BMJ Heart Asia Last 6 Issues

Serum myeloperoxidase: a novel biomarker for evaluation of patients with acute coronary syndrome

Thu, 15 Oct 2009 15:06:05 PDT

Objectives: Myeloperoxidase, an abundant leucocyte enzyme, is elevated in culprit lesions that have ruptured in patients with sudden cardiac injury. Multiple lines of evidence suggest an association between myeloperoxidase and inflammation and acute coronary syndrome. Myeloperoxidase has been proposed as a potent risk marker and diagnostic tool in acute coronary syndrome (ACS). Recent studies have reported the potential use of myeloperoxidase in acute coronary syndrome, but limited reports are available on its utility in different groups of ACS in the emergency department. Therefore the circulating levels of serum myeloperoxidase in patients with acute coronary syndrome and control subjects were studied.

Design and setting: The levels of serum myeloperoxidase were measured by ELISA in 485 patients admitted to emergency care unit, of which 89 patients were diagnosed as non-cardiac chest pain (NCCP). The levels of myeloperoxidase were significantly increased in patients with ACS when compared with controls and NCCP. From the receiver operator characteristic (ROC) curve analysis, the optimum value above which myeloperoxidase can be considered positive was found to be 48.02 U/ml. The area under the curve was found to be 0.956 with 95% CI (0.934 to 0.973) (p<0.0001). A combination analysis of ROC curves of troponin, creatine kinase MB (CK-MB) and myeloperoxidase showed myeloperoxidase to be highly significant. Multivariate analysis revealed myeloperoxidase to be an independent diagnostic marker for early diagnosis of ACS.

Conclusion: Myeloperoxidase, in contrast to troponin and CK-MB, identified patients at risk of ischaemic events, even in the absence of myocardial necrosis, thus highlighting its potent usefulness for risk stratification among patients presenting with chest pain.

Practice viewpoints: AICD, who and when?

Sung, R J, Chan, N-Y — Thu, 15 Oct 2009 15:06:05 PDT

Automatic implantable cardioverter-defibrillator (AICD) is a costly but effective treatment modality for the prevention of sudden cardiac death (SCD). Causes of SCD are age-dependent, disease-specific and affected by racial/ethnic differences. Atherosclerotic heart disease (ASHD) is the most frequent underlying disease in individuals >=35 years old. Available information suggests that Asians have a lower rate of SCD compared with African black individuals and Caucasians. Whether it is for secondary or for primary prevention, physicians should be educated to perform a thorough diagnostic work-up and be able to identify transient and/or reversible causes of lethal ventricular tachyarrhythmias such as acute myocardial infarction, residual ischaemia, electrolyte imbalance, adverse effect of drugs, valvular heart diseases, etc before contemplating AICD implantation. Correction of these reversible causes may avoid the necessity of AICD implantation. The status of left ventricular function is not sufficiently specific for guiding AICD implantation in ASHD patients after acute myocardial infarction. The urgent need is to develop better biological or physiological markers for risk stratification so that patients who would actually benefit from AICD implantation can be readily identified. Such an approach will make the use of AICD more cost-effective. Based on molecular genetic data obtained from patients with inherited structural cardiovascular diseases and malignant arrhythmogenic disorders in which the risk of SCD appears to be gene- and/or mutant-specific, a continuous search for genetic markers for better risk stratification is warranted in patients suffering from ASHD.

Arrhythmogenic right ventricular dysplasia in emergency department

Rao, M, Prashanth, P, Mukhaini, M K — Thu, 15 Oct 2009 15:06:05 PDT

Carotid endarterectomy or stenting?

Ng, P Y — Mon, 08 Jun 2009 19:51:07 PDT

The relative role of surgical or endovascular treatment in carotid stenosis remains controversial. Results of recent studies add even more confusion to the debate. Major clinical trials so far have shown a wide range of complication rates for carotid endarterectomy and carotid stenting. Only surgeons or interventionists who can maintain a complication rate of 3% or below should consider treating patients with asymptomatic disease.

