On the last day of 2002, the American Heart Association (AHA) published its list of the top 10 research advances of the year. These advances were chosen because of their potential impact on the prevention and treatment of cardiovascular disease and stroke. The list was created with the advice of expert clinicians and research scientists and truly highlights findings that span the spectrum from basic sciences (eg, gene therapy and cell transplantation in the heart) to therapeutic interventions (eg, best treatment for atrial fibrillation and refined techniques for carotid endarterectomy) to research demonstrating improvement in outcomes when the published treatment guidelines are followed.
For the second year, the Journal of Cardiovascular Nursing (see last year's JCN issue 18:1) reviews the AHA's list of the top 10 research advances. In this issue, each of the 10 research advances for 2002 is reviewed in a short article. The articles describe the research advancement and supporting investigative work and provide insight as to why these particular research achievements were considered one of the top 10 for the year. Finally, each article notes how the research might impact cardiovascular health as well as what promises and dilemmas the findings pose for the future. The top 10 list includes the following:
1. Gene therapy used to create first biological pacemaker
2. Implantable devices benefit patients with cardiovascular disease
3. A refined angioplasty technique may offer an alternative to carotid endarterectomy
4. Risks of hormone replacement therapy (HRT) outweigh benefits
5. Death rates lower in hospitals that follow heart attack guidelines
6. Obesity is a strong and independent risk factor for heart failure
7. Treating atrial fibrillation: Control rate or rhythm?
8. Cell transplantation therapy strengthens hearts
9. Robotically assisted cardiac surgery successfully corrects heart defects
10. Largest study of hypertension shows diuretic a better choice than newer drugs
In the first article titled "Gene therapy to develop a genetically engineered cardiac pacemaker," Cardiologists Steven M. Pogwizd, MD, and Christopher M. Glenn, MD, describe how researchers have inserted the gene for a mutated, dysfunctional potassium ion channel into contractile guinea pig heart cells causing them to be converted into pacemaker cells. These studies demonstrate that gene transfer technology works. And, while the studies have yet to be conducted in humans, the results hold the promise of a gene therapy that could replace pacemaker devices and provide proof of principle that other less invasive interventions to treat electrophysiological disorders will be developed in the future.
In the second article titled "Implantable devices benefit patients with cardiovascular diseases," Eleanor B. Schron, MS, RN, and Michael J. Domanski, MD (from the Clinical Trials Scientific Research Group, National Heart Lung and Blood Institute), review the clinical impact of implantable cardioverter-defibrillators (ICDs). The article focuses on the results of several recent ICD trials, such as the Multicenter Automatic Defibrillator Trial II (MADIT II), that examined ICD therapy in patients with coronary artery disease (CAD) and with reduced left ventricular ejection fraction (LVEF), therefore testing the idea that perhaps ICDs could be used as a primary prevention tool for sudden cardiac death in this patient population. Previous ICD trials have been conducted in patients with CAD and prior ventricular tachydysrhythmia (qualifying as secondary prevention trials). MADIT II demonstrated that patients with CAD (with reduced LVEF) had a reduced risk of mortality, and hospitalizations and improved quality of life and exercise tolerance.
When atherosclerotic disease occludes the carotid artery, blood flow to the brain is compromised leading to ischemia and stroke. Carotid endarterectomy (a surgical procedure used to open the clogged vessel) has been the standard of therapy. However, in 2002, studies were conducted to compare outcomes between carotid endarterectomy and a "refined" angioplasty (a less invasive procedure where a balloon-tipped catheter is threaded into the area of blockage and expanded, compacting the plaque against the arterial wall). The refinements included stenting and the addition of a small filter that keeps pieces of fat from breaking off the plaque and lodging in arteries that lead to the brain, thereby causing a stroke. In the article "A refined angioplasty and stenting technique may offer an alternative to carotid endarterectomy," Robert Candipan, MD, and Sanjay Gandhi, MD, from the Division of Cardiology at the University of Illinois at Chicago, review recent clinical trials addressing management of patients with carotid artery stenosis, particularly refined angioplasty that reveals potential for reducing mortality and morbidity in comparison with traditional endarterectomy.
The research finding from 2002 than may have surprised most of the biomedical community and had important implications for every woman, was the result of the arm of the Women's Health Initiative (WHI) clinical trial that examined the effect of continuous combined hormone replacement therapy (HRT - Prempro) on the risk of cardiovascular diseases and other outcomes such as breast cancer, colorectal cancer, and hip fracture. This large study demonstrated that taking HRT significantly increased the relative risk of cardiovascular disease. While relative risk of colorectal cancer and hip fracture decreased, the study was terminated early when it was determined that the risks of taking this form of HRT exceeded the benefits. In their article "Estrogen plus progestin therapy: The cardiovascular risks exceed the benefits," Sue Penckofer, PhD, RN, and Diana Hackbarth, PhD, RN, FAAN (School of Nursing, Loyola University, Chicago), and Dorie W. Schwertz, PhD, RN, FAAN, (College of Nursing, University of Illinois at Chicago) describe results of earlier observational studies that suggested HRT would decrease the risk of cardiovascular disease as well as the results of smaller clinical trials that preceded the WHI. Results of WHI are presented along with limitations of the study and potential reasons for the lack of agreement between findings of observational studies and the WHI.
In the next article, Marilyn K. Szekendi, MSN, a Research Nurse Coordinator in Patient Safety, Quality and Operations at Northwestern Memorial Hospital, Chicago, reviews the importance of following patient care guidelines. In her article "Compliance with acute MI guidelines lowers inpatient mortality," Szekendi describes the rationale for patient care guidelines and the results of recent studies that show how "getting with the guidelines" greatly improves clinical outcomes. This recent report demonstrates that a higher level of compliance with the AHA and American College of Cardiology (ACC) guidelines for management of patients with acute myocardial infarction (MI) is associated with a reduction in mortality.
