Daily Cardiology Research Analysis

AIMS: Intraprocedural assessment of residual mitral regurgitation (MR) is crucial for success of transcatheter edge-to-edge mitral valve repair (M-TEER) yet challenging in the case of ambiguous echocardiographic findings. Monitoring left atrial (LA) pressure can complement evaluation of residual MR after device placement. This study aimed to determine the prognostic impact of intraprocedural changes in LA pressure on the clinical outcome following M-TEER. METHODS: We enrolled 299 patients undergoing M-TEER for primary or secondary MR in a prospective observational study. During the procedure, LA mean (LAmP) and LA v wave pressure (LAvP) were recorded before and after device implantation. The primary endpoint was death or hospitalization for heart failure during a 2-year follow-up. RESULTS: Mean age of the study population was 76.6±8.2 years. Secondary mitral regurgitation was identified in 62.9% of the patients. Reduction to MR grade I or II was achieved in 95.3% of cases. During M-TEER, LAvP decreased from 30.5±15.0 to 23.2±10.4 mmHg (p<0.001) after device implantation, accompanied by a modest reduction of LAmP from 16.6±6.3 to 15.3±5.9 mmHg (p=0.006). LAvP post M-TEER was a strong predictor of death or hospitalization for heart failure in both univariate and multivariate analysis, independent of echocardiographic MR severity (hazard ratio per 10 mmHg 1.37 [1.15-1.63], p<0.001 and 1.29 [1.06-1.57], p=0.012). Residual LAvP below 25 mmHg was strongly associated with favourable outcome irrespective of residual echocardiographic MR grade, including patients with residual MR grade I and II. CONCLUSION: High residual LAvP predicts death or hospitalization for heart failure after M-TEER. LAvP after device implantation provides incremental prognostic information beyond echocardiographic MR grading and may therefore assist intraprocedural decision-making during M-TEER.

IMPORTANCE: Hypertension, defined as office systolic blood pressure (SBP) 130 mm Hg or greater and/or diastolic blood pressure 80 mm Hg or greater, affects 43.9% of women and 49.5% of men in the US. Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses. OBSERVATIONS: Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%). Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea. Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]). Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss. Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided. Sleep apnea should be treated when diagnosis is confirmed. Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms. In a meta-analysis of 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately. For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysis of 24 RCTs (3485 patients with resistant hypertension). A meta-analysis of 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6). CONCLUSIONS AND RELEVANCE: True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism. First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives. Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

AIMS: Despite contemporary statin therapy, patients with atherosclerotic cardiovascular disease or high cardiovascular risk experience a residual risk of major adverse events. Eicosapentaenoic acid (EPA) has been evaluated for additional cardiovascular risk reduction, but the consistency and robustness of trial results remain uncertain. The aim of this study was to assess the robustness of randomized controlled trials (RCTs) of highly purified EPA for cardiovascular outcomes. METHODS: MEDLINE and Scopus were searched for phase 3/4 RCTs of EPA published through June 2025. Eligible studies were randomized and placebo-controlled, and reported dichotomous cardiovascular outcomes. Three trials met the inclusion criteria: REDUCE-IT, RESPECT-EPA, and JELIS. Primary and secondary cardiovascular endpoints were extracted. Conventional effect estimates (hazard ratios, relative risk reduction, number needed to treat) were calculated, and robustness was evaluated using the fragility index and fragility quotient. RESULTS: EPA significantly reduced the primary composite endpoint in REDUCE-IT (17.2 vs. 22.0%; hazard ratio 0.75; fragility index 123, fragility quotient 0.01), RESPECT-EPA (9.1 vs. 12.6%; hazard ratio 0.71; fragility index 49, fragility quotient 0.01), and JELIS (2.8 vs. 3.5%; hazard ratio 0.81; fragility index 15, fragility quotient 0.01). Secondary endpoints showed consistent but heterogeneous reductions in nonfatal myocardial infarction, stroke, and revascularization, with robustness highest in REDUCE-IT and more fragile results in RESPECT-EPA and JELIS. Differences in population phenotypes, background statin therapy, trial design, and endpoint definitions contributed to variability in the effect size and fragility. CONCLUSION: EPA added to statins lowers cardiovascular events, most robustly in high-risk patients with elevated triglycerides. Trial design, endpoints, and patient characteristics drive heterogeneity, while fragility analyses complement conventional metrics in interpreting outcomes.