Expert Review of Cardiovascular Therapy最新文献

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.

Introduction: Coronary atherosclerosis, marked by lipid deposition and inflammation, drives cardiovascular morbidity. Traditional treatments focus on lipid reduction, yet newer therapies target plaque composition, aiming to enhance stability and prevent coronary events.

Areas covered: A comprehensive literature search was conducted across PubMed, Embase, and Scopus till January 2025 to identify studies on coronary plaque modification. This review highlights current and emerging therapies for coronary plaque modification. Key pharmacologic agents include Proprotein convertase subtilisin/kexin type 9 inhibitors for lipid management, colchicine for inflammation control, and Glucagon-like peptide-1 receptor agonists, and Sodium-glucose cotransporter-2 inhibitors for metabolic benefits. Clinical trials indicate these agents' roles in reducing plaque volume and vulnerability. Advances in imaging and biomarkers, such as lipoprotein(a) and inflammatory markers, enable refined monitoring of plaque changes over time.

Expert opinion: Future management of atherosclerosis may involve personalized strategies, integrating AI-driven predictive tools and biomarkers to assess individual plaque characteristics and optimize therapy. Continued exploration of targeted anti-inflammatory therapies and novel biomarkers like Lp(a) could enhance outcomes, offering a more precise approach to reducing cardiovascular risk and stabilizing high-risk plaques.

Background: Late adverse myocardial remodeling after ST elevation myocardial infarction (STEMI) is strongly associated with cardiac death. Global Longitudinal strain (GLS) and circumferential diastolic strain rate (CDSR) derived cardiovascular magnetic resonance imaging (CMRI) is a powerful predictor of late myocardial remodeling. However, the Impella's effects on CMRI after STEMI are not fully understood.

Research design and methods: We retrospectively compared the CMRI in the acute (18 [14-22] vs. 14 [6-22] days, p = 0.43) and chronic phases (118 [102-242] vs. 117 [101-202] days, p = 1.0) after anterior STEMI.

Results: Five patients received Impella before percutaneous coronary intervention (PCI), and seven underwent intra-aortic balloon pumping (IABP). There were no significant differences in the peak creatine kinase levels (2595 [2069 -12,932] vs. 4372 [2941-5601] IU/L, p = 0.76) and LVEF upon admission (51 ± 11 vs. 50 ± 9%, p = 1.0). The Impella group had significantly better acute CMRI-derived LVEF (49 ± 10 vs. 35 ± 7%, p = 0.02) and CDSR (0.9 ± 0.2 vs. 0.5 ± 0.3 s^{- 1}, p = 0.018). In the chronic phase, the CMRI-derived LVEF and GLS were significantly higher in the Impella group (54 ± 9 vs. 39 ± 5%, p = 0.01; -9.9 ± 1.3 vs. -6.5 ± 2.2%, p = 0.01).

Conclusions: The Impella implantation led to better LVEF and CDSR in the acute phase than IABP and better maintenance of both the LVEF and GLS through the chronic phase.

Objective: To analyze the cost-effectiveness of apixaban in the prevention of stroke in adult patients with non-valvular atrial fibrillation (NVAF), compared to other direct-acting oral anticoagulants (dabigatran, rivaroxaban, edoxaban) and the vitamin K antagonist acenocoumarol, based on data on effectiveness in clinical practice in Spain obtained in the FANTASIIA study.

Research design and methods: A probabilistic Markov economic model (second-order Monte Carlo simulation) was performed to analyze the costs and utilities (quality-adjusted life years, QALYs) associated with the compared treatments, according to the different probabilities of stroke, major bleeding and death observed in FANTASIIA.

Results: The cost per QALY gained in the patient treated with apixaban versus comparators ranged from €2,919 to €7,462. The probability of apixaban being cost-effective ranges from 91.1% (vs dabigatran 150 mg), 97.8% (vs dabigatran 110 mg), and 100% (vs. rivaroxaban, edoxaban, and acenocoumarol).

Conclusions: Based on the results of the FANTASIIA study, apixaban is a cost-effective treatment (below a willingness to pay of €25,000 per QALY gained) compared to dabigatran, rivaroxaban, edoxaban, and acenocoumarol in treating patients with NVAF.