Journal of the American College of Cardiology Online First

Letter to the Editor Re: Sex Differences in Arterial Stiffness and Ventricular-Arterial Interactions

Coutinho T, Kullo IJ. — Wed, 22 May 2013 00:00:00 GMT

Don’t Die of Something Stupid

DeMaria AN. — Wed, 22 May 2013 00:00:00 GMT

Brief episodes of silent atrial fibrillation were associated with an increased risk of silent cerebral infarct and stroke in type 2 diabetic patients

Marfella R, Sasso F, Siniscalchi M, et al. — Wed, 22 May 2013 00:00:00 GMT

Objective

We evaluated whether subclinical episodes of atrial fibrillation (AF) were associated with an increased risk of silent cerebral infarct (SCI) and stroke in diabetic patients younger than 60 years who did not have other clinical evidence of AF and cerebrovascular disease at baseline.

Background

In type 2 diabetic patients, one quarter of strokes are of unknown cause, and subclinical episodes AF may be a common etiologic factor.

Methods

Longitudinal, observational study was performed on 464 type 2 diabetic patients younger than 60 years and matched them to patients without diabetes. Patients underwent to quarterly 48-hour ECG Holter monitoring (48HM) to detect brief subclinical episodes of AF (AF durations <48 hours.) and followed them for 37 months. The outcomes were a SCI, assessed by brain MRI, and stroke events during the follow-up.

Results

Prevalence of subclinical episodes of AF was significantly greater among patients with diabetes compared with matched healthy subjects (9% vs. 1.6%, P<0.0001). During an average duration of 37 months, 43 stroke events occurred in diabetic population, whereas no events occurred in healthy subjects. Diabetic patients with silent episodes of AF (SAFE-group, n=176) had higher baseline prevalence of SCI (61% versus 29%, P<0.01) and higher stroke events (17.3% versus 5.9%, P<0.01) during the follow-up period than the others (non-SAFE-group, n=288). Episode of silent AF was an independent determinant of SCI (OR 4.441, P<0.001 C.I=2.42 to 8.16) and independent predictors for the occurrence of stroke in diabetic patients (HR, 4.6; P<0.01 C.I 2.7-9.1).

Conclusion

Subclinical episodes of AF occurred frequently in type 2 diabetic patients and were associated with a significantly increased risk of SCI and stroke.

A Novel Paradigm for Heart Failure with Preserved Ejection Fraction: Comorbidities Drive Myocardial Dysfunction and Remodeling Through Coronary Microvascular Endothelial Inflammation

Paulus WJ, Tschöpe C. — Wed, 22 May 2013 00:00:00 GMT

Over the last decennium, myocardial structure, cardiomyocyte function and intramyocardial signaling were shown to be specifically altered in heart failure with preserved ejection fraction (HFPEF). A new paradigm for HFPEF development is therefore proposed, which identifies a systemic proinflammatory state induced by comorbidities as the cause of myocardial structural and functional alterations.The new paradigm presumes the following sequence of events in HFPEF: 1) A high prevalence of comorbidities such as overweight/obesity, diabetes mellitus, chronic obstructive pulmonary disease and salt sensitive hypertension induce a systemic proinflammatory state; 2) A systemic proinflammatory state causes coronary microvascular endothelial inflammation; 3) Coronary microvascular endothelial inflammation reduces nitric oxide (NO) bioavailability, cyclic guanosine monophosphate (cGMP) content and protein kinase G (PKG) activity in adjacent cardiomyocytes; 4) Low PKG activity favours hypertrophy development and raises resting tension because of hypophosphorylation of titin; 5) Both stiff cardiomyocytes and interstitial fibrosis contribute to high diastolic left ventricular (LV) stiffness and HF development.The new HFPEF paradigm shifts emphasis from left ventricular (LV) afterload excess to coronary microvascular inflammation. This shift is supported by a favourable Laplace relationship in concentric LV hypertrophy and by all cardiac chambers showing similar remodeling and dysfunction. Myocardial remodeling in HFPEF differs from heart failure with reduced ejection fraction (HFREF), where remodeling is driven by loss of cardiomyocytes.The new HFPEF paradigm proposes comorbidities, plasma markers of inflammation or vascular hyperaemic responses to be included in diagnostic algorithms and aims at restoring myocardial PKG activity with NO-donors, phosphodiesterase 5 inhibitors and statins.

