The human coronary collateral circulation: development and clinical importance

Coronary collaterals are an alternative source of blood supply to myocardium jeopardized by ischaemia. In comparison with other species, the human coronary collateral circulation is very well developed. Among individuals without coronary artery disease (CAD), there are preformed collateral arteries preventing myocardial ischaemia during a brief vascular occlusion in 20-25%. Determinants of such anastomoses are low heart rate and the absence of systemic arterial hypertension. In patients with CAD, collateral arteries preventing myocardial ischaemia during a brief occlusion are present in every third individual. Collateral flow sufficient to prevent myocardial ischaemia during coronary occlusion amounts to one-fifth to one-fourth the normal flow through the open vessel. Myocardial infarct size, the most important prognostic determinant after such an event, is the product of coronary artery occlusion time, area at risk for infarction, and the inverse of collateral supply. Well-developed coronary collateral arteries in patients with CAD mitigate myocardial infarcts and improve survival. Approximately one-fifth of patients with CAD cannot be revascularized by percutaneous coronary intervention or coronary artery bypass grafting. Therapeutic promotion of collateral growth is a valuable treatment strategy in those patients. It should aim at growth of large conductive collateral arteries (arteriogenesis). Potential arteriogenic approaches include the treatment with granulocyte colony-stimulating factor, physical exercise training, and external counterpulsatio

Adverse events in HEAAL: when to hold and when to fold

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106139/1/ejhfhfs167.pd

The impact of the coronary collateral circulation on mortality: a meta-analysis

Aims The coronary collateral circulation as an alternative source of blood supply has shown benefits regarding several clinical endpoints in patients with myocardial infarction (MI) such as infarct size and left ventricular remodelling. However, its impact on hard endpoints such as mortality and its impact in patients with stable coronary artery disease (CAD) is more controversial. The purpose of this systematic review and meta-analysis was to explore the impact of collateral circulation on all-cause mortality. Methods and results We searched MEDLINE, EMBASE, ISI Web of Science (2001 to 25 April 2011), and conference proceedings for studies evaluating the effect of coronary collaterals on mortality. Random-effect models were used to calculate summary risk ratios (RR). A total of 12 studies enrolling 6529 participants were included in this analysis. Patients with high collateralization showed a reduced mortality compared with those with low collateralization [RR 0.64 (95% confidence interval 0.45-0.91); P= 0.012]. The RR for ‘high collateralization' in patients with stable CAD was 0.59 [0.39-0.89], P= 0.012, in patients with subacute MI it was 0.53 [0.15-1.92]; P= 0.335, and for patients with acute MI it was 0.63 [0.29-1.39]; P= 0.257. Conclusions In patients with CAD, the coronary collateralization has a relevant protective effect. Patients with a high collateralization have a 36% reduced mortality risk compared with patients with low collateralizatio

Mineralocorticoid Receptor Antagonists in High‐Risk Heart Failure Patients With Diabetes Mellitus and/or Chronic Kidney Disease

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142475/1/jah32899.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142475/2/jah32899_am.pd

Future large‐scale clinical trials in cardiovascular medicine: challenges and uncertainties

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146871/1/ejhf1360_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146871/2/ejhf1360.pd

Withdrawal of cerivastatin from the world market

Cerivastatin was recently withdrawn from the market because of 52 deaths attributed to drug-related rhabdomyolysis that lead to kidney failure. The risk was found to be higher among patients who received the full dose (0.8 mg/day) and those who received gemfibrozil concomitantly. Rhabdomyolysis was 10 times more common with cerivastatin than the other five approved statins. We address three important questions raised by this withdrawal. Should we continue to approve drugs on surrogate efficacy? Are all statins interchangeable? Do the benefits outweigh the risks of statins? We conclude that decisions regarding the use of drugs should be based on direct evidence from long-term clinical outcome trials

Is hyperkalaemia in heart failure a risk factor or a risk marker? Implications for renin–angiotensin–aldosterone system inhibitor use

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/143644/1/ejhf1175.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/143644/2/ejhf1175_am.pd

Cardiovascular safety of drugs not intended for cardiovascular use: need for a new conceptual basis for assessment and approval

Recently, several drugs for non-cardiovascular diseases have ceased marketing because of cardiovascular risk, highlighting the importance of evaluating the cardiovascular safety of new drugs even if not intended for cardiovascular diseases. Assessing and ensuring acceptable cardiovascular safety of non-cardiovascular drugs is difficult; nonetheless, governmental regulatory agencies are likely to change the requirements for drug safety information. This article explores our recommendations for rethinking current regulatory policies, emphasizing the need for mandatory post-marketing surveillance registries and highlighting the exposures necessary to subserve the need for greater assessment of safety issue