Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents
Topic: Noninvasive Cardiology
Date Posted: 5/17/2010 2:00:00 PM
Author(s): Hundley WG, Bluemke DA, Finn JP, et al.
Citation: J Am Coll Cardiol 2010;May 17:[Epub ahead of print].
Clinical Trial: No
Related Resources
JACC Article: ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

Perspective: The following are 10 points to remember about this expert consensus document.

1. Cardiac magnetic resonance imaging (CMR) is based on detection of signals from hydrogen nuclei, which have a high concentration within the body. A magnetic field causes hydrogen nuclei to align along a fixed axis. Smaller magnetic pulses are then added (“pulse sequences”), which create an image of the protons. A variety of pulse sequences can be used for specific applications, which subsequently target moving blood or tissue. Magnetic field strengths are expressed in Tesla (T) and typical field strengths used for cardiovascular disease are 1.0, 1.5, and less frequently, 3.0 T. Higher strength fields produce higher spatial resolution.

2. CMR has several advantages, including absence of ionizing radiation or use of radioactive isotopes or iodinated contrast. A second advantage is the ability of CMR to evaluate the entire human body independent of body habitus (within physical limitations of a patient fitting within the scanner) or other disease, such as lung disease, which may interfere with echocardiographic imaging. Third, CMR is a family of examination techniques allowing assessment of anatomical features and function as well as blood flow.

3. Commonly used CMR techniques for evaluating cardiovascular disease include dark blood imaging. With this technique, pulse sequences detect slowly moving protons such as those within myocardium, while faster moving blood pool protons rapidly move out of the imaging plane and are not detected. Conversely, bright blood imaging specifically images the rapidly moving blood within chambers and vessels, and can provide a highly accurate measure of left ventricular (LV) size and function. Phase contrast data from CMR can be used to determine blood velocity from which intracardiac hemodynamics, such as one relevant for valvular heart disease, can be calculated. Tagging techniques allow extraction of highly detailed data regarding myocardial contraction from which strain and strain rate can be calculated. Gadolinium contrast is sequestered in the interstitium, and delayed gadolinium enhancement (LGE) is a highly accurate marker of myocardial fibrosis and scar.

4. CMR plays a valuable role in evaluation of patients with congestive heart failure. It provides a highly accurate assessment of left and right ventricular size, shape and function can identify highly specific morphology associated with diseases such as amyloidosis and myocardial noncompaction, among others. Contrast phase imaging can be used for determination of blood flow velocities from which diastolic function can be assessed. Identification of LGE representing myocardial scar provides prognostic information regarding ventricular arrhythmias.

5. CMR plays multiple roles in patients with known or suspected coronary artery disease (CAD), including determination of LV size and function and detection of occult myocardial infarction. CMR may be used for determining perfusion at rest and stress, and for determination of LV wall motion during dobutamine stress for detection of occult CAD.

6. The most valuable role that CMR plays in patients with valvular heart disease is in determination of left and right ventricular function with a lesser role for precise identification of valve anatomy such as identification of bicuspid aortic valves, vegetations, etc. Intracardiac hemodynamics regarding gradients can also be determined as part of the assessment of valvular heart disease.

7. CMR plays a unique and valuable role in simple and complex congenital heart disease. Its major advantage is that it simultaneously visualizes cardiac and extracardiac vascular structures, and is ideally suited for assessment of complex extracardiac vascular anatomy. It can play a valuable role in presurgical planning in patients with congenital heart disease where three-dimensional representation of a complex, anatomical relationship is routinely available.

8. CMR using magnetic resonance angiography (MRA) can play a valuable role in assessment of the vascular system including detection of disease of the aorta, including aortic dissection and aneurysm and carotid and renal disease. Both anatomical and functional information regarding intraluminal flow can be obtained.

9. Other clinically proven miscellaneous applications of CMR include identification of acute myocarditis, pulmonary angiography for detection of pulmonary embolus, assessment of pericardial disease, including pericardial constriction, and identification and characterization of both benign and malignant intracardiac masses.

10. All medically available devices have been characterized as CMR safe, conditional, or unsafe. Prior to undergoing CMR, patients with medical devices should inform the examiner of the nature and presence of the device, the safety of which subsequently can be determined from published tables. The majority of coronary artery and peripheral vascular stents are weakly or non-ferromagnetic and are considered CMR safe. The potential risks of medical devices in a CMR field include: movement of the device, which is unlikely for non- or weakly ferromagnetic devices (especially if chronically implanted); device heating, which may be particularly relevant for retained transvenous pacemaker and defibrillator leads; or interference with device function, which is a significant consideration for pacemakers. In general, patients with implanted stents can safely undergo CMR, whereas it is recommended that those with pacemaker and defibrillator devices undergo CMR only in highly specialized centers with experience in CMR in these individuals, and the appropriate assembled team to handle any programming issues or complications that arise. William F. Armstrong, M.D., F.A.C.C.

[Chevychelov]

CardiosourceNews from Heart Rhythm 2010

Official Title: A Phase III Prospective Randomized Double-Blind Active Controlled, Multicenter Superiority Study of Vernakalant Injection versus Intravenous Amiodarone in Subjects with Recent Onset Atrial Fibrillation. The AVRO Trial
Event: Heart Rhythm 2010
Topic(s): Arrhythmias
Presenter: John Camm
Writer(s): Fred M. Kusumoto, M.D., F.A.C.C.
Date Posted: 5/14/2010
Summary
A Phase III Prospective Randomized Double-Blind Active Controlled, Multicenter Superiority Study of Vernakalant Injection versus Intravenous Amiodarone in Subjects with Recent Onset Atrial Fibrillation. The AVRO Trial.

Background
Vernakalant is an investigational antiarrhythmic agent that has been shown to be more effective than placebo for rapid conversion (within 90 minutes) of atrial fibrillation after cardiac surgery (vernakanat: 47% vs. placebo: 14%) (Kowey et al). Multiple antiarrhythmic medications including Class 1C drugs such as flecainide/propafenone and Class III drugs such as ibutilide and dofetilide have been used for rapid chemical conversion of atrial fibrillation with moderate success (20-60% depending on the population studied).

Study Design
The investigators randomized patients (n= 254) with recent onset sustained (3 -48 hours) atrial fibrillation in a double blind, active controlled, double blind manner to two serial doses of vernakalant (3 mg/kg followed by an additional 2 mg/kg dose if the patient remained in atrial fibrillation) or serial doses of amiodarone (5 mg/kg followed by a 50 mg dose if the patient remained in atrial fibrillation). The primary endpoint was proportion of patients with conversion to sinus rhythm in 90 minutes. and sSecondary endpoints included: Time to conversion, proportion of patients without symptoms due to atrial fibrillation at 90 minutes, and change in quality of life.

