Optimal Medical Therapy Research Articles

Coronary Sinus Reducer in Refractory Angina: A Targeted Approach to Microvascular Ischemia and Symptom Relief.

Refractory angina remains a therapeutic challenge in patients with advanced coronary artery disease who are not amenable to further revascularization and remain symptomatic despite optimal medical therapy. The coronary sinus reducer (CSR) is a novel, device-based therapy that aims to alleviate angina by increasing coronary sinus pressure and redistributing blood flow toward ischemic myocardial territories, particularly in the subendocardial region. This article reviews current evidence on the comparative effectiveness of CSR relative to established pharmacologic and interventional therapies, with a focus on its potential role in patients with microvascular versus macrovascular ischemia. Data from randomized trials and real-world registries demonstrate significant symptomatic improvement and favorable safety outcomes in the majority of CSR-treated patients, though nonresponder rates remain between 15% and 30%. Emerging evidence suggests CSR may be particularly effective in patients with microvascular dysfunction, such as those with angina and no obstructive coronary artery disease. However, long-term efficacy, ideal patient selection criteria, and mechanistic underpinnings remain areas of ongoing investigation. Current and upcoming trials such as COSIRA-II (CSR for Treatment of RA) and REMEDY-PILOT (Reducing microvascular dysfunction in patients with angina, ischaemia, and unobstructed coronary arteries- a pilot study) aim to address these uncertainties. CSR represents a promising addition to the therapeutic landscape for refractory angina, particularly in complex or no-option cases, pending further clinical validation.

Association of Diuretic Dosage With Outcomes in Patients With Hemodynamically Significant Isolated Tricuspid Valve Regurgitation

Background Tricuspid valve surgery is recommended for severe isolated tricuspid regurgitation (TR) if symptoms persist despite optimal medical therapy. The definition of optimal therapy for TR is unclear beyond managing underlying conditions. Diuretics are the primary treatment for volume retention in TR, but it is unknown whether a “safe diuretic dose” exists for conservative management. We sought to evaluate the association between diuretic dose and outcomes. Methods Adult patients with ≥moderate–severe isolated TR were retrospectively identified from echocardiographic reports. Clinical and echocardiographic data were extracted from electronic medical records and manually reviewed. The primary end point was all‐cause mortality. Loop diuretic doses were converted to furosemide equivalent and categorized into 4 groups: <40 mg, 40 to 79 mg, 80 to 159 mg, and ≥160 mg daily. Results Of 1302 patients (age 72±13 years, 60% female), 565 (43%) had moderate–severe TR and 737 (57%) had severe TR. Median follow‐up was 8.7 (1.4, 14.0) years. Comorbidities increased with higher diuretic doses. A linear relationship between diuretic dose and mortality was observed in spline‐curve analysis. Hazard ratios (and CIs) for mortality adjusted for age, sex, coronary disease, chronic kidney disease, mild pulmonary hypertension, and New York Heart Association III/IV symptoms were 1.21 (0.96–1.53) ( P =0.12) for <40 mg, 1.50 (1.23–1.82) ( P <0.001) for 40 to 79 mg, 1.86 (1.46–2.37) ( P <0.001) for 80 to 159 mg, and 2.90 (2.18–3.88) ( P <0.001) for ≥160 mg furosemide equivalent. Any diuretic dose was associated with significant symptoms (New York Heart Association III–IV), with more patients experiencing symptoms at higher doses. Conclusion A daily loop diuretic dose ≥40 mg furosemide equivalent is associated with increased mortality and greater symptom severity in patients with TR.

Hair Transplant: Patient Candidacy, Medical Optimization, and Surgical Considerations.

