HomeCirculationVol. 127, No. 6Circulation: Clinical Summaries Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCirculation: Clinical SummariesOriginal Research Put Into Perspective for the Practicing Clinician Originally published12 Feb 2013https://doi.org/10.1161/CIR.0b013e31828987e5Circulation. 2013;127:663–664Reduction in First and Recurrent Cardiovascular Events With Ticagrelor Compared With Clopidogrel in the PLATO StudyWe sought to evaluate the effect of potent platelet inhibition after acute coronary syndrome on total (ie, first and recurrent) occurrences of any of cardiovascular event. In the PLATelet inhibition and patient Outcomes (PLATO) study involving 18 624 patients, treatment with the more potent agent ticagrelor, as compared with clopidogrel, reduced not only the first occurrence but also repeated cardiovascular events. Ticagrelor treatment is associated with a slightly increased risk of having a first non–coronary artery bypass graft major bleed but, thereafter, the bleeding risk is similar to clopidogrel despite continuing unchanged long-term treatment. Clinically, these results have important implications for guiding physicians to continue ticagrelor therapy, rather than changing therapy to alternative agents, even for patients who may experience an event while on treatment. See p 673.Elevated Blood Pressure in Pregnancy and Subsequent Chronic Disease RiskHypertension during pregnancy affects ≥10% of all women, and the incidence of hypertensive disorders in pregnancy is increasing. The current study followed women with diagnosed hypertensive disorders during pregnancy for ≈40 years. We observed that ≤33% of all pregnant women had some form of hypertension, with 6.5% having chronic hypertension before or during pregnancy. Any elevation in blood pressure during pregnancy, even isolated systolic or diastolic blood pressure elevations that resolved during or after pregnancy, was associated with increased risk of subsequent cardiovascular diseases. Highest risks were associated with chronic hypertension (63% increase) and superimposed preeclampsia/eclampsia (98% increase) compared with normotensive women. Especially high risks were observed for fatal myocardial infarcts, with risks 100% to 400% higher in hypertensive women compared with normotensive women. We also observed that gestational hypertension was associated with 49% higher risk of subsequent diabetes mellitus and 90% higher risk of chronic kidney disease. All of the women who had transient hypertension during pregnancy were at higher risk (64% to 153%) of developing chronic hypertension. History of blood pressure elevations during pregnancy could be used to identify at-risk individuals for cardiovascular events. Detection of hypertension during pregnancy warrants further cardiovascular disease risk factor screening and at least counseling on lifestyle factors to reduce disease risk. See p 681.Prospective, Multicenter Study of Ventricular Assist Device InfectionsVentricular assist devices (VADs) significantly improve quality of life and decrease mortality in patients with advanced heart failure, including those awaiting cardiac transplantation. Unfortunately, VAD implantation is frequently complicated by infection. To the best of our knowledge, this is the first and largest prospective, multicenter VAD study focused on carefully characterizing the microbiology, epidemiology, risk factors, and outcomes of VAD infections. Previous studies have been small, retrospective, or single-center studies and/or have not used rigorous criteria to diagnose and describe VAD infections. Infectious diseases specialists were closely involved in this study, which details the microbiology of these infections. The results have important implications for guiding perioperative prophylaxis regimens and empirical therapy. Furthermore, we show that although the risk of VAD infection is highest immediately after implantation, the risk of infection persists until at least 1 year after surgery. The percutaneous VAD driveline likely serves as an entry point for pathogens. Although most infections involve the driveline, a substantial proportion also involve multiple sites and/or become invasive. These infections are also associated with increased morbidity and mortality, making prevention crucial. Increased serum creatinine and a history of depression were identified as risk factors for VAD infection. Depression is frequently underdiagnosed and undertreated and has been associated with poor outcomes in other populations. Therefore, we have potentially identified a remediable risk factor for VAD infection that requires further investigation. Given the lack of organ donors and the importance of VAD therapy, we hope this research will lead to better diagnosis, treatment, and prevention of VAD infections. See p 691.Frequency of Myocardial Infarction and Its Relationship to Angiographic Collateral Flow in Territories Supplied by Chronically Occluded Coronary ArteriesDespite totally occluded coronary by heavy atherosclerotic burden, previous myocardial infarction (MI) has been documented only in one half of patients with chronic total occlusion by clinical history or the recently published third universal definition of MI. In this study, cardiac magnetic resonance (CMR) late gadolinium enhancement imaging revealed the footprint of previous MI in most of patients with chronic total occlusion. Hence, most patients with chronic total occlusion should be regarded as having experienced type 1 spontaneous MI. In addition, patients with well-developed collateral vessels showed lesser infarct size and better regional wall motion. This finding suggests a protective role of collateral development against myocardial damage related to chronic total occlusion. Promotion of coronary collateral growth or arteriogenesis, which can be facilitated by physical exercise or cytokine therapy, may be a promising preventive therapy that is protective from the future MI and salvages myocardium even in the complete absence of natural anterograde coronary artery flow. See p 703.Molecular Imaging of the Paracrine Proangiogenic Effects of Progenitor Cell Therapy