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Perspective
Interpreting the Coronary-Artery Calcium Score
A 55-year-old white man presented with an abnormal coronary-artery calcium (CAC) score. He exercised regularly and was asymptomatic. There was no family history of premature coronary artery disease (CAD). He was not overweight, had never smoked, and did not have diabetes. His blood pressure was 122/…
- January 26, 2012
- Grayburn P.A.
- N Engl J Med 2012; 366:294 - 296
Though coronary-artery calcium scoring is not helpful in screening for coronary artery disease in many cases, it's advertised to consumers, and those with positive scores are told to see their physician. How should physicians interpret the scores and counsel patients?
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Review Article
Current Concepts: Cognitive and Neurologic Outcomes after Coronary-Artery Bypass Surgery
Patients referred for coronary revascularization procedures are older and are likely to have more extensive extracardiac vascular disease than those referred for such procedures in the past. Despite these trends, mortality rates for coronary-artery bypass grafting (CABG), without concurrent…
- January 19, 2012
- Selnes O.A., Gottesman R.F., Grega M.A., et al.
- N Engl J Med 2012; 366:250 - 257
- CME
For patients undergoing coronary-artery bypass grafting (CABG), adverse neurologic outcomes, including stroke and cognitive decline, are major concerns. Even mild cognitive deficits before surgery may be a marker for cerebrovascular disease and increased risk.
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Original Article
Cardiac Arrest during Long-Distance Running Races
Participation in long-distance running races has increased annually in the United States. In 2010, there were approximately 2 million participants in marathon and half-marathon races, as compared with fewer than 1 million participants in 2000. This increase has been driven in part by heightened…
- January 12, 2012
- Kim J.H., Malhotra R., Chiampas G., et al.
- N Engl J Med 2012; 366:130 - 140
- CME
The authors report on a U.S. registry of cardiac arrests during marathons and half-marathons. The rate of arrest was equal to or lower than rates for other strenuous physical activities. The most common cause was hypertrophic cardiomyopathy or coronary artery disease.
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Correspondence
Acute Coronary Thrombosis in Boston Marathon Runners
To the Editor: Regular exercise reduces the incidence of coronary atherosclerotic disease and decreases mortality after myocardial infarction, but vigorous activity increases the risk of myocardial infarction and sudden death among patients with occult and diagnosed coronary artery disease. We…
- January 12, 2012
- N Engl J Med 2012; 366:184 - 185
- Free Full Text
Three well-conditioned men who ran the 2011 Boston Marathon had acute coronary thrombosis shortly after completing the marathon. The authors discuss possible explanations for the occurrence of coronary thrombosis after prolonged exertion.
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Editorial
A New Era in Secondary Prevention after Acute Coronary Syndrome
During the past two decades, the use of antiplatelet therapies has been the focus of new studies of secondary prevention after acute coronary syndromes, with more than 75% of patients in contemporary practice treated with dual antiplatelet therapy (aspirin plus a thienopyridine) on hospital…
- January 5, 2012
- Roe M.T. and Ohman E.M.
- N Engl J Med 2012; 366:85 - 87
During the past two decades, the use of antiplatelet therapies has been the focus of new studies of secondary prevention after acute coronary syndromes, with more than 75% of patients in contemporary practice treated with dual antiplatelet therapy (...
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Original Article
Rivaroxaban in Patients with a Recent Acute Coronary Syndrome
After an acute coronary syndrome, patients remain at risk for recurrent cardiovascular events despite standard medical therapy, including long-term antiplatelet therapy with aspirin and an adenosine diphosphate–receptor inhibitor. This risk may be related in part to excess thrombin generation…
- January 5, 2012
- Mega J.L., Braunwald E., Wiviott S.D., et al.
- N Engl J Med 2012; 366:9 - 19
- CME
In patients with acute coronary syndromes, low doses of rivaroxaban were effective in reducing the primary end point of death from cardiovascular causes, myocardial infarction, or stroke. Rivaroxaban also reduced overall mortality, although there was more bleeding.
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Original Article
Thrombin-Receptor Antagonist Vorapaxar in Acute Coronary Syndromes
The risk of recurrent ischemic complications among patients with acute coronary syndromes without ST-segment elevation remains high despite contemporary treatment strategies, including the use of early revascularization and dual antiplatelet therapy. Hence, the assessment of new platelet inhibitors…
- January 5, 2012
- Tricoci P., Huang Z., Held C., et al.
