Therapeutic Advances in Cardiovascular Disease最新文献

Coronary computed tomography angiography (CCTA) is a noninvasive imaging modality of cardiac structures and vasculature considered comparable to invasive coronary angiography for the evaluation of coronary artery disease (CAD) in several major cardiovascular guidelines. Conventional image acquisition, processing, and analysis of CCTA imaging have progressed significantly in the past decade through advances in technology, computation, and engineering. However, the advent of artificial intelligence (AI)-driven analysis of CCTA further drives past the limitations of conventional CCTA, allowing for greater achievements in speed, consistency, accuracy, and safety. AI-driven CCTA (AI-CCTA) has achieved a significant reduction in radiation exposure for patients, allowing for high-quality scans with sub-millisievert radiation doses. AI-CCTA has demonstrated comparable accuracy and consistency in manual coronary artery calcium scoring against expert human readers. An advantage over invasive coronary angiography, which provides luminal information only, CCTA allows for plaque characterization, providing detailed information on the quality of plaque and offering further prognosticative value for the management of CAD. Combined with AI, many recent studies demonstrate the efficacy, accuracy, efficiency, and precision of AI-driven analysis of CCTA imaging for the evaluation of CAD, including assessing degree stenosis, adverse plaque characteristics, and CT fractional flow reserve. The limitations of AI-CCTA include its early phase in investigation, the need for further improvements in AI modeling, possible medicolegal implications, and the need for further large-scale validation studies. Despite these limitations, AI-CCTA represents an important opportunity for improving cardiovascular care in an increasingly advanced and data-driven world of modern medicine.

Background: The no-reflow (NRF) phenomenon is the "Achilles heel" of interventionists after performing percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). No definitive treatment has been proposed for NRF, and preventive strategies are central to improving care for patients who develop NRF.

Objectives: In this study, we aim to investigate the clinical prediction models developed to predict NRF in STEMI patients undergoing primary PCI.

Design: Systematic review.

Data sources and methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were observed. Studies that developed clinical prediction modeling for NRF after primary PCI in STEMI patients were included. Data extraction was performed using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) checklist. The Prediction Model Risk of Bias Assessment Tool (PROBAST) tool was used for critical appraisal of the included studies.

Results: The three most common predictors were age, total ischemic time, and preoperative thrombolysis in myocardial infarction flow grade. Most of the included studies internally validated their developed model via various methods: random split, bootstrapping, and cross-validation. Only three studies (18%) externally validated their model. Six studies (37%) reported a calibration plot with or without the Hosmer-Lemeshow test. The reported area under the curve ranged from 0.648 to 0.925. The most common biases were in the statistical domain.

Conclusion: Clinical prediction models aid in individualizing care for STEMI patients with NRF after primary PCI. Of the 16 included studies, we report four to have a low risk of bias and low concern with regard to our research question, which should undergo external validation with or without updating in future studies.

Background: Elevated lipoprotein(a) [Lp(a)] is a common hyperlipidaemic condition with strong genetic predisposition and is independently associated with ischaemic heart disease (IHD). A Mendelian randomisation study has suggested that elevated Lp(a) is likely to confer similar causal risks as heterozygous familial hypercholesterolemia for premature IHD. We aimed to characterise the clinical profiles of admitted patients with IHD with at least one Lp(a) measurement. We also investigated whether elevated Lp(a) concentration was associated with premature onset of IHD.

Methods: This is a descriptive, non-interventional, retrospective study with data from a single tertiary hospital IHD Lp(a) cohort in Singapore, which consecutively recruited 521 patients with IHD admitted to the hospital.

Results: A total of 82.2% were men, 46.6% had newly diagnosed IHD and 10% had premature IHD. The median Lp(a) levels was 35.2 nmol/L. 70.8% of patients had normal Lp(a) concentrations (<70 nmol/L), 13.4% of people with Lp(a) ⩾ 70 to <120 nmol/L and 15.7% of patients with Lp(a) ⩾ 120 nmol/L. Lp(a) distribution was positively skewed to the right for all ethnicities. Patients of Indian ethnicity and of female gender had higher levels of Lp(a) compared with other ethnicities and gender, respectively. Multivariable regression analysis identified Lp(a) ⩾ 155 mmol/L to be associated with development of premature IHD (OR = 2.90, 95% CI: 1.26-6.67, p = 0.012).

Conclusion: There exist differences in Lp(a) distribution across ethnicities and gender. The subgroup analysis suggests that Lp(a) ⩾ 155 mmol/L was associated with premature onset of IHD.

Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.

Background: Evidence regarding the relationship between dietary calcium intake and severe abdominal aortic calcification (AAC) is limited. Therefore, this study aimed to investigate the association between dietary calcium intake and severe AAC in American adults based on data from the National Health and Nutrition Examination Survey (NHANES).

Methods: The present cross-sectional study utilized data from the NHANES 2013-2014, a population-based dataset. Dietary calcium intake was assessed using two 24-h dietary recall interviews. Quantification of the AAC scores was accomplished utilizing the Kauppila score system, whereby severe AAC was defined as having an AAC score greater than 6. We used multivariable logistic regression models, a restricted cubic spline analysis, and a two-piecewise linear regression model to show the effect of calcium intake on severe AAC.

