Current Opinion in Cardiology最新文献

Purpose of review: Lipoprotein(a) has been identified as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis. However, as reviewed here, there is ongoing debate as to the key pathogenic features of Lp(a) particles and the degree of Lp(a) atherogenicity relative to low-density lipoprotein (LDL).

Recent findings: Genetic analyses have revealed that Lp(a) on a per-particle basis is markedly (about six-fold) more atherogenic than LDL. Oxidized phospholipids carried on Lp(a) have been found to have substantial pro-inflammatory properties triggering pathways that may contribute to atherogenesis. Whether the strength of association of Lp(a) with ASCVD risk is dependent on inflammatory status is a matter of current debate and is critical to implementing intervention strategies. Contradictory reports continue to appear, but most recent studies in large cohorts indicate that the relationship of Lp(a) to risk is independent of C-reactive protein level.

Summary: Lp(a) is a highly atherogenic lipoprotein and a viable target for intervention in a significant proportion of the general population. Better understanding the basis of its enhanced atherogenicity is important for risk assessment and interpreting intervention trials.

Purpose of review: This review evaluates the emerging role of the pullback pressure gradient (PPG) as a standardized metric for assessing coronary artery disease (CAD) patterns and its implications for clinical decision-making when managing patients undergoing percutaneous coronary interventions (PCIs). By integrating PPG with existing physiological assessments, this review highlights the potential benefits of PPG in predicting treatment outcomes and refining therapeutic strategies for CAD.

Recent findings: Recent studies, particularly the PPG Global study have demonstrated a strong correlation between PPG values and post-PCI outcomes, revealing that focal disease is associated with improved fractional flow reserve (FFR) and lower rates of adverse events than vessels with diffuse disease (low PPG). Additionally, PPG has been linked to specific atherosclerotic plaque characteristics, indicating its utility in identifying high-risk plaques. The integration of PPG with advanced imaging techniques further enhances the understanding of CAD patterns and their implications for treatment planning.

Summary: The PPG represents a significant advancement in the management of CAD, providing a reproducible and objective assessment of coronary artery disease patterns that can inform clinical decision-making. As research continues to explore the relationship among PPG, atherosclerotic characteristics, and patient outcomes, its integration into routine practice is expected to improve the effectiveness of PCI and optimize patient management strategies. Future studies are warranted to establish specific PPG thresholds and further investigate its potential in identifying vulnerable plaques and guiding treatment decisions.

Purpose of review: To provide a summary of current understanding of coronary artery calcifications (CACs), outlining the role of calcium in atherosclerosis to comprehend the clinical implications of CAC.

Recent findings: CAC serves as a reliable indicator of coronary artery disease (CAD) and it is associated with cardiovascular events. In recognition of its significance, recent global guidelines have integrated CAC assessment into risk evaluation protocols, highlighting its role as a noninvasive tool for evaluating and stratifying patients' risk for cardiovascular events. Beyond the amount of CAC values, also, calcium morphology had been linked to cardiovascular events.By leveraging CAC assessment, healthcare providers can effectively up or down reclassify patients' risk and tailor preventive strategies accordingly. This comprehensive approach may involve lifestyle modifications, meticulous management of risk factors, and judicious use of preventive medications to mitigate the likelihood of future cardiovascular events, or withhold treatments in those without signs of CAC, to optimize resource use.

Summary: The identification of CAC burden and morphology through noninvasive imaging modalities can reclassify the prediction of future cardiovascular risk and serve as a risk modifier for atherosclerosis. These data underscore the utility of selectively using CAC assessment in both primary and secondary prevention strategies for atherosclerotic cardiovascular disease.

Purpose of review: Redo coronary artery bypass grafting (CABG) remains technically challenging with significant procedural risk but may be the best option for patients in whom repeat revascularization is indicated. This review summarizes the latest data regarding risk of redo CABG, who should receive this surgery, and how to achieve best outcomes.

Recent findings: Over the past two decades, the risk of performing redo CABG has declined and is approaching that of primary CABG in the hands of experienced surgeons. Nonetheless, patients for whom redo CABG is indicated tend to be older and have more complex medical comorbidities. Preoperative imaging is paramount in guiding sternal re-entry and mediastinal dissection, and in how to best employ rescue strategies when needed.

Summary: Patients with complex, progressive coronary disease with unprotected left anterior descending (LAD) coronary artery disease and prior coronary bypass may benefit from the durable, complete revascularization that redo CABG can offer with internal thoracic artery bypass to the LAD and, when possible, arterial inflow to other important coronary targets. Preoperative imaging, careful planning, meticulous surgical technique, myocardial protection, and an experienced surgical team are critical for optimal outcomes.

Purpose of review: To summarize evidence from recent studies of high lipoprotein(a) as a risk factor for peripheral artery disease (PAD), abdominal aortic aneurysms (AAA), and major adverse limb events (MALE). Additionally, provide clinicians with 10-year absolute risk charts enabling risk prediction of PAD and AAA by lipoprotein(a) levels and conventional risk factors.

