Обзор американских кардиологических журналов за неделю (ссылки)

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Moving the Tipping Point
The Decision to Anticoagulate Patients With Atrial Fibrillation
Mark H. Eckman, MD, MS, Daniel E. Singer, MD, Jonathan Rosand, MD, MSc and Steven M. Greenberg, MD, PhD

+ Author Affiliations
From the Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati (M.H.E.), Cincinnati, Ohio; and the Research Group, Departments of Neurology (S.M.G., J.R.) and Clinical Epidemiology Unit (D.E.S.), Massachusetts General Hospital, Boston, Mass.
Correspondence to Mark H. Eckman, MD, University of Cincinnati Medical Center, PO Box 670535, Cincinnati, OH 45267-0535. E-mail [Ссылки доступны только зарегистрированным пользователям ]

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Abstract

Background— The rate of ischemic stroke associated with traditional risk factors for patients with atrial fibrillation has declined over the past 2 decades. Furthermore, new and potentially safer anticoagulants are on the horizon. Thus, the balance between risk factors for stroke and benefit of anticoagulation may be shifting.

Methods and Results— The Markov state transition decision model was used to analyze the CHADS2 score, above which anticoagulation is preferred, first using the stroke rate predicted for the CHADS2 derivation cohort, and then using the stroke rate from the more contemporary AnTicoagulation and Risk Factors In Atrial Fibrillation cohort for any CHADS2 score. The base case was a 69-year-old man with atrial fibrillation. Interventions included oral anticoagulant therapy with warfarin or a hypothetical “new and safer” anticoagulant (based on dabigatran), no antithrombotic therapy, or aspirin. Warfarin is preferred above a stroke rate of 1.7% per year, whereas aspirin is preferred at lower rates of stroke. Anticoagulation with warfarin is preferred even for a score of 0 using the higher rates of the older CHADS2 derivation cohort. Using more contemporary and lower estimates of stroke risk raises the threshold for use of warfarin to a CHADS2 score ≥2. However, anticoagulation with a “new, safer” agent, modeled on the results of the Randomized Evaluation of Long-Term Anticoagulation Therapy trial of dabigatran, leads to a lowering of the threshold for anticoagulation to a stroke rate of 0.9% per year.

Conclusions— Use of a more contemporary estimate of stroke risk shifts the “tipping point,” such that anticoagulation is preferred at a higher CHADS2 score, reducing the number of patients for whom anticoagulation is recommended. The introduction of “new, safer” agents, however, would shift the tipping point in the opposite direction.
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Long-term efficacy of high-dose tirofiban versus double-bolus eptifibatide in patients undergoing percutaneous coronary intervention

Schiariti, Michelea,b; Saladini, Angelaa; Cuturello, Domenicob; Missiroli, Bindoa; Puddu, Paolo Emiliob
Free Access
Article Outline
Author Information

aS. Anna Hospital, Catanzaro, Italy

bDepartment of the Heart and Great Vessels ‘A. Reale’, University ‘La Sapienza’, Rome, Italy

Received 28 January, 2010

Revised 22 April, 2010

Accepted 1 June, 2010

Correspondence to P.E. Puddu, MD, FESC, FACC, Dipartimento del Cuore e Grossi Vasi ‘Attilio Reale’, UOC Biotecnologie Applicate alle Malattie Cardiovascolari, Università degli Studi di Roma ‘La Sapienza’, Viale del Policlinico, 155, Rome 00161, Italy Tel: +39 06 4455291; fax: +39 06 4441600; e-mail: [Ссылки доступны только зарегистрированным пользователям ]
Abstract

Background: There is no head-to-head comparison between tirofiban versus eptifibatide in patients undergoing percutaneous coronary intervention (PCI) when added to standard antiaggregating drugs (AAD) to prevent ischemic events within 1 year.

Methods: We compared real-world patients undergoing PCI who were on oral single AAD and were block randomized to receive, immediately preintervention, high-dose tirofiban (n = 519) or double-bolus eptifibatide (n = 147) and a second oral antiplatelet agent. The incidence of composite ischemic events within 1 year, including death, acute myocardial infarction, angina, stent thrombosis or repeat PCI or coronary bypass surgery (primary end-point) was modelled by forced Cox's regression.

Results: There were overall 65 composite ischemic events: 47 (9.1%) in the tirofiban group and 18 (12.2%) in the eptifibatide group (univariate log-rank test: P = 0.22). On the basis of 21 potential covariates fitted simultaneously, multivariable adjusted hazard ratios showed that age [hazard ratio 1.03, 95% confidence interval (CI) 1.01–1.07, P = 0.01], chronic renal failure (hazard ratio 3.21, 95% CI 1.02–10.10, P = 0.05), pre-PCI values of creatine kinase-myocardial band (CK-MB) (hazard ratio 1.002, 95% CI 1.0002–1.0054, P = 0.04), intra-aortic balloon pump (hazard ratio 5.88, 95% CI 12.33–14.85, P = 0.0002) and the presence of eptifibatide (hazard ratio 1.85, 95% CI 1.04–3.29, P = 0.04) were significant risk factors whereas thrombolysis by tenecteplase (hazard ratio 0.19, 95% CI 0.05–0.69, P = 0.01) was a significant protector. Interestingly, eptifibatide versus tirofiban efficacy was explained based on pre-PCI values of CK-MB.

Conclusion: Head-to-head comparison between eptifibatide and tirofiban in patients undergoing PCI while on double AAD showed that eptifibatide had a lower efficacy on the incidence of composite ischemic events within 1 year, which might be explained by a reduced action on CK-MB pre-PCI.
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Quarky Calcium Release in the Heart
Didier X.P. Brochet, Wenjun Xie, Dongmei Yang, Heping Cheng, W. Jonathan Lederer

From the Center for Biomedical Engineering and Technology (BioMET) (D.X.P.B., W.J.L.), University of Maryland, Baltimore; Institute of Molecular Medicine (W.X., H.C.), National Laboratory of Biomembrane and Membrane Biotechnology, Peking University, Beijing, China; and Laboratory of Cardiovascular Sciences (D.Y.), National Institute on Aging, Baltimore, MD.


