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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper JACC White Paper Clinical Research Pre-Clinical Research

Eugenio Picano, Philippe Pibarot, Patrizio Lancellotti, Jean Luc Monin, Robert O. Bonow

This state-of-the-art paper by Picano and colleagues reviews the utility of and protocols for exercise testing in the evaluation of patients with valvular heart disease. As symptoms may develop slowly and therefore be unnoticed by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can identify patients who would benefit from valve repair or replacement. The protocols can be tailored for patients with aortic or mitral valve disease, both before and after valve replacement or repair. The exercise-induced changes in valve hemodynamics, ventricular function, and pulmonary artery pressure provide the clinician with diagnostic and prognostic information. However, the authors caution that large-scale prospective randomized studies focusing on patient outcomes are lacking for many clinical scenarios.

	JACC White Paper

Top State-of-the-Art Paper JACC White Paper Clinical Research Pre-Clinical Research

 
JACC White Paper.   Management of Antiplatelet Agents in Patients Undergoing Elective Endoscopic Procedures
2261

Richard C. Becker, James Scheiman, Harold L. Dauerman, Frederick Spencer, Sunil Rao, Marc Sabatine, David A. Johnson, Frances Chan, Neena S. Abraham, Eamonn M. M. Quigley, in collaboration with the American College of Cardiology and the American College of Gastroenterology

Representatives of the American College of Cardiology and the American College of Gastroenterology have produced a White Paper designed to aid physicians in the periprocedural management of patients taking platelet-directed pharmacotherapy who are referred for elective endoscopic gastrointestinal procedures. The paper begins by outlining the benefits of both aspirin and thienopyridines in various scenarios, including the potential detrimental effects of sudden drug cessation, particularly in the first 6 months following percutaneous coronary intervention with drug-eluting stents (DES). The recommendation is that elective endoscopic procedures be deferred if possible for 6 months and possibly up to 12 months following DES implantation. For procedures that cannot be delayed, particularly those associated with heightened bleeding risk, consideration should be given to holding thienopyridine treatment for 5 to 7 days but continuing aspirin.

	Clinical Research

Top State-of-the-Art Paper JACC White Paper Clinical Research Pre-Clinical Research

 
Clinical Trials.   Infusion of Human Mesenchymal Stem Cells Safe, Possibly Effective, Post-MI
2277

Joshua M. Hare, Jay H. Traverse, Timothy D. Henry, Nabil Dib, Robert K. Strumpf, Steven P. Schulman, Gary Gerstenblith, Anthony N. DeMaria, Ali E. Denktas, Roger S. Gammon, James B. Hermiller, Jr, Mark A. Reisman, Gary L. Schaer, Warren Sherman

Hare and colleagues investigated the safety and efficacy of intravenous allogeneic human mesenchymal stem cells (hMSCs) in patients with myocardial infarction (MI). These cells are collected from healthy donors rather than the patient; it is believed that they do not generate an immune response, and thus no human leukocyte antigen-matching is required. This was a placebo-controlled, dose-ranging safety trial of intravenous allogeneic hMSCs in 53 post-MI patients. Adverse event rates were similar between the hMSC- and placebo-treated groups, and renal, hepatic, and hematologic laboratory indexes were not different. There were improvements in the frequency of ventricular tachycardia episodes and in the ejection fraction in the subset of anterior MI patients. This trial provides important safety and provisional efficacy data for allogeneic hMSCs in post-infarction patients.

Editorial Comment: Marc S. Penn, Saif Anwaruddin, Ravi Nair, Stephen Ellis, p. 2287

Interventional Cardiology.   Intensive Statin Therapy Particularly Useful in Post-PCI Patients
2290

C. Michael Gibson, Yuri B. Pride, Claudia P. Hochberg, Sarah Sloan, Marc S. Sabatine, Christopher P. Cannon, for the TIMI Study Group

Gibson and colleagues performed a subgroup analysis of the almost 3,000 subjects in the PROVE IT–TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22) trial who underwent percutaneous coronary intervention (PCI) prior to randomization. All subjects in the trial presented with an acute coronary syndrome (ACS), but about one-third did not undergo PCI. Subjects were randomized to either 80 mg atorvastatin daily or 40 mg pravastatin. Treatment with atorvastatin reduced the incidence of the composite end point (hazard ratio: 0.78) and lowered the incidence of both target vessel revascularization (TVR) and non-TVR. There was no significant reduction in the primary end point in subjects who had not undergone PCI. Among patients with ACS who undergo PCI, intensive statin therapy reduces major adverse cardiac events compared with moderate statin therapy.

