Reviews & Analysis

The prevalence of coronary artery disease, and its manifestation as acute coronary syndromes (ACS), has reached a pandemic level as a consequence of modernization of the developing world. Drs. Ruff and Braunwald discuss the evolving demographics of ACS, including the impact of the introduction of troponin testing and the change in the definition of myocardial infarction. They also highlight the importance of modifiable risk factors and adherence to guideline-recommended therapy.

Thoracic aortic dissection (TAD) is the progressive separation of the layers of the thoracic aortic wall; this condition is strongly related to excessive dilatation of the aorta and is associated with very high mortality. The authors of this article present an in-depth review of the incidence, demographic distribution, and factors associated with TAD and related thoracic aortic syndromes, as well as a discussion of the challenges involved in assessing the epidemiology of these conditions.

Although a diminished pharmacodynamic effect of clopidogrel has been demonstrated in patients treated with proton-pump inhibitors (PPIs), whether its clinical efficacy is reduced remains highly controversial. The FDA and European Medicines Agency recommend that PPIs and clopidogrel should not routinely be coadministered, and the 2010 expert consensus guidelines support this recommendation.

The population of aged patients treated with percutaneous coronary intervention (PCI) is growing in contemporary practice. The elderly might derive greater benefits from PCI than younger patients, but also have specific age-related characteristics that can increase interventional risks. The authors of this Review discuss the benefits and challenges of PCI in the elderly and make recommendations to optimize patient care.

Worsening renal function is common among patients hospitalized with acute heart failure and is associated with poor outcomes. Although preliminary studies suggested that adenosine receptor antagonists could preserve renal function and improve diuretic responsiveness, the A₁-receptor antagonist rolofylline did not provide benefit in patients with acute heart failure in PROTECT.

In the past 3 years, several studies have reignited the controversy regarding the cardiovascular risk associated with the use of rosiglitazone. Until a prospective, well-controlled, randomized clinical trial is performed to adjudicate the issue definitively, physicians should be free to exercise clinical judgment, and weigh the comparative risks and benefits of agents such as rosiglitazone on a case-by-case basis.

Vuurmans et al. have reported that, among 69,214 patients who underwent coronary angiography or percutaneous coronary intervention, transradial access was associated with a lower incidence of chronic kidney disease than the femoral approach. We discuss the importance of kidney injury following these procedures, and the potential protective mechanisms of transradial access.

Accurate early diagnosis of acute coronary syndrome (ACS) is a challenging clinical problem. Imaging myocardial fatty acid metabolism with β-methyl-p-[¹²³I]-iodophenyl-pentadecanoic acid single-photon emission computed tomography was shown to improve the accuracy of ACS diagnosis in patients presenting with chest pain and might be a valuable technique in the emergency setting.

The 'funny' current (I_f) has been the subject of 30 years of laboratory research and is an important therapeutic target in heart disease owing to its effects on heart rate. SHIFT, a trial in patients with all-cause heart failure, shows that I_f inhibition reduces combined mortality and rate of hospitalization and opens further avenues of research and therapeutic challenges.

Patient selection for implantation of a cardioverter-defibrillator for primary prevention of sudden cardiac death is especially difficult in inherited arrhythmia syndromes, owing to a lack of randomized outcome studies in this setting. Two registry studies and the first report of a long-term follow-up of defibrillators in primary prophylaxis have provided some information regarding patient selection, but have important limitations.

Abdominal aortic aneurysms (AAAs) are a localized dilatation of the aorta that represents a systemic disease process. Mortality associated with a ruptured AAA is high, but no tests to predict the risk of rupture currently exist. In this Review, Nordon and colleagues outline the pathophysiology and epidemiology of AAA and the risk factors for this condition. They also discuss factors that influence the outcome of patients with AAA after surgical management.

Blood pressure (BP) targets in patients with hypertension and diabetes mellitus have generally been based on global guidelines. However, these targets are often aggressive, and do not consider the patient's individual risk. Some studies have indicated that intensive BP lowering might not always reduce the risk of cardiovascular events. The authors of this Review present the evidence both for and against intensive BP lowering therapy, and suggest a personalized approach to treatment in the future.

Heart failure (HF) is a clinical syndrome that carries substantial morbidity and mortality. The prevalence of HF is increasing and represents a large burden to the health-care system and society. The authors of this Review discuss the epidemiology of HF and the impact of HF on health services. The risk profile of HF is also examined, highlighting factors that contribute to HF and identifying those who are most at risk of developing this syndrome.

In this opinion article, Dr. Vedanthan and Dr. Fuster discuss the urgent need to integrate CVD-related human resource requirements into the global agenda for increasing human resources for health care. They suggest strategies and emphasize gaps in knowledge regarding human resources for global CVD-related care.

Prosthetic aortic valves are often required for patients with aortic stenosis. The optimal choice of valve in middle-aged patients is not clear and the available options all have drawbacks. Patient choice is the most important factor in deciding which valve to use, with biological valves increasingly favored over mechanical valves. The authors of this Review present the various prosthetic aortic valves currently in use and discuss the implications of prosthesis selection in this group of patients.

Congenital heart disease is the most frequent of congenital disorders in newborns. Reliable epidemiological data for congenital heart disease, however, have been difficult to obtain owing to divergences in definitions, classifications, and methodologies of different studies. The authors of this Review discuss the latest changes in the epidemiology of congenital heart disease and its complications.

Increasing life expectancy in industrialized societies has resulted in a huge population of older adults with cardiovascular disease. Pharmacological treatment is the mainstay of therapy for these patients. In this extensive Review, Jerome Fleg and colleagues address the challenges associated with cardiovascular drug therapy in the elderly, as well as providing an in-depth discussion of specific disease states and drug types in this patient population.

Both hypertension and hypotension have been associated with late-life cognitive decline and dementia. Novak and Hajjar discuss evidence supporting the relationship between blood pressure and cognition and its underlying pathophysiological mechanisms. The role that antihypertensive therapy may have in the prevention of cognitive decline is also explored.

Hypertrophic cardiomyopathy is the most common genetic heart disease and is associated with sudden cardiac death and development of heart failure. Risk stratification currently relies only on clinical risk factors, which have low positive predictive value. Myocardial fibrosis, assessed by contrast-enhanced cardiovascular magnetic resonance imaging, may improve risk stratification.

Anxiety has been shown to have prognostic importance in the development of coronary heart disease in initially healthy adults. This finding highlights the need of future research that includes representative samples of women and minorities, and uses precise assessment tools and careful ascertainment of clinical end points.