European Heart Journal Supplements最新文献

Cardiomyopathy classification remains challenging due to their extraordinary clinical, morphological, and genetic heterogeneity. As diagnostic technologies evolve, so too must the frameworks by which we conceptualize and communicate these diseases. Since the 2008 ESC morphofunctional classification and the genotype-phenotype integrated MOGE(S) system proposed in 2013, substantial advances in imaging and genetics have prompted a revised 2023 ESC phenotype-first model. The five current phenotypes-dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy (RCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and non-dilated left ventricular cardiomyopathy (NDLVC)-capture major morphological expressions but display extensive overlap, especially among DCM, ARVC, and NDLVC. This overlap underscores the need for dynamic, multiparametric diagnostic pathways and individualized interpretation.

Functional mitral regurgitation (FMR) is common in patients with heart failure (HF) and is associated with an adverse prognosis. Therefore, both ventricular and atrial phenotypes of FMR represent relevant therapeutic targets in clinical practice. Although randomized clinical trials have primarily focused on the treatment of severe FMR, the prognostic implications and management of moderate FMR have emerged as a topic of increasing interest. This review aims to provide an overview of epidemiology, prognosis, and management of moderate FMR, with a focus on the role of pharmacological treatments and emerging percutaneous strategies.

Ischaemic ventricular tachycardia (VT) represents a major cause of morbidity and mortality in patients with ischaemic heart disease. Transcatheter ablation has emerged as a complementary therapeutic strategy to implantable cardioverter-defibrillators (ICDs) and antiarrhythmic drug therapy. The efficacy, safety, optimal timing, and cost-effectiveness of catheter ablation justify its current role in patients with ischaemic cardiomyopathy who undergo device-based interventions. Randomized clinical trials, including VANISH, VANISH2, and PARTITA, have demonstrated that early ablation significantly reduces VT recurrence and ICD shocks compared with antiarrhythmic drug therapy alone. First-line ablation in patients with preserved left ventricular systolic function (LVEF >35%) is associated with excellent long-term outcomes and low rates of sudden cardiac death. Recent advances in functional substrate mapping techniques have further improved procedural outcomes. Periprocedural mortality remains low (0.4-5%) and is mainly attributable to early VT recurrence rather than procedural complications. Current evidence supports a broader use of catheter ablation in ischaemic VT, which has historically been confined to high-volume centres, and particularly suggests its adoption as an early or first-line strategy in selected patients.

Pregnancy in women with cardiovascular disease (CVD) represents a distinct clinical condition, as the physiological adaptations of pregnancy may interact with underlying cardiac pathology in variable and sometimes unpredictable ways. Consequently, maternal and foetal risk cannot be assumed a priori and requires structured, patient- and disease-specific assessment. The new ESC guidelines on cardiovascular disease and pregnancy incorporate updated evidence following the 2018 version. The contents span from models of multidisciplinary care (the Pregnancy Heart Team, PHT), pre-pregnancy counselling, and pregnancy-related risk assessment, to novel recommendations that are both shared by all pregnancies in women with CVD and specific to each distinct disease. Due to limited prospective or randomized studies largely prevented by ethical reasons, most recommendations are based on evidence level C. This document provides a concise synthesis of innovations in shared management strategies and disease-specific pathways in pregnancy of women with known CVD. It also acknowledges that not all clinical scenarios can be fully captured by guideline-based recommendations. Beyond guidelines, and primarily because approximately 50% of recommendations are Level C evidence, there is considerable decision-making margin for cardiovascular specialists to adhere recommendations. For rare unpredictable complications/events the limited available evidence does not allow recommendations to be made. Looking to the future, the expectation is that AI, which is already generating data and models of care in pregnancy, can help support widespread access to PHT, both in hospitals equipped with the necessary requirements and remotely to all healthcare facilities serving pregnant women with CVDs.

Acute pulmonary embolism represents a major clinical challenge, characterized by a wide spectrum of phenotypic presentations ranging from asymptomatic disease to cardiovascular collapse. Therapeutic management has evolved from a dichotomous paradigm (anticoagulation vs. thrombolysis) to a risk-stratified approach based on early mortality risk and right ventricular function. This article critically reviews current evidence regarding parenteral and oral anticoagulation, systemic thrombolysis, and emerging catheter-directed thrombectomy techniques, in light of the 2019 European Society of Cardiology guidelines and recent clinical trials.

Five modifiable cardiovascular risk factors-hypertension, diabetes, smoking, hypercholesterolemia, and obesity-account for approximately 50% of the global burden of cardiovascular disease. Recent data from the Global Cardiovascular Risk Consortium show that the absence of diabetes and smoking is associated with the lowest risk in terms of life expectancy and years lived free from cardiovascular disease. A systolic blood pressure below 130 mmHg, lower non-HDL cholesterol levels, and normal body weight are associated with a later onset of cardiovascular disease and a more modest increase in life expectancy. The absence of hypertension is correlated with the greatest number of years lived free from cardiovascular events. Smoking is confirmed as one of the most influential risk factors in terms of its impact on health and longevity. Individuals who eliminate hypertension and smoking in midlife gain the greatest number of additional years of life free from cardiovascular disease and all-cause mortality, respectively. Male sex emerges as a traditional, non-modifiable risk factor independent of modifiable risk factors. Finally, even the absence of all the risk factors considered remains associated with a residual lifetime probability of developing cardiovascular disease.

