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Volume 17, No 1/2 - 2016

Volume 17, No 1/2 - 2016

Table of Contents

A Decade of Progress in Regional ST-Segment Elevation Myocardial Infarction Systems of Care: A Tale of Two Cities Treatment Update
Over the past 20 years, care for patients with ST-elevation myocardial infarction (STEMI) has rapidly evolved, not just in terms of how patients are treated, but where patients are treated. The advent of regional STEMI systems of care has decreased the number of “eligible but untreated” patients while improving access to primary percutaneous coronary intervention for patients. These regional STEMI systems of care have consistently demonstrated that rapid transport of STEMI patients is safe and effective, and have shown marked improvements in a variety of clinical outcomes. However, no two STEMI systems are alike, and each must be tailored to the unique geographic, political, and socioeconomic challenges of the region. This article takes an in-depth look at two of the earliest STEMI systems within the United States: the Minneapolis Heart Institute and the Los Angeles County STEMI receiving network. [Rev Cardiovasc Med. 2016;17(1/2):1-6 doi: 10.3909/ricm0808] © 2016 MedReviews®, LLC
A Closer Look at Fractional Flow Reserve in Complex Anatomic Subsets: Left Main Disease, Bifurcation Lesions, and Saphenous Vein Grafts Diagnostic Update
Fractional flow reserve (FFR) is a well-validated tool for determining the functional significance of a coronary artery stenosis, facilitating clinical decisions regarding the need for revascularization. FFR-guided revascularization improves clinical and economic outcomes. However, its application remains challenging in certain complex anatomic subsets, including left main coronary artery stenosis, bifurcation disease, and saphenous vein graft disease. This article reviews recent data supporting the use of FFR in these complex anatomic subsets. [Rev Cardiovasc Med. 2016;17(1/2):7-15 doi: 10.3909/ricm0813] © 2016 MedReviews®, LLC
Emerging Treatments for Heterozygous and Homozygous Familial Hypercholesterolemia CME-certified Articles
Familial hypercholesterolemia (FH) is an autosomal co-dominant disorder marked by extremely high low-density lipoprotein (LDL) cholesterol levels and concomitant premature vascular disease. FH is caused by mutations that most commonly affect three genes integrally involved in the LDL receptor’s ability to clear LDL particles from the circulation. Primary intervention efforts to lower LDL cholesterol have centered on therapies that upregulate the LDL receptor. Unfortunately, most patients are insufficiently responsive to traditional LDL-lowering medications. This article focuses primarily on the clinical management of homozygous FH. [Rev Cardiovasc Med. 2016;17(1/2):16-27 doi: 10.3909/ricm0854] © 2016 MedReviews®, LLC
The Role of Medical Therapy in Moderate to Severe Degenerative Mitral Regurgitation Management Update
Mitral regurgitation (MR) is a common valvular disorder that has important health and economic consequences. Standardized guidelines exist regarding when and in whom to perform mitral valve surgery, but little information is available regarding medical treatment of MR. Many patients with moderate or severe MR do not meet criteria for surgery or are deemed to be at high risk for surgical therapy. We reviewed the available published data on medical therapy in the treatment of patients with primary MR. b-blockers and renin-angiotensin-aldosterone system inhibitors had the strongest supporting evidence for providing beneficial effects. B-blockers appear to lessen MR, prevent deterioration of left ventricular function, and improve survival in asymptomatic patients with moderate to severe primary MR. Angiotensin-converting enzyme inhibitor and angiotensin receptor blocker therapy reduces MR, especially in asymptomatic patients. However, in the setting of hypertrophic cardiomyopathy or mitral valve prolapse, vasodilators can increase the severity of MR. To define the precise role of medical therapy, a larger randomized controlled trial is needed to confirm benefit and assess in which subsets of patients medical therapy is most useful. Medical therapy in some patients improves symptoms, lessens MR, and may delay the need for surgical intervention. [Rev Cardiovasc Med. 2016;17(1/2):28-39 doi: 10.3909/ricm0835] © 2016 MedReviews®, LLC
A Review of the Clinical Subgroup Analyses From the RE-LY Trial Management Update
Dabigatran was the first direct-acting oral anticoagulant approved by the US Food and Drug Administration for prevention of stroke and systemic embolism in people with atrial fibrillation, based on data from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Over 18,000 patients with nonvalvular atrial fibrillation and a moderate-to-high risk of thromboembolic stroke were randomized to warfarin or dabigatran. With respect to the primary endpoints for efficacy and safety, dabigatran was superior to warfarin in the prevention of stroke and thromboembolism and noninferior with respect to major bleeding. Although unified by a common arrhythmia and a similar thromboembolic stroke risk, this large patient population is also significantly heterogeneous with respect to other demographics and comorbidities that raise important questions about the efficacy and safety of dabigatran in specific patient populations. Furthermore, there were significant differences between the warfarin and dabigatran groups with respect to several important secondary endpoints. Understanding the differences in outcomes between specific patient subgroups from the RE-LY trial can better inform the practicing clinician’s ability to offer the best anticoagulation options to individual patients. [Rev Cardiovasc Med. 2016;17(1/2):40-48 doi: 10.3909/ricm0805] © 2016 MedReviews®, LLC
