Antiplatelet pretreatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) is controversial. It is vital that the risk of ischaemia and the risk of haemorrhage are both considered when managing this patient group. Current clinical guidelines do not recommend routine pretreatment in patients presenting with NSTE-ACS who are having coronary angiography within 24 hours. However, a significant portion of these patients will not have coronary angiography until after 24 hours. Pretreatment with antiplatelets may reduce the risk of ischaemic events, but it is associated with bleeding and delays to coronary artery bypass grafting, and it may be deleterious in patients with diagnoses other than NSTE-ACS, such as acute aortic syndromes, pulmonary embolism or intracranial bleeds. This review analyses the most important studies assessing antiplatelet pretreatment in NSTE-ACS.
Few disorders have evoked more interest and controversy in cardiology over recent centuries than floppy mitral valve (FMV)/mitral valve prolapse (MVP). FMV/MVP is a complex entity with multiple genotypes and phenotypes in which the clinical manifestations may not be directly related to the severity of mitral regurgitation. Furthermore, there is a lack of a precise definition of this complex entity. This review emphasises a diagnostic approach based mostly on FMV rather than solely on MVP, which frequently may be a non-specific finding. In addition, a clinical classification of FMV/MVP is presented that separates patients with symptoms not directly related to the severity of mitral regurgitation (referred to as FMV/MVP syndrome) from those in whom symptoms are directly related to mitral regurgitation and its complications. In the future, genetic variants will likely be incorporated into the diagnostic classification and management of this complex entity as this odyssey continues.
Dyslipidaemia remains a major contributor to cardiovascular morbidity and mortality, despite the availability of effective lipid-lowering therapies and well-established European Society of Cardiology/European Atherosclerosis Society guidelines. In clinical practice, the implementation of these recommendations is often suboptimal, with persistent therapeutic inertia and fragmented decision-making processes. The CARDIOLIPID Plan is a proposed cardiovascular risk-centred implementation framework designed to support the practical application of guideline-based care. The model integrates two key components of clinical decision-making: comprehensive cardiovascular risk assessment (CARDIO) and personalised lipid-lowering intervention (LIPID), structured into a sequential and clinically applicable pathway. While the individual elements of the CARDIOLIPID Plan are derived from current evidence and guideline recommendations, their organisation within this framework reflects an interpretation by experts aimed at improving clarity, usability and clinical implementation. The model emphasises early and appropriate treatment intensification, reduction of therapeutic inertia and a holistic, patient-centred approach to cardiovascular risk management. The CARDIOLIPID Plan may serve as a practical tool to enhance the translation of evidence into clinical practice. However, as a conceptual and implementation-oriented framework, it requires validation in real-world settings to assess its impact on treatment outcomes and cardiovascular risk reduction.
Current guideline-based classifications of mitral stenosis rely primarily on parameters ofvalvular narrowing and its associated clinical symptoms. In recent years, novel phenotyping approaches based on the concept of sequential cardiac chamber involvement have been developed for other cardiovascular conditions, including mitral regurgitation, aortic stenosis, and heart failure with preserved ejection fraction. Similarly, the development of an extra-valvular echocardiographic staging system for mitral stenosis, grounded in the extent of cardiac chamber involvement, appears warranted to improve risk stratification and tailor clinical management.
Background:Heart failure with preserved ejection fraction (HFpEF) is a prevalent and challenging cardiovascular condition associated with high morbidity and mortality. Despite the lack of effective pharmacological treatments, recent studies have suggested that sodium-glucose co-transporter 2 inhibitors (SGLT2Is) may offer potential benefits in reducing cardiovascular events in HFpEF patients. The aim of this systematic review and meta-analysis is to assess the efficacy of SGLT2Is in reducing cardiovascular outcomes in individuals with HFpEF. Methods:A comprehensive literature search was conducted across PubMed, Cochrane Library, Embase, and clinical trial registries for studies published up to October 2024. Randomised controlled trials (RCTs) that investigated the use of SGLT2Is in patients with HFpEF and reported on major cardiovascular outcomes were included. Data from eligible studies were pooled to calculate risk ratios (RR) and 95% CIs for the primary outcomes, including major adverse cardiovascular events (MACE) and hospitalisation for heart failure (HHF). Results:Fifteen RCTs involving 12,436 patients with HFpEF were included in the meta-analysis. Treatment with SGLT2Is reduced the risk of MACE (RR=0.79, 95% CI [0.70-0.89]) and HHF (RR=0.72, 95% CI [0.65-0.87]) compared with placebo. Secondary analyses demonstrated reductions in cardiovascular mortality (RR=0.84, 95% CI [0.75-0.95]) and improvements in health-related quality of life as assessed by Kansas City Cardiomyopathy Questionnaire scores. Conclusion:SGLT2Is significantly reduce cardiovascular events, including HHF and MACE, in patients with HFpEF. These findings support the growing evidence for the use of SGLT2Is as a promising therapeutic option in this high-risk patient population.
Background:Statins are a cornerstone of therapy to reduce LDL cholesterol and cardiovascular diseases. However, their use may cause adverse events. This umbrella review aims to comprehensively review the safety profile of statin therapy. Methods:PubMed and Embase were searched to identify systematic reviews, scoping reviews, meta-analyses and network meta-analyses on statin safety. Extracted data included study type, data source, number of included studies, search date range, participant numbers, interventions, safety outcomes, results and funding. Risk of bias was assessed using the AMSTAR 2 instrument. Data underwent descriptive statistical analysis. Results:Seventy-two reviews were included, mostly based on clinical trials (70.8%) and observational studies (59.7%). Only 21 (29.2%) reported results for individual statins, with atorvastatin being the most frequently evaluated individual statin (95.2%). Nearly 86% of the reviews were rated as Critically Low in overall confidence. Statins were associated with an increased risk of new-onset diabetes, particularly rosuvastatin and atorvastatin, whereas pitavastatin may be protective. Liver injury/dysfunction and elevated transaminases were observed, along with a small risk of muscle-related symptoms, specifically at higher statin intensity. Rare serious events, such as necrotising myopathy, were reported. Pregnancy studies indicated an increased risk of spontaneous abortion. Conclusion:Although overall statin safety is favourable, the risks of diabetes, liver dysfunction, enzyme elevations and muscle symptoms require consideration, especially with high-intensity therapy or specific statins. Pitavastatin may be a safer option for patients at metabolic risk. Therapy should be tailored to individual patient factors. Further research is needed to clarify rare or inconsistent outcomes.
Coronary artery obstruction is a commonly fatal complication occurring after transcatheter aortic valve replacement. The main mechanisms are displacement of valve leaflets to overlie the coronary ostium or sequestration of the coronary sinus. The bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure mitigates this risk. It entails deliberate laceration of the valve leaflet to allow it to splay apart during transcatheter heart valve implantation, thus maintaining coronary perfusion. Patient selection is based on key anatomical and imaging-derived parameters. Catheter electrosurgery involves using electrified wires to permit puncture and laceration of the leaflet. The steps undertaken to achieve a successful BASILICA procedure include access, traversal, puncture, laceration and completion, which are described in this review. Challenges faced by the BASILICA operator and practical solutions are also discussed.
