Viewpoint in 2008

In this Viewpoint, Dr Xavier and colleagues discuss the rationale behind their choice to perform a study on a cardiovascular Polypill in the setting of primary prevention, and behind the drug combinations used in The Indian Polycap study. Results of The Indian Polycap study will be available in April 2009.

Drs Rosenson and Pitt review the pathophysiological mechanisms for the increased cardiovascular risk associated with elevated triglycerides, and provide a rationale for the need to conduct a randomized clinical trial of statin therapy versus combined statin and fibrate therapy in patients with acute coronary syndromes.

The Polypill for prevention of cardiovascular disease was first proposed in 2003 and results of the first trials are eagerly anticipated. Regulatory agencies face the challenge of deciding which studies should be requested to meet reasonable demands regarding efficacy and safety of the Polypill in the intended (high-risk) target population. In this Viewpoint, Dr Forslund highlights the important issues that should be considered when generating these regulatory recommendations.

In this thought-provoking Viewpoint and accompanying clinical vignettes, Sengupta and colleagues posit that clinicians should be aware of obstructive sleep apnea in patients with hypertrophic obstructive cardiomyopathy. They hypothesize that this sleep disorder could be the reason cardiomyopathy symptoms remain despite therapy and could also contribute to a raised gradient seen in some patients.

Patient-prosthesis mismatch (PPM) is common after aortic valve replacement and has been shown to be associated with poor hemodynamic and symptomatic status, a high rate of cardiac events, and increased mortality. In this article, Philippe Pibarot and Jean G. Dumesnil highlight the importance of defining and recognizing PPM and its clinical impact. They also assert that, because PPM is a predictable and modifiable risk factor, it is vital to identify susceptible patients and to apply preventive strategies to avoid PPM or reduce its severity.

In this opinion piece, Hideo Mitamura presents some of the new strategies that are increasing the use of automated external defibrillators (AEDs) by lay persons in Japan. Professor Mitamura hopes that, if other countries follow in adopting initiatives such as internet-based maps showing the location of public-access AEDs, the lives of many who suffer an out-of-hospital cardiac arrest will be saved.

Results of the STRADIVARIUS and ADAGIO-Lipids trials have fuelled debate about the use of the controversial CB1 receptor antagonist rimonabant. Here, Vincenzo Di Marzo discusses the key findings from these studies and their potential clinical sequelae, and identifies a subgroup of patients who might derive the most benefit from this drug.

Patients with asymptomatic, severe aortic stenosis are at risk of cardiac death. In this Viewpoint, Pellikka and Sundt assert that aortic valve replacement should be considered in these patients, if surgery is likely to prolong life expectancy. Risk stratification of the asymptomatic aortic stenosis patient remains inadequate, however, and the decision to operate must be individualized, particularly in the elderly. The authors call for a randomized trial to help optimize the selection of patients for surgery.

Werner Mohl and coauthors present their Viewpoint examining pressure-controlled intermittent coronary sinus occlusion (PICSO). Here they postulate that PICSO should be introduced into the clinic as a valuable technique for activation of venous endothelium to initiate myocardial recovery and induce regeneration.

Patients with dilated cardiomyopathy and functional mitral regurgitation (MR) have a very poor prognosis. Surgical correction of MR in this setting is controversial because survival benefit has not been proven; however, patients who have undergone mitral repair often show substantial symptomatic improvement and reverse left ventricular remodeling. Here, Michele De Bonis and Ottavio Alfieri argue that these 'end-stage' patients should not be denied surgery, and that mitral repair should be performed before irreversible deterioration occurs.

In this opinion piece, Dr Alejandro Lucia and colleagues assert that physically inactive modern lifestyles are incompatible with our genetic makeup, which is essentially unchanged from that of our Paleolithic ancestors. The authors highlight the importance of regular physical exercise in preventing the 'diseases of civilization' and to achieving cardiovascular health.

There is much debate surrounding the etiology of cognitive decline following CABG surgery. In this Viewpoint, Neuropsychologist Ola Selnes postulates that this worrying complication is likely to be attributable to patient-related factors, such as the extent of pre-existing cerebrovascular disease, rather than to cardiopulmonary bypass.

A substantial proportion of cardiovascular morbidity and mortality in developing countries is caused by cardiac complications of 'neglected diseases', such as Chagas disease, endomyocardial fibrosis, and rheumatic heart disease. Here, Yacoub et al. discuss management strategies for what they believe are potentially preventable diseases.

Diuretics are used for symptomatic treatment of chronic heart failure; however, no randomized trials have yet assessed the long-term effects of these agents on morbidity and mortality. In this article, Vaz Pérez and colleagues question the assumption that long-term diuretic therapy is beneficial and opine that the currently available data do not support the routine use of diuretics as a cornerstone of long-term medical treatment for patients with chronic heart failure.

The management of patients with corticosteroid-dependent recurrent pericarditis is problematic. In this opinion piece, Imazio et al. assert that corticosteroids are over-prescribed, particularly in cases where the disease etiology is unknown. The authors discuss the weak evidence-base for the use of corticosteroids in pericarditis, and propose a treatment strategy for the minority of cases where these agents are indicated.