Clinical Cardiology最新文献

{"title":"Safety and Efficacy of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Cerebrovascular Ischemic Outcomes in Non-Valvular Atrial Fibrillation: A Systematic Review and Meta-Analysis","authors":"Anam Nasir,&nbsp;Naqash Anwar,&nbsp;Abdullah Bin Kamran,&nbsp;Ayesha Muhammad,&nbsp;Ali Haider,&nbsp;Muhammad Mubashar,&nbsp;Fatima Tariq,&nbsp;Mostafa Helou,&nbsp;Besher Shami","doi":"10.1002/clc.70308","DOIUrl":"10.1002/clc.70308","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Atrial fibrillation (AF) is a major cause of thromboembolic events, including ischemic stroke and transient ischemic attack (TIA). While Vitamin K antagonists (VKAs) have long been used for stroke prevention, Direct Oral Anticoagulants (DOACs) have emerged as potential alternatives due to improved pharmacologic profiles and safety. This systematic review and meta-analysis aimed to compare the efficacy and safety of DOACs versus VKAs in patients with non-valvular AF, with a focus on cerebrovascular ischemic outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A comprehensive search of PubMed, ClinicalTrials.gov, and Cochrane Library was performed in accordance with PRISMA 2020 guidelines. Randomized controlled trials and comparative observational studies reporting cerebrovascular events, major bleeding, and all-cause mortality were included. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Eleven studies encompassing 814 716 patients were included. DOAC use was associated with a significantly lower risk of recurrent cerebrovascular ischemic events compared with VKAs (RR 0.83, 95% CI 0.78–0.88, <i>p</i> &lt; 0.0001). The risk of major bleeding was also reduced with DOACs (RR 0.77, 95% CI 0.71–0.82, <i>p</i> &lt; 0.0001). All-cause mortality was similar between groups (RR 1.02, 95% CI 0.34–3.13), though sensitivity analysis excluding one heterogeneous study favored DOACs (RR 0.79, 95% CI 0.63–0.98).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>In patients with non-valvular AF, DOACs demonstrate superior efficacy in reducing cerebrovascular ischemic outcomes and lower bleeding risk compared to VKAs, with comparable mortality outcomes. These findings support current guidelines recommending DOACs as first-line anticoagulation for stroke prevention in AF.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70308","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147697459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"“Loop Diuretics in Severe Aortic Stenosis: A Marker of Disease Severity, Not a Mortality Driver”","authors":"Ibadullah tahir,&nbsp;Hunain Shahbaz","doi":"10.1002/clc.70306","DOIUrl":"10.1002/clc.70306","url":null,"abstract":"&lt;p&gt;In their study of Loop Diuretics in Sepsis, Maeder and colleagues provide an invaluable dataset on hemodynamic indices of patients with severe aortic stenosis (AS) who are treated with loop diuretics (LDT); however, there are important limitations on the interpretation and methodology used in this study.&lt;/p&gt;&lt;p&gt;The most significant limitation to the study is its retrospective single-center design, which introduces a bias into the selection of patients. Compared to their respective cohorts of loop diuretic users, the LDT users were significantly older, had greater symptoms of AS, and had a higher rate of atrial fibrillation and surgical risk scores, all of which are well recognized risk factors for poor outcomes independent of diuretic use [&lt;span&gt;1, 2&lt;/span&gt;]. As such, they may be confounding by indication. This phenomenon is widely known as confounding by indication and describes the ability to observe a negative outcome of a particular treatment when viewed as a positive outcome in patients who were sicker or at greater risk than others receiving the drug or intervention [&lt;span&gt;3&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;According to the authors' conclusions, the torsemide dose lost its statistical significance after accounting for multiple variables, thus indicating that LDT was more indicative of disease severity rather than being a direct contributor to increased mortality risk [&lt;span&gt;4&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;Secondly, we should be cautious when interpreting the mortality hazard ratio (HR ≈ 2.0) that was reported in this study. Other similar observational studies regarding heart failure and TAVR populations have also indicated that diuretic use serves as an indicator of increased clinical severity and does not serve as an independent risk factor [&lt;span&gt;5, 6&lt;/span&gt;]. Due to the lack of exhaustive variable adjustment, especially adjusting for frailty, comorbidity burden, longitudinal volume status, and postoperative therapy, the association observed between LDT and mortality may be overestimated.