Обзор американских кардиологических журналов за неделю (ссылки)

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Scars indicated by CV magnetic resonance associated with mortality
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Scars found during CV magnetic resonance were shown to be independent predictors of all-cause and cardiac mortality in a population of patients with asymptomatic hypertrophic cardiomyopathy.
This population consisted of 243 consecutive patients with hypertrophic cardiomyopathy who were prospectively enrolled. After an initial CV magnetic resonance, 220 patients were available for clinical follow-up, which was a mean time of 1,090 days afterward. During follow-up, 20 of 220 patients died and two survived sudden cardiac death due to adequate implantable cardioverter defibrillator discharge. Sixteen of the events resulted because of cardiac reasons, whereas the remaining six were associated with cancer and accidents.
According to researchers, the presence of CV magnetic resonance-visualized scars yielded an OR of 5.47 for all-cause mortality and 8.01 for cardiac mortality. “This might be superior to classic clinical risk factors because, in our dataset, the presence of two risk factors yields an OR of 3.86 for all-cause and of 2.2 for cardiac-mortality,” they wrote. In addition, multivariable analysis revealed the presence of late gadolinium enhancement as an independent predictor of death in those with hypertrophic cardiomyopathy.
“These data support the necessity for future large longitudinal follow-up studies to definitely establish late gadolinium enhancement as an independent predictor of cardiac death in hypertrophic cardiomyopathy, as well as to evaluate the incremental prognostic value of additional CMR parameters, such as scar surface area,” the researchers concluded.
Bruder O. J Am Coll Cardiol. 2010;doi:10.1016/j.jacc.2010.05.007.

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Cardiac imaging resulted in substantial radiation exposure
Chen J. J Am Coll Cardiol. 2010;doi:10.1016/j.jacc.2010.05.014.
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Procedures involving cardiac imaging led to sizable radiation exposure and effective doses for U.S. patients, according to study findings.
Researchers used administrative claims to identify cardiac imaging procedures in nonelderly insured adults (n=952,420, aged 18-64) in five U.S. health care markets from 2005 to 2007. They estimated 3-year cumulative doses of radiation from these procedures and then calculated population-based annual rates of radiation exposure of effective doses ≤3 mSv/year, >3 mSv/year to 20 mSv/year or >20 mSv/year.
Of the study population, 90,121 (9.5%) patients underwent at least one cardiac imaging procedure using radiation and had a mean cumulative effective dose of 16.4 mSv (range 1.5-189.5 mSv). Myocardial perfusion imaging accounted for 74% of the cumulative effective dose. Overall, the annual population-based rate of receiving an effective dose of >3 mSv/year to 20 mSv/year was 89 per 1,000, and for cumulative doses >20 mSv/year, it was 3.3 per 1,000.
“Cardiac imaging procedures represent an important source of ionizing radiation in the United States,” the researchers wrote. “The overall distribution of cumulative effective doses is skewed and can lead to sizable radiation exposure for many individuals. Better strategies to minimize the radiation exposure from cardiac imaging procedures should be encouraged.”
Matthew J. Budoff, MD, and Mohit Gupta, MD, both of the Harbor UCLA Medical Center, Torrance, Calif., wrote in an accompanying editorial that further research is needed to define the most appropriate risk stratification algorithm that would provide more optimal use of the imaging modalities.
“It is clear that the benefits of treatment of advanced coronary artery disease far outweigh the induced risk of cancer after imaging in this very high risk cohort,” they concluded. “We need to move beyond radiation models, with so many assumptions, to studies documenting the real risk (if any) to the cardiac patient.”

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Coronary CTA of plaque, stenosis showed improvement with semi-automated software
Ferencik M. Abstract #216.
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The 5th Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography
Semi-automated software improved interobserver agreement for coronary CTA of both stenosis and plaque volume, according to study results.
Researchers analyzed CTA data from participants (n=31) of the ROMICAT trial with at least one coronary stenosis >50%. They analyzed stenoses (n=39) and associated coronary plaques via semi-automated software (Vitrea Enterprise Suite; Vital Images) by two independent readers. The evaluated degrees of stenosis and plaque volumes were defined as low (<90 Hounsfield units), intermediate (91-150 Hounsfield units) and high (>150 Hounsfield units).
Researchers found that manually measured stenosis correlated between readers (mean difference, 4 ± 9%; R²=0.71). Semi-automated stenosis measurements led to an improved correlation (mean difference, 1 ± 8%; R²=0.85), although there was only a moderate correlation between manual and semi-automated measurements (mean difference, 8 ± 15%; R²=0.52). Plaque volume analysis showed notable correlation between readers (mean difference, 19 ± 44 mm³; R²=.83), as well as improvement with semi-automated software (mean difference, –11 ± 14 mm³; R²=.86).
Maros Ferencik, PhD, MD, of Massachusetts General Hospital, Boston, and researcher on the study, said the study limitations that he noted in his presentation were the small sample size, the inclusion of plaques only associated with >50% stenosis, the excellent image quality required for the plaque evaluation and the lack of a comparison to a gold standard (eg, IVUS).
“Semi-automated software improved interobserver agreement for coronary CTA evaluation of stenosis and plaque volume. However, there was difference between manual and semi-automated measurements,” Ferencik said. “Further improvements of semi-automated software will be necessary prior to the implementation in clinical trials.”
This idea has been around for several years but needed a boost in technology, like this one, to make it fast, automated and reproducible to make this feasible for clinical trials. Once validated and widely available, there should be a multicenter evaluation of outcomes and treatments in the groups with different plaque densities.

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CT-STAT: CTA cheaper, faster than standard of care test
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The 5th Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography
CTA was shown to be equally as effective as standard of care evaluation while offering the advantages of being cheaper and faster, results from the CT-STAT trial indicated.
“The motivation to do this [study] was the 6 million visits in the U.S. alone for coronary evaluations and potential acute coronary syndrome,” Gilbert L. Raff, MD, director of the Ministrelli Center for Advanced Cardiovascular Imaging in Royal Oak, Mich., and researcher on the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) study, said during his presentation.
“We had previously done a time and cost study and found that the average patient without an MI took 22 hours to be diagnosed and discharged,” Raff said. “When you think about it from a patient point of view … there is an enormous amount of health care resources being devoted to making this diagnosis.”
Raff and colleagues excluded patients with known CAD and positive enzymes. The final group of low-to-intermediate risk patients (n=749) had a thrombolysis in MI score up to four. Researchers split the patients into two arms: CTA (n=376) or standard of care with myocardial perfusion imaging (n=373). “If the patients had normal CT, they were eligible to go home,” Raff said. “If they had a stenosis of >70%, we recommended but could not enforce that they would have a cath. And if they had an uninterpretable scan or something between 25% and 70%, we recommended they have a stress test.”
Primary study outcomes were diagnostic efficiency — defined as time to diagnosis — and overall cost of care in the ED, whereas the secondary outcome was safety.
In the CTA arm, researchers found no significant stenosis in 297 (82.3%) patients, of whom 262 (72.6%) were discharged immediately, whereas in the standard of care group, myocardial perfusion imaging was normal in 306 patients (90%), and 304 patients (89.4%) were immediately discharged.
“The number of major adverse coronary events that we considered to be a failure of the test were the events in patients with normal or nearly normal index test, and there were three in one case and two in another,” Raff said.
“Both the CTA and the standard of care test using myocardial perfusion imaging are safe and diagnostically accurate,” he said. “Overall, the major adverse coronary events in this case are not significantly different between the two approaches. On the other hand, CTA offers significant advantage in time to diagnosis and a significant advantage in the cost of care.” – by Brian Ellis
For more information:
Raff G. Presented at: The 5th Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography; July 15-18, 2010; Las Vegas.

