Coronary heart disease: Significance of liver X receptor α genomics

Crosstalk between lipid peroxidation and inflammation is known to be a pathognomonic feature for the development of coronary heart disease (CHD). In this regard ligand activated liver X receptor (LXR)-α has emerged as a key molecular switch by its inherent ability to modulate an array of genes involved in these two fundamental cellular processes. In addition, LXR-α has also been found to play a role in hepatic lipogenesis and innate immunity. Although several lines of evidence in experimental model systems have established the atheroprotective nature of LXR-α, human subjects have been reported to possess a paradoxical situation in which increased blood cellular LXR-α gene expression is always accompanied by increased coronary occlusion. This apparent paradox was resolved recently by the finding that CHD patients possess a deregulated LXR-α transcriptome due to impaired ligand-receptor interaction. This blood cellular mutated LXR-α gene expression correlated specifically with the extent of coronary occlusion and hence need is felt to devise new synthetic ligands that could restore the function of this mutated LXR-α protein in order to modulate genes involved in reverse cholesterol transport and suppression of the inflammatory response leading to the effective treatment of CHD.

Alternatives to clopidogrel for acute coronary syndromes: Prasugrel or ticagrelor?

Clopidogrel is a mainstay in the treatment of patients with acute coronary syndromes or those receiving endovascular prostheses. However, its efficacy has been challenged in the recent past by studies suggesting variable individual responsiveness and by new, more potent competitors, such as prasugrel and ticagrelor. But what is the actual body of evidence in support of clopidogrel? Is there any dark side of the moon? What is the role of prasugrel, which has already been approved in Europe and in the United States? And what will be the future role of ticagrelor, when approved for routine clinical practice? We hereby concisely summarize the scope of this clinical choice, providing arguments in favor and against each of the three antiplatelet agents: clopidogrel, prasugrel, and ticagrelor.

Profound thrombocytopenia induced by clopidogrel with a prior history of long-term safe administration

Clopidogrel has shown an excellent safety, tolerability and efficacy ever since its marketing. However, here we report a rare case with profound thrombocytopenia following clopidogrel administration previously safely exposed to this same drug. This reminds us that thrombocytopenia might be induced by clopidogrel even with a prior, safe history of long-term administration.

Aortic stenosis: An update

Aortic stenosis (AS) is the most common valvular heart disease in the world. It is a disease of the elderly and as our population is getting older in both the developed and the developing world, there has been an increase in the prevalence of AS. It is impacting the mortality and morbidity of our elderly population. It is also causing a huge burden on the healthcare system. There has been tremendous progress in our understanding of AS in recent years. Lately, studies have shown that AS is not just a disease of the aortic valve but it affects the entire systemic vasculature. There are studies looking at more sophisticated measures of disease severity that might better predict the optimal timing of valve replacement. The improvement in our understanding in etiology and pathophysiology of the disease process has led to a number of trials with possible treatment options for AS. In this review, we talk about our understanding of the disease and latest developments in disease assessment and management. We look forward to a time when there will be medical treatment for AS.

Regulatory role of mitochondria in oxidative stress and atherosclerosis

Mitochondrial physiology and biogenesis play a crucial role in the initiation and progression of cardiovascular disease following oxidative stress-induced damage such as atherosclerosis (AST). Dysfunctional mitochondria caused by an increase in mitochondrial reactive oxygen species (ROS) production, accumulation of mitochondrial DNA damage, and respiratory chain deficiency induces death of endothelial/smooth muscle cells and favors plaque formation/rupture via the regulation of mitochondrial biogenesis-related genes such as peroxisome proliferator-activated receptor γ coactivator (PGC-1), although more detailed mechanisms still need further study. Based on the effect of healthy mitochondria produced by mitochondrial biogenesis on decreasing ROS-mediated cell death and the recent finding that the regulation of PGC-1 involves mitochondrial fusion-related protein (mitofusin), we thus infer the regulatory role of mitochondrial fusion/fission balance in AST pathophysiology. In this review, the first section discusses the possible association between AST-inducing factors and the molecular regulatory mechanisms of mitochondrial biogenesis and dynamics, and explains the role of mitochondria-dependent regulation in cell apoptosis during AST development. Furthermore, nitric oxide has the Janus-faced effect by protecting vascular damage caused by AST while being a reactive nitrogen species (RNS) which act together with ROS to damage cells. Therefore, in the second section we discuss mitochondrial ATP-sensitive K(+) channels, which regulate mitochondrial ion transport to maintain mitochondrial physiology, involved in the regulation of ROS/RNS production and their influence on AST/cardiovascular diseases (CVD). Through this review, we can further appreciate the multi-regulatory functions of the mitochondria involved in AST development. The understanding of these related mechanisms will benefit drug development in treating AST/CVD through targeted biofunctions of mitochondria.

