Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Colchicine Reduces Postoperative Atrial Fibrillation: Results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) Atrial Fibrillation Substudy
- Controlling for High-Density Lipoprotein Cholesterol Does Not Affect the Magnitude of the Relationship Between Alcohol and Coronary Heart Disease
- High-Molecular-Weight and Total Adiponectin Levels and Incident Symptomatic Peripheral Artery Disease in Women: A Prospective Investigation
- Average Daily Blood Pressure, Not Office Blood Pressure, Is Associated With Progression of Cerebrovascular Disease and Cognitive Decline in Older People
- Long-Term Effects of Percutaneous Coronary Intervention of the Totally Occluded Infarct-Related Artery in the Subacute Phase After Myocardial Infarction
- Outcomes After In-Hospital Cardiac Arrest in Children With Cardiac Disease: A Report From Get With the Guidelines–Resuscitation
- Long-Term Dipeptidyl-Peptidase 4 Inhibition Reduces Atherosclerosis and Inflammation via Effects on Monocyte Recruitment and Chemotaxis
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Colchicine Reduces Postoperative Atrial Fibrillation: Results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) Atrial Fibrillation Substudy
Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery; it is reported in 10% to 65% of cases. POAF increases patient morbidity, length of hospital stay, and management costs. Its prevention is an important management goal. Systemic and local inflammatory responses are believed to contribute to the pathogenesis of POAF. Inflammation, inhomogeneity of atrial conduction, and the incidence of POAF are decreased by corticosteroids. Because of its antiinflammatory effects for the treatment and prevention of pericarditis, colchicine has the potentiality to prevent POAF. The Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) POAF substudy is the first trial designed to assess the efficacy and safety of colchicine for POAF prevention. It is a substudy of the COPPS trial, in which colchicine halved the occurrence of the postpericardiotomy syndrome. On the third postoperative day, consecutive adult patients undergoing cardiac surgery and without contraindications to colchicine were randomized to receive placebo or colchicine on top of standard therapy. The substudy primary efficacy end point was the incidence of POAF on placebo/colchicine treatment at 1 month. Patients on colchicine had a reduced incidence of POAF (12.0% versus 22.0%, respectively; P=0.021; relative risk reduction, 45%; number needed to treat, 11) with a shorter in-hospital stay (9.4±3.7 versus 10.3±4.3 days; P=0.040) and rehabilitation stay (12.1±6.1 versus 13.9±6.5 days; P=0.009). Side effects were similar in the study groups. Such findings may be particularly important for clinical practice because colchicine might represent a cheap and relatively safe option for the prevention of both the postpericardiotomy syndrome and POAF, 2 common and troublesome complications of cardiac surgery. See p 2290.
Controlling for High-Density Lipoprotein Cholesterol Does Not Affect the Magnitude of the Relationship Between Alcohol and Coronary Heart Disease
Moderate intake of alcohol has been shown in many studies worldwide to reduce the risk of coronary heart disease by 20% to 40%. In the present cohort study from Norway, a country with a relatively low average consumption of alcohol, the same protective effect was found. It has previously been suggested that alcohol's protective effect may be due to the effect it has in increasing the HDL-C level. Our main finding is that alcohol does not seem to reduce the risk through changes in HDL-C levels. This finding, if confirmed, together with other studies of the effects of changes in HDL-C level on the risk of cardiovascular risk, may have future implications on the intensity with which serum lipids are managed in clinical practice. See p 2296.
High-Molecular-Weight and Total Adiponectin Levels and Incident Symptomatic Peripheral Artery Disease in Women: A Prospective Investigation
Lower-extremity peripheral artery disease (PAD) is a manifestation of atherosclerosis that has received considerably less clinical and research attention than coronary or cerebrovascular disease. PAD shares many risk factors with other cardiovascular diseases, including smoking, diabetes mellitus, hypertension, and hyperlipidemia; however, less is known about how PAD differs from atherosclerosis of other vascular territories. Studies of biomarkers and future disease risk can improve our ability to detect patients at heightened risk and our understanding of disease pathogenesis and, by extension, may identify potential novel modalities for treatment. Adiponectin is secreted from adipose tissue and is known to be inversely correlated with future diabetes mellitus risk. It may also be antiatherogenic. This study is the first to examine the relationship between adiponectin and PAD as a specific vascular end point. A large population of initially healthy women aged ≥45 years without existing cardiovascular disease was studied. After traditional cardiovascular risk factors were taken into account, women with high-molecular-weight or total adiponectin levels in the highest tertile had a 59% (high-molecular-weight) or 63% (total) reduced risk for future symptomatic PAD (intermittent claudication or lower-extremity revascularization) compared with women with levels in the lowest tertile. Given the lack of a consistently demonstrated relationship between adiponectin and other cardiovascular end points, this striking result, if confirmed, suggests a unique relationship of adiponectin in PAD development that may reflect a more prominent role of adipokines in peripheral atherosclerosis. See p 2303.
