Background: Congestive heart failure (CHF) is associated with worse clinical outcomes in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS); however, the optimal timing of invasive intervention in NSTE-ACS with CHF remains unclear. In this study, we assessed the impact of early vs. delayed invasive strategies on mortality and cardiac events by synthesizing a systematic review of randomized controlled trials of patients with NSTE-ACS.

Methods and Results: We searched MEDLINE, CENTRAL, and the Web of Science for randomized controlled trials comparing early and delayed invasive strategies in patients with NSTE-ACS and CHF, published before February 2023. Observational studies were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction at 2 years. Two eligible studies, including 310 participants, were identified. The primary endpoint occurred in 40 (24.5%) of 163 patients in the early invasive strategy group, compared with 39 (26.5%) of 147 patients in the delayed invasive strategy group, and the effect of an early invasive strategy on the primary outcome was uncertain (risk ratio 0.95 [95% confidence interval 0.66–1.37]). The certainty of the evidence was rated very low.

Conclusions: The effects of an early invasive strategy in patients with NSTE-ACS and CHF remains uncertain, with no clear reduction in composite outcome of mortality and myocardial infarction at 2 years compared with delayed intervention.

Background: The utility of coronary computed tomography angiography (CCTA) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), particularly among low-risk individuals presenting to the emergency department (ED), remains unclear. We conducted a systematic review to assess the clinical benefits of CCTA in low-risk patients presenting to the ED with chest pain.

Methods and Results: A systematic search of MEDLINE, CENTRAL, and Web of Science was performed for randomized controlled trials (RCTs) published up to March 23, 2023, comparing CCTA performed in the ED with standard care in low-risk patients with NSTE-ACS. Low-risk status was defined as resolved symptoms at ED presentation and no troponin elevation or ischemic ECG changes. Seven RCTs were extracted from the databases. No significant differences were observed between the CCTA and standard care groups in all-cause mortality, non-fatal myocardial infarction, ED revisits, or radiation exposure. However, hospital length of stay was significantly shorter and healthcare costs were slightly lower in the CCTA group. Conversely, revascularization and invasive coronary angiography were significantly more frequent in this group.

Conclusions: In low-risk patients with NSTE-ACS, CCTA performed in the ED did not reduce adverse clinical events but was associated with shorter hospital stays and marginally reduced healthcare costs. These findings suggest that CCTA may be a useful tool that supports the safe and early discharge of selected patients.

Background: The optimal timing for mechanical circulatory support (MCS) initiation in patients with acute myocardial infarction complicated by cardiogenic shock (CS) is unknown, so in this study we analyzed whether MCS implementation before percutaneous coronary intervention (PCI) is associated with better outcomes compared to after PCI.

Methods and Results: We conducted a systematic review and meta-analysis using a random-effects model to account for potential heterogeneity. Risk ratios and 95% confidence intervals were used for dichotomous outcomes. PubMed, Web of Science, and CENTRAL were searched up to April 30, 2023. Certainty of evidence was evaluated according to the Risk of Bias in Non-Randomized Studies of Interventions-I tool. A total of 14 observational studies met the inclusion criteria. We found that venoarterial-extracorporeal membrane oxygenation (VA-ECMO) may have little to no positive effect on short-term survival, but the evidence was very uncertain. Impella use probably increases short-term survival (moderate certainty of evidence), whereas the timing of intra-aortic balloon pump (IABP) insertion improves outcomes (very low certainty of evidence). Pre- and post-PCI MCS implementation may result in little to no difference in bleeding complications or stroke incidence across all device types (low to very low certainty of evidence).

Conclusions: Early Impella implementation before PCI may increase short-term survival, whereas the timing of ECMO or IABP implementation may have little to no effect on outcomes; however, the evidence is very uncertain.

Background: Cardiogenic shock, cardiac tamponade, and pulmonary embolism are critical conditions in cardiovascular emergencies, characterized by high mortality rates. Early diagnosis and treatment are essential to improve outcomes. Point-of-care ultrasound (POCUS) has emerged as a noninvasive tool for evaluating shock. However, further assessment through the latest meta-analyses is necessary to comprehensively evaluate its diagnostic accuracy in cardiogenic emergencies. Therefore, in this study, we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of POCUS in patients with cardiogenic and obstructive shock.

