Prospective cohort study.

Population based cohort study and nationwide Danish registries.

The Danish Diet, Cancer and Health study included 57 053 participants (27 178 men and 29 875 women) aged between 50 and 64 years. The study population for this study included the 3107 participants (1999 men, 1108 women) who developed incident AF after inclusion.

A composite of thromboembolism or death.

During a median follow-up of 4.9 years 608 deaths and 211 thromboembolic events occurred. Of those who developed AF, 690 (35%) men and 233 (21%) women had a high intake of alcohol (>20 drinks/week for men and >13 drinks/week for women). After adjustment for use of oral anticoagulation and components of the CHA₂DS₂-VASc score, men with an intake of >27 drinks/week had a higher risk for thromboembolism or death (hazard ratio (HR) 1.33, 95% CI 1.08 to 1.63) than men with an intake of <14 drinks/week. Women with an intake of >20 drinks/week also had a higher risk (HR 1.23, 95% CI 0.78 to 1.96) than women in the low intake category. The higher risk among men was primarily driven by mortality (HR 1.51, 95% CI 1.20 to 1.89), whereas the risk found among women was driven by thromboembolism (HR 1.71, 95% CI 0.81 to 3.60).

High alcohol intake predicts thromboembolism or death, even after adjustment for established clinical risk factors, and may help identify high risk AF patients who could be targeted for stroke and cardiovascular prevention strategies.

To test the hypothesis that a tailored intervention intended to reduce salt intake in addition to standard care will achieve a greater reduction in BP in UK Bangladeshi patients with CKD than standard care alone.

A randomised parallel-group controlled trial conducted over a 6 month period.

A tertiary renal unit based in acute care hospital in East London.

56 adult participants of Bangladeshi origin with CKD and BP >130/80 mm Hg or on antihypertensive medication.

Participants were randomly allocated to receive a tailored low-salt diet or the standard low-salt advice. BP medication, physical activity and weight were monitored.

The primary outcome was change in ambulatory BP. Adherence to dietary advice was assessed by measurement of 24 h urinary salt excretion.

Of 56 participants randomised, six withdrew at the start of the study. During the study, one intervention group participant died, one control group participant moved to Bangladesh. Data were available for the primary endpoint on 48 participants. Compared with control group the intervention urinary sodium excretion fell from 260 mmol/d to 103 mmol/d (–131 to –76, p<0.001) at 6 months and resulted in mean (95% CI) falls in 24 h systolic/diastolic BP of –8 mm Hg (–11 to –5)/2 (–4 to –2) both p<0.001.

A tailored intervention can achieve moderate salt restriction in patients with CKD, resulting in clinically meaningful falls in BP independent of hypertensive medication.

ClinicalTrials.gov NCT00702312.

Standard Cochrane systematic review methodology was used for conducting a literature review of published research. Population prevalence studies of PAD in SA with a WE comparison group were included. Full text studies were selected and reviewed by two authors with independent data extraction. Prevalence differences between SA and WE were analysed using ORs.

129 studies were initially identified and ultimately 15 (n=240 003 patients) studies were included. Only one study reported direct comparative general PAD prevalence between SA and WE (OR=0.26, 95%CI 0.17 to 0.38, p<0.001, n=77 855). Fourteen studies with comparative prevalence data between SA and WE in high-risk populations confirm significantly lower odds of PAD in SA with coronary artery disease (CAD) (OR=0.47, 95%CI 0.39 to 0.56, p<0.001, n=139 313) and diabetes (OR=0.44; 95% CI 0.30 to 0.63, p<0.001, n=22 835).

Reported PAD prevalence is significantly lower in SA than WE for both the CAD and diabetes populations. Explanations for these findings, if true, are unclear. These results underscore the need for further study to clarify mechanisms of ethnic divergence in PAD prevalence.

Prospective observational study.

The Women's Health Initiative (WHI) Observational Study.

93 676 postmenopausal women were followed for an average of 9.8 years for cardiovascular outcomes. After exclusion of women with prevalent AF or incomplete data, 8252 of the remaining 81 892 women developed incident AF.

Incident AF was identified by WHI-ascertained hospitalisation records and diagnosis codes from Medicare claims. Multivariate Cox hazard regression analysis identified independent risk factors for incident AF.

Age, hypertension, obesity, diabetes, myocardial infarction and heart failure were independently associated with incident AF. Hypertension and overweight status accounted for 28.3% and 12.1%, respectively, of the population attributable risk. Hispanic and African–American participants had lower rates of incident AF (HR 0.58, 95% CI 0.47 to 0.70 and HR 0.59, 95% CI 0.53 to 0.65, respectively) than Caucasians.

Caucasian ethnicity, traditional cardiovascular risk factors and peripheral arterial disease were independently associated with higher rates of incident AF in postmenopausal women. Hypertension and overweight status accounted for a large proportion of population attributable risk. Measuring burden of modifiable AF risk factors in older women may help target interventions.

To assess the impact of smoking on clinical and pharmacodynamic response to clopidogrel.

Medline, EMBASE and the Cochrane Library through January 2013 were searched. Reference lists of pertinent literatures and abstracts of major cardiovascular conferences were screened.

Clinical and laboratory studies, which reported major adverse cardiovascular events and on-clopidogrel platelet reactivity categorised by smoking status respectively, were selected.

Descriptive and quantitative data were extracted. The main analyses were performed under a random-effects model. For clinical studies, HR estimates were synthesised according to smoking status; for laboratory studies, standardised mean difference (SMD) of on-clopidogrel platelet reactivity and OR for high on-clopidogrel platelet reactivity were pooled. Heterogeneity was quantified by computing I² statistic.

Of the 1869 citations retrieved, seven clinical studies and 12 laboratory studies involving 111 132 patients with established cardiovascular disease and 6658 patients with acute coronary syndrome and/or stent deployment, respectively, were included for meta-analysis. Pooled clinical results showed that an intensified antiplatelet regimen involving clopidogrel was associated with 10% reduced risk for major adverse cardiovascular events among non-current smokers (HR 0.90; 95% CI 0.85 to 0.96), while this clinical benefit was enhanced by 2.9-fold among current smokers (HR 0.71; 95% CI 0.62 to 0.80). Pooled analysis of laboratory studies revealed that current smokers had significantly lower on-clopidogrel platelet reactivity (SMD –0.30; 95% CI –0.46 to –0.15) but, notably, there was considerable inter-study heterogeneity (I² 76.2%; p=0.000). The analysis based on four studies (n=1423) suggested a significantly lower odds of high on-clopidogrel platelet reactivity among current smokers than those among never smokers (OR 0.33; 95% CI 0.22 to 0.43).

Smoking appears to positively modify the relative clinical efficacy and pharmacodynamic effects of clopidogrel.

A population-based study.

Soroka University Medical Center, a tertiary centre in the southern region of Israel.

A cohort of women with and without a diagnosis of GDM who delivered during the years 1988–1999 with a follow-up period until 2010.

A comparison of the incidence of cardiovascular morbidity.

Of 47 909 deliveries that met the inclusion criteria, 4928 (10.3%) occurred in patients who were diagnosed with GDM. During a follow-up period of more than 10 years, compared with women who gave birth at the same time period, after adjustment for age and ethnicity, patients with GDM had higher rates of cardiovascular morbidity including non-invasive cardiac diagnostic procedures (OR=1.8; 95% CI 1.4 to 2.2), simple cardiovascular events (OR=2.7; 95% CI 2.4 to 3.1) and total cardiovascular hospitalisations (OR=2.3; 95% CI 2.0 to 2.5). In a Cox proportional hazards model, adjusted for comorbidities such as pre-eclampsia and obesity, GDM was independently associated with cardiovascular hospitalisations (adjusted HR 2.6, 95% CI 2.3 to 3).

GDM is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.

Longitudinal cohort study of 309 540 Norwegian men and women aged 40–45 years examined during 1985–1999 followed from 2005 through 2009.

Data from a national health screening programme were linked to the Norwegian Prescription Database (NorPD).

The cohort comprised 162 078 women and 147 462 men; 575 (0.4%) men and 288 women (0.2%) received flecainide and 568 men and 256 women sotalol and were defined as patients with AF.

No interventions.

The outcome was lone fibrillation defined by having at least one prescription of flecainide or sotalol registered in NorPD between 2005 and 2009. Cox proportional hazard regression models were used to assess time to first prescription.

The risk for being prescribed these drugs increased with decreasing baseline resting heart. Adjusted hazard ratio (HR) per 10 beats/min decrease in resting heart rate for flecainide prescription was 1.26 in men (95% CI 1.17 to 1.35) and 1.15 (95% CI 1.05 to 1.27) in women. Similar effects were seen for sotalol in men, but not in women. Men who reported intensive physical activity were more often prescribed flecainide than those in the sedentary group (adjusted HR=3.14, 95% CI 2.17 to 4.54).

This population based study supports the hypothesis that the risk of drug treated lone AF increases with declining resting heart rate in both sexes, and with increasing levels of self-reported physical activity in men.

Prospective randomised controlled trial.

One hundred and forty-three patients aged 12–20 years attending the tertiary centre for paediatric cardiology in Northern Ireland.

Increase in exercise capacity as assessed by duration of exercise stress test, and number of minutes spent in moderate to vigorous physical activity (MVPA) per day.

Eighty-six patients were men (60%), mean age was 15.60±2.27 years. Seventy-three percent were considered to have major CHD. Seventy-two participants were randomised to the intervention group. Following intervention, duration of exercise test increased by 1 min 5 s for the intervention group (p value 0.02) along with increase in predicted VO_2Max (p value 0.02). There was a significant increase in minutes of MVPA per day for the intervention group from baseline to reassessment (p value <0.001) while MVPA remained much the same for the control group. Fourteen patients met the current recommendation for more than 60 min MVPA per day at baseline. This doubled to 29 participants at reassessment. There were no adverse effects or mortalities reported.

Exercise training is safe, feasible and beneficial in adolescents with CHD. Psychological techniques can be employed to maximise the impact of interventions.

ISRCTN27986270.

A 1.5 T CMR scan was performed preoperatively and 6 months postoperatively.

University hospitals of Leeds and Leicester, UK.