Efficacy and safety of valsartan plus hydroclorothiazide for high blood pressure

AIM

To evaluate efficacy and tolerability of the combination valsartan plus hydrochlorothiazide (160 mg and 25 mg daily, respectively) in young-middle aged males with high-normal blood pressure (BP) or first-degree arterial hypertension with evidence of target organ damage.

METHODS

Twenty males with high-normal BP or first-degree hypertension associated with left ventricular concentric remodeling and/or increased aortic stiffness were enrolled. BP at rest and during exercise, and echocardiographic parameters of the left ventricle (LV), were evaluated at baseline and after 3 mo of treatment. The effects of treatment on aortic stiffness, metabolic parameters, renal and erectile function were also assessed.

RESULTS

BP was significantly reduced by treatment both at rest (P < 0.001) and during exercise (P < 0.001), and 85% of patients achieved BP normalization (< 130/85 mmHg). Doppler echocardiography showed a significant reduction of LV mass (P < 0.005). LV hypertrophy was identified in 70% of subjects at baseline and in 5% after 3 mo of treatment. The ratio of early (E) to late (A) trans-mitral diastolic flow velocity increased, (P < 0.05), the relative wall thickness decreased (P < 0.05) and the left ventricular relaxation time shortened (P < 0.005). The left atrial diameter (P < 0.05) and the aortic diameter (P < 0.05) and stiffness (P < 0.005) also decreased.

CONCLUSION

The full-dose combination of valsartan plus hydrochlorothiazide produced optimal BP control with regression of target organ damage, already after 3 mo, without relevant side effects.

Acoustic cardiography to improve detection of coronary artery disease with stress testing

AIM

To assess if performance of 12-lead exercise tolerance testing (ETT) can be improved by simultaneous acoustic cardiography and to compare the diagnostic performances of electrocardiography (ECG) during ETT and acoustic cardiography for detection or exclusion of angiographically proven coronary artery disease (CAD).

METHODS

We conducted an explorative study with retrospective data analysis using a convenience sample of consecutive patients (n = 59, mean age: 62 years) from an outpatient clinic in Switzerland, who were referred for ETT by their general practitioner on suspicion of CAD, and in whom, coronary angiography was carried out. Measurements included sensitivity, specificity, likelihood ratios and receiver operating characteristic curves. A standard, symptom-limited, 12-lead ECG exercise tolerance test was performed by independent persons with simultaneous acoustic cardiography and subsequent cardiac angiography for determination of significant CAD.

RESULTS

Thirty-four of the 59 adult subjects (58%) had a final diagnosis of CAD by angiography, and in 25 subjects, CAD was excluded by angiography. Sensitivity/specificity of ST segment depression in the group was 29%/92%, whereas the most powerful acoustic cardiographic parameter was the strength of the fourth heart sound (S4), with corresponding sensitivity/specificity of 53%/92%. The disjunctive combination of the S4 and ST depression had sensitivity/specificity of 68%/84%.

CONCLUSION

In this preliminary pilot study, the use of acoustic cardiography alone during ETT or disjunctively with ST depression has been shown to be a simple and convenient method for the detection of CAD, which was superior to ST depression on the standardized ECG.

Heart regeneration: Past, present and future

The heart has been considered a post-mitotic organ without regenerative capacity for most of the last century. We review the evidence that led to this hypothesis in the early 1900s and how it was progressively modified, culminating with the report that we renew 50% of our cardiomyocytes during our lifetime. The future of cardiac regenerative therapies is discussed, presenting the difficulties to overcome before repair of the diseased heart can come into clinical practice.

Heart failure in subjects with chronic kidney disease: Best management practices

Renal dysfunction is common in patients with heart failure (HF) and can complicate HF therapy. Treating patients with HF and kidney disease is difficult and requires careful assessment, monitoring and balancing of risk between potential benefits of treatment and adverse impact on renal function. In this review, we address the pathophysiological contexts and management options in this adversarial relation between the heart and the kidney, which exists in a substantial proportion of HF patients. Angiotensin converting enzyme inhibitors and β-blockers are associated with similar reductions in mortality in patients with and without renal insufficiency but usually are less often prescribed in patients with renal insufficiency. Careful monitoring of side effects and renal function should be done in all patients with renal insufficiency and prompt measures should be adopted to prevent further complications.