Methods and Results: Up to December 31, 2023, we systematically reviewed 9 studies reporting all 4 values (true positive, false positive, false negative, and true negative) published in the PubMed, Web of Science, and CENTRAL databases: 8 studies assessed cardiac shock, and 8 assessed obstructive shock separately. For cardiac shock, the pooled sensitivity was 86.1% (95% confidence interval [CI]: 71.5–93.9%), and specificity was 95.8% (95% CI: 94.0–97.2%). For obstructive shock, the pooled sensitivity was 77.5% (95% CI: 62.5–87.6%) and specificity was 97.6% (95% CI: 93.9–99.1%). The area under the curve was 0.96 (95% CI: 0.95–0.98) for cardiogenic shock and 0.94 (95% CI: 0.88–0.98) for obstructive shock.

Conclusions: This meta-analysis suggested that POCUS has reasonable diagnostic accuracy for cardiogenic and obstructive shock, particularly with high pooled specificity.

Background: Cardiogenic shock, a life-threatening condition frequently encountered in emergency departments, requires rapid diagnosis and management. Point-of-care ultrasound (POCUS) is widely used as a bedside tool; however, its impact on prognosis in patients with suspected cardiogenic shock remains unclear. This systematic review aimed to evaluate whether POCUS improves the clinical outcomes in these patients.

Methods and Results: We searched PubMed, Web of Science, and Cochrane Library up to December 31, 2023, for studies evaluating the prognostic impact of POCUS in adults with undifferentiated shock, including cardiogenic shock. From 3,759 identified records, 2 studies (1 randomized controlled trial [RCT] and 1 observational study) involving 5,711 patients with shock were included. The RCT showed no significant differences in in-hospital mortality between the POCUS and non-POCUS groups (relative risk [RR] 0.99 [95% confidence interval (CI) 0.64–1.51]). The observational study reported higher mortality in patients receiving POCUS before intervention (RR 1.25 [95% CI 1.12–1.39]). Overall, POCUS did not significantly reduce mortality in patients with suspected cardiogenic shock. Given the limited number and quality of available studies, the certainty of evidence was low (RCT) and very low (observational study).

Conclusions: Although POCUS plays an essential role in diagnosis and clinical decision-making, our review suggests that it may not significantly improve prognosis in patients with suspected cardiogenic shock. Further studies are required to determine its prognostic value.

Background: With the recent acceleration of manned space exploration, health care in space has become an important issue. Cardiovascular problems, mainly caused by the microgravity environment in space, include decreased red blood cell volume, myocardial atrophy and aerobic capacity, and reduced orthostatic tolerance after return. However, complete physiological countermeasures have not been established and more research is needed.

Methods and Results: A search on PubMed was conducted for English-language articles on cardiovascular changes in space and their countermeasures and post return rehabilitation. Early in space flight, diuresis associated with fluid shifts causes changes in erythrocyte volume, and after prolonged stays, the vestibular and cardiocirculatory systems are induced to show orthostatic intolerance due to decreased blood pressure increasing reflexes, decreased circulating plasma volume, and myocardial atrophy. The main countermeasures include aerobic exercise and strength training in space 6 days a week, for approximately 2 h a day, and a rehabilitation program after return to re-adapt to the Earth’s gravitational environment.

Conclusions: In the near future, when people with heart disease and the elderly will fly in space, new health management techniques that combine the knowledge accumulated in space flight and cardiac rehabilitation on the ground will be necessary for in-flight countermeasures against cardiovascular changes in space and for post-return rehabilitation.

Background: The application of radiofrequency ablation for pulmonary vein isolation (PVI) under general anesthesia (GA) has shown a lower recurrence rate of atrial fibrillation (AF) compared with deep sedation (DS). However, the effect of the different anesthesia methodology on catheter stability remains unclear.

