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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper Clinical Research Works in Progress Pre-Clinical Research

Pedro R. Moreno, Javier Sanz, Valentin Fuster

This review by Moreno and colleagues focuses on the mechanisms and pathways whereby arteries can be maintained or restored to a healthy state. Three systems for maintaining cardiovascular homeostasis are explored—the regenerative production of endothelial progenitor cells, vessel wall angiogenesis, and macrophage-mediated reverse cholesterol transport. Endothelial progenitor cells can restore vessel wall function and reduce atherosclerosis. Angiogenesis is necessary for reducing ischemia in the arterial wall; however, neovessels are susceptible to intraplaque hemorrhage. Finally, therapies that enhance the reverse cholesterol transport system should induce plaque regression through cholesterol efflux.

	Clinical Research

Top State-of-the-Art Paper Clinical Research Works in Progress Pre-Clinical Research

 
Clinical Trials.   Similar Results for SES or MIDCAB Surgery for Proximal LAD Disease
2324

Holger Thiele, Patrick Neumann-Schniedewind, Stephan Jacobs, Enno Boudriot, Thomas Walther, Friedrich-Wilhelm Mohr, Gerhard Schuler, Volkmar Falk

Thiele and colleagues conducted a randomized study to compare sirolimus-eluting stenting (SES) with minimally invasive direct coronary artery bypass (MIDCAB) surgery for patients with isolated proximal left anterior descending (LAD) stenosis. The primary end point was noninferiority in freedom from major adverse cardiac events (MACE). MACE occurred in 7.7% of patients in both groups, but there were differences in the individual components of the combined end point. Death and myocardial infarction occurred in 1.5% versus 7.7% of SES and MIDCAB patients, respectively, but target vessel revascularization occurred in 6.2% of SES versus 0.0% of MIDCAB patients. In isolated proximal LAD disease, SES is noninferior to MIDCAB surgery with a different side effect profile.

Clinical Trials.   Significant Benefits Seen From a Structured Exercise Program Post-CRT

2332

Ashish Y. Patwala, Paul R. Woods, Lisa Sharp, David F. Goldspink, Lip B. Tan, David J. Wright

Patwala and colleagues hypothesized that cardiac resynchronization therapy (CRT) might improve central cardiac output but not peripheral oxygen extraction. Patients who were 3 months post-CRT were randomized to a thrice weekly structured exercise program or to usual care. The exercise group showed further significant improvements in functional, exercise hemodynamic, and quality-of-life measures compared with the control group. These results suggest that exercise training is useful for further augmenting the clinical benefits of CRT.

Editorial Comment

Stanley A. Rubin, p. 2340

Heart Failure.   Percent Lowering of BNP Over the First 5 Days Predicts Subsequent Mortality

2343

Alain Cohen-Solal, Damien Logeart, Bidan Huang, Danlin Cai, Markku S. Nieminen, Alexandre Mebazaa

Cohen-Solal sought to determine if decreases in B-type natriuretic peptide (BNP) levels during the first few days of hospitalization predict subsequent mortality in patients with acutely decompensated heart failure (ADHF) that require inotropes. The SURVIVE trial randomized ADHF subjects to levosimendan or dobutamine. Responders, defined as those patients who had a >30% decline in BNP levels from baseline, had lower all-cause mortality (ACM) at days 1, 3, and 5 than nonresponders. ACM through 31 days was 67% lower in day-5 BNP responders compared with nonresponders. Subjects whose BNP responds to treatment for ADHF have a lower risk of ACM than those with little or no BNP decrease.

Editorial Comment

Mihai Gheorghiade,

Peter S. Pang, p. 2349

Heart Rhythm Disorders.   Clinical Variables Can Help to Distinguish Etiology of Narrow Complex SVT

2353

Esteban González-Torrecilla, Jesús Almendral, Angel Arenal, Felipe Atienza, Leonardo F. Atea, Silvia del Castillo, Francisco Fernández-Avilés

Differentiating atrioventricular nodal re-entrant tachycardias (AVNRTs) from orthodromic reciprocating tachycardias (ORTs) using a concealed accessory pathway can be difficult. González-Torrecilla and colleagues compared a blinded diagnostic interpretation of the electrocardiogram with basic clinical variables from a 7-item questionnaire. Age at the onset of symptoms (odds ratio [OR]: 1.27), the presence of palpitations in the neck (OR: 3.54), and female sex (OR: 2.96) were more common for patients with AVNRTs. Neck palpitations were especially useful at predicting AVNRTs when the electrocardiogram was nondiagnostic.