Subtle Post-Procedural Cognitive Dysfunction following Atrial Fibrillation Ablation

Medi C, Evered L, Silbert B, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

This study sought to determine whether post-operative neurocognitive dysfunction (POCD) occurs following AF ablation.

Background

Ablation for atrial fibrillation (AF) is a highly effective strategy, however the risk of transient ischaemic attack and stroke is approximately 0.5-1%. In addition MRI studies report a 7-14% incidence of silent cerebral infarction. Whether cerebral ischaemia results in POCD after AF ablation is not well-established.

Methods

The study included 150 patients: 60 patients undergoing ablation for paroxysmal AF (PAF); 30 patients undergoing ablation for persistent AF n=30 (PeAF) and 30 patients undergoing ablation for supraventricular tachycardia (SVT) were compared to a matched non-operative control group of patients with AF awaiting radiofrequency ablation (n=30). Patients were administered 8 neuropsychological tests administered at baseline and at 2 days and 3 months post-operatively. Tests were administered at the same time-points to the non-operative control group. Reliable change index was used to calculate POCD.

Results

The incidence of POCD at day 2 post-procedure was 28% in patients with PAF; 27% in patients with PeAF; 13% in patients with SVT; and 0% in AF control patients (p=0.007). At day 90, the incidence of POCD in patients with PAF was 13%, 20% in patients with PeAF; 3% in patients with SVT, and 0% in AF control patients (p=0.03). When analyzing the 3 procedural groups together, 29/120 (24%) patients manifest POCD at day 2 and 15/120 (13%) at day 90 post ablation procedure; p=0.029. On univariate analysis increasing LA access time was associated with POCD at day 2 (p=0.04) and day 90 (p=0.03)

Conclusions

Ablation for atrial fibrillation is associated with a 13-20% incidence of POCD in patients with AF at long-term follow up. These results were seen in a population of predominantly CHADS2 0-1 patients who represent the majority of patients undergoing AF ablation. The long-term implications of these subtle changes require further study.

Transcatheter Aortic Valve Replacement in Europe: Adoption Trends and Factors Influencing Device Utilization

Mylotte D, Osnabrugge RJ, Windecker S, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

We sought to examine the adoption of transcatheter aortic valve replacement (TAVR) in Western Europe and investigate factors that may influence the heterogeneous use of this therapy.

Background

Since commercialization in 2007, the number of TAVR procedures has grown exponentially.

Methods

The adoption of TAVR was investigated in 11 European countries: Germany, France, Italy, United Kingdom, Spain, Netherlands, Switzerland, Belgium, Portugal, Denmark, and Ireland. Data were collected from two sources: (1) lead physicians submitted nation-specific registry data; (2) an implantation-based TAVR-market tracker. Economic indices such as healthcare expenditure per capita, sources of healthcare funding, and reimbursement strategies were correlated to TAVR utilization. Furthermore, we assessed the extent to which TAVR has penetrated its potential patient population.

Results

Between 2007 and 2011, 34,317 patients underwent TAVR. Considerable variation in TAVR utilization existed across nations. In 2011, the number of TAVR implants per million ranged from 6.1 in Portugal to 88.7 in Germany (mean±standard deviation:33±25). The annual number of TAVR implants performed per center across nations also varied widely (range:10-89). The weighted average TAVR penetration rate was low: 17.9%. Significant correlation was found between TAVR use and healthcare spending per capita (r=0.80,p=0.005). TAVR-specific reimbursement systems were associated with higher TAVR use than restricted systems (698±232vs213±112 implants/million ≥75 years,p=0.002).

