Reviews & Analysis

Diagnosis of dyslipidemia currently relies on calculating LDL cholesterol concentration, a strategy with limitations that can lead to underestimation of the patient's lipid levels and, consequently, their cardiovascular risk. In this Viewpoint, James Stein and Patrick McBride discuss how alternative options for characterizing dyslipidemia, such as measurement of apoplipoprotein B-100 and non-HDL cholesterol, and determining LDL particle size by nuclear magnetic resonance spectroscopy, could have clinical application.

The early promise of drug-eluting stents (DESs) led to their rapid assimilation into routine clinical practice, but enthusiasm for this relatively novel technology could be tempered by emerging safety concerns. In this Viewpoint, David Kandzari examines incidence and predictors of stent thrombosis in DESs versus bare-metal stents and contributes to the debate on whether the effi cacy of DESs outweighs the dangers associated with this therapy.

The cardiovascular benefits of statin therapy are well documented; however, no trial has identified a target level for LDL cholesterol below which no further benefit of treatment is seen. With the introduction of more-aggressive optional LDL-cholesterol targets in US guidelines, Antonio Gotto and John Farmer consider the rationale for combination therapy of statins with the cholesterol absorption inhibitor ezetimibe.

The loss of cardiomyocytes in failing or cardiomyopathic hearts is gradual and not accompanied by inflammation or major histomorphologic deformity. Apoptosis, therefore, seems to be the most logical mechanism of cell death. In this Review, Narula et al. discuss the role of apoptosis in systolic dysfunction and heart failure, and in the development of novel strategies for the management of heart failure.

The current treatment for patients receiving coronary stents is dual antiplatelet therapy. Approximately 5% of these patients, however, require long-term anticoagulation because of an underlying chronic medical therapy and, theoretically, should receive triple therapy, which increases bleeding risk. Here, Helft et al. critically appraise the available literature concerning antithrombotic therapy and make recommendations for antiplatelet therapy following revascularization in the small subset of patients already receiving anticoagulation.

Currently, the only proven treatment to re-establish cerebral blood flow in acute ischemic stroke is intravenous tissue plasminogen activator within 3 h of symptom onset. Few patients, however, qualify for this therapy. Here, Juttler et al. provide an integrated view of the current state of reperfusion therapy in acute stroke patients and discuss future treatment options to extend the therapeutic window for intervention.

There are few available data on the incidence and risk factors of thromboembolism in heart failure, and the decision to recommend anticoagulant therapy for these patients is complex. In this Viewpoint, Drs Freudenberger and Halperin discuss the limited existing data on prophylactic approaches to this problem and appeal to physicians to support well-designed, randomized clinical trials of antithrombotic therapy in patients with heart failure.

Gestational glycemic disorders and hypertension in previously healthy women are thought to have a notable bearing on women's cardiovascular risk in later life. In this Review, Banerjee and Cruickshank discuss the opportunities for identification and prevention of early cardiovascular disease in women afforded by these disorders arising.

Claudication is a disabling complication of peripheral arterial disease. Therapy aims to minimize the risk of related cardiovascular events and to improve patients' walking ability by limiting the claudication symptoms. Judith Regensteiner and Kerry Stewart present information on the pharmacological and exercise therapy options currently available.

Enhanced external counterpulsation, a noninvasive treatment that involves the sequential inflation of three sets of lower-extremity cuffs during diastole, can reduce the severity and frequency of angina pectoris. Here, Michaels et al. review the experience from the International EECP Patient Registries to evaluate the therapy's safety and efficacy, and provide a practical guide to the selection of patients and application of enhanced external counterpulsation.

Outcomes after repair of tetralogy of Fallot have been remarkably improved and short-term survival is now excellent. As patients live longer, however, late complication rates and the need for reoperation are rising. In this Review, the major complications of this heterogeneous condition are outlined and the surgical options for management discussed.

Cardiovascular disease kills more women each year than any other condition, yet women's cardiovascular risks continue to be underestimated. Women tend to be diagnosed later in the course of their disease and receive less-intense therapy than men. In this Viewpoint, Sharonne Hayes discusses the causes of disparities in prevention, diagnosis, treatment and outcome between men and women with cardiovascular disease and emphasizes that educating the medical community, and women themselves, is crucial to reducing the sex bias and optimizing care.

Malignant cardiac tumors have a dismal prognosis left untreated but pose a therapeutic challenge to oncologists and cardiac surgeons. Extensive resection can be required and the positions of the tumors create technical difficulties. Primary malignant tumors can also represent aggressive disease. The clinical manifestations and therapeutic options are discussed in this Review.

Although apolipoprotein A-I has benefits in relation to atherosclerosis, this large protein can only be administered intravenously and is difficult and expensive to manufacture. Smaller peptides that mimic apolipoprotein A-I and yield the same beneficial effects have, therefore, been sought. The advances being made in this therapeutic area are described.

After becoming established as a therapy for various anemic states, wider uses—including cardiovascular therapy—are being explored for erythropoietin. The possible mechanisms for actions in the cardiovascular and renal systems are explored in this Review, showing that the therapeutic benefits of this cytokine seem much broader than initially anticipated.

Use of MRI to track cell migration to target tissue, such as after stem cell transplantation in heart failure, offers a potential new way to monitor treatment. Most data come from preclinical studies but suggest a role for this technique in humans. This Review discusses the suitability of various contrast agents and labelling methods.

Although genetic testing for hypertrophic cardiomyopathy and long QT syndrome is now clinically available, are we ready to reap the practical benefits of these molecular discoveries? How can genetic testing for heritable cardiovascular disorders improve the care of our patients now and in the future? As Allison Cirino and Carolyn Ho outline in this month's Viewpoint, the best is yet to come for genetic testing in cardiac disease.