Circulation. 2010 Jul 27;122(4):404-5

Authors: Imagawa H, Ishikawa K

PMID: 20660816 [PubMed - in process]

Prasugrel.

Circulation. 2010 Jul 27;122(4):394-403

Authors: Wiviott SD, Antman EM, Braunwald E

PMID: 20660815 [PubMed - in process]

Thyroid replacement therapy and heart failure.

Circulation. 2010 Jul 27;122(4):385-93

Authors: Gerdes AM, Iervasi G

PMID: 20660814 [PubMed - in process]

European perspectives.

Circulation. 2010 Jul 27;122(4):f19-24

Authors:

PMID: 20660813 [PubMed - in process]

Letter by nakajima and saito regarding article, "human C-reactive protein does not promote atherosclerosis in transgenic rabbits".

Circulation. 2010 Jul 27;122(4):e406

Authors: Nakajima K, Saito M

PMID: 20660812 [PubMed - in process]

Letter by hiemann et Al regarding article, "assessment of microcirculatory remodeling with intracoronary flow velocity and pressure measurements: validation with endomyocardial sampling in cardiac allografts".

Circulation. 2010 Jul 27;122(4):e404

Authors: Hiemann NE, Meyer R, Wellnhofer E

PMID: 20660811 [PubMed - in process]

Bacterial Pericarditis due to Providencia stuartii: An Atypical Case of Relapsing Pericarditis.

Circulation. 2010 Jul 27;122(4):e401-3

Authors: Simon C, Dieli M, Brucato A, Pedrotti P, Brambilla P, Curri SF, Senni M, Pericotti S, Suter F, Ferrazzi P

PMID: 20660810 [PubMed - in process]

Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.

Circulation. 2010 Jul 26;

Authors: Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD,

Abstract-The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain.

PMID: 20660809 [PubMed - as supplied by publisher]

Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease.

Circulation. 2010 Jul 26;

Authors: Kajander S, Joutsiniemi E, Saraste M, Pietilä M, Ukkonen H, Saraste A, Sipilä HT, Teräs M, Mäki M, Airaksinen J, Hartiala J, Knuuti J

BACKGROUND: -Computed tomography (CT) is increasingly used to detect coronary artery disease, but the evaluation of stenoses is often uncertain. Perfusion imaging has an established role in detecting ischemia and guiding therapy. Hybrid positron emission tomography (PET)/CT allows combination angiography and perfusion imaging in short, quantitative, low-radiation-dose protocols. Methods and Results-We enrolled 107 patients with an intermediate (30% to 70%) pretest likelihood of coronary artery disease. All patients underwent PET/CT (quantitative PET with (15)O-water and CT angiography), and the results were compared with the gold standard, invasive angiography, including measurement of fractional flow reserve when appropriate. Although PET and CT angiography alone both demonstrated 97% negative predictive value, CT angiography alone was suboptimal in assessing the severity of stenosis (positive predictive value, 81%). Perfusion imaging alone could not always separate microvascular disease from epicardial stenoses, but hybrid PET/CT significantly improved this accuracy to 98%. The radiation dose of the combined PET and CT protocols was 9.3 mSv (86 patients) with prospective triggering and 21.8 mSv (21 patients) with spiral CT. Conclusion-Cardiac hybrid PET/CT imaging allows accurate noninvasive detection of coronary artery disease in a symptomatic population. The method is feasible and can be performed routinely with <10 mSv in most patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00627172.

PMID: 20660808 [PubMed - as supplied by publisher]

Differences Between Out-of-Hospital Cardiac Arrest in Residential and Public Locations and Implications for Public-Access Defibrillation.

