2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

LASF: a local adaptive segmentation framework for coronary angiogram segments

Coronary artery disease (CAD) remains the leading cause of death globally, highlighting the critical need for accurate diagnostic tools in medical imaging. Traditional segmentation methods for coronary angiograms often struggle with vessel discontinuity and inaccuracies, impeding effective diagnosis and treatment planning. To address these challenges, we developed the Local Adaptive Segmentation Framework (LASF), enhancing the YOLOv8 architecture with dilation and erosion algorithms to improve the continuity and precision of vascular image segmentation. We further enriched the ARCADE dataset by meticulously annotating both proximal and distal vascular segments, thus broadening the dataset's applicability for training robust segmentation models. Our comparative analyses reveal that LASF outperforms well-known models such as UNet and DeepLabV3Plus, demonstrating superior metrics in precision, recall, and F1-score across various testing scenarios. These enhancements ensure more reliable and accurate segmentation, critical for clinical applications. LASF represents a significant advancement in the segmentation of vascular images within coronary angiograms. By effectively addressing the common issues of vessel discontinuity and segmentation accuracy, LASF stands to improve the clinical management of CAD, offering a promising tool for enhancing diagnostic accuracy and patient outcomes in medical settings.

Myocardial perfusion imaging in advanced coronary artery disease

Myocardial perfusion imaging (MPI) is widely adapted as a noninvasive technique to assess the presence and extent of ischemia in patients with symptoms suggestive of obstructive coronary artery disease (CAD). However, as CAD advances, several factors can complicate the interpretation of MPI, subsequently impacting clinical decision-making. This review focuses on the utility of MPI by means of cardiac magnetic resonance (CMR) imaging, single-photon emission computed tomography (SPECT) and positron emission tomography (PET) in patients with advanced CAD-the latter characterized by documented CAD (i.e. prior myocardial infarction [MI] and/or percutaneous coronary intervention [PCI]), prior coronary artery bypass grafting (CABG) or the presence of a chronic total occlusion (CTO). It will discuss factors impacting the interpretation of MPI, the diagnostic performance for detecting obstructive CAD and coronary microvascular dysfunction (CMD), as well as the role of MPI in guiding revascularization.

Routine stress testing with subsequent coronary angiography versus standard of care in high-risk patients after percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials

Routine functional stress testing with subsequent coronary angiography is undertaking to detect early restenosis and guide revascularization in high-risk patients after percutaneous coronary intervention (PCI). However, the safety and efficacy of routine functional stress testing over standard care is still debatable. This meta-analysis compares routine functional stress testing vs. standard care in high-risk patients after PCI. We systematically searched PubMed, Embase, and Cochrane Central databases to identify randomized controlled trials (RCTs) that compared functional stress testing versus standard of care after PCI in high-risk patients from inception to January 2025. We calculated the risk ratios (RRs) with 95 % confidence intervals (CIs) using the random-effects model for clinical outcomes. Four RCTs with 6,290 patients, of whom 3,206 (51 %) underwent routine functional stress testing were included in our analyses. The incidence of target lesion revascularization (TLR) was higher in routine functional stress testing (RR: 1.49; 95 % CI: 1.02-2.18; p = 0.038) compared with standard care. However, no statistically significant difference was observed for individual outcomes of all-cause mortality (RR: 0.89; 95 % CI: 0.48-1.18; p = 0.198), myocardial infarction (MI) (RR: 0.62; 95 % CI: 0.31-1.24; p = 0.174), and hospitalization for any cause (RR: 1.22; 95 % CI: 0.24-6.10; p = 0.809). The risk of MACE did not significantly differ between the groups (RR: 1.11; 95 % CI: 0.82-1.51; p = 0.480). Routine functional stress testing after PCI in high-risk patients was associated with increased incidence of target lesion revascularization, without reducing the risk of major adverse cardiovascular events.

Metal-Organic Frameworks: Unlocking New Frontiers in Cardiovascular Diagnosis and Therapy

Cardiovascular disease (CVD) is one of the most critical diseases which is the predominant cause of death in the world. Early screening and diagnosis of the disease and effective treatment after diagnosis play an important role in the patient's recovery. Metal-organic frameworks (MOFs), a kind of hybrid ordered micro or meso-porous materials, constructed by metal nodes or clusters with organic ligands, due to their special features like high porosity and specific surface area, open metal sites, or ligand tunability, are widely used in various areas including gas storage, catalysis, sensors, biomedicine. Recently, advances in MOFs are bringing new developments and opportunities for the healthcare industry including the theranostic of CVD. In this review, the applications of MOFs are illustrated in the diagnosis and therapy of CVD, including biomarker detection, imaging, drug delivery systems, therapeutic gas delivery platforms, and nanomedicine. Also, the toxicity and biocompatibility of MOFs are discussed. By providing a comprehensive summary of the role played by MOFs in the diagnosis and treatment of CVDs, it is hoped to promote the future applications of MOFs in disease theranostics, especially in CVDs.

What People Want: Exercise and Personalized Intervention as Preferred Strategies to Improve Well-Being and Prevent Chronic Diseases

Background/Objectives: The workplace represents an ideal context for applying policies to foster a healthy lifestyle, guaranteeing advantages both to the individual and the company. Nevertheless, motivation to change one's lifestyle remains an issue. This study aimed to determine subjects' most valued intentions toward lifestyle changes and the target actions to improve lifestyles that they would be willing to invest in economically, information which might help design effective intervention programs. Methods: Classification trees were applied to 2762 employees/ex-employees (55.09 ± 13.80 years; 1107 females and 1655 males) of several Italian companies who voluntarily filled out an anonymous questionnaire on lifestyles (inquiring about, e.g., exercise, nutrition, smoking, and stress) to unveil specific subject typologies that are more likely associated with, e.g., manifesting a specific intention toward lifestyle changes and choosing the two most popular target actions resulting from the survey. Results: The main lifestyle aspect that respondents desired to improve was to become more physically active, and the most preferred tools chosen to improve their lifestyle were the possibility of having a medical specialist consultant to prescribe a tailored lifestyle program and buying a gym/swimming pool membership. Conclusions: This observational study might help tailor worksite health promotion and insurance services offered to employees, initiatives that may play an important role in fostering health/well-being and preventing chronic diseases in the more general population, especially in healthy or young subjects who are more prone to change their behavior if immediate benefits are seen instead of only advantages in the future.

Effect of low-dose colchicine on pericoronary inflammation and coronary plaque composition in chronic coronary disease: a subanalysis of the LoDoCo2 trial

BACKGROUND

Low-dose colchicine (0.5 mg once daily) reduces the risk of major cardiovascular events in coronary disease, but its mechanism of action is not yet fully understood. We investigated whether low-dose colchicine is associated with changes in pericoronary inflammation and plaque composition in patients with chronic coronary disease.

METHODS

We performed a cross-sectional, nationwide, subanalysis of the Low-Dose Colchicine 2 Trial (LoDoCo2, n=5522). CT angiography studies were performed in 151 participants randomised to colchicine or placebo coronary after a median treatment duration of 28.2 months. Pericoronary adipose tissue (PCAT) attenuation measurements around proximal coronary artery segments and quantitative plaque analysis for the entire coronary tree were performed using artificial intelligence-enabled plaque analysis software.

RESULTS

Median PCAT attenuation was not significantly different between the two groups (-79.5 Hounsfield units (HU) for colchicine versus -78.7 HU for placebo, p=0.236). Participants assigned to colchicine had a higher volume (169.6 mm3 vs 113.1 mm3, p=0.041) and burden (9.6% vs 7.0%, p=0.035) of calcified plaque, and higher volume of dense calcified plaque (192.8 mm3 vs 144.3 mm3, p=0.048) compared with placebo, independent of statin therapy. Colchicine treatment was associated with a lower burden of low-attenuation plaque in participants on a low-intensity statin, but not in those on a high-intensity statin (pinteraction=0.037).

CONCLUSIONS

Pericoronary inflammation did not differ among participants who received low-dose colchicine compared with placebo. Low-dose colchicine was associated with a higher volume of calcified plaque, particularly dense calcified plaque, which is considered a feature of plaque stability.

