Current Opinion in Cardiology最新文献

Purpose of review: Obesity-associated hypertension is a pressing and ever-growing public health concern. The prevalence of obesity has increased four-fold over the four preceding decades, with concomitantly rising rates of hypertension not far behind. Importantly, the interplay between these conditions exacerbates cardiovascular disease (CVD) risk, and optimal management strategies remain an evolving challenge. This review synthesizes recent advancements in understanding obesity-associated hypertension pathophysiology and explores emerging therapeutic options, highlighting their relevance in shaping future clinical practice.

Recent findings: Emerging research into understanding obesity-associated hypertension has identified mechanisms, including dysregulated hormonal signaling, increased sympathetic activity, and enhanced inflammation as the key processes underlying obesity-associated hypertension development. With respect to management, new dietary interventions are poised to overtake traditional strategies as the ideal approach to achieving sustained weight loss for obesity-associated hypertension patients. Additionally, while conventional antihypertensive medications highlight the mainstay of standard pharmacotherapy, recent studies highlight the efficacy of diabetic agents and other novel therapies, which have the potential to further shape obesity-associated hypertension management guidelines.

Summary: As an emphasis on precision medicine underscores contemporary research into obesity-associated hypertension management, targeted treatment strategies are emerging as promising alternatives for reducing CVD burden and improving patient outcomes. Ultimately, further research is necessary to continue to refine treatment guidelines and explore the full potential of evolving interventions.

Purpose of review: Although oral anticoagulation (OAC) remains the cornerstone therapy for stroke prevention in atrial fibrillation, several limitations, such as noncompliance and bleeding, limit its effectiveness. Percutaneous left atrial appendage closure (pLAAC) has emerged as a promising therapy. We will review current and potential indications for pLAAC and knowledge gaps.

Recent findings: Current guidelines recommend pLAAC for patients who have atrial fibrillation at moderate to high risk of stroke with a high risk of bleeding or who have a contraindication for OAC. pLAAC is being investigated as a potential therapeutic option for the following patient populations: end-stage renal disease, after atrial fibrillation ablation, and in combination with OAC in patients with a high risk of breakthrough stroke or in patients with prior stroke on OAC. The Left Atrial Appendage Occlusion Study IV (LAAOS-IV) ( n  = 4000) is a randomized trial that will determine the role of pLAAC and OAC compared to OAC alone in preventing ischemic stroke or systemic embolism.

Summary: pLAAC has a growing role in patients with atrial fibrillation with moderate to high stroke risk and contraindication to OAC. Multiple randomized trials are currently underway in different patient populations, which may expand the role of pLAAC.

Purpose of review: Cardiac amyloidosis is an infiltrative cardiomyopathy with characteristic echocardiographic findings. Echocardiography is the initial imaging test to identify restrictive cardiomyopathies, and timely diagnosis is important for treatment and prognosis. This review outlines key echocardiographic "red flags," structural and functional findings, and emerging diagnostic tools that enhance early recognition and monitoring of cardiac amyloidosis.

Recent findings: Classic echocardiographic red flags for cardiac amyloidosis include increased ventricular wall thickness, biatrial enlargement, pericardial effusion, and a granular myocardial appearance. Tissue Doppler imaging shows reduced mitral annular velocities, while advanced disease presents with restrictive filling patterns. Global longitudinal strain with apical sparing is a hallmark finding that distinguishes cardiac amyloidosis from other cardiomyopathies. Left atrial strain has been proposed as a prognostic marker for thromboembolism in cardiac amyloidosis. Evidence shows variability in strain measurements across different vendors, which is an important consideration when comparing results between institutions in both research and clinical practice. Echocardiography can be used in conjunction with multimodal imaging techniques in order to monitor disease progression.

Summary: Echocardiography is the initial diagnostic test of choice and several findings can suggest cardiac amyloidosis. Advances in echocardiographic techniques have enabled earlier detection of cardiac involvement and now play a central role in both diagnosis and ongoing treatment monitoring.

Purpose of review: Sudden cardiac death (SCD) remains a feared and difficult-to-predict outcome in patients with congenital heart disease (CHD). This review examines the latest evidence in risk stratification, with a focus on limitations of existing models and the mechanistic and statistical complexities that hinder individualized decision-making.

Recent findings: New multivariable risk scores for repaired tetralogy of Fallot and systemic right ventricle have improved prognostic resolution. Artificial intelligence-enabled ECG algorithms have shown promise in early identification of high-risk individuals with repaired tetralogy of Fallot. In parallel, three-dimensional cardiac magnetic resonance imaging has been leveraged to delineate arrhythmogenic isthmuses, enhancing substrate-guided interventions. While these tools enhance risk estimation, they require validation specific to the prediction of shockable terminal rhythms, improved interpretability, and integration into individualized decision frameworks.

Summary: SCD risk prediction in CHD is evolving toward a multimodal, individualized approach that emphasizes probabilistic reasoning, shared decision-making, and epistemic humility. Although new models and technologies offer incremental gains, they do not eliminate the uncertainty inherent in predicting rare events. The application of population-based tools to individual patients must be interpreted cautiously, recognizing that SCD represents a final common pathway for diverse pathophysiological processes, and that decisions about ICD implantation entail complex trade-offs.

Purpose of review: Despite significant technological progress over the last decade, the optimal strategy for mapping and ablating intramural premature ventricular complexes (PVCs) remains elusive, with suboptimal success rates.

