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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper Viewpoint and Commentary Clinical Research

Richard O. Cannon III

Patients with angina-like chest pain but no evidence of obstructive coronary artery disease and no structural heart disease are a common occurrence for cardiologists. Cannon describes the initial reports of patients with chest pain with normal coronary angiograms (CPNCA) 50 years ago and the previous and ongoing investigations into its pathophysiology. These patients tend to be female, with an onset of symptoms between age 40 and 50 years, pain that is severe and disabling, and a generally good prognosis. The suspected etiologies range from microvascular dysfunction to exaggerated pain sensitivity. Cannon concludes with the advice that although this syndrome is poorly understood, it should be treated with a sympathetic appreciation of symptoms. His management approach is to perform vasodilator stress cardiac magnetic resonance imaging, and if subendocardial ischemia is present, then anti-ischemic therapy. If no ischemia is evident, he uses a combination of a beta-blocker and imipramine, and he encourages enrollment in an aerobic exercise program.

	Viewpoint and Commentary

Top State-of-the-Art Paper Viewpoint and Commentary Clinical Research

 
Viewpoint and Commentary.   Routine Screening for Depression in Cardiac Patients Is Unwarranted
886

Roy C. Ziegelstein, Brett D. Thombs, James C. Coyne, Peter de Jonge

891

Mary A. Whooley

A recent Science Advisory from the American Heart Association (AHA) recommended routine screening for depression for all patients with coronary heart disease (CHD), based primarily on evidence suggesting a high prevalence of depression in CHD patients. However, a systematic review of the evidence on depression screening and treatment in CHD patients published soon after the AHA advisory found that the majority of patients who screen positive will not have major depression, and that there is no evidence that screening for depression improves CHD or depression outcomes. Ziegelstein and colleagues review the evidence and call for the AHA to reassess their recommendations. In an accompanying Commentary, Mary Whooley acknowledges that screening can improve depression, but only when combined with a collaborative care intervention. She argues "that depression deserves treatment regardless of its cardiovascular effects, reasonable screening tools are available, and screening plus collaborative care is cost effective in primary care settings." Therefore, until screening for depression is shown to improve cardiovascular outcomes, cardiac patients should be screened for depression by primary care providers in the context of a collaborative care treatment program.

	Clinical Research

Top State-of-the-Art Paper Viewpoint and Commentary Clinical Research

 
Interventional Cardiology.   Similar Rates of Stent Thrombosis, Death, and MI at 5 Years for SES Versus BMS

894

Adriano Caixeta, Martin B. Leon, Alexandra J. Lansky, Eugenia Nikolsky, Jiro Aoki, Jeffrey W. Moses, Joachim Schofer, Marie-Claude Morice, Erick Schampaert, Ajay J. Kirtane, Jeffrey J. Popma, Helen Parise, Martin Fahy, Roxana Mehran

Caixeta and colleagues report the patient-level pooled analysis of 5-year clinical outcomes for the 4 large trials that randomized patients to sirolimus-eluting stents (SES) or bare-metal stents (BMS). At 5 years, there was no significant difference in the rate of death, myocardial infarction (MI), or the composite of death/MI between the 2 groups in almost 2,000 subjects. The 5-year incidence of stent thrombosis by the Academic Research Consortium definition did not differ between SES and BMS; the incidence of very late stent thrombosis was also similar between the SES and BMS groups. The 5-year incidence of target vessel revascularization was approximately one-half in the SES group. In this patient-level pooled analysis, there was a reduction in target vessel revascularization without an increase in death, MI, or stent thrombosis with the use of SES.

Interventional Cardiology.   1 in 7 Medicare Patients Readmitted Within 30 Days After PCI

903

Jeptha P. Curtis, Geoffrey Schreiner, Yongfei Wang, Jersey Chen, John A. Spertus, John S. Rumsfeld, Ralph G. Brindis, Harlan M. Krumholz

The readmission rates for many conditions and procedures are influenced by the quality of care, hospital system characteristics, and local practice patterns, but the rate of readmission after percutaneous coronary intervention (PCI) is not known. Curtis and colleagues analyzed Medicare Fee-for-Service (FFS) administrative data to describe readmission rates following PCI. A total of 315,241 PCI procedures performed at 1,108 hospitals were included in the analysis. The all-cause 30-day readmission rate was 14.6%, and the all-cause 30-day mortality rate was 1.0%; the 30-day mortality rate was 6 times higher in those who were readmitted. The median readmission rates varied across hospitals, from 9% in the lowest decile to 22% in the highest decile. These findings warrant further attention to determine if these readmissions, and the associated mortality, are preventable.

