Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Achievement of Dual Low-Density Lipoprotein Cholesterol and High-Sensitivity C-Reactive Protein Targets More Frequent With the Addition of Ezetimibe to Simvastatin and Associated With Better Outcomes in IMPROVE-IT
- Pregnancy Complications and Cardiovascular Disease Death: 50-Year Follow-Up of the Child Health and Development Studies Pregnancy Cohort
- Use of Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry
- Comparison of the Short-Term Risk of Bleeding and Arterial Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients Newly Treated With Dabigatran or Rivaroxaban Versus Vitamin K Antagonists: A French Nationwide Propensity-Matched Cohort Study
- Recanalization Therapies in Acute Ischemic Stroke Patients: Impact of Prior Treatment With Novel Oral Anticoagulants on Bleeding Complications and Outcome: A Pilot Study
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Achievement of Dual Low-Density Lipoprotein Cholesterol and High-Sensitivity C-Reactive Protein Targets More Frequent With the Addition of Ezetimibe to Simvastatin and Associated With Better Outcomes in IMPROVE-IT
Statins lower low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hs-CRP); the addition of ezetimibe, a cholesterol absorption inhibitor, to statins further reduces LDL-C and hs-CRP. In this prespecified analysis of the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) trial, we analyzed the relationship between achieved LDL-C and hs-CRP targets and outcomes for patients randomly assigned to simvastatin monotherapy and the combination of ezetimibe/simvastatin. In the 15 179 patients studied (with n=5121 primary end point events), we found that the addition of ezetimibe to simvastatin significantly increased the likelihood of meeting prespecified targets of LDL-C<70 mg/dL and hs-CRP<2 mg/L 1 month after randomization. Achievement of both LDL-C and hs-CRP targets was associated with significantly improved cardiovascular outcomes in comparison with those meeting neither target after multivariable adjustment. Interestingly, although the addition of ezetimibe increased the likelihood of target attainment, the specific choice of agent used to achieve the target did not impact outcomes differentially, suggesting that, for the agents studied here, target achievement is more important than the mechanism of achievement. Our findings are novel in that they extend previous observations with statin therapy to non–statin-based therapeutic intensification with ezetimibe, an agent with no observed safety signals. See p 1224.
Pregnancy Complications and Cardiovascular Disease Death: 50-Year Follow-Up of the Child Health and Development Studies Pregnancy Cohort
Obstetricians often serve as primary care providers for young women, many of whom may not encounter an alternative opportunity for medical intervention until the end of reproductive life. This gap results in missed opportunities for intervention in high-risk women. We found significant and sizable associations for obstetric complications individually and in combination, and we found 2 new markers of risk: glycosuria and hemoglobin decline over the course of pregnancy. Early-onset preeclampsia warns of the danger of premature cardiovascular disease death, beyond the immediate sequelae of a preeclamptic pregnancy. Similarly, pregnancies complicated by multiple events are shown to identify women at very high risk of subsequent cardiovascular disease. These women could benefit from early intervention and heightened clinical surveillance. Here, we report obstetric complications that define populations of women at substantially increased risk of cardiovascular disease. It is significant that findings are based on prospective observation in a large pregnancy cohort and medically observed complications. Obstetricians can easily use these complications to identify young women at high risk of cardiovascular disease. See p 1234.
Use of Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry
In this study, we sought to describe the overall use, temporal trends, and hospital-level variation in the use of mechanical circulatory support (MCS) for percutaneous coronary intervention in the setting of cardiogenic shock or high-risk percutaneous coronary intervention. In this broad national analysis from 2009 to 2013, just under half of patients undergoing percutaneous coronary intervention in the setting of cardiogenic shock were managed with MCS. Over the study period, the use of intra-aortic balloon pump declined without a concurrent increase in the use of other MCS therapies (ie, TandemHeart, Impella). Despite emerging data on the potential benefits of newer MCS devices, the lack of uptake in the cardiology community may be due, in part, to a paucity of data showing improvement in patient outcomes. In addition, the probability of using intra-aortic balloon pump and other MCS devices varies significantly across hospitals, with the use of newer MCS technologies clustered at large, teaching hospitals. Large-scale randomized clinical trials remain necessary to guide our understanding of the impact of newer MCS therapies on patient outcomes. See p 1243.
