Reviews & Analysis

Advances in treating cardiac arrhythmias include autonomic manipulation, drugs, imaging, devices, and genetics. I have selected articles published in 2014 that further our knowledge in each area, and which are representative of other important articles that could not be cited. Highlighting five diverse areas emphasizes the complexity of treating arrhythmias.

Prevention of cardiovascular diseases (CVDs), particularly atherosclerosis, remains a priority on the global health agenda. A healthy lifestyle at both individual and population levels, combined with pharmacological treatment of CVD risk factors, is recommended. In this Year in Review article, we discuss the major advances in CVD prevention in 2014.

Rheumatological diseases can have a broad spectrum of cardiovascular manifestations that, whilst sometimes mild or clinically silent, can often increase morbidity and mortality. In this Review, Prasad et al. explore the underlying pathophysiology and available management strategies of cardiovascular complications in patients with autoimmune rheumatic diseases, and focus on the vascular aspects of the emerging field of 'cardiorheumatology'.

In elderly patients with degenerative mitral regurgitation who are not ideal candidates for conventional surgical valve repair or replacement, percutaneous valve repair is emerging as an alternative therapeutic option. While percutaneous valve repair is associated with clinical improvement, faster recovery, and reduced perioperative mortality, it should only be considered in patients who will gain the most benefit from it. In this Review, Taramasso and colleagues discuss the treatment options and indications for degenerative mitral regurgitation in elderly patients.

Acute aortic syndrome (AAS) encompasses acute aortic dissection, intramural haematoma, and penetrating aortic ulcer, a group of conditions that carry a risk of imminent aortic rupture. The development of these disorders has been linked to a number of pathologies, including untreated hypertension and connective tissue disorders. In this Review, Clough and Nienaber discuss the epidemiology, diagnostic strategies, and treatment options for each condition.

MicroRNAs regulate the processes that underlie cardiac remodelling after myocardial infarction, including angiogenesis and cardiomyocyte apoptosis and proliferation. In this Review, Boon and Dimmeler summarize the microRNAs that are involved with these postischaemic pathways, and discuss potential therapeutic interventions to enhance cardiac regeneration in patients with acute myocardial infarction.

Biomarkers are needed to accurately represent or predict clinical outcomes for optimal management of patients with atrial fibrillation (AF) in clinical practice. Growth differentiation factor-15, a member of the transforming growth factor-β family, has an independent prognostic role for major bleeding and death in patients with AF receiving oral anticoagulation.

The results of the Q-SYMBIO trial showing a reduction in mortality in patients with heart failure treated with coenzyme Q₁₀ have substantial limitations. Nevertheless, they highlight the need to identify effective new therapies targeted at mitochondrial dysfunction and oxidative stress in heart failure.

Available treatments for atrial fibrillation (AF) often lack sufficient efficacy or have considerable complications, but novel therapies based on the underlying molecular mechanisms of AF can provide useful alternatives. MicroRNAs (miRNAs) regulate gene transcription, and constitute a promising therapeutic approach for the treatment of AF. In this Review article, Luo et al. provide a comprehensive overview of the mechanisms of miRNA action, and explore the available experimental evidence supporting a role for miRNAs as novel therapeutic targets for AF.

Pulmonary arterial hypertension (PAH) is an incurable disease associated with high mortality, but early detection of PAH improves long-term survival. In this Review, Lau and colleagues discuss which individuals warrant screening for PAH, such as those with systemic sclerosis, and summarize the variety of diagnostic tests that could be combined into a multimodal approach to optimize the performance of screening algorithms.

Although PCI can restore epicardial patency, microvascular blockage can occur in up to 50% of patients with acute myocardial infacrtion and lead to intramyocardial haemorrhage. In this Review, Betgem and colleagues discuss the pathophysiology, diagnostic options, and clinical relevance of intramyocardial haemorrhage, as well as potential future therapies to treat this condition.

Traditional Chinese medicine (TCM) has been used in China for >2000 years, and become increasingly popular in Western countries. In this Review, Hao and colleagues describe and assess the randomized controlled trials that have compared TCM with no intervention or modern western medicines for the treatment of cardiovascular diseases.

Atherosclerosis is characterized by increased accumulation of macrophages within the vessel wall. In response to stimuli such as modified lipids, cytokines, and senescent erythrocytes present in the atherosclerotic lesion, these macrophages can alter their functional phenotypes. Different macrophage subsets can influence the growth and composition of the atherosclerotic plaque in distinct ways. In this Review, Chinetti-Gbaguidi et al. highlight the diverse range of macrophage phenotypes present in atherosclerotic lesions, and their roles in both plaque progression and stability.

Novel oral anticoagulants (direct thrombin or factor Xa inhibitors) have become alternative options to vitamin K antagonists owing to their predictable and safe pharmacological profiles. In this Review, Baber and colleagues discuss the overall clinical effect of these drugs, which is a balance between ischaemic benefit and bleeding risk, in patients with atrial fibrillation, venous thromboembolism, or acute coronary syndrome.

In the EORP-AF Pilot registry on the prognosis and treatment of patients with atrial fibrillation (AF), 1-year mortality is high. Symptoms are still common in patients with AF, and hospital readmissions are mainly owing to AF and heart failure. Oral anticoagulation use has increased, but a rhythm-control strategy is uncommon.

Cardiac MRI is a noninvasive phenotyping tool that allows for accurate and easy detection and quantification of myocardial fibrosis in myocardial tissue. In this Review, Ambale-Venkatesh and Lima focus on late-gadolinium enhancement and T1 mapping strategies, and explore the different prognostic applications of this technique.

Combination antiretroviral therapy (cART) has substantially prolonged the lives of patients with HIV infection, but these individuals have an increased risk of coronary heart disease and myocardial infarction compared with uninfected individuals. In this Review, Reiss and colleagues discuss the control of both traditional and immune risk factors, and the appropriate selection of cART regimens, to reduce the risk of cardiovascular complications in patients with HIV.

A new meta-analysis challenges the notion that β-blockers improve survival in patients with heart failure (HF) and concomintant atrial fibrillation (AF). These results should be interpreted with caution. Although the mortality reduction conferred by β-blockers was likely overestimated in the past, benefits should be expected in a sizeable proportion of patients with HF and AF.

Transcatheter aortic valve implantation (TAVI) is an established therapeutic option for high-risk patients with a tricuspid aortic valve, but patients with a bicuspid aortic valve (BAV) are contraindicated. In this Perspectives article, Zhao and colleagues summarize the available evidence for the use of TAVI in patients with a BAV and propose that this procedure might be appropriate in high-risk or inoperable individuals, but that more evidence is required before indications for TAVI can be extended to other patients with a BAV.

Amyloidosis is caused by the aggregation of insoluble fibrous deposits of misfolded proteins. Cardiac deposition can lead to diastolic dysfunction, arrhythmias, and ischaemia. In this Review, Gertz et al. summarize the pathophysiology of the condition, and how best to achieve early diagnosis and treatment, before advanced heart failure occurs.