Review Articles in 2011

In the first of their two Reviews on cardiogenic shock in acute coronary syndromes, Stephen Westaby and colleagues discuss the evolving epidemiology of this condition, its clinical presentation, and predictors of outcome. They also explore the options for medical therapy and the potential role of therapeutic hypothermia in these patients.

Understanding mechanisms of cardiac remodeling, with the goal of developing therapies to stop or reverse its progression, has become a major objective for investigators of heart failure. In this Review, Dr Koitabashi and Professor Kass discuss the evidence for 'reverse remodeling' by existing therapies, and review novel approaches that are currently moving from preclinical to clinical trials.

Arrhythmogenic cardiomyopathy (AC) is a clinically heterogeneous cardiac disease that is associated with ventricular arrhythmias and sudden cardiac death. The authors discuss the diagnosis and genetic basis of AC, and how disruption of desmosomal crosstalk with the nucleus, gap junctions, and ion channels might underlie the pathophysiology of this condition.

In this state-of-the-art Review, Michele De Bonis and colleagues discuss the optimal management of patients with degenerative or function mitral regurgitation, from established surgical techniques to new percutaneous technologies. They also provide an overview of the use of echocardiography in the assessment of MR.

In late 2010 and in 2011, the results of the first randomized controlled trial of transcatheter aortic valve implantation (TAVI) were received with much excitement. In this Review, Dr. Rodés-Cabau discusses the main characteristics of transcatheter valves and the TAVI procedure, and evaluates the acute and late outcomes associated with TAVI.

Congenital defects of the heart affect up to 10 in 1,000 neonates, but mortality has decreased with improved detection and treatment. Drs Roest and de Roos describe the various imaging modalities available to assess patients with congenital heart disease before intervention, and to evaluate systolic, diastolic, valvular, and vascular function during follow-up.

Elevated blood pressure (BP) is probably the most-important, modifiable risk factor for cardiovascular disease. Dr. Ruilope discusses current controversies and challenges in the treatment of patients with arterial hypertension, including the validity of office BP measurements, appropriateness of BP targets, use of combination therapy, and patient compliance.

Hypertrophic cardiomyopathy is the most-common form of monogenically inherited heart disease, and is associated with a high incidence of sudden cardiac death in young patients. The authors review the genetic mutations known to cause the disease, discuss potential pathological mechanisms that might lead to the clinical phenotype, and consider the implications for targeted therapies.

Cardiac remodeling encompasses structural and functional changes of the left ventricle in response to stressors, and precedes clinical heart failure. Evaluation of cardiac remodeling can help to select patients with subclinical heart failure for early treatment. Drs Gjesdal, Blumke, and Lima review population-based studies of cardiac remodeling, describing risk factors, screening strategies, and outcome measures.

Anomalous origination of a coronary artery from the opposite sinus is a congenital heart defect with an uncertain prevalence and prognosis. The authors review the current understanding of the pathophysiology of the condition, the imaging modalities available to diagnose and functionally assess patients, and the medical, interventional, and surgical treatment options.

In the second part of their Review on restenosis after PCI, Jukema and colleagues focus on the technological advances that have fueled revolutionary changes for optimizing outcomes of coronary stenting and the prevention and treatment of in-stent restenosis.

Ectopic foci in pulmonary veins can trigger episodes of atrial fibrillation, but how these foci arise remains unclear. Dr Mark Shen and colleagues review the role of the autonomous nervous system in the induction and maintenance of atrial arrhythmias, and discuss neural modulation as a treatment strategy for patients with atrial fibrillation.

Metabolomics is emerging as a powerful tool for the investigation of the molecular mechanisms of cardiovascular disease, including atherosclerosis, ischemia, myocardial infarction, and heart failure. In this Review, the authors discuss advances in the use of NMR spectroscopy and mass spectrometry, particularly in field of lipidomics, and in the search for novel biomarkers of cardiac disease.

Antiplatelet agents effectively reduce the incidence of ischemic events associated with plaque rupture but can cause adverse effects, most notably hemorrhage. Drs Kalyanasundaram and Lincoff address key adverse effects that are associated with antiplatelet agents and discuss potential interactions between these drugs and other medications.

Restenosis of atherosclerotic lesions after initial treatment with angioplasty and stenting occurs in around 15% of patients. Although this condition is complex and the causative mechanisms have not yet been fully identified, they are thought to include inflammation, proliferation, and matrix remodeling with some patients being more 'predisposed' to developing restenosis than others. In this Review, Jukema and colleagues evaluate the available evidence on the pathophysiology of restenosis and provide an overview of the various risk factors for this disease.

Drs. Chaitman and Laddu review the various approved and experimental pharmacological approaches to treating angina in the context of data from clinical trials, and discuss ongoing and future studies. They also compare the merits of optimal medical therapy with prompt or delayed revascularization by percutaneous coronary intervention or CABG surgery as antianginal strategies.

The field of biological cardiac pacing, which aims to improve upon, supplement and, eventually, to replace electronic pacing has come a long way since its inception more than a decade ago. Broadly, research has been focused on gene and cell therapy. In this Review, Rosen and colleagues highlight milestones achieved through the construction of a 'roadmap' in biological pacing, and discuss the barriers that remain to be overcome before clinical trials of biological pacing can be begun.

Drs Arnold, Cohen, and Magnuson review the published cost-effectiveness analyses of oral antiplatelet therapies for various clinical settings. This information is of increasing importance, given the enormous health-care expenditure worldwide, the advent of novel oral antiplatelet drugs, and the availability in many countries of generic clopidogrel, which is cheaper than the branded version and likely to improve its cost-effectiveness compared with alternative medications.

Evidence is increasing that genetic variation between patients underlies the considerable variability in their response to antiplatelet agents, and, therefore, in clinical outcomes. Drs Ahmad, Voora, and Becker review the genetic loci that seem to have a role in determining platelet response; genes that are involved in the absorption, metabolic activation, and biological activity of aspirin and clopidogrel. Finally, they discuss, in the context of ongoing clinical trials, the merits and potential dangers of using commercial genetic testing and pharmacogenetics to personalize antiplatelet therapy to individual patients.

White-coat hypertension is characterized by an elevation in clinic blood pressure but normal home or ambulatory blood-pressure values, whereas patients with masked hypertension have normal clinic blood pressure and elevated ambulatory or home blood-pressure. In this article, Prof. Mancia and colleagues assess prevalence, diagnosis, and clinical management of white-coat and masked hypertension.