Background: Point-of-care (POC) cardiac troponin testing, although less sensitive than high-sensitivity cardiac troponin assays, allows for rapid bedside evaluation. This study assessed the diagnostic performance of POC troponin tests for both ruling in and ruling out acute myocardial infarction (AMI) at the time of patient presentation.

Methods and Results: In accordance with PRISMA-DTA guidelines, we conducted a systematic review and meta-analysis using PubMed, Web of Science, and the Cochrane Library from inception through June 17, 2023. We included all studies evaluating the diagnostic accuracy of POC troponin assays for identifying AMI among adult patients. Among the 551 studies initially screened, 6 met the eligibility criteria for inclusion. A meta-analysis of diagnostic accuracy based on these 6 observational datasets demonstrated pooled sensitivity and specificity values of 47% (95% confidence interval (CI) 45–49%) and 90% (95% CI 89–90%), respectively, for AMI detection. In a subgroup meta-analysis of non-ST-segment elevation MI using 4 observational datasets, the pooled sensitivity and specificity were 48% (95% CI 45–50%) and 89% (95% CI 89–90%), respectively.

Conclusions: These findings emphasize that the clinical application of POC troponin assays in AMI diagnosis must consider the test’s robust specificity (≈90%) alongside its limited sensitivity (<50%).

Background: Risk scores have been developed to determine the treatment strategies and predict the prognosis of acute coronary syndromes (ACS). It remains unclear whether risk score-guided management improves prognosis. Therefore, this systematic review aimed to evaluate whether the use of risk scores to assess the acute severity of illness affects the prognosis of adult patients with ACS.

Methods and Results: We conducted a systematic review and meta-analysis to evaluate whether risk score-guided management improves clinical outcomes in patients with ACS. We searched MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to November 30, 2024, and included randomized controlled trials comparing risk score-based care with standard care. Two cluster randomized trials, using the Global Registry of Acute Coronary Events risk score (GRS), were identified, with a total of 5,368 patients. A systematic review adjusted for clustering revealed no significant differences in clinical outcomes, including in-hospital and 1-year mortality, in-hospital cardiac arrest, in-hospital recurrent ischemia, in-hospital and 1-year heart failure, and early invasive angiography.

Conclusions: Risk score-guided management of patients with ACS using risk scores, particularly the GRS, did not consistently lead to improved clinical outcomes. Further research is needed to assess whether risk score-guided management can improve patient outcomes.

Background: The optimal device for mechanical circulatory support (MCS) in patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains unknown. Therefore, in this study we aimed to analyze which MCS (intra-aortic balloon pumping (IABP) or IMPELLA) is associated with better outcomes in patients with AMI-related CS.

Methods and Results: This systematic review and meta-analysis used a random-effects model to account for potential heterogeneity. Risk ratios (RRs) and 95% confidence intervals (CIs) were used for the dichotomous outcomes. The PubMed, Web of Science, and CENTRAL databases were searched up to April 30, 2023. The risk of bias was evaluated using the Revised Cochrane risk-of-bias tool for randomized trials (RoB2) tool, and the certainty of evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Two randomized controlled trials were included in the meta-analysis. For the primary outcome of 30-day survival, IMPELLA probably improves the outcome by a small amount compared with IABP (RR0.94 [95% CI 0.5–1.53], 29 fewer per 1,000 [95% CI from 204 fewer to 258 more], low certainty of evidence).

Conclusions: We could not show a survival benefit of IMPELLA compared with IABP in patients with AMI complicated by CS. Further investigation is required to resolve this issue.

Background: Inotropes play a significant role in the treatment of cardiogenic shock (CS). Phosphodiesterase 3 inhibitors (PDE3i) are being used with increasing frequency, despite limited supporting evidence.

