Cardiovascular pharmacotherapy—2015 was a good year

January 2015 saw the launch of a new journal in the European Heart Journal family— European Heart Journal: Cardiovascular Pharmacotherapy. What were the highlights of cardiovascular pharmacotherapy in 2015? As in every year, there were advances in the field of coronary artery disease, heart failure (HF), atrial fibrillation, antithrombotics and anticoagulation, prevention and more. However, it was in the treatment of diabetes that 2015 saw the first study showing outcome benefit - with empagliflozin, a new class of antiglycaemic drug. The EMPA-REG outcome trial showed improved survival and less hospitalization for HF: it is changing concepts and practice. 1 The new era of outcome trials follows the acute awareness of the need to examine cardiovascular safety of antidiabetic drugs. 2 , 3 Assuming that the findings are a class effect, two other ongoing long-term outcome studies examining a SGLT2 inhibitor-based therapeutic regimen vs. standard care are attracting widespread attention (DECLARE-TIMI 58 study with dapagliflozin, VERTIS with ertugliflozin) and will provide essential information in this regard. More recently, and most likely by a different mechanism, survival benefit and reduced cardiovascular events were shown in patients receiving the human glucagon-like peptide 1 analogue liraglutide as part of their antiglycaemic management. 4 The new journal published several papers relating to diabetes and its cardiovascular complications. In a substudy from the ARISTOTLE atrial fibrillation trial, 5 apixaban had similar benefits in reducing stroke, decreasing mortality and causing less intracranial bleeding than warfarin in patients with and without diabetes. 6 Singh et al.7 reported that despite rapid revascularization and treatment of hyperglycaemia in patients with acute myocardial infarction, admission hyperglycaemia was associated with an increased mortality. Coronary artery disease and acute coronary syndromes (ACSs) were as always a major focus of attention in 2015. Jørgensen et al. reported temporal changes in patient characteristics and pharmacotherapy in 156 496 patients referred for coronary angiography between 2000 and 2009 in Denmark. During a 10-year period, there was an increase in mean age of patients, the proportion of female patients, and a 56% increase in the number of coronary angiographies performed. 8 Another study examined the relation between serum potassium levels and short-term mortality in patients receiving loop diuretics after acute myocardial infarction. 9 Potassium levels outside the 3.9–4.5 mmol/L range, especially hyperkalemia, were associated with a substantially increased risk of death. Regarding antithrombotic therapy, glycoprotein IIb/IIIa inhibitors reduce myocardial infarction and peri-procedural thrombotic complications in patients undergoing percutaneous coronary intervention. They may cause bleeding and thrombocytopenia, and risk–benefit should be kept in mind. 10 The EYESHOT study assessed antithrombotic therapies in medically managed patients with ACSs. 11 Almost one-third of EYESHOT ACS patients were managed without revascularization during the index hospitalization. In those treated without revascularization, a lower use of recommended antiplatelet therapy and worse clinical outcome was observed, supporting current guideline management. The issue of cardioprotection around myocardial reperfusion is still unsettled and the use of catalytic antioxidants could still just possibly find a role. 12 Also not to be neglected is the question of microvascular dysfunction, even though there are few data regarding the effectiveness of pharmacological treatments in these patients. 13 In secondary prevention, poor adherence to angiotensin converting enzyme inhibitors (ACE-I)/angiotensin receptor blockers (ARB) prescription medication was associated with a 20% increased risk of recurrent acute myocardial infarction (AMI). 14 The Platelet inhibition Registry in ACS Evaluation Study is a European initiative of experts in cardiology who are managing national or international ACS registries. About 20 completed or ongoing such registries have been set up to document clinical experience with ACS patients, who undergo percutaneous coronary intervention and who are treated with antithrombotic drugs. PIRAEUS aims to expand clinical knowledge on how to provide optimal care and therapy to ACS patients. 15 Atrial fibrillation mandates the optimal use of anticoagulant therapy. 16 Aspirin is now discouraged. In an observational study of 5426 Chinese patients with atrial fibrillation, aspirin was associated with higher risk of gastrointestinal bleeding compared with warfarin and the risk of gastrointestinal haemorrhage in patients on warfarin increased progressively with worsening time in therapeutic range (TTR). 17 Although novel oral anticoagulants (NOACs) are now in widespread use, 18 the benefit–risk balance may be difficult 19 and the challenge of double or triple antiplatelet–anticoagulation in patients with AF and ACS and/or undergoing percutaneous coronary intervention not always straightforward. 20 , 21 Ongoing clinical trials (PIONEER-AF, Re-DUAL PCI, and AUGUSTUS) may shed more light on these issues. HF remains a major topic in cardiovascular pharmacotherapy. Optimized pharmacotherapy is a mainstay of HF management, and adherence to guidelines portends survival benefit, 22 including in patients who have undergone cardiac resynchronization therapy device implantation. 23 Although optimal haemoglobin level for the HF patient is still debated, as is the role of erythropoetic stimulating drugs, iron replacement in patients with HF with reduced ejection fraction has been shown to improve symptoms and exercise capacity. 24 Valsartan/sacubitril (LCZ696) is a first-in-class angiotensin receptor neprilysin inhibitor which has been shown to enhance the endogenous natriuretic peptide actions on neurohormonal activation. The clinical benefit in HF patients was demonstrated in the PARADIGM trial. 25 LCZ696 was also effective in reducing blood pressure in several small studies; its effectiveness and safety in the management of hypertension remain to be proven in larger patient populations. 26 The treatment of hypertension reopened to major discussion following the dubious role of renal denervation and the findings of the only randomized trial (Symplicity HTN-3). 27 What other topics were published in European Heart Journal: Cardiovascular Pharmacotherapy in its first year? A review paper discussed cardiorenal protection during chronic renin–angiotensin–aldosterone system suppression. 28 Use of NSAIDs had an increased risk of atrial fibrillation in patients with prior myocardial infarction. 29 Colchicine had superior clinical efficacy compared with standard therapy for the prevention of recurrent pericarditis and post-pericardiotomy syndrome. 30 The pharmacological challenges in the management of patients with concomitant cardiovascular and chronic obstructive pulmonary disease were reviewed by Ceconi and co-workers. 31 The journal has at time of writing received approval for listing in Medline and continues to grow and fulfil its contribution to cardiovascular pharmacotherapy. Conflict of interest: None declared.