Hani Sabbour

Pulmonary arterial hypertension (PAH) remains associated with substantial morbidity and mortality despite advances in combination therapy. Sotatercept, an activin‐signaling inhibitor, is a novel disease‐modifying therapy targeting pulmonary vascular remodeling. Real‐world data from Middle Eastern populations remain limited. We conducted a retrospective single‐center cohort study evaluating the real‐world effectiveness and safety of Sotatercept in adults with PAH treated at a tertiary pulmonary hypertension expert center in Abu Dhabi, United Arab Emirates, between January 2025 and September 2026. Clinical, echocardiographic, biochemical, and risk‐stratification data were extracted from electronic medical records. Primary outcomes were echocardiographic parameters of pulmonary hemodynamics and right ventricular structure and function, including right atrial (RA) area, systolic pulmonary arterial pressure (SPAP), TAPSE, and TAPSE/SPAP ratio. Secondary outcomes included NT‐proBNP, 6‐min walk distance (6MWD), risk profile, and safety. Thirty‐six patients were prescribed Sotatercept, of whom 33 received at least one dose. Most patients were female (80.6%), with a mean age of 55 years. Significant reductions occurred in RA area (− 2.67 cm ² ; 95% CI, −4.16 to −1.18; p < 0.001), NT‐proBNP (− 46.7 pmol/L; 95% CI, −87.19 to −20.39; p < 0.001), and SPAP (− 6.00 mmHg; 95% CI, −12.00 to −0.50; p = 0.031). TAPSE increased significantly (+ 0.25 cm; 95% CI, 0.17 to 0.33; p < 0.001), and TAPSE/SPAP improved significantly (+ 0.064; 95% CI, 0.030 to 0.108; p < 0.001). Risk profile improved, with 12 patients (36.4%) at low risk at follow‐up; two patients (6.1%) remained at high risk. The 6MWD did not change significantly. Treatment was well tolerated, with no adverse events leading to treatment discontinuation or death; two all‐cause deaths occurred during follow‐up. In this real‐world Middle Eastern PAH cohort, Sotatercept was associated with improved right‐heart remodeling, NT‐proBNP, and risk profile, with acceptable short‐term safety. These findings complement trial evidence and provide early regional support for activin pathway inhibition in routine practice.

Although there are conflicting clinical data on the efficacy of weight reduction in reducing secondary events in patients with comorbid overweight and obesity (OAO) and cardiovascular disease (CVD), there is excellent epidemiological and biological evidence of a cause–effect relationship between OAO, CVD, and other systemic complications. There is also new interventional evidence that pharmacotherapies improve cardiovascular, hepatic, and renal outcomes in individuals with OAO and pre‐existing CVD. New trial data confirm that not all weight loss strategies are equal in terms of reducing cardiovascular risk. Using Global Burden of Disease data and a pooled analysis of registry data on ~30,000 patients with CVD, we estimate that about 34 million patients across the Middle East could benefit from secondary prevention of CVD by targeting OAO phenotypes. Implementing secondary prevention in practice will require updating clinical guidelines on both obesity management and CVD secondary prevention, as well as policy changes that allow for reimbursement. Crucially, it will also require a philosophical shift that there exist distinct OAO phenotypes for which treatment success is not solely dictated by weight loss. The cumulative burden of future cardiovascular risk is set to increase, mandating comprehensive strategies to implement secondary prevention in at‐risk groups, including children.

Cardiovascular disease involves complex molecular, cellular, and physiological derangements that present challenges for traditional diagnostic and therapeutic approaches. Precision medicine is an evolving field that seeks to tailor interventions according to an individual's genetic, molecular, and physiological characteristics. By leveraging advanced omics approaches, including genomics, proteomics, metabolomics, and microbiomics, precision medicine may enable more comprehensive patient phenotyping and support the development of more individualized strategies. The emerging concept of precision cardiac rehabilitation (CR) could provide a more tailored approach to cardiac care by integrating artificial intelligence (AI) with multimodal data, including clinical, imaging, physiological, and omics information. In this context, AI has been explored as a tool to support risk assessment, exercise prescription, and monitoring during CR. However, current evidence remains limited and heterogeneous. Omics-based approaches are primarily confined to research and translational settings, and their role in guiding individualized exercise prescription or clinical decision making in CR remains unestablished. Similarly, while AI shows promise for improving adherence, remote monitoring, and data integration, its effectiveness for optimizing clinical outcomes in CR requires further validation. Overall, precision CR represents a promising but still evolving paradigm. Future progress will depend on well-designed clinical trials, real-world data integration, standardized methodologies, and interdisciplinary collaboration to determine whether these technologies can be safely and effectively integrated into routine clinical practice.

