This Week in Cardiology — Sep 21, 2026

Welcome to This Week in Cardiology. This week we're covering 10 notable papers spanning risk prediction at the bedside, imaging biomarkers for prevention, and long-term outcomes after cardiac surgery and structural intervention. Let's dive in.

We start with two papers that try to put numbers on decisions clinicians currently make by gestalt. In the European Heart Journal, Armstrong and colleagues pooled individual patient data from nearly 16,000 STEMI patients given weight-adjusted tenecteplase across six randomised trials, from ASSENT-2 through STREAM-2, all with the same blood pressure exclusion above 180 over 110. There were 169 intracranial haemorrhages. Above a systolic pressure of 110 millimetres of mercury, every additional millimetre added about 2 percent to the relative risk of bleeding, and the curve turned sharply upward beyond 160. The interaction that matters most clinically is between age and dose: at 30 milligrams of tenecteplase, each additional year of age added about 1 percent to the risk, but at 50 milligrams, each year added close to 7 percent. Women had roughly a 50 percent higher risk than men, and every 5 kilogram decrease in body weight raised the odds by about a sixth. The resulting nomogram, built on age, sex, systolic pressure, weight and dose, discriminated reasonably well. The practical message is that in older, lighter patients — especially older women — pushing systolic pressure down before you give the bolus, and considering a reduced tenecteplase dose, are the two levers you actually control. Alongside that, Heart publishes the EURO-ENDO score from Sambola and colleagues, derived in more than 2,100 patients with left-sided infective endocarditis from the European Society of Cardiology observational registry and externally validated in 377 consecutive patients from two Barcelona centres [2]. Thirty-day mortality was about 12 percent in both cohorts. Eleven variables available at the initial diagnostic evaluation — including prior stroke, prior cardiac surgery, heart failure or cardiogenic shock, creatinine above 2, vegetations over 10 millimetres, abscess, severe regurgitation, negative blood cultures, staph aureus, and crucially whether there is a surgical indication and whether there is intention to operate — gave good discrimination and calibration in validation. This is the first widely validated tool covering the whole left-sided endocarditis population, including patients managed medically, and it is designed to feed into the endocarditis team conversation rather than replace it.

Our second theme is imaging as a prevention and prognosis tool. In Heart, the PRIO-Now study from Hagberg and colleagues tested whether a simple self-reported questionnaire can select who should get coronary calcium scanning [3]. Eight thousand people aged 59 to 60 were invited, about a third of those invited returned the questionnaire, and 563 high-risk respondents completed non-contrast computed tomography. The model's average predicted probability of a calcium score of 100 or more was just over 28 percent, and the observed prevalence was essentially identical — calibration was almost exact. The finding that should make you sit up is the treatment gap: among those who did turn out to have a calcium score of 100 or more, close to two thirds OF THOSE PATIENTS were on no lipid-lowering therapy at all, and only about one in nine had an LDL at or below 1.8 millimoles per litre. Population-wide calcium screening isn't recommended, but a questionnaire-first strategy appears to concentrate the yield, and it uncovers a lot of untreated subclinical atherosclerosis. From the imaging suite of a different kind, Cardiovascular Research publishes a multi-site analysis from Ramirez and colleagues of more than 16,600 patients in the REFINE PET registry undergoing regadenoson rubidium-82 perfusion imaging [4]. They built a fully automated method to compute the splenic ratio — splenic uptake at stress versus rest — as a marker of whether the pharmacological stress actually worked. Over a median follow-up of about three and a half years, a high splenic ratio was independently associated with more major adverse cardiovascular events, and the association was actually stronger, not weaker, in patients with preserved myocardial flow reserve, and stronger still in those with preserved flow reserve and no ischaemia at all. In other words, the reassuring normal scan may be less reassuring when the spleen tells you the vasodilator didn't take. If your laboratory does rubidium PET, this is a free, automatable quality and risk metric sitting in data you already acquire.

