Shock index (SI) and modified shock index (mSI), measured at hospital admission, have been shown to be predictive for mid- and long-term outcomes after acute myocardial infarction (AMI). Whether these associations also hold when indices are measured at discharge is unclear, so this study's aim was to analyze the association between SI and mSI at discharge and long-term mortality after AMI. This analysis included 11,676 AMI cases registered by the population-based Myocardial Infarction Registry Augsburg. The follow-up time was restricted to a maximum of 5years. Patients were categorized into low and high SI or mSI groups through separation at 75th percentiles for STEMI and NSTEMI, respectively. Analysis of survival included Kaplan-Meier curves with log-rank tests and multivariable-adjusted Cox-regression models. Cut-off values were 0.6667 (STEMI) and 0.6545 (NSTEMI) for SI and 0.9231 (STEMI) and 0.9120 (NSTEMI) for mSI. Kaplan-Meier analysis showed significantly higher mortality for high SI and mSI groups in STEMI and NSTEMI patients. In STEMI cases, multivariable-adjusted Cox-regression analyses revealed significantly higher mortality for the high SI group (hazard ratio (HR): 1.25 (1.02-1.53), p value: 0.030), while mSI was non-significantly associated with long-term mortality (HR: 1.21 (0.99-1.48), p value: 0.060). Neither SI nor mSI was independently associated with mortality in NSTEMI. SI and mSI at discharge represent valuable tools for long-term post-infarction risk stratification especially in STEMI cases and can support decision-making regarding individualized ambulatory care.

Mavacamten is the first approved myosin inhibitor for symptomatic obstructive hypertrophic cardiomyopathy (oHCM), addressing hypercontractility and left ventricular outflow tract (LVOT) obstruction. This study evaluates left ventricular performance by non-invasive measurements of pressure-strain loops in patients treated with Mavacamten. In 36 symptomatic oHCM patients, pressure-strain analysis was performed prior to 3 and 12months after Mavacamten therapy. Echocardiographic measurements included LVOT gradient, left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), left atrial strain (LAS), peak strain time dispersion (PSD), and myocardial work parameters (global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE)). Clinical status was evaluated using the New York Heart Association (NYHA) class and stress biomarkers (NTproBNP and high-sensitivity troponin I). Mavacamten therapy significantly reduced LVOT gradients at rest and under provocation. Gradients decreased from 69 ± 36 to 24 ± 27mmHg (p < 0.001) at 3months and further to 11 ± 6mmHg (p = 0.003) at 12months. Provoked gradients decreased from 113 ± 33 to 50 ± 31mmHg (p < 0.001) at 3months and to 31 ± 19mmHg (p = 0.01) at 12months. Clinical symptoms also improved. LVEF was 68 ± 6% at baseline and decreased mildly to 62 ± 5% (p = 0.003), while GLS and LAS remained unchanged. PSD decreased mildly from 116 ± 56 to 97 ± 36ms and further to 93 ± 38ms, but this was not statistically significant (p = 0.07). Under Mavacamten, GWE remained stable. In contrast, GWI, GCW, and GWW decreased significantly from baseline to 3months (GWI, 2098 ± 700 to 1610 ± 440mmHg%, p < 0.001; GCW, 2514 ± 776 to 1951 ± 466mmHg%, p < 0.001; GWW, 312 ± 163 to 249 ± 177mmHg%, p = 0.003), with only mild, non-significant further reductions at 12months (1538 ± 402, 1901 ± 380, and 207 ± 124mmHg%, respectively; p = 0.67, p = 0.74, p = 0.30). Myocardial work indices derived from non-invasive pressure-strain analysis were feasible to obtain in patients with oHCM in this study. Mavacamten therapy decreases workload index, constructive and wasted work, and synchronizes myocardial contractility, reflecting normalization of myocardial energetics. These findings reinforce the role of Mavacamten as a targeted therapy in oHCM.

