Current Opinion in Cardiology最新文献

Purpose of review: The purpose of this review is to elucidate the growing complexity involved in providing pediatric cardiac care in the contemporary era of innovation. Aiming to highlight the phenomenon of chronic critical illness in a pediatric heart center, this review outlines the burdens placed on those caring for these uniquely challenging patients and poses considerations for alleviating those burdens.

Recent findings: As care advancements drive improved survival for children with heart disease, heart centers face a growing population of chronically critically ill patients with high resource utilization and uncertain trajectories. Preterm infants, single ventricles, and complex heart failure patients require significant interventions and expertise. Their lengthy courses challenge care delivery systems and resources, in addition to placing significant emotional and cognitive burdens on the multidisciplinary teams.

Summary: The growing population of chronically critically ill cardiac patients are some of the most challenging both at the system level and on the team members. While undertaking innovative therapies, we must recognize that survival as an outcome cannot be separated from associated costs of achieving that outcome; the resultant burdens of innovation cannot be ignored. Heart centers must take a proactive stance in optimizing care for children with prolonged illness while also addressing the needs of those who care for them.

Purpose of review: We review the utility of coronary artery calcium (CAC) scoring in personalized risk assessment and initiation of cardiovascular disease risk modifying therapy.

Recent findings: Many populations - including South Asians, patients with cancer, patients with human immunodeficiency virus (HIV), younger patients, and elderly patients - were not included during the conception of the current risk stratification tools. CAC scoring may allow clinicians to risk-stratify these individuals and help initiate preventive therapy in higher risk populations. Furthermore, CAC scoring may be able to be integrated into current imaging practices to allow for more ubiquitous and equitable screening practices.

Summary: CAC scoring is an additional, objective metric that may allow for nuanced and personalized risk assessment of future atherosclerotic cardiovascular disease (ASCVD) events.

Purpose of review: To review recent updates in pediatric pulmonary hypertension with a special focus on recent recommendations from the World Symposium of Pulmonary Hypertension (WSPH).

Recent findings: The third pediatric specific WSPH report highlights updated recommendations for pediatric pulmonary hypertension classification, risk stratification, and management approaches, with special focus on an emerging cohort of pulmonary hypertension relating to bronchopulmonary dysplasia, in the premature population.

Summary: Based on real-world data and expert opinion, the newest iteration of the WSPH report encourages recommendations that optimize detection and management of pediatric pulmonary hypertension, with the ultimate goal of enhancing quality of life and long-term prognosis.

Purpose of review: This review critically examines the evolving role of C-reactive protein (CRP) in cardiovascular disease (CVD), addressing its pathogenesis and relationship with various CVDs including coronary artery disease (CAD), heart failure, and atrial fibrillation.

Recent findings: CRP is mechanistically implicated in endothelial dysfunction, oxidative stress, and plaque destabilization. Recent studies demonstrate that lipid-lowering agents (statins, bempedoic acid) and anti-inflammatory therapies (canakinumab, colchicine) reduce CRP levels and improve outcomes in CAD. In heart failure, elevated CRP predicts adverse events, though evidence on phenotypes varies, and novel therapies (glucagon-like peptide-1 agonists, sodium-glucose cotransporter-2 inhibitors) lower CRP independently of weight loss. For atrial fibrillation, CRP correlates with postoperative incidence and recurrence postablation, though data remain inconsistent. Guidelines offer differing opinion with the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines cautiously endorsing CRP for risk stratification in intermediate-risk individuals, while European guidelines advise against its routine use for primary prevention, reflecting unresolved questions about CRP's additive value.

Summary: CRP remains a pivotal inflammation biomarker in CVD, yet its causal role and clinical applicability require clarification. While CRP-guided therapies show promise, discrepancies in guidelines highlight the need for robust trials to determine whether targeting CRP directly improves outcomes. Future research should focus on CRP's pathophysiological mechanisms and validate its utility in personalized CVD management.

Purpose of review: Neurodevelopmental impairments are the most common comorbidity among children, adolescents, and adults with congenital heart disease (CHD). Despite significant advances in operative and perioperative care resulting in increased survival, neurodevelopmental impairments remain prevalent in this population. Neurodevelopmental impairments, though subtle, can have a major impact on quality of life, attainment of independence and societal contribution. In this review, we summarize current knowledge on neurodevelopmental outcomes in the CHD population, including neuroimaging findings, known risk factors and opportunities to optimize outcomes.

Recent findings: Several risk factors have been identified contributing to neurodevelopmental impairments across the lifespan. These include risk factors originating in the prenatal period and new risk factors that are acquired in adulthood. The risk factors encompass several categories, including genetic abnormalities, aberrant cardiovascular physiology, environmental factors, social determinants of health and mental health. Many risk factors can be considered modifiable, though large multicenter studies identifying the most salient risk factors for neurodevelopmental impairment are lacking.

Summary: In this review, we identify potentially modifiable risk factors for neurodevelopmental impairment in the CHD population that can be studies in future neuroprotective clinical trials.

