Cardiology, Peripheral Vasculature, Rhythm Disorders,

This Medical News article is an editor’s choice roundup of the most impactful, newsworthy, and novel studies published in JAMA over the past year.

A new online calculator may help determine relative risk for long-term cardiovascular disease (CVD) for adults aged 30 to 59. The tool uses metrics including blood pressure, cholesterol levels, and body mass index to compute an individual’s 30-year CVD risk relative to others.

This Medical News article is an editor’s choice roundup of the most impactful, newsworthy, and novel studies published in JAMA over the past year.

Background Atrial fibrillation (AF) impacts management decisions in valvular heart disease but its significance in patients with chronic aortic regurgitation (AR) is not well established. Objectives To evaluate the prevalence and prognostic role of AF in patients with chronic, haemodynamically significant AR. Methods Adults with chronic ≥moderate-to-severe AR, from March 2004 to April 2019, were retrospectively identified. Those with acute AR, moderate or worse other valve disease or prior valve surgery were excluded. Patients with AF were identified based on 12-lead ECGs, 1-lead ECGs (showing AF for ≥30 s), or episodes recorded by implanted cardiac devices. Primary outcome was all-cause mortality. Cox regression models were used to assess associations with mortality: model 1 adjusted for age, symptoms (New York Heart Association class II–IV), Charlson Comorbidity Index, left ventricle (LV) end-systolic volume index and AF; model 2 added left atrial volume index and model 3 further added systolic pulmonary artery pressure. Results Of the 1006 included patients (age 59±18 years; 822 (82%) men), 446 (46%) had hypertension and 364 (36%) had a bicuspid aortic valve. AF was present in 161 (16%) patients at the time of ≥moderate-to-severe AR diagnosis. During a median follow-up of 1.6 years (IQR 0.2–6.2), AF was associated with an increased mortality risk in univariate and in all three multivariable models (HR 1.61 (95% CI 1.07 to 2.43), HR 2.21 (95% CI 1.31 to 3.72) and HR 2.06 (95% CI 1.21 to 3.52), respectively), including after propensity matching (HR 1.58 (95% CI 1.01 to 2.48)). Conclusions AF is present in one in six patients with chronic≥moderate-to-severe AR and is associated with an increased risk of mortality even after adjusting for measures of LV systolic and diastolic function. There is a need for future prospective studies to validate these findings and evaluate AF as a potential trigger for early surgery.

Chronic aortic regurgitation (AR) is a progressive disease that often remains asymptomatic until advanced stages. Retrograde flow of blood into the left ventricle (LV) during diastole results in persistent volume overload, elevating end-diastolic pressure and inducing eccentric hypertrophy.1 To preserve forward stroke volume, the LV compensates by expelling both regurgitant and effective volumes during systole. This compensation leads to systolic hypertension, which in turn promotes aortic root dilation and enlargement of the regurgitant orifice—creating a self-perpetuating cycle of worsening haemodynamics.2 As LV end-diastolic pressure rises, it is passively transmitted to the left atrium (LA), resulting in progressive LA dilatation and fibrotic remodelling. These structural changes impair atrial conduction and establish a substrate for atrial fibrillation (AF). Elevated LA pressure also triggers neurohormonal responses, particularly sympathetic activation, which further destabilises atrial electrophysiology.3 Once AF develops, the loss of atrial contraction reduces LV preload, compromises...

Clinical introduction A male in his 20s with good past health presented to the clinic with a 1-month history of fever, polyarthritis and myalgia in the lower limbs. Physical examination revealed diastolic blood pressure of 110 mm Hg and diminished pulsation of dorsalis pedis arteries. Laboratory data showed elevated inflammatory markers, but tests for autoimmune antibodies, cardiac enzymes and infectious diseases were all negative. Electromyogram of the lower limbs showed peroneal and tibial neuropathies. Transthoracic echocardiography revealed elevated pulmonary artery pressure (40 mm Hg) with normal chamber size and function. The patient reported a 6 kg unintentional weight loss and the development of interdigital ulcerations on the feet over the following month. Whole-body positron emission tomography (PET) scan showed two focal strong fluorodeoxyglucose (FDG) avidities of coronary arteries (standardised uptake value maximum (SUVmax)=7.89) and diffuse FDG uptake in the vessels of all limbs (SUVmax=2.92) (figure 1)....

