Writing Committee Research Articles

ICD therapy in women: Are men from Mars and women from Venus?

Heart failure affects approximately 5.8 million people in the United States, with women composing nearly half that population. 1 Lloyd-Jones D. Adams R.J. Brown T.M. et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1385) Google Scholar The annual incidence of heart failure is approximately 670,000 in patients ages 45 years and older, with men and women affected in equal numbers. 1 Lloyd-Jones D. Adams R.J. Brown T.M. et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1385) Google Scholar Treatment of heart failure patients with severe systolic dysfunction includes optimization of medical therapy in addition to primary prevention of sudden cardiac death (SCD) with implantation of an implantable cardioverter-defibrillator (ICD). 2 Hunt S.A. Abraham W.T. Chin M.H. et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009; 119: e391-e479 Crossref PubMed Scopus (1400) Google Scholar , 3 Hunt S.A. Abraham W.T. Chin M.H. et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005; 112: e154-e235 Crossref PubMed Google Scholar This approach to the primary prevention of SCD in patients with heart failure is the result of multiple clinical trials that have evaluated the efficacy of ICDs in this population. 4 Moss A.J. Zareba W. Hall W.J. et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002; 346: 877-883 Crossref PubMed Scopus (5576) Google Scholar , 5 Bardy G.H. Lee K.L. Mark D.B. et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005; 352: 225-237 Crossref PubMed Scopus (5257) Google Scholar The integration of these results into practice guidelines has led to a significant increase in the rate of ICD implantation in the United States. 6 Hammill S.C. Kremers M.S. Kadish A.H. et al. Review of the ICD Registry's third year, expansion to include lead data and pediatric ICD procedures, and role for measuring performance. Heart Rhythm. 2009; 6: 1397-1401 Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Gender differences in clinical outcome and primary prevention defibrillator benefit in patients with severe left ventricular dysfunction: A systematic review and meta-analysisHeart RhythmVol. 7Issue 7PreviewWomen are underrepresented in primary prevention implantable cardioverter-defibrillator (ICD) trials, and data on the benefit of ICD therapy in this subgroup are controversial. Full-Text PDF

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

School Funding Advocacy, Grants, Grant Writing, and ASHA's School Finance Committee

Abstract School-based members of the American Speech-Language-Hearing Association (ASHA) seeking successful advocacy for accessing and obtaining additional funds for services and programs must build their efforts upon an understanding of school funding. Demystifying the complex nature of federal, state, and local funding in order to understand how money flows to local speech-language pathology and audiology programs is the first step toward successful advocacy. In this article, Division 16 affiliates will learn about the important role ASHA's School Finance Committee plays in helping ASHA members understand funding and locate funding sources, and will be provided with tips on advocating for money to support professional and student service needs.

Antiplatelet effects of clopidogrel and bleeding in patients undergoing coronary stent placement.

In patients undergoing percutaneous coronary intervention (PCI), a link between bleeding and excess mortality has been demonstrated. A potential association of platelet response to clopidogrel and bleeding has not been well established yet. The aim of the present study was to assess the impact of clopidogrel responsiveness on the risk of bleeding in clopidogrel-treated patients undergoing PCI. Patients (n=2533) undergoing PCI after pretreatment with 600 mg of clopidogrel were enrolled in this study. Blood was obtained directly before PCI. Adenosine-diphosphate (ADP)-induced platelet aggregation was assessed on a Multiplate analyzer. The primary endpoint was the incidence of in-hospital Thrombolysis in Myocardial Infarction (TIMI) major bleeding and the secondary endpoint was in-hospital TIMI minor bleeding. Receiver-operator curve (ROC) analysis was used to derive the optimal platelet aggregation value defining enhanced clopidogrel responders for the association of measurements with major bleeding. Thirty-four (1.3%) major bleeding events and 137 (5.4%) minor bleeding events were observed. The risk of a major bleeding was significantly higher in patients (n=975) with an enhanced response to clopidogrel as compared with the remaining patients (n=1558) (2.2 vs. 0.8%, unadjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3-5.2, P=0.005; adjusted OR 3.5, 95% CI 1.6-7.3, P=0.001). No significant differences between both groups were observed for the occurrence of minor bleeding events (P=0.68). Enhanced clopidogrel responsiveness is associated with a higher risk of major bleeding. Whether guidance of antiplatelet treatment based on platelet function testing proves useful for avoiding bleeding events warrants further investigation.

