Heart International最新文献

Several organizations have developed guidelines for the management of ST-segment elevation myocardial infarction (STEMI). However, the optimal strategy regarding revascularization in the setting of multivessel disease, specifically with regards to culprit vessel versus complete revascularization, continues to evolve. While previous observational studies promoted culprit vessel-only intervention in patients with STEMI, recent randomized controlled trials suggest potential benefits with multivessel revascularization, either at the time of the index event or in a staged fashion, in patients without cardiogenic shock. This may be due to the known instability of non-culprit lesions in the setting of acute coronary syndrome, and the diffuse coronary processes involved. As additional literature examines culprit vessel versus multivessel revascularization strategies, clinicians continue to be tasked with determining optimal treatment plans for their patients and understanding the factors that promote selected revascularization strategies. This review summarizes and discusses observational studies, randomized control trials and current guidelines in order to evaluate optimal reperfusion strategies for patients presenting with STEMI in the setting of multivessel disease.

Patients with peripheral artery disease (PAD) are at risk for severe morbidity and mortality, including ischaemic-related events. Furthermore, there is heterogeneity within the PAD population, where the drivers of risk for cardiovascular and limb-specific ischaemic events differ. Patients with PAD with concomitant coronary artery disease are at increased risk for cardiovascular ischaemic events, whereas patients with PAD with a prior history of lower-extremity revascularization are at increased risk for limb-specific ischaemic events. The current therapeutic challenge is identifying these risk factors to tailor therapy optimally for each patient. Additionally, the majority of our current medical therapeutics in patients with PAD have been shown to reduce atherothrombotic events, such as myocardial infarction, stroke and cardiovascular death, with a paucity of medical therapeutics specifically targeting a reduction in limb-specific ischaemic events. Over the past several years, there have been several contemporary clinical trials evaluating antithrombotic agents and their efficacy in reducing limb-specific ischaemic events. Specifically, rivaroxaban, with the addition of aspirin, has emerged as an efficacious therapeutic. In this article, we provide a review of the current clinical burden of PAD, the rationale behind current PAD medical therapeutics and the contemporary trials that have described the benefit of a novel therapeutic in PAD, rivaroxaban.

Based on the strength of data from randomized trials and real-world clinical studies, transcatheter aortic valve replacement (TAVR) has become a popular and effective alternative to surgical valve replacement in patients with symptomatic aortic stenosis. The ACURATE neo™ (Boston Scientific, Marlborough, MA, USA) valve system has been commercially available for transfemoral TAVR in Europe since 2014. ACURATE neo2™ is an evolution of the neo design and was declared CE marked by the manufacturer in 2020. The neo and neo2 valves have been studied in high-risk patients, and the currently active randomized trial for neo2 will include over 1,500 patients of all risk categories in the USA. The goal of this review is to help inform the TAVR community about the ACURATE valve.

Coronary artery disease (CAD) is prevalent throughout the world, with a significant impact on global health. There is a vast collection of data in the medical literature relating to the topic of dual antiplatelet therapy (DAPT) in patients considered to be at high cardiovascular (CV) risk. In order to perform a narrative review of literature regarding the use of DAPT in patients with high CV risk, PubMed, Google Scholar and Embase were searched for English-language articles from 1985 to December 2020 by using the medical subject heading terms and keywords 'antiplatelet therapy' and 'high-risk cardiovascular disease', alone or in combination. Both authors critically reviewed the design, population characteristics and results of the selected studies. The topic of DAPT in patients with high CV risk is fluid and constantly evolving. The landmark trials of CURE, TRITON-TIMI 38 and PLATO provided evidence for the optimal use of DAPT in patients after acute coronary syndrome, while the CHARISMA and MATCH trials provided guidance for clinicians for their use in patients with stable coronary artery disease. The American College of Cardiology/American Heart Association focused update, published in 2016, and the European Society of Cardiology guidelines, published in 2017, were developed to provide guidance to clinicians based on the available data at the time to be able to choose the appropriate DAPT strategy that would provide patients with the maximum clinical benefit. The management of DAPT in patients with high CV risk is a challenging task, with new data on the subject constantly being reported. Balancing ischaemic benefit with potential bleeding complications adds to the complexity of managing DAPT in these patients. With all the available data and current clinical guidelines, patients deemed at high CV risk should be considered for DAPT, taking into account individual risk:benefit ratio. In most individuals with high CV risk, the net clinical benefit favours the use of DAPT.

