Jae W. Song, Jiayu Xiao, S. Cen, Xiao Liu, Fang Wu, K. Schlick, Debiao Li, Qi Yang, Shlee S Song, Z. Fan
Background Studies suggest the presence of sex differences in hypertension prevalence and its associated outcomes in atherosclerosis and stroke. We hypothesized a higher intracranial atherosclerosis burden among men with hypertension and acute ischemic stroke compared with women. Methods and Results A multicenter retrospective study was performed from a prospective database identifying patients with hypertension presenting with intracranial atherosclerosis‐related acute ischemic stroke and imaged with intracranial vessel wall magnetic resonance imaging. Proximal and distal plaques on vessel wall magnetic resonance imaging were scored. Negative binomial models assessed the associations between plaque‐count and sex and the interaction between sex and treatment. Covariates were selected by a least absolute shrinkage and selection operator procedure. Sixty‐one patients (n=42 men) were included. There were no significant differences in demographic or cardiovascular risk factors except for smoking history (P=0.002). Adjusted total and proximal plaque counts for men were 1.6 (95% CI, 1.2–2.1; P<0.01) and 1.4 (95% CI, 1.0–1.9; P=0.03) times as high as women, respectively. Female sex was more protective for proximal plaque if treated for hypertension. The risk ratio of men versus women was 1.5 (95% CI, 1.0–2.1) for treated patients. The risk ratio of men versus women was 0.7 (95% CI, 0.4–1.3) for untreated patients. The relative difference between these 2 risk ratios was 2.0 (95% CI, 1.1–3.9), which was statistically significant from the interaction test, P=0.04. Conclusions Men with hypertension with acute ischemic stroke have significantly higher total and proximal plaque burdens than women. Women with hypertension on anti‐hypertensive medication showed a greater reduction in proximal plaque burden than men. Further confirmation with a longitudinal cohort study is needed and may help evaluate whether different treatment guidelines for managing hypertension by sex can help reduce intracranial atherosclerosis burden and ultimately acute ischemic stroke risk.
{"title":"Sex Differences in Intracranial Atherosclerosis in Patients With Hypertension With Acute Ischemic Stroke","authors":"Jae W. Song, Jiayu Xiao, S. Cen, Xiao Liu, Fang Wu, K. Schlick, Debiao Li, Qi Yang, Shlee S Song, Z. Fan","doi":"10.1161/JAHA.122.025579","DOIUrl":"https://doi.org/10.1161/JAHA.122.025579","url":null,"abstract":"Background Studies suggest the presence of sex differences in hypertension prevalence and its associated outcomes in atherosclerosis and stroke. We hypothesized a higher intracranial atherosclerosis burden among men with hypertension and acute ischemic stroke compared with women. Methods and Results A multicenter retrospective study was performed from a prospective database identifying patients with hypertension presenting with intracranial atherosclerosis‐related acute ischemic stroke and imaged with intracranial vessel wall magnetic resonance imaging. Proximal and distal plaques on vessel wall magnetic resonance imaging were scored. Negative binomial models assessed the associations between plaque‐count and sex and the interaction between sex and treatment. Covariates were selected by a least absolute shrinkage and selection operator procedure. Sixty‐one patients (n=42 men) were included. There were no significant differences in demographic or cardiovascular risk factors except for smoking history (P=0.002). Adjusted total and proximal plaque counts for men were 1.6 (95% CI, 1.2–2.1; P<0.01) and 1.4 (95% CI, 1.0–1.9; P=0.03) times as high as women, respectively. Female sex was more protective for proximal plaque if treated for hypertension. The risk ratio of men versus women was 1.5 (95% CI, 1.0–2.1) for treated patients. The risk ratio of men versus women was 0.7 (95% CI, 0.4–1.3) for untreated patients. The relative difference between these 2 risk ratios was 2.0 (95% CI, 1.1–3.9), which was statistically significant from the interaction test, P=0.04. Conclusions Men with hypertension with acute ischemic stroke have significantly higher total and proximal plaque burdens than women. Women with hypertension on anti‐hypertensive medication showed a greater reduction in proximal plaque burden than men. Further confirmation with a longitudinal cohort study is needed and may help evaluate whether different treatment guidelines for managing hypertension by sex can help reduce intracranial atherosclerosis burden and ultimately acute ischemic stroke risk.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75203277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
ecently, our team was asked to evaluate a unique patient for pediatric heart transplant. She was a 5- month- old female patient with trisomy 21 and a tetralogy of Fallot– type atrioventricular septal defect status post complete surgical repair 2 months earlier. The surgery was complicated complete heart block and pacemaker dependence, but she recovered un-eventfully and was discharged home after several weeks. After 3 weeks at home, she presented to the emergency department with lethargy and was found to be in cardiogenic shock. Her echocardiogram demonstrated a severely dilated left ventricle and severely de-pressed biventricular function. She required support with venoarterial extracorporeal membrane oxygen-ation. After 4 days, she was able to be weaned from mechanical circulatory support, but her systolic function demonstrated no signs of recovery despite aggres-sive medical management, prompting referral for heart transplant evaluation. While perhaps an unusual case given the specific congenital heart disease lesion, none of the patient’s cardiac course was particularly impact-ful in terms of our team’s decision making on transplant candidacy. However, her Down syndrome made her extremely unique as a heart transplant candidate at our center. We had never been asked to consider transplant in a patient with trisomy 21 before. We were completely ignorant of the ramifications of Down syndrome on transplant outcomes. Was the increased risk of pulmonary vascular disease present in these patients risk long- term graft function survival? 1 the incidence of leukemia in individuals with Down syndrome, posttransplant lymph-oproliferative
