Residual Cardiovascular Risk: Role of Remnants Cholesterol, Monocyte/HDL Ratio and Lipoprotein Ratios on Personalized Cardiovascular Prevention.

Cardiovascular diseases represent the leading cause of death in the world and are subject to limitations in prevention strategies despite the use of very effective drugs. The concept of residual risk (RR) is intrinsically related to that of global risk of which it represents a very significant percentage. In the cardiovascular field, the term RR refers to the probability of incurring a major cardiovascular event, despite adequate control of the risk factors present in the individual patient. A significant portion of the RR in the cardiovascular field results from the underestimation of additional risk factors not subjected to adequate intervention such as, for example, triglyceride levels in patients treated for the presence of hypertension and/or hypercholesterolemia. The control of the RR therefore appears as an essential condition for the effective reduction of the global risk profile and is based on an integrated intervention that combines all the different prevention strategies derived from the available evidence and capable of interacting on the basis of a strengthening reciprocal between lifestyle and pharmacological and nutraceutical intervention methods.

Cholesterol-Lowering Strategies for Cardiovascular Disease Prevention: The Importance of Intensive Treatment and the Simplification of Medical Therapy.

Cardiovascular diseases (CVDs) are a leading global cause of mortality and are primarily driven by atherosclerotic coronary artery disease. Their pathogenesis involves multi-factorial mechanisms, among which low-density lipoprotein (LDL) plays a causative role. Recent ESC/EAS guidelines advocate for a shift toward new risk estimation algorithms that better emphasize non-fatal cardiovascular events, lifetime risk prediction, and tailored pharmacological approaches, including statin + ezetimibe and triple therapy, in specific cases. Intensive lipid-lowering therapy has been shown to be pivotal, especially in post-acute coronary events. Intracoronary imaging has revealed insights into the composition of plaque and demonstrated the significant regression that can be achieved through the use of statins such as rosuvastatin and atorvastatin. The positive effects of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors, particularly alirocumab and evolocumab, on plaque regression, have been demonstrated. Inclisiran, which targets PCSK9 gene expression, significantly reduces LDL cholesterol. The associated challenges include hesitancy to prescribe intensive regimens and limited treatment adherence, highlighting the need for pharmacological combinations to improve therapeutic outcomes.

Myocardical Infarction with Non-Obstructive Coronary Arteries (MINOCA): pathogenesis, diagnosis and treatment.

The term MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) refers to myocardial infarction cases where coronary arteries exhibit less than 50 % stenosis. MINOCA encompasses a diverse range of pathologies with varying etiologies. Diagnosis involves meeting acute myocardial infarction criteria and excluding other causes (myocarditis, takotsubo syndrome). Clinical features often resemble those of traditional myocardial infarction, but MINOCA patients tend to be younger and more frequently female. Etiological investigations include coronary angiography, intracoronary imaging, and vasomotor function tests. Causes include plaque rupture, coronary dissection, vasospasm, microvascular dysfunction, thromboembolism. Prognosis varies, with some subsets at higher risk. Management involves a tailored approach addressing underlying causes, with emphasis on cardioprotective therapy, risk factor modification, and lifestyle interventions. Further research is needed to refine diagnostic strategies and optimize therapeutic approaches in MINOCA patients.

Hereditary Transthyretin Amyloidosis: How to Differentiate Carriers and Patients Using Speckle-Tracking Echocardiography.

BACKGROUND: Hereditary transthyretin amyloidosis is a rare disease caused by transthyretin (TTR) gene mutations. The aim of our study was to identify early signs of cardiac involvement in patients with a TTR gene mutation in order to differentiate carriers from patients with neurological or cardiac disease. METHODS: A case-control study was carried out on 31 subjects with the TTR mutation. Patients were divided into three groups: 23% with cardiac amyloidosis and polyneuropathy (group A), 42% with only polyneuropathy (group B) and 35% carriers (group C). Speckle-tracking echocardiography (left-ventricular global longitudinal strain-GLS, atrial stiffness) was performed in all patients. The apical/basal longitudinal strain ratio (SAB) and relative apical sparing (RAS) were assessed in all subjects. RESULTS: Analyzing groups C and B, we only found a significant difference in the SAB (p-value 0.001) and RAS (p-value 0.039). These parameters were significantly more impaired in group A compared to group B (SAB p-value 0.008; RAS p-value 0.002). Also, atrial stiffness was significantly impaired in groups A and B compared to group C. CONCLUSIONS: Our study suggests the diagnostic role of the SAB and RAS in cardiac amyloidosis. The SAB and RAS showed a gradual increase from carriers to patients with neurological and cardiac diseases. Thus, these parameters, in addition to atrial stiffness, could be used to monitor carriers. More extensive data are needed.

Effectiveness and Safety of Oral Anticoagulants in Cardiac Amyloidosis: Lights and Shadows.

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy characterized by extracellular deposition of mis-folded proteins called amyloid. Cardiac complications of CA are several: heart failure, aortic valve stenosis, thromboembolism, conduction disorders, atrial fibrillation, and ventricular arrhythmias. Atrial dysfunction is common in CA patients. Several evidences suggest to anticoagulated patients with CA in atrial fibrillation independently from CHA2DS2VaSC score. Considering the high thromboembolic risk in CA patients, anticoagulant therapy should be considered also in CA patients in sinus rhythm, when the atria are enlarged and dysfunctional, and the bleeding risk is low. Unfortunately indication to anticoagulation in patients with CA in sinus rhythm still remains a gray zone. Also drug-drug interactions should be considered in patients with CA. In this review, we will evaluate the effectiveness and safety of oral anticoagulants in CA patients, and we will propose a practical guide for management of anticoagulant therapy in CA patients.