Percutaneous coronary intervention for acute myocardial infarction in a patient with dextrocardia

Situs inversus with dextrocardia is a rare congenital anomaly. There are limited published case reports of successful percutaneous coronary intervention (PCI) in these patients who have atherosclerotic coronary artery disease, especially when presenting with acute myocardial infarction. PCI is technically difficult because of mirror image dextrocardia. We hereby describe a 48-yr-old female, who had acute inferior wall myocardial infarction and underwent successful emergency primary coronary angioplasty and stenting of a proximally occluded right coronary artery. Technical details about PCI are discussed.

Percutaneous coronary intervention for unprotected left main coronary artery stenosis

Hemodynamically significant left main coronary artery stenosis (LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left circumflex artery has no previous patent grafts. Previous randomized studies have demonstrated a significant reduction in mortality when revascularization by coronary artery bypass graft (CABG) surgery was undertaken compared with medical treatment. Therefore, current practice guidelines do not recommend percutaneous coronary intervention (PCI) for such a lesion because of the proven benefit of surgery and high rates of restenosis with the use of bare metal stents. However, with the advent of drug-eluting stents (DES), the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable. Therefore, apart from the current guidelines, PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy. Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.

Impaired diastolic function in naïve untreated human immunodeficiency virus infected patients

AIM

To evaluate cardiac function and structure in untreated human immunodeficiency virus (HIV) patients without clinical evidence of cardiovascular disease.

METHODS

Fifty-three naïve untreated HIV-infected patients and 56 healthy control subjects underwent clinical assessment, electrocardiography (ECG) and echocardiography, including tissue doppler imaging. Moreover, a set of laboratory parameters was obtained from all subjects, including HIV-RNA plasma levels, CD4 cell counts and tumor necrosis factor-α levels.

RESULTS

The two groups showed normal ECG traces and no differences regarding systolic morphologic parameters. In contrast, a higher prevalence of left ventricular diastolic dysfunction (abnormal relaxation or pseudonormal filling pattern) was found in the HIV patients (36% vs 9% in patients and controls, respectively, P <0.001).

CONCLUSION

Subclinical cardiac abnormalities appear in an early stage of the HIV infection, independent of antiretroviral therapy. The data suggest that HIV per se plays a role in the genesis of diastolic dysfunction.

Cardiovascular and metabolic effects of Berberine

Berberine (BBR) is a natural alkaloid isolated from the Coptis Chinensis. While this plant has been used in Ayurvedic and Chinese medicine for more than 2500 years, interest in its effects in metabolic and cardiovascular disease has been growing in the Western world in the last decade. Many papers have been published in these years reporting beneficial effects in carbohydrate and lipid metabolism, endothelial function and the cardiovascular system. In this review, we report a detailed analysis of the scientific literature regarding this topic, describing the effects and the underlying mechanisms of BBR on carbohydrate and lipid metabolism, endothelial function and the cardiovascular system.

Assessment of neovascularization within carotid plaques in patients with ischemic stroke

AIM

To assess neovascularization within human carotid atherosclerotic soft plaques in patients with ischemic stroke.

METHODS

Eighty-one patients with ischemic stroke and 95 patients without stroke who had soft atherosclerotic plaques in the internal carotid artery were studied. The thickest soft plaque in each patient was examined using contrast-enhanced ultrasound. Time-intensity curves were collected from 5 s to 3 min after contrast injection. The neovascularization within the plaques in the internal carotid artery was evaluated using the ACQ software built into the scanner by 2 of the experienced investigators who were blinded to the clinical history of the patients.

RESULTS

Ischemic stroke was present in 7 of 33 patients (21%) with grade I plaque, in 14 of 51 patients (28%) with grade II plaque, in 26 of 43 patients (61%) with grade III plaque, and in 34 of 49 patients (69%) with grade IV plaque (P < 0.001 comparing grade IV plaque with grade I plaque and with grade II plaque and P = 0.001 comparing grade III plaque with grade I plaque and with grade II plaque). Analysis of the time intensity curves revealed that patients with ischemic stroke had a significantly higher intensity of enhancement (IE) than those without ischemic stroke (P < 0.01). The wash-in time (WT) of plaque was significantly shorter in stroke patients (P < 0.05). The sensitivity and specificity for IE in the plaque were 82% and 80%, respectively, and for WT were 68% and 74%, respectively. There was no significant difference in the peak intensity or time to peak between the 2 groups.

