INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Clinical Trials
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Randomized Trial of PES Versus BMS for Unprotected Left Main PCI.
In the first published, randomized trial comparing drug-eluting stents (DES) and bare-metal stents (BMS) for unprotected left main disease, Erglis and colleagues prospectively randomized 103 subjects to BMS or paclitaxel-eluting stent (PES) implantation. All lesions were predilated with a cutting balloon and intravascular ultrasound was used to optimize procedural results. There were no in-hospital deaths, and only 2 deaths (1 in each group) at 6 months. Repeat revascularization procedures for recurrent angina or ischemia were required at 6 months in 16% of BMS patients compared to 2% of DES patients, a benefit attributable to a marked reduction in binary restenosis with the PES (22.0% vs. 5.7%). An accompanying editorial cautions that larger trials with longer duration are needed before percutaneous coronary intervention (PCI) can be widely advocated as an alternative to coronary artery bypass grafting for left main disease. See pages 491 and
498.
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Interventional Cardiology
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Diabetics With Multivessel Disease at Highest Risk for Stent Thrombosis.
In order to understand the risk factors for and frequency of stent thrombosis (ST) after implantation of a sirolimus-eluting stent (SES), researchers in France have created the EVASTENT registry. This registry enrolls diabetic patients undergoing SES implantation, and then enrolls a matched, nondiabetic control. For this report, 1,731 patients were followed for an average of 465 days. Stent thrombosis occurred in 45 subjects (2.6%): 23 subacute and 22 late, including 9 cases at >6 months. The 1-year ST rate was 1.8 times higher in diabetic than in nondiabetic patients; diabetics with multiple-vessel disease were 5 times more likely than nondiabetics with single-vessel disease to experience ST. Eight cases of ST occurred within 10 days after withdrawal of dual antiplatelet therapy. This study helps us to define the risk of, and risk factors for, ST after use of SES, especially the importance of prolonged dual antiplatelet therapy. See page 501. See figure.
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Cardiac Imaging
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Quantitative Perfusion Imaging With MRI: Comparison With FFR and QCA.
The first pass of gadolinium through the myocardium can be plotted as signal intensity versus time allowing accurate quantification of blood flow in small areas of myocardium. Myocardial perfusion reserve (MPR) is calculated as the ratio of simulated stress and rest flows. Costa and colleagues performed MPR analyses on patients who also underwent fractional flow reserve (FFR) and/or quantitative coronary angiography (QCA). Mean MPR was significantly lower in segments with an FFR  0.75. An MPR cutoff of 2.04 was 93% sensitive and 57% specific for an FFR 0.75, with similar results when compared to QCA for a >50% stenosis. This study suggests the MPR measured by cardiac magnetic resonance imaging provides important information regarding the hemodynamic significance of atherosclerotic lesions. See page 514.
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Preclinical Studies
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Endocannabinoid Blockade Reduces Cardiotoxicity of Doxorubicin.
Recent studies show that 90% of children treated with doxorubicin (DOX) manifest at least some cardiac toxicity, yet because of its efficacy it is still widely used. Mukhopadhyay and colleagues hypothesized that the blockade of cannabinoid-1 (CB1) receptors could reduce the toxicity of DOX. Using both hemodynamic data acquired from a mouse model and in vitro studies, pretreatment with a CB1 blocker substantially reduced the cardiotoxicity of DOX. CB1 blockade seems to be effective because the endocannabinoid anandamide is found in high levels in the myocardium after exposure to DOX. This study suggests that CB1 antagonists may represent a novel cardioprotective strategy against DOX-induced cardiotoxicity. See page 528. See figure.
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Preclinical Studies
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Steps Toward the Creation of an Antiatherosclerosis Vaccine.
Recent work suggests that B-cell–mediated immunity, particularly against oxidized low-density lipoprotein (oxLDL), may protect against atherosclerosis by inhibiting the uptake of oxLDL into macrophages. Caligiuri and colleagues noticed that phosphorylcholine (PC) seems to be a significant epitope for oxLDL. They combined PC with a hapten, an immune response stimulator, which was then injected into an in vivo mouse model of atherosclerosis. Immunized mice had a 40% decrease in the extent of atherosclerotic lesions in the proximal aorta. An accompanying editorial describes some of the rationale and future studies needed for the development of an effective vaccine against atherosclerosis. See page 540 and
547. See figure.
Related Articles
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A Randomized Comparison of Paclitaxel-Eluting Stents Versus Bare-Metal Stents for Treatment of Unprotected Left Main Coronary Artery Stenosis
- Andrejs Erglis, Inga Narbute, Indulis Kumsars, Sanda Jegere, Iveta Mintale, Ilja Zakke, Uldis Strazdins, and Andris Saltups
J. Am. Coll. Cardiol. 2007 50: 491-497.
[Abstract]
[Full Text]
[PDF]
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Left Main Drug-Eluting Stents: Natural Progression or a Bridge Too Far?
- Gregg W. Stone, Jeffrey W. Moses, and Martin B. Leon
J. Am. Coll. Cardiol. 2007 50: 498-500.
[Full Text]
[PDF]
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Risk Factors for Stent Thrombosis After Implantation of Sirolimus-Eluting Stents in Diabetic and Nondiabetic Patients: The EVASTENT Matched-Cohort Registry
- Jacques Machecourt, Nicolas Danchin, Jean Marc Lablanche, Jean Marie Fauvel, Jean Louis Bonnet, Stephanie Marliere, Alison Foote, Jean Louis Quesada, Hélène Eltchaninoff, Gérald Vanzetto for the EVASTENT Investigators
J. Am. Coll. Cardiol. 2007 50: 501-508.
[Abstract]
[Full Text]
[PDF]
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Quantitative Magnetic Resonance Perfusion Imaging Detects Anatomic and Physiologic Coronary Artery Disease as Measured by Coronary Angiography and Fractional Flow Reserve
- Marco A. Costa, Steven Shoemaker, Hideki Futamatsu, Chris Klassen, Dominick J. Angiolillo, Minh Nguyen, Alan Siuciak, Paul Gilmore, Martin M. Zenni, Luis Guzman, Theodore A. Bass, and Norbert Wilke
J. Am. Coll. Cardiol. 2007 50: 514-522.
[Abstract]
[Full Text]
[PDF]
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Pharmacological Inhibition of CB1 Cannabinoid Receptor Protects Against Doxorubicin-Induced Cardiotoxicity
- Partha Mukhopadhyay, Sándor Bátkai, Mohanraj Rajesh, Nora Czifra, Judith Harvey-White, György Haskó, Zsuzsanna Zsengeller, Norma P. Gerard, Lucas Liaudet, George Kunos, and Pál Pacher
J. Am. Coll. Cardiol. 2007 50: 528-536.
[Abstract]
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Phosphorylcholine-Targeting Immunization Reduces Atherosclerosis
- Giuseppina Caligiuri, Jamila Khallou-Laschet, Marta Vandaele, Anh-Thu Gaston, Sandrine Delignat, Chantal Mandet, Heinz V. Kohler, Srini V. Kaveri, and Antonino Nicoletti
J. Am. Coll. Cardiol. 2007 50: 540-546.
[Abstract]
[Full Text]
[PDF]
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Promise of Immune Modulation to Inhibit Atherogenesis
- Christoph J. Binder, Karsten Hartvigsen, and Joseph L. Witztum
J. Am. Coll. Cardiol. 2007 50: 547-550.
[Full Text]
[PDF]
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Clinical Trials
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