{"title":"Why Haven’t We Seen This Before? The Importance of Reporting Experience to Improve Access and Equity","authors":"K. Schumacher","doi":"10.1161/JAHA.122.025888","DOIUrl":"https://doi.org/10.1161/JAHA.122.025888","url":null,"abstract":"ecently, our team was asked to evaluate a unique patient for pediatric heart transplant. She was a 5- month- old female patient with trisomy 21 and a tetralogy of Fallot– type atrioventricular septal defect status post complete surgical repair 2 months earlier. The surgery was complicated complete heart block and pacemaker dependence, but she recovered un-eventfully and was discharged home after several weeks. After 3 weeks at home, she presented to the emergency department with lethargy and was found to be in cardiogenic shock. Her echocardiogram demonstrated a severely dilated left ventricle and severely de-pressed biventricular function. She required support with venoarterial extracorporeal membrane oxygen-ation. After 4 days, she was able to be weaned from mechanical circulatory support, but her systolic function demonstrated no signs of recovery despite aggres-sive medical management, prompting referral for heart transplant evaluation. While perhaps an unusual case given the specific congenital heart disease lesion, none of the patient’s cardiac course was particularly impact-ful in terms of our team’s decision making on transplant candidacy. However, her Down syndrome made her extremely unique as a heart transplant candidate at our center. We had never been asked to consider transplant in a patient with trisomy 21 before. We were completely ignorant of the ramifications of Down syndrome on transplant outcomes. Was the increased risk of pulmonary vascular disease present in these patients risk long- term graft function survival? 1 the incidence of leukemia in individuals with Down syndrome, posttransplant lymph-oproliferative","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"92 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79985546","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. El Sabbagh, R. Nishimura, M. Eleid, S. Pislaru, P. Pellikka, C. Rihal, M. Guerrero, D. Hodge, William R. Miranda
Background The aim of this study was to establish prognostic hemodynamic parameters in patients with mitral stenosis secondary to mitral annular calcification. Methods and Results A retrospective cohort of 105 patients undergoing transseptal catheterization for hemodynamic evaluation of mitral annular calcification–related mitral stenosis between 2004 and 2020 was studied. Mitral valve gradient (MVG) and mitral valve area (MVA; calculated by the Gorlin formula) were measured using direct left atrial and left ventricular pressures. The median age of the patients was 70.3 years (58.4–76.7 years), and 53.3% were women. The median MVA was 1.7 cm2 (1.3–2.3 cm2) and MVG was 7.3 mm Hg (5.3–10.3 mm Hg); left ventricular end‐diastolic pressure was 17.6±28.3 mm Hg. During a median of 2.1 years (0.7–4.5 years), there were 63 deaths; 1‐ and 5‐year survival were 76% and 40%, respectively. There was no association between left ventricular end‐diastolic pressure and survival. After adjusting for age and comorbidities, both MVA (hazard ratio [HR], 0.50 per cm2; 95% CI, 0.34–0.73) and MVG (HR, 1.1 per mm Hg; 95% CI, 1.05–1.20) were independent predictors of death. Atrial fibrillation was also independently associated with mortality. When added to a combined model, MVA remained associated with death (HR, 0.51 per cm2; 95% CI, 0.33–0.79) while MVG was not. Conclusions In patients with mitral annular calcification–related mitral stenosis, survival was poor. MVA and MVG were independently associated with death, but MVA was a better predictor of outcomes.
本研究的目的是建立二尖瓣狭窄继发于二尖瓣环钙化患者的预后血流动力学参数。方法与结果回顾性分析2004年至2020年间105例经中隔置管治疗二尖瓣环形钙化相关二尖瓣狭窄的患者。二尖瓣梯度(MVG)和面积(MVA);采用直接左房压和左室压测量。患者中位年龄为70.3岁(58.4 ~ 76.7岁)，女性占53.3%。中位MVA为1.7 cm2 (1.3-2.3 cm2)， MVG为7.3 mm Hg (5.3-10.3 mm Hg);左室舒张末期压为17.6±28.3 mm Hg。在中位2.1年(0.7-4.5年)期间，有63例死亡;1年和5年生存率分别为76%和40%。左室舒张末期压与生存无关联。在调整年龄和合并症后，MVA(风险比[HR]， 0.50 / cm2;95% CI, 0.34-0.73)和MVG (HR, 1.1 / mm Hg;95% CI, 1.05-1.20)是独立的死亡预测因子。心房颤动也与死亡率独立相关。当加入到联合模型中时，MVA仍然与死亡相关(HR, 0.51 / cm2;95% CI, 0.33-0.79)，而MVG没有。结论二尖瓣环形钙化相关二尖瓣狭窄患者生存率较差。MVA和MVG与死亡独立相关，但MVA能更好地预测预后。
{"title":"Invasive Hemodynamic Predictors of Survival in Patients With Mitral Stenosis Secondary to Mitral Annular Calcification","authors":"A. El Sabbagh, R. Nishimura, M. Eleid, S. Pislaru, P. Pellikka, C. Rihal, M. Guerrero, D. Hodge, William R. Miranda","doi":"10.1161/JAHA.121.023107","DOIUrl":"https://doi.org/10.1161/JAHA.121.023107","url":null,"abstract":"Background The aim of this study was to establish prognostic hemodynamic parameters in patients with mitral stenosis secondary to mitral annular calcification. Methods and Results A retrospective cohort of 105 patients undergoing transseptal catheterization for hemodynamic evaluation of mitral annular calcification–related mitral stenosis between 2004 and 2020 was studied. Mitral valve gradient (MVG) and mitral valve area (MVA; calculated by the Gorlin formula) were measured using direct left atrial and left ventricular pressures. The median age of the patients was 70.3 years (58.4–76.7 years), and 53.3% were women. The median MVA was 1.7 cm2 (1.3–2.3 cm2) and MVG was 7.3 mm Hg (5.3–10.3 mm Hg); left ventricular end‐diastolic pressure was 17.6±28.3 mm Hg. During a median of 2.1 years (0.7–4.5 years), there were 63 deaths; 1‐ and 5‐year survival were 76% and 40%, respectively. There was no association between left ventricular end‐diastolic pressure and survival. After adjusting for age and comorbidities, both MVA (hazard ratio [HR], 0.50 per cm2; 95% CI, 0.34–0.73) and MVG (HR, 1.1 per mm Hg; 95% CI, 1.05–1.20) were independent predictors of death. Atrial fibrillation was also independently associated with mortality. When added to a combined model, MVA remained associated with death (HR, 0.51 per cm2; 95% CI, 0.33–0.79) while MVG was not. Conclusions In patients with mitral annular calcification–related mitral stenosis, survival was poor. MVA and MVG were independently associated with death, but MVA was a better predictor of outcomes.