Despite widespread adoption and investment of resources nationally, the pediatric acute care cardiology (ACC) model of care has not been previously evaluated prospectively. To test the hypothesis that adoption of an ACC model will be associated with improved clinical outcomes. This single-center prospective quality improvement study was conducted in a 26-bed ACC unit of a high surgical volume, freestanding children's hospital. The baseline period was May 15 to October 31, 2023, and the intervention period was November 1, 2023, to November 30, 2024. All ACC unit encounters during the baseline and intervention periods were included. Data sources were hospital administrative data, local Pediatric Acute Care Cardiology Collaborative registry, and Patient and Family Experience (PFE) scores. Full-scale change in the model of care: transitioned unit leadership from hospital pediatrics to cardiology, changed attending of record for medical patients to cardiologist, hired nurse practitioners as frontline clinicians, integrated residents into the team, implemented multidisciplinary family-centered rounding, updated communication processes, and transitioned cardiology fellows to in-house overnight call. Complication rate and back transfer to the intensive care unit (ICU) were outcome measures, discharge time was a process measure, 7-day unplanned readmissions and length of stay (LOS) were balancing measures. Standard rules for identifying special cause variation (SCV) were applied. The percentage of patients and families with positive PFE scores (defined as scores of 9 or 10) before and after the intervention were compared using an independent t test. Hypothesis was formulated prior to data collection. There were 483 encounters (45.2% among children aged 1-18 years) in the baseline period and 973 (52.7% among children aged 1-18 years) in the intervention period. Outcome and process measures significantly improved showing SCV following adoption of the ACC model (mean complications: baseline, 23.6% vs intervention, 16.0%; mean back transfer to ICU: baseline, 11.4% vs intervention, 6.9%; mean patient discharge time: baseline, 15.37 hours vs intervention, 14.43 hours). LOS and 7-day unplanned readmissions were unchanged, suggesting no major inadvertent negative consequences of the ACC model. Mean LOS for medical patients decreased (7.83 vs 4.97 days). PFE improved after the intervention (median [SD], preintervention: 76.9% [3.7] vs postintervention: 82.9% [4.3]; P = .04). In this quality improvement study of an ACC model, multiple outcomes improved without evidence of negative consequences. These clinical improvements may justify necessary investment of resources to support ACC models. Adaptation of this model for other subspecialties may help address pediatric resident workforce changes. Ongoing evaluation of resource utilization, sustainability of improvement, and newly embedded improvement efforts is underway.
Adverse drug effects from blood pressure (BP)-lowering drugs contribute to significant undertreatment and poor overall BP control rates. To review adverse effects and discontinuation of BP-lowering drugs and their combinations from the 5 major classes in short-term clinical trials. Cochrane Central Register of Controlled Trials for randomized clinical trials, MEDLINE, and Epistemonikos were searched from the date of inception until December 31, 2024, for double-blind randomized clinical trials of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ARBs), β-blockers, calcium channel blockers (CCBs), thiazide and thiazide-like diuretics, or their combinations, with follow-up durations between 4 and 26 weeks. Data extraction was performed by 2 independent reviewers. Synthesis was performed using fixed-effect network meta-analyses according to drug class, summarized using odds ratios (ORs) and 95% credible intervals (CrIs) and surface under the cumulative ranking curves. Final statistical analysis was conducted in April 2026. Treatment discontinuation due to adverse events (AEs), defined as discontinuation of randomized treatment due to an AE. Secondary outcomes included headache, dizziness, edema, and cough. A total of 716 trials were