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HomeCirculationVol. 83, No. 1An updated coronary risk profile. A statement for health professionals. Free AccessAbstractPDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessAbstractPDF/EPUBAn updated coronary risk profile. A statement for health professionals. K M Anderson, P W Wilson, P M Odell and W B Kannel K M AndersonK M Anderson Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. , P W WilsonP W Wilson Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. , P M OdellP M Odell Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. and W B KannelW B Kannel Office of Scientific Affairs, American Heart Association, Dallas, TX 75231. Originally published1 Jan 1991https://doi.org/10.1161/01.CIR.83.1.356Circulation. 1991;83:356–362 Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hespe C, Giskes K, Harris M and Peiris D (2022) Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation, BMC Health Services Research, 10.1186/s12913-021-07310-6, 22:1, Online publication date: 1-Dec-2022. Lemke E, Vetter V, Berger N, Banszerus V, König M and Demuth I (2022) Cardiovascular health is associated with the epigenetic clock in the Berlin Aging Study II (BASE-II), Mechanisms of Ageing and Development, 10.1016/j.mad.2021.111616, 201, (111616), Online publication date: 1-Jan-2022. 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To our knowledge, the prognostic role of right ventricular-pulmonary artery coupling (RV-PAc) in the context of multiple valvular heart disease (MVD) has so far not been evaluated. Therefore, in this study we assessed the prognostic role of surrogate of RV-PAc in patients affected by one of the most common MVDs: moderate mitral regurgitation (MR) with concomitant moderate tricuspid regurgitation (TR). We collected comprehensive data of patients with coexisting moderate MR and moderate TR at 2 centers between 2014 and 2021. The outcome of interest was all-cause death. RV-PAc was estimated using the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. In the 905 patients included in our study (median age 78 years, 53% female), the relative hazard of the outcome analysis identified ≤ 0.36 as the TAPSE/PASP threshold associated with a hazard > 1.0. At baseline, TAPSE/PASP ≤ 0.36 was associated with worse New York Heart Association class, greater prevalence of atrial fibrillation, and worse remodeling of left- and right-sided chambers (all P < 0.005). After a median follow-up of 2.3 years, compared to patients with TAPSE/PASP > 0.36, those with a low TAPSE/PASP ratio showed significantly worse survival (P < 0.001), and TAPSE/PASP ≤ 0.36 remained a powerful predictor of outcome after adjustment for crucial clinical and echocardiographic variables. Finally, the nested Cox regression model showed an incremental prognostic role of TAPSE/PASP compared with its constituents TAPSE and PASP as separate variables (P value of improved model fit = 0.008). In this large cohort of patients with moderate MR + moderate TR, RV-PAc estimated by TAPSE/PASP was strongly associated with worse baseline clinical presentation and poor long- term prognosis.
The aorta has multiple functions within the cardiovascular system and disease progression remains incompletely understood. Diseases of the aorta cause substantial morbidity and mortality. This review summarizes the management of thoracic aortic disease, current knowledge gaps, and future opportunities. There is an increasing effort to incorporate aortic function, beyond diameter, into risk stratification for aortic disease. Medical therapies focus on slowing growth of aortic aneurysm, minimizing perioperative risk, and reducing overall cardiovascular mortality, focusing on treating hypertension and minimizing lifestyle risks such as smoking and strenuous isometric exercise. Surgical management aims to lower the risk of adverse aortic events, balancing natural history risk vs the risk of prophylactic surgery. Open surgical replacement of aneurysmal segments remains the gold standard for aortic root and ascending aortic aneurysms. Hybrid approaches, combining open and endovascular repair, have been used for the aortic arch with efforts to optimize neurologic outcomes. Custom-made and off-the-shelf devices are available for descending thoracic and thoracoabdominal aortic aneurysms. An interdisciplinary aortic team is essential for the management of complex aortic disease. Large multinational, prospective registries have added important knowledge regarding aortic dissection and genetic aortopathy. Randomized trials are currently underway that will help inform important management decisions. Future efforts should focus on personalized decision making, enabling less invasive therapies, and improving quality of life of those living with the disease.
