Expert Review of Cardiovascular Therapy最新文献

Introduction: Hypercholesterolemia and other dyslipidemias are common risk factors for cardiovascular diseases (CVD) and development of atherosclerosis. International guidelines recommend LDL-C, non-HDL-C, and apoB under some conditions for clinical use in evaluating risk of CVD. In part 2 of this review, newer risk factor data for apoA-1, and the apoB/apoA-1 ratio is presented for atherosclerotic plaques, HDL-C versus apoA-1, inflammatory diseases, cancer, and metastases. Compared to conventional lipids, these apolipoproteins add strong clinical risk information for these CVD disorders and for a range of other diseases.

Areas covered: Prospective studies, reviews, meta-analyses, case control, nested-case, and therapeutic studies are analyzed. Searches were conducted with Google and in PubMed, and CVD journals for peer-reviewed publications. In part 1 of this review, newer risk factor data for apoA-1 and the apoB/apoA-1 ratio are presented for cardiovascular, cerebrovascular, diabetes, and other CVD manifestations of atherosclerosis.

Expert opinion: Strong associations between apoB, apoA-1 and especially the apoB/apoA-1 ratio and development of atherosclerosis-related risk of multiple CVD diseases have been documented world-wide. These data indicate that the balance, i.e. the ratio between the atherogenic apoB and the protective apoA-1, significantly improves risk evaluation and prediction of CVD, hence calling for an update of guidelines.

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: With the substantial increase in direct oral anticoagulant (DOAC) usage, prescribers face complex decisions regarding the appropriate agent selection. This scoping review aimed to identify factors influencing oral anticoagulant choice in clinical practice over time.

Methods: Four databases (Medline, Embase, Scopus, Web of Science) were searched for quantitative observational studies on patients prescribed DOACs for any indication, focusing on factors affecting OAC choice. Studies published from January 2010 to March 2023 were included.

Results: Of the 4659 identified studies, 60 met selection criteria. Most (96%) examined the choice between DOACs and vitamin K antagonists (VKA); while (15%) evaluated factors affecting choice among DOACs. Age and gender were included in 77% and 70% of studies, respectively. Renal impairment (58%), heart failure (48%), previous stroke (43%), and thromboembolic risk (43%) were also commonly assessed. Older age had a significant negative association with DOAC prescribing in (50%) of the studies; renal impairment reduced DOAC initiation, favoring warfarin in (94%).

Conclusions: Several significant key factors were identified as being associated with OAC choice, including demographic factors such as age, and clinical factors such as kidney function, prior stroke, and other comorbidities. Significant factors in the choice among DOACs were advanced age, and renal impairment.

Registration: This systematic review was registered as a PURE protocol (https://pureportal.strath.ac.uk/en/projects/factors-associated-with-the-prescribing-of-direct-acting-oral-ant).

Introduction: In-stent calcification is recognized as a significant contributor to unfavorable clinical outcomes. Understanding the various types and underlying mechanisms of in-stent calcification can help interventional operators to make decisions.

Areas covered: This review will describe the distinct types of in-stent calcification, which are categorized into in-stent smooth calcification and in-stent calcified nodule. The mechanisms and characteristics of in-stent smooth calcification and calcified nodule will be summarized. Given the differences between these two types, treatment approaches will be discussed. This review will focus on histopathology and intracoronary imaging. For the purpose of this review, evidence was gathered from electronic literature searches via PubMed, with a particular focus on primary evidence published in the last 5 years.

Expert opinion: Several treatment devices are available such as conventional balloon, modified balloon, atherectomy device, and intravascular lithotripsy. In-stent smooth calcification and calcified nodule might result in different clinical courses after repeated target lesion revascularization. Understanding the mechanisms with the various types of in-stent calcification may assist operators in selecting appropriate treatment strategies.

Introduction: Severe aortic regurgitation is a progressive condition that can lead to cardiogenic shock, a life-threatening emergency associated with high morbidity and mortality.

Areas covered: This article provides an updated review on how clinicians can diagnose, prevent, and manage aortic regurgitation presenting as cardiogenic shock, as well as discusses emerging technologies that have transformed the management of this condition.