Alopecia is a medical condition that impact many people worldwide and has diverse causes, ranging from autoimmune to genetic factors. Hair transplantation represents a key therapeutic option for patients with progressive hair loss who are seeking improvement beyond the capacity of medications or less invasive procedures. While hair transplantation is most commonly utilized for androgenetic alopecia, individuals with other alopecia diagnoses may also benefit. The two main techniques for hair transplantation include follicular unit transplantation and follicular unit excision. Hair transplantation is particularly important given the profound psychosocial implications and cosmetic disfigurement associated with alopecia. Chronic hair loss patients may experience reduced self-esteem, increased depression and anxiety, and poorer quality of life. Despite the significanceof hair transplantation, comprehensive guidelines informing the clinical and surgical management of transplant candidates remain limited. Therefore, this review aims to explore patient candidacy criteria, pretransplant medical therapy optimization, intraoperative considerations, and postoperative complications and medical management.

SEX DIFFERENCES IN PHARMACOLOGIC OPTIMAL MEDICAL THERAPY FOR ISCHEMIC HEART DISEASE, 2010-2020: AN OBSERVATIONAL STUDY.

Despite guideline recommendations for optimal medical therapy (OMT) in the secondary prevention of ischemic heart disease (IHD)-including antiplatelets, statins, renin-angiotensin-aldosterone system inhibitors (RAASi), and β-blockers-substantial sex disparities in OMT utilization persist. The extent to which national efforts have mitigated these disparities in contemporary cohorts remains unclear. We analyzed data from the 2011-2020 National Health and Nutrition Examination Survey (NHANES) cycles, identifying adults with self-reported IHD (defined as a history of myocardial infarction or coronary heart disease). OMT use in the preceding 30 days was assessed based on participant report and verified through medication containers when available. We evaluated trends in individual drug classes and common combinations, stratified by sex. Among 1,905 adults (mean age 65.4 years; 40.6% women), women had significantly lower rates of OMT use compared to men, including antiplatelets (68.0% vs 77.7%), statins (57.2% vs 73.9%), RAASi (45.6% vs 59.0%), and β-blockers (51.2% vs 61.1%). Women were also less likely to use guideline-recommended combinations such as aspirin plus statins (47.4% vs 64.1%) and all four OMT classes (17.5% vs 32.5%). After adjustment for sociodemographic and clinical factors, women remained less likely to use antiplatelets (OR 0.71; 95% CI, 0.52- 0.94), statins (OR 0.62; 95% CI, 0.40-0.96), and RAASi (OR 0.56; 95% CI, 0.38-0.84), while β-blocker use did not differ significantly. These sex-based disparities were consistent across all survey cycles from 2011 to 2020. In this nationally representative study, women with IHD were significantly less likely than men to receive guideline-directed OMT, with persistent disparities over the past decade. These findings underscore the need for targeted strategies to close the sex gap in cardiovascular prevention.

Admission heart rate and in-hospital mortality in acute myocardial infarction: a contemporary analysis of the MIMIC-III cohort

ObjectiveTo quantify the shape and strength of the association between heart rate (HR) recorded during the first 30 min of intensive-care admission and in-hospital death in contemporary acute myocardial infarction (AMI), after adjustment for modern reperfusion, pharmacotherapy, and haemodynamic variables.MethodsWe extracted 1,510 adults with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of AMI (410.xx) from MIMIC-III (2008–2012). HR was defined as the mean of the first three electrocardiographic readings obtained within 30 min of ICU triage, before administration of rate-modifying drugs. We modelled HR both as clinically meaningful categories (< 60, 60–99, ≥ 100 bpm) and as a continuous exposure using restricted cubic splines (RCS). Multivariable logistic regression adjusted for age, sex, Killip class, systolic blood pressure, coronary revascularisation, β-blocker use, atrial fibrillation/flutter, hypertension, diabetes, chronic obstructive pulmonary disease, serum creatinine, haemoglobin, white blood cell count, sodium, potassium, glucose, platelet count and anion gap. Pre-specified subgroup analyses compared ST-elevation MI (STEMI) with non-ST-elevation ACS (NSTE-ACS).ResultsMean age was 66.7 ± 13.9 years; 33.6% were women; STEMI accounted for 42%. Overall in-hospital mortality was 10.9%. HR ≥ 100 bpm (23% of patients) was associated with higher death risk (adjusted OR 2.45, 95% CI 1.56–3.85) versus 60–99 bpm. Bradycardia < 60 bpm (15%) was also associated with excess risk (adjusted OR 1.58, 95% CI 1.02–2.45), yielding a U-shaped RCS curve (non-linearity p = 0.01). The HR–mortality gradient was steeper in STEMI than in NSTE-ACS (interaction p = 0.04). Findings were robust after including the 46 patients who died within 24 h of admission.ConclusionAdmission HR exhibits a U-shaped, independent relation with early mortality in modern AMI care; values outside 60–99 bpm identify high-risk patients despite urgent reperfusion and optimal medical therapy.

