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Abstract Background The new millennium has witnessed increased understanding of cardiovascular (CV) risk factors and improvement in atherosclerotic cardiovascular disease (ASCVD) management. The role of LDL cholesterol and other atherogenic lipid particles in the development of atherosclerosis is now beyond doubt. Main body Statins have been widely used and recommended in guidelines for preventing and managing ischemic events. However, statins have side effects, and many patients do not achieve their low-density lipoprotein cholesterol (LDL-C) goals. In recent years, non-statin lipid-lowering agents have gained increasing use as adjuncts to statins or as alternatives in patients who cannot tolerate statins. This consensus proposes a simple approach for initiating non-statin lipid-lowering therapy and provides evidence-based recommendations. Our key advancements include the identification of patients at extreme risk for CV events, the consideration of initial combination therapy of statin and ezetimibe in very high-risk and extreme-risk groups and the extended use of bempedoic acid in patients not reaching LDL-C targets especially in resource-limited settings. Conclusions Overall, this consensus statement provides valuable insights into the expanding field of non-statin therapies and offers practical recommendations to enhance CV care, specifically focusing on improving LDL-C control in Egypt. While these recommendations hold promise, further research and real-world data are needed for validation and refinement.

Abstract Background The current expert view of the PCSK9 inhibitors’ use in Egypt is still ambiguous. Main body Hyperlipidemia is an important, if not the most important, risk factor for the occurrence of atherosclerosis worldwide. Egypt is the most populous country in the Middle East and North Africa and has > 15% of the cardiovascular deaths in the region. The burden of dyslipidemia as seen in the recently published CardioRisk project conducted throughout Egypt shows a high prevalence of dyslipidemia as a risk factor that is still reaching up to 71% in female participants. Reaching the targets for LDL lowering, and thus control of hyperlipidemia, is quite often very difficult especially with the update of the last ESC guidelines. With the advent of PCSK9 inhibitors, the control rate of patients, reduction of cardiac major adverse events, and mortality have been improved. However, Egypt is not considered a rich country on the grounds of annual income, and this raises a concern on which patients would benefit from these expensive medications. Revising the randomized control trials, we analyzed the data that would enable us to control LDL in those patients, at risk, to obtain simple clear indications for the use of these rather expensive medications. Conclusion We recommend the use of PCSK9 inhibitors in addition to statins ± ezetimibe in patients with ASCVD, by definition at very high risk; patients with ASCVD at very high risk who do not tolerate appropriate doses of at least three statins; and familial hypercholesterolaemia patients with clinically diagnosed ASCVD, at very high cardiovascular risk.

Background: The newer generation of Bioresorbable Vascular Scaffold ABSORB (BVS 1.1) showed better outcome in regard to scaffold area reduction as a result of improved scaffold design and enhanced polymer processing. Objective: To assess the safety and efficacy of treating significant native coronary artery stenosis using ABSORB BVS. Methods: Ninety-nine patients with de novo native significant coronary artery stenosis were selected between September 2012 and September 2014 and were treated using ABSORB BVS. For each patient, the target and the peri-scaffold segments (5 mm proximal and distal to the scaffold edge) were analyzed by Quantitative Coronary Angiography (QCA) and Intravascular Ultrasound (IVUS) immediately after the procedure and at one year of follow-up. The major clinical endpoint was ischemia-driven major adverse cardiac events (ID-MACE) defined as a composite of cardiac death, myocardial infarction or ischemia-driven target lesion revascularization (ID-TLR). Results: At one year, the overall scaffold area did not demonstrate any significant change. The angiographic insegment late lumen loss was estimated to be 0.11 ± 0.19 mm, while the IVUS assessment revealed a non-significant decrease in the minimal lumen area by 0.5% (p = 0.79), without significant change in the mean lumen area. There were no reported cardiac deaths. However, two cases of ID-TLR were recorded, one case with STEMI after two weeks due to thrombosis at the distal edge of the BVS and another case with restenosis after one year. Both were treated with metallic drug-eluting stents (Xience V). At one year the overall ID-MACE was found to be 2%. Conclusion: The performance of ABSORB BVS in the treatment of significant de novo native coronary artery stenosis makes it an attractive option with favorable early and late outcome.

