European Heart Journal Supplements最新文献

For a long time, a prognostic and therapeutic fatalism accompanied even the most motivated clinicians when they had to deal with a progressive decline in renal function; the modest successes were nullified by an increasingly aggressive syndrome whose therapy had remained the same for more than 30 years. In the meantime, the increased understanding of the physiopathological mechanisms connected to it had not been accompanied by an equal development of drugs capable of counteracting it, and this, also due to the progressive aging of the population, had rapidly made 'chronic kidney disease' (CKD) a problem of World Public Health due to its incidence, prevalence, and exponentially increasing costs in every part of the world. The progressive reduction of glomerular filtration rate, as has been known for some time, is accompanied by an increase in cardiovascular risk, understood as fatal and non-fatal heart attack, stroke, heart failure, and mortality. Therefore, every effort must be aimed at preventing or slowing the decline of renal function to reduce not only critical renal events (the need for dialysis or transplant among the most feared) but also the incidence of cardiovascular events. Since the disease is asymptomatic for a long time (it is often detected occasionally and with culpable delay), it is essential to make a correct and early assessment of renal function with appropriate methods. Once CKD was identified, clinicians, to slow its progression, could rely for a long time only on strict control of those risk factors most responsible for worsening it, such as diabetes and its complications, on the optimization of high blood pressure values and the mandatory use of drugs blocking the renin-angiotensin-aldosterone system, particularly in the presence of albuminuria. This strategy has proven to be only partially effective over time, and most patients still showed a progressive worsening of renal function. Only in the last few years have we had access to two classes of innovative drugs, such as gliflozins and incretins, that have imposed themselves on the therapeutic scene because they have shown that they can slow the progression of CKD, first in patients with Type 2 diabetes and subsequently in patients with CKD regardless of the presence or absence of diabetes. Unexpectedly and convincingly, they have also shown a significant impact on cardiovascular prognosis. Initially antidiabetic drugs, their efficacy has forced the reviewers of both cardiology and nephrology guidelines to indicate them among the drugs to use. Lately, the class of mineralocorticoid receptor antagonist drugs has been enriched by finerenone. This molecule has favourable pharmacokinetic characteristics compared with previous medications of the same class and tested in Phase 3, randomized, placebo-controlled trials (FIDELIO-DKD and FIGARO-DKD) which has been shown to significantly reduce the risk of cardiovascular and renal disease in diabetic patients compared with pla

Aortic stenosis is an increasingly relevant pathology not only for its high prevalence in the population (especially elderly), but also because in recent decades traditional surgery has been accompanied by transcatheter aortic valve implantation, a technique that has allowed a significant increase in effective therapeutic procedures, even in patients previously considered at high surgical risk. It has become essential to make precise diagnoses, based mainly on echo-Doppler that allows to identify the aetiology and severity of the valvular disease. A stenosis is considered severe when the area is <1 cm², the mean gradient exceeds 40 mmHg and the peak velocity is >4 m/s. Although in many cases these cut-offs are decisive, in others a discrepancy between area (<1 cm²) and gradient (<40 mmHg) is observed, requiring the inclusion of other variables such as ejection fraction (EF > or <50%) and the systolic volume index (normal SVi >35 mL/m² or reduced <35 mL/m²) to define the severity of the stenosis. This article describes the reasons for this discrepancy, identifies echo-Doppler parameters that further improve the classification of stenosis severity, and defines the indications for second-level examinations such as computed tomography and transoesophageal echocardiography.

Non-ST-segment elevation myocardial infarction is the prevalent form of infarction, especially in the elderly population. Compared with ST-segment elevation myocardial infarction, the culprit coronary artery lesion is not always traceable, and only a proportion of cases undergoing coronary angiography result in revascularization. At present, there is no evidence that a systematically invasive strategy has better outcomes, especially lower mortality, than a conservative approach. The SENIOR-RITA trial was the largest study in this regard, having randomized 1518 patients aged ≥75 years to invasive vs. conservative strategy with follow-up up to more than 4 years. Frail patients with cognitive impairment and comorbidities were not excluded. The results showed no differences between the two strategies in terms of primary endpoint (composite of cardiovascular death and infarction) or mortality, but a significant reduction in the risk of infarction and subsequent revascularization. These results confirm those of the previous meta-analysis of studies devoted to elderly patients and should be considered in terms of intervention strategy rather than revascularization efficacy. Subsequent antithrombotic therapies need to consider the frailty of these patients and their high haemorrhagic risk, with the increasing trend towards less aggressive and prolonged therapies than in the past.

Excess or dysfunctional adipose tissue is a key pathophysiological factor in cardiovascular-kidney-metabolic syndrome. However, until very recently, there was no evidence that pharmacological treatments for obesity could significantly impact major cardiovascular outcomes. Recently, the SELECT study represented the first, and to date the only, cardiovascular outcome trial conducted in the context of pharmacological treatment for obesity, and subcutaneous (s.c.) semaglutide 2.4 mg is the first molecule capable of leading to a statistically significant reduction in the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke in obese, non-diabetic patients with pre-existing cardiovascular disease. Furthermore, in the context of heart failure with preserved ejection fraction with obesity-related phenotype, s.c. semaglutide 2.4 mg and tirzepatide have been shown to improve prognosis, functional capacity, and quality of life. The main limiting factors for the implementation of semaglutide and tirzepatide are represented by the suboptimal adherence to treatment due to gastrointestinal intolerance, as well as by the reduced accessibility and economic sustainability. It is therefore necessary to wait to see how the drug regulatory agencies and international guidelines will implement the evidence of semaglutide and tirzepatide in the specific setting of the cardiovascular risk of obese patients.

