Daily Cardiology Research Analysis
Analyzed 258 papers and selected 3 impactful papers.
Summary
Across cardiology, three studies stand out: an individual-participant analysis across five HFpEF/HFmrEF trials shows baseline heart rate predicts outcomes only in sinus rhythm, not in atrial fibrillation/flutter; a nationwide study in ACS links intravascular imaging–guided PCI (OCT/IVUS) to lower recurrent ACS; and a multicenter shock cohort suggests accepting lower MAP targets to minimize catecholamine exposure may improve outcomes in heart failure–related cardiogenic shock.
Research Themes
- Heart rate prognostication differs by rhythm in HFpEF/HFmrEF
- Intravascular imaging guidance improves ACS PCI outcomes
- Catecholamine-sparing MAP targets in heart failure–related cardiogenic shock
Selected Articles
1. Heart rate and atrial fibrillation/flutter in HFmrEF/HFpEF: a participant-level analysis across five randomized clinical trials.
Across 19,975 participants from five HFpEF/HFmrEF trials, higher baseline heart rate predicted cardiovascular death/HF hospitalization only in sinus rhythm, not in atrial fibrillation/flutter, with a significant interaction (Pinteraction < .001). This association was not modified by beta-blocker use, challenging heart rate–centric strategies in AF and supporting rhythm-specific risk assessment.
Impact: This participant-level pooled analysis clarifies when heart rate is prognostic in HFpEF/HFmrEF, directly informing whether HR-lowering targets should differ by rhythm and challenging a one-size-fits-all rate-control approach.
Clinical Implications: In HFpEF/HFmrEF, prioritize heart rate as a risk marker and potential treatment target in sinus rhythm; in AF/AFL, focus on rhythm-control strategies and individualized targets rather than aggressive rate reduction alone.
Key Findings
- Heart rate predicted CV death/HF hospitalization only in sinus rhythm, not in atrial fibrillation/flutter (Pinteraction < .001).
- Atrial fibrillation/flutter patients had higher baseline heart rate (75 vs 68 bpm, P < .001) and higher adjusted risk for the primary outcome (HR 1.19 [1.10–1.27]).
- Beta-blocker use did not modify the relationship between baseline heart rate and outcomes.
Methodological Strengths
- Participant-level pooled analysis across five large randomized trials with uniform outcome definitions
- Robust multivariable Cox and Poisson models assessing interaction by rhythm
Limitations
- Post hoc observational analysis within trials; causality cannot be inferred
- Single baseline heart rate assessment without longitudinal HR trajectory data
Future Directions: Prospective trials should test rhythm-specific heart rate targets and evaluate rhythm control versus rate control strategies in HFpEF/HFmrEF with AF.
AIMS: While elevated heart rate is an established marker of risk in HF, the prognostic relevance of heart rate is less certain in patients with comorbid atrial fibrillation/flutter (AFF). We investigated the associations between heart rate and outcomes according to AFF status in 5 HFmrEF/HFpEF clinical trials. METHODS: In a participant-level pooled analysis of the CHARM-Preserved, I-PRESERVE, TOPCAT-Americas, PARAGON-HF, and DELIVER trials, associations between baseline heart rate and outcomes according to AFF status on ECG at enrolment were assessed with multivariable Cox and Poisson regression models. The primary outcome was CV death or HF hospitalization. RESULTS: Among 19 975 participants, 5816 (29%) had AFF on baseline ECG. Patients with AFF were older, more frequently male, had a higher baseline heart rate (75 vs 68 bpm, P < .001), and had an increased risk for the primary outcome (adj HR 1.19 [1.10-1.27]). A significant interaction between heart rate, AFF status, and clinical outcomes was observed, such that patients in sinus rhythm had higher event rates with increasing heart rates, while the incident rates for participants in AFF were similar across the range of baseline heart rate (Pinteraction < .001 for the primary outcome). This relationship was not further modified by concomitant β-blocker use. CONCLUSIONS: In this analysis of five HFmrEF/HFpEF trials, baseline heart rate was associated with significantly higher rates of events only in patients in sinus rhythm but not in those with AFF. The optimal management of AFF in the context of HFmrEF/HFpEF requires a dedicated study.
2. Balancing blood pressure and catecholamine support is critical in heart failure-related cardiogenic shock patients.
In 704 HF-related cardiogenic shock patients across 16 centers, higher catecholamine support (baseline and 7-day summarized inotrope scores) independently predicted lower ICU discharge and higher 30-day mortality. Threshold analyses suggest better outcomes when maintaining a catecholamine dose/MAP ratio below ~0.40–0.43 μg/kg/min/mmHg, implying that tolerating lower MAP to reduce vasopressor/inotrope dose may be beneficial.
Impact: Provides actionable hemodynamic targets linking catecholamine burden relative to MAP with outcomes, challenging traditional fixed MAP goals in HF-related shock.
Clinical Implications: In HF-related CS, consider individualized, catecholamine-sparing strategies (accepting modestly lower MAP) to minimize inotrope/vasopressor exposure while monitoring perfusion markers. Prospective trials are warranted before guideline changes.
Key Findings
- Higher inotropic scores independently predicted lower ICU discharge (baseline OR 0.78; summarized OR 0.46) and higher 30-day mortality (baseline HR 1.27; summarized HR 1.83), all P < .001.
- A catecholamine dose/MAP ratio <0.403 μg/kg/min/mmHg associated with higher ICU discharge; <0.426 associated with lower 30-day mortality.
- Findings suggest that reducing catecholamine dose by accepting lower MAP targets may improve outcomes.
