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Top Cardiology Stories of 2007

. . .selected by the physician-editors of Journal Watch Cardiology

Each year the physician-editors of Journal Watch Cardiology select the stories published during that year that they believe had the greatest impact on cardiovascular diagnosis and treatment. Here are our choices for 2007.

The biggest story of the year was the publication of results from the COURAGE trial: In patients with stable angina and significant coronary stenosis, the 5-year incidence of death or MI of those who were allocated to a percutaneous coronary intervention strategy was similar to that of those who were allocated to a medical-therapy strategy. The study gave support to those who believe that PCI can be safely deferred in these patients.

Safety of drugs and devices was an important topic this year. Concerns about the safety of drug-eluting stents (DES) were the topic of many studies. Some studies pooled randomized trials, others used data from registries; overall, the findings suggested that long-term dual antiplatelet therapy is important to prevent stent thrombosis in DES recipients. Another meta-analysis revealed the possibility that a commonly used drug for diabetes, rosiglitazone, increases the risk for cardiovascular events. This article, along with inconclusive early results from RECORD, a manufacturer-funded randomized trial of rosiglitazone, led the FDA to add a black-box warning to the drug’s label. Subsequent studies failed to exonerate rosiglitazone, although others suggested that pioglitazone, another thiazolidinedione, had a more favorable cardiovascular risk profile. In another study of a common medication, investigators reported that rates of warfarin-associated intracerebral hemorrhage are increasing over time; this increase is most prominent in the elderly population. Finally, failure rates of implantable cardioverter-defibrillator leads attracted attention this year: A large, observational study indicated that these risks are not trivial with contemporary devices.

In December 2006 Pfizer surprised the scientific community by halting the development of torcetrapib, a cholesterol ester transfer protein that held great promise as a drug to raise HDL levels. Reports from three manufacturer-sponsored studies of torcetrapib — ILLUSTRATE, RADIANCE, and ILLUMINATE — were published this year, suggesting that the drug increased blood pressure levels and failed to halt the progression of atherosclerosis.

Improving timeliness of reperfusion therapy for patients with STEMI was the topic of several studies. Particularly notable was the report of RACE, a statewide intervention in North Carolina that showed the value of coordination among institutions. In other important contributions, hospitals in Minnesota reported how they developed systems that result in remarkably rapid treatment times for transfer patients.

Efforts to improve anticoagulation strategies for patients with acute coronary syndromes who undergo PCI formed the basis of TRITON–TIMI 38, which compared clopidogrel with prasugrel, a new thienopyridine that has a faster onset of action and greater potency. The results suggested that prasugrel reduced ischemic events compared with clopidogrel, but at the cost of additional bleeding events. This trade-off may be hard to avoid as we seek optimal regimens.

Deciding between off-pump and on-pump coronary artery surgery is often difficult; many people believe that avoiding cardiopulmonary bypass can improve cognitive outcomes. A study by van Dijk and colleagues, however, suggested otherwise, finding similar rates of cognitive decline for these two procedures. Of even greater concern was that 50% of all the study participants had a substantial decrease in cognitive functioning, even though the mean age was only 61.

Statins seem like miracle drugs, but this year we had negative results from CORONA, a study of rosuvastatin in patients with ischemic cardiomyopathy. It is not yet clear whether these findings are attributable to the study drug (which has not yet been shown to improve outcomes), to the advanced age of the study population, or to decreased responsiveness in patients with heart failure.

Transient ischemic attacks elicit concern, but only a minority of the patients who experience them progress to a stroke. We reported on results of a study of a simple and useful tool to stratify stroke risk that includes only age, blood pressure, clinical features, duration of symptoms, and diabetes.

Overall, 2007 produced quite a number of important articles with direct relevance to clinical practice. We appreciate the opportunity to share these summaries with you and to assist in the translation of new knowledge into better care at the hands of practitioners.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology December 28, 2007