Results and Conclusions
Vernakalant was significantly more effective than amiodarone for converting atrial fibrillation to sinus rhythm within 90 minutes (vernakalant: 51.7% vs. amiodaone: 5.2%). Vernakalant was also more effective than amiodaone for eliminating symptoms due to atrial fibrillation within 90 minutes (vernakalant: 53.4 % vs. amiodarone: 32.8%). Vernakalant was safe and generally well tolerated although patients complained of transient symptoms such as dysgeusia (6.9%), cough (3.4%) and nausea (2.6%). One patient developed nonsustained ventricular tachycardia, but no episodes of Torsades de Pointes or sustained ventricular arrhythmias were observed.

Perspective
The AVRO study found that vernakalant is more effective than intravenous amiodarone for rapid conversion of atrial fibrillation to sinus rhythm. Vernakalant is a promising new (currently investigational) antiarrhythmic medication that may be a useful alternative for rapid conversion of atrial fibrillation to sinus rhythm.

[Chevychelov]

CardiosourceNews from Heart Rhythm 2010

Official Title: Fish Oil to Inhibit Supraventricular Arrhythmias after Cardiac Surgery: The FISH Trial
Event: Heart Rhythm 2010
Topic(s): Arrhythmias, Cardiovascular Surgery
Presenter: Chirag Sandesara
Writer(s): Fred M. Kusumoto, M.D., F.A.C.C.
Date Posted: 5/14/2010
Summary
Perioperative beta-3 polyunsaturated fatty acids (PUFA) do not reduce the incidence of atrial fibrillation after coronary artery bypass grafting surgery (CABG).

Background
Postoperative atrial arrhythmias develop in 20-55% of patients after cardiac surgery and are associated with increased morbidity, mortality, and cost (annual estimated cost exceeding one1 billion dollars). One randomized study found that PUFA given for five 5 days before and after surgery can significantly reduce the development of postoperative atrial fibrillation (Calo et al) that was not confirmed in two similarly sized more recent randomized studies (Heidarsdottir et al, Saravanan et al).

Study Design
In this multicenter, double blind randomized, placebo controlled study, 260 patients undergoing non-emergent CABG were randomized to PUFA (2 g twice daily with a minimum total dosage of 6 g preoperatively and a post operative dose of 2 g once daily) or placebo. The primary endpoint was clinically significant and ECG documented atrial fibrillation or atrial flutter within 14 days after surgery that required treatment. Secondary endpoints included hospital length-of-stay, rehospitalization for atrial fibrillation, perioperative myocardial infarction, stroke, or bleeding.

Results and Conclusions
Perioperative treatment with PUFA was not associated with a decrease in postoperative atrial fibrillation (PUFA: 30% vs. Placebo 33%). Similarly no differences in secondary endpoints such as hospital length-of-stay or perioperative complications were detected between PUFA and placebo. The PUFA doses used in this trial were associated with a significant increase in plasma concentrations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and a decrease in the plasma ratio of -6/-3 from baseline (Screening: 9.10; Surgery: 6.44; POD 4: 6.18) that was not observed in the placebo group.

Perspective
In this modest sized randomized trial, Tthe FISH trial found no benefit with perioperative oral PUFA therapy for reducing the likelihood for developing clinically significant atrial fibrillation after CABG. Although questions on dosing and route (oral vs. intravenous) will continue, three of four studies have not been able to demonstrate a decrease in post-operative AF associated with oral PUFA.
References
Calт L, Bianconi L, Colivicchi F, , et al. N-3 Fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a randomized, controlled trial. J Am Coll Cardiol. 2005;45:1723-8.
Heidarsdottir R, Arnar DO, Skuladottir GV, , et al. Does treatment with n-3 polyunsaturated fatty acids prevent atrial fibrillation after open heart surgery? Europace. 2010;12:356-63.
Saravanan P, Bridgewater B, West AL, O'Neill SC, Calder PC, Davidson NC. Omega-3 fatty acid supplementation does not reduce risk of atrial fibrillation after coronary artery bypass surgery: a randomized, double-blind, placebo-controlled clinical trial. Circ Arrhythm Electrophysiol. 2010;3:46-53.

[Chevychelov]

CardiosourceNews from Heart Rhythm 2010

Official Title: J-Rhythm II Study. A randomized study of Angiotensin II Type 1 Receptor Blocker vs. Dihydropyridine Ca Antagonist for Treatment of Paroxysmal Atrial Fibrillation in Patients with Hypertension
Event: Heart Rhythm 2010
Topic(s): Prevention/Vascular
Presenter: Takeshi Yamashita
Writer(s): Fred M. Kusumoto, M.D., F.A.C.C.
Date Posted: 5/14/2010
Summary
In patients with hypertension and paroxysmal atrial fibrillation, both candesartan and amlodipine reduce blood pressure and frequency of atrial fibrillation at one-year follow-up with no significant differences between the agents for decreasing arrhythmia burden.

Background
Atrial fibrillation is present in 5-7 million people in the United States and is associated with significant morbidity and increased mortality, particularly in those patients with cardiovascular risk factors (Miyasaka et al, Fuster et al). Although radiofrequency catheter ablation and antiarrhythmic medication can be effective for reducing symptoms in selected populations, defining optimal “upstream” strategies for reducing the development or progression of atrial fibrillation would have a far larger impact on overall healthcare.

Study Design
The J-RHYTHM II trial randomized 318 patients with hypertension and paroxysmal atrial fibrillation in an open label manner to candesartan (8-12 mg) or amlodipine (2.5-5 mg). Daily transtelephonic monitoring was performed for one month prior to randomization and during one-year follow-up. The primary endpoint was difference in the number of days per month with atrial fibrillation between baseline and the last month of follow-up. Secondary endpoints included development of persistent atrial fibrillation and/or requiring cardioversion, changes in left atrial dimension, and changes in quality-of-life indices.

Results and Conclusions
Both candesartan and amlodipine reduced the number of days that patients were in atrial fibrillation after one year of therapy as compared with the pre-treatment month-long monitoring period: (candesartan: Decrease in 1.5 days/month; amlodipine: Decrease in 2.5 days/month). There was with no significant difference detected between the two therapies. Both candesartan and amlodipine reduced blood pressure after one year relative to baseline, although amlodipine was more effective than candesartan. During the study period 8% of patients treated with candesartan and 15% of patients treated with amlodipine developed persistent atrial fibrillation or required cardioverion (p = 0.08). Both amlodipine and candesartan were associated with improvement in quality-of-life indices after one year of treatment.

