Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Vitamins C and E to Prevent Complications of Pregnancy-Associated Hypertension
Topic: Prevention/Vascular
Date Posted: 4/7/2010 4:00:00 PM
Author(s): Roberts JM, Myatt L, Spong CY, et al., on behalf of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.
Citation: N Engl J Med 2010;362:1282-1291.
Clinical Trial: yes
Study Question: Do antioxidant vitamins (C and E) reduce the risks of adverse events related to pregnancy-associated hypertension?
Methods: This was a multicenter, randomized, double-blind, placebo-controlled trial of pregnant women conducted between July 2003 and February 2008. Subjects were randomized to vitamin C (1000 mg) and vitamin E (400 IU) or placebo between the 9th and 16th week of pregnancy. All women were nulliparous and at low risk for pre-eclampsia. Women were excluded if a prior pregnancy had lasted greater than 19 weeks 6 days, they had elevated blood pressure (135 and/or 85 mm Hg or higher), proteinuria, used antihypertensive medications, or were taking vitamin C or E supplements. The primary outcome of interest was severe pregnancy-associated hypertension alone or severe or mild hypertension with elevated liver-enzyme levels, thrombocytopenia, elevated serum creatinine levels, eclamptic seizure, medically indicated preterm birth, fetal-growth restriction, or perinatal death.
Results: A total of 10,154 women were included in the study. Outcomes were available for 9,969 women. There were no significant differences between the two groups for the outcomes evaluated including the primary outcome (relative risk, 1.07; 95% confidence interval, 0.91-1.25). Similar rates of pre-eclampsia were also observed (relative risk, 1.07; 95% confidence interval, 0.93-1.24). Rates of adverse perinatal outcomes did not differ between the two groups. Among women randomized at less than 13 weeks compared to those randomized after 13 weeks, no differences were observed between the two groups.
Conclusions: The investigators concluded that supplementation with vitamins C and E, started in the 9th to 16th week of pregnancy, did not reduce the rate of adverse maternal or perinatal outcomes related to pregnancy-associated hypertension among a low-risk cohort of women.
Perspective: These findings do not support the use of vitamin C or E supplementation for the prevention of adverse events related to pregnancy-related hypertension. Many questions remain unanswered, particularly regarding dosing and timing of supplements. However, further understanding regarding the pathophysiology related to pregnancy-associated hypertension is warranted prior to further studies of antioxidant vitamins. Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Outcomes With Concurrent Use of Clopidogrel and Proton-Pump Inhibitors: A Cohort Study
Topic: General Cardiology
Date Posted: 4/8/2010
Author(s): Ray WA, Murray KT, Griffin MR, et al.
Citation: Ann Intern Med 2010;152:337-345.
Clinical Trial: No
Study Question: What are the clinical outcomes (gastrointestinal bleeding and cardiovascular [CV] events) in patients treated with both clopidogrel and proton pump inhibitors (PPIs)?
Methods: This was a retrospective cohort study of 20,596 patients (including 7,593 concurrent users of clopidogrel and PPIs) hospitalized between 1999 and 2005 for myocardial infarction, coronary artery revascularization, or unstable angina pectoris. Baseline and follow-up drug use was assessed from automated records of dispensed prescriptions. Primary outcomes were hospitalizations for gastroduodenal bleeding and serious CV disease (fatal or nonfatal myocardial infarction or sudden cardiac death, stroke, or other CV death).
Results: Pantoprazole and omeprazole accounted for 62% and 9% of concurrent PPI use, respectively. Adjusted incidence of hospitalization for gastroduodenal bleeding in concurrent PPI users was 50% lower than that in nonusers (hazard ratio, 0.50; 95% confidence interval, 0.39-0.65). For patients at highest risk for bleeding, PPI use was associated with an absolute reduction of 28.5 (CI, 11.7-36.9) hospitalizations for gastroduodenal bleeding per 1,000 person-years. The hazard ratio associated with concurrent PPI use for risk for serious CV disease was 0.99 (CI, 0.82-1.19) for the entire cohort and 1.01 (CI, 0.76-1.34) for the subgroup of patients who had percutaneous coronary interventions with stenting during the qualifying hospitalization.
Conclusions: The authors concluded that in patients with serious coronary heart disease treated with clopidogrel, concurrent PPI use was associated with a reduced incidence of hospitalizations for gastroduodenal bleeding without an increase in serious CV events.
Perspective: Patients with CV disease on clopidogrel are commonly also treated with PPIs. Because some PPIs have been shown to inhibit activity of the enzyme responsible for biotransformation of clopidogrel, CYP2C19, concern has been raised that PPI coadministration may reduce the effectiveness of clopidogrel, resulting in increased CV events. This is particularly relevant in patients following stent placement, where clopidogrel is effective in reducing stent thrombosis. While some studies have shown this interaction is clinically significant, recent data from TRITON-TIMI 38 found no increased CV risk associated with PPI use. The current study also supports the concept that the benefits of PPI use in patients at risk of gastrointestinal bleeding outweigh potential adverse CV risks in patients on clopidogrel. Data from additional trials will be helpful to clarify CV risk estimates associated with concomitant PPI and clopidogrel use. Daniel T. Eitzman, M.D., F.A.C.C.

Title: Food Price and Diet and Health Outcomes: 20 Years of the CARDIA Study
Topic: Prevention/Vascular
Date Posted: 4/9/2010
Author(s): Duffey KJ, Gordon-Larsen P, Shikany JM, Guilkey D, Jacobs DR Jr, Popkin BM.
Citation: Arch Intern Med 2010;170:420-426.
Clinical Trial: No
Related Resources
Trial: Coronary Artery Risk Development in Young Adults (CARDIA)

