Ranolazine: A Contemporary Review

Efficacy and Safety of Ranolazine in Diabetic Patients: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have discovered that the antiangina agent ranolazine exerts a glucometabolic effect.

OBJECTIVE

This systematic review and meta-analysis aimed to further understand the efficacy and safety profile of ranolazine in patients with diabetes.

METHODS

Randomized controlled trials (RCTs) were searched in PubMed, Cochrane, and EMBASE databases and in ClinicalTrials.gov up to July 2017. Efficacy end points were defined as the change in hemoglobin A1C (A1C) and fasting serum glucose (FSG) levels. Safety end points included the incidence of hypoglycemia, persistent hyperglycemia, and major adverse cardiovascular events (MACE). Sensitive and subgroup analyses were also conducted.

RESULTS

Seven RCTs with 4461 diabetic patients were selected. Compared with placebo, the use of ranolazine significantly reduced the levels of A1C (weighted mean difference [WMD] = -0.49%; 95% CI = -0.58 to -0.40; P < 0.00001) and FSG (WMD = -6.70 mg/dL; 95% CI = -11.87 to -1.52; P = 0.01). No significant differences were observed in the rates of hypoglycemia (relative risk [RR] = 1.17; 95% CI = 0.76 to 1.80; P = 0.47), persistent hyperglycemia (RR = 0.78; 95% CI = 0.47 to 1.31; P = 0.35), and MACE (RR = 0.65; 95% CI = 0.32 to 1.32; P = 0.23).

CONCLUSION

Ranolazine exerts a positive effect on glucose control and is a well-tolerated agent for patients with diabetes.

[Triple antianginal combinations in the treatment of elderly and senile patients with stable angina]

AIM

To compare the efficiency and safety of antianginal therapy (AAT) using a combination of bisoprolol, ivabradine, and trimetazidine or ranolazine in elderly and senile patients with stable angina.

SUBJECTS AND METHODS

The study enrolled 107 patients aged 60 to 79 years with coronary heart disease and Functional Class II and III angina. When the patients taking bisoprolol 1.25-2.5 mg once daily and ivabradine 2.5-7.5 mg twice daily continued to have angina and/or silent myocardial ischemia, after randomization 54 patients received an additional 35 mg of trimetazidine twice a day and 53 patients had ranolazine 500 mg twice daily. A comprehensive clinical and instrumental study was conducted prior to randomization and after 6 months of triple AAT.

RESULTS

The patients tolerated well both treatments that substantially improved the results of a treadmill exercise test. Trimetazidine reduced to a greater extent the duration of silent ST-segment depression, as evidenced by Holter monitoring. Trimetazidine and ranolazine comparably improved left ventricular systolic and diastolic function, large arterial structure and function, and quality of life in the patients.

CONCLUSION

The combinations of the low-dose β-blocker with ivabradine and trimetazidine or ranolazine may be used to treat refractory stable angina in elderly and senile patients. Trimetazidine is preferred due to its higher efficacy in treating silent myocardial ischemia and to its lower cost.

Predictors and Long-Term Clinical Impact of Acute Stent Malapposition: An Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) Intravascular Ultrasound Substudy

BACKGROUND

The impact of acute stent malapposition (ASM) on long-term clinical outcomes in patients undergoing percutaneous coronary intervention is still controversial. We sought to evaluate predictors and long-term clinical outcomes of ASM.

METHODS AND RESULTS

ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a prospective multicenter study of 8663 patients undergoing percutaneous coronary intervention using drug-eluting stents. In a prespecified intravascular ultrasound-guided substudy, 2072 patients with 2446 culprit lesions had post-percutaneous coronary intervention intravascular ultrasound and were classified according to the presence or absence of ASM. After intravascular ultrasound-guided percutaneous coronary intervention, the overall prevalence of ASM after successful drug-eluting stents implantation was 14.4% per patient and 12.6% per lesion. Compared to lesions without ASM, lesions with ASM had larger in-stent lumen areas, larger stent areas, and larger in-stent vessel areas. A larger mean plaque area along with more attenuated plaque was observed in lesions with ASM versus lesions without ASM. Lesions with ASM had greater proximal and distal reference lumen areas and more distal, but not proximal, reference calcium compared to lesions without ASM. At 2-year follow-up, there was no significant difference in the incidence of cardiac death; myocardial infarction; early, late, or very late stent thrombosis; or clinically driven target lesion revascularization in patients with ASM versus those without ASM. Furthermore, ASM was not an independent predictor of 2-year major adverse cardiac events or target lesion revascularization even when forced into the multivariate model.

CONCLUSIONS

In patients treated with intravascular ultrasound-guided drug-eluting stents implantation, ASM was not associated with adverse clinical events during long-term follow-up including, but not limited to, stent thrombosis.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00638794.

Invasive minimal Microvascular Resistance Is a New Index to Assess Microcirculatory Function Independent of Obstructive Coronary Artery Disease

BACKGROUND

Coronary microcirculatory dysfunction portends a poor cardiovascular outcome. Invasive assessment of microcirculatory dysfunction by coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) is affected by coronary artery disease (CAD). In this study we propose minimal microvascular resistance (mMR) as a new measure of microcirculatory dysfunction and aim to determine whether mMR is influenced by CAD.

METHODS AND RESULTS

We obtained 482 simultaneous measurements of intracoronary Doppler flow velocity and pressure. The mMR is defined as the ratio between distal coronary pressure and flow velocity during the hyperemic wave-free period. Measurements were divided into 2 cohorts. Cohort 1 was a paired analysis involving 81 pairs with a vessel with and without CAD to investigate whether HMR, CFR, and mMR are modulated by CAD. CFR was lower, and HMR was higher, in vessels with CAD than in vessels without CAD: 2.12±0.79 versus 2.56±0.63 mm Hg·cm-1·s, P<0.001, and 2.61±1.22 versus 2.31±0.89 mm Hg·cm-1·s, P=0.04, respectively. mMR was equal in vessels with and without CAD: 1.54±0.77 versus 1.53±0.57 mm Hg·cm-1·s, P=0.90. Differences for CFR occurred when FFR was 0.60 to 0.80 or ≤0.60 but not when FFR ≥0.80. For HMR, the difference occurred only when FFR ≤0.60. For mMR, no difference was observed in any FFR stratum. Cohort 2 was used for validation and showed significant relationships for CFR and HMR with FFR: Pearson r=0.488, P<0.001 and -0.159, P=0.03, respectively; mMR had no association with FFR: Pearson r=0.055; P=0.32.

CONCLUSIONS

mMR is a novel index to assess microcirculatory dysfunction and is not modified by the presence of obstructive CAD.

Revisiting the "Christmas Holiday Effect" in the Southern Hemisphere

BACKGROUND

A "Christmas holiday effect" showing elevated cardiovascular mortality over the Christmas holidays (December 25 to January 7) was demonstrated previously in study from the United States. To separate the effect of seasonality from any holiday effect, a matching analysis was conducted for New Zealand, where the Christmas holiday period falls within the summer season.

METHODS AND RESULTS

New Zealand mortality data for a 25-year period (1988-2013) was analyzed based on the same methodology used in the previous study. Locally weighted smoothing was used to calculate an "expected" number of deaths for each day of the year. The expected value was compared with the actual number of deaths. In addition, mean age at death was estimated and used to assess the life-years lost due to excess mortality. There were 738 409 deaths (197 109 coded as cardiac deaths) during the period. We found evidence of a Christmas holiday effect in our of medical facility's cardiac deaths, with an excess event rate of 4.2% (95% CI 0.7-7.7%) leading to ≈4 additional deaths per annum. The average age of those with fatal cardiac deaths was 76.8 years (SD 13.5) during the Christmas holiday period, resulting in 148 to 222 years of life lost per annum.

CONCLUSIONS

Cardiac mortality is elevated during the Christmas holiday period relative to surrounding time periods. Our findings are consistent with a previously reported study conducted in the United States, suggesting that cardiac mortality does not take a "summer break."

Association of Major Depression With Risk of Ischemic Heart Disease in a Mega-Cohort of Chinese Adults: The China Kadoorie Biobank Study

BACKGROUND

Increasing evidence has suggested that major depression (MD) is associated with an increased risk of ischemic heart disease (IHD). We examined this association in Chinese adults using data from the China Kadoorie Biobank study.

METHODS AND RESULTS

Over 0.5 million adults aged 30 to 79 years were followed from baseline interview (2004-2008) until December 31, 2013. Past year MD was measured with the modified Chinese version of Composite International Diagnostic Interview-Short Form at baseline. Incident IHD cases were identified through linkage to related medical databases, and defined as having International Statistical Classification of Diseases and Related Health Problems 10th Revision codes of I20 to I25. Cox proportional hazards regression models were used to estimate hazard ratios and 95% CIs for the MD-IHD association with adjustment for sociodemographic variables and established cardiovascular risk factors. During 3 423 542 person-years of follow-up, 24 705 incident IHD cases were documented. Higher IHD incidence was observed in participants with MD compared with those without (8.76 versus 7.21 per 1000 person-years), and the multivariable-adjusted hazard ratio was 1.32 (95% CI 1.15-1.53). Geographic location modified the association (P for interaction=0.005), and a positive association was observed in urban residents (hazard ratio 1.72; 95% CI 1.39-2.14) but not rural residents (1.13; 0.93-1.37). Compared with participants without depressive symptoms, the hazard ratio (95% CI) of IHD was 1.13 (1.04-1.23) for those with depressive symptoms only and 1.33 (1.15-1.53) for those with MD.

CONCLUSIONS

Past year major depression was associated with an increased risk of IHD in Chinese adults, independent of other major cardiovascular risk factors.

