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Volume 15, No 2 - 2014

Volume 15, No 2 - 2014

Table of Contents

Multimodality Imaging in Transcatheter Aortic Valve Replacement Treatment Update
Transcatheter aortic valve replacement is a major advance that has dramatically changed our approach to elderly patients with severe aortic stenosis. This advance has been made possible by innovative device and delivery improvements, coupled with rapid developments in multimodality imaging. Multimodality imaging draws from multiple imaging fields and is central to patient evaluation and treatment. The primary modalities to date include transthoracic echocardiography and transesophageal echocardiography, computed tomography, and fluoroscopy. Each of these modalities carries a different weight in the various stages of patient selection, procedural guidance, monitoring, and follow-up. Multimodality imaging ensures optimal device selection, delivery, and patient safety, and will continue to advance as the next generation of aortic valve devices further advance cardiovascular care. [Rev Cardiovasc Med. 2014;15(2):75-85 doi: 10.3909/ricm0701] © 2014 MedReviews®, LLC
Management of Hypercholesterolemia for Prevention of Atherosclerotic Cardiovascular Disease: Focus on the Potential Role of Recombinant Anti-PCSK9 Monoclonal Antibodies CME-certified Article
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability in the United States and other developed nations, and is rising rapidly in the rest of the world. Low-density lipoprotein (LDL) is the major atherogenic particle in most patients at high risk for ASCVD events, and statin-based LDL-lowering treatment is the major focus of treatment for prevention of ASCVD. Despite this, an estimated 57 million US adults (25%) still have moderately elevated levels of LDL-cholesterol (LDL-C) . 160 mg/dL, and many others have an LDL-C above the level considered appropriate for their high-risk status. Although statins are very effective for lowering LDL-C, and other classes of LDL-lowering medications are available, many patients still cannot achieve adequate LDL-lowering with maximal tolerated doses of US Food and Drug Administration–approved treatments. Thus, there is an unmet medical need for statin adjuncts in these patients, as well as for statin alternatives in statin-intolerant patients. A recently discovered human protein, proprotein convertase subtilisin/kexin type 9 (PCSK9), plays an important role in LDL metabolism by promoting degradation of the LDL receptor, and thus reducing clearance of LDL and increasing LDL-C levels. Accordingly, inhibition of PCSK9 activity has become an attractive target for drug development for lowering LDL-C, and human monoclonal antibodies against PCSK9, are now in late-stage clinical development. These antibodies are at least as effective as statins for LDL-C lowering (or more so), and their effects are additive to those of statins. To date, they have been well tolerated and apparently safe in clinical trials. Long-term randomized, controlled trials of their safety, tolerability, and ability to reduce ASCVD are now underway. [Rev Cardiovasc Med. 2014;15(2):86-101 doi: 10.3909/ricm0741] © 2014 MedReviews®, LLC
Height and Heart Disease Disease State Review
Height has a relationship with a number of medical conditions, including heart disease. Atrial fibrillation has been observed to be more common in taller individuals. Marfan syndrome, with its high prevalence of mitral valve disease and abnormalities of the aorta, is associated with increased height. Mitral valve prolapse in patients without Marfan syndrome may be more common in taller people. Conversely, congestive heart failure, coronary artery disease, and possibly aortic valve calcification are less prevalent with increasing height. The relationship between height and health will be of increasing importance as the population grows taller. [Rev Cardiovasc Med. 2014;15(2):102-108 doi: 10.3909/ricm0678] © 2014 MedReviews®, LLC
Lomitapide for the Management of Homozygous Familial Hypercholesterolemia Management Update
Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disorder of low-density lipoprotein cholesterol (LDL-C) metabolism resulting in extremely elevated serum levels of LDL-C and premature atherosclerotic cardiovascular disease. Treatment typically involves multiple pharmacologic agents, as well as mechanical filtration using weekly or biweekly LDL apheresis. Despite combination lipid-lowering therapy, LDL-C levels and cardiovascular morbidity and mortality remain unacceptably high in HoFH patients. The European Commission and the US Food and Drug Administration approved the use of lomitapide, a novel medication designed to address this significant unmet need. Lomitapide is an orally administered inhibitor of microsomal triglyceride transfer protein that is indicated as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available for the reduction of LDL-C, total cholesterol, apolipoprotein B, and non–high-density lipoprotein cholesterol in adult patients with HoFH. The risks of transaminase elevations, hepatic steatosis, and gastrointestinal side effects, and the potential for drug interactions, require vigilant examination of the clinical and laboratory data and patient counseling prior to initiation of lomitapide, as well as regular monitoring during follow-up care. This article highlights important practical considerations for the use of lomitapide in the context of the evaluation and management of a HoFH patient case. [Rev Cardiovasc Med. 2014;15(2):109-118 doi: 10.3909/ricm0735] © 2014 MedReviews®, LLC
The Current and Future Landscape of Urinary Thromboxane Testing to Evaluate Atherothrombotic Risk Risk Stratification Update
Biomarker testing for efficacy of therapy is an accepted way for clinicians to individualize dosing to genetic and/or environmental factors that may be influencing a treatment regimen. Aspirin is used by nearly 43 million Americans on a regular basis to reduce risks associated with various atherothrombotic diseases. Despite its widespread use, many clinicians are unaware of the link between suboptimal response to aspirin therapy and increased risk for inferior clinical outcomes in several disease states, and biomarker testing for efficacy of aspirin therapy is not performed as routinely as efficacy testing in other therapeutic areas. This article reviews the clinical and laboratory aspects of determining whole-body thromboxane production, particularly as it pertains to efficacy assessment of aspirin responsiveness. [Rev Cardiovasc Med. 2014;15(2):119-130 doi: 10.3909/ricm0739] © 2014 MedReviews®, LLC
