Showing papers in "Current Opinion in Cardiology in 2009"
TL;DR: Evidence supports a potential role for both fasting and nonfasting triglycerides as vascular risk factors, owing in part to the accompanying burden of atherogenic remnant particles, small dense low-density lipoprotein, reduced HDL-C and a high frequency of accompanying insulin resistance.
Abstract: Purpose of reviewTargeting triglycerides as a vascular risk factor is justified because of the role of triglyceride-rich lipoproteins in atherogenesis. This review examines recent evidence connecting triglycerides with cardiovascular disease (CVD) in the context of advances in insights concerning th
147 citations
TL;DR: The role of low endothelial shear stress (ESS) in the transition of early, stable plaques to high-risk atherosclerotic lesions is summarized and the effect of recognized cardioprotective medications may be mediated by attenuation of the proinflammatory effect of the low ESS environment in which a plaque develops.
Abstract: Purpose of reviewLocal hemodynamic factors are major determinants of the natural history of individual atherosclerotic plaque progression in coronary arteries. The purpose of this review is to summarize the role of low endothelial shear stress (ESS) in the transition of early, stable plaques to high
113 citations
TL;DR: People with previously repaired coarctation of the aorta require long-term surveillance for local complications with aortic imaging and surveillance and management of hypertension to prevent vascular disease.
Abstract: Purpose of review Coarctation of the aorta is the discrete narrowing of the proximal descending aorta and is the sixth most common lesion in congenital heart disease. Repair of the coarctation can relieve the obstruction, but recurrent coarctation and future aneurysm formation can occur, and a heightened risk of vascular disease is present. This review focuses on advances in the management of native and previously treated coarctation and provides insights into future vascular risk. Recent findings Coarctation of the aorta is associated with other left heart obstructive lesions, and advances in the genetic basis of these conditions have been made. Recurrent coarctation and aneurysm formation are common after surgical and endovascular repair of coarctation of the aorta. Endovascular treatment is an acceptable alternative to surgical repair of native and recurrent coarctation. Covered stents and stent grafts can be used to treat arch complications with a low risk of complications. In spite of repair of the obstruction, hypertension persists and appears to be multifactorial due to a variety of factors, including endothelial dysfunction, aortic stiffness, altered arch morphology and increased ventricular stiffness. Summary People with previously repaired coarctation of the aorta require long-term surveillance for local complications with aortic imaging and surveillance and management of hypertension to prevent vascular disease.
108 citations
TL;DR: The findings suggest that significant health gains can be expected in a general population whose diet reflects the nutritional principles reflected in a Mediterranean diet, which has been consistently shown to be associated with favourable health outcomes and a better quality of life.
Abstract: Purpose of reviewThe optimal dietary strategy for the prevention of chronic degenerative diseases remains a challenging and a highly relevant preventive health issue. In recent years, there have been ongoing investigations of the effectiveness of the Mediterranean diet in preventing the development
99 citations
TL;DR: Without proper dyssynchrony training and experience accumulation in a large number of implanting centers worldwide, a rush into multicenter trials that only focus on experienced device implantation will not be possible to replicate the role of dyss synchrony assessment.
Abstract: Purpose of reviewTo analyze the strength and weakness of various imaging tools for systolic dyssynchrony assessment in the cardiac resynchronization therapy (CRT) era. Also, controversies and problematic issues of the recent predictors of response to cardiac resynchronization therapy study were addr
72 citations
TL;DR: Reactive oxygen species-related mechanisms ofAir pollution cardiotoxicity might become a valid target in developing new pharmacological strategies aimed at decreasing adverse effects of air pollution during extreme episodes (fires, earthquakes, industrial accidents, acts of terrorism).
Abstract: Purpose of reviewAir pollution poses a significant health risk. The article focuses on the adverse effects of air pollution on the cardiovascular system.Recent findingsShort-term and long-term studies clearly indicate that relatively modest exposures to particulate matter in the ambient air are asso
72 citations
TL;DR: The clinical spectrum of patients with a Brugada ECG remains broad, reflecting the heterogeneity of the underlying pathophysiology, and it may be proposed that the ECG pattern of ST-segment elevation in the right precordial leads should not be seen as a marker of a specific syndrome, but rather as a common electrical expression of structural abnormalities in theright ventricle.
Abstract: Purpose of reviewThe Brugada syndrome continues to spark intensive investigation since its earliest description New insight has been gained regarding the genetic, histopathalogic, and metabolic mechanisms of this heritable channelopathy – a heterogeneity that is reflected in the diverse clinical pr
67 citations
TL;DR: Current literature shows that BNP can be useful in providing diagnostic and prognostic data in patients with symptomatic and asymptomatic diastolic dysfunction, and these data can augment the sensitivity and specificity of BNP.