50 (25 TAVI, 25 SAVR; age 77±8 years) high-risk severe symptomatic aortic stenosis (AS) patients.

Valve haemodynamics, ventricular volumes, ejection fraction (EF), mass and MF.

Patients were matched for gender and AS severity but not for age (80±6 vs 73±7 years, p=0.001) or EuroSCORE (22±14 vs 7±3, p<0.001). Aortic valve mean pressure gradient decreased to a greater degree post-TAVI compared to SAVR (21±8 mm Hg vs 35±13 mm Hg, p=0.017). Aortic regurgitation reduced by 8% in both groups, only reaching statistical significance for TAVI (p=0.003). TAVI and SAVR improved (p<0.05) left ventricular (LV) end-systolic volumes (46±18 ml/m² vs 41±17 ml/m²; 44±22 ml/m² vs32±6 ml/m²) and mass (83±20 g/m² vs 65±15 g/m²; 74±11 g/m² vs 59±8 g/m²). SAVR reduced end-diastolic volumes (92±19 ml/m² vs 74±12 ml/m², p<0.001) and TAVI increased EF (52±12% vs 56±10%, p=0.01). MF reduced post-TAVI (10.9±6% vs 8.5±5%, p=0.03) but not post-SAVR (4.2±2% vs 4.1±2%, p=0.98). Myocardial scar (p≤0.01) and baseline ventricular volumes (p<0.001) were the major predictors of reverse remodelling.

TAVI was comparable to SAVR at LV reverse remodelling and superior at reducing the valvular pressure gradient and MF. Future work should assess the prognostic importance of reverse remodelling and fibrosis post-TAVI to aid patient selection.

We studied 50 patients (mean age 53±5.1; 33 male) with the indication for permanent dual-chamber cardiac pacing for HUT-induced vasovagal cardioinhibitory syncope. They were randomised after 1 month of stabilisation period to CLS algorithm features programmed OFF or ON for 18 months each, using a crossover design. The number of syncopal and presyncopal episodes during active treatment was lower than those registered during no treatment (n syncopal episodes: 2 vs 15; p=0.007; n presincopal episodes: 5 vs 30; p = 0.004). Lead parameters remained stable over time, and there were no lead-related complications.

Based on these 36 months follow-up data, it is concluded that dual-chamber CLS is an effective algorithm for preventing syncope recurrences in healthy patients with tilt-induced vasovagal cardioinhibitory syncope.

Two cohort studies including the general population and initiators of statins aged 35–74 years.

UK primary care records in the Clinical Practice Research Datalink.

3.8 million general population patients and 300 914 statin users.

Statin prescribing.

Statin prescribing by CVD risk; observed 5-year CVD risks; variability between practices.

Statin prescribing increased substantially over time to patients with high 10-year CVD risk (≥20%): 7.0% of these received a statin prior to 2007, and 30.4% in 2007 onwards. Prescribing to patients with low risk (<15%) also increased (from 1.9% to 5.0%). Only about half the patients initiating statin treatment were high risk according to CVD risk score. The 5-year CVD risks, as observed during statin treatment, reduced over calendar time (from 17.0% to 7.1%). There was a large variation between general practices in the percentage of high-risk patients prescribed a statin in 2007 onwards, ranging from 8.2% to 61.5%. For low-risk patients, these varied from 2.1% to 29.1%.

There appeared to be substantive overuse in low CVD risk and underuse in high CVD risk (600 000 and 850 000 patients, respectively, in the UK since 2007). There is wide variation between practices in statin prescribing to patients at high CVD risk. There is a clear need for randomised trials for the best strategy to target statin treatment and manage CVD risk for primary prevention.

Epidemiological study of time trends in CHD and stroke mortality.

The populations of the ROI and NI, 1985–2010.

None.

Directly age standardised CHD and stroke mortality rates were calculated and analysed using joinpoint regression to identify years where the slope of the linear trend changed significantly. This was performed separately for specific age groups (25–54, 55–64, 65–74 and 75–84 years) and by gender. Annual percentage change (APC) and 95% CIs are presented.

There was a striking similarity between the two countries, with percentage change between 1985 and 1989 and between 2006 and 2010 of 67% and 69% in CHD mortality, and 64% and 62% in stroke mortality for the ROI and NI, respectively. However, joinpoint analysis identified differences in the pace of change between the two countries. There was an accelerated pace of decline (negative APC) in mortality for both CHD and stroke in both countries from the mid-1990s (APC ROI –8% (95% CI –9.5 to 6.5) and NI –6.6% (–6.9 to –6.3)), but the accelerated decrease started later for CHD mortality in the ROI. In recent years, a levelling off in CHD mortality was observed in the 25–54 year age group in NI and in stroke mortality for men and women in the ROI.

While differences in the pace of change in mortality were observed at different time points, similar, substantial decreases in CHD and stroke mortality were achieved between 1985 and 1989 and between 2006 and 2010 in the ROI and NI despite important differences in health service structures. There is evidence of a levelling in mortality rates in some groups in recent years.

Single-centre retrospective observational study.

Tertiary cardiac centre.

175 patients undergoing TAVI were included in this study.

Survival.

We analysed data from 175 TAVI patients (mean (±SD) age 83±7 years, 49% men, mean Logistic EuroSCORE 23±1, 66% preserved left ventricular ejection fraction (LVEF)). Immediately pre-TAVI, mean RDW was 14.6±1.6% with an RDW>15% in 29% of patients. Over median follow-up of 12 months, the median rate of change in RDW was 0.2% per month, and 51 (29%) patients died. On multivariate survival analyses, baseline RDW≥15.5% predicted death (adjusted HR 2.70, 95% CI 1.40 to 5.22, p=0.003) independently of LVEF, transfemoral approach, baseline pulmonary artery systolic pressure, moderate/severe mitral regurgitation and body mass index. A greater rate of increase in RDW over time was associated with increased mortality (adjusted HR 1.11, 95% CI 1.04 to 1.18, p=0.001) independently of baseline RDW and other significant temporal variables including a change in creatinine, bilirubin, mean cell haemoglobin concentration or urea. An increase in RDW>0.1%/month was associated with a twofold increased risk of mortality.

Baseline RDW≥15.5% and a rising RDW over time strongly correlate to an increased risk of death post-TAVI, and could be used to refine risk stratification. Investigating and ameliorating the causes of RDW expansion may improve survival.

Prospective cohort study.

University Medical Center.

1946 primary prevention ICD recipients (1528 (79%) men and 418 (21%) women). Patients with congenital heart disease were excluded for this analysis.

All-cause mortality, ICD therapy (antitachycardia pacing and shock) and ICD shock.

During a median follow-up of 3.3 years (25th–75th percentile 1.4–5.4), 387 (25%) men and 76 (18%) women died. The estimated 5-year cumulative incidence for all-cause mortality was 20% (95% CI 18% to 23%) for men and 14% (95% CI 9% to 19%) for women (log rank p<0.01). After adjustment for potential confounding covariates all-cause mortality was lower in women (HR 0.65; 95% CI 0.49 to 0.84; p<0.01). The 5-year cumulative incidence for appropriate therapy in men was 24% (95% CI 21% to 28%) as compared with 20% (95% CI 14% to 26%) in women (log rank p=0.07). After adjustment, a non-significant trend remained (HR 0.82; 95% CI 0.64 to 1.06; p=0.13).

In clinical practice, 21% of primary prevention ICD recipients are women. Women have lower mortality and tend to experience less appropriate ICD therapy as compared with their male peers.

Prospective, observational single centre study.

A single tertiary referral centre.

Consecutive patients with LMCA stenting excluding patients with atrial fibrillation and chronic renal failure.

MSCT and IVUS imaging at 9–12 months follow-up were performed for all patients.

Agreement between MSCT and IVUS minimum luminal area (MLA) and minimum luminal diameter (MLD). A receiver operating characteristic (ROC) curve was plotted to find the MSCT cut-off point to diagnose binary restenosis equivalent to 6 mm² by IVUS.

52 patients were analysed. Passing–Bablok regression analysis obtained a β coefficient of 0.786 (0.586 to 1.071) for MLA and 1.250 (0.936 to 1.667) for MLD, ruling out proportional bias. The α coefficient was –3.588 (–8.686 to –0.178) for MLA and –1.713 (–3.583 to –0.257) for MLD, indicating an underestimation trend of MSCT. The ROC curve identified an MLA ≤4.7 mm² as the best threshold to assess in-stent restenosis by MSCT.

Agreement between MSCT and IVUS to assess in-stent MLA and MLD for LMCA stenting is good. An MLA of 4.7 mm² by MSCT is the best threshold to assess binary restenosis. MSCT imaging can be considered in selected patients to assess LMCA in-stent restenosis.

An observational study.

A single tertiary referral centre.

2133 (49.2%) subjects, who were classified as low risk by the NCEP guideline, of 4339 consecutive middle-aged asymptomatic subjects who underwent CCTA with 64-slice scanners as part of a general health evaluation.

The incidence of atherosclerosis plaques, significant stenosis.

In the subjects at low risk, 11.4% (243 of 2133) of subjects had atherosclerosis plaques, 1.3% (28 of 2133) of subjects had significant stenosis, and 0.8% (18 of 2133) of subjects had significant stenosis caused by non-calcified plaque (NCP). Especially, 75.0% (21 of 28) of subjects with significant stenosis and 94.4% (17 of 18) of subjects with significant stenosis caused by NCP were young adults. Mid-term follow-up (29.3±14.9 months) revealed four subjects with cardiac events: three subjects with unstable angina requiring hospital stay and one subject with percutaneous coronary intervention.

Although an asymptomatic population classified as low risk by the NCEP guideline has been regarded as a minimal risk group, the prevalence of atherosclerosis plaques and significant stenosis were not negligible. However, considering very low event rate for those patients, CCTA should not be performed in low-risk asymptomatic subjects, although CCTA might have the potential for identification of high-risk groups in the selected subjects regarded as a minimal-risk group by NCEP guideline.

