Journal of the American College of Cardiology Current Issue

Inside This Issue

Tue, 21 May 2013 00:00:00 GMT

Genomics in Cardiovascular Disease

Roberts R, Marian AJ, Dandona S, et al. — Tue, 21 May 2013 00:00:00 GMT

A paradigm shift toward biology occurred in the 1990s and was subsequently catalyzed by the sequencing of the human genome in 2000. The cost of deoxyribonucleic acid (DNA) sequencing has gone from millions to thousands of dollars with sequencing of one's entire genome costing only $1,000. Rapid DNA sequencing is being embraced for single gene disorders, particularly for sporadic cases and those from small families. Transmission of lethal genes such as associated with Huntington's disease can, through in vitro fertilization, avoid passing it on to one's offspring. DNA sequencing will meet the challenge of elucidating the genetic predisposition for common polygenic diseases, especially in determining the function of the novel common genetic risk variants and identifying the rare variants, which may also partially ascertain the source of the missing heritability. The challenge for DNA sequencing remains great, despite human genome sequences being 99.5% identical, the 3 million single nucleotide polymorphisms responsible for most of the unique features add up to 40 to 60 new mutations per person which, for 7 billion people, is 300 to 400 billion mutations. It is claimed that DNA sequencing has increased 10,000-fold while information storage and retrieval only 16-fold. The physician and health user will be challenged by the convergence of 2 major trends, whole genome sequencing, and the storage/retrieval and integration of the data.

Channeling Post-Infarction Ventricular Tachycardia Ablation “Electroanatomy” Versus Electrophysiology ⁎ ⁎

Haqqani HM, Morton JB, Kalman JM. — Tue, 21 May 2013 00:00:00 GMT

Procedural techniques to eliminate post-infarction ventricular tachycardia (VT) have evolved considerably since the original electrophysiological and surgical experience. Pioneering investigations at the University of Pennsylvania definitely established the re-entrant nature of scar-related VT (by consistently demonstrating reset with fusion) as well as the relation between the infarct scar and VT circuits (1,2). Correlative studies demonstrated that surviving myocyte bundles within dense infarct scar formed the histological substrate underlying re-entrant VTs (3). The success of surgical subendocardial resection of the scar and border zone led to attempts to recapitulate this with catheter ablation. For reliably inducible, hemodynamically tolerated monomorphic VT, catheter ablation became a successful therapy. This success was primarily because of the application of entrainment responses to mapping the location of all the components of the re-entrant VT circuit (4). Unfortunately, most scar-related VT occurs in the context of significant structural heart disease, and only the minority of induced VTs are conventionally mappable. Consequently, the next stage in the evolution of VT ablation was the development of techniques to define ablation targets during sinus rhythm.

Diabetes and Coronary Disease A Need for New Therapies for an Expanding Disease Burden ⁎ ⁎

Lew WW, DeMaria AN. — Tue, 21 May 2013 00:00:00 GMT

The prevalence of diabetes mellitus (DM) has nearly doubled in the adult population of the United States from 4.5% in 1995 to 8.2% in 2010 (1). Patients with DM are more likely to develop cardiovascular disease, have shorter life expectancy (2), and have higher mortality from acute coronary syndromes (ACS) (3). The marked rise in a risk factor with such adverse consequences on coronary artery disease (CAD) has created a global disease burden with an urgent need to find new therapeutic approaches to treat CAD in patients with DM.

Effects of the P-Selectin Antagonist Inclacumab on Myocardial Damage After Percutaneous Coronary Intervention for Non–ST-Segment Elevation Myocardial Infarction Results of the SELECT-ACS Trial

Tardif J, Tanguay J, Wright SS, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

The study aimed to evaluate inclacumab for the reduction of myocardial damage during a percutaneous coronary intervention (PCI) in patients with non–ST-segment elevation myocardial infarction.

