1. Tratta tutti I pazienti con fibrillazione atriale (AF) secondo lo schema AF-CARE, dove: 2. Prescrivi la terapia anticoagulante ai pazienti a rischio di stroke e trombo-embolismo, basandoti sul CHA2DS2-VA score (stesso punteggio per uomini e donne). 3. Non basarti sugli score di bleeding per prescrivere o non prescrivere gli anticoagulanti, ma rimuovi tutti i fattori di rischio emorragico modificabili. 4. Considera l’anticoagulazione per le AF indotte da fattori secondari (ad esempio da sepsi, alcol, tireotossicosi, chirurgia) secondo il rischio del paziente[1]Gundlund A, Kümler T, Bonde AN, Butt JH, Gislason GH, Torp-Pedersen C, et al. Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant—Danish nationwide … Continua a leggere. 5. Considera l’anticoagulazione orale nella AF subclinica diagnosticata tramite device impiantato in pazienti ad alto rischio di stroke e basso rischio emorragico, in quanto progrediscono rapidamente verso le forme clinicamente manifeste. 6. Per i pazienti cardio-operati l’esclusione dell’auricola sinistra, in aggiunta alla terapia anticoagulante, può prevenire il tromboembolismo. 7. L’ablazione transcatetere in pazienti con AF parossistica, considerati adatti, può essere utilizzata come prima scelta terapeutica per alleviare i sintomi, ridurre le recidive e ritardare la progressione dell’AF. 8. Il controllo del ritmo in pazienti selezionati può migliorarne la prognosi in presenza di alto rischio tromboembolico[2]Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med 2020;383:1305–16. https://doi.org/ … Continua a leggere, scompenso cardiaco e FE ridotta e nei casi in cui il controllo del ritmo può permettere di ridurre le ospedalizzazioni e la mortalità[3]Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European … Continua a leggere. 9. La cardioversione di AF richiede una anticoagulazione appropriata e uno studio con ecografia transesofagea se la durata supera le 24 ore. Considera innanzitutto la sicurezza e la possibilità di attendere un ripristino spontaneo del ritmo. 10. La rivalutazione clinica regolare è fondamentale, così come la valutazione del ritmo per ogni individuo che abbia superato i 65 anni e si sottoponga a un controllo medico per facilitare una diagnosi precoce di AF, così come sono utili gli screening di popolazioni a rischio tromboembolico elevato[4]Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, … Continua a leggere. Bibliografia[+] Bibliografia ↑1 Gundlund A, Kümler T, Bonde AN, Butt JH, Gislason GH, Torp-Pedersen C, et al. Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant—Danish nationwide cohort study. BMJ Open 2019;9:e028468 https://doi.org/10. 1136/bmjopen-2018-028468. ↑2 Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med 2020;383:1305–16. https://doi.org/ 10.1056/NEJMoa2019422 ↑3 Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314–3414. https://doi.org/10.1093/eurheartj/ehae176. ↑4 Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet 2021;398:1498–506. https://doi.org/10.1016/S0140-6736(21)01637-8

1. Cochrane ALK, Murphy MP, Ozanne SE, Giussani DA. Pregnancy in obese women and mechanisms of increased cardiovascular risk in offspring. Eur Heart J 2024;45:5127–45. Pregnancy complicated by maternal obesity contributes to an increased cardiovascular risk in offspring, which is increasingly concerning as the rates of obesity and cardiovascular disease are higher than ever before and still growing. There has been much research in humans and preclinical animal models to understand the impact of maternal obesity on offspring health. This review summarizes what is known about the offspring cardiovascular phenotype, describing a mechanistic role for oxidative stress, metabolic inflexibility, and mitochondrial dysfunction in mediating these impairments. It also discusses the impact of secondary postnatal insults, which may reveal latent cardiovascular deficits that originated in utero. Finally, current interventional efforts and gaps of knowledge to limit the developmental origins of cardiovascular dysfunction in offspring of obese pregnancy are highlighted. 2. Zhang Y, Yu S, Chen Z, et al. Gestational diabetes and future cardiovascular diseases: associations by sex-specific genetic data. Eur Heart J 2024;45: 5156–67. This study demonstrated a suggestive causal relationship between genetic predisposition to gestational diabetes mellitus and the risk of coronary artery disease, which was mainly mediated by Type 2 diabetes and hypertension. These findings highlight targeting modifiable cardiometabolic risk factors may reduce the risk of coronary artery disease in women with a history of gestational diabetes mellitus. 