Poor diet quality is a leading risk factor for cardiometabolic disease (ie, diabetes and diseases associated with metabolism and inflammation), which is present in about half of American adults. Support has grown for incorporating the provision of healthy food as a complement to or a component of clinical care. Such "Food Is Medicine" programs provide free or subsidized healthy food directly to patients in close coordination with the health care system. In this review, we systematically examined published randomized controlled trials examining Food Is Medicine programs in the United States, categorizing them into different stages of development using the National Institutes of Health Model for Behavioral Intervention Development. This review identified a total of 14 randomized controlled trials of Food Is Medicine interventions in the United States with noncommunicable disease outcomes, more than one-third of which were early-stage smaller-scale trials (stage 1 randomized controlled trials). Broad variations in populations enrolled; intervention design, duration, and intensity; and outcomes precluded many direct comparisons between studies. Randomized controlled trial data were generally consistent with findings in the observational literature, indicating that common Food Is Medicine approaches often positively influence diet quality and food security, which are theorized to be key mediators for clinical outcomes. However, the impact on clinical outcomes was inconsistent and often failed to reach statistical significance. These observations highlight the need for larger, higher-quality Food Is Medicine studies focusing on the measurement of clinical outcomes within well-designed programs and the need for additional randomized controlled trials that more systematically map out the relationship between participation in different types of Food Is Medicine programs and health outcomes.

Intraoperative transesophageal echocardiography is used with increasing frequency in cardiac surgery for monitoring and diagnostic purposes. Recent data have shown the impact of improved outcomes in patients undergoing cardiac surgery and the use of intraoperative transesophageal echocardiography in managing complex surgical decisions. However, specialty society recommendations have not been updated to reflect these trends. This scientific statement reviews the state-of-the-art practice of intraoperative echocardiography, summarizes the association of the use of intraoperative transesophageal echocardiography with enhanced outcomes, and provides specific perioperative and procedural transesophageal echocardiography considerations in the cardiac surgical population.

Alcohol is one of the most commonly consumed substances in the world, exhibiting complex relationships with multiple aspects of cardiovascular health and disease. The majority of the research on the topic is observational and therefore prone to bias and confounding. The available evidence suggests no risk to possible risk reduction when alcohol is consumed in low amounts (such as no more than 1 to 2 drinks a day) in regard to coronary artery disease, stroke, sudden death, and possibly heart failure. The risk associated with consuming 1 to 2 drinks a day on atrial fibrillation remains unknown. More randomized trials of low to moderate alcohol consumption are needed for more definitive conclusions. In stark contrast, heavier alcohol consumption such as binge drinking or consuming on average ≥3 drinks/d is consistently associated with worse outcomes in every cardiovascular disease entity studied. Considering the level of evidence, it remains unknown whether drinking is part of a healthy lifestyle and therefore clinicians should reinforce healthy lifestyle behaviors such as regularly engaging in physical activity, avoiding tobacco use, and maintaining healthy body weight.

The win ratio is a method for analyzing a hierarchical composite outcome. It has been most widely used in randomized clinical trials (RCTs) in cardiovascular disease. We performed a review of cardiovascular RCTs using the win ratio published between January 2022 and July 2024. The aims were to summarize current use and to provide examples to illustrate effective use and communication. We identified 36 eligible RCTs, mainly in heart failure and ischemic heart disease. Intervention was pharmaceutical in 26, a procedure in 7, and treatment strategy in 3 trials. When outcomes were analyzed with both conventional composite end points or hierarchical analysis, the conclusions tended to be similar. The win ratio was often used to combine evidence from event outcomes and quantitative measures together in a hierarchical composite, as was done in 23 RCTs. It was also used to create a clinically more relevant measure in RCTs by recognizing the clinical priorities among event outcomes. Selected example RCTs illustrate how the clarity of win ratio findings can be improved by (1) complementing the win ratio (a relative measure) with the win difference, (2) identifying which components of a hierarchical composite drive the overall results, and (3) clearly prespecifying the outcomes and win ratio analysis to be used. We conclude with a set of recommendations for future use of hierarchical composite outcomes and the win ratio. When used wisely, the win ratio is a valuable tool in the analysis of RCTs.

