Vascular access for coronary, peripheral, and structural interventions has changed significantly over the past two decades. The evolving demand for both large-bore access for valvular interventions and mechanical support devices, and for safer access for coronary interventions, in patients with comorbidities have driven progress in these areas. This review will provide an overview of the techniques of arterial access in the femoral, forearm (radial and ulnar), and alternative (transcarotid, transaxillary, and transcaval) locations based on the latest evidence and experience.

Coronary artery disease (CAD) is the leading cause of mortality among patients with chronic kidney disease (CKD), presenting unique challenges in diagnosis and management. Advanced CKD patients often present with atypical symptoms, and conventional diagnostic and interventional approaches carry risks, including contrast-induced nephropathy and the potential need for renal replacement therapy. These risks have led to the phenomenon of "renalism," where necessary procedures may be deferred due to concerns over renal injury. Emerging techniques, such as ultra-low contrast angiography (ULCA) and zero-contrast percutaneous coronary intervention (PCI), offer promising solutions by minimizing or eliminating contrast exposure. This review discusses the clinical presentation of CAD in CKD patients, limitations of traditional diagnostic approaches, and the challenges in managing these high-risk patients. It also provides an overview of ULCA and zero-contrast PCI techniques, which have shown both safety and feasibility even in complex cases. As these techniques continue to evolve, zero-contrast PCI holds the potential to become an essential component of revascularization strategies for high-risk CKD patients, enhancing procedural safety while maintaining therapeutic efficacy.

Complications of percutaneous coronary intervention (PCI) can lead to significant morbidity and mortality. In-depth understanding of the mechanisms and management options of these complications as well as timely recognition and action can sometimes be lifesaving. In this review we discuss the mechanisms, prevention methods, diagnosis, and management of three major PCI complications: a) perforation b) acute vessel closure, and c) equipment loss.

Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms of MI, such as spontaneous coronary artery dissection, vasospasm, microvascular dysfunction, embolization, inflammation, coronary anomalies, infectious and infiltrative causes are increasingly being recognized. Emerging data suggest that women are two to five times more likely to have an MI in the absence of coronary atherosclerosis compared to men, but they continue to remain underdiagnosed and undertreated, partly due to underdiagnosis and limited understanding of these mechanisms. Recent advancements in invasive and noninvasive imaging techniques and physiological testing allow for distinguishing these mechanisms from each other, providing a definitive diagnosis and tailored treatment. This review summarizes the existing literature on the non-atherosclerotic coronary causes of MI with a focus on evidence pertaining to women, offering a basis for future studies.

Ejection fraction (EF) is the principal parameter used clinically to assess cardiac function and provides prognostic information. However, significant myocardial damage can be present despite preserved EF. Recently, the measurement of left ventricle (LV) deformation by global longitudinal strain (GLS) has been introduced as a novel early marker of cardiac dysfunction. Cardiotoxicity is a frequent side effect of several drugs most notably those used in the treatment of cancer. Although oncology drugs remain the best known cardiotoxic medications, many other drugs can potentially affect LV function. The early recognition of LV dysfunction due to cardiotoxicity is important and of increasing clinical relevance particularly with the rapid pace of development of new drugs. The aim of our review is to provide an overview of the current literature regarding utility of GLS to assess drug-induced myocardial damage. We propose that GLS is a sensitive early marker of myocardial dysfunction associated with the use of certain medications with high risk of cardiotoxicity. Thus, the use of this technique can potentially alert the clinician to myocardial toxicity before reductions in EF are seen.

Raynaud's phenomenon (RP) is a vascular disease characterized by exaggerated vasoconstriction in response to stressors, mainly cold and emotional stress. This vasoconstriction is mediated solely by alpha 2C-adrenoceptors (α-AR) expressed in vascular smooth muscle cells of dermal arterioles. Several factors, among which is cigarette smoking, are associated with aggravated symptoms of and increased risk for RP. Evidence shows that cigarette smoking induces the production of reactive oxygen species (ROS), which is a major driver of RP pathogenesis. However, the exact mechanism by which smoking contributes to RP or α-AR remains unclear. Here, we show that cigarette smoke extract (CSE) upregulates the expression of α-AR in a concentration- and time-dependent manner in VSMCs extracted from human dermal arterioles. This increase is associated with the activation of p38 MAPK, as pretreatment with SB-202190, a p38 specific inhibitor, attenuated CSE-induced α-AR expression. Furthermore, our results show that CSE induces ROS production followed by increased RhoA activation. We also show that CSE induces translocation of vascular α-AR to the plasma membrane, and that this mobilization is attenuated by inhibiting ROS via N-acetylcysteine or apocynin. Similarly, inhibition of Rho kinase via H- 11522 abolished CSE-induced α-AR translocation. Collectively, these results indicate that CSE activates two different signaling pathways to induce the expression and the translocation of α-AR. While CSE activates a p38-dependent mechanism to increase α-AR expression, it initiates the receptor's spatial and functional rescue via a ROS/RhoA signaling pathway. These results provide mechanistic insight into the effect of cigarette smoking on RP, and further reinforce that smoking avoidance/cessation is critical to manage this disease, especially in the absence of a definitive drug for RP.