Perspective
The results of the J_RHYTHM II trial emphasize the importance of blood pressure control in patients with hypertension and atrial fibrillation. Different hypertension treatment strategies were not associated with differences in arrhythmia burden. However, in this study population, 70% of patients were being treated with Class I antiarrhythmic medication. It is possible that there may be differences between hypertension treatments for the progression or development of atrial fibrillation in other populations where the arrhythmia hasd not yet developed or is less established.
References
Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006;114:119-25
ACC/AHA Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines; Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006;50:562-

[Chevychelov]

Title: A Controlled Trial of Sildenafil in Advanced Idiopathic Pulmonary Fibrosis
Topic: General Cardiology
Date Posted: 5/18/2010 3:00:00 PM
Author(s): The Idiopathic Pulmonary Fibrosis Clinical Research Network.
Citation: N Engl J Med 2010;May 18:[Epub ahead of print].
Clinical Trial: yes
Study Question: What is the effect of sildenafil on walk distance, dyspnea, and quality of life in patients with advanced idiopathic pulmonary fibrosis?
Methods: The investigators conducted a double-blind, randomized, placebo-controlled trial (called the Sildenafil Trial of Exercise Performance in Idiopathic Pulmonary Fibrosis [STEP-IPF]) of sildenafil in two periods. The first period consisted of 12 weeks of a double-blind comparison between sildenafil and a placebo control. The primary outcome was the proportion of patients with an increase in the 6-minute walk distance of 20% or more. Key secondary outcomes included changes in oxygenation, degree of dyspnea, and quality of life. The second period was a 12-week open-label evaluation involving all patients receiving sildenafil.
Results: A total of 180 patients were enrolled in the study. The difference in the primary outcome was not significant, with 9 of 89 patients (10%) in the sildenafil group and 6 of 91 (7%) in the placebo group having an improvement of 20% or more in the 6-minute walk distance (p = 0.39). There were small but significant differences in arterial oxygenation, carbon monoxide diffusion capacity, degree of dyspnea, and quality of life favoring the sildenafil group. Serious adverse events were similar in the two groups.
Conclusions: The authors concluded that this study did not show benefit for sildenafil for the primary outcome in patients with advanced idiopathic pulmonary fibrosis.
Perspective: In this randomized clinical study, sildenafil did not show a significant improvement in the primary endpoint of 6-minute walk distance among patients with advanced idiopathic pulmonary fibrosis. There were small but significant differences in degree of dyspnea and quality of life, which may be of clinical significance. The data provide rationale for further research and studies of sildenafil in this difficult to treat patient cohort. Meanwhile, use of sildenafil in patients with advanced idiopathic pulmonary fibrosis should only be considered after a frank and thorough discussion with the patient regarding lack of evidence of improvement in the primary outcome despite the symptomatic improvement seen in this study and other small case series. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Time to Treatment With Intravenous Alteplase and Outcome in Stroke: An Updated Pooled Analysis of ECASS, ATLANTIS, NINDS, and EPITHET Trials
Topic: General Cardiology
Date Posted: 5/19/2010
Author(s): Lees KR, Bluhmki E, von Kummer R, et al., on behalf of the ECASS, ATLANTIS, NINDS, and EPITHET rt-Pa Study Group Investigators.
Citation: Lancet 2010;375:1695-1703.
Clinical Trial: No
Study Question: What is the contemporary effect of time to treatment with intravenous rt-PA (alteplase) on therapeutic benefit and clinical risk?
Methods: The authors added data from ECASS III (821 patients) and EPITHET (100 patients) trials to a pool of common data elements from six other trials of alteplase for acute stroke (2,775 patients). Multivariate logistic regression was used to assess the relation of stroke onset to start of treatment (OTT) with treatment on favorable 3-month outcome (defined as modified Rankin score 0-1), mortality, and occurrence and outcome of clinically relevant parenchymal hemorrhage. The presence of an arterial occlusion was inferred from the patient’s symptoms and absence of hemorrhage or other causes of ischemic stroke. Vascular imaging was not a requirement in the trials. All patients with confirmed OTT within 360 minutes were included in the analysis.
Results: Treatment was started within 360 minutes of stroke onset in 3,670 patients randomly allocated to alteplase (n = 1,850) or to placebo (n = 1,820). Odds of a favorable 3-month outcome increased as OTT decreased (p = 0.0269) and no benefit of alteplase treatment was seen after around 270 minutes. Adjusted odds of a favorable 3-month outcome were 2.55 (95% confidence interval, 1.44-4.52) for 0-90 minutes, 1.64 (1.12-2.40) for 91-180 minutes, 1.34 (1.06-1.68) for 181-270 minutes, and 1.22 (0.92-1.61) for 271-360 minutes in favor of the alteplase group. Large parenchymal hemorrhage was seen in 96 (5.2%) of 1,850 patients assigned to alteplase and 18 (1.0%) of 1,820 controls, with no clear relation to OTT (p = 0.4140). Adjusted odds of mortality increased with OTT (p = 0.0444) and were 0.78 (0.41-1.48) for 0-90 minutes, 1.13 (0.70-1.82) for 91-180 minutes, 1.22 (0.87-1.71) for 181-270 minutes, and 1.49 (1.00-2.21) for 271-360 minutes.
Conclusions: The authors concluded that patients with ischemic stroke selected by clinical symptoms and CT benefit from intravenous alteplase when treated up to 4.5 hours.
Perspective: This updated pooled analysis suggests that treatment with thrombolysis until 4.5 hours from stroke onset enhances the chance of favorable outcome. Serious hemorrhage rates are independent of stroke onset to start of treatment (OTT), but mortality increases with OTT longer than 4.5 hours. Across the time window studied, this analysis showed that the greatest benefit comes from earlier treatment, since net benefit diminishes and is undetectable in beyond 4.5 hours. These findings should spur a renewed commitment by emergency physicians, neurologists, and policy makers to target very early intervention with a proposed door-to-needle time of <60 minutes in the great majority of patients. Debabrata Mukherjee, M.D., F.A.C.C.