The pulsatile nature of blood flow and the hydrostatic effect of pulmonary capillary wedge pressure are 2 fundamental, yet often overlooked features of right ventricular-pulmonary arterial interactions in advanced heart failure and cardiogenic shock. These 2 features (above all others) define both the mechanical forces experienced by the pulmonary arteries, and in turn, the vascular afterload imposed by the pulmonary circulation on the right ventricular. For over half a century, it has been assumed that the pulsatile components of the pulmonary circulation exist in predictable and constant proportion to resistive afterload. In other words, that the vascular afterload can be estimated from mean pulmonary arterial pressure and pulmonary vascular resistance alone. While this tenet holds true for most forms of pulmonary hypertension, pulmonary hypertension resulting from the passive transmission of elevated left atrial pressure is a notable exception. In these cases, arterial compliance decreases proportionally more than any increase in pulmonary vascular resistance and is highly dependent upon recruitment and distensibility of the pulmonary circulation. As questions regarding the optimal method to predict right ventricular failure resurface, along with a modern armamentarium of techniques to assess pulsatile pressure-flow relations, it serves as a timely reminder that, in those with normal or near-normal pulmonary arterial pressures, the pulsatile component of pulmonary vascular afterload may account for anywhere between one-quarter and half of the total power of the right ventricular. In this State-of-the-Art Review, we address the role of pulmonary circulation in those with advanced heart failure and cardiogenic shock. Unlike previous discussions on this topic, we set aside considerations of established precapillary disease, focusing specifically on the process by which an acute or chronic elevation of pulmonary capillary wedge pressure results in pulmonary hypertension from left-sided heart failure. In doing so, we create a framework to assess pulmonary vascular afterload in an era of advanced therapeutics and device technologies to treat advanced heart failure and cardiogenic shock.

Persistent thoracic false lumen flow and subsequent aortic expansion are common complications following thoracic endovascular aortic repair for type B aortic dissection, as well as aortic arch replacement with the elephant trunk technique for type A aortic dissection. Although thoracic false lumen-perfused branches are known to contribute to thoracic false lumen backflow, robust imaging evidence is still lacking. This review illustrates how these branches perpetuate thoracic false lumen flow through detailed imaging analysis, emphasizing the critical need for advancing rapid, accurate, and minimally invasive imaging techniques and novel therapeutic devices to address this persistent clinical challenge.

Obtaining informed consent for clinical trial participation in acute myocardial infarction presents unique ethical and logistical challenges because of the patient distress, sedation, and the urgency of treatment. Traditional consent procedures often conflict with the narrow enrollment windows, prompting the use of legally authorized representatives and short- and long-form consent models. Although these approaches enable faster trial enrollment, they may compromise patient autonomy, introduce selection bias, or create postenrollment ethical dilemmas. This review explores the complexities of informed consent in acute myocardial infarction research, evaluating the advantages and limitations of existing strategies, including legally authorized representative consent, 2-step consent processes, and alternatives such as deferred and verbal consent. It also examines international variations in regulatory oversight and presents emerging solutions, such as preemptive consent, opt-out models, electronic platforms, and registry-based trials, to streamline the enrollment without delaying care. Ultimately, consent regulations should be re-evaluated and potentially relaxed to better support timely research. A thoughtful reassessment of consent frameworks is essential to ethically and effectively advance acute myocardial infarction research in time-sensitive settings.