Editorial Comment

Francis E. Marchlinski, p. 2359

Hypertension.   Systolic Gradient During Hyperemia Determines Blood Pressure Response to Renal Artery Stenting

2363

Massoud A. Leesar, Jai Varma, Adam Shapira, Ibrahim Fahsah, Seyed T. Raza, Ziad Elghoul, Anthony C. Leonard, Karthikeyan Meganathan, Sohail Ikram

Leesar and colleagues investigated the discordance between the high procedural success and moderate clinical response rates in patients with renal artery stenosis (RAS) who undergo stenting. Subjects with RAS were studied with renal translesional pressure gradients (TPGs) using a pressure wire, intravascular ultrasound, and angiographic parameters. The TPG was obtained both at rest and after induction of renal hyperemia with papaverine. A hyperemic systolic gradient (HSG) 21 mm Hg had the highest sensitivity, specificity, and predictive accuracy, each over 80%, for predicting an improvement in hypertension. An HSG 21 mm Hg appears to indicate physiologically significant RAS that is affecting the blood pressure.

	Works in Progress

Top State-of-the-Art Paper Clinical Research Works in Progress Pre-Clinical Research

 
Cardiac Imaging.   MRI Technique Can Quantify Blood Flow in Skeletal Muscles

2372

Wen-Chau Wu, Emile Mohler III, Sarah J. Ratcliffe, Felix W. Wehrli, John A. Detre, Thomas F. Floyd

Wu and colleagues describe the novel application of continuous arterial spin-labeling (CASL) magnetic resonance imaging (MRI) for measuring calf muscle perfusion in subjects with varying degrees of peripheral arterial disease (PAD). Occlusive cuff pressure was applied to create 5 min of ischemia followed by a period of responsive hyperemic flow. Peak hyperemic flow (PHF) and time-to-peak (TTP) were computed for the 4 muscle groups of the calf. Both PHF and TTP correlated with PAD, as measured by the ankle-brachial index (ABI). TTP was abnormal with any degree of PAD; PHF was preserved for subjects with ABI >0.7. CASL flow measurements are useful for quantifying the effects of PAD on microvascular flow.

	Pre-Clinical Research

Top State-of-the-Art Paper Clinical Research Works in Progress Pre-Clinical Research

 
Pre-Clinical Research.   Sustained Local Release of EPO Stimulates Angiogenesis in an Ischemic Mouse Model

2378

Longhu Li, Hideshi Okada, Genzou Takemura, Masayasu Esaki, Hiroyuki Kobayashi, Hiromitsu Kanamori, Itta Kawamura, Rumi Maruyama, Takako Fujiwara, Hisayoshi Fujiwara, Yasuhiko Tabata, Shinya Minatoguchi

Erythropoietin (EPO) is a potent angiogenic factor, but its use is limited by untoward systemic effects and its short half-life in the plasma. Li and colleagues developed injectable erythropoietin-immersed gelatin hydrogel microspheres (EPO-GHM) that should slowly release EPO into the local tissue. These microspheres were injected into the hind limb muscles of mice after ligation of the femoral artery; the results were compared to several control groups. After 8 weeks, the EPO-GHM group had significantly improved perfusion. Capillary and arteriolar density was significantly increased and there was no evidence of systemic effects such as increased hematocrit. This prolonged, localized drug delivery system appears to harness the beneficial effects of EPO on angiogenesis without systemic effects.

Related Articles

Promoting Mechanisms of Vascular Health: Circulating Progenitor Cells, Angiogenesis, and Reverse Cholesterol Transport

Pedro R. Moreno, Javier Sanz, and Valentin Fuster
J. Am. Coll. Cardiol. 2009 53: 2315-2323. [Abstract] [Full Text] [PDF]

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