Correspondence to Heping (Peace) Cheng, PhD, Institute of Molecular Medicine, Peking University, Beijing 100871, China; (E-mail [Ссылки доступны только зарегистрированным пользователям ]); or to Didier X. P. Brochet, PhD, Center for Biomedical Engineering and Technology (BioMET), University of Maryland, 725 W Lombard St, Baltimore, MD 21201 (E-mail [Ссылки доступны только зарегистрированным пользователям ]).



Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
Sources of Funding
Disclosures
References
What Is Known
What New Information Does...


Rationale:In cardiac myocytes, "Ca2+ sparks" represent the stereotyped elemental unit of Ca2+ release arising from activation of large arrays of ryanodine receptors (RyRs), whereas "Ca2+ blinks" represent the reciprocal Ca2+ depletion signal produced in the terminal cisterns of the junctional sarcoplasmic reticulum. Emerging evidence, however, suggests possible substructures in local Ca2+ release events.

Objective:With improved detection ability and sensitivity provided by simultaneous spark–blink pair measurements, we investigated possible release events that are smaller than sparks and their interplay with regular sparks.

Methods and Results:We directly visualized small solitary release events amid noise: spontaneous Ca2+ quark-like or "quarky" Ca2+ release (QCR) events in rabbit ventricular myocytes. Because the frequency of QCR events in paced myocytes is much higher than the frequency of Ca2+ sparks, the total Ca2+ leak attributable to the small QCR events is approximately equal to that of the spontaneous Ca2+ sparks. Furthermore, the Ca2+ release underlying a spark consists of an initial high-flux stereotypical release component and a low-flux highly variable QCR component. The QCR part of the spark, but not the initial release, is sensitive to cytosolic Ca2+ buffering by EGTA, suggesting that the QCR component is attributable to a Ca2+-induced Ca2+ release mechanism. Experimental evidence, together with modeling, suggests that QCR events may depend on the opening of rogue RyR2s (or small cluster of RyR2s).

Conclusions:QCR events play an important role in shaping elemental Ca2+ release characteristics and the nonspark QCR events contribute to "invisible" Ca2+ leak in health and disease.
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Inflammation, Immunity, and Hypertension
David G. Harrison; Tomasz J. Guzik; Heinrich E. Lob; Meena S. Madhur; Paul J. Marvar; Salim R. Thabet; Antony Vinh; Cornelia M. Weyand

From the Divison of Cardiology (H.L., M.M., S.T., A.V.), Department of Medicine Emory University School of Medicine and the Atlanta Veteran Administration Hospital, Atlanta, GA; Department of Medicine (T.J.G), Jagiellonian University School of Medicine, Krakow, Poland; Department of Medicine (C.W.), Stanford University School of Medicine, Palo Alto, CA; Divisions of Clinical Pharmacology and Cardiology (D.G.H.), Department of Medicine, Vanderbilt University, Nashville, TN.

Correspondence to David G. Harrison, Division of Clinical Pharmacology, Vanderbilt University, 526 Robinson Research Building, Nashville, TN 37232-6602. E-mail [Ссылки доступны только зарегистрированным пользователям ]
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Cardiac Inflammation Contributes to Changes in the Extracellular Matrix in Patients With Heart Failure and Normal Ejection Fraction
Dirk Westermann, MD*, Diana Lindner, PhD*, Mario Kasner, MD, Christine Zietsch, PhD, K. Savvatis, MD, F. Escher, MD, J. von Schlippenbach, MD, C. Skurk, MD, Paul Steendijk, PhD, Alexander Riad, MD, Wolfgang Poller, MD, Heinz-Peter Schultheiss, MD and Carsten Tschöpe, MD

+
Author Affiliations
From the Department of Cardiology and Pneumology (D.W., D.L., M.K., C.Z., K.S., F.E., J.v.S., C.S., A.R., W.P., H.-P.S., C.T.), Charité, Universititäts-Medizin Berlin, Campus Benjamin Franklin, Berlin, Germany, and Department of Cardiology (P.S.), Leiden University Medical Center, Leiden, The Netherlands.
Correspondence to Dirk Westermann, MD, Department of Cardiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. E-mail [Ссылки доступны только зарегистрированным пользователям ]

↵* Drs Westermann and Lindner contributed equally to this work.

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Abstract

Background— The pathophysiology of heart failure with normal ejection fraction (HFNEF) is still under discussion. Here we report the influence of cardiac inflammation on extracellular matrix (ECM) remodeling in patients with HFNEF.

Methods and Results— We investigated left ventricular systolic and diastolic function in 20 patients with HFNEF and 8 control patients by conductance catheter methods and echocardiography. Endomyocardial biopsy samples were also obtained, and ECM proteins as well as cardiac inflammatory cells were investigated. Primary human cardiac fibroblasts were outgrown from the endomyocardial biopsy samples to investigate the gene expression of ECM proteins after stimulation with transforming growth factor-β. Diastolic dysfunction was present in the HFNEF patients compared with the control patients. In endomyocardial biopsy samples from HFNEF patients, we found an accumulation of cardiac collagen, which was accompanied by a decrease in the major collagenase system (matrix metalloproteinase-1) in the heart. Moreover, a subset of inflammatory cells, which expressed the profibrotic growth factor transforming growth factor-β, could be documented in the HFNEF patients. Stimulation of primary human cardiac fibroblasts from HFNEF patients with transforming growth factor-β resulted in transdifferentiation of fibroblasts to myofibroblasts, which produced more collagen and decreased the amount of matrix metalloproteinase-1, the major collagenase in the human heart. A positive correlation between cardiac collagen, as well as the amount of inflammatory cells, and diastolic dysfunction was evident and suggests a direct influence of inflammation on fibrosis triggering diastolic dysfunction.

Conclusions— Cardiac inflammation contributes to diastolic dysfunction in HFNEF by triggering the accumulation of ECM.

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Stroke in CABG-treated patients declined during 27-year period
Tarakji K. JAMA. 2011;305:381-390.

Results from a prospective, single-center study conducted between 1982 and 2009 suggest that patients undergoing CABG surgery had a decreased rate of stroke despite an increased patient risk profile.

In the study, 45,432 consecutive patients (mean age, 63 years) from the Cleveland Clinic underwent CABG surgery. Researchers recorded strokes that occurred after CABG and classified them as occurring intraoperatively or postoperatively.

