Daily Cardiology Research Analysis
Long-term interventional strategy and measurement standardization dominated today’s cardiology literature. An individual patient data analysis of randomized trials shows that upfront double-kissing crush two-stent techniques reduce 6-year target lesion failure versus provisional stenting in true bifurcations. New corrected PISA thresholds markedly improve grading accuracy for secondary tricuspid regurgitation, and a territory-wide cohort reveals a rising incidence and shifting risk profile of he
Summary
Long-term interventional strategy and measurement standardization dominated today’s cardiology literature. An individual patient data analysis of randomized trials shows that upfront double-kissing crush two-stent techniques reduce 6-year target lesion failure versus provisional stenting in true bifurcations. New corrected PISA thresholds markedly improve grading accuracy for secondary tricuspid regurgitation, and a territory-wide cohort reveals a rising incidence and shifting risk profile of heart failure in younger adults.
Research Themes
- Coronary bifurcation PCI strategy and long-term outcomes
- Echocardiographic quantification standards for tricuspid regurgitation
- Epidemiology and risk trends of heart failure in younger adults
Selected Articles
1. Double-kissing crush versus provisional stenting in patients with true coronary artery bifurcation lesions: a pooled individual patient-level analysis of randomised trials (DKCRUSH X trial).
Across four randomized trials (n=1,573), upfront two-stent techniques—particularly DK crush—reduced 6-year target lesion failure compared with provisional stenting (18.2% vs 24.7%; HR 0.71, 95% CI 0.57-0.89). Heterogeneity was negligible (τ²=0.00), supporting durable efficacy, especially in complex bifurcations.
Impact: Provides high-level, long-term evidence to guide stenting strategy selection in true bifurcation lesions, potentially shifting practice toward DK crush in complex anatomy.
Clinical Implications: For true bifurcations, operators should consider upfront DK crush when anatomy is complex, given the 6-year reduction in TLF vs provisional stenting. Training and procedural planning should reflect the technique’s superiority in selected lesions.
Key Findings
- Upfront two-stent strategy reduced 6-year TLF vs provisional stenting (18.2% vs 24.7%; HR 0.71, 95% CI 0.57-0.89).
- Low between-trial heterogeneity (τ²=0.00) supports robustness of the effect.
- Benefit was most notable for DK crush and in complex bifurcation anatomy.
Methodological Strengths
- Individual patient data meta-analysis of randomized trials with centrally adjudicated endpoints
- Long-term (6-year) follow-up enabling durable efficacy assessment
Limitations
- Reporting truncation of heterogeneity metric (I²) in abstract and potential variability in operator expertise across trials
- Generalizability may be limited to true bifurcation lesions treated with contemporary DES and experienced centers
Future Directions: Head-to-head trials comparing DK crush with other two-stent techniques under contemporary imaging guidance; implementation studies on training, procedural efficiency, and cost-effectiveness.
BACKGROUND: Provisional stenting is the standard treatment for patients with coronary artery bifurcation lesions. AIMS: This pooled individual patient data (IPD) analysis aims to evaluate the long-term (six-year) outcomes of provisional stenting versus upfront two-stent techniques in patients with true coronary bifurcation lesions treated with drug-eluting stents. METHODS: A systematic review and IPD analysis of randomised trials with centrally adjudicated endpoints was conducted to assess the efficacy and safety of provisional stenting versus upfront two-stent approaches in patients with true coronary bifurcation lesions undergoing percutaneous coronary intervention with drug-eluting stents. All patients were prospectively followed, with their intervention having been completed at least six years earlier. The primary endpoint, re-evaluated by an independent clinical event committee, was target lesion failure (TLF) - a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularisation - assessed at the final follow-up on 8 November 2024. RESULTS: A total of 6,225 citations were screened, and four randomised trials met the inclusion criteria. Among 1,573 patients in the intention-to-treat population, TLF at six years occurred in 144 patients (Kaplan-Meier estimate 18.2%) in the upfront two-stent group and 193 (Kaplan-Meier estimate 24.7%) in the provisional stenting group (hazard ratio [HR] 0.71, 95% confidence interval [CI]: 0.57-0.89; p=0.0022, τ²=0.00, I CONCLUSIONS: This IPD analysis provides robust long-term evidence that upfront two-stent techniques, particularly double-kissing crush stenting, significantly reduce TLF over a six-year follow-up period compared with provisional stenting, especially in patients with complex bifurcations.
2. Refining tricuspid regurgitation severity assessment with new corrected proximal isovelocity surface area threshold values.
In 213 patients with isolated secondary tricuspid regurgitation, corrected PISA thresholds (EROA <0.22/0.22–0.46/>0.46 cm²; RegVol <18/18–42/>42 mL) achieved high accuracy against 3D echo–derived regurgitant fraction (99% EROA, 94% RegVol), significantly outperforming conventional PISA metrics.
Impact: Provides actionable, empirically derived thresholds for corrected PISA that align with volumetric reference standards, likely to standardize TR severity grading and downstream clinical decisions.
Clinical Implications: Echocardiography labs should incorporate corrected PISA thresholds into reporting for secondary TR to reduce misclassification and to guide timing of intervention and follow-up.
Key Findings
- New corrected PISA thresholds: EROA <0.22/0.22–0.46/>0.46 cm² and RegVol <18/18–42/>42 mL mapped to mild/moderate/severe STR.
- Accuracy against 3D volumetric regurgitant fraction was 99% (EROA) and 94% (RegVol), higher than conventional PISA (EROA 90%, RegVol 41%).
- Study utilized 3D echocardiography stroke volume–based regurgitant fraction as reference standard.
