Guidelines recommend structured self-reported functional capacity assessment for preoperative cardiac risk stratification, including the Duke Activity Status Index (DASI). However, evidence supporting its incremental prognostic value beyond established risk factors remains limited. We evaluated the prognostic performance of the DASI using pooled data from two prospective cohorts. We conducted a pooled cohort analysis of adults undergoing elective major non-cardiac surgery enrolled in the Measurement of Exercise Tolerance before Surgery (METS) and Functional Improvement Trajectories After Surgery (FIT After Surgery) studies, including data collected between March 2013 and April 2023. Before surgery, participants completed the Duke Activity Status Index (DASI), a structured 12-item questionnaire based on daily physical activities, and underwent routine preoperative biomarker measurement. The primary outcome was 30-day major cardiac complications (myocardial infarction or non-fatal cardiac arrest) or death. The secondary outcome was all-cause major complications. Hierarchical logistic regression assessed the incremental prognostic value of the DASI beyond age, Revised Cardiac Risk Index (RCRI), and natriuretic peptide concentration. Prognostic performance was evaluated using the likelihood ratio test (LRT), fraction of new predictive information, net reclassification improvement, c-index, calibration plots, and decision curve analysis. Among 3485 patients, 3.6% (n = 126) experienced the primary outcome and 19% (n = 647) experienced the secondary outcome. The DASI provided prognostic information beyond age, RCRI, and natriuretic peptide concentration for the primary outcome (LRT p = 0.009), and beyond age, sex, and surgery type for the secondary outcome (LRT p < 0.001). Inclusion of the DASI improved prognostic performance across multiple metrics, but overall discrimination of the final models remained modest (c-index 0.70-0.71), with limited net clinical benefit. Predicted risk associated with a given DASI score varied substantially by age, RCRI, and natriuretic peptide concentration, supporting interpretation of the DASI as a continuous prognostic marker rather than a dichotomous screening test. The DASI provides incremental prognostic information for preoperative cardiac risk assessment beyond guideline-recommended predictors. Its prognostic implications are modest, context-dependent, and best interpreted as a continuous prognostic marker alongside established risk factors, rather than as a stand-alone threshold-based tool. Canadian Institutes of Health Research; PSI Foundation; and the Elizabeth A. and Richard J. Currie, O.C. Chair in Translational Anesthesia Research at St. Michael's Hospital and the University of Toronto; The Ottawa Hospital Academic Medical Organization Innovation Fund; Heart and Stroke Foundation of Canada; Ontario Ministry of Health and Long-Term Care; Ontario Ministry of Research, Innovation and Science; UK National Institute of Academic Anaesthesia; UK Clinical Research Collaboration; Australian and New Zealand College of Anaesthetists; Monash University.
Heart failure with preserved ejection fraction (HFpEF) is characterised by systemic congestion and elevated left ventricular filling pressures. Pulmonary transit time (PTT) measured by cardiovascular magnetic resonance (CMR) provides a non-invasive, integrated assessment of cardiopulmonary haemodynamics, but its prognostic value in patients with HFpEF remains uncertain. We aimed to determine whether prolonged PTT independently predicts adverse clinical outcomes in HFpEF. Adult patients with HFpEF were prospectively recruited and underwent comprehensive phenotyping including blood sampling, 12-lead electrocardiography, 6-min walk testing, echocardiography and multiparametric CMR (NCT03050593). PTT was derived from rest first-pass perfusion imaging and normalised to cardiac cycle length. An abnormal PTT threshold was defined as >95th percentile of asymptomatic controls. The primary endpoint was a composite of heart failure hospitalisation or all-cause mortality. Multivariable Cox proportional hazard regression (HR) models were used to investigate associations with clinical outcome. One-hundred and eighteen HFpEF patients were studied (median follow-up 7.7 years). Eighty-one composite events occurred (50 heart failure hospitalisations and 31 deaths). Prolonged PTT independently predicted the composite outcome across four separate models: clinical (HR 2.222 (1.222, 4.041), p=0.009), blood biomarker (HR 1.776 (1.022, 3.087), p=0.042), imaging (HR 2.108 (1.115, 3.983), p=0.020) and a combined model incorporating the strongest markers (HR 2.989 (1.612, 5.543), p<0.001). Prolonged PTT is an independent predictor of death or heart failure hospitalisation in HFpEF. As an easily obtainable and integrative CMR biomarker of cardiopulmonary haemodynamics, PTT may improve risk stratification in HFpEF, although its clinical application requires further investigation.