CONCLUSION

This study shows that the higher the grade of plaque enhancement, the higher the risk of ischemic stroke. The data suggest that the presence of neovascularization is a marker for unstable plaque.

Long term combination treatment for severe idiopathic pulmonary arterial hypertension

We report the long-term follow-up of 3 cases of severe idiopathic pulmonary arterial hypertension, in whom tadalafil plus sitaxentan combination therapy improved the clinical condition and exercise performance without any relevant adverse event.

Heart and HAART: Two sides of the coin for HIV-associated cardiology issues

The introduction of highly active antiretroviral therapy (HAART) has generated a contrast in the cardiac manifestations of acquired immunodeficiency syndrome. In developed countries, we have observed an approximately 30% reduction in the prevalence of human immunodeficiency virus (HIV)-associated cardiomyopathy, possibly related to a reduction of opportunistic infections and myocarditis. In developing countries, however, where the availablity of HAART is limited and the pathogenic impact of nutritional factors is significant, we have observed an approximately 32% increase in the prevalence of HIV-associated cardiomyopathy and a related high mortality rate from congestive heart failure. Also, some HAART regimens in developed countries, especially those including protease inhibitors, have been shown to cause, in a high proportion of HIV-infected patients, an iatrogenic metabolic syndrome (HIV-lipodystrophy syndrome) that is associated with an increased risk of cardiovascular events related to a process of accelerated atherosclerosis, even in young HIV-infected people. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving, HAART regimens, particularly for those with known underlying cardiovascular risk factors. A close collaboration between cardiologists and infectious disease specialists is needed for decisions regarding the use of antiretrovirals, for a careful stratification of cardiovascular risk factors, and for cardiovascular monitoring of HIV-infected patients receiving HAART, according the most recent clinical guidelines.

Antithrombotic management of patients on oral anticoagulation undergoing coronary artery stenting

Patients on oral anticoagulation (OAC), who are referred for coronary artery stenting account for about 5% of the whole population undergoing percutaneous coronary intervention (PCI). Although relatively small, this patient subset poses particular problems owing to the need to balance carefully the risk of bleeding against the risk of stent thrombosis and thromboembolism. Triple therapy (TT) of OAC, aspirin and clopidogrel appears as the most effective for prevention of stent thrombosis and thromboembolism. However, an increased incidence of major bleeding is to be expected during follow-up. Therefore, TT should be prolonged for as short a time as possible, and implantation of drug-eluting stents avoided. Frequent monitoring of international normalized ratio is also warranted, and the intensity of OAC should be targeted at the lower limit of the therapeutic range. Gastric protection should also be considered for all patients on medium- to long-term TT, owing to the observed highest incidence of bleeding at the gastrointestinal site. Peri-procedural management is cumbersome, and a substantial incidence of in-hospital major bleeding has been reported. Since this latter is more related to procedural variables than to TT itself, choice of radial access, avoidance of glycoprotein IIb/IIIa inhibitors, and preference for not interrupting effective OAC should be implemented. However, the evidence on which the recommendations for managing this patient subset are based is limited and of relative poor quality. While waiting for the results of ongoing, large prospective studies that are aimed at conclusively determining optimal medium- to long-term antithrombotic treatment, the official recommendations issued by the Working Group on Thrombosis of the European Society of Cardiology on the management of patients on OAC undergoing PCI with stenting should followed.

Need for new materials, biofunctionalization and non-surgical heart valve technology

Transition from non-surgical heart valve defects repair from bench to bedside is a reality. Some biological material-based designs for transcatheter aortic valve implantation are ready for use. Their drawback, however is their unknown functional as well as structural durability. Moreover, research on new non-biological materials is essential to replace classical animal-derived sources of human heart valve prostheses.