Methodological Strengths
- Use of 3D echocardiography volumetric regurgitant fraction as an independent reference standard
- Direct comparison of corrected vs conventional PISA with predefined accuracy metrics
Limitations
- Single-cohort observational design; external validation in broader STR populations is needed
- Focused on isolated secondary TR; applicability to mixed or primary TR requires study
Future Directions: Prospective multicenter validation, integration with 3D/4D flow and vena contracta area, and outcome-based thresholds linked to intervention timing.
AIMS: Research has shown that the corrected proximal isovelocity surface area (PISA) method yields larger values for regurgitant volume (RegVol) and effective regurgitant orifice area (EROA) than conventional PISA method. However, it remains unclear whether new threshold values are needed for the corrected PISA method to effectively categorize the severity of secondary tricuspid regurgitation (STR). This study sought to identify threshold values for EROA and RegVol measured by the corrected PISA method for a three-grade classification of STR severity. METHODS AND RESULTS: We used three-dimensional echocardiography to determine the volumetric regurgitant fraction (RegFr), calculated as the difference between the right (RV) and left ventricular (LV) stroke volumes (SV) divided by the RVSV. A total of 213 patients (78±10 years; 64% women) with isolated STR were enrolled. Based on RegFr, we classified STR severity into mild (RegFr< 16%), moderate (RegFr 16-49%), and severe (RegFr> 49%) grades. EROA and RegVol were measured using conventional (EROACONV, RegVolCONV) and corrected (EROACORR, RegVolCORR) PISA methods.The threshold values for identifying patients with mild, moderate, and severe STR were <0.22 cm², 0.22-0.46 cm², and >0.46 cm² for EROACORR, respectively; and <18 mL, 18-42 mL, and >42 mL for RegVolCORR, respectively. The accuracy of these new threshold values in predicting STR severity based on RegFr was 99% for EROACORR and 94% for RegVolCORR. These accuracies were significantly higher than those of EROACONV (90%, p<0.001) and RegVolCONV (41%, p<0.001). CONCLUSION: New threshold values for the corrected PISA method must be considered to improve the classification of STR severity.
3. Temporal trends in incidence, clinical characteristics and outcomes among young adults with heart failure: a territory-wide study from 2014 to 2023 on 19,537 patients.
In a territory-wide cohort of 19,537 adults <65 years, standardized incidence of heart failure rose by 20% from 2014 to 2023, with a risk profile shift toward obesity, cardiomyopathy, and lower socioeconomic status, and an increase in HFrEF. Despite improved GDMT uptake, 1-year mortality reductions were modest.
Impact: Defines a pressing epidemiologic shift in heart failure among younger adults with direct implications for prevention, resource allocation, and targeted guideline implementation.
Clinical Implications: Programs should prioritize upstream prevention (obesity, cardiomyopathy detection), equitable GDMT access, and earlier HFrEF screening in younger adults; health systems should adapt capacity planning for rising young HF burden.
Key Findings
- Standardized incidence of HF in adults <65 years increased by 20% (IRR 1.20, 95% CI 1.13-1.27) over 2014–2023.
- Risk factor profile shifted toward obesity, cardiomyopathy, lower socioeconomic status, and ages 45–65; rise in HFrEF subtype.
- Despite improved GDMT uptake, 1-year all-cause mortality showed only modest reductions.
Methodological Strengths
- Territory-wide administrative dataset with age-sex standardization over a 10-year window
- Multivariable modeling and period comparisons to characterize shifts in risk and outcomes
Limitations
- Administrative data subject to coding errors and residual confounding
- Generalizability beyond the studied health system may be limited
Future Directions: Mechanistic studies on early-onset HFrEF drivers, interventions addressing obesity and social determinants, and implementation trials to optimize GDMT in younger HF populations.
BACKGROUND: Heart failure (HF), traditionally considered a disease of the elderly, is increasingly common in younger people, but temporal data remain scarce. This cohort study aimed to examine temporal trends in incidence, comorbidities, risk factor profiles, and clinical outcomes among young HF patients. METHODS: Using a territory-wide administrative database in Hong Kong, we identified 19,537 young adults aged <65 years with incident HF between 2014 and 2023. Data on baseline characteristics, echocardiographic parameters, comorbidities and prescribed medications were retrieved. Annual standardised incidence rates (IRs) of HF were calculated by direct age- and sex-standardisation. Comparisons were made between two 5-year periods: 2014-2018 and 2019-2023. Multivariable regression models were applied to assess temporal shifts in risk factor profiles. The primary outcome was one-year all-cause mortality, with incidence rates reported per 100 person-years. Kaplan-Meier survival curves were plotted to illustrate survival trends. FINDINGS: Among the cohort (median age 57.1 years, 69% men), IRs of young HF increased by 20% (IRR 1.20, 95% CI 1.13-1.27) from 2014 to 2023. Concurrent with fewer comorbidities, young HF patients in 2019-2023 were more likely to present with obesity, cardiomyopathy, lower socioeconomic status, and be aged 45-65 years, contrasting with the conventional risk factors (including history of sudden cardiac arrest) predominant in the 2014-2018 cohort (all INTERPRETATION: The incidence of HF among young adults increased substantially between 2014 and 2023. During this period, the risk factor profile shifted considerably, with a pronounced rise in HFrEF subtype. Despite improved therapeutic management and better use of GDMT, reductions in one-year mortality were modest. Proactive public health strategies are urgently needed to address these emerging challenges in this population. FUNDING: This work was funded by grants from the National Natural Science Foundation of China (No. 82270400) and the Natural Science Foundation of Guangdong Province (No. 2023A1515010731).