INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Clinical Trial
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No Benefit to Preoperative Revascularization Before Noncardiac Surgery.
The DECREASE study randomized patients with extensive ischemia on preoperative stress testing to either angiography and revascularization or proceeding directly to noncardiac surgery. Mortality from randomization to 30 days postoperation was 2 times higher (22% vs. 11%) for patients randomized to revascularization prior to noncardiac surgery. The rates of perioperative nonfatal Q-wave infarctions were similar. After 1 year, mortality rates were similar, implying increased midterm risk from not being revascularized. This trial suggests that perioperative myocardial infarctions may be related to acute plaque rupture rather than flow-limiting lesions and suggests that preoperative revascularization is riskier than proceeding directly to noncardiac surgery, even in patients with evidence of extensive inducible ischemia. See page 1763.
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Clinical Trial
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Pioglitazone Reduces Recurrent MIs.
There is mixed evidence regarding the effectiveness of glycemic control in preventing macrovascular events. Erdmann and colleagues performed a prespecified subgroup analysis of patients with previous myocardial infarction (MI) in the PROACTIVE trial, which randomized subjects with diabetes to either pioglitazone or placebo. Pioglitazone resulted in a 28% risk reduction of fatal and nonfatal MI, and a 19% risk reduction in the end point of nonfatal MI, coronary revascularization, acute coronary synrome, and cardiac death, although the risk for congestive heart failure end points was higher. Although the overall primary end points results for the PROACTIVE trial were negative, these data suggest that in patients with type 2 diabetes and previous MI, pioglitazone may reduce the occurrence of subsequent MI. See page 1772. See figure.
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Interventional Cardiology
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Increasing Coronary Sinus Pressure With Novel Stent May Reduce Angina.
Animal models have shown that increased coronary sinus pressure can reduce infarct size and theoretically may help to open collateral circulation and/or improve flow to the endocardium. Banai and colleagues postulated that a stent that produces a mild obstruction in the coronary sinus would improve refractory angina. The device was percutaneously implanted in 15 patients with severe angina who were then followed for 1 year. There were no procedure-related complications, and the patients showed improvement in their angina scores, stress-induced ST-segment depression, and the extent and severity of myocardial ischemia by either dobutamine echocardiography or thallium single-photon emission computed tomography. This first-in-man study suggests that increasing coronary sinus pressure may be a viable technique for improving refractory angina. See page 1783.
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Cardiac Surgery for Congenital Disease
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Dilation of the New Aortic Root Following the Ross Procedure.
The Ross procedure, primarily useful for pediatric patients with disorders involving the aortic valve, transposes the pulmonic valve to the systemic circulation. Pasquali and colleagues report on serial echocardiograms obtained on 74 patients with an average follow-up of almost 5 years. The new aortic root does dilate faster than expected, and approximately 40% of patients developed severe aortic insufficiency. However, only 12% required repeat surgical interventions. Longer-term follow-up may be needed to determine the clinical significance of the increased rate of aortic dilation, but this study provides important information on the expected rate of aortic dilation in children following the Ross procedure. See page 1806.
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Preclinical Study
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Temporary Pacing May Limit Reperfusion Injury.
Intermittent pacing has been reported to induce ischemic preconditioning. Vanagt and colleagues hypothesized that it may be useful in limiting myocardial damage caused by reperfusion. Using both isolated rabbit heart and pig models, the size of the infarcted myocardium measured with triphenyltetrazolium chloride staining was reduced by more than 50% when the hearts were intermittently paced during the reperfusion period. Further analysis demonstrates that left ventricular pacing significantly altered regional mechanical work but did not affect coronary flow or lactate release. This study suggests that a brief period of ventricular pacing may limit damage from acute ischemia. See page 1813. See figure.
Related Article
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A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients Undergoing Major Vascular Surgery: The DECREASE-V Pilot Study
- Don Poldermans, Olaf Schouten, Radosav Vidakovic, Jeroen J. Bax, Ian R. Thomson, Sanne E. Hoeks, Harm H.H. Feringa, Martin Dunkelgrün, Peter de Jaegere, Alexander Maat, Marc R.H.M. van Sambeek, Miklos D. Kertai, Eric Boersma for the DECREASE Study Group
J. Am. Coll. Cardiol. 2007 49: 1763-1769.
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Clinical Trial
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