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INSIDE THIS ISSUE

Inside This Issue

	Clinical Research

Top Clinical Research From Around the World Year in Cardiology Series

Francesco Liistro, Massimo Fineschi, Simone Grotti, Paolo Angioli, Arcangelo Carrera, Kenneth Ducci, Tommaso Gori, Giovanni Falsini, Carlo Pierli, Leonardo Bolognese

This study by Liistro and colleagues evaluated the long-term clinical efficacy and safety of sirolimus-eluting stents (SES) for in-stent restenosis (ISR). Short-term results from the TRUE (Tuscany Registry Of Unselected In-Stent Restenosis) registry have previously been published, and they showed a 5% rate of target lesion revascularization (TLR) and <1% stent thrombosis (ST) at 9 months. At the 4-year follow-up, cardiac death occurred in 4.5% of patients, nonfatal myocardial infarction in 3.2% of patients, and TLR in 11% of patients. Definite ST occurred in 2% of patients and possible ST in 0.8% of patients. The clinical benefit of SES implantation for bare-metal stent ISR is maintained at 4 years, with a low TLR rate and an overall incidence of ST of 0.7% per year.

Interventional Cardiology.   Bedside Monitoring of Enoxaparin Anticoagulation
617

Johanne Silvain, Farzin Beygui, Annick Ankri, Anne Bellemain-Appaix, Ana Pena, Olivier Barthelemy, Guillaume Cayla, Vanessa Gallois, Sophie Galier, Dominique Costagliola, Jean-Philippe Collet, Gilles Montalescot

Silvain and colleagues evaluated the ability of the bedside test to identify patients treated with enoxaparin with insufficient anti-Xa activity. Whole blood Hemonox (International Technidyne Corporation, Edison, New Jersey) clotting time (CT) was measured at baseline and 10 min after the intravenous administration of enoxaparin in patients receiving additional enoxaparin. These results were compared with plasma chromogenic anti-Xa activity level. The threshold value of 120 s for the Hemonox CT was associated with a 95% sensitivity and a 73% specificity to detect patients with an inadequate anti-Xa level (<0.5 UI/ml). Hemonox CT appears to be a fast and reliable bedside test for detecting patients who are insufficiently anticoagulated with enoxaparin for PCI.

Coronary Artery Disease.   The Absence of Coronary Calcification Does Not Exclude Obstructive Coronary Artery Disease

627

Ilan Gottlieb, Julie M. Miller, Armin Arbab-Zadeh, Marc Dewey, Melvin E. Clouse, Leonardo Sara, Hiroyuki Niinuma, David E. Bush, Narinder Paul, Andrea L. Vavere, John Texter, Jeffery Brinker, João A. C. Lima, Carlos E. Rochitte

The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients. Gottlieb and colleagues measured the CS in almost 300 patients referred for coronary angiography. About one-third of the patients had CS of zero, but 19% of these subjects had at least 1 50% stenosis. In 64 totally occluded vessels, 13 (20%) had no calcium. The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients referred for coronary angiography, and total coronary occlusion can occur in the absence of any detectable calcification.

Editorial Comment: Rita F. Redberg, p. 635

Coronary Artery Disease.   Increased Serum Levels of Vasoconstrictive and Inflammatory Factors Link Emotional Stress to ACS
637

Ute Wilbert-Lampen, Thomas Nickel, David Leistner, Denise Güthlin, Tomas Matis, Christoph Völker, Sebastian Sper, Helmut Küchenhoff, Stefan Kääb, Gerhard Steinbeck

Wilbert-Lampen and colleagues documented higher rates of acute coronary syndromes (ACS) during the 2006 World Cup. For this report, serum levels of soluble CD40L (sCD40L), soluble vascular cell adhesion molecule (sVCAM)-1, monocyte chemoattractant protein (MCP)-1, tumor necrosis factor (TNF)-, high-sensitivity C-reactive protein, regulated on activation, normal T-cell expressed and secreted (RANTES), and endothelin (ET)-1 were measured in patients who experienced an ACS during World Cup matches and were compared with patients who experienced an ACS not associated with emotional stress and with healthy volunteers. sCD40L, sVCAM-1, MCP-1, TNF-, and ET-1 were significantly higher in study patients compared with the reference group. Stress-induced ACS is associated with a profound increase of inflammatory and vasoconstrictive mediators.

Editorial Comment: Karina W. Davidson, Matthew Burg, Daichi Shimbo, p. 643

Heart Failure.   NT-proBNP–Guided Therapy Is Superior to Usual Care

645

Rudolf Berger, Deddo Moertl, Sieglinde Peter, Roozbeh Ahmadi, Martin Huelsmann, Susan Yamuti, Brunhilde Wagner, Richard Pacher

Berger and colleagues investigated whether the addition of N-terminal pro–B-type natriuretic peptide (NT-proBNP)-guided, intensive patient management (BM) to multidisciplinary care (MC) would improve outcomes in patients following a hospitalization due to heart failure (HF). After discharge, patients were randomized to BM, MC, or usual care (UC). MC included consultations from an HF specialist and home care by a specialized HF nurse. NT-proBNP was used to guide up-titration of medications in addition to MC in the BM cohort. After 12 months, the BM group had the highest proportion of antineurohormonal triple-therapy and fewer days of HF hospitalization. The combined end point of death or HF re-hospitalization was lower in the BM group (37%) compared with the MC (50%) and UC groups (65%). Compared with MC alone, knowledge of NT-proBNP levels can improve clinical outcomes.