Recent findings emphasize the potential role of invasive hemodynamic assessment in guiding transcatheter mitral and tricuspid valve percutaneous interventions. Right heart catheterization-derived parameters offer insights into hemodynamic changes associated with valvular heart diseases, pulmonary hypertension phenotyping, and right ventricular to pulmonary artery coupling. This might improve prognostic stratification for candidates to transcatheter therapies. This review provides a clinical overview of available data regarding the utility of preoperative right heart catheterization-derived parameters in patients undergoing mitral and tricuspid percutaneous repair or replacement.

Sarcoidosis is characterized by noncaseating granulomatous inflammation that involves the lungs or lymph nodes in 90% of cases. The prevalence of cardiac involvement in patients with sarcoidosis is thought to be between 5% and 25%. However, cardiac sarcoidosis can also present without extracardiac disease (known as clinically isolated cardiac sarcoidosis) or with previously unrecognized extracardiac disease. The principal manifestations of cardiac sarcoidosis are heart failure or left ventricular systolic dysfunction, high-grade atrioventricular nodal disease, or ventricular arrhythmia. Cardiovascular imaging plays a crucial role in making the diagnosis, partly due to the low yield of endomyocardial biopsy in cardiac sarcoidosis. Cardiovascular imaging is also used for risk stratification for ventricular arrhythmia, to identify patients who may benefit from immunosuppressive therapy, and for longitudinal follow-up on and off therapy. It can also be used to identify alternative diagnoses to cardiac sarcoidosis. This review will discuss how to use imaging in the diagnosis and management of patients with suspected or known cardiac sarcoidosis.

Heart valve replacement in children is fraught with long-term morbidity and mortality rates, largely because conventional implants lack the capacity to grow with the child. Partial heart transplantation presents a potential solution by transplanting only specific segments of a donor heart, thereby providing a living and growing heart valve implant. This approach harnesses the full spectrum of cardiac tissues, which, when freshly procured and supported by immunosuppression, can integrate as functional and potentially growth-capable tissue. This state-of-the-art review discusses the history and development of partial heart transplantation, its indications, recent clinical experiences, regulation, and future directions.

Cardiac intensive care units are witnessing a demographic shift, characterized by patients with increasingly complex or end-stage cardiovascular disease with a greater burden of concomitant comorbid noncardiovascular disease. Despite technical advances in care that may be offered, many critically ill cardiovascular patients will nevertheless experience significant morbidity and mortality during the acute decompensation, including physical and psychological suffering. Palliative care, with its specialized focus on alleviating suffering, aligns treatments with patient and caregiver values and improves overall care planning. Integrating palliative care into cardiovascular disease management extends the therapeutic approach beyond life-sustaining measures to encompass life-enhancing goals, addressing the physical, emotional, psychosocial, and spiritual needs of critically ill patients. This American Heart Association scientific statement aims to explore the definitions and conceptual framework of palliative care and to suggest strategies to integrate palliative care principles into the management of patients with critical cardiovascular illness.

Much work has been done on developing hierarchical composite end point analysis methods, which meaningfully measure the effect of a treatment for patients with heart failure. Two motivations for this work have been as follows: (1) trying to ensure that more severe outcomes are weighted more heavily in the analysis; (2) combining different types of end points such as death, number of recurrent hospitalizations, and continuous functional or biologic end points. Such methods include the win ratio, the win odds, and the proportion in favor of treatment. In this article, our focus is when all components are clinical end points such as death or hospitalizations and do not include continuous end points. We review these methods using HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training). We also describe recent methods for combining different clinical end points, which take into account the time a subject is in a particular clinical state. These include the pairwise win time, the restricted mean time in favor of treatment, the expected win time, and the expected win time against reference. We discuss the US Food and Drug Administration guidances and make general recommendations.