In 2025, Hypertension Canada published a new guideline for the management of hypertension in primary care. Key changes included the adoption of lower blood pressure (BP) thresholds for hypertension diagnosis, treatment initiation, and treatment target. This study sought to evaluate the potential epidemiological effects of the 2025 Hypertension Canada guideline and its implications for Canadian adults. Using data from the population-based CARTaGENE cohort, we compared how transitioning from the 2020 to the 2025 Hypertension Canada guideline recommendations could affect hypertension prevalence, indications for antihypertensive treatment, and BP control rates. We included 16,825 participants in the study. Implementation of the 2025 Hypertension Canada guideline increased the number of individuals with hypertension from 7005 (41.6%) to 8564 (50.9%; 95% confidence interval, 50.2%-51.6%), primarily affecting younger participants and those at low-to-moderate cardiovascular risk. For these individuals, initial nonpharmacological management focused on lifestyle optimization would be recommended. The need for antihypertensive treatment initiation increased by only 1.3% (95% confidence interval, 0.3%-2.4%) and predominantly concerned individuals at high cardiovascular risk. Among treated participants, BP control rates decreased by 8.7% in the low-to-moderate risk group and increased by 9.9% in the high-risk group. Adoption of the 2025 Hypertension Canada guideline will substantially increase the prevalence of hypertension among 40- to 69-year-old Canadians. Nonpharmacological interventions are recommended for all individuals; however, new antihypertensive pharmacotherapy would be recommended for only a small subset, largely limited to those at high cardiovascular risk.
The Canadian Cardiovascular Atlas project, an initiative of the Canadian Cardiovascular Outcomes Research Team (CCORT), will be published as a series of 20 articles in future issues of the Canadian Journal of Cardiology. Through a wide range of data sources and analyses from a number of collaborators across Canada, the CCORT Atlas will provide a comprehensive overview of the current state of cardiac care and disease in Canada. Administrative data, clinical registries and community survey data will be analyzed at the provincial and health region levels. The purposes of this article are to 1) provide an overview of the data types and sources used in the Atlas project, 2) give a general description of the methods and analyses used to report Atlas data and 3) describe how Atlas maps were created and how they can be interpreted.
Research over the past 2 decades has provided a broader understanding of the genetic architecture of coronary artery disease (CAD) and shows that it derives in large part from the cumulative effect of multiple common risk alleles that are individually of small effect size but cumulatively have large effects on CAD risk. The tools applied include genome-wide association study (GWAS), which encompasses thousands of individuals, complemented by deep sequencing and extensive omic data sets. More than 300 genome-wide significant loci associated with CAD risk have been identified using the GWAS approach; 90% of these are situated in intergenic regions. Our research at the University of Ottawa Heart Institute has been carried out in collaboration with an extensive number of groups and individuals around the world. These studies include computational approaches to better understand missing heritability and identify causal pathways, experimental approaches to reveal, at the molecular level, the function of the multiple risk loci. In addition to providing new insight into the biology of atherosclerosis and its clinical sequelae, GWAS findings have important applications in clinical cardiovascular medicine. These include Mendelian randomization analyses to identify causal biomarkers and generation of polygenic risk scores to improve CAD risk prediction and guide decision-making regarding preventive therapies.
Neurologic events (NEs) remain a feared complication after transcatheter aortic valve implantation (TAVI). The relationship between NE timing and prognosis remains uncertain. In this study we aimed to assess the impact of NE on mortality according to NE timing. Patients undergoing TAVI at 18 European centers between 2007 and 2022, included in the Transfusion Requirements in Transcatheter Aortic Valve Implantation (NCT03740425) registry, were stratified according to the timing of NEs. NEs were defined as periprocedural (≤ 30 days) or non-periprocedural (> 30 days) according to the Valvular Academic Research Consortium-3 criteria. The primary endpoint was 2-year all-cause mortality as assessed using restricted mean survival time. Among 10,079 patients undergoing TAVI, 263 (2.6%) experienced an NE over a median follow-up of 20.6 (interquartile range 9.8-38.3) months after TAVI. A total of 171 NEs (65.0%) were periprocedural and 92 (35.0%) non-periprocedural. Fatal stroke accounted for 6.4% of periprocedural NEs and 40.2% of non-periprocedural NEs. Median time from NE to death was 20.4 (9.4-38.1) months. Both types of NEs were associated with significantly reduced 2-year survival time: -164.7 days for periprocedural NEs and -360.5 for non-periprocedural NEs (P for trend = 0.029). The adverse prognostic impact of NE increased progressively over time. In this large multicenter registry, all types of NEs after TAVI were associated with reduced midterm survival. NEs that occurred later had the greatest detrimental effect on life expectancy, showing a significant temporal gradient across NE categories. Further studies are warranted to evaluate preventive strategies and long-term monitoring approaches.
