Kietselaer, Bas

Background General practitioners (GPs) have limited tools for chest pain patients to identify (non-)obstructive coronary artery disease (OCAD). This trial evaluates whether GP access to the coronary artery calcium score (CACS) improves diagnostic efficiency and cardiovascular risk management (CVRM). Methods COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GP patients with stable chest pain (CONCRETE) is a pragmatic, non-blinded implementation study that cluster-randomised 101 Dutch GP offices into CACS or standard of care (SOC). Patients aged ≥40 (men) or ≥45 (women) years, without known CAD, with possible cardiac or non-cardiac chest pain were included. The primary outcome was the proportional 2-year increase in CVRM registrations at GP office level. Patient-level secondary outcomes included cardiologist referral rate, OCAD diagnosis and CVRM enrolment. Results At GP office level, no significant difference in CVRM registration increase was seen for CACS versus SOC (46 CACS practices: +0.3%, 45 SOC practices: +0.2%, p=0.77). Per protocol analysis for patient-level outcomes included 583 patients (57.5% women, mean age 60.6±9.1 years) (CACS arm: 466; SOC arm: 117), recruited between January 2019 and October 2023. The CACS arm showed 47.1% relative reduction in cardiologist referrals compared with SOC (42.5% vs 80.3%; modelled difference 31.3% (95% CI 14.8% to 47.8%)). OCAD detection rates were not significantly different (CACS: 4.9, SOC: 7.7%, p=0.14). Patients with higher CACS had a higher probability of cardiologist referral (from 8.4% for CACS 0 to 94.2% for CACS ≥400, difference +85.7% (95% CI 79.4% to 91.9%)) and of OCAD diagnosis (0% for CACS 0 to 21.2% for CACS ≥400, OR 9.08 (95% CI 4.20 to 19.67)). Compared with SOC, more CACS patients were enrolled in CVRM (36.3% vs 17.0%, p<0.01). Conclusions In this pragmatic, primary-care implementation and proof-of-concept trial, CACS was an effective diagnostic test for stable chest pain patients with (very) low likelihood of OCAD. CACS reduced unnecessary cardiology referrals and enhanced individual preventive care, without demonstrable practice-level impact on CVRM registrations. Registration The CONCRETE study is registered under CCMO Register NL66821.042.18 and closed for enrolment.

Background Immune checkpoint inhibitors (ICI) improve cancer outcomes but are associated with increased atherosclerotic cardiovascular risk. Opportunistic coronary artery calcium (CAC) assessment from routine non-gated computed tomography (CT) using artificial intelligence (AI) may enable rapid cardiovascular risk stratification in this population. We evaluated the association between AI-derived CAC (AI-CAC) scores and 1-year myocardial infarction (MI) and all-cause mortality in patients receiving ICI therapy. Methods We conducted a retrospective multicenter study across three Mayo Clinic sites including patients who underwent chest CT within 3 months prior to ICI initiation between 2011 and 2022. Patients with prior coronary revascularization were excluded. AI-CAC scores derived from non-gated CT scans were categorized as 0, 1–99, 100–399, and ≥400. Cox regression analyses assessed associations with 1-year MI and all-cause mortality. Results Among 1,873 patients (mean age 66 years; 43% women), lung cancer was most common (50.3%), and 91% had at least one cardiovascular risk factor. Higher CAC burden was associated with increased 1-year MI risk (overall p=0.0032). AI-CAC was not associated with all-cause mortality (p=0.79), likely reflecting high cancer-related mortality (50.7% at 1 year). Only 15% of patients were receiving statins despite one-third having CAC >100. Conclusions Opportunistic AI-CAC assessment from routine CT scans provides modest prognostic value for MI risk among patients receiving ICI therapy and may identify opportunities to optimize preventive cardiovascular care. Elevated CAC should prompt risk factor modification rather than influence ICI treatment decisions. Prospective studies are warranted to evaluate clinical implementation and outcomes.

BACKGROUND: Transcatheter mitral valve-in-valve replacement is an established therapy for intermediate and high-risk patients with degenerated bioprostheses, but restricted transcatheter valve (THV) expansion within rigid surgical frames and elevated gradients have raised durability concerns. This study aimed to evaluate midterm outcomes of mitral valve-in-valve patients according to THV expansion and sizing strategy. METHODS: Patients who underwent mitral valve-in-valve with balloon-expandable valves at Mayo Clinic Rochester between 2014 and 2023 were retrospectively analyzed. THV expansion (inflow, waist, outflow) was measured from procedural fluoroscopy and indexed to nominal size, with zero indicating expansion to nominal dimensions. Median index values were used as subgroup cutoffs to compare the incidence of the primary composite outcome of all-cause mortality, heart failure readmission, and valve reintervention. RESULTS: The analysis included 80 patients with a median follow-up of 2.5 years. A total of 53 (66%) valves were underexpanded across all 3 sizes, with median inflow, waist, and outflow expansion indices of −10.2, −16.2, and −3.2, respectively. Across all indices, THV expansion closer to nominal size was associated with lower rates of the primary outcome ( P <0.05). Greater expansion correlated with a larger mitral valve area and lower transvalvular mean gradient. Oversized THVs were significantly less expanded and had a higher incidence of the primary composite outcome compared with recommended-size THVs ( P =0.02). CONCLUSIONS: THV underexpansion in degenerated mitral bioprostheses is common and associated with elevated gradients and worse midterm outcomes. Further research is warranted to define THV expansion targets and improve outcomes following mitral valve-in-valve intervention.

