News & Views in 2011

A subanalysis of the REACH Registry provides a contemporary 'real-world' demonstration of the impact of ethnic and racial differences in cardiovascular risk factors and mortality. This work reinforces the growing notion of ethnicity-specific variations in the risks and outcomes associated with atherothrombotic disease.

The 2011 United Nations summit on noncommunicable diseases (of which cardiovascular diseases are the major component) heralded a new era in global health priorities and strategy. However, clinicians and health administrators alike might overlook the potential convergence of communicable and noncommunicable pathways to heart disease in individuals and communities with cardiovascular risk factors.

The practice of same-day discharge after uncomplicated percutaneous coronary intervention in the USA has been analyzed using a large database including >700,000 patients and, overall, is safe when compared with patients who stay in hospital overnight, but is still rarely used.

A study by Li and coworkers demonstrates that antihypertensive-drug use and untreated hypertension in pregnancy increase the risk of congenital malformations. Supported by the results of meta-analysis, this study heralds a major shift in our understanding of the fetal risks of hypertension and the medications used to treat this condition.

Lovibond and colleagues report that ambulatory blood-pressure monitoring is the cost-effective option for the diagnosis of hypertension. Room for refining this analysis exists, but the focus on cost-saving by avoiding unnecessary treatment is compelling and should receive due consideration by guideline writers.

Indisputable evidence that coronary artery calcium score predicts cardiovascular events in asymptomatic individuals exists, even in patients with low to normal LDL cholesterol and elevated C-reactive protein. Conversely, not all studies demonstrate a predictive role for biochemical markers.

Antithrombotic therapy during percutaneous coronary intervention for ST-segment elevation myocardial infarction has evolved substantially over the past 15 years. With the results of the ATOLL trial, enoxaparin should now be considered a therapeutic alternative to unfractionated heparin in the treatment of such patients. Comparative studies of enoxaparin and bivalirudin, using standardized bleeding definitions, are warranted.

The true prognostic implication of carotid intima–media thickness (CIMT) remains a major question for clinicians and the preventive cardiology community. The merits of using CIMT for assessing asymptomatic individuals at risk for developing cardiovascular disease are discussed, together with the potential issues arising from an analysis of CIMT measurement in the Framingham Offspring Study cohort.

The appropriateness of percutaneous coronary intervention in the US has been examined from a large database of more than 500,000 procedures. The findings are surprising and, given their potential to be applied to quality-improvement initiatives, peer-review, and possibly reimbursement decisions, the proper interpretation of these results is essential.

The final report from the HORIZONS-AMI trial in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction shows that the early benefits of bivalirudin and paclitaxel-eluting stents are sustained at 3 years. Bivalirudin, thrombus aspiration, and drug-eluting stents might be the new standard of care for primary percutaneous coronary intervention.

According to a meta-analysis of five clinical trials, high-dose statin therapy is associated with increased risk of new-onset diabetes mellitus. When treating patients with excessive levels of non-HDL cholesterols despite moderate-dose statin therapy, should we prescribe a strategy known to be efficacious, but associated with safety concerns, or should we prescribe combination therapy that has no proven effects on outcomes?

The STICH trial showed that CABG surgery does not necessarily improve cardiovascular outcomes in patients with coronary artery disease and left ventricular dysfunction who are receiving optimal medical therapy. However, surgical revascularization should still be considered if the coronary artery disease is severe and viable myocardium can be identified.

Over the past 5–10 years, the positive effects of erythropoietin on myocardial infarction have been reported in several experimental, animal models. However, the results of the REVEAL study call into question the beneficial effects of erythropoietin in humans presenting with myocardial infarction.

In the Diuretic Optimization Strategies Evaluation (DOSE), the vexing issue of optimal administration of furosemide in patients with acute decompensated heart failure was tackled. In addition to the trial providing results that are clinically relevant, it also provides a model for future drug trials by addressing parameters such as dose, method of delivery, and duration of therapy.

The results of the SCAST study did not demonstrate any benefit on vascular or functional outcomes from lowering blood pressure in patients with acute stroke, but the findings were not definitive. We hope that other ongoing large-scale trials will resolve this area of clinical equipoise.

The pathophysiological properties of the left atrium are not usually considered for stroke risk stratification of patients with atrial fibrillation. The demonstration that left atrial fibrosis detected by delayed-enhancement MRI is associated with history of stroke highlights the need to take into account histopathological data, in addition to clinical data, in stroke risk stratification.

The ACCORD study investigators have published the results of an extended follow-up of the trial, focused on patients with type 2 diabetes mellitus who had been initially assigned to different intensities of glucose control. These data add to existing knowledge on the benefits of glycemic control in this patient population.

The diagnosis of short QT syndrome is often challenging, as corrected QT intervals of normal individuals and patients with short QT syndrome overlap considerably. We discuss the usefulness and limitations of a new score containing diagnostic criteria that was developed to facilitate the identification of patients with short QT syndrome.

Inflammation has a pivotal role in cardiac remodeling, and circulating biomarkers of inflammation are independently associated with risk of developing heart failure and with prognosis after onset of the condition. Pentraxin 3 has been suggested as a novel biomarker of left ventricular diastolic dysfunction and heart failure with normal ejection fraction.

The renin–angiotensin system is thought to have a key role in the structural remodeling of the left ventricle that accompanies healing after acute myocardial infarction and is an important determinant of long-term prognosis. Does a direct renin inhibitor provide additive benefit to patients already treated with β-blockers and either angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers?