INTRODUCTION: Coronary atherosclerosis, marked by lipid deposition and inflammation, drives cardiovascular morbidity. Traditional treatments focus on lipid reduction, yet newer therapies target plaque composition, aiming...INTRODUCTION: Coronary atherosclerosis, marked by lipid deposition and inflammation, drives cardiovascular morbidity. Traditional treatments focus on lipid reduction, yet newer therapies target plaque composition, aiming to enhance stability and prevent coronary events. AREAS COVERED: A comprehensive literature search was conducted across PubMed, Embase, and Scopus till January 2025 to identify studies on coronary plaque modification. This review highlights current and emerging therapies for coronary plaque modification. Key pharmacologic agents include Proprotein convertase subtilisin/kexin type 9 inhibitors for lipid management, colchicine for inflammation control, and Glucagon-like peptide-1 receptor agonists, and Sodium-glucose cotransporter-2 inhibitors for metabolic benefits. Clinical trials indicate these agents' roles in reducing plaque volume and vulnerability. Advances in imaging and biomarkers, such as lipoprotein(a) and inflammatory markers, enable refined monitoring of plaque changes over time. EXPERT OPINION: Future management of atherosclerosis may involve personalized strategies, integrating AI-driven predictive tools and biomarkers to assess individual plaque characteristics and optimize therapy. Continued exploration of targeted anti-inflammatory therapies and novel biomarkers like Lp(a) could enhance outcomes, offering a more precise approach to reducing cardiovascular risk and stabilizing high-risk plaques.
OBJECTIVE: To analyze the cost-effectiveness of apixaban in the prevention of stroke in adult patients with non-valvular atrial fibrillation (NVAF), compared to other direct-acting oral anticoagulants (dabigatran, rivaro...OBJECTIVE: To analyze the cost-effectiveness of apixaban in the prevention of stroke in adult patients with non-valvular atrial fibrillation (NVAF), compared to other direct-acting oral anticoagulants (dabigatran, rivaroxaban, edoxaban) and the vitamin K antagonist acenocoumarol, based on data on effectiveness in clinical practice in Spain obtained in the FANTASIIA study. RESEARCH DESIGN AND METHODS: A probabilistic Markov economic model (second-order Monte Carlo simulation) was performed to analyze the costs and utilities (quality-adjusted life years, QALYs) associated with the compared treatments, according to the different probabilities of stroke, major bleeding and death observed in FANTASIIA. RESULTS: The cost per QALY gained in the patient treated with apixaban versus comparators ranged from €2,919 to €7,462. The probability of apixaban being cost-effective ranges from 91.1% (vs dabigatran 150 mg), 97.8% (vs dabigatran 110 mg), and 100% (vs. rivaroxaban, edoxaban, and acenocoumarol). CONCLUSIONS: Based on the results of the FANTASIIA study, apixaban is a cost-effective treatment (below a willingness to pay of €25,000 per QALY gained) compared to dabigatran, rivaroxaban, edoxaban, and acenocoumarol in treating patients with NVAF.
BACKGROUND: We present an analysis of cardiovascular-related deaths specific to hematological cancer patients in the United States from 1999 to 2020, examining trends in relation to age, gender, and type of hematological...BACKGROUND: We present an analysis of cardiovascular-related deaths specific to hematological cancer patients in the United States from 1999 to 2020, examining trends in relation to age, gender, and type of hematological cancer. RESEARCH DESIGN AND METHODS: Utilizing the Multiple Cause of Death databases, our research included 88,146 decedents with cardiovascular primary cause of death and with hematologic disease. We determined the percentage of cardiovascular deaths associated with each disease category. Furthermore, we developed age-adjusted mortality rates, categorizing them based on sex, age, race, Latino origin, and the type of hematological cancer. RESULTS: Between 1999 and 2020, there was a decreasing temporal trend in overall cardiovascular mortality for lymphoma, leukemia and multiple myeloma (-38.8% -31.8% & -29.4%). The most common cardiovascular mortality cause in the hematological malignancy population was ischemic heart disease, followed by cerebrovascular disease (53.4%, 20.2%). African American, Asian, and White patients showed decreasing for overall CV death for all hematological malignancies, with African American subgroups showing the lowest mortality reduction over time (AAMR: -26.8%, -41.2%, -33.3%). However, hypertension mortality increased for most racial groups. CONCLUSIONS: Over the last 2 decades, the rate of cardiovascular mortality amongst patients with underlying hematological malignancy has decreased.
