European Heart Journal Supplements最新文献

Functional mitral regurgitation and functional tricuspid regurgitation occur due to cardiac remodelling in the presence of macroscopically normal valve apparatus. Two main mechanisms are involved: a ventricular phenotype (when ventricular remodelling and dysfunction are predominant) and an atrial phenotype (when annulus dilatation and atrial remodelling are predominant). Both phenotypes are frequent in patients with heart failure and are associated with a significant increase in morbidity and mortality, representing a relevant therapeutic target. This work focuses on the epidemiology, pathophysiology, prognosis, and therapy of atrial functional regurgitation.

Coronary computed tomography angiography (CCTA) is a non-invasive diagnostic tool that is increasingly being used as an alternative to invasive coronary angiography (ICA) in patients with suspected coronary artery disease (CAD), providing important information on the extent and severity of CAD. Furthermore, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been recently introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses. ICA has been the preferred diagnostic method to guide the decision-making process between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Recently, two studies have investigated the feasibility of using CCTA rather than ICA to plan CABG. In patients with three-vessel disease and/or left main CAD, the SYNTAX III REVOLUTION trial concluded that clinical decision-making between CABG and PCI using CCTA had a high level of agreement with treatment decisions based on ICA. In the FASTTRACK study, CABG procedures were planned based on CCTA without knowledge of ICA. CABG guided by CCTA showed to be feasible with an acceptable safety profile in a selected population of complex CAD. These intriguing findings should be confirmed in a large randomized trial on the revascularization outcome by comparing patients who underwent a novel non-invasive vs. a traditional invasive roadmap.

The 2024 ESC Guidelines for the management of chronic coronary syndromes expand the concept of CCS (chronic coronary syndrome), adopting a broader vision that includes structural and functional alterations throughout the coronary tree. A significant update concerns the stratification of coronary artery disease risk, with a central role played by the integration of cardiovascular risk factors. In the choice of diagnostic test, coronary computed axial tomography remains the 'gatekeeper' to exclude the disease in low-risk patients. Non-invasive functional tests are preferred in intermediate-high-risk patients, while coronary angiography is recommended for high-risk patients. There is renewed interest in angina and/or ischaemia in the absence of obstructive coronary artery disease (ANOCA/INOCA) patients, in whom the persistence of symptoms requires a complete invasive functional assessment to identify the specific endotype and personalize treatment. The therapeutic approach is characterized by a holistic vision of the patient. The role of aspirin in primary prevention is emphasized. In secondary prevention, revascularization remains essential, especially in patients with ejection fraction > 35% and high anatomical or ischaemic risk. Bypass is preferred in diabetics and patients with complex coronary anatomy, while percutaneous coronary intervention represents a valid alternative, supported by the aid of intracoronary imaging. Increased use of colchicine and semaglutide is recommended.

Systemic inflammation, which contributes to atherosclerosis development and progression, plays a significant role in addressing the residual cardiovascular risk. Several studies have highlighted a linear correlation between high levels of the inflammation marker high-sensitivity C-reactive protein (hsCRP) and cardiovascular events. However, its use as a risk modifier remains debated, primarily due to its low specificity. The search for alternative systemic markers, such as interleukin-6 (IL-6), and signs of local inflammation, such as pericardial fat tissue, may provide improved prognostic tools. Computed tomography (CT)-positron emission tomography (PET) using 68Ga-DOTATATE, which binds to macrophage receptors, appears promising for identifying high-risk coronary lesions. Among invasive methods, optical coherence tomography is the only modality with sufficient resolution to study macrophages. Recent studies have shown how the regulation of inflammation may represent a new therapeutic strategy to safely reduce residual cardiovascular risk, particularly through molecules that inhibit microtubule formation and modulate IL-1α-1β signalling, IL-6, by lowering hsCRP values. The latest European Society of Cardiology guidelines recommended using colchicine in ischaemic heart disease with class IIA indication. However, the evidence of colchicine's efficacy in this context remains conflicting and inconclusive. In addition, using new systemic markers (IL-6) and modern non-invasive CT or CT-PET imaging techniques will lead to better accuracy in the diagnosis of inflammation, not only systemic but also organ- and lesion-specific.

Pulmonary vein stenosis (PVS) has been recognized as a clinical entity complicating radiofrequency or cryoenergy ablation for atrial fibrillation. Although reduced by technical and procedural advancements, this complication portends remarkable morbidity and presents insidiously with non-specific symptoms causing frequent misdiagnosis and wrong management that lead to detection delay and major adverse implications. Non-invasive imaging is key for timely diagnosis and transcatheter procedural planning. Most recent consensus on severe and symptomatic PVS management indicates that stenting is the preferred treatment because of superior long-term patency compared to balloon angioplasty, particularly in patients with larger reference vessel diameter. However, the rate of recurrent stent restenosis is high and remains a great challenge. Goal of our manuscript is to provide a comprehensive review regarding pathophysiology, detection, treatment, and prevention of this serious iatrogenic complication.