Methods and Results: We enrolled 32 patients (16 in each group) who underwent PVI using radiofrequency ablation with the CARTO system. The contact force (CF) at each ablation point and catheter tip movement distance were analyzed using VISITAG^TM. A total of 1,863 points (GA: 964 points, DS: 899 points) were analyzed for the CF, and 1,969 points (GA: 1,000 points, DS: 969 points) were analyzed for the catheter tip movement distance. The GA group demonstrated a significantly higher mean CF (GA: 12.94±5.27 g vs. DS: 11.93±5.11 g; P<0.01), as well as a higher minimum CF (GA: 4.61±3.85 g vs. DS: 3.79±3.98 g, P<0.01), compared with the DS group. Additionally, catheter tip movement distance was significantly shorter in the GA group than in the DS group (GA: 1.65±0.76 mm vs. DS: 2.29±1.10 mm, P<0.01).

Conclusions: Catheter ablation under GA ensures better maintenance of adequate CF and catheter stability than DS.

Background: Catheter ablation (CA) for ventricular tachycardia (VT) is an effective treatment for preventing VT recurrence. However, the optimal timing and outcomes of CA for VT during emergent admission remains unclear.

Methods and Results: We retrospectively investigated patients who underwent CA for VT after emergent admission between 2012 and 2021 using the Japanese Registry of All Cardiac and Vascular Diseases database. The clinical characteristics, complication and outcomes (primary outcome: in-hospital death; secondary outcome: emergent re-admission for VT within 30 days) were compared between the patients who underwent CA within (CA ≤3) and after (CA >3) the third day of admission. A total of 3,827 patients (787 patients had CA ≤3 days, and 3,040 patients had CA >3 days) was enrolled. Compared with the CA >3 days group, those with CA ≤3 were younger and had less comorbidities of underlying heart diseases and medications. After adjusting for baseline characteristics, CA ≤3 days or >3 days after emergent admission was not associated with in-hospital death and re-admission for VT. Furthermore, the emergent re-admission and overall complication rates were not significantly different between the 2 groups.

Conclusions: The clinical background differed substantially between patients who underwent CA within 3 days and those who underwent CA later during emergency hospitalization. An emergency CA for VT is not strongly recommended; however, it might be acceptable in cases with unavoidable circumstances.

Background: Atrial biopsy is technically challenging owing to the atria’s thin walls and relatively thick endocardium. This study assessed the feasibility and safety of echocardiography-guided atrial biopsy in a consecutive cohort of 1,000 patients who underwent catheter ablation for atrial tachyarrhythmias or percutaneous left atrial (LA) appendage occlusion.

Methods and Results: Atrial biopsy was performed at the limbus of the fossa ovalis through the femoral vein using a 5.5-Fr (n=233) or a 7.0-Fr (n=767) bioptome under intracardiac (n=963) or transesophageal (n=37) echocardiography guidance, alongside fluoroscopy. For histological analysis, 5 tissue samples were collected from the same site. Biopsy was successfully completed in 996 (99.6%) patients. Patients were divided based on histological depth into Group A (biopsy beyond the endocardium; n=885) and Group B (endocardial-only biopsy; n=111). Multivariable logistic regression identified larger LA volume, use of a 5.5-Fr bioptome, and amyloid deposition as independent predictors of Group B (P=0.009, P<0.001, and P=0.001, respectively). Moreover, biopsy-related complications were unrecorded.

Conclusions: Echocardiography-guided atrial biopsy is a feasible and safe technique. However, atrial enlargement, smaller bioptome size, and amyloid deposition are associated with unsuccessful endocardial penetration and collection of myocardial tissue.

Background: Unlike the outpatient cardiac rehabilitation (CR) program for chronic heart failure (HF), the acute-phase inpatient CR program is not well established. We aimed to examine whether CR using lumbar-type hybrid assistive limb (HAL; lumbar HAL-CR) therapy improves physical functions in hospitalized aged HF patients.

Methods and Results: Decompensated and hospitalized HF patients were recruited from 2018 to 2019. As soon as possible after the decompensated HF phase, during the same hospitalization, participants underwent 40-min daily sessions of sit-to-stand and squat exercises with the lumbar-type HAL (lumbar HAL-CR program). The outcome measure was the score on the Short Physical Performance Battery (SPPB) before and after lumbar HAL-CR therapy. Twenty-eight HF patients (median age 84.5 years; 18 males) were enrolled. The median number of lumbar HAL-CR therapy sessions was 5.0. The SPPB score (7.0 [5.3–8.8] to 9.0 [7.0–11.0] points; P<0.001) and quadriceps isometric strength (0.25 [0.22–0.38] to 0.30 [0.26–0.37] kgf/kg; P=0.040) were significantly improved. Patients with lower nutrition status had more improvement in SPPB score.