included, with mean (SD) follow-up of 8.6 (5) weeks, including 159 362 participants (mean [SD] age, 54.6 [7] years; 44% female; mean baseline BP, 158/100 mm Hg). Compared with placebo, treatment discontinuation due to AEs was significantly increased by CCBs (OR, 1.43 [95% CrI, 1.23-1.67]; risk difference [RD], 1.2% [95% CrI, 0.6%-2.0%]), angiotensin-converting enzyme inhibitors plus CCBs (OR, 1.46 [95% CrI, 1.13-1.87]; RD, 1.1% [95% CrI, 0.2%-2.4%]), and β-blockers plus thiazide diuretics (OR, 1.58 [95% CrI, 1.04-2.47]; RD, 1.7% [95% CrI, 0.1%-4.3%]). All ARB-containing regimens had fewer treatment discontinuations due to AEs than placebo, and these differences were statistically significant for ARB monotherapy (OR, 0.73 [95% CrI, 0.61-0.86]; RD, -0.8% [95% CrI, -1.3% to -0.4%]) and ARBs plus CCBs (OR, 0.61 [95% CrI, 0.47-0.79]; RD, -1.2% [95% CrI, -1.8% to -0.6%]). In network meta-analyses, 5 combination and 2 monotherapy regimens had higher surface under the cumulative ranking curve values than placebo for treatment discontinuation due to AEs, suggesting overall symptomatic improvement compared with placebo. All regimens significantly increased dizziness, and all but CCBs significantly decreased headache compared with placebo. This meta-analysis of short-term randomized clinical trials found that adverse drug effects that led to discontinuation of BP-lowering therapy varied by drug class and regimen, with several combination therapies being better tolerated than monotherapies. Some regimens were associated with fewer drug withdrawals than placebo, suggesting a net symptomatic improvement. These findings are based on trial-level results and rely on assumptions underlying the network meta-analysis; they may not apply to individual patients.
Septic pulmonary embolism (SPE) is an under-recognized cause of severe infection in children, particularly in low-resource settings. Evidence from Somalia is absent, despite high rates of skin and soft-tissue infection and limited diagnostic capacity. This study described the clinical characteristics, microbiology, radiological features, management, and outcomes of pediatric SPE in a Somali tertiary hospital. We conducted a retrospective review of children aged < 18 years diagnosed with SPE between 2021 and 2025. Data on demographics, clinical presentation, laboratory parameters, radiological findings, microbial isolates, treatments, and outcomes were extracted. Continuous variables were summarized as mean ± SD or median (IQR) and categorical variables as counts and percentages. ICU and non-ICU groups were compared using t-tests or Mann-Whitney U tests and Fisher's exact test where appropriate. Effect sizes (Cohen's d, rank-biserial correlation) were calculated. Due to the small number of events and absence of mortality, no multivariable modelling was performed. Fifteen children met diagnostic criteria for SPE; median age was 12 years and 80% were male. Skin and soft-tissue infections, trauma-related sepsis, and septic thrombophlebitis were the most common sources. Staphylococcus aureus (MSSA/MRSA) accounted for most culture-positive cases while coagulase-negative staphylococci and Gram-negative organisms were less frequent. Radiological findings included peripheral nodules, cavitation, and pleural disease. Five children (33%) required ICU admission and anticoagulation was used in 93%. ICU patients were younger, had higher inflammatory markers and experienced significantly longer hospital stays (p = 0.031; d = 1.49). No in-hospital deaths occurred. Pediatric SPE in Somalia is predominantly staphylococcal in origin and commonly arises from skin, soft-tissue, or trauma-related infections. Despite limited imaging and microbiology resources, characteristic radiological patterns and marked inflammation facilitate diagnosis. Younger age, higher leukocytosis, and prolonged hospitalization were associated with ICU admission, but overall outcomes were favorable with timely antimicrobial therapy, anticoagulation, and procedural interventions. These findings provide urgently needed baseline evidence for SPE in Somali children and underscore the importance of early recognition in resource-limited settings.
