Mitsunori Maruyama

Structured Background: Cardiogenic shock (CS) remains a leading cause of in-hospital mortality in acute myocardial infarction (AMI). Although advanced age is associated with worse outcomes, the prognostic relevance of chronological age may vary by clinical presentation, particularly in the presence of out-of-hospital cardiac arrest (OHCA). We investigated the prognostic impact of octogenarian status in patients with AMI complicated by cardiogenic shock (AMI–CS). Methods: We analyzed patients with AMI–CS enrolled in the multicenter Kanagawa-ACuTe cardIoVascular rEgistry (K-ACTIVE) who underwent percutaneous coronary intervention (PCI). Octogenarian status (≥80 years) was the primary exposure. Multivariable logistic regression was used to evaluate associations with in-hospital mortality, and effect modification by OHCA was assessed. Model performance was evaluated using discrimination and decision curve analysis. Results: Among 658 patients with AMI–CS, 177 (26.9%) were octogenarians, and 279 (42.4%) died during hospitalization. In the primary multivariable analysis, octogenarian status was independently associated with higher in-hospital mortality (adjusted odds ratio [aOR], 2.09; 95% CI, 1.33–3.27). This association was evident among patients without OHCA, whereas no clear age-related gradient was observed among those presenting with OHCA. In multivariable models, heart rate and serum albumin provided incremental prognostic information beyond chronological age. Conclusion: In patients with AMI–CS, the prognostic impact of advanced age varies according to clinical presentation. While advanced age confers excess risk among patients without OHCA, its prognostic value appears limited among those presenting after cardiac arrest. These findings support risk stratification strategies that integrate physiological markers beyond chronological age alone to guide individualized clinical decision-making. Key Points: The prognostic impact of age in acute myocardial infarction complicated by cardiogenic shock is highly context dependent. Octogenarian status was associated with increased mortality among patients without out-of-hospital cardiac arrest (OHCA), whereas no meaningful association was observed among those presenting with OHCA. Unmeasurable vital signs, particularly heart rate, represent clinically meaningful physiological derangement rather than missing data. These parameters added prognostic information beyond that provided by conventional clinical variables. Serum albumin and heart rate, which are routinely available at presentation, appeared to capture aspects of physiological vulnerability not fully explained by chronological age alone. Clinical Perspective: What Is New?: The prognostic relevance of age in AMI complicated by cardiogenic shock (AMI–CS) was not uniform and differed according to clinical presentation. Octogenarians exhibit substantially higher mortality among patients without OHCA, whereas age did not meaningfully influence mortality after OHCA. Unmeasurable vital signs represent clinically informative, missing-not-at-random indicators of disease severity. Explicit modeling of unmeasurable systolic blood pressure and heart rate strengthened prognostic assessment. Serum albumin and heart rate provide prognostic information beyond chronological age in AMI–CS. What Are the Clinical Implications?: Chronological age alone should not determine the aggressiveness of care in patients with AMI–CS. Among patients without OHCA, advanced age may identify a biologically vulnerable subgroup that could benefit from timely revascularization and selectively applied mechanical circulatory support. In patients with OHCA, prognosis appears to be driven predominantly by post–cardiac arrest injury rather than age. Incorporating serum albumin and heart rate into risk assessment may support more equitable, phenotype-based clinical decision-making.

Background: Multiple long-term conditions (MLTCs) are common among individuals with heart failure (HF); however, the influence of sex on clinical characteristics and prognosis remains unclear. This study investigated sex-related differences in clinical characteristics and prognosis in individuals with HF and a high MLTC burden. Methods: We conducted a multicentre retrospective study of 3004 hospitalised patients with HF who survived to discharge. Comorbid chronic conditions were defined using the Charlson Comorbidity Index (CCI), and MLTC burden was quantified using the age-adjusted CCI. Patients were stratified into high (CCI≥6; n=1514) and low (CCI<6; n=1490) MLTC burden groups based on the median age-adjusted CCI, and comparisons were made by sex. The primary outcome was a composite of all-cause death or HF readmission within 1 year. Results: The prevalence of ≥2 comorbid conditions increased with age, peaking before age 85 and declining slightly thereafter. This trend differed by sex, with a steeper age-related increase observed in men. In the high MLTC burden group, females were older, had higher left ventricular ejection fraction and were prescribed fewer medications than men. Dementia and rheumatologic disease were more common in women. Although no significant sex differences in event-free survival were observed overall in either MLTC group, among individuals aged≥75 years with high MLTC burden, men had a significantly higher risk of adverse events than women (HR: 1.334; 95% CI 1.031 to 1.727). A spline-based three-way interaction analysis (age×sex×MLTC burden) demonstrated that male risk exceeded female risk after age 70, only in the high MLTC burden group. Conclusion: In individuals with HF and a high MLTC burden, age-dependent sex differences in prognosis were evident. These findings highlight the importance of incorporating age-specific and sex-specific approaches into personalised HF care. Trial registration number: UMIN000054854.

