News & Views in 2009

New methods of cardiac troponin measurement accurately characterize patients as they present to the emergency department. Decisions on admission or discharge within 1–2 h of initial assessment (rather than 6–12 h thereafter), therefore, have become feasible. This development has potential for a major influence on how patients with chest pain are managed.

Endoscopic harvesting of saphenous veins for use in CABG surgery has become standard practice worldwide. This strategy reduces postoperative infection and hospital stay, and increases patients' satisfaction when compared with open harvest. However, long-term follow-up data provided by Lopes et al. indicate that widespread use of this technique must be urgently reviewed.

The novel antiplatelet agent ticagrelor was evaluated against clopidogrel in the PLATO trial of patients with acute coronary syndromes. This article discusses the main findings and importance of this study, including the reduction in mortality associated with ticagrelor therapy.

The role of endovascular therapy in patients with renal artery stenosis continues to be very controversial. Two reports have added notable findings to the growing body of evidence on this subject. The investigators of these studies aimed to clarify which patients, if any, would benefit from renal artery stent placement.

The results of the CRIB-2 trial, which show that the mineralocorticoid receptor blocker (MRB) spironolactone improves left ventricular mass and aortic stiffness in patients with early stage chronic kidney disease (CKD), provide impetus for large-scale clinical trials to evaluate the effects of this strategy on clinical outcomes. The optimum choice of MRB and its dose, however, remain uncertain given the potential risk of hyperkalemia in patients with CKD.

The diagnosis of unexplained cardiac arrest could soon become obsolete, as so-called molecular autopsy can now be used to identify its underlying causes. The current view of this subject is discussed, and some personal opinions are presented on the assessment of survivors of sudden cardiac arrest and relatives of individuals who do not survive.

Yang and colleagues report on their single-center experience with high-field coronary MRA using a new MR contrast agent. Data on 30 patients were compared with conventional X-ray angiography. Their new coronary MRA approach seems favourable when compared with previous MRA methods.

Factor Xa inhibitors, a new class of oral anticoagulants, have been evaluated in the phase II ATLAS ACS-TIMI 46 and APPRAISE trials. Addition of these agents to standard therapy has tended to reduce the incidence of adverse cardiovascular events at the expense of a dose-dependent increase in the risk of bleeding complications.

Cell therapy for myocardial infarction has received widespread attention. Although short-term effects have been encouraging, Yousef et al. now report substantial benefit of bone marrow mononuclear cells over 5 years of follow-up in an open-label series of 62 patients. Long-term follow-up of randomized trials is eagerly awaited and novel approaches of cell therapy are currently under investigation.

Ultrasonographic screening of older men to detect abdominal aortic aneurysms has been added to the list of programs supported by the National Health Service in England and Scotland, and by Medicare in the US. Two articles in the British Medical Journal addressing the cost-effectiveness of this practice have provided markedly discordant results.

Transcatheter aortic valve implantation has evolved as a viable therapeutic option for high-risk, elderly patients with symptomatic aortic stenosis in select cardiac centers with experience of the procedure. In this article we consider the findings reported by Webb et al. and discuss current criteria for selection of patients, technical features, clinical results, and future developments in this rapidly advancing area.

Cappato et al. have reviewed the major causes of death in patients undergoing catheter ablation of atrial fibrillation. Many of these complications could be prevented by careful catheter manipulation, implementing safe energy settings, adequate anticoagulation, and esophageal monitoring. Urgent pericardial drainage is critical in avoiding death related to cardiac tamponade.

Intentional weight loss is associated with many benefits, including reduced mortality and cardiometabolic and inflammatory risk, as well as improved quality of life. Unintentional weight loss, however, is often a harbinger of future ill-health. Separating these types of weight loss in clinical trials is sometimes difficult and in small trials can produce the 'obesity paradox'.

Lipoprotein(a) has been studied as a risk factor for coronary heart disease, but whether a causal relationship exists has been unclear. A study by Kamstrup and colleagues examining genetically mediated increases in lipoprotein(a) concentration now provides evidence that it could indeed represent a causal coronary risk factor.

Unselected bone-marrow-derived mononuclear cells seem to improve left ventricular function and perhaps short-term clinical outcomes for patients with acute myocardial infarction. The REGENT trial aimed to elucidate whether infusion of selected hematopoetic progenitor cells increases this effect in patients with large infarcts and attenuated left ventricular ejection fraction.

Radiation exposure from cardiac CT is currently under a high level of scrutiny, and many patients may be receiving excessive radiation from this test. A study by Raff and colleagues—aimed at reducing this radiation through a statewide initiative—helps define the potential for improving the safety of cardiac CT at community medical centers.

There are concerns about long-term outcomes associated with drug-eluting stent implantation in high-risk and 'real world' patients, and few data from these settings have been published. Two new papers add to our knowledge on drug-eluting stent use in acute myocardial infarction and for off-label indications.

Drug-eluting stents are an established treatment option for coronary artery disease, although they are not without their problems. The MAHOROBA^® stent attempts to harness the theoretical advantages of both tacrolimus and polymer degradation, but has proved not to be effective in the treatment of de novo coronary lesions.

Patients with venous thromboembolism receive anticoagulants after a thrombotic episode, usually for a fixed period. Discontinuing treatment could lead to recurrence, but prolonged therapy can cause serious bleeding. Ideally, treatment duration should be tailored to individual patients but can this be achieved with ultrasonography, as proposed by the AESOPUS group?

With the aging of the population, the frequency of acute myocardial infarction is rising most rapidly among the elderly, a subgroup at high risk of a fatal outcome. Lorgis et al. observe that N-terminal pro-brain natriuretic peptide, combined with a simple clinical risk score, provides an accurate estimate of prognosis.