Background

P-selectin is an adhesion molecule involved in interactions between endothelial cells, platelets, and leukocytes. Inclacumab is a recombinant monoclonal antibody against P-selectin, with potential anti-inflammatory, antithrombotic, and antiatherogenic properties.

Methods

Patients (N = 544) with non–ST-segment elevation myocardial infarction scheduled for coronary angiography and possible ad hoc PCI were randomized to receive 1 pre-procedural infusion of inclacumab 5 or 20 mg/kg or placebo. The primary endpoint, evaluated in patients who underwent PCI, received study medication, and had available efficacy data (n = 322), was the change in troponin I from baseline at 16 and 24 h after PCI.

Results

There was no effect of inclacumab 5 mg/kg. Placebo-adjusted geometric mean percent changes in troponin I with inclacumab 20 mg/kg were −24.4% at 24 h (p = 0.05) and −22.4% at 16 h (p = 0.07). Peak troponin I was reduced by 23.8% (p = 0.05) and area under the curve over 24 h by 33.9% (p = 0.08). Creatine kinase-myocardial band yielded similar results, with changes of −17.4% at 24 h (p = 0.06) and −16.3% at 16 h (p = 0.09). The incidence of creatine kinase-myocardial band increases >3 times the upper limit of normal within 24 h was 18.3% and 8.9% in the placebo and inclacumab 20-mg/kg groups, respectively (p = 0.05). Placebo-adjusted changes in soluble P-selectin level were −9.5% (p = 0.25) and −22.0% (p < 0.01) with inclacumab 5 and 20 mg/kg. There was no significant difference in adverse events between groups.

Conclusions

Inclacumab appears to reduce myocardial damage after PCI in patients with non–ST-segment elevation myocardial infarction. (A Study of RO4905417 in Patients With Non ST-Elevation Myocardial Infarction [Non-STEMI] Undergoing Percutaneous Coronary Intervention; NCT01327183)

Evaluation of Ranolazine in Patients With Type 2 Diabetes Mellitus and Chronic Stable Angina Results From the TERISA Randomized Clinical Trial (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina)

Kosiborod M, Arnold SV, Spertus JA, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

This study sought to examine the efficacy of ranolazine versus placebo on weekly angina frequency and sublingual nitroglycerin use in subjects with type 2 diabetes mellitus, coronary artery disease (CAD), and chronic stable angina who remain symptomatic despite treatment with up to 2 antianginal agents.

Background

Patients with diabetes have more extensive CAD than those without diabetes, and a high burden of angina. Ranolazine is not only effective in treating angina but also may improve glycemic control, thus providing several potential benefits in this high-risk group. We conducted a randomized trial to test the antianginal benefit of ranolazine in patients with diabetes and stable angina.

Methods

TERISA (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina) was an international, randomized, double-blind trial of ranolazine versus placebo in patients with diabetes, CAD, and stable angina treated with 1 to 2 antianginals. After a single-blind, 4-week placebo run-in, patients were randomized to 8 weeks of double-blind ranolazine (target dose 1000 mg bid) or placebo. Anginal episodes and nitroglycerin use were recorded with daily entry into a novel electronic diary. Primary outcome was the average weekly number of anginal episodes over the last 6 weeks of the study.

Results

A total of 949 patients were randomized across 104 centers in 14 countries. Mean age was 64 years, 61% were men, mean diabetes duration was 7.5 years, and mean baseline HbA1c was 7.3%. Electronic diary data capture was 98% in both groups. Weekly angina frequency was significantly lower with ranolazine versus placebo (3.8 [95% confidence interval (CI): 3.6 to 4.1] episodes vs. 4.3 [95% CI: 4.0 to 4.5] episodes, p = 0.008), as was the weekly sublingual nitroglycerin use (1.7 [95% CI: 1.6 to 1.9] doses vs. 2.1 [95% CI: 1.9 to 2.3] doses, p = 0.003). There was no difference in the incidence of serious adverse events between groups.