Abstract: Purpose of reviewHeart failure with preserved ejection fraction or diastolic heart failure is an increasingly prevalent disease process today. Natriuretic peptides have been shown to provide diagnostic and prognostic utility in patients with systolic heart failure. Here we review current publication
63 citations
TL;DR: A step-by-step approach to evaluation of patients with end-stage heart failure for LVAD implantation is described, including a summary of the recently published guidelines on candidate selection for long-term mechanical circulatory support, current understanding of the optimal timing of device placement in the disease course and the utility of preoperative screening scales to estimate the patient's operative risk.
Abstract: Purpose of reviewSelection of appropriate candidates is one of the most important determinants of successful outcomes of left-ventricular assist device (LVAD) implantation. The review describes a step-by-step approach to evaluation of patients with end-stage heart failure for LVAD implantation.Recen
58 citations
TL;DR: Lipop protein a potentially represents a useful tool for risk stratification in the primary and secondary prevention setting, however, there are still unresolved methodological issues regarding the measurement of lipoprotein a levels.
Abstract: Purpose of reviewTo provide an update of the literature describing the link between lipoprotein a and vascular disease.Recent findingsThere is evidence that elevated plasma lipoprotein a levels are associated with coronary heart disease, stroke and other manifestations of atherosclerosis, Several mechanisms may be implicated, including proinflammatory actions and impaired fibrinolysis.SummaryLipoprotein a potentially represents a useful tool for risk stratification in the primary and secondary prevention setting. However, there are still unresolved methodological issues regarding the measurement of lipoprotein a levels. Targeting lipoprotein a in order to reduce vascular risk is hampered by the lack of well tolerated and effective pharmacological interventions. Moreover, it has not yet been established whether such a reduction will result in fewer vascular events. The risk attributed to lipoprotein a may be reduced by aggressively tackling other vascular risk factors, such as low-density lipoprotein cholesterol.
55 citations
TL;DR: Despite the encouraging findings of these preliminary studies, the future role of ESAs and iron replacement will be determined by ongoing randomized placebo-controlled studies.
Abstract: Purpose of review The earlier enthusiasm for raising hemoglobin in heart failure has been followed by skepticism and concern of potential harm from using erythropoiesis-stimulating agents (ESAs). Recent findings Several recent studies have confirmed the high prevalence and prognostic role of anemia and have shown encouraging signals of the safety of using ESAs in heart failure and potential benefit that may be related to nonhematopoietic effects of ESAs. In addition, recent studies have also suggested a potential beneficial role of iron replacement in heart failure. Summary Despite the encouraging findings of these preliminary studies, the future role of ESAs and iron replacement will be determined by ongoing randomized placebo-controlled studies.
TL;DR: In patients with milder heart failure symptoms, three randomized controlled trials and observational studies failed to convincingly show improvement of functional status, but demonstrated improved ventricular reverse remodelling with more advanced heart failure patients.
Abstract: Purpose of review This paper reviews the effect of cardiac resynchronization therapy (CRT) on patients with heart failure symptoms, in particular, in patients with mild symptoms of heart failure. It provides the rationale and design of a randomized controlled trial to determine if CRT, when added to implantable cardioverter defibrillator, will be beneficial in patients with left ventricular dysfunction, ventricular conduction delay and mild heart failure symptoms. Recent findings CRT has been demonstrated to improve functional capacity, quality of life, and reduce heart failure hospitalization in patients with advanced symptomatic heart failure, and evidence of a ventricular conduction abnormality on ECG. In patients with milder heart failure symptoms, three randomized controlled trials and observational studies failed to convincingly show improvement of functional status, but demonstrated improved ventricular reverse remodelling with more advanced heart failure patients. Summary Two large randomized clinical trials are currently ongoing (RAFT and MADIT-CRT). The results of these trials will determine the efficacy of CRT in patients with systolic heart failure, ventricular conduction abnormality and milder symptoms.
TL;DR: Selective large prospective imaging, biomarker and intervention studies are now required to clearly demonstrate the value of new management pathways for AAA.