In the USA, the estimated prevalence of moderate or severe valve disease is 2.5% using population...]]> 2013-05-30T00:01:54-07:00 info:doi/10.1136/heartjnl-2013-304223 hwp:master-id:heartjnl;heartjnl-2013-304223 BMJ Publishing Group Ltd 2013-05-30 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303767v1?rss=1 Objective

To examine the prevalence of atrial fibrillation (AF) and stroke risk by ethnic group in south and east London; to compare classification with CHA₂DS₂VASc and CHADS₂; to examine the appropriateness of anticoagulant treatment and historic trends in prescribing by gender, age, and ethnicity.

Cross-sectional study.

Routine general practice records from south and east London.

Patients aged 18 years or over with AF.

Risk of stroke by CHA₂DS₂VASc and CHADS₂ score, and prescription of anticoagulant.

In 2011, we identified 6292 patients with AF, with an age adjusted prevalence of 0.63% (1.2% white, 0.4% black African/Caribbean and 0.2% South Asian). 93% of the AF population were at high risk of stroke with a CHA₂DS₂VASc score ≥1, of whom 54% were on warfarin. South Asian patients were at higher stroke risk than white patients (OR 1.67, 95% CI 1.02 to 2.73). Warfarin under-prescribing in people over 80 years of age persisted without improvement throughout 2008–2011. There were no clear differences in warfarin use by ethnic group.

Despite a reduced prevalence of AF among South Asian patients, their risk of stroke is higher than for white patients or black African/Caribbean patients in association with diabetes, cardiovascular disease, and hypertension. Under-prescription of anticoagulation persists in all ethnic groups, a deficit most pronounced in the elderly. Use of the CHA₂DS₂VASc score would enhance optimal management in primary care.

Clinical and laboratory variables were collected before percutaneous coronary intervention. Multivariate analysis was performed to determine which variables are associated with the collateral flow index (CFI).

Data from 295 chronic total occlusion (CTO) patients (Bern, Switzerland, Amsterdam, the Netherlands and Jena, Germany) were pooled. In earlier studies, patients had varying degrees of stenosis. Therefore, different stages of development of the collaterals were used. In our study, a unique group of patients with CTO was analysed.

Instead of angiography used earlier, we used a more accurate method to determine CFI using intracoronary pressure measurements. CFI was calculated from the occlusive pressure distal of the coronary lesion, the aortic pressure and central venous pressure.

The mean CFI was 0.39±0.14. After multivariate analysis, β blockers, hypertension and angina pectoris duration were positively associated with CFI (B: correlation coefficient β=0.07, SE=0.03, p=0.02, B=0.040, SE=0.02, p=0.042 and B=0.001, SE=0.000, p=0.02). Furthermore also after multivariate analysis, high serum leucocytes, prior myocardial infarction and high diastolic blood pressure were negatively associated with CFI (B=–0.01, SE=0.005, p=0.03, B=–0.04, SE=0.02, p=0.03 and B=–0.002, SE=0.001, p=0.011).

In this unique cohort, high serum leucocytes and high diastolic blood pressure are associated with poorly developed collaterals. Interestingly, the use of β blockers is associated with well-developed collaterals, shedding new light on the potential action mode of this drug in patients with CAD.

A literature search was performed in Pubmed, Embase, WHO Global Cardiovascular Infobase, African Journal On-Line, and African Index Medicus using the following search criteria: hypertension, high blood pressure, and Africa/SSA. Epidemiological surveys that used the WHO STEPS approach or similar methods were also included. The overall prevalence of hypertension in SSA was estimated at 16.2% (95% CI 14.2% to 20.3%) with an estimated number of hypertensive individuals to be 74.7 million. The prevalence of hypertension varies widely from country to country. It is projected that the number of affected individuals will increase by 68% (125.5 million) by 2025. Mass migration of rural Africans to urban areas and rapid changes in lifestyle and risk factors account for the rising prevalence of hypertension.

Proactive public health interventions at a population level need to be introduced to control the growing hypertension epidemic, and there needs to be a major improvement in access to hypertensive care for the individual. There is an important need for better epidemiological data and hypertension related outcome trials in SSA.

Wild type (WT) mice and mice with cardiomyocyte specific ATGL overexpression were divided into two groups per genotype that received a weekly intraperitoneal injection of saline or doxorubicin for 4 weeks.

Four weeks of doxorubicin administration significantly impaired in vivo systolic function (11% reduction in ejection fraction, p<0.05), which was associated with increased lung wet to dry weight ratios. Furthermore, doxorubicin induced cardiac dysfunction was independent of changes in glucose and fatty acid oxidation in WT hearts. However, doxorubicin administration significantly reduced myocardial TAG content in WT mice (p<0.05). Importantly, cardiomyocyte specific ATGL overexpression and the resulting decrease in cardiac TAG accumulation attenuated the decrease in ejection fraction (p<0.05) and thus protected mice from doxorubicin induced cardiac dysfunction.

Taken together, our data suggest that chronic reduction in myocardial TAG content by cardiomyocyte specific ATGL overexpression is able to prevent doxorubicin induced cardiac dysfunction.

A retrospective cohort study.

Tertiary care facility in the Netherlands.

All patients who received a single- or dual-chamber ICD in the Leiden University Medical Center between 2002 and 2011. Patients with a pre-existent indication for cardiac pacing were excluded.

Suitability for an S-ICD defined as not reaching one of the following endpoints during follow-up: (1) an atrial and/or right ventricular pacing indication, (2) successful antitachycardia pacing without a subsequent shock or (3) an upgrade to a CRT-D device.

During a median follow-up of 3.4 years (IQR 1.7–5.7 years), 463 patients (34% of the total population of 1345 patients) reached an endpoint. The cumulative incidence of ICD recipients suitable for an initial S-ICD implantation was 55.5% (95% CI 52.0% to 59.0%) after 5 years. Significant predictors for the unsuitability of an S-ICD were: secondary prevention, severe heart failure and prolonged QRS duration.

After 5 years of follow-up, approximately 55% of the patients would have been suitable for an S-ICD implantation. Several baseline clinical characteristics were demonstrated to be useful in the selection of patients suitable for an S-ICD implantation.

Prospective observational cohort study.

University Hospital of Innsbruck.

54 patients with acute STEMI.

Correlation of plasma copeptin with infarct size as well as left ventricular ejection fraction (LVEF) and remodelling.

Participants underwent contrast enhanced cardiac MRI at baseline and 4 months thereafter. Blood samples were drawn 2 days after the onset of symptoms. Copeptin values were determined by an immunofluorescent assay.

Copeptin concentrations (median 10.4 pmol/l, IQR 6.0–14.4) were associated with early and chronic infarct size (r=0.388, p=0.004 at baseline; r=0.385, p=0.011 at follow-up) and inversely related to LVEF at both times (r=–0.484, p<0.001 at baseline; r=–0.461, p<0.001 at follow-up). Patients with adverse remodelling showed higher baseline copeptin values compared to patients without remodelling (p=0.02). Receiver operating characteristic analysis indicated a cut-off value of 16.7 pmol/l for copeptin to best identify patients with future adverse remodelling.

Increased copeptin values 2 days after STEMI are associated with larger acute and chronic infarct sizes. Moreover, elevated copeptin concentrations at baseline were associated with myocardial function and remodelling 4 months post-STEMI. These findings strengthen the role of copeptin as a biomarker of adverse outcome after STEMI.

To determine whether RM strategies improve outcomes for adults who have been recently discharged (<28 days) following an unplanned admission due to heart failure.

Systematic review and network meta-analysis.

Fourteen electronic databases (including MEDLINE, EMBASE and PsycINFO) were searched to January 2012, and supplemented by hand-searching relevant articles.

All randomised-controlled trials (RCTs) or observational cohort studies with a contemporaneous control group were included. RM interventions included home telemonitoring (TM) (including implanted monitoring devices) with medical support provided during office hours or 24/7 and structured telephone support (STS) programmes delivered via human-to-human contact (HH) or human-to-machine interface (HM).

Data were extracted and validity was assessed independently by two reviewers.

Twenty-one RCTs that enrolled 6317 patients were identified (11 studies evaluated STS (10 of which were HH, while 1 was HM), 9 studies assessed TM, and 1 study assessed both STS and TM). No trial of implanted monitoring devices met the inclusion criteria. Compared with usual care, although not reaching statitistical significance, RM trended to reduce all-cause mortality for STS HH (HR: 0.77, 95% credible interval (CrI): 0.55, 1.08), TM during office hours (HR: 0.76, 95% CrI: 0.49, 1.18) and TM24/7 (HR: 0.49, 95% CrI: 0.20, 1.18). Exclusion of one trial that provided better-than-usual support to the control group rendered each of the above comparisons statistically significant. No beneficial effect on mortality was observed with STS HM. Reductions were also observed in all-cause hospitalisations for TM interventions but not for STS interventions. Care packages generally improved health-related quality-of-life and were acceptable to patients.

STS HH and TM with medical support provided during office hours showed beneficial trends, particularly in reducing all-cause mortality for recently discharged patients with heart failure. Where ‘usual’ care is less good, the impact of RM is likely to be greater.

Although it had long been known that evaluating a symptomatic patient during exertion might disclose evidence of coronary artery disease, before the advent of the Bruce treadmill test there was no safe, standardised and validated stress protocol that could be used to monitor cardiovascular haemodynamic changes in exercising patients. Master's two-step test,2 a submaximal exercise...]]> 2013-05-16T00:02:12-07:00 info:doi/10.1136/heartjnl-2013-304003 hwp:master-id:heartjnl;heartjnl-2013-304003 BMJ Publishing Group Ltd 2013-05-16 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-304034v1?rss=1 A 46-year-old male with history of gastro-oesopahgeal reflux disease presented to the hospital with complaints of severe heartburn and epigastric pain. He reported to have ingested approximately 120 tablets of tums (calcium carbonate) within the last 24 h, in order to alleviate his symptoms. He had normal vital signs; however, signs of mild dehydration were noted. Laboratory data were remarkable for severe hypercalcaemia (serum calcium: 16 mg/dl) and acute renal failure (serum creatinine: 4.8 mg/dl). ECG showed short QT and corrected QT (QTc) interval (385 ms and 322 ms, respectively) along with prominent Osborn waves (as marked) (figure 1). Patient was rehydrated and a follow-up ECG after 2 days showed complete normalisation when serum calcium was 9.8 mg/dl (figure 2).

Figure 1

ECG shows prominent Osborn waves and short QT/QTc interval in the presence of severe hypercalcaemia.

