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Atrial fibrillation (AF) is common and its treatment is complex. The new European guidelines emphasize a patient-centered approach, considering the risk factors that contribute to AF and their management in primary and secondary prevention. Recent advances in electrophysiology include the development of new ablation techniques and the implantation of a leadless bicameral pacemaker. Similarly, the management of cardiovascular risk factors is evolving with new recommendations for hypertension and hypercholesterolemia. Finally, new biological markers are included in assessing overall cardiovascular risk. This article reviews recent advances in cardiology, including electrophysiology, cardiovascular prevention, and aortic disease., Competing Interests: M. Roffi déclare des subventions de recherche institutionnelles provenant de Cordis, Terumo, Boston Scientific et biotronik. Les autres auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

The latest ESC recommendations propose several interesting new concepts for the practitioner. The recommendations distinguish between the «apparently healthy» patient and the patient at specific cardiovascular risk (diabetes, renal failure, and familial hypercholesterolemia). New risk calculation tools are proposed (SCORE2 and SCORE2-OP). The proposed LDL-C targets are specific to each group, as a general rule, < 1.8 mmol/l for individuals at high risk and < 1.4 mmol/l for individuals at very high risk. Presence of risk modifiers, comorbidities and patient preferences modulates therapeutic approach which is usually based on optimizing lifestyle and statin medication when necessary., Competing Interests: Le Pr Georg Ehret déclare recevoir des droits d’auteur de UpToDate Inc. Les autres auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Rebuilding one's life after a myocardial infarction requires mobilizing each and every resource available during a difficult period. Medical treatments, physical training and patient education (PE) help to initiate this process. Associating healthcare with art and culture is known to favour an existential « rebirth » and positive biological effects. Since 2019, we propose an initiation to museotherapy (museum in health) to patients in our cardiac rehabilitation program. This article summarizes the evidence about museotherapy benefits in cardiovascular diseases and describes the experience gathered by the cardiology service of the HUG since museotherapy was initiated in 2019., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Cardiovascular diseases and especially coronary artery disease remain the first cause of mortality in Switzerland. Comprehensive cardiac rehabilitation is a validated multidisciplinary intervention, which represents the most appropriate strategy of implementing an effective secondary cardiovascular prevention to reduce the impact of cardiovascular diseases. However, less than half of patients after a myocardial infarction and a tiny proportion of patients with heart failure participate in a rehabilitation program in our country. This article summarizes the current state of cardiac rehabilitation in Switzerland, as well as future developments of cardiac tele-rehabilitation that have accelerated due to the COVID-19 pandemic., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is responsible for the degradation of the LDL-receptor. Inclisiran is a new synthetic interfering ribonucleic acid (siRNA) lowers LDL-cholesterol (LDL-C) levels in the blood by using RNA silencing technology to reduce the production of PCSK9. Inclisiran administered subcutaneously at 0 and 3 months, and then every 6 months has been shown to reduce LDL-C by approximately 50 % in patients at high and very-high cardiovascular risk, or with a diagnosis of familial hypercholesterolemia, but also in patients intolerant to statins. New data are expected, in particular with cardiovascular clinical endpoints, as well as safety for use in adolescents., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, myocardial infarction and sudden cardiac death, among young patient with little/no traditional cardiovascular risk factors. Historically SCAD was considered as a rare pathology, associated primarily with pregnancy and the peripartum period. In recent years, SCAD diagnosis improved thanks to data derived from large registries, thanks to the increased use of diagnostic coronary angiography and the availability of intracoronary imaging. To date there are no randomized trials dedicated to SCAD. However, thanks to global efforts to build national SCAD registries, knowledge of SCAD has tremendously increased during the last years, demonstrating that SCAD is a distinct pathophysiological entity, and presents key differences in management and outcomes compared to ACS of atherosclerotic aetiology., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

