Giornale italiano di cardiologia最新文献

Artificial intelligence (AI) is rapidly transforming the field of aortic imaging, enhancing diagnostic accuracy, risk stratification, and treatment planning. This review provides a comprehensive overview of AI applications in measuring aortic dimensions, detecting and characterizing aneurysms, dissections, and atherosclerotic disease, as well as predicting clinical outcomes. Automated measurement and segmentation tools, powered by deep learning algorithms, offer reproducible and time-efficient assessments, reducing inter- and intraobserver variability. In atherosclerotic disease, AI enables objective quantification of calcification burden and advanced radiomic analysis for prognostic stratification. In acute aortic syndromes, AI-based models improve diagnostic sensitivity, assist in differentiating true from false lumens, and predict complications or surgical outcomes. The integration of emerging technologies such as radiomics, dual-energy computed tomography, photon-counting computed tomography, and computational fluid dynamics further expands predictive capabilities, potentially leading to personalized "digital twin" models for therapeutic decision-making. Despite promising results, challenges remain in software availability, cost, data integration, and defining the radiologist's evolving role. AI holds the potential to become an indispensable tool in aortic disease management, bridging imaging, clinical, and computational domains to improve patient outcomes.

Background: Although international guidelines recommend increasingly lower thresholds for low-density lipoprotein cholesterol (LDL-C), everyday clinical experience shows that many patients fail to reach these targets, exposing themselves to a significant residual cardiovascular risk. Clear Pathway - a patient-centered approach to dyslipidemia - was developed to bridge this gap by promoting an integrated use of oral lipid-lowering therapies.

Methods: In the Clear Pathway project, a panel of hospital cardiologists applied a mini-Delphi methodology in two rounds to evaluate 20 statements related to lipid-lowering therapy, divided into three thematic areas: oral combination and fixed-dose strategies; use of LDL-C target distance as a guide to treatment decisions; and personalization based on patient's clinical profile. Each statement was rated on a 1-5 Likert scale and approved if the average score was ≥4.0. Statements not approved in the first round were reformulated and resubmitted.

Results: In the first round, 17 out of 20 statements met the consensus threshold and were approved without any modification. The three statements not approved (early intensification in post-acute coronary syndrome patients with LDL-C <140 mg/dl, use of bempedoic acid in patients undergoing elective angioplasty, and in those one with stroke) were reformulated and resubmitted during a second round, where they also reached the approval threshold.

Conclusions: The Clear Pathway recommendations outline a model for dyslipidemia management based on integrated oral therapies, with a key role for bempedoic acid. Adopting these guidelines is expected to improve adherence, optimize achievement of LDL-C targets, and reduce the incidence of cardiovascular events in routine clinical practice.

Light chain (AL) amyloidosis is a rare systemic disease caused by monoclonal immunoglobulin light chains with abnormal folding that aggregate into fibrils, which deposit in extracellular tissues. This process leads to cytotoxicity and organ dysfunction. Cardiac involvement is the main prognostic determinant and requires a multidisciplinary management approach. In recent years, the treatment of AL amyloidosis has significantly evolved with the introduction of innovative agents such as proteasome inhibitors, immunomodulators, and monoclonal antibodies like daratumumab, which has shown a favorable impact on hematological outcomes and organ function. The daratumumab-CyBorD regimen is currently the standard first-line therapeutic option. The therapy is tailored based on the stage of cardiac and renal damage, aiming for a complete hematological and organ response. The management of cardiac involvement, including aortic stenosis, atrial fibrillation, thromboembolic risk, conduction disorders, arrhythmias, and heart failure, plays a crucial role in prognosis. An integrated multidisciplinary approach in specialized centers experienced in the disease is essential to optimize clinical outcomes.

Despite the widespread use of lipid-lowering therapies, a significant proportion of patients with atherosclerotic cardiovascular disease fail to achieve the recommended LDL-cholesterol targets, thus remaining at high residual risk. Inhibition of cholesteryl ester transfer protein (CETP) has long been considered a pharmacological strategy, but has historically been hindered by clinical failures. Obicetrapib, a next-generation CETP inhibitor, has recently shown promising results in terms of efficacy and safety. This review critically examines the physiology of CETP, the negative outcomes of earlier CETP inhibitors, and the emerging evidence on obicetrapib, highlighting the potential role of this molecule in the treatment of hypercholesterolemia and in the secondary prevention of atherosclerotic cardiovascular disease.

Angina in non-obstructive coronary artery disease (ANOCA) is a common clinical condition affecting 20-50% of patients undergoing coronary angiography for suspected angina. Despite recent 2024 European guidelines on chronic coronary syndrome emphasizing its significance and clinical implications, ANOCA remains often underdiagnosed and undertreated. The management of ANOCA differs from obstructive coronary artery disease and requires careful interpretation of diagnostic tests and tailored treatment based on accurate clinical assessment. ANOCA diagnosis may involve microvascular dysfunction or vasospasm (epicardial or microvascular), and treatment should be individualized. The impact on patients' quality of life is considerable, with symptom regression due to correct diagnosis. A timely diagnostic and therapeutic approach is crucial to improving patient's quality of life. This review aims to provide a practical guide in managing ANOCA patients, emphasizing the need for comprehensive coronary functional evaluation and optimal risk factor management.

Cardiac amyloidosis is considered a rare disease but is increasingly frequent in elderly patients. In these patients, heterogeneous and peculiar clinical manifestations require specific approaches and dedicated diagnostic-therapeutic pathways. Early diagnosis is important because mortality is high, and the disease is often latent and underdiagnosed. In particular, the light chain form represents a real emergency, due to the rapidly fatal course in the absence of treatment. Specific programs based on a multispecialist approach should be implemented to reduce delays in diagnosis. Thanks to these programs, in recent years patients are often diagnosed at an early stage with a reduction in mortality. In the elderly, health status does not only depend on the disease or age, but also on factors such as frailty, comorbidity, living conditions and psychological factors. In these patients, a pragmatic approach should include a frailty screening using simple and easy-to-use tools. The therapeutic approach in the elderly has the dual objective of treating symptoms and complications of the disease and modifying the course of the disease and slowing its progression with specific therapies. In the context of a universalistic health system such as the Italian one, the introduction of highly innovative, but also expensive, therapies raises significant questions in terms of economic sustainability, accessibility of care and protection of patients' dignity.