bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Application of a Novel Self-expanding Coronary Stent in Acute Myocardial Infarction
Authors: Spaulding Christian ,   Professor of Cardiology, Paris Descartes University and INSERM U 970, and Director, Catheterisation Laboratory, Cardiology Department, Cochin Hospital, 27 rue du Faubourg Saint Jacques, Paris 75679, France. E: christian.spaulding@cch.ap-hop-paris.fr
Published: August 2014

Acute myocardial infarction (AMI) is a severe coronary condition with potentially fatal consequences. Currently, the standard of care is to perform thromboaspiration followed by stent implantation as part of percutaneous coronary intervention. However, due to the thrombus load and vasoconstriction of the artery during the procedure, there is a tendency to underestimate vessel size, resulting in selection of a stent that will be smaller than the artery after clot resolution and vasodilation. This potentially increases the risk of stent malapposition and subsequent stent thrombosis. A novel self-expandable stent was recently developed; preliminary results from the APPOSITION I study demonstrate its feasibility in the treatment of AMI and its ability to follow the enlargement of the artery with near perfect apposition. This self-expandable stent may therefore become an important tool in the treatment of AMI.
Pitfalls and Challenges in the Echocardiographic Diagnosis of Aortic Stenosis
Authors: Chenzbraun Adrian ,   Department of Cardiology, Royal Liverpool University Hospital, Prescott Street, Liverpool, L7 8XP, UK. E: a.chenzbraun@talktalk.net
Published: August 2014

Aortic stenosis is the most prevalent valvulopathy in the developed world, and increasing numbers of elderly patients are considered for aortic valve replacement. Echocardiography displaced catheterisation from its long-standing use in the diagnosis of aortic stenosis and offers a simple, reliable, non-invasive method that is suitable for follow-up for the assessment of aortic stenosis patients. The truly complex nature of the haemodynamic patterns in these patients is responsible for possible inconsistencies and apparently unclear echocardiographic results. Patients with only mild aortic stenosis as supported by valve appearance and calculated area may nevertheless exhibit surprisingly high gradients. On the other hand, patients with truly severe aortic stenosis may have only modestly elevated gradients, whether due to decreased left ventricular function or to other mechanisms still under investigation. This article reviews the frequently encountered ‘puzzling’ echocardiographic scenarios together with their most likely haemodynamic background and significance in terms of final diagnosis and clinical management.
Blood Pressure Lowering for the Prevention of Stroke Recurrence
Authors: Wang Zengwu , Richart Tom , Jin Yu , Staessen Jan A , Liu Lisheng ,   Division of Hypertension, Fu Wai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing,   Studies Co-ordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Diseases, University of Leuven; Department of Epidemiology, Maastricht University,   Studies Co-ordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Diseases, University of Leuven,   Studies Co-ordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Diseases, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Block D, Level 00, B-3000 Leuven, Belgium. E: jan.staessen@med.kuleuven.be or ja.staessen@epid.unimaas.nl; Department of Epidemiology, Maastricht University,   Division of Hypertension, Fu Wai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
Published: August 2014

Stroke is the second most common cause of mortality worldwide. It is the complication of hypertension that has the most direct link to blood pressure. Hypertension affects nearly 30% of the world’s population. In addition to hypertension, a previous history of cerebrovascular disease is a powerful predictor of stroke recurrence. In a meta-analysis of 10 trials of patients with previous cerebrovascular disease, blood-pressure-lowering treatment reduced systolic blood pressure (ΔSBP) by 5.1mmHg and the risk of stroke recurrence by 22% (p=0.0007) compared with no treatment or placebo. In four trials involving diuretics as a component of therapy (ΔSBP 9.6mmHg), the pooled reduction of stroke recurrence averaged 37% (p<0.0001), whereas it was only 7% in six trials of renin system inhibitors (ΔSBP 4.0mmHg). In metaregression analysis, the weighted correlation co-efficient between the odds for stroke recurrence and the blood pressure reduction was -0.57 (p=0.067). The significant heterogeneity (p<0.0001) between diuretics and renin system inhibitors in the prevention of stroke recurrence might be explained by the greater blood pressure reduction of treatments including diuretics. Our results do not support the use of renin system inhibitors for the prevention of stroke recurrence.
Antiplatelet Therapy in Acute Coronary Syndromes
Authors: Koul Sasha , Erlinge David ,   Resident,   Head, Department of Cardiology, Lund University Hospital, SE-22185 Lund, Sweden. E: david.erlinge@med.lu.se
Published: August 2014