3. Di Pietrantonio N, Sánchez-Ceinos J, Shumliakivska M, Rakow A, Mandatori D, Di Tomo P, et al. The inflammatory and oxidative phenotype of gestational diabetes is epigenetically transmitted to the offspring: role of methyltransferase MLL1-induced H3K4me3. Eur Heart J 2024;45:5171–85. Such proof-of-concept study shows persistence of MLL1-dependent H3K4me3 in offspring born to GD women, suggesting an epigeneticdriven transmission of maternal phenotype. These findings may pave the way for pharmacological reprogramming of adverse histone modifications to mitigate abnormal phenotypes underlying early ASCVD. 4. Perkovic V, Tuttle KR, Rossing P, et al. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med 2024;391:109–21. Among patients with complex coronary-artery bifurcation lesions, OCT-guided PCI was associated with a lower incidence of MACE at 2 years than angiography-guided PCI. 5. Mahaffey KW, Tuttle KR, Arici M, et al. Cardiovascular outcomes with semaglutide by severity of chronic kidney disease in type 2 diabetes: the FLOW trial. Eur Heart J 2025;46:1096–108. In this individual patient data meta-analysis, DAPT-based de-escalation was associated with both decreased ischaemic and bleeding endpoints. Reduction in bleeding endpoints was more prominent for the unguided than the guided de-escalation strategy. 6. Badve SV, Bilal A, Lee MMY, et al. Effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes: a metaanalysis of randomised controlled trials. Lancet Diabetes Endocrinol 2025;13:15–28. We found evidence that GLP-1 receptor agonists significantly reduce clinically important kidney events, kidney failure, and cardiovascular events. 7. Pratley RE, Tuttle KR, Rossing P, et al. Effects of semaglutide on heart failure outcomes in diabetes and chronic kidney disease in the FLOW trial. J Am Coll Cardiol 2024;84:1615–28. We found evidence that GLP-1 receptor agonists significantly reduce clinically important kidney events, kidney failure, and cardiovascular events. 8. Butler J, Shah SJ, Petrie MC, et al. Semaglutide versus placebo in people with obesity-related heart failure with preserved ejection fraction: a pooled analysis of the STEP-HFpEF and STEP-HFpEF DM randomised trials. Lancet 2024;403:1635–48. In this prespecified pooled analysis of the STEP-HFpEF and STEP-HFpEF DM trials, semaglutide was superior to placebo in improving heart failure-related symptoms and physical limitations, and reducing bodyweight in participants with obesity-related heart failure with preserved ejection fraction. These effects were largely consistent across patient demographic and clinical characteristics. Semaglutide was well tolerated. 9. Kosiborod MN, Deanfield J, Pratley R, et al. Semaglutide versus placebo in patients with heart failure and mildly reduced or preserved ejection fraction: a pooled analysis of the SELECT, FLOW, STEP-HFpEF, and STEP-HFpEF DM randomised trials. Lancet 2024;404:949–61. In patients with HFpEF, semaglutide reduced the risk of the combined endpoint of cardiovascular death or worsening heart failure events, and worsening heart failure events alone, whereas its effect on cardiovascular death alone was not significant. These data support the use of semaglutide as an efficacious therapy to reduce the risk of clinical heart failure events in patients with HFpEF, for whom few treatment options are currently available. 10. Neuen BL, Fletcher RA, Heath L, et al. Cardiovascular, kidney, and safety outcomes with GLP-1 receptor agonists alone and in combination with SGLT2 inhibitors in type 2 diabetes: a systematic review and meta- analysis. Circulation 2024;150:1781–90. In people with type 2 diabetes, the cardiovascular and kidney benefits of GLP-1 receptor agonists are consistent regardless of SGLT2 inhibitor use. 11. Apperloo EM, Neuen BL, Fletcher RA, et al. Efficacy and safety of SGLT2 inhibitors with and without glucagon-like peptide 1 receptor agonists: a SMART-C collaborative meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol 2024;12: 545–57. The effects of SGLT2 inhibitors on cardiovascular and kidney outcomes are consistent regardless of the background use of GLP-1 receptor agonists. These findings suggest independent effects of these evidence-based therapies and support clinical practice guidelines recommending the use of these agents in combination to improve cardiovascular and kidney metabolic outcomes. 12. Bi Y, Li M, Liu Y, et al. Intensive blood pressure control in patients with type 2 diabetes. N Engl J Med 2025;392:1155–67. Among patients with type 2 diabetes, the incidence of major cardiovascular events was significantly lower with intensive treatment targeting a systolic blood pressure of less than 120 mm Hg than with standard treatment targeting a systolic blood pressure of less than 140 mm Hg. 13. Malhotra A, Grunstein RR, Fietze I, et al. Tirzepatide for the treatment of obstructive sleep apnea and obesity. N Engl J Med 2024;391:1193–205. Among persons with moderate-to-severe obstructive sleep apnea and obesity, tirzepatide reduced the AHI, body weight, hypoxic burden, hsCRP concentration, and systolic blood pressure and improved sleeprelated patient-reported outcomes.

