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IntroductionCardiac anxiety is common following acute coronary syndrome (ACS) and is characterised by fear of recurrence, heightened attention to cardiac sensations and avoidance of cardiac-related activities in daily life. It is associated with depression, reduced quality of life (QoL) and an adverse cardiac prognosis. We have developed a digital cognitive–behavioural therapy protocol for cardiac anxiety (CA-CBT) post ACS, previously evaluated in clinical trials including one randomised controlled trial (RCT), in which the intervention was compared to usual care. This protocol article describes a follow-up RCT, designed to further evaluate the efficacy of CA-CBT compared with an active control receiving a digital cardiac lifestyle intervention (CLI).Method and analysisParticipants with ACS (ST-elevation myocardial infarction (STEMI)/non-STEMI/unstable angina ≥6 months prior) and elevated cardiac anxiety (Cardiac Anxiety Questionnaire; CAQ ≥18 and as per clinical interviews) (n=176) are randomised 1:1 to 8 weeks of CA-CBT or CLI. Primary outcome is change in cardiac anxiety, measured by the CAQ, from pre-intervention to post-intervention. Analyses will be conducted according to the ‘intention-to-treat’ principle, using hierarchical linear mixed-effects model, with random intercepts and including 10 weekly assessments collected during the treatment period. Secondary outcomes include disease-specific Quality of Life (Heart QoL), depression (Patient Health Questionnaire-9), insomnia (Insomnia Severity Index), in addition to both self-rated and accelerometer-measured physical activity. Secondary outcomes will be analysed using similar statistical methods.Ethics and disseminationThe study was approved by the Swedish Ethical Review Authority (Dnr 2023-07605-01), and the first patient enrolled on 7 March 2024. Recruitment is ongoing, and the completion date is expected to fall in the latter half of 2026. All participants receive information about the study and provide informed consent in accordance with ethical guidelines before inclusion. The results will be analysed at group level, and trial outcomes will be published in a peer-reviewed scientific journal, regardless of results.Trial registration numberNCT06298864.

Alcohol use is an important cardiovascular risk factor and a major contributor to morbidity and mortality. Successful implementation of alcohol interventions in cardiology depends on patient acceptability. To understand patient perspectives on the feasibility of implementing alcohol interventions in cardiology services. Multi-site qualitative study. We conducted semi-structured interviews with a heterogenous-purposive sample of 15 adult cardiology patients with hazardous alcohol use. Participants were recruited from three geographically diverse regions in Sweden (Dalarna, Gävleborg, Stockholm) and were varied in terms of sociodemographic characteristics, cardiovascular diagnosis, risk factor profile, and level of alcohol use. We applied the Capability, Opportunity, Motivation and Behaviour (COM-B) system during coding and conducted a reflexive thematic analysis. We identified 56 feasibility factors: 15 related to capability, 10 to opportunity, and 31 to motivation. Four themes emerged: 1. Alcohol use as relevant to cardiology, where participants recognized cardiovascular risk factors, expressed motivation for change, and identified a need to address alcohol use sensitively; 2. Aligning interventions with expectations and goals, where participants linked acceptability of alcohol interventions to personal goals and social norms; 3. Morbidity and shifting priorities, where participants prioritized quality of life and respect for autonomy; 4. Addressing barriers to alcohol dependence treatments, where participants saw a need to improve access to care. Findings suggest that alcohol interventions are acceptable to cardiology patients with hazardous alcohol use. Implementation strategies that prioritize quality of life, respect autonomy, and align with individual expectations and goals may be among the most acceptable. We also identified an opportunity to improve access to treatments for alcohol dependence within multidisciplinary heart teams or hospital-based addiction care services.

