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INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Interventional Cardiology
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Frequent Post-PCI Events in Poor Responders to Clopidogrel.
Multiple studies have shown that the magnitude of the response to clopidogrel is variable, but the clinical significance of this finding remains uncertain. Bliden and colleagues measured pre-percutaneous coronary intervention (PCI) platelet aggregation in patients on chronic clopidogrel who were followed for 1 year. Their criteria identified 22% of patients as nonresponders who were 30 times more likely to suffer a subsequent event, with higher risk in both the first 30 days and the subsequent 11 months. This study suggests that measuring the effectiveness of clopidogrel-induced platelet inhibition identifies patients at increased risk for post-PCI ischemic complications. See page 657. See figure.
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Heart Failure
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Ultrafiltration Reduces Rehospitalization for CHF.
Ultrafiltration is an emerging alternative to loop diuretics for patients with fluid overload. Costanzo and colleagues performed a randomized, multicenter trial comparing ultrafiltration with standard diuretic therapy in 200 heart failure patients admitted with volume overload. At 48 h, weight loss and net fluid loss were both significantly greater in the ultrafiltration group, though symptoms of CHF improved similarly in both groups. Adverse event rates were similar. Subjects treated with ultrafiltration were 44% less likely to be rehospitalized over the next 90 days. These data indicate that in decompensated heart failure, ultrafiltration safely produces greater fluid loss than intravenous diuretics over the first 48 h, and may have sustained benefits over the next 90 days. See page 675.
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Heart Failure
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Severity of Diastolic Dysfunction Predicts Outcomes.
There is limited evidence regarding the significance of echo evidence of diastolic dysfunction (DD) in predicting outcomes in patients with HF and preserved systolic function (HF-PSF). Persson and colleagues examined echo and BNP results in over 300 patients enrolled in the CHARM Preserved Study. DD was found in 67% of study subjects, pseudonormal or restrictive filling in 44%. Over the next 18 months, death or readmission for heart failure correlated strongly with the severity of DD. These results demonstrate the prognostic significance of echo DD in HF-PSF patients, and suggest that an elevated BNP may be a reliable method for distinguishing normal from pseudo-normal filling patterns. See page 687. See figure.
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Preclinical Study
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Everolimus-Eluting Stents May Stabilize Plaques.
Macrophages in atherosclerotic plaques are known to secrete proteolytic enzymes that can lead to rupture of the fibrous cap. Verheye and colleagues studied the effects of everolimus on the composition of atherosclerotic plaques. The first experiment involved placing both control stents and everolimus coated stents in rabbit aortas, which demonstrated that everolimus reduced the number of macrophages over the next 4 weeks. Further studies confirmed that everolimus, by inhibiting the mammalian target of rapamycin (mTOR) protein, resulted in programmed cell death in macrophages but not smooth muscle cells. Stent-based delivery of an mTOR inhibitor appears to be a promising method to selectively remove macrophages from atherosclerotic plaques and thereby improve plaque stability. See page 706. See figure.
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Interventional Cardiology
Heart Failure
