Reviews & Analysis

In 2011, both the PARTNER-A trial, in high-risk patients with severe aortic stenosis, and EVEREST II, in patients with mitral insufficiency, showed noninferiority of transcatheter interventions compared with surgery for the chosen primary end points. However, both of the trials, and important registry data, identified limitations of transcatheter valve interventions.

Major advances in the diagnosis of acute coronary syndromes (ACS) have occurred in 2011, but physicians treating ACS still walk the tightrope between efficacy and bleeding. Key publications have shed light on this delicate balance and heralded a new era of novel oral anticoagulants for the treatment of ACS.

In 2011, key trials with oral factor Xa inhibitors in patients with atrial fibrillation highlighted promising data on these novel anticoagulants. Patients with ≥1 stroke risk factors can be considered for oral anticoagulation. These novel, fixed-dose drugs are given without monitoring, so clinicians must learn to balance stroke and bleeding risks.

In the first of their two Reviews on cardiogenic shock in acute coronary syndromes, Stephen Westaby and colleagues discuss the evolving epidemiology of this condition, its clinical presentation, and predictors of outcome. They also explore the options for medical therapy and the potential role of therapeutic hypothermia in these patients.

The results of several hypertension studies published in 2011 have contributed to our knowledge on the risks of and treatment for this condition, including the effects of slow-wave sleep, nocturnal dosing of medication, variability in post-stroke blood-pressure reduction, and the impacts of a low-sodium diet.

Understanding mechanisms of cardiac remodeling, with the goal of developing therapies to stop or reverse its progression, has become a major objective for investigators of heart failure. In this Review, Dr Koitabashi and Professor Kass discuss the evidence for 'reverse remodeling' by existing therapies, and review novel approaches that are currently moving from preclinical to clinical trials.

Arrhythmogenic cardiomyopathy (AC) is a clinically heterogeneous cardiac disease that is associated with ventricular arrhythmias and sudden cardiac death. The authors discuss the diagnosis and genetic basis of AC, and how disruption of desmosomal crosstalk with the nucleus, gap junctions, and ion channels might underlie the pathophysiology of this condition.

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.

In this state-of-the-art Review, Michele De Bonis and colleagues discuss the optimal management of patients with degenerative or function mitral regurgitation, from established surgical techniques to new percutaneous technologies. They also provide an overview of the use of echocardiography in the assessment of MR.

In late 2010 and in 2011, the results of the first randomized controlled trial of transcatheter aortic valve implantation (TAVI) were received with much excitement. In this Review, Dr. Rodés-Cabau discusses the main characteristics of transcatheter valves and the TAVI procedure, and evaluates the acute and late outcomes associated with TAVI.

This paper explores the rationale for early, 'vitamin-like' use of statins to lower LDL levels in asymptomatic adults aged 35–50 years. The authors describe the features of a trial designed to determine whether this approach could dramatically reduce the burden of atherosclerosis and atherothrombotic events in the general population.

Congenital defects of the heart affect up to 10 in 1,000 neonates, but mortality has decreased with improved detection and treatment. Drs Roest and de Roos describe the various imaging modalities available to assess patients with congenital heart disease before intervention, and to evaluate systolic, diastolic, valvular, and vascular function during follow-up.

Elevated blood pressure (BP) is probably the most-important, modifiable risk factor for cardiovascular disease. Dr. Ruilope discusses current controversies and challenges in the treatment of patients with arterial hypertension, including the validity of office BP measurements, appropriateness of BP targets, use of combination therapy, and patient compliance.

Hypertrophic cardiomyopathy is the most-common form of monogenically inherited heart disease, and is associated with a high incidence of sudden cardiac death in young patients. The authors review the genetic mutations known to cause the disease, discuss potential pathological mechanisms that might lead to the clinical phenotype, and consider the implications for targeted therapies.

Cardiac remodeling encompasses structural and functional changes of the left ventricle in response to stressors, and precedes clinical heart failure. Evaluation of cardiac remodeling can help to select patients with subclinical heart failure for early treatment. Drs Gjesdal, Blumke, and Lima review population-based studies of cardiac remodeling, describing risk factors, screening strategies, and outcome measures.

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.

Anomalous origination of a coronary artery from the opposite sinus is a congenital heart defect with an uncertain prevalence and prognosis. The authors review the current understanding of the pathophysiology of the condition, the imaging modalities available to diagnose and functionally assess patients, and the medical, interventional, and surgical treatment options.