Continuing Cardiology Education最新文献

Percutaneous coronary intervention (PCI) with stent deployment is the dominant form of myocardial revascularization, with millions of procedures performed worldwide each year. Stent design has evolved substantially over time and there are now a wide range of options available to the interventional cardiologist. This review will cover the development of intracoronary stents and the patient and vessel factors which are important in stent selection.

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Cardiovascular disease is the most common cause of death among chronic kidney disease (CKD) patients. As renal function declines, kidney-specific risk factors for cardiovascular events emerge. The aim of this review is to provide an insight on classical as well as non-traditional, kidney-related cardiovascular risk factors with regard to different stages of CKD, including ESRD and renal transplantation, and address specific strategies of cardiovascular disease prevention. Main culprits related to increased cardiovascular risk in patients with CKD include renin–angiotensin system and sympathetic overactivity, endothelial dysfunction, chronic inflammation, and oxidative stress. The CKD associated metabolic bone disorder (CKD-MBD), is associated with cardiovascular effects beyond the already established renal osteodystrophy and hyperparathyroidism. Higher circulating levels of phosphate and fibroblast growth factor 23 (FGF-23) and low vitamin D levels have been linked to increased risk of cardiovascular disease in patients with CDK. Uremia-related as well as renal replacement modality associated factors emerge in patients who initiate renal replacement therapy. Kidney transplant recipients (KTRs) have a lower risk of major cardiovascular events compared with dialysis patients, however conventional cardiovascular risk factors such as dyslipidemia, hypertension, and diabetes are amplified in KTRs, due to the use of immunosuppressive drugs which possess diabetogenic and atherogenic effects. Renal allograft dysfunction is a major risk factor for cardiovascular disease in this patient group. Prevention in the early stages of CKD and multifactorial aggressive interventions targeting established cardiovascular risk factors should be priority whereas future research and randomized clinical trials should assess new management approaches focusing on non-classical risk factors.

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Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and associated with significant morbidity and mortality. Coronary artery disease (CAD) frequently coexists with AF, and management of these associated conditions can be challenging. Bleeding risks of different combinations of evidence-based antithrombotic regimes need to be considered and the effects of different medical therapies for AF or CAD may impact on the other condition. This article reviews the current guidance and consensus statements of the ESC on the management of AF and CAD. The principles of AF management in the context of CAD are considered including upstream therapies to prevent AF, early identification, and antithrombotic risk assessment, and symptomatic rate and rhythm control strategies. Specific scenarios and an illustrative case are discussed to highlight clinical relevance.

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Coronary artery disease is a very common chronic condition affecting large numbers of people across the world. Once detected the natural history of coronary disease is very variable between individuals. Hence, the assessment of symptoms and current burden of disease is a key determinant for the recommendation of drug treatments and other interventions, for example, revascularization, with the aim of improving the quality and quantity of a patient's life. We here review our current approach to assessing the risk of future cardiovascular events in patients presenting with stable coronary artery disease.

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Antiplatelet therapy is an essential component in the treatment of acute coronary syndromes (ACS). ACS management has evolved significantly over recent years with new antiplatelet agents with distinct pharmacological properties that offer a faster onset of action and greater potency. Prospective randomized controlled trials have not only focused on reducing ischemic events, but also on complications. There is a tipping point with safety/efficacy, beyond which bleeding risk can outweigh any anti-ischemic benefit. This tipping point is not fixed and estimating its position for an individual patient remains a major challenge and is critically influenced by a multitude of factors including age and comorbidity. The European Society of Cardiology (ESC) guidelines provide important direction to the trainee and practicing cardiologist. This article outlines development in antiplatelet therapy focusing on mechanism of action, the evolution in the evidence-base, clinical indications, and clinical controversies.

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Heart failure secondary to left ventricular systolic dysfunction is a prevalent condition across Europe with ischemic heart disease the most common etiology. Acute heart failure is a medical emergency and management comprises diuretics and vasodilators. Several alternative intravenous treatments have been trialed in recent years but no mortality benefit has been found with these agents. For chronic heart failure there are several well-characterized disease-modifying treatments available which include beta blockers, ACE inhibitors, mineralocorticoid antagonists, and device therapy. Sacubitril/valsartan is a novel therapy that has recently been demonstrated to have additional prognostic benefit.

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Ventricular arrhythmias occur commonly following myocardial infarction and carry important prognostic implications. The mechanisms involved are varied and time-dependent, changing with the evolution of the infarct, and this has implications for the management of both the arrhythmia and the index ischemic insult, which are discussed in this article. Current evidence-based best practice and management guidelines are reviewed, and consideration is given to some of the unique challenges that managing this group of patients brings.

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Coronary artery disease (CAD) and aortic stenosis (AS) frequently coexist. The advent of transcatheter aortic valve implantation (TAVI) and its increased use over the last decade has brought a paradigm shift in the management of patients with severe AS who are considered inoperable or high risk for sAVR. The most appropriate management of coexistent CAD in patients undergoing TAVI is yet to be defined. In this article, we present a review of the issues arising in the management of CAD in patients with severe AS—with particular reference to those who are undergoing TAVI.

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