INTRODUCTION: The pathophysiology of cardiovascular diseases encompasses a complex interplay of genetic and environmental risk factors. Even if traditional risk factors are treated to target, there remains a residual ris...INTRODUCTION: The pathophysiology of cardiovascular diseases encompasses a complex interplay of genetic and environmental risk factors. Even if traditional risk factors are treated to target, there remains a residual risk. AREAS COVERED: This manuscript reviews the potential role of gut microbiota in the development of cardiovascular disease, and as potential target. A systematic search was conducted until 30 October 2024 on PubMed (MEDLINE), using the MeSH terms [Gut microbiota] + [Dysbiosis] + [Cardiovascular] + [TMAO] + [bile acids] + [short-chain fatty acids]. EXPERT OPINION: The term dysbiosis implies changes in equilibrium, with modifications in the composition and functionality of microbiota and a series of additional factors: reduced diversity and uniformity of microorganisms; reduced short-chain fatty acid-producing bacteria; increased gut permeability; release of metabolites, such as trimethylamine N-oxide, betaine, phenylalanine, tryptophan-kynurenine, phenylacetylglutamine, and lipopolysaccharides; and reduced secondary bile acid excretion, leading to inflammation, oxidative stress, and endothelial dysfunction and facilitating the onset of pathological conditions, including obesity, hypertension, diabetes, atherosclerosis, and heart failure. Attempts to restore gut microbiota balance through different interventions, mainly changes in diet, have been shown to positively affect individual components and metabolites and reduce the risk of cardiovascular disease. In addition, probiotics and prebiotics are potentially useful. Fecal microbiota transplantation is a promising therapy.
INTRODUCTION: People living with HIV (PLHIV) are at higher risk of cardiovascular disease (CVD), and dyslipidemia is a prevalent comorbidity that requires effective treatment. Limitations for the use of statins such as d...INTRODUCTION: People living with HIV (PLHIV) are at higher risk of cardiovascular disease (CVD), and dyslipidemia is a prevalent comorbidity that requires effective treatment. Limitations for the use of statins such as drug interactions and adverse effects highlight the need for alternative therapies. AREAS COVERED: This review evaluates the role of PCSK9 inhibitors in reducing cardiovascular risk in PLHIV with dyslipidemia. We analyzed studies available on PUBMED, using keywords HIV, dyslipidemia, PCSK9 inhibitors, and statin intolerance. We discuss the mechanisms underlying increased cardiovascular risk, limitations of statins, including a recent study using PCSK9 inhibitors. Evolocumab significantly reduced LDL-C levels by 56.9% in PLHIV, with 72.5% of patients achieving ≥50% LDL-C reduction. The trial confirmed the drug's safety. Additionally, PCSK9 inhibitors demonstrated reductions in lipoprotein(a) and inflammatory markers. EXPERT OPINION: PCSK9i present a promising option for lipid management in PLHIV, especially in statin-intolerant individuals or those with residual risk despite statin therapy. Additional non-statin therapies targeting adverse lipid profiles, including low HDL-C, high triglycerides, and lipoprotein(a), are under development. Combined with advancements in antisense oligonucleotides (ASOs) and siRNA technologies, they hold promise for transforming the treatment of dyslipidemia and cardiovascular disease in PLHIV.
INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a critical condition associated with high mortality rates and neurological impairment among survivors. In comatose OHCA patients who achieve return of spontaneous ci...INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a critical condition associated with high mortality rates and neurological impairment among survivors. In comatose OHCA patients who achieve return of spontaneous circulation, early risk stratification is important to inform treatment pathways and potentially improve outcomes. A range of prognostic tools have been developed to predict survival and neurological recovery. Each tool incorporates a unique combination of clinical, biochemical and physiological markers. AREAS COVERED: This review article evaluates the required clinical data, predictive performances and practical applicability of major risk scores. A literature review was conducted in PubMed and Embase for studies published between January 2000 and October 2024. The review emphasizes the variability in discriminative power among the selected scores, with some models offering high sensitivity and specificity in outcome prediction, while others prioritize simplicity and accessibility. EXPERT OPINION: Despite the advancements of these tools, limitations persist in data dependency and the clinical adaptability, highlighting areas for future improvement. Integrating artificial intelligence and real-time analytics could enhance predictive accuracy, offering dynamic prognostic capabilities that adapt to individual patient trajectories. This evolution must be grounded in ethical considerations to ensure predictive technologies complement rather than replace clinical judgment, balancing technology's potential with the complexities of individualized patient care.
BACKGROUND: Stroke is a potential complication of Transcatheter Aortic Valve Replacement (TAVR). Recent trials evaluating Cerebral Embolic Protection Systems (CEPS) to reduce the incidence of stroke after TAVR have been...BACKGROUND: Stroke is a potential complication of Transcatheter Aortic Valve Replacement (TAVR). Recent trials evaluating Cerebral Embolic Protection Systems (CEPS) to reduce the incidence of stroke after TAVR have been conflicting. METHODS: Multiple databases were searched for studies comparing TAVR with or without CEPS and that reported on the primary outcome of periprocedural stroke. Two authors individually screened the titles, the abstracts and the full texts using Covidence. Risk of bias was assessed using Cochrane's ROB-2 and ROBINS-I tools. RESULTS: A total of 15 studies (3 randomized controlled trials, 7 national registries, and 5 cohort studies) met the eligibility criteria and were included in our review. CEPS was associated with lower rates of periprocedural stroke [OR 0.71 (95% CI 0.55, 0.93) = 0.012], as well as lower rates of mortality [OR 0.60 (95% CI 0.49, 0.74) < 0.001]. There was no significant difference between the two groups in the incidence of acute kidney injury [OR 0.91 (95% CI 0.82, 1.01) = 0.087], major vascular complications [OR 0.97 (95% CI 0.83, 1.14) = 0.734], and major life-threatening bleeding [OR 0.89 (95% CI 0.73, 1.07) = 0.222]. CONCLUSIONS: Our findings suggest that the use of CEPS in TAVR is associated with a lower risk of periprocedural stroke and mortality. REGISTRATION: The PROSPERO identification number is CRD42022374055.
BACKGROUND: This study aimed to evaluate the effects of hydroxychloroquine on cardiac functions and left ventricular mass in patients with childhood-onset systemic lupus erythematosus (cSLE). RESEARCH DESIGN AND METHODS:...BACKGROUND: This study aimed to evaluate the effects of hydroxychloroquine on cardiac functions and left ventricular mass in patients with childhood-onset systemic lupus erythematosus (cSLE). RESEARCH DESIGN AND METHODS: Fifty patients with cSLE undergoing treatment with hydroxychloroquine underwent echocardiographic evaluation. All patients exhibited negative disease activity markers and were clinically in remission. RESULTS: The median duration of hydroxychloroquine exposure was 7.1 (5.2-9.5) years, with a median cumulative dose of 784.8 (509.5-3437.6) grams. No correlation was identified between the parameters of left ventricular ejection fraction, left ventricular mass index and geometry, and cumulative hydroxychloroquine dose ( = 0.245, = 0.094, = 0.146, respectively). Furthermore, no significant correlation was identified between the cumulative dose of hydroxychloroquine and diastolic cardiac parameters (all > 0.05). A comparison of the patients who received a cumulative dose of hydroxychloroquine below the median dose (the low-dose group) with those who received a higher dose (the high-dose group) revealed no significant differences in the echocardiographic parameters (all > 0.05). CONCLUSIONS: The findings of this study indicate that chronic hydroxychloroquine use in patients with cSLE does not result in adverse changes in left ventricular mass or impairment of cardiac functions. However, these patients should undergo regular evaluation to monitor for the potential development of cardiotoxicity.
