Expert Review of Cardiovascular Therapy最新文献

Introduction: Atrial fibrillation (AF) is the most common arrhythmia in elderly patients. Antiarrhythmic drugs (AADs) are often required for rate/rhythm control and to improve AF-related symptoms. There is limited evidence on the effectiveness and safety of AADs in elderly AF patients.

Areas covered: This narrative review focuses on the use of AADs in elderly AF patients, summarizing the different physiology, pharmacokinetics, and pharmacodynamics in the older age. Furthermore, the evidence from clinical studies on AADs pointing up data on safety and effectiveness in the elderly was summarized.

Expert opinion: Although AADs represent a cornerstone for symptom relief in patients with AF, these drugs did not show a clinical net benefit compared to rate control, with a potentially increased risk of complications and hospitalizations. Considering also the different pharmacokinetics and the concomitant comorbidities and treatments that characterize older patients, the administration of these drugs should be reserved for selected patients with a high burden of AF-related symptoms.

Introduction: Catheter ablation has traditionally been performed using thermal modalities, which, despite being effective, remain associated with potentially severe complications such as pulmonary vein stenosis and atrioesophageal fistula. Pulsed field ablation (PFA), a non-thermal technique based on irreversible electroporation, has emerged as a promising alternative, with the potential to maintain the efficacy of thermal energies while minimizing collateral damage to surrounding structures.

Areas covered: This review discusses the safety and efficacy of PFA for atrial fibrillation (AF) ablation. We analyzed the latest clinical evidence on PFA lesion durability and effectiveness, integrating insights from our clinical experience and workflow. The safety profile of PFA is critically examined, highlighting its advantages in reducing complications while addressing emerging PFA-specific adverse effects such as hemolysis and coronary vasospasm.

Expert opinion: PFA promises to overcome the safety limitations encountered during AF ablation with thermal modalities. This may permit earlier referrals, treatment of more complex patients, and adoption of a more individualized, extensive ablation approach. Despite this, PFA still requires technological and workflow optimization due to challenges in lesion durability, real-time lesion assessment, and emerging concerns about energy-specific side effects. These issues require operator awareness and are expected to be addressed with second-generation PFA systems.

Introduction: Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of global morbidity and mortality, with elevated low-density lipoprotein cholesterol (LDL-C) established as a primary causal factor. Despite foundational therapies, many high-risk patients fail to achieve optimal LDL-C targets.

Areas covered: This review examines established LDL-C lowering agents (statins and ezetimibe), detailing their mechanisms and limitations, including statin intolerance and residual cardiovascular risk. We provide a comprehensive analysis of novel therapeutic options, including proprotein convertase subtilisin/kexin type 9 (PCSK9) modulators (monoclonal antibodies, small interfering RNA, and emerging oral agents), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like protein 3 (ANGPTL3) inhibitors, and pioneering gene-editing technologies. We discuss mechanisms of action, pivotal efficacy data (LDL-C reduction and plaque modification), safety profiles, and key findings from major cardiovascular outcome trials.

Expert opinion: Novel LDL-C lowering therapies represent a paradigm shift, offering unprecedented efficacy in reducing LDL-C and mitigating ASCVD risk. However, significant challenges remain, including cost-effectiveness concerns, the need for long-term safety data, profound global disparities in access, and persistent clinical inertia that impedes real-world implementation even in well-resourced healthcare systems. Future research should prioritize personalized lipid management, combination strategies, and development of durable, cost-effective solutions to reduce the residual ASCVD burden.

Introduction: Stress-Induced Hyperglycemia (SIH) represents a transient increase in blood glucose levels triggered by acute physiological stress, frequently observed in patients with Acute Coronary Syndrome (ACS). It is linked to adverse outcomes, including higher mortality and an increased risk of Major Adverse Cardiac and Cerebrovascular Events (MACCE). Despite this, SIH remains inadequately defined and underappreciated in clinical risk assessment and patient management.

Areas covered: This narrative review delves into the mechanistic underpinnings of SIH in ACS (neuroendocrine, metabolic and inflammatory pathways). Evidence on current SIH markers [including the Stress-Hyperglycemia Ratio (SHR), Admission Blood Glucose, Glycemic Gap, and Glycemic Variability] was identified through searches of PubMed/MEDLINE for English-language human studies published between January 2017 and May 2025 (certain seminal earlier studies were also retained), with a focus on key subpopulations (diabetes, non-diabetes, and MINOCA). Particular emphasis is placed on SHR as a ratio of acute to chronic hyperglycemia with expanding prognostic applications.

Expert opinion: SIH is a multifaceted phenomenon, superiorly reflected by dynamic indices like SHR rather than traditional measures. Further research into the mechanisms linking SIH with adverse outcomes could lay the groundwork for interventional trials, ultimately reshaping ACS patient risk-stratification and management.

Introduction: High-density lipoprotein cholesterol (HDL-C) has long been regarded as 'good cholesterol,' but clinical trials and epidemiological studies have demonstrated that simply raising HDL-C levels does not reduce cardiovascular events. Attention has therefore shifted from HDL-C quantity to HDL functionality.

Areas covered: This review summarizes evidence from PubMed and Web of Science (2011-2024) on cholesterol efflux capacity (CEC), the most widely studied HDL functionality. CEC reflects the ability of HDL to remove cholesterol from macrophages, representing the first step of reverse cholesterol transport. Cohort and case-control studies consistently indicate that CEC provides incremental predictive value for atherosclerotic cardiovascular disease (ASCVD) beyond traditional lipid parameters. However, results vary across familial hypercholesterolemia cohorts, highlighting the influence of assay methods, treatment exposure, and HDL remodeling. The review also addresses lifestyle and genetic factors (e.g. alcohol consumption, ALDH2 polymorphisms), oxidative stress, and methodological challenges that complicate CEC measurement and standardization.

Expert opinion: While CEC is a promising surrogate marker, it remains a phenomenon rather than a therapeutic target, and there is no conclusive evidence that increasing CEC reduces ASCVD events. Future research should focus on disease-specific molecules, such as FABP5 and ORM1, that impair HDL function. Identifying these pathways may yield novel biomarkers and therapeutic targets, offering a more precise approach to residual cardiovascular risk beyond HDL-C levels.

Introduction: Obstructive sleep apnea (OSA) - characterized by recurrent upper airway obstruction during sleep - remains underdiagnosed and undertreated. Affecting nearly one billion adults globally, OSA is especially prevalent among patients with cardiovascular comorbidities. Diagnosis may be delayed due to atypical symptoms, particularly in women, and healthcare barriers including fragmented care, limited provider training, and restricted access to specialized diagnostics. Untreated OSA contributes to an increased prevalence of resistant hypertension, recurrent arrhythmias (atrial fibrillation), stroke, and heart failure.

Areas covered: This review focuses on the intricate relationship between OSA and cardiovascular health, highlighting key pathophysiological mechanisms such as intermittent hypoxia, autonomic dysregulation, and systemic inflammation that drive structural and functional cardiac impairments. Further, the review highlights the importance of improved screening tools for early detection. The special report is based on systemic search of PubMed.

Expert opinion: Early screening and detection are crucial, given the strong association between untreated OSA and adverse health outcomes. Expert consensus recommends routine OSA screening in high-risk cardiovascular populations and emphasizes comprehensive early interventions; CPAP, lifestyle modification, and metabolic risk management. Integrating OSA assessment into cardiology practice and expanding advanced diagnostic tools may improve detection, reduce morbidity and mortality, and lessen the economic burden on healthcare systems.