Lifestyle Cardiovascular Risk Score, Genetic Risk Score, and Myocardial Infarction in Hispanic/Latino Adults Living in Costa Rica

BACKGROUND

A lifestyle cardiovascular risk score (LCRS) and a genetic risk score (GRS) have been independently associated with myocardial infarction (MI) in Hispanics/Latinos. Interaction or joint association between these scores has not been examined. Thus, our aim was to assess interactive and joint associations between LCRS and GRS, and each individual lifestyle risk factor, on likelihood of MI.

METHODS AND RESULTS

Data included 1534 Costa Rican adults with nonfatal acute MI and 1534 matched controls. The LCRS used estimated coefficients as weights for each factor: unhealthy diet, physical inactivity, smoking, elevated waist:hip ratio, low/high alcohol intake, low socioeconomic status. The GRS included 14 MI-associated risk alleles. Conditional logistic regressions were used to calculate adjusted odds ratios. The odds ratios for MI were 2.72 (2.33, 3.17) per LCRS unit and 1.13 (95% CI 1.06, 1.21) per GRS unit. A significant joint association for highest GRS tertile and highest LCRS tertile and odds of MI was detected (odds ratio=5.43 [3.71, 7.94]; P<1.00×10-7), compared to both lowest tertiles. The odds ratios were 1.74 (1.22, 2.49) under optimal lifestyle and unfavorable genetic profile, and 5.02 (3.46, 7.29) under unhealthy lifestyle but advantageous genetic profile. Significant joint associations were observed for the highest GRS tertile and the highest of each lifestyle component risk category. The interaction term was nonsignificant (P=0.33).

CONCLUSIONS

Lifestyle risk factors and genetics are jointly associated with higher odds of MI among Hispanics/Latinos. Individual and combined lifestyle risk factors showed stronger associations. Efforts to improve lifestyle behaviors could help prevent MI regardless of genetic susceptibility.

Role of T-Cell Dysfunction, Inflammation, and Coagulation in Microvascular Disease in HIV

BACKGROUND

Compared to uninfected adults, HIV-infected adults on antiretroviral therapy are at increased risk of cardiovascular disease. Given the increase in T-cell dysfunction, inflammation, and coagulation in HIV infection, microvascular dysfunction is thought to contribute to this excess cardiovascular risk. However, the relationships between these variables remain undefined.

METHODS AND RESULTS

This was a cross-sectional study of 358 HIV-infected adults from the SCOPE cohort. Macrovascular endothelial function was assessed using flow-mediated dilation of the brachial artery and microvascular function by reactive hyperemia. T-cell phenotype was determined by flow cytometry. Plasma markers of inflammation (tumor necrosis factor-α, interleukin-6, high-sensitivity C-reactive protein, sCD14) and coagulation (fibrinogen, D-dimer) were also measured. In all HIV+ subjects, markers of inflammation (tumor necrosis factor-α, high-sensitivity C-reactive protein), coagulation (D-dimer) and T-cell activation (CD8+PD1+, CD4+interferon+cytomegalovirus-specific) were associated with worse reactive hyperemia after adjusting for traditional cardiovascular risk factors and co-infections. In treated and suppressed subjects, tumor necrosis factor-α and CD8+PD1+ cells remained associated with worse reactive hyperemia after adjustment. Compared to the untreated subjects, CD8+PD1+ cells were increased in the virally suppressed group. Reactive hyperemia was predictive of flow-mediated dilation.

CONCLUSIONS

CD8+PD1+ cells and tumor necrosis factor-α were associated with microvascular dysfunction in all HIV+ subjects and the treated and suppressed group. Additionally, D-dimer, high-sensitivity C-reactive protein, sCD-14, and interleukin-6 were associated with microvascular dysfunction in all HIV+ subjects. Although T-cell dysfunction, inflammation, and microvascular dysfunction are thought to play a role in cardiovascular disease in HIV, this study is the first to look at which T-cell and inflammatory markers are associated with microvascular dysfunction in HIV-infected individuals.

Nkx2-5 Is Expressed in Atherosclerotic Plaques and Attenuates Development of Atherosclerosis in Apolipoprotein E-Deficient Mice

BACKGROUND

NK2 homeobox 5 (Nkx2-5) is a cardiac homeobox transcription factor that is expressed in a broad range of cardiac sublineages. Embryos lacking Nkx2-5 are nonviable attributed to growth retardation and gross abnormalities of the heart. However, the role of Nkx2-5 in atherosclerosis remains elusive. This study aims to elucidate the specific functions of Nkx2-5 during atherogenesis and in established atherosclerotic plaques.

METHODS AND RESULTS

Two types of atherosclerotic lesions were created in ApoE-/- mice through 2 different dietary manipulations. Mice fed a standard chow diet were sacrificed at 20 weeks old, a time point at which mice developed early-stage atherosclerotic lesions. The other half of mice were fed a western diet from 6 to 22 weeks old and then sacrificed. These mice demonstrated advanced atherosclerosis. No Nkx2-5 was detected in normal arteries; however, it was abundantly present in the intima of atherosclerotic lesions and localized in macrophages and smooth muscle cells. Adenovirus gene transfer of Nkx2-5 markedly ameliorated and stabilized the atherosclerotic plaques, and knockdown of Nkx2-5 significantly exacerbated the disease. Molecular studies indicated that expression of specific members of matrix metalloproteinases and tissue inhibitor of metalloproteinases, which play a crucial role in the progression of atherosclerosis, were directly regulated by Nkx2-5. Furthermore, we demonstrated that the compromised endothelial function, which was considered as a hallmark of early atherosclerosis, could be improved by Nkx2-5 gene transfer.

CONCLUSIONS

Nkx2-5 exerts antiatherogenic effects, which may partly be attributed to regulation on matrix metalloproteinases and tissue inhibitor of metalloproteinases, thus stabilizing atherosclerotic plaque; besides, it improves endothelial function by inhibiting leukocyte adhesion to the endothelium.

Secondhand Smoke Exposure and Subclinical Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Few studies have evaluated the association between secondhand smoke (SHS) and subclinical cardiovascular disease among ethnically diverse populations. This study assesses the impact of SHS on inflammation and atherosclerosis (carotid intima-media thickness, coronary artery calcification, and peripheral arterial disease).

METHODS AND RESULTS

We examined 5032 nonsmoking adults aged 45 to 84 years without prior cardiovascular disease participating in the Multi-Ethnic Study of Atherosclerosis (MESA) from 2000 to 2002. SHS exposure was determined by self-report, and urinary cotinine was measured in a representative subset (n=2893). The multi-adjusted geometric mean ratios (95% CIs) for high-sensitivity C-reactive protein and interleukin-6 comparing 407 participants with SHS ≥12 h/wk versus 3035 unexposed participants were 1.13 (1.02-1.26) and 1.04 (0.98-1.11), respectively. The multi-adjusted geometric mean ratio for carotid intima-media thickness was 1.02 (0.97-1.07). Fibrinogen and coronary artery calcification were not associated with SHS. The prevalence of peripheral arterial disease (ankle-brachial index ≤0.9 or ≥1.4) was associated with detectable urinary cotinine (odds ratio, 2.10; 95% CI, 1.09-4.04) but not with self-reported SHS. Urinary cotinine was not associated with inflammation or carotid intima-media thickness.

CONCLUSIONS

Despite limited exposure assessment, this study supports the association of SHS exposure with inflammation and peripheral arterial disease.

Relationship Between Endothelial Wall Shear Stress and High-Risk Atherosclerotic Plaque Characteristics for Identification of Coronary Lesions That Cause Ischemia: A Direct Comparison With Fractional Flow Reserve

BACKGROUND

Wall shear stress (WSS) is an established predictor of coronary atherosclerosis progression. Prior studies have reported that high WSS has been associated with high-risk atherosclerotic plaque characteristics (APCs). WSS and APCs are quantifiable by coronary computed tomography angiography, but the relationship of coronary lesion ischemia-evaluated by fractional flow reserve-to WSS and APCs has not been examined.

METHODS AND RESULTS

WSS measures were obtained from 100 evaluable patients who underwent coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve. Patients were categorized according to tertiles of mean WSS values defined as low, intermediate, and high. Coronary ischemia was defined as fractional flow reserve ≤0.80. Stenosis severity was determined by minimal luminal diameter. APCs were defined as positive remodeling, low attenuation plaque, and spotty calcification. The likelihood of having positive remodeling and low-attenuation plaque was greater in the high WSS group compared with the low WSS group after adjusting for minimal luminal diameter (odds ratio for positive remodeling: 2.54, 95% CI 1.12-5.77; odds ratio for low-attenuation plaque: 2.68, 95% CI 1.02-7.06; both P<0.05). No significant relationship was observed between WSS and fractional flow reserve when adjusting for either minimal luminal diameter or APCs. WSS displayed no incremental benefit above stenosis severity and APCs for detecting lesions that caused ischemia (area under the curve for stenosis and APCs: 0.87, 95% CI 0.81-0.93; area under the curve for stenosis, APCs, and WSS: 0.88, 95% CI 0.82-0.93; P=0.30 for difference).

CONCLUSIONS

High WSS is associated with APCs independent of stenosis severity. WSS provided no added value beyond stenosis severity and APCs for detecting lesions with significant ischemia.

Late Survival After Aortic Valve Replacement in Patients With Moderately Reduced Kidney Function

BACKGROUND

The influence of moderately reduced kidney function on late survival after surgical aortic valve replacement (AVR) is unknown. We analyzed survival after AVR in patients with moderately reduced kidney function.