Conclusions

Our findings indicate that TAVR is underutilized in high and prohibitive surgical risk patients with severe aortic stenosis. National economic indices and reimbursement strategies are closely linked with TAVR use and help explain the inequitable adoption of this therapy.

Heart Failure with Preserved Ejection Fraction: Time for a new approach?

Desai A. — Wed, 22 May 2013 00:00:00 GMT

The Impact of Integration of a Multidetector Computed Tomography Annulus Area Sizing Algorithm on Outcomes of Transcatheter Aortic Valve Replacement: A Prospective, Multicenter, Controlled Trial

Binder RK, Webb JG, Willson AB, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

We prospectively investigated the impact of integration of a multidetector computed tomography (MDCT) annular area sizing algorithm on transcatheter aortic valve replacement (TAVR) outcomes.

Background

Appreciation of the three-dimensional, non-circular geometry of the aortic annulus is important for transcatheter heart valve (THV) sizing.

Methods

Patients being evaluated for TAVR in four centers underwent pre-procedural MDCT. Recommendations for balloon expandable THV size selection were based on a MDCT sizing algorithm with an optimal goal of modest annulus area oversizing (5% – 10%). Consecutive patients, who underwent TAVR with the algorithm (MDCT group), were compared to consecutive patients without the algorithm (control group). The primary endpoint was the incidence of more than mild paravalvular regurgitation (PAR) and the secondary endpoint was the composite of in-hospital death, aortic annulus rupture and severe PAR.

Results

Of 266 patients, 133 consecutive patients underwent TAVR (SAPIEN XT THV) in the MDCT group and 133 consecutive patients in the control group. More than mild PAR was present in 5.3 % (7/133) in the MDCT group and in 12.8 % (17/133) in the control group (p = 0.032). The combined secondary endpoint occurred in 3.8 % (5/133) in the MDCT group and in 11.3 % (15/133) in the control group (p = 0.02), driven by the difference of severe PAR.

Conclusion

The implementation of a MDCT annulus area sizing algorithm for TAVR reduces PAR. Three-dimensional aortic annular assessment and annular area sizing should be considered for TAVR.

Determinants and Outcomes of Acute Transcatheter Valve-in-Valve Therapy or Embolization: A Study of Multiple Valve Implants in the US PARTNER Trial

Makkar RR, Jilaihawi H, Chakravarty T, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

This study sought to investigate the determinants and outcomes of acute insertion of a second transcatheter prosthetic valve (TV) within the first (TV-in-TV) or transcatheter valve embolization (TVE) after Transcatheter Aortic Valve Replacement (TAVR).

Background

Both TAVR failure with TV-in-TV and TVE can occur as a consequence of TAVR malpositioning. Only case reports and limited series pertaining to these complications have been reported to date.

Methods

Patients undergoing TAVR in the PARTNER randomized trial (cohorts A and B), and accompanying registries were studied. Data was dichotomized for those with and without TV-in-TV or TVE respectively.

Results

From a total of 2554 consecutive patients, 63 (2.47%) experienced TV-in-TV and 26 (1.01%) TVE. The indication for TV-in-TV was significant aortic regurgitation (AR) in the vast majority of patients, often due not only to malpositioning but also leaflet dysfunction. Despite similar aortic valve function on follow-up echoes, TV-in-TV was an independent predictor of 1-year cardiovascular mortality (HR 1.86, 95% CI 1.03-3.38, p=0.041), with a non-significant trend to greater all-cause mortality (HR 1.43, 95% CI 0.88-2.33,p=0.15). Technical and anatomical reasons accounted for most cases of TVE. A multivariable analysis found TVE to be an independent predictor of 1-year mortality (HR 2.68, 95% CI 1.34-5.36, p=0.0055), but not cardiovascular mortality (HR 1.30, 95% CI 0.48-3.52, p=0.60).

