2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

In acute MI and anemia, restrictive vs. liberal transfusion did not differ for a composite of recurrent MI or death at 30 d.

SOURCE CITATION: Carson JL, Brooks MM, Hebert PC, et al; MINT Investigators. Restrictive or liberal transfusion strategy in myocardial infarction and anemia. N Engl J Med. 2023;389:2446-2456. 37952133.

In patients with NSTE-ACS and previous CABG, routine invasive vs. conservative management does not improve outcomes.

SOURCE CITATION: Kelham M, Vyas R, Ramaseshan R, et al. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J. 2024;45:2380-2391. 38805681.

After stent implantation for ACS, ticagrelor monotherapy after <1 mo of DAPT vs. 12 mo of DAPT improved 1-y net clinical benefit.

SOURCE CITATION: Hong SJ, Lee SJ, Suh Y, et al; T-PASS (Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome) Investigators. Stopping aspirin within 1 month after stenting for ticagrelor monotherapy in acute coronary syndrome: the T-PASS randomized noninferiority trial. Circulation. 2024;149:562-573. 37878786.

Heteroleptic Magnesium n-Butyl on a Chemically Non-innocent 2-Anilidomethylpyridine Ligand Leading to Diverse Magnesium Hydrides.

Molecular magnesium hydrides and hydride-rich clusters are of significant interest for applications ranging from catalysis and small molecule activation to hydrogen storage. Here, we investigate the 2-anilidomethylpyridine framework NNL as an ancillary support for magnesium organometallics with a special emphasis on hydrides. The proligand NNLH (N-[2,6-bis(1-methylethyl)phenyl]-α,6-diphenyl-2-pyridinemethanamine) gives [(NNL)Mg(nBu)(thf)] (1) by nbutane elimination from Mg(nBu)2(thf)n. A stronger donor such as DMAP replaces the THF from 1 to give [(NNL)Mg(nBu)(dmap)] (2). Both are air-sensitive, and 1 is adventitiously oxidized into [(NNL)Mg(µ-OnBu)]2 (32). The homoleptic [(NNL)2Mg] (8) is made from 1 and a second equiv of NNLH. 1's terminal nBu group is selectively protonated by HN(SiMe3)2 to give [(NNL)MgHMDS] (4; HMDS = N(SiMe3)2), whereas Ph3SiOH partially protonates the backbone anilide as well to give a mixture of [(NNL)Mg(OSiPh3)(thf)] (5) and free NNLH. Like HN(SiMe3)2, aprotic MeOTf also reacts by selectively abstracting the nBu group from 1 to give [(NNL)Mg(µ:κ2-O,O'-OTf)(thf)]2 (62). Interestingly, screening the common synthetic routes for magnesium hydrides leads to diverse outcomes upon varying the Mg precursors and hydride sources. 1 and PhSiH3 give the hydride cluster [{(NNL)2Mg2(µ-H)}2(µ-H)4Mg] (7), whereas 2 and PhSiH3 give the molecular complex [(NNLde)Mg(dmap)2] (9) with a dearomatized pyridyl backbone. 1 and HBpin (pinacolborane) give a product mixture, from which a different hydride cluster [(NNL)2Mg2(µ-H)}2(µ:κ2-O,O'-O2C2Me4)] (10) is identified, showing a rare instance of complete deborylation of a HBpin molecule. 1 and HBcat (catecholborane) also give a product mixture, one of which is the borylated ligand [(NNL)Bcat] (11). HBpin with 4 as the Mg precursor takes the ligand borylation route more selectively to give [(NNL)Bpin] (12). Last, 1 reacts with iPrNH2BH3 to give [(NNL)Mg{NH(iPr)BH3}] (13), which shows a slow and fractional conversion into the dinuclear mixed hydrido amidoborane [(NNL)2Mg2(µ-H){(µ-NH(iPr)BH3}] (14) by partial ß-hydride elimination. In comparison, [(NNL)Mg(iPrNHBH3)(dmap)] (15) arising from the DMAP-bound 2 and iPrNH2BH3 is stable toward such elimination.

(CAAC)CuCl: A Competent Precatalyst for Carbonyl and Ester Hydrosilylation.

