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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 Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

	Interventional Cardiology

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
Impact of Diabetes on the Results of the ARTS-II Trial.  
The ARTS-I (Arterial Revascularization Therapies Study–Part I) trial randomized patients with multivessel disease to either percutaneous coronary intervention (PCI) with bare-metal stents (BMS) or coronary artery bypass graft surgery (CABG). The ARTS-II trial utilized similar entry criteria, but the PCI was performed with sirolimus-eluting stents (SES). This paper focuses on how diabetes altered the outcomes of patients at 3 years. In nondiabetic patients, the incidence of the primary composite end point, which included repeat revascularization (major adverse cardiovascular and cerebrovascular events [MACCE]), was significantly lower in patients receiving SES than BMS and similar to patients assigned to CABG. In diabetic patients, the incidence of MACCE with SES was similar to both the BMS and CABG groups, but the incidence of death/cerebrovascular accident/myocardial infarction was significantly lower than in the BMS group. In summary, at 3 years, PCI using SES for patients with multivessel disease appears to be safer and more efficacious than BMS and similar to CABG, irrespective of the diabetic status of the patient. See page 1957. See figure.

	Antiplatelet Therapy

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
Diabetic Patients Have Reduced Thienopyridine Efficacy Because of Decreased Conversion of Prodrug.  
Erlinge and colleagues evaluated the prevalence and mechanism of poor responsiveness to thienopyridines in patients with and without diabetes. The proportion of patients with poor responsiveness was greater in the clopidogrel group for all definitions and at all time points. Poor responders had significantly lower plasma levels of the active metabolite (AM) and were more likely to have diabetes. When the AM was added to blood prior to testing, poor responders showed normal responsiveness. The mechanism of incomplete platelet inhibition in clopidogrel poor responders is lower plasma levels of its AM and not differences in platelet P2Y₁₂ receptor function. See pages 1968 and 1978. See figure.

	Screening of Athletes

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
The Efficacy of the Italian Pre-Participation Screening Program for Athletes.   Twenty-five years ago, Italy mandated that all athletes participating in competitive sports undergo a standardized pre-participation screening program performed by a specially-trained physician, including a 12-lead electrocardiogram. Corrado and colleagues provide details on the Italian program through a retrospective, observational analysis. Approximately 10% of screened patients were referred for subsequent testing, usually an echocardiogram. The rate of athlete disqualification doubled during this time to approximately 2%. There was a remarkable drop in the rate of sudden death in athletes, from 3.6 per 100,000 to 0.4 per 100,000. This analysis demonstrates that this strategy can reduce the incidence of sudden death related to athletic participation. See pages 1981 and 1997.

	Screening of Athletes

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
Differences in Pre-Participation Screening Guidelines.   Both the American Heart Association and the European Society of Cardiology (ESC) have established consensus guidelines for eligibility/disqualification decisions in competitive athletes with cardiovascular abnormalities. Pelliccia and colleagues provide a detailed comparison between the 2 guidelines, highlighting some of the key differences. For instance, while both documents agree that hypertrophic cardiomyopathy increases the risk of death and that affected athletes should be proscribed from competition, the European guidelines recommend that family members with the same mutation, but no evidence of hypertrophy, also be excluded. There are also differences in the acceptable length of the QT interval corrected for heart rate in patients suspected of long QT syndrome. Some of the discrepancies emanate from social and legal variances, but the authors suggest that attempts should be made to broker a unified statement to avoid confusion. See pages 1990 and 1997.

	Heart Failure

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
Candesartan Is Safe and Effective in Heart Failure Patients With Low BP.  
Meredith and colleagues investigated the efficacy and tolerability of candesartan, according to baseline blood pressure (BP), in the almost 5,000 patients with a low ejection fraction (EF) (40%) in the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity) program. Low systolic blood pressure (SBP) at baseline predicted worse clinical outcomes, but did not modify the positive effects of candesartan on clinical outcomes. For both placebo and candesartan, study drug discontinuation for adverse effects (especially hypotension) was highest in patients with the lowest SBP, but the relative risk of discontinuation was not increased in patients with a low baseline BP. In patients with systolic dysfunction, the relative risks and benefits of candesartan were not altered by low BP. See page 2000. See figure.

	Cardiac Imaging

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
Caffeine Attenuates Adenosine-Induced Perfusion Defects and Can Be Mitigated by High Dose Adenosine.  
Adenosine provokes coronary vasodilation via the arteriolar A_2A adenosine receptors; methylxanthines, including caffeine, competitively inhibit adenosine receptors. Reyes and colleagues repeated adenosine myocardial perfusion scintigraphy (MPS) studies in patients who abstained from caffeine for 12 h prior to their initial study. Before the second study, subjects ingested 200 mg of caffeine, the equivalent of 2 cups of coffee. Caffeine reduced the magnitude of the perfusion defect (summed difference score [SDS] 12 at baseline vs. 4 after caffeine). Some patients were given a larger dose of adenosine (210 µg/kg/min compared with the standard dose of 140 µg/kg/min); with this dose, there was no reduction in SDS. This study confirms that caffeine attenuates adenosine-induced perfusion abnormalities and shows that this attenuation can be overcome with a higher dose of adenosine. See page 2008. See figure.

	Pre-Clinical Research

Top State-of-the-Art Paper Interventional Cardiology Antiplatelet Therapy Screening of Athletes Screening of Athletes Heart Failure Cardiac Imaging Pre-Clinical Research

 
A Novel Tracer Allows SPECT Imaging of Myocardial Fibrosis.  
Van den Borne and colleagues used a mouse model of myocardial infarction (MI) to test the ability of a novel radiolabeled tracer to identify and quantify areas of active myocardial fibrosis. The tracer, Cy5.5-RGD imaging peptide (CRIP), binds to integrins such as _vβ₃, which is expressed by myofibroblasts, and also binds to procollagen I. The specificity of the tracer was confirmed by histopathology. Maximum CRIP uptake was observed in the infarct area and was highest at 2 weeks post-MI. Uptake was reduced by treatment with captopril and losartan. Radiolabeled CRIP allows for noninvasive visualization of interstitial myocardial fibrosis. See pages 2017 and 2029. See figure.

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