News & Views in 2012

Adding C-reactive protein (CRP) level to conventional cardiovascular risk models has been suggested to improve risk prediction for cardiovascular events. However, evaluation of the potential impact of CRP measurement in cardiovascular risk management will require studies designed to quantify the effect of additional CRP assessment on medical decision-making, patient outcomes, and cost-effectiveness.

Not all strategies for the management of chronic heart failure have been shown to be equally effective in improving outcomes, and the ideal programme has yet to be defined. The WHICH? trial sheds some light on whether a clinical, in-hospital or a home-based strategy of care is superior and cost-effective.

Exercise training is an effective treatment option for patients with chronic heart failure to improve aerobic capacity and quality of life via a reduction in major cardiovascular events, including cardiac mortality. However, low adherence rates to exercise training pose a challenge to widespread application of this treatment.

Unexplained sudden cardiac death (SCD) is a major health problem, and prediction and identification of high-risk populations remain a challenge. Epinephrine stress testing could help to identify individuals at risk of SCD, but more research is required before this test could be recommended for routine use.

In a large, new, observational study, β-blocker treatment did not improve clinical outcomes in patients with coronary artery disease (CAD), including those with previous myocardial infarction, and was associated with more events in individuals with risk factors only. The role of β-blockers for secondary prevention in these patients should be reconsidered.

A 3-h algorithm using high-sensitivity assays for cardiac troponin to rule out myocardial infarction (MI) is recommended in current ESC guidelines. Whether faster rule-out algorithms can discriminate between MI and other conditions that elevate the troponin level, or be safely implemented across the whole spectrum of patient risk, is unclear.

Defibrillation testing during implantation of cardioverter–defibrillators is controversial because of potential safety concerns and a lack of evidence for the effectiveness of the procedure. New data from the SAFE-ICD study is helpful, but does not completely resolve the issue.

The concept that raising HDL-cholesterol level will uniformly translate into cardiovascular risk reduction has been challenged by genetic epidemiology studies and large-scale, randomized clinical trials. Studies suggest that we should go beyond HDL cholesterol, and consider emerging biomarkers of HDL concentration, composition, and functionality as surrogates for cardiovascular risk reduction.

The ROMICAT-II trial shows that CT coronary angiography is safe and fast for the exclusion of clinically significant obstructive coronary artery disease in low-risk patients with acute chest pain. Several issues and questions relating to the low prevalence of disease and the actual benefit to patients remain to be answered.

By definition, patients with heart failure and preserved ejection fraction are characterized by a normal or near-normal left ventricular ejection fraction, but marked heterogeneity in the extent of other cardiac structural and functional abnormalities exists. Improved appreciation of this diversity might provide insights into prognosis and therapeutic interventions.

Amin and colleagues have attempted to estimate the cost savings to the US health-care system if drug-eluting coronary stents were more selectively used in patients at low risk of restenosis. Their results and conclusions raise statistical, societal, and ethical issues that need to be considered before this approach should be widely embraced.

A new, observational study suggests that aspirin only marginally increases the bleeding risk in patients with diabetes mellitus, perhaps reflecting impaired platelet inhibition. Inconclusive evidence from small, randomized trials and mechanistic studies reinforces the need for larger trials to determine the relative cardioprotective benefits and bleeding risks of aspirin in these patients.

In the Heidelberg–EPIC study, an association was found between the use of calcium supplements and risk of myocardial infarction, corroborating published data. Given these findings and the absence of clear beneficial effect on fracture risk, the use of these supplements should be discouraged, and individuals advised to obtain calcium from a balanced diet.

To achieve timely restoration of coronary flow in patients with acute myocardial infarction, the decision to call in the cardiac catheterization team has moved ever earlier, and is often made before cardiologist evaluation. Door-to-balloon times have been reduced, but the price of this success is an increase in 'false alarms'.

A spectrum of common illnesses that constitute risk factors for cardiovascular diseases is associated with both cognitive impairment and high population mortality. Many clinical trials are focused on the prevention of cardiovascular mortality, but cognitive impairment should now be regarded as a similarly important outcome.

Infusion of glucose–insulin–potassium (GIK) before hospital admission in patients with signs and symptoms of acute coronary syndrome has been shown to reduce the incidence of cardiac arrest or in-hospital mortality. Whether out-of-hospital GIK in combination with strict glycemic control can prevent progression to MI requires further study.

The BRIDGE-ACS study showed benefits of a quality improvement initiative in adherence to evidence-based therapy for acute coronary syndromes at public hospitals in Brazil. No mortality benefit was observed, but this finding might have been different if all effective therapies for in-hospital treatment of myocardial infarction were included.

Randomized studies and evaluations of large registries have repeatedly shown that epinephrine used as a standard vasopressor for cardiopulmonary resuscitation increases the rate of return of spontaneous circulation. By contrast, epinephrine might decrease long-term survival and impair neurological outcome.

The EINSTEIN-PE trial showed that rivaroxaban has equal efficacy and a lower rate of bleeding than coumarins in the treatment of acute pulmonary embolism. We anticipate regulatory and consumer acceptance for rivaroxaban, representing the first new anticoagulant treatment for venous thromboembolism since the introduction of warfarin compounds 50 years ago.

Much debate surrounds the utility of CYP2C19^*2 genotyping in patients receiving clopidogrel after coronary artery stenting. The effectiveness of its use in a point-of-care setting has now been examined and, given the substantial incremental suppression of platelet reactivity achieved, its routine use might soon be a reality.