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

BACKGROUND AND OBJECTIVE:Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.METHODS:We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.RESULTS:Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.CONCLUSION:Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

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Stroke Telemedicine: State of Affairs

To the Editor: We read with great interest the recent article by Demaerschalk et al1Demaerschalk BM Miley ML Kiernan T-E STARR Coinvestigators et al.Stroke telemedicine.Mayo Clin Proc. 2009; 84: 53-64Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar and the editorial by Meschia2Meschia JF Camera in the emergency department: the evolution of stroke telemedicine [editorial].Mayo Clin Proc. 2009; 84: 3-4Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar about stroke telemedicine. It is a pleasure to see that an increasing number of stroke centers are transferring their expertise to rural areas through telemedicine worldwide. Indeed, the process has been developed much further than described in those articles. For example, studies associated with the Telemedic Project for Integrative Stroke Care (TEMPiS) in Germany demonstrated almost identical long-term mortality and functional outcome after telemedically guided thrombolysis in 170 patients at district hospitals compared with 132 patients with intravenous thrombolysis at 2 stroke centers.3Schwab S Vatankhah B Kukla C TEMPiS Group et al.Long-term outcome after thrombolysis in telemedical stroke care.Neurology. 2007; 69: 898-903Crossref PubMed Scopus (169) Google Scholar In another study associated with TEMPiS,4Audebert HJ Schenkel J Heuschmann PU Bogdahn U Haberl RL Telemedic Pilot Project for Integrative Stroke Care Group Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany.Lancet Neurol. 2006; 5: 742-748Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar 1971 patients at telemedicine-supported hospitals with newly established stroke wards were compared with those at matched control hospitals not taking part in the network. Significantly fewer patients at in-network hospitals had a poor outcome after 3 months. In a multivariate regression analysis, specialized stroke treatment in telemedicine network hospitals independently reduced the probability of a poor outcome (odds ratio, 0.62; 95% confidence interval, 0.52-0.74; P<.0001). At 12- and 30-month follow-up, death and dependency were significantly lower in TEMPiS hospitals.5Audebert HJ Schultes K Tietz V Writing Committee for the Telemedical Project for Integrative Stroke Care (TEMPiS) et al.Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS).Stroke. 2009; 40 (Epub 2008 Nov 20): 902-908Crossref PubMed Scopus (111) Google Scholar During the almost first 4 years of the project, more than 8000 patients were examined via teleconsultation, and for the vast majority, treatment could be continued at the district hospitals without interhospital transfer.6Vatankhah B Schenkel J Fürst A Haberl RL Audebert HJ Telemedically provided stroke expertise beyond normal working hours: the Telemedical Project for Integrative Stroke Care.Cerebrovasc Dis. 2008; 25 (Epub 2008 Feb 27.): 332-337Crossref PubMed Scopus (30) Google Scholar Thus, telemedicine has become a reliable tool in acute stroke care, associated with improved outcome. It is well accepted when used in an integrative approach of organized stroke care. Nevertheless, efficacy data on the use of telemedicine in stroke management are needed from more networks, and the independent effect of teleconsultations on safety and outcome must be demonstrated for more than intravenous thrombolysis. We think that use of telemedicine should increase, eg, to facilitate inclusion of patients with rare causes of stroke into controlled studies. Stroke Telemedicine: State of Affairs–Reply–IMayo Clinic ProceedingsVol. 84Issue 5PreviewWe appreciate the interest that Vatankhah and Audebert have in our recent article and accompanying editorial. We thank them for providing information on their numerous publications generated from the TEMPiS study.1 The network of hospitals in Bavaria that make up TEMPiS has demonstrated that telemedicine can be an effective way of delivering stroke expertise to hospitals that had previously lacked extensive experience with thrombolytic therapy. It is true that the nonrandomized, unblinded, open-intervention TEMPiS study showed that specialized stroke treatment in TEMPiS telemedicine network hospitals independently reduced the probability of a poor outcome. Full-Text PDF