Methodological Strengths
- Multicenter cohort across 16 tertiary centers with center-stratified models
- Use of mixed-effects logistic regression and Cox models with adjustment for key confounders
Limitations
- Retrospective observational design with potential confounding by indication
- MAP targets and dosing were not randomized; external validation is needed
Future Directions: Randomized trials should test catecholamine-sparing MAP targets versus conventional MAP goals in HF-related cardiogenic shock, incorporating perfusion and organ injury biomarkers.
AIMS: Cardiogenic shock (CS) is often treated with catecholamines titrated to an adequate target mean arterial pressure (MAP) while minimizing adverse effects. We aim to assess the optimal catecholamine dose/MAP balance in heart failure-associated CS (HF-CS). METHODS: Patients with HF-CS were retrospectively enrolled from 16 tertiary centres in 5 European countries (2016-2021; NCT03313687). Dosage was quantified by inotropic scores (epinephrine, norepinephrine, and dobutamine). Associations of baseline and seven-day summarized dosage with intensive care unit (ICU) discharge (mixed-effects logistic regression) and 30-day mortality (Cox regression) were analysed. Potential catecholamine/MAP target ratios for optimized outcomes were assessed in models adjusted for age, sex, pH, lactate and prior resuscitation, stratified by centre. RESULTS: N = 704 patients: median age 63 years, 74% male, 34% post-resuscitation, median lactate 5.2 mmol/l. Of these, 53% were discharged from ICU, 48% died within 30 days. Higher inotropic scores independently predicted a lower probability of ICU discharge (baseline score: OR 0.78 [95%-CI 0.69-0.88]; summarized score: OR 0.46 [0.38-0.56]; both P < .001) and higher risk of 30-day mortality (baseline score: HR 1.27 [1.15-1.40], summarized score HR 1.83 [1.60-2.09]; both P < .001). A score/MAP ratio <0.403 µg/kg/min/mmHg was associated with higher ICU discharge odds (ceiling effect); a < 0.426 µg/kg/min/mmHg with lower 30-day mortality hazards (no ceiling effect). Lowering catecholamine doses by accepting reduced MAP targets was linked to better outcomes. CONCLUSION: In HF-CS, higher catecholamine support independently associates with worse outcomes. Accepting lower blood pressure targets to reduce catecholamine dosage may improve outcomes. Validation in randomized controlled trials is urgently needed.
3. Intravascular imaging-guided percutaneous coronary intervention in patients with acute coronary syndrome.
In a nationwide Japanese database including 352,000+ imaging-guided and 32,000 angiography-guided PCI cases for ACS, both IVUS- and OCT-guided PCI were associated with significantly lower 3-year ACS recurrence (IVUS HR 0.76; OCT HR 0.81) after IPTW adjustment. Adoption of imaging guidance increased over time.
Impact: At national scale, this study supports intravascular imaging guidance during ACS PCI as a real-world practice associated with fewer recurrent ACS events, strengthening the case for broader guideline adoption.
Clinical Implications: In ACS PCI, prioritize IVUS/OCT guidance to optimize lesion preparation and stent deployment, with health systems considering quality metrics and reimbursement policies that facilitate imaging use.
Key Findings
- IVUS-guided PCI was associated with lower 3-year ACS recurrence versus angiography-guided PCI (HR 0.76, 95% CI 0.71–0.82; p<0.001).
- OCT-guided PCI was similarly associated with reduced ACS recurrence (HR 0.81, 95% CI 0.71–0.91; p<0.001).
- Use of both imaging modalities increased over time (IVUS from 77.0% to 87.9%; OCT from 4.7% to 6.9%).
Methodological Strengths
- Very large nationwide cohort with three-year follow-up
- Causal inference strengthened via inverse probability of treatment weighting
Limitations
- Retrospective observational design; residual confounding and selection bias remain possible
- Limited granularity on lesion complexity, procedural details, and medical therapy
Future Directions: Prospective registries and randomized strategies in ACS should compare imaging-guided versus angiography-guided PCI with standardized imaging protocols and cost-effectiveness analyses.
BACKGROUND: The recurrences of acute coronary syndrome (ACS) and target vessel failure after percutaneous coronary intervention (PCI) remain clinical concerns. Intravascular imaging, such as optical coherence tomography (OCT) or intravascular ultrasound (IVUS), has demonstrated clinical benefits in patients with stable coronary disease; however, the benefits of its use remains unclear in patients with ACS. AIMS: This study aimed to investigate the benefit of imaging-guided PCI in patients with ACS on the recurrence of ACS using a nationwide database in Japan. METHODS: This retrospective observational study used records from the National Database between April 2014 and March 2021. We included patients hospitalised with ACS aged ≥20 years who had undergone first-time PCI and divided them into imaging-guided PCI (OCT or IVUS) and angiography-guided PCI groups. The primary outcome was ACS recurrence during a 3-year follow-up period. We analysed the association between intravascular imaging and the outcome using inverse probability of treatment weighting. RESULTS: Among the patients with ACS, angiography-guided PCI, OCT-guided PCI, and IVUS-guided PCI were performed in 32,044, 22,748, and 297,944 patients, respectively. During the study period, both OCT- and IVUS-guided PCI rates increased, from 4.7% to 6.9% and from 77.0% to 87.9%, respectively. OCT-guided PCI was associated with a lower risk of ACS recurrence (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.71-0.91; p<0.001); IVUS-guided PCI was also associated with a lower risk of ACS recurrence (HR 0.76, 95% CI: 0.71-0.82; p<0.001). CONCLUSIONS: In real-world clinical practice, the rates of both OCT- and IVUS-guided PCI have increased and have been associated with a lower risk of ACS recurrence compared with angiography-guided PCI in patients with ACS.