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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper Clinical Research

Filippos Triposkiadis, George Karayannis, Grigorios Giamouzis, John Skoularigis, George Louridas, Javed Butler

Activation of the sympathetic nervous system (SNS) provides inotropic support to the failing heart, increasing stroke volume and stimulating peripheral vasoconstriction to maintain mean arterial pressure. However, this activation can also accelerate disease progression. Triposkiadis and colleagues review the role of SNS activation and pharmacological modification in disease progression and reversal. The roles of specific adrenergic receptors (ARs) are reviewed as are the effects of polymorphisms in these ARs. Finally, the utility of various medications that are designed to modulate the SNS, from alpha-blockers to beta-agonists, are reviewed.

	Clinical Research

Top State-of-the-Art Paper Clinical Research

 
Prognosticators in Acute Infarction.   Prognostic Implications of ST-Segment Resolution Differ for PCI and Fibrinolysis

1763

Maria Sejersten, Nana Valeur, Peer Grande, Torsten Toftegaard Nielsen, Peter Clemmensen, for the DANAMI-2 Investigators

The prognostic significance of ST-segment resolution may be different for fibrinolysis compared with primary percutaneous coronary intervention (pPCI) for patients with acute myocardial infarction. Sejersten and colleagues reviewed electrocardiograms from the DANAMI-2 (DANish trial in Acute Myocardial Infarction-2) trial, which randomized patients to fibrinolysis or pPCI. ST-segment resolution at 90 min was more pronounced after pPCI, but there was no difference at 4 h. In the fibrinolysis group, 30-day and long-term mortality rates were significantly higher in patients without ST-segment resolution, while reinfarction rates were higher with complete ST-segment resolution. ST-segment resolution was not associated with the 2 end points in the pPCI group. These results suggest that 4-h ST-segment resolution is an important prognosticator after fibrinolysis but is a less useful surrogate end point after pPCI.

Prognosticators in Acute Infarction.   Cardiac Magnetic Resonance for Post-MI Risk Stratification
1770

Sebastian Kelle, Stijntje D. Roes, Christoph Klein, Thomas Kokocinski, Albert de Roos, Eckart Fleck, Jeroen J. Bax, Eike Nagel

This study by Kelle and colleagues assessed the predictive value of myocardial infarct size compared with contractile reserve in medically-treated patients with previous myocardial infarction (MI). A total of 177 patients with a history of coronary artery disease and evidence of scar tissue on late gadolinium-enhanced (LGE) magnetic resonance imaging were enrolled. Left ventricular (LV) functional parameters at rest and during low-dose dobutamine stimulation were measured. The spatial extent of scar tissue was a stronger predictor of adverse events than LV ejection fraction and LV volumes. In patients with large scar, >6 myocardial segments, transmurality of infarct was not a predictor of events but the presence of contractile reserve was. This study shows that LGE and contractile reserve are useful in predicting events in medically-treated patients with previous MI.

ACE Inhibition and Coronary Surgery.   ACEI Use May Increase Risk of CABG
1778

Antonio Miceli, Radek Capoun, Carlo Fino, Pradeep Narayan, Alan J. Bryan, Gianni D. Angelini, Massimo Caputo

This study by Miceli and colleagues evaluated the effect of pre-operative angiotensin-converting enzyme inhibitor (ACEI) therapy on early clinical outcomes after coronary artery bypass grafting (CABG). Over 3,000 patients who underwent CABG between 1996 and 2008 and who received an ACEI in the 24 h prior to surgery were matched with subjects who had not received an ACEI. Pre-operative ACEI therapy was associated with a 2-fold higher risk of death (1.3% vs. 0.7%). ACEI use was also associated with significantly higher risks of post-operative renal dysfunction (odds ratio [OR]: 1.36), atrial fibrillation (OR: 1.34), and need for inotropic support (OR: 1.22). While a randomized study is needed, these results suggest that ACEIs should be held for at least 24 h prior to CABG surgery.