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"50 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80779462","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Shibbani, Bassel Mohammad Nijres, Daniel Mclennan, A. R. Bischoff, R. Giesinger, P. McNamara, J. Klein, J. Windsor, O. Aldoss
Background Prolonged exposure to a hemodynamically significant patent ductus arteriosus (PDA) is associated with major morbidity, particularly in infants born at <27 weeks’ gestation. High‐frequency jet ventilation (HFJV) is a standard of care at our center. There are no data about transcatheter PDA closure while on HFJV. The aim of this study was to assess the feasibility, safety, and outcomes of HFJV during transcatheter PDA closure. Methods and Results This is a retrospective cohort study of premature infants undergoing transcatheter device closure on HFJV. The primary outcome was successful device placement. Secondary outcomes included procedure time, fluoroscopy time and dose, time off unit, device complications, need for escalation in respiratory support, and 7‐day survival. Subgroup comparative evaluation of patients managed with HFJV versus a small cohort of patients managed with conventional mechanical ventilation was performed. Thirty‐eight patients were included in the study. Median age and median weight at PDA device closure for the HFJV cohort were 32 days (interquartile range, 25.25–42.0 days) and 1115 g (interquartile range, 885–1310 g), respectively. There was successful device placement in 100% of patients. There were no device complications noted. The time off unit and the procedure time were not significantly different between the HFJV group and the conventional ventilation group. Infants managed by HFJV had shorter median fluoroscopy times (4.5 versus 6.1 minutes; P<0.05) and no increased risk of adverse respiratory outcomes. Conclusions Transcatheter PDA closure in premature infants on HFJV is a safe and effective approach that does not compromise device placement success rate and does not lead to secondary complications.
背景:长时间暴露于血流动力学意义重大的动脉导管未闭(PDA)与主要发病率相关，特别是在妊娠<27周出生的婴儿中。高频喷射通风(HFJV)是我们中心的护理标准。在HFJV患者中没有经导管PDA关闭的数据。本研究的目的是评估经导管PDA关闭期间HFJV的可行性、安全性和结果。方法和结果这是一项对HFJV接受经导管装置闭合的早产儿的回顾性队列研究。主要结果是器械放置成功。次要结局包括手术时间、透视时间和剂量、停药时间、器械并发症、呼吸支持升级需求和7天生存率。对采用HFJV治疗的患者与采用传统机械通气治疗的一小组患者进行亚组比较评估。38例患者被纳入研究。HFJV队列PDA装置关闭时的中位年龄和中位体重分别为32天(四分位数范围25.25-42.0天)和1115 g(四分位数范围885-1310 g)。100%的患者成功放置器械。没有发现器械并发症。HFJV组与常规通气组的停药时间、手术时间差异无统计学意义。HFJV治疗的婴儿中位透视时间较短(4.5 vs 6.1分钟;P<0.05)，且没有增加不良呼吸结局的风险。结论经导管PDA闭合治疗HFJV早产儿是一种安全有效的方法，不会影响置入率，也不会导致继发性并发症。
{"title":"Feasibility, Safety, and Short‐Term Outcomes of Transcatheter Patent Ductus Arteriosus Closure in Premature Infants on High‐Frequency Jet Ventilation","authors":"K. Shibbani, Bassel Mohammad Nijres, Daniel Mclennan, A. R. Bischoff, R. Giesinger, P. McNamara, J. Klein, J. Windsor, O. Aldoss","doi":"10.1161/JAHA.122.025343","DOIUrl":"https://doi.org/10.1161/JAHA.122.025343","url":null,"abstract":"Background Prolonged exposure to a hemodynamically significant patent ductus arteriosus (PDA) is associated with major morbidity, particularly in infants born at <27 weeks’ gestation. High‐frequency jet ventilation (HFJV) is a standard of care at our center. There are no data about transcatheter PDA closure while on HFJV. The aim of this study was to assess the feasibility, safety, and outcomes of HFJV during transcatheter PDA closure. Methods and Results This is a retrospective cohort study of premature infants undergoing transcatheter device closure on HFJV. The primary outcome was successful device placement. Secondary outcomes included procedure time, fluoroscopy time and dose, time off unit, device complications, need for escalation in respiratory support, and 7‐day survival. Subgroup comparative evaluation of patients managed with HFJV versus a small cohort of patients managed with conventional mechanical ventilation was performed. Thirty‐eight patients were included in the study. Median age and median weight at PDA device closure for the HFJV cohort were 32 days (interquartile range, 25.25–42.0 days) and 1115 g (interquartile range, 885–1310 g), respectively. There was successful device placement in 100% of patients. There were no device complications noted. The time off unit and the procedure time were not significantly different between the HFJV group and the conventional ventilation group. Infants managed by HFJV had shorter median fluoroscopy times (4.5 versus 6.1 minutes; P<0.05) and no increased risk of adverse respiratory outcomes. Conclusions Transcatheter PDA closure in premature infants on HFJV is a safe and effective approach that does not compromise device placement success rate and does not lead to secondary complications.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"16 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88017436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
R. Mikulík, M. Bar, S. Belaskova, D. Černík, J. Fiksa, R. Herzig, R. Jura, L. Jurák, Lukáš Klečka, J. Neumann, S. Ostrý, D. Šaňák, P. Ševčík, O. Škoda, M. Šrámek, A. Tomek, D. Václavík