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Glomerular diseases are a leading cause of chronic kidney disease (CKD) and kidney failure. Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, reduces the risk of kidney function loss in CKD, but its effects in individuals with CKD due to glomerular diseases are uncertain. To evaluate the efficacy and safety of finerenone in patients with glomerular diseases. Prespecified exploratory subgroup analysis of a phase 3, randomized, double-blind, placebo-controlled trial conducted across 24 countries and regions, focusing on participants with an investigator-reported glomerular disease diagnosis. The overall trial enrolled adults with nondiabetic CKD and an estimated glomerular filtration rate (eGFR) of either (1) at least 25 to less than 60 mL/min/1.73 m2 and urinary albumin to creatinine ratio of at least 200 mg/g to less than 500 mg/g or (2) an eGFR of at least 25 to less than 90 mL/min/1.73 m2 and urinary albumin to creatinine ratio of at least 500 mg/g to less than 3500 mg/g. Finerenone 10 mg or 20 mg taken orally once daily (n = 446) vs matching placebo (n = 457). Annualized rate of eGFR decline (total eGFR slope) from baseline to month 32 (primary outcome of the main trial); percent change in albuminuria to 12 months; and a composite outcome of kidney failure or sustained 40% or more decline in eGFR (prespecified exploratory outcomes). Of 1584 participants, 903 (57.0%) had investigator-reported glomerular disease, including 416 (46.1%) with immunoglobulin A nephropathy, 215 (23.8%) with focal segmental glomerulosclerosis, and 90 (10.0%) with membranous nephropathy. Participants with glomerular disease (mean [SD] age, 51.1 [13.6] years; 362 female [40.1%]; 558 Asian [61.9%]) had a mean eGFR of 48.8 mL/min/1.73 m2 and median urinary albumin to creatinine ratio of 839.6 mg/g. The total eGFR slope up to 32 months was -3.50 mL/min/1.73 m2 per year with finerenone and -4.23 mL/min/1.73 m2 per year with placebo (0.73 mL/min/1.73 m2 per year difference; 95% CI, 0.22-1.24). Finerenone reduced albuminuria at month 12 by 42% (95% CI, 35%-48%) and lowered the risk of kidney failure or 40% or more eGFR decline (7.42 vs 9.60 events per 100 patient-years; hazard ratio, 0.74; 95% CI, 0.57-0.97). In this exploratory analysis, treatment with finerenone slowed kidney function decline, reduced albuminuria, and lowered the risk of kidney failure or substantial loss of kidney function in patients with glomerular diseases. These findings suggest an important role for finerenone in preserving kidney function in this population. ClinicalTrials.gov Identifier: NCT05047263.
The long-term risks of specific cardiovascular diseases (CVDs) among offspring exposed to various types of maternal diabetes in utero and the mechanisms underlying these risks remain unclear. To investigate the association between maternal diabetes during pregnancy and risks of overall CVD and specific CVD subtypes in offspring and whether adverse perinatal and early-life outcomes mediate associations. This nationwide population-based cohort study using linked national registers included individuals born in Sweden between January 1, 1973, and December 31, 2014, with follow-up through December 31, 2023. Maternal diabetes during pregnancy, including gestational diabetes and pregestational diabetes (type 1 and type 2). The main outcomes were incident overall CVD and specific CVD subtypes in offspring, identified from national inpatient and outpatient registers. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs. Sibling analyses were conducted to account for shared familial factors. Mediation analyses assessed the contribution of congenital heart disease (CHD), preterm birth, and large for gestational age (LGA). The study included 4 274 414 individuals (51.39% male; mean [SD] age, 27.4 [15.0] years at the end of follow-up), of whom 61 336 (1.46%) were exposed to maternal diabetes and 4 213 078 (98.56%) were not exposed. During a median 27.6 years (IQR, 17.2-37.4 years) of follow-up, 7.36% of total participants had a diagnosis of CVD. Any maternal diabetes was associated with an increased risk of overall CVD in offspring (HR, 1.16; 95% CI, 1.12-1.20); risk of CVD was higher for pregestational diabetes (HR, 1.29; 95% CI, 1.21-1.38) than for gestational diabetes (HR, 1.11; 95% CI, 1.05-1.17). These associations were also found in sibling analyses. Increased risks in offspring prenatally exposed to maternal diabetes were found for some CVD subtypes, including venous thromboembolism (HR, 1.20; 95% CI, 1.07-1.34), cerebrovascular diseases (HR, 1.31; 95% CI, 1.12-1.52), atrial fibrillation (HR, 1.27; 95% CI, 1.05-1.54), and heart failure (HR, 1.65; 95% CI, 1.37-2.00). In mediation analyses, CHD, preterm birth, and LGA directly and/or indirectly mediated 31.87%, 16.06%, and 14.18% of the association between any diabetes and offspring CVD risk, respectively. This cohort study found that maternal diabetes during pregnancy was associated with increased long-term risks of overall CVD and some CVD subtypes in offspring, particularly following pregestational diabetes. These findings highlight the importance of associations of perinatal and early-life factors and offspring CVD risk later in life, especially in mothers with diabetes.