Sudden Cardiac Death (SCD) is a fatal event occurring within one hour of a witnessed or 24 hours of an unwitnessed Sudden Cardiac Arrest (SCA), being the leading medical cause of death among adolescent and young adult athletes. We examined the epidemiology of sports-related SCD (SrSCD) and SCA (SrSCA) incidence in adolescents and young adults, explainable Artificial Intelligence (xAI) applied to life-threatening arrhythmias, and cardiac electrophysiological models. We systematically searched peer-reviewed studies from eight databases between 2013-2025 (PROSPERO: CRD42024565960), using PROBAST for bias assessment. From 9574 studies, we included 84 (incidence: 16, xAI: 30, modelling: 38). SrSCD incidence ranged from 0.1 to 0.6 per 100,000 participants per year. Gradient-weighted Class Activation Mapping dominated as xAI technique. Cardiac electrophysiological models predominantly focused on cellular and tissue-level electrophysiology. We advocate for standardised SrSCD/SrSCA definitions and integration of epidemiological risk factors with xAI and cardiac modelling frameworks to advance athlete-specific risk stratification.
Cardiac implantable electronic devices (CIEDs) offer lifesaving treatment in patients with significant bradycardia or who at risk for malignant arrhythmias. As the implantation and sophistication of these devices continue to increase, it is imperative for perioperative clinicians to be knowledgeable in their management. While societies have produced documents for guidance, they differ in some recommendations. Furthermore, many societies have released updated or new guidance within the last several years. This review aims to summarize the latest types of CIEDs and perioperative management recommendations. A search in PubMed was performed with a focus on locating guidelines, consensus statements, and practice advisories from major national and international organizations from January 2020 to September 2025. Secondary searches were subsequently conducted based on the content of the initial papers. Only papers in the English language were considered. Five guidance documents were retrieved based on the search. Some had endorsement from numerous groups, but notable organizations included: (I) the American Society of Anesthesiologists (ASA); (II) European Heart Rhythm Association (EHRA)/Heart Rhythm Society; (III) British Heart Rhythm Society; (IV) American Heart Association (AHA)/American College of Cardiology (ACC); and (V) AHA. Familiarity with these devices and how to manage them perioperatively is necessary to safely care for these patients in the perioperative period. Although there are similarities between perioperative management strategies, differences exist between recommendations from various societies. Furthermore, the scope of each of these documents differs, with some being more detailed and others lacking details. In the absence of a universal protocol, clinicians could benefit from being familiar with guidance from each of these organizations, taking into consideration the strengths and limitations of the documents, and applying the recommendation that is most relevant and specific to their patient.
Cardiovascular disease is a major global cause of death, with sudden cardiac death accounting for up to half of cases, largely due to ventricular tachyarrhythmias. In the UK, approximately 60,000 out-of-hospital cardiac arrests occur annually, with survival rates of only 2-12%. Younger individuals are also affected, with one cardiac-related death daily in those under 35 years of age. Despite advances in care, arrhythmia recurrence remains high (40-50% within 5 years). ICDs have become pivotal in preventing sudden cardiac death, with continuous innovations in device design, implantation, and arrhythmia detection since their introduction in 1980. Transvenous single-chamber ICDs remain the standard, while dual-chamber and CRT defibrillator devices serve patients needing atrial pacing or heart failure support. Subcutaneous and extravascular ICD systems protect patients not requiring pacing while avoiding lead-related risks. Device selection must be individualised, considering clinical profile, comorbidities, lifestyle, patient preferences, and operator expertise. Ongoing advances, including leadless pacing and modular anti-tachycardia pacing systems, continue to expand personalised device strategies.
