Cardiac PET imaging is an important noninvasive modality for the diagnosis and management of heart failure. Cardiac PET myocardial perfusion imaging can identify coronary artery disease with high accuracy and also detect myocardial viability, offering crucial information for the treatment of ischemic cardiomyopathy. Additionally, cardiac PET can help diagnose nonischemic cardiomyopathies including sarcoidosis, amyloidosis, and myocarditis. Improved PET scanner technology combined with emerging radiotracers will, in the future, offer disease-specific molecular imaging that will further assist in the diagnosis, prognosis, and treatment selection for a variety of cardiovascular pathologies.

The review discusses angiographic and hemodynamic features of invasive and computed tomography coronary angiography, which inform diagnosis, prognosis, and coronary revascularization in patients with systolic heart failure.

Coronary microvascular dysfunction (CMD) is a prevalent and often underdiagnosed condition with significant implications for adverse cardiovascular outcomes. The pathophysiology of CMD includes structural and functional abnormalities in the coronary microvasculature and epicardial atherosclerosis contributes to downstream reduction in myocardial perfusion and symptoms. Diagnosis relies on advanced invasive or noninvasive imaging techniques, such as PET and cardiac magnetic resonance, capable of quantifying myocardial perfusion and myocardial blood flow reserve. Effective management includes optimizing cardiovascular risk factors and symptom control. Novel therapeutic strategies recently approved for management of diabetes, obesity, and heart failure with preserved ejection fraction offer potentially powerful options for management of CMD.

This review discusses the range of device therapy for ischemic cardiomyopathy (ICM). This article will review the primary data supporting guideline indications for cardiac implantable electronic devices in patients with ICM, with a focus on primary/secondary prevention transvenous implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy, and subcutaneous/extravascular ICDs. In addition, this review discusses emerging device therapy for ICM including left bundle area pacing/defibrillation, cardiac contractility modulation and baroflex activation therapy. Device therapy for ICM continues to evolve to incorporate diverse modalities across the spectrum from prevention of sudden cardiac death to modifying cardiac remodeling and recovery.

Individuals with human immunodeficiency virus (HIV) experience an elevated risk of ischemic heart disease and related cardiovascular sequelae. This is due to a combination of factors including traditional comorbidities, adverse effects of antiretroviral therapy, low-level viremia, viral coinfection, mucosal injury, and chronic immune activation and dysregulation. Understanding the underlying mechanisms, especially as they relate to inflammation, has implications for prevention, diagnostics, and therapeutics. This review highlights some of the foundational and recent literature on clinical phenotypes, diagnostic tools, and promising pharmacotherapies, along with future directions for translational research and clinical implementation.

Management of ischemic cardiomyopathy is challenging, especially when treatment benefits do not clearly exceed the estimated risk of procedures. Myocardial viability assessment provides additional data in this setting to anticipate potential functional recovery and possibly prognostic improvement following revascularization. This evidence comes from the positive signals received from posthoc analyses of some clinical trials. There are multiple clinically available modalities to evaluate myocardial viability among which more sensitive ones such as cardiac magnetic resonance and PET are more preferrable. Yet, there are emerging tools that may further escalate the utility of these modalities.

Obesity is causally linked to heart disease directly by triggering various adverse pathophysiological changes and indirectly through convergent risk factors such as type 2 diabetes, hypertension, dyslipidemia, and sleep disorder. Weight reduction is an important intervention for obesity-related cardiomyopathy, and antiobesity medications that target both obesity and heart failure (HF), particularly sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, have a role in treatment. Bariatric surgery offers a viable treatment option for patients with severe obesity associated with coronary artery disease and HF but requires careful patient selection, preoperative optimization, choice of procedure, and postoperative management to minimize risks.

Coronary artery disease (CAD) is a leading etiology of heart failure (HF) and serves as a significant therapeutic target to ameliorate HF-associated morbidity and mortality. Key management considerations include pharmacologic treatment, electrophysiological devices, and coronary revascularization, aimed toward preventing CAD progression, left ventricular remodeling, sudden death, and reinfarction. The optimal revascularization strategy for patients with CAD and HF who are surgical candidates requires careful assessment of each patients' unique risk/benefit profile and individual preferences. Several novel pharmacologic agents are in development with hopes of adding to the armamentarium of treatment of CAD and HF.

The role of revascularization and percutaneous coronary intervention (PCI) in patients with acute coronary syndrome is well established. However, the incremental value of revascularization over guideline-directed medical therapy is controversial. Currently available data supports the use of PCI to improve angina and quality of life for chronic coronary disease and heart failure (HF). However, there is insufficient data to support revascularization with PCI to improve mortality, reduce cardiovascular events, or improve ejection fraction over medical therapy alone. Additional trials are necessary to identify HF patients who may benefit from revascularization, and the optimal revascularization strategy for this population.

Coronary artery bypass grafting is the major modality of coronary revascularization in patients with ischemic cardiomyopathy as it provides surgical collateralization of the coronary bed protecting the functional myocardium. Myocardial viability testing does not have an established role in the surgical evaluation. Concomitant surgical ventricular restoration does not improve symptoms or survival, though patients with large aneurysms and significant reduction in ventricular size could benefit. Correction of functional mitral regurgitation does not improve survival, and severe functional mitral regurgitation should be addressed via mitral valve replacement. Temporary mechanical circulatory support can be used as a bridge to recovery.