Abstract: Purpose of review: Abdominal aortic aneurysm (AAA) is being diagnosed more frequently in older patients due to the increased use of abdominal imaging and the rising average age of western populations Currently the management of this condition has two important deficiencies:
inadequate methods to identify AAAs at risk of progression and rupture and the current lack of effective nonsurgical therapies In this review recent developments in
identifying new diagnostic, prognostic and therapeutic strategies for AAA are discussed
Recent findings: There are growing number of animal and human association studies which have identified markers and strategies of potential value in improving identification,
monitoring and treatment of AAA
Summary: Selective large prospective imaging, biomarker and intervention studies are now required to clearly demonstrate the value of new management pathways for AAA
TL;DR: Understanding of the mechanisms, diagnosis, and treatment of lamin A/C deficiency is incomplete, and it is clear that patients with this condition have a malignant course and need to be followed aggressively.
Abstract: Purpose of review Familial dilated cardiomyopathy is an underrecognized form of dilated cardiomyopathy. Lamin A/C deficiency is probably the most common cause of familial dilated cardiomyopathy. This review will focus on the emerging knowledge of epidemiology, diagnosis, and treatment of patients with lamin A/C deficiency, as well as possible disease mechanisms. Recent findings Screening of patients with dilated cardiomyopathy continues to indicate that lamin A/C deficiency is a significant cause. Multiple novel mutations have been found, suggesting that many mutations are limited to individuals or families. It is unknown how mutations cause the syndrome, although an animal model has shown that lamin A/C insufficiency causes apoptosis, particularly in the conduction system. Inheritance is predominantly autosomal dominant, but penetrance is variable. For symptomatic patients, the course is malignant, with conduction system disease, atrial fibrillation, heart failure, and sudden cardiac death. The data are contradictory, and currently, there is no clear marker for when a lamin A/C-deficient patient is at risk for sudden death. Summary Lamin A/C deficiency is an important cause of dilated cardiomyopathy, and diagnosis requires that clinicians have a high index of suspicion. Our knowledge of the mechanisms, diagnosis, and treatment of lamin A/C deficiency is incomplete. It is clear that patients with this condition have a malignant course and need to be followed aggressively.
TL;DR: The combination of conventional 2D and Doppler methods and 3D echocardiography is recommended in the evaluation of the RV at the present time because of limitations in clinical settings due to technical factors.
Abstract: Purpose of reviewEvaluation of right ventricular (RV) volume, function and mass has been challenging because of its unique cavity geometry. However, it is indispensable, especially in patients with signs of right-sided heart failure and those with congenital heart diseases. Thus, many investigations
TL;DR: The Dietary Approaches to Stop Hypertension diet and Therapeutic Lifestyle Changes Diet are effective in decreasing cardiovascular morbidity and mortality risk, and such dietary strategies are endorsed by many organizations, including the American Heart Association and the National Heart, Lung and Blood Institute.
Abstract: Purpose of reviewHealthy lifestyle practices play a key role in preventing and treating cardiovascular disease, and central to such strategy is a recommended dietary pattern. Current Dietary Guidelines from the US Department of Agriculture and the American Heart Association advocate a food-based die
TL;DR: There seems to be sufficient evidence that evaluation of CETP inhibitors such as dalcetrapib and anacetrapib should proceed, if cautiously, since it remains uncertain whether the increased CVD risk with torcETrapib was related to agent-specific off-target effects or more generally to CETP inhibition as a mechanism to raise HDL.
Abstract: Purpose of reviewBecause high-density lipoprotein cholesterol (HDL-C) levels are inversely related to cardiovascular disease (CVD), raising HDL-C levels would seem intuitively valuable. However, the recent failure of the cholesteryl ester transfer protein (CETP) inhibitor torcetrapib to decrease CVD
TL;DR: Efforts to develop atrial-selective antiarrhythmics are bearing fruit, but such compounds will need to exhibit equal or superior safety and efficacy compared with multichannel blockers for atrial fibrillation suppression in order to prove their worth.
Abstract: Purpose of reviewRhythm control remains of therapeutic value for many atrial fibrillation patients despite no evidence of survival benefit. This lack of benefit may relate to side effects of conventional antiarrhythmic drugs. The introduction of novel agents was a logical consequence.Recent findings
TL;DR: It is imperative to recognize the detailed anatomy and physiology of the atrioventricular node in every individual patient before the ablation of AVNRT.
Abstract: Purpose of reviewAtrioventricular nodal reentrant tachycardia (AVNRT) is the most common arrhythmia in patients with regular supraventricular tachycardia. Selective radio frequency catheter ablation of the slow pathway has afforded an ideal method to treat most patients with AVNRT. However, there ar
TL;DR: Current clinical literature on isolated left ventricular noncompaction is summarized, with a particular focus on the limitations of current diagnostic criteria and emerging data on the genetics of the disorder.