Conclusions: For the inpatient CR program, lumbar-type HAL therapy improved physical functions in elderly HF patients. Lumbar-type HAL therapy may improve physical functions in aged HF patients within the current short-term period of hospitalization for acute-phase HF.

Background: Grip strength is a simple predictor of cardiovascular events and their prognosis. Early ambulation is related to an increase in functional independence, shortening of hospital stay, and a decrease in the need for readmission in patients with cardiovascular disease. However, little is known about the relationship between grip strength and early ambulation after cardiac surgery.

Methods and Results: In this observational study, 92 patients who underwent scheduled cardiac surgery with extracorporeal circulation without unexpected complications and in whom grip strength was measured before surgery were included. We divided them into 48 low and 44 preserved grip strength groups according to the criterion for frailty and sarcopenia. Age, the percentage of females, and the New York Heart Association classification in the low grip strength group were significantly higher than in the preserved grip strength group. All of the measures of functional status were significantly low in the low grip strength group. There were no significant differences in perioperative procedures between the groups. In-hospital outcomes were poorer, step-ups of rehabilitation were significantly later and the hospitalization stays were significantly longer in the low grip strength group. In the multiple regression analysis, grip strength was an independent predictor of early ambulation.

Conclusions: The results suggest that grip strength is an independent predictor of early ambulation in patients after cardiac surgery with extracorporeal circulation.

Background: Poor sleep quality is a critical concern for patients with cardiac implantable electronic devices (CIEDs). The aim of this study was to investigate the relationship between sleep quality and circadian rest-activity patterns in patients with CIEDs in Japan.

Methods and Results: Fifty-four patients with CIEDs were recruited. Sleep quality was assessed using the Japanese version of the Pittsburgh Sleep Quality Index, with scores ≤5 (n=19 participants) and ≥6 (n=35 participants) indicating good and poor sleep quality, respectively. Participants were instructed to wear ‘Life Microscope’ wristbands for 3 days at home to track their activity levels. Hourly mean values were calculated for the metabolic equivalents from the obtained activity levels, and subsequently evaluated using cosine periodic regression analysis. Parameters of circadian rest-activity patterns analyzed included mesor (mean activity), amplitude (range of activity), and acrophase time (time of peak activity). Sleep metrics, including total sleep time, sleep efficiency, and number of awakenings, were also evaluated. The Mann-Whitney U test showed that the poor sleep quality group exhibited significantly lower mesor, smaller amplitude, and later acrophase time. No other significant between-group differences were found. Furthermore, logistic regression analysis showed that acrophase time remained independently associated with self-reported sleep quality.

Conclusions: Focusing on improving daily activity levels and adjusting acrophase time may be essential to improve sleep quality in patients with CIEDs.

Background: Breast cancer is the most common cancer in women. Although anti-human epidermal growth factor receptor 2 (HER2) therapy is effective in patients with HER2-positive breast cancer, it occasionally induces cancer therapy-related cardiac dysfunction (CTRCD). This study aimed to determine the factors associated with CTRCD in patients with HER2-positive breast cancer treated with trastuzumab.

Methods and Results: We retrospectively analyzed the data of 286 patients with breast cancer who received trastuzumab. Accordingly, patients were categorized into CTRCD (+) and CTRCD (−) groups to elucidate the factors associated with cardiotoxicity. The median age of patients was 54 years. CTRCD was observed in 13 (4.5%) patients, and 2 (0.7%) patients had severe symptomatic heart failure, with a New York Heart Association class ≥III. All patients with CTRCD had a history of epirubicin use, and patients receiving both trastuzumab and pertuzumab had significantly higher rates of CTRCD (P=0.003); the history of pertuzumab administration was an independent predictor of CTRCD development. The median duration from trastuzumab initiation to CTRCD onset and from CTRCD onset to recovery was 244 (interquartile range [IQR] 164–333) and 122 ([IQR] 38–186) days, respectively.