Cu-catalyzed carbonyl hydrosilylation involves a ligated "[(L)CuH]" as the active catalyst, where the ligand L has a crucial role toward the stability, stereoselectivity, and enhancement of the hydridicity. Strongly σ-donating N-heterocyclic carbenes (NHCs), their ring-expanded form, and an abnormal NHC as ligands have yielded robust and efficient Cu catalysts. However, cyclic(alkyl)(amino)carbenes (CAACs), despite being stronger σ-donors than NHCs and already having a salient Cu(I) chemistry, are yet to be reported as a similar ligand platform for this purpose. We establish here the familiar [(Me2CAAC)CuCl] as a powerful precatalyst in this regard. Additionally, it also catalyzes the more challenging ester hydrosilylation, which is a rare feat for a Cu catalyst. Apart from the stronger σ-donating ability, the more steric "openness" of CAACs than bulky NHCs also seems to be advantageous. To corroborate, three new (CAAC)CuCl complexes [(ArCH2,MeCAAC)CuCl] (Ar = Ph, 1-naphthyl, and 1-prenyl) are devised, where the effective steric around the copper is practically unaltered from the case of [(Me2CAAC)CuCl]. All three are equally active in carbonyl and ester hydrosilylation as [(Me2CAAC)CuCl]. Computation suggests the carbonyl insertion into a "(CAAC)Cu-H" as the rate-limiting step. To elucidate the involvement of a "(CAAC)CuH", "(PhCH2,MeCAAC)CuH" is generated in situ and is trapped as its BH3 adduct (PhCH2,MeCAAC)CuBH4.

2-Anilidomethylpyridine-Derived Three-Coordinate Zinc Hydride: The Journey Unveils Anilide Backbone's Reactive Nature.

Low-coordinate heteroleptic zinc hydrides are catalytically important but rare and synthetically challenging. We herein report three-coordinate monomeric zinc hydride on a 2-anilidomethylpyridine framework (NNL). The synthetic success comes through systematically screening a few different routes from different precursors. During the process, the ligand's anilide backbone interestingly appears to be more reactive than Zn's terminal site to electrophilic Lewis and Brønsted acids. The proligand NNLH reacts with [Zn{N(SiMe3)2}2] and ZnEt2 to give [(NNL)ZnA] (A = N(SiMe3)2 (1), Et(2)). Both are inert to PhSiH3 and H2 but react with HBpin only through the internal Zn-Nanilide bond to give the borylated ligand NNLBpin (3). The reactions of 1 and 2 with Ph3EOH (E = C, Si) afford a series of divergent compounds like [(NNLH)Zn(OSiPh3)2] (4), [Zn3(OSiPh3)4Et2] (5), and [EtZn(OCPh3)] (6). But in all cases, it is invariably the Zn-Nanilide bond protonated by the -OH with equal or higher preference than the terminal Zn-N or Zn-C bonds. A DFT analysis rationalizes the origin of such a reactivity pattern. Realizing that an acid-free route might be the key, reacting [(NNL)Li] with ZnBr2 gives [(NNL)Zn(µ-Br)]2 (7), which on successively treating with KOSiPh3 and PhSiH3 gives the desired [(NNL)ZnH] (8) as a three-coordinate monomer with a terminal Zn-H bond. Estimating the ligand steric in 8 shows the openness in Zn's coordination sphere, a desired criterion for efficient catalysis. This and a positive influence of the pyridyl sidearm is reflected in 8's superior activity in hydroborating PhC(O)Me by HBpin in comparison to Jones' two-coordinate anilido zinc hydride.

Factor XI/XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism: A narrative review.

During the past decade, direct oral anticoagulants (DOACs) have advanced and simplified the prevention and treatment of venous thromboembolism (VTE). However, there remains a high incidence of bleeds, which calls for agents that have a reduced risk of bleeding. Factor XI (FXI) deficiency is associated with lower rates of venous thrombosis and stroke compared to the general population with a lower risk of bleeding. In conjunction with this, phase 2 studies have demonstrated safety and the potential for reduced thrombotic events with FXI inhibitors as compared to currently available medications. The aim of this review is to summarize key data on the clinical pharmacology of FXI, the latest developments in clinical trials of FXI inhibitors, and to describe the efficacy and safety profiles of FXI inhibitors for the prevention of venous and arterial thromboembolism.

In HF, with or without PAD, dapagliflozin reduced a composite of worsening HF or CV death and did not increase amputations.

