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Volume 10, No 1 - Winter 2009

Volume 10, No 1 - Winter 2009

Table of Contents

Future Directions in Echocardiography Procedure Review
Future developments in echocardiography will likely focus on the continued evolution of existing techniques, such as real-time 3-dimensional (RT3D) imaging and contrastenhanced imaging; higher resolution imaging; and greater flexibility in imaging systems due to miniaturization, enhanced connectivity, and integration with other techniques. Improvements in RT3D image quality may include expanded parallel processing and use of transesophageal matrix arrays. Two areas of future clinical potential for contrast-enhanced echocardiography/ultrasound are the use of targeted microbubbles for diagnostic and therapeutic applications and expanded vascular imaging. Although molecular imaging holds great promise for the future, in the short-term, it is likely that contrast will be used more extensively for vascular imaging to assess both the effects of interventions on local perfusion and the activity of atherosclerotic plaque based on the size/density of the vasa vasorum. The widespread use of ultrasound will be facilitated by the development of a convenient portable or readily available ultrasonic equivalent of the stethoscope.[Rev Cardiovasc Med. 2009;10(1):4-13]
Significant Gastrointestinal Bleeding in Patients at Risk of Coronary Stent Thrombosis Treatment Update
The evolution of drug-eluting stents (DES), effective periprocedural antithrombotic therapy, and advanced interventional techniques have fueled the surge of percutaneous coronary interventions. Stent thrombosis remains a serious complication of coronary artery stent implantation. Long-term antiplatelet therapy is required to prevent stent thrombosis, especially following DES implantation. Discontinuation of antiplatelet therapy (particularly clopidogrel) is the strongest independent risk factor for the development of stent thrombosis. Bleeding complications, most of which arise from the upper gastrointestinal (GI) tract, are the major limiting factors for antiplatelet therapy. The association of aspirin with the increased risk of upper GI bleeding has been well established. Peptic ulcer bleeding and Helicobacter pylori infection are the 2 most important risk factors for aspirin-associated GI bleeding complications. Endoscopy (for both surveillance and potential intervention), performed either emergently or semielectively, is the primary tool for definitive management of GI bleeding. Considering the increase in GI bleeding risk seen with prolonged antiplatelet therapy, adjunctive proton pump inhibitor therapy and/or eradication of H. pylori infection might be beneficial for DES patients on long-term antiplatelet therapy.[Rev Cardiovasc Med. 2009;10(1):14-24]
Mortality and Atrial Fibrillation: Is There a Causal Relationship? Disease State Review
Almost all studies show that atrial fibrillation (AF) is associated with increased mortality. What is less certain is whether this association is a straightforward cause-and-effect relationship, or if AF is merely a marker of severity of cardiovascular disease(s) or the aging process. AF can lead to the worsening of left ventricular filling, contribute to loss of atrioventricular synchrony, affect cardiac remodeling, and even cause a tachycardia-induced cardiomyopathy. AF could be a marker for underlying atherosclerotic disease that itself determines mortality, or the increased oxygen consumption associated with an increasing ventricular rate may lead to ischemia secondary to increased myocardial consumption and precipitate acute coronary syndromes. Although it is generally accepted that the stasis of atrial blood in AF promotes clot formation, studies have shown increases in specific coagulation factors—all of which have the ability to increase morbidity and/or mortality through their elevations. Another possibility is that AF is not the cause of the hypercoagulable state, but is instead a marker of such a state.[Rev Cardiovasc Med. 2009;10(1):25-28]
Implementing Cardiac Resynchronization Therapy in Routine Clinical Practice: Preoperative Considerations and Implantation Techniques Procedure Review
Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is an established therapy for congestive heart failure in patients with asynchronous ventricular contractions. CRT improves not only exercise tolerance but also the patient’s prognosis. Appropriate patient selection for CRT is essential for a successful therapeutic response. Inclusion criteria are based on symptoms (New York Heart Association classes III and IV), a reduced ejection fraction, and a widened QRS complex. The presence of objective markers of heart failure can be considered a prerequisite for successful CRT. CRT procedures are much longer than regular pacemaker implantations, and thus the risk of infection may be greater. Successful therapy depends on the placement of left ventricular leads, usually via the CS, which is a technically more challenging procedure than regular pacemaker implantations. Complications specific to CRT include ventricular arrhythmia, such as ventricular tachycardia or ventricular fibrillation; total atrioventricular block or sinus arrest without any escape rhythm; and CS dissection.[Rev Cardiovasc Med. 2009;10(1):29-37]
Highlights From the American Heart Association Scientific Sessions, November 8-12, 2008, New Orleans, LA Best of the AHA Scientific Sessions 2008
Highlights From the American Heart Association Scientific Sessions, November 8-12, 2008, New Orleans, LA[Rev Cardiovasc Med. 2009;10(1):43-50]
Lipoproteins, Inflammatory Biomarkers, and Cardiovascular Imaging in the Assessment of Atherosclerotic Disease Activity
Atherosclerosis is present in about 50% of asymptomatic adults at middle age and in nearly all elderly individuals. The traditional diagnostic and treatment paradigm has addressed risk detection and reduction of binary events, including myocardial infarction (MI), stroke, and cardiovascular death. About 50% of all acute coronary syndromes occur in previously asymptomatic subjects, 90% of whom have modifiable risk factors; yet our current screening approaches fail to prevent the 1.2 million acute cardiovascular events that occur annually in the United States. In a patient with active disease, multiple treatment targets can be approached with a variety of lifestyle changes and medical therapy to render the disease quiescent in theory. A future approach may be interception of atherosclerosis before the identification of theoretical or actual risk of episodic events. This case review highlights use of advanced biomarkers and imaging to assess atherosclerotic disease activity in a 49-year-old asymptomatic woman who presents for evaluation after the death of her father from MI.[Rev Cardiovasc Med. 2009;10(1):51-58]