Il pacing del sistema di conduzione (CSP) è un’area relativamente nuova sempre più adottata come fisiologico sostituto al pacing tradizionale del ventricolo destro e come alternativa alla risincronizzazione biventricolare. Le Linee Guida ESC del 2021 sono state molto prudenti al riguardo per l’assenza di dati a quel tempo convincenti, ma da allora nuove evidenze ne hanno dimostrato l’efficacia e la sicurezza. Questa nuova modalità di pacing si è rapidamente diffusa e ha reso necessario un documento di consenso al riguardo[1]Glikson M, Burri H, Abdin A. et al. European Society of Cardiology (ESC) Clinical Consensus Statement on indications for conduction system pacing, with special contribution of the European Heart … Continua a leggere I principali messaggi sono qui riportati: 1) Training. L’impianto di CSP deve essere eseguito da personale medico che abbia ricevuto un adeguato training e acquisito la capacità di effettuare procedure efficaci e sicure. (ADVICE TO DO). 2) Pacing del fascio di His (HBP) versus pacing dell’area della branca sinistra (LBBAP). (ADVICE TO DO). Entrambe le modalità comportano benefii clinici ed emodinamici. Tuttavia, LBBAP è caratterizzata da sensing e pacing superiori e da un minor tasso di complicanze correlate agli elettrodi. LBBAP è inoltre preferibile nei pazienti con blocchi infranodali, quando si pianifica un’ablazione del nodo AV o una sostituzione valvolare aortica, mentre HBP è preferibile se la valvola tricuspide deve essere preservata. (MAY BE APPROPRIATE TO DO). 3) Blocco AV. È appropriato un impianto CSP, senza tener conto della EF e della probabile percentuale di pacing. (MAY BE APPROPRIATE TO DO). 4) Ablazione del nodo AV. È appropriato un impianto CSP, indipendentemente dal valore della EF. Per tale indicazione, è preferibile un impianto LBBAP (MAY BE APPROPRIATE TO DO). 5) Scompenso cardiaco con blocco di branca sinistra, QRS ≥130 ms, e. EF ≤.35. È appropriato impianto CSP-resincronizzazione cardiaca per migliorare la EF, la capacità di esercizio, i sintomi, e per ridurre le ospedalizzazioni per scompenso (MAY BE APPROPRIATE TO DO). 6) Scompenso cardiaco senza blocco di branca sinistra o EF ≥.35. L’impatto di CSP è incerto per mancanza di evidenze. (AREA OF UNCERTAINTY). 7) Cardiomiopatia indotta da pacing o non responsività a terapia di resincronizzazione con biventricolare. È appropriato un upgrading a CSP per migliorare i sintomi di scompenso e la EF (MAY BE APPROPRIATE TO DO). 8) HOT/LOT-CRT. Può essere appropriato proporre una resincronizzazione HOT/LOT (His-Optimized Therapy for Cardiac Resinchronization Therapy/Left Optimized Threrapy for Cardiac Resynchronization Therapy) nel caso di risultato elettrocardiografico o clinico subottimale dell’impianto CSP o di biventricolare, tenendo in considerazione l’esperienza dell’operatore e il rischio procedurale (MAY BE APPROPRIATE TO DO). 9) Impianto non riuscito dell’elettrodo in seno coronarico. Nei candidati a terapia di resincronizzazione cardiaca con biventricolare nei quali l’impianto dell’elettrodo in seno coronarico non abbia successo, si consiglia CSP come terapia “rescue” (ADVICE TO DO). 10) Popolazioni specifiche. In pazienti in cui è desiderabile un dispositivo più semplice (fragilità, breve attesa di vita) è desiderabile un impianto CSP piuttosto che un biventricolare come strategia primaria, considerando l’esperienza dell’operatore (MAY BE APPROPRIATE TO DO). Bibliografia[+] Bibliografia ↑1 Glikson M, Burri H, Abdin A. et al. European Society of Cardiology (ESC) Clinical Consensus Statement on indications for conduction system pacing, with special contribution of the European Heart Rhythm Association of the ESC and endorsed by the Asia Pacific Heart Rhythm Society, the Canadian Heart Rhythm Society, the Heart Rhythm Society, and the Latin American Heart Rhythm Society. Europace 2025;27:euaf050. https://doi.org/10.1093/europace/euaf050