Non-high-density-lipoprotein (non-HDL) cholesterol and apolipoprotein B (apoB) are better markers of atherosclerotic cardiovascular disease (ASCVD) risk than low-density-lipoprotein cholesterol, but whether non-HDL cholesterol or apoB is superior to the other is less clear. To assess if non-HDL cholesterol provides information on ASCVD beyond apoB, and vice versa. The Copenhagen General Population Study, a population-based contemporary cohort study in Danish individuals recruited in 2003-2015 with a median of 13.2 (IQR, 10.3-15.8) years of follow-up, included women and men not taking lipid-lowering medication and with non-HDL cholesterol and apoB measurements at baseline. Data were analyzed from January 3 through June 23, 2025. Continuous non-HDL cholesterol and apoB assessed as absolute levels and SDs as well as categories of concordance/discordance between non-HDL cholesterol and apoB defined by medians-(1) concordant low: non-HDL cholesterol and apoB less than the median; (2) discordant high apoB: non-HDL cholesterol less than the median and apoB greater than the median; (3) discordant high non-HDL cholesterol: non-HDL cholesterol greater than the median and apoB less than the median; and (4) concordant high: non-HDL cholesterol and apoB greater than median values. Myocardial infarction and ASCVD events estimated by Cox proportional hazards regressions using age as 19 years the underlying time scale and delayed entry (left truncation) at baseline. This cohort study in 94 398 individuals (53 042 women [56%]) with a total of 2462 first myocardial infarction (MI) and 5723 first ASCVD events found that any higher levels of non-HDL cholesterol or apoB on continuous scales were associated with similar increased risk of MI and ASCVD; for 1-SD higher levels, the multivariable-adjusted hazard ratio (HR) for ASCVD was 1.16 (95% CI, 1.13-1.19) for non-HDL cholesterol (39 mg/dL) and 1.14 (95% CI, 1.12-1.17) for apoB (30 mg/dL). Further adjusting for non-HDL cholesterol in the apoB model, and vice versa, attenuated the HRs, although the findings were still significant. Compared with concordant low non-HDL cholesterol and apoB, the HR for MI was 1.32 (95% CI, 1.10-1.59) for discordant high apoB, 1.30 (95% CI, 1.05-1.60) for discordant high non-HDL cholesterol, and 1.69 (95% CI, 1.53-1.85) for concordant high non-HDL cholesterol and apoB; corresponding values for ASCVD were 1.14 (95% CI, 1.01-1.29), 1.21 (95% CI, 1.06-1.38), and 1.36 (95% CI, 1.28-1.44). In this study, in individuals not taking lipid-lowering medication, non-HDL cholesterol provides information on ASCVD risk beyond apoB, and vice versa, indicating that both cholesterol content and particle number are important for risk.
Artificial intelligence (AI) is poised to transform heart failure (HF) care across the clinical continuum, yet a substantial gap remains between model development and implementation. This review aims to summarize key AI-enabled innovations across HF care and provide a practical framework for clinical implementation. AI applications based on electrocardiography, echocardiography, electronic health records, wearable devices, and large language models have demonstrated promise for early detection, diagnosis, risk stratification, and treatment optimization in HF. The field is shifting from retrospective model development toward prospective evaluation, workflow integration, and health-system deployment, though challenges related to bias, generalizability, interoperability, and clinician adoption persist. Here, we propose a practical stepwise framework to support the safe, scalable, and sustainable implementation of AI in real-world heart failure care.
