INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Interventional Cardiology
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STEMI Patients With Large Thrombus Burden More Likely to Thrombose Stent.
Investigators from the Thoraxcenter retrospectively reviewed over 800 acute ST-segment elevation myocardial infarction (STEMI) cases treated with drug-eluting stents to determine the impact of thrombus burden (TB) on subsequent cases of stent thrombosis (ST). Intracoronary TB was angiographically estimated and categorized as large (LTB), defined as TB 
2 vessel diameters, or small (STB). The cumulative incidence of angiographic ST at 2 years was 8.2% for patients with LTB versus 1.3% for those with STB. In this report, STEMI patients with LTB are at increased risk for major adverse cardiac events, including increased short- and long-term risk for ST. See page 573. See figure.
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Heart Failure
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Spironolactone Improves LV Remodeling When Added to ARB.
Adding an aldosterone blocker to an angiotensin-converting enzyme inhibitor seems to improve outcomes in severe heart failure; Chan and colleagues sought to understand the utility of adding spironolactone to an angiotensin II receptor blocker (ARB). Fifty-one systolic heart failure patients (left ventricular ejection fraction [LVEF] <40%) were randomly assigned to receive 1-year treatment of candesartan and spironolactone (combination group) or candesartan and placebo (control group). The combination group had substantial improvements in LVEF, left ventricular (LV) end-diastolic volume index, and LV end-systolic volume index, whereas those in the control group did not have significant changes. This small study suggests that adding spironolactone to an ARB can significantly enhance LV reverse remodeling in patients with systolic heart failure. See page 591. See figure.
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Biomarkers
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Novel Biomarker May Link Myocyte Stretch and Inflammation.
Expression of the ST2 protein is enhanced by myocyte stretch, but it is also the receptor for interleukin-33, a pro-inflammatory cytokine, suggesting that ST2 may represent a bridge between inflammatory and neurohormonal systems. Januzzi and colleagues studied the utility of measuring ST2 in subjects presenting with acute dyspnea. An elevated ST2 level was associated with a 5-fold increased risk of death at 1 year in all subjects and a 9-fold increased risk in those with acute heart failure. This protein may serve as a useful adjunctive marker to brain natriuretic peptide levels to further risk stratify patients presenting with dyspnea. See page 607.
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Heart Rhythm Disorders
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Pacemaker Proarrhythmia? The Role of ICDs in Triggering Arrhythmias.
Abrupt changes in ventricular cycle lengths (short-long-short [S-L-S]) may initiate ventricular arrhythmias because both ventricular intervals and activation sequence are altered suddenly. Sweeney and colleagues studied stored electrograms from over 1,300 episodes of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with implantable cardioverter-defibrillators (ICDs). Pacing-facilitated VT/VF (pacing as part of the S-L-S) occurred in approximately 10% of cases, or 3% of patients, with the frequency related to the pacing mode. A commentary by Fisher provides a more accessible summary of this article and concludes that VT/VF in some ICD patients may be initiated by S-L-S sequences that are actively facilitated by antibradycardia pacing. See pages 614 and 623. See figure.
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Autonomic Function
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Central Blockade of Alpha Receptors Ameliorates the Cardiovascular Effects of Cocaine.
Menon and colleagues hypothesized that cocaine stimulates increases in heart rate and blood pressure via increases in sympathetic nerve activity (SNA). Dexmedetomidine is a centrally acting 
2 adrenergic receptor agonist, without peripheral effects. Subjects were exposed to cocaine ± dexmedetomidine. During intranasal cocaine alone, SNA increased by 2-fold, mean arterial pressure by 14 mm Hg, and heart rate by 18 beats/min. Dexmedetomidine abolished all 3 of these increases. This study suggests that cocaine stimulates the cardiovascular system centrally, rather than peripherally, and that dexmedetomidine may be an effective antidote to cocaine’s sympathomimetic actions. See page 626.
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Interventional Cardiology
Heart Failure
