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INSIDE THIS ISSUE OF JACC

Inside This Issue of JACC

	Viewpoint

Top Viewpoint Clinical Research From Around the World

Intracoronary transplantation of peripheral blood- or bone marrow-derived cells is associated with moderate increases in left ventricular ejection fraction and decreases in end-systolic volumes. Although there is substantial variability between trials, meta-analyses suggest an increase in ejection fraction of 3% to 4% with cellular therapy compared with control groups. Reffelmann and colleagues review the data for several other widely accepted treatments for acute myocardial infarction (MI), such as thrombolysis, angiotensin-converting enzyme inhibitors, and beta-blockers, and finds that the effects on cardiac remodeling are in the range of effects seen with these cellular therapies.

	Clinical Research

Top Viewpoint Clinical Research From Around the World

 
Interventional Cardiology.   309 Thrombus Aspiration During STEMI Reduces Infarct Size
Gennaro Sardella, Massimo Mancone, Chiara Bucciarelli-Ducci, Luciano Agati, Raffaele Scardala, Iacopo Carbone, Marco Francone, Angelo Di Roma, Giulia Benedetti, Giulia Conti, Francesco Fedele

Dislodgement of thrombus during primary percutaneous coronary intervention (PPCI) can lead to microvascular obstruction and limit tissue reperfusion despite an open infarct-related artery. Sardella and colleagues randomized almost 200 ST-segment elevation myocardial infarction (STEMI) patients to either standard PPCI or to use of a manual thrombectomy device prior to PPCI. Thrombus aspiration was associated with improved myocardial blush grade and ST-segment resolution. Thrombus aspiration also reduced infarct size and was associated with a lower incidence of cardiac death during follow-up. Thrombus aspiration may reduce distal thrombus embolization and help to preserve microvascular integrity during STEMI.

Coronary Disease Risk.   316 Reducing Non–HDL-C Reduces Cardiac Risk, Regardless of Method
Jennifer G. Robinson, Songfeng Wang, Brian J. Smith, Terry A. Jacobson

Non–high-density lipoprotein cholesterol (HDL-C), which measures circulating levels of the atherogenic apolipoprotein B-containing lipoproteins, may be a superior predictor of cardiovascular risk compared with low-density lipoprotein cholesterol, but less is known about the relationship between non–HDL reduction and coronary heart disease (CHD) risk reduction. Robinson and colleagues performed a meta-analysis of studies that used fibrates, niacin, bile acid sequestrants, ileal bypass surgery, or statins to reduce non–HDL. For statins, a 1% decrease in non–HDL-C was associated with a relative risk decrease of 1%. Results appear to be similar for other lipid-modifying drugs used as monotherapy. Non–HDL-C appears to be an important target of therapy for CHD prevention, with a 1% reduction resulting in an approximately 1% reduction in cardiac risk.

Coronary Disease Risk.   323 Persistently Impaired Endothelial Function Increases Cardiac Risk

Yoshinobu Kitta, Jyun-ei Obata, Takamitsu Nakamura, Mitsumasa Hirano, Yasushi Kodama, Daisuke Fujioka, Yukio Saito, Ken-ichi Kawabata, Keita Sano, Tsuyoshi Kobayashi, Toshiaki Yano, Kazuto Nakamura, Kiyotaka Kugiyama

Endothelial dysfunction is an established predictor of cardiovascular risk, but it is unclear if improving endothelial function can reduce the risk of future events. Kitta and colleagues performed flow-mediated dilation (FMD) assessments on 251 subjects with atherosclerosis. Subjects were then treated for risk factor modification and FMD was repeated 6 months later. FMD was persistently impaired in 41% of patients after 6 months. Cardiac events were 2.5 times more likely to occur in patients with persistently impaired FMD. These results suggest that serial FMD testing may be superior to a single assessment for predicting cardiac risk.