Heart Failure.   African-American Women Have a Higher Risk for Developing Peripartum Cardiomyopathy
654

Mindy B. Gentry, James K. Dias, Antonio Luis, Rakesh Patel, John Thornton, Guy L. Reed

The reported frequency of peripartum cardiomyopathy varies markedly between African and non-African regions, but the risk factors for this disease are otherwise unknown. Gentry and colleagues performed a case-control study at a large hospital that serves a racially heterogeneous population. African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non-African Americans. African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable and stratified analyses. African-American women have a significantly higher risk of developing peripartum cardiomyopathy; further research is needed to clarify the environmental and/or genetic factors that confer this risk.

Valvular Heart Disease.   Evidence of Widespread Vascular Changes in Subjects With BAV and AD

660

Nikolaos Tzemos, Erik Lyseggen, Candice Silversides, Michal Jamorski, Jeffrey H. Tong, Paula Harvey, John Floras, Samuel Siu

Pre-clinical studies have shown that endothelial nitric oxide synthase-deficient mice are predisposed to develop bicuspid aortic valve (BAV) and aortic dilation (AD). Tzemos and colleagues compared several indexes of vascular function in patients with BAV and AD, BAV without AD, and healthy controls. The BAV subjects with AD had blunted brachial flow-mediated vasodilation, higher carotid-femoral pulse wave velocity, and significantly higher plasma levels of matrix metalloproteinase-2 compared with men with BAV and a nondilated aorta and with healthy controls. Subjects with BAV and AD have several vascular alterations that could introduce new targets for screening and perhaps for therapeutic intervention.

Editorial Comment: S. Morteza Farasat, p. 669

Valvular Heart Disease.   Evidence of Oxidative Stress, Permanent Myocyte Damage With MR

671

Mustafa I. Ahmed, James D. Gladden, Silvio H. Litovsky, Steven G. Lloyd, Himanshu Gupta, Seidu Inusah, Thomas Denney, Jr, Pamela Powell, David C. McGiffin, Louis J. Dell'Italia

Ahmed and colleagues studied whether or not there was permanent cardiac damage from isolated mitral regurgitation (MR) even when subjects underwent mitral valve repair (MVR) when their ejection fraction was >60%. Twenty-seven patients with isolated MR had left ventricular (LV) biopsies taken at the time of MVR. Magnetic resonance imaging was performed pre-MVR and 6 months post-MVR and compared with healthy controls. After MVR, LV end-systolic volume index did not improve and remained enlarged compared with controls. LV circumferential and longitudinal strain rates were both below normal post-MVR. LV biopsies demonstrated cardiomyocyte myofibrillar degeneration and increased xanthine oxidase and lipofuscin deposition. These imaging and immunohistochemistry results suggest that MR causes myocyte dysfunction, which does not fully reverse after MVR.

	From Around the World

Top Clinical Research From Around the World Year in Cardiology Series

 
Focus on Africa.   Cardiovascular Diseases in Africa: Challenges and Opportunities
680

Ana Olga H. Mocumbi, Maria Beatriz Ferreira

Rheumatic heart disease, endomyocardial fibrosis, and peripartum cardiomyopathy are the primary causes of heart failure in sub-Saharan Africa. Although affecting several million people, these diseases have been relatively neglected by the medical and scientific communities. The cardiovascular manifestations of infectious diseases, especially tuberculosis, are also common, as are idiopathic disorders such as Takayasu's arteritis and subvalvular left ventricular aneurysms. This paper by Mocumbi and Ferreira discusses the difficulties in the diagnosis and management of "forgotten" conditions, and proposes strategies to stimulate research on these conditions in the African context.

	Year in Cardiology Series

Top Clinical Research From Around the World Year in Cardiology Series

 
Year in Cardiology Series.   The Year in Heart Failure
688

W. H. Wilson Tang, Gary S. Francis

Tang and Francis review last year's literature as it relates to heart failure (HF), from pathophysiology to destination therapy. Some of the highlighted areas include the association between modifiable risk factors and HF, the possible importance of micro-ribonucleic acid in the pathophysiology of HF, and the disappointing results from the I-PRESERVE (Irbesartan in Heart Failure with Preserved Ejection Fraction) trial. Papers showing improved outcomes with device-based therapy suggest that these interventions may be beneficial earlier in the course of therapy. They conclude with the hope that in the near future there may be significant advances in both our understanding of and in the arsenal for treating HF.

Related Articles

Long-Term Effectiveness and Safety of Sirolimus Stent Implantation for Coronary In-Stent Restenosis: Results of the TRUE (Tuscany Registry of Sirolimus for Unselected In-Stent Restenosis) Registry at 4 Years

Francesco Liistro, Massimo Fineschi, Simone Grotti, Paolo Angioli, Arcangelo Carrera, Kenneth Ducci, Tommaso Gori, Giovanni Falsini, Carlo Pierli, and Leonardo Bolognese
J. Am. Coll. Cardiol. 2010 55: 613-616. [Abstract] [Full Text] [PDF]

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