Nobuhiro Ikemura

Background: Avoiding fever is a central tenet of postresuscitation care. However, few data exist describing the association between postresuscitation temperature and survival after in‐hospital cardiac arrest, where response is usually prompt. Methods: Within the GWTG–Resuscitation (Get With The Guidelines–Resuscitation) registry, we identified adults from 2015 to 2024 with an index in‐hospital cardiac arrest and return of spontaneous circulation who survived at least 24 hours after resuscitation. Patients were excluded if they received therapeutic hypothermia after return of spontaneous circulation to better understand the natural history of postresuscitation temperature. The primary exposure was maximum temperature 24 hours after return of spontaneous circulation, categorized by 0.5 °C intervals from <36.3 °C to ≥38.8 °C. Multivariable hierarchical logistic regression evaluated the association between maximum temperature and both survival to hospital discharge and favorable neurological survival. Results: Of 36 514 with return of spontaneous circulation, mean age was 64.2±16.6 years; 61.8% were men, and 69.4% were White individuals. Median maximum temperature was 37.2 °C (interquartile range, 36.8–37.8 °C), 66.3% survived to discharge, and 57.0% had favorable neurological survival. The highest survival (72.7%) was observed in the 36.8 to <37.3°C group (reference), with all other temperature ranges with lower rates of survival to hospital discharge (inverted U‐shaped relationship), with the worst being those in the lowest (<36.3 °C, 48.4%; adjusted odds ratio, 0.42 [95% CI, 0.37–0.46]) and highest (≥38.8 °C, 51.5%; adjusted odds ratio, 0.40 [95% CI, 0.36–0.44]) ranges. A similar relationship was observed with favorable neurological survival. Conclusions: Among patients not treated with therapeutic hypothermia, a postresuscitation temperature of 36.8 to 37.3°C after in‐hospital cardiac arrest was associated with the highest survival rate, with temperatures at high and low extremes with the lowest survival.

Background: Introduction of guideline-directed medical therapy (GDMT) has transformed the care of heart failure (HF) with reduced ejection fraction, establishing four foundational drug classes. Yet, in clinical practice, many patients cannot initiate or maintain all four, and clinicians must pragmatically prioritise agents such as angiotensin receptor-neprilysin inhibitor and sodium-glucose cotransporter-2 inhibitor, whose comparative impacts are still explored. Moreover, the optimal loop diuretic to pair with modern GDMT, which enhances natriuresis, remains uncertain. Methods: Between January 2022 and February 2024, we conducted a multicentre, open-label, randomised, 2×2 factorial design trial for ambulatory patients with symptomatic HF, elevated natriuretic peptide levels and left ventricular ejection fraction (LVEF) <50%, despite conventional therapies (eg, renin-angiotensin-aldosterone system inhibitors and beta-blockers). The patients were assigned to receive either sacubitril/valsartan or dapagliflozin, and torsemide or furosemide. The primary endpoint was the change in the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS) over 6 months; a prespecified secondary endpoint was a hierarchical clinical outcome. Results: Of 231 randomised patients (median age 73 years; median LVEF 36%; 84.0% New York Heart Association class II), changes in KCCQ-OSS did not differ between sacubitril/valsartan and dapagliflozin (adjusted mean difference 2.53 points; 95% confidence interval (CI) −1.81 to 6.88; p=0.25) or between torsemide and furosemide (0.25 points; 95% CI −4.10 to 4.59; p=0.91). Hierarchical composite outcome analyses also showed no significant differences between sacubitril/valsartan and dapagliflozin (win ratio, 1.15; 95% CI 0.71 to 1.88), or between torsemide and furosemide (win ratio, 1.15; 95% CI 0.70 to 1.85). Conclusions: This trial found no evidence of benefit of one treatment over another for health status over 6 months. Given the sample size and predefined power, modest differences between treatments cannot be excluded. Trial registration number: UMIN000045229.

