Expert Review of Cardiovascular Therapy最新文献

Introduction: Bleeding risk assessment plays a critical role in the anticoagulation management for atrial fibrillation (AF), to balance stroke prevention with risk of major hemorrhage. Traditional bleeding risk models, such as HAS-BLED, ORBIT, and ATRIA, offer valuable insights but have limitations in predictive accuracy and clinical applicability. Recent advances in risk stratification have introduced novel models integrating biomarkers, genetic data, and artificial intelligence (AI)-driven algorithms to improve precision and individualized patient care.

Areas covered: This review evaluates strengths and limitations of established bleeding risk assessment tools and explores emerging trends in predictive modeling. It discusses novel risk stratification models- DOAC Score, GARFIELD-AF, and HEMORR₂HAGES, which incorporate renal function markers, hematologic parameters, and genetic polymorphisms to enhance predictive accuracy. Integration of machine learning and digital health tools, such as the Universal Clinician Device (UCD) and the mAFA-II mobile application, was also examined for their role in improving anticoagulation safety and adherence.

Expert opinion: The future of bleeding risk assessment lies in AI-driven, real-time risk prediction models adapting to dynamic patient profiles. Enhanced integration of digital health solutions and learning health systems will minimize adverse events while optimizing stroke prevention. Future research should prioritize the validation and standardization of these novel tools.

Introduction: Νewly diagnosed diabetes mellitus (NDDM) among acute coronary syndrome (ACS) patients represents a distinct clinical entity, although available data remain inconclusive. This systematic review and meta-analysis compared ACS patients with NDDM to those without diabetes mellitus (DM) and those with previously diagnosed DM (PDDM).

Methods: We searched PubMed, Scopus, and CENTRAL until 10 December 2024. We assessed myocardial necrosis, prognosis, coronary artery disease (CAD) extent, left ventricular ejection fraction (LVEF) at discharge, and cardiometabolic profiles. ROBINS-E and GRADE assessed bias risk and evidence certainty, respectively.

Results: Out of 257,859 ACS patients from 34 studies, 5.2% had NDDM. NDDM patients had higher mean peak hs-cardiac troponin I levels compared to PDDM patients (MD 18,389.15 [95% CI 2975.96, 33802.34]) and intermediate post-discharge prognosis between PDDM and non-DM patients [5-MACE; RR 0.80 (95% CI 0.71, 0.91); RR 1.21 (95% CI 1.08, 1.37), respectively]. NDDM patients had similar discharge LVEF to PDDM patients but lower than non-DM patients (MD -2.06% [95% CI -2.93, -1.18]). Their cardiometabolic profile resembled PDDM.

Conclusions: Although the evidence was mostly low-certainty, the high prevalence of NDDM and its potentially unfavorable outcomes compared to non-DM patients could stimulate further research on the effects of intensified DM screening and preventive measures in the community and among ACS patients.

Registration: This systematic review and meta-analysis was registered with PROSPERO (CRD42024501412).

Introduction: Cardiovascular disease remains the leading cause of global mortality and a significant contributor to disability. The incidence of gastrointestinal bleeding (GIB) varies across cardiac conditions, with notable risks observed in patients undergoing complex antiplatelet or anticoagulant therapy, acute coronary syndrome, hypertrophic cardiomyopathy, percutaneous coronary interventions, mechanical cardiac support, acute decompensated heart failure, and post-cardiac surgery.

Areas covered: A comprehensive search of the PubMed/Medline database was conducted to retrieve articles related to GIB and cardiovascular disease from 2014 to 2024. The authors then synthesized a narrative review that endorses an interdisciplinary approach to this challenging paradigm, drawing from cardiology and gastroenterology perspectives to provide a comprehensive overview of the current understanding of the risk of GIB in cardiac patients.

Expert opinion: In acute coronary syndrome, upper GIB significantly increases mortality risk, with early endoscopic intervention proving beneficial. Post-coronary revascularization presents a low GIB incidence but a high mortality rate when it occurs. Decompensated heart failure patients frequently experience GIB due to concomitant conditions. Cardiogenic shock and mechanical cardiac support also show notable GIB risks, with mechanical support patients facing higher mortality. Following transcatheter aortic valve implantation, GIB incidence is low, but hospitalization rates are significant.

Introduction: Atrial septal defect is the most common congenital heart disease in adults. The secundum defect is the most common anatomical variant. Atrial septal defect usually causes subtle or no symptoms in pediatrics. However, as patients age, the left-to-right shunt increases and more symptoms appear. Atrial septal defect closure is indicated when there is a clinically significant left-to-right shunt, either by echocardiographic data in terms of right-sided dilation, hemodynamic parameters with Qp:Qs ratio over 1.5:1, or the appearance of clinical symptoms.

Areas covered: This article reviews secundum atrial septal defects (ASD) with emphasis on device closure outcome in comparison to surgical approaches. The article covers ASD anatomy, pathophysiology, clinical presentation, natural history, imaging evaluation, indications for closure, suitability for transcatheter closure, and outcome of both device closure and surgical closure in the adult patients.

Expert opinion: Atrial septal defect closure can be performed either via a transcatheter approach or a surgical approach. The transcatheter approach is preferred worldwide to close secundum ASDs, provided they meet certain anatomical criteria (size and rim sufficiency). The transcatheter approach is more cost-effective, requires a shorter hospital stay, and has similar outcomes with a lower incidence of complications.

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.