[Chevychelov]

Title: Peripartum Cardiomyopathy as a Part of Familial Dilated Cardiomyopathy
Topic: Heart Failure/Transplant
Date Posted: 5/19/2010
Author(s): van Spaendonck-Zwarts KY, van Tintelen JP, van Veldhuisen DJ, et al.
Citation: Circulation 2010;121:2169-2175.
Clinical Trial: No
Study Question: What is the role of genetic factors in the pathogenesis of peripartum cardiomyopathy (PPCM)?
Methods: The investigators reviewed their database of 90 dilated cardiomyopathy (DCM) families, focusing specifically on the presence of PPCM patients. Then, in a reverse approach, they reviewed 10 PPCM patients seen in their clinic since the early 1990s and performed cardiological screening of the first-degree relatives of three PPCM patients who did not show a full recovery. Finally, they analyzed the genes known to be most commonly involved in DCM in the PPCM patients.
Results: The investigators identified a substantial number (5 of 90, 6%) of DCM families with PPCM patients. Second, cardiological screening of first-degree relatives of three PPCM patients who did not show full recovery revealed undiagnosed DCM in all three families. Finally, genetic analyses revealed a mutation (c.149A>G, p.Gln50Arg) in the gene encoding cardiac troponin C (TNNC1) segregating with disease in a DCM family with a member with PPCM, supporting the genetic nature of disease in this case.
Conclusions: The authors concluded that these findings strongly suggest that a subset of PPCM is an initial manifestation of familial DCM.
Perspective: In this study, the authors identified a substantial number of DCM families with PPCM patients. Furthermore, they found support for the genetic nature of disease in one DCM family with PPCM by identifying a mutation in TNNC1, suggesting that PPCM can be a manifestation of familial DCM. Additional research is needed to confirm these findings and to better understand the interaction between oxidative stress associated with the peripartum/postpartum period and genetic factors. Based on the study, it may be reasonable to do presymptomatic screening for covert DCM in first-degree relatives of PPCM patients using noninvasive techniques. Debabrata Mukherjee, M.D., F.A.C.C.

[Chevychelov]

Title: Carotid Artery Stent Placement
Topic: Cardiovascular Surgery
Date Posted: 5/19/2010
Author(s): White CJ.
Citation: JACC Cardiovasc Interv 2010;3:467-474.
Clinical Trial: No
Related Resources
JACC Cardiovasc Intv Article: Carotid Artery Stent Placement

Perspective: The following are 10 points to remember from this state-of-the-art paper on carotid artery stent placement:

1. Stroke is the third leading cause of death in the United States and the common cause of disability. Most strokes are ischemic in origin.

2. Asymptomatic carotid stenosis (>50%) occurs in 5-10% of patients over the age of 65 years. The prevalence of severe carotid stenosis is less than 1%.

3. The annual risk of stroke associated with a >50% asymptomatic carotid stenosis is ~1-4.3%. The risk is higher in those with severe stenosis or those with progressive increase in the degree of carotid narrowing.

4. Most strokes occur in patients with no prior symptoms. Occurrence of a TIA is associated with a 15% risk of stroke at 1 month. The risk of stroke associated with a symptomatic stenosis increases with the degree of carotid narrowing.

5. Carotid endarterectomy (CEA) is considered beneficial if the risk of perioperative stroke or death is 3% or less in an asymptomatic patient and ≤6% for symptomatic patients.

6. Studies comparing carotid stenting (CAS) to CEA have demonstrated disparate results, with trials with experienced interventionalists demonstrating little difference in outcome between the two strategies while others showing better outcomes with CEA. The recently reported CREST trial demonstrated no difference in the primary endpoint between the two strategies.

7. Most of the data suggest no difference in risk of major stroke, whereas minor strokes are increased with CAS. Conversely, the risk of myocardial infarction and cranial neuropathies is increased with CEA. There appears to be an age interaction, with younger patients (<69 years) demonstrating better outcomes with CAS and older patients better outcomes with CEA.

8. Long-term outcome appears similar between CEA and CAS irrespective of the trial.

9. Contemporary preventive therapy (statins and contemporary antihypertensive therapy) has not been compared with carotid revascularization, and it is not clear if the advantage of carotid revascularization in patients with asymptomatic carotid stenosis is still extant in patients treated with aggressive medical therapy.

10. CEA and CAS should be viewed as complementary therapies since there are patients who clearly do better with one versus the other therapy, while a large group of patients could be treated with either strategy. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

[Chevychelov]

Title: Intravascular Ultrasound Findings in Patients With Very Late Stent Thrombosis After Either Drug-Eluting or Bare-Metal Stent Implantation
Topic: Interventional Cardiology
Date Posted: 5/20/2010
Author(s): Lee CW, Kang SJ, Park DW, et al.
Citation: J Am Coll Cardiol 2010;55:1936-1942.
Clinical Trial: No
Related Resources
JACC Article: Intravascular Ultrasound Findings in Patients With Very Late Stent Thrombosis After Either Drug-Eluting or Bare-Metal Stent Implantation