Cardiac surgery performed through a midline chest incision (median sternotomy) is associated with substantial postoperative pain and opioid use, the latter of which remains the dominant modality of analgesia. Contemporary international guidelines prioritise opioid-sparing, multimodal strategies; however, robust randomised evidence to support specific opioid-sparing analgesic approaches in cardiac surgery is lacking. EPOCH CardioLink-10 was a pan-Canadian, multicentre, randomised, double-blind, placebo-controlled trial in adults undergoing cardiac surgery via median sternotomy. Participants were assigned to receive bilateral superficial parasternal intercostal plane (SPIP) blocks with either 0.2% ropivacaine or placebo (0.9% sodium chloride), delivered via indwelling catheters. Study interventions were delivered at a basal infusion rate (0.1-1 mL/h) after a 20 mL bolus post-insertion. Bolus dosing of 5 mL every 3-4 h was continued for 48 h. In the ropivacaine arm, this resulted in a maximum total ropivacaine dose of 592 mg over the infusion period. The primary outcome was cumulative opioid consumption over 72 h following catheter insertion, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included subjective pain scores, cumulative use of opioid to discharge, rates of delirium, and participant-reported Quality of Recovery-15 score (ClinicalTrials.govNCT06028126). Between Aug 16, 2023, and Dec 22, 2025, 650 patients were screened, and 318 included in the modified intention-to-treat population (164 in the ropivacaine group, 154 in the placebo group). Median age was 67 years (IQR 61-72), 72 (23%) participants were female, 178 (56%) were White, and 69 (22%) were South Asian. Over 72 h, ropivacaine reduced opioid consumption compared with placebo (least-squares mean difference -20.7 MMEs [95% CI -39.0 to -2.3]; p = 0.027). Pain scores and other secondary outcomes were similar between groups. There were no serious block-related complications and there was no pre-specified analysis of adverse events. The findings of this multicentre, randomised trial suggest that bilateral SPIP blockade with ropivacaine may be a pragmatic option to manage sternotomy pain with lower opioid consumption post-cardiac surgery. Grants from the Canadian Institutes of Health Research (CIHR) [Principal Applicant: C D Mazer], the Dr. Timothy & Mrs. Linda Tang Anesthesia Research Fund at the University of Calgary, Calgary, AB [A J Gregory and C D Noss], and the CardioLink Research Trial Platform at St. Michael's Hospital, Toronto, ON. In-kind support from the Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS [P de Jager and J L Dougherty].
Resting hemodynamic assessment of suspected pulmonary hypertension (PH) in older adults with cardiovascular risk factors may not effectively discriminate pre-capillary from post-capillary disease. Exercise right-heart catheterization (RHC) can improve the ability to make this distinction, yet its clinical value remains unclear. We aimed to describe the challenges encountered in hemodynamic exercise phenotyping in this population and evaluate the relationships of exercise classifications to worsening clinical events, including mortality. We prospectively recruited patients aged > 50 years with ≥ 1 cardiovascular risk factor referred for hemodynamic assessment of suspected PH, to undergo cycle-ergometry during initial RHC. Resting hemodynamics were classified per the 2022 European Society of Cardiology/European Respiratory Society guidelines, and exercise pressure-flow relationships were analyzed but not disclosed to treating physicians. Win-ratio and