Conclusions

Acute TV-in-TV and TVE are serious sequelae of TAVR, often resulting in multiple valve implants. They carry an excess of mortality and are caused by anatomic and technical factors, which may be avoidable with judicious procedural planning.

Preserve the Brain: Primary Goal in the Therapy of Atrial Fibrillation

Prystowsky EN, Padanilam BJ. — Wed, 22 May 2013 00:00:00 GMT

Modeling Serum Level of S100B and Bispectral Index to Predict Outcome After Cardiac Arrest

Stammet P, Wagner DR, Gilson G, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

To evaluate multimodal prognostication in patients after cardiac arrest.

Background

Accurate methods to predict outcome after cardiac arrest are lacking.

Methods

Seventy-five patients with cardiac arrest treated by therapeutic hypothermia after cardiac resuscitation were enrolled in this prospective observational study. Serum levels of neuron-specific enolase (NSE) and neuron-enriched S100 beta (S100B) were measured 48h after cardiac arrest. Bispectral index (BIS) was continuously monitored during the first 48h after cardiac arrest.

Results

The primary end-point was neurological outcome, as defined by the cerebral performance category (CPC) at 6-months follow-up: scores 1-2 indicated good outcome and scores 3-5 poor outcome. The secondary end-point was survival. 46 (61%) patients survived at 6-months and 41 (55%) patients had CPC 1-2. Levels of NSE and S100B were higher in patients with poor outcome compared to patients with good outcome (4-fold and 10-fold, respectively; P<0.001). BIS was lower in patients with poor outcome (10-fold, P<0.001). NSE, S100B or BIS alone predicted neurological outcome with areas under the receiver-operating characteristic curve (AUC) above 0.80. Combined determination of S100B and BIS had an incremental predictive value (AUC=0.95). S100B improved discriminations based on BIS (P=0.0008), and BIS improved discriminations based on S100B (P<10-5). Patients with S100B level above 0.03 μg/L and BIS below 5.5 had a 3.6-fold higher risk of poor neurological outcome (P<0.0001). S100B and BIS predicted 6-months mortality (log-rank statistic 50.41, P<0.001).

Conclusions

Combined determination of serum level of S100B and BIS monitoring accurately predicts outcome after cardiac arrest.

Routine coronary computed tomographic angiography reduces unnecessary hospital admissions, length of stay, recidivism rates, and invasive coronary angiography in the Emergency Department triage of chest pain

Poon M, Cortegiano M, Abramowicz AJ, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

Assess the effects on resource utilization of routine coronary computed tomographic angiography (CCTA) in triaging chest pain patients in the Emergency Department (ED).

Background

The routine use of CCTA for ED evaluation of chest pain is feasible and safe.

Methods

We conducted a retrospective multivariate analysis of 894 risk-matched cohorts of ED patients presenting with chest pain to assess the impact of CCTA vs. standard evaluation on admissions rate, length of stay, major adverse cardiovascular event rates, recidivism rates, and downstream resource utilization.

Results

The overall admission rate was lower for CCTA (14% vs. 40%, p<0.001). Standard evaluation was 5.5 times more likely to be admitted (OR = 5.53, P<0.001). Expected ED length of stay for standard evaluation was about 1.6 times longer (OR = 1.55, p<0.001). There was no difference in the rates of deaths and acute myocardial infarction within 30 days of the index visit in either group. The odds of returning to the ED within 30 days for recurrent chest pain were 5 times greater for standard evaluation (OR = 5.06, p=0.022). Standard evaluation was 7 times more likely to undergo invasive coronary angiography without revascularization (OR = 7.17, p≤ 0.001), while neither group was significantly more likely to receive revascularization (OR = 2.06, p=0.193). The median radiation dose for CCTA was 5.88 (n = 1039, C.I. 5.2 to 6.4) mSv.

Conclusions

Routine use of CCTA in ED evaluation of chest pain reduces healthcare resource utilization.