During the 27 years, 705 patients (1.6%) had a stroke, with 279 occurring intraoperatively and 409 occurring postoperatively. The prevalence of stroke peaked at 2.6% in 1988 but decreased by 4.69% per year (P=.04) afterward, even with increasing patient comorbidity.

Older age and variables of arteriosclerotic burden were also reported as risk factors for intraoperative and postoperative stroke. Lowest intraoperative stroke rates were reported with on-pump beating-heart CABG (0%) and off-pump CABG (0.14%), whereas the highest was found with on-pump CABG with hypothermic circulatory arrest (5.3%).

Khaldoun G. Tarakji, MD, and colleagues said the decrease in occurrence of stroke but increase in patient risk profile is likely the result of improving preoperative assessment, intraoperative anesthetic and surgical techniques, and postoperative care.

“Further studies are needed to develop better strategies to minimize the occurrence of stroke among patients undergoing CABG,” they said.
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CDC findings highlight continued need for better control of hypertension, LDL
CDC. MMWR. 2011;60:1-6.
CDC. MMWR. 2011;60:7-12.

Two analyses have found that more than half of those with hypertension in the United States need to have it controlled, and despite improvements, LDL control still remains low. The findings were published in a February release of the CDC’s Morbidity and Mortality Weekly Report.

Hypertension controlled in nearly half of adults

The CDC’s look into hypertension prevalence began with data from the National Health and Nutrition Examination Survey that included 68 million US adults (age >18 years) with hypertension during the 2005-2008 survey period. Hypertension was defined as systolic/diastolic BP of at least 140 mm Hg/90 mm Hg, with less than 140 mm Hg/90 mm Hg defined as controlled hypertension.

Of the study population, 48 million (70%) were receiving pharmacological treatment, with hypertension controlled in 31 million (46%). Populations with hypertension noted for having a low percentage of BP control included those without a usual source of medical care (12%) and those without insurance (29%). Control prevalence was also low in young adults (aged 18-39 years; 31%) and Mexican Americans (37%). Although no changes in the prevalence of hypertension from the 1999-2002 survey period were reported, the CDC said there were significant increases in treatment and control.

Room for more improvement in LDL control

For its analysis of LDL control, the CDC also examined data from the 1999-2002 and 2005-2008 survey cycles of NHANES. The final population from the 2005-2008 cycle included an estimated 71 million US adults aged at least 20 years who had high LDL, as stated in the National Cholesterol Education Program – Adult Treatment Panel III primary prevention guidelines.

According to CDC’s data, 34 million adults (48.1%) had their LDL treated while 23 million (33.2%) had it controlled. Although at a treatment rate roughly 22% lower compared with hypertension, LDL treatment increased nearly 20% compared with 6 years earlier, suggesting a “striking” improvement in the prevalence of treatment and control. Despite this, the CDC said more must be done about the estimated one-third of Americans with high LDL, of which only one-third are controlled.

Other data of note from the analysis were the low prevalence of LDL control among those who reported receiving medical care less than twice in the previous year (11.7%), having income below the poverty level (21.9%), as well as those who were uninsured (13.5%) or Mexican American (20.3%).
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Stroke center admission linked with improved mortality, thrombolytic-therapy use
Xian Y. JAMA. 2011;305:373-380.

Patients admitted to stroke centers for acute ischemic stroke had lower 30-day all-cause mortality and more frequently used thrombolytic therapy when compared with nondesignated hospitals, new data have shown.

“Previous evaluations of stroke center quality performance have primarily focused on process measures with limited information on patient outcomes,” the researchers wrote. “Even though the differences in outcomes between stroke centers and nondesignated hospitals were modest, our study suggests that the implementation and establishment of a [Brain Attack Coalition]-recommended stroke system of care was associated with improvement in some outcomes for patients with acute ischemic stroke.”

Researchers of the observational study collected data from the New York Statewide Planning and Research Cooperative System and compared mortality for patients admitted with acute ischemic stroke (n=30,947) between 2005 and 2006 at designated stroke centers (n=15,297) and nondesignated hospitals (n=15,650).

At 30 days, researchers found that patients admitted to stroke centers had lower all-cause mortality (10.1% vs. 12.5%; P<.001) and were more likely to use thrombolytic therapy (4.8% vs. 1.7%; P<.001) compared with those admitted to nondesignated hospitals. Statistically significant differences were also observed with mortality at 1-day, 7-day and 1-year follow-up.

To determine whether the findings were specific to stroke, researchers also tested 30-day all-cause mortality rates of patients with gastrointestinal hemorrhage and acute MI at designated and nondesignated centers and found that the outcomes were similar.

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Worldwide adult obesity prevalence has doubled since 1980
Finucane M. Lancet. 2011; doi:10.1016/S0140-6736(10)62037-5.
Danaei G. Lancet. 2011; doi:10.1016/S0140-6736(10)62036-3.
Farzadfar F. Lancet. 2011; doi:10.1016/S0140-6736(10)62038-7.

Three studies of global health trends recently published in The Lancet suggested the worldwide prevalence of obesity has doubled since 1980, but that average BP and cholesterol levels have decreased in wealthy Western countries.

The three studies were conducted by the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. To calculate their totals, the authors culled health data of adults 25 years and older from published and unpublished health examination surveys and epidemiological studies across 199 countries and territories. To define their trends, they compared data from 2008 to data from 1980.
Results from the BMI study indicated that more than one in 10 of the world’s adults was obese in 2008, with women more likely to be obese than men. Obesity was defined as having a BMI above 30 kg/m². Overall, the study estimated that more than half a billion adults worldwide are obese.

The study of systolic blood pressure (SBP) observed a slight decrease in the percentage of the world’s population with uncontrolled hypertension, defined as SBP higher than 140 mm Hg or diastolic blood pressure higher than 90 mm Hg. High-income countries achieved larger reductions in uncontrolled hypertension, with men in North America faring the best by losing 2.8 mm Hg in SBP per decade on average. Increases in SPB in both sexes were observed in Oceania, east Africa, and south and southeast Asia.

The final study reported that the 2008 age-standardized mean cholesterol level worldwide was 4.6 mmol/L for men and 4.76 mmol/L for women. The researchers also found average cholesterol levels decreasing by 0.2 mmol/L per decade in North America, Australia and Europe. Cholesterol increases were observed in east and southeast Asia and the Pacific region (0.8 mmol/L per decade for men and 0.9 mmol/L per decade for women).