Drugs inhibiting platelet function play a major role in the treatment of acute coronary syndromes (ACS). The first drug used, which is still considered the cornerstone of therapy today, is aspirin. Although very impressive in acutely decreasing rates of myocardial infarction as well as death, long-term data are scarce, despite our current recommendation for lifelong aspirin. The thienopyridines, most notably clopidogrel, are the next line of antiplatelet drugs. Well-documented data support the usage of clopidogrel for non-STEMI-ACS (NSTE-ACS). Although positive mortality data exist regarding clopidogrel and STEMI patients in a medically treated population, including thrombolysis, no larger amounts of randomised data exist in a primary PCI setting. Poor responders to aspirin and/or clopidogrel are a clinical problem, with these individuals constituting a higherrisk group for recurrent ischaemic events. Whereas very little can be done regarding aspirin resistance, clopidogrel resistance might be diminished by increasing the dosage or changing to more potent and newer-generation antiplatelet drugs. The role of glycoprotein IIb/IIIa inhibitors has diminished drastically and instead paved the way for thrombin antagonists (bivalirudin), which have fewer bleeding complications with resulting better long-term mortality. Novel adenosine diphosphate (ADP)-receptor blockers such as prasugrel and ticagrelor have shown increased efficacy over clopidogrel and hold great promise for the future. However, not all patients may benefit from these new drugs and economic constraints may also limit their use. Platelet function tests could possibly help in identifying risk groups in need of stronger platelet inhibition.
Management of the Asymptomatic Diabetic Patient with Evidence of Ischaemia
Authors: Bliagos Dimitrios , Kirtane Ajay J , Moses Jeffrey W ,   Center for Interventional Vascular Therapy, Columbia University Medical Center/New York Presbyterian Hospital,   Center for Interventional Vascular Therapy, Columbia University Medical Center/New York Presbyterian Hospital,   Center for Interventional Vascular Therapy, Columbia University Medical Center/New York Presbyterian Hospital, 161 Fort Washington Avenue 5th Fl, New York, NY 10032, US. E: jmoses@crf.org
Published: August 2014

In the US, a total of 23.6 million people have diabetes, representing 7.8% of the population, and the prevalence of diabetes is on the rise due to an increasingly sedentary lifestyle, increasing obesity and an ageing population. Coronary artery disease is the leading cause of death in patients with diabetes, despite a reduction in cardiovascular events over the last 50 years, due in part to better medical therapy. Asymptomatic diabetic patients with evidence of ischaemia on stress testing have higher cardiac mortality; increasing amounts of ischaemia are associated with higher mortality rates. Revascularisation of high-risk patients, or those with significant ischaemia, has the potential to improve outcomes in this patient population. The choice of which revascularisation strategy to choose – either percutaneous coronary intervention (PCI) or coronary artery bypass grafting – should be carefully individualised, and must always be implemented against the background of optimal medical therapy.
Percutaneous Heart Valve Therapy – Options, Risks and Benefits
Authors: Ussia Gian Paolo , Barbanti Marco , Cammalleri Valeria , Scarabelli Marilena , Mulè Massimiliano , Tamburino Corrado ,   Division of Cardiology, Ferrarotto Hospital, University of Catania; Excellence Through Newest Advances (ETNA) Foundation,   Division of Cardiology, Ferrarotto Hospital, University of Catania,   Division of Cardiology, Ferrarotto Hospital, University of Catania,   Division of Cardiology, Ferrarotto Hospital, University of Catania,   Division of Cardiology, Ferrarotto Hospital, University of Catania,   Director of Cardiology Division, Post-graduate School of Cardiology, Ferrarotto Hospital, University of Catania, Italy. E: tambucor@unict.it; Excellence Through Newest Advances (ETNA) Foundation
Published: August 2014

Transcatheter valve therapy is emerging as an effective option for aortic valve stenosis and mitral regurgitation. In 1992, Anderson demonstrated the feasibility of percutaneous implantation of catheter-based valve prosthesis. Since then, many technical and device advances have been made, and transcatheter aortic valve implantation and mitral valve repair have became a concrete alternative to surgical replacement.
Latest Strategies and Patient Outcomes in the Treatment of ST-segment-elevation Myocardial Infarction
Authors: Sánchez Pedro L , Calleja Isaac Pascual , Bueno Héctor , Fernández-Avilés Francisco ,   Cardiology Service, Hospital General Universitario Gregorio Marañón,   Cardiology Service, Hospital General Universitario Gregorio Marañón,   Cardiology Service, Hospital General Universitario Gregorio Marañón,   Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain. E: faviles@secardiologia.es
Published: August 2014

The goal of treatment strategies for patients with ST-segment-elevation myocardial infarction (STEMI) is to reperfuse the occluded coronary artery as rapidly and safely as possible. This article discusses evidence in terms of the latest appropriate treatment strategies for patients with STEMI, taking into consideration timing and logistical barriers. We also present the reperfusion pathway we use.
Cardiac Resynchronisation Therapy – Evolving Strategies to Enhance Response
Authors: Singh Jagmeet P ,   Associate Professor of Medicine, and Director, Cardiac Resynchronization Therapy Program, Cardiac Arrhythmia Service, Massachusetts General Hospital Heart Center, Harvard Medical School, Boston, MA 02114, US. E: jsingh@partners.org
Published: August 2014