Kaplan-Meier analyses evaluated associations between exercise hemodynamic phenotypes and worsening clinical events. Among 43 patients (aged 72 ± 9 years, 47% female), 37 completed exercise. Resting classifications included the following: No-PH (19%), pulmonary arterial hypertension (PAH) (53%), and PH associated with left-heart disease (PH-LHD; 28%). Exercise hemodynamics revealed predominantly PH-LHD (62%), and 22% of patients demonstrated limited increases in cardiac output. The win-ratio was unfavourable for resting PH-LHD vs PAH (0.59; P = 0.035), but no differences in mortality incidence were present (P = 0.858). Conversely, the win-ratio was unfavourable for exercise PAH vs PH-LHD (0.59; P = 0.037), and exercise PAH demonstrated a higher mortality incidence (P = 0.031). In older patients with cardiovascular risk factors undergoing RHC to diagnose suspected incident PH, the upfront addition of exercise was challenging, yielding inconclusive results in approximately one-third of patients. Results also showed that time to death was more unfavourable for those with exercise PAH. L’évaluation hémodynamique au repos de l’hypertension pulmonaire (HTP) suspectée chez les personnes âgées présentant des facteurs de risque cardiovasculaire peut ne pas permettre de faire efficacement la distinction entre les formes pré- et post-capillaires. Le cathétérisme cardiaque droit d’effort permet de mieux faire cette distinction, mais sa valeur clinique demeure incertaine. Nous avons cherché à décrire les difficultés rencontrées lors du phénotypage hémodynamique à l’effort dans cette population et à évaluer les relations entre la classification selon l’effort et l’aggravation clinique, y compris la mortalité. Nous avons recruté de manière prospective des patients âgés de plus de 50 ans présentant au moins un facteur de risque cardiovasculaire, adressés pour une évaluation hémodynamique visant à confirmer une HTP suspectée et pour un test d’ergométrie cyclique pendant un cathétérisme cardiaque droit initial. Les paramètres hémodynamiques au repos ont été classés conformément aux lignes directrices de 2022 de la European Society of Cardiology/European Respiratory Society. Les relations pression-débit à l’effort ont été évaluées, mais n’ont pas été divulguées aux médecins traitants. Les analyses du win-ratio et de Kaplan-Meier ont permis d’évaluer les liens entre les phénotypes hémodynamiques à l’effort et l’aggravation clinique. Sur 43 patients (72 ± 9 ans, 47 % de femmes), 37 ont réalisé l’exercice. La classification au repos était la suivante : absence d’HTP (19 %), hypertension artérielle pulmonaire (HTAP) (53 %) et HTP associée à une maladie cardiaque gauche (HTP-MCG) (28 %). L’évaluation hémodynamique à l’effort a mis en évidence une prédominance des cas d’HTP-MCG (62 %); 22 % de patients présentaient une élévation limitée du débit cardiaque. Le win-ratio a été défavorable pour l’HTP-MCG au repos comparativement à l’HTAP (0,59; p = 0,035), mais aucune différence n’a été observée au niveau de la mortalité (p = 0,858). À l’inverse, le win-ratio a été défavorable pour l’HTAP à l’effort comparativement à l’HTP-MCG (0,59; p = 0,037), tandis que l’HTAP à l’effort a été associée à une mortalité plus élevée (p = 0,031). Chez les patients âgés présentant des facteurs de risque cardiovasculaire qui se prêtent à un cathétérisme cardiaque droit pour diagnostiquer une HTP suspectée, l’exécution initiale d’un test d’effort s’est avérée difficile, et les résultats non concluants dans environ le tiers des cas. Le délai avant le décès a été plus défavorable en cas d’HTAP à l’effort.