Study Question: Is there a relationship between food prices and individual intake of “healthy” versus “unhealthy” choices, and are there potential health benefits?
Methods: A 20-year longitudinal study included 12,123 respondent days from 5,115 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Associations between food price, dietary intake, overall energy intake, weight, and homeostatic model assessment insulin resistance (HOMA-IR) scores were assessed using conditional log-log and linear regression models.
Results: The real price (inflated to 2006 US dollars) of soda and pizza decreased over time. The largest percentage decrease was for soda, falling from $2.71 to $1.42 (48% decrease; the price of whole milk increased). During periods with a 10% increase in the price of soda or pizza, there was a -7.12% or -11.5% change in energy from these foods, respectively. A $1.00 increase in soda price was also associated with lower daily energy intake (-124 kcal), lower weight (-1.05 kg), and lower HOMA-IR score (-0.42); similar trends were observed for pizza. A $1.00 increase in the price of both soda and pizza was associated with greater changes in total energy intake (-181.49 kcal), body weight (-1.65 kg), and HOMA-IR (-0.45).
Conclusions: Policies aimed at altering the price of soda or away-from-home pizza may be effective mechanisms to steer US adults toward a more healthful diet and help reduce long-term weight gain or insulin levels over time.
Perspective: This type of data likely influenced government policy regarding availability of soda and pizza in schools, and of course would encourage use of taxation to address the fattening of America. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Evaluation of Bromocriptine in the Treatment of Acute Severe Peripartum Cardiomyopathy: A Proof-of-Concept Pilot Study
Topic: Heart Failure/Transplant
Date Posted: 4/9/2010
Author(s): Sliwa K, Blauwet L, Tibazarwa K, et al.
Citation: Circulation 2010;121:1465-1473.
Clinical Trial: No
Study Question: Does bromocriptine have beneficial effects in acute severe peripartum cardiomyopathy (PPCM)?
Methods: The investigators conducted a prospective, single-center, randomized, open-label, proof-of-concept pilot study of women with newly diagnosed PPCM receiving standard care (PPCM-Std; n = 10) versus standard care plus bromocriptine for 8 weeks (PPCM-Br, n = 10). There were no significant differences in baseline characteristics, including serum 16-kDa prolactin levels and cathepsin D activity, between the two study groups. Because mothers receiving bromocriptine could not breast-feed, the 6-month outcome of their children (n = 21) was studied as a secondary endpoint. The investigators performed blinded clinical, hemodynamic, and echocardiographic assessments at baseline and 6 months after diagnosis. Cardiac magnetic resonance imaging was performed 4-6 weeks after diagnosis in PPCM-Br patients.
Results: The investigators found that PPCM-Br patients displayed greater recovery of left ventricular ejection fraction (27-58%; p = 0.012) compared with PPCM-Std patients (27-36%) at 6 months. One patient in the PPCM-Br group died compared with four patients in the PPCM-Std group. Significantly fewer PPCM-Br patients (n = 1, 10%) experienced the composite endpoint of poor outcome defined as death, New York Heart Association functional class III/IV, or left ventricular ejection fraction ≤35% at 6 months compared with the PPCM-Std patients (n = 8, 80%; p = 0.006). Cardiac magnetic resonance imaging revealed no intracavitary thrombi. Infants of mothers in both groups showed normal growth and survival.
Conclusions: The investigators concluded that addition of bromocriptine to standard heart failure therapy appeared to improve left ventricular ejection fraction and a composite clinical outcome in women with acute severe PPCM, although the number of patients studied was small and the results cannot be considered definitive.
Perspective: Prolactin, mainly its 16-kDa angiostatic and proapoptotic form, has been shown to be an factor in PPCM pathophysiology (Cell 2007;128:589-600 ). In animal models, blockade of prolactin with the dopamine-2D agonist, bromocriptine, prevents the onset of PPCM. Earlier reports have also shown bromocriptine to be effective in women with PPCM (J Am Coll Cardiol 2007;50:2354-2355). The findings of this study represent one more piece of evidence suggesting that bromocriptine is beneficial in PPCM. However, the natural history of PPCM is variable, and therefore, double-blind randomized studies are now needed to confirm the efficacy of this therapy in PPCM, a potentially life-threatening condition. Ragavendra R. Baliga, M.B.B.S.

Title: Drugs vs. Ablation for the Treatment of Atrial Fibrillation: The Evidence Supporting Catheter Ablation
Topic: Arrhythmias
Date Posted: 4/9/2010
Author(s): Nault I, Miyazaki S, Forclaz A, et al.
Citation: Eur Heart J 2010;Mar 23:[Epub ahead of print].
Clinical Trial: No
Study Question: Is radiofrequency catheter ablation (RFCA) more effective than antiarrhythmic drug therapy (ADT) for suppressing atrial fibrillation (AF)?
Methods: A systematic literature search yielded eight studies and two review articles that compared ADT and RFCA in patients with AF. The results of these studies were analyzed.
Results: A total of 763 patients participated in seven studies that directly compared ADT (n = 383) with RFCA (n = 380). Freedom from atrial arrhythmias was significantly higher with RFCA (79%) than with ADT (32%). In the four studies that were limited to patients with paroxysmal AF, the efficacy was 81% with RFCA and 29% with ADT. Large-scale surveys reported that the mortality rate of RFCA of AF is 0.1% and that the most common severe complications are pericardial tamponade (1.2%), cerebral thromboembolism (1%), and symptomatic pulmonary vein stenosis (0.6%).
Conclusions: RFCA is more effective than ADT for restoring and maintaining long-term sinus rhythm.
Perspective: Because of considerable variability in ablation strategy and the intensity of monitoring for asymptomatic AF during follow-up, pooling the results of published studies on the efficacy of RFCA is of questionable value. Furthermore, most patients recruited into these studies already had failed to respond to ADT with ≥1 agent, creating a bias against ADT. Despite these flaws, it does seem likely that RFCA is more effective than ADT for preventing AF. But this does not necessarily imply that RFCA should be first-line therapy for AF. Even if the efficacy of ADT is only about 30%, why not try ADT first and reserve an invasive procedure for patients who are not satisfied with their response to drug therapy? Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: Determinants of Functional Recovery After Myocardial Infarction of Patients Treated With Bone Marrow-Derived Stem Cells After Thrombolytic Therapy
Topic: General Cardiology
Date Posted: 4/9/2010
Author(s): Miettinen JA, Ylitalo K, Hedberg P, et al.
Citation: Heart 2010;96:362-367.
Clinical Trial: No
Study Question: What factors are associated with functional recovery after myocardial infarction in patients treated with bone marrow-derived stem cells (BMC) following coronary reperfusion therapy?
Methods: Seventy-eight patients with ST-elevation MI (STEMI) were randomly assigned to receive either intracoronary BMC (n = 39) or placebo (n = 39) into the infarct-related artery 2-6 days following coronary reperfusion therapy. Efficacy of the BMC treatment was assessed by measurement of the change of global left ventricular ejection fraction (LVEF) from baseline to 6 months after STEMI. Various predefined variables (e.g., the levels of certain natriuretic peptides and inflammatory cytokines) were also analyzed as determinants of improvement in LVEF.
Results: In the BMC group, the most powerful determinant of the change in LVEF was the baseline LVEF (r = -0.58, p < 0.001). Patients with baseline LVEF at or below the median (≤62.5%) experienced a more marked improvement in LVEF (+12.7 ± 2.5 %units, p < 0.001) than those above the median (-0.8 ± 6.3 %units, p = 0.10). Elevated N-terminal probrain natriuretic peptide (p < 0.001) and N-terminal proatrial natriuretic peptide (p = 0.052) levels were also associated with improvement in LVEF in the BMC group, but not in the placebo group.
Conclusions: The global LVEF recovers most significantly after intracoronary infusion of BMC in patients with the most severe impairment of LVEF on admission. The baseline levels of natriuretic peptides are associated with LVEF recovery after BMC treatment.
Perspective: The effects of cell-based therapies on recovery of LV function following acute MI have been modest at best. The current study indicates that subgroups of MI patients may be more likely to benefit than others; in particular, those with the most myocardial damage may be most likely to benefit from this type of therapy. However, the LVEFs in this study following MI were relatively preserved. Additional studies with larger sample sizes and larger infarcts are needed to further evaluate this therapy. Daniel T. Eitzman, M.D., F.A.C.C.

