1. Schwertz, Dorie W. PhD, RN, FAAN, FAHA

Article Content

For the last 11 years, the American Heart Association (AHA) has assembled a list of what they consider to be the "Top 10 Research Advances" reported as an article or abstract during the previous year. And, for several years, the Journal of Cardiovascular Nursing has published a special issue summarizing these advances. Every one of the Top 10 Advances is a product of a team of investigators, and in many cases, nurse researchers were an integral part of the team. This year, we took a somewhat different approach than in the past Top 10 special issues. We felt that it would be beneficial to have the principal investigators or coinvestigators represent their own work. Therefore, we went to the source, that is, the authors of the original report, and invited the principal investigator to write the article or asked if one of the coinvestigators (particularly a nurse investigator) would be interested in the project. This year, we are very excited that most of our authors were involved in the original work. Where this was not possible, the authors are experts in the relevant field.


The first of the Top 10 Research Advances for 2005 actually combines the work of 2 teams of German investigators. The studies examine the therapeutic potential of bone marrow-derived stem cells for 2 cardiovascular pathologies. In the first article of this Special Issue, Dr Thomas Bartsch describes the design and outcome of a study reported by himself and colleagues at the November 2005 AHA Scientific Sessions. Results of the investigation demonstrated that infusion of bone marrow-derived progenitor cells into the lower limbs of persons with deficient blood flow due to peripheral artery disease improved function (walking distance), ankle-brachial index, capillary-venous oxygen saturation, and endothelial cell function compared with placebo. The second study, reported by Dr Volker Schachinger at the 2005 AHA Scientific Session, described how intracoronary infusion of bone marrow-derived progenitor cells to myocardial infarction (MI) survivors significantly improved pumping function of the heart (measured by ejection fraction) compared with placebo. Other positive outcomes of the study included less heart enlargement, fewer hospitalizations, fewer new MI, and fewer deaths in the stem cell-treated group. The study, named the REPAIR Trial, was a large (more than 200 participants), randomized, double-blind, multicentered trial. We were unable to find an author to discuss the REPAIR Trial. Therefore, Dr Bartsch's article represents the first of the Top 10 Advances. In fact, it may be best to wait another year to review progress with stem/progenitor cell therapy after MI because there is much controversy as to whether infusion of a patient's own bone marrow-derived progenitor cells does exert a positive therapeutic effect after MI. At the same AHA Scientific Sessions, where Dr Schachinger reported positive results, Dr Ketil Lunde of Oslo, Norway, reported the negative results of the ASTAMI Trial, whereby bone marrow progenitor cells were injected into coronary tissue after left anterior wall MI. Six months later, no differences were found in cardiac function or remodeling between the control and treatment groups.


The second of the Top 10 Research Advances brings hope to those wanting to "kick the smoking habit." Dr Serena Tonstad, the principal investigator from a group centered in Oslo, Norway, reports on the very encouraging effect of the drug varenicline on smoking cessation. This experimental drug is an [alpha]4[beta]2 nicotine receptor partial agonist. The efficacy of varenicline on smoking cessation was compared with that of bupropion and placebo. Two thousand participants were treated for a period of 12 weeks and followed for another 40 weeks. After 12 weeks, "quit rates" were 44% in the varenicline group compared with 30% and 17.7% in the bupropion and placebo groups, respectively. Varenicline also exerted a significant effect on maintenance of abstinence at 24 and 52 weeks. The importance of this substantial increase in quit rates has tremendous implications for improving the overall health of a large number of individuals.


Dr Geraldine Budd and Dr Laura Hayman outline the AHA's scientific statement in "Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention, and Treatment." This consensus statement was named third on the list of the Top 10 Research Advances for 2005. Dr Hayman, a well-respected nurse researcher in the area of health behaviors in childhood and adolescence, particularly focusing on the prevention of obesity and cardiovascular disease, was a member of the scientific statement writing group, where she represented the nursing perspective. The statement describes the extent of the problem of overweight children and adolescents and the physical and psychological consequences of being overweight and suggests multifaceted approaches for preventing and treating childhood obesity. The enormity of the problem of childhood obesity and the importance of finding methods to combat the problem are clear when considering the associated increased risk for type 2 diabetes, increased blood pressure, and many other long-term physical and psychological ailments.