Third theme: epidemiology and sex differences, and here the news is sobering. In the Journal of the American Heart Association, Anjum and colleagues report the Norwegian AFNOR study, using mandatory national registry data on more than 227,000 incident strokes between 2001 and 2021 [5]. Atrial fibrillation-related strokes rose from about a fifth to nearly a third of all strokes over those two decades. Non-AF ischaemic stroke incidence fell substantially, from roughly 204 to 131 per 100,000 person-years, but AF-related ischaemic stroke incidence did not budge at all — and it rose in those aged 15 to 64. Nearly seven in ten AF-related ischaemic strokes occurred in people who were not anticoagulated. Meanwhile, AF-related intracerebral haemorrhage rose in those aged 75 and over, driven by anticoagulated patients. So two decades of progress have largely bypassed atrial fibrillation: we are still missing detection and treatment in the young, and paying a bleeding price in the old. That theme of bleeding risk in older anticoagulated patients ties directly back to the tenecteplase nomogram [1]. Staying with sex differences, Heart reports a Japanese nationwide registry analysis of fulminant myocarditis from Moriwaki and colleagues, covering 696 patients between 2012 and 2017 [6]. Ventricular fibrillation within 30 days occurred in 17 percent overall, but in 22 percent of women versus 14 percent of men, and after adjustment for age, ejection fraction, renal function and peak creatine kinase, female sex carried roughly a 60 percent higher risk of early VF. Ninety-day mortality, though, was around 35 percent in both sexes with no meaningful difference. The implication is about monitoring intensity and threshold for defibrillator-capable support in women presenting with fulminant myocarditis, not about prognosis overall.

Finally, surgical and structural outcomes. Also in Heart, David and colleagues analysed all 76,223 Swedish adults without a prior device who had cardiac surgery between 2006 and 2020 [7]. Just under 3 percent received a permanent pacemaker within 30 days. Over a mean follow-up of nearly seven years, pacemaker implantation was associated with a modest but significant increase in all-cause mortality — on the order of 9 percent relative — and a considerably larger, roughly one-third higher risk of heart failure hospitalisation, consistent across surgical subtypes. This is observational and the pacemaker may be a marker of a more damaged heart rather than the cause, but it argues for deliberate long-term follow-up rather than treating post-surgical pacing as a closed issue. In the Journal of the American Heart Association, Wang and colleagues reanalysed just under 1,600 patients with isolated proximal LAD disease from the PATENCY trial, measuring where on the LAD the internal mammary graft was sewn using postoperative computed tomography angiography [8]. A more distal anastomosis, beyond about 46 percent of heart height, was associated with a three-year graft occlusion rate of just over 2 percent versus more than 6 percent for proximal anastomoses — roughly a two-thirds reduction in the odds of occlusion — although major adverse cardiac events at three years did not differ significantly between the groups. It is a secondary, exploratory analysis with a data-derived threshold, so treat it as hypothesis-generating. And a meta-analysis in the same journal by Kharsa and colleagues pooled eight studies and nearly 2,000 patients undergoing transcatheter mitral valve replacement with the SAPIEN valve, comparing valve-in-valve with valve-in-ring [9]. Thirty-day and in-hospital mortality, stroke, major bleeding and embolisation were all comparable, but valve-in-ring carried substantially more left ventricular outflow tract obstruction, about five times the odds of reintervention, and roughly double the acute kidney injury — useful for consenting and for planning outflow tract protection. Rounding out the week, Heart also carries a practical review from Jain and Kittleson on post-transplant immunosuppression and rejection for the general cardiologist, covering the tacrolimus-based triple regimen and the shift from routine endomyocardial biopsy toward donor-derived cell-free DNA surveillance, with antibody-mediated rejection remaining the unsolved problem [10].

If you only have time for one paper this week, make it the tenecteplase intracranial haemorrhage analysis in the European Heart Journal [1]. It converts a feared, unpredictable complication into two modifiable levers — blood pressure before the bolus and dose in older, lighter patients — with an individualised nomogram you can actually use in a pharmacoinvasive system.

Here are the key takeaways from this week in Cardiology. Before giving tenecteplase, optimise systolic pressure and think hard about dose reduction in older, lighter patients and in women, where intracranial bleeding risk climbs steeply. In left-sided endocarditis, there is now an externally validated eleven-variable score to anchor early thirty-day mortality estimates in team discussions. Two decades of falling stroke rates have not touched atrial fibrillation-related stroke, most of which still occurs off anticoagulation, while AF-related brain bleeds are rising in the very old. Women with fulminant myocarditis have a meaningfully higher risk of early ventricular fibrillation despite similar mortality, so monitor accordingly. And in imaging, a self-report questionnaire can efficiently target calcium scoring in the late fifties, while an automated splenic ratio flags patients whose apparently normal PET stress study may have under-stressed them.

That's your roundup for This Week in Cardiology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.