Conduction System Pacing (CSP) is recommended when high ventricular pacing burden is expected, and as an alternative to cardiac resynchronization. Multiple studies have demonstrated the importance of achieving CSP over deep septal pacing, with associated improved clinical outcomes. There are various currently accepted criteria to ascertain CSP lead placement, which all require an electrophysiology (EP) system. EP systems are not widely available, limiting CSP lead placement to tertiary hospitals and specialized centers. The purpose of this study was to identify ECG-only criteria capable of confirming CSP capture and thereby improve accessibility to this pacing strategy. We retrospectively extracted all attempted CSP implantations at our centre. Established CSP criteria were assessed for each patient, alongside the presence of ECG-only features. The presence of three ECG-only criteria was found to be highly predictive of CSP in patients without a previously paced rhythm: terminal S wave in V5-V6, and isoelectric ST segment in V6, and a positive T wave in V5-V6. When applied to patients with unpaced baseline rhythms and a V6-V1 interpeak interval > 44 ms, these criteria demonstrated a predictive accuracy of 80.4%, with a sensitivity of 87.8% and a specificity of 76.5%. These findings suggest that CSP capture may be reliably identified using a combination of simple ECG-based markers in patients without prior ventricular pacing. Implementation of these criteria may facilitate broader adoption of CSP by enabling reliable confirmation of capture without the need for EP systems, thereby expanding patient access to this physiologic pacing strategy.
Transcatheter tricuspid valve intervention (TTVI) has expanded therapeutic options for tricuspid regurgitation (TR); however, a substantial proportion of patients remain ineligible because of anatomical and clinical constraints. We sought to characterize patients screened out from TTVI and evaluate their clinical outcomes. In this single-centre retrospective cohort study (January 2021 to May 2025), we included consecutive patients with symptomatic severe TR referred for TTVI evaluation who were deemed ineligible by a multidisciplinary heart team. Patients were identified through institutional logs and clinical trial screening databases. Baseline clinical, echocardiographic, and hemodynamic data were collected. Outcomes included 1-year all-cause mortality, heart failure hospitalization (HFH), and their composite. Among 205 patients evaluated, 83 (40.5%) were deemed ineligible. The mean age was 72.2 years, with a high burden of comorbidities. Severe or torrential TR was present in 84.4% of patients. The most frequent reasons for exclusion were unfavourable anatomy, including significant tricuspid annular dilation (69.5%) and a coaptation gap ≥ 7-10 mm (59.8%). Patients who died within 1 year had higher right-sided filling pressures on invasive hemodynamic assessment. At 1 year, all-cause mortality was 20.5%, HFH occurred in 31.3%, and the composite end point in 51.8%. Kaplan-Meier estimates showed survival of 77.5% and freedom from HFH of 58.3% at 12 months. Patients deemed ineligible for TTVI represent a high-risk cohort with substantial morbidity and mortality at 1 year. These findings underscore the importance of earlier referral, optimized screening strategies, and continued device innovation to expand treatment eligibility.