Ischemia on Dobutamine Stress Echocardiography Predicts Efficacy of PCI: Results From the ORBITA-2 Trial

BACKGROUND

ORBITA-2 (The Placebo-Controlled Trial of Percutaneous Coronary Intervention for the Relief of Stable Angina) found that percutaneous coronary intervention (PCI) relieved angina in patients with single-vessel and multivessel stable coronary artery disease (CAD) on little or no antianginal medication. Whereas symptom characteristics and invasive physiological assessments can predict PCI efficacy, the role of noninvasive imaging with dobutamine stress echocardiography (DSE) remains unclear.

OBJECTIVES

This DSE-stratified secondary analysis of ORBITA-2 investigates the relationship between ischemia, assessed by DSE, and the placebo-controlled efficacy of PCI.

METHODS

Participants with angina, single-vessel or multivessel CAD, and ischemia were enrolled. Following discontinuation of antianginal medications, patients were evaluated prerandomization using the ORBITA-app, questionnaires, DSE, and exercise treadmill testing. Stress echocardiography scores were calculated for each left ventricular segment at peak stress, with normal, hypokinetic, akinetic, dyskinetic, and aneurysmal segments scoring 0 to 4, respectively. Bayesian proportional odds modeling was used.

RESULTS

Prerandomization DSE data were available for 262 patients. The median age was 65.5 years (Q1-Q3: 59-71 years), and 208 (79.4%) were male. At baseline, the median stress echocardiography score was 1.42 in the PCI group (n = 133) and 1.00 in the placebo group (n = 129), with an overall median score of 1.25 (Q1-Q3: 0.33-2.92). Higher stress echocardiography scores were strongly associated with greater placebo-controlled improvements in angina symptom score following PCI (OR: 1.23; 95% credible interval [CrI]: 1.13-1.35; Pr(interaction) > 99.9%). Higher scores also predicted significant reduction in daily angina episodes (OR: 1.36; 95% CrI: 1.24-1.49; Pr(interaction) > 99.9%), as well as improvement in the Seattle Angina Questionnaire angina frequency score (8.22; 95% CrI: 0.96-15.50; Pr(interaction) = 98.7%), and Seattle Angina Questionnaire quality of life score (8.95; 95% CrI: 2.05-16.00; Pr(interaction) = 99.3%). The relationship between stress echocardiography score and reduction in daily angina episodes remained consistent, irrespective of symptom characteristics.

CONCLUSIONS

In patients with single- and multivessel stable CAD on little or no antianginal medication, the placebo-controlled efficacy of PCI was predicted by the degree of ischemia detected on DSE. The greater the burden of baseline ischemia, the greater the improvement in symptoms and quality of life with PCI.

Coronary computed tomography angiography to guide percutaneous coronary intervention: Expert opinion from a SCAI/SCCT roundtable

Coronary computed tomography angiography (CCTA) has emerged as an important tool for planning percutaneous coronary intervention (PCI). While it has traditionally been employed for diagnostic purposes, increasing evidence and real-world experience suggest that CCTA can be used for the pre-procedural planning of PCI and inform patient triage, shared decision-making, case complexity, and resource use. This approach mirrors how computed tomography angiography is routinely used to plan structural interventions. To address these emerging opportunities, the Society for Cardiovascular Angiography & Interventions (SCAI) and the Society of Cardiovascular Computed Tomography (SCCT) organized a multidisciplinary, expert scientific roundtable on the use of CCTA for guiding PCI. The goal of this document is to provide a state-of-the-art overview of CCTA-guided PCI, focused on practical applications and key coronary lesion subsets, define unmet needs and barriers, and outline future directions.

Access to CCTA at safety-net hospitals across the United States

BACKGROUND

Coronary CT angiography (CCTA) has received a class 1A indication for the evaluation of patients with acute and stable chest pain after studies revealed the use of CCTA reduces mortality, rates of MI, unnecessary invasive procedures, and healthcare expenditure compared to traditional stress testing. Despite this recommendation, hospitals across the U.S. have not adopted CCTA at levels expected for standard of care. We sought to evaluate the availability of CCTA at U.S. safety-net hospitals.

METHODS

U.S. safety-net hospitals were identified using the Lown Institute definition. The ability to perform CCTA at each of these hospitals was assessed. Data was stratified based on rural vs. urban geography, bed size, state, and academic status. Critical access hospitals, specialty hospitals, and those without emergency services were excluded. Variations in CCTA availability were compared with Chi-square tests.

RESULTS

391 safety-net hospitals in the U.S. were identified according to the criteria, of which 179 (45.8 ​%) offer CCTA. Availability of CCTA varied significantly depending on the size of the facility (0-49 beds: 7.7 ​%, 50-99 beds: 43.8 ​%, 100-199 beds: 45.6 ​%, 200-399 beds: 71 ​%, and ≥400 beds: 88.9 ​%, p ​< ​0.001), rural vs. urban setting, (22 ​% vs. 57 ​%, p ​< ​0.001), and academic vs. non-academic settings (97 ​% vs. 41 ​%, p ​< ​0.001).

CONCLUSIONS

Fewer than half of identified U.S. safety-net hospitals were found to provide CCTA for the evaluation of cardiac patients despite its 1A recommendation. This research highlights alarming trends in cardiovascular health care disparities and serves as a call to action to combat inequity through the expansion of CCTA availability.

Comparison of cardiac computed tomography recommendations in recent ESC vs. ACC/AHA guidelines

Cardiac computed tomography (CCT) continues to expand with increasing applications and technological advancements. Growing evidence on the clinical utility of CCT necessitates evaluating how this knowledge is incorporated into European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. We aimed to provide a comprehensive comparison of CCT indications between ESC and ACC/AHA guidelines to identify areas of consensus and divergence in the current landscape of CCT utilization. ESC and ACC/AHA guidelines were systematically reviewed for CCT recommendations. The class of recommendation (COR) and level of evidence (LOE) were compared using χ2 or Fisher exact tests. The latest ESC guidelines included 40 recommendations regarding CCT: 18 (45%) COR-I, 14 (35%) COR-IIa, 6 (15%) COR-IIb, and 2 (5%) COR-III. Two (5%) recommendation had LOE-A, 20 (50%) had LOE-B, and 18 (45%) had LOE-C. The latest ACC/AHA guidelines consisted of 54 recommendations: 18 (33.3%) COR-I, 28 (51.9%) COR-IIa, 6 (11.1%) COR-IIb, and 2 (3.7%) COR-III. Two recommendations were assigned LOE-A (3.7%), 30 (55.6%) were classified as LOE-B, and 22 (40.7%) as LOE-C. ACC/AHA guidelines had a significantly higher proportion of COR-IIa recommendations (P = 0.04) and similar proportions of COR-I and COR-IIb recommendations (P = 0.28; P = 0.76), compared to ESC guidelines. The proportion of LOE-B and LOE-C recommendations weren't statistically different (P = 0.54; P = 0.84). ACC/AHA guidelines included more CCT recommendations with a higher COR and LOE than ESC guidelines. These findings highlight the need for continued research and consensus-building to establish standardized, evidence-based CCT recommendations in clinical practice.

Thoracic pain: From guidelines to clinical practice

Thoracic pain is the most prevalent symptom in patients with cardiovascular diseases. Diagnosis and patient management are guided by the pain attributes, analytical parameters, and several different imaging modalities. Invasive imaging tests and cardiac magnetic resonance are highly relevant in this context, as set out in the 2023 European guidelines for the management of acute coronary syndromes, the 2023 American guidelines for the management of patients with chronic coronary disease, and the 2021 American guidelines for the evaluation and diagnosis of chest pain. This article focuses on the role that these guidelines attribute to non-invasive cardiac imaging (computed tomography and cardiac magnetic resonance) in the management of both acute and chronic coronary syndrome.

