Circulation. 2006;113:329
(Circulation. 2006;113:329.)
© 2006 American Heart Association, Inc.
Issue Highlights
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MORTALITY AND CARDIOVASCULAR RISK ACROSS THE ANKLE-ARM INDEX SPECTRUM: RESULTS FROM THE CARDIOVASCULAR HEALTH STUDY, by O’Hare et al.
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The ankle arm index (AAI; ratio of ankle and arm systolic blood
pressures) has been used as an indicator of subclinical and
clinical peripheral vascular disease, and values below 0.9 and
above 1.4 have been reported to indicate an adverse vascular
prognosis. In this issue of
Circulation, O’Hare and colleagues
evaluated the mortality and cardiovascular risks associated
with a broad range of AAI (categories defined in 0.1 unit increments
from 0.6 to 1.4) in a large elderly community-based sample.
Compared to the referent group with an AAI between 1.10 and
1.20, values below 1.0 and above 1.4 were associated with higher
all-cause and cardiovascular mortality. Specifically, an AAI
in the range 0.9 to 1.0 (often regarded as normal) was associated
with a 40% higher mortality risk compared to the referent group,
whereas a value above 1.40 was associated with a 57% greater
mortality hazard. The authors noted effect modification by age,
with stronger associations of high and low AAI with mortality
risk in people below age 75 years. Overall, these observational
data emphasize the nonlinear relations of AAI and mortality
risk and raise the possibility that the mortality risk associated
with a low AAI may extend to values above the traditional cut
point of 0.9 (ie, to the range 0.9 to 1.0). See p
388.
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IMPACT OF PROSTHESIS-PATIENT MISMATCH ON LONG-TERM SURVIVAL IN PATIENTS WITH SMALL ST JUDE MEDICAL MECHANICAL PROSTHESES IN THE AORTIC POSITION, by Mohty-Echahidi et al.
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The issue of prosthesis-patient mismatch continues to be an
area of active clinical investigation. The article by Mohty-Echahidi
et al focuses on long-term survival in a defined population
of patients receiving an aortic valve with a small (19 or 21
mm) St Jude prosthesis. Three-hundred eighty-eight patients
were studied and the degree of mismatch was measured by postoperative
transesophageal echocardiography in each patient. The effective
orifice area index is defined as the echo-derived prosthesis
effective orifice area divided by the patient’s body surface
area. The patients with severely mismatched effective orifice
area index <0.6 cm
2/m
2 comprised 17% of the study patients.
These patients were observed to have a significantly worse survival
at 5 years (72%) and 8 years (41%) than those patients with
moderate mismatch (0.6 cm
2/m
2 to 0.85 cm
2/m
2) or no significant
mismatch (>0.85 cm
2/m
2). Severe mismatch was an independent
predictor of mortality (hazard ratio=2.18,
P=0.007) and congestive
heart failure (hazard ratio=3.1,
P= 0.009). The ability of a
surgeon to predict potential mismatch should be part of current
surgical practice. The effective orifice areas for specific
valves are available in tables provided by the manufacturers.
The surgeon can calculate the effective orifice area index and
choose a hemodynamically superior prosthesis or perform an annular
enlargement to avoid mismatch, thus improving outcomes in cardiac
surgery. See p
420.
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EFFECT OF INTENSIVE VERSUS STANDARD LIPID-LOWERING TREATMENT WITH ATORVASTATIN ON THE PROGRESSION OF CALCIFIED CORONARY ATHEROSCLEROSIS OVER 12 MONTHS: A MULTICENTER, RANDOMIZED, DOUBLE-BLIND TRIAL, by Schmermund et al.
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Emerging clinical trials suggest that low-density lipoprotein
(LDL) cholesterol lowering beyond previously defined targets
improves clinical outcomes in patients with coronary artery
disease and those with multiple cardiovascular risk factors.
Quantification of coronary artery calcification by electron-beam
computed tomography has been shown to provide prognostic information
in patients with known or suspected coronary artery disease.
In this issue of
Circulation, Schmermund et al evaluate whether
intensive LDL lowering using high-dose atorvastatin reduces
the presence of coronary artery calcification as assessed by
electron-beam computed tomography compared to treatment with
low dose atorvastatin. In this randomized controlled trial of
471 patients, the mean LDL after 12 months of treatment was
87±33 mg/dL in the high-dose group and was 109±28
mg/dL in the low-dose group. However, the progression in calcium
score did not differ between groups. This unexpected funding
may have implications for the clinical utility of coronary calcium
score as a surrogate marker for cardiovascular risk. See p
427.
Visit http://www.circ.ahajournals.org:
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Images in Cardiovascular Medicine
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Not So Mural Thrombus. See p
e38.
Cardiomyopathy Resulting From Primary Hyperoxaluria Type II. See p e39.
Role of Inflammation in Atherosclerosis: Immunohistochemical and Electron Microscopic Images of a Coronary Endarterectomy Specimen. See p e41.
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Correspondence
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See p
e44.
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