Canadian Cardiology Today

Cardiogenic Shock in the Canadian Landscape: Key Concepts for the Practicing Clinician

Jordan D. Gibson — 2025-03-19

Cardiogenic shock (CS) is generally defined as a state of end-organ hypoperfusion secondary to an inability of the heart to deliver sufficient oxygenated blood to the tissues. Although CS is often initiated by an event that specifically affects the cardiovascular system, without prompt intervention, it can lead to a cascade of insults on other organ systems that result in additional morbidity and mortality. Despite advances in temporary mechanical circulatory support (MCS) technology over the past 2 decades, studies have consistently reported a 30% to 50% mortality rate for patients with CS at 6 to 12 months, though this rate may exceed 70% depending on the severity of the shock and individual patient factors. This review will provide an overview of key concepts in CS including current definitions, hemodynamic assessment, shock state classifications, and prognostication.

The Importance of Hypertriglyceridemia: Risk of Atherosclerosis and Available Treatments

Robert A. Hegele — 2025-03-19

Serum triglycerides are derived from both exogenous and endogenous sources. Exogenous triglycerides are obtained through the diet and circulate post prandially within large, intestinally-derived chylomicron particles, which are normally cleared within 3 to 4 hours after eating. Endogenous triglycerides are hepatically produced and circulate in smaller very low density lipoprotein (VLDL) particles, which are remodelled in plasma to form even smaller triglyceride-depleted low density lipoprotein (LDL) particles. While the atherogenic impact of LDL and its cholesterol content are well appreciated, the atherogenic role of triglyceride-rich lipoprotein particles, including VLDL and various remnant lipoprotein species, had only recently come into focus.

Approximately 25% of the population has mild-to-moderate hypertriglyceridemia, characterized by triglyceride levels ranging from 2 to 9.9 mmol/L, while approximately 1 in 500 has severe hypertriglyceridemia, defined as triglyceride levels >10 mmol/L. Pathogenic DNA variants within the gene encoding the triglyceride clearing enzyme lipoprotein lipase (LPL) or one of its co-factors (APOC2, APOA5, GPIHBP1 or LMF1) can cause severe hypertriglyceridemia, that presents in childhood. Adults with milder forms of genetic predisposition in combination with secondary factors, can also express triglyceride levels this high.

PCSK9 Targeted Therapy to Lower Cholesterol and Reduce Cardiovascular Events

Beth L. Abramson — 2025-03-19

Cardiovascular disease (CVD) is an insidious threat that requires attention. Modifying risk factors can work toward preventing the current CVD epidemic. Elevated low-density lipoprotein cholesterol (LDL-c) is a well-established and modifiable risk factor for cardiovascular, cerebrovascular, and peripheral vascular diseases. Despite receiving maximally tolerated doses of statin therapy, many Canadian patients with CVD do not achieve LDL-c targets. Additional lipid-lowering therapies, such as ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), are warranted.

This paper reviews the mechanisms of action and clinical trial evidence for contemporary lipid-lowering therapies, including PCSK9 inhibitor monoclonal antibodies such as evolocumab and alirocumab, and small interfering RNA (siRNA) modulators such as inclisiran, to aid Canadian clinicians in maintaining best practices.

Use of Antiplatelet Agents in Canadian Patients: A Reflection of the 2023 Antiplatelet Guidelines

Guillaume Marquis-Gravel — 2025-03-19

Antiplatelet agents play a fundamental role in secondary prevention of atherosclerotic cardiovascular disease by reducing the risk of recurrent ischemic events. Over the past decades, developments and refinements in antiplatelet therapy have been made through the commercialization of novel classes (P2Y12 inhibitors, glycoprotein [GP] IIb/IIIa inhibitors), modes of administration (oral and intravenous), and combination strategies (dual antiplatelet therapy [DAPT] of different durations). Recently, concerns have been raised regarding the prognostic impact of bleeding events associated with antiplatelet agents. Consequently, multiple strategies have been studied to optimize the fine balance between ischemic protection and bleeding avoidance with these agents. The 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy by the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology distilled the most recent evidence on this topic from a Canadian perspective. This review offers insights into the implementation of the guidelines’ recommendations in routine clinical practice within the Canadian setting.