&lt;/p&gt;&lt;p&gt;Lastly, it is worth noting that the generalizability of these results is limited because studies were conducted using only torasemide, different prescribing patterns around the world, and a patient population that included both torasemide and bicarb TAVI. Both AS and HF clinical practice guidelines view the use of diuretics for symptom relief, but not for predicting overall long term outcome. Neither set of guidelines states that using diuretics prior to AVR would have a negative effect on their outcome [&lt;span&gt;7, 8&lt;/span&gt;]&lt;/p&gt;&lt;p&gt;It is possible that the assumption that using diuretics will negatively impact their survival is not completely accurate. Although the authors advocate treating LDT in AS as a “red flag” for immediate evaluation, it is important to remember the most frequent reason for starting a loop diuretic was the presence of pulmonary congestion or symptoms of heart failure reflecting the progressive nature of the disease. Therefore, LDT appears to identify a physio","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70306","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147688406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"C-Reactive Protein–Triglyceride–Glucose Index and Coronary Artery Calcium Progression: A Prospective Cohort Analysis","authors":"Qing-Yun Hao,&nbsp;Ze-Hua Li,&nbsp;Jun Weng,&nbsp;Zi-Bin Zhan,&nbsp;Kun-Hao Bai,&nbsp;Jing-Bin Guo,&nbsp;Xiao-Ping Cui,&nbsp;Jing-Wei Gao,&nbsp;Yu-Hong Zeng","doi":"10.1002/clc.70304","DOIUrl":"10.1002/clc.70304","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>The <i>C</i>-reactive protein–triglyceride–glucose index (CTI) reflects systemic inflammation and insulin resistance, but its relationship with coronary artery calcium (CAC) progression remains unclear. This study examined the association between CTI and CAC progression in a longitudinal cohort.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study with CAC measurements at years 15, 20, and 25 were included. CTI was calculated from fasting blood samples at year 15 and categorized into quartiles. CAC was quantified using standardized computed tomography. CAC progression was defined as incident CAC &gt; 0 for those with baseline CAC = 0, an annualized CAC increase ≥ 10 units for those with baseline CAC: 0–100, or an annualized percent increase ≥10% for those with baseline CAC ≥ 100. Cox proportional hazards models estimated hazard ratios (HRs), adjusting for cardiovascular risk factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 2655 participants (mean age 40.3 ± 3.6 years; 44.7% men), 704 (26.5%) experienced CAC progression over 8.9 ± 2.0 years. After adjustment, individuals in the highest CTI quartile had a 38% higher risk of CAC progression compared with the lowest quartile (HR = 1.380; 95% CI: 1.072–1.775). Subgroup analyses by age, sex, race, body mass index, and baseline CAC status were consistent, and results remained robust after excluding participants with baseline diabetes or lipid-lowering medication use.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Higher CTI was independently associated with increased CAC progression, supporting its potential utility as a biomarker for identifying individuals at elevated risk of subclinical atherosclerosis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Trial Registration</h3>\u0000 \u0000 <p>URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005130.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70304","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147688351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Remnant Cholesterol Inflammatory Index and Its Association With All-Cause Mortality Among General Population and Individuals With Cardiovascular–Kidney–Metabolic Syndrome Stages 0–3: Evidence From Two Nationwide Studies","authors":"Chen-Zhang Ou,&nbsp;Zhong-Qiang Liu,&nbsp;Yu-Jun Xiong,&nbsp;Shiqin Chen,&nbsp;Tian Lv,&nbsp;Jingjing Lou","doi":"10.1002/clc.70297","DOIUrl":"10.1002/clc.70297","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Early identification of mortality risk in cardiovascular–kidney–metabolic (CKM) stages 0–3 remains challenging. The remnant cholesterol inflammatory index (RCII) has been associated with adverse outcomes, but its comparative prognostic performance in early CKM stages is unclear.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We analyzed data from two nationally representative cohorts, the U.S. National Health and Nutrition Examination Survey (NHANES) and the China Health and Retirement Longitudinal Study (CHARLS). RCII was compared with established metabolic indices for all-cause mortality using Cox regression, receiver operating characteristic analyses, and restricted cubic splines, with stratification by CKM stages.