Despite advances in its understanding and treatment, coronary heart disease remains the leading cause of death worldwide. Acute coronary syndromes most commonly result as a consequence of the rupture of non-flow-limiting, high-risk coronary artery plaques. Advances in multimodality imaging have allowed the detailed assessment of the high-risk plaque including the assessment of plaque burden, high-risk plaque features, plaque activity and thrombosis. This in turn may help identify those patients at greatest risk, and thus benefit from intensification of pharmacotherapies or from local preventative strategies including coronary revascularisation. However, the optimal management of high-risk plaques and the prevention of consequent adverse coronary events have yet to be established. Further development and observational studies are required to determine how best to apply high-risk plaque metrics into clinical practice. Nevertheless, a new era of precision medicine is upon us, with advanced plaque imaging allowing enhanced risk stratification and targeting of the growing armamentarium of atherosclerotic therapies to the highest risk patients.

Background Cardiovascular disease (CVD) burden and risk factor management among cancer survivors, especially in socioeconomically deprived, multiethnic populations, remain understudied. This study examines CVD burden and risk factor control in survivors of 20 cancer types within a diverse urban population. Methods This matched cohort study used electronic health records from 127 urban primary care practices. Cancer survivors were matched to non-cancer comparators at a 1:4 ratio. Cancer and CVD diagnoses were defined using standard clinical code sets. Sociodemographic variables, lifestyle behaviours, blood pressure, cholesterol levels and statin prescriptions were analysed. Multivariable regression evaluated associations between cancer history, CVD prevalence and risk factor control. Results The cohort included 18 839 cancer survivors (43% men, average age 64±15 years), with high ethnic diversity (48% White, 24% Black, 22% Asian) and high deprivation levels. Cancer survivors had elevated odds of all CVDs considered, independent of shared risk factors. Heart failure was more common in haematological (OR 2.12; 95% CI 1.44 to 3.09) and breast cancer survivors (OR 1.38; 95% CI 1.16 to 1.64). Patients with bladder (OR 1.50; 95% CI 1.20 to 1.87) and lung cancer (OR 1.44; 95% CI 1.09 to 1.87) had higher odds of ischaemic heart disease. Venous thromboembolism risk was highest in ovarian cancer (OR 5.72; 95% CI 3.54 to 9.32). Blood pressure control was slightly better in cancer survivors (OR 0.92; 95% CI 0.87 to 0.97), yet one in three patients did not meet guideline-directed targets. Statin use and cholesterol management were similar between survivors and controls, but disparities were observed within certain ethnic groups. Conclusion Cancer survivors have an elevated risk of CVD, with variations by cancer type and ethnicity. Despite comparable or slightly better control of major risk factors, a significant proportion of cancer survivors do not achieve guideline-recommended targets, highlighting the need for optimised management strategies, particularly in high-risk subgroups.

Background and objective Prior studies have suggested that patients with premature ventricular complexes (PVCs) may have an increased risk for atrial fibrillation (AF) and stroke. It is unclear whether frequent PVCs are linked to an increased risk of AF and stroke in patients where structural heart disease (SHD) has been excluded. We aimed to study if PVCs increase the risk of AF or stroke in patients without SHD. Methods In this retrospective observational cohort study, we included patients who received a PVC diagnosis at three major hospitals in Stockholm, Sweden. The patients had no history of heart disease, normal results at stress test and echocardiography, and no previous diagnosis of AF or stroke. For each case, four matched controls were obtained from the general population. We used inverse probability weighting (IPW) to control for differences in baseline characteristics. Results A total of 751 PVC patients and 3041 controls were included. The median age was 59 years, and 2239 (59%) were women. The median follow-up time was 5.2 years. There was a higher risk of AF among patients in the PVC group compared with the control group in the unadjusted analysis (HR 2.08, 95% CI 1.35 to 3.20, p=0.0009). After IPW, there was no significant difference in the risk of AF (HR 1.44, 95% CI 0.88 to 2.37) or stroke (HR 1.32, 95% CI 0.81 to 2.14) between the PVC group and the control group. Conclusion In patients with PVCs but without SHD, there was no increased risk of AF or stroke compared with controls from the general population after adjusting for known confounders. However, PVCs were associated with AF in the crude cohort, suggesting that PVCs may be a clinical marker for AF.

