Cardiogenic shock (CS) caused by severe aortic stenosis (AS) is an archetype of supply-demand mismatch in which increased left ventricular afterload, impaired coronary perfusion, and concentric hypertrophy, combine to cause multiorgan hypoperfusion. Early relief of valvular obstruction through emergency transcatheter aortic valve replacement (TAVR) or, in selected cases, balloon aortic valvuloplasty (BAV) as bridge therapy, can be life-saving. Although emergency TAVR demonstrates acceptable procedural success rates and survival compared with BAV alone, short-term mortality remains high due to shock severity, comorbidities, use of mechanical circulatory support (MCS), and procedural and logistical challenges. This review outlines current hemodynamic phenotypes of CS, a streamlined door-to-valve pathway, appropriate use of MCS, a framework for selecting emergency TAVR or BAV bridging, procedural management tailored to shock physiology, and predictors of clinical outcomes, providing evidence-based guidance to optimize rescue therapy in AS patients with CS.

Background: Chronic kidney disease and cardiovascular disease (CKD-CVD) frequently coexist, creating challenges to prognosis, exercise capacity, and quality of life (QOL). CKD is common across cardiovascular conditions, underscoring the need for comprehensive management. Newer concepts of cardiovascular-kidney-metabolic syndrome (CKM) and chronic cardiovascular-kidney disorder (CCKD) emphasize shared risk factors and interconnected pathophysiological mechanisms. Within this paradigm, exercise therapy has emerged as a promising intervention to improve exercise capacity.

Methods and Results: This narrative review synthesizes conceptual advancements in the CKM-CCKD frameworks and summarizes recent literature on exercise therapy within these frameworks. The CKM-CCKD frameworks highlight the importance of addressing common risk factors and mechanisms underlying CKD-CVD. Exercise therapy comprising individualized aerobic programs is being increasingly recognized for its potential. However, its effectiveness can be limited by factors such as anemia, which correlates with impaired peak oxygen uptake and anaerobic thresholds in patients with renal dysfunction. Tailored regimens addressing reduced capacity, multimorbidity, and psychosocial factors, including patient-reported outcomes, further support inclusivity and effectiveness in clinical practice.

Conclusions: Within the CKM-CCKD frameworks, exercise therapy represents an important strategy to target shared risk factors and mechanisms in CKD-CVD. Future work should emphasize evidence-based interventions, early implementation, and individualized approaches to strengthen the translational value of these frameworks and improve QOL in this high-risk population.

Background: Atrial fibrillation (AF) is a major risk factor for ischemic stroke, with >90% of thrombi in nonvalvular AF originating in the left atrial appendage (LAA). Thoracoscopic LAA occlusion (LAAO), with or without ablation, is a minimally invasive alternative to endocardial devices or anticoagulation, but multicenter data are limited.

Methods and Results: The Totally Thoracoscopic Left Atrial Appendage Occlusion Study (TT-LAAOS) is a multicenter Japanese registry of thoracoscopic LAAO in nonvalvular AF. From March 2018 to December 2024, 567 patients underwent the procedure at 6 institutions using stapler excision or epicardial clip. Outcomes included procedural success, anatomic closure, cerebrovascular events, and anticoagulant withdrawal. Mean age was 72 years; 63.5% had long-standing persistent AF. Median CHADS₂and CHA₂DS₂ VASc scores were 2 and 4, respectively. Success was 99.8% with no intraoperative deaths; residual stumps >10 mm were found in 1.5%. At discharge, sinus rhythm was present in 45%. Anticoagulants were stopped in 15% immediately and 63% within 1 month. During 875.8 patient years of follow-up (median 13 months), freedom from stroke or transient ischemic attack was 99.5% (0.34/100 patient years), with no thromboembolic deaths.

Conclusions: Thoracoscopic LAAO, with or without ablation, is safe and effective for stroke prevention in AF, with high success, reliable closure, and very low midterm events.