Conclusions

Among patients with diabetes and chronic angina despite treatment with up to 2 agents, ranolazine reduced angina and sublingual nitroglycerin use and was well tolerated. (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina [TERISA]; NCT01425359)

Patterns of Use and Comparative Effectiveness of Bleeding Avoidance Strategies in Men and Women Following Percutaneous Coronary Interventions An Observational Study From the National Cardiovascular Data Registry

Daugherty SL, Thompson LE, Kim S, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

This study sought to compared the use and effectiveness of bleeding avoidance strategies (BAS) by sex.

Background

Women have higher rates of bleeding following percutaneous coronary intervention (PCI).

Methods

Among 570,777 men (67.5%) and women (32.5%) who underwent PCI in the National Cardiovascular Data Registry's CathPCI Registry between July 1, 2009 and March 31, 2011, in-hospital bleeding rates and the use of BAS (vascular closure devices, bivalirudin, radial approach, and their combinations) were assessed. The relative risk of bleeding for each BAS compared with no BAS was determined in women and men using multivariable logistic regressions adjusted for clinical characteristics and the propensity for receiving BAS. Finally, the absolute risk differences in bleeding associated with BAS were compared.

Results

Overall, the use of any BAS differed slightly between women and men (75.4% vs. 75.7%, p = 0.01). When BAS was not used, women had significantly higher rates of bleeding than men (12.5% vs. 6.2%, p < 0.01). Both sexes had similar adjusted risk reductions of bleeding when any BAS was used (women, odds ratio: 0.60, 95% confidence interval [CI]: 0.57 to 0.63; men, odds ratio: 0.62, 95% CI: 0.59 to 0.65). Women and men had lower absolute bleeding risks with BAS; however, these absolute risk differences were greater in women (6.3% vs. 3.2%, p < 0.01).

Conclusions

Women continue to have almost twice the rate of bleeding following PCI. The use of any BAS was associated with a similarly lower risk of bleeding for men and women; however, the absolute risk differences were substantially higher in women. These data underscore the importance of applying effective strategies to limit post-PCI bleeding, especially in women.

Prognostic Interplay of Coronary Artery Calcification and Underlying Vascular Dysfunction in Patients With Suspected Coronary Artery Disease

Naya M, Murthy VL, Foster CR, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

This study sought to evaluate the interrelation of atherosclerotic burden, as assessed by coronary artery calcium (CAC) score and coronary vascular function, as assessed by quantitative estimates of coronary flow reserve (CFR), with respect to prediction of clinical outcomes.

Background

The contribution of coronary vascular dysfunction, atherosclerotic burden, and the 2 combined to cardiac events is unknown.

Method

A total of 901 consecutive patients underwent 82Rubidium myocardial perfusion imaging (MPI) positron emission tomography (PET) and CAC scan. All patients had normal MPI. The primary endpoint was a composite of major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, late revascularization, and admission for heart failure.

Results

At baseline, CFR decreased (2.15 ± 0.72, 2.02 ± 0.65, and 1.88 ± 0.64, p < 0.0001) with increasing levels of CAC (0, 1 to 399, and ≥400). Over a median of 1.53 years (interquartile range: 0.77 to 2.44), there were 57 MACE. Annual risk-adjusted MACE rates were higher for patients with CFR <2.0 compared with ≥2.0 (1.9 vs. 5.5%/year, p = 0.0007) but were only borderline associated with CAC (3.1%, 3.4%, and 6.2%/year for CAC of 0, 1 to 399, and ≥400, respectively; p = 0.09). Annualized adjusted MACE was increased in the presence of impaired CFR even among patients with CAC = 0 (1.4% vs. 5.2%, p = 0.03). Cox proportional hazards analysis revealed that CFR improved model fit, risk discrimination, and risk reclassification over clinical risk, whereas CAC only modestly improved model fit without improving risk discrimination or reclassification.