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PROTECTION I-III: Radiation dose not necessarily associated with cardiac CTA image quality
By
The 5th Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography
Lowering cardiac CTA radiation dosages proved to be equally as effective in cardiac CTA image quality as previous standards that recommended a higher amount, according to results from the PROTECTION trials.
The Prospective Multicenter Study on Radiation Dose Estimates of Cardiac CT Angiography in Daily Practice (PROTECTION) trial began as the result of the rapid increase in use of cardiac CTA as a non-invasive imaging modality and the concerns associated with it in regards to the exposure to ionizing radiation. In his presentation, Jörg Hausleiter, MD, an associate professor of medicine from the German Heart Centre in Munich, and researcher on the PROTECTION trials, gave an overview of the findings from the first three phases, as well as some insight into the work being done in PROTECTION IV.
In phase 1, Hausleiter and colleagues performed a prospective, observational, multicenter, multivendor and industry independent study from February to December 2007 involving patients (n=1,965) undergoing cardiac CTA. Researchers gathered image data, patient and scan information of all consecutive electrocardiogram-gated or –triggered cardiac CTAs performed during 1 month. After using an average of 12 mSv, which was notably lower than several earlier studies of cardiac CTA radiation doses, their findings confirmed the possibility to significantly reduce radiation dose while maintaining diagnostic image quality and showed the wide degree of variability in radiation between sites.
Phase 2 involved non-obese patients (n=400) who were separated into two arms, those randomly assigned to receive a coronary CTA with a tube voltage of either 120 kV (n=198) or 100 kV (n=202). After a 30-day follow-up, patients who received 120 kV had a mean radiation dose of 12.1 mSv, whereas the 100 kV group’s mean radiation dose was 8.4 mSv, although no inferiority was reported with the lower dose.
Hausleiter also presented findings from the PROTECTION III trial, which featured patients (n=400) randomly assigned to either sequential cardiac CTA (n=200) or spiral CTA (n=200). Although those in the spiral CTA group were exposed to significantly higher radiation doses, researchers found that image quality did not change between arms. “The image quality was maintained with sequential scanning protocol with an image quality score of 3.36 [vs.] 3.37 with the spiral scan technique,” Hausleiter said. “However, the dose reduction was tremendous … with an almost 70% reduction in radiation dose with the sequential scan mode.”
Regarding what to expect from the currently under way PROTECTION IV, a non-inferiority, international, multicenter trial, Hausleiter said it will be evaluating the performance of the high-pitch scan technique. “This is a new technique, and there are some preliminary data that show it can [produce] high image quality,” he said. – by Brian Ellis
For more information:
Hausleiter J. Presented at: The 5th Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography; July 15-18, 2010; Las Vegas.

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Contributions of Remote Monitoring to the Follow-Up of Implantable Cardioverter-Defibrillator Leads Under Advisory
Guedon-Moreau L, Chevalier P, Marquie C, et al.
Eur Heart J 2010;Jun 30:[Epub ahead of print].
Study Question: How often does remote monitoring allow early detection of implantable cardioverter-defibrillator (ICD) lead malfunction?

Diagnosis of Cardiac Device-Related Infective Endocarditis After Device Removal
Le Dolley Y, Thuny F, Mancini J, et al.
J Am Coll Cardiol Img 2010;3:673-681.
Study Question: Are residual floating masses in the right atrium after percutaneous cardiac device lead extraction a sign of cardiac device-related infective endocarditis (CDRIE)?

Stenting Versus Endarterectomy for Treatment of Carotid-Artery Stenosis
Brott TG, Hobson RW 2nd, Howard G, et al., on behalf of the CREST Investigators.
N Engl J Med 2010;363:11-23.
Study Question: What is the safety and efficacy of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in average risk patients?

The Importance of the Level of Maternal Anti-Ro/SSA Antibodies as a Prognostic Marker of the Development of Cardiac Neonatal Lupus Erythematosus: A Prospective Study of 186 Antibody-Exposed Fetuses and Infants
Jaeggi E, Laskin C, Hamilton R, Kingdom J, Silverman E.
J Am Coll Cardiol 2010;55:2778-2784.
Study Question: Are cardiac complications of neonatal lupus erythematosus (NLE) related to maternal anti-Ro and anti-La autoantibody levels?

A Frequent Variant in the ABCA1 Gene Is Associated With Increased Coronary Heart Disease Risk and a Better Response to Statin Treatment in Familial Hypercholesterolemia Patients
Versmissen J, Oosterveer DM, Yazdanpanah M, et al.
Eur Heart J 2010;Jul 1:[Epub ahead of print].
Study Question: Does a polymorphism in the ABCA1 gene affect coronary artery disease (CAD) risk and response to statin treatment?

Exercise-Induced Cardiac Troponin Elevation: Evidence, Mechanisms, and Implications
Shave R, Baggish A, George K, et al.
J Am Coll Cardiol 2010;56:169-176.
Perspective: The following are 10 points to remember about this state-of-the-art paper.

The Quality of Care Provided to Hospitalized Patients at the End of Life
Walling AM, Asch SM, Lorenz KA, et al.
Arch Intern Med 2010;170:1057-1063.
Study Question: What is the quality of end-of-life care among hospitalized patients?

Divergent Trends in Survival and Readmission Following a Hospitalization for Heart Failure in the Veterans Affairs Health Care System 2002 to 2006
Heidenreich PA, Sahay A, Kapoor JR, Pham MX, Massie B.
J Am Coll Cardiol 2010;56:362-368.
Study Question: To what extent have hospitalization rates and the associated mortality improved following recent changes in heart failure management within the Veterans Affairs Health Care System?

When Is Door-to-Balloon Time Critical? Analysis From the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials
Brodie BR, Gersh BJ, Stuckey T, et al.
J Am Coll Cardiol 2010;56:407-413.
Study Question: What is the impact of door-to-balloon (D2B) time on mortality based on time to presentation and clinical risk in patients with ST-elevation myocardial infarction (STEMI)?

A Retrospective Comparison of Mortality in Critically Ill Hospitalized Patients Undergoing Echocardiography With and Without an Ultrasound Contrast Agent
Exuzides A, Main ML, Colby C, Grayburn PA, Feinstein SB, Goldman JH.
J Am Coll Cardiol Img 2010;3:578-585.
Study Question: How does same day all-cause mortality (ACM) in critically ill patients undergoing echocardiography compare, with and without an ultrasound contrast agent (UCA)?