Myocardial revascularization remains a cornerstone in the management of acute coronary syndromes (ACS) and chronic coronary disease. Advances in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have significantly improved patient outcomes. PCI innovations include the evolution from balloon angioplasty to contemporary drug-eluting stents, imaging- and physiology-guided interventions, and the adoption of transradial access; all contribute to safer, more durable revascularization. Meanwhile, CABG continues to demonstrate superior long-term survival and freedom from major adverse cardiac events in good operative candidates with complex or multivessel coronary disease. Modern surgical innovations, including off-pump techniques and minimally invasive CABG, have reduced procedural trauma, enhanced recovery, helped to avoid aortic manipulations and maintain excellent patency and long-term survival outcomes. The integration of robotic assistance further enabled multiarterial nonsternotomy CABG, and represents a paradigm shift toward less invasive, curative approaches. The concept of hybrid coronary revascularization-combining the durability of CABG with the precision of PCI alongside guideline-directed medical therapy and multidisciplinary heart teams, is also central to the future of advanced coronary care. In this comprehensive review we highlight major milestones in myocardial revascularization, the unique contributions of Canadian research, and the ongoing transitions toward patient-centred, minimally invasive, and collaborative treatment models.
Although tissue contact significantly affects pulsed field ablation (PFA) efficacy, evidence supporting contact force-guided PFA for recurrent left atrial flutter (AFL) remains scarce. In this study we investigated the efficacy and safety of PFA in this difficult-to-treat population compared with radiofrequency ablation (RFA). Patients with atypical AFL who had undergone at least 1 previous persistent atrial fibrillation ablation were prospectively enrolled for PFA and compared with a retrospectively analyzed control group treated with conventional RFA at the same period. Coronary artery spasm risk was assessed via coronary angiography. The efficacy end points were recurrence of atrial arrhythmias after a 3-month blanking period. The safety end point included severe procedure-related complications. A total of 253 patients were included in this study (mean age 59 years, 68% male), 119 patients received PFA treatment, 134 patients received RFA. At 12-month follow-up, the RFA group demonstrated a significant higher atrial tachyarrhythmia recurrence rate compared with the PFA group (36% vs 24%; log rank P = 0.027). In the multivariable Cox regression model, PFA was linked to lower risk of the recurrence risk compared with RFA (hazard ratio, 0.56; 95% confidential interval, 0.35-0.90; P = 0.017). Moreover, acute mitral isthmus block rate in the PFA group was significantly higher than in the RFA group (100% vs 64%; P < 0.001). No procedure-related complications were observed, including esophageal fistula, phrenic nerve injury, and coronary artery spasm. In patients with refractory left AFL post atrial fibrillation ablation, contact force-guided PFA appears promising and demonstrates favourable efficacy compared with conventional RFA.
Patients with systemic lupus erythematosus (SLE) are at increased risk of a wide range of cardiovascular manifestations, which contribute substantially to morbidity and mortality. Multimodality cardiovascular imaging plays a central role in the detection, characterization and monitoring of cardiac involvement in SLE. This review provides an overview of the clinical presentation and imaging features of major cardiovascular manifestations in SLE, including pericardial disease, myocarditis, coronary artery disease, and valvular involvement. The strengths and limitations of echocardiography, cardiac magnetic resonance, computed tomography and nuclear imaging techniques are discussed. For each entity, we highlight the specific imaging findings that change management, practical next test choices, and common situations where repeat imaging or escalation to another modality are helpful. Improved integration of multimodality imaging may enable earlier diagnosis, better risk stratification, and more targeted management of cardiovascular disease in patients with SLE.
Bicuspid aortic valve (BAV) stenosis presents specific challenges for transcatheter aortic valve implantation (TAVI). Several transcatheter heart valve (THV) sizing strategies have been proposed. The CASPER algorithm indicates whether and how much to downsize the THV based on anatomical characteristics. The aim of this study is to prospectively assess the CASPER algorithm in a multicenter cohort of BAV patients treated with a self-expandable THV. Consecutive BAV patients undergoing TAVI were prospectively enrolled across six centers from 2022 to 2024. Pre-procedural computed tomography (MSCT) was used for THV sizing according to CASPER. Procedural features and clinical outcomes at 30 days and 1 year were recorded. Patients were compared based on whether CASPER recommended downsizing. A total of 101 patients were included, and THV downsizing was advised in 39 cases (34.6%). The mean post-TAVI transvalvular gradient was 8.3±4.3mmHg, and moderate paravalvular leak occurred in six patients (6%). No deaths or major structural complications were reported, while the 30-day permanent pacemaker implantation rate was 25%. No significant differences between downsizing and non-downsizing groups were observed regarding procedural characteristics, hemodynamic performance, or clinical outcomes. Post-procedural MSCT (available in 84/101 patients, 83%) showed comparable THV eccentricity in both groups. The CASPER algorithm offers a practical and reproducible sizing strategy for use in BAV anatomy and appears to support appropriate THV expansion while identifying cases requiring downsizing. However, in the absence of a comparator group, these findings should be considered hypothesis-generating and require validation in prospective comparative or randomized studies. NCT04817735.