[Chevychelov]

ARIC Study: C-IMT, Plaque and Risk Stratification
The Future of Antiarrhythmic Agents
[Ссылки доступны только зарегистрированным пользователям ]

[Chevychelov]

Title: Atrial Fibrillation Is Independently Associated With Senile, Vascular, and Alzheimer’s Dementia
Topic: Arrhythmias
Date Posted: 4/12/2010
Author(s): Bunch TJ, Weiss JP, Crandall BG, et al.
Citation: Heart Rhythm 2010;7:433-437.
Clinical Trial: No
Study Question: Is atrial fibrillation associated with dementia?
Methods: Data from the Intermountain Heart Collaborative Study were used for the present analysis. Dementia was categorized into four groups: vascular, senile, Alzheimer’s, and nonspecific. Patients with pre-existing dementia or atrial fibrillation were excluded. Atrial fibrillation status was determined by a search of the hospital discharge summaries and the electrocardiographic database for all Intermountain Healthcare hospitals.
Results: Of the 37,025 consecutive patients (mean age 60.6 ± 17.9 years) included in the study, 10,161 developed atrial fibrillation, and 1,535 developed dementia over the 5-year follow-up period. Patients with dementia were older and had higher rates of hypertension, coronary artery disease, renal failure, heart failure, and prior strokes. Atrial fibrillation was independently associated with all dementia types, with the highest risk observed among those <70 years of age. Among subjects with dementia, those who had atrial fibrillation were at increased risk for death (hazard ratio [HR], 1.38; p = 0.01 for vascular dementia, HR, 1.41; p = 0.001 for senile dementia, HR, 1.44; p < 0.0001 for Alzheimer’s dementia, and HR, 1.38; p < 0.0001 for nonspecific dementia).
Conclusions: The authors concluded that atrial fibrillation was independently associated with all types of dementia, and the highest risk of Alzheimer’s dementia was in the younger subjects. In addition, the presence of atrial fibrillation in patients with dementia identified those at increased risk of death.
Perspective: These findings are clinically relevant in that they may assist providers in identification of patients that may require closer monitoring and support. However, a central question remains unanswered: Would maintenance of sinus rhythm reduce incident dementia? Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Dietary Glycemic Load and Index and Risk of Coronary Heart Disease in a Large Italian Cohort: The EPICOR Study
Topic: Prevention/Vascular
Date Posted: 4/13/2010
Author(s): Sieri S, Krogh V, Berrino F, et al.
Citation: Arch Intern Med 2010;170:640-647.
Clinical Trial: No
Study Question: Is glycemic load associated with increased risk of coronary heart disease (CHD)?
Methods: Data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study’s Italian cohort were used for the present study. Subjects were excluded if they had a prior history of cardiovascular disease or diabetes, or if data were missing on diet or lifestyle factors. The primary outcome of interest was CHD, defined as the occurrence of acute myocardial infarction, acute coronary syndrome, or coronary revascularization during follow-up.
Results: A total of 47,749 subjects (32,578) were followed over a median of 7.9 years. CHD events were experienced in 158 men and 305 women. Women in the highest quartile for carbohydrate intake had a significantly greater risk for CHD compared to those in the lowest quartile (relative risk [RR], 2.0; 95% confidence interval [CI], 1.16-3.43). No such association was observed in men. Increasing carbohydrate intake from high-glycemic index foods was also associated with increased risk for CHD in women (RR, 1.68; 95% CI, 1.02-2.75), which was not observed with low-glycemic index foods. A similar observation was noted for high glycemic load (RR, 2.24; 95% CI, 1.26-3.98) also among the women subjects, but not observed in men subjects.
Conclusions: The investigators concluded that among this cohort of Italian men and women, high dietary glycemic load (and index) and carbohydrate intake was associated with CHD risk in women, but not men.
Perspective: It is surprising that high glycemic load and carbohydrate intake is associated with increased CHD risk in women, but not men. Understanding factors that may explain this possible gender difference is warranted. Elizabeth A. Jackson, M.D., F.A.C.C.

