary responses. However, the effects of structured exercise interventions in HCM have not been comprehensively synthesized. The main objective was to determine the effect of exercise training on bodyweight, functional capacity, echocardiography, blood pressure, heart rate (HR), double product, and NT-proBNP in HCM patients. Randomized controlled trials (RCTs) and non-randomized individualized endurance and concurrent training interventions including cardiopulmonary exercise test and echocardiographic measures in adult (≥ 18 years) obstructive and non-obstructive HCM patients were extracted from PubMed, Web of Science, and Cochrane in December 2025. Random-effects meta-analyses and meta-regressions were performed, and risk of bias was assessed using the ROBINS-I V2 tool for internal validity. Data from 8 studies (3 RCTs) with 205 low to moderate risk patients showed that training significantly (all p < 0.05) increased [mean (95% CI)]: peak VO2 (pVO2) [2.3 (0.76, 3.83) mL kg-1 min-1], predicted pVO2 [8.1 (2.7, 13.4) %], exercise time [1.0 (0.5, 1.5) min], peak HR [5.2 (0.04, 10.3) bpm], and HR reserve (HRR) [5.5 (2.5, 8.5) bpm]; and decreased body mass index [- 1.12 (- 2.13, - 0.11) kg m-2], and rest HR [- 3.1 (- 5.7, - 0.4) bpm]. A lower baseline HRR was associated with broader increments in pVO2 [1.3 (0.8, 1.9) mL kg-1·min-1, R2 = 0.86, p < 0.05, per 10-unit decrease]. A small between-group difference in maximal wall thickness was observed in controlled data compared to usual care [- 0.9 (- 1.7,- 0.1) mm, p < 0.05, k = 3]. Other echocardiographic features, blood pressure, and NT-proBNP did not change. There were no differences between endurance and concurrent training. No adverse events were reported in these cohorts. Individualized exercise interventions in low to moderate risk HCM patients were associated with improvements in functional capacity, exercise tolerance, cardiac adaptability, and chronotropic competence. The effect of beta-blockers on HRR and subsequent functional adaptations to training warrants future research. Results should be interpreted cautiously due to heterogeneous study populations, predominantly mild/low-risk HCM phenotypes, the limited number of interventions, and restricted generalizability beyond individualized, guided, and mostly on-site supervised exercise settings. Trial registration The protocol was registered in PROSPERO: CRD420251058384. INFOGRAPHIC. Exercise training is emerging as a promising therapeutic strategy for individuals with hypertrophic cardiomyopathy (HCM). This study systematically reviewed and analyzed evidence from eight clinical trials including 205 low to moderate risk patients with obstructive and non-obstructive phenotypes. Importantly, all interventions were individualized, guided, and followed up by the researchers and no adverse events were reported in these cohorts.The available evidence suggests that structured exercise programs are associated with meaningful improvements in multiple areas of health. Participants showed increased functional capacity, reflected by higher peak oxygen consumption (pVO2) and longer exercise time. These increases were significantly higher compared to control groups consisting in usual care, and similar between endurance-only and concurrent endurance + resistance training interventions. Exercise training was also associated with improved heart rate responses during physical activity, including higher peak values, greater reserve, and lower resting heart rate.Importantly, no adverse structural or functional changes in heart imaging were observed, confirming that short to mid-term exercise programs were not associated with adverse changes in cardiac morphology in HCM. Moreover, a small between-group reduction in maximal wall thickness (~ 1 mm) was observed compared to usual care.Overall, structured exercise programs lasting approximately 2–3 months or longer may be sufficient to induce positive adaptations. These findings support the emerging role of individualized exercise as a potential component of HCM management in selected patients, while more research on longer programs and greater cohorts is warranted.