Editorial Comment: Dean J. Kereiakes, p. 908

Interventional Cardiology.   MSCT After Percutaneous Aortic Valve Replacement

911

Carl J. Schultz, Annick Weustink, Nicolo Piazza, Amber Otten, Nico Mollet, Gabriel Krestin, Robert J. van Geuns, Pim de Feyter, Patrick W. J. Serruys, Peter de Jaegere

Schultz and colleagues used multislice computed tomography (MSCT) to study distortion in the geometry of the CoreValve ReValving System (CRS) (Medtronic, Luxembourgh, Luxembourgh) after implantation for aortic stenosis. This distortion could be caused by inappropriate sizing or incomplete or nonuniform expansion, and could affect leaflet coaptation acutely or shorten long-term durability. Thirty patients had MSCT at a median 1.5 months after PAVR. The difference between the longest and shortest diameters (the degree of deformation) at the ventricular end was 4.4 mm and decreased progressively toward the outflow. Incomplete apposition of the CRS frame was present in 62% of patients at the ventricular end. These results will help to determine appropriate sizing and geometrical characteristics of percutaneous aortic valves.

Heart Failure.   Testosterone Injections Improves Exercise Capacity in Men With CHF

919

Giuseppe Caminiti, Maurizio Volterrani, Ferdinando Iellamo, Giuseppe Marazzi, Rosalba Massaro, Marco Miceli, Caterina Mammi, Massimo Piepoli, Massimo Fini, Giuseppe M. C. Rosano

This study by Caminiti and colleagues assessed the effect of 12 weeks of testosterone administration on maximal exercise capacity, ventilatory efficiency, muscle strength, insulin resistance, and baroreflex sensitivity (BRS) in elderly patients with chronic heart failure (CHF). Seventy elderly male subjects with CHF were randomly assigned to testosterone or placebo. Peak oxygen consumption, ventilation/carbon dioxide output, and 6-min walk test significantly improved with testosterone. There were also improvements in homeostasis model assessment, quadriceps maximal isometric strength, and BRS. These results suggest that long-acting testosterone therapy improves exercise capacity, muscle strength, glucose metabolism, and BRS in men with heart failure.

Editorial Comment: Pål Aukrust, Thor Ueland, Lars Gullestad, Arne Yndestad, p. 928

Genetics/Genomics.   Mutations in RNA Binding Protein Gene Associated With Familial DCM
930

Katharine M. Brauch, Margaret L. Karst, Kathleen J. Herron, Mariza de Andrade, Patricia A. Pellikka, Richard J. Rodeheffer, Virginia V. Michels, Timothy M. Olson

Brauch and colleagues used genome-wide linkage analysis to study 2 large families with autosomal dominant inherited dilated cardiomyopathy (DCM). Overlapping loci for DCM were independently mapped to chromosome 10q25-q26. Deoxyribonucleic acid sequencing revealed distinct heterozygous missense mutations in exon 9 of RBM20, encoding ribonucleic acid (RNA) binding motif protein 20. Further testing showed that this mutation hotspot accounted for 3% of all DCM cases, 5% of confirmed or suspected familial cases, and 13% of cases with a history of sudden death. RBM20 is preferentially expressed in the heart and encodes motifs prototypical of spliceosome proteins that regulate alternative pre-messenger RNA splicing.

Editorial Comment: Calum A. MacRae, William J. McKenna, p. 942

Genetics/Genomics.   Common Genetic Variations in NPY1R Linked to Hypertension

944

Lei Wang, Fangwen Rao, Kuixing Zhang, Manjula Mahata, Juan L. Rodriguez-Flores, Maple M. Fung, Jill Waalen, Myles G. Cockburn, Bruce A. Hamilton, Sushil K. Mahata, Daniel T. O'Connor

Neuropeptide Y (NPY) exhibits a range of important physiological activities, including central regulation of endocrine secretion, and potent vasoactive effects. Neuropeptide Y1 receptor (NPY1R) is the major subtype of NPY receptor. Wang and colleagues sequenced NPY1R in a series of patients and found 2 common polymorphisms. In subjects with the most extreme blood pressures (BPs), promoter A-585T and 3'-UTR A+1050G polymorphisms each had substantial effects upon both diastolic and systolic BP, and the 2 were additive. These variations also affected baroreflex responses and the response to cold-pressor challenge. The alleles that increased BP in vivo (3'-UTR +1050G, promoter A-585) also decreased NPY1R expression in cultured chromaffin cells. These results indicate that genetic variation at the NPY1R locus affects heritable autonomic control of the circulation, and ultimately systemic hypertension.

Related Articles

Microvascular Angina and the Continuing Dilemma of Chest Pain With Normal Coronary Angiograms

Richard O. Cannon, III
J. Am. Coll. Cardiol. 2009 54: 877-885. [Abstract] [Full Text] [PDF]

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