Pantera Lux Drug-Coated Balloon for the Treatment of Coronary Artery Lesions in Routine Practice

Background/Objectives: We sought to confirm the performance and safety of the Pantera Lux paclitaxel-coated balloon (pDCB) when used as per the instructions for use at a single high-volume center. Methods: In this retrospective analysis, 386 consecutive patients were categorized into three groups: the treatment of drug-eluting stent in-stent restenosis (DES-ISR) lesions (n = 191), bare-metal stent in-stent restenosis (BMS-ISR) lesions (n = 127), and de novo lesions (n = 68). The primary endpoint at 12 months was target-lesion revascularization (TLR). Secondary endpoints were device success, target-vessel myocardial infarction (TV-MI), and cardiac death. Results: The baseline characteristics were balanced between the groups, with a median age of 71.3 years, 25% being female, 32% being diabetic. The majority presented with chronic coronary syndrome (82.9%). Type C lesions were more often observed in the DES-IRS group as compared with the BMS-IRS and de novo groups (15.6% vs. 7.9% vs. 7.4%, p < 0.001). Cutting balloons were more often used in the DES-IRS group (41.0% vs. 19.7% vs. 1.5%, p < 0.001). The residual stenosis rate was 7.6% vs. 3.3% vs. 7.3% (p = 0.002). The TLR at 12 months was 8.9% vs. 2.4% vs. 1.5% (p = 0.013). Device success was achieved in 98.8% vs. 98.5% vs. 100% of cases (p = 0.8). TV-MI occurred in 3.2% vs. 0.8% vs. 1.5% (p = 0.5) and cardiac death in 2.6% vs. 0.0% vs. 2.9% (p = 0.13) in DES-IRS vs. BMS-IRS vs. de novo lesions. Conclusions: In this single-center observation, we confirmed the safety and efficacy of the Pantera Lux paclitaxel-coated balloon for the treatment of DES-IRS, BMS-IRS, and de novo lesions with low TLR rates at 12 months.

Molecular imaging of cardiovascular disease: Current status and future perspective

Advancements in knowledge of cardiovascular disease, pharmacology, and chemistry have led to the development of newer radiopharmaceuticals and targets for new and more suitable molecules. Molecular imaging encompasses multiple imaging techniques for identifying the characteristics of key components involved in disease. Despite its limitations in spatial resolution, the affinity for key molecules compensates for disadvantages in diagnosing diseases and elucidating their pathophysiology. This review introduce established molecular tracers involved in clinical practice and emerging tracers already applied in clinical studies, classifying the key component in A: artery, specifically those vulnerable plaque (A-I) inflammatory cells [18F-FDG]; A-II) lipid/fatty acid; A-III) hypoxia; A-IV) angiogenesis; A-V) protease [18F/68Ga-FAPI]; A-VI) thrombus/hemorrhage; A-VII) apoptosis and A-VIII) microcalcification [18F-NaF]) and B: myocardium, including myocardial ischemia, infarction and myocardiopathy (B-I) myocardial ischemia; B-II) myocardial infarction (myocardial damage and fibrosis); B-III) myocarditis and endocarditis; B-IV) sarcoidosis; B-V) amyloidosis; B-VI) metabolism; B-VII) innervation imaging). In addition to cardiovascular-specific tracers tested in animal models, many radiotracers may have been developed in other areas, such as oncology imaging or neuroimaging. While this review does not cover all available tracers, some of them hold potential for future use assessing cardiovascular disease. Advances in molecular biology, pharmaceuticals, and imaging sciences will facilitate the identification of precise disease mechanisms, enabling precise diagnoses, better assessment of disease status, and enhanced therapeutic evaluation in this multi-modality era.

RAAS inhibitors in pregnancy, breastfeeding and women of childbearing potential: a review of national and international clinical practice guidelines

Globally prevalent conditions such as hypertension, heart failure, ischaemic heart disease (IHD) and chronic kidney disease (CKD) are frequently and effectively treated with blockers of the renin-angiotensin-aldosterone system (RAAS) as a first line treatment in the UK and worldwide. RAAS blockers are prohibited in pregnancy due to their adverse fetal effects. We reviewed clinical guidelines from the National Institute of Health and Care Excellence (NICE) on the management of cardiovascular and kidney disease with RAAS blockers in pregnancy, with other UK, European and American guidance as comparators. Whilst guidelines agree on the strict avoidance of RAAS blockers in pregnancy, nuanced considerations regarding prescription in women of childbearing potential, contraception, timing of RAAS blocker withdrawal and breastfeeding are not consistently addressed in clinical guidelines. We call for consistent wording and more explicit advice on RAAS blocker prescription in women of childbearing potential, in pregnancy and in the postpartum period in future iterations of clinical guidelines.

The Impact of Technology-Based Cardiac Rehabilitation on Exercise Capacity and Adherence in Patients with Coronary Artery Disease: An Artificial Intelligence Analysis

BACKGROUND

Exercise training programs improve exercise capacity and quality of life (QoL) in patients with coronary artery disease (CAD). Although artificial intelligence (AI) has been used to design such programs, there are still few studies evaluating their effectiveness.

OBJECTIVES

This study compared the effects of technology-based and traditional programs for cardiac rehabilitation (CR) on exercise capacity and participation in patients with CAD using AI for data analysis.

METHODS

A total of 52 patients with CAD were randomly assigned to three groups: i) telerehabilitation group (TRG) (n=18); ii) mobile application group (MAG) (n=13); and iii) control group (CG), which received only physical activity recommendations (n=21). TRG and MAG participants completed a 12-week program with calisthenic and resistance exercises three times a week. Exercise capacity was assessed using the Incremental Shuttle Walk Test (ISWT), and QoL was measured with the Short Form-36 (SF-36). Patient feedback was analyzed using a fine-tuned BERT-based natural language processing (NLP) model. Anomaly detection methods were applied to find mismatches between self-reported adherence and ISWT results. Statistical significance was set at p<0.05.

RESULTS

Both TRG [44.4% female] (Δ=87.2±15.2 m) and MAG [50% female] (Δ=89.4±70.4 m) had significant ISWT improvements compared to CG [47.6% female] (Δ=10.9±28.2 m) (p=0.001). Adherence was higher in TRG (100%) and MAG (80%) than in CG (30%) (p<0.001). Patient-reported satisfaction, analyzed via NLP, showed a significant positive correlation with ISWT improvements (r=0.75, p<0.001). Findings show the potential of AI to support outcome assessment in CR.

CONCLUSIONS

Technology-based CR programs improve exercise capacity and adherence in patients with CAD, supporting the use of AI-driven tools. NLP analysis helped link patient feedback to exercise outcomes and detect inconsistencies, showing its value in enhancing CR evaluation.

Insights from autopsy-initiated pathological studies of the pathogenesis and clinical manifestations of atherosclerosis and ischemic heart disease: Part I. Atherosclerosis

CONTEXT

Ischemic heart disease (IHD) due to coronary atherosclerosis constitutes the leading cause of morbidity and mortality worldwide. This review was undertaken to document the historical basis for our contemporary understanding of atherosclerosis-based disease and to provide a rationale for continued support for autopsy-based research to make further progress in reducing the morbidity and mortality from atherosclerosis-related disease.

OBJECTIVES

To analyze the contributions of the autopsy-initiated pathological studies to complement and validate other lines of investigation in determining the pathology and pathogenesis of the leading worldwide cause of morbidity and mortality, namely, atherosclerosis and its major complications of coronary atherosclerosis, ischemic heart disease, coronary thrombosis, acute myocardial infarction, and sudden cardiac death.

DATA SOURCES

Systematic search on PubMed to gather relevant studies concerning autopsy studies and reviews of the pathology and pathogenesis of atherosclerosis, ischemic heart disease, coronary atherosclerosis, coronary thrombosis, myocardial infarction, and sudden cardiac death CONCLUSIONS: Extensive published reports have confirmed the continuing importance of the autopsy as a powerful tool to understand the pathogenesis, clinical features, and therapeutic options for major diseases. This specifically has been shown by the analysis of atherosclerosis and its major manifestation of ischemic heart disease, as presented in this (Part I) and its companion (Part II) review. Autopsy-initiated pathological studies have documented the prevalence and natural history of atherosclerosis in different human populations in relationship to the prevalence of risk factors and established that the clinically silent phase of the disease begins in the first decades of life. Insights from these studies have been essential in developing and evaluating strategies for continued progress in preventing and controlling the disability and death associated with atherosclerotic heart disease.

Evolving trends in acid suppression therapy among patients undergoing dual antiplatelet therapy: A Nationwide study in South Korea from 2018 to 2022

AIMS

We aimed to examine the recent trends in the use of acid suppression therapies, including proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs) and potassium-competitive acid blockers (P-CABs), in patients undergoing dual antiplatelet therapy (DAPT) as aspirin-clopidogrel following coronary stent implantation in South Korea between 2018 and 2022.

METHODS

This observational study analysed data from the Health Insurance Review and Assessment Service (HIRA) on patients who underwent coronary stent implantation and received aspirin-clopidogrel DAPT. Patients who received acid suppression therapy for >60 days during DAPT were included in the analysis. Trends in the use of PPIs, H2RAs and P-CABs were assessed at 6-month intervals using the Cochran-Armitage trend test.

