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Abstract Background Ventricular arrhythmias (VA) are common complications of acute coronary syndromes (ACS) and can cause cardiac arrest and adverse outcomes. However, the prognostic impact of VA according to their timing in relation to percutaneous coronary intervention (PCI) remains unclear. Purpose To assess the prognostic significance of VA in patients with ACS undergoing PCI according to the timing of occurrence (before, during, or after PCI). Methods We performed a systematic review and meta-analysis of observational studies reporting all-cause mortality with and without VA (sustained VT/VF) in ACS patients undergoing PCI. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models for short-term (30 days/in-hospital) and long-term (1 year) mortality. Between-study heterogeneity was assessed using the I² statistic. We conducted subgroup analyses for studies that stratified VA according to timing, defined as VA before PCI (prior to arrival in the catheterization laboratory), VA during PCI (in the catheterization laboratory or immediately after reperfusion), VA after PCI (following completion of PCI). Each timing category was compared to patients who did not develop VA within the same time window (before, during or after PCI). Results Twelve studies comprising 49306 patients were included, of whom 4320 (8.76%) experienced VA. The mean age of the patients ranged from 60 to 70 years, and the follow-up ranged from hospital discharge to 8 years. VA was associated with increased short-term (OR 5.02 [3.91-6.44]) and long-term mortality (OR 3.00 [2.86-3.82]). However, in patients alive at discharge/30 days, subsequent long-term mortality risk did not differ between those with and without VA (OR 1.21 [0.70-2.09]) (Figure 1). The subgroup analyses showed that patients with VA were associated with higher short-term mortality compared to patients without VA within each time window: before (OR 4.32 [3.29-5.66]), during (OR 4.29 [2.08-8.84]), and after PCI (OR 9.29 [3.12-27.63]) (Figure 2). VA after PCI was associated with the highest OR for short-term mortality. Conclusions VA significantly worsens short-term outcomes in ACS patients undergoing PCI. Subgroup analysis shows that VA increases mortality in each timing category, before, during and after PCI, with the poorest prognosis observed for arrhythmias developed after reperfusion, in whom reversible acute ischemia may play a lesser role and underlying arrhythmic substrate may predominate.Figure 1Figure 2

Background Female sex is associated with lower incidence of myocardial infarction, especially at younger ages. However, sex differences in mortality and coronary artery disease patterns among young patients with ST‐segment–elevation myocardial infarction are not well established. This study evaluated sex differences in in‐hospital and 1‐year all‐cause death and in the extent of coronary artery disease in patients aged ≤45 years with ST‐segment–elevation myocardial infarction. Methods A systematic review (December 9, 2025) was conducted using PubMed, Cochrane, Embase, major cardiology conference proceedings, and ClinicalTrials.gov . Studies comparing sexes for outcomes were included. Non‐English publications, abstracts without full text, and studies published before 2010 were excluded. A random‐effects meta‐analysis was performed, with results presented as relative risks (RR) and 95% CIs. Heterogeneity was assessed using τ and I 2 , risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. The study was registered on the International Prospective Register of Systematic Reviews. Results Eleven studies including 738 029 patients with ST‐segment–elevation myocardial infarction (22% women) were analyzed. Female sex was associated with higher unadjusted in‐hospital (RR, 1.56 [95% CI, 1.40–1.74]; τ=0.04; I 2 =0%) and 1‐year mortality rate (RR, 1.78 [95% CI, 1.50–2.12]; τ=0.00; I 2 =0%). Women more frequently had single‐vessel disease (73% versus 60%; RR, 1.13 [95% CI, 1.03–1.23]; τ=0.07; I 2 =67%), while men had 2‐vessel (23% versus 18%; RR, 0.76 [95% CI, 0.68–0.85]; τ=0.00; I 2 =0%;) and 3‐vessel disease (16% versus 9%; RR, 0.49 [95% CI, 0.27–0.86]; τ=0.41; I 2 =33%). Conclusions In young patients with ST‐segment–elevation myocardial infarction, female sex is associated with higher unadjusted in‐hospital and 1‐year death despite less extensive CAD. Further studies adjusting for comorbidities and standardizing CAD definitions are needed.