Background The benefit of intravenous thrombolysis is time dependent. It remains unclear, however, whether dramatic shortening of door‐to‐needle time (DNT) among different types of hospitals nationwide does not compromise safety and still improves outcome. Methods and Results Multifaceted intervention to shorten DNT was introduced at a national level, and prospectively collected data from a registry between 2004 and 2019 were analyzed. Generalized estimating equation was used to identify the association between DNT and outcomes independently from prespecified baseline variables. The primary outcome was modified Rankin score 0 to 1 at 3 months, and secondary outcomes were parenchymal hemorrhage/intracerebral hemorrhage (ICH), any ICH, and death. Of 31 316 patients treated with intravenous thrombolysis alone, 18 861 (60%) had available data: age 70±13 years, National Institutes of Health Stroke Scale at baseline (median, 8; interquartile range, 5–14), and 45% men. DNT groups 0 to 20 minutes, 21 to 40 minutes, 41 to 60 minutes, and >60 minutes had 3536 (19%), 5333 (28%), 4856 (26%), and 5136 (27%) patients. National median DNT dropped from 74 minutes in 2004 to 22 minutes in 2019. Shorter DNT had proportional benefit: it increased the odds of achieving modified Rankin score 0 to 1 and decreased the odds of parenchymal hemorrhage/ICH, any ICH, and mortality. Patients with DNT ≤20 minutes, 21 to 40 minutes, and 41 to 60 minutes as compared with DNT >60 minutes had adjusted odds ratios for modified Rankin score 0 to 1 of the following: 1.30 (95% CI, 1.12–1.51), 1.33 (95% CI, 1.15–1.54), and 1.15 (95% CI, 1.02–1.29), and for parenchymal hemorrhage/ICH: 0.57 (95% CI, 0.45–0.71), 0.76 (95% CI, 0.61–0.94), 0.83 (95% CI, 0.70–0.99), respectively. Conclusions Ultrashort initiation of thrombolysis is feasible, improves outcome, and makes treatments safer because of fewer intracerebral hemorrhages. Stroke management should be optimized to initiate thrombolysis as soon as possible optimally within 20 minutes from arrival to a hospital.
{"title":"Ultrashort Door‐to‐Needle Time for Intravenous Thrombolysis Is Safer and Improves Outcome in the Czech Republic: Nationwide Study 2004 to 2019","authors":"R. Mikulík, M. Bar, S. Belaskova, D. Černík, J. Fiksa, R. Herzig, R. Jura, L. Jurák, Lukáš Klečka, J. Neumann, S. Ostrý, D. Šaňák, P. Ševčík, O. Škoda, M. Šrámek, A. Tomek, D. Václavík","doi":"10.1161/JAHA.121.023524","DOIUrl":"https://doi.org/10.1161/JAHA.121.023524","url":null,"abstract":"Background The benefit of intravenous thrombolysis is time dependent. It remains unclear, however, whether dramatic shortening of door‐to‐needle time (DNT) among different types of hospitals nationwide does not compromise safety and still improves outcome. Methods and Results Multifaceted intervention to shorten DNT was introduced at a national level, and prospectively collected data from a registry between 2004 and 2019 were analyzed. Generalized estimating equation was used to identify the association between DNT and outcomes independently from prespecified baseline variables. The primary outcome was modified Rankin score 0 to 1 at 3 months, and secondary outcomes were parenchymal hemorrhage/intracerebral hemorrhage (ICH), any ICH, and death. Of 31 316 patients treated with intravenous thrombolysis alone, 18 861 (60%) had available data: age 70±13 years, National Institutes of Health Stroke Scale at baseline (median, 8; interquartile range, 5–14), and 45% men. DNT groups 0 to 20 minutes, 21 to 40 minutes, 41 to 60 minutes, and >60 minutes had 3536 (19%), 5333 (28%), 4856 (26%), and 5136 (27%) patients. National median DNT dropped from 74 minutes in 2004 to 22 minutes in 2019. Shorter DNT had proportional benefit: it increased the odds of achieving modified Rankin score 0 to 1 and decreased the odds of parenchymal hemorrhage/ICH, any ICH, and mortality. Patients with DNT ≤20 minutes, 21 to 40 minutes, and 41 to 60 minutes as compared with DNT >60 minutes had adjusted odds ratios for modified Rankin score 0 to 1 of the following: 1.30 (95% CI, 1.12–1.51), 1.33 (95% CI, 1.15–1.54), and 1.15 (95% CI, 1.02–1.29), and for parenchymal hemorrhage/ICH: 0.57 (95% CI, 0.45–0.71), 0.76 (95% CI, 0.61–0.94), 0.83 (95% CI, 0.70–0.99), respectively. Conclusions Ultrashort initiation of thrombolysis is feasible, improves outcome, and makes treatments safer because of fewer intracerebral hemorrhages. Stroke management should be optimized to initiate thrombolysis as soon as possible optimally within 20 minutes from arrival to a hospital.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"36 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78715623","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. E. Goh, B. Bohn, C. Marotz, Rebecca L Molinsky, Sumith Roy, B. Paster, Ching-Yuan Chen, M. Rosenbaum, M. Yuzefpolskaya, P. Colombo, M. Desvarieux, P. Papapanou, D. Jacobs, R. Knight, R. Demmer
Background The enterosalivary nitrate–nitrite–nitric oxide (NO3–NO2–NO) pathway generates NO following oral microbiota‐mediated production of salivary nitrite, potentially linking the oral microbiota to reduced cardiometabolic risk. Nitrite depletion by oral bacteria may also be important for determining the net nitrite available systemically. We examine if higher abundance of oral microbial genes favoring increased oral nitrite generation and decreased nitrite depletion is associated with a better cardiometabolic profile cross‐sectionally. Methods and Results This study includes 764 adults (mean [SD] age 32 [9] years, 71% women) enrolled in ORIGINS (Oral Infections, Glucose Intolerance, and Insulin Resistance Study). Microbial DNA from subgingival dental plaques underwent 16S rRNA gene sequencing; PICRUSt2 was used to estimate functional gene profiles. To represent the different components and pathways of nitrogen metabolism in bacteria, predicted gene abundances were operationalized to create summary scores by (1) bacterial nitrogen metabolic pathway or (2) biochemical product (NO2, NO, or ammonia [NH3]) formed by the action of the bacterial reductases encoded. Finally, nitrite generation‐to‐depletion ratios of