Study Question: What are the intravascular ultrasound (IVUS) findings at drug-eluting stent (DES) and bare-metal stent (BMS) sites in patients with very late stent thrombosis (VLST)?
Methods: A total of 30 consecutive VLST patients with acute myocardial infarction (DES, n = 23; BMS, n = 7) were enrolled in the study. Patients underwent IVUS examination before coronary angioplasty. The IVUS images were recorded on s-VHS videotape or computer disk and analyzed by personnel unaware of the type of stent implanted.
Results: The baseline characteristics were similar for the two groups, with the exception of reference vessel size, lesion length, stent length, minimal lumen diameter, and diameter stenosis after the procedure. Overall, VLST occurred at a mean 50.8 ± 36.2 months after the index procedure, and occurred earlier after DES than BMS (33.2 ± 12.5 months vs. 108.4 ± 26.5 months, p < 0.001). IVUS variables were generally similar for the two groups. However, plaque burden at the distal reference segment, stent, and neointimal area of the in-stent segment were smaller in the DES group. Stent malapposition was observed in 73.9% of DES patients, but in no BMS patients (p = 0.001). Disease progression with neointimal rupture within the stent was observed in 10 DES patients (43.5%) and 7 BMS patients (100%; p = 0.010).
Conclusions: The authors concluded that stent malapposition was unique to DES-related VLST, whereas disease progression with neointimal rupture was more common in BMS patients.
Perspective: These results suggest that different mechanisms underlie VLST depending upon the stent type. Stent malapposition plays a key role in DES-related VLST, whereas neoatherosclerosis with plaque rupture plays a key role in BMS-related VLST. Despite the limitations of a single-center retrospective analysis, the study provides important insight into the mechanism of stent thrombosis in different stent types. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Incremental Prognostic Value of Coronary CT Angiography in Patients With Suspected Coronary Artery Disease
Topic: Noninvasive Cardiology
Date Posted: 5/20/2010
Author(s): Russo V, Zavalloni A, Bacchi-Reggiani L, et al.
Citation: Circ Cardiovasc Imaging 2010;May 11:[Epub ahead of print].
Clinical Trial: No
Study Question: What is the prognostic value of multi-detector computed tomographic coronary angiography (MDCTCA) in patients with suspected but undocumented coronary artery disease (CAD) and, in particular, the incremental prognostic value, as compared to clinical risk and calcium scoring (CCS)?
Methods: A total of 441 patients with suspected CAD underwent MDCTCA to evaluate the presence and severity of the disease. Indications for MDCTCA included typical or atypical chest pain, pathological or equivocal exercise test, high cardiovascular risk profile, and preoperative cardiac risk stratification before major surgery (34.5%). Persons with known CAD were excluded. A pretest likelihood of CAD was obtained using the Morise score, which includes clinical variables and risk factors together with the presence and type of symptoms (low likelihood of CAD = <30%, intermediate likelihood = 30-70%, and high likelihood of CAD = >70%). Patients were followed up for the occurrence of hard cardiac events (cardiac death, nonfatal myocardial infarction, and unstable angina requiring hospitalization).
Results: Mean age was 59.7 ± 11.6 years, 72.6% were male, 31.3% were smokers; 62% were asymptomatic, and 20.6% had atypical and 17.3% typical chest pain. Likelihood of CAD was low in 10.9%, intermediate in 69.4%, and high in 19.7%. Agatston CCS was ≤10 in 45%, 11-400 in 37%, and >400 in 18%. Coronary lesions were detected in 297 (67.3%) patients of whom 53% had at least one >50% stenosis. During a mean follow-up of 31.9 ± 14.8 months, 44 hard cardiac events occurred in 40 patients. The CCS had a modest incremental prognostic value as compared to a clinical risk model (p = 0.018), whereas MDCTCA provided an additional incremental prognostic value, as compared to a clinical risk model plus calcium scoring (hazard ratio, 2.445) when considering both nonobstructive versus obstructive CAD (p = 0.016) as well as plaque composition (calcified vs. noncalcified and/or mixed plaques, p = 0.0001). During follow-up, patients with normal coronary arteries had an annualized incidence rate of 0.88% as compared to those with mild CAD (3.89%) and to patients with significant CAD (8.09%). The presence of noncalcified or mixed plaques, regardless of lesion severity, was found to be the strongest predictor of events (p < 0.0001) as a potential marker of plaque vulnerability.
Conclusions: MDCTCA provides independent and incremental prognostic information, as compared to baseline clinical risk factors and calcium scoring in patients with suspected CAD.
Perspective: The robust results could have been influenced by the relatively high annual event rate (nearly 1% in those with normal coronary arteries and 4% in those without significant stenosis), and were obtained with a 16-slice MDCT scanner, which has limited resolution compared to 64-slice CT angiography. Except for the WISE study, which assessed the utility of various tests in symptomatic women, the ability of various diagnostic tools (nuclear and echo stress imaging) to detect and improve prognostication in coronary disease has never been subjected to rigorous clinical investigation. The clinical utility of combining CT angiography with CCS for characterizing risk in symptomatic and asymptomatic persons at risk is intuitive, but needs to be evaluated against other strategies such as simply aggressive medical treatment of all but the very low risk for CAD. Radiation dosing from a chest X-ray is 0.06 mSv, a mammogram 0.7 mSv, and CT angiography varies from 3.7-13 mSv, which is clearly associated with incremental risk for cancer. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Determinants of Coronary Calcium Conversion Among Patients With a Normal Coronary Calcium Scan: What Is the “Warranty Period” for Remaining Normal?
Topic: Noninvasive Cardiology
Date Posted: 5/20/2010
Author(s): Min JK, Lin FY, Gidseg DS, et al.
Citation: J Am Coll Cardiol 2010;55:1110-1117.
Clinical Trial: No
Related Resources
JACC Article: Determinants of Coronary Calcium Conversion Among Patients With a Normal Coronary Calcium Scan: What is the “Warranty Period” for Remaining Normal?

Study Question: What are the frequency and clinical predictors of conversion from normal to abnormal coronary artery calcium (CAC) scans?
Methods: CAC scanning was performed annually for 5 years in 442 patients with baseline CAC = 0. CAC and clinical predictors were compared to a cohort of 621 subjects with baseline CAC >0. CAC was expressed in Hounsfield units (HU), and clinical predictors of age, diabetes, smoking, and others were tabulated.
Results: CAC progressed from an initial value of 0 in 106 of the 422 subjects (25.1%) with a mean time to conversion to abnormal of 4.1 ± 0.9 years. The number of subjects converting at years 1-5 was 2 (0.5%), 5 (1.2%), 24 (5.7%), 26 (6.2%), and 49 (11.6%). Age, smoking, diabetes, and hypertension were all significantly associated with the risk of conversion to CAC >0, but did not relate to the time at which conversion occurred. At the time of conversion, the average CAC score was 19 ± 19. Compared to subjects with baseline CAC >0, those with CAC = 0 were younger (48.8 ± 8.9 vs. 56.6 ± 8.6 years). The prevalence of hypertension, diabetes, smoking, and lipid disorder in those with CAC = 0 was 46%, 9.5%, 32%, and 66.4% compared to 56.5%, 16.3%, 36.4%, and 76.7% (p = NS for smoking, otherwise p ≤ 0.002). For individuals with a baseline CAC >0, 497 of the 621 (80%) had progression over a mean of 1.9 ± 1.1 years of follow-up with an average CAC increase of 45.5 ± 89.6 HU. The progression was statistically related to male gender, lipid status, smoking, and baseline CAC score, with only CAC score remaining independently predictive on multivariable analysis. Among propensity-matched cohorts, those with baseline CAC >0 had a higher frequency of progression than those with CAC = 0.
Conclusions: Progression of CAC from baseline score of 0 occurs at a low frequency within the first 4 years, and the presence of conversion is related to traditional risk factors. No traditional risk factor, however, predicts the timing with which conversion occurs.
Perspective: CAC scoring has been used as both a diagnostic and prognostic technique. Numerous studies have demonstrated the progressive likelihood of the presence and severity of coronary disease based on CAC and, furthermore, a higher likelihood of events and higher prevalence of positive cardiovascular stress testing with higher CAC. This study essentially asks the question: 'What is the warranty of a normal CAC?' This study, performed in a population of patients at intermediate risk of coronary disease but without clinical evidence of such at baseline scanning, suggests that the likelihood of progression from a CAC of 0 to advanced coronary calcium is negligible within 5 years and that the likelihood of progression to CAC >0 is low within the first 2-3 years after establishing a baseline. It appears that all patients in this study received the benefit of aggressive medical therapy for risk factor modification including uniform use of statins in those with elevated lipids. Not evaluated in this study was any link between conversion from a CAC of 0 and occurrence of events or change in symptomatic status. Assuming a link between CAC and cardiovascular events and/or need for further cardiovascular testing, it appears that serial determination of CAC is unwarranted at intervals <3-4 years in individuals with a score of 0 at baseline. William F. Armstrong, M.D., F.A.C.C.