Background: We conducted an updated meta-analysis of the routine use of cerebral embolic protection (CEP) devices in Transcathter Aortic Valve Replacement (TAVR). This analysis follows the recent BHF PROTECTED TAVI trial which is the largest randomized controlled trial to date. Methods: Electronic databases were searched through April 2025 for eligible randomized controlled trials (RCTs). The primary outcome was overall incidence of stroke, disabling stroke and non-disabling stroke all reported at 2-5 days and 30 days were primary outcomes for our analyses. Results: 8 RCTs with a total of 11,692 patients were included. No statistically significant difference was found between CEP group and the control group in overall stroke incidence at 2-5 days and 30 days as the following (RR=0.95, 95%CI: [0.75,1.19], p=0.64) and (RR=0.93, 95%CI: [0.57,1.53], p=0.79). Similarly, the pooled analysis revealed no statistically significant difference between the two groups in terms of disabling stroke at 2-5 days (RR=0.70, 95%CI: [0.41,1.18], p=0.18), and at 30 days (RR=1.18, 95%CI: [0.36,3.87], p=0.78). CEP group and control group didn’t show statistically significant difference in non- disabling stroke at 2-5 days and 30 days as the results showed: (RR=1.17, 95%CI: [0.84,1.63], p=0.36) and (RR=0.86, 95%CI: [0.49,1.51], P=0.61) respectively. Conclusion: Our meta-analysis found no statistically significant evidence that cerebral embolic protection (CEP) devices reduce the incidence of stroke—disabling or non-disabling in the 2-5 days following TAVR or after 30 days. Major bleeding, major vascular complication and AKI showed no statistically significant results indicating a neutral safety profile.

Objective Despite promising outcomes from pilot initiatives, the transition to widespread adoption and upscaling of eHealth solutions in the hospital context remains challenging. This study aims to explore the barriers and facilitators influencing the implementation of eCoaches from the perspective of professionals. Methods A qualitative research design was employed, involving individual semi-structured interviews with management and healthcare professionals ( n = 10) who were involved with an eCoach either for heart failure (HF) or inflammatory bowel disease (IBD). Both eCoaches supported remote monitoring, advisory, educational, and interactive care activities. Interview topics were guided by the Consolidated Framework for Implementation Research (CFIR), including the original five domains and the added domain Patients′ needs and Resources. Data were analyzed thematically. Results Barriers and facilitators were identified across all CFIR domains: eCoach design and licensing costs (Intervention Characteristics); financial compensation (Outer Setting); integration into care pathways, Information and Communication Technology (ICT) infrastructure, team dynamics, and task reallocation (Inner Setting); intrinsic motivation, beliefs, and competencies of professionals (Characteristics of Individuals); patient resources and digital literacy (Patients’ Needs and Resources); and availability of evidence and management information (Process of Implementation). Conclusion This study underscores the complex nature of implementing eCoaches within the hospital setting, where barriers and facilitators span multiple interrelated domains. To overcome “pilotitis” and achieve the sustainable integration of blended care for patients with chronic conditions, comprehensive implementation strategies that concurrently address all relevant domains are essential. By illuminating the experiences of healthcare professionals, this study offers actionable insights to guide the design, implementation, and upscaling of eCoaches and related eHealth technologies.

