Reviews & Analysis

Drug-eluting stents are an established treatment option for coronary artery disease, although they are not without their problems. The MAHOROBA^® stent attempts to harness the theoretical advantages of both tacrolimus and polymer degradation, but has proved not to be effective in the treatment of de novo coronary lesions.

Patients with venous thromboembolism receive anticoagulants after a thrombotic episode, usually for a fixed period. Discontinuing treatment could lead to recurrence, but prolonged therapy can cause serious bleeding. Ideally, treatment duration should be tailored to individual patients but can this be achieved with ultrasonography, as proposed by the AESOPUS group?

With the aging of the population, the frequency of acute myocardial infarction is rising most rapidly among the elderly, a subgroup at high risk of a fatal outcome. Lorgis et al. observe that N-terminal pro-brain natriuretic peptide, combined with a simple clinical risk score, provides an accurate estimate of prognosis.

Atrial fibrillation is a growing problem worldwide. Lee, Kruse and McCarthy review surgical options for the treatment and cure of atrial fibrillation. They discuss the classic maze procedure, new technologies that have allowed minimally invasive modifications of this procedure, and the future directions of surgical therapy for atrial fibrillation.

The underlying cause of idiopathic dilated cardiomyopathy remains unknown, although studies have suggested a genetic component or involvement of inflammatory and autoimmune responses. Several studies have also shown that vascular dysfunction is present in idiopathic dilated cardiomyopathy. Roura and Bayes-Genis review these studies and suggest a reinterpretation of the pathophysiology in terms of the vascular changes.

Traditional and nontraditional factors increase cardiovascular risk in patients with kidney disease. In this Review, Dr. van der Zee and colleagues highlight important cardiovascular risk factors in patients with varying degrees of kidney function and discuss therapeutic strategies for reducing cardiovascular risk in these patients.

Currently available imaging techniques provide anatomical definition and functional information and have limited ability to report on disease processes at the molecular level. Molecular imaging techniques can, however, supply information about specific proteins, biomolecules, biological pathways or cellular processes. Here, Stanley Shaw discusses molecular imaging targets used in cardiovascular research and emerging approaches to the discovery or application of new molecular imaging probes.

Pulmonary vein antrum isolation is an accepted alternative to antiarrhythmic therapy for restoring normal sinus rhythm in patients with atrial fibrillation. The procedure has a high initial success rate, but many patients subsequently experience recurrence of the arrhythmia. Cardiac magnetic resonance might offer a means of identifying patients who are more likely to experience successful long-term results from pulmonary vein antrum isolation.

The results of HF-ACTION—the largest ever intervention trial of a nonpharmacological treatment for chronic heart failure—have been reported. The investigators randomly allocated participants to either a structured exercise program or to usual care. Although the primary end point was not reached at the prespecified significance level, the background evidence and data from previous trials and other prespecified analyses compel me to conclude that exercise training should be recommended for patients with stable chronic heart failure.

Stroke risk in patients with nonvalvular atrial fibrillation increases markedly with age. Although anticoagulation is more effective than antiplatelet therapy in atrial fibrillation, it tends to be underutilized in the elderly. A study by van Walraven et al. examines the influence of age on stroke prevention therapy in atrial fibrillation.

The DIAD trial investigators have demonstrated that screening for inducible myocardial ischemia did not improve overall clinical outcome in a contemporary cohort of patients with asymptomatic type 2 diabetes, most of whom were receiving excellent medical management and few of whom underwent revascularization. Future studies should be designed to evaluate the clinical value and cost effectiveness of unconditional treatment versus screening using techniques to detect atherosclerotic and ischemic burden, coupled with therapeutic interventions, risk-factor management, and selective use of revascularization in high-risk patients.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is challenging to diagnose because of nonspecific findings, particularly in the early phases of the disease. Clinical diagnosis is made on the basis of several criteria, but these lack sensitivity. Asimaki et al. suggest that immunohistochemical analysis of myocardial desmosomal proteins is a highly sensitive and specific diagnostic test for ARVD/C.

Professor Stephen Westaby and colleagues describe the case of a patient who presented with cardiogenic shock that swiftly deteriorated to severe heart failure. CT revealed a large adrenal tumor that was subsequently indentified as pheochromocytoma. After the tumor was removed, the patient underwent left ventricular assist device implantation as a bridge to left ventricular recovery.

Sex differences in vascular biology are determined not only by gender-related differences in sex steroid levels, but also by gender-specific tissue and cellular differences that mediate sex-specific responses to a variety of stimuli. This Review discusses the influence of estrogen and testosterone on the development of atherosclerosis, through direct vascular effects and via effects on cardiovascular risk.

As part of our series of articles focusing on molecular imaging, Drs Razzouk and Farkouh explore the role of imaging in clinical trials and how anatomical and functional parameters detected using imaging techniques are being used as surrogate markers for clinical end points. The authors also consider the impact of emerging imaging technologies on the future of clinical trial design.

In the second part of their Review on circulating biomarkers of abdominal aortic aneurysm, Hellenthal et al. explore issues concerning the definition of AAA progression, and examine the role of various markers of inflammatory in predicting aortic expansion and rupture.

In a substantial group of patients with acute myocardial infarction, reperfusion of myocardial tissue is hindered by dysfunction of the microvasculature, despite successful restoration of the epicardial coronary flow through percutaneous coronary intervention. This Review discusses the role of angiogenesis in restoration of the microvasculature after reperfused acute myocardial infarction.

In the second article of our Molecular Imaging series, Dr. Lindner focuses on molecular imaging of cardiovascular diseases using contrast-enhanced ultrasound. The basics of targeted ultrasound contrast agents, the progress that has been made in imaging key events in cardiovascular medicine, and other potential clinical applications of targeted microbubbles are discussed.

Low levels of HDL-cholesterol are associated with an increased risk of coronary heart disease. Rader and Duffy discuss new strategies that are currently in development to improve HDL levels and/or function.