Cardiogenic shock (CS) is a cardiovascular emergency with short-term mortality ranging from 30% to 40% despite an expanding therapeutic armamentarium. Structured systems of care have transformed outcomes in ST-segment-elevation myocardial infarction, stroke, and out-of-hospital cardiac arrest through tiered hospital designations, standardized protocols, and regionalized networks, yet no analogous framework exists for CS. CS differs from these conditions in ways that complicate direct application of existing models: the appropriate intervention varies by cause, hemodynamic phenotype, and shock severity; the therapeutic trajectory is iterative and uncertain rather than binary and time-fixed; prehospital identification is rarely feasible; and the exit strategy, encompassing myocardial recovery, durable mechanical support, transplantation, or palliation, has no parallel in other cardiovascular emergencies. Observational data suggest an association between structured multidisciplinary care, regionalized networks, and more consistent care delivery though causal relationships remain unestablished, and no standardized national framework for CS center designation yet exists. We propose that CS systems of care should be organized around a node-based model in which each hospital tier has a defined role, transfer is guided by physiological trajectory and exit strategy candidacy rather than geography, and system performance is evaluated by metrics of timing, outcomes, and equity. The American Heart Association Cardiogenic Shock Registry, designed to enroll consecutive patients across all etiologies and severity levels, represents the natural infrastructure around which this framework can be constructed. Realizing this vision will require dedicated registries, implementation research, and a definition of success that extends beyond in-hospital survival to encompass recovery, function, and equitable access to care.

Cardiogenic shock (CS) is a highly heterogeneous syndrome with persistently high mortality despite advances in therapies, including temporary mechanical circulatory support. The disparate results of trials on temporary mechanical circulatory support in CS suggest that improved strategies, including better patient selection, are needed in the context of CS heterogeneity. Notably, a microaxial flow pump device has recently shown a survival benefit in ST-segment-elevation myocardial infarction-associated CS in the DanGer Shock trial (Danish-German Cardiogenic Shock), marking a positive outcome amid many negative or neutral trials. As CS phenotyping becomes increasingly important for developing tailored therapeutic strategies, it is essential to identify factors contributing to variable phenotypes, including shock severity, cause, hemodynamic profile, ventricular function, shock pattern, and patient-centered factors that may influence microaxial flow pump candidacy. Successful CS management with a microaxial flow pump may be best guided by an individualized and proactive approach, tailored to each patient's risk profile and clinical course. It is rational to implement this strategy at centers capable of providing and managing advanced temporary mechanical circulatory support options while determining candidacy for advanced heart failure therapies. Our review underscores the importance of CS phenotyping and tailoring temporary mechanical circulatory support-particularly microaxial flow pump support-to patient-specific factors that are central to optimizing outcomes in CS management.

Reentrant atrial tachycardias (ATs) are frequent after atrial switch for dextro-transposition of the great arteries and are associated with adverse prognosis. Catheter ablation is first-line therapy, yet long-term outcomes and predictors of recurrence remain poorly defined. Our aim was to characterize induced AT circuits, describe acute and long-term catheter ablation outcomes, and identify recurrence predictors in dextro-transposition of the great arteries.

Single-center ambispective cohort of consecutive adults with dextro-transposition of the great arteries undergoing a first AT ablation (2003-2025). Arrhythmias were mechanically induced with decremental pacing or extra stimuli. Acute success was defined as elimination of all clinical and reproducibly inducible tachycardias (cycle length >200 ms), with bidirectional cavotricuspid isthmus block when applicable. Recurrence was defined as any documented AT >30 seconds.

Thirty-three patients underwent 46 procedures. During the index procedure, 66 ATs were induced; 51 (83%) were characterized: 32 (63%) were cavotricuspid isthmus-dependent and 11 (22%) incisional. Cavotricuspid isthmus block was achieved in 84%; acute noninducibility in 73%. Median follow-up was 7.0 years (interquartile range, 2.5-10.4). Overall, 15 patients (45.5%) recurred; 1-year freedom was 75%. Recurrence was strongly associated with failed or uncertain acute efficacy, severely impaired systemic right ventricular fractional shortening ≤22%, prolonged PR interval (220 ms), and greater number of inducible ATs (all P<0.05). In multivariable modelling, these 4 variables yielded an optimism-corrected C-index of 0.85. Eleven (33%) underwent redo ablation; 8 achieved acute noninducibility, and only 3 recurred thereafter.

