Reviews & Analysis

Both the cardiovascular research and clinical communities are ideally positioned to develop and implement precision medicine to achieve more effective prevention and treatment. This Review highlights the advances in modern biomedicine that make possible the precision medicine era, provides current examples of the use of this approach in the cardiovascular field, and defines the goals and barriers to implementation of a precision medicine system.

Refractory cardiogenic shock carries a poor prognosis, with an inhospital mortality of ∼50%. In this Review, Reyentovich and colleagues discuss the current therapeutic and management options available for patients with refractory cardiogenic shock.

Mitochondria provide energy for specialized functions at the cellular and organ level. The remarkable symbiotic relationship between mitochondria and the cell touches on every aspect of cell biology. Recent studies in mitochondrial biology have uncovered ways in which mitochondria affect human disease and have identified new targets for clinical intervention.

The underlying mechanisms for the continued sex-based disparities in acute coronary syndromes (ACS) remain unclear. In this Review, Pagidipati and Peterson discuss the current evidence for sex-related differences in the clinical presentation, pathophysiology, evaluation, management, and outcomes of ACS, and identify urgent research questions that need to be addressed in areas that range from clinical evaluation and management, to representation of women in clinical research.

Many patients who undergo doxorubicin chemotherapy develop cardiac complications later in life. Patient-derived cardiomyocytes can be used to predict individual susceptibility to drug-induced cardiotoxicity, as evidenced by enhanced doxorubicin responses in cardiomyocytes derived from induced pluripotent stem cells of patients who developed heart failure after chemotherapy.

Elevated heart rate can induce myocardial ischaemia in patients with coronary artery disease, and is a risk factor for cardiovascular events in those with heart failure. In this Review, Ferrari and Fox discuss the evidence for therapeutic heart rate reduction, drawing particularly on data from the BEAUTIFUL, SHIFT, and SIGNIFY trials.

A range of established and emerging invasive and noninvasive imaging modalities can be used to evaluate various parameters of coronary atherosclerosis, including functional severity, plaque burden, and high-risk characteristics. In this Review, Dweck et al. assess the relative strengths and weaknesses of these techniques, how they might be complementary when used in combination, and barriers that exist to their translation into clinical practice.

Veins are the most commonly used conduits for surgical revascularization; however, they are associated with a high failure rate. In this Review, de Vries and colleagues discuss the pathophysiological mechanisms underlying the development of vein graft failure, and summarize the current and developing therapies used to prevent graft failure.

Results from the HOPE-3 randomized trial reinforce and expand the evidence base supporting current clinical practice guidelines that recommend initiation of statin therapy in individuals at intermediate risk of atherosclerotic events. Furthermore, the results support the initiation of antihypertensive medication for patients with blood pressure above threshold values.

Sex has an important role in the diagnosis of coronary artery disease (CAD). Results from the PROMISE trial highlight the influence of sex on presentation characteristics, diagnostic testing, and subsequent cardiac events among patients with suspected CAD. Differences in plaque characteristics among patients with stable CAD have also been suggested.

Clinical trials are designed to test efficacy and safety of interventions in populations with carefully defined medical illnesses. Clinical practice is aimed at caring for individuals who might have similar characteristics. Clinical trial guidelines can obscure benefits of interventions in individuals, which might account for the failure to demonstrate benefit of a renin inhibitor in heart failure.

Newly published data recovered from a large, randomized, controlled trial conducted >4 decades ago show no difference in mortality between individuals with a diet rich in saturated fat and those with a diet rich in linoleic acid, despite the cholesterol-lowering effect of the latter. These findings challenge the widely accepted diet–heart hypothesis.

In this Review, Parati et al. outline the complex interactions between heart failure and sleep alterations, with a focus on sleep-disordered breathing, and describe the pathophysiology, diagnosis, and treatment of these sleep disorders. In the context of increasing evidence from clinical trials, the authors aim to raise awareness among clinicians of the importance of sleep-disordered breathing in heart failure management.

This Review summarizes the existing knowledge on the effects of vitamin D on cardiovascular diseases and the associated risk factors. Pilz and colleagues provide an update on clinical studies on vitamin D and cardiovascular risk, discuss ongoing vitamin D research, and consider the management of vitamin D deficiency from the perspective of cardiovascular health.

Multivalvular disease is common among patients with valvular disease, and has a complex pathophysiology. In this Review, Unger et al. discuss the mechanisms, diagnosis, and percutaneous and surgical treatment of multivalvular disease, focusing on the combinations of valve pathologies that are most often encountered in clinical practice.

A new report has demonstrated the combined use of optical coherence tomography and molecular imaging within human coronary arteries. This combination provides a unique opportunity to look at plaque from a view not previously possible, opening the field for greater understanding of plaque biology in research and clinical practice.

Diabetes mellitus and hypertension are closely related, and guidelines have recommended aggressive treatment of hypertension in patients with diabetes. However, no single clinical trial is conclusive. An extensive review of the use of blood-pressure-lowering drugs in patients with diabetes supports treating blood pressure >140/90 mmHg, whereas reducing blood pressure in people with normal or high–normal blood pressure might have untoward effects.

A loss-of-function mutation in the gene encoding scavenger receptor class B member 1 (SRB1) has been identified. This mutation increases the risk of coronary heart disease (CHD) despite being associated with increased concentration of HDL cholesterol. Upregulation of SRB1 expression might be a novel therapeutic approach for reducing CHD risk.

Although patients with chronic kidney disease (CKD) are at high risk of developing cardiovascular disease, therapies proven to protect both the cardiovascular and renal systems are used only at low doses or not at all. Ruiz-Hurtado et al. describe available and emerging treatments that can provide adequate cardiorenal protection without adverse effects in patients with CKD.

Transcatheter aortic valve implantation (TAVI) is increasingly being used in patients with intermediate-risk and lower-risk profiles, but little is known about the durability of TAVI devices beyond 5 years. In this Review, Arsalan and Walther summarize the existing data on TAVI durability, highlight differences between surgical and transcatheter treatment of aortic stenosis that might influence durability, and discuss clinical solutions for failed prostheses.