Reviews & Analysis

Randomized studies and evaluations of large registries have repeatedly shown that epinephrine used as a standard vasopressor for cardiopulmonary resuscitation increases the rate of return of spontaneous circulation. By contrast, epinephrine might decrease long-term survival and impair neurological outcome.

Oral anticoagulation therapy is the most effective strategy for preventing thromboembolic complications in pregnant women with prosthetic heart valves. However, this therapy is associated with increased fetal morbidity and mortality. The authors discuss the controversies surrounding the choice of prosthetic heart valve in women of childbearing age and the advantages and disadvantages of various anticoagulation strategies during pregnancy.

The EINSTEIN-PE trial showed that rivaroxaban has equal efficacy and a lower rate of bleeding than coumarins in the treatment of acute pulmonary embolism. We anticipate regulatory and consumer acceptance for rivaroxaban, representing the first new anticoagulant treatment for venous thromboembolism since the introduction of warfarin compounds 50 years ago.

Much debate surrounds the utility of CYP2C19^*2 genotyping in patients receiving clopidogrel after coronary artery stenting. The effectiveness of its use in a point-of-care setting has now been examined and, given the substantial incremental suppression of platelet reactivity achieved, its routine use might soon be a reality.

Many barriers exist to the translation and implementation of European and US guidelines for cardiovascular disease into clinical practice in China, but also to the development of Chinese-specific guidelines. Professors Zhao and Hu give their expert perspectives on the multifaceted reasons for these barriers, and how future guidelines for Chinese clinical practice should be developed and applied.

The role of biomarkers in the management of patients with acute heart failure (HF) has evolved rapidly in the past several years to meet the need for earlier diagnosis, better risk stratification, and cost-effective treatment. In this state-of-the-art Review, Drs Maisel and Choudhary provide an update on biomarkers used for the diagnosis and management of patients with acute HF, as well as non-HF markers indicative of damage to the organs and systems most-commonly affected by HF.

Transcatheter aortic valve implantation is increasingly being used to treat aortic valve disease in patients at high surgical risk, but data indicate an emerging association between the procedure and incident conduction abnormalities. The authors review the frequency, potential anatomical and procedural causes, and clinical consequences of these adverse effects.

Direct inhibitors of thrombin are a novel class of anticoagulant. The authors critically review the data from clinical trials on the use of the parenteral and oral forms of these drugs for primary or secondary prevention or treatment in patients with acute coronary syndrome, atrial fibrillation, or venous thromboembolism, or those undergoing percutaneous coronary intervention or orthopedic surgery.

Cardiovascular disease (CVD) is an under-recognized major health problem among women in South-East Asia, which is compounded by psychological, social, and cultural issues as well as by misconceptions about the disease. In this Review, leading female cardiologists from South-East Asia discuss the changing prevalence of CVD and cardiovascular risk factors among women in the region. The 'heart health awareness' strategies implemented by governments and national heart associations are reviewed, together with the barriers and challenges to improving women's cardiovascular health in South-East Asia.

No suitable tools for predicting long-term mortality after coronary revascularization are available. Current guidance is based on old data from small studies, and does not reflect contemporary revascularization strategies. Two new models for predicting survival, developed using large registry databases, could help guide decision making in patients undergoing percutaneous coronary intervention or CABG surgery.

Psychological stress is thought to contribute to the cardiovascular disease process at several stages, including the long-term development of coronary heart disease and acute triggering of cardiac events. In this Review, Steptoe and Kivimäki summarize the evidence for the association between stress and cardiovascular disease, with a focus on external work-related and social stressors. They also discuss the effects of stress-management strategies on cardiovascular health.

Molecular biomarkers could provide a window into the pathophysiology of chronic heart failure, potentially improving our ability to predict adverse outcomes, provide novel drug targets, and even help gauge therapeutic efficacy. In this Review, Ahmad et al. examine some emerging biomarkers of the biomechanical stretch, inflammation, ventricular remodeling, myocardial injury, and renal dysfunction that occur in chronic heart failure, and discuss their potential role within a multimarker-based strategy.

Paravalvular aortic regurgitation (PAR) after transcatheter aortic valve replacement is common and independently associated with increased morbidity and mortality. The determinants of PAR are uncertain, but new data extend our understanding, and a simple practice change in preprocedural imaging could help dramatically to reduce the incidence of this important complication.

Hypertension is the most prevalent controllable disease in the adult population of the developed world. Although various effective treatments are available, the development of novel therapies is still required. The authors review key advances in pharmacological and nonpharmacological therapies for hypertension in 2010–2011 and comment on possible future developments.

Commenting on the results of their meta-analysis, Holmes et al. suggest that CYP2C19 genotype does not affect clinical outcome in patients receiving clopidogrel therapy. However, we do not believe that the data support this conclusion; an association between genotype and outcome remains plausible and could be considered when choosing treatment.

Efforts to improve health-care quality and efficiency will fail if patients with chronic disease do not adhere to medications and healthy lifestyles. A novel, psychological approach is to change behavior using 'affect' and 'affirmations'. We explore this strategy's potential, when added to the existing arsenal of interventions, to improve adherence.

Dabigatran has been associated with an increase in acute coronary events when compared with warfarin in several randomized trials, and now in a meta-analysis by Uchino and Hernandez. We critically review the evidence for this association and consider the implications for patient care.

Hypertension is a highly prevalent modifiable risk factor for cardiovascular disease, which is particularly common among older adults. The elderly represent an important, although often overlooked, group of patients for whom assessment and treatment of hypertension requires special consideration. Comorbidities, multiple drug regimens, and potential causes of secondary hypertension can all affect the management of these individuals. Drs Pimenta and Oparil review the pathophysiology of hypertension in the elderly and how best to assess and treat these patients.

Octogenarians are a growing population of patients undergoing percutaneous coronary intervention (PCI) and, yet, they are under-represented in clinical trials. Wang et al. demonstrate the increasing need for PCI, but declining use of drug-eluting stents in this age group, despite associated reductions in mortality, myocardial infarction, and rehospitalization.

The balance of benefits and risks of aspirin in primary prevention is far less clear than in secondary prevention; further data from randomized trials of individuals at intermediate cardiovascular risk are needed. Decisions about aspirin in primary prevention should be made on a case-by-case basis, and general guidelines are not justified.