Title: Enhanced Depression Care for Patients With Acute Coronary Syndrome and Persistent Depression Symptoms: Coronary Psychosocial Evaluation Studies Randomized Controlled Trial
Topic: General Cardiology
Date Posted: 4/13/2010
Author(s): Davidson KW, Rieckmann N, Clemow L, et al.
Citation: Arch Intern Med 2010;170:600-608.
Clinical Trial: yes
Study Question: Does an enhanced depression treatment for patients after acute coronary syndrome (ACS) improve depressive symptoms and reduce adverse cardiac events?
Methods: This was a randomized controlled trial conducted from January 2005 through February 2008 with ACS patients from five hospitals. A 3-month observation period prior to randomization was used to identify patients with persistent depressive symptoms. Following this observation phase, a 6-month trial was conducted. Patients were randomized to the intervention, which included patient preference for problem-solving therapy and/or pharmacotherapy, followed by a stepped-care approach. The control group received usual care and a third group of nondepressed patients was used as an observational group. The primary outcome of interest was patient satisfaction with depression care. Secondary outcomes included change in depressive symptoms (measured with Beck Depression Inventory), major adverse cardiac events, and death.
Results: A total of 237 patients were enrolled (80 in the intervention group, 77 in the control group, and 80 in the observation group). The number of patients who reported being satisfied with the depression care received was higher in the intervention group compared to those in the control group (odds ratio, 5.4; 95% confidence interval, 2.2-12.9). The Beck Depression Inventory Score decreased more in the intervention group (change, -5.7 vs. -1.9). At the end of the trial, three patients in the intervention group experienced adverse cardiac events, as did 10 patients in the usual care group and five in the nondepressed group.
Conclusions: The investigators concluded that an enhanced treatment for depression among patients with ACS was associated with greater satisfaction with care, reduced depressive symptoms, and a trend toward reduced cardiac events.
Perspective: Depressive symptoms are frequently experienced by patients after ACS. Finding effective interventions for depression can only help improve overall cardiac care. These findings suggest that this enhanced program may be effective for treatment of depression. Larger-scale studies are needed to confirm and extend these results. Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Feasibility of FDG Imaging of the Coronary Arteries: Comparison Between Acute Coronary Syndrome and Stable Angina
Topic: Noninvasive Cardiology
Date Posted: 4/12/2010 5:00:00 PM
Author(s): Rogers IS, Nasir K, Figueroa AL, et al.
Citation: JACC Cardiovasc Imaging 2010;3:388-397.
Clinical Trial: No
Related Resources
JACC Cardiovasc Img Article: Feasibility of FDG Imaging of the Coronary Arteries: Comparison Between Acute Coronary Syndrome and Stable Angina

Study Question: Is the presence of fluorodeoxyglucose (FDG) uptake within the ascending aorta and left main coronary artery (LM), measured using positron emission tomography (PET) a measure of plaque inflammation?
Methods: Twenty-five patients (10 acute coronary syndrome [ACS] and 15 stable coronary artery disease (CAD; STABLE) underwent cardiac computed tomographic angiography and PET imaging with 18-FDG after invasive angiography. Images were co-registered, and FDG uptake was measured at locations of interest for calculation of target-to-background ratios (TBRs). Additionally, FDG uptake was measured at the site of the lesion deemed clinically responsible for the presenting syndrome (culprit) by virtue of locating the stent deployed to treat the syndrome.
Results: Mean age was 57.9 ± 9.8 years and 72% were male; 20% of the ACS and 68% of the STABLE group had a history of CAD. The FDG uptake was higher in the ACS versus the STABLE groups in the ascending aorta (median TBR 3.30 vs. 2.43, p = 0.02), as well as the LM (2.48 vs. 2.00, p = 0.03). The TBR was greater for culprit lesions associated with ACS than for lesions stented for stable coronary syndromes (2.61 vs. 1.74, p = 0.02). Furthermore, the TBR in the stented lesions (in ACS and STABLE groups) correlated with C-reactive protein (r = 0.58, p = 0.04).
Conclusions: In patients with recent ACS, FDG accumulation is increased both within the culprit lesion as well as in the ascending aorta and LM. This observation provides evidence of up-regulation of activity within atherosclerotic plaques in ACS and supports intensification of efforts to refine PET methods to image coronary plaque inflammation.
Perspective: FDG PET imaging provides a measure of glycolysis, which is increased in inflamed tissues including atherosclerotic plaques. The finding of increased uptake in the left main and aorta in persons with ACS is consistent with pathologic studies and clinical observations that the presence of one or more unstable plaques probably identifies the ‘vulnerable patient.’ Melvyn Rubenfire, M.D., F.A.C.C.

Title: Proximal Endovascular Occlusion for Carotid Artery Stenting: Results From a Prospective Registry of 1,300 Patients
Topic: Interventional Cardiology
Date Posted: 4/12/2010 5:00:00 PM
Author(s): Stabile E, Salemme L, Sorropago G, et al.
Citation: J Am Coll Cardiol 2010;55:1661-1667.
Clinical Trial: No
Related Resources
JACC Article: Proximal Endovascular Occlusion for Carotid Artery Stenting: Results From a Prospective Registry of 1,300 Patients

Study Question: What is the outcome of unselected patients undergoing carotid artery stenting (CAS) using proximal endovascular occlusion (PEO)?
Methods: The authors reported the outcome of 1,300 patients who underwent CAS at a single Italian center using PEO. An independent neurological assessment was performed before the procedure and at 1 hour, 24 hours, and 30 days after the procedure.
Results: PEO was achieved using the MOMA device. The procedure was successful in all but four patients (procedural success 99.7%). The in-hospital complication rate was low and included five deaths (0.38%), six major strokes (0.46%), and five minor strokes (0.38%). There was no acute myocardial infarction. By 30 days of follow-up, there were two additional deaths and one patient had a minor stroke. The overall 30-day stroke and death incidence was 1.38% (n = 19) and was higher in the symptomatic patients compared with asymptomatic patients (30-day stroke and death 3.04% vs. 0.82%; p < 0.01). There was no significant difference in outcome of those at high surgical risk compared with those at average surgical risk. Independent predictors of adverse events were symptomatic status, operator experience, and hypertension.
Conclusions: CAS performed using PEO is safe and effective in an unselected patient population.
Perspective: CAS provides a similar long-term efficacy compared with CEA, but multiple studies have demonstrated a higher rate of procedural stroke with CAS. This study had one of the lowest rates of stroke described with CAS, and it would be important to evaluate if similar results can be reproduced across multiple centers. This study provides strong support for using PEO in patients undergoing CAS. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

[Chevychelov]

Title: Survival After Application of Automatic External Defibrillators Before Arrival of the Emergency Medical System: Evaluation in the Resuscitation Outcomes Consortium Population of 21 Million
Topic: Arrhythmias
Date Posted: 4/12/2010 5:00:00 PM
Author(s): Weisfeldt ML, Sitlani CM, Ornato JP, et al., on behalf of the ROC Investigators.
Citation: J Am Coll Cardiol 2010;55:1713-1720.
Clinical Trial: No
Related Resources
JACC Article: Survival After Application of Automatic External Defibrillators Before Arrival of the Emergency Medical System: Evaluation in the Resuscitation Outcomes Consortium Population of 21 Million