Changes in natriuretic peptide levels following patiromer-enabled optimization of medical therapy in heart failure: A post hoc analysis of the DIAMOND study.

Changes in natriuretic peptide levels following patiromer-enabled optimization of medical therapy in heart failure: A post hoc analysis of the DIAMOND study.

Chronic Total Occlusions: Current Approaches, Evidence and Outcomes.

Chronic total occlusions (CTOs), defined as complete coronary artery blockages persisting for over three months, are frequently encountered in up to 25% of coronary angiograms. Although percutaneous coronary intervention (PCI) for CTO remains technically challenging, advancements in guidewires, microcatheters, re-entry devices, and intravascular imaging, along with the expertise of specialized operators, have significantly improved procedural success rates, now exceeding 90% in expert centers. While recent evidence, such as the SYNTAX II study, emphasizes the importance of complete revascularization, over half of CTO cases continue to be managed conservatively with optimal medical therapy (OMT), partly due to the limited high-quality randomized evidence supporting revascularization. Observational studies have demonstrated that successful CTO-PCI is associated with improved angina relief, quality of life, left ventricular function, and possibly long-term survival. Extended observational follow-up, such as the Korean and Canadian registries, suggests long-term reductions in cardiac and all-cause mortality with CTO revascularization. However, randomized controlled trials (RCTs) have primarily shown symptomatic benefit, with no consistent reduction in major adverse cardiac events (MACE) or mortality, likely due to limited sample sizes, short follow-up, and treatment crossovers. Various strategies, including the hybrid algorithm, guide CTO interventions by balancing antegrade and retrograde techniques based on lesion complexity. Imaging modalities such as coronary CT angiography and intravascular ultrasound play a pivotal role in planning and optimizing these procedures. Future innovations, such as real-time fusion imaging of CCTA with coronary angiography, may enhance lesion visualization and guidewire navigation. While current guidelines recommend CTO-PCI in selected symptomatic patients with demonstrable ischemia or viable myocardium, the decision should be individualized, incorporating anatomical feasibility, comorbidities, patient preferences, and input from a multidisciplinary Heart Team. Looking ahead, adequately powered RCTs with extended follow-up are essential to determine the long-term clinical impact of CTO-PCI on hard outcomes such as mortality and myocardial infarction.

Invasive coronary function testing in clinical practice: Implementing the 2024 ESC guidelines on chronic coronary syndromes.

Invasive coronary function testing in clinical practice: Implementing the 2024 ESC guidelines on chronic coronary syndromes.

Impact of Contemporary Optimal Medical Therapy on Patients with Reduced Ejection Fraction Undergoing Surgery for Severe Chronic Aortic Regurgitation

Impact of Contemporary Optimal Medical Therapy on Patients with Reduced Ejection Fraction Undergoing Surgery for Severe Chronic Aortic Regurgitation

Direct-to-Physician Marketing and Uptake of Optimal Medical Therapy for Heart Failure With Reduced Ejection Fraction.

Direct-to-Physician Marketing and Uptake of Optimal Medical Therapy for Heart Failure With Reduced Ejection Fraction.

Tolerability and Adverse Effects in a Specialized Heart Failure Guideline-Directed Medical Therapy Optimization Program.