The Roundtable on Obesity Solutions (ROOS), established in 2014, is a unique organization of multisectoral voices addressing the public health challenge of obesity. The ROOS brings together practitioners, researchers, funders, companies, health systems, government agencies, and the lived experience to dialogue and guide the national conversation about the multilevel challenges and opportunities related to obesity. This paper presents insights and key learnings from a symposium developed to celebrating the 10th Anniversary of the ROOS. The first six years (2014-2019) of the ROOS marked a period in which dialogue was initiated, multi-sectoral perspectives were captured, and important viewpoints were deliberated and published. In 2020, the ROOS engaged in a strategic planning process enabled by systems science that ultimately resulted in the creation of a roadmap focused on drivers and solutions of obesity. This roadmap generated an agenda focused on upstream social and structural drivers of obesity with an emphasis on the integration of equity, gaps, strategies, and the lived experience. Three main priorities identified in this roadmap included structural racism, social norms, and health communications. Based on this work, the ROOS has had significant impact in the areas of equity, weight stigma, and the lived experience. Much work remains. To date, obesity solutions available for prevention and treatment have been vastly underutilized. Future directions should: 1) include increasing access to effective prevention and treatment options; 2) a focus on how best to implement new technologies in obesity prevention and care; 3) addressing issues of equity, literacy, and stigma that remain unresolved; and 4) leveraging the influence of regional cultures, policies, and social norms. We hope that insights gained over the previous 10 years will inspire another decade of impact for the ROOS.

Regular physical activity (PA) is important for reducing the risk of chronic diseases and improving overall health. Activity Quotient (AQ) is a novel metric that translates heart rate during PA into a weekly score, providing an objective measure of an individual's PA. We prospectively examined the association of AQ with cancer and cardiovascular (CVD) mortality outcomes, the two major causes of death, in a Taiwanese population.

Despite widespread attempts from governments and leading health organisations worldwide to promote equity in healthy living medicine, the evidence suggests that attempts to curb worsening public health have been almost entirely ineffective. Despite significant advancements in knowledge, medicine, and technology, as well as the promotion of guidelines and the implementation of numerous global initiatives aimed at addressing health disparities and mitigating the progression of non-communicable diseases (NCDs) worldwide, substantial work remains to be undertaken particularly in addressing inequalities in physical activity. Achieving equitable access to health resources and parity in health outcomes remains a critical and unresolved challenge. Whilst it is recognized that the public health paradigm is broad and complex, with many intersecting and interacting parts, the actions and considerations required to address the urgent and escalating scale of the problem appear at a crossroads of now or never. Throughout this narrative review, we describe the effectiveness of landmark physical activity-related guidelines, policies and national interventions that have been implemented since the turn of the century to address physical activity behaviour in the context of health inequalities.

Coronary artery in-stent restenosis (ISR) is driven by neointimal hyperplasia and neo-atherosclerosis in previously placed stents. Drug eluting stents (DES) have been adopted as first line therapy for the initial episode of ISR. However, recurrent ISR has limited durable salvage options. In this article we review the pathophysiology, incidence, and management options of recurrent DES- ISR.

Myocardial viability assessment is used to determine if chronically dysfunctional myocardium may benefit from coronary revascularization. Cardiac magnetic resonance with late gadolinium enhancement is the current gold standard for visualizing myocardial scar and provides valuable insight into myocardial viability. Viability assessments can also be made with Cardiac Positron Emission Tomography, Echocardiography, Single Photon Emission Tomography, and Cardiac Computed Tomography with each having advantages and disadvantages. Despite the classical interpretation that viability predicts segmental functional improvement, more recent studies have found that revascularization of viable myocardium has conflicting roles in predicting benefits for patients, especially as it relates to major adverse cardiovascular events, development of heart failure symptoms, and all-cause mortality. This review covers these conflicts along with an in-depth review of the pathophysiologic processes that are fundamental to myocardial viability and the various methods used for determining viability.