SOURCE CITATION: Butt JH, Kondo T, Yang M, et al. Heart failure, peripheral artery disease, and dapagliflozin: a patient-level meta-analysis of DAPA-HF and DELIVER. Eur Heart J. 2023;44:2170-2183. 37220172.

Influenza vaccination in mitigating vascular events and risk.

PURPOSE OF REVIEW: Influenza imparts a significant health burden on the United States and global population. Furthermore, influenza is associated with acute cardiovascular events, including heart failure exacerbations, acute coronary syndromes, strokes, and overall cardiovascular mortality. We review the role of seasonal influenza vaccination in mitigating cardiovascular risk. RECENT FINDINGS: A large study assessed the impact of influenza vaccine on cardiovascular outcomes and mortality using the US National Inpatient Sample (NIS) database. This study included 22 634 643 hospitalizations. Vaccination against influenza was associated with a reduction in myocardial infarctions (MI) [relative risk (RR) = 0.84, 95% CI 0.82-0.87, P  < 0.001], transient ischemic attacks (RR = 0.93, 95% CI 0.9-0.96, P  < 0.001), cardiac arrests (RR = 0.36, 95% CI 0.33-0.39, P  < 0.001), strokes (RR = 0.94, 95% CI 0.91-0.97, P  < 0.001), and overall mortality (RR = 0.38, 95% CI 0.36-0.4, P  < 0.001). SUMMARY: Available data suggests that seasonal influenza vaccination is very effective in mitigating cardiovascular risk. Increasing the rates of influenza vaccination, especially among those with cardiovascular risk factors, is critical in preventing infection and attenuating influenza-related cardiovascular complications and adverse outcomes.

A N-Heterocyclic Carbene-Supported Zinc Catalyst for the 1,2-Regioselective Hydroboration of N-Heteroarenes.

A fluorenyl-tethered N-heterocyclic carbene LH (LH=[(Flu)H-(CH2 )2 -NHCDipp ]) and its monoanionic version L- are explored in complexation with zinc towards the hydroboration of N-heteroarenes, carbonyl, ester, amide, and nitrile under ambient condition. The N-heteroarenes exhibit high 1,2-regioselectivity which is justified by computational analyses. The relative hydroboration rates of differently p-substituted (electron donating vs. withdrawing) pyridines are also addressed. The monodentate LH offers a better catalytic activity than the chelating L- for steric reasons despite both giving three-coordinate zinc complexes. The mechanism involves a Zn-H species at the heart of these catalytic processes which is trapped by Ph2 CO. Computational studies suggest that the barrier to form the hydride complex is comparable to the barrier required for the following hydride transfer to pyridine.

A 2-Anilidomethylpyridine Ligand Framework Showcasing Hydride Storage and Transfer Abilities in Its Aluminum Chemistry.

Dearomatized 1,4-dihydropyridyl motifs are significant in both chemistry and biology for their potential abilities to deliver the stored hydride, driven by rearomatization. Biological cofactors like nicotinamide adenine dinucleotide (NADH) and organic 'hydride sources' like Hantzsch esters are prime examples. An organoaluminum chemistry on a 2-anilidomethylpyridine framework is reported, where such hydride storage and transfer abilities are displayed by the ligand's pyridyl unit. The pyridylmethylaniline proligand (NN LH) is simultaneously deprotonated and 1,4-hydroaluminated by AlH3 (NMe2 Et) to [(NN Lde )AlH(NMe2 Et)] (1; NN Lde =hydride-inserted dearomatized version of NN L). A hydride abstraction by B(C6 F5 )3 rearomatizes the pyridyl moiety to give the cationic aluminum hydride [(NN L)AlH(NMe2 Et)][HB(C6 F5 )3 ] (6). Notably, such chemical non-innocence is priorly unseen in this established ligand class. The hydroalumination mechanism is investigated by isolating the intermediate [(NN L)AlH2 ] (2) and by control experiments, and is also analyzed by DFT calculation. The results advocate an intriguing 'self-promoting' pathway, which underlines alane's Lewis acid/Brønsted base duality. NMe2 Et carrying the alane also plays a crucial role. In contrast, the chemistry between NN LH and AlMe3 is much different, giving only [(NN L)AlMe2 ] (4) from the adduct [(NN LH)AlMe3 ] (3) by deprotonation but not a subsequent pyridyl dearomatization in the presence or absence of NMe2 Et. This divergence is also justified by DFT analyses.