Abstract: Purpose of reviewIsolated left ventricular noncompaction (LVNC) is a myocardial disorder characterized by excessive and prominent trabeculations of the left ventricle, associated with progressive systolic failure, stroke and arrhythmia. Until quite recently, LVNC was thought to be extremely rare, bu
TL;DR: New developments in standardization of echocardiography, the introduction of three-dimensional echOCardiography and new functional techniques such as tissue Doppler and Speqle tracking strengthen the position of pediatric echokardiography as the most important diagnostic tool for patients with congenital heart disease.
Abstract: Purpose of review Echocardiography in pediatric and congenital heart disease is a key diagnostic technique in patients with congenital heart disease. Due to new technological developments, it has become a rapidly evolving field. Recent findings In this review, we focus on recent developments in standardization and validation of standard techniques in pediatric and congenital echocardiography. This is mainly related to standardization of image acquisition and normalization of measurements for body size. The rest of the review is focused on the application of three-dimensional echocardiography, tissue Doppler imaging and Speqle tracking techniques to pediatric heart disease. Summary New developments in standardization of echocardiography, the introduction of three-dimensional echocardiography and new functional techniques such as tissue Doppler and Speqle tracking strengthen the position of pediatric echocardiography as the most important diagnostic tool for patients with congenital heart disease.
TL;DR: The best imaging modalities to assess for pulmonary vein stenosis are CT and MRI, and in asymptomatic patients, the data suggest that such patients will also derive benefit.
Abstract: Purpose of review The diagnosis of pulmonary vein stenosis, following catheter ablation of atrial fibrillation, potentially carries significant morbidity for affected patients It is important that physicians remain aware of the entity and have an understanding of how to treat such patients There has been controversy in how to assess patients following atrial fibrillation ablation, and how to treat asymptomatic patients with pulmonary vein stenosis This article reviews the recently published data Recent findings The reported incidence of pulmonary vein stenosis is decreasing Nonetheless, it may not be found if not sought, as even patients with severe pulmonary vein stenosis may be asymptomatic Also, patients with symptoms may be misdiagnosed if pulmonary vein stenosis is not included in the differential diagnosis Computed tomography (CT) and MRI have been shown to be the diagnostic modalities of choice The treatment options for severe pulmonary vein stenosis and occlusion are primarily that of pulmonary vein angioplasty with or without stenting Despite the observed rate of restenosis, patients derive benefit from pulmonary vein angioplasty Summary The best imaging modalities to assess for pulmonary vein stenosis are CT and MRI Early intervention in symptomatic patients with severe pulmonary vein stenosis is warranted; in asymptomatic patients, the data suggest that such patients will also derive benefit
TL;DR: Novel well tolerated and efficacious treatment strategies for raising HDL-C are required to target atherosclerosis and enhance CVD risk reduction.
Abstract: Purpose of reviewDespite optimally reducing low-density lipoprotein cholesterol (LDL-C) levels to recommended targets using intensive statin therapy, the risk of cardiovascular disease (CVD) remains significant. Low levels of high-density lipoprotein cholesterol (HDL-C; <1.03 mmol/l or <40 mg/dl) ar
TL;DR: Although the clinical value of RT3DE evaluation of the left ventricle is already well established, future improvements will determine whether this methodology can become the new standard reference technique for accurate and repeatable measurement of left ventricular volumes, mass, regionalleft ventricular function and dyssynchrony.
Abstract: Purpose of review The purpose of this review is to provide readers with an update on the latest developments and the current status of the real-time three-dimensional echocardiographic (RT3DE) quantitative evaluation of left ventricular volumes and function. Recent findings In recent years, the growing availability of RT3DE imaging technology, its ease of use and its multiple attractive features have sparked significant interest in the echocardiography community, resulting in a large number of research papers, most of which have endorsed RT3DE imaging for clinical use by demonstrating its unique capabilities in different scenarios. In parallel, the clinical acceptance of this new tool has broadened significantly. Summary Although the clinical value of RT3DE evaluation of the left ventricle is already well established, future improvements will determine whether this methodology can become the new standard reference technique for accurate and repeatable measurement of left ventricular volumes, mass, regional left ventricular function and dyssynchrony.
TL;DR: The results of the Atrial Fibrillation and Congestive Heart Failure trial indicate that a routine strategy of rhythm control does not reduce rate of death and suggest that rate control should be considered a primary approach for patients with atrial fibrillationand heart failure.
