Publications

The paradoxical relationship between lipid levels (TC and LDL-C) and the risk of AF remains consistent in both statin users and non-users.

Background Cardiovascular diseases(CVD) increase mortality risk from coronavirus infection(COVID-19), but there are concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both “direct”, through infection, and “indirect”, through changes in healthcare. Methods We used population-based electronic health records from 3,862,012 individuals in England to estimate pre- and post-COVID-19 mortality risk(“direct” effect) for people with incident and prevalent CVD. We incorporated: (i)pre-COVID-19 risk by age, sex and comorbidities, (ii)estimated population COVID-19 prevalence, and (iii)estimated relative impact of COVID-19 on mortality(relative risk, RR: 1.5, 2.0 and 3.0). For “indirect” effects, we analysed weekly mortality and emergency department data for England/Wales and monthly hospital data from England(n=2), China(n=5) and Italy(n=1) for CVD referral, diagnosis and treatment until 1 May 2020. Findings CVD service activity decreased by 60-100% compared with pre-pandemic levels in eight hospitals across China, Italy and England during the pandemic. In China, activity remained below pre-COVID-19 levels for 2-3 months even after easing lockdown, and is still reduced in Italy and England. Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous(peak RR 1.4). For total CVD(incident and prevalent), at 10% population COVID-19 rate, we estimated direct impact of 31,205 and 62,410 excess deaths in England at RR 1.5 and 2.0 respectively, and indirect effect of 49932 to 99865 excess deaths. Interpretation Supply and demand for CVD services have dramatically reduced across countries with potential for substantial, but avoidable, excess mortality during and after the COVID-19 pandemic. Funding NIHR, HDR UK, Astra Zeneca

Aims: The aim of the present meta-analysis was to evaluate the effectiveness and safety of non–vitamin K antagonist oral anticoagulants (NOACs) vs. vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients with polypharmacy. Methods and results: Randomized controlled trials or observational studies reporting the data about the NOACs and VKAs therapy among AF patients with polypharmacy were included. The search was performed in the PubMed and Embase databases up to November 2022. There were no differences in the rates of SSE but increased risk of all-cause death and major bleeding between moderate polypharmacy and severe polypharmacy versus no-polypharmacy patients. The use of NOACs compared with VKAs was significantly associated with reduced risks of stroke or systemic embolism (SSE) in AF patients with moderate polypharmacy (hazard ratios [HRs], 0.77 [95% confidence intervals [CIs], 0.69–0.86]) and severe polypharmacy (HR, 0.76 [95% CI, 0.69–0.82]) and there was no significant difference in major bleeding (moderate polypharmacy: HR, 0.87 [95% CI, 0.74–1.01]; severe polypharmacy: HR, 0.91 [95% CI, 0.79–1.06]) between the two groups. There were no differences in the rates of ischemic stroke, all-cause death, and gastrointestinal bleeding but reduced risk of any bleeding between the NOACs and VKAs users. Compared with VKAs, the risk of intracranial hemorrhage was reduced in patients with moderate polypharmacy but not in patients with severe polypharmacy in NOACs users. Conclusion: In patients with AF and polypharmacy, NOACs showed advantages over VKAs in SSE and bleeding, and non-inferiority in major bleeding, ischemic stroke, all-cause death, intracranial hemorrhage, and gastrointestinal bleeding.

We assessed 1-year outcomes in patients with atrial fibrillation enrolled in the EurObservational Research Programme AF General Pilot Registry (EORP-AF), in relation to kidney function, as assessed by glomerular filtration rate (eGFR). In a cohort of 2398 patients (median age 69 years; 61% male), eGFR (ml/min/1.73 m(2)) calculated using the CKD-EPI formula was ≥80 in 35.1%, 50-79 in 47.2%, 30-49 in 13.9% and <30 in 3.7% of patients. In a logistic regression analysis, eGFR category was an independent predictor of stroke/TIA or death, with elevated odds ratios associated with severe to mild renal impairment, ie. eGFR < 30 ml/min/1.73 m(2) [OR 3.641, 95% CI 1.572-8.433, p < 0.0001], 30-49 ml/min/1.73 m(2) [OR 3.303, 95% CI 1.740-6.270, p = 0.0026] or 50-79 ml/min/1.73 m2 [OR 2.094, 95% CI 1.194-3.672, p = 0.0003]. The discriminant capability for the risk of death was tested among various eGFR calculation algorithms: the best was the Cockcroft-Gault equation adjusted for BSA, followed by Cockcroft-Gault equation, and CKD-EPI equation, while the worst was the MDRD equation. In conclusion in this prospective observational registry, renal function was a major determinant of adverse outcomes at 1 year, and even mild or moderate renal impairments were associated with an increased risk of stroke/TIA/death.

The NULL-EASE score has good discriminative performance (sensitivity and accuracy) in our multiethnic Asian cohort, but the cutoff of ≥3 falls short of the desired level of specificity for therapeutic decision-making.