Results: Out of the 2640 individuals examined, 10.9% had severe AAC. Following the adjustment for confounding variables, an independent association was discovered between an augmented intake of dietary calcium and the incidence of severe AAC. When comparing individuals in the second quartile (Q2) of dietary calcium intake with those in the lowest quartile (Q1), a decrease in the occurrence of severe AAC was observed (odds ratio: 0.66; 95% confidence interval: 0.44-0.99). Furthermore, the relationship between dietary calcium intake and severe AAC demonstrated an L-shaped pattern, with an inflection point observed at 907.259 mg/day. Subgroup analyses revealed no significant interaction effects.

Conclusion: The study revealed that the relationship between dietary calcium intake and severe AAC in American adults is L-shaped, with an inflection point of 907.259 mg/day. Further research is required to confirm this association.

Aims: The HEYMANS study observed patients receiving evolocumab as part of routine clinical hyperlipidemia management. It was designed to capture data on clinical parameters relevant to health authorities and physicians.

Methods: This was a European multi-country observational cohort serial chart review study; data on the Swiss cohort are reported here. Patients were prescribed evolocumab as per the Swiss reimbursement criteria in force at the time and were invited chronologically. The study consisted of a 6-month period prior to initiation of evolocumab, a 12-month core observation period (entered by 75 patients, completed by 74 patients), and an 18-month extended observation period (entered by 40 patients, completed by 34 patients). The primary objective was to describe the clinical characteristics of patients receiving evolocumab. Secondary objectives included to describe lipid levels, evolocumab use, and patterns of use of other lipid-lowering therapies (LLT, that is, statins and/or ezetimibe) over time. The study was conducted in the Swiss cohort between May 2017 and June 2021.

Results: Patients who received evolocumab in Swiss routine practice mostly were in secondary prevention (93%) and had a history of statin intolerance (85%) with 53% receiving no background LLT. One-third had familial hypercholesterolemia. Patients initiated evolocumab at a median low-density lipoprotein cholesterol (LDL-C) of 3.6 mmol/L, which decreased by 54% within 3 months to 1.6 mmol/L and was stable thereafter. Overall, 61% achieved the LDL-C goal of <1.4 mmol/L with more patients attaining this goal when they received evolocumab with a statin and/or ezetimibe (84%) compared to 41% when receiving evolocumab alone. An LDL-C reduction of ⩾50% was achieved by 85% of patients. Persistence with evolocumab at 12 months was 85%.

Conclusion: In Swiss clinical practice, evolocumab was mainly prescribed to patients with very high cardiovascular risk, who had very high LDL-C levels. Most patients continued to use evolocumab throughout the study period. In these patients, LDL-C was reduced by >50% within 3 months and LDL-C reductions were maintained over time. Guideline-recommended LDL-C goals for this very high-risk cohort were more frequently attained in patients receiving a combination of statin and/or ezetimibe and evolocumab.

Trial registration: ClinicalTrials.gov Identifier: NCT02770131.

Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device.

Heart failure (HF) is a significant public health concern characterized by notable rates of morbidity and mortality. Multimorbidity, ranging from 43% to 98% among HF patients, significantly impacts prognosis and treatment response. HF management requires a holistic approach, including guideline-directed medical therapy. Sacubitril/valsartan (angiotensin receptor neprilysin inhibitor [ARNI]) is a cornerstone of HF treatment, supported by robust evidence from large-scale clinical trials across different levels of left ventricular ejection fraction. The recommendations presented in this paper have been developed by a group of cardiologists in India who convened in expert opinion meetings to discuss the utilization of ARNI in chronic HF patients with five different comorbid conditions like type 2 diabetes mellitus (T2DM), chronic kidney disease, myocardial infarction (MI), obesity, and hypertension. Key focus areas include initiation, dose titration, and management across different HF phenotypes and comorbidities. Emphasis is placed on the efficacy of ARNI irrespective of glycemic status in the T2DM population, its role in HF patients with obesity, and addressing challenges related to renal function decline and hyperkalemia. Additionally, the document highlights ARNI's potential benefits in hypertensive and post-MI HF patients, alongside observations on the obesity paradox in HF prognosis. Overall, these recommendations aim to optimize ARNI therapy in HF patient populations with different comorbidities, addressing specific challenges and considerations to improve outcomes and quality of life.

Awareness, proper diagnosis and treatment of cardiac amyloidosis have increased, but there are still several unmet needs that have to be addressed for the optimal care of the disease. In this comprehensive review, we describe current and future treatments for both hereditary and wild-type TTR cardiac amyloidosis and also review lifestyle, including current challenges and opportunities for specific dietary concerns and exercise sports for these patients.

Currently, cardiovascular risk stratification to guide preventive therapy relies on clinical scores based on cardiovascular risk factors. However, the discriminative power of these scores is relatively modest. The use of coronary artery calcium score (CACS) and coronary CT angiography (CCTA) has surfaced as methods for enhancing the estimation of risk and potentially providing insights for personalized treatment in individual patients. CACS improves overall cardiovascular risk prediction and may be used to improve the yield of statin therapy in primary prevention, and possibly identify patients with a favorable risk/benefit relationship for antiplatelet therapies. CCTA holds promise to guide anti-atherosclerotic therapies and to monitor individual response to these treatments by assessing individual plaque features, quantifying total plaque volume and composition, and assessing peri-coronary adipose tissue. In this review, we aim to summarize current evidence regarding the use of CACS and CCTA for guiding lipid-lowering and antiplatelet therapy and discuss the possibility of using plaque burden and plaque phenotyping to monitor response to anti-atherosclerotic therapies.