- N Engl J Med 2012; 366:20 - 33
In this trial, vorapaxar, a protease-activated–receptor 1 antagonist that inhibits thrombin-induced platelet activation, was not effective in reducing the primary cardiovascular efficacy end point, and it increased rates of bleeding, including serious bleeding and intracranial hemorrhage.
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Review Article
200th Anniversary Article: A Tale of Coronary Artery Disease and Myocardial Infarction
The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress…
- January 5, 2012
- Nabel E.G. and Braunwald E.
- N Engl J Med 2012; 366:54 - 63
- Free Full Text
In this review of heart disease, Nabel and Braunwald focus on two themes — coronary artery disease and myocardial infarction — and explain how our understanding has evolved over the past two centuries. The authors consider therapies that have led to improved survival.
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Editorial
Niacin at 56 Years of Age — Time for an Early Retirement?
A reduction in serum cholesterol with niacin therapy in humans was first described in 1955, when Altschul and colleagues reported, in a letter to the editor, the findings in 11 healthy medical students and 57 patients. Subsequent clinical studies showed multiple favorable effects of niacin therapy…
- December 15, 2011
- Giugliano R.P.
- N Engl J Med 2011; 365:2318 - 2320
A reduction in serum cholesterol with niacin therapy in humans was first described in 1955, when Altschul and colleagues reported, in a letter to the editor, the findings in 11 healthy medical students and 57 patients.¹ Subsequent clinical studies showed ...
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Perspective
Needed: Pragmatic Clinical Trials for Statin-Intolerant Patients
Statins are the most commonly prescribed drugs for lowering low-density lipoprotein (LDL) cholesterol levels. They've been amply studied in phase 3, randomized clinical trials and have been shown in primary and secondary prevention trials to reduce the risk of cardiovascular events. Statin use has…
- December 15, 2011
- Maningat P. and Breslow J.L.
- N Engl J Med 2011; 365:2250 - 2251
Statins have adverse effects, but it's difficult to design randomized trials of alternative therapies for statin-intolerant patients. Pragmatic clinical trials, performed in the context of usual care with broad eligibility criteria, are well suited to this purpose.
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Original Article
Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy
More than 18 million North Americans have coronary heart disease, and despite profound advances in both pharmacologic and interventional management, both morbidity and mortality remain appreciable. Elevated low-density lipoprotein (LDL) cholesterol levels are an established predictor of the risk of…
- December 15, 2011
- The AIM-HIGH Investigators
- N Engl J Med 2011; 365:2255 - 2267
- CME
In this clinical trial involving patients with established cardiovascular disease, the addition of niacin to intensive statin therapy provided no additional clinical benefit over a period of 3 years, despite favorable changes in lipid levels.
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Original Article
Effect of Two Intensive Statin Regimens on Progression of Coronary Disease
Randomized clinical trials have consistently shown that inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins) reduce cardiovascular event rates.– The favorable effects of statins extend across a range of levels of low-density lipoprotein (LDL) cholesterol, with no apparent lower…
- December 1, 2011
- Nicholls S.J., Ballantyne C.M., Barter P.J., et al.
- N Engl J Med 2011; 365:2078 - 2087
- Free Full Text
- CME
In this trial, intravascular ultrasonography was used to compare the effects of atorvastatin versus rosuvastatin on regression of coronary atherosclerosis. Both statins led to regression in two thirds of patients, with no significant difference between their effects.
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Review Article
Genomic Medicine: Genomics of Cardiovascular Disease
Cardiovascular disease is the leading cause of death in the United States. Considerable progress has been made in the past 50 years to define, identify, and modify risk factors for cardiovascular disease (e.g. hypertension, dyslipidemia, obesity, type 2 diabetes, cigarette smoking, and physical…
- December 1, 2011
- O'Donnell C.J. and Nabel E.G.
- N Engl J Med 2011; 365:2098 - 2109
- Free Full Text
- Interactive/Multimedia
The authors provide an overview of how genetic and genomic studies have improved our understanding of the cause of cardiovascular disease.
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Editorial
Improving Adherence — Money Isn't the Only Thing
Interventions that both improve outcomes and save costs are unusual, but the provision of lifesaving medications to survivors of myocardial infarction is one such example. In the past, physicians' poor compliance with evidence-based guidelines was a major reason for suboptimal use of such…
- December 1, 2011
- Goldman L. and Epstein A.M.