Background: There are limited numbers of studies of the relationship between maximum tongue pressure (MTP) and respiratory muscle strength in older patients with acute heart failure (AHF).

Methods and Results: Patients aged ≥65 years hospitalized with AHF were analyzed. MTP, maximal inspiratory mouth pressure (PI_max), and maximal expiratory mouth pressure (PE_max), which serve as indicators of swallowing, inspiratory, and expiratory muscle strength, respectively, were measured. The prevalence of sarcopenic dysphagia and respiratory sarcopenia was also assessed. The effect of respiratory muscle strength on MTP was evaluated using linear regression models, with MTP at the commencement of rehabilitation (baseline) or hospital discharge as the dependent variable and respiratory muscle strength measured at the baseline as the independent variable across four models. A total of 168 patients (median age: 85 years) were included in the final analysis. Sarcopenic dysphagia was observed in 16.7% of patients at baseline and 11.3% at hospital discharge (P=0.067). The prevalence of respiratory sarcopenia significantly increased from 59.7% at baseline to 70.7% at hospital discharge (P=0.018). MTP at hospital discharge was significantly associated with PI_maxat baseline (β=0.335); MTP at baseline was significantly associated with PI_maxat baseline (β=0.309).

Conclusions: PI_maxwas independently associated with MTP in older patients with AHF and may indicate a need for more intensive physical therapy interventions.

Background: This study aimed to examine the impact of post-discharge exercise habits on functional decline in older patients with heart failure (HF).

Methods and Results: Sixty-three older patients hospitalized due to HF (mean age 79.7±7.1 years; 46.0% male) were enrolled. Patients were categorized as exercisers if they reported engaging in moderate-intensity exercise for at least 30 min, ≥4 times per week, at 6 months post-discharge. Physical function was measured using the Short Physical Performance Battery (SPPB) at discharge and 6 months thereafter. Functional decline, the primary outcome, was defined as a decrease of ≥1 point in SPPB score over 6 months. The underlying etiologies of HF were arrhythmia (n=37; 58.7%), valvular heart disease (n=37; 58.7%), and ischemic heart disease (n=27; 42.9%). Patients were grouped into exercisers (n=36; 57.1%) and non-exercisers (n=27; 42.9%). Non-exercisers showed a significantly higher incidence of functional decline compared with exercisers (29.6% [n=8] vs. 2.8% [n=1]; P=0.003). Firth’s penalized likelihood logistic regression revealed that non-exercising status independently predicted functional decline (odds ratio 5.98; 95% confidence interval 1.41–35.44; P=0.014) after adjusting for relevant confounders.

Conclusions: Absence of post-discharge exercise habits significantly increased the risk of functional decline in older HF patients.

Background: In order to collect information on the onset of cardiovascular disease (CVD) events for participants, the Tohoku Medical Megabank Organization (ToMMo) constructed a system to identify CVD events using a self-administered questionnaire regarding CVD onset. The association between traditional cardiovascular risk factors and CVD onset was also examined.

Methods and Results: This study included participants from the ToMMo’s Community-based Cohort Study and the Birth and Three-Generation Cohort Study. To identify CVD onset, the participants were first asked about stroke, myocardial infarction, and angina pectoris using self-administered questionnaires. Next, for those reporting onset, the ToMMo mailed structured CVD registration forms to their medical institutions. These institutions used medical records to complete and return the forms. CVD onset was then determined at event adjudication meetings involving multiple physicians and epidemiologists, based on the information from these registration forms. A nested case–control study with 602 CVD cases and 1,204 matched controls using data from a Community-based Cohort Study of the ToMMo was conducted. Using conditional logistic regression models, we found significant association between traditional CVD risk factors, such as hypertension and dyslipidemia, and CVD onset.

Conclusions: The ToMMo establishes a system for identifying CVD onset in cohort study participants. In the future, combining participants’ lifestyles and genomic information with CVD onset may help build evidence for personalized prevention and medicine.

