Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Predictors for New-Onset Complete Heart Block After Transcatheter Aortic Valve Implantation
Topic: Cardiovascular Surgery
Date Posted: 6/4/2010
Author(s): Bleiziffer S, Ruge H, Hцrer J, et al.
Citation: JACC Cardiovasc Interv 2010;3:524-530.
Clinical Trial: No
Study Question: What are the risk factors for new-onset atrioventricular (AV) block requiring pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI)?
Methods: Between June 2007 and January 2009, 200 elderly patients >75 years of age underwent TAVI for symptomatic high-grade aortic stenosis at the author’s institution. For logistic regression analysis, they included 159 patients (mean age: 81 ± 6 years, EuroSCORE: 22 ± 13%) who underwent TAVI (n = 116 transfemoral, n = 4 via subclavian artery, n = 37 transapical, n = 2 transaortic) between June 2007 and January 2009 and who had no previously implanted PM.
Results: Thirty-five patients (22%) developed new-onset postoperative AV block with the need of PM implantation. Logistic regression revealed a twofold increased risk for new-onset AV block in patients in whom a large valve is implanted in a small annulus (32% pacemaker implantations; odds ratio [OR], 2.378; p = NS), a fourfold increased risk with the implantation of the CoreValve (Medtronic, Minneapolis, MN) versus the Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) (27% pacemaker implantations; OR, 3.781; p = NS), and a fivefold increased risk for patients who exhibit an AV block episode instantly during the implantation procedure (49% pacemaker implantations; OR, 4.819; p = 0.001). Pre-existing ECG alterations were not identified as risk factors for AV block after TAVI.
Conclusions: The authors concluded that conduction tissue impairment is provoked by mechanical compression with large prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract.
Perspective: This analysis suggests that valve-related AV block requiring pacemaker implantation is a frequent finding after TAVI that may occur in up to 22% of patients. The most important finding from this study is that patients who experience an AV block instantly in the operating room after balloon valvuloplasty or after valve deployment exhibit an almost fivefold risk to develop permanent AV block with the eventual need for pacemaker implantation. It appears that conduction tissue impairment is provoked by mechanical compression with relatively large balloons and prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract. Continuous postoperative ECG monitoring to detect high-grade AV block for at least 3 days appears prudent in all patients, and until discharge in patients with increased risk for this complication. A pacemaker may be indicated if episodes of high-grade AV block were diagnosed during the postoperative course. Debabrata Mukherjee, M.D., F.A.C.C.

[Chevychelov]

Title: Predictors for New-Onset Complete Heart Block After Transcatheter Aortic Valve Implantation
Topic: Cardiovascular Surgery
Date Posted: 6/4/2010
Author(s): Bleiziffer S, Ruge H, Hцrer J, et al.
Citation: JACC Cardiovasc Interv 2010;3:524-530.
Clinical Trial: No
Study Question: What are the risk factors for new-onset atrioventricular (AV) block requiring pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI)?
Methods: Between June 2007 and January 2009, 200 elderly patients >75 years of age underwent TAVI for symptomatic high-grade aortic stenosis at the author’s institution. For logistic regression analysis, they included 159 patients (mean age: 81 ± 6 years, EuroSCORE: 22 ± 13%) who underwent TAVI (n = 116 transfemoral, n = 4 via subclavian artery, n = 37 transapical, n = 2 transaortic) between June 2007 and January 2009 and who had no previously implanted PM.
Results: Thirty-five patients (22%) developed new-onset postoperative AV block with the need of PM implantation. Logistic regression revealed a twofold increased risk for new-onset AV block in patients in whom a large valve is implanted in a small annulus (32% pacemaker implantations; odds ratio [OR], 2.378; p = NS), a fourfold increased risk with the implantation of the CoreValve (Medtronic, Minneapolis, MN) versus the Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) (27% pacemaker implantations; OR, 3.781; p = NS), and a fivefold increased risk for patients who exhibit an AV block episode instantly during the implantation procedure (49% pacemaker implantations; OR, 4.819; p = 0.001). Pre-existing ECG alterations were not identified as risk factors for AV block after TAVI.
Conclusions: The authors concluded that conduction tissue impairment is provoked by mechanical compression with large prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract.
Perspective: This analysis suggests that valve-related AV block requiring pacemaker implantation is a frequent finding after TAVI that may occur in up to 22% of patients. The most important finding from this study is that patients who experience an AV block instantly in the operating room after balloon valvuloplasty or after valve deployment exhibit an almost fivefold risk to develop permanent AV block with the eventual need for pacemaker implantation. It appears that conduction tissue impairment is provoked by mechanical compression with relatively large balloons and prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract. Continuous postoperative ECG monitoring to detect high-grade AV block for at least 3 days appears prudent in all patients, and until discharge in patients with increased risk for this complication. A pacemaker may be indicated if episodes of high-grade AV block were diagnosed during the postoperative course. Debabrata Mukherjee, M.D., F.A.C.C.

[Chevychelov]

Title: Echocardiographic Dyssynchrony and Health Status Outcomes From Cardiac Resynchronization Therapy: Insights From the PROSPECT Trial
Topic: Noninvasive Cardiology
Date Posted: 6/7/2010
Author(s): Chan PS, Khumri T, Chung ES, et al.
Citation: JACC Cardiovasc Imaging 2010;3:451-460.
Clinical Trial: No
Study Question: What are the prognostic implications of mechanical dyssynchrony, as identified by echocardiography, for improvement in health status after cardiac resynchronization therapy (CRT)?
Methods: This is an analysis of data from a subset of 324 patients from the PROSPECT study, which originally evaluated 12 echocardiographic parameters as predictors of favorable remodeling and clinical response in patients with left ventricular systolic dysfunction and congestive heart failure (CHF). In this analysis of echocardiographic data, the parameters of interventricular mechanical delay (IVMD), left ventricular filling time (LVFT), and left ventricular pre-excitation interval (LVPI) were compared to clinical improvement as scored by the Kansas City Cardiomyopathy Questionnaire (KCCQ), which was administered to patients at baseline and 6 months after enrollment and scored as a continuous variable (0-100). The three echo parameters noted above were selected from the 12 previously defined dyssynchrony parameters on the basis of consistent availability.
Results: Mean patient age was 68 years and 71% were male. Mean QRS duration was 164 ± 23 ms and mean LV ejection fraction was 0.29. At baseline, KCCQ was 50.7 ± 19.5 and at 6 months was 70.9 ± 22.2. Categorical improvement in KCCQ was defined as 10.0 difference between baseline and 6 months. Wider QRS duration, beta-blocker use, and echocardiographic paramenters had a bivariate association with 6-month improvement in KCCQ following CRT. On multivariable analysis, IVMD ≥40 ms was associated with a +5.18 improvement in KCCQ and LVFT ≤40% with a 5.19 increase (each p ≤ 0.03). Clinical variables associated with 6-month improvement in KCCQ included male sex, lower baseline KCCQ, and use of beta-blockers. A ≥10 point increase in KCCQ was noted in 64% of patients with baseline KCCQ <25, 79% of those with baseline KCCQ 25-49, 61% of those with baseline KCCQ 50-74, and 38% of those with baseline KCCQ ≥75. Multivariable analysis suggested that IVMD ≥40 ms (odds ratio, 1.85), lower baseline KCCQ, and beta-blocker use were associated with CRT response. The risk of death was 76% lower in KCCQ responders than in those without favorable response.
Conclusions: At baseline, IVMD ≥40 ms and LVFT ≥40% are associated with improvement in health status at 6 months, as measured by the KCCQ.
Perspective: This is a revisit of data from the PROSPECT study, which evaluated 12 echocardiographic and Doppler parameters of LV dyssynchrony in patients with symptomatic heart failure in an effort to identify markers of clinical or anatomically favorable response to CRT. The original PROSPECT study used a fairly simple clinical endpoint, whereas the study reported here used a far more detailed analysis of patient symptomatic status. The original PROSPECT study concluded that no single echocardiographic variable was either reproducible enough or had the predictive value to be of clinical relevance in decision making. The study reported here, based on a subset of the same patients and using 3 of the original 12 parameters, identified an overall favorable clinical response in 65% of subjects (defined as ≥10 point increase in KCCQ). The original PROSPECT study revealed a 74% clinical response in individuals with IVMD ≥40 ms. In the original PROSPECT study, however, individuals with IVMD <40 ms had a 64% favorable response. The PROSPECT study was commonly criticized because of its failure to demonstrate an echocardiographic predictor of clinical or anatomical response to CRT. The current study refines the assessment of overall health and heart failure status and appears to suggest that the simpler Doppler-derived measures of mechanical dyssynchrony may be predictive of a favorable response. The authors provide a mathematical model including KCCQ scores, clinical variables, and measures of dyssynchrony for predicting a quantitative response to CRT, which will require future prospective evaluation. William F. Armstrong, M.D., F.A.C.C.

