Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Long-Term Cardiovascular Mortality After Procedure-Related or Spontaneous Myocardial Infarction in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Collaborative Analysis of Individual Patient Data From the FRISC II, ICTUS, and RITA-3 Trials (FIR)
- American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal Definition of Myocardial Infarction Classification System and the Risk of Cardiovascular Death: Observations From the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38)
- Very Late Stent Thrombosis and Late Target Lesion Revascularization After Sirolimus-Eluting Stent Implantation: Five-Year Outcome of the j-Cypher Registry
- Identification of a Monocyte-Predisposed Hierarchy of Hematopoietic Progenitor Cells in the Adventitia of Postnatal Murine Aorta
- Type 2 Diabetes Mellitus Is Associated With Faster Degeneration of Bioprosthetic Valve: Results From a Propensity Score–Matched Italian Multicenter Study
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Long-Term Cardiovascular Mortality After Procedure-Related or Spontaneous Myocardial Infarction in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Collaborative Analysis of Individual Patient Data From the FRISC II, ICTUS, and RITA-3 Trials (FIR)
Although procedure-related myocardial infarction (MI) has been linked to adverse outcomes, the independent prognostic significance has been a topic for debate. This is in contrast to a spontaneous MI, which is clearly associated with adverse outcomes. We evaluated long-term cardiovascular mortality after both types of MI in the FRISC II, ICTUS, and RITA-3 (FIR) pooled data set of patients with non–ST-elevation acute coronary syndrome randomized to either a routine invasive or a selective invasive treatment strategy and 5-year follow-up of all patients. After adjustments for established risk factors for adverse long-term outcomes, no increased 5-year cardiovascular mortality was observed after the occurrence of a procedure-related MI within 6 months after randomization (hazard ratio 0.66; 95% confidence interval, 0.35–1.25; P=0.20). In contrast, the occurrence of a spontaneous MI within 6 months after randomization was associated with a substantially increased cardiovascular mortality (adjusted hazard ratio 2.79; 95% confidence interval, 2.04–3.83; P<0.001). In conclusion, long-term follow-up of all patients with non–ST-elevation acute coronary syndrome randomized to routine versus selective invasive treatment in the FIR trials showed a substantial adverse prognostic impact of spontaneous MI but no association between events that fulfilled the criteria of procedure-related MI and 5-year cardiovascular mortality. Potential clinical implications or questions include the need to routinely measure serial cardiac biomarkers after revascularization, the interpretation or use of a procedure-related MI as an outcome in clinical trials, and the use of medical treatment to reduce these procedure-related MIs. See p 568.
American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal Definition of Myocardial Infarction Classification System and the Risk of Cardiovascular Death: Observations From the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38)
The ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction (MI) includes a classification system that incorporates the diverse clinical settings in which myocardial injury can be detected, particularly in the era of sensitive biomarkers of myonecrosis. This evolution in the classification of MI has important implications for clinicians and researchers. We investigated the association between new or recurrent MI by subtype according to the ESC/ACCF/AHA/WHF Task Force for the Redefinition of MI Classification System and the risk of cardiovascular death among 13 608 patients with acute coronary syndrome in TRITON-TIMI 38. We found that patients who experienced an MI during follow-up had a higher risk of cardiovascular death than patients without an MI. Importantly, this higher risk was present across all subtypes of MI, including type 1 (spontaneous), type 4a (peri–percutaneous coronary intervention), and type 4b (stent thrombosis). Our findings demonstrate the applicability of the ESC/ACCF/AHA/WHF Universal MI Classification System and underscore the clinical relevance of MI and the need for better therapies aimed at attenuating the risk of recurrent MI after acute coronary syndromes. See p 577.
