Reviews & Analysis

Medical devices are often life-saving therapies in patients with advanced heart failure whose condition worsens despite optimal medical therapy. Drs Abraham and Smith expertly review the development of cardiac resynchronization therapy and left ventricular assist devices, describe the current challenges associated with these treatment strategies, and speculate on future advances in this fast-moving field.

In the diseased heart, cardiomyocytes undergo necrotic cell death. A healing response results in myofibroblast production of collagen and other matrix molecules, which initially serve to preserve the structural integrity of the myocardium. However, myofibroblast dispersion fails to occur in many cardiac diseases, and perpetual matrix formation leads to adverse remodelling of the heart. In this Review, Weber et al. discuss relevant mechanisms of cardiac fibrosis and consequent remodelling, and highlight potential strategies for cardioprotection.

The success of transcatheter therapeutics relies heavily on the choice of vascular access site and on adequate arteriotomy closure. In this article, Byrne and colleagues review the state-of-the-art and future developments in vascular closure devices. They also compare the safety and efficacy of radial artery and femoral artery access for diagnostic and interventional procedures.

Adding C-reactive protein (CRP) level to conventional cardiovascular risk models has been suggested to improve risk prediction for cardiovascular events. However, evaluation of the potential impact of CRP measurement in cardiovascular risk management will require studies designed to quantify the effect of additional CRP assessment on medical decision-making, patient outcomes, and cost-effectiveness.

Not all strategies for the management of chronic heart failure have been shown to be equally effective in improving outcomes, and the ideal programme has yet to be defined. The WHICH? trial sheds some light on whether a clinical, in-hospital or a home-based strategy of care is superior and cost-effective.

Timeliness of reperfusion is paramount in the management of patients with ST segment elevation myocardial infarction. Both fibrinolysis and primary percutaneous coronary intervention are inherently associated with patient and health-care system delays. In this Review, Jens F. Lassen and colleagues describe the types of delay to reperfusion and their effects on outcome, and discuss strategies to optimize reperfusion therapy in these patients.

Exercise training is an effective treatment option for patients with chronic heart failure to improve aerobic capacity and quality of life via a reduction in major cardiovascular events, including cardiac mortality. However, low adherence rates to exercise training pose a challenge to widespread application of this treatment.

Unexplained sudden cardiac death (SCD) is a major health problem, and prediction and identification of high-risk populations remain a challenge. Epinephrine stress testing could help to identify individuals at risk of SCD, but more research is required before this test could be recommended for routine use.

In a large, new, observational study, β-blocker treatment did not improve clinical outcomes in patients with coronary artery disease (CAD), including those with previous myocardial infarction, and was associated with more events in individuals with risk factors only. The role of β-blockers for secondary prevention in these patients should be reconsidered.

In dilated cardiomyopathy (DCM), the function of the heart is altered by the change in the shape of the left ventricle. Restoring the natural 'ellipse' of the heart from the dilated, spherical form using surgical ventricular restoration (SVR) can correct the relationship between structure and function. This technique is often combined with other interventions to simultaneously treat the vessels, valves, and ventricle. Buckberg and colleagues discuss the role and reported benefits of this procedure in patients with ischemic DCM with systolic dysfunction, and consider future uses for SVR.

Rheumatic heart disease (RHD) is preventable, yet continues to be a leading cause of morbidity and mortality in children in developing countries. In this Review, Kathryn Roberts and colleagues examine whether RHD fulfils the 1994 Council of Europe criteria for a disease suitable for screening, assess cardiac auscultation and echocardiography as methods of screening for RHD, and discuss areas of controversy that require further research in order to make recommendations about screening for this disease.

An epidemic of obesity and related cardiovascular comorbidities is occurring worldwide. In this comprehensive Review, the authors describe the various forms of adipose tissue and the complex roles of adipokines in cardiac health and disease. They also discuss the contribution of adipose tissue to inflammatory processes, and finally review the potential use of stem cells derived from adipose tissue in cardiac tissue engineering.

Ca²⁺ cycling defects in cardiac myocytes are a hallmark of heart failure. Roger Hajjar and colleagues discuss the association between abnormalities in sarcoplasmic reticulum Ca²⁺handling proteins and heart failure as well as the potential therapeutic benefits of novel treatment strategies that target these proteins.

A 3-h algorithm using high-sensitivity assays for cardiac troponin to rule out myocardial infarction (MI) is recommended in current ESC guidelines. Whether faster rule-out algorithms can discriminate between MI and other conditions that elevate the troponin level, or be safely implemented across the whole spectrum of patient risk, is unclear.

Defibrillation testing during implantation of cardioverter–defibrillators is controversial because of potential safety concerns and a lack of evidence for the effectiveness of the procedure. New data from the SAFE-ICD study is helpful, but does not completely resolve the issue.

The association between obstructive sleep apnea (OSA) and cardiovascular morbidity and mortality is largely the result of myocardial anomalies. In this Review, the authors discuss the mechanisms that lead to myocardial damage and cardiac dysfunction in patients with OSA, and the potential beneficial effects of nasal continuous positive airway pressure on cardiac symptoms and hemodynamic parameters in these patients.

In this Review, the authors present evidence for a causal relationship between the presence of large, dense, reactive platelets in the circulation and the onset of acute coronary syndromes (ACS). The increase in mean platelet volume in the pathogenesis of ACS can potentially overwhelm current therapeutics. Therefore, the control system for the production of these large platelets should be further researched to facilitate the development of new therapeutics that comprehensively prevent ACS.

The concept that raising HDL-cholesterol level will uniformly translate into cardiovascular risk reduction has been challenged by genetic epidemiology studies and large-scale, randomized clinical trials. Studies suggest that we should go beyond HDL cholesterol, and consider emerging biomarkers of HDL concentration, composition, and functionality as surrogates for cardiovascular risk reduction.

The ROMICAT-II trial shows that CT coronary angiography is safe and fast for the exclusion of clinically significant obstructive coronary artery disease in low-risk patients with acute chest pain. Several issues and questions relating to the low prevalence of disease and the actual benefit to patients remain to be answered.

By definition, patients with heart failure and preserved ejection fraction are characterized by a normal or near-normal left ventricular ejection fraction, but marked heterogeneity in the extent of other cardiac structural and functional abnormalities exists. Improved appreciation of this diversity might provide insights into prognosis and therapeutic interventions.