Average Daily Blood Pressure, Not Office Blood Pressure, Is Associated With Progression of Cerebrovascular Disease and Cognitive Decline in Older People
High blood pressure (BP) is a risk factor for cerebrovascular disease, including stroke. Little is known about the importance of BP on the progression of microvascular disease of the brain, which has been associated with functional decline in mobility and cognition in older people. In this prospective cohort study of older people averaging 82 years of age, relations among clinic and ambulatory BP, white matter hyperintensity volume, and functional status were determined over 2 years. Changes in the 24-hour ambulatory systolic BP, but not clinic systolic BP, were associated with the amount of white matter hyperintensity volume accrued at the 24-month follow-up and the progression of white matter hyperintensity volume from baseline, as well as measures of executive function/processing speed. Higher levels of 24-hour systolic BP were associated with white matter hyperintensity volume and mobility measures at 2 years; no such relation was seen with clinic systolic BP. Hence, these data demonstrate the importance of 24-hour systolic BP in the progression of brain white matter hyperintensity volume burden associated with impairment of function in older people. The 24-hour systolic BP may be a potential target for intervention in the elderly to reduce vascular disease of the brain and impairment of function. See p 2312.
Long-Term Effects of Percutaneous Coronary Intervention of the Totally Occluded Infarct-Related Artery in the Subacute Phase After Myocardial Infarction
A substantial proportion of patients with myocardial infarction do not receive early reperfusion, for example, because of late presentation. Persistent total occlusion of the infarct-related artery is a marker of subsequent risk. Despite observational data suggesting a benefit for late opening of occluded infarct-related arteries after myocardial infarction, the Occluded Artery Trial (OAT) demonstrated no reduction in the composite of death, reinfarction, and class IV heart failure over an ≈3-year mean follow-up. OAT randomized 2201 stable patients with total infarct-related artery occlusion >24 hours (calendar days 3–28) after myocardial infarction. Patients with severe inducible ischemia, rest angina, class III to IV heart failure, and 3-vessel/left main disease were excluded. Follow-up was extended to determine whether late trends would favor either treatment group for the primary end point and angina (6-year median survivor follow-up; longest, 9 years). Rates of the primary end point, reinfarction, death, and class IV heart failure were similar for the percutaneous coronary intervention and medical therapy only groups. No interaction between baseline characteristics and treatment group on outcomes was observed, including for those at highest risk. The vast majority of patients at each follow-up visit did not report angina. There was less angina in the PCI group through early follow-up; by 3 years, the between-group difference was <4 per 100 and did not reach statistical significance. Additional follow-up of the OAT cohort with >12 000 total patient-years provides robust evidence for no long-term reduction in clinical events with a strategy of routine percutaneous coronary intervention of the totally occluded infarct-related artery in clinically stable patients in the subacute phase after myocardial infarction. See p 2320.
Outcomes After In-Hospital Cardiac Arrest in Children With Cardiac Disease: A Report From Get With the Guidelines–Resuscitation
Survival after cardiac arrest is poor; however, small case series have suggested that children with cardiac disease who experience a cardiac arrest have better outcomes. Our study of 3323 pediatric patients using Get With the Guidelines–Resuscitation found that survival to hospital discharge was 37% in children with surgical cardiac disease compared with 28% in children with medical cardiac disease and 23% in children without cardiac disease. Although multiple previous studies have examined survival after cardiac arrest in the pediatric patients, children undergoing cardiac surgery are a unique population, and their survival after arrest has not been well studied. Children after cardiac surgery have a much higher risk of cardiac arrest compared with other pediatric populations, so this improved survival is encouraging for the providers who care for them. Notable is the higher odds of survival with the use of extracorporeal cardiopulmonary resuscitation, and this report adds to previous studies that have found extracorporeal cardiopulmonary resuscitation to be an effective rescue therapy. This study will be useful for medical providers when evaluating a patient's prognosis and provides information for researchers wanting to study this unique group of patients. See p 2329.
Long-Term Dipeptidyl-Peptidase 4 Inhibition Reduces Atherosclerosis and Inflammation via Effects on Monocyte Recruitment and Chemotaxis
The incretin hormones glucagon-like peptide and glucose-dependent insulotropic polypeptide play a key role in the regulation of postprandial glycemia and satiety. Incretin hormones are inactivated by the exopeptidase dipeptidyl-peptidase 4 (DPP-4). Both small-molecule inhibitors of DPP-4 and DPP-4–resistant incretin analogs are increasingly common treatments for type II diabetes mellitus, although their effects in reducing long-term cardiovascular complications remain to be established. An expanding list of potential beneficial effects of DPP-4 inhibition on the cardiovascular system includes glucagon-like peptide–mediated effects on cardioprotective pathways, nitric oxide–dependent vasodilation, and non–glucagon-like peptide effects that relate to a pathophysiological role for DPP-4 in regulating inflammation. In this study, we investigated the net effects of long-term DPP-4 inhibition with alogliptin in a model of atherosclerosis and insulin resistance. DPP-4 activity was increased in atherosclerosis with a reduction in response to treatment. DPP-4 inhibition improved insulin resistance, blood pressure, and visceral adiposity with reductions in atherosclerosis and inflammation (evidenced by a reduction in plaque and adipose inflammatory macrophage content) and a shift to an alternately activated macrophage phenotype. DPP-4 inhibition prevented monocyte migration and actin polymerization in vitro via Rac-dependent mechanisms and prevented in vivo migration of labeled monocytes to the aorta in response to exogenously administered tumor necrosis factor-α and DPP-4. These data support a net effect of DPP-4 inhibition in reducing adipose and vascular inflammation with a concomitant reduction in atherosclerosis and support a therapeutic role for these agents in preventing cardiovascular complications in type II diabetes mellitus. See p 2338.
- © 2011 American Heart Association, Inc.
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