Revista Espanola de Cardiologia Suplementos最新文献

The management of antithrombotic treatment in patients who are receiving oral anticoagulants for atrial fibrillation and who are scheduled for a percutaneous coronary intervention is particularly complex, mainly because they have an elevated risk of bleeding due to their combined use of antiplatelet and anticoagulant agents. Despite the lack of evidence available in this setting, a number of clinical trials carried out in recent years have attempted to evaluate the safety and efficacy of triple antithrombotic therapy (i.e. dual antiplatelet therapy plus an anticoagulant drug) and dual antithrombotic therapy (i.e. a single antiplatelet agent plus an anticoagulant drug), both potentially based on vitamin K antagonists or direct oral anticoagulants. The aim of this article was to provide an overview of what is currently known about different approaches to triple and dual antithrombotic therapy in patients who are undergoing anticoagulation for nonvalvular atrial fibrillation and who are scheduled for percutaneous coronary intervention. In addition, some practical recommendations for the clinical management of these patients are made.

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.

One third of patients with non-ischemic dilated cardiomyopathy (NIDCM) experience sudden cardiac death (SCD). Current guidelines recommend that an implantable cardioverter‐defibrillator (ICD) is used in NIDCM patients with symptomatic heart failure and a left ventricular ejection fraction ≤35%. However, although there is clear evidence of prognostic benefits in patients with an ischemic etiology, findings are not so consistent in those whose symptoms have a non-coronary origin. Results from the DANISH study (Danish Study to Assess the Efficacy of ICDs in Patients with Non-Ischemic Systolic Heart Failure on Mortality) suggest that ICDs do not increase survival in patients with NIDCM. To date, left ventricular ejection fraction and New York Heart Association functional class have been the key indicators for identifying NIDCM patients who are candidates for primary prevention using an ICD. Today, there are new drugs that could provide a greater reduction in the risk of SCD and alternative, more-specific markers that could give better risk estimates in patients. The aims of this article were to review and discuss studies on the use of ICDs in patients with NIDCM and to analyze the application of classical and newly emergent risk markers. Finally, an individualized SCD risk stratification is proposed for future use.

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

Atrial fibrillation is associated with high morbidity and mortality, which are principally due to an increased risk of thromboembolism – the risk of stroke and systemic embolism are elevated five-fold. Moreover, strokes secondary to atrial fibrillation are associated with higher mortality, greater dependency and poorer recovery, and there is a high rate of recurrence. Anticoagulant treatment decreases the risk of thrombotic events; compared with placebo, the rate of strokes is reduced by 64% and mortality is reduced by 26%.However, anticoagulant treatment is associated with an increased risk of hemorrhagic complications. In particular, the risk of intracranial hemorrhage, a fatal complication, is increased. The emergence of direct oral anticoagulants has not only improved the efficacy of anticoagulant treatment but, importantly, has also increased its safety. However, as patients do not all have the same thromboembolic and hemorrhagic risks, it is essential that these risks are evaluated in individual patients with atrial fibrillation and that potentially modifiable hemorrhagic risk factors are identified. Finally, it is important that anticoagulant drug treatment is adjusted to suit the individual patient to optimize the benefits of treatment whilesimultaneously reducing the risks.

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.

Heart failure with a reduced left ventricular ejection fraction (HFrEF) commonly coexists with diabetes. In recent years, sacubitril-valsartan and the family of sodium-glucose cotransporter-2 (SGLT2) inhibitors have become established as part of the routine therapeutic armamentarium for clinicians dealing with heart failure. In patients with HFrEF, sacubitril-valsartan has been associated with a substantially better prognosis and quality of life compared with enalapril. In addition, the family of SGLT2 inhibitors have demonstrated significant clinical benefits in a more varied patient population with a low prevalence of heart failure at baseline: they preserved renal function and reduced hospitalization for heart failure. The aim of this article was to review the evidence currently available on these two drugs classes and on their use in combination.

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

Renal impairment is common in patients with heart failure (HF) and HF increases with decreasing estimated glomerular filtration. Furthermore, renal impairment has an impact on the prognosis in patients with HF. In general, recommendations for the treatment of patients with HF and concomitant chronic kidney disease (CKD) are not different from those for patients with normal renal function. However, patients with moderate- to-severe renal impairment have been excluded from most clinical trials, and evidence and safety data on the therapies to be used in such patients are scarce. In the present paper, existing evidences on currently available therapies for HF in patients with moderate-to-severe CKD, including ultrafiltration with peritoneal dialysis, are discussed. Therapy complications, such as hyperkalaemia and renal function impairment, are also described. Dual angiotensin receptor-neprilysin inhibitors appear promising as a therapy that could safely reduce the risk of HF among patients with CKD. Their benefit could be mediated, among other mechanisms, by their renal effects. Other therapies, such as sodium-glucose cotransporter-2 inhibitors, have proved beneficial in HF in diabetic patients showing various degrees of renal function.

Clinical trials are needed to obtain new evidence on the therapies for heart failure and to confidently reduce the excess risk of cardiovascular disease in renal disease.

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

Cholesterol is a key modifiable risk factor for the development of atherosclerosis. Numerous studies have shown that statins can reduce plasma cholesterol levels and decrease the development of atherosclerotic complications, both in primary and secondary prevention. In fact, clinical practice guidelines recommend the use of statins as essential drugs in the control of hypercholesterolaemia, recommending stricter levels of low-density lipoprotein cholesterol in patients at high cardiovascular risk and in secondary prevention. Despite this, numerous patients are not adequately controlled, which is due to various factors depending on the drugs, the doctor and the patients. Therefore, there is a substantial margin for improvement in the degree of control of patients with hypercholesterolaemia.

In the last few decades, advances in cardiovascular medicine have significantly reduced the mortality associated with acute coronary syndrome. However, new difficulties and opportunities for improvement have emerged over the years, with growing clinical investigation, higher drug costs and a change in research responsibilities that should be coordinated with the aim of advancing in the fight against cardiovascular disease.

The increasing amount of real-world data available on the use of double antiplatelet therapy with new antiplatelet agents, including data from Spanish centers (e.g. the EPICOR, ARIAM and ACHILLES studies), appear to confirm the findings of large pivotal trials. Generally, use of these agents results in substantial clinical benefits, including fewer ischemic events and lower mortality, but there is usually an associated increase risk of hemorrhage. The uptake of these new antiplatelet agents continues to grow relative to that of clopidogrel-based double antiplatelet therapy. In addition, prolonged use of dual antiplatelet therapy is common practice in the real world, with substantial variations between countries. Therapeutic outcomes depend to a large extent on the risk profiles of, and the balance between ischemic and hemorrhagic risk in, patients included in individual case series.