Cardioplegia and myocardial protection strategies continue to evolve, with wide variation in reported practices. However, there is no contemporary report of these practices in pediatrics. We conducted a survey of pediatric cardioplegia practice among major institutions across Asia, Europe, and North America. A survey was distributed to members of the Congenital Heart Surgeons Society, European Congenital Heart Surgeons Association, and Asian Association for Pediatric and Congenital Heart Surgery. Responses were collected from March to September 2024. Questions focused on cardioplegia type, delivery, adjunct protection, del Nido usage, and differences in practices based on patient age or complexity. Complete responses were obtained from 71 surgeons and 7 perfusionists representing 70 institutions. Although the types of solutions used vary across Asia and Europe, >80% of North America respondents reported using del Nido. Cold cardioplegia (<10 °C) was the predominant strategy (92%; n = 72 of 78 respondents). The most frequent dosing was induction between 20 and 30 mL/kg (76%; n = 59) and redosing between 10 and 20 mL/kg (63%; n = 49), with a wide range of redose timing (10-120 minutes). Notably, 28% of respondents (n = 22) reported giving only single-dose cardioplegia, and 56% (n = 44) reported using topical cooling, with only 8% (n = 6) using "hot shot" cardioplegia. Among respondents using del Nido, 91% (n = 43 of 47) reported using it exclusively for all cases. Institutions in North America are using primarily del Nido, while heterogeneity remains in cardioplegia use across Asia and Europe. There also remains significant variation in practices, highlighting the need for clinical outcomes studies to determine an optimal cardioplegia strategy.
Aortic coarctation (CoA) is a major cause of arterial hypertension in young individuals, with recurrence occurring in up to one-third of patients throughout life despite guideline-directed management. We conducted a development and validation study at a single centre in Berlin, Germany, utilising routinely collected electronic health records, cardiovascular magnetic resonance (CMR), and mid-/long-term follow-up data from 218 visits (160 individuals with CoA receiving standard of care, guideline-based management) collected between January 2014 and April 2022. Machine learning (ML) models (CatBoost, XGBoost, random forest, support vector classifiers, neural networks, logistic regression, and K-nearest neighbours) were developed to predict three endpoints: re-coarctation requiring intervention (CoA-I), aortic surgery (CoA-S) as a subset of CoA-I, and persistent arterial hypertension. The dataset was divided by random stratified split into a training set (n = 159; for model development with five-fold cross-validation), and a hold-out test set (n = 59; for out-of-sample validation). Stratification was based on sex, age, and CoA-I status. We included a final set of 38 clinically relevant features, encompassing baseline characteristics, medication intake, echocardiography, CMR, electrocardiography (ECG), and treatment decisions. ClinicalTrials.gov Identifier: NCT02591940. Tree-based and support vector classifier models performed best after Bayesian hyperparameter optimisation, yielding high performance in a stratified validation cohort: area under the receiver operating characteristic curve (ROC AUC) 0.90 ± 0.01 for CoA-I, 0.90 ± 0.01 for CoA-S, and 0.84 ± 0.01 for hypertension. Shapley Additive exPlanations (SHAP) highlighted peak Doppler gradient, time since index visit, and ventricular size indices as key predictors for CoA-I. In inverse-probability-weighted analyses, antihypertensive medication was associated with a lower CoA-I probability (-17.3%; 95% confidence interval [CI], -28.2 to -6.4; p = 0.002), with concordant propensity-score-matched findings. An open-access research interface (https://icm.dhzc.charite.de/calc_coa) incorporates treatment thresholds and personalised risk estimates from an updatable ML framework. These findings suggest that patient-specific multimodal ML-based risk estimates may complement guideline-based care by identifying patients at increased risk of CoA-I or persistent hypertension, with the potential to support more tailored follow-up and reduce lifetime exposure to brachiocephalic hypertension. In adjusted cohort-level analyses, antihypertensive medication was associated with a lower probability of CoA-I. This study was supported by the European Commission's Seventh Framework Programme (FP7, project ID 611232). M.K. acknowledges support within the Charité Digital Clinician Scientist Programme funded by DFG. M.K. and T.K. have received funding within the CHAIN project (Project ID: 101314833), supported by the European Union's EU4Health Programme. T.K. and M.K. acknowledge support within the Collaborative Research Centre SFB 1470, funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), project ID 437531118. M.K. has received funding from the Bundesministerium für Forschung, Technologie und Raumfahrt (BMFTR, Federal Ministry of Research, Technology and Space), VADYS-ME, grant number 01EJ2406A.