Inhibitors of the renin-angiotensin-aldosterone system remain foundational therapies for arterial hypertension across major international guidelines. Their effectiveness, however, may be partially attenuated by the phenomenon of aldosterone escape, characterized by chronic elevation of adrenal aldosterone due to activation of alternative enzymatic pathways. Mineralocorticoid receptor antagonists are recommended as first-line therapy for resistant hypertension, yet their clinical utility is limited by poor adherence and high discontinuation rates, driven largely by hyperkalaemia and sex hormone-related adverse effects such as gynaecomastia, impotence, and menstrual irregularities. Recent pharmacologic research has focused on alternative strategies for suppressing aldosterone activity, particularly through the development of selective aldosterone synthase inhibitors (ASIs). This approach has led to the emergence of highly selective agents such as baxdrostat and lorundrostat. Clinical studies have demonstrated meaningful reductions in blood pressure among patients with resistant or uncontrolled hypertension, with favourable tolerability and without clinically significant adverse events. Further studies are required to determine the impact of ASIs on hypertensive-mediated organ damage, major cardiovascular events, nephrovascular outcomes, and long-term safety.

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 receptor inhibitor (P2Y12i) for 12 months represents the standard of care after acute coronary syndrome (ACS). However, balancing ischaemic protection against bleeding risk remains challenging, providing the rationale for the development of de-escalation strategies. European and U.S. guidelines allow shortening the duration of DAPT in patients at high bleeding risk, whilst still maintaining 12 months as the reference recommendation. Interest in abbreviated DAPT regimens has been driven by improvements in percutaneous coronary intervention devices and techniques, as well as by a better understanding of the temporal evolution of ischaemic and bleeding risks. Several trials have shown that short-duration DAPT followed by monotherapy-particularly with a P2Y12i-is not inferior in terms of ischaemic outcomes and significantly reduces bleeding events. In this context, the NEO-MINDSET trial failed to demonstrate the non-inferiority of immediate P2Y12i monotherapy compared with standard DAPT. In contrast, the TARGET-FIRST study confirmed the safety of ASA discontinuation after 30 days in selected patients, with a clear bleeding benefit. Overall, the available evidence indicates that immediate discontinuation of ASA in patients with acute coronary syndrome is not universally safe, whereas strategies based on at least 1 month of DAPT followed by monotherapy with a potent P2Y12i currently represent the most balanced approach for selected patients. More refined personalization of antiplatelet therapy, guided by an integrated assessment of ischaemic and bleeding risks, represents the future perspective in this field.

Obesity is a chronic, multifactorial condition strongly associated with increased cardiovascular and metabolic risk, as well as the development of systemic complications. Recent evidence from randomized controlled trials-including SELECT, STEP-HFpEF, STEP-HFpEF DM, SUMMIT, and SURMOUNT-5-has demonstrated the effectiveness of glucagon-like peptide-1 receptor agonists and dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 agonists in the treatment of obesity, with clinical benefits that appear to extend beyond weight reduction alone. In addition to substantial reductions in fat mass, these agents improve cardiovascular parameters (including reductions in major adverse cardiovascular events), functional capacity, and quality of life. Additional benefits have been observed at the metabolic level, with reductions in glycated haemoglobin, blood pressure, triglycerides, and systemic inflammatory markers such as high-sensitivity C-reactive protein. These results confirm that pharmacological modulation of the incretin axis should not be viewed merely as an adjunctive strategy for weight loss, but rather as an integrated therapeutic intervention capable of modifying overall cardiovascular risk and improving the inflammatory and metabolic profile of the obese patient. In light of these findings, a re-evaluation of the role of pharmacological therapy in the clinical management paradigm of obesity is warranted.

Severe mitral regurgitation (MR) is associated with an unfavourable prognosis, characterized by high mortality and reduced quality of life. Mitral surgery remains the gold standard for degenerative MR in patients with low operative risk, ensuring durability and improved survival; however, in elderly or frail patients, perioperative risk limits the applicability of surgical treatment. In this context, transcatheter edge-to-edge repair (TEER), predominantly with MitraClip™, has assumed an increasingly important role. The 2025 ESC/EACTS Guidelines recommend TEER in patients with severe secondary MR who remain symptomatic despite optimized medical therapy and cardiac resynchronization, with evidence demonstrating reduced hospitalizations and improved quality of life. Randomized trials such as COAPT and RESHAPE-HF2 have consolidated these findings, while the MATTERHORN study has shown non-inferiority of TEER compared with surgery in terms of clinical efficacy, with a superior safety profile. In primary MR, ongoing studies (REPAIR-MR, MITRA-HR) are evaluating the effectiveness of TEER vs. surgery in patients at moderate or high surgical risk. In summary, MitraClip currently represents the preferred therapeutic option in patients with high-risk secondary MR, while surgery remains indicated for repairable primary MR in low-risk surgical candidates.