Current Opinion in Cardiology最新文献

Purpose of review: A low ceiling of efficacy exists for the treatment of persistent atrial fibrillation via pulmonary vein isolation without adjunctive ablations, which is likely because they do not target an individual patient's specific underlying disease mechanisms. Electrographic flow (EGF) mapping is the first system that reliably displays wavefront propagation through the atria. It is a promising tool for localizing sources of atrial fibrillation, guiding targeted ablation, and visualizing conduction through the atrial substrate.

Recent findings: We describe EGF mapping with emphasis on contemporary studies examining map reproducibility and use cases in the preclinical and clinical environment. Animal experiments demonstrated that maps were interpretable across increasingly complex rhythms with pacing during spontaneously persistent atrial fibrillation reliably simulating EGF sources. The FLOW-AF randomized controlled trial showed that source ablation improved outcomes and that EGF map properties may be used to phenotype patients based on their atrial fibrillation mechanisms and recurrence likelihoods.

Summary: Targeted ablation strategies balance the risks of insufficiently ablating atrial fibrillation triggers with exacerbating disease through additional scar formation. EGF mapping leverages spatiotemporal relationships in voltage to localize sources and quantify substrate health. Further research is needed to optimize phenotyping and treatment efforts.

Purpose of review: To describe the challenges that health professionals often face when attempting to provide optimal primary and secondary prevention care of atherosclerotic cardiovascular disease (ASCVD) to South Asian immigrant patients who face adverse socioeconomic factors, such as many of the South Asian men and women who live in Catalonia, and to present a number of constructive approaches that can help minimize those barriers.

Recent findings: The challenges include limited health literacy, frequent language barriers, cultural factors that limit the relevance of standard lifestyle advice, financial barriers, limited access to preventive care, racism, and other barriers. Approaches that can help minimize them and enhance the quality of secondary cardiovascular preventive care in this group include empathy, using support from cultural mediators, enhanced proficiency using readily available translation programs, approaches that minimize financial barriers and simplify treatment regimes, and provision of more culturally competent lifestyle advice, among others.

Summary: We hope that the notions included in this review will help physicians and healthcare system managers around the world become more aware and culturally competent when treating South Asian patients with ASCVD. The ongoing Pul-Cat and other studies will illuminate the most effective steps moving forward.

Purpose of review: Although pulsed field ablation (PFA) has emerged as an innovative nonthermal catheter ablation modality, recent reports raise concerns about its potential impact on nearby coronary arteries. This review provides a comprehensive overview of the current understanding and future directions regarding the effects of PFA on or near coronary arteries.

Recent findings: Clinical studies have demonstrated the risks of acute transient vasospasm after delivery of PFA, especially with ablation of structures in proximity to the coronary arteries, such as the cavotricuspid and mitral isthmuses. The clinical incidence has been reported to be approximately 0.14%, according to the largest multicenter registry. Nitroglycerin pretreatment has been demonstrated to mitigate vasospastic events. However, early preclinical models indicate that chronic neointimal hyperplasia, tunica media fibrosis and mild coronary artery narrowing may occur, suggesting long-term coronary injury after delivering PFA near coronary arteries.

Summary: Despite reducing collateral tissue damage compared with thermal methods, PFA near coronary arteries may require careful procedural planning and proactive use of nitroglycerin to reduce coronary vasospasm. Further research is essential to elucidate the mechanisms underlying PFA-induced coronary spasm, optimize catheter design and placement, and assess the long-term coronary health implications.

Purpose of review: Patients with nonischemic and ischemic cardiomyopathy (NICM and ICM) exhibit re-entrant tachycardias related to scar tissue in subepicardial, in addition to typical subendocardial locations. Control of ventricular arrhythmias related to these targets has remained elusive despite advances in mapping and ablation technology.

Recent findings: Percutaneous epicardial ablation is the standard after failed endocardial ventricular ablation, but recurrence rates are disappointing. Pulsed-field energy has been associated with coronary artery spasm and therefore may be less suitable for epicardial ablation. Commercially available energy sources, including pulsed-field, have limited depths of myocardial penetration when applied epicardially. Lateral volumetric thermal spreading of ablation injury is associated with decreasing depth of ablation and is difficult to control. A new cryoablation technology based on liquid helium and developed specifically for epicardial work may be able to overcome these limitations.

Summary: Ablation strategies that can improve lesion formation in subepicardial ventricular myocardium may improve outcomes of ablation in nonsubendocardial NICM and ICM targets.

Purpose of review: This review examines current evidence on pharmacologically induced plaque stabilization in the context of a growing range of new therapies. It explores the potential for a paradigm shift in atherosclerotic cardiovascular disease (ASCVD) prevention, where treatments may not need to be lifelong to achieve lasting benefits.