This essay describes the author’s experience going from clinician to patient and back again.
Inclisiran is a small interfering ribonucleic acid targeting hepatic proprotein convertase subtilisin/kexin type 9 messenger RNA, that effectively reduces low-density lipoprotein cholesterol (LDL-C) levels. The effect of inclisiran on cardiovascular (CV) outcomes has not been formally tested. VICTORION-2 Prevent (NCT05030428) is an ongoing, Phase 3 randomized, double-blind, placebo-controlled, international trial assessing the efficacy and safety of inclisiran in preventing CV events in patients with established atherosclerotic cardiovascular disease (ASCVD) receiving high-intensity statin therapy. Patients with established ASCVD (history of myocardial infarction [MI], ischemic stroke, or symptomatic peripheral artery disease), and fasting plasma LDL-C ≥1.8 mmol/L (70 mg/dL) despite high-intensity statin therapy (≥20 mg rosuvastatin or ≥40 mg atorvastatin daily) will be enrolled. Patients will be treated with inclisiran sodium 300 mg or placebo, administered subcutaneously at Day 1, Day 90, and every 6 months thereafter. The primary outcome will include time to first occurrence of 3-point major adverse CV events (3P-MACE; composite of CV death, MI, or ischemic stroke). Secondary outcomes will include time to occurrence of CV death, time to first occurrence of 4P-MACE (composite of 3P-MACE and urgent revascularization), and major adverse limb event (all adjudicated outcomes), time to occurrence of all-cause death, and long-term safety of inclisiran. Safety will be monitored using a selective safety data collection strategy. VICTORION-2 Prevent will provide robust data on CV benefits and safety of inclisiran in patients with established ASCVD and not at guideline-recommended LDL-C goals despite high-intensity statin treatment.
The optimal antithrombotic therapy for patients with chronic coronary syndrome (CCS) who also require long-term oral anticoagulation (OAC) remains uncertain. The aim of this study was to evaluate the safety and efficacy of OAC monotherapy compared with OAC plus single antiplatelet therapy (SAPT) in CCS patients with an indication for long-term anticoagulation. Randomized trials comparing OAC monotherapy with OAC plus SAPT in patients with CCS and indication for long-term OAC from the PubMed, Cochrane Central, Web of Science, and Scopus databases up to November 10, 2025 were included in this systematic review and meta-analysis. HRs and 95% CIs were estimated through a random-effects meta-analytical framework. The primary efficacy endpoint was trial-defined major adverse cardiovascular events, and the primary safety endpoint was any bleeding. Six trials comprising 5,924 patients were included. The median follow-up duration was 2.3 years (Q1-Q3: 1.3-2.9 years), the median CHA2DS2-VASc score was 4.2 (Q1-Q3: 4.0-4.6), and the median time from revascularization to randomization 3.8 years (Q1-Q3: 3.2-4.4 years). Compared with OAC plus SAPT, OAC monotherapy showed similar rates of major adverse cardiovascular events (6.8% vs 8.2%; HR: 0.85; 95% CI: 0.64-1.09; I2 =23%) and reduced risk of bleeding (8.9% vs 16.1%; HR: 0.49; 95% CI: 0.44-0.55; I2 =8%). OAC monotherapy also reduced cardiovascular death (HR: 0.69; 95% CI: 0.48-0.97; I2 =0%), net adverse clinical events (HR: 0.60; 95% CI: 0.47-0.78; I2 =66%), and major bleeding (HR: 0.46; 95% CI: 0.32-0.66; I2 =47%) compared with OAC plus SAPT. There were no significant differences in myocardial infarction, stroke, or all-cause mortality. In patients with CCS requiring long-term OAC, OAC monotherapy was associated with reduced bleeding, cardiovascular death, and net adverse clinical events compared with OAC plus SAPT. (Anticoagulation Alone vs Anticoagulation Plus Antiplatelet Therapy in Atrial Fibrillation With Stable Coronary Disease: A Meta-Analysis of Randomized Trials; CRD420251174643).