[Chevychelov]

Title: Bleeding Complications With Dual Antiplatelet Therapy Among Patients With Stable Vascular Disease or Risk Factors for Vascular Disease. Results From the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) Trial
Topic: General Cardiology
Date Posted: 6/8/2010
Author(s): Berger PB, Bhatt DL, Fuster V, et al., on behalf of the CHARISMA Investigators.
Citation: Circulation 2010;121:2575-2583.
Clinical Trial: No
Related Resources
Trial: Clopidogrel for High Atherothrombotic Risk, Ischemic Stabilization, Management, and Avoidance (CHARISMA )

Study Question: What are the incidence, implication, and outcomes associated with dual antiplatelet therapy (DAPT)?
Methods: The authors analyzed the outcome of patients enrolled in the CHARISMA trial who were randomized to DAPT. CHARISMA randomized patients with established stable vascular disease or multiple risk factors for vascular disease without established disease, to either aspirin or aspirin plus clopidogrel. Severe bleeding was defined by the GUSTO trial criteria, and comprised of fatal bleeding and intracranial hemorrhage, or bleeding causing hemodynamic compromise requiring blood or fluid replacement, inotropes, or surgery. Moderate bleeding was defined as bleeding requiring transfusion, but not meeting any of the severe bleeding criterion.
Results: Randomization to clopidogrel was associated with an increase in bleeding with severe bleeding occurring in 1.7% of the clopidogrel group versus 1.3% on placebo (p = 0.087), and moderate bleeding in 2.1% versus 1.3%, respectively (p < 0.001). The most common site of bleeding was gastrointestinal, followed by intracranial and bleeding related to surgical procedures. The risk of bleeding was greatest in the first year and patients who did not suffer moderate or severe bleeding during the first year were no more likely than placebo-treated patients to have bleeding subsequently. There was no difference in the frequency of bleeding in patients with established disease compared to those with risk factors only. Moderate bleeding was a strong predictor of subsequent all-cause mortality (hazard ratio, 2.55; 95% confidence interval, 1.71-3.80; p < 0.0001).
Conclusions: Use of DAPT is associated with an increased risk of bleeding, with the incremental risk associated with DAPT being concentrated in the first year.
Perspective: This important paper provides key data on long-term bleeding risk in patients on DAPT. The incremental risk of severe bleeding with DAPT versus aspirin alone was 0.4% and 0.8% with respect to moderate bleeding. Further, the additive risk of bleeding was concentrated in the first year. These data should be of immense help to physicians and patients weighing the risk–benefit ratio of DAPT. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

Title: Periprocedural Stroke and Management of Major Bleeding Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation. The Impact of Periprocedural Therapeutic International Normalized Ratio
Topic: Arrhythmias
Date Posted: 6/8/2010
Author(s): Di Biase L, Burkhardt JD, Mohanty P, et al.
Citation: Circulation 2010;121:2550-2556.
Clinical Trial: No
Study Question: What is the impact of a therapeutic international normalized ratio (INR) on stroke and bleeding complications during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF)?
Methods: A total of 6,454 patients (mean age 57 years) underwent RFCA of AF at nine centers. The patients were classified into three groups: group I: 8-mm-tip ablation catheter, off warfarin (n = 2,488); group II: open irrigated-tip catheter, off warfarin (n = 1,348); and group III: open irrigated-tip catheter, on warfarin with INR >2 (n = 2,618). Heparin was used in all groups to maintain an activated clotting time >350 seconds.
Results: The incidence of stroke and transient ischemic attack was significantly lower in group III (0%) than in groups I (1.1%) or II (0.9%). There was no significant difference in the risk of cardiac tamponade between the patients on or off warfarin (0.3% and 0.2%, respectively) or in the risk of major bleeding complication between the three groups (0.4, 0.8, and 0.4%, respectively in groups I-III). The mean amount of pericardial drainage was significantly higher in the patients on warfarin (1,200 cc) than in patients off warfarin (700 cc).
Conclusions: A therapeutic INR during RFCA of AF reduces the risk of cerebral thromboembolic complications without increasing the risk of cardiac tamponade or major bleeding complications.
Perspective: This important study demonstrates that maintaining a therapeutic INR with warfarin during RFCA of AF improves the safety profile of the procedure. The impact of warfarin on the amount of pericardial drainage can be minimized by emergent infusion of factor VII (which was not used in this study). Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: A Multimarker Approach to Assess the Influence of Inflammation on the Incidence of Atrial Fibrillation in Women
Topic: Arrhythmias
Date Posted: 6/8/2010
Author(s): Conen D, Ridker PM, Everett BM, et al.
Citation: Eur Heart J 2010;May 25:[Epub ahead of print].
Clinical Trial: No
Study Question: Does inflammation promote atrial fibrillation (AF) in women?
Methods: The subjects of this prospective study were 24,734 women (median age 53 years) free of cardiovascular disease and AF at entry who were followed for a median of 14.4 years. Blood samples at entry were analyzed for three biomarkers of inflammation: C-reactive protein, soluble intercellular adhesion molecule-1, and fibrinogen. An inflammation score of 0-3 was used to indicate the number of biomarkers in the highest tertile per individual.
Results: A first episode of AF occurred in 3% of women. Each of the three biomarkers was associated with the occurrence of AF (hazard ratio [HR], 1.10-1.11). Inflammatory scores of 1, 2, and 3 were independently associated with a progressively higher risk of AF (HRs of 1.37, 1.49, and 1.68, respectively).
Conclusions: Biomarkers of inflammation are independently associated with the onset of AF in women.
Perspective: There is mounting evidence that inflammation plays a role in new-onset AF, AF after open-heart surgery, and recurrent AF after cardioversion or catheter ablation. A proarrhythmic effect of inflammation may explain why non-antiarrhythmic agents that have anti-inflammatory effects, including statins and fish oil, have been shown to prevent AF in some studies. Fred Morady, M.D., F.A.C.C.

