A View From the AHA

After a few days in Chicago at the meeting of the American Heart Association one cannot help but be impressed by the dimension of research and the youth and vigor of the attendees. Hardly a gray hair was seen, and coming from a “gray head” like this, it was inspirational.

This year's president, Dr. Raymond J. Gibbons of the Mayo Clinic, Rochester, Minn., called attention to the fact that in spite of our success, there are many barriers to overcome in translating our success to patients worldwide. In this country, we face the fact that almost 46 million Americans have no health insurance and are essentially excluded from preventive cardiac care and the fruits of our research. Many of our patients, both urban and rural, might just as well be in Africa as to live around the corner from a major medical center like mine.

It became apparent during the meeting that our success has made it increasingly difficult to prove new, potentially beneficial treatments. A number of randomized clinical trials were presented, testing therapy in acute myocardial infarction where the reported annual placebo mortality was 4% over a 1-year period. Although mortality has gone down, the incidence of coronary artery disease has not.

The success of our combined reperfusion and remodeling therapy for acute myocardial infarction has reduced the event rates to levels that require huge populations or therapies with efficacy that exceeds anything that we have studied to date. The problem of recruiting large populations was reemphasized by Dr. Robert Califf, newly appointed head of the Duke Translational Medicine Institute in Durham, N.C., who noted that because of the poor participation of American cardiologists, most current randomized clinical trials are being carried out in Europe and Asia. Although the diseases of the heart are ubiquitous, therapeutic interventions tested in diverse social and clinical settings may not be applicable to Americans. We are, in fact, “outsourcing” our research.

The issues relating to drug eluting stents (DES) and bare metal stents were extensively discussed. It is clear that the decrease in in-stent restenosis attributed to DES has some significant disadvantages. But the failure of the DES to endothelialize appears to lead to inflammation and thrombus formation in and around the stent and confers in those patients a lifetime risk of in-stent thrombosis and dependency on a very expensive antiplatelet therapy. What emerged from these sessions was the imperative for new types of stents.

An additional cautionary note injected into the world of percutaneous coronary intervention was provided by the report of the Occluded Artery Trial, which shocked many angiographers. The investigators examined the benefit of PCI in persistent total occlusion from 3 to 28 days after an MI and were surprised to learn that there was no benefit associated with late PCI (see p. 1).

One additional study, the Alternans Before Cardioverter Defibrillator trial, may give some hope that we can begin to define patients who will gain the most benefit from implantable cardioverter defibrillators. Using microwave T-wave alternans and electrophysiologic studies in heart failure patients with ejection fractions of less than 40%, the investigators were able to identify patients who are at low risk and may not need an ICD (see p. 8). These diagnostic techniques provide the possibility that we may be able to make better choices for ICD therapy.

As always, awards were given to distinguished scientists involved in cardiovascular research. None was more deserving than Dr. William Kannel, the creator and driving force of the Framingham Heart Study, who is professor of medicine and public health at Boston University School of Medicine. Initiated almost half a century ago, the massive study created the scientific foundation upon which we have built much of today's clinical science. It is hard to imagine where cardiovascular research would be without that center and his leadership. It was a long overdue award to a true pioneer to whom the cardiology community and the world owe a great debt. Congratulations, Bill!

After a few days in Chicago at the meeting of the American Heart Association one cannot help but be impressed by the dimension of research and the youth and vigor of the attendees. Hardly a gray hair was seen, and coming from a “gray head” like this, it was inspirational.

This year's president, Dr. Raymond J. Gibbons of the Mayo Clinic, Rochester, Minn., called attention to the fact that in spite of our success, there are many barriers to overcome in translating our success to patients worldwide. In this country, we face the fact that almost 46 million Americans have no health insurance and are essentially excluded from preventive cardiac care and the fruits of our research. Many of our patients, both urban and rural, might just as well be in Africa as to live around the corner from a major medical center like mine.

It became apparent during the meeting that our success has made it increasingly difficult to prove new, potentially beneficial treatments. A number of randomized clinical trials were presented, testing therapy in acute myocardial infarction where the reported annual placebo mortality was 4% over a 1-year period. Although mortality has gone down, the incidence of coronary artery disease has not.

The success of our combined reperfusion and remodeling therapy for acute myocardial infarction has reduced the event rates to levels that require huge populations or therapies with efficacy that exceeds anything that we have studied to date. The problem of recruiting large populations was reemphasized by Dr. Robert Califf, newly appointed head of the Duke Translational Medicine Institute in Durham, N.C., who noted that because of the poor participation of American cardiologists, most current randomized clinical trials are being carried out in Europe and Asia. Although the diseases of the heart are ubiquitous, therapeutic interventions tested in diverse social and clinical settings may not be applicable to Americans. We are, in fact, “outsourcing” our research.