In dextro-transposition of the great arteries postatrial switch, cavotricuspid isthmus-dependent flutter is most common, but scar-related circuits are frequent. Catheter ablation is safe and acutely effective, but long-term recurrence remains substantial. Failed acute efficacy, severely impaired systemic right ventricle contractility, prolonged PR interval, and multiple inducible ATs identify patients at highest risk and may guide follow-up and referral for early repeat ablation.

The molecular mechanisms linking vascular aging (VA) and heart failure (HF) remain elusive, hindering therapeutic strategies for their comorbidity. This study aimed to identify key biomarkers and pathways potentially involved in VA-HF synergy using integrative computational approaches.

We analyzed the GSE57338 dataset (136 controls, 177 HF samples) to identify HF-associated differentially expressed genes (DEGs) and constructed a weighted gene co-expression network (WGCNA). Vascular aging-related targets were retrieved from GeneCards (n = 16,243). Consensus genes (CGs) were derived by intersecting DEGs, WGCNA hub genes, and VA-related targets. Functional enrichment, machine learning prioritization (LASSO regression, Random Forest, and SHAP-XGBoost), and network analysis (GeneMANIA) were applied to identify potential regulators. Top candidates were experimentally validated using qPCR in doxorubicin-induced rat primary vascular smooth muscle cells and human VSMC cell line for the VA model, and H9C2 cardiomyoblast injury model for HF. Further validation was performed in a mouse model of doxorubicin-induced HF, assessing cardiac function by echocardiography, myocardial fibrosis by Masson's trichrome staining, and vascular aging markers (P16, P21) by qPCR.

We identified 272 CGs enriched in cGMP-PKG signaling, cytoskeletal regulation, and PPAR pathways. Machine learning prioritized 12 core genes, with HMOX2 as the top predictor (AUC = 0.978). qPCR analysis confirmed upregulation of HMOX2, S1PR3, and SERPINA3 in doxorubicin-treated rat primary vascular smooth muscle cells, human VSMC cell line, and H9C2 cardiomyoblasts compared to controls (P < 0.05). In the mouse model, doxorubicin administration induced significant cardiac dysfunction and myocardial fibrosis, accompanied by elevated expression of senescence markers P16 and P21 in vascular tissues. These findings collectively suggest that these genes may play important roles in VA-HF comorbidity (P < 0.05).

Neonates with ductal-dependent pulmonary blood flow (DP-PBF) require timely palliation to maintain pulmonary perfusion. Patent ductus arteriosus (PDA) stenting has emerged as a less invasive alternative to modified Blalock-Taussig shunt (mBTS), but comparative data on longitudinal pulmonary artery growth and clinical outcomes remain limited.

This multicenter retrospective cohort study included infants with DP-PBF who underwent PDA stenting or mBTS as first-stage palliation at Queen Sirikit National Institute of Child Health and Songklanagarind Hospital, Thailand, between January 2017 and December 2022. Pulmonary artery growth was assessed using the McGoon ratio and Nakata index at baseline, 2 months, and 12 months. Longitudinal changes were analyzed using linear mixed-effects models with adjustment for ventricular physiology. Procedural complications were compared, and mortality was evaluated using Kaplan-Meier analysis, Cox regression, and 12-month restricted mean survival time.

Eighty-six infants were included: 41 underwent PDA stenting and 45 underwent mBTS. Baseline pulmonary artery measurements were comparable, although diagnostic composition differed between groups. At 2 months, PDA stenting was associated with greater pulmonary artery growth than mBTS, with a higher McGoon ratio (mean difference, 0.18; 95% CI, 0.05-0.31; p = 0.005) and Nakata index (mean difference, 51.2 mm2/m2; 95% CI, 23.0-79.5; p < 0.001). By 12 months, the Nakata index was similar between groups (p = 0.90), whereas a statistically significant between-group difference in McGoon ratio remained (mean difference, 0.15; 95% CI, 0.02-0.29; p = 0.028). Procedural complications were less frequent after PDA stenting than after mBTS (17.1% vs 57.8%; risk ratio for mBTS vs PDA stenting, 3.38; 95% CI, 1.65-6.95; p = 0.001). Although mortality was numerically lower after PDA stenting, time-to-event analyses did not show a statistically significant survival difference.

