INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Clinical Trial
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AngioJet Ineffective for STEMI.
Distal embolization of thrombus is thought to be a significant cause of "no reflow" after angioplasty for acute infarctions, and many strategies to reduce thrombus burden have been proposed. The AngioJet device uses saline flow to break apart the clot and then a suction catheter to remove the pieces. Ali and colleagues report the results of the AiMI study, which randomized almost 500 patients with acute ST-segment elevation myocardial infarction to either standard percutaneous coronary intervention (PCI) or rheolytic thrombectomy prior to balloon inflation. All of the major end points favored standard PCI, which had smaller infarct size, higher rates of post-procedural Thrombolysis In Myocardial Infarction flow grade 3, and reduced 30-day mortality. The group randomized to PCI did have an unexpectedly low (<1%) 30-day mortality, which may explain some of the worse outcomes in the thrombectomy group, but this trial provides no evidence that thrombectomy should be routinely performed. Rather, this study suggests that routine thrombectomy is harmful. See page 244.
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Interventional Cardiology
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Cost Comparisons of Drug-Eluting Stents.
 Two articles and an editorial in this issue compare the costs and benefits of drug-eluting stents. Bakhai and colleagues used data from the TAXUS-IV trial along with supplemental assumptions about costs to determine if paclitaxel-eluting stents (PES) are cost effective. Choosing a PES adds approximately $2,000 to the initial procedure, but because of fewer costly target vessel revascularizations (TVRs) over the subsequent year, the net cost is only $572 per PES. For patients without mandatory angiographic follow-up, the extra cost was only $97 per patient. Elezi and colleagues used data from the 450 patients enrolled in the ISAR trials, which randomized patients to either sirolimus- or paclitaxel-eluting stents. In these two trials, sirolimus stents were only half as likely to require TVR, resulting in total costs that were approximately $2,000 less per patient. An editorial by Vaitkus addresses the difficulties and limitations in performing these types of analyses and offers suggestions to make these analyses more relevant for decision-makers. See pages 253, 262, and 268. See figure.
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Diabetes and Cardiovascular Risk
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Prediabetes and Cardiovascular Risk.
Diabetes is a known cardiovascular risk factor and impaired fasting glucose (IFG) is thought to represent "prediabetes." In 2003, the American Diabetes Association lowered the threshold for diagnosing IFG from 110 mg/dl to 100 mg/dl. Kim and colleagues preformed a retrospective chart review to study the consequences of the new definition and its relationship with cardiac risk. The prevalence of IFG in this group of patients ages 30 to 69 years was found to increase from 8% to 35% with the new definition. Compared to those with fasting glucose <100 mg/dl, the odds ratio for a previous cardiac event was not significantly different for those with a glucose level of 100 to 110 mg/dl, but was for those with a glucose level >110 mg/dl. This study suggests that labeling one-third of patients with IFG may dilute the significance of this diagnosis in identifying those most in need of primary prevention. See page 293.
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Cardiac Imaging
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Prevalence of Atherosclerosis by MSCT in Intermediate-Risk Patients.
Hausleiter and colleagues used 64-slice coronary computed tomography to prospectively evaluate 160 patients with intermediate risk for occlusive coronary artery disease; for example, those with chest pain on exertion but negative stress test or positive stress test but no chest pain. Quantification of coronary calcium and identification of atherosclerotic plaque were the primary measures. Approximately one-third of patients had no calcium and no atherosclerotic plaque, one-third had only calcified plaques, and the final one-third had both kinds of plaque. Only 6% had noncalcified plaques without additional areas of coronary calcium. Patients with noncalcifed plaques had higher low-density lipoprotein and C-reactive protein levels than those with only calcified plaques. Computed tomographic angiography may be useful in further risk-stratifying intermediate-risk individuals and in identifying vulnerable plaques. See page 312.
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Heart Rhythm Disorders
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Spectral Analysis of AF Ablation.
 Spectral analysis of electrocardiograms can be used to identify high-frequency sources that may perpetuate atrial fibrillation (AF). This technique uses either standard or intracardiac electrocardiograms filtered for signals between 0 to 80 MHz; the QRS complex is then mathematically subtracted and the frequency characteristics of the remaining signal are transformed to identify a dominant frequency (DF). Lemola and colleagues report that the DF is higher during persistent than paroxysmal AF and that both pulmonary vein isolation and electrogram-guided ablation reduce the DF, although there were differences in predicting long-term success based on these changes. This technique may prove useful in understanding the pathophysiology of AF. See page 340. See figure.
Related Article
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Rheolytic Thrombectomy With Percutaneous Coronary Intervention for Infarct Size Reduction in Acute Myocardial Infarction: 30-Day Results From a Multicenter Randomized Study
- Arshad Ali, David Cox, Nabil Dib, Bruce Brodie, Daniel Berman, Navin Gupta, Kevin Browne, Robert Iwaoka, Michael Azrin, Dwight Stapleton, Cindy Setum, Jeffrey Popma for the AIMI Investigators
J. Am. Coll. Cardiol. 2006 48: 244-252.
[Abstract]
[Full Text]
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Clinical Trial
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