Abstract Introduction As mortality rates from COVID-19 disease fall, the high prevalence of long-term sequelae (Long COVID) is becoming increasingly widespread, challenging healthcare systems globally. Traditional pathways of care for Long Term Conditions (LTCs) have tended to be managed by disease-specific specialties, an approach that has been ineffective in delivering care for patients with multi-morbidity. The multi-system nature of Long COVID and its impact on physical and psychological health demands a more effective model of holistic, integrated care. The evolution of integrated care systems (ICSs) in the UK presents an important opportunity to explore areas of mutual benefit to LTC, multi-morbidity and Long COVID care. There may be benefits in comparing and contrasting ICPs for Long COVID with ICPs for other LTCs. Methods and analysis This study aims to evaluate health services requirements for ICPs for Long COVID and their applicability to other LTCs including multi-morbidity and the overlap with medically not yet explained symptoms (MNYES). The study will follow a Delphi design and involve an expert panel of stakeholders including people with lived experience, as well as clinicians with expertise in Long COVID and other LTCs. Study processes will include expert panel and moderator panel meetings, surveys, and interviews. The Delphi process is part of the overall STIMULATE-ICP programme, aimed at improving integrated care for people with Long COVID. Ethics and dissemination Ethical approval for this Delphi study has been obtained (Research Governance Board of the University of York) as have approvals for the other STIMULATE-ICP studies. Study outcomes are likely to inform policy for ICPs across LTCs. Results will be disseminated through scientific publication, conference presentation and communications with patients and stakeholders involved in care of other LTCs and Long COVID. Registration Researchregistry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/6246bfeeeaaed6001f08dadc/ .

Coronary microvascular dysfunction (CMD) is being increasingly recognised as a significant contributor to myocardial ischaemia, particularly in patients without obstructive coronary artery disease. This review explores the anatomy and physiology of the coronary microcirculation, emphasising the role of endothelial dysfunction and endothelin-1 in CMD pathogenesis. We discuss diagnostic approaches, including invasive and non-invasive techniques, such as PET, cardiac MRI and intracoronary physiological testing. Current management strategies focus on risk factor modification and tailored pharmacotherapy, with emerging therapies targeting endothelin pathways. A comprehensive understanding of CMD is essential for improving diagnostic accuracy and developing effective treatments for patients presenting with ischaemic symptoms absent of angiographic evidence of coronary obstruction.

Patients with atrial fibrillation (AF) often have clinical complexity phenotypes. Latent class analysis (LCA) is based on the concept of modeling of both observed and unobserved (latent) variables. We hypothesized that LCA can help in identification of AF patient groups with different risk profiles and identify patients who benefit most from the Atrial fibrillation Better Care (ABC) pathway.We studied non-valvular AF patients in the prospective multicenter COOL-AF registry. The outcomes were all-cause death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. Components of CHA₂DS₂-VASc score, HAS-BLED score, and ABC pathway were recorded.A total of 3,405 patients were studied. We identified 3 LCA groups from 42 variables: LCA class 1 (<i>n</i> = 1,238), LCA class 2 (<i>n</i> = 1,790), and LCA class 3 (<i>n</i> = 377). Overall, the incidence rates of composite outcomes, death, SSE, major bleeding, and heart failure were 8.69, 4.21, 1.51, 2.27, and 2.84 per 100 person-years, respectively. When compared to LCA class 1, hazard ratios (HR) of composite outcome of LCA classes 3 and 2 were 3.86 (3.06-4.86) and 2.31 (1.91-2.79), respectively. ABC pathway compliance was associated with better outcomes in LCA classes 2 and 3 with the HR of 0.63 (0.51-0.76) and 0.57 (0.39-0.84), but not in LCA class 1.LCA can identify patients who are at risk of developing adverse clinical outcomes. The implementation of holistic management based on the ABC pathway was associated with a reduction in the composite outcomes as well as the individual outcomes.

This editorial refers to ‘gender differences in complications following catheter Ablation of atrial fibrillation’, by Ngo et al. Catheter ablation (CA) has evolved as an important treatment modality for patients with atrial fibrillation (AF), with recent guidelines1 strongly endorsing its use in appropriate patients. With steady enhancements in catheter technology and in peri-procedural protocols over the years, success rates have improved and complication rates have reduced, contributing to an exponential growth in this often transformative treatment. However, one issue continues to vex us: that of sex differences in the uptake, success rates, and safety of CA. Why do women have poorer outcomes and higher complication rates with CA than men? In the current issue of the European Heart Journal—Quality of Care and Clinical Outcomes, Ngo et al.2 investigated potential gender-related differences in the risk of procedural complications following CA for AF, occurring up to 30 days after discharge. They identified 35 211 patients undergoing CA between 2008 and 2017 in Australia and New Zealand. They found that women represented only ∼30% of this population, were older, with higher prevalence of hypertension, valvular heart disease, haematological disorders, and prior AF-related hospitalizations as compared to men. The overall rate of procedure-related complications was higher in women (6.96% vs. 5.42%, P < 0.001), particularly pericardial effusion, bleeding, vascular injury, pericarditis, and complete atrioventricular block, a finding consistent with previous reports.3 The authors also reported that all-cause mortality and stroke/transient ischaemic attack rates, during the short period evaluated, did not differ between sexes. The results persisted even after adjustment for baseline characteristics and in the propensity score-matched cohort analysis.

Among young adults, NAFLD assessed using FLI was positively correlated with the AF risk. These findings support the evidence of AF screening in young adults with high FLI scores.

Baseline MR and TR were associated with increased all-cause and cardiovascular mortality post-TAVI, however, neither of them was independent predictor for all-cause or cardiovascular mortality.