Title: Legal Risks of “Curbside” Consults
Topic: General Cardiology
Date Posted: 6/8/2010
Author(s): Cotton VR.
Citation: Am J Cardiol 2010;May 17:[Epub ahead of print].
Clinical Trial: No
Study Question: What are the medical-legal ramifications of curbside consults, and is there a role for them in medicine?
Methods: In this editorial, the author (a physician and lawyer) discusses the studies, court opinions, and implications of curbside consults. As background, a PubMed search was conducted for reports or studies on data, commentaries, or recommendations related to curbside consulting in medicine.
Results: One study showed that primary care physicians obtain an average of 3.2 curbside consults and specialists receive an average of 3.6 consults weekly. The most commonly curbsided specialties include cardiology, gastroenterology, and infectious disease. The most common reason for a curbside consult is to aid in determining appropriate patient testing and treatment and to determine need for formal consultation, but 81% of consults involve patients unknown to the consultant. Over 80% of specialists and 50% of primary care doctors found the information conveyed in a curbside consult inadequate.
Conclusions: The author provided a commentary on the risks and benefits of curbside consultation in medicine. To successfully sue for malpractice, a plaintiff must show that a doctor-patient relationship existed. Limiting a curbside to an informal discussion between two physicians reduces liability and courts have protected physicians in this role as a means of maintaining communication, education, and professional association amongst colleagues. Physicians on call for an emergency room, covering for another physician, or supervising other health care providers, are legally responsible for medical recommendations conveyed.
Perspective: Most physicians have participated in a curbside consultation at some point. In this profession, such intellectual banter is a source of physician communication and education, and can serve in the betterment of patient care at a potential reduced societal cost if provided guidance reduces unnecessary testing, unnecessary referral, or improves outcomes or lengths of stay (through recommendations for formal consultation or alone). The curbside, however, should be treated by the consultant and the colleague as an informal discussion. Complex patients and issues well beyond the nonspecialist’s expertise are likely best handled through formal consultation so all details can be ascertained and a care plan can be devised. Jennifer Cowger, M.D.

[Chevychelov]

Title: Asymptomatic Embolisation for Prediction of Stroke in the Asymptomatic Carotid Emboli Study (ACES): A Prospective Observational Study
Topic: Cardiovascular Surgery
Date Posted: 6/9/2010
Author(s): Markus HS, King A, Shipley M, et al.
Citation: Lancet Neurol 2010;May 28:[Epub ahead of print].
Clinical Trial: No
Study Question: What is the prognostic implication of asymptomatic embolic signals detected by transcranial doppler (TCD) with respect to future stroke risk in patients with asymptomatic carotid stenosis?
Methods: The authors reported the results of the Asymptomatic Carotid Emboli Study (ACES).The study enrolled 482 patients with asymptomatic carotid stenosis of at least 70% from 26 centers worldwide. All patients had two 1-hour TCD recordings from the ipsilateral middle cerebral artery at baseline and one 1-hour recording at 6, 12, and 18 months. Patients were followed for 2 years. The primary endpoint was the occurrence of ipsilateral stroke and transient ischemic attack (TIA).
Results: Of the 482 patients who were recruited, 467 had evaluable recordings. Embolic signals were present in 77 (16%) patients at baseline. Presence of embolic signals at baseline was associated with an increased risk of future ipsilateral stroke and TIA over the next 2 years (hazard ratio [HR], 2.54; 95% confidence interval [CI], 1.20-5.36; p = 0.015) and ipsilateral stroke (HR, 5.57; 95% CI, 1.61-19.32; p = 0.007). The absolute annual risk of ipsilateral stroke or TIA between baseline and 2 years was 7.13% in patients with embolic signals compared with 3.04% in those without. The absolute risk of ipsilateral stroke was 3.62% in patients with embolic signals and 0.70% in those without. The presence of embolic signal at the start of a 6-month study period conferred an absolute annual risk of ipsilateral stroke of 5.50% compared with 0.89% in those without embolic signals. The positive predictive value of embolic signals for prediction of ischemic cerebral embolic events was 94.2%, and the negative predictive value was 14.6%.
Conclusions: Detection of asymptomatic embolization on TCD can identify patients with asymptomatic carotid stenosis who are at a higher risk of stroke and TIA.
Perspective: This study provides corroboration to smaller earlier studies and establishes a role for TCD in detecting patients at the greatest risk from subsequent ischemic events from asymptomatic carotid stenosis. While the absolute risk of stroke in patients with asymptomatic carotid stenosis is low, it can be reduced further by carotid endarterectomy (CEA). The upfront risk of death and stroke associated with CEA makes this a challenging trade off since a large number of patients need to undergo CEA to reduce the risk of stroke that might occur only in a small subset. If the negative and positive predictive value of TCD demonstrated in this study can be validated in larger studies, one can envision a strategy of following patients with carotid stenosis with TCD, treating most patients medically and reserving revascularization for those with evidence of embolization. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

