Circulation. 2008;118:465-466
doi: 10.1161/CIRCULATIONAHA.108.189737
(Circulation. 2008;118:465-466.)
© 2008 American Heart Association, Inc.
Clinical Summaries
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Does Sodium Nitroprusside Decrease the Incidence of Atrial Fibrillation After Myocardial Revascularization? A Pilot Study
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Postoperative atrial fibrillation (AF) is a frequent complication
after coronary artery bypass grafting and is associated with
increased morbidity and hospital stay. In this pilot study,
we investigated whether sodium nitroprusside (SNP), a nitric
oxide donor administered during surgery, can reduce the frequency
of AF. We prospectively randomized 100 consecutive patients
undergoing elective coronary artery bypass graft operations
to a control group (dextrose 5% in water) and an SNP group (treated
with SNP 0.5 µg · kg
–1 · min
–1 during the rewarming period). During the hospitalization, AF
episodes were significantly reduced in the SNP group, and the
duration of AF in the SNP group was significantly shorter than
that in the control group. C-reactive protein levels were higher
postoperatively in the control group than in the SNP group.
Postoperative AF patients had a prolonged postoperative hospital
stay. The present study shows that intraoperative treatment
with SNP decreases postoperative AF. Whether this is mediated
through an antiinflammatory mechanism of NO is unclear. These
findings will require confirmation in a larger study. See p
476.
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Relation Between Body Mass Index, Waist Circumference, and Death After Acute Myocardial Infarction
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The present study underscores the high prevalence of increased
body mass index and waist circumference in patients with acute
myocardial infarction, present in one quarter and one half of
the patients, respectively. Until the epidemic progression of
obesity is confronted, cardiologists will be faced with a growing
prevalence of obesity in patients with acute myocardial infarction.
Given this high prevalence, the characterization of cardiovascular
risk associated with obesity after the index event is important.
Most studies have reported a lower rate of death after myocardial
infarction for patients with increased body mass index (the
obesity paradox). We found that much of this apparent obesity
paradox is related to confounding by baseline characteristics
associated with survival. Neither body mass index nor waist
circumference was an independent predictor of survival. However,
in both men and women, a high waist circumference with low body
mass index (presumably reflecting visceral obesity with low
muscle mass and lack of functional subcutaneous adipose tissue)
was predictive of increased 1-year death rate. This emphasizes
the need to measure both body mass index and waistline in patients
with myocardial infarction, particularly to identify this sizable
fraction of the patient population at high risk of death. See
p
482.
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Patient-Reported Health Status in Coronary Heart Disease in the United States: Age, Sex, Racial, and Ethnic Differences
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Quality of life has become an increasingly important outcome
in coronary heart disease (CHD) from both clinical and public
health perspectives. This study examined the national impact
of CHD on health-related quality of life and other patient-reported
health statuses measured by the Short Form 12 (Physical Component
Summary-12 and Mental Component Summary-12) and EuroQoL (EQ-5D
index and EQ visual analog scale). Using data from the 2000
and 2002 Medical Expenditure Panel Surveys, we observed the
impairment of health status associated with CHD in all measures
but more prominently in physical health score and self-reported
health. The adjusted differences between the CHD and non-CHD
populations were –1.2 for Mental Component Summary-12
(2.4% of the score in the non-CHD population), –4.6 for
Physical Component Summary-12 (9.2%), –0.04 for EQ-5D
(4.6%), and –7.3 for EQ visual analog scale (9.0%). In
some measures, the impairment was more pronounced in younger
patients, women, blacks, and Hispanics, which indicates disparities
in quality of life across different demographic groups. In addition
to preventing CHD, healthcare providers and public health departments
should work together to improve health-related quality of life
and perceived health status of CHD patients. Particular attention
should be given to the most vulnerable groups. See p
491.