Patients with out-of-hospital cardiac arrest and in-hospital cardiac arrest have a poor prognosis. Laboratory biomarkers that are frequently altered in critically ill patients with cardiac arrest are liver function tests. However, the predictive value of abnormal liver function tests in the cardiac arrest setting remains unclear. Four hundred seven patients who were treated after cardiac arrest in an intensive care unit at a tertiary-care hospital were included in the analysis. To classify LFT abnormalities, we used established upper limit of normal values and multiples thereof according to the NIH Common Terminology Criteria for Adverse Events (CTCAE). Kaplan-Meier estimates and cox proportional hazard models combined with the CardShock risk score were performed to investigate the association between liver function abnormalities and patient outcomes. Thirty-nine different combinations of elevated liver function tests have been observed in the study cohort. The most common abnormalities included an increase in aspartate aminotransferase (AST) levels, followed by an increase in alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) levels. Kaplan-Meier estimates showed significant differences in 90-day survival rates depending on severity of AST, ALT, bilirubin, and INR elevations. A cox proportional hazard model analysis demonstrated that a combined increase in bilirubin and INR together with the CardShock risk score allowed the highest mortality prediction. Abnormal liver function tests can be frequently observed after cardiac arrest, with different patterns of damage having different prognostic relevance. The combination of elevated bilirubin and INR offers important prognostic information regarding 90-day mortality, particularly when added to validated risk tools, and can be used to identify patients at risk.

Heart failure (HF) remains a leading cause of hospitalization and death in Germany, significantly impairing patients' quality of life (QoL) despite advances in therapy. Structured, multidisciplinary care programs may improve long-term outcomes. HI-PLUS is a pragmatic trial investigating whether a complex intervention can improve QoL in HF patients. We describe the trial design and pilot feasibility study findings. HI-PLUS is a cluster-randomized, parallel-arm controlled trial (DRKS00031997) targeting 56 clusters, each comprising a cardiology practice and up to five general practitioners (GPs), targeting 1350 patients. The control arm receives guideline-recommended care. The intervention adds five elements: (a) care supported by specially trained non-physician staff HF qualified (HF-MPA); (b) accredited HF-MPA training curriculum certified by the German Society of Cardiology; (c) eHealth platform for telemonitoring and symptom reporting; (d) portable telemedical devices, if needed; and (e) enhanced communication between cardiologists and GPs facilitated by HF-MPAs and the eHealth platform. The primary endpoint is change in HF-specific QoL after 12months, measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS). A pilot feasibility study that was conducted prior to commencement of patient recruitment confirmed the feasibility and acceptability of the proposed trial procedures. The HI-PLUS trial addresses recognized gaps in HF care. If effective, it could serve as a scalable model for integrated HF care throughout Germany.

Right ventricular pacing leads to left ventricular (LV) dyssynchrony, which is a critical factor in the pathophysiology of pacing-induced LV dysfunction (PIVD) and cardiomyopathy (PICM). This study aimed to determine the incidence of PIVD and PICM and evaluate the prognostic value of the real-time three-dimensional echocardiography (RT3DE)-derived systolic dyssynchrony index (SDI), measured shortly after pacemaker implantation, in predicting their development. In this prospective observational study, 108 patients undergoing permanent RV pacing. Only 60 patients with preserved baseline LV ejection fraction (LVEF ≥ 50%) were enrolled. Comprehensive echocardiography, including global longitudinal strain (GLS) and RT3DE for SDI (Tmsv 16-SD) calculation, was performed at baseline, 7-10 days, and 6 months post-implantation. Patients were classified at 6 months as preserved (LVEF reduction ≤ 10%, final LVEF ≥ 50%), PIVD (LVEF reduction > 10%, final LVEF ≥ 50%), or PICM (LVEF reduction > 10%, final LVEF < 50%). The patients' mean age was 62.4 ± 16.3 years, 32 patients were males (53.3%). Mean follow-up was 6.53 ± 0.75 months. Twenty-five patients (41.7%) developed LV impairment; of them, 16 (85%) patients had PIVD, and nine (15%) patients had PICM. While baseline characteristics were similar, the dysfunction group exhibited significantly higher SDI and worse GLS as early as 7-10 days post-pacing. At 6 months, there were significant differences between the preserved group (35 patients) and impaired LV group regarding LV EF (63.6 ± 5 vs. 49.8 ± 11.6, p < 0.001), GLS (- 15.6 ± 3 vs. - 10.9 ± 3.8, p < 0.001), SDI% (2.4 ± 1.2 vs. - 7.9 ± 5.9, p < 0.001), and excursion (5.8 ± 2.23 vs. 3.2 ± 2.1, p < 0.001). In multivariate analysis, both SDI (odds ratio [OR], 5.38; 95% CI, 1.56-18.52; p = 0.008) and GLS (OR, 1.39; 95% CI, 1.02-1.90; p = 0.040) at 7-10 days were independent predictors of 6-month dysfunction. Receiver operating characteristic analysis showed that an SDI > 1.49% predicted dysfunction with an area under the curve of 0.843 (84% sensitivity, 71% specificity). A clear gradient of worsening SDI and GLS was observed from Preserved to PIVD to PICM. Mechanical dyssynchrony quantified by RT3DE-derived SDI is a powerful, independent predictor of pacing-induced LV dysfunction, identifiable within the first week after implantation. This early measurement offers a critical opportunity for risk stratification and guided intervention to prevent the progression to overt cardiomyopathy.