1. Vrints C, Andreotti F, Koskinas KC et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024;45: 3415–537.  Chronic Coronary Syndromes are a range of clinical presentations or syndromes that arise due to structural and/or functional alterations related to chronic diseases of the coronary arteries and/or microcirculation. These alterations can lead to transient, reversible, myocardial demand vs blood supply mismatch resulting in hypoperfusion (ischaemia), usually (but not always) provoked by exertion, emotion or other stress, and may manifest as angina, other chest discomfort, or dyspnoea, or be asymptomatic. Although stable for long periods, chronic coronary diseases are frequently progressive and may destabilize at any moment with the development of an ACS.  2. Gao XF, Ge Z, Kong XQ, et al. Intravascular ultrasound vs angiography-guided drugcoated balloon angioplasty: the ULTIMATE III trial. JACC Cardiovasc Interv 2024; 17: 1519–28.  This study demonstrated that IVUS-guided drug-coated balloon angioplasty is associated with a lower late lumen loss in patients with a de novo coronary lesion compared with angiography guidance. 3. Gao X, Tian N, Kan J, et al. Drug-coated balloon angioplasty of the side branch during provisional stenting: the multicenter randomized DCB-BIF trial. J Am Coll Cardiol 2025;85:1–15. In patients with simple and true coronary bifurcation lesions undergoing provisional stenting, main vessel stenting with a drugcoated balloon for the compromised side branch resulted in a lower 1-year rate of the composite outcome compared with an non-coated balloon intervention for the side branch. The high rates of periprocedural myocardial infarction, which occurred early and did not lead to revascularization, are of unclear clinical significance. 4. Park SJ, Ahn JM, Kang DY, et al. Preventive percutaneous coronary intervention versus optimal medical therapy alone for the treatment of vulnerable atherosclerotic coronary plaques (PREVENT): a multicentre, open-label, andomized controlled trial. Lancet 2024;403:1753–65. In patients with non-flow-limiting vulnerable coronary plaques, preventive percutaneous coronary intervention reduced major adverse cardiac events arising from high-risk vulnerable plaques, compared with optimal medical therapy alone. Given that PREVENT is the first large trial to show the potential effect of the focal treatment for vulnerable plaques, these findings support consideration to expand indications for percutaneous coronary intervention to include non-flowlimiting, high-risk vulnerable plaques. 5. Møller JE, Engstrøm T, Jensen LO, et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med 2024;390: 1382–93. The routine use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. The incidence of a composite of adverse events was higher with the use of the microaxial flow pump. 6. Jørgensen TH, Thyregod HGH, Savontaus M, et al. Transcatheter aortic valve implantation in low-risk tricuspid or bicuspid aortic stenosis: the NOTION-2 trial. Eur Heart J 2024;45:3804–14.  Among low-risk patients aged ≤75 years with severe symptomatic aortic stenosis, the rate of the composite of death, stroke, or rehospitalization at 1 year was similar between TAVI and surgery. Transcatheter aortic valve implantation outcomes in young bicuspid AS patients warrant caution and should be further investigated. 7. Lønborg J, Jabbari R, Sabbah M, et al. PCI in patients undergoing transcatheter aortic-valve implantation. N Engl J Med 2025;392:217–27. Among patients with coronary artery disease who were undergoing TAVI, PCI was associated with a lower risk of a composite of death from any cause, myocardial infarction, or urgent revascularization at a median follow-up of 2 years than conservative treatment. 8. Généreux P, Schwartz A, Oldemeyer JB, et al. Transcatheter aortic-valve replacement (TAVR) for asymptomatic severe aortic stenosis. N Engl J Med 2025;392:217–27.   Among patients with asymptomatic severe aortic stenosis, a strategy of early TAVR was superior to clinical surveillance in reducing the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes. 9. Baldus S, Doenst T, Pfister R, et al. Transcatheter repair versus mitral-valve surgery for secondary mitral regurgitation. N Engl J Med 2024; 391:1787–98. Among patients with heart failure and secondary mitral regurgitation, transcatheter edge-to-edge repair was noninferior to mitralvalve surgery with respect to a composite of death, rehospitalization for heart failure, stroke, reintervention, or implantation of an assist device in the left ventricle at 1 year. 10. Jaber WA, Gonsalves CF, Stortecky S, et al. Large-bore mechanical thrombectomy versus catheter-directed thrombolysis I n the management of intermediate-risk pulmonary embolism: primary results of the PEERLESS randomized controlled trial. Circulation 2025;151:260–73. PEERLESS met its primary end point in favor of large-bore mechanical thrombectomy Windows compared with catheter-directed thrombolysis in treatment of intermediaterisk pulmonary embolism. Large-bore mechanical thrombectomy had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with catheter-directed thrombolysisT, with no difference in mortality or bleeding.