"Our results show that overweight and obesity, high BP and high cholesterol are no longer Western problems or problems of wealthy nations. Their presence has shifted towards low- and middle-income countries, making them global problems,” author Majid Ezzati, PhD, Imperial College London, United Kingdom, said in a press release.

"The findings are an opportunity to implement policies that lead to healthier diets, especially lower salt intake, at all levels of economic development, as well as looking at how we improve detection and control through the primary healthcare system.,” Ezzati continued. “Policies and targets for cardiovascular risk factors should get special attention at the High-level Meeting of the United Nations General Assembly on Non-Communicable Diseases in September 2011."
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Women with PAD lost mobility faster than men with PAD
McDermott M. J Am Coll Cardiol. 2011;57:707-714.

Women with lower-extremity peripheral arterial disease experienced faster functional declines than men with the condition. These functional declines included decreased endurance, lowered walking velocity and the development of mobility disabilities, according to a study.

For up to 4 years, researchers had 380 men and women with PAD undergo annual walking tests. A 6-minute walk screened for endurance mobility disability, whereas a 4-minute walk test measured declines in walking velocity. Patients who passed the tests at baseline were tracked annually. A loss of mobility was defined as losing the ability to walk for one-quarter mile or to walk up and down one flight of stairs without assistance.

At 4 years, women were more likely than men to lose the ability to walk for 6 uninterrupted minutes (HR=2.30; 95% CI, 1.30-4.06). The distance women achieved in the 6-minute walk declined faster than men (P=.041). Women were also more likely to develop a mobility disability (HR=1.79; 95% CI, 1.30-3.03), and they had quicker declines in walking velocity (P=.022). These results were adjusted for age, race, BMI, the ankle brachial index, level of physical activities and comorbidities, according to the study.

The researchers also measured the participants’ calf muscles with CT at baseline and 2- and 4-year visits. At baseline, woman had smaller calves, lower muscle density and poorer knee extension strength. When the sex differences in function decline were adjusted for calf differences, the differences in functional decline lost statistical significance.

“These findings suggest that lower calf muscle area and reduced knee extension strength in women at baseline may explain in part the faster rates of functional decline in women with PAD as compared with men with PAD,” the researchers wrote in the study. “Identifying sex differences in lower extremity outcomes among patients with PAD will help clinicians to provide prognostic information and to make optimal therapeutic decisions for patients with PAD.”

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PROSPECT: Major adverse CV events after PCI in patients with ACS attributed to culprit, nonculprit lesions
Stone G. N Engl J Med. 2011;364:226-235.

Data from the PROSPECT trial have indicated that major adverse CV events occurring in patients with acute coronary syndrome who underwent percutaneous coronary intervention were the result of culprit and nonculprit lesions equally.

“The primary purpose of this natural-history study was to provide prospective in vivo confirmation of the hypothesis that ACS arise from atheromas with certain histopathological characteristics, and that these characteristics are not necessarily dependent on the degree of angiographic stenosis at that site,” the researchers wrote. “Although most of the lesions responsible for major adverse CV events during follow-up were angiographically mild, intravascular ultrasonography showed that most had either a small luminal area, a large plaque burden, or both — findings that are consistent with the results of pathological studies.”

The Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) trial featured 697 patients with ACS. After PCI, all patients underwent three-vessel coronary angiography and gray-scale and radiofrequency IVUS (Eagle Eye, In-Vision Gold; Volcano) imaging.

After a median follow-up of 3.4 years, researchers reported a 3-year rate of major adverse CV events of 20.4%, which researchers reported was related to culprit lesions in 12.9% of patients and nonculprit lesions in 11.6%.

Furthermore, nonculprit lesions were predominately mild at baseline. After multivariate analysis, nonculprit lesions that were associated with recurrent events were more likely than those not associated to be characterized by plaque burden of at least 70% (HR=5.03; 95% CI, 2.51-10.11), a minimal luminal area of 4 mm2 or less (HR=3.21; 95% CI, 1.61-6.42), or to be classified by radiofrequency intravascular ultrasonography as thin-cap fibroatheromas (HR=3.35; 95% CI, 1.77-6.36).

Initial Cardiology Today coverage of the PROSPECT trial from Cardiovascular Research Technologies 2010 can be viewed here.

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FINESSE-ANGIO: Pre-cath abciximab before primary PCI linked to higher infarct-related artery patency rates
Prati F. J Am Coll Cardiol Intv. 2010;3:1284-1291.

Pre-cath lab administration of abciximab, both alone and with half-dose reteplase, when preceding primary percutaneous coronary intervention led to higher rates of infarct-related artery patency at baseline coronary angiography vs. standard primary percutaneous coronary intervention, according to data from the FINESSE-ANGIO trial.

Researchers for the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events-Angiographic (FINESSE-ANGIO) study tested the effects of three different treatments — pre-cath lab administration of half-dose reteplase (Retavase, EKR Therapeutics) plus abciximab (ReoPro, Centocor), abciximab alone or abciximab administered directly before primary PCI — on patency of infarct-related artery during basal coronary angiography. The trial included 637 patients from the FINESSE study.

According to results, patients taking reteplase plus abciximab experienced higher rates of baseline infarct-related artery patency when compared with abciximab alone (76.1% vs. 43.7%; P<.0001) and abciximab taken immediately before PCI procedure (76.1% vs. 32.7%; P<.0001). No significant differences were reported in the post-PCI thrombolysis in MI or the rates of post-PCI TIMI flow grade 3, myocardial blush grade 2/3.

“Primary PCI preceded by pre-catheterization treatment with abciximab alone, and especially with abciximab plus half-dose reteplase, resulted in higher [infarct-related artery] patency rates at baseline coronary angiography compared with standard primary PCI,” the researchers wrote. “Whether clinical benefit correlated with pharmacologically induced or improved pre-PCI myocardial reperfusion may be restricted to higher risk subsets remains to be determined by future prospective studies.”

In an accompanying editorial, Bernard J. Gersh, MB, ChB, DPhil, of the Mayo Clinic, Rochester, Minn.,and Gregg W. Stone, MD,of Columbia University Medical Center, New York, commented on the importance of early treatment.

