Revista Espanola de Cardiologia Suplementos最新文献

Clinical trials have found that sacubitril–valsartan is effective in reducing the risk of hospitalization and death from heart failure and real-life data have confirmed the drug combination’s effectiveness and safety. Moreover, early use during hospitalization, in both patients with de novo heart failure and previously untreated patients, also appears to be safe and is recommended for simplifying patient management and easing transitional care. In addition, sacubitril-valsartan has a beneficial effect on cardiac remodeling, as demonstrated by the results of the PROVE-HF study, which is greater with an early onset and at higher doses in observational studies.

Supplement information: this article is part of a supplement entitled “Questions on a new era for heart failure treatment” which is sponsored by Novartis

For many years, the left ventricle has been the focus of interest and research in cardiovascular medicine, with the right ventricle remaining on the sidelines. However, the recognition that right ventricular dysfunction is the principle prognostic indicator in the majority of cardiovascular diseases has led to increased interest in achieving a more detailed understanding of the physiology and pathophysiology of the right ventricle and its treatment. Right ventricular function can be affected by numerous mechanisms; one main mechanism is the pressure overload that occurs in pulmonary hypertension, whose most frequent cause in our discipline is, in fact, left heart disease. However, regardless of the etiology of pulmonary hypertension, right ventricular function determines prognosis in affected patients. Correspondingly, many of the therapies employed for left heart failure are also used for right ventricular dysfunction, although firm evidence to support this use is lacking. This article summarizes the pathophysiological basis for the development of right heart failure and reviews current evidence on its treatment when managing congestion is paramount. In addition, the role of neurohormonal modulation is considered and, finally, potential therapeutic strategies currently in development are reviewed.

Supplement information: this article is part of a supplement entitled “Questions on a new era for heart failure treatment” which is sponsored by Novartis

Patients with atrial fibrillation and coronary artery disease often have an elevated risk of both ischemia and bleeding. In the context of oral anticoagulation, clopidogrel is the P2Y₁₂ inhibitor with the best safety profile. However, although it is recommended for patients with acute coronary syndromes, there is still some debate today about whether it should be used for pretreatment before invasive procedures. In patients scheduled to undergo an elective percutaneous coronary intervention, heparin bridging before the procedure is not recommended because this approach has been associated with an increased incidence of adverse events. Radial access should be preferred in the majority of cases when hemodynamics and the coronary anatomy permit. Although the evidence is still limited, it is recommended that low-dose unfractionated heparin should be administered during the procedure.

Supplement information: this article is part of a supplement entitled “Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update”, which is sponsored by Boehringer Ingelheim.

Atrial fibrillation is the most prevalent cardiac arrhythmia in the general population. Its presence increases the risk of thromboembolic events 5-fold. Although antithrombotic treatment reduces this risk, in contrast it increases the potential risk of bleeding, with intracranial hemorrhage being the most feared complication. However, not all patients have the same risk. Consequently, a number of different thromboembolic riskscores have been developed in recent years (e.g. the CHADS₂, CHA₂DS₂-VASc and ATRIA stroke risk scores). The CHA₂DS₂-VASc score is the one recommended by clinical practice guidelines for optimizing antithrombotic therapy in patients with atrial fibrillation. These same clinical guidelines recommend that both bleeding and thromboembolic risk should be assessed and various risk scores have been proposed for assessing hemorrhagic risk (e.g. the HEMORR₂HAGES, HAS-BLED, ATRIA bleeding risk and ORBIT-AF scores). Currently, however, none has been explicitly recommended in European guidelines. It is vital that the net clinical benefit of antithrombotic therapy is assessed to ensure that the expected advantages of anticoagulation treatment outweigh the harm that could be caused by potential hemorrhages.

Supplement information: this article is part of a supplement entitled “Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update”, which is sponsored by Boehringer Ingelheim.

Patients with atrial fibrillation should be treated with oral anticoagulant drugs to lower their cardioembolic risk. Moreover, if they are to undergo percutaneous coronary intervention, they should receive dual antiplatelet therapy to reduce the incidence of stent thrombosis. Therefore, these patients should be treated with both an oral anticoagulant and an antiplatelet agent. This regimen markedly reduces the risk of thromboembolic events, but is associated with a substantial increase in hemorrhagic complications. Reliable information is available on embolic, hemorrhagic and ischemic risks and on the benefit and potential complications of anticoagulation and antiaggregation in different clinical scenarios. However, percutaneous coronary intervention in these patients raises a number of very specific issues. In addition, the recent publications of studies that have evaluated particular direct oral anticoagulants (i.e. rivaroxaban, dabigatran and apixaban) have provided new information that could significantly alter treatment in these patients. Some of the main topics for debate are whether dual antithrombotic therapy is necessary, whether triple therapy may be preferable, which patients should be treated and for how long, and which antiaggregants should be added. This article highlights the most important evidence-based findings and outlines a number of recommendations, with the aim of identifying the most practical clinical approach in this complex scenario.