Inclusion and exclusion criteria for CRT

Clinical practice guidelines for cardiac resynchronization therapy (CRT) have recently been updated by both European and American scientific societies (Table 1). 1 Vardas P. Auricchio A. Blanc J.J. et al. Guidelines for cardiac pacing and cardiac resynchronization therapy. Europace. 2007; 9: 959-998 Crossref PubMed Scopus (253) Google Scholar , 2 Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemaker and antiarrhythmia device): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeon. Circulation. 2008; 117: e350-e408 Crossref PubMed Scopus (1199) Google Scholar These are largely consistent with respect to class I and IIa recommendations. For the first time, these guidelines have included 2 new groups of heart failure patients: patients with chronic atrial fibrillation and patients in whom frequent dependence on ventricular pacing is anticipated. Although these guidelines share common ground, there are also important differences. Prominent among these is that European guidelines distinguish between the levels of evidence for the 2 types of CRT: A for CRT-P (pacing only) and B for CRT-D (with implantable cardioverter-defibrillator back-up). This peculiar situation has arisen as a result of the lack of randomized, controlled, head-to-head comparisons of CRT-P and CRT-D. Another important difference relates to atrial fibrillation: whereas U.S. guidelines consider CRT appropriate for patients with atrial fibrillation without distinction among paroxysmal, permanent, or persistent, European guidelines recommend CRT only in patients with chronic atrial fibrillation who also undergo atrioventricular junction ablation. Table 1Clinical practice guidelines for cardiac resynchronization therapy ESC/EHRA ACC/AHA/HRS 2007 2008 Guidelines on pacing and CRT Cardiac pacemakers and antiarrhythmia devices Class I LVEF ≤35% LVEF ≤35% QRS ≥120 ms QRS ≥120 ms NYHA III–IV NYHA III–IV OMT ambulatory LV dilatation OMT Sinus rhythm Sinus rhythm As above Class I for an ICD (upgrade or replacement) Class IIa As above As above Permanent pacing (upgrade or replacement) Frequent dependence on ventricular pacing As above As above Permanent atrial fibrillation and indication for AV junction ablation Atrial fibrillation ACC = American College of Cardiology; AHA = American Heart Association; AV = atrioventricular; CRT = cardiac resynchronization therapy; EHRA = European Heart Rhythm Association; ESC = European Society of Cardiology; HRS = Heart Rhythm Society; ICD = implantable cardioverter-defibrillator; LV = left ventricle; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association functional class; OMT = optimal medical therapy. Open table in a new tab ACC = American College of Cardiology; AHA = American Heart Association; AV = atrioventricular; CRT = cardiac resynchronization therapy; EHRA = European Heart Rhythm Association; ESC = European Society of Cardiology; HRS = Heart Rhythm Society; ICD = implantable cardioverter-defibrillator; LV = left ventricle; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association functional class; OMT = optimal medical therapy.

Coronary Stents and Chronic Anticoagulation

Case Presentation: A 76-year-old man was admitted with retrosternal chest pain. The ECG on admission showed inferolateral ST depression, and troponin levels were elevated, confirming the diagnosis of an acute coronary syndrome. The patient had a history of hypertension and aortic valve replacement with a metallic bileaflet valve 7 years before. He was being treated with warfarin and low-dose aspirin and had an international normalized ratio (INR) of 2.5. Coronary angiography revealed a long subocclusive lesion of the proximal right coronary artery. At that point, there was a question about the optimal treatment for this patient regarding the type of stent to be selected and the need for future combined antiplatelet and anticoagulation treatment. Oral anticoagulation was routinely used for coronary stent thrombosis prevention during the first era of stents.1 It has since been replaced by the combination of aspirin and a thienopyridine because studies have shown a definite advantage of the antiplatelet combination on coronary events2–4 and on reducing the risk of access-site bleeding complications. However, ≈5%5,6 of patients undergoing percutaneous coronary intervention (PCI) also present with an indication for oral anticoagulation therapy. In such cases, the type of stent selected; the use of oral anticoagulants, antiplatelets, or their combinations; the target INR; and the duration of treatment are essential considerations in relation to the risk of stent thrombosis/thromboembolic events and bleeding risk. With the introduction and widespread use of drug-eluting stents (DES) in recent years and given the necessity for longer duration of dual antiplatelet therapy, the issue of concurrent warfarin and antiplatelet therapy has become even more important. The existing guidelines do not offer a convincing solution to these issues. For acute coronary syndrome patients with an indication for anticoagulation, triple therapy (warfarin, aspirin, and clopidogrel) for the minimum time possible and a maintenance …