In this cohort, PDA stenting was associated with greater early pulmonary artery growth and fewer observed procedural complications compared with mBTS. By 12 months, the Nakata index was similar between groups, whereas a statistically significant difference in McGoon ratio remained. These findings should be interpreted cautiously because of non-randomized treatment allocation, differences in diagnostic composition, and potential residual confounding.

Dyslipidemia is a key risk factor for cardiovascular disease, and its prevalence continues to rise with population aging in Japan. A 2024 change to the fee categories in Japan's insurance system aimed to encourage a more holistic approach and better patient involvement in developing treatment plans; however, the real-world impact of these changes on patient outcomes remains unclear. Using a nationwide claims database, we sought to: (1) describe the achievement of low-density lipoprotein cholesterol goals and major adverse cardiovascular events among patients with dyslipidemia; (2) compare lipid control and outcomes under the previous disease-specific management fee with those under the new lifestyle disease management fee, and (3) identify patient groups that may benefit from additional lifestyle-based interventions. We conducted a retrospective cohort study among adults aged ≥ 18 years with dyslipidemia (International Classification of Diseases, Tenth Revision code E78) and at least one lipid measurement. In total, 590,000 patients contributed 23,600,010 outpatient visits. Ourpatient visits were the unit of observation for lipid and fee-category analyses; cardiovascular outcomes and patient-years were analyzed at the patient level. The primary outcome was low-density lipoprotein cholesterol goal attainment; secondary outcomes were changes in lipid parameters, major adverse cardiovascular events, and all-cause mortality. Low-density lipoprotein cholesterol goals were attained at 58.3% of outpatient visits under the previous fee and 58.5% under the new fee, and less often in secondary than in primary prevention, despite high statin use and frequent combination therapy with ezetimibe or fibrate. Lipid levels were broadly similar across fee periods. Cardiovascular event rates were also similar, but post-revision patient-years were limited to approximately 6 months (58,500 vs. 1,542,800 patient-years); therefore, this comparison is exploratory and cannot exclude an effect of the new fee structure. Longer follow-up and complementary designs are needed to evaluate the causal impact of the new fee on outcomes.

Previous studies suggests that illness uncertainty is associated with quality of life in chronic illness, yet the underlying mechanisms remain unclear, particularly in coronary artery disease (CAD). This study aims to explore the relationship between uncertainty in illness, perceived stress, coping strategies, and quality of life in patients with coronary artery disease.

This cross-sectional study was conducted in 150 patients with CAD recruited at a specialized heart clinic affiliated with Tabriz University of Medical Sciences, Tabriz (Iran) in 2024. Uncertainty in illness, perceived stress, coping strategies, and QoL were evaluated through self-reported questionnaires. The multiple mediation model was analyzed using SPSS and Amos software, with a P-value of less than 0.05 considered significant.

The mean (SD) scores of uncertainty in illness, perceived stress, coping strategies, physical, and psychological quality of life were 66.77 (11.97) (in a range of 23-115), 29.57 (4.96), 59.91 (10.32), 11.95 (2.90), and 16.48 (1.69), respectively. The Pearson correlation indicated a significant positive correlation between uncertainty in illness and perceived stress (r = 0.50, P < 0.001). Additionally, uncertainty in illness was negatively and significantly correlated with coping strategies (r = -0.41, P < 0.001) and physical QoL (r = -0.32, P < 0.001). There was also a significant negative correlation between perceived stress and coping strategies (r = -0.29, P < 0.001) as well as between perceived stress and physical QoL (r = -0.37, P < 0.001). Furthermore, a significant positive correlation was found between psychological QoL and physical QoL (r = 0.39, P < 0.001).

Uncertainty in illness and perceived stress are important factors that affect QoL in patients with coronary artery disease. It is recommended to implement well-structured interventions aimed at decreasing illness uncertainty and perceived stress while improving physical quality of life in patients with coronary artery disease.