Figure 2

ECG shows complete resolution of acute changes. Calcium levels were normal when this tracing was...]]> 2013-05-16T00:02:12-07:00 info:doi/10.1136/heartjnl-2013-304034 hwp:master-id:heartjnl;heartjnl-2013-304034 BMJ Publishing Group Ltd 2013-05-16 Miscellanea http://heart.bmj.com/cgi/content/short/heartjnl-2013-303987v1?rss=1 Descriptive text

A 54-year-old woman with hypertension presented with acute disabling chest pain for 2 h and a blood pressure of 86/57mm Hg. The diagnosis of acute anterior wall ST segment elevation myocardial infarction (STEMI) was based on ECG (figure 1) and bedside transthoracic echocardiography findings disclosing anterior wall hypokinesis with mild aortic regurgitation without pericardial effusion. Urgent coronary angiography revealed the striking pulsatile luminal collapse of all three coronary arteries mimicking severe coronary spasm (figure 2A,B, white arrows and online supplementary video 1). Another intriguing finding was the distended lumen during the peak of dye injection, which turned into a cave-in at the end of the injection in the proximal segment of the artery. Intravascular ultrasound performed in the left main (figure 2A,B, black arrow) and the left circumflex arteries (figure 2A,B, arrow with a dashed line) indicated dynamic luminal narrowing caused by...]]> 2013-05-16T00:02:12-07:00 info:doi/10.1136/heartjnl-2013-303987 hwp:master-id:heartjnl;heartjnl-2013-303987 BMJ Publishing Group Ltd 2013-05-16 Miscellanea http://heart.bmj.com/cgi/content/short/heartjnl-2013-303769v1?rss=1 A 52-year-old man lost consciousness while running on a hot day. He had been a professional football player for 15 years. ECG showed sinus rhythm, high R voltages with T inversion fulfilling the criteria for left ventricular (LV) hypertrophy (Figure 1A). This ECG LV hypertrophy pattern had been discovered at the age of 15 interpreted as ‘athlete's heart’. An echocardiographic exam showed normal ventricular volumes, wall thickness and contractility, but a defect in the apical interventricular septum was present (Figure 1B; online supplementary video S1). A cardiac MRI study revealed an ‘outpouching’ of the apical segment of the interventricular septum protruding into the right ventricular apex and surrounded by trabeculations, diagnostic criteria for a muscular LV apical diverticulum (Figure 1C,D; online supplementary video S2). An ECG LV hypertrophy pattern with T waves inversion can be observed in half of LV diverticula; associated coronary arteries anomalies are described too. 2013-05-16T00:02:12-07:00 info:doi/10.1136/heartjnl-2013-303769 hwp:master-id:heartjnl;heartjnl-2013-303769 BMJ Publishing Group Ltd 2013-05-16 Miscellanea http://heart.bmj.com/cgi/content/short/heartjnl-2013-304039v1?rss=1

The Authors’ reply

The question posed by Al-Attar et al1 in response to our analysis of bilateral internal mammary artery (BIMA) use in the USA using the Nationwide Inpatient Sample2 cannot be answered by this or other national databases as, to the best of our knowledge, none currently contain data on the technique of conduit harvest, sternal closure or glycaemic control. Randomised multi-centre studies such as the Arterial Revascularization Trial3 likely represent the best way to evaluate the optimal strategy for successful BIMA use. Irrespective, while the many barriers to BIMA revascularisation identified by John Puskas in his recent editorial ‘Why did you not use both internal thoracic arteries?’ remain a factor in surgical decision making,4 the rate of BIMA use in the USA is likely to remain close to the 3.9% we observed in our analysis. We agree wholeheartedly with Dr Puskas:...]]> 2013-05-16T00:02:11-07:00 info:doi/10.1136/heartjnl-2013-304039 hwp:master-id:heartjnl;heartjnl-2013-304039 BMJ Publishing Group Ltd 2013-05-16 PostScript http://heart.bmj.com/cgi/content/short/heartjnl-2012-303193v1?rss=1 Endomyocardial fibrosis (EMF) continues to be an important and disabling disease in many parts of Africa, although its prevalence has declined in some parts of the continent. Increased access to medical care in general and increased availability of echocardiography in some parts of the continent have led to recognition of the disease in areas in which the disease had not been previously reported, and this has given new insights into its natural history. However, the early manifestations of EMF continue to elude clinicians and researchers, and no progress has been made in defining its aetiology. Advances have, however, been made in establishing the epidemiology and improving clinical diagnosis and management, through modern medical therapy and improved surgical techniques. Research is still required to define clinical, biological and echocardiographic markers of early stages of EMF, so that advances in the knowledge of its pathogenesis and pathophysiology can be made. This will hopefully determine preventive measures and avoid the burden of this debilitating condition in this continent.

To summarise and critically review the current literature on genotype–phenotype associations in patients with HCM and to perform a meta-analysis on selected clinical features.

PubMed/Medline was searched up to January 2013. Retrieved articles were checked for additional publications.

Observational, cross-sectional and prospectively designed English language human studies that analysed the relationship between the presence of mutations in sarcomeric protein genes and clinical parameters.

The pooled analysis was confined to studies reporting on cohorts of unrelated and consecutive patients in which at least two sarcomere genes were sequenced. A random effect meta-regression model was used to determine the overall prevalence of predefined clinical features: age at presentation, gender, family history of HCM, family history of sudden cardiac death (SCD), and maximum left ventricular wall thickness (MLVWT). The I² statistic was used to estimate the proportion of total variability in the prevalence data attributable to the heterogeneity between studies.

Eighteen publications (corresponding to a total of 2459 patients) were selected for the pooled analysis. The presence of any sarcomere gene mutation was associated with a younger age at presentation (38.4 vs 46.0 years, p<0.0005), a family history of HCM (50.6% vs 23.1%, p<0.0005), a family history of SCD (27.0% vs 14.9%, p<0.0005) and greater MLVWT (21.0 vs 19.3 mm, p=0.03). There were no differences when the two most frequently affected genes, MYBPC3 and MYH7, were compared. A total of 53 family studies were also included in the review. These were characterised by pronounced variability and the majority of studies reporting on outcomes analysed small cross-sectional cohorts and were unsuitable for pooled analyses.

The presence of a mutation in any sarcomere gene is associated with a number of clinical features. The heterogeneous nature of the disease and the inconsistency of study design precludes the establishment of more precise genotype–phenotype relationships. Large scale studies examining the relation between genotype, disease severity, and prognosis are required.

Prospective, non-randomised, diagnostic study.

Academic hospital-based study.

65 patients (42 men age 70.4±9) with typical or atypical chest pain.

CTA and CT-MPI with adenosine stress using a fast dual-source CT system. At subsequent invasive angiography, FFR measurement was performed in coronary arteries to define haemodynamic relevance of stenosis.

We tried to correlate haemodynamically relevant stenosis (FFR < 0.80) to a reduced myocardial blood flow (MBF) as assessed by CT-MPI and determined the DA of CT-MPI for the detection of haemodynamically relevant stenosis.

Sensitivity and negative predictive value (NPV) of CTA alone were very high (100% respectively) for ruling out haemodynamically significant stenoses, specificity, Positive predictive value (PPV) and DA were low (43.8, 67.3 and 72%, respectively). CT-MPI showed a significant increase in specificity, PPV and DA for the detection of haemodynamically relevant stenoses (65.6, 74.4 and 81.5%, respectively) with persisting high sensitivity and NPV for ruling out haemodynamically relevant stenoses (97% and 95.5% respectively). The combination of CTA and CT-MPI showed no further increase in detection of haemodynamically significant stenosis compared with CT-MPI alone.

Our data suggest that CT-MPI permits the detection of haemodynamically relevant coronary artery stenoses with a moderate DA. CT may, therefore, allow the simultaneous assessment of both coronary morphology and function.

A prospective population-based cohort study.

The National Survey on Circulatory Disorders and the National Nutrition Survey of Japan.

A total of 4348 community-dwelling men (mean age 49.3 years), without cardiovascular diseases at baseline, from randomly selected areas across Japan.

Cardiac death (200 men) during the 24-year follow-up.

Dietary MDn3FAs intake was assessed using a dietary method to estimate individual intake of household-based weighed food records for 3 days. Cox models were used to calculate HRs and 95% CIs adjusted for possible confounding factors. JPE was present in 340 participants (7.8%). The median daily intake of MDn3FAs was 0.35%kcal (0.92 g/day). The risk of cardiac death was significantly higher in participants with JPE than in those without JPE in the low intake group (<0.35%kcal; adjusted HR 3.51; 95% CI 1.84 to 6.73; p<0.001), but not in the high intake group (≥0.35%kcal; adjusted HR 1.09; 95% CI 0.56 to 2.16; p=0.795). The interaction between dietary MDn3FAs intake and JPE on the risk of cardiac death was statistically significant (p=0.006).

The increased risk of cardiac death associated with JPE may be attenuated by higher dietary MDn3FAs intake.

To assess survival, incidence of SCD after ASA and effects of ASA on the traditional risk factors (RFs) for SCD.

An observational cohort-study (follow-up 8.4±4 years).

A dual-centre cohort.

470 consecutive patients (age 56±14 years) with obstructive hypertrophic cardiomyopathy (HCM) (1996–2010).

Clinically applied echo-contrast-guided ASA treatments.

All-cause mortality, SCD and RFs for SCD before and after ASA.

The 10-year survival was 88% (annual all-cause death rate 1.2%) after ASA compared with 84% (p=0.06) in a matched background population. The 10-year survival free of SCD was 95% (annual SCD rate 0.5%). ASA reduced the prevalence of abnormal blood pressure response (from 23% to 9%, p<0.001), syncope (26% to 2%, p<0.001), non-sustained ventricular tachycardia (NSVT) (23% to 17%, p<0.05) and maximal wall thickness ≥30 mm (7% to 2%, p<0.001). There was a family history of SCD in 19% of the patients. The proportion of patients at high risk—that is, two or more RFs (n=89), was reduced from 25% to 8% (p<0.001). A RF score ≥2 before ASA was not associated with SCD (n=361, p=0.31).

