Elgendy, Islam Y.

Importance Elevated low-density lipoprotein cholesterol (LDL-C) is a modifiable risk factor for cardiovascular disease, the leading cause of premature death worldwide. Assessing the LDL-C–related burden is critical for guiding prevention and treatment strategies. Objectives To estimate the global, regional, and national burden of ischemic heart disease and ischemic stroke attributable to elevated LDL-C (relative to 35-54 mg/dL) from 1990 to 2023 and to quantify the contributions of population growth, aging, risk-deleted burden, and exposure changes to burden trends. Design, Setting, and Population This comparative risk assessment, part of the Global Burden of Disease Study 2023, estimated population-level LDL-C exposure and associated health loss in 204 countries and territories. Mean LDL-C levels were estimated using spatiotemporal gaussian process regression based on 806 studies across 161 countries. Relative risks were derived from meta-analyses of 38 randomized clinical trials. Population-attributable fractions for deaths and disability-adjusted life-years (DALYs) were estimated by age and sex for adults aged 25 years or older from 1990 to 2023, with 95% uncertainty intervals. Exposure Population-level LDL-C concentrations. Main Outcomes and Measures Population-attributable fractions, counts, and rates (all ages and age standardized per 100 000) of LDL-C–attributable deaths and DALYs from ischemic heart disease and ischemic stroke, with uncertainty intervals. Results In 2023, elevated LDL-C accounted for 3.6 million deaths (95% uncertainty interval, 2.2-5.4 million; 6.0% of global mortality) and 90.7 million DALYs (95% uncertainty interval, 58.9-123.3 million; 3.2% of DALYs). Although global all-ages rates remained stable, age-standardized death and DALY rates decreased by 45.6% and 39.5%, respectively, since 1990. In 2023, age-standardized LDL-C–attributable DALY rates were highest in Eastern Europe and lowest in high-income Asia-Pacific. One-third of the global LDL-C burden occurred in India and China. Population growth and aging drove the increasing burden, with notable regional disparities in LDL-C exposure and risk-deleted DALY rates shifting toward middle-sociodemographic settings. Conclusions and Relevance Despite declining age-standardized rates, the absolute LDL-C burden has increased since 1990 due to demographic changes and has shifted toward middle-sociodemographic countries. Measurement and surveillance gaps persist. Strengthened prevention, diagnosis, and treatment access strategies are essential to mitigate the health burden of LDL-C.

Abstract Objective To evaluate the short- and long-term clinical outcomes of transcatheter aortic valve replacement (TAVR) among participants with RA and aortic stenosis compared with those without RA, using real-world data from a large multicentre registry. Methods Using the TriNetX Research Network, participants with aortic stenosis undergoing TAVR with (RA+) vs without (RA−) RA were identified. Odds ratios (ORs) with 95% CIs estimated 30-day all-cause mortality, permanent pacemaker implantation, ischaemic stroke, acute kidney injury, myocardial infarction, cardiogenic shock, major vascular complications, and major or life-threatening bleeding were evaluated. Five-year outcomes included all-cause mortality, ischaemic stroke, myocardial infarction and all-cause hospitalization. Cox regression was used to estimate hazard ratios (HRs) with 95% CIs. Results A total of 1414 RA+ (4.3%) and 39 004 RA− participants were eligible. After matching, 1374 were included in each cohort. At 30 days, outcomes did not differ between RA+ and RA− groups; mortality was 2.0% vs 1.5% (OR 1.29; 95% CI 0.73–2.29), with no significant differences in other endpoints. Over 5 years, mortality was 23.8% vs 20.5% (OR 1.12; 95% CI 0.97–1.31), and stroke, myocardial infarction and hospitalization were similar; HRs were concordant with OR estimates. In sex-based analyses of RA patients, outcomes did not differ by sex. Conclusion In this large observational study, TAVR was not associated with excess short- or long-term risk in patients with RA. These findings support TAVR as a safe therapeutic option in RA patients with aortic stenosis.

Mediastinal radiation potentiates aortic stenosis and complicates its treatment. We compared the short and midterm-outcomes with transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with prior mediastinal radiation. Electronic databases were searched from inception through December 2024. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes were pooled as mean differences (MDs) with respective 95% confidence intervals (CIs). Six observational studies were identified, including 2458 TAVR patients and 1873 SAVR patients. In the short-term, TAVR was associated with lower rate of mortality (RR: 0.54; 95% CI: 0.34–0.88), atrial fibrillation (RR: 0.31; 95% CI: 0.15–0.65), acute kidney injury (RR: 0.75; 95% CI: 0.59–0.95), bleeding (RR: 0.37, 95% CI: 0.33–0.42), and shorter length of hospital stay (MD: −4.30; 95% CI: −5.45 to −3.15). One-year mortality was comparable between the 2 groups (RR: 1.04; 95% CI: 0.50–2.13). This meta-analysis of observational studies of patients with prior mediastinal radiation demonstrated that TAVR was associated with better short-term outcomes compared to SAVR. While 1-year mortality appeared similar between the 2 interventions, this finding should be interpreted with caution. However, randomized controlled trials are needed to validate these findings.