Study Question: Does bystander use of an automatic external defibrillator (AED) improve survival after out-of-hospital cardiac arrest (OHCA)?
Methods: The subjects of this study were 13,769 patients (median age 67 years) with OHCA who were entered into a registry during a 17-month period in 2005-2007. The relationship between AED use and survival to hospital discharge was analyzed.
Results: An AED was used before arrival of emergency medical system (EMS) personnel in 289/13,769 patients (2.1%). Survival in the overall group was 7%, compared to 24% when an AED was applied before EMS arrival and 38% when an AED shock was delivered before EMS arrival. By multivariate analysis that accounted for multiple potential confounding variables, the use of an AED before EMS arrival significantly increased the odds of survival by 80%.
Conclusions: The use of community-based AEDs in patients with OHCA improves survival.
Perspective: Prior observational studies on the value of community-based AEDs have reported conflicting results, with some studies reporting no impact on survival of patients with OHCA. However, a prospective, randomized, community-based study (the PAD trial) reported a 2-fold improvement in survival with the use of AEDs. The 1.8-fold survival benefit with AEDs in the present study confirms the results of the PAD trial in a larger population of patients. These results emphasize the importance of both early defibrillation and public education programs to improve survival after OHCA. Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: Contemporary Mortality Risk Prediction for Percutaneous Coronary Intervention: Results From 588,398 Procedures in the National Cardiovascular Data Registry
Topic: Interventional Cardiology
Date Posted: 4/14/2010
Author(s): Peterson ED, Dai D, DeLong ER, et al.
Citation: J Am Coll Cardiol 2010;Mar 31:[Epub ahead of print].
Clinical Trial: No
Related Resources
JACC Article: Contemporary Mortality Risk Prediction for Percutaneous Coronary Intervention: Results From 588,398 Procedures in the National Cardiovascular Data Registry