Divergent Synthesis of Chelating Aziridines and Cyclic(Alkyl)(Amino)Carbenes (CAACs) from Pyridyl-Tethered Robust Azomethine Ylides.

Azomethine ylides are typically in situ generated synthons for making N-heterocycles through cycloaddition reactions. But an offbeat aspect about them is the isomeric nature of aldiminium-based azomethine ylides and (alkyl/aryl)(amino)carbenes, interconvertible by a formal 1,3-H+ transfer. Herein, two thermally robust azomethine ylides with a N-appended picolyl sidearm are isolated, which cyclize to py aziridines at 80 °C but unprecedentedly result N-pico CAAC-CuCl (CAAC=cyclic(alkyl)(amino)carbene) complexes when heated with CuCl at merely 60 °C. The pendant Npy , as revealed by computational analysis, plays a crucial role in this unusual 1,3-H+ shift using a deprotonation-protonation sequence, as well as in placing the CuCl at the carbenic site in tandem. The softer nature of Cu(I) is also critical. Chelating CAACs are rare and one with a N-tethered additional donor is priorly unknown. Both N-pico CAAC and py aziridine are bidentate chelators giving highly active cationic Rh(I) catalysts for hydrosilylating unactivated olefins by Et3 SiH. Notably, the py aziridine-Rh(I) is superior than the N-pico CAAC-Rh(I) catalyst.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.

Semaglutide for weight loss and cardiometabolic risk reduction in overweight/obesity.

PURPOSE OF REVIEW: Cardiovascular disease is the most common cause of morbidity and mortality worldwide, and the risk is heightened in the presence of obesity. We review semaglutide, a drug recently approved for chronic weight management in adults with obesity or who are overweight. RECENT FINDINGS: On 4 June 2021, the US Food and Drug Administration approved semaglutide injection at 2.4 mg once weekly for chronic weight management in adults with obesity or overweight with at least one weight-related condition such as high blood pressure, type 2 diabetes mellitus, or high cholesterol. This subcutaneous injection is the first approved drug for chronic weight management in adults with general obesity or overweight since 2014. The drug is indicated for weight management in patients with a BMI of 27 kg/m2 or greater who have at least one weight-related ailment or in patients with a BMI of 30 kg/m2 or greater. SUMMARY: Semaglutide offers adults with obesity or overweight a new treatment in conjunction with a weight management program consisting of reduced calorie diet and increased physical activity.

Which are the optimal thromboprophylaxis strategies for hospitalized patients with COVID-19? current controversies.

Novel coronavirus 2019 (COVID-19) represents a significant risk factor for the development of venous thromboembolism (VTE) in hospitalized with both moderate and severe/critical COVID-19. Herein, we present a brief updated review on emerging robust data on diverse thromboprophylaxis strategies used to mitigate VTE complications, as well as a personal point of view of current controversies in regards the use of therapeutic and prophylactic anticoagulation strategies, particularly in the moderately-ill subgroup of patients with COVID-19.

Outcomes of rotational atherectomy versus orbital atherectomy for the treatment of heavily calcified coronary stenosis: A systematic review and meta-analysis.

INTRODUCTION: The optimal approach to deal with severe coronary artery calcification (CAC) during percutaneous coronary intervention (PCI) remains ill-defined. METHODS: We conducted an electronic database search of all published studies comparing Orbital versus Rotational Atherectomy in patients undergoing PCI. RESULTS: Eight observational studies were included in the analysis. Overall, there were no significant differences in Major-adverse-cardiac-events/MACE (OR: 0.81, CI: 0.63-1.05, p = .11), myocardial-infarction/MI (OR: 0.75, CI: 0.56-1.00, p = .05), all-cause mortality (OR: 0.82, CI: 0.25-2.64, p = .73) or Target-vessel-revascularization/TVR (OR: 0.72, CI: 0.38-1.36, p = .31). However, OA was associated with lower long-term MACE (1-year), (OR: 0.66, CI: 0.44-0.99, p = .04), long-term TVR (OR: 0.40, CI: 0.18-0.89, p = .03), and short-term MI (in-hospital and 30-day) (OR: 0.64, CI: 0.44-0.94, p = .02). OA was associated with more coronary artery dissections (OR: 2.61, CI: 1.38-4.92, p = .003) and device-related coronary perforations (OR: 2.79, CI: 1.08-7.19, p = .03). There were no differences in cardiac tamponade (OR: 1.78, CI: 0.37-8.69, p = .47). OA was noted to have significantly lower fluoroscopy time (MD: -3.96 min, CI: -7.67, -0.25; p = .04) compared to RA. No significant difference was noted in terms of contrast volume between the two groups (OR: -4.35 ml, CI: -14.52, 23.22; p = .65). CONCLUSION: Although there was no difference in overall MACE, MI, all-cause mortality and TVR, OA was associated with lower long-term MACE and short-term MI. OA is associated with lower fluoroscopy time but higher rates of coronary artery dissection and coronary perforation.