Advances in diastolic heart failure

More than 50% of people living with congestive heart failure have diastolic heart failure (DHF). Most of them are older than 70 years, and female. The prevalence of DHF has increased with time. DHF is caused by left ventricular (LV) diastolic dysfunction (DD) which is induced by diastolic dyssynchrony. Cardiac and extracardiac factors play important roles in the development of heart failure (HF) symptoms. The diagnosis of DHF is generally based on typical symptoms and signs of HF, preserved or normal LV ejection fraction, DD and no valvular abnormalities on examination, using noninvasive and invasive methodologies. The outcomes with pharmacological therapy in patients with DHF are frequently neutral in clinical trials, and prognosis still remains poor with a 5-year mortality of 42.3% after hospitalization for HF. Further trials are necessary.

Stopping the cardiovascular disease continuum: Focus on prevention

The cardiovascular disease continuum (CVDC) is a sequence of events, which begins from a host of cardiovascular risk factors that consists of diabetes mellitus, dyslipidemia, hypertension, smoking and visceral obesity. If it is not intervened with early, it inexorably progresses to atherosclerosis, coronary artery disease, myocardial infarction, left ventricular hypertrophy, and left ventricular dilatation, which lead to left ventricular diastolic or systolic dysfunction and eventually end-stage heart failure and death. Treatment intervention at any stage during its course will either arrest or delay its progress. In this editorial, the cardiovascular risk factors that initiate and perpetuate the CVDC are briefly discussed, with an emphasis on their early prevention or aggressive treatment.

Perfusionist strategies for blood conservation in pediatric cardiac surgery

There is increasing concern about the safety of homologous blood transfusion during cardiac surgery, and a restrictive transfusion practice is associated with improved outcome. Transfusion-free pediatric cardiac surgery is unrealistic for the vast majority of procedures in neonates or small infants; however, considerable progress has been made by using techniques that decrease the need for homologous blood products or even allow bloodless surgery in older infants and children. These techniques involve a decrease in prime volume by downsizing the bypass circuit with the help of vacuum-assisted venous drainage, microplegia, autologous blood predonation with or without infusion of recombinant (erythropoietin), cell salvaging, ultrafiltration and retrograde autologous priming. The three major techniques which are simple, safe, efficient, and cost-effective are: a prime volume as small as possible, cardioplegia with negligible hydric balance and circuit residual blood salvaged without any alteration. Furthermore, these three techniques can be used for all the patients, including emergencies and small babies. In every pediatric surgical unit, a strategy to decrease or avoid blood bank transfusion must be implemented. A strategy to minimize transfusion requirement requires a combined effort involving the entire surgical team with pre-, peri-, and postoperative planning and management.

Use of the impedance threshold device in cardiopulmonary resuscitation

Although approximately one million sudden cardiac deaths occur yearly in the US and Europe, cardiac arrest (CA) remains a clinical condition still characterized by a poor prognosis. In an effort to improve the cardiopulmonary resuscitation (CPR) technique, the 2005 American Heart Association (AHA) Guidelines for CPR gave the impedance threshold device (ITD) a Class IIa recommendation. The AHA recommendation means that there is strong evidence to demonstrate that ITD enhances circulation, improves hemodynamics and increases the likelihood of resuscitation in patients in CA. During standard CPR, venous blood return to the heart relies on the natural elastic recoil of the chest which creates a transient decrease in intrathoracic pressure. The ITD further decreases intrathoracic pressure by preventing respiratory gases from entering the lungs during the decompression phase of CPR. Thus, although ITD is placed into the respiratory circuit it works as a circulatory enhancer device that provides its therapeutic benefit with each chest decompression. The ease of use of this device, its ability to be incorporated into a mask and other airway devices, the absence of device-related adverse effects and few requirements in additional training, suggest that ITD may be a favorable new device for improving CPR efficiency. Since the literature is short of studies with clinically meaningful outcomes such as neurological outcome and long term survival, further evidence is still needed.

Current advances in the understanding of coronary vasospasm

Recent years have witnessed progress in our understanding of coronary vasospasm (CVS). It is evident that this is not only an East Asian but also a global disease associated with significant symptoms and possible lethal sequelae for afflicted individuals. A correct diagnosis depends on the understanding of pathogenesis and symptomatology of CVS. With the correct diagnosis, we can manage CVS patients effectively and promptly, providing optimal patient safety. Advances in our understanding of interactions between inflammation, endothelium, and smooth muscle cells have led to substantial progress in understanding the pathogenesis of symptoms in CVS and have provided some insights into the basic etiology of this disorder in some patient subpopulations. We look forward to a time when therapy will address pathophysiology and perhaps, even the primary etiology.

