Expert Review of Cardiovascular Therapy最新文献

Introduction: There is an unmet need for effective medical therapies in the treatment of obstructive hypertrophic cardiomyopathy (HCM). This is changing with emergence of cardiac myosin inhibitors (CMI), which reduce cardiac myocyte hypercontractility, normalize left ventricular function, and reduce left ventricular outflow tract obstruction. Mavacamten and aficamten are the first 2 drugs in this class with high-quality phase III randomized clinical trial data (Based on PUBMED search, last query April 2025).

Areas covered: In the current review, we perform a detailed analysis of the background characteristics, primary endpoints, efficacy, and safety data available from 4 phase III randomized trials in which mavacamten and aficamten were tested against placebo. This includes understanding clinically meaningful class-based effects vs. specific drug differences.

Expert opinion: CMI therapy represents an exciting evolution in management of HCM patients, targeting for the first time the underlying pathophysiologic mechanisms of the disease. There is a growing body of evidence based on high-quality scientific investigation that are broadening the therapeutic options for patients with this condition. However, as different drugs emerge in the same class, it is crucial to appreciate clinically meaningful class-based effects vs. specific drug differences.

Introduction: The standard therapy for acute low- and intermediate-risk pulmonary embolism (PE) is anticoagulation, while concomitant systemic thrombolysis is reserved only for high-risk patients. Studies reporting thrombolysis in the former categories have yielded mixed results.

Methods: Two databases and two trial registers were searched for randomized- and non-randomized trials. The Mantel-Haenszel method, along with a fixed-effect model, was used for analysing dichotomous outcomes.

Results: Sixteen trials were included. Concomitant use of tPA analogues resulted in lower all-cause mortality (OR = 0.53;95%-CI:0.32-0.89;p = 0.02), PE recurrence (OR = 0.47;95%-CI:0.24-0.90; p = 0.01) and, treatment-escalations (OR = 0.39;95%-CI:0.25-0.61;p < 0.00001) while causing a higher incidence of major- (OR = 2.84;95%-CI:1.82-4.43; p < 0.00001) and minor-bleeding (OR = 4.31;95%-CI:3.26-5.71;p < 0.00001). Subgroup analysis based on the type of tPA used showed similar results except for the significantly lower major-bleeding with alteplase compared to tenecteplase (p = 0.003) and a lower incidence of bleeding events with low dosage while maintaining relatively similar treatment efficacy.

Conclusions: Systemic thrombolysis significantly reduced all-cause mortality, PE recurrence, and treatment escalations but increased major and minor bleeding risk, with low-dose alteplase causing fewer bleeding complications compared to full-dose therapy/tenecteplase. Although the included trials showcased substantial sample-sizes and standardized dosing protocols, their baseline imbalances introduced potential confounding bias. Notably, mortality reduction lost statistical-significance upon excluding non-randomized trials and trials with baseline imbalances.

Registration: This paper was registered on PROSPERO (CRD42024553660).

Introduction: Artificial intelligence (AI) has emerged as a revolutionary technology that is changing clinical practice, including management of patients with cardiovascular diseases.

Areas covered: From a clinical practice perspective, this manuscript reviews the impact of AI on the management of cardiovascular diseases, and current challenges and opportunities. For this purpose, a systematic search was conducted on PubMed (MEDLINE), using the MeSH terms [Artificial intelligence] + [Cardiology] + [Cardiovascular] up to February 2025. Original data from clinical trials, observational studies and reviews of interest were reviewed.

Expert opinion: Cardiovascular diseases remain the first cause of morbidity, disability, and death worldwide, mainly owing to late diagnosis, insufficient control of cardiovascular risk factors, and poor use of guideline-recommended therapies. Moreover, the high prevalence of cardiac disease increases stress on the health system, which is already overloaded, challenging its capacity to provide quality patient care. AI-based algorithms may assist clinicians by promoting personalized medicine, improving efficiency, and better anticipating outcomes. Although some AI-based technical solutions are currently implemented, most will be ready for use in the coming years. Nonetheless, many challenges, barriers, and ethical concerns remain, and the effective implementation of AI in routine practice will take some time. In this context, it seems necessary to increase medical knowledge of how AI works, its impact on cardiovascular diseases, and its potential translation to clinical practice.

