Expert Review of Cardiovascular Therapy最新文献

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.

Introduction: The optimal management of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. This systematic review assessed routine invasive versus conservative strategies in this population.

Methods: PubMed, Embase, and Scopus were searched through September 2024 for randomized controlled trials comparing both strategies. The primary outcome was major adverse cardiovascular events (MACE); secondary outcomes included all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, revascularization, stroke, and bleeding. Evidence certainty was evaluated using GRADE, and meta-analyses applied random-effects models.

Results: Seven RCTs (n = 2,997; mean age 81-86 years; 49% female) were included. Invasive strategy reduced MACE risk (HR 0.77, 95% CI 0.65-0.92), with consistent point estimate direction across trials. Myocardial infarction (HR 0.70, 95% CI 0.59-0.84) and revascularization (HR 0.45, 95% CI 0.23-0.90) were also significantly reduced. No significant differences were observed for all-cause mortality (HR1.04, 95% CI 0.90-1.19), cardiovascular mortality (HR 1.10, 95% CI 0.86-1.41), stroke (HR 0.78, 95% CI 0.53-1.16), or bleeding (RR1.23, 95% CI 0.90-1.69). Evidence certainty was moderate for most outcomes.

Conclusions: In elderly NSTE-ACS patients, routine invasive strategy reduces cardiovascular events without significantly increasing bleeding, supporting individualized treatment decisions.

Registration: The protocol for this study was registered in the PROSPERO repository (CRD42024600769).

Background: We assessed the sex and racial/ethnic disparities on in-hospital outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

Research design and methods: This retrospective study analyzed TAVR procedures performed during 2016-2019. Data from the National Inpatient Sample database identified 155,610 patients who underwent TAVR. Outcomes included in-hospital mortality, stroke, major bleeding, and other complications, assessed separately by sex and race/ethnicity (White, Black, and Hispanic). Logistic regression was used to estimate odds ratio (OR) with its 95% confidence interval (CI).

Results: Women had higher odds of in-hospital mortality (OR 1.33, 95% CI 1.07-1.64), bleeding, and vascular complications, but lower odds of pacemaker implantation and renal replacement therapy compared with men. Hispanic patients had increased mortality (OR 1.86, 95% CI 1.26-2.75) and black patients had increased odds of stroke (OR 2.06, 95% CI 1.24-3.44). Subgroup analysis showed that Hispanic women had the highest mortality odds (OR 2.42, 95% CI 1.46-4.01).

Conclusions: There are significant sex and racial/ethnic disparities in TAVR outcomes, particularly among minority women. Women had a higher odds of mortality, major bleeding, and vascular complications compared to men. Racial disparities were also seen, with Hispanic patients having an increased odds of mortality and black patients having an increased odds of stroke.

Background: Patients with surgically repaired tetralogy of Fallot (rTOF) often develop chronic pulmonary regurgitation (PR), necessitating pulmonary valve replacement (PVR). While cardiac MRI is crucial for PVR timing, its availability is limited. This study evaluates electrocardiographic (ECG) findings - specifically the R-wave amplitude in lead V1 (V1R) and the sum of the R-wave amplitude in lead V1 and the deepest S-wave amplitude in lead V5 or V6 (V1R + V5S or V6S) - as predictors of cardiac MRI findings.

Patients and methods: We retrospectively analyzed 35 rTOF patients (mean age 34 ± 9 years; 60% male) who underwent cardiac MRI from 2019 to 2022, assessing correlations between ECG parameters (V1R, V1R + V5S or V6S, and QRS duration) and MRI findings (RVESVI and RVEDVI).

Results: V1R showed significant correlation with RVESVI (r = 0.486, p = 0.003) and was notably higher in patients with RVESVI ≥ 80 mL/m². A V1R cutoff of 20 mm identified RVESVI ≥ 80 mL/m² with 67% sensitivity and 77% specificity.

Conclusions: V1R on ECG may help predict the need for cardiac MRI, aiding in the timely PVR planning for rTOF patients.