Utilization of heart failure (HF) guideline-directed medical therapy (GDMT) to target doses is suboptimal, with studies citing adverse effects (AEs), physiological factors, and therapeutic inertia as potential contributing factors. The objective of our study was to explore tolerability and GDMT titration-limiting AEs in a specialized heart failure optimization program implemented at our institution. We studied the baseline characteristics of 254 patients who successfully completed our program and analyzed the frequency and severity of the four most common GDMT-related AEs: hypotension, bradycardia, hyperkalemia, and renal dysfunction. Patients who achieved target doses were younger, more likely to have nonischemic HF, less likely to have a recent HF-related hospitalization, had less coronary artery disease, and were more likely to be obese. Multivariate analyses revealed significant associations between beta blocker suboptimal dosing (< 50% of target dose) and older age (odds ratio [OR]: 1.04; 95% confidence interval [CI]: 1.0-1.07; p = 0.031), presence of atrial fibrillation (OR: 2.57; 95% CI: 1.18-5.58; p = 0.017), and absence of hypertension (OR: 0.39; 95% CI: 0.17-0.89; p = 0.025). For angiotensin converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor neprilysin inhibitors, suboptimal dosing was associated with the presence of atrial fibrillation (OR: 2.08; 95% CI: 1.04-4.17; p = 0.039). Of the patients who completed the program, 59.1% encountered at least one AE that hindered the titration to target GDMT doses. Our findings highlight the complexities of GDMT optimization within a specialized program and the need for standardized definitions of GDMT-related AEs and management strategies.

Revascularization versus optimal medical therapy in chronic coronary syndrome in women: A systematic review.

Revascularization versus optimal medical therapy in chronic coronary syndrome in women: A systematic review.

Impact of optimal medical therapy in heart failure certification for hospitalists on guideline-directed medical therapy utilization

BACKGROUNDSignificant gaps in guideline-directed medical therapy (GDMT) for heart failure (HF) stem from shortages of cardiologists and advanced HF providers, as well as a lack of optimal HF management knowledge among hospitalists. This study compared the impact of optimal medical therapy in HF (OMT-HF) certification on GDMT implementation and patient outcomes between an intervention group (IG) of hospitalists and a standard-of-care comparison group (SOC-CG).AIMTo evaluate if OMT-HF has a difference in GDMT and patients in outcomes between IG and SOC-CG.METHODSThis study was implemented from November 2022 to May 2023. Hospitalized cardiology patients with HF and left ventricular ejection fraction ≤ 40% were randomized to IG or SOC-CG. Exclusion criteria included patients in cardiogenic shock, unable to consent, or at high risk. Follow-up was at 30 days post-discharge. Differences between groups were analyzed using Fisher’s exact test for categorical variables and Wilcoxon rank-sum or unpaired t-test for continuous variables. Changes in Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores were evaluated using a paired t-test.RESULTSIG patients had lower readmission rates [(9 (42.85%) vs 11 (17.46%), P = 0.03] and a decreased trend in mortality 30-day post discharge. IG patients also showed greater mean improvements in total (-27.03 ± 24.59 vs -5.85 ± 23.52, P < 0.001), physical (-13.8 ± 12.3 vs -2.71 ± 11.16, P < 0.001) and emotional (-4.76 ± 8.10 vs -1.42 ± 5.98) dimensions on the MLWHFQ compared to SOC-CG, however, change in emotional dimension did not reach statistical significance.CONCLUSIONHospitalist OMT-HF certification may lead to better 30-day outcomes in hospitalized HF patients including quality of life, mortality and readmission rates. Larger prospective studies are warranted to validate these findings.

Comparing Stenting with Medical Therapy Versus Medical Therapy Alone in Patients with Intracranial Atherosclerotic Stenosis: A Current Systematic Review and Meta-Analysis.