Abstract Aims Left ventricular (LV) ventricular-arterial coupling (VAC) refers to the ratio of afterload (effective arterial elastance) to contractility (end-systolic elastance) as an integrated marker of cardiac performance. We sought to determine whether the echocardiographic VAC ratio, defined using the ratio of LV end-systolic volume (LVESV) to stroke volume (SV), predicted mortality in the cardiac intensive care unit (CICU). Methods and results Mayo Clinic CICU patients from 2007 and 2018 were included. Ventricular-arterial coupling ratio was calculated as the Teichholz LVESV divided by the SV calculated from LV outflow tract Doppler. The primary outcome was in-hospital mortality and the secondary outcome was all-cause 1-year mortality. A total of 4685 patients were included with a median age of 69 (58, 79) years (37.2% females), with acute coronary syndrome in 54.9% and heart failure in 49.0%. A higher VAC ratio was associated with greater severity of illness, worse echocardiographic findings, and more use of critical care therapies. A total of 329 (7%) patients died during hospitalization. Patients with a higher VAC ratio had higher in-hospital mortality overall and in each admission diagnosis subgroup. After multivariable adjustment, patients with a VAC ratio >2 were at higher risk of in-hospital mortality (adjusted odds ratio 1.63, 95% confidence interval 1.17–2.28, P = 0.010). One-year mortality was higher for patients with a higher VAC ratio, especially VAC >2. Conclusion Ventricular-arterial uncoupling was associated with worse outcomes in an unselected CICU cohort. The echocardiographic VAC ratio is a simple non-invasive bedside measure that can be used for risk prediction in the CICU.

Background: Cardiomyopathies (CM) are a leading cause of heart failure. Identification of genetic risk preemptively may allow detection of the earliest phenotypic manifestations through implementation of interval-based cardiac screening. Previous population-based genetic screening studies have limited follow-up and inadequate phenotyping. Hypothesis: Disease penetrance of CM variants is significantly higher than previously reported. Aims: To determine the prevalence, penetrance, and disease expression of incidental CM-related genetic variants in an unselected, richly phenotyped, adult population. Methods: We analyzed a random sample of 10,000 patients from a quaternary medical center-based biobank cohort for reportable variants in 22-cardiomyopathy genes. Prioritization of genetic variants was performed using Semi-Automated Variant Interpretation, a novel software that has been previously developed and validated at our center. Prioritized variants were then manually curated by 2 independent variant interpretation specialists. Clinical phenotypes and outcomes of participants with likely pathogenic/pathogenic (LP/P) variants were determined. Results: LP/P cardiomyopathy variants were present in 1% of our cohort (n=104) within the following genes: TNNT2 (n=1), DES (n=2), LMNA (n=2), MYL2 (n=2), TNNI3 (n=2), DSG (n=4), FLNC (n=4), DSC2 (n=6), SCN5A (n=7), PKP2 (n=10), DSP (n=12), MYH7 (n=14), TTN (n=17), MYBPC3 (n=21). Only 1 participant carried two different LP/P variants. A definitive disease penetrance defined as heart failure or cardiomyopathy was found in 34% of genotype positive (G+) individuals. Possible disease penetrance defined as presence of structural heart disease identified by echocardiography was found in an additional 16% of participants (concentric left ventricular hypertrophy, diastolic dysfunction, biatrial and left atrial enlargement). Combined definitive and possible disease penetrance was found in 50% of G+ individuals. Arrhythmias and/or cardiac conduction disease (atrial fibrillation, atrioventricular block, ventricular arrhythmia) were present in 31% of G+ individuals. Conclusion: Cardiomyopathy associated LP/P variants are present in a small subset of a large quaternary medical center population as previously reported but unlike prior studies, disease penetrance manifesting as cardiac structural abnormalities and heart failure is high in G+ individuals.

Background: Ventricular-arterial coupling (VAC) refers to the ratio of afterload (effective arterial elastance) to contractility (left ventricular (LV) end-systolic elastance) as an integrated marker of cardiac performance. Echocardiography might be used to evaluate VAC through a simple time-efficient bedside evaluation. Hypothesis: VAC is useful for mortality risk stratification in an unselected cardiac intensive care unit (CICU) cohort. Aims: We sought to determine whether the VAC ratio, defined using the ratio of LV end-systolic volume (LVESV) to stroke volume (SV), predicted mortality in the CICU. Methods: Consecutive patients admitted to the Mayo Clinic CICU between 2007 and 2018 were included. The simplified VAC ratio was calculated as the LVESV calculated from 2D measurements using the Teichholz formula divided by the SV calculated from the LV outflow tract pulsed wave Doppler measurement, with values >1 reflecting ventricular-arterial uncoupling. The main outcome was all-cause in-hospital mortality. Results: We included 4685 patients with a median age of 69 (58-79) years; 37% were females. The median VAC ratio was 1.0 (0.7 to 1.8) and 21% of patients had a VAC ratio >2. Most clinical and echocardiographic variables differed in patients with higher VAC ratio, reflecting greater severity of illness with worse cardiac systolic and diastolic function. A total of 329 (7.0%) patients died during hospitalization. An incremental association was observed between a higher VAC and in-hospital mortality (unadjusted OR 1.22, 95% CI 1.16-1.29, p<0.001). Patients with a VAC ratio >1 (unadjusted OR 2.85, 95% CI 2.22-3.69, p <0.001) and especially those with VAC ratio >2 (unadjusted OR 4.28, 95% CI 3.24-5.69, p<0.001) had higher in-hospital mortality overall and in each admission diagnosis subgroup of interest ( Figure ). After multivariable adjustment, patients with a VAC ratio >2 remained at higher risk of in-hospital mortality (adjusted OR 1.63, 95% CI 1.17-2.28, p = 0.01). Conclusions: Ventricular-arterial uncoupling was associated with worse outcomes in an unselected CICU cohort. The echocardiographic VAC ratio is a simple non-invasive bedside measure that can be used for risk prediction in the CICU.

