News & Views in 2013

Intensive antithrombotic therapies reduce ischaemic complications of percutaneous coronary intervention for ST-segment elevation myocardial infarction, but at a cost of increased bleeding. Bivalirudin consistently reduces haemorrhagic risk, even with potent new oral antiplatelet drugs and contemporary interventional practice. The benefit of bivalirudin must, however, be balanced against increased risk of early subacute stent thrombosis.

Controversy surrounds the use of polypills in the primary prevention of cardiovascular disease, particularly in relation to which individuals should be targeted for treatment. Coronary artery calcium imaging has been presented as being of potential benefit in excluding those who are least likely to benefit from such treatment.

In the POST trial, mechanical ischaemic postconditioning did not have a significant cardioprotective effect in patients with ST-segment elevation myocardial infarction. However, the sample size, the principal end point (ST-segment regression), and the postconditioning protocol used are important limitations in this trial. Whether mechanical postconditioning has cardioprotective clinical benefits remains unanswered.

The effect of a fixed-dose combination drug strategy ('polypill') on patients' adherence to medication was analysed in a series of 2,004 individuals with, or at high risk of, cardiovascular disease in the UMPIRE study. The polypill improved adherence by >20%, but the reduction in blood-pressure and cholesterol levels was modest.

A case–control study of five classes of antihypertensive medication used among 2,851 women shows that taking calcium-channel blockers for ≥10 years is associated with increased risk of invasive ductal and lobular breast carcinoma. These results are intriguing, but warrant additional investigation given the study limitations and inconsistent findings in the literature.

Remote ischaemic conditioning has been extensively studied, and encouraging proof-of-concept clinical trial data have emerged. A study newly published in The Lancet takes the field an important step forward, demonstrating for the first time that remote ischaemic conditioning before CABG surgery reduces all-cause mortality.

PCSK9 antibodies effectively lower the LDL-cholesterol level and, therefore, address an unmet clinical need in patients with either refractory hypercholesterolaemia, statin intolerance, or an elevated lipoprotein(a) level. On the basis of ongoing clinical outcome trials, these agents might reset the target LDL-cholesterol level to <50 mg/dl.

Prosthetic valve endocarditis (PVE) is a devastating disease, and guidelines currently recommend early surgery in patients with PVE and associated complications. However, a study from the International Collaboration on Endocarditis suggests that, after correcting for treatment selection bias and survivor bias, early surgery might not be beneficial.

Debate surrounds the best method of treating patent foramen ovale (PFO). Randomized trials suggest that catheter-based closure of PFO is beneficial for secondary stroke prevention; however, with multiple devices available, which performs best in a head-to-head trial? A paper published in the European Heart Journal might have the answer.

Ischaemic heart disease (IHD) causes a large number of deaths in the European Union, but a new study reveals important inequalities in IHD mortality between countries. Surveillance systems might help to identify these differences and define tailored treatment strategies, so that the burden of IHD can be reduced across Europe.

The selection of end points for clinical trials of heart failure is challenging, with important implications for patients, the medical community, and regulatory agencies. The standards used in clinical research on patients with heart failure influence the effectiveness and value of future clinical trials, and the extent to which they can be translated into clinical practice.

In a study conducted in selected US hospitals, bypassing the emergency department with direct transport to the cardiac catheterization laboratory resulted in a reduced time to reperfusion for patients with ST-segment elevation myocardial infarction. However, this strategy was used infrequently—mostly during working hours—and varied significantly between hospitals.

Adverse trends in blood pressure, diabetes mellitus, and other cardiometabolic risk factors, together with population growth and ageing, are contributing to the burden of cardiovascular diseases in Africa. This increasing problem, coupled with inadequate access to effective interventions for prevention, diagnosis, and treatment, is creating major public-health challenges across the continent.

The BLOCK HF trial demonstrated that, during continual cardiac pacing, adverse left ventricular remodelling and deterioration of systolic function occurred more frequently with right ventricular than with biventricular pacing. These findings will increase the role of biventricular pacing for the preservation of left ventricular function in patients with atrioventricular block.

Renal denervation for the treatment of resistant hypertension is approved in Europe and is being studied in the USA. A newly published ESC consensus document integrates all the published data on this procedure, and summarizes how best to define, evaluate, and follow up patients who are candidates for the procedure.

The therapeutic efficacy of bone-marrow-derived cells in patients with acute or chronic myocardial infarction has been a matter of intense debate. Three new clinical trials—the Swiss-AMI, CELLWAVE, and C-CURE studies—unfortunately do not resolve the controversy in the field of cell therapy for the damaged heart.

Three randomized clinical trials have added data to the debate about whether off-pump CABG surgery has any advantages over the on-pump approach. A growing consensus is emerging; however, understanding the conflicting results of these trials, and how they might apply to clinical practice, requires careful attention to trial design.

Areas of thinned myocardium (≤5.5 mm) were previously thought to be regions of transmural infarction, without remaining viable tissue. However, new data using late-enhancement cardiovascular magnetic resonance imaging now show that, in 18% of patients with ventricular wall thinning, substantial viable myocardium remains, which can improve in function after revascularization.

The results of MASS COMM support the safety of performing percutaneous coronary intervention at centres without on-site cardiothoracic surgery services. To translate these findings into clinical practice, robust quality oversight programmes, with direct measurement of procedural outcomes and complications, are needed. The VA CART programme provides a model for such a strategy.

Wide variation exists in the use of inferior vena cava filters for the treatment of venous thromboembolism, possibly because of a deficit of evidence on the efficacy of these devices, and a lack of consensus on their use. Future guidelines should be evidence-based and account for the development of novel anticoagulants.