Cardiology

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.

We assessed how well dobutamine stress echocardiography predicted morbidity and mortality in 2349 patients with diabetes mellitus over a follow-up period of 13.2 years. Results showed that age, failure to achieve the target heart rate, and the percentage of ischemic segments were independent predictors of both mortality and cardiovascular morbidity. Using clinical and stress echocardiographic parameters, a simple model for risk stratification was developed.

Cardiovascular disease is a leading cause of death for persons with diabetes, accounting for almost 80% of mortality in this group in the United States.

In the Prevention of Syncope Trial, we evaluated whether beta-blocker treatment with metoprolol was beneficial for the treatment of patients with vasovagal syncope. Results showed little evidence that metoprolol was effective in reducing the burden of syncopal symptoms. In a substudy analysis, neither age nor response to isoproterenol was useful in selecting which patients might benefit from metoprolol.

Neurocardiogenic syncope (vasovagal syncope) is the most common cause of loss of consciousness, ranging in various studies from 18% to 58% of all syncopal events.

Only one third of patients admitted to the hospital with acute myocardial infarction have normal renal function, and 17% have severe renal impairment. Decreased renal function is associated with the presence of comorbid conditions, underuse of effective treatments, and higher mortality. Renal function parameters should not only be included in scoring systems to assess risk levels, but patients with abnormal renal function should benefit from careful application of guidelines-recommended treatments for acute and long-term care.

Multiple observational and randomized trials support the finding that renal insufficiency has a significant, independent, graded effect on the risk of cardiovascular events and cardiovascular mortality.

More important than the choice of pharmaceutical agent in the treatment of elderly hypertensive patients is the achievement of goal blood pressure. Low-dose diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are equally effective in reducing cardiovascular end points. Most patients will require 2 or more drugs to achieve target blood pressure, and physicians should feel comfortable prescribing 3 to 4 agents to a significant proportion of patients.

In their review, Gradman and Morsy emphasize the need to treat isolated systolic hypertension (ISH) and systolic/diastolic hypertension in elderly patients.

Studies have shown that elderly patients with heart failure are undertreated with evidence-based therapy, such as angiotensin-converting enzyme inhibitors and beta-blockers, although these therapeutic options appear to be effective in this age group. The risk of some side effects may be increased in elderly patients, and physicians should be aware of those when prescribing therapy. Cardiac resynchronization therapy is predicted to play a major role in future heart failure treatment, including in the elderly population.

Heart failure is the leading cause of hospitalization among Medicare beneficiaries, and it is the most costly diagnosis-related group by a factor of 2.

We evaluated the potential benefit of using myocardial perfusion scintigraphy as a gatekeeping technique prior to performing coronary angiography and revascularization procedures in patients with stable angina pectoris. Results showed that about half of all catheterizations and almost one fifth of coronary revascularizations could be avoided, assuming that only patients with reversible (stress-induced) myocardial ischemia and a minority of patients with "fixed" perfusion defects (present both at rest and during stress) would benefit from coronary revascularization.

The study by Høilund-Carlsen and Johansen evaluates the benefits of using myocardial perfusion scintigraphy (MPS) in a new way—as a gatekeeping technique for further invasive diagnostic and therapeutic procedures among patients with stable angina pectoris.

In a case-control substudy of the Veterans Affairs High-Density Lipoprotein Intervention Trial, therapy with gemfibrozil was shown to reduce the total number of low-density lipoprotein (LDL) particles, especially small, more oxidizable LDL particles, which was associated with a reduced risk of coronary heart disease (CHD) events. Gemfibrozil also increased small-sized high-density lipoprotein particle numbers, which also correlated with a decrease in CHD events. Notably, these changes in particle numbers were not associated with significant changes in lipoprotein cholesterol concentrations, which current guidelines have made the principal target of lipid therapy.

Conventional measurements of cardiac lipoprotein risk include cholesterol, triglyceride, and high-density lipoprotein (HDL) cholesterol levels. Low-density lipoprotein (LDL) cholesterol is estimated from these measurements.

We prospectively studied the relationship between C-reactive protein, obtained within 12 to 24 hours of symptom onset, and long-term risk of death and heart failure in survivors of acute myocardial infarction. The risk of death and heart failure increased progressively with increasing quartiles of C-reactive protein. We found a graded positive relationship between C-reactive protein levels and post-discharge mortality and heart failure.

Biomarkers seem to be proliferating everywhere, with at least 1 "major" new marker appearing each year.