Resistant hypertension (RH), defined as uncontrolled blood pressure on three or more antihypertensive agents (including a diuretic) or controlled blood pressure on four or more, poses a major clinical challenge.It disproportionately drives adverse cardiovascular outcomes, including stroke, heart failure and chronic kidney disease.Accurate diagnosis first requires distinguishing true RH from pseudo-resistance, which stems from inaccurate measurement, poor medication adherence and clinical inertia.The pathophysiology is multifactorial, driven by mechanisms such as sympathetic nervous system overactivity, renin-angiotensin-aldosterone system dysregulation, obesity and obstructive sleep apnoea.Consequently, effective management extends beyond mere drug intensification.It demands a comprehensive strategy that addresses lifestyle factors, ensures therapeutic adherence and treats secondary causes.For eligible patients, device-based therapies, such as renal denervation, are emerging as valuable adjuncts to pharmacological treatment.This article synthesizes the current understanding of RH's epidemiology, pathophysiology and diagnostic workup.It also critically examines the evolving landscape of integrated therapeutic strategies, discussing on-going controversies and future research directions to improve patient outcomes.Hypertension affects over 1.4 billion adults worldwide and remains the leading modifiable risk factor for global cardiovascular (CV) morbidity and mortality.It is responsible for an estimated 10.8 million deaths annually and contributes significantly to the global burden of ischaemic heart disease, stroke, heart failure and chronic kidney disease (CKD). 1 Despite the availability of safe, effective antihypertensive therapies, a substantial proportion of patients exhibit persistent blood pressure (BP) elevation despite multi-drug treatment, a condition termed resistant hypertension (RH).This particularly challenging subset is often associated with poor BP control rates, high CV risk and substantial healthcare utilization.This comprehensive article examines the current understanding of RH from epidemiological patterns and pathophysiological mechanisms to diagnostic challenges and evolving therapeutic strategies.We critically evaluate the evidence base for contemporary management approaches and discuss future directions for improving outcomes in this high-risk patient population. Review Hypertension Heart International EpidemiologyRH represents a significant global health problem, with estimates suggesting that between 100 and 500 million individuals worldwide may be affected. 2This wide range reflects differences in diagnostic criteria, study methodologies and population characteristics across regions.In a comprehensive meta-analysis that included 91 cohort and cross-sectional studies involving more than 3.2 million patients with hypertension, the prevalence of RH was estimated to be approximately 10%. 5 Data suggest that the prevalence of RH is around 8.5-20% among US adults with hypertension. [6][7]7][8] Insights from the largest analysis of patients with RH (Cardiovascular Quality Improvement and Care Innovation Consortium [CV-QUIC]) reported a prevalence of RH to be 8.5% using the contemporary BP cutoff of 130/80 mmHg. 7Contemporary data from the National Health and Nutrition Examination Survey (NHANES) found that 15.9% of adult patients with hypertension met the criteria for RH, highlighting the widespread impact of this entity. 9The burden of RH is particularly pronounced in low-and middle-income countries, where the prevalence of hypertension is rising rapidly and control rates remain suboptimal.Data from the Jaipur Heart Watch study in India reported the prevalence of RH to be 19.4%. 10 RH is more common among older adults, males, individuals of African ancestry and those with comorbid metabolic syndromes or CKD.Data from the Research Action for Health Network (REACHnet) reported that patients with RH had a significantly higher prevalence of diabetes, dyslipidaemia, coronary artery disease, stroke, heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, myocardial infarction (MI), CKD, sleep apnoea and other comorbidities when compared with patients with controlled hypertension. 8RH carries a significant clinical burden, as these patients are at greater risk for target-organ damage, including left ventricular hypertrophy, diastolic dysfunction, carotid intimal-medial thickening and microalbuminuria. 11Patients with RH have a twofold increased risk of CV disease events compared with patients whose hypertension is responsive to treatment.Longitudinal cohort studies demonstrate that RH confers an elevated risk of MI (hazard ratio [HR]: 1.47), stroke (HR: 1.42), heart failure (HR:1.70) and all-cause mortality (HR: 1.33) compared with controlled hypertension. 12RH significantly accelerates renal decline, conferring an increased risk for advanced CKD and nearly doubling the likelihood of progressing to end-stage renal disease. 13The burden of RH extends beyond individual patients to healthcare systems, with increased rates of hospitalizations, healthcare utilization and medication costs. 14fective identification and management of RH is, therefore, a public health priority.

Left bundle branch area pacing has been a breakthrough in pacing therapy and is being increasingly adopted. It delivers a more physiological form of pacing compared with right ventricular and biventricular pacing and also avoids the risk of perforation of the ventricular free wall. However, the therapy comes at the price of new complications related to the transseptal route for placing the lead. This article provides an update on these complications and discusses how to avoid and manage these adverse events.