Previously developed machine-learning (ML)-based decision support tools for patients presenting with suspected non-ST-segment elevation myocardial infarction (NSTEMI) remain proprietary, limiting public accessibility and clinical adoption. To address this limitation, we used two international prospective multicentre diagnostic studies for model derivation and internal validation, and one large prospective European study for external validation, evaluating two open-access ML-based models. The derivation and internal validation cohort comprised 8763 patients (34% women) enrolled across 13 and 12 sites, respectively, in Switzerland, Spain, the Czech Republic, Poland, Belgium, Germany, the UK, Italy and the USA between April 2006 and September 2020, and between August 2011 and June 2013. The external validation cohort included 4882 patients (41% women) from Germany. Patients were excluded if they had a ST-segment elevation myocardial infarction, unclear final diagnosis, renal failure or an absent 12-lead electrocardiogram. A single-high-sensitivity cardiac troponin (hs-cTn) model incorporated information available at emergency department presentation, while a serial-hs-cTn model additionally utilised the second hs-cTn measurement and the time interval between samples. The final diagnosis of NSTEMI was centrally adjudicated by two independent cardiologists in all studies. The diagnostic performance of both models was compared with the European Society of Cardiology (ESC) hs-cTn-0/1 h-algorithm. This study is registered with ClinicalTrials.gov, numbers NCT00470587 and NCT03111862. The single-hs-cTn- and serial-hs-cTn model demonstrated excellent discrimination in internal validation, and external validation, with an area under the receiver-operating-characteristic curve of 0.94 [0.92-0.95], and 0.91 [0.90-0.92], and 0.96 [0.96-0.97], and 0.96 [0.95-0.97], respectively. Calibration was good across all datasets. Compared to the ESC-0/1 h algorithm, FAST-NSTEMI provided comparable safety metrics while triaging more patients to rule-out or rule-in. Triage efficacy improved substantially with the single-hs-cTn model (internal validation 52.4% versus 29.8%, external validation 32.1% versus 14.9%) and modestly with the serial-hs-cTn model (internal validation 80.8% versus 76.9%, external validation 77.1% versus 72.8%, all p < 0.01). The FAST-NSTEMI ML-models offer excellent discrimination, good calibration, high safety, and improved triage efficacy compared to the ESC 0/1 h-algorithm. Further external validation or prospective implementations are warranted to confirm the generalisability of the findings and the clinical utility of the models. Swiss National Science Foundation and Swiss Heart Foundation.
Kawasaki disease (KD) occurring in childhood has been epidemiologically associated with increased adult cardiovascular risk, particularly in children who develop coronary aneurysms during the acute phase. However, the causal nature of this association remains uncertain. This study employed genetic causal association analysis to investigate potential causal effects of KD on adult-onset cardiovascular complications. This study provides new data from our cohort, representing the largest sample size for a KD genome-wide association study (GWAS) analysis and has not been reported before. We first enrolled a prospective KD cohort of 316 patients who received whole-exome sequencing (WES) analysis. We then performed a GWAS analysis and conducted further analyses using summary-level statistics from the IEU Open GWAS database, the GWAS Catalog, and our East Asian KD cohorts. The inverse variance weighted (IVW) method served as the primary analytical approach. All analyses were performed using R software. We established the largest WES-based KD cohort to date, with 316 children receiving WES and GWAS analyses. Then, in the following assessment, no significant causal associations were observed between KD and major adult cardiovascular outcomes. Replication analyses in European populations revealed modest evidence of potential causal associations with specific conditions. The IVW method indicated weak causal associations with ventricular arrhythmia (OR = 1.0296, 95% CI = 1.0037-1.0562, P = 0.025) and chronic heart failure (OR = 1.0110, 95% CI = 1.0007-1.0213, P = 0.0354) in particular traits. However, neither association was reproduced across independent GWAS datasets or corroborated by sensitivity analyses; therefore, these observations should be regarded as exploratory. This analysis provides genetic evidence that does not support a strong causal relationship between childhood KD and an increased risk of most adult cardiovascular diseases. Given the limited KD GWAS sample sizes and relaxed instrument-selection thresholds, these findings should be interpreted cautiously. However, they do not exclude clinically important long-term cardiovascular sequelae in patients with coronary artery involvement after KD.
