Reviews & Analysis

Echocardiography is a useful imaging modality for the evaluation of heart failure and its response to treatment. In the past 5 years, the application of speckle tracking technology to 3D echocardiographic datasets (3D wall motion tracking) has enabled comprehensive evaluation of cardiac mechanics in three dimensions. Here, Yiu-fai Cheung discusses the principles of 3D wall motion tracking, the assessment of myocardial deformation using this novel imaging modality, its clinical applications and limitations, as well as the future of this technology.

Amin and colleagues have attempted to estimate the cost savings to the US health-care system if drug-eluting coronary stents were more selectively used in patients at low risk of restenosis. Their results and conclusions raise statistical, societal, and ethical issues that need to be considered before this approach should be widely embraced.

Preliminary evidence suggests that therapies focused on nutrition and weight loss might reduce the incidence of peripheral arterial disease (PAD), as well as ameliorate functional impairment and improve ischemic outcomes in patients with PAD. The authors summarize the available data on the effects of nutrition and anthropometric factors on PAD incidence and risk, and discuss potential nutritional strategies for the prevention and treatment of the disease.

Myocardial infarction is a major cause of morbidity and mortality worldwide. In this consensus document, experts from the ESC, ACCF, AHA, and WHF update the universal definition and classification of myocardial infarction to integrate the latest evidence on the detection of myocardial injury and necrosis using biomarker assays and imaging techniques.

Despite advances in prevention of cardiovascular disease, a high proportion of cardiac events occur in asymptomatic people who do not have a high level of risk. Much remains unknown about the value of novel risk markers for the identification of candidates for primary prevention. Here, Polonsky and Greenland argue that clinical trials of these markers in asymptomatic, low-risk populations are greatly needed to determine their effectiveness.

A major problem in Central and South America, Chagas disease is now also affecting individuals residing in other parts of the world. Many patients with late-stage disease have chronic cardiomyopathy and associated arrhythmias. In this Perspectives article, Professor Benaim and Dr Paniz Mondolfi discuss the potential for amiodarone and dronedarone to be used as dual-action (antiarrhythmic and antiparasitic) agents in patients with Chagas disease.

A new, observational study suggests that aspirin only marginally increases the bleeding risk in patients with diabetes mellitus, perhaps reflecting impaired platelet inhibition. Inconclusive evidence from small, randomized trials and mechanistic studies reinforces the need for larger trials to determine the relative cardioprotective benefits and bleeding risks of aspirin in these patients.

Chagas disease is endemic in Latin America, but the migration of infected individuals makes the condition an increasingly global problem. The authors review the epidemiology, pathogenesis, diagnosis, and treatment of the disease, focusing particularly on the risk stratification and management of patients with Chagas cardiomyopathy.

Syncope is a transient, self-terminating period of cerebral hypoperfusion that usually results from systemic hypotension. Many patients with this condition are successfully treated according to current guidelines. However, the authors identify and expertly review the current understanding of four key challenges in the characterization, diagnosis, risk stratification, and treatment of patients with suspected syncope.

In the Heidelberg–EPIC study, an association was found between the use of calcium supplements and risk of myocardial infarction, corroborating published data. Given these findings and the absence of clear beneficial effect on fracture risk, the use of these supplements should be discouraged, and individuals advised to obtain calcium from a balanced diet.

Dr Javier Escaned discusses the increasing problem of time-dependent failure of coronary artery bypass grafts, and the subsequent need for secondary revascularization. Issues such as the substrate and epidemiology of graft failure, the choice of secondary revascularization modality, the specific problems inherent in repeat CABG surgery and percutaneous coronary intervention, and the importance of secondary prevention are reviewed.

To achieve timely restoration of coronary flow in patients with acute myocardial infarction, the decision to call in the cardiac catheterization team has moved ever earlier, and is often made before cardiologist evaluation. Door-to-balloon times have been reduced, but the price of this success is an increase in 'false alarms'.

A spectrum of common illnesses that constitute risk factors for cardiovascular diseases is associated with both cognitive impairment and high population mortality. Many clinical trials are focused on the prevention of cardiovascular mortality, but cognitive impairment should now be regarded as a similarly important outcome.

Depression increases the risk of cardiovascular disease and is a predictor of poor cardiovascular outcomes. The authors outline these epidemiological findings, describe the pathophysiological mechanisms that might underlie the risk of cardiovascular disease in patients with depression, and describe new data on the effects of successful treatment of depression on biological risk factors for coronary artery disease.

Abnormalities in the control of intracellular calcium are involved in several forms of inherited arrhythmias. The genetic mutations that cause these abnormalities have generated much research interest in the past decade. Here, Venetucci et al. provide an overview of the structural organization and the function of calcium-handling proteins and describe the mechanisms by which mutations determine the various clinical phenotypes of calcium channelopathies.

High-quality cardiopulmonary resuscitation started as soon as possible after cardiac arrest increases the rate of return of spontaneous circulation and improves long-term neurologically intact outcome. The authors discuss the latest evidence for successful resuscitation and subsequent patient care.

In the past decade, improvements in procedural techniques and the understanding of electrophysiological mechanisms have led to the establishment of effective ablation strategies for almost all types of ventricular tachycardia. The underlying cardiac disease, the site of origin, and the electrophysiological mechanism of the arrhythmia should all be considered when choosing the optimal ablation strategy for an individual patient.

Infusion of glucose–insulin–potassium (GIK) before hospital admission in patients with signs and symptoms of acute coronary syndrome has been shown to reduce the incidence of cardiac arrest or in-hospital mortality. Whether out-of-hospital GIK in combination with strict glycemic control can prevent progression to MI requires further study.

Arterial injury is an inevitable consequence of all interventional coronary procedures. In this Review, the authors explain the importance of a competent, functional endothelium for vascular health and describe the processes that are required for full endothelial recovery after arterial injury.

The BRIDGE-ACS study showed benefits of a quality improvement initiative in adherence to evidence-based therapy for acute coronary syndromes at public hospitals in Brazil. No mortality benefit was observed, but this finding might have been different if all effective therapies for in-hospital treatment of myocardial infarction were included.