Bicycle Riding, Walking, and Weight Gain in Premenopausal Women
Lusk AC, Mekary RA, Feskanich D, Willett WC.
Arch Intern Med 2010;170:1050-1056.
Study Question: Does bike riding prevent weight gain over time in women?

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Title: ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac Transplant: A Report of the ACCF/AHA/ACP Task Force on Clinical Competence and Training
Date Posted: July 20, 2010
Authors: Francis GS, Greenberg BH, Hsu DT, et al.
Citation: J Am Coll Cardiol 2010;56:424-453.

Perspective:
The following are 10 points to remember about this clinical competence and training statement:

1. This document represents a joint effort between the American College of Cardiology Foundation (ACCF), American College of Physicians (ACP), American Heart Association (AHA), Heart Failure Society of America (HFSA), and the International Society for Heart and Lung Transplantation (ISHLT), to delineate professional knowledge base and skill requirements necessary for competency in managing adult and pediatric patients with advanced heart failure (HF) and heart transplant.

2. For level 3 Core Cardiology Training Statement (COCATS) certification in adult HF/Transplant, an individual must complete a 3-year cardiovascular medicine fellowship, a 1-year fellowship in Advanced HF and Transplant, and successfully pass the HF/Transplant American Board of Internal Medicine (ABIM) certifying exam. Alternative certification pathways are outlined for those individuals who presently focus their practice in HF/Transplant care, but trained prior to the development of a defined specialty fellowship.

3. HF/Transplant specialists are expected to have a thorough understanding of cardiovascular biology and physiology, cardiopulmonary hemodynamic interpretation, cardiopulmonary exercise testing, and implantable cardioverter defibrillator (ICD) interrogation and basic arrhythmia management.

4. The HF/Transplant specialist is expected to understand how to diagnose acute decompensated HF and chronic compensated HF, and to implement appropriate evidence-based HF management, including pharmaceuticals, ICDs and biventricular pacemakers, and patient education with use of disease management programs to reduce readmission.

5. It is recommended that training in heart transplant be obtained at an institution that performs at least 10 heart transplants yearly, and the clinician should have clinical experience caring for no fewer than 30 post-transplant patients, 5 of whom are new transplants.

6. The HF/Transplant specialist should have a thorough understanding of patient selection and preoperative optimization for cardiac transplant; cardiac rejection and rejection monitoring with proficiency in cardiac biopsy; immunosuppressive therapies and their complications/side effects and drug-drug interactions; and post-transplant complications including infection, malignancy, and graft dysfunction.

7. While the document did not specifically delineate criteria on mechanical circulatory support experience (i.e., center left ventricular assist device volume and clinician exposure), the clinician is expected to understand the indications and contraindications for percutaneous, intracorporal and extracorporeal mechanical circulatory support (MCS); patient MCS risk assessment and device selection; pre- and postoperative patient management and optimization; and have an understanding of MCS device alarms and complications.

8. The HF/Transplant specialist should be familiar with common congenital heart defects likely to result in HF as well as the manifestation of cardiac dysfunction associated with the lesions, and understand when transplant and MCS referral is appropriate or contraindicated.

9. The HF/Transplant specialist should be familiar with palliative care, quality of life at the end of life goals, and patient and family bereavement.

10. The HF/Transplant specialist should remain current on HF/Transplant-related research and guidelines, and participate in continuing medical education. Volume targets to maintain competency have not yet been delineated.

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FDA Considering Future of Rosiglitazone (Avandia)
Updated July 21, 2010

Following an intensive two-day hearing regarding the conflicting data surrounding rosiglitazone (Avandia), a U.S. Food and Drug Administration (FDA) advisory panel voted in late July to keep the drug on the market with the addition of warnings and stricter product labeling.

Of the 20 members who voted not to remove the drug, the overwhelming majority recommended that it include stricter labeling. Half of those votes suggested that rosiglitazone be restricted to prescription only by physicians with special knowledge in use of the drug. Some panelists also indicated that additional patient education is needed. Only three of the panelists voted to keep rosiglitazone on the market without additional product labeling. The 12 members recommending removal of rosiglitazone argued that pioglitazone works just as well without the known added risks of ischemic events.

The panel was also tasked with making recommendations in eight additional areas, including safety of rosiglitazone as compared to pioglitazone and other hypoglycemic drugs. In evaluating whether rosiglitazone presents greater risk compared to non-thiazolidinedione (TZD) diabetes drugs and pioglitazone, the panel voted 18-6 in favor of the notion that sufficient evidence exists to support an increased risk of ischemic cardiac events with rosiglitazone as compared to non-TZDs. Nine voting members were unable to make a decision on this specific point. The panel also voted 21-4 when asked to determine whether rosiglitazone is less safe than pioglitazone. Eight panel members were unable to decide.

In addition to voting on whether or not the drug should remain on the market and specific safety concerns relative to comparable drugs, the panel was charged with recommending whether or not TIDE, the ongoing international trial designed to compare rosiglitazone to pioglitazone with respect to risk of MI, should continue. In a 20-10 vote, the panel recommended that TIDE carry on (one panelist did not vote and another two were no longer present at the FDA meeting).

Though the FDA panelists failed to reach a unanimous consensus on any of the nine recommendations, they agreed the available data are confusing and additional information is needed. They also seemed to agree that many flaws exist in the data presently available.

"Based on the panelists' comments, there were no easy answers here," said ACC President Ralph Brindis, M.D., M.P.H., F.A.C.C., in a statement following the hearing. According to Brindis, until there is further evidence, physicians should continue working with their patients on a case-by-case basis to determine risks and benefits of rosiglitazone in considering available treatment alternatives.

The meeting marked the second time the FDA convened a panel to review data on rosiglitazone. The first advisory panel was held in 2007 following a publication in The New England Journal of Medicine linking the drug to heart disease risks. At that time, panelists determined that the drug should stay on the market and recommended the addition of a black box warning indicating that rosiglitazone should not be used for patients requiring insulin, patients with a history of coronary artery disease, congestive heart failure or long-term users of nitrates. To underscore the difficult nature of the task at hand, many of the same experts who voted to keep rosiglitazone on the market in 2007 voted to either remove or restrict the drug at this time.

To date, the FDA has not made a final decision on the fate of rosiglitazone. However, the agency on July 21 ordered new enrollment in the TIDE trial to stop. Patients already enrolled in the trial may continue to participate. "This pause in enrollment will give clinical trial investigators and patients time to learn about the data presented to the FDA Advisory Committee and the Committee's recommendations," said Ellen Strahlman, M.D., GlaxoSmithKline's chief medical officer, in a statement.

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Title: HDL Cholesterol and Residual Risk of First Cardiovascular Events After Treatment With Potent Statin Therapy: An Analysis From the JUPITER Trial
Date Posted: July 22, 2010
Authors: Ridker PM, Genest J, Boekholdt SM, et al.
Citation: Lancet 2010;376:333-339.