Background: Caregivers of patients with heart failure (HF) provide self-care support. Caregiver Contribution to Self-Care of Heart Failure Index (CC-SCHFI) version 2 assesses the caregiver’s contribution (CC) to self-care maintenance, symptom perception, and self-care management of patients with HF. We translated CC-SCHFI version 2 into Japanese and evaluated its psychometric properties.

Methods and Results: This cross-sectional study enrolled Japanese caregivers of patients with HF. To determine structural validity, confirmatory factor analyses were conducted using the structure of the original version. Convergent validity assessed the association between each scale and self-efficacy. For internal consistency, model-based internal consistency coefficients were calculated. The participants were 103 caregivers. Regarding structural validity, the original 2-factor structure was appropriate for the CC to self-care maintenance scale. In contrast, due to model instability or low discriminant validity, 1-factor models with modifications were adopted for the CC to symptom perception and self-care management scales, showing an acceptable fit. Regarding convergent validity, all scales showed significant associations with self-efficacy. Model-based internal consistency coefficients were sufficient for all scales (0.803, 0.888, and 0.861 for the CC to self-care maintenance, symptom perception, and self-care management scales, respectively).

Conclusions: The Japanese CC-SCHFI version 2 is a reliable and valid scale for assessing the CC to self-care in Japanese patients with HF.

Background: Although transcatheter aortic valve replacement (TAVR) improves heart failure (HF) conditions for patients with severe aortic stenosis, more than 10% of patients have HF rehospitalization within 1 year. In contrast, the continuation of loop diuretics (LD) may lead to adverse outcomes in patients with HF. This study investigated the impact of LD reduction on HF rehospitalization in post-TAVR patients using a nationwide database.

Methods and Results: This retrospective observational study used the National Database of Japan from 2014 to 2021. Patients undergoing first-time TAVR without worsening HF within 90 days post-procedure were included and categorized according to changes in LD dose at 90 days: No LD group; Reduced LD group; and Non-Reduced LD group. The primary outcome was HF rehospitalization within 2 years. Inverse probability of treatment weighting was performed to evaluate the association between LD dose changes and outcomes. Among 29,358 eligible patients, 19,070 were not prescribed LD, 5,596 were in the Reduced LD group, and 4,692 were in the Non-reduced LD group. Compared with the Non-reduced LD group, the Reduced LD group had a significantly lower risk of HF rehospitalization (HR 0.46; 95% confidence interval 0.41–0.51; P<0.001).

Conclusions: LD reduction was associated with reduced HF rehospitalization in stable HF patients after TAVR.

Background: Acute decompensated heart failure (ADHF) causes multi-organ damage associated with congestion, hypoperfusion, or both. However, its impact on pancreatic exocrine function (PEF), which can be associated with impaired digestion and absorption and contribute to malnutrition, remains unclear. Thus, in this proof-of-concept study, we investigated whether hospitalized patients with ADHF have impaired PEF.

Methods and Results: Patients admitted to the cardiac intensive care unit were enrolled. Following initial stabilization, the N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) test, which is the only clinically available PEF test in Japan, was performed. Data from 51 patients (age 73.3±9.8 years; 80.4% men; body mass index 23.9±5.0 kg/m²) were assessed. Patients hospitalized for ADHF (n=33) exhibited significantly lower levels of urinary PABA excretion rate (i.e., pancreatic function diagnostic [PFD] value) than in those hospitalized for other cardiovascular conditions (52.4±20.1% vs. 66.4±17.3%; P=0.022). Simple regression analyses revealed that decreased PFD values were associated with advanced age, increased hemoglobin A1c level, impaired kidney function, low urinary volume in the BT-PABA test, and ADHF-related hospitalization. Multiple regression analysis revealed that only reduced estimated glomerular filtration rate (coefficient 0.319; P=0.031) and ADHF-related hospitalization (coefficient −0.326; P=0.027) were associated with poor PFD values.