Cardiac resynchronisation therapy (CRT) has gained widespread acceptance as a safe and effective therapeutic strategy for congestive heart failure (CHF) refractory to optimal medical therapy. The use of implantable devices has substantially altered the natural history of systolic heart failure. These devices exert their physiological impact through ventricular remodelling, associated with a reduction in left ventricular (LV) volumes and an improvement in ejection fraction (EF). Several prospective randomised studies have shown that this in turn translates into long-term clinical benefits such as improved quality of life, increased functional capacity and reduction in hospitalisation for heart failure and overall mortality. Despite these obvious benefits, there remain more than a few unresolved concerns, the most important being that up to one-third of patients treated with CRT do not derive any detectable benefit. There are several determinants of successful delivery and response to CRT, including selecting the appropriate patient, patient-specific optimal LV pacing lead placement and appropriate post-implant device care and follow-up. This article highlights the importance of collectively working on all of these aspects of CRT to enhance and maximise response.
Controlling Blood Pressure without Drugs – Developing New Strategies
Authors: Schlaich Markus P , Esler Murray D ,   Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute and Heart Centre, Alfred Hospital, Melbourne, PO Box 6492, St Kilda Road Central, Melbourne Victoria 8008, Australia. E: markus.schlaich@bakeridi.edu.au,   Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute and Heart Centre, Alfred Hospital, Melbourne
Published: August 2014

Non-optimal blood pressure is the leading cause of death globally, and each year is responsible for seven million deaths. Current therapeutic strategies for hypertension are mainly based on lifestyle interventions and pharmacological approaches, but rates of blood pressure control remain unsatisfactory and additional options are required. In this context, novel device-based approaches specifically targeting the sympathetic nervous system as a major player in blood pressure control have recently been tested clinically with promising results. Device-based approaches may provide additional and more effective treatment of hypertension and its adverse consequences in the future.
Hypertensive Heart Disease – Diagnosis, Prognostic Value and Changes During Antihypertensive Treatment, Left Ventricular Structure and Function
Authors: Wachtell Kristian ,   Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. E: kristian@wachtell.net
Published: August 2014

Hypertensive heart disease is prevalent and during the last decade it has been determined that patients with left ventricular (LV) hypertrophy have increased cardiovascular morbidity and mortality. However, many have doubted the effectiveness of LV mass assessment because it is difficult to measure, and there were no data showing a relation between reduced LV mass and improvement in LV systolic and diastolic function and improved cardiovascular outcome. However, improvements to echocardiographic equipment have made it possible to measure LV mass with the same precision as for aortic valve replacement. Reduction of LV hypertrophy, independent of the simultaneous blood pressure reduction, is associated with large improvements in cardiovascular morbidity and mortality. A reduction in LV mass by 25g/m² leads to a 34% reduction in cardiovascular mortality. Time-varying analyses showed 66% associated risk reduction in cardiovascular mortality if patients with LV hypertrophy were treated to limits of LV mass. Hypertension causes impaired LV systolic function by increased afterload and LV hypertrophy. Normal estimations of LV ejection fraction tend to overestimate LV systolic function; however, improvement of LV systolic function by antihypertensive treatment leads to an improvement of cardiovascular morbidity and mortality. Furthermore, even though there is significant improvement in LV diastolic function during antihypertensive treatment, this occurs more slowly compared with the treatment effects on LV systolic function, and diastolic function does not, compared with LV systolic function, translate into improvement in cardiovascular morbidity and mortality. The perspective of finding cardiac target organ damage is used not only to classify the cardiovascular risk of patients, but also to indicate to the treating physician that specific treatment is needed.
Adjusting Therapy in Pulmonary Arterial Hypertension – The Role of Novel Echocardiographic Techniques
Authors: Coghlan John G , Pellerin Denis ,   Royal Free Campus, Department of Cardiology, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. E: Gerry.Coghlan@royalfree.nhs.uk,   The Heart Hospital, University College London
Published: August 2014

In theory, echocardiography allows an accurate measurement of pulmonary artery pressure, approximate right atrial pressure, cardiac output, right ventricular diastolic function and non-volumetric assessment of systolic function, as well as some insight into the structural alterations of right ventricular architecture. Unfortunately, the vast array of possible measures complicates distillation of the few parameters that provide reproducible prognostically important information. The modest reductions in afterload achieved with current therapies (<5mmHg on average) and the unpredictability of right ventricular response, coupled with the complexity of the populations treated, means that only large-scale survival studies should be considered when determining which parameters inform patient management. Of currently widely used measures, only tricuspid annular plane systolic excursion (TAPSE) and pericardial effusion are recommended when adjusting therapy. Increased use of contrast echo, strain rate imaging, vector velocity imaging and 3D echocardiography appear to hold most hope for the future; however, none as yet has the database to support inclusion in standard clinical practice.
Prognostic Value of Stress Myocardial Single-photon-emission Computed Tomography in the Elderly
Authors: Dellegrottaglie Santo , Costanzo Pierluigi , Paolillo Stefania , Marciano Caterina , Gargiulo Paola , Cuocolo Alberto , Chiariello Massimo , Perrone-Filardi Pasquale ,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples, Zena and Michael A Wiener Cardiovascular Institute, and Marie-Josée and Henry R Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples,   Department of Biomorphological and Functional Sciences, Federico II University, Naples,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples,   Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Federico II University, Via S Pansini 5, Naples 80131, Italy. E: fpperron@unina.it
Published: August 2014