ABSTRACT Objective Pre‐eclampsia complicates up to 8% of pregnancies and is associated with increased risk of ischemic cardiac and cerebral disease, which may be prevented through management of cardiovascular risk when early disease stages are detected. This meta‐analysis aimed to determine the prevalence of clinical and subclinical atherosclerosis in women after pre‐eclamptic vs non‐pre‐eclamptic pregnancy with advancing maternal age. Methods A systematic search of the literature was conducted in PubMed, Embase and Web of Science for studies reporting on the prevalence of atherosclerosis in women with a previous pre‐eclamptic pregnancy and those with a previous uncomplicated pregnancy. Any systemic atherosclerosis documented using ultrasound or computed tomography was included. Random‐effects meta‐analysis was used to compute the odds ratio (OR) with 95% CI for the association between pre‐eclampsia and the presence of atherosclerosis. Subgroup analysis was conducted according to average maternal age at evaluation. Results A total of 11 articles were included (13 217 participants). The average maternal age at evaluation ranged from 32 to 60 years. Within this age range, the pooled OR for the presence of atherosclerotic plaque after pre‐eclampsia was 1.57 (95% CI, 1.39–1.78). The pooled OR of developing atherosclerotic plaque after a pre‐eclamptic vs non‐pre‐eclamptic pregnancy increased gradually with advancing maternal age. The OR was not significant in the 30–39‐year‐old group (0.64 (95% CI, 0.10–4.15)), but the odds of finding an atherosclerotic plaque were significantly increased after pre‐eclamptic pregnancy in the 40–49‐year‐old group (OR, 1.59 (95% CI, 1.34–1.89)) and 50–60‐year‐old group (OR, 2.00 (95% CI, 1.30–3.08)). At any given age, the percentage plaque prevalence in formerly pre‐eclamptic women was roughly equal to that seen 10 years later in women with a previous non‐pre‐eclamptic pregnancy. Conclusions Women with a previous pre‐eclamptic pregnancy exhibit atherosclerosis more frequently and approximately 10 years earlier compared with women with a previous non‐pre‐eclamptic pregnancy. Targeted primary prevention is required to reduce morbidity and mortality from premature cardiovascular disease in women after pre‐eclampsia. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Background Low-dose colchicine (0.5 mg once daily) reduces the risk of major cardiovascular events in coronary disease, but its mechanism of action is not yet fully understood. We investigated whether low-dose colchicine is associated with changes in pericoronary inflammation and plaque composition in patients with chronic coronary disease. Methods We performed a cross-sectional, nationwide, subanalysis of the Low-Dose Colchicine 2 Trial (LoDoCo2, n=5522). CT angiography studies were performed in 151 participants randomised to colchicine or placebo after a median treatment duration of 28.2 months. Pericoronary adipose tissue (PCAT) attenuation measurements around proximal coronary artery segments and quantitative plaque analysis for the entire coronary tree were performed using artificial intelligence-enabled plaque analysis software. Results Median PCAT attenuation was not significantly different between the two groups (−79.5 Hounsfield units (HU) for colchicine versus −78.7 HU for placebo, p=0.236). Participants assigned to colchicine had a higher volume (169.6 mm 3 vs 113.1 mm 3 , p=0.041) and burden (9.6% vs 7.0%, p=0.035) of calcified plaque, and higher volume of dense calcified plaque (192.8 mm 3 vs 144.3 mm 3 , p=0.048) compared with placebo, independent of statin therapy. Colchicine treatment was associated with a lower burden of low-attenuation plaque in participants on a low-intensity statin, but not in those on a high-intensity statin (p interaction =0.037). Conclusions Pericoronary inflammation did not differ among participants who received low-dose colchicine compared with placebo. Low-dose colchicine was associated with a higher volume of calcified plaque, particularly dense calcified plaque, which is considered a feature of plaque stability.

Abstract Background Up to eight percent of pregnant women have pre-eclampsia. These women have an increased risk of future ischemic heart and cerebral disease. This warrants early cardiovascular risk management in early disease stages. This meta-analysis determines how the prevalence of subclinical atherosclerosis in women after pre-eclamptic compared to non-pre-eclamptic pregnancies changes over time. Methods A systematic search was used. Studies reporting the prevalence of systemic atherosclerosis using ultrasound or computed tomography in formerly pre-eclamptic and non-pre-eclamptic women were included. A random-effects meta-analysis provided overall odds ratio’s (OR (95% confidence interval (CI)) for the association between pre-eclampsia and the prevalence of atherosclerosis. Results Eleven articles could be included with a total of 13,217 participants. Maternal age ranged from 33 to 60 years. Within this age period, pooled OR of developing atherosclerosis after pre-eclampsia was 1.57 (95%CI 1.39-1.78). The pooled odds of developing atherosclerotic plaque after a pre-eclamptic versus a non-pre-eclamptic pregnancy increased gradually with age. The odds ratio was not significantly different in the 30-39 age group (OR 0.64 (95%CI 0.10-4.15)), but there was a statistically significantly increased odds of finding an atherosclerotic plaque in the 40-49 (OR 1.59 (95%CI 1.34-1.89)) and 50-60 age groups (OR 2.00 (95%CI 1.30-3.08)) after pre-eclamptic pregnancies compared to non-pre-eclamptic pregnancies. Conclusions Formerly pre-eclamptic women have earlier and more frequent atherosclerosis and occurs ten years earlier than in non-pre-eclamptic women. Targeted prevention strategies are required to prevent premature cardiovascular disease morbidity and mortality in formerly pre-eclamptic women.