ABSTRACT Background Pulmonary vein isolation is a standard therapy for paroxysmal atrial fibrillation (AF). Pulsed field ablation (PFA) has emerged as a novel approach aiming to improve efficacy and safety over conventional thermal ablation (CTA) (radiofrequency and cryoballoon). This meta‐analysis evaluated outcomes of PFA versus thermal ablation in paroxysmal AF. Methods Electronic databases were searched through May 2025 for randomized controlled trials (RCTs) and observational studies that compared the efficacy and safety of PFA versus CTA. The primary outcome was AF recurrence. Summary estimates were conducted using random effects. Results A total of six studies, involving 1928 patients, were included. The incidence of AF recurrence was significantly lower among patients treated with PFA (risk ratio [RR] 0.67; 95% confidence interval [CI] 0.53–0.85). PFA was associated with a lower incidence of any atrial arrhythmia recurrence (RR 0.78, 95% CI: 0.61–0.99). The total procedure duration was significantly shorter with PFA (mean difference −21.46 min (95% CI: −26.04 to −16.88)), but there was no difference in fluoroscopy time. The rates of esophageal injury and phrenic nerve palsy were lower with PFA. However, the data were limited for these two outcomes, and a meta‐analysis was not conducted for them. There was no difference between the two groups in the incidence of stroke or pericardial tamponade. Conclusion Among patients with paroxysmal AF undergoing catheter ablation, PFA is associated with favorable outcomes, including lower recurrence and shorter procedure time compared to conventional ablation modalities.

Importance Nontraumatic subarachnoid hemorrhage (SAH) represents the third most common stroke type with unique etiologies, risk factors, diagnostics, and treatments. Nevertheless, epidemiological studies often cluster SAH with other stroke types leaving its distinct burden estimates obscure. Objective To estimate the worldwide burden of SAH. Design, Setting, and Participants Based on the repeated cross-sectional Global Burden of Disease (GBD) 2021 study, the global burden of SAH in 1990 to 2021 was estimated. Moreover, the SAH burden was compared with other diseases, and its associations with 14 individual risk factors were investigated with available data in the GBD 2021 study. The GBD study included the burden estimates of nontraumatic SAH among all ages in 204 countries and territories between 1990 and 2021. Exposures SAH and 14 modifiable risk factors. Main Outcomes and Measures Absolute numbers and age-standardized rates with 95% uncertainty intervals (UIs) of SAH incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) as well as risk factor–specific population attributable fractions (PAFs). Results In 2021, the global age-standardized SAH incidence was 8.3 (95% UI, 7.3-9.5), prevalence was 92.2 (95% UI, 84.1-100.6), mortality was 4.2 (95% UI, 3.7-4.8), and DALY rate was 125.2 (95% UI, 110.5-142.6) per 100 000 people. The highest burden estimates were found in Latin America, the Caribbean, Oceania, and high-income Asia Pacific. Although the absolute number of SAH cases increased, especially in regions with a low sociodemographic index, all age-standardized burden rates decreased between 1990 and 2021: the incidence by 28.8% (95% UI, 25.7%-31.6%), prevalence by 16.1% (95% UI, 14.8%-17.7%), mortality by 56.1% (95% UI, 40.7%-64.3%), and DALY rate by 54.6% (95% UI, 42.8%-61.9%). Of 300 diseases, SAH ranked as the 36th most common cause of death and 59th most common cause of DALY in the world. Of all worldwide SAH-related DALYs, 71.6% (95% UI, 63.8%-78.6%) were associated with the 14 modeled risk factors of which high systolic blood pressure (population attributable fraction [PAF] = 51.6%; 95% UI, 38.0%-62.6%) and smoking (PAF = 14.4%; 95% UI, 12.4%-16.5%) had the highest attribution. Conclusions and Relevance Although the global age-standardized burden rates of SAH more than halved over the last 3 decades, SAH remained one of the most common cardiovascular and neurological causes of death and disabilities in the world, with increasing absolute case numbers. These findings suggest evidence for the potential health benefits of proactive public health planning and resource allocation toward the prevention of SAH.