Introduction: Left atrial appendage occlusion (LAAO) represents a strategy to minimize thromboembolic risk in atrial fibrillation (AF) patients. However, LAAO carries some risks of periprocedural bleeding, device embolization, peri-device leaks or device-related thrombosis; the latter is due to direct blood contact with the device, justifying and represents the rationale behind antithrombotic therapy following LAAO.

Areas covered: A comprehensive literature search (PubMed, Web of Science, Cochrane) has been performed up to November 2024. Antithrombotic drugs after LAAO include vitamin K antagonists (VKA), direct oral anticoagulants (DOAC), antiplatelet drugs, and their combinations. Initially, high-intensity regimens were implemented, while current strategies prioritize simplified approaches to promote device healing without increasing the bleeding risk. The aims of our review were to define the rationale and implications for post-LAAO antithrombotic therapy and provide an overview of current evidence on various antithrombotic regimens.

Expert opinion: The optimal post-LAAO antithrombotic regimen remains controversial, highlighting the need for randomized trials on this topic. Current data suggest that DOACs have the lowest probability of thromboembolic events and major bleeding, while DAPT may be preferred in patients who do not tolerate OAC; finally, single antiplatelet therapy or no antithrombotic therapy are alternative options for patients at high bleeding risk.

Introduction: Tricuspid regurgitation (TR) is a prevalent condition and is independently associated with high morbidity and mortality rates. Despite its prognostic impact, TR remains undertreated, with patients often referred at late stages when medical therapy is ineffective and surgical intervention high risk. Emerging transcatheter therapies offer a promising alternative for safer and effective management of this elderly patient population with numerous comorbidities.

Areas covered: This review highlights recent advances in treatment strategies and future directions for addressing significant TR. The literature search was conducted across the PubMed, Embase, Scopus, and Google Scholar databases. A structured search strategy was developed using 'tricuspid regurgitation' and 'management' or 'treatment' or 'therapy' and 'surgery' or 'tricuspid valve repair' or 'tricuspid valve replacement' or 'transcatheter tricuspid intervention' as MeSH terms and keywords. Selected articles from 2017 to present were critically analyzed for strengths, limitations, and gaps in evidence.

Expert opinion: Enhancing disease awareness, the involvement of multidisciplinary Heart Team and intervening earlier are critical priorities for TR therapies to prevent treatment futility. Improved device designs, more performant imaging techniques, and dedicated research endpoints will help optimizing the management of TR.

Introduction: Low-dose aspirin has been the cornerstone of single and dual antiplatelet treatment across the cardiovascular risk continuum. It has a well-established efficacy and safety profile, supported by large-scale, placebo-controlled trials as well as long-standing clinical experience. Low-dose aspirin has the highest recommendations in international guidelines for patients with chronic coronary syndromes (CCS), including a lifelong recommendation in patients post vascular interventions and those without prior myocardial infarction or revascularization but with evidence of significant obstructive coronary artery disease.P2Y₁₂ inhibitors - including clopidogrel, ticagrelor, and prasugrel - have recently been explored as an alternatives to low-dose aspirin in patients with CCS, with various trials comparing their efficacy and safety to aspirin.

Areas covered: We reviewed the pharmacodynamic and pharmacokinetic properties of low-dose aspirin and P2Y₁₂ inhibitors, data from trials and meta-analyses, and factors that may influence adherence to therapy.

Expert opinion: The usefulness and generalizability of the current data on P2Y₁₂ inhibitor monotherapy are limited by a lack of large-scale, multicenter, multiethnic trials. Furthermore, P2Y₁₂ inhibitors lack the evidence for long-term safety and efficacy that are associated with low-dose aspirin. We feel that low-dose aspirin remains a cornerstone therapy in the management of patients with CCS.

Introduction: Dynamic reassessment of stroke and bleeding risks is a cornerstone of patient-centered care in atrial fibrillation (AF) management. Unlike traditional approaches that evaluate these risks only at diagnosis or at initiation of oral anticoagulation, current evidence emphasizes periodic reassessment due to the evolving nature of risks.

