Background: A pulmonary artery catheter (PAC) provides detailed hemodynamic data, and managing a patient with cardiogenic shock (CS) using a PAC potentially improves patient outcomes. Therefore, in this systematic review and meta-analysis we aimed to evaluate whether a PAC is associated with better outcomes in patients with CS.

Methods and Results: Studies comparing PAC and non-PAC management in patients with CS were identified from the PubMed, Web of Science, and CENTRAL databases. There were no randomized controlled trials (RCTs). Of the 19 studies that met the inclusion criteria, 12 without a critical risk of bias were analyzed. PAC use was associated with lower in-hospital mortality when evaluated as a dichotomous outcome. Similar trends were observed in the time-to-event analyses. Substantial heterogeneity was observed across the studies. Subgroup analysis revealed better outcomes with PAC in patients with CS related to heart failure, but not in those with acute coronary syndrome. Sensitivity analyses, which included studies with a critical risk of bias, showed consistent trends favoring PAC use for crude in-hospital mortality. The overall certainty of the evidence was very low because of inconsistencies and biases.

Conclusions: The PAC-guided CS management was associated with better in-hospital mortality, particularly in patients with heart failure-related CS. However, RCTs that evaluated the efficacy of PAC use as a primary purpose were not included, necessitating further RCTs to confirm these findings.

Transthyretin amyloid cardiomyopathy (ATTR-CM) is increasingly recognized as a cause of heart failure with preserved ejection fraction in older adults. Tafamidis, a transthyretin stabilizer, is the first disease-modifying therapy approved for ATTR-CM. Although its efficacy was demonstrated in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) trial, real-world data are essential to evaluate its effectiveness across broader and more diverse patient populations. This review synthesizes real-world evidence on tafamidis, including patient characteristics, diagnostic and therapeutic delays, and clinical outcomes such as mortality, hospitalization, cardiac biomarker trends, imaging findings, and functional capacity. Compared with clinical trial participants, real-world patients are generally older, often present with more advanced disease, and initiate treatment later in the disease course. Nevertheless, observational studies from Japan and other countries consistently show that tafamidis is associated with improved survival, reduced heart failure hospitalizations, stabilization of cardiac structure and biomarkers, and preservation of physical function – especially when therapy is started early. Accumulating such data will be crucial for optimizing patient care, particularly in the context of future treatment strategies involving emerging agents such as a next-generation oral transthyretin stabilizer and a subcutaneously administered RNA interference therapeutic. This review aims to bridge the gap between clinical trial findings and routine practice, supporting informed decision-making in the management of this progressive and underdiagnosed condition.

Background: Coronary artery disease (CAD) is becoming increasingly prevalent in aging populations. Long-diffuse CAD (ldCAD), characterized by lesions ≥30 mm, poses significant treatment challenges. This study aimed to evaluate the long-term prognostic differences between single long stents (SLS) and overlapping stents (OLS) in patients with ldCAD using second-generation and later drug-eluting stents (DES).

Methods and Results: A systematic review and meta-analysis of studies published between 2000 and October 2024 in PubMed, Embase, Web of Science, and the Cochrane Library was conducted. The primary outcome was major adverse cardiovascular events (MACE) over 1 year. The secondary outcomes were cardiac death, target lesion revascularization, target vessel revascularization (TVR), and fatal or non-fatal myocardial infarction (MI). The analysis included 5 studies with 2,756 patients, indicating no significant differences between SLS and OLS regarding MACE and TVR. However, MI incidence was significantly lower with SLS, whereas OLS showed a higher MI incidence, likely due to differences in lesion length rather than the strategy itself. Subanalyses indicated that SLS significantly reduced contrast volume compared with OLS, with a trend toward shorter lesions and stent lengths.

Conclusions: Stent overlap has minimal impact on prognosis with newer DES. Despite limitations from non-randomized data, further research is needed to optimize ldCAD treatment strategies and guide clinical practice.

Background: The optimal revascularization strategy for calcified lesions in patients with acute coronary syndrome (ACS) remains unclear. This study aimed to compare the short-term outcomes of intravascular lithotripsy (IVL) and rotational atherectomy (RA) for patients with ACS resulting from calcified lesions.

Methods and Results: Among 3,556 consecutive patients with ACS who underwent primary percutaneous coronary intervention (PCI) between 2016 and 2024, we retrospectively analyzed 52 patients who received drug-eluting stents with either IVL (n=24) or RA (n=28) for calcified lesions. The primary outcome was the incidence of major adverse cardiovascular events (MACE). In addition, we evaluated slow-flow or no-reflow phenomena incidence during PCI and the procedural success rate. Compared with patients with RA, those with IVL had a smaller preprocedural minimum lumen diameter and a larger preprocedural reference vessel diameter. Primary outcomes and procedural success rates were comparable between both groups. However, the slow-flow or no-reflow incidence was significantly lower in the IVL group than in the RA group. After adjusting for confounders, IVL was independently associated with a lower slow-flow or no-reflow incidence.

