Cheng-Gang Zhu

Atherosclerotic cardiovascular disease (ASCVD) continues to be a leading cause of morbidity and mortality worldwide, with elevated low-density lipoprotein cholesterol (LDL-C) being a major modifiable risk factor. Despite the efficacy of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in LDL-C reduction, suboptimal adherence remains a significant challenge and may limit the cardiovascular benefits achievable with these therapies. Recaticimab, the first Fc-engineered anti-PCSK9 monoclonal antibody incorporating YTE mutation (M252Y/S254T/T256E), was specifically designed to prolong half-life through enhanced neonatal Fc receptor (FcRn) binding, thereby enabling ultra-long dosing intervals of up to 12 weeks. Results from three Phase III clinical trials demonstrated that recaticimab achieves potent and sustained LDL-C reductions, either as monotherapy or in combination with statins, with a favorable safety and tolerability profile. By integrating the YTE mutation-derived structural innovation with robust Phase III clinical evidence, recaticimab may help address some limitations of existing PCSK9 inhibitors, including frequent injections and suboptimal persistence in real-world use. However, whether these pharmacological advantages translate into improved cardiovascular outcomes remains to be established, particularly given that current clinical evidence is largely derived from studies conducted in Chinese populations, and thus requires further validation in broader populations. Future studies should evaluate its impact on real-world adherence, cardiovascular outcomes, and cost effectiveness.

Elevated low-density lipoprotein cholesterol (LDL-C) is a key modifiable risk factor in atherosclerotic cardiovascular diseases. While statins are the first-line therapy for LDL-C management, challenges such as limited additional benefits with dose escalation and an increased risk of adverse drug reactions at higher doses remain. Ezetimibe is widely recommended in clinical guidelines and has become an essential component of lipid-lowering therapy, particularly for patients requiring additional LDL-C reduction beyond what statins alone can achieve. Ezetimibe monotherapy reduces LDL-C levels by approximately 17.1-25.9% and significantly lowers the risk of major adverse cardiovascular events compared with placebo. For patients whose LDL-C levels remain uncontrolled with statin therapy, adding ezetimibe not only achieves greater LDL-C reduction but also improves goal attainment, reduces plaque burden, enhances plaque stability, and lowers the incidence of cardiovascular events. Furthermore, combining ezetimibe with statins into one tablet offers advantages in medication management, improving patient compliance and convenience. In addition, combining ezetimibe with nonstatin lipid-lowering agents also offers a comprehensive approach to lipid management, especially in complex cases of dyslipidemia or cardiovascular risk management. Despite robust clinical evidence and good tolerability, the adoption of ezetimibe combination therapy in real-world practice remains limited, likely owing to insufficient awareness among clinicians and patients. In this review, we summarize the current evidence to support clinical decision-making and promote the optimal use of ezetimibe in the management of atherosclerotic cardiovascular diseases.

Background: Drug-coated balloons (DCB) have been evaluated to be safe and practical in treating coronary small vessel disease (SVD). However, evidence about the practicality and safety of DCB in treating coronary lesions with diameters greater than 3.0 mm is limited. Methods: 1166 patients who received DCB angioplasty were enrolled and divided into groups of SVD or large vessel disease (LVD) according to the target vessel diameters (<3.0 mm for SVD; ≥3.0 mm for LVD). All participants received a 2-year follow-up. The two main outcomes were patient-oriented composite endpoint (patient-oriented composite endpoint (POCE), all-cause mortality, all myocardial infarctions [MI], or any revascularization), and target lesion failure (target lesion failure (TLF), cardiac death, target vessel MI, or ischemia-driven target lesion revascularization). Results: In these patients, a total of 30 (2.6%) TLF and 82 (7.0%) POCE were recorded. Patients in the LVD group showed statistically greater rates of lesion success compared to the SVD group (752 [96.0%] vs. 380 [99.2%], p = 0.004) and procedural success (751 [95.9%] vs. 380 [99.2%], p = 0.003). No significant difference was found in the 2-year risk of TLF (hazard ratio (HR) 1.41, 95% CI 0.58–3.44; p = 0.455), POCE (HR 1.29, 95% CI 0.76–2.20; p = 0.354), MI (HR 0.88, 95% CI 0.24–3.13; p = 0.837), revascularization (HR 1.22, 95% CI 0.68–2.21; p = 0.506), and stroke (HR 0.78, 95% CI 0.03–15.26; p = 0.784) between the SVD and LVD groups. Conclusions: There was no discernible inferiority of the DCB intervention in the LVD group as compared to the SVD group. The DCB intervention is practical for coronary lesions with diameters higher than 3.0 mm.