Background: Atrial fibrillation (AF) is considered the major cause of stroke in the elderly. Alternative therapies to the anticoagulant therapy are warranted, particularly in patients who are ineligible or at high risk of bleeding. The left atrial appendage (LAA) is a prominent source of thrombi in nonvalvular AF, accounting for 90% of thrombi. As a result, surgical and transcatheter techniques have been explored to reduce the risk of stroke in patients with AF by occluding the LAA. Objectives: To assess the safety and efficacy of LAA closure in patients with nonvalvular atrial fibrillation (AF) ineligible for warfarin therapy. Methods: A prospective study that evaluated LAA closure with the Watchman device (Boston Scientific, Natick, MA; group A) in fifteen patients with nonvalvular AF and CHADS2 (congestive heart failure, hypertension, age ⩾75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ⩾1, who were considered ineligible for warfarin therapy. The primary efficacy endpoint was the combined events of ischemic/hemorrhagic stroke, systemic embolism and cardiovascular/unexplained death during a period of six months follow-up. Results: Successful closure of the LAA using the Watchman device was achieved in 15 patients (100%). The mean age was found to be 67.9 ± 9 years with 40% of them being males. No device or procedure related adverse events were detected. The mean CHADS2 score was 2.4 ± 0.8, while the mean CHA2DS2-VASC score was 4.4 ± 1.0. After a mean period of 8 ± 2 months of follow-up, no device dislodgement or device-related thrombi were documented. The all-cause stroke (ischemic and hemorrhagic) and systemic embolism were 0%. The device and procedure related mortality was found to be 0%. Only one patient died after 8 months of device implantation from pneumonia. Conclusion: LAA closure with the Watchman device can be safely performed, and may be a reasonable alternative to consider for patients at high risk for stroke but with contraindications to systemic oral anticoagulation or with high risk of bleeding.

Objective: To evaluate the feasibility, efficacy, and safety of the ABSORB BVS (Bioresorbable Vascular Scaffold) for the treatment of de novo native coronary artery stenosis. Methods: Thirty patients with ischemic heart disease were selected between September 2012 and December 2012 and received ABSORB BVS for the treatment of de novo native significant coronary artery stenosis. Patients were followed up for six months after the procedure. In each patient, the treated segment and the periscaffold segments (5 mm proximal and distal to the scaffold edge) were analyzed by Quantitative coronary angiography (QCA) and phased-array intravascular ultrasound (IVUS) catheters in paired matched angiographic views after the procedure and at follow-up. The major clinical end point was ischemia-driven major adverse cardiac events (ID-MACE) defined as a composite of cardiac death, myocardial infarction or ischemia-driven target lesion revascularization. Results: Overall the scaffold area remained unchanged. The angiographic late lumen loss amounted to 0.27 ± 0.32 mm with an IVUS relative decrease in minimal lumen area of 1.94% (p = 0.12), without significant changes in the mean lumen area. After 2 weeks, 1 patient presented with STEMI, control coronary angiography revealed a patent stent with thrombus distal to it that was treated with a metallic drug-eluting stent (Xience V). There were no cardiac deaths or ischemia-driven target lesion revascularizations. At six months the hierarchical ID-MACE was 3.3%. Conclusions: ABSORB BVS seems an attractive option for the treatment of significant de novo native coronary artery stenosis with low risk of serious adverse events.