de Vere F, Wijesuriya N, Howell S
… +6 more, Elliott MK, Mehta V, Mannakkara NN, Strocchi M, Niederer SA, Rinaldi CA
Expert Rev Cardiovasc Ther
· 2024 Dec · PMID 39695920
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INTRODUCTION: Cardiac Resynchronization Therapy (CRT) is an effective treatment for heart failure (HF) in approximately two-thirds of recipients, with a third remaining CRT 'non-responders.' There is an increasing body o...INTRODUCTION: Cardiac Resynchronization Therapy (CRT) is an effective treatment for heart failure (HF) in approximately two-thirds of recipients, with a third remaining CRT 'non-responders.' There is an increasing body of evidence exploring the reasons behind non-response, as well as ways to preempt or counteract it. AREAS COVERED: This review will examine the most recent evidence regarding optimizing outcomes from CRT, as well as explore whether traditional CRT indeed remains the best first-line therapy for electrical resynchronization in HF. We will start by discussing methods of preempting non-response, such as refining patient selection and procedural technique, before reviewing how responses can be optimized post-implantation. For the purpose of this review, evidence was gathered from electronic literature searches (via PubMed and GoogleScholar), with a particular focus on primary evidence published in the last 5 years. EXPERT OPINION: Ever-expanding research in the field of device therapy has armed physicians with more tools than ever to treat dyssynchronous HF. Newer developments, such as artificial intelligence (AI) guided device programming and conduction system pacing (CSP) are particularly exciting, and we will discuss how they could eventually lead to truly personalized care by maximizing outcomes from CRT.
INTRODUCTION: Hypertension is very common and a major risk factor for cardiovascular disease, heart failure, chronic kidney disease, strokes, and death. However, at present only 14% of patients of developing countries ha...INTRODUCTION: Hypertension is very common and a major risk factor for cardiovascular disease, heart failure, chronic kidney disease, strokes, and death. However, at present only 14% of patients of developing countries have their blood pressure (BP) well controlled. The causes for the failure to control the BP are multiple and one of them could be the formulation of antihypertensive drugs. AREAS COVERED: The recent development of nanotechnology by incorporating the drugs into nanoparticles is a new promising field of nanomedicine and preliminary studies have shown this nanoformulation to be more effective in the treatment of hypertension than the existing drug formulations. Another recent development is the nanoformulation of genes used for the treatment of hypertension and cardiovascular diseases. For current information, a Medline search was conducted between 2017 and 2024 and 36 pertinent papers were selected. EXPERT OPINION: The nanoformulations of drugs help achieve better drug concentrations, improve drug stability, low solubility, short half life, oral bioavailability, narrow therapeutic index, and poor pharmacokinetic and pharmacodynamic profiles, and decrease the adverse effects of antihypertensive drugs. Also, the nanoformulation of genes for the treatment of hypertension has been shown in preliminary studies to be effective, but more research is needed.