Background Patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension (PAH/CTEPH) may experience physiological stress at high altitude. We investigated pulmonary haemodynamics and right heart function during incremental (IET) and constant work-rate exercise tests (CWRET) at high (2500 m) vs low altitude (470 m). Methods In this randomised crossover trial, patients with stable PAH/CTEPH without resting hypoxaemia performed IET and CWRET at both altitudes. Systolic pulmonary arterial pressure (sPAP) and right ventricular (RV) arterial coupling (tricuspid annular plane systolic excursion/sPAP) were assessed by echocardiography. Results Among 27 patients (44% women, 61±14 years), sPAP was higher at rest at 2500 m vs 470 m (mean difference: 14 mm Hg, 95% CI 7 to 23), but increased linearly during exercise with similar slopes at each altitude (7.9 vs 9.7 mm Hg/min, respectively). RV arterial coupling was lower at high altitude at rest (difference: –0.13 mm/mm Hg, 95% CI –0.26 to –0.04) but decreased comparably during exercise. During CWRET, sPAP rose steeply in the first 3 min, plateauing thereafter, with no altitude-dependent differences in pressure-flow slope. Oxygen delivery was reduced at high altitude. Conclusion Despite higher baseline sPAP and reduced RV coupling at rest, exercise-induced haemodynamic changes were similar at both high and low altitudes, suggesting short-term altitude exposure does not exacerbate cardiopulmonary stress during exercise in stable PAH/CTEPH. The exercise protocol (IET vs CWRET) alters haemodynamic trajectories more than altitude. Trial registration number NCT05107700.

Background Although treatment options for heart failure (HF) have improved, advanced HF (AdHF) remains a challenging condition, impacting over 10% of patients with a poor prognosis. In severe cases, patients may experience resistance to or intolerance of conventional therapies, leading to frequent hospitalisations and a heightened risk of death. Vericiguat, a novel treatment for HF with reduced ejection fraction (HFrEF), has shown promise in improving outcomes for patients with worsening HF. The VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial demonstrated that vericiguat can reduce the risk of adverse events in patients with EF<45% following a worsening HF event. However, its safety and efficacy in AdHF patients previously receiving chronic levosimendan infusions remain unclear. Methods and results In this prospective study, we evaluated the safety and tolerability of vericiguat in AdHF patients treated with monthly levosimendan infusions at our clinic. Among 18 patients, 8 were eligible for vericiguat, which was associated with better echocardiographic findings, improved quality of life and lower 1-year mortality compared with non-eligible patients. However, 37.5% of patients discontinued the drug due to symptomatic hypotension, highlighting a key challenge in managing this fragile population. Despite this, vericiguat was generally well-tolerated, and no severe adverse effects were observed. Discussion This study provides the first prospective evidence supporting the safe use of vericiguat in AdHF patients on chronic levosimendan. However, careful monitoring for hypotension is essential, and titration may be more difficult in this population. Further research is needed to optimise treatment strategies for these high-risk patients.

Background Atrial fibrillation (AF) impacts management decisions in valvular heart disease but its significance in patients with chronic aortic regurgitation (AR) is not well established. Objectives To evaluate the prevalence and prognostic role of AF in patients with chronic, haemodynamically significant AR. Methods Adults with chronic ≥moderate-to-severe AR, from March 2004 to April 2019, were retrospectively identified. Those with acute AR, moderate or worse other valve disease or prior valve surgery were excluded. Patients with AF were identified based on 12-lead ECGs, 1-lead ECGs (showing AF for ≥30 s), or episodes recorded by implanted cardiac devices. Primary outcome was all-cause mortality. Cox regression models were used to assess associations with mortality: model 1 adjusted for age, symptoms (New York Heart Association class II–IV), Charlson Comorbidity Index, left ventricle (LV) end-systolic volume index and AF; model 2 added left atrial volume index and model 3 further added systolic pulmonary artery pressure. Results Of the 1006 included patients (age 59±18 years; 822 (82%) men), 446 (46%) had hypertension and 364 (36%) had a bicuspid aortic valve. AF was present in 161 (16%) patients at the time of ≥moderate-to-severe AR diagnosis. During a median follow-up of 1.6 years (IQR 0.2–6.2), AF was associated with an increased mortality risk in univariate and in all three multivariable models (HR 1.61 (95% CI 1.07 to 2.43), HR 2.21 (95% CI 1.31 to 3.72) and HR 2.06 (95% CI 1.21 to 3.52), respectively), including after propensity matching (HR 1.58 (95% CI 1.01 to 2.48)). Conclusions AF is present in one in six patients with chronic≥moderate-to-severe AR and is associated with an increased risk of mortality even after adjusting for measures of LV systolic and diastolic function. There is a need for future prospective studies to validate these findings and evaluate AF as a potential trigger for early surgery.