“For decades, we have appreciated that acute MI is a time-critical phenomenon and that early therapy is crucial for myocardial recovery, especially in the hyperacute phase, when ‘time is myocardium.’ Educating the public to seek treatment at an early stage after symptom onset is likely to reduce mortality to a greater degree than pharmacological facilitation before PCI, although translation of this goal to reality in a community setting is and will continue to be extremely difficult,” Gersh and Stone said.

Disclosure: This study was coordinated in part with research funding from Centocor. Dr. Stone and Dr. Gersh report no relevant financial disclosures.

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Наиболее читаемые статьи в 2010

Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults
Medicine & Science in Sports & Exercise
Official Journal of the American College of Sports Medicine
Overweight and obesity affects more than 66% of the adult population and is associated with a variety of chronic diseases. Weight reduction reduces health risks associated with chronic diseases and is therefore encouraged by major health agencies. Guidelines of the National Heart, Lung, and Blood Institute (NHLBI) encourage a 10% reduction in weight, although considerable literature indicates reduction in health risk with 3% to 5% reduction in weight. Physical activity is recommended as a component of weight management for prevention of weight gain, for weight loss, and for prevention of weight regain after weight loss. In 2001, the American College of Sports Medicine published a Position Stand that recommended a minimum of 150 minutes per week of moderate–intensity physical activity for overweight and obese adults to improve health; however, 200–300 minutes per week was recommended for long–term weight loss. More recent evidence has supported this recommendation and has indicated more physical activity may be necessary to prevent weight regain after weight loss. To this end, the article reexamines the evidence from 1999 to determine whether there is a level at which physical activity is effective for prevention of weight gain, for weight loss, and prevention of weight regain.
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Dabigatran added to guidelines for management of patients with AF
Wann LS. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2011.01.010.

The 2011 Focused Update on the Management of Patients with Atrial Fibrillation has incorporated dabigatran into its recommendations for the treatment of atrial fibrillation.

The focused update was a collaborative effort of the American College of Cardiology Foundation, American Heart Association and the Heart Rhythm Society. The recommendations come after dabigatran (Pradaxa, Boehringer-Ingelheim), an oral direct thrombin inhibitor, was recently approved by the FDA for stroke prevention in patients with nonvalvular AF.

According to the new recommendation, “Dabigatran is useful as an alternative to warfarin (Coumadin, Bristol-Myers Squibb) for the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent AF and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure (creatinine clearance <15 mL/minute) or advanced liver disease (impaired baseline clotting function).” The level of evidence for the recommendation was categorized as B, which indicates in this instance that the data were derived from a single randomized trial (RE-LY).
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Carotid stenting comparable to carotid endarterectomy for long-term stroke prevention
De Rango P. J Am Coll Cardiol. 2011;57:664-671.

For stroke prevention, carotid artery stenting can have similar 5-year outcomes to carotid endarterectomy, provided the physician uses sound judgment in choosing which technique to perform, according to a recent study.

Researchers prospectively tracked 1,118 patients who were treated by carotid endarterectomy (CEA) and 1,084 patients who underwent carotid artery stenting (CAS). Overall, 71% were men, and the mean age was 71.3 years. All of the patients were either more than 60% symptomatic or more than 70% asymptomatic for carotid stenosis. The choice of revascularization method was left to the treating physician. Typically, patients with known allergies to aspirin, clopidogrel, or contrast media and renal insufficiency were excluded from CAS, as were those patients with aortic arch anatomy, severe peripheral vascular disease precluding femoral access or extremely tortuous carotid anatomy. Patients with high-neck carotid bifurcation and long carotid lesions, as well as obese patients or those taking ongoing dual antiplatelet therapy, were generally excluded from CEA, according to the study.

Overall, 30-day stroke/death rates were 2.8% in the CAS group and 2% in the CEA group — a statistical similarity (P=.27). The risk of 30-day stroke or death was higher in symptomatic (3.5%) vs. asymptomatic (2%) patients (P=.04) but was statistically similar. At 5 years, survival rates were statistically similar between the two groups: 82% in CAS and 87.7% in CEA (P=.05). There were no sex- or age-related significant outcome differences, according to the study.

Per Kaplan-Meier estimates, the composite of any periprocedural stroke or death and ipsilateral stroke at 5 years after the procedure were similar in all patients (4.7% vs. 3.7%; P=.4). Kaplan-Meier estimates were similar for the subgroups of symptomatic (8.7% vs. 4.9%; P=.7) in CEA and asymptomatic (2.5% vs. 3.3%; P=.2) in CAS.

“When physicians use their clinical judgment to select the appropriate technique for carotid revascularization, CAS can offer efficacy and durability comparable to CEA with benefits persisting at 5 years,” the researchers concluded.

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MADIT-CRT: CRT-D more effective in women than men
Arshad A. J Am Coll Cardiol. 2011;57:813-820.

Women in the randomized MADIT-CRT trial had significantly greater reductions in death or HF, HF alone and all-cause mortality with cardiac resynchronization therapy using defibrillator than men.

Researchers of the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) enrolled 1,820 patients (24.9% women) and analyzed sex-specific outcomes comparing the effect of cardiac resynchronization therapy with defibrillator (CRT-D) against implantable cardioverter defibrillator therapy.

They found better results with CRT-D for female patients, culminating with a 70% reduction in HF (P<.001) and a 69% reduction in death or HF (P<.001), which were significantly lower when compared with men (P<.01 for each).

Also reported was a 72% reduction of all-cause mortality in women (P<.02), as well as an 82% reduction in mortality for those with QRS of at least 150 ms and 78% reduction in those with left bundle branch block (LBBB) conduction disturbance. However, for female patients with non-LBBB, rates of death or HF (HR=1.97; 95% CI, 0.40-9.64), as well as HF alone (HR=1.95; 95% CI, 0.40-9.53), were nearly two times greater.

Significant differences in baseline characteristics between women and men, the researchers wrote, could explain part of the observed findings because a greater proportion of women had a substrate of nonischemic cardiomyopathy and an underlying LBBB pattern.

“It is possible that among patients with heart disease, the risk of HF is greater for women than for men, resulting in a greater benefit from preventive CRT-D therapy in women,” they said.

