Continuing Cardiology Education最新文献

Atrial fibrillation is a complex arrhythmia that is difficult to treat with conventional antiarrhythmic agents. Novel pharmacological approaches are in progress focused on the development of agents with selective affinity to ion channels predominately involved in the atrium. In parallel, research efforts have been focused on the development of agents targeting to modification of those pathways and molecular mediators which are involved in the propagation and maintenance of atrial fibrillation (AF). In this review, we focus on the basic and clinical pharmacology of new and emerging antiarrhythmic drugs such as vernakalant, dronedarone, and ranolazine, whereas we briefly comment on the future directions of antiarrhythmic therapy in AF.

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Coronary near-infrared spectroscopy (NIRS) is an intravascular imaging modality with high sensitivity and specificity for lipid core plaque detection. A combined modality catheter that coregisters NIRS measurements with intravascular ultrasound (IVUS) is available, providing the operator with both structural and compositional data. NIRS/IVUS can identify plaques at risk for periprocedural myocardial infarction during stenting, allowing implementation of preventive strategies. NIRS/IVUS is currently being studied for identification of vulnerable plaques and vulnerable patients at risk of future cardiovascular events.

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Coronary artery disease (CAD) remains as a principal cause of morbidity and mortality worldwide. Despite the advancements in medical therapy and interventional procedures during the past years, the rate of major adverse cardiac events remains high both in individuals without previous history of heart disease and in patients with known CAD. Improved strategies of risk stratification for identifying subclinical atherosclerosis and asymptomatic individuals at high risk for cardiac events may help in intensifying treatment at targeted population groups, thereby providing enhanced primary prevention. Latest technological progress has made available new methodologies (e.g., fractional flow reserve and virtual surrogates) for assessing coronary anatomy and obstructive lesions precipitating acute cardiac events. Coronary imaging using either invasive (e.g., intravascular ultrasound, optical coherence tomography) or noninvasive (e.g., multislice computed tomography) modalities has enabled the detailed identification of atherosclerotic plaque features and inflammatory processes, thereby providing a “histology-like” quantification of the disease burden within coronary arteries. Additionally, the local hemodynamic environment, in particular endothelial shear stress, is considered as a primary stimulus for plaque development and progression. In vivo assessment of endothelial shear stress in humans has been made possible using three-dimensional coronary imaging and computational fluid dynamics techniques, and could potentially provide a more comprehensive evaluation of the risk for disease progression. Combined assessment of cardiovascular burden focusing on the functional significance of obstructive CAD, the anatomic features of plaque vulnerability, and the local hemodynamic milieu could yield an increased predictive capacity for prognostication, and thus enable preemptive strategies that could avert cardiac events.

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Coronary artery disease (CAD) remains the most common cause of death overall and is the leading cause of cardiovascular mortality worldwide 1. Although huge advances in medical therapy have been made within the last decades, the number of worldwide deaths due to CAD will further increase according to current forecasts 2. Based on the knowledge and understanding of CAD which cardiovascular research has provided over the last decades, patient care has made substantial progress in daily clinical practice. Although the implementation and further refinement of invasive treatment techniques have paved the way for revolutionary concepts especially in the setting of acute coronary syndromes, a true mortality benefit after percutaneous coronary intervention (PCI) of stable lesions has not been shown to date, which may partly be explained by incomplete understanding of atherosclerotic lesion progression underlying the symptomatic presentation of patients with CAD. Therefore, the following review focuses on traditional knowledge and novel concepts of stable atherosclerotic coronary plaque progression from a pathological point of view, to provide a foundation for future technological refinements and novel therapeutic approaches.

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This article discusses the current value of optical coherence tomography (OCT) for the assessment of stable coronary lesions. OCT generates intracoronary images with unprecedented image resolution, namely a 10-fold higher image resolution compared to conventional intravascular ultrasound. OCT is able to visualize a variety of atherosclerotic plaques features that have been associated with rapid lesion progression and clinical events. There is broad agreement that the detailed, easy accessible, and interpretable information of OCT on the presence of atherosclerosis, its extent, lumen narrowing, as well as on the result of any interventional measure can be of clinical value, at least in individual patients and in specific clinical scenarios. Preliminary data indicate that OCT can change the operator's intention-to-treat and modify the overall revascularization strategy, potentially avoiding unnecessary interventional procedures. OCT might be efficient in complex interventions including treatment of long lesions, diffuse disease, bifurcations, as well as in all cases of angiographically ambiguous lesions. As such, OCT might emerge, next to its undisputed position in research, as tool of choice in all clinical scenarios where angiography is limited by its nature as two-dimensional luminogram.

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Noninvasive access to coronary anatomy has long been anticipated and eventually became available with the emergence of multislice computed tomography angiography (MSCTA). MSCTA offers the possibility to identify coronary artery disease already in its preclinical phase. This unprecedented information proves to be useful in clinical practice as it allows the appropriate allocation of preventive therapies such as statin and aspirin.

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