Circulation: Cardiovascular Interventions Editors’ Picks

Abstract

HomeCirculation: Cardiovascular InterventionsVol. 6, No. 5Circulation: Cardiovascular Interventions Editors’ Picks Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCirculation: Cardiovascular Interventions Editors’ PicksMost Important Articles in Antiplatelet Therapy The Editors The Editors Search for more papers by this author Originally published1 Oct 2013https://doi.org/10.1161/CIRCINTERVENTIONS.113.000848Circulation: Cardiovascular Interventions. 2013;6:e60–e64OutcomesShort- Versus Long-term Duration of Dual-Antiplatelet Therapy After Coronary Stenting: A Randomized Multicenter TrialSummary: This study focusing on 2013 patients undergoing coronary stent implantation who received bare-metal, zotarolimus-eluting, paclitaxel-eluting, or everolimus-eluting stent implantation and were subsequently allocated to up to 6 months versus 24 months of clopidogrel therapy in addition to aspirin failed to show the anticipated superiority of long-term duration of dual-antiplatelet therapy in terms of a lower composite ischemic end point of overall death, myocardial infarction, or cerebrovascular accidents. The cumulative risk of the primary outcome at 2 years was 10.1% with 24-month dual-antiplatelet therapy compared with 10.0% with 6-month dual-antiplatelet therapy (hazard ratio, 0.98; 95% confidence interval, 0.74–1.29; P=0.91). The individual risks of death, myocardial infarction, cerebrovascular accident, or stent thrombosis did not differ between the study groups; however, there was a consistently greater risk of hemorrhage in the 24-month clopidogrel group according to all prespecified bleeding definitions, including the recently proposed Bleeding Academic Research Consortium classification. Two Korean studies have also previously reported a lack of benefit of either 12 or 24 months of clopidogrel therapy during 6 or 12 months of therapy, respectively. Therefore, altogether, the available evidence does not support the concept that the longer the duration of clopidogrel therapy after drug-eluting stent implantation, the better the outcomes. On the contrary, this study identifies the potential for harm with respect to major bleeding associated with prolonged use of dual-antiplatelet therapy.Conclusions: A regimen of 24 months of clopidogrel therapy in patients who had received a balanced mixture of drug-eluting or bare-metal stents was not significantly more effective than a 6-month clopidogrel regimen in reducing the composite of death due to any cause, myocardial infarction, or cerebrovascular accident.1Six-Month Versus 12-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents: The Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting (EXCELLENT) Randomized, Multicenter StudySummary: The optimal duration of dual antiplatelet therapy (DAPT) after implantation of drug-eluting coronary stents remains undetermined. Although premature discontinuation of thienopyridine therapy was reported to be the major determinant of stent thrombosis after implantation of drug-eluting stents, some studies suggest that there is no apparent clinical benefit from DAPT for >6 months. In the Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting (EXCELLENT) trial, the authors compared 6-month DAPT with 12-month DAPT in patients receiving drug-eluting stents. The authors’ trial showed that the rate of target vessel failure was not significantly different between the 6- and 12-month DAPT groups after percutaneous coronary intervention with drug-eluting stents (4.8% versus 4.3%) and that 6-month DAPT was noninferior to 12-month DAPT in the risk of target vessel failure. However, stent thrombosis tended to occur more frequently in the 6-month DAPT group than in the 12-month group (0.9% versus 0.1%). In subgroup analysis, target vessel failure occurred more frequently in the 6-month DAPT group than in the 12-month group among diabetic patients (hazard ratio, 3.16; 95% confidence interval, 1.42–7.03). Although 6-month DAPT cannot be recommended in the general population on the basis of the authors’ trial, these data may be helpful for physicians to decide the duration of DAPT case by case in real-world practice, eg, in patients with increased bleeding risk or undergoing elective surgery.Conclusions: Six-month DAPT did not increase the risk of target vessel failure at 12 months after implantation of drug-eluting stents compared with 12-month DAPT. However, the noninferiority margin was wide, and the study was underpowered for death or myocardial infarction. The authors’ results need to be confirmed in larger trials.2Short-term Outcomes of Acute Myocardial Infarction in Patients With Acute Kidney Injury: A Report From the National Cardiovascular Data