The Evolut Low Risk trial (Transcatheter Aortic Valve Replacement With the Medtronic Transcatheter Aortic Valve Replacement System In Patients at Low Risk for Surgical Aortic Valve Replacement; ClinicalTrials.gov identifier: NCT02701283) provides reassuring evidence that transcatheter aortic valve replacement remains non-inferior to surgery at 5-year follow-up with regard to mortality and disabling stroke in low-risk patients. Valve performance, durability and quality-of-life improvements were excellent in both groups.

With 24 patents granted for different catheters stents and other medical devices, Dr Heuser served as a principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 50 pharmaceutical products and participated in more than 100 research studies.He authored numerous articles, textbooks and medical manuscripts, and was frequently invited to international medical conferences to present findings of research originating in Phoenix.Dr Heuser developed the first catheter treatment for leakage of the mitral valve, which has presaged the catheter treatment that is now available routinely for narrowing or leakage of the mitral valve.His hydrophilic or "water loving" wire, co-developed with an engineer, is utilized in approximately 20% in all angioplasty procedures performed worldwide.The covered stent that Dr Heuser co-invented is currently used in every catheter lab worldwide that performs angioplasty and stenting.

Introduction: This systematic review aims to summarize the procedural arrhythmia termination rates in catheter ablation (CA) procedures of atrial or ventricular arrhythmias using the commonly used mapping systems (CARTO, Rhythmia and EnSite/NavX). Materials and Methods: A systematic search in MEDLINE and Cochrane databases through February 2021 was performed. Results: With regard to atrial fibrillation ablation procedures, acute success rates ranged from 15.4 to 96.0% and 9.1 to 100.0% using the CARTO and EnSite/NavX mapping systems, respectively; acute atrial tachycardia (AT) termination to sinus rhythm ranged from 75 to 100% using the CARTO system. The acute success rate for different types of AT ranged from 75 to 97% using Rhythmia, while the NavX mapping system was also found to have excellent efficacy in the setting of AT, with acute arrhythmia termination rates ranging from 73 to 99%. With regard to ventricular tachycardia, in the setting of ischaemic cardiomyopathy, acute success rates ranged from 70 to 100% using CARTO and 64% using EnSite/NavX systems. The acute success rate using the Rhythmia system ranged from 61.5 to 100.0% for different clinical settings. Conclusions: Mapping systems have played a crucial role in high-density mapping and the observed high procedural success rates of atrial and ventricular CA procedures. More data are needed for the comparative efficacy of mapping systems in acute arrhythmia termination, across different clinical settings.

The development of clinical congestion resulting from volume overload, either by renal fluid retention or redistribution of blood volume from venous reservoirs, is a recurrent scenario in patients with chronic heart failure (HF). As a result, the treatment of congestion, most commonly by initiating aggressive diuretic therapy, is a front-line issue in the management of patients with HF. However, the association of clinical congestion and volume overload with physical signs and symptoms, as well as other surrogates of volume assessment, has limitations in accuracy and, therefore, reliability to direct appropriate interventions. The ability to quantitate intravascular volume and identify the variability in volume profiles among patients with HF can uniquely inform individualized volume management and aid in risk stratification. This tool is provided by contemporary nuclear medicine-based BVA-100 methodology, which uses the well-established indicator-dilution principle and is a requested topic for discussion in this review.

Second-generation drug-eluting stents (DES) are considered standard of care for revascularization of patients undergoing percutaneous coronary intervention. Besides the polymer and antiproliferative drug used, the metallic backbone of DES is an attractive target for further development. Ultrathin-strut DES (≤70 μm strut thickness) are more flexible, have an improved trackability and crossability compared to conventional second-generation DES. Importantly, ultrathin-strut DES reduce the risk of in-stent restenosis, thereby decreasing the risk of angiographic and clinical restenosis. In this narrative review, we will discuss the clinical outcomes of the commercially available ultrathin-strut DES.

Several organizations have developed guidelines for the management of ST-segment elevation myocardial infarction (STEMI). However, the optimal strategy regarding revascularization in the setting of multivessel disease, specifically with regards to culprit vessel versus complete revascularization, continues to evolve. While previous observational studies promoted culprit vessel-only intervention in patients with STEMI, recent randomized controlled trials suggest potential benefits with multivessel revascularization, either at the time of the index event or in a staged fashion, in patients without cardiogenic shock. This may be due to the known instability of non-culprit lesions in the setting of acute coronary syndrome, and the diffuse coronary processes involved. As additional literature examines culprit vessel versus multivessel revascularization strategies, clinicians continue to be tasked with determining optimal treatment plans for their patients and understanding the factors that promote selected revascularization strategies. This review summarizes and discusses observational studies, randomized control trials and current guidelines in order to evaluate optimal reperfusion strategies for patients presenting with STEMI in the setting of multivessel disease.

Left main bifurcation percutaneous coronary intervention is a challenging subset that requires expertise in techniques that are in constant modification. Imaging is important in lesion preparation and optimising outcomes. The interventionalist needs to be highly skilled in the different techniques, as missteps may lead to stent thrombosis and critical in-stent restenosis. Lesion classification between simple and complex identifies those who would best benefit from a two-stent technique. Current technical approaches and practice considerations are summarised in this manuscript.