News & Views in 2010

Although the majority of implanted valves used in aortic valve surgery are tissue valves (bioprostheses), the mechanisms by which they interact with the host are not well understood. A new study by Flameng et al. gives insight into the structural and functional changes that result from patient–bioprosthesis mismatch.

Kantor and colleagues from the Hospital for Sick Children in Toronto, Canada have reported that outcomes for medically treated pediatric patients with dilated cardiomyopathy (DCM) have not changed over a 30-year period, despite institution of neurohormonal inhibition therapy. These findings are placed in the context of the worldwide experience of pediatric DCM and the limited number of studies of neurohormonal inhibition therapy in children with heart failure.

The optimal reperfusion strategy for patients with ST-segment elevation myocardial infarction who are admitted to community hospitals without a catheterization laboratory is still a matter of debate. The long-term results of the DANAMI-2 study contribute to the evidence base for optimal reperfusion, but should be interpreted with caution and in the context of the wider literature on this subject.

The effectiveness of existing strategies for management of atrial fibrillation is limited, which has stimulated research into novel therapeutic approaches. A new meta-analysis of randomized controlled trials of inhibitors of the renin–angiotensin system highlights the clinical benefits of these agents and underscores their potential in the prevention and treatment of this disease.

Admissions for heart failure are associated with an unacceptably high rate of early readmission and mortality. An early postdischarge visit with targeted interventions in high-risk patients may decrease this high event rate. Determining who should be seen early postdischarge and what should be done during the visit remains to be established.

CABG surgery has been considered the optimal revascularization strategy for patients with diabetes mellitus who have left main and/or multivessel coronary artery disease. The results of a new analysis of data from the SYNTAX trial challenge this conventional wisdom and highlight additional coronary revascularization options to physicians and patients.

The diagnosis of diabetes mellitus in clinical practice has been mainly based on the measurement of glucose levels in blood. Growing evidence, including results from a new large-scale population study, however, strongly suggests that the assessment of glycated hemoglobin levels has advantages over measurement of glucose levels in predicting the risk of developing diabetes or cardiovascular disease.

Whether thiazolidinediones should be used to treat patients with type 2 diabetes mellitus is controversial, as studies on the cardiovascular effects of these drugs have produced conflicting results. A trial in which rosiglitazone and glipizide were compared supports earlier findings that rosiglitazone does not have an adverse effect on the progression of coronary atherosclerosis.

The relationship between patent foramen ovale and migraine is a hotly debated issue. Conflicting data on the association or independence of these conditions have been reported by various study groups around the world. Now, a large-scale case–control study has shown no association between the two entities; however, there were a number of methodological flaws in this study and we are unlikely to see the end of the controversy in the near future.

The impact of overlap of drug-eluting stents on clinical and angiographic outcomes is controversial. Individuals with long coronary lesions requiring implantation of multiple stents are an important patient subgroup for whom careful evaluation and decision-making with optimal stent deployment is needed to ensure the best possible short-term and long-term results.

Combination therapy is used to lower blood pressure in the majority of patients with hypertension, yet there has been little evidence as to which classes of antihypertensive agents are most effective. The publication of findings from the ACCOMPLISH trial provides an opportunity to explore the merits of various combination therapies, with a focus on renal risk reduction.

Carotid endarterectomy (CEA) is considered the gold standard for treatment of stenosis, but carotid artery stenting (CAS) is a less invasive procedure that offers a promising alternative. Short-term data from ICASS suggest that CEA is superior to CAS; however, features of the study design may have affected the results, and long-term data are needed before conclusions can be made.

The ankle–brachial index (ABI) can be used to assess the risk of cardiovascular events. The AAA trial aimed to determine whether low-dose aspirin was of net benefit among apparently healthy people with an ABI ≤0.95. The largely negative findings of this study raise important mechanistic and practical questions.

The safest and most effective treatment for symptomatic vertebral artery stenosis has not yet been proven. Here, we discuss the merits and pitfalls of endovascular treatment for this under-recognized disease entity.

The development of left ventricular assist devices could be considered an 'imaginative leap'. In the current phase of critical evaluation of these devices, a study of patients who received first-generation left ventricular assist devices has indicated that they might affect late post-transplant survival. The validity and significance of these findings need to be examined further.

A continuous-flow left ventricular assist device (LVAD) improved survival free from disabling stroke compared with a pulsatile LVAD, when used as destination therapy over a 2-year period in patients with advanced heart failure. Both devices improved patient quality of life. Continuous-flow devices are smaller, lighter, and more simple than pulsatile LVADs and have the potential to fulfill all the requirements of a permanently implanted blood pump.

Klersy et al. have performed a meta-analysis of remote monitoring of patients with heart failure. Programs using structured telephone support (telephone-monitoring approach) were combined with those using transmission of physiological data (technology-assisted approach) in combination with telephone communication. Results from this study may inform policy makers regarding a potential solution to reducing hospital readmissions.

Patients with structural heart disease are at risk for life-threatening ventricular tachycardias (VTs). Implantable cardioverter-defibrillators (ICDs) can terminate VT, but often at the cost of traumatic shocks, syncope, or even exacerbation of underlying heart disease. Catheter ablation for VT can reduce the need for ICD therapies and is an increasingly important adjunct to the treatment of these patients.

Aldosterone antagonists decrease the mortality of patients with heart failure, but an observational study by Albert and colleagues has found that a surprisingly low number of patients receive aldosterone antagonists before discharge from hospital. This article highlights potential reasons for why there is such an underuse of efficient drugs in heart failure.

A novel three-catheter radiofrequency ablation system has been reported to reduce procedure time, but maintain ablation success rates, in patients with persistent atrial fibrillation. The findings are promising; however, important limitations and concerns must be overcome before use of this system can be considered the standard-of-care for catheter treatment of persistent atrial fibrillation.