Duration of Symptoms Is Not Always the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

Loop Diuretics in Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is a common and highly morbid cardiovascular disorder. Most hospitalizations for ADHF are related to symptoms of congestion, and the vast majority of ADHF patients are treated with intravenous loop diuretics. Despite this nearly ubiquitous use, data supporting the safety and efficacy of loop diuretics in ADHF are limited, and controversy exists about the best way to use loop diuretics with regard to both dosing and means of administration (continuous infusion vs. intermittent boluses). We reviewed the data supporting the safety and efficacy of loop diuretics in patients with ADHF. A large body of observational literature suggests that loop diuretics, especially at higher doses, may be associated with increased mortality in patients with heart failure even after detailed adjustment for other measures of disease severity. Additionally, multiple small underpowered trials suggest that continuous infusion may be equivalent or superior to intermittent bolus dosing. In summary, there is a critical need to develop more robust data on the use of loop diuretics in ADHF. In that context, the NIH Heart Failure Clinical Research Network has begun the Diuretics Optimization Strategies Evaluation (DOSE) study, a multi-center, double-blind, randomized controlled trial that will enroll 300 patients with ADHF. The DOSE study will randomize patients using a 2 × 2 factorial design to low dose vs. high dose furosemide, and intermittent bolus vs. continuous infusion. Successful completion of the DOSE study will provide important data on the optimal clinical use of loop diuretics in ADHF.

ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging

ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging

Further Insight into the Technique and Outcomes of “Curative” Catheter Ablation of Atrial Fibrillation

During the past decade, catheter ablation of atrial fibrillation (AF) has emerged as an important treatment option for patients with symptomatic AF refractory to ≥1 antiarrhythmic agents. Electric isolation of the pulmonary vein musculature (PVI) has been identified as the primary end point for both catheter- and surgical-based AF ablation procedures.1 What is less clear is whether the addition of “linear lesions” or ablation of atrial sites demonstrating complex atrial electrograms improves outcome for patients with paroxysmal, persistent, or long-standing persistent AF.2,3 This issue remains an area of active discussion, debate, and investigation. Article see p 269 In this issue of Circulation: Arrhythmia and Electrophysiology , Gaita et al2 report the results of a prospective single-center randomized study of 204 patients who underwent catheter ablation for treatment of paroxysmal or persistent/permanent AF. Patients were stratified according to whether they had paroxysmal (n=125) or persistent/permanent (n=79) AF and were then randomized in a 2:1 fashion to undergo PVI alone or PVI combined with a “roof line” and a “left mitral line.” Follow-up visits that included an ECG, 24-hour Holter, and an echocardiogram were set up at 1, 3, 6, 12, 18, 24, and 30 months and then every year thereafter. If a patient experienced symptoms between follow-up visits, an event monitor was prescribed. A recurrence was defined as a symptomatic or asymptomatic episode of AF or atrial flutter lasting ≥30 seconds after a 2-month blanking period. Patients who developed a recurrence after the blanking period were offered a repeat ablation procedure. The outcome of ablation was evaluated at 12 months of follow-up and at completion of the study. Each patient was followed for a minimum of 3 years. Among the 125 patients with paroxysmal AF, the single-procedure success rate at 12 months was 46% with PVI alone versus …

Risks and Benefits of Antiplatelet Therapy in Uremic Patients

Patients with renal insufficiency are at an increased risk for cardiovascular morbidity and mortality. Despite being at a substantial risk for thrombotic events, patients with renal insufficiency also experience a greater number of hemorrhagic complications associated with antiplatelet therapy than individuals with normal renal function. This review focuses on the benefits and risks of antiplatelet therapy in patients with impaired kidney function suffering from an acute coronary syndrome.

