INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Biomarkers and Coronary Disease
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Both Troponin and BNP Identify Patients Who Benefit From Revascularization.
Several studies have found that elevated levels of troponin identify acute coronary syndrome patients at increased risk, and that these patients do better if revascularized than if medically treated. James and colleagues confirm and expand these findings with data from the GUSTO-IV trial. In this trial both troponin-T and N-terminal pro-B-type natriuretic peptide (BNP) stratified patients as either high or low risk for 1-year mortality. Furthermore, subjects with elevated levels of either marker (for troponin >0.1 and >237 ng/l for BNP) had lower mortality if they were revascularized than those who were not revascularized. This study demonstrates that both troponin and BNP cannot only identify those at increased risk of death, but can also identify those most likely to benefit from revascularization. See page 1146.
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Risk for Cardiovascular Disease
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Changes in the Risk Factors for CHD Among U.S. Adults.
Recent studies have suggested that the risk of dying from coronary heart disease has decreased, but the reasons are unclear. Ajani and Ford compared data from the National Health and Nutrition Examination Survey (NHANES) surveys in 1988 to 1994 and 1999 to 2002, to determine if the 10-year Framingham risk of coronary heart disease (CHD) had changed. Overall, there was no difference in the risk of CHD or in the percentages of respondents at high and intermediate risk; however, there were changes in the individual risk factors. Specifically, the rates of smoking were less, but there was increased prevalence of diabetes and systolic hypertension that appeared to be due to increased rates of obesity. This study suggests that overall risk has not changed significantly and programs to reduce the risk of CHD need to be multi-pronged. See page 1177.
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Enhanced External Counterpulsation
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EECP Improves Functional Capacity in Patients With Systolic Dysfunction.
Because of its transient ventricular unloading and improvements in peripheral vascular resistance, enhanced external counterpulsation (EECP) may be beneficial in patients with systolic dysfunction. The PEECH (Prospective Evaluation of EECP in Congestive Heart Failure) trial randomized subjects with an ejection fraction <35% to either continued medical therapy or medical therapy plus 35 1-h EECP sessions. Enhanced external counterpulsation resulted in more subjects improving their exercise treadmill time, but there were no improvements in oxygen utilization. The improvement in functional capacity and heart failure symptoms suggests a role for EECP in these patients, but the lack of change in other criteria raises questions about the placebo effect. See page 1198.
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Heart Failure
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Intravenous Iron Improves Heart Failure Symptoms.
Anemia is common in patients with chronic heart failure (CHF) and is associated with higher morbidity and mortality. The combination of erythropoietin (EPO) and iron increases hemoglobin (Hb) and improves symptoms and exercise capacity in anemic CHF patients, but the efficacy of iron without EPO is unknown. Bolger and colleagues performed a small pilot study in 16 patients with CHF and Hb <12 mg/dl. Subjects received up to five 10-ml infusions of 200 mg of iron sucrose, which was well tolerated. This resulted in an increase in mean Hb from 11.2 to 12.6 mg/dl and an average 40-m improvement in the 6-min walk test and improvements in the Minnesota Living with Heart Failure score. This pilot study suggests the need for a larger, randomized study of the efficacy of iron infusions in patients with anemia and CHF. See page 1225. See figure.
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Heart Rhythm Disorders
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Statins Reduce Mortality in Nonischemic Cardiomyopathies.
Whereas the benefit of statins in patients with coronary artery disease is clear, their role in patients with nonischemic cardiomyopathies is less clear. The DEFINITE trial studied patients with nonischemic cardiomyopathies. Goldberger and colleagues reanalyzed the data and stratified subjects based on whether or not they were taking statin medications. Despite similar baseline characteristics, the rates of both total mortality and sudden arrhythmic death were 5 times higher in those not taking statins. This study strongly suggests that statins may improve mortality in patients with nonischemic cardiomyopathies. See page 1228. See figure.
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Pediatric Cardiology
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Impaired Heart Rate Response Predicts Mortality in Adults With Congenital Heart Disease.
There is a need for a simple test that can identify patients with a history of congenital heart disease (CHD) at increased risk for death. Diller and colleagues examined the heart rate response to treadmill exercise and peak oxygen consumption (peak VO2) in over 700 adults with CHD. An abnormal heart rate response to exercise identified patients with an increased risk of mortality, independently of anti-arrhythmic therapy, peak VO2, or functional class. Heart rate reserve, the difference between peak heart rate and resting heart rate, is a simple and inexpensive way to identify CHD patients at the greatest risk for death. See page 1250. See figure.
Related Article
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Troponin-T and N-Terminal Pro-B-Type Natriuretic Peptide Predict Mortality Benefit From Coronary Revascularization in Acute Coronary Syndromes: A GUSTO-IV Substudy
- Stefan K. James, Johan Lindbäck, Johanna Tilly, Agneta Siegbahn, Per Venge, Paul Armstrong, Robert Califf, Maarten L. Simoons, Lars Wallentin, and Bertil Lindahl
J. Am. Coll. Cardiol. 2006 48: 1146-1154.
[Abstract]
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Biomarkers and Coronary Disease
Risk for Cardiovascular Disease
