Focus on the importance of vaccination in cardiovascular prevention and on the role of late gadolinium enhancement in predicting sudden death

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This Focus Issue on imaging and epidemiology, prevention, and healthcare policies contains the Special Article entitled ‘Vaccination as a new form of cardiovascular prevention: a European Society of Cardiology clinical consensus statement: With the contribution of the European Association of Preventive Cardiology (EAPC), the Association for Acute CardioVascular Care (ACVC), and the Heart Failure Association (HFA) of the ESC’ by Bettina Heidecker from the Deutsches Herzzentrum der Charité Berlin in Germany, and colleagues.1 The authors note that vaccination is increasingly acknowledged as an effective preventive measure not only against specific infections, but also for the prevention of cardiovascular disease in high-risk patients.2–9 Specifically, a growing body of evidence suggests that vaccines against influenza, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), respiratory syncytial virus, herpes zoster, and other viruses significantly reduce infection and, for influenza, the incidence of major adverse cardiovascular events in vaccinated individuals. This clinical consensus statement examines the existing literature and accumulated evidence, and offers practical clinical advice on vaccination timing and target demographics, specifically addressing complex clinical scenarios with a focus on cardiovascular conditions. It includes guidelines for vaccinating vulnerable populations such as immunosuppressed individuals, patients with congenital heart disease, and pregnant women, as well as safety and potential complications of the procedure. In a State of the Art Review article entitled ‘Circadian rhythms in cardiovascular disease’, Ilse Kelters from the University Medical Centre Utrecht in the Netherlands and colleagues remind us that circadian rhythms, controlled by the suprachiasmatic nucleus and peripheral clocks, regulate 24 h cycles in biological processes occurring in the cardiovascular system.10 Circadian rhythms influence autonomic balance, with parasympathetic dominance during sleep supporting cardiac recovery and sympathetic activation during the day supporting circulatory demand. Congruent with systemic and cellular circadian rhythmicity, 24 h patterns arise in the pathophysiology of cardiovascular diseases, including ischaemic heart disease, heart failure, and arrhythmias. Daily variations influence the timing and outcome of myocardial infarction, with studies reporting patterns in infarct size depending on the time of onset. Similar daily patterns are observed in cardio- and cerebrovascular complications. In heart failure, circadian rhythms are dampened but remain intact, suggesting the potential for incorporating timing in diagnostics and therapies. Sudden cardiac death follows a distinct pattern, with a higher incidence in the morning. Atrial fibrillation onset, on the other hand, occurs more frequently at night. Risk factors and modifiers, such as physiological, psychological, lifestyle, and environmental factors and comorbidities, interact with circadian rhythms, thereby impacting cellular pathomechanisms and development of cardiovascular health and disease. Chronotherapy, which aligns treatments with circadian rhythms, has demonstrated potential for improving the efficacy of cardiovascular therapies. This review examines the influence of circadian rhythms on cardiovascular health in the context of specific cardiac diseases and risk factors, and it highlights the therapeutic opportunities informed by circadian patterns. While rigorous longitudinal study of a widely and enthusiastically consumed dietary substance has it challenges, recent exponential growth in the scientific evaluation of coffee consumption has resulted in a clearer appreciation of the link between this common drink and health outcomes. In a State of the Art Review article entitled ‘Coffee and cardiovascular disease’, Thomas A. Dewland from the University of California, San Francisco in the USA and colleagues point out that coffee has complex effects that can vary between individuals depending on both inherited predispositions and consumption habits.11 Despite the common concern and conventional ‘wisdom’ that coffee can promote various cardiovascular diseases, the available data suggest that moderate coffee consumption is associated with a reduced risk of hypertension, type 2 diabetes, myocardial infarction, arrhythmias, heart failure, and even overall mortality. Some exceptions have emerged, including the potentially harmful effects of unfiltered coffee with respect to LDL cholesterol and randomized controlled data demonstrating an acute increase in frequency of premature ventricular contractions with coffee consumption (Figure 1). In many instances, the beneficial effects of coffee appear to be independent of caffeine. Given the ubiquity of coffee consumption and the growing prevalence of cardiovascular disease, translating the latest science into accessible knowledge has the capability to tremendously empower patients and impact global health. Relationships between coffee and various forms of cardiovascular disease11 The prediction and management of sudden cardiac death risk continue to pose significant challenges in cardiovascular care despite advances in therapies over the last two decades. In a State of the Art Review article entitled ‘Late gadolinium enhancement imaging and sudden cardiac death’, Sanjay K. Prasad from Imperial College London in the UK, and colleagues indicate that late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR)—a marker of myocardial fibrosis—is a powerful non-invasive tool with the potential to aid the prediction of sudden death and direct the use of preventative therapies in several cardiovascular conditions.12 In this review, the authors provide a critical appraisal of the current evidence base underpinning the utility of LGE in both ischaemic and non-ischaemic cardiomyopathies, together with a focus on future perspectives and the role for machine learning and digital twin technologies. Infective endocarditis (IE) is a challenging clinical condition.13–18 In particular, IE is a serious complication after mitral valve (MV) intervention. In a Clinical Research article entitled ‘Mitral valve replacement or repair and long-term risk of infective endocarditis: a Danish nationwide study’, Amna Alhakak from the Copenhagen University Hospital–Rigshospitalet in Denmark, and colleagues indicate that information on the long-term risk of first-time IE after MV replacement or repair is lacking.19 The 10 year incidence of first-time IE was examined in patients undergoing MV replacement or repair, compared with those at moderate risk of IE. Using Danish nationwide registries (2000–20), the study population included patients undergoing isolated MV replacement or repair and patients at moderate risk of IE. The moderate-risk group included cardiac implantable electronic devices, congenital heart valve anomalies, hypertrophic cardiomyopathy, rheumatic heart diseases, and non-rheumatic degenerative valve diseases. The Aalen–Johansen estimator and cause-specific Cox regression models were used to determine the 10 year comparative incidences of IE. The study population included 1220 patients undergoing MV replacement, 3239 undergoing MV repair, and 209 517 at moderate risk of IE. The 10 year cumulative incidences of IE were 6.1% for MV replacement, 1.6% for MV repair, and 1.7% for the moderate-risk group. Compared with the moderate-risk group, after multivariable adjustment, MV replacement was associated with a higher 10 year IE rate (hazard ratio 3.52), whereas MV repair was not associated with IE (Figure 2). Ten year cumulative incidence of first-time infective endocarditis in patients undergoing mitral valve replacement, mitral valve repair, and in those at moderate risk of infective endocarditis, based on a Danish nationwide study (2000–20). Hazard ratios were estimated using cause-specific Cox regression, adjusted for sex, age, stroke, chronic obstructive pulmonary disease, diabetes, cancer, liver disease, chronic renal disease, and calendar year. CI, confidence interval; IE, infective endocarditis; HR, hazard ratio; MV, mitral valve; NS, non-significant19 The authors conclude that in this nationwide study, MV replacement is associated with a 3.5-fold increased 10 year IE rate, whereas MV repair is not significantly associated with IE, compared with patients at moderate risk of IE. These findings highlight the need for further investigation into preventive measures, including targeted antibiotic prophylaxis. The manuscript is accompanied by an Editorial by Daniele Giacoppo from the Università di Catania in Italy.20 Giacoppo notes that the large sample size overcomes the statistical power limitations of most previous studies on IE after surgery, and the availability of a follow-up of 10 years enables the comprehensive evaluation of the disease, avoiding conclusions with limited time horizons which are not representative of the life expectancy of many patients undergoing MV surgery. Thus, after multiple studies on native and prosthetic aortic valve IE, the analysis of Danish registries represents an outstanding opportunity to define the contemporary risk of IE after MV repair and MV replacement, providing insights for implementing preventive strategies and surveillance programmes for patients who have undergone prosthetic MV replacement. It also promotes new investigations on preventive treatment requirements between patients who have undergone MV repair and those who have undergone MV replacement. Implementing societal recommendations for primary prevention implantable cardioverter-defibrillators (ICDs) in cardiac sarcoidosis requires an accurate diagnosis. However, cardiac sarcoidosis diagnostic schemes are inconsistent and often produce conflicting results. In a Clinical Research article entitled ‘Prediction of ventricular arrhythmic outcomes in suspected cardiac sarcoidosis: a comparison of cardiovascular magnetic resonance phenotyping vs societal recommendations for implantable cardioverter-defibrillator placement’, Harold Mathijssen from the St. Antonius Hospital in Nieuwegein, the Netherlands, aimed to compare the discriminative accuracy of CMR imaging phenotyping with the societal recommendations for predicting long-term ventricular arrhythmic outcomes in patients with suspected cardiac sarcoidosis, regardless of their diagnostic status.21 This multicentre study included patients with histology-proven sarcoidosis who underwent CMR imaging for suspected cardiac involvement and were ineligible for secondary prevention ICDs. The study outcome was a composite of fatal or life-threatening ventricular arrhythmias. Outcomes were compared based on eligibility for ICDs by societal recommendations or CMR phenotyping. Among 1514 patients, 84 experienced the study outcome during a median follow-up of 4.5 years and a maximum follow-up of 10 years. CMR phenotyping outperformed societal recommendations in discriminative accuracy, with areas under the curve of 0.861 and 0.776 for 5 and 10 year outcomes, respectively. The authors conclude that in patients with suspected cardiac sarcoidosis, CMR phenotyping shows greater discriminative accuracy than societal recommendations for predicting fatal or life-threatening ventricular arrhythmias, suggesting that it may be more effective at identifying candidates for primary prevention ICDs. The manuscript is accompanied by an Editorial by Ana Pericao from the The Royal Brompton Hospital in London, UK, and colleagues.22 The authors highlight that the work of Mathijssen et al. significantly contributes to improving the awareness that CMR phenotyping of patients with suspected cardiac sarcoidosis may be more effective than societal recommendations for patients with diagnosed disease in identifying patients who would benefit from a primary prevention ICD. It aids in shifting the paradigm from diagnosis-based risk stratification to imaging-based phenotypic risk prediction. This should stimulate more research that may improve the prognosis for patients with cardiac sarcoidosis in the future. The editors hope that this issue of the European Heart Journal will be of interest to its readers. Dr. Crea reports speaker fees from Abbott, Amgen, Astra Zeneca, BMS, Chiesi, Daiichi Sankyo, Menarini outside the submitted work. With thanks to Lindsay Washington, Johanna Huggler, Amelia Meier-Batschelet, and Martin Meyer for help with compilation of this article.