- N Engl J Med 2011; 365:2131 - 2133
Interventions that both improve outcomes and save costs are unusual, but the provision of lifesaving medications to survivors of myocardial infarction is one such example.¹ In the past, physicians' poor compliance with evidence-based guidelines was a ...
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Special Article
Full Coverage for Preventive Medications after Myocardial Infarction
The use of medications based on solid clinical evidence has contributed substantially to reductions in cardiovascular morbidity and mortality. For patients with acute myocardial infarction, prescribing of these highly effective therapies is now nearly universal at the time of hospital discharge in…
- December 1, 2011
- Choudhry N.K., Avorn J., Glynn R.J., et al.
- N Engl J Med 2011; 365:2088 - 2097
- CME
In this trial, eliminating copayments for medications after hospitalization for MI did not reduce the primary outcome (first major vascular event or revascularization) but did improve medication adherence and secondary outcomes, without significantly increasing total spending.
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Original Article
Abciximab and Heparin versus Bivalirudin for Non–ST-Elevation Myocardial Infarction
An invasive strategy of coronary angiography, with revascularization when appropriate, is recommended for high-risk patients who have an acute coronary syndrome. Owing to the key role that the rupture of an atherosclerotic plaque, which is highly prothrombotic, plays in the pathogenesis of these…
- November 24, 2011
- Kastrati A., Neumann F.-J., Schulz S., et al.
- N Engl J Med 2011; 365:1980 - 1989
- CME
This trial compared the combination of abciximab and unfractionated heparin with bivalirudin in patients with non–ST-segment elevation MI who were undergoing coronary stenting. The two regimens had similar efficacy, but there was more bleeding with abciximab and heparin.
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Case Records of the Massachusetts General Hospital
Case 36-2011 — A 93-Year-Old Woman with Shortness of Breath and Chest Pain
Presentation of Case. Dr. Pooja Agrawal (Emergency Medicine): A 93-year-old woman was seen in the emergency department at this hospital because of chest pain and shortness of breath. The patient had been in her usual state of health, with hypertension and chronic renal insufficiency, until the…
- November 24, 2011
- Senecal E.L., Rosenfield K., Caldera A.E., Passeri J.J.
- N Engl J Med 2011; 365:2021 - 2028
- Video
A 93-year-old woman was seen in the emergency department because of a 3-hour history of chest pain and shortness of breath. An electrocardiogram showed ST-segment elevations. A diagnostic procedure was performed.
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Editorial
Childhood Obesity and Coronary Heart Disease
Obesity is the most common nutritional problem among children in both developed and underdeveloped countries. Despite efforts over the past decade to prevent and control obesity, data from the 2003–2006 National Health and Nutrition Examination Surveys (NHANES) show that 16.3% of children and…
- November 17, 2011
- Rocchini A.P.
- N Engl J Med 2011; 365:1927 - 1929
Obesity is the most common nutritional problem among children in both developed and underdeveloped countries. Despite efforts over the past decade to prevent and control obesity, data from the 2003–2006 National Health and Nutrition Examination Surveys (...
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Original Article
Childhood Adiposity, Adult Adiposity, and Cardiovascular Risk Factors
During the past three decades, the prevalences of overweight and obesity in the pediatric population have increased substantially. Childhood obesity is a predictor of an increased rate of death, owing primarily to an increased risk of cardiovascular disease.– Forecasts suggest that the "obesity…
- November 17, 2011
- Juonala M., Magnussen C.G., Berenson G.S., et al.
- N Engl J Med 2011; 365:1876 - 1885
- CME
In four prospective cohort studies, obese adults who were overweight or obese in childhood had increased rates of cardiovascular risk factors. Those who were overweight or obese as children but not as adults had risks similar to the risks among those who were never obese.
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Original Article
Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome
Patients with acute coronary syndromes frequently have recurrent ischemic events despite the use of currently recommended antiplatelet therapy, revascularization procedures as appropriate, and other evidence-based secondary preventive measures.– Oral anticoagulation therapy with vitamin K…
- August 25, 2011
- Alexander J.H., Lopes R.D., James S., et al.
- N Engl J Med 2011; 365:699 - 708
In a randomized trial, patients with an acute coronary syndrome were assigned to receive apixaban or placebo in addition to standard therapy. The apixaban group had a higher rate of TIMI major bleeding and no significant reduction in recurrent ischemic events.
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