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INSIDE THIS ISSUE OF JACC

Inside This Issue of JACC

	State-of-the-Art Paper

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

	Acute Coronary Syndromes

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
Increased Risk for Bleeding in Patients Undergoing CABG Who Received Clopidogrel.  
Early administration of clopidogrel has been recommended for acute coronary syndromes (ACS), but this may increase the risk of bleeding in patients subsequently referred for CABG. Berger and colleagues performed a retrospective chart review of 600 ACS patients who underwent CABG, one-half of whom had received clopidogrel. After multivariable regression analysis, clopidogrel exposure within 5 days was associated with a 4.6 times higher rate of reoperation and a 1.8 times greater risk of major bleeding. The risk of reoperation or major bleeding decreased with each subsequent day between clopidogrel exposure and CABG and appeared to reach background level at 6 days. See page 1693. See figure.

	Heart Failure

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
Preferences for Length Versus Quality of Life in Patients With CHF.  
Stevenson and colleagues hypothesized that changes in patient preferences for quality of life versus length of life would be linked to changes in symptoms and functional capacity. This preference was assessed by asking the question: "Would you prefer living 2 years in your current state of health or living 1 day in excellent health?," which is known as the time trade-off (TTO). The distribution of TTO results was bimodal with most values at the extremes: 49% expressed almost no willingness to trade time at baseline and 28% to trade almost all time in order to feel better. The average TTO changed by only 4% (1 to 24 months) after hospital discharge. These results help clinicians to understand how patient's symptoms affect their preferences for care. See pages 1702 and 1709. See figure.

	Heart Rhythm Disorders

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
Protocol Described to Differentiate JT From AVNRT.  
Distinguishing junctional tachycardia (JT) from atrioventricular nodal re-entrant tachycardia (AVNRT) during an electrophysiology study is difficult because both arrhythmias are confined to a small anatomic area in and around the atrioventricular node. Padanilam and colleagues describe a technique using induced premature atrial complexes to differentiate JT from AVNRT, based on changes, or lack of changes, in subsequent His bundle recordings. The technique was then validated in a cohort of patients and was shown to aid in their diagnosis and management. See page 1711. See figure.

	Cardiomyopathy

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
ASA Does Not Increase Risk of Arrhythmias.   Alcohol septal ablation (ASA) is an effective therapy for symptomatic hypertrophic cardiomyopathy (HCM), however it may be proarrhythmic because of the iatrogenic scar created during the procedure. Cuoco and colleagues reviewed the records of 123 consecutive patients who underwent ASA and had an implantable cardioverter-defibrillator (ICD) implanted for primary prevention of sudden cardiac death (SCD) based on standard criteria for patients with HCM. Only 9 appropriate ICD shocks were recorded, producing an estimated annual event rate of 2.8%, which is lower than would be predicted based on the HCM risk factors. These results suggest that ASA is not proarrhythmic, but instead may actually reduce the likelihood of SCD in patients with HCM. See page 1718.

	Cardiac Imaging

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
High Negative Predictive Value for 64-Slice CT Scans.  
This study evaluated the diagnostic accuracy of electrocardiographically-gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals with chest pain, but no known coronary artery disease. Over 200 subjects referred for nonemergent coronary angiography first underwent CCTA at 1 of 16 sites. On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect a 70% stenosis were 94%, 83%, 48%, and 99%, respectively. In this prospective multicenter trial, 64-multidetector row CCTA demonstrated a high diagnostic accuracy for the detection of obstructive coronary stenosis, with a 99% negative predictive value at both the patient- and the vessel-level. See pages 1724 and 1733. See figure.

	Peripheral Arterial Disease

Top State-of-the-Art Paper Acute Coronary Syndromes Heart Failure Heart Rhythm Disorders Cardiomyopathy Cardiac Imaging Peripheral Arterial Disease

 
Decreases in ABI Associated With Increased Mortality.   A low ankle-brachial index (ABI) has been associated with increased risk of cardiovascular events. However, the prognostic significance of a declining compared with a stable ABI has not been studied. Criqui and colleagues reviewed records from patients who had serial assessments of ABI and were then monitored for clinical events. In the Cox models adjusted for cardiovascular disease risk factors, very low (<0.7) and in some cases low (0.70 ABI <0.90) ABI were associated with increased all-cause mortality and cardiovascular mortality. Those who had a decrease of ABI >0.15 were 2.4 times more likely to have died at 3 years. Progressive peripheral arterial disease, measured by a decline in ABI, is a marker of increased risk of death. See pages 1736 and 1743.

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