Dual antiplatelet therapy for primary and secondary prevention.

The concomitant use of aspirin and an ADP receptor (P2Y12) blocker, also known as dual antiplatelet therapy (DAPT), has been extensively investigated as a primary and secondary prevention strategy in an effort to reduce the risk of cardiovascular events. In this manuscript the authors review the current guideline recommendations for DAPT and discuss the scientific data that supports these recommendations. Reported are also the scientific knowledge gaps and how future studies are likely to delineate these issues. Incremental knowledge is not likely to be an alternative to individualized care provided by the astute clinician to his patient. In consideration for prescribing DAPT (drug, dosage and duration) the clinician will have to weigh the potential benefits (reduction in death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke) and risks (severe or life-threatening bleeding) for each and every patient.

Fractional flow reserve (FFR): changing the practice of interventional cardiology.

Fractional flow reserve (FFR) has become an extremely valuable tool for assessing the hemodynamic significance of intermediate coronary lesions. This manuscript delineates the current guidelines regarding the use of FFR and discusses emerging indications for the use of this diagnostic tool and how they compare with and complement non-invasive or other invasive diagnostic modalities. The manuscript addresses some of the key unanswered questions related to FFR, the potential pitfalls of this tool and discusses future directions of use and research.

Emerging oral anticoagulants for stroke prevention in patients with non-valvular atrial fibrillation.

In patients with atrial fibrillation (AF) warfarin has been the mainstay therapy for stroke prevention. In recent randomized clinical trials (RCTs) oral direct thrombin inhibitor (Dabigatran) and factor Xa inhibitors (Rivaroxaban and Apixaban) challenged the efficacy and safety benchmarks set by warfarin. These drugs boast a rapid onset of action, shorter half-life and fewer drug and dietary interactions. Moreover, these new anticoagulants do not require monitoring, titration or dose adjustments. These agents have already been approved for prevention of stroke or systemic embolism in patients with AF. Uncertainty regarding suitability, efficacy and safety in certain patient subsets and issues related to the ability effectively monitor the pharmacodynamic effects and reverse the therapeutic effects of these drugs should be addressed as we engage in a widespread use of these agents in various patient subsets.

Routine stress testing after percutaneous coronary interventions.

Percutaneous coronary intervention (PCI) is the most frequently performed cardiovascular procedure. Many physicians caring for post-PCI patients have routinely subjected patients to periodic stress testing. In the recent years, due to widespread use of drug eluting stents the combined rates of major adverse cardiac events (MACE) and in-stent restenosis (ISR) dropped <10% in the initial 12 months post-PCI, with only half of these patients bearing symptoms. This has translated into reduced pre-test probability of post-PCI ischemia. Consequently, the beneficial effect of this practice came into question. Moreover, in addition to its financial implications, routine post-PCI stress testing may carry potential harm: medication or exercise induced arrhythmia, infarction and/or death, patient irradiation exposure, false-positive tests resulting in excessive invasive testing or interventions, and the illusion of "wellness" in the face of a somewhat unpredictable disease. This review addresses the role stress testing post-PCI: it is concluded that routine stress testing in clinically stable asymptomatic post-PCI patients should be discouraged. Selective utilization of stress testing in patients with exceptionally high risk of ISR or MACE can be utilized to answer important clinical questions or guide and refine clinical care.

Clinical applicability of coronary atherosclerotic lesion characterization.

Native coronary atherosclerosis (CAS) is a diffuse and progressive disease process that is occasionally associated with either clinical atherothrombosis and/or major adverse cardiac events (MACE) including: ST elevation myocardial infarction (STEMI), acute coronary syndromes without ST elevation (ACSWSTE), heart failure, cardiac arrest and sudden cardiac death. Both, the timing and coronary site responsible for the MACE are currently unpredictable. Cardiovascular investigators have engaged in the task of characterizing CAS lesions in order to enhance our knowledge of CAS pathophysiology. It was expected that the knowledge acquired will allow scientists and clinicians to develop effective strategies to detect and treat "vulnerable plaque" (VP) prior to the evolution of MACE. This review discusses the emerging data regarding the pathology and natural history of the VP and vulnerable patient and the progress made in characterizing atherosclerotic plaque instability and vulnerability. Future directions in the field of plaque characterization and their potential clinical and research applications are discussed.