PCSK9 (proprotein convertase subtilisin kexin 9) monoclonal antibodies (mAb) are new therapeutic agents to lower efficiently LDL-cholesterol levels. New data from large clinical trials suggest that the addition of PCSK9 mAb to statins can reduce the incidence of major adverse cardiovascular events in very high risk patients. Alirocumab and evolocumab are two agents available in Switzerland with specific limitations for reimbursement. PCSK9 mAb should be considered in patients with clinical atherosclerotic cardiovascular disease (ASCVD), as well as in patients with familial hypercholesterolemia without ASCVD who have substantially high LDL-cholesterol levels despite the use of statin at maximally tolerated dose with or without ezetimibe, or intolerance to appropriate doses of several statins., Competing Interests: Le Dr Baris Gencer déclare avoir participé à des congrès scientifiques de sociétés savantes comme employé du Service de cardiologie des Hôpitaux universitaires de Genève, dont les frais ont été couverts en partie par Amgen et Sanofi. Le Dr David Nanchen déclare être investigateur pour des études cliniques sur les inhibiteurs du PCSK9 dont les sponsors sont Amgen et Pfizer. Le Dr David Nanchen déclare n’avoir reçu aucune rémunération personnelle en argent ou en nature de ces industries pharmaceutiques. Le Dr Tinh-Hai Collet et le Pr Nicolas Rodondi n’ont pas de conflit d’intérêts à déclarer. Le Pr François Mach a reçu des honoraires pour des advisory board ou des conférences scientifiques de la part des sociétés pharmaceutiques Amgen, AstraZeneca, MSD, Pfizer et Sanofi.

Cardiac rehabilitation is a well-defined multidisciplinary program with the objective to reduce mortality and morbidity, while also improving the exercise capacity and quality of life of the patient following a myocardial infarction. Despite the fact that a cardiovascular rehabilitation program is now recommended by international guidelines for all patients who have suffered from an acute coronary syndrome, only half of all patients actually participate to such a program in Switzerland. Even worse, especially when taking into consideration the population in Geneva, less than 5 % of patients follow a long-term cardiac maintenance program (phase III). Since 2015, our project has been to encourage patients who have completed a phase II cardiac rehabilitation program, to resume regular physical activity in the long term., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors appear to represent an important development in the management of hypercholesterolemia. US Food and Drug Administration and European Medicines Agency approved alirocumab and evolocumab, injected drugs administered subcutaneously every 2 or 4 weeks, for patients with hypercholesterolemia, such as those who not reached the cholesterol targets or those with intolerance to statin, especially in secondary prevention or familial hypercholesterolemia. This decision is based on several clinical trials suggesting that these drugs have a powerful effect on levels of LDL-cholesterol with an acceptable safety compared to placebo. Large clinical studies are currently performed to assess the impact of PCSK9 inhibitors on major adverse cardiovascular events in secondary prevention.

Lipid-lowering treatment in the elderly patient is conditioned by a high incidence and prevalence of cardiovascular disease in the setting of a limited remaining life span. The clinical benefit of statin therapy can be seen after a few months, thus supporting use in secondary prevention even when the lifespan is restricted to a few years. Recent guidelines propose the use of moderate doses in the elderly > 75 years. The evidence for treatment in primary prevention is weaker and the evaluation of the total cardiovascular risk is complicated by the high baseline risk of many elderly. Rational treatment decisions should be based on biologic rather than chronologic age. Statins are generally well tolerated in the elderly, requiring clinical monitoring only, with particular attention to pharmacokinetic interactions and renal failure.

Although lipid-lowering therapy in patients with established coronary heart disease (secondary prevention) is generally accepted, its benefit is often questioned in asympto- matic patients. The ongoing debate about the usefulness of statin therapy has disturbed many patients, especially in the French- and Italian-speaking parts of Switzerland, which lead too often to treatment discontinuation, even in patients who would benefit the most from it. In the primary prevention, the reduction in LDL cholesterol levels with statins decreases the risk for cardiovascular events. The higher the baseline risk, the greater the benefits in terms of absolute risk reduction; hence, using a scoring tool to evaluate the cardiovascular risk is needed. For patients at low risk, lifestyle interventions are preferable.

Testosterone treatment was largely prescribed and marketed as a potential therapy to treat symptoms of aging. Testosterone levels decrease progressively with aging and low testosterone levels were associated with an increase risk of cardiovascular events and death. Controversies persist whether this association is causal or mediated by confounders of the general health. Systematic screening of testosterone is not recommended in a check-up visit, but only in case of suggestive symptoms. Furthermore a recent meta-analysis and large prospective cohort studies have reported a concern regarding the safety of testosterone therapy and the associated risk of major cardiovascular events. The decision to prescribe testosterone should be made with the patient after evaluating the risks and benefits.

The achievement rate of recommended low-density lipoprotein cholesterol (LDL-C) targets of < 1.8 mmol/l for secondary prevention in very high risk patients is difficult. Observational studies reported that loss of function mutation of the PCS9 was associated with LDL-C decrease level and reduction of cardiovascular events. Monoclonal antibodies to PCSK9 (REGN727 and AMG 145, PSCK9 inhibitors) have been tested in clinical studies of phase I and II and showed LDL-C level reduction of 60-70% compared to placebo. This approach appears safe and well-tolerated. The PCSK9 inhibitors are now tested in large phase III clinical studies to assess the long-term safety and efficacy of this new promising approach.