Relapse during rituximab (RTX)-based maintenance therapy remains a clinical problem in ANCA-associated vasculitis (AAV). Mycophenolate mofetil (MMF) has been investigated as an alternative; however, evidence regarding its use after relapse during RTX-based maintenance is limited. We aimed to retrospectively describe clinical outcomes in patients with AAV who relapsed during RTX-based maintenance according to whether MMF was included in the initial post-relapse treatment strategy. We retrospectively analyzed 17 patients with AAV who experienced their first relapse during RTX-based maintenance after remission induction. Baseline was defined as the time of the first relapse. Post-relapse treatment included glucocorticoid escalation and/or RTX re-administration; patients were categorized according to whether MMF was additionally included in the initial treatment strategy (MMF-added group, n = 9; MMF-not-added group, n = 8). All outcomes were evaluated descriptively. In the MMF-added group, MMF was initiated at a median of 0.4 months after the first relapse (interquartile range [IQR], 0.3-0.4 months; range, 0.3-0.5 months). The median age was 76 years (IQR, 73-81 years); 16 patients (94.1%) were MPO-ANCA-positive. During a median follow-up of 28 months (IQR, 21-33 months), all patients achieved remission after post-relapse treatment intensification. No second relapse occurred in the MMF-added group, whereas three patients in the MMF-not-added group experienced a second relapse. Glucocorticoids were discontinued in all nine patients in the MMF-added group, whereas in the MMF-not-added group, all eight patients continued glucocorticoids while they were managed without MMF. Severe infections requiring hospitalization occurred in none of the patients in the MMF-added group and in three patients in the MMF-not-added group. Because treatment allocation was non-randomized and post-relapse treatment strategies differed with respect to RTX scheduling, concomitant therapies, and physician-directed glucocorticoid tapering, the independent effect of MMF could not be determined. Therefore, these descriptive and hypothesis-generating findings warrant confirmation in future prospective studies.

Corticosteroids are suggested for selected patients with septic shock, but their association with outcomes has not been specifically investigated in patients with hospital-acquired bloodstream infections (HA-BSI). We explored the association between hydrocortisone use and day-28 mortality in this population.

Data from the prospective EUROBACT-2 study were used to assess the association between hydrocortisone use and day-28 mortality in ICU patients with HA-BSI and sepsis. Patients receiving hydrocortisone were compared with patients not receiving hydrocortisone. A 1:1 propensity score matching procedure was performed using nearest-neighbour matching without replacement and a caliper of 0.2 standard deviation of the logit propensity score, followed by multivariable logistic regression with cluster-robust standard errors by matched pair.

Among 2,401 analyzed patients, 608 (25%) received hydrocortisone during the HA-BSI episode. The final propensity score included age, sex, Charlson comorbidity score, ICU admission diagnosis, SOFA score without cardiovascular component, septic shock, country of inclusion, lactate at HA-BSI diagnosis, and ICU-acquired versus non-ICU-acquired HA-BSI. Matching yielded 521 pairs (1,042 patients). In the multivariable model, hydrocortisone use was associated with increased day-28 mortality in the overall matched cohort (OR 1.448; 95% CI 1.096-1.914; p = 0.009). This association was observed in patients with sepsis without shock (OR 1.697; 95% CI 1.051-2.740; p = 0.031) and in the female subgroup (OR 1.718; 95% CI 1.055-2.796; p = 0.030), but not in patients with septic shock or in those receiving norepinephrine-equivalent dose ≥0.25 µg/kg/min.

Hydrocortisone use was not associated with improved day-28 survival in ICU patients with HA-BSI. In the matched analysis, hydrocortisone use was associated with higher day-28 mortality in the overall cohort, whereas no significant association was observed in patients with septic shock or high-dose norepinephrine. These findings are observational and hypothesis-generating and should not be interpreted causally.

Secondary medical prevention after stroke is effective and well evidenced, making long-term follow-up crucial. This follow-up is mainly made by general practitioners (GPs) in Sweden. Low target achievement and up to fourfold practice variation in dispensation of secondary preventive drugs between different primary care units in Region Stockholm has been described. Although several factors in individual practices have been observed to be associated with insufficient target achievements, the underlying reasons for this variation are unclear.

To explore the perspectives of GPs concerning secondary preventive practices after stroke to shed light on areas of improvement.

This qualitative study was based on eight focus group discussions with 49 GPs in Region Stockholm. They were strategically invited in relation to target achievement, and the interviews (45-55 min) were conducted using a semi-structured interview guide. The interviews were transcribed and analysed using qualitative content analysis.

There were two themes: "Multifaceted mission in an insufficiently organized healthcare system" and "The complexity of adherence". There were six categories that encompassed shortcomings in the areas of: sufficient time for the patients, the overarching structure of the healthcare system, the internal structure of follow-ups, medical adherence, the responsibility for renewals of medication and tools for adherence.

The perspectives of GPs revealed structural problems at different levels in the health care system as well as difficulties in handling medication adherence indicating a need for improvement. GPs touched on solutions including increasing the number of GPs, education and improved referrals from hospital to primary care.