Cardiovascular Effects of Altitude on Performance Athletes Cardiovascular Training Update
Altitude plays an important role in cardiovascular performance and training for athletes. Whether it is mountaineers, skiers, or sea-level athletes trying to gain an edge by training or living at increased altitude, there are many potential benefits and harms of such endeavors. Echocardiographic studies done on athletes at increased altitude have shown evidence for right ventricular dysfunction and pulmonary hypertension, but no change in left ventricular ejection fraction. In addition, 10% of athletes are susceptible to pulmonary hypertension and high-altitude pulmonary edema. Some studies suggest that echocardiography may be able to identify athletes susceptible to high-altitude pulmonary edema prior to competing or training at increased altitudes. Further research is needed on the long-term effects of altitude training, as repeated, transient episodes of pulmonary hypertension and right ventricular dysfunction may have long-term implications. Current literature suggests that performance athletes are not at higher risk for ventricular arrhythmias when training or competing at increased altitudes. For sea-level athletes, the optimal strategy for attaining the benefits while minimizing the harms of altitude training still needs to be clarified, although—for now—the “live high, train low” approach appears to have the most rationale. [Rev Cardiovasc Med. 2016;17(1/2):49-56 doi: 10.3909/ricm0810] © 2016 MedReviews®, LLC
The Role of Cardiac Magnetic Resonance Imaging in Hypertrophic Cardiomyopathyey Diagnostic Update
Until recently, the only imaging technique for the diagnosis and management of hypertrophic cardiomyopathy (HCM) was two-dimensional echocardiography, and the use of cardiac magnetic resonance imaging (cMRI) was limited to patients with poor acoustic windows. Now, cMRI has gained an essential role in the diagnosis of HCM, providing superior visualization of myocardial hypertrophy—even in remote zones of the left ventricle—and visualization of subtle changes in thickness and contractility over time. The morphologic accuracy of cMRI allows for the differentiation of HCM from other pathologic conditions with hypertrophic phenotype. Moreover, cMRI sheds light on the in vivo fibrotic changes in cardiac ultrastructure, offering an important advantage in the understanding of pathologic mechanisms of the disease, allowing early dentification, risk stratification, and timely therapeutic management. [Rev Cardiovasc Med. 2016;17(1/2):57-64 doi: 10.3909/ricm0811] © 2016 MedReviews®, LLC
An Update From the California Chapter of the American College of Cardiology Board of Directors
[Rev Cardiovasc Med. 2016;17(1/2):65-66 doi: 10.3909/ricmCAACC1712B] © 2016 MedReviews®, LLC
Leading the Way: Cardiology and the Future of HealthTech Innovation
[Rev Cardiovasc Med. 2016;17(1/2):67-68 doi: 10.3909/ricmCAACC1712] © 2016 MedReviews®, LLC
Forty Years of Chest Pain: A Case Report and Contemporary Review of the Diagnostic and Therapeutic Options for Myocardial Bridging
A 48-year-old woman with 40 years of intermittent squeezing chest pain presented with worsening symptoms. Results of an ambulatory electrocardiogram, echocardiogram, and exercise treadmill were unremarkable. Persistent symptoms prompted a computed tomography coronary angiogram (CTCA) that revealed mid-left anterior descending artery myocardial bridging (MB) that was not physiologically significant by exercise single-photon emission CT. Conservative treatment was pursued. Anatomic MB is prevalent in a large proportion of the general population and are increasingly identified by CTCA. The majority are benign, physiologically significant bridging is uncommon, but accelerated proximal atherosclerosis can occur. B-blockers and nondihydropyridine calcium-channel blockers are the primary treatment options, with surgical myomectomy, coronary artery bypass, and stenting reserved for patients refractory to medical therapy with demonstrable ischemia. Head-to-head evaluation of nonpharmacologic therapies is needed. Intracoronary techniques provide simultaneous anatomical and physiological assessment but CTCA fractional flow reserve and hybrid positron emission tomography with concomitant spatial imaging systems are evolving as noninvasive alternatives. [Rev Cardiovasc Med. 2016;17(1/2):69-75 doi: 10.3909/ricm0814] © 2016 MedReviews®, LLC
Vascular Complications of Percutaneous Transradial Cardiac Catheterization
The percutaneous transradial approach for coronary angiography and percutaneous coronary intervention is increasing in the United States. Although its vascular safety profile is better than the traditional femoral approach, it is important to learn about potential complications. In this article, we present two cases of vascular complications, namely, pseudoaneurysm and radial artery occlusion, after transradial cardiac catheterization, along with a review of the relevant literature. [Rev Cardiovasc Med. 2016;17(1/2):76-79 doi: 10.3909/ricm0801] © 2016 MedReviews®, LLC
Isolated Left Ventricular Noncompaction Cardiomyopathy: A Transient Disease?
Isolated left ventricular noncompaction is either a distinct cardiomyopathy or a morphologic trait shared by several different types of cardiomyopathies. Although there is no current gold standard for its diagnosis, cardiac imaging is the most commonly accepted modality. Described is a case of left ventricular noncompaction that resolved 2 years after the initial diagnosis. [Rev Cardiovasc Med. 2016;17(1/2):80-84 doi: 10.3909/riu0817] © 2016 MedReviews®, LLC