The Canadian medical community in general, and the Canadian Cardiovascular Society (CCS) in particular, have played a major role in promoting evidencebased clinical practice in Canada. The Heart Failure Guideline Consensus Panel of the CCS published one of the first national guidelines on the clinical evidence for the diagnosis and treatment of heart failure in 1994 and published a comprehensive update in The Canadian Journal of Cardiology in December 2001.
Coronary microvascular and vasomotor dysfunction (CMVD) is not a novel entity, and it disproportionally affects more women than men presenting with cardiac symptoms in the setting of nonobstructive coronary artery disease. Recent advances in the development and validation of diagnostic tools have brought CMVD into sharper focus, driving renewed interest and momentum in cardiovascular research within this field. In this review, we summarize current understanding of CMVD pathophysiology, discuss available diagnostic modalities and their limitations, and review contemporary management strategies, with particular emphasis on the multidisciplinary contributions of allied health professionals and the role of patient-support groups. Importantly, we emphasize the recognition of sex-specific differences in the prevalence, underlying mechanisms, symptom burden, and prognosis of CMVD as a clinical and research priority, as it provides the biological and clinical rationale for sex-specific diagnostic strategies and more personalized management and therapeutic approaches. Finally, we also discuss our perspective on how different organizations can help promote the awareness and research to enhance our ability to diagnose and treat this condition in future.
Hysterectomy is the most frequently performed surgery in non-pregnant females yet may have under-appreciated implications for long-term chronic disease risk. This study investigated the association between benign hysterectomy with ovarian conservation and future risk of cardiometabolic disease. This was a population-based cohort study of females aged 20-39 years in Alberta (1997-2021) and included: (i) an overall cohort with all eligible females (n=1,191,263); and (ii) a matched sub-cohort of exposed females (n=45,331) age-matched with 6 unexposed females (n=271,986). The primary outcome was first diagnosis of cardiometabolic disease and secondary outcomes were 10 cardiometabolic diseases. We used Cox proportional hazards regression modelling with age as the time scale (median follow-up 13.3 years) in the overall cohort; and Royston-Parmar models with time since surgery as the time scale (median follow-up 10.3 years) in the age-matched sub-cohort. Models were adjusted for birth year or year of hysterectomy, and time-varying rural residence, material deprivation quintile, continuity of primary care, and comorbidities. In the overall cohort, hysterectomy was associated with accelerated time to first diagnosis of cardiometabolic disease (aHR 1.33, 95% CI 1.30 to 1.36) and with incidence of 7/10 cardiometabolic diseases; the strongest associations were chronic kidney disease (1.29, 1.23 to 1.35), ischemic heart disease (1.31, 1.25 to 1.38), metabolic dysfunction-associated steatotic liver disease (1.43, 1.32 to 1.55), and stroke (1.33, 1.23 to 1.45). Results were similar in the age-matched sub-cohort. Benign hysterectomy with ovarian conservation may be an important female-specific risk factor for cardiometabolic disease, warranting judicious use and expanded patient counselling on potential long-term health risks.