Moderate or severe aortic insufficiency (AI) is a relatively rare condition but with significant clinical implications, especially in elderly patients at high surgical risk. Although surgical aortic valve replacement remains the gold standard for treatment, a significant proportion of patients are not eligible due to the high surgical risk. In recent years, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of aortic stenosis, but its application to AI has encountered significant challenges, mainly related to specific anatomical characteristics of this population. This review provides an overview of the evolution of the transcatheter treatment of AI, highlighting the critical issues of first-generation TAVI devices and the improvements achieved with new-generation and dedicated devices, such as JenaValve and J-Valve. Preliminary data demonstrate encouraging procedural results, including a reduction in residual insufficiency and improved safety in patients at high surgical risk. However, limitations remain, including the high incidence of pacemaker implantation and the lack of long-term randomized clinical trials. In light of technological advances, TAVI represents a promising therapeutic option for selected patients with AI, if performed in high-volume centres with extensive experience in the treatment of aortic disease.

REC-CAGEFREE I is a randomized open-label trial conducted in 2272 patients with de novo non-complex coronary artery disease in China, which demonstrated that a strategy of paclitaxel-coated drug-eluting balloon angioplasty [Swide (Shenqi Medical, Shanghai, China)] and bail-out stent did not achieve non-inferiority to sirolimus-eluting stent implantation [Firebird 2 (Microport, Shanghai, China)] on the primary composite endpoint, defined as cardiovascular death, target vessel myocardial infarction, or clinically and physiologically indicated target lesion revascularization, assessed at 2 years. In this manuscript, we report the salient data of this study, highlighting relevant details about the design, the type of lesions included, and the clinical implications of these results. The main limitation of this study is the evaluation of lesions where the drug-eluting stents have demonstrated excellent short- and long-term results.

In the last 10 years, leadless pacemaker (PM) therapy has moved beyond the experimental phase and has become an established therapeutic option. A substantial body of data are now available, even with medium-length follow-ups, suggesting that leadless PMs are associated with fewer infections and fewer overall complications, particularly in the long term, compared with transvenous PMs. The introduction of VDD(R) pacing and, more recently, DDD(R), has expanded the indication area of these devices to a significantly larger number of patients. High costs, limited experience with replacement and the lack of randomized studies still limit their widespread adoption. However, for many patients, the leadless PM already represents the first therapeutic choice.

Stereotactic radiotherapy (STAR) represents a new and promising therapeutic option for patients with ventricular tachycardias refractory to conventional therapies; it allows the delivery of a high and highly shaped radiation dose on a three-dimensional target, inducing an anti-arrhythmic effect already in the first week post-treatment, mediated, in part, by the reprogramming of the electrical conduction of the substrate. The procedure's success depends on the precise definition of the target to be irradiated, made possible by integrating electrophysiological data and anatomical-structural information provided by non-invasive imaging methods. Among these, cardiac computed tomography, thanks to continuous technological progress, is configured as a valid alternative to magnetic resonance imaging. It distinguishes itself for faster execution times in patients who are often hemodynamically unstable and lower susceptibility to artefacts generated by implantable devices. Computed tomography allows the identification of relevant tissue characteristics of the arrhythmogenic substrate, such as wall thinning, adipose replacement, and, above all, myocardial fibrosis, which can be assessed through the analysis of the late iodine enhancement technique. Emerging technologies, such as photon counting scanners and advanced software for the three-dimensional visualization of tissue characteristics of electrophysiological interest, promise to further enhance the use of this imaging modality in the procedural workflow of STAR.

Mineralcorticoid receptor (MR) blockade is a mainstay of treatment for heart failure with reduced ejection fraction (HFrEF); however, the benefit is less well established in heart failure with mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). The TOPCAT study failed to demonstrate a reduction in cardiovascular mortality and heart failure (HF) hospitalizations in this population but suggested potential benefits of mineralocorticoid receptor antagonists (MRAs) in specific patients subgroups. The FINEARTS-HF study, which evaluated the non-steroidal MRA finerenone in patients with HFmrEF or HFpEF, demonstrated a significant reduction in the primary composite endpoint of cardiovascular death and events related to worsening of heart failure (WHF), primarily driven by a decrease in total WHF events. Moreover, the FINEARTS-HF study demonstrated consistent efficacy across the entire left ventricular ejection fraction (LVEF) spectrum, regardless of sodium-glucose cotransporter 2 inhibitors use, sex, or age, with an early onset of benefit and a favourable safety and tolerability profile. Finerenone is currently indicated in class I in diabetic patients with chronic kidney disease to reduce the risk of HF; in light of the FINEARTS-HF results, it could become a new pillar of therapy for patients with HFpEF and HFmrEF.

Following the publication of numerous cardiovascular outcome studies conducted with new glucose-lowering agents, there has been a substantial change in the treatment paradigm of patients with type 2 diabetes, shifting the focus from simple glycaemic control to cardiovascular risk management. National and international guidelines of cardiology and diabetes societies have now acknowledged the important cardioprotective effects of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide receptor agonists, to the point that they are now considered first-line drugs in the management of cardiovascular risk in high-risk patients or with established cardiovascular disease, and also outside the context of established diabetes. In this brief review, we will analyse the clinical and pathophysiological evidence underlying this important paradigm shift, hypothesizing their early use in many cardiovascular patients, particularly in the pre-diabetes phase. Overall, these drugs are now a cornerstone in the therapeutic armamentarium, which the cardiologist must fully master, even independently of diabetologists.