Elderly subjects are expected to account for 30% of the European population by 2050. Currently, more than two-thirds of all cardiovascular deaths are registered in subjects >65 years of age. In the elderly, exercise electrocardiogram (ECG) testing (EET) may be more difficult both to perform and to interpret compared with the situation in younger subjects, but it is still recommended as the initial non-invasive method for evaluating coronary artery disease (CAD). Single-photon-emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) has demonstrated the ability to successfully stratify risk of adverse cardiac events in elderly (>65 years of age) as well as in very elderly (>80 years of age) patients. The finding of a normal MPS study in an elderly patient has been repeatedly associated with a low level of risk (~1% annual event rate). Practical advantages over EET are the possibility of accurately identifying myocardial ischaemia in the large subgroup of elderly subjects with ECG abnormalities and of using pharmacological stress in subjects unable to exercise.
Angiography for Diagnosing Peripheral Arterial Occlusive Disease – A Technical, Clinical and Cost Comparison of Contrast-enhanced Magnetic Resonance Angiography and Unenhanced Magnetic Resonance Imaging Techniques with a Focus on Fresh Blood Imaging
Authors: Schwenke Carsten , Boos Monica , Hentrich Rainer , Blankenburg Michael , Rohrer Martin ,   Schwenke Consulting: Strategies and Solutions in Statistics (SCO:SSiS), SCO:SSiS, Zeltinger Str 58g, 13465 Berlin, Germany. E: carsten.schwenke@scossis.de,   Bayer Schering Pharma AG,   Radiological Centre, Rottweil,   Bayer Schering Pharma AG,   Bayer Schering Pharma AG
Published: August 2014

This study compares the clinical and technical utility of non-contrast-enhanced magnetic resonance angiography (nce-MRA) and contrastenhanced MRA (ce-MRA) in a mini-review of patients with suspected peripheral arterial occlusive disease (PAOD) in whom both MRA approaches were indicated. It also looks at the costs of angiography for diagnosing peripheral arterial occlusive disease using either ce-MRA or nce-MRA in comparison with the example of fresh blood imaging (FBI). The costs for MRA were taken from a previous cost study and those for nce-MRA/FBI from published data and appropriate calculations. The average total investigation costs for ce-MRA were found to be €205, including €59 for consumables, mainly originating from the contrast agent costs (according to German list prices for 2009). On the other hand, for nce-MRA, average total costs ranged from €190 to €239, depending on the acquisition time (12–32 minutes), and a larger number of additional diagnostic investigations were found. Irrespective of costs, several clinical and technical benefits such as image quality, higher robustness and the absence of limitations with complex vessel courses favoured ce-MRA. The consequences of using ce-MRA were fewer technical failures and, therefore, a higher throughput of patients indicated for contrast agent use in the radiology department; this led to more procedures per day and, therefore, more efficient use of diagnostic imaging resources.
Mitralign Percutaneous Annuloplasty System for the Treatment of Functional Mitral Regurgitation
Authors: Mandinov Lazar , Asch Federico M , Grube Eberhard ,   Mitralign Inc., 3 Highwood Drive, Tewksbury, MA 01876, US. E: lmandinov@mitralign.com,   Washington Hospital Center and Medstar Health Research Institute,   Elisabeth Hospital, Essen
Published: August 2014

Mitralign, Inc. (Tewksbury, MA) has developed a proprietary mitral valve repair system that attempts to mimic surgical suture annuloplasty. The Mitralign system is a set of devices approaching the posterior mitral annulus through the left ventricle. A steerable catheter is delivered via a 12.5Fr deflectable guide catheter between the papillary muscles facing the posterior annulus. The steerable catheter and a two-arm (Bident) catheter help place two pairs of wires through the annulus at the P1 and P3 locations. Each crossing wire is passed into the left atrium under transoesophageal (TEE) guidance. Once the wire pair is placed at one location, surgical pledgets are delivered over the wires and anchored across the annulus. The pledgets are pulled together to decrease the annulus circumference and the achieved plication is locked in place. Once the entire procedure is completed at one location, the next wire pair is placed at the other scallop location. TEE is an enabling imaging modality for the Mitralign procedure, which is performed with close collaboration between interventional cardiologists and echocardiologists.
Cardiac Resynchronisation Therapy in Heart Failure Patients with Atrial Fibrillation
Authors: Gasparini Maurizio , Cappelleri Alessio , Galimberti Paola , Ceriotti Carlo , Montorio Angelica ,   IRCCS Istituto Clinico Humanitas, Rozzano/Milano, Via Manzoni 56 RozzanoMilan, Italy. E: maurizio.gasparini@humanitas.it,   IRCCS Istituto Clinico Humanitas, Rozzano/Milano,   IRCCS Istituto Clinico Humanitas, Rozzano/Milano,   IRCCS Istituto Clinico Humanitas, Rozzano/Milano,   IRCCS Istituto Clinico Humanitas, Rozzano/Milano
Published: August 2014