The Journal of Cardiovascular Nursing's 2003 issue on the Top 10 Research Advances reviewed the benefits of drug-eluting coronary stents particularly related to the inhibition of restenosis at short time periods after stent placement. The fourth article of the Top 10 Research Advances for 2005 documents that these benefits continue for at least 3 years. Late thrombotic events were a real concern with drug-eluting stents because the eluted drugs could delay endothelial cell repopulation of the vessel wall, with a consequent reduction in the powerful antiplatelet effects of these cells. Also, in fact, there is evidence of increased late thrombotic events in patients receiving these stents. However, with antiplatelet treatment, intervention with drug-eluting stents continues to dramatically decrease negative cardiovascular events in patients 3 years after placement. Michelle Fennessy, RN, MSN, and her colleague Dr William Borden review the continued encouraging results from RAVEL (RAndomized Study with the Sirolimus-eluting VELocity Balloon Expandable Stent) and other clinical trials and examine the benefits of drug-eluting stents in persons with diabetes and those with multivessel disease. Thus far, in RAVEL, 113 patients receiving sirolimus-eluting stents and 114 patients receiving bare metal (non-drug eluting) stents have been followed for over 3 years. The drug-eluting Cypher stent group had significantly fewer revascularization procedures, MI, and deaths than did the bare metal stent group. Fennessy and Borden are experts in coronary revascularization procedures and stent placement. Their practice at the University of Chicago Hospitals focuses on these patients.


In October 2003, a meeting was held in Atlanta, Ga, to discover and describe ethnic and racial disparities in health and healthcare and to determine what was needed to eradicate these disparities. In March 2005, the journal Circulation summarized the results of that conference. In this special Top 10 issue of the Journal of Cardiovascular Nursing, Dr George Mensah, principal author of the executive summary on the health disparities report, and colleague Dr Sandra Dunbar review the report findings. In their article entitled "A Framework for Addressing Disparities in Cardiovascular Health," evidence of and reasons for disparities in cardiovascular health are discussed. The authors also provide a conceptual framework that may be used in the effort to eliminate disparities.


The sixth of the Top 10 Research Advances for 2005 addresses scientific evidence showing that exposure to secondhand smoke is nearly as dangerous as smoking itself. Dr Joaquin Barnoya of the University of California at San Francisco (UCSF) and Unidad de Cirugia Cardiovascular de Guatemala and Dr Stanton Glantz of UCSF describe the pathophysiological effects of secondhand smoke on the cardiovascular system. Their original work, recognized by the AHA, discussed the results of a meta-analysis of 29 research studies that were published primarily in the last 10 years. The findings suggest that passive smoke increases the risk of coronary heart disease by approximately 30% to 40%, a level much higher than would be predicted based on the level of exposure to smoke toxins. The results have important implications for interventions aimed at reducing cardiovascular disease as evidenced by municipalities that have implemented smoke-free legislation and have experienced a subsequent large decrease in hospital admissions for acute MI.


An article published in the New England Journal of Medicine (volume 352) is the source of the seventh Top 10 Research Advance for 2005. Jill Anderson, RN, a member of the study team, headed by Dr Gust Bardy (both from Seattle Institute of Cardiovascular Research), summarizes the results of a clinical investigation of the prophylactic use of an implantable cardiac defibrillator in patients with heart failure. In total, more than 2,500 patients with class II or class III heart failure were randomized to receive conventional therapy plus implantable cardiac defibrillator, amiodarone, or placebo. Some of the results of the study were surprising. For instance, implantable cardiac defibrillator therapy had greater benefits in patients with New York Heart Association class II heart failure than in those with class III disease. In addition, treatment with amiodarone had no beneficial effects in class II patients and seemed to be harmful in class III patients. Although more studies are needed to confirm and extend these results, the findings will have immediate effects on practice.