Global T-wave Inversion on Electrocardiogram: What Is the Differential? Diagnostic Review
Global T-wave inversion as seen on electrocardiogram is associated with a variety of pathophysiologic states, including cardiac, pulmonary, and cerebrovascular disease, and acute electrolyte disorders. Although some of these are chronic conditions, others are acute emergencies, necessitating early diagnosis and treatment. This article reviews and provides examples of possible etiologies of global T-wave inversion on electrocardiogram. [Rev Cardiovasc Med. 2014;15(2):131-141 doi: 10.3909/ricm0655] © 2014 MedReviews®, LLC
Left Atrial Appendage Occlusion With the WATCHMAN™ for Stroke Prevention in Atrial Fibrillation Prevention Update
Atrial fibrillation (AF) is a major cause of stroke and systemic embolism. Although warfarin and the novel oral anticoagulants reduce thromboembolic risk, they are associated with an ongoing bleeding hazard, in addition to other limitations that deter their use. The left atrial appendage (LAA) appears to be the primary source of thrombus in AF; therefore, LAA closure represents a mechanical strategy for stroke prevention in these patients. The WATCHMAN™ LAA closure device (Boston Scientific, Natick, MA) is a nitinol-framed occluder that is implanted percutaneously under echocardiographic and fluoroscopic guidance. Data from two randomized clinical trials support the clinical efficacy of transcatheter LAA occlusion with the WATCHMAN and demonstrate that procedural safety has improved significantly since initial experience. This article summarizes the rationale, procedural technique, safety, and clinical efficacy of the WATCHMAN device in patients with AF at high risk for thromboembolic events. [Rev Cardiovasc Med. 2014;15(2):142-151 doi: 10.3909/ricm0733] © 2014 MedReviews®, LLC
Coronary Artery Fistulae Diagnosis and Treatment Review
Coronary artery fistulae and coronary cameral fistulae are rare anomalies that are discovered incidentally in patients undergoing coronary angiography. This article reviews the classification, management, and complications of these fistulae, and discusses a variety of presentations. [Rev Cardiovasc Med. 2014;15(2):152-157 doi: 10.3909/ricm0670] © 2014 MedReviews®, LLC
Therapeutic Potentials of Phosphodiesterase-5 Inhibitors in Cardiovascular Disease Treatment Update
Phosphodiesterase-5 (PDE5) inhibitors have been approved by the US Food and Drug Administration for the treatment of erectile dysfunction and more recently for pulmonary arterial hypertension (World Health Organization functional class I). PDE5 inhibitors can induce vasodilation; in addition, through a complex pathway involving nitric oxide, cyclic guanosine monophosphate, and protein kinase G, it can reduce apoptosis and suppress cell proliferation. The presence of PDE5 inhibitors in various tissues and systemic vasculature make them potential targets in a variety of cardiovascular diseases. In many in vitro and in vivo studies, PDE5 inhibitors have been shown to have positive effects in systolic and diastolic congestive heart failure, ischemic heart disease, doxorubicin cardiomyopathy, and pulmonary arterial hypertension. They also improved vasoconstriction in Raynaud phenomenon, peripheral artery disease, and hypoxic brain conditions. This article reviews the therapeutic potentials of PDE5 inhibitors in different cardiovascular diseases. [Rev Cardiovasc Med. 2014;15(2):158-167 doi: 10.3909/ricm0679] © 2014 MedReviews®, LLC
Influenza and Coronary Artery Disease: Exploring a Clinical Association With Myocardial Infarction and Analyzing the Utility of Vaccination in Prevention of Myocardial Infarction Disease Prevention Update
Both coronary artery disease and influenza outbreaks contribute significantly to worldwide morbidity and mortality. An increasing number of epidemiologic studies have concluded that a temporal association exists between acute viral illnesses and myocardial infarction. Viral illnesses such as influenza can cause or exacerbate coronary atherosclerosis by activating inflammatory pathways. Data from a large case-controlled trial and two randomized controlled trials suggest that influenza vaccination in patients with coronary artery disease may lead to a decrease in incidence, morbidity, and mortality from acute myocardial infarction. A meta-analysis of the two randomized controlled trials for cardiovascular death demonstrated a pooled relative risk of 0.39 (95% confidence interval, 0.20-0.77) for patients who received the influenza vaccine compared with placebo. [Rev Cardiovasc Med. 2014;15(2):168-175 doi: 10.3909/ricm0692] © 2014 MedReviews®, LLC
Coronary Revascularization: Then, Now, Future Trends
[Rev Cardiovasc Med. 2014;15(2):176-177 doi: 10.3909/ricm15-2CAACC] © 2014 MedReviews®, LLC
ACC.14: Update on the Prevention, Diagnosis, and Treatment of Cardiovascular Disease Highlights From the 63rd Annual Scientific Sessions of the American College of Cardiology, March 29-31, 2014, Washington, DC
[Rev Cardiovasc Med. 2014;15(2):178-188 doi: 10.3909/ricm0740] © 2014 MedReviews®, LLC
Subclavian Artery Stenosis: A Case Series and Review of the Literature
Subclavian artery stenosis (SAS) is a significant form of peripheral artery disease, which may be a marker of diffuse atherosclerosis and increased risk for cardiovascular events. SAS can lead to symptomatic ischemia affecting the upper extremities, the brain, and, in some cases, the heart. In general, asymptomatic subclavian artery disease is treated with medical therapy and invasive treatment is reserved for the more symptomatic patients. This article discusses the evaluation of four patients with varying presentations of subclavian artery disease. [Rev Cardiovasc Med. 2014;15(2):189-195 doi: 10.3909/ricm0723] © 2014 MedReviews®, LLC