Abstract: Purpose of review The present review will examine the prognostic importance of atrial fibrillation and heart failure, explore the different therapeutic options for treating atrial fibrillation and present the results of the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial. Recent findings The Atrial Fibrillation and Congestive Heart Failure trial was a randomized trial involving patients with both atrial fibrillation and heart failure. The trial was designed to compare the maintenance of sinus rhythm with the control of ventricular rate in patients with left ventricular dysfunction, heart failure and a history of atrial fibrillation. There was no significant difference in the rate of death from cardiovascular causes in the rhythm-control group as compared with the rate-control strategy. In addition, there was no significant difference in any of the secondary outcomes including death from any cause, worsening heart failure or stroke. The rate-control strategy eliminated the need for repeated cardioversion and reduced rates of hospitalization. Summary The results of the Atrial Fibrillation and Congestive Heart Failure trial indicate that a routine strategy of rhythm control does not reduce rate of death and suggest that rate control should be considered a primary approach for patients with atrial fibrillation and heart failure.
TL;DR: Evidence continues to build supporting the usefulness of Lp PLA2 as a predictor of coronary events in the general population and in those with established coronary heart disease, as well as as a possible therapeutic target.
Abstract: Purpose of reviewLipoprotein-associated phospholipase A2 (Lp PLA2) is postulated to occupy a key position in the pathogenic sequence leading to formation of complex atherosclerotic lesions. This study reviews evidence supporting its role as a biomarker of vascular disease and as a possible therapeut
TL;DR: With careful planning in advance and shared partnership among sponsors, host-country research practitioners, government agencies and the community, many of the challenges facing clinical trial research can be overcome over the medium to long term.
Abstract: Purpose of review To provide a broad perspective of contextual factors involved in the conduct of clinical trials in developing countries. Recent findings The quantity of research in developing countries continues to be inadequate, with clinical trials comprising a small fraction of the total research output. Most trials done in developing countries tend to be designed in developed countries and led by investigators in those nations. The main challenges in the conduct of trials in developing countries stem from the vulnerability of the populations due to illiteracy, poverty, limited research infrastructure, lack of sufficient numbers of experienced investigators and trained support personnel, and fragmented healthcare system. Summary There is a need to formulate and conduct trials to test treatments that are context-specific and socially relevant. With careful planning in advance and shared partnership among sponsors, host-country research practitioners, government agencies and the community, many of the challenges facing clinical trial research can be overcome over the medium to long term. This would enable conformity to contemporary guidelines in both letter and spirit and hopefully develop research questions addressing the needs of developing countries.
TL;DR: The use of left ventricular assist devices to help treat pulmonary hypertension in heart failure is an emerging strategy in transplant-eligible patients and should take into consideration novel pharmacologic and device-based therapies.
Abstract: Purpose of reviewCompared with the left ventricle, studies of right ventricular failure as a distinct clinical entity have lagged behind. Evolving appreciation of the prognostic significance of right ventricular dysfunction in the heart failure population and advances in noninvasive imaging have pro
TL;DR: A prospective, single-blind, randomized, controlled trial to address the dilemma of periprocedural management of patients with moderate-to-high risk of arterial thromboembolic events on chronic oral anticoagulation therapy.
Abstract: Purpose of review Many patients requiring cardiac arrhythmia device surgery are on chronic oral anticoagulation therapy. The periprocedural management of their anticoagulation presents a dilemma to physicians, particularly in the subset of patients with moderate-to-high risk of arterial thromboembolic events. Physicians have responded by treating patients with bridging anticoagulation while oral anticoagulation is temporarily discontinued. However, there are a number of downsides to bridging anticoagulation around device surgery; there is a substantial risk of significant device pocket hematoma with important clinical sequelae; bridging anticoagulation may lead to more arterial thromboembolic events and bridging anticoagulation is expensive. Recent findings In response to these issues, a number of centers have explored the option of performing device surgery without cessation of oral anticoagulation. The observational data suggest a greatly reduced hematoma rate with this strategy. Despite these encouraging results, most physicians are reluctant to move to operating on continued Coumadin in the absence of confirmatory data from a randomized trial. Summary We have designed a prospective, single-blind, randomized, controlled trial to address this clinical question. In the conventional arm, patients will be bridged. In the experimental arm, patients will continue on oral anticoagulation and the primary outcome is clinically significant hematoma. Our study has clinical relevance to at least 70 000 patients per year in North America.
TL;DR: Fenofibrate and bezafibrate are reasonable second-line therapies for dyslipidaemia and in diabetes, and well tolerated in combination therapy.
Abstract: PurposeNew data have emerged over the last few years about the role of fibrates in treatment of microvascular and macrovascular disease.Recent findingsEndpoint studies have been conducted with fibrates in coronary heart disease (CHD) since 1971 and initial results were contradictory. Fibrates later