Title: Effect of High-Dose Allopurinol on Exercise in Patients With Chronic Stable Angina: A Randomised, Placebo Controlled Crossover Trial
Topic: General Cardiology
Date Posted: 6/7/2010 8:00:00 PM
Author(s): Noman A, Ang DS, Ogston S, Lang CC, Struthers AD.
Citation: Lancet 2010;June 8:[Epub ahead of print].
Clinical Trial: yes
Study Question: Does high-dose allopurinol prolong exercise capability in patients with chronic stable angina?
Methods: A total of 65 patients (ages 18-85 years) with angiographically documented coronary artery disease, a positive exercise tolerance test, and stable chronic angina pectoris (for at least 2 months) were recruited into a double-blind, randomized, placebo-controlled, crossover study conducted in the United Kingdom. Patients were assigned to allopurinol (week 1, 100 mg/d; week 2, 300 mg/d; then 300 mg twice daily) or placebo for 6 weeks before crossover. Primary endpoint was the time to ST depression, and the secondary endpoints were total exercise time and time to chest pain using a completed case analysis.
Results: Mean age was 64 years and 83% were men; 70% were Canadian Cardiovascular Society (CCS) angina class II, and 15% CCS I and III; 84% had ≥2-vessel disease and 85% had normal left ventricular ejection fraction (LEVF). Concomitant antianginal treatment: 87% beta-blockers, 58% nitrates, 22% calcium channel blockers, and 22% nicorandil. Allopurinol increased the median time to ST depression to 298 s (interquartile range [IQR], 211-408) from a baseline of 232 s (182-380), and placebo increased it to 249 s (200-375; p = 0.0002). The point estimate (absolute difference between allopurinol and placebo) was 43 s (95% confidence interval [CI], 31-58 s). Allopurinol increased median total exercise time to 393 s (IQR, 280-519s) from a baseline of 301 s (251-447), and placebo increased it to 307 s (232-430; p = 0.0003); the point estimate was 58 s (95% CI, 45-77). Allopurinol increased the time to chest pain from a baseline of 234 s (IQR, 189-382) to 304 s (222-421), and placebo increased it to 272 s (200-380; p = 0.001); the point estimate was 38 s (95% CI, 17-55). No adverse effects of treatment were reported.
Conclusions: Allopurinol seems to be a useful, inexpensive, well-tolerated, and safe anti-ischemic drug for patients with angina.
Perspective: The absolute increase in median time to ST depression with allopurinol of 43 s (10% increase) is similar to classic antianginal drugs: amlodipine 36 s (13%), nitrates 60 s (11%), and about 50 s (15%) with atenolol and ranolazine. Inhibiting xanthine oxidase with allopurinol has been shown to decrease myocardial oxygen demand per unit of cardiac output, improve endothelial function, and reduce afterload, each of which may help explain its anti-ischemic and antianginal effect. The results are impressive in light of the use of beta-blockers in 87%. Of course the safety and efficacy of allopurinol, particularly 600 mg daily, needs to be assessed in a much larger cohort. It is possible that this very inexpensive generic drug will reduce the need for revascularization, improve quality of life, and also reduce coronary events. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Detection of Depression in Cardiac Inpatients: Feasibility and Results of Systematic Screening
Topic: Prevention/Vascular
Date Posted: 6/7/2010
Author(s): Sowden G, Mastromauro CA, Januzzi JL, Fricchione GL, Huffman JC.
Citation: Am Heart J 2010;159:780-787.
Clinical Trial: No
Study Question: A recent American Heart Association (AHA) Prevention Committee report recommended depression screening of all coronary heart disease patients using two- and nine-item instruments from the Patient Health Questionnaire (PHQ-2 and PHQ-9) to identify patients who may need further assessment and treatment. What is the feasibility and result of such screening on inpatient cardiac units?
Methods: The PHQ-2 was added to the nursing interview data set on three cardiac units in a general hospital; this screen was completed as part of routine clinical care. Screened patients with a PHQ-2 score ≥3 were approached for further depression evaluation (PHQ-9) by a social worker. Rates and results of depression screening, reasons for patients not being screened, and patient acceptance were determined.
Results: For a 12-month period, 4,783 patients were admitted to the cardiac units; 3,504 (73.3%) received PHQ-2 depression screening. The most common reason for not screening was confusion or sedation (21% intensive care unit, 4% in step down). Mean age of all patients was 65.7 years (standard deviation, 14.6 years), and 63.1% of subjects were men. 8.7% had a PHQ-2 score ≥3; 74.1% of the positive-screen patients had a PHQ-9 score of ≥10, suggestive of major depression. Only 53.7% of patients with a PHQ-2 score of 3 had a PHQ-9 score ≥10, compared to 87.1% of those with a PHQ-2 = 6. Nurses (n = 66) reported high satisfaction with the screening process, and mean reported PHQ-2 screening time was 1.4 (±1.1) minutes.
Conclusions: Systematic depression screening of cardiac patients using methods outlined by the AHA Prevention Committee is feasible, well-accepted, and does not appear markedly resource-intensive. Future studies should link these methods to an efficient and effective program of depression management in this vulnerable population.
Perspective: The PHQ-9 is a nine-item depression scale that awards 0-3 points for each question. The nine items are based directly on the nine diagnostic criteria for major depressive disorder. A score of ≥10 is associated with a moderate likelihood of depression and ≥14 a high likelihood. Screening with the PHQ-2 is a validated approach. The two questions address depressed mood and anhedonia in the preceding 2 weeks. Only 9% of subjects in this study had positive PHQ-2 scores, compared to depression rates of at least 15% in other studies of cardiac patients in both the inpatient and outpatient settings. This may be related to the study protocol design to have the PHQ-2 administered during nursing intake. It is also not clear why a social worker was used to help complete the PHQ-9 rather than the patient alone. While patient acceptance was fine, further studies are necessary to help identify the optimal timing for both compliance and accuracy. For example, while 15-20% of patients with an acute coronary syndrome have depression at 4 weeks post-discharge, one-third are new since discharge and a similar number who tested positive in the hospital are no longer depressed. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Impact of Pressure Recovery on Echocardiographic Assessment of Asymptomatic Aortic Stenosis: A SEAS Substudy
Topic: Noninvasive Cardiology
Date Posted: 6/9/2010 5:00:00 PM
Author(s): Bahlmann E, Cramariuc D, Gerdts E, et al.
Citation: JACC Cardiovasc Img 2010;3:555-562.
Clinical Trial: No
Related Resources
Trial: Simvastatin and Ezetimibe in Aortic Stenosis (SEAS)

Study Question: What is the diagnostic importance of pressure recovery in the evaluation of aortic stenosis (AS) severity?
Methods: Data from 1,563 patients in the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) study were used. Inner aortic diameter was measured at the annulus, sinuses of ********, sinotubular junction, and supracoronary level. Aortic valve area index (AVAI) was calculated by the continuity equation, and pressure recovery and pressure recovery adjusted AVAI (energy loss index [ELI]) were calculated by validated equations. Primarily, sinotubular junction diameter was used to calculate pressure recovery and ELI, but pressure recovery and ELI calculated at different aortic root levels were compared. Severe AS was identified as AVAI and ELI ≤0.6 cm2/m2. Patients were grouped in tertiles of peak transaortic velocity.
Results: Pressure recovery increased with increasing peak transaortic velocity. Overestimation of AS severity by unadjusted AVAI was largest in the lowest tertile, and if pressure recovery was assessed at the sinotubular junction. In multivariate analysis, a larger difference between AVAI and ELI was associated with lower peak transaortic velocity (beta = 0.35) independent of higher left ventricular ejection fraction (beta = -0.049), male sex (beta = -0.075), younger age (beta = 0.093), and smaller aortic sinus diameter (beta = 0.233) (multiple R2 = 0.18, p < 0.001). Overall, 47.5% of patients classified as having severe AS by AVAI were reclassified to nonsevere AS when pressure recovery was taken into account.
Conclusions: For accurate assessment of AS severity, pressure recovery adjustment of AVA should be routinely performed. Estimation of pressure recovery at the sinotubular junction is suggested.
Perspective: Success can breed complacency. Doppler echocardiography has been appropriately accepted as the ‘gold standard’ for hemodynamic assessment of heart valve disease. Exceptions to the rules, instances in which echo/Doppler substantially under- or over-estimates transvalvular stenosis severity, have been well described, but are clinically neglected. Since its early recognition as a factor in Doppler estimation of valve stenosis, pressure recovery has taken on the role of a curiosity, occurring only in certain unusual clinical settings. However, this study serves as a wake-up call. Echo/Doppler rightly deserves to be the ‘gold standard’ for the assessment of valve hemodynamics, but it must be done right. If pressure recovery accounts for a change in the clinical grade of AS severity in a substantial number of patients with AS, then considering the impact of pressure recovery should become routine practice in the clinical echocardiography laboratory. The bad news is that a little bit of physics might have to find its way back into the world of cardiology. David S. Bach, M.D., F.A.C.C.