Study Question:
What is the association between high-density lipoprotein cholesterol (HDL-C) concentrations and occurrence of cardiovascular events when low-density lipoprotein cholesterol (LDL-C) concentrations are reduced to the very low ranges with high-dose statin treatment?
Methods:
Participants in the randomized placebo-controlled JUPITER trial were adults without diabetes or previous cardiovascular disease, and had baseline concentrations of LDL-C <3.37 mmol/L and high-sensitivity C-reactive protein of 2 mg/L or more. Participants were randomly allocated to receive rosuvastatin 20 mg per day or placebo, with participants and adjudicators masked to treatment assignment. In the present analysis, the investigators divided the participants into quartiles of HDL-C or apolipoprotein A1, and sought evidence of association between these quartiles and the JUPITER trial primary endpoint of first nonfatal myocardial infarction or stroke, hospitalization for unstable angina, arterial revascularization, or cardiovascular death.
Results:
For 17,802 patients in the JUPITER trial, rosuvastatin 20 mg per day reduced the incidence of the primary endpoint by 44% (p < 0.0001). In 8,901 (50%) patients given placebo (who had a median on-treatment LDL-C concentration of 2.80 mmol/L [interquartile range (IQR), 2.43-3.24]), HDL-C concentrations were inversely related to vascular risk both at baseline (top quartile vs. bottom quartile hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.35-0.83; p = 0.0039) and on-treatment (0.55; 0.35-0.87; p = 0.0047). By contrast, among the 8,900 (50%) patients given rosuvastatin 20 mg (who had a median on-treatment LDL-C concentration of 1.42 mmol/L [IQR, 1.14-1.86]), no significant relationships were noted between quartiles of HDL-C concentration and vascular risk either at baseline (1.12; 0.62-2.03; p = 0.82) or on-treatment (1.03; 0.57-1.87; p = 0.97). Their analyses for apolipoprotein A1 showed an equivalent strong relation to frequency of primary outcomes in the placebo group, but little association in the rosuvastatin group.
Conclusions:
The authors concluded that HDL-C concentrations are not predictive of residual vascular risk among patients treated with potent statin therapy who attain very low concentrations of LDL-C.
Perspective:
This analysis from the JUPITER trial suggests that although measurement of HDL-C concentration is useful as part of initial cardiovascular risk assessment, HDL-C concentrations are not predictive of residual vascular risk among patients treated with potent statin therapy who attain very low concentrations of LDL-C. These data and recent secondary prevention data from the TNT and PROVE IT trials provide little evidence to support the hypotheses that HDL-C levels predict risk of vascular events in the setting of high-dose statin therapy. These data, however, should not dissuade clinicians from measurement of HDL-C concentration as part of an initial cardiovascular risk assessment. Randomized trials will be needed to definitively test the role of potent HDL-raising therapies in the statin era of reducing cardiovascular disease events.
Author(s):
Debabrata Mukherjee, M.D., F.A.C.C.
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Title: Prospective Study of Obstructive Sleep Apnea and Incident Coronary Heart Disease and Heart Failure. The Sleep Heart Health Study
Date Posted: July 21, 2010
Authors: Gottlieb DJ, Yenokyan G, Newman AB, et al.
Citation: Circulation 2010;122:352-360.

Study Question:
Is obstructive sleep apnea (OSA) associated with the development of cardiac disease?
Methods:
This was a prospective epidemiologic study of subjects ≥40 years of age, free of coronary heart disease (CHD) and heart failure (HF) at baseline. All subjects underwent in-home polysonography, and the apnea-hypopnea index (AHI) was calculated. Incident CHD was defined as myocardial infarction, revascularization, or CHD death following polysonography. Incident HF was defined as the first occurrence of HF during the follow-up period.
Results:
There were 4,422 subjects (56% women) followed for a mean of 8.7 years. Twenty-four percent of men and 11% of women had moderate or worse OSA (AHI >14) on baseline polysonography. In women, there was no association between the AHI and the development of incident CHD or HF. The AHI predicted the development of incident HF in men (adjusted hazard ratio, 1.13 [1.02, 1.26] per 10 units of AHI), but was only predictive of CHD development in men who were ≤70 years of age (adjusted hazard ratio, 1.1 [1.00-1.21] per 10 AHI units).
Conclusions:
OSA may be associated with the development of HF in men ≥40 years old. Its association with the development of CHD is less clear.
Perspective:
At this time, it is not definitively known if OSA is an independent risk factor for the development of CHD or HF. Some have hypothesized that OSA instigates negative neurohormonal responses that can lead to HF development, but it is also possible that OSA is just a marker for the presence of other known, or stronger, CHD and HF risks. Unfortunately, this study fails to shed significant light on the query. A major limitation of the study is a vague definition of HF without a clearly mandated imaging or standardized New York Heart Association functional class assessment at follow-up. The reader is not provided information on ejection fraction or diastology assessment at baseline or at follow-up, and individuals with subclinical (stage B) HF may have been missed. Finally, pulmonary hypertension induced by OSA can have a large impact on a subject’s functional capacity and right ventricular (RV) function. It is unknown if the definition of HF included isolated RV failure and if OSA is associated with an increased incidence of RV dysfunction or pulmonary hypertension in this cohort. Many questions remain regarding OSA and its role in CHD and HF development.
Author(s):
Jennifer Cowger, M.D.

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Title: When Is Door-to-Balloon Time Critical? Analysis From the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials
Date Posted: July 19, 2010
Authors: Brodie BR, Gersh BJ, Stuckey T, et al.
Citation: J Am Coll Cardiol 2010;56:407-413.

Study Question:
What is the impact of door-to-balloon (D2B) time on mortality based on time to presentation and clinical risk in patients with ST-elevation myocardial infarction (STEMI)?
Methods:
The authors assessed the impact of D2B time on mortality in 4,548 patients enrolled in the CADILLAC and HORIZONS-AMI trials.
Results:
Patients with a D2B time of 90 minutes or less had a 1-year mortality of 3.1% versus 4.3% in those with a D2B time greater than 90 minutes. Among patients presenting within 90 minutes of symptom onset, short D2B time was associated with a lower mortality (1.9% vs. 3.8%, p = 0.029), but not in those with a delayed presentation (4.0% vs. 4.6%, p = 0.47). Short D2B times were associated with a similarly relative reduction in mortality in high- and low-risk patients, although the absolute benefit was greater in the highest risk patients.
Conclusions:
D2B time of ≤90 minutes is associated with a lower mortality rate in patients with early presentation, but there is no difference in mortality of patients who present late.
Perspective:
Considerable effort has been expended to ensure rapid re-perfusion in patients with STEMI, although most patients present beyond the 3-hour window where one would anticipate maximal myocardial salvage. This study elegantly demonstrates that maximal benefit is achieved in patients who present early and get reperfused quickly. While marked reductions have been achieved in D2B time nationally, there has been relatively little improvement in time to presentation. Communitywide efforts are needed to reduce time to presentation so that the benefits of early reperfusion can be maximized.