Angina caused by coronary microvascular dysfunction (CMD) represents a particularly challenging clinical scenario. Coronary sinus Reducer implantation is a safe and effective therapy for patients with refractory angina and obstructive coronary artery disease (CAD). We evaluated the efficacy of Reducer implantation in patients with angina and CMD, on microvascular function parameters, angina severity, functional capacity and quality of life (QoL). Patients with refractory angina, non-obstructive CAD, and evidence of CMD underwent Reducer implantation. Invasive evaluation of microvascular function, including index of microcirculatory resistance (IMR), coronary flow reserve (CFR), resistive reserve ratio (RRR) and microvascular resistance reserve (MRR) was performed at baseline and 4 months after Reducer implantation. Angina symptoms, functional capacity, and QoL were evaluated by Canadian Cardiovascular Society (CCS) class, 6-minute walk test (6mWT), and Seattle Angina Questionnaire (SAQ), respectively, at baseline and 4 months following Reducer implantation. Forty patients (median age 68 [IQR 59-77], 55% female) were included. At 4 months, IMR decreased (35 [25-43] to 17 [10-32], p < 0.001), CFR increased (1.6 [IQR 1.3-2.0] to 2.8 [1.9-3.3], p<0.001), RRR increased (1.9 [1.7-2.3] to 2.9 [2.0-3.7], p<0.001) and MRR increased (2.1 [IQR 1.7-2.5] to 3.3 [IQR 2.3-4.0], p<0.001). CCS class improved from a median of III to II, alongside significant improvements in 6mWT distance (300 [IQR 231-400] to 383 [IQR 278-452] meters, p<0.001) and all 5 SAQ domains (p<0.05 for all). Reducer implantation significantly improved coronary microvascular function, angina symptoms, functional capacity, and QoL in patients with angina and evidence of microvascular dysfunction.
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Although familial AF (FAF) frequently follows an autosomal dominant inheritance pattern, the genetic mechanisms remain incompletely defined. We sought to identify the causal variant within a previously established linkage region on chromosome 10q22-q24. Additional recombination events and fine mapping reduced the original linkage interval to 0.8 Mb. Targeted sequencing of the locus was performed in affected and unaffected family members. Patient-specific induced pluripotent stem cells (hiPSCs) were differentiated into atrial cardiomyocytes (hiPSC-aCMs) to assess gene expression and ion channel function. Refinement of the locus identified three genes (KCNMA1; DLG5; and POLR3A). A novel 15-kb tandem duplication within intron 1 of KCNMA1 segregated with disease in six families and was absent in controls and population databases. Patient-derived hiPSC-aCMs demonstrated reduced KCNMA1 and POLR3A mRNA and protein expression, accompanied by decreased paxilline-sensitive outward current. We identify a rare intronic structural variant in KCNMA1 associated with familial AF. The variant segregates with disease and is associated with reduced KCNMA1 expression and BK channel activity in patient-specific cardiomyocytes. These findings implicate the 10q22-q24 locus and highlight the potential contribution of non-coding structural variation to inherited atrial arrhythmia.
Coronary artery bypass graft surgery (CABG) has traditionally utilised an in-situ left internal mammary artery (LIMA) graft to the left anterior descending artery, in addition to aortocoronary anastomoses to graft non-LAD target vessels. Composite grafting provides an opportunity to avoid aortic anastomoses by utilizing non-aortic anastomoses to provide greater efficiency in the use of conduits for improved all-cause mortality and reduced aortic manipulation to lower the incidence of postoperative stroke. We performed a network meta-analysis (NMA) to compare aortocoronary and various composite grafting strategies for CABG. A systematic search of six electronic databases identified all publications reporting outcomes of CABG with aortocoronary or composite grafting strategies. The primary outcome was in-hospital or 30-day all-cause mortality, and studies which reported this were included in a NMA. Our study protocol was registered with PROSPERO (CRD42023402665) and conformed with PRISMA 2020 and MOOSE guidelines. A systematic search of six electronic databases identified all publications reporting outcomes of the included operations. A total of 6656 articles were screened, of which 24 studies (8 RCTs and 16 observational studies) were included with a total of 9692 patients. There was no difference in conventional aortocoronary anastomosis and composite grafting for the outcome of in-hospital or 30-day all-cause mortality (p=0.387). There was also no difference in rates of stroke (p=0.277), myocardial infarction (p=0.09), reoperation for bleeding (p=0.500), postoperative atrial fibrillation (p=0.219) and deep sternal wound infection (p=0.549). This Bayesian NMA of 9692 patients demonstrated that composite grafting CABG can be performed as safely as conventional aortocoronary CABG.