Expert Review of Cardiovascular Therapy最新文献

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.

Background: The impact of ventricular arrhythmia in patients with sarcoidosis has not been well studied. Our objective was to determine the association of ventricular arrhythmia with clinically relevant outcomes in sarcoidosis patients.

Research design and methods: We included adult patients with sarcoidosis from a nationally representative database, the Nationwide Readmission Database, admitted between 1 January 2011 and 31 December 2018. We assessed whether ventricular tachycardia and fibrillation (VTVF) increases mortality risk, the need for automatic implantable cardioverter-defibrillator (AICD), or permanent pacemaker during hospitalization in sarcoidosis patients. Logistic and Cox regressions were performed.

Results: Out of 570,807 sarcoidosis patients 15,459 (2.71%) developed VTVF. In a multivariable-adjusted logistic regression, ventricular arrhythmias were significantly associated with mortality (aOR 2.98; 95% CI 2.66-3.34, p < 0.001), AICD (aOR 17.69; 95% CI 14.8-21.2, p < 0.001) or permanent pacemaker placement (aOR 3.41; 95% CI 2.87-4.06, p < 0.001). In a multivariable-adjusted Cox regression, ventricular arrhythmias were not significantly associated with 30-day all cause readmission (aHR 0.94; 95% CI 0.84-1.05, p = 0.251).

Conclusions: VTVF in sarcoidosis patients was associated with increased mortality risk, AICD, and/or pacemaker placement but not readmissions. Aggressive monitoring of these patients to identify VTVF may improve outcomes.

Introduction: Compelling evidence shows that unfavorably altered (prothrombotic) fibrin clot properties such as more compact and poorly lysable fibrin networks contribute to thrombo-embolic events in cardiovascular disease.

Areas covered: Following a literature search in Medline, Embase, TRIP, and the Cochrane Database of Systematic Reviews, this review summarizes the current evidence on therapeutic strategies, that are currently used or tested in cardiovascular disease including coronary artery disease, peripheral artery disease, atrial fibrillation, heart failure, and their thrombotic manifestations, in particular myocardial infarction and ischemic stroke, in the context of altered plasma fibrin clot characteristics.

Expert opinion: Anticoagulants (heparins, vitamin K antagonists, and direct oral anticoagulants), aspirin, and statins favorably modify fibrin clot characteristics, which might contribute to their efficacy in various clinical settings. Encouraging results suggest that novel treatments not yet approved in cardiovascular disease, including factor XI inhibitors and lipoprotein (a) reducing agents, might be beneficial, in part through improved fibrin clot phenotype, which gives hope for reducing the residual risk of thromboembolism in cardiovascular disease, which persists despite the recommended management.

Introduction: Prosthetic valve thrombosis (PVT) is a life-threatening complication of mechanical heart valve replacement. Management has evolved over decades, from urgent surgical intervention to low dose ultraslow thrombolytic therapy.

Areas covered: This review provides a historical to present-day analysis of thrombolytic strategies in PVT, comparing accelerated dosing with slower infusion protocols. We synthesize clinical evidence and elucidate mechanistic insights into how infusion rate and dosage influence clot resolution and safety. We searched the PubMed database from inception to May 2025 using combinations of appropriate keywords.

Expert opinion: The development of lower dose, slower infusion protocols, notably using Alteplase without bolus, has dramatically improved outcomes. Clinical trials show comparable or superior thrombosis resolution rates with ultraslow infusion versus rapid infusion or surgery, but with markedly reduced complication rates. Mechanistically, ultraslow infusion may help to localize fibrinolysis to the thrombus site, minimizing systemic fibrinogen depletion and hemorrhagic risk. Ultraslow (25 hours) low-dose (25 mg) thrombolysis with Alteplase is a safe and effective first-line therapy for PVT patients, achieving high success in clot resolution while limiting bleeding and embolic complications. Ongoing evidence and mechanistic rationale suggest that, in the absence of contraindications, this strategy can often be preferable to traditional rapid high-dose thrombolysis or emergency surgery.