Heart failure (HF) has a global prevalence of 1–2%, and the incidence around the world is growing. The prevalence increases with age, from around 1% for those aged 10% for those aged 70 years or over. Based on studies in hospitalized patients, about 50% of patients have heart failure with reduced ejection fraction (HFrEF), and 50% have heart failure with preserved ejection fraction (HFpEF). HF is associated with high morbidity and mortality, and HF-related hospitalizations are common, costly, and impact both quality of life and prognosis. More than 5–10% of patients deteriorate into advanced HF (AdHF) with worse outcomes, up to cardiogenic shock (CS) condition. Right heart catheterization (RHC) is essential to assess hemodynamics in the diagnosis and care of patients with HF. The aim of this article is to review the evidence on RHC in various clinical scenarios of patients with HF.

Acute heart failure (AHF) is a complex clinical syndrome characterized by the rapid or gradual onset of symptoms and/or signs of heart failure (HF), leading to an unplanned hospital admission or an emergency department visit. AHF is the leading cause of hospitalization in patients over 65 years, thus significantly impacting public health care. However, its prognosis remains poor with high rates of mortality and rehospitalization. Many pre-existing cardiac conditions can lead to AHF, but it can also arise de novo due to acute events. Therefore, understanding AHF etiology could improve patient management and outcomes. Cardiomyopathies (CMPs) are a heterogeneous group of heart muscle diseases, including dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy (RCM), non-dilated cardiomyopathy (NDLVC), and arrhythmogenic right ventricular cardiomyopathy (ARVC), that frequently present with HF. Patients with CMPs are under-represented in AHF studies compared to other etiologies, and therefore therapeutic responses and prognoses remain unknown. In DCM, AHF represents the most frequent cause of death despite treatment improvements. Additionally, DCM is the first indication for heart transplant (HT) among young and middle-aged adults. In HCM, the progression to AHF is rare and more frequent in patients with concomitant severe left ventricle (LV) obstruction and hypertrophy or severe LV systolic dysfunction. HF is the natural evolution of patients with RCM and HF is associated with poor outcomes irrespective of RCM etiology. Furthermore, while the occurrence of AHF is rare among patients with ARVC, this condition in NDLVC patients is currently unknown. In this manuscript, we assessed the available evidence on AHF in patients with CMPs. Data on clinical presentation, therapeutic management, and clinical outcomes according to specific CMPs are limited. Future HF studies assessing the clinical presentation, treatment, and prognosis of specific CMPs are warranted.

In the past decades, percutaneous coronary intervention (PCI) has become the most common modality for myocardial revascularization in patients with coronary artery disease (CAD). Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is essential in all patients undergoing PCI to prevent thrombotic complications. A large proportion of patients undergoing PCI also have concomitant atrial fibrillation (AF), thus requiring an oral anticoagulant (OAC) to prevent ischemic stroke or systemic embolism. However, the association between OAC and DAPT further increases the risk of bleeding. Compared with a triple antithrombotic therapy (TAT), dual antithrombotic therapy (DAT) has shown to reduce bleeding events, but at the cost of higher risk of stent thrombosis. In this field, patients with AF undergoing PCI represent a special population with significant challenges, and several strategies are needed to reduce the risk for bleeding complications. In this review, we will discuss both the procedural and antithrombotic strategies to optimize ischemic and bleeding outcomes in patients with AF undergoing PCI.

Cardiovascular diseases (CVDs), including coronary artery disease (CAD), are the main causes of mortality and morbidity worldwide. The pathophysiology of CAD includes atherosclerosis, a chronic process leading to atherosclerotic plaque development. Clinical manifestations could be chronic, such as in the chronic coronary syndrome (CCS) scenario, or acute, such as acute coronary syndrome (ACS). The risk of subsequent cardiovascular (CV) events depends on the risk category defined by international guidelines. In particular, patients who have experienced a CV event requiring percutaneous coronary intervention (PCI) remain at heightened residual risk for subsequent events, despite advancements in standard-of-care strategies. Therefore, comprehensive residual risk management is essential in this population to mitigate ischemic risk. Secondary prevention includes different targets of treatments—hypertension, dyslipidemia, diabetes mellitus, body weight control, smoking habit reduction, and healthy lifestyle promotion. Nevertheless, there is a critical, unmet need for therapeutic strategies for this high-risk population. Growing evidence shows that atherogenic lipids and vascular inflammation drive residual risk after PCI, despite guideline-directed therapy. This review summarizes more recent evidence about secondary prevention focusing on optimal medical therapy (OMT), targeting lipids and inflammation for patients undergoing PCI.

Despite important advances in diagnosis and treatment, heart failure (HF) remains a syndrome with substantial morbidity and dismal prognosis. Although implementation and optimization of existing technologies and drugs may lead to better management of HF, new or alternative strategies are desirable. In this regard, basic science is expected to give fundamental inputs, by expanding the knowledge of the pathways underlying HF development and progression, identifying approaches that may improve HF detection and prognostic stratification, and finding novel treatments. Here, we discuss recent basic science insights that encompass major areas of translational research in HF and have high potential clinical impact.

Although dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y₁₂ receptor inhibitor is currently recommended in patients with acute coronary syndrome (ACS), its use in elderly patients remain challenging. The aim of this trial is to evaluate the pharmacodynamic and pharmacokinetic profile of ticagrelor 60 vs. 90 mg twice daily among elderly patients (≥75 years) with ACS undergoing percutaneous coronary intervention (PCI). PLINY The ELDER (NCT04739384) was a randomized, crossover trial testing the non-inferiority of a lower vs. standard dose of ticagrelor with respect to the primary endpoint of P2Y₁₂ inhibition as determined by pre-dose P2Y₁₂ reaction units (PRU) using the VerifyNow-P2Y₁₂ (Accumetrics, San Diego, CA). Other pharmacodynamic tests included light transmittance aggregometry, multiple electrode aggregometry, and response to aspirin. Plasma levels of ticagrelor and its active metabolite AR-C124910XX were also evaluated. A total of 50 patients (mean age 79.6±4.0 years, females 44%) was included in the trial. Ticagrelor 60 mg was non-inferior to ticagrelor 90 mg according to VerifyNow-P2Y₁₂ results (PRU 26.4±32.1 vs. 30.4±39.0; least squares mean difference: -4; 95% confidence interval: -16.27 to 8.06; p for non-inferiority=0.002). Other pharmacodynamic parameters were similar between the two ticagrelor doses and there were no differences in response to aspirin. Plasma levels of ticagrelor (398.29±312.36 ng/mL vs. 579.57±351.73 ng/mL, p=0.006) and its active metabolite were significantly lower during treatment with ticagrelor 60 mg. Although plasma concentrations were lower, ticagrelor 60 mg twice daily provided a similar magnitude of platelet inhibition compared with ticagrelor 90 mg twice daily among elderly patients undergoing PCI. Clinical Trial registration: EudraCT 2019-002391-13. Clinicaltrials.gov NCT04739384.