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Across both cohorts, higher RCII was consistently associated with increased all-cause mortality in the general population and among individuals with CKM stages 0–3. RCII demonstrated superior discriminatory performance compared with other metabolic indices. These associations remained robust after multivariable adjustment and were driven primarily by individuals in the highest RCII category. In NHANES, RCII showed comparable associations with cardiovascular and non-cardiovascular mortality.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>RCII is a strong and independent predictor of all-cause mortality across diverse populations and CKM stages 0–3.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70297","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147668552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sodium–Glucose Cotransporter 2 Inhibitors: Does One Size Fit All?","authors":"Paula Cristina Morariu,&nbsp;Maria Mihaela Godun,&nbsp;Marius Traian Dragos Marcu,&nbsp;Mariana Floria","doi":"10.1002/clc.70299","DOIUrl":"10.1002/clc.70299","url":null,"abstract":"&lt;p&gt;I read with great interest the article by Balata et al. [&lt;span&gt;1&lt;/span&gt;] about the impact of Empagliflozin versus Dapagliflozin on left ventricular remodeling in heart failure patients. This new standard of treatment in heart failure, sodium–glucose cotransporter 2 inhibitors (SGLT2i), appeared ten years ago. Since 2015 we know that, in patients with type 2 diabetes at high cardiovascular risk, adding Empagliflozin to standard care can decreases significantly the rate of major cardiovascular events and all-cause mortality compared with placebo [&lt;span&gt;2&lt;/span&gt;]. Since 2021 it is well known that SGLT2i reduced significantly the risk of cardiovascular death and heart failure-related hospitalizations in patients with chronic heart failure and reduced left ventricular ejection fraction [&lt;span&gt;3&lt;/span&gt;]. Later, data appeared for preserved left ventricular ejection fraction representing a turning point in current therapy of these patients [&lt;span&gt;3&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;In the study of Balata et al. [&lt;span&gt;1&lt;/span&gt;], the authors concluded that Empagliflozin, compared with Dapagliflozin, demonstrated more important effects on left ventricular remodeling assessed by standard echocardiographic markers. Even there were no differences between the two groups regarding heart failure hospitalizations or all-cause mortality, rapid left ventricular filling and sphericity index (i.e. ventricular remodeling) were significantly improved in the Empagliflozin group. The authors stated that it is uncertain whether SGLT2i have differential effects on cardiac structure and function.&lt;/p&gt;&lt;p&gt;Firstly, we consider that there are already some preclinical literature data about these effects of Empagliflozin. Therefore, we do not fully agree that the mechanisms underlying the benefits of Empagliflozin remain completely unclear. Empagliflozin improves cardiac diastolic function (relaxation) in female mice in the setting of obesity and diabetes, as well as profibrotic/prohypertrophic proteins, serum, glucocorticoid regulated kinase 1, epithelial sodium channel profibrosis signaling and associated interstitial fibrosis [&lt;span&gt;4&lt;/span&gt;]. In addition, eccentric left ventricular hypertrophy was slightly improved by Empagliflozin, assesed by a reduction in cardiomyocyte cross sectional area [&lt;span&gt;4&lt;/span&gt;]. Also, Empagliflozin can ameliorate atrial structural and electrical remodeling as well as improve mitochondrial function and mitochondrial biogenesis [&lt;span&gt;5&lt;/span&gt;]. Even in patients with acute decompensated heart failure, immediate addition of Empagliflozin to standard therapy improves echocardiographic parameters of left atrial volume in patients following recompensation [&lt;span&gt;6&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;Secondly, NT-proBNP can be a surrogate marker for the degree of left ventricular wall stress. In this study, NT-proBNP was higher in Empagliflozin group and left ventricular remodeling was significantly greater in this group; not only the remodeling was more important but also it was carried ","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70299","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147662221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How to Reduce the Incidence of Recurrence Following Catheter Ablation for Atrial Fibrillation","authors":"Naoya Kataoka,&nbsp;Teruhiko Imamura","doi":"10.1002/clc.70302","DOIUrl":"10.1002/clc.70302","url":null,"abstract":"<p>The recurrence of atrial fibrillation (AF) following catheter ablation remains an unresolved clinical issue. The authors developed a novel risk model to predict AF recurrence by integrating electro-anatomical voltage mapping with hematological and inflammatory biomarkers [<span>1</span>]. This approach is innovative and clinically relevant; however, several points warrant further discussion.