Background and aims: Our goals in the study were to (1) quantify the discordance in LDL-C levels between equations (the Friedewald, Sampson, and Martin/Hopkins equations) and compare them with direct LDL-C (dLDL-C); and (2) explore the proportion of misclassified patients by calculated LDL-C using these three different equations. Methods: A total of 30,349 consecutive patients with angiographically confirmed coronary artery disease (CAD) were prospectively enrolled. Concordance was defined as if the LDL-C was <1.8 mmol/L with each pairwise comparison of LDL-C equations. Estimated LDL-C that fell into the same category as dLDL-C at the following levels: <1.4, 1.4 to 1.7, 1.8 to 2.5, 2.6 to 2.9, and ≥3.0 mmol/L was considered to have been correctly categorized. Results: The concordance was 96.3% (Sampson vs. Martin/Hopkins), 95.0% (Friedewald vs. Sampson), and 91.4% (Friedewald vs. Martin/Hopkins), respectively. This proportion fell to 82.4% in those with hypertriglyceridemia (TG ≥ 1.7 mmol/L). With an accurate classification rate of 73.6%, the Martin/Hopkins equation outperformed the Sampson equation (69.5%) and the Friedewald equation (59.3%) by a wide margin. Conclusions: Comparing it to the validated Martin/Hopkins equation, the Friedewald equation produced the lowest levels of LDL-C, followed by the Sampson equation. In the classification of LDL-C, the Martin/Hopkins equation has also been shown to be more accurate. There is a significant difference between the equations and the direct measurement method, which may lead to overtreatment or undertreatment.