Clinical outcomes after revascularization, both for surgery and percutaneous coronary intervention (PCI), is significantly worse in diabetic patients compared with non-diabetic patients. While in acute coronary syndrome, PCI is favored because of the increased risk of surgery performed during ongoing infarction, in stable patients assessment of clinical factors, such as coronary anatomy and comorbidities should guide decision of the revascularization modality (e.g., surgical, PCI, or conservative). Surgery should be favored in patients with multivessel coronary disease and acceptable surgical risk. Overall, the threshold for surgery compared to PCI should be lower in diabetic patients compared with non-diabetic ones.

Untill recently, congenital heart disease was considered as a childhood's disease. With improvement in pediatric survival, adults with a congenital heart disease (ACHD) represent an emerging group of patients who need specialized medical care. In 2010, the ESC published newguidelines on global and specific management of adults with congenital heart disease. ACHD centers organize appropriate medical care for these patients, promote specialist training and national scientific research in collaboration with other national ACHD centers.

The proven benefits of beta blockers and angiotensin converting enzyme (ACE) inhibitors in the treatment of chronic heart failure, could be linked, at least in part, to their heart-rate-lowering properties. The link between a high heart rate and cardiovascular morbidity and mortality has been demonstrated in the general population, as well as in patients with hypertension, coronary artery disease, and chronic heart failure. Ivabradine is a specific inhibitor of the if current in the sino-atrial node, without any other known cardiovascular effect, such as myocardial contraction or intracardiac conduction. The effects of ivabradine on reducing resting heart-rate, and, therefore, cardiovascular outcomes have been studied in two large studies: BEAUTIFUL, and, more recently, SHIFT, both of which are discussed in this article.

Elevated heart rate induces an increase in myocardial oxygen consumption as well as a decrease in oxygen delivery. Myocardial ischemia is double in patients with resting heart rate above 80 bpm, compared to those with heart rate below 60 bpm. In addition, angina during effort increases the risk of mortality, directly depending on the degree of angina. Thus, in patients with myocardial angina, reducing heart rate could decrease symptoms and improve cardiovascular prognosis. A recent retrospective analysis of the results from the BEAUTIFUL study provides new evidence on this topic and is discussed in this article.

Heart transplantation (HTx) started in 1987 at two university hospitals (CHUV, HUG) in the western part of Switzerland, with 223 HTx performed at the CHUV until December 2010. Between 1987 and 2003, 106 HTx were realized at the HUG resulting in a total of 329 HTx in the western part of Switzerland. After the relocation of organ transplantation activity in the western part of Switzerland in 2003, the surgical part and the early postoperative care of HTx remained limited to the CHUV. However, every other HTx activity are pursued at the two university hospitals (CHUV, HUG). This article summarizes the actual protocols for selection and pre-transplant follow-up of HTx candidates in the western part of Switzerland, permitting a uniform structure of pretransplant follow-up in the western part of Switzerland.

Clopidogrel hydrogen sulfate is an antiplatelet agent administered, alone or in combination with acetyl salicylic acid, approved in the prevention of cardiovascular events based on large-scale clinical trials. The new salt formulations clopidogrel where approved based on pharmacokinetic measurements of the inactive prodrug on few healthy volunteers, without any other medication. Clopidogrel hydrogen sulfate has a wide variability in platelet response and the pharmacokinetic of the active metabolite is not dose-linear. Ideally, new clopidogrel salts should be tested for therapeutic equivalence in the target patient population. Should this not be feasible, consistent bioequivalence data should be obtained for the active metabolite, using a properly validated and standardized test method.

Recurrence of cardiovascular events and mortality remain high after acute coronary syndromes. A Swiss multicentric study, "Inflammation and acute coronary syndromes (ACS)--Novel strategies for prevention and clinical managements", is currently underway with the support of the Swiss National Science Foundation. The study includes a clinical research subproject of which the aim is to assess the impact of the ELIPS program (multi-dimEnsionaL prevention Program after acute coronary Syndrome) on the recurrence of cardiovascular events after an ACS. The basic research sub-projects aim to investigate novel cardiovascular risk biomarkers and genetic determinants of recurrence and to study the role of stem cells after an ACS. Another sub-project will evaluate intracoronary imaging techniques and the efficacy of different types of stents.