</p><p>Although multiple biomarkers have been proposed to predict AF recurrence—including inflammatory markers, as highlighted in the present study [<span>1</span>], as well as oxidative stress–related biomarkers [<span>2</span>]—the precise causal relationship between these biomarkers and AF recurrence remains unclear. In particular, whether these circulating biomarkers directly reflect atrial substrate remodeling or merely represent epiphenomena associated with advanced disease is uncertain. An analysis exploring the correlation between biomarker levels and the extent of low-voltage areas might further clarify the mechanistic link between systemic inflammation and atrial structural remodeling.</p><p>The ultimate goal of catheter ablation for AF extends beyond rhythm control to the prevention of clinically meaningful outcomes, such as heart failure exacerbation and thromboembolic events. In this context, baseline data on thrombotic and bleeding risks—assessed using established scores such as CHA₂DS₂-VASc and HAS-BLED—would be informative. Evaluating whether the proposed novel risk score is associated not only with AF recurrence but also with these downstream clinical outcomes would further strengthen its clinical utility.</p><p>An important unanswered question is how AF recurrence can be reduced in patients identified as high risk by this model. Our group has previously demonstrated that impaired mitochondrial function, particularly defective mitochondrial autophagy, is associated with AF recurrence after catheter ablation [<span>3</span>]. From this perspective, therapeutic strategies targeting mitochondrial dysfunction may represent a promising adjunctive approach. For example, metformin has been reported to improve mitochondrial function and may reduce AF recurrence even in patients without diabetes mellitus. Incorporating such mechanistically driven interventions into future studies could provide a more comprehensive strategy for personalized AF management.</p><p>The authors declare no conflicts of interest.</p><p>The authors have nothing to report.</p>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70302","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147662310","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How to Interpret Long-Term Prognostic Impact of Catheter Ablation for Electrical Storm","authors":"Naoya Kataoka,&nbsp;Teruhiko Imamura","doi":"10.1002/clc.70301","DOIUrl":"10.1002/clc.70301","url":null,"abstract":"&lt;p&gt;While the number of catheter ablation procedures performed for refractory electrical storm has been increasing, their long-term clinical impact remains uncertain. In the present study, the authors demonstrated that ventricular tachycardia (VT) ablation was safe and effective for managing electrical storm, providing high acute procedural success and allowing most patients to be discharged [&lt;span&gt;1&lt;/span&gt;]. Conversely, these patients continued to face high risks of long-term morbidity and mortality. Several concerns have been raised.&lt;/p&gt;&lt;p&gt;The retrospective single-arm design without a control group introduces major selection bias [&lt;span&gt;1&lt;/span&gt;]. Patients who experienced an electrical storm but did not undergo VT ablation were excluded from analysis, and their clinical outcomes remain unknown. The inclusion of a comparator cohort treated with medical therapy alone—regarding survival, end-organ function, requirement for mechanical circulatory support or ventilation support, re-hospitalization, and VT recurrence—would further clarify the true clinical implication of VT ablation in this population [&lt;span&gt;2&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;Most participants had heart failure with reduced ejection fraction, and lower left ventricular ejection fraction was associated with worse long-term outcomes following VT ablation [&lt;span&gt;1&lt;/span&gt;]. Given that guideline-directed medical therapy (GDMT) for heart failure has a significant impact on improving cardiac function and prognosis [&lt;span&gt;3&lt;/span&gt;], the prescription rate and optimization of GDMT should be considered when interpreting the effect of VT ablation. Whether post-ablation medical therapy was optimized and whether GDMT intensification influenced clinical outcomes remains unclear.