Post-acute COVID-19 (PACS) are associated with cardiovascular dysfunction, especially postural orthostatic tachycardia syndrome (POTS). Patients with PACS, both in the absence or presence of POTS, exhibit a wide range of persisting symptoms long after the acute infection. Some of these symptoms may stem from alterations in cardiovascular homeostasis, but the exact mechanisms are poorly understood. The aim of this study was to provide a broad molecular characterization of patients with PACS with (PACS + POTS) and without (PACS-POTS) POTS compared to healthy subjects, including a broad proteomic characterization with a focus on plasma cardiometabolic proteins, quantification of cytokines/chemokines and determination of plasma sphingolipid levels. Twenty-one healthy subjects without a prior COVID-19 infection (mean age 43 years, 95% females), 20 non-hospitalized patients with PACS + POTS (mean age 39 years, 95% females) and 22 non-hospitalized patients with PACS-POTS (mean age 44 years, 100% females) were studied. PACS patients were non-hospitalized and recruited ≈18 months after the acute infection. Cardiometabolic proteomic analyses revealed a dysregulation of ≈200 out of 700 analyzed proteins in both PACS groups vs. healthy subjects with the majority (> 90%) being upregulated. There was a large overlap (> 90%) with no major differences between the PACS groups. Gene ontology enrichment analysis revealed alterations in hemostasis/coagulation, metabolism, immune responses, and angiogenesis in PACS vs. healthy controls. Furthermore, 11 out of 33 cytokines/chemokines were significantly upregulated both in PACS + POTS and PACS-POTS vs. healthy controls and none of the cytokines were downregulated. There were no differences in between the PACS groups in the cytokine levels. Lastly, 16 and 19 out of 88 sphingolipids were significantly dysregulated in PACS + POTS and PACS-POTS, respectively, compared to controls with no differences between the groups. Collectively, these observations suggest a clear and distinct dysregulation in the proteome, cytokines/chemokines, and sphingolipid levels in PACS patients compared to healthy subjects without any clear signature associated with POTS. This enhances our understanding and might pave the way for future experimental and clinical investigations to elucidate and/or target resolution of inflammation and micro-clots and restore the hemostasis and immunity in PACS.

BackgroundAtrial fibrillation (AF) is linked to significant morbidity and mortality, with ischaemic stroke being a leading cause of death. Identifying modifiable risk and protective factors may help reduce stroke incidence in patients with AF.MethodsThis umbrella review evaluated meta-analyses of observational studies and randomised controlled trials (RCTs) to assess the association of protective and risk factors with stroke and transient ischaemic attack (TIA) in patients with AF. Observational associations were graded with the Ioannidis framework. Associations from RCTs and non-randomised baseline factors in meta-analyses of RCTs were assessed with GRADE (Grading of Recommendations Assessment, Development and Evaluation). Composite risk scores were summarised separately as risk-stratification tools.Results35 studies were included, comprising 23 meta-analyses of observational studies, reporting on 45 associations and 22 meta-analyses of RCTs on 24 associations based on data from over 7 276 000 participants. Among observational studies, only high levels of N-terminal pro-brain Natriuretic Peptide (NT-proBNP) provided convincing evidence of stroke risk. Previous stroke/TIA and age (65–74 years) were also associated with stroke, supported by a highly suggestive level of evidence. Among meta-analyses of non-randomised factors, female sex, kidney failure, non-paroxysmal AF and type 2 diabetes mellitus were risk factors with moderate to high evidence. However, other well-established risk factors, such as hypertension and vascular disease, were associated with stroke; however, they were supported with a weak level of evidence.ConclusionsDespite stroke being the most severe complication of AF, this umbrella review reveals that few risk factors are supported by high-level evidence. Our findings confirm that elevated NT-proBNP, age and prior stroke are credible stroke risk factors in patients with AF. However, risk factors with weaker evidence, such as hypertension and vascular disease, require further investigation to clarify their actual impact. PROSPERO registration number CRD42023471263.

Background When developing a clinical prediction model (CPM), a case-mix shift could occur in the development dataset where the distribution of individual predictors changes, potentially affecting model performance. This study exploits the case-mix shift that is already observed in the development dataset to address the case-mix shift between the development and deployment phase of a CPM. Methods We propose a Membership-based method to correct for case-mix shift in the development phase of CPMs. This method uses a probabilistic similarity metric to re-weight data samples in the source set (before the case-mix shift) to more closely match the target set (after the case-mix shift), assuming the target set reflects the target population. We apply the proposed method in a real-world dataset of myocardial infarction patients with out-of-hospital cardiac arrest within 90 days as the outcome. We design nine scenarios (including case-mix shift and no case-mix shift with a range of target/source sets sample sizes) to explore the impact on predictive performance of CPM developed with the proposed method in comparison to CPMs developed by either using all data samples but ignore the shift, or only using the most recent data. We report calibration and discrimination on development and 200 bootstrap samples. Results and Conclusions The proposed method shows promise in accounting for case-mix shift when developing a CPM, particularly when the target set sample size is insufficient. In a partial case-mix shift scenario with an insufficient target sample size, the Membership-based model achieved an optimism-adjusted calibration slope (c-slope) of 0.98, outperforming other models. Conversely, when the target set sample size is sufficient, the Unweighted model on target data only had an optimism-adjusted c-slope of 0.95, compared to 0.92 for the Membership-based model. In complete case-mix shift cases, the Membership-based and Unweighted on target data only models performed similarly. Both achieved an optimism-adjusted c-slope of 0.77 with insufficient target sample size, and optimism-adjusted c-slope of 0.94 with a sufficient target sample size. Further investigation and testing are needed, as well as accounting for other types of data distribution shift to improve model fit for the latest distribution shift in the development dataset.