A new journal focusing on cardiovascular disease in the Asia Pacific region

Lim, M. C L — Wed, 08 Apr 2009 01:05:48 PDT

Recent advances in diagnosis and management of hypertrophic cardiomyopathy

Siswanto, B B, Aryani, R — Mon, 15 Jun 2009 15:01:54 PDT

Hypertrophic cardiomyopathy (HCM) is characterised by a thickened but non-dilated left ventricle in the absence of another cardiac or systemic condition capable of producing the magnitude of hypertrophy evident. It is the most common familial genetic disease of the heart (1/500 to 1/1000), as well as the most common cause of sudden cardiac death in young people and athletes. Survival rates of patients with HCM have improved from the 1960s onwards. Natural history in patients with HCM might vary from developing severe heart failure or atrial fibrillation, some die suddenly, often at a young age and in the absence of previous symptoms. Because of its heterogeneous clinical course and expression, HCM frequently presents uncertainty and represents a management dilemma to cardiovascular specialists and other practitioners.

Valvular regurgitation and stenosis: when is surgery required?

Goel, R, Sengupta, P P, Mookadam, F, Chaliki, H P, Khandheria, B K, Tajik, A J — Tue, 31 Mar 2009 15:54:41 PDT

Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases

Choosing pacemakers appropriately

Panicker, G K, Desai, B, Lokhandwala, Y — Tue, 31 Mar 2009 15:54:41 PDT

The range of implantable cardiac pacing devices has expanded, with the advances in available technology. Indications for cardiac pacing devices, that is pacemakers, implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy devices (CRTs), have expanded for the treatment, diagnosis and monitoring of bradycardia, tachycardia and heart failure. While the need for pacemakers is increasing, not all patients who require pacemakers are receiving them, especially in the Asia-Pacific region. There is a need to be more critical in advising the use of more expensive devices like ICDs and CRT/CRT-D devices, since most patients in the Asia-Pacific region pay out of pocket for these therapies. The AHA-ACC guidelines need not be blindly followed, since they are too wide-sweeping and are often based on the intention-to-treat basis of trials rather than on the parameters of the patients actually enrolled.

Practical applications of cardiovascular magnetic resonance

Alpendurada, F, Wong, J, Pennell, D J — Tue, 24 Mar 2009 11:11:57 PDT

Recent developments in magnetic resonance imaging have focused attention on evaluation of patients with cardiac disease. These improvements have been substantiated by a large and expanding body of clinical evidence, making cardiovascular magnetic resonance the imaging modality of choice in a wide variety of cardiovascular disorders. A brief review on the current applications of cardiovascular magnetic resonance is provided, with reference to some of the most relevant studies, statements and reviews published in this field.

The evolving role of molecular imaging for coronary artery disease: where do we stand today?

Chua, T — Fri, 06 Mar 2009 15:37:59 PST

The landscape of cardiac imaging is changing rapidly. There are promising new developments in molecular imaging on the horizon. It is likely that nuclear cardiology will continue to play an important role in the evaluation of CAD, but that role must evolve to meet clinical needs, competing technologies and the increasing emphasis on ensuring that imaging adds value and improves outcomes. This review offers some suggestions on the optimal role nuclear imaging can play vis-à-vis alternative options such as CT, but more data are needed before definitive recommendations can be made. Randomised trials comparing different diagnostic strategies can and should be performed to strengthen the foundations of clinical practice in nuclear cardiology. An evidence-based approach to imaging is here to stay.

The evidence on trial: cholesterol lowering and cancer

Tonkin, A M, Forbes, A, Haas, S J — Fri, 06 Mar 2009 15:37:59 PST

Choice of DES: is there a difference?

Kaul, U, Bhatia, V — Fri, 06 Mar 2009 15:37:59 PST

Restenosis after percutaneous coronary interventions has been a major limitation of this otherwise very well-accepted method of coronary revascularisation. Coronary stents work by scaffolding the intimal flaps and preventing elastic recoil, which was a major problem after balloon angioplasty. The neointimal growth response to stenting contributes significantly to the restenotic process. Randomised studies comparing coronary artery bypass surgery with coronary stenting especially in multivessel disease clearly highlighted this problem. The problem has been greater in magnitude in special subgroups: diabetics, patients with small vessels (<=2.5 mm in diameter), long segments of disease (>=20 mm in length), etc. These limitations of Bare metal stents have been addressed by drug-eluting stents (DESs). Third-generation stents with bioabsorbable polymers like the Biolimus releasing Biomatrix stent have already become available in Europe and parts of Asia. A longer follow-up will prove their long-term safety vis-à-vis first-generation DES. The polymer-free stent with capability of using more than one drug, though very attractive, needs larger multicentric studies before gaining wider acceptance. The fully bioabsorbable stent is yet another promising concept. The feasibility has already been demonstrated, and finer refinements are under way. The future of newer DES thus is very promising, and most of the issues related to first-generation DES are at the threshold of being solved.