Very Late Stent Thrombosis and Late Target Lesion Revascularization After Sirolimus-Eluting Stent Implantation: Five-Year Outcome of the j-Cypher Registry
There is a scarcity of long-term data from large-scale drug-eluting stent registries with a large enough sample size to evaluate low-frequency events such as stent thrombosis (ST). Five-year outcomes were evaluated in 12 812 consecutive patients undergoing sirolimus-eluting stent implantation in the j-Cypher registry. Cumulative incidence of definite ST was low (30 day, 0.3%; 1 year, 0.6%; and 5 years, 1.6%). However, late and very late ST continued to occur without attenuation up to 5 years after sirolimus-eluting stent implantation (0.26%/y). Cumulative incidence of target lesion revascularization within the first year was low (7.3%). However, late target lesion revascularization beyond 1 year also continued to occur without attenuation up to 5 years (2.2%/y). Independent risk factors of ST were completely different according to the timing of ST onset, suggesting the presence of different pathophysiological mechanisms of ST according to the timing of ST onset: acute coronary syndrome and target of proximal left anterior descending coronary artery for early ST; side-branch stenting, diabetes mellitus, and end-stage renal disease with or without hemodialysis for late ST; and current smoking and total stent length >28 mm for very late ST. Independent risk factors of late target lesion revascularization beyond 1 year were generally similar to those risk factors identified for early target lesion revascularization. Late adverse events such as very late ST and late target lesion revascularization are continuous hazards, lasting at least up to 5 years after implantation of the first-generation drug-eluting stents (sirolimus-eluting stents), which should be the targets for developing improved coronary stents. See p 584.
Identification of a Monocyte-Predisposed Hierarchy of Hematopoietic Progenitor Cells in the Adventitia of Postnatal Murine Aorta
Leukocytes play diverse and critical roles in vascular biology and disease, including the development and progression of atherosclerosis. The source of leukocytes in the vascular wall has generally been considered to be remote tissues such as bone marrow or spleen via the peripheral circulation. This article presents new evidence that demonstrates that mature murine arteries contain resident stem and progenitor cells that are capable of forming hematopoietic colonies in culture and repopulating different types of blood cells after whole-body irradiation. These hematopoietic populations are strongly skewed toward monocyte/macrophage and lymphocyte lineages and are notably upregulated in proatherogenic mice. They are contained primarily among adventitial cells that express stem cell antigen-1, where they may be resident for prolonged periods, perhaps even constitutively. The presence of such stem and progenitor cells in the arterial adventitia provides a new paradigm to support the local origins of vascular leukocytes, in turn paving the way for a greater understanding of the regulation and involvement of inflammatory cells during vascular responses to acute and chronic injury. Ultimately, defining the role of these cells in human arteries in both health and disease may also provide new therapeutic opportunities to affect the evolution of different vascular disease processes, including atherosclerosis, aneurysm formation, vasculitis, ischemia, and malignancy. See p 592.
Type 2 Diabetes Mellitus Is Associated With Faster Degeneration of Bioprosthetic Valve: Results From a Propensity Score–Matched Italian Multicenter Study
Biological prostheses are increasingly implanted to treat disparate cardiac valve diseases. Postoperative structural valve degeneration represents the most relevant drawback of such artificial valves, sometimes leading to substantial leaflet tissue derangement, clinical deterioration and ultimately, reoperation. The causes and pathogenetic mechanisms of artificial valve structural impairment are not yet fully understood. Atherosclerosis-related risk factors have been suggested recently, through analysis of postoperative outcome in limited patient experiences, to play a role in postimplantation bioprosthetic failure. This multicenter retrospective study sought to investigate specifically the early and long-term influence of type 2 diabetes mellitus in terms of composite outcome in patients undergoing bioprosthetic heart valve implantation in the aortic or mitral position. Propensity score analysis enabled a 1:1 match in 2226 diabetic and nondiabetic subjects among 6184 patients submitted to cardiac valve replacement with biological valves during a 21-year period. In this study, type 2 diabetes mellitus was shown to be an independent predictor of unfavorable outcome, either in terms of reduced life expectancy or in terms of structural bioprosthetic valve degeneration, with the insulin-treated subjects showing the most unfavorable postoperative results. Furthermore, diabetes mellitus was shown to negatively affect postoperative tissue valve performance, irrespective of other associated cardiovascular risk factors. Additional studies are needed to disclose the pathogenetic mechanisms by which such a metabolic disorder may affect the structural integrity of tissue valves and to investigate methods to reduce such an adverse event. Meanwhile, strict clinical surveillance is advised on the basis of the currently witnessed higher rate of structural valve degeneration in diabetic patients submitted to cardiac valve replacement with a biological prosthesis. See p 604.
- © 2012 American Heart Association, Inc.
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