Objective To investigate clinicians’ preferences for alcohol screening and brief interventions in clinical cardiology settings. Results A total of 664 cardiology clinicians responded to a cross-sectional survey (30.9% response rate), including 55.1% nurses, 21.4% assistant nurses, 18.8% doctors, and 4.7% other clinical staff. Among these participants, 87.5% indicated that patients should be screened for alcohol use on cardiology wards, 79.8% in outpatient clinics, 49.1% in emergency departments, and 45.9% on coronary care units. Doctors and nurses were the preferred professions to be responsible for screening across all clinical contexts, while fewer respondents indicated that assistant nurses or physiotherapists should be responsible for screening ( p  < .001). Most participants (85.2%) indicated that patients should be screened in more than one clinical context and 84.6% indicated that more than one profession should be responsible for alcohol screening. Clinicians’ preferred modality for assessing alcohol use was verbal screening (92% of participants), followed by questionnaires (53.5%), digital tools (28.5%), and alcohol biomarkers (22.1%, p  < .001). Just over half of participants (58%) indicated that they would like to attend training on brief interventions. Findings suggest that task sharing, teamwork, and training may be effective strategies for implementation of alcohol screening and brief interventions in clinical cardiology.

The COVID-19 pandemic has had a significant impact on global public health, with long-term consequences that are still largely unknown. This study aimed to assess the data regarding acute cardiovascular hospital admissions in five European centers before and during the pandemic. A multicenter, multinational observational registry was created, comparing admissions to the emergency departments during a 3-months period in 2020 (during the pandemic) with the corresponding period in 2019 (pre-pandemic). Data on patient demographics, COVID-19 test results, primary diagnosis, comorbidities, heart failure profile, medication use, and laboratory results were collected. A total of 8778 patients were included in the analysis, with 4447 patients in 2019 and 4331 patients in 2020. The results showed significant differences in the distribution of cardiovascular diseases between the two years. The frequency of pulmonary embolism (PE) increased in 2020 compared to 2019, while acute heart failure (AHF) and other cardiovascular diseases decreased. The odds of PE incidence among hospitalized patients in 2020 were 1.316-fold greater than in 2019. The incidence of AHF was 50.83% less likely to be observed in 2020, and the odds for other cardiovascular diseases increased by 17.42% between the 2 years. Regarding acute coronary syndrome (ACS), the distribution of its types differed between 2019 and 2020, with an increase in the odds of ST-segment elevation myocardial infarction (STEMI) in 2020. Stratification based on sex revealed further insights. Among men, the incidence of AHF decreased in 2020, while other cardiovascular diseases increased. In women, only the incidence of STEMI showed a significant increase. When analyzing the influence of SARS-CoV-2 infection, COVID-positive patients had a higher incidence of PE compared to COVID-negative patients. COVID-positive patients with ACS also exhibited symptoms of heart failure more frequently than COVID-negative patients. These findings provide valuable information on the impact of the COVID-19 pandemic on acute cardiovascular hospital admissions. The increased incidence of PE and changes in the distribution of other cardiovascular diseases highlight the importance of monitoring and managing cardiovascular health during and post pandemic period. The differences observed between sexes emphasize the need for further research to understand potential sex-specific effects of COVID-19 on cardiovascular outcomes.

PurposeCather ablation is known to influence the autonomic nervous system. This study sought to investigate the association of sinus heart rate pre-/post-ablation and recurrences in patients with atrial fibrillation undergoing pulmonary vein isolation (PVI).MethodsBetween January 2012 and December 2017, data of 482 patients undergoing their first PVI were included. Sinus heart rate was recorded before (PRE), directly post-ablation (POST) and 3 months post-ablation (3 M). All patients were screened for atrial tachyarrhythmia recurrences during the one-year follow-up.ResultsIn the total study cohort, the mean resting sinus heart rate at PRE [mean 57.9 bpm (95% CI 57.1–58.7 bpm)] increased by over 10 bpm to POST [mean 69.4 bpm (95% CI 68.5–70.3 bpm); p < 0.001] followed by a slight decrease at 3 M [mean 67.3 bpm (95% CI 66.4–68.2 bpm)] but still remaining higher compared to PRE (p < 0.001). This pattern was observed in patients with and without recurrences at POST and 3 M (both p < 0.001 compared to PRE). However, at 3 M the mean sinus heart rate was significantly lower in patients with compared to patients without recurrences (p = 0.031). In this regard, patients with a heart rate change < 11 bpm (PRE to 3 M) or, as an alternative parameter, patients with a heart rate < 60 bpm at 3 M had a significantly higher risk of recurrences compared to the remaining patients (Hazard ratio (HR) 1.82 (95% CI 1.32–2.49), p < 0.001 and HR 1.64 (95% CI 1.20–2.25), p = 0.002, respectively).ConclusionOur study confirms the impact of PVI on cardiac autonomic function with a significant sinus heart rate increase post-ablation. Patients with a sinus heart rate change < 11 bpm (PRE to 3 M) are at higher risk for recurrences during one-year post-PVI.