Valvular heart disease (VHD) is a major cause of cardiovascular morbidity and mortality worldwide. The impact of environmental stress on the prognosis of patients with VHD is unknown. This study aims to explore the impact of ambient air pollution exposure on the clinical outcomes of patients with VHD. Data were derived from the China-VHD registry, a national multicentre prospective cohort study. Monthly ambient particulate matter with a diameter <2.5 μm (PM2.5) exposure was derived from the ChinaHighAirPollutants (CHAP) dataset at 1×1 km resolution. Using residential address, clinical data from patients diagnosed with VHD between April and June 2018 were linked to ambient PM2.5 exposure concentrations. Patients were followed up until they lost or experienced the primary outcome (defined as all-cause mortality or heart failure hospitalisation) for 2 years. Time-varying Cox proportional hazards regression models were applied to evaluate the association between monthly ambient PM2.5 exposure and outcomes. A total of 12 258 VHD patients were included. Mean age at enrolment was 61.2±13.7 years, and 54.7% were male. Mean baseline ambient PM2.5 exposure was 43.50±12.25 µg/m3. After 2 years of follow-up, 1577 patients (12.9%) experienced the primary outcome. The estimated HR for all-cause mortality or heart failure hospitalisation was 1.24 (95% CI 1.07 to 1.43) for individuals in the highest tertile of monthly ambient PM2.5 exposure compared with those in the lowest tertile. Each IQR (21.80 µg/m³) increase in monthly ambient PM2.5 exposure was associated with a 1.11-fold higher risk of the primary outcome (95% CI 1.04 to 1.18). This association was consistent across subgroups. Exposure to air pollution was associated with adverse outcomes in patients with VHD. These findings highlight the potential role of a key environmental factor in the progression and prognosis of VHD. NCT03484806.
The long-term association between premature ventricular complexes (PVCs) on ventricular structural and functional remodelling has not been well evaluated. The aim of this study was to assess the association between PVC burden and ventricular remodelling in individuals without structural heart disease. This retrospective study analysed patients who underwent Holter monitoring and echocardiography between February 2007 and July 2017 at the Asan Medical Center, Korea. Patients were categorised based on PVC burden: <1%, 1-10% and ≥10%. The primary outcome was a composite of newly developed cardiac structural or functional remodelling, including left ventricular (LV) systolic dysfunction (<40%), severe LV enlargement and moderate-to-severe mitral and tricuspid regurgitations. Each component and all-cause mortality were also assessed. A total of 5040 patients with PVCs without structural heart disease were evaluated (mean age 58.8±13.1 years, 47.1% female). Higher PVC burden was associated with younger age, fewer comorbidities and lower baseline LV ejection fraction. The incidence of the primary outcome was significantly higher in the 1%-10% or PVC ≥10% groups compared with the <1% group (at 8 years, 8.7% vs 14.5% vs 14.4% for <1%, 1-10% and ≥10%, respectively; p<0.001). Higher PVC burden also correlated with increased rates of LV dysfunction (2.0%, 4.9%, 7.9%; p=0.009) and enlargement (5.8%, 8.5%, 7.3%; p=0.007). A PVC burden >1% was associated with long-term ventricular structural or functional remodelling. Given the dynamic nature of PVC burden, even patients with 1-10% burden may warrant follow-up monitoring, as a single 24-hour Holter may underestimate future risk.
Respiratory failure occurs frequently in cardiogenic shock but with varying severity. It is unknown whether invasive ventilation should be used strictly, reserved for severe respiratory failure, or liberally, reducing stress and increasing compliance with intensive care procedures. Aim of this study was to evaluate the impact of invasive ventilation on outcomes in patients with heart failure-related cardiogenic shock across the severity of respiratory failure. Patients with heart failure-related cardiogenic shock treated 2010-2021 in 16 tertiary care centers in five countries were enrolled. Cox regression models were constructed to assess the impact of overall invasive ventilation and invasive ventilation stratified by PaO2/FiO2 ≤ 100, 101-200, and > 200 on 30-day mortality, adjusted for relevant confounders. Of N = 1010 patients (median age 64 years, 724 (71.7%) male), 659 patients (65.2%) received invasive ventilation. In patients receiving invasive ventilation, 30-day mortality was 1.67 times higher (95% confidence interval (CI) 1.26-2.22, p < 0.001) than in patients without invasive ventilation. Although patients with a worse PaO2/FiO2 of ≤ 100 and 101-200 had the highest mortality risk (hazard ratio (HR) 1.74, 95% CI 1.19-2.53, p = 0.004 and HR 1.82, 95% CI 1.29-2.56, p < 0.001), the same trend towards increased mortality persisted even in patients with preserved gas exchange and PaO2/FiO2 > 200 (HR 1.39, 95% CI 0.99-1.97, p = 0.06). In patients with cardiogenic shock, invasive ventilation was associated with higher mortality, with a non-significant trend towards higher mortality even in patients with preserved gas exchange. The results call for further analyses on this topic, specifically to clarify whether dedicated ventilator settings or weaning strategies may improve outcomes for affected patients.