Areas covered: Stroke and bleeding risks in AF patients are influenced by aging, new comorbidities, and worsening health conditions, requiring updates to management plans to optimize outcomes. Dynamic increases in CHA₂DS₂-VASc (or the sex-less CHA₂DS₂-VA) and HAS-BLED scores are associated with heightened risks of stroke and bleeding, underscoring the need for regular reassessment. Addressing modifiable risk factors such as hypertension, renal dysfunction, and concurrent medications is key to improving outcomes. Although several guidelines now recommend risk reassessment at least annually, optimal timing remains unclear. Evidence supports more frequent reassessments for low-risk stroke patients (every 4 months) and high-risk bleeding patients (within 4-6 weeks) to promptly identify changes requiring intervention.

Expert opinion: Despite its benefits, challenges remain regarding risk reassessment, including the lack of universally applicable intervals and the complexity of multidisciplinary evaluations. Future advancements in artificial intelligence tools are expected to enhance risk reassessment by enabling more precise, personalized, and dynamic patient management.

Introduction: Kidney transplant recipients (KTRs) have substantially lower risk for cardiovascular events compared to dialysis, but it remains significantly higher than in the general population due to the synergistic action of traditional and nontraditional factors. Among them, endothelial dysfunction is suggested to be involved pathogenetically in cardiovascular and renal disease progression, with its improvement being another potential benefit of transplantation.

Areas covered: VOP was the first technique to be used, followed by several functional methods, most commonly FMD. Over the years, several biomarkers of endothelial dysfunction have been used to assess microvascular function. The totality of evidence in KTRs suggests the improvement of endothelial dysfunction after transplantation, but with several gaps in knowledge, including rarity of studies using novel, more accurate techniques. This review presents the current functional methods and biomarkers used to evaluate microvascular and endothelial function in KTRs, discussing the existing evidence on their changes after transplantation and their associations with comorbidities and outcomes in this population. A comprehensive literature search was conducted in PubMed and Scopus for articles published until December 2024.

Expert opinion: Novel methods assessing endothelial function offer a comprehensive, real-time evaluation of microvascular function and should be more widely used to enhance our understanding in this area.

Introduction: Pre-hospital delay (p-HD) in acute coronary syndrome (ACS) influences the ability to perform percutaneous coronary intervention in a timely manner. Many factors, including age, have been identified to affect p-HD. An association between different age groups and p-HD in various ACS types is unclear. Moreover, data regarding the relationship between p-HD, age, and mortality are inconsistent.

Areas covered: In this review, we present current evidence of how p-HD influences mortality in various age groups and subtypes of ACS. Specific subgroups with knowledge gaps and future perspectives are identified.

Expert opinion: We identify specific subgroups of ACS where p-HD affects mortality in different age groups. First, p-HD may significantly affect the long-term prognosis of younger STEMI patients. Second, NSTEMI with known or presumed complex coronary lesions, often related to older age groups, might significantly benefit from p-HD reduction. Third, NSTEMI with ongoing myocardial infarction suffer from considerable p-HD, irrespective of age. These patients might benefit from reduced p-HD by improved education, public awareness, and increased medical service vigilance. Finally, incorporating artificial intelligence (AI) in pre-hospital care may provide further p-HD reduction.

Introduction: Refractory angina (RA) is a debilitating condition characterized by persistent angina despite optimized medical therapy and limited options for further revascularization, leading to diminished quality of life and increased healthcare utilization. The RA patient population is rapidly expanding with significant unmet needs. Specialty clinics should be developed to focus on the long-term efficacy and safety of clinically available and novel treatment strategies, emphasizing quality of life.

Areas covered: Patient-focused Comprehensive Angina Relief (CARE) clinics can enhance care and outcomes by providing individualized management for complex RA. This review summarizes peer-reviewed articles from PubMed and trial data from ClinicalTrials.gov. We discuss the epidemiology and pathophysiology of RA, introduce standardized tools for evaluating angina and psychosocial factors, and address symptom management. We also review treatment options such as risk factor modification, medication, and complex revascularization. Additionally, we explore emerging therapies, including coronary sinus occlusion, regenerative therapy, and neuromodulation for 'no-option' RA.

Expert opinion: In the next five years, patients with refractory chest pain with or without coronary artery disease will increasingly be referred to specialty clinics for follow-up. Conducting more randomized control clinical trials with larger population subsets will bring novel therapies to the forefront.