Circulation. 2010 Jul 26;

Authors: Folke F, Gislason GH, Lippert FK, Nielsen SL, Weeke P, Hansen ML, Fosbøl EL, Andersen SS, Rasmussen S, Schramm TK, Køber L, Torp-Pedersen C

BACKGROUND: -The majority of out-of-hospital cardiac arrests (OHCAs) occur in residential locations, but knowledge about strategic placement of automated external defibrillators in residential areas is lacking. We examined whether residential OHCA areas suitable for placement of automated external defibrillators could be identified on the basis of demographic characteristics and characterized individuals with OHCA in residential locations. Methods and Results-We studied 4828 OHCAs in Copenhagen between 1994 and 2005. The incidence and characteristics of OHCA were examined in every 100x100-m (109.4x109.4-yd) residential area according to its underlying demographic characteristics. By combining >/=2 demographic characteristics, it was possible to identify 100x100-m (109.4x109.4-yd) areas with at least 1 arrest every 5.6 years (characterized by >300 persons per area and lowest income) to 1 arrest every 4.3 years (characterized by >300 persons per area, lowest income, low education, and highest age). These areas covered 9.0% and 0.8% of all residential OHCAs, respectively. Individuals with OHCA in residential locations differed from public ones in that the patients were older (70.6 versus 60.6 years; P<0.0001), the ambulance response interval was longer (6.0 versus 5.0 minutes; P<0.0001), arrests occurred more often at night (21.2% versus 11.2%; P<0.0001), the patients had ventricular fibrillation less often (12.8% versus 38.1%; P<0.0001), and the patients had a worse 30-day survival rate (3.2% versus 13.9%; P<0.0001). Conclusions-On the basis of simple demographic characteristics of a city center, we could identify residential areas suitable for automated external defibrillator placement. Individuals with OHCA in residential locations were more likely to have characteristics associated with poor outcome compared with public arrests.

PMID: 20660807 [PubMed - as supplied by publisher]

First Clinical Application of an Actively Reversible Direct Factor IXa Inhibitor as an Anticoagulation Strategy in Patients Undergoing Percutaneous Coronary Intervention.

Circulation. 2010 Jul 26;

Authors: Cohen MG, Purdy DA, Rossi JS, Grinfeld LR, Myles SK, Aberle LH, Greenbaum AB, Fry E, Chan MY, Tonkens RM, Zelenkofske S, Alexander JH, Harrington RA, Rusconi CP, Becker RC

BACKGROUND: -The ideal anticoagulant should prevent ischemic complications without increasing the risk of bleeding. Controlled anticoagulation is possible with the REG1 system, an RNA aptamer pair comprising the direct factor IXa inhibitor RB006 and its active control agent RB007. Methods and Results-This phase 2a study included a roll-in group (n=2) treated with REG1 plus glycoprotein IIb/IIIa inhibitors followed by 2 groups randomized 5:1 to REG1 or unfractionated heparin. In group 1 (n=12), RB006 was partially reversed with RB007 after percutaneous coronary intervention and fully reversed 4 hours later. In group 2 (n=12), RB006 was fully reversed with RB007 immediately after percutaneous coronary intervention. Femoral sheaths were removed after complete reversal. Patients were pretreated with aspirin and clopidogrel. End points included major bleeding within 48 hours; composite of death, myocardial infarction, or urgent target vessel revascularization within 14 days; and pharmacodynamic measures. All cases were successful, with final Thrombolysis in Myocardial Infarction grade 3 flow and no angiographic thrombotic complications. There were 2 ischemic end points in the REG1 group and 1 in the unfractionated heparin group, with 1 major bleed in the unfractionated heparin group. Median activated clotting time values rose from 151 to 236 seconds after RB006. Administration of the partial RB007 dose reversed anticoagulation to an intermediate activated clotting time value of 186 seconds. Complete reversal with RB007 returned the median activated clotting time value to 144 seconds. Both reversal strategies enabled scheduled femoral sheath removal. Conclusions-This study demonstrates the clinical translation of a novel platform of anticoagulation targeting factor IXa and its active reversal to percutaneous coronary intervention and provides the basis for further investigation. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00715455.

PMID: 20660806 [PubMed - as supplied by publisher]

Improving Evidence-Based Care for Heart Failure in Outpatient Cardiology Practices. Primary Results of the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF).