Abstract Aims Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are prevalent comorbidities associated with significant morbidity/mortality. We assessed prevalence of, patient profiles and outcomes associated with COPD across the ejection fraction (EF) spectrum. Methods HF patients enrolled in the Swedish HF registry between 2005 and 2021 were considered. Multivariable logistic regression models were fitted to assess patient characteristics independently associated with COPD and Cox regression models for investigating the associations between COPD and outcomes, that is, morbidity/mortality. Results Among 97 904 HF patients, COPD prevalence was 13%, highest in HF with preserved EF [HFpEF: 16%, HF with mildly reduced EF (HFmrEF): 12%, HF with reduced EF (HFrEF): 11%]. Key patient characteristics independently associated with a diagnosis of COPD included higher EF, female sex, smoking, obstructive sleep disorder, peripheral artery disease, a lower educational level, more severe HF, more likely mineralocorticoid receptor antagonist and diuretic use but less likely use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin-receptor-neprilysin inhibitors (not in HFrEF), beta-blockers, HF device therapies, and follow-up in HF nurse-led clinics. COPD was independently associated with a 15% higher risk of cardiovascular (CV) death/HF hospitalization [hazard ratio: 1.15 (95% confidence interval: 1.11–1.18)], CV death, non-CV death, all-cause death and HF hospitalizations, regardless of EF. Conclusions COPD was present in every eight patient with HF, and more common with preserved EF. Patients with COPD had more severe HF, heavier comorbidity burden and worse morbidity/mortality regardless of EF. Our results call for improved diagnostic and management strategies in patients with HF and COPD. Central illustration. Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin-receptor-neprilysin inhibitor; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CRT, cardiac resynchronization therapy; CV, cardiovascular; EF, ejection fraction; eGFR, estimated glomerular filtration rate (calculated by Chronic Kidney Disease Epidemiology Collaboration formula); HF, heart failure; HFH, heart failure hospitalization; HR, hazard ratio; ICD, implantable cardioverter-defibrillator device; NYHA, New York Heart Association class.

Premature ventricular contractions (PVCs) are a common cardiac condition often associated with disabling symptoms and impaired quality of life (QoL). Current treatment strategies have limited effectiveness in reducing symptoms and restoring QoL for patients with PVCs. Symptom preoccupation, involving cardiac-related fear, hypervigilance, and avoidance behavior, is associated with disability in other cardiac conditions and can be effectively targeted by cognitive behavioral therapy (CBT). The aim of this study was to evaluate the effect of a PVC-specific CBT protocol targeting symptom preoccupation in patients with symptomatic idiopathic PVCs. Nineteen patients diagnosed with symptomatic idiopathic PVCs and symptom preoccupation underwent PVC-specific CBT over 10 weeks. The treatment was delivered by a licensed psychologist via videoconference in conjunction with online text-based information and homework assignments. The main components of the treatment were exposure to cardiac-related symptoms and reducing cardiac-related avoidance and control behavior. Self-rated measures were collected at baseline, post treatment, and at 3- and 6-month follow-ups. The primary outcome was PVC-specific QoL at posttreatment assessment measured with a PVC-adapted version of the Atrial Fibrillation Effects on Quality of Life questionnaire. Secondary measures included symptom preoccupation measured with the Cardiac Anxiety Questionnaire. PVC burden was evaluated with 5-day continuous electrocardiogram recordings at baseline, post treatment, and 6-month follow-up. We observed large improvements in PVC-specific QoL (Cohen d=1.62, P<.001) and symptom preoccupation (Cohen d=1.73, P<.001) post treatment. These results were sustained at the 3- and 6-month follow-ups. PVC burden, as measured with 5-day continuous electrocardiogram, remained unchanged throughout follow-up. However, self-reported PVC symptoms were significantly lower at posttreatment assessment and at both the 3- and 6-month follow-ups. Reduction in symptom preoccupation had a statistically significant mediating effect of the intervention on PVC-specific QoL in an explorative mediation analysis. This uncontrolled pilot study shows preliminary promising results for PVC-specific CBT as a potentially effective treatment approach for patients with symptomatic idiopathic PVCs and symptom preoccupation. The substantial improvements in PVC-specific QoL and symptom preoccupation, along with the decreased self-reported PVC-related symptoms warrant further investigation in a larger randomized controlled trial. ClinicalTrials.gov NCT05087238; https://clinicaltrials.gov/study/NCT05087238.