Renal impairment and heart failure with preserved ejection fraction early post-myocardial infarction

AIM

To study if impaired renal function is associated with increased risk of peri-infarct heart failure (HF) in patients with preserved ejection fraction (EF).

METHODS

Patients with occluded infarct-related arteries (IRAs) between 1 to 28 d after myocardial infarction (MI) were grouped into chronic kidney disease (CKD) stages based on estimated glomerular filtration rate (eGFR). Rates of early post-MI HF were compared among eGFR groups. Logistic regression was used to explore independent predictors of HF.

RESULTS

Reduced eGFR was present in 71.1% of 2160 patients, with significant renal impairment (eGFR < 60 mL/min every 1.73 m(2)) in 14.8%. The prevalence of HF was higher with worsening renal function: 15.5%, 17.8% and 29.4% in patients with CKD stages 1, 2 and 3 or 4, respectively (P < 0.0001), despite a small absolute difference in mean EF across eGFR groups: 48.2 ± 10.0, 47.9 ± 11.3 and 46.2 ± 12.1, respectively (P = 0.02). The prevalence of HF was again higher with worsening renal function among patients with preserved EF: 10.1%, 13.6% and 23.6% (P < 0.0001), but this relationship was not significant among patients with depressed EF: 27.1%, 26.2% and 37.9% (P = 0.071). Moreover, eGFR was an independent correlate of HF in patients with preserved EF (P = 0.003) but not in patients with depressed EF (P = 0.181).

CONCLUSION

A significant proportion of post-MI patients with occluded IRAs have impaired renal function. Impaired renal function was associated with an increased rate of early post-MI HF, the association being strongest in patients with preserved EF. These findings have implications for management of peri-infarct HF.

Congenital solitary coronary artery fistulas characterized by their drainage sites

Last centuries have witnessed tremendous sophistication and progress in the detection, diagnosis and treatment of coronary artery fistulas (CAFs). In many countries, CAFs were reported to be visualized and treated using several imaging techniques and different management strategies. Reports from nearly all continents of the globe have contributed to the description of CAFs, not only in Asia and Europe but also throughout North and Latin America. However, these reports have to be cautiously analyzed as many of them were published as a case report and careful interpretation is warranted due to possible publication bias. A literature search was performed using PubMed search interface to select papers dealing with congenital CAFs in adult population between 2000-2009. A total of 233 subjects were collected, and analysed according to their drainage site and treatment modality. They were divided into two subgroups: percutaneous transluminal embolization group (PTE group, n = 122) and surgical ligation group (SL group, n = 111). In the SL group, atherosclerotic coronary artery disease (19%) and associated congenital lesions (23%) were more prevalent compared with the PTE group (9% and 8%), respectively. Infective endocarditis was more frequently seen in the SL group besides syncope, congestive heart failure and hemopericardium. In both groups multimodality diagnostic workup composed of several non-invasive and invasive imaging techniques for fistula visualization were performed and drainage sites into the different cardiac chambers and intrathoracic great vessels were similarly distributed in the two groups.

Speckle tracking echocardiography: A new approach to myocardial function

Echocardiography is the most common diagnostic method for assessing cardiac function but some limitations affect this technique. Until now, visual assessment of wall motion and thickening has allowed only a subjective evaluation of myocardial function and requires long-term training. Recently, new echocardiographic techniques have been introduced to evaluate myocardial mechanics. Tissue Doppler imaging (TDI) technique is limited by angle-dependency such that only deformation along the ultrasound beam can be derived from velocities, while myocardium deforms simultaneously in three dimensions. Speckle tracking echocardiography (STE) is a more recent technique that provides a global approach to left ventricular myocardial mechanics, giving information about the three spatial dimensions of cardiac deformation. In this editorial, we describe the physical and pathophysiological concepts of STE, discussing the differences compared to TDI and underlining the pitfalls of this new technique.

What is the purpose of launching World Journal of Cardiology?