Title: Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction
Topic: General Cardiology
Date Posted: 6/9/2010 5:00:00 PM
Author(s): Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS.
Citation: N Engl J Med 2010;362:2155-2165.
Clinical Trial: No
Study Question: Have trends in the incidences and outcomes related to acute myocardial infarction (AMI) changed in recent times?
Methods: Data from Kaiser Permanente Northern California, a large, community-based population of patients hospitalized for AMI, were used for the present analysis. Patients were included if they were 30 years or older and experienced an AMI between 1999 and 2008. Patient characteristics, outpatient medications, and cardiac biomarker levels were identified from health plan databases. Mortality (30-day) was assessed through administrative databases, state death data, and Social Security Administration files. The outcomes of interest were age- and sex-adjusted incident rates of AMI, ST-elevation myocardial infarction (STEMI), and non-STEMI (NSTEMI).
Results: A total of 46,086 hospitalizations for AMI over 18,691,131 person-years of follow-up (from 1999 to 2008) were included. The majority of AMIs were NSTEMIs (66.9%) and 33.1% were STEMIs. The proportion of STEMIs decreased over time, from 47% in 1999 to 22.9% in 2008. Age- and sex-adjusted incidence of MI increased from 274 cases per 100,000 person-years in 1999 to 287 cases per 100,000 person-years in 2000, after which a decline was observed to 208 cases per 100,000 person-years in 2008. This represented a 24% relative decrease over the time period examined. For STEMI, both the age- and sex-adjusted incident rate decreased over time from 133 cases per 100,000 person-years in 1999 to 50 cases per 100,000 person-years in 2008. The incidence of NSTEMI increased from 155 cases per 100,000 person-years in 1999 to 202 cases per 100,000 person-years in 2004, after which rates decreased. In more recent years, patients hospitalized with AMI were more likely to be older, female, and have coexisting illness including hypertension, diabetes mellitus, and dyslipidemia. The number of patients who underwent revascularization procedures within 30 days after AMI increased from 40.7% in 1999 to 47.2% in 2008. For patients admitted with STEMI, the rates of revascularization increased from 49.4% in 1999 to 69.6% in 2008. For patients with NSTEMI, the rates of revascularization increased from 33.4% in 1999 to 41.3% in 2008. Age- and sex-adjusted 30-day mortality decreased from 10.5 in 1999 to 7.8% in 2008. This decrease was largely due to a reduction in case fatality rates for NSTEMI (from 10.0% in 1999 to 7.6% in 2008). No significant changes were observed for STEMI. The adjusted odds of 30-day mortality in 2008 as compared to 1999 was 0.76 (95% confidence interval [CI], 0.65-0.89). The adjusted odds of 30-mortality over time for patients with NSTEMI was 0.82 (95% CI, 0.67-0.99) and the odds of 30-mortality over time for patients with STEMI was 0.93 (95% CI, 0.71-1.20).
Conclusions: The investigators concluded that in this population, the incidence of AMI has decreased over time with a significant reduction in the incidence of STEMI as well as a lower death rate after NSTEMI. Potential factors related to the decline in AMI rates include smoking bans, and improved management of blood pressure and lipids.
Perspective: These data demonstrated an encouraging trend in the reduction of AMI. However, continued efforts to prevent AMI, in particular NSTEMI, are warranted. Given the prevalence of obesity and related cardiac risk factors such as hypertension and diabetes mellitus, continued aggressive prevention measures combined with monitoring of population trends are needed. Elizabeth A. Jackson, M.D., F.A.C.C.

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Title: Complications Associated With Revision of Sprint Fidelis Leads: Report From the Canadian Heart Rhythm Society Device Advisory Committee
Topic: Arrhythmias
Date Posted: 6/10/2010
Author(s): Parkash R, Crystal E, Bashir J, et al.
Citation: Circulation 2010;121:2384-2387.
Clinical Trial: No
Study Question: What is the complication rate associated with revision of Sprint Fidelis leads?
Methods: All Canadian centers that implant implantable cardioverter defibrillators (ICDs) were surveyed to determine the complications associated with revision of a Sprint Fidelis lead.
Results: A total of 6,237 Sprint Fidelis leads were implanted in 2004-2007. During 40 months of follow-up, 310 leads (5.0%) were revised because of a lead fracture and 158 leads were revised for other reasons. Among the 468 leads that were revised, 53% were explanted. The overall complication rate was 14.5%, and 50% of the complications were major: death in 0.4% of patients, cardiac arrest in 0.4%, superior vena cava tear in 0.2%, and other complications that required reoperation in 6.2%. There was no significant difference in the rate of major complications or death between patients who did and did not undergo lead extraction.
Conclusions: A high complication rate of approximately 15% associated with lead revision should be taken into account when deciding whether to prophylactically revise a Sprint Fidelis lead that is functioning normally.
Perspective: The incidence of fracture of the Sprint Fidelis lead initially was estimated to be 1-1.5%/year, but the incidence has increased over time and now appears to be 2-3%/year. The most common clinical consequence of lead fracture is inappropriate shocks, and fortunately the risk of syncope or death resulting from lead failure has been very low (<0.1%). In light of the 15% complication rate associated with lead revision, the risk:benefit ratio of lead revision currently favors close observation of Sprint Fidelis leads that show no signs of malfunction. Fred Morady, M.D., F.A.C.C.