Background Radiation exposure of the heart secondary to radiotherapy can lead to potential cardiac injury. However, the hazard ratio (HR) for cardiac morbidity and mortality associated with undergoing breast cancer radiotherapy remains unknown. Objectives To pool the HRs for cardiovascular risk in patients with breast cancer treated with or without radiotherapy, compare the cardiac risk among irradiated patients divided by the laterality of radiotherapy and further assess the association between the cardiac radiation dose and cardiac morbidity. Methods A literature search was conducted using MEDLINE, EMBASE and the Cochrane Library from inception to 1 December 2024. Studies that reported HRs with 95% CIs for the associations of interest were included. Pooled effect estimates were obtained using random-effects meta-analysis. Subgroup analyses were carried out to investigate the influence of the treatment period on cardiovascular outcomes. Publication bias was evaluated using the Egger and Begger’s tests. Results Thirty-one studies involving 610 690 participants were ultimately included. Compared with patients who did not receive radiotherapy, patients who underwent radiotherapy experienced increased risks for developing heart failure (HR: 1.37; 95% CI 1.20 to 1.57). Among patients treated with radiotherapy, left-sided radiotherapy increased the risk of subsequent coronary artery disease (HR: 1.11; 95% CI 1.05 to 1.16). There was a linear correlation between the mean heart exposure dose and cardiac morbidity development (HR: 1.12; 95% CI 1.05 to 1.19). When patients were grouped by treatment period, the risk of cardiac mortality in patients treated with left-sided radiotherapy decreased after 1989 (HR: 1.30 vs 1.02, p<0.01*). No evidence of significant publication bias was identified. Conclusions Radiotherapy for breast cancer was associated with an increased risk of experiencing adverse cardiovascular events, which was highly dependent on the cardiac irradiation dose. With advances in radiation techniques, cardiovascular prognosis is expected to improve further.

Atrial fibrillation (AF) and premature ventricular complexes (PVCs) are two of the most prevalent arrhythmias in the general population. It is not surprising that their prevalence increases further with longer monitoring durations and among patients with structural heart disease (SHD). The Coumel triangle—which includes three key components in arrhythmogenesis (the arrhythmogenic substrate, modulating factors and triggering factors)—may help explain why AF and PVCs frequently coexist in clinical practice. But it is unknown whether the link between them is causal or coincidental. In fact, the possible pathophysiological relationship between PVC and AF is multifactorial and incompletely understood, but several mechanisms have been proposed as possible explanations. On the one hand, frequent PVCs can induce retrograde ventriculoatrial conduction, resulting in atrial depolarisations that act as ectopic atrial beats. These ectopic beats may serve as triggers for AF, particularly in the presence of a vulnerable atrial substrate.1 But also, both...

Background Patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension (PAH/CTEPH) may experience physiological stress at high altitude. We investigated pulmonary haemodynamics and right heart function during incremental (IET) and constant work-rate exercise tests (CWRET) at high (2500 m) vs low altitude (470 m). Methods In this randomised crossover trial, patients with stable PAH/CTEPH without resting hypoxaemia performed IET and CWRET at both altitudes. Systolic pulmonary arterial pressure (sPAP) and right ventricular (RV) arterial coupling (tricuspid annular plane systolic excursion/sPAP) were assessed by echocardiography. Results Among 27 patients (44% women, 61±14 years), sPAP was higher at rest at 2500 m vs 470 m (mean difference: 14 mm Hg, 95% CI 7 to 23), but increased linearly during exercise with similar slopes at each altitude (7.9 vs 9.7 mm Hg/min, respectively). RV arterial coupling was lower at high altitude at rest (difference: –0.13 mm/mm Hg, 95% CI –0.26 to –0.04) but decreased comparably during exercise. During CWRET, sPAP rose steeply in the first 3 min, plateauing thereafter, with no altitude-dependent differences in pressure-flow slope. Oxygen delivery was reduced at high altitude. Conclusion Despite higher baseline sPAP and reduced RV coupling at rest, exercise-induced haemodynamic changes were similar at both high and low altitudes, suggesting short-term altitude exposure does not exacerbate cardiopulmonary stress during exercise in stable PAH/CTEPH. The exercise protocol (IET vs CWRET) alters haemodynamic trajectories more than altitude. Trial registration number NCT05107700.