[Chevychelov]

Title: Conventional and Chest-Compression-Only Cardiopulmonary Resuscitation by Bystanders for Children Who Have Out-of-Hospital Cardiac Arrests: A Prospective, Nationwide, Population-Based Cohort Study
Topic: Arrhythmias
Date Posted: 5/21/2010
Author(s): Kitamura T, Iwami T, Kawamura T, et al., on behalf of the Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency.
Citation: Lancet 2010;375:1347-1354.
Clinical Trial: No
Study Question: What is the optimal type of cardiopulmonary resuscitation (CPR) for pediatric patients with out-of-hospital cardiac arrest (OHCA)?
Methods: The data in this study were obtained from a nationwide registry of OHCAs in Japan. Children ages 17 years or younger were included in the study. The 1° outcome was favorable neurological outcome at 1 month of follow-up.
Results: Data from 5,170 children with OHCA were analyzed. The OHCA was from a noncardiac cause in 71% of patients. One-month survival with favorable neurological outcome was 3.2%. Twenty-seven percent of the OHCAs were witnessed by bystanders. When there was a noncardiac cause of OHCA, the 1° outcome was significantly more frequent after bystander CPR (5.1%) than with no bystander CPR (1.5%) and after conventional CPR (7.2%) than after compression-only CPR (1.6%). When there was a cardiac cause of OHCA, the incidence of the 1° outcome was significantly higher with bystander CPR (9.5%) than without bystander CPR (4.1%), but did not differ significantly after conventional CPR (9.9%) versus compression-only CPR (8.9%).
Conclusions: Rescue breaths provide incremental value compared to compression-only CPR in children with OHCA, but only when the cardiac arrest results from a noncardiac etiology.
Perspective: Observational studies in adults have indicated that compression-only CPR yields similar or better outcomes than does conventional CPR in adults with OHCA, and the American Heart Association now recommends compression-only CPR for OHCA of presumed cardiac origin. In children, OHCA is more often noncardiac in etiology (e.g., drowning, trauma, respiratory disease) than in adults. Therefore, unless there is a witnessed sudden collapse consistent with a cardiac-based OHCA, conventional CPR with rescue breaths is indicated. Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: Effect of B-Vitamin Therapy on Progression of Diabetic Nephropathy: A Randomized Controlled Trial
Topic: General Cardiology
Date Posted: 5/21/2010
Author(s): House AA, Eliasziw M, Cattran DC, et al.
Citation: JAMA 2010;303:1603-1609.
Clinical Trial: yes
Study Question: Does therapy with B vitamins affect diabetic nephropathy?
Methods: This was a randomized, multicenter, double-blind, placebo-controlled trial, which randomized subjects to a combination of B vitamins (2.5 mg/d of folic acid, 25 mg/d of B6, and 1 mg/d of B12) or placebo, between May 2001 and July 2007. Subjects were known diabetics, either type 1 or 2. Potential subjects were excluded if they had advanced renal failure (creatinine clearance <30 mg/min or were on dialysis), were awaiting imminent dialysis, or women who were pregnant. The primary outcome of interest was changes in radionuclide glomerular filtration rate (GFR) between baseline and 36 months. Secondary outcomes included the occurrence of dialysis, and a composite outcome of myocardial infarction, stroke, revascularization, and all-cause mortality. Plasma total homocysteine was also measured from five university centers.
Results: A total of 238 subjects were included in the study. The mean follow-up was 31.9 months. At 36 months, GFR had decreased by a mean of 16.5 ml/min/1.73 m2 in those taking the B vitamins compared to 10.7 ml/min/1.73 m2 (p = 0.02). There was no difference between groups in the occurrence of dialysis (hazard ratio [HR], 1.1; 95% CI, 0.4-2.6); however, the composite cardiovascular disease outcome occurred more often in the B vitamin group (HR, 2.0; 95% CI, 1.0-4.0). Plasma total homocysteine decreased by a mean of 2.2 µmol/L at 36 months in the B vitamin groups, as compared to 2.6 µmol/L in the placebo group.
Conclusions: The investigators concluded that among patients with diabetic nephropathy, high-dose B vitamins were associated with a greater decrease in GFR and higher risk of vascular events.
Perspective: The results of this randomized controlled trial suggest that B vitamins do not have a role in the clinical management of diabetic patients with nephropathy. Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Mood Food: Chocolate and Depressive Symptoms in a Cross-sectional Analysis
Topic: Prevention/Vascular
Date Posted: 5/21/2010
Author(s): Rose N, Koperski S, Golomb BA.
Citation: Arch Intern Med 2010;170:699-703.
Clinical Trial: No
Study Question: Is chocolate consumption associated with depression?
Methods: Data from 1,018 subjects (ages 20-85 years) residing in the San Diego area were used for the present analysis. Subjects using antidepressants were excluded from the study. Information on diet including chocolate intake was obtained through the Fred Hutchinson Food Frequency Questionnaire and the Statin Study Questionnaire (which asked participants how many times per week they consumed chocolate). Mood was assessed through the Center for Epidemiologic Studies Depression Scale (CES-D), with screening positive for possible depression as a CES-D score of 16 or greater.
Results: Of the 1,018 adults sampled, 324 were women, 80.4% were white, and the mean age of the cohort was 57.6 years. Mean body mass index was 27.8 kg/m2. Among 931 subjects who were not taking antidepressants and who provided information on chocolate consumption, the mean CES-D score was 7.7 (median 6.0) and mean chocolate consumption was 6.0 servings per month. Those who had a CES-D score ≥16 reported higher intake of chocolate compared to those who scored <16 (8.4 servings per month vs. 5.4 servings per month, p = 0.004). Subjects who had CES-D scores ≥20 reported an average of 11.8 servings of chocolate per month. These findings were similar for men and women when examined separately. No significance differences between groups were observed in regard to intake of fat, carbohydrates, or total energy intake.
Conclusions: The authors concluded that higher CES-D depression scores were positively associated with chocolate intake; however, further study would be needed to determine causality.
Perspective: These findings suggest men and women who have depressive symptoms may be using chocolate to modulate mood. Given the cross-sectional nature of this study, questions remain unanswered in terms of the direction of the association. In addition, the type of chocolate with respect to cocoa content was not addressed. Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Pressure Frequency Characteristics of the Pericardial Space and Thorax During Subxiphoid Access for Epicardial Ventricular Tachycardia Ablation
Topic: Arrhythmias
Date Posted: 5/24/2010
Author(s): Mahapatra S, Tucker-Schwartz J, Wiggins D, et al.
Citation: Heart Rhythm 2010;7:604-609.
Clinical Trial: No
Study Question: Are pressure-frequency measurements helpful for identifying the pericardial space during percutaneous access procedures?
Methods: Pressure was measured for 2 minutes in the pericardial space and in the thorax during sheath withdrawal in 20 patients who underwent subxyphoid percutaneous access of the pericardial space for epicardial ablation of ventricular tachycardia (VT). All patients were intubated and ventilated at 12 breaths/minute. Spectral analysis of the pressure recordings was performed offline by fast Fourier transformation.
Results: The mean pressures in the thorax (7.7 mm Hg) and pericardial space (7.8 mm Hg) did not differ significantly. Spectral analysis demonstrated a single peak at a mean of 0.2 Hz in the thorax pressure recordings and a dominant frequency at a mean of 0.2 Hz plus a second, smaller peak at a mean of 1.16 Hz in the pericardial pressure recordings.
Conclusions: Spectral analysis of pressure recordings reflects the respiratory rate in the thorax and the respiratory rate plus the heart rate in the pericardial space. These pressure-frequency characteristics are useful for identifying the pericardial space during pericardial access procedures.
Perspective: One of the limiting factors for widespread adaptation of epicardial ablation into clinical practice is the risk of right ventricular perforation. Fluoroscopy with contrast injections is helpful but not foolproof. The technique described in this study may facilitate recognition of when the percutaneous needle has passed from the thorax into the pericardial space. However, use of this technique in clinical practice will require the availability of a needle that has a pressure sensor at its tip and the capability for online spectral analysis. Fred Morady, M.D., F.A.C.C.