Study Question: What are the factors that predict mortality risk following percutaneous coronary intervention (PCI)?
Methods: Data from 181,775 procedures performed from January 2004 to March 2006 were used to develop risk models based on preprocedural and/or angiographic factors using logistic regression. These models were independently evaluated in two validation cohorts: contemporary (n = 121,183, January 2004 to March 2006) and prospective (n = 285,440, March 2006 to March 2007). Model discrimination and calibration were assessed in the overall population, within the two validation samples, and among select subpopulations of both of these groups.
Results: Overall, PCI in-hospital mortality was 1.27%, ranging from 0.65% in elective PCI to 4.81% in ST-segment elevation myocardial infarction patients. Multiple preprocedural clinical factors were significantly associated with in-hospital mortality. Angiographic variables provided only modest incremental information to preprocedural risk assessments. The overall National Cardiovascular Data Registry (NCDR) model, as well as a simplified NCDR risk score (based on eight key preprocedure factors), had excellent discrimination (c-index: 0.93 and 0.91, respectively). Discrimination and calibration of both risk tools were retained among specific patient subgroups, in the validation samples, and when used to estimate 30-day mortality rates among Medicare patients.
Conclusions: The authors concluded that risks for early mortality following PCI can be accurately predicted in contemporary practice.
Perspective: The authors used data from the NCDR CathPCI Registry, cosponsored by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions, and developed and validated contemporary models for assessing periprocedural PCI mortality risk. Each of these appear to have excellent predictive accuracy throughout the full spectrum of patient risk, and important patient subgroups. It is possible that these models will have multiple future applications including bedside risk estimation, comparison of hospital performance, and risk adjustment. Independent validation in other large PCI databases would provide additional support for clinical use of this model. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Effect of Noninsulin Antidiabetic Drugs Added to Metformin Therapy on Glycemic Control, Weight Gain, and Hypoglycemia in Type 2 Diabetes
Topic: Prevention/Vascular
Date Posted: 4/13/2010 4:00:00 PM
Author(s): Phung OJ, Scholle JM, Talwar M, Coleman CI.
Citation: JAMA 2010;303:1410-1418.
Clinical Trial: No
Study Question: What is the relative efficacy, risk of weight gain, and hypoglycemia associated with noninsulin antidiabetic drugs in patients with type 2 diabetes mellitus (DM) not controlled by metformin alone?
Methods: A literature search was conducted via MEDLINE and Cochrane CENTRAL through January 2010, as well as a manual search of references for additional relevant studies. Study selection included randomized controlled trials (RCTs) with at least 3 months’ duration, evaluating noninsulin antidiabetic drugs added to metformin in patients experiencing an inadequate response to maximized and stable (≥4 weeks at ≥1500 mg or maximally tolerated dose) metformin therapy. Mixed-treatment comparison meta-analysis was used to calculate the weighted mean difference for changes from baseline in glycosylated hemoglobin (HbA1c) and body weight and relative risk (RR) of HbA1c goal attainment and hypoglycemia.
Results: Overall, 27 RCTs (n = 11,198) were included. Mean (range) trial duration was 32 (12-52) weeks. The different classes of drugs were associated with similar HbA1c reductions (range, 0.64%-0.97%) compared with placebo. Although use of thiazolidinediones, sulfonylureas, and glinides were associated with weight gain (range, 1.77-2.08 kg), glucagon-like peptide-1 analogs, α-glucosidase inhibitors, and dipeptidyl peptidase-4 inhibitors were associated with weight loss or no weight change. Sulfonylureas and glinides were associated with higher rates of hypoglycemia than with placebo (RR range, 4.57-7.50).
Conclusions: When added to maximal metformin therapy, all noninsulin antidiabetic drugs were associated with similar HbA1c reductions, but differed in their associations with weight gain and risk of hypoglycemia.
Perspective: Weight gain and hypoglycemia are clearly important unintended consequences of hypoglycemic agents. The relative value of combining metformin with first and second generation hypoglycemics compared to the third and fourth generation agents, which are associated with weight loss and less hypoglycemia, needs to be assessed in clinical trials. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction
Topic: General Cardiology
Date Posted: 4/13/2010 4:00:00 PM
Author(s): Smolderen KG, Spertus JA, Nallamothu BK.
Citation: JAMA 2010;303:1392-1400.
Clinical Trial: No
Study Question: What is the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during acute myocardial infarction (AMI)?
Methods: This was a multicenter, prospective study using a registry of 3,721 AMI patients enrolled between April 2005, and December 2008, at 24 US hospitals. Health insurance status was categorized as: insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records, while financial concerns among those with health insurance were determined from structured interviews. The primary outcome measure was prehospital delay times (≤2 hours, >2-6 hours, or >6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.
Results: Of 3,721 patients, 2,294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (p < 0.001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21; 95% confidence interval, 1.05-1.41; p = 0.01) and with uninsured patients (adjusted odds ratio, 1.38; 95% confidence interval, 1.17-1.63; p < 0.001).
Conclusions: The authors concluded that lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
Perspective: The authors found that uninsured patients and insured patients with financial concerns about accessing medical treatment were more likely to delay seeking emergency care for AMI, a common presentation of coronary artery disease. These findings underscore important consequences from inadequate or absent health care insurance coverage for the substantial number of individuals in the United States experiencing AMIs. Efforts to reduce prehospital delays for AMI and other emergency conditions may have only limited benefit unless US health care insurance coverage is extended and improved. If financial concern about the cost of care can be eliminated or ameliorated, patients are more likely to present in a timely manner. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Remote Ischemic Conditioning Before Hospital Admission, as a Complement to Angioplasty, and Effect on Myocardial Salvage in Patients With Acute Myocardial Infarction: A Randomised Trial
Topic: Interventional Cardiology
Date Posted: 4/15/2010
Author(s): Bшtker HE, Kharbanda R, Schmidt MR, et al.
Citation: Lancet 2010;375:727-734.
Clinical Trial: yes
Study Question: Does remote ischemic conditioning, done before primary percutaneous coronary intervention (PPCI), increase myocardial salvage?
Methods: A total of 333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerized block randomization to receive PPCI with (n = 166 patients) versus without (n = 167) remote conditioning (intermittent arm ischemia through four cycles of 5-minute inflation and 5-minute deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to the hospital, and PPCI in the hospital. The primary endpoint was myocardial salvage index at 30 days after PPCI, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol.
Results: Eighty-two patients were excluded on arrival at the hospital because they did not meet inclusion criteria, 32 were lost to follow-up, and 77 did not complete the follow-up with data for salvage index. Median salvage index was 0.75 (interquartile range, 0.50-0.93; n = 73) in the remote conditioning group versus 0.55 (0.35-0.88, n = 69) in the control group, with median difference of 0.10 (95% confidence interval [CI], 0.01-0.22; p = 0.0333); mean salvage index was 0.69 (standard deviation, 0.27) versus 0.57 (0.26), with mean difference of 0.12 (95% CI, 0.01-0.21; p = 0.0333). Major adverse coronary events were death (n = 3 per group), reinfarction (n = 1 per group), and heart failure (n = 3 per group).
Conclusions: The authors concluded that remote ischemic conditioning before hospital admission increases myocardial salvage, and has a favorable safety profile.
Perspective: The current study shows that remote ischemic conditioning induced by intermittent upper-arm ischemia and done before PPCI, can attenuate reperfusion injury in patients with evolving myocardial infarction, thereby resulting in increased myocardial salvage. This protective effect seemed to be strongest in patients with totally occluded vessels and with infarcts in the left anterior descending artery, both of which were associated with almost double the area at risk. The effectiveness of remote conditioning after onset of target-organ ischemia could have implications for myocardial infarction and stroke treated with thrombolytics, but needs to be tested in large-scale clinical trials. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Association Between Admission Supine Systolic Blood Pressure and 1-Year Mortality in Patients Admitted to the Intensive Care Unit for Acute Chest Pain
Topic: Prevention/Vascular
Date Posted: 4/14/2010
Author(s): Stenestrand U, Wijkman M, Fredrikson M, Nystrom FH.
Citation: JAMA 2010;303:1167-1172.
Clinical Trial: No
Study Question: What is the relation between long-term mortality and admission blood pressure (BP) in patients admitted to the medical intensive care unit (ICU) for acute chest pain?
Methods: The authors evaluated the RIKS-HIA (Registry of Information and Knowledge About Swedish Heart Intensive Care Admissions) to analyze the association between long-term mortality and supine admission systolic BP in 119,151 patients who were treated at any Swedish ICU for the symptom of chest pain from 1997 through 2007. Patients were divided into quartiles of systolic BP Q1, <128 mm Hg; Q2, from 128 to 144 mm Hg; Q3, from 145 to 162 mm Hg; and Q4, ≥163 mm Hg. The main outcome measure was all-cause mortality.
Results: Mean follow-up was 2.47 years. The highest mortality was seen in the first quartile and the lowest in the fourth quartile. After adjusting for age, sex, smoking, diastolic BP, use of antihypertensive medication at admission and discharge, and use of lipid-lowering and antiplatelet medication at discharge, patients in the fourth quartile had the lowest 1-year mortality compared with quartile 2 (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.72-0.80), while the hazard was worse in quartile 1 (HR, 1.46; 95% CI, 1.39-1.52) and intermediate for Q3 (HR, 0.83; 95% CI, 0.79-0.87). The better prognosis in Q4 compared with Q2 was maintained in patients with a final diagnosis of angina or myocardial infarction (HR, 0.75; 95% CI, 0.71-0.80).
Conclusions: A higher systolic BP at admission in patients admitted to the ICU is associated with a better long-term survival.
Perspective: The association between a higher BP and better short-term outcome in patients with chest pain has been previously established (Khot, JAMA 2003). This study suggests that this association is valid for intermediate-term mortality. While high BP may be of prognostic importance in large hospitalized populations, its direct implication for patient care is somewhat unclear. Poorly controlled hypertension remains a major public health problem, and the results of this study should not distract from the need to ensure optimal BP control in all patients. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