The heart relies on finely tuned spatial heterogeneity in wall structure, fibre orientation, blood distribution and excitation-contraction coupling to maintain mechanical homeostasis. Even minor deviations may interact with anisotropy to promote maladaptation and disease. While cardiomyopathies have classically been attributed to primary cellular defects, emerging evidence suggests that abnormal regional stress may act as a primary driver of pathology even in the absence of intrinsic sarcomeric dysfunction. This review proposes the concept of 'cardiac mechanopathies', conditions in which misdirected or disproportionate mechanical forces are hypothesised to act as primary determinants of maladaptive remodelling, culminating in a cardiomyopathic phenotype. Clinical paradigms include arrhythmogenic mitral valve prolapse and apical hypertrophic cardiomyopathy with papillary muscle displacement. While a direct causality link still needs to be established, this concept is conceived as a working hypothesis for future studies. Advanced imaging may help identify subtle structural abnormalities early, while insights into the molecular basis of maladaptation may reveal new therapeutic targets. Clinically, studies are needed to understand whether reducing mechanical stress through interventions and lifestyle modifications can mitigate disease expression and progression.
Shorter dual antiplatelet therapy (DAPT) regimens may offer a more favourable risk-benefit profile compared with longer treatment. The aim of this study was to determine the optimal duration by assessing net adverse clinical events (NACE). We searched for randomised controlled trials that compared clinical outcomes of different DAPT durations in patients with ischaemic heart disease from Medline, Scopus and the Cochrane Library. A network meta-analysis was subsequently conducted for DAPT durations of 1 month, 3 months, 6 months, 12 months and >12 months. The primary outcome was defined as NACE, a composite of death, myocardial infarction, stroke, stent thrombosis and bleeding events. Individual components of NACE served as secondary outcomes. Five DAPT durations were ranked for each outcome using surface under the cumulative ranking. This analysis included 31 randomised controlled trials comprising 95 910 patients. 1-month DAPT was associated with a significantly lower risk of NACE compared with 3-month, 6-month, 12-month and >12 month DAPT (risk ratio (CI): 0.74 (0.58 to 0.93); 0.63 (0.50 to 0.80); 0.64 (0.53 to 0.78); and 0.67 (0.51 to 0.87), respectively). There were no significant differences in death, myocardial infarction, stroke or stent thrombosis with 1-month DAPT, except for a higher risk of myocardial infarction compared with >12 month DAPT (risk ratio (CI): 1.53 (1.02 to 2.30)). Notably, 1-month DAPT was associated with a significantly lower risk of bleeding events compared with 12-month and >12 month DAPT (risk ratio (CI): 0.57 (0.40 to 0.83) and 0.47 (0.29 to 0.77), respectively). The SUCRA value for NACE was the highest for the 1-month regimen (99.8, 65.4, 24.6, 21.9 and 38.3 for 1 month, 3 months, 6 months, 12 months and >12 months, respectively). 1-month DAPT may offer the lowest risk balance between ischaemic and bleeding risks; however, these findings should be applied within an individualised, patient-specific risk management framework.