RegistrySummary: Acute kidney injury (AKI) is a risk factor for long-term adverse outcomes, including acute myocardial infarction and death. The authors sought to explore the relationship between severity of AKI and in-hospital outcomes in the setting of acute myocardial infarction using the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry–Get With the Guidelines (GWTG), a nationwide sample of myocardial infarction patients admitted to 383 hospitals in the United States. AKI was defined using absolute changes in serum creatinine (SCr; peak SCr minus admission SCr) and categorized as no AKI (SCr change, <0.3 mg/dL), mild AKI (SCr change, 0.3–<0.5 mg/dL), moderate AKI (SCr change, 0.5–<1.0 mg/dL), and severe AKI (SCr change, ≥1.0 mg/dL). Overall, in-hospital mortality rates for those with mild, moderate, and severe AKI were 6.6%, 14.2%, and 31.8% compared with 2.1% without AKI and demonstrated similar increases in subgroups with or without prior chronic kidney disease, in-hospital shock, or coronary artery bypass graft surgery. In multivariable regression, the adjusted odds ratios for in-hospital death were 2.4 (95% confidence interval, 2.0–2.7), 4.5 (95% confidence interval, 3.9–5.1), and 12.6 (95% confidence interval, 11.1–14.3) for mild, moderate, and severe AKI compared with those without AKI. Although patients with AKI were less likely to undergo early invasive care or to receive antiplatelet therapies, rates of major bleeding ranged from 8.4% (no AKI) to 32.7% (severe AKI). AKI is common, occurring in 16% of acute myocardial infarction patients. Furthermore, it is strongly associated with mortality and bleeding, underscoring the importance of efforts to identify risk factors and to prevent AKI in acute myocardial infarction care.Conclusions: AKI is common and associated with mortality and bleeding, underscoring the importance of efforts to identify risk factors and to prevent AKI in acute myocardial infarction care.3Duration of Dual Antiplatelet Therapy and Long-term Clinical Outcome After Coronary Drug-Eluting Stent Implantation: Landmark Analyses From the CREDO-Kyoto PCI/CABG Registry Cohort-2Summary: Current guidelines recommend administration of dual antiplatelet therapy consisting of aspirin and thienopyridine for at least 1 year after coronary drug-eluting stent implantation. The current study from CREDO-Kyoto Registry prolonged thienopyridine therapy was not associated with decreased risk for serious cardiovascular events, whereas it was associated with a trend toward an increased risk for bleeding in both 4- and 13-month landmark analyses. Discontinuation of both aspirin and thienopyridine therapy, but not discontinuation of thienopyridine therapy only, was associated with an increased risk of serious cardiovascular events and definite stent thrombosis within 1 year.Conclusions: Prolonged thienopyridine therapy beyond 4 and 13 months seemed not to be associated with reduction in ischemic events but to be associated with a trend toward increased bleeding. Optimal duration of DAPT after DES implantation might be shorter than the currently recommended 1-year interval.4Prolonged Clopidogrel Use After Bare Metal and Drug-Eluting Stent Placement: The Veterans Administration Drug-Eluting Stent StudySummary: Dual antiplatelet therapy with aspirin and clopidogrel is recommended for 12 months for patients with drug-eluting stents and for at least 1 month for bare metal stents and preferably for 1 year. It is not known whether prolonged dual antiplatelet therapy is of value beyond 1 year, as current trials have shown mixed results. In the national VA database, patients with both drug-eluting stents and bare metal stents demonstrated a reduced mortality and myocardial infarction rate without an increase in major bleeding with prolonged clopidogrel use beyond 12 months. The benefit was significantly stronger for drug-eluting stents.Conclusions: Patients receiving clopidogrel beyond 12 months had a lower risk of death or myocardial infarction compared with patients receiving clopidogrel ≤12 months. The risk reduction was greater for drug-eluting stents. These data support longer durations of dual antiplatelet therapy for patients receiving a stent, particularly for those receiving a drug-eluting stent.5Evaluating the Impact of Public Health Notification: Duke Clopidogrel ExperienceSummary: The Institute of Medicine has highlighted the need for advancements in implementation science to address the lag between medical discovery and dissemination. The need for rapid information dissemination and practice change is particularly important when serious safety concerns are identified. In late 2006, concerns were raised that drug-eluting stent (DES) patients who received clopidogrel for <6 months