Background and objective Prior studies have suggested that patients with premature ventricular complexes (PVCs) may have an increased risk for atrial fibrillation (AF) and stroke. It is unclear whether frequent PVCs are linked to an increased risk of AF and stroke in patients where structural heart disease (SHD) has been excluded. We aimed to study if PVCs increase the risk of AF or stroke in patients without SHD. Methods In this retrospective observational cohort study, we included patients who received a PVC diagnosis at three major hospitals in Stockholm, Sweden. The patients had no history of heart disease, normal results at stress test and echocardiography, and no previous diagnosis of AF or stroke. For each case, four matched controls were obtained from the general population. We used inverse probability weighting (IPW) to control for differences in baseline characteristics. Results A total of 751 PVC patients and 3041 controls were included. The median age was 59 years, and 2239 (59%) were women. The median follow-up time was 5.2 years. There was a higher risk of AF among patients in the PVC group compared with the control group in the unadjusted analysis (HR 2.08, 95% CI 1.35 to 3.20, p=0.0009). After IPW, there was no significant difference in the risk of AF (HR 1.44, 95% CI 0.88 to 2.37) or stroke (HR 1.32, 95% CI 0.81 to 2.14) between the PVC group and the control group. Conclusion In patients with PVCs but without SHD, there was no increased risk of AF or stroke compared with controls from the general population after adjusting for known confounders. However, PVCs were associated with AF in the crude cohort, suggesting that PVCs may be a clinical marker for AF.

Background Although treatment options for heart failure (HF) have improved, advanced HF (AdHF) remains a challenging condition, impacting over 10% of patients with a poor prognosis. In severe cases, patients may experience resistance to or intolerance of conventional therapies, leading to frequent hospitalisations and a heightened risk of death. Vericiguat, a novel treatment for HF with reduced ejection fraction (HFrEF), has shown promise in improving outcomes for patients with worsening HF. The VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial demonstrated that vericiguat can reduce the risk of adverse events in patients with EF<45% following a worsening HF event. However, its safety and efficacy in AdHF patients previously receiving chronic levosimendan infusions remain unclear. Methods and results In this prospective study, we evaluated the safety and tolerability of vericiguat in AdHF patients treated with monthly levosimendan infusions at our clinic. Among 18 patients, 8 were eligible for vericiguat, which was associated with better echocardiographic findings, improved quality of life and lower 1-year mortality compared with non-eligible patients. However, 37.5% of patients discontinued the drug due to symptomatic hypotension, highlighting a key challenge in managing this fragile population. Despite this, vericiguat was generally well-tolerated, and no severe adverse effects were observed. Discussion This study provides the first prospective evidence supporting the safe use of vericiguat in AdHF patients on chronic levosimendan. However, careful monitoring for hypotension is essential, and titration may be more difficult in this population. Further research is needed to optimise treatment strategies for these high-risk patients.