Survival in ASA-treated patients was similar to that in the background population. The number of RFs, including the prevalence of NSVT, was markedly reduced by ASA and the incidence of SCD was correspondingly low. Thus, clinically applied ASA was safe.

The diagnostic armamentarium for the work-up of LVH has increased greatly over the past years. Today, non-invasive imaging modalities such as cardiovascular magnetic resonance (CMR) allow a detailed and comprehensive work-up of hypertrophied hearts and...]]> 2013-04-30T00:00:26-07:00 info:doi/10.1136/heartjnl-2011-301528 hwp:master-id:heartjnl;heartjnl-2011-301528 BMJ Publishing Group Ltd 2013-04-30 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2013-303654v1?rss=1 Objective

To examine the risk of thoracic aortic disease (TAD) when one or more first-degree relatives are affected, and to relate the risk of family history to the risk of other cardiopulmonary comorbidity.

Population-based, matched, case-control study.

Registry-based investigation.

All cases, nationwide, of TAD diagnosed 2001–2005 in individuals born 1932 or later (n=2436) were identified, and a random control-group (n=12 152) matched for age, sex and geography was generated. First-degree relatives were identified in the Multigeneration Registry. Family history of TAD was assessed by cross-linking nationwide health registries.

None.

Family history was present in 108 cases (4.4%), compared with 93 (0.77%) controls (p<0.0001). The risk of TAD increased with number of affected relatives: OR 5.8 (95% CI 4.3 to 7.7) vs OR 20 (2.2 to 179) with one versus two or more affected relatives. The relative risk of TAD was highest in the youngest (≤49 years) age group and slightly more pronounced in women than in men (OR 7.2 (4.2 to 12) vs OR 5.5 (3.9 to 7.7)). Among cardiopulmonary comorbidities, heart failure conferred the highest relative risk, OR 6.3 (4.1 to 9.8).

Family history confers a significantly increased (sixfold to 20-fold) relative risk of TAD. The effect is more pronounced in women and in younger subjects, and is not conveyed by cardiopulmonary comorbidity. Knowledge of family history is important to counselling, treatment indications, surveillance and screening protocols.

Follow-up of a prospective cohort.

Tertiary university hospital.

We studied 163 consecutive patients who underwent PMC because of restenosis occurring 16±8 years after previous commissurotomy (closed-heart in 121, open-heart in 30 and PMC in 12). Mean age was 48±14 years; 62 patients (38%) had valve calcification. Restenosis was due to bicommissural fusion in all cases.

PMC using a single or double balloon in 80 patients and the Inoue balloon in 83.

Good immediate results (IR) (valve area ≥1.5 cm² with MR≤2/4) were obtained in 135 pts (83%). 20-year rates were 27.9±4.7% for cardiovascular survival without mitral surgery and 14.8±3.9% for good functional results (cardiovascular survival without reintervention on the mitral valve and in New York Heart Association (NYHA) class I or II). After good IR, 20-year rates were 33.2±5.5% for cardiovascular survival without surgery and 17.9±4.7% for good functional results. After good IR, multivariate predictive factors of poor late functional results were higher NYHA class (p=0.01), atrial fibrillation (p=0.0002) and higher mean mitral gradient after PMC (p=0.004).

In patients with restenosis after mitral commissurotomy, PMC provides good IR in most cases. After good IR, one patient out of three remains free from surgery and one out of five has good functional results at 20 years. These findings support the use of PMC after previous commissurotomy, particularly in selected patients with few symptoms and in sinus rhythm.

A cross-sectional study was performed in 266 adults aged ≥35 years in Puno, Peru (3825 m above sea level). We stratified participants by their long-term history of exposure to clean fuel (n=112) or biomass fuel (n=154) and measured 24 h indoor particulate matter (PM_2.5) in a random subset (n=84). Participants completed questionnaires and underwent a clinical assessment, laboratory analyses and carotid artery ultrasound. The main outcome measures were CIMT, carotid plaque and blood pressure.

The groups were similar in age and gender. The biomass fuel group had greater unadjusted mean CIMT (0.66 vs 0.60 mm; p<0.001), carotid plaque prevalence (26% vs 14%; p=0.03), systolic blood pressure (118 vs 111 mm Hg; p<0.001) and median household PM_2.5 (280 vs 14 µg/m³; p<0.001). In multivariable regression, the biomass fuel group had greater mean CIMT (mean difference=0.03 mm, 95% CI 0.01 to 0.06; p=0.02), a higher prevalence of carotid plaques (OR=2.6, 95% CI 1.1 to 6.0; p=0.03) and higher systolic blood pressure (mean difference=9.2 mm Hg, 95% CI 5.4 to 13.0; p<0.001).

Chronic exposure to biomass fuel was associated with increased CIMT, increased prevalence of atherosclerotic plaques and higher blood pressure. These findings identify biomass fuel use as a risk factor for CVD, which may have important global health implications.

Prospective, multicentre study.

We measured hs-cTn using four different methods (hs-cTnT Roche, hs-cTnI Siemens, hs-cTnI Beckman Coulter and hs-cTnI Abbott) in consecutive patients presenting to the emergency department with acute chest pain. Two independent cardiologists adjudicated the final diagnosis. Patients were followed for death or AMI during a mean period of 24 months.

Among 2072 consecutive patients with hs-cTnT measurements available, 21.4% had an adjudicated diagnosis of AMI (sensitivity 89.6%, 95% CI 86.4% to 92.3%, negative predictive value (NPV): 96.5%, 95% CI 95.4% to 97.4%). Among 1180 consecutive patients with hs-cTnI Siemens measurements available, 20.0% had AMI (sensitivity 94.1%, 95% CI 90.3% to 96.7%, NPV: 98.0%, 95% CI: 96.6% to 98.9%). Among 1151 consecutive patients with hs-cTnI Beckman Coulter measurements available, 19.7% had AMI (sensitivity 92.1%, 95% CI 87.8% to 95.2%, NPV: 97.5%, 95% CI 96.0% to 98.5%). Among 1567 consecutive patients with hs-cTnI Abbott measurements available, 20.0% had AMI (sensitivity 77.2%, 95% CI 72.1% to 81.7%, NPV: 94.3%, 95% CI 92.8% to 95.5%).

Normal hs-cTn levels at presentation should not be used as a single parameter to rule out AMI as 6%–23% of adjudicated AMI cases had normal levels of hs-cTn levels at presentation. Our data highlight the lack of standardisation among hs-cTnI assays resulting in substantial differences in sensitivity and NPV at the 99th percentile.

Observational retrospective study.

Three tertiary hospitals in the USA.

1363 consecutive patients who underwent CTO PCI between 2006 and 2011.

Procedural success and inhospital complications, which were compared between patients with and without prior CABG.

Compared to patients without prior CABG, those with prior CABG were older, had more comorbidities, were treated more frequently with the retrograde approach (46.7% vs 27.1%, p<0.001) and had lower technical success rates (79.7% vs 88.3%, p=0.015). Of the 24 (1.8%) major inhospital complications, 11 occurred in patients with prior CABG and 13 in patients without prior CABG (2.1% vs 1.5%, p=0.392). In multivariable analysis prior CABG was independently associated with lower technical success rate (OR 0.49, 95% CIs 0.35 to 0.70, p<0.001).

In a large multicentre registry, CTO PCI was frequently performed among patients with prior CABG, with higher use of the retrograde approach and similar complications but lower technical success rates compared to patients without prior CABG.

In order to assess current practice measuring HRR, we surveyed 74 studies that used a variety of exercise types, protocols and methods of analysis. A tally of these studies indicates that graded treadmill exercise was the preferred exercise protocol, having been used in approximately 72% of the studies, followed by cycle ergometry in 25% and other methods in...]]> 2013-04-16T00:01:05-07:00 info:doi/10.1136/heartjnl-2013-303863 hwp:master-id:heartjnl;heartjnl-2013-303863 BMJ Publishing Group Ltd 2013-04-16 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303733v1?rss=1 More than two million percutaneous coronary intervention (PCI) procedures are performed worldwide each year.1 Periprocedural myocardial infarction is one of the most common complications with evidence of myonecrosis in almost half of all PCI procedures.2 Defining periprocedural myocardial infarction is, however, not straightforward. The latest expert consensus on the Universal Definition of Myocardial Infarction defines PCI-related myocardial infarction (type IVa) as either an increase in cardiac troponin 5-fold greater than the 99th percentile upper reference limit (URL) in patients with normal baseline values (≤99th percentile URL), or a more than 20% increase in patients with already elevated but stable or falling baseline troponin concentrations.3 In addition to this, the definition further stipulates that clinical evidence of myocardial ischaemia, angiographic loss of patency of a major or minor coronary artery patency or imaging evidence of new loss of viable myocardium or new regional wall motion...]]> 2013-04-16T00:01:05-07:00 info:doi/10.1136/heartjnl-2013-303733 hwp:master-id:heartjnl;heartjnl-2013-303733 BMJ Publishing Group Ltd 2013-04-16 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303667v1?rss=1

In the recent Heart paper, Cuculi et al1 from Oxford University challenge two conventional wisdoms in clinical cardiology: first, biomarkers do not have a role in the management of patients presenting with suspected ST-elevation myocardial infarction (STEMI); and second, in the absence of cardiogenic shock, there is no remaining unmet clinical need in STEMI as contemporary coronary reperfusion strategies yield excellent patient outcomes.