Background: Intracranial atherosclerotic stenosis (ICAS) is a significant cause of ischemic stroke worldwide, with high recurrence rates despite optimal medical therapy. While endovascular stenting has been proposed as an adjunctive treatment, its clinical benefit remains controversial as a first line therapy. Objective: To evaluate the efficacy and safety of stenting plus medical therapy (STN+MT) compared to medical therapy alone (MT) in patients with symptomatic ICAS through a systematic review and meta-analysis of randomized controlled trials (RCTs). Methods: We systematically searched PubMed, Web of Science, the Cochrane Library, Embase, Scopus, and EBSCO for RCTs comparing STN+MT with MT in adult patients with symptomatic ICAS. Primary outcomes included transient ischemic attack (TIA), stroke, intracerebral hemorrhage (ICH), and death at 30 days and 1 year. Pooled risk ratios with 95% confidence intervals were calculated using random-effects or fixed-effects models as appropriate. Meta-regression was conducted to assess effect modification by study-level characteristics. Results: Four trials comprising 990 patients were included. STN+MT was associated with significantly higher 30-day risk of stroke and ICH compared to MT alone. No significant differences in TIA, stroke, ICH, or death were found at 1 year. Meta-regression revealed no significant effect modifiers, suggesting consistent findings across subgroups. Conclusions: Our meta-analysis consolidates the evidence that intracranial stenting as a first line therapy offers no significant advantage over medical therapy in preventing stroke in symptomatic ICAS, while it does pose added early risks. This holds true across different trials, patient demographics, and clinical scenarios examined. The consistency of this message across multiple RCTs provides a high level of evidence to guide practice. At present, aggressive medical therapy alone should be the default management for most patients. Endovascular intervention should be reserved for clinical trial settings or carefully selected salvage cases, until and unless new evidence emerges to change the risk-benefit calculus such as the promising use of balloon angioplasty in the BASIS trial.

An approach to heart failure for the public-sector primary care clinician

Heart failure poses a significant global health challenge, with a considerable burden in Africa, where the annual mortality rate stands at 34%, twice the global average. Patients suffering from acute heart failure occupy numerous beds at the district level, and only a limited number can be referred for further evaluation and imaging at secondary or tertiary care facilities. Patients rely on their primary care physicians for the diagnosis and management of heart failure, as well as for identifying those who would benefit from referral to cardiology and formal echocardiography. This article discusses the significance of the new heart failure guidelines within the South African primary care public setting. It emphasises the importance of identifying risk factors and considers the value of access to family physicians, outreach clinic doctors, training on available adult primary care guidelines and telemedicine-supported cardiac ultrasound. Optimal medical therapy, which includes angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and spironolactone, has been shown to reduce readmissions and mortality rates. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a potent addition to conventional therapy and are currently being considered for inclusion in the National Essential Medicines List. Patients admitted to the hospital should not be discharged while experiencing persistent congestion, as this is associated with an increased risk of rehospitalisation, mortality and higher healthcare costs. Comprehensive patient education regarding medications, thorough follow-up during the six weeks post-discharge and linkage to primary healthcare are associated with decreased hospitalisation rates and improved outcomes.

A shift of treatment approaches in internal carotid artery stenosis

The purpose of this review is to objectively present and discuss the scientific literature that is critical for decision-making on the optimal choice of prevention and treatment method for patients with atherosclerotic stenosis of the internal carotid artery (ICA). The evolution of approaches to the treatment of the disease over the past 3–4 decades is analyzed. A summary of the evidence base regarding the efficacy and safety of surgical and drug methods for the prevention and treatment of stroke in symptomatic and asymptomatic patients with ICA stenosis is provided. Conclusions are made regarding the current priorities in the choice of stroke prevention and treatment in patients with ICA stenosis. The review analyzes current randomized trials and explains why they are unlikely to determine routine indications for carotid artery procedures. Previous randomized trials have shown the effectiveness of carotid endarterectomy in reducing the risk of stroke. However, not all patients benefit from the procedure, especially asymptomatic patients. In any given patient, it is usually impossible to be certain of the cause of stroke or transient ischemic attack. Relevant global recommendations for carotid artery procedures, including ways to improve them, are discussed. Conclusion: The cornerstone of stroke prevention is optimal medical therapy, as this procedure is noninvasive and protects against all complications of atherosclerosis in various vascular beds in all at-risk individuals. The important question remains whether carotid surgery is beneficial to the patient in the modern era, and if so, for whom?