High-sensitivity cardiac troponin (hs-cTn) algorithms are established for early rule-out of acute myocardial infarction, but coronary angiographic (CAG) findings in emergency department (ED) patients undergoing invasive evaluation despite fulfilling rule-out criteria remain insufficiently described. To characterise the coronary anatomy and clinical profile of ED patients with chest pain undergoing urgent CAG despite fulfilling hs-cTnT-based early rule-out criteria. This retrospective single-centre study included adults with suspected acute coronary syndrome from 1 January 2020 to 1 January 2023. All patients fulfilled the serial European Society of Cardiology 0/1-hour rule-out pathway, defined as baseline hs-cTnT <12 ng/L and a 1-hour absolute change <3 ng/L. Patients undergoing urgent CAG during index hospitalisation comprised the angiographic cohort. Findings were categorised as significant stenosis (≥70% in a major non-left-main epicardial artery or ≥50% in the left main), intermediate stenosis (50%-69% in a non-left-main artery) or non-obstructive coronary artery disease (<50%). Baseline and 1-hour hs-cTnT concentrations, 1-hour and relative 1-hour changes, History, ECG, Age, Risk factors and Troponin (HEART) scores and angiographic findings were compared. Of 646 patients, 376 underwent urgent CAG. Significant stenosis was found in 109 (29.0%), intermediate stenosis in 220 (58.5%) and non-obstructive disease in 47 (12.5%). Baseline and 1-hour hs-cTnT concentrations and HEART scores differed significantly across angiographic categories, with the highest values in the significant stenosis group and the lowest in the non-obstructive group. The 1-hour and relative 1-hour hs-cTnT changes also differed overall, although significant pairwise differences were limited to the intermediate and non-obstructive groups. Relative hs-cTnT change showed limited discrimination for non-obstructive disease, whereas the HEART score showed moderate discrimination for ≥50% angiographic stenosis. Among selected ED patients undergoing urgent CAG despite hs-cTnT-based rule-out, intermediate or significant stenosis was common. These findings descriptively characterise coronary anatomy in this cohort but do not establish culprit-lesion status, functional significance, appropriateness of angiography or failure of the hs-cTnT rule-out algorithm.
A customizable, dynamic geometric phantom was developed to bridge the gap between simplistic static phantoms and highly realistic, complex 4D solutions. The phantom enables initial testing, helps detect implementation errors, and supports quantitative evaluation of new dynamic acquisition and reconstruction methods. It is formed from a series of superellipsoids using the constructive solid geometry technique and serves as a schematic representation of a human torso, including the lungs, liver, and stomach, as well as a four-chamber heart, major vessels, and simplified skeletal structures. This design allows full parameterization of voxel intensities and organ volumes. Respiratory and cardiac motions are modeled using built-in, decoupled signal generators. A high-performance, open-source reference implementation was developed in Julia and is available both as a library and a standalone console application. The phantom's capabilities were demonstrated through four experiments. The difference between the input and measured lung volumes was quantified, yielding a maximum relative error of 5.5% and a median error of 2.5%. The relative error of the cardiac chamber volumes ranged from 1.76% to 3.67%. Performance was benchmarked across multiple phantom sizes and thread counts, and a realistic Cartesian MRI simulation demonstrated how the phantom can be used to quantify motion blur and artifacts. The proposed dynamic geometric phantom provides an intermediate option between simple static phantoms and complex, proprietary, anatomically realistic 4D models. It provides a highly customizable, easy-to-use, open-source tool for researchers developing new reconstruction algorithms, and it can be easily integrated into existing reconstruction pipelines.
Granulicatella elegans (G. elegans) is a fastidious, nutritionally variant streptococcus (NVS) that represents a rare but clinically significant cause of infective endocarditis (IE), particularly in patients with congenital heart disease (CHD). Diagnosis is frequently delayed owing to its specific culture requirements and an indolent, non-specific clinical presentation. We present a case of a six-year-old male with complex CHD who presented with an 11-day history of low-grade fever, anorexia, and asthenia. Seven months prior, he had undergone dental caries repair without antibiotic prophylaxis. Transthoracic echocardiography (TTE) showed no vegetations. After 18 days of incubation in enriched culture media, blood cultures yielded the identification of G. elegans. A diagnosis of possible IE was established per the modified Duke criteria. Treatment with ceftriaxone and gentamicin was initiated per the European Society of Cardiology (ESC) 2023 guidelines, subsequently switched to vancomycin due to hematological toxicity. The patient was discharged in stable condition and remained asymptomatic at a three-year follow-up. Comparison with five previously published pediatric cases of Granulicatella IE was made. G. elegans IE should be considered in any child with CHD and prolonged unexplained fever, even in the absence of classical echocardiographic findings.
