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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

Theodoros D. Karamitsos, Jane M. Francis, Saul Myerson, Joseph B. Selvanayagam, Stefan Neubauer

In this state-of-the-art paper, Karamitsos and colleagues review the role of cardiovascular magnetic resonance (CMR) imaging for the management of patients with heart failure. CMR offers a comprehensive assessment of heart failure patients and is now the gold standard imaging technique to assess myocardial anatomy, regional and global function, and viability. Furthermore, it can identify and quantify areas of perfusion abnormality and acute tissue injury in patients with ischemic cardiomyopathy. In those with nonischemic heart failure, fibrosis, infiltration, and iron overload can be detected. The high measurement accuracy of CMR makes it an ideal technique for monitoring disease progression and the effects of treatment.

	Viewpoint and Commentary

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

 
Viewpoint and Commentary.   The Evidence for Recommending Early Statin Treatment for ACS Patients
1425

Ryan P. Morrissey, George A. Diamond, Sanjay Kaul

1434

David D. Waters, Ivy Ku

Current guidelines recommend initiating high-dose statin therapy pre-discharge regardless of the baseline low-density lipoprotein level in patients with acute coronary syndromes (ACS) with a Class I Level of Evidence: A. Morrissey and colleagues review the evidence and argue that early initiation of high-dose statin therapy reduces recurrent ischemia and may reduce revascularization, but does not confer benefit in terms of hard clinical outcomes, such as death or myocardial infarction. In addition, it may be associated with increased liver- and muscle-related adverse outcomes. Waters and Ku respond by defending the current guidelines. They counter that, not only are the guidelines based upon sound evidence of benefit on hard outcomes, but also that clinically important "soft" outcomes are also reduced within the first 30 days.

	Clinical Research

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

 
Acute MI and Antiplatelet Therapy.   Higher Clopidogrel Loading Dose Superior in STEMI Patients

1438

George Dangas, Roxana Mehran, Giulio Guagliumi, Adriano Caixeta, Bernhard Witzenbichler, Jiro Aoki, Jan Z. Peruga, Bruce R. Brodie, Dariusz Dudek, Ran Kornowski, LeRoy E. Rabbani, Helen Parise, Gregg W. Stone, for the HORIZONS-AMI Trial Investigators

Dangas and colleagues reviewed results from the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, which enrolled ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention to determine if a higher 600-mg loading dose of clopidogrel is superior to a 300-mg dose. All patients in the trial received clopidogrel prior to catheterization, but the dose was operator-dependent. Patients who received 600 mg of clopidogrel had significantly lower 30-day mortality, reinfarction, and stent thrombosis without higher bleeding rates. There was a similar reduction in net adverse cardiac events regardless of whether patients were randomized to unfractionated heparin or bivalirudin. These results suggest that a 600-mg loading dose of clopidogrel is more efficacious than a 300-mg dose for STEMI patients.

Editorial Comment: Daniel I. Simon, Sahil A. Parikh, p. 1447

Heart Rhythm Disorders.   Use of a Novel Set of Multielectrode Catheters for Ablation of Persistent Atrial Fibrillation

1450

Christoph Scharf, Lucas Boersma, Wyn Davies, Prapa Kanagaratnam, Nicholas S. Peters, Vince Paul, Edward Rowland, Andrew Grace, Simon Fynn, Lam Dang, Hakan Oral, Fred Morady

Radiofrequency ablation (RFA) of persistent atrial fibrillation (AF) is a lengthy and challenging procedure with a risk of thermal injury to structures near the heart. Scharf and colleagues describe their results with the use of a novel trio of multielectrode, duty-cycled RFA catheters. During a mean total procedure time of 155 min, complete pulmonary vein isolation and complex fractionated atrial electrogram ablation was achieved in all patients. In 50% of patients, redo ablation was necessary within 3 months. There were no device-related adverse events. At 6 months, there was a >80% reduction in AF in 80% of patients. This preliminary study demonstrates efficacy comparable to standard techniques with a low complication rate and a relatively short procedure time.

Cardiac Imaging.   CMR Registry Reveals Broad Clinical Utility
1457

Oliver Bruder, Steffen Schneider, Detlef Nothnagel, Thorsten Dill, Vinzenz Hombach, Jeanette Schulz-Menger, Eike Nagel, Massimo Lombardi, Albert C. van Rossum, Anja Wagner, Juerg Schwitter, Jochen Senges, Georg V. Sabin, Udo Sechtem, Heiko Mahrholdt

The EuroCMR Registry Pilot Phase collected information from 20 medical centers in Germany performing cardiovascular magnetic resonance (CMR) imaging to evaluate the indications, image quality, safety, and impact on patient management of CMR imaging. These results are based on more than 11,000 patients, 88% of whom received a gadolinium-based contrast agent. The most frequent indications for CMR were workup of myocarditis/cardiomyopathies (32%), suspected coronary artery disease/ischemia (31%), and myocardial viability (15%). Image quality was good or excellent in 90% and inadequate in only 1.8%. Severe complications, those that required inpatient monitoring, occurred in only 5 cases (0.05%), and were all associated with stress testing. In 62% of cases, CMR findings resulted in a change of patient management, and in 16% of cases the final diagnosis based on CMR was different from the diagnosis before CMR. These results suggest that CMR as used in clinical practice is safe and has a strong impact on patient management.

Biomarkers.   Utility of BNP as a Screening Test for Cardiovascular Disease in Children

1467

Yuk M. Law, Andrew W. Hoyer, Mark D. Reller, Michael Silberbach

This study by Law and colleagues assessed the ability of plasma B-type natriuretic peptide (BNP) levels to diagnose significant cardiovascular disease in the pediatric population. Subjects were eligible for this study if the treating physician requested an urgent pediatric cardiology consult to evaluate a patient. A BNP level was obtained but the results were blinded. The consulting cardiologist then determined if the patient had a significant cardiovascular disease. Neonates up to 7 days of age with a BNP >170 pg/ml had a 91% chance of having significant cardiovascular disease; for older children, a BNP >41 pg/ml indicated a 77% chance. Plasma BNP appears to be a useful test to diagnose significant structural or functional cardiovascular disease in children, although optimal cutoff values are different from those in adults.

Editorial Comment: Thenral Socrates, Nisha Arenja, Christian Mueller, p. 1476

Related Articles

The Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure

Theodoros D. Karamitsos, Jane M. Francis, Saul Myerson, Joseph B. Selvanayagam, and Stefan Neubauer
J. Am. Coll. Cardiol. 2009 54: 1407-1424. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Articles