1 | Cho MS, Kang DY, Ahn JM, et al. Edoxaban antithrombotic therapy for atrial fibrillation and stable coronary artery disease. N Engl J Med 2024; 391:2075–86. https://doi.org/10.1056/NEJMoa2407362. In patients with atrial fibrillation and stable coronary artery disease, edoxaban monotherapy led to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than dual antithrombotic therapy. 2 | Joosten LPT, van Doorn S, van de Ven PM, et al. Safety of switching from a vitamin K antagonist to a non-vitamin K antagonist oral anticoagulant in frail older patients with atrial fibrillation: results of the FRAILAF randomized controlled trial.  Circulation 2024;149:279–89. https://doi.org/10.1161/ CIRCULA-TIONAHA.123.066485. Switching international normalized ratio– guided VKA treatment to an NOAC in frail older patients with atrial fibrillation was associated with more bleeding complications compared with continuing VKA treatment, without an associated reduction in thromboembolic complications. 3 | Werring DJ, Dehbi HM, Ahmed N, et al. Optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS): a multicentre, blinded-endpoint, phase 4, randomised controlled trial.  Lancet 2024; https://doi. org/10.1016/S0140-6736(24) 02197-4. Early DOAC initiation within 4 days after ischaemic stroke associated with atrial fibrillation was non-inferior to delayed initiation for the composite outcome of ischaemic stroke, intracranial haemorrhage, unclassifiable stroke, or systemic embolism at 90 days. 4 | Ge Z, Kan J, Gao X, et al. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo- controlled, double-blind clinical trial. Lancet 2024;403:1866–78. https://doi. org/10.w1016/S0140-6736(24)00473-2. In patients with an acute coronary syndrome who had percutaneous coronary intervention with contemporary drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention resulted in a lower rate of clinically relevant bleeding and a similar rate of MACCE compared with ticagrelor plus aspirin. Along with the results from previous studies, these findings show that most patients in this population can benefit from superior clinical outcomes with aspirin discontinuation and maintenance on ticagrelor monotherapy after 1 month of dual antiplatelet therapy.  5 | Natsuaki M, Watanabe H, Morimoto T, et al. An aspirin-free versus dual antiplatelet strategy for coronary stenting: STOPDAPT-3 randomized trial. Circulation 2024;149: 585–600. https://doi.org/10.1161/ CIRCULATIONAHA. 123.066720. The aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI. However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events. 6 | Watanabe H, Natsuaki M, Morimoto T, et al. Aspirin vs. clopidogrel monotherapy after percutaneous coronary intervention: 1-year follow-up of the STOPDAPT-3 trial. Eur Heart J 2024;45:5042–54. https://doi. org/10.1093/ eurheartj/ehae617. Aspirin monotherapy compared with clopidogrel monotherapy was associated with similar cardiovascular and bleeding outcomes beyond 1 month and up to 1 year after percutaneous coronary intervention with drug-eluting stents. 7. | van Ginkel DJ, Bor WL, Aarts HM, et al. Continuation versus interruption of oral anticoagulation during TAVI. N Engl J Med 2024;392:438–49. https://doi.org/10.1056/NEJMoa2407794 8. In patients undergoing TAVI with a concomitant indication for oral anticoagulation, periprocedural continuation was not noninferior to interruption of oral anticoagulation during TAVI with respect to the incidence of a composite of death from cardiovascular causes, stroke, myocardial infarction, major vascular complications, or major bleeding at 30 days. 8 | Jaber WA, Gonsalves CF, Stortecky S, et al. Large-bore mechanical thrombectomy versus catheter-directed thrombolysis in the management of intermediate-risk pulmonary embolism: primary results of the PEERLESS randomized controlled trial. Circulation. 2024;151:260–73. https://doi.org/10.1161/CIRCULATIONAHA. 124.072364. PEERLESS met its primary end point in favor of LBMT compared with CDT in treatment of intermediate-risk pulmonary embolism. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with CDT, with no difference in mortality or bleeding. 