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Title: Cardiac Origins of the Postural Orthostatic Tachycardia Syndrome
Date Posted: July 9, 2010
Authors: Fu Q, VanGundy TB, Galbreath M, et al.
Citation: J Am Coll Cardiol 2010;55:2858-2868.

Study Question:
What is the mechanism of the postural orthostatic tachycardia syndrome (POTS)?
Methods:
Twenty-seven patients (mean age 26 years) with POTS and 16 healthy control subjects (mean age 28 years) underwent comprehensive autonomic function testing, blood volume measurement, and cardiac magnetic resonance imaging. Twenty-five of the POTS patients were re-evaluated after a 3-month exercise program.
Results:
The mean supine and standing heart rates (HRs) were 88 and 114 bpm, respectively, in the POTS patients, and 72 and 89 bpm in the controls. Compared to the controls, the mean blood volume was significantly smaller in the POTS patients (60 vs. 71 ml/kg), as was the mean left ventricular mass (1.26 vs. 1.45 g/kg). There was no evidence of autonomic dysfunction in the POTS patients. Exercise training was associated with significant increases in blood volume and left ventricular mass of 7% and 12%, respectively, a mean decrease in upright HR of 9 bpm, and an improvement in quality of life.
Conclusions:
POTS results from a small heart and low blood volume, not from autonomic dysfunction. Exercise training is an effective therapy for POTS.
Perspective:
The Grinch, a character created by Dr. Seuss, had a heart that was ‘2 sizes too small,’ and, therefore, the authors of this study propose that POTS be referred to as the ‘Grinch Syndrome.’ This interesting study raises the question of whether a small heart also plays a role in another syndrome associated with sinus tachycardia, namely inappropriate sinus tachycardia.

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JUPITER: HDL not predictive of residual vascular risk among patients with low LDL levels
Ridker PM. Lancet. 2010; doi:10.1016/S0140-6736(10)60713-1.
Hausenloy DJ. Lancet. 2010; doi:10.1016/ S0140-6736(10)61021-5.
By
HDL concentrations were not indicative of residual vascular risk in patients who received statin therapy and attained very low LDL concentration, despite HDL being useful as part of initial CV risk assessment, according to new data from the JUPITER trial.
Participants in this randomized, placebo-controlled trial were adults (n=17,802) without diabetes or previous CV disease with baseline LDL concentrations less than 3.37 mmol/L and high-sensitivity CRP of at least 2 mg/L. Researchers randomly allocated patients by a computer-generated sequence to receive either 20 mg rosuvastatin (Crestor, AstraZeneca) per day or placebo. Both participants and adjudicators were masked to treatment assignment.
Primary endpoint incidence — including the first occurrence of non-fatal MI, non-fatal stroke, hospitalization for unstable angina, arterial revascularization or CV death — decreased in the rosuvastatin group (n=8,900) by 44% (P<.0001). In the patients given placebo (n=8,901), HDL concentrations were inversely associated with vascular risk at both baseline (top quartile vs. bottom quartile, HR=0.54; 95% CI, 0.35-0.83) and on-treatment (HR=0.55; 95% CI, 0.35-0.87). Conversely, patients given rosuvastatin (with a median on-treatment LDL concentration of 1.42 mmol/L) had no significant relationships between quartiles of HDL concentration and vascular risk either at baseline (HR=1.12; 95% CI, 0.62-2.03) or on-treatment (HR=1.03; 95% CI, 0.57-1.87).
Derek J. Hausenloy, PhD, Lionel Opie, MD, and Derek M. Yellon, PhD, all with the Hatter Institute, London, hypothesized in an accompanying editorial on why HDL levels did not predict CV risk at low concentrations of LDL.
“Perhaps, in patients with a low CV risk … who are treated to very low concentrations of LDL cholesterol, the relation between HDL cholesterol and CV risk is lessened,” they wrote. “Possibly, at very low LDL cholesterol concentrations, other lipid measures (such as the apolipoprotein B and apolipoprotein A-I ratio) will provide more accurate prediction of CV risk than do HDL cholesterol concentrations.”
According to study researchers, additional research testing the actual cause for their findings is needed.
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FDA conducting safety review of angiotensin receptor blockers’ link to cancer
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The FDA announced Thursday that it will conduct a review of angiotensin receptor blockers after a meta-analysis, published in Lancet Oncology, suggested that the class of drug may be linked with a small increased risk for cancer.
The review is ongoing, and no conclusions have been drawn between the use of angiotensin receptor blockers (ARBs) and cancer. The FDA said, at this time, the benefits of this class of drug outweigh any potential risk.
The FDA will review the available data on these medications and evaluate additional ways to better assess a possible link between use of ARBs and cancer. It will update the public when this review is complete.
The meta-analysis combined cancer-related findings from several clinical trials. The study found a small increased risk of reported new cancers in patients taking an ARB compared with those not taking an ARB. No statistically significant difference in cancer mortality was observed.
These clinical trials were not designed to study the effects of ARBs on cancer risk. The findings require close examination for more detailed information about the patients who were reported to have cancer so that it can be determined whether this cancer was in fact new. ARBs have been shown to provide significant benefit in many patients with certain heart-related conditions such as high BP and HF.
The FDA asked health care professionals to report adverse events involving ARBs to the FDA MedWatch program.

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IMPROVE HF: Implementation of practice-specific improvement programs linked with better care for patients with HF
Fonarow G. Circulation. 2010;doi: 10.1161/CIRCULATIONAHA.109.934471.
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The implementation of practice-specific performance improvement interventions was associated with improved use of guideline-recommended therapies for patients with chronic HF, primary results from the IMPROVE HF trial suggested.
“Despite compelling scientific evidence and readily accessible national guidelines, beneficial therapies for HF remain underused in many care settings,” the researchers wrote in their study. “IMPROVE HF is the first large-scale outpatient performance improvement initiative designed to assess the effects of a practice-specific, process-of-care improvement intervention on HF patient care.”
Researchers collected data on 34,810 participants with HF or post-MI and reduced ejection fraction (≤35%) from 167 U.S. outpatient cardiology practices. Participants were followed longitudinally for intervention at 12 and 24 months, including single-point-in-time cohorts measured at 6 and 18 months. The researchers then measured adherence to a set of practice-specific guideline-recommended performance improvement interventions designed to improve the quality of HF care delivery.
According to the study results, the performance improvement interventions were associated with improvement in five of seven quality measures at 24 months after implementation (P<.001). The researchers reported that adherence to evidence-based, guideline-recommended care among practices was associated with an absolute increase of 25.1% for aldosterone antagonist use, a 29.9% increase for cardiac resynchronization therapy use and a 27.4% increase in the use of implantable cardioverter defibrillators vs. baseline (P<.001). The use of beta-blockers (6.2%) and HF education tools (12.6%) also increased after implementation.
The use of anticoagulation in patients with permanent, paroxysmal or persistent atrial fibrillation, however, decreased, and the increased use of ACE inhibitors and angiotensin receptor blockers was not statistically significant. When analyzed at an aggregate level, improvements in six of seven improvement measures were reported. The 20% or more absolute improvement in at least three of the seven quality measures met the study’s primary endpoint, according to the researchers.
“The results of this study suggest a favorable impact of applying performance improvement techniques of clinical decision support, reminder systems, guideline-driven care improvement tools, educational outreach, collaborative support, performance profiling and feedback in real-world cardiology practices,” they concluded. “Implementation of this defined and scalable practice-specific intervention may enhance use of guideline-recommended HF therapies previously demonstrated to improve outcomes.”