We assessed whether oral acetazolamide (ACZ) increases diuresis and reduces chloride loss when given alongside high-dose intravenous (IV) furosemide in patients admitted to hospital with HF. ADA-HF was a single-centre, open-label, randomised controlled trial. Patients were randomised to ACZ 250mg twice daily plus high-dose (240mg per day) IV furosemide infusion (standard of care (SoC)) versus SoC alone for 4days. The co-primary endpoints were (1) daily net fluid loss between baseline and day 4 and (2) change in serum chloride level from baseline to day 4. A total of 46 patients (median age, 76; 65% male; median N-terminal pro-B-type natriuretic peptide, 4097ng/L) from a screened population of 207 were randomised (23 to ACZ, 23 to SoC). The median daily net fluid loss was 1073mL (1st-3rd quartile range 682-1419mL) in the ACZ arm vs. 1029mL (201-1432mL) in the SoC arm (P = 0.51). There was no change in serum chloride concentration in the ACZ arm, whereas chloride fell by 7 (2-10) mmol/L in the SoC arm (P < 0.001). The number of adverse and serious adverse events ((S)AE) was numerically greater in the ACZ arm (51 events in 16 patients vs. 29 events in 10 patients, P = 0.24). Overall, 8 patients (30%) experienced (S)AEs possibly related to ACZ, and two of whom withdrew from the trial. Acetazolamide has a significant "chloride-sparing" effect in patients given high-dose IV furosemide. However, ACZ did not significantly increase diuresis, and side effects from oral ACZ were frequent. ISRCTN13060336; 9/2/2023.

Left atrial appendage (LAA) thrombus formation is associated with elevated stroke risk and mortality. This study was designed to compare different therapeutic strategies in patients presenting with LAA thrombi despite adequate oral anticoagulation (OAC) therapy. In this retrospective single-center study, patients with atrial fibrillation (AF) and LAA thrombus despite adequate OAC for more than three weeks were identified. A follow-up transesophageal echo (TEE) was performed at least four weeks after the initial TEE. Thrombus resolution was assessed for each treatment cycle, defined as the interval of OAC therapy between two consecutive TEE examinations. The study included 216 patients who underwent a total of 294 treatment cycles. At baseline, 47% (n = 101) of patients were receiving novel oral anticoagulants (NOACs), while 53% (n = 115) were treated with vitamin-K antagonists (VKAs). Treatment options included switching OAC from VKA to NOAC (n = 18), from NOAC to a different NOAC (n = 14) and from NOAC to VKA (n = 77); or maintaining the same NOAC (n = 28) or VKA (n = 157). Overall, LAA thrombi resolved in 70% (152/216) after a mean follow up time of 130 (SD 195) days). No significant differences regarding resolution rate between the five different anticoagulation strategies were observed (p = 0.866). Multivariate regression analysis identified tricuspid annular plane systolic excursion as independently predictive of LAA thrombus persistence (OR 0.87; 95% CI 0.78-0.98; p = 0.026). This is the largest cohort of patients presenting with LAA thrombi despite adequate OAC. Overall resolution was 70%. Modification of the anticoagulation regimen did not result in higher thrombus resolution rates compared with continuation of the same therapy.