Methods and Results: We performed a systematic review to assess the clinical importance of PDE3i in CS. The search included studies that compared the effect of ‘PDE3i with or without inotropes’ with ‘No PDE3i with or without inotropes’ in patients with cardiogenic shock. Early death, cardiac arrest, and initiation of renal replacement therapy were assessed as outcomes. We identified 2 randomized controlled trials (RCT) with a total of 224 patients who met the eligibility requirements from the PubMed, Web of Science, and CENTRAL databases, up until October 31, 2024. One RCT compared milrinone with dobutamine (DOB), and another compared enoximone with levosimendan. Meta-analysis revealed that PDE3i were neither superior nor inferior for the outcomes in the total cohort (odds ratio [OR] 1.47, 95% confidence interval [CI] 0.35–6.26 for early deaths; OR 1.14, 95% CI 0.42–3.14 for cardiac arrest; OR 1.53, 95% CI 0.80–2.92 for the initiation of renal replacement therapy).

Conclusions: The present systematic review revealed no difference in outcomes, early deaths, cardiac arrest and initiation of renal replacement therapy when using PDE3i in patients with CS treated with or without other inotropes.

Background: Several antiarrhythmic agents, including amiodarone (AMD) and nifekalant (NIF), are used in the management of life-threatening arrhythmias such as ventricular fibrillation (VF) and ventricular tachycardia (VT). Although a few studies have compared the antiarrhythmic effect of NIF and AMD, most have focused on termination or defibrillation of VF/VT. In this meta-analysis, we aimed to assess the current evidence on the preventive effects of NIF and AMD on recurrent VF and electrical storm (ES).

Methods and Results: The protocol was registered in PROSPERO (CRD42024578486). PubMed (MEDLINE and PMC), Cochrane Central Register of Controlled Trials (CENTRAL), Science Citation Index Expanded, and Igaku Chuo Zasshi were searched for observational studies and randomized controlled trials evaluating patients with cardiac arrest due to recurrent VF and ES treated with AMD or NIF, published before 28 August 2024. The primary endpoint was the recurrence of VF/VT. Secondary outcomes included short-term death and incidence of torsades de pointes (TdP). 5 eligible studies comprising 222 participants were included. Evidence regarding differences between NIF and AMD in the recurrence of VF/VT, short-term death, and incidence of TdP was of very low certainty and remains highly uncertain.

Conclusions: NIF and AMD may have little to no difference in preventing the recurrence of VF/VT, short-term death, or incidence of TdP; however, the certainty of the evidence is very low.

Intravenous magnesium is commonly used in clinical practice for treating Torsade de Pointes (TdP), although supporting evidence remains limited. This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines. Four online databases were searched for relevant studies published as of November 27, 2024, but only 4 observational studies met the inclusion criteria. TdP resolved in a substantial proportion of patients treated with intravenous magnesium (78.3% [N=36/46]), although most studies lacked a control group. No serious adverse events related to magnesium were reported (0% [N=0/46]). Despite several limitations that preclude firm conclusions, intravenous magnesium appears to be a relatively safe and effective treatment for TdP. However, TdP progressed to ventricular fibrillation (VF) in 21.7% (N=10/46) of patients, underscoring the need for readiness to perform immediate electrical defibrillation during treatment. Further high-quality studies are warranted to validate these findings.

Intravenous atropine is widely recommended as the first-line treatment for symptomatic bradycardia, but because the optimal initial dose remains uncertain, the aim of this scoping review was to examine the existing literature on the efficacy and safety of intravenous atropine at specific doses in adult patients with symptomatic bradycardia and to identify gaps in evidence. A systematic search of 4 databases (PubMed, CENTRAL, Web of Science, and Ichushi-Web) was conducted from inception to December 16, 2024. Studies were included if they reported administration of a specified dose of atropine in adult patients, regardless of study design. No randomized controlled trials directly comparing 0.5 mg vs. 1.0 mg were found. A total of 19 studies were included and categorized into groups based on initial atropine dose: low (<0.5 mg), moderate (0.5 mg ≤ dose <1.0 mg), high (≥1.0 mg), and those spanning multiple categories. No consistent relationship was found between atropine dose and clinical outcomes, such as heart rate response or adverse effects. None of the moderate-dose studies reported worsening bradycardia. Moderate-dose atropine could be safe, and the current practice of using 0.5 mg as an initial dose in Japan, where 0.5 mg/mL prefilled syringes are commercially available, appears clinically reasonable. However, in the absence of high-quality comparative data, future research should apply rigorous study designs to determine the optimal atropine dose in emergency care settings.