Comparison of the Short-Term Risk of Bleeding and Arterial Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients Newly Treated With Dabigatran or Rivaroxaban Versus Vitamin K Antagonists: A French Nationwide Propensity-Matched Cohort Study
The non–vitamin K antagonists (VKA) oral anticoagulants (NOACs), such as the direct thrombin inhibitor dabigatran and the factor Xa inhibitor rivaroxaban, have provided patients who have atrial fibrillation with a convenient, fixed-dose alternative to VKAs. Although NOACs might have some advantages over VKAs, some concerns have emerged about their safety. Few real-world data has been reported so far, and few studies have specifically focused on the early phase of therapy. However, early bleeding and thromboembolic risks have been observed to be significantly higher during the first 90 days of therapy in patients who have atrial fibrillation initiating warfarin. We therefore conducted a large postmarketing study using the French medicoadministrative databases to better investigate the short-term comparative effectiveness and safety of each specific agent of NOAC versus VKA. In this nationwide propensity-matched cohort study (8443 dabigatran- and 4651 rivaroxaban-treated patients matched with at least 1 VKA user), no significant difference between NOAC (dabigatran or rivaroxaban) and VKA was found in terms of hospitalizations for bleeding or for arterial thromboembolic events during the early phase of therapy among new users with nonvalvular atrial fibrillation. Physicians must therefore be as cautious when initiating NOACs as when initiating VKAs, particularly in view of the absence of a NOAC antidote and objective monitoring of the extent of anticoagulation. These results are consistent with those from the few observational studies published to date and offer clinicians a more comprehensive picture of the NOAC benefit-risk balance during the early phase of treatment. See p 1252.
Recanalization Therapies in Acute Ischemic Stroke Patients: Impact of Prior Treatment With Novel Oral Anticoagulants on Bleeding Complications and Outcome: A Pilot Study
Non-vitamin K antagonist oral anticoagulants (NOACs) changed clinical practice and are now frequently used for stroke prevention in patients with atrial fibrillation. Despite their efficacy, patients with atrial fibrillation taking NOACs might experience an ischemic stroke. Clinical physicians are faced with the dilemma to evaluate patients on NOACs who present with ischemic stroke in stroke centers and to balance the risk of bleeding complications against benefits of recanalization therapies like intravenous thrombolysis (IVT) and intra-arterial treatment (IAT, including mechanical thrombectomy). This multicenter observational pilot study is the first to report on a cohort of patients with a previous recent (within the last 48 hours) intake of a NOAC treated with IVT/IAT for ischemic stroke and compares bleeding complications and outcome with a large data set of patients who were either on Vitamin K antagonists or without anticoagulation before IVT/IAT. In this study, in selected patients with ischemic stroke under NOAC treatment, IVT/IAT had a safety profile similar to both IVT/IAT in patients on subtherapeutic Vitamin K antagonist treatment or in those without previous anticoagulation. The present study suggests that IVT/IAT in patients with a previous intake of a NOAC might be safe and that specific clotting tests (eg, calibrated anti–factor Xa assays or hemoclot test) might be helpful to guide or support treatment decisions. Nevertheless, treatment with IVT/IAT in patients with a previous intake of a NOAC should be based on individual treatment decisions balancing the risks and benefits. It should be discussed with patients and next-of-kin. However, more data are needed and results from ongoing research studies are warranted (for example, NOACISP-ACUTE, cinicaltrials.gov: NCT02353585). See p 1261.
- © 2015 American Heart Association, Inc.
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