Conclusions: PEF was impaired in hospitalized patients with ADHF. Our findings could inform further hypotheses regarding how improved PEF in hospitalized patients with ADHF affects their nutritional status.

Background: Although angiopoietin-like protein 3 (ANGPTL3) has emerged as a novel therapeutic target for lipid modulation, its prognostic significance in chronic coronary syndrome (CCS) remains unclear. This study aimed to evaluate the clinical determinants and prognostic value of circulating ANGPTL3 levels in patients with CCS.

Methods and Results: We prospectively enrolled 264 consecutive patients with CCS (median age 74 years; 73% male) undergoing cardiac catheterization. Serum ANGPTL3 levels were measured using an enzyme-linked immunosorbent assay. The primary endpoint was major adverse cardiovascular events (MACE). Female sex, elevated C-reactive protein and B-type natriuretic peptide, low high-density lipoprotein cholesterol levels, and absence of statin use were independently associated with higher ANGPTL3 levels. During follow up, 35 patients experienced MACE. In multivariable Cox regression models, ANGPTL3 remained an independent predictor of MACE. Receiver operating characteristic analysis identified 90.7 ng/mL as the optimal cut-off value for event discrimination. Kaplan-Meier curves demonstrated significantly higher event rates among patients with ANGPTL3 >90.7 ng/mL. In patients with CCS with low-density lipoprotein cholesterol (LDL-C) <70 mg/dL, elevated ANGPTL3 levels were also associated with increased MACE risk.

Conclusions: Circulating ANGPTL3 levels independently predict adverse cardiovascular outcomes in CCS, including those in patients who achieve LDL-C targets, and may help identify residual cardiovascular risk not captured by traditional lipid parameters.

Background: Microvascular spasm (MVS), a phenotype of microvascular dysfunction in patients with angina with non-obstructive coronary arteries (ANOCA), involves transient microvascular constriction. The angiography-derived index of microcirculatory resistance (A-IMR) is a less invasive method for assessing microcirculatory resistance. We aimed to evaluate MVS characteristics using A-IMR.

Methods and Results: We retrospectively studied ANOCA patients who underwent acetylcholine spasm provocation tests (SPT). Patients were classified into no-spasm, epicardial spasm (ECS), or MVS groups. A-IMR was measured before and after SPT. Of 109 patients, 21 (19.3%) had MVS. The MVS group had more women (76.2% vs. 42.0%; P=0.01) than the other 2 groups combined. While pre-SPT A-IMR values were similar, post-SPT A-IMR after nitroglycerin was significantly higher in the MVS group than the no-spasm group, especially in the left anterior descending (LAD) artery (44.60 vs. 33.54; P=0.007). ∆A-IMR (post- minus pre-SPT) was significantly greater in the MVS group for both the LAD (9.89 vs. −9.26; P=0.001) and right coronary artery (RCA; 3.22 vs. −6.83; P=0.001). Multivariable analysis showed ∆A-IMR in the LAD and RCA were independently associated with MVS.

Conclusions: Serial A-IMR assessment during SPT reveals sustained nitrate-resistant microvascular constriction in patients with MVS, which may confound standard post-SPT physiological assessments such as coronary flow reserve or IMR. These findings underscore the need for careful interpretation of physiological data in the presence of MVS.

Background: Primary cardiac tumors are rare, and the prognostic impact of their histological subtypes remains poorly understood. We assessed the clinical outcomes of benign and malignant tumors using long-term follow-up data from pathologically confirmed cases.

