Cardiology

The development of new and innovative mechanical and pharmacologic therapies for the broad spectrum of cardiovascular disease has led to dramatic changes in the makeup of clinical practice.

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.

Diabetes is a potent risk factor for adverse outcomes following acute myocardial infarction,1 but the mechanisms responsible for this association are not well understood.

In a separate analysis of patients enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, thin patients and those with moderate-to-severe obesity were at increased risk for cardiovascular events. These results indicate that patients at the low anda high ends of the body size spectrum should be treated aggressively to lower the risk of cardiovascular events.

The observed relationship linking obesity, severity of hypertension, and increase in cardiovascular risk was traditionally thought to emanate from the increase in circulatory volume, persistently increased systemic resistance from obesity, and clustering of major cardiovascular risk factors (eg, hypercholesterolemia and diabetes mellitus) among obese 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

We conducted 2 feasibility studies to assess the performance and safety of the percutaneous left atrial appendage (LAA) transcatheter occlusion system for the prevention of stroke in high-risk patients with nonrheumatic atrial fibrillation. Results showed that percutaneous LAA occlusion can be performed using the device at acceptable risk. This procedure may be particularly useful for patients at increased risk of ischemic stroke with a contraindication to anticoagulation therapy.

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

We compared the use of early, minimally invasive ultrafiltration with usual care in patients with acute decompensated heart failure in a randomized controlled trial. Ultrafiltration therapy resulted in greater fluid removal than standard therapy and was shown to be a safe and effective alternative to loop diuretics for sodium and fluid homeostasis in patients with heart failure. More research is needed to identify those patients most likely to benefit from this approach.

The literature is replete with studies of treatments for chronic heart failure that have shown morbidity and mortality benefits.

We evaluated the performance of the 64-slice spiral computed tomography coronary angiography scanner in 52 symptomatic patients with stable sinus rhythm and found that it was highly reliable in ruling out the presence of a significant coronary stenosis. This technique may be regarded as a suitable alternative to invasive coronary angiography.

Despite advances in cardiac testing, noninvasive methodologies remain limited in their accuracy to (1) determine the etiology of chest pain; (2) detect preclinical coronary artery disease; and (3) track the progression of atherosclerotic lesions in native and revascularized coronary vessels.

Up to 100 sudden deaths occur among high school and college athletes each year in the United States, most commonly resulting from hypertrophic cardiomyopathy and other cardiac disorders. Studies have shown that preparticipation screening examinations that include a 12-lead electrocardiogram, which is not currently required in the United States, can identify asymptomatic athletes with hypertrophic cardiomyopathy. The current dilemma is how the United States, with its large population and emphasis on reducing health care costs, can realistically implement an effective prescreening process to identify these athletes.

When Hank Gathers collapsedon court during a college basketball game against Portland State on March 4, 1990, and later died, the event both jolted the national consciousness and set into motion changes in the athletic preparticipation screening process. Although another collapse had occurred just 4 months before, and an irregular heartbeat was detected at that time, Gathers was not compliant with the prescribed beta blocker and continued to play. An autopsy revealed that the 23-year-old Gathers suffered from cardiomyopathy.

An asymptomatic 66-year-old man with a history of nonobstructing carotid artery plaque and sleep apnea was referred for cardiac computed tomography (CT) scanning for risk stratification. He exercised on a regular basis with no symptoms and had normal results on at least 2 nuclear stress tests, the last test being performed only 12 months earlier.

In this issue, Schubert and Helenowski present a very dramatic instance of an increasingly common application of computed tomography (CT) coronary angiography—detection of an anomalous origin of the coronaries (page 40).

We performed a cost-utility analysis comparing treatment with aspirin, statins, and the combination of aspirin and statins among middle-aged men with no previous history of cardiovascular disease and with different underlying coronary artery disease (CAD) risk levels. Results showed that for men with a 10-year risk of CAD of 7.5% or higher, treatment with aspirin cost less and was more beneficial than no treatment. When the patient's 10-year risk of CAD before treatment was greater than 10%, adding a statin to aspirin treatment was cost effective.

Practicing cardiologists often joke about putting "statins" in the drinking water to stem the epidemic of atherosclerotic cardiovascular disease, but curiously, I don't believe that refers, even in jest, to a cocktail combination of drugs.

We performed cineventriculography, unenhanced echocardiography, contrast-enhanced echocardiography, and magnetic resonance imaging to define the presence of regional left ventricular wall motion abnormalities. Interobserver agreement in the analysis of regional wall motion abnormality was highest for contrast-enhanced echocardiography, followed by cineventriculography and cardiac magnetic resonance imaging; it was lowest for unenhanced echocardiography. Contrast-enhanced echocardiography also showed the highest accuracy in the detection of panel-defined regional wall motion abnormalities.

The lack of a reliable quantitative measurement analysis package for regional left ventricular wall motion is not new.