News & Views in 2010

Although a diminished pharmacodynamic effect of clopidogrel has been demonstrated in patients treated with proton-pump inhibitors (PPIs), whether its clinical efficacy is reduced remains highly controversial. The FDA and European Medicines Agency recommend that PPIs and clopidogrel should not routinely be coadministered, and the 2010 expert consensus guidelines support this recommendation.

Worsening renal function is common among patients hospitalized with acute heart failure and is associated with poor outcomes. Although preliminary studies suggested that adenosine receptor antagonists could preserve renal function and improve diuretic responsiveness, the A₁-receptor antagonist rolofylline did not provide benefit in patients with acute heart failure in PROTECT.

In the past 3 years, several studies have reignited the controversy regarding the cardiovascular risk associated with the use of rosiglitazone. Until a prospective, well-controlled, randomized clinical trial is performed to adjudicate the issue definitively, physicians should be free to exercise clinical judgment, and weigh the comparative risks and benefits of agents such as rosiglitazone on a case-by-case basis.

Vuurmans et al. have reported that, among 69,214 patients who underwent coronary angiography or percutaneous coronary intervention, transradial access was associated with a lower incidence of chronic kidney disease than the femoral approach. We discuss the importance of kidney injury following these procedures, and the potential protective mechanisms of transradial access.

Accurate early diagnosis of acute coronary syndrome (ACS) is a challenging clinical problem. Imaging myocardial fatty acid metabolism with β-methyl-p-[¹²³I]-iodophenyl-pentadecanoic acid single-photon emission computed tomography was shown to improve the accuracy of ACS diagnosis in patients presenting with chest pain and might be a valuable technique in the emergency setting.

The 'funny' current (I_f) has been the subject of 30 years of laboratory research and is an important therapeutic target in heart disease owing to its effects on heart rate. SHIFT, a trial in patients with all-cause heart failure, shows that I_f inhibition reduces combined mortality and rate of hospitalization and opens further avenues of research and therapeutic challenges.

Patient selection for implantation of a cardioverter-defibrillator for primary prevention of sudden cardiac death is especially difficult in inherited arrhythmia syndromes, owing to a lack of randomized outcome studies in this setting. Two registry studies and the first report of a long-term follow-up of defibrillators in primary prophylaxis have provided some information regarding patient selection, but have important limitations.

Hypertrophic cardiomyopathy is the most common genetic heart disease and is associated with sudden cardiac death and development of heart failure. Risk stratification currently relies only on clinical risk factors, which have low positive predictive value. Myocardial fibrosis, assessed by contrast-enhanced cardiovascular magnetic resonance imaging, may improve risk stratification.

Anxiety has been shown to have prognostic importance in the development of coronary heart disease in initially healthy adults. This finding highlights the need of future research that includes representative samples of women and minorities, and uses precise assessment tools and careful ascertainment of clinical end points.

Current medical therapies for chronic stable angina pectoris do not always render patients free of symptoms and may not be well tolerated. Xanthine oxidase inhibition with drugs such as allopurinol might be a promising new approach to treat these patients.

Patients with diabetes mellitus and hypertension are at high cardiovascular risk and treatment guidelines recommend aggressive blood pressure (BP) control. However, a reanalysis of data from the previously published INVEST trial indicates that achieving systolic BPs <130 mmHg in patients with diabetes and coronary artery disease increases mortality, although this finding might reflect the speculative conclusions produced by post-hoc analyses.

The hope that a simple, affordable, and safe homocysteine-lowering intervention with folic acid and vitamin B₁₂ would improve outcomes for patients with established cardiovascular or renal disease has been crushed by the null results from large B-vitamin treatment trials completed to date.

The best strategy for management of patients with non-ST-segment elevation acute coronary syndrome is still a matter of debate. A meta-analysis, in which results from three large-scale studies were pooled, shows that a routine invasive approach is associated with better 5-year outcomes than a selectively invasive approach.

Transvenous leads are the most common source of complications associated with the use of implantable cardioverter-defibrillators (ICDs). A preliminary experience with an entirely subcutaneous ICD system, which avoids the need for transvenous leads, has been reported. We discuss these results and the importance of investigations in this new field.

T2-weighted cardiovascular magnetic resonance imaging (T2W-CMR) has been championed as the best noninvasive method to determine the myocardial area at risk and to quantify myocardial salvage in patients with acute coronary syndromes. However, several unresolved issues warrant discussion and we urge caution when utilizing T2W-CMR for this purpose.

Determining the appropriate dose of warfarin that should be used in each patient is challenging, and the rate of adverse events at the beginning of therapy remains high. Testing for genetic variability related to warfarin sensitivity at the start of treatment is a promising strategy to guide dosing in clinical practice.

Mechanical reperfusion in acute myocardial infarction does not always result in desirable optimal microvascular perfusion. Failure to achieve a normal myocardial blush in the infarcted region by contrast injection immediately after percutaneous coronary intervention—the 'no-reflow' phenomenon—is an ominous sign whose prognostic importance may go beyond its intimate association with infarct size.

The optimum strategy to treat patients with coronary artery disease (CAD) has been under debate. New data show that revascularization guided by fractional flow measurements leads to better outcomes than revascularization guided by arteriography. We call for a paradigm shift in CAD care, with coronary flow measurements by PET as key to diagnosis and clinical decision-making.

The association between periodontitis and other chronic diseases, such as cardiovascular disease (CVD) and type 2 diabetes mellitus, could be related to systemic inflammation initiated by a local inflammatory challenge. Oliveira et al. have added lack of oral hygiene, and its link with systemic inflammation, to the spectrum of risk factors for CVD.

The ability to identify which patients with atherosclerosis are at higher risk of future cardiovascular events is important not only for decisions about medical therapy, but also for decisions about surgical or percutaneous intervention. Pathological findings of plaque features that predict cardiovascular events may point the way to noninvasive imaging approaches to identify high-risk plaques.