Conclusions: In HER2-positive breast cancer, CTRCD occurred more frequently in patients using anthracycline followed by trastuzumab and pertuzumab simultaneously. Systolic dysfunction was reversible in all patients, and normalization of cardiac function took approximately 4 months from CTRCD onset.

Background: Hospitalization-associated disability (HAD) is associated with poor prognosis in patients with heart failure (HF); however, the impact of HAD in older HF patients who require long-term care remains unclear. Therefore, the aim of this study was to determine the prognostic impact of the care level and HAD onset in older HF patients.

Methods and Results: This study included 9,973 patients (mean age 82.6±7.7 years; 50.8% male) out of 10,062 older HF patients enrolled in a nationwide multicenter registry (Japanese Physical Therapy Multicenter Registry of Older Frail Patients With Heart Failure) for analysis. Patients were classified into 4 groups according to the level of care required under long-term care insurance (LTCI) during hospitalization. The level of care required was a risk factor for all-cause mortality and composite outcomes. In the HAD group, the adjusted hazard ratio for all-cause mortality increased with care level severity There was no interaction between the level of care required and HAD in relation to the outcomes.

Conclusions: In older HF patients, both the level of care required and HAD are poor prognostic factors. In the HAD group, the level of care required is an important indicator for planning interventions to prevent poor outcomes under the LTCI system.

Background: We previously reported that prasugrel treatment resulted in stable inhibition of platelet aggregation compared with clopidogrel in patients with acute large artery atherosclerosis (LAA) or high-risk transient ischemic attack (TIA). However, the differences by disease subtypes were not assessed. This subgroup analysis of the open-label ACUTE-PRAS study examined differences in P2Y₁₂reaction units between prasugrel and clopidogrel by disease subtypes (acute LAA and high-risk TIA).

Methods and Results: We measured platelet reaction units (PRU) by disease subtypes for each treatment arm. Eighty-eight patients were included in each treatment arm in the full analysis. In the prasugrel group, there were 61 (69.3%) patients with LAA and 27 (30.7%) patients with high-risk TIA. In the clopidogrel group, there were 64 (72.7%) patients with LAA and 24 (27.3%) patients with high-risk TIA. Among patients with LAA, PRU at Day 5 were numerically lower in the prasugrel group than in the clopidogrel group (arithmetic mean±standard deviation at Day 5: 128.8±49.0 vs. 178.9±60.5). In contrast, PRU at Day 5 were similar between prasugrel and clopidogrel in patients with high-risk TIA.

Conclusions: Prasugrel may have the potential to elicit stronger platelet aggregation inhibitory effects compared with clopidogrel in patients with acute LAA.

Background: Hypertension and coronary artery disease (CAD) are predominant factors of heart failure (HF). The American College of Cardiology/American Heart Association and the Japanese Circulation Society/Japanese Heart Failure Society stages of HF emphasize the development and progression of disease, and advanced stages and progression are associated with reduced survival. In patients with new-onset or worsening HF, albuminuria is consistently associated with clinical and circulating biomarkers of congestion. Esaxerenone is an oral, non-steroidal, selective mineralocorticoid receptor antagonist. It has not been elucidated whether esaxerenone reduces the urinary albumin-to-creatinine ratio (UACR) in hypertensive patients concomitant with HF and albuminuria.

Methods and Results: The ESPIAL trial (jRCTs 051210066) is a multicenter, randomized, open-label, active-controlled, parallel-group, exploratory, investigator-initiated clinical study to evaluate whether esaxerenone reduces UACR in hypertensive patients concomitant with HF and albuminuria. This study enrolled hypertensive patients concomitant with HF and albuminuria. The patients were randomized to an esaxerenone group or an amlodipine group in a 1 : 1 ratio. The primary outcome was the ratio of UACR before treatment and 24 weeks after treatment.

Conclusions: The ESPIAL trial evaluates the effect of esaxerenone on reduction of UACR in hypertensive patients concomitant with HF and albuminuria.