2023年 · 第03卷第04期

For the first time, European Society of Cardiology (ESC) guidelines have aggregated in 1 single document recommendations for the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and ST-elevation myocardial infarction (STEMI). From a clinical perspective, this is coherent, as the spectrum of clinical presentations in acute coronary syndromes (ACS) may range from new onset or progressive troponin-negative angina to STEMI, cardiogenic shock, or cardiac arrest. In addition, the management pathways of NSTE-ACS and STEMI patients are widely similar. Compared with previous editions of the guidelines, the extensive document is improved also from a graphic perspective, containing several appealing and easy-to-understand figures. New or modified recommendations include, among others, the topics of diagnostic work-up, timing of invasive strategy, revascularization in multi-vessel disease, intravascular imaging, cardiac arrest, cardiogenic shock, and antithrombotic treatment. For the first time in the field of ACS, ESC guidelines have incorporated a section on patient perspectives with dedicated recommendations. Some of the most relevant changes in recommendations impacting clinical practice are discussed in this article.

Objective: Invasive hemodynamic evaluation and acute vasoreactivity testing are recommended in the diagnosis of pulmonary arterial hypertension (PAH), but their clinical role in children with PAH associated with congenital heart defects (CHD) is unclear. This study aims to investigate acute hemodynamic responses to inhaled iloprost, and its role in prognosis in children with PAH-CHD. Methods: A retrospective analysis was conducted on 83 pediatric patients with PAH-CHD in whom invasive hemodynamics were evaluated before and after a single inhaled dose of iloprost at a single center between 2010 and 2022. Details of the CHD corrective operation, medical treatment, and outcome for each patient were obtained via medical records or telephone contact. A composite endpoint of all-cause death, admission for worsening heart failure during follow-up, and event-free survival was defined, and risk factors associated with this composite endpoint were analyzed. Results: The patient age was (11.3 ± 4.6) years, and 60 (72.3%) were female. Fifty-nine (71.1%) patients were diagnosed with Eisenmenger syndrome. After iloprost inhalation, mean pulmonary artery pressure decreased from (78.2 ± 11.5) to (72.3 ± 13.2) mmHg (P < 0.001), and pulmonary vascular resistance index (PVRI) decreased from (18.0 ± 7.9) to (14.5 ± 8.1) WU·m2 (P < 0.001). A total of 38 (45.8%) patients had a positive response, defined as a PVRI decrease >25% with stable systemic pressure. Thirty-seven (44.6%) patients underwent a corrective CHD operation at a median of 24 d after hemodynamic evaluation. Nine patients died, and 15 met the composite endpoint during a follow-up period of 5.4 (3.8, 8.8) years. Five-year event-free survival estimates were 96.7% (95% confidence interval: 90.3%–100%) in patients with a positive response, and 82.8% (95% confidence interval: 71.7%–94.5%) in patients with a non-positive response (log-rank P = 0.012). A positive PVRI response and higher pulmonary arterial oxygen saturation after iloprost inhalation, lower baseline brain natriuretic peptide, and PAH-targeted therapy at follow-up were significantly associated with a favorable clinical outcome. A positive acute vasoreactivity testing response and PAH-targeted therapy at follow-up were independent predictors of outcome in multivariate Cox analysis. Conclusions: Acute inhalation of iloprost can lead to a significant decrease in hemodynamic parameters. Responsiveness to inhaled iloprost is associated with better outcomes and can be a valuable predictor of outcomes.

Objective: Percutaneous coronary intervention is one of the most common procedures used for the invasive treatment of patients with coronary heart disease; the incidence of in-stent restenosis (ISR) after percutaneous coronary intervention is 5% to 15%. In this study, a competitive endogenous RNA (ceRNA) network was constructed to investigate potential mechanisms involved in ISR. Methods: The expression data for differentially expressed microRNAs (DEmiRNAs) and messenger RNAs (mRNAs) between patients with and without ISR were obtained using limma package. Long noncoding RNAs (lncRNAs) were predicted based on the DEmiRNAs using the miRDB, miRTarBase, and TargetScan databases. An ISR-specific ceRNA network was subsequently constructed and investigated. To verify the key miRNAs of ceRNA, patients with and without ISR were enrolled from Guangdong Provincial Hospital of Chinese Medicine between January 2017 and December 2018 (n = 8, respectively); plasma was collected from all enrolled patients. Results: Based on the raw data obtained from the Gene Expression Omnibus database, 472 DEmiRNAs and 304 differentially expressed messenger RNAs between patients with and without ISR were identified. A ceRNA network was constructed by combining 270 lncRNAs, 3 miRNAs (miR-125, miR-140, and miR-206), and 4 mRNAs (STRADB, TKT, PCTP, and BTG2). The hub genes of the ceRNA network of ISR included the following: miR-125, miR-206, miR-140, PCDHB9, CASC2, BAK1P1, CSPG4P3Y, CSPG4P4Y, STRCP1, and GRIP2. Verification of miRNAs of ceRNA also showed that the expression of miR-206 was upregulated in patients with ISR vs. those without ISR (P < 0.05). In contrast, the expression of miR-140 and miR-125 was downregulated in patients with ISR vs. those without ISR (P < 0.05). Conclusions: This study constructed noncoding RNA-related ceRNA networks for ISR. The results indicated that miR-206, miR-125, and miR-140 may be biomarkers of ISR.