Associations between Combined Influenza and Pneumococcal Pneumonia Vaccination and Cardiovascular Outcomes.

BACKGROUND: In 2017, the CDC listed heart disease as the leading cause of death, with pneumonia and influenza being the eighth cause of death. Several studies have suggested the protective effects of influenza vaccination on myocardial infarction (MI). Available evidence supports the use of influenza vaccination in decreasing cardiovascular events, and the Joint Commission considers influenza vaccination a metric of quality care for hospitalized patients. Our specific aim was to evaluate the combined use of pneumococcal pneumonia vaccine (PPV) and influenza vaccine on cardiovascular outcomes and mortality. METHODS: A retrospective observational study was conducted using the 2012-2015 US National Inpatient Sample (NIS) database, to compare cardiovascular events in adult patients who did and did not receive vaccination during their hospitalization. ICD-9 codes were used to extract data for specific variables. The outcomes included MI, transient ischemic attacks, cardiac arrest, stroke, heart failure, and death. Adjusted relative risks (RR) were calculated using survey-weighted generalized linear models after adjusting for gender, race, socioeconomic status, diabetes, hypertension, hyperlipidemia, smoking status, prior coronary artery disease, and cerebrovascular disease. The effect of vaccination on in-hospital mortality was assessed in each subgroup of cardiovascular events using RR regressions. RESULTS: This study included 22,634,643 hospitalizations, of which 21,929,592 did not receive immunization. Vaccination solely against influenza was associated with lower MI (RR = 0.84, 95% CI: 0.82-0.87, p < 0.001), TIA (RR = 0.93, 95% CI: 0.9-0.96, p < 0.001), cardiac arrest (RR = 0.36, 95% CI: 0.33-0.39, p < 0.001), stroke (RR = 0.94, 95% CI: 0.91-0.97, p < 0.001), and mortality (RR = 0.38, 95% CI: 0.36-0.4, p < 0.001). Vaccination with PPV alone was associated with MI (RR = 1.13, 95% CI: 1.11-1.16, p < 0.001), TIA (RR = 1.28, 95% CI: 1.26-1.31, p < 0.001), stroke (RR = 1.21, 95% CI: 1.18-1.24, p < 0.001), and lower mortality (RR = 0.47, 95% CI: 0.45-0.49, p < 0.001). Combined PPV and influenza vaccine was associated with lower mortality (2.21% vs. 1.03%, p < 0.001) and lower cardiac arrest (0.61% vs. 0.51%, p < 0.001). In the adjusted analysis, the RR was 0.46 (95% CI: 0.43, 0.49) for mortality in the combined vaccinated cohort. The combined vaccination group also had a significantly reduced risk of mortality among those admitted with MI (RR = 0.46), transient ischemic attacks (RR = 0.58), and stroke (RR = 0.42) compared to the nonvaccinated group. CONCLUSIONS: Our study shows a significantly reduced risk of mortality with influenza vaccine and PPV and with combined pneumococcal and influenza vaccination. These data suggest that in-hospital administration of pneumonia and influenza vaccines appears safe and supports the use of combined vaccination during hospitalization due to their cardiovascular benefits.

Direct oral anticoagulants in chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) represents the later stage consequence of at least one or more unresolved episodes of acute pulmonary embolism; thus, indefinite anticoagulation is strongly recommended by current practice guidelines. Historically, vitamin K antagonists have been widely used in these patients. However, recent data indicate a shift toward direct oral anticoagulants (DOACs), despite lack of data on the safety and efficacy in this patient population. Herein, we briefly discuss the current rationale for oral anticoagulation use in CTEPH, addressing important issues and controversies involved with the use of DOACs, opening a strategy for further clinical research in the field of oral anticoagulation.