Cardiology Today’s initial coverage of MADIT-CRT can be viewed here. – by Brian Ellis

Dr. Arshad and her colleagues report that women in the MADIT-CRT trial obtained significantly greater reductions in death or HF, HF alone, and all-cause mortality with CRT-D therapy than men. Although these findings were associated with greater echocardiographic evidence of reverse remodeling in women compared with men, the differences were small. Furthermore, female patients were more likely to have nonischemic cardiomyopathy and LBBB and less likely to have renal dysfunction than men; these factors are known to be associated with improved outcomes. Conversely, men had more ischemic heart disease, prior revascularization and renal dysfunction. Thus, the overall findings are not surprising.

On the other hand, it is notable that women with ICDs rather than CRT-Ds had worse outcomes than men, and women had a significantly overall higher likelihood of device-related adverse events than men. Despite these findings, just as in the case of atrial fibrillation and age, male gender should not be taken to mean that men should not receive CRT-D therapy, since the subset is less likely to respond. Patients who are male, the elderly and those with atrial fibrillation simply have blunting of beneficial responses, not absent response. Why women with nonischemic cardiomyopathy seem to be more responsive to CRT than are men remains unknown.
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LEAPS: Locomotor training not superior to home-based therapy post-stroke

International Stroke Conference 2011

Results from the LEAPS trial have indicated that a locomotor training program featuring body weight-supported treadmill training did not produce superior outcomes in patients post-stroke when compared with a rigorous home-based physical therapy, although both did produce improvements in mobility at 1 year.

“The important message [of this study] is that patients do change and they improve over time. What we found is that the more high-tech intervention didn’t help them walk any better [and that] the home-based exercise program works as well,” Pamela W. Duncan, PhD, professor and research fellow at Duke University School of Medicine, Durham, North Carolina, and investigator on the trial, said in an interview with Cardiology Today.

The Multi-site Phase III Randomized Trial of Physical Therapy Interventions to Improve Walking Recovery Post-stroke (LEAPS) was the largest randomized controlled trial performed in rehab, including 408 patients following stroke. The patients were randomly assigned to three groups: early locomotor training program (LTP; n=139) at two months post-stroke, late LTP (n=143) at 6 months post-stroke and home-based therapy (n=126) 2 months post-stroke.

At 1 year following stroke, the researchers found that functional outcome did not differ significantly between groups, with improved functional walking ability reported in 50.4% of the early-LTP group, 53.8% of the late-LTP group and 51.6% of the home-based therapy arm. Additionally, those in the early LTP group did not have improved change in comfortable walking speed at 1 year when compared with the late-LTP group (0.23 ± 0.20 m/s vs. 0.24 ± 0.23 m/s).

In the study’s secondary outcome, Duncan and fellow colleagues found that when compared to usual care at 6 months, those who received more structured, progressive interventions recovered twice as well.

“So, in stroke as in heart disease, exercise and maintaining your strength and mobility is extremely important and we have to figure out ways to do this more effectively,” Duncan said. – by Brian Ellis

We know that recovery and rehabilitation post-stroke is very important. We are looking for new approaches to improve outcomes in our stroke survivors. Walking and mobility are two of the biggest things that affect quality of life in a stroke survivor.

Although [the LEAPS researchers] hoped that this innovative approach to improving walking would be beneficial they weren’t able to show that. However, they were able to show that if you do home-based physical therapy at 2 months post the usual time period for rehab you had some very important recovery in terms of walking and mobility at 6 months and a year. This is important to us because sometimes the early acute rehab period passes and both patients and physicians neglect the longer-term importance of physical therapy and rehab. I try to emphasize it to my patients but sometimes insurance doesn’t cover it and other things kick in. I think this implies that home-based physical therapy started two months after stroke could still be very important for improving long-term outcomes.

So I think this shows us that sometimes the more innovative, possibly more costly approach isn’t always better than old-fashioned home-based physical therapy which I think that this trial shows is a very important rehabilitation opportunity for us to improve outcomes.

I think the LEAPS result is a transformative result. It shows us that intensive and prolonged therapy to improve gait is better than our usual care of only short and modest intensity therapy. It didn’t really matter which way we delivered the intensive and prolonged therapy, whether it was home-based physical therapy or a sophisticated locomotor weight elevation program. But we didn’t know for the lower extremity and for gait whether intensive therapy was better than standard care. We knew that for upper extremity before and this means that we need to change the way we’re taking care of patients. We need to have them engage much more often in prolonged therapy so that they can gain all the benefit they can while their brain is plastic and responsive to change after a stroke

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‘Ideal’ CV health extremely low among the middle-aged
Bambs C. Circulation. 2011;doi:10.1161/CIRCULATIONAHA.110.980151.

Less than 10% of a new study’s participants met at least five of the seven “ideal” CV health components stated in the American Heart Association’s 2020 Impact Goal.

The 2020 Impact Goal was designed to improve CV health of all Americans by 20% and reduce CVD and stroke mortality by 20%. The AHA’s definition of ideal CV health encompasses four health behaviors, which are smoking status, BMI, physical activity, and fruit and vegetable consumption, and three health factors, including total cholesterol, BP and fasting plasma glucose.

The researchers used the criteria to evaluate 1,933 participants (mean age, 59 years; 44% blacks, 56% whites; 66% women) of the community-based Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study.

Overall, only one participant met all seven components of the AHA definition, whereas less than 10% met at least five. Further, only 2% had all four components of the ideal health behaviors index and 1.4% had all three of the health factors’ index. After adjustment for age, sex and income level, blacks had significantly lower odds of having at least five ideal CV health components than whites (OR=0.18; 95% CI, 0.10-0.34).

Additionally, men had significantly worse status regarding smoking, BP, BMI and fasting plasma glucose, whereas women had poorer total cholesterol and physical activity status.

“Because of the comprehensive nature of the new AHA construct of CV health, we anticipated a low prevalence of ideal categories,” the researchers wrote. “However, the fact that only one out of 1,933 participants met the definition of ideal CV health and that the indices of ideal health behaviors and factors were only met by 2% and 1.4% of the participants, respectively, is especially concerning because of the participatory nature of our project, the use of a community-based recruitment strategy and the inherent healthy volunteer bias that we expected to be associated with more favorable findings.”

This large gap separating the prevalence of ideal CV health from AHA’s goals, the researchers said, suggests that the attainment of the stated goals for the next decade may be much more challenging than originally conceived.