Jessica S. Coviello, MSN, APRN, and Karin V. Nystrom, MSN, APRN, acute care nurse practitioners, review the subject of obesity and heart failure in their article "Obesity as a risk factor for heart failure." In this article, the incidence and pathophysiology of obesity are briefly reviewed, along with recent research findings revealing that overweight women (body mass index [BMI] = 25.0-29.9) and over-weight men (BMI > 30) had a 50% and 20% increase in heart failure risk, respectively. As Coviello and Nystrom highlight, these findings are of great concern, since it is estimated that worldwide, nearly 1 billion people are overweight or obese.
As reviewed by Marilyn A. Prasun, PhD, RN, CCNSc (Advanced Practice Nurse), and Abraham G. Kocheril, MD (Cardiologist), FACC, FACP, the best treatment strategy for atrial fibrillation, one of the most common sustained cardiac dysrhythmias, remains unknown. The initial management strategy has generally been to correct the rhythm and restore sinus rhythm (rhythm control). However, an alternative strategy has been to control the ventricular response rate of atrial fibrillation (rate control). Prasun and Kocheril in their article "Treating atrial fibrillation: rhythm control or rate control" discuss the results of the Atrial Fibrillation Follow-up Investigation in Rhythm Management (AFFIRM) Trial, which was designed to examine rhythm control vs rate control in patients with atrial fibrillation. Interestingly, in terms of survival rates there was no difference between the rhythm-control and rate-control group. However, there was a trend for lower risk of adverse drug effects in the rate-control group. Importantly, this trial, as well as data from other trials, also underscores the need for anticoagulation therapy in patients with atrial fibrillation.
Mariann R. Piano, PhD, RN, and Timothy M. Carrigan, BSN, RN, review how cellular cardiomyoplasty (CCM) may be a new therapeutic approach for regenerating the myocardium. In their article "Cellular cardiomyoplasty: A new therapeutic approach for regenerating the myocardium," Piano and Carrigan review how cellular cardiomyoplasty involves the transplantation of cells that reside in one tissue into that of another tissue type. The goal of CCM therapy is to replace damaged, hypocontractile, and necrotic cardiac myocytes with functioning myocytes (myogenesis) or to enhance angiogenesis and vascularization in ischemic myocardium. Data generated from animal studies and small clinical trials, involving patients with end-stage heart failure, are promising. Even though this represents an exciting new strategy many questions remain, such as which cell type should be used for transplant (eg, bonemarrow-derived cells or skeletal myoblasts), how many cells and which method is most effective for enrichment, and how do cells differentiate and survive? Despite these unknowns, CCM holds promise as a potential treatment of specific cardiovascular diseases, such as MI and heart failure.
Surgical correction of congenital atrial septal defect traditionally requires open heart surgery. However, the success of a robotically assisted procedure that requires only 4 very small incisions to repair the defect was reported at the 2002 AHA Scientific Sessions. With the use of the robotically assisted endoscopic procedure, patients had much shorter hospital stays and returned to work in half the time compared to traditional surgery. Nancy A. Pike, RN, MN, FNP, and Steven R. Gundry, MD, FACS, FACC, in their article "Robotically assisted cardiac surgery: minimally invasive techniques to totally endoscopic heart surgery" discuss historical advances in minimally invasive surgery, robotic microsurgery systems that are used in these procedures, surgical training that is required for robotic surgery, the specific results of the surgical trial to correct atrial septal defect that was conducted at Columbia-Presbyterian Medical Center in New York, and the future of robotic surgery.
In the final article of this series, Therese S. Geraci, MSN, RN, and Stephen A. Geraci, MD (Veteran Affairs Medical Center, Memphis, Tenn, and University of Wisconsin - Madison, respectively) summarize the important findings of ALLHAT in their article "What ALLHAT tells us about treating high-risk patients with hypertension and hyperlipidemia." These authors provide a concise review and summary of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). The purpose of ALLHAT, the largest study of hypertension to be ever conducted, was to determine if more expensive antihypertensive drugs such as calcium-channel blockers and angiotensin-converting enzyme inhibitors offered additional health benefits over less costly older diuretic agents. As reviewed by Geraci and Geraci, the findings of ALLHAT provided evidence that less expensive diuretics are very effective in reducing cardiovascular morbidity and mortality when compared to newer but more expensive drugs such as lisinopril and amlodipine.
The primary goal of this special issue "Top 10 Research Advances for 2002" is to provide cardiovascular nurses and other health care professionals with science that has been designated as "late breaking" and "innovative," in terms of the science's relevance or importance for impacting cardiovascular health and treatment. This is the second issue of the Journal of Cardiovascular Nursing that is dedicated to reviewing the AHA top research advances and it is interesting to compare the difference in emphasis from 2001 to 2002. Research advances appear to fall into several categories including basic research (eg, studies in animals and cells), new surgical interventions and devices, optimization of pharmacotherapeutics, risk factors and prevention, and outcomes research. In 2001, 4 of the top 10 research advances could be classified as basic research whereas this year there were only 2 (Gene therapy used to create first biological pacemaker and Cell transplantation therapy strengthens hearts). In both 2001 and 2002, 3 advances could be categorized as surgical interventions and devices. In 2001 there was 1 advance that primarily addressed pharmacotherapeutics whereas this year there were 3. Risk factors and prevention were the subjects of 1 article this year and 2 in 2001. Interestingly, this year 1 advance was in the category of outcomes research. The categories themselves underscore the many fronts upon which advances are being made and the necessity for cardiovascular health care professionals to maintain an understanding of research derived from the various categories of research. We are grateful to the interdisciplinary team of contributors that worked hard to achieve this goal.