Since 2018, the Resuscitation Quality Improvement (RQI) program to enhance cardiopulmonary resuscitation (CPR) training and skill retention has expanded to many US hospitals. To evaluate whether adoption of the RQI program is associated with higher in-hospital cardiac arrest (IHCA) survival, compared with control (non-RQI) hospitals. This cohort study included 237 US hospitals participating in Get With The Guidelines-Resuscitation registry between 2017 and 2023. Control hospitals were uniquely matched to an RQI hospital if they had a 2-year risk-standardized survival rate (RSSR) to discharge for IHCA that was within 1% of the RQI hospital's RSSR during the 2-year preintervention period before RQI adoption, and if both had annual IHCA case volume within 50 cases of each other. Hierarchical models were used to conduct a difference-in-differences analysis to compare the 2-year postintervention vs 2-year preintervention IHCA survival rates at RQI vs control hospitals. Analyses were conducted from December 12, 2024, to October 6, 2025. Hospital adoption of RQI program. RSSR to hospital discharge and return of spontaneous circulation (ROSC). Of 237 hospitals, 107 control hospitals were matched to 18 RQI hospitals (5 adopted RQI in 2019, 8 in 2020, and 5 in 2021), constituting a total of 49 870 IHCAs. Mean (SD) RSSR to hospital discharge at RQI hospitals decreased from 25.3% (3.5%) in the preintervention period to 21.2% (3.8%) in the postintervention period, whereas mean (SD) RSSR at control hospitals decreased from 25.0% (2.9%) to 21.5% (4.4%). When postintervention vs preintervention survival rates were compared between the groups, RQI adoption was not associated with improvements in survival to discharge (difference-in-differences adjusted odds ratio [OR], 0.95 [95% CI, 0.81-1.10]; P = .48). For ROSC, mean (SD) RSSR at RQI hospitals decreased from 73.4% (5.7%) in the preintervention period to 69.1% (5.1%) in the postintervention period, whereas it decreased from 70.9% (6.9%) to 69.1% (7.5%) at control hospitals. When postintervention vs preintervention ROSC rates were compared, RQI adoption was not associated with higher rates of ROSC (difference-in-differences adjusted OR, 0.98 [95% CI, 0.81-1.18]; P = .85). In this cohort study using a national registry of IHCA data, compared with control hospitals, hospital adoption of the RQI program was not associated with improved rates of survival to discharge or ROSC in the 2 years after implementation. These findings suggest that a program focused solely on CPR delivery may not be sufficient to improve IHCA survival.
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This case report describes a woman in her 60s who had an inferior wall myocardial infarction 1 year prior and presented to the emergency department with worsening dyspnea and anasarca for the past 2 months.
Scheduled cardioversion is a common and resource-intensive procedure in rhythm treatment of atrial fibrillation and atrial flutter. Cancellations of cardioversion procedures are common due to spontaneous conversion to sinus rhythm. To study the efficacy and feasibility of precardioversion rhythm monitoring using smartphone photoplethysmography compared to standard of care in scheduled cardioversion of atrial fibrillation. This randomized, single-blinded study took place at a tertiary hospital in Sweden. Adult patients (≥18 years) with persistent atrial fibrillation or flutter scheduled for cardioversion were included. Exclusion criteria were having a cardiac implantable electronic device or inability to consent or comply with study procedures. The study took place from September 2022 to February 2025. Precardioversion ambulatory heart rhythm monitoring using smartphone photoplethysmography and reminders to support adherence to anticoagulation in the intervention group compared to standard of care (no intervention). Heart rhythm recordings were automatically transferred following recording and overread daily. A single-lead electrocardiogram recording was made simultaneous to each photoplethysmography recording for validation purposes. In case of spontaneous conversion to sinus rhythm in the intervention group, participants were contacted and cardioversion was canceled. In the control group, no further action was taken in case of rhythm conversion. The primary efficacy outcome was proportion of same-day cancellations of scheduled atrial fibrillation or flutter cardioversions. In total, 206 patients were randomized, with 105 participants assigned to intervention and 101 assigned to control (standard care). Three participants were excluded after randomization due to having a cardiac implantable device, leaving 104 and 99 participants for final analysis in the intervention and control group, respectively. The median (IQR) age was 69.7 (61.6-75.6) years and 149 (72.3%) were male. The participants performed 5226 heart rhythm recordings precardioversion, and the median (IQR) number of daily recordings per participant precardioversion was 2.1 (2.0-2.3). There were 4.8% (5/104) same-day cancellations of scheduled cardioversions in the intervention group compared to 23.2% (23/99) in the control group (P < .001). For same-day cancellations due to spontaneous sinus rhythm conversion, the corresponding results were 1.0% (1/104) vs 18.2% (18/99) (P < .001). The results of this study suggest that precardioversion monitoring using smartphone photoplethysmography represents a highly scalable digital intervention that significantly reduced same-day cancellations. ClinicalTrials.gov Identifier: NCT04300270.