RESULTS

Of the 128 121 patients studied who received DAPT, 61 731 (48.2%) were prescribed acid suppression therapy. The proportion of patients receiving concomitant acid suppressants with DAPT increased from 42.8% in 2018 to 53.8% in 2022. PPIs were the most commonly used therapies (78.9%), followed by H2RAs (14.6%) and P-CABs (6.5%). PPI use peaked in 2020 and declined thereafter, whereas P-CAB use steadily increased, surpassing that of H2RA by 2021.

CONCLUSIONS

The landscape of acid suppression therapy for patients undergoing DAPT has evolved with a growing preference for P-CABs. This shift highlights the need for further research comparing the efficacy and safety of acid suppressants to guide clinical decision making.

Design and rationale of the efficacy of endothelin receptor antagonism in treatment of coronary artery spasm: a randomized controlled trial (EDIT-CAS)

BACKGROUND

Patients with angina and no obstructive coronary artery disease frequently have vasomotor dysfunction as the underlying mechanism for symptoms. Patients with vasomotor dysfunction have a high angina burden and their treatment frequently fails to reduce complaints sufficiently. Targeted therapies are currently unavailable due to heterogeneity in the patient population and incomplete understanding of the underlying pathophysiological mechanisms. One of the vasomotor dysfunction endotypes, epicardial spasm, is hypothesized to be a possible target for endothelin receptor antagonism treatment.

METHODS

The EDIT-CAS trial is a registry based, double blind, randomised, placebo-controlled clinical trial and aims to compare the efficacy of 10 weeks of add-on bosentan treatment versus placebo to prevent epicardial spasm at repeat spasm provocation test. Secondary and explorative outcomes are the effect on anginal complaints, safety of bosentan treatment, changes in coronary reactivity and the relationship between baseline endothelin levels and treatment success. We will include 100 patients with previously diagnosed epicardial vasospasm on a maximal triggering dose of 100 micrograms of acetylcholine and continuing angina(-like) symptoms at least weekly despite optimal medical treatment.

TRIAL REGISTRATION

The is registered in Clinical Trials Information System (2023-507782-25-00) and ClinicalTrials.gov (NCT06432452).

2025 AHA/ACC Clinical Performance and Quality Measures for Patients With Chronic Coronary Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

Resibufogenin protects against atherosclerosis in ApoE-/- mice through blocking NLRP3 inflammasome assembly

INTRODUCTION

Atherosclerosis (AS), a major cause of cardiovascular diseases, is characterized by lipid accumulation and chronic inflammation within arterial walls. Traditional treatments, such as statins, are often ineffective for many patients, highlighting the need for novel therapeutic strategies.

OBJECTIVE

This study explores the potential of Resibufogenin (RBG) as an NLRP3 inflammasome inhibitor for treating AS in ApoE-/- mice.

METHODS

We performed experiments encompassing cellular studies, animal model assessments, molecular simulations, and binding assays to assess RBG's impact on the NLRP3 inflammasome, inflammatory cytokine release, and foam cell formation.

RESULTS

RBG treatment alleviated AS in ApoE-/- mice, evidenced by reduced body weight, smaller atherosclerotic plaques, and improved serum lipid profiles. Transcriptomics and molecular biology demonstrated that RBG suppressed the expression of key inflammatory markers such as NLRP3. RBG also reduced macrophage infiltration and promoted polarization toward the anti-inflammatory M2 phenotype. Molecular docking, SPR, Pull-down studies identified a non-covalent interaction between RBG and the CYS-279 residue of NLRP3, confirming its role as a potent NLRP3 inhibitor.

CONCLUSION

RBG effectively inhibits NLRP3 inflammasome activation, reduces pro-inflammatory cytokine release, and decreases formation of foamy macrophages, thereby slowing the progression of AS. Although these findings highlight RBG as a promising therapeutic approach for cardiovascular diseases, further research is necessary to assess its safety and effectiveness in humans and to investigate possible synergistic effects with other treatments.

Outcomes After CABG Compared With FFR-Guided PCI in Patients Presenting With Acute Coronary Syndrome

BACKGROUND

There are limited data comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

OBJECTIVES

The aim of this study was to evaluate differences in outcomes in patients presenting with or without NSTE-ACS after CABG compared with fractional flow reserve (FFR)-guided PCI using current generation drug-eluting stents.

METHODS

The FAME 3 trial (Fractional flow reserve versus Angiography for Multivessel Evaluation; NCT02100722) was an investigator-initiated, randomized controlled trial to attest noninferiority of FFR-guided PCI using the current-generation drug-eluting stents to CABG with respect to the primary endpoint, defined as a composite of death, myocardial infarction (MI), stroke, or repeat revascularization at 1 year, in 1,500 patients with 3-vessel coronary artery disease. The prespecified key secondary endpoint was a composite of death, MI, or stroke at 3 years.

RESULTS

Of 1,500 patients enrolled, 587 (39.2%) presented with NSTE-ACS. Patients were followed up for a median of 1,080 days (Q1-Q3: 1,080-1,080 days). At 3 years, the risk of the composite of death, MI, or stroke was similar between patients presenting with NSTE-ACS and with chronic coronary syndrome (CCS) (11.8% vs 10.0%; adjusted HR [aHR]: 1.20; 95% CI: 0.81-1.77; P = 0.37). Patients presenting with NSTE-ACS had a similar risk of death, MI, or stroke at 3 years after CABG as compared with PCI (aHR: 0.98; 95% CI: 0.60-1.60; P = 0.94), whereas patients presenting with CCS had a significantly reduced risk after CABG compared with PCI (aHR: 0.58; 95% CI: 0.38-0.90; P = 0.02; Pinteraction = 0.11), which was driven by a lower risk of MI (aHR: 0.32; 95% CI: 0.15-0.64; P = 0.002; Pinteraction = 0.01).

CONCLUSIONS

The risk of death, MI, or stroke at 3 years was similar after CABG compared with FFR-guided PCI in patients presenting with NSTE-ACS, but reduced by CABG in patients presenting with CCS. (Fractional flow reserve versus Angiography for Multivessel Evaluation [FAME 3]; NCT02100722).

Residual cholesterol and inflammatory risk in statin-treated patients undergoing percutaneous coronary intervention†

BACKGROUND AND AIMS

Elevated LDL-cholesterol levels and inflammation, as assessed by high-sensitivity C-reactive protein, correlate with cardiovascular risk. However, data on the relative impact of residual LDL-cholesterol and inflammatory risk among statin-treated patients undergoing percutaneous coronary intervention (PCI) is lacking. Hence, this study aimed to investigate the impact of residual cholesterol/inflammatory risk in patients on statin therapy undergoing PCI.

METHODS

From 2012 to 2022, patients at a tertiary centre undergoing PCI were analysed. Patients were stratified according to LDL-cholesterol (≥70 vs <70 mg/dL) and high-sensitivity C-reactive protein (≥2 vs <2 mg/L) levels: no residual cholesterol or inflammatory risk, residual cholesterol risk, residual inflammatory risk, and combined residual cholesterol and inflammatory risk. Patients presenting with acute myocardial infarction, cancer, no statin treatment at admission, or high-sensitivity C-reactive protein levels >10 mg/L were excluded. The primary endpoint was major adverse cardiovascular events (MACEs), defined as the composite of all-cause mortality, spontaneous myocardial infarction, and stroke 1 year after the index PCI.

RESULTS

A total of 15 494 patients were included. After 1-year follow-up, individuals with isolated residual inflammatory risk had the highest MACE rate (5.1%), followed by patients with combined cholesterol and inflammatory risk, no residual risk, and isolated residual cholesterol risk. After multivariable Cox regression analysis, patients with residual inflammatory risk had a 1.8-fold higher risk for MACE (adjusted hazard ratio: 1.78, 95% confidence interval 1.36-2.33, P < .001) compared with those with no residual cholesterol or inflammatory risk. This was similar in patients with combined residual cholesterol and inflammatory risk (adjusted hazard ratio: 1.56, 95% confidence interval 1.19-2.04, P = 0.001). Of note, no independent association of isolated residual cholesterol risk (adjusted hazard ratio: 1.01, 95% confidence interval .76-1.35, P-value = .920) with MACE was noted (P-trend across all groups <.001).

CONCLUSIONS

Among statin-treated patients undergoing PCI, residual inflammation but not cholesterol risk was associated with an increased risk of MACE during follow-up.