Background Cardiovascular disease (CVD) burden and risk factor management among cancer survivors, especially in socioeconomically deprived, multiethnic populations, remain understudied. This study examines CVD burden and risk factor control in survivors of 20 cancer types within a diverse urban population. Methods This matched cohort study used electronic health records from 127 urban primary care practices. Cancer survivors were matched to non-cancer comparators at a 1:4 ratio. Cancer and CVD diagnoses were defined using standard clinical code sets. Sociodemographic variables, lifestyle behaviours, blood pressure, cholesterol levels and statin prescriptions were analysed. Multivariable regression evaluated associations between cancer history, CVD prevalence and risk factor control. Results The cohort included 18 839 cancer survivors (43% men, average age 64±15 years), with high ethnic diversity (48% White, 24% Black, 22% Asian) and high deprivation levels. Cancer survivors had elevated odds of all CVDs considered, independent of shared risk factors. Heart failure was more common in haematological (OR 2.12; 95% CI 1.44 to 3.09) and breast cancer survivors (OR 1.38; 95% CI 1.16 to 1.64). Patients with bladder (OR 1.50; 95% CI 1.20 to 1.87) and lung cancer (OR 1.44; 95% CI 1.09 to 1.87) had higher odds of ischaemic heart disease. Venous thromboembolism risk was highest in ovarian cancer (OR 5.72; 95% CI 3.54 to 9.32). Blood pressure control was slightly better in cancer survivors (OR 0.92; 95% CI 0.87 to 0.97), yet one in three patients did not meet guideline-directed targets. Statin use and cholesterol management were similar between survivors and controls, but disparities were observed within certain ethnic groups. Conclusion Cancer survivors have an elevated risk of CVD, with variations by cancer type and ethnicity. Despite comparable or slightly better control of major risk factors, a significant proportion of cancer survivors do not achieve guideline-recommended targets, highlighting the need for optimised management strategies, particularly in high-risk subgroups.

Background Radiation exposure of the heart secondary to radiotherapy can lead to potential cardiac injury. However, the hazard ratio (HR) for cardiac morbidity and mortality associated with undergoing breast cancer radiotherapy remains unknown. Objectives To pool the HRs for cardiovascular risk in patients with breast cancer treated with or without radiotherapy, compare the cardiac risk among irradiated patients divided by the laterality of radiotherapy and further assess the association between the cardiac radiation dose and cardiac morbidity. Methods A literature search was conducted using MEDLINE, EMBASE and the Cochrane Library from inception to 1 December 2024. Studies that reported HRs with 95% CIs for the associations of interest were included. Pooled effect estimates were obtained using random-effects meta-analysis. Subgroup analyses were carried out to investigate the influence of the treatment period on cardiovascular outcomes. Publication bias was evaluated using the Egger and Begger’s tests. Results Thirty-one studies involving 610 690 participants were ultimately included. Compared with patients who did not receive radiotherapy, patients who underwent radiotherapy experienced increased risks for developing heart failure (HR: 1.37; 95% CI 1.20 to 1.57). Among patients treated with radiotherapy, left-sided radiotherapy increased the risk of subsequent coronary artery disease (HR: 1.11; 95% CI 1.05 to 1.16). There was a linear correlation between the mean heart exposure dose and cardiac morbidity development (HR: 1.12; 95% CI 1.05 to 1.19). When patients were grouped by treatment period, the risk of cardiac mortality in patients treated with left-sided radiotherapy decreased after 1989 (HR: 1.30 vs 1.02, p<0.01*). No evidence of significant publication bias was identified. Conclusions Radiotherapy for breast cancer was associated with an increased risk of experiencing adverse cardiovascular events, which was highly dependent on the cardiac irradiation dose. With advances in radiation techniques, cardiovascular prognosis is expected to improve further.

Despite advances in its understanding and treatment, coronary heart disease remains the leading cause of death worldwide. Acute coronary syndromes most commonly result as a consequence of the rupture of non-flow-limiting, high-risk coronary artery plaques. Advances in multimodality imaging have allowed the detailed assessment of the high-risk plaque including the assessment of plaque burden, high-risk plaque features, plaque activity and thrombosis. This in turn may help identify those patients at greatest risk, and thus benefit from intensification of pharmacotherapies or from local preventative strategies including coronary revascularisation. However, the optimal management of high-risk plaques and the prevention of consequent adverse coronary events have yet to be established. Further development and observational studies are required to determine how best to apply high-risk plaque metrics into clinical practice. Nevertheless, a new era of precision medicine is upon us, with advanced plaque imaging allowing enhanced risk stratification and targeting of the growing armamentarium of atherosclerotic therapies to the highest risk patients.