Conclusions: In patients with ACS due to calcified lesions, there was no significant difference in 30-day MACE incidence between both groups. However, slow-flow incidence was lower in the IVL group.

Background: Caregiver support is essential for patients with heart failure to receive continued care at home.

Methods and Results: This cross-sectional study of 60 heart failure patients and their primary caregivers (consent rate 62.5%) examined the relationship between the caregivers’ assessment of caregiving using the Caregiver Reaction Assessment Japanese version and the patients’ and caregivers’ sociodemographic factors, the patients’ physical condition, the caregiving activities, and health-related quality of life assessed using Short Form-8. The results indicated that Short Form-8 scores were inversely associated with positive appraisal of caregiving (β=−0.33; P=0.01). The impact on the schedule of daily living was associated with caregivers’ mental health (β=–0.28; P=0.04) and the frequency of practical support related to medical treatment (β=0.25; P=0.05). There were associations between the following: impact on health (2.3±0.9) and caregiver employment (β=–0.27; P=0.03); lack of family support (2.2±0.8) and hours of care per day (β=0.25; P=0.05); and impact on finances (2.3±1.2) and functional health literacy (β=0.25; P=0.05).

Conclusions: Evaluating caregiving appraisal and related factors among caregivers of patients with heart failure may lead to effective support for caregivers.

Background: Collaboration between cardiologists and oncologists was recommended as part of Japan’s Basic Plan to Promote Disease Control Programs in 2023. We evaluated the extent of this collaboration regarding anthracycline-related cardiomyopathy (ARCM).

Methods and Results: Self-administered questionnaires on ARCM were distributed to all cardiologists and leading oncologists in hospitals across the Niigata Prefecture. Overall, 126 cardiologists and 41 leading oncologists from 29 hospitals responded to the survey. Clinical experience with ARCM was reported by 76.2% of cardiologists and 58.5% of leading oncologists (P=0.044). Guideline recommendations for the early detection and treatment of ARCM were known by 89.1% of cardiologists and 87.8% of leading oncologists. Among the 20 hospitals providing chemotherapy, 12 (60%) had matching answers for ‘post-event consultation’ or ‘pre-event consultation’ between the cardiology and oncology departments. Regarding ‘pre-event consultation’, 4 hospitals had consistent responses for the most proactive response, whereas only 1 hospital had consistent responses from both departments for the majority response. The agreement of responses between the 2 departments was significant for the most proactive response (k=0.485; P=0.005), but not for the majority response (k=0.059; P=0.675).

Conclusions: The importance of early detection and treatment of ARCM was understood at the individual level; however, increased emphasis on ‘pre-event consultation’ is necessary to establish an interdepartmental early detection system.

Background: Empagliflozin and dapagliflozin are both approved for the treatment of chronic heart failure (CHF), but their comparative efficacy remains uncertain. Therefore, we aimed to prospectively compare the effects of 10 mg empagliflozin and 10 mg dapagliflozin on NT-proBNP levels and clinical outcomes in patients with stable CHF.

Methods and Results: In this single-center, open-label, prospective crossover study, 25 patients with stable CHF (age 74.3±11.9 years; 68% male) were enrolled. Patients were initially treated with either empagliflozin (n=6) or dapagliflozin (n=19) for ≥3 months before switching to the alternative agent. Follow-up assessments were conducted 1 month after the switch. Patients then selected their preferred agent and were followed for ≥1year. NT-proBNP levels were significantly higher in patients initially treated with empagliflozin compared to those treated with dapagliflozin (3,334±2,107 vs. 1,101±923 pg/mL, P=0.001). However, NT-proBNP levels did not change significantly in either group following the crossover. During follow-up, 6 patients (24%) were hospitalized for worsening HF, with no significant difference between treatment groups. Notably, NT-proBNP ≥1,453 pg/mL was significantly associated with poorer outcomes (P=0.008).

Conclusions: In this crossover study, empagliflozin and dapagliflozin showed comparable effects on NT-proBNP levels and clinical outcomes, supporting their interchangeable use in stable CHF.