Coronary function testing (CFT) can be used to delineate the underlying mechanisms of chest pain in angina with nonobstructive coronary arteries (ANOCA). However, the association between overlapping ANOCA endotypes and angina burden remains poorly defined. To investigate the impact of multiple ANOCA endotypes on angina burden. This cross-sectional study included patients with suspected ANOCA who underwent acetylcholine provocation testing for endothelium-dependent abnormalities, adenosine-mediated physiology testing for endothelium-independent abnormalities, and intravascular ultrasound with hemodynamic testing for a functionally significant myocardial bridge between August 2007 and February 2025 at Stanford Hospital. Data were analyzed from March 2025 through May 2025. The primary outcome was the association between the number of ANOCA endotypes and angina burden. The Seattle Angina Questionnaire (SAQ) was used to evaluate overall angina burden. Patients undergoing comprehensive CFT for ANOCA. A total of 485 patients (mean [SD] age, 52 [14] years; 352 female patients [73%]) were included. There were 36 patients (7%) with no abnormalities, 150 patients (31%) with 1 endotype, 215 patients (44%) with 2 endotypes, and 84 patients (17%) with 3 endotypes identified on CFT. Mean (SD) SAQ summary scores were comparable among patients with an endothelium-dependent abnormality (50.5 [18.3]), an endothelium-independent abnormality (49.3 [19.9]), and myocardial bridging (49.8 [19.2]), and worsened with an increasing number of endotypes identified at CFT (normal CFT finding: 55.9 [17.6]; 1 endotype: 53.8 [17.7]; 2 endotypes: 51.2 [18.3]; and 3 endotypes: 45.7 [20.0]; P = .003). After multivariable adjustment, each additional endotype identified on CFT was associated with a lower SAQ summary score (B = -3.55; 95% CI, -5.56 to -1.54; P < .001). In this observational cross-sectional study, multiple endotypes frequently coexisted in patients with ANOCA, and a greater number of endotypes identified on CFT was associated with worse angina.