Recent findings: Numerous studies support high lipoprotein(a) as an independent risk factor for PAD, AAA, and MALE. The strongest evidence is from the Copenhagen General Population Study (CGPS) and the UK Biobank, two large general population-based cohorts. In the CGPS, a 50 mg/dl higher genetically determined lipoprotein(a) associated with hazard ratios of 1.39 (1.24-1.56) for PAD and 1.21 (1.01-1.44) for AAA. Corresponding hazard ratio in the UK Biobank were 1.38 (1.30-1.46) and 1.42 (1.28-1.59). In CGPS participants with levels at least 99th (≥143 mg/dl) vs, less than 50th percentile (≤9 mg/dl), hazard ratios were 2.99 (2.09-4.30) for PAD and 2.22 (1.21-4.07) for AAA, with a corresponding incidence rate ratio for MALE of 3.04 (1.55-5.98) in participants with PAD.

Summary: Evidence from both observational and genetic studies support high lipoprotein(a) as a causal risk factor for PAD, AAA, and MALE, and highlight the potential of future lipoprotein(a)-lowering therapy to reduce the substantial morbidity and mortality associated with these diseases.

Purpose of review: Acute coronary syndromes (ACS) are a leading cause of morbidity and mortality worldwide, with approximately 1.2 million hospitalizations annually in the U.S. This review aims to explore the contemporary evidence regarding revascularization strategies, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), in ACS patients. It also addresses the unresolved questions concerning the optimal procedural aspects of surgery and antithrombotic therapy for secondary prevention postsurgery.

Recent findings: Recent studies highlight that while PCI is generally preferred for its timeliness in high-risk non-ST-elevation ACS (NSTE-ACS) patients, CABG offers a benefit in terms of cardiovascular events in those with multivessel disease, particularly in the presence of diabetes and higher coronary disease complexity. For ST-elevation myocardial infarction (STEMI), CABG is less frequently utilized due to the preference for primary PCI, but it remains crucial for patients with complex anatomy or failed PCI. Furthermore, the optimal timing and type of antiplatelet therapy post-CABG remain controversial, with current evidence supporting the use of dual antiplatelet therapy (DAPT) to reduce ischemic events but necessitating careful management to balance bleeding risks.

Summary: In patients with ACS, the choice between PCI and CABG depends on the complexity of coronary disease and patient comorbidities. CABG is particularly beneficial for multivessel disease in NSTE-ACS and specific STEMI cases where PCI is not feasible. The management of antiplatelet therapy postsurgery requires a nuanced approach to minimize bleeding risks while preventing thrombotic complications. Further randomized clinical trials are needed to solidify these findings and guide clinical practice.

Purpose of review: This review summarises the shifting paradigms in the treatment of ischemic left ventricular dysfunction, spotlighting the revascularization for ischemic ventricular dysfunction-British cardiovascular intervention society-2 (REVIVED-BCIS2) trial results and its impact on key therapeutic goals: survival, left ventricular function, arrhythmia prevention, quality of life and viability testing.

Recent findings: The REVIVED-BCIS2 trial, and its subsequent sub studies highlighted that (PCI) does not provide additional benefits to optimal medical therapy in terms of improving survival, left ventricular (LV) function, arrhythmic risk or quality of life. Additionally, viability testing did not differentiate patients who could benefit from PCI, although scar burden was found to be a significant predictor of outcome in these patients.

Summary: The outcomes of REVIVED have challenged multiple existing beliefs in the field of ischaemic left ventricular dysfunction management, emphasising the importance of investigating evidence free areas in our practice. Future work, including the STICH3 international consortium of trials, aims to answer some of the remaining unanswered questions.

Purpose of review: Cardiac amyloidosis is a condition marked by the misfolding of precursor proteins into insoluble amyloid fibrils, leading to restrictive cardiomyopathy and heart failure symptoms. This review discusses advancements in nuclear imaging techniques that enhance the diagnosis and guide the management of cardiac amyloidosis, addressing the critical need for early and accurate detection in clinical practice.

Recent findings: Recent studies and guidelines emphasizes the pivotal role of nuclear imaging techniques in diagnosing cardiac amyloidosis. Cardiac scintigraphy, using bone-avid tracers like 99mTc-PYP, 99mTc-DPD, and 99mTc-HMDP, is instrumental in distinguishing between transthyretin amyloidosis and light chain amyloidosis. PET, with tracers such as 11C-Pittsburgh Compound B (11C-PiB) and 18F-Florbetapir, offers significant potential in measuring amyloid burden and monitoring disease progression, providing detailed insights into the myocardial involvement.

Summary: The advancements in nuclear imaging techniques significantly impact the management of cardiac amyloidosis. These methods allow for a more accurate diagnosis, detailed assessment of disease extent, and better differentiation between amyloidosis types, which are crucial for tailoring treatment approaches. The integration of these techniques into clinical practice is essential for improving patient outcomes and advancing research in cardiac amyloidosis.