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INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Paper

Top State-of-the-Art Paper Clinical Research

Morton J. Kern, Habib Samady

Kern and Samady review the physiologic rationale and the clinical data which suggest that stable coronary stenoses be evaluated for physiologic significance prior to performing revascularization. They note the limits of angiographic visualization, and review how lengthy moderate stenoses may restrict flow more than short, high-grade lesions. Most of the paper reviews the clinical literature and finds significant support for only performing revascularization if the fractional flow reserve is reduced, typically <0.75. This review recommends that coronary angiography and coronary physiology be integrated for optimal patient outcomes.

	Clinical Research

Top State-of-the-Art Paper Clinical Research

 
Interventional Cardiology.   MSCT, TTE, or TEE to Measure the Aortic Annulus Prior to TAVI

186

David Messika-Zeitoun, Jean-Michel Serfaty, Eric Brochet, Gregory Ducrocq, Laurent Lepage, Delphine Detaint, Fabien Hyafil, Dominique Himbert, Nicoletta Pasi, Jean-Pierre Laissy, Bernard Iung, Alec Vahanian

Messika-Zeitoun and colleagues compared the measurements of the aortic annulus obtained with 3 different imaging modalities: transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT). There were strong correlations between the echocardiographic methods, but less for comparisons between MSCT and either TEE or TTE. The choice of valve prosthesis size, or the feasibility of performing transcatheter aortic valve implantation (TAVI), would have been different in 17% of patients if TTE measurements were used instead of TEE, and for 40% if MSCT measurements were used. In this group of patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT are not identical, and the method used has important potential clinical implications.

Editorial Comment: E. Murat Tuzcu, Samir R. Kapadia, Paul Schoenhagen, p. 195

Lipid-Lowering and Stroke.   Cholesterol Lowering and the Risk of Stroke

198

Raffaele De Caterina, Marco Scarano, RosaMaria Marfisi, Giuseppe Lucisano, Francesco Palma, Alfonso Tatasciore, Roberto Marchioli

De Caterina and colleagues performed a comprehensive meta-analysis of randomized clinical trials reporting the effects of cholesterol-lowering treatments on stroke. The studies reviewed included over 250,000 subjects with almost 1 million person-years of exposure. The odds ratio (OR) for stroke in actively-treated groups versus controls was 0.88. While statins decreased the risk of total stroke significantly (OR: 0.85), the benefit of nonstatin interventions was smaller and not statistically significant (diet OR: 0.92, fibrates OR: 0.98, other treatments OR: 0.81). Each 1% reduction of total cholesterol predicted a 0.8% relative risk reduction of stroke. These results show that statins effectively decrease the risk of stroke, and their benefit is proportional to the extent in reduction of total and low-density lipoprotein cholesterol.

Heart Failure.   Anthracycline-Induced Cardiomyopathy

213

Daniela Cardinale, Alessandro Colombo, Giuseppina Lamantia, Nicola Colombo, Maurizio Civelli, Gaia De Giacomi, Mara Rubino, Fabrizio Veglia, Cesare Fiorentini, Carlo M. Cipolla

The natural history of anthracycline-induced cardiomyopathy (AC-CMP), as well as its response to modern heart failure (HF) therapy, remains poorly defined. Cardinale and colleagues report on 201 consecutive patients with a left ventricular ejection fraction (LVEF) 45% presumably due to AC-CMP. Enalapril and, when possible, carvedilol were promptly initiated after detection of LVEF reduction, and serial measurements were then obtained. Forty-two percent of patients had improvement of their LVEF to >50%, another 13% had their LVEF improve >10% but still remained <50%, and 45% had no improvement. The percentage of responders progressively decreased as the time from the end of chemotherapy to the start of HF treatment increased. In patients developing AC-CMP, LVEF recovery may be achieved when cardiac dysfunction is detected early and modern HF treatment is initiated promptly.

Cardiac Imaging.   Normal Stress-Only SPECT Predicts Low Risk

221

Su Min Chang, Faisal Nabi, Jiaqiong Xu, Umara Raza, John J. Mahmarian

Chang and colleagues determined the long-term mortality for all subjects who had a normal single-photon emission computed tomography (SPECT) perfusion study and then compared outcomes between those who had a stress-only study and those who had both rest and stress imaging. The unadjusted annual mortality rate in patients who had a normal SPECT using a stress-only protocol was lower than in those who required additional rest imaging, but there were no significant differences after adjustment for baseline clinical characteristics. The stress-only group received a 61% lower radiopharmaceutical dosage. Patients determined to have a normal SPECT based on stress imaging alone have a similar mortality rate as those who have a normal SPECT based on evaluation of both stress and rest images and have a much lower radiation exposure.

Editorial Comment: Ami E. Iskandrian, p. 231

Ethnicity and LV Hypertrophy.   Some Hispanics Appear to Be More Susceptible to Developing LVH

234

Carlos J. Rodriguez, Ana V. Diez-Roux, Andrew Moran, Zhezhen Jin, Richard A. Kronmal, Joao Lima, Shunichi Homma, David A. Bluemke, R. Graham Barr

Rodriguez and colleagues examined the prevalence of left ventricular hypertrophy (LVH) and left ventricular (LV) remodeling patterns within Hispanic subgroups compared with non-Hispanic whites. Cardiac magnetic resonance imaging was performed in over 1,000 Hispanics who self-reported their ancestry as Mexican, Caribbean, or Central/South American. LVH was defined as the upper 95th percentile of indexed LV mass in a healthy reference population. Hispanic subgroups were more likely to have LVH than non-Hispanic whites after adjustment for hypertension and other covariates (Caribbean-origin Hispanics = odds ratio [OR]: 1.8; Mexican-origin Hispanics = OR: 2.2; Central/South Americans = OR: 1.5). All Hispanic subgroups had a higher prevalence of concentric and eccentric hypertrophy compared with non-Hispanic whites. Differences among Hispanic subgroups regarding LVH and LV remodeling should be taken into account when evaluating cardiovascular risk in this population.

Biomarkers.   Soluble ST2 Is Marker for Predicting Post-MI Recovery
243

Robin A. P. Weir, Ashley M. Miller, Grace E. J. Murphy, Suzanne Clements, Tracey Steedman, John M. C. Connell, Iain B. McInnes, Henry J. Dargie, John J. V. McMurray

This study by Weir and colleagues assessed the relationship between serum concentrations of the soluble interleukin-1 receptor family member ST2 (sST2) and serial change in left ventricular (LV) function following acute myocardial infarction (AMI) in 100 subjects with LV dysfunction early after AMI. Median sST2 decreased from 263 pg/ml at baseline to 140 pg/ml at 24 weeks. sST2 correlated significantly with LV ejection fraction both at baseline and at 24 weeks. sST2 was significantly higher in those with greater infarct transmurality and endocardial extent, and in the presence of microvascular obstruction. Measurement of sST2 early after AMI assists in the prediction of medium-term LV functional recovery.

Editorial Comment: Stephanie A. Moore, James L. Januzzi, Jr, p. 251

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