INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Clinical Trial
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PTCA Equivalent to CABG, Except in Diabetics.
The BARI (Bypass Angioplasty Revascularization Investigation) trial randomized almost 2,000 patients with multivessel coronary artery disease to either balloon angioplasty or coronary artery bypass grafting (CABG) between 1988 and 1990. This article examines mortality through 10 years. The 10-year survival was equivalent for both strategies in the whole population and in patients without diabetes; however, the 10-year risk of cardiac death was 1.7 times higher with percutaneous transluminal coronary angioplasty (PTCA) for the subgroup with diabetes. This trial confirms that patients with diabetes are at higher risk for cardiovascular mortality and seem to do better with CABG rather than percutaneous coronary intervention. See page 1600. See figure.
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Interventional Cardiology
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Enalaprilat May Protect Against Acute Ischemia.
Angiotensin-converting enzyme inhibitors increase the bioavailability of bradykinin; bradykinin may be one of the substances that induce the protective effects of cardiac preconditioning. Leesar and colleagues studied the effect of intracoronary infusions of enalaprilat on the chest pain and electrocardiographic effects of occlusive balloon inflations. Patients randomized to enalaprilat had less chest pain and less ST-segment changes during balloon inflations than those randomized to placebo. This study suggests that pretreatment with enalaprilat attenuates the manifestations of myocardial ischemia and may mimic the effect of ischemic preconditioning. See page 1607. See figure.
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Heart Failure
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Increased Mortality in CHF Patients With Obstructive Sleep Apnea.
Obstructive sleep apnea (OSA) leads to several hemodynamic consequences that may increase stress on the heart. Wang and colleagues performed polysomnography on all patients with an ejection fraction <45% referred to their heart failure clinic and then followed them for mortality. Nearly 25% of their patients had OSA. The risk of death was nearly 3 times higher in those with OSA versus those with mild or no OSA. There were trends in the data suggesting that treating OSA with continuous positive airway pressure (CPAP) may reduce the increased mortality, but there were only 14 patients with OSA who used the CPAP machine regularly. This study demonstrates that OSA is an independent risk for mortality in patients with heart failure; larger trials are needed to assess the ability of CPAP to mitigate this risk. See page 1625.
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Heart Rhythm Disorders
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Open Irrigation Catheter for PVI Increases Complication Rate.
Open irrigation catheters (OIC), which infuse heparinized saline through the tip, should be able to deliver higher power without increasing the temperature of the catheter. Kanj and colleagues performed a pilot study of a novel OIC catheter in nearly 200 patients undergoing pulmonary vein isolation (PVI) procedures. Use of high peak power with the OIC resulted in shorter procedure times and good 6-month success rates, but 20% of patients developed pericardial effusions, and nearly 20% experienced odynophagia, thought to be due to edema/erythema in the anterior esophagus. A second arm with a lower power setting for the OIC resulted in more frequent recurrences of atrial fibrillation. Although there is still promise for OICs to improve outcomes for PVI, neither of these tested protocols was superior to the use of a standard 8-mm catheter. See page 1634.
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Cardiac Imaging
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Automated Analysis of Strain in Dobutamine Stress Echocardiography.
Although dobutamine stress echocardiography is well-validated for risk stratification, its reliance on visual assessment may lessen its accuracy, especially for mild degrees of ischemia. Bjork Ingul and colleagues developed an automated method to analyze myocardial deformation that tracks segment motion laterally using its speckle pattern and axially by tissue Doppler. Two methods of analysis, changes in velocity gradient and changes in segment length, were compared to visual assessment. Both methods measure end-systolic strain and both methods had sensitivities >85% when compared to angiography. This sensitivity was superior to that of visual assessment, although overall accuracies were similar. This automated method for calculating end-systolic strain provides an objective measure of cardiac function and may improve the sensitivity of dobutamine stress echocardiography. See page 1651.
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Valvular Heart Disease
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Increased Aortic Stiffness in Patients With Bicuspid Aortic Valves.
Grotenhuis and colleagues hypothesized that patients with bicuspid aortic valves (BAV) may have abnormalities of the ascending aorta because these patients have higher rates of aortic dilation and dissection. They used magnetic resonance imaging to compare the diameters and elasticity of the aortas in patients with BAV, but no stenosis across the valve, compared to controls. Bicuspid aortic valve patients showed reduced aortic elasticity as indicated by increased pulse wave velocity in the aortic arch, reduced aortic root distensibility, and increased left ventricular mass. Reduced aortic elasticity and aortic root dilatation are frequently present in patients with nonstenotic BAVs and may suggest a common molecular abnormality. See page 1660. See figure.
Related Article
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The Final 10-Year Follow-Up Results From the BARI Randomized Trial
- The BARI Investigators
J. Am. Coll. Cardiol. 2007 49: 1600-1606.
[Abstract]
[Full Text]
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