Conclusions

In symptomatic patients with normal MPI, global CFR but not CAC provides significant incremental risk stratification over clinical risk score for prediction of major adverse cardiac events.

Relationship Between Voltage Map “Channels” and the Location of Critical Isthmus Sites in Patients With Post-Infarction Cardiomyopathy and Ventricular Tachycardia

Mountantonakis SE, Park RE, Frankel DS, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

The goal of this study was to determine the relationship of the ventricular tachycardia (VT) isthmus to channels of preserved voltage on an electroanatomic voltage map in postinfarction cardiomyopathy.

Background

Substrate mapping in patients with postinfarction cardiomyopathy and VT may involve lowering the voltage cutoff that defines the scar (<1.5 mV) to identify “channels” of relative higher voltage within the scar. However, the prevalence of channels within the scar identified by using electroanatomic mapping and the relationship to the protected VT isthmus identified by entrainment mapping is unknown.

Methods

Detailed bipolar endocardial voltage maps (398 ± 152 points) from 24 patients (mean age 69 ± 9 years) with postinfarction cardiomyopathy (ejection fraction 33 ± 9%) and tolerated VT were reviewed. Endocardial scar was defined according to voltage <1.5 mV. Isolated late potentials (ILPs) were identified and tagged on the electroanatomic voltage map. The baseline voltage cutoffs were then adjusted until all channels were identified. The VT isthmus was identified using entrainment mapping.

Results

Inferior and anterior/lateral infarction was present by voltage mapping in 18 and 6 patients, respectively (scar area 44 ± 24 cm2). By adjusting voltage cutoffs, 37 channels were identified in 21 (88%) of 24 patients. The presence of ILPs within a channel was seen in 11 (46%) of 24 patients and 17 (46%) of 37 channels. A VT isthmus site was contained within a channel in only 11 of 24 patients or 11 of 37 channels. No difference in voltage characteristics was identified between clinical and nonclinical channels. Voltage channels with ILPs harbored the clinical isthmus with a sensitivity and specificity of 78% and 85%, respectively.

Conclusions

Channels were identified in 88% of patients with VT by adjusting the voltage limits of bipolar maps; however, the specificity of those channels in predicting the location of VT isthmus sites was only 30%. The presence of ILPs inside the voltage channel significantly increases the specificity for identifying the clinical VT isthmus.

Renal Impairment and Ischemic Stroke Risk Assessment in Patients With Atrial Fibrillation The Loire Valley Atrial Fibrillation Project

Banerjee A, Fauchier L, Vourc'h P, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

This study sought to determine the risk of ischemic stroke (IS)/thromboembolism (TE) associated with renal impairment and its incremental predictive value over established risk stratification scores (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke [CHADS2] and congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke, vascular disease, age 65 to 74 years, sex category (female) [CHA2DS2-VASc]) in patients with atrial fibrillation (AF).

Background

Risk stratification schemes for prediction of IS/TE in patients with AF are validated but do not include renal impairment.

Methods

Patients diagnosed with nonvalvular AF and available estimated glomerular filtration rate (eGFR) data in a 4-hospital institution between 2000 and 2010 were identified. The study population was stratified by renal impairment defined by serum creatinine level and by eGFR measured at time of diagnosis of AF. Independent risk factors of IS/TE (including renal impairment) were investigated in Cox regression models. The incremental predictive value of renal impairment over CHADS2 and CHA2DS2-VASc were assessed with the c-statistic, net reclassification improvement, and integrated discrimination improvement. We focused on the 1-year outcomes in our analyses.