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CDC survey: Statin use increased 23% over past two decades

A CDC survey found that the percentage of adults 45 years and older who use statins increased from 2% between 1988 and 1994 to 25% between 2005 and 2008. Further findings from the study indicated that half of men aged 65 to 74 years had taken a statin in between 2005 and 2008 compared with more than one-third of women in the same age group.

The 34th annual report of the national health survey was released last week CDC’s National Center for Health Statistics. Entitled “Health, United States, 2010,” the report compiled health data from federal and state health agencies, and included an in-depth feature on death and dying.

While not exclusively focused on cardiology, this year’s report included a number of CV highlights. For example, in 2007, the report found that heart disease was the leading cause of the death in the United States, followed by cancer. Exactly one quarter of all death in America in 2007 due to heart disease.

Despite being the leading cause of death, the heart disease death rate for adults 65 years of age and older decreased by 26% to 1,309 deaths per 100,000 population. Heart disease accounted for 28% of deaths for adults in this age group in 2007.

The report also observed that hypertension, defined as either having high BP or as taking antihypertensive medications, increased with age. Between 2005 and 2008, roughly 34% of adults aged 45 to 54 years had hypertension, vs. 67% of men and 80% of women aged 75 years and older.

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Updated guidelines for CVD prevention in women encompass clinical practice findings
Mosca L. Circulation. 2011;doi:10.1161/CIR.0b013e31820faaf8

The 2011 update to the American Heart Association’s guidelines for the prevention of CVD in women has incorporated benefits and risks associated with clinical practice findings, besides those observed in clinical research. Further, the guidelines also feature changes regarding the CVD risk classification threshold.

The AHA first published women-specific clinical recommendations for prevention of CVD in 1999. One of the major changes with the present guidelines compared with earlier ones, executive writing committee and expert panel members of the guidelines wrote, was that the benefits and risks observed in clinical practice of preventive therapies were strongly considered, and recommendations were not limited to evidence of benefits observed in clinical research.

“Hence, in the transformation from ‘evidence-based’ to ‘effectiveness-based’ guidelines for the prevention of CVD in women, the panel voted to update recommendations to those therapies that have been shown to have sufficient evidence of clinical benefit for CVD outcomes,” the writing committee and panel members wrote.

The updated guidelines now include modifications to the risk classification algorithm that acknowledge several 10-year risk equations for predicting 10-year global CVD risk, such as the updated Framingham CVD risk profile and Reynolds risk score for women. The new threshold for defining high risk is at least a 10% 10-year risk of all CVD, instead of an at least 20% Framingham 10-year predicted risk for CHD alone, which had previously identified women at high risk in the 2007 update.

“Indeed, it is difficult for a woman<75 years of age, even with several markedly elevated risk factors, to exceed a 10% (let alone a 20%) 10-year predicted risk for CHD with the Adult Treatment Panel III risk estimator,” the guideline authors wrote.

Besides recognizing the importance of racial, ethnic and socioeconomic traits in determining a patient’s risk for CVD, the guidelines also include several illnesses that put a woman at risk, including gestational diabetes, preeclampsia and pregnancy-induced hypertension, as well as those that put her at high risk, including clinically manifest CHD and diabetes.

Because most of the data used to develop these guidelines was based on trials of CHD prevention, the authors said future guidelines “should consider recommendations for specific outcomes of particular importance to women, such as stroke.” This, they said, is particularly critical because 55,000 more women die of stroke than men every year before they reach the age of 75 years
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Resource use increased among Medicare beneficiaries with HF at end of life
Unroe K. Arch Intern Med. 2011;171:196-203.

During the last 6 months of life, days of intensive care, hospice use and cost all increased for Medicare beneficiaries with HF during an 8-year period, according to findings from the Archives of Internal Medicine.

“Heart failure is listed on one in eight death certificates in the United States. Although some people live with HF for years, more than one-quarter of Medicare beneficiaries die within 1 year of the incident diagnosis, and 36% die within 1 year of a HF–related hospitalization,” the researchers wrote. “In this longitudinal analysis … we found that most patients [with HF] frequently accessed the health care system and spent some time in the hospital.”

The retrospective cohort study featured 229,543 Medicare beneficiaries with HF who died from 2000 to 2007. Investigators analyzed the beneficiaries’ resource use during the last 180 days of life, including all-cause hospitalizations, hospice, home health, ICU days, skilled nursing facility stays, durable medical equipment, outpatient physician visits and cardiac procedures.

Throughout the study period, about 80% of beneficiaries were hospitalized in the last 6 months of life. Investigators found that days in intensive care rose (3.5 to 4.6; P<.001), as did use of hospice (19% to 40%; P<.001) and unadjusted mean cost per beneficiary (26% increase; $28,766 to $36,216; P<.001).

When age, race, sex, geographic region and comorbid conditions were adjusted for, cost still increased by 11%. Renal disease, black race and chronic obstructive pulmonary disease were each independent predictors of higher costs, whereas increasing age was a strong independent factor for lower costs. Additionally, regional differences remained after adjustment, with higher costs of care found in the Northeast and West vs. the South.

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Referral strategy led to high rate of cardiac rehabilitation use
Grace S. Arch Intern Med. 2011;171:235-241.

Automatic referral combined with a liaison referral resulted in the highest rates of cardiac rehabilitation use among patients in a prospective controlled study.

Researchers in the Canadian study enrolled 2,635 inpatients with CAD from 11 Ontario hospitals and referred them to one of 52 cardiac rehabilitation programs. Patients were asked to complete a sociodemographic survey, and clinical data were obtained from medical charts. After 1 year, patients were then sent a follow-up survey that assessed self-reported cardiac rehabilitation referral, enrollment and participation, of which 1,809 patients responded.

According to study data, adjusted analyses indicated that referral strategy was significantly related to cardiac rehabilitation referral and enrollment (P<.001), with the greatest cardiac rehabilitation use found in the combined automatic and liaison referral strategy (OR=8.41; 85.8% referral, 73.5% enrollment) when compared with usual referral (32.2% referral, 29% enrollment). Other strategies showing high cardiac rehabilitation use when compared with usual referral were automatic only (OR=3.27; 70.2% referral, 60% enrollment) and liaison only (OR=3.35; 59% referral, 50.6% enrollment).