Acute Myocardial Infarction.   EMS Transmission of ECGs Improves Door-to-Balloon Times and Outcomes
2296

Sune H. Pedersen, Soren Galatius, Peter R. Hansen, Rasmus Mogelvang, Steen Z. Abildstrom, Rikke Sørensen, Ulla Davidsen, Anders Galloe, Ulrik Abildgaard, Allan Iversen, Jan Bech, Jan K. Madsen, Jan S. Jensen

Pedersen and colleagues reviewed outcomes of almost 1,500 ST-segment elevation myocardial infarction (STEMI) patients treated at their institution. The subjects were divided by those who had been triaged in the field via wireless transmission of the electrocardiogram (ECG) from the emergency medical services (EMS) personnel to a cardiologist at the hospital, and those who were triaged after they arrived at the hospital, either the same institution or one that required ambulance transfer for primary percutaneous coronary intervention (pPCI). Patients admitted by field triage had a significantly shorter median door-to-balloon time; door-to-balloon times <90 min were achieved in nearly two-thirds of field-triaged patients but only one-third of nonfield-triaged patients. Patients who were triaged in the field also had better clinical outcomes. This study shows that field triage of STEMI patients to pPCI can significantly reduce door-to-balloon times.

Cardiovascular Risk.   Improved Vascular Risk Prediction With Behavioral and Anthropometric Factors
2303

Ralph L. Sacco, Minesh Khatri, Tatjana Rundek, Qiang Xu, Hannah Gardener, Bernadette Boden-Albala, Marco R. Di Tullio, Shunichi Homma, Mitchell S. V. Elkind, Myunghee C. Paik

Most of the commonly used cardiovascular risk models were not designed to predict the risk of stroke, myocardial infarction, or vascular death, which Sacco and colleagues define as global vascular risk; they also do not include behavioral risk factors or anthropometric measures and have lacked ethnic diversity. The NOMAS (Northern Manhattan Study) included significant proportions of Hispanic and African-American participants. The global vascular risk score (GVRS) was constructed by adding variables to the traditional Framingham cardiovascular variables. Variables that significantly added to the traditional Framingham profile included waist circumference, alcohol consumption, and physical activity. Continuous measures for blood pressure and fasting blood sugar also seemed to improve accuracy. Ten-year event-free probabilities ranged from 0.95 for the first quartile of GVRS to 0.56 for the fourth quartile. The GVRS combines traditional, behavioral, and anthropometric risk factors, uses continuous variables for physiological parameters, and is applicable to nonwhite subjects; it appears to improve risk stratification.

Valvular Heart Disease.   Lateral and Horizontal BAVs Likely Have Different Causes

2312

Borja Fernández, Ana C. Durán, Teresa Fernández-Gallego, M. Carmen Fernández, Miguel Such, Josep M. Arqué, Valentín Sans-Coma

Bicuspid aortic valve (BAV) is the most frequent congenital heart disease, with 2 main anatomical types: laterolateral and anteroposterior. Fernández and colleagues compared the embryonic morphological development of these valves in a strain of mice prone to laterolateral BAV and a strain of hamsters prone to develop anteroposterior BAV. Laterolateral BAVs result from a defective development of the outflow tract endocardial cushions, while anteroposterior BAVs, on the other hand, result from fusion of the right and left conotruncal ridges. These results suggest that laterolateral and anteroposterior BAVs are different etiological entities and likely are caused by different genetic aberrations.

Editorial Comment: Robert H. Anderson, Robert P. Thompson, Christine B. Kern, p. 2319

	Pre-Clinical Research

Top State-of-the-Art Paper JACC White Paper Clinical Research Pre-Clinical Research

 
Pre-Clinical Research.   Paclitaxel May Activate Rho-Kinase, Thereby Promoting Vasoconstriction

2321

Takashi Shiroto, Satoshi Yasuda, Ryuji Tsuburaya, Yoshitaka Ito, Jun Takahashi, Kenta Ito, Hatsue Ishibashi-Ueda, Hiroaki Shimokawa

Some studies suggest that drug-eluting stents (DES) may provoke coronary vasoconstriction that is not seen with bare-metal stents. In a series of experiments, Shiroto and colleagues studied the effect of paclitaxel on vasoconstriction. The major findings of this study were: 1) paclitaxel increased Rho-kinase expression and activity in cultured human coronary artery smooth muscle cells; 2) paclitaxel-eluting stents enhanced coronary vasoconstriction in response to serotonin in pigs; 3) the constrictive response was abolished by a Rho-kinase inhibitor; and 4) these functional alterations of the coronary arteries were associated with enhanced microthrombus formation and inflammatory cell infiltration in areas with increased Rho-kinase activity. These results suggest that the Rho-kinase pathway plays an important role in the pathogenesis of DES-induced coronary vasoconstriction.

Editorial Comment: Georg Nickenig, Jan-Malte Sinning, p. 2330

Related Articles

The Emerging Role of Exercise Testing and Stress Echocardiography in Valvular Heart Disease

Eugenio Picano, Philippe Pibarot, Patrizio Lancellotti, Jean Luc Monin, and Robert O. Bonow
J. Am. Coll. Cardiol. 2009 54: 2251-2260. [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