INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Interventional Cardiology
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Periprocedural Bleeding Is a Robust Risk Marker for Post-PCI Mortality.
Traditionally, the composite triple end point used to assess PCI procedures is the combined incidence of death, myocardial infarction (MI), and urgent revascularization (UR) at 30 days. Recently, some studies have used a quadruple end point that includes periprocedural bleeding complications. Ndrepepa and colleagues combined data from the 4 ISAR trials to investigate the relationship between bleeding and 1-year mortality. The hazard ratio for 1-year mortality was 3.0 for bleeding, 2.3 for MI, and 2.5 for UR; all 3 outcomes had similar discriminatory power. This study demonstrates a strong relationship between periprocedural bleeding and 1-year mortality and supports the inclusion of periprocedural bleeding in a 30-day quadruple end point. See pages 690 and
698. See figure.
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Interventional Cardiology
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The Problem With Composite End Points.
The term MACE (major adverse cardiac events) is a commonly used end point for cardiovascular research; however, there is no standard definition for MACE. Kip and colleagues conducted a 2-phase literature review on the use of MACE as a composite end point, and then simulated different definitions of MACE in a large percutaneous coronary intervention registry. The review identified substantial heterogeneity in the outcomes used to define MACE; these different definitions of MACE significantly altered the apparent efficacy of various interventions. The authors conclude that the term MACE should not be used unless a standard definition can be agreed upon. See page 701. See figure.
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Lipids and CAD
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Lower TGs Improve Outcomes in Post-ACS Patients.
The risk associated with elevated triglycerides (TGs) in patients achieving optimal low-density lipoprotein (LDL) reduction is unclear. Miller and colleagues studied the effect of TG levels on outcomes in patients enrolled in the PROVE IT-TIMI 22 trial, which randomized post–acute coronary syndrome (ACS) patients to either atorvastatin 80 mg/day or pravastatin 40 mg/day. Subjects with TG <150 mg/dl were at reduced risk for future events, independent of the LDL level. Those with LDL <70 mg/dl and TG <150 mg/dl were at the lowest risk. These data suggest that both LDL cholesterol and TG levels are important therapeutic parameters in patients following ACS. See page 724. See figure.
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Heart Rhythm Disorders
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EVM Can Distinguish ARVD From RVOT.
It can be difficult to distinguish the fairly benign right ventricular outflow tract (RVOT) tachycardia from the more dangerous arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). Corrado and colleagues performed right ventricular electroanatomic voltage mapping (EVM), using a CARTO system, in 27 patients with RVOT tachycardia and morphologically normal right ventricles. In 26% of patients, they identified areas of low signal amplitude; these patients were more likely to have fibrofatty replacement of the myocardium on biopsy. Forty three percent of these patients went on to require an implantable cardioverter-defibrillator, versus none of the patients with normal EVMs. Electroanatomic voltage mapping may be a valid method for distinguishing early or minor ARVC/D from idiopathic RVOT tachycardia. See pages 731 and
740. See figure.
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Pulmonary Hypertension
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Prolonged RV Contraction Causes Septal Bowing in PAH Patients.
In pulmonary arterial hypertension (PAH), leftward ventricular septal bowing (LVSB) is most prominent in early diastole and seems to be caused by a relative delay in maximal right ventricle (RV) pressure. However, it is not clear if this delay is caused by delayed onset of RV contraction or prolonged RV contraction. Marcus and colleagues studied patients with PAH using cine magnetic resonance imaging. There was no delay in the onset of contraction in the RV; however, peak RV free wall strain occurred 120 ms after the peak strain in the septum and 59 ms after closure of the pulmonic valve. In PAH, LVSB is caused by lengthening of the duration of RV contraction, which results in decreased left ventricle filling and, therefore, decreased stroke volume. See pages 750 and
758. See figure.
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Interventional Cardiology
Interventional Cardiology