gene abundances were created from the above summary scores. A composite cardiometabolic Z score was created from cardiometabolic risk variables, with higher scores associated with worse cardiometabolic health. We performed multivariable linear regression analysis with cardiometabolic Z score as the outcome and the gene abundance summary scores and ratios as predictor variables, adjusting for sex, age, race, and ethnicity in the simple adjusted model. A 1 SD higher NO versus NH3 summary ratio was inversely associated with a −0.10 (false discovery rate q=0.003) lower composite cardiometabolic Z score in simple adjusted models. Higher NH3 summary score (suggestive of nitrite depletion) was associated with higher cardiometabolic risk, with a 0.06 (false discovery rate q=0.04) higher composite cardiometabolic Z score. Conclusions Increased net capacity for nitrite generation versus depletion by oral bacteria, assessed through a metagenome estimation approach, is associated with lower levels of cardiometabolic risk.
{"title":"Nitrite Generating and Depleting Capacity of the Oral Microbiome and Cardiometabolic Risk: Results from ORIGINS","authors":"C. E. Goh, B. Bohn, C. Marotz, Rebecca L Molinsky, Sumith Roy, B. Paster, Ching-Yuan Chen, M. Rosenbaum, M. Yuzefpolskaya, P. Colombo, M. Desvarieux, P. Papapanou, D. Jacobs, R. Knight, R. Demmer","doi":"10.1161/JAHA.121.023038","DOIUrl":"https://doi.org/10.1161/JAHA.121.023038","url":null,"abstract":"Background The enterosalivary nitrate–nitrite–nitric oxide (NO3–NO2–NO) pathway generates NO following oral microbiota‐mediated production of salivary nitrite, potentially linking the oral microbiota to reduced cardiometabolic risk. Nitrite depletion by oral bacteria may also be important for determining the net nitrite available systemically. We examine if higher abundance of oral microbial genes favoring increased oral nitrite generation and decreased nitrite depletion is associated with a better cardiometabolic profile cross‐sectionally. Methods and Results This study includes 764 adults (mean [SD] age 32 [9] years, 71% women) enrolled in ORIGINS (Oral Infections, Glucose Intolerance, and Insulin Resistance Study). Microbial DNA from subgingival dental plaques underwent 16S rRNA gene sequencing; PICRUSt2 was used to estimate functional gene profiles. To represent the different components and pathways of nitrogen metabolism in bacteria, predicted gene abundances were operationalized to create summary scores by (1) bacterial nitrogen metabolic pathway or (2) biochemical product (NO2, NO, or ammonia [NH3]) formed by the action of the bacterial reductases encoded. Finally, nitrite generation‐to‐depletion ratios of gene abundances were created from the above summary scores. A composite cardiometabolic Z score was created from cardiometabolic risk variables, with higher scores associated with worse cardiometabolic health. We performed multivariable linear regression analysis with cardiometabolic Z score as the outcome and the gene abundance summary scores and ratios as predictor variables, adjusting for sex, age, race, and ethnicity in the simple adjusted model. A 1 SD higher NO versus NH3 summary ratio was inversely associated with a −0.10 (false discovery rate q=0.003) lower composite cardiometabolic Z score in simple adjusted models. Higher NH3 summary score (suggestive of nitrite depletion) was associated with higher cardiometabolic risk, with a 0.06 (false discovery rate q=0.04) higher composite cardiometabolic Z score. Conclusions Increased net capacity for nitrite generation versus depletion by oral bacteria, assessed through a metagenome estimation approach, is associated with lower levels of cardiometabolic risk.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"15 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73918640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Taha, S. Nielsen, S. Franzén, Mary Rezk, A. Ahlsson, L. Friberg, Staffan Björck, A. Jeppsson, L. Bergfeldt
Background The CHA2DS2‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke or TIA [transient ischemic attack], vascular disease, age 65 to 74 years, sex category female; 2 indicates 2 points, otherwise 1 point) scoring system is recommended to guide decisions on oral anticoagulation therapy for stroke prevention in patients with nonsurgery atrial fibrillation. A score ≥1 in men and ≥2 in women, corresponding to an annual stroke risk exceeding 1%, warrants long‐term oral anticoagulation provided the bleeding risk is acceptable. However, in patients with new‐onset postoperative atrial fibrillation, the optimal risk stratification method is unknown. The aim of this study was therefore to evaluate the CHA2DS2‐VASc scoring system for estimating the 1‐year ischemic stroke risk in patients with new‐onset postoperative atrial fibrillation after coronary artery bypass grafting. Methods and Results All patients with new‐onset postoperative atrial fibrillation and without oral anticoagulation after first‐time isolated coronary artery bypass grafting performed in Sweden during 2007 to 2017 were eligible for this registry‐based observational cohort study. The 1‐year ischemic stroke rate at each step of the CHA2DS2‐VASc score was estimated using a Kaplan‐Meier estimator. Of the 6368 patients included (mean age, 69.9 years; 81% men), >97% were treated with antiplatelet drugs. There were 147 ischemic strokes during the first year of follow‐up. The ischemic stroke rate at 1 year was 0.3%, 0.7%, and 1.5% in patients with CHA2DS2‐VASc scores of 1, 2, and 3, respectively, and ≥2.3% in patients with a score ≥4. A sensitivity analysis, with the inclusion of patients on anticoagulants, was performed and supported the primary results. Conclusions Patients with new‐onset atrial fibrillation after coronary artery bypass grafting and a CHA2DS2‐VASc score <3 have such a low 1‐year risk for ischemic stroke that oral anticoagulation therapy should probably be avoided.