Expert opinion: Clinicians can reduce the risk of aortic regurgitation manifesting as cardiogenic shock through a combination of early diagnosis, vigilant monitoring, optimized medical management, and timely intervention. Advanced imaging modalities, such as echocardiography and computed cardiac tomography, are essential for assessing valve function and identifying high-risk patients before decompensation occurs. For patients at risk, early referral to a multidisciplinary Heart Team is crucial for determining the optimal intervention, whether surgical or transcatheter. Future advancements in transcatheter therapies, including dedicated devices for aortic valve replacement, hold promise for expanding treatment options for high-risk patients.

Background: Lipoprotein (Lp)(a) is a genetically inherited lipoprotein implicated in the progression of cardiovascular diseases and atherosclerosis. This study aims to examine whether elevated Lp(a) levels contribute to the development of subclinical atherosclerosis, compared to individuals with normal Lp(a) levels, using parameters such as coronary flow reserve (CFR).

Research design and methods: The study population included 25 patients with elevated Lp(a) levels and 30 subjects with normal Lp(a) levels, recruited prospectively. Conventional echocardiographic measurements were performed according to established guidelines. Main outcome measures included the comparison of CFR values between the groups.

Results: The CFR was found to be significantly decreased in the group with elevated Lp(a) levels compared to the control group (2.0 ± 0.5 vs. 2.5 ± 0.6, p < 0.001). Additionally, a negative and statistically significant correlation was observed between Lp(a) levels and CFR, indicating that higher Lp(a) levels are associated with lower CFR values (r: -0.657, p < 0.001).

Conclusions: Our study demonstrates that elevated Lp(a) levels are significantly associated with subclinical atherosclerosis and impaired coronary vasomotor function. These findings suggest that lowering Lp(a) levels could effectively reduce the risk of atherosclerotic disease by targeting its role in atherosclerosis pathogenesis.

Introduction: Twenty to twenty-five percent of patients with hypertrophic cardiomyopathy (HCM) have concurrent atrial fibrillation (AF). It is unclear whether direct oral anticoagulants (DOAC) are a safe and effective alternative to vitamin K antagonists (VKA) in concurrent HCM and AF.

Methods: We performed a systematic review and meta-analysis of original reports comparing DOACs versus VKAs in concurrent HCM and AF. The protocol was published in PROSPERO -CRD42024575553. MEDLINE, Embase, and Cochrane Central were searched from inception to October 2024.

Results: From 1119 records retrieved by the search, we identified 8 different observational studies (n = 14,243). Compared to VKAs, DOACs were associated with a lower rate of thromboembolic events 318/8322 vs. 559/5921 (OR 0.44, 95% CI 0.23-0.83; p = 0.0118; I² = 84%; NNT = 18), and less major bleeds 289/8322 vs. 327/5921 (OR 0.54, 95% CI 0.36-0.80; p = 0.0021; I²  = 76%; NNT = 49). Apixaban and dabigatran were associated with lower rate of thromboembolic events, major bleeding, all-cause death, and intracranial hemorrhage, and Rivaroxaban associated with less all-cause deaths and intracranial hemorrhages, compared to VKAs (all p < 0.05).

Conclusions: DOACs demonstrated good efficacy and a favorable safety profile in patients with HCM and AF compared to VKAs.Registration: The protocol for this meta-analysis was published in PROSPERO (CRD420245755530).

Background: Exercise intolerance is a significant symptom of heart failure with reduced ejection fraction (HFrEF) and is associated with poor outcomes. While sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiovascular benefits, their impact on functional capacity remains debated. This study aimed to assess the effects of SGLT2i on exercise capacity and quality of life in patients with ischemic and non-ischemic HFrEF.

Research design and methods: Patients with a recent diagnosis of HFrEF and stable clinical status, referred to a heart failure unit, were prospectively enrolled. Exercise capacity was evaluated using the six-minute walk test (6MWT), and quality of life with the Minnesota Living with Heart Failure Questionnaire (MLHFQ) both at baseline and after 6 months. Patients were stratified by etiology and analyzed according to SGLT2i use.

Results: A total of 462 patients were included (275 non-ischemic, 187 ischemic); 86 (18.6%) received SGLT2i (45 non-ischemic, 41 ischemic). At 6 months, SGLT2i treatment significantly improved 6MWT in non-ischemic patients (+31.9 m, p = 0.005), but not in ischemic patients (+9.0 m, p = 0.411; P-interaction = 0.034). MLHFQ scores improved similarly in both groups, with no significant differences related to SGLT2i use.

Conclusions: SGLT2i improved exercise capacity only in non-ischemic HFrEF patients, suggesting a differential response based on etiology.