were at elevated risk for late-stent thrombosis and worse outcomes compared with bare-metal stent patients. These concerns prompted major medical societies to issue a joint Clinical Alert and Science Advisory stressing the importance of a 12-month dual-antiplatelet regimen for DES patients not at high risk of bleeding. The Duke Heart Center decided to supplement national messaging by sending letters to all of their DES patients and their referring physicians. The letters outlined the available evidence and suggested that the patients contact their physicians to evaluate their use of dual-antiplatelet therapy. The combination of public and patient-provider direct communication was associated with an immediate increase in the percent of DES patients reporting clopidogrel use at 6- and 12-month follow-up, with no reported change in clopidogrel use for bare-metal stent patients. Local messages directed to DES patients and their referring physicians served to amplify and focus public health messaging from external sources.Conclusions: The combination of national scientific and regulatory messaging supplemented by local, personal communications to DES patients and their primary healthcare providers was associated with a significant increase in patient-reported clopidogrel use.6Bleeding After Initiation of Multiple Antithrombotic Drugs, Including Triple Therapy, in Atrial Fibrillation Patients Following Myocardial Infarction and Coronary Intervention: A Nationwide Cohort StudySummary: Uncertainty remains regarding optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction or undergoing coronary intervention. Present expert statements (Level C evidence) recommend triple therapy with aspirin, clopidogrel, and vitamin K antagonist, with treatment limited to as short a time as possible because of a perceived greater risk of bleeding with prolonged treatment. In the current study, the authors examined the risk of bleeding associated with different antithrombotic treatment regimens in a nationwide real-life cohort of patients with atrial fibrillation and myocardial infarction and/or coronary intervention. The authors demonstrated an immediately high risk of bleeding with triple therapy that decreases over time. Nevertheless, the risk was continually elevated in comparison with less intense antithrombotic regimens, which suggests that triple therapy has no safe therapeutic window. No benefit was present for a combined thromboembolic end point of cardiovascular death, myocardial infarction, and ischemic stroke for triple therapy relative to vitamin K antagonist plus a single antiplatelet agent. Until data from randomized trials are available, the authors’ results suggest that triple therapy should only be prescribed after careful evaluation of bleeding risk.Conclusions: High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.7Drug ResistanceAntiplatelet Drug Response Status Does Not Predict Recurrent Ischemic Events in Stable Cardiovascular Patients: Results of the Antiplatelet Drug Resistances and Ischemic Events StudySummary: Poor biological response to antiplatelet drugs has repeatedly been associated with recurrence of ischemic events in cardiovascular patients. However, most studies involved coronary artery disease patients with recent vessel injury shortly after the initiation of antiplatelet therapy. The present study provides outcome data on 771 stable cardiovascular patients who were treated with aspirin and/or clopidogrel and were followed up for 3 years and in whom antiplatelet drug responsiveness was characterized twice with various platelet function assays at least 1 month after their last acute ischemic event. Major adverse cardiovascular events (MACEs) occurred in 16% of the patients. Hypertension, smoking, older age, and elevated low-density lipoprotein cholesterol were predictive of MACE recurrence, but neither the results of the specific assays (serum thromboxane B2 for the response to aspirin and vasodilator phosphoprotein platelet reactivity index for the response to clopidogrel), nor those of the aggregation-based platelet function assays added any incremental predictive value for the recurrence of MACEs. MACE-free survival was not significantly different for patients with only 1 good response (to either aspirin or clopidogrel; hazard ratio, 0.94; 95% confidence interval, 0.51–1.76) and for patients with a good response to both aspirin and clopidogrel (hazard ratio, 0.87; 95% confidence interval, 0.44–1.69) compared with patients with poor responses to both drugs. These results contrast with studies of other populations, including acute patients and/or patients assessed for platelet reactivity <1 month after treatment initiation.Conclusions: Biological antiplatelet drug