{"title":"Stroke Risk Stratification in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting","authors":"A. Taha, S. Nielsen, S. Franzén, Mary Rezk, A. Ahlsson, L. Friberg, Staffan Björck, A. Jeppsson, L. Bergfeldt","doi":"10.1161/JAHA.121.024703","DOIUrl":"https://doi.org/10.1161/JAHA.121.024703","url":null,"abstract":"Background The CHA2DS2‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke or TIA [transient ischemic attack], vascular disease, age 65 to 74 years, sex category female; 2 indicates 2 points, otherwise 1 point) scoring system is recommended to guide decisions on oral anticoagulation therapy for stroke prevention in patients with nonsurgery atrial fibrillation. A score ≥1 in men and ≥2 in women, corresponding to an annual stroke risk exceeding 1%, warrants long‐term oral anticoagulation provided the bleeding risk is acceptable. However, in patients with new‐onset postoperative atrial fibrillation, the optimal risk stratification method is unknown. The aim of this study was therefore to evaluate the CHA2DS2‐VASc scoring system for estimating the 1‐year ischemic stroke risk in patients with new‐onset postoperative atrial fibrillation after coronary artery bypass grafting. Methods and Results All patients with new‐onset postoperative atrial fibrillation and without oral anticoagulation after first‐time isolated coronary artery bypass grafting performed in Sweden during 2007 to 2017 were eligible for this registry‐based observational cohort study. The 1‐year ischemic stroke rate at each step of the CHA2DS2‐VASc score was estimated using a Kaplan‐Meier estimator. Of the 6368 patients included (mean age, 69.9 years; 81% men), >97% were treated with antiplatelet drugs. There were 147 ischemic strokes during the first year of follow‐up. The ischemic stroke rate at 1 year was 0.3%, 0.7%, and 1.5% in patients with CHA2DS2‐VASc scores of 1, 2, and 3, respectively, and ≥2.3% in patients with a score ≥4. A sensitivity analysis, with the inclusion of patients on anticoagulants, was performed and supported the primary results. Conclusions Patients with new‐onset atrial fibrillation after coronary artery bypass grafting and a CHA2DS2‐VASc score <3 have such a low 1‐year risk for ischemic stroke that oral anticoagulation therapy should probably be avoided.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"40 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74331219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Tjahjadi, S. Butcher, T. Zegkos, C. Sia, K. Hirasawa, V. Kamperidis, J. N. Ngiam, R. Wong, G. Efthimiadis, Jeroen J. Bax, V. Delgado, N. Ajmone Marsan
Hypertrophic cardiomyopathy (HCM) is a common form of inherited cardiomyopathy with a prevalence in the general population reported as 0.2% in different international studies.1 Although differences in disease expression and outcome are described among White and Black patients with HCM,2 it is largely unknown whether Asian patients present also a different HCM phenotype. Only 1 study included 133 Asian patients and highlighted health disparities among ethnicities relating to access to genetic testing and implantable cardioverterdefibrillator (ICDs) use.3 In our study, a total of 1661 consecutive patients (1210 European patients; 451 Asian patients including 308 Chinese, 83 Malay, and 60 South Asian patients) diagnosed with HCM according to current criteria1 were included from 3 centers (Leiden University Medical Center, The Netherlands; National University Hospital, Singapore; Aristoteleio University of Thessaloniki, Greece). This study aimed to evaluate the differences between patients with HCM from the European centers (n=1214, 1% Asian ethnicities) and the Asian center (n=447, 97% Asian ethnicities), to elucidate the influence of ethnicity, differences in care patterns, and sociocultural factors on patient outcome. The institutional review boards approved this retrospective analysis and waived the need for informed consent. The data that support the findings of this study are available from the corresponding author upon reasonable request. At the time of diagnosis, patients from the Asian center were older than those from the European centers (59 [47– 68] years versus 52 [41– 62] years, P<0.001), with similar proportion of men (71% versus 67%, P=0.093) and lower body surface area (1.7±0.2 m2 versus 2.0±0.2 m2, P<0.001). Diabetes (22% versus 16%, P=0.004) was more frequent in European centers, whereas hypertension (23% versus 49%, P<0.001) and coronary artery disease (8% versus 28%, P<0.001) were more prevalent in the Asian center. New York Heart Association functional class (class III– IV 7% versus 10%, P=0.096) at presentation was not significantly different between patients from Asian and European centers. By echocardiography, patients from the Asian center presented with smaller septal wall thickness (16 [13– 19] mm versus 18 [16– 22] mm, P<0.001) but the maximum wall thickness (19 [17– 22] mm versus 19 [16– 22] mm,
