INTRODUCTION: Cardiovascular disease (CVD) remains the leading global cause of mortality. To advance prevention, the American Heart Association introduced Life's Simple 7 (LS7) in 2010 and updated it in 2022 to Life's Es...INTRODUCTION: Cardiovascular disease (CVD) remains the leading global cause of mortality. To advance prevention, the American Heart Association introduced Life's Simple 7 (LS7) in 2010 and updated it in 2022 to Life's Essential 8 (LE8). This paper reviews the development, scientific foundation, and predictive validity of LE8 across major U.S. and international cohorts, including its applications beyond cardiovascular health. AREAS COVERED: A comprehensive search on PubMed, EMBASE, and Scopus was conducted through December 2025 to identify studies evaluating LS7 and LE8 in U.S. and international populations. Evidence from prospective cohorts, registries, and validation studies was synthesized to assess predictive value and clinical applications. LE8 incorporates diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure, each scored on a 0-100 scale. Higher LE8 scores consistently predict lower risks of CVD, stroke, heart failure, cognitive decline, and all-cause mortality. Data from major cohorts (NHANES, ARIC, CARDIA, REGARDS) confirm its prognostic validity, while international studies demonstrate external reproducibility. EXPERT OPINION: LE8 provides a practical framework for cardiovascular health assessment and risk communication, with potential benefits for prevention and healthcare cost reduction. However, limitations in clinical implementation, incomplete consideration of psychosocial and environmental factors, and reliance on self-reported measures remain important challenges.
BACKGROUND: Sex differences may influence outcomes of dual antiplatelet therapy after acute ischemic stroke or transient ischemic attack (TIA). We evaluated whether treatment effects of clopidogrel plus aspirin differ by...BACKGROUND: Sex differences may influence outcomes of dual antiplatelet therapy after acute ischemic stroke or transient ischemic attack (TIA). We evaluated whether treatment effects of clopidogrel plus aspirin differ by sex in patients with mild ischemic stroke or high-risk TIA. . RESEARCH DESIGN AND METHODS: This prespecified subgroup analysis used data from the INSPIRES trial, a multicenter, double-blind, placebo-controlled randomized trial conducted in China. Patients aged 35-80 years enrolled within 72 hours of symptom onset were randomized to clopidogrel plus aspirin or aspirin alone. The primary efficacy outcome was new stroke within 90 days, and the primary safety outcome was moderate-to-severe bleeding. Sex-by-treatment interaction was assessed. RESULTS: Among 6,100 patients (female 35.8%), new stroke occurred in 7.9% of females and 6.95% of males in the clopidogrel plus aspirin group, compared with 9.9% and 8.71% in the aspirin group, respectively. No significant sex-by-treatment interaction was observed for stroke prevention. Rates of moderate-to-severe bleeding were low and similar between females and males, with no evidence of interaction. CONCLUSIONS: In this prespecified subgroup analysis, clopidogrel plus aspirin showed no sex-based differences in efficacy or safety. These findings do not support sex-specific treatment effects. . TRIAL REGISTRATION: ClinicalTrials.gov (NCT03635749).
INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis across all surgical risk strata. As its use expands to younger, lower-risk patients, the durability of...INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis across all surgical risk strata. As its use expands to younger, lower-risk patients, the durability of transcatheter heart valves and the clinical consequences of prosthetic failure have become critically important. Despite a growing literature on reintervention strategies, systematic prevention of TAVR failure remains comparatively underemphasized. AREAS COVERED: We searched PubMed and the Cochrane Library (2000-2026, English language) for studies on TAVR failure and its prevention. This review examines the mechanisms of TAVR failure, including structural valve deterioration, paravalvular leak, prosthesis-patient mismatch, subclinical leaflet thrombosis, valve endocarditis, and device migration; appraises current management, including valve-in-valve TAVR, redo surgical aortic valve replacement, and medical therapy; and reviews prevention strategies spanning patient selection, procedural optimization, antithrombotic management, structural surveillance, coronary access preservation, and lifetime planning. EXPERT OPINION: The evidence base has focused disproportionately on reintervention rather than prevention. Greater emphasis on structured lifetime management planning at index TAVR, individualized antithrombotic strategies, and evidence-based surveillance is needed. Several proposed measures, however, including routine anticoagulation for subclinical leaflet thrombosis and routine CT or artificial-intelligence-based surveillance, are not yet supported by outcome data and require prospective validation.