Objective: This network meta-analysis aims to compare the efficacy and safety of different targeted drug combination treatment for pulmonary arterial hypertension (PAH). Methods: Searches were conducted in Cochrane, PubMed, EMBASE, China National Knowledge Infrastructure, China Biomedical Literature Database, Wanfang Database, and VIP Chinese Science and Technology Journal Data to identify both published and unpublished randomized controlled trials from inception until January 1, 2022. The risk of bias in the included studies was assessed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. A network meta-analysis was performed using Stata 16.0 software. The efficacy and safety of different targeted drugs combined treatment for PAH were evaluated based on forest plot, funnel plot, and surface under the cumulative ranking. Results: A total of 29 randomized controlled trails with 4,448 patients treated with 10 different types of targeted drug combinations were included in this study. The results of the surface under the cumulative ranking showed that the combination regimen was the best clinical option to improve symptoms and delay progression in patients with pulmonary artery hypertension compared with monotherapy. Sildenafil in combination with ambrisentan significantly improved the 6-minute walk distance and reduced N-terminal pro-brain natriuretic peptide levels. Bosentan in combination with sildenafil significantly reduced mean pulmonary artery pressure, whereas bosentan in combination with epoprostenol was more effective than other combinations in reducing pulmonary vascular resistance. Bosentan in combination with tadalafil significantly improved the Borg dyspnea score, and bosentan in combination with iloprost was the best combination for improving World Health Organization functional class/New York Heart Association functional class. In terms of safety, there was no significant reduction in the incidence of adverse events, hospitalizations, or all-cause mortality for combination therapy compared with monotherapy. Bosentan combined with sildenafil significantly reduced the risk of serious adverse events, but the risk of discontinuation due to an adverse event was higher than monotherapy. Sildenafil combined with epoprostenol reduced the risk of clinical worsening in patients with PAH. Conclusion: Compared with monotherapy, targeted drug combinations for PAH significantly improves exercise tolerance, pulmonary hemodynamic parameters, and reduces the risk of serious adverse events and clinical worsening in patients. Bosentan in combination with sildenafil and bosentan in combination with iloprost are combinations of targeted agents with significant efficacy and better safety profile than monotherapy for the treatment of PAH. Sildenafil in combination with epoprostenol has a low risk of clinical worsening in PAH.

Right ventricular function is independently associated with poor clinical outcomes in patients with various cardiovascular diseases including pulmonary hypertension (PH). The complex geometry and mode of contractility means the right ventricle (RV) inlet and outlet are not in line; hence, 2-dimensional echocardiography fails to accurately quantify RV volumes and function in such patients. Three-dimensional echocardiography (3DE) allows for reliable and reproducible quantification of RV volumes and function by overcoming these limitations of conventional echocardiography. This review focuses on the 3DE assessment of RV function in patients with PH and discusses the following points: (1) acquiring an RV data set for 3DE imaging, including details of all available 3DE systems and software utilized in daily practice; (2) the reliability and feasibility of RV remodeling measured with 3DE with different modalities in patients with PH; and (3) the prognostic value of 3DE-derived RV function in such patients.

Chronic pulmonary artery stenosis (CPAS) is characterized by a reduction or complete obstruction of the cross-sectional area of the pulmonary artery owing to various causes. The condition exhibits similar pathophysiological progress, leading to pulmonary hypertension (PH), reduced physical endurance, right heart failure, and death. Although CPAS is often regarded as a subgroup of PH, it can manifest independently for an extended duration before the onset of PH and can significantly impact patient quality of life. It may therefore be more appropriate to consider PH as pathophysiological progression of CPAS, thereby recognizing CPAS as a distinct disease entity.

Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks, leading to high postoperative mortality rates. However, for some patients eligible for transcatheter aortic valve implantation (TAVI), computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure. This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVI. This approach reduces contrast usage during the TAVI procedure, significantly mitigating the risks of renal injury and heart function deterioration.