INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Interventional Cardiology
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SES Reduce In-Stent Restenosis in SVGs.
Previous randomized studies comparing sirolimus-eluting stents (SES) to bare-metal stents (BMS) have excluded lesions in saphenous vein grafts, yet these lesions have higher rates of restenosis compared to native vessels. The RRISC (Reduction of Restenosis In Saphenous vein grafts with Cypher stent) trial randomized 75 subjects to either SES or BMS in a double-blind fashion with mandated follow-up angiography at 6 months. Binary in-stent restenosis was reduced from 30% to 10% when using SES. This study suggests that the risk of in-stent restenosis is high in SVGs, but can be substantially reduced through the use of SES. See page 2423.
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Postinfarction Myocardial Perfusion Imaging
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Questioning the Routine Invasive Paradigm.
Deciding which patients should proceed directly to angiography remains challenging as both medical therapy and revascularization success continue to evolve. The INSPIRE (Adenosine Sestamibi Post-Infarction Evaluation) trial is a large multinational study with 2 main aims. The first aim was to determine if single-photon emission computed tomography (SPECT) imaging can identify low risk post-myocardial infarction (MI) patients who can be discharged early. One-third of patients were classified as low risk with small (<20%) perfusion defects, preserved left ventricular function and <10% residual ischemia. The 1-year risk of death or reinfarction was <2% in this group. The second aim of this study was to compare aggressive anti-anginal medical therapy with revascularization in a higher risk group in which patients had large total (>20%) and ischemic (>10%) perfusion defects, but an ejection fraction >35%. Both medical therapy and revascularization resulted in an approximately 20% reduction in perfusion and ischemic defects after 2 months with similar clinical outcomes. These 2 related trials offer support to strategies that do not mandate routine invasive strategy. See pages 2448, 2458, and 2468. See figure.
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Heart Failure
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Iron Deficiency Underestimated in CHF Patients With Anemia.
Several recent studies have found higher mortality in patients with congestive heart failure (CHF) who are anemic, with an approximate 3% increase in mortality for every 1% decrease in hematocrit. Nanas and colleagues performed extensive analyses on 37 patients with anemia and decompensated heart failure. The analyses included not only serum measures of iron, ferritin, and erythropoietin, but also bone marrow biopsies. Iron deficiency anemia was confirmed by bone-marrow aspiration in 73% of patients and 5% had dilutional anemia. No specific cause was identified in 19%, who were considered to have "anemia of chronic disease." Neither serum ferritin nor serum iron levels reliably identified iron-deficient patients. While the etiology of anemia in heart failure is complex, this study suggests that iron deficiency is prevalent and a trial of iron therapy may be considered even if serum iron and ferritin levels are normal. See pages 2485 and 2490. See figure.
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Heart Rhythm Disorders
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Long-Term Follow-Up of Pulmonary Vein Stenosis After AF Ablation.
In a previously published study, Di Biase and colleagues found that approximately 1% of patients had at least one pulmonary vein (PV) occlude after PV isolation procedures. In this report, long term follow-up of 18 patients is reported. Using serial computed tomography scans, most patients were asymptomatic if only one PV was occluded as long as the other PV for that lung had a <50% stenosis. For those with stenoses of both PVs nuclear perfusion scans demonstrated decreased lung perfusion which also correlated with patient symptoms and response to opening of the blockage. In this study, patients with a single pulmonary vein occlusion (PVO) are mostly asymptomatic, but in patients with concomitant ipsilateral pulmonary vein stenosis/PVO, interventions to restore pulmonary flow and prevent associated lung disease should be considered. See page 2493.
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Cardiac Imaging
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Head-to-Head Comparison of MDCT and MPI.
Multi-slice computed tomography (MSCT) is able to accurately determine the presence or absence of coronary stenoses when compared to coronary angiography, but does not provide data on myocardial perfusion. Schuijf and colleagues performed MSCT in 114 patients referred for nuclear myocardial perfusion imaging (MPI) studies; one-half of these patients subsequently underwent coronary angiography. Ninety percent of patients with no lesions on MSCT had a normal MPI. When the MSCT was abnormal, it was 50-50 whether the MPI would also be abnormal, yet the MSCT showed excellent correlation with subsequent angiography. The authors conclude that MPI and MSCT provide different and complementary information on coronary artery disease, namely detection of atherosclerosis versus detection of ischemia. An editorial by Dorbala and colleagues comments on how MSCT may be incorporated into diagnostic algorithms in the future. See pages 2508 and 2515. See figure.
Related Article
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Randomized Double-Blind Comparison of Sirolimus-Eluting Stent Versus Bare-Metal Stent Implantation in Diseased Saphenous Vein Grafts: Six-Month Angiographic, Intravascular Ultrasound, and Clinical Follow-Up of the RRISC Trial
- Paul Vermeersch, Pierfrancesco Agostoni, Stefan Verheye, Paul Van den Heuvel, Carl Convens, Nico Bruining, Frank Van den Branden, and Glenn Van Langenhove
J. Am. Coll. Cardiol. 2006 48: 2423-2431.
[Abstract]
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Interventional Cardiology
Postinfarction Myocardial...