Recent findings: Recent studies have highlighted the limitations of traditional activation mapping and pointed towards newer indices for accurately localizing the site of origin (SOO) of intramural PVCs. Emerging technologies - including bipolar ablation, intramyocardial needle ablation, and pulsed field ablation - have demonstrated early promise in improving lesion depth and transmurality, potentially overcoming the constraints of conventional radiofrequency ablation.

Summary: Intramural PVCs are challenging for the electrophysiologist. While definitive strategies remain to be validated in large-scale, randomized studies, a pragmatic and systematic mapping approach, coupled with judicious use of conventional and emerging technologies, allows the electrophysiologist to circumvent the current limitations and achieve optimal outcomes in this challenging subset of ventricular arrhythmias. This review provides a contemporary overview and outlines a stepwise approach for managing intramural PVCs.

Purpose of review: Symptom relief is now recognized as the primary remit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease. The relationship between the nature of angina symptoms and the likelihood of successful symptom relief from PCI had not been systematically studied until recently.

Recent findings: The ORBITA-2 symptom-stratified analysis found that while the severity and nature of symptoms were poorly associated with the severity of coronary disease, the nature of the symptoms powerfully predicted the efficacy of PCI in relieving angina. Specifically, patients with typical or "Rose angina" were most likely to benefit from PCI, while those with atypical symptoms were less likely to see significant improvement beyond placebo. Furthermore, the ORBITA-STAR study demonstrated that patients whose angina symptoms closely matched those induced by balloon occlusion at the site of a coronary stenosis were significantly more likely to experience symptom relief from PCI.

Summary: Symptom analysis offers a powerful tool for predicting the efficacy of PCI. Misattributing noncardiac symptoms as angina often results in ineffective intervention, highlighting the critical importance of accurate and thoughtful symptom assessment, particularly in identifying typical angina. The persistent challenge of residual angina despite technically successful PCI reflects not a failure of the intervention itself, but a shortcoming in diagnostic precision to identify those who will benefit. Future research should focus on refining clinical predictors to better guide the selection of patients most likely to benefit from revascularization.

Purpose of review: This paper reviews the current understanding of coronary vascular dysfunction (CVDys) in patients with angina and no obstructive coronary artery disease (ANOCA), based on recent findings from a comprehensive, large-scale study. It also discusses potential future directions for research and clinical practice.

Recent findings: CVDys involves enhanced vasoconstriction or impaired vasodilation caused by endothelium-dependent and/or -independent dysfunction in the epicardial or microvascular coronary arteries. It is classified into four subtypes based on anatomical location and underlying mechanisms, and can be assessed using coronary reactivity testing (CRT). Previous studies have evaluated their prognostic implications separately or in limited populations.A recent study assessed all subtypes within a single ANOCA cohort and confirmed that endothelium-dependent epicardial dysfunction and both types of microvascular dysfunction are associated with worse prognosis. Moreover, it demonstrated that microvascular function - both endothelium-dependent and -independent - serves as an independent prognostic factor for major adverse cardiovascular events. These findings emphasize the value of CRT-based comprehensive evaluation for risk stratification.

Summary: While evidence regarding the prognostic impact of CVDys has become increasingly robust, effective treatment strategies remain undefined. Future efforts should focus on developing CRT-guided interventions targeting coronary dysfunction, with the goal of improving clinical outcomes.

Purpose of review: Complete revascularization (CR) by percutaneous coronary intervention (PCI) in acute coronary syndromes with multivessel coronary artery disease (CAD) was previously contraindicated in the absence of cardiogenic shock or high-risk ischemia. Over the last decade, CR has been a focus of recent clinical investigation and practice evolution due to high-quality evidence supporting hard cardiovascular outcome benefit, contributing to a reversal in international guidelines. This review provides concise syntheses of contemporary and emerging randomized evidence underpinning current strategies and unresolved questions regarding patient selection, timing of CR and guidance modalities for the identification and treatment of nonculprit lesions.

Recent findings: The randomized evidence base supporting CR with PCI for acute coronary syndromes (ACS) and multivessel CAD has increased recently with large-scale trials comparing immediate versus staged CR and physiology-guided versus angiography-guided CR, including reports of longer-term comparative outcomes. Enough events have recently accrued to enable demonstration of all-cause mortality benefits with CR.

Summary: Contemporary randomized data increasingly support CR with PCI in haemodynamically stable patients. However, ACS type, timing of intervention and method of evaluation still necessitate individualized shared clinical decision-making, and further trials are required to validate the optimal PCI strategies by which to achieve CR in the correct populations.

Purpose of review: High-risk plaque (HRP) features are commonly observed in patients with acute coronary syndromes (ACS); however, their individual predictive value remains limited. This review explores the importance of integrating anatomical and physiological assessments to enhance risk stratification and optimize therapeutic decision-making.

Recent findings: Studies have indicated that combining HRP evaluation with hemodynamic assessment significantly improves prognostic accuracy, particularly in guiding revascularization strategies. Although the interaction between HRP and inflammatory biomarkers remains incompletely understood, specific plaque characteristics, such as positive remodeling, have demonstrated consistent associations with lesion-specific inflammation. Furthermore, emerging evidence suggests that hemodynamic stress plays a crucial role in plaque progression and disruption, reinforcing the need for a more comprehensive approach.

Summary: A refined strategy that incorporates plaque burden, functional significance, and vascular inflammation is promising for improving cardiovascular risk prediction. By integrating these elements, HRP assessment may improve patient outcomes by optimizing preventive interventions and mitigating the progression of atherosclerotic disease.