Results

Of 8,962 eligible individuals, 5,912 (66%) had nonvalvular AF and available eGFR data. Renal impairment by both creatinine and eGFR definitions was associated with higher rates of IS/TE at 1 year, compared with normal renal function. After adjustment for CHADS2 risk factors, renal impairment did not significantly increase the risk of IS/TE at 1 year (hazard ratio: 1.06; 95% confidence interval [CI]: 0.75 to 1.49 for renal impairment; and hazard ratio: 1.09; 95% CI: 0.84 to 1.41 for eGFR). When renal impairment was added to existing risk scoring systems for stroke/TE (CHADS2 and CHA2DS2-VASc), it did not independently add to the predictive value of the scores, whether defined by serum creatinine level or eGFR. This was evident even when the analysis was confined to only those patients with at least 1 year of follow-up.

Conclusions

Renal impairment was not an independent predictor of IS/TE in patients with AF and did not significantly improve the predictive ability of the CHADS2 or CHA2DS2-VASc scores.

Targeting P-Selectin During Coronary Interventions The Elusive Link Between Inflammation and Platelets to Prevent Myocardial Damage ⁎ ⁎

Alfonso F, Angiolillo DJ. — Tue, 21 May 2013 00:00:00 GMT

Unprecedented advancements in interventional techniques and the advent of new drug-eluting stents coupled with refinements in adjuvant antithrombotic strategies have led to significant improvement in acute procedural success and long-term clinical outcomes after percutaneous coronary interventions (PCI) (1). Currently, PCI remains the most frequent form of coronary revascularization, including complex patients presenting significant clinical and anatomic challenges (1). However, myocardial injury is frequently induced during PCI (2). In particular, brief episodes of transient coronary flow deterioration or distal microembolization of particulated atherothrombotic debris (at the main vessel or its side branches) may be associated with microvascular injury and myocardial inflammation with subsequent increase in cardiac markers (2). This problem—occurring in “angiographically successful” PCI—is more evident in patients undergoing complex and prolonged procedures, particularly when multiple lesions are treated (1,2). Nowadays, the use of very sensitive cardiac markers enables the identification of even subtle degrees of myocardial damage that otherwise would remain clinically unrecognized. The prognostic implications of such troponin increases have been strongly debated (2,3,4). The new universal definition of myocardial infarction recommended that the diagnosis of procedure-related myocardial infarction (type 4a) requires a clear increase (>5 times normal values) in cardiac troponin levels together with objective signs of ischemia (2). Instead, the term myocardial injury should be used in patients with lower troponin levels. Notably, type 4a myocardial infarction, regardless of size, is associated with an increased long-term risk of cardiovascular death, which can be mitigated with the use of more potent antiplatelet treatment regimens (3,4). The availability of these uniquely sensitive and specific biomarkers of cardiac injury also represents a new opportunity to further scrutinize the potential clinical value of several new adjuvant pharmacological therapies aimed to optimize the results of coronary revascularization. In this regard, drugs able to reduce the extent of myocardial injury at an “analytical level” may then gain further promise and eventually emerge as primetime strategies to effectively reduce episodes of clinically relevant myonecrosis and, more importantly, improve long-term prognosis.

Triple Antithrombotic Therapy With Prasugrel in the Stented Patient Concern for More Bleeding ⁎ ⁎

Gurbel PA, Tantry US. — Tue, 21 May 2013 00:00:00 GMT

There is a large body of evidence, including results of prospective trials, that supports oral anticoagulation therapy (OAT) as the optimal strategy to prevent fibrin-centric thrombotic events (FCTEs). Examples of FCTEs include thromboembolism in patients with mechanical heart valves, deep vein thrombosis, and atrial fibrillation (AF) (1). In a large prospective trial, warfarin was found to be superior to dual antiplatelet therapy (DAPT) with aspirin + clopidogrel in the prevention of vascular events in patients with AF plus 1 or more risk factors for stroke (2). European and American guidelines include a Class I recommendation for lifelong OAT in patients with AF who are at moderate to high risk of thromboembolism (3). It has also been demonstrated in prospective, randomized trials that DAPT with aspirin and a thienopyridine is superior to aspirin + warfarin in the prevention of the platelet-centric thrombotic event (PCTE), stent thrombosis (4). In the European and American Guidelines there is a Class I recommendation to administer uninterrupted DAPT for 1 to 12 months depending on the type of stent used (5,6).

Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation

Sarafoff N, Martischnig A, Wealer J, et al. — Tue, 21 May 2013 00:00:00 GMT

Objectives

This study sought to evaluate whether prasugrel may serve as an alternative to clopidogrel in patients with triple therapy.

Background

Approximately 10% of patients who receive dual antiplatelet therapy after percutaneous coronary intervention have an indication for oral anticoagulation and are thus treated with triple therapy. The standard adenosine diphosphate receptor blocker in this setting is clopidogrel. Data regarding prasugrel as part of triple therapy are not available.

Methods

We analyzed a consecutive series of 377 patients who underwent drug-eluting stent implantation and had an indication for oral anticoagulation between February 2009 and December 2011 and were treated with a 6-month regimen of aspirin and oral anticoagulation with either prasugrel or clopidogrel. The primary endpoint was a composite of Thrombolysis In Myocardial Infarction (TIMI) major and minor bleeding at 6 months. The secondary endpoint was a composite of death, myocardial infarction, ischemic stroke, or definite stent thrombosis.

Results

Twenty-one patients (5.6%) received prasugrel instead of clopidogrel. These patients had a higher-risk profile at baseline, and the majority had high platelet reactivity to clopidogrel. TIMI major and minor bleeding occurred significantly more often in the prasugrel compared with the clopidogrel group (6 [28.6%) vs. 24 [6.7%]; unadjusted hazard ratio (HR): 4.6, 95% confidence interval [CI]: 1.9 to 11.4], p < 0.001; adjusted HR: 3.2, 95% CI: 1.1 to 9.1], p = 0.03). There was no significant difference regarding the combined ischemic secondary endpoint (2 [9.5%] vs. 25 [7.0%]; unadjusted HR: 1.4, 95% CI: 0.3 to 6.1], p = 0.61).

Conclusions

These findings suggest that substitution of prasugrel for clopidogrel in patients needing triple therapy increases the risk of bleeding. However, specific randomized trials are needed to define the role of newer adenosine diphosphate receptor antagonists in this setting.

Doubly Obstructive Hypertrophic Cardiomyopathy

Geske JB, Scantlebury DC, Nishimura RA. — Tue, 21 May 2013 00:00:00 GMT

A 40-year-old woman with hypertrophic cardiomyopathy presented with New York Heart Association functional class III dyspnea and angina despite optimal medical therapy. Left heart catheterization with a high-fidelity, micromanometer-tipped left ventricular (LV) catheter through a transseptal approach was performed to determine location and severity of obstruction.

Unilateral Rib Notching in a Tetralogy of Fallot

Sim M. — Tue, 21 May 2013 00:00:00 GMT

A 39-year-old man with an unrepaired tetralogy of Fallot presented with exertional dyspnea and cyanotic spells. Examination revealed lip cyanosis and clubbing of fingers (A). Chest radiograph showed lacy reticular vascularity in bilateral lower lungs and notching of the fourth and fifth right posterior ribs (B, arrows). Cardiac magnetic resonance study revealed right ventricular hypertrophy, a ventricular septal defect, and an overriding aorta (C, Online Video 1), and an angiogram demonstrated pulmonic stenosis and left pulmonary arterial atresia (D, Online Video 2). There were substantial major aortopulmonary collateral arteries (D, Online Video 2, small arrows) perfusing the left and right lower lungs. The right subclavian artery was stenotic with collateral arteries (D, large arrows, Online Video 2) arising proximally with an extrapulmonary intercostal course to the perfuse right lung, which caused unilateral rib notching. The well-developed collateral circulation resembled multiple “palliative shunts,” which alleviated his symptoms for decades.

