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Volume 12, No 4 - 2011

Volume 12, No 4 - 2011

Table of Contents

Treatment of Hypertriglyceridemia With Fibric Acid Derivatives: Impact on Lipid Subfractions and Translation Into a Reduction in Cardiovascular Events Treatment Update
This review investigates how the treatment of hypertriglyceridemia with fibric acid derivatives impacts lipid concentrations, lipid particle size, and the rate of cardiovascular events: expressly, to decide whether the use of fibric acid derivatives is an effective treatment option in the reduction of cardiovascular endpoints for patients with specific lipid parameters at baseline. Fibric acid derivatives reduce fasting triglyceride (TG) values by 15% to 50% (depending on baseline level) and low-density lipoprotein cholesterol (LDL-C) by 8%, and raise high-density lipoprotein cholesterol (HDL-C) by 9%. In conjunction with a statin, the amount of TG lowering is approximately doubled with the addition of the fibrate. When measured, fibrates decrease the TG concentration of very low-density lipoprotein cholesterol particles while increasing the TG content of LDL particles. The mean size of LDL particles increases and there is a substantial reduction in the number and proportion of small, dense LDL. In randomized trials in primary and secondary prevention populations, fibrates were associated with a significant reduction in nonfatal myocardial infarction in most studies. In the subgroup with elevated TG and/or depressed HDL-C at baseline, all trials have found statistically significant relative risk reductions of 27% to 65% in the primary cardiovascular endpoint of myocardial infarction and cardiovascular death. [Rev Cardiovasc Med. 2011;12(4):173-185 doi: 10.3909/ricm0619] © 2011 MedReviews®, LLC
Clinical Impact of Renal Dysfunction in Heart Failure Disease State Review
Renal impairment in heart failure (HF) patients has been increasingly recognized as an independent risk factor for morbidity and mortality. In the most recent European and American guidelines for HF management, renal dysfunction was considered an index of poor prognosis independent of the presence of other traditionally investigated risk factors. Different mechanisms appear to be implicated in worsening renal function in patients with acute decompensated HF (ADHF) in contrast to chronic HF. In patients with acute ADHF, renal impairment has been attributed to renal hypoperfusion due to reduced cardiac output and decreased systemic blood pressure. In these patients, neurohormonal activation of the renin-angiotensin and sympathetic nervous systems plays a key role. In chronic and clinically stable HF, other mechanisms, including microvascular damage, oxidative stress, inflammation, and fibrosis, lead to a reduced number of functioning nephrons. Differentiating transient functional changes in renal filtration and acute renal tubular injury with loss of functioning nephrons is a critical step in understanding cardiorenal syndromes and selection of patients for novel therapeutic approaches. [Rev Cardiovasc Med. 2011;12(4):186-199 doi: 10.3909/ricm0581] © 2011 MedReviews®, LLC
Galectin-3: A Novel Blood Test for the Evaluation and Management of Patients With Heart Failure Management Update
Replacement of functional myocytes with crosslinked collagen as a result of tissue fibrosis is a final common pathway that is central to the progression of heart failure (HF), irrespective of etiology. In response to a variety of mechanical and neurohormonal stimuli, macrophages secrete galectin-3, which works as a paracrine and endocrine factor to stimulate additional macrophages, pericytes, myofibroblasts, and fibroblasts. The response to this signal is cellular proliferation and secretion of procollagen I. This protein is then irreversibly crosslinked to form collagen and result in cardiac fibrosis. With a commercially available assay, galectin-3 can now be measured in blood and has been found to aid in the prognosis of both systolic and nonsystolic HF. Measurement of galectin-3 before hospital discharge, on outpatient evaluation for suspected HF, and approximately twice per year for those with stable symptoms is supported by the evidence available at this time. Levels > 25.9 ng/mL, independent of symptoms, clinical findings, and other laboratory measures, predict a patient who is likely to have rapid progression of HF, resulting in hospitalization and death. In addition, a doubling in galectin-3 level over the course of 6 months, irrespective of baseline value, identifies a high-risk patient in whom additional care management efforts and advanced therapies could be warranted. [Rev Cardiovasc Med. 2011;12(4):200-210 doi: 10.3909/ricm0624] © 2011 MedReviews®, LLC