Circulation. 2010 Jul 26;

Authors: Fonarow GC, Albert NM, Curtis AB, Gattis Stough W, Gheorghiade M, Heywood JT, McBride ML, Johnson Inge P, Mehra MR, O'Connor CM, Reynolds D, Walsh MN, Yancy CW

BACKGROUND: -A treatment gap exists between heart failure (HF) guidelines and the clinical care of patients. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) prospectively tested a multidimensional practice-specific performance improvement intervention on the use of guideline-recommended therapies for HF in outpatient cardiology practices. Methods and Results-Performance data were collected in a random sample of HF patients from 167 US outpatient cardiology practices at baseline, longitudinally after intervention at 12 and 24 months, and in single-point-in-time patient cohorts at 6 and 18 months. Participants included 34 810 patients with reduced left ventricular ejection fraction (</=35%) and chronic HF or previous myocardial infarction. To quantify guideline adherence, 7 quality measures were assessed. Interventions included clinical decision support tools, structured improvement strategies, and chart audits with feedback. The performance improvement intervention resulted in significant improvements in 5 of 7 quality measures at the 24-month assessment compared with baseline: beta-blocker (92.2% versus 86.0%, +6.2%), aldosterone antagonist (60.3% versus 34.5%, +25.1%), cardiac resynchronization therapy (66.3% versus 37.2%, +29.9%), implantable cardioverter-defibrillator (77.5% versus 50.1%, +27.4%), and HF education (72.1% versus 59.5%, +12.6%) (each P<0.001). There were no statistically significant improvements in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use or anticoagulation for atrial fibrillation. Sensitivity analyses at the patient level and limited to patients with both baseline and 24-month quality measure data yielded similar results. Improvements in the single-point-in-time cohorts were smaller, and there were no concurrent control practices. Conclusions-The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting, a defined and scalable practice-specific performance improvement intervention, was associated with substantial improvements in the use of guideline-recommended therapies in eligible patients with HF in outpatient cardiology practices. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00303979.

PMID: 20660805 [PubMed - as supplied by publisher]

Correlates of Echocardiographic Indices of Cardiac Remodeling Over the Adult Life Course. Longitudinal Observations From the Framingham Heart Study.

Circulation. 2010 Jul 26;

Authors: Cheng S, Xanthakis V, Sullivan LM, Lieb W, Massaro J, Aragam J, Benjamin EJ, Vasan RS

BACKGROUND: -The heart progressively remodels over the life course, yet longitudinal data characterizing such remodeling in the community are limited. Methods and Results-Using multilevel modeling, we analyzed up to 4 serial echocardiographic observations obtained over a 16-year period in 4062 Framingham Heart Study participants (mean age 45 years, 54% women; 11 485 person-observations). We related left ventricular (LV) wall thickness, LV systolic and diastolic dimensions, and fractional shortening to age, sex, body mass index, blood pressure (including antihypertensive medication use), smoking, and diabetes mellitus (separate analyses for each echocardiographic measure). With advancing age, LV dimensions decreased, whereas fractional shortening and LV wall thickness increased concomitantly. Male sex, body mass index, and blood pressure indices/hypertension treatment were significantly related to both greater LV dimensions and LV wall thickness. The effect of age on cardiac remodeling was influenced by key covariates (P<0.05 for all interactions): Women and individuals with diabetes mellitus experienced greater age-associated increases in LV wall thickness; presence of diabetes or a higher blood pressure was associated with a lesser decrease in LV diastolic dimensions with increasing age; and antihypertensive medication use was a marker of an attenuated increase in fractional shortening with aging. Conclusions-Cardiac remodeling over the adult life course is characterized by a distinct pattern of increasing LV wall thickness, decreasing LV dimensions, and increasing fractional shortening with advancing age. Overall, female sex, greater blood pressure load, and presence of diabetes mellitus serve to attenuate this remodeling pattern. These observations suggest a mechanism for the preponderance of women with hypertension and individuals with diabetes among patients with diastolic heart failure.