Chronic aortic regurgitation (AR) is a progressive disease that often remains asymptomatic until advanced stages. Retrograde flow of blood into the left ventricle (LV) during diastole results in persistent volume overload, elevating end-diastolic pressure and inducing eccentric hypertrophy.1 To preserve forward stroke volume, the LV compensates by expelling both regurgitant and effective volumes during systole. This compensation leads to systolic hypertension, which in turn promotes aortic root dilation and enlargement of the regurgitant orifice—creating a self-perpetuating cycle of worsening haemodynamics.2 As LV end-diastolic pressure rises, it is passively transmitted to the left atrium (LA), resulting in progressive LA dilatation and fibrotic remodelling. These structural changes impair atrial conduction and establish a substrate for atrial fibrillation (AF). Elevated LA pressure also triggers neurohormonal responses, particularly sympathetic activation, which further destabilises atrial electrophysiology.3 Once AF develops, the loss of atrial contraction reduces LV preload, compromises...

Atrial fibrillation (AF) and premature ventricular complexes (PVCs) are two of the most prevalent arrhythmias in the general population. It is not surprising that their prevalence increases further with longer monitoring durations and among patients with structural heart disease (SHD). The Coumel triangle—which includes three key components in arrhythmogenesis (the arrhythmogenic substrate, modulating factors and triggering factors)—may help explain why AF and PVCs frequently coexist in clinical practice. But it is unknown whether the link between them is causal or coincidental. In fact, the possible pathophysiological relationship between PVC and AF is multifactorial and incompletely understood, but several mechanisms have been proposed as possible explanations. On the one hand, frequent PVCs can induce retrograde ventriculoatrial conduction, resulting in atrial depolarisations that act as ectopic atrial beats. These ectopic beats may serve as triggers for AF, particularly in the presence of a vulnerable atrial substrate.1 But also, both...

Clinical introduction A male in his 20s with good past health presented to the clinic with a 1-month history of fever, polyarthritis and myalgia in the lower limbs. Physical examination revealed diastolic blood pressure of 110 mm Hg and diminished pulsation of dorsalis pedis arteries. Laboratory data showed elevated inflammatory markers, but tests for autoimmune antibodies, cardiac enzymes and infectious diseases were all negative. Electromyogram of the lower limbs showed peroneal and tibial neuropathies. Transthoracic echocardiography revealed elevated pulmonary artery pressure (40 mm Hg) with normal chamber size and function. The patient reported a 6 kg unintentional weight loss and the development of interdigital ulcerations on the feet over the following month. Whole-body positron emission tomography (PET) scan showed two focal strong fluorodeoxyglucose (FDG) avidities of coronary arteries (standardised uptake value maximum (SUVmax)=7.89) and diffuse FDG uptake in the vessels of all limbs (SUVmax=2.92) (figure 1)....

Heart block is one of the more frequent adverse events of aortic valve replacement therapy, in both surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR). Data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry report a 30-day permanent pacemaker (PM) implantation rate of 11.3%, with extensive site-level variation (0%-36%). Current guidance from the 2020 American College of Cardiology Expert Consensus Decision Pathway recommends PM implantation for symptomatic bradycardia or complete heart block (CHB) and monitoring with consideration of electrophysiology study (EPS) for new or progressive conduction disturbances. Yet more than 2 decades after the introduction of TAVR, uncertainty remains regarding which conduction changes truly warrant permanent pacing, and different strategies have been proposed for conduction disturbance management.

This Special Communication discusses the potential of the Ziltivekimab Cardiovascular Outcomes Trial (ZEUS) to provide a fully novel approach for prevention of myocardial infarction, stroke, cardiovascular death, and kidney function decline among high-risk patients with chronic kidney disease.

This Special Communication discusses the potential of the Ziltivekimab Cardiovascular Outcomes Trial (ZEUS) to provide a fully novel approach for prevention of myocardial infarction, stroke, cardiovascular death, and kidney function decline among high-risk patients with chronic kidney disease.

A previously healthy man had headache, chest pain, abdominal pain, vomiting, and diarrhea 1 hour after eating raw tuna sashimi. His blood pressure was 67/42 mm Hg, and he had an erythematous nonpruritic rash on his upper torso, ST-segment elevation in lead aVR, and ST-segment depressions in leads II, III, aVF, and V3-6. What is the diagnosis and what would you do next?

This cohort study investigates the association between marathon-induced troponin T release and long-term right ventricular remodeling after 10 years of repetitive endurance exercise.

