This issue of the Journal of Cardiovascular Nursing reviews the American Heart Association's (AHA's) 2006 list of the "Top 10 Research Advances," which AHA generates at the end of each calendar year, for the fields of stroke and heart disease. The list highlights studies reported during the previous year that will have the greatest impact on each field. For the past 5 years, I have edited a special issue of the Journal of Cardiovascular Nursing that summarizes research chosen for the Top 10 list. For the last 2 years, I invited the principal investigators responsible for the original research to write the review. This year, 9 of the 10 investigators or an associated colleague agreed to write the review. The other was written by the issue editor and an expert in the field.
The Top 10
Every investigation chosen as a Top 10 Research Advance for 2006 is a significant study with important results. Five of the 10 are likely to immediately and directly influence clinical practice. The first of the Top 10 reports the results of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels Trial. The trial results demonstrate that high-dose statin therapy reduces the risk of a second stroke in persons who have experienced a previous stroke or transient ischemic attack. The second recognized study reports that use of selective type-2 cyclooxygenase inhibitors and high-dose, non-aspirin, nonsteroidal anti-inflammatory drugs increases the risk of rehospitalization and death in patients with previous myocardial infarction. The results of the third of the Top 10 found a significant increase in birth defects in infants exposed to angiotensin-converting enzyme inhibitors during the first 3 months of pregnancy. Accordingly, angiotensin-converting enzyme inhibitors should be avoided during this period of pregnancy. The noteworthy finding of the fourth article is that ventricular assist devices can be used to successfully bridge children to heart transplant therapy. The risk of adverse events in children is no greater than that of adults. This finding, based on a retrospective study, will increase survival in children who might have previously died while waiting for transplant. The fifth acknowledged research advance that resulted from the Occluded Artery Trial. This prospective clinical trial revealed that, in contrast to early coronary artery reperfusion therapy after myocardial infarction, late (3-28 days) percutaneous coronary intervention performed to open an occluded artery provides no benefit over medical management alone. The results emphasize the importance of early reperfusion and appropriate medical management.
Three of the Top 10 Research Advances for 2006 were new AHA Practice Guidelines or AHA Scientific Statements or research that examined whether following Practice Guidelines led to better outcomes. The sixth of the Top 10 Research Advances was the updated guidelines for secondary prevention of stroke. The guidelines emphasize modification of risk factors and suggest that similar treatment approaches can benefit those patients who have had either a previous stroke or transient ischemic attack. The AHA Scientific Statement on Promoting Physical Activity in Children and Youth was recognized as the seventh research advance. The statement highlights a trend toward decreased physical activity and increased prevalence of obesity in children. The statement suggests that schools are well positioned to play a key role in ensuring children's participation in a healthy level of activity. The Coordinated School Health Model provided a framework for specific recommendations to achieve evidence-based goals. The eighth of the Top 10 Research Advances examined whether adherence to American College of Cardiology/AHA guidelines for treatment of non-ST-segment elevation acute coronary syndrome improves patient outcomes. The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation study found that higher guideline adherence rates significantly decreased in-hospital mortality of patients with this specific form of acute coronary syndrome. The results validate the assumption that following the guidelines can improve quality of care.
The last two recognized research advances are more theoretical or basic. One examined blood lipid levels in more than 6,000 adolescents who had taken part in previous National Health and Nutrition Examination Surveys. Statistical modeling was used to establish age-specific normal blood lipid levels and thresholds for lipid and lipoprotein levels that are associated with increased cardiovascular disease risk in adulthood. When validated, these values will help identify children in need of preventative interventions. Finally, only 1 of the Top 10 Research Advances named in 2006 could be considered a "basic" research study. The 10th study reports on progress in the development of an in vivo, autologous, tissue-engineered valve conduit that brings closer to reality the possibility of replacing diseased heart valves with bioengineered valves.
