Cross-sectional studies suggest that retinal microvascular abnormalities measured by optical coherence tomography angiography (OCTA) are associated with cerebral small vessel disease (cSVD) and cognitive impairment, but longitudinal relationships remain unclear. We investigated whether OCTA measures are associated with brain cSVD markers and cognition over time and whether baseline OCTA was associated with brain and cognitive outcomes after mild ischemic stroke.

We conducted a prospective longitudinal cohort study recruiting patients with lacunar or mild cortical ischemic stroke (modified Rankin Scale ≤2) from a hospital stroke service. Participants underwent OCTA, brain MRI, and medical and cognitive assessment (MoCA) at baseline and 1 year. OCTA metrics included vessel density (VD), foveal avascular zone area, vessel radius, tortuosity, and flow index from superficial and deep vascular layers. MRI outcomes included white matter hyperintensity (WMH) volume, basal ganglia perivascular space (PVS) volume, and mean diffusivity in normal-appearing white matter. We used linear mixed-effects models to assess (1) whether retinal measures were associated with brain and cognitive markers over time and (2) whether baseline retinal measures were associated with 1-year outcomes, adjusting for age, sex, systolic blood pressure, smoking, diabetes, stroke severity, disability, and stroke subtype.

A total of 189 participants (mean age 64.8 years; 37% female) were assessed at baseline and 154 at 1 year. Longitudinal reductions in retinal VD were associated with WMH increase (superficial layer, standardized β [95% CI] -0.045 [-0.067 to -0.023]; deep layer -0.050 [-0.074 to -0.026]). Increases in retinal VD and reductions in retinal flow were associated with increased PVS volume. Lower MoCA over 1 year tracked with decreases in deep retinal VD (0.136 [0.036-0.236]). Baseline retinal measures were associated with future outcomes: In particular, lower baseline VD in both layers was associated with worse MoCA at 1 year (superficial layer 0.125 [0.043-0.207]; deep layer 0.242 [0.162-0.322]).

OCTA-measured retinal microvascular features are associated with cSVD progression and worsening cognition after mild stroke, while baseline OCTA was associated with future brain and cognitive outcomes. These findings suggest that OCTA holds promise as a noninvasive tool for monitoring retinal microvascular pathology in stroke populations enriched for cSVD, warranting further investigation in larger cohorts.

Interfacility transfer for emergent treatment is critical to stroke systems of care. Understanding the transfer population enables transfer system optimization.

We performed a nationwide longitudinal cross-sectional study to characterize the population emergently transferred for ischemic stroke care from 2016 to 2022. Using Medicare fee-for-service (FFS) claims, we included patients 65 years or older admitted with ischemic stroke. County-level Medicare Advantage penetration rates were used to extrapolate the results to estimate nationwide emergent transfers. Multilevel logistic regression identified features distinguishing the transferred from the nontransferred population.

From 2016 to 2022, we identified 824,551 FFS beneficiaries (57% female) admitted for ischemic stroke: 99,751 (12%) underwent emergent transfer, while 724,800 (88%) were not transferred. The transfer population was younger (mean 78.2 years vs 80.1 years) with a higher rate of thrombectomy (15.9% vs 2.8%) and thrombolysis (24.1% vs 10.0%). Their presenting facility was more likely to be rural (55.3% vs 22.6%), have <100 beds (56.6% vs 11.9%), or be a critical access hospital (24.9% vs 2.8%). Nontransferred patients more frequently presented to a teaching facility (66.2% vs 32.3%), stroke center (83.2% vs 51.9%), or vertically integrated facility (93.5% vs 76.5%). Estimated nationwide emergent transfers increased from 2016 (21,221; 12% of admissions) to 2019 (26,720; 15%) and then decreased through 2022 (21,902; 12%). Multilevel logistic modeling showed a strong association between the transfer population and presentation to a critical access hospital (OR 2.8, 95% CI 2.4-3.3), prestroke hemiplegia (OR 2.3, 95% CI 2.3-2.4), or prestroke cerebrovascular disease (OR 2.2, 95% CI 2.2-2.3). Features associated with the nontransferred population include presentation to a facility with >400 beds (OR 0.01, 95% CI 0.01-0.01, reference ≤100 beds), a stroke center (OR 0.4, 95% CI 0.4-0.5), older age (OR 0.6, 95% CI 0.6-0.6), and more affluence (4th quartile of ADI OR 0.6, 95% CI 0.5-0.7).

