Reviews & Analysis

Randomized trial data on pericardial diseases are scarce, but a number of new studies are moving the management of these conditions from empirically-based to evidence-based medicine. Massimo Imazio and colleagues show how the emerging data and the first guidelines for pericardial disease can be used to tailor management to the individual patient.

Factor Xa inhibitors, a new class of oral anticoagulants, have been evaluated in the phase II ATLAS ACS-TIMI 46 and APPRAISE trials. Addition of these agents to standard therapy has tended to reduce the incidence of adverse cardiovascular events at the expense of a dose-dependent increase in the risk of bleeding complications.

Cell therapy for myocardial infarction has received widespread attention. Although short-term effects have been encouraging, Yousef et al. now report substantial benefit of bone marrow mononuclear cells over 5 years of follow-up in an open-label series of 62 patients. Long-term follow-up of randomized trials is eagerly awaited and novel approaches of cell therapy are currently under investigation.

Ultrasonographic screening of older men to detect abdominal aortic aneurysms has been added to the list of programs supported by the National Health Service in England and Scotland, and by Medicare in the US. Two articles in the British Medical Journal addressing the cost-effectiveness of this practice have provided markedly discordant results.

Transcatheter aortic valve implantation has evolved as a viable therapeutic option for high-risk, elderly patients with symptomatic aortic stenosis in select cardiac centers with experience of the procedure. In this article we consider the findings reported by Webb et al. and discuss current criteria for selection of patients, technical features, clinical results, and future developments in this rapidly advancing area.

The extent of coronary calcification is thought to reflect the total coronary atherosclerotic burden. In this Review, Drs. Alexopoulos and Raggi discuss the current uncertainty about the role of coronary artery calcium in various disease states, the utility of calcium screening and current recommendations on its use.

Patients of low socioeconomic status (SES) with cardiovascular disease are a highly vulnerable, but often under-served, population. In high income countries in particular, these individuals develop cardiovascular disease younger, have more risk factors, and are less likely to benefit from treatment than are patients of higher socioeconomic status. In this Review, Clark et al. examine how socioeconomic status is linked to adverse cardiovascular outcomes and what clinicians can do to address inequalities.

Rheumatic heart disease is a substantial global health problem that particularly affects developing countries. In this article, Andrew Steer and Jonathan Carapetis review the pathophysiology and epidemiology of this disease and discuss strategies for diagnosis, prevention, and treatment. They also emphasize the importance of secondary prophylaxis programs and highlight the potential for vaccine development.

Myocardial angiogenesis occurs in response to hypoxia in ischemic tissues. This Review discusses imaging techniques that can be used to assess the effectiveness of exogenous angiogenic agents in promoting the growth of collateral vessels in ischemic myocardium.

Cappato et al. have reviewed the major causes of death in patients undergoing catheter ablation of atrial fibrillation. Many of these complications could be prevented by careful catheter manipulation, implementing safe energy settings, adequate anticoagulation, and esophageal monitoring. Urgent pericardial drainage is critical in avoiding death related to cardiac tamponade.

Intentional weight loss is associated with many benefits, including reduced mortality and cardiometabolic and inflammatory risk, as well as improved quality of life. Unintentional weight loss, however, is often a harbinger of future ill-health. Separating these types of weight loss in clinical trials is sometimes difficult and in small trials can produce the 'obesity paradox'.

Lipoprotein(a) has been studied as a risk factor for coronary heart disease, but whether a causal relationship exists has been unclear. A study by Kamstrup and colleagues examining genetically mediated increases in lipoprotein(a) concentration now provides evidence that it could indeed represent a causal coronary risk factor.

Unselected bone-marrow-derived mononuclear cells seem to improve left ventricular function and perhaps short-term clinical outcomes for patients with acute myocardial infarction. The REGENT trial aimed to elucidate whether infusion of selected hematopoetic progenitor cells increases this effect in patients with large infarcts and attenuated left ventricular ejection fraction.

Radiation exposure from cardiac CT is currently under a high level of scrutiny, and many patients may be receiving excessive radiation from this test. A study by Raff and colleagues—aimed at reducing this radiation through a statewide initiative—helps define the potential for improving the safety of cardiac CT at community medical centers.

Ongoing medical education and recertification of specialists is important in minimizing medical errors and ensuring that patients receive quality care. This Review discusses the processes by which cardiovascular specialists are assessed in different geographical regions.

Individualized drug therapy requires physicians to be able to accurately predict an individual's response to a drug. 'Pharmacogenetics' is the study of the role of inheritance in variation in drug response phenotypes. Pharmacogenetics is now moving genome-wide to become 'pharmacogenomics'. This article reviews the development, promise and challenges of pharmacogenomics, using examples of drugs used to treat or prevent cardiovascular disease.

Treatment of hypertension is associated with a reduction in the risk of cardiovascular complications such as stroke. In this Review, Morris Brown discusses vaccines that target components of the renin–angiotensin system as a potential strategy not only for treating hypertension, but for preventing the development of treatment-resistant hypertension.

In this extensive Review, Stefan Pilz and colleagues discuss the potential mechanisms by which vitamin D might affect blood pressure and explore the clinical evidence for an association between vitamin D and arterial hypertension. The authors also make recommendations for vitamin D supplementation in patients with hypertension and 25-hydroxyvitamin D levels below target values.

Consumption of fruit and vegetables has been associated with reduced risk of coronary heart disease. This Review discusses epidemiological studies of the association between fruit and vegetable consumption and coronary heart disease, and assesses the significance of the findings.

There are concerns about long-term outcomes associated with drug-eluting stent implantation in high-risk and 'real world' patients, and few data from these settings have been published. Two new papers add to our knowledge on drug-eluting stent use in acute myocardial infarction and for off-label indications.