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Commencing Volume 19, Issue 1, MedReviews has ceased the publication of this journal. Reviews in Cardiovascular Medicine will continue to be published by IMRPress, Ltd. (www.imrpress.com)

Volume 8, No 3 - Summer 2007

Volume 8, No 3 - Summer 2007

Table of Contents

Strategies to Improve Early Reperfusion in ST-Elevation Myocardial Infarction Treatment Update
It is well established that rapid and complete reperfusion in ST-elevation myocardial infarction reduces infarct size and improves long-term morbidity and mortality rates. Randomized clinical trials demonstrate that primary angioplasty (percutaneous coronary intervention [PCI]) is superior to fibrinolytic therapy in reducing mortality, reinfarction, and recurrent ischemia if performed in a timely manner by an experienced team. Despite this evidence, a minority of patients are treated with primary PCI in the United States. Efforts to improve access and to develop systems that facilitate the availability of timely primary PCI are being addressed. Suggested solutions include coordination of emergency medical services (EMS) systems, performance of 12-lead electrocardiography in the ambulance, and early notification of the catheterization laboratory team. Improved access would require limited expansion of hospitals capable of primary PCI, particularly in rural areas. Although these strategies may help, there is growing enthusiasm for the development of primary PCI centers, with triage of patients to these centers through either an EMS bypass system or an interhospital transfer system. [Rev Cardiovasc Med. 2007;8(3):127-134]
Evolving Clinical Application of Cardiac MRI Diagnostic Review
Over the past decade, cardiac magnetic resonance imaging (MRI) has emerged as a new technology representing the next major advance in noninvasive cardiac imaging. It provides unique and accurate data representative of cardiac structure, function, and perfusion at both the gross anatomical and myocardial levels. Cardiac MRI proves to be highly accurate and reproducible in many challenging areas in clinical cardiology, including diagnosis of constrictive pericarditis, differentiation of ischemic from dilated cardiomyopathy, confirmation of the diagnosis of myocarditis, and definition and quantification of myocardial viability. As compelling studies support its clinical utility, the evolution of cardiac MRI is gaining speed. In many cases, such as the diagnosis of anomalous origin of the coronary arteries, it is the gold standard diagnostic technique. [Rev Cardiovasc Med. 2007;8(3):135-144]
Diabetes and Cardiovascular Disease: Explaining the Relationship Prevention Review
Diabetes is a risk factor for cardiovascular disease. However, even elevated glucose levels below the diabetic range increase cardiovascular risk. There are several possible explanations for this relationship. First, glucose and its metabolites have direct toxic effects on vascular endothelium. Second, abnormal glucose is evidence of absolute or relative insulin deficiency, which can predispose patients to cardiovascular disease via endothelial dysfunction, lipid abnormalities, and inflammation. Third, antecedent factors, such as toxins, abnormal energy storage, and hypertension, may contribute to the development of both diabetes and cardiovascular disease. Whether glucose lowering can reduce the risk of cardiovascular disease is currently being studied in a number of large trials. [Rev Cardiovasc Med. 2007;8(3):145-153]
A Perspective on Telmisartan and Cardiovascular Risk Treatment Update
The angiotensin receptor blockers (ARBs) are well established as safe and effective in the treatment of arterial hypertension. Telmisartan is an ARB with potent bloodpressure– lowering effects. It has a long terminal half-life of about 24 hours (the longest of any of the ARBs), which enables it to sustain blood pressure reductions in the early morning hours, after the previous morning dosing. Unlike the angiotensinconverting enzyme (ACE) inhibitors, the ARBs have not been shown to reduce mortality and morbidity in high-risk patients with coronary disease, peripheral vascular disease, cerebrovascular disease, or diabetes with cardiovascular risk factors without evidence of heart failure or low ejection fraction. Two studies, the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomized AssessmeNt Study in ACE-I INtolerant Subjects with Cardiovascular Disease (TRANSCEND) trial, are examining the benefits of ARBs alone and in combination with ACE inhibitors in high-risk patients. [Rev Cardiovasc Med. 2007;8(3):154-159]
Proximal Embolic Protection With Aspiration in Percutaneous Coronary Intervention of Acute Myocardial Infarction Using the Proxis™ Device Treatment Update
Distal embolization during primary percutaneous coronary intervention (PCI) occurs in at least 15% of patients and is a strong predictor of more extensive myocardial damage and a poor prognosis. Several devices are designed to evacuate the intracoronary thrombus or to prevent distal embolization. The Proxis device is a proximal embolic protection system that completely blocks antegrade flow during PCI. It may prevent distal embolization during recanalization of thrombotic coronary occlusion and thus improve outcome. We created a registry of 172 patients with ST-segment elevation myocardial infarction who underwent primary PCI with proximal embolic protection and aspiration. The mean ST-segment elevation resolution (STR) at 1 hour was 77.7%  15.2; STR was greater than 50% in 94% and greater than 70% in 72% of patients. The 1-year cumulative major adverse cardiac and cerebrovascular events rate was 10.5%. The overall mortality at 1 year was 2.3%. [Rev Cardiovasc Med. 2007;8(3):160-166]
Best of the ASH 2007 Scientific Sessions Meeting Review
Highlights From the 22nd Annual American Society of Hypertension Scientific Meeting and Exposition, May 19-22, 2007, Chicago, IL [Rev Cardiovasc Med. 2007;8(3):167-173]
Evaluation of Anomalous Aortic Origins of the Coronaries by 64-Slice Cardiac Computed Tomography Case Review
Approximately 20% of coronary artery anomalies produce sudden death or lifethreatening symptoms, including arrhythmias, syncope, and myocardial infarction. The most common clinical symptom of coronary artery anomaly is angina or exertional syncope. Physical examination is usually unrevealing in the absence of myocardial infarction or symptoms of ongoing ischemia. The rapid advent of cardiac computed tomography (CT) technology has made it an important adjunct to the diagnosis of coronary anomalies by angiography. The authors describe the case of a 54-year-old white man who presented with gangrenous toes. He had severe peripheral vascular disease, a femoral-popliteal bypass graft, residual hemiparesis from an ischemic stroke, hypertension, deep vein thrombosis, and a recent myocardial infarction. He underwent a 64-slice cardiac CT angiogram, which showed an interarterial course of the left main coronary artery between the aorta and the pulmonary trunk. [Rev Cardiovasc Med. 2007;8(3):175-181]
Successful Treatment of a Distal Saphenous Vein Graft Lesion Using the Proxis™ Embolic Protection System Case Review
“No-reflow” complicates 10% to 15% of saphenous vein graft (SVG) percutaneous coronary interventions (PCIs). It is suggested by some studies to be the cause of a 31% rate of acute myocardial infarction and may increase in-hospital mortality 10-fold. A 73-year-old white male with a history of coronary artery bypass surgery, paroxysmal atrial fibrillation, hyperlipidemia, and renal insufficiency presented with progressive exertional chest pain relieved by rest. Angiography revealed a minor stenosis in the right coronary artery and the left anterior descending artery (LAD). The left internal mammary artery to the LAD was occluded, as was the native circumflex. The patient underwent primary PCI of the SVG to the posterior lateral branch with balloon predilation of the target vessel, which resulted in a “no-reflow” phenomenon. The patient then underwent intervention with the Proxis Embolic Protection System, which reduced the distal stenosis to 0% with thrombolysis in myocardial infarction 3 flow. [Rev Cardiovasc Med. 2007;8(3):182-184]