Title: Association of Estimated Glomerular Filtration Rate and Albuminuria With All-Cause and Cardiovascular Mortality in General Population Cohorts: A Collaborative Meta-Analysis
Topic: General Cardiology
Date Posted: 6/10/2010
Author(s): Chronic Kidney Disease Prognosis Consortium.
Citation: Lancet 2010;May 18:[Epub ahead of print].
Clinical Trial: No
Study Question: What are the independent and combined associations of estimated glomerular filtration rate (eGFR) and albuminuria with mortality?
Methods: In this collaborative meta-analysis of general population cohorts, the investigators pooled standardized data for all-cause and cardiovascular mortality from studies containing at least 1,000 participants and baseline information about eGFR and urine albumin concentrations. Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality associated with eGFR and albuminuria, adjusted for potential confounders.
Results: The analysis included 105,872 participants (730,577 person-years) from 14 studies with urine albumin-to-creatinine ratio (ACR) measurements and 1,128,310 participants (4,732,110 person-years) from seven studies with urine protein dipstick measurements. In studies with ACR measurements, risk of mortality was unrelated to eGFR between 75 ml/min/1.73 m2 and 105 ml/min/1.73 m2 and increased at lower eGFRs. Compared with eGFR 95 ml/min/1.73 m2, adjusted HRs for all-cause mortality were 1.18 (95% CI, 1.05-1.32) for eGFR 60 ml/min/1.73 m2, 1.57 (1.39-1.78) for 45 ml/min/1.73 m2, and 3.14 (2.39-4.13) for 15 ml/min/1.73 m2. ACR was associated with risk of mortality linearly on the log-log scale without threshold effects. Compared with ACR 0.6 mg/mmol, adjusted HRs for all-cause mortality were 1.20 (1.15-1.26) for ACR 1.1 mg/mmol, 1.63 (1.50-1.77) for 3.4 mg/mmol, and 2.22 (1.97-2.51) for 33.9 mg/mmol. eGFR and ACR were multiplicatively associated with risk of mortality without evidence of interaction. Similar findings were recorded for cardiovascular mortality and in studies with dipstick measurements.
Conclusions: The authors concluded that eGFR less than 60 ml/min/1.73 m2 and urine ACR 1.1 mg/mmol (10 mg/g) or more are independent predictors of mortality risk in the general population.
Perspective: This meta-analysis, which included more than 100,000 individuals, showed that eGFR and albuminuria were associated with all-cause mortality and cardiovascular mortality independently of each other and traditional cardiovascular risk factors. These findings provide a quantitative basis for use of these two kidney measures for risk assessment and definition and staging of chronic kidney disease. These easy to use and widely applicable markers of risk require additional prospective evaluation. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Duration of Red Cell Storage Before Transfusion and In-Hospital Mortality
Topic: General Cardiology
Date Posted: 6/10/2010
Author(s): Eikelboom JW, Cook RJ, Liu Y, Huddle NM.
Citation: Am Heart J 2010;159:737-743.
Clinical Trial: No
Study Question: What is the association between duration of pretransfusion storage of red cells and in-hospital mortality?
Methods: The authors used multivariable Cox regression modeling with time-dependent stratification to assess the effect of age of transfused red blood cells on risk of in-hospital mortality in a registry of consecutive patients admitted to an acute care facility with a major diagnosis of cardiovascular disease. The primary outcome was in-hospital mortality.
Results: Four thousand nine hundred thirty-three consecutive patients with a major diagnosis of cardiovascular disease admitted to acute care facilities in Hamilton, Canada, received 21,435 units of red cells. The median number of units received was 3 (interquartile range 2-5), and the median age of transfused blood was 17 (interquartile range 13-22) days. After adjustment for demographics, clinical characteristics, and time-dependent covariates and stratification by the number of units transfused, the relative risk for death was 1.02 for every 1-day increase in maximum age of blood. The adjusted relative risk for death increased with each increasing quartile of maximum age of blood, with patients in the highest quartile having a relative risk for death of 1.48 (95% confidence interval, 1.07-2.05) compared with those in the lowest (reference) quartile.
Conclusions: The authors concluded that in hospitalized patients with a major diagnosis of cardiovascular disease, there is a modest independent association between increasing duration of storage of red cells and risk of in-hospital mortality.
Perspective: This study suggests a modest independent association between increasing maximum age of red cells and risk of in-hospital mortality in patients with a major diagnosis of cardiovascular disease. The results should prompt research to develop improved methods of red cell storage, rejuvenation, and delivery. Further studies of the effect of age of red blood cells on mortality are also needed to accurately quantify the risk in other patient populations and explore the mechanisms of the association. Meanwhile, it would seem logical to develop regional and national networks to study how transfusion is currently being used and how to make it safer by reserving transfusions only for occasions in which clinical evidence demonstrates that the overall benefit of blood transfusions outweighs the potential risks. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Prognostic Significance of Strain Doppler Imaging in Light-Chain Amyloidosis
Topic: Noninvasive Cardiology
Date Posted: 6/11/2010
Author(s): Koyama J, Falk RH.
Citation: JACC Cardiovasc Img 2010;3:333-342.
Clinical Trial: No
Study Question: What is the prognostic relevance of strain and strain rate imaging in patients with light-chain (AL) amyloidosis both with and without clinical evidence of congestive heart failure (CHF)?
Methods: Detailed echocardiography and Doppler, tissue velocity imaging (TVI) for strain, and strain rate were performed in 119 patients with biopsy-proven AL amyloidosis. Patients were excluded for a history of significant hypertension or valvular heart disease. TVI was performed in basal, mid, and apical segments in the anterior, lateral, septal, and inferior walls. Cardiac amyloid (CA) was considered present if left ventricular (LV) wall thickness was >12 mm.
Results: There was no echo evidence of CA in 49 patients (Group 1). Thirty-three patients had echo evidence of CA but no clinical evidence of CHF (Group 2), and the remaining 37 had both clinical CHF and CA (Group 3). Diastolic LV wall thickness was 10.2 ± 1.2, 14.5 ± 1.8, and 15.8 ± 2.7 mm in Groups 1, 2, and 3, respectively (p < 0.0001 for Groups 2/3 vs. 1). Fractional shortening was lower in Group 3 (28.2 ± 9.6%) compared to Groups 1 and 2 (42.7 ± 7.9 and 41.3 ± 8.6%, p < 0.0001) and left atrial dimension was larger in Group 3 than Group 1 (46.6 ± 6.9 vs. 41.5 ± 7.5 mm, p < 0.0001). Mitral E/A ratio was substantially higher in Group 3 (2.71 ± 1.15) than in either Group 1 (1.08 ± 0.51) or Group 2 (1.15 ± 0.72) (both comparisons p < 0.0001). With TVI, peak systolic velocity was similar in Groups 1 and 2 across all sites, but was lower in Group 3 at the base and mid LV. Average strain in basal segments was -18.3 ± 4.9 in Group 1, -13.9 ± 5.0 in Group 2, and -6.5 ± 4.3 in Group 3 (p < 0.001 compared to Groups 1 and 2), with similar trends seen for mid and apical strain. There were 39 deaths during a mean follow-up of 285 ± 136 days, 22 of which were either sudden or related to CHF. Stepwise regression revealed that mean basal strain, TVI-E-apex, and mitral valve deceleration time were independent predictors of death, but that the only independent predictor on multivariable analysis was basal systolic strain. Receiver operating characteristic analysis suggested basal strain of -13% was the optimal cut-off value for the whole group as well as for the two groups without clinical CHF (Groups 1 + 2). Within the CHF group (Group 3), basal strain value of <-4.6 predicted all-cause mortality.
Conclusions: Among patients with AL amyloidosis, mean basal strain is an independent and powerful predictor of all-cause mortality and is superior to standard two-dimensional echocardiographic and Doppler flow measurements.
Perspective: Measures of myocardial deformation including strain, strain rate, and torsion have been applied to patients with known or suspected CA. Previous studies have suggested that subclinical CA can be identified using these sophisticated measures. Previous studies have also suggested the prognostic relevance of diastolic dysfunction and other echocardiographic parameters in patients with documented cardiac amyloidosis. This study evaluated a consecutive series of 119 patients, none of whom had significant underlying hypertensive cardiovascular disease, atrial fibrillation, or valvular heart disease and identified basal strain using TDI as an independent predictor of both all-cause and cardiac mortality. Both tissue Doppler imaging and speckle tracking techniques can be used to determine strain and strain rate at multiple levels of the left ventricle. It should be emphasized that in this study, it was only the basal strain values that retained prognostic relevance. Absolute strain and strain rate values are location dependent within the left ventricle and will be platform and technique dependent as well. As such, the threshold identified as optimal in this study (-13%) may not translate to clinical practice using other techniques such as speckle tracking or even other ultrasound platforms. As sophisticated measures of myocardial deformation have clearly shown promise for detection of preclinical amyloid not otherwise identified by echocardiography and for prognostic purposes, the next logical extension of this type of study will be to identify changes in myocardial mechanics related to therapy designed to combat amyloidosis. William F. Armstrong, M.D., F.A.C.C.

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Title: Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches. A Scientific Statement From the American Heart Association
Topic: Cardiovascular Surgery
Date Posted: 6/14/2010
Author(s): Coady MA, Ikonomidis JS, Cheung AT, et al., on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia and Council on Peripheral Vascular Disease.
Citation: Circulation 2010;121:2780-2804.
Clinical Trial: No
Perspective: The following are 10 points to remember from the American Heart Association (AHA) Scientific Statement on surgical management of descending thoracic aortic disease (TAD).

1. Descending TAD is increasingly recognized, composed of distinct etiologies with predictable and well defined clinical behaviors.

2. Historically, surgical intervention for descending TAD has been associated with high rates of paraplegia and mortality. However, in recent years, particularly at high-volume centers, mortality (4-9%) and paraplegia (<3%) rates have improved.