Recurrent pericarditis is associated with significant morbidity and adverse impact on quality of life. Contemporary studies have emphasized the key role of autoinflammatory pathways in its pathophysiology, mainly through the activation of inflammasomes and the production of interleukin (IL)-1α and IL-1β. The IL-1 pathway has emerged as a promising target for the treatment of these patients. A novel IL-1 inhibitor, rilonacept, functions as an IL-1 trap binding to the circulating IL-1α and IL-1β mitigating their inflammatory response. Recently, the RHAPSODY phase III clinical trial evaluated the use of rilonacept in patients with recurrent pericarditis, who were refractory to colchicine, or steroid-dependent. Rilonacept significantly reduced symptoms, inflammatory markers and recurrent episodes, and increased successful withdrawal of steroids. The safety profile of the medication is favourable and well tolerated by patients, with local injection site reaction being the most common side effect described. These results have shifted the paradigm of the understanding of the disease and promise to become part of the armamentarium of medications for the standard of care of these patients, with potential use as monotherapy. The changing landscape of therapeutics and pathophysiology warrants increased recognition and understanding from the international cardiology community about this novel drug and its implication in managing these complex patients.The objective of this review is to describe the bio-action of rilonacept in the treatment of recurrent pericarditis.

The current treatment of sustained paroxysmal supraventricular tachycardia (PSVT) often requires attendance at a medical facility. This burden is driven by the lack of an effective self-administered treatment for PSVT. Etripamil (Milestone Pharmaceuticals, Saint-Laurent, QC, Canada) is a novel intra-nasal preparation of a rapidly effective but short-acting calcium-channel blocker, which shows promise in offering out-of-hospital treatment for patients with PSVT. Studies, to date, have demonstrated good tolerability and potential efficacy, with a safety profile that is acceptable for unsupervised self-administration. This article reviews the current epidemiology and international guidelines for the treatment of acute PSVT, the pharmacology and clinical trial evidence behind the novel agent etripamil, and considers its potential role in the management of patients with PSVT.

Sodium-glucose cotransporter (SGLT) 2 inhibitors, or gliflozins, have quickly risen to prominence within the cardiovascular field due to their substantial benefit in the management of heart failure with reduced ejection fraction (HFrEF). SGLT channels are present throughout the body in various isoforms, but SGLT1 and SGLT2 have been the centre of medical investigation due to known genetic mutations. SGLT2 plays a major role in renal re-absorption of glucose, prompting the development of SGLT2 inhibitors to promote glycosuria and aid in diabetes management. The United States Food and Drug Administration requires evaluation of new antidiabetic medications for cardiovascular safety, prompting several randomized controlled trials of SGLT2 inhibitors over the past 5 years. These initial trials demonstrated superiority in cardiovascular outcomes with SGLT2 inhibitor use and suggested particular benefit in heart failure (HF) outcomes, prompting further study of their mechanisms. Subsequent SGLT2 inhibitor studies have demonstrated reductions in HF hospitalizations and cardiovascular mortality in patients with HFrEF, regardless of the presence of diabetes mellitus. In this review, we discuss the mechanism of action and major clinical trial results that have propelled SGLT2 inhibitors into a key role for patients with HFrEF.

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality globally. Despite significant advances in pharmacotherapies and the beneficial effects of statin therapy on ASCVD outcomes and progression of atherosclerosis, residual cardiovascular (CV) risk remains. Extensive evidence has identified the contribution of atherogenic dyslipidaemia, which is particularly characterised by elevated triglycerides (TGL) as a key driver of CV risk, even if low-density lipoprotein cholesterol levels are well controlled. Epidemiologic and genetic/Mendelian randomisation studies have demonstrated that elevated TGL levels serve as an independent marker for an increased risk of ischaemic events, highlighting TGLs as a suitable therapeutic target. Clinical studies have shown that omega 3 fatty acids (OM3FA) are effective in lowering TGLs; however, to date, trials and meta-analyses of combined OM3FA products have not demonstrated any clinical CV outcome benefit in patients receiving statins. However, icosapent ethyl (IPE) - a highly purified, stable ethyl ester of eicosapentaenoic acid (EPA) - has been rigorously demonstrated in multiple studies to be a useful adjunctive therapy to address residual CV risk. EPA is an omega-3 polyunsaturated fatty acid that is incorporated into membrane phospholipid bilayers and is reported to exert multiple beneficial effects along the pathway of coronary atherosclerosis. In this brief review, we will provide an overview of the mode of action of IPE in coronary atherosclerosis, the robust clinical evidence and trial data supporting its use, and expert consensus/recommendations on its use in specific populations, as an adjunct to existing anti-atherosclerotic therapies.

Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.

Complex, high-risk percutaneous coronary intervention (HR-PCI) is increasingly being performed, often with mechanical circulatory support (MCS), though to date, there are limited randomised data on the efficacy of MCS for HR-PCI. The majority of MCS is provided by intra-aortic balloon pumps, but increasingly Impella® (Abiomed, Danvers, MA, USA) heart pumps are being used. While the Impella pumps provide greater increases in cardiac output, these devices require large bore access, which has been associated with an increased risk of bleeding and vascular complications. Decisions regarding the use of Impella are often based on risk-benefit considerations, with Impella-related bleeding risk being a major factor that can impact decisions for planned use. While bleeding risk related to large bore access is a concern, published data on the risk have been quite variable. Thus, the goal of this article is to provide a comprehensive review of reports describing bleeding and vascular complications for Impella-supported HR-PCI.