Cardiac resynchronisation therapy (CRT) is an important device-based, non-pharmacological approach that has been shown to improve left ventricular (LV) function and reduce both morbidity and mortality rates in selected patients affected by advanced heart failure (HF), with New York Heart Association (NYHA) functional class III–IV, ejection fraction (EF) ≤35%, QRS duration ≥120ms and on optimal medical therapy. Patients with atrial fibrillation (AF), who constitute an important subgroup of HF patients, are nowadays considered eligible for receiving CRT as described in the latest European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines, with some relevant differences in terms of how to manage the interference of natural rhythm and biventricular pacing. In this article, the authors explain how AF may interfere with adequate CRT delivery and how to manage different AF burdens, trying to obtain the best effects of CRT in AF patients.
Echocardiographic Assessment of Diastolic Heart Failure
Authors: Popescu Bogdan A , Beladan Carmen C , Ginghină Carmen ,   ‘Carol Davila’ University of Medicine and Pharmacy, ‘Professor Dr CC Iliescu’ Institute of Cardiovascular Diseases, Bucharest, Sos Fundeni 258, Sector 2, 022328 Bucharest, Romania. E: bogdan.a.popescu@gmail.com,   ‘Carol Davila’ University of Medicine and Pharmacy, ‘Professor Dr CC Iliescu’ Institute of Cardiovascular Diseases, Bucharest,   ‘Carol Davila’ University of Medicine and Pharmacy, ‘Professor Dr CC Iliescu’ Institute of Cardiovascular Diseases, Bucharest
Published: August 2014

A normal ejection fraction (EF) is present in >50% of patients with clinical features of heart failure (HF). This entity has been referred to as HF with normal EF (HFNEF), or diastolic HF. The underlying pathophysiology of HFNEF is still under debate and this is reflected in the unsatisfactory results of pharmacological treatment and in the high mortality and morbidity rates, which are similar to those for systolic HF. By providing evidence of left ventricular (LV) diastolic dysfunction in patients with clinical features of HF and normal LVEF, echocardiography, the most practical and widely available diagnostic modality, can offer two of the three current diagnostic criteria for HFNEF. Moreover, abnormalities in LV myocardial deformation and torsional dynamics at rest and during exercise were recently demonstrated in HFNEF patients by echocardiography. Newer echocardiographic parameters may improve the understanding of this complex entity, but further studies are needed before using them in clinical practice for the diagnostic and therapeutic approach of patients with HFNEF. This article discusses the current echocardiographic approach to the diagnosis of diastolic HF, as well as the potential role of newer echo indices and modalities.
Implications of Remodelling in Atrial Fibrillation Therapy
Authors: Girmatsion Zenawit , Ehrlich Joachim R ,   Division of Cardiology, Section of Electrophysiology, JW Goethe University, Frankfurt,   Assistant Professor of Medicine, Division of Cardiology, Section of Electrophysiology, JW Goethe University, Frankfurt, Germany. E: j.ehrlich@em.uni-frankfurt.de
Published: August 2014

Atrial fibrillation (AF) is a common arrhythmia that in most cases occurs secondary to other (mostly cardiac) disorders. AF itself has a prominent tendency to alter various properties of the human heart that eventually stabilise the arrhythmia and may lead to complications of the disease. Due to its great prevalence and rising incidence, improved treatment options for AF are eminent targets of basic and clinical research and industrial development. This article covers the consequences in terms of electrical, structural and endothelial/inflammatory remodelling associated with AF and respective therapeutic options arising from such alterations. For instance, atrial-specific antiarrhythmic drugs have been found to exploit properties of electrically remodelled atria, early antifibrotic therapy with angiotensin-converting enzyme inhibitors may be beneficial in preventing structural changes and reversal of endothelial dysfunction may be helpful in reducing AF-associated complications. Research during the past two decades has provided profound, novel insights that might turn into therapeutic benefit for affected patients in the near future.
Atrial Fibrillation and Flecainide – Safety, Effectiveness and Quality of Life Outcomes
Authors: Provenier Frank , Droogmans Steven ,   Cardiologist, Department of Cardiology, AZ Maria Middelares Ghent, Dienst Cardiologie, Kortrijksesteenweg 1026, 9000 Gent, Belgium. E: frankprovenier@azmmsj.be,   Cardiologist, Department of Cardiology, AZ Maria Middelares Ghentl; Cardiologist, Department of Cardiology, UZ Brussels
Published: August 2014

Flecainide is a class IC antiarrhythmic agent indicated for patients with atrial fibrillation without any evidence of structural heart disease. This brief review of four recent studies on flecainide focuses on safety aspects, efficacy and the debate on impact on quality of life in this patient population. This article also briefly summarises data from the Cardiac Arrhythmia Suppression Trial (CAST) and the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, which investigated the effect of antiarrhythmics such as flecainide on morbidity and mortality. When administered according to recommended guidelines, flecainide is safe and is not associated with increased mortality. It is effective for the treatment of atrial fibrillation, improving quality of life in these patients.
Atrial Fibrillation Electroanatomical 3D Mapping Optimisation Thanks to a Novel High-density Mapping Catheter – The Inquiry™ AFocus™ II
Authors: Jean-Paul Albenque , Chaumeil Arnaud , Combes Stephane , Senouf David , Martins Luis , Deplagne Antoine , Combes Nicolas , Boveda Serge ,   Department of Rythmology, Clinique Pasteur, Department of Electrophysiology and Pacing/Defibrillation, Clinique Pasteur, 43–45 avenue de Lombez 31076 Toulouse Cedex 3, France. E: j.albenque@clinique-pasteur.com,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse,   Department of Rythmology, Clinique Pasteur, Toulouse
Published: August 2014