Background: Decline or inadequate recovery of activities of daily living (ADL) during hospitalization is crucial for clinical prognosis. In this study we investigated the relationship between cardiac rehabilitation (CR) and ADL recovery in patients with cardiovascular disease (CVD), with the aim of exploring associations that may contribute to the development of rehabilitation interventions.

Methods and Results: This study analyzed consecutive patients hospitalized with CVD. ADL was assessed using the Barthel index (BI) at the commencement of rehabilitation and discharge. As the outcome measure for ADL, relative functional gain: BI effectiveness, calculated as (discharge BI − initial BI) / (100 − initial BI), was adopted in order to compensate ceiling effect of BI. BI effectiveness ≥0.5 defined the ADL recovery group, while <0.5 defined the ADL non-recovery group. Of the 2,938 patients screened, 1,582 (median age 79 years, male 59%) were included after exclusions. The ADL recovery group consisted of 1,162 patients, the ADL non-recovery group, 420 patients. Between-group comparisons and multivariate regression analysis identified age and initial BI as highly significant ADL recovery determinants. Recursive partitioning analysis showed CR volumes of ≥75 min/day for patients ≥75 years and ≥45 min/day for those <75 years with lower initial BI were associated with ADL recovery. These CR volumes also reduced the institutionalization odds ratios (OR=0.42 and OR=0.34, P<0.001) compared to CR volumes <45 min/day.

Conclusions: CR volume was associated with ADL recovery, especially for older patients with low baseline function at admission. Optimizing CR volume based on patient background and condition may contribute to enhance ADL recovery and improved clinical prognosis.

Background: Difficulties opening plastic bottles may be associated with muscle weakness. We investigated association between the ability to open plastic bottles and muscle weakness, and determined cut-off values for and sex-related differences in handgrip strength and pinch strength associated with opening plastic bottles in patients with coronary artery disease (CAD).

Methods and Results: This cross-sectional study enrolled 224 consecutive patients with CAD who underwent in-hospital cardiac rehabilitation. Multiple linear regression analyses was used to determine the association between the ability to open plastic bottles and muscle weakness, with cut-off values for handgrip strength, lateral pinch strength, and 3-fingered pinch strength required to open plastic bottles determined by receiver operating characteristic curve analyses. Multiple linear regression showed that the ability to open plastic bottles was independently associated with handgrip, lateral pinch, and 3-fingered pinch strength after adjusting for confounders. Areas under the curves for all patients were 0.96 (95% confidence interval [CI] 0.93–0.99), 0.91 (95% CI 0.83–0.99), and 0.93 (95% CI 0.88–0.99) for handgrip, lateral pinch, and 3-fingered pinch strength, respectively, with corresponding cut-off values of 20.0, 7.1, and 6.1 kgf.

Conclusions: The ability to open plastic bottles was independently associated with handgrip strength and pinch strength in patients with CAD. Evaluating the ability to open plastic bottles may be a simple and practical tool for assessing muscle weakness in patients with CAD.

Background: This study aimed to identify fall risk indicators associated with future falls among older patients with cardiovascular disease (CVD), based on a multidimensional assessment.

Methods and Results: In this prospective cohort study, 129 patients aged ≥65 years with CVD were enrolled between 2021 and 2023. Participants were classified into fall and non-fall groups based on fall incidence during a 1-year follow up. We assessed physical frailty, systolic blood pressure, polypharmacy, and the Falls Efficacy Scale International (FES-I) to evaluate concern about falling. The overall 1-year fall incidence was 17.0% (22 falls), equating to 0.28 falls per person-year. Compared with the non-fall group, the fall group was older, had lower physical function and blood pressure, and higher FES-I scores. Multivariate logistic regression, adjusted with propensity scores, revealed that a FES-I score ≥28 was a significant predictor of falls (odds ratio [OR] 8.906, 95% confidence interval [CI] 2.556–13.031, P=0.001; adjusted OR 2.964, 95% CI 1.038–8.460, P=0.042). Receiver operating characteristic analysis identified a FES-I cut-off of 28, with an area under the curve of 0.684 (95% CI 0.527–0.840, P=0.017).