3. Endovascular thoracic aortic stent grafts are an attractive treatment option in descending TAD due to lower published risks of mortality and paraplegia, particularly in the high surgical risk groups (i.e., the elderly and those with significant chronic obstructive pulmonary disease).

4. Though technically feasible in a variety of clinical settings, some considerations for the broad application of stent grafting in descending TAD include:
Lack of long-term data on durability (>5 years).
Lack of prospective randomized trials to directly compare open and endovascular therapy.
Re-intervention rates, primarily for endoleak, are not insignificant.
Risk of stroke approaches 4%.
Frequent need for left subclavian bypass procedures in order to secure adequate landing zones.

5. Patients with the Marfan syndrome or other connective tissue diseases were excluded from stent-graft trials and are not ideal candidates for stent grafting.

6. Though feasible in most cases, stent graft therapy of thoracic aortic aneurysm should not be performed at aortic sizes smaller than what is recommended for traditional surgery. Patient selection should be based on lack of candidacy for open surgery, life expectancy, and anatomic suitability.

7. Traditional surgery for complicated acute type B dissection carries significant morbidity and mortality. Endovascular therapy is emerging as an alternative with high rates of technical success, false lumen thrombosis, and low complication rates.

8. Prophylactic stent grafting to prevent complications of chronic type B dissection is compared to medical management in the INSTEAD and ABSORB trials, but long-term data are not yet available.

9. Stent grafting can be performed as an alternative to high-risk surgery in intramural hematoma and penetrating atherosclerotic ulcers (PAUs) in the descending aorta. Stent grafting of PAU is associated with higher complication rates due to the diffuse nature of atherosclerotic disease. The risk of endoleak is higher in these patients.

10. Treatment of traumatic aortic transaction with stent grafts is an alternative to surgery in high-risk cases. However, in this younger population, questions remain regarding graft durability, impact of frequent imaging, and radiation exposure, and long-term consequences of left subclavian coverage (required in an estimated 80% of cases). Anna M. Booher, M.D.

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Title: Angiotensin-Receptor Blockade and Risk of Cancer: Meta-Analysis of Randomised Controlled Trials
Topic: General Cardiology
Date Posted: 6/14/2010
Author(s): Sipahi I, Debanne SM, Rowland DY, Simon DI, Fang JC.
Citation: Lancet Oncol 2010;Jun 14:[Epub ahead of print].
Clinical Trial: No
Study Question: Are angiotensin-receptor blockers (ARBs) associated with increased risk for cancer?
Methods: This was a meta-analysis, including all publicly available data for the development of cancers from randomized controlled trials of ARBs. From the 2,057 reports identified (1,531 from Medline, 503 from Scopus, and 23 from Cochrane databases), 1,997 reports were excluded. Exclusion criteria included duration of the trial <1 year, <100 patients, use of ARBs in all groups, nonrandomized trial design, or lack of information on cancers. A total of nine trials were included in the final analysis, of which five had data on new cancer occurrences, five had information on common types of specific solid-organ cancers, and eight had information on cancer death. The primary outcome of interest was incident cancer, with a secondary outcome of interest being occurrence of specific solid-organ cancers.
Results: Telmisartan was the study drug for 85.7% of patients (n = 30,014) who received an ARB in randomized controlled trials that had data on cancer outcomes. Patients randomized to ARBs had a significant increased risk for new cancers, as compared with patients in the control groups (7.2% vs. 6.0%; relative risk [RR], 1.08; 95% confidence interval [CI], 1.01-1.15). After limiting the analysis to trials with cancer as a prespecified endpoint, the RR was 1.11 (95% CI, 1.04-1.18). For solid organ cancers, only new lung cancer was significantly higher among patients randomized to ARBs compared to controls (0.9% vs. 0.7%; RR, 1.25; 95% CI, 1.05-1.49). No statistically significant difference in cancer deaths was observed between patients randomized to ARBs as compared to controls (1.8% vs. 1.65; RR, 1.07; 95 CI, 0.97-1.18).
Conclusions: The investigators concluded that this meta-analysis of randomized controlled trials observed a modest association between ARBs and cancer risk. Further investigation would be needed to understand the potential risk associated with particular drugs.
Perspective: This meta-analysis provides some interesting findings regarding use of ARBs and risk of cancer, which suggests a modest increase in cancer risk. Understanding the risk and benefits of ARBs in patients can be further investigated to determine if specific patients are at increased risk for cancers. Elizabeth A. Jackson, M.D., F.A.C.C.

Title: White Rice, Brown Rice, and Risk of Type 2 Diabetes in US Men and Women
Topic: Prevention/Vascular
Date Posted: 6/14/2010 4:00:00 PM
Author(s): Sun Q, Spiegelman D, van Dam RM, et al.
Citation: Arch Intern Med 2010;170:961-969.
Clinical Trial: No
Study Question: Is rice consumption associated with risk of type 2 diabetes?
Methods: Subjects enrolled in three prospective cohorts were used for the present analysis. Men from the Health Professionals Follow-up Study (age range, 32-87 years) were included, in addition to women from the Nurses’ Health Study (age range, 26-45 years) and Nurses’ Health Study II (age range, 26-45 years). Subjects were excluded if they had a history of cardiovascular disease or cancer at baseline. Five categories of white rice intake were created, ranging from <1 serving per month, to ≥5 servings per week. Three categories of brown rice were created, ranging from <1 serving per month to ≥2 servings per week.
Results: A total of 39,765 men and 157,463 women were included in this analysis. Over the 20 years of follow-up, 2,648 cases of type 2 diabetes were observed in the Health Professionals Follow-up Study cohort. In the original Nurses’ Health Study cohort, 5,550 cases were observed over 22 years of follow-up, and in the Nurses’ Health Study II cohort, 2,359 cases were observed during 14 years of follow-up. After adjustment for age, diet, and lifestyle factors such as physical activity, intake of white rice (≥5 servings per week vs. <1 per month) was associated with a higher risk for type 2 diabetes. The pooled relative risk was 1.7 (95% CI, 1.02-1.36). In contrast, intake of brown rice appeared protective, with a relative risk of 0.89 (95% confidence interval [CI], 0.81-0.97) for high intake (≥2 servings per week) compared to low intake (<1 serving per month). Replacing 50 g/day of white rice in the diet with the same amount of brown rice was estimated to lower the risk of type 2 diabetes by 16% (95% CI, 9%-21%). The same replacement of whole grains as a group was estimated to be associated with a 36% (95% CI, 30%-42%) lower risk for type 2 diabetes.
Conclusions: The investigators concluded that substitution of whole grains, including brown rice for white rice, lowers risk of type 2 diabetes.
Perspective: These findings provide further evidence for recommending whole grains (including brown rice) to patients at risk for diabetes. Dietary changes can have a significant impact on cardiovascular disease prevention; health care providers can use findings from studies such as this to educate their patients regarding healthy dietary practices. Elizabeth A. Jackson, M.D., F.A.C.C.

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Risk markers used in conjunction may improve prediction of sudden cardiac death
By

Microvolt T-wave alternans and electrophysiologic study identified distinct arrhythmogenic substrates that, when used in conjunction, were shown to better predict the complex electroanatomic substrates underlying sudden cardiac death risk.

