News & Comment

Left atrial appendage occlusion (LAAO) has been rapidly adopted for stroke prevention in patients with non-valvular atrial fibrillation and a contraindication to oral anticoagulation. Ongoing and planned clinical trials on LAAO and the development of new devices might expand clinical indications and address the remaining challenges of device-related thrombus and peridevice leak.

The risk of stroke in patients with atrial high-rate episodes (AHREs) depends on age, comorbidities and AHRE burden. Two randomized clinical trials on the use of oral anticoagulant therapy for stroke prevention in older patients with short and rare AHREs have reported conflicting findings on the efficacy of oral anticoagulation in this patient population, although both trials report a significantly increased risk of major bleeding with oral anticoagulation.

Transcatheter aortic valve implantation (TAVI) has become an important treatment option for aortic stenosis, even among younger patients, with similar rates of efficacy as compared with surgical valve replacement. However, complications including device failure persist; these can be addressed by surgical explantation and repeat TAVI. Ongoing research emphasizes the long-term potential of TAVI as an alternative to surgical intervention for aortic stenosis.

The population of patients who undergo cardiac surgery is becoming older and more medically complex, and frailty is increasingly prevalent. Prehabilitation is a multicomponent programme intended to better prepare these vulnerable patients for the stresses of surgery. Nonetheless, the effectiveness, implementation and effects on long-term outcomes of prehabilitation have not been clearly established. In particular, frailty might not be easily mitigated by prehabilitation.

The link between migraine and cardiovascular disease is complex and involves overlapping mechanisms, such as endovascular disturbances. Challenges in measuring migraine, in distinguishing between causation and prediction, and in the understanding of clinical implications highlight the need for further research to guide treatment and cardiovascular risk assessment for the millions of individuals living with migraine.

Novel non-steroidal mineralocorticoid receptor antagonists (MRAs) have improved pharmacological properties compared with steroidal MRAs. Among the non-steroidal MRAs, finerenone has been approved for patients with chronic kidney disease who have diabetes mellitus and has demonstrated favourable safety and promising early results in patients with heart failure.

In patients with an acute myocardial infarction, disrupted circadian rhythms during the initial days in the cardiac intensive care unit, caused by factors such as noise, excessive night-time light and frequent patient–staff interactions, can have devastating effects on cardiac repair and long-term prognosis. Providing care that aligns with the patient’s natural circadian rhythms is critical for optimum long-term recovery. Incorporating ‘circadian medicine’ into clinical practice will provide important health-care benefits.

Unloading left atrial hypertension by catheter-based, transvenous creation of atrial shunts is being explored to treat heart failure. So far, trials including sham control have demonstrated safety and efficacy in lowering left-sided cardiac filling pressures. Ongoing trials will determine the effect on clinical outcomes.

Contemporary tools to predict cardiovascular risk lack accuracy on an individual-patient level. The use of single-cell RNA sequencing to identify specific leukocyte patterns might overcome some of these limitations, propelling us towards a precision medicine approach.

Research consistently shows that gender-affirming practices improve markers of cardiovascular health. Consequently, the focus of the management of the cardiovascular health of transgender and non-binary populations should not be on their hormone therapies and surgical histories, but should instead be rooted in the routine screening of cardiovascular risk factors.

Factor XIa inhibitors are being tested in clinical trials, with the assumption that these agents are as effective as direct oral anticoagulants but cause fewer bleeding events. Findings from phase II trials of direct inhibitors of factor XIa for the prevention of first-ever and recurrent ischaemic stroke or recurrent major coronary artery events suggest fewer bleeding events but with uncertainty about efficacy.

Hypertrophic cardiomyopathy (HCM) is defined by ventricular hypertrophy. However, the broader phenotype includes abnormal cardiomyocyte orientation (disarray), myocardial ischaemia and electrical abnormalities, which seem to manifest before overt hypertrophy. With advances in cascade genetic testing and novel therapeutic agents, the detection of subclinical HCM is a rapidly emerging priority. In this context, we outline the role of novel biomarkers, particularly quantitative perfusion and diffusion tensor MRI.

The post-acute sequelae of COVID-19 present major problems for many patients, their physicians and the health-care system. They are unrelated to the severity of the initial infection, are often highly symptomatic and can occur after vaccination. Many sequelae involve cardiovascular autonomic dysfunction, with postural orthostatic tachycardia syndrome in 30% of individuals. Prognosis is unknown, and treatment is still unsatisfactory.