Conclusions: The 1-year fall incidence among older patients with CVD was comparable with rates in community-dwelling older adults. Higher concern about falling, as measured using FES-I, was significantly associated with future falls.

Background: The physician ordered advance code (PAC), a treatment code used in Japanese hospitals based on the physician orders for life sustaining treatment paradigm, plays a crucial role in guiding treatment decisions for patients with acute heart failure (AHF). However, data on the clinical characteristics, decision-making processes, and outcomes associated with PAC in Japanese patients are limited.

Methods and Results: We retrospectively analyzed data from 1,203 AHF patients across multiple centers in Japan. Patients were categorized based on the presence or absence of PAC orders; clinical characteristics and mortality outcomes were compared between the 2 groups. Patients with PAC orders were significantly older, more often female, and had lower activities of daily living scores. Cognitive impairment was markedly more prevalent in the PAC than non-PAC group. PAC decisions were primarily communicated to family members rather than to patients themselves, with only 7.3% of patients directly informed. The median time from admission to final PAC order was 2 days, with 74.1% finalized within 5 days. PAC orders frequently permitted intravenous therapies, but limited resuscitative measures in only 15% of patients. In-hospital and 2-year mortality rates were substantially higher in the PAC than non-PAC group.

Conclusions: PAC designation reflected poor clinical status and was linked to significantly worse mortality outcome. Enhancing shared decision-making and aligning PAC with patient values are essential steps to optimize care for this vulnerable population.

Background: This study aimed to assess the accuracy and intra-operator reproducibility of ischemia assessments from coronary angiography, as performed by interventional cardiologists, and its influence on treatment strategies.

Methods and Results: Twenty-two interventionalists predicted fractional flow reserve (predFFR) from 194 angiograms obtained from patients with single-vessel disease in the Objective Randomized Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) study. For each case, respondents selected either angio-guided percutaneous coronary intervention (PCI), medication, or a physiology-guided approach. Respondents were divided into high- and low-physiology-use groups based on the frequency of selecting physiology-guided treatment. Physiological strategies were chosen for 60.3% and 23.9% of the cases in the high and low groups, respectively. Correlations between predFFR and measured FFR values were weak (r=0.451; P<0.001), with 84.7% agreement for fractional flow reserve ≤0.80 and 75.0% for severity classification. Intra-operator agreement for treatment strategy in duplicate cases was 76.9%. Bland–Altman analysis showed considerable variability in repeated predFFR estimations (limits of agreement −0.16 to +0.15), exceeding thresholds considered acceptable in clinical practice. Although the diagnostic concordance was similar, the low group made more inappropriate treatment decisions, notably selecting PCIs for non-ischemic lesions, and more often opted for medication in truly ischemic patients compared with the high group (P<0.001).

Conclusions: Visual prediction of ischemia from angiography is limited in accuracy and reproducibility. Physiological assessment remains essential for determining the appropriate treatment.

Background: Patients with endstage kidney disease undergoing hemodialysis (HD) have higher risks of ischemic and bleeding events after percutaneous coronary intervention (PCI). However, the association between high platelet reactivity (HPR) and clinical events in dialysis patients remains unclear. This post hoc analysis of the PENDULUM registry examined the relationships of HPR with major adverse cardiac and cerebrovascular events (MACCE) and major bleeding in dialysis patients.

Methods and Results: Based on P2Y₁₂reaction unit (PRU) levels, patients were stratified into HPR (PRU >208) and non-HPR (PRU ≤208) groups. Clinical events were assessed up to 30 months after the index PCI. A total of 6,266 patients were enrolled. Of the 5,907 patients with available PRU data, 357 were dialysis patients (HPR, n=199; Non-HPR, n=158), and 5,550 were non-dialysis patients (HPR, n=2,030; Non-HPR, n=3,520). Dialysis patients had significantly more frequent MACCE and major bleeding than non-dialysis patients. In non-dialysis patients, MACCE, but not bleeding events, were significantly more common in the HPR subgroup. However, in dialysis patients, no significant association was found between HPR and both MACCE and major bleeding.

Conclusions: HPR was not associated with increased risks of MACCE and major bleeding in dialysis patients.