Hypothermia: Is it Good for the Brain and Not for the Arteries?

Conti C. — Tue, 21 May 2013 00:00:00 GMT

I read with interest the research correspondence letter by Penela et al. (1). As pointed out by the authors, the protocol for induced hypothermia is designed to reduce the temperature of the patient to 32°C to 34°C for up to 24 h. The results of this form of therapy are summarized in the Annals of Neurology (2). Up to two-thirds of patients receiving hypothermia therapy might go home with good function, but recovery of higher intellectual faculties has not been well-studied, and nothing is reported about the effects of hypothermia on atherosclerotic vessels in these patients.

Predictive Value of 6-Min Walk Test Distance Versus Cardiopulmonary Exercise Testing in Systolic Heart Failure Same Value for Different Approaches?

Guazzi M, Bandera F. — Tue, 21 May 2013 00:00:00 GMT

The study by Forman et al. (1) increases the perspectives on how the distance of the 6-min walk test (6MWT) and the measured oxygen uptake (VO₂) and ventilatory efficiency (VE/VCO₂ slope) may add to the prognostic workup of heart failure (HF) patients.

Reply

Forman DE, Fleg JL, Kitzman DW, et al. — Tue, 21 May 2013 00:00:00 GMT

We thank Drs. Guazzi and Bandera for their thoughtful comments in which they assert the value of incorporating multiple variables from cardiopulmonary exercise (CPX) testing to best reflect the complex pathophysiology of chronic heart failure (HF) and thereby maximize its prognostic value. We agree with this concept, and even made a similar point in our paper, “Oscillatory expiratory breathing, end-tidal partial pressure of carbon dioxide, VE/VO₂ ratios, recovery gas exchange dynamics, and heart rate and blood pressure responses are among an extensive array of CPX assessments that can be used to enhance prognostic assessment” (1). Unfortunately, these additional gas exchange variables were not collected as part of the HF-ACTION (Heart Failure–A Randomized Controlled Trial Investigating Outcomes of Exercise Training) trial database.

The Incidence and Clinical Outcome of Constrictive Physiology After Coronary Artery Bypass Graft Surgery

Im E, Shim C, Hong G, et al. — Tue, 21 May 2013 00:00:00 GMT

Previous reports have shown changes in the etiologic spectrum of constrictive pericarditis, characterized mainly by a declining incidence of tuberculous pericarditis and an increase in cases resulting from cardiac surgery (1). Constrictive physiology (CP) not only is found in patients with symptomatic constrictive pericarditis but is also more commonly observed in post-cardiac surgery patients when assessed with comprehensive echocardiographic examination. However, few data are available with regard to echocardiographically observed post-operative CP. Therefore, the purpose of this study was to investigate the incidence and clinical course of CP observed on post-operative echocardiographic examination in patients who had undergone isolated coronary artery bypass graft (CABG) surgery.

The Nanny State and “Coercive Paternalism”

DeMaria AN. — Tue, 21 May 2013 00:00:00 GMT

“The free man owns himself. He can damage himself with either eating or drinking; he can ruin himself with gambling. If he does he is certainly a damn fool, and he might possibly be a damned soul; but if he may not, he is not a free man any more than a dog.”G. K. Chesterton (1) While researching a recent Editor's Page on obesity I came across the concept of the “nanny state,” and was surprised that many of my friends were unfamiliar with the term. The Free Dictionary defines the nanny state variously as: 1) a government that makes decisions for people that they might otherwise make for themselves, especially those relating to private and personal behavior; and 2) a government perceived as having excessive interest in or control over the welfare of its citizens, especially in the enforcement of extensive public health and safety regulations. Obviously, the term has pejorative connotations in and of itself. However, the more I read and thought about it, the more I agonized as to how I felt about a role for government in what are considered private and personal decisions. Since many of the articles we publish have implications regarding health care policy, I thought I would elaborate on the issue in an Editor's Page.