European Heart Journal Supplements最新文献

Over the past decade, non-vitamin K antagonist oral anticoagulants have revolutionized anticoagulation therapy, offering substantial benefits over traditional vitamin K antagonists. Non-vitamin K antagonist oral anticoagulants offer reduced bleeding risks, fixed dosing without frequent monitoring, and fewer drug and dietary interactions. Their effectiveness has been demonstrated in preventing stroke in atrial fibrillation, managing venous thromboembolism, and offering new options for patients with coronary artery disease and cancer-associated thrombosis. However, challenges remain, including bleeding risks, high costs, and limited efficacy in certain patient populations. Current research is focused on addressing these limitations, with Factor XI inhibitors emerging as a promising advancement for safer anticoagulation. This review provides an overview of the clinical highlights, challenges, and future directions of anticoagulation therapy.

The human heart's conduction system consists of specialized cardiomyocytes that generate and transmit electrical impulses, leading to the rhythmic and synchronized contraction of the atria and ventricles, which is crucial for the normal cardiac cycle. In conduction system pacing (CSP), pacing leads are placed in the His bundle region and the left bundle branch area to achieve physiological cardiac activation. This method offers a more natural alternative to the myocardial stimulation provided by conventional right ventricular pacing and biventricular pacing. In this review, we describe the implantation techniques for CSP and discuss the current recommendations for their use.

Electrical storm (ES) is a life-threatening condition characterized by at least three separate episodes of ventricular arrhythmia (VAs) over 24 h, each one requiring intervention. Early recognition and prompt treatment are crucial to improving outcomes. In addition to identifying and correcting potential reversible causes, performing acute cardiac life support if required, and interrogating/reprogramming the implantable cardioverter defibrillator in present, the acute management of ES (within 12-24 h upon presentation) nowadays mostly relies on antiarrhythmic drugs and percutaneous left ganglion sympathetic block (PLSGB), that will be the focus of the present review. The choice of the drug should consider several factors, including the aetiology and mechanism of VAs, the underlying cardiac function, and the potential risk of adverse events. Intravenous amiodarone, the most used and recommended drug in the setting of high burden VAs and structural heart disorders, mostly exerts dose and rate infusion dependent antiadrenergic effects in the first hours, and may lead to severe hypotension. PLSGB has an excellent safety-efficacy profile and can be easily performed by trained cardiologists at bedside.

Cardiac amyloidosis (CA) is a progressive, underdiagnosed condition caused by the deposition of misfolded proteins in the myocardium, forming amyloid fibrils that impair cardiac structure and function. This review highlights recent advances in the diagnosis and treatment of amyloid light-chain (AL) and transthyretin (ATTR) CA, which globally account for most cases of CA. Novel diagnostic tools, including artificial intelligence-enhanced analysis and advanced imaging modalities like positron emission tomography with amyloid-specific tracers, might improve detection rates and diagnostic accuracy to enable non-invasive subtype differentiation. Furthermore, many innovative treatments are being investigated. For AL-CA, anti-fibril therapies are showing promising results, complementing traditional chemotherapy and autologous stem cell transplantation. In ATTR-CA, gene silencing and anti-fibril therapies are being tested in clinical trials and hold promise of halting disease progression and reducing amyloid deposits, respectively.

The prevalence of heart failure with preserved ejection fraction (HFpEF) is increasing and prognosis remains poor, with a high risk of mortality or hospitalizations for worsening heart failure events. Apart from sodium-glucose cotransporter-2 inhibitors and diuretics, the management of HFpEF is nowadays based on the different aetiologies and cardiovascular or non-cardiovascular comorbidities. A great heterogeneity of clinical profiles has been described in HFpEF, with several recent studies focused on the identification of different HFpEF phenotypes. In this review, we summarize available evidence on phenotype profiling in HFpEF, describing the different phenotypes with the relative therapeutic implications, and reporting other specific clinical conditions relevant for HFpEF differential diagnosis.

The 'chronic kidney disease' (CKD) definition that best outlines the complex syndrome commonly called 'kidney failure' has become a problem of World Public Health due to its incidence and prevalence and due to exponentially increasing costs in every part of the world. The progressive reduction in the glomerular filtration rate, as known, goes hand in hand with an increase in cardiovascular risk understood as fatal and non-fatal heart attack, stroke, heart failure, and mortality. Therefore, every effort must aim at preventing or slowing down the decline in renal function in order to reduce not only critical renal events (the need for dialysis or transplantation among the most dreadful) but also the incidence of cardiovascular events. Since the disease is asymptomatic for a long time (often its detection is occasional and done with guilty delay), it is clearly important to make a correct and early evaluation of renal function with appropriate methods. Furthermore, it is crucial to make an aetiological diagnosis, when it is possible, of CKD because this will allow for the most targeted therapy possible. For a long time, an effective approach for the majority of people with CKD could only count on strict control of the diabetic disease and its complications, optimization of high blood pressure values, and the mandatory use of drugs blocking the renin-angiotensin-aldosterone system, particularly in the presence of albuminuria. Over time, this strategy proved to be only partially effective and the majority of patients nonetheless showed a progressive worsening of renal function. Only recently have we had access to two classes of innovative drugs such as glyphozines and incretins which have established themselves on the therapeutic scene because they have shown to be able to slow down the progression of CKD, first in patients with type 2 diabetes and subsequently in patients with CKD whether or not they have diabetes. Unexpectedly and convincingly, they have also been shown to significantly impact cardiovascular prognosis. From initially antidiabetic drugs, their effectiveness has forced the medical iconography to enrich itself with a new therapeutic niche by rightly speaking of 'cardio-nephro-metabolic' drugs.