Objectives: To evaluate the feasibility, efficacy, and safety of catheter-based radiofrequency renal sympathetic denervation for treatment of resistant hypertension. Background: In a subpopulation of patients with essential hypertension, therapeutic targets are not met, despite the use of multiple types of medication. In this paper we describe our first experience with a novel percutaneous treatment modality using renal artery radiofrequency (RF) ablation. Methods: Thirty patients with essential hypertension unresponsive to at least three types of antihypertensive medical therapy (baseline office systolic blood pressure ⩾160 mmHg) were selected between March and September 2012 and received percutaneous RF ablation. Patients were followed up for 6 months after treatment. The primary effectiveness endpoint was change in seated office-based measurement of systolic blood pressure at 6 months. Another thirty patients were taken as control. Results: A reduction of mean office blood pressure was seen from 170/102 ± 9/5 mmHg at baseline to 151/91 ± 8/6 mmHg at 6 months follow-up (p = 0.001). Also, we noted a significant decrease in plasma renin activity (3.66 ± 0.64 versus 3.37 ± 0.47 ng/mL/h; p = 0.003). No periprocedural complications, adverse events or change in renal function were noted during follow-up. Conclusion: Catheter-based renal denervation seems an attractive minimally invasive treatment option in patients with resistant hypertension, with a low risk of serious adverse events.

Objectives: To evaluate the feasibility, efficacy, and safety of the MitraClip system in patients with severe MR. Background: Mitral valve repair for mitral regurgitation (MR) has been performed by the use of a surgically created double orifice. Percutaneous repair based on this surgical approach has been developed by the use of a MitraClip device. Methods: Five patients with 3 to 4+ MR were selected in accordance with the American Heart Association/American College of Cardiology guidelines between March 2013 and May 2013 and underwent percutaneous mitral repair with the MitraClip system with 6 months follow up after the procedure. The primary acute safety endpoint was freedom from major adverse events (MAEs) at 30 days. The primary efficacy endpoint was acute procedural success defined as clip implant with the reduction of MR to equal or less than grade II, based on current guidelines. Results: No transseptal complications were reported (0%). There was no procedural mortality. No patients experienced MAE at 30 days. No cases of clip detachment or embolization were observed. Acute procedural success was achieved in all treated patients (100%). There was an improvement in the severity of MR in all patients as assessed acutely. Acute MR reduction by 3 grades was achieved in 2 patients and by 2 grades in 3 patients (reduction ⩾2 grades in 100%). Conclusions: Our initial results with the MitraClip device in a very small number of patients indicate that percutaneous edge-to-edge mitral valve repair is feasible and may be accomplished with favorable short-term safety and efficacy results.

To evaluate the feasibility, efficacy, and safety of the MitraClip system in patients with severe MR. Background: Mitral valve repair for mitral regurgitation (MR) has been performed by the use of a surgically created double orifice. Percutaneous repair based on this surgical approach has been developed by use of the MitraClip device to secure the mitral leaflets. Methods: Five Patients with 3 to 4+ MR were selected in accordance with the American Heart Association/American College of Cardiology guidelines between March 2013 and May 2013 and underwent percutaneous mitral repair with MitraClip system . Patients were followed up for six months after procedure. The primary acute safety endpoint was freedom from major adverse events (MAEs) at 30 days, defined as the composite of death, myocardial infarction, non-elective cardiac surgery for adverse events, renal failure, transfusion of more than 2 units of blood, ventilation for more than 48 h, deep wound infection, septicemia. The primary efficacy endpoint is acute device success defined as clip implant with reduction of MR to equal or less than grade II, based on current guidelines. Results: A total of 5 patients were treated. No patients (0%) had a major adverse event,. Freedom from clip embolization was 100%. Partial clip detachment had not occurred in any patients (0%) patients. Overall, 4 of 5 (80%) patients achieved acute procedural success, and 3 (60%) were discharged with MR of ⩽1+. Conclusions: Our initial results with the MitraClip device in a very small number of patients indicate that percutaneous edge-to edge mitral valve repair is feasible and may be accomplished with favorable short-term safety and efficacy results.