METHODS AND RESULTS

All patients who underwent primary AVR in Sweden 1997-2013 were identified from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register. Patients were categorized according to estimated glomerular filtration rate (eGFR). Of 13 102 patients, 9836 (75%) had normal kidney function (eGFR >60 mL/min per 1.73 m2) and 3266 (25%) had moderately reduced kidney function (eGFR 30-60 mL/min per 1.73 m2). Mean follow-up time was 6.2 years. Mortality was higher in patients with moderately reduced kidney function; 5-, 10-, and 15-year survival was 76%, 48%, and 25% versus 89%, 73%, and 55% (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18-1.38; P<0.001). Patients with moderately reduced kidney function had a nonsignificantly higher risk of major bleeding (HR, 1.18; 95% CI, 1.00-1.39; P=0.051) and a lower risk for aortic valve reoperation (HR, 0.54; 95% CI, 0.38-0.79; P=0.001) compared to those with normal kidney function. In patients with moderately reduced kidney function, survival was similar in those who received bioprostheses compared to those who received mechanical valves (HR, 0.85; 95% CI, 0.70-1.03; P=0.094).

CONCLUSIONS

Moderately reduced kidney function was strongly associated with increased mortality after AVR. These results have important implications for preoperative risk stratification, and suggest that patients with eGFR 30 to 60 mL/min per 1.73 m2 warrant careful observation after AVR.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.

Clinical and Epidemiological Implications of 24-Hour Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Kenyan Adults: A Population-Based Study

BACKGROUND

The clinical and epidemiological implications of using ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension have not been studied at a population level in sub-Saharan Africa. We examined the impact of ABPM use among Kenyan adults.

METHODS AND RESULTS

We performed a nested case-control study of diagnostic accuracy. We selected an age-stratified random sample of 1248 adults from the list of residents of the Kilifi Health and Demographic Surveillance System in Kenya. All participants underwent a screening blood pressure (BP) measurement. All those with screening BP ≥140/90 mm Hg and a random subset of those with screening BP <140/90 mm Hg were invited to undergo ABPM. Based on the 2 tests, participants were categorized as sustained hypertensive, masked hypertensive, "white coat" hypertensive, or normotensive. Analyses were weighted by the probability of undergoing ABPM. Screening BP ≥140/90 mm Hg was present in 359 of 986 participants, translating to a crude population prevalence of 23.1% (95% CI 16.5-31.5%). Age standardized prevalence of screening BP ≥140/90 mm Hg was 26.5% (95% CI 19.3-35.6%). On ABPM, 186 of 415 participants were confirmed to be hypertensive, with crude prevalence of 15.6% (95% CI 9.4-23.1%) and age-standardized prevalence of 17.1% (95% CI 11.0-24.4%). Age-standardized prevalence of masked and white coat hypertension were 7.6% (95% CI 2.8-13.7%) and 3.8% (95% CI 1.7-6.1%), respectively. The sensitivity and specificity of screening BP measurements were 80% (95% CI 73-86%) and 84% (95% CI 79-88%), respectively. BP indices and validity measures showed strong age-related trends.

CONCLUSIONS

Screening BP measurement significantly overestimated hypertension prevalence while failing to identify ≈50% of true hypertension diagnosed by ABPM. Our findings suggest significant clinical and epidemiological benefits of ABPM use for diagnosing hypertension in Kenyan adults.

Effectiveness of Chlorthalidone Plus Amiloride for the Prevention of Hypertension: The PREVER-Prevention Randomized Clinical Trial

BACKGROUND

Prehypertension is associated with higher cardiovascular risk, target organ damage, and incidence of hypertension. The Prevention of Hypertension in Patients with PreHypertension (PREVER-Prevention) trial aimed to evaluate the efficacy and safety of a low-dose diuretic for the prevention of hypertension and end-organ damage.

METHODS AND RESULTS

This randomized, parallel, double-blind, placebo-controlled trial was conducted in 21 Brazilian academic medical centers. Participants with prehypertension who were aged 30 to 70 years and who did not reach optimal blood pressure after 3 months of lifestyle intervention were randomized to a chlorthalidone/amiloride combination pill or placebo and were evaluated every 3 months during 18 months of treatment. The primary outcome was incidence of hypertension. Development or worsening of microalbuminuria, new-onset diabetes mellitus, and reduction of left ventricular mass were secondary outcomes. Participant characteristics were evenly distributed by trial arms. The incidence of hypertension was significantly lower in 372 study participants allocated to diuretics compared with 358 allocated to placebo (hazard ratio 0.56, 95% CI 0.38-0.82), resulting in a cumulative incidence of 11.7% in the diuretic arm versus 19.5% in the placebo arm (P=0.004). Adverse events; levels of blood glucose, glycosylated hemoglobin, creatinine, and microalbuminuria; and incidence of diabetes mellitus were no different between the 2 arms. Left ventricular mass assessed through Sokolow-Lyon voltage and voltage-duration product decreased to a greater extent in participants allocated to diuretic therapy compared with placebo (P=0.02).

CONCLUSIONS

A combination of low-dose chlorthalidone and amiloride effectively reduces the risk of incident hypertension and beneficially affects left ventricular mass in patients with prehypertension.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov, www.ensaiosclinicos.gov. Unique identifiers: NCT00970931, RBR-74rr6s.

Neurohormonal Activation After Atrial Fibrillation Initiation in Patients Eligible for Catheter Ablation: A Randomized Controlled Study

BACKGROUND

Biomarker activation in atrial fibrillation (AF) has been widely studied, but the immediate effect of AF initiation remains unclear. We studied the effect of AF initiation on 2 cardiac biomarkers: the N-terminal fragment of the proB-type natriuretic peptide (NT-proBNP), the midregional fragment of the N-terminal of pro-atrial natriuretic peptide (MR-proANP), and 2 extracardiac biomarkers-the copeptin and the midregional portion of proadrenomedullin (MR-proADM).

METHODS AND RESULTS

This was a randomized controlled study, including 45 patients with AF who had been referred for radiofrequency ablation to the University Hospital, Linköping, Sweden, between February 2012 and April 2014. Freedom from AF during the 4 days prior to radiofrequency ablation was confirmed by transtelephonic ECGs. Biomarkers were collected from the femoral vein (fv), coronary sinus (CS), and left atrium (LA) prior to AF initiation (baseline) and 30 minutes later. The MR-proANP and NT-proBNP concentrations increased in the intervention group compared with the control group 30 minutes after the initiation of AF (MR-proANP: Pfv<0.001, PCS<0.001, PLA<0.001; NT-proBNP: PLA<0.001). Copeptin levels in patients without ischemic heart disease were decreased after the initiation of AF (Pfv=0.003, PCS=0.015, PLA=0.011).

CONCLUSIONS

AF is a strong stimulus that results in immediate activation of different biomarkers.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01553045.

NCK Associated Protein 1 Modulated by miRNA-214 Determines Vascular Smooth Muscle Cell Migration, Proliferation, and Neointima Hyperplasia

BACKGROUND

MicroRNA miR-214 has been implicated in many biological cellular functions, but the impact of miR-214 and its target genes on vascular smooth muscle cell (VSMC) proliferation, migration, and neointima smooth muscle cell hyperplasia is unknown.

METHODS AND RESULTS

Expression of miR-214 was closely regulated by different pathogenic stimuli in VSMCs through a transcriptional mechanism and decreased in response to vascular injury. Overexpression of miR-214 in serum-starved VSMCs significantly decreased VSMC proliferation and migration, whereas knockdown of miR-214 dramatically increased VSMC proliferation and migration. Gene and protein biochemical assays, including proteomic analyses, showed that NCK associated protein 1 (NCKAP1)-a major component of the WAVE complex that regulates lamellipodia formation and cell motility-was negatively regulated by miR-214 in VSMCs. Luciferase assays showed that miR-214 substantially repressed wild-type but not the miR-214 binding site mutated version of NCKAP1 3' untranslated region luciferase activity in VSMCs. This result confirmed that NCKAP1 is the functional target of miR-214 in VSMCs. NCKAP1 knockdown in VSMCs recapitulates the inhibitory effects of miR-214 overexpression on actin polymerization, cell migration, and proliferation. Data from cotransfection experiments also revealed that inhibition of NCKAP1 is required for miR-214-mediated lamellipodia formation, cell motility, and growth. Importantly, locally enforced expression of miR-214 in the injured vessels significantly reduced NCKAP1 expression levels, inhibited VSMC proliferation, and prevented neointima smooth muscle cell hyperplasia after injury.

CONCLUSIONS

We uncovered an important role of miR-214 and its target gene NCKAP1 in modulating VSMC functions and neointima hyperplasia. Our findings suggest that miR-214 represents a potential therapeutic target for vascular diseases.

Associations Between Blood Pressure and Outcomes Among Blacks in the Jackson Heart Study

BACKGROUND

In 2014, new hypertension guidelines liberalized blood pressure goals for persons 60 years and older. Little is known about the implications for blacks.

METHODS AND RESULTS

Using data from 2000 through 2011 for 5280 participants in the Jackson Heart Study, a community-based black cohort in Jackson, Mississippi, we examined whether higher blood pressure was associated with greater risk of mortality and heart failure hospitalization, and whether the risk was the same across age groups. We investigated associations between baseline blood pressure and both mortality and heart failure hospitalization. We also tested for interactions between age and blood pressure in the mortality model. Median systolic and diastolic blood pressures at baseline were 125 mm Hg (25th-75th percentile, 114-137 mm Hg) and 79 mm Hg (72-86 mm Hg), respectively. Median follow-up was 9 years for mortality and 7 years for heart failure hospitalization. After multivariable adjustment, every 10 mm Hg increase in systolic blood pressure was associated with greater risks of mortality (hazard ratio, 1.12; 95% CI, 1.06-1.17) and heart failure hospitalization (1.07; 95% CI, 1.00-1.14). The mortality risk per 10 mm Hg increase in systolic blood pressure was greater in participants younger than 60 years (1.26; 95% CI, 1.13-1.42) than among participants 60 years and older (1.09; 95% CI, 1.03-1.15).