Background: Patients with normal resting left ventricular ejection fraction (LVEF) without either coronary artery disease (CAD) or a hypertensive response can paradoxically develop reduced LVEF during exercise stress echocardiography (ESE). The clinical phenotype and outcomes of these patients is unknown. Hypothesis: Patients who paradoxically develop reduced LVEF during exercise may represent a sub-phenotype of heart failure with preserved LVEF (HFpEF). Aims: To describe the baseline characteristics and clinical outcomes of this unique patient population. Methods: Among all ESE performed between January 2003 and December 2022, patients without a hypertensive response to exercise and without CAD by angiogram within 90 days of ESE, who had a resting LVEF ≥50% with a ≥5% LVEF decrease during ESE were identified. All-cause mortality, HF hospitalization, and atrial fibrillation (AF) outcomes were assessed. Kaplan-Meier and Cox regression methods were used to analyze time-to-event outcomes. Results: Among 213,643 stress echocardiograms performed, 134 patients met eligibility criteria (Table 1). The mean age of the population was 66±10 years, 76% were women, and 16% had AF at baseline. Mean LVEF was 58±4% at rest and 43±4% at peak stress. Stress electrocardiogram met criteria for ischemia in 14%. The 10-year all-cause mortality risk was 12.9% (95% CI 5.5-20.3) with 10 (37%) of 27 deaths due to cancer (Figure 1, Panel A). The 10-year estimated risk of HF hospitalization was 17.6% (95% CI 9.0-26.2) (Figure 1, Panel B). Among 112 patients without AF at baseline, the 10-year risk of developing AF was 23.4% (95% CI 13.4-33.4). Conclusions: Patients with exercise-induced reduced LVEF in the absence of obstructive CAD have a high incidence of HF hospitalizations and AF. Given the preponderance of women, risk for AF, HF hospitalizations, and cancer-related deaths, the possibility that this condition is an early sub-phenotype of HFpEF should be investigated.

Background: Electrocardiography-based artificial intelligence (AI-ECG) validated models that detect cardiac disease are increasingly being applied in clinical practice. The utility of such tools to detect insidious cardiac disease in patients with normal baseline left ventricular ejection fraction (LVEF) who paradoxically develop reduced LVEF during exercise stress echocardiography (ESE), and do not have coronary artery disease (CAD) or hypertension, is unknown. Hypothesis: AI-ECG is useful to diagnose insidious cardiac disease and predict clinical outcomes in patients with exercise-induced cardiomyopathy. Aims: To assess the utility of AI ECG in patients with exercise-induced cardiomyopathy. Methods: Among all ESE performed between January 2003 and December 2022, patients without a hypertensive response to exercise and without CAD (confirmed by coronary angiography within 90 days after ESE), with resting LVEF ≥50% and a paradoxical ≥5% LVEF decrease during ESE were identified. A previously validated AI-ECG algorithm that predicts atrial fibrillation (AF), reduced LVEF, and cardiac amyloidosis (CA) was applied to the baseline ECG closest to the time of ESE. The predicted probability of AF, reduced LVEF, and CA if above the published thresholds, was determined. Results: There were 134 patients with exercise-induced cardiomyopathy who were identified. The mean age of this cohort was 66±10 years, 76% were women and 16% had AF at baseline. Mean LVEF was 58±4% at rest and 43±4% at peak stress. The median follow-up period was 6.8 years (IQR 3.0-12.2). Among patients without a baseline history of AF (n=112), AI-ECG identified 29% with a significant probability of AF, which was associated with a subsequent AF diagnosis at univariable analysis (HR 2.505, 95%CI 1.016-6.177, p=0.046). There were 10 patients with an AI-ECG prediction of reduced LVEF among whom 3 were subsequently hospitalized with HF. AI-ECG was positive for CA in 8 and 3 amongst these had subsequent HF hospitalizations (Table). Conclusions: Baseline AI-ECG may help predict subsequent AF and diagnose preclinical amyloid cardiomyopathy in patients who by resting echocardiography do not seem to have cardiac disease but with exercise develop reduced LVEF.