Cirillo C, Perillo A, Monda E
… +13 more, Palmiero G, Verrillo F, Rubino M, Diana G, Dongiglio F, Caiazza M, Cirillo A, Fusco A, Fumagalli C, Bossone E, Russo MG, Calabro P, Limongelli G
INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is defined by an increased left ventricular wall thickness not solely explainable by abnormal loading conditions. Estimated prevalence is 1:200-500 with roughly 60% of case...INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is defined by an increased left ventricular wall thickness not solely explainable by abnormal loading conditions. Estimated prevalence is 1:200-500 with roughly 60% of cases showing a familiar trait. Medical treatment and surgical interventions significantly altered prognosis in HCM. Recently, new therapies have been introduced in clinical practice and a patient-centric approach is key to HCM optimal management. This review aims to summarize the current HCM therapies focusing on the importance of personalized care and delineate therapeutic approaches under investigation. AREAS COVERED: The review summarizes and critically evaluates the available data on currently available pharmacological and non-pharmacological therapies for HCM. The evidence in support of the use of beta-blockers, non-dihydropyridine calcium channel blockers, disopyramide, and cardiac myosin inhibitors is discussed. Furthermore, data and controversies on sudden death prevention, surgical and non-surgical septal reduction therapies are reported. Finally, future perspectives in HCM management such as new drugs and gene therapies are explored. EXPERT OPINION: The authors stress the need for a personalized and tailored approach to managing patients with HCM, which is not only based on phenotypes and risk stratification, but also patients' preferences, needs, and beliefs.
INTRODUCTION: Mitral regurgitation is one of the most common forms of valvular heart diseases for which there have been several innovative treatment strategies that have developed over the last several decades. We descri...INTRODUCTION: Mitral regurgitation is one of the most common forms of valvular heart diseases for which there have been several innovative treatment strategies that have developed over the last several decades. We describe the various treatment modalities that have been used for the last several decades. All articles in PubMed, Cochrane, and Embase were screened from inception to August 2024 for the following - 'Mitral valve regurgitation' 'Mitral valve repair' 'Mitral valve replacement' 'Robotic mitral surgery' 'Transcatheter mitral valve repair.' AREAS COVERED: Mitral regurgitation (MR) is classified into primary and secondary MR. Causes of primary MR include degenerative disease, rheumatic heart disease, and infective endocarditis. Secondary MR is observed in the setting of left ventricle (LV) pathology, including ischemic or dilated cardiomyopathy. In secondary MR, annular dilation, papillary muscle displacement, tethering of chordae tendineae and/or mitral valve (MV) leaflets result in leaflet restriction and malcoaptation. EXPERT OPINION: In this review, we discuss various modalities for the treatment of mitral regurgitation, as well as newer treatment options for MR including robotic MV repair and other minimally invasive procedures. Several ongoing randomized controlled trials in this topic will help shed more light and provide guidance to deliver the optimal care for our patients.
INTRODUCTION: Managing patients with multiple risk factors for CVDs can present distinct challenges for healthcare providers, therefore addressing them can be paramount to optimize patient care. AREAS COVERED: This narra...INTRODUCTION: Managing patients with multiple risk factors for CVDs can present distinct challenges for healthcare providers, therefore addressing them can be paramount to optimize patient care. AREAS COVERED: This narrative review explores the burden that CVDs place on healthcare systems as well as how we can best optimize the risk management of these patients. Through a comprehensive review of literature, guidelines and clinical studies, this paper explores various approaches to risk management, lifestyle modifications and pharmacological interventions utilized in the management of CVDs. Furthermore, emerging technologies such as machine learning (ML) are discussed, highlighting potential opportunities for future research. By reviewing existing recommendations and evidence, this paper aims to provide insight into optimizing strategies and improving the outcomes for patients with multiple CVDs. EXPERT OPINION: Optimizing risk factors can have a significant impact on patient outcomes, as such each patient should have a clear plan on how to manage these risk factors to minimize adverse healthcare results.
