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Inflammation might be involved in the pathophysiology of atrial fibrillation. Glucocorticoid use can attenuate inflammation and might be an effective therapy for atrial fibrillation. However, some population-based studies have reported an increased risk of atrial fibrillation associated with glucocorticoid use. Whether this link results from a direct effect of glucocorticoids or from the underlying inflammatory disease remains to be elucidated.
The two CHAMPION trials failed to show superiority of cangrelor (a rapid-acting, reversible intravenous platelet P2Y12 adenosine receptor antagonist) versus clopidogrel in patients with acute coronary syndromes undergoing percutaneous coronary intervention. The CHAMPION PCI trial, however, did show a significant reduction in death and stent thrombosis suggesting benefit in those without clopidogrel pretreatment.
Tibaldi et al. have addressed the feasibility of 'hospital-at-home' care as an alternative to hospitalization for elderly patients with chronic heart failure. Although this study addresses an important subject, and the results are intriguing, extrapolation to other settings may not be easy. The study should, therefore, be regarded as hypothesis-generating rather than definitive.
Two large trials were conducted to evaluate the effects of an angiotensin-converting-enzyme inhibitor, an angiotensin-receptor blocker or a combination of both in high cardiovascular risk patients. A decrease in the prevalence of left ventricular hypertrophy (LVH) was reported, but this did not translate into a prognostic benefit. New-onset LVH was associated with an increase in cardiovascular events.
Defibrillators, with or without cardiac resynchronization therapy, can reduce the rate of sudden death. However, shocks are unpleasant, often unnecessary, and can damage myocardium or defibrillator leads, thereby increasing morbidity and mortality and detracting from the benefits of this therapy. Conservative programming of devices may reduce such risks.
Despite angiographically successful primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction, microcirculatory failure is common and leads to an increased risk of morbidity and mortality. The administration of intracoronary streptokinase immediately after PCI may improve outcomes and provides a promising potential therapy for the future.
The ROOBY investigators found off-pump CABG surgery to be significantly inferior to on-pump surgery with regard to 1 year mortality, revascularization, or new myocardial infarction. This unexpected finding could be related to the fact that most of the participating surgeons were experienced in on-pump CABG surgery, but relatively inexperienced in the off-pump procedure.
Amiodarone effectively maintains sinus rhythm in patients with atrial fibrillation, and although dronedarone is less effective it has a better safety profile. The choice of antiarrhythmic drug (or nonpharmacological strategy) depends on the ultimate goal of therapy, which should be considered in the context of the patient's clinical presentation and the treatment tailored to the individual.
The Carillon system is a percutaneously delivered, coronary-sinus-based mitral annuloplasty device. A safety and feasibility trial now demonstrates low rates of major adverse events, with improvements in quality of life. Though promising, this report raises important questions related to relative efficacy and durability compared with other relevant therapies, and related to current clinical indications.
Stroke is the leading cause of morbidity and mortality in patients with atrial fibrillation. Whereas warfarin reduces the risk of stroke, its interactions with other drugs and food, individual differences in its efficacy and the need for frequent monitoring make its use inconvenient. Dabigatran etexilate might represent a step forward in the care of patients with atrial fibrillation.
Clinical trial data, including those from MADIT-CRT, support the use of cardiac resynchronization therapy in patients with asymptomatic and mildly symptomatic heart failure and ventricular dyssynchrony. However, important questions remain about which of these patients benefit most from this therapy.