Implantable cardioverter-defibrillator (ICD) is a cornerstone therapy for the prevention of sudden cardiac death. However, clinical profiles and in-hospital outcomes may differ according to device type-single-chamber ICD, dual-chamber ICD, or cardiac resynchronization therapy defibrillator (CRT-D). This study aimed to compare hospitalization parameters and peri-procedural complications among patients receiving these device types. We retrospectively analyzed 2,001 consecutive ICD recipients (single-chamber: 815; dual-chamber: 463; CRT-D: 723). Baseline characteristics, intensive care unit (ICU) utilization, procedure-related complications, and discharge outcomes were compared across groups. The main endpoint was defined as major adverse cardiovascular and cerebrovascular events (MACCE), and the second endpoint was defined as an extended MACCE including both MACCE and intensive care unit (ICU) admission. CRT-D recipients were older (67.5 ± 10.4years, p < 0.01) and had a higher prevalence of comorbidities, including obesity (12.3%, p = 0.03), diabetes mellitus (30.2%, p = 0.04), permanent atrial fibrillation (10.1%, p < 0.01), and chronic kidney disease (31%, p < 0.01), compared with single- and dual-chamber ICD patients. Post-procedural ICU admission was highest in the dual-chamber ICD group (44.5%, p < 0.01), while ICU stay was shortest among CRT-D recipients (median 2.9days, p < 0.01), who also required mechanical ventilation less frequently (8.7%, p < 0.01). Overall complication rates were lowest in the single-chamber ICD group (7.5%). Compared with single-chamber ICDs, implantation of dual-chamber ICDs was associated with a significantly higher risk of extended MACCE [OR:1.65, (95% CI:1.30-2.09)], whereas CRT-Ds were associated with a significantly lower risk [OR:0.75, (95% CI:0.60-0.94)]. Furthermore, CRT-Ds were associated with a substantially lower extended MACCE risk compared with dual-chamber ICDs [OR: 0.45, (95% CI:0.35-0x".58)]. Defibrillator type and age emerged as significant predictors of MACCE. For the extended MACCE endpoint, defibrillator type remained a significant predictor, whereas age was not. Despite their older age and higher comorbidity burden, recipients of CRT-D exhibited the lowest incidence of MACCE. Defibrillator type and age were identified as relevant predictors of MACCE in this patient population.

Pregnancy leads to profound physiological changes within the cardiovascular system. However, in women with pre-existing or pregnancy-associated cardiovascular disease (CVD) these adaptations may be insufficient and lead to maternal or fetal complications. The prognostic value of cardiac biomarkers such as N-terminal B-type natriuretic peptide (NTproBNP) and high-sensitivity cardiac troponin-T (hscTnT) in this population remains unclear. In this prospective, single-center cohort study, we included women with pre-existing CVD or who developed CVD during pregnancy. Patients were assessed before pregnancy, during each trimester, and in the postpartum period, when feasible. Biomarker trajectories (NT-proBNP, hs-cTnT) were recorded and their association with maternal complications at delivery was evaluated. Diagnostic accuracy was estimated using receiver operating characteristic curves (ROC). 67 women were included (median age 33.0years, IQR 30.0-37.0): 46 patients (73.1%) with pre-existing CVD and 21 patients (31.3%) who developed CVD during pregnancy. 50 women were observed until delivery and in 30 cases (60%) a maternal and/or fetal complication occurred at birth. Peak NT-proBNP demonstrated good discrimination for maternal complications (AUC 0.722; 95% CI 0.552-0.892) with an optimal cut-off of 209ng/L (sensitivity 72%, specificity 67%, Youden 0.39). Peak hs-cTnT showed good discrimination as well (AUC 0.729; 95% CI 0.568-0.890) with a cut-off of 22.0pg/mL (sensitivity 55%, specificity 84%, Youden 0.39). In this high-risk real-world cohort of pregnant women with CVD, maternal and/or fetal complications at delivery were common. Elevated NT-proBNP-and to a lesser extent hs-cTnT-was associated with higher complication rates and showed potential for improving risk stratification and monitoring. These findings support multidisciplinary surveillance of pregnant women with CVD and warrant further investigation in larger, multicenter studies.