Daily Cardiology Research Analysis

BACKGROUND: Hypertension is common in patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), and current guidelines recommend treating systolic blood pressure (SBP) to a target <130 mm Hg. However, data supporting treatment to this target are limited. Additionally, pulse pressure (PP), a marker of aortic stiffness, has been associated with increased risk of cardiovascular events, but its prognostic impact in HFpEF has not been extensively studied. OBJECTIVES: This study aimed to explore the impact of baseline SBP and PP on cardiovascular outcomes in patients with HFmrEF or HFpEF. METHODS: The I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction), TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist)-Americas, PARAGON-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin-Receptor Blocker Global Outcomes in HF With Preserved Ejection Fraction), and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trials were global, randomized clinical trials testing irbesartan, spironolactone, sacubitril/valsartan, and dapagliflozin, respectively, against either a placebo or an active comparator (valsartan, in PARAGON-HF), in patients with heart failure and a left ventricular ejection fraction ≥40% (in DELIVER) or ≥45% (in the other trials). The relationship between continuous baseline SBP and PP, and the primary endpoint (first heart failure hospitalization or cardiovascular death) was analyzed with restricted cubic splines. We further evaluated the prognostic impact of SBP categories (<120, 120-129, 130-139, and ≥140 mm Hg) and PP quartiles on the primary endpoint. RESULTS: A total of 16,950 patients (mean age 71 ± 9 years; 49% male; mean SBP 131 ± 15 mm Hg; mean PP 55 ± 14 mm Hg) were included. The relationship between SBP and the primary endpoint was J-shaped, with the lowest risk at 120 to 130 mm Hg. A similar pattern was found for PP, with the lowest risk at 50 to 60 mm Hg. The highest SBP category (reference: 120-129 mm Hg) and PP quartile (reference: 46-54 mm Hg) were associated with a higher risk of the primary outcome (HR: 1.22; 95% CI: 1.10-1.34 and HR: 1.22; 95% CI: 1.11-1.34, respectively). Higher PP was associated with greater cardiovascular risk, regardless of SBP. CONCLUSIONS: Our analysis of a large pooled dataset from 4 clinical trials, including >16,900 patients with HFmrEF/HFpEF, indicates a J-shaped relationship between both SBP and PP and cardiovascular risk. The lowest risk was observed at SBP levels between 120 and 130 mm Hg and PP values between 50 and 60 mm Hg (I-PRESERVE [Irbesartan in Heart Failure With Preserved Systolic Function], NCT00095238; TOPCAT [Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist], NCT00094302; PARAGON-HF [Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction], NCT01920711; DELIVER [Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure], NCT03619213).

IMPORTANCE: Hypertension underpins significant global morbidity and mortality. Early lifestyle intervention and treatment are effective in reducing adverse outcomes. Artificial intelligence-enhanced electrocardiography (AI-ECG) has been shown to identify a broad spectrum of subclinical disease and may be useful for predicting incident hypertension. OBJECTIVE: To develop an AI-ECG risk estimator (AIRE) to predict incident hypertension (AIRE-HTN) and stratify risk for hypertension-associated adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS: This was a development and external validation prognostic cohort study conducted at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, a secondary care setting. External validation was conducted in the UK Biobank (UKB), a UK-based volunteer cohort. AIRE-HTN was trained and tested to predict incident hypertension using routinely collected ECGs from patients at BIDMC between 2014 and 2023. The algorithm was then evaluated to risk stratify patients for hypertension- associated adverse outcomes and externally validated on UKB data between 2014 and 2022 for both incident hypertension and risk stratification. MAIN OUTCOMES AND MEASURES: AIRE-HTN, which uses a residual convolutional neural network architecture with a discrete-time survival loss function, was trained to predict incident hypertension. RESULTS: AIRE-HTN was trained on 1 163 401 ECGs from 189 539 patients (mean [SD] age, 57.7 [18.7] years; 98 747 female [52.1%]) at BIDMC. A total of 19 423 BIDMC patients composed the test set and were evaluated for incident hypertension. From the UKB, AIRE-HTN was tested on 65 610 ECGs from same number of participants (mean [SD] age, 65.4 [7.9] years; 33 785 female [51.5%]). A total of 35 806 UKB patients were evaluated for incident hypertension. AIRE-HTN predicted incident hypertension (BIDMC: n = 6446 [33%] events; C index, 0.70; 95% CI, 0.69-0.71; UKB: n = 1532 [4%] events; C index, 0.70; 95% CI, 0.69-0.71). Performance was maintained in individuals without left ventricular hypertrophy and those with normal ECGs (C indices, 0.67-0.72). AIRE-HTN was significantly additive to existing clinical risk factors in predicting incident hypertension (continuous net reclassification index, BIDMC: 0.44; 95% CI, 0.33-0.53; UKB: 0.32; 95% CI, 0.23-0.37). In adjusted Cox models, AIRE-HTN score was an independent predictor of cardiovascular death (hazard ratio [HR] per standard deviation, 2.24; 95% CI, 1.67-3.00) and stratified risk for heart failure (HR, 2.60; 95% CI, 2.22-3.04), myocardial infarction (HR, 3.13; 95% CI, 2.55-3.83), ischemic stroke (HR, 1.23; 95% CI, 1.11-1.37), and chronic kidney disease (HR, 1.89; 95% CI, 1.68-2.12), beyond traditional risk factors. CONCLUSIONS AND RELEVANCE: Results suggest that AIRE-HTN, an AI-ECG model, can predict incident hypertension and identify patients at risk of hypertension-related adverse events, beyond conventional clinical risk factors.

BACKGROUND: The results of randomized clinical trials comparing the outcomes of different strategies for driving PCI are mixed, and it remains unclear which technique for driving PCI offers the greatest benefit. The aim of the study was to compare the clinical efficacy of different techniques to guide percutaneous coronary intervention (PCI). METHODS: We search major electronic databases for randomized clinical trials evaluating clinical outcomes of PCI with stent implantation guided by coronary angiography (CA), fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The primary outcome was cardiac death. RESULTS: The results from 39 randomized trials (29,614 patients) were included in the network meta-analyses. Compared with CA, the use of OCT (RR: 0.33, 95 % CI: 0.19-0.54), IVUS (RR: 0.47, 95 % CI: 0.31-0.71) and FFR (RR: 0.61, 95 % CI: 0.38-0.97) were associated with reduced risk of cardiac death; there were no differences between OCT, IVUS and OCT was ranked as the best strategy. PCI guidance using OCT, FFR and IVUS was also associated with a reduction of myocardial infarction. The use of OCT or IVUS for PCI guidance was associated with a significant reduction in target lesion failure, target vessel revascularization, target lesion revascularization and stent thrombosis, compared with CA. OCT-guided PCI was associated with a significant reduction in all-cause death compared with CA-guided PCI and with a reduction in TLF compared with FFR- and iFR-guided PCI. Pooled estimates were mostly consistent across several sensitivity analyses. CONCLUSIONS: Compared with angiography-guided PCI, both an intravascular imaging-guided strategy and a physiology-guided strategy are associated with better clinical outcomes.