Emergent transfers for ischemic stroke in the United States have decreased since 2019, reversing a long-standing trend of continual increase. Receipt of thrombectomy or thrombolysis, presentation to a small facility, a nonstroke center, or in a less affluent area are associated with the transfer population.

Hypertension is a leading preventable cause of cardiovascular disease, yet a substantial proportion of adults remain undiagnosed, limiting opportunities for early intervention. A predictive model was commissioned by the North West London (NWL) Integrated Care Board to identify undiagnosed hypertension. The model was developed using health records from the Whole Systems Integrated Care (WSIC) database.

We aimed to independently evaluate the predictive performance of the model as it would be encountered in deployment, how performance varied by demographic characteristics, and practical utility.

To evaluate the predictive model, we conducted a retrospective cohort study of 1,802,920 individuals aged 16 years or older, registered with a general practice in NWL, and with no prior diagnosis of hypertension from May 2023 to May 2024. We assessed the model's predictions against recorded hypertension status using medical diagnoses and blood pressure records. Logistic regression models were used to assess the sensitivity and specificity of the model's predictions by sociodemographic groups. We also compared the model's performance against a more interpretable regression approach.

The model yielded an overall sensitivity of 62.7% (95% CI 62.5-62.8) and specificity of 60.7% (95% CI 60.5-60.8). Positive predictive value ranged from 31.5% (95% CI 31.2-31.8) to 42.9% (95% CI 42.5-43.2), and negative predictive value ranged from 77.6% (95% CI 77.2-77.9) to 84.9% (95% CI 84.7-85.2). Sensitivity was higher in older adults and Black patients; specificity was higher in younger adults, female patients, and White patients. Overall, sensitivity was higher for those living in areas of higher socioeconomic deprivation, while specificity was lower. These effects plateaued in the 2 least deprived quintiles of deprivation, which were comparable in both sensitivity and specificity. Predictions varied by age, with 96.2% (58,951/61,281) of those aged 70 to 79 predicted to have hypertension, whereas 0.08% of those aged 20 to 39 were predicted to have the condition. The model's performance was comparable with a more interpretable logistic regression model.

Despite the model's relatively good performance for those without hypertension, the positive predictive value was low, and a significant proportion of true cases remained undetected. Furthermore, there was considerable variation in performance associated with demographic characteristics, suggesting tailored approaches to case-finding may be beneficial in ensuring equity across demographic groups. Especially given the importance of understanding possible biases in predictive models, we recommend that, where there is no loss in performance, more parsimonious, transparent models be selected for prediction in health care settings. The findings of this evaluation can guide the practical application of the model, inform enhancements, direct targeted screening initiatives, and support cost-benefit analyses for broader implementation to improve hypertension management.

Hemofiltration during pediatric cardiopulmonary bypass (CPB) is essential to mitigate hemodilution, inflammatory responses, and postoperative complications. Conventional ultrafiltration (CUF) is widely practiced, but novel methods such as subzero balanced ultrafiltration combined with simple modified ultrafiltration (SBUF-SMUF) may offer superior outcomes.

To compare the clinical efficacy and safety of CUF versus SBUF-SMUF in pediatric patients undergoing open-heart surgery.

In this prospective randomized, outcome-assessor-blinded clinical trial, 80 pediatric patients with congenital heart disease were allocated to either CUF (n = 40) or SBUF-SMUF (n = 40) during CPB. Baseline demographics, intraoperative characteristics, fluid balance, blood product utilization, and postoperative outcomes were assessed. Statistical analysis was conducted using independent t-tests, Chi-square tests, and Fisher's exact tests. Statistical significance was defined as a two-tailed p-Value of less than 0.05.

Demographic and preoperative variables were comparable between groups. Mean fluid balance was significantly positive in the CUF group (+192.1 ± 178.8 mL) but negative in the SBUF-SMUF group (-105.0 ± 78.9 mL, p < 0.001). The SBUF-SMUF group required significantly less intraoperative PRBC (141.7 ± 70.2 vs. 261.0 ± 68.8 mL, p < 0.001) and postoperative FFP transfusion (2% vs. 10%, p = 0.020). Post-bypass hematocrit levels were higher (31.2% vs. 27.3%, p = 0.001) and extubation occurred earlier in the SBUF-SMUF group (1.05 ± 1.03 vs. 2.27 ± 2.37 days, p = 0.006). No significant differences were observed in potassium levels or incidence of acute kidney injury.