Title: Impact of Cytochrome P450 2C19 Loss-of-Function Polymorphism and of Major Demographic Characteristics on Residual Platelet Function After Loading and Maintenance Treatment With Clopidogrel in Patients Undergoing Elective Coronary Stent Placement
Topic: Interventional Cardiology
Date Posted: 5/24/2010 5:00:00 PM
Author(s): Hochholzer W, Trenk D, Fromm MF, et al.
Citation: J Am Coll Cardiol 2010;55:2427-2434.
Clinical Trial: No
Related Resources
JACC Article: Impact of Cytochrome P450 2C19 Loss-of-Function Polymorphism and of Major Demographic Characteristics on Residual Platelet Function After Loading and Maintenance Treatment With Clopidogrel in Patients Undergoing Elective Coronary Stent Placement

Study Question: What is the relative impact of demographic and clinical variables versus the cytochrome P450 2C19 (CYP2C19) polymorphism on antiplatelet effects of clopidogrel?
Methods: This analysis enrolled 760 patients undergoing elective coronary stent implantation after loading with 600 mg of clopidogrel. Residual platelet aggregation was determined by optical aggregometry (adenosine diphosphate 5 µmol/L) before discharge. The investigators analyzed the predictive value of the CYP2C19*2 polymorphism and baseline variables for an insufficient antiplatelet response by multivariable regression analysis and classification and regression trees analysis, and determined the proportion responsible for the antiplatelet response of these predictors by multivariable linear regression analysis.
Results: Major independent predictors for an insufficient antiplatelet response to clopidogrel were CYP2C19*2 carrier status (odds ratio [OR], 2.74; 95% confidence interval [CI], 1.93-3.90) together with age (OR, 1.03; 95% CI, 1.01-1.05), diabetes mellitus (OR, 1.75; 95% CI, 1.19-2.56), and body mass index (OR, 1.06; 95% CI, 1.02-1.11). The classification and regression trees analysis demonstrated that CYP2C19*2 carrier status followed by diabetes mellitus was the best discriminator between a sufficient and an insufficient antiplatelet response to clopidogrel. The full linear regression model including all of these parameters could only explain 11.5% of the antiplatelet response (5.2% by CYP2C19*2 carrier status alone).
Conclusions: The authors concluded that in patients critically dependent on adequate platelet inhibition, genotyping alone or in combination with clinical factors cannot replace phenotyping of platelet function.
Perspective: The primary finding of this analysis is that the CYP2C19*2 loss-of-function polymorphism and several clinical variables (diabetes mellitus, age, and body mass index) show a statistical highly significant association with high on-clopidogrel residual platelet aggregation. However, despite confirming the strong impact of the CYP2C19 loss-of-function polymorphism on antiplatelet effect of clopidogrel, the current data suggest that genotyping for CYP2C19 is insufficient for clinical decision-making without platelet function testing. Furthermore, addition of clinical variables could not fully correct this shortcoming. Based on all available data, it seems reasonable to integrate both genotyping and platelet function measurement to assess ischemic risk and to guide antiplatelet therapy in appropriate high-risk patients. Debabrata Mukherjee, M.D., F.A.C.C.

[Chevychelov]

Title: Choice of Prosthetic Heart Valve in Adults: An Update
Topic: Cardiovascular Surgery
Date Posted: 5/24/2010 5:00:00 PM
Author(s): Rahimtoola SH.
Citation: J Am Coll Cardiol 2010;55:2413-2426.
Clinical Trial: No
Related Resources
JACC Article: Choice of Prosthetic Heart Valve in Adults: An Update

Perspective: The following are 10 points to remember about choice of prosthetic heart valve (PHV) in adults.

1. Patient survival after PHV has increased markedly and it is essential to consider the patient’s point of view regarding the ideal PHV.

2. At present, the choice of PHV in most clinical situations is between a mechanical PHV and a stented bioprosthesis. An important determining factor in the choice between these two PHVs is which of the two complications—anticoagulation therapy or structural valve deterioration (SVD)—one wants to avoid.

