INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Interventional Cardiology
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Risk of 30-Day MACE Linked to Response to Clopidogrel Loading.
There has been much interest lately in the variability of response to clopidogrel loading, but there is little evidence to confirm that this variability correlates with increased risk of peri-procedural complications after percutaneous coronary intervention (PCI). The EXCELSIOR (Impact of Extent of Clopidogrel-Induced Platelet Inhibition During Elective Stent Implantation on Clinical Event Rate) Trial studied adenosine diphosphate-induced platelet aggregation prior to PCI and 30-day major adverse cardiac events in 800 patients undergoing elective PCI, all of whom received 600 mg of clopidogrel at least 2 h before the procedure. The rate of adverse events was higher in patients who had reduced responsiveness to clopidogrel. An accompanying editorial by Alfonso and Angiolillo integrates the findings of this study with others; they see clear evidence that the risk of peri-procedural complications is related to the degree of platelet inhibition, but confusion arises as to the best methods for measuring platelet inhibition, for loading clopidogrel, and strategies for those patients whose platelets are not adequately inhibited. See page 1742. See figure.
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Pharmacotherapy of HDL and LDL
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Safety and Efficacy of Torcetrapib.
Inhibition of cholesteryl ester transfer protein (CETP) is a recently identified mechanism for raising high-density lipoprotein cholesterol (HDL-C) levels by decreasing the transfer of cholesterol esters from HDL-C to low-density lipoprotein cholesterol (LDL-C) particles. Two related studies in this issue look at the safety and efficacy of torcetrapib either alone or in combination with atorvastatin. In double-blind trials with dose escalation, torcetrapib increased HDL-C up to 54.5% for the highest doses and modestly lowered LDL-C (by 16%) when used as monotherapy. Treatment-related adverse events were similar across placebo and torcetrapib treatment groups, with no evidence of dose-related side effects, although there were a few cases of substantial elevations in blood pressure that will merit further study. An accompanying editorial by Milani and Lavie examines the potential of agents that inhibit CETP to reduce cardiovascular risk. See page 1774, 1782, and 1791. See figure.
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Metabolic Syndrome
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Metabolic Syndrome—A Confluence of Risk Factors.
The metabolic syndrome accurately predicts the risk of subsequent cardiac events, but disagreement remains as to whether there is a synergistic effect among these risk factors such that the risk with the syndrome is greater than the sum of the risks of the individual components. Iribarren and colleagues studied 400 subjects who had experienced a cardiac event at a young age and compared them with control subjects with no cardiac history. The presence of the metabolic syndrome using either Adult Treatment Panel III criteria or the American Heart Association/National Heart, Lung, and Blood Institute criteria was associated with a 5-times higher risk of cardiac disease if diabetes was not present and 8 times higher in the presence of diabetes. However, after using multivariable regression to control for the individual components of risk, there was no additional risk to meeting the criteria of metabolic syndrome. Although it is clear that the metabolic syndrome imparts a high risk of early-onset cardiac events, the prognostic information associated with the syndrome appears not to be greater than the sum of its parts. See page 1800.
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Cardiac Imaging
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PET Imaging Can Detect Carotid Plaque Inflammation.
Determining which patients with carotid stenoses are at high risk for subsequent cerebrovascular accident (CVA) is difficult. An imaging modality that could detect active inflammation, and thus the risk of plaque rupture, may help to stratify these patients. Fluorodeoxyglucose positron emission tomography (FDG-PET) can detect areas of increased glucose utilitization and active cellular metabolism. Tawakol and colleagues performed FDG-PET scans on patients before they underwent carotid endarterectomies. Histologic analyses were then compared with the PET images. There was a strong correlation between increased FDG-PET activity and the number of macrophages in the atherosclerotic plaque. This imaging modality is able to accurately determine the degree of inflammation in carotid atherosclerotic plaques, which may have implications for the subsequent risk of CVA or for monitoring response to therapy. See page 1818. See figure.
Related Article
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Impact of the Degree of Peri-Interventional Platelet Inhibition After Loading With Clopidogrel on Early Clinical Outcome of Elective Coronary Stent Placement
- Willibald Hochholzer, Dietmar Trenk, Hans-Peter Bestehorn, Benjamin Fischer, Christian M. Valina, Miroslaw Ferenc, Michael Gick, Angelika Caputo, Heinz Joachim Büttner, and Franz-Josef Neumann
J. Am. Coll. Cardiol. 2006 48: 1742-1750.
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Interventional Cardiology
Pharmacotherapy of HDL and...
