Clinical Cardiology最新文献

I read with great interest the article by Meunier et al. reporting the 3-year outcomes of a stent-less strategy (SLS) that used scoring balloon lesion preparation followed by paclitaxel-coated balloon angioplasty (DCB), with a bailout drug-eluting stent (DES) only when required [1]. The prospective, all-comers design and the long follow-up provide valuable real-world data on this evolving “leave-nothing-behind” approach, extending earlier 1-year evidence from the same group [2].

The authors are to be commended for proposing a practical algorithm in routine care and for introducing the “metal index” as a simple way to capture stent burden. The high proportion of patients eligible for SLS (≈85%) and the very low 3-year target lesion revascularization (TLR) rate in the DCB-only group (2.6%) are encouraging findings.

Some points, however, deserve clarification. First, patients in the bailout-DES group had longer lesions and more complex anatomy (multivessel disease, chronic total occlusion, bifurcation lesions). These are well-known predictors of adverse outcomes, and residual confounding may explain their higher TLR rates. Second, the main analysis relied on unadjusted Kaplan–Meier curves; a multivariable Cox model adjusting for lesion length, clinical presentation, left ventricular function, and lesion type would help clarify whether the metal index or SLS independently predicts TLR. Third, antiplatelet therapy was heterogeneous and incompletely described; given that prolonged dual therapy was common even in DCB patients, reporting both ischemic and bleeding outcomes is essential. Finally, ~8% of patients were lost to follow-up; sensitivity analyses would increase confidence in the results.

Comparable long-term results with “less DES” strategies have been described in chronic total occlusion cohorts, supporting the concept of minimizing stent burden when feasible [3].

In summary, the SLS algorithm is promising, safe, and associated with low 3-year TLR rates. Larger multicenter randomized trials with standardized lesion preparation and prespecified bleeding endpoints are needed to confirm these findings.

Sincerely,

The author has nothing to report.

This comprehensive meta-analysis reveals that GLP-1 and dual GLP-1/GIP receptor agonists are associated with reduced risk of composite cardiovascular endpoints and worsening heart failure events. However, no statistically significant differences were observed regarding all-cause or cardiovascular mortality.

We read with great interest the article titled “Epicardial Fat Thickness as a Marker of Coronary Artery Disease in Diabetics: A Single Center Study” [1]. The authors highlight significant findings regarding epicardial fat thickness (EFT) as an effective marker of coronary artery disease (CAD) severity in diabetic patients. However, several methodological and analytical aspects warrant further clarification and discussion.

Firstly, the exclusion criteria used in the study notably omit consideration of chronic kidney disease (CKD), frequently comorbid with diabetes mellitus and potentially impactful on both CAD prevalence and EFT [2]. Additionally, the retrospective design of this study raises critical questions regarding the practicality and reliability of assessing CAD presence and severity in a substantial patient cohort (n = 2340). The authors describe employing invasive and noninvasive tests retrospectively based on clinical indications, but the specifics of these indications and the process for systematically retrieving and validating past clinical data remain unclear. This approach might introduce substantial bias related to clinician-dependent test selection.

Moreover, despite collecting detailed lipid profiles, the study did not address statin therapy usage, an essential consideration given its widespread use and known influence on CAD progression and potentially EFT itself. Future investigations would benefit from clarifying the role of statins or other pharmacotherapies that may influence EFT and CAD outcomes.

In summary, while this study provides insightful findings that underscore EFT's potential as a noninvasive cardiovascular marker, addressing these methodological and analytical concerns would considerably enhance the study's robustness and clinical applicability.

Sincerely,

Data sharing is not applicable for this article.

The prognostic impact of catheter ablation in patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) remains controversial. Using a nationwide database, the authors demonstrated that catheter ablation was associated with cardiovascular and cerebral benefits, as well as a reduction in all-cause mortality, in patients with AF and HFpEF [1]. Several concerns arise from these findings.

The authors assessed all-cause mortality in the HFpEF cohort, although the prescription rates of guideline-directed medical therapy—including sodium–glucose cotransporter-2 inhibitors—were extremely low [1]. This may limit the interpretation of mortality reduction attributable to catheter ablation itself.

The major causes of death in HFpEF are generally noncardiac [2]. The mechanism by which catheter ablation would reduce all-cause mortality in this population therefore remains unclear. Catheter ablation helps prevent thrombus formation and stroke, and may reduce worsening heart failure by preserving atrial contraction. However, it is unlikely to directly decrease noncardiac events, which represent a substantial proportion of deaths in HFpEF.

The authors excluded patients who underwent valve replacement [1]. Yet, one of the most advanced clinical scenarios of HFpEF with AF involves significant valvular disease—particularly mitral regurgitation—that requires intervention [3]. Including such patients would improve the generalizability of the findings to a more representative HFpEF population. Moreover, individuals with severe valvular disease often have markedly remodeled atria and are seldom considered for catheter ablation.

Another important issue not evaluated in this study is bleeding related to anticoagulant therapy [1]. Patients with HFpEF may be at higher risk of bleeding complications than those with reduced ejection fraction [4]. In this regard, we strongly recommend considering left atrial appendage closure at the time of catheter ablation to mitigate anticoagulant-related bleeding risk, if applicable.

The authors have nothing to report.

The authors have nothing to report.

The authors declare no conflicts of interest.

The authors have nothing to report.