Background: This study aimed to establish a systematic method for diagnosing atrioventricular nodal reentrant tachycardia (AVNRT) with a bystander concealed nodoventricular pathway (cNVP).Methods: We analyzed 13 cases of AVNRT with a bystander cNVP, 11 connected to the slow pathway (cNVP‐SP) and two to the fast pathway (cNVP‐FP), along with two cases of cNVP‐related orthodromic reciprocating tachycardia (ORT).Results: The diagnostic process was summarized in three steps. Step 1 was identification of the presence of an accessory pathway by resetting the tachycardia with delay (n = 9) and termination without atrial capture (n = 4) immediately after delivery of a His‐refractory premature ventricular contraction (PVC). Step 2 was exclusion of ORT by atrio‐His block during the tachycardia (n = 4), disappearance of the reset phenomenon after the early PVC (n = 7), or dissociation of His from the tachycardia during ventricular overdrive pacing (n = 1). Moreover, tachycardia reset/termination without the atrial capture (n = 2/2) 1 cycle after the His‐refractory PVC was specifically diagnostic. Exceptionally, the disappearance of the reset phenomenon was also observed in the two cNVP‐ORTs. Step 3 was verification of the AVN as the cNVP insertion site, evidenced by an atrial reset/block preceding the His reset/block in fast–slow AVNRT with a cNVP‐SP and slow–fast AVNRT with a cNVP‐FP or His reset preceding the atrial reset in slow–fast AVNRT with a cNVP‐SP.Conclusion: AVNRT with a bystander cNVP can be diagnosed in the three steps with few exceptions. Notably, tachycardia reset/termination without atrial capture one cycle after delivery of a His‐refractory PVC is specifically diagnostic.

Background: The fibrillatory wave amplitude (FWA) during atrial fibrillation (AF) is thought to reflect structural atrial remodeling, but it remains unclear what determines the FWA. Methods: 114 consecutive patients were prospectively studied who underwent catheter ablation of AF. The mean FWA was computed by automated surface ECG analyses. The extent of the left atrial (LA) voltage-defined atrial fibrosis and conduction properties were estimated by a three-dimensional high-density electroanatomical mapping system. The LA size was evaluated by transthoracic echocardiography. The study patients were divided into 2 groups according to an FWA in lead V1 above the median value of 46 µV (high FWA group, n=57) or below 46 µV (low FWA group, n=57). Results: There were no differences in the age, gender, CHADS2 score, prevalence of paroxysmal AF, medications, ablation strategy, and LA volume index between the two groups. The LA low voltage areas in the low FWA group were not different from those in the high FWA group. The total LA activation time and local LA conduction velocity did not differ between the two groups. During a median follow-up of 710 days, the recurrence rate after ablation was significantly higher in patients with a low FWA than a high FWA (log-rank P=0.02). In a multivariate analysis, non-paroxysmal AF, the LA volume index, and FWA were independent predictors of recurrence after ablation. Conclusions: The FWA was not correlated with the markers of atrial structural remodeling. Nevertheless, the FWA could still provide information for predicting the clinical outcome after AF ablation. Background: The fibrillatory wave amplitude (FWA) during atrial fibrillation (AF) is thought to reflect structural atrial remodeling, but it remains unclear what determines the FWA. Methods: 114 consecutive patients were prospectively studied who underwent catheter ablation of AF. The mean FWA was computed by automated surface ECG analyses. The extent of the left atrial (LA) voltage-defined atrial fibrosis and conduction properties were estimated by a three-dimensional high-density electroanatomical mapping system. The LA size was evaluated by transthoracic echocardiography. The study patients were divided into 2 groups according to an FWA in lead V1 above the median value of 46 µV (high FWA group, n=57) or below 46 µV (low FWA group, n=57). Results: There were no differences in the age, gender, CHADS2 score, prevalence of paroxysmal AF, medications, ablation strategy, and LA volume index between the two groups. The LA low voltage areas in the low FWA group were not different from those in the high FWA group. The total LA activation time and local LA conduction velocity did not differ between the two groups. During a median follow-up of 710 days, the recurrence rate after ablation was significantly higher in patients with a low FWA than a high FWA (log-rank P=0.02). In a multivariate analysis, non-paroxysmal AF, the LA volume index, and FWA were independent predictors of recurrence after ablation. Conclusions: The FWA was not correlated with the markers of atrial structural remodeling. Nevertheless, the FWA could still provide information for predicting the clinical outcome after AF ablation.

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