Despite advancements in resuscitation guidelines, in-hospital cardiac arrests (IHCA) remain associated with high mortality and morbidity. We aimed to evaluate predictive factors associated with survival in patients suffering an IHCA. A systematic literature search was conducted to identify studies reporting factors associated with survival to hospital discharge following IHCA (2000-2024; English language). Data were extracted for all reported variables including patient demographics, arrest characteristics, and interventions. Variables with low heterogeneity were meta-analyzed using a random-effects model to generate odds ratios (OR) or standardized mean differences (SMD) for survival. Twelve studies comprising 5,088 patients were included. Key predictors of survival included witnessed arrest (OR 2.99, p=0.009), arrest in the operating room (OR 2.19, p=0.005), initial shockable rhythm (OR 3.96, p<0.001), and cardiac cause for arrest (OR 3.44, p<0.001). Conversely pulseless electrical activity as the initial rhythm (OR 0.47, p<0.001) and older age (SMD -0.30, p=0.03) were associated with increased mortality. Sex, baseline comorbidities, CPR duration, and requirement of extracorporeal membrane oxygenation were not significant, and high heterogeneity was observed for CPR (I[2]=97%), witnessed arrest (I[2]=89%), and shockable rhythm (I[2]=83%), which should be considered when interpreting the pooled estimates. In conclusion, survival following IHCA is more strongly associated with arrest characteristics and clinical context than baseline comorbidity burden. These findings may support early risk stratification and guide peri-arrest decision-making. STUDY REGISTRATION: PROSPERO CRD42024520780 CLINICAL PERSPECTIVES: In-hospital cardiac arrest (IHCA) carries persistently high mortality despite advances in resuscitation. This meta-analysis of 12 studies comprising 5,088 patients demonstrates that survival is predominantly determined by arrest-specific and contextual factors rather than baseline comorbidity burden. Shockable initial rhythm, witnessed arrest, cardiac etiology, and procedural arrest location were the strongest predictors of survival, while non-shockable rhythms, intubation and older age predicted mortality. Sex and traditional cardiovascular risk factors were not significantly associated with outcomes. These findings support early peri-arrest risk stratification, resuscitation decisions and inform goals-of-care discussions in patients experiencing IHCA.

A 74-year-old man with mixed bicuspid aortic valve disease, combining severe calcific stenosis with severe regurgitation, and a left ventricular ejection fraction of 26% presented in normotensive cardiogenic shock with anuria and an arterial lactate of 12 mmol/L. Computed tomography showed a fibrocalcific left-right raphe and an aortic angulation of 66 degrees. Emergency transfemoral transcatheter aortic valve implantation was undertaken. The delivery system could not be advanced across the aortic arch despite escalation of guidewire support, and ventricular fibrillation degenerated into pulseless electrical activity refractory to resuscitation. Peripheral venoarterial extracorporeal membrane oxygenation was established, after which a 29 mm self-expanding prosthesis was implanted with an acceptable haemodynamic result and patent coronary ostia. Pulseless electrical activity nonetheless persisted. Return of spontaneous circulation followed only after a microaxial pump was advanced retrogradely across the freshly deployed prosthesis under fluoroscopic guidance alone, establishing an ECMELLA configuration. The patient died of multiorgan failure two days later. This sequence identifies continued left ventricular loading, rather than any residual valve lesion, as the reason resuscitation failed, and argues for anticipating unloading when extracorporeal support is instituted across a valve just rendered competent in a severely dysfunctional ventricle. The outcome appeared determined by end-organ injury already established before intervention.

We describe a case of swallowing-induced ventricular tachycardia in a young, otherwise healthy male with a structurally normal heart which was refractory to multiple anti-arrhythmic medication and was successfully treated with ablation of a cardiac ganglion in the crux of the heart. We use this case to describe an unusual disease presentation and highlight current evidence related to evaluation and management of ventricular arrhythmias and add to the limited body of evidence related to swallowing induced tachycardia.