Induction therapy is the use of potent immunosuppression in the perioperative period with the intent to diminish rejection rates in at-risk patients or as a renal-protective strategy. The potent immunomodulatory effects of these agents must be balanced against the recipient's risk of infectious or malignant complications, among others. There is a notable lack of clinically useful risk stratification models that integrate these competing risks and guide the clinician in the use of these therapies. This review integrates the existing evidence on the utility and safety of various induction regimens and highlights the gaps of knowledge in the field. In addition, we frame the discussion in view of the changing landscape of heart transplantation where many unknowns remain, such as the impact of induction immunosuppression on patients bridged with mechanical circulatory devices or receiving organs from hepatitis C-positive or donation after circulatory death donors, among others.

The "open vein hypothesis" postulates that early thrombus clearance and restoration of venous blood flow may prevent postthrombotic syndrome after proximal deep vein thrombosis. Since its proposal several decades ago, new insights from basic and clinical studies have motivated a re-evaluation and refinement of this hypothesis. According to data from these studies, susceptibility to postthrombotic syndrome occurs as a result of differences in genetic composition, thrombophilic conditions, predilection to inflammation and fibrosis, endogenous fibrinolytic capability, timing of symptom presentation and treatment initiation, and efficacy of antithrombotic therapy. Although initial restoration of an open vein appears to be beneficial for selected patient groups, freedom from postthrombotic syndrome is more likely in the setting of long-term venous patency, reduced recurrent thrombotic episodes, and reduced perithrombotic (eg, vein wall and valve) inflammation. These underlying biological mechanisms need further elucidation, with a long-term goal of personalizing treatment by mapping the individuals' clinical presentation with their underlying risk factors and assessing time-dependent biological processes that occur as a clinical venous thrombosis resolves. This scientific statement (1) highlights historical fundamentals of the open vein hypothesis and then showcases new research insights into the pathophysiological factors driving postthrombotic syndrome; (2) discusses advantages and disadvantages of imaging modalities for deep vein thrombosis used in clinical practice, including the potential to depict thrombus chronicity and status of vein wall injury; (3) proposes measures to develop integrated multidisciplinary care for deep vein thrombosis focused on the reduction of postthrombotic syndrome; and (4) identifies priority areas and questions for further research.

The Get With the Guidelines-Heart Failure program was developed in 2005 with the goal of bringing evidence-based guidelines in heart failure management into widespread clinical practice. The program includes workshops, webinars, tool kits, chart abstraction, performance benchmarking, and achievement awards to drive quality improvement at participating hospitals. Two decades after its inception, the program has grown to include over 600 participating institutions across the United States. Linking registry data to Centers for Medicare and Medicaid Services claims has also allowed for the evaluation of longitudinal outcomes. Get With the Guidelines-Heart Failure has helped improve the quality of care for patients and has contributed substantially to the understanding of clinical science and optimal management of heart failure. This narrative review provides an overview of the indelible impact of the Get With the Guidelines-Heart Failure program on quality heart failure care over the past 20 years and highlights future challenges and directions.

Despite advances in cardiovascular care and improved outcomes, fragmented healthcare systems, nonequitable access to health care, and nonuniform and unbiased collection and access to healthcare data have exacerbated disparities in healthcare provision and further delayed the technological-enabled implementation of precision medicine. Precision medicine relies on a foundation of accurate and valid omics and phenomics that can be harnessed at scale from electronic health records. Big data approaches in noncardiovascular healthcare domains have helped improve efficiency and expedite the development of novel therapeutics; therefore, applying such an approach to cardiovascular precision medicine is an opportunity to further advance the field. Several endeavors, including the American Heart Association Precision Medicine platform and public-private partnerships (such as BigData@Heart in Europe), as well as cloud-based platforms, such as Terra used for the National Institutes of Health All of Us, are attempting to temporally and ontologically harmonize data. This state-of-the-art review summarizes best practices used in cardiovascular genomic and precision medicine and provides recommendations for systems' requirements that could enhance and accelerate the integration of these platforms.