INTRODUCTION: Despite foundational quadruple guideline-directed medical therapy (GDMT), patients with heart failure with reduced ejection fraction (HFrEF) face substantial residual risk. Vericiguat, a novel soluble guany...INTRODUCTION: Despite foundational quadruple guideline-directed medical therapy (GDMT), patients with heart failure with reduced ejection fraction (HFrEF) face substantial residual risk. Vericiguat, a novel soluble guanylate cyclase (sGC) stimulator, provides a crucial therapeutic option by directly targeting the impaired NO-sGC-cGMP signaling pathway to mitigate this risk. AREAS COVERED: This review synthesizes current literature tracking vericiguat's trajectory from pivotal clinical trials (VICTORIA, VELOCITY, and VICTOR) to its emerging real-world implementation. We examine its efficacy, hemodynamic and renal tolerability, and safety profile across the HFrEF spectrum. Additionally, we provide a framework for clinical decision-making, addressing optimal patient selection, initiation timing, and the navigation of polypharmacy. EXPERT OPINION: Current evidence suggests that vericiguat may represent a valuable adjunctive therapy for selected high-risk patients with HFrEF, with a generally favorable hemodynamic and renal tolerability profile that appears not to substantially exacerbate hypotension or hyperkalemia when integrated with contemporary guideline-directed medical therapy. To maximize its real-world implementation, clinicians must overcome clinical inertia and embrace the purposeful deprescribing of non-essential symptomatic medications. Future research should prioritize advanced renal disease cohorts and biomarker-guided phenotyping, ultimately shifting vericiguat from a reactive post-decompensation therapy to an earlier, proactive intervention within a personalized treatment strategy.
INTRODUCTION: Prediabetic neuropathy is increasingly recognized as an early consequence of glucose dysregulation that may precede type 2 diabetes and contribute to cardiovascular risk. AREAS COVERED: This narrative revie...INTRODUCTION: Prediabetic neuropathy is increasingly recognized as an early consequence of glucose dysregulation that may precede type 2 diabetes and contribute to cardiovascular risk. AREAS COVERED: This narrative review summarizes current evidence on autonomic dysfunction in prediabetes, including its epidemiology, pathophysiology, clinical significance, and therapeutic implications. A literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science for studies published between 2010 and 2026. Evidence indicates that alterations in heart rate variability, impaired baroreflex sensitivity, endothelial dysfunction, and chronic low-grade inflammation contribute to autonomic imbalance and increased cardiovascular risk in individuals with impaired fasting glucose or impaired glucose tolerance. EXPERT OPINION: Autonomic dysfunction should be considered an early manifestation of cardiometabolic disease rather than a late complication of diabetes. Although accumulating evidence supports its prognostic relevance, routine screening remains limited by the absence of standardized diagnostic criteria and clear guideline recommendations. Incorporating autonomic assessment into risk stratification may facilitate earlier identification of high-risk individuals and support targeted preventive strategies. Future studies should focus on validating diagnostic thresholds and determining whether early intervention improves long-term cardiovascular outcomes.
INTRODUCTION: Aortic stenosis (AS) is the most common and the deadliest valvular disease. The treatment of asymptomatic patients with severe AS remains a subject of investigation. Recently, ESC/EACTS guidelines for valvu...INTRODUCTION: Aortic stenosis (AS) is the most common and the deadliest valvular disease. The treatment of asymptomatic patients with severe AS remains a subject of investigation. Recently, ESC/EACTS guidelines for valvular diseases introduced a new indication for the treatment of asymptomatic low-risk patients with isolated high-gradient severe AS, as an alternative to clinical surveillance. AREA COVERED: This paper attempts to provide a rational, clinically oriented and evidence-based approach to the treatment of asymptomatic patients with high-gradient severe AS without additional adverse factors such as decrease in left ventricular systolic function or increase in natriuretic peptides. We searched for original and review papers through the PubMed database using the keywords: aortic stenosis, asymptomatic, risk stratification and intervention, without limiting the time period of the analyzed papers. EXPERT OPINION: The latest ESC/EACTS recommendations for the treatment of asymptomatic AS should be considered adequate. Considering differences in patient characteristics and heterogeneous treatment modalities, as well as differences in institutional-level outcomes, the optimal intervention strategy still needs clarification. Ongoing trials in asymptomatic patients with severe AS should provide significant new evidence. The diverse array of therapeutic options emphasizes the need for TAVI vs. SAVR randomized trial in middle-aged asymptomatic patients.