responsiveness, measured with specific or aggregation-based assays, has no incremental predictive value over common cardiovascular risk factors for MACE recurrence in stable cardiovascular outpatients. These results do not support platelet function testing for MACE risk evaluation in stable cardiovascular patients.8No Association of ABCB1 C3435T Genotype With Clopidogrel Response or Risk of Stent Thrombosis in Patients Undergoing Coronary StentingSummary: Clopidogrel antiplatelet efficacy is subject to genetic variants in genes associated with absorption and bioactivation of the drug. The CYP2C19*2 loss-of-function polymorphism is a major determinant of clopidogrel bioactivation. Conflicting data exist on ABCB1 C3435T genotypes and their influence on clopidogrel antiplatelet efficacy. ABCB1 C3435T genotypes do not show an influence on the antiplatelet response to clopidogrel as determined by platelet function testing. ABCB1 C3435T genotypes do not show an influence on the risk for early drug-eluting stent thrombosis after coronary stenting.Conclusions: ABCB1 C3435T genotypes did not influence the antiplatelet response to clopidogrel or the risk of ST in clopidogrel-treated patients undergoing percutaneous coronary intervention. Routine genotyping of ABCB1 C3435T polymorphisms should not be recommended for risk stratification in clopidogrel-treated patients undergoing percutaneous coronary intervention who are similar to those evaluated in the present study.9Platelet Function Measurement–Based Strategy to Reduce Bleeding and Waiting Time in Clopidogrel-Treated Patients Undergoing Coronary Artery Bypass Graft Surgery: The Timing Based on Platelet Function Strategy to Reduce Clopidogrel-Associated Bleeding Related to CABG (TARGET-CABG) StudySummary: The antiplatelet effect of clopidogrel is highly variable and is negligible in up to 30% of patients; 10–15% of patients with acute coronary syndrome require coronary artery bypass graft surgery (CABG). The recent literature yields heterogeneous results with increased as well as similar bleeding events in patients on clopidogrel therapy clopidogrel before CABG. In patients on dual antiplatelet therapy needing CABG, targeted waiting based on preoperative platelet function monitoring shortens the recommended preoperative waiting period and results in similar bleeding as compared with clopidogrel-naive patients.Conclusions: A strategy based on preoperative platelet function testing to determine the timing of CABG in clopidogrel-treated patients was associated with the same amount of bleeding observed in clopidogrel-naive patients and ≈50% shorter waiting time than recommended in the current guidelines.10CYP2C19 But Not PON1 Genetic Variants Influence Clopidogrel Pharmacokinetics, Pharmacodynamics, and Clinical Efficacy in Post–Myocardial Infarction PatientsSummary: A significant portion of the variability in platelet response to clopidogrel is explained by the variable generation of its active metabolite. CYP2C19 has been identified as key determinant of clopidogrel activation but explains only a limited portion of the overall variability. Paraoxonase-1 (PON1) has recently been proposed as a more crucial enzyme than CYP2C19 for clopidogrel metabolic activation. In contrast to CYP2C19, PON1 is not involved in clopidogrel active metabolite generation as measured in vivo in patients with coronary artery disease. PON1 does not influence platelet responsiveness to clopidogrel loading and maintenance doses, nor does it modify the risk of cardiovascular outcomes in clopidogrel-treated young post–myocardial infarction patients.Conclusions: The authors’ study does not confirm that PON1 Q192R or L55M can influence clopidogrel pharmacokinetics or pharmacodynamics in post-MI patients.11Clinical Outcomes in Patients With the Concomitant Use of Clopidogrel and Proton Pump Inhibitors After Percutaneous Coronary Intervention: An Analysis From the Guthrie Health Off-Label Stent (GHOST) InvestigatorsSummary: Some observational studies have demonstrated higher adverse cardiovascular outcomes in patients taking clopidogrel with proton pump inhibitors (PPIs) compared with clopidogrel alone. However, other studies, including a large, randomized placebo-controlled trial, have failed to demonstrate any increase in the risk of adverse clinical events with the combination. In 2651 consecutive patients discharged from the hospital alive after coronary stenting, the authors found no difference in the 6-month incidence of major adverse cardiovascular events or net adverse clinical events (a composite of major adverse clinical events and thrombolysis in myocardial infarction major or minor bleeding) in patients who received PPI at discharge versus those who did not. Thus, the present study