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Title: Bupropion and Cognitive Behavioral Therapy for Weight-Concerned Women Smokers
Topic: Prevention/Vascular
Date Posted: 4/14/2010
Author(s): Levine MD, Perkins KA, Kalarchian MA, et al.
Citation: Arch Intern Med 2010;170:543-550.
Clinical Trial: yes
Study Question: Does a combination of bupropion and cognitive behavioral therapy enhance abstinence among weight-concerned women smokers?
Methods: This was a randomized double-blind placebo-controlled trial of women smokers who reported concern regarding weight gain, conducted between September 1999 and October 2005. All subjects, women between the ages of 18 and 65 years, expressed an interest in quitting smoking, smoked 10 or more cigarettes per day, and reported concerns about weight again after smoking cessation. All women received smoking cessation counseling. Subjects were randomized to one of two adjunctive counseling components, one of which was cognitive behavioral therapy, which included a focus on weight. Women were also randomized to bupropion or placebo for 6 months. The primary outcomes of interest were rates and duration of biochemically verified prolonged abstinence. Additional outcomes included point-prevalent abstinence, post-cessation weight gain, and changes in nicotine withdrawal, depressive symptoms, and weight concerns.
Results: A total of 349 women (86% white) were included in the study. Women in the cognitive behavioral therapy for smoking-related weight concerns plus bupropion group experienced higher rates of abstinence and longer time to relapse compared to those in the standard behavioral therapy plus bupropion group (34% vs. 21%, p = 0.05). At 12 months, rates of sustained abstinence did not differ between the two groups. For women receiving standard behavior therapy, women randomized to bupropion versus placebo, no differences in abstinence rates were observed at either 6 or 12 months. There were no significant differences in abstinent women in weight gain or weight concerns between the groups. Women randomized to standard behavioral therapy plus bupropion had greater decreases in nicotine withdrawal and depressive symptoms compared to women receiving standard behavioral therapy plus placebo.
Conclusions: The investigators concluded that among weight concerned women smokers, bupropion together with cognitive behavioral therapy, which included a focus on weight, was effective at sustained abstinence and was not associated with changes in weight postsmoking cessation.
Perspective: This study highlights the use of behavioral programs which meet the concerns of smokers. For women who may have concerns regarding possible weight gain with smoking cessation, a behavioral program that addresses such concerns makes sense. Combining therapy with pharmacologic agents such as bupropion appears to increase the rates of sustained abstinence, although abstinence rates at 12 months are not optimal, suggesting that further research on different frequencies or duration of counseling is needed. Elizabeth A. Jackson, M.D., F.A.C.C.

Title: Myeloperoxidase and C-Reactive Protein Have Combined Utility for Long-Term Prediction of Cardiovascular Mortality After Coronary Angiography
Topic: Prevention/Vascular
Date Posted: 4/14/2010
Author(s): Heslop CL, Frohlich JJ, Hill JS.
Citation: J Am Coll Cardiol 2010;55:1102-1109.
Clinical Trial: No
Related Resources
JACC Article: Myeloperoxidase and C-Reactive Protein Have Combined Utility for Long-Term Prediction of Cardiovascular Mortality After Coronary Angiography

Study Question: Do plasma levels of oxidative stress biomarkers predict cardiovascular (CV) mortality after coronary angiography?
Methods: Myeloperoxidase (MPO), nitrotyrosine, oxidized low-density lipoprotein, and antioxidant capacity were measured in a prospective cohort of 885 selective coronary angiography patients followed up for >13 years for CV mortality.
Results: MPO independently predicted coronary artery disease, and top tertile MPO levels predicted a 2.4-fold risk of CV mortality (95% confidence interval [CI], 1.47-2.98), compared with patients with lowest tertile MPO levels. MPO also improved risk model discrimination and patient risk category classification. Elevations in multiple oxidative stress biomarkers predicted increased mortality risk; however, the strongest risk prediction was achieved by assessing MPO and C-reactive protein (CRP) together. Patients with either MPO or CRP elevated had 5.3-fold higher CV mortality risk (95% CI, 1.86-14.9), and patients with high levels of both MPO and CRP had a 4.3-fold risk compared with patients with only elevated markers (95% CI, 2.26-8.31). These results remained significant, with adjustment for CV risk factors and baseline disease burden.
Conclusions: The authors concluded that MPO accurately predicted CV mortality risk in coronary angiography patients. Considering MPO and CRP together may improve long-term risk assessment and coronary artery disease patient outcomes.
Perspective: Atherosclerosis is a systemic, complex disorder, involving numerous biological pathways. Although targeting cholesterol metabolism with statin therapy has proved highly beneficial to the population at risk for complications of atherosclerosis, there remains residual risk, and additional biomarkers for risk stratifying patients and guiding existing and future treatment strategies are needed. Combinations of biomarkers reflecting different pathways involved in atherogenesis/plaque rupture may be particularly useful for assessing risk as demonstrated in this study; however, additional studies will be needed to determine clinical usefulness. Daniel T. Eitzman, M.D., F.A.C.C.

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Title: S38G Single-Nucleotide Polymorphism at the KCNE1 Locus Is Associated With Heart Failure
Topic: Heart Failure/Transplant
Date Posted: 4/15/2010
Author(s): Fatini C, Sticchi E, Marcucci R, et al.
Citation: Heart Rhythm 2010;7:363-367.
Clinical Trial: No
Study Question: What is the association of single-nucleotide polymorphism (SNP) S38G in KCNE1 with heart failure (HF)?
Methods: Investigators genotyped 197 out of 323 previously investigated patients, along with 352 healthy controls comparable for age and sex. This study was replicated in 186 HF patients and in 200 healthy subjects comparable for age and sex.
Results: A significant difference in genotype distribution and allele frequency between patients and controls was observed for the KCNE1 S38G SNP (p = 0.002 and p = 0.0008, respectively). The KCNE1 38G variant was associated with a significant predisposition to HF under a dominant (odds ratio [OR], 2.22 [1.23-3.28]; p = 0.008) and additive (OR, 2.13 [1.09-4.15]; p = 0.03) model, after adjustment for age, sex, and traditional cardiovascular risk factors. No difference in genotype distribution and allele frequency for the KCNE1 S38G SNP according to functional New York Heart Association class was found (p = 0.4 and p = 0.3, respectively). In the HF replication study, the KCNE1 38G allele frequency was significantly higher in comparison with that observed in the control population (38G = 0.59 vs. 0.49; p = 0.004). The 38G allele was associated with HF predisposition under the recessive (OR [95% confidence interval (CI)] 2.49 [1.45- 4.29]; p = 0.001) and additive models (OR [95% CI] 2.63 [1.29-5.35]; p = 0.008), after adjustment for traditional risk factors.
Conclusions: The KCNE1 S38G SNP is associated with predisposition to HF in two study populations.
Perspective: The S38G KCNE1 SNP may affect potassium current, leading to increased action potential duration. This SNP has been associated with predisposition to atrial fibrillation in some studies. The current study now suggests a possible association of this SNP with HF, presumably by affecting functional properties of ventricular myocytes, although the mechanism remains to be shown. Additional studies in larger populations with genome-wide data will be helpful to confirm this association. Daniel T. Eitzman, M.D., F.A.C.C.