The first issue of World Journal of Cardiology (WJC), whose preparatory work was initiated on December 13, 2009, will be published on December 31, 2009. The WJC Editorial Board has now been established and consists of 298 distinguished experts from 40 countries. Our purpose of launching WJC is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Prostate-specific antigen kallikrein and the heart

Currently, there is growing interest regarding prostate-specific antigen (PSA) and the cardiovascular system. Increased PSA serum levels have been reported after prolonged cardiopulmonary resuscitation, cardiac surgery, extracorporeal cardiopulmonary bypass, acute myocardial infarction (AMI) and coronary artery stenting. The possible role of PSA in cardiac events has been questioned due to the finding of PSA decrease during AMI and by the correlation of variation in PSA levels with coronary lesions and occurrence of major adverse cardiac events. Complexed PSA forms and uncomplexed PSA forms are observed in the bloodstream but the increasing formation of irreversible bound PSA seems to be a crucial finding during AMI. Large studies need to be carried out to confirm these preliminary results and to elucidate unclear aspects. These findings present many potential directions for future research including the role of uncomplexed forms of PSA, the possible distribution of PSA in the heart, the relative expression levels in heart disease states, the mode of expression regulation and other potential specific substrates. The journey of PSA investigation could be longer than initially expected.

Key questions resulting from the JUPITER trial assessing cardiovascular disease intervention with rosuvastatin

THIS PAPER PRESENTS AN ANALYSIS OF THE RECENTLY PUBLISHED JUSTIFICATION FOR THE USE OF STATINS IN PREVENTION (JUPITER: an intervention trial evaluating rosuvastatin) trial, which tested the statin rosuvastatin in apparently healthy individuals with no prior cardiovascular (CVD) disease and with normal plasma low density lipoprotein (LDL) cholesterol concentrations but with raised plasma high sensitivity C-reactive protein (hsCRP) levels. The rate of the combined primary CVD endpoint was significantly reduced in the treatment arm after a median of under 2 years. The JUPITER trial is distinct from previous studies examining statin use in primary prevention groups because the target group for drug therapy was apparently healthy men and women at low or intermediate risk for developing CVD. On the basis of JUPITER's findings, there are key questions that should be assessed on the therapeutic intervention of CVD regarding: the primary prevention groups that should be targeted for statin therapy, the utility of targets in addition to plasma LDL cholesterol levels, and the need to consider the metabolic state of individuals targeted for therapy (including the presence of obesity and inflammation). The conclusion from the current analysis is that the JUPITER results warrant further LDL cholesterol lowering than is currently targeted in primary prevention groups that have a pre-existing condition or lifestyle that elevates CVD risk but still do not have a high global CVD risk (as assessed with current algorithms). This group is not captured in current widely used CVD risk calculations, however, with the identification of useful biomarkers, such as hsCRP, this group can be better identified and targeted for intervention.

Cardiovascular disease: A global problem extending into the developing world

This article reviews the current status of cardiovascular disease (CVD) on the international scale. Presently viewed as an epidemic that has migrated from westernized societies to developing countries, several important issues are elaborated upon. They include the basis for the increasing prevalence of CVD and the associated societal implications. The challenges related to lack of resources and infrastructure support may also impede successful implementation of proven strategies to reduce CVD. In addition to traditional risk factors such as cigarette smoking, hypertension, obesity, hyperlipidemia, diabetes mellitus and insulin resistance, many developing countries must also contend with other risk biomarkers. Included in this grouping are human immunodeficiency virus/acquired immunodeficiency syndrome and other infectious/inflammatory processes as well as nutritional and vitamin deficiencies that make preventive measures more difficult to prioritize. Taken together, greater partnering between local governments, affiliated hospitals and international societies is needed to enhance and facilitate efforts aimed at optimizing standard of care measures in developing countries in order to reduce cardiovascular risk.

Present concepts in management of atrial fibrillation: From drug therapy to ablation

Atrial fibrillation (AF) management requires knowledge of its pattern of presentation, underlying conditions, and decisions about restoration and maintenance of sinus rhythm, control of the ventricular rate, and anti-thrombotic therapy. Maintenance of sinus rhythm is a desirable goal in AF patients because the prevention of recurrence may improve cardiac function, relieve symptoms and reduce the likelihood of adverse events. Anti-arrhythmic drug therapy is the first-line treatment for patients with paroxysmal and persistent AF based on current guidelines. However, currently used drugs have limited efficacy and cause cardiac and extracardiac toxicity. Thus, there is a continued need to develop new drugs, device and ablative approaches to rhythm management. Additionally, simpler and safer stroke prevention regimens are needed for AF patients on life-long anticoagulation, including occlusion of the left atrial appendage. The results of the Randomized Evaluation of Long-Term Anticoagulant Therapy study are encouraging in these settings. Knowledge on the pathophysiology of AF is rapidly expanding and identification of focally localized triggers has led to the development of new treatment options for this arrhythmia. Conversely, the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate. In the minority of patients in whom AF cannot be adequately managed by pharmacological therapy, the most appropriate type of non-pharmacological therapy must be selected on an individualized basis. Curative treatment of AF with catheter ablation is now a legitimate option for a large number of patients. The evolution of hybrid therapy, in which two or more different strategies are employed in the same patient, may be an effective approach to management of AF. In any case, planning a treatment regimen for AF should include evaluation of the risks inherent in the use of various drugs as well as more invasive strategies.