Registro Multicêntrico Brasileiro de Ablação Septal Alcoólica em Pacientes com Miocardiopatia Hipertrófica Obstrutiva Sintomática – Registro BRASA

ResumoFundamento A ablação septal alcoólica (ASA) é uma alternativa à miectomia cirúrgica para pacientes com cardiomiopatia hipertrófica obstrutiva (CMHO) sintomática e obstrução significativa da via de saída do ventrículo esquerdo (VSVE). Embora amplamente estudada em outros países, ainda há poucos dados sobre os resultados da ASA no Brasil.Objetivo Avaliar a segurança e a eficácia da ASA em pacientes sintomáticos com CMHO, tratados com terapia medicamentosa otimizada, utilizando técnicas atuais em diferentes centros brasileiros.Métodos Foram incluídos pacientes com CMHO e angina (classificação da Canadian Cardiovascular Society [CCS]) ou dispneia (classificação da New York Heart Association [NYHA]) em classe funcional acima de II, sem resposta ao tratamento medicamentoso otimizado. O desfecho primário de eficácia foi definido como a redução superior a 50% no gradiente máximo da VSVE em repouso, com valor final <50 mmHg. Os pacientes foram classificados como responsivos ou não responsivos. Um valor de p<0.05 foi considerado estatisticamente significativo.Resultados Um total de 41 pacientes (idade mediana de 66,4 anos; 73% mulheres) foi submetido à ASA. No início, 93,2% estavam em classe funcional III/IV da NYHA ou CCS. A fração de ejeção do ventrículo esquerdo (FEVE) média era de 66,4%, e o gradiente médio da VSVE era de 88,4 mmHg. Após 12 meses, 92,8% apresentaram melhora para classe funcional I/II da NYHA ou CCS (p<0,01). O gradiente médio da VSVE caiu de 88,4 mmHg para 27,0 mmHg (p=0,003), e a espessura do septo interventricular (SIV) diminuiu de 19,3 mm para 14,7 mm (p=0,048). Pacientes responsivos apresentaram gradientes basais menores (73,4 vs 112,6 mmHg, p=0,04) e menos hospitalizações (21,1% vs 82,4%, p=0,04). Bloqueio atrioventricular completo ocorreu em 16,7% dos casos, e 4,8% necessitaram de marcapasso. Não houve óbitos durante o seguimento mediano de 394 dias. Na última avaliação presencial, 78,4% estavam em classe funcional I/II.Conclusões A ASA é uma opção segura e eficaz para alívio dos sintomas em pacientes selecionados com CMHO. O procedimento reduz o gradiente da VSVE e a espessura septal. Pacientes com gradientes basais mais elevados apresentaram menor taxa de resposta.

Incidence, Predictors, and Outcomes of Complete Angina Relief in Symptomatic Patients in the ISCHEMIA Trial.

