INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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State-of-the-Art Paper
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Strategies to Identify and Treat Resistant Hypertension.
This state-of-the-art paper focuses on resistant hypertension, which Sarafidis and Bakris define as failure to achieve goal blood pressure (BP) with maximum tolerated dose of at least 3 antihypertensive drugs including a diuretic. The prevalence of resistant hypertension is increasing due to aging, obesity, sleep apnea, and kidney disease. Management must begin with patient evaluation to confirm the diagnosis and exclude "pseudo-resistance." BP control is achievable if the treatment regimen focuses on the etiology of hypertension and logical combinations of medications. See page 1749. See figure.
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Interventional Cardiology
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Bivalirudin May Reduce Costs in ACS Patients.
The ACUITY trial randomized acute coronary syndrome (ACS) patients with a planned early invasive strategy to either bivalirudin with or without glycoprotein IIb/IIIa inhibition (GPI) or heparin with routine GPI. There were no differences in ischemic outcomes, but there was reduced bleeding in the bivalirudin arms. This economic analysis of the trial shows that during the initial hospitalization, use of bivalirudin monotherapy resulted in net savings of  $600/patient compared with heparin + routine upstream GPI and $200/patient compared with heparin + catheterization laboratory GPI. These cost savings were obtained despite higher costs for antithrombotic therapy and were driven by reductions in bleeding complications and earlier hospital discharge. This analysis suggests that bivalirudin monotherapy is an economically attractive alternative to heparin-based regimens in ACS patients. See page 1758.
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Preventive Cardiology
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Meta-Analysis Shows Mortality Benefit for Primary Prevention With Statins.
The use of statins for primary prevention of cardiovascular mortality and events is still questioned. Mills and colleagues conducted a meta-analysis of 19 randomized trials with over 60,000 subjects and at least 1 year of follow-up. The relative risk (RR) for all-cause mortality was 0.93, and for cardiovascular deaths was 0.89. The RR for myocardial infarctions was 0.77. There was no evidence of increased risk for cancer or rhabdomylosis. This meta-analysis confirms that statins can reduce the risk of death in primary prevention patients. See page 1769. See figure.
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Rhythm Disorders in Heart Failure
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Altered Calcium Cycling Associated With T-Wave Alternans, Risk of VT.
Narayan and colleagues hypothesized that abnormalities of calcium cycling might explain ventricular action potential (AP) oscillations. Fifty-three subjects with reduced left ventricular (LV) function and 18 control patients underwent a protocol to identify subtle changes in the AP morphology. AP alternans, slight variations in beat-to-beat AP morphology, had higher magnitude in subjects with LV dysfunction. AP alternans predicted ventricular tachycardia (VT)/ventricular fibrillation (VF) during follow-up. Some patients with systolic dysfunction have ventricular AP alternans that predicts the risk of VT/VF and appears to be caused by altered calcium cycling. See page 1782. See figure.
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Cardiac Effects of Diabetes
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Myocardial Steatosis Linked to Diabetes and Diastolic Dysfunction.
Recent evidence suggests that increased myocardial fatty acid uptake may be the cause of diabetic nonischemic cardiomyopathy. Rijzewijk and colleagues report that myocardial triglyceride content is significantly higher in diabetic patients compared with healthy volunteers. Indexes of diastolic function, including left ventricular E/A ratio and E peak deceleration, were also impaired in diabetic patients. Impaired diastolic filling correlated with myocardial triglyceride content, independently of age, body mass index, heart rate, visceral fat, and diastolic blood pressure. Myocardial triglyceride content is increased in diabetic patients and may be the link between diabetes and impaired left ventricular diastolic function. See pages 1793 and
1800. See figure.
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Pre-Clinical Research
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Calcium Dependent NOX5 NADPH Oxidase Active in Atherosclerotic Lesions.