The David-I procedure is the standard surgical treatment for patients with aortic root aneurysms and preserved aortic valve morphology. Its application in patients with bicuspid aortic valves presents additional challenges. This study compares long-term outcomes of the elective, isolated David-I procedure in patients with bicuspid aortic valves and tricuspid aortic valves. We retrospectively reviewed all elective patients undergoing an isolated David-I procedure between 2004 and 2019. Patients with bicuspid aortic valves or tricuspid aortic valves and isolated aortic root aneurysms with or without aortic regurgitation due to annular dilatation were included, independent of severity. Patients with structural aortic valve disease were scheduled for a Bentall procedure. Surgical indications followed European Society of Cardiology and American College of Cardiology/American Heart Association guidelines. Emergency and concomitant procedures were excluded. Follow-up data were obtained from patient questionnaires and echocardiographic reports from referring cardiologists. Thirty-five patients with bicuspid aortic valves and 134 patients with tricuspid aortic valves were included. Patients with bicuspid aortic valves were significantly younger (45.3 ± 11 vs 51.8 ± 12 years, P = .002). Median follow-up was 10 years (interquartile range, 4-12). Mortality was 0% in the bicuspid aortic valve group and 6.7% in the tricuspid aortic valve group (P = .002). Redo procedures were required more frequently in the bicuspid aortic valve group (22.9% vs 7.5%, P = .014). Moderate to severe aortic regurgitation occurred in 25.7% of the bicuspid aortic valve group and 18.7% of the tricuspid aortic valve group, without significant difference. The elective, isolated David-I procedure can be performed with excellent long-term survival in patients with bicuspid aortic valves. However, compared with tricuspid valves, patients with bicuspid aortic valves show a higher rate of redo procedures, indicating the need for careful patient selection and long-term follow-up.
Cardiomyopathies are important causes of arrhythmias, sudden cardiac death, and heart failure. With accumulating knowledge in clinical, genetic, and molecular phenotyping, the number of distinct disease entities is growing. There is a need for broad, inclusive, high-quality prospective multi-center registries to better analyze these phenotypes, provide accurate risk stratification, and tailor therapies. The Dutch Cardiomyopathy Registry (DCR) will serve as a longitudinal registry for all cardiomyopathy patients, exploiting previously built local databases, allowing adequately powered research studies. The DCR is a multi-center observational registry that unites all Dutch University Medical centers. The registry will have local and central shared databases, which will be hosted and coordinated by the Netherlands Heart Institute. Patients with an established cardiomyopathy diagnosis and carriers of pathogenic or likely-pathogenic cardiomyopathy gene variants will be included. Furthermore, selected family members and individuals who are referred for screening for potential cardiomyopathy are eligible for inclusion. The subjects will receive, per best clinical practice, guideline-recommended diagnostics and treatment. Clinical data will be collected from clinical care at baseline and follow-up, including clinical visits, imaging studies, laboratory assessments, ECG, and additional functional tests. Outcome data consists of clinical performance status, cardiovascular complications and major adverse events, recorded through regular electronic health record files. The DCR will function as a national database, providing relevant information on epidemiology, demographics, natural history, diagnosis, and treatment. This will aid risk prediction and monitoring of new therapies. The DCR can identify patients who are eligible for future studies, including registry-based research.
