Springer Science and Business Media LLC

Intracranial hemorrhage (ICH) is the most feared complication of antithrombotic medication use for the treatment and prevention of ischemic stroke. The risk of ICH while on blood thinners varies not only among different types of antithrombotics but also for the same agent used in different patient populations. Individual patients have different susceptibilities to ICH mostly due to the presence or absence of bleeding-prone cerebral pathologies such as cerebral amyloid angiopathy or hypertensive small vessel disease. The recent development and FDA approval of novel anticoagulants may lead to increased safety when compared to previously used medications, and the emergence of nonpharmacologic approaches may obviate the need for long-term anticoagulant strategies in certain clinical situations, such as left atrial appendage closure for stroke prevention in atrial fibrillation. As such, blanket recommendations for antithrombotic choice cannot be justified. Good practices in vascular neurology dictate combining all available data in order to choose the treatment that has the best risk-benefit ratio for each individual patient.

Cardiac resynchronization therapy (CRT) represents a new class of heart failure therapy that provides symptom relief and decreased need of hospitalization in a significant number of patients already receiving maximal medical intervention. Patients with ischemic or nonischemic dilated cardiomyopathy, coupled with interventricular conduction delays, who have New York Heart Association class III or IV symptoms, are currently candidates for CRT. This device-based intervention reverses adverse ventricular remodeling, decreases the severity of mitral regurgitation, and increases cardiac efficiency and output. New selection criteria are being considered in an attempt to identify patients who have a high chance of responding, and possibly, to identify patients that have a high chance of not responding to CRT. These efforts are in response to the 20% to 25% “nonresponder” rate observed when the currently accepted inclusion criteria are used. Other patient populations may also benefit from CRT, including those in need of antibradycardia pacing, patients with atrial fibrillation, and some who meet the criteria for prophylactic implantation of a cardiac defibrillator. This review focuses on the current strategies to refine patient selection criteria and addresses some of the practical issues in prescribing CRT.

Myocardial adaptation to athletics and exercise training is a well-described process that has garnered much interest over the past decades. By contrast, our understanding of how the vascular system adapts in the trained athlete remains limited. The goal of this review is to provide a comprehensive overview of the impact of exercise on structure and function of the extra-cardiac vascular system. While structural changes in the size of the aorta are rare in young athletes, emerging data suggest that long-term athletic participation may be a risk factor for aortic dilation in middle-age and beyond. In addition, new findings show that even modest amounts of athletic training such as participation in an individual’s first marathon can have important salutary effects on vascular health. Vascular adaptations represent an important part of the athletic phenotype and likely play an important role in the overall cardiovascular health of the trained athlete.

Patients with cardiogenic shock (CS) continue to have high rates of morbidity and mortality. We aimed to describe current principles in the management of CS including coronary revascularization, medical management, mechanical circulatory support, and supportive care. Revascularization is still recommended, but trials have not found a benefit in the revascularization of nonculprit artery lesions. New mechanical circulatory support options are available, but optimal use remains uncertain. Overall improvement in outcomes appears to have plateaued. There remain substantial knowledge gaps about the management of CS. The ideal timing and selection criteria for mechanical support remain under-developed. There has been little systematic study to inform medical management or supportive care of this patient population. A more expansive research focus is necessary to improve the care of CS.

Non-ST segment elevation myocardial infarction (non-STEMI) is a common presentation of the acute coronary syndrome (ACS) spectrum. Currently, the recommended treatment option is an invasive approach with angiography plus coronary revascularization to treat the culprit lesion. However, unlike in STEMI—in which the culprit lesion can be easily identified—in non-STEMI identifying the culprit lesion is difficult. Therefore, some have advocated for a more definitive approach to addressing all severe lesions in patients presenting with non-STEMI. The current European guidelines for percutaneous coronary intervention (PCI) for multivessel versus culprit-only stenting state that “the decision to perform either culprit vessel or complete revascularization can be made on an individual basis,” whereas the American College of Cardiology/American Heart Association guidelines for multivessel PCl in patients presenting with ACS recommend that “it be performed when there is a high likelihood of success and a low risk of morbidity and the vessels to be dilated subtend a moderate or large area of viable myocardium and have high risk by noninvasive testing.” Although lesions and coronary anatomies are each unique and the risk and benefit of coronary intervention to each lesion should be carefully examined, we recommend stenting the culprit lesion and other severe lesions after careful consideration, in a staged fashion if necessary. If the severity of nonculprit lesions is in question, fractional flow reserve or intravascular ultrasound should be considered.

To outline a comprehensive clinical evaluation of secondary mitral regurgitation (SMR) and to review the state-of-the-art, diagnostic advances, therapeutic challenges, and future developments. SMR is commonly observed in heart failure patients. With an increasing heart failure incidence in an aging population, the prevalence of SMR is expected to rise significantly. SMR is associated with more symptoms, increased hospitalizations for heart failure, and overall worse prognosis. Both diagnostic approach and therapeutic management are challenging, but recent studies provide solutions and significant developments in this rapidly evolving field. SMR is a complex valvular heart disease, affecting a significant proportion of heart failure patients, and is associated with a worse prognosis. Key challenges are refinement of diagnostic assessment to improve patient selection for the respective therapeutic approach. Mastering the challenge of SMR requires a multidisciplinary collaborative effort, both in clinical practice and scientific approach to optimize patient outcomes.

Interventional cardiologists are increasingly being called upon to perform complex revascularization in patients who are deemed not to be candidates for surgical revascularization and, until recently, many of these patients would have only been offered medical management. Further, changing demographics have resulted in an increasingly elderly and frail population with diabetes and chronic kidney disease being referred for revascularization. Owing to the increasing prevalence of coronary artery calcification and the importance of achieving complete revascularization, advanced tools and techniques are required to safely revascularize this patient population. Coronary artery calcification is a marker for increased periprocedural complications and worse long-term outcomes in percutaneous intervention. Its presence may mandate advanced revascularization strategies to facilitate safe revascularization. Several studies have highlighted the importance of intracoronary imaging and there have been iterative changes and new devices that have been developed that can facilitate revascularization in the setting of significant coronary artery calcification. Successful coronary revascularization is increasingly dependent on the rational use of intraavascular imaging, specialized balloons and atherectomy to overcome complex coronary artery disease and calcification. A rational strategy for the safe use of advanced techniques and tools is presented here.

Triglycerides are routinely obtained with standard lipid testing, but their role in cardiovascular risk is controversial. An excess of triglycerides is commonly encountered in patients with the metabolic syndrome or diabetes, and represents an excess burden of small, dense low-density lipoproteins (LDLs), which confers additive risk for cardiovascular disease. Current guidelines prioritize LDL targets first, but treatment of triglycerides once LDL targets are achieved bears consideration. Beyond lifestyle modification, potential pharmacologic therapies include statins, fibrates, niacin, omega-3 fatty acids and antidiabetic drugs. There are few trials to date comparing these agents directly in the management of hypertriglyceridemia, but available data seems to demonstrate that the greatest benefit of triglyceride lowering is experienced in a subgroup of patients with an atherogenic lipid profile (elevated triglycerides, low high-density lipoprotein (HDL), elevated small, dense LDL particles). Here, we discuss the current understanding of how triglyceride elevations impart cardiovascular risk, current therapies and the data supporting their use, and ongoing studies to elucidate the degree to which treatment of triglycerides modifies risk of future cardiovascular events.