Cardiology

We compared the rates of cardiac catheterization in 2136 non–ST-segment elevation acute coronary syndrome patients who were stratified according to their baseline thrombolysis in myocardial infarction (TIMI) risk score. Higher-risk patients were referred for catheterization at a similar rate as low-risk patients. The main reasons why physicians did not make referrals included (1) clinical trial evidence did not support an early invasive approach and (2) 68% of patients were thought not to be at high enough risk; however, 59% of these patients were found to be higher risk when their baseline TIMI risk scores were recalculated. Patients who were referred for catheterization had better in-hospital and 1-year outcomes. Our findings indicate that a significant opportunity remains to improve upon accurate risk stratification and adherence to an early invasive strategy for higher-risk patients.

A 59-year-old Indian man with a medical history significant for orally controlled diabetes presented to the emergency department after experiencing a witnessed seizure.

Despite contemporary management, patients with acute coronary syndrome (ACS) remain at risk of recurrent adverse cardiovascular events.

Rates of death and myocardial infarction were assessed for a national sample of acute coronary syndrome patients after stopping clopidogrel. In the first 90 days after stopping treatment, patients experienced a nearly twofold increased risk of adverse events compared with subsequent follow-up intervals for patients treated medically without stents and for patients treated with coronary stents. This suggests a possible clopidogrel rebound effect, but additional studies are needed to support this hypothesis and to identify strategies to reduce early events after clopidogrel cessation.

The benefits of intensive glycemic control appear to be confined to microvascular disease, with 3 randomized controlled clinical trials failing to demonstrate a macrovascular benefit with intensive glycemic control in patients with type 2 diabetes.

The US House of Representatives voted last week to approve the Heart Disease Education, Analysis Research, and Treatment for Women Act, legislation.

Percutaneous closure of the patent foramen ovale (PFO) can be accomplished within 15 minutes using only fl uoroscopy for guidance. Local anesthesia and femoral vein puncture in the groin with a 9 French catheter can achieve about a 90% complete closure rate when the Amplatzer® PFO Occluder is used. Complications are extremely rare and physical restrictions are unnecessary starting a couple of hours after the intervention. Aspirin and clopidogrel (Plavix) are typically prescribed for a few months after the procedure, and the therapy concludes with transesophageal echocardiography at follow-up approximately 6 months later.

Migraines, including those with aura, are common and generally benign, affecting between 10% and 15% of the population.

Although multivessel coronary artery disease (CAD) is commonly encountered in patients with acute coronary syndrome (ACS), no randomized controlled trials have evaluated the effi cacy of singlevessel percutaneous coronary intervention (PCI) versus multivessel PCI.

We found that lower cholesterol levels in middle age predicted lower total mortality and better physical quality of life in old age after 39 years of follow-up. No difference was seen in the mental component of quality of life. These findings support current guidelines for cholesterol goals and show that a low risk-factor level in midlife can affect long-term mortality and morbidity, postpone physical disability, and improve quality of life in old age.

The article by Rehman and colleagues (page 27) offers two important observations about the control of hypertension in African American men.

For 50 years, hypertension has been recognized as the most significant risk factor for the development of symptomatic cardiovascular disease in Western society.

We showed that a significant reduction in thoracic aortic plaques and low-density lipoprotein cholesterol levels occurred after 12 months of treatment with atorvastatin. In the abdominal aorta, however, the change in atherosclerotic plaques correlated with age. These results show that plaques in the thoracic and abdominal aortas may respond differently to lipid-lowering therapy, and other factors, such as aging, may be more important for plaque progression in the abdominal aorta.

Cardiovascular drugs affect women differently than they do men because of differences in pharmacokinetics, pharmacodynamics, and physiology. Results of recent studies on the use of cardiovascular agents in women are presented, with an emphasis on the need to include an appropriate proportion of women in future studies, to adapt the dosage to the weight of the patient, and to incorporate hormonal aspects into the analysis.

Depression at the time of coronary artery bypass graft (CABG) surgery is associated with a lack of functional benefits at 6 months after the surgery. These negative effects appear to be stronger for women than for men. Further research is needed to determine whether the treatment of depression after CABG surgery can improve outcomes. In the meantime, current guidelines recommend evaluation for symptoms of depression after CABG surgery and consideration of treatment for both men and women.

We examined the relationship between the 6-minute walk test and self-perceived changes in symptoms in 1077 elderly patients with chronic heart failure. We found that changes in 6-minute walk test distance were sensitive to changes in self-perceived symptoms of heart failure.

Ballistic injuries may be diagnostically challenging because of the unpredictable trajectory of projectiles and the possibility of their migration via the enteric, vascular, genitourinary, or central nervous systems.

We examined the association between plasma N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) levels and the occurrence of cardiac events, including cardiogenic shock and mortality, among hospitalized diabetic patients with acute myocardial infarction. Nt-pro-BNP level was shown to be a reliable predictor of outcome in this group of patients.

We evaluated how well patients taking spironolactone were monitored for hyperkalemia, as well as the association between spironolactone and hyperkalemia. Only two thirds of patients received testing for serum potassium and creatinine levels, and higher baseline serum creatinine levels predicted a high risk of hyperkalemia. These results indicate that appropriate patient selection and close monitoring are essential, especially for patients with renal impairment.

In 1999 Pitt and colleagues published the results of the RALES trial, an important study showing that the addition of a relatively small dose of the aldosterone antagonist spironolactone to a regimen that included angiotensin-converting enzyme (ACE) in­hibitors for patients with severe congestive heart failure (NYHA Class III-IV) had a striking benefit on mortality

Atrial fibrillation commonly affects millions of patients, and often causes the disabling complication of cardioembolic stroke.