Importance: Unprotected left main percutaneous coronary intervention (LM PCI) is recognized as a reasonable strategy for patients who have coronary artery disease with low anatomic complexity. However, recent trends in its procedural volume, patient characteristics, and procedural techniques and their association with clinical outcomes have not been well described, making it important to confirm the safety of LM PCI in contemporary clinical practice. Objectives: To examine temporal trends in the use and in-hospital outcomes of unprotected LM PCI in Japan. Design, Setting, and Participants: This retrospective cohort study used prospectively collected data from the nationwide, multicenter Japanese Percutaneous Coronary Intervention registry including approximately 1100 PCI-capable institutions across Japan. Data were restricted to the period after the registry’s 2019 update to ensure consistency in definitions. Temporal trends in PCI procedures were analyzed from January 2019 through December 2023. Patients with prior coronary artery bypass grafting, recent cardiogenic shock, cardiac arrest within 24 hours of treatment, restenosis, or balloon angioplasty alone were excluded. Exposures: Calendar year of PCI (2019-2023). Main Outcomes and Measures: The primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess temporal trends and whether differences were explained by baseline or procedural characteristics. Results: Among 851 468 included procedures (mean [SD] patient age, 74.1 [10.2] years; 78.1% men), unprotected LM PCI accounted for 9490 of 182 739 PCI procedures in 2019 (5.2%) and 8583 of 164 332 in 2023 (5.2%). From 2019 to 2023, mean (SD) patient age increased from 73.4 (10.1) to 74.6 (10.1) years, and patients were more likely to have heart failure (increasing from 1676 of 9058 cases in 2019 [18.5%] to 1704 of 8200 [20.8%] in 2023). Unadjusted in-hospital mortality increased from 148 cases in 2019 (1.6%) to 157 in 2023 (1.9%), but this was not significant after adjusting for patient characteristics (adjusted odds ratio for 2023 vs 2019: 1.08; 95% CI, 0.85-1.37). From 2019 to 2023, further adjustment for procedural factors, including increased use of radial access (from 5789 cases [63.9%] to 5985 cases [73.0%]) and mechanical circulatory support (from 828 cases [9.1%] to 941 cases [11.5%]), did not alter the association between year and mortality. Conclusions and Relevance: In a nationwide Japanese PCI registry, unprotected LM PCI consistently accounted for 5% of PCI procedures. Although unadjusted in-hospital mortality rose modestly over time, the findings indicate this was largely explained by increasing patient complexity, with risk-adjusted outcomes remaining stable, supporting the continued role of LM PCI as a safe revascularization option in contemporary practice.

Background: Same‐day discharge (SDD) after percutaneous coronary intervention (PCI) may be altered when complications occur. We sought to determine whether risk of the most common complication, acute kidney injury (AKI), is associated with SDD in practice. Methods: Using the NCDR (National Cardiovascular Data Registry) CathPCI registry, we calculated the AKI risk for elective PCIs from 2018 to 2022 using the NCDR prediction model. Hierarchical logistic regression models were constructed to predict SDD with AKI risk and procedural variables as fixed effects, and site as a random effect. Trends in SDD rate across AKI risk categories were described and variability across sites was quantified using median odds ratios (ORs). Results: Among 1 033 096 eligible patients, 414 297 (40.1%) had SDD after PCI and rates increased throughout the study period (27.9% in 2018 to 53.4% in 2022; 1.9% per quarter). Higher AKI risks were associated with lower SDD rates (OR, 0.97 per 1% increase in AKI risk [95% CI 0.968–0.971]) although even in 2022, 41.2% of high‐risk patients underwent SDD. Marked variation in SDD practices was observed across sites (overall median OR, 3.75 [95% CI 2.63–5.34]) even among the highest risk group (median OR, 3.60 [95% CI 2.34–5.56]). Conclusions: Although patients at higher risk of AKI are less likely to undergo SDD overall, currently, 2 in 5 patients with >10% AKI risk are discharged the day of their procedure with marked variation across sites. Further work is needed to better understand the postdischarge risk of SDD in patients at higher AKI risk to improve delivery and safety of PCI.

Background: Atrial fibrillation (AF) is managed with various strategies, including rate and rhythm control, to improve patients' health status. Although its incidence increases with age, how age affects health status improvements following AF treatment remains unknown. Methods: Using data from a multicenter registry for outpatients with newly recognized AF, baseline and 1‐year health status was assessed with the Atrial Fibrillation Effect on Quality‐of‐life quesTionnaire (AFEQT). The associations between age and 1‐year changes in AFEQT‐overall summary and subdomain scores with rate or rhythm control strategies were estimated using generalized additive models. To address nonlinear relationships, we developed multivariable linear regression models with age range categories (<65, 65–75, and ≥75 years). Results: Among 2786 patients (31.7% women); 946 were <65, 1019 were ≥65 to 75, and 821 were ≥75 years, with rate control pursued in 23.4%, 42.0%, and 66.4%, respectively, and their mean 1‐year improvements in the AFEQT overall summary were 11.1 (SD: 16.6), 8.0 (17.0), and 4.7 (18.2), respectively. After multivariable adjustment, older age was independently associated with less AFEQT overall summary improvement, regardless of treatment strategy. Patients aged ≥75 years had a smaller AFEQT overall summary improvements than those aged <65 years (difference between groups −3.86 points [−5.29 to −2.42]), primarily driven by smaller improvements in AFEQT daily activities scores with similar improvements in the AFEQT symptoms or treatment concern domains. Conclusions: Although older adults with AF exhibited smaller gains in functional limitation following disease‐specific treatment, they experienced measurable improvements in overall health status regardless of treatment strategies.