Daily Cardiology Research Analysis

BACKGROUND: Ablation of atrial fibrillation can restore normal heart rhythm, but its effect on clinical outcomes is uncertain. PURPOSE: To determine the effect of ablation on ischemic stroke at more than 30 days (primary outcome). DATA SOURCES: Search of 9 databases without language restrictions from 1 January 1987 to 13 September 2024, and bridge search of 2 databases to 1 May 2025. STUDY SELECTION: Randomized controlled trials of catheter or surgical ablation versus no ablation that had at least 1 month of follow-up and reported stroke and/or mortality. DATA EXTRACTION: Dual independent data extraction and risk-of-bias assessment. DATA SYNTHESIS: Compared with medical therapy, catheter ablation reduced risks for ischemic stroke after 30 days (relative risk [RR], 0.63 [95% CI, 0.43 to 0.92]), mortality (RR, 0.73 [CI, 0.60 to 0.88]), and heart failure (HF) hospitalization (RR, 0.68 [CI, 0.55 to 0.85]). However, catheter ablation increased the RR for ischemic stroke at or before 30 days (6.81 [CI, 1.56 to 29.8]) such that the RRs were 0.77 (CI, 0.55 to 1.09) for any ischemic stroke and 0.77 (CI, 0.57 to 1.05) for all strokes. Surgical ablation reduced the RRs for ischemic stroke (0.54 [CI, 0.34 to 0.86]) and stroke from any cause (0.54 [CI, 0.35 to 0.82]) but had uncertain benefit for other outcomes; RRs were 0.63 (CI, 0.37 to 1.06) for ischemic stroke after 30 days, 0.90 (CI, 0.70 to 1.15) for mortality, and 0.90 (CI, 0.60 to 1.35) for HF hospitalization. LIMITATIONS: Clinical heterogeneity of trials, lack of participant-level data, and inclusion of unblinded trials. CONCLUSION: Catheter ablation reduced the risks for ischemic stroke at more than 30 days, mortality, and HF hospitalization. Surgical ablation had uncertain benefit, except for stroke. PRIMARY FUNDING SOURCE: National Center for Advancing Translational Sciences of the National Institutes of Health (Awards TL1TR002344 and UL1TR002345). (PROSPERO: CRD42023409751).

Coronary multivessel disease (MVD) affects approximately 50% of the patients presenting with acute coronary syndrome (ACS). The optimal revascularization strategy after culprit lesion treatment, including the optimal method to select non-culprit lesions amenable to revascularization, remains unsettled. This study sought to compare culprit-only revascularization, angiography-guided complete revascularization, and physiology-guided complete revascularization in multivessel disease (MVD) patients with acute coronary syndrome (ACS). We searched PUBMED and Web of Science for randomized controlled trials investigating outcomes following culprit-only revascularization, angiography-guided complete revascularization or physiology-guided complete revascularization in patients with ACS and MVD. We identified 14 randomized studies and 11,871 participants with ACS and MVD, of whom 5090 underwent culprit-only intervention, 3641 angiography-guided complete revascularization, 3140 physiology-guided complete revascularization). Major adverse cardiac events (MACE) were lower in both angiography- (IRR 0.60, 95%-CI 0.46-0.79) or physiology-guided (IRR 0.65, 95%-CI 0.50-0.85) complete revascularization compared with culprit-only revascularization. P-score for treatment ranking was higher for angiography- (0.834) than physiology-guidance (0.666). The estimated effects for all-cause and cardiovascular death vs. culprit-only revascularization were 0.89 (95%-CI 0.61-1.30) and 0.82 (95%-CI 0.48-1.40) for angiography-guidance, and 0.78 (95%-CI 0.55-1.11) and 0.64 (95%-CI 0.40-1.01) for physiology-guidance, respectively. For both all-cause death and cardiovascular death, the highest benefit was estimated for physiology-guidance (P-scores respectively 0.821 and 0.870). In patients with ACS and MVD, both angiography- and physiology-guided complete revascularization are superior to culprit-only revascularization with respect to MACE reduction. Angiography-guidance and physiology-guidance were comparable for future events prevention.

BACKGROUND: A 50% decline in estimated glomerular filtration rate (eGFR) has been introduced as a new kidney endpoint in heart failure (HF) trials. However, its prognostic significance beyond the initial 6 months following HF diagnosis, during which patients often undergo medical therapy optimization, remains uncertain-particularly for patients without diabetes. OBJECTIVES: This study aims to determine the long-term prognostic implications of eGFR decline focusing on risks for all-cause mortality and end-stage kidney disease (ESKD). METHODS: The authors conducted a nationwide cohort study of all new-onset patients diagnosed with HF between 2014 and 2021. eGFR trajectory was assessed from months 6 to 12 post-diagnosis categorizing patients into 3 groups: stable eGFR (<25% decline), 25%-50% decline, and >50% decline. Only patients who survived the first year post-diagnosis were included in the landmark analysis with the primary outcomes of all-cause mortality and ESKD. RESULTS: Among 45,385 patients with HF (median age: 73.6, 63.8% male), 82.5% had stable eGFR, 14.2% had a 25%-50% decline, and 3.3% had >50% decline at 1 year. In patients without diabetes, eGFR decline >25% was associated with increased 5-year mortality, with absolute risks of 33.2%, 53.8%, and 63.0% for stable eGFR, 25%-50% decline, and >50% decline, respectively. In patients with diabetes, absolute mortality risk was generally higher but followed the same trend (42.8%, 58.6%, and 65.6% for stable eGFR, 25%-50% decline, and >50% decline, respectively). The risk of developing ESKD also increased with eGFR decline. In patients without diabetes, absolute risks were 3.3%, 7.9%, and 11.5% for stable eGFR, 25%-50% decline, and >50% decline, respectively, whereas the absolute risk of ESKD was notably higher in patients with diabetes (7.4%, 15.6%, and 21.1% for stable eGFR, 25%-50% decline, and >50% decline, respectively). CONCLUSIONS: In this large real-world study, a >50% eGFR decline was associated with increased mortality and ESKD risk irrespective of diabetes status, underscoring its clinical relevance.