does not suggest a clinically relevant interaction between clopidogrel and PPIs. Gastrointestinal side effects are a common reason for premature discontinuation of antiplatelet therapy after percutaneous coronary intervention, which is associated with an increased risk of adverse clinical cardiovascular events. Use of PPIs decreases gastrointestinal side effects related to antiplatelet agents. The authors’ findings are reassuring and support the recent endorsement for PPI use in combination with dual antiplatelet therapy in high-risk patients.Conclusions: The use of PPIs with dual antiplatelet therapy was not associated with any adverse influence on MACE or NACE after PCI.12New AgentsNovel Antiplatelet Drug Revacept (Dimeric Glycoprotein VI-Fc) Specifically and Efficiently Inhibited Collagen-Induced Platelet Aggregation Without Affecting General Hemostasis in HumansSummary: Treating atherothrombosis with Revacept in patients with acute cerebral arterial syndromes or acute coronary syndromes is a novel concept. This study drug is a soluble form of the platelet glycoprotein VI receptor, and binds specifically to collagen structures of ruptured plaques. Therefore, the first steps of platelet adhesion and the consecutive platelet aggregation are prevented without affecting the general platelet function and hemostasis. Revacept would be the first drug to block platelet function potently without increasing bleeding complications in patients. Preclinical and phase I studies in healthy volunteers have proved the mode of action and safety of this study drug. Despite tremendous progress in the treatment of patients with acute coronary or cerebral syndromes, decreased thrombus formation and reduction of ischemic complications are often achieved at the expense of increased bleeding. Therefore, a potent drug that inhibits platelet activation but would not affect general hemostasis would pose a significant improvement for the treatment of patients with acute arterial syndromes. The problem of increased bleeding has often hampered therapeutic benefits in the prevention or reduction of ischemia by antiplatelet or other antithrombotic drugs, especially in patients with ischemic strokes. Efficacy studies in patients must prove that the expectations will hold true in the future to develop a safe and potent platelet inhibitory drug.Conclusions: This phase I study demonstrated that Revacept is a safe and well-tolerated new antiplatelet compound with a clear dose-dependent pharmacokinetic profile with specific, dose-related inhibition of platelet aggregation despite completely unaltered general hemostasis.13Optimizing Platelet Inhibition With Prasugrel—Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38)Summary: Several recent studies have shown that intensified dual antiplatelet therapy can reduce the risk of major cardiovascular events in patients with acute coronary syndromes, but with an increase in bleeding. The balance between benefit (prevention of ischemic events) and risk (significant bleeding) is therefore a key consideration in choosing the intensity of antiplatelet therapy. This analysis of the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel—Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38), which compared prasugrel to standard-dose clopidogrel in patients with acute coronary syndromes undergoing a planned percutaneous coronary intervention, showed that the most common types of serious bleeding were gastrointestinal and vascular access site bleeding. Variables most strongly associated with risk of serious bleeding were female sex, use of a glycoprotein IIb/IIIa inhibitor, duration of intervention, age, assignment to prasugrel, ST-elevation myocardial infarction, femoral access for angiography, creatinine clearance, hypercholesterolemia, and hypertension. Serious bleeding was significantly associated with mortality after correction for these factors. Analyses focusing on the time dependency of this relationship showed that this association existed only for the first week after an instrumented or traumatic bleeding event.Conclusions: The major predictors of serious bleeding were a combination of patient and procedural characteristics and antiplatelet therapies. Although serious bleeding was strongly associated with mortality within the first month of the bleeding event, this association was not significant beyond 40 days.14Randomized Assessment of Ticagrelor Versus Prasugrel Antiplatelet Effects in Patients With ST-Segment–Elevation Myocardial InfarctionSummary: Ticagrelor and prasugrel inhibit platelet aggregation to a greater degree than clopidogrel, which becomes apparent approximately 1 hour post loading dose. Both ticagrelor and prasugrel exhibit an initial delay in the onset of antiplatelet effects in ST-segment–elevation myocardial infarction patients. Platelet reactivity does not differ among patients treated with either ticagrelor or prasugrel during the first 24 hours of ST-segment–elevation myocardial infarction.Conclusions: In patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, both ticagrelor and prasugrel exhibit an initial delay in the onset of their antiplatelet action. Ticagrelor did not seem superior to prasugrel in reducing PR during the first 24 hours of ST-segment–elevation myocardial infarction.15Pharmacokinetic and Pharmacodynamic Effects of Elinogrel: Results of the Platelet Function Substudy From the Intravenous and Oral Administration of Elinogrel to Evaluate Tolerability and Efficacy in Nonurgent Percutaneous Coronary Intervention Patients (INNOVATE-PCI) TrialSummary: Elinogrel is the only selective, competitive, and reversible platelet P2Y12 inhibitor available in both intravenous (IV) and oral formulations. Transitioning from IV to oral formulations of other classes of P2Y12 receptor antagonists is associated with drug interactions requiring judicious timing of their administration. An IV bolus of elinogrel achieves more rapid and potent platelet inhibitory effects compared with clopidogrel, which are sustained during the transition to its oral formulation reaching lower, but not statistically significant, levels of platelet reactivity compared with clopidogrel during chronic therapy in patients undergoing PCI. The pharmacodynamic effects of elinogrel match its pharmacokinetic profile.Conclusions: Compared with clopidogrel, the combination of IV and oral elinogrel achieves more rapid and enhanced antiplatelet effects that were sustained through the transition to oral elinogrel in the peri-PCI period, but these were not significant during chronic dosing in this pilot investigation.16Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndromes and a History of Stroke or Transient Ischemic AttackSummary: Patients with acute coronary syndromes and a history of prior stroke are at a high risk of ischemic and bleeding events and constitute a treatment challenge. Therefore, novel and more potent antithrombotic agents need to be evaluated with regard to the balance between efficacy and safety, particularly in the most vulnerable patients. Ticagrelor provides faster, greater, and more consistent platelet inhibition than clopidogrel. The PLATelet inhibition and patient Outcomes (PLATO) trial showed that ticagrelor was superior to clopidogrel in a broad population of patients with acute coronary syndromes for the prevention of cardiovascular death, myocardial infarction, or stroke but with an increase in overall major bleeding events not associated with coronary artery bypass surgery. Among the 18 624 patients randomized in the PLATO study, 1152 (6.2%) were reported as having a history of stroke or transient ischemic attack. These patients presented higher rates of the primary composite end point (myocardial infarction, CV death, and stroke) at 1 year compared with those patients without prior stroke or transient ischemic attack. The reduction of the primary composite outcome and total mortality at 1 year with ticagrelor versus clopidogrel was consistent with the overall trial results. The rates of overall PLATO-defined major bleeding events associated with coronary artery bypass graft surgery, as well as major bleeding events, were similar, and intracranial bleeding occurred infrequently in the randomized groups. In light of a favorable clinical net benefit and associated impact on mortality, the results of the present study suggest that treatment with ticagrelor should not be withheld in acute coronary syndrome patients with a history of ischemic stroke or transient ischemic attack for safety concerns if otherwise indicated.Conclusions: Patients with acute coronary syndrome with a prior history of ischemic stroke or TIA had higher rates of clinical outcomes than patients without prior stroke or TIA. However, the efficacy and bleeding results of ticagrelor in these high-risk patients were consistent with the overall trial population, with a favorable clinical net benefit and associated impact on mortality.17FootnotesThe following are highlights from the series, Circulation: Cardiovascular Interventions Topic Review. This series summarizes the most important articles, as selected by the editors, that have been published in the Circulation portfolio. The studies included in this article represent the most noteworthy research in antiplatelet therapy. (Circ Cardiovasc Interv. 2013;6:e60–e64.)Correspondence to The Editors, Circulation: Cardiovascular Interventions Editorial Office, 560 Harrison Ave, Suite 502, Boston, MA 02118. E-mail [email protected]