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Climate change may reverse decades of improvements in cardiovascular disease (CVD) mortality in the US; however, comprehensive regional projections of heat-related CVD burden in the US are unavailable. To use the county-level observed (2010-2016) heat-related CVD burden in the US to obtain the projected rates through 2050 according to the mean (shared socioeconomic pathway [SSP] 2-4.5) and high (SSP5-8.5) greenhouse gas (GHG) emission pathways. This cross-sectional ecological analysis used county-level summary data including all counties in the contiguous US from 2010 through 2016 as baseline data with projections to 2030 and 2050 under SSP 2-4.5 and SSP 5-8.5 scenarios. Estimates of CVD related disability-adjusted life-year (DALY), years of life lost (YLL) and years lived with disability (YLD) were collected from all US counties between 2010 through 2016. Midyear population data were also collected for the same period. Daily mean temperature recordings were obtained for each county for this study period and for years 2030 and 2050 for the SSP 2-4.5 and SSP 5-8.5 pathways, which signify mean and high greenhouse emissions, respectively. These data were analyzed from August through December 2025. Daily mean temperature in the baseline period (2010-2016) and years 2030 and 2050 for the 2 GHG emissions pathways (SSP2-4.5, SSP5-8.5) were obtained. County-specific mean annual heat excess was calculated as the difference between daily mean temperature and the county-specific theoretical minimum risk exposure level (TMREL) for the baseline period, as well as for each projected year's GHG emission pathway. Heat-attributable CVD burden measured in DALY per 100 000 population and population attributable fraction, stratified by age, income, and geography. Baseline national median heat-attributable CVD burden was 138.5 DALYs per 100 000. The Pacific Northwest showed highest baseline burden, while Southern and Midwestern states demonstrated steepest projected increases. Under SSP5-8.5, burden increased to 418.2 DALYs per 100 000 by 2050, corresponding to approximately 50 000 to 70 000 additional annual cardiovascular deaths. Demographic aging contributes an additional 34% to heat-attributable CVD DALY independent of temperature increases by 2050. Middle-income and low-income counties experienced approximately twice the relative increases of high-income counties. Heat-attributable CVD burden will increase substantially by 2050, disproportionately affecting economically vulnerable populations. Heat mitigation must become central to cardiovascular prevention, with targeted interventions prioritizing vulnerable communities.
Female patients with heart failure (HF) are older and more often present with preserved left ventricular ejection fraction (LVEF), whereas male patients present with more ischemic disease. Despite these differences, an emergency department-based acute HF strategy may be equally applicable to both sexes. To determine whether the strategy for acute HF management in the Comparison of Outcomes and Access to Care for Heart Failure (COACH) trial differed by sex. This prespecified secondary analysis of the multicenter COACH stepped-wedge, cluster-randomized clinical trial included 10 acute care hospitals in Ontario, Canada. Data were collected from January 15, 2017, to January 15, 2019. Participants included patients presenting to a study emergency department with acute HF. Cox proportional hazards regression with interactions was used to evaluate whether intervention effects differed for females and males and to estimate sex-specific association with treatment. Data were analyzed from July 2024 to May 2025. Risk stratification for disposition decisions from the emergency department and risk-guided postdischarge transitional care, examining sex interactions. Composite of death or cardiovascular hospitalizations at 30 days (primary outcome) and during extended follow-up to 20 months (co-primary outcome). A total of 5452 patients were included in the analysis (median age, 78.0 [IQR, 68.0-85.0] years). The 2461 females were older (median age, 80.0 [IQR, 71.0-87.0] years) than the 2991 males (median age, 76.0 [IQR, 66.0-84.0] years). Females had more preserved LVEF (≥50%) compared with males (1107 [45.0%] vs 885 [29.6%]; standardized mean difference, 0.32). Males had more prior myocardial infarction compared with females (565 [18.9%] vs 338 [13.7%]; standardized mean difference, 0.14). There was no interaction by sex at 30 days (hazard ratios [HRs] for primary outcome, 0.88 [95% CI, 0.68-1.14] for females and 0.88 [95% CI, 0.71-1.08] for males; P = .98 for interaction) or 20 months (HRs for co-primary outcome, 0.99 [95% CI, 0.90-1.09] in females and 0.92 [95% CI, 0.85-1.00] in males; P = .38 for interaction). There was a significant interaction by sex for 20-month HF readmissions (P = .01 for interaction), with adjusted HRs of 0.92 (95% CI, 0.72-1.19) in females and 0.71 (95% CI, 0.58-0.87) in males. There were no sex interactions for other outcomes at either time point. In this secondary analysis of a stepped-wedge, cluster-randomized clinical trial, risk stratification for emergency department-based decision-making for disposition decisions and rapid postdischarge transitional care was similarly beneficial in males and females, with comparable outcomes after accounting for multiplicity. ClinicalTrials.gov Identifier: NCT02674438.