Expert Review of Cardiovascular Therapy最新文献

Background: Population aging, cardiovascular disease burden, and evolving clinical practices may influence procedure rates, key to health policy planning. This study aimed to describe cardiac implantable electronic devices (CIED) implantation trends in the Brazilian Universal Health System (SUS) over 12 years.

Research design and methods: Ecological study using open data on hospital claims (2008-2019) for permanent pacemaker (PM), implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy with pacemaker (CRT-P) or defibrillator (CRT-D) implants. Annual percent changes (APC) with 95% confidence interval (CI) were estimated by linear regression of the logarithm of age and sex standardized implantation rates per million (MM) population (Brazil 2019 population).

Results: 216,927 CIED implants were analyzed. Annual implant volume rose from 14,466 to 20,726 (+43.3%). Nonetheless, the standardized rate declined from 108.9 to 98.2/MM (-9.8%), with an APC of -1.2% (95%CI -1.7% to -0.7%). PM and ICD rates were stable, but CRT trends diverged (CRT-D increasing, CRT-P decreasing). Regional analyses showed negative trends for PM and CRT-P, and heterogeneous ICD/CRT-D patterns.

Conclusions: Despite increasing volume, standardized CIED implantation rates declined in SUS, especially for PM and CRT-P. Divergent regional trends highlight the need for targeted health policies to ensure equitable access to advanced CIED therapies.

Background: Obstructive sleep apnea (OSA) and hypertension (HTN) frequently coexist and are associated with increased cardiovascular morbidity and mortality in the United States.

Research design and methods: Mortality data from 1999-2023 were obtained from the CDC WONDER Multiple Causes of Death database. Deaths were identified when ICD-10 codes for OSA (G47.3) and HTN (I10-I15) were listed as underlying or contributing causes of death. Age-adjusted mortality rates (AAMRs) were calculated and stratified by demographic and geographic factors. Temporal trends were evaluated using Joinpoint regression, and mortality was forecasted using Poisson regression model.

Results: A total of 107,514 deaths were associated with OSA and HTN between 1999 and 2023. AAMRs increased from 0.4 in 1999 to 12.4 in 2023, with higher rates observed among males, adults aged ≥75 years, NH-White individuals, rural populations, and residents of the Midwest. Among states, West Virginia had the highest AAMR. Forecasting models project continued increases in overall mortality, with AAMRs reaching 55.38 by 2035.

Conclusions: Mortality associated with OSA and HTN has increased substantially over the past two decades, disproportionately affecting older adults, males, and rural populations. Forecasted trends highlight the need for targeted prevention, early diagnosis, and improved access to effective therapies.

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: Sudden cardiac death (SCD) remains a major cause of mortality despite substantial progress in heart failure management and arrhythmia prevention. Current implantable cardioverter-defibrillator (ICD) guideline recommendations, mainly based on left ventricular ejection fraction (LVEF), are largely derived from historical trials and may no longer reflect contemporary patient populations or therapies.

Areas covered: This review critically appraises the historical and contemporary ICD evidence base with particular attention to evolving background therapy, competing risks of non-arrhythmic death, device technology, and modern risk stratification strategies. ICD trials cited in major international guidelines were reviewed and supplemented by a targeted PubMed literature search using ICD-related keywords, including relevant publications through September 2025. We emphasize emerging tools such as cardiac magnetic-resonance-imaging, genomics, artificial intelligence, remote monitoring data, and modular cardiac rhythm management systems.

Expert opinion: We propose a future ICD trial framework grounded in multimodal risk assessment, competing-risk-adjusted endpoints, pragmatic and adaptive trial designs, and device-specific evaluation pathways. We further outline how future guidelines may evolve to incorporate enriched patient phenotyping, precision risk prediction, and personalized device selection. Together, these developments signal a paradigm shift toward an individualized, digitally supported, and modular approach to SCD prevention in the next decade.

Introduction: Right ventricular apical pacing (RVAP) has been a standard treatment for patients experiencing symptomatic advanced atrioventricular (AV) block. However, due to electrical and subsequent mechanical dyssynchrony, RVAP might lead to pacing-induced cardiomyopathy (PICM). Various predisposing risk factors for PICM have been identified.

Areas covered: This review, based on a literature search of PubMed and Scopus databases (up to April 2025), focuses on alternative pacing strategies, including conduction system pacing (CSP) and biventricular pacing (BiVP), to reduce PICM.

Expert opinion: Implementing pacing strategies that encourage physiological ventricular activation, like CSP and BiVP, can greatly diminish the risk of PICM in patients with AV block. Implementing alternative pacing strategies necessitates careful patient selection and consideration of individual anatomical and clinical factors. A team-based approach should be utilized to identify the most suitable pacing method for each patient, with the goal of optimizing cardiac function and reducing the risk of PICM.