Evaluation of Secondary Prevention Knowledge in Patients with Coronary Artery Disease

Background and Objectives: Most patients with cardiovascular disease have limited health literacy and knowledge. The promotion of knowledge among patients with coronary artery disease is an integral part of health maintenance and the minimisation of secondary cardiac events. The aim of this study was to map the percent proportion of answers and scores obtained from them in the studied domains. Materials and Methods: In this cross-sectional study, a Coronary Artery Disease Education Questionnaire (CADE-Q II) was used to verify knowledge gaps in the five studied domains. In total, 253 patients with coronary artery disease completed the CADE-Q II, which targeted five domains: health status, risk factors, exercise, nutrition and psychosocial risk. Data were collected between June 2021 and November 2024. Results: An analysis of the data found a total mean CADE-Q II score of 61.05 ± 11.42 SD out of 93 points. Our research showed that the total mean score of a group of patients corresponded to an acceptable level of knowledge. Patients in the cohort provided a total of 7843 responses for the five study domains. In total, 46.8% of patients scored all answers correctly in terms of risk factors, 49.0% in terms of nutrition, 53.1% in terms of health status, 64.4% in terms of psychosocial risk, and 65.0% in terms of exercise. Conclusions: The use of the CADE-Q II questionnaire, with its focus on the studied domains, verifies patient knowledge and provides a foundation for education, the provision of effective information and the promotion of secondary prevention knowledge.

The relationship and differences in the triglyceride-glucose index and all-cause mortality in patients with coronary heart disease combined with cerebrovascular and other comorbidities: an analysis of the MIMIC-IV database

Objective

This study aims to investigate the predictive capability of the triglyceride-glucose index (TyG index) for all-cause mortality among patients with coronary heart disease (CHD), particularly in those with cerebrovascular disease (CVD) and other comorbidities, based on the MIMIC-IV database.

Methods

Using the ICD-9/10 coding standards, eligible CHD patients were identified from the MIMIC-IV database (version 3.0) with defined inclusion and exclusion criteria to ensure sample representativeness. Patients were categorized into CVD and other comorbidity groups. Data on mortality rates at 90 days, 1 year, and overall were collected, along with the TyG index and relevant covariates associated with survival risk. Baseline analyses, Spearman correlation, and restricted cubic splines (RCS) were employed to assess the nonlinear relationship between the TyG index and mortality. Kaplan-Meier curves and Cox proportional hazards models were utilized to evaluate survival risk.

Results

A total of 1,872 CHD patients were included, with 578 having CVD and a mortality rate of 50.17%; 1,294 had other comorbidities with a mortality rate of 64.91%. RCS analysis indicated a nonlinear relationship between the TyG index and mortality risk. For patients with concurrent CVD, the lowest mortality risk occurred at a TyG index of 9.37 mmol/L, while for those with other comorbidities, the lowest risk was observed at 9.36 mmol/L. Cox regression analysis revealed a significant association between the TyG index and survival risk in all CHD patients (HR = 1.15, 95%CI: 1.04-1.28, P < 0.01). In patients with other comorbidities, an increase in the TyG index was significantly correlated with elevated mortality risk (HR = 1.21, 95%CI: 1.02-1.34, P < 0.01).

Conclusion

The TyG index exhibits a nonlinear relationship with mortality risk in CHD patients, with elevated levels significantly increasing mortality risk in those with other comorbidities. These findings suggest that the TyG index may serve as a critical metabolic marker for prognostic evaluation in CHD patients, warranting further clinical attention.

Key Concepts in Cardiovascular Secondary Prevention: A Case-Based Review

Atherosclerotic cardiovascular disease (ASCVD) continues to be a growing global health concern with ischemic heart disease and stroke as leading causes of years of life lost. While aging is a major ASCVD risk factor, recent trends show a concerning rise in its incidence among younger adults driven, in part, by increased rates of risk factors such as hypertension and diabetes. These individuals with ASCVD are at elevated risk of recurrence years following their initial event, further underscoring the need for aggressive implementation of secondary prevention strategies to reduce morbidity and mortality. This case-based review discusses evidence-based pharmacological approaches to ASCVD secondary prevention-focusing on the roles of antiplatelets, lipid lowering therapies, antihypertensive medications, and glucose lowering treatments, in practical clinical settings.

Contemporary management of ischemic cardiomyopathy: The synergy of medical, revascularization, and device therapies

Ischemic heart disease (IHD) is the leading global cause of death, affecting millions and leading to significant morbidity and mortality. Ischemic cardiomyopathy (ICM), a manifestation of IHD, results in severe left ventricular dysfunction due to coronary artery disease and poses a significant challenge due to the complex pathophysiology, variable clinical presentation, and overall poor prognosis. Recent advances in medical therapy, device interventions, and revascularization techniques offer newfound hope in improving ICM patient outcomes. This article reviews the state-of-the-art management approaches for ICM, emphasizing the importance of personalized treatment plans that integrate the various contemporary therapies to address the multiple mechanisms of disease development and progression. A meticulously tailored treatment approach for each individual patient offers the hope of prolonged survival through the synergy of therapies designed to address the different and complex mechanisms that contribute to their disease process.

Colchicine in Coronary Artery Disease: Where Do We Stand?

ABSTRACT

Colchicine is an anti-inflammatory drug for different inflammatory conditions and is approved for secondary prevention of cardiovascular events in patients with coronary artery disease, mainly based on the results of the LODOCO2 and COLCOT trials. The recently published CLEAR SYNERGY trial reported neutral results for colchicine in patients with acute myocardial infarction undergoing percutaneous coronary intervention, challenging the previous reported benefits of colchicine. While colchicine appeared rather safe across the different studies, the variation in efficacy may suggest that the one-size-fits-all for the treatment of acute and chronic forms of coronary artery disease may not be appropriate, and that low-dose colchicine may be beneficial as an add-on therapy in patients who are stable or recovering from acute event, and not so helpful in patients with acute myocardial infarction already receiving intensive pharmaco-invasive therapies.

Evaluate the effect of virtual nurse-guided discharge education app on disease knowledge and symptom response in patients following coronary events

BACKGROUND

Pre-discharge patient education promotes better self-care and secondary prevention following acute coronary syndrome (ACS). Traditional methods do not adapt well to staff and patient time limitations and varied health literacy levels. Self-administered digital methods using engagement strategies may address these issues.

OBJECTIVES

To evaluate whether a co-designed, self-administered, virtual nurse avatar-guided patient education app can improve ACS knowledge, beliefs, and medication adherence, and be acceptable for patients and nurses.

METHODS

A prospective pre-post-test study was used with patients recruited during hospitalisation for ACS and their associated nursing staff. Patients, alongside usual care, were provided with the education app on a tablet at discharge to use immediately and over the following month. Data were collected immediately following use and one-month post on heart disease knowledge, ACS symptom response attitudes and beliefs and medication adherence. User satisfaction data was collected from both patients and nurses.

RESULTS

Participants included nurses (n = 22) and patients (n = 22) who were diagnosed with ST-elevation myocardial infarction (STEMI) (73 %), aged mean 59.7 years and 40 % had not completed high school. Patients' heart disease knowledge improved from pre to one-month post-use (15.7 vs 17.0; p < 0.001) and from immediately post to one-month post-use (16.3 vs 17.0; p = 0.003). Patients' ACS symptom knowledge and response beliefs improved from pre- to immediate post-use (13.8 vs 15.5; p = 0.008; 23.8 vs 25.1; p = 0.038), and to one-month post-use (13.8 vs 17.0; p < 0.001; 23.8 vs 25.7; p = 0.025), and ACS symptom response attitudes improved from pre- to one-month post-use (15.8 vs 17.0; p = 0.036). Patients and nurses rated the app's presentation, content, usability, and usefulness highly; 86% of nurses thought the app would help with discharge education.

CONCLUSION

A co-designed, self-administered, virtual nurse avatar-guided education app can improve heart disease knowledge, attitudes, and beliefs following ACS with high nurse and patient acceptability.

Clinical practice patterns among older multimorbid adults presenting with suspected ischemic symptoms: A multi-center survey

Background

When patients with suspected or known coronary artery disease (CAD) present with new or worsening ischemic symptoms, initial referral to imaging or optimization of guideline directed medical therapy (GDMT) with deferral of testing are both acceptable management approaches.

Methods

In this 12-center study, a 19-item survey exploring preferred management strategy for symptomatic older adults (≥75 years) with or without known CAD, and major patient and clinical factors driving this decision making was administered to clinicians.