Background: Coronary microvascular dysfunction (CMD) is associated with myocardial ischemia in patients without obstructive coronary artery disease (CAD). Epicardial fat volume (EFV) has been reported to be associated with epicardial CAD and diastolic dysfunction. However, because its impact on CMD remains unclear, we aimed to investigate the relationship between CMD and EFV.

Methods and Results: This study included 103 patients without obstructive CAD who underwent assessment of CMD and EFV. CMD was defined as either coronary flow reserve (CFR) <2.0 or index of microcirculatory resistance (IMR) ≥25. EFV was quantified using computed tomography and the EFV index was calculated. CMD was identified in 34 (33%) patients. The EFV index was significantly larger in the CMD group than in the non-CMD group (86.1±27.9 vs. 65.8±20.0 cm³/m²; P<0.01). Notably, patients with low CFR (<2.0) and high IMR (≥25) had a larger EFV index (102.1±33.4 cm³/m²). Univariable logistic regression analysis indicated a significant relationship between CMD and the EFV index (odds ratio (OR): 1.04; P<0.01). In the multivariable model, EFV index was significantly associated with CMD (OR: 1.03; P<0.01). The EFV index significantly correlated with CFR (r=−0.39, P<0.01) and IMR (r=0.32, P<0.01).

Conclusions: EFV was associated with CMD in patients without obstructive CAD.

Background: Cardiac sarcoidosis is a major cause of secondary cardiomyopathy leading to lethal arrhythmias and heart failure; however, identifying specific imaging findings of cardiac sarcoidosis remains a major issue. We re-examined the macroscopic morphology of post-mortem hearts to identify and reconfirm crucial findings for the clinical diagnosis of cardiac sarcoidosis.

Methods and Results: We examined 14 autopsied hearts from patients who were diagnosed with cardiac sarcoidosis from 2002 to 2019 at several medical institutions in Japan. The cases were classified into 2 groups: ante-mortem diagnosis (Group A, n=8), and post-mortem diagnosis (Group B, n=6). Of the 14 hearts, steroids were only administered in Group A. Seven macroscopic features were re-evaluated in all hearts: (1) epicardial irregularity (n=5); (2) fibrosis in the posterior interventricular junction (n=11); (3) ventricular septum wall thinning (n=9); (4) diffuse left ventricular wall thinning (n=4); (5) ventricular aneurysms (n=3); (6) papillary muscle deformities (n=12); and (7) white colored fibrosis (n=8).

Conclusions: This study highlights the underreported macroscopic findings of cardiac sarcoidosis. The 7 features highlight the uniqueness of cardiac sarcoidosis, which warrants recognition of this disease as a distinct pathological entity rather than merely a dilated cardiomyopathy-like secondary cardiomyopathy.

Background: Metabolic diseases such as obesity and type 2 diabetes are on the rise and have become a significant global public health issue. Mitochondrial function and biogenesis in visceral adipose tissue are key factors influencing the development of obesity and related metabolic disorders. In addition, chronic inflammation involving immune cells can lead to obesity-related metabolic disorders. Given these underlying mechanisms, we aimed to test whether the treatment of frozen-thawed isolated mitochondrial preparations (MRC-Q) from cultured cells had a protective effect on adipose tissue inflammation and remodeling in a high-fat diet-induced mouse model.

Methods and Results: MRC-Q was given intraperitoneally every 2 weeks to the mice in the diet-induced obesity (DIO) model. The results demonstrated that MRC-Q reduced the amount of adipose tissue and the body weight of the DIO mice, reduced blood glucose, and improved glucose tolerance. This process was accompanied by M2 macrophage polarization and suppression of pro-inflammatory responses in the visceral fat of mice. In addition, in vitro experiments indicated that MRC-Q could directly transform macrophages to the M2 phenotype.

Conclusions: A novel mitochondrial preparation, MRC-Q, protected against adipose tissue remodeling in DIO mice by promoting M2 macrophage polarization, and inhibiting pro-inflammatory responses in visceral fat.

Background: Endovascular therapy (EVT) for severely calcified femoropopliteal (FP) lesions in patients with peripheral artery disease (PAD) is challenging. This study evaluates the clinical utility of rotational atherectomy and orbital atherectomy in EVT for such lesions.