Real-life data is very useful for gaining a better understanding of care in practice and identifying areas for improvement. This study aimed to assess changes in the clinical characteristics, care and outcomes of patients hospitalised with acute heart failure (HF). Two multicentre snapshot surveys were conducted in 2009 and 2021 following the same methodology and enrolled 1658 and 1513 patients, respectively. Clinical characteristics, hospitalisation pathways, in-hospital management and short-term outcomes during a 6-month follow-up were collected. While the age of patients and the proportion in each left ventricular ejection fraction (LVEF) category remained largely unchanged (76 years and 53% with reduced LVEF in the two surveys), there was a rise in the prevalence of most comorbidities. Emergency department was the predominant and increasing route for hospitalisation (64-71%), and admission to critical care units remained frequent and stable (40%). In patients with reduced LVEF, the prescription rate of ACE inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ARNis) decreased from 77.8% to 70.6%, while the use of beta-blockers and mineralocorticoid receptor antagonists increased (67.7-74.2% and 26.6-35.5%, respectively) at discharge. Mortality at 1 and 6 months declined from 8.9% to 7.6% and from 24.7% to 21.3%, respectively. This difference was also significant after matching the two cohorts (HR 0.78 (0.66-0.94)). This improvement in mortality was observed in most patients except in the most elderly and those with preserved LVEF. A comparison of two cross-sectional surveys of acute HF, conducted 12 years apart, reveals an increasing burden of comorbidities, as well as a lack of dedicated admission pathways and a significant shortcoming in the prescription of evidence-based HF drugs on discharge. However, there has been a significant decrease in short-term mortality. NCT01080937 and NCT05232058.
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The relevance of cardiovascular disease in people with a history of cancer has increased in parallel with dramatic improvements in cancer-specific outcomes. There is an urgent need to improve the evidence underpinning cardio-oncology practice. Research prioritisation is essential and needs to account for multidisciplinary healthcare professional (HCP) perspectives, as well as patients and carers. The NIHR-BHF Cardiovascular Partnership Theme in Cardio-Oncology conducted two UK-wide online surveys to identify research priorities. The first was distributed to HCPs with cardiology, oncology and haemato-oncology backgrounds. The second was distributed to patients and carers (PCs) with experience of cancer and/or cardiovascular disease. Surveys were co-designed by clinicians and patients. HCP Survey: 127 responded; 53% prioritised research 'during cancer treatment'. Immune checkpoint inhibitors and targeted therapies were identified as the highest-priority drug classes. Cardiac dysfunction/heart failure (53%) and myocarditis (22%) were priority cardiovascular toxicities of interest. The development of a cardio-oncology registry was marginally favoured over randomised trials. Prospective randomised open-label blinded endpoints (PROBE) designs were considered of similar priority to double-blinded placebo controlled trials. PC Survey: 267 responded. 54% were concerned about the impact of cancer treatment upon cardiovascular health. PC research priorities were: prevention of cardiac side effects (58%), long-term cardiac monitoring, and early detection of side effects. Willingness to participate in research was high. HCPs and PCs from the UK prioritised prevention and detection of cardiac dysfunction during and immediately following cancer therapy, particularly with agents such as immune checkpoint inhibitors and targeted therapies. These findings provide important strategy-setting insights for large-scale collaborative cardio-oncology studies.
Chagas cardiomyopathy, caused by chronic infection with Trypanosoma cruzi, is a leading cause of non-ischaemic heart failure in Latin America and is increasingly recognised worldwide due to migration. Its pathogenesis is multifactorial, involving persistent parasitism, immune-mediated myocardial injury, microvascular dysfunction and progressive fibrosis, leading to a heterogeneous clinical spectrum. Four main phenotypes are recognised, including subclinical, arrhythmic, heart failure and thromboembolic, which often overlap and evolve throughout the disease course.Diagnosis relies on serological confirmation of T. cruzi infection, with electrocardiography and echocardiography forming the cornerstone of cardiac evaluation and risk stratification. Management includes antiparasitic therapy for acute, congenital and early chronic infection, and guideline-directed heart failure and arrhythmia management in established cardiomyopathy, including device therapy and heart transplantation in advanced cases.Despite advances in understanding disease mechanisms and clinical management, early detection remains a major challenge, particularly in non-endemic settings where under-recognition and limited access to specialised care persist. Strengthening screening strategies, expanding access to diagnostic tools and implementing multidisciplinary care models are critical to improving outcomes.This state-of-the-art review summarises current evidence on the pathophysiology, clinical spectrum, diagnosis and management of Chagas cardiomyopathy and highlights key controversies, knowledge gaps and research priorities to guide future advances in care.
