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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper Viewpoint News from the NHLBI Clinical Research

Eileen M. Hsich, Ileana L. Piña

This piece by Hsich and Piña reviews sex differences in the diagnosis and treatment of heart failure (HF) and offers practical suggestions to guide therapy when treating females with HF. Nearly 50% of those affected by HF are women. Women are less likely to have coronary artery disease and more likely to have hypertension and valvular disease. Women often present at an older age with better systolic function and have better survival. Despite these known sex differences, medical management recommendations are the same for women and men since prospective sex-specific clinical trials have not been performed. However, this review suggests that women may respond differently to some therapies and that prospective sex-specific data is needed.

	Viewpoint

Top State-of-the-Art Paper Viewpoint News from the NHLBI Clinical Research

 
Health Reform.   The Role of the ACC and its Members in Promoting Health System Reform
499

James T. Dove, W. Douglas Weaver, Jack Lewin

In this Viewpoint article, Drs. Dove, Weaver, and Lewin discuss the growing momentum for health system reform and the role of the American College of Cardiology (ACC) in this process. Designing a health care delivery system that delivers quality, patient-centered care requires the involvement of both patients and medical professionals. The ACC is encouraging health care providers to transform health care from the inside out. The ACC is also advocating for a system that encompasses these 6 principals necessary for reform: universal coverage, coverage through an expansion of public and private (pluralistic) programs, a focus on patient value, emphasis on professionalism, coordination across sources and sites of care, and payment reforms that reward quality and ensure value.

	News from the NHLBI

Top State-of-the-Art Paper Viewpoint News from the NHLBI Clinical Research

 
News from the NHLBI.   NHLBI Develops Website to Explain Pediatric Research to Children and Parents

502

Victoria L. Pemberton, Jonathan R. Kaltman, Gail D. Pearson

In the fall of 2008, the National Heart, Lung, and Blood Institute (NHLBI) launched Children and Clinical Studies, a multimedia website to educate the public and researchers about children's participation in clinical research. The "no more hand-me-downs" theme emphasizes the importance of research focused on pediatric conditions. Both children and parents will find information about participating in a research trial, which should facilitate the process of informed consent and hopefully improve the likelihood that children will participate.

	Clinical Research

Top State-of-the-Art Paper Viewpoint News from the NHLBI Clinical Research

 
Clinical Trial.   Spironolactone Reduces LV Hypertrophy in Patients With CKD

505

Nicola C. Edwards, Richard P. Steeds, Paul M. Stewart, Charles J. Ferro, Jonathan N. Townend

Activation of the renin-angiotensin-aldosterone system in patients with chronic kidney disease (CKD) is believed to cause left ventricular (LV) hypertrophy and arterial stiffness. Edwards and colleagues randomized subjects with CKD (glomerular filtration rate 30 to 69 ml/min/1.73 m²) who were already taking an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker to 25 mg/day of spironolactone or placebo. LV mass and arterial stiffness were measured before and after 40 weeks of treatment. Compared with placebo, spironolactone resulted in significant reductions in LV mass (–14 g vs. +3 g), pulse wave velocity, augmentation index, and improved aortic distensibility. The utility of spironolactone for reducing adverse cardiovascular events in patients with CKD merits further study.

Editorial Comment: William C. Little, Paul M. Kirkman, p. 513

Coronary Artery Disease.   Wide Variations in Frequency of Referrals for Cardiac Rehabilitation

515

Todd M. Brown, Adrian F. Hernandez, Vera Bittner, Christopher P. Cannon, Gray Ellrodt, Li Liang, Eric D. Peterson, Ileana L. Piña, Monika M. Safford, Gregg C. Fonarow, on behalf of the American Heart Association Get With The Guidelines Investigators

Cardiac rehabilitation reduces morbidity and mortality and is a Class I indication following myocardial infarction (MI) or revascularization. However, it appears to be underutilized, with only 19% of Medicare patients with appropriate indications enrolled. Brown and colleagues analyzed over 70,000 patients discharged alive following an MI, percutaneous coronary intervention, or coronary artery bypass graft surgery from 156 hospitals. Only 56% were referred to cardiac rehabilitation at discharge. The referral rate by hospital ranged from 0% to 100%: only one-third of hospitals referred >60% of eligible patients. Despite strong evidence for benefit, only one-half of eligible patients are referred for cardiac rehabilitation.