Background: Although tafamidis is used in patients with wild-type transthyretin cardiac amyloidosis (ATTRwt-CM), the effects of β-blockers, one of the conventional heart failure medications, are unclear. Therefore, this study aimed to investigate the effect of β-blockers on left ventricular function using speckle-tracking echocardiography after 1 year of treatment in patients with ATTRwt-CM.

Methods and Results: We included 46 patients (median age, 78 years) with ATTRwt-CM confirmed via biopsy. We analyzed laboratory and echocardiographic data, including global longitudinal strain (GLS) to determine left ventricular strain, using 2D speckle-tracking echocardiography and compared the changes in these parameters before and 1 year after treatment with tafamidis between 24 patients who did not receive β-blockers and 22 patients who received β-blockers. The absolute GLS deterioration was higher in patients taking β-blockers by a mean of 0.48±1.55% compared with −0.68±1.65% in patients not taking β-blockers (P=0.0181). However, other conventional heart failure medications showed no change in the GLS.

Conclusions: Left ventricular function may deteriorate with the use of β-blockers in patients with ATTRwt-CM treated with tafamidis for 1 year.

Background: We developed the SaFIS, a structured self-administered food intake survey for patients with cardiovascular diseases needing dietary improvements.

Methods and Results: The SaFIS comprised questions on 31 items, including staple foods (7 items) and food ingredients (24 items), based on the foods recommended by the Japanese Atherosclerosis Society for the Prevention of Arteriosclerotic Disease. To evaluate reproducibility, SaFIS was administered twice with a 1-month interval using the intraclass correlation coefficient (ICC [1,1]). Validity was assessed by comparing energy and nutrient content from a weighed dietary record (WDR) with the first SaFIS survey using Bland-Altman plots. Reproducibility values were energy (ICC 0.90, 95% confidence interval: 0.80–0.95), protein (0.90, 0.80–0.95), fat (0.76, 0.54–0.88), saturated fatty acids (0.78, 0.58–0.89), monounsaturated fatty acids (0.76, 0.56–0.88), polyunsaturated fatty acids (0.82, 0.66–0.91), carbohydrates (0.89, 0.79–0.95), and dietary fiber (0.86, 0.71–0.93). Bland-Altman values indicated SaFIS-based energy, protein, carbohydrate, monounsaturated fatty acids, and dietary fiber were 67.2 kJ, 5.7 g, 3.9 g, 0.5 g, and 1.8 g greater than WDR-based values, respectively. SaFIS-based fat, saturated, and polyunsaturated fatty acid values were 0.7 g, 1.3 g, and 0.39 g less than WDR-based values, respectively.

Conclusions: SaFIS demonstrated high reproducibility and validity with clinical potential. Subsequent introduction to digital health from the usability perspective is planned.

Background: Prolonged exposure to high low-density lipoprotein cholesterol (LDL-C) levels may be associated with arteriosclerosis progression. This study investigated whether the running average of LDL-C (Ra-LDL-C) measured after percutaneous coronary intervention (PCI) was associated with the occurrence of subsequent cardiovascular events.

Methods and Results: The clinical records of 1,761 patients who underwent successful PCI were examined retrospectively. Ra-LDL-C values were calculated by adding consecutive LDL-C values and averaging them. Based on the Ra-LDL-C over an observation period of up to 10 years after PCI, patients were divided into 3 groups: Ra-LDL-C <70, 70–100, and ≥100 mg/dL. The incidence of major adverse cardiovascular events (MACE; defined as coronary-related death, myocardial infarction, and new coronary stenosis of non-culprit lesions) was investigated in these groups. Kaplan-Meier analysis demonstrated that the incidence of MACE was significantly lower in the Ra-LDL-C <70 mg/dL group than in the other 2 groups. Multivariate analysis indicated that the Ra-LDL-C was significantly correlated with the incidence of MACE. Furthermore, the incidence of MACE was significantly lower among patients with Ra-LDL-C values lower than LDL-C values 3 months after PCI.

Conclusions: High Ra-LDL-C values are a predictor of increased recurrence of MACE after PCI, and long-term management of LDL-C using Ra-LDL-C values may be useful for preventing cardiovascular disease.