3. Mechanical PHVs that are approved by the Food and Drug Administration and have good and comparable outcomes at ≥15-20 years of follow-up will likely have good outcomes on very long-term follow-up.

4. Currently for the overwhelming majority of adult patients ages >60-65 years, the choice of a biological PHV is a stented bioprosthesis. However, there are exceptions; for example, for active infective endocarditis with an associated abscess or uncontrolled infection, a homograft valve may be chosen.

5. Anticoagulants are essential with the use of mechanical valves, and can be instituted and maintained in many patients with low risk. The disadvantages include lifetime needs of therapy and tests, difficulties in initiating and maintaining an adequate international normalized ratio in many patients, and major risks of bleeding.

6. The risks of bleeding are increased for patients ≥65 years old, greatly so for those ≥75 years old, and for those with CHADS2 score ≥3.

7. All biological valves are at risk for SVD. The age of the patient at the time of PHV implantation is the most important determinant of SVD.

8. Typically, in ‘young’ people, use of a biological valve will result in reoperation, probably in multiple reoperations.

9. There is no significant difference in valve areas at 6 months between a bileaflet mechanical valve and porcine bioprosthesis for valves with the same valve size.

10. The physicians involved in the decision-making process should be very knowledgeable about the patient outcomes with the use of the various PHV, and they should be completely discussed with the patient. The final choice of PHV should be a joint decision by the patient, cardiologist, and cardiac surgeon. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Impact of the ALLHAT/JNC7 Dissemination Project on Thiazide-Type Diuretic Use
Topic: Prevention/Vascular
Date Posted: 5/24/2010 4:00:00 PM
Author(s): Stafford RS, Bartholomew LK, Cushman WC, et al., on behalf of the ALLHAT Collaborative Research Group.
Citation: Arch Intern Med 2010;170:851-858.
Clinical Trial: No
Related Resources
Trial: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

Study Question: What was the impact of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) results on physician practice patterns?
Methods: To improve discrimination and adoption of changes in practice management resulting from landmark trials and changes in guidelines, specific strategies are considered. Academic detailing incorporates several approaches used in pharmaceutical marketing including use of investigator-educators as opinion leaders, and communication of antihypertensive management through individualized small groups. Two national databases were used to evaluate this academic detailing model. The National Disease and Therapeutic Index is a physician-based survey, which surveys approximately 4,800 physicians every 3 months; data collection included prescribing information on antihypertensives. Data from this survey overlapped with academic detailing efforts in 176 counties from 38 states. The IMS Health Xponent database is a national computerized sample of approximately 36,000 retail pharmacies. Practice patterns prior to 2004 and in 2007 were compared. In addition, national trends in use of thiazide type diuretics were examined for an 8-year time period (2000-2008).
Results: The ALLHAT findings were published in 2002. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) was published in 2003. Survey data showed that thiazide-type diuretic use increased in most in US counties where academic detailing activity was the greatest (an increase from 37.9% to 46.5%, p < 0.05) compared to counties where activity was moderate or low. Pharmacy dispensing data showed that thiazide-type diuretic prescriptions increased by 8.7% in counties with dissemination project activities compared to 3.9% in counties without such activities (p < 0.001). On a national level, thiazide-type diuretic use did not increase between 2004 and 2008.
Conclusions: The investigators suggest the ALLHAT/JNC7 dissemination project was associated with a small effect on thiazide-type diuretic use, demonstrating that academic detailing may increase physician implementation of clinical trials.
Perspective: These findings suggest a modest adoption of thiazide diuretics, as recommended by the ALLHAT findings and JNC7. However, this project was initiated 2 years after the publication of ALLHAT; thus, antihypertensive management may have already undergone significant changes. Further research would be needed to understand specific factors related to the adoption of recommendations for control of blood pressure. Elizabeth A. Jackson, M.D., F.A.C.C.

[Chevychelov]

Title: Overtime Work and Incident Coronary Heart Disease: The Whitehall II Prospective Cohort Study
Topic: Prevention/Vascular
Date Posted: 5/25/2010
Author(s): Virtanen M, Ferrie JE, Singh-Manoux A, et al.
Citation: Eur Heart J 2010; May 11:[Epub ahead of print].
Clinical Trial: No
Study Question: Is working overtime associated with increased risk of heart disease?
Methods: Data from the Whitehall cohort were used for the present study. British civil servants working in London, England, who were between the ages of 31-61, worked full-time, and were free of coronary heart disease (CHD) at baseline were included in this analysis. Questions regarding hours of work per day were originally asked in the 1991-94 questionnaires. Follow-up extended through 2002-2004. The primary outcome of interest was fatal CHD, nonfatal myocardial infarction (MI), or angina. Models adjusting for multiple factors including sociodemographic factors, CHD risk factors, and job grade were used to examine risk associated with levels of overtime work including, 1 hour, 2 hours, and 3-4 hours with no overtime defined as the reference group.
Results: A total of 4,262 men and 1,752 women were included in the analysis. Mean follow-up was 11.2 years. Within the cohort, 54% reported no overtime work, 21% reported approximately 1 hour of overtime, 15% reported 2 hours of overtime, and 10% reported 3-4 hours of regular overtime. Workers who reported regular overtime work were more often male, married, smokers, drank alcohol, and in higher occupational grades. They also reported more psychological stress and type A behavior. Workers who reported regular overtime were more likely to have lower high-density lipoprotein cholesterol levels. Subjects who reported working 3-4 hours of overtime had an increased risk of CHD death, nonfatal MI, or angina (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.15-2.23), which was not significantly attenuated after adjustment for cardiovascular risk factors (HR, 1.56; 95% CI, 1.11-2.19). A similar result was observed when just CHD mortality and nonfatal MI was used as the outcome. A significant interaction between decision latitude and overtime work was observed, such that subjects with low-decision latitude but higher overtime work had a higher risk of CHD events (HR, 1.78; 95% CI, 1.10-2.89), whereas those with a higher decision latitude and overtime work had a lower nonsignificant risk of CHD events (HR, 1.26; 95% CI, 0.77-2.04).
Conclusions: The investigators concluded that overtime work is associated with increased risk for CHD events, independently of CHD risk factors.
Perspective: These findings suggest that clinicians may want to ask patients about occupational work habits and counsel them regarding regular overtime work. Longer work hours often translate into reduction in leisure time activities. Since leisure time activities can decrease stress and promote physical activity, the results of this study are not surprising. Elizabeth A. Jackson, M.D., F.A.C.C