INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Acute Coronary Syndrome
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Limited Effect of G-CSF in Acute MI Patients.
While animal models suggest that stem cell mobilization by granulocyte colony-stimulating factor (G-CSF) has a positive impact on cardiac regeneration after acute myocardial infarction (MI), the findings in human trials have been inconsistent. Zohlnhöfer and colleagues performed a meta-analysis of 10 trials that randomized post-MI subjects to G-CSF and reported serial assessments of ejection fraction (EF). While significant improvements in EF were observed in both G-CSF and placebo groups, there was not any benefit with G-CSF. This meta-analysis does not support a beneficial effect of G-CSF in post-MI patients. See pages 1429 and
1438.
See figure.
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Acute Coronary Syndrome
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No Significant Change in LDL Levels During ACS.
Conventional wisdom is that cholesterol levels measured during an acute coronary syndrome (ACS) are falsely low. This wisdom is based on limited evidence. Pitt and colleagues analyzed changes in lipid parameters in the first 4 days after admission for ACS in over 500 subjects. Blood samples were taken at admission (fasting or non-fasting sample) and on Days 2 and 4 (fasting samples) for the direct measurement of serum lipid levels. There were some statistically significant changes, but these were clinically irrelevant as they ranged from 1% to 4%. These findings suggest that directly-measured serum low-density lipoprotein (LDL) cholesterol does not change to a clinically significant extent during hospitalization for an ACS and can be used to initiate lipid-lowering therapy of the proper intensity. See pages 1440 and
1446.
See figure.
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Coronary Artery Disease
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Atorvastatin 80 mg Is Highly Effective in Patients With Kidney Disease.
Concerns regarding efficacy and toxicity have limited the utilization of high dose statin therapy in patients with chronic kidney disease (CKD). This subanalysis of the TNT (Treating to New Targets) study investigated the effects of atorvastatin in patients with and without pre-existing CKD, which was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2. Nearly one-third of the >9,000 subjects in the TNT study had CKD; these patients were 1.3 times more likely to suffer a major cardiovascular event. Compared with atorvastatin 10 mg, atorvastatin 80 mg reduced the relative risk of major cardiovascular events by 32% in patients with CKD and 15% in patients with normal eGFR. Both doses of atorvastatin were well tolerated in patients with CKD. These results suggest that aggressive lipid-lowering with atorvastatin 80 mg is both safe and effective in reducing cardiovascular events in a high-risk population with CKD and coronary artery disease. See page 1448.
See figure.
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Heart Rhythm Disorders
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Two LV Leads May Improve Cardiac Remodeling Compared With Standard Biventricular Pacing.
While biventricular pacing can augment left ventricular (LV) reverse remodeling, only 60% of patients will benefit with a >10% decrease in LV end-systolic volume. Leclercq and colleagues hypothesized that stimulating the LV at multiple sites might improve ventricular resynchronization. They performed a randomized crossover study to compare the safety and efficacy of triple-site (3-V) with 2 LV leads versus standard dual-site (2-V) biventricular stimulation. A cardiac resynchronization therapy device connected to 1 RV and 2 LV leads, inserted in 2 separate coronary sinus tributaries, was successfully implanted in 34 patients. A significantly higher LV ejection fraction and smaller LV end-systolic volume were found after 3 months of 3-V than 2-V pacing. See pages 1455 and
1463.
See figure.
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Valvular Heart Disease
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Improving Mortality for Valve Replacement in Patients With LF/LGAS.
Levy and colleagues studied outcomes from >200 consecutive patients with low-flow/low-gradient aortic stenosis (LF/LGAS), which was defined as an aortic valve area <1 cm2, ejection fraction  35%, and mean gradient 30 mm Hg. The perioperative mortality rate has decreased from 20% in the early 1990s to a contemporary rate of approximately 10%. Operative risk was higher in patients with no contractile reserve during dobutamine infusion, those with multivessel coronary artery disease, and those with lower mean gradients. The authors conclude that given the very poor prognosis of unoperated LF/LGAS, aortic valve replacement is a reasonable choice for most patients with LF/LGAS. See page 1466.
Related Articles
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Stem Cell Mobilization by Granulocyte Colony-Stimulating Factor for Myocardial Recovery After Acute Myocardial Infarction: A Meta-Analysis
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An Imperfect Syllogism: Granulocyte Colony-Stimulating Factor Mobilization and Cardiac Regeneration
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Lipid Levels After Acute Coronary Syndromes
- Bertram Pitt, Joseph Loscalzo, Joseph Ycas, and Joel S. Raichlen
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Lipid Levels in the Post-Acute Coronary Syndrome Setting: Destabilizing Another Myth?
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Intensive Lipid Lowering With Atorvastatin in Patients With Coronary Heart Disease and Chronic Kidney Disease: The TNT (Treating to New Targets) Study
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A Randomized Comparison of Triple-Site Versus Dual-Site Ventricular Stimulation in Patients With Congestive Heart Failure
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Cardiac Resynchronization Therapy: The More Pacing Sites, the Better the Outcome?
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Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis: Operative Risk Stratification and Long-Term Outcome: A European Multicenter Study
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Acute Coronary Syndrome
Acute Coronary Syndrome