Editorial Comment: David S. Bach, p. 1785

Vascular Effects of Nicotinic Acid.   Niacin Significantly Reduces Carotid Atherosclerosis in Statin-Treated Patients

1787

Justin M. S. Lee, Matthew D. Robson, Ly-Mee Yu, Cheerag C. Shirodaria, Colin Cunnington, Ilias Kylintireas, Janet E. Digby, Thomas Bannister, Ashok Handa, Frank Wiesmann, Paul N. Durrington, Keith M. Channon, Stefan Neubauer, Robin P. Choudhury

Nicotinic acid (NA) raises high-density lipoprotein cholesterol (HDL-C), reduces low-density lipoprotein cholesterol (LDL-C), and is widely used as an adjunct to statin therapy, but there is limited evidence that the addition of NA slows or reverses disease progression. Lee and colleagues performed a double-blind, randomized, placebo-controlled study of 2 g daily modified-release NA added to statin therapy in patients with low HDL-C (<40 mg/dl) and other risk factors. The primary end point was the change in carotid artery wall area after 1 year, as quantified by magnetic resonance imaging; NA increased HDL-C by 23%, decreased LDL-C by 19%, and significantly reduced carotid wall area compared with placebo. There was a significant inverse correlation between the change in carotid wall area and the change in HDL-C, but no relationship with the change in LDL-C. In statin-treated patients with low HDL-C, high-dose modified-release NA reverses carotid atherosclerosis.

Editorial Comment: Farouc A. Jaffer, p. 1795

Cardiac Effects of Sleep Apnea.   Increased Risk of Arrhythmias During Periods of Sleep-Disordered Breathing
1797

Ken Monahan, Amy Storfer-Isser, Reena Mehra, Eyal Shahar, Murray Mittleman, Jeff Rottman, Naresh Punjabi, Mark Sanders, Stuart F. Quan, Helaine Resnick, Susan Redline

Previous studies have shown an increased risk for atrial fibrillation and nonsustained ventricular tachycardia (NSVT) in subjects with sleep-disordered breathing (SDB), but it is unclear if respiratory disturbances actually trigger nocturnal arrhythmias. Overnight polysomnograms from over 2,500 subjects were screened for paroxysmal atrial fibrillation and NSVT. Monahan and colleagues used a case-crossover design to determine whether apneas and/or hypopneas preceded these arrhythmias within 90 s by determining if breathing disturbances also occurred during periods of sinus rhythm without ectopy. The odds of an arrhythmia following a respiratory disturbance were nearly 18 times higher than the odds of an arrhythmia during normal breathing. These results support a direct temporal and causal link between SDB and arrhythmias.

Cardiac Effects of Sleep Apnea.   Sleep Apnea Common, Possibly Pathologic, for Patients With HCM
1805

Mackram F. Eleid, Tomas Konecny, Marek Orban, Partho P. Sengupta, Virend K. Somers, James M. Parish, Farouk Mookadam, Peter A. Brady, Barbara L. Sullivan, Bijoy K. Khandheria, Steve R. Ommen, A. Jamil Tajik

Dynamic left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy (HCM) is potentiated by sympathetic stimulation, and thus could occur during the nocturnal hypoxia-induced hyperadrenergic state caused by obstructive sleep apnea (OSA). This study by Eleid and colleagues sought to determine the prevalence of OSA in patients with HCM. One hundred subjects with HCM were screened with nocturnal oximetry, and 71% were found to be abnormal with repetitive oxygen desaturations (5 events/h). This prevalence was higher than an age- and sex-matched control group. HCM patients with abnormal oximetry were more symptomatic than those without. Further studies are needed to determine if OSA treatment modifies disease progression in HCM.

Editorial Comment: Ian Wilcox, Christopher Semsarian, p. 1810

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The Sympathetic Nervous System in Heart Failure: Physiology, Pathophysiology, and Clinical Implications

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J. Am. Coll. Cardiol. 2009 54: 1747-1762. [Abstract] [Full Text] [PDF]

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