2022年 · 第02卷第04期

Intravenous anticoagulant therapy is critical to prevent ischemic events without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Heparin and bivalirudin are the most commonly used adjunctive anticoagulant agents during PPCI. However, the superiority of the 2 most optimal regimens with these agents in patients undergoing PPCI remains controversial. The BivaliRudin with prolonged high-dose Infusion durinG PPCI versus Heparin Trial 4 (BRIGHT-4) is a large-scale, prospective, multicenter, active-control, parallel-group, open-label, randomized trial designed to test whether bivalirudin with a post-PCI high-dose infusion is superior to heparin monotherapy in STEMI patients undergoing PPCI. A total of 6000 patients will be enrolled and randomly assigned to receive bivalirudin or heparin in a 1:1 ratio. Patients allocated to the bivalirudin group will be treated with a high-dose bivalirudin infusion (1.75 mg/(kg·h)) after PCI for 2 to 4 hours. In the heparin group, the use of glycoprotein IIb/IIIa inhibitors will be reserved for the development of procedural thrombotic complications. The efficacy and safety of bivalirudin will be evaluated at 30 days, 6 months, and 12 months after the randomization. The primary endpoint is a composite of all-cause death or Bleeding Academic Research Consortium (BARC) types 3 to 5 bleeding at 30 days after randomization. The BRIGHT-4 study protocol has received approval from the ethics committee of General Hospital of Northern Theater Command (Shenyang, China). The procedures set out in this protocol are in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. The results will be published following the Consolidated Standards of Reporting Trials statement in a peer-reviewed scientific journal (Trial registration number: NCT03822975).

Heart failure (HF) is a major public health problem around the world. Although currently available therapies have improved outcomes, morbidity and mortality in patients with HF remain unacceptably high. Most guideline-recommended therapies for HF are indicated for patients with a reduced left ventricular ejection fraction (HFrEF). Until recently, treatment options that improved outcomes in patients with HF and preserved left ventricular ejection fraction or mildly reduced ejection fraction were limited. Over the past several years, however, several new drugs including angiotensin receptor neprilysin inhibitors (ARNIs), sodium glucose cotransporter 2 inhibitors (SGLT2 inhibitors), soluble guanylate cyclase stimulators, and a cardiac myotrope, omecamtiv mecarbil have all reported positive results in pivotal phase III clinical trials. Moreover, the results of these studies have provided evidence that both ARNIs and SGLT2 inhibitors can improve clinical outcomes in patients with HF across a broad spectrum of LVEF, not just in HFrEF. This article presents the rationale for the use of each of these 4 new classes of drugs, reviews the results from pivotal clinical trials showing their safety and efficacy, and provides a framework for how each drug has begun to be integrated into new HF management guidelines. Collectively, these new drugs provide hope for the millions of patients around the world who suffer from HF.

The outcomes of patients with myocardial infarction (MI) have substantially improved given the rapid progress that has occurred in revascularization techniques and secondary prevention, and the majority of MI patients subsequently enter a chronic stable phase. Therefore, the long-term management of patients with MI has become a core issue in daily clinical practice for cardiologists. The long-term incidence of adverse events can be further reduced using newly developed medications and therapies ranging from lipid-lowering agents (eg, proprotein convertase subtilisin/kexin type 9 inhibitors) to anti-thrombotic treatments (eg, shortened dual anti-platelet therapy). However, a considerable number of patients still experience adverse events, as some residual risk can remain despite intensive secondary prevention, such as continuously elevated cholesterol levels, chronic cardiovascular inflammation, and rapid atherosclerosis progression due to increased plaque instability. Therefore, the present review sought to summarize and discuss recent advances in several key aspects regarding the long-term management of MI patients, with the expectation of clarifying the available treatment strategies for various clinical scenarios, examining the gaps between trial evidence and clinical practice, and providing possible directions for future research.

Treatment of aortic arch (AA) diseases is challenging for surgeons. Conventional open surgery remains the "gold standard" but is associated with significant morbidity and mortality despite improvements in techniques. In the last 2 decades, thoracic endovascular aortic repair (TEVAR) has become the first-line treatment for diseases of the descending aorta, and its indications have expanded gradually. Various strategies have been proposed to preserve supra-aortic branches in TEVAR: hybrid technique, chimney technique, fenestration technique (including custom-made fenestrated or "scalloped" stent grafts, in situ fenestration, and physician-modified fenestration), and branched stent grafts. Though acceptable outcomes of endovascular aortic repair have been documented, the evidence regarding its long-term safety and efficacy is lacking, and concerns remain about the risk of cerebrovascular events, retrograde type-A dissection, endoleaks, and branch occlusion. This review discusses the current status and progress of endovascular repair of the AA, and looks toward future trends. We believe that multidisciplinary collaboration of a "HENDO" team (professionals in hybrid repair, endovascular repair, open surgery, cardiovascular anesthesia, and genetics) is essential for future repair of the AA to provide the optimal treatment.