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November 2023 Br J Cardiol 2023;30(suppl 3):S3–S12
Inspiring change within the NHS to improve collaborative working and patient care across CVD
Ahmet Fuat, Chris Gale, Guy Lloyd, Helen Williams, Jim Moore, Trudie Lobban, Vijay Kunadian, Wajid Hussain
A post-meeting report from the Bayer 2022 Cardiovascular Exchange Summit ‘Inspire change’...
May 2023 Br J Cardiol 2023;30(suppl 2):S3
Introduction
Derek Connolly
Cardiovascular disease remains the world’s biggest killer.1 Whilst we have made enormous progress in preventive cardiology, there remains a large residual risk despite optimal current medical therapies.2...
May 2023 Br J Cardiol 2023;30(suppl 2):S4–S9
Triglyceride-rich lipoproteins and their role in cardiovascular disease
Chris J Packard
Epidemiological and genetic studies have revealed that plasma triglyceride (TG) levels are strongly and causally related to atherosclerotic cardiovascular disease (ASCVD). The concentration of this lipid in the circulation is a biomarker of the abundance of triglyceride-rich lipoproteins (TRLs) and their cholesterol-enriched remnants which are generated during lipolysis. Furthermore, both clinical trials and registry data have shown that elevated levels of TRLs contribute significantly to the ‘residual’ risk in individuals treated with statins. Addressing this residual risk is an unmet need in strategies to prevent cardiovascular disease in populations and individuals. Plasma TG levels can be lowered using diet and lifestyle interventions through known actions on the production and clearance of chylomicrons and very low-density lipoprotein (VLDL). Novel pharmacotherapy to regulate TG levels is under development; however, clinical trials have already identified agents that can reduce the risk of ASCVD in individuals with elevated plasma TG levels....
May 2023 Br J Cardiol 2023;30(suppl 2):S10–S14
The evidence for fish oils and eicosapentaenoic acid in managing hypertriglyceridaemia
Muntaser Omari, Holli Evans, Azfar G Zaman
There remains residual cardiovascular (CV) risk in some optimally treated patients with low levels of low-density lipoprotein cholesterol (LDL-C), which is associated with elevated triglyceride (TG) levels. Several trials of TG lowering drugs have failed to demonstrate a concomitant reduction in CV events. The Reduction of Cardiovascular Events with Icosapent Ethyl – Intervention Trial (REDUCE-IT) tested icosapent ethyl (IPE) – a purified formulation of the n-3 PUFA (omega-3 polyunsaturated fatty acid), eicosapentaenoic acid (EPA) – in high-risk CV patients with elevated TG levels and reported a significant reduction in a composite of CV events and revascularisations independent of TG reduction. These findings provide mechanistic insights into CV event reduction in patients with controlled LDL-C. The benefits are associated with on-treatment EPA levels and are in keeping with the broad pleiotropic actions previously reported in cellular and clinical studies that favourably modulate atherosclerotic plaque composition and progression. The association of high-dose IPE with atrial fibrillation provides a cautionary footnote and careful consideration of the risk-benefit ratio is required when commencing treatment with IPE....
May 2023 Br J Cardiol 2023;30(suppl 2):S15–S18
REDUCE-IT: findings and implications for practice
Michael Miller
The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) was a randomised, double-blind, placebo-controlled trial designed to test the hypothesis that patients with hypertriglyceridaemia and a prior history of cardiovascular (CV) disease or diabetes and multiple CV disease risk factors would benefit from icosapent ethyl (IPE), a highly purified (>96%) form of eicosapentaenoic acid (EPA). Participants (n=8,179) were assigned to IPE 2 g twice daily or matching placebo and monitored for a median period of 4.9 years. Overall, there was a 25% relative risk reduction and 4.8% (p<0.0001) absolute risk reduction in the primary composite end point (CV death, non-fatal myocardial infarction [MI], non-fatal stroke, coronary revascularisation or hospitalisation for unstable angina) in the IPE versus placebo group. Similarly, the key secondary composite end points of CV death, non-fatal MI and non-fatal stroke were reduced by 26% (p<0.0001) with an absolute between-group difference of 3.6%. A number of prespecified and/or post-hoc analyses have consistently demonstrated favourable results with IPE use. Considering the reductions in multiple CV events, REDUCE-IT was a landmark CV clinical trial that demonstrated the benefit of IPE in high-risk patients with hypertriglyceridaemia....
May 2023 Br J Cardiol 2023;30(suppl 2):S19–S21
Icosapent ethyl use in clinical practice: current and future directions
Lucrezia Volpe, Charalambos Antoniades
Icosapent ethyl has been found to improve cardiovascular (CV) disease risk in high-risk patients when added to statin treatment; it has received regulatory clearance and recently, National Institute of Health and Care Excellence (NICE) approval1 to be used in the UK for selected patients with hypertriglyceridaemia. There are currently limited treatment options available to reduce the risk of CV events in people with controlled levels of low-density lipoprotein-cholesterol (on a statin) and raised triglyceride levels....