Real-world data on the adoption and clinical performance of angiography-derived physiology in the United States (U.S.) remain limited. We evaluated the implementation of FFRangio (CathWorks, Tel Aviv, Israel) and associated clinical outcomes across a multicenter U.S. healthcare system. We performed a multicenter observational cohort study across 4 centers involving consecutive adult patients undergoing invasive coronary angiography in whom FFRangio was performed in at least 1 coronary vessel based on clinical indication. The primary endpoint was target-vessel failure (TVF), defined as a composite of cardiovascular death, target vessel myocardial infarction and target vessel revascularization during follow-up, stratified by FFRangio values >0.80 versus ≤0.80. A total of 675 vessels in 469 patients were assessed by FFRangio; 240 (36%) had values ≤0.80 and 435 (64%) >0.80. Among lesions with FFRangio ≤0.80, 182 (76%) underwent PCI, 27 (11%) CABG, and 32 (13%) were managed medically. Among lesions with FFRangio >0.80, revascularization was deferred in 406 (92%), with 22 (5%) undergoing PCI and 12 (3%) CABG. The LAD was the most frequently treated vessel (51%). At a median follow-up of 10.2 months, the incidence rate of TVF was 1.55% per 100 lesion-years (95% confidence interval [CI]: 0.57-3.36) in the FFRangio >0.80 group versus 6.30 per 100 lesion-years (95% CI, 3.25-11.0) in the FFRangio ≤0.80 group (hazard ratio [HR] 4.61, 95% CI: 1.61-13.2; p=0.002). Among deferred lesions with FFRangio >0.80, TVF rate was 1.73 per 100 lesion-years (95% CI: 0.64-3.77). In conclusion, FFRangio supported safe deferral of revascularization and risk-stratification, with low event rates among lesions with values >0.80.

Optimal perioperative management of patients on dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains controversial, with substantial variability in current clinical practice. The MARS registry is a prospective multicenter observational study evaluating perioperative outcomes in post-PCI patients on DAPT undergoing surgery within 2 years of PCI. We assessed the incidence of Net Adverse Cardiovascular Events (NACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction (MI), ischemic stroke, urgent coronary revascularization, or Bleeding Academic Research Consortium (BARC) type ≥3 bleeding. A total of 132 consecutive patients undergoing moderate- to high-risk surgery were followed from 14 days preoperatively to 30 days postoperatively. Of the 132 patients, 79 underwent non-cardiac surgery (NCS) and 53 underwent cardiac surgery (CS). The mean age was 66 years, and 68% were male. Diabetes mellitus was present in 48%, chronic kidney disease in 29%, and 42% had undergone PCI for an acute coronary syndrome. Mean time from PCI to surgery was 269 ± 217 days. Prior bleeding and stent thrombosis were reported in 11% and 5% of patients, respectively. Aspirin was continued in 60% and P2Y12 inhibitors in 36%, with mean discontinuation 4 and 6 days preoperatively, respectively. Intravenous antiplatelet bridging with cangrelor was used in 12 patients (9.1%) and unfractionated heparin as anticoagulant therapy in 15 patients (11.0%). NACE occurred more frequently after CS compared with NCS (18.9% vs. 10.1%, p=0.17). Major bleeding (BARC ≥3) occurred in 5.3% with no difference between CS and NCS. There were no cardiovascular deaths and no difference in all-cause mortality. Compared with no bridging, cangrelor bridging was associated with numerically higher NACE (25.0% vs. 12.5%, p=0.22), without differences in bleeding. On multivariable logistic regression, cangrelor bridging was not independently associated with NACE (adjusted OR 2.18, 95% CI 0.43-8.71, p=0.34). In conclusion, among post-PCI patients on DAPT undergoing moderate- to high-risk surgery, aspirin was continued in 60%, cangrelor bridging was used in 9.1%, and although NACE rates were numerically higher after cardiac surgery and with bridging, these differences were not significant after multivariable adjustment, consistent with confounding by indication.