Measuring Quality in Heart Failure

As we approach the end of the first decade of the 21st century, it is evident that the epidemic of heart failure has not abated, nor have concerns about the quality of care received by patients with this condition. Recent data from the American Heart Association1 and the Centers for Disease Control and Prevention2 reaffirm that the number of patients hospitalized with heart failure has grown steadily over the past 30 years. With aging of the US population, this trend will undoubtedly continue, but it is also noteworthy that the increase in heart failure hospitalizations over the past few decades is not limited to the Medicare population.2 Moreover, the outcome of heart failure patients after hospital discharge is not improving. Despite evidence-based guidelines, performance measures, quality improvement programs, and public reporting of hospital-level performance data, the number of patients dying or readmitted to hospitals within 30 days of hospital discharge has not declined3–6 and is equivalent in patients with depressed and those with preserved left ventricular systolic function.7 Hospital readmission is expensive and contributes to the increasing economic burden of heart failure, but this is often a preventable event. However, the characteristics of patients who will require rehospitalization have not been identified,5 and it is impossible to predict which patients will be readmitted. In many cases it is not the patient, but the healthcare system involving multiple providers and transitions of care, that makes the conditions ripe for high readmission rates. Article See p 29 The fundamental first step in identifying and correcting gaps in healthcare quality is setting standards of care through development of evidence-based clinical practice guidelines. From quality indicators emphasized in guidelines, clinical performance measures can be derived to evaluate the quality of care provided by hospitals and by individual practitioners. …

Are All Fish Equally Close to the Heart?–2

To the Editor: Lee et al provide a nice review of the cardiovascular benefit of omega-3 fatty acids. I question their claim that the Japan EPA Lipid Intervention Study (JELIS)1Yokoyama M Origasa H Matsuzaki M Japan EPA Lipid Intervention Study (JELIS) Investigators et al.Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis.Lancet. 2007; 369: 1090-1098Abstract Full Text Full Text PDF PubMed Scopus (1936) Google Scholar and Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico (GISSI-Prevenzione)2GISSI-Prevenzione Investigators Dietary supplementation with n-3 poly-unsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial.Lancet. 1999; 354: 447-455Abstract Full Text Full Text PDF PubMed Scopus (3729) Google Scholar trial demonstrate a lower cardiovascular risk despite “aggressive” therapy with standard pharmacotherapy. In the JELIS trial, the maximum dose of statin allowed was 10 mg of pravastatin, resulting in a reported 25% reduction in low-density lipoprotein cholesterol (LDL-C) from the baseline value of 183 mg/dL (to convert to mmol/L, multiply by 0.0259). This cannot be considered aggressive statin therapy considering the current recommendations from the American College of Cardiology and American Heart Association3Anderson JL Adams CD Antman EM et al.ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction).J Am Coll Cardiol. 2007; 50: e1-e157Abstract Full Text Full Text PDF PubMed Scopus (1572) Google Scholar of a target LDL-C of 70 mg/dL in patients with prior myocardial infarction. It remains unknown whether the 19% relative risk reduction in cardiovascular events associated with omega-3 fatty acids, driven primarily by the secondary outcome arm, would have been maintained in the context of aggressive statin use. Similarly, in the GISSI-Prevenzione trial, which enrolled patients who had had myocardial infarctions, only 46% of patients were receiving cholesterol-lowering drugs at 46 months, despite LDL-C levels of 137 mg/dL at baseline. Further research is necessary to determine whether omega-3 fatty acids provide cardiovascular benefit when cholesterol treatment follows the current guidelines. Are All Fish Equally Close to the Heart?–1Mayo Clinic ProceedingsVol. 83Issue 6PreviewTo the Editor: I read with great interest the recent article by Lee et al1 on the cardioprotective effect of omega-3 fatty acids. Supported by data from multiple clinical trials, the authors emphasized the beneficial effects of a mixture of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) on cardiovascular outcomes and all-cause mortality. I was particularly impressed by the growing body of evidence showing the synergistic effect of fish oil and statins on lowering triglycerides. Full-Text PDF

