Clinical Outlook

Oral anticoagulants are the cornerstone of stroke risk prevention in patients with atrial fibrillation, regardless of whether sinus rhythm is restored. Evidence from two new randomized trials questions the need for long-term treatment with oral anticoagulants after successful ablation of atrial fibrillation and promises to change clinical practice.

The use of robotics in cardiac surgery initially replicated components of operations, then evolved to assist with entire operations, and is now becoming the standard of care for an increasing number of cardiac procedures. Its expanded use and rapid innovation promise to combine high-precision, partially automated cardiac surgery with robotically deployed devices, thereby transforming the surgical experience for both patients and surgeons.

New evidence from five randomized trials suggests that withholding β-blockers after myocardial infarction (MI) is safe for carefully selected, low-risk patients. However, even if β-blockers are not required to treat ventricular dysfunction, hypertension or arrhythmias, it might still be wiser to continue treatment during the vulnerable period immediately after MI and withdraw treatment several months later.

Artificial intelligence (AI) technologies are revolutionizing cardiovascular health by analysing environmental factors at an unprecedented scale. Geospatial AI integrates vast datasets — from satellite imagery down to street-level views — to identify complex risk patterns, which enables personalized predictions and guides precision interventions to mitigate the environmental burden of disease.

Cardiac resynchronization therapy is used to treat dyssynchronous heart failure. Lead-related complications and anatomical constraints can limit pacing lead placement, but leadless systems are now becoming available. These new systems overcome lead-related issues, offering a new option for patients with complex disease (such as congenital heart disease) by eliminating intravascular hardware.

Heart transplantation remains the optimal long-term treatment for appropriate patients with advanced heart failure. However, the donor heart shortage is a limiting factor, and the risk profile of transplant candidates is worsening. In this landscape, the utility of conventional cold static storage for donor hearts is increasingly limited. In this Clinical Outlook, we discuss new methods of donor heart preservation that are transforming the future of heart transplantation.

Epigenetic editing holds great promise for the treatment of many diseases, including cardiovascular disease. However, realizing this potential requires more than developing robust technology and demands a steadfast focus on patient needs and inclusion, to ensure that access to epigenetic medicine will be equitable and will benefit diverse populations worldwide.

Differing definitions and questionable prognostic significance have caused confusion and controversy around the applicability of the current definitions of periprocedural and perioperative myocardial infarction in clinical practice. In this Clinical Outlook, we review the definitions and the clinical and prognostic relevance of the various entities and provide implications for clinical practice.

In this Clinical Outlook, we describe available multiomic studies in cardiovascular medicine, discuss the advantages and potential of multiomic techniques for clinical translation in cardiology, and highlight three promising aspects: the generation of unprecedented cellular atlases, the identification of composite diagnostic and prognostic biomarkers derived from integrative multiomic signatures, and the isolation of potential therapeutic targets from unbiased comprehensive datasets and analyses.

Inflammation is a new therapeutic target for the prevention of cardiovascular disease. Colchicine is a potential cheap option to target inflammation and prevent atherosclerotic plaque destabilization. We discuss major clinical trials and guidelines on the use of colchicine in patients with coronary syndromes, especially acute coronary syndromes, in whom results have been conflicting.

Population studies have reported that proton-pump inhibitors (PPIs) increase cardiovascular mortality, at least in part owing to an increased propensity for life-threatening arrhythmias, but these findings have largely been ignored. We propose a series of recommendations for prescribers of PPIs to ensure a balance of the benefits against the potential arrhythmic risks.

Preliminary experience with the use of transcatheter aortic valve implantation (TAVI) to treat non-calcific aortic regurgitation has raised concerns about the short-term effectiveness of TAVI in this setting. A deeper understanding of the interaction between transcatheter heart valves and anatomy in patients with non-calcific aortic valve disease, coupled with the introduction of dedicated TAVI devices, is providing new opportunities in the management of this condition.

The advent of pulsed-field ablation — a series of ultra-rapid, high-energy pulses that result in non-thermal cell death via electroporation — is revolutionizing the field of atrial fibrillation ablation. Data on first iterations of the technology indicate that safety and efficacy are at least similar to that of thermal ablation but with meaningfully shorter procedure duration.

In ST-segment elevation myocardial infarction, the role of interventional modification of thrombi in the coronary arteries before stenting is controversial. However, innovations in stroke intervention have sparked renewed interest in thrombus modification approaches. We discuss current and emerging techniques to extract or disperse thrombi, aiming to reduce downstream embolization, microvascular obstruction and myocardial injury.

Atrial fibrillation is the most common sustained arrhythmia and imposes a substantial burden on patients and health-care providers. Clinical evidence suggests that antiarrhythmic therapy to restore and maintain sinus rhythm (rhythm control) can reduce adverse cardiovascular outcomes in patients with new-onset atrial fibrillation. As a result, a paradigm shift towards rhythm control over rate control therapy is emerging, increasing the clinical need for effective and safe antiarrhythmic drugs.

A molecular autopsy is undertaken in cases of sudden cardiac death with no definitive cause found after conventional autopsy, with the aim of identifying a pathological genetic variant that could account for the death. Greater awareness of malignant arrhythmias in the absence of structural changes in inherited cardiomyopathies has increased the applicability of molecular autopsies, and resulted in improved care of families but new challenges for clinicians.

Heart valve replacement in newborn babies remains an unsolved problem because currently used heart valve implants do not grow. This lack of implant growth mandates serial re-operations until adult-size valve implants can be fitted. Partial heart transplantation is a new approach to solve this problem by transplanting only the part of the heart that contains the necessary valve.

Left atrial appendage occlusion (LAAO) has been rapidly adopted for stroke prevention in patients with non-valvular atrial fibrillation and a contraindication to oral anticoagulation. Ongoing and planned clinical trials on LAAO and the development of new devices might expand clinical indications and address the remaining challenges of device-related thrombus and peridevice leak.

The risk of stroke in patients with atrial high-rate episodes (AHREs) depends on age, comorbidities and AHRE burden. Two randomized clinical trials on the use of oral anticoagulant therapy for stroke prevention in older patients with short and rare AHREs have reported conflicting findings on the efficacy of oral anticoagulation in this patient population, although both trials report a significantly increased risk of major bleeding with oral anticoagulation.

Transcatheter aortic valve implantation (TAVI) has become an important treatment option for aortic stenosis, even among younger patients, with similar rates of efficacy as compared with surgical valve replacement. However, complications including device failure persist; these can be addressed by surgical explantation and repeat TAVI. Ongoing research emphasizes the long-term potential of TAVI as an alternative to surgical intervention for aortic stenosis.