肥厚性心肌病(HCM)是一种常见的遗传性心肌病，在不同的国际研究中，一般人群的患病率为0.2%尽管白人和黑人HCM患者的疾病表达和结果存在差异，但亚洲患者是否也存在不同的HCM表型在很大程度上是未知的。只有一项研究纳入了133名亚洲患者，并强调了不同种族在获得基因检测和使用植入式心脏除颤器(icd)方面的健康差异在我们的研究中，共有1661名连续患者(1210名欧洲患者;根据现行标准诊断为HCM的451名亚洲患者，包括308名中国人、83名马来人和60名南亚患者，来自3个中心(荷兰莱顿大学医学中心;新加坡国立大学医院;亚里士多德大学，塞萨洛尼基，希腊)。本研究旨在评估欧洲中心(n=1214, 1%为亚洲种族)和亚洲中心(n=447, 97%为亚洲种族)HCM患者之间的差异，以阐明种族、护理模式差异和社会文化因素对患者预后的影响。机构审查委员会批准了这项回顾性分析，并放弃了知情同意的需要。支持本研究结果的数据可根据通讯作者的合理要求提供。诊断时，来自亚洲中心的患者比来自欧洲中心的患者年龄大(59[47 - 68]岁比52[41 - 62]岁，P<0.001)，男性比例相似(71%比67%，P=0.093)，下体表面积(1.7±0.2 m2比2.0±0.2 m2, P<0.001)。糖尿病(22%对16%，P=0.004)在欧洲中心更为常见，而高血压(23%对49%，P<0.001)和冠状动脉疾病(8%对28%，P<0.001)在亚洲中心更为普遍。来自亚洲和欧洲中心的患者就诊时纽约心脏协会功能分级(III - IV级7% vs 10%， P=0.096)无显著差异。超声心动图显示，亚洲中心患者的间隔壁厚度较小(16 [13 - 19]mm vs 18 [16 - 22] mm, P<0.001)，但最大间隔壁厚度(19 [17 - 22]mm vs 19 [16 - 22] mm)。
{"title":"Differences in Characteristics and Outcomes Between Patients With Hypertrophic Cardiomyopathy From Asian and European Centers","authors":"C. Tjahjadi, S. Butcher, T. Zegkos, C. Sia, K. Hirasawa, V. Kamperidis, J. N. Ngiam, R. Wong, G. Efthimiadis, Jeroen J. Bax, V. Delgado, N. Ajmone Marsan","doi":"10.1161/JAHA.121.023313","DOIUrl":"https://doi.org/10.1161/JAHA.121.023313","url":null,"abstract":"Hypertrophic cardiomyopathy (HCM) is a common form of inherited cardiomyopathy with a prevalence in the general population reported as 0.2% in different international studies.1 Although differences in disease expression and outcome are described among White and Black patients with HCM,2 it is largely unknown whether Asian patients present also a different HCM phenotype. Only 1 study included 133 Asian patients and highlighted health disparities among ethnicities relating to access to genetic testing and implantable cardioverterdefibrillator (ICDs) use.3 In our study, a total of 1661 consecutive patients (1210 European patients; 451 Asian patients including 308 Chinese, 83 Malay, and 60 South Asian patients) diagnosed with HCM according to current criteria1 were included from 3 centers (Leiden University Medical Center, The Netherlands; National University Hospital, Singapore; Aristoteleio University of Thessaloniki, Greece). This study aimed to evaluate the differences between patients with HCM from the European centers (n=1214, 1% Asian ethnicities) and the Asian center (n=447, 97% Asian ethnicities), to elucidate the influence of ethnicity, differences in care patterns, and sociocultural factors on patient outcome. The institutional review boards approved this retrospective analysis and waived the need for informed consent. The data that support the findings of this study are available from the corresponding author upon reasonable request. At the time of diagnosis, patients from the Asian center were older than those from the European centers (59 [47– 68] years versus 52 [41– 62] years, P<0.001), with similar proportion of men (71% versus 67%, P=0.093) and lower body surface area (1.7±0.2 m2 versus 2.0±0.2 m2, P<0.001). Diabetes (22% versus 16%, P=0.004) was more frequent in European centers, whereas hypertension (23% versus 49%, P<0.001) and coronary artery disease (8% versus 28%, P<0.001) were more prevalent in the Asian center. New York Heart Association functional class (class III– IV 7% versus 10%, P=0.096) at presentation was not significantly different between patients from Asian and European centers. By echocardiography, patients from the Asian center presented with smaller septal wall thickness (16 [13– 19] mm versus 18 [16– 22] mm, P<0.001) but the maximum wall thickness (19 [17– 22] mm versus 19 [16– 22] mm,","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89481369","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bahadir Simsek, Spyridon Kostantinis, J. Karacsonyi, E. Brilakis
Symptom relief is currently the main indication for CTO PCI.2,5 Several observational studies and 36– 8 of 49 randomizedcontrolled trials showed symptom improvement with CTO PCI compared with optimal medical therapy (OMT) alone. In the EuroCTO (randomized multicenter trial to compare revascularization with OMT for the treatment of chronic total coronary occlusions) trial, 396 patients were randomized to OMT versus OMT+PCI. At 12 months, patients who underwent CTO PCI had greater improvements in angina frequency, quality of life, and physical limitation, as assessed by Seattle Angina Questionnaire.3 In the ImpactorCTO (Impact on Inducible Myocardial Ischemia of Percutaneous Coronary Intervention Versus Optimal Medical Therapy in Patients With Right Coronary Artery Chronic Total Occlusion) trial, 94 patients with angina and isolated dominant right coronary artery CTOs were randomized to OMT versus OMT+PCI. At 12 months, the CTO PCI group had significantly lower myocardial ischemia burden, improved 6minute walk distance, and improved health, as assessed by the 36Item Short Form Survey.4 In the COMETCTO (Randomized Controlled Comparison of Optimal Medical Therapy With Percutaneous Recanalization of Chronic Total Occlusion) trial, 100 patients were randomized to OMT versus OMT+PCI; at 9month followup, patients who underwent CTO PCI had significantly improved physical limitation, angina, treatment satisfaction,