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Veterans with HF experienced decreased mortality, increased rehospitalization during 4-year interval
Heidenreich P. J Am Coll Cardiol. 2010;56:362–368.
O’Connor C. J Am Coll Cardiol. 2010;56:369-371.
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Data from a study appearing in the Journal of American Cardiology has shown that veterans hospitalized with HF had a significant decline in mortality, whereas their rehospitalization rates appeared to increase during a 4-year period.
This study included patients (n=50,125) with a hospitalization for HF in the Veterans Affairs health care system from 2002 to 2006. Researchers compared rates of HF hospitalizations, 30-day rehospitalization for HF and 30-day mortality after discharge. They adjusted OR for outcome for patient diagnoses within the past year, laboratory data and clustering of patients within hospitals.
Mean age in patients (70 years) did not change during the 4-year period, but there were increases for most comorbidities, as the mean Charlson score rose from 1.72 to 1.89 (P<.0001). HF admission rates were steady at roughly 5 per 1,000 veterans. Additionally, 30-day mortality decreased from 7.1% to 5%, whereas rehospitalization for HF at 30 days increased from 5.6% to 6.1%.
This led researchers to conclude that the findings have implications for using rehospitalization as a measure of quality of care. “Additional studies are needed to determine the reasons for the decline in mortality and to determine which fraction of hospitalizations are preventable,” they said.
Christopher M. O’Connor, MD, and Mona Fiuzat, PharmD, both with Duke institutions in Durham, N.C., said in an accompanying editorial that the findings may lead one to conclude that the health care administrators in the VA system have performed with mixed results, with an “A” for mortality reduction and a “C–” for rehospitalization. “However, an in-depth analysis of the VA report indicates this may be far from the truth,” they wrote. “Rehospitalization after HF admission is complex, multifactorial and not clearly related to quality.”

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Title: The Quality of Care Provided to Hospitalized Patients at the End of Life
Date Posted: July 15, 2010
Authors: Walling AM, Asch SM, Lorenz KA, et al.
Citation: Arch Intern Med 2010;170:1057-1063.

Study Question:
What is the quality of end-of-life care among hospitalized patients?
Methods:
Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators. Patients who died during hospitalization and were hospitalized for at least 3 days between April 2005 and April 2006 in a major university medical center were included in the analysis.
Results:
A total of 496 patients were included in the study population, of which 47% were women. The mean age was 62 years, with 28% being 75 years or older. Primary reasons for hospitalization and death included advanced cancer (21%), end-stage liver disease (16%), end-stage pulmonary disease (11%), end-stage renal disease (9%), and end-stage heart failure (6%). Median hospital length of stay was 11 days, with 63% of patients hospitalized for 10 or more days. Do not resuscitate (DNR) orders were present in 84% of patients, with 28% of orders written on the day of death (median time of DNR orders was 2 days prior to death). Of the 359 patients receiving mechanical ventilation, 46% had ventilator withdrawn prior to death. Family meetings were documented in 55% of patients. Patient preferences for care related to resuscitation status were respected with fidelity. Timely documentation of discussion about patient preferences on admission to the intensive care unit occurred less than 50% of the time. Only 18% of patients had advance directives in their medical record at any point during hospitalization. Only 25% of patients with implantable cardioverter defibrillators, who were expected to die, had documentation regarding deactivation of the device. Only 29% of patients undergoing withdrawal of mechanical ventilation had dyspnea assessments documented in their charts.
Conclusions:
The authors concluded that quality of end-of-life care, as documented in medical charts, can be improved. Advance directives, palliative care plans, and assessment of symptoms such as pain and dyspnea are important components of end-of-life care.
Perspective:
Cardiovascular disease is a leading cause of death. End-of-life care for patients with heart disease, in particular heart failure, is an increasingly common part of hospital management. Yet training in end-of-life care is often not a component of cardiovascular training. Further study of the quality of care related to end-of-life care is needed.
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Title: Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease
Date Posted: July 6, 2010
Authors: Cooper-DeHoff RM, Gong Y, Handberg EM, et al.
Citation: JAMA 2010;304:61-68.

Study Question:
Does tight blood pressure (BP) control reduce cardiovascular (CV) outcomes among patient with diabetes and coronary artery disease (CAD)?
Methods:
Data from the International Verapamil SR-Trandolapril (INVEST) trial were used for this analysis. An observational subgroup of 6,400 participants (from the 22,576 INVEST subjects) who were 50 years or older, had diabetes, and had CAD were recruited between September 1997 and December 2000, from 862 sites in 14 countries. Subjects received first-line treatment of either a calcium antagonist or beta-blocker followed by an angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve a systolic BP of <130 mm Hg and a diastolic BP of <85 mm Hg. Patients were categorized by control into three groups: tight control <130 mm Hg, usual control 130 to <140 mm Hg, and uncontrolled ≥140 mm Hg. The primary outcome of interest included all-cause mortality, nonfatal myocardial infarction, or nonfatal stroke.
Results:
A total of 6,400 subjects were included (mean age 66 years, 54% women), of which 35.2% had tight BP control, 30.8% had usual BP control, and 34% had uncontrolled systolic BP. Over 16,893 patients-years of follow-up, cardiovascular outcomes were experienced in 286 (12.7%) subjects who had tight BP control, 249 (12.6%) who had usual BP control, and 431 (19.8%) who had uncontrolled BP. Subjects in the usual control group had fewer CV disease (CVD) events, as compared to those with uncontrolled BP (12.6% vs. 9.8%; hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.71). No significant difference was observed in CVD event rates for those in the usual BP control group compared to those in the tight BP control group (12.6% vs. 12.7%; HR, 1.11; 95% CI, 0.93-1.32). Regarding all-cause mortality, the event rate was 11.0% in the tight control group versus 10.2% in the usual control group (HR, 1.20; 95% CI, 0.99-1.45). Over the extended follow-up period (through 2008), all-cause mortality was higher among the tightly controlled group, as compared to the usual control group (22.8% vs. 21.8%; HR, 1.15; 95% CI, 1.01-1.32).
Conclusions:
The authors concluded that tight control of BP among patients with CAD and diabetes was not associated with fewer CV events compared with usual control.
Perspective:
This important study suggests that BP control among patients with CAD and diabetes should be <140 mm Hg; however, tight control under 130 mm Hg does not provide added benefit.