Recent findings: Since 2015, over 14 novel therapies have been introduced, each shown to reduce ASCVD risk when added to standard care with statins and aspirin. More than 80% of ischemic heart disease patients are now eligible for one or more of these treatments, increasing the risk of polypharmacy, treatment burden, and adverse side effects. As more therapies become available, this challenge is expected to grow. Many of these treatments have demonstrated plaque regression and stabilization, as evidenced by both intravascular ultrasound and computed tomography angiography, which likely explains much of their efficacy.

Summary: The increasing number of novel therapies presents challenges in preventing ASCVD without leading to lifelong polypharmacy and increased patient burden. Since many of these drugs act through plaque stabilization, a new approach may be feasible - using these treatments for shorter durations to induce plaque regression, followed by less intensive maintenance therapies to preserve stability. This approach warrants further investigation in future studies.

Purpose of review: To review the current evidence and highlight future strategies regarding consideration of coronary artery calcium (CAC) density in cardiovascular disease (CVD) risk stratification.

Recent findings: Expressed as the product of plaque area and a peak calcium density weighting factor, the Agatston method is the gold-standard for measuring CAC on noncontrast cardiac computed tomography. Over the last decade, observational data have suggested that calcium density is inversely associated with CVD events and confers additional prognostic information independent of traditional risk factors and Agatston CAC scores. Specific density measures have been assessed including peak calcium density, mean CAC density, and CAC area-density discordance. Beyond calcium density, the number of affected arteries and regional distribution of CAC which may be correlated with CAC density have also improved the predictive utility of the Agatston score.

Summary: Calcium density is inversely associated with CVD risk after considering plaque area and/or volume. Calcium markers including density, vessel involvement, and regional distribution confer additional prognostic information for the prediction of incident CVD among those with prevalent subclinical atherosclerosis. A future area of study includes calcium radiomics ('calcium-omics') and whether the artificial intelligence-derived automated measurement of calcium markers beyond the Agatston score may be of value in CVD risk stratification among individuals with early to advanced subclinical atherosclerosis.

Purpose of review: New-onset atrial fibrillation (NOAF) is the most prevalent arrhythmia among critically ill patients, correlating with heightened morbidity and mortality rates. Current evidence for managing NOAF in this patient population is limited.

Recent findings: Numerous meta-analyses have been conducted to assess the efficacy of atrial fibrillation treatments in acute settings, including rate or rhythm control strategies, anticoagulation, and intensive care interventions. The employment of β-blockers for rate control appears to confer greater benefits in critically ill patients. However, the advantage of anticoagulation remains ambiguous because of bleeding risks, which is partly attributed to the scarcity of evidence in the complex context of critical illness. Approximately one-third of patients with transient atrial fibrillation face recurrence within a year. Therefore, vigilant posthospitalization follow-up and monitoring should be considered for high-risk patients to detect atrial fibrillation recurrence. Long-term anticoagulation strategies should be tailored to individual patient profiles, weighing the risks of thromboembolism.

Summary: Factors predicting atrial fibrillation recurrence include age, the burden of atrial fibrillation, and atrial size. There are significant knowledge gaps concerning NOAF in critically ill patients, highlighting the need for further research, particularly randomized clinical trials.

Purpose of review: Survival statistics for out-of-hospital cardiac arrests remain unsatisfactory. Prompt defibrillation of shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia, is crucial for improving survival. Automated external defibrillators (AEDs) and wearable cardiac defibrillators (WCDs) seek to improve the survival rates following out-of-hospital cardiac arrests. We aim to review the indications, utility, advancements, and limitations of AEDs and WCDs, as well as their role in contemporary and future clinical practice.

Recent findings: Recent advancements in these technologies, such as smartphone applications and drone delivery of AEDs and less inappropriate shocks and decreased size of WCDs, have increased their ubiquity and efficacy. However, implementation of this technology remains limited due to lack of resources and suboptimal patient adherence.

Summary: Out of hospital cardiac arrests continue to pose a significant public health challenge. Advancements in AEDs and WCDs aim to facilitate prompt defibrillation of shockable rhythms with the goal of improving survival rates. However, they remain underutilized due to limited resources and suboptimal patient adherence. As these technologies continue to evolve to become smaller, lighter and more affordable, their utilization and accessibility are expected to improve.

Purpose of review: This review examines the selective cardiac injury induced by pulsed electric fields during atrial fibrillation ablation. It consolidates findings from both preclinical and clinical studies on cardiac selectivity and explores the potential mechanisms behind this selectivity.

Recent findings: Preclinical studies indicate that pulsed electric fields cause significantly more myocardial injury compared with other tissues. Clinical studies have similarly shown that complication rates for pulsed field ablation are notably lower than those for radiofrequency and cryoballoon ablation.

Summary: Pulsed field ablation demonstrates a notable selectivity for myocardial injury, likely because of the unique functional and metabolic characteristics of cardiomyocytes. This review delves into the underlying principles of cardiac selectivity and proposes future directions for improving this selectivity. It is important to note that while pulsed field ablation shows promise, its cardiac selectivity is not absolute, as some complications still occur, necessitating further research.