Background: Coronary in-stent restenosis (ISR) secondary to neointimal hyperplasia or neoatherosclerosis remains a significant challenge following percutaneous coronary interventions (PCI), with no consensus on the optimal revascularization strategy. We compared the outcome of PCI for ISR using drug-coated balloons (DCB) and drug-eluting stents (DES) and investigated the time trends in their clinical outcomes. Methods: PubMed, Embase, Scopus, and the Cochrane Library databases were searched through May 2024. We included randomized controlled trials (RCTs) comparing DCB versus DES among patients with coronary ISR. The primary outcome was target lesion revascularization (TLR). Secondary outcomes included all-cause mortality, myocardial infarction (MI), stent thrombosis, and late lumen loss (LLL). Random-effects models were employed to analyze outcomes within 1-year and beyond 1-year intervals. Meta-regression analysis was used to investigate the effect of age, sex, history of diabetes, hypertension, dyslipidemia, smoking, and ejection fraction on all outcomes by applying mixed-effect models. Results: We included 10 RCTs (1034 patients in the DCB group and 943 patients in the DES group). We found similar incidence of 1-year TLR (odds ratio [OR] 1.36; 95% confidence interval [CI] 0.86, 2.14; P 0.194; I 2 43.3%) and >1-year TLR (OR 0.94; 95% CI 0.57, 1.56; P 0.817; I 2 0%) with the use of DCB versus DES. The risks of all-cause mortality, MI, and stent thrombosis were comparable between DCB and DES in 1-year and beyond 1-year follow-ups. At 6-9 months angiographic follow-up, DCB was associated with non-significantly lower LLL compared to DES (standardized mean difference [SMD] -0.12 millimeters; 95% CI -0.29, 0.05; P 0.170; I 2 71.7%). Meta-regression indicated that higher prevalence of diabetes was associated with an increased risk of 1-year revascularization after DCB compared to DES (Estimate 0.07; P 0.003; I 2 0%). Additionally, male sex was associated with an increased LLL in DCB versus DES (Estimate 0.034; P 0.001; I 2 41.8%). No association was found between other baseline characteristics and measured clinical outcomes. Conclusion: DCB demonstrated comparable PCI outcomes compared to DES in patients with coronary ISR.

Abstract Background Evidence suggests an association between obesity and the risk for cardiomyopathy development, however robust evidence is still lacking. In this study we sought to explore the relationship of obesity with hypertrophic (HCM) and dilated cardiomyopathy (DCM) and possible interactions with sex using large scale epidemiological real-world data. Methods and Results We analyzed data from the Nationwide Inpatient Sample (NIS) of U.S. hospitalizations for the years 2015-2019. There were a total of n=46,934 admissions with a diagnosis of HCM and n=170,924 with DCM. There was a significant interaction between cardiomyopathies’ diagnosis with sex and age subgroups; the rates of both DCM and HCM increased with age (p<0.001 for both); DCM diagnosis was significantly higher in males compared with females (0.85% vs. 0.35%, p<0.001). After adjustment for age, sex, race, and presence of arterial hypertension there was a significant stepwise positive association between obesity and the population rates of both cardiomyopathy subtypes. For hospitalized patients with a body mass index (BMI) ≥30kg/m2 there was an odds ratio (OR) of 1.68 (95%CI: 1.55-1.81, p<0.001) for HCM andOR=1.82 (95%CI: 1.79-1.84, p<0.001) for DCM. More importantly, the positive relationship between a cardiomyopathy diagnosis (HCM or DCM) with increasing BMI was driven by the male sex (p<0.001 for both) and it was non-significant in females. Conclusions The findings from this nationwide observational analysis support a sexual dimorphism in the relationship between obesity and hypertrophic or dilated cardiomyopathy, which should be further investigated.Cardiomyopathy-obesity

SummaryEvidence suggests an association between obesity and the risk for cardiomyopathy development; however, robust evidence is still lacking. In this study we sought to explore the relationship of obesity with hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) and possible interactions with sex using large‐scale epidemiological real‐world data. We analysed data from the Nationwide Inpatient Sample of US hospitalisations for the years 2015–2019. There were a total of 46 934 admissions with diagnosis of HCM and 170 924 with DCM. There was a significant interaction between cardiomyopathies' diagnosis with sex and age subgroups; the rates of both DCM and HCM increased with age (p < .001 for both); DCM diagnosis was significantly higher in males compared with females (0.85% vs. 0.35%, p < .001). After adjustment for age, sex, race and presence of arterial hypertension there was a significant stepwise positive association between obesity and the population rates of both cardiomyopathy subtypes. For hospitalised patients with a body mass index (BMI) ≥30 kg/m2 there was an odds ratio (OR) of 1.68 (95% CI: 1.55–1.81, p < .001) for HCM and OR = 1.82 (95% CI: 1.79–1.84, p < .001) for DCM. More importantly, the positive relationship between a cardiomyopathy diagnosis (HCM or DCM) with increasing BMI was driven by the male sex (p < .001 for both) and it was non‐significant in females. The findings from this nationwide observational analysis support a sexual dimorphism in the relationship between obesity and HCM or DCM, which should be further investigated.

ImportanceStroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.ObjectiveTo present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.Design, Setting, and ParticipantsAn in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.ExposuresIn this study, no particular exposure was specifically targeted.Main Outcomes and MeasuresThe primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.ResultsIn 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).Conclusions and RelevanceIn this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.