Purpose of review: Near infrared spectroscopy (NIRS) has been increasingly adopted as standard monitoring in postoperative care of pediatric cardiac patients. Several reports have established its association with both markers of perfusion and adverse outcomes. The correlation with markers of perfusion is not strong and exhibits wide limit of agreement, making the determination of critical thresholds and its integration in treatment algorithms challenging.

Recent findings: A growing body of literature support the use of NIRS for hemodynamic monitoring in pediatric cardiac patients. Recent reports corroborate prior findings of weak to moderate correlation of NIRS with markers of global and regional perfusion and confirm its association with adverse outcomes. The challenge of lack of treatment thresholds remains, limiting clinical utility. Evidence of improvement of outcomes with the use of NIRS remains limited.

Summary: NIRS is a useful monitor of regional and global perfusion and can inform management decisions but cannot be used as the sole decision-making tool. Large, randomized studies are needed to define its use as decision making tool and facilitate its integration in treatment algorithms.

Purpose of review: This review explores the complex relationship between climate change and cardiovascular health. It examines the mechanisms through which climate change impacts cardiovascular risk, highlights recent findings on regional trends, and discusses mitigation strategies.

Recent findings: Climate change significantly contributes to cardiovascular morbidity and mortality through mechanisms such as temperature extremes, air pollution, and food insecurity. Heatwaves increase risks of dehydration, electrolyte imbalance, and acute cardiovascular events, while cold spells exacerbate myocardial stress and pollution-related cardiovascular risks. Air pollution, including fine particulate matter (PM2.5), induces systemic inflammation, endothelial dysfunction, and atherosclerosis. Emerging data highlight regional variations, with urbanization exacerbating risks in Asia-Pacific and Middle Eastern populations, while extreme heat and cold challenge resilience in Europe and Latin America. Studies also link socioeconomic stress from climate-induced displacement and resource shortages to chronic cardiovascular conditions. Notably, urban greening and air quality regulations demonstrate potential for reducing cardiovascular risks.

Summary: Climate change amplifies cardiovascular risks through diverse mechanisms, disproportionately affecting vulnerable populations. Targeted strategies, including public health campaigns, sustainable urban planning, and technological innovations, can mitigate these risks. Advances in generative artificial intelligence and big data analytics offer opportunities to tailor interventions and enhance predictive modeling. A multidisciplinary approach integrating public health, environmental science, and clinical expertise is critical to addressing these challenges. Urgent action is required to mitigate the long-term cardiovascular impacts of climate change and foster resilient health systems globally.

Purpose of review: Hypertension is one of the most common comorbidities affecting patients after solid organ transplantation. Here we review the mechanisms leading to hypertension, along with common practices in terms of medical management. Glucagon-like peptide-1 receptor (GLP-1R) agonists, baroreflex therapy, and renal denervation are common interventions utilized prior to heart transplant. Special considerations for their management throughout the perioperative and postoperative period are covered here.

Recent findings: Most common medical management includes utilization of calcium channel blockers, followed by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. GLP-1R agonists have shown significant benefit in recent cardiovascular outcome trials. Preoperative management centers around risks associated with slowed gastric emptying, while reinitiation after heart transplant must take into consideration initiation and tolerance of immunosuppressive therapies. Baroreflex activation therapy has been approved for therapy of heart failure, with many patients proceeding to heart transplant. The device is frequently deactivated after transplantation, with little published experience regarding reinitiation of therapy after heart transplant. There is renewed interest in renal denervation as a treatment for refractory hypertension. The incidence of hypertension after heart transplant in those patients that have undergone previous renal denervation remains unknown, however there is limited experience with its use after renal transplant.

Summary: Further studies are required to elucidate optimal medical management of hypertension following heart transplantation. GLP-1R agonists, baroreflex activation therapy, and renal denervation are emerging therapies prior to transplant that require further investigation.

Purpose of review: Statin medications play a pivotal role in the primary and secondary prevention and management of cardiovascular disease due to their potent lipid-lowering and anti-inflammatory effects. Nevertheless, the clinical application of statins is often hampered by statin-associated muscle symptoms (SAMS), which deter patient adherence and treatment efficacy considerably. SAMS currently affects 10-20% of statin users, thus understanding potential mitigation strategies is crucial. This review focuses on the role of vitamin D in mitigating SAMS, given the growing interest in vitamin D deficiency as a potentially modifiable risk factor.

Recent findings: Despite observational suggestions linking vitamin D deficiency to heightened SAMS risk, recent studies have yielded conflicting results on the role of vitamin D supplementation in preventing SAMS. Some studies report an improvement in statin tolerance following vitamin D repletion. However, recent large-scale clinical trials, particularly the Vitamin D and Omega-3 trial (VITAL) report no significant benefit of vitamin D supplementation in preventing SAMS or reducing statin discontinuation rates, regardless of baseline vitamin D levels.

Summary: Observational data provides evidence for the use of vitamin D supplementation in SAMS management, however conflicting evidence in recent clinical trials do not support its routine use for preventing or treating SAMS. To explore alternative strategies in improving statin tolerance and adherence, this discourse aims to elucidate the current understanding the complex mechanisms underlying SAMS, the influence of serum vitamin D levels, and the implications for clinical management.