The issues relating to drug eluting stents (DES) and bare metal stents were extensively discussed. It is clear that the decrease in in-stent restenosis attributed to DES has some significant disadvantages. But the failure of the DES to endothelialize appears to lead to inflammation and thrombus formation in and around the stent and confers in those patients a lifetime risk of in-stent thrombosis and dependency on a very expensive antiplatelet therapy. What emerged from these sessions was the imperative for new types of stents.

An additional cautionary note injected into the world of percutaneous coronary intervention was provided by the report of the Occluded Artery Trial, which shocked many angiographers. The investigators examined the benefit of PCI in persistent total occlusion from 3 to 28 days after an MI and were surprised to learn that there was no benefit associated with late PCI (see p. 1).

One additional study, the Alternans Before Cardioverter Defibrillator trial, may give some hope that we can begin to define patients who will gain the most benefit from implantable cardioverter defibrillators. Using microwave T-wave alternans and electrophysiologic studies in heart failure patients with ejection fractions of less than 40%, the investigators were able to identify patients who are at low risk and may not need an ICD (see p. 8). These diagnostic techniques provide the possibility that we may be able to make better choices for ICD therapy.

As always, awards were given to distinguished scientists involved in cardiovascular research. None was more deserving than Dr. William Kannel, the creator and driving force of the Framingham Heart Study, who is professor of medicine and public health at Boston University School of Medicine. Initiated almost half a century ago, the massive study created the scientific foundation upon which we have built much of today's clinical science. It is hard to imagine where cardiovascular research would be without that center and his leadership. It was a long overdue award to a true pioneer to whom the cardiology community and the world owe a great debt. Congratulations, Bill!

After a few days in Chicago at the meeting of the American Heart Association one cannot help but be impressed by the dimension of research and the youth and vigor of the attendees. Hardly a gray hair was seen, and coming from a “gray head” like this, it was inspirational.

This year's president, Dr. Raymond J. Gibbons of the Mayo Clinic, Rochester, Minn., called attention to the fact that in spite of our success, there are many barriers to overcome in translating our success to patients worldwide. In this country, we face the fact that almost 46 million Americans have no health insurance and are essentially excluded from preventive cardiac care and the fruits of our research. Many of our patients, both urban and rural, might just as well be in Africa as to live around the corner from a major medical center like mine.

It became apparent during the meeting that our success has made it increasingly difficult to prove new, potentially beneficial treatments. A number of randomized clinical trials were presented, testing therapy in acute myocardial infarction where the reported annual placebo mortality was 4% over a 1-year period. Although mortality has gone down, the incidence of coronary artery disease has not.

The success of our combined reperfusion and remodeling therapy for acute myocardial infarction has reduced the event rates to levels that require huge populations or therapies with efficacy that exceeds anything that we have studied to date. The problem of recruiting large populations was reemphasized by Dr. Robert Califf, newly appointed head of the Duke Translational Medicine Institute in Durham, N.C., who noted that because of the poor participation of American cardiologists, most current randomized clinical trials are being carried out in Europe and Asia. Although the diseases of the heart are ubiquitous, therapeutic interventions tested in diverse social and clinical settings may not be applicable to Americans. We are, in fact, “outsourcing” our research.

The issues relating to drug eluting stents (DES) and bare metal stents were extensively discussed. It is clear that the decrease in in-stent restenosis attributed to DES has some significant disadvantages. But the failure of the DES to endothelialize appears to lead to inflammation and thrombus formation in and around the stent and confers in those patients a lifetime risk of in-stent thrombosis and dependency on a very expensive antiplatelet therapy. What emerged from these sessions was the imperative for new types of stents.

An additional cautionary note injected into the world of percutaneous coronary intervention was provided by the report of the Occluded Artery Trial, which shocked many angiographers. The investigators examined the benefit of PCI in persistent total occlusion from 3 to 28 days after an MI and were surprised to learn that there was no benefit associated with late PCI (see p. 1).

One additional study, the Alternans Before Cardioverter Defibrillator trial, may give some hope that we can begin to define patients who will gain the most benefit from implantable cardioverter defibrillators. Using microwave T-wave alternans and electrophysiologic studies in heart failure patients with ejection fractions of less than 40%, the investigators were able to identify patients who are at low risk and may not need an ICD (see p. 8). These diagnostic techniques provide the possibility that we may be able to make better choices for ICD therapy.

As always, awards were given to distinguished scientists involved in cardiovascular research. None was more deserving than Dr. William Kannel, the creator and driving force of the Framingham Heart Study, who is professor of medicine and public health at Boston University School of Medicine. Initiated almost half a century ago, the massive study created the scientific foundation upon which we have built much of today's clinical science. It is hard to imagine where cardiovascular research would be without that center and his leadership. It was a long overdue award to a true pioneer to whom the cardiology community and the world owe a great debt. Congratulations, Bill!