Santos IS, Goulart AC, Olmos RD
… +11 more, Varella AC, Quintino CR, Gebara OCE, Lopes ATA, Lopes FPPL, Gooden TE, Thomas GN, Lip GYH, Lotufo PA, Benseñor IM, on behalf of the NIHR Global Health Research Group on Atrial Fibrillation Management
BACKGROUND: Information about integrated care for patients with atrial fibrillation (AF) in low- and middle-income countries is scarce. METHODS: We analyzed multicentre data from 699 patients with AF treated in São Paulo...BACKGROUND: Information about integrated care for patients with atrial fibrillation (AF) in low- and middle-income countries is scarce. METHODS: We analyzed multicentre data from 699 patients with AF treated in São Paulo, Brazil. ABC compliance was defined as (1) adequate anticoagulation ('A' component); (2) controlled AF symptoms ('B' component); and (3) comorbidities treatment ('C' component). We built logistic regression models to identify characteristics associated with ABC compliance. RESULTS: Mean age was 69.4 ± 14.4 years (45.8% women; 57.4% from private healthcare). Compliance with ABC pathway, and with the 'A,' 'B' and 'C' components occurred in 20.9%, 42.3%, 81.7% and 50.1% of the participants, respectively. Lack of ABC compliance was associated with female sex (adjusted odds ratio [aOR]: 1.66; = 0.015), intermediate (aOR: 3.37; < 0.001) and high (aOR: 9.17; < 0.001) bleeding risk. Patients with AF treated in public units had worse performance for the 'A' component (aOR: 2.50; < 0.001) and better performance for the 'C' component (aOR: 0.49; < 0.001) compared to those using private healthcare. CONCLUSIONS: Compliance with the ABC pathway in São Paulo, Brazil was low. Lack of ABC compliance was more common in women and individuals with high bleeding risk. We found a mixed pattern of ABC compliance in public and private units.
INTRODUCTION: PCI for severely calcified lesions is still challenging. Calcified lesions are associated with suboptimal results and increased risks of adverse cardiovascular events after PCI. Therefore, optimized strateg...INTRODUCTION: PCI for severely calcified lesions is still challenging. Calcified lesions are associated with suboptimal results and increased risks of adverse cardiovascular events after PCI. Therefore, optimized strategies for the treatment of calcified lesions are clinically needed. AREAS COVERED: This review summarizes the current evidence on PCI for calcified lesions. It covers pathological features of calcified lesions, the role of intravascular imaging, and the applicability of a variety of lesion preparation devices. In addition, this review discusses the efficacy and limitations of pharmacological therapies for calcified lesions. EXPERT OPINION: A broad range of calcified plaque modification devices is currently available, and high-resolution intravascular imaging has enabled detailed assessment of calcified plaque morphology . The combination of appropriate devices and intravascular imaging will further improve not only acute procedural success but clinical outcomes after PCI for calcified lesions. However, important challenges remain, including limited calcified lesion-specific evidence, the lack of universally validated optimization criteria, and the absence of a standardized treatment algorithm. Further investigation is warranted to establish practical and evidence-based therapeutic approaches for calcified lesions.
INTRODUCTION: Though cardiac pacing has evolved substantially since its introduction, continued advancement is necessary to meet the needs of small patients and those with congenital heart disease. AREAS COVERED: This na...INTRODUCTION: Though cardiac pacing has evolved substantially since its introduction, continued advancement is necessary to meet the needs of small patients and those with congenital heart disease. AREAS COVERED: This narrative review summarizes current and emerging technologies for pediatric pacing based on a comprehensive search via PubMed and Google Scholar of peer-reviewed literature through April 2026. Technologies discussed include leadless pacemakers, pediatric-specific pulse generators for neonates, minimally invasive epicardial access techniques, and alternative pacing strategies for those with abnormal systemic venous anatomy. Additional areas of investigation include novel battery technologies such as energy harvesting, wireless power transfer, and experimental approaches to fetal pacing. EXPERT OPINION: Although modern pacing systems have improved substantially over recent decades, current technologies do not meet the needs of many pediatric patients. Continued innovation in lead design, power sources, and minimally invasive implantation will be necessary to improve durability, reduce procedural burden and device-related morbidity, and expand pacing options for children with congenital and acquired conduction system disease. Given the relative rarity of conduction system disease in pediatric populations, multicenter collaboration is essential to support continued development of pediatric-specific technologies.
INTRODUCTION: Heart failure remains a leading cause of morbidity and mortality, yet diagnosis continues to occur late in routine practice, frequently during emergency hospitalization. Primary care is well positioned to d...INTRODUCTION: Heart failure remains a leading cause of morbidity and mortality, yet diagnosis continues to occur late in routine practice, frequently during emergency hospitalization. Primary care is well positioned to detect heart failure earlier, but indiscriminate screening approaches have not delivered timely diagnosis at scale. This has prompted growing interest in targeted screening strategies while raising important practical implementation challenges. AREAS COVERED: This Special Report synthesizes the evidence and operational pathways underpinning screening for heart failure in primary care. Heart failure is a heterogeneous umbrella diagnosis, with important implications for how screening pathways are designed and scaled across its subtypes. Evidence from existing screening pathways and implementation studies is considered, from established biomarkers to newer diagnostic approaches, including machine learning-enabled tools and risk prediction models. A systematic search of PubMedMEDLINE, EMBASE, and the Cochrane Library was conducted using key terms including 'heart failure,' 'screening,' 'primary care,' and 'artificial intelligence,' encompassing publications up to January 2026. EXPERT OPINION: Implementation of any innovative technology in healthcare relies on effective pathway redesign as the primary determinant of impact. Progress will depend on targeted, risk-based screening pathways evaluated through pragmatic, implementation-aware trials to determine whether screening improves outcomes, for whom, and under what conditions.