The study included 566 patients with ischemic cardiomyopathy from the Alternans Before Cardioverter Defibrillator trial. Participants had a left ventricular ejection fraction ≤0.40 and nonsustained ventricular tachycardia. All patients underwent electrophysiologic study and microvolt T-wave alternans.

Researchers reported 28 stable ventricular tachyarrhythmic events and 10 unstable ventricular tachyarrhythmic events. Microvolt T-wave alternans were predictive of unstable ventricular tachyarrhythmic events (event rate 2.7% in abnormals vs. 0% in normals), whereas electrophysiologic study was not predictive (1.5% vs. 3.2%). Conversely, electrophysiologic study predicted stable ventricular tachyarrhythmic events (9.7% vs. 2.2%), but microvolt T-wave alternans did not predict them (5.5% vs. 4.4%). Although the extent of LV contractile dysfunction alone (LVEF ≤0.30 vs. LVEF ≥0.31) did not predict events, microvolt T-wave alternans predicted events better than electrophysiologic study in patients with LVEF ≤0.30. In contrast, electrophysiologic study predicted events better than microvolt T-wave alternans in patients with LVEF >0.30.

“Our data strongly suggest that combining multiple risk markers, rather than using LVEF alone, will capture some of the complexity associated with the risk of sudden cardiac death,” the researchers concluded. “These data can serve as a basis for future randomized studies using combinations of risk markers to identify patients at highest risk of sudden death.”

One of the main interests of the study, wrote Sandeep V. Pandit, PhD, of the Center for Arrhythmia Research, University of Michigan in Ann Arbor, in an accompanying editorial, was the question of why a stable arrhythmia is typically the outcome of an electrophysiologic study test, whereas a T-wave alternans test leads to unstable arrhythmias in patients with ischemic cardiomyopathy.

“The results,” Pandit wrote, “… suggest that clinical trials with a larger cohort of patients and longer duration are needed in order to assess whether the T-wave alternans test can increase our ability to identify patients at risk for arrhythmogenesis and to distinguish between varied arrhythmogenic substrates.”
Amit G. Heart Rhythm. 2010;7:763-768

Halting anticoagulation after device implantation linked with increased hematomas, thromboembolic events
By

Cessation of warfarin with bridging anticoagulation when implanting a pacemaker or defibrillator was associated with a higher incidence of thromboembolic events and other adverse outcomes, study results suggested.

Researchers from several Minnesota institutions retrospectively evaluated 459 patients on chronic warfarin (Coumadin, Bristol-Meyers Squibb) therapy who underwent device surgery between April 2004 and September 2008. During the perioperative period, 222 patients continued taking warfarin. Warfarin was temporarily withheld and bridging therapy administered in 123 patients; a total of 114 patients had warfarin temporarily withheld and had no bridging therapy.

Researchers reported no differences for thromboembolism in the three study groups with regard to age, sex or risk factors. Patients who continued warfarin therapy had a lower incidence of pocket hematoma (P=.004) and shorter hospital stays (P<.0001) vs. patients in the bridging group. Continued warfarin use resulted in a lower incidence of transient ischemic attacks vs. withholding both warfarin and bridging therapy (0% vs. 3.5%, P=.01).

Study limitations included the observational and nonrandomized nature of the data and the possible presence of patient selection bias.

“Implantation of pacemakers and defibrillators in patients on continued warfarin therapy with therapeutic INR appears to be safe and cost effective compared to bridging therapy or temporarily withholding of anticoagulation,” the researchers observed. “These findings need to be confirmed by multicenter, prospective, randomized, controlled studies.”
Ahmed I. Heart Rhythm. 2010; 7:745-749.

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ICD shocks not associated with increased risk for death or acute decompensated HF
By
Implantable cardioverter defibrillator shocks delivered during induced ventricular arrhythmias at the time of noninvasive electrophysiology study testing did not increase the risk for death or acute decompensated HF as compared with recipients of appropriate implantable cardioverter defibrillator shocks, study data indicated.
The cohort evaluation consisted of 1,372 patients undergoing ICD implantation from December 1997 to January 2007. Researchers evaluated the probability of all-cause mortality and hospitalization for acute decompensated HF based on the type of ICD shock received using multivariable Cox proportional analyses. The four analyzed shocks included implantation shocks only (n=694), additional noninvasive electrophysiology study shocks only (n=319), additional appropriate shocks only (n=128) or additional inappropriate shocks only (n=104).
The risk for death (adjusted HR=0.91; 95% CI, 0.69-1.20) or acute decompensated HF (adjusted HR=0.71; 95% CI, 0.46-1.16) were similar between recipients of noninvasive electrophysiology study shocks and recipients of implantation shocks. Patients who received appropriate ICD shocks had an increased risk for death (adjusted HR=2.09; 95% CI, 1.38-2.69) and acute decompensated HF (adjusted HR=2.40; 95% CI, 1.51-3.81) vs. those receiving implantation shocks, and also increased risk for death (adjusted HR=2.61; 95% CI, 1.86-3.67) and acute decompensated HF (adjusted HR=2.29; 95% CI, 1.33-3.97) vs. noninvasive electrophysiology study shocks.
“ICD shocks delivered for induced arrhythmias at the time of noninvasive electrophysiology study testing do not increase the risk of death or acute decompensated HF in this study. The occurrence of spontaneous arrhythmias in vulnerable substrates may explain the increased risk,” the researchers concluded.
In an accompanying editorial, Harikrishna Tandri, MD, of The Johns Hopkins University School of Medicine in Baltimore, said the conclusion may not be as decisive as the results indicated.

“A high-energy shock may be more detrimental to a failing heart, in which the cellular reparative mechanisms are already overburdened,” Tandri wrote. “Electrophysiologic and mechanical consequences of shock may be just more than the ‘straw that broke the camel’s back’ and may send the patients into a downward spiral of HF and, ultimately, death.”
Bhavnani S. Heart Rhythm. 2010;7:755-760.

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Catheter ablation outcomes similar in elderly patients with ventricular tachycardia
By

Advanced age was not a cause for preclusion of catheter ablation in the elderly when compared with a younger population, according to study findings.

Researchers performed radiofrequency catheter ablation in 289 consecutive patients with recurrent postinfarct ventricular tachycardia (VT) refractory to antiarrhythmic drugs between January 1999 and September 2008. After excluding four patients who underwent ethanol or cryothermal ablation, researchers compared mortality and outcomes of the remaining elderly population (age ≥75 years; n=72) vs. the younger one (age <75 years; n=213).

According to the results, inducible VTs were abolished or modified in 79.2% of the elderly population and 87.8% of the younger population. Major complications, including cardiogenic shock, cardiac tamponade and cerebral infarction, occurred in 5.6% of elderly patients and 2.3% of younger patients. Periprocedural mortality was similar between the groups (2.8% elderly vs. 4.2% younger). During a mean follow-up of 42 months, 50% of the elderly group and 35.2% of the younger group died. Among those patients, no VT was observed in 63.9% of the elderly patients and 60.1% of the younger patients at a mean follow-up of 18 months.

“The risks and outcomes in selected elderly patients with recurrent VT who are referred for catheter ablation are similar to that of younger patients,” the researchers concluded. “Advanced age should not preclude ablation when recurrent VT is adversely affecting quality of life in elderly patients who otherwise have a reasonable expectation for survival.”

Inada K. Heart Rhythm. 2010;7:740-744.