The eighth of the AHA's Top 10 Research Advances reports on a particularly unique therapy for limb function recovery in stroke survivors. Dr Fu-Zen Shaw, principal investigator of the study, and colleague Jai-Ching Chen from Hsinchu, Taiwan, describe how 46 stroke survivors with paralyzed upper limbs received standard rehabilitation therapy or standard therapy plus thermal stimulation. The thermal stimulation consisted of alternating hot/cold, cold/hot cycles applied to the patient's hands with thermal packs, 5 days a week for 6 weeks. The investigators, who used 6 criteria to examine limb function, were blinded to treatment. After 6 weeks, the thermal treatment protocol group had significantly improved grasp strength, wrist extension, and sensory function compared with the conventional rehabilitation group. Thus, this seemingly simple treatment, when combined with other conventional therapies, seems to offer a cost-effective strategy for improving functional outcomes after stroke.


The ninth of the Top 10 Research Advances underscores the future promise of pharmacogenomics. The study results, outlined by the principal investigator, Dr David Lanfear from the Henry Ford Heart and Vascular Institute in Detroit, Mich, and his colleagues Dr John Spertus from the Mid American Heart Institute and the University of Missouri (Kansas City) and Dr Howard McLeod from the University of Washington School of Medicine (Saint Louis), demonstrate that in patients experiencing acute coronary syndrome who are treated with [beta]-blockers, specific beta2-adrenergic receptor genotypes are associated with significantly greater survival rates than in patients with other beta2-adrenergic receptor genotypes. This study shows that one day, it may be possible to design optimal individualized, genetically based therapies for patients with acute coronary syndromes. Dr Lanfear discusses future studies designed to confirm and extend the results of this exciting study, as well as the challenges that will need to be surmounted to translate the findings into clinical practice.


The 10th and final article of the Top 10 Research Advances was written by Dr Qureshi (Neurological Institute of New Jersey) and colleagues Drs Suri and Fareed. This article describes the results of a study that examined the rate of conversion of prehypertension to hypertension and the relationship between prehypertension and incidence of cardiovascular diseases, including MI. Data from the Framingham study were examined, and it was determined that persons with prehypertension were at significantly higher risk for heart disease and MI than were those with normal blood pressure. The research team determined that if the risk of prehypertension were eliminated, nearly half of the MI could be eliminated. Currently, there is no recommended pharmacotherapy for prehypertension, but persons with prehypertension can often be successfully treated with lifestyle changes. The findings of this study suggest that lifestyle modifications to lower even mild elevations in blood pressure can have a significant impact on cardiovascular health.


This Top 10 Research Advances issue of the Journal of Cardiovascular Nursing differs from previous issues in several ways. First, by taking the approach of asking the principal investigators or one of the collaborating investigators in the principal research group to represent their own work, this issue has taken on an international flare. The fact that this issue has authors from Guatemala, Norway, Germany, Taiwan, and across the United States reflects the worldwide interest and collaborations aimed at reducing cardiovascular disease. Second, over the last several years, there has been a steady increase in the number of Top 10 Research Advances that have direct clinical or public health benefit and a corresponding drop in the number of basic science studies that are considered by the AHA to be among the Top 10 Research Advances. This year, none of the chosen studies were conducted in animal or cell culture models. In fact, only one (Lanfear's "Beta2-Adrenergic Receptor Genotype Predicts Survival: Implications and Future Directions"), or possibly 2 (Bartsch's "Autologous Nonnuclear Stem Cell Transplantation in Patients With Peripheral Occlusive Arterial Disease"), might be considered "basic" science studies, although they are clinically based. In contrast, when we published our first AHA Top 10 Research Advances issue in 2001, 4 articles would have been considered basic research. This decline in basic science articles may reflect the AHA's growing emphasis on outcomes research. It may also be a reflection of the AHA's immediate goal of decreasing heart disease by 25% by the year 2010, or it may be related to the emphasis of the National Institutes of Health on translational research. Regardless, all of the 2005 Top 10 Research Advances are worthy of special recognition, and each is likely to have a significant impact on future cardiovascular health.


Once again, it is the intention of the issue and team of Editors of the Journal of Cardiovascular Nursing that this Special Issue will help keep the readership up-to-date with the latest research findings across the field of cardiovascular science and encourage nurses to apply the information gained from many of these studies. It is hoped that this knowledge will translate into benefits in cardiovascular health for us, for our patients, and for people throughout the world. As always, we are tremendously indebted to and sincerely thank the authors whose contributions permitted the production of this special issue.


Dorie W. Schwertz, PhD, RN, FAAN, FAHA


Associate Editor