In their investigation, the authors report the course of plasma neuropeptide Y levels in patients undergoing successful percutaneous coronary intervention (PCI) and relate these to non-invasive and invasive measures of the success of myocardial reperfusion and the coronary microcirculation.1 In the vast majority of patients with STEMI, a complete thrombotic occlusion in the epicardial segment of one of the coronary arteries results in ischaemia and cell death of a large amount of cardiomyocytes supplied by that artery. To salvage cardiomyocytes at risk, therapy...]]> 2013-04-10T00:00:26-07:00 info:doi/10.1136/heartjnl-2013-303667 hwp:master-id:heartjnl;heartjnl-2013-303667 BMJ Publishing Group Ltd 2013-04-10 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303964v1?rss=1 Introduction

The burden of valvular heart disease (VHD) is rising rapidly as life expectancy increases. The prevalence in the USA alone is 13% in those aged over 75 years,1 while the global prevalence of rheumatic heart disease is estimated at 15.6–19.6 million.2 Despite this, the treatment of VHD still lacks an adequate research base. None of the 64 recommendations in the 2012 European Society of Cardiology (ESC) VHD guidelines3 had Level A evidence and only 14% had Level B evidence. This compares with 28% at Level A and 42% at Level B among the 270 recommendations in the 2010 ESC myocardial revascularisation guidelines.4 Therefore, there is an urgent need to stimulate the investigation. In this article, we identify deficits in our knowledge which may be amenable to research and make a call for national and international collaborative efforts to address this evidence...]]> 2013-04-10T00:00:25-07:00 info:doi/10.1136/heartjnl-2013-303964 hwp:master-id:heartjnl;heartjnl-2013-303964 BMJ Publishing Group Ltd 2013-04-10 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303648v1?rss=1 Objective

The inflammatory cytokine, tumour necrosis factor α (TNF-α), exerts deleterious cardiovascular effects. We wished to determine the effects of TNF-α antagonism on endothelial function and platelet activation in patients with acute myocardial infarction.

A double-blind, parallel group, randomised controlled trial performed in a tertiary referral cardiac centre. 26 patients presenting with acute myocardial infarction randomised to receive an intravenous infusion of etanercept (10 mg) or saline placebo.

Leucocyte count, plasma cytokine concentrations, flow cytometric measures of platelet activation and peripheral vasomotor and fibrinolytic function were determined before and 24 h after study intervention.

Consistent with effective conjugation of circulating TNF-α, plasma TNF-α concentrations increased in all patients following etanercept (254±15 vs 0.12±0.02 pg/ml; p<0.0001), but not saline infusion. Etanercept treatment reduced neutrophil (7.4±0.6 vs 8.8±0.6x10⁹ cells/l; p=0.03) and plasma interleukin-6 concentrations (5.8±2.0 vs 10.6±4.0 pg/ml; p=0.012) at 24 h but increased platelet–monocyte aggregation (30±5 vs 20±3%; p=0.02). Vasodilatation in response to substance P, acetylcholine and sodium nitroprusside, and acute tissue plasminogen activator release were unaffected by either treatment (p>0.1 for all).

Following acute myocardial infarction, etanercept reduces systemic inflammation but increases platelet activation without affecting peripheral vasomotor or fibrinolytic function. We conclude that TNF-α antagonism is unlikely to be a beneficial therapeutic strategy in patients with acute myocardial infarction.

Collaborative monitoring software development and implementation in three specialist centres.

Analyses incorporated 2 years of data routinely audited by the National Institute of Cardiac Outcomes Research (NICOR). Exclusion criteria were patients over 16 or undergoing non-cardiac or only catheter procedures. We applied the partial risk adjustment in surgery (PRAiS) risk model for death within 30 days following surgery and generated variable life-adjusted display (VLAD) charts for each centre. These were shared with each clinical team and feedback was sought.

Participating centres were Great Ormond Street Hospital, Evelina Children's Hospital and The Royal Hospital for Sick Children in Glasgow. Data captured all procedures performed between 1 January 2010 and 31 December 2011. This incorporated 2490 30-day episodes of care, 66 of which were associated with a death within 30 days.The VLAD charts generated for each centre displayed trends in outcomes benchmarked to recent national outcomes. All centres ended the 2-year period within four deaths from what would be expected. The VLAD charts were shared in multidisciplinary meetings and clinical teams reported that they were a useful addition to existing quality assurance initiatives. Each centre is continuing to use the prototype software to monitor their in-house surgical outcomes.

Timely and routine monitoring of risk-adjusted mortality following paediatric cardiac surgery is feasible. Close liaison with hospital data managers as well as clinicians was crucial to the success of the project.

To confirm or refute the association, a meta-analysis of published papers was conducted.

PubMed, Web of Knowledge and Scopus were systematically searched to identify appropriate articles. Reference lists were then hand searched for additional relevant titles.

To be included, articles had to assess the association between miscarriage and subsequent cardiovascular disease in otherwise healthy women. Only women who had miscarriages were considered exposed. Pooled association measures, using random effects meta-analysis, were calculated for coronary heart disease and cerebrovascular disease. Publication bias and between-study heterogeneity were evaluated.

Two authors individually reviewed all studies and extracted data on patient and study characteristics along with cardiovascular outcomes.

10 studies were identified, with 517 504 individuals included in the coronary heart disease meta-analysis and 134 461 individuals in the cerebrovascular disease analysis. A history of miscarriage was associated with a greater odds of developing coronary heart disease, OR (95% CI) =1.45 (1.18 to 1.78), but not with cerebrovascular disease, OR=1.11 (0.72 to 1.69). There was a strong association between recurrent miscarriage and coronary heart disease OR=1.99 (1.13 to 3.50). Evidence was found for moderate between-study heterogeneity and publication bias in the coronary heart disease analysis.

The meta-analysis indicates that a history of miscarriage or recurrent miscarriage is associated with a greater risk of subsequent coronary heart disease.

The initial management of patients with valve disease is usually conservative and meticulous...]]> 2013-03-26T00:00:33-07:00 info:doi/10.1136/heartjnl-2013-303754 hwp:master-id:heartjnl;heartjnl-2013-303754 BMJ Publishing Group Ltd 2013-03-26 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2013-303591v1?rss=1

A 76-year-old man had severe aortic stenosis and underwent elective transcatheter aortic valve implantation (TAVI). Aortic annulus sizing by transthoracic echocardiography (TTE) was 25 mm. Multislice CT showed adequate iliofemoral arteries calibre with no severe calcifications. The procedure took place by right transfemoral access using a percutaneous closure device (ProStar XL Percutaneous Vascular Surgical System; Abbott Vascular, Redwood City, California, USA). A 26 mm balloon-expandable Edwards–Sapien XT valve (Edwards Lifesciences, Irvine, California, USA) was successfully advanced, however, with some resistance at the level of the iliac artery. After the deployment of the stented valve (figure 1A), and the retrieval of the delivery system, acute haemodynamic deterioration occurred. Supra-aortic angiography confirmed the patency of the coronaries with a well-seated valve with no significant intravalvular or paravalvular aortic leak. TTE showed no pericardial effusion. Abdominal aortic angiography identified massive contrast media extravasation at the level of the right external iliac artery...]]> 2013-03-22T00:00:34-07:00 info:doi/10.1136/heartjnl-2013-303591 hwp:master-id:heartjnl;heartjnl-2013-303591 BMJ Publishing Group Ltd 2013-03-22 Miscellanea http://heart.bmj.com/cgi/content/short/heartjnl-2012-303308v1?rss=1

Cardiovascular diseases are the major cause of death worldwide and currently affect 36.3% of the US population.^w1 The majority of this population comprises patients with acute myocardial infarction (AMI) and chronic ischaemic heart failure. Despite the considerable contribution of percutaneous coronary revascularisation and coronary artery bypass grafting (CABG) in coronary artery disease (CAD) patients, the long term benefits remain unsatisfactory. Moreover, heart transplantation, as a last resort, is available for a very limited patient population.

Cell transplantation emerged initially as a potential therapy to treat heart failure. Cardiomyocytes are generally considered to be post-mitotic, and do not regenerate upon loss or damage. However, recently Bergmann and co-workers were able to demonstrate that 50% of adult cardiomyocytes are exchanged during a normal lifespan,1 which has propelled investigations into the potential use of cardiovascular regenerative therapy. Moreover, recent improvements in preparation techniques of stem cells, the creation of stable stem...]]> 2013-03-22T00:00:18-07:00 info:doi/10.1136/heartjnl-2012-303308 hwp:master-id:heartjnl;heartjnl-2012-303308 BMJ Publishing Group Ltd 2013-03-22 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2013-303656v1?rss=1

Atrial fibrillation (AF) is the most common cardiac rhythm disorder1 and one of the most important risk factors for stroke, particularly in the elderly. Stroke-related AF is associated with significant morbidity, mortality and healthcare costs.2 Although we have abundant evidence from randomised trials that anticoagulation, and to a lesser extent antiplatelet therapy, is highly efficacious in preventing stroke in patients with AF, these therapies remain underused, especially in older patients. With an ageing population and an AF prevalence that is rapidly rising,1 a better understanding of the stroke prevention practices in real-world settings is critically important to implement preventive strategies that will improve the outcomes and reduce healthcare costs.

Cowan et al3 report the results of their investigation on the use of stroke prevention therapy for management of AF among 1857 primary-care practices across England from July 2009 to March 2012. Using...]]> 2013-03-21T00:00:35-07:00 info:doi/10.1136/heartjnl-2013-303656 hwp:master-id:heartjnl;heartjnl-2013-303656 BMJ Publishing Group Ltd 2013-03-21 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2012-302048v1?rss=1 Non-compaction cardiomyopathy (NCM) is a myocardial disorder, which is thought to occur due to the failure of left ventricle (LV) compaction during embryogenesis, leading to distinct morphological characteristics in the ventricular chamber.1 It was first described about 80 years ago, in association with complex congenital heart diseases. More recently, Chin et al2 reported the isolated form of non-compaction LV, and since then many other reports have been published. The involvement of the right ventricle in the non-compaction process has been increasingly identified and the condition is now included among the cardiomyopathies. The nomenclature of this entity has been variable, being known as ‘spongy myocardium’ or ‘persistent embryonic myocardium’, but more frequently known as ‘LV non-compaction’ or NCM. Therefore, the latter term will be the one used in this article.

