Reviews & Analysis

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.

Patients with chronic coronary artery disease can develop angina that is refractory to standard medical treatment. Henry and colleagues review the novel treatment strategies being developed for those individuals who are not suitable candidates for traditional revascularization, including pharmacological metabolic modulation, therapeutic angiogenesis, neuromodulation, and other invasive and noninvasive techniques.

Adherence to medication is a prerequisite for treatment to be effective, but fewer than half of patients are adherent to long-term therapies for cardiovascular diseases, such as antihypertensive drugs and statins. In this Perspectives article, Tajouri and colleagues propose that multifaceted, individually tailored strategies that harness incentives schemes and modern technology are required to improve both adherence to medication and patient health.

Chelation therapy with ethylenediamine tetra acetic acid is increasingly being used in patients with cardiovascular disease, without definitive evidence for its efficacy. In this Perspectives article, Sidhu et al. discuss data from major studies of chelation therapy in this field, with particular emphasis on TACT. They opine that the findings from this trial are not robust and do not marshal evidence in support of the potential clinical use of chelation therapy for cardiovascular disease.

Endovascular aneurysm repair has become the standard of care in many hospitals for patients with abdominal aortic aneurysms (AAAs) who have anatomy deemed suitable for the procedure. In this Review, Dominique Buck and colleagues discuss evidence-based practice and evaluate promising new strategies for endovascular repair of AAAs. The role of imaging in the management of AAAs is also highlighted.

Ventricular tachyarrhythmias are a leading cause of sudden cardiac death (SCD). In this Review, Bezzina et al. discuss the genetics of SCD, and how gene discovery programmes will contribute to the identification of novel genes involved in SCD in the coming years.

Intensive antithrombotic therapies reduce ischaemic complications of percutaneous coronary intervention for ST-segment elevation myocardial infarction, but at a cost of increased bleeding. Bivalirudin consistently reduces haemorrhagic risk, even with potent new oral antiplatelet drugs and contemporary interventional practice. The benefit of bivalirudin must, however, be balanced against increased risk of early subacute stent thrombosis.

Controversy surrounds the use of polypills in the primary prevention of cardiovascular disease, particularly in relation to which individuals should be targeted for treatment. Coronary artery calcium imaging has been presented as being of potential benefit in excluding those who are least likely to benefit from such treatment.

Infection of the endocardium or prosthetic surfaces in the heart, if ineffectively treated, is associated with severe complications and a high mortality. In this Review, Karl Werdan and colleagues summarize the pathogen–host interactions and mechanisms of increased risk in patients with infective endocarditis, including immunosenescence in elderly patients, and the transition from local infection to systemic sepsis and shock.

In the POST trial, mechanical ischaemic postconditioning did not have a significant cardioprotective effect in patients with ST-segment elevation myocardial infarction. However, the sample size, the principal end point (ST-segment regression), and the postconditioning protocol used are important limitations in this trial. Whether mechanical postconditioning has cardioprotective clinical benefits remains unanswered.

As patients with paediatric cardiological conditions become adults, they should be transitioned to adult care. In this Review, McCrindle and Kovacs discuss how this transition should occur, and what should be done to avoid lapses in care during and after this process.

The aim of minimally invasive surgery for congenital heart disease in paediatric patients is to reduce the trauma of the operation at each stage of management. In this Review, paediatric cardiac surgeons Emile Bacha and David Kalfa discuss various techniques for minimally invasive surgery, including sternal-sparing incisions, video-assisted thoracoscopic and robotically assisted surgery, hybrid procedures, and other trauma-sparing strategies. They also highlight the importance of multidisciplinary care, and emotional support for the patient and their family after hospital discharge.

Cardiologists and intensivists often regard death as failure, continuing to pursue active treatment while potentially denying patients access to alternatives such as symptom control and end-of-life care. In this Review, Price and Haxby describe how decision-making should be shared between the patient, their family, and the physician, to ensure that high-quality, patient-centred care is provided to critically ill patients with cardiac disease.

De novostenosis of coronary or peripheral arteries as well as restenosis of previously stented vessels are increasingly prevalent clinical problems. In this Review, Byrne and colleagues summarize the evidence for the use of novel balloon catheters covered with antiproliferative drug both to restore vessel patency and to provide long-lasting inhibition of cell regrowth.

Silent cerebral infarcts frequently occur in association with cardiovascular disease and cardiac interventional procedures, but their prognostic importance is unknown. In this Review, Hassell and colleagues assess the incidence and detection of silent cerebral infarcts, and their possible association with adverse neurological outcomes, such as stroke, depression, cognitive decline, and dementia.

Opium is a widely abused substance throughout the Middle East and Asia. In this Perspectives article, Dr Masoudkabir and colleagues dispel the commonly held misconception in these regions that opium has beneficial effects on cardiovascular health, and summarize the available evidence showing that, conversely, opium use is a risk factor for cardiometabolic diseases.

Percutaneous transcatheter mechanical occlusion of the left atrial appendage (LAA) is a nonpharmacological treatment option for stroke prevention in patients with atrial fibrillation who cannot receive anticoagulant drugs. In this Review, Cheuk-Man Yu and colleagues present the rationale for LAA occlusion in patients with AF, the available occlusion devices and the clinical evidence for their use, and discuss the role of imaging techniques in device implantation and the management of procedural complications.

The effect of a fixed-dose combination drug strategy ('polypill') on patients' adherence to medication was analysed in a series of 2,004 individuals with, or at high risk of, cardiovascular disease in the UMPIRE study. The polypill improved adherence by >20%, but the reduction in blood-pressure and cholesterol levels was modest.

Transcatheter aortic valve replacement (TAVR) is an effective treatment for patients with severe aortic stenosis who are not suitable candidates for surgery. However, serious complications such as myocardial infarction, cerebrovascular events, vascular complications, bleeding, acute kidney injury, valve regurgitation, valve malpositioning, coronary obstruction, and conduction disturbances and arrhythmias, can occur. In this Review, Alec Vahanian and colleagues describe TAVR-related complications, the mechanisms that cause these events, and methods of preventing them.