Provocation of an autoimmune response to cardiac voltage-gated sodium channel Na V 1.5 induces cardiac conduction defects in rats

Korkmaz S, Zitron E, Bangert A, et al. — Wed, 22 May 2013 00:00:00 GMT

Objective

This study tested the hypothesis that inducing an autoimmune response against the cardiac sodium channel (NaV1.5) induces arrhythmias.

Background

Sporadical evidence supports the concept that autoantibodies may cause cardiac arrhythmias but substantial experimental investigations using in vivo models have been lacking to date. The NaV1.5 is essential for cardiac impulse propagation and its dysfunction has been linked to conduction disease.

Methods

Rats were immunized with a peptide sequence derived from the third extracellular loop of the first domain of NaV1.5. After 28 days, we evaluated in vivo both the electrical and mechanical parameters of cardiac function. Histopathology, myocardial gene and protein expression were assessed. Whole-cell patch-clamp was used to measure sodium current (INa) density in isolated cardiomyocytes.

Results

NaV1.5-immunized rats had high titers of autoantibodies against NaV1.5. On ECG recording, NaV1.5-immunized animals showed significantly prolonged PR-intervals. During holter ECG-monitoring we observed repeated prolonged episodes of third-degree atrioventricular and sinoatrial block in every NaV1.5-immunized animal, but not in controls. Immunization had no effect on cardiac function. In comparison to controls, myocardial NaV1.5 mRNA and protein levels were decreased in immunized rats. INa density was reduced in cardiomyocytes incubated with sera from NaV1.5-immunized rats and from patients with idiopathic atrioventricular block (AVB) in comparison to sera from respective controls. In patients with idiopathic AVB, we observed autoantibodies against NaV1.5 that were absent in sera from healthy controls.

Conclusions

Provocation of an autoimmune response against NaV1.5 induces conductance defects probably caused by a reduced expression level and an inhibition of NaV1.5 by autoantibodies, resulting in decreased INa.

Changes in Cardiovascular Risk Factors by Hysterectomy Status with and without Oophorectomy: Study of Women’s Health across the Nation

Matthews KA, Gibson CJ, El Khoudary SR, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

To compare the changes in risk factors for cardiovascular disease (CVD) leading up to and following hysterectomy with or without bilateral oophorectomy with the changes observed up to and following natural menopause.

Background

Evidence suggests that hysterectomy status with or without bilateral oophorectomy may increase risk for CVD but most studies retrospectively assess menopausal status.

Methods

Study of Women’s Health across the Nation enrolled 3,302 premenopausal women not using hormone therapy between the ages of 42-52 years of age and followed them annually for over 11 years for sociodemographic characteristics, menopausal status, surgeries, body mass index (BMI), medication use, lifestyle factors, lipids, blood pressure, insulin resistance, and hemostatic and inflammatory factors. By 2008, 1,769 women had reached natural menopause, 77 women had a hysterectomy with ovarian conservation, and 106 women had a hysterectomy with bilateral oophorectomy. Piece-wise hierarchical growth models compared these groups on annual changes in CVD risk factors prior to and following final menstrual period (FMP) or surgery.

Results

Multivariable analyses showed that annual changes in CVD risk factors did not vary by group with few exceptions, and the significant group differences that did emerge were not in the anticipated direction.

Conclusions

Hysterectomy with or without ovarian conservation is not a key determinant of CVD risk factor status either before or after elective surgery in mid-life. These results should provide reassurance to women and their clinicians that hysterectomy in mid-life is unlikely to accelerate women’s CVD risk.

Cardiac Troponin after Percutaneous Coronary Intervention and 1-Year Mortality in NSTE ACS Using Systematic Evaluation of Biomarker Trends

Tricoci P, Leonardi S, White J, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

We reviewed cardiac troponin (cTn) trends during non–ST-segment elevation acute coronary syndrome (NSTE ACS) in patients undergoing percutaneous coronary intervention (PCI) in EARLY ACS and SYNERGY and studied the relationship between post-PCI cTn and mortality.