The OneMap™ tool, a new software feature of the EnSite Velocity™ System, and the new Inquiry™ AFocus™ II double loop duodecapolar diagnostic catheter (DDC) were created to provide faster data collection to efficiently deal with complex arrhythmias such as persistent atrial fibrillation ablation (AF). Our study was performed to compare acquisition criteria, time needed to create the maps, number of collected points, relevance of complex fractionated atrial electrogram (CFE) mapping and correlation between CFE maps with the new DDC and a 4mm irrigated ablation catheter (ABL), Therapy™ Cool Path™ Duo, using the OneMap tool. Ten patients undergoing persistent AF ablation were enrolled. With the DDC, more points were collected (485±173 versus 183±37) and the time needed to create CFE maps was shorter (12±4 versus 24±2 minutes). There were 39 zones detected with the DDC against 35 with the ABL. The correlation between the maps was 80%; however, four additional regions were detected with the DDC (an 11% increase). In conclusion, the Inquiry AFocus II DDC is a feasible, fast and accurate tool for automatic CFE mapping using OneMap.
Current Status and Future Directions of Ventricular Arrhythmia Ablation
Authors: Zeppenfeld Katja , Schalij Martin J ,   Department of Cardiology, Leiden University Medical Centre, Postbus 9600, 2300 RC Leiden, The Netherlands. E: k.zeppenfeld@lumc.nl,   Department of Cardiology, Leiden University Medical Centre
Published: August 2014

Ventricular tachycardia (VT) catheter ablation has evolved over the past decade, allowing effective treatment of haemodynamically unstable and epicardial VTs in patients with structural heart disease previously not amenable to ablation. Catheter ablation reduces VT recurrences and thereby implantable cardioverter–defibrillator (ICD) shocks in 67–75% of patients, with a low incidence of procedure-related complications when performed in highly experienced centres. It can be life-saving in patients with electrical storm. Early use of ablation can be considered in selected patients who receive an ICD as an alternative to drug therapy provided that the procedure can be performed safely. Although acute results are promising, outcomes over the long-term are less favourable. An improved understanding of the VT substrate is mandatory for further advancement of a substrate-based ablation approach. Pre-procedural and intra-procedural imaging are likely to contribute to this. Whether catheter ablation will become first-line treatment for VT in structural heart disease and ultimately allow ICD implantation to be avoided in selected patients needs further evaluation.
Implantable Monitors – Recent Developments
Authors: Sommer Philipp , Hindricks Gerhard ,   Cardiologist and Consultant, Heart Centre Leipzig, Cardiology, Department of Electrophysiology, Struempellstr 39, 04289 Leipzig, Germany. E: philipp.sommer@herzzentrum-leipzig.de,   Heart Centre, Leipzig
Published: August 2014

For many years implantable cardiac monitors have proved to be helpful diagnostic tools for illuminating mechanisms of syncopes and documenting symptomatic arrhythmias in selected patients. With an increasing number of patients being treated interventionally for atrial fibrillation (AF), continuous rhythm monitoring with implantable devices can help to address several unsolved questions in this field, such as the true AF burden after an ablation procedure, the percentage of completely asymptomatic recidives and the long-term efficacy of catheter ablation, and can thereby influence the timing for discontinuation of antiarrhythmic drug treatment or even oral anticoagulation. The recently published Reveal® XT Performance Trial (XPECT) quantified the performance of the first implantable cardiac monitor with dedicated AF detection capabilities. In this validation study the AF detection algorithm was proved to deliver reliable detection of the presence or absence of AF. In addition, the AF burden could be reliably assessed and quantified. In the future, continuous monitoring strategies may be helpful to overcome the shortcomings of non-continuous monitoring and may be able to better document AF recurrence, identify the type of recurrence and document the burden of AF.
Quantification by Speckle Tracking at Rest and During Stress
Authors: Cuculi Florim , Zuber Michel , Erne Paul ,   Department of Cardiology, John Radcliffe Hospital, Oxford,   Department of Cardiology, Luzerner Kantonsspital, Luzern,   Department of Cardiology, Kantonsspital Luzern, 6000 Luzern 16, Switzerland. E: paul.erne@ksl.ch
Published: August 2014

The introduction of speckle tracking imaging and the opportunity to objectify regional myocardial function in an angle-independent fashion has opened a wide array of opportunities. Quantitative echocardiography is likely to reduce intra-observer variability and shorten learning curves and this will allow broader use of these new imaging modalities in clinical routine and for research purposes. Tissue Doppler is used for deformation imaging, but has disadvantages that can be overcome with 2D speckle tracking. This article briefly summarises the technical details of 2D speckle tracking (strain and strain rate) and gives an overview on current and potential future applications of this new technique at rest and during stress.
Use of Antiarrhythmic Medications in Women
Authors: Lampert Rachel ,   Associate Professor of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, Yale Cardiology, 333 Cedar Street, FMP 3 New Haven, CT 06520, US. E: rachel.lampert@yale.edu
Published: August 2014