&lt;/p&gt;&lt;p&gt;VT recurrence continued to occur soon after the ablation procedure in the present cohort [&lt;span&gt;1&lt;/span&gt;], despite the general notion that the cumulative incidence of VT recurrence tends to plateau during the first year after ablation [&lt;span&gt;4&lt;/span&gt;]. This early recurrence pattern may suggest that the enrolled patients were more critically ill than conventional ablation cohorts, or that urgent ablation during electrical storm might not always achieve sufficient substrate modification. More detailed baseline information—such as hemodynamic severity, extent of myocardial scar, refractory arrhythmia burden before the procedure, and requirement for vasopressors or temporary mechanical support—would help clarify the clinical severity of this population.&lt;/p&gt;&lt;p&gt;The study highlights that successful VT ablation does not fully mitigate long-term risks in patients with electrical storm [&lt;span&gt;1&lt;/span&gt;]. This condition often reflects advanced structural heart disease, and aggressive post-ablation management—including heart failure optimization, candidacy assessment for ventricular assist devices or transplantation, and structured follow-up—may be essential to improve outcomes. Future studies should explore whether integrating substrate-based ablat","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70301","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147662294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluating Sex-Based Disparities in STEMI Care: A Call for Methodological Rigor","authors":"Noor-ul-Eman Haider","doi":"10.1002/clc.70298","DOIUrl":"10.1002/clc.70298","url":null,"abstract":"&lt;p&gt;Dear Esteemed Editor,&lt;/p&gt;&lt;p&gt;We read with much interest the paper by Evelo et al., “Evaluation of Sex-Based Differences in the Prescription of the Combination of Evidence-Based Medicine After the Occurrence of an Acute ST-Elevation Myocardial Infarction,” published in Clinical Cardiology [&lt;span&gt;1&lt;/span&gt;]. The authors are to be commended on using electronic health records to investigate an intriguing question: whether women and men experience similar prescriptions of evidence-based treatments following STEMI. Their paper is relevant, especially with the recent fervor regarding sex differences in cardiovascular treatment. Two telling methodological concerns render the quality of the findings and, in our view, warrant particular attention prior to reaching conclusions.&lt;/p&gt;&lt;p&gt;One of them quite critically is omitting to control confounding when presenting clinical outcomes. The authors have stated that “all mentioned secondary outcomes were not adjusted for confounders.” The paper does note, though, that the women were much more likely to have adverse events, with 6-month mortality of 5.0% versus 2.7% in men, and 6-month stroke rate of 5.5% versus 2.9% in men. Such rates, unadjusted as they are multivariable, are vulnerable to impugning causative association with the adverse outcome of sex per se [&lt;span&gt;2&lt;/span&gt;]. In the real world, such heterogeneity may represent heterogeneity in procedural volume, comorbidity burden, age, or frailty—components the authors knew were present but did not consider in outcome analyses [&lt;span&gt;3&lt;/span&gt;]. Without control, readers cannot help but wonder whether under-treatment of interventions was somehow mediating observed heterogeneity, or whether they are risk-adjusted at baseline. Additional research with multivariable Cox regression, propensity score matching, or mediation analysis would provide more reliable data [&lt;span&gt;4&lt;/span&gt;] on whether varying prescribing is responsible for poorer outcomes in women.&lt;/p&gt;&lt;p&gt;Secondly, loss of significant clinical covariates owing to missing data is troubling. The authors state that “variables were omitted from analysis if more than 50% of the values were missing.” Yet even those factors short of threshold were recorded as missing at very high rates. Notably, left ventricular ejection fraction (&lt;b&gt;LVEF&lt;/b&gt;)—a critical determinant of treatment eligibility and outcome [&lt;span&gt;5-7&lt;/span&gt;]—was “unknown” in 44.8% of women and 40.7% of men. Clustering nearly half the cohort as “unknown” could obscure clinically important differences and ruin adjusted models. Practice in clinical epidemiology now advises the application of multiple imputation with auxiliary variables to mitigate such missingness bias [&lt;span&gt;8, 9&lt;/span&gt;]. Without robust control, multivariable estimates of this study—for example, the aforementioned adjusted odds ratio for sex (&lt;b&gt;1.01; 95% CI: 0.73–1.39&lt;/b&gt;)—are at risk of instability and misattribution.