Residual left ventricular (LV) hypertrophy and incomplete reverse remodelling after transcatheter aortic valve replacement (TAVR) are associated with adverse outcomes. Whether renin-angiotensin system inhibitors (RASi) promote reverse remodelling in patients with heart failure and LV ejection fraction (LVEF) ≥40% following TAVR remains uncertain. In this multicentre, prospective, randomised, open-label, blinded-endpoint trial, patients aged ≥60 years with symptomatic severe aortic stenosis, LVEF ≥40% and successful TAVR were randomly assigned (1:1) to standard care alone or standard care plus RASi (ACE inhibitor, angiotensin II receptor blocker or angiotensin receptor-neprilysin inhibitor). The primary endpoint was change in LV mass index (LVMI) at 12 months. Secondary endpoints included changes in LV volumes, LVEF, N-terminal pro-B-type natriuretic peptide (NT-proBNP) and functional status. A total of 200 patients were randomised; 194 were included in the modified intention-to-treat analysis (RASi n=95; control n=99). At 12 months, RASi therapy was associated with a greater reduction in LVMI compared with control (adjusted mean difference -12.77 g/m², 95% CI -24.73 to -0.81; p=0.036). Consistent improvements were observed in LV end-diastolic and end-systolic volumes. Functional status (New York Heart Association class) improved modestly in the RASi group. No significant differences were observed in LVEF or NT-proBNP. In patients with heart failure and LVEF ≥40% following TAVR, RAS inhibition led to enhanced reverse LV remodelling over 12 months, reflected by greater regression of LV mass and volumes. These findings support the potential role for RASi in modifying post-TAVR myocardial remodelling, although larger trials are required to determine whether these structural benefits translate into improved clinical outcomes. ChiCTR2100042266.
Mavacamten, a selective cardiac myosin inhibitor, is a therapeutic option for hypertrophic cardiomyopathy (HCM). Its impact on exercise capacity, health-related quality of life and left ventricular outflow tract (LVOT) obstruction, alongside differential phenotype effects, remains incompletely characterised. This meta-analysis evaluates mavacamten's efficacy and safety in adults with HCM. We searched PubMed, Scopus and Web of Science through October 2025 for randomised controlled trials (RCTs) assessing mavacamten in HCM. Outcomes included New York Heart Association (NYHA) class, Kansas City Cardiomyopathy Questionnaire (KCCQ-CSS), peak VO₂, LVOT gradient, cardiac structure, biomarkers and adverse events. Data were pooled using random-effects models, stratified by phenotype (obstructive HCM (oHCM) vs non-obstructive HCM (nHCM)). Risk of bias was assessed via Cochrane risk-of-bias tool for randomised trials (RoB-2), alongside trial sequential analysis and Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Five RCTs (1083 patients; 444 oHCM, 639 nHCM) were included. In oHCM, mavacamten markedly improved NYHA class (OR 4.94; 95% CI 3.25 to 7.49) and KCCQ-CSS (MD 8.99), with substantial LVOT gradient reductions. Serious adverse events did not increase overall in either phenotype. The risk of left ventricular ejection fraction declining <50% was considerably elevated in nHCM (OR 14.35; 95% CI 5.92 to 34.77)-though based on limited events, requiring cautious interpretation-but not elevated in oHCM (OR 2.08; 95% CI 0.79 to 5.48). Additionally, nHCM patients showed no functional benefit and a suggestive KCCQ-CSS worsening (MD -0.70, 95% CI -1.26 to -0.14). Biomarkers (NT-proBNP, hs-cTnI) decreased substantially across both phenotypes, confirming biological activity. Mavacamten appears effective in oHCM, improving symptoms and obstruction with a reassuring safety profile. In nHCM, it drives biochemical and structural remodelling without conferring meaningful symptomatic benefit, while potentially posing a considerably elevated risk of clinically relevant systolic dysfunction. These findings support phenotype-guided precision therapy, urging stringent echocardiographic surveillance and caution regarding off-label use in non-obstructive disease. CRD420251176149.