The "leave nothing behind" paradigm using drug-coated balloons (DCBs) has reshaped femoropopliteal peripheral artery disease treatment, though clinical success remains heavily contingent upon optimal vessel preparation. In a recent issue of The American Journal of Cardiology, Li and colleagues address the limitations of conventional plain old balloon angioplasty (POBA) through a propensity score-matched analysis of 508 patients from the multicenter PROMISING registry, comparing specialized vessel preparation using the nitinol-constrained Chocolate balloon against POBA prior to DCB angioplasty. The Chocolate balloon significantly reduced the primary endpoint of bailout stenting (20.47% vs. 29.92%) and facilitated larger final DCB diameters, though these acute mechanical advantages did not translate into statistically significant differences in clinical outcomes at 12 months. This commentary examines this striking "procedural-to-clinical paradox," highlighting how the potent antiproliferative effect of DCBs and the acute compensatory function of bailout stents may temporarily mask early clinical divergence. Given that cumulative mechanical failures of permanent metallic implants typically emerge beyond one year in hostile biomechanical environments, longer-term observation remains essential to capture the true clinical dividend of a stent-free strategy.

Heritable thoracic aortic diseases (HTAD) include genetic conditions that increase risk of thoracic aortic aneurysm and dissection. The 2022 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend genetic testing for at-risk individuals, but real-world uptake remains unclear. We evaluated adherence to testing recommendations and demographic differences across major HTAD risk cohorts. We conducted a retrospective study using the TriNetX Research Network (2005-2025). Three guideline-based cohorts were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes: (1) thoracic aortic aneurysm/dissection before age 60, (2) family history of thoracic aortic disease, and (3) non-thoracic arterial aneurysms. Genetic testing was defined by ICD-10-CM codes for genetic screening or susceptibility. Testing prevalence was stratified by age, sex, race, and ethnicity, and annual testing incidence (2005-2024) was evaluated. Among 57,935 patients with thoracic aortic aneurysm/dissection before age 60, 1,205 (2.09%) underwent genetic testing. Among 2,811,862 patients with a family history of thoracic aortic disease, 66,699 (2.38%) received testing. Among 347,000 patients with non-thoracic arterial aneurysms, 4,913 (1.42%) underwent testing. Testing was consistently higher in females than males and varied across age groups. Annual testing incidence increased over time but remained <0.6% by 2024. In conclusion, genetic testing for HTAD remains markedly underutilized, with < 2.5% of at-risk patients tested despite guideline recommendations, highlighting persistent implementation gaps and the need to improve equitable access to genetic evaluation.

Greater left ventricular (LV) wall stress has been associated with adverse clinical outcomes among patients with heart failure (HF). We examined the relation between LV wall stress and the risk of incident HF. Using data from the Vanderbilt Synthetic Derivative, we studied 29,246 adult patients without prevalent HF or ≥ moderate valve disease who underwent transthoracic echocardiography between 2014-2020. LV end diastolic wall stress (LVEDWS) was calculated from chamber and wall thickness measures and E/e' as a surrogate for LV end diastolic pressure. Incident HF was ascertained from ICD-9/10 codes. Correlates of LVEDWS were examined with multivariable linear regression. The association between LVEDWS and risk of incident HF was tested in Cox regression adjusted for demographics, comorbidities, blood pressure, body mass index, laboratory data including B-type natriuretic peptide, LVEF, and LV mass index. The cohort had a median age of 59 years, 54% females, with 11% of individuals identifying as Black. Median LVEDWS was 14.5 (IQR: 11.8-18.0) kdynes/cm[2]. Cross sectional correlates of LVEDWS ranked according to Chi-squared value were LVEF, heart rate, female sex, and LV mass index. Over a maximum follow-up time of 8.2 years (median 3.7 years), 3,082 (11%) individuals developed incident HF. In multivariable Cox regression, each 1-unit increase in LVEDWS significantly associated with an increased risk of incident HF (aHR: 1.019; 95%CI 1.014-1.024), which was largely consistent across subgroups. In conclusion, among a broad range of patients clinically referred for echocardiography, greater non-invasively measured LVEDWS associates with higher risk for incident HF.

Transcatheter aortic valve replacement in patients with small aortic annuli presents unique challenges related to prosthesis-patient mismatch, residual gradients, conduction disturbances, and lifetime valve management. Recent observational data have suggested potential differences in mid-term survival between self-expanding valve and balloon-expandable valve platforms; however, these findings have not been consistently supported by other observational studies or long-term randomized evidence. Importantly, both severe prosthesis-patient mismatch and permanent pacemaker implantation may carry prognostic implications, underscoring the competing risks involved in valve selection. In conclusion, current evidence does not establish the clinical superiority of one transcatheter valve platform over another, supporting an individualized approach to valve selection.