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INSIDE THIS ISSUE OF JACC

Inside This Issue of JACC

	State-of-the-Art Papers

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

	Myocardial Infarction

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
Pre-Hospital ECG Reduces Door-to-Balloon Time.   Diercks and colleagues reviewed data from over 12,000 ST-segment elevation myocardial infarction (STEMI) patients who were treated at a hospital participating in the NCDR-ACTION registry. Slightly more than 25% of patients transported by emergency medical service (EMS) providers had a pre-hospital electrocardiogram (ECG). These patients were more likely to undergo primary percutaneous coronary intervention (PCI), and there were shorter door-to-needle times for patients receiving fibrinolytic therapy (19 min vs. 29 min) and shorter door-to-balloon times for patients undergoing primary PCI (61 min vs. 75 min). There was also a strong trend towards lower risk-adjusted in-hospital mortality. Only 25% of confirmed STEMI patients transported by EMS received a pre-hospital ECG, but those who did had shorter times to reperfusion. See page 161.

	Coronary Artery Disease

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
Leptin Does Not Independently Increase Cardiac Risk.  
Obese individuals have high levels of leptin, and experimental evidence links elevations in leptin and/or leptin resistance to atherogenesis, but the association in humans is less well documented. Sattar and colleagues compared leptin levels in 550 men with fatal coronary heart disease (CHD) or nonfatal myocardial infarction to 1,184 control subjects. Baseline leptin correlated with several cardiac risk factors, even after adjusting for body mass index (BMI). Individuals in the top tertile of leptin levels had an odds ratio for CHD of 1.25 compared with those in the lowest tertile, but this decreased to 0.98 after adjustment for BMI. This study almost doubles the number of incident CHD cases studied in relation to leptin levels, and suggests that the increased risk seen with elevated leptin is primarily driven by higher BMI. See page 167. See figure.

	Coronary Artery Disease

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
Women Suspected of CAD Have Higher Medical Costs if Depressed.   In almost 1,000 women referred for coronary angiography, Rutledge and colleagues screened for depression and then calculated the medical costs over a period of 5 years. Seventeen percent of 45% of women were depressed using the various definitions. Depressed women had adjusted annual cardiovascular costs that were $1,550 to $3,300 higher than nondepressed groups, despite having less coronary artery disease (CAD) on the baseline angiogram. These results reinforce the importance of assessing for depression in clinical populations and support the hypothesis that improved management of depression can reduce medical costs. See page 176.

	Heart Failure

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
BBs Show Substantial Benefit in Elderly, "Real World" Patients.  
Beta-blockers (BBs) reduce mortality in patients with left ventricular systolic dysfunction (LVSD) enrolled in clinical trials, but these patients are not representative of the general heart failure population, particularly elderly patients. Hernandez and colleagues combined data from the OPTIMIZE-HF registry and the Medicare database to study the effectiveness of BBs in nonselected patients over the age of 65 years. Patients who were initiated on BBs during their initial hospitalization for congestive heart failure and who had LVSD had an adjusted hazard ratio of 0.77 for mortality compared with BB-eligible patients not started on a BB. Patients with preserved systolic function had no benefit with BBs. In elderly patients hospitalized with heart failure and LVSD, starting BBs during the initial hospitalization appears to substantially lower the risk of death. See page 184. See figure.

	Heart Failure

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
Prognostic Implication of BRS Testing Not Affected by BB Usage.   La Rovere and colleagues assessed the impact of chronic beta-blocker (BB) use on baroreflex sensitivity (BRS) testing, which is the change in heart rate precipitated by a pharmacologically induced change in blood pressure. In 103 heart failure (HF) patients treated with BBs for at least 3 months and 144 untreated patients, BRS was significantly depressed among patients who had more severe HF and more compromised left ventricular function. During follow-up, a depressed BRS (<3.0 ms/mm Hg) was significantly associated with poor outcomes independent of BB usage. This study shows that BB usage does not reduce the sensitivity of BRS testing. See page 193.

	Endothelial Dysfunction

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
High-Intensity Interval Exercise Ameliorates the Effects of a High-Fat Meal.  
A high-fat meal (HFM) transiently impairs endothelial function, an effect that may be reduced by exercise, but the mechanism responsible for this has yet to be defined. Tyldum and colleagues performed 3 flow-mediated dilation (FMD) studies on subjects after an HFM. For the control study, patients did not exercise for 48 h. For the continuous moderate exercise (CME), subjects walked on a treadmill for approximately 45 min at 60% to 70% of maximal heart rate the day prior. For high-intensity interval exercise (HIIE), subjects did four 4-min intervals of strenuous exercise. In control and CME subjects, the brachial artery diameter was significantly decreased by the HFM, but not in the HIIE group. FMD in the HIIE trial remained elevated following the HFM, in contrast to the control and CME groups. Antioxidant status was strongly correlated with FMD. These findings reveal a clinically relevant protective effect of exercise that is intensity dependent and related to antioxidant capacity. See page 200. See figure.

	Pre-Clinical Research

Top State-of-the-Art Papers Myocardial Infarction Coronary Artery Disease Coronary Artery Disease Heart Failure Heart Failure Endothelial Dysfunction Pre-Clinical Research

 
Sildenafil Improves Function, Prevents Dilation in Mouse Pressure Overload Model.  
Recent research suggests that sildenafil (SIL) can prevent the development of cardiac hypertrophy and dysfunction in mice subjected to pressure-overload, but the effectiveness in models of established cardiac hypertrophy is unknown. Nagayama and colleagues studied this in mice subjected to transverse aortic constriction (TAC) for 3 weeks to establish hypertrophy/dilation and subsequently treated with SIL (100 mg/kg/day) or placebo for 6 weeks. Mice treated with SIL had less chamber dilation, less dysfunction, less fibrosis, and increased myocardial protein kinase G activity. Studies from isolated myocytes suggest that SIL improved cellular calcium handling. These results suggest that SIL may be useful for treating hypertrophic cardiac disease by preventing further cardiac and myocyte dysfunction and progressive remodeling. See pages 207 and216. See figure.

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