9 | Vriesendorp PA, Nanayakkara S, Heuts S, et al. Routine protamine administration for bleeding in transcatheter aortic valve implantation: the ACE-PROTAVI randomized clinical trial. JAMA Cardiol 2024;9:901–8. https://doi.org/10.1001jamacardio.2024. In the ACE-PROTAVI randomized clinical trial, routine administration of protamine increased the rate of hemostasis success and decreased TTH. The beneficial effect of protamine was reflected in a reduction in minor vascular complications, procedural time, and postprocedural hospital stay duration in patients receiving routine protamine compared with patients receiving placebo. 10 | Luijten D, Douillet D, Luijken K, et al. Safety of treating acute pulmonary embolism at home: an individual patient data metaanalysis. Eur Heart J 2024;45:2933–50. The incidence of adverse events in hometreated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding. 11 | Ruff CT, Patel SM, Giugliano RP et al. AZALEA–TIMI 71 Investigators. Abelacimab versus rivaroxaban in patients with atrial fibrillation. N Engl J Med 2025;392:361–71. Among patients with atrial fibrillation who were at moderate-to-high risk for stroke, treatment with abelacimab resulted in markedly lower levels of free factor XI and fewer bleeding events than treatment with rivaroxaban. 12 | Piccini JP, Patel MR, Steffel J, et al. Asundexian versus apixaban in patients with atrial fibrillation. N Engl J Med 2025;392:23–32. Among patients with atrial fibrillation at risk for stroke, treatment with asundexian at a dose of 50 mg once daily was associated with a higher incidence of stroke or systemic embolism than treatment with apixaban in the period before the trial was stopped prematurely. There were fewer major bleeding events with asundexian than with apixaban during this time.

1. Boden WE, De Caterina R, Kaski JC, et al. Myocardial ischaemic syndromes: a new nomenclature to harmonize evolving international clinical practice guidelines. Eur Hear J 2024; 45:3701–6https://doi. org/10.1093/eurheartj/ ehae278. The authors propose a new binary classification of ‘acute myocardial ischaemic syndromes’ and ‘non-acute myocardial ischaemic syndromes’, which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction. 2. Yndigegn T, Lindahl B, Mars K, et al. Beta-blockers after myocardial infarction and preserved ejection fraction. N Engl J Med 2024;390: 1372–81.  . Among patients with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (≥50%), longterm beta-blocker treatment did not lead to a lower risk of the composite primary end point of death from any cause or new myocardial infarction than no beta-blocker use. 3. Silvain J, Cayla G, Ferrari E, et al. Betablocker interruption or continuation after myocardial infarction. N Engl J Med2024; 391:1277–86. IIn patients with a history of myocardial infarction, interruption of long-term beta-blocker treatment was not found to be noninferior to a strategy of beta-blocker continuation. 4. Butler J, Jones WS, Udell JA, et al. Empagliflozin after acute myocardial infarction. N Engl J Med 2024;390: 1455–66. https://doi.org/10.1056/NEJMoa2314051. https://www.nejm.org/doi/10.1056/NEJMoa2314051?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed . Among patients at increased risk for heart failure after acute myocardial infarction, treatment with empagliflozin did not lead to a significantly lower risk of a first hospitalization for heart failure or death from any cause than placebo. 5. Park S-J, Ahn J-M, Kang D-Y, et al. Preventive percutaneous coronary intervention versus optimal medical therapy alone for the treatment of vulnerable atherosclerotic coronary plaques (PREVENT): a multicentre, open-label, randomised controlled trial.  Lancet 2024;403:1753–65. https://doi.org/ 10.1016/S0140-6736(24)00413-6. In patients with non-flow-limiting vulnerable coronary plaques, preventive percutaneous coronary intervention reduced major adverse cardiac events arising from high-risk vulnerable plaques, compared with optimal medical therapy alone. Given that PREVENT is the first large trial to show the potential effect of the focal treatment for vulnerable plaques, these findings support consideration to expand indications for percutaneous coronary intervention to include non-flowlimiting, high-risk vulnerable plaques. 