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J Am Coll Cardiol, 2008; 51:29-30, doi:10.1016/S0735-1097(08)00879-6
© 2008 by the American College of Cardiology Foundation
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INSIDE THIS ISSUE OF JACC

Inside This Issue of JACC


   Acute Myocardial Infarction
Top
 Acute Myocardial Infarction
Atherosclerosis
 Heart Failure
 Heart Rhythm Disorders
 Cardiac Imaging
 
Post-MI Medical Therapy Improves Outcomes in Elderly.  
Figure 1
Setoguchi and colleagues hypothesized that increased use of statins, beta-blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin-II receptor blockers (ARBs) would be associated with improving trends in long-term prognosis after myocardial infarction (MI) in the elderly. Data from pharmacy assistance programs and Medicare in 2 states for the years 1995 to 2004 was used to identify patients with MI who survived ≥30 days after discharge. After adjusting for demographics and comorbidities, post-MI mortality decreased by 3% per year. This reduction appeared to be entirely secondary to increased usage of statins, BBs, ACEIs/ARBs, and antiplatelet drugs after discharge, rather than to more revascularization. Post-MI outcomes are improving for elderly patients secondary to expanded use of several classes of medications. See pages 1247 and 1255. See figure.


   Atherosclerosis
Top
 Acute Myocardial Infarction
 Atherosclerosis
Heart Failure
 Heart Rhythm Disorders
 Cardiac Imaging
 
Areas of Hypoxia Found in Atherosclerotic Lesions.  
Figure 2
Areas with active angiogenesis have been found in atherosclerotic plaques and are thought to contribute to plaque growth and plaque instability. Sluimer and colleagues hypothesized that this angiogeneses is stimulated by hypoxia. Atherosclerotic plaques were collected from patients undergoing carotid endarterectomy. Prior to surgery, subjects were injected with pimonidazole, which undergoes certain changes in areas of hypoxia that can be detected with an antibody. Significant areas of hypoxia, especially within the macrophage-rich center of the lesions, were found. These areas correlated with the presence of thrombus, angiogenesis, and expression of vascular endothelial growth factor. This is the first study directly demonstrating hypoxia in advanced human atherosclerosis and its correlation with the presence of factors related to angiogenesis. See pages 1258 and 1266. See figure.


   Heart Failure
Top
 Acute Myocardial Infarction
 Atherosclerosis
 Heart Failure
Heart Rhythm Disorders
 Cardiac Imaging
 
Baseline Renal Dysfunction Increases Risk in Patients With CHF.   Rises in serum creatinine levels in patients hospitalized for congestive heart failure (CHF) have been ascribed to the cardio-renal syndrome, which is poorly understood. Nohria and colleagues analyzed the effect of baseline reduced renal function (glomerular filtration rate <60 ml/min) or changes in serum creatinine (>0.3 mg/dl) on outcomes for patients with ejection fraction <35% hospitalized with heart failure. Baseline renal insufficiency, but not worsening renal function, was associated with an increased risk of death and rehospitalization. There was no correlation between baseline hemodynamics (one-half of the patients were randomized to have pulmonary artery catheters) or change in hemodynamics and worsening renal function. These results suggest that baseline renal dysfunction makes the kidney more susceptible to cardiac compromise. See pages 1268 and 1275.


   Heart Rhythm Disorders
Top
 Acute Myocardial Infarction
 Atherosclerosis
 Heart Failure
 Heart Rhythm Disorders
Cardiac Imaging
 
Syncope Associated With Increased Need for ICD Therapy and Increased Mortality.   While syncope related to ventricular arrhythmias is certainly a risk factor for poor outcomes, the importance of syncope that is not clearly related to a ventricular arrhythmia is less clear. Olshansky and colleagues reviewed data from the SCD-HeFT (Sudden Cardiac Death Heart Failure Trial) to examine the impact of syncope on outcomes. Among the 811 subjects who received an implantable cardioverter-defibrillator (ICD), 6% had syncope before randomization; 38% of these subjects had an appropriate shock during follow-up. This was nearly twice as frequent as those with no history of syncope. Post-randomization syncope was associated with increased risk of death (heart rate = 1.4) For congestive heart failure patients with ejection fraction <35%, syncope is associated with increased risk for appropriate ICD activations and increased mortality. See page 1277.