INTRODUCTION: Antihypertensive treatment provides substantial benefits in older people. However, many challenges remain, including the ideal blood pressure (BP) target to be achieved. Because the elderly population is pa...INTRODUCTION: Antihypertensive treatment provides substantial benefits in older people. However, many challenges remain, including the ideal blood pressure (BP) target to be achieved. Because the elderly population is particularly vulnerable to adverse events, BP control should be carefully managed. Some studies have evaluated the cardiovascular effects of different BP targets in older patients, with mixed results and uncertainty about the most appropriate BP target. However, pooled analyses suggest that intensive BP lowering provides greater cardiovascular protection than less intensive strategies in elderly hypertensive patients. AREAS COVERED: Understanding the balance between the risks and benefits of intensive BP targets and individualizing treatment is essential to ensure that older patients receive appropriate treatment to reduce the risk of cardiovascular complications. We reviewed data from clinical trials which investigated the protective effects of BP lowering drugs in elderly hypertensive patients aged ≥65 years. EXPERT OPINION: Evidence suggests that age does not preclude an aggressive strategy for treating hypertension in elderly patients. Being 'tolerant' with one hand and 'intensive' with the other should become a universal standard in the management of elderly hypertensive patients. The lowest well-tolerated BP could be a simple and universally applicable BP target in the management of hypertensive patients, including the elderly.
INTRODUCTION: The transition to or from direct oral anticoagulants (DOACs) is common in clinical practice. AREAS COVERED: A literature search was conducted on PubMed, Google Scholar, and UpToDate up to March 2024 for con...INTRODUCTION: The transition to or from direct oral anticoagulants (DOACs) is common in clinical practice. AREAS COVERED: A literature search was conducted on PubMed, Google Scholar, and UpToDate up to March 2024 for conditions and approaches for transitioning from one agent to the other. No randomized clinical trials were retrieved except for two studies regarding switching to DOAC in well-conducted vitamin K antagonist (VKA) therapy. A narrative review was conducted addressing the conditions for switching from one agent to the other, such as thromboembolic events and major bleeding during anticoagulation, development or worsening of kidney or liver failure, initiation of interfering drugs, adverse events such as allergic reactions, frailty, patients' preferences, and affordability. During transitions from one anticoagulant to the other, the risk of both thromboembolic and bleeding complications should be minimized. The current approaches for such transitions are derived from those employed in clinical trials evaluating DOAC and from product information. EXPERT OPINION: Many uncertainties remain regarding those circumstances requiring a change in anticoagulant strategies, as they lack evidence-based guidance. It can be envisaged that the problem of switching to and from DOAC will need additional studies especially addressing the conditions and the best approach to such transitions.
INTRODUCTION: Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding i...INTRODUCTION: Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management, and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management. AREAS COVERED: This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management. EXPERT OPINION: Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.
INTRODUCTION: Eprosartan is an angiotensin receptor blocker (ARB) used for management of essential hypertension. With unique pharmacological characteristics, dual action mechanism, and clinical effectiveness, eprosartan...INTRODUCTION: Eprosartan is an angiotensin receptor blocker (ARB) used for management of essential hypertension. With unique pharmacological characteristics, dual action mechanism, and clinical effectiveness, eprosartan offers additional advantages over other ARBs in specific patient populations. AREAS COVERED: A comprehensive review of the literature was performed across publicly available databases, with no time limitations, to ensure the inclusion of all relevant studies. The review focuses on presenting the efficacy and safety profile of eprosartan, alone or in combination with other agents. Additionally, it explores the etiology of hypertension concerning the structure and function of angiotensin II type 1 receptors. Further, the efficacy of eprosartan in special populations and its additional benefits are also discussed. EXPERT OPINION: Eprosartan effectively reduces blood pressure (BP), with a 24-hour BP-lowering effect at 600 mg/day. Eprosartan demonstrates similar or better efficacy than other ARBs, such as telmisartan and losartan, particularly in managing coagulation-related abnormalities and peripheral resistance. In combination therapy, eprosartan with hydrochlorothiazide significantly enhances BP reduction. Eprosartan is well-tolerated, with a low incidence of adverse events, making it a reliable choice for long-term hypertension management across various patient populations, such as those with comorbid diabetes and renal disease and older adults.