Supplement information: this article is part of a supplement entitled “Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update”, which is sponsored by Boehringer Ingelheim.

New data confirm the usefulness of sacubitril–valsartan in patients with de novo heart failure (HF) with a reduced left ventricular ejection fraction. Most of these patients do not receive regular treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor blockers (ARBs). Although fewer data are available on the usefulness of sacubitril–valsartan in patients with de novo HF than in those with chronic HF, more is known about its use in patients with de novo HF than about the use of other HF drugs, such as ACE inhibitors and ARBs, in these patients. In fact, recent reports support giving sacubitril–valsartan to patients with de novo HF, particularly to those admitted to hospital. Sacubitril–valsartan has similar benefits to enalapril in both patients with de novo HF and those with a history of HF. Consequently, the initial hospital admission for HF with a reduced ejection fraction is a good time to start sacubitril–valsartan. Although information on the use of neprilysin inhibitors in ambulatory patients with de novo HF is scarcer, the data suggest these drugs could also be started in this setting.

Hospitalization for heart failure is part of the natural history of the disease and indicates a deterioration. Even the first hospitalization is associated with an increased risk of death and of repeat hospitalization after discharge. During this period of vulnerability, it is essential that transitional care is carefully managed both before and after discharge: organizational measures should be coordinated and treatment that can modify the disease course should be boosted. The PIONEER and TRANSITION studies demonstrated that sacubitril–valsartan can be started during hospitalization, that it is well tolerated and safe, and that its early administration improves prognostic markers and reduces the risk of rehospitalization compared with enalapril. These benefits extend to patients with de novo heart failure and to those who have not previously received angiotensin-converting enzyme inhibitors. Consequently, there are new opportunities for providing these patients with the treatment needed to reduce the risks associated with hospitalization and to slow disease progression.

Supplement information: this article is part of a supplement entitled “Questions on a new era for heart failure treatment” which is sponsored by Novartis

Patients on long-term oral anticoagulation therapy who are scheduled to undergo a percutaneous coronary intervention are a high-risk population with a large number of comorbid conditions. This is a growing population that has a complicated prognosis because ischemic and bleeding events can occur over the short, medium and long term. Antithrombotic therapy, without doubt a key consideration in these patients, could have a substantial impact on prognosis. Maintenance therapy with oral anticoagulants is also a priority. Over the last few years, several antithrombotic regimens have been investigated with the principle aim of reducing hemorrhagic events while maintaining efficacy. To this end, studies have focused on: (i) shortening the duration of the dual antiplatelet therapy added to anticoagulation; and (ii) the use of antiplatelet monotherapy, particularly clopidogrel, along with an oral anticoagulant. Recently, the emergence of direct oral anticoagulants has generated great hope and excitement. These new drugs, which have a better safety profile than dicoumarinic anticoagulants, could produce substantial prognostic improvements in this context. The results of three clinical trials of direct oral anticoagulants in these highly complex patients are currently available. Their findings, together with another trial that is now in the follow-up phase, have the potential to substantially modify our usual clinical practice in coming years.

Supplement information: this article is part of a supplement entitled “Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update”, which is sponsored by Boehringer Ingelheim.

Data from the PARADIGM-HF clinical trial and other key studies in patients with heart failure with a reduced ejection fraction (HFrEF) show that those described as "stable" (i.e. the majority in New York Heart Association [NYHA] functional class II with no recent admission for heart failure) actually have a very poor clinical prognosis: they have a high rate of admission for heart failure and a cardiovascular mortality of 25% in the following 3 years. Moreover, most patients with HFrEF who suffer sudden death did not experience a significant deterioration in functional capacity. This "false impression of clinical stability", therefore, does not imply a good prognosis or the absence of disease progression.

In the PARADIGM-HF study, which included mostly stable patients in NYHA functional class II, treatment with sacubitril-valsartan significantly reduced the risk of death or hospitalization due to heart failure compared with enalapril. Remarkably, the risk of sudden death was also decreased significantly. Traditionally, implantable cardioverter-defibrillators (ICDs) provide the most effective way of reducing the risk of sudden death in these patients. However, they do not prevent 100% of these deaths and up to 50% of patients with ICDs experience sudden death via various mechanisms. This illustrates why we should strengthen medical treatment during the stable clinical phase, which is the scenario for which the greatest amount of solid scientific evidence is available. Once a patient has been diagnosed with HFrEF, therefore, it is essential to act in full accordance with the evidence without waiting for the next decompensation. Therapeutic inertia and delaying action until clinical deterioration is evident will only result in a "desperate empiricism". Nevertheless, the uptake of drugs such as sacubitril-valsartan in routine clinical practice is still relatively low even when their use is indicated by consensus guidelines, which undoubtedly gives pause for thought.

Supplement information: this article is part of a supplement entitled "Questions on a new era for heart failure treatment" which is sponsored by Novartis