Opinion

Opium is a widely abused substance throughout the Middle East and Asia. In this Perspectives article, Dr Masoudkabir and colleagues dispel the commonly held misconception in these regions that opium has beneficial effects on cardiovascular health, and summarize the available evidence showing that, conversely, opium use is a risk factor for cardiometabolic diseases.

Heart transplantation has become the treatment of choice for eligible patients with end-stage heart failure. In this Perspectives article, David Baran challenges the presupposed need for multidrug immunosuppression after transplantation, and draws on data and experience from the TICTAC randomized trial to explore the potential efficacy and benefits of monotherapy.

In this opinion article, the authors discuss multicentre clinical trials in Asia. Asians have been under-represented in many clinical trials; differences in cardiovascular disease risk and drug responses between Asians and white people underscore the importance of ethnicity-specific intervention testing. Challenges specific to Asia need to be addressed before Asia can rival Europe and the USA as a location-of-choice for clinical trials.

Resistant hypertension is difficult to treat. In a Perspectives, Solini and Ruilope argue that many patients with resistant hypertension actually have mismanaged primary hypertension. They discuss how to identify misclassified patients and how to correctly manage hypertension.

In many clinical trials, procedure-related myocardial infarctions are assigned a similar prognostic value to spontaneous myocardial infarctions. Robbert de Winter and colleagues argue that procedure-related myocardial infarctions do not necessarily have important prognostic implications, and that the recent definition of a procedure-related myocardial infarction, including a relevant biomarker increase and supporting evidence, needs to be closely followed.

In this opinion article, the authors suggest an alternative hypothesis for the pathogenesis of rheumatic heart disease. They believe that an interaction between streptococcal M protein and the infected individual's collagen results in the production of anticollagen autoantibodies. They also believe that molecular mimicry, which has previously been implicated in rheumatic heart disease, probably has no role in the pathogenesis of this condition.

Current algorithms for cardiovascular-risk prediction focus on identifying individuals who are at high short-term risk of experiencing a cardiovascular event. Drs Karmali and Lloyd-Jones advocate that lifetime-risk estimation should be used as an adjunct to 10 year risk prediction, to motivate individuals who have a low short-term, but substantial lifetime, risk (such as many women and young men) to adopt healthy, preventive behaviour.

Despite advances in prevention of cardiovascular disease, a high proportion of cardiac events occur in asymptomatic people who do not have a high level of risk. Much remains unknown about the value of novel risk markers for the identification of candidates for primary prevention. Here, Polonsky and Greenland argue that clinical trials of these markers in asymptomatic, low-risk populations are greatly needed to determine their effectiveness.

A major problem in Central and South America, Chagas disease is now also affecting individuals residing in other parts of the world. Many patients with late-stage disease have chronic cardiomyopathy and associated arrhythmias. In this Perspectives article, Professor Benaim and Dr Paniz Mondolfi discuss the potential for amiodarone and dronedarone to be used as dual-action (antiarrhythmic and antiparasitic) agents in patients with Chagas disease.

Many barriers exist to the translation and implementation of European and US guidelines for cardiovascular disease into clinical practice in China, but also to the development of Chinese-specific guidelines. Professors Zhao and Hu give their expert perspectives on the multifaceted reasons for these barriers, and how future guidelines for Chinese clinical practice should be developed and applied.

The primary objective of invasive treatment strategies for multivessel coronary artery disease is complete anatomical revascularization. As objective evidence of ischemia can be provided by a functional assessment based on fractional flow reserve, the focus of contemporary treatment could shift from anatomical to functional revascularization. In this Perspectives article, the authors summarize the data that supports contemporary functional revascularization and its applicability to real-world practice.

This paper explores the rationale for early, 'vitamin-like' use of statins to lower LDL levels in asymptomatic adults aged 35–50 years. The authors describe the features of a trial designed to determine whether this approach could dramatically reduce the burden of atherosclerosis and atherothrombotic events in the general population.

No worldwide consensus exists regarding the best way to manage patients with asymptomatic carotid artery stenosis (CAS). In this thought-provoking article, Professor A. Ross Naylor presents his argument against the use of a 'one size fits all' approach involving the costly widespread use of surgical or percutaneous interventions, a high percentage of which are unnecessary. Instead, he recommends that the medical community should increase efforts to identify those at particularly high risk for stroke, who are the only patients likely to really benefit from these interventions

Patients with atrial fibrillation are at substantial risk of thromboembolism and acute ischemic stroke. Professor Gregory Lip gives his perspective on the role of using the antiplatelet agent aspirin for stroke prevention in these patients, compared with warfarin and novel anticoagulant drugs, supported by data from randomized, clinical trials and guideline recommendations.

Obesity is known to have an adverse impact on health. However, the utility of BMI as a measure of obesity to predict total and cardiovascular mortality has been called into question. The authors of this article outline why BMI might not be the most appropriate measure of obesity, and they suggest other methods to determine body fat and its distribution that could be more accurate for assessing cardiovascular risk.

Comprehensive recommendations for surgical intervention exist for patients with degenerative aortic or mitral vale disease who experience symptoms or left ventricular dysfunction. However, for asymptomatic individuals with valve disease, the optimum management strategy is less clear. In this opinion article, Vaishnava and colleagues present the case for performing early valve surgery in this patients and argue against the more-conventional approach of watchful waiting.

In this opinion article, Dr. Vedanthan and Dr. Fuster discuss the urgent need to integrate CVD-related human resource requirements into the global agenda for increasing human resources for health care. They suggest strategies and emphasize gaps in knowledge regarding human resources for global CVD-related care.

Obesity is a major health challenge that is associated with chronic disease. The authors of this Perspectives article put forward a model that places sedentary behavior and calorie overload upstream of numerous disease processes. The authors highlight the importance of physical activity and cardiorespiratory fitness, which are possibly stronger predictors of risk than traditional factors, such as obesity.

The current guidelines for prevention of cardiovascular disease are based on estimates of long-term risk. Smeeth and Hingorani recommend awareness of the importance of fluctuations of risk over short periods of time and suggest a new paradigm for management of cardiovascular disease that is based on targeting therapy to short periods of enhanced risk.

Controversy exists as to whether the detection of myocardial edema, to quantify myocardial damage and assess myocardial salvage, is ready for clinical use or is still only practical as a research tool. In this Perspectives article, Matthias Friedrich explains his point of view on this issue—that myocardial edema imaging using magnetic resonance technology should be seen as the essential diagnostic modality of choice for patients with suspected myocardial injury by virtue of its safety, versatility, and cost-efficiency.