CONCLUSIONS

Adults in all age groups were at greater risk of mortality as systolic blood pressure increased. In the context of the 2014 hypertension guidelines, these findings should be considered when determining treatment goals in black patients.

Interleukin-37 and Dendritic Cells Treated With Interleukin-37 Plus Troponin I Ameliorate Cardiac Remodeling After Myocardial Infarction

BACKGROUND

Excessive immune-mediated inflammatory reactions play a deleterious role in postinfarction ventricular remodeling. Interleukin-37 (IL-37) emerges as an inhibitor of both innate and adaptive immunity. However, the exact role of IL-37 and IL-37 plus troponin I (TnI)-treated dendritic cells (DCs) in ventricular remodeling after myocardial infarction (MI) remains elusive.

METHODS AND RESULTS

MI was induced by permanent ligation of the left anterior descending artery. Our results showed that treatment with recombinant human IL-37 significantly ameliorated ventricular remodeling after MI, as demonstrated by decreased infarct size, better cardiac function, lower mortality, restricted inflammatory responses, decreased myocardial fibrosis, and inhibited cardiomyocyte apoptosis. In vitro, we examined the phenotype of IL-37 plus TnI-conditioned DCs of male C57BL/6 mice and their capacity to influence the number of regulatory T cells. Our results revealed that IL-37 plus TnI-conditioned DCs obtained the characteristics of tolerogenic DCs (tDCs) and expanded the number of regulatory T cells when co-cultured with splenic CD4+ T cells. Interestingly, we also found that adoptive transfer of these antigen-loaded tDCs markedly increased the number of regulatory T cells in the spleen, attenuated the infiltration of inflammatory cells in the infarct hearts, decreased myocardial fibrosis, and improved cardiac function.

CONCLUSIONS

Our results reveal a beneficial role of IL-37 or tDCs treated with IL-37 plus TnI in post-MI remodeling that is possibly mediated by reestablishing a tolerogenic immune response, indicating that IL-37 or adoptive transfer of IL-37 plus TnI-treated tDCs may be a novel therapeutic strategy for ventricular remodeling after MI.

Impact of Surgical Ablation of Atrial Fibrillation on the Progression of Tricuspid Regurgitation and Right-Sided Heart Remodeling After Mitral-Valve Surgery: A Propensity-Score Matching Analysis

BACKGROUND

This study assessed the role of surgical ablation for atrial fibrillation (AF) in decreasing tricuspid regurgitation (TR) and right-sided heart remodeling in patients after mitral valve procedure.

METHODS AND RESULTS

Between 1994 and 2014, 1568 consecutive patients with AF undergoing mitral valve procedure were identified. In 26.0% (n=408), surgical ablation of AF was used. Propensity-score matching (PSM) was performed on the basis of 41 known perioperative risk variables. Survival, reoperation, stroke, and moderate-to-severe TR, as well as echocardiography indices in long-term follow-up, were compared in 406 matched patient pairs (ablated and nonablated groups). The nonablated group showed significantly higher risks of death (hazard ratio [HR], 1.644; 95% CI, 1.081-2.501; P=0.020), reoperation (HR, 2.644; 95% CI, 1.299-5.466; P=0.008), and moderate-to-severe TR (HR, 1.436; 95% CI, 1.059-1.948; P=0.020), associated with a significantly deteriorated cardiac function, progression of TR, and right-sided heart remodeling after 5-year follow-up. In a subgroup comparison of ablated patients with sinus rhythm versus AF recurrence, a PSM analysis was performed at the 5-year follow-up. The recurrent group showed significantly higher risks of moderate-to-severe TR (HR, 2.427; 95% CI, 1.261-4.671; P=0.008). AF recurrence was associated with progressive TR and significant deterioration in right-sided heart remodeling.

CONCLUSIONS

In a retrospective PSM analysis, mitral valve disease with AF was associated with TR progression as well as right-sided heart remodeling, which are alleviated by surgical ablation.

Patent Foramen Ovale With Atrial Septal Aneurysm Is Strongly Associated With Migraine With Aura: A Large Observational Study

BACKGROUND

A patent foramen ovale (PFO) with atrial septal aneurysm (ASA) has been identified as a risk factor for cryptogenic stroke. Patients with migraine with aura (MA) appear to be at risk for silent brain infarction, which might be related to the presence of a PFO. However, the association between MA and PFO with ASA has never been reported. We examined this association in a large observational study.

METHODS AND RESULTS

Patients (>18 years) who underwent an agitated saline transesophageal echocardiography (cTEE) at our outpatient clinics within a timeframe of 4 years were eligible to be included. Before cTEE they received a validated headache questionnaire. Two neurologists diagnosed migraine with or without aura according to the International Headache Criteria. A total of 889 patients (mean age 56.4±14.3 years, 41.7% women) were included. A PFO was present in 23.2%, an isolated ASA in 2.7%, and a PFO with ASA in 6.9%. The occurrence of migraine was 18.9%; the occurrence of MA was 8.1%. The prevalence of PFO with ASA was significantly higher in patients with MA compared to patients without migraine (18.1% vs 6.1%; OR 3.72, 95% CI 1.86-7.44, P<0.001). However, a PFO without ASA was not significantly associated with MA (OR 1.50, 95% CI 0.79-2.82, P=0.21). Interestingly, a PFO with ASA was strongly associated with MA (OR 2.71, 95% CI 1.23-5.95, P=0.01).

CONCLUSION

In this large observational study, PFO with ASA was significantly associated with MA only. PFO closure studies should focus on this specific intra-atrial anomaly.

Prevalence and Clinical Significance of Discordant Changes in Fractional and Coronary Flow Reserve After Elective Percutaneous Coronary Intervention

BACKGROUND

Fractional flow reserve (FFR) and coronary flow reserve (CFR) are well-validated physiological indices; however, changes in FFR and CFR after percutaneous coronary intervention (PCI) remain elusive. We sought to evaluate these changes and to investigate whether physiological indices predict cardiac event-free survival after PCI.

METHODS AND RESULTS

Physiological assessment of 220 stenoses from 220 patients was performed before and after PCI. The changes in FFR and CFR were studied, and factors associated with CFR change were investigated. Follow-up data were collected to determine the predictor of cardiac events. CFR increase was found in 158 (71.8%) territories, and 62 (28.2%) presented a decrease, whereas FFR increased in all 220 (100%) territories. Pre- and post-PCI percentage diameter stenoses were 57.7±11.2% and 7.48±4.79%, respectively. Post-PCI CFR increase was associated with pre-PCI indices including low FFR, low CFR and high microvascular resistance, and post-PCI hyperemic coronary flow increase. Post-PCI CFR decrease was not associated with significant post-PCI hyperemic coronary flow increase. At a median follow-up of 24.3 months, adverse event-free survival was significantly worse in patients with lower pre-PCI CFR (log-rank test λ2=7.26; P=0.007). Cox proportional hazards analysis showed that lower pre-PCI CFR (hazard ratio 0.73; 95% CI 0.55-0.97; P=0.028) was an independent predictor of adverse cardiovascular events after PCI.

CONCLUSIONS

CFR decrease after PCI was not uncommon, and discordant change in FFR and CFR was associated with high pre-PCI CFR, low pre-PCI microvascular resistance, and no significant post-PCI hyperemic coronary flow increase. Pre-PCI CFR, not post-PCI physiological indices, may help identify patients who require adjunctive management strategy after successful PCI.

Prognostic Value of Cardiac Troponin T and Sex in Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND

In patients with stable coronary artery disease undergoing elective percutaneous coronary intervention, the prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) and the influence of sex remain poorly defined.

METHODS AND RESULTS

Consecutive patients with stable coronary artery disease who underwent elective percutaneous coronary intervention were included. Primary endpoint was all-cause mortality. Unadjusted hazard ratio (HR) in overall and sex-specific population and multivariable adjusted HR were calculated by using Cox proportional hazard models. In a total of 5626 patients, elevated hs-cTnT levels, more than the sex-specific 99th percentile upper reference limit of normal (URL), were observed in 2221 patients (39%) at baseline. During follow-up (median, 14.5 months; 25th-75th percentiles, 6.4-27.2 months), 265 patients died. Mortality was higher in patients with the sex-specific 99th percentile URL compared to those with normal hs-cTnT (17.3% vs 3.4%; HR=6.10; 95% CI, 4.58-8.14; P<0.001). hs-cTnT was an independent predictor of mortality in multivariable adjusted models. The C-statistic was significantly increased by adding hs-cTnT to the basic prediction model for mortality (0.793-0.815; P<0.001). There was a significant interaction between hs-cTnT and sex on mortality. Differences in all-cause mortality between patients with more than the sex-specific 99th percentile URL and those with normal hs-cTnT were numerically larger in male than female patients (male, HR=6.45; 95% CI, 4.68-8.87, P<0.001; female, HR=4.29, 95% CI, 2.36-9.03; P<0.001).

CONCLUSIONS

In patients with stable coronary artery disease undergoing elective percutaneous coronary intervention, preprocedural hs-cTnT was a strong predictor of mortality in both men and women.

Impact of Alcohol Consumption on the Outcome of Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation

BACKGROUND

Although several studies have reported an association between atrial fibrillation (AF) and alcohol, the impact of alcohol consumption on the outcome after catheter ablation (CA) for AF has not been discussed. We aimed to elucidate the effect of alcohol consumption on the outcome of CA for paroxysmal AF.