&lt;/p&gt;&lt;p&gt;These frailties all argue for more methodological gravitas in lar","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70298","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147662280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Updated Meta-Analysis of Left Bundle Branch Area Pacing Versus Right Ventricular Pacing in Conduction System Disorders: Insights From New Evidence","authors":"Rehan Ishaque,&nbsp;George S. Abela,&nbsp;Ghazal Ishaque,&nbsp;Amina Akram,&nbsp;F. N. U. Reya,&nbsp;Furqan Tarique Memon,&nbsp;Hamza Danish,&nbsp;Amna Ikram,&nbsp;Zulfiqar Qutrio Baloch,&nbsp;Supratik Rayamajhi","doi":"10.1002/clc.70278","DOIUrl":"10.1002/clc.70278","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Right ventricular pacing (RVP) has long been the standard therapy for bradyarrhythmias but may induce ventricular dyssynchrony and adverse cardiac remodeling. Physiologic pacing strategies that preserve the native conduction system, particularly left bundle branch area pacing (LBBAP), have emerged as promising alternatives. This study aimed to evaluate the comparative efficacy and safety of LBBAP versus RVP through an updated meta-analysis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Following PRISMA guidelines, we systematically searched PubMed, Cochrane CENTRAL, and ClinicalTrials.gov for relevant studies published through June 2025. Studies comparing LBBAP and RVP in patients undergoing pacemaker implantation were included. Pooled estimates were calculated using random-effects models.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 40 studies comprising 8290 patients were included. LBBAP was associated with significantly shorter QRS duration compared with RVP (30 studies, <i>n</i> = 5510; MD −35.56 ms, 95% CI −41.88 to −29.24; <i>p</i> &lt; 0.0001). Structural remodeling also favored LBBAP, with greater improvement in left ventricular ejection fraction (16 studies, <i>n</i> = 1693; MD +3.77%, 95% CI 2.43–5.12; <i>p</i> &lt; 0.0001) and greater reduction in left ventricular end-diastolic diameter (13 studies, <i>n</i> = 1666; MD −2.33 mm, 95% CI −3.59 to −1.07; <i>p</i> &lt; 0.0001). Clinically, LBBAP was associated with lower heart failure hospitalization (RR 0.38, 95% CI 0.29–0.52; <i>p</i> &lt; 0.0001) and reduced all-cause mortality (RR 0.55, 95% CI 0.41–0.72; <i>p</i> &lt; 0.0001), along with greater reduction in NT-proBNP levels.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>LBBAP provides superior electrical synchrony, improved cardiac remodeling, and favorable clinical outcomes compared with RVP, while maintaining a comparable procedural safety profile.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13065497/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147644186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lipoprotein(a) and the Risk of Heart Failure: A Dose-Response Meta-Analysis","authors":"Yongmei He,&nbsp;Jun Liu,&nbsp;Jingwei Zhuang,&nbsp;Hongjia Hu","doi":"10.1002/clc.70289","DOIUrl":"10.1002/clc.70289","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Lipoprotein(a) [Lp(a)] is a genetically determined lipoprotein implicated in cardiovascular disease, but its role in heart failure (HF) remains uncertain. Observational studies indicate a link between elevated Lp(a) and HF risk, but the dose-response relationship remains unexplored. This meta-analysis aimed to quantify the association between circulating Lp(a) levels and HF incidence.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A systematic search of PubMed, Embase, and Web of Science identified prospective cohort studies reporting hazard ratios (HRs) for HF incidence across different Lp(a) levels. A random-effects model was applied to pool effect estimates while accounting for heterogeneity, and restricted cubic splines assessed dose-response relationships.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Five prospective cohort studies with 400 631 participants were included. During a mean follow-up duration of 11.0 years, 10 598 (2.6%) patients developed HF. A high Lp(a) level was associated with an increased HF risk (HR: 1.34, 95% CI: 1.14–1.59, <i>p</i> &lt; 0.001), with moderate heterogeneity (I² = 69%). Subgroup analysis showed a stronger association in studies using an Lp(a) cutoff of ≥ 50 mg/dL (HR: 1.68) compared to those with a cutoff of &lt; 50 mg/dL (HR: 1.16, p for subgroup difference &lt; 0.01), which completely explained the heterogeneity. The dose-response analysis revealed a nonlinear association (p for non-linearity = 0.001). HF risk increased nearly linearly below 55 mg/dL, then slowed, and plateaued at 160 mg/dL.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Elevated Lp(a) is associated with an increased HF risk in a nonlinear pattern, with risk escalation slowing at higher concentrations.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"49 4","pages":""},"PeriodicalIF":2.3,"publicationDate":"2026-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13054834/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147627369","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}