Pathogenesis of Elevated Peripheral Pulse Pressure

“Ashes to ashes, dust to dust, if the cancer don’t get us, the arteriosclerosis must” — —Richard Gordon in The Alarming History of Medicine, 1993 Substantial evidence suggests that arterial remodeling evolves over a life course under the conjoint influence of genes, environmental factors (including vascular risk factors), and lifestyle characteristics (such as diet and physical activity).1 Such arterial remodeling involves multiple vascular territories and is panarterial, ie, it involves all layers of the arterial wall.1 More recently, considerable attention has focused on the physiological aspects of propagation of blood within the aorta, and several important concepts have evolved. First, the aorta is no longer regarded as just a passive conduit that transports blood to the vital organs. Rather, it is a complex organ that remodels in dynamic fashion in response to biomechanical stresses that accumulate over the life course.1 The different segments of the aorta vary in their relations to risk factors, underscoring the heterogeneity in remodeling characteristics across the arterial tree.2 Second, age-associated changes in the aortic wall include fragmentation of the elastin fibers, increased synthesis of collagen, and calcification. The molecular epidemiology of these vascular remodeling changes have been well characterized, and are complex, being mediated via the interaction of vascular smooth muscle cells, integrins, metalloproteinases, endothelial function, and the renin-angiotensin axis, inflammation, and other pathways.1 Third, vascular flow propagation is the combination of steady flow (mean arterial pressure) and pulsatile (pulse pressure) components. The proximal (central) aorta stiffens with age, and these changes are associated with an increase in the pulsatile component (increased central pulse pressure), which in turn places a burden of increased afterload on the left ventricle. There is widespread agreement that elevated pulsatile load is associated with increased risk of cardiovascular disease, including myocardial infarction, stroke, and heart …

Barriers to Anticoagulation in Patients With Atrial Fibrillation

See related article, pages 227–230. Atrial fibrillation (AF) is not a benign cardiac arrhythmia but instead confers a 5-fold increased risk of stroke compared with age-matched people in sinus rhythm.1 AF patients also have a worse outcome after stroke, with elevated mortality and stroke recurrence rates,2 longer hospital stays,3 and lower discharge rates to their own homes.3 Current estimates suggest that AF afflicts ≈2.2 million Americans,4 whereas in the United Kingdom ≈740 000 individuals are thought to have AF,5 with >46 000 new cases being diagnosed each year.6 Given the increasing prevalence of AF and the associated thromboembolic complications, there are significant numbers of patients who require chronic oral anticoagulation (OAC). Current guidelines7,8 recommend that AF patients at moderate to high risk of stroke should be commenced on chronic anticoagulation with a vitamin K antagonist (VKA). These recommendations are based on data from meta-analyses of 13 randomized controlled trials which have demonstrated significant reductions in stroke9,10 and mortality10 with the use of warfarin. Despite the overwhelming evidence of the benefit of warfarin thromboprophylaxis in patients with AF, such therapy remains significantly underused. OAC care varies considerably from country to country and physicians tend to undertreat more than overtreat.11,12 Physicians’ dilemma of whether to prescribe warfarin is reflected in the recent Euro Heart Survey of AF patients, which revealed that only 67% of patients eligible for VKAs were actually prescribed it,13 although actual ‘real-life’ prescription of OAC may be significantly lower than this. So, why are eligible patients with AF not prescribed OAC? Warfarin itself is plagued by a number of inherent problems, the most important being the narrow therapeutic international normalized ratio (INR) window (target INR 2.5, range 2.0 to 3.0) which must be maintained, given that …