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Directed and Systematic Differentiation of Cardiovascular Cells From Mouse Induced Pluripotent Stem Cells
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The recent invention of skin fibroblast-derived pluripotent
cells, induced pluripotent stem (iPS) cells, opened a new gate
for regenerative medicine. Establishment of iPS cells from adult
human tissue is further facilitating development of cell transplantation–based
regenerative strategies by avoiding the legal and ethical controversy
over human embryonic stem cells. This study discusses a directed
and systematic differentiation method of using mouse iPS cells
for various cardiovascular cells, which would provide a scientific
and technological basis for human iPS cell differentiation.
As well as the direct application to cell-based regenerative
medicine, this study also examines and elucidates the cellular
and molecular mechanisms of cardiovascular cell differentiation,
thereby contributing to identify novel targets for gene therapy
and drug discovery. Furthermore, this system could be directly
involved in screening of small molecules to find cardiovascular
regenerating substances. This study therefore may greatly contribute
to the clinical application of iPS cells and develop novel regenerative
medicine for cardiovascular diseases. See p
498.
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Generation of Functional Murine Cardiac Myocytes From Induced Pluripotent Stem Cells
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The lack of suitable cell sources is still a major hurdle for
the development of cardiac cell replacement therapies. The formation
of functional cardiomyocytes from adult stem cells is still
controversial. Human embryonic stem cells are ethically problematic
and will not readily be accessible as an autologous cell source.
The availability of induced pluripotent stem (iPS) cells now
represents significant progress toward the development of patient-derived
autologous cells. The aim of this study was to evaluate the
general usefulness of iPS cells for myocardial restoration demonstrating
the generation of functional iPS cell–derived cardiomyocytes.
Analyses on molecular, structural, and functional levels documented
that iPS cell–derived cardiomyocytes show typical features
of embryonic stem cell–derived cardiomyocytes. Reverse
transcription polymerase chain reaction and immunocytology revealed
expression of typical cardiac marker genes. Spontaneous rhythmic
intracellular Ca
2+ fluctuations with amplitudes of Ca
2+ transients
comparable to embryonic stem cell derivatives were observed.
Simultaneous Ca
2+ release within clusters of iPS cell–derived
cardiomyocytes indicated functional coupling of the cells, and
electrophysiological studies with multielectrode arrays further
demonstrated functionality and presence of the β-adrenergic
and muscarinergic signaling cascade. In conclusion, iPS cells
allow the derivation of autologous functional cardiomyocytes
for cellular cardiomyoplasty and myocardial tissue engineering.
See p
507.
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Evidence of Arteriolar Narrowing in Low-Birth-Weight Children
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Low birth weight and other markers of poor in utero growth are
associated with increased risk of adult cardiovascular disease.
We hypothesized that a potential mechanism underlying this phenomenon
is poor in utero growth that could adversely influence microvascular
structure. We tested this hypothesis by examining the relation
of birth weight and other markers of in utero growth to retinal
microvascular caliber in a population-based study of 1369 children
aged 6 years attending 34 schools in Sydney, Australia. Lower
birth weight, shorter birth length, and smaller head circumference
were all associated with narrower retinal arteriolar caliber.
Each kilogram decrease in birth weight was associated with a
2.3-µm (95% CI 0.6 to 3.9,
P=0.01) narrower retinal arteriolar
caliber after controlling for age, gender, ethnicity, height,
body mass index, axial length, mean arterial blood pressure,
and prematurity. These data support our study hypothesis, and
we thus speculate that the adverse influence of poor in utero
growth on microvascular structure may explain in part the documented
increased susceptibility to development of hypertension and
cardiovascular disease among persons with low and low-normal
birth weight. Our results highlight the influences of early
life environment on the development of microvasculature structural
changes. They have potential implications for medical interventions
during gestation. Because both low birth weight and retinal
arteriolar narrowing are potential subclinical markers of future
cardiovascular risk, the presence of both factors may indicate
a need for closer monitoring, lifestyle modifications, and other
interventions in this subgroup. See p
518.
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