The SBUF-SMUF technique is safe, effective, and superior to CUF in optimizing fluid balance, reducing blood product utilization, and facilitating earlier extubation in pediatric cardiac surgery. No additional risk of oliguria or electrolyte imbalance was observed compared to CUF. Its simplicity and reproducibility support its consideration as a standard approach in pediatric CPB.

Adenosine is a vital medication in cardiac surgery, particularly in valvular heart procedures. While its use has been linked to improved postoperative cardiac function in some studies, there remains significant uncertainty regarding the adenosine usage in aortic reperfusion phase. This lack of consensus poses challenges for surgeons, perfusionists, and anesthesiologists alike. This study aims to explore the impact of adenosine on clinical outcomes in patients undergoing valvular heart surgery.

This prospective randomized controlled trial was conducted over a three-month period. Sixty patients undergoing valvular heart surgery were enrolled using a continuous sampling method and randomly allocated into two equal groups of 30 patients each. The intervention group received adenosine-enriched aortic root reperfusion immediately prior to aortic declamping, while the control group underwent standard warm blood aortic root reperfusion. Both groups were matched for demographic and clinical characteristics to ensure comparability.

Results indicated no significant differences in mean cardiopulmonary bypass (CPB) time, aortic cross-clamping duration, or mechanical ventilation between the intervention and control groups. However, the intervention group that received adenosine had a higher rate of antiarrhythmic agent usage in the operating room (P < 0.05). Inotropic agent usage was similar in both groups during surgery and in the ICU. Additionally, laboratory parameters on the first day of ICU admission were comparable between groups.

Results in the control group showed more favorable outcomes in terms of anti-arrhythmic drug usage, electroshock application, and arrhythmia prevalence. This study showed advantages for the standard warm blood aortic root reperfusion technique in managing post-operative cardiac rhythm disturbances, in comparison with the trial group.

Diabetes mellitus (DM) is a chronic, multifactorial disease with systemic effects, demanding ongoing clinical vigilance and risk-reduction strategies. Among its most prevalent microvascular complications is diabetic retinopathy (DR), affecting 30-40% of individuals with DM and associated with sustained hyperglycaemia. This study investigates the role of erythropoietin (EPO), a glycoprotein primarily known for its role in erythropoiesis, in retinal pathology.

Secondary analysis was conducted on 117 participants from the Australian cohort of the LANDMark study, examining the relationship between systemic EPO levels and DR severity, as measured by the Early Treatment Diabetic Retinopathy Study (ETDRS) Severity Scale.

Significant positive correlations were observed between serum EPO and DR severity at both baseline and the four-year follow-up (baseline: ρ = 0.212, p = 0.025; four-year ρ = 0.205, p = 0.030). Ordinal regression indicated that both baseline and four-year EPO levels were associated with higher DR severity at the four-year follow-up (baseline: log-odds coefficient = 2.258, OR ≈ 9.57, p < 0.01; four-year: log-odds coefficient = 2.111, OR ≈ 8.26, p = 0.01).

These findings suggest that systemic EPO shows a modest association with subsequent retinopathy severity and may reflect an exploratory biomarker of ocular disease activity.

Cardiogenic shock describes a syndrome of systemic hypoperfusion due to insufficient cardiac output. Therapeutic interventions aim to restore systemic perfusion and oxygen delivery, relieve congestion, and reverse the primary culprit pathologies that precipitate shock. Cardiogenic shock care often emphasizes acute rescue and survival; however, survival does not always equal meaningful recovery. In this review, we propose a recovery-focused framework in which myocardial and end-organ recovery are treated as explicit, measurable targets. Building upon prior frameworks proposed for the management of shock, we organize cardiogenic shock management into four overlapping phases: salvage, optimization, stabilization, and de-escalation. Each phase addresses a distinct clinical question: can the patient be rescued, is perfusion and unloading sufficient to prevent further injury, is meaningful myocardial and end-organ recovery occurring, and is recovery durable enough to withdraw support? We synthesize current strategies and highlight emerging targets and research priorities spanning early identification and triage, integrated macro- and microcirculatory monitoring, phenotype-guided management, targeted metabolic and immunologic therapies, use of mechanical circulatory support as a recovery platform, and structured de-escalation of care.