This essay stems from a controversial recommendation present in the 2022 European Guidelines which indicated the appropriateness of considering an implantable cardioverter defibrillator (ICD) implant even for still asymptomatic long QT syndrome (LQTS) patients deemed to be at high risk by the 1-2-3 LQTS score based on QTc and genotype calculated prior to the institution of therapy. As 15 years ago, we also had proposed, but never used, a risk score called M-FACT to identify patients at high risk of an appropriate ICD shock, we felt the responsibility of assessing what would have happened to our patients if we had rigorously used that score. We performed a study recently published in the European Heart Journal which brought to general attention two concepts important for clinical management. One is that all LQTS patients should be seen at least once a year for a reassessment of arrhythmic risk based on standard electrocardiogram, 12-lead 24 h Holter recording and an exercise stress test. The other is that, based on these yearly visits, we perform 'therapy optimization' by adding to the standard β-blocker therapy either left cardiac sympathetic denervation or mexiletine or an ICD implant. On almost 1000 LQTS patients, all genotyped, this dynamic approach was accompanied by not a single death, few events, and out of 142 patients who should have received an ICD based on the score, only 22 did and only 3 had an ICD shock. These data and concepts call for a reconsideration of the recommendation made by the guidelines.

Over the past three decades, ischaemia research has been the cornerstone of the management and treatment of patients with atherosclerotic CAD. A robust body of evidence, including non-randomized and randomized trials, has supported the use of invasive and non-invasive coronary function tests to guide coronary revascularization. However, more recent data have questioned the clinical benefits of adopting this approach, especially in patients admitted with acute myocardial infarction. The increasing use of intracoronary imaging has identified the morphological features of plaques at higher risk of causing subsequent acute coronary events, despite the fact that they were not obstructive at the time of the index investigation. However, although functional assessment does not appear to have the same potential for identifying high-risk plaques as imaging modalities, it offers the simplicity and reproducibility of plaque assessment as a unique advantage. Furthermore, the ideal approach for the treatment of the so-called vulnerable plaques is still far from being identified, while a robust body of evidence supports the role of functionally guided revascularization, especially in stable patients. Overall, ischaemia research still provides non-negligible information that contributes to a personalized approach to improve patient outcomes.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to reduce cardiovascular (CV) mortality and heart failure (HF) hospitalizations, independently from left ventricular ejection fraction (EF). Their efficacy has been assessed both in patients with reduced and preserved EF, with notable benefits in renal outcomes as well. The initiation of SGLT2i in the early phase of hospitalization for acute HF has proven to be safe and beneficial. The EMPULSE and DICTATE-AHF trials support early empagliflozin and dapagliflozin use, respectively, reducing worsening HF events, improving quality of life, and enhancing diuretic efficiency. Notably, these benefits emerge shortly after the initiation of therapy, underscoring the importance of early integration into guideline-directed medical therapy (GDMT). Despite concerns regarding deterioration of renal function, SGLT2i appear to be safe even in patients with low estimated glomerular filtration rates (eGFR). Data suggest that SGLT2i benefits persist without increased safety risks, reassuring clinicians of their efficacy in patients experiencing renal decline. Concerns about volume depletion induced by SGLT2i have also been addressed, with documented enhanced diuresis without adverse renal impacts. Moreover, SGLT2i have been associated with a lower risk of hyperkalaemia events, thus allowing for better optimization of GDMT, including the use of mineralocorticoid receptor antagonists. Overall, these findings highlight the broad CV, renal, and metabolic benefits of SGLT2i, advocating for their early and widespread use in HF management, regardless of EF or eGFR.

Subclinical atrial fibrillation (AF) and atrial high-rate episodes (AHREs) are often detected incidentally through cardiac implantable electronic devices or wearables, especially in asymptomatic patients. These episodes pose a clinical challenge as they are associated with an increased risk of stroke, albeit at a lower rate compared with clinical AF. This review discusses the evolving understanding of AHRE, highlighting the uncertainties regarding optimal management, particularly the use of oral anticoagulants. Two key trials, ARTESiA and NOAH-AFNET 6, investigated anticoagulation in patients with device-detected AHRE. ARTESiA found that apixaban significantly reduced stroke or systemic embolism, but with an increased risk of major bleeding. In contrast, NOAH-AFNET 6, which tested edoxaban, did not demonstrate a significant benefit in reducing cardiovascular events but also observed higher bleeding rates. A meta-analysis of these trials confirmed the efficacy of oral anticoagulants in lowering ischaemic stroke risk, though with an elevated bleeding risk. Given these findings, clinical decision-making in patients with AHRE must be individualized, taking into account stroke risk, bleeding risk, and patient preferences. Shared decision-making is crucial to balance the benefits and risks of anticoagulation, especially in the context of progression to clinical AF and its associated stroke risk. Moreover, it is essential to educate patients about the risk of bleeding complications and emphasize the importance of close monitoring. Future research may further clarify optimal anticoagulation strategies and better define high-risk subgroups that would most benefit from therapy.