Results

There were 96 respondents (70.8 % cardiologists, 20.9 % primary care physicians/geriatricians). Among patients without known CAD, 59 (61.4 %) respondents favored early referral to testing, 6 (6.3 %) opted for initial GDMT and 23 (24.0 %) preferred both. For patients with known CAD, 27 (28.1 %) prioritized initial GDMT optimization, 37 (38.6 %) would refer for early testing and 19.8 % both. Key factors influencing initial preference for GDMT optimization were unoptimized anti-anginal medications, patient preference, increased complication risk, frailty, cognitive impairment and comorbidities. Key factors influencing preference for initial imaging were increasing symptom severity, already optimized GDMT, and electrocardiogram changes. When imaging revealed ischemia, clinicians reported weighing symptom severity, ischemic burden, current medications, comorbidities, frailty, and procedural risks before referring for invasive cardiac angiography.

Conclusion

Both initial GDMT optimization and referral for imaging are frequently used approaches for the symptomatic older patient with suspected or known CAD. The survey highlighted the importance of patient characteristics such as frailty, cognitive impairment, multimorbidity and the gap in clinical guidance on how to optimally manage symptomatic older adults with CAD.

Coronary Artery Disease and Heart Failure: Medical Management and Future Direction

Coronary artery disease (CAD) is a leading etiology of heart failure (HF) and serves as a significant therapeutic target to ameliorate HF-associated morbidity and mortality. Key management considerations include pharmacologic treatment, electrophysiological devices, and coronary revascularization, aimed toward preventing CAD progression, left ventricular remodeling, sudden death, and reinfarction. The optimal revascularization strategy for patients with CAD and HF who are surgical candidates requires careful assessment of each patients' unique risk/benefit profile and individual preferences. Several novel pharmacologic agents are in development with hopes of adding to the armamentarium of treatment of CAD and HF.

Safety, Feasibility, and Diagnostic Yield of Invasive Coronary Function Testing: Netherlands Registry of Invasive Coronary Vasomotor Function Testing

Importance

Patients with angina and no obstructive coronary artery disease frequently have coronary vasomotor dysfunction as underlying pathophysiological mechanism, comprising epicardial spasm, microvascular spasm, and/or microcirculatory dysfunction. These endotypes can be diagnosed by invasive coronary function testing which has previously shown to be safe in tertiary and expert centers.

Objective

To determine the prevalence of vasomotor dysfunction in patients with angina and no obstructive coronary artery disease who were clinically referred for a coronary function test (CFT); and assess safety and feasibility of a CFT.

Design, Setting, and Participants

This quality improvement study was performed using the Netherlands Registry of Invasive Coronary Vasomotor Function Testing (NL-CFT), a prospective, observational registry, in 15 participating hospitals (2 tertiary and 13 nontertiary). Patients with angina and no obstructive coronary artery disease who were referred for a clinically indicated CFT between December 2020 and January 2024 were included.

Main Outcomes and Measures

A complete CFT consisted of acetylcholine spasm provocation testing and assessment of microcirculatory function. Prevalence of different endotypes based on test results and overall safety were assessed.

Results

Among a total of 1207 patients included, 978 (81%) were female; and the mean (SD) age was 60 (10) years. The prevalence of coronary vasomotor dysfunction was very high (78%). There were 11 (0.9%) major and 10 (0.8%) minor complications reported. Of them, 3 major and all minor were definitely related to the coronary function test. No procedural death, myocardial infarction, or stroke was observed. No differences were found in the occurrence of complications between tertiary and nontertiary centers.

Conclusions and Relevance

This study found that a CFT was feasible and safe to perform in both tertiary and nontertiary centers with a high diagnostic yield.

Guideline-Directed Medical Therapy and Outcomes in the ISCHEMIA Trial

BACKGROUND

Guideline-directed medical therapy (GDMT) with multiple risk factor goals is recommended for patients with chronic coronary disease (CCD), yet achieving all GDMT goals is uncommon. The relative importance of these goals and timing of their attainment on cardiovascular events is uncertain.

OBJECTIVES

This study aims to describe the relationship between achieving specific GDMT goals, when they are achieved, and clinical outcomes.

METHODS

This was an observational study of participants with CCD in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. The primary outcome was cardiovascular (CV) death or myocardial infarction (MI). GDMT goals were systolic blood pressure (SBP) <130 mm Hg, low-density lipoprotein cholesterol <70 mg/dL, not smoking, and antiplatelet therapy. Frequency of GDMT goals met at baseline and during follow-up is described. Bayesian joint modeling for longitudinal goal status and time-to-event analyses characterized the relative importance of specific GDMT goal attainment and timing with CV death/MI.

RESULTS

All 5,179 ISCHEMIA participants were included. Among 4,914 participants with complete data on all 4 GDMT goals at baseline, 386 (9%), 2,073 (42%), 1,843 (38%), and 612 (12%) met 0-1, 2, 3, and 4 GDMT goals, respectively. The 4-year cumulative event rate for CV death/MI was highest for participants who attained no GDMT goals (24.5%; 95% credible interval [CrI]: 13.5%-42.2%) and lowest for those who attained all goals at baseline and remained at goal during follow-up (8.7%; 95% CrI: 6.7%-10.9%). SBP goal attainment was associated with a significant absolute event reduction in CV death/MI (-5.1%; 95% CrI: -11.3% to -1.0%), followed by antiplatelet therapy (-11.2%; 95% CrI: -29.1% to 0.8%), achieving low-density lipoprotein cholesterol <70 mg/dL (-2.0%; 95% CrI: -6.0% to 2.4%), and not smoking (-1.7%; 95% CrI: -9.3% to 4.2%). Ten millimeters of mercury lower SBP during follow-up was associated with 10% relative risk reduction of CV death/MI (RR [relative risk] = 0.90; 95% CrI: 0.82-0.98), after adjusting for other GDMT goals and baseline characteristics.

CONCLUSIONS

Among participants with CCD, early attainment and maintenance of GDMT goals, especially SBP, were associated with fewer cardiovascular events. Compared with no GDMT goals at target, having all 4 GDMT goals at target at baseline was associated with an absolute 16% fewer CV deaths and MIs. (ISCHEMIA [International Study of Comparative Health Effectiveness With Medical and Invasive Approaches]; NCT01471522).

GLP-1 Receptor Agonists and Myocardial Perfusion: Bridging Mechanisms to Clinical Outcomes

Coronary microvascular dysfunction (CMD) is a key contributor to myocardial ischemia and adverse cardiovascular outcomes, particularly in individuals with metabolic disorders such as type 2 diabetes (T2D). While conventional therapies primarily target epicardial coronary disease, effective treatments for CMD remain limited. Glucagon-like peptide-1 receptor (GLP-1R) agonists have emerged as promising agents with cardiovascular benefits extending beyond glycemic control. Preclinical and clinical evidence suggests that GLP-1R activation enhances coronary microvascular function through mechanisms including improved endothelial function, increased nitric oxide bioavailability, attenuation of oxidative stress, and reduced vascular inflammation. Moreover, GLP-1R agonists have been shown to improve myocardial blood flow, myocardial perfusion reserve, and coronary endothelial function, particularly in high-risk populations. Despite these promising findings, inconsistencies remain across studies due to variability in patient populations, study designs, and imaging methodologies. This review summarizes current evidence on the role of GLP-1R agonists in myocardial perfusion, bridging mechanistic insights with clinical outcomes. Further large-scale, well-designed trials are needed to clarify their long-term impact on coronary microcirculation and explore their potential as targeted therapies for CMD.

Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of Randomized Trials

BACKGROUND

The optimal long-term antithrombotic strategy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) remains uncertain. Individual randomized controlled trials (RCTs) had variations in their reported results and were not powered for effectiveness outcomes.

OBJECTIVES

This study aimed to pool the results of RCTs comparing the effectiveness and safety of oral anticoagulation (OAC) monotherapy vs OAC plus single antiplatelet therapy (SAPT) in patients with AF and stable CAD.

METHODS

We systematically searched PubMed, Embase, and ClinicalTrials.gov until September 09, 2024. The primary effectiveness outcome was a composite of myocardial infarction, ischemic stroke, systemic embolism, or death. The primary safety outcome was major bleeding. We obtained unpublished results from principal investigators of the included RCTs, as needed, to calculate pooled HRs and 95% CIs and to perform prespecified subgroup analyses.