METHODS AND RESULTS

We examined 1361 consecutive patients with paroxysmal AF (mean age, 61±11 years, 334 women) who underwent CA, including 623 (45.8%) patients who consumed alcohol. The clinical characteristics and outcomes of CA were compared between patients who did and did not consume alcohol. No significant differences were seen in the left atrial size, duration of AF history, and incidence of nonpulmonary vein foci between 2 groups (P=NS). Although the AF recurrence-free rate after the initial CA was higher in patients who did not consume alcohol (261/623 [41.9%] versus 252/738 [34.1%]; mean follow-up, 44.4±30.7 months; P=0.003), the outcome after the final CA was similar between 2 groups (patients who consumed alcohol: 111/628 [17.7%] versus patients who did not consume alcohol: 138/738 [18.7%]; mean follow-up, 53.1±25.8 months; P=0.67). The frequency (hazard ratio 1.07 per 1 day/week increase, CI 1.00-1.15, P=0.04) of alcohol consumption was significantly associated with AF recurrence after CA.

CONCLUSIONS

The frequency of alcohol consumption may be associated with AF recurrence after the initial CA for paroxysmal AF, but it may not affect the outcome after the final CA.

Cardiorespiratory Fitness and Highly Sensitive Cardiac Troponin Levels in a Preventive Medicine Cohort

BACKGROUND

Cardiorespiratory fitness (CRF) and highly sensitive cardiac troponin T (hs-cTnT) are associated with risk of all-cause and cardiovascular mortality as well as incident heart failure. A link of low CRF to subclinical cardiac injury may explain this association. We hypothesized that CRF would be inversely associated with hs-cTnT measured in healthy adults over age 50.

METHODS AND RESULTS

We evaluated 2498 participants (24.7% female, mean age 58.7 years) from the Cooper Center Longitudinal Study between August 2008 and January 2012. Plasma specimens obtained shortly before CRF estimates by Balke treadmill testing were used for hs-cTnT assays. CRF was grouped into low CRF (category 1), moderate CRF (categories 2-3), and high CRF (categories 4-5). Multivariable logistic regression was used to estimate the association of CRF with hs-cTnT. The prevalence of measurable hs-cTnT (≥3 ng/L) was 78.5%. In multivariable analyses, low-fit individuals were significantly more likely than high-fit individuals to have elevated hs-cTnT (≥14 ng/L) (odds ratio 2.47, 95% CI 1.10-5.36).

CONCLUSIONS

In healthy older adults, CRF is inversely associated with hs-cTnT level adjusted for other risk factors. Prospective studies are needed to evaluate whether improving CRF is effective in preventing subclinical cardiac injury.

Temporal Reduction in Chronotropic Index Predicts Risk of Cardiovascular Death Among Healthy Middle-Aged Men: a 28-Year Follow-Up Study

BACKGROUND

Chronotropic index is a standardized measure of heart rate (HR) increment during exercise that reflects the combined effects of age, resting HR, and physical fitness. Low chronotropic index has been reported to predict disease and death. We tested whether temporal change in chronotropic index over 7 years influenced risk of cardiovascular death through up to 28 years.

METHODS AND RESULTS

Chronotropic index was calculated ([achieved maximal HR-resting HR]/[age-predicted maximal HR-resting HR]) after a symptom-limited bicycle ECG exercise test in 1420 healthy men at 2 examinations 7 years apart, in 1972 and 1979. Events of cardiovascular death were registered by manual scrutiny of all participants' hospital charts and the Norwegian Cause of Death Registry. The participants were divided into quartiles of temporal change in chronotropic index, with quartile one having the most negative value. Cox proportional hazard regression models were used to estimate risks and adjusted for classical cardiovascular risk factors. Incidence of cardiovascular death was 310 (22%) during median of 21 years of follow-up. After multivariable adjustment, and comparison with quartile four (mean +0.11), quartiles one (-0.16), two (-0.04), and three (+0.02) were associated with hazard ratios 1.50 (95% CI 1.10-2.05), 1.10 (0.79-1.53), and 1.04 (0.74-1.45) for cardiovascular death. Results remained robust also after exclusion of 31 participants with exercise ECG-induced signs of coronary ischemia.

CONCLUSIONS

Temporal reduction in chronotropic index was associated with increased long-term risk of cardiovascular death and might be a clinically important predictor when assessing risk in healthy individuals over a longer time.

Elongation of Long-Chain Fatty Acid Family Member 6 (Elovl6)-Driven Fatty Acid Metabolism Regulates Vascular Smooth Muscle Cell Phenotype Through AMP-Activated Protein Kinase/Krüppel-Like Factor 4 (AMPK/KLF4) Signaling

BACKGROUND

Fatty acids constitute the critical components of cell structure and function, and dysregulation of fatty acid composition may exert diverging vascular effects including proliferation, migration, and differentiation of vascular smooth muscle cells (VSMCs). However, direct evidence for this hypothesis has been lacking. We investigated the role of elongation of long-chain fatty acid member 6 (Elovl6), a rate-limiting enzyme catalyzing the elongation of saturated and monounsaturated long-chain fatty acid, in the regulation of phenotypic switching of VSMC.

METHODS AND RESULTS

Neointima formation following wire injury was markedly inhibited in Elovl6-null (Elovl6-/-) mice, and cultured VSMCs with siRNA-mediated knockdown of Elovl6 was barely responsive to PDGF-BB. Elovl6 inhibition induced cell cycle suppressors p53 and p21 and reduced the mammalian targets of rapamycin (mTOR) phosphorylation and VSMC marker expression. These changes are ascribed to increased palmitate levels and reduced oleate levels, changes that lead to reactive oxygen species (ROS) production and resulting AMP-activated protein kinase (AMPK) activation. Notably, Elovl6 inhibition robustly induced the pluripotency gene Krüppel-like factor 4 (KLF4) expression in VSMC, and KLF4 knockdown significantly attenuated AMPK-induced phenotypic switching of VSMC, indicating that KLF4 is a bona fide target of AMPK.

CONCLUSIONS

We demonstrate for the first time that dysregulation of Elovl6-driven long-chain fatty acid metabolism induces phenotypic switching of VSMC via ROS production and AMPK/KLF4 signaling that leads to growth arrest and downregulation of VSMC marker expression. The modulation of Elovl6-mediated cellular processes may provide an intriguing approach for tackling atherosclerosis and postangioplasty restenosis.

Association of Cholesterol Efflux Capacity With Clinical Features of Metabolic Syndrome: Relevance to Atherosclerosis

BACKGROUND

The contribution of high-density lipoprotein to cardiovascular benefit is closely linked to its role in the cellular cholesterol efflux process; however, various clinical and biochemical variables are known to modulate the overall cholesterol efflux process. The aim of this study was to evaluate the extent to which clinical and biological anomalies associated with the establishment of the metabolic syndrome modulate cholesterol efflux capacity and contribute to development of atherosclerosis.

METHODS AND RESULTS

This study involved patients (n=1202) displaying atherogenic dyslipidemia in primary prevention who were referred to our prevention center. Among these patients, 25% presented at least 3 criteria of the metabolic syndrome, as defined by the National Cholesterol Education Program Adult Treatment Panel III. We measured the capacity of 40-fold diluted serum to mediate cholesterol efflux from cholesterol-loaded human THP-1 macrophages. Cholesterol efflux capacity was reduced progressively by 4% to 11% (P<0.0001) as a function of the increasing number of coexisting criteria for the metabolic syndrome from 1 to 5. This observation was primarily related to reductions in scavenger receptor class B member 1 and ATP binding cassette subfamily G member 1-dependent efflux. Multivariate analyses indicate that serum efflux capacity was significantly associated with established metabolic syndrome (odds ratio 0.45; 95% CI 0.28-0.72; P=0.009) independent of age, low-density lipoprotein cholesterol, status with regard to lipid-lowering therapy, smoking status, and alcohol consumption.

CONCLUSIONS

Our study revealed that individual criteria of metabolic syndrome are closely related synergistically to cholesterol efflux capacity. In addition, established metabolic syndrome and cholesterol efflux capacity were independently associated with clinical features of atherosclerosis.

Association of Systemic Arterial Properties With Right Ventricular Morphology: The Multi-Ethnic Study of Atherosclerosis (MESA)-Right Ventricle Study

BACKGROUND

Systemic arterial stiffness is recognized as a major contributor to development of left ventricular dysfunction and failure; however, the relationship of systemic arterial properties and the right ventricle (RV) is unknown.

METHODS AND RESULTS

The associations between systemic arterial measures (total arterial compliance [TAC], systemic vascular resistance [SVR], and aortic augmentation index [AI]) and RV morphology (mass, end-systolic [RVESV] and end-diastolic volume [RVEDV], and ejection fraction [RVEF]) were examined using data from the Multi-Ethnic Study of Atherosclerosis. All analyses were adjusted for anthropometric, demographic, and clinical variables and the corresponding left ventricular parameter. A total of 3842 subjects without clinical cardiovascular disease were included with a mean age of 61 years, 48% male, 39% non-Hispanic white, 25% Chinese-American, 23% Hispanic, and 13% black. RV measures were within normal range for age and sex. A 1-mL/mm Hg decrease in TAC was associated with 3.9-mL smaller RVESV, 7.6-mL smaller RVEDV, and 2.4-g lower RV mass. A 5-Wood-unit increase in SVR was associated with 0.6-mL decrease in RVESV, 1.7-mL decrease in RVEDV, and 0.4-g decrease in RV mass. A 1% increase in AI was associated with 0.2-mL decrease in RVEDV. We found significant effect modification by age, sex, and race for some of these relationships, with males, whites, and younger individuals having greater decreases in RV volumes and mass.

CONCLUSIONS

Markers of increased systemic arterial load were associated with smaller RV volumes and lower RV mass in a population of adults without clinical cardiovascular disease.

Contemporary Trends and Age-Specific Sex Differences in Management and Outcome for Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND

Age- and sex-specific differences exist in the treatment and outcome of ST-elevation myocardial infarction (STEMI). We sought to describe age- and sex-matched contemporary trends of in-hospital management and outcome of patients with STEMI.