The NOX-based nicotinamide adenine dinucleotide phosphate (NADPH) oxidases are major sources of reactive oxygen species (ROS) in human vessels, but the location and activity of the recently described NOX5 is less well understood. Guzik and colleagues analyzed segments of human coronary arteries harvested from explanted hearts of patients with either coronary artery disease (CAD) or nonischemic cardiomyopathies. There was a marked increase in NOX5 protein and messenger ribonucleic acid in patients with CAD. NOX5-dependent production of ROS was 7-fold higher in patients with CAD. This article identifies NOX5 as a calcium-dependent source of ROS in atherosclerosis. See pages 1803 and
1810. See figure.
Related Articles
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Resistant Hypertension: An Overview of Evaluation and Treatment
- Pantelis A. Sarafidis and George L. Bakris
J. Am. Coll. Cardiol. 2008 52: 1749-1757.
[Abstract]
[Full Text]
[PDF]
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Economic Evaluation of Bivalirudin With or Without Glycoprotein IIb/IIIa Inhibition Versus Heparin With Routine Glycoprotein IIb/IIIa Inhibition for Early Invasive Management of Acute Coronary Syndromes
- Duane S. Pinto, Gregg W. Stone, Chunxue Shi, Elizabeth S. Dunn, Matthew R. Reynolds, Meghan York, Joshua Walczak, Ronna H. Berezin, Roxana Mehran, Brent T. McLaurin, David A. Cox, E. Magnus Ohman, A. Michael Lincoff, David J. Cohen on behalf of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) Investigators
J. Am. Coll. Cardiol. 2008 52: 1758-1768.
[Abstract]
[Full Text]
[PDF]
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Primary Prevention of Cardiovascular Mortality and Events With Statin Treatments: A Network Meta-Analysis Involving More Than 65,000 Patients
- Edward J. Mills, Beth Rachlis, Ping Wu, Philip J. Devereaux, Paul Arora, and Dan Perri
J. Am. Coll. Cardiol. 2008 52: 1769-1781.
[Abstract]
[Full Text]
[PDF]
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Action Potential Dynamics Explain Arrhythmic Vulnerability in Human Heart Failure: A Clinical and Modeling Study Implicating Abnormal Calcium Handling
- Sanjiv M. Narayan, Jason D. Bayer, Gautam Lalani, and Natalia A. Trayanova
J. Am. Coll. Cardiol. 2008 52: 1782-1792.
[Abstract]
[Full Text]
[PDF]
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Myocardial Steatosis Is an Independent Predictor of Diastolic Dysfunction in Type 2 Diabetes Mellitus
- Luuk J. Rijzewijk, Rutger W. van der Meer, Johannes W.A. Smit, Michaela Diamant, Jeroen J. Bax, Sebastiaan Hammer, Johannes A. Romijn, Albert de Roos, and Hildo J. Lamb
J. Am. Coll. Cardiol. 2008 52: 1793-1799.
[Abstract]
[Full Text]
[PDF]
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Steatosis and Diastolic Dysfunction: The Skinny on Myocardial Fat
- Jason B. Lindsey and Steven P. Marso
J. Am. Coll. Cardiol. 2008 52: 1800-1802.
[Full Text]
[PDF]
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Calcium-Dependent NOX5 Nicotinamide Adenine Dinucleotide Phosphate Oxidase Contributes to Vascular Oxidative Stress in Human Coronary Artery Disease
- Tomasz J. Guzik, Wei Chen, Maria C. Gongora, Bartlomiej Guzik, Heinrich E. Lob, Deepa Mangalat, Nyssa Hoch, Sergey Dikalov, Pawel Rudzinski, Boguslaw Kapelak, Jerzy Sadowski, and David G. Harrison
J. Am. Coll. Cardiol. 2008 52: 1803-1809.
[Abstract]
[Full Text]
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NOX5, a New "Radical" Player in Human Atherosclerosis?
- Eberhard Schulz and Thomas Münzel
J. Am. Coll. Cardiol. 2008 52: 1810-1812.
[Full Text]
[PDF]
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State-of-the-Art Paper
Interventional Cardiology