Background

The prognostic value of cTn post-PCI is controversial. In patients with NSTE ACS, it is especially difficult to distinguish between cTn elevations due to PCI or index myocardial infarction (MI).

Methods

Time and cTn (indexed by upper limit of normal [ULN]) data pairs were plotted for 10,199 patients and independently reviewed by 2 physicians to identify patients in whom post-PCI cTn elevation could be distinguished from that of index MI. Post-PCI cTn peak was identified for each plot, and its relationship with 1-year mortality was evaluated using Cox modeling, correcting for 15 clinical variables from the EARLY ACS 1-year mortality model (including baseline cTn). We used an identical methodology to assess the association between creatine kinase-MB (CK-MB) and 1-year mortality.

Results

Patients with cTn (re)elevation post-PCI not evaluable were identified and excluded from further analysis (4198 [41%] with cTn rising prior to PCI; 229 [2%] with missing cTn). Among the remainder (N=5772 [57%]), in the multivariable model, peak cTn post-PCI was associated with a 7% increase in mortality (hazard ratio [HR] for 10x ULN increase, 1.07; 95% confidence interval [CI], 1.02–1.11; p=0.0038). Peak post-PCI CK-MB was significantly associated with 1-year mortality (HR for 1x ULN increase, 1.13; 95% CI, 1.05–1.21; p=0.0013).

Conclusions

We used a methodology that differentiated post-PCI cTn (re)elevation from that of presenting MI in more than half of patients with NSTE ACS undergoing PCI. This identified a highly significant relationship between post-PCI cTn and 1-year mortality, with implication for both incorporating a cTn post-PCI MI definition and preventing PCI-related myonecrosis.

Impact of Genetics on the Clinical Management of Channelopathies

Schwartz PJ, Ackerman MJ, George AL, et al. — Wed, 22 May 2013 00:00:00 GMT

There are few areas in cardiology where the impact of genetics and of genetic testing on clinical management has been as great as in cardiac channelopathies, arrhythmic disorders of genetic origin related to the ionic control of the cardiac action potential. Among the growing number of diseases identified as channelopathies, three are sufficiently prevalent to represent significant clinical and societal problems and to warrant adequate understanding by practicing cardiologists: long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, and Brugada syndrome.This review will focus selectively on the impact of genetic discoveries on clinical management of these three diseases. For each disorder, we will discuss to what extent genetic knowledge and clinical genetic test results modify the way cardiologists should approach and manage affected patients. We will also address the optimal use of genetic testing including its potential limitations and the potential medico-legal implications when such testing is not performed. We will highlight how important can be to understand the ways by which genotype can impact clinical manifestations, risk stratification, and responses to the therapy. We will also illustrate the close bridge between molecular biology and clinical medicine, and will emphasize that consideration of the genetic basis for these hereditable arrhythmia syndromes, as well as the proper use and interpretation of clinical genetic testing, should remain the standard-of-care.

Biodegradable Polymer Biolimus-eluting Stent versus Durable Polymer Everolimus-eluting Stent: a randomized, controlled, non-inferiority trial

Natsuaki M, Kozuma K, Morimoto T, et al. — Wed, 22 May 2013 00:00:00 GMT

Objectives

The NOBORITM Biolimus-Eluting versus XIENCETM/PROMUSTM Everolimus-eluting stent Trial (NEXT) was designed for evaluating non-inferiority of biolimus-eluting stent (BES) relative to everolimus-eluting stent (EES) in terms of target-lesion revascularization (TLR) at 1-year.

Background

Efficacy and safety data comparing biodegradable polymer BES with durable polymer cobalt-chromium EES are currently limited.

Methods

NEXT trial is a prospective, multicenter, randomized, open label, non-inferiority trial comparing BES with EES.