Atrial and ventricular arrhythmias are highly comorbid with ischemic cardiomyopathy (ICM) and are associated with worsening symptoms, morbidity, and mortality. This review will discuss the pathophysiology, evaluation, and treatment of each arrhythmia in ICM with a focus on novel evaluation strategies and catheter-directed interventions. For atrial fibrillation /atrial flutter, recent studies have demonstrated mortality and symptom benefit with early rhythm control with catheter ablation. With respect to ventricular tachycardia, scar characterization is being investigated to change primary prevention and novel ablation technologies and strategies are being explored.

This review describes the role of echocardiography in the diagnosis and prognostication of coronary artery disease (CAD). It describes the diagnostic capabilities of echocardiography using rest and stress imaging, speckle tracking strain imaging with myocardial work index, as well as the use of myocardial perfusion imaging. It also evaluates the use of echocardiography in the assessment of common complications from CAD and the incremental value of incorporating right ventricular, left atrial, and diastolic function assessment in these patients. In addition, the review aims to highlight the prognostic value of echocardiography, especially in the determination of myocardial viability.

PET of the myocardium in patients with low ejection fraction has classically focused on identifying ischemic and viable myocardium. In this review, we use a case-based format to challenge these simplistic notions while integrating the results from recent clinical trials. The basic message is that, for most patients, severely reduced left ventricular function is due predominantly to nonischemic cardiomyopathy, not scar or ischemia. Consequently, we emphasize several practical pitfalls when using cardiac PET imaging in this population to improve its clinical value.

Cardiac amyloidosis (CA) encompasses a group of disorders characterized by an abnormal accumulation of amyloid fibrils in the heart, leading to impaired cardiac function and ultimately heart failure. While the incidence of immunoglobulin light chains amyloidosis incidence seems stable at 8 to 15.2 cases per million persons (PMP)/year, the incidence and prevalence of wild type transthyretin-CA are steadily increasing, being currently estimated at 14 to 27 cases PMP/year and 30 to 170 cases PMP, respectively. This review explores the dynamic landscape of CA epidemiology and its implications for screening and management strategies.

PET has recently demonstrated promising capabilities in the diagnosis and differentiation of various forms of CA. Tracers labeled with 18F, such as 18F-flutemetamol, 18F-florbetapir, and 18F-florbetaben, are being increasingly researched due to their extended half-life, eliminating the requirement for on-site cyclotrons. Unlike bone tracers, PET amyloid-binding tracers exhibit a higher affinity for light-chain fibrils, potentially enabling accurate differentiation between various types of CA. The methodology for measuring tracer uptake in PET imaging, whether dynamic or static, facilitates the quantification of disease severity and could act as a marker for monitoring the disease, assessing treatment response.

Amyloidosis is characterized by protein misfolding and extracellular deposition of insoluble beta-sheet fibrils. It represents a heterogeneous disease with different aetiologies and clinical manifestations. Cardiac involvement (ie, cardiac amyloidosis) has an adverse prognosis, early diagnosis and amyloid typing being crucial for treatment. Recently, the non-invasive diagnosis of CA has increased using imaging techniques, particularly in TTR forms with no monoclonal protein. In the other settings and with inconclusive peripheral biopsy, the EMB allows the demonstration of amyloid by Congo red staining under polarized light, whereas amyloid typing is performed by using immunohistochemistry, immune-electron microscopy and/or proteomics.

Cardiac amyloidosis is an infiltrative myocardial disease whose prevalence significantly increased in recent years. Its clinical history is changing due to the advent of novel therapies, and careful risk stratification has become impelling. Arrhythmias, frequently found during the course of the disease, include conduction system disease, atrial fibrillation (AF), and ventricular arrhythmias (VAs). Arrhythmic risk stratification is a key to identify those patients at higher risk to develop advanced atrioventricular blocks, asymptomatic AFs, or major VAs. This carries significant clinical implications concerning the indication and timing of implantable cardiac devices, as well as the initiation of anticoagulation therapy.

Systemic light chain (AL) amyloidosis stems from abnormal production of amyloidogenic immunoglobulin light chains by plasma cells or B-cell disorders. It can present locally or systemically, with systemic forms posing significant mortality risks, especially if cardiac involvement is present. Delayed diagnosis due to nonspecific symptoms leads to progressive organ dysfunction. Early recognition is vital for timely treatment, aiming to suppress amyloid production and reduce organ damage, thus promoting recovery and improving survival rates. This review article provides a comprehensive overview of the recent advancements in medical therapy for patients with AL cardiac amyloidosis.

Notwithstanding the dramatic improvement associated with Tafamidis in Heart Failure due to wild-type transthyretin cardiac amyloidosis (ATTRwt-CA), the effect of exercise training on ATTRwt-CA remains unexplored. We hereby present rationale and design of the Exercise training and Rehabilitation in Cardiac Amyloidosis study. This interventional, controlled study will randomize ATTRwt-CA patients into a control group and a training group. Primary endpoint will be the distance obtained at the 6-min walk test. Quality-of-life, peak oxygen consumption, left and right heart architecture and function, and natriuretic peptides will be secondary endpoints.