Serum oxidizability potential of ischemic heart disease patients is associated with exercise test results and disease severity

AIM

To find out whether serum oxidizability potential correlates with exercise test (EXT) parameters and predicts their results in chronic ischemic heart disease (IHD) patients.

METHODS

Oxidizability potential was determined in a group of chronic IHD patients who underwent a symptom limited EXT upon initiation of a cardiac rehabilitation program. The thermo-chemiluminescence (TCL) assay was used to assess serum oxidizability potential. This assay is based on heat-induced oxidation of serum, leading to the formation of electronically excited species in the form of unstable carbonyls, which further decompose into stable carbonyls and light energy (low chemiluminescence). Measured photons emission is represented by a kinetic curve which is described by its amplitude and slope (= ratio). We assessed the correlations of TCL ratio with exercise duration, metabolic equivalents (METS), maximal heart rate (mHR), maximal systolic BP, > 1 mm S-T depression, diabetes, hypertension, smoking, left ventricular ejection fraction (LVEF) > or < 40%, previous myocardial infarction, and aorto-coronary by-pass surgery and compared to the TCL ratio measured in a group of healthy controls.

RESULTS

A high TCL ratio (%) correlated well with METS (r = 0.84), with mHR (r = 0.79) and with exercise induced S-T segment shift (r = 0.87, P < 0.05). A lower serum oxidizability potential, expressed as a low TCL ratio, thus suggestive of a previous high oxidative stress, was found in IHD patients compared to healthy controls, and, in particular, in patients with low LVEF%. The TCL ratio (%) in IHD patients was 193 ± 21, compared to 215 ± 13 in controls (P < 0.05), and was 188 ± 14.7 in patients with LVEF < 40% as compared to 200 ± 11.9 in those with LVEF > 40% (P < 0.01). A trend for lower TCL ratio (%) was found in diabetic, hypertensive, and post-coronary bypass surgery patients. A paradoxically low TCL ratio (low oxidizability potential) was observed in patients without S-T depression compared to patients with S-T depression (189 ± 22 vs 201 ± 15, P = NS), due to the fact these patients had a much lower LVEF% and a lower exercise capacity.

CONCLUSION

Serum oxidizability potential is associated with EXT parameters, results, and IHD severity. TCL ratio is an "easy-to-measure marker" that might be incorporated into risk assessment and prediction in chronic IHD patients.

Atherosclerosis, inflammation and Chlamydia pneumoniae

Coronary heart disease is the single most common cause of illness and death in the developed world. Coronary atherosclerosis is by far the most frequent cause of ischemic heart disease, and plaque disruption with superimposed thrombosis is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death. Atherosclerosis is the result of a complex interaction between blood elements, disturbed flow, and vessel wall abnormality, involving several pathological processes: inflammation, with increased endothelial permeability, endothelial activation, and monocyte recruitment; growth, with smooth muscle cell proliferation, migration, and matrix synthesis; degeneration, with lipid accumulation; necrosis, possibly related to the cytotoxic effect of oxidized lipid; calcification/ossification, which may represent an active rather than a dystrophic process; and thrombosis, with platelet recruitment and fibrin formation. In this review we discuss these processes and the possible pathological effects of Chlamydia infection and the ensuing phlogosis.

Oxidative status and cardiovascular risk in women: Keeping pink at heart

Although cardiovascular disease (CVD) has always been perceived as a pathology regarding essentially males, incidence and death from cardiovascular events dramatically increase after menopause in women. Obviously, while many aspects of CVD are similar in both sexes, it is now clear that there are significant differences as well. Exploration of these gender-related differences in CVD might provide a basis for the development of new strategies in the management of patients with CVD from a gender point of view. In particular, a growing amount of data suggested the possible major role of oxidative stress in female patients and the possibility to integrate this new biomarker in future study evaluating CVD risk in women.