6. Foley MJ, Rajkumar CA, Ahmed-Jushuf F, et al. Coronary sinus reducer for the treatment of refractory angina (ORBITA-COSMIC): a randomised, placebo-controlled trial. Lancet 2024;403:1543–53. https://doi. org/10. 1016/S0140-6736(24)00256-3. ORBITA-COSMIC found no evidence that the CSR improved transmural myocardial perfusion, but the CSR did improve angina compared with placebo. These findings provide evidence for the use of CSR as a further antianginal option for patients with stable coronary artery disease.   7. Chan K, Wahome E, Tsiachristas A, et al. Inflammatory risk and cardiovascular events in patients without obstructive coronary artery disease: the ORFAN multicentre, longitudinal cohort study. Lancet 2024;403: 2606–18. The perivascular fat attenuation index (FAI) score captures inflammatory risk beyond the current clinical risk stratification and coronary CT angiography interpretation, particularly among patients without obstructive coronary artery disease (CAD). The previously trained artificial intelligence -Risk prognostic algorithm, which integrates FAI Score with traditional cardiovascular risk factors and coronary atherosclerotic plaque burden classified individuals into risk categories, with good alignment between predicted and observed events, leading to significant reclassification of risk, particularly among those without obstructive CAD on coronary CT angiography. 8. Nurmohamed NS, Min JK, Anthopolos R, et al. Atherosclerosis quantification and cardiovascular risk: the ISCHEMIA trial. Eur Hear J 2024;45:3735–47. Quantitative coronary CT angiography parameters of stenosis severity and atherosclerotic burden were independently associated with cardiovascular death and MI in a patient population with advanced coronary artery disease and moderate or severe myocardial ischaemia. However, these parameters offered only modest improvement in prognostic value beyond clinical risk characteristics. 9. Serruys PW, Kageyama S, Pompilio G, et al. Coronary bypass surgery guided by computed tomography in a low-risk population. Eur Hear J 2024;45:1804–15. The planning and execution of CABG with the sole knowledge of anatomy from coronary CT angiography and without any visual information from conventional coronary angiography, in patients referred for coronary artery bypass graft is feasible and deemed safe in a select population with chronic coronary syndrome and low surgical risk. Efficacy and confirmed safety will have to be demonstrated in randomized controlled studies. 10. Sinha A, Dutta U, Demir OM, et al. Rethinking false positive exercise electrocardiographic stress tests by assessing coronary microvascular function. J Am Coll Cardiol 2024;83:291–9. Using comprehensive coronary physiology as the reference standard, ischemic ECG changes during exercise were highly specific for coronary microvascular dysfunction in our patient cohort. This is an important finding that highlights the limitations of using obstructive coronary artery disease as a reference standard to assess the accuracy of noninvasive imaging modalities.

The year in cardiovascular medicine 2024: the top 10 papers in heart failure. Solomon SD, McMurray JJV, Vaduga,et al.Finerenone in heart failure with mildly reduced or preserved ejection fraction.
N Engl J Med 2024;391:1475–85.
Nei pazienti con scompenso cardiaco a FE moderatamente depressa o conservata, finerenone ha ridotto rispetto al placebo un endpoint composito di morte per causa cardiovascolare ed eventi correlati a peggioramento dello scompenso.

Kosiborod MN, Petrie MC, Borlaug BA, et al. Semaglutide in patients with obesity-related heart failure and type 2 diabetes. N Engl J Med 2024;390:1394–407.
Nei pazienti obesi con diabete di tipo 2 e con scompenso a FE conservata, la semaglutide ha ridotto significativamente, rispetto al placebo a 1 anno di follow-up, il peso, i sintomi e le limitazioni fisiche correlate allo scompenso.

Packer M, Zile MR, Kramer CM, et al. Tirzepatide for heart failure with preserved ejection fraction and obesity. N Engl J Med 2024. Online ahead of print.
Nei pazienti obesi con scompenso a FE conservata, tirzepatide ha ridotto rispetto al placebo un endpoint composito di morte cardiovascolare e peggioramento dello scompenso, migliorando lo stato di salute.