Heart Rhythm Disorders.   Ablation May Reduce Frequency of Idiopathic VF
522

Sébastien Knecht, Frédéric Sacher, Matthew Wright, Mélèze Hocini, Akihiko Nogami, Thomas Arentz, Bertrand Petit, Robert Franck, Christian De Chillou, Dominique Lamaison, Jéronimo Farré, Thomas Lavergne, Thierry Verbeet, Isabelle Nault, Seiichiro Matsuo, Lionel Leroux, Rukshen Weerasooriya, Bruno Cauchemez, Nicolas Lellouche, Nicolas Derval, Sanjiv M. Narayan, Pierre Jaïs, Jacques Clementy, Michel Haïssaguerre

This multicenter study sought to evaluate the long-term efficacy of ablation for idiopathic ventricular fibrillation (VF). Thirty-eight consecutive patients underwent ablation of primary idiopathic VF that was triggered by a short coupled ventricular premature beat (VPB). Most subjects had experienced 2 or more VF episodes in the preceding year. Catheter ablation was guided by activation mapping of VPBs. During a median post-procedural follow-up of 63 months, only 18% of patients experienced VF recurrence; 5 of the 7 who had recurrent VF underwent a second ablation with no subsequent VF episodes. Ablation for idiopathic VF may reduce the frequency of VF episodes for patients with idiopathic VF.

Editorial Comment: Bruce D. Lindsay, p. 529

Heart Rhythm Disorders.   People With Anxiety and Emotional Distress at Increased Risk for Ventricular Arrhythmias

531

Krista C. van den Broek, Ivan Nyklíek, Pepijn H. van der Voort, Marco Alings, Albert Meijer, Johan Denollet

This prospective study by van den Broek and colleagues examined the interaction between Type D personality and the risk for ventricular arrhythmias. Type D patients tend to experience increased negative emotions (e.g., worry, having a gloomy view of life) paired with emotional nonexpression. Almost 400 patients were assessed for anxiety, depression, and Type D personality prior to implantation of an implantable cardioverter-defibrillator. Neither depression nor anxiety predicted subsequent arrhythmias. However, anxious patients with a Type D personality had a significantly increased rate of ventricular arrhythmias (adjusted hazard ratio: 1.7). Personality traits may modify the effect of anxiety in pre-disposing to increased risk of ventricular arrhythmias.

Cardiac Imaging.   Perfusion Imaging May Be Unnecessary in Those Who Achieve 10 METs of Exercise

538

Jamieson M. Bourque, Benjamin H. Holland, Denny D. Watson, George A. Beller

Bourque and colleagues sought to identify the prevalence of significant ischemia (defined as 10% of the left ventricle [LV]) on exercise single-photon emission computed tomography imaging in patients able to achieve 10 metabolic equivalents (METs) of exercise and 85% of their maximum age-predicted heart rate. Of the approximately 500 subjects who achieved 10 METs, only 0.4% had significant ischemia; no patient who achieved 10 METs without exercise ST-segment depression had 10% LV ischemia, and only 0.7% had 5% to 9% LV ischemia. The authors suggest that patients who achieve 10 METs without ST-segment depression do not need to be injected with nuclear tracer, potentially resulting in significant cost savings.

Editorial Comment: Frans J. Th. Wackers, p. 546

Cardiac Imaging.   MRI May Be Safe in Patients With ICDs
549

Claas P. Naehle, Katharina Strach, Daniel Thomas, Carsten Meyer, Markus Linhart, Sascha Bitaraf, Harold Litt, Jörg Otto Schwab, Hans Schild, Torsten Sommer

Performing a magnetic resonance imaging (MRI) scan on a patient with an implantable cardioverter-defibrillator (ICD) may be more dangerous than on a patient with a traditional pacemaker. Naehle and colleagues report on their experience performing MRI on 18 patients with ICDs. Nonpacemaker-dependent ICD patients had their ICDs reprogrammed pre-MRI to minimize pacing, and arrhythmia detection was programmed on, but therapy delivery off. All examinations were completed safely with no patient symptoms. No significant changes of capture thresholds or lead impedance were observed. In 2 magnetic resonance examinations, oversensing of radiofrequency noise as ventricular fibrillation occurred. In conclusion, MRI of nonpacemaker-dependent ICD patients can be performed under controlled conditions by taking both MRI- and pacemaker-related precautions.

Editorial Comment: Ariel Roguin, p. 556

Related Articles

Heart Failure in Women: A Need for Prospective Data

Eileen M. Hsich and Ileana L. Piña
J. Am. Coll. Cardiol. 2009 54: 491-498. [Abstract] [Full Text] [PDF]

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