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Title: HDL Cholesterol and Residual Risk of First Cardiovascular Events After Treatment With Potent Statin Therapy: An Analysis From the JUPITER Trial
Date Posted: July 22, 2010
Authors: Ridker PM, Genest J, Boekholdt SM, et al.
Citation: Lancet 2010;376:333-339.

Study Question:
What is the association between high-density lipoprotein cholesterol (HDL-C) concentrations and occurrence of cardiovascular events when low-density lipoprotein cholesterol (LDL-C) concentrations are reduced to the very low ranges with high-dose statin treatment?
Methods:
Participants in the randomized placebo-controlled JUPITER trial were adults without diabetes or previous cardiovascular disease, and had baseline concentrations of LDL-C <3.37 mmol/L and high-sensitivity C-reactive protein of 2 mg/L or more. Participants were randomly allocated to receive rosuvastatin 20 mg per day or placebo, with participants and adjudicators masked to treatment assignment. In the present analysis, the investigators divided the participants into quartiles of HDL-C or apolipoprotein A1, and sought evidence of association between these quartiles and the JUPITER trial primary endpoint of first nonfatal myocardial infarction or stroke, hospitalization for unstable angina, arterial revascularization, or cardiovascular death.
Results:
For 17,802 patients in the JUPITER trial, rosuvastatin 20 mg per day reduced the incidence of the primary endpoint by 44% (p < 0.0001). In 8,901 (50%) patients given placebo (who had a median on-treatment LDL-C concentration of 2.80 mmol/L [interquartile range (IQR), 2.43-3.24]), HDL-C concentrations were inversely related to vascular risk both at baseline (top quartile vs. bottom quartile hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.35-0.83; p = 0.0039) and on-treatment (0.55; 0.35-0.87; p = 0.0047). By contrast, among the 8,900 (50%) patients given rosuvastatin 20 mg (who had a median on-treatment LDL-C concentration of 1.42 mmol/L [IQR, 1.14-1.86]), no significant relationships were noted between quartiles of HDL-C concentration and vascular risk either at baseline (1.12; 0.62-2.03; p = 0.82) or on-treatment (1.03; 0.57-1.87; p = 0.97). Their analyses for apolipoprotein A1 showed an equivalent strong relation to frequency of primary outcomes in the placebo group, but little association in the rosuvastatin group.
Conclusions:
The authors concluded that HDL-C concentrations are not predictive of residual vascular risk among patients treated with potent statin therapy who attain very low concentrations of LDL-C.
Perspective:
This analysis from the JUPITER trial suggests that although measurement of HDL-C concentration is useful as part of initial cardiovascular risk assessment, HDL-C concentrations are not predictive of residual vascular risk among patients treated with potent statin therapy who attain very low concentrations of LDL-C. These data and recent secondary prevention data from the TNT and PROVE IT trials provide little evidence to support the hypotheses that HDL-C levels predict risk of vascular events in the setting of high-dose statin therapy. These data, however, should not dissuade clinicians from measurement of HDL-C concentration as part of an initial cardiovascular risk assessment. Randomized trials will be needed to definitively test the role of potent HDL-raising therapies in the statin era of reducing cardiovascular disease events.
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Title: Efficacy and Safety of Automatic Remote Monitoring for Implantable Cardioverter-Defibrillator Follow-Up. The Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) Trial
Date Posted: July 21, 2010
Authors: Varma N, Epstein AE, Irimpen A, Schweikert R, Love C, on behalf of the TRUST Investigators.
Citation: Circulation 2010;122:325-332.

Study Question:
What is the incremental value of automatic remote monitoring compared to conventional device clinic follow-up in patients with implantable cardioverter-defibrillators (ICDs)?
Methods:
A total of 1,339 ICD recipients (mean age 63 years) were randomly assigned to remote home monitoring (HM) with automatic daily transmission of ICD data (n = 908) or to conventional device interrogation in clinic every 3 months (n = 431). The 1° efficacy endpoint was the number of in-office device evaluations, and the 1° safety endpoint was major adverse events (death, stroke, and events requiring surgical intervention).
Results:
The mean duration of follow-up was 1 year. The mean number of in-office device evaluations was significantly lower in the HM group than in the conventional group (2.1 vs. 3.8). A major adverse event occurred in 10% of patients, with no difference between the two groups. The median time to evaluation of arrhythmic events was <2 days in the HM group compared to 36 days in the conventional group.
Conclusions:
Remote HM of ICDs allows the early detection of ICD events without compromising safety.
Perspective:
This is the first large-scale clinical trial to compare automatic remote HM of ICDs to conventional follow-up in a device clinic. The two major advantages of HM over conventional clinic evaluations are that it does not depend on patient compliance and that it allows much earlier detection of a system malfunction.

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Title: Prospective Study of Obstructive Sleep Apnea and Incident Coronary Heart Disease and Heart Failure. The Sleep Heart Health Study
Date Posted: July 21, 2010
Authors: Gottlieb DJ, Yenokyan G, Newman AB, et al.
Citation: Circulation 2010;122:352-360.

Study Question:
Is obstructive sleep apnea (OSA) associated with the development of cardiac disease?
Methods:
This was a prospective epidemiologic study of subjects ≥40 years of age, free of coronary heart disease (CHD) and heart failure (HF) at baseline. All subjects underwent in-home polysonography, and the apnea-hypopnea index (AHI) was calculated. Incident CHD was defined as myocardial infarction, revascularization, or CHD death following polysonography. Incident HF was defined as the first occurrence of HF during the follow-up period.
Results:
There were 4,422 subjects (56% women) followed for a mean of 8.7 years. Twenty-four percent of men and 11% of women had moderate or worse OSA (AHI >14) on baseline polysonography. In women, there was no association between the AHI and the development of incident CHD or HF. The AHI predicted the development of incident HF in men (adjusted hazard ratio, 1.13 [1.02, 1.26] per 10 units of AHI), but was only predictive of CHD development in men who were ≤70 years of age (adjusted hazard ratio, 1.1 [1.00-1.21] per 10 AHI units).
Conclusions:
OSA may be associated with the development of HF in men ≥40 years old. Its association with the development of CHD is less clear.
Perspective:
At this time, it is not definitively known if OSA is an independent risk factor for the development of CHD or HF. Some have hypothesized that OSA instigates negative neurohormonal responses that can lead to HF development, but it is also possible that OSA is just a marker for the presence of other known, or stronger, CHD and HF risks. Unfortunately, this study fails to shed significant light on the query. A major limitation of the study is a vague definition of HF without a clearly mandated imaging or standardized New York Heart Association functional class assessment at follow-up. The reader is not provided information on ejection fraction or diastology assessment at baseline or at follow-up, and individuals with subclinical (stage B) HF may have been missed. Finally, pulmonary hypertension induced by OSA can have a large impact on a subject’s functional capacity and right ventricular (RV) function. It is unknown if the definition of HF included isolated RV failure and if OSA is associated with an increased incidence of RV dysfunction or pulmonary hypertension in this cohort. Many questions remain regarding OSA and its role in CHD and HF development.