Editorial Comment

Peter Ganz and Priscilla Y. Hsue, p. 331

Heart Failure.   334 Seattle Heart Failure Model May Underestimate Risk in Advanced HF

Andreas P. Kalogeropoulos, Vasiliki V. Georgiopoulou, Grigorios Giamouzis, Andrew L. Smith, Syed A. Agha, Sana Waheed, Sonjoy Laskar, John Puskas, Sandra Dunbar, David Vega, Wayne C. Levy, Javed Butler

The Seattle Heart Failure Model (SHFM) provides prognostic information for patients with heart failure (HF); it was developed from clinical trial databases and published data. Kalogeropoulos and colleagues studied the accuracy of the SHFM in over 400 patients referred for possible cardiac transplantation. The SHFM underestimated absolute risk in this cohort (observed vs. predicted event rate: 11% vs. 9% at 1 year and 28% vs. 23% at 3 years). Risk underprediction was more prominent in patients with an implantable device and in black patients. In patients with advanced HF, the SHFM offers adequate discrimination of high risk versus low risk, but underestimates absolute risk.

Editorial Comment

Stephen S. Gottlieb, p. 343

Cardiac Imaging.   345 Absolute CAC More Accurate Than Age-Gender-Race/Ethnicity-Adjusted Percentile

Matthew J. Budoff, Khurram Nasir, Robyn L. McClelland, Robert Detrano, Nathan Wong, Roger S. Blumenthal, George Kondos, Richard A. Kronmal

Many centers now report an age-gender-race/ethnicity-adjusted percentile score for coronary artery calcium (CAC) to adjust for the typically higher levels seen in males and the elderly. Budoff and colleagues reviewed CAC scores and clinical outcomes to determine if these percentiles predict cardiovascular risk better than the absolute CAC score. Both methods robustly predicted risk, with a hazard ratio (HR) of >16 for a score >90th percentile and an HR >20 for an Agatston score >400. The area under the curve for the absolute score was higher than for the adjusted percentiles. The authors conclude that patients with low absolute scores are low risk, regardless of their percentile rank, whereas those with a CAC score >400 are high risk regardless of the percentile.

Editorial Comment

François Shiele and Nicolas Meneveau, p. 353

Cardiac Resynchronization Therapy.   355 More Frequent Pacing Improves CRT Outcomes

Bruce A. Koplan, Andrew J. Kaplan, Stan Weiner, Paul W. Jones, Milan Seth, Shelly A. Christman

Koplan and colleagues sought to determine whether or not patients with cardiac resynchronization therapy (CRT) devices have improved outcomes when the ventricular pacing percentage is at or near 100% compared with those with less frequent pacing. The records of almost 2,000 subjects enrolled in clinical trials were reviewed. Subjects paced at 93% to 100% (quartiles 2 to 4) had a 44% reduction in the combined end point of hospitalization for heart failure and mortality compared to those with <92% pacing. CRT appears to be most effective when biventricular pacing occurs >92% of the time, and strategies to increase this percentage may be efficacious.

Editorial Comment

Mitchell N. Faddis, p. 361

	From Around the World

Top Viewpoint Clinical Research From Around the World

 
Focus on China.   363 Additive Risks Between Tobacco Exposure and MetS in Chinese Subjects

Yao He, Tai Hing Lam, Bin Jiang, Jie Wang, Xiaoyong Sai, Li Fan, Xiaoying Li, Yinhe Qin, Frank B. Hu

More than 72% of all Chinese (>600 million people) are regularly exposed to tobacco smoke, either actively or passively, and almost one-half of elderly Chinese meet criteria for the metabolic syndrome (MetS). He and colleagues randomly sampled urban, elderly Chinese subjects to study the interactions among MetS, tobacco exposure, and cardiovascular disease (CVD). Compared with never smokers without MetS, the risk of CVD in subjects with MetS was 1.8 times higher in never smokers and 3.5 times higher in current smokers. In women, the risk of CVD nearly doubled with either secondhand smoke exposure or MetS, and was 3 times higher in women with both. The combination of tobacco smoke exposure and MetS substantially increases the risk of CVD; current trends suggest a dramatic increase in CVD in China.

Related Articles

Promise of Blood- and Bone Marrow-Derived Stem Cell Transplantation for Functional Cardiac Repair: Putting It in Perspective With Existing Therapy

Thorsten Reffelmann, Stephanie Könemann, and Robert A. Kloner
J. Am. Coll. Cardiol. 2009 53: 305-308. [Abstract] [Full Text] [PDF]

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