Methods and Results: We retrospectively analyzed 42 consecutive patients diagnosed with primary cardiac tumors between 2007 and 2022 at a single center. Among them, 41 patients who underwent surgical resection were followed longitudinally and included in the present study. Clinical features, tumor distribution, and outcomes were assessed by histological type, with particular focus on long-term prognosis. Histological diagnoses were confirmed in each case. Myxomas accounted for 73% (n=30), diffuse large B-cell lymphomas (DLBCLs) for 7% (n=3), and other benign tumors for 20% (n=8) of cases. Myxomas were predominantly located in the left atrium and showed excellent long-term outcomes, with no recurrence or tumor-related deaths over a median follow-up of 12.8 years. In contrast, all patients with DLBCL had right-sided tumors and died within 2 years due to disease progression despite surgery and chemotherapy. Kaplan-Meier analysis showed significant differences (P<0.001) in survival among tumor types, with DLBCL showing uniformly poor outcomes.

Conclusions: Benign cardiac tumors had favorable outcomes, with myxomas showing a particularly excellent prognosis. In contrast, malignant tumors were uniformly associated with early death. Histological subtype may be associated with survival.

Background: Because snowfall may affect the acute outcomes of severe cardiovascular diseases by prolonging emergency medical service (EMS) response times, we investigated the association between snowfall and EMS response times for out-of-hospital cardiac arrests (OHCAs) in the regions of Japan.

Methods and Results: We used the Utstein database, a nationwide population-based registry that collects data on all OHCA patients in Japan, during winter from 2009 to 2019. A prefecture-specific logistic regression model was applied to estimate odds ratios (ORs) of prolongation of EMS response time (≥7 min), which was associated with poorer neurological outcomes, on days with moderate/heavy snowfall compared to no-snowfall days. A random-effects meta-analysis model was applied to obtain pooled ORs in both overall and subgroup analyses (“heavy snowfall prefectures” and “non-heavy snowfall prefectures”). Among 94,428 bystander-witnessed cardiogenic OHCA patients, the ORs of prolonged EMS response time were 1.05 (95% confidence interval (CI): 0.96, 1.14) on moderate snowfall days and 1.22 (95% CI: 1.07, 1.40) on heavy snowfall days, compared to no-snowfall days. Subgroup analysis revealed no statistical difference between heavy snowfall prefectures and non-heavy snowfall prefectures, although ORs were higher for heavy snowfall prefectures.

Conclusions: Snowfall prolongs EMS response time to cardiogenic OHCA in both areas with heavy snowfall and those with less snowfall, which may also impact survival and neurological outcomes.

Background: Patients with myeloproliferative neoplasms (MPN) are known to complicate pulmonary hypertension (PH). Half of patients with MPN-associated PH have chronic thromboembolic PH (CTEPH); however, the prevalence, clinical characteristics, and treatment response remain unclear.

Methods and Results: Nagoya PH registry database was retrospectively analyzed. Of 129 CTEPH patients, 82 were included. Clinical characteristics and treatment response were compared between CTEPH patients with MPN (MPN group) and those without MPN (non-MPN group). As the treatment course at Nagoya University Hospital, medical treatment was initiated before performing balloon pulmonary angioplasty (BPA)/pulmonary endarterectomy (PEA). Right heart catheterization was performed at pre-medication, post-medication, and post-BPA/PEA. Seven patients had concomitant MPN as the underlying cause for CTEPH, accounting for 5.4% (7/129) of CTEPH cases. Baseline clinical characteristics were comparable between the MPN and non-MPN groups. No significant difference was observed in ∆pulmonary vascular resistance (PVR) from baseline to post-medical treatment (−3.59 WU in the MPN group vs. −3.80 WU in the non-MPN group; P=0.67) and baseline to post-BPA/PEA (−6.92 WU in the MPN group vs. −7.60 WU in the non-MPN group; P=0.35).

Conclusions: As hemodynamic responses to treatment in CTEPH patients with MPN were comparable with those without MPN, their prognosis may improve with multimodal CTEPH treatment similar to non-MPN cases.

