Expert Review of Cardiovascular Therapy最新文献

Introduction: Atrial fibrillation (AF) affects 10-20% of patients undergoing coronary artery bypass grafting (CABG) and is associated with increased postoperative morbidity and mortality. Although studies support the safety and effectiveness of surgical ablation (SA), and guidelines recommend its use during CABG for patients with preexisting AF, clinical adoption remains limited.

Areas covered: In this review, we outline current guideline recommendations, evaluate the evidence base, highlight recent analyses, and examine persistent barriers to the adoption of SA during CABG, informed by studies identified through searches of PubMed and Google Scholar.

Expert opinion: Small randomized studies demonstrate that SA restores sinus rhythm following CABG, while observational studies suggest rhythm restoration improves survival and reduces thromboembolic events. Recent national database analyses have lent further support, finding an association between SA and long-term survival. Analytic approaches included analysis by treatment type using propensity-score risk adjustment and, more recently, using surgeon frequency of SA as an instrumental variable. However, concerns about unmeasured confounding, sparse rhythm follow-up, and limited lesion-set granularity, undermine confidence and contribute to underuse. A randomized trial comparing long-term outcomes between pulmonary vein isolation, left atrial, and bi-atrial lesion sets is critically needed to guide optimal implementation of SA during CABG.

Introduction: Pulmonary vein (PV) isolation remains the cornerstone of atrial fibrillation (AF) catheter ablation. While the single-tip radiofrequency based PV isolation in conjunction with a 3-D mapping system was for many years considered to be the 'gold standard,' the strategy of PV isolation have evolved tremendously in the recent years.

Area covered: This review explores the latest energy source and catheter technologies developed in order to improve the efficiency, safety and persistence of acute success over the long-term follow-up in patients undergoing PV isolation for AF ablation. Relevant articles were searched in PubMed, Scopus, and Cochrane databases up to August 2025.

Expert opinion: Radiofrequency remains a milestone, especially in the field of the point-by-point ablation manner. The introduction of the temperature-controlled ablation catheters allows ablation with higher power settings compared to standard power-controlled ablation resulting in high acute and one-year success rate with a low incidence of complications. Similar results have been reported with both cryoballoon ablation system, with shorter procedural time and longer fluoroscopy time. Pulsed field ablation is a novel ablation modality, largely non-thermal, aiming at creating transmural, durable ablation lesions while reducing the risk of collateral damage.

Introduction: Secretoneurin (SN) is a prognostic biomarker in cardiovascular disease (CVD), and circulating SN concentrations have been associated with clinical outcomes in various cohort of CVDs. SN reflects other cellular pathways than established CV biomarkers, and SN provides incremental prognostic information to established CV risk indices. SN has been found to have several beneficial properties and SN could have potential as a future therapeutic strategy in CVD.

Areas covered: This review discusses SN as a novel cardiovascular biomarker and a potential therapeutic strategy in cardiovascular medicine. The authors have considered relevant papers identified by PubMed.

Expert opinion: SN is a prognostic biomarker in CVD, and unraveling the underlying pathophysiology of SN will be important to advance SN as a biomarker and potential future therapy in CVD. The future for SN as a biomarker and therapy is attractive and could be of future clinical relevance.

Introduction: Patients with an unprotected left main coronary artery (ULMCA) presenting with acute coronary syndrome (ACS) were underrepresented in randomized trials. We aimed to compare the outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in these patients.

Methods: Electronic databases were searched for studies comparing CABG vs PCI for patients with ULMCA presenting with ACS. The primary outcome was all-cause mortality. The outcomes were reported using a risk ratio (RR) and 95% confidence interval (CI) using random-effect model.

Results: A total of 7 studies with 4033 patients were included. There was no difference in the incidence of all-cause mortality between CABG and PCI. CABG was associated with a trend toward a higher incidence of stroke in short-term, but with lower rates of lower target vessel revascularization, and target lesion revascularization during long-term follow-up.

Conclusions: CABG and PCI were associated with comparable long-term mortality among patients with ULMCA who presented with ACS. However, CABG was associated with a lower incidence of MI and revascularization but a trend toward a higher incidence of stroke. These findings could help with informed decision-making among patients with ULMCA presenting with ACS.

Registration: The protocol was registered on PROSPERO (CRD420251034578).

Background: The aim was to determine the use of Sodium - Glucose Cotransporter-2 Inhibitors (SGLT2i) in patients with heart failure with and without diabetes mellitus in Colombia.

Research design and methods: The use of SGLT2i in patients with heart failure, followed for one year was evaluated. The patterns of use, indications, adherence and persistence of SGLT2i were analyzed. Descriptive and multivariate analyses were performed.

Results: A total of 500 patients were selected, with a mean age of 70.8 ± 12.8 years and 53.0% men; 57.2% started management with dapagliflozin. SGLT2i were most frequently used for heart failure with a reduced ejection fraction (HFrEF) and New York Heart Association classification of II or III (41.0%). The drug adherence rate was 80.9 ± 16.4%, and 71.8% of the patients reported persistent SGLT2i use for one year. Hospitalizations were less common during SGLT2i treatment than in the previous year (12.2% vs. 24.4%; p < 0.001). Having a Charlson Comorbidity Index ≥3 increased the probability of persistence of SGLT2i use at one year (Odds Ratio:4.56; 95%-Confidence Interval:1.46-14.27).