INTRODUCTION: Artificial intelligence (AI) is playing a transformative role in cardiovascular care by enabling more precise prediction of adverse clinical events across prevention, imaging, electrophysiology, and interve...INTRODUCTION: Artificial intelligence (AI) is playing a transformative role in cardiovascular care by enabling more precise prediction of adverse clinical events across prevention, imaging, electrophysiology, and interventional practice. AI models integrate high-dimensional clinical data and imaging-derived phenotypes to improve risk stratification beyond traditional scoring systems, identifying patients who may benefit from earlier, targeted interventions. AREAS COVERED: This review examines recent advances in AI-based cardiovascular event prediction, focusing on coronary artery disease, heart failure, cardiac arrhythmias, and valvular heart disease. In these domains, AI transcends conventional markers-such as ejection fraction and stenosis severity-to extract prognostically relevant insights from complex data streams. Despite this potential, clinical translation remains limited. Many models are retrospective, rely heavily on discrimination metrics, and lack consistent validation across diverse health systems and patient subgroups. Furthermore, risk estimates are rarely linked to explicit management pathways. EXPERT OPINION: To facilitate adoption, we prioritize: rigorous external and prospective validation with a focus on calibration and fairness; coupling predictions with actionable care algorithms; and developing interpretable, workflow-integrated tools. Overcoming these barriers is essential to establishing AI-based risk prediction as a reliable clinical standard.
INTRODUCTION: Precision cardiac electrophysiology seeks to provide healthcare strategies tailored to the individual patient. The concept of digital twins is fundamental to this approach. Digital twins in cardiac electrop...INTRODUCTION: Precision cardiac electrophysiology seeks to provide healthcare strategies tailored to the individual patient. The concept of digital twins is fundamental to this approach. Digital twins in cardiac electrophysiology are personalized computer models that replicate the electrical activity of patients' hearts. By integrating patient-specific data with mechanistic simulations, they can predict disease risk and help optimize therapy planning. AREAS COVERED: This narrative review summarizes the state-of-the-art of cardiac digital twins, including advances in anatomical and functional twinning, as well as illustrative case studies. It then discusses key technical/clinical challenges, focusing on model development, data recording and integration, and pathways toward clinical implementation. EXPERT OPINION: Fueled by growing data availability and advances in computational power, the vision of cardiac digital twins is moving from theoretical concept to potential clinical reality. For instance, digital twins could guide ablation in patients with persistent atrial fibrillation by identifying potential targets through computer simulations. However, given the potentially substantial costs, identifying patient groups and clinical applications in which digital twins provide the greatest value is essential. In parallel, artificial intelligence-based precision medicine may offer a more cost-effective and efficient alternative for certain scenarios, while digital twins likely remain most valuable when mechanistic insight is required.
INTRODUCTION: Sudden cardiac arrest (SCA) remains one of the most devastating complications of pediatric hypertrophic cardiomyopathy (HCM). Despite major advances in genetic diagnostics, cardiac imaging, and risk stratif...INTRODUCTION: Sudden cardiac arrest (SCA) remains one of the most devastating complications of pediatric hypertrophic cardiomyopathy (HCM). Despite major advances in genetic diagnostics, cardiac imaging, and risk stratification strategies, the prevention of sudden cardiac death (SCD) in children and adolescents with HCM remains an unresolved clinical challenge. Contemporary guideline-based approaches and pediatric-specific risk models have improved decision-making regarding implantable cardioverter-defibrillator (ICD) implantation in diagnosed patients; however, these strategies are inherently limited by their reliance on an established HCM phenotype. A substantial proportion of pediatric patients experience SCA as the initial clinical manifestation of disease, without any warning symptoms. AREAS COVERED: In this expert review, we conducted a MEDLINE-based literature search using the keywords HCM, SCA, and pediatric to synthesize current evidence on the epidemiology, age-specific characteristics, and arrhythmogenic mechanisms of pediatric HCM, and also highlight the limitations of existing risk stratification models and prevention strategies. We discuss emerging insights into electrical vulnerability that may precede overt structural disease, as well as the evolving role of electrocardiography-based screening strategies. EXPERT OPINION: By integrating clinical experience with recent advances-including artificial intelligence-enhanced electrocardiography-we propose a shift from post-diagnosis risk prediction toward upstream detection of vulnerable individuals.