Reviews & Analysis

Asian individuals have a higher risk of stroke associated with atrial fibrillation (AF) than white patients. The use of the vitamin K antagonist warfarin is low in Asian countries, owing to the challenge of controlling anticoagulation and the high-risk of haemorrhage with warfarin in Asians. The non-vitamin K antagonist, oral anticoagulant drugs offer a solution to these challenges. In this article, Sabir et al. discuss the use of these agents in the management of AF in Asian populations.

Left cardiac sympathetic denervation (LCSD) has antiarrhythmic and antifibrillatory effects that are beneficial for patients with channelopathies, such as long QT syndrome or catecholaminergic polymorphic ventricular tachycardia. In this Review, Peter Schwartz expertly summarizes the development and current indications for LCSD, including emerging evidence for a potential beneficial effect in patients with ischaemic cardiomyopathy or heart failure.

The use of multipotent stem cells to achieve regeneration in cardiovascular disease has been the subject of continuous evaluation over the past decade. Dr Behfar and colleagues review experience obtained from trials of 'first-generation' cell-based therapy, and discuss the advances that have enabled the development of 'next-generation' stem-cell-based therapies targeting cardiovascular disease.

The term 'athlete's heart' refers to the plethora of electrical, structural, and functional cardiac adaptations that occur in athletes undertaking vigorous training regimens. The manifestations of cardiac adaptation to exercise can resemble the signs of cardiac disease that precede sudden cardiac death. Differentiation between athlete's heart and cardiac pathology presents a challenge for physicians. In this Review, Sheikh and Sharma describe the impact of ethnicity on cardiac adaptation to exercise, with a focus on black athletes, and discuss the impact of ethnically mediated changes on preparticipation cardiovascular evaluation.

The Eighth Joint National Committee (JNC 8) guidelines on hypertension have generated great interest among physicians. These guidelines differ from those published in 2003 (the JNC 7)—in the document format, blood-pressure cut-off values, and recommendations for antihypertensive drug use. The JNC 8 have some limitations that could affect clinical practice.

Currently, numerous tests are available for the assessment and triage of patients with stable ischaemic heart disease. National societies in the USA have collaborated to develop appropriate use criteria to give guidance to clinicians about the evidence-based use of these tests.

The prevalence of calcific aortic valve disease (CAVD) is increasing as the global population ages. In the absence of a specific drug therapy, the only treatment for CAVD is valve replacement. In this Review, Hutcheson et al. discuss the mechanisms of CAVD and identify potential therapeutic targets that warrant further investigation.

Transcatheter aortic valve implantation (TAVI) is increasingly used to treat patients with aortic stenosis for whom the risks associated with surgery are very high. In this Review, the new generation of TAVI devices are discussed, many of which have features that allow repositioning of the device and reduce paravalvular leakage.

New findings published in 2013 strongly support the use of novel oral anticoagulants in the treatment of thromboembolic disorders. These drugs have been shown to have a more-favourable benefit-to-risk profile than older compounds, enabling their use from the start of treatment and in the whole spectrum of clinical presentations.

The new ACC/AHA cardiovascular-risk guidelines feature updated equations for women, distinct equations for African–American individuals, and include stroke prediction. However, the equations rely on the same traditional risk factors as previous versions, are driven predominantly by age, and curtail the intermediate-risk group, in which personalized risk assessment is recommended.

The VISTA-16 trial of varespladib, a secretory phospholipase A₂ (sPLA₂) inhibitor, in patients with an acute coronary syndrome was terminated prematurely owing to futility and a signal towards harm. Despite these discouraging results, therapies that target inflammation to modify pathways in atherogenesis remain an area of active investigation.

In 2013, advances in noninvasive imaging methods pushed traditional boundaries in the detection, diagnosis, and functional assessment of coronary artery disease, atherosclerotic plaque, and myocardial function. We highlight five important studies that demonstrate how these developments are allowing medicine to become increasingly evidence-based and personalized.

Cardiomyopathy classification has been subject to revisions for >60 years. The new MOGE(S) classification system, which incorporates information on structural and functional abnormalities, organ involvement, genetics, aetiology, and disease severity, is a step towards a globally accepted nomenclature, but needs to be applicable in all health-care systems around the world.

A number of gene variants that cause hypercoagulability, and can lead to venous thromboembolism, have been identified. The two main mechanisms are loss-of-function of anticoagulant proteins and gain-of-function of procoagulants. In this Review, Ida Martinelli and colleagues discuss the main causes of inherited thrombophilia, the associated clinical manifestations, and the implications for screening and antithrombotic prophylaxis in affected individuals and their families.

Dystrophinopathies, such as Duchenne muscular dystrophy, Becker muscular dystrophy, and X linked dilated cardiomyopathy, can have cardiac sequelae. In this Review, Finsterer and Cripe discuss how the onset of cardiac involvement should be delayed in these patients, and then how it should be treated. The use of both pharmacological and nonpharmacological tools is described.

Catheter-based revascularization has emerged as the gold-standard therapy for most patients with acute coronary syndromes (ACS). Optimizing outcomes in these patients requires appropriate adjunctive pharmacological therapy and percutaneous coronary intervention. Five studies published in 2013 are expected to have a major effect on treatment and prognosis of patients with ACS.

A scientific statement on the prevention and treatment of thrombosis in children with congenital heart disease has been published by Giglia et al. on behalf of the AHA. This paper adds substantially to the current literature, and yet highlights the major limitations in our current understanding and knowledge in this field.

The coronary collateral circulation protects the myocardium when blood flow is reduced because of an occlusion. In this Review, Zimarino and colleagues discuss the development of collateral vessels through tissue remodelling. Collaterals and their underlying adaptative mechanisms are clinically important to modern interventional cardiology.