Title: Modeled Economic Evaluation of Alternative Strategies to Reduce Sudden Cardiac Death Among Children Treated for Attention Deficit/Hyperactivity Disorder
Topic: Congenital Heart Disease
Date Posted: 4/15/2010
Author(s): Denchev P, Kaltman JR, Schoenbaum M, Vitiello B.
Citation: Circulation 2010;121:1329-1337.
Clinical Trial: No
Study Question: What is the cost-effectiveness of pretreatment screening with electrocardiogram (ECG) for reducing sudden cardiac death (SCD) risk in children with attention deficit/hyperactivity disorder (ADHD)?
Methods: A state-transition Markov model was constructed with 10 annual cycles spanning 7-17 years of age. Three strategies were studied: 1) performing a history and physical with cardiology referral if abnormal; 2) performing a history and physical with ECG if history and physical is normal and subsequent cardiology referral if either is abnormal; or 3) performing a screening history and physical with ECG, and referral only if ECG is abnormal. Multiple assumptions were made, most importantly that stimulants increase the risk of SCD in patients with heart disease by 10%. In the model, children with SCD-associated cardiac abnormalities would be restricted from competitive athletic activities and would not receive stimulants.
Results: The incremental cost-effectiveness of strategy 2 (history and physical followed by ECG if abnormal) was $39,300 per life saved. The incremental cost-effectiveness of strategy 3 (referral only if screening ECG was abnormal) was $27,300 per life saved. The expected cost benefits of screening were due mostly because of restriction from athletics as opposed to SCD as a result of stimulant use.
Conclusions: Adding ECG screening to history and physical pretreatment screening for children with ADHD has borderline cost-effectiveness for preventing SCD, with improved cost-effectiveness with ECG screening alone.
Perspective: This interesting economic analysis is limited by the large number (no less than 10) of significant assumptions made in constructing the statistical model. The most important of these is the premise underlying the study, that stimulants do in fact confer additional risk on children with underlying congenital heart disease. The authors acknowledge that this has not yet been demonstrated in the literature. Interestingly, this study shows overlap with another controversial issue, which is ECG screening prior to sports participation. This practice is common in some parts of Europe, but is not part of preparticipation screening in the United States. Most of the cost benefit of screening in this study came from the expected restriction from sports for children found to have structural heart disease, as opposed to the avoidance of stimulants. Timothy B. Cotts, M.D., F.A.C.C.

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Title: Attenuation of the Effect of the FTO rs9939609 Polymorphism on Total and Central Body Fat by Physical Activity in Adolescents: The HELENA Study
Topic: Prevention/Vascular
Date Posted: 4/16/2010
Author(s): Ruiz JR, Labayen I, Ortega FB, et al., on behalf of the HELENA Study Group.
Citation: Arch Pediatr Adolesc Med 2010;164:328-333.
Clinical Trial: No
Study Question: Does physical activity attenuate the effect of the FTO rs9939609 polymorphism on body fat in adolescents?
Methods: Data from the subjects enrolled in the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study were used for the present analysis. A total of 3,865 adolescents were recruited into the study, of which 1,155 provided blood samples; 752 of these were tested for the FTO rs9939609 polymorphism and had data on physical activity. Physical activity was assessed through accelerometry worn for between 3 and 7 days for at least 8 hours. Weight, height, waist circumference, and triceps and subscapular skinfold thickness were measured.
Results: A total of 752 (413 girls) were included in the study. The A allele of the FTO rs9939609 polymorphism was significantly associated with high body mass index (BMI) (+0.42 per risk allele), higher body fat percentage (+1.03% per risk allele), and higher waist circumference (+0.85 cm per risk allele). Significant or borderline gene-physical activity interactions were observed for BMI (p = 0.02), body fat percentage (p = 0.06), and waist circumference (p = 0.10). The effect of the FTO rs9939609 polymorphism on body fat was lower among adolescents who met daily physical activity recommendations (defined as 60 minutes per day or more of moderate to vigorous physical activity) compared with those who did not meet these activity guidelines. Results were similar for boys and girls.
Conclusions: The investigators concluded that adolescents who met daily physical activity recommendations may significantly reduce the effect of the FTO rs9939609 polymorphism on obesity.
Perspective: These data support recommendations for daily physical activity among children and adolescents. Further research such as randomized controlled trials to study the association of physical activity and body fat in relation to the FTO rs9939609 polymorphism would add to these current findings. Elizabeth A. Jackson, M.D., F.A.C.C.

Title: Prospective Randomized Comparison Between the Conventional Electroanatomical System and Three-Dimensional Rotational Angiography During Catheter Ablation for Atrial Fibrillation
Topic: Arrhythmias
Date Posted: 4/16/2010
Author(s): Knecht S, Wright M, Akrivakis S, et al.
Citation: Heart Rhythm 2010;7:459-465.
Clinical Trial: No
Study Question: Does three-dimensional rotational atriography (3DRA) affect the outcome of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) compared to electroanatomical mapping (EAM) systems?
Methods: Ninety-one patients (mean age 58 years) undergoing RFCA of AF (persistent in 63%) were randomly assigned to 3DRA (n = 47) or imaging with a Carto EAM system (n = 44). The RFCA strategy consisted of pulmonary vein isolation plus substrate modification as clinically indicated.
Results: There was no significant difference in the mean time required for 3DRA (14 minutes) versus creation of the Carto map (17 minutes). The mean procedure time was 224 minutes and did not differ significantly between the 3DRA and Carto groups. There was no significant difference in radiation exposure between the two groups. At a mean of 10 months of follow-up, 52% of patients were free of AF/flutter, with no significant difference between the two study groups.
Conclusions: 3DRA does not increase the amount of radiation exposure compared to an EAM system and does not affect the efficacy of RFCA of AF.
Perspective: In theory, a major advantage of 3DRA over EAM is that it provides an accurate, real-time reconstruction of the left atrium (LA) and pulmonary veins that is not operator dependent. Although EAM can be integrated with anatomically accurate computed tomography (CT) images of the LA, LA volume may have been different at the time of CT and CT exposes patients to more radiation than 3DRA. Disadvantages of 3DRA include its lack of advanced mapping functions and the need for a contrast agent. This study shows that either imaging modality can be used, depending on operator preference, without compromising clinical outcomes. Fred Morady, M.D., F.A.C.C.