Elevated low-density lipoprotein cholesterol (LDL-C) is a modifiable risk factor for cardiovascular disease, the leading cause of premature death worldwide. Assessing the LDL-C-related burden is critical for guiding prevention and treatment strategies. To estimate the global, regional, and national burden of ischemic heart disease and ischemic stroke attributable to elevated LDL-C (relative to 35-54 mg/dL) from 1990 to 2023 and to quantify the contributions of population growth, aging, risk-deleted burden, and exposure changes to burden trends. This comparative risk assessment, part of the Global Burden of Disease Study 2023, estimated population-level LDL-C exposure and associated health loss in 204 countries and territories. Mean LDL-C levels were estimated using spatiotemporal gaussian process regression based on 806 studies across 161 countries. Relative risks were derived from meta-analyses of 38 randomized clinical trials. Population-attributable fractions for deaths and disability-adjusted life-years (DALYs) were estimated by age and sex for adults aged 25 years or older from 1990 to 2023, with 95% uncertainty intervals. Population-level LDL-C concentrations. Population-attributable fractions, counts, and rates (all ages and age standardized per 100 000) of LDL-C-attributable deaths and DALYs from ischemic heart disease and ischemic stroke, with uncertainty intervals. In 2023, elevated LDL-C accounted for 3.6 million deaths (95% uncertainty interval, 2.2-5.4 million; 6.0% of global mortality) and 90.7 million DALYs (95% uncertainty interval, 58.9-123.3 million; 3.2% of DALYs). Although global all-ages rates remained stable, age-standardized death and DALY rates decreased by 45.6% and 39.5%, respectively, since 1990. In 2023, age-standardized LDL-C-attributable DALY rates were highest in Eastern Europe and lowest in high-income Asia-Pacific. One-third of the global LDL-C burden occurred in India and China. Population growth and aging drove the increasing burden, with notable regional disparities in LDL-C exposure and risk-deleted DALY rates shifting toward middle-sociodemographic settings. Despite declining age-standardized rates, the absolute LDL-C burden has increased since 1990 due to demographic changes and has shifted toward middle-sociodemographic countries. Measurement and surveillance gaps persist. Strengthened prevention, diagnosis, and treatment access strategies are essential to mitigate the health burden of LDL-C.
Clinical artificial intelligence (AI) models are usually reported as finished artifacts, but each model reflects a limited human search across a much larger space of architectures, inputs, losses, optimizers, and training recipes. We tested whether autonomous code-writing agents could perform a controlled model-development experiment: proposing and evaluating code changes, and seeking performance gains without new data or human-guided edits. We built two such agents: an Iteration Agent that searches sequentially, keeping the best variant at each step, and an Evolution Agent that searches for variations in parallel using multiple large language models and prioritizes high-performing lineages across generations. In two architecturally distinct AI-enhanced electrocardiography (AI-ECG) models for structural heart disease, agent-optimized variants improved rank discrimination across held-out, external, and cross-institution evaluations, with area under the receiver operating characteristic curve gains of +0.006 to +0.039 (paired p < 0.05). At a fixed 90% sensitivity, specificity rose by up to 7.1 percentage points and positive predictive value by up to 4.8 percentage points. The selected code changes were substantive, spanning architecture, representation, and training recipe variations. These findings position autonomous agents as an auditable layer for clinical AI model improvement, provided that candidate selection, external validation, and post-update governance are explicit. We release these agents as an open, reusable toolkit.
Lung function measurement is central to assessing disease severity and monitoring progression in bronchiectasis. Although home spirometry is convenient for remote monitoring, there is limited evidence for its performance. In an a priori defined substudy in the CLEAR trial (a multicentre, randomised, open-label study of hypertonic saline and carbocisteine versus usual care in bronchiectasis), we assessed the performance of home spirometry in adults with bronchiectasis using the PANACEA framework (seven domains: test Performance, disease mANAgement, Cost, patient Experience, clinician Experience, researcher Experience, and Access). Participants performed supervised 'clinic' spirometry at five visits and unsupervised 'home' spirometry weekly and during exacerbations over 52 weeks. Analyses evaluated agreement, longitudinal variation, changes in lung function across exacerbations, measurement quality, adherence and patient experience. Agreement was evaluated using Bland-Altman analysis; other outcomes were summarised descriptively. 257 participants had home spirometry data. Clinic and home spirometry demonstrated close agreement, with a mean forced expiratory volume in 1 s (FEV1) difference of 20 mL (95% CI -130 to 170). Variability decreased over time (coefficient of variation 12.25% to 8.81%). Among 462 exacerbations, 195 had spirometry data within 7 days of exacerbation start/end dates. A >100 mL decline in FEV1 occurred in 48% of exacerbations; 35% returned to within 100 mL of pre-exacerbation stable values by exacerbation end. Most spirometry sessions met American Thoracic Society/European Respiratory Society quality criteria, adherence declined over time while patient experience was generally positive. Home spirometry demonstrates good agreement with clinic spirometry, with variability between measurements decreasing over time. Home spirometry detected changes in lung function across exacerbations, although variability may limit interpretation at the individual patient level. With appropriate patient support to maintain adherence, home spirometry has potential as a tool for remote monitoring and decentralised clinical trials in bronchiectasis. ISRCTN89040295.