Background: Evaluation of the utility of regional longitudinal strain (LS) to identify transthyretin amyloid cardiomyopathy (ATTR-CM).

Methods and Results: From 2016 to 2019 we enrolled 66 patients aged ≥70 years who underwent ^{99 m}Tc-labeled pyrophosphate scintigraphy and had enough information for 2-dimensional speckle-tracking echocardiography. Patients were divided into ATTR-CM group (n=37) and non-amyloid cardiomyopathy group (n=29). Basal inferior LS was significantly lower in the ATTR-CM group than in the non-amyloid cardiomyopathy group (4.6±3.9 vs. 10.7±5.4, P<0.01). ROC analysis showed that the basal inferior LS value was useful for identifying ATTR-CM (area under curve: 0.86).

Conclusions: Basal inferior LS value is the most useful for identifying ATTR-CM.

Background: Slow flow caused by distal embolization during percutaneous coronary intervention (PCI) worsens outcomes. Near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS) can quantify the preoperative lipid burden. We investigated the utility of combining measurement of plaque size and lipid burden.

Methods and Results: We analyzed 91 stable-angina patients undergoing NIRS-IVUS-guided PCI. Slow flow (≥1-grade TIMI decrease) occurred in 17 (18.7%). Those lesions had larger plaque area (13.8 vs. 9.9 mm², P<0.001) and higher maxLCBI_{4 mm}(625 vs. 436, P<0.001). Cutoffs were 12.0 mm²and 523, respectively. Either criterion identified all slow-flow cases (sensitivity 100%).

Conclusions: Combined assessment of plaque area and maxLCBI_{4 mm}enables simple and highly sensitive identification of lesions at risk of slow flow during PCI.

Background: Clinical trial results suggest inclisiran lowers low-density lipoprotein-cholesterol (LDL-C), but long-term real-world data in Japanese coronary artery disease (CAD) patients are limited.

Methods and Results: We retrospectively studied 40 CAD patients treated with inclisiran and followed for 12 months, assessing LDL-C levels at baseline and every 3 months; endpoints were within-patient LDL-C change, MACE (exploratory), and safety. Mean LDL-C fell by 59%, 56%, and 57% at 3, 6, and 12 months, respectively (all P<0.05). Adverse reactions comprised 1 case of MACE and 1 of injection-site reaction over the 12 months.

Conclusions: In this single-center cohort, inclisiran was associated with sustained LDL-C reductions and acceptable tolerability over 1 year.

Background: This nationwide survey investigated new heart failure drug prescriptions by Japanese pediatric cardiologists.

Methods and Results: Among 97 responding institutions, 357 patients received sodium-glucose cotransporter-2 inhibitors (SGLT-2i; n=189), angiotensin receptor-neprilysin inhibitors (ARNI; n=89), selective hyperpolarization-activated cyclic nucleotide-gated channel (HCN) blockers (n=76), or soluble guanylate cyclase (sGC) stimulators (n=3). SGLT-2i were predominantly prescribed in post-Fontan patients (45%), with one-third being children under 18 years. ARNI were commonly used for biventricular congenital heart disease (CHD) and cardiomyopathy (47% and 29%), with 40% under 18 years.

Conclusions: Pediatric-specific clinical trials and appropriate usage guidelines are urgently needed.

Background: The effectiveness of multiple arterial grafting (MAG) for hemodialysis (HD) patients is unclear.

Methods and Results: We retrospectively analyzed 149 HD patients who underwent either MAG (n=97) or single arterial grafting (SAG) (n=52). After adjusting for preoperative characteristics using inverse probability of treatment weighting, the adjusted estimated 5-year rates of freedom from all-cause death and cardiac death in the MAG vs. SAG groups were 54.8% vs. 60.4% (P=0.779) and 83.5% vs. 87.4% (P=0.869), respectively.

Conclusions: MAG did not improve the midterm outcomes for HD patients compared to SAG.

