Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Effect of Repetitive Intra-Arterial Infusion of Bone Marrow Mononuclear Cells in Patients With No-Option Limb Ischemia: The Randomized, Double-Blind, Placebo-Controlled Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) Trial
- Systematic Review of Patients Presenting With Suspected Myocardial Infarction and Nonobstructive Coronary Arteries
- Rapid and Body Weight–Independent Improvement of Endothelial and High-Density Lipoprotein Function After Roux-en-Y Gastric Bypass: Role of Glucagon-Like Peptide-1
- Racial Disparities in Outcomes of Adult Heart Transplantation
- Predicting Graft Loss by 1 Year in Pediatric Heart Transplantation Candidates: An Analysis of the Pediatric Heart Transplant Study Database
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Effect of Repetitive Intra-Arterial Infusion of Bone Marrow Mononuclear Cells in Patients With No-Option Limb Ischemia: The Randomized, Double-Blind, Placebo-Controlled Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) Trial
The results of our double-blind, placebo-controlled, randomized Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) trial show no benefit of repetitive intra-arterial infusion of autologous bone marrow–derived mononuclear cells over placebo on prespecified clinical outcomes (eg, major amputation, quality of life, wound healing) in patients with severe, nonrevascularizable peripheral artery disease. The lack of benefit of autologous bone marrow–derived mononuclear cells in our study does not exclude the potential benefit of alternative cell sources or subpopulations, different administration locations and routes, or that in patients with milder disease. Further study is warranted to investigate whether cell therapy strategies with selected cell populations, enhanced bone marrow cell function, or different modes of administration can provide therapeutic benefit in patients with advanced peripheral artery disease. The general improvement in clinical outcomes observed in both the placebo- and bone marrow–derived mononuclear cell–treated groups during follow-up stresses the need for future randomized clinical trials to implement a rigorous double-blinded, placebo-controlled design. See p 851.
Systematic Review of Patients Presenting With Suspected Myocardial Infarction and Nonobstructive Coronary Arteries
This article systematically summarizes the published literature concerning patients with myocardial infarction with nonobstructive coronary arteries. These patients account for 6% of all those experiencing an acute myocardial infarct. Although they have a similar prevalence for many risk factors to those with myocardial infarction associated with obstructive coronary artery disease, in comparison they tend to be younger, more often female, and less likely to have hyperlipidemia. Moreover, although their prognosis is better than those with obstructive coronary artery disease, it remains guarded with an all-cause mortality of 4.7% (95% confidence interval, 2.6%–6.9%) at 12 months. The key clinical practice implication from this study is that myocardial infarction with nonobstructive coronary arteries should be considered as a working diagnosis that necessitates further investigation for an underlying cause (ie, similar to that required for a heart failure diagnosis). Important causes include myocarditis, Tako-tsubo cardiomyopathy, vasospastic angina, and hereditary thrombophilia disorders, all of which require different management strategies. Cardiac magnetic resonance imaging is a useful initial investigation to delineate some of these causes. Assessment for coronary artery spasm and thrombophilia disorders should also be considered. The importance of identifying these causes resides with the potential to use effective therapies that otherwise may not have been considered and that may impact on prognosis (eg, calcium channel blockers for coronary spasm). Accordingly, there is the potential to reduce the guarded prognosis in these patients. See p 861.
Rapid and Body Weight–Independent Improvement of Endothelial and High-Density Lipoprotein Function After Roux-en-Y Gastric Bypass: Role of Glucagon-Like Peptide-1
Obesity is a public health priority because of the associated increase in morbidity and cardiovascular mortality. Currently, the most effective treatment for severe obesity is bariatric surgery, which induces sustained weight loss and is associated with a long-term reduction in obesity-associated comorbidity and cardiovascular mortality. The current understanding of the mechanisms underlying these beneficial effects suggests that a crucial role is played by the unique metabolic and hormonal changes after bariatric surgeries, in particular Roux-en-Y gastric bypass or vertical sleeve gastrectomy, rather than simply as the consequence of weight loss. The gut hormone glucagon-like peptide-1 (GLP-1), which increases rapidly after certain bariatric surgeries such as Roux en-Y gastric bypass and sleeve gastrectomy, but not after dietary restriction, seems to specifically mediate some metabolic benefits of bariatric surgery. In the present study, which uses a rat model of Roux-en-Y gastric bypass, higher plasma levels of GLP-1 were associated with increased aortic nitric oxide bioavailability, improved endothelium-dependent relaxation, and normalized endothelium-protective properties of high-density lipoprotein independently of weight loss. Furthermore, in morbidly obese patients, increased plasma levels of GLP-1 after Roux-en-Y gastric bypass were associated with a rapid improvement in the endothelium-protective properties of high-density lipoprotein, confirming the clinical relevance of the experimental animal findings. Thus, Roux-en-Y gastric bypass exerts rapid endothelium-protective effects beyond the surgery-induced weight loss. These effects are mediated, at least in part, by GLP-1 and GLP-1 receptor signaling. These findings may allow the identification of novel and less invasive treatment strategies targeting molecular cardiovascular and metabolic pathways affected by obesity. See p 871.
Racial Disparities in Outcomes of Adult Heart Transplantation
In this analysis of >18 000 heart transplant patients over a 10-year period in the United States, we demonstrate that black recipients are at increased risk of posttransplant mortality, a finding that applies to both poor-performing and excellent-performing transplant centers. A higher proportion of blacks were transplanted at centers with higher-than-expected mortality. In multivariable analysis, there was no clear dominant source for the increased risk-adjusted mortality observed in blacks. Although blacks have a propensity to be transplanted at worse performing centers, center effect alone does not explain the mortality difference between ethnicities, and referral of minorities to better performing centers would not likely eliminate these racial disparities in outcomes. See p 882.
Predicting Graft Loss by 1 Year in Pediatric Heart Transplantation Candidates: An Analysis of the Pediatric Heart Transplant Study Database
This is the most detailed study of risk factors for graft loss in pediatric heart transplantation patients published; it uses data from the Pediatric Heart Transplant Study. Previous studies of risk factors in pediatric patients have consistently demonstrated that the cause of heart disease is a risk factor for poor outcome, but none have attempted to evaluate and compare risk factors for transplantation outcome within individual disease pathogeneses. Unlike all previous studies of pediatric risk factors, before analysis, the data were stratified into 2 cohorts: congenital heart disease and myopathies. By doing this, disease-specific risk factors were determined that were previously unappreciated. Furthermore, it was discovered that risk factors differ significantly between disease groups. These new risk factors allowed disease-specific multivariable models that will aid in pediatric pre–heart transplantation risk stratification and which could assist with improved assessment of center performance. See p 890.
- © 2015 American Heart Association, Inc.
- Racial Disparities in Outcomes of Adult Heart Transplantation
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