METHODS AND RESULTS

We analyzed data from 5 Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with STEMI. All the analyses were age- and sex-matched, considering 4 age classes: <55, 55 to 64, 65 to 74, and ≥75 years. A total of 13 235 patients were classified as having STEMI (72.1% men and 27.9% women). A progressive shift from thrombolysis to primary percutaneous coronary intervention occurred over time, with a concomitant increase in overall reperfusion rates (P for trend <0.0001), which was consistent across sex and age classes. The crude rates of in-hospital death were 3.2% in men and 8.4% in women (P<0.0001), with a significant increase over age classes for both sexes and a significant decrease over time for both sexes (all P for trend <0.01). On multivariable analysis, age (odds ratio 1.09, 95% CI 1.07-1.10, P<0.0001) and female sex (odds ratio 1.44, 95% CI 1.07-1.93, P=0.009) were found to be significantly associated with in-hospital mortality after adjustment for other risk factors, but no significant interaction between these 2 variables was observed (P for interaction=0.61).

CONCLUSIONS

Despite a nationwide shift from thrombolytic therapy to primary percutaneous coronary intervention for STEMI affecting both sexes and all ages, women continue to experience higher in-hospital mortality than men, irrespective of age.

Relationship Between Language Preference and Intravenous Thrombolysis Among Acute Ischemic Stroke Patients

BACKGROUND

Approximately 20% of the US population primarily speaks a language other than English at home. Yet the effect of language preference on treatment of acute ischemic stroke (AIS) patients remains unknown. We aimed to evaluate the influence of language preference on AIS patients' receipt of intravenous (IV) thrombolysis.

METHODS AND RESULTS

We analyzed data from 3894 AIS patients who participated in the American Heart Association "Get With The Guidelines®-Stroke" program at our hospital from January 1, 2003 to April 30, 2014. Information included patients' language in which they preferred to receive medical care. We used descriptive statistics and stepwise logistic regression models to examine associations between patients' language preference and receipt of IV thrombolysis, adjusting for relevant covariates. A total of 306/3295 (9.3%) AIS patients preferred to speak a non-English language and represented 25 different languages. Multivariable analyses adjusting for other socioeconomic factors showed that non-English-preferring patients were more likely than English-preferring patients to receive IV thrombolysis (OR=1.64; CI=1.09-2.48; P=0.02). However, in models that also included age, sex, and initial NIH Stroke Scale, patients' language preference was no longer significant (OR 1.38; CI=0.88-2.15; P=0.16), but NIH Stroke Scale was strongly associated with receiving IV thrombolysis (OR=1.15 per point; CI=1.13-1.16; P<0.0001).

CONCLUSIONS

Contrary to our hypothesis, non-English-preferring was not associated with lower rates of IV thrombolysis among AIS patients once initial stroke severity was accounted for.

Common Variant in Glycoprotein Ia Increases Long-Term Adverse Events Risk After Coronary Artery Bypass Graft Surgery

BACKGROUND

This study was aimed to investigate the clinical relevance between glycoprotein Ia (GPIA) rs1126643C/T polymorphism and the outcome of coronary artery disease after coronary artery bypass graft (CABG) surgery and explore the involved potential mechanisms.

METHODS AND RESULTS

We genotyped GPIA rs1126643 polymorphism of 1592 patients who underwent CABG and followed up for a median period of 72.8 months. Patients who are GPIA rs1126643 T-allele carriers have a higher major adverse cardiac or cerebrovascular events risk post-CABG than those who are CC homozygotes (hazard ratio [HR]=1.29; P=0.022). The clinical association between the risk allele (T) carriage and major adverse cardiac or cerebrovascular events was confirmed in another cohort study, which included 646 CABG patients from various health centers across China. Meanwhile, rs1126643 T allele was also linked with increased risk of major adverse cardiac or cerebrovascular events (HR=1.73; P=0.019). To explore the underlying mechanisms, we prospectively recruited 131 coronary artery disease patients, assessed their platelet aggregation function, and focused on detecting their GPIA mRNA level and protein expression. Results showed that patients with rs1126643 T allele have elevated platelet aggregation activity (P=0.029) when protein expression is increased (P<0.001) and not affected by glycoprotein Ia mRNA level.

CONCLUSIONS

The synonymous common variant, GPIA rs1126643, increases the long-term adverse events risk of CABG by augmenting GPIa protein expression and enhancing platelet aggregation function. This finding can serve as the implication of improving secondary prevention of CABG patients.

Relationship Between Anemia and Mortality Outcomes in a National Acute Coronary Syndrome Cohort: Insights From the UK Myocardial Ischemia National Audit Project Registry

BACKGROUND

We aim to determine the prevalence of anemia in acute coronary syndrome (ACS) patients and compare their clinical characteristics, management, and clinical outcomes to those without anemia in an unselected national ACS cohort.

METHODS AND RESULTS

The Myocardial Ischemia National Audit Project (MINAP) registry collects data on all adults admitted to hospital trusts in England and Wales with diagnosis of an ACS. We conducted a retrospective cohort study by analyzing patients in this registry between January 2006 and December 2010 and followed them up until August 2011. Multiple logistic regressions were used to determine factors associated with anemia and the adjusted odds of 30-day mortality with 1 g/dL incremental hemoglobin increase and the 30-day and 1-year mortality for anemic compared to nonanemic groups. Analyses were adjusted for covariates. Our analysis of 422 855 patients with ACS showed that 27.7% of patients presenting with ACS are anemic and that these patients are older, have a greater prevalence of renal disease, peripheral vascular disease, diabetes mellitus, and previous acute myocardial infarction, and are less likely to receive evidence-based therapies shown to improve clinical outcomes. Finally, our analysis suggests that anemia is independently associated with 30-day (OR 1.28, 95% CI 1.22-1.35) and 1-year mortality (OR 1.31, 95% CI 1.27-1.35), and we observed a reverse J-shaped relationship between hemoglobin levels and mortality outcomes.

CONCLUSIONS

The prevalence of anemia in a contemporary national ACS cohort is clinically significant. Patients with anemia are older and multimorbid and less likely to receive evidence-based therapies shown to improve clinical outcomes, with the presence of anemia independently associated with mortality outcomes.

Myocardial Immunocompetent Cells and Macrophage Phenotypes as Histopathological Surrogates for Diagnosis of Cardiac Sarcoidosis in Japanese

BACKGROUND

The histological diagnosis of cardiac sarcoidosis (CS) is based on the presence of myocardial granulomas; however, the sensitivity of endomyocardial biopsy is relatively low. We investigated whether immunocompetent cells including dendritic cells (DC) and macrophages in nongranuloma sections of endomyocardial biopsy samples could be histopathological surrogates for CS diagnosis.

METHODS AND RESULTS

The numbers of DC and macrophages were investigated in 95 consecutive CS patients and 50 patients with nonischemic cardiomyopathy as controls. All patients underwent endomyocardial biopsy, and immunohistochemical staining was performed on all samples. We examined these immunocompetent cells in nongranuloma sections in CS patients diagnosed by the presence of myocardial granulomas (n=26) and in CS patients without myocardial granulomas diagnosed by the Japanese Ministry of Health Welfare 2007 criteria (n=65) or the Heart Rhythm Society 2014 criteria (n=26). In CS patients with and without myocardial granulomas, CD209+ DC and CD68+ macrophages were more frequently observed (P<0.01) and CD163+M2 macrophages were less frequently observed (P<0.01) in nongranuloma sections compared to controls. Furthermore, the combination of decreased CD163+M2/CD68+ macrophage ratio and increased number of CD209+ DC in nongranuloma sections of CS patients demonstrated high specificity (100%, 95% CI 92.7-100) for CS diagnosis with each diagnostic criteria and the presence of myocardial granulomas.

CONCLUSIONS

Increased number of DC and decreased M2 among all macrophages in nongranuloma sections of myocardium showed high specificity for CS diagnosis, suggesting DC and macrophage phenotypes as histopathological surrogates for the diagnosis of CS.

Clinical Outcomes of Vasospastic Angina Patients Presenting With Acute Coronary Syndrome

BACKGROUND

Coronary vasospasm is an important pathogenesis of acute coronary syndrome (ACS). However, the clinical features and prognosis of vasospastic angina (VA) patients presenting with ACS (VAACS) are still unclear. We aimed to evaluate the clinical characteristics and long-term outcomes of VAACS patients without significant coronary artery stenosis.

METHODS AND RESULTS

A total of 986 VA patients confirmed by ergonovine provocation test were analyzed. VAACS was defined as VA patients visiting the emergency room with documented electrocardiographic changes, significant arrhythmias, or elevated cardiac biomarkers. VA patients with elevated cardiac biomarkers were further considered to have myocardial infarction (MI; VAMI). During 4.4 years of median follow-up, we investigated major adverse cardiac events including cardiac death, MI, revascularization, and rehospitalization because of recurrent angina. The VAACS group consisted of 149 patients (15.1%), and VAMI occurred in 81 patients (8.2%). VAACS patients were younger and had a higher prevalence of diabetes mellitus, MI history, and higher levels of inflammatory markers compared with non-VAACS patients. In multivariable Cox regression analyses, VAACS patients were associated with an increased risk of major adverse cardiac events (hazard ratio, 1.65; 95% CI 1.14-2.37; P=0.007) and recurrent MI hazard ratio, 2.57; 95% CI, 1.35-4.87; P=0.004). In addition, VAMI patients had an increased risk of major adverse cardiac events (hazard ratio, 1.75; 95% CI, 1.11-2.76; P=0.016) and recurrent MI (hazard ratio, 2.43; 95% CI, 1.09-5.40; P=0.03).

CONCLUSION

VAACS patients showed worse clinical outcomes, driven mainly by recurrent MI. Therefore, intensive medical treatment might be required in VAACS patients.

