Nature reviews. Cardiology
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Right ventricular (RV) failure is a complex problem with poor outcomes. Diagnosis requires a high degree of clinical suspicion, because many of the signs and symptoms of this condition are nonspecific and can be acute or chronic. Identification of the underlying aetiology, which can include pulmonary hypertension, cardiomyopathy, myocardial infarction, congenital or valvular heart disease, and sepsis, is essential. ⋯ The complex 3D geometry of the right ventricle and its intricate interactions with the left ventricle have left many questions about RV failure unanswered. However, promising new targeted therapies are under development and mechanical support is becoming increasingly feasible. The next decade will be an exciting time for advances in our understanding and management of RV failure.
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In a new, observational study, survival and neurological outcome at 1 month after out-of-hospital cardiac arrest were worse in patients treated with an advanced airway than in those treated with bag–mask ventilation. These results contradict the common assumption that advanced airway management is associated with improved outcome.
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Fibrinolysis is recommended in European and US guidelines for patients with ST-segment elevation myocardial infarction (STEMI) when a strategy of primary percutaneous coronary intervention (PPCI) is associated with ≥120 min delay from first medical contact (FMC), defined as call to the emergency medical services or self-presentation at hospital. Current evidence indicates that reperfusion therapy should be initiated as soon as possible after FMC. However, fibrinolysis cannot be initiated instantaneously at FMC, and PPCI is superior to fibrinolysis in reducing mortality if the extra time needed to perform PPCI instead of fibrinolysis (so-called PCI-related delay) is <120 min. ⋯ In the future, an ideal recommendation would be to initiate reperfusion as soon as possible, preferably within 120 min of FMC in the case of PPCI. When the expected PCI-related delay is <120 min, PPCI should be the preferred reperfusion strategy, even if the FMC-to-PPCI delay is >120 min. Setting up a health-care system enabling prehospital diagnosis of STEMI with field triage of patients directly to catheterization laboratories at large-volume PCI centres (bypassing local hospitals, coronary care units, emergency departments, and intensive care units) will help to increase the proportion of patients with STEMI who will benefit from PPCI.
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In a large, new, observational study, β-blocker treatment did not improve clinical outcomes in patients with coronary artery disease (CAD), including those with previous myocardial infarction, and was associated with more events in individuals with risk factors only. The role of β-blockers for secondary prevention in these patients should be reconsidered.
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The ROMICAT-II trial shows that CT coronary angiography is safe and fast for the exclusion of clinically significant obstructive coronary artery disease in low-risk patients with acute chest pain. Several issues and questions relating to the low prevalence of disease and the actual benefit to patients remain to be answered.