Year in Review

Cardiac arrhythmias produce considerable morbidity and mortality, and are challenging to treat. Advances reported in 2015 will help to guide physicians in the use of therapeutic approaches ranging from established pharmaceutical agents through ablation of arrhythmic sources to novel uses of implanted devices for life-threatening bradyarrhythmias and tachyarrhythmias.

In 2015, success in clinical trials in heart failure was obtained mainly from prevention, whereas treatments showed neutral or even adverse effects. A new glucose-lowering medication prevents development of heart failure. Treating central sleep apnoea might be harmful. In Chagas cardiomyopathy, benznidazole treatment did not affect long-term clinical outcomes.

Despite favourable results in pivotal clinical trials involving novel direct oral anticoagulants, vitamin K antagonists remain the most commonly prescribed anticoagulant. Newer oral anticoagulants are slated for a wide range of additional indications, and specific antidotes to neutralize associated bleeding complications are currently under development.

A number of studies in 2014 have enhanced our knowledge of the pathophysiology of hypertension, including the effects of a low-salt diet, hypertension in resource-poor countries, hypoxia-induced blood pressure elevation, antihypertensive therapies, the therapeutic role of renal denervation, and the effect of cardiovascular risk on adverse outcomes in patients with hypertension.

Decision-making between percutaneous and surgical revascularization in patients with multivessel coronary artery disease (CAD) is challenging. Current guidelines recommend surgery as the preferred revascularization strategy in patients with multivessel disease, and the 5-year SYNTAX trial results published this year further validates this. However, last-generation drug-eluting stents might challenge surgery in the contemporary setting.

Combined inhibition of angiotensin receptor and neprilysin reduces mortality from chronic heart failure over the current gold-standard angiotensin-converting-enzyme inhibitors. However, spironolactone treatment does not improve outcomes in patients who have heart failure with preserved ejection fraction. Iron deficiency contributes to reduced morbidity in chronic heart failure.

Advances in treating cardiac arrhythmias include autonomic manipulation, drugs, imaging, devices, and genetics. I have selected articles published in 2014 that further our knowledge in each area, and which are representative of other important articles that could not be cited. Highlighting five diverse areas emphasizes the complexity of treating arrhythmias.

Prevention of cardiovascular diseases (CVDs), particularly atherosclerosis, remains a priority on the global health agenda. A healthy lifestyle at both individual and population levels, combined with pharmacological treatment of CVD risk factors, is recommended. In this Year in Review article, we discuss the major advances in CVD prevention in 2014.

New findings published in 2013 strongly support the use of novel oral anticoagulants in the treatment of thromboembolic disorders. These drugs have been shown to have a more-favourable benefit-to-risk profile than older compounds, enabling their use from the start of treatment and in the whole spectrum of clinical presentations.

In 2013, advances in noninvasive imaging methods pushed traditional boundaries in the detection, diagnosis, and functional assessment of coronary artery disease, atherosclerotic plaque, and myocardial function. We highlight five important studies that demonstrate how these developments are allowing medicine to become increasingly evidence-based and personalized.

Catheter-based revascularization has emerged as the gold-standard therapy for most patients with acute coronary syndromes (ACS). Optimizing outcomes in these patients requires appropriate adjunctive pharmacological therapy and percutaneous coronary intervention. Five studies published in 2013 are expected to have a major effect on treatment and prognosis of patients with ACS.

In 2013, clinical trials in heart failure focused on drugs and devices that might improve treatment of symptomatic patients beyond standard therapy. None achieved this aim. Therefore, future efforts should emphasize increased adherence to current, evidence-based therapy, and trials might better address efforts to prevent, rather than treat, heart failure.

The new ACC/AHA guidelines on treatment of blood cholesterol focus on intensity of statin therapy rather than target levels of lipids. Early studies show substantial reductions in LDL-cholesterol level with antibodies against PCSK9. MicroRNA silencing and gene-repair techniques to treat dyslipidaemia are promising strategies under development.

In 2012, results from three studies in interventional cardiology have enhanced our knowledge on the best practices to improve clinical outcomes. These trials were focused on treatment safety as well as efficacy. The optimal therapeutic strategy for patients undergoing percutaneous coronary intervention continues to evolve.

Studies published in 2012 in the field of HDL research have provided further evidence suggesting that a low HDL-cholesterol level, in the absence of related lipid or nonlipid risk factors, is not associated with increased risk of coronary heart disease.

Atrial fibrillation (AF) is increasingly being treated using percutaneous or surgical procedures. During 2012, various key studies improved our understanding of which forms of AF respond best to catheter ablation, how to optimize the ablation procedure and postprocedural care, and which patients should receive medical therapy.

New findings published in 2012 have challenged common beliefs about stable coronary artery disease. Studies have shown that β-blockers and n-3-polyunsaturated fatty acids have no impact on prognosis, that percutaneous coronary intervention is not always the best option, and that women do not have worse cardiovascular outcomes than men.

In the 2012 ESC guidelines for the management of heart failure, various gaps in the clinical evidence base were identified. Four studies published in 2012 go some way to resolving this data deficit, and treatment recommendations can now be updated accordingly.

Studies published in 2011 in the field of heart failure have reinforced the benefit of cardiac resynchronization therapy in patients with mild symptoms and confirmed the value of left ventricular assist devices and CABG surgery in selected patients. Conversely, the efficacy of nesiritide in acute heart failure has been questioned.

In 2011, both the PARTNER-A trial, in high-risk patients with severe aortic stenosis, and EVEREST II, in patients with mitral insufficiency, showed noninferiority of transcatheter interventions compared with surgery for the chosen primary end points. However, both of the trials, and important registry data, identified limitations of transcatheter valve interventions.