In people with type 2 diabetes (T2D), the presence of microvascular disease is associated with increased risk for macrovascular events [(1)][1]. Of particular interest is whether microvascular disease is a risk factor for heart failure (HF) or has a role in its pathophysiology [(2)][2]. The

BACKGROUNDThis study was undertaken to determine whether use of the direct renin inhibitor aliskiren would reduce cardiovascular and renal events in patients with type 2 diabetes and chronic kidney disease, cardiovascular disease, or both.METHODSIn a double-blind fashion, we randomly assigned 8561 patients to aliskiren (300 mg daily) or placebo as an adjunct to an angiotensin-converting-enzyme inhibitor or an angiotensin-receptor blocker. The primary end point was a composite of the time to cardiovascular death or a first occurrence of cardiac arrest with resuscitation; nonfatal myocardial infarction; nonfatal stroke; unplanned hospitalization for heart failure; end-stage renal disease, death attributable to kidney failure, or the need for renal-replacement therapy with no dialysis or transplantation available or initiated; or doubling of the baseline serum creatinine level.RESULTSThe trial was stopped prematurely after the second interim efficacy analysis. After a median follow-up of 32.9 months, the primary end point had occurred in 783 patients (18.3%) assigned to aliskiren as compared with 732 (17.1%) assigned to placebo (hazard ratio, 1.08; 95% confidence interval [CI], 0.98 to 1.20; P=0.12). Effects on secondary renal end points were similar. Systolic and diastolic blood pressures were lower with aliskiren (between-group differences, 1.3 and 0.6 mm Hg, respectively) and the mean reduction in the urinary albumin-to-creatinine ratio was greater (between-group difference, 14 percentage points; 95% CI, 11 to 17). The proportion of patients with hyperkalemia (serum potassium level, ≥6 mmol per liter) was significantly higher in the aliskiren group than in the placebo group (11.2% vs. 7.2%), as was the proportion with reported hypotension (12.1% vs. 8.3%) (P<0.001 for both comparisons).CONCLUSIONSThe addition of aliskiren to standard therapy with renin-angiotensin system blockade in patients with type 2 diabetes who are at high risk for cardiovascular and renal events is not supported by these data and may even be harmful. (Funded by Novartis; ALTITUDE ClinicalTrials.gov number, NCT00549757.).

Acute arrhythmia is a condition covering a wide variety of rhythm disturbances. The aim of this article is to give practical recommendations for the management of the patient presenting with an acute arrhythmia. We discuss bradycardia and tachycardia. Tachycardias are divided into the small QRS complex tachycardias and the wide QRS complex tachycardias. Other important issues are the distinction between the hemodynamic stable and unstable patient and the need for trombo-embolic prevention of the patient with atrial fibrillation. Flowcharts with diagnostic means and therapeutic schemes as well as a table with practical considerations for electrical cardioversion are provided.

BACKGROUND:A substantial proportion of patients receiving fibrinolytic therapy for myocardial infarction with ST-segment elevation have inadequate reperfusion or reocclusion of the infarct-related artery, leading to an increased risk of complications and death.METHODS:We enrolled 3491 patients, 18 to 75 years of age, who presented within 12 hours after the onset of an ST-elevation myocardial infarction and randomly assigned them to receive clopidogrel (300-mg loading dose, followed by 75 mg once daily) or placebo. Patients received a fibrinolytic agent, aspirin, and when appropriate, heparin (dispensed according to body weight) and were scheduled to undergo angiography 48 to 192 hours after the start of study medication. The primary efficacy end point was a composite of an occluded infarct-related artery (defined by a Thrombolysis in Myocardial Infarction flow grade of 0 or 1) on angiography or death or recurrent myocardial infarction before angiography.RESULTS:The rates of the primary efficacy end point were 21.7 percent in the placebo group and 15.0 percent in the clopidogrel group, representing an absolute reduction of 6.7 percentage points in the rate and a 36 percent reduction in the odds of the end point with clopidogrel therapy (95 percent confidence interval, 24 to 47 percent; P<0.001). By 30 days, clopidogrel therapy reduced the odds of the composite end point of death from cardiovascular causes, recurrent myocardial infarction, or recurrent ischemia leading to the need for urgent revascularization by 20 percent (from 14.1 to 11.6 percent, P=0.03). The rates of major bleeding and intracranial hemorrhage were similar in the two groups.CONCLUSIONS:In patients 75 years of age or younger who have myocardial infarction with ST-segment elevation and who receive aspirin and a standard fibrinolytic regimen, the addition of clopidogrel improves the patency rate of the infarct-related artery and reduces ischemic complications.