Effects of the P-Selectin Antagonist Inclacumab on Myocardial Damage After Percutaneous Coronary Intervention According to Timing of Infusion: Insights From the SELECT-ACS Trial

BACKGROUND

The Effects of the P-Selectin Antagonist Inclacumab on Myocardial Damage After Percutaneous Coronary Intervention for Non-ST-Segment Elevation Myocardial Infarction (SELECT-ACS) trial suggested beneficial effects of inclacumab, a monoclonal antibody directed against P-selectin, on periprocedural myocardial damage. This study evaluated the effect of inclacumab on myocardial damage according to varying time intervals between study drug infusion and percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Patients (n=544) enrolled in the SELECT-ACS trial and randomized to receive 1 infusion of placebo or inclacumab (5 or 20 mg/kg, administered between 1 and 24 hours before PCI) were divided according to the time interval between study drug infusion and PCI. The primary end point was the change in troponin I from baseline at 16 and 24 hours after PCI. In patients receiving inclacumab 20 mg/kg with a short (less than median) time interval between infusion and PCI, placebo-adjusted geometric mean percent changes in troponin I, creatine kinase-myocardial band, and peak troponin I at 24 hours were -45.6% (P=0.005), -30.7% (P=0.01), and -37.3% (P=0.02), respectively. No significant changes were observed in patients with a long (greater than median) time interval between infusion and PCI. Placebo-adjusted geometric mean percent changes in troponin I and creatine kinase-myocardial band were -43.5% (P=0.02) and -26.0% (P=0.07), respectively, when inclacumab 20 mg/kg was administered between 1 and 3 hours before PCI, whereas the drug had no effect with longer intervals.

CONCLUSIONS

Inclacumab 20 mg/kg significantly reduces myocardial damage after PCI in patients with non-ST-segment elevation myocardial infarction, and benefits are larger when the infusion is administered <3 hours before PCI.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01327183.

Toll-Like Receptor (TLR)4 and MyD88 are Essential for Atheroprotection by Peritoneal B1a B Cells

BACKGROUND

We previously identified peritoneal B1a cells that secrete natural IgM as a key atheroprotective B cell subset. However, the molecules that activate atheroprotective B1a cells are unknown. Here, we investigated whether Toll-like receptors (TLRs) TLR2, TLR4, and TLR9 expressed by B1a cells are required for IgM-mediated atheroprotection.

METHODS AND RESULTS

We adoptively transferred B1a cells from wild-type mice or from mice deficient in TLR2, TLR4, TLR9, or myeloid differentiation primary response 88 (MyD88) into ApoE-/- mice depleted of peritoneal B1a cells by splenectomy and fed a high-fat diet for 8 weeks. Elevations in plasma total, anti-oxLDL (oxidized low-density lipoprotein), anti-leukocyte, anti-CD3, anti-CD8, and anti-CD4 IgMs in atherosclerotic mice required B1a cells expressing TLR4 and MyD88, indicating a critical role for TLR4-MyD88 signaling for IgM secretion. Suppression of atherosclerosis was also critically dependent on B1a cells expressing TLR4-MyD88. Atherosclerosis suppression was associated not only with reductions in lesion apoptotic cells, necrotic cores, and oxLDL, but also with reduced lesion CD4+ and CD8+ T cells. Transforming growth factor beta 1 (TGF-β1) expression, including macrophages expressing TGF-β1, was increased, consistent with increased IgM-mediated phagocytosis of apoptotic cells by macrophages. Reductions in lesion inflammatory cytokines tumor necrosis factor alpha (TNF-α), interleukin (IL) 1β, and IL-18 were consistent with augmented TGF-β1 expression.

CONCLUSIONS

TLR4-MyD88 expression on B1a cells is critical for their IgM-dependent atheroprotection that not only reduced lesion apoptotic cells and necrotic cores, but also decreased CD4 and CD8 T-cell infiltrates and augmented TGF-β1 expression accompanied by reduced lesion inflammatory cytokines TNF-α, IL-1β, and IL-18.

Impact of Cost Sharing on Therapeutic Substitution: The Story of Statins in 2006

BACKGROUND

Cost sharing is widely used to encourage therapeutic substitution. This study aimed to examine the impact of increases in patient cost-sharing differentials for brand name and generic drugs on statin utilization on entry into the Medicare Part D coverage gap.

METHOD AND RESULTS

Using 5% Medicare Chronic Condition Warehouse files from 2006, this quasi-experimental study examined patients with hyperlipidemia who filled prescriptions for atorvastatin or rosuvastatin between January and March 2006. Propensity score matching and difference-in-difference regressions were used to compare changes in statin utilization for the study group (patients who were not eligible for low-income subsidies [non-LIS] and had generic-only gap coverage) to those of a control group (LIS patients who faced the same cost sharing before and during the Part D coverage gap). In the final sample, 801 patients in the study group were matched to 801 patients in the control group. We found that, compared to the control group, the study group had a larger decline in any monthly brand-name statin use (-0.24 30-day fills, P<0.001). This was only partially offset by increased monthly generic statin use (+0.06 30-day fill, P<0.001), with an overall drop in any monthly statin use (-0.18 30-day fills, P<0.001). Overall adherence with statins declined (OR 0.81, P<0.001), and statin discontinuation increased (OR 1.62, P<0.001) in the study group as compared to the control group.

CONCLUSIONS

Increases in cost-sharing differentials for brand name and generic drugs on coverage gap entry were associated with discontinuation of statins in Medicare Part D patients with hyperlipidemia.

Premature Cardiac Aging in South Asian Compared to Afro-Caribbean Subjects in a Community-Based Screening Study

BACKGROUND

People of South Asian (SAs) and African Caribbean (AC) origin have increased cardiovascular morbidity, but underlying mechanisms are poorly understood. Aging is the key predictor of deterioration in diastolic function, which can be assessed by echocardiography using E/e' ratio as a surrogate of left ventricular (LV) filling pressure. The study aimed to assess a possibility of premature cardiac aging in SA and AC subjects.

METHODS AND RESULTS

We studied 4540 subjects: 2880 SA and 1660 AC subjects. All participants underwent detailed echocardiography, including LV ejection fraction, average septal-lateral E/e', and LV mass index (LVMI). When compared to ACs, SAs were younger, with lower mean LVMI, systolic blood pressure (BP), diastolic BP, and body mass index (BMI), as well as a lower prevalence of hypertension and smoking (P≤0.001 for all). In a multivariate linear regression model including age, sex, ethnicity, BP, heart rate, BMI, waist circumference, LVMI, history of smoking, hypertension, coronary artery disease, diabetes mellitus, medications, SA origin was independently associated with higher E/e' (regression coefficient±standard error, -0.66±0.10; P<0.001, adjusted R2 for the model 0.21; P<0.001). Furthermore, SAs had significantly accelerated age-dependent increase in E/e' compared to ACs. On multivariable Cox regression analysis without adjustment for E/e', SA ethnicity was independently predictive of mortality (P=0.04). After additional adjustment for E/e', the ethnicity lost its significance value, whereas E/e' was independently predictive of higher risk of death (P=0.008).

CONCLUSIONS

Premature cardiac aging is evident in SAs and may contribute to high cardiovascular morbidity in this ethnic group, compared to ACs.

MiR-590 Promotes Transdifferentiation of Porcine and Human Fibroblasts Toward a Cardiomyocyte-Like Fate by Directly Repressing Specificity Protein 1

BACKGROUND

Reprogramming of cardiac fibroblasts into induced cardiomyocyte-like cells represents a promising potential new therapy for treating heart disease, inducing significant improvements in postinfarct ventricular function in rodent models. Because reprogramming factors effective in transdifferentiating rodent cells are not sufficient to reprogram human cells, we sought to identify reprogramming factors potentially applicable to human studies.

METHODS AND RESULTS

Lentivirus vectors expressing Gata4, Mef2c, and Tbx5 (GMT); Hand2 (H), Myocardin (My), or microRNA (miR)-590 were administered to rat, porcine, and human cardiac fibroblasts in vitro. induced cardiomyocyte-like cell production was then evaluated by assessing expression of the cardiomyocyte marker, cardiac troponin T (cTnT), whereas signaling pathway studies were performed to identify reprogramming factor targets. GMT administration induced cTnT expression in ≈6% of rat fibroblasts, but failed to induce cTnT expression in porcine or human cardiac fibroblasts. Addition of H/My and/or miR-590 to GMT administration resulted in cTNT expression in ≈5% of porcine and human fibroblasts and also upregulated the expression of the cardiac genes, MYH6 and TNNT2. When cocultured with murine cardiomyocytes, cTnT-expressing porcine cardiac fibroblasts exhibited spontaneous contractions. Administration of GMT plus either H/My or miR-590 alone also downregulated fibroblast genes COL1A1 and COL3A1. miR-590 was shown to directly suppress the zinc finger protein, specificity protein 1 (Sp1), which was able to substitute for miR-590 in inducing cellular reprogramming.

CONCLUSIONS

These data support porcine studies as a surrogate for testing human cardiac reprogramming, and suggest that miR-590-mediated repression of Sp1 represents an alternative pathway for enhancing human cardiac cellular reprogramming.

Effect of High (200 μg/kg per Minute) Adenosine Dose Infusion on Fractional Flow Reserve Variability

BACKGROUND

Variations in distal coronary pressure (Pd)/aortic pressure (Pa) ratio during steady-state hyperemia with standard (140 μg/kg per minute) adenosine dose may hamper accurate fractional flow reserve assessment. This study investigated to what extent an increased adenosine dose can overcome Pd/Pa variation.