Background: Transradial artery (TRA) access for percutaneous coronary intervention (PCI) was associated with lower risks of major bleeding and vascular complications compared to transfemoral artery access. Use of large-bore (≥7-Fr) guiding catheters through TRA approach increased the likelihood of radial artery occlusion (RAO). This study aimed to investigate whether use of the thin-walled 7-Fr Glidesheath Slender, allowing PCI with large-caliber guiding catheters, is superior to standard 7-Fr Cordis sheath with respect to periprocedural RAO within 24 hours after transradial coronary intervention (TRI) in complex lesions. Methods: A prospective randomized, controlled, single-blinded (patient-blinded) trial was conducted, randomizing 504 patients with TRI for complex lesions to either 7-Fr Glidesheath Slender or conventional 7-Fr Cordis sheath. The primary outcome was defined as the incidence of periprocedural RAO with Doppler ultrasound during the first 24 hours after TRI. Results: The incidence of early RAO was 10.3% for 7-Fr Glidesheath Slender and 13.5% for conventional 7-Fr sheath (p = 0.271). The procedural success rate for Glidesheath Slender was 92.9% and for Cordis sheath was 93.7% (p = 0.722). There was no signficiant difference between treatment arms in terms of local hematoma and radial spasm, whereas use of the Glidesheath Slender was associated with significantly less pain during the procedure (numeric rating scale [NRS], 2.27 ± 0.75 vs. 2.45 ± 0.95, p = 0.017). The assessment of radial artery in ultrasound parameters after complex TRI was improved with Glidesheath Slender. Conclusions: Among patients with complex coronary lesions undergoing TRI, 7-Fr Glidesheath Slender was not superior to conventional 7-Fr in the prevention of periprocedural RAO within 24 hours following complex PCI, without reducing RAO occurrence. Clinical Trial Registration: NCT04748068.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is considered to have multiple roles in the development of atherosclerosis, which is recently reported to participate in the thrombotic process. We aimed to examine the relationship between PCSK9 concentration, coagulation indexes and cardiovascular events. A total of 2293 consecutive patients with angina-like chest pain and without lipid-lowering drugs treatment were enrolled and followed up for major adverse cardiovascular events (MACEs). Circulating PCSK9 concentration was determined by ELISA. The routine coagulation tests including activated partial thromboplastin time (APTT), prothrombin time (PT) and thrombin time were performed. The associations between PCSK9 concentration, routine coagulation indicators and MACEs were analyzed. Patients with high PCSK9 levels had lower PT and APTT levels (all p < 0.05). However, PCSK9 concentration was only independently and negatively correlated with PT (β = − 0.115, p < 0.001). During a mean of 38.3 months, 186 (8.1%) MACEs were occurred. Multiple Cox regression analysis indicated high PCSK9 or low PT levels as risk factors related to MACEs. When the prognosis was analyzed by the combination of PCSK9 and PT levels, patients with high PCSK9 and low PT had higher incidence of MACEs compared to those with low PCSK9 and high PT. Our study firstly suggested that PCSK9 concentration was negatively correlated with plasma levels of PT. Furthermore, high PCSK9 and low PT were associated with MACEs and the combination of PCSK9 with PT had an addictive effect on predicting cardiovascular outcomes in patients with chest pain, which was useful for further subdivision of cardiovascular risks.

Objectives: We aimed to explore the impact of 7‐Fr sheaths on the incidence of early radial artery occlusion (RAO) after transradial coronary intervention (TRI) in Chinese patients.Background: RAO precludes future use of the vessel for vascular access. Transradial catheterization is usually performed via 5‐Fr or 6‐Fr catheters; 7‐Fr sheath insertion enables complex coronary interventions but may increase the RAO risk.Methods: We prospectively enrolled 130 consecutive patients undergoing complex TRI using 7‐Fr sheaths. Radial artery ultrasound assessment was performed before and after TRI. Early RAO was defined as the absence of flow on ultrasound within 6–24 hr after TRI. Multivariate logistic regression was used to determine the factors related to early RAO after TRI.Results: 7‐Fr sheaths were mainly used for chronic total occlusion (44.6%), bifurcation (30.0%), and tortuous calcification (25.4%) lesions. All patients were successfully sheathed. Percutaneous coronary intervention (PCI) procedural success was 96.2%; 119 patients (91.5%) had preserved radial artery patency after TRI. All 11 RAO cases (8.5%) were asymptomatic. The radial artery diameter was significantly larger postoperatively (3.1 ± 0.4 mm) than preoperatively (2.6 ± 0.5 mm) (p < .001). No parameters significantly differed between patients with and without RAO. TRI history was the only independent risk factor of early RAO (odds ratio: 6.047, 95% confidence interval: 1.100–33.253,p= .039).Conclusions: 7‐Fr sheath use after transradial access for complex PCI is feasible and safe. Evaluating the radial artery within 24 hr after TRI allows timely RAO recognition, important for taking measures to maintain radial artery patency and preserve access for future TRIs.