Methods and Results: This single-center retrospective study enrolled 62 consecutive patients with symptomatic PAD (71.0% male; median age 76 years; diabetes 71.0%; hemodialysis 30.6%; chronic limb-threatening ischemia 27.4%) due to severely calcified FP lesions (chronic total occlusion 32.3%; average lesion length 150 mm; Peripheral Arterial Calcium Scoring System classification: grade 1, 6.5%; grade 2, 12.9%; grade 3, 22.6%; and grade 4, 54.8%) who underwent EVT with atherectomy systems. The luminal gain was evaluated using angiography and intravascular ultrasound (IVUS). Quantitative vascular analysis showed stenosis diameters of 86.6% (pretreatment), 48.4% (after atherectomy), and 25.5% (after adjunctive balloon angioplasty). IVUS indicated the minimum lumen area increased from 2.0 mm²to 8.1 mm²after atherectomy and 17.8 mm²after angioplasty (P<0.001). Superficial calcium arcs decreased from 195.9° (141.6, 360) to 158.7° (119.9, 211.2; P<0.001). Procedural success was achieved in all patients. Distal embolization occurred in 7 patients. No major adverse events occurred within 30 days.

Conclusions: Atherectomy systems significantly increased lumen dimensions in severely calcified FP lesions by removing superficial calcium without increasing the risk of major complications. However, a notable incidence of distal embolism remains unavoidable.

Background: Malnutrition has been associated with poor prognosis in patients with lower extremity arterial disease (LEAD). Malnutrition can influence adverse bleeding events in patients with coronary artery disease. However, the association between bleeding events and malnutrition in patients with LEAD remains unclear. Therefore, this study evaluated the association between nutritional screening with controlled nutritional status (CONUT) score and bleeding events in patients with LEAD.

Methods and Results: This single-center retrospective observational study included 297 patients with LEAD who underwent endovascular therapy between January 2016 and December 2021. The high CONUT group was compared with the low CONUT group. The primary outcome was freedom from bleeding events, which was defined as Bleeding Academic Research Consortium type 3 or type 5. The high CONUT group had significantly higher cumulative bleeding events than the low CONUT group (log-rank P value <0.0001). Univariate analysis revealed that patients with a high CONUT score (hazard ratio [HR] 4.48; 95% confidence Interval [CI] 1.92–10.4; P=0.0005), chronic limb-threatening ischemia (HR 5.30; 95% CI 2.07–13.5; P=0.0005), non-ambulatory (HR 3.12; 95% CI 1.11–8.77; P= 0.03), and chronic kidney disease on hemodialysis (HR 4.01; 95% CI 1.72–9.33; P=0.001) had significantly more bleeding events than those with low CONUT scores.

Conclusions: A high CONUT score at admission is closely associated with bleeding events in patients with LEAD.

Background: Right ventricular (RV) function is a prognostic factor in patients with pulmonary arterial hypertension (PAH). Cardiovascular magnetic resonance (CMR) imaging has been used to assess RV function. However, it is not determined whether RV longitudinal strain (LS) with a feature-tracking method can accurately assess RV contractility. In this study, feature-tracking-based RVLS and RV ejection fraction (RVEF) were compared with contractile properties of RV muscle obtained from rat hearts with PAH.

Methods and Results: Monocrotaline (MCT-rats, n=19) or solvent (Ctr-rats, n=4) was injected subcutaneously into rats. Four weeks after the injection, retrospective electrocardiogram-gated cine magnetic resonance (8 phases/beat) was imaged using a 7-T magnetic resonance imaging (MRI) scanner and RV pressure was measured. Trabeculae were dissected from the RV and electrically stimulated. Force was measured and maximum dF/dt was calculated as a parameter of contractile properties. Compared with Ctr-rats, MCT-rats showed higher systolic RV pressure. RVLS in all MCT-rats was lower than that in Ctr-rats, while RVEF was preserved (>40%) in 8 out of 16 MCT-rats. MCT-rats showed lower developed force and maximum dF/dt than Ctr-rats. Maximum dF/dt was linearly correlated with RVLS. In contrast, whether RVEF was preserved, maximum dF/dt was decreased in MCT-rats.

Conclusions: The present study suggests that RVLS with a feature-tracking method can assess RV contractile properties more accurately than RVEF in rats with PAH. It is useful to estimate the RV function based on feature tracking.

Background: Large language models (LLMs) have shown potential in medical education, but their application to cardiology specialist examinations remains underexplored. We compared the performances of a retrieval-augmented generation LLM (RAG-LLM) ‘CardioCanon’ against general-purpose LLMs.

Methods and Results: A total of 96 publicly available text-based open-source multiple-choice questions from the Japanese Cardiology Specialist Examination (1997–2022) were used. CardioCanon showed similar option-level accuracy to ChatGPT-4o and Gemini 2.0 Flash (81.0%, 76.0%, and 77.2%, respectively), but higher case-based accuracy than ChatGPT (57.3% vs. 29.2%, P<0.001).

Conclusions: RAG techniques can enhance AI-assisted examination performance by improving case-level reasoning and decision-making.