Mitral regurgitation and tricuspid regurgitation are the most common valvular heart diseases in patients with heart failure and have independent prognostic value. Transcatheter interventions are now available for the treatment of valvular heart disease, and their efficacy and safety have been tested in randomized controlled trials. However, evidence is still limited and sometimes inconclusive because several aspects of these trials limit their interpretation or consistency. These include heterogeneity in the pathogenesis and clinical characteristics of patients, the dynamic nature of secondary atrioventricular valve disease severity, the role of heart failure medications and devices, dependency on procedural results and operators' skills, smaller number of patients enrolled and the power to detect differences in trials, and limitations to use patients' reported outcomes with unblinded study protocols. These specific aspects of trials in patients with atrioventricular valve disease are reviewed in this article with a focus on possible solutions to generate further evidence for the efficacy and safety for transcatheter treatments of atrioventricular valve disease in patients with heart failure.

Superficial femoral artery disease poses significant challenges in patients with peripheral artery disease due to its unique anatomic and physiological characteristics. While conservative measures remain the initial approach for chronic, stable symptoms, endovascular therapies have gained prominence due to their minimally invasive nature, expedited recovery times, and preservation of future treatment options when performed correctly. Options for endovascular interventions include balloon angioplasty (percutaneous transluminal angioplasty [standard], drug-coated balloon), stenting (bare metal, drug-eluting, covered stents), with or without adjunct therapy (atherectomy or intravascular lithotripsy). Randomized controlled trials have demonstrated superior outcomes with drug-coated balloons and drug-eluting stents over bare metal stents or percutaneous transluminal angioplasty alone, particularly in long, heavily calcified lesions. However, challenges such as in-stent restenosis, stent fracture, and in-stent thrombosis persist, driving ongoing innovation in device technology and drug formulations on devices. Emerging therapies such as bioresorbable scaffolds and percutaneous bypass devices offer promising alternatives. Further research is needed to refine treatment strategies, minimize risks, and optimize outcomes.

Despite major advances in recent years, the timely detection and prevention of incipient congestion in patients with chronic heart failure remains challenging. Most approaches are either invasive or require the acquisition of additional hardware. Leveraging voice analysis for the purposes of diagnosing, predicting risks, and telemonitoring clinical outcomes of patients with heart failure represents a promising, cost-effective, and convenient alternative compared with hitherto deployed methods. To expand this field, close collaboration of several disciplines of medicine and computer science is an obligatory requirement. The current review aims to lay out the state-of-the-art in this quickly advancing area of research. It elucidates the foundation for voice feature extraction, describes the prospective capabilities of this evolving technology, and outlines the challenges involved in identifying vocal biomarkers both in general and in the context of heart failure.

Cardiovascular disease remains a leading cause of morbidity and mortality in adults despite recent scientific advancements. Although people are living longer lives, there may be an adverse impact on quality of life, necessitating a greater need for palliative care services and support. Palliative care for adults with advanced cardiovascular disease has the potential to significantly improve quality of life for individuals living with cardiovascular disease and their informal care partners. Effective communication, shared decision-making, age-friendly care principles, and advance care planning are vital components of palliative care and support comprehensive and holistic care throughout the advanced cardiovascular disease trajectory and across care settings. Current evidence highlights the benefits of palliative care in managing symptoms, reducing psychological distress, and supporting both people with cardiovascular disease and their care partners. However, significant gaps exist in palliative care research related to non-heart failure populations, care partner outcomes, and palliative care implementation in diverse populations. This scientific statement (1) discusses the application of effective communication, shared decision-making, age-friendly care, and advance care planning in advanced cardiovascular disease palliative care; (2) provides a summary of recent evidence related to palliative care and symptom management, quality of life, spiritual and psychological support, and bereavement support in individuals with advanced cardiovascular disease and their care partners; (3) discusses issues involving diversity, equity, and inclusion in cardiovascular disease palliative care; (4) highlights the ethical and legal concerns surrounding palliative care and implanted cardiac devices; and (5) provides strategies for palliative care engagement in adults with advanced cardiovascular disease for the care team.