US Cardiology Review最新文献

Heart failure remains a huge societal concern despite medical advancement, with an annual direct cost of over $30 billion. While guideline-directed medical therapy (GDMT) is proven to reduce morbidity and mortality, many eligible patients with heart failure with reduced ejection fraction (HFrEF) are not receiving one or more of the recommended medications, often due to suboptimal initiation and titration in the outpatient setting. Hospitalization serves as a key point to initiate and titrate GDMT. Four evidence-based therapies have clinical benefit within 30 days of initiation and form a crucial foundation for HFrEF therapy: renin-angiotensin-aldosterone system inhibitors with or without a neprilysin inhibitor, β-blockers, mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2 inhibitors. The authors present a practical guide for the implementation of these four pillars of GDMT during a hospitalization for acute heart failure.

Coronary artery disease (CAD) patients may have an obstructive disease on invasive coronary angiography, but few of these patients have had flow-limiting obstructive disease diagnosed on invasive fractional flow reserve (FFR). FFR is infrequently performed because of its cost- and time-effectiveness. Advancement in non-invasive imaging has enabled FFR to be derived non-invasively using coronary CT angiography (CCTA), without the need for induction of hyperemia or modification of the standard CCTA acquisition protocol. FFR derived from CCTA (FFR_CT) has been shown to have excellent correlation with invasive FFR, and remains an effective diagnostic tool in the presence of reduced signal-to-noise ratio, coronary calcification and motion artifact. The utility of FFR_CT has also helped to deepen our understanding of hemodynamically significant CAD. Hence, there is now interest in exploring the possible interplay between these mechanistic forces and their effect on the development of coronary plaque and the vulnerability of these plaques.

Complex percutaneous coronary intervention (PCI) patients are a high-risk population for ischemic complications. Antiplatelet therapy in such patients remains controversial, as the beneficial effects of the use of more potent agents or prolonged dual antiplatelet treatment (DAPT) on atherothrombotic complications are hindered by a concomitant increase in bleeding rates. The aim of this article is to describe ischemic and bleeding outcomes associated with complex PCI procedures and to compare different types and durations of DAPT regimens in terms of safety and efficacy outcomes. Issues concerning special patient groups, such as those with left main, chronic total occlusion, or bifurcation lesions, are discussed.

Drug-eluting stents (DES) are the gold standard for percutaneous coronary interventions (PCI); however, technical and anatomical challenges need to be addressed to ensure optimal apposition and prevent late adverse events. Complex vessel anatomies, including ectatic or aneurysmatic vessels, or significant differences in diameter in left main stenosis of the coronary artery, are clinical indications in which current PCI techniques attempt to shape conventional DES to follow vessel anatomy, thus modifying the original stent scaffold and its properties. However, due to their design, balloon-expandable cobalt-chromium and cobalt-nickel DES have limitations regarding their expansion capacity, which can result in undersizing and malapposition. New stent scaffolds have recently been introduced into clinical practice to address these challenging anatomies, including a drug-eluting nitinol stent platform. The nature of the nitinol device allows conformability to the native vessel, covering complex anatomies without manual adaptation. In this article, the authors present the rationale and current data on self-apposing nitinol DES in left main stenosis, and suggest that the device may be safely and effectively used with comparable rates of adverse cardiovascular events, as seen with second-generation balloon-expandable DES.

Coronary angiography has been considered the gold standard for the diagnosis of coronary artery disease and guidance of percutaneous coronary intervention (PCI). However, 2D-projection angiography cannot completely reflect the 3D coronary lumen. Intravascular ultrasound (IVUS) can overcome a number of limitations of coronary angiography by providing more information about the dimensions of the vessel lumen, plaque characteristics, stent deployment, and the mechanisms of device failure. Growing data from observational studies and randomized controlled trials have confirmed the clinical benefit of IVUS guidance during PCI. This article summarizes the evidence regarding IVUS guidance to highlight its advantages and to support the use of IVUS during PCI.

Coronary bifurcations with significant lesions >10 mm in the side branch (SB) are likely to require two-stent treatment techniques. To date, double kissing Crush (DK-Crush) stenting has demonstrated higher rates of final kissing balloon inflation and better clinical outcomes. The technical iterations that lead to optimal clinical outcomes have been attributed to the first kissing balloon that repairs the distorted proximal segment and fully expands the orifice of the side stent. One potential caution, which relates to all Crush techniques, is the possibility of the guidewire crossing in an inappropriate position toward the Crushed SB stent. When this occurs, the SB stent may be further Crushed, leaving the ostium uncovered, which potentially negates the benefit of the Crush technique. In our experience, proximal side optimization (PSO) during DK-Crush stenting ensures stent size 'accommodation' to the larger vessel diameter in the proximal segment and better strut apposition to the wall, which is particularly important in the ostial segment. The benefits of this additional modification of the established DK-Crush technique are reduction or elimination of the risk of SB stent distortion, increase of the space of optimal wiring, and avoidance of guidewire advancement under the stent struts, even in unfavorable anatomies with extreme angulation. The author describes a step-by-step approach of a proposed PSO technique, which is easy to perform without any additional procedural time or costs.

There seems to be a unique interplay between 2019 novel coronavirus (SARS-CoV-2) and cardiovascular diseases, although it is predominantly a respiratory illness. Patients with pre-existing cardiovascular co-morbidities appear to be at highest risk for mortality from coronavirus disease 2019 (COVID-19) along with the elderly; COVID-19 also contributes to cardiovascular complications, including acute coronary syndromes, arrhythmias, myocarditis, acute heart failure, and, in the most severe cases, cardiogenic shock and death. Several medications proposed in the treatment of COVID-19 require cardiac monitoring owing to their cardiac-specific adverse effects. Ultimately, the COVID-19 pandemic has jeopardized the safety of heart transplantation and has placed transplant recipients on immunosuppressive therapies at significant risk. In this article, the authors summarize the rapidly emerging data on the cardiovascular implications of SARS-CoV-2 and COVID-19.