March 2023 Br J Cardiol 2023;30(suppl 1):S3–S4
Introduction: overcoming barriers to treating severe aortic stenosis
Bernard Prendergast
Severe aortic stenosis (AS) has a poor prognosis1 – the five-year mortality rate, estimated at 67%, is worse than in many cancers and even higher (94%) in those who do not undergo intervention.1–3 However, while patients with suspected cancer may expect to enter a treatment pathway within two weeks of presentation, those with severe AS may wait many months before diagnosis, assessment or treatment....
March 2023 Br J Cardiol 2023;30(suppl 1):S5–S11
The past, present and future of aortic stenosis treatment
Hélène Eltchaninoff, Clinton Lloyd, Bernard Prendergast
Aortic stenosis (AS) is characterised by progressive narrowing of the aortic valve,1 which may be clinically silent or associated with a range of symptoms caused by reduced cardiac output, including shortness of breath, angina and syncope.2 Symptomatic patients are typically elderly with multiple comorbidities.3 Severity of AS is determined using an integrated approach based on echocardiographic parameters, valve morphology, blood pressure and symptoms.4 Both moderate and severe AS are associated with poor prognosis, but whereas severe AS is an indication for prompt intervention,5 the benefits of intervention in moderate AS remain under investigation.6,7 Herein, we describe the epidemiology of AS, the history and evolution of AS treatments, and key studies that have driven the development of AS treatment guidelines....
March 2023 Br J Cardiol 2023;30(suppl 1):S12–S17
A standardised network to improve the detection and referral of patients with aortic stenosis
Victoria Delgado, Philippe Pibarot, Neil Ruparelia, Francesco Saia
Transcatheter aortic valve implantation (TAVI) has revolutionised the treatment of severe aortic stenosis (AS) over the last 15 years, improving patient survival regardless of operative risk and reducing treatment burden.1–4 Management aims in severe AS are promptly delivering appropriate treatment for patients and optimising survival and quality of life outcomes. Despite adequate treatment options, many patients with severe symptomatic AS remain undiagnosed or suffer delays in referral for treatment, resulting in poor outcomes.5,6 Access-to-care challenges during the COVID-19 pandemic have exacerbated these issues but have also highlighted the importance of developing a streamlined, consistent and robust treatment pathway for patients with severe AS.7 This article discusses how to break down the barriers to successful detection, referral and treatment of patients with severe AS, and provides strategies to achieve a streamlined patient pathway based on a standardised network of healthcare professionals....
March 2023 Br J Cardiol 2023;30(suppl 1):S18–S24
Ensuring continuous and sustainable access to aortic stenosis treatment
Eric Durand, Sandra Lauck, Derk Frank, John Rawlins
The incidence of aortic stenosis (AS) worldwide is expected to increase steeply over the next three decades, mainly driven by an ageing population.1,2 In the face of this emerging epidemic, the demand for AS treatment resources is increasing, including the provision of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). The COVID-19 pandemic added challenges for patients with AS, who cannot delay their treatment without impacting clinical outcomes.3 In this setting, TAVI is recognised as an effective and efficient solution for treating AS in eligible patients, offering no significant delays in treatment (depending on local resources), no excess complications or mortality, and a shorter hospital length-of-stay compared to treatment before COVID 19.4,5 A successful TAVI programme aims to resolve AS safely and efficiently, enabling the patient to be discharged home rapidly without sustaining in-hospital complications and thus improving outcomes. This requires individualised treatment decisions based on patient presentation and preferences, and available local resources. Data from clinical trials and real-world studies have driven improvements in the care coordination for patients undergoing TAVI, transforming patient pathways toward the TAVI programme goals.6–12 Based on these data, a streamlined TAVI pathway aimed at safe and early discharge of patients is recommended to optimise outcomes and improve access to care....
January 2023
Protected: Definition of terms used in supplement
There is no excerpt because this is a protected post....
July 2022 Br J Cardiol 2022;29(suppl 2):S2
What’s new in heart failure guidance – a user’s guide: Introduction
Paul Kalra
Heart failure is such a common problem that all healthcare professionals should be familiar with the contemporary management of these patients. When there are delays in making the diagnosis or treatment is not optimised, patients are at risk of premature death, hospitalisation and many suffer impaired quality of life. To improve outcomes for patients with heart failure, it is imperative that the diagnosis is suspected and made as early as possible. Whilst heart failure specialists are integral to the delivery of optimal patient-centred care, every opportunity should be taken to optimise treatment. We can all help make a real difference for patients....
July 2022 Br J Cardiol 2022;29(suppl 2):S3–S6
New developments in the investigations and diagnosis of heart failure
Patricia Campbell
This article reviews some of the new concepts, new recommendations, along with changes to recommendations, in the diagnosis and investigation of heart failure (HF) in the European Society of Cardiology (ESC) 2021 Guidelines for the diagnosis and treatment of acute and chronic heart failure, and contrasts these with the 2016 version of the guidelines....