Background: The atherogenicity of remnant cholesterol (RC) has been underlined by recent guidelines, which was linked to coronary artery disease (CAD), especially for patients with diabetes mellitus (DM). This study aimed to examine the prognostic value of plasma RC in the patients with CAD under different glucose metabolism status. Methods: Fasting plasma RC were directly calculated or measured in 4331 patients with CAD. Patients were followed for the occurrence of major adverse cardiovascular events (MACEs) and categorized according to both glucose metabolism status [DM, pre-DM, normoglycemia (NG)] and RC levels. Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals. Results: During a mean follow-up of 5.1 years, 541 (12.5%) MACEs occurred. The risk for MACEs was significantly higher in patients with elevated RC levels after adjustment for potential confounders. No significant difference in MACEs was observed between pre-DM and NG groups (p > 0.05). When stratified by combined status of glucose metabolism and RC, highest levels of calculated and measured RC were significant and independent predictors of developing MACEs in pre-DM (HR: 1.64 and 1.98; both p < 0.05) and DM (HR: 1.62 and 2.05; both p < 0.05). High RC levels were also positively associated with MACEs in patients with uncontrolled DM. . Conclusions: In this large-scale and long-term follow-up cohort study, data firstly demonstrated that higher RC levels were significantly associated with the worse prognosis in DM and pre-DM patients with CAD, suggesting that RC may be a target for patients with impaired glucose metabolism.

Objectives: To investigate the long‐term outcomes of percutaneous coronary intervention (PCI) in patients with previous ischemic stroke.Background: Ischemic stroke and coronary artery disease (CAD) are leading causes of death that often coexist with each other. With the increased use of PCI in high‐risk patients with CAD, the association between prior ischemic stroke and cardiovascular/cerebrovascular events in patients with CAD undergoing PCI has been a topic of interest.Methods: We enrolled 10,300 consecutive patients who had undergone PCI from January 2013 to December 2013 and classified them into the prior ischemic stroke group (n = 1,106) and no prior ischemic stroke group (n = 9,194). The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCEs) during follow‐up. The secondary endpoints included each component of the primary endpoint and stent thrombosis (ST).Results: Overall, 10.7% patients had a history of ischemic stroke. At a median 29‐month follow‐up, MACCEs following PCI occurred with 2‐year incidences of 15.4% in the prior ischemic stroke group and 11.7% in the no prior ischemic stroke group. Cox regression analysis demonstrated that prior ischemic stroke was independently associated with a higher risk of MACCEs (adjusted hazard ratio [HR] = 1.294; 95% confidence interval [CI]: 1.100–1.522; P = 0.002), recurrent stroke (adjusted HR = 2.463; 95% CI: 1.729–3.507; P = 0.000), and ST (adjusted HR = 1.787; 95% CI: 1.075–2.971; P = 0.025). A high residual syntax score and low renal function were independent risk factors for MACCEs.Conclusions: Increased concern and active treatment strategies are needed in patients undergoing PCI who have a history of ischemic stroke.

Objectives To describe procedural details of the double rewire (DR) crush technique, a novel modified crush technique, and report the clinical outcomes of patients who underwent the procedure. Background In the management of complex bifurcation lesions, there is a need to use elective two‐stent techniques that stent the side branch (SB) before main vessel (MV) stenting and keep SB open. Methods We studied 48 patients with 49 bifurcation lesions who underwent percutaneous coronary intervention (PCI) using the DR‐crush technique between January and December 2013. Baseline, postprocedural, and follow‐up quantitative coronary angiographic analyses were performed. Procedural characteristics and clinical outcomes at follow‐up were assessed. Results Majority of the patients (60.4%, 29/48) had acute coronary syndrome. Most bifurcation lesions (77.6%, 38/49) were classified as Medina 1, 1, 1. Final kissing balloon inflation was successfully performed in all patients. After PCI, MV and SB of all patients had Thrombolysis In Myocardial Infarction 3 blood flow. None of the patients had MV or SB diameter stenosis ≥50% after PCI. At a mean follow‐up period of 2.4 years, target vessel revascularization occurred in 2.1% and myocardial infarction in 2.1%. No deaths occurred in this period. Conclusions The DR‐crush technique is feasible in coronary bifurcation stenting. Patients who underwent this procedure had relatively low incidence of adverse events. Larger studies are warranted for further confirmation of the findings.