Introduction: Long-standing persistent atrial fibrillation (LSPAF) is among the most challenging arrhythmia phenotypes to manage, due to extensive atrial remodeling, fibrosis, and the presence of complex non-pulmonary vein substrates and triggers. Conventional antiarrhythmic drug (AAD) therapy provides limited efficacy and is constrained by short- and long-term toxicity. Catheter ablation (CA) remains the cornerstone of rhythm control but offers modest single-procedure success.

Areas covered: This review examines current treatment strategies for LSPAF, including pharmacologic rhythm control, CA, and hybrid surgical - endocardial approaches. Evidence from major clinical trials and meta-analyses is summarized, highlighting the limitations of pulmonary vein isolation (PVI) as a stand-alone therapy and the role of adjunctive strategies. The article also discusses novel approaches, including pulsed field ablation (PFA), fibrosis-guided mapping, and insights from recent international guidelines.

Expert opinion: CA remains the most effective rhythm-control strategy for LSPAF, but durable arrhythmia-free survival often requires repeat or hybrid procedures. Hybrid ablation should be considered, particularly in patients with advanced atrial remodeling. Emerging technologies, including PFA, offer the potential for improved outcomes. Future progress will depend on dedicated LSPAF trials with standardized endpoints, long-term follow-up, and broader patient representation to refine selection, optimize lesion sets, and establish the role of next-generation technologies.

Background: Acute limb ischemia (ALI) is a critical vascular emergency marked by a sudden reduction in blood flow to the limb, significantly increasing amputation risk. Revascularization outcomes in urban versus rural areas have not been examined.

Research design and methods: The National Inpatient Sample from 2016 to 2021 identified patients with ALI who underwent revascularization. Propensity score matching compared outcomes, analyzed using STATA version 18.

Results: Of 85,760 hospitalizations for ALI receiving percutaneous revascularization 81,880 (95.5%) were in urban centers and 3,880 (4.5%) in rural facilities. Patients in urban hospitals showed higher mortality (4% vs. 2.7%), myocardial infarction (MI) (3.4% vs. 2.7%), cardiogenic shock (1.6% vs. 0.6%), cardiac arrest (6.5% vs. 5.9%), major adverse cardiovascular and cerebrovascular events (MACCE) (7.5% vs. 5.3%), mechanical circulatory support (1.1% vs. 0.5%), and acute kidney injury (18.5% vs. 15.4%). However, urban patients had lower intravascular ultrasound (IVUS) (3.4% vs. 6.5%), major amputation (6.3% vs. 7.8%), fasciotomy (1.8% vs. 2.2%), and major adverse limb events (MALE) (46.4% vs. 49.1%), with a significant difference of p < 0.01 compared to rural hospitals.

Conclusions: Urban hospitals in the United States report elevated mortality rates and significant cardiovascular events in comparison to their rural counterparts.

Introduction: Fractional flow reserve (FFR) is widely used to assess the functional significance of coronary artery disease (CAD). However, the severity of anatomical stenosis does not always correspond with the extent of myocardial ischemia. This discordance highlights the limitations of angiographic assessment alone and underscores the need for more comprehensive evaluation strategies. Recent advances in intravascular imaging have provided deeper insights into the contribution of plaque itself to myocardial ischemia. A PubMed search was conducted for relevant studies published up to May 2025.

Areas covered: This review summarizes current evidence on the relationship between intravascular imaging-derived plaque characteristics and FFR. Key features examined include plaque burden, lipidic and calcified plaques, and plaque microstructures. Of these, large plaque burden and lipid-rich plaque characteristics show the most consistent associations with reduced FFR. Mechanistic explanations such as impaired vasodilatory capacity and localized endothelial dysfunction are also explored.

Expert opinion: Plaque morphology contributes important diagnostic and prognostic information beyond luminal narrowing. Integrating morphological imaging with physiological assessment is expected to improve clinical decision-making and management of CAD. Future research should focus on validating integrated imaging-physiology strategies to personalize treatment and improve outcomes in patients with CAD.

Introduction: The association between vascular biomarkers as indices of atherosclerosis and cardiovascular events has been widely reported. Measurement of vascular biomarkers has been used for risk stratification and prognostic prediction in hypertensive patients and has been included in various hypertension guidelines.

Areas covered: This article describes the evidence for various vascular biomarkers in hypertension practice, their interpretation in guidelines and future perspectives.

Expert opinion: Regarding the risk stratification of physiological vascular tests in hypertensive patients, while some hypertension guidelines provide cutoff values for physiological tests, the reference values for blood biomarkers are not clearly defined. Future evidence on the contribution of vascular biomarker measurements to improve outcome in hypertensive patients is expected, including the establishment of appropriate cutoff values based on large studies of blood biomarkers and future evidence on cardio-ankle vascular index.