The characteristic features of NCM have been described as including a two-layered ventricular wall, comprising a thinner compact epicardial...]]> 2013-03-16T00:00:25-07:00 info:doi/10.1136/heartjnl-2012-302048 hwp:master-id:heartjnl;heartjnl-2012-302048 BMJ Publishing Group Ltd 2013-03-16 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2013-303790v1?rss=1 This editorial celebrates 40 years of the British Society for Cardiovascular Research (BSCR). The Society originated, as many things do, in a small informal gathering. David Hearse (working in London with Professor Sir Ernst Chain in the Department of Biochemistry at the Imperial College of Science and Technology) and Keith Gibson (working with Peter Harris at the Cardiothoracic Institute in Beaumont Street) were lamenting the lack of a forum in which to discuss current issues in basic cardiovascular research. To improve the situation, they assembled a committee with John Muir, Winifred Nayler, Mark Noble, Desmond Fitzgerald and Peter Harris, who was elected as the first Chair of the nascent Society (table 1), named at that time the Cardiac Muscle Research Group (CMRG). Encouragingly, attendance at their inaugural meeting on 12 December 1973 far exceeded expectations of ‘perhaps as many as nineteen’. Indeed, over 60 delegates enjoyed two sessions; one...]]> 2013-03-12T00:00:35-07:00 info:doi/10.1136/heartjnl-2013-303790 hwp:master-id:heartjnl;heartjnl-2013-303790 BMJ Publishing Group Ltd 2013-03-12 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2012-302337v3?rss=1 Notice of retraction

This paper was published on-line in Heart on 21 August 2012. It reports a meta-analysis of six earlier papers.1–6 It has come to our attention that two of these papers contain duplicate data in tables reporting baseline data and treatment effects.3 4

The matter was considered by BMJ Publishing Ethics Committee. The Committee considered that without sight of the raw data on which the two papers containing the duplicate data were based, their reliability could not be substantiated. Following inquiries, it turns out that the raw data are no longer available having been lost as a result of computer failure.

Under the circumstances, it was the Committee's recommendation that the Heart meta-analysis should be retracted on the ground that the reliability of the data on which it is based cannot be substantiated.

To provide new insight in relation to: 1) cardiac adaptation to divergent training patterns in male athletes, 2) a developing research database using cardiac magnetic resonance (CMR) in athletes; 3) functional data derived from tissue-Doppler analysis as well as right ventricular (RV) and left atrial (LA) measurements in athletes; and 4) an awareness of the impact of body size on cardiac dimensions.

Systematic review and meta-analysis of prospective trials. Data extraction performed by two researchers.

Pub Med, Medline, Scopus and ISI Web of knowledge scholarly data base.

Prospective studies were included if they were echocardiographic or CMR trials of elite young male athletes, with clear indication of type of sports and passed a quality criteria checklist.

All left ventricular (LV) structural parameters were higher in athletes than in controls. Only LV end-diastolic diameter and volume were higher in endurance athletes than in resistance athletes: 54.8 mm (95% CI 54.1 to 55.6) vs 52.4 mm (95% CI 51.2 to 53.6); p<0.001 and 171 ml (95% CI 157 to 185) vs 131 ml (95% CI 120 to 142); p<0.001, respectively. RV end-diastolic volume, mass and LA diameter were higher in endurance athletes than controls. LV end-diastolic volume was larger when CMR was used rather than echocardiography: 178 ml (95% CI Q7 162 to 194) vs 135 ml (95% CI 128 to 142); p<0.001. Meta-analysis regression models demonstrated positive and significant associations between body surface area (BSA) and LV mass, RV mass and LA diameter.

Morphological features of the male AH were noted in both athlete groups. A training-specific pattern of concentric hypertrophy was not discerned in resistance athletes. Both imaging mode and BSA can have a significant impact on the interpretation of AH data.

Early results comparing CABG with PCI in patients with diabetes came from randomised clinical trial subgroup analyses.5 Only one reported a significant survival advantage for CABG, 2013-03-08T00:02:08-08:00 info:doi/10.1136/heartjnl-2013-303820 hwp:master-id:heartjnl;heartjnl-2013-303820 BMJ Publishing Group Ltd 2013-03-08 Editorials http://heart.bmj.com/cgi/content/short/heartjnl-2012-302883v1?rss=1 Genes and environmental factors contribute to an individual's risk of hypertension. Recent advances in DNA sequencing technology have enabled the discovery of new causative genes in inherited forms of hypertension, identifying novel pathways for blood pressure control. Meta-analyses of genome-wide association studies have also identified regions of the genome that are significantly associated with blood pressure control, and these regions may be involved in an individual's response to antihypertensive medication. This article reviews the latest gene discoveries in inherited forms of hypertension, recent meta-analyses of genome-wide association studies, genetic determinants of antihypertensive therapy response, and development of genetic risk scores.

CS is a condition characterised by inadequate tissue perfusion, usually in the setting of AMI. There have been many definitions applied to the diagnosis of CS, but the most uniformly accepted clinical definition of CS is decreased cardiac output and evidence of tissue hypoxia in the...]]> 2013-03-06T00:01:05-08:00 info:doi/10.1136/heartjnl-2012-302028 hwp:master-id:heartjnl;heartjnl-2012-302028 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-302160v2?rss=1

Sudden cardiac death (SCD) in the athlete, though uncommon, is the most devastating sport related event. It is widely publicised by the news media with the implication that such a fatality is preventable. The previous year of 2012 was notorious for SCD during sports. Several tragic events occurred in top level athletes—including a 25-year-old Italian soccer player, a 26-year-old Norwegian swimmer, a 24-year-old Serbian rower, and a 32-year-old runner in the London marathon. In addition, the 23-year-old soccer player Fabrice Muamba experienced an on-pitch aborted SCD during an English FA Cup match. These events have revived the debate regarding the need for a preparticipation cardiovascular evaluation of athletes and the inclusion of a 12 lead ECG in the screening protocol.

This article aims to review the field of SCD in the athlete, to highlight the areas of controversy on preparticipation screening, to address the opposing points of view in a...]]> 2013-03-06T00:00:46-08:00 info:doi/10.1136/heartjnl-2012-302160 hwp:master-id:heartjnl;heartjnl-2012-302160 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-302042v2?rss=1

Since the inaugural description in 1959 by Prinzmetal,1 coronary artery spasm and abnormal coronary artery vasomotion have been extensively studied both clinically and scientifically. There is no doubt that abnormal epicardial and microvascular coronary vasomotion play an important role in ischaemic heart disease. However, after the introduction of percutaneous coronary intervention, the number of articles and the clinical interest in abnormal coronary vasomotion have declined considerably, at least in the USA and Europe. As a consequence, the functional aspects of coronary artery disease have received less and less attention. There has been a revival of the topic recently, mainly because abnormal coronary vasomotion of the microcirculation has come into focus,2 but also because the clinical presentation of chest pain with unobstructed coronary arteries continues to represent a diagnostic challenge for the clinician.3

In this article we describe common patterns of coronary vasomotor responses to...]]> 2013-03-06T00:00:45-08:00 info:doi/10.1136/heartjnl-2012-302042 hwp:master-id:heartjnl;heartjnl-2012-302042 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-301751v2?rss=1

Cardiovascular surgeries have become progressively more sophisticated and complicated, due to factors such as the increasingly advanced age of patients, significant comorbidities, and increasing surgical complexity—minimally invasive procedures, reoperations and simultaneous procedures such as combined valve surgery and revascularisation, multiple valve replacements, combined valve and vascular surgery, as well as complicated aneurysm surgeries. Traditionally imaging studies with echocardiography and conventional angiography are increasingly complemented by tomographic techniques such as multidetector CT and MRI. In this context, echocardiography and angiography have significant shortcomings due to limited field of view focused on the examined cardiovascular structures, without significant insight into their spatial relationship vis-à-vis surrounding structures. The strength of CT and MRI is in the assessment of the spatial relationship of cardiovascular and extracardiac structures. In addition, the broadening of the scope of practice of both imaging and interventional cardiologists has made it more imperative to understand the various aspects of...]]> 2013-03-06T00:00:44-08:00 info:doi/10.1136/heartjnl-2012-301751 hwp:master-id:heartjnl;heartjnl-2012-301751 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-301725v2?rss=1 Hypertension is highly prevalent and one of the most frequent chronic diseases worldwide.1 Prognoses for the next decades suggest that up to 50% of the adult population will be diagnosed as hypertensives using the standard guideline definitions of hypertension.1 Approximately 5–20% of all patients with high blood pressure are resistant to drug treatment,2 defined as blood pressure uncontrolled (>140/90 mm Hg; >130–139/80–85 mm Hg in patients with diabetes mellitus; >130/80 mm Hg in chronic kidney disease), despite the use of at least three antihypertensive agents of different classes, including a diuretic, at maximum or highest tolerated doses.3 Attention should be paid to differentiate between true resistance and pseudo-resistance, which is probably related to poor medication adherence, situational evoked blood pressure elevation (white coat hypertension), or suboptimal drug combination.4 In approximately 20% of all patients suffering from resistant hypertension, a secondary, potentially reversible cause can be found,...]]> 2013-03-06T00:00:43-08:00 info:doi/10.1136/heartjnl-2012-301725 hwp:master-id:heartjnl;heartjnl-2012-301725 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-302527v2?rss=1 Percutaneous catheter based edge-to-edge mitral valve (MV) repair with a mitral clip (MitraClip, Abbott Vascular, Abbott Park, Illinois, USA) mimics Alfieri's surgical technique, bringing the anterior and posterior leaflets together from beneath the valve with a metallic stitch (clip). The procedure creates a ‘double orifice’ repair, re-establishing leaflet coaptation and thereby reducing mitral regurgitation (MR).

In 2005, Feldman et al published their initial feasibility data (EVEREST (Endovascular Valve Edge-to-Edge Repair) phase 1 clinical trial) of a cohort of 27 patients with moderate-to-severe MR who were symptomatic or asymptomatic with compromised left ventricular (LV) function.1 Patients were selected on the basis of specific valve morphology for which the procedure was thought to be particularly suited. In the case of degenerative MV regurgitation (ie, flail leaflet), anatomical inclusion criteria were a regurgitant jet originating from the A2/P2 segment with a flail gap of <10 mm and a flail width of <15 mm. In the...]]> 2013-03-06T00:00:42-08:00 info:doi/10.1136/heartjnl-2012-302527 hwp:master-id:heartjnl;heartjnl-2012-302527 BMJ Publishing Group Ltd 2013-03-06 Education in Heart http://heart.bmj.com/cgi/content/short/heartjnl-2012-303407v1?rss=1 Background

There is a relative paucity of data linking inappropriate implantable cardioverter-defibrillator (ICD) shocks to adverse clinical outcomes.

To examine the association between inappropriate ICD shocks and mortality or heart transplantation in a large population cohort.

A cohort study which included all subjects who underwent ICD implantation between 1998 and 2008 and were followed up at our institution.