Selection Criteria of the Top 10
Two trends were apparent when comparing the AHA's Top 10 Research Advances for 2006 to their other Top 10 lists over the past 10 years. First, there has been a noticeable decline in the number of basic science studies and a rise in the number of AHA Guidelines and Scientific Statements. The choices for 2006 prompted me to think about what criteria should be used to determine the Top 10 Research Advances during a previous year in any scientific field. In discussing this question with colleagues, students, and friends, an interesting philosophical dichotomy became clear. In general, the question being addressed could be rephrased as, "What positively distinguishes the value of a research result such that it stands out from others?" Both sides believed that the particular discovery resulting from the research should have a great impact on the field. However, where the schism occurs is in what defines "greatest impact." One view (and I admit to subscribing to this philosophy) is that the discovery is innovative and fundamental and has a profound impact on the direction of the science. It generates other advances and is more likely to focus on new theories and approaches than outcomes. The discovery causes a shift in perspective that spawns a flurry of new discovery. It is like a stone thrown in a pond that generates concentric ripples of influence. Figure 1 illustrates the concept. The other view is that the research discovery must have a profound and immediate influence on human morbidity, mortality, and quality of life. It is more likely to be applied and to affect human outcomes. To me, and in agreement with those who hold this view, this research finding would be placed on the outermost concentric ring of Figure 1, thereby bordering on human application.
The question of what criteria should be used to recognize a seminal research advance is not new. In 2000, the Nobel Prize for Medicine was awarded to 3 neuroscientists (Doctors Carlsson, Greengard, and Kandel) who conducted research on neuronal signaling. Their discoveries were basic and provided a framework for the future discovery of the mechanism of Parkinson disease. However, hundreds of neuroscientists wrote a letter to the awards committee suggesting that another scientist (Doctor Hornykiewicz) should have received the award. Doctor Hornykiewicz determined that depletion of the brain neurotransmitter dopamine was the cause of Parkinson disease. He further discovered that dopamine replacement through treatment with the precursor l-dopa greatly improved the condition of the patient with Parkinson disease. The debate highlights the issue of whether the relative value of basic fundamental discovery versus application of a fundamental principle is more important.
The debate underlying the question of what constitutes the most important research advances continues between science and medicine. It is a difficult question to answer because science and medicine are partners along a continuum. One's philosophical stance (not surprisingly) stems from the work and goals of an individual or group. Most clinicians I spoke with believed that a discovery that changed clinical practice was most important. The basic scientists subscribed to the view that the discovery should be fundamental. Interestingly, it was a student who suggested that the top research advances should be "translational." In 2000, the AHA said the following about the Top 10 list: "First created in 1996, the annual 'Top 10' list highlights research achievements in basic and clinical research that may have significant impact on the prevention and treatment of heart disease and stroke" (news release on the AHA Web site on December 28, 2000).1 Unlike the selection process for research that deserves a Nobel Prize, choosing a top research advance from the last year does not allow the perspective of history to determine which discovery has a lasting impact. The news release for the Top 10 list for 2006 stated: "The American Heart Association's Top 10 list was created in 1996 and highlights the year's major gains in heart disease and stroke research" (news release on the AHA Web site on February 7, 2007).2 The primary goal of AHA is to reduce coronary heart disease, stroke, and risk by 25% by 2010. This is a short time frame and requires research advances that almost immediately are applied and impact outcomes.
In my discussions with colleagues, students, and friends about choices for the AHA's Top 10 Research Advances for 2006, the inclusion of Guidelines and Scientific Statements was hotly debated. These consensus publications are clearly important to the AHA's goals, but are they "research"? The majority did not think that compilation, classification, and ranking of the level of validity of research on a given clinical problem constituted a research advance. This by no means belittles its significance.
There was general consensus that some factors that can influence the selection of an outstanding research advance should be minimized. These include the politics of discovery, economic issues, and the "cool factor." The cool factor is a bias toward recognizing a given research advance because it uses the hottest new technique or falls within an area of research that is the latest trend. An author friend of mine brought up the point that, in mathematics, "zero" has been considered to be one of the greatest discoveries-a concept from which all else can be measured. The discovery of zero certainly has incredibly far-reaching impact-and that is beyond cool.
A Final Word
Once again, I am indebted to and wish to thank the authors who contributed to this issue. Their work is laudable, and without their commitment to research and help with this project, the issue could not be produced. I invite comments about the issue as a whole, as well as thoughts and opinions regarding the question of criteria used to select the Top 10 Research Advances in any scientific field.
Sincerely,
Dorie Schwertz, PhD, RN, FAAN, FAHA
University of Illinois at Chicago
[email protected]
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