July 2022 Br J Cardiol 2022;29(suppl 2):S7–S12
Drug therapy in heart failure – an update from the 2021 ESC heart failure guideline
Helen Hardy, Paul R Kalra
There have been several key developments in heart failure (HF) management since the 2016 European Society of Cardiology (ESC) HF guidelines were published. The updated 2021 ESC HF Guidelines reflect the modern management of the patient with HF, with an emphasis on evidence-based, individualised care. This overview aims to provide clinicians (whether specialist or non-specialist) with a summary of the major update in drug therapy for HF according to the recent 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic HF....
July 2022 Br J Cardiol 2022;29(suppl 2):S13–S16
Guidance on lifestyle, rehabilitation and devices in heart failure patients
Savvas Hadjiphilippou, Rebecca Lane
The aim of the updated 2021 European Society of Cardiology (ESC) heart failure guidelines is to help health care professionals manage people with cardiac failure according to the best available evidence. There is now a wealth of clinical trial data to help select the best management to improve outcomes for people with heart failure; for many, it is now both a preventable and treatable condition. This paper reviews the new advice on lifestyle, rehabilitation, remote monitoring, and the use of devices in this patient population....
March 2022 Br J Cardiol 2022;29(suppl 1):S3–S6
Lipoprotein(a): a historical perspective
R Dermot G Neely
Nearly 60 years after it was first described by the Norwegian physician and geneticist Kare Berg in 1963, lipoprotein(a) (Lp[a]) has finally become accepted as an inherited, causal cardiovascular disease risk factor, and a potential target for new therapeutic interventions. Why has it taken so long? A major reason has been the technical challenge of Lp(a) measurement, which has long confounded attempts to prove a causal role for Lp(a) in long-term prospective atherosclerotic cardiovascular disease (ASCVD) outcome studies. Due to its unique macromolecular structure, with a highly variable number of kringle IV type 2 domains in the covalently bound apolipoprotein(a) moiety, serum concentrations spanning a range of 1000-fold between individuals, and instability on long-term storage, it is extraordinarily difficult to quantify Lp(a) reliably. Only with more recent advances in understanding of the genetic determinants of Lp(a) concentrations, the advent of genome-wide association studies, and large-scale epidemiological investigations using the Mendelian-randomisation approach, has conclusive evidence finally been assembled to show that elevated Lp(a) concentrations are causally associated with increased risk of ASCVD....
March 2022 Br J Cardiol 2022;29(suppl 1):S7–S10
Lipoprotein(a): mechanisms of pathogenicity
Tina Z Khan
Lipoprotein(a) (Lp[a]) promotes the progression of atherosclerosis and cardiovascular disease through numerous pleiotropic effects including Lp(a) deposition in the intima, inflammatory cell recruitment and binding of pro-inflammatory-oxidised phospholipids, such as oxidised low-density lipoprotein (LDL). In addition, elevated Lp(a) has prothrombotic properties via the inhibition of fibrinolysis and enhanced coagulation. The cardiovascular manifestations associated with raised Lp(a), which is co-dominantly inherited, are also mediated by its genotypic profile; suggesting that, in future, genetic profiling of patients with raised Lp(a) may help in terms of cardiovascular risk stratification. Whether the multi-factorial pathogenic effects of Lp(a) can be reversed by lowering raised Lp(a) remains an interesting and clinically important question. So far, only a handful of small randomised studies have attempted to address this question, and have mainly been limited to assessing the impact of lipoprotein apheresis, which is a non-selective therapy for Lp(a). Nevertheless they have shown promising findings, such as demonstrating improvements in atherosclerotic plaque burden, myocardial perfusion, microvascular function, thrombogenic parameters and oxidised LDL. In future, mechanistic studies involving specific Lp(a)-lowering therapies are needed to establish the specific role that Lp(a) plays in the progression of cardiovascular disease....
March 2022 Br J Cardiol 2022;29(suppl 1):S11–S14
Lipoprotein(a): marker and target in calcific aortic valve disease
Kang H Zheng, Marc R Dweck
Calcific aortic valve disease (CAVD) is the most common valvular disorder and is set to become a major healthcare burden with an ageing population. Currently, there are no approved medical therapies known to halt or slow down progression of CAVD. Novel insights in the valvular pathophysiology of aortic stenosis could result in the identification of modifiable risk factors and disease pathways to prevent or slow down CAVD. Elevated plasma levels of lipoprotein(a) (Lp[a]), a low-density lipoprotein (LDL)-like particle, have been recognised to be a strong, genetic and highly likely causal risk factor for CAVD. This review will address the present state of knowledge with regards to the role of Lp(a) in the pathophysiology of CAVD....