PMID: 20660804 [PubMed - as supplied by publisher]

Pathogenesis of Sudden Unexpected Death in a Clinical Trial of Patients With Myocardial Infarction and Left Ventricular Dysfunction, Heart Failure, or Both.

Circulation. 2010 Jul 26;

Authors: Pouleur AC, Barkoudah E, Uno H, Skali H, Finn PV, Zelenkofske SL, Belenkov YN, Mareev V, Velazquez EJ, Rouleau JL, Maggioni AP, Køber L, Califf RM, McMurray JJ, Pfeffer MA, Solomon SD,

BACKGROUND: -The frequency of sudden unexpected death is highest in the early post-myocardial infarction (MI) period; nevertheless, 2 recent trials showed no improvement in mortality with early placement of an implantable cardioverter-defibrillator after MI. Methods and Results-To better understand the pathophysiological events that lead to sudden death after MI, we assessed autopsy records in a series of cases classified as sudden death events in patients from the VALsartan In Acute myocardial infarctioN Trial (VALIANT). Autopsy records were available in 398 cases (14% of deaths). We determined that 105 patients had clinical circumstances consistent with sudden death. On the basis of the autopsy findings, we assessed the probable cause of sudden death and evaluated how these causes varied with time after MI. Of 105 deaths considered sudden on clinical grounds, autopsy suggested the following causes: 3 index MIs in the first 7 days (2.9%); 28 recurrent MIs (26.6%); 13 cardiac ruptures (12.4%); 4 pump failures (3.8%); 2 other cardiovascular causes (stroke or pulmonary embolism; 1.9%); and 1 noncardiovascular cause (1%). Fifty-four cases (51.4%) had no acute specific autopsy evidence other than the index MI and were thus presumed arrhythmic. The percentage of sudden death due to recurrent MI or rupture was highest in the first month after the index MI. By contrast, after 3 months, the percentage of presumed arrhythmic death was higher than recurrent MI or rupture (chi(2)=23.3, P<0.0001). Conclusions-Recurrent MI or cardiac rupture accounts for a high proportion of sudden death in the early period after acute MI, whereas arrhythmic death may be more likely subsequently. These findings may help explain the lack of benefit of early implantable cardioverter-defibrillator therapy.

PMID: 20660803 [PubMed - as supplied by publisher]

Hypertension in Pregnancy and Later Cardiovascular Risk. Common Antecedents?

Circulation. 2010 Jul 26;

Authors: Romundstad PR, Magnussen EB, Smith GD, Vatten LJ

BACKGROUND: -Preeclampsia and gestational hypertension are associated with increased risk for cardiovascular disease later in life. We have assessed whether the effect can be attributed to factors that operate in pregnancy or to prepregnancy risk factors that are shared by both disorders. Methods and Results-Longitudinal data from 2 consecutive waves of a Norwegian population-based study (the Nord-Trøndelag Health Study [HUNT]) were combined with data from the Medical Birth Registry of Norway. Among 24 865 women who had participated in both HUNT 1 and 2, we indentified 3225 women with a singleton birth between the 2 studies who had standardized measurements of blood pressure, serum lipids, and body mass index. The crude results showed that women who experienced preeclampsia or gestational hypertension in pregnancy had substantially higher levels of body mass index and systolic and diastolic blood pressures and unfavorable lipids compared with other women. However, after adjustment for prepregnancy measurements, the difference in body mass index was attenuated by >65%, and the difference in blood pressure was attenuated by approximately 50%. In relation to high-density lipoprotein cholesterol and triglycerides, differences between the groups were attenuated by 40% and 72%, respectively. Conclusions-These results suggest that the positive association of preeclampsia and gestational hypertension with postpregnancy cardiovascular risk factors may be due largely to shared prepregnancy risk factors rather than reflecting a direct influence of the hypertensive disorder in pregnancy.

PMID: 20660802 [PubMed - as supplied by publisher]