This cohort study among consecutive patients undergoing transcatheter aortic valve replacement (TAVR) analyzes mechanisms underlying heart block complicating TAVR to improve prediction of intraprocedural and delayed heart block.

This Special Communication discusses the potential of the Ziltivekimab Cardiovascular Outcomes Trial (ZEUS) to provide a fully novel approach for prevention of myocardial infarction, stroke, cardiovascular death, and kidney function decline among high-risk patients with chronic kidney disease.

This cohort study among consecutive patients undergoing transcatheter aortic valve replacement (TAVR) analyzes mechanisms underlying heart block complicating TAVR to improve prediction of intraprocedural and delayed heart block.

Heart block is one of the more frequent adverse events of aortic valve replacement therapy, in both surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR). Data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry report a 30-day permanent pacemaker (PM) implantation rate of 11.3%, with extensive site-level variation (0%-36%). Current guidance from the 2020 American College of Cardiology Expert Consensus Decision Pathway recommends PM implantation for symptomatic bradycardia or complete heart block (CHB) and monitoring with consideration of electrophysiology study (EPS) for new or progressive conduction disturbances. Yet more than 2 decades after the introduction of TAVR, uncertainty remains regarding which conduction changes truly warrant permanent pacing, and different strategies have been proposed for conduction disturbance management.

This secondary post hoc analysis of a randomized clinical trial investigates the association of obstructive coronary artery disease with patient-reported disease-specific health status and clinical efficacy among patients with symptomatic severe aortic stenosis undergoing transcatheter aortic valve replacement.

Greater nighttime light exposure may increase the risk of cardiovascular disease, according to a recent large study published in JAMA Network Open.

Greater nighttime light exposure may increase the risk of cardiovascular disease, according to a recent large study published in JAMA Network Open.

Greater nighttime light exposure may increase the risk of cardiovascular disease, according to a recent large study published in JAMA Network Open.

The US Food and Drug Administration (FDA) recently approved Novo Nordisk’s oral semaglutide, marketed as Rybelsus, to reduce the risk of major adverse cardiac events in adults with type 2 diabetes who are at high risk of these conditions.

Cardiology

Greater nighttime light exposure may increase the risk of cardiovascular disease, according to a recent large study published in JAMA Network Open.

Greater nighttime light exposure may increase the risk of cardiovascular disease, according to a recent large study published in JAMA Network Open.

This cohort study estimates the 1-year absolute excess risk of any cardiovascular event following laboratory-confirmed respiratory syncytial virus (RSV) infection among adults in Denmark.

Mustafa Eray Kilic<br />Dec 1, 2025; 111:1175-1183<br />Systematic review

This multicenter randomized clinical trial conducted in China determines whether intracardiac echocardiography is noninferior to transesophageal echocardiography in preventing periprocedural thromboembolic events in atrial fibrillation ablation.

Cardiac Imaging

Nicholas I-Hsien Kuo<br />Nov 17, 2025; 0:heartjnl-2025-325776v1-heartjnl-2025-325776<br />Cardiac risk factors and prevention

Peter Alexander John Haworth<br />Nov 17, 2025; 0:heartjnl-2025-327110v1-heartjnl-2025-327110<br />Healthcare delivery, economics and global health

Jiao Li<br />Nov 9, 2025; 0:heartjnl-2025-326273v1-heartjnl-2025-326273<br />Reviews

This randomized clinical trial tests whether metformin improved 6-minute walk distance at 6 months compared with placebo in people with peripheral artery disease without diabetes.

Wilhelm Storck<br />Nov 1, 2025; 111:1047-1056<br />Systematic review

David Kylhammar<br />Oct 1, 2025; 111:904-909<br />Aortic and vascular disease

Tsung-Ying Tsai<br />Aug 27, 2025; 0:heartjnl-2025-325769v1-heartjnl-2025-325769<br />Coronary artery disease

This cross-sectional study compares the prevalence of cardiovascular-related conditions across racial and ethnic groups for transgender, gender-diverse, and cisgender people using quantitative intersectional methods.

Peter S Sever<br />Aug 1, 2025; 111:769-775<br />Cardiac risk factors and prevention

Qian Zhang<br />Jul 1, 2025; 111:662-670<br />Reviews

Oliver Ian Brown<br />Mar 1, 2025; 111:e2-e2<br />Consensus statement