2026, Volume 33 (online first)

A 78-year-old man presented to the cancer assessment bay with a history of progressive fatigue, generalised muscle pain, and bilateral ptosis after completing two cycles of nivolumab/ipilimumab for metastatic renal cancer. Physical examination revealed mild bilateral ptosis (right > left), worsening with upward gaze, binocular diplopia, and fatigable weakness in the right shoulder. Electrocardiogram (ECG) showed a new right-bundle branch block (RBBB), with left-axis deviation, and left ventricular hypertrophy. Blood analyses showed elevated troponin I, brain natriuretic peptide, and creatine kinase with values of 221 ng/L, 114 ng/L, and 1,109 U/L, respectively. He was managed as immune checkpoint inhibitor-related severe myocarditis, myositis, and myasthenia gravis overlap (triple M) syndrome with high-dose steroids and pyridostigmine, resulting in clinical and biochemical improvement. However, immunotherapy was permanently discontinued, and follow-up imaging after three months showed evidence of disease progression. This case explores the importance of a multi-disciplinary approach in the effective management of a rare and severe immune-related toxicity and the impact of toxicities on treatment options and cancer progression....

Cardiovascular medicine is undergoing transformation driven by machine learning (ML) technologies.1 Algorithms now assist in imaging interpretation, electrocardiogram (ECG) analysis, and outcome prediction, with increasing sophistication.1,2 The adoption of ML-powered diagnostic tools in cardiology is growing, yet training programmes remain largely unchanged, creating a disconnect between skills taught and those required in contemporary practice.1–4 Despite rigorous clinical preparation, many cardiology trainees complete their education with insufficient knowledge of the ML technologies increasingly present in clinical workflows.5,6 As these applications become more prevalent, training programmes must integrate relevant ML education to ensure cardiologists can effectively evaluate, implement, and collaborate with artificial intelligence (AI) systems, rather than merely function as passive end-users of increasingly sophisticated technology....

Immune checkpoint inhibitors (ICIs) have revolutionised cancer care, but can cause serious cardiac immune-related adverse events (irAEs), particularly myocarditis, which carries up to 50% mortality. This study explores patient pathways to improve early recognition and management of ICI myocarditis in acute settings. This was a retrospective, single-centre case series from a UK tertiary hospital with a specialist cardio-oncology multi-disciplinary team (MDT). Ten patients referred to the cardio-oncology MDT between March and August 2024 were included if diagnosed with myocarditis, pericarditis, or arrhythmias linked to ICI treatment. Clinical pathways were described using structured vignettes. Seven patients had myocarditis, two pericarditis, and one bradyarrhythmia. Fatigue (57%) was the most common presenting symptom in myocarditis. Echocardiography was unremarkable in 86% of cases, while cardiac magnetic resonance imaging (MRI) confirmed myocarditis in 57%. N-terminal pro-B-type natriuretic protein (NT-proBNP) rose 17-fold from baseline compared with a four-fold rise in troponin T. Early MDT referral facilitated prompt diagnosis and treatment, while delayed recognition was associated with worse outcomes. This case series highlights the importance of early MDT involvement, and the utility of additional cardiac biomarkers, such as NT-proBNP. It provides practical guidance to improve the acute care pathway for patients developing ICI-associated cardiac toxicities....

Risk stratification for sudden cardiac death (SCD) and the selection of patients for prophylactic implantable cardiac defibrillator (ICD) in hypertrophic cardiomyopathy (HCM) are still evolving and far from ideal. I present a historical case of HCM that did not have recognised SCD risk factors. This case highlights the deficiency of the present risk-stratification strategy for HCM and European Society of Cardiology (ESC) risk-scoring system....

Infective endocarditis (IE) is a rare, life-threatening infection of the cardiac endocardium caused by bacterial seeding. On the other hand, atopic dermatitis (AD) is a common inflammatory skin condition that disrupts the epidermal barrier, increasing susceptibility to Staphylococcus aureus colonisation and recurrent bacteraemia. This provides a biologically plausible bridge to IE, which we explore in this current literature review. MEDLINE, Embase and CENTRAL were searched from inception to 7 April 2025. Sixteen studies were included – 15 case reports and one retrospective cohort study – which were grouped into three categories: well-controlled AD with no predisposing risk factors, AD with predisposing risk factors, and uncontrolled AD or alternative AD management. This review is made up of 24 patients with IE secondary to AD. Of the 16 studies, nine originated from Japan. Mean age was 29.6 years (range 15–42 years), which is significantly younger than classic IE cohorts (mean 60.0 years). Staph. aureus accounted for 23/24 patients, and the mitral valve was affected in 18/24 cases. In terms of patient outcomes, all but one patient survived, but valve surgery was necessary in 20/24 patients. In conclusion, AD-related IE shows a distinct pattern: younger patients, Staph. aureus dominance and mitral valve involvement requiring mitral valve surgery in the majority. This potential link appears to be under-recognised, hence, greater cross-speciality awareness and rigorous AD control for those at high risk is recommended. The heavy Japanese skew in the literature highlights the need for broader case documentation in other regions to confirm this link across different patient demographics....

The management and prevention of cardiovascular diseases (CVD) is based on adequate adherence to medications and lifestyle changes. The reported rates of adherence with cardiovascular medications range from 30% to 70%, with patients often not taking all or part of their prescribed medications. The rates of non-adherence are even higher for individual cardiovascular risk factors. Assessment of medication adherence is an important part of the management of CVD. Many interrelated socio-economic and healthcare-related factors play a role in an individual patient’s adherence to medications. Understanding how these different factors affect each individual patient can lead to strategies that improve levels of adherence. This would help improve our control of CVDs, both at an individual patient level, and also at the level of national and international health....

Small-interfering RNA (siRNA)-based therapies, such as inclisiran, offer a novel approach to reducing low-density lipoprotein-cholesterol (LDL-C) and preventing cardiovascular disease (CVD). Inclisiran inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9) synthesis, enhancing LDL-receptor recycling and LDL-particle clearance. Although clinical trials have established its efficacy with LDL-C reductions of 44–52%, real-world studies have reported variable reductions over shorter follow-up periods. This study aimed to assess the long-term efficacy and safety of inclisiran in a diverse real-world cohort. A total of 238 patients initiating inclisiran between January 2022 and January 2024 at a tertiary lipid service were included. Data on lipid profiles, comorbidities, and medication history were collected from electronic healthcare records. LDL-C reductions were analysed at each dose using a Bayesian hierarchical model, and subgroup analyses explored the influence of familial hypercholesterolaemia (FH) and baseline lipid-lowering therapy. Inclisiran therapy resulted in a mean LDL-C reduction of 48.4% following the first dose, sustained over 27 months. Patients receiving three or more lipid-lowering therapies at baseline achieved greater LDL-C reductions compared with others (67.4% after first dose vs. 47.6%). No discernible differences in efficacy were observed between patients with and without FH. Inclisiran was well tolerated, with only six patients discontinuing therapy due to adverse events or preference. Approximately 35% of patients met the European Society of Cardiology LDL-C target of <1.4 mmol/L after the first dose, declining to 28% after the fourth dose. These real-world findings demonstrate that inclisiran is a well-tolerated and effective lipid-lowering therapy, achieving reductions comparable with clinical trial results. Greater reductions in patients on multiple baseline therapies suggest the importance of comprehensive lipid management. While achieving stringent LDL-C targets remains challenging, inclisiran’s practical benefits, including infrequent dosing and good tolerability, underscore its potential to improve CVD outcomes in diverse populations....