PURPOSE OF REVIEW:Residual inflammatory risk remains an important driver of recurrent vascular events despite contemporary lipid-lowering and antithrombotic therapies. Low-dose colchicine is the first widely available anti-inflammatory therapy to be incorporated into contemporary guidelines for secondary prevention in coronary artery disease. This review summarizes contemporary evidence on the efficacy and safety of low-dose colchicine for secondary prevention. RECENT FINDINGS:Large randomized trials have demonstrated that colchicine reduces recurrent ischemic events in patients with chronic coronary disease and after myocardial infarction. Recent trials in acute myocardial infarction and stroke populations, however, have produced heterogeneous results. Nevertheless, contemporary meta-analyses consistently demonstrate reductions in major adverse cardiovascular events (MACE), driven mainly by fewer myocardial infarctions, strokes, and coronary revascularizations. Safety data are reassuring, with no consistent excess in serious infection, cancer, pneumonia, or noncardiovascular death, although gastrointestinal intolerance remains the most common adverse effect. SUMMARY:Low-dose colchicine has established residual inflammation as an actionable target in secondary prevention of vascular events in patients with chronic coronary disease or recent myocardial infarction. Ongoing trials will clarify colchicine's role across broader vascular indications. Future work should also focus on implementing the use of colchicine for prevention of clinical events in patients with coronary artery disease in clinical practice.
PURPOSE OF REVIEW:Nonobstructive coronary artery disease (NOCA) is now frequently detected by coronary CT angiography (CCTA), but the term compresses biologically distinct patterns into a single anatomic label. This review examines how CT-derived markers can reorganize NOCA around plaque burden, inflammatory activity, clinical expression, and temporal change. RECENT FINDINGS:Recent work distinguishes three related but distinct tasks in NOCA: identify disease, stratify risk, and define phenotypes that may inform future prevention strategies. CCTA addresses the atherosclerotic and prognostic dimensions by quantifying plaque burden, plaque composition, and high-risk features; CT-derived inflammatory and cardiometabolic markers may further identify active vascular and metabolic phenotypes. In symptomatic patients, CCTA and fractional flow reserve CT can evaluate epicardial anatomy and lesion-specific hemodynamic significance, but normal or nonobstructive findings do not exclude coronary microvascular dysfunction or vasospasm. In asymptomatic patients, coronary artery calcium and CCTA can reveal subclinical atherosclerosis and refine preventive risk assessment. Serial imaging and intervention studies suggest that adverse plaque phenotypes can stabilize or change with intensive prevention, but outcome-proven CCTA-guided treatment algorithms are still lacking. SUMMARY:CCTA is evolving into a multidimensional phenotyping tool for NOCA. Its immediate value is refined risk stratification; whether these markers will improve outcomes remains unproven and should be tested prospectively.
PURPOSE OF REVIEW:Of patients undergoing coronary artery bypass grafting (CABG), 10-20% have preexisting atrial fibrillation (AF), which remains undertreated at the time of surgery. With rapidly evolving data, interest and enthusiasm for concomitant surgical management of AF have grown concurrently. This review summarizes the contemporary evidence, techniques, and approaches for surgical management of AF in patients undergoing CABG and proposes tailored operative strategies for these patients at the time of surgery. RECENT FINDINGS:Concomitant surgical management of AF at the time of CABG is underutilized, with only 30-40% of eligible patients receiving concomitant AF treatment. Surgeons can offer a spectrum of options to concurrently treat AF, from left atrial appendage occlusion (LAAO) to a full biatrial Cox-maze iteration without significant additional perioperative risk. Contemporary large-scale observational analyses suggest concomitant surgical ablation improves rhythm outcomes and is associated with improved survival, and lower risk of stroke long-term. SUMMARY:Concomitant LAAO is essential. Ablation techniques can be tailored based on the patient's burden of AF, clinical complexity, and surgeon expertise. A robust randomized trial is needed to convince clinicians to expand adoption.
PURPOSE OF REVIEW:Antithrombotic therapy for patients with atrial fibrillation (AF) after acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) requires balancing prevention of stroke and coronary events against bleeding. Recent recurrent-event and patient-centered analyses of AUGUSTUS make this review timely by reframing treatment benefit beyond first events. RECENT FINDINGS:Four dedicated trials support dual antithrombotic therapy with direct oral anticoagulants (DOAC) plus P2Y 12 inhibitor and early aspirin withdrawal to reduce bleeding without significant increase in ischemic events. However, aspirin-free strategies differ by anticoagulation indication: in patients without anticoagulation, very early aspirin withdrawal after ACS or PCI may increase the risk of coronary events, whereas in patients with AF receiving anticoagulation, oral anticoagulation may assume the early antithrombotic role of aspirin. AUGUSTUS showed that apixaban and placebo each reduced bleeding compared with vitamin K antagonist and aspirin. The recent total-event analyses further showed lower cumulative bleeding with apixaban than with vitamin K antagonist, and substantially greater cumulative bleeding with randomized aspirin than with placebo, along with similar total ischemic events and hospitalizations. SUMMARY:For patients with AF after ACS or PCI, DOAC-based dual antithrombotic therapy provides the most favorable cumulative safety-efficacy balance. Future research should focus on the timing of aspirin discontinuation and validate recurrent-event endpoints.
PURPOSE OF REVIEW:Coronary artery bypass grafting (CABG) improves prognosis in advanced coronary artery disease but does not halt native-vessel atherosclerosis or prevent graft failure. This review summarizes key advances in secondary prevention after CABG, emphasizing contemporary evidence, treatment shortcomings, and practical implications for long-term care. RECENT FINDINGS:Intensive lipid lowering remains key, with high-intensity statins, ezetimibe, and PCSK9 inhibitors used sequentially to achieve very low LDL-C targets, while triglyceride-lowering therapy may benefit selected high-risk patients. Aspirin remains the cornerstone of antithrombotic therapy, whereas dual antiplatelet therapy should be patient-specific. Routine long-term beta-blocker or renin-angiotensin system inhibitor therapy should be guided by established indications rather than CABG alone, while calcium channel blockers may have a role after radial artery grafting. SGLT2 inhibitors, GLP-1 receptor agonists, cardiac rehabilitation, smoking cessation, obesity management, vaccination, and mental health and cognitive screening have broadened secondary prevention beyond traditional risk-factor control. SUMMARY:Secondary prevention after CABG is a lifelong, multidisciplinary strategy aimed at preserving graft function, slowing disease progression, improving quality of life, and reducing recurrent cardiovascular events. Contemporary care should be individualized according to clinical phenotype, conduit strategy, comorbidity burden, thrombotic and bleeding risk, functional status, and treatment burden. Future studies should clarify persistent evidence gaps in antithrombotic therapy, cardiometabolic treatment, graft-specific outcomes, rehabilitation delivery, adherence, and patient-centered care.