Background: The number of adult congenital heart disease (ACHD) patients is rising due to advancements in surgery and medical treatment for congenital heart disease (CHD) during childhood. However, acute treatment and stroke prevention measures in ACHD patients have been insufficiently assessed. To address this insufficiency, we conducted a retrospective single-center investigation of the clinical characteristics of ACHD patients who experienced stroke.

Methods and Results: We studied adult patients with acute stroke hospitalized within 7 days of onset between January 2011 and March 2017. Among 4,837 adults with stroke, 22 (0.5%) had CHD, including 19 with ischemic stroke and 3 with intracerebral hemorrhage. Compared with the non-CHD group, the ACHD group was younger (median age 56 vs. 75 years; P<0.01), had a higher incidence of large vessel occlusion (LVO; 53 vs. 24%; P=0.01), and exhibited more favorable functional outcomes at discharge (median modified Rankin scale 2 vs. 3; P=0.03). Atrial septal defect (ASD) was the most common underlying CHD, accounting for 55% of cases.

Conclusions: ACHD patients with acute stroke were significantly younger and more frequently developed LVO compared with the general stroke population, with ASD being the most common type of CHD. Despite their favorable short-term prognosis, these characteristics must be considered to implement effective acute treatment and prevention strategies.

Background: The microbial landscape of infective endocarditis (IE) has evolved over time, with Staphylococcus species recognized as the predominant pathogens. This shift has complicated IE management, and its impact on clinical outcomes remains unclear. We investigated recent microbial trends and their relationship with clinical outcomes in patients with IE.

Methods and Results: This study retrospectively examined 222 consecutive patients with suspected IE who underwent transesophageal echocardiography. Fifty-six met the modified Duke criteria for definite IE and were included in the final analysis. Microbiological trends indicated a significant increase and decrease in Staphylococcus spp. (P=0.040) and Streptococcus spp. (P<0.001) abundance, respectively. Patients infected with Staphylococcus spp. were more frequently treated surgically (75%) than those with other pathogens. Despite being associated with more extensive intracardiac lesions, Staphylococcus correlated with better functional status at discharge, with the highest proportion of patients achieving modified Rankin Scale (mRS) scores of 0–3 (P=0.049). Multivariate logistic regression analysis identified surgical intervention (odds ratio [OR] 5.40; 95% confidence interval [CI] 1.25–23.27; P=0.024) and younger age (OR 0.94; 95% CI 0.90–0.99; P=0.031) as independent predictors of favorable outcomes (mRS score 0–3).

Conclusions: Staphylococcus spp. are predominant pathogens in IE and are frequently associated with intense intracardiac involvement. Age and appropriately timed surgical intervention correlated with improved functional outcomes, indicating that early recognition and individualized treatment strategies may enhance prognosis. Timely and pathogen-directed management are important in IE.

Background: Elevated pulmonary arterial pressure (PAP) is associated with poor prognosis in patients with functional mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVr). Nitric oxide (NO) inhalation therapy reduces PAP and pulmonary vascular resistance (PVR) after open-heart surgery, but its efficacy in patients with pulmonary hypertension (PH) undergoing catheter intervention remains unclear.

Methods and Results: This open-label, interventional, randomized controlled trial will investigate the efficacy of NO inhalation therapy after TMVr for MR complicated by PH. A total of 40 patients aged ≥18 years diagnosed with PH (mean PAP >20 mmHg) during preoperative right heart catheterization and scheduled for TMVr for MR are included in this study. Patients receiving pulmonary vasodilators, with NO contraindications, and with unstable conditions requiring intravenous catecholamines or mechanical circulatory support devices are excluded. Eligible patients are randomly allocated to the NO inhalation or control group in a 1 : 1 ratio. NO (20 ppm) is administered post-TMVr (D0) until the day after TMVr (D1). The control group is administered oxygen as necessary. The primary endpoint is the change in PVR (baseline to D1). The secondary endpoints include changes in cardiac index and mean PAP (baseline to D1), changes in PVR immediately before NO administration post-TMVr to D1, and postoperative complication rates.

Conclusions: This study will assess the efficacy of NO inhalation in patients with PH undergoing TMVr for MR.