Background: The rising global older population increases the incidence of atrial fibrillation (AF), a major cause of stroke and heart failure, necessitating access to effective treatment. Catheter ablation (CA) has evolved into a primary treatment option, driven by significant advancements in device innovation, but is not available in all facilities.

Methods and Results: According to public data from Japan (the Vital Statistics survey of Japanese events in 2022, the Japanese government Survey of Household Economy, the Survey on the Impact of the Diagnosis Procedure Combination System, and publicly available data from the Japan Heart Rhythm Society), a severe regional disparity exists in access to CA due to the uneven distribution of arrhythmia specialists. Ablation procedures per 10,000 population across the 47 prefectures averaged 6.67 (95% CI: 6.19–7.12), with a range of 3.02–9.24. This access gap is the “paradox of technological innovation”, associated with inequitable treatment outcomes, higher AF-related hospitalization, and poorer quality of life in underserved prefectures. Structural threats, including a shrinking cardiologist workforce and new work constraints (Restrictions under the Work Style Reform-related Laws by the Japanese Government), risk worsening this disparity. Addressing this requires a paradigm shift toward equitable dissemination of CA.

Conclusions: The future of arrhythmia care rests not only on pursuing cutting-edge technology but also on formulating evidence-based, policy-oriented action plans to fulfill the professional and societal responsibility of eliminating treatment inequity.

Background: The Japanese Resuscitation Council’s 2020 Guidelines recommend transmitting a prehospital 12-lead electrocardiogram (PH-ECG) for adult patients suspected of having ST-elevation myocardial infarction (STEMI). Nationwide, the primary methods of ECG transmission are either prefecture-specific emergency transport systems or cloud-based services. However, prefectural systems often lack convenience, while cloud-based services are associated with substantial implementation costs.

Methods and Results: A smartphone application (JOIN^®), which enables ambulance information-sharing with receiving hospital physicians, has been widely adopted across Japan. Leveraging its photo function to transmit ECGs, we initiated prehospital ECG transmission from ambulances without incurring additional costs. Over the past year, the system has been utilized in approximately 20 cases at our hospital. Analysis of transport times by shift period (weekday daytime vs. non-shift hours [weekday nighttime and weekends/holidays]) revealed no significant difference during daytime shifts. However, during non-shift hours, the ECG transmission group demonstrated a tendency for shorter door-to-catheterization laboratory time (25±5.0 vs. 51±18 min).

Conclusions: Obtaining a 12-lead ECG prior to hospital arrival reduces waiting times for catheter-based treatment. When ambulances and receiving hospitals are connected via a smartphone application, the photo function can facilitate prehospital ECG transmission without additional implementation costs. This approach may represent a novel strategy to improve outcomes for STEMI patients.

Background: Acute coronary syndrome (ACS) is the critical situation caused by decreased blood flow of the coronary arteries. The most recent clinical guideline compiled by the Japanese Circulation Society (JCS) recommends lowering low-density lipoprotein cholesterol (LDL-C) to <70 mg/dL in patients with ACS, because of the lack of clinical evidence. It has been shown that there are substantial numbers of patients with familial hypercholesterolemia (FH) among ACS patients. On this basis, we intend assembling a multicenter registry to establish the evidence for lowering LDL-C <55 mg/dL while also clarifying the proportion of FH patients among Japanese ACS patients using a prespecified clinical pathway.

Methods and Results: The Hokuriku-plus ACS registry is a prospective, observational, multicenter cohort study, enrolling consecutive ACS patients from 14 participating hospitals in Hokuriku region of Japan from October 2025 to September 2027. A total of 1,000 patients will be enrolled followed over 1 year. The primary endpoint is the proportion of patients who attain LDL-C <55 mg/dL at 4 weeks. This study has been registered at the Japan Registry of Clinical Trials (jRCT1040250123).

Conclusions: We will disseminate the final results at international conferences and in a peer-reviewed journal.