Temporal Variation of Heart Failure Hospitalization: Does It Exist? Disease State Review
Congestive heart failure (CHF) is the end stage of many cardiac diseases, and one of the leading causes of mortality and morbidity around the world. Coronary heart disease and hypertension (either singly or together) are the main etiology for CHF. It has been reported that major acute cardiovascular events (myocardial infarction, sudden death, cardiac arrest, ischemic and hemorrhagic stroke, pulmonary embolism, rupture/dissection of aortic aneurysms) do not occur randomly through time, but exhibit a specific temporal periodicity characterized by seasonal (winter), weekly (Monday), and circadian (morning) patterns of onset. Thus, because the major causes of CHF present a temporal pattern, in the past several years some studies have investigated the temporal variation of CHF hospitalization and mortality, with results indicating the possibility of a preference for winter months, Mondays, and nighttime, respectively. [Rev Cardiovasc Med. 2011;12(4):211-218 doi: 10.3909/ricm0579] © 2011 MedReviews®, LLC
Incidence of Neoplastic Disease in Cardiac Allograft Recipients Management Update
Incidence of neoplastic disease represents a serious complication after heart transplantation. In this review, the authors discuss the incidence, causes, and types of tumors in cardiac allograft recipients. Prevention and tumor monitoring for early treatment are highlighted. [Rev Cardiovasc Med. 2011;12(4):219-226 doi: 10.3909/ricm0582] © 2011 MedReviews®, LLC
Stormy Times: A Change of Season—Embrace the Opportunity and Make a Difference
[Rev Cardiovasc Med. 2011;12(4):227-229 doi: 10.3909/ricm0628a] © 2011 MedReviews®, LLC
Cardiology Training in the United Kingdom
[Rev Cardiovasc Med. 2011;12(4):229-230 doi: 10.3909/ricm0628b] © 2011 MedReviews®, LLC
Stenting Techniques for Patients With Bifurcation Coronary Artery Disease
Atherosclerotic lesions at the bifurcation of coronary arteries are associated with higher rates of restenosis following stenting, and can be technically challenging when performing percutaneous coronary intervention (PCI). Many techniques have arisen for PCI of these lesions, often incorporating the use of multiple balloons and the placement of two or more stents. A technique commonly used for bifurcations is kissing balloon angioplasty, in which two balloons are inflated simultaneously to prevent the shifting of plaque into the side branch. Provisional side branch stenting is the technique of using a stent for the main branch, and stenting the side branch only if necessary. Multiple-stent techniques include T-stenting, crush technique, culotte, simultaneous kissing stents, V-stenting, and Y-stenting; the goal of these techniques is to provide maximal apposition to the vessel wall with effective drug delivery in the case of drug-eluting stents. Additionally, dedicated bifurcation stents also exist, with apertures that allow placement of additional stents. Debulking techniques such as atherectomy can be employed as stand-alone procedures or to debulk lesions prior to bifurcation stenting. Despite these many options for PCI of bifurcation lesions, there are currently inadequate data to indicate which of these techniques is superior, and many trials have found that complex stenting techniques provide no additional benefits when compared with provisional side branch stenting. Additional, well-designed randomized trials evaluating specific stenting techniques are necessary to determine the best practice for bifurcation lesions. [Rev Cardiovasc Med. 2011;12(4):231-239 doi: 10.3909/ricm0588] © 2011 MedReviews®, LLC
News and Views From the Literature Computed Tomography
[Rev Cardiovasc Med. 2011;12(4):240-242 doi: 10.3909/ricm0625] © 2011 MedReviews®, LLC
News and Views From the Literature Drug-Eluting Stents
[Rev Cardiovasc Med. 2011;12(4):242-243 doi: 10.3909/ricm0626] © 2011 MedReviews®, LLC
News and Views From the Literature Magnetic Resonance Imaging
[Rev Cardiovasc Med. 2011;12(4):244-245 doi: 10.3909/ricm0627] © 2011 MedReviews®, LLC