News & Views in 2011

A network meta-analysis by Trelle and colleagues has confirmed that the routine use of all nonsteroidal anti-inflammatory drugs, both nonselective and selective, is associated with an increased risk of cardiovascular events. Although a rigorous method was used in this analysis, comparative safety research in which data from randomized clinical trials is used has some important strengths and weaknesses to consider.

On the basis of a meta-analysis of randomized studies assessing reductions in 24 h ambulatory blood pressure, investigators have concluded that hydrochlorothiazide is an inappropriate first-line drug for antihypertensive treatment. This conclusion has the potential to change current prescribing practice for patients with hypertension, but should meta-analyses be considered the ultimate level of evidence, particularly those based on a surrogate outcome?

Monitoring for worsening congestion in patients with chronic heart failure has proven to be very challenging. The CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients (CHAMPION) trial has now demonstrated that wireless monitoring of pulmonary artery pressures is safe and reduces rates of hospitalization.

Multiple placebo-controlled trials have demonstrated that intravenous vernakalant, a novel antiarrhythmic agent, effectively converts recent-onset atrial fibrillation in ∼50% of patients within 90 min of administration. Results from the AVRO trial corroborate these findings and further show that vernakalant is superior to amiodarone in the treatment of this condition.

New therapeutic strategies are needed for patients with atherosclerosis. Despite failing to reach its primary end point, a multicenter, phase II, randomized, placebo-controlled trial of RVX-208—an oral, synthetic quinazoline molecule that stimulates expression of endogenous apolipoprotein A-I—has provided somewhat encouraging results. Nevertheless, detailed investigations are still needed if we are ever to realize the full atheroprotective potential of novel HDL-targeted therapies.

The long-term effectiveness of catheter ablation of atrial fibrillation is highly dependent on the endurance of ablation lesions over time. When ablation does not result in a permanent lesion, conduction recovery in arrhythmogenic structures previously targeted will almost inevitably lead to recurrence of arrhythmia.

In 2009, the FAME investigators reported that percutaneous coronary intervention guided by fractional flow reserve (FFR) could reduce the incidence of cardiovascular events when compared with angiographically guided PCI. The economic study conducted on the basis of FAME has now shown that an FFR-guided approach can also result in reduced costs.

Meta-regression of trials using carotid intima–media thickness (CIMT) as a surrogate end point leads to unreliable results owing to heterogeneity in methods, interventions, and outcomes of pooled trials. CIMT will continue to be a worthwhile surrogate trial end point supported by two decades of technical progress and clinical atherosclerosis research.

Omega-3 fatty acids have anti-inflammatory, antioxidant and membrane-stabilizing properties that indicate they could be useful in suppressing cardiac rhythm disorders. These natural dietary constituents are of particular interest for the treatment of atrial fibrillation, a common and problematic cardiac arrhythmia. However, a new, well-designed clinical study has raised major questions about their value for this indication.

Over the past decade, the use of β-blockers has transformed the management and prognosis of patients with heart failure (HF). A post hoc analysis of the SENIORS study now raises questions about the validity of a composite 'ischemic' end point that includes sudden death in trials of β-blocker therapy for patients with HF.