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To bridge the current gap between the known mechanisms of atrial fibrillation (AF) and the clinical management of patients with this arrhythmia, Fabritz and colleagues propose a roadmap to develop a set of clinical markers that reflect the major causes of AF in patients. A new, mechanism-based classification of AF can provide the basis for personalized prevention and management.
Atrial fibrillation (AF) and heart failure (HF) are evolving epidemics with increasing global prevalence. HF is known to promote AF, but how AF exacerbates or even causes HF is uncertain. In this Review, Ling and colleagues present the current understanding of the epidemiology and pathophysiology of AF–HF, and the roles of pharmacological and interventional therapies in the management of patients with this comorbidity.
The introduction of a new high-sensitivity troponin immunoassay might revolutionize the way acute coronary syndrome is diagnosed. The high analytical sensitivity of the assay enables earlier and more accurate identification of myocardial injury than with currently used methods, and also allows for the safe discharge of patients without myocardial ischaemia.
The numerous physiological changes that occur during pregnancy can affect the pharmacokinetics of drugs that a woman is receiving, often warranting an alteration in dosage. The well-being of the fetus is a major concern among pregnant women who require treatment for their heart disease. In this Review, Pieper provides an overview of the pharmacokinetic changes in drugs for cardiovascular disease during pregnancy, and how these might affect the fetus.
Coronary revascularization has a prominent role in the management of chronic, stable coronary artery disease, but decision-making guided by angiography alone for identifying haemodynamically relevant lesions can be challenging. The DEFER study now demonstrates favourable 15-year outcomes after deferral of revascularization in angiographically relevant, but functionally nonsignificant, coronary lesions.
The results of the first randomized, controlled trial to assess adaptive servo-ventilation (ASV) for central sleep apnoea were expected to confirm the positive findings from previous observational studies and meta-analyses. However, ASV did not have the expected beneficial effects for patients with heart failure and reduced ejection fraction.
Systems of care have been established to optimize treatment of ST-segment elevation myocardial infarction (STEMI) occurring out of hospital, but not for patients in hospital. Unfavourable clinical characteristics of patients, combined with suboptimal strategies for diagnosis and treatment, mean that inpatient STEMI is associated with high mortality. Eliminating system delays and increasing use of reperfusion therapy could improve outcomes for inpatient STEMI.
Regulatory T (TREG) cells are important for the induction and maintenance of immune homeostasis and tolerance. Numerous experimental and clinical studies have suggested a role for TREG cells in protection against cardiovascular diseases, particularly atherosclerosis and abdominal aortic aneurysms. In this Review, Meng and colleagues summarize the available evidence on the role of TREGcells in several cardiovascular disorders, such as atherosclerosis, hypertension, Kawasaki disease, and myocardial infarction.
The structural and temporal characteristics of atherosclerotic plaques differ between native coronary artery disease, vein-graft atherosclerosis, and in-stent neoatherosclerosis. In this Review, Yahagi et al. compare the shared and divergent morphological features, giving insight into the pathogenesis of atheroma formation, and provide an updated classification scheme for atherosclerotic lesions.
Mitral valve disease is a common cause of heart failure and death. In this Review from members of the Leducq Transatlantic Network, Levine and colleagues extensively summarize the molecular and cellular mechanisms underlying the dynamic changes that occur during progression of mitral valve disease, and indicate how improved understanding of the pathophysiology might lead to the discovery of novel therapeutic options.
Exposure to air pollution and to metals in the environment contributes to the development and severity of cardiovascular disease. Cosselman et al. review the pathophysiological processes associated with long-term and short-term exposure to these pollutants, at levels above and below current regulatory standards, and discuss the need for further reductions in levels of environmental pollutants.
Bone morphogenetic proteins (BMPs) and their receptors are important for the development and modulation of cardiovascular structure and function. Morrell and colleagues discuss physiological roles and regulation of BMP signalling in cardiovascular health and disease, and based on this advancing knowledge, they suggest opportunities for therapeutic intervention for a range of cardiovascular diseases, such as atherosclerosis and pulmonary arterial hypertension.
Among patients with diabetes mellitus and ischaemic heart disease, high-sensitivity testing effectively identified 39.3% of patients with elevated troponin levels who were at high 5-year risk of cardiovascular death, myocardial infarction, or stroke. Compared with optimal medical therapy, revascularization did not reduce ischaemic events among patients with elevated troponin levels.
Heart failure is a major global health problem with unmet therapeutic requirements despite the development of neurohormonal modulators for systolic heart failure. In this Review, the authors discuss the evidence resulting from clinical trials of novel pharmacological agents targeting contractility, neurohormonal signalling, vasodilatation, renal preservation, inflammation, and myocardial protection.
Acute heart failure (AHF) is a complex disease characterized by an acute worsening of heart failure symptoms, usually in patients with pre-existing heart failure. Clinical evaluation of patients with AHF involves the assessment of clinical history, a comprehensive physical examination, and laboratory and diagnostic testing. In this Review, Mentz and O'Connor highlight the literature on the clinical evaluation of AHF, in addition to summarizing the pathophysiological mechanisms underlying its development.
A new systematic review and meta-analysis by Lee and colleagues confirms the safety of nonprimary percutaneous coronary intervention (PCI) at centres without onsite surgical backup. In daily clinical practice at PCI centres without onsite surgical facilities, quality assurance and improvement programmes are important to ensure high-quality care.
High-density lipoproteins (HDLs) have various antiatherosclerotic effects; however, inflammation can cause HDL to become dysfunctional, which impairs its protective properties. In this Review, Rosenson and colleagues discuss the mechanisms by which HDL and apolipoprotein A-I protect against atherosclerosis, and how diagnostic and therapeutic approaches might target these proteins when they become dysfunctional.
Antiplatelet therapy with oral P2Y12-receptor inhibitors (clopidogrel, prasugrel, and ticagrelor) is widely used in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. However, patients often need to switch between these drugs for a variety of clinical reasons. In this Review, Rollini et al. summarize the practical considerations when switching therapies, including discussion of the new intravenous P2Y12-receptor inhibitor cangrelor.
Most idiopathic ventricular arrhythmias (including forms of premature ventricular contraction and ventricular tachycardia) originate from the right or left ventricular outflow tracts. In this Review, Lerman summarizes how these arrhythmias are triggered by cAMP-mediated mechanisms, addresses the differential diagnosis between these and other arrhythmias, and discusses optimal treatment strategies, usually involving catheter-based radiofrequency ablation.
Many patients with pericarditis experience recurrent episodes. In this Review, Imazio et al. emphasize the importance of identifying the aetiology of the disease, and summarize the available evidence for the various treatment options. First-line anti-inflammatory therapy involves aspirin, NSAIDs, and colchicine; additional and alternative options include corticosteroids, anakinra, azathioprine, and intravenous immunoglobulins.