{"title":"Scores for Chronic Total Occlusion Percutaneous Coronary Intervention: A Window to the Future?","authors":"Bahadir Simsek, Spyridon Kostantinis, J. Karacsonyi, E. Brilakis","doi":"10.1161/JAHA.122.026070","DOIUrl":"https://doi.org/10.1161/JAHA.122.026070","url":null,"abstract":"Symptom relief is currently the main indication for CTO PCI.2,5 Several observational studies and 36– 8 of 49 randomizedcontrolled trials showed symptom improvement with CTO PCI compared with optimal medical therapy (OMT) alone. In the EuroCTO (randomized multicenter trial to compare revascularization with OMT for the treatment of chronic total coronary occlusions) trial, 396 patients were randomized to OMT versus OMT+PCI. At 12 months, patients who underwent CTO PCI had greater improvements in angina frequency, quality of life, and physical limitation, as assessed by Seattle Angina Questionnaire.3 In the ImpactorCTO (Impact on Inducible Myocardial Ischemia of Percutaneous Coronary Intervention Versus Optimal Medical Therapy in Patients With Right Coronary Artery Chronic Total Occlusion) trial, 94 patients with angina and isolated dominant right coronary artery CTOs were randomized to OMT versus OMT+PCI. At 12 months, the CTO PCI group had significantly lower myocardial ischemia burden, improved 6minute walk distance, and improved health, as assessed by the 36Item Short Form Survey.4 In the COMETCTO (Randomized Controlled Comparison of Optimal Medical Therapy With Percutaneous Recanalization of Chronic Total Occlusion) trial, 100 patients were randomized to OMT versus OMT+PCI; at 9month followup, patients who underwent CTO PCI had significantly improved physical limitation, angina, treatment satisfaction,","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"158 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83841549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Santos-Gallego, J. A. Requena-Ibáñez, J. Badimón
fter drug- eluting stent implantation, the classic therapy was dual antiplatelet therapy (DAPT) for 1 year and then stopping P2Y12 inhibitor while maintaining aspirin forever. The main limitation is the in-creased risk of bleeding with prolonged DAPT strategy might offset the ischemic benefit. Given that ischemic risk is higher in the initial phase whereas bleeding risk is maintained in the long term, deescalation therapies have been proposed, either with shorter DAPT durations or with aspirin- free strategies. 1 In fact, DAPT should follow the Goldilocks principle 2 (not too short, not too long). Recent studies (GLOBAL- LEADERS, 3 TWILIGHT [Ticagrelor with Aspirin or Alone in High- Risk Patients after Coronary Intervention], 4 TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus- Eluting Stent for Acute Coronary Syndrome], 5 STOP- DAPT [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus- Eluting Cobalt-Chromium Stent], 6 SMART- CHOICE [Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Anti- platelet Therapy in Patients Undergoing Implantation of Coronary Drug- Eluting Stents] 7 ) suggest that the deescalation strategy with an abbreviated DAPT period after percutaneous coronary intervention (1– 3 months) followed by aspirin cessation and P2Y12 inhibitor monotherapy mitigates bleeding risk without losing efficacy for ischemic prevention. Among all these trials, GLOBAL- LEADERS 3 offers the largest sample size and is the only one designed as a superiority trial.
{"title":"Per‐Protocol Versus Intention‐to‐Treat in Clinical Trials: The Example of GLOBAL‐LEADERS Trial","authors":"C. Santos-Gallego, J. A. Requena-Ibáñez, J. Badimón","doi":"10.1161/JAHA.122.025561","DOIUrl":"https://doi.org/10.1161/JAHA.122.025561","url":null,"abstract":"fter drug- eluting stent implantation, the classic therapy was dual antiplatelet therapy (DAPT) for 1 year and then stopping P2Y12 inhibitor while maintaining aspirin forever. The main limitation is the in-creased risk of bleeding with prolonged DAPT strategy might offset the ischemic benefit. Given that ischemic risk is higher in the initial phase whereas bleeding risk is maintained in the long term, deescalation therapies have been proposed, either with shorter DAPT durations or with aspirin- free strategies. 1 In fact, DAPT should follow the Goldilocks principle 2 (not too short, not too long). Recent studies (GLOBAL- LEADERS, 3 TWILIGHT [Ticagrelor with Aspirin or Alone in High- Risk Patients after Coronary Intervention], 4 TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus- Eluting Stent for Acute Coronary Syndrome], 5 STOP- DAPT [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus- Eluting Cobalt-Chromium Stent], 6 SMART- CHOICE [Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Anti- platelet Therapy in Patients Undergoing Implantation of Coronary Drug- Eluting Stents] 7 ) suggest that the deescalation strategy with an abbreviated DAPT period after percutaneous coronary intervention (1– 3 months) followed by aspirin cessation and P2Y12 inhibitor monotherapy mitigates bleeding risk without losing efficacy for ischemic prevention. Among all these trials, GLOBAL- LEADERS 3 offers the largest sample size and is the only one designed as a superiority trial.","PeriodicalId":17189,"journal":{"name":"Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease","volume":"98 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83938131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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