The United States is facing a growing health care affordability crisis. In 2024, national health expenditures totalled $5.3 trillion, or $15 474 per person, accounting for 18.0% of the U.S. economy. Spending on health care continues to rise, propelled by high prices for services, drugs, and devices; growing administrative complexity; chronic underinvestment in prevention, primary care, and public health; and the mounting burden of chronic conditions such as cardiovascular disease. Patients, even those with insurance, frequently face financial hardship, delayed or foregone care, and medical debt because of gaps in coverage and inadequate consumer protections. Addressing this crisis will require coordinated action across the health care system, guided by evidence and a commitment to shared responsibility among key stakeholders. This Presidential Advisory from the American Heart Association draws on interviews and listening sessions with patients, clinicians, payers, employers, health system leaders, and public health experts to examine the many dimensions of affordability and offer a practical framework for action. The Advisory presents 5 core principles to guide efforts to address the affordability crisis: ensuring access to high-quality care without financial hardship; minimizing cost sharing for high-value services; creating shared accountability across the health care system; investing in the workforce, infrastructure, and data systems needed to support progress; and addressing the social and structural factors that make care less affordable for many communities. The evidence, tools, and expertise to combat the health care affordability crisis already exist. What is needed now is the collective will to act.

RBM20 (RNA binding motif protein 20) is a cardiac splicing factor responsible for the splicing of several cardiac genes such as titin (TTN), triadin (TRDN), ryanodine receptor 2 (RYR2), PDZ and LIM domain protein 1 (PDLIM1), and calcium/calmodulin-dependent protein kinase II (CAMK2D). Pathogenic variants in RBM20 are a major cause of familial dilated cardiomyopathy, and lead to missplicing of RBM20 target genes.

Intramyocardial hemorrhage (IMH) is a major determinant of adverse outcome in patients with ST-segment-elevation myocardial infarction, therefore making it a promising therapeutic target. This study aimed to investigate the association between coronary culprit lesion location and IMH in acute ST-segment-elevation myocardial infarction.

Perivascular adipose tissue (PVAT) attenuation on computed tomography angiography reflects vascular inflammation. However, its prognostic value in patients undergoing endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) remains unclear.

Congenital heart disease (CHD) is a leading cause of pediatric morbidity and mortality worldwide. The genetics of CHD in African populations is not well understood, although it has been shown in other settings that a genetic diagnosis can have implications for patient management and risk stratification. In this study, we aimed to identify pathogenic and likely pathogenic (P/LP) variants in a cohort of patients with CHD from Southern Africa.

While GWAS (genome-wide association studies) have identified over 1000 obesity-associated loci, their functional impact on gene expression remains unclear. Moreover, many studies have not fully captured the genetic architecture of obesity in high-risk populations or considered the complexity of adiposity beyond traditional measures. To address these gaps, this study explores the genetic and transcriptomic pathways of obesity using diverse obesity phenotypes in a high-risk population.

The clinical utility of physiology-guided revascularization for decision-making in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) remains uncertain. The aim of this study is to evaluate the diagnostic performance and prognostic significance of fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) according to the severity of CKD.

To improve survival in patients at risk of sudden cardiac death, subcutaneous ICDs (S-ICDs) require optimal implant positioning for effective shocks. Defibrillation (DF) testing is recommended but carries serious risks. The PRAETORIAN score predicts defibrillation outcomes based on chest X-rays. The PRAETORIAN-DFT trial evaluated whether omission of DF testing guided by the PRAETORIAN score is non-inferior for first-shock efficacy.

Background: Circulatory support escalation is often required during cardiogenic shock (CS) treatment. Currently, no large-scale data is available to inform how escalation strategies integrate in contemporary CS management and affect outcomes. Methods: We assessed the frequency, outcomes, and prognostic implications of escalation from a retrospective international registry of CS patients from 4 cardiac intensive care units. Escalation was defined as any incremental change in the circulatory support strategy after an initial bundle of care was established for at least 4 hours. Results: Among 602 consecutive CS patients, escalation was required in 30%. Patients were escalated to inotropes/vasopressors (36%), IABP (39%), Impella (14%) or V-A ECMO (11%). Escalation was associated with a higher hospital mortality rate (43% vs 21%; p<0.001; ORadj 3.42; 95% CI 2.21-3.35) and a greater transition to heart replacement therapies (23% vs 5%; p<0.001; ORadj 6.01; 95% CI 3.31-11.27), when adjusted for age, sex, chronic kidney disease, markers of CS severity on admission, CS etiology, and admission source. Escalation was associated with a higher risk of complications including acute kidney injury, major bleeding, and stroke. These outcomes occurred more frequently with high-profile mechanical circulatory support (Impella, V-A ECMO). Complications mediated 24% (95%CI 9-40%) of the association between escalation and hospital death. Escalated patients were successfully discharged alive in 42%. Age, SCAI B to C stage at escalation, TAPSE at escalation, and mean urinary output ≥1 mL/kg/hour in the 6 hours preceding escalation were independently associated with successful escalation when adjusted for sex, chronic kidney disease, and markers of CS severity on admission and at time of escalation. Conclusions: Circulatory support escalation is prevalent in patients treated for CS. Escalation is associated with a higher risk of hospital death, complications and transition to HRT, consistently with the intrinsically higher risk profile and expected trajectory of escalated patients. However, outcomes may differ according to the specific escalation strategy. Resorting to escalation in younger patients, in less severe CS stages, when the right ventricular function and urinary output are still preserved is associated with a higher chance of subsequent survival.