More interventions that better manage cardiovascular disease are urgently needed in the Middle East. To discuss this issue, we held a symposium at the Heart Masters Middle East 2023 congress (Dubai, UAE; May 2023) on personalized management of angina and heart failure (HF). This narrative review summarizes the content of our symposium. Many patients with chronic stable angina have ongoing symptoms and poor quality of life (QoL) despite beta-blocker + calcium-channel blocker therapy and revascularization. Further, angina is often under-recognized in clinical practice. Clinicians should consider adding newer antianginal agents (long-acting nitrates, ranolazine, trimetazidine, ivabradine) to beta-blockers + calcium-channel blockers based on patient risk factors. Individualized therapy is recommended because several mechanisms can cause angina. Agents that act at a cellular level (e.g., trimetazidine) can prevent ischemia in cardiomyocytes. Trimetazidine provides early and sustained antianginal effects, with improvements in myocardial metabolism and exercise capacity. In our view, trimetazidine may be considered as second-line therapy for angina that is suboptimally controlled on first-line therapy, and could be added to first-line therapy for angina occurring after myocardial infarction or revascularization, and comorbid with diabetes. Ivabradine reduces elevated heart rate and, when added to beta-blockers, improves angina symptoms, exercise capacity and QoL. Few patients with HF with reduced ejection fraction receive medications at target doses. Guidelines suggest rapid initiation of first-line agents from four drug classes, with a simultaneous strategy favored over a sequential one. In patients with HF with reduced ejection fraction in sinus rhythm and elevated heart rate, ivabradine should be added to maximum tolerated doses of beta-blockers. Adding ivabradine to first-line therapy improves heart rate control and QoL, and reduces HF-related hospitalization and mortality.

The emerging concept of the cardiovascular-kidney-metabolic (CKM) syndrome encapsulates the interrelated nature of metabolic processes and metabolic dysfunction. Prediabetes, which describes the presence of elevations of blood glucose measurements insufficient to provoke a diagnosis of type 2 diabetes (T2D), is an important, – and crucially, reversible – early manifestation of the CKM syndrome. Numerous clinical studies and meta-analyses have shown that a substantial minority of people with prediabetes have microvascular and/or macrovascular complications reminiscent of those seen in clinical T2D. Prediabetes therefore represents an early stage of a continuum of increased insulin resistance, hyperglycaemia and associated vascular risk that begins at blood glucose concentrations that are well below those required for a diagnosis of diabetes. This condition also provides an opportunity for early intervention. All people with prediabetes should receive a multifactorial lifestyle intervention that focuses of weight management, nutrition, physical activity and smoking cessation. Where this is insufficient, ineffective or not followed, metformin remains the best studied pharmacotherapy for the management of prediabetes, with formal therapeutic indications for this purpose in many countries and support within international guidelines. Weight management is crucial for diabetes prevention, and weight loss during receipt of incretin agonist drugs is effective in diabetes prevention in populations with prediabetes, although consideration should be given to how long the treatment should be maintained and how the patient should be managed when it is ultimately withdrawn.

Background: Pulmonary arterial hypertension (PAH) is a progressive, fatal cardiopulmonary disorder characterized by elevated pulmonary vascular resistance leading to right heart failure. Current treatment utilizes pathway-specific vasodilators, including numerous prostacyclin therapies with diverse delivery methods. Despite available options, head-to-head studies comparing these treatments remain scarce.Aim: This network meta-analysis seeks to systematically evaluate all prostacyclin-based PAH therapies to guide clinical decision-making regarding treatment selection.Methods: We implemented a frequentist approach to network meta-analysis (NWM). For continuous outcomes, we calculated pooled mean differences (MD), whereas risk ratios (RR) were determined for binary endpoints. All estimates incorporated 95% confidence intervals. Results achieving p-values below 0.05 were considered statistically significant.Results: Our NWM comprising 32 studies (N = 7,819) revealed significant mortality reduction with treprostinil versus placebo (RR 0.66, 95%CI 0.49–0.90), while epoprostenol transitioned demonstrated superior survival benefit (P-score 0.78). For functional capacity, epoprostenol exhibited the greatest 6-Minute Walking Distance (6MWD) improvement (46.84 m, 95%CI 21.90–71.78; P-score 0.90) versus placebo. Hemodynamically, epoprostenol achieved optimal Pulmonary Arterial Pressure (PAP) reduction (−6.29 mmHg, 95%CI -6.99 to −5.59; P-score 0.95), while iloprost demonstrated superior Pulmonary Vascular Resistance (PVR) improvement (−342.09, 95%CI -410.30 to −273.87; P-score 1.00). Epoprostenol ranked highest for Right Atrial Pressure (RAP) reduction (−2.41 mmHg, 95%CI -2.65 to −2.18) and cardiac index improvement (0.56, 95%CI 0.49–0.63). Regarding clinical worsening, selexipag showed potential superiority (RR 0.62, 95%CI 0.51–0.74; P-score 0.95) compared to treprostinil (P-score 0.55).Conclusion: Our NMA demonstrates that prostacyclin pathway therapies offer benefits in PAH management. While epoprostenol exhibits superior improvements in hemodynamics and functional capacity, treprostinil reduces mortality by 34%, and selexipag excels in preventing clinical worsening and hospitalizations.