Conclusions: SGLT2i use predominates in patients with HFrEF and in those with a high comorbidity burden. Adherence and persistence were similar to or even better than those reported in other real-world evidence studies.

Introduction: Acute coronary syndromes (ACS) remain the leading cause of mortality in developed countries, particularly affecting older adults. Managing vulnerable patients - particularly those who are frail or have significant comorbidities such as anemia or chronic kidney disease (CKD) - is challenging due to the lack of evidence-based guidelines tailored to this group.

Areas covered: This review explores the management of non-ST-elevation acute coronary syndrome (NST-ACS) with a focus on antithrombotic therapy, invasive strategies, and cardiac rehabilitation (CR). Special attention is given to patients with frailty, atrial fibrillation (AF), and CKD, recognizing their complexity. For this purpose, studies specifically addressing the management of elderly patients with NST-ACS were reviewed.

Expert opinion: Optimal management of elderly patients with NSTE-ACS requires a personalized approach. Antithrombotic therapy should be individualized, avoiding rigid guidelines. Less potent antiplatelet agents (e.g. clopidogrel) combined with direct oral anticoagulants (DOACs) offer improved safety in patients with AF. Early invasive strategies can reduce adverse events but may carry procedural risks in frail individuals. Systematic comprehensive geriatric assessment (CGA) should guide decision-making; and multidisciplinary care is essential to improving outcomes. Home-based or hybrid CR programs still need to be widely implemented and the integration of caregivers into them can enhance outcomes.

Introduction: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) represents a diagnostic challenge, requiring the exclusion of non-ischemic causes such as myocarditis, Takotsubo syndrome, and cardiomyopathies. Cardiac magnetic resonance (CMR) plays a pivotal role in differentiating MINOCA from these conditions by providing detailed tissue characterization to identify inflammation, edema, and fibrosis. This review explores the expanding role of CMR in diagnosing, reclassifying, and managing MINOCA, emphasizing its ability to guide treatment, improve prognosis, and aid risk stratification by identifying underlying causes.

Areas covered: This narrative review discusses recent advancements in CMR protocols for suspected MINOCA, its role in distinguishing ischemic from non-ischemic causes of acute myocardial injury, and its emerging utility in risk stratification and personalized therapy. Relevant articles were searched in PubMed, Scopus, and Cochrane databases up to February 2025.

Expert opinion: CMR is the noninvasive gold standard for diagnosing MINOCA. Its emerging role in evaluating coronary microcirculation, along with integrated approaches using coronary computed tomography, will further enhance the noninvasive assessment of MINOCA, in particular determining potential coronary and non-coronary etiologies.

Introduction: Cardiac Troponin (cTn) is fundamental to the diagnosis of myocardial injury. High sensitivity cTn assays have transformed acute cardiac care by shifting the focus toward rapid rule-out of myocardial infarction, allowing the early identification and safe discharge of low-risk patients. However, cTn proteins and their assays have limitations.

Areas covered: The review summarizes cTn as a biomarker of myocardial injury, high-sensitivity cTn assay performance, and their combined impact on chest pain pathways. It explores Cardiac Myosin-Binding Protein C (cMyC) and discusses the evidence behind its use as an alternative biomarker. Studies available on Pubmed were analyzed using keywords cTn, cMyC, myocardial infarction, triage, chest pain and assay. The second half of this review explores the proteolysis of both these biomarkers, and how this information could be used in clinical practice.

Expert opinion: Both hs-cTn and hs-cMyC assays have shown equivalent diagnostic performance in the rule-out of myocardial infarction. Unfortunately, both are also plagued by the similar liabilities: decreased specificity for Type 1 AMI, and an inability to distinguish between types of myocardial injury. Proteolysis of each biomarker differs according to underlying pathology. Novel assays that quantify distinct forms could enhance patient triage.

Introduction: The presence of acute hypertension-mediated organ damage (HMOD) makes the difference between hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U). In the case of unrecognized ('false negative') acute HMOD, a misclassification ensues: the diagnosis is HTN-U instead of HTN-E, and the treatment of these patients is inadequate.

Areas covered: This review aims to investigate the presence of undiagnosed acute HMODs in the hypertension (HTN) guidelines, to analyze the significance of the undiagnosed acute HMODs, and to evaluate the gaps in the knowledge on the topic. The following databases were searched: Scopus, PubMed, Cambridge, Oxford Journals, Springer, Science Direct, SAGE, Wiley, and Google Scholar.

Expert opinion: There is insufficient awareness of the problem of unrecognized ('false negative') acute HMODs in clinical practice. HTN-Es have poor prognosis, with high risk of cardiovascular events and even death. Acute HMODs are prerequisite for the diagnosis of HTN-E, and it can be expected that undetected HMODs have even worse outcome. Therefore, undetected (false - negative) acute HMODs are worth of accepting and studying.