Multivariable Cox regression analyses were conducted to investigate the effect of inappropriate shocks on the risk of death and heart transplantation. Appropriate and inappropriate ICD therapies were modelled as time-dependent covariates.

A total of 1698 patients were included. During a median follow-up of 30 months, there were 246 (14.5%) deaths and 42 (2.5%) heart transplants. The incidence of inappropriate shocks was 10% at 1 year and 14% at 2 years. In the adjusted model, inappropriate shocks were not associated with death or transplantation (HR=0.97, 95% CI 0.70 to 1.36, p value=0.873). In contrast, appropriate shocks were associated with adverse outcomes (HR=3.11, 95% CI 2.41 to 4.02, p value<0.001). The lack of association between inappropriate shocks and outcomes persisted for those with severely impaired  left ventricular function (ejection fraction <30%) and for those receiving multiple inappropriate treatments.

In this study, we observed no association between inappropriate ICD shocks and increased mortality or heart transplantation, even among those with severely impaired cardiac function. These findings question whether inappropriate ICD shocks lead to adverse outcomes.

We adopted a novel approach to systematically implement the universal definition of MI. Two physicians blinded to treatment allocation reviewed plots of CK-MB and troponin values in relation to time of randomisation and percutaneous coronary intervention (PCI) to identify patients with stable or falling biomarkers pre-PCI (ie, primary cohort), and those with post-PCI CK-MB elevations.

The CHAMPION PLATFORM trial.

Non-ST-elevation acute coronary syndromes (95%) and stable angina patients (5%).

Cangrelor versus placebo.

The efficacy of cangrelor compared with placebo using the reclassified events (type 4a MI) and the original clinical events committee-adjudicated (CEC PCI-MI) results was investigated.

Of 5295 patients, 3406 (64.4%) were in the primary cohort. Type 4a MI occurred in 4.3% (226 events/5295 patients) while original CEC PCI-MI occurred in 6.5% (344 events/5295 patients), a significant difference (p<0.0001). Using the reclassified MI events, the primary composite endpoint of death, MI, or ischaemia-driven revascularisation through 48 h occurred in 5.4% of patients (4.9% cangrelor, 6.0% placebo; OR 0.80; 95% CI 0.63 to 1.02) as opposed to 7.5% of the primary analyses (7.0% cangrelor, 8.0% placebo; OR 0.87; 95% CI 0.71 to 1.07).

Systematic, strict implementation of the universal MI definition with emphasis on baseline assessment may enhance discrimination in detecting PCI-MI and may allow for more rigorous assessment of interventions in patients undergoing early PCI.

Prospective observational study.

University hospital heart centre.

64 patients (62.6±11.7 years-old, 73% male) presenting throughout the 24-h cycle of clinical activity with ST elevation myocardial infarction.

PPCI.

NPY was measured (ELISA) in peripheral blood taken before and immediately after PPCI and at 6, 24 and 48 h post-PPCI. Reperfusion was assessed by angiographic criteria, ST segment resolution, invasive measurement of coronary flow reserve and the index of microcirculatory resistance.

Plasma NPY levels were highest before PPCI (17.4 (8.8–42.2) pg/ml, median (IQR)) and dropped significantly post-PPCI (12.4 (6.5–26.7) pg/ml, p<0.0001) and after 6 h (9.0 (2.6–21.5) pg/ml, p=0.008). Patients with admission NPY levels above the median were significantly more hypertensive and tachycardic and were more likely to have diabetes mellitus. Patients with angiographic no-reflow (less than thrombolysis in myocardial infarction 3 flow and myocardial blush grade >2, n=16) or no electrocardiographic ST resolution (<70%, n=30) following PPCI had significantly higher plasma NPY levels. Patients with a coronary flow reserve <1.5 or index of microcirculatory resistance >33 also had significantly higher plasma NPY levels pre-PPCI and post-PPCI.

Plasma NPY levels correlate with indices of reperfusion and coronary microvascular resistance.

Epidemiological study.

1857 general practices in England representing a practice population of 13.1 million registered patients.

231 833 patients with a history of AF.

The primary outcome was AC and AP use by CHADS₂ score and age groups <30 years, 30–49 years, 50–64 years, 65–79 years and >79 years.

231 833 patients with a history of AF were identified, giving a prevalence among uploading practices of 1.76%. Prevalence of AF varied markedly between practices, related to differing practice age profiles. The total number of patients with AF in a practice was strongly predicted by the number of patients aged 65 years and over in the practice. 57.0% of the AF population had a CHADS₂ score ≥2 and 83.7%≥1. 114 212 (49.3%) patients received AC therapy. AC uptake increased with increasing CHADS₂ score up to a score of 3, but thereafter reached a plateau. Among 132 099 patients with a CHADS₂ score ≥2, 72 211 (54.7%) received an AC, 14 987(11.3%) were recorded as having a contraindication or having declined AC therapy, leaving 44 901 (34.0%) not on AC therapy and without a recorded contraindication or recorded refusal. Among patients not prescribed an AC, 79.9% were prescribed an AP. The use of AC declined in the elderly (for CHADS₂≥2, 47.4% of patients ≥80 years, compared with 64.5% for patients aged <80 years, p<0.001). By contrast, AP uptake was more prevalent among elderly patients.

Over one-third of patients with AF and known risk factors who are eligible for AC do not receive them. There is a high use of AP among patients not receiving AC. Uptake of AC is particularly poor among patients aged 80 years and over.

To identify clinical and periprocedural factors that may have an impact on clinical outcome.

Multi-centre longitudinal cohort study.

Tertiary referral centres.

Here we report on the first 100 consecutive patients treated with percutaneous MVR in Switzerland between March 2009 and April 2011. All of them had moderate–severe (3+) or severe (4+) MR, and 62% had functional MR. 82% of the patients were in New York Heart Association (NYHA) class III/IV, mean left ventricular ejection fraction was 48% and the median European System for Cardiac Operative Risk Evaluation was 16.9%.

MitraClip implantation performed under echocardiographic and fluoroscopic guidance in general anaesthesia.

Clinical, echocardiographic and procedural data were prospectively collected.

Acute procedural success (APS, defined as successful clip implantation with residual MR grade ≤2+) was achieved in 85% of patients. Overall survival at 6 and 12 months was 89.9% (95% CI 81.8 to 94.6) and 84.6% (95% CI 74.7 to 91.0), respectively. Univariate Cox regression analysis identified APS (p=0.0069) and discharge MR grade (p=0.03) as significant predictors of survival.

In our consecutive cohort of patients, APS was achieved in 85%. APS and residual discharge MR grade are important predictors of mid-term survival after percutaneous MVR.

All database participants receive feedback reports which they may voluntarily share with their hospitals or payers, or publicly report. STS analyses are regularly used as the basis for local, regional and national quality improvement efforts.

More than 90% of adult cardiac programmes in the USA participate, as do the majority of paediatric cardiac programmes, and general thoracic participation continues to increase. Since the inception of the Database in 1989, more than 5 million patient records have been submitted.

Each of the three subspecialty databases includes several hundred variables that characterise patient demographics, diagnosis, medical history, clinical risk factors and urgency of presentation, operative details and postoperative course including adverse outcomes.

Data are entered by trained data abstractors and by the care team, using detailed data specifications for each element.

Quality and consistency checks assure accurate and complete data, missing data are rare, and audits are performed annually of selected participant sites.

All major outcomes are reported including complications, status at discharge and mortality.

Applications for STS Database participants to use aggregate national data for research are available at http://www.sts.org/quality-research-patient-safety/research/publications-and-research/access-data-sts-national-database.

Abciximab represents a cornerstone in the treatment of STEMI patients undergoing primary PCI. Intracoronary abciximab bolus administration has been proposed as an alternative strategy to the standard intravenous route. However, whether intracoronary abciximab effectively improves clinical outcomes compared with standard route remains unknown.

Individual data of 1198 patients enrolled in five trials were entered into the pooled analysis. The primary endpoint of the study was the occurrence of all-cause death and reinfarction at 30-day follow-up. Secondary endpoints were all-cause death, reinfarction and target-vessel revascularisation (TVR).

No significant heterogeneity was found across trials. Compared with the intravenous route, intracoronary abciximab administration significantly reduced the risk of the composite of death and reinfarction (HR 0.52, 95% CI 0.29 to 0.94; p=0.03), death (HR 0.44, 95% CI 0.20 to 0.95; p=0.04) and TVR (HR 0.53, 95% CI 0.29 to 0.99; p=0.045), without a significant impact on the risk of reinfarction (HR 0.54, 95% CI 0.24 to 1.21; p=0.13). However, after correction for baseline differences, only the composite of death/reinfarction and death remained significant.

In STEMI patients undergoing primary PCI, intracoronary abciximab administration, when compared with the intravenous standard route, can improve short-term clinical outcomes mainly by reducing the risk of death.

Prospective cross-sectional study in tertiary health care setting.

Thirty-six CoAs (age 16±1 years; neonatal surgery only: n=16; surgery and/or stent implantation: n=20) and 37 age-matched controls were examined by very-high resolution ultrasound, echocardiography and applanation tonometry.

CoA was associated with increased right arm systolic BP (p<0.001), intima-media thickness (IMT) in the common carotid (p<0.001), right brachial (p<0.05) and radial (p<0.05) arteries and ascending aortic stiffness (p<0.05). Carotid IMT correlated positively with age at first intervention (r=0.36, p<0.05). With left subclavian flap type repair, left arm systolic BP (p<0.001) and left brachial (p<0.001), radial (p<0.001) and ulnar (p<0.05) arterial IMTs were all reduced. When adjusted for BP, body mass index, age and gender, only carotid IMT (p<0.001) and LV-mass (p=0.013) of stented patients, as well as left arm arterial IMTs (p<0.01) in subclavian flap type repair patients remained different from controls. The significant associations of stented patients disappeared after adjustment for later patient age at intervention (median 8.7 vs 0.03 years, p<0.001). Residual arm-leg BP gradients correlated positively with carotid and brachial IMT.

CoA repair in early childhood is associated with increased preductal arterial IMT, LV mass and ascending aortic stiffness in adolescents. The more pronounced cardiovascular abnormalities after CoA stent implantation are likely related to the older patient age at the time of intervention.