   Cardiac Imaging
Top
 Acute Myocardial Infarction
 Atherosclerosis
 Heart Failure
 Heart Rhythm Disorders
 Cardiac Imaging
 
Appropriateness of Cardiac Imaging Studies.  
Figure 3
The American College of Cardiology and the American Society of Nuclear Cardiology have developed appropriateness criteria for stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to address concerns about the growth in cardiac imaging studies. However, there is little information regarding the number of studies that would be classified as inappropriate in a typical setting. Gibbons and colleagues reviewed the case histories for all patients undergoing stress SPECT MPI and stress echocardiography for 2 weeks at the Mayo Clinic. Sixty-four percent of both stress SPECT MPI and stress echocardiography were considered appropriate; 14% of stress SPECT MPI and 18% of stress echocardiography were inappropriate. Eighty-eight percent of the inappropriate studies were performed for 1 of 4 indications, including asymptomatic low-risk patients or unnecessary pre-operative evaluations. The authors suggest that education may reduce inappropriate test ordering, but also that establishing the appropriateness of a particular test is difficult due to both a lack of clinical information and gaps in the published criteria. See pages 1283 and 1290. See figure.


Related articles in JACC:

Improvements in Long-Term Mortality After Myocardial Infarction and Increased Use of Cardiovascular Drugs After Discharge: A 10-Year Trend Analysis
Soko Setoguchi, Robert J. Glynn, Jerry Avorn, Murray A. Mittleman, Raisa Levin, and Wolfgang C. Winkelmayer
JACC 2008 51: 1247-1254. [Abstract] [Full Text]  

Reducing Post-Myocardial Infarction Mortality in the Elderly: The Power and Promise of Secondary Prevention
William E. Boden and David J. Maron
JACC 2008 51: 1255-1257. [Full Text]  

Hypoxia, Hypoxia-Inducible Transcription Factor, and Macrophages in Human Atherosclerotic Plaques Are Correlated With Intraplaque Angiogenesis
Judith C. Sluimer, Jean-Marie Gasc, Job L. van Wanroij, Natasja Kisters, Mathijs Groeneweg, Maarten D. Sollewijn Gelpke, Jack P. Cleutjens, Luc H. van den Akker, Pierre Corvol, Bradly G. Wouters, Mat J. Daemen, and Ann-Pascale J. Bijnens
JACC 2008 51: 1258-1265. [Abstract] [Full Text]  

The Paradox of Hypoxic and Oxidative Stress in Atherosclerosis
Manuel Mayr, Anissa Sidibe, and Anna Zampetaki
JACC 2008 51: 1266-1267. [Full Text]  

Cardiorenal Interactions: Insights From the ESCAPE Trial
Anju Nohria, Vic Hasselblad, Amanda Stebbins, Daniel F. Pauly, Gregg C. Fonarow, Monica Shah, Clyde W. Yancy, Robert M. Califf, Lynne W. Stevenson, and James A. Hill
JACC 2008 51: 1268-1274. [Abstract] [Full Text]  

Mapping Directions for the Cardiorenal Conundrum: Where You End Up Depends Upon Where You Started, So Where Do We Go From Here?
Larry A. Weinrauch, Julie Lin, and Scott D. Solomon
JACC 2008 51: 1275-1276. [Full Text]  

Syncope Predicts the Outcome of Cardiomyopathy Patients: Analysis of the SCD-HeFT Study
Brian Olshansky, Jeanne E. Poole, George Johnson, Jill Anderson, Anne S. Hellkamp, Douglas Packer, Daniel B. Mark, Kerry L. Lee, Gust H. Bardy, and for the SCD-HeFT Investigators
JACC 2008 51: 1277-1282. [Abstract] [Full Text]  

Application of Appropriateness Criteria to Stress Single-Photon Emission Computed Tomography Sestamibi Studies and Stress Echocardiograms in an Academic Medical Center
Raymond J. Gibbons, Todd D. Miller, David Hodge, Lynn Urban, Philip A. Araoz, Patricia Pellikka, and Robert B. McCully
JACC 2008 51: 1283-1289. [Abstract] [Full Text]  

Is Appropriateness Appropriate?
Robert O. Bonow
JACC 2008 51: 1290-1291. [Full Text]  




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