RESULTS

Among 690 screened records, 4 RCTs with 4,092 randomized patients were included (2 using edoxaban, 1 using rivaroxaban, and 1 using any oral anticoagulant; mean age 73.9 years, 20.1% women). The median follow-up durations ranged from 12 to 30 months (overall estimated weighted mean follow-up of 21.9 months). There were no statistically significant differences between OAC monotherapy vs OAC plus SAPT in the primary effectiveness outcome (7.3% vs 8.2%; HR: 0.90; 95% CI: 0.72-1.12), myocardial infarction (1.0% vs 0.7%; HR: 1.51; 95% CI: 0.75-3.04), ischemic stroke (1.9% vs 2.1%; HR: 0.89; 95% CI: 0.57-1.37), all-cause death (4.2% vs 5.3%; HR: 0.94; 95% CI: 0.49-1.80), or cardiovascular death (2.4% vs 3.0%; HR: 0.79; 95% CI: 0.54-1.15). OAC monotherapy was associated with a lower risk of major bleeding than OAC plus SAPT (3.3% vs 5.7%; HR: 0.59; 95% CI: 0.44-0.79). Subgroup analyses did not show significant interactions for effectiveness but suggested that the magnitude of bleeding reduction may be greater among men (Pinteraction = 0.03) and among patients with diabetes mellitus (Pinteraction = 0.04).

CONCLUSIONS

In patients with AF and stable CAD, OAC monotherapy, compared with OAC plus SAPT, was not associated with a statistically significant increased risk of ischemic events but resulted in a significantly reduced risk of bleeding.

Quantitative correlation between carotid or lower limb atherosclerosis and coronary heart disease: a retrospective observational study

Background

Early diagnosis and intervention are key for the treatment of coronary heart disease (CHD). Ultrasound is used to assess risk stratification in patients with coronary artery disease. However, few studies quantify the relationship between carotid or lower limb atherosclerosis and coronary revascularization. The purpose of this study is to demonstrate that the semi-quantitative degree of atherosclerosis in the neck or lower extremity vessels can predict the need for coronary revascularization, thereby establishing a predictive model for coronary revascularization based on peripheral vascular disease.

Methods

Patients who underwent coronary angiography and peripheral vascular ultrasound were randomly selected for semi-quantitative analysis of the degree of coronary artery and peripheral vascular stenosis. Data from 306 patients were collected.

Results

The semiquantitative score, grade score and lower limb score from vascular ultrasound were positively correlated with the Gensini score of coronary artery lesions. The semi-quantitative score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 83.74% and 61.72%, respectively. The graded score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 77.24% and 72.13%, respectively. The lower extremity score (score = 3) predicted the sensitivity and specificity for coronary revascularization at 90.24% and 54.55%, respectively.

Conclusions

Carotid semiquantitative scores, grade scores, and lower limb scores are predictive factors for the need for coronary revascularization and can serve as auxiliary examinations for the early diagnosis of coronary artery disease.

High-sensitivity C-reactive Protein in Atherosclerotic Cardiovascular Disease: To Measure or Not to Measure?

Inflammation and dyslipidemia are central to the pathogenesis of atherosclerotic cardiovascular disease (ASCVD). While lipid-lowering therapies are the cornerstone of ASCVD prevention and treatment, there are other emerging targets, including inflammation (which has been dubbed the 'residual inflammatory risk'), that can be addressed after LDL cholesterol thresholds have been reached. Research over the past 20 years has identified C-reactive protein (CRP) as a key marker of inflammation with atherosclerosis. The association of more sensitive measures of CRP (high- sensitivity C-reactive protein [hsCRP]) with ASCVD risk in epidemiological studies has also led to its incorporation as a risk enhancer in primary prevention guidelines and its incorporation into risk stratification tools. While there are no formal recommendations related to measurement of hsCRP in secondary prevention, consideration should be given to an individualized approach that addresses inflammatory risk in those with major adverse cardiovascular events, despite maximal lipid-lowering therapy and well-controlled LDL cholesterol levels. The aim of this review is to discuss the role of inflammation in ASCVD, the use of hsCRP as a tool to assess residual inflammatory risk to target upstream pathways such as glucose intolerance and obesity, and to consider use of additional anti-inflammatory medications for ASCVD risk reduction. The authors provide clinical context around when to measure hsCRP in clinical practice and how to address residual inflammatory risk in ASCVD.

Comparative effectiveness of potassium-competitive acid blockers and proton pump inhibitors in dual antiplatelet therapy patients: a nationwide cohort study

BACKGROUND

Proton pump inhibitors (PPIs) are widely used in combination with dual antiplatelet therapy (DAPT) to reduce the risk of gastrointestinal bleeding; however, some PPIs may interfere with clopidogrel metabolism through CYP2C19 inhibition. Potassium-competitive acid blockers (P-CABs) have emerged as alternatives to PPIs, although their effectiveness in patients receiving DAPT have not been sufficiently explored.

AIM

This study aimed to compare the effectiveness of PPIs and P-CABs in preventing cardiovascular events and gastrointestinal bleeding among patients receiving DAPT after coronary stent implantation.

METHOD

A retrospective cohort design was employed using nationwide claim data from South Korea. The study included patients who received aspirin-clopidogrel DAPT with PPI or P-CAB for a minimum of 60 days. After applying propensity score matching (PSM) at a 1:1 ratio, survival analysis was conducted. The primary outcome was a composite of acute myocardial infarction, ischemic stroke, revascularization, and in-hospital mortality. Secondary outcomes involved the individual components of the composite outcome and gastrointestinal bleeding.

RESULTS

The initial cohort included 39,234 patients in the PPI group and 3,434 in the P-CAB group. After 1:1 PSM, 3,434 patients were included in each group. No statistically significant differences were observed between the PPI and P-CAB groups for the primary outcome (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.68-1.07; p = 0.167) and gastrointestinal bleeding (HR, 1.36; 95% CI, 0.76-2.42; p = 0.3).

CONCLUSION

Both PPIs and P-CABs appear to be viable options for acid suppression in patients undergoing DAPT, with no significant differences in cardiovascular or gastrointestinal outcomes.

The relationship between dietary inflammatory index in adults and coronary heart disease: from NHANES 1999-2018

Background

Previous studies have shown that pro-inflammatory diets increase the risk of coronary heart disease (CHD) and all-cause mortality. The dietary inflammatory index (DII) is a quantitative measure of dietary inflammation, and its accuracy has been validated by several studies.

Methods

This study included 43,842 participants aged ≥18 years from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The data of CHD was obtained through a questionnaire survey, and the DII was calculated using 24-h dietary recall data. Generalized linear models and logistic regression were used to determine the mediation factors, and subgroup analyses were conducted to evaluate the interaction between DII and CHD. Mean decrease in Gini (MDG) was used to determine the importance of individual dietary components.

Results

The age of the participants was 49.81 ± 18.10 years, with 20,793 (47.4%) being male. A total of 1,892 (4.3%) participants were diagnosed with CHD, and the median DII score was 1.33 (0.11, 2.40). After adjusting for potential confounders, logistic regression analysis revealed that DII independently associated with CHD [OR: 1.049 (1.012-1.087), p = 0.008]. Triglyceride-glucose index, visceral adiposity index, body mass index, waist-to-height ratio, high-density lipoprotein, and glomerular filtration rate (all p < 0.05) may mediate the relationship between DII and CHD. Subgroup analyses showed that DII was more sensitive in participants aged <75 years (p < 0.001), females (p = 0.028), those with low cholesterol levels (p = 0.004), and individuals with low Framingham risk scores (p = 0.005). MDG analysis indicated that carbohydrate, vitamin C and iron intake have the greatest impact on CHD.

Conclusion

This study suggests that various metabolic and lipid indicators play a mediating role in the relationship between DII and CHD. DII may have a greater adverse impact on traditional low-risk CHD populations.

Exploring associations between estrogen and gene candidates identified by coronary artery disease genome-wide association studies

Introduction

Coronary artery disease (CAD) is the leading cause of death around the world, with epidemiological sex and gender differences in prevalence, pathophysiology and outcomes. It has been hypothesized that sex steroids, like estrogen, may contribute to these sex differences. There is a relatively large genetic component to developing CAD, with heritability estimates ranging between 40%-60%. In the last two decades, genome-wide association studies (GWAS) have contributed substantially to advancing the understanding of genetic candidates contributing to CAD. The aim of this study was to determine if genes discovered in CAD GWASs are affected by estrogen via direct modulation or indirect down-stream targets.

