Celebrating 20 years of advances in cardiology

In the fall of 1984, Cardiology Review first appeared and was known as Cardiology Board Review. We are celebrating the 20th anniversary of our journal with this special issue. Now is a good time to take stock of changes in the field because the past two decades have seen impressive strides in the diagnosis and treatment of cardiovascular disease.

Several new drugs have been approved for hypertension treatment since Cardiology Review was founded. Twenty years ago, our antihypertensive armamentarium did not include angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers. Today, these are some of our most popular agents. At the same time, there are still conflicting views on which drugs to use as first-line agents and which combinations to employ. Many

of the drugs in use have been shown to cause regression of left ventricular hypertrophy. Ironi-

cally, diuretics are the exception; however, because of the recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7), this class of drugs is once again considered a first-line agent. Many of my colleagues are not so sure of the wisdom of this recommendation, nor am I.

Momentous changes are apparent in the treatment of heart failure. The ramifications of these changes are discussed by Drs. Gretchen Wells and William C. Little and commented on in depth by Dr. Michael W. Rich.

It also seems there is always a new drug to treat arrhythmias (atrial or ventricular), and the past two decades have seen a slew of such agents. None has had the impact of amiodarone for both types of arrhythmias, yet the greatest advance in this field has been nonpharmacologic. Despite drug therapy, we are now clearly in the era of automatic implantable cardioverter-defibrillators, which are extremely important life-saving devices. Dr. Stephen C. Vlay discusses the impact of device therapy in the past 20 years. Dr. William J. Mandel comments on his review and adds some thoughts of his own.

The major advance in coronary artery disease (CAD) treatment has been the widespread use of interventional therapy, especially drug-eluting stents. Drs. Sailajah Janarthanan and Joseph S. Alpert nicely sum up where we stand today in the management of chronic angina, and Dr. Kanu Chatterjee provides additional insightful comments. Therapy of acute myocardial infarction (MI) has also been

revolutionized, first with thrombolytic agents, then with per-cutaneous transluminal coron-ary angioplasty, and finally with stents.

In lipid therapy we have had a fantastic breakthrough as well. The class of drugs commonly referred to as statins (HMG-CoA reductase inhibitors) have been shown to dramatically lower low-density lipoprotein cholesterol levels and to markedly improve the endothelial function of two of the most important arterial systems in the body—those supplying the heart and the brain. Thereduction in morbidity and mortality associated with these drugs in patients with known CAD (secondary prevention) is obviously of clinical importance, but I think in the long run the primary prevention of cardiovascular events in apparently healthy subjects will have an even greater public health impact.

Just as statins have revolutionized lipid management, ACE inhibitors have done the same for diabetes, in many cases blunting the deleterious effect of this disease on the kidney and the vasculature (statins here are helpful as well). The controversy over whether tight blood glucose control can slow the development of vascular events now appears to be resolved—tight control helps. The major impact of the thrombolytic agents is just now being felt in stroke patients,

a good decade after the breakthrough in the acute MI field. Treating a “brain attack” is now becoming more like treating a “heart attack.”

This issue also features a bonus overview article. It appears in the combined stroke and arrhythmias section. Dr. Ethan Levine provides updates of current concepts in the relationship between atrial fibrillation and stroke, especially pathophysiology and treatment.

I hope you enjoy this issue. Cardiology Review is 20 years old and still going strong. Happy Birthday!