Introduction: Atherosclerotic cardiovascular disease (ASCVD) and cancer are the leading causes of death globally. While traditionally viewed as distinct, growing evidence reveals significant overlap in their risk factors and pathophysiology, suggesting a shared biological basis that warrants closer clinical and research attention.

Areas covered: This review explores modifiable lifestyle and pathological risk factors that contribute to both ASCVD and cancer, including tobacco use, poor diet, physical inactivity, environmental toxins, hypertension, hyperlipidemia, obesity, insulin resistance, and sex hormone dysregulation. Mechanistically, these factors converge on common pathways such as chronic inflammation, oxidative stress, and hormonal imbalance, facilitating both atherogenesis and tumorigenesis. The paper also highlights how these shared mechanisms offer opportunities for unified prevention and treatment strategies.

Expert opinion: Understanding these connections is critical for dual-risk stratification, prevention, and management strategies. Emerging approaches such as personalized medicine, leveraging genomic and biomarker data, and multidisciplinary care models that integrate cardiology and oncology expertise offer opportunities to optimize outcomes. Advances in multi-omics and targeted therapies promise to further elucidate the shared mechanisms, paving the way for innovative interventions. This comprehensive understanding highlights the need for integrated care to address the dual burden of ASCVD and cancer and improve patient outcomes.

Introduction: Beta-blocker therapy reduced mortality and cardiovascular events following acute coronary syndromes (ACS) in the pre-reperfusion era. In the contemporary era of early mechanical reperfusion and modern secondary prevention, the benefit of beta-blockers after ACS without reduced left ventricular ejection fraction (LVEF) has been questioned. This review was based on PubMed database searches from inception to January 2025.

Areas covered: The recent REDUCE-AMI and ABYSS trials were the first adequately powered contemporary randomized trials evaluating beta-blockers after ACS without reduced LVEF. Contemporary observational evidence is also discussed. Implications for different LVEF categories (41-49% versus ≥ 50%), ACS subtypes, beta-blocker therapy duration, optimal dose, and interaction with other secondary prevention therapies are addressed.

Expert opinion: We estimate that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LVEF ≥ 50%. Beta-blocker prescription should be individualized with shared decision-making, balancing the risk of cardiovascular event against potential benefits of deprescription. Factors favoring beta-blocker discontinuation include adverse effects, polypharmacy, >1-3 years of stability post-ACS, and specific comorbidities (e.g. heart failure with preserved LVEF). Factors favoring beta-blocker prescription/continuation (besides established indications such as LVEF ≤ 40%, arrhythmias, angina, and refractory hypertension) include good tolerance, LVEF 41-49%, and non-adherence to other secondary prevention therapies.

Introduction: Bleeding risk stratification tools are essential for optimizing ischemic protection while minimizing bleeding complications in patients with myocardial infarction, particularly for those undergoing percutaneous coronary intervention (PCI) or dual antiplatelet therapy.

Areas covered: A structured search of PubMed, Scopus, and Web of Science was conducted for studies published from January 2005 to December 2024. This review evaluates traditional and novel bleeding risk models in MI management. Established tools like CRUSADE, ACUITY-HORIZONS, ACTION, and PRECISE-DAPT aid in predicting in-hospital and early post-discharge bleeding but have limitations in long-term risk assessment and adapting to modern PCI techniques. Emerging models - SWEDEHEART, ARC-HBR, CREDO-KYOTO, and BleeMACS - offer enhanced risk stratification by incorporating broader clinical variables and long-term bleeding predictors, improving their applicability to contemporary MI management.

Expert opinion: Despite advancements, current models exhibit moderate predictive accuracy (c-statistics 0.70-0.80) and rely on static baseline factors, limiting real-time applicability. They also fail to integrate ischemic risk assessment, creating challenges in balancing thrombotic and bleeding risks. Future research should focus on AI-driven dynamic risk models, broader validation across diverse populations, and integrating bleeding and ischemic risk stratification into a unified framework. Embedding these tools into electronic health records will enhance clinical decision-making and improve patient outcomes.