METHODS AND RESULTS

In a prospective, single-arm study, out of 95 prospectively screened patients, 38 (40.0%) exhibited significant (≥0.05 difference of max Pd/Pa minus min Pd/Pa) variations in Pd/Pa from 15 s post Pd/Pa dip and until the end of a 3-minute adenosine (140 μg/kg per minute) infusion. Thirty patients agreed to participate in a post 5-minute repeat fractional flow reserve assessment using 200 μg/kg per minute 3-minute adenosine infusion. The study's co-primary end point of Pd/Pa coefficient of dispersion was lower for the high versus standard adenosine dose: 1.31 (1.13-2.72) versus 2.76 (2.38-5.60), P=0.002. The study's co-primary end point of ΔPd/Pa was also lower for the high versus standard adenosine dose: 0.065 (0.038-0.10) versus 0.08 (0.06-0.11), P=0.002. This difference was mainly driven by the lowering effect of the high adenosine dose on the maximum Pd/Pa compared to the standard dose: 0.84 (0.81-0.93) versus 0.90 (0.83-0.95), P=0.007, while minimum Pd/Pa remained unaffected. High adenosine dose was adequately tolerated by all patients, without requiring infusion discontinuation in any case.

CONCLUSIONS

Pd/Pa variability is frequently observed during standard adenosine infusion and is significantly decreased following a high (200 μg/kg per minute) adenosine dose. This is achieved without a significant difference in the minimum Pd/Pa.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02350439.

25-Hydroxyvitamin D Levels and Markers of Subclinical Myocardial Damage and Wall Stress: The Atherosclerosis Risk in Communities Study

BACKGROUND

Low 25-hydroxyvitamin D (25[OH]D) is associated with increased cardiovascular disease risk. Less known is whether 25(OH)D deficiency contributes to subclinical myocardial damage and wall stress (high-sensitivity cardiac troponin T [hs-cTnT] and N-terminal pro-brain natriuretic peptide [NT-proBNP]) or whether associations vary among subgroups.

METHODS AND RESULTS

Overall, 11 311 Atherosclerosis Risk in Communities participants without prevalent cardiovascular disease had 25(OH)D, hs-cTnT, and NT-proBNP measured at baseline (1990-1992), and 8990 had measurements of hs-cTnT and NT-proBNP repeated 6 years later. We examined associations of deficient 25(OH)D (<20 ng/mL) with prevalent elevated hs-cTnT (≥14 ng/L) and NT-proBNP (≥100 pg/mL), change in hs-cTnT and NT-proBNP, and incident elevated hs-cTnT and NT-proBNP. We tested for interactions by age (<56 and ≥56 years), sex, and race. In fully adjusted models, 25(OH)D was not associated with prevalent elevated hs-cTnT and NT-proBNP. Deficient 25(OH)D, however, was associated with increased 6-year change in hs-cTnT (β=0.54 ng/L [95% CI 0.08-1.01]) but not change in NT-proBNP. Deficiency in 25(OH)D was not associated with incident elevated hs-cTnT in the overall cohort but was associated with incident elevated hs-cTnT in younger but not older adults (relative risk 2.18 [95% CI 1.21-3.94] versus 0.78 [95% CI 0.56-1.08], respectively; P=0.01 for interaction by age). Deficient 25(OH)D was also associated with incident elevated NT-proBNP in men but not women (P=0.01 for interaction by sex).

CONCLUSIONS

Vitamin D deficiency was associated with increased 6-year change in hs-cTnT levels. Hypothesis-generating differences in associations by age and sex, but not race, were observed. If these associations are causal, further research is needed to understand mechanisms by which low 25(OH)D confers increased risk in these subgroups and whether treating deficient 25(OH)D can prevent myocardial damage and wall stress.

Long-Term Visit-to-Visit Blood Pressure Variability and Renal Function Decline in Patients With Hypertension Over 15 Years

BACKGROUND

Visit-to-visit variability of systolic blood pressure (SBP) has been shown to contribute to cardiovascular events and all-cause mortality. However, little is known about its long-term effect on renal function. We aim to examine the relationship between visit-to-visit blood pressure variability (BPV) and decline in renal function in patients with hypertension and to determine the level of systolic BPV that is associated with significant renal function decline.

METHODS AND RESULTS

This is a 15-year retrospective cohort study of 825 hypertensive patients. Blood pressure readings every 3 months were retrieved from the 15 years of clinic visits. We used SD and coefficient of variation as a measure of systolic BPV. Serum creatinine was captured and estimated glomerular filtration rate was calculated at baseline, 5, 10, and 15 years. The mean SD of SBP was 14.2±3.1 mm Hg and coefficient of variation of SBP was 10.2±2%. Mean for estimated glomerular filtration rate slope was -1.0±1.5 mL/min per 1.73 m2 per year. There was a significant relationship between BPV and slope of estimated glomerular filtration rate (SD: r=-0.16, P<0.001; coefficient of variation: r=-0.14, P<0.001, Pearson's correlation). BPV of SBP for each individual was significantly associated with slope of estimated glomerular filtration rate after adjustment for mean SBP and other confounders. The cutoff values estimated by the receiver operating characteristic curve for the onset of chronic kidney disease for SD of SBP was 13.5 mm Hg and coefficient of variation of SBP was 9.74%.

CONCLUSIONS

Long-term visit-to-visit variability of SBP is an independent determinant of renal deterioration in patients with hypertension. Hence, every effort should be made to reduce BPV in order to slow down the decline of renal function.

Comparison of Drug-Eluting and Bare Metal Stents in Patients With Chronic Kidney Disease: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Drug-eluting stents (DESs) and bare metal stents (BMSs) are both recommended to improve coronary revascularization and to treat coronary artery disease in patients with chronic kidney disease (CKD). However, the potential superiority of DESs over BMSs for reducing the incidence of long-term major adverse cardiovascular events and mortality in CKD patients has not been established, and the results remain controversial. We aimed to systematically assess and quantify the total weight of evidence regarding the use of DESs versus BMSs in CKD patients.

METHODS AND RESULTS

In this systematic review and conventional meta-analysis, electronic studies published in any language until May 20, 2016, were systematically searched through PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials and observational studies comparing outcomes in CKD patients with DESs versus BMSs and extracted data in a standard form. Pooled odd ratios and 95% CIs were calculated using random- and fixed-effects models. Finally, 38 studies involving 123 396 patients were included. The use of DESs versus BMSs was associated with significant reductions in major adverse cardiovascular events (pooled odds ratio 0.75; 95% CI, 0.64-0.88; P<0.001), all-cause mortality (odds ratio 0.81; 95% CI, 0.73-0.90; P<0.001), myocardial infarction, target-lesion revascularization, and target-vessel revascularization. The superiority of DESs over BMSs for improving clinical outcomes was attenuated in randomized controlled trials.

CONCLUSIONS

The use of DESs significantly improves the above outcomes in CKD patients. Nevertheless, large-sized randomized controlled trials are necessary to determine the real effect on CKD patients and whether efficacy differs by type of DES.

Relationship of Platelet Reactivity With Bleeding Outcomes During Long-Term Treatment With Dual Antiplatelet Therapy for Medically Managed Patients With Non-ST-Segment Elevation Acute Coronary Syndromes

BACKGROUND

The relationship between "on-treatment" low platelet reactivity and longitudinal risks of major bleeding dual antiplatelet therapy following acute coronary syndromes remains uncertain, especially for patients who do not undergo percutaneous coronary intervention.

METHODS AND RESULTS

We analyzed 2428 medically managed acute coronary syndromes patients from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial who had serial platelet reactivity measurements (P2Y12 reaction units; PRUs) and were randomized to aspirin+prasugrel versus aspirin+clopidogrel for up to 30 months. Contal's method was used to determine whether a cut point for steady-state PRU values could distinguish high versus low bleeding risk using 2-level composites: Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe/life-threatening or moderate bleeding unrelated to coronary artery bypass grafting (CABG) and non-CABG Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding. Exploratory analyses used 3-level composites that incorporated mild and minimal GUSTO and TIMI events. Continuous measures of PRUs (per 10-unit decrease) were not independently associated with the 2-level GUSTO (adjusted hazard ratio [HR], 1.01; 95% CI, 0.96-1.06) or TIMI composites (1.02; 0.98-1.07). Furthermore, no PRU cut point could significantly distinguish bleeding risk using the 2-level composites. However, the PRU cut point of 75 differentiated bleeding risk with the 3-level composites of GUSTO (26.5% vs 12.6%; adjusted HR, 2.28; 95% CI, 1.77-2.94; P<0.001) and TIMI bleeding events (25.9% vs 12.2%; adjusted HR, 2.30; 95% CI, 1.78-2.97; P<0.001).

CONCLUSIONS

Among medically managed non-ST-segment elevation acute coronary syndromes patients receiving prolonged dual antiplatelet therapy, PRU values were not significantly associated with the long-term risk of major bleeding events, suggesting that low on-treatment platelet reactivity does not independently predict serious bleeding risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00699998.

Role of Ranolazine in cardiovascular disease and diabetes: Exploring beyond angina

Ranolazine was FDA approved for chronic angina in 2006. Since then, there has been extensive research involving this drug. The mechanism of action, debatable at the time of approval, has been demonstrated. Ranolazine acts via inhibition of late sodium channel current in the myocardium. This acts by lowering abnormally high cytosolic calcium levels. Other possible clinical applications of Ranolazine have also been explored. Out of many lines of investigation, its effects in atrial fibrillation, especially post-CABG and recurrent atrial fibrillation show promise. It has also shown definite HbA1c lowering effects when used in diabetics with coronary artery disease. Other possible indications for the drug include pulmonary arterial hypertension, diastolic dysfunction and chemotherapy-induced cardiotoxicity. This review aims to summarize major research regarding Ranolazine in potential applications beyond chronic angina. There are few dedicated large, randomized, phase III trials exploring the newer effects of Ranolazine. There are a few such trials underway, but more are needed.