Daily Cardiology Research Analysis
Analyzed 68 papers and selected 3 impactful papers.
Summary
Analyzed 68 papers and selected 3 impactful articles.
Selected Articles
1. Impact of advanced cardiac damage in severe aortic stenosis on short-term and mid-term mortality and rehospitalisation after transcatheter aortic valve implantation: a systematic review and meta-analysis.
Across 34 studies (26,076 patients), advancing extra-valvular cardiac damage (notably right ventricular dysfunction, stage 4) was associated with progressively higher 12-month all-cause and cardiovascular mortality after TAVI, with some increase in rehospitalisation. Findings support incorporating cardiac damage staging (for example, Généreux stages) into preprocedural assessment to refine risk stratification and management.
Impact: This meta-analysis provides high-level evidence that extra-valvular damage powerfully predicts post-TAVI outcomes, informing patient selection and peri-procedural planning. It consolidates heterogeneous literature into a clinically actionable staging framework.
Clinical Implications: Pre-TAVI evaluation should routinely stage extra-valvular cardiac damage (e.g., RVD, PH, TR) to anticipate mortality risk and guide decisions on timing, valve selection, and intensified post-procedural monitoring and optimization.
Key Findings
- Twelve-month all-cause mortality increases stepwise with cardiac damage stage: borderline HR 1.61, stage 3 HR 2.06, stage 4 HR 2.77.
- Cardiovascular mortality is highest in stage 4 (HR 3.13; RR 2.63).
- Rehospitalisation risk is elevated in stage 3 (RR 1.33) though data are limited.
- Meta-regression implicates age, sex, and comorbidities as contributors to heterogeneity.
Methodological Strengths
- Prospective PROSPERO registration and systematic multi-database search with predefined inclusion criteria
- Random-effects meta-analysis with risk-of-bias assessment (JBI) and meta-regression to explore heterogeneity
Limitations
- Predominantly observational cohorts subject to residual confounding
- Limited rehospitalisation data and variability in diagnostic definitions across studies
Future Directions: Prospective studies standardizing cardiac damage staging pre-TAVI and testing tailored management pathways (e.g., RV optimization, PH therapy) to improve outcomes.
BACKGROUND: Severe aortic stenosis (AS) is commonly associated with advanced cardiac damage, including right ventricular dysfunction (RVD), pulmonary hypertension (PH) and tricuspid regurgitation (TR), which may worsen prognosis after transcatheter aortic valve implantation (TAVI). This systematic review and meta-analysis aimed to assess the effect of these conditions on short-term and mid-term mortality and rehospitalisation following TAVI. METHODS: We conducted a systematic search of PubMed, Scopus and Web of Science for studies published up to June 2025. Eligible studies included adults with AS undergoing TAVI and reported outcomes at 1 month, 6 months or 12 months stratified by the presence of RVD, PH or TR. Studies had to report either HRs, risk ratios (RRs) or sufficient raw event data for mortality or rehospitalisation. Data were synthesised using a random-effects meta-analysis. Subgroup analyses were conducted by cardiac damage severity according to the Généreux staging system and stratified by valve type and diagnostic modality. Risk of bias in included studies was assessed using the Joanna Briggs Institute's checklist for cohort studies. Meta-regression was performed to explore sources of between-study heterogeneity. RESULTS: A total of 34 studies including 26 076 patients met inclusion criteria. Twelve-month HRs for all-cause mortality increased with advancing cardiac damage: borderline stage HR 1.61 (1.22-2.12), stage 3 HR 2.06 (1.63-2.60) and stage 4 HR 2.77 (2.11-3.64). RRs followed a similar trend. Cardiovascular mortality was highest in stage 4 (HR 3.13 (1.20-8.17); RR 2.63 (1.54-4.47)). Rehospitalisation data were limited but suggested elevated risk in stage 3 (RR 1.33 (1.12-1.58)). Meta-regression indicated that age, sex and comorbidities contributed to between-study heterogeneity, particularly in stage 3 analyses. CONCLUSION: Extravalvular cardiac damage, especially RVD (stage 4), is strongly associated with increased short-term and mid-term mortality and rehospitalisation after TAVI. Even borderline-stage patients face elevated risk, underscoring the continuous nature of AS-related cardiac injury. Incorporating cardiac damage staging into preprocedural assessment can enhance risk stratification and guide management to improve patient outcomes. PROSPERO REGISTRATION NUMBER: CRD420250638838.
2. Empagliflozin in De Novo vs Acute Decompensated Chronic Heart Failure: A Prespecified Analysis From EMPULSE.
In a prespecified subgroup analysis of the EMPULSE RCT, in-hospital empagliflozin provided comparable 90-day hierarchical clinical benefits in both de novo and acutely decompensated HF, with good tolerability despite a reduced diuretic response in ADHF. These findings support initiating empagliflozin during hospitalization across acute HF presentations.
Impact: Extends robust RCT evidence for SGLT2 inhibition to both de novo and ADHF phenotypes, addressing a common initiation timing question and supporting early, in-hospital use.
Clinical Implications: Consider routine in-hospital initiation of empagliflozin (10 mg daily) after stabilization for all acute HF patients, irrespective of de novo vs ADHF status, with monitoring of volume status and diuretic response.
Key Findings
- Randomized, stratified comparison (NHF n=175; ADHF n=355) showed similar 90-day hierarchical clinical benefit (win ratio 1.29 NHF; 1.39 ADHF).
- Empagliflozin was well tolerated in both subgroups.
- ADHF patients exhibited a reduced diuretic response, yet overall clinical benefit was preserved.
