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The introduction and subsequent iterations of drug-eluting stent technologies have substantially improved the efficacy and safety of percutaneous coronary interventions. However, the incidence of in-stent restenosis (ISR) and the resultant need for repeated revascularization still occur at a rate of 1%-2% per year. Given that millions of drug-eluting stents are implanted each year around the globe, ISR can be considered as a pathologic entity of public health significance. The mechanisms of ISR are multifactorial. Since the first description of the angiographic patterns of ISR, the advent of intracoronary imaging has further elucidated the mechanisms and patterns of ISR. The armamentarium and treatment strategies of ISR have also evolved over time. Currently, an individualized approach using intracoronary imaging to characterize the underlying substrate of ISR is recommended. In this paper, we comprehensively reviewed the incidence, mechanisms, and imaging characterization of ISR and propose a contemporary treatment algorithm.

Fractional flow reserve (FFR) is considered nowadays as the gold standard for invasive assessment of physiologic stenosis significance and an indispensable tool for decision making in coronary revascularization. Use of FFR in the catheterization laboratory accurately identifies which lesions should be stented and improves the outcome in most elective clinical and angiographic conditions. Recently, FFR has been upgraded to a class IA classification in multivessel percutaneous coronary intervention in the guidelines on coronary revascularization of the European Society of Cardiology. In this state-of-the-art paper, the basic concept of FFR and its application, characteristics, and use in several subsets of patients are discussed from a practical point of view. (J Am Coll Cardiol 2012;59:1045-57) (C) 2012 by the American College of Cardiology Foundation

We read with interest the paper by Galie et al [(1)][1]. In their cohort, in 40% of patients with pulmonary arterial hypertension (PAH) with angina, left main coronary artery (LMCA) stenosis ≥50% was confirmed by coronary angiography (CA). Of those, 94% were percutaneously treated based on

Objectives. The primary objective of the International Verapamil SR/Trandolapril Study (INVEST) is to compare the risk for adverse outcomes (all-cause mortality, nonfatal myocardial infarction [MI] or nonfatal stroke) in hypertensive patients with coronary artery disease (CAD) treated with either a calcium antagonist-based or a noncalcium antagonist-based strategy. Background. Treatment recommendations for hypertension include initial therapy with a diuretic or beta-adrenergic blocking agent, for which reductions in morbidity and mortality are documented from randomized trials but are less than expected from epidemiologic data. For this reason, recent attention has focused on calcium antagonists or angiotensin-converting enzyme inhibitors. While these agents reduce blood pressure, outcome data from large randomized trials are lacking, but some case-control data, dominated by short-acting dihydropyridines, suggest an increased risk of cardiovascular events. These studies had methodologic limitations and did not differentiate among calcium antagonist types and formulations. Several studies differentiating among calcium antagonist types and an overview of published randomized trials show no increased risk with verapamil and suggestion for benefit in CAD patients. Methods. A total of 27,000 CAD patients with hypertension will be randomized at 1,500 primary care sites to receive either a calcium antagonist-based (verapamil) or beta-blocker/diuretic-based (atenolol/hydrochlorothiazide) antihypertensive care strategy. The study uses a novel, electronic “paper-less” system for direct on-screen data entry, randomization and drug distribution from a mail pharmacy linked to the coordination center via the Internet. Results. Contract negotiations with the United States and international sites are ongoing. Patients being enrolled are predominantly elderly (72% aged 60 years or older) men (54%), with either an abnormal coronary angiogram or prior MI (71%). In addition to hypertension, CAD and elderly age, most patients (89%) have one or more associated conditions (diabetes, dyslipidemia, smoking, cerebral or peripheral vascular disease, etc.) contributing to increased risk for adverse outcome. While 26% have diabetes, most of these are noninsulin dependent. Using the protocol strategies, target blood pressures (according to JNC VI) have been reached in 58% at the fourth visit, and as expected most (89%) are requiring multiple antihypertensive drugs. Conclusion. The design and baseline characteristics of the initial patients recruited for a prospective, randomized, international, multicenter study comparing two therapeutic strategies to control hypertension in CAD patients are described.

In this issue of the Journal , 2 papers [(1,2)][1] address an important question: how can we use computed tomographic coronary angiography (CTCA) to quantify prognosis and stenosis in patients with coronary artery disease? Simple coronary calcium scoring (CCS), using a technique proposed by Agatston

There is increased interest in and use of cardiac computed tomographic and magnetic resonance imaging as the technology continues to improve. We have many small single-center trials on the diagnostic accuracy of these techniques, but no studies that show a patient benefit from testing. The American College of Cardiology has recently tackled the "appropriateness challenge" for imaging tests, including computed tomographic and magnetic resonance imaging. The importance of outcomes data and risks of continuing our investment in computed tomography without outcomes data on benefits for patient care are discussed in this paper.

We read with great interest the paper about the DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study, which compared fractional flow reserve (FFR) derived from coronary computed tomography angiography (CTA) with invasive FFR measurements ([1][

I read with interest the paper by Meijboom et al. ([1][1]) relating to diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTA) and the editorial comment on the limitations of CTA by Nissen ([2][2]). Bluemke et al. ([3][3]), in a scientific statement on noninvasive coronary

We read with interest the recent paper by Meijboom et al. ([1][1]) and the corresponding editorial by Nissen ([2][2]). We wish to make 3 comments. First, as with almost all previous validation studies comparing computed tomography coronary angiography (CTCA) with invasive coronary angiography (ICA

The concept of depressor reflexes originating in the heart was introduced by von Bezold in 1867 and was later revived by Jarisch. The Bezold-Jarisch reflex originates in cardiac sensory receptors with nonmyelinated vagal afferent pathways. The left ventricle, particularly the inferoposterior wall, is a principal location for these sensory receptors. Stimulation of these inhibitory cardiac receptors by stretch, chemical substances or drugs increases parasympathetic activity and inhibits sympathetic activity. These effects promote reflex bradycardia, vasodilation and hypotension (Bezold-Jarisch reflex) and also modulate renin release and vasopressin secretion. Conversely, decreases in the activity of these inhibitory sensory receptors reflexly increase sympathetic activity, vascular resistance, plasma renin activity and vasopressin.Long regarded as pharmacologic curiosities, it is now clear that reflexes originating in these inhibitory cardiac sensory receptors are important to the pathophysiology of many cardiovascular disorders. This paper reviews the role of inhibitory cardiac sensory receptors in several clinical states including 1) bradycardia, hypotension and gastrointestinal disorders with inferoposterior myocardial ischemia and infarction, 2) bradycardia and hypotension during coronary arteriography, 3) exertional syncope in aortic stenosis, 4) vasovagal syncope, 5) neurohumoral excitation in chronic heart failure, and 6) the therapeutic effects of digitalis.

In their recent paper, Dr. Bettencourt and colleagues [(1)][1] report similar accuracy for the detection of coronary artery disease (CAD) between cardiac magnetic resonance (CMR) perfusion and an integrated computed tomography (CT) perfusion/angiography protocol. Unfortunately, the authors did not

We read with interest the paper by Koo et al. ([1][1]) regarding the diagnostic accuracy of noninvasive measurement of fractional flow reserve (FFR) from coronary computed tomography angiography data (FFRCT). We do recognize the potential clinical and economic relevance of the validation of a

The paper by Taylor et al. [(1)][1] on a new method for the calculation of fractional flow reserve (FFR) from cardiac computed tomography (CTA) images of the coronary arteries is elegant and interesting, with some striking pictures, and it offers the possibility of calculating this important