Marnicq van Es

Aims: Obesity and atrial fibrillation (AF) are global epidemics, often co-existing and compounding cardiovascular risk. While catheter ablation has emerged as an effective strategy for rhythm control in symptomatic AF, it remains unclear whether obesity modifies its benefit. This post hoc analysis of the CABANA trial investigates the influence of baseline obesity on clinical outcomes after catheter ablation vs. drug therapy in AF patients. Methods and results: A total of 2170 CABANA participants with available body mass index (BMI) were included. Obesity was defined by BMI ≥ 30 kg/m2, and Class II obesity by BMI ≥ 35 kg/m2. Adverse outcomes, AF recurrence, and functional status were analysed using Cox, mixed-effects, and generalized estimating equation models, assessing treatment-by-obesity interactions. Obese patients exhibited higher comorbidity burden, worse baseline functional status, and more persistent AF compared to non-obese counterparts. Higher BMI was associated with increased cardiovascular hospitalization and a higher New York Heart Association functional class. Catheter ablation significantly reduced the risk of AF recurrence and improved symptom burden and functional capacity, irrespective of obesity status. No significant interaction was found between BMI and treatment effect on the primary composite endpoint of cardiovascular hospitalization or all-cause mortality. However, patients with Class II obesity or higher had worse absolute outcomes despite similar relative benefits from ablation. Conclusion: While obesity is associated with worse baseline status and outcomes, it was not shown to significantly alter the relative effectiveness of AF ablation compared to drug therapy. These findings support a multifaceted approach integrating rhythm control with upstream interventions targeting obesity-related atrial remodelling and comorbidity management.

Aims: Albuminuria is a key diagnostic and prognostic biomarker of chronic kidney disease (CKD), associated with adverse cardiovascular and renal outcomes. Despite guideline recommendations, urine albumin-to-creatinine ratio (UACR) testing is infrequently performed in cardiology. This study assessed the uptake of UACR testing, the estimated prevalence of undiagnosed albuminuria, and the use of disease-modifying therapies in patients with cardio-kidney-metabolic (CKM) disease. Methods and results: We conducted a retrospective cohort study of all adults seen at the cardiology department of a tertiary referral centre between 2019 and 2024. Data were extracted using CTcue, an AI-driven platform. Albuminuria was defined as UACR ≥30 mg/g. A weighted logistic regression model estimated albuminuria prevalence in untested patients. Among 77 351 patients (44.8% female, mean age 64.4 years), only 8.9% had a recorded UACR, of whom 46.4% had albuminuria. Testing rates were low across high-risk groups: 29.9% in diabetes, 21.7% in heart failure, and 13.7% in hypertension. In untested patients, the predicted prevalence of albuminuria was 36.6%, and highest in those with eGFR <30 mL/min/1.73m2 (70.0%), heart failure (47.8%), or diabetes (46.8%). Use of disease-modifying therapies was low, even among patients with confirmed albuminuria. In patients with documented vs. predicted albuminuria, 43.0% vs. 39.1% received renin–angiotensin system inhibitors, 12.8% vs. 5.7% received SGLT2 inhibitors, and <1% in both groups received finerenone. Conclusion: Albuminuria is substantially underdetected in cardiology practice, possibly contributing to underuse of effective CKM therapies. Systematic UACR screening with structured treatment protocols may help close this gap and improve outcomes for patients with CKM disease.

Aims: Left ventricular outflow tract obstruction (LVOTO) drives symptoms and functional limitation in obstructive hypertrophic cardiomyopathy (oHCM). Some patients may only show treatment-qualifying obstruction during exercise echocardiography, yet their clinical profile and response to cardiac myosin inhibition are not well defined. This study compared the characteristics and therapeutic response of patients requiring exercise echocardiography to establish eligibility for mavacamten versus those meeting criteria at rest or during Valsalva. Methods and results: A single-centre retrospective cohort of 56 symptomatic oHCM patients treated with mavacamten was evaluated. LVOTO was assessed at rest, with Valsalva, and during exercise; patients were classified as ‘exercise’ or ‘non-exercise’ LVOTO based on the provocation manoeuvre eliciting a qualifying gradient (≥50 mmHg). Haemodynamic (Valsalva LVOT gradient) and symptomatic (NYHA class) response were assessed at 12 and 24 weeks. A total of 42.9% qualified for mavacamten exclusively during exercise echocardiography. Although resting and Valsalva gradients were lower by definition, these patients showed similar baseline functional limitation and exercise capacity (pVO2; 17.9 ± 7.4 vs. 16.8 ± 5.5 mL/kg/min, P = .550). By 24 weeks, most patients in both groups achieved non-obstructive gradients (<30 mmHg; 93.3% vs. 96.4%, P = .646) and NYHA class improvement (75.0% vs. 93.3%, P = .266), without significant between-group differences. Conclusion: Patients requiring exercise echocardiography to document treatment-qualifying LVOTO do not exhibit a milder disease phenotype and derive similar treatment benefits from mavacamten compared to those with resting or Valsalva-provoked obstruction. Exercise echocardiography identifies a substantial proportion of symptomatic HCM patients with significant LVOTO missed by resting assessment and is essential for guiding treatment eligibility.