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Dyssynchrony Indices to Predict Response to Cardiac Resynchronization Therapy: A Comprehensive, Prospective Single-Center Study
Miyazaki C, Redfield MM, Powell BD, et al.
Circ Heart Fail 2010;Jul 20:[Epub ahead of print].
Study Question: Do echocardiographic indices of dyssynchrony predict reverse remodeling or clinical response to cardiac resynchronization therapy (CRT)?


Use of Angiotensin Converting Enzyme Inhibitors Is Associated With Increased Growth Rate of Abdominal Aortic Aneurysms
Sweeting MJ, Thompson SG, Brown LC, Greenhalgh RM, Powell JT.
J Vasc Surg 2010;52:1-4.
Study Question: A recent retrospective Canadian study using a large administrative database has suggested that patients taking angiotensin-converting enzyme (ACE) inhibitors are less likely to present with a ruptured abdominal aortic aneurysm (AAA). The authors hypothesize that concurrent use of ACE inhibitors may be associated with a reduction in aneurysm growth rates.

Geographic Variation in Carotid Revascularization Among Medicare Beneficiaries, 2003-2006
Patel MR, Greiner MA, DiMartino LD, et al.
Arch Intern Med 2010;170:1218-1225.
Study Question: Have patterns of carotid artery revascularization changed since the Medicare national coverage decision in 2004 supporting carotid artery stenting (CAS) in patients at high surgical risk and those with symptomatic disease? And, is there geographic variation in and predictors of the use of carotid endarterectomy (CEA) and CAS?

Prognostic Value of Mid-Regional Pro-Adrenomedullin Levels Taken on Admission and Discharge in Non–ST-Elevation Myocardial Infarction: The LAMP (Leicester Acute Myocardial Infarction Peptide) II Study
Dhillon OS, Khan SQ, Narayan HK, et al.
J Am Coll Cardiol 2010;56:125-133.
Study Question: What is the prognostic value of admission and discharge mid-regional pro-adrenomedullin (sAM) levels in non–ST-elevation myocardial infarction (NSTEMI)?

Prognostic Value of Plasma Fibrinolysis Activation Markers in Cardiovascular Disease
Gorog DA.
J Am Coll Cardiol 2010;55:2701-2709.
Perspective: The following are 10 points to remember about this state-of-the-art paper.

Mitral Regurgitation due to Degenerative Mitral-Valve Disease
Foster E.
N Engl J Med 2010;363:156-165.
Perspective: Degenerative mitral valve disease is the most common form of organic mitral valve disease in the United States and other developed countries. Mitral valve prolapse, defined echocardiographically as systolic displacement of the mitral valve leaflets ≥2 mm beyond the annulus, is the most common functional abnormality associated with degenerative mitral valve disease, and is associated with both leaflet redundancy and chordal elongation.

Assessment of the Potential Heart Donor: A Role for Biomarkers?
Dronavalli VB, Banner NR, Bonser RS.
J Am Coll Cardiol 2010;56:352-361.
Perspective: The following are 10 points to remember about this state-of-the-art paper.

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Title: Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest
Date Posted: July 28, 2010
Authors: Svensson L, Bohm K, Castren M, et al.
Citation: N Engl J Med 2010;363:434-442.

Study Question:
Does compression-only cardiopulmonary resuscitation (CPR) result in better outcomes than conventional CPR?
Methods:
The subjects of this randomized clinical trial were 1,276 patients (mean age 68 years) with out-of-hospital cardiac arrest (OHCA). When the OHCA was reported to the emergency dispatcher by a witness, the dispatcher gave the bystander instructions to perform either compression-only CPR (n = 620) or conventional CPR (n = 656; two mouth-to-mouth ventilations alternating with 15 chest compressions). The 1° endpoint was 30-day survival.
Results:
There was not a significant difference in 30-day survival between the compression-only group (8.7%) and the conventional CPR group (7%).
Conclusions:
The investigators concluded that compression-only bystander CPR before the arrival of emergency medical services personnel does not compromise or significantly improve survival in patients with OHCA.
Perspective:
Experimental studies and retrospective clinical registry studies have demonstrated that elimination of ventilation during bystander CPR does not affect survival or neurological outcomes. At least in theory, compression-only CPR could improve survival by eliminating periodic interruptions in blood flow to the heart and brain during mouth-to-mouth ventilation. There was in fact a trend toward better survival with compression-only CPR in this study, but the difference was not significant, perhaps because the study was underpowered. In any event, there is no evidence that compression-only CPR compromises outcomes. Because it is easier to teach than conventional CPR and because many bystanders understandably are reluctant to perform mouth-to-mouth ventilation, compression-only CPR appears to be the preferred technique for bystander CPR.
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Title: CPR With Chest Compression Alone or With Rescue Breathing
Date Posted: July 28, 2010
Authors: Rea TD, Fahrenbruch C, Culley L, et al.
Citation: N Engl J Med 2010;363:423-433.

Study Question:
What are the outcomes with dispatcher-assisted cardiopulmonary resuscitation (CPR) when instructions consisted of chest compression alone and when instructions consisted of chest compression plus rescue breathing?
Methods:
The Dispatcher-Assisted Resuscitation Trial (DART) was a multicenter, randomized trial of dispatcher instructions to bystanders for performing CPR. The patients were persons 18 years of age or older with out-of-hospital arrest for whom dispatchers initiated CPR instruction to bystanders. Patients were randomly assigned to receive chest compression alone or chest compression plus rescue breathing. The primary outcome was survival to hospital discharge. Secondary outcomes included a favorable neurologic outcome at discharge.
Results:
Of the 1,941 patients who met the inclusion criteria, 981 were randomly assigned to receive chest compression alone and 960 to receive chest compression plus rescue breathing. The investigators observed no significant difference between the two groups in the proportion of patients who survived to hospital discharge (12.5% with chest compression alone and 11.0% with chest compression plus rescue breathing, p = 0.31) or in the proportion who survived with a favorable neurologic outcome in the two sites that assessed this secondary outcome (14.4% and 11.5%, respectively; p = 0.13). Prespecified subgroup analyses showed a trend toward a higher proportion of patients surviving to hospital discharge with chest compression alone, as compared with chest compression plus rescue breathing for patients with a cardiac cause of arrest (15.5% vs. 12.3%, p = 0.09) and for those with shockable rhythms (31.9% vs. 25.7%, p = 0.09).
Conclusions:
The authors concluded that the results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing.
Perspective:
This study suggests that CPR instructions consisting of chest compression alone did not increase survival to hospital discharge overall, as compared with instructions consisting of chest compression plus rescue breathing. However, it appears that chest compression alone may increase survival among certain subgroups of patients (i.e., those with a cardiac cause of arrest and those with ventricular fibrillation). The results, viewed in the context of other available data, provide support for a CPR strategy that emphasizes chest compression and minimizes the role of rescue breathing. Future studies are needed to further assess type-specific CPR aimed at the underlying cause of arrest.