Methodological Strengths
- Prespecified subgroup analysis within an RCT with stratified randomization by HF status
- Hierarchical composite endpoint assessed via win ratio, capturing mortality, worsening HF, and patient-reported outcomes
Limitations
- Subgroup analysis with limited power for between-subgroup comparisons and potential interaction testing
- Follow-up limited to 90 days; long-term comparative effects by HF phenotype are unknown
Future Directions: Head-to-head implementation trials testing standardized in-hospital initiation pathways and longer-term outcomes across HF phenotypes, including diuretic-sparing strategies.
BACKGROUND: In EMPULSE (A Study to Test the Effect of Empagliflozin in Patients Who Are in Hospital for Acute Heart Failure), the sodium-glucose cotransporter 2 inhibitor empagliflozin improved clinical outcomes in patients hospitalized for heart failure (HF). OBJECTIVES: This prespecified analysis examined efficacy, safety, and tolerability of empagliflozin in subgroups with de novo heart failure (NHF) vs acute decompensated heart failure (ADHF). METHODS: After stabilization, participants were randomized 1:1 to empagliflozin 10 mg/d or placebo, stratified by HF status (NHF: n = 175; ADHF: n = 355). The primary endpoint was a hierarchical composite of death, worsening HF, or ≥5-point difference in Kansas City Cardiomyopathy Questionnaire-Total Symptom Score (KCCQ-TSS) change at day 90, assessed using a win ratio. RESULTS: Participants with NHF were younger, had fewer comorbidities, had higher blood pressure and heart rate, and better KCCQ-TSS. Prescription of diuretic agents was similar between subgroups. The win ratio was 1.29 (95% CI: 0.89-1.89) for NHF and 1.39 (95% CI: 1.07-1.81) for ADHF (P CONCLUSIONS: In-hospital initiation of empagliflozin produced similar clinical benefits in NHF and ADHF despite the reduced diuretic response in participants with ADHF and was well tolerated. This supports in-hospital initiation of empagliflozin in all patients with acute HF (A Study to Test the Effect of Empagliflozin in Patients Who Are in Hospital for Acute Heart Failure [EMPULSE]; NCT04157751).
3. Association of atrial high-rate episodes daily burden with the risk of cardiovascular death, heart failure hospitalization, and stroke.
Among 1,160 device patients followed for 3 years, a daily AHRE burden ≥6 minutes predicted a >4-fold increase in major cardiovascular events in those without prior AF, driven by cardiovascular death, HF hospitalization, and progression to long-lasting AF, but not stroke/TIA. No association was seen in patients with prior AF.
Impact: Defines a pragmatic AHRE burden threshold associated with hard outcomes in a large, prospectively followed device cohort, informing remote monitoring triage and intervention timing.
Clinical Implications: In device patients without prior AF, sustained AHRE burden ≥6 minutes should prompt closer surveillance and optimization of HF therapy; stroke prevention decisions may require individualized assessment given lack of association with stroke/TIA.
Key Findings
- AHRE ≥6 minutes occurred in 52.5% of patients; 47.1% had no prior AF.
- Without prior AF, AHRE ≥6 minutes associated with the primary composite (HR 4.9), cardiovascular death (p=0.033), HF hospitalization (p<0.001), and progression to long-lasting AF (p<0.001).
- No association with stroke/TIA (p=0.34) and no significant associations in patients with prior AF.
Methodological Strengths
- Prospective 3-year follow-up with continuous device monitoring in a large cohort from an RCT framework (B3)
- Time-varying AHRE burden modeled using competing-risk survival analyses and stratification by prior AF
Limitations
- Generalizability limited to sinus node dysfunction populations with dual-chamber devices
- Stroke/TIA analyses may be underpowered; threshold of 6 minutes may not capture all risk profiles
Future Directions: Randomized trials testing management strategies triggered by AHRE burden thresholds (e.g., HF therapy intensification or antiarrhythmic approaches) and validation across broader device populations.
BACKGROUND: The clinical significance of device-detected atrial high-rate episodes (AHREs) is believed to increase with AHRE burden. OBJECTIVE: This study evaluated whether a daily burden ≥6 minutes is associated with major cardiovascular outcomes. METHODS: We analyzed 1160 patients with sinus node dysfunction and dual-chamber pacemakers or defibrillators from the B3 randomized trial, followed for 3 years. The primary composite endpoint included cardiovascular death, worsening heart failure hospitalization (WHFH), and stroke or transient ischemic attack (TIA). Secondary endpoints were individual components of the primary endpoint and progression to long-lasting AF. Using competing-risk survival models with AHRE burden as a time-varying covariate, we calculated CHA RESULTS: AHRE burden ≥6 minutes occurred in 52.5% of patients, 47.1% of whom had no prior AF. There were 65 primary events (10 cardiovascular deaths, 39 WHFHs, 16 strokes/TIAs). In patients without prior AF, AHRE burden ≥6 minutes was significantly associated with the primary endpoint (HR 4.9; 95% CI, 2.19-10.91; p<0.001), as well as with cardiovascular death (p=0.033), WHFH (p<0.001), and long-lasting AF (p<0.001), but not with stroke/TIA (p=0.34). In contrast, no significant association was found in patients with prior AF (HR 0.83; 95% CI, 0.37-1.87; p=0.65). CONCLUSION: In patients without prior AF, a daily AHRE burden ≥6 minutes was linked to a >4-fold increased risk of major cardiovascular events, mainly driven by cardiovascular death, WHFH, and progression to long-lasting AF. No such association was observed in patients with prior AF.