Reviews & Analysis

The 2014 revision of the 2005 AHA consensus statement on the evaluation of women with suspected ischaemic heart disease is a major update. The authors discuss the spectrum of ischaemic heart disease and review new data on the diagnostic and prognostic performance of the various diagnostic testing modalities now available.

Uncertainty surrounds the benefit of β-blocker treatment in various clinical settings. The researchers in a new retrospective analysis of preoperative β-blocker use in CABG surgery now add to the debate, and suggest that these drugs might not improve perioperative outcomes.

Cryptogenic stroke is an apology for ignorance about the cause of ischaemic stroke. Now, in two new studies involving long-term electrocardiogram monitoring, investigators from the EMBRACE and CRYSTAL-AF trials suggest that many instances of cryptogenic stroke might be caused by undetected atrial fibrillation.

In an analysis of electronic health records, 1.25 million patients aged ≥30 years without diagnosed cardiovascular disease experienced 83,098 cardiovascular events during follow-up (median 5.2 years). Associations between incident cardiovascular disease and blood pressure differed for systolic and diastolic blood pressures and between the 12 cardiovascular end points examined.

A meta-analysis by investigators from FDA of three major trials of cardiac resynchronization therapy (CRT) demonstrated that women have a reduced rate of heart failure (HF) and death with CRT at a shorter QRS duration than men. Recognizing these sex-specific differences is important to improve outcomes for women with HF.

Constrictive pericarditis arises from a stiffening of the pericardium, which prevents complete or satisfactory diastolic filling of the heart. In this Review, Syed and colleagues discuss the pathophysiology of constrictive pericarditis and how to differentiate the disease from other causes of heart failure with preserved ejection fraction that have a similar presentation. Finally, the authors detail how best to treat patients with pericardial constriction, including by complete pericardiectomy.

Cardiac rehabilitation participation reduces mortality and rehospitalization of patients with cardiovascular disease, but this cost-effective treatment programme is still underused worldwide. In this Review, Turk-Adawi and colleagues describe the global availability of cardiac rehabilitation and highlight strategies that might increase its use, particularly in low and middle-income countries.

Atherosclerosis is a chronic, multifactorial disease in which inflammatory processes have long been known to be involved. Heat shock proteins (HSPs) are a group of proteins whose expression is increased when cells are exposed to elevated temperatures or other stressors, including classic risk factors for atherosclerosis. In this Review, Georg Wick and colleagues describe the role of HSPs in the initiation and potentiation of atherosclerosis, summarize the data supporting their theory of concept of atherosclerosis as an autoimmune disease in terms of the HSPs, specifically HSP60, and outline possible future developments in this field.

Cardiovascular and renal disease often have similar origins and shared risk factors. With the progression of chronic kidney disease, additional risk factors develop, contributing to the evolution of both diseases. In this Perspectives article, Ruiz-Hurtado and Ruilope postulate that that simultaneous protection for both cardiovascular and renal disease can be achieved with the same therapy. They review the evidence from clinical trials supporting this theory, and discuss strategies to prevent both cardiovascular and chronic kidney disease.

In May 2014, the FDA astutely stated that any decision to use aspirin should be an individual clinical judgement by health-care providers. Almost simultaneously, the MESA investigators formulated, but did not test, a hypothesis that coronary artery calcification scoring might aid health-care providers in making this judgement.

Mineralocorticoid-receptor antagonists (MRAs) have been shown to reduce adverse cardiovascular outcomes in high-risk patients with ST-segment elevation myocardial infarction (STEMI). Preliminary data suggest that MRAs might improve natriuretic-peptide profiles in patients with STEMI who do not have heart failure, but their clinical efficacy in this patient population requires further study.

Statins and other drugs are widely used to lower the LDL-cholesterol level, which has been shown to prevent cardiovascular events. In this Review, Dadu and Ballantyne review the latest evidence on a novel class of LDL-lowering agents: proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In particular, monoclonal antibodies against PCSK9 have proven efficacious and safe in phase I–III clinical trials.

Approximately half of all patients with heart failure have preserved ejection fraction (HFpEF), a syndrome for which no treatment has proven to be effective in clinical trials. The pathophysiology of HFpEF is heterogeneous, with multiple individual mechanisms frequently coexisting within the same patient to cause symptomatic heart failure. In this Review, Barry Borlaug discusses the current understanding of the pathophysiological mechanisms underlying HFpEF, and how they might be mechanistically related to typical risk factors for HFpEF, including ageing, obesity, and hypertension.

Mutations in theSCN5A gene, which encodes the cardiac sodium channel, are well known to cause gain or loss of channel function and, consequently, various cardiac arrhythmias. However, greater phenotypic variability exists than can be ascribed directly to mutation-dependent changes in channel biophysical properties. In this Perspectives article, Liu et al. propose that additional intrinsic and extrinsic modifiers of channel behaviour might help to explain this variability and to improve genotype–phenotype correlations.

The left atrial appendage (LAA) is the main location of thrombus formation in patients with atrial fibrillation. This Review by Romero et al. is focused on the pathophysiology, assessment, and clinical implications of stasis and thrombus formation in the LAA. The advantages and disadvantages of the available imaging modalities for LAA assessment are discussed, and the authors explore the role of cardiac imaging in the therapeutic use of LAA closure devices.

¹⁸F-FDG is the most-commonly used tracer in PET imaging of atherosclerosis.¹⁸F-FDG uptake can be used to identify patients at the highest risk of clinical events and as a surrogate end point in clinical trials of antiatherosclerotic therapies. However, background myocardial uptake of ¹⁸F-FDG can make identifying high-risk coronary artery plaque difficult. Several novel PET tracers have, therefore, also been tested in atherosclerosis imaging. Here, Tarkin et al. review the role of state-of-the-art PET imaging of inflammation in atherosclerosis, including the rationale for this modality, and its current and future uses.

Analysis of cardiovascular registry data suggests that cardiologists who practice femoral cardiac catheterization can convert to safer transradial approaches with a learning experience of 30–50 procedures. This conversion is associated with no loss of procedural success and no increase in serious adverse outcomes.

Blood motion in the heart features vortices, the stability of which is vital to the dynamic balance between rotating blood and myocardial tissue and to the development of cardiac dysfunction. In this Perspectives article, Pedrizzetti et al. examine cardiac vortex flow as a sensitive pathogenetic indicator and modulator of left ventricular remodelling towards heart failure, and the role of cardiac vortices for risk stratification of patients following cardiac surgery or device therapy.

In the CORP-2 trial, patients with multiple recurrences of idiopathic or autoimmune pericarditis were randomly assigned to receive colchicine or placebo, in addition to standard anti-inflammatory therapy. After 6 months, colchicine significantly reduced recurrent pericarditis rates. Are we moving closer to a reliable treatment for this common disease?

Percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO) is currently infrequently performed due to technical difficulty or perceived risk of complication. In this Review, Hoebers et al, provide a comprehensive overview of CTO–PCI and the selection criteria for those patients who might benefit from the procedure, which the authors believe should be performed more frequently to treat CTOs. The authors also discuss emerging technologies that might improve CTO–PCI.