The six-minute walk test (6MWT) is a prognostic sub-maximal exercise test used clinically as a measure of functional capacity. With the emergence of advanced sensors, 6MWTs are being performed remotely via smartphones and other devices. The My Heart Counts Cardiovascular Health Study is a smartphone application that serves as a digital platform for studies of human cardiovascular health, and has been used to perform 30,475 6MWTs on 8922 unique participants.

To determine the cardiorespiratory fitness (CRF) levels needed to avoid the Grim Reaper (Death) among older adults. We hypothesized that an above average peak oxygen uptake (VO) is needed for 70-77-year-old men and women to delay the encounter with Death.

The presence and severity of calcified coronary plaque negatively impacts angiographic and clinical outcomes following percutaneous coronary intervention (PCI). Severe coronary calcification is associated with suboptimal stent delivery, deployment, apposition and expansion which can lead to in-stent restenosis and/or thrombosis. Severe coronary calcification is associated with incremental hazard for adverse clinical events, including death, during 5-10 years following PCI despite the use of new generation drug- eluting stents. Multiple technologies including high-pressure noncompliant and modified (cutting/scoring) balloons, atheroablative technologies (laser, rotational or orbital atherectomy), and more recently, intravascular lithotripsy have been used to modify calcified plaque and facilitate optimal coronary stent implantation. Intravascular imaging is critically important to determine the extent and distribution (superficial or deep) of coronary calcification and to aid selection and sequence for use of calcium modifying technologies. Unfortunately, large scale randomized comparative trials of calcium modifying technologies are limited and the relative safety and effectiveness of these modalities is poorly defined. Recent mechanistic and clinical data supporting the use of plaque modifying technologies are reviewed to provide insights into their optimal use.

The retrograde approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly contributed to the success rates of CTO PCI. It is usually performed in complex CTO lesions, in which the antegrade approach is not feasible or fails. In this article we discuss the steps to perform retrograde CTO PCI and its complications and success rates. Considering the moderate to high success rates of the retrograde approach in the hands of experienced operators and higher complication rates than antegrade only procedures, optimizing the safety of retrograde CTO PCI is of paramount importance.

Ischemic cardiomyopathy (ICM) is characterized by myocardial dysfunction due to myocardial ischemia, associated with the presence of significant coronary artery disease (CAD). We provide a comprehensive review of the current evidence for coronary revascularization in ICM, including consideration of the different modalities of coronary artery bypass grafting and percutaneous coronary intervention. In addition to a contemporary assessment of the literature, we aim to provide real-world insights and perspectives to guide clinical decision-making in this heterogeneous and complex patient population.

American culture encourages overconsumption, fueled by ubiquitous availability and pervasive marketing of ultra-processed foods and other addictive substances. This chronic overindulgence has contributed to rising rates of obesity, type 2 diabetes (T2D), substance abuse, mental health disorders and premature mortality. Glucose-like peptide-1 agonists (GLP-1RAs) affect the brain's reward pathway that mediates addiction to foods and various other substances. Evolving data suggest that tirzepatide and semaglutide may be the first effective "anti-consumption" agents with potential applications in reducing food cravings, obesity, alcohol consumption, nicotine addiction, recreational drug use, and even uncontrollable shopping behaviors. Tirzepatide and semaglutide, unlike prior weight-loss drugs, are effective and relatively safe/well-tolerated medications that are associated with reduced risks for myocardial infarction, stroke, cardiovascular death, heart failure, progressive kidney and liver disease, obstructive sleep apnea, debilitating osteoarthritis, polycystic ovarian syndrome, neurodegenerative disease and premature mortality. Observational studies show that GLP-1RAs are associated with spontaneous nonvolitional reductions in use of alcohol, nicotine, and recreational drugs. Because obesity and substance abuse are so prevalent in the United States, GLP-1RA drugs may be uniquely helpful in addressing overconsumption and addiction issues thereby improving overall health and life expectancy.

Revascularization has been demonstrated to be clearly superior to medical therapy for significant unprotected left main coronary artery (LMCA) disease. Coronary artery bypass graft surgery (CABG) has a class 1 indication in both the American and European society guidelines for the treatment of LMCA disease. However, for the population of patients who are declined CABG after a heart team evaluation, percutaneous coronary interventional (PCI) may be an efficacious alternative. This review summarizes the data on percutaneous coronary intervention of distal left main coronary artery disease including the various contemporary techniques and associated challenges.

Studies regarding effects of omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), on risk of atrial fibrillation (AF) have reported discordant results. The aim of this review is to clarify effects of marine omega-3 intake on risk of AF.