Takotsubo syndrome (TS) also named transient left ventricular apical ballooning syndrome is a particularly entity of the acute coronary syndrome with normal coronary arteries. The predominance is neatly postmenopausal women. The aetiology and physiopathology of TS are subject to many hypothesis, sometime contradictory. However, emotional, physiological and environmental stressors are implicated factors. The typical image at the ventriculography is a systolic left ventricular apical ballooning reversible in a few days to weeks with an excellent prognostic. The treatment is based on supportive care. The goal of this article is to review the actual knowledge about TS to help the general practitioner, aboard this entity in the management of an ACS.

This article gives a brief overview of the importance of heart rate as a risk factor in patients with coronary heart diseases. Increased heart rate (> or = 70 bpm) is associated with an increased risk for cardiovascular events. Ivabradine, the first of the therapeutic class of I(f) current inhibitors, is a selective and specific inhibitor of the I(f) current, resulting in the exclusive reduction in heart rate, while preserving the contractility of the myocardium, atrioventricular conduction, ventricular repolarization and blood pressure. Ivabradine is a new efficient and safe therapeutic option in the treatment of coronary artery disease. The available evidence demonstrates that ivabradine provides clinical benefits in coronary artery disease patients, symptomatic or not with a heart rate > or = 70 bpm, irrespective of the background therapy.

Heart transplantation remains the best therapeutic option for the treatment of end-stage heart failure. However, good survival rates can be obtained only if patients are closely monitored, particularly for their immunosuppressive regimens. Currently, a triple-drug regimen usually based on calcineurin-inhibitors (cyclosporin A or tacrolimus), anti-proliferative agents and steroids is used in most recipients. New agents such as the mTOR inhibitors, a more recently developed class of immunosuppressive drugs, can also be used in some patients. The aim of this article is to review currently used immunosuppressive regimens after heart transplantation, and to propose some individualized options depending on specific patient characteristics and recent pharmacological developments in the field.

Most patients with chronic heart failure (CHF) can safely engage in sexual activity and be treated for erectile dysfunction with sildenafil, provided that they do not have active coronary ischemia and do not require treatment with nitrates. Clinicians should know the physiological requirements for sexual activity and the impact chronic heart failure has on sexual performance. Fear of cardiac events during intercourse can interfere with patients' ability to perform and enjoy sex, and thus, it is important that the physician be able to counsel patients with chronic heart failure about sexual activity.

Elevated resting heart rate is an independent cardiovascular risk factor and rate reduction is beneficial. It is not known whether reduction of heart rate per se can improve outcome. Studies of beta-blockers in post-myocardial infarction patients suggest that this may be the case, but beta-blockers, may be poorly tolerated or contraindicated. Similarly, heart rate lowering calcium antagonists are associated with modest event-rate reduction only in selected patients. The new selective inhibitor of the sinus node If current, ivabradine, looks promising in terms of reducing myocardial ischaemia. Its mode of action, the exclusive reduction of heart rate through selective inhibition of the sinus node If current, provides comparable efficacy to existing treatments. Ivabradine is licensed in Europe for use in stable angina.

Erectile dysfunction is defined as the inability to achieve and/or maintain an erection sufficient to permit satisfactory sexual intercourse. Most cases of erectile dysfunction have a vascular etiology and, in patients with known cardiovascular disease, the degree of erectile dysfunction correlates with severity of that disease. In addition, cardiovascular disease and erectile dysfunction share the same risk factors for atherosclerosis and have a common pathophysiology (endothelial dysfunction); thus, erectile dysfunction appears as an early and sentinel symptom in patients with occult vascular disease, of the coronary or carotid arteries.

Recent advances in molecular genetics have resulted in the identification of pathogenic mutations in a number of genes which cause hypertrophic cardiomyopathy (HCM). In order to integrate this increasing genetic knowledge of HCM into the cardiology clinic, we offer all patients and their families diagnosis and genetic counselling based on these current data. In addition, within the framework of a multidisciplinary project between the Divisions of Medical Genetics, Cardiology and Pediatric Cardiology of the University Hospitals of Geneva, we have developed a resequencing array enabling rapid molecular diagnosis of HCM. Data from this study will enhance our understanding of the aetiology of HCM, and improve our knowledge of genotype-phenotype correlations. This information will enable us to develop new therapeutic and preventive concepts, with the aim of tailoring therapies to the specific genetic variant of each patient and its family.