European Heart Journal - Cardiovascular Pharmacotherapy最新文献

The clinically important link between LDL cholesterol (LDL - C) lowering and cardiovascular (CV) risk reduction is well-established and reflected in the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidaemia. They recommend a stepwise approach to reaching LDL - C goals, beginning with statin monotherapy at the highest tolerated dose. However, real-world data show a large gap between guideline LDL - C goal recommendations and their achievement in clinical practice. The treatment paradigm should shift from the concept of high-intensity statins to that of high-intensity, lipid-lowering therapy (LLT), preferably as upfront combination LLT, to overcome the residual CV risk associated with inadequate lipid management. A multidisciplinary expert panel convened to propose treatment algorithms to support this treatment approach in patients at high and very high CV risk. The experts completed a questionnaire on the benefits of combination therapy and the role that novel LLTs, including bempedoic acid, might play in future guidelines. The integration of new LLTs into the suggested treatment algorithms for patients at high CV risk, very high CV risk, and those with complete or partial statin intolerance was discussed. Each algorithm considers baseline CV risk and LDL - C levels when recommending the initial treatment strategy. This expert consensus endorses the use of statin combination therapy as first-line therapy in patients at high and very high CV risk, and, in some circumstances, in patients with statin intolerance when appropriate. Given recent, compelling evidence, including real-world data, combination therapy as first-line treatment should be considered to help patients achieve their LDL - C goals.

Aims: The role of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in patients with cardiac amyloidosis (CA) is controversial. However, they have shown encouraging results in several clinical settings, including heart failure, myocardial infarction, chronic kidney disease, and various forms of restrictive cardiomyopathy. The current study aims to evaluate the tolerability and efficacy of SGLT2i in patients with CA.

Methods and results: PubMed, Scopus, Cochrane Library, and Embase were scanned for eligible articles up to 28th of March 2025. Safety endpoints included the cumulative prevalence of adverse events (AEs) and drug discontinuation (DD) in the SGLT2i-group. Efficacy endpoints were the pooled risk ratio (RR) of all-cause death (ACD) and hospitalization due to worsening heart failure (WHF) between treatment- and control-groups, as well as the difference between mean change of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in both treatment- and control-groups. Thirteen observational studies, encompassing 19 227 patients, were included in the meta-analysis. Sodium-glucose co-transporter 2 inhibitors use in patients with CA resulted to be tolerable, as demonstrated by a low absolute cumulative prevalence of both AEs [8%; 95% confidence interval (CI) 2-17, nine studies, 603 patients] and DD (4%; 95% CI: 1-7, nine studies, 603 patients). Furthermore, its use was associated with a reduction in the risk of ACD (RR 0.59; 95% CI: 0.48-0.72) and NT-proBNP levels (median difference: -525.54; 95% CI: -718.09 to -332.98), despite no significant association with WHF was noted.

Conclusion: The administration of SGLT2i proved to be well tolerated in patients with CA. Randomized controlled trials are urgently needed to confirm the prognostic improvement associated with their use in this clinical setting.

Study registration: CRD42025632733.

Aims: Transcatheter mitral valve replacement (TMVR) has become a feasible alternative to surgical mitral valve replacement (SMVR) in selected patients at high surgical risk. The risk of valve thrombosis following SMVR and TMVR, and the optimal antithrombotic therapy following these procedures, remains uncertain. We aimed to compare the incidence of bioprosthetic mitral valve thrombosis (bMVT) after SMVR and TMVR, and the incidence of bMVT between patients on different antithrombotic regimens.

Methods and results: A literature search of Medline, Embase, and Cochrane Library was performed between January 2000 and August 2024. Random-effects models were used to derive pooled estimates of the incidence of bMVT in the absence of prior or active endocarditis and valve thrombosis. A total of 47 studies (6170 patients, total follow-up 9541.8 patient-years) were eligible for inclusion. The overall incidence of bMVT was 5.05 [95% confidence interval (CI) 3.18-8.01, I2 = 82%] per 100-patient-years. Subclinical bMVT was more common than clinically significant bMVT: incidence 19.11 vs. 7.91 per 100-patient-years, adjusted incidence rate ratio (aIRR) 4.62 (95% CI 1.39-15.36), P = 0.012. bMVT was numerically more common after TMVR than SMVR, but the comparison was not statistically significant: incidence 7.03 vs. 0.58 per 100-patient-years, aIRR 2.19 (95% CI 0.72-6.72), P = 0.170. Patients on vitamin-K antagonists (VKA) had a lower incidence of bMVT than patients on direct oral anticoagulants (DOAC; incidence 5.72 vs. 17.08, aIRR 0.31, 95% CI 0.13-0.73, P = 0.007).

Conclusions: bMVT is not uncommon, with numerically higher incidence in transcatheter compared to surgical valves, but the comparison was not statistically significant. VKAs are associated with a lower incidence of bMVT compared to DOACs.