Women are more susceptible than men to pro-arrhythmia from QT-interval-prolonging agents. This increased vulnerability stems from longer repolarisation in women. The specific mechanisms of this difference include protective effects of testosterone and potential QT-prolonging effects of oestrogen. Differences between men and women in underlying electrophysiological properties of the myocardium, and possibly differences in acute autonomic responses, also play a role. Care should be taken in the use of QT-prolonging drugs in women.
Diagnosis and Ablation of Fascicular Tachycardia
Authors: Nogami Akihiko ,   Director, Heart Rhythm Management, Yokohama Rosai Hospital, and Clinical Professor of Cardiology, Tokyo Medical and Dental University, School of Medicine, 3211 Kozukue, Kohoku, Yokohama, Kanagawa 222-0036, Japan. E: akihiko-ind@umin.ac.jp
Published: August 2014

Verapamil-sensitive fascicular ventricular tachycardia (VT) is the most common form of idiopathic left VT. According to the QRS morphology and the successful ablation site, left fascicular VT can be classified into three subgroups: left posterior fascicular VT, whose QRS morphology shows right bundle branch block (RBBB) configuration and superior axis (common form); left anterior fascicular VT, whose QRS morphology shows RBBB configuration and right-axis deviation (uncommon form), and upper septal fascicular VT, whose QRS morphology shows narrow QRS configuration and normal or right-axis deviation (rare form). Posterior and anterior fascicular VT can be successfully ablated at the posterior or anterior mid-septum with a diastolic Purkinje potential during VT or at the VT exit site with a fused pre-systolic Purkinje potential. Upper septal fascicular VT can also be ablated at the site with diastolic Purkinje potential at the upper septum. Recognition of the heterogeneity of this VT and its unique characteristics should facilitate appropriate diagnosis and therapy.
Personalised Antiplatelet Therapy – Whether to Choose Genotype or Phenotype
Authors: Bonello Laurent ,   Intensive Care and Interventional Cardiology Unit, Department of Cardiology, Hopital Nord, Chemin des Bourrely, 13015 Marseille, France. E: laurentbonello@yahoo.fr
Published: August 2014

A significant proportion of patients do not achieve optimal platelet reactivity inhibition after a loading dose of clopidogrel. The large interindividual variability in clopidogrel responsiveness is related to several factors, including the genetic polymorphism of hepatic cytochromes 2C19 2*, which has recently been highlighted by a US Food and Drug Administration (FDA) warning. In fact, patients exhibiting reduced clopidogrel metabolism and/or low clopidogrel responsiveness (i.e. high on-treatment platelet reactivity) have an increased rate of thrombotic events following percutaneous coronary intervention. In this article, current knowledge on this important clinical issue is summarised. While the future of genetic testing remains undetermined, several trials are under way to demonstrate the potential utility of platelet reactivity testing with P2Y12-ADP receptor antagonists.
Diagnosis of Acute Myocardial Infarction Using Highly Sensitive Cardiac Troponin Assays
Authors: Reiter Miriam , Reichlin Tobias , Twerenbold Raphael , Mueller Christian ,   Department of Internal Medicine,   Department of Cardiology, University Hospital Basel,   Department of Internal Medicine,   Department of Internal Medicine, University Hospital Basel, Petersgraben 4, Basel CH-4031, Switzerland. E: chmueller@uhbs.ch; Department of Cardiology, University Hospital Basel
Published: August 2014

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality worldwide. Determining the level of cardiac troponins (cTn), structural proteins unique to the heart, is a cornerstone of AMI diagnosis. One important limitation of standard cTn assays is a sensitivity deficit at presentation due to a delayed increase of circulating cTn levels. Recent multicentre studies have shown that novel, more sensitive and more precise cTn assays improve the early diagnosis of AMI. cTn must be interpreted as a quantitative variable. ‘Detectable’ levels will become the standard and must be clearly differentiated from ‘elevated’ levels. The differential diagnosis of a small amount of cardiomyocyte necrosis and, therefore, mild elevation of cTn, is broad and includes acute and chronic disorders. The differential diagnosis of more extensive cardiomyocyte necrosis, and therefore substantial elevation of cTn, is much smaller and largely restricted to AMI, myocarditis and Tako-Tsubo cardiomyopathy.
Hypertension in Octogenarians – Treatment Strategies and Challenges
Authors: Mackenzie Isla S , MacDonald Thomas M ,   Medicines Monitoring Unit and Hypertension Research Centre, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Isla S Mackenzie, Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Mailbox 2, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK. E: i.s.mackenzie@dundee.ac.uk,   Medicines Monitoring Unit and Hypertension Research Centre, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School
Published: August 2014

The demographics of westernised countries are changing and older people now represent a larger and increasing proportion of the overall population. Since age is a potent risk factor for hypertension, this has resulted in many more octogenarians and older who require antihypertensive therapy. In this article we discuss the evidence base for drug treatment of octogenarians and older. We discuss the choice of drug therapies and outline some of the features that make treatment of such patients a challenge, in particular drug intolerance. We discuss the role of prescribing multiple low-dose therapies to increase the benefits while mitigating the adverse effects. We also discuss the thorny issues of polypharmacy and resistant hypertension and finally we discuss the role of ambulatory blood pressure monitoring as a tool for avoiding blood pressure misclassification in older subjects.
Emerging Cardiac Resynchronisation Therapy Indications
Authors: Eitel Charlotte , Hindricks Gerhard , Piorkowski Christopher ,   Electrophysiology Fellow, Charlotte Eitel, University of Leipzig, Heart Center, Department of Electrophysiology, Strümpellstrasse 39, 04289 Leipzig, Germany. E: charlotteeitel@gmx.de,   Director,   Head Consultant, Department of Electrophysiology, University of Leipzig Heart Centre
Published: August 2014