The results of this study, when combined with the results of a recent systematic review of the field, the researchers wrote, suggest that wider adoption of combined automatic- and liaison-based referral strategies should be promoted.

“Discussion with health care providers involved in cardiac rehabilitation referral at participating institutions revealed that this combination of strategies may be most effective because it targets the health care provider and patient,” they said. “Implementation could potentially raise cardiac rehabilitation use 45% (range, 29.1%-74%), suggesting that major public health gains could be achieved in the population being treated for cardiac disease.”
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Prognostic impact of no-reflow following acute myocardial infarction
An article from the e-journal of the ESC Council for Cardiology Practice

Conclusion

Contrast-enhanced CMR is a useful non-invasive technique for assessing the presence and extent of microvascular obstruction. No-reflow phenomenon has important prognostic implications, and the use of CMR can help to identify and quantify areas of microvascular damage in patients with STEMI. It could become a powerful tool to stratify the risk of patients and in future to differentiate the effectiveness of different techniques of reperfusion.
[Ссылки доступны только зарегистрированным пользователям ]

[Chevychelov]

Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction
LaPointe NM, Al-Khatib SM, Piccini JP, et al.
Circ Cardiovasc Qual Outcomes 2011;Feb 8:[Epub ahead of print].
Study Question: How often do eligible patients with heart failure (HF) not receive an implantable cardioverter-defibrillator (ICD) for the primary prevention of sudden cardiac death (SCD)?

Additional Ablation of Complex Fractionated Atrial Electrograms (CFAEs) After Pulmonary Vein Antral Isolation (PVAI) in Patients With Atrial Fibrillation: A Meta-Analysis
Li W, Bai Years, Zhang H, et al.
Circulation Arrhyth Electrophysiol 2011;Feb 8:[Epub ahead of print].
Study Question: Does ablation of complex fractionated atrial electrograms (CFAEs) improve the efficacy of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) when performed after pulmonary vein antrum isolation (PVAI)?

Effects of Aspirin Responsiveness and Platelet Reactivity on Early Vein Graft Thrombosis After Coronary Artery Bypass Graft Surgery
Gluckman TJ, McLean RC, Schulman SP, et al.
J Am Coll Cardiol 2011;57:1069-1077.
Study Question: What parameters of platelet function following coronary artery bypass graft surgery (CABG) in patients on aspirin (ASA) are predictive of early bypass graft failure?

Association of Myocardial Enzyme Elevation and Survival Following Coronary Artery Bypass Graft Surgery
Domanski MJ, Mahaffey K, Hasselblad V, et al.
JAMA 2011;305:585-591.
Study Question: What is the relationship between peak post-coronary artery bypass grafting (CABG) elevation of biomarkers of myocardial damage and early, intermediate-, and long-term mortality?

Prenatal Ultrasound Screening of Congenital Heart Disease in an Unselected Population: A 21-Year Experience
Marek J, Tomek V, Škovránek J, Povýšilová V, Šamánek M.
Heart 2011;97:124-130.
Study Question: What is the prevalence of congenital heart disease and the impact of a national prenatal ultrasound screening program on outcomes in a discrete patient population?

Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians
Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P, on behalf of the Clinical Guidelines Committee of the American College of Physicians.
Ann Intern Med 2011;154:260-267.
Perspective: The following are 10 points to remember about these guidelines on the use of intensive insulin therapy (IIT) for the management of glycemic control in hospitalized patients

5-Year Follow-Up After Primary Percutaneous Coronary Intervention With a Paclitaxel-Eluting Stent Versus a Bare-Metal Stent in Acute ST-Segment Elevation Myocardial Infarction: A Follow-Up Study of the PASSION (Paclitaxel-Eluting Versus Conventional Stent in Myocardial Infarction With ST-Segment Elevation) Trial
Vink MA, Dirksen MT, Suttorp MJ, et al.
JACC Cardiovasc Interv 2011;4:24-29.
Study Question: What are the long-term outcomes of the PASSION (Paclitaxel-Eluting Versus Conventional Stent in Myocardial Infarction With ST-Segment Elevation) trial?

Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke: Patient Characteristics, Hospital Factors, and Outcomes Associated With Door-to-Needle Times Within 60 Minutes
Fonarow GC, Smith EE, Saver JL, et al.
Circulation 2011;123:750-758.
Study Question: What were the presenting characteristics of acute ischemic stroke patients treated with intravenous tissue-type plasminogen activator (tPA) within 3 hours of symptom onset in whom a door-to-needle time ≤60 minutes was achieved, hospital-level variation in door-to-needle times, in-hospital clinical outcomes, and temporal trends in timely thrombolytic care?

Relationship Between Risk Stratification at Admission and Treatment Effects of Early Invasive Management Following Fibrinolysis: Insights From the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)
Yan AT, Yan RT, Cantor WJ, et al.
Eur Heart J 2011; Feb 8:[Epub ahead of print].
Study Question: Does risk stratification using the Global Registry of Acute Coronary Events (GRACE) influence effectiveness of early routine percutaneous coronary intervention (PCI) after fibrinolysis for ST-segment elevation myocardial infarction (STEMI)?

Compelling Evidence of Long-Term Outcomes in Pulmonary Arterial Hypertension? A Clinical Perspective
Gomberg-Maitland M, Dufton C, Oudiz RJ, Benza RL.
J Am Coll Cardiol 2011;57:1053-1061.
Conclusions: The following are 10 points to remember from a review of clinical trials in pulmonary arterial hypertension (PAH).

Quantitative Troponin and Death, Cardiogenic Shock, Cardiac Arrest and New Heart Failure in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS): Insights From the Global Registry of Acute Coronary Events
Jolly SS, Shenkman H, Brieger D, et al., on behalf of the GRACE Investigators.
Heart 2011;97:197-202.
Study Question: What is the implication of the absolute level of troponin elevation in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS)?

Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention
Earnshaw SR, Scheiman J, Fendrick AM, McDade C, Pignone M.
Arch Intern Med 2011;171:218-225.
Study Question: What is the cost-utility of aspirin treatment with or without a proton pump inhibitor (PPI) for coronary heart disease (CHD) prevention among men at different risks for CHD and gastrointestinal (GI) bleeding?