Viewpoint in 2007

Marvin J Slepian and Jack G Copeland present their Viewpoint on the University of Arizona's experience with the CardioWest^™total artificial heart (TAH-t) in patients with protracted refractory cardiogenic shock accompanying acute myocardial infarction. The authors assert that the TAH-t could provide a lifeline to patients whose prognosis would otherwise be bleak.

In this Viewpoint, Edward Frohlich provides an update to his Review from 2004 and posits that the role of salt in hypertension is far more complex than thought previously—that it 'simply' raises arterial pressure.

Cardiogenic shock is the leading cause of death in patients with acute ST-segment elevation myocardial infarction. In this Viewpoint, Drs Henriques and de Mol introduce the AMC MACH (Academic Medical Center Mechanical support for Acute Congestive Heart failure in STEMI patients) program and discuss how newly available percutaneous left ventricular assist devices used in this scheme could provide a bridge to heart transplantation or recovery in patients who would otherwise be unlikely to survive.

In this article, Professors Yacoub and Miller review the current status of left-ventricular-assist-device (LVAD) therapy for patients with chronic heart failure. The authors discuss the advantages and disadvantages of the available devices, how the indications for LVADs have evolved, and address the question 'are LVADs ready for long-term use?'

The Case Study by Satoda and colleagues, published in this issue ofNature Clinical Practice Cardiovascular Medicine, provides Paolo Angelini with an intriguing introduction to his Viewpoint on spontaneous coronary artery dissection (SCAD). Dr Angelini discusses our current understanding of this condition, and highlights recent progress in refining the diagnosis and definition of SCAD, made possible by new imaging modalities.

Atrioesophageal fistula is a rare but potentially fatal complication of radiofrequency catheter ablation for atrial fibrillation. Early recognition of this condition is crucial, and raising awareness could help reduce mortality. Here, Scanavaccaet al. discuss how and why fistulas occur, and suggest ways in which they could be avoided in future.

The number of elderly patients with cardiac conditions in the US is increasing, but these individuals receive fewer evidence-based therapies than their younger counterparts. Fibrinolytic therapy, in particular, is underused in the elderly and is commonly withheld on the basis of advanced age alone. In this Viewpoint, Cheuk-Kit Wong and Harvey D White seek to redress this situation by reviewing the evidence for fibrinolytic therapy in elderly patients and advocating that this treatment should not be denied unless there are clear contraindications.

Cigarette smoking contributes to 5 million deaths globally each year and up to 35% of tobacco-related deaths in developed countries have cardiovascular causes. In this Viewpoint, Professor of Psychiatry and Neuroscience, Robert Anthenelli, reviews the growing number of therapeutic options for treating tobacco dependence, and urges cardiologists to adopt a more proactive and persistent approach to motivating smoking cessation in their patients.

Although familial hypercholesterolemia is eminently treatable, the majority of cases go undetected, and this disorder remains a major challenge for preventive medicine. In this timely Viewpoint, Gerald Watts, Barry Lewis, and David Sullivan discuss how new genetic screening initiatives, together with a co-operative approach to treatment, could result in a quantum leap for coronary disease prevention.

In this Viewpoint, Michael Farkouh and colleagues question the evidence that C-reactive protein (CRP) is an independent predictor of future cardiovascular events. They suggest that failure to adjust for all components of the metabolic syndrome (MetS) in previous studies has bought into question the value of CRP over established traditional risk factors. The authors postulate that CRP is only a marker of the MetS and has limited incremental value in cardiovascular risk stratification.

Programmed ventricular stimulation has been proposed as a method of risk stratification in patients with repaired tetralogy of Fallot. In this Viewpoint, Paul Khairy reveals how Bayes' theorem can be used to identify patients most likely to benefit from programmed ventricular stimulation, and to demonstrate that routine electrophysiological testing is unnecessary.

Recent intensification of the controversy surrounding drug-eluting stents (DESs) has polarized opinion on how best to manage patients referred for percutaneous coronary intervention. In this Viewpoint, Farkouhet al.advocate a strategy of profiling patients to determine their suitability for DES implantation, based on their individual risk of developing late-stent thrombosis or bleeding associated with prolonged antiplatelet therapy.

'End-stage' hypertrophic cardiomyopathy (HCM) is one of the most serious manifestations of HCM, yet its etiology remains poorly understood. Here, Yacoub et al. discuss recent advances in our knowledge of end-stage HCM, explore avenues for future research, and propose that elucidating this 'mysterious' condition might provide a model for other myocardial diseases.

In recent years, virtual reality simulation has become recommended for training in complex endovascular procedures. Here, Christopher Cates discusses the benefits of this emerging paradigm in medical education, highlighting the applications of the state-of-the-art Vascular Interventional System Trainer (VIST^®) for carotid artery stenting.

Cardiologists have been hesitant to prescribe extended-release dipyridamole and aspirin for stroke prevention in patients with cardiovascular disease because of concerns that this combination might increase the risk of cardiac events. Here, Gregory Albers reviews new ESPRIT data, which demonstrate that the combination is more effective than aspirin alone for the prevention of stroke in patients with a recent cerebrovascular event, and does not increase cardiac risk. Cardiologists should now be reassured that dipyridamole and aspirin is appropriate for patients with recent stroke and cardiovascular disease.

Collaboration between clinicians and basic scientists is vital for effective bench-to-bedside research translations, but the interdependent nature of the two professions is currently underemphasized. Cardiovascular developmental biology in particular has important implications for our understanding of adult disease processes. Here Roger Markwald and Jonathan Butcher discuss key discoveries in developmental biology that have the potential to impact the diagnosis and treatment of adult cardiac disease, and appeal to clinicians and basic scientists alike to improve dialogue and learn from each other.

Five years on from the initial report in Nature that cell therapy showed potential therapeutic benefit for cardiac disease, Eric Adler and Thomas Maddox present their Viewpoint on the first three randomized, clinical trials of bone marrow cell therapy in patients with myocardial infarction.

Catheter ablation of atrial fibrillation is a relatively novel procedure that has rapidly become widely practiced. In this Viewpoint, Hugh Calkins highlights the potential dangers of this intervention, and cautions that it is premature to adopt catheter ablation as first-line therapy for patients with atrial fibrillation until data from large, prospective multicenter clinical trials are available.