in Limb IschemiaThe number of patients with severe symptoms from coronary and peripheral artery disease who are not candidates for revascularization therapy because of age, comorbidities, and/or diffuse distribution of disease is steadily growing. Proangiogenic cell therapy is a promising therapeutic alternative. However, the exact mechanisms by which stem cells promote vascular remodeling are unknown and are important for optimization of therapy in terms of cell type, dose, and method of administration. In this study, we used contrast ultrasound perfusion to demonstrate that multipotential adult progenitor cells given intramuscularly increased microvascular blood flow and volume in a murine ischemic limb model. On a structural level, the improvement in flow was due to arteriolar remodeling. Using molecular imaging, histology, and intravital microscopy, we showed that in the setting of ischemia, multipotential adult progenitor cells migrate to a perivascular location where they recruit a specific population of monocytic cells that are recognized to be proangiogenic and important in wound healing. This process was accomplished by stimulation of endothelial cell adhesion molecules that participate in leukocyte recruitment and by chemokine signaling of monocytes to migrate into tissue. These results add to the growing body of science indicating that stem cells promote flow recovery more from their paracrine effects on host cells than from their engraftment into new blood vessels and that a specific proangiogenic aspect of the inflammatory response is a mediator of this process. See p 710.Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients With Atrial FibrillationAlthough effective, oral anticoagulation with warfarin to prevent stroke in patients with atrial fibrillation has limitations. The multicenter PROTECT AF trial was conducted in 707 patients with nonvalvular atrial fibrillation and CHADS2 score ≥1 to compare a strategy of percutaneous left atrial appendage closure with a filter device (Watchman) versus oral anticoagulation with warfarin. For patients randomized to Watchman implantation, warfarin was continued for ≈45 days, followed by clopidogrel for 4.5 months and lifelong aspirin. After 2.3±1.1 years of follow-up (1588 patient-years), the event rates of the composite primary efficacy end point of stroke, systemic embolism, and cardiovascular death were 3.0% and 4.3% (percent per 100 patient-years) in the Watchman and warfarin groups, respectively (rate ratio [RR], 0.71; 95% confidence interval [CI], 0.44%–1.30% per year), which met the criteria for noninferiority. There were more primary safety events in the Watchman group (5.5% per year; 95% CI, 4.2%–7.1% per year) than in the control group (3.6% per year, 95% CI, 2.2%–5.3% per year; RR, 1.53; 95% CI, 0.95%–2.70% per year). When the effect of left atrial appendage closure was isolated from complications of implantation and concomitant transient anticoagulation in a secondary analysis, the Watchman was superior to warfarin (probability of superiority=0.953). Among patients with stroke before they entered the study, the 2 strategies were equally effective, with rates of 5.3% per year and 8.2% per year, respectively, (RR, 0.64; 95% CI, 0.24%–1.74% per year). Thus, the “local” strategy of left atrial appendage closure with the Watchman device is noninferior to “systemic” anticoagulation with warfarin. PROTECT AF has, for the first time, implicated the left atrial appendage in the pathogenesis of stroke in atrial fibrillation. See p 720.A History of Stroke/Transient Ischemic Attack Indicates High Risks of Cardiovascular Event and Hemorrhagic Stroke in Patients With Coronary Artery DiseaseRandomized trials of antithrombotics in coronary artery disease have identified previous stroke/transient ischemic attack (TIA) as a marker of increased intracranial bleeding risk. Based on an analysis of the international REACH (REduction of Atherothrombosis for Continued Health) registry of atherothrombosis, we further characterized the risk of ischemic and bleeding events associated with a history of stroke/TIA in patients with coronary artery disease. Baseline characteristics and 4-year follow-up of 26 389 patients with coronary artery disease, including 4460 patients (16.9%) with a history of stroke/TIA, were analyzed. Those analyses showed that in patients with coronary artery disease, a history of stroke/TIA was associated with an independent increase in risk of death, myocardial infarction, or stroke (adjusted hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.40–1.65; P<0.001), including both ischemic (adjusted HR, 3.06; 95% CI, 2.62–3.57; P<0.001) and hemorrhagic stroke (adjusted HR, 1.76; 95% CI, 1.00–3.08; P=0.05), the latter being smaller in absolute terms. This excess risk of hemorrhagic stroke was particularly high in patients receiving dual antiplatelet therapy (adjusted HR, 5.21; 95% CI, 1.24–21.90) and in the first year after stroke/TIA(adjusted HR, 3.03; 95% CI, 1.51–6.08 for the first year). This observation is important for selection of antithrombotic therapy in these patients. See p 730. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sueda S and Sakaue T (2022) Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations, Journal of Cardiology, 10.1016/j.jjcc.2022.04.002, Online publication date: 1-May-2022. Liu X, Shen M, Yan H, Long P, Jiang H, Zhang Y, Zhou L, Yu K, Qiu G, Yang H, Li X, Min X, He M, Zhang X, Choi H, Wang C and Wu T (2022) Alternations in the gut microbiota and metabolome with newly diagnosed unstable angina, Journal of Genetics and Genomics, 10.1016/j.jgg.2021.11.009, 49:3, (240-248), Online publication date: 1-Mar-2022. 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Dong H, Li X, Xiao D and Tang Y (2022) Late Percutaneous Coronary Intervention is Associated with Better Prognosis of Patients with Acute Myocardial Infarction, International Journal of General Medicine, 10.2147/IJGM.S357330, Volume 15, (2621-2627) February 12, 2013Vol 127, Issue 6 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIR.0b013e31828987e5 Originally publishedFebruary 12, 2013 PDF download Advertisement