Patients with chronic coronary disease experience less angina with revascularization plus optimal medical therapy compared with optimal medical therapy alone. However, patients may prefer to better understand their individual likelihood of complete angina relief associated with each treatment approach before selecting a strategy. We therefore sought to determine the incidence, predictors, and outcomes of complete angina relief in symptomatic patients treated with invasive management using revascularization plus optimal medical therapy or conservative therapy with optimal medical therapy alone in the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial. Angina was assessed using the Seattle Angina Questionnaire Angina Frequency (AF) score. We analyzed patients in the invasive management treatment arm with angina at baseline (Seattle Angina Questionnaire Angina Frequency <100) who underwent revascularization and all patients in the conservative therapy arm with angina at baseline. The primary outcome was angina status at 12 months defined as a Seattle Angina Questionnaire Angina Frequency=100 (complete angina relief) or Seattle Angina Questionnaire Angina Frequency <100 (persistent angina). The association of angina status with the composite of cardiovascular death/myocardial infarction was assessed at 5 years. Among 1376 patients in the conservative therapy arm with angina at baseline, 50% experienced complete angina relief at 12 months. Independent predictors included older age, male sex, recent angina onset, and less baseline angina. Among 1158 patients who underwent revascularization, 70% achieved complete angina relief. Predictors included younger age, nonsmoking, coronary artery bypass graft, and less baseline angina. Cardiovascular death/myocardial infarction rates at 5 years did not differ between patients with or without complete angina relief. Complete angina relief at 12 months in symptomatic patients with chronic coronary disease was achieved in 70% of patients undergoing revascularization and 50% of patients treated ith conservative therapy and did not influence cardiovascular death/myocardial infarction outcomes. https://ischemiatrial.org/; ISCHEMIA Trial. Accession Number HLB02742323a.

Telemonitored standardized titration for heart failure with reduced ejection fraction, an open clinical cohort study

Abstract Objectives To evaluate feasibility, efficacy, and safety of standardized medical titration at home using telemonitoring Background Treatment for heart failure with reduced ejection fraction (HFrEF) has advanced rapidly, emphasizing swift initiation and titration of guideline-directed medical therapy (GDMT) to improve outcomes. Implementing this in practice remains a significant challenge for healthcare. This study proposes a standardized home-based titration process incorporating home-based monitoring (HBM) to enhance GDMT titration, reduce delays, and limit the need for in-clinic assessment visits. Methods 60 patients were enrolled in this open cohort study. Standardized pre-specified titration schedules in combination with HBM were evaluated. Outcome measures included the time to optimal medical therapy (OMT), doses of GDMT at eight weeks and six months, and safety evaluation through adverse events. Results The median time to OMT was 48 days (IQR 42-60). All participants achieved OMT within six months. At eight weeks, 73%, 85%, and 88% had reached target doses for beta-blockers, ACE inhibitors, and mineral receptor antagonists, respectively. All participants reached SGLT2i target dosage. By six months, 62%, 73%, 80%, and 97% were on target doses for these medications, and 43% had achieved target doses for all four GDMT drugs. No serious adverse events occurred during titration. Conclusion We present a novel and promising approach for achieving OMT and high GDMT doses in patients with HFrEF. The utilization of standardized protocols has the potential to optimize the titration process of GDMT, and with HBM support, it can be accomplished with few in-clinic visits. Trial registration number NCT05637853

Long-term survival after multidisciplinary heart team–guided management of complex coronary artery disease

Objective Guidelines recommend a multidisciplinary heart team approach for managing complex coronary artery disease (CAD), yet its impact on clinical outcomes and adherence to recommendations is rarely reported. Methods Between June 2021 and August 2022, 210 high-risk patients with isolated, complex CAD were evaluated at our institution’s weekly heart team conference for consideration of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), hybrid PCI/CABG, or optimal medical therapy (OMT). Adherence to recommendations and clinical outcomes, including 30-day, 1-year, and 2-year mortality, were assessed. Results Overall adherence to heart team recommendations was 92%, with 96% adherence for CABG, 90% for PCI, 87% for OMT, and 75% for hybrid PCI/CABG. CABG was the most frequently recommended treatment (53%) and demonstrated the lowest mortality at 1 year (4%) and 2 years (6%) compared with PCI (1 year, 28%; 2 year, 40%) and OMT (1 year, 10%; 2 year, 20%). CABG patients had a lower-than-expected mortality (observed-to-expected ratio 0.9), while PCI was associated with significantly higher mortality (observed-to-expected ratio 3.0). Conclusion This single-center multidisciplinary heart team approach for complex CAD offers a collaborative, patient-centered model that facilitates high adherence rates and favorable patient outcomes. These findings highlight the potential benefits of integrating multidisciplinary evaluation and support its implementation into standard practice for high-risk CAD patients.