Cardiogenic shock remains associated with high short-term mortality despite contemporary advances in care. The association between institutional cardiac capability and outcomes-particularly among transferred patients and after accounting for clinical instability-remains incompletely defined. We sought to evaluate the association between hierarchical hospital cardiac capability and in-hospital mortality using a latent measure of acute physiological severity.

Using the National Inpatient Sample (2016-2022), hospitals were classified into 5 hierarchical tiers ranging from non-percutaneous coronary intervention (tier 1) to heart transplant/durable left ventricular assist device (LVAD) centers (tier 5). Generalized structural equation modeling assessed the relationship between hospital tier and mortality. A latent Acute Severity construct-comprising cardiac arrest, acute kidney and liver injury, and mechanical ventilation-was incorporated to model the effects of clinical instability.

Among an estimated 1 177 180 cardiogenic shock hospitalizations, most occurred at cardiac surgical and transplant/LVAD centers. Crude mortality declined stepwise from non-percutaneous coronary intervention hospitals (64.4%) to transplant/LVAD centers (36.5%). After adjustment, a higher hospital tier was independently associated with lower mortality (tier 2 odds ratio [OR], 0.43 [95% CI, 0.38-0.48]; tier 3 OR, 0.37 [95% CI, 0.32-0.43]; tier 4 OR, 0.34 [95% CI, 0.30-0.38]; tier 5 OR, 0.36 [95% CI, 0.31-0.41]). Although transfer-in status was associated with increased mortality (OR 1.36 [95% CI, 1.30-1.43]), this association was attenuated at cardiac surgical and transplant/LVAD centers, consistent with mitigation of transfer-associated risk.

Higher hospital cardiac capability is independently associated with lower mortality among patients with cardiogenic shock. Advanced centers are associated with mitigation of transfer-associated risk, supporting regionalized hub-and-spoke systems with early referral to high-capability centers.

Cardiogenic shock remains the leading cause of death in patients with acute myocardial infarction and severe acute heart failure. Temporary mechanical circulatory support devices have emerged as important adjuncts for restoring systemic perfusion, unloading the failing ventricle, and stabilizing patients for cardiogenic shock and during high-risk percutaneous coronary interventions. However, currently available devices are associated with important limitations, including vascular complications, hemolysis, and uncertain survival benefit. Technological innovation has led to the development of new percutaneous mechanical support systems designed to deliver higher cardiac output with more limited vascular access and improved hemocompatibility. This review summarizes the current evidence regarding current and emerging temporary mechanical circulatory support devices used in cardiogenic shock and high-risk percutaneous coronary interventions. Literature from major clinical trials, observational registries, and device development studies was reviewed to evaluate device mechanisms, hemodynamic performance, and emerging technologies.

Acute kidney injury (AKI) is a frequent and prognostically decisive complication of cardiogenic shock (CS), conferring substantially increased short- and long-term mortality. As understanding of CS has evolved beyond an isolated low-output model, AKI is increasingly recognized as a consequence of multifactorial pathophysiology encompassing venous congestion, neurohormonal dysregulation, microcirculatory dysfunction, inflammation, and iatrogenic injury from shock therapies. Despite this expanded mechanistic framework, approaches to the diagnosis and management of AKI in CS remain highly variable, and no single strategy has consistently improved renal or survival outcomes. Emerging data suggest multiple biologically distinct phenotypes of AKI in CS that may enable future targeted therapeutics. This review synthesizes contemporary evidence on the classification, epidemiology, and mechanisms of AKI in CS across distinct phenotypes, including early- versus late-onset, acute versus acute-on-chronic, and cardiorenal versus cardiometabolic presentations. We further discuss the renal effects of contemporary shock therapies, including vasoactive agents, temporary mechanical circulatory support, and renal replacement strategies. Finally, we highlight emerging diagnostic tools, including noninvasive vascular imaging and renal biomarkers, alongside novel device-based approaches to improve renal perfusion and congestion. Advancing care in CS will depend on redefining AKI not only as a binary marker of renal dysfunction but also as a mechanistically heterogeneous component of shock biology amenable to targeted intervention.