Circulation. 2007;115:2789
doi: 10.1161/CIRCULATIONAHA.107.183530
(Circulation. 2007;115:2789.)
© 2007 American Heart Association, Inc.
Issue Highlights
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OUTCOMES AND OPTIMAL ANTITHROMBOTIC THERAPY IN WOMEN UNDERGOING FIBRINOLYSIS FOR ST-ELEVATION MYOCARDIAL INFARCTION, by Mega et al.
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The manifestations, complications, and outcomes of cardiovascular
disease differ between women and men. Because of these differences,
the safety and efficacy of pharmacological reperfusion and antithrombotic
therapies in women with ST-elevation myocardial infarction have
been of particular interest. In this issue of
Circulation, Mega
and colleagues report on the characteristics and treatment-specific
outcomes of 4783 women with ST-elevation myocardial infarction
with planned fibrinolysis randomized to enoxaparin or unfractionated
heparin in the Enoxaparin and Thrombolysis Reperfusion for Acute
Myocardial Infarction Treatment–Thrombolysis in Myocardial
Infarction (ExTRACT-TIMI) 25 study. In this large, contemporary
clinical trial, women, when compared with men, presented with
a profile of higher baseline risk and had increased short-term
mortality. After adjusting for age and other clinical variables,
women continued to have a 1.25-fold higher 30-day risk of death
but similar risk of intracerebral hemorrhage. The relative risk
reduction in death and nonfatal myocardial infarction for enoxaparin
versus unfractionated heparin was similar in women and men,
with a larger absolute risk reduction observed in women. Although
the excess risk of bleeding with enoxaparin was seen for both
women and men, net clinical benefit strongly favored enoxaparin
in both sexes. See p 2822 (editorial p
2796).
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CLINICAL REMINDERS ATTACHED TO ECHOCARDIOGRAPHY REPORTS OF PATIENTS WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION INCREASE USE OF ß-BLOCKERS: A RANDOMIZED TRIAL, by Heidenreich et al.
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Despite strong evidence that specific treatments improve outcomes
for selected patient groups, studies indicate that underutilization
of these effective therapies remains common. Although many experts
have recommended interventions to improve practice, few have
undergone rigorous scrutiny. Moreover, with the emergence of
increasingly sophisticated health information technology, there
is a need to determine if electronic decision support tools
can improve practice. Investigators at the Veterans Affairs
Palo Alto Health Care System conducted a randomized clinical
trial of 1546 patients with depressed left ventricular systolic
function who were candidates for ß-blocker therapy.
They assessed whether a reminder system, integrated into their
electronic health record and embedded in the echocardiography
reports, could increase the appropriate use of ß-blocker
therapy. The reminder simply stated, "Note: Patients with reduced
ejection fraction have a survival benefit with ß-blockers
(initial dose: carvedilol 3.125 mg BID or metoprolol succinate
12.5 mg BID)." This type of evaluation provides critical evidence
for the effectiveness of such interventions to improve care.
See p
2829.
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B-TYPE NATRIURETIC PEPTIDE IN LOW-FLOW, LOW-GRADIENT AORTIC STENOSIS: RELATIONSHIP TO HEMODYNAMICS AND CLINICAL OUTCOME: RESULTS FROM THE MULTICENTER TRULY OR PSEUDO-SEVERE AORTIC STENOSIS (TOPAS) STUDY, by Bergler-Klein et al.
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and
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PARADOXICAL LOW-FLOW, LOW-GRADIENT SEVERE AORTIC STENOSIS DESPITE PRESERVED EJECTION FRACTION IS ASSOCIATED WITH HIGHER AFTERLOAD AND REDUCED SURVIVAL, by Hachicha et al.
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Timing of aortic valve replacement in patients with aortic stenosis
has traditionally been determined by the development of classic
symptoms. However, experienced clinicians have long recognized
this complexity and have used other measures of physiological
and hemodynamic significance to support operative intervention.
In this week’s issue, there are 2 manuscripts that provide
important advances in our understanding of aortic stenosis.
Investigators from the Truly or Pseudo-Severe Aortic Stenosis
(TOPAS) study evaluated 69 patients and demonstrated that B-type
natriuretic peptide can provide useful information in predicting
outcome in patients treated surgically as well as in the entire
cohort. In the second study, Hachicha et al described 512 patients
with severe aortic stenosis and identified 181 patients with
low-flow output despite normal LV ejection fraction. Careful
analysis of this cohort demonstrated that this group has more
advanced disease with a higher level of left ventricular global
afterload as measured by valvulo-arterial impedance. These patients
were older, predominantly female, and had a worse prognosis.
Together, these 2 studies highlight the potential pitfalls in
simple calculation of aortic valve area and demonstrate that
a comprehensive clinical, hemodynamic, and laboratory assessment
of new and established tests and concepts needs to be incorporated
into our assessment of patients with aortic stenosis. See pp
2848 and 2856 (editorial p
2799).
Visit http://circ.ahajournals.org:
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Images in Cardiovascular Medicine
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Conservative Treatment of a Left Atrial Hematoma and a Localized
Tamponade Occurring During Treatment of Coronary Total Occlusion.
See p
e603.
Pacemaker Implantation in a Patient With Dextrocardia, Corrected Transposition, and Situs Inversus. See p e607.
Prominent Crypt Formation in the Inferoseptum of a Hypertrophic Cardiomyopathy Mutation Carrier Mimics Noncompaction Cardiomyopathy. See p e610.
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Correspondence
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See p
e612.
Related Articles:
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Women, Acute Ischemic Heart Disease, and Antithrombotic Therapy: Challenges and Opportunities
- Robert A. Harrington
Circulation 2007 115: 2796-2798.
[Full Text]
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Aortic Stenosis: Two Steps Forward, One Step Back
- Blase A. Carabello
Circulation 2007 115: 2799-2800.
[Full Text]
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Conservative Treatment of a Left Atrial Hematoma and a Localized Tamponade Occurring During Treatment of Coronary Total Occlusion
- Davide Tavano, Mauro Carlino, Matteo Pisani, and Antonio Colombo
Circulation 2007 115: e603-e606.
[Full Text]
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Pacemaker Implantation in a Patient With Dextrocardia, Corrected Transposition, and Situs Inversus
- Rajesh N. Subbiah, Lorne J. Gula, Raymond Yee, Allan C. Skanes, George J. Klein, and Andrew D. Krahn
Circulation 2007 115: e607-e609.
[Full Text]
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Prominent Crypt Formation in the Inferoseptum of a Hypertrophic Cardiomyopathy Mutation Carrier Mimics Noncompaction Cardiomyopathy
- Tjeerd Germans, Pieter A. Dijkmans, Arthur A.M. Wilde, Otto Kamp, and Albert C. van Rossum
Circulation 2007 115: e610-e611.
[Full Text]
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Letter by Grover et al Regarding Article, "Percutaneous Implantation of the CoreValve Self-Expanding Valve Prosthesis in High-Risk Patients With Aortic Valve Disease: The Siegburg First-in-Man Study"
- Frederick L. Grover, John E. Mayer, Jr, Nicholas Kouchoukos, Robert Guyton, Fred Edwards, and Joseph Bavaria
Circulation 2007 115: e612.
[Full Text]
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Clinical Reminders Attached to Echocardiography Reports of Patients With Reduced Left Ventricular Ejection Fraction Increase Use of ß-Blockers: A Randomized Trial
- Paul A. Heidenreich, Parisa Gholami, Anju Sahay, Barry Massie, and Mary K. Goldstein
Circulation 2007 115: 2829-2834.
[Abstract]
[Full Text]
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