The evidence that conventional right ventricular pacing can result in the development of cardiomyopathy and heart failure over time has prompted the search for alternative pacing sites. Conduction system pacing (CSP) represents an attempt to overcome the limitations of conventional pacing and to provide an alternative for patients with reduced EF and various degrees of dyssynchrony for whom resynchronization therapy is not feasible for technical or anatomical reasons. In particular, His bundle pacing and left bundle branch area pacing (LBBAP), with their advantages and disadvantages, have been shown to meet the criteria of physiological pacing. The former, although technically more challenging and less satisfactory in terms of electrical parameters, allows to obtain a QRS complex that is identical to the spontaneous one. The latter produces a wider paced QRS and although the technical complexity at the time of implantation is significantly reduced, is subject to a series of mechanical complications related to the trans-septal positioning of the lead. Careful patient selection along with an adequate learning curve for the operators make CSP a safe and effective procedure, although burdened by a higher complication rate compared with conventional pacing. Future studies will clarify its role, which is currently limited by current ESC guidelines to His Pacing only as an alternative procedure in case of failure of resynchronization therapy (class of recommendation IIa), after the 'ablate and pace' procedure or as an alternative to right ventricular pacing in patients with AV block, left ventricular ejection fraction <40% and an expected right ventricular pacing percentage >20% (class of recommendation IIb).

Despite major improvements in primary and secondary prevention, a flattening in the improvement of survival curves of patients with or at risk of acute myocardial infarction has been reached in recent years. Pharmacological therapies that reduce LDL cholesterol (LDL-C) levels have shown incremental clinical and vascular benefits according to the achieved LDL-C levels. However, a non-negligible rate of events still occurs in patients achieving very low LDL-C levels. In addition to risk factors related to inflammatory pathways, emerging lipid-related factors seem to account for this residual atherothrombotic burden, with accumulative evidence establishing lipoprotein (a) (Lp(a)) as the single greatest emerging risk factor. Ongoing trials will evaluate whether the pharmacological reduction of Lp(a) levels reduces the incidence of cardiac events, and therefore may represent a novel therapeutic target. In addition, implementing atherosclerosis imaging may help improve traditional clinical scores to identify better patients at high risk of cardiovascular events who may benefit more from early and effective treatment strategies. In the era of tailored medicine, direct imaging of atherosclerosis can play a crucial role in helping clinicians better stratify patient risk and patients better understand the burden of their disease, ultimately improving medication adherence and goal attainment.

Mitral regurgitation (MR) is the most common valvular disease in industrialized countries, with a significant impact on patient quality of life and survival, especially in an increasingly elderly and comorbid population. Repair surgery is considered the treatment of choice for primary MR, offering excellent long-term outcomes. However, the MitraClip system, a less invasive percutaneous option based on the edge-to-edge principle, has proved to be a valid alternative for patients at high surgical risk, showing initial benefits in terms of fewer post-operative complications. Surgery remains superior in terms of durability and prevention of residual regurgitation, but the MitraClip system offers advantages in selected patients, with improvements in quality of life and reductions in hospitalizations for heart failure. A multidisciplinary approach and careful patient selection are essential to optimize outcomes.

Semaglutide, a glucagon-like peptide-1 receptor agonist, is a well-established agent in managing patients with high cardiovascular risk. Initially, a formulation was introduced for weekly subcutaneous administration that demonstrated good tolerability and excellent efficacy in controlling glycaemia in patients with type 2 diabetes mellitus and in reducing body weight in obese and/or overweight subjects, even non-diabetics. Subsequent evidence has shown that the advantages of this drug go beyond simple glucose homoeostasis and weight reduction. Several randomized clinical trials have, in fact, highlighted the effect of semaglutide on improving cardiovascular outcomes with a significant reduction in events in subjects with already diagnosed cardiovascular disease or at high risk. Furthermore, this drug has also proved effective in slowing the progression of nephropathy in diabetic patients and patients with chronic renal failure. These effects are probably due to multiple mechanisms related to weight loss and glycaemic control, anti-inflammatory and antithrombotic properties, and a direct mechanism of vascular and renal protection. More recently, a formulation that requires the oral intake of the drug once a day has been introduced on the market, which maintains the efficacy results of the subcutaneous formulation unchanged.

E-cigarettes and heated tobacco products have been marketed as safer alternatives to traditional cigarettes, leading consumers to believe that they will reduce health risks. However, the scientific evidence collected so far calls this hypothesis into question. Their use as a means of smoking cessation has not only not led to unequivocal results on their effectiveness, but some studies even suggest that they could increase the risk of initiation to smoking or relapse into nicotine addiction. Furthermore, research indicates that both e-cigs and heated tobacco products contain toxic substances and can consequently cause health risks, such as lung, cardiovascular, and oncological diseases. The combination, or the so-called dual consumption, of these products with traditional cigarettes, seems to even further amplify the risks of cancer and other smoking-related diseases. It is important to underline that the long-term effects of these new forms of nicotine consumption are still being studied. However, the information available so far suggests that these are not harmless products at all. The lack of regulation and the variety of products on the market also make it difficult to assess the specific risks associated with each device.