Methods

A scoping review was conducted using MEDLINE and EMBASE for studies of atherosclerotic coronary artery disease and a genome-wide association study (GWAS) design. Analysis was limited to candidate genes with corresponding single nucleotide polymorphisms (SNPs) surpassing genome-wide significance and had been mapped to genes by study authors. The number of studies that conducted sex-stratified analyses with significant genes were quantified. A literature search of the final gene lists was done to examine any evidence suggesting estrogen may modulate the genes and/or gene products.

Results

There were 60 eligible CAD GWASs meeting inclusion criteria for data extraction. Of these 60, only 36 had genome-wide significant SNPs reported, and only 3 of these had significant SNPs from sex-stratified analyses mapped to genes. From these 36 studies, a total of 61 genes were curated, of which 26 genes (43%) were found to have modulation by estrogen. All 26 were discovered in studies that adjusted for sex. 12/26 genes were also discovered in studies that conducted sex-stratified analyses. 12/26 genes were classified as having a role in lipid synthesis, metabolism and/or lipoprotein mechanisms, while 11/26 were classified as having a role in vascular integrity, and 3/26 were classified as having a role in thrombosis.

Discussion

This study provides further evidence of the relationship between estrogen, genetic risk and the development of CAD. More sex-stratified research will need to be conducted to further characterize estrogen's relation to sex differences in the pathology and progression of CAD.

Serum proteomic profiling reveals potential predictive indicators for coronary artery calcification in stable ischemic heart disease

Coronary artery calcification (CAC) is a common complication in patients with stable ischemic heart disease (SIHD). However, the early diagnosis and understanding of the pathogenesis of CAC in SIHD patients remain underdeveloped. This study aimed to analyze aberrant alterations in the serum proteome of SIHD patients, as well as SIHD patients with severe CAC (CAC_SIHD), and to explore the potential risk factors of CAC in SIHD patients. Serum proteomic profiles were obtained from individuals with SIHD (n = 6), CAC_SIHD (n = 6), and healthy controls (n = 9), and were analyzed using nano liquid chromatography tandem mass spectrometry (LC-MS/MS). The aberrant alterations in proteins and immune cells in the serum of SIHD and CAC_SIHD patients were characterized through differential protein expression analysis and single-sample gene set enrichment analysis analysis, respectively. Differentially expressed proteins (DEPs) were further subjected to gene ontology functional enrichment and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. Finally, Receiver Operating Characteristic analysis was performed on the DEPs between SIHD and CAC_SIHD to identify potential predictive factors of CAC. Abnormalities in multiple complement pathways and lipid metabolism were observed in SIHD and CAC_SIHD patients. Moreover, SIHD and CAC_SIHD were characterized by an increased presence of T cells and natural killer cells, along with a reduced presence of B cells. Subsequent analysis of serum proteins revealed that RNASE1 and MSLN may be potential predictive indicators for the early detection and diagnosis of CAC in SIHD patients. In conclusion, our research extensively examined the variations in serum proteins in patients with SIHD and CAC_SIHD, identifying key indicators and metabolic pathways associated with these conditions. These findings not only provide new insights into the pathological mechanisms of SIHD and CAC_SIHD, but also suggest potential factors for the early diagnosis of CAC in SIHD patients, which imply potential clinical applications.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Discordance and Performance of the ARC-HBR and PRECISE-DAPT High Bleeding Risk Definitions After Coronary Stenting

BACKGROUND

The aim of the ARC-HBR (Academic Research Consortium for High Bleeding Risk) and PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score definitions for high bleeding risk is to identify patients who would benefit from shorter or less intensive antiplatelet therapy after coronary stenting.

OBJECTIVES

The aim of this study was to assess the performance of the ARC-HBR and PRECISE-DAPT score definitions for high bleeding risk in routine clinical practice.

METHODS

Using nationwide registers, all patients in Stockholm, Sweden, who were discharged after coronary stenting with dual antiplatelet therapy (January 1, 2013, to July 1, 2018) were included. Patients were categorized as high bleeding risk according to the 2 risk tools, and risk for bleeding (BARC [Bleeding Academic Research Consortium] types 3-5 or TIMI major or minor) and ischemic events (myocardial infarction or ischemic stroke) within 1 year after discharge was assessed.

RESULTS

Of 7,562 patients, the proportions categorized as high bleeding risk were 27% (2,004 of 7,562) using the ARC-HBR definition and 38% (2,894 of 7,562) using the PRECISE-DAPT score; 22% (1,696 of 7,562) had discordant categorization of high bleeding risk comparing the 2 risk tools. Patients with vs without high bleeding risk according to the ARC-HBR definition had higher risk for BARC type 3 to 5 bleeding (1-year risk 7.1% vs 2.3%; HR: 3.21; 95% CI: 2.47-4.17) and ischemic events (7.8% vs 2.8%; HR: 2.96; 95% CI: 2.31-3.79). Patients with vs without high bleeding risk according to the PRECISE-DAPT score had higher risk for TIMI major or minor bleeding (4.4% vs 2.1%; HR: 2.17; 95% CI: 1.63-2.89) and ischemic events (6.2% vs 2.7%; HR: 2.38; 95% CI: 1.85-3.05). The PRECISE-DAPT score underestimated bleeding risk across almost all score levels (median absolute difference between observed and predicted 1-year risk 1.1%; Q1-Q3: 0.8%-1.4%).

CONCLUSIONS

There was substantial discordance in the categorization of high bleeding risk between the ARC-HBR definition and the PRECISE-DAPT score. Both tools identified patients at increased bleeding risk, but those patients also had increased ischemic risk. The PRECISE-DAPT score underestimated bleeding risk. Guideline-recommended high bleeding risk definitions may not be generalizable across patient populations, and refined scoring systems are needed.

Design and Evaluation of ACAFiB-APP, a clinical decision support system for anticoagulant considerations in patients with atrial fibrillation

BACKGROUND

Patients with atrial fibrillation are at risk for various complications, including thromboembolic events. This study involves developing and evaluating a Clinical Decision Support System (CDSS) to select appropriate anticoagulant drug, considering comorbidities, laboratory data, and concurrent medications. The system is based on a streamlined interpretation of the most recent globally accepted clinical guidelines.

METHODS

Primarily a semi-structured interview regarding the challenges in the field of thromboprophylaxis for AF and clinical pharmacists and cardiologists' needs in practice was conducted. Then the required data were extracted from the latest guidelines and confirmed by the expert panel. Using Microsoft Visio software each scenario and its corresponding rules were modeled. Dart programming language, the Flutter framework, and the Visual Studio editor were used to develop the application. Finally, the uMARS questionnaire was used to evaluate the application quality.

RESULTS

The selection of the anticoagulants was reported to be the most challenging domain by 78.6% of the participants in the interview. According to the designed algorithms, the application was developed using Asp.net with the Microsoft SQL Server database platform. This CDSS is called ACAFiB-APP, which stands for Anticoagulant in AF Application. The user goes through various calculators and obtains the required data, moreover, the user will choose one or more comorbidities/clinical scenarios. Finally, ACAFiB-APP will represent the proper anticoagulant options with dosing and related considerations. All of the sections in the uMARS questionnaire received acceptable scores.

CONCLUSIONS

The CDSS will facilitate the informed selection of anticoagulants for complicated AF cases by considering the patient clinical scenario.

CLINICAL TRIAL NUMBER

Not applicable.

Management of Stable Coronary Artery Disease and Acute Coronary Syndrome in Patients with Cancer

PURPOSE OF REVIEW

This review examines the current evidence and management strategies for stable coronary artery disease (CAD) and acute coronary syndrome (ACS) in patients with cancer. We outline the unique challenges, optimal treatment approaches, and outcomes in this growing population.

RECENT FINDINGS

First-line medications for CAD management are consistently underutilized in cancer patients despite serving as standard of care. As a corollary, medical optimization in CAD management in general is less likely to occur in patients with cancer. Early invasive strategies in ACS show improved survival, yet cancer patients receive percutaneous coronary intervention less frequently than non-cancer patients. Optimization of medical management should be prioritized in stable CAD; revascularization with PCI is first line for most patients presenting with ACS. Modification of risk factors contributing to both CAD and cancer is of utmost importance. Cancer survivors should receive vigilant, long-term monitoring for the development of signs of CAD.