We describe the case of a 79-year-old woman with mitral insufficiency and a double-orifice mitral valve (DOMV), discovered by echocardiography. Transthoracic echocardiography showed two insufficiency jets. Transesophageal echocardiography revealed a DOMV. Each orifice was provided with a subvalvular apparatus. No associated congenital abnormalities were present. Our case demonstrates that even in elderly patients with a double regurgitant jet, DOMV should be suspected and assessed by transesophageal echocardiography.

Le groupe Interdisciplinaire Belge de Cardiologie Aigue (BIWAC), comprenant des cardiologues, des intensivistes, des urgentistes, propose un consensus de prise en charge des douleurs thoraciques aigues en phase pre-hospitaliere et hospitaliere precoce. Des regles generales et des arbres decisionnels sont proposes afin de pouvoir traiter au mieux les patients souffrant de syndromes coronaires aigus.

The Belgium Interdisciplinary Working Group on Acute Cardiology (BIWAC), including cardiologists, intensivists and urgentists was formed to give consensus regarding the management of acute chest pain in the prehospital and the early hospital phases. General recommendations and critical pathways are proposed to improve the treatment of the patients with acute coronary syndromes.

The role of ischaemia in the natural history of sustained monomorphic ventricular tachycardia not related to acute myocardial infarction is not well documented. We examined 38 patients (mean age 60 years, mean ejection fraction 33%) with programmed electric stimulation and thallium scintigraphy to study the presence of perfusion defects and to assess its prognostic significance. Reversible perfusion defects (RPD), alone or in combination, were seen in 17 patients (44.7%), persistent perfusion defects (PPD) in 31 (81.5%), and RPD and PRD combined existed in 14 patients (37%). Normal scintigrams were obtained in only four patients. Segmental analysis gave a mean 'infarction score' (number of PPDs on a total of 15 segments) of 4.2; the mean 'ischaemia' score (number of RPDs) was 1.2. Recurrence of tachycardia or sudden death was observed in 14 patients during a follow-up of 17 +/- 13 months. The predictive value (PV) of the presence of a RPD for recurrence was 63%, the PV of its absence was 82%; the predictive accuracy was 74% (P = 0.0069). This was as important as the data obtained with the drug studies (+PV 83%; -PV 86%; overall PV 83%, P = 0.002). The mean ischaemia score was 3.3 in the group with recurrence and 2 in the patients without recurrence. As pharmacological studies are only feasible in a subgroup with inducible tachycardia, thallium scintigraphy is of benefit to a larger group for predicting effective drug therapy and the risk of recurrence.

Microbiological features, diagnostic investigations, treatment, and complication rate in 53 cases of infective endocarditis were reviewed in this study. Infection occurred both on prosthetic (47%) and native valves (38%), while in 15% of the cases no prior valvular disease was known. Streptococcal (38%) and staphylococcal (30%) infections were predominant. In 17% of the cases apparent negative blood cultures were obtained. The most frequent portal of entry was dental infection or manipulation (45%), however in 28% of the patients etiology remained obscure. Major clinical signs and symptoms included heart murmurs (96%), fever (91%), dyspnoea (32%), and splenomegaly (30%). Echocardiography revealed vegetations in 78%, aortic and mitral valve being nearly equally affected. All patients were medically treated and 53% received antibiotics prior to blood cultures. Associations of ampicillin or penicillin with an aminoglycoside (43%) and penicillinase-resistant antibiotics (30%) were most frequently administered. In 28% of the patients, it was necessary to insert a prosthetic (aortic or mitral) valve. During follow-up, heart failure (28%), embolization (11%), and infections (11%) were the major complications.