Expert Review of Cardiovascular Therapy最新文献

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.

Introduction: Sleep disorders such as insomnia, restless legs syndrome (RLS) and sleep disordered breathing such as obstructive sleep apnea (OSA) and central sleep apnea (CSA) are increasingly recognized as independent risk factors for acute cardiovascular events.

Areas covered: This review highlights the key mechanisms linking sleep disorders to acute cardiovascular events, including autonomic dysregulation, intermittent hypoxia, systemic inflammation, and endothelial dysfunction. These contribute to arrhythmias, acute coronary syndromes, heart failure exacerbations, and strokes. OSA stands out due to its strong association with cardiovascular risk through repetitive hypoxia and sympathetic activation. Treatment options like CPAP, ASV, and phrenic nerve stimulation show benefits, though long-term cardiovascular outcomes are still being studied. Despite growing evidence, sleep disorders remain underdiagnosed in cardiac patients, underscoring the need for improved screening and management.

Expert opinion: Integrating sleep evaluations into routine cardiovascular care could help reduce acute events and improve outcomes. Increased screening, better awareness among clinicians, and accessible treatment pathways are essential. Further longitudinal research is needed to confirm causal links and assess the sustained cardiovascular benefits of managing sleep disorders, especially in high-risk groups.

Introduction: While effective in stable angina and chronic heart failure, ivabradine's role in acute myocardial infarction (AMI) is less clear. We assessed the effects of ivabradine versus placebo or standard care on all-cause mortality, major adverse cardiovascular events (MACE) and heart failure in AMI patients.

Methods: We systematically searched six databases through April 2025 for randomized controlled trials (RCTs) comparing ivabradine to control therapy in AMI. Primary outcomes included all-cause mortality, MACE, and heart failure incidence. Random-effects meta-analysis was conducted, with sensitivity analyses using the IVhet model. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and publication bias was explored via funnel plots.

Results: Fifteen RCTs involving 2220 patients (ivabradine: 1126; control: 1094) were included. Ivabradine did not significantly reduce all-cause mortality (OR 0.66, 95% CI: 0.38-1.16), though the trend favored treatment. It significantly reduced MACE (OR 0.49, 95% CI: 0.30-0.82; I² = 12%) and heart failure events (OR 0.60, 95% CI: 0.40-0.90). Subgroup analysis indicated greater benefit when combined with beta-blockers. Sensitivity analyses confirmed these findings.

Conclusion: Ivabradine may reduce cardiovascular complications post-AMI, particularly MACE and heart failure, and may serve as a useful adjunct to standard therapy. Further large-scale trials are warranted.

Registration: This systematic review and meta-analysis was registered on PROSPERO (CRD420251054716).

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 3D mapping system was for many years considered to be the 'gold standard,' the strategy of PV isolation has 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 nonthermal, 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).

Introduction: New-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia after coronary artery bypass grafting (CABG). Traditionally regarded as a benign and self-limiting event, more recent evidence highlights its association with prolonged hospitalization, increased healthcare utilization, and a heightened risk of stroke, recurrent atrial fibrillation, and heart failure. Understanding its significance is essential for patient care and long-term outcomes. PubMed was searched using terms related to POAF and CABG, supplemented by the review of relevant guidelines and key publications.

Areas covered: This narrative review summarizes recent evidence on the epidemiology, pathophysiology, prophylaxis, and treatment of POAF after CABG. Evidence for pharmacological prophylaxis (e.g. amiodarone, beta-blockers) and surgical strategies (e.g. posterior pericardiotomy, atrial pacing) is summarized, along with current approaches for acute management and stroke prevention. The literature reveals significant heterogeneity in treatment strategies, particularly regarding anticoagulation, with emerging trials expected to refine clinical practice.

Expert opinion: Current evidence suggests that POAF functions more as an indicator of underlying patient vulnerability than as a direct driver of adverse outcomes. Clinically, management must balance arrhythmia control, stroke and bleeding risk, and individualized anticoagulation decisions. Research efforts should prioritize robust risk stratification tools and randomized evidence to guide tailored therapy.