Cardiac resynchronisation therapy (CRT) is an efficacious and cost-effective therapy in patients with highly symptomatic systolic heart failure and delayed ventricular conduction. Current guidelines recommend CRT as a class I indication for patients with sinus rhythm, New York Heart Association (NYHA) functional class III or ambulatory class IV, a QRS duration ≥120ms, and left ventricular ejection fraction (LVEF) ≤35%, despite optimal pharmacological therapy. Recent trials resulted in an extension of current recommendations to patients with mild heart failure, patients with atrial fibrillation, and patients with an indication for permanent right ventricular pacing with the aim of morbidity reduction. The effectiveness of CRT in patients with narrow QRS, patients with end-stage heart failure and cardiogenic shock, and patients with an LVEF >35% still needs to be proved. This article reviews current evidence and clinical applications of CRT in heart failure and provides an outlook on future developments.
Implantable Cardiac Monitors for the Detection of Atrial Fibrillation – How Far Have We Come?
Authors: Meyer Christian , Martinek Martin , Pürerfellner Helmut ,   Department of Cardiology, Public Hospital Elisabethinen, University of Düsseldorf, Medical Faculty, Division of Cardiology, Pneumology and Angiology, Moorenstr. 5, 40225 Düsseldorf, Germany. E: Christian.Meyer@med.uni-duesseldorf.de; Division of Cardiology, Pneumology and Angiology, Department of Medicine, Heinrich-Heine-University Düsseldorf,   Department of Cardiology, Public Hospital Elisabethinen, Linz,   Department of Cardiology, Public Hospital Elisabethinen, Academic Teaching Hospital of the Universities of Innsbruck and Graz, Fadingerstrasse 1, A-4010 Linz, Austria. E: helmut.puererfellner@elisabethinen.or.at
Published: August 2014

Symptoms are insensitive and non-specific for the diagnosis of atrial fibrillation (AF). Extensive Holter monitor recordings are essential to correctly diagnose AF and, subsequently, to inform therapeutic decisions for its management. Pacemakers and implantable cardioverter defibrillators that detect atrial arrhythmias are a valuable resource for the investigation and quantification of AF. The application of these monitoring systems, however, is limited to a relatively small number of patients. Additional monitoring technologies are therefore necessary to detect the large number of asymptomatic AF episodes, as well as their resulting morbidities (including stroke and heart failure) and mortality. New, non-invasive systems could allow outsourcing of long-term Holter monitoring from the hospital, with attendant improvements in the extent of Holter monitoring and the quality of recording results. Subcutaneous implantable systems, with automated detection algorithms for atrial arrhythmias, represent a new opportunity for long-term rhythm monitoring. In summary, improving implantable cardiac monitors for AF detection could allow us not only to objectively evaluate the efficacy of different therapies but also to refine the future therapeutic management of AF.
Prevention of Thromboembolism in Atrial Fibrillation Patients
Authors: Kuzniatsova Nadzeya , Lip Gregory YH ,   University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham,   University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, UK. E: g.y.h.lip@bham.ac.uk
Published: August 2014

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial morbidity and mortality, particularly due to thromboembolic complications. Antithrombotic therapy reduces the risk of stroke and other thromboembolic events, with the greatest benefit seen in individuals at the highest absolute risk of stroke. There is increasing recognition of the superiority of oral anticoagulation over antiplatelet therapy for stroke prevention in atrial fibrillation. Nevertheless, oral anticoagulation is underused, especially in elderly people, which may in part be explained by uncertainty in the assessment of both risk of stroke and bleeding in an individual patient. The new European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation, which have recently been updated, recommend a risk-factor-based approach to thromboprophylaxis in patients with atrial fibrillation and provide practical tools for the assessment of individual risk. In this article we summarise strategies for prevention of thromboembolism in patients with atrial fibrillation as recommended by the ESC guidelines. New oral anticoagulants are also discussed.
Overview of Treatment Options for Critical Limb Ischaemia Patients
Authors: Baumann Frederic , Diehm Nicolas ,   Clinical and Interventional Angiology, Swiss Cardiovascular Centre, Inselspital, University Hospital Berne,   Director of Vascular Research, Swiss Cardiovascular Centre, Clinical and Interventional Angiology, Inselspital, University Hospital Berne, Switzerland. E: diehm@gmx.ch
Published: August 2014

Patients with critical limb ischaemia (CLI) constitute a subgroup of patients with particularly severe peripheral arterial occlusive disease (PAD). Treatment modalities for these patients that often exhibit multilevel lesions and severe vascular calcifications are complicated due to multiple comorbidities, i.e. of cardiac and vascular but also of renal origin. These need to be taken into consideration while planning treatment options. Although CLI is associated with considerably high morbidity and mortality rates, the clinical outcome of patients being subjected to revascularisation has improved substantially in recent years. This is mainly due to improved secondary prevention strategies as well as dedicated endovascular innovations for this most challenging patient cohort. The aim of this article is to provide a discussion of the contemporary treatment concepts for CLI patients with a focus on arterial revascularisation.