1.Segan L, Canovas R, Nanayakkara S, Chieng D, Prabhu S, Voskoboinik A, et al. New-onset atrial fibrillation prediction: the HARMS2-AF risk score. Eur Heart J 2023; 44:3443–52.  The HARMS2-AF score ( Hypertension= 4 points- ; Age – 60–64 years = 1 point and age ≥65 years = 2 points; Raised BMI (BMI ≥30 kg/m 2 = 1 point ; Male sex = 2 points ; Sleep apnea =2 points ; Smoking = 1 point ; Alcohol 7–14 standard drinks/week = 1 point and ≥15 standard drinks/week= 2 points) maintained predictive performance  with an AUC 0.782 (0.775–0.789) in the derivation cohort and AUC 0.775 (0.769–0.781) in the  validation cohort at 5 years. This novel lifestyle risk score  may help identify individuals at risk of AF in the general community and assist population screening. 2.Lyth J, Svennberg E, Bernfort L, Aronsson M, Frykman V, Al-Khalili F, et al. Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study. Eur Heart J 2023;44:196–204. Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation 3.Xing LY, Diederichsen SZ, Hojberg S, Krieger DW, Graff C, Frikke-Schmidt R, et al. Effects of atrial fibrillation screening according to N-terminal pro-B-type natriuretic peptide: a secondary analysis of the randomized LOOP study. Circulation 2023;147: 1788–97. In an older population with additional stroke risk factors, ILR screening for AF was associated with a significant reduction in stroke risk among individuals with higher         NT-proBNP levels but not among those with lower levels. These findings should be considered hypothesis generating and warrant further study before clinical implementation. 4.Kirchhof P, Toennis T, Goette A, Camm AJ, Diener HC, Becher N, et al. Anticoagulation with edoxaban in patients with atrial high-rate episodes. N Engl J Med 2023;389: 1167–79. Among patients with device-detected atrial high-rate episodes (AHREs) , anticoagulation with edoxaban did not significantly reduce the incidence of a composite of cardiovascular death, stroke, or systemic embolism as compared with placebo, but it led to a higher incidence of a composite of death or major bleeding. The incidence of stroke was low in both groups. 5.Healey JS, Lopes RD, Granger CB, Alings M, Rivard L, McIntyre WF, et al. Apixaban for stroke prevention in subclinical atrial fibrillation. N Engl J Med 2024;390:107–17. Among patients with subclinical atrial fibrillation ( asymptomatic episodes lasting 6 minutes to 24 hours) apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. 6.Kalman JM, Al-Kaisey AM, Parameswaran R, Hawson J, Anderson RD, Lim M, et al. Impact of early vs. delayed atrial fibrillation catheter ablation on atrial arrhythmia recurrences. Eur Heart J 2023;44:2447–54.  Compared with an early ablation strategy, delaying AF ablation by 12 months for antiarrhythmic drug  management did not result in reduced ablation efficacy. 7.Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, et al. Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med 2023;389: 1660–71. Among patients with paroxysmal atrial fibrillation receiving a catheter-based therapy, pulsed field ablation was noninferior to conventional thermal ablation with respect to freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation and with respect to device- and procedure-related serious adverse events at 1 year. 8.Sohns C, Fox H, Marrouche NF, Crijns HJGM, Costard-Jaeckle A, Bergau L, et al. Catheter ablation in end-stage heart failure with atrial fibrillation. N Engl J Med 2023; 389:1380–9. Among patients with atrial fibrillation and end-stage heart failure, the combination of catheter ablation and guideline-directed medical therapy was associated with a lower likelihood of a composite of death from any cause, implantation of a left ventricular assist device, or urgent heart transplantation than medical therapy alone 9.Andrade JG, Deyell MW, Macle L, Steinberg JS, Glotzer TV, Hawkins NM, et al. Healthcare utilization and quality of life for atrial fibrillation burden: the CIRCA-DOSE study. Eur Heart J 2023;44:765–76.   AF recurrence, as defined by 30 s of arrhythmia, lacks clinical relevance. AF episode durations >1 h or burdens >0.1% were associated with increased rates of healthcare utilization. 10.Pappone C, Ciconte G, Anastasia L, Gaita F, Grant E, Micaglio E, et al. Right ventricular epicardial arrhythmogenic substrate in long-QT syndrome patients at risk of sudden death. Europace 2023;25:948–55.  This study reveals that, among high-risk LQTS patients, regions localized in the epicardium of the right ventricle harbour structural electrophysiological abnormalities. Elimination of these abnormal electrical activities successfully prevented malignant ventricular arrhythmia recurrences.