Results

Between May and October 2011, 3235 patients were randomly assigned to receive either BES (1617 patients) or EES (1618 patients). At 1-year, the primary efficacy endpoint of TLR occurred in 67 patients (4.2%) in the BES group, and in 66 patients (4.2%) in the EES group, demonstrating non-inferiority of BES relative to EES (P non-inferiority<0.0001, and P superiority=0.93). Cumulative incidence of definite stent thrombosis was low and similar between the 2 groups (0.25% versus 0.06%, P=0.18). Angiographic sub-study enrolling 528 patients (BES: 263 patients, and EES: 265 patients) demonstrated non-inferiority of BES relative to EES regarding the primary angiographic endpoint of in-segment late loss (0.03±0.39mm versus 0.06±0.45mm, P non-inferiority<0.0001, and P superiority=0.52) at 266±43 days after stent implantation.

Conclusions

One-year clinical and angiographic outcome after BES implantation was non-inferior to and not different from that after EES implantation in a mostly stable coronary artery disease population. One-year clinical outcome after both BES- and EES-use was excellent with low rate of TLR and extremely low rate of stent thrombosis.

Clinical trial identifier

NCT01303640

Transcatheter Aortic Valve Adoption Rates

Webb JG, Barbanti M. — Wed, 22 May 2013 00:00:00 GMT

Endovascular Imaging and 3D Reconstruction of Spontaneous Coronary Artery Dissection

Stefano C, Matteo G, Foin N, et al. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor: Instantaneous wave-free (iFR): Numerically different, but diagnostically superior to FFR? Is lower always better?

Sen S, Nijjer S, Petraco R, et al. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor: Multidetector Computed Tomography Stress-Rest Perfusion Imaging for Detection of Coronary Artery Disease

Sharma A. — Wed, 22 May 2013 00:00:00 GMT

Reply to letter “Instantaneous wave-free (iFR): Numerically different, but diagnostically superior to FFR? Is lower always better?”

Johnson NP, Kirkeeide RL, Gould K. — Wed, 22 May 2013 00:00:00 GMT

Reply to Letter to the Editor: “Multidetector Computed Tomography Stress-Rest Perfusion Imaging for Detection of Coronary Artery Disease”

Bettencourt N. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor: Comparison of Cardiac Magnetic Resonance and Computed Tomography Stress-Rest Perfusion Imaging for Detection of Coronary Artery Disease

Bauml MA, Farzaneh-Far A. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor: Here We Go Again

Ghali JK. — Wed, 22 May 2013 00:00:00 GMT

Reply to letter to the editor: Here We Go Again

Ruwald MH, Moss AJ. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor Re: “Intracoronary compared with intravenous bolus abciximab application during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: cardiac magnetic resonance substudy of the AIDA-STEMI trial”

Iancu AC, Ober C. — Wed, 22 May 2013 00:00:00 GMT

Letter to the Editor: B-type Natriuretic Peptide and Prognosis in Heart Failure Patients With Preserved and Reduced Ejection Fraction

Haeck JE. — Wed, 22 May 2013 00:00:00 GMT

Reply to Letter to the Editor: B-Type Natriuretic Peptide and Prognosis in Heart Failure Patients with Preserved and Reduced Ejection Fraction

van Veldhuisen DJ, Jaarsma T, Hillege HL. — Wed, 22 May 2013 00:00:00 GMT

Reply to Letter to the Editor: Comparison of Cardiac Magnetic Resonance and Computed Tomography Stress-Rest Perfusion Imaging for Detection of Coronary Artery Disease

Bettencourt N, Nagel E. — Wed, 22 May 2013 00:00:00 GMT

Reply to letter of Iancu et al concerning our publication in JACC “Intracoronary compared with intravenous bolus abciximab application during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: cardiac magnetic resonance substudy of the AIDA-STEMI trial” (J Am Coll Cardiol. 2013 Apr 2;61(13):1447-54)

Eitel I, Desch S, Thiele H. — Wed, 22 May 2013 00:00:00 GMT

Double-Orifice Tricuspid Annulus

Moya Mur J, Carlos Becker Filho D, Rodríguez Muñoz D, et al. — Wed, 22 May 2013 00:00:00 GMT